Every finding on record at Eaton County Medical Care Facility

This citation pertains to intake #: 3152667Based on interview and record review, the facility failed to treat residents with dignity and respect for 1 of 3 residents (Resident #2), reviewed for resident rights and dignity.Findings:Resident #2 (R2) Review of an admission Record revealed R2 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Dementia with anxiety, Alzheimer's Disease, and adjustment disorder with anxiety. Further review of R2's admission Record revealed R2 had a Durable Power of Attorney (DPOA F)Review of a Minimum Data Set (MDS) assessment for R2, with a reference date of 6/23/26 revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated R2 was severely cognitively impaired. Review of R2's Care Plan initiated on 3/26/26 revealed, (R2) may make inappropriate comments/gestures towards staff and other residents. If this occurs explain the importance of appropriate conversation and relations with others. Remind him that staff is here to care for him, and it is not appropriate or respectful. Redirect the conversation to an appropriate topic.Review of a Complaint/Incident Investigation Report submitted to the State Agency on 7/30/26 revealed, CNA (Certified Nursing Assistant), (CNA G), reported at 3:45pm to the Administrator, (Nursing Home Administrator [NHA]), that he observed (CNA H) acting inappropriately in front of and with (R2). Allegedly, while (CNA H) was toileting (R2), she was laughing and said to the resident, Hey (R2), say this, before whispering in his ear. (R2) then said, Shut the F**k up, (CNA D), referring to the other CNA in the room providing care, (CNA D). (CNA H) then verbally told resident (R2) to say, Kiss my a**, which (R2) proceeded to say, as (CNA H) laughed. (CNA H) continued to laugh with resident (R2) and proceeded to pretend to play bongos on resident (R2's) head. Resident (R2) has been deemed incapacitated.Review of the resident's care plan does reflect a history of inappropriate comments and gestures. Regardless of her stated intent, the CNA demonstrated poor judgment and failed to maintain professional boundaries. Her conduct was inappropriate, inconsistent with the organization's expectations. A review of her personnel file did not reveal that there have been previous concerns regarding this type of behavior.During an interview on 8/20/26 at 2:03 PM, CNA D reported that CNA H was often her hall partner and was on 7/30/26. CNA D reported that CNA H's co-workers often complained about her attitude stating CNA H would get really upset about thing that she shouldn't have but reported she had never behaved inappropriately with residents as she did on 7/30/26. CNA D reported she and CNA H assisted R2 to the bathroom and CNA H was encouraging R2 to make inappropriate comments towards CNA D. CNA D confirmed that R2 had a history of vulgar behaviors and language and reported she did not feel it was appropriate of CNA H to provoke an escalation of R2's known behaviors as staff were to discourage those behaviors.During an interview on 8/20/26 at 5:07 PM, NHA confirmed that an Incident Report related to CNA H's inappropriate conduct towards R2 was not completed.Review of R2's Electronic Medical Record revealed no documentation that DPOA F was notified of CNA H's inappropriate conduct towards R2.During an interview on 8/19/26 at 2:01 PM, DPOA F was asked if she was notified of CNA H's inappropriate conduct towards R2 to which she stated she was not aware at all and was only notified of R2's increased behaviors of inappropriate comments to other residents and staff. DPOA F reported she was meeting with management today (8/19/26) regarding R2's increased behaviors and was disappointed that the incident occurred and that she was not notified by facility staff. DPOA F reported that R2 was never like this (inappropriate towards others) and expected to be involved in his plan of care.During an interview on 8/20/26 at 11:45 AM, Unit Manager (UM) E reported that following a staff to resident incident and Incident Report should be completed and the DPOA should be notified. UM E reported she would expect documentation that a DPOA was notified to be documented in R2's Electronic Medical Record (EMR) and in the Incident Report.Review of the facility policy, Abuse Program last reviewed/revised 11/2022 revealed, .It is the policy of this facility to prevent abuse by providing residents, families and staff information and education on how and to whom to report concerns, incidents and grievances without the fear of reprisal or retribution. The facility will provide feedback regarding complaints and concerns. The facility leadership will assess the needs of the residents in the facility to be able to identify concerns in order to prevent potential abuse. It is the policy of this facility that all staff monitor residents and will know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute abuse will be investigated.The Administrator or designee will keep the resident or his/her resident representative informed of the progress of the investigation.The Administrator or designee will inform the resident and/or his/her representative of the findings of the investigation and corrective action taken.

This citation pertains to intake #'s: 3156104 and 3168038Based on interview and record review the facility failed to 1.) coordinate care and treatment orders with outside entities and 2.) ensure a comprehensive resident focused treatment plan was implemented for 2 of 3 residents (Resident #1 and #6), reviewed for quality of care.Findings:Resident #1 (R1)Review of an admission Record revealed R1 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: basal and squamous carcinoma (skin cancer) of the scalp and neck and zoster (shingles).Review of a Complaint/Incident Investigation Report submitted to the State Agency on 8/12/26 revealed, Pt's (patients) surgical wounds on scalp were not cared for and became infected, Pt's prescriptions that were sent from the medical office for.a fungal infection were not filled or dispensed to the patient. and it was also alleged staff do not follow wound care orders as directed.Review of R1's Follow Up Appointment-New Patient Orders dated 7/22/26 revealed the following handwritten documentation, Findings: 1. Head wounds x2 Healing well. Continue cleansing both wounds daily and apply mupirocin antibiotic ointment daily.ORDERS: 1. Continue daily soap + water washes + mupirocin application. 2. Cleanse BID (twice daily) with soap + water, then apply ciclopirox 0.77% cream BID after washing. Written next to the finding was (stop date?).3 weeks. Indicating the licensed nurse implementing the order questioned the length of time the treatment was to continue and obtained clarification from the outside provider/dermatologist.Review of R1's Dermatology Visit Note dated 7/23/26 revealed, I saw (R1) on July 22, 2026 for rash and follow up on abscess.ciclopirox 0.77% topical cream.apply to rash on the lower back twice daily until clear. and mupirocin 2% topical ointment.(apply to affected area) of head twice daily. On the last page, there was the provider signature and the date 7/24/26 confirming the provider reviewed the note/recommendation. There was no other handwritten documentation indicating the provider wished to alter/modify the demagogy consultant's recommendations.Review of R1's Order Summary revealed:Order dated 7/22/26-8/1/26: Ciclopirox Olamine External Cream 0.77 % Apply to lower back topically two times a day.for 10 Days. Cleanse with soap and water then apply cream. (Ciclopirox was ordered to be applied until the area was clear. A stop date of 10 days was not indicated for ciclopirox).ANDOrder Dated 7/24/26-8/12/26: Mupirocin External Ointment 2 % Apply to Scalp wounds X 2 topically one time a day for Post surgical scalp wound for 3 Weeks. Wound care was not indicated on the order summary (mupirocin was ordered to be applied twice a day per the final Dermatology Visit Note.)Review of R1's Physician's Order Notes dated 7/22/26 and 7/23/26 revealed, Need order stop date for Mupirocin. (practitioner name omitted) would like Dermatology to decide stop date. AND (name omitted) Dermatology returned call and ordered Mupirocin ointment to scalp wounds for 3 weeks of which should be her return to dermatology. There was no clarification order obtained for the ciclopirox duration or a clarification order obtained for the treatment frequency (daily versus twice daily) for the mupirocin.Review of R1's Physician Progress Note dated 7/22/26 (late entry note documented on 8/11/26) revealed, .She is followed by dermatology for dermatitis of the head wound along with low back rash (indicating the provider wished to follow dermatology practitioner's treatment plan). Dermatology recommending mupirocin ointment to both the head wound and low back rash once daily. (inaccurate description of R1's treatment plan indicating the provider did not thoroughly review the dermatology practitioner's aftercare instructions/treatment orders.)Review of R1's July and August Treatment Administration Record revealed the ciclopirox was administered until 8/1/26 and then discontinued. The mupirocin was administered once daily and did not reflect that wound care was provided.Review of R1's Physician's Order Note dated 8/3/26 revealed, WCN (Wound Care Nurse) assessed back, all lesions are scabbed/closed. No redness, drainage or odor noted. Denies pain.(Medical Director [MD] J) notified via phone. Leave back OTA (open to air) at this time. Indicating the skin issue had not resolved (was not clear) and the treatment was discontinued despite the dermatology practitioner's recommendation.Review of R1's Progress Notes revealed no documentation from 7/22/26-8/12/26 that wound care was completed for R1's head wounds.Review of R1's Follow Up Appointment-New Patient Orders dated 8/12/26 revealed, FINDINGS: 1. Unhealed scalp wounds x 2. 2. Back wound/rash, not improved. ORDERS: Use soap and water.to clean both wounds daily, then apply mupirocin 2% ointment to both areas.Apply ciclopirox 0.77% cream twice daily to back.Review of R1's Dermatology Visit Note dated 8/12/26 revealed, This is an [AGE] year old female who: 1. Is following up for dermatitis.on the trunk. She was seen on July 22, 2026 at which time she was prescribed.ciclopirox 0.77% topical cream Apply to rash on the lower back twice daily until clear.unknown if ever administered to pt, not listed on medication list pt presented with today.prescriptions will be sent again.2. Is following up for abscess on the left medial frontal scalp and right superior parietal scalp. She was seen on July 22, 2026 at which time the following treatment recommendations were given, .mupirocin 2%.twice a day.The patient presents for further evaluation and management. The patient did not follow the treatment plan as directed.Plan: Prescription Medication Management. ciclopirox 0.77% topical cream.apply to rash on the lower back twice daily until clear. and mupirocin 2% topical ointment.(apply to affected area) of head twice daily. There was no handwritten provider signature and date to confirm the provider reviewed the note/recommendation.Review of R1's Order Summary revealed:Order dated 8/13/26-present: Ciclopirox Topical Gel 0.77 % Apply to back topically two times [NAME] for apply to lower back (wound care was not indicated on the order.)ANDOrder Dated 8/14/26: Mupirocin External Ointment 2 % Apply to Scalp wounds X 2 topically one time a day for Post surgical scalp wound for 3 Weeks use soap and water to clean, no alcohol wipes or hand wipes. (Mupirocin was ordered to be applied twice a day per the Dermatology Visit Note.)Review of R1's August Treatment Administration Record revealed the ciclopirox did not reflect that wound care was provided. The mupirocin was administered only once daily.Review of R1's Electronic Medical Record revealed no documentation that the provider reviewed R1's 8/12/26 dermatology consult notes or directed staff to modify the treatment plan.Review of R1's Nurse's Notes written by Unit Manager (UM) E revealed:On 8/12/26, VM (voicemail) left for (name omitted) Dermatology for return call regarding clarification of medication order.On 8/13/26, revealed, VM left for (name omitted) Dermatology for medication clarification.On 8/18/26, Return information from Dermatology indicated that it was unclear whether their previous orders were issued and administered to resident; same orders issued again. Voicemail questioning whether that order was based on status of wounds, or if it was ordered as they were unclear about administration.During an interview on 8/20/26 at 4:21 PM, UM E reported that the floor nurse receives the handwritten Follow Up Appointment-New Patient Orders and implements the orders. If there was a need for clarification the nurse would reach out to the consulting practitioner. UM E reported that she had discussed with the facility practitioner the Follow Up Appointment-New Patient Orders versus the Dermatology Visit Note dated 8/12/26 and it was determined to go with the handwritten notes as the Dermatology Visit Note was preliminary. UM E reported she did reach out to the dermatology office for clarification on an oral medication that had been administered and completed from the visit on 7/22/26. Upon review of the Dermatology Visit Note she identified that the dermatology office was unaware that the oral medication had been completed and was seeking clarification on restarting the medication. UM E did not indicate a clarification order for the mupirocin was attempted despite the dermatology practitioner's treatment recommendation from 7/22/26 and 8/12/26.During an interview on 8/20/26 at 2:19 PM, the Director of Nursing (DON) confirmed there were no wound treatment orders for the mupirocin from 7/22/26-8/12/26 with no documentation in the EMR indicating the treatments were completed. DON confirmed there were no wound treatment orders for the current ciclopirox order with inadequate documentation in the EMR that the treatments were being completed. DON stated, treatments need to be documented and reported the licensed nurses were completing wound care prior to the administration of the medications stating they (licensed nurses) are washing her wounds, but it needs to be documented and confirmed that wound care was to include soap and water, not wipes.DON reported that the ciclopirox ordered on 7/22/26 was discontinued after 10 days due to how it was written on the handwritten Follow Up Appointment-New Patient Orders note. The transcribing nurse read the ciclopirox order and an oral medication order as one note (not as 2 separate orders). DON reported that the provider signed off on the transcribed order on 7/24/26 and did not change the duration. DON reported that the facility had only received the handwritten Follow Up Appointment-New Patient Orders and did not have the printed report to validate the orders at that time. DON reported that following the completion of the 10 days of the ciclopirox, MD J directed the wound care nurse to leave R1's back open to air (no new orders) as the area was scabbed (area/skin not clear as directed in the Dermatology Visit Note).Resident #6 (R6)Review of an admission Record revealed R6 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: a stroke affecting the left side.Review of R6's Skin/Wound Note dated 8/1/26 revealed, cna (Certified Nursing Assistant) when doing nightly bed bath and care on resident found on palmar side of residents left hand at the mcp (Metacarpophalangeal) joint on index finger area is open and appears to be an exposed tendon. Treatment was initiated at that time.Review of R6's Order Summary dated 8/3/26-present revealed, L (left) Plantar Index Finger: cleanse with soap and water, dry WELL, apply thin layer of white petrolatum, cover with small piece of xeroform. Okay to put gauze between xeroform and brace/splint. Do not place gauze directly over tendon. two times a day for Alteration in Skin Integrity.Review of R6's Progress Notes dated 8/3/26 revealed R6's Durable Power of Attorney (DPOA K) consented to the services of the wound clinic/consultant. The wound consultant assessed R6 on 8/4/26 with recommendations to assess R6 weekly (8/11/26 and 8/18/26).Review of R6's Electronic Medical Record (EMR) revealed no wound consultant assessments/progress notes from 8/4/26, 8/11/26, or 8/18/26.On 8/19/26 at 1:20 PM a copy of R6's wound consultant notes from 8/4/26 was requested. On 8/20/26 at 11:36 AM a copy of R6's wound consultant notes from 8/11/26 and 8/18/26 were requested. Documents were received on 8/20/26.During an interview on 8/20/26 at 2:19 PM, Director of Nursing (DON) confirmed she obtained R6's wound consultants notes dated 8/11/26 and 8/18/26 the morning of 8/20/26. Confirming they were not available for review for healthcare providers in R6's EMR prior to the request.Review of R6's Wound Clinic Progress Notes dated 8/4/26, 8/11/26, and 8/18/26 revealed, .The wound is currently managed with xeroform, gauze, and a WHFO (Wrist-Hand-Finger-Orthosis) splint.Plan of Care discussed with facility nursing staff - Cleanse wound with wound cleanser, pat dry with gauze, apply gauze soaked with Vashe for 5 minutes. Cover wound with xeroform, cover with gauze, apply WHFO splint to left hand to keep pressure off of area. Change 2 times per week on Tuesday and Friday, and as needed for soiled or dislodged dressing. (wound clinic) to see patient on Tuesday. The notes did not reflect the facility's physician, Medical Doctor [MD] J or Wound Nurse (WN) I had discussed and/or disagreed with the treatment plan with the wound clinic provider. The Wound Clinic Progress Notes were not signed and dated by the provider to reflect that the report had been reviewed.Review of R6's EMR on 8/19/26 revealed no Physician Progress Notes from the facility practitioners were completed related to the rejection of R6's wound consultants treatment recommendations from 8/4/26, 8/11/26 or 8/18/26.During an interview on 8/20/26 at 4:00 PM (with a second surveyor present), WN I reported that she was the wound nurse responsible for R6's wound assessments and treatment coordination. WN I reported that on 8/4/26 the wound practitioner assessed R6 between 10 AM-12 PM and made recommendations for treatment. WN I reported that MD J later assessed R6 that evening and redocumented the treatment initiated on 8/3/26 in his progress note stating, the medical director has the final say further reporting that MD J's progress notes reflected treatment twice a day.WN I reported that MD J did not follow the wound clinic recommendations due to concerns that the wound would dry out and reported she discussed it with the wound consultant on 8/11/26 and they (wound consultant) agreed (documentation related to that verbal encounter was not reflected in R6's EMR as of the morning of 8/20/26). WN I was unable to provide documentation related to that encounter and was unable to provide documentation reflecting that MD J overtly rejected the wound consultant's recommendations.WN I confirmed there were no wound consultant notes available for review in R6's EMR from the 8/4/26, 8/11/26, or 8/18/26 assessments until 8/20/26 (following the surveyors request on 8/19/26 and 8/20/26). WN I was asked how MD J was made aware of the wound consultant's recommendations without access to the reports but did not provide a conclusive/decisive answer.WN I was asked why there were no progress notes in the EMR to reflect that MD J did not want to follow the wound consultant's recommendation and why the wound consultant's notes continued to reflect a recommendation for treatment change to which she stated she just got the notes from (wound clinic) today (8/20/26) further stating that they (wound consultant) said they agreed (to MD J's treatment plan) but their notes don't reflect thatWN I was asked why the wound consultant would continue to recommend biweekly dressing changes and did not reference MD J's treatment preference in the 8/11/26 and 8/18/26 progress notes. WN I did not provide a conclusive/decisive answer but confirmed there was no documentation regarding MD J's order to reject the wound consultant's recommendation with MD J's rationale documentation or documentation of her discussion with the wound consultant on 8/11/26 (confirming the wound consultant's assessment and recommendations were not reviewed and discussed as evidenced by the wound consultants repeated treatment recommendation beginning on 8/4/26 and endorsed on 8/11/26 and 8/18/26.)WN I was asked if she was responsible for ensuring the wound consultants recommendations/progress notes were obtained and reviewed following the assessment. WN I reported that following a wound consultant assessment, the clinic was to fax over the progress notes with treatment recommendations, and those notes were then uploaded into the EMR for the facility practitioners to review.Review of R6's Physician Progress Notes revealed:A note dated 8/4/26 at 6:15 PM (late entry note documented on 8/20/26 at 9:30 AM)A note dated 8/11/26 at 6:30 PM (late entry note documented on 8/20/26 at 9:34 AM)A note dated 8/14/26 at 6:15 PM (late entry note documented on 8/20/26 at 9:36 AM)All 3 notes contained the following identical documentation, .On 08/04/2026 patient is evaluated by the wound clinic they agreed a venous ulcer management including hand brace as tolerated, hand surgeon consultation, L Plantar Index Finger: cleanse with soap and water, dry WELL, apply thin layer of white petrolatum, cover with small piece of xeroform. Okay to put gauze between xeroform and brace/splint. Do not place gauze directly over tendon two times a day.Discussed with interdisciplinary team about his physical condition venous non pressure ulcer of the left hand index plantar aspect wound and its management in detail they desire for conservative treatment family is okay to see the hand surgeon and their recommendations they are willing to follow-up with the wound clinic team.Considered wound care with wound clinic recommendations L Plantar Index Finger: cleanse with soap and water, dry WELL, apply thin layer of white petrolatum, cover with small piece of xeroform. Okay to put gauze between xeroform and brace/splint. Do not place gauze directly over tendon two times a day. hand surgery consult use the hand brace as tolerated monitor every shift and prn contact me and also wound clinic if any changes of condition. The notes did not reflect that MD J discussed the treatment plan with the wound consultant or with WN I. There was no documentation related to the wound drying out or of the rejection of the wound consultant's recommendation. The notes reflected R6's treatment order initiated prior to wound consultant's assessment. The notes referred only to the consultation on 8/4/26. There was no documentation to reflect that the plan of care was reviewed following the consults on 8/11/26 or 8/18/26 (as evidenced by identical late entry notes on 8/4/26 and 8/11/26, the absence of follow-up progress notes from 8/18/26, and the absence of the signed/dated consultation reports in the EMR.)During an interview on 8/20/26 at 5:15 PM, WN I reported that she contacted the wound consultant and requested they modify their notes dated 8/11/26 and 8/18/26. WN I reported she documented a late entry note (dated 8/20/26 at 4/10 PM) regarding MD J's treatment preference discussed on 8/11/26.During an interview via email at survey exit, supplemental documentation was received which included ammended Wound Clinic Progress Notes dated 8/11/26 and 8/18/26, both reflected, Vashe (Wound Cleanser)-Understood that the facility may not have Vashe available. Ok to use mild soap and water to cleanse the wound. Primary Dressing/Apply: Xeroform Secondary Dressing/Apply/Cover/Secure With: Gauze Other: - WHFO Splint Dressing Change/Application Other: - Update 8/20/26 @ 1616 (4:16 PM): Discussion with wound nurse on 8/11/26 regarding dressing change frequency and (wound clinic) recommends twice per week dressing changes. Case discussed with (WN I) at the facility who had spoken with (MD J) who encouraged BID (twice a day) dressing changes to prevent the patients tendon from drying out. Provider agrees with the doctors recommendation and will update the order to BID dressing changes. Note, the original Wound Clinic Progress Note dated 8/18/26 did not reflect that a discussion had been had on 8/11/26 or that the treatment had been changed to twice a day at that time as indicated in the addendum. The wound treatment recommended on 8/4/26 was endorsed on 8/11/26 and 8/18/26 until WN I contacted the wound consultant on 8/20/26 at 4:10 PM (per progress note dated 8/20/26 at 4:10 PM) following the interview with the surveyors.The Nursing Home Administrator (NHA) stated, .Facility-wide, recommendations and proposed orders from external providers are reviewed by the resident's attending physician, (MD J). Once reviewed and approved by (MD J), the orders are implemented by the facility. If (MD J) determines that a different treatment or order is clinically appropriate, the facility follows the orders issued or approved by him as the resident's attending physician.We are providing this supplemental documentation to clarify that, although (wound clinic) consultation notes contain treatment recommendations, those recommendations should not be interpreted as active facility orders unless and until they have been reviewed and approved by the attending physician.However, R6's EMR did not contain the 8/4/26, 8/11/26, or 8/18/26 Wound Clinic Progress Notes and MD J's progress notes/assessments did not reflect that the recommendations had been reviewed and rejected.Review of R6's EMR revealed no documentation that the DPOA was involved in R6's treatment decisions and notified of the wound consultant's recommendations or the facility physicians preferred treatment plan.During an interview on 8/20/26 at 10:21 AM, DPOA K was aware that R6 was being seen/assessed by the wound clinic but did not report that he was involved in R6's treatment plan or that he was aware that the wound clinic orders were not implemented.Review of Fundamentals of Nursing ([NAME] and [NAME]) 12th edition revealed, All members of the interprofessional team are responsible for communicating effectively and in a timely manner. As a member of that team, you are held accountable for the accuracy of the documentation you enter into the patient's record. Regulations from agencies such as The Joint Commission (TJC) and the CMS require health care agencies to monitor and evaluate the quality and appropriateness of patient care. [NAME], P. A., [NAME], A. G., Stockert, P. A., Hall, A., & [NAME], W. R. (2025). Fundamentals of nursing (12th ed.) [E book]. Elsevier.Review of Fundamentals of Nursing ([NAME] and [NAME]) 12th edition revealed, The health record is a valuable resource for patient assessment. It contains a patient's medical history, summaries of ongoing assessments and care activities, laboratory and diagnostic test results, current physical findings, and a health care provider's treatment plan. In some cases, the health record contains consultation notes. Health records offer baseline and ongoing objective and subjective information about a patient's response to illness and progress to date.A timely, clear, and concise record is necessary for use by other health care professionals (see Chapter 26). If you do not document an assessment finding or a suspected problem, it is lost and unavailable to anyone else caring for the patient. If information is not specific, the reader is left with only general impressions. Observing and documenting patient status are legal and professional responsibilities for all nurses. The nurse practice acts in all states and the ANA Nursing's Social Policy Statement ( ANA, 2010 ) require accurate data collection and documenting as independent functions essential to the role of the professional nurse. [NAME], P. A., [NAME], A. G., Stockert, P. A., Hall, A., & [NAME], W. R. (2025). Fundamentals of nursing (12th ed.) [E book]. Elsevier.

This citation pertains to intake # 3158456 Based on interview and record review, the facility failed to provide required transfer assistance for one of three residents (Resident #3) reviewed for accidents/hazards. Findings:Resident #3 (R3) Review of an admission Record revealed R3 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses of a recent stroke with left sided weakness and paralysis. The most recent BIMS (brief interview for mental status) revealed a score of 15 out of 15, which indicated that R3 was cognitively intact. During an interview on 08/19/26 at 5:40 PM, Family Member (FM) L stated the following regarding an incident at the facility on the afternoon of 12/27/25 that involved R3: (a) R3 asked for help going to the bathroom, (b) an aide came in to assist, (c) R3 told the aide that she required two persons to assist her to the bathroom, (d) the aide ignored R3's request for additional help, (e) R3 told the aide a second time that she needed two staff persons to transfer her to the bathroom, (f) the aide told R3 I got this, (g) R3 and the aide went into the bathroom, (g) a short time later FM L heard R3 screaming, went to the bathroom and saw R3 on the floor. Review of a Corrective Action Progressive Steps/Termination Record dated 12/30/25, for Certified Nurse Aide (CNA) M reflected the following; On 12/27/25 (CNA M) failed to follow the correct transfer status and Kardex for (R3) during a transfer .after R3 had voiced that she needed 2 staff members for the transfer. During an interview on 08/20/26 at 9:58 AM, the Director of Nursing indicated that CNA M had not followed R3's correct transfer status.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 118 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:On 02/10/2026 at 10:20 A.M., An initial tour of the food service was conducted with Culinary Services Manager E. The following items were noted:Walk-In Freezer: The air curtain strips were observed (cracked, brittle, missing). The entrance door gasket was also observed (worn, torn, etched). Frozen water condensation droplets and severe heavy frost deposits were further observed on the walk-in freezer ceiling, adjacent to the refrigeration fan unit. The effected area measured approximately 8-feet-wide by 8-feet-long. Culinary Services Manager E indicated she would contact maintenance for necessary repairs as soon as possible.The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.The [NAME] Beach microwave oven interior ceiling was observed (yellowed, etched, particulate). The ceiling/wall junctures were also observed (etched, corroded, particulate). Culinary Services Manager E stated: I will remove the microwave and have the unit replaced.The 2022 FDA Model Food Code section 4-501.13 states: Microwave ovens shall meet the safety standards specified in 21 CFR 1030.10 Microwave ovens. Failure of microwave ovens to meet the CFR standards could result in human exposure to radiation leakage, resulting in possible medical problems to consumers and employees using the machines.3 of 6 ventilation hood light assemblies were observed non-functional. Culinary Services Manager E indicated she would have maintenance replace the faulty lighting as soon as possible.The 2022 FDA Model Food Code section 6-303.11 states: The light intensity shall be:(A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor.On 02/10/2026 at 11:25 A.M., A comprehensive tour of the Unit A Kitchenette was conducted with Culinary Services Manager E. The following items were noted:The Formica laminate surface was observed (etched, scored, porous, particulate), adjacent to the two-compartment sink. The damaged area measured approximately 2-inches-wide by 8-inches-long. Culinary Services Manager E indicated she would contact maintenance for necessary repairs as soon as possible.The 2022 FDA Model Food Code section 4-101.19 states: NonFOOD-CONTACT SURFACES of EQUIPMENT that are exposed to splash, spillage, or other FOOD soiling or that require frequent cleaning shall be constructed of a CORROSION-RESISTANT, nonabsorbent, and SMOOTH material.On 02/12/2026 at 09:00 A.M., Record review of the Policy/Procedure entitled: Dietary: Refrigerator - Freezer dated 5/20 revealed under Policy: A most important function of refrigeration is to protect against food borne illness. Record review of the Policy/Procedure entitled: Dietary: Refrigerator - Freezer dated 5/20 further revealed under Procedure: (4) Freezers must also be maintained free of excessive frost and ice buildup. Accumulated frost can interfere with air circulation, compromise temperature control, reduce efficiency, and increase risk of unsafe temperature fluctuation. Freezers shall be defrosted as needed to prevent ice accumulation from exceeding 1/4 inch in thickness or according to manufacturer recommendations. During defrosting: (1) Food must be removed and placed in another freezer or refrigerated unit that maintains safe temperatures. (2) Temperature must be monitored to ensure food does not rise above 41 degrees Fahrenheit, if temporarily stored in refrigeration. (3) Interior surfaces must be cleaned and sanitized prior to returning food to the unit. (4) The unit must return to 0 degrees Fahrenheit or below before food is restocked.On 02/12/2026 at 09:30 A.M., Record review of the Policy/Procedure entitled: Dietary Cleaning & Equipment Standards dated 2/04/2025 revealed under Policy: Dietary service shall maintain appropriate cleaning and equipment standards to prevent occurrence and/or spread of foodborne illness within the facility. Record review of the Policy/Procedure entitled: Dietary Cleaning & Equipment Standards dated 2/04/2025 further revealed under Procedure: Equipment: (6) All Dietary staff are responsible for reporting any faulty or potentially faulty, malfunctioning equipment or any equipment in need of repair to both maintenance via intranet work requests and to the Dietary Director.

Based on observation, interview and record review the facility failed to provide impactful and meaningful activities for four Residents (#24, #55, #104, & #109) of four residents reviewed for activities.Findings include:Resident #55 (R55) Review of the clinical record and Minimum Data Set (MDS) assessment dated [DATE] revealed R55 was admitted to the facility on [DATE] with diagnoses that included dementia. According to the MDS, R55 had long and short-term memory impairment and was severely impaired regarding daily decision-making skills. R55 resided on the facility's secured dementia unit. On [DATE] at 11:32 AM, during the screening process R55 was observed sitting in his wheelchair sleeping in the secured units lounge/common area. Several other residents were observed sitting in the same area, 4 of which were also asleep. On [DATE] at 2:26 PM, R55 was observed in common area on unit, with approximately 6 other residents, the television was broadcasting a music channel but it was barely audible. R55 was observed bent over looking at their knee. Another resident was observed looking at magazine. Two other residents were sleeping and two others just sitting with blank stares. There were no attempts made by staff to engage with R55 or attempts to have R55 engage with his peers. The activity calendar posted on the unit read 9:30 staff visit- 11:00 staff visits- 4:00 and 7:30 staff visits there was no other activity listed. On [DATE] at 9:47 AM, R55 was observed sitting in his wheelchair bent forward and the radio was playing in common area. Two other residents were also sitting in the common area and were observed sleeping. No staff were present. The posted Activity Calendar read 9:00 activities on unit-11:00 activities on unit and 4:00 activities on unit On [DATE] at 9:32 AM, 6 residents, including Resident #55 were observed sleeping sitting in their wheelchairs in the common area. The television was on, but volume was very low and barely audible. Staff were observed at the nurse's station desk conversing. The posted Activity Calendar read 9:00 activities on unit-11:00 activities on unit and 4:00 activities on unit Review of R55's kardex (care guide) dated [DATE] revealed R55 liked pet visits, music, fiddle pet, special events, television, video calls, religious activities, back rubs and the barber shop. Review of R55's activity participation record revealed no participation in group activities for the last 30 days and the only activity recorded was noted as people watching on [DATE], [DATE] and [DATE]. There was no documentation R55 was offered and refused any activities over the last 30 days. On [DATE] at 10:41 am, during an interview, Activity Director D reported the facility recently had a shelter in place protocol due to covid and influenza. When queried why the activity calendar for the week of the survey listed activity on unit or staff visit opposed to actual structured activities being held or offered, Activity Director D offered no explanation. Resident #109 (R109) During an interview and observation on [DATE] at 1:52 PM, R109 stated they were locked down on the unit and they cannot go to other units to visit residents that were their friends. R109 stated they could only leave the unit with family on outings. R109 added that they have been locked down for weeks. During an interview and observation on [DATE] at 1:45 PM, R24 stated if they didn't have something to do, they would have to sit there and stare at each other. R24 stated they may get two activities a day if they are lucky. During an interview and observation on [DATE] at 2:03 PM, six residents were observed playing Bingo in the dining room on 300 hall/Melody Lane with Activity Aide E. The activity sheet hanging outside of the dining room doors listed two activities that day, one at 10:00 AM and one at 2:00 PM. Resident #104 (R104) Review of the medical record reflected R104 was admitted to the facility on [DATE] with diagnoses including legal blindness, cognitive communication deficit, abnormalities of gait and mobility and dementia. The most recent MDS assessment dated [DATE] revealed R104 had a Brief Interview of Mental Status (BIMS) of 12 out of 15 indicating they were mildly cognitively impaired. Section G0100, Activities of Daily Living (ADL) Assistance revealed R104 needed assistance of one person with personal care. During an interview and observation on [DATE] on 2:44 PM, Family Member (FM) J stated R104 didn't do much of anything since the shutdown. FM J stated R104 used to go down to Bingo when he had someone to help me with the numbers and markers, until that person got sick and died. R104 stated he didn't have anyone to help him anymore. R104 stated he enjoyed going down to the activities, but he was told they don't have enough help to assist him one on one with activities, and since he is legally blind, why bother going. FM J stated he got R104 set up with books on tape from the library, but R104 could not operate the player himself, so it sat in the drawer. When R104 was asked if anyone had offered to help him with the books on tapes and he stated, No. R104 added, it would be great if they could, and all he does is watch/listen to the TV all day, every day. Record review of the task sheet showing R104's participation in a group activity was zero. R104's participation in independent activity was marked for watching TV five times in the last 30 days. TV is not an independent activity as it takes no effort or engagement for someone to turn the TV on. R104 was marked two times for family visits, which takes no effort or engagement from the facility staff. R104 was marked for one-on-one activity 8 times in the last 30 days. R104's task sheet for group activity was not marked at all in the last 30 days, showing activity staff did not get him involved with the group activities on his unit. The kardex revealed R104 enjoyed Activities of interest: Staff Visits, Family Visits, TV (Gameshows-Listens), Music (has a radio), Pet Visits, Socializing with Others, Exercise, Current Events and Outside Visits (Weather Permitting). He is legally blind. Activities off unit are on hold. Staff will provide visits and support. R104 was born in [NAME], graduated high school, is divorced, has 2 children, is a registered voter, was a [NAME] and bingo is comforting to him. R104's care plan documents he likes to watches/listens to the TV, listens to music, visits with staff and attends some group activities in his leisure time. Activities of interest: Staff Visits, Family Visits, TV (Gameshows-Listens), Music (has a radio), Pet Visits, Socializing with Others, Exercise, Current Events and Outside Visits (Weather Permitting). He is legally blind. Activities off unit are on hold. Staff will provide visits and support. Resident #109 (R109) Review of the medical record reflected R109 was admitted to the facility on [DATE] with diagnoses including stroke affecting right non-dominant side, depression, and dementia. The most recent MDS assessment dated [DATE] revealed R109 had a BIMS of 15 out of 15, indicating they were cognitively intact. Section G0100, Activities of Daily Living (ADL) Assistance revealed R109 needed assistance of two people with personal care. During an interview on [DATE] at 3:44 PM, R109 stated they could not hold resident counsel in the Great Room and they had to have a meeting on each hall due to a shelter in place. R109 stated he thought the other units/halls held their own meeting, but had no idea what was discussed because they did not bring back that information to him as Resident Council President. R109 stated he and two other residents held a meeting, with one resident taking minutes and indicated they could not have any joint meetings, activities or get togethers. R109 stated before shelter in place, they had a monthly Birthday party, they would go on a trip once a month and all that had been cancelled. R109 stated there wasn't anything to do, and that the facility may do one or two activities a day, but with the limited activity aides, the facility could not involve everyone. During an observation on [DATE] at 1:47 PM, R109 sat in his wheelchair sitting in the hallway of his unit waiting for something to do. R109 stated they had Bingo at 2:00, second activity today, otherwise just sitting here staring at each other. The kardex documented R109 had been assessed for safety and is able to sign himself in/out to attend activities in the community via appropriate transportation. Activities of interest: Table Games, Bingo, Bingo Store, Cards, Exercise, Crafts, TV, Cell Phone, Read, Music, Staff Visits, Family Visits, Current Events (on TV), Outings, Socializing with Others, Outside Visits(Weather Permitting), Barber Shop, Special Events, Resident Council, Birthday Party, Trivia, Fish Watching and People Watch. He often enjoys decorating his room for the holidays. He will at times listen to other conversations. Staff will redirect as needed. Activities off unit are on hold. Staff will provide visits and support. Playing bingo is comforting to him. He is the President of Resident Council. R109's Care plan documents Activities of interest: Table Games, Bingo, Bingo Store, Cards, Exercise, Crafts, TV, Cell Phone, Read, Music, Staff Visits, Family Visits, Current Events (on TV), Outings, Socializing with Others, Outside Visits (Weather Permitting), Barber Shop, Special Events, Resident Council, Birthday Party, Trivia, Fish Watching and People Watch. He often enjoys decorating his room for the holidays. He will at times listen to other conversations. Staff will redirect as needed. Activities off unit are on hold. Staff will provide visits and support. R109 attended group activity less than once a day, enjoys Bingo, exercises and current events. R109's independent activity task was blank for the last 30 days, showing no participation. On the completed task sheet for one-on-one activity, R109 received a social visit, with no way of knowing how long that visit was. Resident #24 (R24) Review of the medical record reflected R24 was admitted to the facility on [DATE] with diagnoses including hereditary spastic paraplegia (weakness and stiffness in legs), atrial fibrillation (irregular heart pattern), polyosteoarthritis (protective cartilage that cushions the ends of the bones wear down over time), chronic pain and unspecified dementia. The most recent MDS assessment dated [DATE] revealed R24 had a BIMS of 13 out of 15, indicating they were cognitively intact. Section G0100, Activities of Daily Living (ADL) Assistance revealed R24 needed assistance of one to two people for personal care. During an interview and observation on [DATE] at 1:47 PM, R24 sat in her wheelchair sitting in the hallway of her unit waiting for something to do. R24 stated they have Bingo at 2:00 PM, second activity today, R24 stated otherwise we are just sitting here staring at each other. Record review of R24's one-on-one activity and activity participation revealed R24 had someone stop by for a social visit with her one to three times daily for the last 30 days. Charting did not reflect the amount of time that was spent with R24, nor did it reflect R24 being involved in any other activity as listed on her kardex that she enjoys. R24 enjoys Staff Visits, Family Visits, Table Games, Cards, Euchre, Bingo, Bingo Store, Beauty Shop, Exercise, TV, Cell Phone, Tablet, Music, Pet Visits, Socializing with Others, Outside Visits(Weather Permitting), Resident Council, Manicures, People Watch, Outings, Current Events, Read, Trivia, Crafts and Special Events. Activities off unit are on hold. Staff will provide visits and support, playing cards is comforting to her. R24's task completion log revealed she received one on one activity prn visits, nothing scheduled. No documentation to support what that one-on-one activity was. Group activity was marked prn at dinner time, so her being taken to the dining room was marked as group activity. No documentation to support what that group activity was. R24's care plan list Activities of interest: Staff Visits, Family Visits, Table Games, Cards, Euchre, Bingo, Bingo Store, Beauty Shop, Exercise, TV, Cell Phone, Tablet, Music, Pet Visits, Socializing with Others, Outside Visits (Weather Permitting), Resident Council, Manicures, People Watch, Outings, Current Events, Read, Trivia, Crafts and Special Events. Activities off unit are on hold. Staff will provide visits and support. Independent Activity was marked prn. No documentation to support what that independent activity was. During an interview and observation on [DATE] at 3:50 PM, Activity Aide F stated she was assigned to hall 300. Due to having one covid positive resident on this unit, Activity Aide F stated she went in and out of resident's rooms to visit with them and offered to bring things in for them to do, color pictures, etc. When asked how much time she would spend with them, Activity Aide F stated anywhere from a couple of minutes to 10-20 minutes. When asked how Activity Aide F was able to do all that when there were 24 residents on that unit, Activity Aide F stated she tried to see as many residents as she before the 10:00 AM activity and then between that and the afternoon activity at 2:00 PM, and then after the 2:00 PM activity. When asked if they were able to see all residents on the unit daily, Activity Aide F stated they tried their best to see everyone. During an observation and interview on [DATE] at 3:52 PM, Activity Aide G stated he was setting up for Bingo on hall 400 in the dining room. Four residents were wheeled down to the dining room in their wheelchairs to play Bingo, while the remaining nine residents were sitting in their rooms with no interactive activity. This writer walked down the 400 hall to observe residents in their rooms; four were sleeping, four were awake and watching TV. There were no activity materials visible from the doorway to engage these residents in meaningful interaction. During an observation on [DATE] at 9:25 AM, there were no activities going on in the dining room on 400 hall. Administrative Activity Aide I stated she did not hold an activity in the dining room this morning, she was painting fingernails. Writer asked what the other 12 residents were doing this morning for an activity. Administrative Activity Aide I stated painting fingernails is the activity this morning. During an observation and interview on [DATE] at 9:37 AM, Activity Aide F was painting resident's fingernails in the dining room. Activity Aide F stated she was on this floor every day other than on her breaks. Writer asked what activity the men had while the women get their nails done. Activity Aide F stated the men can get their nails done too, it's not just for women. Writer asked how many men wanted their nails painted? Activity Aide F stated she wasn't sure yet. Writer stated most likely not many, so Bingo at 2:00 PM would be their only activity today. During an interview on [DATE] at 10:05 AM, Activity Aide J stated he went into R104's room [ROOM NUMBER] times yesterday and tried to get him larger bingo cards and R104 still struggled seeing the numbers and indicated R104 hasn't attended lately. When asked if they had someone else that could assist him like the lady that helped him before, Activity Aide J stated that lady passed away and with them in lock down, they have minimal people working on the units. Activity Aide J stated maybe once the facility opened up; they can get someone to help him. During an observation on [DATE] at 10:25 AM, while walking back to the conference room, a resident on 100 hall was observed sitting in his wheelchair out in the hallway and was heard stating, there isn't anything to do, I'm just sitting on my ass . my ass hurts. An unnamed Certified Nurse Aide asked him what he would like to do, an activity aide walked by and stated they were doing nails this morning. Writer asked her what they were doing for the men this morning, she stated, There is only so many of them and walked away. During an interview on [DATE] at 10:41 AM, Activity Director D stated he was a full time Activity Director and also helped with driving residents to appointments with the facility van. Activity Director D stated he had 13 activity Aides who were part-time or pool/casual employees. Activity Director D stated the part time and pool staff could work up to 20 hours a week. Activity Director D then stated he had two full time staff besides himself. Activity Director D stated they were put in shelter in place the middle of [DATE]. Activity Director D stated they could no longer meet as a group and they had to hold activities on each unit due to residents not being able to leave their units. Activity Director D was asked if the staff were able to get all the residents to an activity. Activity Director D stated yes, he thought so. Activity Director D was asked to see the original calendar of activities prior to [DATE], and the current calendar of activities after [DATE]. During this same interview, Activity Director D stated the 300 hall was the most represented hall for activity attendance. Activity Director D stated Activity Aide F still did group activities in the dining room on that unit. Writer asked why there were only four residents observed in attendance out of the 26 residents on 300 hall? Activity Director D stated he wasn't sure. Activity Director D looked at the condensed activity calendar then stated some of the outside people wanted to wait until after the isolation was lifted. Activity Director D stated the aides could do any activities that they wanted to with residents, based on attention span, like they usually do. Writer asked Activity Director D how he knew which residents were involved with activities and which ones were not, he stated he wasn't sure. Activity Director D stated he was the one responsible for the activity care plans. During this same interview, Activity Director D stated Activity Aide G was on 400 hall today. Writer asked what activities were planned for that location and Activity Director D stated he didn't not know what Activity Aide G did today. Activity Director D then stated he believed Activity Aide H was on 100 hall. Activity Director D then stated they had 3-4 activity aide's working during the day for the whole building. Activity Director D then stated he gets his update on the isolation halls from the Administrator and Infection Preventionist. Writer asked Activity Director D what halls/units were shelter in place Activity Director D stated he didn't know, he was unsure. Record review of the calendar of activities prior to [DATE], provided seven to eight activities daily in the Great Room for all residents to attend. These activities were held between 9:00 AM to 7:30 PM daily. The condensed calendar following [DATE], activities offered three times a day on each hall with times 10:00 AM, 2:00 PM and 4:30 PM daily, if they did receive three activities a day. Activity calendars were hung outside of the dining room on each unit, and many had only two activities offered for the whole day. Record review of resident council meeting minutes from February 3, 2026, discussed the fact that residents could not go to other halls and hold joint meetings, they had to be held on each unit. Resident Council minutes noted three residents from the 300-hall met for a Resident Council meeting and one resident from 200 hall attended their own Resident Council meeting on [DATE]. No other notes or minutes were included that reflected if other units were able to hold a meeting. Reading those minutes, it discusses due to the units being in isolation Rescheduling events and outing due to isolation. Through observation, interview, record review, the facility failed to implement a condensed resident centered activities program that incorporated all resident's interests, hobbies and preferences which is integral to maintaining a resident's physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 (Resident #8) of 24 reviewed for MDS assessments. Review of the clinical record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident 8 (R8) was admitted to the facility on [DATE] with acute respiratory failure. The MDS dated [DATE] revealed Section N0415 question 1. E. was coded Yes for having been administered an anticoagulant medication within the last 7 days. Review of R8's Medication Administration Record (MAR) for November 2025 and monthly Physician orders for November 2025 revealed, R8 was not prescribed or administered an anticoagulant medication. On 02/12/26 at 3:10pm, during an interview with Registered Nurse/MDS Coordinator C, R8's November MDS, MAR and physician orders were reviewed. Registered Nurse/MDS Coordinator C agreed there was no documentation to support R8 was administered an anticoagulant medication. RN C acknowledged the MDS dated [DATE] was coded incorrectly.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen. Findings include: During a tour of the kitchen, starting at 12:54 PM on 12/17/24, it was observed that a box of vegetables and large bag of potatoes were found stored on the floor of walk-in cooler three. An interview with Head Chef (HC) F found that deliveries come Monday and Thursday. During a tour of the walk-in freezer, at 1:42 PM on 12/17/24, it was observed that multiple boxes of food product were found stored on the floor such as vegetables and buttermilk biscuits. An interview with HC F found that the staff member who regularly puts product away has been off work. According to the 2022 FDA Food Code section 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. During a tour of the kitchen, at 1:01 PM on 12/17/24, it was observed that black spotted debris accumulation was evident on the tops and side gaskets of the two door traulsen cooler. During an observation of clean utensil drawers, next to the stand-up mixer, at 1:05 PM on 12/17/24, it was observed that an accumulation of crumb debris was present inside of partitions and cubbies that help separate equipment. During an observation of the clean mechanical scoop drawers, at 1:35 PM on 12/17/24, it was observed that three white mechanical scoops were found with stuck on food debris in their inside portions and under the metal scoop slide. When asked if she could see the debris, HC F stated yes. Further review of the clean utensil drawer found an accumulation of crumb debris inside of the cubbies that help separate and organize the drawer. During a tour of the facility, at 1:39 PM on 12/17/24, an interview with HC F found that the meat slicer gets used weekly and is taken apart and cleaned after use. At this time observation of the meat slicer found a small amount of dried stuck on meat debris on the back side lip of the blade. Further observation found an accumulation of debris on the inside non-food contact portion of the slicer. Observations of the kitchenettes, starting at 2:14 PM on 12/17/24, found an increased accumulation of debris on the spouts of the ice machines in the following locations: Unit A, Pine, and Melody Trail. Ice spouts were found with a heavy accumulation of crusted white debris coating the inside spouts while the ice machine in Melody trail was found with a large white crusted growth around the inside spout of the machine. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During an interview with HC F, at 1:18 PM on 12/17/24, found that staff use the one compartment sink, next to the stand-up mixer, for food preparation. Observation of the sink found that it was directly connected to the wastewater drain. Observation of the three-compartment sink at 1:20 PM on 12/17/24, found that the sanitizer compartment of the sink did not have a visible air gap present to preclude against the contamination of wastewater backflow. Observation of the one compartment preparation sink, near the drink station, was found to be directly connected to the wastewater system. An interview with HC F, at 8:45 AM on 12/18/24, found that maintenance I believes that the air gaps for the preparation sinks and the three compartment sink are located in a crawl space below the kitchen. At 1:36 PM on 12/18/24, with Maintenance I, The surveyor went down into the crawl space below the kitchen and found that the preparation sink next to the stand up mixer and the three compartment sink were directly connected to the waste water system. Further observation found that the preparation sink next to the drink station contained an air break, where the drain had sunk down into the pipe no longer making a physical gap. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed . During an observation of the dry storage shelf, near the cook line, at 1:25 PM on 12/17/24, found an open gallon container of soy sauce with roughly a 1/4 of the product left. A review of the manufactures directions found it states to Refrigerate 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, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54C (130F) or above; or (2) At 5C (41F) or less. During a tour of Unit A kitchenette, at 2:15 PM on 12/17/24, observation of the ice cart found a covered cooler half full of water with ice floating in it. When asked about how the ice coolers are taken care of, HC F stated that they get taken back to the kitchen each day to be cleaned between uses. There was no observation that found a way for the water to self drain from the cooler. Observation of the Pine kitchenette, at 2:34 PM on 12/17/24, found the ice chest half full with ice floating in water. Observation of the Unit A Kitchenette, at 9:43 AM on 12/18/24, found the ice chest only full of water. According to the 2022 FDA Food Code section 3-303.12 Storage or Display of Food in Contact with Water or Ice.(B) Except as specified in (C) and (D) of this section, unPACKAGED FOOD may not be stored in direct contact with undrained ice .

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During a tour of the facility, at 10:35 AM on 12/18/24, an interview with Maintenance (M) I found that Building Services Director (BSD) H handles the Water Management Plan (WMP). During a tour of Unit A soiled utility room, at 10:40 AM on 12/18/24, it was observed that water in the hopper was found to be low in the bowl. After flushing the hopper, the water in the bowl filled up with roughly two times the amount of water, indicating that the fixture is not regularly flushed to remove stagnation due to lack of use. During a tour of the Garden Grove janitors' closet, at 10:53 AM on 12/18/24, it was observed that a standard mop sink was present with no chemical dispense. When asked if this closet gets used very often, M I stated that housekeepers get chemicals from the main mop sink off the service hall and doesn't think staff use these hallway janitor sinks often. At this time, the surveyor turned on the hot and cold-water lines of the sink and found brown water momentarily come out until it turned clear. During a tour of the Victorian Lane janitors sink, at 11:09 AM on 12/18/24, it was observed that brown water momentarily came out of the faucet when the cold and hot water taps were turned on. During a tour of the Melody Trail janitors sink, at 11:23 AM on 12/18/24, it was observed that brown water momentarily came out of the faucet when the cold-water tap was turned on. During a tour of the Melody Trail soiled utility room, at 11:29 AM on 12/18/24, it was observed that water in the bowl the hopper was found very low and depleted, indicating a stagnant water line. Upon flushing the hopper, the water came back roughly two times the amount found in the bowl originally. During a tour of the Melody Trail spa room, at 11:32 AM on 12/18/24, it was observed that the room had a spa tub for use. An interview with M I found that the tub does not get used often. When asked if this was an area where staff are flushing water, M I was unsure. During a tour of the Harmony Way spa room, at 11:36 AM on 12/18/24, it was observed that the room had a spa tub for use. The tub was found dry and with bits of dust and debris inside of the tub basin. An interview with BSD H, at 2:32 PM on 12/18/24, found that some water fixtures in the facility are regularly flushed by staff, but the hoppers, janitor sinks, and spa tubs were not on a regular flushing schedule. When asked who was on the Water Management Team, BSD H stated that its mostly him. When asked if the facility samples water as part of the WMP, BSD H stated that he takes samples with a test strip that looks at multiple factors in the water. When asked what his control measures and limits are for the samples, BSD H was unsure and stated he uses the bottle as a gauge. A review of the test strips found that one of the indicators it tests for is total chlorine, when asked what residual he would look for regarding total chlorine, BSD H pointed to the test strip scale and stated 5 to 10 (parts per million). When asked if the facility has performed a risk assessment to identify where Legionella and other opportunist pathogens of premises plumbing could grow and spread, BSD H was unsure. A record review of facility provided documentation found no completed Centers for Disease Control (CDC) toolkit, and no reference to using the American Society of Heating Refrigeration and Air Conditioning Engineers (ASHRAE) Guidelines. A document entitled Water Management Program Team, dated [DATE], found members, including M I and BSD H. A review of the facility provided document entitled [NAME] County Health & Rehabilitation Services Policy and Procedure - Safe Water, revised 11/22, found that It is the Policy of [NAME] County Health & Rehabilitation Services to monitor drinking water for safety and have interventions in place when a concern arises. The document went on to state Housekeepers will turn on all showers, sinks as part of daily cleaning to ensure there is no stagnant water in pipes. Further review of the policy and procedure found that Water will be tested quarterly (more often if necessary) in house, using water testing kits. Testing sites will include 1 area from each section of the building. Findings will be documented on Quarterly Test Logs. A review of the facility provided Quarterly Water Test log, with most recent entries on 12/9/24, found no specified control limits to base results on. The log was also found with no values to indicate results, only a check mark and a line. No provided documentation was available describing control points, control measures, or control limits the facility has in place to reduce the risk of Legionella and other OPPP.

Based on observation, interview, and record review, the facility failed to ensure their medication error rate was below 5% when five medication errors were observed from a total of 35 opportunities for four residents (R42, R58, R100, and R129) of seven reviewed resulting in a medication error rate of 14.29%. Findings include: Resident 100 (R100) Review of the medical record revealed R100 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/24 revealed R100 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/19/24 at 7:53 AM, Licensed Practical Nurse (LPN) D was observed preparing and administering medications to R100. LPN D measured 17 grams of Miralax (laxative medication) powder and placed the powder in a plastic cup. R100 was seated at a dining room table eating breakfast and had some coffee in a cup. LPN D handed R100 the cup of Miralax powder. R100 then poured the powder into their oatmeal, mixed it, and then consumed the oatmeal. R100 reported they did not want to waste my fluids (R100 was on a fluid restriction) on their medications. LPN D reported R100 usually mixed the Miralax powder in their oatmeal. Review of the Physician's Order Note dated 12/18/24 revealed Patient would like MiraLAX increased .okay to increase MiraLAX 17 gram [twice a day]. Review of the Physician's Order dated 12/18/24 revealed an order for Miralax 17 grams by mouth two times a day for constipation, mix with 4 to 8 ounces of water or juice. The order did not specify if the medication was included in or in addition to R100's fluid restriction. Resident # 58 (R58) Review of the medical record revealed R58 was admitted to the facility on [DATE]. The MDS with an ARD of 9/25/24 revealed R58 scored 15 out of 15 on the BIMS. On 12/19/24 at 8:00 AM, LPN D was observed preparing and administering medications to R58. LPN D administered two tablets of Geri-kot (sennosides 8.6 milligrams) to R100. The medication given did not include docusate sodium 50 milligrams (mg). Review of the Physician's order dated 9/22/23 revealed an order for Senna-Docusate Sodium oral tablet 8.6-50 mg, give 2 tablets by mouth two times a day for constipation. In an interview on 12/19/24 at 11:06 AM, Clinical Mentor (CM) E reported Miralax should be mixed with 4 ounces of a water or other beverage. CM E reported they were not aware R100 mixed their Miralax with oatmeal. In an interview on 12/19/24 at 12:00 PM, Director of Nursing (DON) B reported the dietitian usually considered all fluids given with medications when calculating fluid restriction amounts. DON B reported Miralax should not be mixed with food/oatmeal unless it was approved or there was a specific reason. DON B reported the facility stocked both sennosides and Senna-Docusate Sodium. According to www.miralax.com, directions included stir and dissolve in any 4 to 8 ounces of beverage (cold, hot or room temperature), then drink. Do not combine with starch-based thickeners used for difficulty swallowing. 34705 Resident #42(R42) Review of the medical record revealed R42 was admitted to the facility on [DATE]. R42 Face Sheet reflected diagnoses that included psychotic disorder with delusions, personality disorder, major depressive disorder, anxiety disorder and mood disorder. During an observation on 12/19/24 at 7:40 am, Licensed Practical Nurse (LPN) U administered R42 Cymbalta Delayed Release 60mg, after opening capsule and placing contents in yogurt. Review of R42 Physician Order, dated 9/11/24, reflected, Cymbalta Capsule Delayed Release Particles (DULoxetineHCl)Give 60 mg by mouth one time a day related to MAJOR DEPRESSIVE DISORDER . Resident R129(R129) Review of the medical record revealed R129 was admitted to the facility on [DATE]. R129 Face Sheet reflected diagnoses that included vitamin D deficiency, and Osteoarthritis. Review of R129 Physician order, dated 12/18/24, reflected, Calcium Oral Tablet 500 MG(Calcium)Give 1 tablet by mouth two times a day related to VITAMIN D DEFICIENCY . Gabapentin 300mg three times daily. During an observation on 12/19/24 at 8:30 p.m., LPN V prepared Calcium 500mg with vitamin D 1 tablet for R129. After surveyor verbally read physician order out loud LPN V reported would wait to administer Calcium with vitamin D because physician order was for just Calcium that was not available in medication cart and removed from the medication cup. (LPN V planned to administer prior to surveyor influence). Continued observation revealed LPN V administered R129 Gabapentin 300 mg one capsule. Review of R129 Medication Administration Record(MAR) on 12/19/24 at 11:50 AM, reflected R129 had received second dose of gabapentin 300 mg on 12/19/24.(First dose observed given at 8:31 a.m.) During an interview on 12/19/24 at 12:26 PM, LPN V reported administered R129 second dose of Gabapentin 300 mg at 11:16 a.m. after review of R129 MAR. During an interview and observation on 12/19/24 at 1:30 PM, LPN U reported no crush medication list was usually in book at the Nurse Station and verified was unable to locate in binder. During an interview and observation on 12/19/24 at 1:45 PM, Registered Nurse(RN) W do not crush medication list was usually located in the folder on the medication cart and verified was missing. RN W reported would always call pharmacy if needed. During an interview on 12/19/24 at 2:30 PM, Director of Nursing (DON) B reported would expect that Cymbalta Delayed released capsule not be opened prior to administering. DON B reported would expect R129 Gabapentin 300mg be administered about every six hours three times daily. During an interview on 12/20/24 at 10:10 AM, DON B reported would expect nurses to follow physician medication orders.

Based on observation and interview, the facility failed to dispose of expired medications in two of four medication carts, appropriately store refrigerated medications in one of three medication storage rooms reviewed, and secure medications (R97), resulting in the potential for decreased efficacy of medications, medication contamination, medication errors and adverse side effects in a current facility census of 127 residents. Findings include: Review of the facility provided medication cart and room map reflected 6 medication rooms and 7 medication carts. During an observation on 12/19/24 at 1:48 PM, Registered Nurse(RN) W unlocked the, rehab high medication cart. Located in the cart was an open bottle of Benadryl 25mg with manufacture expiration dated of 10/2024 and Insta Glucose with manufacture expiration date of 6/2023. During an observation and interview on 12/19/24 at 2:50 PM, License Practical Nurse(LPN) X unlocked the Pine Ridge Medication resident medication refrigerator, located in the medication room, with several resident medications as well as unlabeled frozen food in freezer and what appeared to be unlabeled drink in frig. LPN X reported resident medication frig should not have food or drinks stored in it and reported was unsure who put them there. LPN X verified only nurses have keys to medication rooms. LPN X unlocked Pine Ridge medication cart and verified Benadryl 25 mg had manufacture expiration date of 9/2024 and colace with manufacture expiration date of 11/2024. LPN X reported plan to discard both medications. During an interview on 12/20/24 at 10:10 AM, Director of Nursing(DON) B reported food should not be stored in resident medication refrigerator and medications should be discarded according to manufacture expiration dates. 45038 Resident #97 (R97) Review of the medical record revealed R97 was admitted to the facility 03/16/2023 with diagnoses that included dementia, heart disease, protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), hypertension, emphysema, anxiety, low back pain, scoliosis (spinal deformity), adjustment disorder, cognitive communication deficit, arthritis, peripheral vascular disease (PVD), Alzheimer's, cardiomegaly (enlarged heart), and hyperlipidemia (high fat content in blood). The most recent Minimum Data Set (MDS), with an Assessment Reference Date of 11/20/2024, revealed R97 had a Brief Interview for Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. During observation and interview on 12/17/2024 at 01:34 p.m. R97 was observed sitting up on the side of her bed. A medication cup was setting R97's over the bed table. Six pills were observed in the medication cup. Three of the pills were white, one pill was orange, and two pills were yellow. R97 could not explain what the pills in the medication cup were. When asked what the pills in the medication cup where, R97 responded ask them. When questioned who them were she responded Staff. In an interview on 12/18/2024 at 12: 55 p.m. Registered Nurse (RN) J explained that it was professional practice that medication was not to be left at the bedside of a resident. She explained that it was professional practice to observe the resident taking the medication that was provided by the nursing staff. In an interview on 12/19/2024 at 11:59 a.m. Director of Nursing (DON) B explained that residents could only self-administer medication if an assessment was completed by the interdisciplinary team and a physician order would be obtained. DON B explained that self-medication administration would be included in the resident's plan of care. DON B explained that it was the facility policy that the nurse providing the medication would witness the resident taking the medication. DON B confirmed that R97 did not have an assessment for self-medication administration. DON B also confirmed R97 did not have a physician order for self-medication administration. Review of facility policy entitled Medication by Licensed Personnel , most recent review date of 10/2024, revealed 12. Remain with the resident/patient until all mediation are taken

Based on interview and record review, the facility failed to ensure updated and accurate advanced directive information was in place for 1 residents (#329) of 2 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 potentially affecting up to the facility census of 127 residents. Findings include: Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 revealed that, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician. (c) Two witnesses [AGE] years of age or older, at least 1 of whom is not the declarant's spouse, parent, child, grandchild, sibling, or presumptive heir. (3) The names of all signatories shall be printed or typed below the corresponding signatures. A witness shall not sign an order unless the declarant or the declarant's patient advocate appears to the witness to be of sound mind and under no duress, fraud, or undue influence. Review of R329 physician signed DNR order, dated 12/13/24, reflected the document was signed by R329 responsible party on 12/11/24 and included one witness signature.(document was missing second witness signature and date. During an interview on 12/18/24 at 3:50 pm, Admission coordinator(AC) S reported the facility process for completing DNR order on admission included resident or responsible party was required to sign along with two witnesses and physician. AC S reported two witnesses required to verify resident wishes being honored. During an interview on 12/18/24 at 4:20 PM, Palliative Care Clinical Mentor (CM) T reported admission nurse was responsible for completing DNR documents with resident/responsible party. CM T reported DNR order should include two witnesses and verified R329's was missing a witness statement.

Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act 42CFR483.12(c) Findings include: Resident #22 (R#22) Review of the medical record reflected R22 was an initial admission to the facility on [DATE] with a readmission on 10/03/24. Diagnoses of Paraplegia, Vascular Dementia, Speech and Language deficits following other Diagnosis, Cerebrovascular Disease, Dysphagia Oropharyngeal Phase, Weakness and Pathological Fracture, left Humerus, subsequent Fracture with routine healing. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/16/2024, revealed R22 had a Brief Interview of Mental Status (BIMS) of 99 (count not answer) out of 0 to 15. Under section G0100, Activities of Daily Living (ADL) assistance reveals R22 was dependent of all care. During an interview on 12/18/24 at 08:35 AM, family member Y stated that R22 suffered a broken arm, and nobody knew why, she had asked and did not get any answers. Record review revealed R22 had an X-Ray due to aspiration pneumonia on 12/11/24 and the fracture to the left shoulder was found incidentally. Order dated 12/11/2024 00:24, Physician's Order Note Data: CXR results received: Conclusion: 1. No acute focal consolidation or effusion. 2. No significant change from comparison imaging. 3. left humeral neck fracture, possibly pathologic. Recommend shoulder radiographs and/or CT versus MRI. Action: Notified physician Response: New orders: STAT left shoulder XR. Resident to be non-weight bearing to left arm until results of left shoulder XR. Record review revealed 12/11/2024 08:00. Incident/Accident Note (name of facility): Resident found to have a possible pathologic L humerus fracture as an incidental finding on chest x-ray. Resident has no complaints or signs/symptoms of pain or discomfort. X ray completed stat of left shoulder, findings confirmed, resident sent to emergency room per physician order. Record review revealed on 12/11/2024 08:39. Physician's Order Note Data: Results of left shoulder 2-view X-ray: Proximal left humeral fx. Action: RN called physician to notify of above results. Response: Physician stated to send resident to local emergency room for further evaluation/treatment. Record review revealed on 12/11/2024 08:42. Nurse's Note Describe observation/situation: Registered Nurse (RN) called resident's daughter (DPOA/legal guardian) to notify her of results of left shoulder X-ray. Informed her that X-ray positive for left humeral fracture, and that physician ordered to send resident to local emergency department for further evaluation/treatment. Resident's daughter agreeable with sending him to the local emergency department. Resident to be sent to local emergency department and daughter stated she will meet him there. Resident's daughter verbalized understanding of all information given. Record review revealed on 12/11/2024 09:00. Nurse's Note Describe observation/situation: RN called county 911 to transport resident to local emergency department. Record review revealed on 12/11/2024 09:20. Nurse's Note. Describe observation/situation: Report called to local emergency department. Record review revealed on 12/11/2024 12:45. Nurse's Note. Describe observation/situation: resident returned from local emergency department. Record review revealed on 12/11/2024 14:50. Physician's Order Note Data: Results: There is a fracture through the humeral neck without significant angulation or displacement. Correlate clinically in regard to the age of this fracture as it may be acute/subacute. Degenerative Joint Disease. Conclusion: Proximal left humeral fracture. Action: NP reviewed and provided orders for non-weight bearing, no laying on left side, 2 persons with check and change for stabilization of left upper extremity, no mechanical lift. Record review revealed on 12/12/2024 04:58. Incident/Accident Note (name of facility): Resident is resting in bed quietly with no complaints of pain or discomfort at this time. Will continue to monitor. Record review revealed on 12/12/2024 14:25. Incident/Accident Note (name of facility): Resident complained of left arm pain seems to be located more around left elbow. left arm is contracted with elbow bent towards chest, Little to no range of motion. No left side lying. During an interview on 12/18/24 at 12:15 PM, writer asked LNA A if she had an incident report on this injury of unknown origin and the investigation. Record review revealed minimal details in the resident's electronic medical records. On 12/18/24 at 3:00pm, writer was still waiting for information of the incident report and investigation. Record review of the incident/ investigation revealed that was an injury of unknown origin. Information received on12/18/24 by LNA A included an incident report, physician review of injury, a new progress note dated 12/17/24 by Director of Nursing (DON) B within 16 pages. There was not an investigation completed. On 12/19/24 at 08:25 AM, writer requested full incident report and investigation again from the LNA A for the third time. On 12/19/24 at 08:30 AM, Record review of the updated incident with investigation presented now contains 91 pages of information from the incident, physician review of injury dated 12/16/24, event investigation completed by the DON B, grievance/concern witness statement form dated 12/18/24 by CNA Z, grievance/concern witness statement form dated 12/19/24 by Registered Nurse (RN) AA, grievance/concern witness statement form dated 12/18/24 by Clinical Mentor BB. Incident statement form dated 12/11/24 by Clinical Mentor BB. Incident statement form dated 12/18/24 by CNA CC with the 18th date crossed out and 11 written over it. Incident statement form dated 12/18/24 by Hospitality Aide/ Nurse Aide in Training DD with the 18th date crossed out and 11 written over it. Incident statement form dated 12/18/24 by Restorative CNA EE with the 18th date crossed out and 11 written over it. Record review included a Radiology report dated 12/11/24 showing the fractured left humerus neck fracture. After visit report from emergency department of closed 2-part nondisplaced fracture to the surgical neck of the humerus. Kardex updated 12/13/24. Care plan of 22 pages updated on 12/13/24 for a focus of R22 had a possible pathological left humerus neck fracture discovered by incidental finding on chest x-ray, only intervention on care plan was Resident's left arm to be supported by staff when proving care dated 12/13/24. Every hour repositioning of resident and offload only on right side related to left arm humerus fracture. No other interventions updated on the care plan. No resident interviews included in the investigation plan. Presented investigation was completed after the incident and forms filled in during the annual survey. During an interview on 12/19/24 at 11:00 AM, R22 stated he has pain in his left arm. Stated he fell , when asked questions about the fractured left arm he could only shake his head yes or no. Refused to let writer look at his left arm. When asked if staff reposition him every hour, he shook his head no. R22 could use the bed controller to put his bed in a reclined position so he could rest. Writer asked him if he wanted to rest, R22 shock his head yes, so writer told R22 that I would come back later. During an interview on 12/20/24 at 08:54 AM, RN Clinical Mentor BB stated she couldn't give much information as it was incidental findings, she asked for an Xray of his lungs, it was done on the 10th, nurse called the Medical Director (MD), ordered a stat Xray on left shoulder, results came in early on the 11th, MD contacted, MD sent him out to the emergency room , contacted daughter, who would meet resident at the local emergency department. R22 came back to the facility after several hours. Writer asked about the investigation on the injury. Clinical Mentor BB stated when a resident gets an injury on that unit, they start getting statements, talking to staff working that shift, had to be an immediate intervention, MD and family contacted, DON B and LNA A notified. Immediate intervention was he was sent to the emergency department and mobilized the arm. Clinical Mentor BB stated the interventions are case by case. In this case, he didn't come out of his room, another resident would not witness it because the door is shut. Other residents are good reporters, they are alert & oriented to what's going on. Clinical Mentor BB stated she didn't think it was abuse, because there was no bruising, not found on the floor, he would have other marks on his skin, scratching, etc. Medical Director and Nurse Practitioner believed it was a pathological explanation of this injury. Clinical Mentor BB stated nothing indicated to make her suspicious of anything. Clinical Mentor BB added that part of the investigation would be to start an incident packet, a resident event review. Clinical Mentor BB stated they were unable to find how this happened, she did skin assessment weekly, every Tuesday, yesterday R22 had pain in his right hip, he did not speak, she answered his call light, complained of pain, can node his head to answer yes or no. Provides protection to left elbow, hand protector. Offloading boots were on, no skin issues, no bruising. During an interview on 12/20/24 at 09:30 AM, DON B stated anytime there is an injury, they complete an Incident and accident report, notify the MD, complete an assessment. DON B added that they figure in any factors that could have caused the injury, complete skin assessments, pain assessment, staff statements, course of events that lead to the incident. Set up repeat assessments, pain assessments, skin assessments, labs, updating the care plan based on need to add interventions. DON B stated they notify the family and shared this event in the interdisciplinary team (IDT) meeting every morning. During an interview on 12/20/24 at 10:58 AM, LNA A stated that staff contact her when there is an injury, if it's not suspicious it comes to her, or an allegation, means unwitnessed injury. LNA A then stated if it is suspicious, she would ask questions around the incident, determine if it's an allegation of abuse or neglect, report to social worker. LNA A added, depending if its abuse and neglect, social worker and nurse manager will discuss with the staff working on the floor, depends on the situation or incident. LNA A stated it depends on what they are investigating, then they may interview other residents. Social worker would interview other residents to see if they feel safe. If not an allegation of abuse or neglect, they would not interview residents. LNA A stated she was notified that morning of incident, was told he had a pathological fracture. Writer asked if there was an allegation of abuse or neglect. LNA A stated she did not feel it was abuse or neglect, so they did not feel the need to investigate or report this incident to the state. LNA A stated she had no concerns; BB had been his clinical mentor for years. LNA A stated she reports it only if it's an allegation of abuse or neglect, if not no.

Based on interview and record review, the facility failed to ensure all injuries of unknown source were thoroughly investigated, in one of one resident (R#22) reviewed for abuse, resulting in the potential for injuries of unknown origin not being investigated. Findings include: Resident #22 (R#22) Review of the medical record reflected R22 was an initial admission to the facility on [DATE] with a readmission on 10/03/24. Diagnoses of Paraplegia, Vascular Dementia, Speech and Language deficits following other Diagnosis, Cerebrovascular Disease, Dysphagia Oropharyngeal Phase, Weakness and Pathological Fracture, left Humerus, subsequent Fracture with routine healing. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/16/2024, revealed R22 had a Brief Interview of Mental Status (BIMS) of 99 (could not answer) out of 0 to 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R22 is dependent of all care. During an interview on 12/18/24 at 08:35 AM, family member Y stated that R22 suffered a broken arm, and nobody knew why, she had asked and did not get any answers. Record review revealed R22 had an X-Ray due to aspiration pneumonia on 12/11/24 and the fracture to the left shoulder was found incidentally. Order dated 12/11/2024 00:24, Physician's Order Note Data: CXR results received: Conclusion: 1. No acute focal consolidation or effusion. 2. No significant change from comparison imaging. 3. left humeral neck fracture, possibly pathologic. Recommend shoulder radiographs and/or CT versus MRI. Action: Notified physician Response: New orders: STAT left shoulder XR. Resident to be non-weight bearing to left arm until results of left shoulder fracture. Record review revealed 12/11/2024 08:00. Incident/Accident Note (Name of facility): Resident found to have a possible pathologic L humerus fracture as an incidental finding on chest x-ray. Resident has no complaints or signs/symptoms of pain or discomfort. X ray completed stat of left shoulder, findings confirmed, resident sent to emergency room per physician order. Record review revealed on 12/11/2024 08:39. Physician's Order Note Data: Results of left shoulder 2-view X-ray: Proximal left humeral fx. Action: RN called physician to notify of above results. Response: Physician stated to send resident to local emergency department for further evaluation/treatment. Record review revealed on 12/11/2024 08:42. Nurse's Note Describe observation/situation: RN called resident's daughter (DPOA/legal guardian) to notify her of results of left shoulder X-ray. Informed her that X-ray positive for left humeral fracture, and that physician ordered to send resident to local emergency department for further evaluation/treatment. Resident's daughter agreeable with sending him to the local emergency department. Resident to be sent to local emergency department and daughter stated she will meet him there. Resident's daughter verbalized understanding of all information given. Record review revealed on 12/11/2024 09:00. Nurse's Note Describe observation/situation: RN called county 911 to transport resident to local emergency department. Record review revealed on 12/11/2024 09:20. Nurse's Note. Describe observation/situation: Report called to local emergency department. Record review revealed on 12/11/2024 12:45. Nurse's Note. Describe observation/situation: resident returned from emergency department. Record review revealed on 12/11/2024 14:50. Physician's Order Note Data: Results: There is a fracture through the humeral neck without significant angulation or displacement. Correlate clinically in regard to the age of this fracture as it may be acute/subacute. Degenerative Joint Disease. Conclusion: Proximal left humeral fracture. Action: NP reviewed and provided orders for non-weight bearing, no laying on left side, 2 persons with check and change for stabilization of left upper extremity, no mechanical lift. Record review revealed on 12/12/2024 04:58. Incident/Accident Note (Name of facility): Resident is resting in bed quietly with no complaints of pain or discomfort at this time. Will continue to monitor. Record review revealed on 12/12/2024 14:25. Incident/Accident Note (Name of facility): Resident complained of left arm pain seems to be located more around lt. elbow. left arm is contracted with elbow bent towards chest, Little to no range of motion. No left side lying. During an interview on 12/18/24 at 12:15 PM, writer asked LNA A if she had an incident report on this injury of unknown origin and the investigation. Record review revealed minimal details in the resident's electronic medical records. On 12/18/24 at 3:00pm, writer was still waiting for information of the incident report and investigation. Record review of the incident/ investigation revealed that was an injury of unknown origin. Information received on 12/18/24 by LNA A included an incident report, physician review of injury, a new progress note dated 12/17/24 by Director of Nursing (DON) B within 16 pages. There was not a completed investigation. On 12/19/24 at 08:25 AM, writer requested full incident report with investigation again from the LNA A for the third time. On 12/19/24 at 08:30 AM, Record review of the updated incident with investigation presented now contains 91 pages of information from the incident, physician review of injury dated 12/16/24, event investigation completed by the DON B, grievance/concern witness statement form dated 12/18/24 by CNA Z, grievance/concern witness statement form dated 12/19/24 by Registered Nurse (RN) AA, grievance/concern witness statement form dated 12/18/24 by Clinical Mentor BB. Incident statement form dated 12/11/24 by Clinical Mentor BB. Incident statement form dated 12/18/24 by CNA CC with the 18th date crossed out and 11 written over it. Incident statement form dated 12/18/24 by Hospitality Aide/ Nurse Aide in Training DD with the 18th date crossed out and 11 written over it. Incident statement form dated 12/18/24 by Restorative CNA EE with the 18th date crossed out and 11 written over it. Record review included a Radiology report dated 12/11/24 showing the fractured left humerus neck fracture. After visit report from emergency department of closed 2-part nondisplaced fracture to the surgical neck of the humerus. Kardex updated 12/13/24. Care plan of 22 pages updated on 12/13/24 for a focus of R22 had a pathological left humerus neck fracture discovered by incidental finding on chest x-ray, only intervention on care plan was Resident's left arm to be supported by staff when proving care dated 12/13/24. Every hour repositioning of resident and offload only on right side related to left arm humerus fracture. No other interventions updated on the care plan. No resident interviews included in the investigation. Presented investigation was completed after the incident and forms filled in during the annual survey. During an interview on 12/19/24 at 11:00 AM, R22 stated he has pain in his left arm. Stated he fell , when asked questions about the fractured left arm he could only shake his head yes or no. Refused to let writer look at his left arm. When asked if staff reposition him every hour, he shook his head no. R22 could use the bed controller to put his bed in a reclined position so he could rest. Writer asked him if he wanted to rest, R22 shock his head yes, so writer told R22 that I would come back later. During an interview on 12/20/24 at 08:54 AM, RN Clinical Mentor BB stated she couldn't give much information as it was incidental findings, she asked for an Xray of his lungs, it was done on the 10Th, nurse called the Medical Director (MD), ordered a stat Xray on left shoulder, results came in early on the 11th, MD contacted, MD sent him out to the local emergency department, contacted daughter, who would meet resident at the local emergency department. R22 came back to the facility after several hours. Writer asked about the investigation on the injury. Clinical Mentor BB stated when a resident gets an injury on that unit, they start getting statements, talking to staff working that shift, had to be an immediate intervention, MD and family contacted, DON B and LNA A notified. Immediate intervention was he was sent to the local emergency department and mobilized the arm. Clinical Mentor BB stated the interventions are case by case. In this case, he doesn't come out of his room, another resident would not witness it because the door is shut. Other residents are good reporters, they are alert & oriented to what's going on. Clinical Mentor BB stated she didn't think it was abuse, because there was no bruising, not found on the floor, he would have other marks on his skin, scratching, etc. Medical Director and Nurse Practitioner believed it was a pathological explanation of this injury. Clinical Mentor BB stated nothing indicated to make her suspicious of anything. Clinical Mentor BB added that part of the investigation would be to start an incident packet, a resident event review. Clinical Mentor BB stated they were unable to find how this happened, she did skin assessment weekly, every Tuesday, yesterday R22 had pain in his right hip, he did not speak, she answered his call light, complained of pain, can node his head to answer yes or no. Provides protection to left elbow, hand protector. Offloading boots were on, no skin issues, no bruising. During an interview on 12/20/24 at 09:30 AM, DON B stated anytime there is an injury, they complete an Incident and Accident report, notify the MD, complete an assessment. DON B added that they figure in any factors that could have caused the injury, complete skin assessments, pain assessment, staff statements, course of events that lead to the incident. Set up repeat assessments, pain assessments, skin assessments, labs, updating the care plan based on need to add interventions. DON B stated they notify the family and shared this event in the interdisciplinary team (IDT) meeting every morning. During an interview on 12/20/24 at 10:58 AM, LNA A stated that staff contact her when there is an injury, if it's not suspicious comes to her, or an allegation, means unwitnessed injury. LNA A then stated if it is suspicious, she ask questions around the incident, determine if it's an allegation of abuse or neglect, report to social worker. LNA A added, depending if its abuse and neglect, social worker and nurse manager will discuss with the staff working on the floor, depends on the situation or incident. LNA A stated it depends on what they are investigating, they may interview other residents. Social worker would interview other residents to see if they feel safe. If not an allegation of abuse or neglect, they would not interview residents. LNA A stated she was notified that morning of incident, told he had a pathological fracture. Writer asked if there was an allegation of abuse or neglect. LNA A stated she did not feel it was abuse or neglect, so they did not feel the need to investigate or report this incident to the state. LNA A stated she had no concerns; BB had been his clinical mentor for years. LNA A stated she reports it only if it's an allegation of abuse or neglect, if not no.

Based on observation, interview, and record review the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident (#20) of 21 residents reviewed for accurate assessments. Findings Included: Resident #20 (R20) Review of the medical record revealed R20 was admitted to the facility 07/13/2018 with diagnoses that included heart failure, chronic kidney disease, end stage renal disease, dependence on renal dialysis, atrial fibrillation, type 2 diabetes, peripheral vascular disease (PVD), hypothyroidism (low thyroid hormone), atherosclerosis (plaque in arteries), hypotension, pneumonia, insomnia, depression, anemia (low red blood cells), and anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date of 09/18/2024, revealed R20 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 12/18/2024 at 08:55 a.m. R20 was observed sitting up in a chair beside her bed. R20 explained that she had been hospitalized in January of 2024 because she had COVID-19. R20 denied that she ever had pneumonia. Review of R20's medical record demonstrated Section I (Active Diagnoses) of the Minimum Data Set (MDS), with an Assessment Reference Date of 09/18/2024, revealed subsection I2000 (pneumonia) had been document as yes. Review of R20's diagnoses record revealed pneumonia which had been added to the diagnoses record on 01/12/2024 and did not have any list that diagnoses had been resolved. Review of the discharge summary dated 01/12/2024 revealed a diagnosis of pneumonia. Review of Centers for Medicare/Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual Section I revealed I: Active Diagnoses in the Last 7 Days- Active Diagnoses in the last y days- check all that apply In an interview on 12/19/2024 at 09:40 a.m. Minimum Data Set (MDS) Nurse L confirmed that R20's MDS, with an Assessment Reference Date (ARD) of 09/18/2024, revealed that R20 had an active diagnosis of pneumonia. MDS Nurse L also confirmed that the diagnoses of pneumonia was added to R20's diagnoses record on 01/12/2024. MDS L could not demonstrate any other documentation that R20 had pneumonia in the last seven days of the MDS ARD of 09/18/2024. In an interview on 12/19/2024 at 10:21 a.m. Minimum Data Set (MDS) Nurse L explained that R20's MDS, with an Assessment Reference Date (ARD) of 09/18/2024 was incorrect because of the diagnoses of pneumonia and a corrected MDS had been completed and re-submitted to Center for Medicare/Medicaid Services (CMS).

Based on interview and record review, the facility failed to complete adequate monitoring for the use of an anticoagulant (blood thinner) medication for one (R100) of five reviewed. Findings include: Review of the medical record revealed R100 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/24 revealed R100 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician' Order dated 11/11/24 revealed an order for Coumadin (blood thinner medication) 8.5 milligrams (mg) at bedtime for atrial fibrillation. Review of the Physician's Order dated 10/4/24 revealed an order to check PT/INR (prothrombin time/international normalized ratio-measures how long it takes the blood to clot) every Monday. Review of the Physician's Order Note dated 12/9/24 revealed Reviewed PTINR with provider .continue with same dose of coumadin [every day at bedtime] and recheck on [Wednesday] and Friday due to [antibiotic] extension. Review of the Physician's Order dated 12/9/24 revealed an order for PT/INR Wednesday and Friday 12/11/24 and 12/13/24. This was in addition to R100's standing order of a PT/INR every week on Mondays. Review of the medical record revealed R100 did not have a PT/INR documented as completed with results on 12/11/24 and 12/13/24. On 12/19/24 at 10:48 AM, Nursing Home Administrator (NHA) A reported PT/INR results should be documented in the progress notes and physician's orders. In an interview on 12/19/24 at 11:06 AM, Clinical Mentor (CM) E reported R100's PT/INR tests on 12/11/24 and 12/13/24 were not completed. CM E reported the Physician's Order was entered incorrectly as a therapy order instead of a nursing order.

This citation includes intake MI00144331. Based on observation, interview and record review, the facility failed to act promptly on grievances and or concern forms reported in and out of resident council meetings and provide responses and resolutions to 26 grievances filed in the last six months, as reported during a confidential resident council meeting, resulting in unresolved resident concerns and decreased quality of life. Findings include during a confidential interview with resident council group on 08/07/24 at 2:30 PM in one Community and 08/07/24 at 3:00 PM in the second Community where 18 residents attended. The last six months concern forms were reviewed and discussed for resolution. Concerns shared during two private meetings on 08/07/24 at 2:30 PM in one Community and 08/07/24 at 3:00 PM in the second Community. 1) Resident Council Meeting had to be split into two separate meetings due to over crowding in the room they usually met in. 2) Resident Council Confidential interview stated the meetings were recorded and some residents were uncomfortable speaking up about concerns knowing the conversation was recorded. 3) Resident requested the local fire department could come in and do a presentation. No documented follow up. 4) Concern voiced about the loud noise on their community hallway. No documented follow up. 5) Staff do not knock on their doors before walking in. No documented follow up. 6) Request to see the diabetic menu and asked for sugar free jello. No documented follow up. 7) Missing clothes from the laundry department. No documented follow up. 8) Male resident requested having manicures during Men's group. No documented follow up. 9) Vegetable's over/under cooked. No documented follow up. 10) Residents voiced they wanted to go outside and enjoy the warm weather. No documented follow up. 11) Resident council minutes did not reflect the two separate meetings held by two different people. 12) Resident council meetings were scheduled at the same time so the president could not attend both meetings. 13) No allowed powered recliners in their rooms. No documented follow up. 14) No receiving the food items, they ordered for meals. Remains an ongoing issue. 15) Last ones served their meals, receive cold food. No documented follow up. During an interview on 08/08/24 at 11:00 AM, Activity Manager (AM) C stated the resident council meetings were separated due to overcrowding. Also stated that he had not had the Ombudsman attend any of the resident council meetings before. AM C stated the current president of resident council knows who she is from the last facility he was at. Writer asked AM C for signed consents allowing facility to record the resident council meetings and the people attending. AM C stated he didn't believe he had any but would look and get back to this writer. AM C never provided signed consents to this writer. Concern/ Grievance forms reviewed for completion and resolution. 1) Resident wanted to go outside and enjoy the warm weather. No follow through documented. No audits or tracking of these concerns. 2) Resident complained that staff were loud providing care to her roommate. No follow through documented. No audits or tracking of these concerns. 3) Resident complained that staff do not knock loud enough for her to hear them. They then walk in, and it startles her. Asked them to knock louder and introduce themselves then they walk in her room. No follow through documented. No audits or tracking of these concerns. 4) Resident complained of being woke up early to get her vital signs taken. Requested to have it done another time. No follow through documented. No audits or tracking of these concerns. 5) Resident complained that another resident says rude things to her in passing down the hallway. No follow through documented. No audits or tracking of these concerns. 6) Resident requested two sugar free jello's for her night snack related to Diabetes. They were taken from the refrigerator by other people. Told they would monitor the availability of jello. No follow through documented. No audits or tracking of concern. 7) Resident missing several light-colored sweaters. Laundry was unable to find the missing items. Family replaced the sweaters. 8) Resident was left naked laying on her side in her room following bathing with her door open. No follow through documented. No audits or tracking of these concerns. 9) Resident had feces left on her skin and bedding following bathing. CNA was not allowed to provide care for her anymore. CNA was still providing care to other residents. No follow through documented. No audits or tracking of these concerns. 10) Resident had jello was taken from the refrigerator for her night snack again. No follow through documented. No audits or tracking of these concerns. 11) Resident wanted to warm up food in the microwave. 12) Resident saved chicken from her lunch to eat in the evening and staff gave it to another resident. It was labeled, dated in the refrigerator. 13) Resident reported CNA was not attentive while providing care. No audits or tracking of these concerns. 14) Resident woke up at 6:00 am to check vital signs when resident requested to not be woke up. Care plan updated to not wake resident up in the morning for vital signs. No audits or tracking of these concerns. 15) Resident reported there were no activities on Sunday. Resident provided an activity calendar and would follow up with activities. No follow through documented. No audits or tracking of these concerns. 16) Resident reported the dining room runs out of coffee every meal. No follow through documented. No audits or tracking of these concerns. 17) Resident complained of not having assist bars to help her roll on her side to have a bowel movement, to be changed, to be bathed and checked. 18) Resident asked somebody to come and talk to her about her last couple of complaints she wrote up and nobody has talked to her about it. No documented follow up. No audits or tracking of these concerns. 19) Resident complained of someone eating her sandwich which she bought at the cafe herself. Also asked for her own refrigerator so people wound not eat her food. Refrigerator was denied. No further follow up, no audits to track patterns or trends of residents' complaints. 20) Resident requested to see the doctor when he came in, not the physicians assistant. Was not seen by the doctor as requested. No audits tracking of these concerns. 21) Resident requested to have different types of chips provided. Message would be relayed to the kitchen. No follow through documented. No audits or tracking of these concerns. 22) Resident asked to receive sugar free jello and getting a diabetic menu. No follow through documented. No audits or tracking of these concerns. 23) Resident complained about not being able to go outside to get some fresh air and sunshine. No follow through documented. No audits or tracking of these concerns. 24) Resident complained of missing food from the refrigerator that was labeled and dated. No follow through documented. No audits or tracking of these concerns. 25) Resident complained that her jello is missing from the refrigerator again. No follow through documented. No audits or tracking of these concerns. 26) Resident complained again about not getting to go outside. Resident was instructed to go to the front desk to be let out, nobody had been at the desk to let her outside. No follow through documented. No audits or tracking of these concerns. 27) Resident requested her morning shower, which was her preferred time to take them. Follow up statement stated she received her shower in the evening per her preference. Resident restated that evenings were not her preferred time. No audits or tracking of these concerns. 28) Resident complained of loud noise in the dining room during meals. Clinical leadership would try to be in the dining room during meals to address noise. No follow through documented. No audits or tracking of these concerns. Record review of the complaint/Grievance forms were not filled out completely. Many areas were left blank, staff would add comments or typed statements without the staff's name and date to show who followed up. No where on those forms did it show that a resident signed their name to it, to show the complaint was resolved to the resident's satisfaction. It revealed there were still concerns identified during this time and the forms did not reveal any follow up, correction or identifying the root cause to these concerns. During an interview on 08/08/24 at 2:00 PM, Nursing Home Administrator (NHA) A stated Social Services Director (SSD) D took over the grievance process. NHA A also stated that SSD D would bring the grievances to her to discuss, then take them to the resident to address, and then they go back to the NHA A. NHA A stated if there were staff named in the concern/grievance, she would re-education and if identified as a pattern, it would be written up as a disciplinary action. NHA A stated that historically the concerns/grievances would be handed off to the department managers looking for a simple solution, if it was resolved it would be closed. NHA A stated from the department managers, it was put in writing, met with the residents, and turned it back in to NHA A. NHA A stated that she did not educate SSD D on the completion of the grievance process. NHA A also stated that SSD D would do the best she could to address the concerns/grievances but did not follow the process of completing the grievance form and process. NHA A stated that various staff members would write on the form, type a separate form without a date or signature on the document. Record review revealed NHA A had not signed off on any of the concern/grievance forms showing completion.

Based on observation, interview and record review facility failed to: 1) accurately assess, monitor and prevent the development of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for one Resident (R37) of three reviewed for pressure ulcers, resulting in facility acquired stage 3, a deep tissue pressure injury, and unstageable pressure wounds and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status. Findings include: Review of the facility, Skin Care Policy, dated 2/22, reflected, It is the policy of the [named facility] to routinely protect residents/patients from skin breakdown and injury. All nursing staff when working with residents/patients in giving care will inspect, apply preventative treatments (when necessary), and document each resident/patient ' s skin for any changes and to communicate skin concerns to the wound nurse for assessment and intervention .Any treatment that requires assessment, ongoing monitoring, and re-evaluation to determine effectiveness needs to be performed/applied by a licensed nurse (ex. Biofreeze, pain relief, antifungal cream, s/sx of rash resolving, etc.). Using the Skin Care Protocol, the charge nurse will provide the necessary treatment or referral to the Wound Care nurse. All stageable wounds will be referred to the Wound Care Nurse .The specified cream used will have an order written in PCC that will be transcribed onto the TAR for assessment and documentation purposes .The skin care plan will be updated when creams are ordered. The focus/problem statements should be updated with the current condition/issue and the treatment intervention should state: Apply treatment per orders.The wound nurse and/or clinical mentor will assess all new skin issues that are documented in POC and document in the Skin Assessment UDA instead a Progress note .All residents/patients with skin issues will be assessed and documented on by the Clinical Mentor and/or Wound Care Nurse every 7 days. This includes any residents/patients that have interventions from the Skin Care Protocol .All residents/patients that have stageable wounds will be followed, assessed, and documented on by the Wound Care Nurse on a weekly basis . Review of the facility, Skin Protocol, dated 12/22, reflected, PRESSURE INJURIES: This staging system should be used ONLY to describe pressure injuries. Wounds that are not caused by pressure should not be staged with this system. i.e. arterial, venous, diabetic, skin tears, tape burns, dermatitis, maceration or excoriation. A pressure injury is a localized injury to the skin and/or underlying tissue. This injury is usually located over a bony prominence, as a result of pressure. They may also be related to pressure in combination with friction and/or shear. Stage I: Non-blanchable Erythema .Stage 2: Partial thickness- loss of dermis presenting as a shallow open ulcer with a red/pink wound bed. Without slough or serum filled bulla or vesicle. Stage 3: Full thickness tissue loss-Slough may be present. Sub-cutaneous fat may be visible but bone, tendon or muscle is not exposed. The difference between Stage 2 and Stage 3 is the depth .Unstageable: Full thickness skin or tissue. Depth is unknown due to being obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Suspected Deep Tissue Injury: Depth is unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shearing . Review of the Face Sheet and Minimum Data Set (MDS) with ARD date 8/2/23, reflected R37 was a [AGE] year old male admitted to the facility on [DATE] related to dementia, Alzheimer's disease, chronic obstructive pulmonary disease, hypertension (high blood pressure), kidney disease, urinary tract infection with chronic indwelling catheter, heart failure, anxiety, and depression. The MDS reflected R37 had a BIM (assessment tool) score of 00 which indicated his ability to make daily decisions was severely impaired, and he required two-person physical assist with bed mobility, transfers, dressing, toileting, and one person assist with locomotion on unit, eating, hygiene, and bathing. The MDS assessment reflected R37 had no behaviors including rejection of care. Continued review of the MDS, dated with ARD date 10/18/23, reflected no rejection of care. Further review of the MDS reflected one new unstageable pressure ulcer that was not present on admission or readmission. During an observation on 10/30/23 at 3:10 PM, R37 had a contact isolation sign posted outside his door with the door open. R37 was lying flat on back yelling out for staff to removed pants. Staff observed enter R37 room and reinforce he did not have pants on. R37 appeared confused but easily redirected. During an observation on 10/31/23 around 7:30 a.m., R37 was in bed, lying flat on back with eyes closed. Review of the facility Matrix, dated 10/30/23, reflected R37 had a unstageable facility acquired pressure ulcer. Review of the Braden Scale for Predicting Pressure Sore Risk, dated 7/26/23, reflected R37 had a score of 13, which indicated moderate risk. Further review of the Braden assessment completed on 5/19/23 reflected a score of 16, which indicated at risk for developing pressure ulcer. Review of R37 Nursing Progress Notes, dated 7/20/23 at 3:05 p.m, reflected, On assessment of resident's buttocks/coccyx area, it was noted that there is a small area of excoriation at inferior portion of coccyx. It was also noted that area surrounding coccyx and extending onto bilateral buttocks is erythematous. RN [registered nurse] placed an Allevyn over area of excoriation and applied Chamosyn to all erythematius areas. RN notified CM[clinical mentor] regarding this issue. Also notified wound team . Review of R37's Treatment Administration Record (TAR), reflected, Weekly Assessment Due: Please complete resident's weekly assessment and document in the Nursing Assessment Form - Long Term Care every day shift every Fri for Monitoring. The TAR reflected staff initials on 7/11, 7/14, 7/21, and 7/28. Review of the Electronic Medical Record (EMR), reflected no evidence of the Nursing Assessment Form, dated 7/21/23. Continued review of the EMR reflected a Nursing Assessment Form, dated 7/28/23 at 2:34 pm, reflected R37 had a new or worsening skin or wound with notes that included, Coccyx and upper buttocks skin breakdown. TX started to wash with soap and water apply chamosyn and hydrocellular foam dressing change daily.(eight days after first observed 7/20/23). Continued review of the EMR reflected no evidence R37 new coccyx skin breakdown had been assessed by CM or wound nurse between 7/20/23 and 7/28/23. Review of R37's Nursing Progress Note, dated 7/30/23, reflected, RN performed skin assessment on resident. With assessment, it was noted that there is a significant area of concern on resident's sacrococcygeal area. Tissue denuded noted with gentle cleansing with sterile saline and 3X3 gauze. Beneath denuded tissue, area is open and bright red. In center of denuded area, there is an area with black tissue at the base, and another separate small area with yellow slough tissue at its base. Peri-wound area is noted to be largely erythematous. Erythema does not blanch on palpation. RN suspects Kennedy ulcer, however, will leave diagnosis to wound team. Treatment of area included gentle cleansing with sterile saline on a 3X3 gauze, and pat dry with gauze. Prescribed dressing placed over area and secured with paper tape. Resident turned on side to offload area as much as possible and will continue to turn resident Q2 hours and PRN. RN also noted on skin assessment that resident has developed blanchable erythema of bilateral heels. Skin noted placed on both heels, and heels also covered with Allevyn . Note completed by Registered Nurse (RN) D. Review of the, Skin and Wound Evaluation V7.0, dated 7/31/23, reflected R37 had a new facility acquired unstageable (obscured full-thickness skin and tissue loss) pressure ulcer to the coccyx that measured: 4cm length x 3.3 cm width x 0.5 cm depth. The Evaluation reflected wound bed was 60% slough (non-viable skin) and 20% eschar(dead tissue) with no epithelial or granulation indicated. Review of the, Skin and Wound Evaluation V7.0, dated 10/5/23, reflected R37 had facility acquired unstageable pressure ulcer to the coccyx area that measured: 0.5cm x 0.4cm x 0 cm. The evaluation reflected 100% slough to wound bed. Review of the, Skin and Wound Evaluation V7.0, dated 10/31/23, reflected R37 had a facility acquired unstageable pressure ulcer to the coccyx area that measured: 4.4 cm x 3.9 cm x 0.4 cm. The evaluation reflected 100% slough to the wound bed. Review of the Wound Evaluation, dated 10/31/23, reflected a deteriorating facility acquired unstageable coccyx pressure wound. The evaluation included notes, Unstageable to coccyx, deteriorating. Increase in size of wound this week. Area is 100% slough. Periwound intact, fragile, with purple erythema. Scant serous drainage. No odor noted. Denies pain to area. Medihoney, and foam dressing. Review of the Physician orders, dated 7/1/23 through 7/31/23, reflected R37 had an order for, Cleanse coccyx and buttocks with soap and water dry apply chamosyn and hydrocellular foam dressing. Change daily one time a day for Skin breakdown coccyx Start Date-07/29/2023. The Physician orders reflected no evidence of treatment orders for R37 coccyx skin breakdown between 7/20/23 and 7/28/23(eight days). Review of the Palliative Care Determination Form, dated 8/2/23, reflected R37 was determined to have life expectancy of 6 months or less, as evidenced by, Decline of intake, weight loss (not significant). cognitive decline slower processing time, increased hours in bed, increased weakness/requires increased assist with cares, unstageable pressure to coccyx. The form indicated R37 was appropriate for palliative care related to end stage dementia. Review of the Weekly Skin Assessment V2, dated 8/8/23, reflected R37 had blanchable redness to bilateral heels with treatment started for skin prep to heels.(documented on 7/30/23 nursing progress note as blanchable erythema of bilateral heels). Review of the Treatment Administration Record (TAR), dated 8/1/23 through 8/31/23, reflected R37 had order for skin prep to bilateral heels daily starting 8/8/23. Continued review of the TAR reflected additional order that reflected, L heel: cleanse with NS, apply thin layer of chamosyn, cover with 4x4 allevyn Q3D every day shift every 3 day(s) for Preventative Skin Care, dated 8/18/23 through 8/30/23. The TAR reflected no evidence of treatments orders between 8/1/23 and 8/8/23 for R37 heels. Review of the Skin Wound Progress Note, dated 8/15/23, reflected, WCN assessed bilateral heels. R heel intact, dry and calloused. L heel intact, soft, and slow to blanch. Recommending chamosyn and allevyn to L heel Q3D preventatively. Review of R37 Weekly Skin Assessment V2, dated 9/26/23, reflected, left Heel red, blanching and boggy right heel has area of callous. Review with the Skin and Wound Evaluation V7.0, dated 10/17/23, reflected R37 had a new(no date completed) facility acquired stage 2 pressure ulcer to the left heel that measured: 1.9cm x 1.2cm x 0cm with 100% epithelial(wound covered, surface intact). (Suspected Deep Tissue Injury according to facility Skin Protocol). Continued review of the assessment included a note, NEW [NAME] Stage 2 to L Heel. Area is 100% epithelial. Periwound intact and fragile. No drainage or odor noted. Denies pain. Recommending skin [NAME], white foam (non-adherent) and kerlix. Review of the Skin and Wound Evaluation V7.0, dated 10/24/23, reflected R37 had a new(no date completed) facility acquired deep tissue injury to the left heel. Review with the Skin and Wound Evaluation V7.0, dated 10/31/23, reflected R37 had a new(no date completed) facility acquired deep tissue injury to the left heel that measured: 1.8cm x 1.3cm x 0cm with 100% epithelial. Review of the MDS, dated [DATE], reflected R37 had one unstageable pressure ulcer not present on admission and no unstageable pressure injuries presenting as deep tissue injury, locked on 10/25/23.(Skin and Wound Evaluation evidence of deep tissue injury, dated 10/17/23 and 10/24/23). Review of R37 Care Plan, dated 7/3/23 through 11/1/23, reflected interventions that included, Rolling: Extensive assist with Bed mobility device with revision date of 7/3/23. Continued review of the Care Plan reflected update, dated 8/1/23, Rolling: Extensive assist x 2 with Bed mobility device. The Care Plan reflected most recent update, dated 10/16/23, that included, Bed mobility: dependent Supine > sit: dependent Sit > supine: dependent Rolling: dependent with Bed mobility device Boosting up in bed; dependent .touch pad call light on chest while in bed for safety due to resident's visual deficit, dated 10/6/23 . Heel manager while in bed, revised 5/21/23 to current . Specialty Mattress, initiated 10/31/23(coccyx wound identified 7/20/23 according to Progress Notes) .Treatments per orders, initiated 10/9/23 . Turn every 2 hours side to side and as needed, Date Initiated: 08/01/2023, revised 8/14/23 to include, Turn every 1 hours side to side and as needed to current (11/1/23) .Weekly and as needed skin checks Date Initiated: 08/09/2023. During an observation on 10/31/23 at 4:15 p.m., R37 in bed on back with eyes closed. During an observation on 10/31/23 at 2:46 PM, R37 was laying in the bed, flat on back with heels elevated with eyes closed. During an interview on 10/31/23 at 3:00 PM, Wound Nurse (WN) G reported had been the facility wound care nurse since March 2022. WN G reported she was not wound care certified. WN G reported staff email WN G and wound team for all new abnormal skin issues and completes evaluation within 24 hours. WC G reported documents in skin and wound evaluation with picture and follows all true Pressure Ulcers, vascular wounds, surgical wounds every seven days. WN G reported nurses are expected to complete skin assessments on rehab unit every shift and long-term units weekly and palliative residents every shift located under assessment tab of EMR. WN G reported she is responsible for staging 95% of all resident wounds and follows about 35 to 40 wounds every 7 days currently at facility. WN G reported determines wound treatments and consults with Medical Director and Nurse Practioner as needed. During an observation on 10/31/23 at 5:15 pm, R37 was lying flat on back in bed, eyes closed in same position. During an observation on 11/1/23 at 8:10 AM, R37 was lying flat on back in air mattress, eyes closed, lights off with catheter bag located on window side of bed. During an interview on 11/01/23 at 8:20 AM, RN D reported was R37 nurse and regularly cared for R37. RN D reported R37 received daily dressing changes to coccyx and left heel Kennedy ulcers. RN D reported WN G stages wounds. During an observation on 11/01/23 at 8:25 AM, R37 was laying on back in bed with head of bed elevated with student assisting with meal. During an interview and observation on 11/01/23 at 12:09 PM, Certified Nurse Aid(CNA) H reported was responsible for caring for R37 at that time. CNA H reported had repositioned R37 about 10:30 a.m. and performed catheter care. CNA H was questioned if R37 had a cath secure in place and location? CNA H reported thought cath secure was in place on left leg but could not recall. CNA H entered R37 room and verified R37's cath secure was located on the right leg. R37's call light was located on the floor when CNA H entered the room CNA H placed on top of R37's blankets without clipping on. CNA H reported was working today as CNA staff but usually responsible for restorative therapy. Review of the CNA documentation task, Turn & reposition side to side every hour while in bed on 11/1/23 at 3:30 p.m., reflected no evidence or documentation that R37 had been turned and repositioned since 11/1/23 at 4:00 a.m. (over 10 hours). Review of the CNA documentation task, Standards of Care, including Was Resident cared for following standards of care, Kardex, and CNA treatment sheet? on 11/1/23 at 3:00 p.m. The Task was last documented as completed on 10/31/23 at 10:12 p.m. Review of the TAR, dated 9/1/23 through 10/31/23, reflected 19 holes with missing documentation to indicated treatments were completed. During an observation on 11/1/23 at about 3:45pm, RN D asked CNA H assist with R37 wound care. CNA H responded he was unable to assist because he was finally able to do his actual job duties, while pushing a scale down the hall. During an observation on 11/01/23 at 4:00 PM, RN D entered R37 room after gathering wound care supplies with CNA I to assist. R37 was lying in bed on back and RN D spoke to R37 directly in ear and explained plan because R37 was very hard of hearing. R37 appeared calm and able to follow direction with no resistance of care. R37 top covers were pulled down and R37 t-shirt was gathered tight around upper chest and saturated in what appeared to be urine. The fitted sheet was urine stained with a large, dried circle ring stain that appeared to be urine. The pad under R37 appeared to be urine saturated. CNA I and RN D removed R37 brief which appeared dry with recent loose stool observed. CNA I and RN D gathered additional supplies after reported need to clean urine from R37 skin from the shoulders down with soap and water. Staff removed urine-soaked clothing and linens and performed pericare. R37 had very red raised skin that appeared to be missing top layer of dermis in straight line of right upper back rib area about 6 inches long and 2 inches wide with open area thin straight line about 1 inch long. RN D reported was a new wound and appeared to be caused by saturated t-shirt that was gather up around R37 chest. An additional area of red raised erythema was observed at right flank area near ribs about 5 inches by 1 inch. R37 repeated several times that back rib area was painful and was overheard say, ouch while CNA gently cleaned back with soap and water. RN D reported both those area were new for R37. RN D removed the undated dressing from R37 coccyx area. R37's coccyx area was very red with open wound, about silver dollar size, to right coccyx area with slough present, appeared to be full thickness skin loss(stage 3) and dark red non blanchable area extending from right to left coccyx about pear size with three darker area within that appeared deep tissue injury about dime to quarter size. R37 had bright red area on right inner knee that appeared to be from other knee pressure about golf ball size. R37 had bright red indentations of foley catheter tubing on right upper thigh. RN D reported verified large area of non-blanchable skin to coccyx was new along with area on right inner knee and right upper thigh. RN D reported they needed to position pillows better to prevent pressure points. RN D completed wound care to coccyx area and R37 complained of pain during treatment. R37 followed directions from staff with no resistance after staff verbalized plan directly in R37 ear related to very hard of hearing. During an interview on 11/01/23 at 5:00 PM, CNA I stated, I am so embarrassed. CNA I reported was not R37 CNA that day and had no idea what she was walking into. CNA I reported R37's CNA had left today at 1:00 p.m. CNA I verified R37's brief was dry and pad, fitted sheet and t-shirt were saturated in urine. CNA I reported if staff would have been turning R37 every hour they should have seen that. CNA I reported R37 required every one hour turning and repositioning related to skin breakdown and staff know because on R37 Kardex. CNA I reported R37 allows staff to reposition him.

Based on observation, interview, and record review, the facility failed to 1) maintain sanitary food and non-food contact surfaces, 2) store chemicals away from food, 3) maintain equipment, and 4) provide ventilation for steam exhausting equipment, resulting in the potential for foodborne illness, chemical contamination, and improper ventilation. These deficient practices affect all 112 residents who consume food from the kitchen. Findings include: On 10/30/23 at 10:17 AM, the ice scoop holder, located in the main kitchen, was observed to have discolored water accumulating at the bottom. At this time, Director of Dietary Services (DDS) C took the ice scoop holder to the dish room to be washed. On 10/30/23 at 10:22 AM, the Steam & Hold steamer was observed to have steam exhausting through the door gasket while the door was shut, indicating the door gasket is not sealing properly. A large rag was observed to be placed underneath the steamer to collect moisture accumulation from the faulty gasket. Additionally, the Steam & Hold steamer was not positioned under a ventilation hood to exhaust steam and vapor. According to the 2017 FDA Food Code Section 6-304.11 Mechanical. If necessary to keep rooms free of excessive heat, steam, condensation, vapors, obnoxious odors, smoke, and fumes, mechanical ventilation of sufficient capacity shall be provided. On 10/30/23 at 10:24 AM, a red bucket of sanitizer was observed to be stored on the lower shelf of the stainless steel preparation table, on top of a plastic container. At this time, DDS C confirmed that there was food (Japanese style bread crumbs) in the plastic container and had a staff member move the sanitizer bucket to prevent contamination of the food product. According to the 2017 FDA Food Code Section 7-201.11 Separation. POISONOUS OR TOXIC MATERIALS shall be stored so they can not contaminate FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLESERVICE and SINGLE-USE ARTICLES by: (A) Separating the POISONOUS OR TOXIC MATERIALS by spacing or partitioning; P and (B) Locating the POISONOUS OR TOXIC MATERIALS in an area that is not above FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE or SINGLE-USE ARTICLES. This paragraph does not apply to EQUIPMENT and UTENSIL cleaners and SANITIZERS that are stored in WAREWASHING areas for availability and convenience if the materials are stored to prevent contamination of FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES. P On 10/30/23 at 10:25 AM, six spatulas, located in the bottom drawer at the preparation table across from the cookline, were observed to have handles that were melted and disfigured, allowing for crevice's that make the spatulas not easily cleanable. At this time, DDS C stated that they need to order new spatulas. According to the 2017 FDA Food Code Section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. On 10/30/23 at 10:29 AM, soil and mineral accumulation was observed on the floor underneath the three-compartment sink. At this time, DDS C was queried on the frequency of cleaning and stated that housekeeping does a monthly deep clean under the equipment. According to the 2017 FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing.

This citation pertains to intakes MI00139713 and MI00139715. Based on interview and record review, the facility failed to permit a resident to return to the nursing home following a hospitalization stay, in 1 of 3 residents reviewed for hospitalization (R317), resulting in loss of home, limited access to social support and decreased quality of life. R317's Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/08/23 revealed he was admitted on [DATE]. R317 had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 07 (00-07 Severe Impairment). The same MDS revealed R317 had physical behavioral symptoms directed toward others that occurred 1 to 3 days during the 7-day look-back period. R317 had verbal behavioral symptoms directed toward others that occurred 1 to 3 days during the 7-day look-back period. The same MDS indicated R317 received antipsychotic medication on a routine basis. Behavior Progress Notes dated 6/25/23 at 9:24 AM revealed R317 walked out of his room without his walker; when staff offered his walker and wheelchair, food, fluids, or pain medication, he became agitated and stated Get out of my way! I'm getting out of here! R317 began hitting, kicking, and grabbing staff. Distraction, therapeutic communication, validation, redirection were ineffective. The nurse was unable to obtain vital signs. The same note indicated R317's physician was notified; and orders were received to transfer R317 to the hospital for evaluation and then be admitted to a psychiatric unit. Resident 317's MDS dated [DATE] revealed he had an unplanned discharge on 6/25/23, and return was anticipated. Psychiatric Evaluation dated 6/30/23 revealed R317's chief complaint was I wanna go. The same evaluation indicated he was taking two antipsychotic medications (Zyprexa and Seroquel) as well at Ativan (antianxiety) and Trazodone (antidepressant) that could have caused R317 frequent falls. Psychiatric Note dated 6/30/23 revealed R317 had an acute urinary tract infection present on admission and received antibiotics. R317's medications included Norvasc for high blood pressure, Flomax for enlargement of prostate gland, Haldol (antipsychotic), for psychosis, Magnesium oxide, melatonin (supplement), Lexapro (antidepressant) for depression. Psychiatric Progress Note dated 7/11/23 revealed R317 had a diagnosis of major neurocognitive disorder, Alzheimer's type with behaviors and was stable for discharge. R317's medications included Haldol 7.5 milligrams (mg) three times a day for psychosis. The Mayo Clinic website at https://www.mayoclinic.org/drugs-supplements/haloperidol-oral-route/proper-use/drg-20064173; revealed the dose for older adults was usually not more than 100 mg per day. The same website indicated Haldol came in liquid form and was administered orally with a dropper. R317 received 22.5 mg of Haldol daily. The Psychiatric Hospital's Daily Nursing Narrative dated 7/17/23 at 4:00 PM revealed R317 was alert and confused related to dementia. R317 could follow commands and make needs known. R317 ate 100 percent of meals unassisted on that shift. R317 at times required the assistance of two staff persons when transferring, toileting, and other activities of daily living. Progress Note dated 9/08/23 at 2:30 PM revealed the facility interdisciplinary team (IDT) staff had a video conference meeting with R317's daughter, the Ombudsman, and psychiatric hospital staff regarding readmission to the nursing home. The facility's Medical Director discussed his concerns regarding R317 with the hospital staff. The facility discussed multiple different interventions trialed at the facility along with medication changes. The facility had concerns with the heavy dose of medication regimen and use of liquid Haldol (antipsychotic). The hospital staff reported R317 continued to yell out, and at times was not redirectable. The facility discussed concern with R317's significant physical decline in relation to the medication regimen. The facility discussed plan of continuing to review and assess patient's condition and level of care needs with the hospital and Ombudsman. The same note indicated the facility did not feel they were able to meet R317's needs. Progress Note dated 10/06/23 at 5:00 PM indicated the IDT and medical director reviewed R317's updated psychiatric notes. The IDT felt R317 was chemically restrained and requested the psychiatric hospital do a gradual dose reduction and continued monitoring of behaviors. On 11/01/23 at 10:26 AM Registered Nurse/Unit Manager (UM) E stated R317 was having a lot of behaviors and attempted to treat him at the facility. R317 was a danger to staff and other residents. R317 grabbed staff member by the hair and wouldn't let her go. R317 was transferred to the hospital after that after incident. He always had behavior of calling out for his wife, she was here every day. UM E stated R317 was still in the psychiatric unit and were monitoring his behaviors, and he had no improvements. During an interview on 11/01/23 at 10:42 AM Admissions Director F stated the team continued to assess R317's condition and readmission was a possibility. AD F stated the IDT felt the facility could not meet R317's needs and the psychiatric facility sent updates every two weeks. Nursing Home Administrator (NHA) A was interviewed on 11/01/23 at 2:17 PM and stated the plan for R317's return to the nursing home was to reduce his sedation, and stated he was chemically restrained. The facility had not started the involuntary discharge and intend to re-admit him once a gradual dose reduction was completed. NHA A stated R317 would require a Geri chair (reclined chair) and was a very different presentation. NHA A stated R317's screaming on the unit could be very problematic. NHA A stated there were other residents at the facility that were taking antipsychotic medications. In review of the Facility Assessment (resident population needs/resources) was reviewed last on July 2023, indicated common resident diagnoses of residents at facility included psychosis (hallucinations and delusions), impaired cognition, mental disorder, depression, bipolar disorder, schizophrenia, post-traumatic stress disorder, anxiety disorder, behavior that needed interventions.

Based on observation, interview, and record review, the facility failed to ensure appropriate medication storage for one of three medication carts. Findings include: During the initial tour of the facility on 10/30/23 at 10:40 a.m, revealed the facility had 6 medication carts. During an observation and interview on 10/31/23 at 4:19 PM, Licensed Practical Nurse(LPN) J unlocked the Melody Trail medication cart. This surveyor opened the second drawer and observed eight medication cups with several unidentified medications in each cup. LPN J reported she had prepared evening medications in advance for the eight resident that lived in the following rooms: 300, 302, 304, 305, 311, 313, 317 and 323 because it was easier. During an interview on 10/31/23 at 5:14 PM, Registered Nurse (RN) K reported medications should not be prepared in advance in cups for several residents at one time because of increased risk for medication errors. RN K reported the facility Policy and Procedure indicates to prepare medications just prior to administering. During an interview on 11/01/23 at 2:55 PM, Director of Nursing (DON) B reported would expect staff to prepare medications for each resident immediately prior to administration and document immediately after to decrease the risk of medication errors. DON B reported would not expect staff to prepare several resident medications at one time and store in unlabeled cups in advance.

Based on observation, interview and record review, the facility failed to implement new interventions to prevent a fall with major injury in one of seven residents reviewed for abuse (Resident #5), resulting in hospital transfer, pain, two rib fractures, and other injuries. Findings include: Resident #5 (R5) R5's Minimum Data Set (MDS) assessment dated [DATE] indicated he was admitted to the facility on [DATE], his Brief Interview for Mental Status, a short performance-based cognitive screener for nursing home (NH) residents score was 00 (,d+[DATE] Severe Impairment). The same MDS assessment indicated R5 was not steady walking and required limited assistance of one person when walking in his room or in the corridor. The same MDS assessment revealed R5 did not have any physical symptoms directed toward others, verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, or rejection of care during the 7-day look-back period. The same MDS indicated R5 had 2 or more falls with no injury and 2 or more falls with injury (except major) since the last assessment. R5's medical record indicated he had the diagnoses of dementia, heart failure, [CONDITION(S)], gait and mobility abnormality, and speech and language deficits. Fall Report dated [DATE] at 6:50 AM indicated R5 was found sitting on the floor with his back to the bed in his room. R5 sustained a skin tear that measured 0.4 centimeters (cm) by 0.2 cm. R5's antibiotic treatment for a urinary tract infection was extended 5 days. R5's [DATE] at 1:50 AM fall report investigation indicated staff responded to R5's bed alarm, R5 was observed in his room, on his knees, kneeling over the bed. The same investigation indicated R5 was placed in his wheelchair in the hallway for increased monitoring by staff. R5's care plan, attached to the same fall investigation, indicated his goal was not to sustain injury from a fall through the next review. In review of the facility's fall investigation on [DATE] at 4:15 AM, R5 was sitting in the hallway outside of another resident's room; the other resident screamed about R5 being next to her door. Licensed Practical Nurse (LPN) XX moved R5 in his wheelchair, without his wheelchair foot pedals in place and R5 put his foot down on the floor and fell forward from his wheelchair. The same investigation indicated R5 complained of pain to his right knee and sustained a skin tear to the right knee that required a dressing and an abrasion to the right elbow. The same document indicated LPN XX was educated. Clinical Care Mentor (CM) F was interviewed on [DATE] at approximately 11:55 AM and confirmed LPN XX was educated on [DATE] to use wheelchair foot pedals when transporting R5 in his wheelchair and no other staff were educated. Event Investigation Packets indicated on [DATE] at 10:35 PM, R5's alarm sounded, the nurse was in the office, and heard R5 swear, and then found him sitting on the floor in the hallway in front of his wheelchair. The same investigation indicated R5 reopened the skin tear on his right arm. The fall investigation checklist indicated the new immediate intervention was one to one supervision. There were no long-term fall interventions for R5 included in the facility's fall investigation. There were no changes to R5's fall care plan. Fall report dated [DATE] at 7:45 AM, indicated R5 yelled out, his alarm went off, and he was observed lying on his back in the doorway of his room. R5 had a bump and laceration on his left forehead and complained of pain in his left hip. Staff reported R5 was last observed lying in bed. In review of R5's neurological assessment dated [DATE] at 8:35 AM, it was noted he was drowsy, there was no indication R5's physician was notified. Nurses progress note dated [DATE] at 9:52 AM, indicated R5 physician was notified of the fall and the physician order was received for an x-ray of the left hip due to pain. Nurses progress note dated [DATE] at 3:31 PM indicated a physician order was received for x-rays of both hips for R5 due to complaints of pain. Nurses progress note dated [DATE] at 6:05 PM revealed R5 was pale and not responding verbally to staff. R5 was staring unfocused off into the distance. Pupils were sluggish and reacting minimally. The same note indicated the Clinical Mentor was asked to come in to evaluate R5 and was determined to need further evaluation. R5 was transferred to the hospital emergency room for further evaluation. The same note indicated R5 left the facility with paramedics at 6:05 PM. On [DATE] at 10:24 AM, a video recording was observed with CM F from [DATE] at 7:30 AM until 8:30 AM. CM F stated this was the only timeframe he had requested and saved video/audio footage from R5's fall on [DATE]. The video had a view of the middle of R5's hallway, near nurses' station and across from the dining room. At 7:40 AM, an alarm sounded and then R5 cried out. At 7:46 AM, the vital signs machine was taken into his room following the fall. Licensed Practical Nurse (LPN) YY was observed on the video walking from R5's room to the nurse's station and stated to another staff member R5 had just bashed his head. Staff took R5 into the dining room for breakfast, staff pushed R5 in his wheelchair without foot pedals. After breakfast, R5 was placed at the nurse's station in full view of the camera. R5's second set of vital signs were obtained at the nurse's station at 8:12 AM. No neurological assessments were observed while R5 was sitting in his wheelchair at the nurse's station from 8:05 AM until the end of the video at 8:30 AM. In review of R5's medical record, Neurological Assessments with vital signs were documented as completed on [DATE] at 8:05 AM and again at 8:20 AM; neurological checks were not observed during the video between 8:05 AM and 8:30 AM. Vital signs were obtained per video at 8:12 AM and 8:29 AM. R5's fall was documented it occurred at 7:45 AM, the video indicated the fall occurred at 7:40 AM. In review of the facility's Neurological Assessment Policy, reviewed ,d+[DATE] indicated neuro and vital signs would be completed every 15 minutes for the first hour, then every 30 minutes for the second hour, then every two hours for 24 hours, then every shift for 24 hours. Three out of four unwitnessed falls between [DATE] and [DATE] occurred in R5's room. On [DATE] CM F stated there were no staff educated regarding inaccurate vital signs and neurological assessments from R5's [DATE] fall. CM F stated the facility did not provide long-term one to one monitoring for residents. Hospital records were reviewed from [DATE] to [DATE], R5 was transferred on [DATE] to the main hospital for further care. R5 had posterior rib fractures (11 & 12) on the right side and a pneumothorax (air entered chest and lung collapsed). The hospital considered R5 a fall risk and an alarm and safety sitter were provided during his stay. The same record revealed R5's death on [DATE] at 1:15 AM. The Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.17.1, [DATE], manual, indicated falls were a leading cause of injury, morbidity and mortality in older adults and a previous fall, especially a recent fall, recurrent falls and falls with significant injury were the most important predictors of risk for future falls and injurious falls. Director of Nursing (DON) B and Nursing Home Administrator (NHA) A were on vacation during the duration of the survey and unable to be interviewed.

This citation pertains to MI 932 Based on interview and record review, the facility failed to supervise residents (Residents #1 and #2) to prevent resident to resident sexual abuse out of 2 residents reviewed for abuse from a total sample of 3 residents resulting in Resident #2 sexually abusing Resident #1. Findings Include: Review of the face sheet and most recent MDS assessment dated [DATE] revealed that Resident #1 was a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #1 had clear speech, understood, understands and had modified independence making decisions regarding tasks of daily living. Review of the face sheet and most recent MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #2 had clear speech, understood others, understands, was moderately impaired cognitively and used a wheelchair for ambulation. Review of the Resident Event Review dated 1/4/17 at 3:15 a.m. revealed, CENA (Certified Nursing Assistant X) was checking rooms and observed (Resident #2) in (Resident #1's) room leaning over him. (Resident #1's) brief was undone. Res. (residents) immediately separated . Review of a signed written statement from CNA X dated 1/4/16 at 3:15 a.m. revealed, I was taking a wheelchair down to central supply when I noticed (Resident #2) was not in his bed or room. I began looking in other rooms and then found (Resident #2) in (Resident #1's) room leaning over him. I immediately went inside, turned on the light and pulled (Resident #2) away from (Resident #1's) bedside .I got (Resident #2) out of (Resident #1's) room and went to (Resident #1) to make sure he was okay. I then observed (Resident #1's) brief undone and his private parts hanging out. I then asked (Resident #1) if (Resident #2) had been touching him (Resident #1). (Resident #1) nodded his head yes. During an interview on 2/10/17 at 11:50 a.m., Resident #1 was able to answer surveyor's questions with head nods and shakes. When asked if he remembered another resident touching his penis, Resident #1 nodded his head yes. When asked if he felt violated, Resident #1 nodded his head yes. During an interview on 2/14/17 at 11:11 a.m., when asked if Resident #1 would be able to answer yes/no questions appropriately and accurately, Social Worker (SW) Y stated, I would say so. Review of the State's Public Sex Offender Registry, accessed on 2/10/17, revealed that Resident #2 was currently on probation related to a criminal sexual conduct offense, and was put on the Sex Offender Registry on 7/15/15. Review of the medical record, to include behavior notes and the Behavior Tracking Log, Resident #2 had numerous documented inappropriate comments, gestures and attempts to touch staff members. These included trying to touch other's private parts. As part of the facility's investigation, staff members were asked to write statements asking them if they knew of any resident concerns with Resident #2, the following are those statements: Review of CNA FF's written statement dated 1/5/17 revealed, (Supplemental Resident #5) told me that (Resident #2) told her that he wants to be in bed with her . Review of CNA GG's written statement dated 1/5/17 revealed, I have had (Supplemental Resident #4 and Supplemental Resident #5) voice concerns about (Resident #2). (Supplemental Resident #4) would be concerned when (Resident #2) first got there about him coming into her room at night .(Supplemental Resident #5) would want to know when (Resident #2) was still up at night . Review of CNA II's written statement dated 1/5/17 revealed, (Supplemental Resident #4) made comments about (Resident #2) entering her room at different times unwanted. Review of Licensed Practical Nurse (LPN) DD's written statement dated 1/4/17 revealed, (Resident #2) went into (Supplemental Resident #4's) room and she put her call light on and yelled for help. Review of CNA JJ's written statement dated 1/5/17 revealed, On two separate occasions we had to explain to (Resident #2) that (Supplemental Resident #7) was not his brother .(Resident #2) refused to leave (Supplemental Resident #7) alone .I later saw (Resident #2) sitting outside (Supplemental Resident #7's) door looking at (Supplemental Resident #7). During an interview with Supplemental Resident #7 on 2/14/17 at 3:05 p.m., when asked if he had concerns with Resident #2, Supplemental Resident #7 stated, Yes, he was after me. He would block me in with his wheelchair and not let me move. Review of CNA E's written statement dated 1/4/17 revealed, that Supplemental Resident #4 had a concern of, (Resident #2) went into her room. She did not like that. Review of CNA G's written statement dated 1/7/17 revealed, I (CNA G) was told by (Supplemental Resident #4) on multiple occasions that (Resident #2) has entered (Supplemental Resident #4's) room in the middle of the night and woke her up, resulting in (Supplemental Resident #4) being very upset and scared by it. Review of Resident #2's Kardex (document that CNA's use to assist them with cares for residents) dated 1/4/17 revealed, (Resident #2) has a silent alarm mounted on the bathroom side of his bed. Please assure this is turned on. Review of the facility's Evidence of Investigation 5 Day Investigation document dated 1/4/16 revealed, On 11/9/16, after running a monthly (name of state) Public Sex Offender Registry check .the facility discovered that (Resident #2) was on probation for criminal sexual conduct .The same day she was notified, the (Nursing Home Administrator (NHA) A) directed staff to update care plan with appropriate information and develop interventions to ensure resident safety. In addition, Clinical Mentor of (Name of unit), Assistant Director of Nursing (ADON) C made staff aware that (Resident #2) needed to be supervised while out of room at all times .Appropriate interventions, including a silent alarm in his room to alert staff when he has left his room and close supervision when out of room, were in place. However, at the time of the incident, it appears the alarm was not sounding. Review of CNA BB's written statement dated 1/5/17 revealed, .I can't remember for certain if the alarm was switched back to on or if the curtain was over to the point of blocking the alarm. During a telephone interview on 2/14/17 at 2:30 p.m., CNA BB confirmed that he could not remember if the alarm was back on or not (on 1/4/17). CNA BB further stated that, Yes, lots of other residents were uncomfortable around (Resident #2). CNA BB further stated, No, I did not know (Resident #2) was supposed to have close supervision when (Resident #2) was out of his room. Though the 5 Day Investigation document dated 1/4/16 stated that the intervention of close supervision when out of his room was in place, Review of Resident #2's fall risk care plan revealed that the intervention of direct supervision when out of room. was not initiated until 1/4/17 by Assistant Director of Nursing (ADON) C. During an interview on 2/14/17 at 10:06 a.m., when asked about the intervention of direct supervision when out of room not being initiated on the care plan until 1/4/17, ADON C stated, I can say it was mainly verbal, I guess next time we will not protect other people's privacy. When asked why it was ok to put the intervention of direct supervision when out of room. on the care plan on 1/4/17, ADON stated, Because (Resident #2) actually did something (referring to Resident #2 touching Resident #1). When asked about having the knowledge that came about on 11/9/16, when the facility ran a Public Sex Offender Registry check, and discovered that (Resident #2) was on probation for criminal sexual conduct, ADON stated, but that was in the past. During an interview on 2/14/17 at 2:44 p.m., when asked why resident #2 had an alarm, CNA E, who worked on Resident #'2's hall, stated, because he was self transferring, we didn't want him to fall. When asked if she was aware that as of 11/9/16, Resident #2 was supposed to have, directly supervision when out of room, CNA E stated, I knew they were putting the alarm on him, but not the direct supervision part. During an interview on 2/14/17 at 2:50 p.m., when asked why resident #2 had an alarm, CNA G, who worked on Resident #'2's hall, stated, I was told it was because (Resident #2) could not stand on his own, and that we needed to know when (Resident #2) was attempting to stand. During an interview on 2/14/17 at 2:55 p.m., when asked why resident #2 had an alarm, LPN DD, who worked on Resident #'2's hall, stated, So we knew when he was getting out of bed. So he wouldn't fall. During an interview on 2/14/17 at 3:00 p.m., when asked why resident #2 had an alarm, CNA EE, who worked on Resident #'2's hall, stated, it would let us know when he was trying to get up by himself, we didn't want him to fall. When asked if she was aware that as of 11/9/16, Resident #2 was supposed to have, directly supervision when out of room, CNA EE stated, I do not remember that. Further review of the facility's 5 Day Investigation revealed that the facility created a video time line for the Resident to Resident incident 1/3/17-1/4/17, this timeline revealed the following: 1:40 a.m.-CNA BB takes (Resident #2) back to his room 2:38 a.m.- Resident #2 leaves his room alarm not sounding 2:39 a.m.- Resident #2 enters Resident #1's room 3:08 a.m.- RN J leaves the floor to go to lunch 3:10 a.m.- CNA X enters Resident #1's room Review of this video timeline revealed that Resident #2 was out of his room, unsupervised, for over 30 minutes. During an interview on 2/10/17 at 7:30 a.m., when asked if she saw Resident #2 in his room on 1/4/17 at 3:08 a.m., when she walked by the room while going to lunch, RN J stated, No, I did not see him in there, but because we have the alarm, we use that for him when he is moving.

This citation pertains to MI 014 and MI 932 Based on interview, and record review, the facility failed to implement resident care plans in 2 of 3 sampled residents (Resident #2 and #3), in a total sample of 3 residents, resulting in: 1.) Resident #2 sexually abusing another resident after the facility did not follow the care plan regarding alarms and supervision and 2.) Resident #3 having multiple falls with injuries after facility staff did not follow a care plan for falls. Findings include: Review of American Nurses Association, Standards of Professional Nursing Practice 2010 Edition, revealed that standard practice of care includes collaborating with healthcare providers from diverse backgrounds to implement and integrate the plan of care once developed. Resident #3 Review of the face sheet and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #3 was an [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #3 had clear speech, was understood, understands was moderately impaired cognitively, required extensive assistance of one staff member for transfers, ambulation and activities of daily living. Further review of the MDS revealed Resident #3 had a history of [REDACTED]. Review of the medical record revealed that Resident #3 had sustained falls on [DATE], [DATE], [DATE] and [DATE]. According to the Physician Review of Injury document, on [DATE], Resident #3 sustained 2 separate lacerations, one requiring 3 sutures, the other requiring 6 sutures. Resident #3 also sustained multiple facial fractures from the fall on [DATE]. According to the Physician Review of Injury document, on [DATE], Resident #3 sustained a dislocated knee, and multiple abrasions, skin tears and bruises from the fall on [DATE]. After Resident #3's fall on [DATE], according to hospital Emergency Department (ED) record dated [DATE], Resident #3 arrived at the hospital at 11:25 p.m., and expired inhouse. Further review of the record revealed that Resident #3 was being seen in the ER related to, fell and hit her head .Has become increasingly lethargic .patient was unresponsive upon arrival to ED. Review of the Resident Event Review report dated [DATE] at 11:05 a.m. revealed, Resident #3, .was observed on the floor, laying on her R (right) side, head nearest doorway, feet nearest bed. Pt states she was trying to get into bed . Further review of this report revealed that Clinical Mentor, RN S statement concerning the fall was, I was walking past (Resident #3's) room and saw that the patient was attempting to take off her L (left) arm sling, she states she didn't want or need it on. She stated she wanted to lay down I saw (Certified Nursing Assistant (CNA) NN) in pt (patient) room next door and so I let her (the other staff member) know that (Resident #3) wanted to lay down .I then proceeded to other pt (patient) care needs. Further review of the report revealed that 30 minutes after RN S did not assist Resident #3 to lay down as requested, Resident #3 was found on the floor. Further review of the report revealed that Resident #3, .attempts to self transfer without staff assistance .Patient has dementia and poor safety awareness . Under the Summary of Root Cause Analysis section, it states (Resident #3) stated she was trying to get into bed .Patient (Resident #3) attempts to self transfer without staff assistance . Review of the at risk for falls care plan dated [DATE] revealed that Resident #3 as a high fall risk and required, Frequent checks . Further review of this care plan revealed, Assess (Resident #3's) needs starting on admission and continue to re-assess through out stay: She will require 24 hour close monitoring for care as she is a high fall risk and has cognitive impairments. Review of the Incident/Accident note dated [DATE] at 7:40 a.m. revealed, (COTA OO) came out of room to speak to this nurse at med (medication) cart when loud bang noise heard. Went into (Resident #3's) room to observe her lying on her left side on the floor with head against the closet door. c/o (complain of) pain to lt (left) face, lt side of nose, lt elbow .Skin Assessment .Provided wound care to skin tear to Lt elbow: 2.0 cm (centimeters) x 4.0 cm. Hematoma superior to Lt eye 4.0 cm x 3.0 cm, discoloration starting. Abrasion to Lt cheek 1.4 cm x 1.0 cm. Discoloration to Rt knee 2.4 cm x 2.4 cm .(Doctor) notified with orders to send to ER (emergency room ) for evaluation . Review of the hospital radiology report dated [DATE] revealed, Acute [MEDICAL CONDITION] aspect of the anterior wall the right maxillary sinus (sinus fracture) . Review of the Resident Event Review document dated [DATE] at 7:25 a.m., revealed that (Resident #3) stated that she was trying to get up, stated she fell on rt (right) knee. She was observed on the floor. Further review of this document revealed that Certified Occupational Therapy Assistant (COTA) OO, Entered (Resident 3's) room at 0715 (7:15 a.m.) for ADLs (activities of daily living). Woke (Resident #3) and she refused showering but had robe .relayed to (Resident #3) importance of her feet flat on floor .(sitting on) edge of bed with feet flat on floor raised bed slightly from bed time .Informed (Resident #3) would be back momentarily and to stay sitting and went into hall to talk to nursing .Appox (approximately) one minute later as headed back to room heard noise and observed (Resident #3's) bed raised very high and (Resident #3) lying on the floor .fully staffed possibly preventable if staff stayed in the room with the patient (Resident #3), pt is forgetful and confused at times .Summary: (Resident #3) was left unassisted while she was sitting on edge of her bed. (Resident #3's) personal belongings were not within reach .(Resident #3) has numerous [DIAGNOSES REDACTED]. (Resident #3) is also known to have very poor safety awareness. (Resident #3) has history of prior falls, and self transferring. Further review of this document revealed that existing interventions that were in place at the time of the fall included, Falling Star, do not leave alone in bathroom, frequent checks, red gripper socks on at all times as tolerated, foot rest of w/c (wheelchair), geri hips (hip protectors). Review of the risk for falls care plan dated [DATE] and updated [DATE] revealed that bilateral floor mats when in bed. Bed in lowest position when in bed. were also interventions that were to be in place to keep Resident #3 safe. Review of the complete fall investigation and Resident Event Review, failed to reveal that the safety intervention of bilateral floor mats when in bed was followed before Resident #3's fall on [DATE]. During an interview on [DATE] at 10:55 a.m., Clinical Mentor, RN S stated that when a resident was on the Falling Star program, it indicated that the resident was a very high risk for falls, that the resident should be checked on frequently. During an interview on [DATE] at 11:27 a.m., while reviewing the fall documentation, and asked about the interventions of bed in lowest position, and bilateral fall mats when in bed Director of Nursing (DON) B agreed that the bed was not in the lowest position when Resident #3 fell on [DATE]. DON B further stated, I don't have an answer as to why the floor mats are not mentioned (in the fall investigation record). Review of the physician's orders [REDACTED]. Patient was yelling get me up. This RN ran to room from the nurses station and patient was at the foot of her bed, laying on her right side, facing the wall with clock. Patient log rolled on to her back on the floor mat .Patient transferred to her bed using proper technique and 3 staff. Patient began to get upset and told the RCT's (Resident Care Technicians), don't touch me.Neur (neurological) checks stable patient is confused intermittently .Patient with c/o right shoulder and right hip pain. Right hip swollen to ,[DATE]+ .When observed on floor per this RN, j collar (neck brace) was off and floor mat was leaning against bed side table. RCT's stated that floor mat was placed when patient transferred to bed . Review of the Emergency Department Physician Documentation dated [DATE] at 11:54 p.m., revealed Resident #3, Reportedly fell earlier this afternoon. Throughout the afternoon-evening she has been becoming less responsive . Further review of the documentation revealed that Resident #3 expired at 12:20 (on [DATE]). Review of the EMS (Emergency Medical Services), Prehospital Care Report dated [DATE], revealed, Dispatched for a female one fall and change in responsiveness. Patient had a fall 6 hours prior to staff at medical care facility calling 911. Review of the Autopsy Report dated [DATE] revealed, Cause of Death: [MEDICAL CONDITION] cardiovascular disease. Contributing Condition: Fractures of right clavicle, right ribs and pelvis . Further review of the Autopsy Report revealed, There were fractures of the medial right clavicle, lateral right 7th rib, posterior right 8th and 9th ribs and the medial aspect of the right superior pubic ramus. Review of the medical record failed to reveal that the injuries of Fractures of right clavicle, right ribs and pelvis were present prior to Resident #3 falling in the facility on [DATE] at 4:10 p.m. Review of the Resident Event Review dated [DATE] at 4:10 p.m., revealed RN MM was, Charting at the nurses station .heard (Resident #3) yell for help. Nurse ran to check on patient and patient (Resident #3) was observed on the floor. Review of the falls care plan dated [DATE] and updated [DATE], revealed that following interventions for Resident #3's safety, Miami J collar (brace used to immobilize that cervical spine) to be on at all times .bilateral floor mats when in bed. Bed in lowest position when in bed .Falling Star .Frequent checks, (history) of multiple falls with fx's (fractures), high fall risk . Further review of the Resident Event Review dated [DATE] revealed, .before fall (Resident #3) was in bed after fall (Resident #3) was on floor near the left side of the bed .her j collar was off and floor mat folded in half and leaning against the bedside table During an interview on [DATE] at 11:09 a.m., when asked if Resident #3 ever took her neck collar off, Registered Nurse (RN) K, who was regularly assigned to care for Resident #3 stated, I never had a problem with it. She complained about out, but always had it on. During an interview on [DATE] at 12:30 p.m., when asked if Resident #3 ever took her neck collar off, or moved her floor mats, Certified Nursing Assistant (CNA) N, who was regularly assigned to care for Resident #3 stated, No, I had never seen her do that before. During an interview on [DATE] at 12:50 p.m., when asked if Resident #3 ever took her neck collar off CNA O, who worked with Resident #3, 3 days a week, stated, that She never did when I was here. She would tug at it but would never take it off. When asked if she heard of other staff saying that Resident #3 would take her neck collar off, CNA O stated, No, she would grab at it and say that she wanted it off, but it never came off. When asked if she ever witnessed Resident #3 moving her floor mat, CNA O stated, No, never. During an interview on [DATE] at 1:30 p.m., when asked if she had ever seen Resident #3 take her neck brace off or move her floor mat, CNA Q stated, I have seen her neck brace off before. No I never witnessed her folding her mat up and placing it away. When asked if she felt Resident #3 would have been capable of folding up the floor mat and leaning it against the table, CNA Q stated, no, but you never know. Review of Resident #3's Behavior Tracking Log Sheet dated [DATE] thru [DATE] revealed, each row of the log is has a time/date stamp of the behavior. The log sheet is completed in chronological order, the dates on the left of the form are in this order, ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] (this is presumably ,[DATE], as the documented behavior is refusing heels up device, and there is a correlating nursing note dated [DATE] stating, pt refused to use her heels up device.), ,[DATE] (this is presumably ,[DATE], as the documented behavior is trying to take off braces and sling, and there is a correlating nursing note dated ,[DATE] stating, Patient refused wearing brace after lunch after lying down in bed. Threw it on the floor and refused to put it back on. Nurse attempted to calm patient down which was effective but patient continued to refuse putting brace back on. Encouraged patient to keep neck still and if she gets up she needs to put it back on. Pt agreed and allowed staff to re-apply brace when she woke up from her nap.). The last entry on the form is dated ,[DATE] and documented by CNA W, which is the only date out of order, the behaviors of pt wandering into hallway/pt rooms and moved blue pad were documented as occurring at 7:00 a.m., review of the nurses noted for [DATE] failed to reveal any documentation of this behavior. Further review of this log revealed that the interventions used to intervene Resident #3's behaviors were talk calmly and educated on call light and not going into others rooms. Further review of the Behavior Tracking Log revealed the behavior of, Trying to take off braces and sling was only documented 3 times, [DATE], [DATE] and [DATE]. Further review of the Log Sheet failed to reveal whether the resident was removing her neck brace, or her sling or both. Furthermore, the log failed to reveal if the resident actually took the brace completely off, or was just trying to take it off. Review of all the nurses notes in the medical record revealed the following notes that discussed the resident taking, or attempting to take off her neck brace, there were no other documented instances of Resident #3 taking off her neck brace: [DATE] .SW (social work) observed .resident taking neck brace off .nurse came in and put brace back on . and [DATE] .Patient observed taking off her neck brace and left arm sling twice this evening. Review of written statement dated [DATE] and signed by Certified Nursing Assistant (CNA) W revealed, The last time I saw the resident was at 3:00 p.m. and at that time they were lying in bed w/ (with) blue mat on the floor and be in lowest position. Further review of this statement failed to reveal that Resident #3's Miami J Collar was in place and that there were bilateral floor mats in place. Review of written statement dated [DATE] and signed by CNA Q revealed, The last time I saw the resident was at 1605 (4:05 p.m.) and at that time they were in bed resting. Further review of this statement failed to reveal that the interventions of Miami J Collar, bed in lowest position, and bilateral floor mats were in place. During an interview on [DATE] at 10:55, when asked if she was the one that completed Resident #3's [DATE] fall investigation, Clinical Mentor, RN S stated that she was. When asked to discuss Resident #3 and the fall, RN S stated, (Resident #3) was on frequent checks .anybody that walks by should be looking into the room and making sure she is safe. While looking at the complete fall investigation and when asked if the fall mats were in place at the time of fall on [DATE], RN S stated, According to the event it says no, it says the floor mat was leaning against the bedside table. When asked if Resident #3's neck brace was on at the time of the fall, RN S stated, No, it was not. When asked when the last time it was known that Resident #3's neck brace was on, and that the bilateral fall mats were in place, RN S stated, Unfortunately it is hard to say, because these statement don't specifically say if it was on or off. When asked why the floor mats were not in place, RN S stated, Well the only time they are in place is when the resident is in bed. If she is up, then the floor mats would not be in place. RN S stated, that she did remember helping a CNA provide cares to Resident #3 before she fell . During an interview on [DATE] at 1:00 p.m., and while watching surveillance video from [DATE] with RN S, CNA Q is observed walking out of Resident #3's room at 2:30 p.m. Further review of the video revealed that at 3:15 p.m. RN S is seen walking into Resident #3's room, and then out of the room at 3:16 p.m. RN S stated that at this time Resident #3 was in the bathroom, on the shower chair and that CNA W was also in the room. RN S further stated that the floor mat would not have been in place at that time, because the resident was not in bed. Further review of the video reveals that at 3:22 p.m., CNA W was seen leaving Resident #3's room. Further review of the video reveals that at 4:06 p.m., CNA Q is seen walking, at a normal pace, down the hall. As CNA Q walks by Resident #3's room, she takes two short glances to her right, and never breaks stride. Further review of the video reveals that at 4:08 p.m. RN LL was seen responding to Resident #3's yelling. During an interview on [DATE] at 12:15 p.m., when asked when the last time she had seen Resident #3 before her fall on [DATE], CNA Q stated, It was 4:05 p.m. CNA Q further stated that Resident #3's eyes were closed, that the bed was in the lowest position, the floor mats were in place and that Resident #3's neck brace was one. When asked, CNA Q stated, No, (Resident #3) never took her neck brace off completely. CNA Q further stated that she never seen Resident #3 move her blue floor mat, I don't think she (Resident #3) could have moved it (the floor mat) on her own. On [DATE] at 1:55 p.m., while walking down the 500 hall with Clinical Mentor, RN S, we attempted to replicate that same speed, path and glances that CNA Q would have performed, per video review. RN S agreed, that at the pace, the path and the glances that CNA Q did in the video, one would not have been able to see into Resident #3's room and be able to see the blue mat being in place, nor the neck brace on. After review of the complete [DATE] fall investigation, CNA W was the last staff member that was in the room with Resident #3, this was at 3:22 p.m CNA W was also the staff member that logged on the behavior tracking log, out of date sequence, that Resident #3 moved blue pad. It should be further noted that the behavior of moved blue pad was numbered 8, which is the last entry of listed behaviors. CNA Q stated that she last seen Resident #3 at 4:05 p.m., however after re-enacting CNA Q's walking down the hallway, CNA Q would not have been able to see if the blue floor mat was in place, nor would she have been able to see if the neck brace was on or off. If the neck brace was on, and the floor mat was in place, according to the video review and statements from staff, Resident #3 would have had to gotten up from bed, remove her neck brace, fold the floor mat, place it against the bedside table and then fall, all within a 2 minute time span. Resident #1 and Resident #2 Review of the face sheet and most recent MDS assessment dated [DATE] revealed that Resident #1 was a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #1 had clear speech, understood, understands and had modified independence making decisions regarding tasks of daily living. Review of the face sheet and most recent MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #2 had clear speech, understood others, understands, was moderately impaired cognitively and used a wheelchair for ambulation. Review of the Resident Event Review dated [DATE] at 3:15 a.m. revealed, CENA (Certified Nursing Assistant X) was checking rooms and observed (Resident #2) in (Resident #1's) room leaning over him. (Resident #1's) brief was undone. Res. (residents) immediately separated . Review of a signed written statement from CNA X dated [DATE] at 3:15 a.m. revealed, I was taking a wheelchair down to central supply when I noticed (Resident #2) was not in his bed or room. I began looking in other rooms and then found (Resident #2) in (Resident #1's) room leaning over him. I immediately went inside, turned on the light and pulled (Resident #2) away from (Resident #1's) bedside .I got (Resident #2) out of (Resident #1's) room and went to (Resident #1) to make sure he was okay. I then observed (Resident #1's) brief undone and his private parts hanging out. I then asked (Resident #1) if (Resident #2) had been touching him (Resident #1). (Resident #1) nodded his head yes. During an interview on [DATE] at 11:50 a.m., Resident #1 was able to answer surveyor's questions with head nods and shakes. When asked if he remembered another resident touching his penis, Resident #1 nodded his head yes. When asked if he felt violated, Resident #1 nodded his head yes. During an interview on [DATE] at 11:11 a.m., when asked if Resident #1 would be able to answer yes/no questions appropriately and accurately, Social Worker (SW) Y stated, I would say so. Review of the State's Public Sex Offender Registry, accessed on [DATE], revealed that Resident #2 was currently on probation related to a criminal sexual conduct offense, and was put on the Sex Offender Registry on [DATE]. Review of the medical record, to include behavior notes and the Behavior Tracking Log, Resident #2 had numerous documented inappropriate comments, gestures and attempts to touch staff members. These included trying to touch other's private parts. As part of the facility's investigation, staff members were asked to write statements asking them if they knew of any resident concerns with Resident #2, the following are those statements: Review of CNA FF's written statement dated [DATE] revealed, (Supplemental Resident #5) told me that (Resident #2) told her that he wants to be in bed with her . Review of CNA GG's written statement dated [DATE] revealed, I have had (Supplemental Resident #4 and Supplemental Resident #5) voice concerns about (Resident #2). (Supplemental Resident #4) would be concerned when (Resident #2) first got there about him coming into her room at night .(Supplemental Resident #5) would want to know when (Resident #2) was still up at night . Review of CNA II's written statement dated [DATE] revealed, (Supplemental Resident #4) made comments about (Resident #2) entering her room at different times unwanted. Review of Licensed Practical Nurse (LPN) DD's written statement dated [DATE] revealed, (Resident #2) went into (Supplemental Resident #4's) room and she put her call light on and yelled for help. Review of CNA JJ's written statement dated [DATE] revealed, On two separate occasions we had to explain to (Resident #2) that (Supplemental Resident #7) was not his brother .(Resident #2) refused to leave (Supplemental Resident #7) alone .I later saw (Resident #2) sitting outside (Supplemental Resident #7's) door looking at (Supplemental Resident #7). During an interview on [DATE] at 3:05 p.m., when asked if he had concerns with Resident #2, Supplemental Resident #7 stated, Yes, he was after me. He would block me in with his wheelchair and not let me move. Review of CNA E's written statement dated [DATE] revealed, that Supplemental Resident #4 had a concern of, (Resident #2) went into her room. She did not like that. Review of CNA G's written statement dated [DATE] revealed, I (CNA G) was told by (Supplemental Resident #4) on multiple occasions that (Resident #2) has entered (Supplemental Resident #4's) room in the middle of the night and woke her up, resulting in (Supplemental Resident #4) being very upset and scared by it. Review of Resident #2's Kardex (document that CNA's use to assist them with cares for residents) dated [DATE] revealed, (Resident #2) has a silent alarm mounted on the bathroom side of his bed. Please assure this is turned on. Review of the facility's Evidence of Investigation 5 Day Investigation document dated [DATE] revealed, On [DATE], after running a monthly (name of state) Public Sex Offender Registry check .the facility discovered that (Resident #2) was on probation for criminal sexual conduct .The same day she was notified, the (Nursing Home Administrator (NHA) A) directed staff to update care plan with appropriate information and develop interventions to ensure resident safety. In addition, Clinical Mentor of (Name of unit), Assistant Director of Nursing (ADON) C made staff aware that (Resident #2) needed to be supervised while out of room at all times .Appropriate interventions, including a silent alarm in his room to alert staff when he has left his room and close supervision when out of room, were in place. However, at the time of the incident, it appears the alarm was not sounding. Review of CNA BB's written statement dated [DATE] revealed, .I can't remember for certain if the alarm was switched back to on or if the curtain was over to the point of blocking the alarm. During a telephone interview on [DATE] at 2:30 p.m., CNA BB confirmed that he could not remember if the the alarm was back on or not (on [DATE]). CNA BB further stated that, Yes, lots of other residents were uncomfortable around (Resident #2). CNA BB further stated, No, I did not know (Resident #2) was supposed to have close supervision when (Resident #2) was out of his room. Though the 5 Day Investigation document dated [DATE] stated that the intervention of close supervision when out of his room was in place, Review of Resident #2's fall risk care plan revealed that the intervention of direct supervision when out of room. was not initiated until [DATE] by Assistant Director of Nursing (ADON) C. During an interview on [DATE] at 10:06 a.m., when asked about the intervention of direct supervision when out of room not being initiated on the care plan until [DATE], ADON C stated, I can say it was mainly verbal, I guess next time we will not protect other people's privacy. When asked why it was ok to put the intervention of direct supervision when out of room. on the care plan on [DATE], ADON stated, Because (Resident #2) actually did something (referring to Resident #2 touching Resident #1). When asked about having the knowledge that came about on [DATE], when the facility ran a Public Sex Offender Registry check, and discovered that (Resident #2) was on probation for criminal sexual conduct, ADON stated, but that was in the past. During an interview on [DATE] at 2:44 p.m., when asked why resident #2 had an alarm, CNA E, who worked on Resident #'2's hall, stated, because he was self transferring, we didn't want him to fall. When asked if she was aware that as of [DATE], Resident #2 was supposed to have, directly supervision when out of room, CNA E stated, I knew they were putting the alarm on him, but not the direct supervision part. During an interview on [DATE] at 2:50 p.m., when asked why resident #2 had an alarm, CNA G, who worked on Resident #'2's hall, stated, I was told it was because (Resident #2) could not stand on his own, and that we needed to know when (Resident #2) was attempting to stand. During an interview on [DATE] at 2:55 p.m., when asked why resident #2 had an alarm, LPN DD, who worked on Resident #'2's hall, stated, So we knew when he was getting out of bed. So he wouldn't fall. During an interview on [DATE] at 3:00 p.m., when asked why resident #2 had an alarm, CNA EE, who worked on Resident #'2's hall, stated, it would let us know when he was trying to get up by himself, we didn't want him to fall. When asked if she was aware that as of [DATE], Resident #2 was supposed to have, directly supervision when out of room, CNA EE stated, I do not remember that Further review of the facility's 5 Day Investigation revealed that the facility created a video time line for the Resident to Resident incident [DATE]-[DATE], this timeline revealed the following: 1:40 a.m.-CNA BB takes (Resident #2) back to his room 2:38 a.m.- Resident #2 leaves his room alarm not sounding 2:39 a.m.- Resident #2 enters Resident #1's room 3:08 a.m.- RN J leaves the floor to go to lunch 3:10 a.m.- CNA X enters Resident #1's room Review of this timeline revealed Resident #2 was out of his room, unsupervised, for 32 minutes. During an interview on [DATE] at 7:30 a.m., when asked if she saw Resident #2 in his room on [DATE] at 3:08 a.m., when she walked by the room while going to lunch, RN J stated, No, I did not see him in there, but because we have the alarm, we use that for him when he is moving.

This citation pertains to MI 014 and MI 932 Based on interview and record review the facility failed to provide supervision and interventions to prevent falls for 1 (Resident #3) of 3 residents reviewed for falls and provide supervision and interventions for 1 (Resident #2) of 2 residents reviewed for abuse, from a total sample of 3 residents, resulting in Resident #3 sustaining 4 falls, two of which resulted in multiple fractures and ultimately contributing to death and Resident #2 sexually abusing Resident #1. Findings Include: Resident #3 Review of the face sheet and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #3 was an [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #3 had clear speech, was understood, understands was moderately impaired cognitively, required extensive assistance of one staff member for transfers, ambulation and activities of daily living. Further review of the MDS revealed Resident #3 had a history of [REDACTED]. Review of the medical record revealed that Resident #3 had sustained falls on [DATE], [DATE], [DATE] and [DATE]. According to the Physician Review of Injury document, on [DATE], Resident #3 sustained 2 separate lacerations, one requiring 3 sutures, the other requiring 6 sutures. Resident #3 also sustained multiple facial fractures from the fall on [DATE]. According to the Physician Review of Injury document, on [DATE], Resident #3 sustained a dislocated knee, and multiple abrasions, skin tears and bruises from the fall on [DATE]. After Resident #3's fall on [DATE], according to hospital Emergency Department (ED) record dated [DATE], Resident #3 arrived at the hospital at 11:25 p.m., and expired inhouse. Further review of the record revealed that Resident #3 was being seen in the ER related to, fell and hit her head .Has become increasingly lethargic .patient was unresponsive upon arrival to ER. Review of the Resident Event Review report dated [DATE] at 11:05 a.m. revealed, Resident #3, .was observed on the floor, laying on her R (right) side, head nearest doorway, feet nearest bed. Pt states she was trying to get into bed . Further review of this report revealed that Clinical Mentor, RN S statement concerning the fall was, I was walking past (Resident #3's) room and saw that the patient was attempting to take off her L (left) arm sling, she states she didn't want or need it on. She stated she wanted to lay down I saw (Certified Nursing Assistant (CNA) NN) in pt (patient) room next door and so I let her (the other staff member) know that (Resident #3) wanted to lay down .I then proceeded to other pt (patient) care needs. Further review of the report revealed that 30 minutes after RN S did not assist Resident #3 to lay down as requested, Resident #3 was found on the floor. Further review of the report revealed that Resident #3, .attempts to self transfer without staff assistance .Patient has dementia and poor safety awareness . Under the Summary of Root Cause Analysis section, it states (Resident #3) stated she was trying to get into bed .Patient attempts to self transfer without staff assistance . Review of the at risk for falls care plan dated [DATE] revealed that Resident #3 as a high fall risk and required, Frequent checks . Further review of this care plan revealed, Assess (Resident #3's) needs starting on admission and continue to re-assess through out stay: She will require 24 hour close monitoring for care as she is a high fall risk and has cognitive impairments. Review of the Incident/Accident note dated [DATE] at 7:40 a.m. revealed, (COTA OO) came out of room to speak to this nurse at med (medication) cart when loud bang noise heard. Went into (Resident #3's) room to observe her lying on her left side on the floor with head against the closet door. c/o (complain of) pain to lt (left) face, lt side of nose, lt elbow .Skin Assessment .Provided wound care to skin tear to Lt elbow: 2.0 cm (centimeters) x 4.0 cm. Hematoma superior to Lt eye 4.0 cm x 3.0 cm, discoloration starting. Abrasion to Lt cheek 1.4 cm x 1.0 cm. Discoloration to Rt knee 2.4 cm x 2.4 cm .(Doctor) notified with orders to send to ER (emergency room ) for evaluation . Review of the hospital radiology report dated [DATE] revealed, Acute fracture of the inferior aspect of the anterior wall the right maxillary sinus (sinus fracture) . Review of the Resident Event Review document dated [DATE] at 7:25 a.m., revealed that (Resident #3) stated that she was trying to get up, stated she fell on rt (right) knee. She was observed on the floor. Further review of this document revealed that Certified Occupational Therapy Assistant (COTA) OO, Entered (Resident 3's) room at 0715 (7:15 a.m.) for ADLs (activities of daily living). Woke (Resident #3) and she refused showering but had robe .relayed to (Resident #3) importance of her feet flat on floor .(sitting on) edge of bed with feet flat on floor raised bed slightly from bed time .Informed (Resident #3) would be back momentarily and to stay sitting and went into hall to talk to nursing .Appox (approximately) one minute later as headed back to room heard noise and observed (Resident #3's) bed raised very high and (Resident #3) lying on the floor .fully staffed possibly preventable if staff stayed in the room with the patient (Resident #3), pt is forgetful and confused at times .Summary: (Resident #3) was left unassisted while she was sitting on edge of her bed. (Resident #3's) personal belongings were not within reach .(Resident #3) has numerous [DIAGNOSES REDACTED]. (Resident #3) is also known to have very poor safety awareness. (Resident #3) has history of prior falls, and self transferring. Further review of this document revealed that existing interventions that were in place at the time of the fall included, Falling Star, do not leave alone in bathroom, frequent checks, red gripper socks on at all times as tolerated, foot rest of w/c (wheelchair), geri hips (hip protectors). Review of the risk for falls care plan dated [DATE] and updated [DATE] revealed that bilateral floor mats when in bed. Bed in lowest position when in bed. were also to interventions that were to be in place to keep Resident #3 safe. Review of the complete fall investigation and Resident Event Review, failed to reveal that the safety intervention of bilateral floor mats when in bed was in place during Resident #3's fall on [DATE]. During an interview on [DATE] at 10:55 a.m., Clinical Mentor, RN S stated that when a resident was on the Falling Star program, it indicated that the resident was a very high risk for falls, that the resident should be checked on frequently. During an interview on [DATE] at 11:27 a.m., while reviewing the fall documentation, and asked about the interventions of bed in lowest position, and bilateral fall mats when in bed Director of Nursing (DON) B agreed that the bed was not in the lowest position when Resident #3 fell on [DATE]. DON B further stated, I don't have an answer as to why the floor mats are not mentioned (in the fall investigation record). Review of the physician's orders [REDACTED]. Patient was yelling get me up. This RN ran to room from the nurses station and patient was at the foot of her bed, laying on her right side, facing the wall with clock. Patient log rolled on to her back on the floor mat .Patient transferred to her bed using proper technique and 3 staff. Patient began to get upset and told the RCT's (Resident Care Technicians), don't touch me.Neur (neurological) checks stable patient is confused intermittently .Patient with c/o right shoulder and right hip pain. Right hip swollen to ,[DATE]+ .When observed on floor per this RN, j collar (neck brace) was off and floor mat was leaning against bed side table. RCT's stated that floor mat was placed when patient transferred to bed . Review of the Emergency Department Physician Documentation dated [DATE] at 11:54 p.m., revealed Resident #3, Reportedly fell earlier this afternoon. Throughout the afternoon-evening she has been becoming less responsive . Further review of the documentation revealed that Resident #3 expired at 12:20 (on [DATE]). Review of the EMS (Emergency Medical Services), Prehospital Care Report dated [DATE], revealed, Dispatched for a female one fall and change in responsiveness. Patient had a fall 6 hours prior to staff at medical care facility calling 911. Review of the Autopsy Report dated [DATE] revealed, Cause of Death: Atherosclerotic cardiovascular disease. Contributing Condition: Fractures of right clavicle, right ribs and pelvis . Further review of the Autopsy Report revealed, There were fractures of the medial right clavicle, lateral right 7th rib, posterior right 8th and 9th ribs and the medial aspect of the right superior pubic ramus. Review of the medical record failed to reveal that the injuries of Fractures of right clavicle, right ribs and pelvis were present prior to Resident #3 falling in the facility on [DATE] at 4:10 p.m. Review of the Resident Event Review dated [DATE] at 4:10 p.m., revealed RN MM was, Charting at the nurses station .heard (Resident #3) yell for help. Nurse ran to check on patient and patient (Resident #3) was observed on the floor. Review of the falls care plan dated [DATE] and updated [DATE], revealed that following interventions for Resident #3's safety, Miami J collar (brace used to immobilize that cervical spine) to be on at all times .bilateral floor mats when in bed. Bed in lowest position when in bed .Falling Star .Frequent checks, (history) of multiple falls with fx's (fractures), high fall risk . Further review of the Resident Event Review dated [DATE] revealed, .before fall (Resident #3) was in bed after fall (Resident #3) was on floor near the left side of the bed .her j collar was off and floor mat folded in half and leaning against the bedside table During an interview on [DATE] at 11:09 a.m., when asked if Resident #3 ever took her neck collar off, Registered Nurse (RN) K, who was regularly assigned to care for Resident #3 stated, I never had a problem with it. She complained about out, but always had it on. During an interview on [DATE] at 12:30 p.m., when asked if Resident #3 ever took her neck collar off, or moved her floor mats, Certified Nursing Assistant (CNA) N, who was regularly assigned to care for Resident #3 stated, No, I had never seen her do that before. During an interview on [DATE] at 12:50 p.m., when asked if Resident #3 ever took her neck collar off CNA O, who worked with Resident #3 3 days a week, stated, that She never did when I was here. She would tug at it but would never take it off. When asked if she heard of other staff saying that Resident #3 would take her neck collar off, CNA O stated, No, she would grab at it and say that she wanted it off, but it never came off. When asked if she ever witnessed Resident #3 moving her floor mat, CNA O stated, No, never. During an interview on [DATE] at 1:30 p.m., when asked if she ever seen Resident #3 take her neck brace off or move her floor mat, CNA Q stated, I have seen her neck brace off before. No I never witnessed her folding her mat up and placing it away. When asked if she felt Resident #3 would have been capable of folding up the floor mat and leaning it against the table, CNA Q stated, no, but you never know. Review of Resident #3's Behavior Tracking Log Sheet dated [DATE] thru [DATE] revealed, each row of the log is has a time/date stamp of the behavior. The log sheet is completed in chronological order, the dates on the left of the form are in this order, ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] (this is presumably ,[DATE], as the documented behavior is refusing heels up device, and there is a correlating nursing note dated [DATE] stating, pt refused to use her heels up device.), ,[DATE] (this is presumably ,[DATE], as the documented behavior is trying to take off braces and sling, and there is a correlating nursing note dated ,[DATE] stating, Patient refused wearing brace after lunch after lying down in bed. Threw it on the floor and refused to put it back on. Nurse attempted to calm patient down which was effective but patient continued to refuse putting brace back on. Encouraged patient to keep neck still and if she gets up she needs to put it back on. Pt agreed and allowed staff to re-apply brace when she woke up from her nap.). The last entry on the form is dated ,[DATE] and documented by CNA W, which is the only date out of order, the behaviors of pt wandering into hallway/pt rooms and moved blue pad were documented as occurring at 7:00 a.m., review of the nurses noted for [DATE] failed to reveal any documentation of this behavior. Further review of this log revealed that the interventions used to intervene Resident #3's behaviors were talk calmly and educated on call light and not going into others rooms. Further review of the Behavior Tracking Log revealed the behavior of, Trying to take off braces and sling was only documented 3 times, [DATE], [DATE] and [DATE]. Further review of the Log Sheet failed to reveal whether the resident was removing her neck brace, or her sling or both. Furthermore, the log failed to reveal if the resident actually took the brace completely off, or was just trying to take it off. Review of all the nurses notes in the medical record revealed the following notes that discussed the resident taking, or attempting to take off her neck brace, there were no other documented instances of Resident #3 taking off her neck brace: [DATE] .SW (social work) observed .resident taking neck brace off .nurse came in and put brace back on . and [DATE] .Patient observed taking off her neck brace and left arm sling twice this evening. Review of written statement dated [DATE] and signed by Certified Nursing Assistant (CNA) W revealed, The last time I saw the resident was at 3:00 p.m. and at that time they were lying in bed w/ (with) blue mat on the floor and be in lowest position. Further review of this statement failed to reveal that Resident #3's Miami J Collar were in place and that there were bilateral floor mats in place. Review of written statement dated [DATE] and signed by CNA Q revealed, The last time I saw the resident was at 1605 (4:05 p.m.) and at that time they were in bed resting. Further review of this statement failed to reveal that the interventions of Miami J Collar, bed in lowest position, and bilateral floor mats were in place. During an interview on [DATE] at 10:55, when asked if she was the one that completed Resident #3's [DATE] fall investigation, Clinical Mentor, RN S stated that she was. When asked to discuss Resident #3 and the fall, RN S stated, (Resident #3) was on frequent checks .anybody that walks by should be looking into the room and making sure she is safe. While looking at the complete fall investigation and when asked if the fall mats were in place at the time of fall on [DATE], RN S stated, According to the event it says no, it says the floor mat was leaning against the bedside table. When asked if Resident #3's neck brace was on at the time of the fall, RN S stated, No, it was not. When asked when the last time it was known that Resident #3's neck brace was on, and that the bilateral fall mats were in place, RN S stated, Unfortunately it is hard to say, because these statement don't specifically say if it was on or off. When asked why the floor mats were not in place, RN S stated, Well the only time they are in place is when the resident is in bed. If she is up, then the floor mats would not be in place. RN S stated, that she did remember helping a CNA provide cares to Resident #3 before she fell . During an interview on [DATE] at 1:00 p.m., and while watching surveillance video from [DATE] with RN S, CNA Q is observed walking out of Resident #3's room at 2:30 p.m. Further review of the video revealed that at 3:15 p.m. RN S is seen walking into Resident #3's room, and then out of the room at 3:16 p.m. RN S stated that at this time Resident #3 was in the bathroom, on the shower chair and that CNA W was also in the room. RN S further stated that the floor mat would not have been in place at that time, because the resident was not in bed. Further review of the video reveals that at 3:22 p.m., CNA W was seen leaving Resident #3's room. Further review of the video reveals that at 4:06 p.m., CNA Q is seen walking, at a normal pace, down the hall. As CNA Q walks by Resident #3's room, she takes two short glances to her right, and never breaks stride. Further review of the video reveals that at 4:08 p.m. RN LL was seen responding to Resident #3's yelling. During an interview on [DATE] at 12:15 p.m., when asked when the last time she had seen Resident #3 before her fall on [DATE], CNA Q stated, It was 4:05 p.m. CNA Q further stated that Resident #3's eyes were closed, that the bed was in the lowest position, the floor mats were in place and that Resident #3's neck brace was one. When asked, CNA Q stated, No, (Resident #3) never took her neck brace off completely. CNA Q further stated that she never seen Resident #3 move her blue floor mat, I don't think she (Resident #3) could have moved it (the floor mat) on her own. On [DATE] at 1:55 p.m., while walking down the 500 hall with Clinical Mentor, RN S, we attempted to replicate that same speed, path and glances that CNA Q would have performed, per video review. RN S agreed, that at the pace, the path and the glances that CNA Q did in the video, one would not have been able to see into Resident #3's room and be able to see the blue mat being in place, nor the neck brace on. After review of the complete [DATE] fall investigation, CNA W was the last staff member that was in the room with Resident #3, this was at 3:22 p.m CNA W was also the staff member that logged on the behavior tracking log, out of date sequence, that Resident #3 moved blue pad. It should be further noted that the behavior of moved blue pad was numbered 8, which is the last of listed behaviors. CNA Q stated that she last seen Resident #3 at 4:05 p.m., however after re-enacting CNA Q's walking down the hallway, CNA Q would not have been able to see if the blue floor mat was in place, nor would she have been able to see if the neck brace was on or off. If the neck brace was on, and the floor mat was in place, according to the video review and statements from staff, Resident #3 would have had to gotten up from bed, remove her neck brace, fold the floor mat, place it against the bedside table and then fall, all within a 2 minute time span. Resident #1 and Resident #2 Review of the face sheet and most recent MDS assessment dated [DATE] revealed that Resident #1 was a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #1 had clear speech, understood, understands and had modified independence making decisions regarding tasks of daily living. Review of the face sheet and most recent MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #2 had clear speech, understood others, understands, was moderately impaired cognitively and used a wheelchair for ambulation. Review of the Resident Event Review dated [DATE] at 3:15 a.m. revealed, CENA (Certified Nursing Assistant X) was checking rooms and observed (Resident #2) in (Resident #1's) room leaning over him. (Resident #1's) brief was undone. Res. (residents) immediately separated . Review of a signed written statement from CNA X dated [DATE] at 3:15 a.m. revealed, I was taking a wheelchair down to central supply when I noticed (Resident #2) was not in his bed or room. I began looking in other rooms and then found (Resident #2) in (Resident #1's) room leaning over him. I immediately went inside, turned on the light and pulled (Resident #2) away from (Resident #1's) bedside .I got (Resident #2) out of (Resident #1's) room and went to (Resident #1) to make sure he was okay. I then observed (Resident #1's) brief undone and his private parts hanging out. I then asked (Resident #1) if (Resident #2) had been touching him (Resident #1). (Resident #1) nodded his head yes. During an interview on [DATE] at 11:50 a.m., Resident #1 was able to answer surveyor's questions with head nods and shakes. When asked if he remembered another resident touching his penis, Resident #1 nodded his head yes. When asked if he felt violated, Resident #1 nodded his head yes. During an interview on [DATE] at 11:11 a.m., when asked if Resident #1 would be able to answer yes/no questions appropriately and accurately, Social Worker (SW) Y stated, I would say so. Review of the State's Public Sex Offender Registry, accessed on [DATE], revealed that Resident #2 was currently on probation related to a criminal sexual conduct offense, and was put on the Sex Offender Registry on [DATE]. Review of the medical record, to include behavior notes and the Behavior Tracking Log, Resident #2 had numerous documented inappropriate comments, gestures and attempts to touch staff members. These included trying to touch other's private parts. As part of the facility's investigation, staff members were asked to write statements asking them if they knew of any resident concerns with Resident #2, the following are those statements: Review of CNA FF's written statement dated [DATE] revealed, (Supplemental Resident #5) told me that (Resident #2) told her that he wants to be in bed with her . Review of CNA GG's written statement dated [DATE] revealed, I have had (Supplemental Resident #4 and Supplemental Resident #5) voice concerns about (Resident #2). (Supplemental Resident #4) would be concerned when (Resident #2) first got there about him coming into her room at night .(Supplemental Resident #5) would want to know when (Resident #2) was still up at night . Review of CNA II's written statement dated [DATE] revealed, (Supplemental Resident #4) made comments about (Resident #2) entering her room at different times unwanted. Review of Licensed Practical Nurse (LPN) DD's written statement dated [DATE] revealed, (Resident #2) went into (Supplemental Resident #4's) room and she put her call light on and yelled for help. Review of CNA JJ's written statement dated [DATE] revealed, On two separate occasions we had to explain to (Resident #2) that (Supplemental Resident #7) was not his brother .(Resident #2) refused to leave (Supplemental Resident #7) alone .I later saw (Resident #2) sitting outside (Supplemental Resident #7's) door looking at (Supplemental Resident #7). During an interview on [DATE] at 3:05 p.m., when asked if he had concerns with Resident #2, Supplemental Resident #7 stated, Yes, he was after me. He would block me in with his wheelchair and not let me move. Review of CNA E's written statement dated [DATE] revealed, that Supplemental Resident #4 had a concern of, (Resident #2) went into her room. She did not like that. Review of CNA G's written statement dated [DATE] revealed, I (CNA G) was told by (Supplemental Resident #4) on multiple occasions that (Resident #2) has entered (Supplemental Resident #4's) room in the middle of the night and woke her up, resulting in (Supplemental Resident #4) being very upset and scared by it. Review of Resident #2's Kardex (document that CNA's use to assist them with cares for residents) dated [DATE] revealed, (Resident #2) has a silent alarm mounted on the bathroom side of his bed. Please assure this is turned on. Review of the facility's Evidence of Investigation 5 Day Investigation document dated [DATE] revealed, On [DATE], after running a monthly (name of state) Public Sex Offender Registry check .the facility discovered that (Resident #2) was on probation for criminal sexual conduct .The same day she was notified, the (Nursing Home Administrator (NHA) A) directed staff to update care plan with appropriate information and develop interventions to ensure resident safety. In addition, Clinical Mentor of (Name of unit), Assistant Director of Nursing (ADON) C made staff aware that (Resident #2) needed to be supervised while out of room at all times .Appropriate interventions, including a silent alarm in his room to alert staff when he has left his room and close supervision when out of room, were in place. However, at the time of the incident, it appears the alarm was not sounding. Review of CNA BB's written statement dated [DATE] revealed, .I can't remember for certain if the alarm was switched back to on or if the curtain was over to the point of blocking the alarm. During a telephone interview on [DATE] at 2:30 p.m., CNA BB confirmed that he could not remember if the the alarm was back on or not (on [DATE]). CNA BB further stated that, Yes, lots of other residents were uncomfortable around (Resident #2). CNA BB further stated, No, I did not know (Resident #2) was supposed to have close supervision when (Resident #2) was out of his room. Though the 5 Day Investigation document dated [DATE] stated that the intervention of close supervision when out of his room was in place, Review of Resident #2's fall risk care plan revealed that the intervention of direct supervision when out of room. was not initiated until [DATE] by Assistant Director of Nursing (ADON) C. During an interview on [DATE] at 10:06 a.m., when asked about the intervention of direct supervision when out of room not being initiated on the care plan until [DATE], ADON C stated, I can say it was mainly verbal, I guess next time we will not protect other people's privacy (referring to Resident #2's history of criminal sexual conduct). When asked why it was ok to put the intervention of direct supervision when out of room. on the care plan on [DATE], ADON stated, Because (Resident #2) actually did something (referring to Resident #2 touching Resident #1). When asked about having the knowledge that came about on [DATE], when the facility ran a Public Sex Offender Registry check, and discovered that (Resident #2) was on probation for criminal sexual conduct, ADON stated, but that was in the past. When surveyor explained he was put on the registry in 2015, ADON stated, Oh, I did not know that. During an interview on [DATE] at 2:44 p.m., when asked why resident #2 had an alarm, CNA E, who worked on Resident #'2's hall, stated, because he was self transferring, we didn't want him to fall. When asked if she was aware that as of [DATE], Resident #2 was supposed to have, directly supervision when out of room, CNA E stated, I knew they were putting the alarm on him, but not the direct supervision part. During an interview on [DATE] at 2:50 p.m., when asked why resident #2 had an alarm, CNA G, who worked on Resident #'2's hall, stated, I was told it was because (Resident #2) could not stand on his own, and that we needed to know when (Resident #2) was attempting to stand. During an interview on [DATE] at 2:55 p.m., when asked why resident #2 had an alarm, LPN DD, who worked on Resident #'2's hall, stated, So we knew when he was getting out of bed. So he wouldn't fall. During an interview on [DATE] at 3:00 p.m., when asked why resident #2 had an alarm, CNA EE, who worked on Resident #'2's hall, stated, it would let us know when he was trying to get up by himself, we didn't want him to fall. When asked if she was aware that as of [DATE], Resident #2 was supposed to have, directly supervision when out of room, CNA EE stated, I do not remember that Further review of the facility's 5 Day Investigation revealed that the facility created a video time line for the Resident to Resident incident [DATE]-[DATE], this timeline revealed the following: 1:40 a.m.-CNA BB takes (Resident #2) back to his room 2:38 a.m.- Resident #2 leaves his room alarm not sounding 2:39 a.m.- Resident #2 enters Resident #1's room 3:08 a.m.- RN J leaves the floor to go to lunch 3:10 a.m.- CNA X enters Resident #1's room During an interview on [DATE] at 7:30 a.m., when asked if she saw Resident #2 in his room on [DATE] at 3:08 a.m., when she walked by the room while going to lunch, RN J stated, No, I did not see him in there, but because we have the alarm, we use that for him when he is moving.

This citation pertains to intake number MI 977. Based on interview and record review the facility failed to provide supervision and interventions to prevent an injury to 1 (Resident #3) of a total of 3 sampled residents reviewed for injuries, resulting in Resident #3 sustaining a broken hand. Findings: Review of the Admission Record dated 2/20/13 revealed Resident #3 was a [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was moderately impaired cognitively, spoke Spanish and required an interpreter to communicate and required extensive assistance of 1 person for bathing. Review of the Radiology Report dated 12/23/14 revealed, "Reason: Bruising, Swelling...Results: Oblique fracture of the fifth metacarpal shaft (bone in the hand). There is associated soft tissue swelling" Review of the Nurse's Note dated 12/12/14 at 9:15 a.m. revealed, "resident (complaining of) pain on left hand. observed swelling on palm of left hand. Asked resident if she remembered how it got there and she stated that she does not know how it got there." Review of the Incident/Accident Note dated 12/12/14 at 5:50 p.m. revealed, "Dashboard alert possible bruise- this nurse went to assess resident and left back of hand and palm has discoloration. Back of left hand 7.5 cm (centimeter) long by 5 cm wide discoloration with some swelling, palm of hand 2cm diameter discoloration. No s/sx (signs/symptoms) of pain, no c/o (complaints of) pain. She did not know how it happened. Clinical mentor and POA...notified, FYI added to doctor's folder." Review of the Grievance/Concern Witness Statement Form completed by Certified Nursing Assistant (CENA) "D", dated 12/16/14, revealed, "At or around 6am December 12th (Resident #3) was getting up to use the bathroom...so I went in to assit (sic) with the toileting and getting (Resident #3) ready for shower. While in shower she becomes combative grabbing the shower cord and trying to stand up. Im trying to keep her safe and trying to keep her from standing. I also am trying to get the shower head from her. I didn't see her hit her hand on anything in the shower." During an interview on 1/6/15 at 1:55 p.m., CENA "D" stated, "On the 12th (12/12/14) at about 6:00 a.m. I gave (Resident #3) a shower, she doesn't like her showers and became combative, she was grabbing at the shower head, she wasn't hitting with it, just trying to get it away from me...I don't think that her fighting me in the shower would have broken a bone". During the follow up interview with CENA "D" on 1/7/15 at 1:15 p.m., CENA "D" stated that Resident #3 was grabbing the shower head and then CENA "D" grabbed Resident #3's hand and pried it away from the shower head. CENA "D" further stated, "It could have" caused Resident #3's hand injury, she did holler when I grabbed her hand". During an interview on 1/7/15 at 1217 p.m., NHA "A" stated that she became aware of Resident #3's bruised hand on December 16th, and then asked CD "S" to start an investigation into the bruise. NHA "A" further stated that during the investigation she spoke with CENA "D", and determined that CENA "D" was trying to take Resident #3's hand off of the shower head. NHA "A" further stated, (CENA "D") trying to get the shower head from (Resident #3) was appropriate at the time". NHA "A" further stated that, "Yes, that is what I think as well", that CENA "D" pried the shower from Resident #3's hand. During an interview on 1/8/15 at 9:37 a.m., Physician "O" read Radiology Report dated 12/23/14 and stated, "It looks more like an oblique fracture (the fracture that Resident #3 sustained), which is more of a torque injury, like at an angle or torque from a force". This surveyor asked Physician "O" if someone were to grab and pry Resident #3's hand from a shower head, could that have caused the hand fracture, Physician "O"'s response was, "It's possible". ( )

BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO SUPERVISE A RESIDENT TO PREVENT A FALL IN 1 OF 5 RESIDENTS (#6)REVIEWED FOR FALLS OUT OF A TOTAL OF 24 SAMPLED RESIDENTS RESULTING IN A FRACTURED HIP. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET REFLECTED THAT RESIDENT #6 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. SHE WAS REadmitted on [DATE] AFTER A FALL AND FRACTURE AT THE FACILITY. A REVIEW OF THE MINIMUM DATA SET (MDS) FUNCTIONAL STATUS (MEASURE OF RESIDENT'S ABILITIES) DATED 12/23/11 REFLECTED THAT RESIDENT #6 REQUIRED LIMITED ASSISTANCE OF 1 STAFF TO POSITION HERSELF IN BED, MOVE BETWEEN SURFACES, WALK IN HER ROOM, THE CORRIDORS AND OFF-UNIT, USE THE TOILET AND DO PERSONAL CARE FROM THE WAIST UP. SHE NEEDED EXTENSIVE ASSIST OF 1 STAFF FOR BATHING. SHE REQUIRED EXTENSIVE ASSIST OF 1 STAFF FOR DRESSING AND SETUP ONLY FOR MEALS. A REVIEW OF THE PLAN OF CARE DATED 9/15/11 REFLECTED THAT RESIDENT #6 WAS AT RISK FOR FALLS. A REVIEW OF AN INCIDENT STATEMENT DATED 12/29/11 AND PROVIDED BY THE DIRECTOR OF NURSING (DON) REFLECTED THAT RESIDENT #6 HIT HER HEAD ON HER NIGHTSTAND AFTER STANDING AND ATTEMPTING TO REMOVE HER COAT WITHOUT ASKING FOR ASSISTANCE. A CHAIR SENSOR WAS PUT IN PLACE TO REMIND RESIDENT #6 TO ASK FOR ASSISTANCE BEFORE RISING FROM HER CHAIR. A REVIEW OF AN INCIDENT REPORT PROVIDED BY THE DON AND DATED 12/31/11 REFLECTED THAT RESIDENT #6 fell IN HER BATHROOM AND HIT HER HEAD ON THE FAUCET WHILE CLEANING HER DENTURES. THE INTERVENTION ON THE PLAN OF CARE DATED 1/5/12 REFLECTED, "ENCOURAGE RESIDENT #18 TO SIT AT SINK TO CLEAN MOUTH AND DENTURES; ASSIST AS NEEDED." A REVIEW OF PROGRESS NOTES DATED 3/3/12 REFLECTED THAT RESIDENT #6 fell IN HER BATHROOM WHILE TRYING TO WALK WITH HER WALKER OUT OF THE BATHROOM. A REVIEW OF AN INCIDENT STATEMENT FORM DATED 3/3/12 AND PROVIDED BY THE DON REFLECTED THAT RESIDENT #6 WAS STANDING AT THE SINK, FIXING HER HAIR, AND ASKED HER CERTIFIED NURSE ASSISTANT (CNA) TO GET HER WHITE SWEATER. THE CNA LEFT RESIDENT #6 STANDING AT THE SINK, AND HAD TO TURN HER BACK ON THE RESIDENT TO LOCATE THE SWEATER. WHEN THE CNA TURNED AROUND, SHE SAW RESIDENT #6'S WALKER COMING OUT OF THE BATHROOM, AND THE RESIDENT FALLING TO THE FLOOR. A REVIEW OF THE INCIDENT REPORT DATED 3/3/12 AND PROVIDED BY THE DON FOR RESIDENT #6 REVEALED THAT A DATE OF 3/8/12 WAS ADDED TO INDICATE A "FRACTURE" UNDER THE SECTION TITLED PHYSICAL ASSESSMENT ABNORMALITIES. RESIDENT #6 WAS SUBSEQUENTLY SENT TO THE HOSPITAL AND RETURNED to the facility on [DATE], AFTER REPAIR OF A FRACTURED HIP. ON 5/23/12 AT 11:10 AM RESIDENT #6'S FALL AND FRACTURE WAS REVIEWED WITH UNIT MANAGER STAFF "P" IN HER OFFICE. STAFF "P" STATED THAT LIMITED ASSIST MEANT THAT THE STAFF PERSON WAS TO BE "RIGHT THERE, SUPPORTING/HELPING THE RESIDENT WITH 1 HAND." A REVIEW OF THE MDS FUNCTIONAL STATUS DATED 4/12/12 REFLECTED THAT RESIDENT #6 NOW NEEDED EXTENSIVE ASSISTANCE OF 2 STAFF TO POSITION HERSELF IN BED AND MOVE BETWEEN SURFACES. SHE WAS UNABLE TO WALK, AND REQUIRED A WHEEL CHAIR WITH ASSIST OF 1 STAFF FOR MOBILITY OUTSIDE HER ROOM AND OFF-UNIT. SHE NOW NEEDED EXTENSIVE ASSIST OF 1 PERSON FOR PERSONAL CARE FROM THE WAIST UP AND DRESSING, AND EXTENSIVE ASSIST WITH 2 STAFF FOR BATHING AND TOILETING. RESIDENT #6 ALSO NEEDED SUPERVISION OF 1 STAFF AND SET UP FOR MEALS. THESE RATINGS REFLECTED THAT RESIDENT #6 SUFFERED A DECLINE IN HER ABILITY TO FUNCTION AFTER A FALL AND FRACTURED HIP. ( )