Every finding on record at Clearstream Rehabilitation and Nursing Center

Based on observation, interview, and record review the facility failed to provide food at a palatable temperature for 1 of 1 resident (R33), resulting in the potential for decreased food consumption for all residents who receive food from the kitchen and nutritional decline.Findings Include: Resident #33 During an interview on 5/3/2026 at 10:08 AM, Resident #33 reported ongoing concerns with cold food. Resident #33 reported she felt that the food was a bit warmer when served in the dining room, but when she ate meals in her room, the food was always cold. Resident #33 reported she had spoken with multiple facility staff members on numerous occasions about her concerns with food, but they were still serving cold food often. In a follow up interview on 5/4/2026 at 1:11 PM, Resident #33 was sitting in her chair in the dining room. Resident #33 reported she had just eaten her lunch, which was served cold, even though she had received her meal in the dining room. Resident #33 voiced frustration about being served cold food frequently. In a follow up interview on 5/5/2026 at 12:37 PM, Resident #33 was sitting up in her bed eating her lunch. Resident #33 voiced frustration that her meal was served cold. Resident #33 reported she felt like the staff tried to get meal trays delivered to rooms as fast as they could, but the food temperature was still cold by the time the meal was served to her. Resident #33 reported that her pork chop and potatoes at this meal were not warm to her mouth. In an observation on 5/5/26 at 12:46 PM, meal trays were delivered to the B hall. This writer intercepted the last tray available on the cart as a sample tray at 12:50 PM, the porkchop was 126.5 and the roasted potatoes were 117 degrees. Review of the facility's Proper food portions and plating policy dated 2/26/25 revealed, POLICY: It is the policy of this facility to ensure that all meals are portioned appropriately . providing adequate food quantity while maintaining palatability and visual appeal . On 5/4/26 at 11:49 AM, an interview with Dietary Director (DD) W found that hot food on the steam table should stay hot through service. When asked if temperatures of the product were taken before service, [NAME] JJ stated that they got in a hurry today and preservice temperatures were not taken of items on the steam table. At this time, the surveyor took temperatures of the asparagus and the chicken breasts and found the asparagus around 165F and the chicken breast ranging from 110F to 138F. Staff continued plating meals knowing this information. On 5/4/26 at 12:30 PM, a test tray was plated for the D hall unit and was placed first on the D hall cart with 11 trays that followed for the residents of D hall. On 5/4/26 at 12:46 PM, the meal cart arrived in D hall and two staff started delivering trays. On 5/4/26 at 12:56 PM, all meals on the D hall were delivered and the test tray was back in the conference room with the following temperatures noted: Chicken Breast was 96F, [NAME] was 102F, and the asparagus was 101F.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings Include:On 5/4/26 at starting at 8:05 AM, a follow-up tour of the kitchen with Dietary Director (DD) W occurred.On 5/4/26 at 8:26 AM, observation of the shelf above the hand sink found a spray bottle with a yellow solution that didn't have a common name for labeling.According to the 2022 FDA Food Code section 7-102.11 Common Name. Working containers used for storing POISONOUS OR TOXIC MATERIALS such as cleaners and SANITIZERS taken from bulk supplies shall be clearly and individually identified with the common name of the material.On 5/4/26 at 8:28 AM, observation of the three-door cooler labeled #1, found a cooked ham and a bag of cooked brats sitting on two log packages of raw ground beef in the bottom right of the cooler. When asked about proper storage in the cooler, DD W stated the ready to eat food, like the cooked ham and brats, should not be stored with raw product and moved the ham and brats to a higher shelf.On 5/4/26 at 3:22 PM, observation of the three-door cooler labeled #1 found that a box of raw shaved steak was sitting on top of a box of cooked roasts on the bottom left of the cooler. Further review of the cooler found staff had rearranged the right side so that a tray of drinks could be added to the reach in cooler, in order to do so, the cooked ham and package of cooked brats was moved back to the bottom shelf and was found laying on the log packages of raw ground beef. At this time, an interview with DD W found that cold hold storage can get tough sometimes with limited space and large deliveries, but we should not store items like this.According to the 2022 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below or when combined as ingredients, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY-TO-EAT FOOD such as fruits and vegetables, P (b) Cooked READY-TO-EAT FOOD, P and (c) Fruits and vegetables before they are washed; P.On 5/4/26 at 8:41 AM, Observation of the preparation table spice rack found an open container of lemon juice sitting at room temperature. A review of the container found that it requires refrigeration after opening.According to the 2022 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above,.or (2) At 5C (41F) or less.On 5/4/26 at 8:42 AM, Observation of the underside of the preparation cook line found five large metal sheet pans that were stacked and stored wet with moisture on the surfaces between the pans.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 as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD.On 5/4/26 at 9:33 AM, observation of the ice machine holder in the dining room found that it didn't have a way to properly drain and the ice scoop was sitting in the holder with roughly one inch of stagnant water sitting in the bottom of the scoop holder. When shown to DD W, she stated it gets washed regularly, but it should have a way to drain the water.According to the 2022 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.On 5/4/26 starting at 11:45 AM, observation of lunch service observed staff, who plated food from the steam table, lay the handles of their tongs or mechanical scoop into the food product while plating meals. The mechanical scoop was observed laying in the container of rice three times while plating. The tong handles were observed laying in the container of chicken breast for the second half of service while staff used their gloved hands to grab the chicken.According to the 2022 FDA Food Code section 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: (A) Except as specified under (B) of this section, in the FOOD with their handles above the top of the FOOD and the container.

Based on interview and record review, the facility failed to ensure updated and accurate advanced directive information was in place for 2 (Resident #10 and Resident #5) of 18 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings include:Resident #10 Review of an admission Record revealed Resident #10 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain) and major depressive disorder (condition characterized by persistent low mood, loss of interests in activities and low energy lasting at least 2 weeks). Review of a Minimum Data Set (MDS) assessment for Resident 10 with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment score of 9/15, which indicated the resident was moderately cognitively impaired. Review of Resident #10's Banner (Top portion of electronic medical record (EMR) that staff use to quickly identify pertinent resident information such as code status) revealed, Full Code which indicated that all possible life-saving measures will be used to save Resident #10's life. This included cardiopulmonary resuscitation (CPR) and any other medical interventions deemed necessary by physicians. Review of Advanced Directives for Resident #10, signed by a patient advocate on [DATE] revealed I fully understand the impact and potential consequences of these choices and wish to emphasize my desire to have the procedure performed or withheld, as indicated in the chart below.Cardiopulmonary Resuscitation (CPR), No. Review of Physician Orders for Resident #10 revealed Full code, status of order: active, start date [DATE]. In an interview on [DATE] at 11:51M, SW H reported although Resident #10's patient advocate signed a Do Not Resuscitate Advanced Directive on [DATE], the facility did not feel it could honor the direction of the form because the patient advocate (Resident #10's son) did not have guardianship over her at that time. SW H confirmed Resident #10's son was later granted temporary guardianship, but the facility had not pursued getting an updated Advanced Directive form for Resident #10. In an interview, Registered Nurse (RN) K reported if a resident's heart stopped beating, she would look in the resident's banner within the electronic medical record to determine if the resident wanted CPR. Resident #5 Review of an admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included depression and visual hallucinations. Review of Resident #5's Banner (Top portion of electronic medical record (EMR) that staff use to quickly identify pertinent resident information such as code status) revealed, Full Code which indicated that all possible life-saving measures will be used to save Resident #5's life. This included cardiopulmonary resuscitation (CPR) and any other medical interventions deemed necessary by physicians. Review of Resident #5's Advance Directive form dated [DATE] revealed, . I (Resident #5), being sound mind freely acknowledge that if I am unconscious or terminally ill, and unable to participate in my own medical decisions, I expressly and ambiguously wish the following personal choices for my care to be honored by all who read this document. I fully understand the impact and potential consequences of these choices and wish to emphasize my desire to have the procedures performed or withheld, as indicated in the chart below: CPR: This was marked as unsure . Noted that the form was signed by Resident #5's guardian on [DATE]. Review of Resident #5's Do-Not-Resuscitate (DNR) Order Guardian Consent revealed, . Guardian Consent: I authorize that in the event the ward's (Resident #5) heart and breathing should stop; no person shall attempt to resuscitate the ward. I fully understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. Noted that the form was signed by Resident #5's guardian on [DATE], but the form was not signed by two witnesses or a physician. During an interview on [DATE] at 3:48 PM, Social Worker (SW) H reported she thought that Resident #5 was listed as a full code in his EMR because Resident #5's guardian had indicated that she was unsure about CPR on Resident #5's Advance Directive form. When this writer queried about the DNR order that was signed by Resident #5's guardian, SW H reported she was unaware that Resident #5 had an incomplete DNR form scanned into his EMR. SW H reported the facility reviewed resident advance directives quarterly at resident care conferences. SW H reported Resident #5's most recent care conference was on [DATE]. SW H reviewed Resident #5's Care Conference notes from [DATE] and confirmed that the facility staff had not reviewed Resident #5's Code status/Advance Directives at this conference. On [DATE] at 4:00 PM, Nursing Home Administrator (NHA) A sent this writer via email the facility's Advance Directive Action Plan dated [DATE] revealed, Assessment: The facility identified that updated guardianship paperwork was not being obtained, and code statuses were still being signed by the guardian on file. Action Steps: SW completed a guardianship audit to identify who we needed to request documents for . Status Report: Completed on [DATE]. SW reached out to guardians to request updated documents and verify code status signatures were appropriate . Status Report: Completed on [DATE]. In a follow up interview on [DATE] at 8:26 AM, SW H reported she had reached out to Resident #5's guardian on [DATE] and had a lengthy discussion on the discrepancy with Resident #5's code status. SW H reported that Resident #5's guardian had told her that she felt that she did not think that Resident #5 would want to live in his current state, and she felt that he would want to be DNR. This writer attempted to contact Resident #5's guardian on [DATE] at 3:50 PM. Attempts to contact Resident #5's guardian was unsuccessful by the time of survey exit. Review of the facility's Advance Directive policy dated [DATE] revealed, Policy: It is the policy of this facility to:1. Provide written information to residents at time of admission regarding a.Their right under State Law to accept or refuse medical treatment and the right to formulate Advance Directives such as the Natural Death Act, Durable Power of Attorney for Health Care Decision, or living will, in accordance with the Resident Self Determination Act. The facility's policy to implement such decisions and directives .Procedure: 1. Designated staff will review and explain the specified State Law addressing Advance Directives options and Life Sustaining Treatment with the resident and/or representative. 2. Staff will provide the resident and/or representative with information regarding advance care planning which will address types of Advance Directives, treatment options and refusal of treatment. 3. Information will be reviewed and the resident and/or representative will be asked to sign and acknowledge that they have received the information on Advance Care Planning. 4. An Advance Directive form (as provided by the healthcare facility) shall be completed with resident and/or legal representative to verify treatment options as well as code status .6. The resident's Advance Directive choices/options shall be reviewed during the re-assessment and quarterly care planning process .

Based on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 (Resident #67) of 4 residents reviewed for abuse resulting in Resident #67 being inappropriately touched by Resident #43. Findings include: Resident #67Review of an admission Record revealed Resident #67 was originally admitted to the facility on [DATE] with pertinent diagnoses which included major depressive disorder and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #67, with a reference date of 2/16/26 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident # 67 was cognitively intact. Review of Resident #67's Progress Note dated 12/10/25 revealed, Writer was walking to the top of the hall near the nurse's station and overheard (Resident #67) yelling loudly that (Resident #43) had grabbed her butt. They were both separated .Review of Resident #67's Progress Note dated 12/11/25 and documented by SW H revealed, This writer spoke privately with (Resident #67) in my office. She said she was very upset when touched inappropriately, but is feeling calm now . (Resident #67) has a plan to move rooms . She says moving rooms will increase her feeling of safety .Resident #43 Review of an admission Record revealed Resident #43 was originally admitted to the facility on [DATE] with pertinent diagnoses which included bipolar disorder (mental health condition that causes severe mood swings) and other sexual disorder (used to classify other sexual disorders that involve atypical patterns of sexual behavior or development not covered by more specific categories.)Review of a Minimum Data Set (MDS) assessment for Resident #43, with a reference date of 3/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident # 43 was moderately cognitively impaired. Review of Resident #43's Care Plan revealed, Focus: (Resident #43) has a behavior concern r/t (related to) Sexual Disorder. (Resident #43) has a history of inappropriate touching of other residents and staff, typically female and history of inappropriate social behaviors in the past. Date Initiated: 10/01/2024. Interventions: (Resident #43) will be assisted by staff last into meals/activities and will seat (sic) at an area with males only. Last in the dining area and first out of meals and activities. Date Initiated: 10/17/2024 .Review of Resident #43's Progress Note dated 12/10/25 and documented by Licensed Practical Nurse (LPN) J revealed, This writer was walking to the top of the hall near the nurse's station and heard (Resident #67) yelling that he (Resident #43) grabbed her butt .Review of Resident #43's Progress Note dated 12/11/25 and documented by SW H revealed, This writer spoke privately with (Resident #43) in my office. (Resident #43) stated that he is aware that he touched a woman inappropriately in the facility . (Resident #43) has a history of this behavior. He showed remorse and stated he knows it's not right . Review of Resident #43's Progress Note dated 12/15/25 and documented by SW H revealed, This writer spoke privately with (Resident #43) in my office This writer asked him how his safety plan was going, to keep his hands to himself. (Resident #43) asked How did you know about that? . (resident #43) was smiling and seemed content .Review of the facility's Facility Reported Investigation (FRI) dated 12/15/25 revealed, Incident Summary: Resident #67 was standing in the common area, speaking to Certified Nursing Assistant (CNA) O. Resident #43 was propelling in his wheelchair behind Resident #67 when he reached out, making contact with her buttocks. The CNA (CNA O) separated residents immediately . Resident follow up: The police showed up to the facility on [DATE] at 10:30 AM. The officer followed up with (Resident #43), according to the officer, (Resident #43) was unable to recall the situation that had occurred on the evening of 12/10/25 . Social Services followed up with (Resident #43) later in the morning, and he was able to recall being inappropriate with a female resident. (Resident #43) was remorseful, began crying and stated he knows it's not right. On 12/12/25, when Social Services followed up with Resident #43, he could not recall the occurrence . Social Services followed up with (Resident #67). (Resident #67) said she was upset that the occurrence happened, but is feeling calm now . The Administrator (NHA) A followed up with this resident as well, (Resident #67) expressed that she understands that (Resident #43) has cognitive complexities and she is not afraid of him. (Resident #67) agreed that she would stay away from (Resident #43) and requested to be moved to a different unit .Conclusion: Based on the findings of the investigation, review of the clinical record, and interviews with staff members and residents, a decisive conclusion was made that the occurrence could not be verified as abuse or neglect . During an interview on 5/5/2026 at 8:11 AM, Resident #67 reported she was walking out of the dining room after dinner on 12/10/25 and she had stopped to chat with CNA O. Resident #67 reported that Resident #43 had followed behind her from the dining room to the nurse's station where he approached her and grabbed her butt. Resident #67 reported that she was very pissed and was so close to hitting Resident #43 because she was tired of him going after women in the facility. Resident #67 reported that CNA O immediately intervened and told Resident #43 not to touch women, like they always tell him, but he doesn't care. Resident #67 reported that she was worried about being on the same hall as Resident #43, so she was willing to move rooms to stay away from him. Resident #67 reported that she felt like the facility responded appropriately after the incident occurred, but she wished that they were able to keep a better eye on Resident #43 because those kinds of things should never happen. During an interview on 5/4/2026 at 3:27 PM, Licensed Practical Nurse (LPN) J reported she was the nurse caring for Resident #43 when he approached Resident #67 and grabbed her butt. LPN J reported she did not observe Resident #43 grab Resident #67, but she had heard Resident #67, so she went to the nurse's station where CNA O had told her that Resident #43 had exited the dining room and grabbed Resident #67's butt. LPN J reported Resident #43 had a history of touching females inappropriately and staff needed to monitor him around female residents at all times. During an interview on 5/4/2026 at 2:08 PM, SW H reported she had been made aware on 12/11/25 that Resident #43 had approached Resident #67 and grabbed her butt. SW H reported Resident #43's brother had reported to her that Resident #43 had a history of sexually inappropriate behavior towards women. SW H reported that she felt that Resident #43's actions were not intentional, but that he was just reaching in general. SW H then confirmed that Resident #43 had reported to her that he knew what he had done was not right. This writer attempted to reach CNA O via telephone on 5/05/2026 at 11:32 AM. This writer was unsuccessful in speaking to CNA O prior to survey exit.During an interview on 5/5/2026 at 11:47 AM, NHA A reported he was aware that Resident #43 had a history of inappropriately touching females. NHA A confirmed that the incident had occurred in a common area as Resident #43 was exiting the dining room without staff assistance. When this writer queried about Resident #67's care plan intervention for staff to assisted Resident #43 last into meals/activities and will keep Resident #43 at an area with males only. Last in the dining area and first out of meals and activities, NHA A reported he was not aware of that intervention, and he had missed that staff had not escorted Resident #43 out of the dining area. NHA A reported that he felt that the incident between Resident #43 and Resident #67 did not rise to level of abuse because Resident #67 had reported to him that she understood that Resident #43 had cognitive complexities and she was not offended or that Resident #43 had meant to harm her. NHA A confirmed that Resident #67 had voiced frustration and requested to be moved to another hall to get away from Resident #43. Review of the facility's Abuse policy dated 6/28/25 revealed, Policy: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. This includes but is not limited to freedom from any physical or chemical restraint not required to treat the resident's medical symptoms . Types of sexual abuse: Sexual is defined as non-consensual sexual contact of any type with a resident. Generally, sexual contact is nonconsensual if the resident either: appears to want the contact to occur but lacks the cognitive ability to consent; or does not want the contact to occur . 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, and coerced nudity; forced observation of masturbation and/or pornography; and taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g. posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident .

Based on interview and record review the facility failed to ensure that written bed hold notice was provided to 1 (Resident #95) of 3 residents reviewed for transfer and discharge from the facility.Findings include:Resident #95 Review of an admission Record revealed Resident #95 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: malignant neoplasm (cancer that has spread to other parts of the body), weakness, and hypertension (high blood pressure). Review of a Minimum Data Set (MDS) assessment for Resident #95, with a reference date of 2/9/26 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #95 was mildly cognitively impaired.Review of Progress Note for Resident #95 dated 2/11/26 at 14:35 (2:35 PM) revealed .they recommended transfer to ED (emergency department) for eval (evaluation).Resident notified.(Name Omitted) provider notified and ordered to transfer.Review of Progress Note for Resident #95 dated 2/11/26 at 15:14 (3:14 PM) revealed Resident transferred to ED at this time vial ambulance on a stretcher.Review of Resident #95's medical record revealed no noted bed hold policy form and/or documentation that a bed hold was provided to Resident #95 prior to her transfer to the ED on 2/11/26.In an electronic communication (E-mail) on 5/4/26 at 3:17 PM, Nursing Home Administrator (NHA) A reported he was unable to provide a written bed hold policy that was provided to Resident #95 before her transfer on 2/11/26.In an interview on 5/5/26 at 1:18 PM, Agency Licensed Practical Nurse (LPN) M reported there was a packet of paperwork that needed to be set with a resident when they transferred to the hospital, but she was unsure what forms were in the packet.In an interview on 5/5/26 at 1:18 PM, LPN F reported there was a packet that went with a resident who was transferred to the hospital and sometimes that packet was forgotten.In an interview on 5/5/26 at 1:30 PM, LPN F provided a document titled Discharge Checklist and reported the checklist should be used when a resident needed to be transferred to the hospital. LPN F reviewed the list with this surveyor and confirmed that a written bed hold needed to be provided to a resident prior to transfer. Review of Discharge Checklist with an effective date of 11/30/20 revealed .Discharge to hospital: Bed hold policy for hospital transfer or therapeutic leave.provide copy to patient and/or patient representative.Review of facility policy Bed Hold Policy revealed .Facility must provide a copy of this policy to the resident and an immediate family member or legal representative before and when a resident is transferred for hospitalization or therapeutic leave.In an interview on 5/5/26 at 10:25 AM, Interim Director of Nursing (DON) B reported bed holds not being provide to the residents was a problem. Interim-DON B reported the bed hold notice was in the transfer packets, but the nurses were not sending the packets with the residents at transfer.In an interview on 5/5/26 at 10:27 AM, NHA A reported the business office staff position was vacant, and he recently discovered the former business office staff was not completing the follow up with bed hold policy with residents and/or resident representatives. NHA A reported there was no staff follow up for bed hold notices with resident's who transferred out of the facility.

Based on interview and record review, the facility failed to review and revise a comprehensive, individualized plan of care after a resident-to-resident abuse incident for 1 (Resident #43) of 18 residents reviewed for care plans, resulting in the potential for unmet care needs and impaired physical, mental, and psychosocial well-being. Findings include:Resident #43 Review of an admission Record revealed Resident #43 was originally admitted to the facility on [DATE] with pertinent diagnoses which included bipolar disorder (mental health condition that causes severe mood swings) and other sexual disorder (used to classify other sexual disorders that involve atypical patterns of sexual behavior or development not covered by more specific categories.)Review of the facility's Facility Reported Investigation (FRI) dated 12/15/25 revealed, Incident Summary: Resident #67 was standing in the common area, speaking to Certified Nursing Assistant (CNA) O. Resident #43 was propelling in his wheelchair behind Resident #67 when he reached out, making contact with her buttocks. The CNA (CNA O) separated residents immediately . Resident follow up: The police showed up to the facility on [DATE] at 10:30 AM. The officer followed up with (Resident #43), according to the officer, (Resident #43) was unable to recall the situation that had occurred on the evening of 12/10/25 . Social Services followed up with (Resident #43) later in the morning, and he was able to recall being inappropriate with a female resident. (Resident #43) was remorseful, began crying and stated he knows it's not right. On 12/12/25, when Social Services followed up with Resident #43, he could not recall the occurrence . Social Services followed up with (Resident #67). (Resident #67) said she was upset that the occurrence happened, but is feeling calm now . The Administrator (NHA) A followed up with this resident as well, (Resident #67) expressed that she understands that (Resident #43) has cognitive complexities and she is not afraid of him. (Resident #67) agreed that she would stay away from (Resident #43) and requested to be moved to a different unit .Conclusion: Based on the findings of the investigation, review of the clinical record, and interviews with staff members and residents, a decisive conclusion was made that the occurrence could not be verified as abuse or neglect .Review of Resident #43's Care Plan revealed, Focus: (Resident #43) has a behavior concern r/t (related to) Sexual Disorder. (Resident #43) has a history of inappropriate touching of other residents and staff, typically female and history of inappropriate social behaviors in the past. Date Initiated: 10/01/2024. Interventions: (Resident #43) received psychiatric services from (local psych services provider). Date initiated: 12/22/25. (Noted that Resident #43 was already followed by psych services, and this was not a new intervention.) (Resident #43) will be assisted by staff last into meals/activities and will seat (sic) at an area with males only. Last in the dining area and first out of meals and activities, Staff will re-direct resident away from female residents when in common areas, BEHAVIORS: Inappropriate and unwanted touching of other residents, especially female residents. Report and document per facility protocol. CNAs to do a STOP & WATCH ALERT in POC (plan of care) if inappropriate behavior is observed, explain all procedures to the resident before starting and allow the resident time to adjust before proceeding, intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed, provide resident opportunity for positive interaction and/or attention, i.e.; engage in conversation during care, address by name when passing by, etc., Praise any indication of resident's progress/improvement in behavior, Assist (Resident #43) to develop more appropriate methods of coping and interacting, Encourage the resident to express feelings appropriately, Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Follow up as indicated, Discuss with medical provider, resident &/or family, i.e. ongoing need for use of medication. Review behaviors/interventions and alternative therapies attempted and their effectiveness as per facility policy, and consult with pharmacy and medical provider to consider dosage reduction when clinically appropriate per facility protocol. Date initiated: 10/1/24. Noted no new interventions were added after Resident #43's incident on 12/10/25. During an interview on 5/4/2026 at 2:08 PM, SW H reported she had been made aware on 12/11/25 that Resident #43 had approached Resident #67 and grabbed her butt. SW H reported Resident #43's brother had reported to her that Resident #43 had a history of sexually inappropriate behavior towards women. SW H was unable to report what new interventions had been placed in Resident #43's care plan to address Resident #43's sexually inappropriate behavior, and alternative ways to attempt to mitigate further behaviors from occurring. During an interview on 5/5/2026 at 11:47 AM, NHA A reported he was aware that Resident #43 had a history of inappropriately touching females. NHA A reported he had conducted the investigation after the resident-to-resident incident. NHA A was unable to report what interventions the facility had initiated after the incident to mitigate further behaviors from occurring with Resident #43. NHA A reviewed Resident #43's care plan with this writer and confirmed that the facility had missed updating Resident #43's care plan interventions after the resident-to-resident incident on 12/10/25. Review of the facility's Care Planning policy dated 1/15/20 revealed, Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. Procedure: .8. The Care Plan will be reviewed and revised by the IDT after each assessment and as the resident's care needs change .

Based on observation, interview and record review, the facility failed to implement pressure ulcer prevention interventions, consistent with professional standards of practice for 1 (Resident #42) of 1 resident reviewed for pressure ulcer prevention, resulting in the potential for the development of an avoidable pressure ulcer.Findings include:Resident #42Review of an admission Record revealed Resident #42 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia (a syndrome characterized by a progressive, irreversible decline in memory, thinking, behavior, and the ability to perform daily tasks), and moderate protein-calorie malnutrition (deficiency of proteins, calories and micronutrients absorption causing loss of muscle and body fat). Review of a Minimum Data Set (MDS) assessment for Resident #42 with a reference date of 2/11/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 0/15, which indicated the resident was severely cognitively impaired. Section GG revealed Resident #42 was dependent (helper does all the effort) for rolling in bed, transferring to a chair/bed. Section M of the MDS revealed Resident #42 was at risk for developing pressure ulcers.Review of a Care Plan for Resident #42 with a reference date of 12/9/25 revealed the following focus/goal/interventions: (Resident #42) is at risk for potential impairment of skin integrity.Goal: (Resident #42) will maintain intact skin.Interventions.elbow pads when up in (name of specialty wheelchair brand) chair, can remove when in bed.During an observation on 5/3/26 at 10:06am, Resident #42 was up in his specialty wheelchair in the common area of the memory care unit. Both elbows were resting directly on the armrest of the wheelchair, with no elbow pads in place.During an observation on 5/3/26 at 10:09am, a mint green elbow pad was noted on Resident #42's nightstand.During an observation on 5/4/26 at 12:51pm, Resident #42 was up in his specialty chair in the common area of the memory care unit. Resident #42 was wearing an elbow pad on his right elbow. The skin on Resident #42's left elbow was gathered in several folds as it rested directly on the armrest of the wheelchair. Resident #42's left forearm rested on his chest, making the skin on his elbow easily visible.During an interview on 5/5/26 at 12:12pm, hospice certified nursing assistant (CNA) HH reported he gave Resident #42 a shower this morning, but he was not sure if Resident #42 was wearing his elbow pads at this time.During an observation and interview on 5/5/26 at 12:15pm, Resident #42 sat in his specialty wheelchair, wearing a long sleeve shirt, with both elbows resting on the armrest of the wheelchair. Registered Nurse (RN) K gently touched Resident #42's elbows and confirmed the resident was not wearing elbow pads on either arm. When queried, RN K reported she had looked all over the building and could not find any elbow pads for Resident #42 this morning. RN K confirmed per physician's orders, Resident #42 was supposed to use bilateral elbow pads when he was out of bed to prevent skin breakdown on his elbows.Review of a Physician's Order for Resident #42 with a reference date of 2/13/26 revealed Apply elbow pads bilaterally while up and remove when in bed.Review of a Skin Monitoring and Management-Pressure Ulcer policy with a reference date of 7/11/18 revealed .Prevention: In order to prevent development of skin breakdown.nursing staff shall implement.use of pressure relieving/reducing devices.

Based on observation, interview, and record review, the facility failed to implement care plan interventions for fall prevention for 1 (Resident #58) of 3 residents reviewed for accidents, resulting in the potential for falls and injury. Findings include:Resident #58Review of an admission Record revealed Resident #58 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease (progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out daily tasks), lack of coordination and muscle wasting (reduction in muscle mass, strength and function). Review of a Minimum Data Set (MDS) assessment for Resident #58 with a reference date of 4/23/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 1/15, which indicated the resident was severely cognitively impaired. Section J revealed Resident #58 had a fall with injury since the previous assessment.Review of a Care Plan for Resident #58 with a reference date of 2/18/26 revealed the following focus/goal/interventions: (Resident #58) is at risk for fall r/t (related to) medical condition, muscle wasting .history of sacrum (shield shaped bone at the base of the spine) fracture. Goal: (Resident #58) will remain free from fall related injury.Interventions.sign on walker that says please take me with you.be sure call light is within reach.During an observation on 5/4/26 at 9:44am, Resident #58 was asleep, lying on her right side with her torso resting on the upper half of her bed. Resident #58's feet were planted on the floor next to her bed. Resident #58's call light was under the foot of the bed, near the wall, out of reach. The resident's walker sat nearby with the brakes locked but there was no sign on the walker.During an observation on 5/4/26 at 12:53pm, Resident #58 sat at the edge of her bed and ate her lunch. Resident #58's call light remained under the foot of her bed, near the wall, out of reach. The resident's walker sat nearby with the brakes locked but there was no sign on the walker.During an observation on 5/4/26 at 3:26pm, Resident #58 sat at the edge of her bed. Her call light was under her bed, behind her feet, out of reach. The resident's walker sat nearby with the brakes locked but there was no sign on the walker.During an observation on 5/4/26 at 3:28pm, Resident #58 emerged from her room and walked into the hallway without her walker. The resident's walker sat nearby with the brakes locked but there was no sign on the walker.During an observation on 5/4/26 at 3:28pm, Licensed Practical Nurse (LPN) FF and Activity Assistant (AA) BB approached Resident #58, reminded her she needed to use her walker when she walked, encouraged the resident to sit back down on her bed and left the room after the resident was seated.During an observation on 5/4/26 at 3:30pm, Resident #58 sat at the edge of her bed, her call light remained on the floor, behind her feet, out of reach.In an interview on 5/4/26 at 3:57pm, Certified Nursing Assistant (CNA) II reported Resident #58 sometimes used the call light to alert the staff that she needed something.

Based on observation, interview, and record review the facility failed to develop and implement person-centered dementia care interventions based on lifelong habits and personality for 2 (Resident #63 and Resident #18) of 7 residents reviewed for dementia care, resulting in Resident #63 experiencing agitation and avoidable stress and Resident #18 breeching other residents' personal space, being yelled at and at risk for aggressive responses from others.Findings include: Review of The Unmet Needs Model, [NAME]-[NAME] and [NAME] (1995), revealed that those with dementia develop problem behaviors from an imbalance in the interaction between life-long habits and personality, current physical and mental states and less than optimal environmental conditions.Review of Revenge of the Introvert, Psychology Today 2010, revealed .Rather than being averse to social engagement, introverts become overwhelmed by too much of it. they.seem to process more information than others in any given situation. To digest it, they do best in quiet environments, interacting one on one. Solitude, quite literally, allows introverts to hear themselves think.Review of Nicotine Withdrawal, https://my.clevelandclinic.org/health/diseases/21587-nicotine-withdrawal, revealed Nicotine withdrawal is the physical and psychological symptoms you feel when you.reduce use of nicotine. Common symptoms include cravings, irritability.feeling frustrated, angry.feeling anxious or jumpy.trouble concentrating.Resident #63Review of an admission Record revealed Resident #63 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: anxiety disorder (a group of mental health conditions characterized by persistent, excessive, and uncontrollable fear, dread and worry that interferes with daily life), major depressive disorder (persistent low mood, sadness, or a significant loss of activities lasting at least two weeks), vascular dementia without behaviors (a declined in thinking skills caused by conditions that block or reduce blood flow to the brain) and personal history of nicotine dependence (a chronic, compulsive brain disorder resulting in a person becoming physically and psychologically addicted to nicotine).Review of a Minimum Data Set (MDS) assessment for Resident #63 with a reference date of 4/27/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 3/15, which indicated the resident was severely cognitively impaired. Section D revealed Resident #63 reported feeling down, depressed, or hopeless 2-6 days of the 14-day assessment period. Section F of the MDS revealed it was very important to Resident #63 to do his favorites activities and to go outside when the weather was good.Review of a Care Plan for Resident #63 with a reference date of 4/15/26 revealed the following focus/goal/interventions: 1. Focus: (Resident #63) has a behavior concern r/t (related to) exhibition of behavior agitation with residents and staff. Goal: (Resident #63) will have fewer episodes.of yelling or threatening hitting or kicking.Interventions: (Resident #63) is a smoker. He may be craving a cigarette. Offer him a smoke break.offer (brand of soda), chocolate, and (brand of potato chips) when he is agitated.intervene as necessary to protect the rights and safety of others.2. Focus: (Resident #63) will need encouragement to meet emotional, intellectual, physical, and social needs.Goal (Resident #63) will attend/participate in activities of choice.Interventions:.record (Resident #63's) prior level of activity involvement and interests by talking.with family.provide a program of activities that are of interest and empowers (Resident #63) by encouraging/allowing choice, self-expression.During an observation on 5/3/26 at 10:36am, Resident #63 walked down the hall of the memory care unit; Resident #18 walked next to him while making rapid, continuous, incoherent vocalizations. Resident #18 walked on Resident #63's right side. While walking, Resident #63 made eye contact with the surveyor, raised his eyebrows and widened his eyes, then quickly brought his right fist tightly to his chest, pointed his right elbow outward, toward Resident #18 and made a rapid jabbing motion toward her with his elbow, indicating he wanted to hit the other her. Resident #63 rolled his eyes as he gestured toward the other resident. When queried if he was ok, Resident #63 stated Maybe!, then rolled his eyes, tilted his head toward Resident #18 and shrugged his shoulders.In an interview on 5/4/26 at 1:27pm, Registered Nurse (RN) K reported Resident #63 became frustrated with other residents when they walked near and/or made frequent vocalizations. RN K reported Resident #63 yelled Get out of here! at Resident #18 earlier on this date. When further queried, RN K reported Resident #63 usually sat in the same recliner in the common area each day and when Resident #18 got near him, or other residents were laughing nearby, Resident #63 became agitated. RN K reported she tried to place a storage shelf and end tables around Resident #63's chair to keep other residents from getting too close to him, but that proved ineffective. RN K reported recently she heard Resident #63 yelling and found him standing with a raised fist directed toward another resident that was near his chair. RN K reported most of the time, Resident #63 was agitated by Resident #18 because she walked near him quite often, picked up whatever items she saw and was very vocal.In an interview on 5/4/26 at 3:50pm, Social Worker (SW) H reported she coordinated individualized dementia care interventions to reduce stress responses (behaviors) for Resident #63. SW H reported Resident #63 had been happy lately and was very laid back. SW H confirmed she was not aware of any instances of Resident #63 becoming stressed by the presence of other residents in the last several weeks. When queried if staff ever encourage Resident #63 to go to an area that would provide less stimulation when he was stressed, SW H stated No, we don't want him to self-isolate.Review of the Medication Administration Record for Resident #63, with a reference period of February-May 5, 2026, revealed no documented episodes of Resident #63 demonstrating agitation toward other residents.During an observation on 5/3/26 at 12:11pm, Resident #63 sat in the common area in his favorite recliner, surrounded by residents playing a balloon batting game. Resident #63 refused to participate; his right knee bounced up and down rapidly throughout the time the activity was underway.During an observation on 5/4/26 at 2:15pm, Resident #63 sat in a recliner in the common area of the memory care unit, 7 other residents, 2 staff and 2 family members were present. The family members sat next to Resident #63 and assisted another resident with opening some gifts. The family members spoke cheerfully with excitement as the unknown resident opened her gifts, staff were talking with other residents, and the television was playing an animated movie. Resident #63 sat with a furrowed brow, his right knee bouncing up and down rapidly, his hands rested on the arms, gripping the armrests firmly. Resident #63 stared straight ahead. No intervention was offered to Resident #63.In an interview on 5/4/26 at 3:35pm, Licensed Practical Nurse (LPN) FF reported Resident #63 was easily agitated by other residents and various stimulus in the common area of the memory care unit. LPN FF reported Resident #63 appeared protective of the recliner he often used in the common area and yelled at others if they came near the area immediately surrounding the chair. LPN FF reported Resident #63 seemed stressed by the family members visiting their loved one near him on this date.During an observation on 5/5/26 at 9:16am, Resident #63 sat in a recliner in the common area of the memory care unit. The room was quiet; all residents in the room were resting. The television was playing softly. Resident #63 appeared calm, no expression on his face, his legs were still.In an interview on 5/4/26 at 9:38am, RN K reported Resident #63 used to like to smoke after meals and she knew some staff took him outside for smoke breaks, but it did not happen on a scheduled basis. RN K reported at times, Resident #63 would approach her by the medication cart, near the door he exited for smoke breaks, and his hands were shaking which she believed was symptom of him wanting to go outside to smoke. When Resident #63 approached her in that manner, she coordinated with staff so he could go outside to smoke. RN K reported Resident #63 could no longer consistently verbalize his needs. RN K stated When I'm here, I ask them (staff) not to offer.to take him out to smoke, unless he comes up to me and his hands are shaking. RN K reported she did not think Resident #63 remembered that he liked to smoke. RN K reported the physician had discussed potentially placing Resident #63 on a nicotine patch but that had not happened.In an interview on 5/4/26 at 10:31am, Activities Director (AD) EE confirmed it was important to gather information about each residents lifelong interests and social patterns from family members if the resident could not communicate the information, because each resident should have individualized care.In an interview on 5/4/26 at 2:11pm, Activity Assistant (AA) BB reported Resident #63 did not like to participate in most group activities. AA BB reported Resident #63 was easily overwhelmed and frequently became agitated toward other residents while he was in the common area of the memory care unit. AA BB reported Resident #63 yelled at other residents when he was agitated, especially Resident #18.In an interview on 5/4/26 at 3:41pm Certified Nursing Assistant (CNA) GG reported Resident #63 regularly demonstrated agitation toward other residents in the common area, but appeared calm when he was in a quiet place and he liked to watch television in his room.In an interview on 5/5/26 at 8:30am, SW H reported Resident #63 has behaviors and will smoke to help with them, but she did not believe the behaviors were being documented. SW H reported Resident #63 was supposed to have scheduled smoking times. When queried, SW H reported she knew LPN FF took Resident #63 out to smoke when he worked. Director of Nursing (DON) B reported Resident #63's communications skills were declining but at times he voiced that he wanted a cigarette. DON B reported Family Member (FM) DD regularly took Resident #63 on a leave of absence and allowed him to smoke.In an interview on 5/5/26 at 8:56am, Licensed Practical Nurse (LPN) CC reported Resident #63 sat in the common area and watched television most of the time but was easily agitated by other residents and recently yelled, Shut the f### up! at other residents in the common area. LPN CC reported staff did not encourage Resident #63 to spend any time in his room because he would have to lay in his bed and anytime, he did so, he fell asleep. LPN CC reported having a recliner in Resident #63's room would very useful because he could watch television and not be disturbed by other residents. Review of a Provider Note for Resident #63 with a reference date of 4/2/26 revealed Agitation.Pt's (patient's) agitation is labile, unknown trigger at this time.Review of a Psychiatry Follow Up report for Resident #63 with a reference date of 4/8/26 revealed .progress notes show episodes of increased anxiety, agitation and confusion.facility staff report that he gets angry, irritable and may attempt to swat or kick when other residents are by him.He states, my mood has not been good.In an interview on 5/5/26 at 4:37pm FM DD reported? no one at the facility had asked him about Resident #63's lifelong preferences or leisure interests. FM DD reported throughout his life, Resident #63 preferred to keep to himself, and didn't enjoy being around crowds of people. FM reported he took Resident #63 on leave of absence regularly and upon returning to the facility, Resident #63 always wanted to smoke a cigarette. FM DD reported he though staff were assisting Resident #63 with smoking several times a day, per Resident #18's preference. FM DD reported Resident #63 had smoked for many years and it was important to him.Resident #18Review of an admission Record revealed Resident #18 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills) and generalized anxiety disorder (mental health condition characterized by persistent feelings of worry and restlessness).Review of a Minimum Data Set (MDS) assessment for Resident #18 with a reference date of 2/26/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 2/15, which indicated the resident was severely cognitively impaired. Section E of the MDS revealed Resident #18 wandered daily and her wandering had worsened since the previous assessment.Review of a Care Plan for Resident #18 with a reference date of 6/2/25 revealed the following focuses/goals/interventions: 1. Focus: (Resident #18) spends time walking around in the unit pick up sensory items.Goal: (Resident #18) will participate in activities of choice 3-5 times daily.Interventions:.offer to set up table top activities for (Resident #18) to stack or fold.encourage (Resident #18) to participate in activities of interest such as music, picture books and sensory stimulation activities.2. Focus: (Resident #18) .exhibits wandering behavior.Goal: minimize risk of elopement. Interventions: (Resident #18) likes to go in and out of other peers rooms. Distractions (sic) and redirect (Resident #18) from going into and out of peers rooms.Identify pattern of wandering.provide visual reminders and or deterrents to high-risk locations. Of note, there were no interventions to address Resident #18 entering Resident #63's personal space or related to the conflicts between Resident #18 and Resident #63.During an observation on 5/3/26 at 12:18pm, Resident #18 wandered into room [ROOM NUMBER] on the memory care unit. A resident within the room was heard yelling at Resident #18, Out, Out, Out!.During an observation on 5/5/26 at 11:59am, Resident #18 wandered into Resident #63's room. The Stop Sign door sign was not in place.Review of a Psychiatry Follow Up progress note for Resident #18 with a reference date of 4/22/26 revealed .Facility staff report she (Resident #18) wanders in and out of other residents' rooms.Review of a Philosophy of Dementia Care policy with reference date of 1/1/2020 revealed The dementia care philosophy within the facility embraces a person-centered, relationship-based approach which supports the quality of life that respects the dignity, identify and individual needs of each person.We are committed to understanding and meeting each person's needs, preferences, and desires in a safe environment that is tailored to meet his/her stage specific needs.Review of a Memory Care Program/Clinical Approach policy with a reference date of 1/1/2020 revealed .truly individualized care requires a shift from control of behavior to one more attuned to allowing and supporting the person to be his/her own unique self.Using the reasonable person concept, though Resident #63 could not verbally express his feelings, it is reasonable to assume he experienced frustration and anxiety when his lifelong preferences were not supported.Using the reasonable person concept, thought Resident #18 could not verbally express her feelings, it is reasonable to assume she would not want to experience being yelled at by other residents, would not want to risk being the target of additional acts of aggression, and would want support in respecting the personal space of others.

Based on interview and record review, the facility failed to maintain accurate and complete medical records for 1 of 18 residents (Resident #5) reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents. Findings include:Resident #5 Review of an admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included depression and visual hallucinations. Review of Resident #5's Letters of Conservatorship dated [DATE] revealed that Resident #5 was appointed a conservator (A person or organization appointed by a court to manage the personal care, financial affairs, or both, of an adult who cannot handle these responsibilities independently.) The letter of conservatorship expiration date was [DATE] . Notice concerning letters of conservatorship. All new and reissued letters of conservatorship will expire annually, 8 weeks beyond after the anniversary date of the appointment of the conservator . Noted that [DATE] was the date of 8 weeks past [DATE], when the letter of conservatorship expired. During an interview on [DATE] at 1:56 PM, Social Worker (SW) H reported she was aware that Resident #5's conservatorship was expired. SW H reported she reached out to Resident #5's conservator for updated conservatorship paperwork on [DATE] and had not received any communication back. SW H reported she had not followed up since. SW H reported that the facility should review guardianship/conservatorship paperwork quarterly at resident care conferences. Review of Resident #5's Care Conference note dated [DATE] did not include notes regarding the discussion of Resident #5's conservatorship paperwork. Review of the facility's Advance Directive Action Plan dated [DATE] revealed, Assessment: The facility identified that updated guardianship paperwork was not being obtained, and code statuses were still being signed by the guardian on file. Action Steps: SW completed a guardianship audit to identify who we needed to request documents for . Status Report: Completed on [DATE]. SW reached out to guardians to request updated documents and verify code status signatures were appropriate . Status Report: Completed on [DATE]. Review of email dated [DATE] that SW H sent to Resident #5's conservator revealed, Hi (Name redacted), I was wondering if you could please provide the facility a copy of the updated guardianship paperwork for (Resident #5?) . no response by Resident #5's guardian was provided. Noted that SW H did not provide verification that she had reached out to Resident #5's conservator prior to [DATE], which conflicts with the facility's Advance Directive Action Plan which noted that SW H had reached out to all facility guardians/conservators to obtain updated paperwork on [DATE]. Review of email dated [DATE] received from Nursing Home Administrator (NHA) A sent to Resident #5's conservator revealed, Hi (name redacted) . I am the Administrator . I wanted to reach out and see if you are able to provide us with updated guardianship paperwork for (Resident #5) .During a follow up interview on [DATE] at 8:26 AM, SW H reported she had called Resident #5's conservator on [DATE], and that Resident #5's conservator did not realize that Resident #5's conservator paperwork was expired, and that she was going to follow up with the court regarding this. SW H reported that moving forward, she would be utilizing a spreadsheet to track paperwork that would be expiring soon so she could follow up with guardians sooner.

This citation pertains to intake #2674240Based on observation, interview and record review, the facility failed to protect the residents' right to be free from resident-to-resident physical abuse for 2 (Resident #103 and Resident #104) of 4 residents reviewed for abuse resulting in Resident #104 grabbing Resident #103 by the arm, and Resident #103 slapping Resident #104 in the face.Findings include:Resident #103Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills) and generalized anxiety disorder (mental health condition characterized by persistent feelings of worry and restlessness).Review of a Minimum Data Set (MDS) assessment for Resident #103 with a reference date of 11/29/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 0/15, which indicated the resident was severely cognitively impaired.Review of a Care Plan for Resident #103 with reference date of 6/2/25 revealed the following focus/goal/interventions Focus: (Resident #103) spends time walking around in the unit picking up sensory items.Goal: Resident will participate in activities of choice.Interventions.staff will.offer cues and prompts as needed. Resident #103 did not have a care plan related to picking up other residents' belongings.Review of an Incident Report with a reference date of 11/13/25, authored by Nursing Home Administrator (NHA) A revealed Perpetrator Name: Resident #103, name omitted. Witnesses: FM EE, name omitted. Incident summary: (Resident #103) was walking by (Resident #104) and picked (Resident #104's) gloves up. Resident #103 walked away.Resident #104 followed her and took ahold of her (Resident #103) arm. (Resident #103) made open hand contact with Resident #104's face.In an interview on 2/26/26 at 3:47pm, Resident #103's Durable Power of Attorney (DPOA) DD reported the facility had contacted her on 11/13/25 and reported she hit another resident in the face after the resident grabbed Resident #103 by the arm. DPOA DD reported Resident #103 could no longer successfully express her emotions, but in the past, she would have been upset if someone was physically aggressive toward her and would have reacted. DPOA DD reported Resident #103 walked around the unit and picked up various items frequently.During an observation on 2/26/26 at 1:30pm Resident #103 was standing in the dining area. Approximately 15 other residents were seated at the tables, awaiting lunch. Resident #103 wandered around the room, then walked down the hall and entered another resident's room.In an interview on 2/26/26 at 1:35pm, Licensed Practical Nurse (LPN) E reported Resident ##103 walked around and explored her environment by picking items up frequently but did not have the capacity to consider ownership of the items she was handling. Resident #104Review of an admission Record revealed Resident # 104 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia (a decline in mental ability-specifically memory, thinking and reasoning), major depressive disorder (a serious mental health condition characterized by persistent, intense feelings of sadness, worthlessness, and loss of interests) and suicidal ideation (thoughts or preoccupations with ending one's own life).Review of a Minimum Data Set (MDS) assessment for Resident #104 with a reference date of 11/14/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 12/15, which indicated the resident was moderately cognitively impaired.Review of a Care Plan for Resident #104 with a reference date of 5/29/25 revealed the following focus/goal/interventions: Focus: (Resident #104) is at risk for a psychosocial well-being concern r/t (related to) Suicidal Ideation.history of attempting suicide. Goal: The resident will have no indications of psychosocial well-being problem. Interventions.when conflict arises, remove residents to calm safe environment. Resident #104 had no care plan related to her frustration with peers.Review of a Progress Note for Resident #104 with a reference date of 11/13/25 revealed This writer spoke with (Resident #104) about a disagreement she had with another resident about her gloves. I asked if she was still upset that.she stated that she was upset at first.Review of a Psychiatry Initial Evaluation for Resident #104 with a reference date of 2/11/26 revealed .Social/Psychiatric.She argues with another resident at facility.current symptoms include anxiety, depression, irritability.In an interview on 2/26/26 at 3:24pm, Resident #104 was unable to recall the altercation that took place on 11/13/25.In an interview on 2/26/26 at 4:02pm, Certified Nursing Assistant (CNA) Q reported she did not witness the altercation between Resident #103 and Resident #104, but she did know that Resident #104 felt frustrated by the actions of other residents and would respond by yelling at them.In an interview on 2/26/26 at 2:27pm, Family Member (FM) BB reported on 11/13/25 at approximately 2:30pm, in the dining area of the memory care unit, she witnessed a physical altercation, during which Resident #104 grabbed Resident #103 by the arm and Resident #103 slapped Resident #104 in the face. FM BB reported Resident #103 walked past Resident #104 and picked up a pair of gloves that were next to Resident #104. FM BB reported as Resident #103 carried the gloves and began walking down the hall, Resident #104 went after her (Resident #103), forcefully grabbed Resident #103's arm and pulled back in a manner that caused Resident #103 to turn around. Resident #103 then slapped Resident #104 on the side of her face. FM BB reported Resident #104 appeared angered after being struck in the face and stated, She slapped me in the face!. Using the reasonable person concept: (a legal concept that describes what a fictitious person of ordinary [NAME] would do under the circumstances), 1. Resident #103 would not want to be grabbed forcefully by the arm and would experience frustration and anxiety because of that act. 2. Resident #104 would not want to be slapped in the face as she tried to retrieve her own belongings and would experience pain, frustration, anger and anxiety because of this act. Review of a Resident Rights, Abuse and Neglect policy with a reference date of 6/28/25 revealed POLICY: It is the policy of the facility to provide professional care.in an environment that is free from any type of abuse.Types of Abuse and Examples: Physical: Physical abuse includes but not limited to infection of injury.Example: hitting, slapping.grabbing.

Based on observation, interview, and record review the facility failed to ensure 2 rooms (Resident #61's room and the Spa room between C and D hall) were maintained in a sanitary and orderly manner and failed to ensure a home-like dining environment for 1 (the locked memory care unit's dining room; Living Moments Lane) of 2 dining rooms resulting in being unsatisfied, having a dining experience with an institutionalized practice rather than home-like, and the potential for feelings of sadness and/or discontent with one's living environment. Findings include: During an observation on 04/01/25 at 08:36 AM, in the locked memory care unit, residents dining in the unit's dining room at all tables were served their breakfast meals on top of trays that were placed on top of the dining table and left there for the duration of the meal. During an observation on 04/01/25 at 01:14 PM, in the locked memory care unit, residents dining in the unit's dining room at all tables were served their lunch meals on top of trays that were placed on top of the dining table and left there for the duration of the meal. During an observation on 04/02/25 at 08:15 AM, residents were observed in the facility's main dining room (where resident's from the three of the four units could dine at; the other unit is the locked memory care unit) eating breakfast, and meals were not left on the tray. Instead of placing the meal trays on the dining table that held the cup, bowl, plate, and silverware the dining ware items were taken off the tray and placed in front of the resident directly onto the dining table in front of residents. During an observation on 04/02/25 at 08:32 AM, in the locked memory care unit, residents dining in the unit's dining room at all tables were served their breakfast meals on top of trays that were placed on top of the dining table and left there for the duration of the meal. During an interview on 04/02/25 at 09:08 AM, Dietary Director UU reported she doesn't know why the locked memory care unit served the meals on the trays in the dining room but the main dining room doesn't serve that way. Dietary Director UU reported the dietary staff put the food on the trays to be placed in the meal carts to be taken to the units/dining rooms and then nursing staff handle the trays from there. During an interview on 04/02/25 at 09:45 AM, Director of Nursing (DON) B reported meals should not be served on trays on the table in the dining rooms within the facility. DON B confirmed the meals shouldn't be served differently, on the trays on the table in the dining room, of the locked memory care unit. During an interview on 04/02/25 at 10:07 AM, Certified Nurse Aide (CNA) VV reported in the locked memory care unit staff served residents' meals on the trays on the dining room's tables, but in the other part of the building (the dining room where the other three units' residents can dine) food is taken off the trays and put on the table in front of the residents. CNA VV reported this way of serving differently based on the unit was how it has been done and stated, Just doing what I'm told. CNA VV reported she doesn't know why it is done this way in the locked unit but not out in the non-locked dining area of the building. Review of the facility's Meal Service, Nursing Responsibility policy, adopted 7/11/2018, stated, Be courteous and encourage an enhanced, pleasant dining atmosphere. Resident's in the facility's locked memory care unit's are placed there due to impaired cognitive status and therefore during interviews were unable to report if being fed on trays on the dining table bothered them or not, or how they had dined at home prior to admission to the unit. Applying the reasonable person concept, meals served on trays which are placed on the table in front of the diner can increase the institutional feel of the dining environment and make it less home-like. A reasonable person likely would choose to not be served meals on trays in a dining room. 38384 R61 According to the Minimum Data Set (MDS) dated [DATE], R61 was cognitively intact as evidenced by her BIMS (Brief Interview Mental Status) score of 14/15. During an observation and interview on 3/31/25 at 12:15 PM, R61 was awake in bed with her head-of-bed (HOB) at the window. The windowsill track was littered with dead bugs, dust, and debris. The tile sill was cracked and chipped with a large chunk of it missing. The veneer around the bed head board was pulled away from the wood leaving an area large enough to put a hand through. R61 stated, I keep my house neat, tidy, and clean. I would never have my house like this. I have a handyman that helps me at home to keep things fixed. I'm glad I'm going home tomorrow. During an observation and interview on 4/1/25 at 8:00 AM, the window curtain at R61's HOB had a stain the size of a saucer cup at eye level of the resident. R61 stated, I'll be glad when I go home today. I would have stains like this cleaned up. 38905 During a tour of the spa room between the C hall and D hall, with Maintenance Director (MD) DD, at 2:46 PM on 3/31/25, observation found a padded shower chair with stuck on and smeared brown debris. When asked if he could see the accumulation, MD DD, stated yes. Observation of the supply and stock cabinet in the spa room, found black spotted debris on the inside walls of the top left door of the cabinet. Further interview with MD DD found that the facility is planning to do some renovations in the spa room and remove the cabinet at some point.

Based on observation, interview, and record review, the facility failed to maintain professional standards of nursing practice and notify the provider of missed medication doses, 2 of 19 residents (Resident #6 and Resident #338) reviewed for professional standards, resulting in missed medications and treatments, and the potential for the worsening of a condition and a delay in treatment. Findings include: 47659 Resident #6 Review of an Admission Record revealed Resident #6 was originally admitted to the facility on [DATE] with pertinent diagnoses which included atrial fibrillation (irregular rapid heart rate that commonly causes poor blood flow). Review of Resident #6's Medication Administration Orders (MAR) revealed, Symbicort Inhalation Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) (combination inhaler used to treat asthma and chronic obstructive pulmonary disease) 2 puff inhale orally every morning and at bedtime . During a medication administration observation on 4/1/25 at 8:19 AM, Licensed Practical Nurse (LPN) Y was preparing Resident #6's morning medications and reported that she could not find Resident #6's inhaler. LPN Y reported that the inhaler must not have been re-ordered so she would not be able to give Resident #6 her ordered morning dose of the inhaler medication. LPN Y reported that nurses were responsible for re-ordering medications when they were low, and that many of the staff were not good at re-ordering medications. LPN Y reported that is was common for residents to miss medications when they were not re-ordered timely and that she would need to order the medication. During a follow up interview on 4/1/25 at 12:11 PM, LPN Y reported that she did not notify the facility's medical doctor that Resident #6 had missed her morning dose of Symbicort. LPN Y reported that she didn't think it was necessary to contact the facility's medical doctor because it was just an inhaler. Resident #338 Review of an Admission Record revealed Resident #338 was originally admitted to the facility on [DATE] with pertinent diagnoses which included hypertension (high blood pressure). Review of Resident #338's MAR revealed, Coreg Oral Tablet 3.125 MG (Carvedilol) (blood pressure medication). Give 1 tablet by mouth two times a day for HTN (hypertension) hold dose if SBP (systolic blood pressure) less than 90 or HR (heart rate) less than 50. Review of Resident #338's MAR revealed, Enteral Feed Order two times a day for prevent clogging. Flush q12 hours with 60 ml water via PEG (tube inserted into the stomach and used to provide medication and nutrition when a person is unable to eat or drink normally). Start date 4/1/25 During an medication administration observation and interview on 04/01/25 08:00 AM, LPN Y reported that the facility did not have any of Resident #338's medications available because Resident #338 was readmitted to the facility the day before, and she did not know if the nurse that readmitted Resident #338 yesterday had ordered the medications. LPN Y also reported that Resident #338 was readmitted with a peg tube used for tube feeding, but Resident #338 did not have feeding tube orders in place. LPN Y reported that she did not know if Resident #338 was supposed to receive enteral feedings, or flushes for her peg tube, and that she was going to have to ask the Unit Manager about Resident #338's feeding tube. LPN Y reported that she was able to obtain most of Resident #338's medications from the facility's Pyxis (automated medication dispensing system), but that the facility did not have Resident #338's Coreg medication, so Resident #338 would miss her morning dose of Coreg. LPN Y reported that nurses were responsible for ordering medications for residents when they were admitted to the facility as well as re-ordering medications before a resident ran out. LPN Y did not know the process for when nurses were expected to re-order resident medications, and reported she would typically reorder medications when there were 2-3 days of the medication left. During an interview on 4/02/25 at 12:06 PM, Registered Nurse (RN) FF reported that nursing staff at the facility were not good at reordering medications, and residents often missed medications because the facility did not have them. RN FF confirmed that she did not know the policy for re-ordering medications, but that she would reorder them when there were 3-4 days left. RN FF reported that when a resident missed a medication she would use her judgement on if she should notify the provider or not. During an interview on 4/2/25 at 12:12 PM, Unit Manager (UM) BB reported that nurses were responsible for calling the pharmacy when a resident is admitted to the facility to ensure that the medications would be delivered before their next dose is due. UM BB confirmed that nurses were also responsible for reordering medications for residents, and were suppose to order them when the resident had 5 doses remaining. UM BB confirmed that nurses were expected to notify the provider anytime a resident missed a medication. UM BB reported that two nurses were supposed to be review admission orders with a second nurse to ensure accuracy of orders. During an interview on 4/2/25 at 12:36 PM, UM CC confirmed that she was the Unit Manager for the unit that Resident #338 resided on. UM CC reported that she had not been notified by LPN Y that Resident #338 did not have orders in place for her feeding tube. UM CC reviewed Resident #338's electronic medical record (EMR) with this writer and confirmed that the facility had not put orders in place for Resident #338's feeding tube until 4/1/25, which was 24 hours after she was admitted . UM CC confirmed that Resident #338 had missed her feeding tube being flushed on 3/31/25 and the morning flush on 4/1/25. UM CC reported that nursing staff should have followed the hospital discharge orders for Resident #338, and she should have not missed any care for her feeding tube. UM CC confirmed that two nurses were suppose to verify new admission orders for accuracy and to ensure all orders were in place. During an interview on 4/2/25 at 1:46 PM, LPN AA reported that she was the nurse that readmitted Resident #338 to the facility. LPN AA confirmed that she had not put in orders for Resident #338's peg tube, and that she had just looked at the medication orders for Resident #338. LPN AA reported that Resident #338 was admitted back to the facility late in her shift, and she probably missed a few things with Resident #338's admission. During an interview on 4/2/25 at 11:38 AM, Pharmacist PP reported that the pharmacy delivered medications to the facility twice and day, and that they were also available 24 hours a day to drop ship urgent medications the same day. Pharmacist PP confirmed that the pharmacy was able to provide medications via drop ship if the nursing staff called and requested it. Pharmacist PP reported that if a resident was admitted after the cut off times for the daily deliveries, the nurse could call and request a drop shipment to ensure that the resident did not miss any medication doses. During an interview on 4/2/25 at 2:45 PM, Director of Nursing (DON) B reported that the night shift nurses were expected to review the facility's medication carts nightly and reorder any medications that were low. DON B reported nurses were expected to reorder medications when there were 7 doses remaining. DON B reported that nurses were expected to notify the provider anytime a resident missed a medication dose. DON B confirmed that residents should never miss a medication dose because the facility failed to reorder it timely. DON B reported that nurses were expected to ensure medications were ordered for a new admission by requesting a pharmacy drop shipment if needed. DON B reported that nurses were supposed to verify admission orders with a second nurse to ensure accuracy. DON B confirmed that he had several concerns with Resident #338 readmission orders. DON B confirmed that the nurse did not have a second nurse verify the orders, and that tube feed orders were not in place for Resident #338. DON B confirmed that the facility provider should have been notified about Resident #6 missing a dose of her symbicort inhaler. Review of the facility's Medication Order policy last reviewed 8/1/24 revealed, POLICY: It is the policy of this facility that medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders are received only by licensed nurses or pharmacists and confirmed in writing by the prescriber. Procedure: .3. If the prescribed medication is not available: Attempt to pull the medication from the Back-up box. If the medication is not available in the back-up box, notify the provider and follow up with directives given.

Based on observation, interview, and record review the facility failed to ensure facial hair grooming was offered and/or provided and/or clean hair was maintained for 4 (Residents #12, 14, 17, 53) of 6 residents reviewed that were dependent on staff for activities of daily living resulting in unwanted facial hair, debris in hair, appearing unkempt, and the potential for feeling embarrassed or having decreased self-worth. Findings include: Resident #12 Review of Resident #12's most recent brief interview for mental status score, dated 2/19/2025, was scored 5 which indicated Resident #12 had severe cognitive impairment. During an observation and interview on 03/31/25 at 10:57 AM, Resident #12 was seated in her wheelchair in the dining/activity room of the locked memory care unit of the facility, appeared confused, and was unable to answer questions asked by the surveyor. Resident #12 had long white facial hairs over the surface of her chin. The hairs' lengths varied, but many were approximately half an inch in length. During an observation on 03/31/25 at 03:49 PM, Resident #12 was seated in her wheelchair facing the television in the activity/dining room of the memory care unit and her white chin hairs observed remained the same as they had appeared on 03/31/25 at 10:57 AM. During an observation on 04/01/25 at 08:27 AM, Resident #12 was seated in her wheelchair at a table in the activity/dining room of the memory care unit and was observed to have facial hair that presented the way it had during observations made the day prior, 03/31/2025. During an observation on 04/01/25 at 01:34 PM, Resident #12's facial hair remained on her face unshaven and was in the activity/dining room. During an interview on 04/02/25 at 09:30 AM, Director of Nursing B was asked to provide any documentation that would explain why Resident #12's facial hair was not shaven, and no documentation was received before the end of the survey. Review of Resident #12's activity of daily living (ADL) care plan, revised 4/2/25, stated, Resident (#12) has an ADL self-care performance deficit .The resident is Dependent requiring assistance by 1 staff with personal hygiene .This also includes shaving of facial hair . Resident #14 Review of Resident #14's most recent brief interview for mental status score, dated 2/1/25, was scored 3 which indicated Resident #14 had severe cognitive impairment. During an observation and interview on 03/31/25 at 10:50 AM, Resident #14 was seated upright in her wheelchair in the dining/activity room of the locked memory care unit of the facility, appeared confused, and was unable to answer questions asked by the surveyor. Resident #12 had long white facial hairs over the surface of her chin and across her entire top lip. The hairs of the upper lip were the length and quantity that presented like a mustache. Facial hair lengths varied, but many were approximately half an inch in length on the chin. During an observation on 03/31/25 at 03:48 PM, Resident #14 was seated in the dining room of the memory care unit and her facial hair presented the same way it had on 3/31/25 at 10:50 AM. During an observation on 04/01/25 at 08:46 AM, Resident #14 was eating breakfast in the dining room of the memory care unit. Resident #14's facial hair presented the same it had as the day prior, 03/31/25. Standing at the entrance to the dining room with Resident #14 approximately 10 feet away at a table her facial hair was clearly visible. During an observation on 04/01/25 at 01:31 PM, Resident #14 was eating lunch in the dining room of the memory care unit. Resident #14's facial hair presented the same it had as earlier that day; 04/01/25 at 08:46 AM. During an observation on 04/02/25 at 08:39 AM, Resident #14 was eating breakfast in the dining room of the memory care unit. Resident #14's facial hair presented the same as it had on 03/31/25 and 04/01/25. During an interview on 04/02/25 at 09:30 AM, Director of Nursing B was asked to provide any documentation that would explain why Resident #14's facial hair was not shaven, and no documentation was received before the end of the survey. Review of Resident #14's activities of daily living (ADL) care plan, revised 9/17/2019, stated, (Resident #14) requires assistance with ADL's. An intervention, dated 4/2/25, stated, PERSONAL HYGIENE: The resident requires hand over hand/Dependent assistance by 1 staff with personal hygiene and oral care. This also includes shaving of facial hair as needed with shower days. During an interview on 04/02/25 at 12:35 PM, family member NN of Resident #14 reported Resident #14 would not have wanted facial hair, would have wanted it shaved, and she had observed Resident #14 ask staff to shave her during a visit in the past, but couldn't recall the date of that occurrence. Resident #17 Review of Resident #17's most recent brief interview for mental status score, dated 2/28/25, was scored 0 which indicated Resident #17 had severe cognitive impairment. During an observation and interview on 03/31/25 at 11:05 AM, Resident #17 was seated in her wheelchair in the memory care unit's activity/dining room. She was confused and unable to answer questions asked by the surveyor. Resident #17 had a visible black mustache across the upper lip and long hairs on her chin with varying length. Some chin hairs were approximately one half inch in length. Resident #17 also had brown debris, unknown material, in various areas on the top of her head's hair with most accumulated towards the front of the head. The brown material was on top of the hair and not down at the scalp area. At approximately 8 feet away the brown material across the top of her hair was visible. During an observation on 04/01/25 at 09:11 AM, Resident #17 was asleep in her bed. The facial hair and brown flakes on top of her head's hair was still present as it was observed on 03/31/25 at 11:05 AM. During an observation on 04/02/25 at 08:38 AM, Resident #17 was seated in her wheelchair in the memory care unit's dining room eating breakfast. Her facial hair and debris in her head's hair presented as they had on 03/31/25 and 04/01/25. During an interview on 04/02/25 at 09:30 AM, Director of Nursing B was asked to provide any documentation that would explain why Resident #14's facial hair was not shaven, and no documentation was received before the end of the survey. Review of Resident #17's activities of daily living (ADL) care plan, created 11/27/2024, stated, Resident (#17) has an ADL self-care performance deficit r/t Pervasive Developmental Disorder (also known as autism spectrum disorder; group of developmental delays). Resident #53 Review of Resident #53's most recent brief interview for mental status score, dated 3/26/25, was scored 0 which indicated Resident #53 had severe cognitive impairment. During an observation and interview on 04/01/25 at 08:26 AM, Resident # 53 was seated in her wheelchair in the activity room waiting for breakfast in the locked memory care unit. Resident #53 had many long chin hairs of varying length, with the longest one being approximately an inch in length. The resident was confused and unable to answer questions asked by the surveyor. During an observation on 04/02/25 at 08:39 AM, Resident #53 was eating breakfast in the dining room, seated upright in her wheelchair, and her chin hairs presented as they had on 04/01/25 at 08:26 AM. Review of Resident #53's activities of daily living (ADL) care plan, revised 3/10/2021, stated, Resident (#53) has an ADL self-care performance deficit r/t (related to) dementia. During an interview on 04/02/25 at 08:48 AM, Registered Nurse (RN) FF reported she wasn't aware if Residents #12, 14, 17, and 53 desired having facial hair or not. RN FF reported the staff focus first on getting the bath done and sometimes the facial hair doesn't get addressed. RN FF reported she wasn't aware of any documentation that would have shown refusals/choosing not to have facial hair grooming completed or that would have indicated a preference to have facial hair for Residents #12, 14, 17, and 53. Review of the facility's Shaving policy, adopted 7/11/2018, stated, It is the policy of this facility to improve the resident's appearance. In accordance with the resident's preference. Residents #12, 14, 17, and 53 had severe cognitive impairment and couldn't answer questions regarding if they wanted facial hair or how it made them feel. Applying the reasonable person concept, a female resident, not always but often, wouldn't desire to have facial hair and it potentially could be bothersome and/or cause feelings of embarrassment.

Based on observation, interview, and record review the facility failed to consistently provide residents with their food and beverage preferences for 12 residents (Residents #17, 53, 65, 2, 64, 85, 12, 14, 76, 22, 24, and 338) out of a facility census of 88 resulting in incorrect items provided, decreased satisfaction, and the potential for frustration, weight loss, and/or dehydration. Findings include: During an observation on 04/01/25 at 08:55 AM, Resident #17's breakfast tray was delivered to the dining room of the locked memory care unit and the meal ticket stated, Beverages Apple Juice, Chocolate Boost (nutritional supplement drink), . She was provided a red beverage (not apple juice) and was given a Vanilla Ensure Plus nutritional supplement drink (this is not a comparative product as it contains 110 calories more than an original Boost drink). Additionally, the alternate product provided was vanilla, when her meal ticket preference indicated the Chocolate flavor should be provided. During an interview on 04/01/25 at 08:59 AM, Registered Nurse FF reported if Resident #17 sleeps through breakfast when she wakes up they offer her an ensure. Review of Resident #17's nutrition care plan, revised 2/14/25, stated, Resident (#17) has nutritional problem or potential nutritional problem .Supplements as ordered . During an observation on 04/01/25 at 09:02 AM, Resident #53 was served a vanilla Ensure Plus, but her meal ticket stated, Boost. The products are not the similar in nutrive value as Ensure Plus contains 110 more calories than a Boost. During an observation on 04/01/25 at 09:04 AM, Resident #65 had consumed 100% of his solid foods, but his red beverage (not apple juice) cup appeared to have little to none consumed. His meal ticket on the table stated, Beverages Apple Juice . During an observation on 04/01/25 at 09:16 AM, Resident #2's meal was served with a red beverage (not apple juice) and an Ensure Plus nutrition supplement. Resident #2's meal ticket stated, Beverages Apple Juice, Boost, ., however she was given a red juice and an Ensure Plus. Observed in her room was an unopened Chocolate Boost dated 3/31/25 which indicated Boost was available, but she was served an Ensure Plus at this meal. The meal ticket also stated, Note Likes the sweet breakfasts. Please send TWO when having Pancakes, French Toast, and Waffles. Resident #2 was served only one portion of French toast; not a double portion. During an interview on 04/01/25 at 09:18 AM, Certified Nurse Aide (CNA) VV entered Resident #2's room and confirmed Resident #2 likes the sweet breakfasts and will often eat a double portion. CNA VV confirmed Resident #2 was only served one portion and not a double portion of the French toast and reported it depends if they (the kitchen) have enough or who is serving regarding if Resident #2 received double portions. During an observation on 04/01/25 at 01:04 PM, Resident #64's lunch meal in the facility's main dining room had broccoli served on the plate. The meal ticket for Resident #64 stated, Dislikes Broccoli .Note Will only eat these Vegetables. Cream corn, carrots, green beans, salad, and COLD beets. During an observation on 04/01/25 at 01:08 PM, Resident #85's lunch meal served in the facility's main dining room had a vanilla Ensure Plus, but the meal ticket stated, Supplements BOOST. Vanilla Ensure Plus is a different product than boost and contained 110 more calories than Boost. During an observation on 04/01/25 at 01:14 PM, Resident #17 was eating lunch in the dining room of the locked memory care unit of the facility near the back door. Resident #17 was served a vanilla Ensure Plus and a red beverage (not apple juice). Resident #17's meal ticket stated, Beverages . Apple Juice, Chocolate Boost . At the same table, Resident #12 was served a vanilla Ensure Plus, but her meal ticket stated, Boost. At the table closest to the dining room entrance Resident #14 was served mashed potatoes and gravy but in her dislikes section of the meal ticket it stated, Dislikes .Gravies . During an observation and interview on 04/01/25 at 01:24 PM, Resident #2 was served lunch in the locked memory care unit's dining room which included a vanilla Ensure Plus supplement drink, but her meal ticket stated, Beverages .Boost. Certified Nurse Aides VV and N reported the beverages and supplements come on the trays from the dietary department. CNA N confirmed they had Boost drinks in their unit's refrigerator. During an observation on 04/01/25 at 01:28 PM, Resident #76 was eating lunch in a chair in front of the television of the locked memory care unit's activity/dining room. Resident #76's lunch meal was served with a vanilla Ensure Plus, but his meal ticket stated, Beverages boost . During an observation and interview on 04/02/25 at 08:15 AM, Resident #22 was eating breakfast in the facility's main dining room. Resident #22 was served a red beverage (not apple juice) and reported he doesn't like the red beverage and prefers apple juice. Resident #22 reported he only gets apple juice served sometimes. Resident #22's meal ticket stated, Beverages .4 oz (ounce) Apple Juice. During an observation on 04/02/25 at 08:19 AM, Resident #24 was eating breakfast in the facility's main dining room. Resident #24 reported she is a diabetic and prefers sugar free condiments and estimated she receives sugar free condiments/jellies twice a week. Resident #24 was served regular/non-sugar free strawberry jam and grape jelly. Resident #24's meal ticket stated, CCHO - NAS (consistent carbohydrate (a diabetic diet intervention) no added salt diet) .Note Sugar Free Condiments .Would like Hot Cereal: Sunday, Tuesday, Thursday, Saturday .Would Like Fruit Loops: Monday, Wednesday, and Friday. This meal observed was on a Wednesday, and Resident #24 was served oatmeal and not fruit loops. During an observation and interview on 04/02/25 at 08:24 AM, Resident #338 was eating independently in the main dining room of the facility. Resident #338 was served a red beverage (not apple juice or orange juice). During an interview at the meal Resident #338 reported she couldn't drink it asked the surveyor what the red beverage was. Resident #338's meal ticket stated, Beverages 4 oz Apple of (or) Orange Juice). Resident #338 proceeded to ask facility staff for an apple or orange juice. During an observation on 04/02/25 at 08:30 AM, Resident #2's breakfast was served in her room of the locked memory care unit. Resident #2 was served a red beverage (not apple juice) and a strawberry Mightyshake nutritional drink. Resident #2's meal ticket stated, Beverages Apple Juice, Boost. The Mightyshake (4 fluid ounces) is a different drink than Boost (8 fluid ounces) and has a different fluid content. During an observation on 04/02/25 at 08:32 AM, Resident #17 on the locked memory care unit was served a strawberry Mightyshake nutritional drink and a red beverage (not apple juice). Resident #17's meal ticket stated, Beverages Apple Juice, Chocolate Boost . During an observation on 04/02/25 at 08:34 AM, Resident #53 was eating in the locked memory care unit's dining room. Her meal ticket stated, Beverages Boost . but was provided a strawberry mighty shake nutritional drink. During an interview on 04/02/25 at 09:09 AM, Dietary Director UU confirmed the beverage line on residents' meal tickets were based on preferences and stated. Dietary Director UU reported whatever the resident or the family had reported as a preference is what is displayed on the meal tickets. Dietary Director UU confirmed the only red colored drinks were punch, cranberry, or Boost breeze (a nutritional drink supplement) and not apple juice or an apple juice blend. Dietary Director UU reported the facility's Registered Dietitian reported they could swap Boost for Ensure, and vice versa, and confirmed this was for the regular versions and not the Plus versions. Dietary Director UU reported the Ensure Plus version of ensure is newer to the facility. Dietary Director UU reported she she doesn't order the nutrition drink supplements and they (the kitchen/dietary department) give what they have when serving the meals/beverages. Review of the facility's Food Refusals, Substitutes for policy, adopted 7/11/2018, stated, Purpose: To provide an adequate diet within the food preferences of the residents .Every effort will be made to ascertain individual food preferences upon admission and at quarterly resident interviews so that equivalent food substitutes can be prepared in advance of meal service . Substitutes provided should be from the same food group and nutritionally equivalent . Per the nutritional drinks/supplements' manufacturer websites, Ensure Plus, 8 fluid ounces, is 350 calories and 13 grams of protein. Original Ensure, 8 fluid ounces, is 250 calories and 9 grams of protein. Boost original, 8 fluid ounces, is 240 calories and 10 grams of protein. Boost is available in a Plus version which is 360 calories and 14 grams of protein Mightyshake (strawberry), 4 onces (not 8 and therefore contained a different quantity of fluid), is 220 calories and 6 grams of protein. When Ensure Plus was provided instead of Boost original it was not of similar nutritive value; a 110 calorie differential. Applying the reasonable person concept, in regards to preferences, someone likely would prefer the taste of one nutritional supplement over the other. The residents observed on the locked memory care unit were unable to vocalize how being given the incorrect items made them feel or the impact it had on their consumption for nutritional drinks, other beverages, and foods.

Based on interview and record review, the facility failed to ensure residents were cared for with dignity and respect for 1 (Resident #54) of 2 residents reviewed for dignity, resulting in the potential for feelings of embarrassment, frustration, depression, and loss of self-worth and an overall deterioration of psychological well-being. Findings include: Resident #54 Review of an Minimum Data Set (MDS) assessment revealed Resident #54 was originally admitted to the facility on [DATE] with pertinent diagnoses which included diabetes. Review of an MDS assessment for Resident #54, with a reference date of 2/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #54 was cognitively intact. During an interview on 3/31/25 at 1:48 PM, Resident #54 reported that she was frustrated with how some of the staff interacted with and talked about residents. Resident #54 reported that a few days ago, she had overheard Certified Nursing Assistants (CNA) P and Q in the hallway making fun of a resident. Resident #54 reported that she had heard one of the CNA's ask the resident if he ever showered, and that the resident smelled like fish. Resident #54 reported that she was very upset by this so she reported it immediately to Unit Manager (UM) CC. Resident #54 was not able to confirm which resident staff were talking to, since she overheard it from her room, but she reported that she was still very upset because it just bothered me hearing staff talk about us like that. Resident #54 reported that the way that staff interacted with residents was on ongoing problem, and that she had reported it to management on several occasions. During an interview on 4/2/25 at 10:29 AM, Social Services Director (SSD) GG reported that Resident #54 had reported concerns to her before about the way that staff treated her. SSD GG reported that she felt like Resident #54 typically had concerns with agency staff, and she had never looked into the concerns reported to her by Resident #54 before because usually the agency staff never come back after the concerns are reported. SSD GG confirmed that Resident #54 had reported concerns to her related to overhearing staff talk about residents in the hallway. SSD GG reported that she thought that those concerns were being addressed by the nursing team. During an interview on 4/2/25 at 12:28 PM, UM CC reported that Resident #54 did recently report concerns related to how staff were talking about a resident. UM CC reported that Resident #54 was unable to report the correct name of the resident that she thought staff were talking about, so she did not investigate that concern further. UM CC confirmed that Resident #54 had overheard the staff talking from her room, so she did not see which resident room the staff were in at the time. UM CC reported that she had talked to CNA P and Q that night and told them to keep their voices down and make sure that people could not hear them. UM CC confirmed that she did follow up with any of the residents on the hall to see if they had concerns with how staff were treating them, or investigate the concern further. UM CC confirmed that she did not report this concern to the Nursing Home Administrator (NHA) or the Director of Nursing (DON), but that she did report the concern to the Assistant Director of Nursing (ADON). During an interview on 4/02/25 at 2:12 PM, CNA P reported that she had been accused of talking loudly and inappropriately in front of residents recently and had been talked to by UM CC about this. CNA P reported that UM CC had told her that she needed to be quiet, and that she needed to stop talking about residents. CNA P reported that she did not know why UM CC had talked to her, and that she did not elaborate on what had been reported to her. CNA P reported that she had ongoing concerns with how staff treated residents. CNA P reported that she did not say anything that she felt was inappropriate on the night that UM CC talked to her. CNA P reported that she had ongoing issues with Resident #54, and that Resident #54 had reported concerns about her to the nurse that night, but she did not know why. During an interview on 4/2/25 at 2:23 PM, CNA Q reported that she had recently been talked to by UM CC along with two other CNA's about being quiet and not talking about residents. CNA Q reported that she had overheard CNA P and CNA WW talking about a resident while in a resident room. CNA Q reported that she heard one of the CNA's discussing that the resident was incontinent (lack of control of bladder or bowels), being lazy, and that the resident smelled bad. CNA Q reported that she was not sure which staff member said this about the resident, but that one CNA said it and the other agreed. CNA Q was unable to confirm which resident room the staff were in so she did not know which resident the CNA's were discussing. During an interview on 4/2/25 at 2:29 PM, ADON C reported that she had been made aware of Resident #54 reporting a concern to UM CC. ADON C reported that she was unaware of the details of the concerns reported to UM CC. ADON C reported that she did not investigate the concern further because she thought that UM CC had handled it. ADON C confirmed that she had issues with CNA P and CNA WW in the past related to how they were caring for residents. During an interview on 4/2/25 at 3:25 PM, DON B reported that he had not been aware of the concern that Resident #54 had reported to UM CC. DON B confirmed that UM CC should have reported this concern to him, and that the facility should have looked into this concern further. On 4/1/2025 at 1:43 PM, this writer requested grievance forms from Resident #54 from the last 3 months. The facility did not provide any grievance forms for Resident #54 prior to survey exit. Review of an Educational Opportunity form dated 4/26/18 for CNA P revealed, Educational Prompt: (CNA P) raised voice at a resident stated If you want my job stay here until 10. I'm not dealing with it. Then slammed the door

Based on interview and record review, the facility failed to ensure an updated and accurate advanced directive information was in place for 1 of 19 residents (Resident #338) reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings include: Resident #338 Review of an Admission Record revealed Resident #338 was originally admitted to the facility on [DATE] with pertinent diagnoses which included hypertension (high blood pressure). Review of Resident #338's Designation of Patient Advocate Form dated 7/23/24 revealed Resident #338 had designated Family Member (FM) RR as her patient advocate to act in accordance with her end of life decisions .2. Specific Instructions Regarding Life-Sustaining Treatment: I understand I do not have to choose one of the instructions regarding life sustaining treatment listed below. If I choose one, I will sign below mu choice. Choice 1: I do not want my life to be prolonged by providing or continuing life sustaining treatment if any of the following medical conditions exist: I am in an irreversible coma or persistent vegetative state. I am terminally ill and life-sustaining procedures would serve only to artificially delay my death. Under any circumstances where my medical condition is such that the burdens of treatment outweigh the expected benefits. In weighing the burdens and benefit of treatment, I want my Patient Advocate to consider the relief of suffering and the quality of my life as well as the extent of possibly prolonging my life. I understand that this decision could or would allow me to die. If this statement reflects your desires, sign here. This was signed by Resident #338. Review of Resident #338's Determination of Inability to Participate in Complex Decision Making form dated 8/28/24 indicated that Resident #338 had been evaluated and was deemed unable to make medical treatment decisions, and that FM RR Durable Power of Attorney (DPOA) was activated, and FM RR would be responsible for making medical treatment decisions. It was noted that Resident #338 was listed as a Full Code at the facility. Indicating that all life sustaining treatment would be performed on Resident #338 if needed. Review of Interdisciplinary Team (IDT) Progress Note dated 11/5/24 revealed, .Quarterly Care Conference held for Resident. Resident is in facility for long term care. Resident is a Full Code but DPOA would like to change code status to DNR (Do Not Resuscitate) . Review of Resident #338's Progress Note dated 1/24/2025 revealed, Contacted FM RR and does not want any part of medical decision making for resident any longer. Social services notified to address this concern. Review of Interdisciplinary Team (IDT) Progress Note dated 2/4/25 revealed, Resident's DPOA is active and (FM RR) does not want to continue taking responsibility and the process for guardianship will be started . During an interview on 4/2/25 at 8:18 AM, FM RR reported that he had informed the facility that he wanted Resident #338's code status to be DNR. FM RR reported that the facility was supposed to send him the paperwork to change Resident #338's code status, but he never received it. FM RR reported that he had been making the medical treatment decisions for Resident #338, but he lived in another state and it made it hard for him, so he had requested the facility obtain a guardian for Resident #338. During an interview on 4/2/25 at 10:08, Social Services Director (SSD) GG reported that she had been made aware in November 2024 that FM RR wanted Resident #338's code status changed to DNR. SSD GG reported that the facility was supposed to send him the paperwork to sign, but that they did not do this. SSD GG was unable to report why the facility had not sent the paperwork. SSD GG reported that she was also aware that FM RR no longer wanted to make medical treatment decisions for Resident #338. SSD GG reported that the facility had not started the process of obtaining a legal guardian for Resident #338 because she had been sent to the hospital on 2/18/25 and recently returned to the facility. SSD GG reviewed Resident #338's Designation of Patient Advocate Form dated 7/23/24 with this writer and confirmed that Resident #338 did not want life sustaining treatment, which would be indicated under the full code status.

Based on interview, and record review, the facility failed to notify the responsible party of a change in resident condition in 1 of 2 residents (R7) reviewed for notification of changes, resulting in the guardian/emergency contact not being made aware of an injury of unknown origin (R7) causing the inability to participate in timely medical decision-making. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R7 was moderately cognitively impaired as evidenced by her BIMS (Brief Interview Mental Status) score of 10/15. Her diagnoses included dementia and Alzheimer's disease with no mention of intermittent urinary catheterization. Review of R7's Progress Note dated 3/15/2025 at 00:30 (AM) revealed, . When doing straight cath at this time noted that her labia (inner and outer folds of vulva at either side of vagina) was bruised bilaterally (both sides) and swollen. Had 1/4-inch laceration above urethra (duct that drains urine from body) . During an interview on 4/2/25 at 12:27 PM, Registered Nurse (RN) EE stated, (R7) on 3/15/25 she had to be cathed, when I separated the labia, it was swollen and black and blue and a small scratch like thing above the labia. I asked the nurse from the shift before me about it and said yes the area was swollen and bruised and had not told anyone about it, including family. I told the ADON (Assistant Director of Nursing), who asked me if I had called the family. I did not contact the family. During an interview on 4/2/25 at 12:15 PM, Director of Nursing (DON) B stated,(R7's) Emergency Contact/Resident Representative was not notified on 3/15/25 when the bruising and tear were found.

This citation pertains to intake MI00150533 Based on interview, and record review, the facility failed to prevent the misappropriation of resident narcotic medications in 1 of 1 residents (Resident #64) reviewed for misappropriation of property, resulting in loss of resident's pain medication, and the potential for uncontrolled pain and discomfort. Findings include: Resident #64 Review of an Admission Record revealed Resident #64 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness. Review of the facility's Drug Diversion Investigation revealed, On Thursday January 23rd at approximately 4:30 PM (Director of Nursing B) received a phone call from (Facility pharmacy) regarding a narcotic discrepancy regarding (Resident #64) Percocet (narcotic) script (prescription) . The pharmacy stated that they had a discrepancy for 20 unaccounted for Percocet . (DON B) was also unable to locate the shift narcotic count sheet for same said script. There was no line item on the count sheet where the medication was removed from count. An audit of all medication carts and their narcotic drawers took place. A Chart review for (Resident #64) was completed looking for the narcotic count sheet. All four medication carts in the building were audited along with the medication room. The medication in question remained unable to be located. On Friday January 24th, 2025, a police report was filed . An audit of all controlled substances on (Facility unit) was conducted to compare narcotic sheet sign outs with MAR charting. Based on this audit, interviews were conducted with two nurses, (Registered Nurse (RN) XX) and (Licensed Practical Nurse (LPN) AA) .(RN XX) was interviewed on Friday January 24th, 2025, at 3 pm. (RN XX) stated that she was unaware of any missing narcotic medications or narcotic count sheets. She was unable to recall what narcotic sheet she signed out the January 17th, 2025, 1900 dose of Percocet that she administered to (Resident #64). (RN XX) was not (sic) on duty when the missing medication was signed in at the facility and she is unable to account for its where about at this time. After the interview (RN XX) took a drug test. It was positive for opioids and oxycodone. At this time (RN XX) was suspended pending further investigation. (LPN AA) was interviewed on Friday January 24th at 3:30 pm. She had not worked on or around the date of the missing medication coming into the facility . At the end of the interview (LPN AA) took a urine drug screen and it was negative. During the investigation it was discovered that on January 20th, 2025, (Facility Medical Doctor (FMD)YY) had sent a script for (Resident #64) Norco (narcotic medication) to the Pharmacy. The Norco script arrived later that evening and was signed for by (RN XX). It was further determined that she failed to add this medication to the shift-to-shift narcotic count sheet. She should have had a narcotic card count of 35 scripts at this time, but she only accounted for 34. On Monday January 27th, 2025, (RN XX) was asked to provide a valid script for her controlled substance, and to come in for a few more questions. (RN XX) provided an undated script for Norco. (DON B) asked if her initials (initials redacted) were the ones on the Norco Narcotic Count sheet for (Resident #64) dated 1/20/25 and she said, yes. When asked why the medication and script was not logged onto her shift-to-shift count sheet, she was unable to provide an explanation and continued to deny having taken any medications from the facility . Conclusion: While the medication is still unable to be located. It is suspected that on January 20th to January 21st during (RN XX) shift she pulled the Percocet card out of the Narc (narcotic) drawer and replaced it with the Norco card script that had just arrived from Pharmacy. This kept the narcotic card count correct, but failed to reflect the addition of the Norco Script and removal of the Percocet Script. Due to the nurse not being able to produce a script for oxycodone, not having an explanation for the missing narcotic card and narcotic sheet and not following procedure with the adding of the Norco script to the narcotic count log, the facility has concluded that the diversion was substantiated.(RN XX) submitted a letter of resignation to (DON B) on Monday January 27th, 2025, effective immediately prior to (the facility) separating employment with (RNXX) . Review of Resident #64's Medication Administration Record revealed that RN XX was the last nurse to document the administration of Percocet for Resident #64 on 1/17/25. During an interview on 4/2/25 at 1:46 PM, LPN AA reported that she had been questioned by DON B regarding missing narcotic medications for Resident #64. LPN AA reported that had talked to Medical Doctor (MD) YY about changing Resident #64's pain medication from Percocet to Norco because in the past the facility had used Norco to treat Resident #64's pain prior to dressing changes, and it always seemed to work well for him. LPN AA reported that Resident #64 had been in and out of hospital a few times around that time with different issues and her first thought was that maybe there was a new medication that was causing some of the side effects Resident #64 reported, so she talked to MD YY and asked to discontinue the Percocet for Resident #64 and try Norco again, which he agreed to do. LPN AA reported that when the Norco prescription was delivered, the nurse that received it should have added the Norco to the count log and then removed the Percocet to destroy. LPN AA reported that the new Norco prescription for Resident #64 was delivered on 1/11/25 and she was not at the facility that day so she did not know what had happened. LPN AA confirmed that she took a drug test at the facility and her drug screen was negative. During an interview on 4/2/25 at 7:49 AM, RN XX reported that she was questioned by DON B in January 2025 because the pharmacy had reported missing medications. RN XX reported that DON B went over the narcotic count sheet with her and asked her if she knew why the medications were missing. RN XX reported that she was unable to answer why there were missing narcotic medications and she did not know what had happened. RN XX was unable to report why the narcotic count card was noted at 34 instead of 35. RN XX confirmed that the facility did ask her take a drug test. RN XX reported that she thought her drug test was only positive for opioids, which was a medication she was prescribed. RN XX reported that she did provide the facility with a prescription for the opioid medication that she took. RN XX reported that she did not know anything else about the investigation because she chose to resign on 1/27/25. RN XX reported that she did not resign because she was being investigated for possible drug diversion. It was noted that the facility had provided photos of RN XX and LPN AA urine drug screen results in the drug diversion investigation folder. The photos noted that RN XX' urine drug screen showed positive results for opioids and oxycodone and LPN AA urine drug screen was negative. During an interview on 4/2/25 at 2:45 PM, DON B reported that he had completed the investigation into the missing narcotic medications. DON B reported that when he was notified by the pharmacy that there was a discrepancy in the narcotics, he immediately audited the facility carts to try to find the missing medication. DON B reported that when he was unable to locate the missing narcotic, he began an drug diversion investigation. DON B reported that he had noted when he reviewed the narcotic count logs and discovered that RN XX had signed for the the new prescription of Norco for Resident #64, but did not add the new prescription to the count, so the count remained at 34, when it should have been 35. DON BB reviewed the investigation file with this writer and showed this writer the count sheets and where RN XX failed to document the new norco prescription and the removal of the percocet prescription on the narcotic count sheet. DON B reported that Resident #64's order had been changed from Percocet to Norco, so the Percocet should have been removed from the cart, and destroyed by two nurses together. DON B reported that since RN XX could not report why she did not remove the Percocet card from the cart, and since she was the nurse that had signed for the delievery of the Norco, tested positive for opioids and oxycodone and was unable to provide a valid script to support the use of those medications, it was determined that RN XX had diverted the percocet from Resident #64. During an interview on 4/2/25 at 1:13 PM, Consulting Pharmacist (CP) OO reported that she had been notified about the missing narcotics in January 2025. CP OO confirmed that the facility was not able to locate the missing narcotic medication. CP OO reported that nurses were supposed document all new narcotics delivered and removed from the count log, and RN XX had failed to document the delivery of the norco prescription and the removal of the percocet narcotic. CP OO reported that is was pretty easy to track RN XX on the missing narcotics, because she had signed for the delivery of the norco prescription, and she was the last to document the administration of Percocet to Resident #64. CP OO confirmed that she audited the narcotic count logs every month and frequently noted discrepancies in nurses documenting administration of narcotics on the count log but not in the resident's medication administration record. Review of an Disciplinary Action Report for RN XX dated 7/26/24 revealed, Rule Violated: Following Department Policies and Procedures. Describe what happened: Medication were signed out of the narcotic book as given, but were not signed out in the MAR as given. These PRN (as needed) medications must be signed out to ensure the safety for the residents .

Based on interview and record review, the facility failed to operationalize its abuse policy and procedure for 1 resident (R7) of 2 residents reviewed for potential sexual abuse, resulting in staff not reporting observations of abuse to the Nursing Home Administrator immediately, potential for further resident to resident observations of abuse to go unreported and uninvestigated. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R7 was moderately cognitively impaired as evidenced by her BIMS (Brief Interview Mental Status) score of 10/15. Her diagnoses included dementia and Alzheimer's disease with no mention of intermittent urinary catheterization. Review of R7's Progress Note dated 3/15/2025 at 00:30 (AM) revealed, . When doing straight cathed (using a device to drain urine from bladder) at this time noted that her labia (inner and outer folds of vulva at either side of vagina) was bruised bilaterally (both sides) and swollen. Had 1/4-inch laceration above urethra (duct that drains urine from body) . During an interview on 4/1/25 at 4:22 PM, Nursing Home Administrator (NHA) A stated, I am the Abuse Coordinator. Today (4/1/25) was the first day I heard about the injury to (R7). (ADON) (Assistant Director of Nursing) C) brought it to my attention. The first staff heard about injury of unknown origin to (R7) was a progress note written 3/15/25. An injury of unknown origin should be reported to me immediately if suspicious in nature. During an interview on 4/1/25 at 4:25 PM, Director of Nursing (DON) B stated, I was called on 3/15/25 at 5:30 AM by the ADON telling me (R7) she read a progress note about (R7) having a bruised swollen labia with a tear. The NHA was not notified by the ADON or myself. During an interview on 4/1/25 at 5:20 PM, Licensed Practical Nurse (LPN) Y stated, I got an order from (Physician KK) to straight cath (R7). While straight cathing (R7), I noticed a red mark by her clitoris (female genital organ) and slight swelling. I told the oncoming nurse (RN EE). I did not report what I saw to the Abuse Coordinator I just talked to the ADON the next morning. During an interview on 4/2/25 at 12:27 PM, Registered Nurse (RN) EE stated, (R7) on 3/15/25 she had to be cathed, when I separated the labia, it was swollen and black and blue and a small scratch like thing above the labia. I asked the nurse from the shift before me about it and said yes, the area was swollen and bruised and had not told anyone about it, including the Nursing Home Administrator/Abuse Coordinator. I told the ADON (Assistant Director of Nursing), who asked me if I had notified anyone, and I did not. Review of facility Abuse Training completion signature page, dated December 2024, RN EE and LPN Y acknowledged they received the training including types of abuse/neglect and to report all allegations and/or suspicions of abuse must be reported to the Administrator or designee immediately. Review of facility policy Abuse and Neglect dated 7/11/2018, revealed, .It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse . or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations . The administrator is the abuse coordinator in this facility, and is responsible for developing and implementing abuse prevention training curriculum . Identify events, such as suspicious bruising of residents . An injury should be classified as an injury of unknown source when both of the following conditions are met: -The source of injury was not observed by any person, or the source of injury could not be explained by the resident; and -The injury is suspicious because of the extent of the injury or the location of the injury (example: the injury is located in an area not generally vulnerable to trauma) . All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee .REPORTING: all allegations and/or suspicions of abuse/neglect must be immediately reported to the facility Administrator or designee in the absence of the administrator.

This citation pertains to intakes: MI00146150, MI00146185, MI00146924 This citation has 2 deficient practice statements. DPS #1: Based on observation, interview, and record review, the facility failed to ensure the safety and prevent elopement for 3 (Resident#100, Resident #101, Resident #105) of 5 residents reviewed for elopement, resulting in an Immediate Jeopardy when Resident #100 and Resident #101 left the premises alone, unbeknownst to staff, for an extended period, and were later found in the community and the likelihood for serious harm and/or injury for Resident #105. Findings include: Review of the facility Elopment Policy dated [DATE] and revised [DATE] revealed, Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual plan of care. Procedure: 1. Residents who have been assessed at risk for elopement/wandering shall be provided at least one of the following safety precautions by the facility: a. An adult electronic monitoring safety device will be used to notify/alert staff by sounding an alarm when the resident enters the perimeter around an alarmed door. b. Door alarms placed on facility exits. c. Keypad controlled elevators. d. Resident will be listed in the Elopement Book, which will be located at the reception desk and each nursing station. 1. As part of the facility ' s Preventative Maintenance Program, all doors and elevator keypads will be checked for proper function on a weekly basis by the Maintenance department/designee. These checks will be documented with date and time completed. 2. Residents with an adult electronic monitoring safety device will be checked every shift to ensure device is in place. 3. Adult electronic monitoring safety device will be checked weekly to ensure the device is functioning properly and is not expired. 4. At no time shall a door alarm be turned off, without the continual supervision of the exit. *If the alarm must be turned off, it is the responsibility of the person disarming it to make sure it is functioning properly once the alarm is turned back on. Residents/Elopement : 1. All residents shall be reviewed for safety awareness impairment and elopement/wandering concerns upon admission, readmission, quarterly, significant change in condition and as needed. 2. Residents identified as at risk for elopement/wandering will have a plan of care implemented to address their elopement/wandering behaviors. 3. All residents who are at risk for possible elopement/wandering shall be accompanied by staff or responsible party when leaving the residents unit and/or facility grounds 5. When the door alarm sounds, staff members shall immediately respond to determine the cause of the alarm. Review of Elopement: Assessment and Safety Essentials by [NAME] Struck, RN, published [DATE], Provider Magazine revealed While wandering in a facility can present harmful situations .the opportunities for injury multiply after a resident elopes from the nursing facility. Additional risk assessment should be performed after there is any change in the resident's condition .(assessment) should include physical, psychological and historical factors .a resident's history is of paramount importance in the assessment process .factors that signal concern include .problem with adjustment to the facility .stating a desire to go home or feeling imprisoned .hovering near exits . Resident #100 Review of an Admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cerebral infarction (stroke), peripheral vascular disease (disease causing reduced blood flow), muscle weakness, and cognitive communication deficit(difficulty communicating related to disruption in cognitive processes, such as memory, attention, or problem solving). Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] which indicated Resident #100 was moderately cognitively impaired. Section GG of the MDS revealed Resident #100 could propel his wheelchair 150 feet independently. Review of a Care Plan for Resident #100, with a reference date of [DATE], revealed focuses/goals/interventions of: 1. Focus: Resident has limited physical mobility r/t bilateral amputation of all toes. Goal: Resident will remain free of complications related to immobility, such as .skin-breakdown, fall related injury through the next review date. Interventions: .Resident is NON-WEIGHT BEARING .due to bilateral toe amputation of all toes .total mechanical lift .however resident is non-compliant . 2. Focus: Resident at risk for falls .Goal: Resident will remain free from fall related injury .Interventions: provide assistance as needed for mobility .assure utilization of appropriate devices .assistive device: wheelchair . Resident had no care plan related to elopement concerns at the time of his elopement. Review of a Fall Risk Assessment for Resident #100, with a reference date of [DATE] revealed the resident was at a high risk for falling. Review of a Wandering Risk Scale assessment for Resident #100, with a reference date of [DATE], revealed the assessment was deemed not applicable because Resident is ONE OF THE FOLLOWING: comatose, dependent on ADL and cannot move without assistance, and/or stuporous. As a result, Resident #100 scored 0 (low risk) for elopement. Review of a Certification of Incapacity for Resident #100, with a reference date of [DATE], revealed the resident was deemed unable to make medical decisions for himself based on a lack of awareness of risks/benefits, and an inability to develop a reasonable rationale for decisions. Review of a Nursing Progress Note for Resident #100, with a reference date of [DATE] revealed Resident oriented to his room. He states he is frustrated with the facility and feels like a prisoner. He would like to go home. Review of a Physical Therapy Progress Note for Resident #100, with a reference date of [DATE], revealed the resident was already able to transfer and walk without assistance but in doing so, was noncompliant with his weightbearing restrictions. Review of a Behavior Health Assessment for Resident #100, with a reference date of [DATE] revealed the resident was diagnosed with adjustment disorder with depressed mood on this date. Review of a Nursing Progress Note for Resident #100, with a reference date of [DATE] revealed Resident not following fluid restriction, self-transfers to bathroom to fill cup. Resident states he is leaving tomorrow. In an interview on [DATE] at 1:47pm, Certified Nursing Assistant (CNA) N reported Resident #100 expressed his desire to go home almost every day, resisted any assistance with cares, refused to follow his non-weightbearing status on his feet, and hovered by various doors frequently. In an interview on [DATE] at 9:31am, Resident #109 reported on [DATE] at approximately 8:30pm, the door alarm for the front door of the facility was sounding for nearly 20 minutes and she went to investigate the situation. Resident #109 reported she arrived at the lobby near the front door, the alarmed continued to sound and she was not able to locate any staff. Resident #109 reported she did not see anyone outside and opted to turn off the alarm herself. Resident #109 reported there was a reset button for the alarm that was easily accessible to everyone, and she pushed it to turn off the alarm. Resident #109 reported she learned later that a resident had eloped that evening. Resident #109 also reported that she and other independent residents had a code to use to exit the building without activating the alarm. Review of a Nursing Progress Note for Resident #100, with a reference date of [DATE] revealed This resident was last observed by nurse around 19:30 (7:30pm) .Resident found at 21:42 (9:42pm) at (local business 0.25 miles from facility). Resident states he wants to go home and that's why he left. In an interview on [DATE], at 11:41am, family member/durable power of attorney (FM) AA for Resident #100 reported Resident #100 had expressed a desire to leave the facility repeatedly since his admission and was calling anyone who'd answer the phone demanding they come pick him up. FM AA reported Resident #100 had a long history of not complying with medical recommendations and rules put in place by others. FM AA reported he was not surprised when the facility called him on [DATE] and reported Resident #100 left the building because the resident had been saying for weeks that he wanted to leave, and the facility was aware of this as well. FM AA reported he did not believe Resident #100 was safe to leave the facility alone because his mental capacity had worsened in recent months. In an interview on [DATE] at 11:26am, Nursing Home Administrator (NHA) A reported Resident #100 repeatedly expressed a desire to go home within a few days of his arrival and had been assessed as a low risk for elopement at the time of his admission but had not been reassessed until after he eloped on [DATE]. NHA A also reported the resident had a long history of noncompliance and poor decision making. NHA A confirmed at the time of his elopement, Resident #100's care plan had no interventions in place to reduce his risk of elopement, but a care plan would have been generated had he been reassessed and deemed at risk. Resident #100 no longer resided in the facility. An effort to contact Resident #100 was made on [DATE] at 11:49am. The telephone number provided had been disconnected. Resident #101 Review of an Admission Record revealed Resident #101, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia, fracture of unspecified part of right clavicle, repeated falls, and age-related osteoporosis (disease that causes bones to become weak and more likely to break). Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] which indicated Resident #101 was moderately cognitively impaired. Section GG of the MDS revealed Resident #101 required supervision and/or steadying assistance to walk 150'. Review of a Care Plan for Resident # 101, with a reference date of [DATE], revealed a focus/goal/interventions of: Resident is an elopement risk .Goal: Minimize risk of elopement .Interventions: Distract resident when increased wandering by offering pleasant diversions .encourage family visits during peak exit-seeking times . Review of a Physician's Progress Note from another facility dated [DATE], located in Resident #101's current medical record, revealed SW (social worker) working with locked unit facility for increased risk of elopement with patterns of wandering and exit seeking behaviors . Review of a Federally Mandated Visit physician note for Resident #101, with a reference date of [DATE] revealed: Patient .previously presented to (name of another skilled nursing facility) for rehab .he required further oversight due to increased risk of elopement .and exit seeking . and was transferred to this facility. In an interview on [DATE], at 3:02pm, Certified Nursing Assistant (CNA) C reported she regularly cared for Resident #101 and to her knowledge, he had no history of exit seeking prior to [DATE]. CNA C reported when she went to retrieve Resident #101's lunch tray from his room on [DATE] at approximately 12:30pm, she became concerned because the resident was not in his room and was not on the locked memory care in which he resided. CNA C reported a search began. CNA C reported the door alarms were not sounding at that time. CNA C reported she later cared for Resident #101 when he was returned to the unit. CNA C described Resident #101 as tired and thirsty upon his return. Review of a General Progress Note for Resident #101 with a reference date of [DATE] revealed .after lunch staff began to pick up trays .Resident (#101's) tray had not been touched .all staff began checking all rooms .staff exited building .Resident was observed standing at mail truck, a police car on scene .Resident appeared out of breath and was holding onto the mail truck . In an interview on [DATE] at 12:49pm, Postal Carrier (PC) Z reported she was driving on the facility street, going west when she saw an elderly man walking on the side of the road. PC Z reported she was concerned the man's safety because he looked lost, was dressed too warmly for the weather, the road was heavily trafficked, and she stopped to assist him. PC Z reported the man was Resident #101 and he was more than a block away from the facility. PC Z described Resident #101 as thirsty, tired, winded, and disoriented. PC Z reported Resident #101 was clothed in unseasonably warm clothes with long sleeves and a jacket. In an observation on [DATE] at 1:00pm, it was determined that the roadway on which Resident #101 was found, had a speed limit of 25mph and there was no sidewalk for pedestrians. The road surface was uneven, and the road was frequently used by vehicles as it led from a large residential area to main thoroughfare of the city. In an interview, Legal Guardian (LG) BB for Resident #101 reported the resident transferred to this facility from another facility on [DATE] after the first facility couldn't give him what needed because he was trying to leave the facility. LG BB reported the transition to a nursing facility had been very stressful and confusing for Resident #101 and she worried about his well being if he eloped since he did not know where he was and would not be able to maintain his own safety. LG BB reported Resident #101 had no family members involved in his life. In an interview on [DATE] at 8:21am, Maintenance Supervisor (MS) L reported prior to [DATE], the facility did not have a followed schedule for checking door alarms and there was a bypass button accessible to anyone in the lobby area that would shut off the alarm. MS L reported some doors in the facility had personal alarm monitors, including the exit door in the locked memory care unit but personal alarms were not used for resident's in the memory care unit. MS L reported he worked at the facility for 4 years but had no documentation of door alarm checks prior to ,d+[DATE]. Resident #105 Review of an Admission Record revealed Resident #105, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia(chronic condition that affects thinking, reasoning, and memory)major depressive disorder, and psychotic disorder (mental disorder characterized by disconnect with reality). Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] which indicated Resident #105 was cognitively intact. Review of a Care Plan for Resident # 105, with a reference date of [DATE], revealed a focus/goal/interventions of: Focus: Resident is a smoker .Goal: Resident will not suffer injury from unsafe smoking practices .Interventions: Resident must have supervision with smoking . Resident #105 had no care plan related to elopement as of [DATE] at 3:08pm. Review of a Wandering Risk Scale assessment for Resident #105, with a reference date of [DATE] revealed the resident was deemed at risk for wandering/elopement on this date. In an interview on [DATE] at 1:34pm, Certified Nursing Assistant (CNA) F reported Resident #105 left the building unsupervised several times during the period of ,d+[DATE]/-[DATE]. CNA F reported the resident was supposed to be supervised any time she left the building now because she was recently deemed not her own person and was no longer safe. CNA F reported she was unsure how or when the resident left the facility, that no alarms sounded until the resident triggered the alarm while trying to re-enter the facility. In an interview on [DATE] at 9:42 am, Certified Nursing Assistant (CNA) S reported until [DATE], Resident #105 and several other used the alarm code to go outside alone and smoke. CNA S reported having the alarm code would allow residents to open exterior doors without an alarm sounding. Review of a Nursing Progress Note for Resident #105, with a reference date of [DATE] revealed: Resident went outside this am and knew the code to get out of the door. In an interview on [DATE], at 9:51am, Resident #105 reported she knew the alarm code for the exterior doors until about a week ago and stated, It was 1 2 3 4 for a long time and we would go out alone to smoke. In an interview on [DATE] at 10:41am, Social Services Coordinator (SS) GG reported at around 8:00am on this date, she heard the door alarm sounding, responded, and found Resident #105 outside alone, raking leaves. In an interview on [DATE] at 11:01am, MDS Coordinator (MDS/RN) O reported Resident #105 was deemed at risk for wandering/elopement on [DATE] and should have had a personal alarm bracelet placed at that time but did not have one until [DATE]. MDS/RN O confirmed Resident #105 went outdoors to smoke regularly. MDS/RN O also confirmed there was no record of staff checking the personal alarm to ensure it was functioning properly. MDS/RN O confirmed that Resident #105 was not safe to go outdoors alone. In an interview on [DATE] at 11:26am, Registered Nurse/Staff Development Coordinator (RN) D reported there was no physician order for the use of a personal alarm that had been placed on Resident #105 on [DATE] or to check the device daily. RN D also confirmed the resident did not have an active care plan in place for her risk of elopement until [DATE]. When further queried, RN D reported she believed she told staff to place a personal alarm on Resident #105 over the weekend after they reported the resident left to building without supervision. Review of a Wandering Risk Scale assessment for Resident #105, with a reference date of [DATE] revealed the resident was deemed high risk for wandering/elopement and had wandered in the past month. In an interview on [DATE] at 11:30am, Nursing Home Administrator (NHA) A confirmed that the facility's policy was for all residents who were at risk for elopement/wandering to be accompanied by staff or a responsible party when leaving the residents unit and/or facility grounds. NHA A also confirmed residents identified at risk for elopement/wandering should have a plan of care to address their safety needs. On [DATE] at 1:57 PM, Nursing Home Administrator (NHA) A was verbally notified and received written notification of the Immediate Jeopardy that began on [DATE] due to the facility's failure to prevent the elopement of Resident #100 and Resident #101 and Resident #105. A written plan for removal for the Immediate Jeopardy was received on [DATE] at and the following was verified on [DATE]: On [DATE], all licensed nurses present in the facility were re-educated on warning signs of elopement, reassessing residents to determine their risk of elopement and development of an elopement care plan and communicating new resident needs related to elopement to the interdisciplinary team. Non licensed staff were educated on resident warning signs for elopement and need to report signs to the nurse immediately. Plan put in place to educate every staff member prior to their next working shift. On [DATE], Facility confirmed all at risk residents had a care plan to address their needs related to their risk of elopement as well as a functioning personal alarm. On [DATE], Facility confirmed all door alarms and personal safety alarms were in working order and were monitored for functionality daily. On [DATE], Resident #101 was placed on 15-minute checks until a personal safety alarm was placed on him. On [DATE], Facility ensured the door codes were changed. On [DATE], Facility ensured elopement drills will be conducted on a weekly basis. On [DATE], Facility ensured signs were posted to educate visitors on the need to avoid assisting any resident through a door and to have staff escort visitors out of the building. On [DATE], Facility ensured the elopement book was reviewed and up to date. On [DATE], Facility reviewed the elopement policy and deemed it was appropriate. On [DATE], Facility ensured all windows were functioning properly. On [DATE], Facility ensured behavior tracking orders for elopement tendencies were added to all residents at risk. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of harm due to:1. the fact that not all facility staff have received the education and sustained compliance has not been verified by the State Agency and 2. Resident #106 had sustained harm in a fall. DPS #2: Based on observation, interview, and record review, the facility failed to minimize the risk of injury during mechanical lift transfers for 1 (Resident #106) of 3 residents reviewed for falls, with a potential to impact 19 residents who rely on the use of a mechanical lift for transfers. Findings include: Review of a (product name and brand omitted) Operating and Product Care Instructions manual, with a reference date of ,d+[DATE], pg. 4 revealed: (product name omitted) is intended to be used with (brand name omitted) slings. Only use (brand name omitted) supplied slings and stretchers that designed to be used with (product name omitted) .the expected operational life for fabric slings is approximately 2 years from the date of purchase. Review of a (Product Brand Omitted) Slings User Guide, with a reference date of ,d+[DATE], provided by the facility revealed: Operating instructions .always check that the sling attachment clips are fully in position before and during the commencement of the lifting cycle .Care for your slings .if the sling label is missing or cannot be read the sling should also be withdrawn from use. Review of an Admission Record revealed Resident #106, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cerebral infarction (stroke), major depressive disorder, unspecified dementia, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of [DATE] revealed Resident #106 could not complete a Brief Interview for Mental Status due to her level of dementia. Section GG of the MDS revealed Resident #106 required maximal assistance (helper does more than half the effort) to transfer from bed to wheelchair. Section K of the MDS revealed Resident #106 weighed 126 pounds. Review of a Care Plan for Resident # 106, with a reference date of [DATE], revealed a focus/goal/interventions of: Resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) end stage dementia. Goal: Resident will participate in ADL tasks with therapy services as ordered .Interventions: TRANSFER: TOTAL Mechanical lift-yellow sling 2 person assist with all transfers .([DATE]). Review of an Investigation Summary with a reference date of [DATE] revealed: (Resident #106) was being transferred via lift following care plan with proper sling .the lift sling came detached and resident fell to floor .(Resident #106) sent to hospital .returned .with stitches to the laceration to the back of her head and a hematoma. Conclusion: it was concluded that due to size of resident (weight 125#) the connectors did not seat completely causing them to disconnect from the securement pegs .Pt (patient) will be a two person assist with all transfers needs going forward. Review of an Emergency Department Progress Note for Resident #106, with a reference date of [DATE] revealed: Diagnosis: injury of the head .patient .presents after falling from (name of device) lift, has a cervical collar on .spoke with her durable power of attorney and he does not want any imaging done .the patient did have significant bleeding from her head wound .I did place several deep and wide sutures pulled tight around this area .ultimately 4 sutures placed in total . In an interview on [DATE], at 9:33am, Agency Certified Nursing Assistant (CNA) X reported on [DATE] as she was transferring Resident #106 from her bed to the wheelchair, 2 of the 4 straps (both on the resident's right side) became unclipped from the fastening pins of the device, which caused Resident #106 to fall to the floor. CNA X reported she had been trained to use that type of lift at another facility. CNA X reported she attached the sling clips while Resident #106 laid in bed, assisted the resident into a seated position and then initiated lifting the resident with the device. CNA X reported Resident #106 fell as the device was moving her off the bed. In an interview on [DATE] at 1:39pm, Certified Nursing Assistant (CNA) G reported she used the mechanical lift to transfer residents several times a day and had experienced the sling clips popping off the placement pins at times. As a result, CNA G reported she always checked the placement of the clips as the resident began to be lifted from a surface. In an interview on [DATE] at 2:14pm, Certified Nursing Assistant (CNA) G reported she transferred Resident #106 regularly using the mechanical lift and had learned it was important to use the device slowly and double check the clips to ensure they stayed in place. In an interview on [DATE] at 2:44pm, Physical Therapist (DPT) Y, movement specialist consultant from the mechanical lift company, reported a facility should have their lift slings evaluated every ,d+[DATE] months by a qualified personnel. DPT Y reported it was a safety concern to use a sling that did not have a manufacturer's tag because the age of the sling could not be determined. DPT Y reported the slings were only designed to be safely used for approximately 2 years before the wear experienced during normal use would make them no longer effective. DPT Y reported the composite material clips may experience slight changes in opening on the clip that would not appear significant but could reduce their effectiveness with remaining snapped on the lift pins. DPT Y reported facility's must schedule preventative maintenance appointments specifically for the slings because the facility's entire sling inventory would not be inspected when the company provide maintenance for the mechanical lift machines. DPT Y reported based on Resident #106's weight of 126 pounds, the sling used to transfer her was the correct size. In an interview on [DATE] at 2:56pm, Nursing Home Administrator (NHA) A reported the facility had not done routine inspections of the mechanical lift slings until a new process was implemented on [DATE]. NHA A reported the facility planned to have laundry staff inspect the slings for holes and fraying in the soft materials. When further queried, NHA A reported the facility did not reach out to the manufacturer regarding Resident #106's fall during the use of their mechanical lift and did not seek guidance regarding sling maintenance. NHA A did not voice a plan to have the slings professionally inspected. NHA A provided the sling that was used for the transfer during Resident #106's fall. During an observation on [DATE] at 3:05pm, the sling NHA A provided, it was noted that a manufacturer's tag was not present. The sling was a lavender color with green trim and had four black composite material clips. The edges of the opening on the clips appeared somewhat worn. When the sling clips were placed on the pins of the mechanical lift, they unsnapped from the pins when light pressure was applied. During an interview on [DATE] at 4:09pm, Director of Nursing (DON) B examined the sling that was used for the transfer during which Resident #106 fell . DON B confirmed the brand and age of the sling could not be confirmed because the sling did not have a manufacturer's tag. The facility was not able to provide an invoice to determine the age of the sling used for Resident #106. During an observation on [DATE] at 9:03am, Certified Nursing Assistant (CNA) J was alone with Resident #106, in the resident's room. Resident #106 sat in her wheelchair with the mechanical lift sling under here. CNA J reported she was going to transfer Resident #106 to bed. CNA J fastened the sling clips to the securement pins on the mechanical lift and pushed the controller that activated the lift. As Resident #106 began to rise from her chair, the surveyor asked the CNA to stop and return the resident to her wheelchair. CNA J was asked to review Resident #106's plan of care regarding her needs for transfers. Upon reviewing the plan of care, CNA J confirmed that Resident #106 needed 2 staff members present for transfers. When further queried about why she initiated a transfer for Resident #106 with only one staff member, CNA J reported she was not aware the resident needed 2 staff members present for transfers.

This citation pertains to intakes MI00146152, MI00146926 Based on interview, and record review, the facility failed to protect the residents right to be free from resident to resident abuse for 4 (Resident #102, Resident #103, Resident #107 and Resident #108) of 5 residents reviewed for abuse, resulting in Resident #102 physically assaulting Resident #103, and Resident #107 grabbing Resident #108 in a sexual manner. Findings include: Resident #102 Review of an Admission Record revealed Resident #102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia (a group of thinking and social symptoms that interfere with daily functioning). Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 6/11/24 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #102 was severely cognitively impaired. Section E revealed Resident #102 exhibited physical behavioral symptoms directed toward others during 1-3 days of the assessment period and wandered daily. Review of a Care Plan for Resident # 102, with a reference date of 7/10/24, revealed a focus/goal/interventions of: Focus: Resident has potential to be physically aggressive r/t (related to) Dementia with behavioral disturbances .Goal: Resident will not harm self or others .Interventions: When resident becomes agitated: intervene before agitation escalates; guid away from source of distress .report IMMEDIATELY any s/sx (signs and symptoms) of resident posing danger .to others. Review of a Behavior Log revealed Resident #102 exhibited wandering, abusive language, and threatening behavior in the days prior to the assault on Resident #103 on 7/9/24. In an interview on 9/11/24 at 9:16am, Family Member (FM) CC reported Resident #102 had several episodes of physical aggression that were directed toward staff and other residents. FM CC reported she and her daughter asked the facility to evaluate and change Resident #102's medications to reduce his physically aggressive behaviors. Resident #103 Review of an Admission Record revealed Resident #103, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified intellectual disability, adjustment disorder with depression (strong emotional reaction to a change in life), and dementia. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 8/19/24 revealed Resident #103 could not complete a Brief Interview for Mental Status due to his cognitive limitations. Section C revealed Resident #103 had short- and long-term memory issues but could recall the location of his room and the names and faces of staff. Section E revealed the resident had no behavioral issues during the 14-day assessment period. Review of a Care Plan for Resident # 103, with a reference date of 8/23/22, revealed a focus/goal/interventions of: Focus: Resident has mood concern r/t (related to) intellectual disability. Goal: Resident will exhibit indicators of depression, mania, anxiety or sad mood less than daily by next review. Interventions: When conflict arise, remove resident to a calm safe environment and allow to vent/share feelings .behavioral health consults as needed .monitor/record/report mood to MD (Doctor of Medicine) . Review of a Incident Investigation Report with a reference date of 7/9/24 revealed while in his room, Resident #103 was struck with a closed fist several times by Resident #102. Review of a History of Present Illness report from the contractual behavioral health services for the facility, with a reference date of 7/10/24, revealed Behavior log over the past month is unremarkable. Yesterday he was physically attacked by another resident when he was sleeping in bed .complained of left should pain and was scared and sad after the event. In an interview on 9/11/24 at 3:26pm, Certified Nursing Assistant (CNA) E reported on 7/9/24 at approximately 10:45am, she was assisting a resident with a shower in the shower room that shares a wall with Resident #103's room. CNA E reported she heard blood curdling screams coming through the wall and ran to help. CNA E reported she was the first staff member to arrive and saw Resident #102 standing over Resident #103, who was sat on the end of his bed. CNA E reported she saw Resident #102 strike Resident #103 on both sides of his upper body at least 5 times with a closed fist. Resident #103 had his arms up over his face and was slumped forward. CNA E got in between the 2 residents and when she did, Resident #103 clung to her. Additional staff arrived and CNA E removed Resident #103 from the room. CNA E reported Resident #103 sobbed after the incident and even after he stopped crying, he appeared scared. In an interview on 9/12/24 at 3:05pm, Certified Nursing Assistant (CNA) M reported she responded to the altercation between Resident #102 and Resident #103 and saw Resident #103 with his arms up covering his face. CNA M reported Resident #103 emotional upset, crying and had reddened areas on his upper torso. Review of a Social Services Progress Note with a reference date of 7/9/24, at 13:10pm, revealed when asked if he was alright, Resident #103 rubbed his left shoulder and indicated he was in pain. Review of a Skin Observation Shower Sheet for Resident #103, with a reference date of 7/15/24, revealed he had a fading yellowish bruise on his left shoulder. Resident #103 was not able to answer questions during an attempted interview on 9/11/24 at 9:16am. In an interview on 9/11/24 at 3:17pm, Legal Guardian (LG) FF reported she received a telephone call on 7/9/24 from the facility and was told Resident #103 was hit by another resident several times. LG FF reported Resident #103 was not able to expressive his thoughts and feelings well, but no one would want to be treated that way and it was the facility' responsible to maintain his safety, and ensure he was not abused. LG FF reported she wondered if Resident #103 should move to another facility after that incident. Using the reasonable person concept, though Resident #103 had decreased ability to verbally express his own thoughts due to his cognitive deficits, he clearly experienced emotional distress and pain following the physical abuse that occurred on 7/9/24. This emotional distress has the potential to continue well past the date of the incident based on the reasonable person concept. Resident #107 Review of an Admission Record revealed Resident #107, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia (a group of thinking and social problems that interfere with daily functioning), and cognitive communication deficit (difficulty with communication caused by a disruption in cognitive processes, such as memory, attention, or problem solving). Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 9/13/24 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #107 was severely cognitively impaired. Section E revealed Resident #107 exhibited physical behavioral symptoms directed toward others (e.g hitting, kicking .grabbing, abusing others sexually) during 1-3 days of the assessment period. Review of a Care Plan for Resident #107, with a reference date of 6/18/19, revealed a focus/goal/interventions of: Focus: (Resident #107) has potential to be .socially inappropriate .has the potential to be inappropriate with touch towards other residents. Goal: (Resident #107) will verbalize understanding of need to control .behavior through the review date as well as not touch other residents. Interventions: Encourage resident to sit at table with men for meals .monitor behaviors. Review of an Incident Investigation Report with a reference date of 9/10/24, revealed CNA (Certified Nursing Assistant U) witnessed (Resident #107) reach out and grab (Resident #108's) bottom as she was walking past him in the dining room. Attempts to contact CNA U were not successful during the survey. Resident #108 Review of an Admission Record revealed Resident #108, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: mild intellectual disabilities (developmental disorder that affects a person's intellectual functioning and adaptive behaviors). Review of a Minimum Data Set (MDS) assessment for Resident #108, with a reference date of 8/2/24 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #108 was moderately cognitively impaired. Section I of the MDS revealed Resident #108 was diagnosed with bipolar disorder (disorder associated with mood swings ranging from depressive lows to manic highs) and major depressive disorder (persistent depressed mood). Review of a Care Plan for Resident #108, with a reference date of 10/31/23, revealed a focus/goal/interventions of: Focus: Resident has mood concern r/t (related to) depression. Goal: Resident will participate in decision making and care activities as able .Intervention: Administer medications as ordered, monitor/document .effectiveness. Review of a General Progress Note for Resident #108, written by Registered Nurse (RN) Q on 9/10/24 at 7:00pm, revealed This resident was taken to a private room and asked what happened. She stated that a man had grabbed her butt. This staff nurse asked if she was ok, and she stated no. Resident #108 reported she did not feel safe and did not want to see the man again. The resident was moved to a private room on another unit for the night. Review of a Social Services note for Resident #108 dated 9/11/24 at 5:15pm, revealed a day after Resident #107 grabbed Resident #108, she remained upset, was concerned the resident was looking into her room and decided she wanted to move to another hallway. In an interview on 9/17/24 at 9:36am, Resident #108 a man (named Resident #107) recently grabbed her bottom while she was in the dining room and the incident made her angry enough that I wanted to fight back. Resident #108 reported she cried after the incident because she was very stressed. Resident #108 reported when the incident happened, she felt scared and sad as well. Resident #108 reported after the incident, she decided to move to a different hallway permanently, and to change her seating assignment in the dining room so she wouldn't be close to Resident #107. In an interview on 9/17/24 at 12:15pm, Registered Nurse (RN) Q reported she went to Resident #108 immediately after Certified Nursing Assistant (CNA) Q told her about the incident involving Resident #107 grabbing Resident #108's bottom. RN Q described Resident #108 as pretty shaken up at the time. RN Q reported Resident #108 told her she did not feel safe, was scared to see Resident #107 and ultimately was assisted with going to another room for the night. RN Q reported she had cared for Resident #107 for nearly 2 years and had seen the resident exhibit sexually inappropriate behaviors toward others when he had an acute illness. When further queried, RN Q reported Resident #107 who was acutely ill at the time of the incident, grabbed RN Q in a sexually inappropriate manner prior to the resident's dinner time on 9/10/24. When further queried, RN Q reported she was not aware of any steps that were been taken to ensure the safety of the female residents that Resident #107 would encounter in the dining room that evening. Review of the facility's Abuse and Neglect policy with a reference date of 7/11/18 revealed: POLICY: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse .Definitions of Abuse .Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means, examples: hitting .grabbing .punching .Sexual: Sexual abuse includes but is not limited to harassment .or sexual assault.

This citation pertains to intake #MI00143822. Based on interview and record review, the facility failed to use a sit-to-stand lift (a medical device used to assist individuals in transitioning from a seated to a standing position), as recommended by therapy and per care plan, during a transfer from the resident's bed to wheelchair in 1 (Resident #100) of 3 residents reviewed for safety, resulting in the resident sustaining a laceration requiring sutures. Findings include: Review of an Admission Record revealed Resident #100 was a female, originally admitted to the facility 3/6/24, with pertinent diagnoses which included: muscle weakness (generalized), and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 3/11/24 revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated Resident #100 was severely cognitively impaired. Review of a General Progress Note dated 3/11/24 at 7:38 PM revealed, Note Text: CNA (certified nurse aide) reported to writer that pt (patient) had sustained an injury to the right leg. CNA was transferring pt from bed to chair and pt said ow after CNA placed pt into w/c (wheelchair) and noticed injury notified charge nurse. Writer assessed wound to RLL (right lower leg) right of shin and was foundto (sic) be a laceration. d/t (due to) cognitive decline pt was not able to described (sic) what happened. (ambulance company name omitted) was notified and sent to (hospital name omitted) ER (emergency room ) for evaluation . Review of a Physician's Order for Resident #100 revealed, Send to ER (emergency room ) for evaluation of RLE (right lower extremity) d/t (due to) laceration to RLE Verbal .3/11/24 Review of Resident #100's Care Plan in place at the time of the injury revealed a focus of, Resident has limited physical mobility r/t (related to) (r/t was left blank) Date Initiated: 3/7/24 and care planned interventions which included: Resident is PARTIAL WEIGHT BEARING with a date created and initiated on 3/7/24 and Sit to stand for transfers with a date created and initiated on 3/11/24. Review of a General Progress Note dated 3/11/24 at 2:04 PM revealed, Note Text: resident is A&O (alert and oriented) x1 to her self (sic), resident is very weak and difficult to get out of bed, resident will yell out while just laying in her bed c/o (complain of) pain, staff barely touch her and she will yell out. PRN (as needed) Tylenol given so by the time therapy worked with her around 1300 (1:00 PM) resident still yelled out but her daughter was at bedside and kept encouraging resident to keep pushing that she needed to get up and out of bed. therapy has given the okay to use the sit to stand with this resident and to really work on getting her up for meals . Review of Resident #100's Emergency Department hospital records revealed, .female presenting to the emergency department today .Per nursing home report, EMS (emergency medical services) reports and patient reports there is an unknown mechanism of injury. They initially had said it was an abrasion but upon further investigation they noted it was more of a laceration that needed stitches therefore they sent her in for evaluation .Patient has a 9.9 cm (centimeter) laceration to her right lower extremity laterally. This does have subcutaneous fat exposed throughout laceration. There is no muscle damage. It is very tender to palpation .Laceration Repair .Repair method: Sutures .Number of sutures: 10 (7 simple interrupted, 3 mattress) . In an interview on 6/20/24 at 3:49 PM, Certified Nurse Aide (CNA) W reported she had been the CNA who transferred Resident #100 when she had sustained a laceration to her leg. CNA W reported she had heard Resident #100 yelling that she had to go to the bathroom. CNA W reported she went into Resident #100's room and tried to get her in her wheelchair. CNA W reported she had not checked Resident #100's care plan prior to assisting her. CNA W stated, I just stood her up unfortunately. CNA W reported she had not used a gait belt (a safety device used when transferring a patient), nor had she used the sit-to-stand lift during the transfer. CNA W reported during the transfer, she had stood Resident #100 up and twisted her to try to get her (Resident #100) into the wheelchair and Resident #100 said ouch. CNA W reported when she looked down, she saw a massive cut on Resident #100's leg. CNA W reported that after it happened, first the nurse came in to assess the wound and then Director of Nursing (DON) came in to assess the wound. CNA W reported she told both the nurse and the DON that she had transferred Resident #100 without the sit-to stand and that she had not used the gait belt. In an interview on 6/21/24 at 10:47 AM, DON B reported he had been at the facility at the time Resident #100 received the injury during the transfer and had conducted his investigation immediately. DON B reported he had asked CNA W what had happened to which CNA W had reported that she stood Resident #100 up and pivoted her to her wheelchair. DON B confirmed that CNA W had transferred Resident #100 incorrectly in that she should have used the sit-to-stand lift during the transfer but had not.

Based on observation, interview, and record review, the facility failed to implement facility fall protocols and utilize gait-transfer belts/implement interventions before and after falls and provide adequate supervision for 2 residents (Resident #65 & #64) of 3 reviewed for falls/supervision resulting in a fall with a fracture needing surgical repair for Resident #65 and the potential for accidents and injuries to residents at risk for falls. Findings include: Resident #65 Review of an Admission Record revealed Resident #65, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #65, with a reference date of 2/16/24 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #65 was cognitively intact. Review of Resident #65's MDS assessment dated [DATE] revealed: Section GG - Functional Abilities and Goals - Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided resident Resident #65 was Coded .2 for transfers/toileting .which the MDS assessment revealed: 02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort Review of Resident #65's Incident-Accident dated 11/19/23 revealed: Incident Description-Nursing Description: (Certified Nurse Aide-CNA TT) had returned with (Resident #65) to his room after going for a walk. (Resident #65) needed to use the restroom, he was standing in the doorway of his bathroom with his walker and shoes on. He stepped forward and his left foot got tangled up and he fell . Patient Description: His feet got tangled and he fell over Immediate Action Taken. Description: Vitals taken, patient observed for injuries, neuro not started as CNA in the room, and it was observed. (Resident #65) was assisted into bed with the assistance of 2 staff members. Patient Taken to Hospital? No . During an interview on 3/24/24 at 2:03 PM., CNA TT reported I was assisting Resident #65 on his daily walk, when he needed to use the bathroom. CNA TT reported as they (CNA TT & Resident #65) walked from the unit to his room, and towards the bathroom she allowed him to enter into the bathroom unattended and he then tripped over his foot and fell . CNA TT reported at the time Resident #65 was using a 4-wheeled walker. CNA TT reported Resident #65 was a 1-person assist with ambulation (walking). CNA TT reported it happened very quickly, he (Resident #65) just went down to the floor, and she (CNA TT) attempted to grab his pants reaching as he was falling but could not catch or break his fall. CNA TT reported Resident #65 did end up with a broken hip and needing a surgical repair. CNA TT reported it was not noticed immediately that he had an injury it was the following day (Resident #65) started to complain of pain. CNA TT reports he had an X-ray completed and was sent out to the hospital after the results were noted he had a fractured hip. CNA TT reported she did not use a gait belt around (Resident #65's) waist, and should have because all residents who are an assist with ambulation are require to have a gait belt in use with all transfers, and ambulation. Review of Resident #65's Care Plan revealed: Focus- (Resident #65) at risk for falls r/t (related to) late effects of CVA (stroke) Date Initiated: 08/11/2022 .(with a revision date of 11/27/23) .Interventions- Follow facility fall protocol .Date Initiated: 09/08/2022 Weight bearing as tolerated Date Initiated: 11/24/2023 . During an interview on 3/26/24 at 1:48 PM., Resident #65 reported when he broke his hip a back in November 2023 he was on his way to use the bathroom after his daily walk with (CNA TT). Resident #65 reported when they got to the doorway of the bathroom (CNA TT) had let him enter the bathroom alone, and he tripped over his own feet, then falling into the bathroom. Resident #65 reported (CNA TT) did not happen to be using a gait-transfer belt that day. Resident #65 reported he since has not been walking daily as he was with (CNA TT), but he is still able to walk with a walker and assistance. Resident #65 reported he misses his daily walks, and walking in general. Resident #65 reported he is now basically wheelchair bound, and (CNA TT) nor any other CNA assist him with a regular walking routine, and also started using a lift at times to transfer him to and from his bed to wheelchair, and back. Resident #65 reported he does not feel the lift is necessary, and would much rather be assisted using a gait belt like many of the CNA's still use currently use. Resident #65 reported he really enjoyed his time walking with (CNA TT) and hopes that she is not avoiding walking him out of guilt. Resident #65 reported had (CNATT) used the gait belt that day she would have been able to at least lessen the impact of the fall. During an interview on 3/26/24 at 2:02 PM., Director of Nursing (DON) B reported he was made aware of Resident #65's fall which resulted in a fractured hip. DON B reported he was unsure if the CNA (CNA TT) had used a gait-transfer belt. DON B reported it is required and facility practice and policy to use a gait-transfer belt with all dependant residents with all transfers, ambulation and toileting. DON B and this surveyor discussed if any investigation and or education were offered to nursing staff about safe transfers, gait belt use, and falls protocols were completed. DON B reported he and/or the Interdisciplinary Team (IDT) had not done any of those things for nursing staff. 47659 Resident #64 Review of an Admission Record revealed Resident #64 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia. Review of a Minimum Data Set (MDS) assessment for Resident #64, with a reference date of 1/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #64 was severely cognitively impaired. Review of Resident #64's Care Plan revealed, Resident at risk for falls r/t (related to) dx (diagnosis) of dementia Date Initiated: 07/19/2022. Interventions: Anti Thrust Cushion to W/C (wheelchair) for positioning and comfort. Date Initiated: 02/01/2024 .Encourage the resident to participate in activities that promote physical activity for strengthening and improved mobility such as: Schedule walks for resident three times a day. Date Initiated: 01/19/2024 . NON-SLIP GRIP PAD: between cushion and w/c to aide with cushion not sliding Date Initiated: 12/27/2023. Review of Resident #64's Incident/accident reports indicated that Resident #64 had 8 falls between 10/2023 and 3/2024. It was noted that 5 of the 8 incident/accident reports did not include updated interventions to prevent further occurrences of falls. During an observation on 3/24/24 at 10:06 AM, Resident #64 and 10 other residents were in the main living room area on the unit with Certified Nursing Assistant's (CNA) G and N. At 10:09 AM, CNA G and N left the main living room area to complete care for a resident, which left Resident #64 and 10 other residents unsupervised in the main living room area. At 10:11 AM, Resident #64 was observed attempting to stand up get out of his wheelchair. At 10:18 AM, Resident #64 stood up and began walking away from his wheelchair. Resident # 64's gait was noted to be shuffled. Resident #64 walked about 15 feet and was noticed by a facility maintenance worker that was in the hallway. The maintenance worker intervened and assisted Resident #64 back to his wheelchair and then left the living room area, where Resident #64 remained unsupervised. Resident #64 continued to attempt to stand up and walk away from his wheelchair. At 10:22 AM, CNA N returned to the living room area and assisted Resident #64 to the restroom. At 10:41 AM, Resident #64 began to attempt to stand up and walk from his wheelchair. At 10:48 AM, CNA N left the main living room area which left Resident #64 and 10 other residents unsupervised. It was noted that Resident #64 continued to attempt to stand up out of his wheelchair and attempt to walk. During an interview on 3/26/24 at 12:03 PM, CNA E reported that staff were not supposed to leave the residents unsupervised in the main living area, but sometimes that was impossible as there were residents in their rooms that also needed assistance. CNA E reported that Resident #64 was a major fall risk, and he needed constant supervision which was not possible when there was only one or two CNA's on the unit, which was the typical staff ratio on the unit. During an interview on 3/24/24 at 1:01 PM, Registered Nurse (RN) KK reported that typical staffing for the unit included two CNA's and one nurse, but the nurse had to float to another unit throughout the day. RN KK reported that staff were not supposed to leave residents in the main living room area unsupervised, but that it was not always possible because of staffing. RN KK reported that Resident #64 was a major fall risk and required constant supervision. RN KK reported that staffing on the unit was dangerous for the residents on the unit, and that staff could not supervise the residents as they were supposed to. During an interview on 3/25/24 at 8:38 AM, Licensed Practical Nurse (LPN) BB reported that one staff member was always supposed to be in the main living room area of the unit. LPN BB reported that Resident #64 was a major fall risk and that he had experienced multiple falls in the facility. LPN BB reported that Resident #64 required constant supervision. LPN BB was unaware of any interventions that the facility had tried to help Resident #64 with his frequent attempts to self transfer and decrease falls. During an interview on 3/25/24 at 11:34 AM, LPN DD reported that Resident #64 frequently attempted to self transfer out of his wheelchair and required constant supervision. LPN DD reported that one staff member was required to remain in the main living room area and supervise residents at all times. LPN DD was unaware of any interventions that the facility had tried to help Resident #64 with his frequent attempts to self transfer and decrease falls. During an interview on 3/25/24 at 11:59 AM, CNA G reported that staffing on the unit made it hard for staff to constantly supervise all residents and complete resident care. CNA G reported that Resident #64 was a fall risk, and frequently attempted to self transfer out of his wheelchair. CNA G was unaware of any interventions that the facility had tried to help Resident #64 with his frequent attempts to self transfer and decrease falls. During an interview on 3/25/24 at 12:09 PM, CNA N reported that staffing on the unit made it impossible to supervise the residents as required and keep up with resident care. CNA N reported that staff tried to not leave residents unsupervised, but they often had to. CNA N reported that Resident #64 was a fall risk, and he had fallen frequently at the facility. CNA N was unaware of any interventions that the facility had tried to help Resident #64 with his frequent attempts to self transfer and decrease falls. During an interview on 3/25/24 at 2:27 PM, CNA C reported that Resident #64 was a major fall risk and required constant staff supervision. CNA C was unaware of any interventions that the facility had tried to help Resident #64 with his frequent attempts to self transfer and decrease falls. During an interview on 3/26/24 at 1:52 PM, CNA D reported that Resident #64 was a fall risk and had fallen at the facility several times. CNA D that the unit did not have enough staff to provide to constant supervision that the residents on the unit required, especially for Resident #64. CNA D unaware of any interventions that the facility had tried to help Resident #64 with his frequent attempts to self transfer and decrease falls. During an interview on 3/26/24 at 10:45 AM, Family Member (FM) RR reported that Resident #64 was supposed to be walked at least three times a day by staff to reduce his anxiety and prevent falls, but that the facility was not walking Resident #64 regularly. FM RR reported that they felt that the facility did not seem to have the staff to monitor the residents on the unit like they needed. FM RR reported that they had voiced their concerns to the facility, but they did not feel that the facility had addressed their concerns. During an interview on 3/26/24 09:49 AM, Director of Nursing (DON) B reported that the fall interventions in place for Resident #64 included daily walks and constant supervision. DON B reported that it was his expectation that staff never leave the main living room area of the unit unsupervised. DON B did not elaborate on how the nursing staff were to complete their work and provide the necessary supervision at the same time with only 2 CNA's on the unit. Review of a facility Policy / Procedure titled Fall Prevention dated 7/11/2018 revealed: POLICY: It is the policy of this facility that the Fall Prevention Program is designed to ensure a safe environment for all residents. Each resident will be evaluated upon admission, quarterly and as needed by an RN/LPN to assess his/her individual level of risk. The Interdisciplinary Team will review the Fall Risk Assessment completed by the nursing department and if appropriate, a fall prevention protocol will be initiated. PURPOSE: 1 .To identify residents at risk in a timely manner. 2 . To gather accurate, objective and consistent data for the purpose of implementing and individualized plan of care designated to meet the resident's needs 3 . To ensure consistency in the implementation of preventive measures to assist with the reduction of falls .4. To evaluate outcomes .5. The Director of Nursing/designee will be responsible for tracking resident falls. 6. The Director of Nursing/designee will be responsible for ensuring that residents who have been identified at risk or who have experienced a recent fall have all recommended interventions in place as well as current assessments and documentation reflecting family/responsible party. 7. The Director of Nursing/designee will conduct a weekly Fall Committee Meeting consisting of Interdisciplinary Team members. They will review the falls for the week to identify issues and/or trends Review of a facility Policy / Procedure titled Gait Belt-Transfer Belt dated 7/11/2018 revealed: POLICY: It is the policy of this facility to: Provide safety for the unsteady and/or confused resident. Aid in the transfer of the dependent resident. Prevent injuries to employees and residents (i.e. back strain or potential for chronic disability, resident falls, or fractures). Allow the resident and aide to feel more secure during a transfer. PROCEDURE: Supplies: Gait belt/ Transfer belt Gather supplies. Explain procedure to resident. Provide privacy. Wash hands. AMBULATION .1. Place gait belt around resident's waist. 2. Assist with non-slip shoes and any prescribed brace. 3. Assist resident to standing position. 4. Grasp belt at the back. 5. Walk on resident weak side and a little to the back. 6. Observe face for: A. Signs of pain B. Perspiration C. Pallor D. Cyanosis 7. Observe for general weakness in body and gait. 8. Know and respect residents' limitations. 9. Discard equipment or return it to the appropriate location. 10. Wash hands. 11. Document all appropriate information in medical record

This citation pertains to Intake # MI 302. Based on observation, interview, and record review, the facility failed to implement transmission-based precautions for new admissions/readmissions, ensure new admissions/readmissions remained in private rooms when possible, and utilize appropriate PPE (Personal Protective Equipment) per CDC guidance to prevent the spread of COVID-19, in 5 of 5 residents (Resident #105, #103, #106, #107, & #108) reviewed for infection control, resulting in an Immediate Jeopardy when on 9/4/20, Resident #105 was admitted to the facility from the hospital with no transmission-based precautions in place for care. This deficient practice placed all 74 residents at risk for serious harm and/or death due to the likelihood of cross-contamination and development and transmission of a highly contagious infection, COVID-19, within a susceptible population. Findings include: On 9/16/20, Administrator A was notified of an Immediate Jeopardy that began on 9/4/20 when Resident #105 was admitted to the facility from the hospital, with no transmission-based precautions in place for care. On 9/17/20, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. Residents Identified: -Resident #103, #105, #106, #107 and #108 have been placed under transmission precautions for a minimum of a 14-day quarantine per CDC guidance. -The facility's 8 new admissions had been placed under transmission precautions for a minimum of a 14-day quarantine per CDC guidance. -Staff will utilize appropriate PPE while providing care to residents under transmission precautions per CDC guidance. -All newly admitted and readmitted residents will be placed in isolation with droplet precautions for a minimum of 14 days and cohorted as applicable per CDC guidance. 2. Other Residents at Potential Risk: -On September 16, 2020, the facility completed an audit to ensure that all new admissions and re-admission were placed on a transition unit and monitored for a minimum of 14 days and ensured staff were using all recommended PPE per CDC guidelines. -Donning/Doffing policies, Droplet/Contact precaution polices and COVID19 policies were reviewed on 9/16/20 by the IDT (Interdisciplinary Team) and deemed appropriate. 3. In-Service: -On September 16, 2020, 31% of facility staff were in-serviced on Guidance-COVID-19 Core Practices Policy and Procedure. Staff will be in-serviced prior to placing on the schedule (Note onsite verification revealed education for all actively working staff members was not initiated until 9/17/20). In-service focused specifically: o Transmission Precautions o Appropriate PPE while providing care to residents under transmission precautions o Cohorting of all new admissions. o New admissions/readmissions will be placed on a transition unit for a minimum of a 14-day quarantine 4. Monitoring: -New admissions/re-admissions will continue to be placed on a transition unit and monitored a minimum of 14 days. -Staff will be monitored to ensure that they are utilizing all appropriate PPE for residents placed under transmission precautions. -Monitoring will be completed 5 times a week for 4 weeks then weekly thereafter. -DON/designee is responsible for this monitoring. -Audits will be reviewed monthly at the facility's QAPI meeting. Although the Immediate Jeopardy was removed on 9/17/20, the facility remained out of compliance at a scope of widespread and severity of no actual harm with the potential for minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency. Review of the Centers for Disease Control and Prevention (CDC) guidance Preparing for COVID-19 in Nursing Homes, updated 6/25/20, revealed .Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 .HCP (Health Care Providers) should wear a facemask at all times while they are in the facility .When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others .Cloth face coverings should NOT be worn by HCP instead of a respirator or facemask if PPE is required . Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html Review of the Centers for Disease Control and Prevention (CDC) guidance Responding to Coronavirus (COVID-19) in Nursing Homes, updated 4/30/20, revealed .Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19 .All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown .Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE .New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). Testing at the end of this period could be considered to increase certainty . Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html Review of the facility policy/procedure COVID-19 Core Practices, updated 9/2/20, revealed .This document is designed to provide guidance to the facility regarding the COVID19 core practices that should remain in place even when the facility resumes normal practices/activities .The facility will implement source control measure(s) .Staff members will wear a face mask at all times while they are in the facility .When available, facemasks are generally preferred over cloth face coverings for staff members as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Cloth face coverings should NOT be worn by staff members instead of a N95 or facemask if PPE is required .The facility will have a plan for managing new admissions and re-admissions whose COVID-19 status is unknown .Resident placed in a single person room or in separate observation area .Staff members will wear an N95 or higher level respirator (or facemask if a N95 or respirator is not available), eye protection (eye goggles or face shield that covers the front and sides of the face), gloves and gown when caring for these residents .Resident will be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after admission .Testing at the end of this period can be considered to increase certainty that the resident is not infected . In an interview on 9/15/20 at 8:58 a.m., Minimum Data Set (MDS) Coordinator N reported the Beechwood Lane unit within the facility is for new admissions/readmissions. MDS Coordinator N reported staff are required to wear eye protection and a mask when on the unit. In an observation on 9/15/20 at 9:48 a.m., observed a sign on the closed doors leading to the Beechwood Lane unit which read .Notice Everyone Entering This Unit Needs to be Wearing a Face Mask and a Face Shield . No additional signage or postings noted to indicate the need for gowns/gloves/or N95 masks when providing care to newly admitted residents on the Beechwood Lane unit. In an observation on 9/15/20 at 9:50 a.m., observed the Beechwood Lane unit. No gowns or isolation carts were noted in the hallway, and no signage was noted on any of the resident rooms to indicate the need for transmission-based precautions. Noted Resident #103, #105, #106, #107, and #108 all resided on the Beechwood Lane unit. In an interview on 9/15/20 at 9:59 a.m., Certified Nursing Assistant (CNA) R reported PPE required on the Beechwood Lane unit included eye protection and a face mask, along with gloves. CNA R reported all of the residents on the Beechwood Lane unit are tested for COVID-19 prior to admission. CNA R reported if any newly admitted residents developed symptoms of COVID-19, they would be placed on transmission-based precautions, and gowns would be utilized for care. In an observation on 9/15/20 at 11:48 a.m., observed Licensed Practical Nurse (LPN) Z at the medication cart on the Beechwood Lane unit. Noted LPN Z wore a cloth face mask and eye protection while on the unit. In an interview on 9/15/20 at 11:48 a.m., LPN Z reported both eye protection and a face mask are required on the Beechwood Lane unit. LPN Z reported staff can either wear a cloth mask or a surgical mask while on the unit, depending on preference. LPN Z reported gowns would be utilized for residents with symptoms of COVID-19, or those who test positive for COVID-19. Resident #105 Review of an Admission Record revealed Resident #105 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #105, dated 9/9/20, revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated the resident was cognitively intact. Review of an Order Summary Report, dated 9/16/20, revealed no physician's order related to the need for transmission-based precautions when providing care to Resident #105. Review of a current Care Plan, dated 9/16/20, revealed no focus related to the risk of development of COVID-19, and no interventions to indicate the need for transmission-based precautions when providing care to Resident #105. In an observation on 9/15/20 at 11:36 a.m., observed Resident #105 in her room, working with Physical Therapy Assistant (PTA) I. Noted Resident #105 had a roommate at this time. Observed PTA I wore a cloth mask and eye protection while she worked with Resident #105. No gown, gloves, or N95 mask were utilized for care, and no signage was noted on the door to Resident #105's room to indicate the need for transmission-based precautions. In an observation on 9/15/20 at 11:44 a.m., observed Resident #105 as she walked in the hallway using a gait belt and walker, with the assistance of PTA I. Noted Resident #105 wore a cloth mask while in the hallway, and PTA I wore a cloth mask and eye protection, with no gown, gloves, or N95 mask utilized for care. In an interview on 9/15/20 at 2:30 p.m., PTA I reported she had been wearing a surgical mask, but her glasses had fogged up, so she switched to her personal cloth mask. PTA I reported a mask and eye protection is required on the Beechwood Lane unit. PTA I reported if a resident required additional transmission-based precautions, there would be a sign on the door to the resident's room, and a cart of Personal Protective Equipment (PPE) in the hallway. In an observation on 9/16/20 at 9:55 a.m., observed Licensed Practical Nurse (LPN) Z enter Resident #105's room and administer Resident #105's morning medications. Noted LPN Z wore a cloth mask and eye protection for medication administration. No gown, gloves, or N95 mask were utilized. No sign noted on Resident #105's door to indicate the need for transmission-based precautions. Resident #103 Review of an Admission Record revealed Resident #103 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of an Order Summary Report, dated 9/15/20, revealed no physician's order related to the need for transmission-based precautions when providing care to Resident #103. Review of a current Care Plan, dated 9/15/20, revealed no focus related to the risk of development of COVID-19, and no interventions to indicate the need for transmission-based precautions when providing care to Resident #103. In an observation on 9/15/20 at 2:17 p.m., observed Housekeeper Y as she cleaned in Resident #103's room. Noted Housekeeper Y wore a white cloth mask and eye protection while in Resident #103's room. No gown was utilized. Noted Resident #103 had a roommate at this time. In an interview on 9/15/20 at 2:20 p.m., Housekeeper Y reported staff have the option to wear either a surgical mask or a cloth mask while on the Beechwood Lane unit. Housekeeper Y stated .I would wear a gown .if there was a case of COVID . or if the resident had symptoms of COVID-19 or had tested positive for COVID-19. Housekeeper Y reported there would be a sign on the door to the resident's room to indicate the need for transmission-based precautions. In an observation on 9/16/20 at 9:30 a.m., observed Certified Nursing Assistant (CNA) R respond to a call light for Resident #103. Noted CNA R wore a surgical mask and eye protection as she entered Resident #103's room. No gown, gloves, or N95 mask were worn. In an observation on 9/16/20 at 9:45 a.m., observed Licensed Practical Nurse (LPN) Z enter Resident #103's room and administer Resident #103's morning medications. Noted LPN Z wore a cloth mask and eye protection for medication administration. No gown, gloves, or N95 mask were utilized. No sign noted on Resident #103's door to indicate the need for transmission-based precautions. In an interview on 9/16/20 at 9:51 a.m., LPN Z reported since she started at the facility, she has not encountered a situation where an N95 mask was needed, and has not provided care to any residents on transmission-based precautions. Resident #106 Review of an Admission Record revealed Resident #106 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of an Order Summary Report, dated 9/17/20, revealed no physician's order related to the need for transmission-based precautions when providing care to Resident #106. Review of a current Care Plan, dated 9/17/20, revealed no focus related to the risk of development of COVID-19, and no interventions to indicate the need for transmission-based precautions when providing care to Resident #106. In an observation on 9/16/20 at 9:31 a.m., observed Certified Nursing Assistant (CNA) R as she responded to a call light for Resident #106. Noted CNA R wore a surgical mask and eye protection to assist Resident #106 with a transfer. No gown or N95 mask were utilized for care. No sign was noted on Resident #106's door to indicate the need for transmission-based precautions. In an observation on 9/16/20 at 10:18 a.m., observed Speech Language Pathologist (SLP) T as she sat beside Resident #106's bed and worked with the resident on speech/swallowing exercises. Noted SLP T wore a cloth mask and eye protection, with no gown, gloves, or N95 mask utilized. No sign was noted on Resident #106's door to indicate the need for transmission-based precautions. In an interview on 9/16/20 at 10:26 a.m., SLP T reported that full PPE (gown, gloves, N95 mask, and eye protection) is utilized for residents on .respiratory precautions . SLP T reported residents on transmission-based precautions should have a sign on the door to indicate the type of precautions, and a bin of PPE outside the door, near the entrance to the room. SLP T reported the Beechwood Lane unit is for newly admitted /readmitted residents, and reported the only PPE required is a mask and eye protection. SLP T reported in regard to masks, it is up to the staff member to decide which type of mask they want to wear (cloth, surgical, or N95). Resident #107 Review of an Admission Record revealed Resident #107 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of an Order Summary Report, dated 9/17/20, revealed no physician's order related to the need for transmission-based precautions when providing care to Resident #107. Review of a current Care Plan for Resident #107, dated 9/17/20, revealed the focus .Resident is at risk for/has a psychosocial well-being concern r/t (related to) Disease process, recent admission and medically imposed restrictions associated with covid 19 precautions . initiated 9/14/20, with interventions which included .Educate staff, residents, family and visitors of covid 19 s/s (signs/symptoms) and precautions. Follow facility protocol for covid screening and precautions . In an interview on 9/16/20 at 9:56 a.m., Physical Therapist (PT) S reported N95 masks are available for use, but not required to be worn for newly admitted /readmitted residents. In an observation on 9/16/20 at 10:12 a.m., PT S entered Resident #107's room to assist with AM care. Noted PT S wore a surgical mask and a face shield, with no gown or N95 mask utilized for care. Observed Resident #107 had a roommate at this time. Observed Certified Occupational Therapy Assistant (COTA) U enter Resident #107's room to assist PT S with care provided. Noted COTA U wore a surgical mask and eye protection, with no gown or N95 mask utilized for care provided. No signage noted on Resident #107's door to indicate the need for transmission-based precautions. In an interview on 9/16/20 at 10:53 a.m., COTA U reported the only PPE required on the Beechwood Lane unit is a mask and eye protection. COTA U reported full PPE (gowns, eye protection, gloves, and N95 masks) would be required if they had a resident who was positive or presumed positive for COVID-19. Resident #108 Review of an Admission Record revealed Resident #108 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of an Order Summary Report, dated 9/17/20, revealed no physician's order related to the need for transmission-based precautions when providing care to Resident #108. Review of a current Care Plan for Resident #108, dated 9/17/20, revealed the focus .Resident is at risk for/has a psychosocial well-being concern r/t (related to) admission to snf (Skilled Nursing Facility) for medical condition, ineffective coping, and medically imposed restrictions associated with covid 19 precautions . initiated 9/10/20, with interventions which included .Educate staff, residents, family and visitors of covid 19 s/s (signs/symptoms) and precautions. Follow facility protocol for covid 19 screening and precautions . In an observation on 9/16/20 at 10:56 a.m., observed Speech Language Pathologist (SLP) T as she sat beside Resident #108's bed and provided therapy services. Noted SLP T wore a cloth mask and eye protection, with no gown, gloves, or N95 mask utilized. No sign was noted on Resident #108's door to indicate the need for transmission-based precautions. Note LPN Z, PTA I, Housekeeper Y, SLP T, PT S, and COTA U all provide care and services to residents throughout the facility, outside of the Beechwood Lane unit. In an interview on 9/16/20 at 11:09 a.m., with MDS Coordinator N and Executive Assistant O, MDS Coordinator N reported newly admitted and readmitted residents are tested for COVID-19 prior to admission, and once a negative test is verified, placed on the Beechwood Lane unit for 14 days. MDS Coordinator N reported all staff are required to wear a mask and eye protection when on the Beechwood Lane unit. MDS Coordinator N and Executive Assistant O reported any type of cloth or surgical mask would be appropriate for use on the Beechwood Lane unit when providing care for newly admitted /readmitted residents. Executive Assistant O reported the N95 masks are available for staff, but not required. In an interview on 9/16/20 at 12:11 p.m., Region Five Medical Response Coalition Staff BB reported all recommendations made to facilities follow the State of Michigan guidelines and the CDC recommendations. Region Five Medical Response Coalition Staff BB reported all newly admitted /readmitted residents to Long Term Care (LTC) facilities should be placed in transmission-based precautions and cared for using all recommended COVID-19 PPE, even if they tested negative for COVID-19 prior to admission. In an interview on 9/16/20 at 1:28 p.m., Health Department Emergency Preparedness Coordinator AA reported even with a negative COVID-19 test, newly admitted /readmitted residents to LTC facilities should be placed on transmission-based precautions and cared for using all recommended COVID-19 PPE. In an interview on 9/16/20 at 1:43 p.m., Health Department Communicable Disease Section Staff CC reported the current recommendation for new admissions to LTC facilities is to isolate the residents for 14 days and care for the residents with full PPE (gown, gloves, eye protection, and an N95 mask), even if a negative COVID-19 test is obtained prior to admission.

This citation pertains to intake number MI 143. Based on observation, interview, and record review, the facility failed to implement safety interventions to prevent a fall with injury and thoroughly investigate the cause of a fall for 1 (Resident #101) of 3 residents reviewed for falls, resulting in a fall with fracture and the decreased potential to preventing further falls with injuries. Findings include: Review of a Face Sheet revealed Resident #101 was an 81year-old female, originally admitted to the facility on [DATE] and re-admitted [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 1/24/19 revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated Resident #101 was cognitively impaired. The MDS further indicated, Resident #101 did not have balance during transitions and walking. Her transfer into a standing position and walking in her room required supervision with a one-person physical assist. To move about the facility a wheelchair was utilized as the MDS indicated Resident #101 could not ambulate on her own. Review of Resident #101's Physician order [REDACTED]. Review of Resident #101's Resident Profile, (care guide for nursing staff) dated 2/4/19, revealed the Problem Category: Falls had an Approach Category that included Resident #101 should wear proper footwear, the call-light and frequently used and assistive devices be within reach, and a pressure alarm to bed and chair. Review of the Unusual Occurrence Report dated 2/1/19 at 5:50 pm revealed Resident #101 had an unattended fall and was found in her room on her back and complained of right hip and back pain. The Post Fall Assessment revealed there was an alarm in place and working at the time of the fall. Review of the written witness statement by Certified Nursing Assistant (CNA) I revealed Resident #101 had a pressure alarm in place, but it was not sounding when she found the resident in the room on the floor. CNA I documented that a visitor in the room stated Resident #101 had turned the alarm off. Resident #101 was sent to the hospital for evaluation. During an interview on 2/12/19 at 3:57 PM, Certified Nursing Assistant (CNA) I stated, (Resident #101) has an alarm on her wheelchair and bed. She turns off the alarms to both all the time. She was a CNA for 30 some years and she knows how to turn them off. Everyone knows she knows how to turn off the alarms. The nurses have seen her turn off the alarms. I never told the Director of Nursing. When she turns them off, the alarms, she would get up and fidget in her room. As soon as we knew she had turned off the alarms we would stand by her while she would be doing what she wanted to do in her room. I never considered it as a behavior because she did this her whole life; it was her room. It is where she lived. During an interview on 2/12/19 at 12:20 PM, Certified Nursing Assistant (CNA) L stated, (Resident #101) will stand up and turn off the pressure alarm when she doesn't want it on. During an observation and interview on 2/12/19 at 12:12 PM, Resident 101 stated, I know I have some kind of something under my bed (pointing to the alarm next to her bed). I know how to turn it off. Observed Resident #101 lean towards the alarm. Resident #101 stated, I can't move my leg; I broke it. It has things holding it together. I can't fall again because I might break it again and that would be bad. I'm just not doing very well.(sic) During an interview on 2/12/19 at 2:24 pm, Licensed Practical Nurse (LPN) K stated, (Resident #101) has a bed alarm. When she tries to get up I go in when I hear it; it is high pitched. She was non-complainant in getting up on her own and moseying around her room. One night I heard the alarm and she was standing in her room looking for her clothes. I always checked on her frequently. During an interview on 2/12/19 at 2:37 PM, Registered Nurse (RN) F stated, (Resident #101) first came here she would try to get up. She said she had places to go and wanted to go smoke. She has a pressure alarm on her bed. She was a nurse aide for years and worked here on night shift. She probably knows about the alarms and how to turn them off. During an interview on 2/12/19 at 2:41 PM, CNA H stated, (Resident #101) would shut the alarm off and we (referring to nursing staff) would find her in her closet. There were no orders to check on her. I would check on her every time I would walk by her room. I've told the nurses. The nurses told me to just keep an eye on her. I did not document any time she shut off alarm. There really is no place to document what a resident does. During an interview on 2/12/19 at 3:32 PM, LPN/Education-Training Director O stated, I did not know (Resident #101) shut off her bed alarm. During an interview on 2/12/19 at 2:54 PM, Director of Nursing (DON) B stated, I wasn't aware of (Resident #101) getting up and shutting off her alarm. The night she fell the alarm went off. A visitor was on the other side of the curtain, heard the alarm, and saw (Resident #101) shut it off and fall. I didn't know she shut off her alarm. No one told me. I did not interview the visitor that was in the room at the time of the fall. She (Resident #101) was sent to the hospital after the fall for right hip pain. It was fractured and was surgically repaired. It happened on a Friday and she returned to the facility on the next Monday. Maintenance put the grip strips next to her bed that Monday. I was not aware she could or would turn off the alarm. During a second interview on 2/12/19 at 3:36 PM, DON B stated, I don't remember if I talked to anyone that wasn't present during this fall. The witness statements were of staff working that hall. They weren't in the room when (Resident #101) fell . Our Falls Committee is held during QA (Quality Assurance). Any time there is a fall and it is discussed during morning Triage so the other Department Heads are aware. The Administrator asks each Department Head what is going on in their area and that is how we know what is going on. We have never talked about (Resident #101) turning off her alarm. During an interview on 2/12/19 at 4:07 PM, Familiy Member J stated, (Resident #101) knew about the alarm on her bed. She would turn it off. (Resident #101) said she was trying to get something out of her closet when she fell . Review of Resident #101's Care Plan: Falls, dated 12/17/18, revealed the Care Plan was edited on 2/12/19 due to Resident #101 being readmitted to the facility after a fall with injury to right hip that required surgical repair. Resident #101 was at risk for falls and injury related to dementia, weakness, high blood pressure, and medications. The goal of the care plan was to have interventions in place to alleviate the risk of falls with significant injury. The Approach (intervention) to achieve the goal was to have a pressure alarm attached to Resident #10's bed and chair with a start date of 2/4/19. On the edit date, the pressure alarm to the bed was attached to the call-light system. Not included in the Care Plan was an intervention to stop Resident #101 from shutting off the pressure alarm. Review of Resident #101's Unusal Incidence Occurance Report Follow-up, dated 2/1/19, indicated the only action to prevent potental for reoccurrence was to place non-skid strips in front of Resident #101's bed. Documentation did not indicate that Resident #101's ability to turn off alarms would be addressed.

This citation pertains to intake numbers MI 842 and MI 056 Based on interview and record review, the facility failed to utilize the appropriate lift for a transfer for 1 of 4 sampled residents (Resident #703), reviewed for accidents/falls, from a total sample of 4, resulting in a fall with femur fractures when the resident was unable to support her weight in the lift during a transfer. Findings include: Review of the policy and procedure for Fall Management, no date, revealed The facility will identify each resident at risk for falls and implement a plan of care to alleviate the risk for falls .A plan of care will be developed for resident's identified as at risk with interventions to alleviate the risk for falls. Review of the Face Sheet revealed Resident #703 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #703, dated 8/18/16, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated that the resident was cognitively intact. Further review of the MDS assessment revealed the resident required extensive assistance with her transfers, had impaired range of motion in her upper extremities, and used a limb prosthesis. Review of the Falls Care Plan for Resident #703, revised 8/29/16, revealed the resident was .at risk for falling related to incontinence, use of psychoactive medications, diuretics, narcotic medications, unilateral (one sided) BKA (below knee amputation) . with interventions listed, which included .total lift for all transfers . with an approach start date of 8/15/16. Review of the Resident Profile for Resident #703, used by the Certified Nursing Assistants CNAs to identify care plan approaches revealed the approach, .Total lift for all transfers . with a start date of 8/15/16. Review of an Unusual Occurrence Incident Report, for a fall that occurred on 8/25/16 at 7:00 a.m., revealed that Resident #703 was lowered to the floor by a nurse and two CNAs after she lost her grip and began slipping out of the sling of the Encore lift, a sit-to-stand style of lift used for transfers. After the incident, X-rays were ordered for the right shoulder, right knee, and left hip due to increased pain in those areas. Per the report, action taken to prevent potential reoccurrence included Education to CNA related to using proper ordered assistive device .checking ADL's (Activities of Daily Living) for each resident prior to assistance. In an interview on 9/21/16 at 2:13 p.m., Licensed Practical Nurse (LPN) E reported that she responded to a request for assistance due to a fall on 8/25/16. LPN E reported that CNA I had attempted to transfer the resident with a sit-to-stand lift to her electric wheelchair. The resident was unable to transfer successfully and had to be lowered to the floor. LPN E reported that after the fall, the total lift was used to assist the resident back to the bed. LPN E stated that after the fall she asked the resident what had happened, and she reported that she had lost her grip and could not support her weight on the lift. LPN E indicated that X-rays were ordered after the fall due to increased complaints of pain. Review of the Witness Investigation Statement for CNA I, the CNA who had transferred Resident #703 with the Encore lift at the time of the fall, revealed After getting the resident checked and changed and dressed sat resident up on side of bed and proceeded to get her in the encore lift .before I could get her in her chair, she stated she could not hold on an starting sliding down .called code yellow and she ended up sitting on her foot rest . Review of the X-ray report for Resident #703, dated 8/25/16, revealed .Total left hip prosthesis is seen, appearing to be in good position. A vertical lucent line is faintly visualized in the lateral aspect of the proximal right femur, suggesting a recent hairline fracture .Total right knee prosthesis seen, appearing to be in good position. An oblique vertical hairline undisplaced fracture, appearing to be acute is seen in the distal portion of the shaft of the right femur well above the level of the knee joint . In an interview on 9/21/16 at 5:07 p.m., Director of Nursing (DON) B reported that CNA I should have used the total lift to transfer Resident #703 on 8/25/16, as stated in the care plan. DON B clarified that the resident had only used the sit-to-stand lift with therapy. DON B reported that the expectation for transfers would be to check the resident's care plan/resident profile prior to the transfer to verify transfer status.

Based on observation, interview, and record review, the facility failed to prevent avoidable pressure ulcers for 2 of 4 residents reviewed for pressure ulcers (Resident #1 and Resident #2), from a total of 15 sampled residents, resulting in 3 unstageable pressure ulcers for Resident #2, and the potential for infection, pain, debility, and the potential for reoccurrence of pressure ulcers for Residents #1 and #2. Findings include: Review of the facility Pressure Ulcer Prevention Policy and Procedure, dated 8/2013, revealed, Resident who enters the facility without pressure sores do not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable . The policy did not specify how, when, or by whom the facility acquired pressure ulcers were to be analyzed as to whether they were avoidable/unavoidable. Resident #2 According to Resident #2's MDS/Minimum Data Set, dated dated [DATE], he was admitted to the facility on [DATE], had severe cognitive impairment, needed total assistance with ADLS/Activities of Daily Living, was incontinent of bowel and bladder, had no pressure ulcers but was at risk for developing pressure ulcers, and had [DIAGNOSES REDACTED]. Resident #2's Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other records dated 9/08/15, revealed he had an unstageable Pressure area on his left heel. (4 cm x 7 cm x deep tissue injury); the Skin Grid revealed the left heel pressure areas measurement remained on 9/14/15, 9/23/15, 9/29/15, 10/07/15, and 10/15/15 (4 cm x 7 cm x unstageable), and on 10/22/15 it was improved (0.5 x 0.5 x unstageable). Another of Resident #2's Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other records dated 9/08/15, 9/14/15, 9/23/15, 9/29/15, and 10/07/15 revealed he had a R/right lateral heel and foot deep tissue injury (3 cm x 6 cm x unable to determine); on 10/15/15 the area measured 3 cm x 3 cm and 1/2 dried dark skin dried and cm off on bandage .; on 10/22/15 it remained unstageable - area is 100% necrotic (dead tissue), mild odor and moderate drainage (1 cm x 1.5 cm). Resident #2's Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other records, dated 9/30/15, revealed an unstageable - other on his buttocks (2 x 0.5). On 10/07/15 the area was documented as Stage II (1.5 cm x 0.4 cm x 0.2 cm); on 10/14/15 it was still classified as Stage II (1 cm x 0.4 cm x 0.2 cm), and on 10/22/15 it was resolved. Review of all of Resident #2's physician progress notes [REDACTED]. 10/01/15, revealed no documentation regarding Resident #2's skin condition. According to Physician Orders, an alternating air mattress was ordered for Resident #2 on 10/02/15. According to Resident #2's Skin Integrity Assessment and Plan of Care, dated 4/22/15, Goal: Alleviate risk for development of pressure ulcers, and Approaches included: .turn and reposition q (every) 2 hours .float heels in bed ., and on 9/10/15 bil (bilateral) heel protectors .keep pressure off heels .alternating air mattress .last up/first down. According to Dietary Progress Notes, dated 9/09/15, .cont's (continues) with dys (dysphagia/difficulty swallowing) diet with PO (oral) intakes 80 - 90 % stable. Receives 4 oz (ounces) Healthshakes qd (every day) .no S/S (signs and symptoms) dehydration . Recommend [MEDICATION NAME] foods to provide (added calories) to promote healing . On 10/27/15 at 12:10 AM, Resident #2 was observed sitting in a high back chair with a pummel cushion and a pressure alarm under his buttock. This Surveyor attempted to speak with Resident #2, but he did not respond with words, eye contact, or facial/movements. On 10/28/15 at 9:15 AM and 10:00 AM, Resident #2 was observed laying in bed on his back with pillow under his legs; at 12:30pm he was observed sitting up in a high back/titling wheelchair at an approximately 35 degree angle; at 3:30 PM Resident #2 was observed with a wedge cushion with a slick blue cover on it, positioned on his left side - however, Resident #2 was not turned to his side/he was completely on his back. In an interview, on 10/28/15 at 3:20 PM, LPN/Licensed Practical Nurse/Unit Manager Q reported she was not sure why Resident #2 developed pressure ulcers at the facility, and said, We turn him and reposition him, and get him up in the wheelchair. I really don't know why. When asked if she thought Resident #2's pressure sores were avoidable or unavoidable LPN Q said he probably should not have acquired the pressure ulcers because he was eating 100 % of his meals and drinks well too. In an interview, on 10/28/15 at 3:31 PM, Medical Director J reported Resident #2's pressure ulcers were avoidable. On 10/28/15 at 5:10 PM, Resident #2 was observed laying in bed on his back. On 10/29/15 at 8:30 AM, Resident #2 was observed sitting upright in his high back wheelchair. In an interview, on 10/29/15 at 8:35 AM, LPN/Wound Nurse R stated she did not know how to determine if a pressure ulcer was avoidable or unavoidable, and did not know whether Resident #2's pommel (positioning) cushion provided adequate pressure relief. Wound Nurse R said, I don't know a lot about cushions. Wound Nurse R stated, (Resident #2) turns pretty good, but likes to slip off the wedge. On 10/29/15 at 9:19 AM, DON/Director of Nursing B reported the facility did not analyze whether facility acquired pressure ulcers were avoidable or unavoidable. In the presence of Wound Nurse R, on 10/29/15 at 1:45 PM, this Surveyor observed Resident #2's coccyx and left heel were healed and a red, approximately 1 cm x 0.5 cm x 0.25 cm red area remained on his right heel. Wound Nurse R stated Resident #2 acquired his heel pressure ulcers from bearing down. On 10/29/15 at 9:20 AM, 10:15 AM, Resident #1 was observed in his bed laying quietly on his back and his heels on the bed; at 1:05 PM he was observed sitting upright and motionless in his high back/tilting wheelchair. ( ) Resident #1 According to Resident #1's MDS dated [DATE] and 10/05/15, he was admitted to the facility on [DATE], needed extensive assistance with ADLs, had an indwelling catheter, was on oxygen, had no pressure ulcers, and had [DIAGNOSES REDACTED]. According to a physician progress notes [REDACTED].#1 also had [DIAGNOSES REDACTED]. According to Resident #1's Admission Data Collection, dated 2/20/14, Resident #1 had a pink area on his coccyx, and a Admission Skin Assessment, dated 4/06/15, revealed Resident #1's coccyx was red. Resident #1's Braden Pressure Ulcer Risk Tool, dated 4/06/15, 4/10/15, 5/29/15, 7/02/15, and 7/13/15 revealed a score of 12 each of those days (12 or less = High Risk). On the last Braden Pressure Ulcer Risk Assessment recorded, dated 10/04/15, revealed RN/Registered Nurse/Unit Manager L gave Resident #1 a score of 16 (Low Risk). According to physician orders [REDACTED]. Pat Dry and apply Maxsorb. Cover with [MEDICATION NAME] (dressing). Change daily and prn/as needed. Observe q (every) shift til resolved. According to Resident #1's Skin Integrity Assessment & Plan of Care, open area L/left buttock (dated 10/20/15), and abrasion to R buttock (dated 10/21/15); the Goal was Alleviate risk for development of pressure ulcers; and Approaches included: Turn and position q 2 hours .float heels in bed .no brief in bed .turn q 2 hours/avoid back, and last up/first down. According to TAR/Treatment Administration Records, Resident #1 had a pommel cushion to wheelchair (started 5/29/15), and a Broda chair for increased postioning (started 8/13/15). According to Dietary Notes, dated 10/05/15, .PO (by mouth) intakes are good at 80 - 100 % - stable wt (weight) .Skin remains intact - labs (9/2) alb ([MEDICATION NAME]/protein) 2.9 (L/low) - improved was 2.6 )7/4) .no noted S/S (signs/symptoms) dehydration . According to a Skin Grid, dated 10/20/15, Resident #1 had a wound on his left buttocks that measured 0.5 cm x 0.5 cm x 0.1 cm, amount of drainage - minimal, that was not caused by pressure (other was checked). On 10/27/15 at 12:10 PM, Resident #1 was observed with his oxygen cannula on his chin, sitting up in a Gerichair with a pommel cushion (positioning device between his legs). LPN/Wound Nurse R stated Resident #1 needed the pommel cushion because he scooches forward and would fall out of the chair if he did not have it. On 10/28/15 at 9:15 AM, 10:00 AM, and 10:30 AM Resident #1 was observed laying in bed on his back at an approximate 20 degree angle. On 10/28/15 at 10:30 AM, in the presence of LPN O and LPN P, this Surveyor observed peri care and wound care for Resident #1. After LPN O and LPN P turned Resident #1 to his left side, they removed an adult brief ( Plan of Care: no brief in bed) soiled with a large amount soft stool. There was a Stage II pressure ulcer present on Resident #1's left buttock and when cleansed, Resident #1 winced and cried out. LPN P measured the red, cratered open area (0.7 cm x 0.6 cm x depth not measured. The tissue surrounding the wound (approximately 4 cm in diameter) was brownish red and intact. After LPN O and LPN P completed care, they repositioned Resident #1 on his back. On 10/28/15 at 12:30 PM, Resident #1 was observed sitting upright at a 45 degree angle in his Geri chair. In an interview, on 10/28/15 at 3:20 PM, LPN/Licensed Practical Nurse/Unit Manager Q was asked why she thought Resident #1 acquired the pressure ulcer and Unit Manager Q said, I don't know .He's a good eater. Eats well and drinking almost 100 %. On 10/28/15 at 3:30 PM and 5:10 PM, Resident #1 was observed laying on his back in bed. On 10/29/15 at 8:45 AM, Resident #1 was observed sitting upright in his Geri chair. On 10/29/15 at 10:18 AM Nurse Aide N reported I just left him. I just turned (Resident #1) on his side .I have no idea why he got a pressure ulcer. I make sure he is turned every 2 hours. He is turned toward the bathroom right now. A lot of times he ends up again on his back. There is a pillow under his heels .The pillows are a little flat. This Surveyor and Nurse Aide N went to Resident #1's room and observed him laying on his back with his heels resting on the bed; the pillows Nurse Aide N used to support Resident #1 were flat/ineffective. ( )

This citation has 2 deficiency practice statements, A & B. This portion of the citation pertains to MI 040. A. Based on observation, interview and record review the facility failed to ensure accurate monitoring of the hydrocollator temperature and documentation of hot pack treatments and protect 1 resident (#1) from hot pack burns out of 5 residents evaluated for accidents from a total sample of 18 resulting in 2 partial thickness burns. Findings include: According to the Face Sheet and [DIAGNOSES REDACTED]. According to the Minimum Data Set (resident assessment), dated 8/18/14, Resident #1 had good long and short term memory and required the assistance of 1 staff for repositioning in bed, transfers, dressing, hygiene, toileting and bathing. According to the facility's "Individual Plan Report" (care plan for aides), Resident #1 was to be repositioned every 2 hours while in bed. According to the facility's incident/accident report, Resident #1 was found to have a a reddened area with a smaller, white area on her right upper back at approximately 6:45 a.m. on Friday, 8/29/14. According to the Michigan Department of Community Health: Scalding Injuries Caused By Excessive Hot Water, Food and Hot Beverage Temperatures, revised 8/5/09, the elderly are particularly at increased risk because their skin tends to be less sensitive and reaction times are reduced, causing a tendency to not pull away from hot water quickly enough to avoid scalding. Their thinner skin also burns full depth more quickly. According to the facility's "Pain Data Collection" assessment, dated 8/29/14, the following was documented for Resident #1: under pain location: "(upper) r (right) back"; date of onset: "8/29/14"; cause of pain: "burn"; duration of pain: "worse when laying down". On 9/9/14 at 11:30 a.m. Licensed Practical Nurse (LPN) "DD" was observed during a dressing change on Resident #1's upper right back area. Resident #1 was seated in her recliner, fully dressed and groomed, wearing glasses and shoes with a red afghan on her lap. LPN "DD" removed the bandaid, and an approximately 1/2 inch by 1/4 inch light-brown area with intact skin was observed. LPN "DD" said that the other blister had healed. On 9/9/14 at 1:50 p.m., Certified Nurse Assistant (CNA) "V" was interviewed. When asked, CNA "V" said that she assisted Resident #1 to the bathroom at the beginning of the day shift on Friday, 8/29/14. While preparing to bath and dress Resident #1, CNA "V" noticed a reddened area on Resident #1's right upper back. As CNA "V" left the room to report to a nurse, she noted a cold-to-the-touch hot pack in Resident #1's bed. When asked, CNA "V" said that she was not told in report that Resident #1 was given a hot pack in the night, nor was she aware that Resident #1 had received hot pack therapy from anyone in the past. When asked if she had ever received training on applying hot packs to the elderly resident, CNA "V" said, "No, but I do know that heat is a danger to the elderly's thin skin". On 9/9/14 at 2:15 p.m., Rehab Director "T" was interviewed. When asked Rehab Director "T" said that the professional use of hot pack treatment on elderly residents had not changed in several years. When asked how hot pack treatments were done by the therapy department, Rehab Director "T" said that: -6 to 8 layers of padding and another layer of terry cloth were used between the hot pack and the skin; each pad was equivalent to 4 layers of terry cloth, so, 2 pads are used with another layer of terry cloth. -maximum time was 20 minutes for a treatment. -the hydrocolator's (device filled with water to heat the hot packs) temperature was checked every few days and recorded on a log, and they kept their temperature at 160 degrees Farenheit. -the therapist applying the hot pack to a resident would assess the resident's skin under the hot pack after 5 minutes of treatment. -hot packs were documented on therapy progress notes as, "modalities as needed", and required a physician's orders [REDACTED]. -the hot pack might be applied in the resident's room by a therapist. When asked, Rehab Director "T" said that hot pack therapy was only provided while the resident was receiving therapy from rehab. When asked where hot packs were placed on Resident #1, Rehab Director "T" said her chronic pain was upper lumbar and lower thoracic spinal pain (above the waist and just below the rib cage). On 9/9/14 at 2:45 p.m., Education Nurse "S" was interviewed. Nurse "S" said that she was called to the room by LPN "U" to assess a reddened area on Resident #1's right upper back area. Nurse "S" noticed that a "cold-to-the-touch" hot pack was in Resident#1's bed. When asked to describe the area, Nurse "S" sketched an area approximately 4 inches by 5 inches resembling the shape of a butterfly. The lower left reddened area had an approximately 1/2 inch white area, and the next day, a second, 1/2 inch white area was observed on the right lower aspect of the reddened area. These 2 areas developed into blisters, approximately 1/2 inch each, within 24 hours. When asked if Resident #1's burn area was painful, Nurse "S" said that, when she asked, Resident #1 stated, "It hurts down here", and rubbed an area lower on her spine. When asked, Nurse "S" was aware that therapy had used hot packs for Resident #1 while she was receiving their services, and that hot packs, "absolutely", needed an order from the physician. Nurse "S" said that there was no order for hot pack treatment for [REDACTED]. When asked, Nurse "S" said that CNAs "never" did hot pack treatments". "Superficial partial thickness burns extend superficially into the second layer of skin. Symptoms include: red skin that blanches (turns white) when pressure is applied (such as when pressing a finger on the skin), clear blisters (open or closed) are present and the skin (in the opened blister) is moist and painful". Found on-line at, http://www.woundcarecenters.org/article/wound-types/partial-thickness-burns. On 9/9/14 at 4:00 p.m., LPN"G" was interviewed via phone. When asked if she recalled documenting that Resident #1 received hot pack treatments for back pain in May 2014, LPN "G" said that she did. When asked who provided the hot packs, LPN "G" said that the therapy department did them. In an interview on 9/10/14 at 6:45 a.m., CNA "R" recalled that CNA "P" asked LPN "O" for a hot pack for Resident #1 around 2:30 a.m. LPN "O" was on her lunch break, said that hot packs were kept in the therapy room. CNA "R" said that, at about 4 p.m., she noticed a hot pack under Resident #1's right side while repositioning her. CNA "R" said that she placed the hot pack under Resident #1's left upper back. CNA "R" said, "I should have removed the heating pad and told the nurse". When asked if she had ever received training on hot pack treatments, CNA "R" said she couldn't recall, but didn't think so, "Maybe during her CNA class". When asked, CNA "R" said that she had never seen hot packs on another resident. ( ) B. Based on observation, interview, and record review, the facility failed to effectively maintain 2 of 14 restroom commode base mounts (D4 and D17) reviewed for stability, effecting 2 residents (Resident #6 & #11), resulting in the increased potential for resident accidental falls and/or injury. Findings include: On 9/10/14 at 1:35 p.m., an environmental tour of resident rooms was conducted with the Director of Maintenance "K" and the Director of Housekeeping and Laundry Services "L". The following item was noted: Commodes Resident #6 resided in Room D17, private room. The Minimum (MDS) data set [DATE] revealed Resident #6 was sometimes incontinent of bladder and not incontinent of bowel, was able to walk in the room with 2 person assist and required 2 person assist with bathing and hygiene. Resident #11 resided in Room D4 bed 2. The Minimum (MDS) data set [DATE] indicated Resident #11 was not incontinent of either bowel or bladder and was able to ambulate with a walker and/or wheelchair in the room. 2 (D4 and D17) of 14 restroom commode base mounts were observed loose allowing the entire porcelain fixture to shift from side to side, creating an accidental fall and/or injury hazard. The commode base could be moved from side to side approximately one to two feet, creating a personal resident injury hazard. Licensed Practical Nurse "Y" was queried regarding the loose commode base mount in room D17. LPN "Y" indicated she was not aware of the situation. Certified Nursing Assistant "Z" was queried regarding the loose commode base mount in room D17. CNA "Z" indicated she was not aware of the situation and was responsible for routinely checking resident rooms D12 thru D17 weekly during "Ambassador Rounds."

This citation pertains to intake number MI 363. Based on interview and record review the facility failed to prevent a fall with injury for 1 of 5 residents (#102) reviewed for falls, from a total sample of 4 residents, resulting in Resident #102 sustaining a left hip fracture. Findings include: The professional standard of quality for analyzing falls is "the facility's staff and practitioners attempt to identify causes of the conditions or problem...the facility's staff and practitioners use the information to decide how to best manage a resident's condition, symptom, or situation." (Clinical Process Guideline: Evaluation of Falls/Falls risk, Memorandum Dated 2/13/14, MDCH Clinical Advisory Panel) According to Legal and Ethical Issues in Nursing, 4th Edition, (Guido, G, 2006), a major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure, patient identification, medical support for the selected diagnoses, justification of the medical therapies used, accurate documentation of that which has transpired, and preservation of the record for a reasonable time period. Documentation must show continuity of care, interventions used, and patient responses. Nurses' notes are to be concise, clear, timely, and complete. According to the Face Sheet (undated) and the [DIAGNOSES REDACTED].#102 was a [AGE] year old male that was admitted to the facility 5/20/13 with [DIAGNOSES REDACTED]. Per the Significant Change MDS (Minimum Data Set - an assessment tool) dated 3/10/14, Resident #102 was severely cognitively impaired and demonstrated short and long term memory loss. Resident #102 required extensive assist of one staff member for bed mobility, transfer, dressing, and toileting. Resident #102 was occasionally incontinent (less that 7 episodes in the last 7 days). During an interview with Certified Nurse Aide (CNA) "C", on 4/2/14 at 11:00 a.m. on C-hall, CNA "C" stated that Resident #102 required staff assist with all ADL's (activities of daily living), was unable to control bladder function and wore an adult incontinent brief. According to the "Accident/Incident Report", dated 3/24/14 at 7:40 a.m., Resident #102 was "observed on floor on left hip...c/o (complained of) pain in left hip on movement/gentle ROM (range of motion). Under "Section A- Investigation, #4 Time last toileted it reflected 4:29 a.m. Per the facility document "Post Fall Assessment and Follow Up". It reflected the time of the fall was 7:40 a.m. in (Resident #102's room number), the question "Was the resident incontinent?" was checked "yes", the question "Can the resident toilet independently?" was checked "no", the question "Time resident was last toileted and by whom" were blank (no answer provided), the question "When was the resident last seen?" was at 6:00 a.m. by Registered Nurse (RN) "F". During an interview with the day shift RN "F" on 4/3/14 at 11:25 a.m. in the front office, RN "F" stated that prior to Resident #102's fall at 7:40 a.m., she had last seen Resident #102 at 6:00 a.m. but had not provided any hands on care. Review of the facility document "Bowel and Bladder Detail Report", the last documented entry of toileting or incontinent care for Resident #102 prior to the fall on 3/24/14 at 7:40 a.m. was 3/24/14 at 4:29 a.m. During an interview with day shift CNA "C" on 4/2/14 at 11:00 a.m. on C-hall, CNA "C", stated that she was assigned to Resident #102 for the shift beginning at 6:00 a.m. on 3/24/14, but had not toileted or checked for toileting needs yet on her shift, prior to the fall at 7:40 a.m., as Resident #102 was sleeping. CNA "C" stated she was unsure when Resident #102 was checked or toileted for his incontinent needs prior to the fall. During a telephone interview with midnight shift CNA "K" on 4/4/14 at 10:00 a.m., CNA "K" stated that she had been assigned to Resident #102 on the morning of 3/24/14. CNA "K" stated that she had last checked and changed Resident #102 about 4:30 a.m. and that the facility routine was to check resident's every two hours to see if residents need toileting or incontinent care including if needed brief change. Documentation in Caretracker (where CNA's document resident care) would only be needed if actual care was provided. During an interview with the Director of Nursing (DON) "B" and Licensed Nurse (facility educator) "L" on 4/3/14 at 3:30 p.m. in the front office, Both DON "B" and Licensed Nurse "L" stated that resident's individual toileting plan would be placed on resident's individual "Plan of Care" and the "Resident Care Guide". Resident #102 was on a toileting program but the facility standard of care and expectation was that residents are to be checked every two hours for toileting needs and assisted as needed. The expectation was that every two hours check would be recorded in Caretracker (where CNA's document resident care). DON "B" confirmed that Resident #102 had been incontinent at time of fall and was unable to confirm the last time Resident #102 had been checked and changed as per facility standard. DON "B" stated that Resident #102 was sent to the hospital on [DATE] with left hip fracture.

This citation pertains to intake # MI 666 Based on interview and record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical well-being of 1 (Resident #103) of 5 sampled residents from a total sample of 5 residents, when the facility failed to assess and monitor Resident #103 when Resident #103 was found to have a decreased level of consciousness on [DATE] and symptoms of a urinary tract infection [MEDICAL CONDITION]. Furthermore, the facility failed to notify Resident #103's physician of the acute change in condition; turned away an ambulance dispatched to transport Resident #103 to the hospital and failed to send Resident #103 to the hospital until another seven hours had elapsed. This deficient practice resulted in Immediate Jeopardy for Resident #103, who subsequently died , and placed 21 other Residents, identified by the facility being at risk for fluid volume deficit related [MEDICAL CONDITION] (a severe blood infection), specifically residents with Foley catheters, tube feedings and fluid restrictions, at risk for serious harm, injury and/or death. Findings include: Review of the Face Sheet revealed that Resident #103 was a [AGE] year-old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #103 had a court-appointed guardian. In an interview on [DATE], Licensed Practical Nurse (LPN) #5 reported that on [DATE] at 8:02 AM, Resident #103 had a decreased level of consciousness and was leaning to the right in his wheelchair. LPN #5 reported that she called 911 to send Resident #103 to the hospital and then called the legal guardian to report the change in condition and the fact that Resident #103 was being sent to the hospital. LPN #5 said she prepared the paper work and then asked the Unit Manager, Registered Nurse (RN) #4, to assist with Resident #103 because LPN #5 was caring for another resident, who was also being sent to the hospital. LPN #5 said she found out after lunch that Resident #103 was still at the facility and that RN #4 had sent the ambulance away. In an interview on [DATE] at 1:55 p.m., RN #4 said that on [DATE] at approximately 11:15 AM, she assessed Resident #103 in bed and noted his abdomen was distended and there was no urine in his Foley (urinary drainage) bag. RN #4 reported that she replaced Resident #103's catheter and had an immediate discharge of bloody, foul-smelling urine. RN #4 reported that after she inserted the new catheter, 600 cc of cloudy, foul smelling red urine came out and was used for a urine analysis (UA). RN #4 said Resident #103 became responsive and returned to his normal self after the 600 cc of urine was obtained. RN #4 reported she did not inform the physician of Resident #103's change in condition on [DATE]. Review of Nursing Progress notes for Resident #103, dated [DATE], revealed RN #4 made two notes for Resident #103 on that date. The first note was at 12:15 PM and documented that Resident #103 was lethargic, leaning to the right and was slow to respond. Resident #103's catheter (urinary drainage) bag was empty, prompting RN #4 to change Resident #103's catheter and Resident #103 had an immediate discharge of a moderate amount of bloody urine. When the new catheter was inserted, Resident #103 had 600 cc of pale red, cloudy, foul smelling urine. This urine sample was sent out for testing. RN #4 documented again at 2:00 PM that Resident #103 was resting quietly in bed and responded to voice. Resident #103's urine in the catheter tubing was still red. No vital signs were noted. Review of the Nurse's Note, dated [DATE] at 2:30 PM, revealed Resident #103 had amber urine with particulate matter having a foul odor. The note indicated Resident #103 had his eyes closed, his respirations were even, his skin was warm to the touch and he had a fever of 100.4 degrees Fahrenheit. The note indicated Resident #103 received a Tylenol suppository for the fever. There was no documentation that the physician was notified of Resident #103's fever or urinary symptoms. Review of the Nurse's Note, dated [DATE] at 4:00 PM, revealed Resident #103's court-appointed guardian arrived at the facility and "was concerned about the resident's level of consciousness and requested he be sent to the emergency room (ER). Doctor notified." In an interview on [DATE] at 12:35 p.m., RN #6 stated that during shift report on [DATE], she heard about Resident #103's catheter problem and that the ambulance had been sent away by her supervisor, RN #4. RN #6 said she was told to monitor Resident #103 and to let him rest. RN #6 said she was concerned about Resident #103 because, at 2:30 p.m., he had a fever of 100.4 degrees Fahrenheit, required narcotics for pain relief, and had amber-colored, foul-smelling urine. RN #6 said Resident #103's legal guardian came in at 4:00 p.m. and wanted Resident #103 sent to the hospital. RN #6 was not sure what to do because her supervisor (RN #4) thought Resident #103 should stay at the facility. RN #6 said she called the Director of Nursing (DON) #1, who told her to write the order to send Resident #103 to the hospital because the guardian requested it. RN #6 said she called Resident #103's physician to inform him of the guardian's wishes that Resident #103 be sent to the hospital. Review of the Ambulance Run Sheet, dated [DATE], indicated that the Emergency Medical Service (EMS) was sent out on a first response and priority emergency status to the facility at 11:18 a.m. and arrived at 11:38 a.m. The run sheet indicated that EMS did not transport Resident #103 to the hospital because RN #4 reported to the Emergency Medical Technician (EMT) #10 that she had fixed Resident #103's catheter and he (#103) had returned to his normal level of consciousness. EMT #10 documented Resident #103 was not transported Against Medical Advice (AMA) due to RN #4 refusing transport. Review of a second Ambulance Run Sheet, dated [DATE], revealed EMS arrived at the facility at 6:23 PM and found Resident #103 with an altered level of consciousness, blood pressure of ,[DATE], pulse of 92, respiration of 24, oxygen level at 89%, and blood sugar of 199 mg/dl. The run sheet indicated EMS "was at the facility for the same resident earlier" but "left AMA" because RN #4 had sent them away. During an interview with EMT #10, on [DATE], at 11:15 AM, EMT #10 said he responded to the facility around 11:00 AM and again around 6:00 PM for the same resident (Resident #103). EMT #10 said that at the time of the first run to the facility, at approximately 11:00 AM, a facility nurse (RN #4) said that Resident #103 no longer needed hospitalization because she (RN #4) had fixed Resident #103's catheter. EMT #10 said he told RN #4 if she was not going to send Resident #103 she was going to have to sign for the refusal. The Surveyor asked EMT #10 if he verbally told RN #4 that she was signing an Against Medical Advice (AMA) statement and he said he did not. EMT #10 said when he returned again around 6:00 PM, Resident #103 was now obviously in need of hospitalization and should have been sent earlier. Review of the hospital History and Physical Report, dated [DATE], revealed Resident #103 was admitted to the hospital on [DATE] and was diagnosed with [REDACTED]. Review of the Death Certificate, dated [DATE], revealed Resident #103 died on [DATE] with the cause of death listed as asystole (cardiac standstill),[MEDICAL CONDITION], and a urinary tract infection [MEDICAL CONDITION]. On [DATE], Nursing Home Administrator (NHA) #1 was informed of the Immediate Jeopardy that began on [DATE], when the facility failed to assess and monitor Resident #103, who exhibited signs and symptoms of a UTI and was found with a decreased level of consciousness. In addition, the facility failed to notify the physician of an acute change of condition; turned away an ambulance dispatched to transport Resident #103 to the hospital and did not send Resident #103 to the hospital until another seven hours had elapsed. Resident #103 subsequently died . This deficient practice placed 21 residents at risk for fluid volume deficit related [MEDICAL CONDITION] (a severe blood infection), at risk for serious harm, injury and/or death. On [DATE] the surveyor confirmed the facility implemented the following to remove the Immediate Jeopardy: 1. Residents at risk were assessed by the Director of Nursing and or designee for current condition and one resident was placed on Input & Output (I & O) as ordered by the physician on [DATE]. 2. I & O policy was reviewed and approved by the Medical Director on [DATE]. Changes included: a. Monitor I & O for 5 days on new admission to establish a baseline; b. If output exceeds intake by 500 cc for one day - notify the Physician. Resident with Foley catheters on I & O as ordered by the Physician, that have output less than 240 cc in an 8 hour period - notify the Physician. (Residents with [MEDICAL CONDITION] may require different parameters - follow parameters as ordered by the Physician). 3. Change of Condition policy was reviewed on [DATE] and was deemed appropriate. 4. Licensed Nurses (18 out of 24) were educated on [DATE] regarding: a. Revision of I & O policy; b. Change in Condition; c. Resident Assessment; d. Physician Notification; and, e. Documentation and Resident Transfers. No employees were allowed to start work until educated. 5. The Director of Nursing has developed a Nursing Assessment Communication Tool to properly notify the Physician of the Residents condition, initiated on [DATE]. 6. As of [DATE], the Administrator and/or designee will be responsible for reviewing the findings with updates provided to the Quality Performance Improvement monthly for the follow-up as needed until compliance has been sustained for one quarter. The Administrator will be responsible for attaining and maintaining compliance. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope and severity of isolated with severity of no actual harm but potential for more than minimal harm, which is not Immediate Jeopardy, due to not all staff being educated on policy changes and to sustained compliance not having been verified by the State Agency. ( )

This citation pertains to intake # MI 666 Based on interview and record review, the facility failed to notify the physician of an acute change in condition and need for hospitalization for 1 (Resident #103) of 5 sampled residents from a total sample of 5, resulting in Resident #103 not being sent to the hospital until 7 hours after a change in his condition. Findings include: Review of the Face Sheet revealed that Resident #103 was a [AGE] year-old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #103 had a court appointed guardian. In an interview on [DATE], Licensed Practical Nurse (LPN) #5 reported that on [DATE] 8:02 AM, Resident #103 had a decreased level of consciousness and was leaning to the right in his wheelchair. LPN #5 reported that she called 911 to send Resident #103 to the hospital and then called the legal guardian to report the change in condition and the fact that Resident #103 was being sent to the hospital. LPN #5 said she prepared the paper work and then asked the Unit Manager, Registered Nurse (RN) #4, to assist with Resident #103 because LPN #5 was caring for another resident, who was also being sent to the hospital. LPN #5 said she found out after lunch that Resident #103 was still at the facility and that RN #4 had sent the ambulance away. LPN #5 said she did not call Resident #103's physician to notify him of Resident #103's change in condition. In an interview on [DATE] at 1:55 p.m., Registered Nurse (RN) #4 said that on [DATE] at approximately 11:15 AM, she assessed Resident #103 in bed and noted his abdomen was distended and there was no urine in his Foley (urinary drainage) bag. RN #4 reported that she replaced Resident #103's catheter and had an immediate discharge of bloody, foul-smelling urine. RN #4 reported that after she inserted the new catheter, 600 cc of cloudy, foul smelling red urine came out and was used for a urine analysis (UA). RN #4 said Resident #103 became responsive and returned to his normal self after the 600 cc of urine was obtained. RN #4 reported she did not inform the physician of Resident #103's change in condition on [DATE]. Review of the Nurse's Note, dated [DATE] at 2:30 PM, revealed Resident #103 had amber urine with particulate matter having a foul odor. The note indicated Resident #103 had his eyes closed, his respirations were even, his skin was warm to the touch and he had a fever of 100.4 degrees Fahrenheit. The note indicated Resident #103 received a Tylenol suppository for the fever. There was no documentation that the physician was notified of Resident #103's fever or urinary symptoms. Review of the Nurse's Note, dated [DATE] at 4:00 PM, revealed Resident #103's court-appointed guardian arrived at the facility and "was concerned about the resident's level of consciousness and requested he be sent to the emergency room (ER). Doctor notified." In an interview on [DATE] at 12:35 p.m., RN #6 stated that during shift report on [DATE], she heard about Resident #103's catheter problem and that the ambulance had been sent away by her supervisor, RN #4. RN #6 said she was told to monitor Resident #103 and to let him rest. RN #6 said she was concerned about Resident #103 because, at 2:30 p.m., he had a fever of 100.4 degrees Fahrenheit, required narcotics for pain relief, and had amber-colored, foul-smelling urine. RN #6 said Resident #103's legal guardian came in at 4:00 p.m. and wanted Resident #103 sent to the hospital. During an interview on [DATE], when the Surveyor reviewed the nurse's notes for Resident #103 on the date [DATE] with Physician #9, Physician #9 heard that the nurses had called 911. Physician #9 asked the Surveyor, "was I (Physician #9) notified (that Resident #103 was sent to the hospital)?" Physician #9 would not comment on at what point he thought the nurses should have notified him of the change in Resident #103s condition. According to the nurses' documentation, Physician #9 was not been informed of Resident #103's change in condition until Resident #103 had been transferred to the hospital on the evening of [DATE], upon the guardian's request. Review of the hospital History and Physical Report, dated [DATE], revealed Resident #103 was admitted to the hospital on [DATE] and was diagnosed with [REDACTED]. Review of the Death Certificate, dated [DATE], revealed that Resident #103 died on [DATE] with the cause of death listed as asystole (cardiac standstill),[MEDICAL CONDITION], and a urinary tract infection [MEDICAL CONDITION]. ( )

This citation pertains to intake # MI 666 Based on observation, interview and record review the facility failed to ensure that 1 (#105) of 5 sampled residents, of a total sample of 5 entered the facility without an indwelling catheter was not catheterized unless the resident's clinical condition demonstrated that catheterization was necessary, when Resident #105 received an unnecessary indwelling urinary catheter, resulting in the development of a urinary tract infection. Findings include: Review of Resident # 105's face sheet revealed he was a [AGE] year old male admitted to the facility on [DATE]. Review of Resident # 105's [DIAGNOSES REDACTED]. Review of Resident #105's care plan for bladder incontinence, dated 2-27-13 revealed Resident #105 had an indwelling urinary catheter (Foley) in place for wound healing. On 3-29-13, at 11:20 AM, Resident #105 was observed in bed with a Foley catheter in place. The urine drainage bag was observed to have 1000 cc of bright red (blood colored) liquid in it. On 3-29-13 at 11:30 AM, Licensed Practical Nurse (LPN) #5 was interviewed about Resident #105's condition. LPN #5 said the 3rd shift had changed Resident #105's catheter and a urine sample was sent to the laboratory. LPN #5 said Resident #105 had the catheter in place for wound healing. On 3-29-13 at 1:25 PM, Registered Nurse (RN) #11 was asked to provide the medical reason for Resident #105's Foley catheter. RN #11 said it was placed due to a stage II ulcer on Resident #105's leg and went on to explain she (RN #11) was aware that this reason was not medical justification. RN #11 said Resident #105's physician would be contacted. Review of Resident #105's progress notes dated 3-29-13 (no time) revealed that Resident #105's Foley catheter was removed and a urine sample was sent to the laboratory for analysis. Doctors' orders dated 3-29-13 documented the order to discontinue the Foley catheter. Review of Doctors orders dated 3-29-13 revealed Resident #105 had an order for [REDACTED]. Progress notes dated 3-30-13 at 12:25 AM documented Resident # 105's vital signs as: blood pressure 150/76, Temperature 102.4 degrees Fahrenheit, pulse 84 and respirations 24. Resident #105's physician was contacted and Resident #105 was sent to the emergency room . Progress notes dated 3-29-13 at 6:25 AM, documented Resident #105 was admitted to the hospital with [REDACTED].

This citation pertains to intake # MI 666 Based on interview and record review, the facility failed to provide one (#103) of 5 sampled residents of a total sample of 5 with sufficient fluid intake to maintain proper hydration and health, resulting in Resident #103 being sent to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Findings include: Review of the Face Sheet revealed that Resident #103 was a [AGE] year-old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #103 had a court appointed guardian. Review of Resident #103's Nutritional Risk assessment dated [DATE] revealed Resident #103 weighed 138 pounds and required 1,882 cc of fluid daily. Review of Resident #103's Intake & Output (I & O) by day chart revealed that the facility documented daily fluid intakes for Resident #103 starting on the day of his admission ([DATE]) through his discharge on [DATE]. Resident #103's daily fluid intake varied significantly form 720 cc to 1560. At no point did Resident #103 reach his required intake of 1,882 cc. Resident #103's documented fluid output was frequently greater than the amount of fluid intake, putting Resident #103 into a negative fluid balance. (signs and symptoms of dehydration) In an interview on [DATE], Licensed Practical Nurse (LPN) #5 reported that on [DATE] at 8:02 AM, Resident #103 had a decreased level of consciousness and was leaning to the right in his wheelchair. LPN #5 reported that she called 911 to send Resident #103 to the hospital and then called the legal guardian to report the change in condition and the fact that Resident #103 was being sent to the hospital. LPN #5 said she prepared the paper work and then asked the Unit Manager, Registered Nurse (RN) #4, to assist with Resident #103 because LPN #5 was caring for another resident, who was also being sent to the hospital. LPN #5 said she found out after lunch that Resident #103 was still at the facility and that RN #4 had sent the ambulance away. In an interview on [DATE] at 1:55 p.m., RN #4 said that on [DATE] at approximately 11:15 AM, she assessed Resident #103 in bed and noted his abdomen was distended and there was no urine in his Foley (urinary drainage) bag. RN #4 reported that she replaced Resident #103's catheter and had an immediate discharge of bloody, foul-smelling urine. RN #4 reported that after she inserted the new catheter, 600 cc of cloudy, foul smelling red urine came out and was used for a urine analysis (UA). RN #4 said Resident #103 became responsive and returned to his normal self after the 600 cc of urine was obtained. RN #4 reported she did not inform the physician of Resident #103's change in condition on [DATE]. In an interview with RN #4 (unit manager) on [DATE] at 2:50 PM, the Surveyor showed RN #4 the input and output record that was in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Surveyor asked RN #4 how often she (RN #4) reviewed this information on residents and RN #4 said, "I do not look at it (the documentation) much." In an interview with the Director of Nursing (DON #1) on [DATE] at 2:40 PM, the Surveyor asked DON #1 to explain who monitors Residents' I & O records and DON #1 responded that the Unit Managers were to review the records for a 24 hour window. Review of the Nurse's Note, dated [DATE] at 2:30 PM, revealed Resident #103 had amber urine with particulate matter having a foul odor. The note indicated Resident #103 had his eyes closed, his respirations were even, his skin was warm to the touch and he had a fever of 100.4 degrees Fahrenheit. The note indicated Resident #103 received a Tylenol suppository for the fever. There was no documentation that the physician was notified of Resident #103's fever or urinary symptoms. Review of the Nurse's Note, dated [DATE] at 4:00 PM, revealed Resident #103's court-appointed guardian arrived at the facility and "was concerned about the resident's level of consciousness and requested he be sent to the emergency room (ER). Doctor notified." In an interview on [DATE] at 12:35 p.m., RN #6 stated that during shift report on [DATE], she heard about Resident #103's catheter problem and that the ambulance had been sent away by her supervisor, RN #4. RN #6 said she was told to monitor Resident #103 and to let him rest. RN #6 said she was concerned about Resident #103 because, at 2:30 p.m., he had a fever of 100.4 degrees Fahrenheit, required narcotics for pain relief, and had amber-colored, foul-smelling urine. RN #6 said Resident #103's legal guardian came in at 4:00 p.m. and wanted Resident #103 sent to the hospital. Review of the hospital History and Physical Report, dated [DATE], revealed Resident #103 was admitted to the hospital on [DATE] and was diagnosed with [REDACTED]. Review of the Death Certificate, dated [DATE], revealed Resident #103 died on [DATE] with the cause of death listed as asystole (cardiac standstill),[MEDICAL CONDITION], and a urinary tract infection [MEDICAL CONDITION]. ( )

This citation pertains to intake number MI 03. Based on observation, interview, and record review the facility failed to ensure the safety (use proper equipment during a mechanical lift) in 1 of 3 sampled residents (Resident #502), out of a total sample of 5 residents, resulting in Resident #502's right leg sliding off the foot platform causing a shift in his weight that pulled Resident #502's shoulder up to an abnormal position causing pain, a bone chip, and a dislocated shoulder. Findings include: Per the facility face sheet Resident #502 was a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a "Minimum Data Set" ((MDS) dated [DATE] revealed that Resident #502 had unclear speech, sometimes understood others and sometimes was understood by others, required extensive assistance for transfers, and did not ambulate. Review of a care plan dated 8/29/2012 and titled "Resident is Totally Dependent on Staff to Perform ADLs (activities of daily living) due to: Dementia and CVA (stroke) with right Hemiparesis (unable to move the right side/ extremities). Review of a CNA "Care Guide" (not dated) revealed that Resident #502 was to be lifted with an Encore lift for changing of his brief and obtaining a weight. Review of a facility "Accident/Incident Report" dated 9/5/2012 revealed, "Resident (#502) was being transferred and during the transfer; knees buckled and arm went up and c/o (complaints of) pain in the right shoulder." Review of a "Witness Investigation Statement" dated 9/5/2012 from CNA #1 revealed, "...I had my gate belt tightened around his (Resident #502's) feet...his (Resident #502) foot lifted off, he (Resident #502) buckled his knees..." In an interview on 10/29/2012 at 1:20 PM, CNA #1 stated that she used the Encore to perform a weight on Resident #502. CNA #1 said she pulled the Encore away from the bed to obtain the weight. CNA #1 stated that Resident #502's foot slipped off the back of the foot platform causing Resident #502's body to turn to the right side. Therefore the shift in Resident #502's body caused Resident #502's arm to dangle in the lift. CNA #1 said that she lowered Resident #502 to the floor. Observation of the lift technique that CNA #1 used was conducted on 10/29/2012 at 1:40 PM. CNA #1 performed the technique that she used with Director of Nursing (DON) #2. DON #2 sat on the side of the bed as indicated by CNA #1. CNA #1 stated that Resident #502 had bed bolsters on his bed at the time (side pads that make the bed deeper to prevent rolling out of bed), and stated that she could not sit Resident #502 back down on his bed at the time his foot slipped off the lift because she could not get Resident #502 up over the bed bolsters. CNA #1 placed the sling around DON #2's upper body and then placed the leg strap around DON #502's legs. CNA #1 proceeded to lift DON #2 up and revealed that Resident #502's right foot lifted up and slid off the back of the lift foot platform. CNA #1 demonstrated with DON #2 that Resident #502's body twisted to the right causing Resident #502 to not be able to stand straight up. Observation revealed that the Encore lift had arm rests at the point of where Resident #502 held onto the hand bars. During the observation it was revealed that at the time Resident #502's right foot slid off the foot platform his right shoulder was forced up with the arm rests, as observed during the demonstration. In an interview on 10/29/2012 at 2:25 PM, CNA #1 stated that she in fact did not use the supplied leg strap that was supplied with the Encore lift but stated that she used her gait belt instead. CNA #1 said the supplied leg strap was not with the Encore at the time she used the lift on Resident #502. CNA #1 said that she did not go look for the strap but instead used her gait belt. CNA #1 said she did not know where the leg strap was at the time. CNA #1 said she did not know if other CNAs used their gait belts instead of the supplied leg strap when using the Encore lift on other residents. In an interview on 10/29/2012 at 2:30 PM, Licensed Practical Nurse (LPN) #3 said she was aware that CNA #1 used her gait belt to secure Resident #502's leg while up in the Encore lift instead of the supplied leg strap that came with the Encore lift. LPN #3 said she educated and disciplined CNA #1 for not using the Encore lift appropriately. LPN #3 said the correct leg strap was always in a bag that hung on the lift at all times. LPN #3 said CNA #1 reported to her that she (CNA #1) used her gait belt because she was in a hurry and Resident #502 was "yelling". LPN #3 said that she did not educate all staff or investigate as to whether other CNAs had been using their gait belts when using the Encore lift instead of the supplied leg strap that came with the lift. Observation of the supplied leg strap that came with the Encore lift and a gait belt that the CNAs used was conducted on 10/29/2012 at 2:30 PM. The gait belt was observed to be approximately 2 inches in width and the supplied leg strap that came with the Encore lift was approximately 4 inches in width. Review of an "Employee Conduct Report" dated 96/2012 revealed CNA #1 received a "first notice" of discipline for a minor infraction of the facility safety rule. Review of a statement written by DON #2 dated 9/11/2012 revealed the following, "...resident (#502) buckled his knees causing arm to extend higher than normal for this resident (#502)...resident (#502) complained of right shoulder pain...X-rays obtained show a dislocation of right shoulder...Orthopedic Doctor stated dislocation is possibly old versus new...would not have noted dislocation due to non-use of arm. In an interview on 10/30/2012 at 2:28 PM, the Orthopedic Physician (OP) #4 stated that Resident #502's shoulder was dislocated and stated that on 9/5/2012 he had seen Resident #502 in the emergency room . OP #4 said Resident #502's shoulder dislocation was acute and not chronic and said that he had re-set Resident #502's shoulder in the emergency room . OP #4 said Resident #502 had slid down while on a lift device (Encore) which in turn acutely raised Resident #502's shoulder up causing Resident #502's shoulder to become dislocated. OP #4 also stated that a chip was noted in Resident #502's greater tuberosity (top of the humerus/upper arm bone) and stated that the chip was caused from the impact. OP #4 said Resident #502's shoulder was not previously dislocated. OP#4 stated that if Resident #502's shoulder dislocation was chronically dislocated then he (OP #4) would not have been able to re-set Resident #502's shoulder. OP #4 said Resident #502's dislocated shoulder was caused from his slip while in the lift device. Review of a hospital x-ray report dated 9/5/2012 revealed that Resident #502 had a dislocation of his right shoulder with a chip fracture of the humerus (top bone in the arm). Review of a physician progress notes [REDACTED]. Per the facility face sheet Resident #502 was admitted to the facility on [DATE]. Review of nurses' notes dated 7/10/2012 through 9/5/2012 revealed Resident #502 did not complain of pain and, in fact, nurses' notes revealed documentation that Resident #502 denied pain until 9/5/2012 after the incident with the Encore lift on 9/5/2012 at 10:20 AM. Nurses' notes revealed on 9/5/2012, "Resident (#502) was being transferred and during transfer knees buckled and arm went up and acute (brief and severe not chronic but new) c/o pain in right shoulder." The nurses' notes revealed that Resident #502 was transferred to the emergency room . ( )

This citation pertains to Intake Number MI 594 Based on interview and record review, the facility failed to 1) provide care according to professional standards of quality, and 2) assess and monitor for change of condition to maintain or improve outcomes for 1 of 5 sampled residents (#101) in a total of 5 sampled residents, resulting in an Immediate Jeopardy (IJ) when Resident #101 was found with grey skin that was cool to the touch, no respirations, no pulse, no blood pressure, and the staff facility failed to initiate Cardiopulmonary Resuscitation (CPR) and Emergency Medical Services (EMS), despite Resident (#101) being a FULL CODE. These deficient practices place all residents who may require emergent care at risk for serious harm, injury, and/or death. Findings include: According to the Fundamentals of Nursing, Sixth Edition, Potter and Perry (2005), "[MEDICAL CONDITION] is characterized by an absence of pulse and respiration. If the nurse determines that the client has [MEDICAL CONDITION], Cardiopulmonary Resuscitation (CPR) must be initiated. CPR is a basic emergency procedure of artificial respiration and manual external cardiac massage". According to The Legal and Ethical Issues in Nursing, Fourth Edition, Guido, (2006), "Standards of care must have and use the knowledge and skill ordinarily possessed and used by nurses actively [MEDICATION NAME] in the nurse's specialty area'. According to the Nurse's Problem Solver, (1995), "by providing emergency resuscitative support, these procedures restore spontaneous heart rate and respirations and prevent hypoxic damage to the brain and other vital organs. Responding to a code swiftly and effectively is essential to saving a patients life". Per the American Red Cross First Aid and Safety Handbook, (2011), " a person in [MEDICAL CONDITION] is unconscious, not breathing and has no heartbeat". The Handbook revealed that a person in [MEDICAL CONDITION] will have the greatest chance of survival if there is 1) early access to the Emergency Medical Services (EMS) system, 2) early CPR, 3) early defibrillation, and 4) early advanced medical care. The Handbook also revealed that "without early CPR and defibrillation, the chances for survival is greatly reduced". The handbook mentioned that "once you begin CPR, do no stop except in one of these situations...another trained responder or EMS personnel take over". According to the National Diabetes Information Clearinghouse, "Diabetic Overview" ([DATE]), "...Healthy eating, physical activity, and blood glucose testing are the basic management tools for type 2 diabetes. Much of the daily care involves keeping blood glucose levels from going too low or too high. When blood glucose levels drop too low- a condition know as [DIAGNOSES REDACTED]- a person can become nervous, shaky, and confused. Judgment can be impaired...". Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected that Resident #101 was a [AGE] year old female admitted to the facility on [DATE]. Resident #101's daily decision making skills were cognitively intact, she was able to understand others and make herself understood. Resident #101 was always continent of both bowel and bladder. Resident #101's [DIAGNOSES REDACTED]. Resident #101 was admitted with a recent [MEDICAL CONDITION]. Review of the Accident/Incident Report dated [DATE] at 7:50 p.m. reflected that Resident #101 had no vital signs and that Physician #1 and the family were called at 7:50 p.m. on [DATE]. Three witness statements attached to the Accident/Incident Report reflected that: 1) Licensed Practical Nurse (LPN) #3's written statement documented "At 7:50 p.m., I went in to check on Resident (#101) ...upon entering room, I noted ...Resident (#101)'s skin cool and gray, lips gray, mouth open and eyes fixed, there were no respirations, no pulse, or blood pressure. Resident (#101) observed to be clinically expired...at 8:50 p.m. ... when looking for listing of preferences of funeral home, I noted Resident (#101)'s code status". 2) LPN #2's written statement indicated that she was told by a Certified Nursing Assistant (CNA not specified) that LPN #3 "needs your help...she (LPN #3) sounds kind of urgent...LPN #3 was in (Resident #101's) room with stethoscope and blood pressure cuff in hand and stated "She's dead I can't get anything" Resident (#101) was lying on her back not breathing no heart rate, eyes fixed, skin color was gray. At this point I called Manager on call to inform her of Resident (#101)'s death, and went back to my hall...I was informed that Resident (#101) was a Full Code at 8:40 by (RN #1) nurse. (LPN #3) made no comment to me about code status at any time. I did not know myself that Resident (#101) was a Full Code". 3) Registered Nurse (RN) #1's statement documented,"I was informed by (LPN #2) that (Resident #101) had just expired. I asked (LPN #2) "was she a no code?". Her (LPN #2) response was "yes" she was a No code....(LPN #3) was at the Nurse Station Desk looking in the chart for information...for (Resident #101). I suggested that LPN #3 look under Advanced Directives,...(LPN #3) turned to Advanced directives we noticed the choice had been made for resusitation (sic)...I told her (LPN #3) to call the On-Call Nurse Manager immediately and report that Resident (#101) was a Full Code and had not been resusitated (sic)". In interviews on [DATE] at 11:50 a.m. and [DATE] at 12:45 p.m., LPN #3 reported that she found Resident #101 lying in bed, skin cool and grey, lips grey, mouth open, eyes fixed, no blood pressure, no pulse, and no respiration. LPN #3 reported that she had LPN #2 confirm her findings, paged Physician #1 and Resident #101's family. LPN #3 reported she had CNA #3 clean Resident #101 then LPN #3 went to finish her medication pass. LPN #3 reported that she never checked Resident #101's code status until she looked for the funeral home. In an interview on [DATE] at 9:20 a.m., LPN #2 reported that she did not ask LPN #3 if Resident #101 was a FULL CODE or check Resident #101's chart to see if she was a FULL CODE. In an interview on [DATE] at 4:45 p.m., RN #1 reported that when LPN #2 came to the Nurses Station and reported that Resident #101 had died , he asked LPN #2 if Resident #101 was a No Code and LPN #2 said "yes". RN #1 did not question or verify Resident #101's code status, RN #1 continued with assigned duties. In an interview on [DATE] at 5:20 p.m., RN #2 (the On-Call Unit Manager) reported that she received a call from LPN #2 that Resident #101 had passed away. RN #2 did not ask LPN #2 if Resident #101 was a FULL CODE. In an interview on [DATE] at 5:10 p.m., the Director of Nursing (DON) reported that at 7:56 p.m. she received a voice mail from RN #2, that Resident #101 had died . The DON reported that she returned the call to RN #2 at 7:57 p.m., but did not ask if Resident #101 was a FULL CODE Review of Nursing Progress Notes dated [DATE] at 10:00 p.m., reflected that LPN #3 "went into resident's room at 7:50 (p.m.) to check on Resident and IV (intravenous line). Noted no blood pressure, no pulse, no respirations. Called and informed Nurse Manager, paged Physician #1, and left message with" family to "call facility. Resident's skin gray and cool to touch, eyes fixed and mouth open noted on assessment. Resident had urinated on self. Findings told to Nurse manager RN on call". 10:40 p.m. family returned call and notified of how LPN #3 found Resident #101. 10:45 p.m. family called to inform LPN #3 of Funeral Home, Funeral Home notified. 10:50 p.m. Physician #1 "notified. Order noted to release body to funeral home. In an interview on [DATE] at 1:34 p.m., Physician #1 (the On-Call Physician) reported that he got a page about the condition of Resident #101. Physician #1 returned the call about an hour later and ask LPN #3 if CPR had been started and was told no that Resident #101 was not responsive and cold. In an interview on [DATE] at 1:45 p.m., RN #4 reported that she had drawn Resident #101's blood work per physician's orders [REDACTED]. Review of the Laboratory Report dated [DATE], collected at 4:00 p.m., received at 5:22 p.m. and results at 6:02 p.m., reflected that Resident #101 had a glucose of 45 (normal 70 - 99 mg/dL), "CRITICAL RESULTS", repeated and called to Medical Director by Lab Tech #1 at 6:02 p.m. "READ-BACK VERIFIED, Potassium 6.1 (normal 3.5 - 5.3 mEq/L) CRITICAL RESULTS", repeated and called to Medical Director by Lab Tech #1 at 6:02 p.m." READ-BACK VERIFIED". In an interview on [DATE] at 1:30 p.m., the Medical Director reported that the local laboratory did call him with the critical lab results for Resident #101, but he was not on call. The Medical Director reported that he requested Laboratory Technician (Lab Tech) #1 call the facility with the results, because he did not know which Nursing Home Resident #101 was living at, and who ordered the labs, or why the labs were ordered. In an interview on [DATE] at 7:20 p.m., Lab Tech #1 reported that he did call the Medical Director with the critical lab results for Resident #101, because the Medical Director was listed on the Laboratory Report as Resident #101's physician. The Lab Tech #1 reported that if the Medical Director had requested he call the facility with the critical lab results he would have. Review of the Comprehensive Plan of Care dated [DATE], reflected that Resident #101 was at risk for hypo/[MEDICAL CONDITION] (low or high blood sugar) related to her [DIAGNOSES REDACTED]. Review of the History and Physical dated [DATE] reflected that Resident #101's past medical history included Type 2 diabetes, which was diet-controlled. In an interview on [DATE] at 9:26 a.m., RN #5 reported that she did not check Resident #101's blood sugar, because she did not even think to do it since Resident #101 was not on insulin. In an interview on [DATE] at 1:45 p.m., RN #4 reported that since Resident #101 was not on routine finger sticks (a test to check blood sugar) it was not the first thought on her mind to check her blood sugar level. On [DATE] at 3:50 p.m., the Administrator was notified of the Immediate Jeopardy that began on [DATE] when the facility failed to ensure that staff responded appropriately to a medical emergency. This deficient practice placed all residents at high risk for possible physical harm, injury, and/or death. On [DATE], the surveyor confirmed that the facility staff implemented the following to remove the immediate jeopardy: 1. All Licensed Nurses have been educated regarding how to determine Resident's code Status and protocol regarding "Code Blue Medical". Education started on [DATE] and 23 out of 25 nurses have been educated as of [DATE]. all nurses were educated before they were allowed to work any hours in this facility. New hires will be educated during nursing orientation. Policies reviewed and deemed appropriate on [DATE] are, * Death of a Resident * Do Not Resuscitate * Emergency 911 * Emergency Code Blue 2. "Mock Codes" will be called at least weekly to ensure accuracy of responding to a "CODE" 4 out of 4 "Mock Codes" have been called with 100% accuracy. Director of Nursing and /or designee will be responsible to run all Mock Codes. Education and Training Director will be responsible for all documentation on this Educational Learning tool. This process was started on [DATE]. 3. All residents have the potential to be affected by this incident. the Administrator and/or designee have audited all resident's charts for accuracy of their code status. 77 out of 77 resident charts have been audited. This process was started and completed on [DATE]. 4. The Director of Nursing has audited all Licensed Nurse CPR certifications to ensure that none have expired. 25 out of 25 have been audited with 100% accuracy. This process was started and completed on [DATE]. 5. The Director of Nursing has developed a computer generated 24 hour sheet that is being printed each morning by the first shift nurses. Changes regarding new admits and or discharges are being added or subtracted as they occur. Nurses keep all pertinent information on this sheet including resident code status. Director of Nursing and/or designee is responsible for making changes as they occur. Review of these forms is being done every business day during Morning Triage and again during afternoon follow-up meeting. This process was started on [DATE]. 6. CENA's will be educated beginning [DATE] regarding "Resident Change in condition and what and when to report changes to their charge nurse". This education will be completed by the Education and Training Director and all CENA's will receive this education before they can work any hours in this facility. Education received is: * Basic Observation review. * What to report, who to report to * What to do in a "Code Blue Medical Emergency! Although Immediate Jeopardy was removed on [DATE] at 6:00 p.m., the facility remained out of compliance at a scope of pattern and a severity of no actual harm, but potential for more than minimal harm that is not Immediate Jeopardy, because all staff had not been educated and sustained compliance has not been verified by the State Agency. ( )

This citation pertains to Intake Number MI 594. Based on interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical well being for 1 of 5 sampled residents (#101) in a total of 5 sampled residents, resulting in an Immediate Jeopardy (IJ) when Resident #101 was found with grey skin which was cool to the touch, no respiration, no pulse, no blood pressure, and the staff facility failed to initiate Cardiopulmonary Resuscitation (CPR) and Emergency Medical Services (EMS), despite Resident (#101) being a FULL CODE. These deficient practices place all residents who require emergent care at risk for serious harm, injury, and/or death. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected that Resident #101 was a [AGE] year old female admitted to the facility on [DATE]. Resident #101's daily decision making skills were cognitively intact, she was able to understand others and make herself understood. Resident #101 was always continent of both bowel and bladder. Resident #101's [DIAGNOSES REDACTED]. Resident #101 was admitted with a recent [MEDICAL CONDITION]. Review of the Patient Transfer Record dated [DATE] reflected that Resident #101 was a FULL CODE. Review of the Cardiopulmonary Resuscitation Consent (CPR) dated [DATE] and signed by Resident #101 reflected that Resident #101 documented the box for RESUSCITATION which stated "I am expressing a desire to have CPR and/or external defibrillation performed in the event of [MEDICAL CONDITION]. I understand that in the event of an observed or unobserved [MEDICAL CONDITION], nursing staff will initiate CPR and the use of the Automatic External Defibrillator (AED) device and emergency medical personnel will be called". Review of Nursing Progress Notes dated [DATE] to [DATE] at 2:00 p.m., reflected that Resident #101 complained of left sided neck pain. The Nursing Progress Notes did not reflect that the physician was notified of the neck pain. The Nursing Progress Notes dated [DATE] at 11:00 p.m. reflected "Resident (#101) remains in bed and c/o (complains) not feeling well she c/o N/V (nausea and vomiting) Dr. gave N.O. (new order) while here". The Nursing Progress Notes dated [DATE] to [DATE] reflected that Resident #101 continued to complain of nausea , left lower abdominal pain, remained in bed, and was incontinent of urine. The Nursing Progress Notes dated [DATE] reflected that Resident #101's blood pressure at 2:00 a.m. was documented as ,[DATE] (normal ,[DATE]), at 3:25 p.m. new orders were received from Physician #1 (the On-Call Physician), after Registered Nurse (RN) #5 reported that Resident #101 had a change in level of consciousness, weight loss (amount not indicated), , due to not eating or drinking, at 3:30 p.m. the IV was placed in Resident #101 and [MEDICATION NAME] Ringers was started, the blood work was drawn by RN #4 and delivered to the local laboratory by RN #4 . In an interview on [DATE] at 1:25 p.m., RN #5 reported that on [DATE] Resident #101 was just not herself, not eating, and just not responding well and that RN #4 (Unit Manager) spoke with her about Resident #101's change in condition. RN #4 reported to RN #5 that Resident #101 was a FULL CODE so the physician needed to be called about the changes in Resident #101's condition that RN #5 was seeing. Review of physician's orders [REDACTED].#1. At 3:25 p.m. a BMP (Basic Metabolic Panel - a group of 8 blood test used as a general screening tool) was noted as ordered by Physician #1. Review of the Accident/Incident Report dated [DATE] at 7:50 p.m. reflected that Resident #101 had no vital signs and that Physician #1 and the family were called at 7:50 p.m. on [DATE]. Three witness statements attached to the Accident/Incident Report reflected that: 1) Licensed Practical Nurse (LPN) #3 documented "At 7:50 p.m., I went in to check on Resident (#101) ...upon entering room, I noted ...Resident (#101)'s skin cool and gray, lips gray, mouth open and eyes fixed, there were no respirations, no pulse, or blood pressure. Resident (#101) observed to be clinically expired ... at 8:50 p.m. ... when looking for listing of preferences of funeral home, I noted Resident (#101)'s code status". 2) LPN #2's written statement indicated that she was told by a Certified Nursing Assistant (CNA not specified) that LPN #3 "needs your help...she (LPN #3) sounds kind of urgent...LPN #3 was in (Resident #101's) room with stethoscope and blood pressure cuff in hand and stated "She's dead I can't get anything" Resident (#101) was lying on her back not breathing, no heart rate, eyes fixed, skin color was gray. At this point I called Manager on call to inform her of Resident (#101)'s death, and went back to my hall...I was informed that Resident (#101) was a Full Code at 8:40 (p.m.) by (RN #1) (LPN #3) made no comment to me about code status at any time. I did not know myself that Resident (#101) was a Full Code". 3) Registered Nurse (RN) #1's statement documented,"I was informed by (LPN #2) that (Resident #101) had just expired. I asked (LPN #2) "was she a no code?". Her (LPN #2) response was "yes" she was a No code....(LPN #3) was at the Nurse Station Desk looking in the chart for information...for (Resident #101). I suggested that LPN #3 look under Advanced Directives,...(LPN #3) turned to Advanced directives we notice the choice had been made for resusitation (sic)...I told her (LPN #3) to call the On-Call Nurse Manager immediately and report that Resident (#101) was a Full Code and had not been resusitated (sic)". Review of Nursing Progress Notes dated [DATE] at 10:00 p.m., reflected that Licensed Practical Nurse (LPN) #3 "went into resident's room at 7:50 (p.m.) to check on Resident and IV (intravenous line). Noted no blood pressure, no pulse, no respirations. Called and informed Nurse Manager, paged Physician #1, and left message with "family to call facility". Resident's skin gray and cool to touch, eyes fixed and mouth open noted on assessment. Resident had urinated on self. Findings told to Nurse manager RN on call". At 10:40 p.m. family returned call and were notified of how LPN #3 found Resident #101. At 10:45 p.m. family called to inform LPN #3 of Funeral Home, Funeral Home notified. At "10:50 p.m. Physician #1 notified. Order noted to release body to funeral home". In interviews on [DATE] at 11:50 a.m. and [DATE] at 12:45 p.m., LPN #3 reported receiving report from the 6 a.m. - 2 p.m. charge nurse that Resident #101 had not eaten or drank much, that an IV was started and blood work drawn from Resident #101 by RN #4. LPN #3 stated "I do not know why the Doctor ordered the labs". LPN #3 reported that on [DATE] at 4:30 p.m. she entered Resident #101's room to give her scheduled medication mixed in applesauce, Resident #101 was hard to arouse, spit her medications out, and went back to sleep. LPN #3 reported that she did not take Resident #101's vitals or do an assessment, she just continued with the medication pass to the other residents. LPN #3 reported that at 6:00 p.m. CNA #3 went in to Resident #101's room, but Resident #101 would not eat. LPN #3 reported that at 6:30 - 7:00 p.m. she took her lunch and then began passing medications again. LPN #3 reported that she found Resident #101 at 7:50 p.m. lying in bed, skin cool and grey, lips grey, mouth open, eyes fixed, no blood pressure , no pulse, and no respiration, LPN #3 reported that she had LPN #2 confirm her findings, paged Physician #1 and Resident #101's family, had CNA #3 clean Resident #101, then LPN #3 went to finish her medication pass. LPN #3 reported that she never checked Resident #101's code status until she looked for the funeral home. In an interview on [DATE] at 3:51 p.m. and [DATE] at 2:05 p.m., CNA #3 reported that at 6:00 p.m. on [DATE] Resident #101 was sleeping, CNA #3 rolled the head of Resident #101's bed up to a sitting position and attempted to wake Resident #101 by rubbing her arm and saying her name, CNA #3 reported that Resident #101's skin was "a little chilly", but there was a fan on. CNA #3 reported that Resident #101 did not wake up. CNA #3 reported that she did not report to LPN #3 that she was unable to wake Resident #101, because Resident #101 had been sleepy all day and had not been feeling well for about a week. In an interview on [DATE] at 2:05 p.m., CNA #5 reported that the x-ray person came to have her assist during the x-ray of Resident #101. According to the X-ray Report dated [DATE], the order was received at 3:48 p.m. and the X-ray Technician (Tech). service time is documented as [DATE] at 6:26 p.m.. CNA #5 reported that Resident #101 was not responding and she really had to lift to move Resident #101 for the X-ray Tech to position the x-ray plates under Resident #101. CNA #5 reported that Resident #101 was breathing, and she put the head of the bed at about 30 degrees, but Resident #101 did not respond during the entire x-ray process. CNA #5 reported that she did not inform the nurse that Resident #101 had not responded, because there was an IV going and CNA #5 thought maybe Resident #101 had taken pain medication. CNA #5 reported that about 7:45 p.m. LPN #3 came out of Resident #101's room and asked CNA #5 to help her, CNA #5 reported that Resident #101 looked yellow, the head of the bed was in a sitting position 90 degrees. CNA #5 reported that LPN #2 came in to check Resident #101, and LPN #3 and LPN #2 both stated Resident #101 was dead, both LPN's left the room. CNA #5 reported that CNA #3 came in and they both cleaned Resident #101 and changed her bedding. In an interview on [DATE] at 9:20 a.m., LPN #2 reported that CNA #3 told her LPN #3 needed her in Resident #101's room, and when she arrived LPN #3 was coming out of Resident #101's room and said "she's dead". LPN #2 reported going into Resident #101's room and observing that Resident #101 was cool, grey, had no respirations, and no heart rate. LPN #2 reported that LPN #3 asked her to call the Nurse Manager RN #2 and let her know Resident #101 had died . LPN #2 reported that she did not ask LPN #3 if Resident #101 was a FULL CODE or check Resident #101's chart to see if she was a FULL CODE. In an interview on [DATE] at 4:45 p.m., RN #1 reported that when LPN #2 came to the Nurses Station and reported that Resident #101 had died , he asked LPN #2 if Resident #101 was a No Code and LPN #2 said "yes". RN #1 did not question or verify Resident #101's code status, RN #1 continued with assigned duties. In an interview on [DATE] at 5:20 p.m., RN #2 the On-Call Unit Manager reported that she received a call from LPN #2 that Resident #101 had passed away. RN #2 did not ask LPN #2 if Resident #101 was a FULL CODE. RN #2 reported that LPN #3 called her back about an hour after the call from LPN #2 to tell her that Resident #101 was a FULL CODE. In an interview on [DATE] at 5:10 p.m., the Director of Nursing (DON) reported that at 7:56 p.m. she received a voice mail from RN #2, the On-Call Nurse Manager that Resident #101 had died . The DON reported that she returned the call to RN #2 at 7:57 p.m., but did not ask if Resident #101 was a FULL CODE In an interview on [DATE] at 1:34 p.m., Physician #1 reported that he got a page about the condition of Resident #101 and to call back as-soon-as-possible. Physician #1 returned the call about an hour later and asked LPN #3 if CPR had been started and was told no that Resident #101 was not responsive and cold. Review of the Comprehensive Plan of Care dated [DATE], reflected that Resident #101 was at risk for hypo/[MEDICAL CONDITION] (low or high blood sugar) related to her [DIAGNOSES REDACTED]. Review of the History and Physical dated [DATE] reflected that Resident #101's past medical history included Type 2 diabetes, which was diet-controlled. In an interview on [DATE] at 9:26 a.m., RN #5 reported that she did not check Resident #101's blood sugar, because she did not even think to do it since Resident #101 was not on insulin. Review of the Laboratory Report dated [DATE], collected at 4:00 p.m., received at 5:22 p.m. and results at 6:02 p.m., reflected that Resident #101 had a glucose of 45 (normal 70 - 99 mg/dL), "CRITICAL RESULTS", repeated and called to the Medical Director of the Facility, by Lab Tech #1 at 6:02 p.m. "READ-BACK VERIFIED, Potassium 6.1 (normal 3.5 - 5.3 mEq/L) CRITICAL RESULTS", repeated and called to Medical Director of Facility, by Lab Tech #1 at 6:02 p.m. "READ-BACK VERIFIED". In interviews on [DATE] at 1:15 p.m. and [DATE] at 1:45 p.m., Resisted Nurse (RN) #4 reported that she had drawn Resident #101's blood per physician's orders [REDACTED]. RN #4 reported that when she came to work on [DATE] and was told Resident #101 had died she called the laboratory for the blood work results from [DATE] and was "shocked" to see that the critical lab values had been called to the Medical Director and not the facility. RN #4 reported that she "did not know why the Medical Director would not relate the critical labs to the facility as our facility is the only one who uses that laboratory". RN #4 reported that the UA was not obtained per physician's orders [REDACTED]. RN #4 reported that since Resident #101 was not on routine finger sticks (a test to check blood sugar) it was not the first thought on her mind to check her blood sugar level. In an interview on [DATE] at 1:30 p.m., the Medical Director reported that Lab Tech #1 did call him with the critical lab results for Resident #101, but he was not on call. The Medical Director reported that he requested Lab Tech #1 call the facility with the results. The Medical Director reported that he did not know who ordered the labs, or why they were ordered. In an interview on [DATE] at 7:20 p.m., Lab Tech #1 reported that he did call the Medical Director on [DATE] at 6:02 p.m. with the critical lab results for Resident #101, because the Medical Director was listed on the Laboratory Report as Resident #101's physician. Lab Tech #1 reported that if the Medical Director had requested he call the facility with the critical lab results he would have, but that he did not recall the Medical Director asking him to call the facility. Review of the Certificate of Death revived [DATE], reflected that Resident #101 was pronounced dead on [DATE] at 7:50 p.m., the cause of death was listed as [MEDICAL CONDITION], Pacemaker - Arrythmia, and [MEDICAL CONDITION]. On [DATE] at 3:50 p.m., the Administrator was notified of the Immediate Jeopardy that began on [DATE] when the facility failed to ensure that staff responded appropriately to a medical emergency. This deficient practice placed all residents at high risk for possible physical harm, injury, and/or death. On [DATE], the surveyor confirmed that the facility staff implemented the following to remove the immediate jeopardy: 1. All Licensed Nurses have been educated regarding how to determine Resident's code Status and protocol regarding "Code Blue Medical". Education started on [DATE] and 23 out of 25 nurses have been educated as of [DATE]. all nurses were educated before they were allowed to work any hours in this facility. New hires will be educated during nursing orientation. Policies reviewed and deemed appropriate on [DATE] are, * Death of a Resident * Do Not Resuscitate * Emergency 911 * Emergency Code Blue 2. "Mock Codes" will be called at least weekly to ensure accuracy of responding to a "CODE" 4 out of 4 "Mock Codes" have been called with 100% accuracy. Director of Nursing and /or designee will be responsible to run all Mock Codes. Education and Training Director will be responsible for all documentation on this Educational Learning tool. This process was started on [DATE]. 3. All residents have the potential to be affected by this incident. the Administrator and/or designee have audited all resident's charts for accuracy of their code status. 77 out of 77 resident charts have been audited. This process was started and completed on [DATE]. 4. The Director of Nursing has audited all Licensed Nurse CPR certifications to ensure that none have expired. 25 out of 25 have been audited with 100% accuracy. This process was started and completed on [DATE]. 5. The Director of Nursing has developed a computer generated 24 hour sheet that is being printed each morning by the first shift nurses. Changes regarding new admits and or discharges are being added or subtracted as they occur. Nurses keep all pertinent information on this sheet including resident code status. Director of Nursing and/or designee is responsible for making changes as they occur. Review of these forms is being done every business day during Morning Triage and again during afternoon follow-up meeting. This process was started on [DATE]. 6. CENA's will be educated beginning [DATE] regarding "Resident Change in condition and what and when to report changes to their charge nurse". This education will be completed by the Education and Training Director and all CENA's will receive this education before they can work any hours in this facility. Education received is: * Basic Observation review. * What to report, who to report to * What to do in a "Code Blue Medical Emergency! Although Immediate Jeopardy was removed on [DATE] at 6:00 p.m., the facility remained out of compliance at a scope of pattern and a severity of no actual harm, but potential for more than minimal harm that is not Immediate Jeopardy, because all staff had not been educated and sustained compliance has not been verified by the State Agency. ( )