Every finding on record at Greenfield Rehab and Nursing Center

Based on observation, interview and record review, the facility failed to ensure a resident was positioned safely during provision of care and ensure fall interventions were maintained for two (R30 and R15) of nine residents reviewed for accidents, resulting in R30 sustaining a closed fracture of proximal end of right humerus; and the facility failed to ensure an environment free from accident hazards for three (R2, R32, and R45) of nine residents reviewed for accidents. Findings include:R30: On 8/10/26 at 10:10 AM, during an interview with R30's roommate, the roommate reported a concern that R30 had fallen out of bed about a month ago when the nursing assistant was providing care and R30 fractured their collar bone. They further reported when they heard R30 fall out of bed, they went out and told the nursing staff. On 8/10/26 at 10:15 AM, R30 was observed lying in bed, flat on their back with a black sling to their right arm. When asked about the recent fall, R30 reported they had pain when their arm gets moved or jerked and further reported they fell out of bed when an aide left them on their right side and they fractured their humerus. R30 reported this happened about four weeks ago. Review of the clinical record revealed R30 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: closed fracture of proximal end of right humerus (7/11/26) and other displaced fracture of upper end of right humerus (10/27/22). According to the Minimum Data Set (MDS) assessment dated [DATE], R30 had no communication concerns, had intact cognition, had functional limitation in range of motion to one side of both the upper and lower extremities, was dependent on toileting hygiene, dressing, shower/bathing, and personal hygiene, was dependent on rolling left and right and had no falls since the prior assessment. Review of the care plans included: Resident has an ADL (Activity of Daily Living) self-care performance deficit r/t (related to): debility, weakness, and limited ROM (Range of Motion) of left upper extremity and bilateral lower extremities. This care plan was initiated on 11/1/22. Current interventions included: TOILET USE: 2 person assist bed level. Initiated 3/13/26. BED MOBILITY: 2 person assist. Initiated 11/1/22. DRESSING: 2 person assist. Initiated 3/13/26. Review of the progress notes included: An entry on 7/11/26 at 9:48 PM read, .Resident returned from [name of local hospital], was sent earlier today r/t (related to) a suspected impacted fracture or [sic] the surgical neck of humerus. Resident arrived via [name of local Emergency Response Service/EMS] EMS transport by 2 EMT (Emergency Medical Technician). DX: (Diagnosis) Closed fracture of proximal end of right humerus. Rt (Right) sling in place. An entry on 7/11/26 at 1:09 PM read, [Emergency Response Service] on site to transfer resident to [name of local hospital] for evaluation r/t suspected fracture to surgical neck of humerus. An entry on 7/11/26 at 12:33 PM read, X ray results show a suspected impacted fracture or the surgical neck of humerus.send resident to ER (Emergency Room) for evaluation. An entry on 7/11/26 at 9:16 AM by Nurse 'I' read, While responding to a CNA's (Certified Nursing Assistant's) request to perform the pt. (patient) wound dressing, I am entering the pt room and found the pt. lying on the floor on the left [sic] side of the bed. The pt was lying on his left [sic] arm. the pt. is AOX3 (alert and oriented x 3 to person, place and time). He denial hitting his head or any part of his Bordy [sic] during fall. the pt. c/o (complained of) pain in his right arm and shoulder. Bruising and swelling were noted to the right arm.Pt. stated. I rolled out of the bed Pt denial hitting his head or losing consciousness but reported pain in the right arm. On 8/10/26 at 3:43 PM, the facility was requested to provide all accident/incident reports and facility investigations for the past three months for R30. On 8/11/26 at 8:15 AM, the Administrator and Corporate Clinical Staff (Nurse 'H') provided documentation of R30's fall with injury from 7/11/26. The Administrator reported the staff member (Certified Nursing Assistant/CNA 'G') was providing incontinence care to the resident and identified the pressure ulcer dressing was soiled and needed changing and they left the resident unattended to notify the nurse and that was when the resident fell and injured themselves. Review of the documentation provided regarding R30's fall incident on 7/11/26 included: .On the morning of the incident at approximately 7:00 a.m., [CNA 'G'] was providing incontinent care to a resident requiring a two-person assist. After turning the resident onto his side, the CNA observed that the resident's wound dressing required changing. The CNA left the resident unattended in the turned position to locate a nurse to perform the dressing change. The CNA returned in less than two minutes with the assigned nurse and found the resident on the floor. The resident's care plan and Kardex clearly identified that he required a two-person assist for bed mobility and personal care. The CNA failed to follow the resident's Kardex instructions by leaving the resident unattended during care. The resident was immediately assessed, the physician and responsible party were notified, and resident was transferred to the hospital for further evaluation. The Cena was subjected to disciplinary escalation and terminated. WITNESS STATEMENT .[CNA 'G'] .Date of incident: 07/11/2026 .Date/Time/Place of interview: HR (Human Resource) office 7/13/2026 4:29 pm .STATEMENT: I was in the middle of giving care for [R30], he had a patch that needed to be changed, I stepped out to find the Nurse but the patient fell, I don't recall if I left him on his side or not, within 2 minutes the nurse came with me and we found him (patient) on the floor. On 8/11/26 at 11:08 AM, and 8/12/26 at 9:35 AM, CNA 'G' was attempted to be contacted at the number provided and there was no response and unable to leave a message. On 8/11/26 at 11:11 AM, CNA 'G' was texted a message to return the call, however there was no response by the end of the survey. R15: On 8/10/26 at approximately 10:30 a.m., R15 was observed in their room, lying in their bed. R15 was observed to not have any grip socks on with bare feet, their mattress was observed to be a normal flat mattress, and no urinal was observed in R15's room. R15's wheelchair was observed to be in the corner of the room not located near their bed. On 8/10/26 at approximately 3:26 p.m., R15 was observed in their room, lying in their bed. R15 was observed to not have any grip socks on with bare feet, their mattress was observed to be a normal flat mattress, and no urinal was observed in R15's room. R15's wheelchair was observed to be in the corner of the room not located near their bed. R15's water cup was observed out of their reach. On 8/11/26 at approximately 12:27 p.m., R15 was observed in their room, lying in their bed. R15 was observed to not have any grip socks on with bare feet, their mattress was observed to be a normal flat mattress, and no urinal was observed in R15's room. R15's wheelchair was observed to be in the corner of the room not located near their bed. On 8/10/26 the medical record for R15 was reviewed and revealed the following: R15 was initially admitted to the facility on [DATE] and had diagnoses that included Dementia and Repeated falls. R15's MDS assessment with an ARD (assessment reference date) of 5/26/26 revealed R15 needed assistance from facility staff with most of their activities of daily living. R15's BIMS score (brief interview of mental status) was 11 that indicated R15 had moderately impaired cognition. A review of R15's care plan revealed the following: Focus-At risk for falls due to dementia, potential medication side effects, Vision/Hearing problems Date Initiated: 11/24/2023 .Interventions- DPM (defined perimeter mattress) to act as a tactile prompt for body positioning. Date Initiated: 11/24/2023 . Encourage pt to keep w/c (wheelchair) at bedside while in bed. Date Initiated: 02/02/2026 . Encourage resident to keep his drinking water within reach. Date Initiated: 03/13/2026 . Encourage resident to wear grip socks while in bed. Date Initiated: 06/27/2025 .Keep Urinal at bedside and empty as needed. Date Initiated: 06/30/2025 A review of R15's Kardex (a care guide for the direct care staff) revealed the following: DPM to act as a tactile prompt for body positioning .Safety-Anticipate needs, Encourage pt (patient) to allow staff assistance getting up and dressed after breakfast, Encourage pt to keep bed in its lowest position at night, Encourage pt to keep w/c at bedside while in bed, Encourage resident to keep his drinking water within reach, Encourage resident to sit up in chair for meals, Encourage resident to wear grip socks while in bed, Frequent rounding, . On 8/11/26 at approximately 2:15 p.m., R15's room was observed with Nurse Manager E (NM E). NM E was queried if R15 had a high risk of falls and they reported they did. NM E was queried regarding R15 not having the DPM on their bed, as well as the urinal in their room and they indicated they should be in place and that all of the staff should be making sure the interventions that were included in the plan of care are implemented. NM E reported they would get a DPM on R15's bed and place a urinal in their room. According to the facility's policy titled, Fall Management Guidelines dated 12/13/23: .The facility staff.will implement a resident-centered comprehensive care plan that addresses the fall management program.individualized interventions to try to minimize the consequences of risk factors that are not modifiable. ACCIDENT HAZARDS: On 8/10/26 at 10:14 AM, 8/11/26 at 1:13 PM, and 8/12/26 at 11:30 AM, R45's room was observed to have a black power strip in use with a tube-feeding pump plugged into it. On 8/10/26 at 10:08 AM, and 8/11/26 at 10:44 AM, R29's room was observed to have a black power strip in use with their hospital bed plugged into it. R32: On 8/10/26 at 10:08 AM, R32 was observed lying in bed. R32 was receiving oxygen via nasal cannula from an oxygen concentrator that was plugged into a power strip. The power strip was plugged into a wall outlet next to R32's roommate's bed. A BIPAP (bilevel positive airway pressure) machine (a machine to help you breathe while sleeping) and a nebulizer machine (for administering breathing treatments) were plugged into the power strip. On 8/11/26 at 12:58 PM, an observation of R32's room was made with the Maintenance Director (Staff 'P'). Staff 'P' confirmed R32's medical equipment including the oxygen concentrator, BIPAP machine, and nebulizer were plugged into the power strip. Staff 'P' reported they should not be using a power strip for medical equipment, especially the oxygen concentrator. Staff 'P' reported there were not enough outlets in all of the resident rooms to accommodate the medical equipment. A review of R32's clinical record revealed R32 was admitted into the facility on 3/18/26 and readmitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease and obstructive sleep apnea. A review of R32's MDS assessment dated [DATE] revealed R32 had intact cognition and received oxygen therapy. A review of R32's Physician's Orders revealed orders for a BIPAP machine at bedtime, oxygen 4 liters continuous via nasal cannula, and albuterol sulfate via nebulizer. R2: On 8/10/26 at 9:43 AM, R2 was observed lying in bed. R2 had a low air loss mattress, was receiving oxygen via nasal cannula, and had a CPAP (continuous positive airway pressure) machine and nebulizer machine plugged into a power strip which was plugged into a single outlet on the wall. On 8/11/26 at 1:10 PM, an observation of R2's room was conducted with Staff 'P'. Staff 'P' confirmed R2's medical equipment plugged into the power strip and reported it should be plugged into a wall outlet. A review of R2's clinical record revealed R2 was admitted into the facility on 6/26/25 and readmitted on [DATE] with diagnoses that included: pressure ulcers, obstructive sleep apnea, and chronic obstructive pulmonary disease. A review of R2's MDS assessment dated [DATE] revealed R2 had intact cognition and received oxygen therapy and had unhealed pressure ulcers. A review of R2's Physician's Orders revealed active orders for CPAP at bedtime, wound treatments, oxygen 2 liters continuous via nasal cannula, and albuterol sulfate via nebulization. On 8/11/26 at 12:58 PM, Staff 'P' was asked about the facility's use of power strips with resident equipment, Staff 'P' reported that the facility didn't have enough plugs in the resident rooms, so sometimes they used power strips for things like their cell phone chargers that are surge protectors. When asked about if there should be any medical equipment such as oxygen, breathing machines, or tube feeding, Staff 'P' reported there should not be any medical equipment used with the power strips. Staff 'P' was asked to accompany to observe several rooms. On 8/11/26 at 1:05 PM, Staff 'P' confirmed the multiple resident rooms with power strips in use with the medical equipment and reported they would address that immediately and was unable to offer any further explanation as to why that had occurred. When asked if they utilized any documentation for the monitoring of equipment, Staff 'P' reported they did not. On 8/11/26 at 1:35 PM, an interview was conducted with the DON. The DON reported he was not aware that resident medical equipment was being plugged into power strips. On 8/12/26 at 9:05 AM, the Administrator reported they did not have a policy for use of power strips.

Based on observation, interview, and record review, the facility failed to maintain the kitchen equipment and ensure safe food storage practices, resulting in the potential to spread foodborne illness to all residents that consume food from the kitchen. Findings include:On 08/10/2026 at 9:05 AM, observations made on a kitchen tour with Dietary Manager (DM) O included:four trays of raw (not pasteurized) eggs stored on the shelf over a tray of butter and cartons of pasteurized egg product in a cookline refrigerator unit. juice gun soiled with colored juice buildup inside the nozzle; the black plastic holder was also sticky with buildup. DM O said the juice gun is cleaned weekly.interior top of microwave oven soiled with dried food debris; when pointed out, DM O concurred it was soiled and will have it cleaned.On 08/10/2026 at 9:40 AM, observed the service line domestic style refrigerator/freezer in use for storage of beverages for meal service, including individual cartons of milk and nutritional supplement shakes. The unit thermometer read 55 F and product temperatures were 54 F. DM O discarded the milk cartons and shakes. On 08/10/2026 at 12:00 PM, observed the service line beverage refrigerator still not holding 41 F or below; the unit thermometer read 57 F and contained only cups of juice. DM O indicated this unit would only be used for short term storage of portioned juice for meal service and will have the unit serviced.On 08/10/2026 at 10:15 AM, observed the 2nd floor dish room area. The exterior top of the dish machine was coated with a powdery build up. When wiped it came off onto paper towel. DM O indicated that the surface isn't cleaned because of the electronic unit, but will address this with the dish machine vendor. On 08/10/2026 at 10:20 AM, observed 2 ice machines in the 2nd floor dish room with the exteriors soiled with dust build up. DM O indicated the surfaces will be cleaned.On 08/10/2026 at 11:55 AM, observed the kitchen utensil drawer for storage of clean mechanical scoops lined with foil; under the foil observed standing water and debris build up on the drawer surface. DM O indicated they will clean the drawer surface. On 08/11/2026 at 9:55 AM, observed mini-refrigerator for resident/outside food storage at the 2South supply room full of several bags of resident food items without any space for cold air to circulate in the unit. ADON R indicated that DM O monitors the temperature daily. The unit thermometer was reading 52 F. Record Review of a policy document posted in the supply room titled Maintaining a safe food temperature in lab, snack, and med. refrigerators dated 3/20/2017 indicated: All refrigerators must be kept a consistent temperature- lab/snack: no lower than 34 and no higher than 40 degrees. On 08/11/2026 at 10:15 AM, observed mini-refrigerator at the 2North supply room with unit thermometer reading 45 F. No food was currently being stored in the unit. On 08/11/2026 at 2:00 PM, observed the 2South unit portable hydration station cart in the hallway; including an ice chest of ice and the ice scoop stored in a foam cup on the side of the cart facing the hallway where residents and staff pass by and open to potential airborne contamination.On 08/11/2026 at 3:30 PM, interviewed DM O regarding the policy for monitoring the mini-refrigerator units. DM O indicated that she monitors the unit temperatures daily and is aware the temperature can fluctuate with overusage or if the door is not sealed. DM O acknowledged the 2South unit was overfilled and the items were discarded. When she re-checked, the unit temperature was below 39 F. According to the 2022 FDA Food Code: Section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: .separating raw animal FOODS during storage, preparation, holding, and display from:(a) . other raw READY-TO-EAT FOOD such as fruits and vegetables, P (b) Cooked READY-TO-EAT FOOD, P and(c) Fruits and vegetables before they are washedSection 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.(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.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.Section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) .TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above. or (2) At 5 C (41 F) or less.Section 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored:. (E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not time/temperature control for safety food.

Based on observation, interview, and record review, the facility failed to implement key elements of an effective water management plan including a site-specific written plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility. Findings include: On 08/10/2026 at 10:40 AM, interviewed Maintenance Director (MD) P about the water management program (WMP). When asked about legionella control measures, MD P indicated that control measures for flushing fixtures at vacant rooms were recently reviewed with housekeeping staff. When asked about any other low use fixtures, none were identified. When asked about any additional control measures, MD P indicated that an annual legionella test is conducted and results reviewed. Record review of a WMP cover sheet titled Water Management Program: Yearly Review of [NAME] indicates WMP review was completed by MD P dated 11/13/25. This document indicates 6 key measures were reviewed, including 3. Monitoring: Control Measures set out in the risk assessment are still effective. Record review of WMP documents included review of a corporate policy, titled Select Facility: Water Management Program dated 6/13/2017 and states the following: 6. Based on the risk assessment, control measures will be established to address potential hazards. A variety of measures may be used, including physical controls, temperature management, disinfectant level control, visual environmental inspections, and environmental testing when warranted. Record review of a document titled Water System Infection Control Risk assessment dated [DATE] was viewed; this document was a checklist and no specific written guidance for control measures, critical limits, or corrective actions followed. A water system general flow diagram, but no written description of the water supply was provided. The flow diagram did not include types and numbers of fixtures (e.g. utility sinks and therapy tub were not identified).No written guidance was provided for the validation water sample testing that is completed. Record review of an email dated 2/5/2024 from a local public health official indicated the following recommendations for the facility WMP: [local public health agency] would like to provide you the following recommendations:Routinely review and update your water management plan (WMP) to comply with CDC guidelines CMS requires that facilities develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of grown [sic] and spread of Legionella and other opportunistic pathogens in water. The CDC toolkit is included in your WMP, but your WMP needs to more clearly include the following:Identification of areas where Legionella can grow and spreadControl measures and how they are monitoredMethods of intervention when control measures are not metValidation of the WMPThe use of flushing should be included in your WMPAdditional record review of the WMP found no documentation that these items were addressed in the current plan. When asked about this specific guidance, MD P indicated they could work on this. On 08/11/2026 at 10:30 AM, observed the hot water heating system in the boiler room with MD P and viewed documentation of Point of Use ([NAME]) hot water temperatures at resident hand sinks. MD P indicated that hot water heater temperatures are not recorded and that the chlorine kit that is available has not been used. On 08/11/2026 at 12:15 PM, interviewed Nursing Home Administrator (NHA) regarding the WMP. When asked how the Water Management Team functions, NHA described the flushing protocols that are in place when rooms are vacant, hot water temperature monitoring at resident point-of-use fixtures, and annual legionella testing. When asked about written documentation, including site specific plans for control measures/monitoring, NHA indicated the team can look at that. NHA was not familiar with the 2024 email guidance from the local public health agency.

Based on observation, interview, and record review, the facility failed to maintain repair of the premises and required backflow prevention at plumbing fixtures as well as storage of resident care equipment in a clean state, resulting in an increased potential for contamination. Findings include:On 08/11/2026 at 11:20 AM, on an environmental tour with Housekeeping Manager (HK) Q observed the 2South shower room with broken tile baseboard in the shower area.On 08/11/2026 at 11:30 AM, observed the 2North shower room with the shower grab bar with paint peeling off the surface. On the floor the adhesive grip surface was peeling off with the edges curled up. At this time HK Q indicated these items would be shared to maintenance. On 08/11/2026 at 11:36 AM, observed the 2nd floor custodial closet with the utility sink out of order. HK Q indicated that currently custodial staff have to get their carts filled from the 1st floor utility sink.On 08/11/2026 at 11:42 AM, observed the 1South shower room with the adhesive grip strips peeling off the floor. Observed the shower bed with yellow liquid in the catch mat below the bed.On 08/11/2026 at 11:43 AM, observed the 1st floor custodial closet utility sink connected to the chemical tower with shut off valves downstream of the atmospheric vacuum breaker (AVB) without the required wasting tee to relieve the backpressure on the AVB.On 08/11/2026 at 11:45 AM, observed the 1North shower room with the shower bed soiled with debris and liquid in the creases of the mat. At this time when asked about the procedures for cleaning of resident care showering equipment, Licensed Practical Nurse (LPN) D indicated the shower bed should be cleaned after each use and would be cleaned at this time. Record review of policy titled Homelike Environment dated 9/21/23 indicated: Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Record review of policy titled Preventative Maintenance Program dated 11/1/20 indicated: The Maintenance Director is responsible for developing and maintain [sic] a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on observation, interview, and record review, the facility failed to provide a dignified dining experience for 15 of 15 residents reviewed for dining, and ensure residents were assisted with their right to vote in the primary election for 17 of 17 residents who wished to remain anonymous who participated in the resident council interview. Findings include: On 8/10/26 at 12:34 PM, observations of the main dining room lunch meal revealed there were 15 residents present and two family members. Staff were observed serving residents their lunch meal by removing meal trays from a portable food cart and then placing the entire meal tray in front of the residents without offering to remove any of the items to ensure a non-institutional/dignified dining experience. On 8/11/26 at 12:40 PM, additional observations of the facility's lunch meal revealed the same observations of staff serving the residents their lunch meal with the meal trays placed directly in front of them. On 8/12/26 at 11:45 AM, an interview was conducted with the Administrator. When asked about the facility's dining program and whether trays should be removed during the residents' dining experience, the Administrator acknowledged that was their current practice and reported, We need to start doing that. According to the facility's policy titled, Dignity dated 9/21/2023: .Resident will be treated with dignity and respect at all times . This policy did not address dignity with dining. On 8/11/26 at 10:00 AM, a resident council interview was conducted with 17 residents. When queried about how they were informed of their rights while residing in the facility, specifically, their right to vote in elections, all 17 residents said they were not informed of how they could vote in the primary election that was held on 8/4/26. When asked by a show of hands, how many residents would have wanted to vote in the election, three residents raised their hands. On 8/12/26 at 12:40 PM, an interview was conducted with Activities Manager 'M'. Activities Manager 'M' reported they started in that role in May 2026. When queried about what was done to ensure residents knew of their right to vote in the recent primary election and how it was facilitated to ensure they could vote if they wanted to, Activities Manager 'M' said voting was not discussed with the residents and said the Social Services department may have been responsible to do that. On 8/12/26 at 1:16 PM, an interview was conducted with Social Services Director 'T'. When queried about how residents were informed and assisted with their right to vote, Social Services Director 'T' reported the Activities department was responsible to assist residents with voting. On 8/12/26 at 1:44 PM, an interview was conducted with Regional Activities Director 'S'. Regional Activities Director 'S' explained they provided oversight to the facility's activities program while Activities Manager 'M' obtained the required education to serve as the Activities Director. When queried about voting and how residents were informed of their right to vote and how to facilitate voting while residing in the facility, Regional Activities Director 'S' reported when they were the Activities Director, they had a process to ensure residents who wanted to vote received their absentee ballots and they were returned by mail, but they did not assist with anything for the primary election that was on 8/4/26 and said Activities Manager 'M' would have been responsible for that. On 8/12/26 at approximately 2:30 PM, an interview was conducted with the Administrator. The Administrator did not know the residents were not assisted with voting in the primary election. A review of a facility policy titled, Resident Voting, dated 11/1/20, revealed, in part, the following, .Resident have the right to exercise their right to vote while residing at the facility. The facility will assist the resident with exercising this right .60 days prior to an election, if feasible, voting will be discussed at the monthly Resident Council Meeting and notices will be posted at the facility .Prior to each election, residents will be asked if they need assistance in obtaining an absentee voting ballot. This will be done with the assist of the Recreation Therapy Department and/or their family members .

Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment, affecting multiple residents throughout the facility, including R12, R20, R45 and R55. Findings include:Observations of the environment during the survey from 8/10/26 - 8/12/26 included the following concerns:R12: On 8/10/26 at 10:15 AM, R12's wheelchair was observed to have worn out fabric on both the right and left arm rest which exposed inside foam. The overbed tray table was observed to have areas of broken plastic edges which exposed swollen particle board. The shared bathroom toilet was observed to have missing caulk around the base of the toilet and floor area with dark blackish colored staining.R20: On 8/10/26 at 10:31 AM, R20 was observed lying in bed awake but did not respond to questions asked. The wall near the end of the footboard was observed to have a large gouge in the drywall and the thin baseboard molding near the floor was peeled back and exposed dark brown staining underneath.R45: On 8/11/26 at 1:13 PM, R45's room was observed to have a window air conditioning unit that was heavily soiled with thick dust/debris in the external grid (where the air blows out).R55: On 8/11/26 at 11:48 AM, R55 was observed asleep in the room, seated in a mobile recliner chair. The armrest of the recliner was observed worn out which exposed the inner padding in several areas. The inside of the chair was also observed to have dried on food/drink debris. The overbed tray table was observed to have lifted edges which exposed the particle board and hard plastic edges.On 8/11/26 at 12:58 PM, an interview was conducted with the Maintenance Director (Staff 'P') who reported they had been in their role since 2022. When asked if they utilized any documentation of audits of resident equipment that might need repair or to be replaced, Staff 'P' reported all staff were to report any concerns into their electronic reporting system which gives them alerts on items that need to be fixed or repaired. Staff 'P' further reported if there were things like worn out armrest, those could tear up residents' skin.On 8/11/26 at 1:05 PM, Staff 'P' confirmed the same observations as indicated earlier and reported those would need to get addressed and should have been reported via the electronic reporting system but were not. Staff 'P' reported the nursing staff were responsible for cleaning the resident equipment on the midnight shift and housekeeping should've addressed the cleaning of the AC unit as part of their daily cleaning routine.Review of the electronic reporting documentation provided by the facility for the past two months from 6/11/26 - 8/12/26 included only closed work orders. The most recent completed work order was on 8/6/26.According to the facility's policy titled, Preventative Maintenance Program dated 11/1/2020: .A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public .The Maintenance Director is responsible for developing and maintain a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner .Documentation shall be completed for all tasks and kept in the Maintenance Director's office for at least three years.According to the facility's policy titled, Homelike Environment dated 9/21/2023: .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .clean, sanitary, and orderly environment .Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment .Staff may assist in providing a safe and homelike environment by .Reporting any furniture in disrepair to the maintenance department .Reporting any unresolved environmental concerns to the administrator .

Based on observation, interview, and record review, the facility failed to properly label and store medications in two of four medication rooms, two of five medication carts, and one of four treatment carts. Findings include:On [DATE] at 9:15 AM Wound Care Nurse (WCN) 'A' was observed preparing supplies for a wound care treatment. It was observed the drawer of the treatment cart had had three plastic cups prepared with (product name) wound care wipes and one cup with iodine-soaked gauze in them. The cups were not covered to protect them from contamination. On [DATE] at 1:05 PM, an observation of the 2 North medication room was conducted with Nurse 'B'. Stored in the medication room was a medium sized black storage tub labelled Power Failure Supply Box. The box contained various items such as flashlights, batteries, and extension cords. At the bottom of the box was a (name brand) inhaler for the treatment of chronic obstructive pulmonary disease. The inhaler was observed to have an expiration date of 3/2020. On [DATE] at 1:22 PM, an observation of the 2 South medication cart was conducted with Nurse 'C'. A bottle of dorzolamide eye drops (for treatment of increased pressure in the eye) in a box was observed in the top left drawer of the medication cart. The box had a second bottle of dorzolamide taped to it and the bottle taped to the box had an expiration date of 7/2026. The nurse was asked about the bottle taped to the box and said a resident had brought it from home and they stored it in the medication cart with the other bottle provided from the facility pharmacy. They were asked if they were aware the medication was expired and said they were not. Continued review of the medication cart revealed an albuterol rescue inhaler with no cap, and no resident name stored in the bottom left drawer of the cart. On [DATE] at 1:45 PM an observation of the 1 North medication room was conducted with Nurse 'D'. Multiple medications requiring refrigeration were observed in the refrigerator. The needle of the thermometer contained in the refrigerator was in the red area that read spoilage and the temperature was noted to be 48 degrees. An observation of the freezer portion of the medication storage refrigerator revealed approximately one inch of crusty, frosty, ice build-up. A review of the medication room refrigerator temperature logs for the 1 North medication room revealed no documented temperature for [DATE] AM shift, [DATE] AM shift, and [DATE] AM shift. On [DATE] at 1:52 PM an observation of 1 South medication cart was conducted with Nurse 'F'. Upon inspection of the cart, a box containing one (name brand) pain patch with an expiration date of 11/2024 was observed.On [DATE] at 2:05 PM, an interview was conducted with the facility's DON regarding the dorzolamide eye drops observed in the 2 South medication cart. They said the expiration date should have been reviewed and if expired, the medication should not have been stored in the cart. On [DATE] at 10:15 AM, a second observation of the refrigerator on the 1 North unit was conducted with Unit Manager 'E'. Multiple medications requiring refrigeration were observed in the refrigerator. The needle of the thermometer contained in the refrigerator was in the red area that read spoilage and the temperature was observed to still read 48 degrees. It was further observed the freezer portion of the medication storage refrigerator remained with the crusty, frosty, ice build-up.A second review of the medication room refrigerator temperature logs for the 1 North medication room revealed no documented temperature for [DATE] AM shift, [DATE] AM shift, [DATE] AM, and [DATE] AM shift. On [DATE] at 1:15 PM, an interview was conducted with the facility's DON. They said they informed the refrigerator was not at the proper temperature and they were working on it. A review of a facility provided policy titled, Medication Treatment and Storage reviewed 2/2026 was conducted and read, .It is the policy of this facility to ensure accurate labeling and dating of of medications and treatments for safe administration and safe and secure storage (including proper temperature controls, appropriate humidity and ling controls, limited access, and mechanisms to minimize loss or diversion) of all medication and treatments.

Based on observation, interview, and record review, the facility failed to ensure call lights were easily accessible and within reach for two (R55 and R20) of two residents reviewed for call light placement, resulting in the inability to summons help when needed. Findings include:R20:On 8/11/26 at 10:46 AM, R20 was observed seated in a wheelchair with an overbed table placed in front of them. The call light was observed out of their reach, hung over the headboard near the wall approximately five feet away.On 8/11/26 at 12:37 PM, R20 was not in the room, but a lunch meal was left on their overbed table. Nurse 'D' reported the resident was at a care conference and should be back soon. The call light remained hung on top of headboard near the wall (same as earlier observation).On 8/11/26 at 1:15 PM, there were multiple staff observed in the resident's room seated around R20 who was in a wheelchair approximately two feet away from the side of the bed and the call light remained on top of the headboard near the wall out of reach.On 8/11/26 at 1:24 PM, R20 was alone in their room, seated in a wheelchair eating a hotdog in a bun. They were observed to cough and began holding their hand up to their throat. When approached, R20 gave thumbs up sign and proceeded to cough. The call light remained on top of the headboard near the wall out of reach.On 8/11/26 at 1:27 PM, Certified Nursing Assistant (CNA 'K') was walking near R20's room and was asked to check on R20 since they were coughing and touching their throat. CNA 'K' approached R20, confirmed they were okay, then exited the room without addressing the placement of the call light.On 8/11/26 at 1:29 PM, Nurse 'D' was asked about R20's coughing observed while eating and they went in to check on R20. Nurse 'D' was about to exit the room and was asked about the call light placement and how it should be positioned. Nurse 'D' reported the call light should be near the resident and proceeded to move the resident's wheelchair closer to the bed and brought the call light over.Review of the clinical record revealed R20 was admitted into the facility on [DATE] with diagnoses that included: unspecified severe protein-calorie malnutrition, deaf nonspeaking, not elsewhere classified, unspecified asthma, type 1 diabetes mellitus without complications, and adult failure to thrive. According to the care plans, R20 utilized a sign language interpreter and communication board for expressing their needs. The Minimum Data Set (MDS) assessment dated [DATE] documented R20 had moderate cognitive impairment, had no speech, and sometimes understood others and sometimes makes self-understood. R55:On 8/11/26 at 11:48 AM, R55 was observed asleep while seated in a mobile recliner chair in their room approximately four feet away from the foot of the bed. The call light was observed coiled up on top of the mattress and out of resident's reach. On 8/11/26 at 12:38 PM, R55 was observed positioned in the mobile recliner chair in the same manner as and the call light remained coiled near the head of the bed and out of reach. A nursing assistant was observed setting the resident up with their lunch meal and left the room without ensuring the call light was in reach.On 8/11/26 at 1:35 PM Nurse 'D' was asked to observe R55 and confirmed the call light was coiled up on the bed, out of reach. Nurse 'D' reported R55 liked to sit over on that side of the room and reported their spouse who was also a resident would be able to wheel over and press the call light if help was needed. When asked if that should be up to other residents, Nurse 'D' reported it should not.Review of the clinical record revealed R55 was initially admitted into the facility on 7/5/19 and readmitted on [DATE] with diagnoses that included: sepsis, acute kidney failure, metabolic encephalopathy, and unspecified dementia moderate, and conversion disorder with seizures or convulsions.On 8/12/26 at 9:00 AM, an interview was conducted with the Director of Nursing (DON) in the presence of the Corporate Clinical Nurse (Nurse 'H'). When asked to explain the facility's process for call lights and how they should be maintained, the DON reported they should be in reach with the patient all the time. When asked if the facility had previously identified any concerns with call light placement, the DON reported they were aware of concerns with long wait times but not with placement. The DON was informed of the multiple observations and interviews with staff and further reported other residents were not responsible for using their call light to get help for their roommate and all staff should be making sure the call lights were placed in reach wherever they were in the room. When asked about R55's preference to be up in the mobile recliner chair which was further away than the call light cord extended, the DON reported they had a bell that should be used in that case.According to the facility's policy titled, Call Light Accessibility and Timely Response dated 8/16/2023: .Staff will ensure the call light is .within reach of residents, and secured, as needed .The call system will be accessible to residents while in their room at bedside as well as in the bathroom and shower room .

Based on interview and record review, the facility failed to ensure the resident's right to access their medical record upon request was honored for one (R31) of 17 residents who participated in the resident council interview. Findings include:On 8/11/26 at 10:00 AM, a resident council interview was conducted with 17 residents. When queried about resident rights and if anyone had ever requested access to their medical records, R31 reported they requested access to their medical record a few months ago and was told they had to pay $100. R31 reported they did not want to pay $100 so they never got to see their medical record. On 8/12/26 at approximately 1:00 PM, R31 was further interviewed about their request for access to their medical record. R31 reported they wanted a copy of their record but was not offered the option to review the record without printing it out. When queried about whether they wanted their entire medical record, R31 reported they were concerned about how many medications they were receiving and wanted a list of the medications they were prescribed so they could see what they were taking. A review of Resident Council Meeting Minutes from 3/10/26 revealed an attached Concern Form for R31 that documented, Resident stated that she needed to access her medical record. It was documented that the Administrator was the designated staff member to follow up with the concern. The following was documented in the Action taken regarding concern section: Guardian was called. Guardian was agreeable to provide her (R31) with medical records so long as she pays from her allowance money. Resident was informed. She declined using her allowance money. It was documented the concern was resolved and R31 was satisfied with the resolution. However, as mentioned above, R31 still had a concern with accessing their medical record as of 8/11/26. On 8/12/26 at approximately 2:52 PM, an interview was conducted with the Administrator. When queried about the facility's process for ensuring residents had the right to access their medical record upon request, the Administrator reported if a resident wanted access to their medical record, they were required to complete a medical record request form. Once that was completed, they would be asked for payment and then it would be handled at a corporate level to print out the medical record. When queried about R31 and the concern form that noted they wanted access to their medical record and not a physical copy of the record, the Administrator reported R31 asked for a copy of the record. When queried about whether there was further conversation about any specific parts of the record they wanted to access or if the option to view the record on a computer was discussed, the Administrator reported their process was to collect payment and he contacted R31's guardian who agreed if R31 paid out of their allowance. R31 did not wish to pay so they were not provided any access to their medical record. When queried about how the concern was considered resolved, the Administrator reported R31 changed their mind about wanting access to the medical record once they were asked to provide payment. A review of R31's clinical record revealed R31 was admitted into the facility on 9/17/25. A review of R31's Minimum Data Set (MDS) assessment dated [DATE] revealed R31 had intact cognition. A review of a facility policy regarding resident access to medical records was requested. However, it was not provided prior to the end of the survey. A policy regarding Surveyor access to medical records was provided.

Based on interview and record review, the facility failed to ensure two (R36 and R14) of 17 residents who attended the resident council interview were free to express grievances without reprisal. Findings include:R36 On 8/11/26 at 10:00 AM, a resident council interview was held with 17 residents. When queried about whether the residents felt they could express grievances or complaints without fear of being retaliated against, one resident (R36), reported they did not always feel comfortable making complaints because of something that happened in the past. R36 was given the opportunity to explain in private and said they were comfortable sharing in the group interview. R36 reported that during their last care conference they expressed a concern about a nurse who was often not available on the night shift. R36 said they could not find the nurse and at times would find her sleeping. The nurse was identified as Licensed Practical Nurse (LPN) 'I'. R36 further reported the Director of Nursing (DON) followed up on the concern, but that he was not present at the care conference. R36 heard the DON talking to LPN 'I' about R36's concern and on a later date R36 was confronted about why she told the DON. R36 reported LPN 'I' was also heard telling other residents about R36's complaint. A review of a Concern Form for R36 dated 6/10/26 completed by the DON noted, The resident stated that sometimes she would not find the nurse when she needs her medications. The concern was assigned to the DON to follow-up, and it was documented as resolved on 6/10/26. In the section for Action taken regarding concern the form documented the names of LPN 'I', the DON, the Administrator, and the Assistant Director of Nursing (ADON) and nothing else. It was noted that the grievance was resolved and noted, The employee received education on medication administration, customer service and patient care needs. On 8/12/26 at 9:11 AM, an interview was conducted with the DON. When queried about how the facility ensured residents had the right to express grievances without feeling intimidated or retaliated against, the DON reported they follow their grievance process for documenting the concern and it would be assigned to a staff member to follow up. The DON reported if the grievance was about a specific staff member, that staff member should never confront the resident about the concern. When queried about R36's concern about LPN 'I' on 6/10/26, the DON reported he was assigned to look into the concern. R36 reported that at times when she needed her medication, she was unable to find LPN 'I'. The DON reported he asked LPN 'I' about it and she denied it, but the DON stated, But this patient (R36) if alert and oriented so as far as I am concerned, it happened. When queried about whether he was aware that LPN 'I' confronted R36 about making the complaint, the DON reported that was one of the reasons LPN 'I's employment was terminated. A review of LPN 'I's personnel file revealed an Employee Counseling & Corrective Action Record dated 7/15/26 that indicated LPN 'I' was terminated from employment due to Job performance, failure to report a witnessed fall and approaching a resident to question regarding a concern. The form was signed by the DON and Human Resources Director. A review of a Witness Statement revealed on 7/14/26 Resident (R36) informed writer that when the patient needs her meds the nurse is not available to give to her, and she did report that prior in June, then the nurse approached her this day (7/14/26) and asked why she reported that to the DON. A review of R36's clinical record revealed R36 was admitted into the facility on 3/4/26 with diagnoses that included: fatty liver, hypertension, osteoarthritis, depression, and anxiety. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R36 had intact cognition. R14 On 8/12/26 at 12:48 PM, an interview was conducted with Dietary Manager 'O' regarding a concern brought up on the resident council interview about snacks not being passed or provided in the evenings on the 1 South Unit. On 8/12/26 at 1:44 PM, R14, who was the president of the resident council, came to the conference room to speak with the Health Care Surveyor. R14 said they were sent to the conference room by Dietary Manager 'O' who was almost in tears to make sure it was known that the residents were not blaming Dietary Manager 'O' for the snacks not being passed and that it was a nursing problem. R14 then asked the surveyor to follow up with Dietary Manager 'O' to let her know she was not being blamed. A review of R14's clinical record revealed R14 was admitted into the facility on 4/12/19 and readmitted on [DATE]. A review of a MDS assessment dated [DATE] revealed R14 had intact cognition. A review of a facility policy titled, Concern (Grievance) Process, revised 5/31/24, revealed, in part, the following, .Residents, family, and resident representatives have the right to voice or file concerns/grievance without discrimination or reprisal in any form, and without fear of discrimination or reprisal including interference, coercion, or discrimination .Any staff involved in the concern investigation or resolution will take steps to preserve the confidentiality of information and/or documentation related to the concern and will share it only with those who have a need to know .

Based on observation, interview and record review, the facility failed to complete accurate RAI (Resident Assessment Instrument) assessments for three residents (R2, R32 and R94) of three residents reviewed for accuracy of assessments. Findings include: R94 On 8/11/26 at approximately 8:54 a.m., R94 was observed in their room, laying in their bed. R94 was queried if they were receiving dialysis treatments and they reported that they were and that they went to the dialysis center every Tuesday, Thursday and Saturday. On 8/11/26 a review of the medical record for R94 revealed the following: R94 was initially admitted to the facility on [DATE] and had diagnoses that included End Stage Renal Disease and Dependence on renal dialysis. A review of R94's MDS (minimum data set) with an ARD (assessment reference date) of 7/21/26 documented R94 was not on dialysis while a resident in the facility. A Physician's order revealed the following: Dialysis Treatment Tx Center Name: [local dialysis center] Treatment days: Tues, Thurs, Sat Treatment chair time: 11am PU (pick up) Time: 10:30amTransport Name: .every shift every Tue, Thu, Sat for Dialysis Treatment Please look at pick up time and chair time. Ensure packed food if needed. Ensure communication packet for Dialysis center is ready A review of R94's care plan revealed the following: Focus- The resident needs dialysis Hemodialysis related to End stage renal failure. Date Initiated: 03/18/2026 .Coordinate dialysis care with dialysis center. Date Initiated: 07/01/2026 . On 8/11/26 at approximately 3:54 p.m., Regional MDS Coordinator U (RMDSC U) was interviewed pertaining to R94's MDS assessment dated [DATE] in which R94 was not coded as having dialysis while a resident at the facility and they reported they would review the assessment and follow-up. On 8/12/26 at approximately 11:00 a.m., during a follow up interview with RMDSC U, they reported they had reviewed R94's assessment for 7/21/26 and that R94 had been coded incorrectly for not having dialysis and that a modification of the assessment would have to be completed and transmitted. R2 On 8/10/26 at 9:43 AM, R2 reported having terrible wounds on my backside that are big, red, and bloody. R2 reported they did not think their wounds were getting better and was not being repositioned frequently. R2 was observed to have a low air loss mattress, positioning wedges, and protective heel boots that they said they did not like to wear by choice. A review of R2's clinical record revealed R2 was admitted into the facility on 6/26/25 and readmitted on [DATE] with diagnoses that included: Pressure ulcer sacral stage 4 (full-thickness skin and fat loss); pressure ulcer stage 3 (full-thickness skin loss) right buttock; pressure ulcer stage 2 (partial-thickness skin loss) right buttock; and pressure ulcer stage 3 other. On 8/11/26 at 9:26 AM, an observation of R2's wound treatments revealed they had three pressure ulcers to their sacrum, right buttock, and left buttock. A review of R2's most recent comprehensive annual MDS assessment (Section M) dated 7/3/26 revealed R2 had six stage 3 pressure ulcers, four that were present upon admission. It was documented that R2 did not have any pressure ulcer/injury care in place. On 8/11/26 at 3:58 PM, an interview was conducted with Regional MDS Coordinator 'U'. At that time, R2's MDS assessment, Section M was reviewed. When queried about whether R2 should be coded for pressure ulcer/injury care if they had pressure ulcers and were receiving treatment, Regional MDS Coordinator 'U' reported they should and she would look into it. On 8/12/26 at 11:00 AM, Regional MDS Coordinator 'U' followed up and reported R2's MDS assessment was not completed accurately and would be modified for pressure ulcer care. R32 On 8/10/26 at 10:08 AM, R32 was observed lying in bed. R32 was receiving oxygen via nasal cannula. A BIPAP (bilevel positive airway pressure) machine was observed at bedside. A review of R32's clinical record revealed R32 was admitted into the facility on 3/18/26 and readmitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease and obstructive sleep apnea. A review of R32's Physician's Orders revealed an active order for .AVAPS (average volume-assured pressure support at HS (bedtime) . A review of R32's MDS assessment dated [DATE] revealed R32 had intact cognition. According to Section O, R32 received oxygen therapy, but was not coded for a BIPAP machine or non-invasive mechanical ventilation. On 8/12/26 at 11:00 AM, an interview was conducted with Regional MDS Coordinator 'U' regarding R32 having an order for a BIPAP machine but not being coded on the MDS for one. Regional MDS Coordinator 'U' reported she would look into it. On 8/12/26 at approximately 1:15 PM, Regional MDS Coordinator 'U' followed up and reported there was an oversight with R32's MDS and he should have been coded for use of a BIPAP machine. A review of a facility policy titled, Accurate Resident Assessment - MDS, dated [DATE], revealed, in part, the following, .Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline .

Based on observation, interview and record review, the facility failed to ensure medication administration standards of practice were followed for one resident (R17) of six residents reviewed for medication administration. Findings include: On 08/10/2026 at approximately 9:44 a.m., R17 was observed in their room, lying in their bed. R17 was observed to have three different medication cups with each one containing a blue pill on their bedside table. R17 was asked what pill it was and they reported it was for their stomach. R17 indicated they were supposed to be administered [brand name for esomeprazole]. R17 was queried why they had three different cups of the pill, and they reported the Nursing staff did not watch them take their medications and left the room. R17 reported they did not take the blue pill and left it in the cup, and the Nurses did not pick them up. On 8/10/26 at approximately 3:19 p.m., R17 was observed in their room, lying in a geriatric chair. R17 was observed to still have a medication cup with a blue pill in it, located on their bedside table. R17 was queried regarding the pill, and they reported they did not take it, and the Nurse never came back and retrieved it. On 8/11/26 at approximately 1:02 p.m., the Director of Nursing (DON) was interviewed pertaining to the multiple medication cups that contained the blue pill on R17's bedside table. The DON reported the Nursing staff should have watched the resident to ensure they swallowed all of their medications. The DON indicated that R17 was very specific about their medications and only wanted to take the omeprazole the pharmacy delivered and not the over-the-counter type. The DON was asked if the Nursing standard of practice was to ensure residents swallowed all of their medications and documented and disposed of any medications the resident chose not to take and they reported it was. On 8/11/26 at approximately 1:10 p.m., R17 was observed in their room with the DON. R17 still had a medication cup with one of the blue pills on their bedside table. R17 reported to the DON that they did not take that kind of pill and wanted the brand name of it. The DON was observed taking the medication cup with the omeprazole pill out of R17's room for disposal. On 8/10/26 the medical record for R17 was reviewed and revealed the following: R17 was initially admitted to the facility on [DATE] and had diagnoses that included Gastro-esophageal reflux disease (GERD). A review of R17's MDS (minimum data set) with an ARD (assessment reference date) of 7/16/26 revealed R17 needed assistance from facility staff with most of their activities of daily living. R17's BIMS score (brief interview of mental status) was 12 that indicated they had moderately impaired cognition. A Physician order dated 3/26/26 revealed the following: Omeprazole Oral Capsule Delayed Release 20 MG (Omeprazole) Give 1 capsule by mouth two times a day for GERD-Start Date 03/27/2026 0600 A review of R17's care plan revealed the following: Focus-The resident has an alteration in gastrointestinal status r/t (related to) GERD (Gastroesophageal Reflux Disease.) Date Initiated: 02/09/2024 . Give medications as ordered. Monitor/document side effects and effectiveness. Date Initiated: 02/09/2024 . On 8/11/26 a facility document titled medication and treatment storage was reviewed and revealed the following: POLICY OVERVIEW: It is the policy of this facility to ensure accurate labeling and dating of medications and treatments for safe administration and safe and secure storage (including proper temperature controls, appropriate humidity and light controls, limited access, and mechanisms to minimize loss or diversion) of all medication and treatments .During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart

This citation pertains to Intake Number: 3096069 Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided according to physician's orders and plan of care for one (R32) of three residents reviewed for respiratory care, resulting in the resident calling 911 due to not being able to breathe and experiencing temporary hypoxemia (desaturation of oxygen levels in the blood). Findings include: A review of a complaint submitted to the State Agency revealed on 7/16/26, Patient (R32) called 911 directly on his cell phone at 0500 hrs (5:00 AM) because he was having difficulty breathing. (Local Fire Department) responded via priority response. Arrived to the patient's bedside to find a non-ambulatory male complaining of difficulty breathing with an initial oxygen (O2) saturation reading of 88% (normal is 90-100%). Patient was wearing a nasal cannula in his nose. The nasal cannula was connected to a CPAP (continuous positive airway pressure) machine (a machine that delivers continuous pressurized air to prevent airway collapse while sleeping) that was not turned on. The CPAP machine would not turn on. Upon further investigation it was found that the CPAP machine was not plugged in and had no power. There was an oxygen condenser in the room which was running and set to 3 liters per minute, but was not connected to the nasal cannula or any other breathing attachment. This condenser was out of reach of the non-ambulatory patient. Upon connecting the patient's nasal cannula to the condenser, the patient's oxygen saturation rose immediately from 88% to 96%. Patient stated he felt much relief and no longer wished to be transported to the ER (Emergency Room) .Facility staff briefed on the hardware issues that were the proximal cause of the patient's breathing complaint. On 8/10/26 at 10:08 AM, R32 was observed lying in bed receiving oxygen via nasal cannula (NC). On R32's bedside table, a CPAP machine and a nebulizer were observed. The O2 concentrator, BIPAP (bilevel position airway pressure) machine (a machine to help you breathe while sleeping), and nebulizer (breathing treatment machine) were plugged into a power strip. The power strip was plugged into an outlet on the wall behind the head of R32's bed, located next to R32's roommate's bed. An interview was attempted with R32. However, R32 was difficult to understand and was unable to be interviewed. When queried about calling 911, R32 appeared to acknowledge that, but was unable to clearly give additional information. A review of R32's clinical record revealed R32 was admitted into the facility on 3/18/26 and readmitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea. A review of R32's (Minimum Data Set) MDS assessment dated [DATE] revealed R32 had intact cognition and received oxygen therapy. A review of R32's Physician's Orders (on 7/16/26) revealed orders for the following: .AVAPS (average volume assured pressure support - BIPAP) at HS (bedtime) .Oxygen Bleed in 5 lpm (liters per minute) for hypercapnic (abnormal levels of carbon dioxide in the blood) Respiratory Failure Assist Resident with Mask Placement, Oxygen Connection, Device Activation. Document any refusals . Oxygen Delivery via NC .4 lpm .continuous .every shift for Hypoxia (low oxygen level) . A review of R32's progress notes revealed no documentation on 7/16/26 that indicated R32 called 911 or that the fire department/paramedics were in the facility. A review of the nursing staff schedule and assignment sheets for 7/15/26 and 7/16/26 revealed R32's assigned Certified Nursing Assistant (CNA) on the midnight shift of 7/15/26 (who would have been working at 5:00 AM on 7/16/26) was CNA 'V' and R32's assigned nurse was LPN 'W'. On 8/11/26 at 8:53 AM, an interview was conducted with CNA 'V' via the telephone. When queried about what happened with R32 on the midnight shift of 7/15/26 (5:00 AM on 7/16/26), CNA 'V' said she remembered R32 called 911 and the paramedics came and said his oxygen was not plugged in. CNA 'V' said R32 called 911 frequently. CNA 'V' did not recall seeing R32's oxygen concentrator or BIPAP machine unplugged and reported the nurses were responsible to ensure the resident's received oxygen according to their orders. On 8/11/ at 12:16 PM, an interview was conducted with LPN 'W' via the telephone. When queried about what happened on the midnight shift of 7/15/26 with R32, LPN 'W' reported the fire department arrived at the facility after R32 called 911. 911 said R32 called and said he could not breathe. According to LPN 'W', R32 did not complain or show signs of low oxygen throughout the night and LPN 'W' said she made sure everything was hooked up. The fire department told LPN 'W' that the BIPAP was unplugged. LPN 'W' explained that the plug often came out of the outlet because it was plugged into the outlet next to R32's roommate's bed. R32's roommate was known to move the bed up and down which frequently knocked the plug out of the outlet. LPN 'W' stated, He (the roommate) does it regularly. LPN 'W' explained the oxygen and the BIPAP machine were plugged into a power strip or extension cord that was plugged into the outlet next to R32's roommate's bed. When queried about what was done when it was discovered the plug was coming out of the wall, LPN 'A' said she made sure the bed was not against the wall when she was working. When queried about whether anyone was contacted about the known issue with the plug coming out of the outlet, LPN 'W' said she was not sure if she contacted anyone and might have told the oncoming nurse and stated, I can't really remember because he (R32) called 911 a lot. On 8/11/26 at 12:58 PM, a second observation confirmed the power strip in R32's room was plugged into the outlet next to the roommate's bed and the O2 concentrator and BIPAP machine were plugged into the power strip. This observation was confirmed by Maintenance Director 'P'. On 8/11/26 at 1:35 PM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's protocol if a resident called 911 and they came to the facility, the DON reported the nurse was to contact him. When queried about the lack of documentation from the midnight shift on 7/15/26 going into 7/16/26 about R32 calling 911 when he was having trouble breathing and the fire department discovered the machine was unplugged, the DON reported he was not aware of this incident and it was not reported to him. The DON was not aware R32's roommate was moving the bed up and down and frequently causing the plug to come out of the outlet and reported something could have been done to fix that had it been reported. The DON acknowledged being aware that R32 called 911 frequently saying he could not breathe, but did not know about the oxygen being unplugged. A review of R32's care plans revealed the following: A care plan initiated on 3/30/26 that noted, At risk for changes in behavior & mood .removing his oxygen and calling 9-1-1 stating he cannot breathe . A care plan initiated on 7/8/26 that noted, The resident has altered respiratory status/Difficulty Breathing related to COPD .Administer medications as ordered .BIPAP/CPAP/AVAP (not specified) per physician orders .O2 at 3L (on 7/8/26, R32's Physician's Order was for 5 lpm) via (not specified) .

Based on interview and record review, the facility failed to document the administration of controlled substances on the controlled substance logs for three residents (R#'s 51, 24, and 9) of three residents reviewed for controlled substances, resulting in the potential for inaccurate counts of controlled substances. Findings include:On 8/11/26 at 1:15 PM, an observation of the 2 North medication cart was conducted with Nurse 'B'. A review of the cart's controlled substance logs were compared with the actual number of controlled substances stocked in the cart and the following was revealed: R51 had a supply of alprazolam (anti-anxiety medication) 0.25 mg tablets. The log documented there were 19 tablets remaining, however; there were only 18 tablets stocked in the cart. R24 had a supply of oxycodone (narcotic pain medication) 10 mg tablets. The log documented there were 17 tablets remaining, however; there were only 16 tablets stocked in the cart. R9 had a supply of oxycodone 10 mg tablets. The log documented there were seven tablets remaining, however; there were only six tablets stocked in the cart. At that time, Nurse 'B' said they administered all three of the missing medications, but they should have signed the medications out at the time they were given.On 8/12/26 at 1:15 PM, an interview was conducted with the facility's Director of Nursing. They were asked when nurses should sign controlled substances out on the log and said it should be done at the time they gave them. A review of a facility provided policy titled, Controlled Medication Guidelines reviewed 2/2026 was conducted and read, .Administering Controlled Medications:.When the licensed nurse removes the controlled medication from the package, they will document the quantity removed and the quantity left on the Controlled Drug Receipt/Record/Disposition Form.

Based on interview and record review, the facility failed to complete medical provider ordered laboratory diagnostics (labs) for one resident (R15) of two residents reviewed for laboratory diagnostics. Findings include:On 8/10/26 the medical record for R15 was reviewed and revealed the following: R15 was initially admitted to the facility on [DATE] and had diagnoses that included Dementia and Repeated falls. R15's MDS (minimum data set) with an ARD (assessment reference date) of 5/26/26 revealed R15 needed assistance from facility staff with most of their activities of daily living. R15's BIMS score (brief interview of mental status) was 11 that indicated R15 had moderately impaired cognition. A review of R15's care plans revealed the following: Risk for Bleeding internally or externally related to medication intake, currently [brand name of clopidogrel]. Date Initiated: 02/13/2023 .Interventions-Pertinent labs as ordered, monitor and report any abnormal results to PCP (Primary Care Physician) promptly. Date Initiated: 02/13/2023 . A Laboratory note dated 5/15/2026 at 08:57 a.m., revealed the following: Laboratory Note Text: Writer spoke with NP (Nurse Practitioner) concerning resident lab results. New order to collect CBC (complete blood count) and BMP (basic metabolic panel) in one month. Further review of R15's medical record did not reveal any lab results available since the previous lab results that were reported on 5/15/26. No Physician's order was observed entered in the electronic medical record for processing. No documentation of refusal was noted in the record or that the physician was notified of the diagnostics not being completed as ordered. On 8/12/26 at 8:41 a.m., R15's order for the CBC and BMP noted in the laboratory note dated 5/15/26 was reviewed with Nurse Manager E (NM E). NM E reported the Nurse should have entered the order for the diagnostics to be done but they did not so the CBC and BMP were never completed. No documentation of refusal was noted in the record or that the physician was notified of the lab not being done. No results from the CBC and BMP noted on 5/15/26 and due to be completed in June 2026 were provided by the end of the survey.

This citation pertains to intake 3020087.Based on observation, interview and record review, the facility failed to maintain the exterior dumpster area in a clean/sanitary manner. This deficient practice had the potential to affect all residents, staff and visitors. Findings include:Review of a complaint reported to the State Agency on 5/20/26 included allegations that the garage door is broken and left open, the trash in the dumpster outside is overflowing, and there is trash all over the parking lot and around the building.On 6/15/26 at 8:25 AM, upon arriving to the facility the garbage/refuse area in the parking lot at the back of the facility was observed to have two smaller dumpsters that were packed and overflowing with both lids open. There were additional trash bins, and other debris and garbage on the surrounding ground and under the dumpster. Additionally, the area near the north side of the building side-door entrance was observed to have five pallets stored along the brick wall.On 6/15/26 at 10:50 AM, an observation of the facility's outside environment was conducted with the Maintenance Director (Staff 'A'). At that time, observation of the external garage/shed revealed a broken garage door that was in the fully open position, and the entire inside of the garage/shed was filled with multiple items. These items included: multiple medical equipment (bladder scan, walkers, wheelchairs, beds), there were several boxes, bins, window air conditioning units, metal shelving units, large helium tanks, window blinds, and several boxes of resident clothing. During this observation, there was a small black kitten observed inside the back of the garage/shed.Staff 'A' was asked how long the garage/shed had been in this condition and they reported since they started in 2019. They further reported all of the items in the garage/shed were due to be picked up today and they had rented a dumpster just last week.Additional observations included:The grassy area behind the brick wall that separated the two smaller dumpsters and the property to the left of the garage/shed was observed to have multiple broken furniture, bins, and other items stored along the wall. The exit door closest to the dumpster area was observed to have a small garbage container on wheels and the surrounding grass was littered with debris/garbage, including used (turned inside out) disposable gloves. The two smaller dumpsters were observed to be completed full and had garbage bags spilled out onto the surrounding concrete including some debris under the dumpster. Staff 'A' reported Maintenance was not responsible for maintaining the garbage area and that would be the Housekeeping Supervisor (Staff 'B'). Staff 'A' reported garbage pick-up was scheduled for Monday, Wednesday, and Friday and reported the dumpster lids should be closed even if full and proceeded to close the lids. When asked if the facility had discussed a potential increase in garbage/refuse pick-up given the increased facility census, Staff 'A' reported they had not.To the left of the two smaller dumpsters, there was an unlocked storage unit/pod. When asked to see the inside, Staff 'A' proceeded to lift the unlocked door up. The entire inside of the storage unit/pod was filled with multiple boxes, bags and a suitcase. These items were not stacked neatly and there was no way to enter the storage unit/pod to see beyond the initial items up front.When asked about the items, Staff 'A' reported those were items from residents that had passed away, some had holiday decorations, and some were clothes for those residents that didn't have their own clothes. There were several boxes and a suitcase near the front of the storage unit/pod that were labelled with resident's names. One suitcase was observed to be covered with dust and thick spider webs. Staff 'A' reported the had passed away a while ago. When asked what the process was for storing residents' personal items when they passed, Staff 'A' reported Staff 'B' had attempted to contact the family to pick up but there was no follow-up.Staff 'A' further reported Staff 'B' was responsible for maintaining the dumpster area and at that time, Staff 'A' called Staff 'B' by phone. Staff 'B' reported they were not working today but could answer questions. When asked about the items in the storage unit/pod, Staff 'B' reported those were from previous residents they had attempted to get in contact with but never came to get their items. They further reported some of the items included clothing that was used to provide to those residents that might not have clothing available.Staff 'A' and Staff 'B' were asked why these items were not locked and they reported they were not able to answer that question but could put a lock on there today and proceeded to inform Staff 'B' by phone that they intended to place a lock.Additional observations to the left side of the storage unit/pod revealed more trash debris on the ground and a rusted dining room chair.On 6/15/26 at 1:21 PM, the facility was requested via email to provide a policy for maintaining garbage/refuse. There was no further documentation or information provided for a policy.

This citation pertains to intake 3020087.Based on observation, interview and record review, the facility failed to ensure an environment free from accident hazards (broken/sharp handrail). This deficient practice has the potential to affect multiple residents who are independently ambulatory with, or without an assistive device. Findings include:Review of a complaint reported to the State Agency on 5/20/26 included an allegation that handrails were broken and not being fixed.On 6/15/26 at 10:00 AM, observation of the wood handrail outside room [ROOM NUMBER] was observed split with a sharp edge and metal nail exposed.On 6/15/26 at 10:15 AM, an interview was conducted with the Maintenance Director (Staff 'A'). They reported they've been in that role since 2019 and they had a full-time assistant that had been on vacation since May 30th. When asked if they performed any facility audits that included handrail inspections to ensure they were maintained safely, Staff 'A' reported they did not and if staff identified any concerns they would report those to their electronic reporting system. When asked if they were aware of any current concerns with handrails, Staff 'A' reported they were not. At that time, Staff 'A' was asked to observe the handrail outside of room [ROOM NUMBER] and confirmed the broken rail with nail exposed. Staff 'A' reported it appeared as if staff had hit the handrail with a mechanical lift.On 6/15/26 at 1:21 PM, the facility was requested via email to provide a policy accident hazards (handrail maintenance) and any electronic reporting log for work order requests for the past 30 days.Review of the facility's electronic reporting system for work orders provided for 5/15 - 6/15/26 revealed there were none that identified concerns with handrails.According to the facility policies provided for handrails:A policy titled, Maintenance Inspection dated 11/1/2020: .It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.The Director of Maintenance Services will perform routine inspections of the physical plant using the Maintenance Checklist/(electronic reporting work order system).A facility policy titled, Preventative Maintenance Program dated 11/1/2020: .The Maintenance Director is responsible for developing and maintain a schedule of maintenance services to ensure that the building, grounds, and equipment are maintained in a safe and operable manner.Documentation shall be completed for all tasks and kept in the Maintenance Director's office for at least three years.

This citation pertains to intake 3021235.Based on interview and record review the facility failed to ensure that the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was provided and completed for one (R303) of one resident reviewed for beneficiary notification, resulting in the residents and/or their representatives not being informed timely of private pay charges for continued services while they remained in the facility. Findings include:Review of an allegation reported to the State Agency on 5/13/26 included a concern that R303 was not provided with appropriate notifications regarding their Medicare benefits.On 6/15/26 at 10:05 AM, an interview was conducted with R303 at their bedside. When asked to discuss the facility's process for notification of their Medicare benefit changes since admission, R303 reported they were in the process of filing another appeal because they feel they need more skilled therapy services. R303 further reported they had copies of the notices provided to them and reviewed them at that time. This documentation included three Notice of Medicare Non-Coverage (NOMNC) forms signed by the resident on 4/20/26, 4/23/26, and 4/30/26.When asked if they were also provided with a SNFABN form when the NOMNCs were provided, R303 reported they were not sure what that form was and deferred to the NOMNC forms. R303 then reported if they had been given SNFABN forms they would have had copies of those too.Review of the three NOMNC documents scanned into R303's electronic health record (EHR) included:A NOMNC form signed by R303 on 4/20/26 documented Medicare Coverage of Your Current Skilled Nursing Services Will End on 4/22/2026. There was no SNFABN available for review. (The SNFABN notice is a document that identifies the potential detailed charges of continued services if the resident or their representative choose to continue with those skilled services they received while covered under their Medicare A benefits.)A NOMNC form signed by R303 on 4/23/26 documented Medicare Coverage of Your Current Skilled Nursing Services Will End on 4/25/2026. There was no SNFABN available for review.A NOMNC form signed by R303 on 4/30/26 documented Medicare Coverage of Your Current Skilled Nursing Services Will End on 5/2/2026. There was no SNFABN available for review.Further review of the clinical record revealed R303 was initially admitted into the facility on 3/2/26 with diagnoses that included: other pulmonary embolism without acute cor pulmonale, chronic systolic heart failure, chronic kidney disease stage 4, essential hypertension, and unspecified protein-calorie malnutrition. The profile section identified R303 was their own responsible party.According to the Minimum Data Set (MDS) assessment dated [DATE], R303 had intact cognition and required assistance with some activities of daily living, including dressing, bathing and transfers from bed and toilet.Review of R303's census information documented upon admission on [DATE] the resident's primary payer was Medicare A, and on 5/3/26 the payor status changed from Medicare A to Medicaid.On 6/16/26 at 11:35 AM, the facility was requested to provide all SNFABN notices that were provided to R303 since admission.On 6/16/26 at 11:52 AM, the Administrator responded via email that there were NO ABNs Available for R303. At 11:58 AM, the Administrator sent an additional response that read, As far as the ABN, NOMNC was issued and resident has gone through multiple appeals and as far as we know, he is going through multiple appeals at the moment .On 6/16/26 at 12:05 PM, an interview was conducted with the Regional Business Office Manager (Staff 'C') who reported they had been covering as the interim Business Office Manager two days a week since the beginning of May 2026. When asked about the facility's process for providing the required notices given to residents that were determined to no longer meet skilled criteria for their Medicare A benefits, Staff 'C' reported the social worker was responsible for providing the NOMNC notices and the business office was responsible for providing the SNFABN. Staff 'C' further reported the facility had been aware of R303's multiple appeals after the NOMNCs were issued but had not received any feedback from the appeals other than the initial appeal in which R303 was successful. When asked if the SNFABN should be given when the NOMNC notices were issued, Staff 'C' reported they should be, and was unable to report why that had not been done for R303.According to the facility's policy titled, Advanced Beneficiary Notification (ABN) dated 3/1/2025: .It is the policy of the facility to provide timely written notice to traditional Medicare beneficiaries when it is determined that Medicare will no longer provide coverage for skilled services. The Advanced Beneficiary Notification (ABN) is utilized to convey the cost of services and potential resident financial liability.Once the provider or resident's health plan determines that Medicare beneficiary will no longer qualify for Medicare skilled services, the Business Office Manager will issue the 'Advanced Beneficiary Notice' form to the resident and/or authorized representative. The Advanced Beneficiary Form should be given in addition to the Notice of Medicare Non-Coverage form.A copy of the Advanced Beneficiary Notification should be provided to the resident regardless of whether or not they signed it.

This citation pertains to intake: 3018571.Based on interview and record reviews the facility failed to accurately assess the nutritional status and obtain weights per the facility's policy for one (R302) of one person reviewed for nutrition. Findings include:A review of the medical record revealed that R302 was admitted to the facility on [DATE] and transferred to the hospital on 4/9/26. The resident did not return to the facility. R302 was admitted with diagnoses that included: dementia, severe protein calorie malnutrition and acute osteomyelitis (infection and inflammation of the bone) of the right femur and required staff assistance for all Activities of Daily Living (ADLs).A review of an admission Note dated 3/10/26 at 10:13 PM, documented in part . Pt (patient) received from (hospital name). Patient requires 1:1 (one on one) assistance with feeding. patient placed on puree diet.A review of the hospital documentation provided to the facility upon R302's admission noted a hospital weight of 51.8 kg (kilograms) which converts to 114 lbs (pounds). The hospital documentation also noted the resident required one on one feeding. The hospital document was dated 3/5/26.A review of the facility Nursing admission assessment dated [DATE] at 9:37 PM, documented a weight obtained the next day on 3/11/26 of 89 lbs.This revealed a 25 lb. discrepancy between the hospital weight and the weight obtained by the facility staff.A review of the weight log noted one other weight obtained by the facility staff on 4/3/26 at 97 lbs.A review of a facility policy titled Weights revised 2/4/26, documented in part . The purpose of this policy is to provide guidelines for weighing residents. Residents are weighed upon admission and then weekly for a total of four weeks.The facility staff failed to obtain the residents weight per their policy.A review of the admission Nutritional Evaluation dated 3/14/26 at 1:47 PM, revealed that the dietician failed to identify the hospital weight and the facility weight discrepancy. Further review of the assessment noted the Usual Body Weight and Weight History to be left blank.On 6/15/26 at 11:41 AM, an attempt was made to interview the Dietician H via telephone, however unsuccessful. A return phone call was not received by the end of the survey.On 6/15/26 at 11:53 AM, the Director of Nursing (DON) was interviewed and was asked about the admission nutritional evaluation and why R302 weights were not obtained per the facility policy and the DON acknowledged it should have been. The DON stated they would try to get in touch with Dietician H to ask about the Nutritional Evaluation and why it was not completed in its entirety.On 6/15/26 at 2:55 PM, the DON reported that Dietician H believed the hospital documented a random weight for R302 and reported the facility obtained an actual weight. No further explanation or documentation was provided for review.

This citation pertains to intake: 3018535 & 3018571.Based on interview and record reviews the facility failed to ensure Physical & Occupational Therapy (PT/OT) services were provided as ordered by the Physician in the residents therapy plan for one (R302) of one resident reviewed for therapy services.Findings include:A review of multiple complaints submitted to the State Agency (SA) documented concerns of the facility's failure to provide appropriate physical and occupational rehabilitation services to R302.A review of the medical record revealed that R302 was admitted to the facility on [DATE] and transferred to the hospital on 4/9/26. The resident did not return to the facility. R302 was admitted with diagnoses that included: dementia, severe protein calorie malnutrition and acute osteomyelitis (infection and inflammation of the bone) of the right femur and required staff assistance for all Activities of Daily Living (ADLs).On 6/15/26 at 9:35 AM, the Therapy Director (TD) F was asked to provide the Physical Therapy (PT) and Occupational Therapy (OT) admission & discharge evaluations and all encounter evaluations for R302.A review of R302's Physical Therapy PT Evaluation & Plan of Treatment with a Certification Period of 3/11/2026 to 4/9/2026, documented the following, . Frequency: 5 time(s)/week, Duration: 30 day(s), Intensity: Daily, Cert. (certification period): 3/11/2026 - 4/9/2026.The treatment plan was electronically signed by the Physical Therapist and the Medical Physician on 3/11/2026.A review of the Physical Therapy Treatment Encounter Note(s) revealed the resident had PT services on the following dates:3/11/26, 3/12/26, 3/16/26, 3/18/26, 3/19/26, 3/25/26, 3/27/26, 4/1/26, and 4/2/26. This is a total of nine PT sessions provided to R302.With the admission date of 3/10/26 and discharge date of 4/9/26, and a treatment plan implemented with a frequency of five times a week, R302 should have been provided more PT sessions than nine.A review of R302's Occupational Therapy OT Evaluation & Plan of Treatment with a Certification Period of 3/11/2026 to 4/9/2026, documented the following, . Frequency: 5 time(s)/week, Duration: 30 day(s), Intensity: Daily, Cert. Period: 3/11/2026 - 4/9/2026.The treatment plan was electronically signed by the Occupational Therapist and Medical Physician on 3/11/2026.A review of the Occupational Therapy Treatment Encounter Note(s) revealed the resident had OT services on the following dates:3/11/26, 3/16/26, 3/17/26, 3/24/26, 3/26/26, 4/1/26, and 4/2/26. A total of seven OT sessions.With the admission date of 3/10/26 and discharge date of 4/9/26, and a treatment plan implemented with a frequency of five times a week, R302 should have been provided more than seven OT sessions.On 6/15/26 at 12:04 PM, TD F was interviewed (in attendance was the facility's Regional Clinical Support - RCS G) and asked why the therapy department failed to provide Physical Therapy and Occupational Therapy services five times a week according to the residents plan of treatment signed by the Physician. TD F began looking through their laptop and stated they would look into it further and follow back up. At 1:25 PM, TD F returned and stated they were able to find three refusals and verbalized . that's all I have. TD F was asked to provide the three refusals for review. A review of the three refusals provided noted the following:On 3/13/26, the resident was Unavailable for OT.On 3/31/26, the resident refused Occupational Therapy treatment.On 3/30/26, the . pt (patient) found very sleepy and unable to stay awake to attend the session. For OT services.No PT refusals were provided.

This citation pertains to Complaint #2633707.Based on observation, interview, and record review, the facility failed to prevent a significant medication error when they did not administer insulin according to physician's orders for one (R801) of three residents reviewed for medication administration, resulting in the resident being hospitalized in the intensive care unit (ICU) for low blood sugar after they received 100 units of short acting insulin instead of the ordered three units. Findings include:A review of a complaint submitted to the State Survey Agency (SSA) revealed an allegation that on 9/28/25, R801 was given 100 units of insulin by facility staff instead of the prescribed three units.On 10/7/25 at 8:40 AM, an interview was conducted with R801. R801 reported she was given too much insulin and was admitted to the ICU for a couple days. R801 reported she experienced dizziness and then her blood sugar went down. R801 reported she was given some sugar stuff either by EMS (emergency medical services) or the facility to make her blood sugar increase.On 10/7/25 at 8:59 AM, an observation of R801's insulin and the insulin syringes present in the medication cart was conducted with Licensed Practical Nurse (LPN) 'A'. R801's Insulin Lispro (short acting insulin) was observed in a vial that required inserting a needle attached to a syringe to draw up the prescribed dose. At that time, LPN 'A' said the insulin syringes were not present in the medication cart and obtained a box of single use syringes with an orange cap that were labeled to be used with insulin. One syringe held one ml which was equal to 100 units of insulin.A review of R801's clinical record revealed, R801 was admitted into the facility on 4/1/25 and readmitted on [DATE] with diagnoses that included: necrotizing fasciitis and type 2 diabetes mellitus upon initial admission date of 4/1/25 and a diagnosis of hypoglycemia (low blood sugar) as of 10/1/25. A review of R801's physician's orders revealed an order with a start date of 9/3/25 and a discontinued date of 10/1/25 for Insulin Lispro (short acting insulin) Injection Solution 100 unit/milliliter (ml).inject 3 units subcutaneously before meals.Notify MD (medical doctor) if BG (blood glucose) is (less than) 60 or (greater than) 400. A review of R801's Treatment Administration Record (TAR) for September 2025 revealed on 9/28/25 at 4:30 PM, Registered Nurse (RN) 'B' administered insulin to R801 as evidenced by her electronic signature on the TAR. A review of a Nursing - Progress Note dated 9/28/25 at 6:43 PM, written by RN 'C' revealed, RN thinks pt (patient) received 100ml (100 ml would be 100 syringes filled up) of insulin instead of 3ml (3 ml of insulin lispro would be 300 units per the strength noted in the physician's order and would require filling up the syringe 3 times). Resident alert and oriented, no signs or symptoms of hypoglycemia, 911 called, on call called, sugar rechecked 118 result, DON (Director of Nursing) notified, resident taken to hospital.On 10/7/25 at 10:28 AM, an interview was conducted with RN 'C' via the telephone. When queried about what happened with R801's insulin, RN 'C reported she read the strength of the insulin (100 units/ml) instead of the prescribed dose and gave 100 units instead of three units. RN 'B' reported she discovered the error when she went to sign off that the insulin was administered. RN 'B' notified the nurse who was previously her preceptor, RN 'D', called 911, assessed R801, and rechecked the resident's blood sugar. When queried about whether she rechecked the order after she filled the whole syringe with insulin to ensure the proper dose, RN 'C' said she did but compared it with the strength again. RN 'C' reported she did not have a lot of experience administering insulin, that it was her first bedside nursing job and she never worked in a long-term care facility previously. RN 'C' reported she received three days of orientation where she shadowed another nurse and asked for a couple extra days before being assigned on her own. RN 'C' further reported when she drew up R801's insulin, she thought it was a lot, but because another resident on that same set was prescribed a very high dose of insulin she thought it was correct. RN 'C' did not seek out clarification and verified the dose, but read the incorrect part of the order. On 10/7/25 at 9:36 AM, an interview was conducted with RN 'D' via the telephone. When queried about what happened with R801's insulin on 9/28/25, RN 'D' reported RN 'C' came to her and said she thought she had a medication error. When queried about the error, RN 'D' reported RN 'C' thought she gave 100 units of insulin to R801 instead of 3 units. RN 'D' reported R801 was assessed and blood sugar was rechecked. At that time, R801's blood sugar remained at baseline. RN 'D' reported RN 'C' called the physician and sent R801 out 911. A review of an Incident Report dated 9/28/25 at 5:00 PM, completed by RN 'C', revealed a statement by RN 'C' taken on 10/1/25 that noted, .I took the pt (patient's) blood 124. I read the order thinking the medication strength was the dose to be given, drew up 100 units in the insulin syringe instead of the 3 units ordered. I administered the insulin in her left arm. I went to chart administration was complete and realized I had made a medication error. I immediately notified (RN 'D') who had been my preceptor and called 911 while (RN 'D') assessed the resident. I then retook the residents blood sugar while (RN 'D') notified the DON (Director of Nursing). EMS (Emergency Medical Services) arrived, I called the Provider oncall and notified them patient was being transferred due to being given 100 units of insulin.On 10/7/25 at approximately 12:45 PM, an interview was conducted with the DON. When queried about the medication error made by RN 'C', the DON reported RN 'C' should have confirmed the insulin dose when she noticed she filled up the whole syringe. A review of R801's hospital records revealed the following: An ED (Emergency Department) Provider Note dated 9/28/25 revealed the following documentation, .5:26 PM.Patient.may have received excessive insulin in error at nursing facility. Per EMS she accidentally received 100 units lispro instead of 3 units. Her initial blood glucose on arrival to out emergency department was 103, but she did receive some oral glucose prior to arrival.6:16 PM Repeat POC (point-of-care) glucose 48 (low). D50 (Dextrose 50%) given with improvement to 185. Will admit for serial blood sugar checks and management.8:20 PM MICU (Medical Intensive Care Unit) evaluated patient, and they will admit her to the MICU admission at this time. Switched dextrose gtt (glucose tolerance test) to D10 (Dextrose 10%) and solu-cortef (steroid medication) given.A review of a facility policy titled, Medication Administration, dated 8/7/23, revealed, in part, the following, .Medications are administered in accordance with the following rights of medication administration.Right dose.

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for one (R93) of two residents reviewed for death by neglecting to adequately assess/monitor a resident with an identified change in condition, timely notify the physician of resident's status and timely transfer the resident to a higher level of care, resulting in a delay in identifying and treating the resident with a history of respiratory distress leading to death in the facility. The deficient practice resulted in the increased likelihood of serious harm, serious injury and /or death to occur. Findings include:The Immediate Jeopardy (IJ) began on [DATE] when the facility staff failed to adequately assess/monitor R93 who had an identified change in condition and timely notify the physician of the continued decline.The IJ was identified on [DATE] and the Administrator was notified of the Immediate Jeopardy on [DATE] at approximately 1:47 PM. A plan for removal was requested at that time to remove the immediacy.The surveyor team confirmed by Observation, Interview and Record review that the Immediate Jeopardy was removed on [DATE] based on the facility's implementation of an acceptable plan of removal. The noncompliance remains at an isolated event with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency (SA).A review of R93's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: abscess of lung with pneumonia, COPD (chronic obstructive pulmonary disease) and type II diabetes. A Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was their own responsible party and noted as Full Code status.Continued review of R93's clinical record revealed, in part, the following:[DATE]: admission Evaluation: .R93.Clinical Evaluation.Mental Status: Alert.Orientation: Situation, Place, Person, Time.Clinical Evaluation Respiratory - Lung Sounds .that noted the resident did NOT (emphasis added) display any crackles.Stridor (high-pitched, noisy breathing sound that indicates a partial blockage or narrowing in the upper airway).and Wheezing in the upper/lower right and left lobes.Productive cough description: .coughing up clear mucoid secretions and had 02 running via a nasal canula. Interventions.monitored for signs and symptoms of respiratory distress and report to the MD (medical doctor) PRN (as needed)XXX[DATE]- Nursing Progress Note: Resident alert and responsive oriented X3 received no acute cardiac or respiratory distress 02 (oxygen) at 2L (liter).SP02 (blood oxygen saturation) 96% (normal levels run generally between 90%-100%).XXX[DATE] (late entry)- Physician Team: .visit for continuation of subacute rehab.presenting for continuation of subacute rehab due to.myelopathy (injury to spinal cord).denies SOB (shortness of breath.Medications.albuterol solutions .3ml inhale orally every 6 hours as needed for SOB.XXX[DATE]-Social Work: .her BIMS (brief interview for mental status) score is 14/15, indicating intact cognition.reported that she is on waiting list for subsidized apartments.goal to walk and complete ADLs (activities of daily living).XXX[DATE]: Social Work: .worker reported he spoke with resident.informed him that she plans to remain in the facility for placement until her functional mobility and health status improve.XXX[DATE]: Nursing Progress Note: .Resident returned to the facility from an appointment with (name redacted) in stable condition.No signs of distress.XXX[DATE] (12:06): Physician Team Note: .[R93].Chief Complaint: Upper back-left shoulder pain.respiratory difficulty.hospitalized for COPD.and bacterial pneumonia. reports shortness of breath requiring 2 liters of continuous oxygen.Assessment and plan:.history of COPD.hospitalization for COPD exacerbation with bacterial pneumonia.On physical exam, bilateral wheezes were noted with use of accessory muscles and poor air exchange. Patient is on 2 liters of continuous oxygen.Plan: Start scheduled albuterol nebulizer treatments every 4 hours.Decision made to initiate scheduled nebulizer treatments with albuterol every 4 hours in addition to existing PRN (as needed) inhaler. *It should be noted that following the physician visit on [DATE],no orders for scheduled nebulizer treatments were noted in R93's clinical record.A review of R93's MAR/TAR (Medication/Treatment Administration Record) showed no indication that Albuterol Sulfate was either administered as a PRN (as needed) or scheduled treatment for the entire month of [DATE]XXX[DATE] (1:07 PM): Nursing Progress Note: Resident said she was not feeling well, on assessment she had HR (heart rate) of 138 (average between 60-100 beats per minute), BP (blood pressure) 94/68, SPO2 of 89 with 2l via NC, her 02 was increased to 5L and the NP (nurse practitioner) was informed and she gave an order for .9% Nacl (sodium chloride used to maintain fluid balance) and labs ordered of bmp (basic metabolic panel and cbc (complte blood count) for Monday. (Authored by Nurse Y)[DATE] : Nursing Progress Note: Called Medical Director back concerning this patient. The patient has been seen on IV (intravenous) fluid and half a little gone and she started having crackles in her lungs and she was coughing. She also ordered a STAT chest X-ray and we faxed and called them and it was received. (Authored by Nurse Y)[DATE] (9:41 PM): Order: Chest x-ray to rule of <sic> pneumonia. *It should be noted that a STAT chest order was never completedXXX[DATE] (3:09AM): Nursing Progress Note: At approximately 2:05, writer entered resident's room to administer a scheduled breathing treatment (*it should be noted that there were no orders to administer scheduled breathing treatments at 2:00 AM). Upon entry resident was found unresponsive and not breathing. No pulse was detected. Code Blue was immediately initiated. Resident was last seen at 0100 during hourly rounds. CPR (cardiopulmonary resuscitation) was commenced per facility protocol. Emergency Medical Services (EMS) arrived and assumed resuscitative efforts. CPR continued under EMS supervision. Despite continued effort, resident was pronounced deceased by EMS at 2:50. (Authored by Nurse X). *It should be noted that there was no indication that R93's vitals were taken by Nurse X.On [DATE] at approximately 10:42 AM, a phone interview was conducted with Nurse X. Nurse X reported that they were a LPN (licensed practical nurse), employed for almost one year, usually worked the midnight shift and was no longer employed by the facility. Nurse X did not disclose the reason why they no longer were employed by the facility. Nurse X was then queried as to the death of R93. Nurse X noted that they came to work on [DATE] at approximately 11:00 PM and were informed by Nurse Y that R93 showed signs of a decline (trouble breathing, crackles and wheezing) during the day/evening shift. Nurse X further stated that Nurse Y reported to them that they had contacted the physician twice on the prior shift(s) and that the physician did not want the resident sent to the Hospital. Nurse ‘X noted that they saw R93 when they started the shift and they were breathing hard, and the resident did not seem like herself. Nurse X was asked if they recalled if they ever did a full assessment including vitals between the start of the shift (11 PM and 2:05 AM) as there was no indication in R93's record that it had been completed. Nurse X stated they might have but could not recall when. Nurse X was asked why they decided to provide a scheduled breathing treatment at approximately 2:05 AM as indicated in their note. Nurse X reported that they thought it would help R93 with their breathing. Nurse ‘X was asked when and how they determined there was an issue as to R93's breathing and did it occur at 1 AM as it had been noted that was the last time they were seen, Nurse X could not provide an answer. When Nurse X was asked if they contacted the physician regarding R93 having breathing issues and/or to inform them that the STAT X-ray had not been completed, they replied that they did not contact the physician as Nurse Y told them they did not want the resident sent out to the hospital. Nurse X ended the call by saying they discussed the incident with the Director of Nursing (DON) following the death of R93 but could not provide specific information.On [DATE] at 10:47 AM, Nurse X called back and asked if it would be okay/legal for her to have called 911 on [DATE] even when Nurse Y stated the physician told them not to send R93 to the hospital.A review of Nurse Xs personnel file noted that on [DATE], Nurse X was terminated for taking excessive breaks from facility during shift. Witnessed by the Administrator. *It should be noted that Nurse X did not have any other corrective action documents in their file prior to their termination.On [DATE] at approximately 3:35 PM, an interview was conducted with Nurse Y. Nurse Y reported they were a Registered Nurse (RN) and have been employed for the facility for about a year. Nurse Y was asked about R93 who had exhibited a change in condition on [DATE] and their death on [DATE]. Nurse Y reported that the resident noted they were not feeling well earlier in the day and when they did an assessment, they found an abnormal increase in their heart rate and decline in SP02 levels. They stated that they contacted Nurse Practitioner (name redacted) who ordered labs to be completed and ordered sodium chloride solution. Nurse Y stated that they administered the sodium chloride solution (MAR review shows it was administered at 4:04 PM) and also increased the resident's 02 to 5 L. Nurse Y further reported that the resident's breathing was improved once their 02 was increased. Nurse Y stated that when the sodium (IV) was halfway completed, they heard crackles without the use of a stethoscope and contacted the physician. The physician ordered a STAT x-ray (R93's clinical record indicates an order was completed on [DATE] at 9:41 PM). Nurse Y further reported that during the shift change at approximately 11:00 PM on Friday -[DATE], they informed Nurse X about R93's status, the order for the STAT x-ray and instructed her to contact the physician if x-ray services did not show up and/or if there were any changes to R93s condition. *It should be noted that Nurse Y never reported that the physician/physician extender told her that they should not send the resident to the hospital.On [DATE] at approximately 9:21 AM, an interview and record review were conducted with Medical Director (MD) Z regarding R93's death at the facility. MD Z reported that they were very familiar with R93, aware they had COPD, general wheezing and a history of smoking. However, they were surprised to hear of their death as they had seen them a few days prior and found them to be stable with some continuous wheezing needing addition breathing treatments (*It should be noted that additional scheduled breathing treatments/albuterol was not ordered) . MD Z was asked about being contacted on [DATE] regarding R93 and the need for a STAT x-ray. MD Z reported that while notes/orders indicate they were contacted, most likely facility staff contacted Nurse Practitioner (NP) AA as they were covering the weekend for them. MD Z stated that based on notes that the resident was showing signs of decline, nursing staff should have continued to monitor/ assess the resident and contact them/their extender of any changes. MD Z stated that when nursing staff heard crackles without the use of a stethoscope, most likely R93 had signs of Stridor (term used for noisy breathing that comes from the upper airway and can be heard without the use of a stethoscope) and had it not been resolved and an x-ray was not completed the resident should have been sent to the hospital.On [DATE] at approximately 11:00 AM, an interview was conducted with ADON C as the DON was not available during the Survey. ADON C was asked if they were aware of R93's change in condition and subsequent death. ADON C stated that they were on vacation when the incident happened. ADON C was asked about the facility protocol pertaining to STAT-x rays. ADON C reported that STAT is not always STAT and it depends on the company. When asked if R93 should have been sent to the hospital following noted crackles in their lungs, the ADON reported that most likely they would have sent them out.On [DATE] at approximately 2:29 PM, a phone interview was conducted with NP AA. NP AA reported that they were the on call NP on [DATE] and never saw R93 on that day. NP ‘AA stated that they recalled the order for a STAT x-ray and told the nurse to call back and/or send the resident to the hospital if nothing resolved. They further indicated that they were not contacted by any staff following the call that noted the order for the STAT x-ray.The facility policy titled Abuse (updated [DATE]) was reviewed and documented, in part, the following: .Residents have the right to be free from neglect.The facility will educate its staff.on prohibiting and preventing all forms of.neglect.identifying what constitutes neglect.recognizing signs of neglect.definitions:.Neglect: Failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish.The facility policy titled, Change in Condition Evaluation ([DATE]) was reviewed and documented, in part, the following: General information: An acute change in condition is a clinically important deviation from a resident's baseline in physical.or functional status. Acute changes in condition can occur abruptly, over several hours, or over several days.There are a multitude of tools to assist the Licensed Nurse with evaluating changes in condition.signs and symptoms, vital signs.cardiovascular status evaluation/changes.the nurse may recommend to the practitioner lab and/or radiology results related to the condition and monitoring.shortness of breath.The Immediate Jeopardy that began on [DATE] was removed on [DATE] at 12:44 PM when the facility took the following actions to remove the immediacy, including the following:1. Residents that currently reside in the facility were assessed by licensed nurses on [DATE] to include any acute condition change, lung sounds, and vital signs and stat orders have been completed. Residents that currently reside in the facility are stable with no acute changes noted.2. Nursing staff have been educated on Change of Condition Education and Abuse to include notifying the physician if any residents have a Change of Condition, including any change in respiratory status. Education was completed on [DATE]. A return demonstration has been completed with the nursing staff to ensure nursing staff is aware as to when to notify the physician with a change in condition.3. Nursing staff have been educated on when Stat orders are ordered and not completed within a 4 hour window to notify the physician that the stat has not been completed for further direction on the order. Education has been completed with Nurses by [DATE]. No nurses will work until the education is completed as of [DATE].4. No Nursing staff will work until Education is completed as of [DATE].5. Audits will be conducted by unit manager/designee on 8 residents per a week for 8 weeks to monitor signs of change of condition and to ensure stat orders are completed within a 4-hour window.

This citation pertains to intake #MI00147465 Based on observation, interview, and record review the facility failed to ensure freedom from staff neglect for one resident, (R903) of three residents reviewed for abuse, resulting in a significant delay of administration of an anti-anxiety medication and feelings of sadness, frustration, anger, anxiety, fear, and disappointment with care. Findings include: An abbreviated survey was conducted at [NAME] Nursing and Rehab on 10/23/24 to address the facility reported incident. A review of a facility provided policy titled, Abuse updated 5/24/23 was reviewed and read, Residents have the right to be free from abuse, neglect, exploitation, mistreatment .Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .Neglect: Failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . On 10/22/24 at 10:08 AM, a review of R903's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: mouth cancer, protein calorie malnutrition, adult failure to thrive, dysphagia (difficulty swallowing), presence of a feeding tube, and anxiety disorder. R903's Minimum Data Set assessment dated [DATE] revealed they were cognitively intact and ranged from independent to set-up assist and supervision for various activities of daily living. A review of a progress note entered into the record by Regional Nurse Consultant 'F' dated 10/1/24 at approximately 5:45 PM revealed R903 had received a new order from Dr. 'E' for Ativan (anti-anxiety medication) 0.5mg (milligrams) by mouth every six hours, as needed. R903's orders were reviewed and revealed the order for the Ativan had been entered into the computer as an active order by Nurse Consultant 'F' on 10/1/24 at 5:47 PM. On 10/22/24 at 11:48 AM review of facility provided investigation documents for an incident between R903 and Licensed Practical Nurse (LPN) 'B' was conducted. The documents contained the following: An incident summary that read, .On 10/1/24 at approximately 9:30 pm, the Administrator was notified that a physical altercation occurred between the resident (R903) and LPN ('B'). When the Administrator asked the nurse what happened, (LPN 'B') stated, When I was giving him the medication, he stood up out of his wheelchair and punched me in the face 5 times. I pushed him back down into his wheelchair .In conclusion, it was identified that the nurse (LPN 'B') neglected to provide the resident with the PRN (as needed) Ativan that he was requesting for approximately 4 hours. A review of R903's physician's orders and medication administration record (MAR) revealed the following: A signed physician's order from Dr. 'E' dated 10/1/24 at 5:47 PM for Ativan 0.5 mg every 6 hours, as needed for anxiety. A MAR for October 2024 that indicated LPN 'B' administered R903's Ativan at 9:25 PM, approximately four hours after the medication had been ordered. Continued review of the facility's investigation revealed the following witness statements: A statement by the facility's Administrator dated 10/2/24 that read, I was approached by (R903) in the 1 north <sic> hallway on 10/1/2024. It was probably between 5 and 5:30 p.m. He said 'I want my Ativan. The nurse said I have medication in the cart, but it's not in the computer. I don't know what that means. Can you help me?' I approached the nurse (LPN 'B') who was standing at the med cart and asked her what he meant as she was standing with an <sic> ear shot of me and the resident. She said 'he <sic> has a sleeve of medication in the cart with his name on it, but I don't have an order for it.' I asked if I could see something on her computer real quick. I clicked on the order tab in (eMAR program) to view the completed/struck out/discontinued orders and found a PRN order for Ativan that looked to have ended due to the 14 day stop day. She seemed to be irritated already so I told her I would get one of the nurse managers to see if they could get an updated order. I called (Regional Nurse Consultant 'F') .and asked her if she could assist with getting the order quickly, and she said yes. Before I left for the evening, around 7:15 p.m., I walked down the 1 north hallway up to (LPN 'B') and told her that the order was in and to make sure she gives (R903) his medication . Around 9:15 p.m. my cell phone rang at home. The call ended before I could get my phone. I saw it was (LPN 'B') and I called her back 8 times in a row before I got a hold of her. When she answered she said she was busy being a nurse and a CNA (certified nurse aide) and she's tired .She continued 'So I'm down here working hard and I'm tired and I want to take a break, but the resident (R903) is starting to call me names and follow me around.' I asked if she had given him the Ativan yet. She said No, and that she told the resident she wanted to take her break and that he needs to give her a minute .I told her at this point he has been waiting for the Ativan for 4 hours and to give it to him. I explained that he had a rough day and she knew that, and all of this could be avoided if she had just given him the medication that he has been asking for. She kept going back and forth with me essentially giving reasons why she should take a break instead of giving him his medication .I told her no less that 5 times to 'just give him the medication'. She finally said Ok <sic> and we hung up the phone . About 10-15 minutes later, my phone rang again. It was (LPN 'B'). I answered .and she screamed 'YOUR PATIENT JUST PUNCHED ME IN THE FACE!' .I asked her what happened exactly? she said 'He was talking all this stuff to me and called me a (expletive) .I just started to pop his pills and when I was giving him the medication he stood up out of the wheelchair and punched me in the face 5 times and I pushed him back down into his wheelchair and called 911'. I asked her if she was okay and if she needed to go to urgent care and she said 'I'm pressing charges and I'm probably not coming back!' .A few minutes later I texted (LPN 'B') with (DON, Director of Nursing) included on the message to let (LPN 'B') know she was suspended .(The DON) informed me that (LPN 'B') threatened to bring her husband to the facility to beat the resident up . A statement from the facility's DON dated 10/2/24 was reviewed and read, I missed a call from (LPN 'B') at 9:08 p.m. I called her back at 9:21 p.m. I spoke to her about the resident (R903). She stated that she didn't have an Ativan order for him .I texted (Dr. 'E') for Ativan and I told (LPN 'B') that per (Dr. 'E') it was okay to enter the order and give the medication. I spoke to her again around 10 p.m. when she stated she was punched by the resident and she was going to call her husband to come into the facility because the resident was harassing her .I said to her that she cannot call her husband to come to the building .you cannot fight the patient, you cannot do anything to the patient .She said 'What am I supposed to do if the patient is hitting and punching me?' I said 'Get away from the patient, that's a patient!' I also told her that (Registered Nurse, RN 'A') is going to take care of that patient . It was noted, R903 had an order obtained by Regional Nurse Consultant 'F' for Ativan dated 10/1/24 at 5:47 PM, prior to LPN 'B' calling the facility's DON and them calling Dr. 'E'. Continued review of the witness statements revealed a statement dated 10/2/24 from RN 'A' that read, .Yesterday I was coming from one south <sic> and the resident (R903) approached me and stated that the nurse was not giving him his medication and while we were talking, the nurse (LPN 'B') came from outside. I told her that the resident wants his medication and the nurse stated 'I have to take my break because I am entitled to one' and she left to go on her break. The resident then stated 'you see how she is treating me'. It was about 9pm <sic>. The don (Director of Nursing) called me asked me to tell the nurse (LPN 'B') that she could not call her husband to come to the building . A statement from LPN 'B' dated 10/2/24 was reviewed and read, When I came onto the shift, (R903) was getting into it with (LPN 'G') .He was being petty .He said he wanted Ativan. I told him I saw a sleeve of Ativan in the drawer but you don't have an order for it. I told him to let me call the doctor, and just give me a minute. He asked who he can talk to about this .Then the Administrator was coming around the hall. We had addressed it with her because she was on the hall. She was going to call the nurse practitioner or somebody to see if she could get an order. I was still working .Sometimes my blood sugar drops. I don't feel like I need to explain to the patient that I'm lightheaded. I told him to give me a minute. He was saying I was waiting all day, now I got to wait for you to take a break. I went out the door to call the Administrator .She told me that in the meantime that I called her I could have given him his medication. I come <sic> back in the building and (RN 'A') is standing there. RN 'A' said he (R903) needs his meds. I told them I'm going to get them .I called (the DON) and (the DON) said not to panic and to give him his meds . A statement from R903 dated 10/2/24 was reviewed and read, I was attacked by one of the nurses .What happened to me should not have happened to me or any other resident in the facility .She didn't give me the Ativan. I was asking for it. She pushed me in the chair. I swung at her .She pushed me down. I stood back up because I didn't want her to trap me in the chair .The police came but it took a while .The girl (LPN 'B') told me in front of everybody she was going to get her husband to come up here and beat me up. I guess I was harassing her .or non-stop asking for my Ativan and my pain medicine. My anxiety was running high because I had not had my anxiety pill all day. She put a road block in so I went around to talked <sic> to the Administrator and she said she was going to work on it and see if she could get the medicine quicker. Every time I went to the nurse she kept saying it's got to get in the computer. You don't have to keep coming to me. When it gets into the computer I will come to you .The lady said I'm tired from doing all that work to get your medicine and I want to take a break. (RN 'A') said why don't you give him the medicine first. She snapped at (RN 'A') and said I want to take a break. She turned around and disappeared at the nurse's station. I sat in my doorway and watched for her and she eventually came out. I asked her if she felt better now? She said No <sic> My <sic> contract tells me I can take a break whenever I want and if you keep talking you're going to have to get this medicine from someone else. I told her the contract says she has to take care of patients and she's holding me up from getting my medicine. I asked her why she is still talking about what your contract says instead of giving me my medicine- that's time you could be giving me the medicine. She said, 'Look I'm done. Someone will be here in a couple of hours to give you your medicine'. She went over to the computer and started typing and was giving the guy next to me his medicine .She kept treating it like the medicine order wasn't in the computer. (RN 'A') ended up giving me the medicine . A witness statement from a resident dated 10/2/24 was reviewed and read, .The nurse (LPN 'B') called 911. I saw her do that. Then she said she was going to call her husband also insinuating that he was going to come and beat the resident (R903) up. It started over his medication. All day she was having altercations with people. She got really funny with me. I asked her (LPN 'B') what her name was. She looked at me really funny and said how many times do you have to ask me what my name is? You've asked me 7 times. I told her I've had a stroke so I don't remember some of the names sometimes. Then she got really funny with me. She was hard to get along with. She has a major attitude. She has a great big chip on her shoulder. She said an awful lot of the F word. It was very loud. She was very loud and trying to throw her weight around .I heard her using the F word at times. That I know for a fact because that's what brought me out into the hall. A review of another resident witness statement dated 10/2/24 was conducted and read, .The nurse warned him a few times to stop bothering her because she's busy and has all these people to take care of. Then there must have been a fight. I heard her say she was going to call her husband . On 10/23/24 at 9:24 AM, a telephone interview was conducted with RN 'A' regarding their recollection of the incident between R903 and LPN 'B'. RN 'A' said they went downstairs for something and while down there R903 approached them and said the nurse (LPN 'B') did not give him his medicine. RN 'A' said while they were talking with R903, LPN 'B' came into the building from outside and he told her to give R903 his medication. They continued to say LPN 'B' told them they were, Entitled to a break. RN 'A' said they thought LPN 'B' had returned from their break since they had come in from outside and they were going to give R903 his medication. RN 'A' said they went back upstairs and shortly after received a call from the facility's DON who told them not to let LPN 'B's husband into the building as LPN 'B' had threatened to have their husband come to the facility to, beat up R903. On 10/23/24 at 10:38 AM, a telephone interview was conducted with LPN 'B' regarding the incident with R903. LPN 'B' said R903 got, aggressive with them around 9:00 in the evening on 10/1/24, and punched them in the face. They continued to say R903 wanted his Ativan at about 5:30 PM but they didn't have an order for it. They said R903 went to the Administrator and the Administrator was going to get the order. They were asked why they didn't administer the medication around 9 PM after the Administrator obtained the order earlier in the evening and they said, I didn't know if the order was in. They were asked about their phone call to the Administrator just prior to the incident and said the Administrator told them they obtained the order and to give R903 the medication. They further said RN 'A' also came downstairs and told them to administer R903's medication. They were again asked why they delayed checking for the order and administering the medications when the order was entered at 5:47 PM and they said, Every time I tried, he rolled up on me and I couldn't check. They were then asked if they could have asked for assistance from another nurse in the building to check for the order and administer the medication and said they could have. They were also asked if they threatened to call their husband to come to the facility and they denied the threat. On 10/23/24 at 1:00 PM, an interview was conducted with the facility's Administrator, DON, and Regional Nurse Consultant 'F' regarding the incident. They reported Nurse Consultant 'F' obtained the order for R903's Ativan at 5:47 PM. The Administrator said they told LPN 'B' the order was in and to give R903 his medication prior to them leaving the building at approximately 7:30 PM. The Administrator said LPN 'B' called them at approximately 9:15 and they sounded, aggravated. The Administrator said they asked LPN 'B' if they gave R903 their Ativan and LPN 'B' said they had not. The Administrator then said they told LPN 'B' several times over the phone to give them their medication. The Administrator said the whole incident could have been avoided if LPN 'B' did not neglect giving R903 their medication several hours after the order was obtained. They further indicated they terminated LPN 'B's employment and reported the incident of neglect to the appropriate licensing agencies. On 10/23/24 at 1:30 PM, R903 was observed in their room. An interview was conducted with R903 regarding the incident with LPN 'B'. They were hesitant to speak of the incident, but eventually said, She attacked me and knocked me into my chair. They were asked if they knew what provoked the incident and said, they were having a bad day and they wanted their anxiety medication. They admitted ly said, I was bugging her for it, but she wouldn't give it to me. He further explained earlier in the evening the Administrator told him the order had been obtained and he asked for it several times but LPN 'B', denied to give it to him. At that time in the interview, it was observed tears were [NAME] up in R903's eyes and began running down their cheeks. R903 then went on to say the nurse was, purposely withholding my medications. Through tears R903 then said, She is a horrible nurse, I cannot believe she could be that mean on purpose. She was so aggravated with me, but all she had to do was give me my medications.

This citation pertains to Intake Number(s): MI00138288, MI00140123, and MI00144352. Based on observation, interview, and record review, the facility failed to protect three (R33, R35, and R21) residents' rights to be free from physical and verbal abuse by staff and other residents (R50 and R61). Findings include: R33 Record review revealed R33 was a long-term resident of the facility originally admitted to the facility on [DATE]. R33 had a hospitalization during their stay at the facility. Most recently they were readmitted to the facility on [DATE]. R33's diagnoses included polyneuropathy, liver failure, spinal stenosis, and osteoarthritis. Based on most the recent Minimum Data Set (MDS) assessment dated [DATE], R33 had a Brief Interview for Mental Status (BIMS) score of 10/15, indicative of moderate impairment with their cognition. A facility reported incident that was submitted to the state agency dated 10/5/23 revealed that R33 suffered physical and psycho-social harm inflicted by an LPN (Licensed Practical Nurse) approximately 6 months ago (between 3/23/23 and 3/28/23) that was witnessed by a CNA (Certified Nursing Assistant). The investigation summary also read (R33 name omitted) stated that she pulled and twisted (gender pronoun omitted) arm some time ago. When asked since (gender omitted) falls frequently if she was trying to help (gender pronoun omitted) up, (gender omitted) stated that it was more out of anger that she pulled (gender pronoun omitted) arm. When asked if anything happened when (gender omitted) was on the floor, (gender omitted) said that she yelled at (gender pronoun omitted) and kicked .did not claim to sustain physical injury from the incident. (gender omitted) cried profusely throughout the interview. The alleged perpetrator and the witness who failed to report the abuse continued to work at the facility after the incident (for approximately over 6 months) until their employment was terminated after investigation, that was initiated on 10/5/23. The investigation report also revealed that that witness had reported to the abuse coordinator that they were fearful of the perpetrator. Review of the report from the local Police Department (PD) revealed that the local PD was notified of the staff witnessed abuse that happened over 6 months ago (in March 2023) and was reported to the abuse coordinator/administrator on 10/5/23 at 3 PM, was reported to local PD on 10/6/23, at 11:30 AM. The report that was grouped under aggravated/felonious assault read in part, (R33 name omitted) continued that (perpetrator name omitted) is always mean to (gender pronoun omitted) and is very aggressive with her words. (R33 name omitted) advised that (perpetrator name omitted) has only assaulted (gender pronoun omitted) the one time which was a about five months ago, when (gender pronoun omitted) had fallen down in (gender pronoun omitted) room .It should be noted that (R33 name omitted) was still distraught from the incident and cried throughout our conversation . Further review of the local PD report revealed that the CNA had witnessed the entire incident and it read, (Witness name omitted) continued that she saw (perpetrator) kick (R33 name omitted) while (gender pronoun omitted) was on the floor, and then proceed to lift (gender pronoun omitted) up with (gender pronoun omitted) arm, while itwas behind (gender pronoun omitted) back . An initial observation was completed on 5/13/24, at approximately 12:45 PM. An interview was completed during this observation. R33 was queried about their stay at the facility and how they were treated by the facility staff. R33 reported that they liked their stay at the facility and most of the staff were nice. When queried further, R33 reported that the staff member who were mean to them no longer worked at the facility. Multiple follow-up observations were completed throughout the survey between 5/13/24 and 5/15/24. R33 remembered the surveyor and they were able to recall and ask to follow up questions from the previous visit/conversations. Review of R33's Electronic Medical Record (EMR) revealed that R33 had a guardian (sister) and they were under hospice care. Review of the investigation report read, The guardian (name omitted) was interviewed on 10/6/2023. She stated that (relationship omitted) complained about 6 months ago that the nurse pulled his arm and kicked (pronoun omitted) (Guardian name omitted) stated that (relationship omitted) understands and knows what's going on cognitively but needs help with medical decisions. Further review of EMR revealed that R33 had a BIMS score of 15/15, based on MDS assessments dated 1/11/24 and 10/11/23. Review of a social work progress note dated 10/5/23 at 14:29, read Resident made an allegation of abuse that has been reported to the State of Michigan. At readmit resident was anxious, depressed, tearful, and resistant to care. Resident focus was on the incident. Resident was difficult to stay on task. Resident mood behavior should be monitored as needed .referred resident to psych. A progress note dated 10/6/23, at 14:26 read Conducted wellness visit secondary to an abuse allegation. Resident was emotional about (gender omitted) concern but content with the facility response to ensure safety. Recommended psych services follow-up and to continue to monitor (gender pronoun omitted) well-being. A social work progress note dated 10/6/23 at 15:37 read in part, Resident is a readmit to the facility. Resident is alert and orientedx3. Resident scored a 15 on the readmit BIMS assessment. Resident to sign on to (Provider name omitted) Choice hospice 10/7/23. Resident RX (prescribed) lorazepam for agitation. Resident presented with alteration in mood. Resident has periods of tearfulness since readmit. Referral sent to (provider name omitted) for medication management and supportive therapy. An interview was completed with Human Resource (HR) Director T on 5/14/24 at approximately 4:45 PM in the Administrator's office. HR Director T was queried about the incident and how they had narrowed down the dates as the incident was reported after approximately 6 months. HR Director T reported that the CNA who witnessed the incident was speaking with them about the alleged perpetrator (LPN) and they were upset about how the LPN was treating them (witness). When the director T queried further on why, the CNA reported that the LPN had been upset as they had witnessed the LPN being physically abusive to R33 several months ago. They added that when they heard this from the CNA they had followed up with the unit manager and the abuse coordinator (Administrator) at that time. The Administrator followed up with their investigation. Director T reported that both staff members were terminated upon completion of the investigation. HR Director T was queried how they had narrowed down the time frame for the incident. They reported that the CNA was able to recall the time frame as the incident happened prior to their scheduled vacation. An interview with the Administrator was completed on 5/14/24, at approximately 4:35 PM. The administrator who investigated and reported the incident was no longer working at the facility. The current reported that they were aware of the incident and harm. They also reported that the incident was not reported timely and confirmed that both the perpetrator and witness were terminated. Administrator was notified that the incident was not reported to the local PD timely and it was reported the next day (approximately after 21 hours) from time it was [NAME] to the attention of the abuse coordinator (previous administrator). Administrator reported that they understood the concern. An interview was completed with Assistant Director of Nursing (ADON) who was covering as the interim DON, on 5/15/24 at approximately 8:30 AM. ADON was queried about the abuse prevention and reporting process. ADON reported that if staff witnessed any abuse they should intervene and stop to ensure that resident were safe and report to the abuse coordinator (administrator) immediately. Abuse coordinator would initiate the investigation and notification. Notified of the staff to resident abuse to R33 and concern with not reporting timely. ADON reported that this was prior to their current role as ADON and they understood the concerns. 32568 R50 and R35 A review of a complaint submitted to the State Survey Agency revealed multiple allegations of resident to resident abuse, including an allegation that R50 physically assaulted R35 by hitting him 5 times in the head. On 5/13/24 at approximately 8:30 AM, R35 was observed seated on the side of his bed eating breakfast. When interviewed, R35 appeared confused, but did answer some questions. When queried about whether he was previously in another room with a different roommate, R35 reported he was. R35 began rubbing his arms and stated, I have these knots here on my arm. When queried about any issues or altercations that occurred with his previous roommate, R35 reported that was why his room was changed. R35 stated, He came after me, then he left, and I don't know. He was in and out. On 5/13/24 at approximately 8:45 AM, R50 was observed walking in the hallway pushing an empty wheelchair. When addressed R50 did not respond to any questions or greeting. A review of R35's clinical record revealed R35 was admitted into the facility on [DATE] with diagnoses that included: vascular dementia and a personal history of childhood abuse. A review of a MDS assessment dated [DATE] revealed R35 had severely impaired cognition and no behaviors. A review of an Incident Note dated 3/27/24 at 4:11 AM, written by Registered Nurse (RN) 'M', revealed, Resident involved in physical altercation at approximately 0325 (3:25 AM) with roommate .Room changed . A review of an incident report for R35 dated 3/27/24 at 3:30 AM, completed by RN 'M', revealed, CENA (Certified Nursing Assistant) heard a noise entered the room to investigate sound observed (R50) strike (R35) 4 times. It was documented that R35 stated, He just hit me. The incident report noted that R35 grabbed R50's footboard (on the bed) to propel forward in the wheelchair. It was noted that Certified Nursing Assistant (CNA) 'N' was a witness to the incident. On 5/14/24 at 9:03 AM, an interview was conducted with RN 'M' via the telephone. When queried about the incident that occurred between R35 and R50 on 3/27/24, RN 'M' explained a CNA reported to her that R35 was trying to propel in the wheelchair out of the room, grabbed R50's bed to help move forward, and R50 assaulted (R35) in the head. RN 'M' explained R50 was known to have aggressive and threatening behaviors if anyone touched his stuff or even if staff were to bump up on his bed. RN 'M' reported R50 would have done better in a private room due to his aggressive and threatening behaviors toward others. RN 'M' further reported she moved R35 to another room, but R50 received another roommate and had a roommate currently. RN 'M' further reported the facility had a lot of resident to resident incidents. On 5/14/24 at 9:14 AM, a telephone interview was attempted with CNA 'N'. CNA 'N' was not available prior to the end of the survey. A review of R50's clinical record revealed R50 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Wernicke's encephalopathy (a neurological disorder) and adjustment disorder. A review of a MDS assessment dated [DATE] revealed R50 had intact cognition and no behaviors. However, there was witnessed resident to resident abuse that was perpetrated by R50 on 3/27/24, which was within the seven day look back period for the MDS assessment. A review of R50's progress notes revealed no documentation that he had hit R35 in the head on 3/27/24. A review of a care plan initiated on 3/27/24 revealed, The resident is/has potential to be physically aggressive r/t (related to) poor impulse control. A review of an Incident Report dated 3/27/24 at 3:52 AM written by RN 'M' revealed, CENA reported to writer that she observed resident physically struck roommate (R35) approximately 4 times .Resident refused to speak . On 5/14/24 at 3:04 PM, an interview was conducted with the Administrator who was the facility's Abuse Coordinator. The Administrator reported she was unaware that R50 hit R35 in the head on 3/27/24 and first heard about it that day (5/14/24). 34275 R21 and R61 On 5/13/24 at approximately 8:27 AM, R21 was observed sitting in their room in a wheelchair. The resident was alert and able to answer all questions asked. When asked if they felt safe in the facility, R21 stated that they do now, but not in the past. R21 reported that they lived in a different room with R61 who at many times was psychotic and verbally aggressive. They further reported that they finally had had enough of the roommate's verbal abuse after they started yelling antisemitic slurs at them. R21 stated about a week or so ago their roommate (R61) was snoring loudly, and they had to turn up their TV, after doing so, R61 yelled at them and stated, Turn off the TV you dirty [NAME] and then said, the only good [NAME], is a dead [NAME]. R21 stated that they reported the incident to the Administrator. R21 noted that that they were allowed to change rooms and hoped they never will run into R61 again. A review of R21's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: end stage renal disease and pressure ulcers to the left heel. A review of the resident MDS noted the resident had a BIMS score of 13/15 (cognitively intact cognition). There were no behavior concerns noted in R21's MDS. The census section in the resident electronic medical record (EMR) noted the resident changed rooms on 5/7/24. There was no documentation in R21's record that noted why there was a room change. On 5/13/24 at approximately 2:19 PM, a request for any Investigation/Accident (IA) reports and/or grievances and/or Facility Reported Incidents (FRI) pertaining to R21 and R61. *No documents pertaining to incidents between R21 and R61 was provided by the end of the survey. On 5/14/24 at approximately 11:19 AM, an interview was conducted with the Administrator/Abuse Coordinator. When asked if R21's had ever reported an incident with their roommate (R61) they indicated that they did. When asked what the incident involved, the Administrator reported that it had something to do with the television and statements and worries about the resident (R21) being Jewish. When asked if there had been any investigation into the incident and whether they could provide any documentation pertaining to any incidents involving R21 and R61. They further noted that they moved R21 out of the room and they believed the resident felt safe after that. On 5/15/23 at approximately 8:53 AM, an interview was conducted with R61. R61 was asked about R21 moving out of their room. R61 noted that they did not get along and that they had a difference of opinion when it came to religion. R61 did not provide any further information. A review of R61's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that include end stage renal disease and depression. A review of the resident's MDS noted the resident had a BIMS of 15/15 (intact cognition). Continued review of R61's clinical record documented, in part, the following: 2/29/24: Alert Note: Behavior concerns have been noted by care staff . 2/27/24: Alert Note: Behavioral Concerns have been noted by staff. Resident will become angry and use inappropriate language towards staff . 12/26/23: Psychiatry: .seen as urgent consult .to assess mood. Refused to go to multiple dialysis sessions and has been agitated at dialysis .he is aware of the consequences of refusing dialysis .he does not like his roommate and wants the roommate out of the room. He has had 5 other roommates .he was seen in his room. He was irritable during the visit and admits to being frustrated .he does not want any psych meds . *It should be noted that at the time of the interview with psychiatry, R61 was roommates with R21. 12/15/23: Behavior Note: Resident came to SW (social worker) office cursing and yelling obstinacies <sic>about his roommate smell and want him out his room. SW advised that if he is unable to co-assist with his room and he is the one not happy then he is the one that has chosen to move. Resident continue to yell and state he is not moving. It should be noted that at the time of this interview with the SW, R61 was roommates with R21. Further the SW who authored this Note was no longer employed by the facility as such no interview was conducted. Again, no documentation was provided regarding incidents pertaining to R21 and R61. A review of a facility policy titled Abuse, updated 5/24/23, revealed, in part, the following: Residents have the right to be free from abuse .:

This citation pertains to intake(s): MI00144245 & MI00144212. Based on observation, interviews, and record reviews the facility failed to protect the resident's right to be free from physical restraints and/or mistreatment during care for one (R704) of five residents reviewed for mistreatment and/or abuse by Certified Nursing Assistant (CNA) K, resulting in R704 to have a fracture of the fourth digit to their right hand. Findings include: Review of the medical record revealed R704 was initially admitted to the facility in 2017, with a readmitted [DATE] and diagnoses that included: dementia, hemiplegia and hemiparesis affecting the right dominant side, chronic kidney disease and most recently a fracture of the fourth metacarpal bone. A Brief Interview for Mental Status (BIMS) score completed on 4/25/24 documented a score of 3, which indicated severely impaired cognition. R704 required staff assistance for all Activities of Daily Living (ADLs). On 5/1/24 at 10:33 AM, accompanied by Human Resource Director (HRD) A to act as an interpreter in translating the interview with R704 (whose primary language is Arabic/Chaldean) and the surveyor. HRD A was asked to be honest in the translation of the surveyor's questions and R704's responses. R704 was observed sleeping up right in a geri chair wearing a green shirt and black pants. R704's right hand and fingers was visibly swollen and yellow in color. R704 was awakened by verbal prompts from HRD A and asked R704 how their hand became injured, R704 stated a male pressed on his right hand and hurt him. R704 did not know the name of the male. R704 stated they had seen the male since the incident occurred and R704 stated they kicked them out of their room and the male left. When asked, R704 stated the same male had hurt them in the past, however R704 would not elaborate on the prior incidents. R704 was asked if they felt safe in the facility and R704 responded No. When asked why R704 stated that, it was because of the incident that happened to their right hand. R704's roommate who spoke English was in the room at the time of the interview. HRD A was asked to exit the room and R704's roommate was interviewed. R704's roommate was asked if they had witnessed any staff members hurting R704 and the roommate responded yes and then stated they would not answer any further questions. R704's roommate stated in part . It's best if I stayed out of it . Despite further attempts R704's roommate declined to be interviewed further. Review of an incident report dated 4/24/24 at 12:12 PM, documented in part . Resident observed with right hand swelling (back of hand) and swelling to 4th and 5th digits . Resident is alert to name with confusion. When asked what happened to his hand, he shook his head no while guarding his hand . notified (physician name) new order STAT (immediate) right hand x-ray 2 views related to pain and swelling . Review of a right-hand radiology report dated 4/24/24, documented in part . Pain in right hand . Multiple views of the right hand show a fracture of the fourth digit at the P1 segment . IMPRESSION: Acute fracture of the fourth digit at the P1 segment . Review of a statement obtained by the facility from CNA H (the aide assigned to R704 on 4/24/24 day shift, who first identified an abnormality with R704's right hand, reported the following in part . When I went into the room (4/24/24 Day shift) the patient was holding his hand and expressing that it hurt I noticed his finger looked blue/gray but not bruised. I was trying to also ask (R704's name) what happened but he wasn't able to fully communicate anything regarding his hand which is how some days are for him. I immediately notify the nurse . On 5/1/24 at 11:18 AM, a telephone interview was attempted with CNA H however unsuccessful. CNA H never returned the surveyor's phone call. Review of the facility's staff assignment sheet documented Certified Nursing Assistant (CNA) K assigned to R704 on the evening of 4/23/24 and CNA J assigned to the same hallway as CNA K but assigned to a different set of residents. Review of the facility's investigation file revealed no statement obtained from CNA J. On 5/1/24 at 11:18 AM, an attempt to conduct a telephone interview was made with CNA J, however unsuccessful. A voicemail was left for CNA J to return the call. At 11:50 AM, CNA J returned the call and was asked if they knew anything about the incident of R704 right finger fracture and CNA J stated in part, . No, I don't give care with (CNA K) . I don't assist him at all . CNA J stated they had never helped CNA K with R704 using the Hoyer lift. CNA J explained there was an incident when they first started working at the facility (CNA J's start date was 3/6/24) where . (CNA K) was very aggressive with his tone of voice to me and the resident ( another resident). I felt uncomfortable so I stepped outside the room and told the nurse . CNA J stated CNA K basically told the resident to stop yelling and to let him do his job. CNA J stated I told CNA K it's not okay to yell at (another resident) and he told me to stop talking to the resident. CNA J then stated CNA K said . didn't I tell you to stop talking to them, just do your job! CNA J stated they just stay away from CNA K now and get another CNA from a different unit if they need help with a resident. Review of CNA K's statement (no date), documented in part ADON (assistant director of nursing) asked (CNA K) did he work Tuesday afternoon and did anything happen the last time that he worked. He responded, 'yes I worked' but could not recall anything of importance happening on his shift Tuesday. ADON asked did he have any issues with any resident being combative, or who refused care. (CNA K) said, 'umm no'. He did state that on Wednesday afternoon he noticed swelling to (R704's) finger. I informed (CNA K) regarding the allegations and then he stated that (R704) is combative with care, he does resist care from him and when he does that, he (CNA K) gets assistance from (CNA M) who speaks the same language as R704. (CNA K) does recall a time last week when he was transferring resident (R704) from chair to bed to perform a bed bath because resident was combative and refusing a shower, that <sic> when he was trying to change him that (CNA M) held his (R704) hands to stop him from swinging <sic> them. Review of R704's medical record revealed R704 required a two-person assistance for bed mobility, toilet use and transfer with a mechanical lift. This indicated CNA K should not have attempted to transfer R704 initially without a second staff present to assist. On 5/1/24 at 2:18 PM, a telephone interview was conducted with CNA K, when asked CNA K explained they were suspended and would be called by the Administration after the investigation. CNA K went on to state that R704 is very combative sometimes when they are providing R704's care. CNA K went on to say how R704's hands was held because they were swinging at them (CNA K and CNA M) but would not clarify when asked who held R704's hands down. Review of CNA M's statement dated 4/30/24, documented in part . (CNA M name) was interviewed and recalls on 4/15/24 that she was approached by another CNA to help assist with care due to resident being incontinent of stool. (CNA M) does report having to hold his hands due to him pinching, biting, and trying to punch her in the face. Even though he was combative she did not want to leave him with stool on him, so his hands were held during peri care . On 5/2/24 at 9:07 AM, a voice message was left on CNA M's voicemail to return the call for a telephone interview. At 10:10 AM, CNA M returned the call and when asked about the incident that involved themselves, CNA K and R704, CNA M stated that CNA K usually comes to get them when CNA K needs help and the residents refuse care. CNA M stated CNA K came to them and stated they tried to change R704, however R704 wouldn't let CNA K change them. CNA M stated they tried to talk to R704 because they had had a big bowel movement. CNA M stated in part . (R704) tried to punch me and pinch me. So, I said okay (R704's name) I have to change you, so (CNA K) tried to protect me, and held (R704's) hand so that I can change (R704) . Review of R704's care plans revealed no care plan implemented for combative behaviors identified by the facility staff. Review of the medical record revealed no documentation of R704 to have been combative with staff. Review of the facility documents noted the date of 4/15/24, of the alleged incident of CNA K and CNA M holding the hands of R704 due to combativeness. The incident happened more than a week prior to the identification of R704's hand to have been swollen, discolored, and confirmed as fractured. Review of a statement obtained from Unit Manager (UM) I documented in part . 4/25/24 at approx. 1030 AM myself (RN Unit Manager), (Human Resource Director - HRD A), and (previous Social Worker) were in the room interviewing (R704). Patient was asked questions to obtain an understanding/description of the person that he alleged bent his finger back. (HRD A name) is being translator for conversation. Patient was asked what does he look like? (R704) describes the man as regular brown hair, long face, no beard, unsure about moustache, older man but not old enough to have gray hair. Patient was asked what the person was wearing he explains sometimes he wears jeans, always wears a jacket. Patient explains that his jacket is similar to mine in color ( I have on navy blue). Patient also explains that he thinks he works here, he sees him all the time and that the man has hurt him before. When patient was asked about what time of day the incident occurred the patient stated he is unsure of time of day because it always seems like day light because of people coming up and down the hallway/walking past his room. Patient explains that he has never hurt him as bad as this time but has hurt him many times before. Patient states the man has changed him and fed him before. (R704) also goes into explanation that he asks the man 'why do you hurt me?' and the man will not respond. Also (R704) explains that when the man hurts him he will cuss at the man, and after ask for forgiveness the man will say I don't forgive you and walk away . On 5/1/24 at 12:10 PM, a telephone interview was conducted with UM I who explained they were no longer employed with the facility as of the day before (4/30/24) due to the following investigation involving R704. UM I went on to say how they were instructed to interview the staff and residents regarding the abuse allegation incident that involved R704, as well as the other unit managers were also assigned to do the same. The unit managers were assigned different units to ensure all residents were interviewed in the facility. UM I stated the description provided by R704 of the alleged perpetrator identified CNA K. CNA K was assigned to R704 on 4/23/24, the evening before R704's right hand swelling and pain was identified. UM I stated the previous Social Worker (PSW) L , HRD A were both present for the interview with R704 when the resident stated the man was abusing R704 for a long time but it hasn't been this bad. UM I went on to state how R704 described CNA K as the alleged perpetrator. UM I went on to state how R704 described the man as white complexion, not African American and that CNA K is the only male CNA who is not African American in the facility. On 5/2/24 at 9:01 AM, a telephone interview was attempted with the previous Social Worker (PSW) L, however initially unsuccessful. A message was left to return the call. At 11:03 AM, PSW L returned the call and when asked stated they were in attendance when R704 was interviewed by UM I. PSW L had explained they put in a 30-day notice to the facility and their last day was supposed to be May 19th 2024, however they were approached on Monday (4/29/24) by the Administration and asked to terminate their employment with the facility that day with no loss of wages. PSW L then stated on the day of the interview R704's hand was visibly black in color from front to back. PSW L stated they didn't feel comfortable with HRD A translating the interview with R704 because R704 kept saying he didn't say that. PSW L then stated, CNA K was identified as the alleged perpetrator through the resident's description. PSW L stated in part . (R704's) BIMS (Brief Interview for Mental Status) score was low but when it came down to the incident (R704) was very clear. He kept saying it and repeating it . Review of a Facility Investigation dated 4/29/24, documented in part, . Swelling was observed on 4/24/2024 by nursing assistant and reported to the staff nurse . The floor nurse ordered an X-ray to the right hand and the results were read on 4/25/24. The results showed a fracture of the 4th digit at P1 segment . The resident stated a white man with regular brown hair long face no beard older but no gray hair who works here came in 3-4 days ago and hurt him twisted his hand I told him to stop but he kept going. It's very painful .Fracture to 4 digit on right hand . Police was notified and arrived on 4/25/24 @ (at) 1600 (4:00 PM) . Immediate suspicion of staff member based on the resident description and who cared for the resident was preliminary suspended pending investigation . Resident interview with translator: 4/25/24 Resident stated that he seen a white male, somebody from here came and hurt me, not my roommate, but a white man who walks up and down on unit. Resident further stated, I don't know what day (it happened)-3 or 4 days ago unsure. [NAME] man maybe speaks to roommate and makes jokes with him. He twisted my hand. I told him to stop but he kept on going and it was very painful . stated that he feels safe the man just needs to apologize . Staff schedule was reviewed for 4/23/24 and 4/24/24. A staff member matching that description was reviewed and suspended pending completion of investigation . Staff member (CNA K) reports caring for the resident on 4/23/24 and remembers the hand swelling but also knows the resident is combative and does sometimes resist care. He also reports when these situations occur, he gets another staff member to hold his (R704's) hands . Conclusion . it is determined the fracture was contributed to the resident having comorbidities with lead induced gout and osteoarthritis around the joints and the factors of the staff assisting him with hygiene during outburst, that the fracture located at the 4th digit P1 segment most likely occurred when the hands were held and the resident was moving his hands around. Due to the outcome of the investigation and in abundance of caution the facility completed re-education to all Nurses and Nursing Assistance <sic> on how to respond to resident during a Catastrophic Reaction . On 5/1/24 at 3:56 PM, the Administrator (who also serves as the facility's Abuse Coordinator) and HRD A was interviewed and asked when they were first notified of the allegation of abuse reported by R704 and the Administrator stated they were notified on 4/25/24 by the ADON. The Administrator was asked why they were not notified on 4/24/24 of R704's right hand swelling and the Administrator stated they were not notified until the X-ray confirmed the fracture of unknown origin. The Administrator stated that is when their investigation began. The Administrator was asked how it is possible that none of the Administration team followed up with R704 on 4/24/24 to ask how their unexplained and unwitnessed swelling of the hand occurred, the Administrator stated they were unsure. When asked who conducted the abuse allegation investigation the Administrator stated themselves, the ADON and the Regional Nurse Consultant (RNC) G. On 5/2/24 at 11:20 AM, the Administrator, ADON, and RNC G was interviewed together with UM I in attendance via speaker phone. Each party was asked their role in the investigation of R704's allegation of abuse and the Administrator stated they made sure all of the information was handed in by the timeline. The ADON stated they typed some statements, conducted interviews, spoke to the police officers with UM I. The ADON stated when they were done, they handed the folder to the Administrator on Friday morning. RNC G stated they witnessed a few interviews with the ADON and helped to type the report. UM I stated they obtained statements from staff members and residents and provided the statements to the ADON. The Administrator was then asked the results of the facility's investigation and the Administrator stated they could not substantiate the abuse allegation. The Administrator was asked if they took into consideration the statement provided by R704 on 4/25/24 and considered the fact that R704 was still consistent with their statement when interviewed by the surveyor on 5/1/24 and the Administrator stated they took the residents statement into account and that is why CNA K was suspended. The Administrator was then asked how they believed R704's fractured finger occurred, and the Administrator stated they were not sure if R704 was abused or if they caught their finger in their wheelchair. The Administrator was asked the employment status for CNA K and the Administrator stated they were awaiting the results of the investigation. When asked what investigation results, they were waiting for being that the facility had concluded their investigation, the Administrator did not specify. UM I then stated they were called into the Administrator's office on 4/29/24 and was asked by Regional Director of Operation (RDO) N to edit the statement UM I obtained from CNA J. UM I stated they refused to edit the statement of CNA J and was terminated on the next day on 4/30/24. At this time the Administrator was asked why CNA J's statement was missing from the investigation file and the Administrator was unsure. RDO N asked to review the file to find CNA J's statement and was unable to find the statement. At 2:01 PM, the Administrator emailed CNA J's statement to the surveyor. Review of CNA J's statement documented in part, . Not when providing care. He (R704) does hit or grab only when you are attempting to put him in <sic> Hoyer lift. He grabs the sling, but he does not flail his arms. I stopped going into patients' rooms with (CNA K) because he makes me uncomfortable and feel scared, he talks aggressively to staff and sometimes patients and one time I experienced him talking to (another resident's name) in a different language and she became very upset screaming at him to get out, he had to of said something that he wasn't supposed to say to her . Review of a facility policy titled Abuse dated 5/23/24, documented in part . Residents have the right to be free from abuse . mistreatment . This includes, but is not limited to . any physical .restraint that is not required to treat the patient/resident's medical symptoms .

This citation pertains to intake #MI00136875 Based on interview and record review the facility failed to prevent the elopement of one resident (R901) of two residents reviewed for elopement, resulting in immediate jeopardy (IJ) when R#901 who was previously identified as an elopement risk and had severe cognitive impairment, exited the building and left the facility premises without staff supervision increasing the likelihood of serious injury, serious harm, serious impairment, or death. Findings include: On [DATE], a facility reported incident that was submitted to the State Agency was reviewed and indicated that R901 had eloped from the facility grounds without the knowledge of the facility staff on [DATE]. On [DATE] at approximately 11:50 a.m., R901 was observed sitting in a chair in the main day room. R901 was queried regarding leaving the facility on [DATE] and they indicated that they were just passing through and that they were trying to get back to their job at the local TV station. R901 was queried where they were going to go once they got on the bus and they could not provide any specific answers and reverted back to their job at the TV station. On [DATE] the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] and had diagnoses including Dementia, Mild cognitive impairment and Adjustment disorder with anxiety. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of [DATE] revealed R901 had a BIMS (brief interview of mental status) score of three indicating severely impaired cognition. A review of R901's plan of care revealed the following: Focus-Resident has been identified to be at risk for elopement. Res (resident) asks and seek to go to work [local TV station] or go to the social security office. He is able to ambulate without difficulty. He does exhibit exit seeking behaviors at times. Res has a wander guard in place. Date Initiated: [DATE] .Interventions- Frequent visual checks throughout each shift. Date Initiated: [DATE] Wanderguard (an alert device to prevent elopement) as ordered. Monitor for placement q (every) shift and check for proper functioning q week .Take photograph of resident to maintain on file for identification purposes with family or resident consent. Date Initiated: [DATE] . A Psychiatry note by the Psychologist with an effective date of [DATE] revealed the following: I certify that my clinical findings support that this client/clt is facility bound at this time due to: medical issues and memory issues which makes client unsafe to leave the facility alone and illness requiring supportive devices/special transportation/assistance of another person in order to leave their residence .He still has desires and ambition about going back to work at [local TV station) as an assignment editor (while this is unrealistic, this passion is very therapeutic for him). Note: this is his baseline. He has hx (history) of vascular dementia and high ordered processing issues. His insight into his memory problems are poor and this is longterm care .STM (short term memory) issues evident. Working memory issues evident. He presented w (with)/ confusion. Clt was oriented to person and place. He was not oriented to time. His time perception is poor. His insight appeared poor. Judgment appeared poor . A Nursing note dated [DATE] revealed the following: : Resident alert with some confusion, checked vital signs at the beginning of the shift. T(temperature) 98.1, BP (blood pressure) ,d+[DATE], P (pulse) 71, R (respirations) 18, SPO2 (oxygen saturation) ;97%, told resident his blood pressure was high, resident state that I should stop messing with the young girls Checked on resident after dinner was served, saw food by the bedside but resident was not in the room. Checked again on resident In about an hour, resident's food was still by the bedside but resident was not in his room. I quickly went to the Main dining room, did not find him, went to [R901's old room] which used to be his room, but he was no where to be found. Rushed to the front desk, where the nursing supervisor was sitting, asked him, if he had seen the resident. The nursing supervisor told me he saw him at door and he let him out. I, then went to [unit on the first floor] told the nurse over there to call code white (W) [code for a missing resident]. The nurse on [first floor nursing unit] nursing supervisor and I went outside looking for the resident. We went to the convenient store by the building and asked the store manager whether he seen the resident, we walked around the building and we could not find him. I came back to the facility, called 911 and gave the police the description of the resident. The police arrived on the facility about the same time the Administrator arrived. The Administrator and I gave the police report and description of the resident. On [DATE] a review of the county/probate guardianship verification system revealed R901 had a court appointed legal guardian for being a legally incapacitated individual. On [DATE] a review of the facility investigation pertaining to R901's elopement from the facility grounds was reviewed and revealed the following: Investigation Summary: On [DATE] at approximately 7:15PM, the facility called a Code for a missing resident [R901] soon after realizing he was not in his room. [Nurse A] was assigned to resident [R901] and stated that he noticed his tray table was sitting in his room and he was not there. He checked the dining hall as well as his old room. He rushed to the front and discovered another staff had let him out in front. A Code W was called for a missing resident and the staff searched inside and outside of the building. 911 was called and the Administrator who arrived around the same time. [Weekend Nurse Supervisor C] stated he was sitting at the front desk doing some work when resident [R901] approached about going outside. [R901] signed the LOA (leave of absence) book and [Weekend Nurse Supervisor C] let him outside in front. [Weekend Nurse Supervisor C] stated he knows not to let out residents that are high risk for elopement. He stated he thought he was safe to go out and was not aware he was high risk. He also did not hear any Wanderguard Alarms set off. Resident [R901] was listed in the Elopement Binder as a high-risk resident and [Weekend Nurse Supervisor C] did not check the binder per Policy and Procedure. [Weekend Nurse Supervisor C] was placed under suspension immediately pending investigation and later termed due to poor performance .Resident [R901] family stated that he is very [NAME] and knows how to navigate the community, churches, and ask people for bus money to get places. [R901] exited the building at approximately 6:15PM and was discovered missing around 7:15PM when staff paged overhead the Code. [Staff member] called the Administrator at 7:24PM and the police were called around 7:30PM. The Administrator, Police, and daughter/Guardian of [R901] found him at 7:50PM at a bus-stop about a half-mile from the facility near the [Corner of two major roads] .He was wearing his Wanderguard on his right ankle . His-wanderguard Device was tested with the portable testing device but did not set off the alarm near the front door. The wanderguard had past its expiration date, so the anklet was swapped out for a newer device not yet expired . On [DATE] at approximately 10:22 a.m., Weekend Nurse Supervisor C (WNS C) was queried regarding R901's elopement on [DATE] and they indicated that they had been at the front desk and it was a busy day with visitors coming and going. They reported that they thought all residents at risk for elopement were residing on the second floor and that anyone on the first floor could sign themselves out and leave the facility. WNS C was queried if they had checked the elopement awareness binder at the front desk to see if R901 was elopement risk and they indicated they did not. WNS C was queried if they had heard R901's wandergaurd alert that they were by the door and they indicated they did not and did not see the wanderguard on R901 but that they thought the system might have been broken. WNS C was queried if R901 was permitted to be outside the facility without staff supervision and they indicated that they should not have been and that they were on the elopement program. On [DATE] at approximately 10:39 p.m., the Administrator was queried as to why they did not have copies of R901's letters of guardianship in their record and they indicated that they had a new Social Worker and they were starting to get trained on utilizing resources. The Administrator was queried if R901 was permitted to be outside the facility without supervision and they indicated they were not supposed to be and that WNS C should have checked the elopement binder to be aware of R901's status. The Administrator then indicated that education for all staff had been completed on leave of absence and elopement identification process as well as wanderguards being checked for functionality. The Administrator indicated that they were made aware of R901 sitting at the bus stop by their own family member and that the police and themselves arrived to the bus stop at approximately the same time along with R901's guardian to bring R901 back to the facility. The Administrator indicated the facility corrected the deficiency with education, audits, wanderguard device inspections and did a past non compliance with a date of alleged compliance of [DATE]. On [DATE] a facility document titled Elopement Policy was reviewed and revealed the following: 1.0 POLICY-This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk to develop a person centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff . The IJ began on [DATE], it was identified by the survey team on [DATE] and the facility was notified of the IJ on [DATE], and a removal plan was requested. On [DATE], the State Agency completed onsite verification that the Immediate Jeopardy was removed on [DATE], however the facility remained out of compliance at a scope of isolated and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. On [DATE] Removal of the immediacy was confirmed onsite when the facility took the following actions: [DATE]-Resident #901 was returned to the facility with no injuries by the staff and the police. Resident #901 was cooperative with staff and the Police. [DATE]-Resident #901 was immediately placed on a 1:1 supervision [DATE]-the Policy on Elopement was reviewed and deemed appropriate. [DATE]-Education was initiated with all staff. Education was completed on [DATE] of all staff on being able to identify and are aware of the residents who are at risk for elopement with audits also in place. [DATE]-Staff on shift educated and elopement drills initiated. [DATE]- All Wanderguard Devices and Wanderguard door alarms were checked to be in proper working order. [DATE]-All residents were re-evaluated for need for Wanderguard and provided a working Wanderguard Device. All current residents were assessed for elopement risk including those with severe impaired cognition/legally incapacitated. Those at risk for elopement had orders reviewed and the care plan updated to ensure staff is aware of elopement risk. The process for identifying those patients at risk for elopement was completed with education to the staff.

This citation pertains to intake #MI000133364 Based on observation, interview and record review, the facility failed to ensure a resident was treated with dignity and respect and provided an environment that promoted and enhanced the resident's autonomy for two (R70 and R24) of nine residents reviewed for self-determination/dignity, resulting in the loss of autonomy and expressions of extreme frustration, loss of self-worth and helplessness. Findings include: According to the facility's policy titled, Resident Rights under the Michigan Public Health Code dated 11/20/2017: .The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility, including .The facility shall treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility shall provide equal access to quality care regardless of diagnosis, severity of condition, or payment source .The facility shall ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility .The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights to be supported by the facility in the exercise of his or her rights as required under this subpart .In the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative .The resident retains the right to exercise those rights not delegated to a resident representative . R70 On 5/3/23 at 2:40 PM, R70 was asked about general life in the facility, and they reported concerns regarding the facility filing and having a guardian assigned. R70 reported there was another hearing coming up to contest the need for a guardian. When asked if they had attended the initial court hearing, R70 reported they did not have access to zoom and no one from the facility offered to do that. They further reported they wanted to be at the upcoming one because they did not need or want a guardian. R70 further reported they had provided POA (Power of Attorney) documentation to the facility prior to the initial hearing that identified if they were unable to make decisions, his son would be the representative. On 5/4/23 at 10:40 AM, R70 was asked to follow up about the guardianship and stated they were extremely upset, and they did not need one. When asked what they knew about the reason for the guardianship, R70 reported it only because he wasn't paying his bills initially, but his son was assisting with making payments and wants it known I do not want or need a guardian. My rights were taken away! Review of the clinical record revealed R70 was admitted into the facility on [DATE], readmitted on [DATE] with diagnoses that included: hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, aphasia, cerebral ischemia, chronic ischemic heart disease, demyelinating disease of central nervous system, adult failure to thrive, and metabolic encephalopathy. According to the Minimum Data Set (MDS) assessment dated [DATE], R70 had no concerns with communication or understanding others, had intact cognition, had no mood or behavior concerns, and was independent with most aspects of care. The section preferences which read, F. How important is it to you to have your family or a close friend involved in discussion about your care? was marked as 1. Very Important. Review of the contact information in the electronic health record (EHR) identified only R70's son as the emergency contact and also identified the son was the responsible party as well as health and financial POA. Review of a facility document to determine the resident's decision-making ability signed by a physician (name illegible) on 3/23/23 had an X marked next to Is ABLE to participate in their medical treatment decisions at this time. There was one additional capacity document dated 11/19/21 which also identified R70 was ABLE to participate in their medical treatment decisions. There was no documentation in the electronic health record (EHR) that indicated R70 was NOT competent. Review of R70's Durable POA documentation initiated on 2/15/23 identified their son as attorney in fact and documented, .In the event a judicial proceeding is brought to establish a conservatorship over my property, I hereby appoint (name of son), to serve as Conservator . Further review of the clinical record revealed on 3/22/23, (Name of public guardianship agency) was appointed temporary guardianship of R70. The order regarding appointment of temporary guardian of incapacitated individual inaccurately noted, .The individual does not have a guardian, an emergency exists, and no other person appears to have the authority to act in the circumstances. A showing has been made that the individual is incapacitated . It is unknown what was done to show this resident was incapacitated as the EHR did not identify any supporting documentation of this and why this reflected there was no other person, as documentation indicated there was. Review of the social work progress notes from the former Regional Social Worker/SW (Staff 'D') included: An entry on 1/26/23 at 2:14 PM which read, Probate Court returned Petition for Guardianship requesting more information. (Staff 'D') contacted (Staff 'E' at public guardianship agency) .(Staff 'E') requested letter signed by physician stating recommends resident needs guardian. (Staff 'D') completed letter. Physician signed. (Staff 'D') sent to (name of public guardianship agency). (Name of public guardianship agency) to process guardianship documents. This documentation was not available in R70's EHR. An entry on 2/3/23 at 1:33 PM read, (Staff 'E') from (Name of public guardianship agency) completed Petition for Guardianship, forwarded to SW, SW signed, scanned, and returned to (Staff 'E'). An entry on 2/17/23 at 3:26 PM read, SW presented Notice of Hearing 3-22-23 at 8:30am via Zoom call to Petition for Appointment of Guardian of Incapacitated Individual to resident and return Proof of Service to (name redacted) at (Guardianship Company) at Family Options. An entry on 2/21/23 at 10:54 AM read, Quarterly progress note Social Work has completed a quarterly interview and review. Resident has been a long-term care. Social Work completed a cognitive screening and BIMS (Brief Interview for Mental Status exam) score of 13/15 (indicated intact cognition) was obtained. Cognitive status has had no significant change this past quarter and patient remains stable. Mood screening was complete .score of 0/27 obtained. Mood status has remained stable this past quarter .Advanced Directive for care was reviewed, remains appropriate and resident/family would like code status to remain a DNR (do not resuscitate) .Social Work obtained input from resident/family and updated care plans accordingly . Review of an additional psych progress note form Nurse Practitioner (NP 'F') on 2/22/23 at 9:11 AM read, .Reviewed chart including progress notes, medications and labs. He is not on any psychiatric medications .No behaviors noted, he is currently his own responsible party. Guardianship is pending per chart. He is seen in his room. He is pleasant and cooperative with visit. He denies any concerns with mood. He reports sleep and appetite are good. He is friendly and social. He does not appear in any distress and is joking with me. BIMs 13 .Psychiatric: denies depression; denies suicidal ideation; denies anxiety; denies insomnia; denies hallucinations; denies paranoia; denies delusions .General: Calm, attentive and in no acute distress. Grooming: Neat and appropriate to situation .Mental Status Exam: Demeanor: +Cooperative; +Engaging; +Pleasant; Orientation: Alert and oriented x4 Attention/Concentration: Good Judgment: +Fair; Insight: +Fair; Impulse Control: Good Speech: Fluent .Thought Process: Organized Flight of Ideas: None Loosening of Associations: Normal Thought Content: No apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychosis .Memory/Immediate: Grossly Intact Memory/Recent: Grossly Intact Memory/Remote: Grossly intact Fund of knowledge: Demonstrates good fund of knowledge Abstract Thinking: Intact Mood: Normal with no signs of either depression or mood elevation. Affect: Congruent with mood; appropriate to the situation . On 5/4/23 at 10:17 AM, a phone interview was conducted with Staff 'D'. When asked to recall the specific events and reason for petitioning R70 to have a guardianship, Staff 'D' reported they were no longer employed at the facility and had been assisting the facility in their role as Regional Social Worker following a citation received during another State survey. Staff 'D' reported the reason for the petition was, Because he owed a large sum of money. Staff 'D' was asked why a conservatorship with the son was not considered as this was also identified within the resident's POA documentation and they reported they were not sure, but had proceeded with asking (Name of public guardianship agency) to petition for guardianship. When asked to confirm whether they had filed, or if the guardianship agency did, Staff 'D' reported they had initiated guardianship for ten other residents and they had asked the guardianship agency to fill out the paperwork, in which Staff 'D' then signed and returned the forms to the guardianship agency to file and the facility paid the court fees. On 5/4/23 at 10:29 AM, a phone interview was conducted with R70's son. When asked to recall the events and reason for the resident's guardianship, the son reported Because he had a past due bill and it's really all about this. The son acknowledged the past due bill and further reported they had been assisting R70 with paying every month for awhile now and that this was such a violation of their father's rights as a human being. On 5/4/23 at 10:48 AM, an interview was conducted with Corporate Clinical Staff (Nurse 'J') and current Social Work Director (SW 'H'). When asked whether they could provide any additional information about R70's guardianship, SW 'H' reported they were in the process of correcting and clearing up issues from Staff 'D' and R70 had a hearing later this month and would be informing them that the resident does not need a guardian and is competent. Nurse 'J' reported the plan of correction for another survey was with the concern the facility was not assisting residents with Medicaid applications and therefore building up higher balances. When asked why guardianship had been pursued and not a conservatorship, both acknowledged the same concern. On 5/4/23 11:33 AM, the Administrator reported they wanted to discuss the concerns about R70's guardianship. The Administrator provided a letter signed on 1/24/23 by Physician 'C' and further reported due to issues with those physician services, they were asked to leave and now have a new physician group in the facility. The Administrator confirmed Physician 'C' was requesting guardianship for R70 and only included medical diagnoses. There was no clinical indication of the for the reason why they were requesting guardianship and also had no mention of the resident's level of capacity. The Administrator reported the facility had done an audit of anyone with large balances which included R70 as part of the facility's plan of correction for another survey in which medically related social services was cited. When asked why the facility had pursued guardianship for R70 when they had documentation the resident had capacity and other documentation of who they wanted as a decision maker in the event that was needed, the Administrator acknowledged the concern and further reported the current social worker was working with R70 and the family to terminate the current guardianship appointment. The Administrator was informed of the discussion with Staff 'D' and the concern regarding R70's rights/autonomy being removed unnecessarily. R24 On 5/3/23 at 11:00 AM, R24 provided this surveyor with a hand written note due to not being able to verbally communicate. This note read, .I have a concern I have a problem with I have a communication problem with staff and Director of Nursing (DON) he doesn't have time to communicate with me I fell <sic> neglected when I can't voice my concerns on paper .I feel strongly about this because you might not know it is hard to communicate when you don't have speech and you have to write everything down people blow you off and don't have time!!! Review of the clinical record revealed R24 was admitted into the facility on [DATE] with diagnoses that included: malignant neoplasm of overlapping sites of larynx, acquired absence of larynx, tracheostomy status, and adjustment disorder with mixed anxiety and depressed mood. According to the MDS assessment dated [DATE], R24 had unclear speech, but was able to make self understood and able to understand others and had intact cognition. Review of the care plans included an alteration in communication initiated on 11/8/22. Interventions included: Communication board or paper and pencil to communicate as needed. Use simple questions/commands. Ask open-ended questions, give resident time to respond. Ask for feedback to ensure understanding. Speak on an adult level, speaking clearly and slower than normal. Validate that resident has heard message as intended by asking for feedback. On 5/3/23 at 1:20 PM, an interview was conducted with the Administrator to review R24's concerns. The Administrator reported R24's concerns usually stemmed around their tracheostomy supplies and that the resident was able to do their own trach care but goes through supplies very fast due to using too much solution and they have had frequent conversations with the resident as well as the DON to discuss this. Administrator was informed that R24 expressed concern that they felt neglected when the DON spoke with them and did not have time to wait for the resident to write out concerns. Administrator reported they would follow up with the DON. On 5/4/23 at 8:30 AM, an interview was conducted with the DON to review R24's concerns. When asked if the Administrator had discussed any concerns about R24, the DON reported they were going to but then got diverted with other things that were needed. The DON reported they frequently spoke to R24 and their concerns were usually around the supplies for their tracheostomy and that was not their intention to make the resident feel that way and would follow-up with R24. The DON was informed that although that might not have been their intention, that was the perception of the resident and how they felt.

This citation pertains to Intake Number(s): MI00133024 and MI00133027. Based on observation, interview, and record review, the facility failed to implement effective interventions to prevent elopements for one (R707) of three residents reviewed for elopement, resulting in an Immediate Jeopardy (IJ) when R707, who had severely impaired cognition, a history of eloping through the second story window, and known exit seeking behaviors, eloped through the second story window of their room for the third time, was found a quarter mile away, bleeding from the mouth and arm, in approximately 32 degrees Fahrenheit weather, in the dark, near a highly trafficked road. R707 was taken to the hospital where it was identified that he sustained vertebral (spine) body compression fractures. This had the likelihood to result in serious injury, harm, and/or death. Findings include: Review of two Facility Reported Incidents (FRI) submitted to the State Agency on 11/10/22 revealed R707 eloped from the facility twice on that date (11/10/22). Review of R707's clinical record revealed R707 was admitted into the facility on [DATE] and discharged on [DATE] with diagnoses that included: Alzheimer's Disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R707 had severely impaired cognition and was independent with bed mobility, transfers, and walking. Review of R707's care plans revealed the following: A care plan initiated on 10/11/22 that read, Risk for elopement related dementia process and confusion as evidenced by prior attempts and history of elopement, attempts to get out of building, pulling handles of locked doors. Risk for injury due to wandering behavior throughout facility, observed in others' rooms. The care plan included the following interventions: Frequent visual checks throughout each shift (initiated 10/11/22), ONE ON ONE CARE RT (related to) ELOPEMENT (initiated 11/10/22), Place on timed monitoring if elopement attempts continue (initiated 10/11/22), Provide one-on-one staff monitor if resident appears to be involved in active attempts to elope from the building or unit (initiated 10/11/22), Q (every) 15 minutes check (initiated 11/29/22), Wanderguard as ordered. Monitor for placement q shift and check for proper functioning q week (initiated 10/11/22). Review of R707's progress notes revealed the following: A Behavior Note dated 10/5/22 documented, Received resident up and ambulating with his belongings in hand stating he is going home .Resident paced the hallway with his belongings all through the shift looking for the exit door . A Behavior Note dated 10/6/22 documented, Resident up half the night walking with his belongings wanting to go home, resident was redirected multiple times, resident would go back to room and out again with his belongings. A Psychiatry progress note dated 10/18/22 documented, .(R707) came from a group home where chart indicates he eloped. No behaviors noted per staff . A Nursing - Progress Note dated 11/10/22 at 4:45 PM, written by the Director of Nursing (DON), documented, Patient went out of the building unassisted. He was accompanied into the building by the assigned staff .Wanderguard was put in place. Patient stated that he got out for fresh air and did not want to go anywhere. He was not able to provide any details or answer any more questions 'juts <sic> let me rest. Will you? I am back, ok and I promise I wouldn't do it again' .Wanderguard .is checked every shift . A Nursing - Progress Note dated 11/10/22 at 11:50 PM, written by the DON, documented, Patient stated that he went out through the window. He does not know how he took out the screws to push the window to give him enough access to go through the window. He stated, 'I got out by jumping through the window' .Patient is not one on one around the clock until further notice . Daily progress notes between 11/11/22 and 11/25/22 documented R707 remained on one-on-one supervision and did not have any exit seeking behaviors or elopement attempts. An Incident Note dated 11/25/22 at 5:45 PM, written by the DON, documented, Assigned nurse stated that patient cut off his wander guard .Patient remains on one on one. He did not explain how he cut the wander guard off. A Nursing - Progress Note dated 11/29/22 documented, Resident transferred to (room number) tested positive for COVID. A Nursing - Progress Note dated 11/29/22 at 1:58 PM documented, .Resident is an elopement risk, and during the last part of the shift resident was up and down looking out the window, nurse redirected resident several times which was effective . A Nursing - Progress Note dated 11/30/22 at 7:09 AM documented R707 was on q 15 check (R707 previously received one on one supervision). An Incident Note dated 11/30/22 at 5:26 PM, written by the Administrator, documented, Interdisciplinary Management Team discussion about managing elopement risk with decision to remove the one-on-one sitter due to the resident being COVID positive and transfer to the COVID unit. Resident placed on 15 minutes checks with room located directly across from the Nurse's Station. Window screws were checked by the Administrator with Nurse present and were intact to prevent exiting the windows. A Nursing - Progress Note dated 11/30/22 at 10:10 PM, written by Nurse 'J', documented, .Resident came out of room to Nursing Station at about 7:50 PM, was re-directed back to his room. Resident came out again in about 10 minutes, walking in the Hallway. Resident was again redirected to his room. resident said, 'Good Night' and went to his room. Checked on resident in about 15 minutes and observed him pacing back and forth in his room. Checked on resident at about 8:55pm, this time he was not found in his room. I quickly searched all the rooms on 2 South, resident was nowhere to be found. Came down to the first floor to notify other staff members, called code WHITE (code for missing resident), Called 911 to notify (local police) about the incident. On 12/6/22 at 3:40 PM, an observation was made of the 2 North unit. The double doors that separate the unit from the center hallway required a code to enter or exit the unit. Once the code was entered, there was a 10 second delay where the door could be reopened before the lock was re-engaged. On 12/6/22 at 3:45 PM, an observavtion of R707's room where he resided from 10/5/22 until 11/29/22 when he was transferred to the COVID unit was made. The room was located on the second floor of the facility. A large window was observed to have several screws screwed into the panel where the window would slide open and closed. The screws were partially screwed in vertically to the panel which prevented the window from opening past the screws. However, when pulled, the screws did not appear secure and the panel they were screwed into wiggled and lifted up when the screws were forcefully pulled. A ledge approximately two and a half feet wide was located below the window. The facility parking lot was located outside the window to the north. The facility was located on a highly trafficked road that ran north and south. On 12/6/22 at approximately 5:00 PM, an unobstructed stairway leading to the basement was observed outside and was accessible from the parking lot. On 12/7/22 at 9:05 AM, an interview was conducted with Nurse 'L'. Nurse 'L' was R707's assigned nurse on the day shift (7:00 AM to 3:30 PM) on 11/10/22. When queried about R707's elopement on 11/10/22, Nurse 'L' reported her shift was done and she was not on the unit when it was discovered R707 was outside of the building. Nurse 'L' reported there was a lot going on on the 2 North unit on 11/10/22 and the double doors were propped open often that day due to maintenance being done. Nurse 'L' reported R707 did not exhibit any exit seeking behaviors and usually stayed in his room watching television. Nurse 'L' reported she was downstairs when another staff member brought R707 back into the facility through the front door. Nurse 'L' reported she asked R707 how he got out and he couldn't really say. When queried about the last time Nurse 'L' saw R707 during her shift, Nurse 'L' reported it was between 2:30 PM and 3:30 PM. Nurse 'L' did not see R707 leave the unit during her shift. On 12/7/22 at 9:25 AM, an interview was conducted with Certified Nursing Assistant (CNA) 'M'. CNA 'M' was R707's assigned CNA on the day shift on 11/10/22. When queried about R707's elopement on 11/10/22, CNA 'M' reported she was not in the building when it was discovered R707 left the facility. CNA 'M' reported R707 came out of his room two times during her shift and had his belongings packed in a bag. CNA 'M' reported she redirected R707 to his room each time. CNA 'M' did not report it to the nurse. CNA 'M' reported the last time she saw R707 was around 2:00 PM and he was seated on his bed. CNA 'M' did not see R707 leave the unit during her shift. On 12/7/22 at 8:45 AM, a phone interview was conducted with Nurse 'H'. Nurse 'H' was assigned to R707 on the afternoon shift (3:00 PM to 11:00 PM) on 11/10/22. When queried about R707's elopements on 11/10/22, Nurse 'H' reported she had already started her shift when a nurse brought R707 back to the unit after he was found outside and they placed a Wanderguard on his ankle. Nurse 'H' reported she was seated at the nurse's station which was located across from R707's room when R707 came out of his room with packed bags and stated, 'Let me out of here! My wife is outside.' Nurse 'H' reported she told R707 that he could see his wife the following day and redirected him to his room. Nurse 'H' further explained that about one to two hours later, the assigned CNA (CNA 'I')reported R707 was not found in his room and was brought back by police approximately 30 to 45 minutes after he was discovered missing. When queried about how R707 got out of the building, Nurse 'H' reported she did not see him leave the unit and R707 reported he removed the screws from the window in his room and climbed out from the second story window. Nurse 'H' reported police found R707 several blocks away from the facility. When queried about whether any additional interventions were implemented after R707 exhibited exit seeking behavior during that shift, Nurse 'G' reported no additional interventions were implemented other than checking on him. On 12/7/22 at 8:43 AM, a phone interview was attempted with CNA 'I', but was unsuccessful. On 12/7/22 at 9:35 AM, a phone interview was conducted with Nurse 'J'. Nurse 'J' was R707's assigned nurse on the afternoon shift (3:00 PM to 11:00 PM) of 11/30/22. Nurse 'J' reported he was the only staff member assigned to the 2 South unit which was used for residents who tested positive for COVID-19. When queried about R707's elopement on 11/30/22, Nurse 'J' reported he checked on R707 every 10 to 15 minutes and after dinner R707 came to the nurse's station and asked Where are the girls? Are the girls here?' (It should be noted that prior to this date, R707 had received one on one supervision since 11/10/22). Nurse 'J' reported he told R707 that 'the girls' were not there and it was just him (Nurse 'J') and redirected R707 back to his room. Nurse 'J' reported R707 came back out of his room and asked about the 'girls' and would not go back to his room when redirected. R707 wandered the hallway and then said, 'Good Night' and went into his room and closed the door. Nurse 'J' explained around 8:00 PM or 8:30 PM he planned to provide care to another resident and instead decided to check on R707. At that time, R707 was not found in his room, the bathroom, the adjoining room, or anywhere on the unit. Nurse 'J' reported he went to the first floor of the facility and another nurse called a code white and called 911. Nurse 'J' explained that some staff went outside to look for R707 and he was not on the facility property. A nurse and a CNA then got in their car to look for R707 and found him holding on to a sign at an apartment complex several blocks away, bleeding from his mouth and arm. Nurse 'J' reported the police came to the location resident was found and he was taken to the hospital. When queried about any additional interventions that were implemented when R707 was exhibiting exit seeking behaviors, Nurse 'J' reported he was checking on him every 15 minutes and did not see R707 leave the unit. Nurse 'J' reported he was aware that R707 had climbed out of his window when on 2 North and that he was taken off of one-on-one supervision on 2 South and he was the only staff member assigned. Nurse 'J' reported the Administrator checked R707's window earlier and said it was secure, but later they discovered the screen to the bathroom window was removed and the window was able to be lifted over the screw that was supposed to prevent the window from opening all the way. Review of the facility's investigations into R707's elopements revealed the following: An Investigation Summary conducted for the elopement that occurred on 11/10/22 at 4:05 PM, documented, (R707) was observed in the facility parking lot adjacent to the building at approximately 4:05 PM. He walked back in through the door and staff returned him to his unit and room. History: .diagnoses of Alzheimer's Disease .ambulated independently .He is considered an elopement risk related to dementia process and confusion as well as wandering behavior .(R707) was seen by another resident .around 4:05 PM. She stated she saw (R707) in the facility parking lot. CNA .was covering the front desk when (R707) walked in through the front entrance at 4:09 PM .(R707) was returned to his room under close supervision. The Director of Nursing immediately issued (R707) a Wanderguard bracelet .the doors and alarms were checked to ensure they were intact (Nurse 'L') was assigned to the Memory Care Unit (2 North) at the time of the incident and stated she did not see (R707) leave the Unit or hear any door alarms (It should be noted that Nurse 'L' reported she had left the unit after her shift was over and reported she was no longer on the unit when it was discovered R707 was outside of the facility) .(CNA 'I') stated that he did not observe (R707) leave the unit or hear any door alarms (It should be noted that CNA 'M' was the assigned CNA on the day shift until 3:00 PM) .(R707) was having a good day and went between his room and wandering the unit. He will often take his bag and belongings and walk around looking for the door. He may push on the door but not forcefully try to open it. None of the staff reported seeing (R707) wander through the facility outside of the Memory Care Unit .It was later determined that the resident had exited through his 2nd story window. The resident later articulated he had removed the screw and exited through the window .The investigation showed that the staff were unaware of his exiting via the window because it did not trigger door alarms . An Investigation Summary conducted for the elopement that occurred on 11/10/22 at 10:26 PM, documented, On 11/10/2022 at approximately 10:26 PM, the Administrator came to check on (R707) and the resident was missing .The staff checked the facility and externally around the facility and were unable to locate (R707) .The Administrator contacted (local police department) at 10:31 PM. The resident was found and returned by 10:51 PM walking down the sidewalk within blocks of the facility (It should be noted that the facility is located on a highly trafficked road) .(Nurse 'H') was assigned to the Memory Care Unit at the time of the incident and stated she did not see (R707) leave the Unit or hear alarms for Emergency Exit Doors or the Wanderguard .CNA 'I' was monitoring the resident on the Memory Care Unit from the hallway when (R707) was discovered to be missing. (CNA 'I') thought (R707) to be in his room resting at that time and was shocked since he did not observe (R707) leave the Unit or hear any alarms. None of the staff reported seeing (R707) wander through the facility outside of the Memory Care Unit or hearing any alarms .After returning to the Unit, the Administrator and staff walked the unit with (R707) to observe how he left the Unit. (R707) then clearly articulated that he exited his room window on the 2nd floor by removing the screw, exiting to the ledge and down to a brick wall and then the parking lot. He said he 'wanted some fresh air'. He explained that he is a retired [NAME] and used to lay bricks at high elevations .was placed on One-on-One supervision .The Maintenance Director immediately drove in to reinforce the screws for (R707's) window. He also audited all resident windows in the facility and replaced any screws .The investigation showed that the staff were unaware of his exiting via the window because it did not trigger door alarms or the Wanderguard. Based on the investigation, (R707 exited a few minutes prior to staff discovering he was missing (It should be noted that Nurse 'H' reported in an interview that one to two hours had passed between the time R707 asked to leave the building and when he was discovered to be missing) . An Investigation Summary for the elopement that occurred on 11/30/22 at 8:56 PM documented, On 11/30/2022 at approximately 8:56 PM, (R707) was discovered missing from his room. The facility activated the Emergency Procedure and notified the police. (R707) was found and taken via Emergency Medical Services to the hospital .(R707's) Care Plan stated that he has impaired cognition due to Alzheimer's Disease. He is considered a risk for elopement related to dementia process and confusion as well as wandering behavior. He is a former [NAME] who laid bricks including elevations. He is handy and comfortable with climbing and heights. He attempts to remove screws from windows and exit including climbing from the 2nd story ledge. He also removes his Wanderguard .On 11/30/2022 at approximately 8:56 PM, (Nurse 'J') discovered (R707) was missing from his room. He immediately searched his room and the unit The staff called 911 at approximately 9:00 PM. They notified the Administrator at 9:08 PM who also contacted the police at 9:11 PM .The staff searched inside and outside the building and .located (R707) outside a neighboring apartment complex. He was alert and said they he 'fell ' and was bleeding from his right elbow, knees, and mouth. The EMS arrived shortly after at approximately 9:15 PM and took him to the hospital .(R707) tested positive for COVID-19 on 11/30/2022 (Progress notes documented R707 was moved to the COVID unit on 11/29/22) and was moved to the COVID unit. The IDT discussed the move and decided to discharge one-on-one sitter while on the COVID unit. (R707) was located directly across from the Nurse's Station (it should be noted that R707 was near the Nurse's Station on 2 North, as well) and place on 15-minute checks and only a few patients on the unit. The Administrator checked the screws for the windows were intact due to the elopement risk of exiting windows. (Nurse 'J') was present. (Nurse 'J') stated that he was at the Nurse's Station when (R707) entered his room and closed the door. (Nurse 'J') checked on (R707) momentarily and discovered he was missing. (R707) had been wandering the Unit prior to going missing and (Nurse 'J') redirected him to his room .None of the staff reported seeing (R707) wander through the facility outside the COVID unit or hearing any alarms .The Administrator, Director of Nursing, and the Maintenance Director inspected the Unit and found the window screws were all intact. The screws are checked as part of an ongoing audit. It was noted that the screw for the window in (R707's) bathroom was drilled horizontally through the frame and not vertically like most other windows. When sliding the window, the screw prevented movement beyond 6 inches. With more force the window could be lifted within the frame over the height of the screw and could then be opened wide enough to exit .The screen also had been removed and was discovered on the floor in (R707's) room. The window was found in a closed position. (R707) exited that window to the 2nd story ledge and closed the window behind him. The Administrator walked the 2nd story ledge and found no easy way down to the main level. It appears he somehow lowered himself to a grassy area to absorb the fall .He told the staff he 'fell '. It is unclear if his injuries were from lowering from the 2nd story ledge and/or falling while ambulating at night .The Maintenance Director immediately drilled a vertical screw in the bathroom window .The facility completed an Involuntary Transfer Form due to the high risk of harm (R707) poses to himself and the inability of the facility to prevent .The investigation showed that staff were unaware of his exiting via the window because it did not trigger door alarms or the Wanderguard (It should be noted that by 11/30/22, R707 had exited his room on 2 North two times through the window). Review of a handwritten and signed statement by Nurse 'N' revealed R707 was located R707 holding on to an apartment sign' at cross roads that included the main road the facility was located on and (street name) which was approximately a quarter mile north of the facility. It was documented in the statement that there was a moderate amount of blood noted to mouth, elbows, and knees and R707 was wearing a T-shirt and pants (It should be noted that the temperature on the night on 11/30/22 was approximately 32 degrees F) . On 12/7/22 at 10:17 AM, an interview was conducted with the DON. When queried about how R707 climbed out of the window on 11/30/22 after climbing out twice prior to that date on 11/10/22, the DON reported R707 was taken off of one-on-one supervision when he was moved to the COVID unit because nobody wanted to sit with a COVID positive resident for eight hours a day. The DON further explained there were only four other residents on the unit so they could not justify assigning a CNA to that unit and instead only staffed one nurse (Nurse 'J') on 11/30/22 afternoon shift. When queried about what could have been done to prevent R707 from escaping through the 2nd story window a third time on 11/30/22, the DON reported one-on-one supervision, but he received 15-minute checks. The DON further reported that R707 was able to lift the window over the screw in the bathroom window and open it to climb out. On 12/7/22 at 11:11 AM, an interview was conducted with the Administrator. When queried about the root cause of R707's elopements, the Administrator reported it was due to the screws in the window not preventing the window from opening. The Administrator reported that R707 did not make any elopement attempts while on one-on-one supervision between 11/11/22 and 11/29/22 and after checking the window in R707's room on 2 South after he was moved to the COVID unit we felt the screws were holding so we removed one-on-one supervision. Review of R707's hospital records indicated R707 arrived at the hospital on 11/30/22 at 9:51 PM and was admitted inpatient on 12/1/22. An ED (emergency department) Provider Note documented R707 reportedly 'escaped' and fell outside. Has done this in the past .He does report nonspecific pain when palpating his low back .R (right) elbow with skin tears .Final Impression: .T12 (12th thoracic - upper back - vertebrae in the spine) and L2 (second lumbar - lower back - vertebrae) Vertebral body compression fractures. Review of a facility policy titled, Elopement Policy dated 8/2022, revealed, in part, the following: This facility ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .adequate supervision will be provided to help prevent accidents or elopements . The Immediate Jeopardy began 11/30/2022, was identified on 12/8/22 at 8:00 AM, the Administrator was notified of the Immediate Jeopardy on 12/8/22 at 8:16 AM and a plan to remove the immediacy was requested. The surveyor confirmed the Immediate Jeopardy was removed on 12/8/22 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team which included: -All current residents were reassessed for the need of one-on-one supervision on 12/8/2022 -Interdisciplinary Team (IDT) which includes Administrator, Director of Nursing, Infection Control Nurse, Wound Care Nurse, and clinical personal were educated by Regional Nurse Consultant on updated facility procedure about initiating and removing one-on-one supervision on 12/8/2022 -The facility will act to implement a new procedure for adding and removing one-on-one supervision which includes approval from the Regional Nurse Consultant/Designee and the Facility Medical Director by 12/8/2022. -Maintenance began the installation of anti-tamper screws with bumpers for windows in resident rooms and resident bathrooms in The Memory Care Unit and will be completed by 12/8/2022. Although the immediacy was removed the facility's deficient practice was not corrected and remained at a pattern with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency.

This citation pertains to intake #MI 315 and MI 246 Based on interview and record review, the facility failed to ensure 18 residents (R901, R905, R909, R910, R911, R915, R916, R917, R918, R919, R920, R921, R922, R923, R924, R925, R926 and R927) of 18 residents reviewed for abuse/neglect, were provided an environment free of neglect, resulting in an immediate jeopardy (IJ) when Nurse A failed to ensure Nursing supervision was provided and medication/treatments were administered during the afternoon shift (3:00 PM.-1:00 PM.) on 3/22/22 for the 18 residents residing on the unit, increasing the likelihood for serious injury and/or death. Findings include: The IJ began on 3/22/22. The IJ was identified on 4/13/22. The facility was notified of the IJ on 4/13/22 at 2:18 p.m., A plan to remove the immediacy was requested. The immediacy was removed on 4/13/22 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. On 4/12/22 at 9:10 AM, R905 was observed lying in the bed. R905 was asked if there had been any issues with getting her medications. R905 explained she had gone to an appointment a couple weeks ago (3/22/22 at 10:30 AM) and came back around 3 PM. R905 stated that she asked for her medications she had missed and was told she had to wait until the next nurse came on the unit before she could get them. Review of the clinical record revealed R905 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R905 was cognitively intact. Review of R905's March 2022 Treatment Administration Record (TAR) revealed an order that read in part, Consult Orthopedic: Appointment is scheduled for 3/22/22 at 10:30 a.m Review of R905's March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] At 6:00 PM, .[MEDICATION(S)] Sodium Gel 1 % . [MEDICATION(S)] Tablet 10-325 MG (milligrams) . At 9:00 PM, .Hydrocortisone Tablet 10 MG . [MEDICATION(S)] Sodium Tablet 40 MG . [MEDICATION(S)] Tablet 400 MG . [MEDICATION(S)] Tablet 30 MG ([MEDICATION(S)]) . [MEDICATION(S)] Tablet 150 MG . [MEDICATION(S)] HCl Tablet 10 MG . [MEDICATION(S)] Capsule Delayed Release Particles 60 MG . [MEDICATION(S)] Tablet 5 MG ([MEDICATION(S)]) . Hydrocortisone Lotion 2 % . [MEDICATION(S)] Pain Relief 4 % Patch . [MEDICATION(S)] Sodium Tablet Delayed Release 40 MG . At 10:00 PM, .[MEDICATION(S)] Capsule 10 MG . [MEDICATION(S)] Tablet 800 MG . Review of the nursing schedule for 3/22/22 on the 2 South Unit revealed, the day shift (7:00 AM - 3:00 PM) nurse was Licensed Practical Nurse (LPN) A, and for the midnight shift (11:00 PM - 7:00 AM) was Registered Nurse (RN) B, both had check marks next to their names indicating they were present for their shift. For the afternoon shift (3:00 PM - 11:00 PM), LPN E's name was handwritten on the schedule with @7 (indicating they would be in at 7:00 PM) written underneath and NCNS (no call no show) beside the name, no check mark was next to the name. On 4/13/22 at 8:10 AM, RN B was interviewed and asked about 3/22/22. RN B explained he could not remember the exact date, but recently when he came in, he was told there had not been an afternoon nurse and he had to have a nurse from another unit (LPN C) unlock the medication cart because the keys for the cart were locked inside. When asked if not having a nurse to relieve was common, RN B explained he would not leave if there was no replacement, but other nurses had and that he was still there because he was waiting for his replacement even though his sift had ended at 7:00 AM. On 4/13/22 at 8:18 AM, LPN C, who worked on 3/22/22 on the 2 North Unit for the afternoon and midnight shift, was interviewed by phone and asked about 3/22/22. LPN C explained she did not remember anything, and she would not know if there was no nurse on 2 South unless someone said something to her. When asked if she remembered having to open the medication cart when RN B got there, LPN C explained some of the agency nurses would not stay to give report and they would leave right at 3:00 PM or 11:00 PM when their shift ended, and they would usually lock the keys in the medication carts. On 4/13/22 at 9:30 AM, Scheduler L was interviewed and asked what nurses had been scheduled for 2 South on 3/22/22. Scheduler L explained LPN A had been the day nurse, and LPN E was scheduled to be the afternoon nurse, but he had called and said he would not be in until 7:00 PM because he was stuck at this other job. Scheduler L continued to explain she had left at 4:00 PM and had been unaware LPN E had been a no call, no show at 7:00 PM. Scheduler L was asked who the nurse had been from 3:00 PM until 7:00 PM, when LPN E said he would be in. Scheduler L explained there had been no nurse for the 2 South Unit from the time LPN A left until RN B came in at 11:00 PM. When asked if there were any other nurses that could have been covering the 2 South Unit during the afternoon shift on 3/22/22, Scheduler L stated that RN F was covering as manager that day but was unaware if RN F was covering the 2 South Unit. On 4/13/22 at 3:50 PM, Human Relations (HR) N was interviewed and asked if there was a way to know when RN F had left on 3/22/22 as RN F had a salary position and did not use the time clock machine. HR N produced a report titled, TIME SHEET - STAFF signed by RN F that listed Time OUT as 4:30 PM on 3/22/22. Review of time punches for LPN A and RN B on 3/22/22 revealed LPN A had punched out at 3:45 PM, and RN B punched in at 11:16 PM. It should be noted that is 7 hours 30 minutes the 2 South Unit had no nurse on duty. On 4/13/22 at 9:35 AM, Administrative Assistant M was interviewed and asked for RN F's phone number. Administrative Assistant M explained RN F was out of the country on vacation. RN F was not available for interview during the survey. On 4/1322 at 9:40 AM, LPN A was interviewed and asked who she had given report to before she left on 3/22/22. LPN A explained she had been told the afternoon nurse would not be in until 7:00 PM, so she counted the narcotic medications with another nurse, but she could not remember who the nurse was. When asked if it had been RN F that she counted off with, LPN A explained she knew it had not been RN F. LPN A was asked what she did with the medication cart keys if there was no nurse to take over. LPN A explained she would usually lock them in the medication cart. On 4/13/22 a facility document titled Controlled Substance Shift Inventory was reviewed for 3/22/22 which revealed no Nurse had signed off on the Controlled substance count at 3:00 PM for the outgoing Nurse or the Incoming Nurse lines. On 4/13/22 at 10:08 AM, the Director of Nursing (DON) was interviewed and asked about not having an afternoon nurse providing care for the residents on the 2 South Unit on 3/22/22. The DON explained he had recently fired his two Unit Managers because they had left the facility when there was no nurse covering a unit, but he himself was at the facility and had worked the floor. The DON continued to explain that on 3/22/22 he was not at the facility and that no one had called him and told him there was no afternoon nurse. When asked if a nurse could leave if there was no nurse to relieve them, the DON explained no nurse should ever leave if there was no replacement, that was considered abandonment of your patients. On 4/13/22 at 3:28 PM, Certified Nursing Assistant (CNA) D, who was the afternoon CNA for 2 South on 3/22/22 was asked if they remembered there being no nurse on the unit. CNA D explained he did know he worked that day but did not remember who the nurse was as there were so many different agency nurses that had worked there. When told there had been no nurse that day, no medications passed, no treatments done, no assessments documented, CNA D explained he did not remember that there had been no nurse. On 4/13/22 at 3:40 PM, LPN C was interviewed and asked again if she remembered there being no afternoon nurse for the 2 South unit on 3/22/22. LPN C explained that usually it was not the whole shift there would be no nurse. When asked if the 2 South CNA had come to her to tell her about a resident needing a nurse, LPN C explained that she remembered R910 telling her there was not a nurse. On 4/14/22 at 10:59 AM, RN B was reinterviewed by phone and asked who had told him there had been no afternoon nurse on 3/22/22. RN B explained he knew R910 told him, and a couple other residents, but he could not remember who. On 4/14/22 at approximately 9:25 a.m., The facility Administrator (abuse coordinator) was queried regarding the incident on 3/22/22 pertaining to the 18 residents on the 2 South unit who were not provided a covering Nurse on the afternoon shift. The administrator indicated they were unaware of the incident and that none of their staff had informed them that Nurse A had left the unit without ensuring another Nurse had arrived to provide coverage. The Administrator indicated that any of the staff members working on the second floor should have notified them that the unit did not have a Nurse. The Administrator indicated that all the staff members working on the 2nd floor had been previously in-serviced on reporting abuse and neglect. Review of the facility's Daily Census dated 3/22/22 revealed R901, R905, R909, R910, R911, R915, R916, R917, R918, R919, R920, R921, R922, R923, R924, R925, R926 and R927 were residing on the 2 South Unit. R916 Review of the closed record revealed R916 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R916 had moderately impaired cognition. Review of R916's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Tablet 0.5 MG . SennaCon Tablet 8.6 MG . [MEDICATION(S)] Capsule 24 MCG (micrograms) ([MEDICATION(S)]) . Famotidine Tablet 20 MG . [MEDICATION(S)] Tablet 400 MG . R919 Review of the clinical record revealed R919 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R919 was cognitively intact. Review of R919's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] At 4:30 PM: .[MEDICATION(S)] Mix 75/25 KwikPen (75/25) 100 UNIT/ML Suspension pen-injector . At 6:00 PM: .[MEDICATION(S)] Aerosol Solution 108 (90 Base) MCG/ACT . [MEDICATION(S)] Nebulization Solution (2.5 MG/3ML) 0.083% . At 9:00 PM: .[MEDICATION(S)] Tablet 10 MG . [MEDICATION(S)] Tablet . Semgiee (yfgn)(Insulin) 100 UNIT/ML (milliliters) . [MEDICATION(S)] Tablet 5 MG . [MEDICATION(S)]-Salmeterol 100-50 MCG/DOSE Aerosol Powder, breath activated . R922 Review of the clinical record revealed R922 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R922 was cognitively intact. Review of R922's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] At 5:00 PM: .[MEDICATION(S)] Sodium Tablet 5 MG . At 6:00 PM: .[MEDICATION(S)] Aerosol Powder Breath Activated . At 9:00 PM: .[MEDICATION(S)] Tablet 5000 UNIT . [MEDICATION(S)] Diskus Aerosol Powder Breath Activated 100-50 MCG/DOSE ([MEDICATION(S)]-Salmeterol) . [MEDICATION(S)] Sodium Capsule 100 MG . [MEDICATION(S)] Skin Protectant Ointment 50 % (Skin Protectants, Misc.) . [MEDICATION(S)] Tablet 500 MG . [MEDICATION(S)] Tablet 50 MG . Senna Tablet 8.6 MG (Sennosides) . [MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) MG/3ML . Review of R922's March 2022 TAR revealed 1 treatment not given on 3/22/22, afternoon shift: .[MEDICATION(S)] Powder 0 UNIT/GM (grams)([MEDICATION(S)]) . R925 Review of the clinical record revealed R925 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R925 was cognitively intact. Review of R925's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Tablet 5 MG . [MEDICATION(S)] Tablet 10 MG . [MEDICATION(S)] Tablet 50 MG . [MEDICATION(S)] Tablet 3.125 MG ([MEDICATION(S)]) . [MEDICATION(S)] HCl Tablet 500 MG . [MEDICATION(S)] HCl Capsule 5 MG . R927 Review of the clinical record revealed R927 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R927 had moderately impaired cognition. Review of R927's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .Famotidine Tablet 20 MG . Med Pass 2.0 . Review of R927's March 2022 TAR revealed one treatment not given on 3/22/22, afternoon shift: Orthosis/Splint to be applied to: L elbow ext. splint & palm protector, apply after breakfast and remove before dinner . Resident #901 On 4/12/22 the medical record for R901 was reviewed and revealed the following: R901was admitted into the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Review of R901's March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] At 5:00 PM: .[MEDICATION(S)] 800 MG Tablet . At 9:00 PM: .[MEDICATION(S)] Sodium Tablet 5 MG . [MEDICATION(S)] Tablet 2 MG .[MEDICATION(S)] HCl Tablet 25 MG .Sodium [MEDICATION(S)] Tablet 650 MG . A Review of R901's March 2022 treatment administration record (TAR) revealed the following treatments were ordered by the Physician but not completed on 3/22/22: Evening shift treatment: .cleanse COCCYX and SACRUM wounds with wound cleanser and pat dry. use kerlix to pack wound. Cover with 4x4 gauze and ABD pad. Secure with tape . Resident #910 On 4/12/22 the medical record for R910 was reviewed and revealed the following: R910 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Review of R901's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] At 9:00 PM: .[MEDICATION(S)] HCl Tablet 10 MG . [MEDICATION(S)] Tablet 40 MG .[MEDICATION(S)] Tablet 50 MG .[MEDICATION(S)] Tablet 5 MG ([MEDICATION(S)]) .Lactobacillus Capsule .[MEDICATION(S)] Tablet 25 MG .[MEDICATION(S)] Tablet 10 MG ([MEDICATION(S)]) .[MEDICATION(S)] Capsule 300 MG .Med Pass 2.0 . At 10:00 PM: .[MEDICATION(S)] Tablet 4 MG ([MEDICATION(S)] HCl) . Resident #915 On 4/13/22 the medical record for R915 was reviewed and revealed the following: R915 was admitted into the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Review of R915's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] At 9:00 PM: .[MEDICATION(S)] Solution 0.005 % .Med Plus 2.0 4 oz . Resident #918 On 4/12/22 the medical record for R918 was reviewed and revealed the following: R918 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Review of R918's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] At 9:00 PM: .[MEDICATION(S)] Concentrate 2 MG/ML . [MEDICATION(S)] Tablet 7.5 MG .[MEDICATION(S)] Sodium Tablet 10 MG .[MEDICATION(S)] Sodium Extended Capsule 100 MG (for seizures) .[MEDICATION(S)] Sodium Tablet 10 MG .[MEDICATION(S)] Tablet 200 MG (for seizures) .[MEDICATION(S)] Capsule 100 MG (for seizures) .Oyster Shell Calcium Tablet 500 .[MEDICATION(S)] Tablet 10 MG . At 10:00 PM: .[MEDICATION(S)] Capsule 300 MG . Resident #921 On 4/12/22 the medical record for R921 was reviewed and revealed the following: R921 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Review of R921's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] At 9:00 PM: .[MEDICATION(S)] Tablet 20 MG . [MEDICATION(S)] Tablet 3 MG .[MEDICATION(S)] Tablet 15 MG .[MEDICATION(S)] Powder .[MEDICATION(S)] Sodium Capsule 100 MG .[MEDICATION(S)] XR Tablet Extended Release 24 Hour 50-1000 MG ([MEDICATION(S)]-[MEDICATION(S)] HCl ER) .Oyster Shell Calcium/Vitamin D Tablet 500-200 MG-UNIT (Calcium Carb-[MEDICATION(S)]) .Senna Tablet 8.6 MG .Med Pass 2.0 . Resident #924 On 4/12/22 the medical record for R924 was reviewed and revealed the following: R924 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Review of R924's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] At 5:00 PM: .Enteral Feed Order-every evening and night shift for Difficulty chewing and swallowing-[MEDICATION(S)] 1.5 at 67 cc per hour-Start at 5 P.M for 15 hours . At 9:00 PM: .[MEDICATION(S)] Tablet 20 MG .[MEDICATION(S)] Tablet 2.5 MG (blood thinner) .[MEDICATION(S)] Tablet 25 MG . A Review of R924's March 2022 TAR revealed the following treatments were ordered by the Physician but not completed on 3/22/22: Evening shift treatment: .Triad paste to coccyx Q (every)-shift every shift for skin protection . R911 On 4/11/22 at 1:20 p.m., R911 was in bed with Family Member 'T' visiting at the bedside. When asked about their care at the facility and if they had received their medications in a timely manner, R911 stated, Sometimes they (facility) don't have a nurse at all. Sometimes the DON has to step in and do it . Family Member 'T' explained that on 3/19/22 at 6:15 p.m., she went to go look for a nurse and could not find one and she had to change R911's brief by herself after he had an episode of diarrhea . I was not able to find anyone until about 7:30 p.m. Resident 911 explained on another occasion, he was frantically ringing the bell and was not getting any response. Family Member 'T' reported, It was on 3/22/22 at 6:00 p.m., when I was visiting around 7:30 p.m., the bell (call light) was pressed because R911 wanted his pain meds. Family Member 'T' stated, At 7:39 p.m., I went to look for the nurse and was told that the nurse that was supposed to work on the 3:00 p.m. shift did not show up. Family Member 'T' further stated, He (R911) had not received his pain meds by the time I left the facility at 11:00 p.m. Review of the clinical record revealed R911 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the admission MDS assessment dated [DATE], R911 was cognitively intact. Review of R911's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Tablet 80 MG . [MEDICATION(S)] Tablet Disintegrating 15 MG . Senna Tablet 8.6 MG . Aspirin Tablet 325 MG . [MEDICATION(S)] Tablet 6.25 MG . [MEDICATION(S)] Sodium Capsule 100 MG . [MEDICATION(S)] Sulfate Tablet 325 . [MEDICATION(S)]-Salmeterol 100-50 MCG/DOSE . [MEDICATION(S)] Tablet 400 MG . [MEDICATION(S)] HCl Tablet 1000 MG . [MEDICATION(S)]-[MEDICATION(S)] Tablet 24-26 MG . [MEDICATION(S)] HCl Tablet 5 MG . Give 1 tablet by mouth every 4 hours for pain . [MEDICATION(S)] Ointment 500 UNIT/GM . R917 Review of the clinical record revealed R917 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the quarterly MDS assessment dated [DATE], R917 was cognitively intact. Review of R917's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Tablet 20 MG . [MEDICATION(S)] XR Tablet Extended Release 24 Hour 200 MG . [MEDICATION(S)] ER Tablet Extended Release 24 Hour 500 MG . R920 Review of the closed clinical record revealed R920 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the admission MDS assessment dated [DATE], R920 was cognitively intact. Review of R920's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .: GuaiFENesin ER Tablet Extended Release 12 Hour 600 MG . [MEDICATION(S)] Capsule 100 MG . at 22:00 (10:00 p.m.) [MEDICATION(S)] Solution 20 GM/30 ML . at 18:00 (6:00 p.m.) R923 Review of the closed clinical record revealed R923 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the admission MDS assessment dated [DATE], R923 was cognitively intact. Review of R923's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .: [MEDICATION(S)] Tablet 5 MG . Senna Tablet 8.6 MG . [MEDICATION(S)] Tablet 50 MG . [MEDICATION(S)] Capsule Delayed Release Particles 20 MG . [MEDICATION(S)] Sodium Capsule 100 MG . Famotidine Tablet 20 MG . [MEDICATION(S)] Tablet 400 MG . at 22:00 (10:00 p.m.) [MEDICATION(S)] Tablet 10 MG . at 18:00 (6:00 p.m.) [MEDICATION(S)] Capsule 300 MG . at 18:00 [MEDICATION(S)] Tablet 10-325 MG ([MEDICATION(S)]-Acetaminophen) . at 1800 R926 Review of the clinical record revealed R926 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R926's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .: [MEDICATION(S)] Tablet 40 MG . [MEDICATION(S)] Tablet 25 MG . [MEDICATION(S)] Tablet 5 MG . [MEDICATION(S)] Sodium Tablet 100 MG . [MEDICATION(S)] Tablet 25 MG . Omeprazole Capsule Delayed Release 20 MG . at 16:30 (4:30 p.m.) Pepcid Tablet 20 MG . Saline Nasal Spray Solution 0.65 % . at 18:00 (6:00 p.m.) Pratropium-[MEDICATION(S)] Solution 0.5- 2.5 (3) MG/3 ML . at 18:00 & 22:00 [MEDICATION(S)] Ointment 500 UNIT/GM . On 4/13/22 a facility document titled Abuse Program was reviewed and revealed the following: Policy: It is our policy to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants, clinicians, volunteers, staff, or other agencies servicing the resident, family members or legal guardians, friends, or other individuals. The focus on the resident as the locus of control and supporting the resident in making their own choices and having control of their daily lives is the approach of person centered care .Definition of Neglect, Mistreatment and Misappropriation of Resident's Property . Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. A resident has been neglected whenever ALL of the following conditions are satisfied: 1. The facility fails to provide or arrange for medical, dental, nursing, dietary, physical therapy, pharmacy, rehabilitation, psychological, speech, audiological or other treatments or services to the resident in question; and 2. The facility's failure to provide these treatments or services is either intentional or the result of carelessness; and 3. The failure to provide these treatments or services results in a deterioration of the resident's physical, mental or emotional condition .Examples of Neglect: The following actions or omissions constitute neglect whenever they result in a noticeable deterioration of the resident's physical, mental or emotional condition: 1. Failure to carry out a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (i.e. lack of appropriate wound care) 2. Failure to carry out nursing, treatment, or individual resident care plans. 3. Failure to notify a resident's attending physician and other responsible persons in the event of an incident involving that resident. 4. Failure to notify a resident's attending physician and other responsible persons in the event of a significant change in that resident's physical, mental or emotional condition. 5. Failure to provide an adequate number of nutritionally balanced, properly prepared, and medically appropriate meals. 6. Failure to adequately supervise the whereabouts and/or activities of a resident. 7. The elopement of a resident who remains missing for more than two (2) hours and/or where there is a strong potential that there may be an immediate threat to the resident's life. 8. Failure to take precautionary measures that have been ordered and which are reasonably necessary to protect the health or safety of a resident. 9. Refusal or failure to provide any service to the resident for the purpose of punishing, disciplining or retaliation. 10. Allowing the physical environment to deteriorate to the point that residents are subject to hazardous situations such as electrical, water or structural hazards. 11. Leaving a resident lying in feces or urine soaked linens for an extended period of time. 12. Leaving a resident restrained in other than an immediate emergency, without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 13. Inappropriate transfers resulting in injury. 14. Lack of adequate monitoring of necessary lab values. 15. Failure to provide goods and services necessary to avoid harm or mental anguish . The immediacy was removed when the facility implemented the following: -Posting of a designated staff member at front desk who was responsible for reporting staffing issues to management. -Facility staff were in serviced on scheduling expectations and everyone's responsibility to ensure adequate staffing for appropriate care of our residents. -Staffing policy was reviewed with updates to the staffing policy immediate and ongoing education on policy specifics to all staff. Management or designee are rounding at end and beginning of shift to ensure adequate staffing.

Based on observation, interview, and record review the facility failed to prevent the development of a pressure ulcer and consistently complete and document skin assessments for one resident (R45) of two resident's reviewed for pressure ulcers, resulting in the development of a stage III pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer) on their coccyx area. Findings include: On 1/31/22 at approximately 10:35 a.m., R45 was observed in room laying up in bed. R45 was queried if they had a wound and they indicated they did, and it was on their back. R45 was observed to have an alternating pressure mattress with the setting on float and normal pressure. On 2/1/22 The medical record for R45 was reviewed and revealed the following: R45 was last admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R45's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1-18-21 revealed R45 needed extensive assistance with most of their activities of daily living. R45's BIMS score (brief interview of mental status) was five indicating severely impaired cognition. Section M indicated that R45 was at risk of developing pressure ulcers. A review of R45's careplan revealed the following: Problem start date 8/23/2019 .Category: Skin Integrity. I am at risk for alteration in skin integrity due to decreased mobility .approach start date 8/23/2019-Weekly skin assessment by licensed nurse An initial Nursing assessment dated [DATE] revealed R45 had no pressure ulcers upon admission to the facility and had a Braden score of (16) indicating a mild risk of pressure ulcer development. Further review of the assessment indicated if a resident had a Braden score of 18 or less/and or skin integrity problems that were identified then an interdisciplinary referral and careplan should be initiated. A Physicians order dated 1/11/21 revealed the following: weekly skin assessment. Once a day on Mon (Monday) Further review of the medical record revealed skin assessment sheet documentation for February 2021 which indicated a brief description of the skin (redness or open areas, blisters, bruises, skin tears etc.) a diagram of where skin impairments were located and measurements of any new opened areas. No weekly skin assessment sheets were available for January 2021. A Nursing note dated 1/11/21 revealed the following: .Resident guardian notified of resident arrival to [NAME]. Resident is alert and has s/s (signs/symptoms) of weakness Resident is confused about where he is Resident is resting in bed with call light in place. Dr aware of resident arrival. Guardian notified of resident arrival. Resident left underarm pit is swollen and tender. An Interdisciplinary team note dated 1/19/21 revealed the following: QUARTERLY THERAPY SCREEN completed per MDS 1/4 assessment. [R45] is an 85 y/o (year old) LTC (long term care) resident to [Name of facility] with a complex past medical history that put pt (patient) at risk for decline in function .Pt. was recently d/c (discharged ) to our sister facility due to Covid + on 12/29 readmitted on [DATE]. Based on last MDS assessment it appears that pt is exhibiting a decline in bed mobility, TFs (transfers) and w/c (wheelchair) mobility . A weekly wound note dated 1/29/21 revealed the following: Weekly Wound rounds completed by wound care team. Resident noted to have Stage 3 to Coccyx/Left Buttocks. status of not healed. Initial wound encounter measurements are 2 x 5.5 x 0.2 cm. There is moderate amount of sero-sang drainage noted. Wound bed has necrotic base epithelization. The periwound skin moisture is normal, the periwound skin exhibited: Scarring, [CONDITION(S)]. Resident has order for low air loss mattress, See Tars for new orders. Writer inform Doctor and resident Guardian. Resident tolerated dressing changes with no problem. A wound care evaluation completed by the Nurse Practitioner dated 1/29/21 revealed the following: Chief Complaint-This information was obtained from the caregiver. This patient was seen today as a consultation for evaluation of the patient's wounds .Location: Trunk. Context: Pressure ulcer .Wound #2 Coccyx /left buttocks is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2cm (centimeters) length x 5.5cm width x 0.2cm depth, with an area of 11 sq (square) cm and a volume of 2.2 cubic cm. There is a moderate amount of sero-sanguineous drainage noted. Wound bed has Necrotic Base epithelialization. The periwound skin moisture is normal. The periwound skin exhibited: Scarring, [CONDITION(S)] .General Notes: Irregular edges .Diagnosis 1.Pressure ulcer stage Ill coccyx/left buttocks . No documentation prior to 1/29/21 revealed pressure ulcer development for R45 was unavoidable. On 2/02/22 at approximately 11:30 a.m., during a conversation with the Director of Nursing (DON) the DON was queried for the skin assessment sheet documentation for the weekly skin assessments completed in January 2021. The DON indicated that R45's wound developed on 1/29 but that it may have been earlier and was not identified. The DON then was observed reviewing the record and indicated that R45's coccyx wound was identified on 1/29/21. The DON was queried for the missing weekly skin assessments sheets documenting the condition/integrity of R45's skin from January 2021. On 2/02/22 at 1:36 p.m., the DON was queried again for the missing skin assessment sheets for January 2021 and indicated they could not provide any of the weekly skin assessment sheets for January 2021. The DON indicated that all they had available was the January 2021 MAR (medication administration record) that indicated a skin assessment was done but did not have any of the weekly skin assessment sheets that documented the integrity and condition of R45's skin. The DON was then queried how the facilty staff identify the beginigns of skin breakdown, and they reported the Nurses should have been documenting the skin condition/integristy on the required weekly skin assessment sheets. No skin assessments sheets identifying the condition of R45's skin for Janaury 2021 were received before the end of the survey. On 2/2/22 a facility document titled Skin-Pressure Ulcer Guidelines was reviewed and revealed the following: POLICY: Based on the Comprehensive Assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual 's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing .9. Weekly skin and oral cavity assessments will be completed on each patient regardless of Braden Scale score or skin condition. Assess skin when a new risk factor develops known to be associated with an increased risk of breakdown. The outcome of this assessment shall be documented on the backside of the treatment record. This will be completed by the primary nurse and/or nurse designee .

This citation pertains to intake #MI 711. Based on interview and record review, the facility failed to prevent neglect (provide necessary medications, assessments and monitoring) to one (R#702) of seven residents reviewed for abuse, resulting in lack of adequate pain management, delayed identification of and treatment of [REDACTED]. Findings include: A complaint was submitted to the State Agency that alleged R#702 had presented to the emergency room with right knee swelling and warmth, which was later confirmed at the hospital to be multiple fractures. The allegations further expressed concern that the facility had not reported any incidents which might have resulted in an injury and were concerned about neglect of R#702. Review of R#702's hospital records from 7/11/19 to 7/15/19 included in part, the following documentation: .admitting [DIAGNOSES REDACTED].presented the ED (emergency department) from (name of facility) for right knee swelling and warmth. Patient A/OX0 (alert and oriented not to time, place, person, or situation) at baseline .Today staff nursing home noted redness and warmth to right knee .R (right) leg XR (x-ray) showed comminuted intra articular [MEDICAL CONDITION] tibia appears to be (name of a type of classification system to determine severity, not only increased energy imparted to the bone at the time of injury, and frequently there is extensive soft-tissue injury) and possible [MEDICAL CONDITION] metadiaphyseal region of the femur and the proximal aspect of the fibula .Patient was to be discharged and to follow with surgery outpatient however .Patient to be admitted for cardiology consult .Past Medical History .Assistance needed for ambulation and movement pt (patient) needs hoyer lift and 2+ person assist in ECF (extended care facility) .Multiple x-rays of her right lower extremity were obtained and revealed a comminuted intra-articular [MEDICAL CONDITION] tibia with a possible fibula fracture. A CT (computed tomography - a scan that can reveal anatomic details of internal organs that cannot be seen in conventional x-rays) scan of her right knee confirmed the intra-articular tibial fracture and a nondisplaced proximal fibula fracture .On further questioning of (name of R#702) later in the day she replied yes to being dropped at her ECF and was tearful .She is A & O x 0-1, so it is unclear as to what actually happened at her ECF. On discussion with the nurse at the ECF, there were no notes documenting an injury .She does have a previous femur fracture while residing at the same facility in (YEAR) .Concern for neglect - per records ECF denied knowledge of the patient falling or any other event that could have caused her fracture - upon questioning (name of R#702) she became upset and cried when asked if she was dropped and adamantly said yes. When asked if she rolled out of bed or tried to get out of bed she said no. At baseline she is bedbound and staff uses hoyer lift for transfers - concern was that she was dropped by staff resulting in injury and it was not reported . An onsite investigation into the above complaint was conducted on 7/22/19. R#702's clinical record was reviewed and revealed the following: R#702 was admitted into the facility on [DATE] and readmitted on [DATE]. As of this review, R#702 had not returned to the facility following the hospital transfer on 7/11/19. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R#702 scored a 9/15 on brief interview for mental status exam (which indicated moderately impaired cognition), exhibited no behavior concerns, and required two plus persons for physical assistance with transfers, and had no falls during this assessment period. Progress notes revealed the following: On 7/7/19 at 7:20 PM, Licensed Practical Nurse (LPN M) documented, Resident refused shower. Writer and witness attempted 3 x to transfer resident to shower chair; after each attempt resident would try to stand, and begin to sob. Left vmail (voicemail) for (name of Legal Guardian). On 7/10/19 at 10:15 PM, LPN O documented, resident was offered a shower x 3, she started crying and stated she doesn't want a shower, she was given a bed bath instead .no other skin issues noted. On 7/11/19 at 8:22 AM, LPN N documented, resident crying c/o (complaining of) rt. (right) leg pain noted rt. leg swollen painful and warm to touch medicated for pain with little relief transferring resident out to (name of local hospital) for further evaluation .message left with primary Dr. Spoke with DON (Director of Nursing) regarding transfer of the resident. On 7/11/19 at 9:50 AM, LPN Q documented, in part: Resident transfer to hospital via (name of ambulance transport) x 2 man unit at 9:51 AM. Physician orders [REDACTED].>Pain assessment q (every) shift and record pain score .Use FLACC Scale (Face, Legs, Activity, Cry, Consolability scale used to assess pain for individuals that are unable to communicate their pain) [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (milligrams) 1 po (by mouth) Q4 prn (every four hours as needed) [MEDICATION NAME] 325 mg 2 po Q4prn Review of R#702's Medication Administration Records (MARs) for (MONTH) 2019 revealed there was only one entry of pain noted on 7/11/19 which read, yes. Review of the documented prn medication that had been administered to R#702 revealed the resident had not received any [MEDICATION NAME] for (MONTH) 2019. R#702 had received [MEDICATION NAME]-acetaminphen 5-325mg on 7/10/19 at 11:28 PM which a documented PRN Reason: Pain level = 9 and PRN Result = NE (not effective) and 7/11/19 at 8:20 AM which documented a PRN Reason: Pain level = yes and PRN Result = NE. There was no documentation of whether the Physician had been contacted regarding the crying out upon standing on 7/7/19, and the unresolved pain first identified on 7/10/19 at 11:28 PM, or what other interventions had been implemented for pain relief. Review of the notes section of the bottom of the MAR documented, 07/11/2019 09:49 AM - Pain Level: yes Comment: c/o right leg pain. There was no other documentation of pain assessment, or medications administered for (MONTH) 2019. On 7/22/19 at 11:45 AM, a phone interview was conducted with LPN O. When asked to recall the events regarding R#702's hospital transfer, LPN O reported, I work the evening shift. That day when I started on shift, that day was her shower day. Asked assigned CNA (name of Non-Certified Nursing Assistant C) to give (R#702) shower. Sometimes she refused. She came back and said she (R#702) didn't want a shower and was crying. I said ok and she was going to give bed bath. I didn't see her (R#702) so I assumed she gave her a bed bath. After that no other activity until end of shift and while counting medications, (name of R#702) room was near the cart and I heard her crying. We finished counting meds and asked her why she was crying. She started pointing to right leg, she was crying continuously. I went back with oncoming nurse and I knew something was wrong. She has a history of broken leg in past. I knew it was hurting her. I gave her the pain pill and told oncoming nurse who was assigned at that time. Cause the oncoming nurse was there with me, she knew (about R#702's pain and complaint of right leg). When I asked the CNA why she (R#702) was crying like that, she said 'I did absolutely nothing'. When asked to provide name of the nurse aide, LPN O reported, (NA C). LPN O further reported, I hear in the morning the leg was bruised. I made sure she got the [MEDICATION NAME] (dose administered on 7/10/19 at 11:28 PM) cause I knew she had a history of [REDACTED]. When asked if the DON, Administrator or Physician had been contacted, LPN O stated, I reported to (name of oncoming LPN N). When I went with LPN N to look at the leg it (bruise) wasn't showing but I knew the history on that same leg, if touch it she was going to cry. On 7/22/19 at 11:44 AM, LPN N was contacted by phone for an interview, but there was no answer and a message was left. There was no further contact provided by the end of the survey. On 7/22/19 at 12:01 PM, LPN M was contacted by phone for an interview, but there was no answer and a message was left. There was no further contact provided by the end of the survey. On 7/22/19 at 12:04 PM, LPN Q was interviewed by phone. When asked to recall the events regarding R#702's complaints of pain and hospital transfer, LPN Q reported, I came on the day shift and (name of LPN N) sent her (R#702) out. A CNA (unidentified staff) approached me and said one of the residents complained of pain and leg kinda swollen. I hadn't even clocked in yet. Nurse (LPN N) came and asked if I wanted to take keys (to the medication cart) and I said no, lets do walking rounds. Nurse (LPN N) said she was in pain last night and she had gone in and they assessed her. I asked (name of LPN N) what did you do? I said don't just leave her like this and she (LPN N) called the Doctor. She (LPN N) should've done everything she was supposed to do. As in there was a resident in bed one that said she fell in shower .When we touched her, she yelled out. Decided to send her out, too long to wait for an x-ray. When asked to confirm the nurse that was working the midnight shift from 11:00 PM to 7:00 AM, LPN Q reported, It was LPN 'N'. On 7/22/19 at approximately 10:00 AM, the Director of Nursing (DON) was asked to provide any incident/accident reports for R#702. The DON reported they were in the process of completing an investigation and that the Nurse Aide (NA C) was currently suspended pending investigation. On 7/22/19 at 12:34 PM, an interview was conducted with the Assistant Director of Nursing (ADON). At that time, the ADON confirmed the names of staff that had worked with R#702 on 7/10/19 and 7/11/19, with the exception of an agency nurse aide (no specific name/information was provided by the end of the survey). On 7/22/19 at 12:45 PM, the ADON was asked to review the 7/7/19 progress note which identified R#702 was crying out upon attempting to stand for a shower and what had been done to investigate further. The ADON was unable to offer any further explanation. When asked about the delay in administration of pain medication as documented on the MAR when there were orders for every 4 hours PRN on 7/10/19 to 7/11/19, the ADON confirmed the documented administration and was unable to offer any further explanation. At that time, the ADON was requested to provide the controlled substance documentation for R#702's use of [MEDICATION NAME]-[MEDICATION NAME], personnel file for NA C, including any education/competency documentation. On 7/22/19 at approximately 2:00 PM, review of R#702's Controlled Drug Receipt/Record/Disposition for the [MEDICATION NAME]-[MEDICATION NAME] documented only three administrations in (MONTH) (7/9 at 9:00 PM, 7/10 at 11:30 PM, and 7/11 at 8:20 AM). On 7/22/19 at 12:54 PM, a phone interview was conducted with NA C. At that time, NA C reported she had still been on suspension pending investigation and had not heard anything yet from the facility as to when, or if she could return. When asked to recall the events surrounding her suspension, NA C reported, They said I dropped (name of R#702). When asked if NA C had transferred R#702 during the afternoon shift on 7/10/19, NA C stated, Me and another person. She's agency transferred her into bed from the wheelchair. I don't have a gait belt. I had one side and the other girl had other side. When asked if R#702 required two person assistance with transfers, and if so, was a mechanical lift used, NA C reported, She needs two person, it was her shower day. Went to DON cause nurse insisted I give her a shower. I knew her history of falling in shower. I left it alone till 7:30 (PM) said giving bed bath and had to pass trays first. I gave her a bed bath and she was fine and went to sleep. When asked if she had received a bed bath by just NA C, NA C stated, Yes. NA C further reported, She (R#702) knows how to point to something if wrong. When asked what the facility's policy or protocol was for transferring residents safely, NA C stated, To use two people. When asked to describe how R#702 had been transferred from the wheelchair to the bed on 7/10/19, NA C reported, When there are two people, one has one side, the other has the other side and we lift up under her arms and set her down. She's on heavy side. When asked how long she had been working at the facility and what training had been provided regarding transfers, NA C reported, Been there about 2-3 months, I don't have my 90 days in. This is my first time working in a nursing home. When asked how long she had been on suspension, NA C stated, They suspended me last on 7/11/19. I did last rounds when I came to (name of R#702) she, the afternoon nurse (LPN O) was talking with the midnight nurse (LPN N) about her leg and the midnight nurse (LPN N) said 'Well everytime her leg hurts with shower. Still traumatized of events years ago.' She (R#702) knows how to point. Lately she's been crying cause she was used to no roommate. On 7/22/19 at 1:58 PM, an interview was conducted with the DON. At that time, the DON reported, The CNA (NA C) is not terminated yet. Still suspended pending investigation. When asked about why the incident report of an injury of unknown origin had not been reported to the State Agency until 7/17/19, the DON reported, Part of the problem was I was out with migraine. I asked the ADON and when I returned, the ADON's report was put into a folder. We were focused on trying to get the x-ray but her guardian hasn't signed the release form yet. At that time, the DON was asked about the delay in administration of the pain medication, unsafe transfer, as well as identification and investigation into R#702's injury of unknown origin and was unable to offer any further explanation. On 7/22/19 at 3:44 PM, an interview was conducted with the ADON. When asked about the staff's access to gait belts, and safe transfer protocol, the ADON reported, They get a gait belt evaluation and also checked off to display they know how to use the gait belt. Competency they get in orientation. The ADON was requested to provide NA C's competency documentation since her date of hire. On 7/22/19 at 3:52 PM, an interview was conducted with the DON. When asked if a resident that requires 2+ person physical assistance with transfers is done without the use of mechanical lift, the ADON reported, Can use gait belt with two people for max assist residents. When asked if a transfer utilizing holding under the arms was considered safe, the DON reported, I'm not going to answer that. On 7/22/19 at 4:27 PM, the ADON reported there was no documentation of a competency evaluation. The ADON provided in-service education regarding transfers that NA C attended on 6/7/19. When asked what type of competency evaluation was completed during orientation, the ADON reported, At a minimum do transfers, perineal, gait belt use. As for (name of NA C) I don't have any competency and can't explain why. Review of the facility's Abuse and Neglect Prohibition Policy dated Revision Date: (MONTH) 2010 documented, in part: .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The interpretive guideline also includes the concepts of inappropriately monitoring and supervising when it further explains, neglect occurs when facility staff fails to monitor and/or supervise the delivery of resident care and services to assure that care is provided to resident need. Additionally, the work willful is not part of the definition, so even unintended lack of service that causes harm will be deemed neglect . Review of the facility's Abuse Investigation and Reporting policy dated Revised (MONTH) (YEAR) documented, in part: .If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual . Review of the facility's Change in a Resident's Condition or Status policy dated Revised (MONTH) (YEAR) documented, in part: .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) .accident or incident involving the resident .discovery of injuries of an unknown source .specific instruction to notify the Physician of the changes in the resident's condition . Review of the facility's Safe Lift/Transfer of Residents policy dated Revised 8/27/15 documented, in part: .Transfer Belts are to be used when indicated with all patients' transfers. The transfer belt provides a secure firm hold to help stabilize and manage patients during ambulation and transfers .

The two citations pertain to intake #'s MI 9 and MI 7 This citation has two deficient practices. Deficient Practice #1 Pertaining to MI# 9 Based on observation, interview, and record review, the facility failed to utilize a gait belt during a transfer of one resident (R#502), of two residents reviewed for falls, resulting in a fractured humerus (long bone in the upper arm), pain documented as a score of 10/10, and a decrease in the resident's bed mobility status. Findings include: On 2/20/19 at approximately 9:40 AM, R#502 was observed in bed asleep. R#502 appeared to be a larger man with a right [MEDICAL CONDITION]. A prosthetic leg was observed at the bedside in the seat of R#502's wheelchair. On 2/20/19 a review of a facility investigation file for a fall sustained by R#502 was conducted. The filed contained a typed document titled, 5 Day Investigation-(R#502) that read, .On (MONTH) 17, 2019 he was in his room being transferred/assisted to bed from his wheelchair. (Certified Nursing Assistant (CNA) 'D') was standing alongside the bed and wheelchair when resident he lost his balance causing him to fall on his right side onto the bed. There was a pop heard by (CNA 'D'), who immediately reported the incident to his Charge Nurse (Registered Nurse (RN) 'E') .Nurse ('E') and CNA ('D') returned to the bedside of (R#502). Upon assessment resident right shoulder looked displaced . A review of RN 'E's interview of the event was reviewed and read, I was getting ready to do the blood sugar on resident .when (CNA 'D') came to me and said that he heard a popping sound when he transferred (R#502) to bed. I went to examine (R#502), upon examination his shoulder looked like it was out of place. I asked (CNA 'D') if he rolled (R#502) on his side. (CNA 'D') said he transferred (R#502) into the bed and when he rolled im <sic> over he heard a snapping sound .(R#502) complained of pain and I medicated him .I did noiot <sic> see (CNA 'D') with a gait belt . A review of CNA 'D's interview of the event was reviewed and read, On 1/17/19 I was transferring (R#502) from his wc (wheelchair) his bed without using a gait belt , when he lost his balance and fell on to the bed with him landing on his right side. I heard a snapping sound when he landed on the bed. I went to get the nurse (RN 'E') , I told her I heard the snapping sound. We both went to his room .When Nurse (RN 'E') moved his right arm (R#502) complained of pain . A review of R#502's Medication Administration Record [REDACTED]. A review of the radiology x-ray results contained in the file read, .Findings RIGHT SHOULDER: Findings: There is a moderately displaced fracture of proximal shaft of humerus .RIGHT SCAPULA: There is acute moderately displaced fracture of proximal shaft of humerus .RIGHT CLAVICLE: There is acute moderately displaced fracture of proximal shaft of humerus . A review of R#502's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#502's Minimum Data Set (MDS) assessments for 11/6/18 and 2/2/19 was conducted. It was noted both MDS assessments had R#502 requiring extensive two person assistance with transferring. An ADL (activity of daily living)/mobility care plan was reviewed and had an approach start date of 5/17/18 that read, I require max (2) person assist with transfers. It was discovered a therapy evaluation had been performed on 11/5/18 that indicated the resident was a maximum assist of one person, making it unclear through conflicting documentation what R#502's transfer status was. Further review of R#502's MDS assessments showed a decline in R#502's bed mobility having been documented as an extensive one person assist on the 11/6/18 MDS and requiring extensive two person assistance on the MDS dated [DATE], after the fall. On 2/20/19 at 3:35 PM, an interview with the facility's Administrator and Director of Nursing was conducted regarding R#503's fall resulting in a fracture. It was explained that CNA 'D' did not use a gait belt for transferring R#502 and during the transfer, R#502 fell into the bed and sustained a fracture to his right humerus, causing a decline in his bed mobility status. A request was made for a policy on the use of gait belts when transferring residents. A facility policy titled, Falls-Clinical Protocol with a revision date of (MONTH) 2012, was received and reviewed; however, this policy did not address the use of gait belts when transferring residents. Deficient Practice #2 Pertaining to intake #MI 7 Based on interview and record review, the facility failed to ensure the proper function of alarm doors for one resident (R#503) of one resident reviewed for elopement, resulting in the resident eloping from the facility. Findings include: On 2/20/19 a review of a facility investigation file for R#503's elopement on 12/8/18 was reviewed. The file contained a typed document titled, 5 Day Investigation that read, .Resident passed through second floor fire door at approximately 5:35 a.m. Resident was discovered going between cars along the north exterior wall of the building by two employees .Both employees approached resident (R#503) who was clothed and wearing shoes. Nurse ('F') noted a wrist band on his wrist. Both persons immediately assisted (R#503) into the building .Resident (#503) was taken back to the second floor north unit to be assessed by Nurse ('H') .At approximately 5:48 (a.m.) the DON (Director of Nursing) notified Administrator (name redacted) of the resident exiting the building .(DON) arrived at the building at approximately 6:30 a.m. and immediately went to the second floor to investigate .The 2 north door was pushed open and the alarm did not sound. The battery was immediately replaced and when the door was opened the alarm sounded . On 2/20/19 at 3:35 PM, an interview with the facility's Administrator and DON was conducted regarding R#503's elopement on 12/8/18. During the interview, the DON confirmed that the battery in the alarm door was not functioning and R#503 was able to exit the second floor into the stairwell and exit the building from the stairwell door. At that time, a request was made for evidence that the door was tested for proper functioning prior to R#503's elopement; however, no documentation was provided by the end of the survey. A request was made for a policy pertaining to checking the function of alarm doors and a policy titled Elopements with a revision date of (MONTH) 2007 was provided. This policy was reviewed and did not address routine or periodic function of facility doors. A review of a second facility provided document titled, Rights of Resident in (State Name Redacted) Nursing Facilities was reviewed and read, .Safe Environment: You have a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living . The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey.

This citation refers to Intake Number(s): MI 383. Based on observation, interview, and record review, the facility failed to prevent one (#801) of five residents reviewed for elopement, who had severely impaired cognition and could ambulate independently from exiting the facility when an alarmed emergency exit door on the 2 North unit was not properly engaged and a second door on the 2 Central unit was jammed and did not alarm when opened, resulting in an Immediate Jeopardy (IJ) when resident #801 exited the building. This had the likelihood to result in serious injury, harm, and/or death to all the residents on the unit who are independently ambulatory with impaired cognition. The Immediate Jeopardy was identified on 7/18/18 at 3:00 P.M. The Immediate Jeopardy started on 6/29/18. The administrator was notified on 7/18/18 at 4:09 P.M. and a plan of removal was requested to remove the immediacy. The immediacy was removed on 7/18/18 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the facility's deficient practice was not corrected and remained at a pattern that is not immediate jeopardy. Findings include: On 7/18/18 at 12:34 P.M., an investigation conducted by the facility regarding an elopement by R#801 was reviewed. The 5 Day Investigation documented the following: On (MONTH) 29, (YEAR) (R#801) was last noted to be on his unit at approximately 6:50 A.M. by CENA (Certified Nursing Assistant - CNA) A. At approximately 7:00 A.M. resident was noted missing and a Code White (missing resident) was immediately called by (Nurse F) .The (city name redacted) Police Department was notified at 7:09 A.M. by the Administrator. At 7:09 A.M. Resident was found by (Nurse B) and (the Administrator) at (business name redacted) Daycare located at (address redacted). An interview was conducted with (Daycare Director C). (Daycare Director C) states that (R#801) was seen at the front porch at 7:00 A.M. upon her arrival to the Daycare center. She further states that the resident sat in the rocking chair at the day care. (R#801) has the dexterity to ambulate safely without assistance .The fire alarm door on the second floor was found unlocked therefore it did not alarm to notify employees, thus; concluding that the resident exited from the second-floor fire exit door. The fire exit door was immediately locked and all other fire exit doors were checked and found to be locked . .Resident does not have any recall of events . .Wanderguard (a exit alert signaling system) was placed on resident . .procedure added to the Elopement prevention policy to include procedure for the fire exit doors/activation of the alarms for the facility fire exit doors . .In conclusion resident left the facility without notifying the staff through the fire exit door located on the second floor. The resident was located within nineteen (19) minutes and returned to the facility .Staff have been educated on appropriately locking the fire exit doors . On 7/18/18 at approximately 1:20 P.M., an observation of the second floor was conducted. R#801's room was located at the end of the 2 North hallway near an emergency exit door. Inside the emergency exit door was one flight of stairs that led downward to a door that opened to the back, north side of the facility into the parking lot. R#801 was observed lying in bed. An attempt to interview R#801 was made. R#801 appeared confused. When asked if he ever went outside, R#801 stated, I don't know what they are running. When asked if he ever left the building, R#801 stated, Yeah! I did! When asked how he left the building, R#801 stated, In my car. At that time, the emergency exit door at the end of the 2 North hallway was opened to test the alarm. The door produced a loud alarm when opened. Nurse Supervisor H retrieved a key to disengage the alarm. An observation of an emergency exit door located on the 2 Central hallway (around the corner and to the left of the 2 North unit) was conducted with Nurse Supervisor H. A sign on the door noted, Emergency Exit Only .Alarmed Emergency Exit .Stairway to outside only . An attempt was made to open the emergency exit door and it did not open. Nurse Supervisor H attempted to open the door by pushing the arm of the door and it did not open. Nurse Supervisor H used the key in the door and eventually was able to open the door. When the door opened, it did not alarm. Nurse Supervisor H stated, It was jammed or something. It's supposed to alarm. Nurse Supervisor H inserted the key multiple times to attempt to activate the alarm and was not successful. At approximately 1:35 P.M., the Maintenance Director came to the unit. When queried about how the door worked and if it stayed locked or open, the Maintenance Director reported it stayed locked to engage the alarm, but not locked where it could not be opened. The Maintenance Director stated, You just push the arm and open the door. When queried about why the door did not alarm when opened, the Maintenance Director attempted to use the key to engage the alarm and was not successful. The Maintenance Director stated, I'll have to check this out because something is not right here. The Maintenance Director took the cover off of the box attached to the door that contained the alarming mechanisms and a battery. The Maintenance Director changed the battery in the door, rechecked the door by closing it and opening it, and the door alarmed. When asked how often the emergency exit doors were checked to ensure they were functioning and the alarms were engaged, the Maintenance Director reported all the doors were checked every Friday. Logs for the emergency exit door checks were requested for the past year at that time. On 7/18/18 at 2:15 P.M., an observation was made of the outside of the facility beginning at the emergency exit door on the 2 North Unit that R#801 exited from. There were multiple dumpsters to the right of the door and the main parking lot for the facility. A sidewalk was located at the end of the parking lot/driveway near a main road. The daycare center was located one block from the facility. On 7/18/18 at 2:40 P.M., the Maintenance Director provided Exit Doors & Alarms Audit (Daily) forms from (MONTH) (YEAR) through (MONTH) (YEAR) which documented weekly audits of the doors with the last date checked being 7/13/18 (5 days prior). On 7/18/18 at 2:45 P.M., the Maintenance Director was interviewed about the emergency exit doors. The Maintenance Director reported that he checked all the doors and they were now working and alarming. When queried about R#801 exiting the building on 6/29/18, the Maintenance Director reported he was unaware of any residents exiting the building through a non-alarming emergency exit door. On 7/18/18 at 2:26 P.M., a telephone call was placed to Daycare Director C who was unavailable at that time. On 7/19/18 at 1:10 P.M., Daycare Director C returned the phone call and placed Daycare Employee D on the phone to be interviewed (Daycare Employee D was the person who found R#801 at the Daycare Center). Daycare Employee D reported she arrived at the Daycare center on 6/29/18 at approximately 7:00 A.M. and entered the building through the locked back door. Daycare Employee D stated, When I got into the building, he (R#801) was sitting in a rocking chair in the infant room. He was saying he was tired and wanted to go lay down. Daycare Employee D reported the front and back door of the center were kept locked when the building was closed and stated, But he must have got in through the front door because I had to unlock the back door to get in. Daycare Employee D reported there were no other employees present at the Daycare center when she arrived. Daycare Employee D stated, I called my manager and then called the police. Then we went outside (the employee and R#801) and they (staff from the facility) were driving down the street and the man (who worked at the facility) took him back to the nursing home. On 7/18/18 at 2:38 P.M., a telephone call was placed to Nurse B. There was no answer and a message was left. Nurse B was unable to be interviewed prior to the end of the survey. On 7/18/18 at approximately 3:00 P.M., the Administrator provided a list of residents who resided in the facility who were considered an elopement risk, including but not limited to R#801, R#802, R#803, R#804, and R#805. On 7/18/18 at 3:14 P.M., CNA A was interviewed via the telephone. When queried about the day R#801 eloped from the facility from the second floor, CNA A stated, I can't really tell you much. I think it was around 6:50 (A.M.) or something. My coworker noticed when doing rounds. CNA A indicated she was not assigned to R#801 on 6/28/18 midnight shift (which ended the morning of 6/29/19). CNA A reported R#801 was able to ambulate well independently. On 7/18/18 at 4:52 P.M., Nurse E (the charge nurse working on the 2 North unit on the 6/28/18 to 6/29/18 midnight shift) was interviewed via the telephone. Nurse E was asked what happened with R#801 on 6/29/18. Nurse E stated, I was told he was missing close to shift change (going into the day shift) somewhere around 6:50 A.M., close to 7. I placed the elopement code. After, the CNA went to the emergency door and opened it and the alarm didn't go off and she saw that the door was open downstairs. I called the code, called the (Administrator), grabbed the keys and got in the car and drove around the block. By the time I got back around, they already found him. Nurse E was asked if she ever witnessed R#801 attempting to exit the emergency exit door in the past. Nurse E stated, I have witnessed him in the past, but the alarm goes off. You can hear it on the whole unit. He has tried to get out before, but we've always been able to redirect him. On 7/18/18 at 4:56 P.M., R#810's clinical record was reviewed and revealed the following: R#801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#801 had severely impaired cognition (indicated by a Brief Interview of Mental Status - BIMS score of 4), had no wandering behaviors, and was independent with no required supervision for bed mobility, transfers, and walking in the room and on the unit. A progress note written by Nurse E on 2/16/18 at 7:17 A.M. documented, Writer heard door alarming, writer ran out of another residents room when I saw him standing at the opened emergency door on unit . A quarterly assessment progress note written by social work dated 5/6/18 documented, .(R#801) is up ambulating w/o assistance daily. He wanders the unit and in and out of peers rooms per staff. He is easily re-directed and has not been at risk for elopement. He is confused with short term, long-term memory loss and decision making deficits . The assessment did not mention the attempt to leave the unit through the emergency door on 2/16/18. Progress notes dated 1/2/18, 1/3/18, 1/5/18, 1/10/18, 1/25/18, 1/30/18 documented R#801 wandering up and down the hallway and/or in and out of other residents' rooms. A care plan dated 11/10/17 (prior to 6/29/18 when R#801 eloped from the facility) documented, I tend to wander and pace the unit. I will state that I have to go to work. I have gone into peers rooms. I will walk up and down the hallway but I don't seek to exit .I don't have a wanderguard. I have a [DIAGNOSES REDACTED].#801's attempt to exit the unit through the emergency exit door on 2/16/18. On 7/19/18 at 8:15 A.M., all elopement risk assessments from the past year for R#801 were requested from the Administrator. On 7/19/18 at 9:00 A.M., the Administrator was interviewed about the progress note that documented R#801 having a history of attempting to exit through the emergency exit door on the 2 North unit on 2/16/18. The Administrator reported she was unaware of it until the investigation started (for the 6/29/18 elopement). The Administrator stated, Now we took the keys (to the emergency exit doors) away from the nurses. They were addressing the situations, but not relocking/engaging the door alarms. On 7/19/18 at 9:30 P.M., Elopement Risk Review Tool forms for R#801 were reviewed and revealed R#801 was scored to be at risk for elopement (a total of 7 or more) on 12/15/17 with a score of 12, 1/1/18 with a score of 13, 5/2/18 with a score of 13, and 6/19/18 with a score of 13. The 5/2/18 tool documented 5 in the elopement state section which indicated Paces, random or repetitious travel with no exit seeking behavior instead of 12 which indicated Has attempted to leave, or has successfully left-Exhibits exit seeking behavior. ((R#801) was observed opening the emergency exit door on 2/16/19 and successfully exited the building through the same door on 6/29/18.) On 7/19/18 at 8:28 A.M., R#802's clinical record was reviewed and revealed R#802 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented R#802 had severely impaired cognition, wandering behaviors, and was independent with bed mobility, transfers, and walking. A care plan for R#802 dated 4/3/18 documented, I am at risk for elopement .observed on the 1st floor attempting to exit the facility .I have removed my Wanderguard multiple times . On 7/19/18 at 8:45 A.M., R#803's clinical record was reviewed and revealed R#803 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R#803 was discharged to the hospital on [DATE]. A MDS assessment dated [DATE] documented R#803 had severely impaired cognition, daily wandering behaviors, and was independent with walking. Progress notes were reviewed for R#803 and they revealed the following: On 6/13/18, .Wanderguard placed .risk for elopement, ambulatory and confused . On 7/2/18 at 9:46 P.M., .Resident observed ambulating throughout unit. Attempted to open door to go outside unit without assistance . On 7/11/18 at 9:52 P.M., .Several times today resident had to be redirected away from the emergency and hallway doors. Resident no longer has wanderguard on resident took it off . On 7/12/18 at 9:47 P.M., .pacing hallway, reusing to be redirected .Yelling and hollering when you approach him. Resident stated, 'I am leaving I am going home.' Resident attempted to open emergency door was stop by staff . A care plan dated 6/15/18 documented, I am able to ambulate independently. I am confused and will wander. I need redirection when I do begin to wander. I am diagnosed with [REDACTED].#803 attempted to open the doors to go outside, repeatedly required redirection away from emergency and hallway doors, and verbalized wanting to leave. A Wandering and Elopement Risk Review Tool dated 6/29/18 documented R#803 was at risk for elopement. On 7/19/18 at 9:00 A.M., the Administrator was interviewed and asked if she had knowledge of R#803's exit seeking behaviors documented above. The Administrator reported she was unaware of any of the documented attempts. On 7/19/18 at 9:25 A.M., R#804's clinical record was reviewed and revealed R#804 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Social Services note dated 7/16/18 documented, .Cognitive deficits .wanderguard .Risk for wandering .ambulated independently with a cane .He has the capability of getting on the elevator without assistance . An elopement risk assessment indicated R#804 was at risk for elopement. On 7/19/18 at 9:34 A.M., R#805's clinical record was reviewed and revealed R#805 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Progress notes indicated R#805 was independently ambulatory and wore a wanderguard device. An Elopement Risk Assessment indicated R#805 was at risk for elopement. The facility's policy titled, Elopement Prevention (Updated (MONTH) 29, (YEAR)) was reviewed on 7/18/18 and it documented the following: .Policy to identify residents who may have a history of exit seeking behavior and/or are a potential elopement risk . .A care plan will be developed when a resident has been identified to be exit seeking . .Environmental Considerations .1. All fire door exits will have an alarm that activates when the door is opened . The Facility submitted the following acceptable plan including supporting documentation to remove the immediacy on 7/18/18: Immediate Corrective Action: 1. Resident #801 was identified as missing through an unlocked fire alarm exit door. Resident was returned to facility within 19 minutes did not sustain any mental, physical or psychosocial distress. The event did not affect resident's functional ability. Wander guard was placed on the resident. The fire door is alarmed and functional on (MONTH) 29, (YEAR) 7:10am. 2. The Maintenance Director immediately assessed the 2 Central fire door adjacent to room [ROOM NUMBER], the push bar mechanism was functional, batteries changed on the alarm 3:00pm on (MONTH) 18, (YEAR). Identification of other: 1. All other facility fire doors were check by the Maintenance Director and found to be functional and alarm sounding at 4:15pm on (MONTH) 18, (YEAR). The 2 north Fire alarm door next to the dining room, 2 South fire exit door adjacent to the social work office, 1 north fire door adjacent to room [ROOM NUMBER], 1 south fire door adjacent to room [ROOM NUMBER], 1 Central fire door adjacent to room [ROOM NUMBER] and the fire exit alarm door in the basement. Additionally, the 2 Central fire alarm exit door was rechecked. 2. Resident Elopement assessments reviewed and updated as indicated on 6-29-18. Resident care plans were updated based on resident risk assessment. 3. All residents scoring a seven (7) or above have be placed in facility elopement/risk monitoring binders and a green arm band and/or wander guard has been placed for those identified for risk or elopement precaution. 4. Facility elopement prevention policy updated to include criteria for risk versus actual wandering 5. Staff were in-serviced on elopement policy and procedure and new protocol on 6-29-18. 6. Staff were in-serviced on fire exit door alarms on 6-29-18. Systemic changes: 1. Maintenance Director/designee will immediately complete fire exit alarm door audits daily. 2. Staff were in-serviced on elopement policy and procedure and new protocol on 6-29-18. 3. Staff were in-serviced on fire exit door alarms on 6-29-18. 4. Restorative log updated to reflect new elopement risk tool on 6-29-18. 5. Residents who identified at risk will have their picture and demographic information placed in binder and located at the front desk, each nursing station, kitchen and therapy department. Monitoring: The DON/designee will audit 100% of elopement risk assessments for completion, elopement books for updates and placement of green arm bands and wander guards weekly. The Maintenance director/designee will conduct daily audits of all of facility fire exit alarm doors. Findings will be reviewed at QAPI meetings quarterly. Administrator will assure on going compliance.

This Citation Pertains to MI 051 Based on observation, interview and record review the facility failed to ensure one Resident (#503) of six residents reviewed for abuse and neglect was free from verbal abuse from a total sample of 22. Resulting in hurt feelings, crying and anger. Findings include: According to the clinical record that was reviewed on 8-22-2017 at 1:00 PM, Resident #503 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] reflected a brief interview score (BIMS) of 15 (cognitively intact), further review of the MDS reflected Resident #503 was continent of bowel and bladder but required extensive assistance with hygiene from one staff person. On 8-22-2017 the facility's five day investigation summary dated 5-30-2017 regarding an allegation of verbal abuse was reviewed. The Administrator whom also serves as the facility's Abuse Prohibition Coordinator conducted the investigation which reflected, on 5-21-2017 Certified Nursing Assistant (CNA) X was witnessed to have yelled at Resident #503. The witnesses's were identified as Licensed Practical Nurse (LPN) V and supplemental Resident 18. The witness statement dated 5-21-2017 signed by Resident #503 reflected in part She (CNA X) started talking to me very impolitely and in a rude tone of voice, my roommate also heard her. She said why can't you wipe yourself you're a grown woman. I told her if I could I would, but I am a large woman and I have a lot of swelling, I don't need a lot of help I just can't reach to wipe myself. On 8-22-2017 at 1:19 PM an attempt to contact CNA X via phone was made and a detailed voice mail requesting a return call was made but not received. LPN V was interviewed via phone on 8-22-2017 at 1:25 PM and she reported the incident occurred on 5-21-2017 at approximately 8:30 am, I was at the nurses desk, I could here them yelling at each other, if you know where her room is and the Nurses desk, you know it's a good way away. When I came in the room (Resident name) was on the toilet, the CNA pointing her finger in her (Resident #503) face yelling at her and chastising her for wanting help and stated to me these two fat b****** are always on the call light. She (Resident#503) was very upset and crying. The CNA (CNA X) was really over the top. On 8-24-2017 at 9:40 am, during a bedside interview with Resident #503 she reported the 5-21-2017 incident occurred in the morning. She left me on the toilet for almost a half an hour, I started yelling because it hurt sitting so long, my call light was on, she (CNA X) came in screaming at me. She (CNA X) made me cry, honestly she hurt my feelings, she pissed me off, I didn't deserve that. Supplemental Resident #18 was interviewed on 8-24-2017 at 10:05 am. According to the MDS dated [DATE] she had a BIMS of 14 (cognitively intact). Supplemental Resident #18 reported she and Resident #503 were roommates on 5-21-2017 and she was in bed and witnessed the abuse that occurred on 5-21-2017 The Aide was very nasty, yelling and screaming at her (Resident #503), the Nurse came running in because it sounded like they were killing each other. The Aide was so mad because she had to help her, and kept saying she (Resident #503) was young and should be able to wipe herself. On 8-24-2017 at 11:30 am, an attempt to interview the Director of Nursing (DON) was made. The DON reported she was not involved with the investigation and refused to answer any questions. On 8-24-2017 at 2:00 PM during an interview with the Administrator she reported that CNA X was no longer employed at the facility, and could not recall specific events from 5-21-2017 It's all in the report. A copy of CNA X's termination letter dated June 6, 2017 was obtained by Human Resource Director Y on 8-24-2017 3:45 PM and read in part Upon the completion of our investigation; (name of facility) has determined that you were in violation of Federal Tag F226, Tag 241 and (name of facility) Policy and Standard of Conduct regarding Resident Abuse & Dignity. According to the facility policy titled Abuse Program Policy and Procedure dated 10/07 with a revision date of 3/2017 reflected in part .Maintain an environment free from abuse and neglect. The resident has the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, neglect and misappropriation of resident property, maltreatment and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals . Verbal Abuse: Defined as the use of oral, written gestured language that willfully includes tone of voice that is demeaning, rude, disrespectful, disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend or disability.

This citation has two deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to ensure hot water temperatures were within a safe range of 105-120 degrees Fahrenheit for three (#802, #810 and 816) of 22 sampled residents and eleven supplemental sampled residents (#'s 72, 76, 77, 78, 79, 80, 82, 83, 85, 90 and 91) who could access the handwashing sinks in the bathrooms independently from a total of 29 residents living on the 2 North unit. The hot water temperatures ranged from 121.9-125.5 degrees Fahrenheit, resulting in the potential for serious injury, harm, or death from scalding. This resulted in an Immediate Jeopardy (IJ) to the health and safety of these residents. The Immediate Jeopardy was identified on 8/31/16 at 11:00 am. The administrator was notified of the Immediate Jeopardy on 8/31/16 at 3:15 P.M. and a plan of correction was requested to remove the immediacy. The IJ was removed on 8/31/16 based on the facility's implementation of corrective action on 8/31/16 as verified onsite by the survey team. Although the IJ was removed, the facility's deficient practice was not corrected and remained at a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 8/31/2016 at 11 AM, during a general observation of the facility with Maintenance Director 'O', water temperatures were obtained and found to exceed the maximum safe temperature of 120 degrees Fahrenheit (F) on the 2 North unit in the shared hand sinks in adjoining resident restrooms. The following water temperatures were observed: Room # Hot water temperature (Degree F) 204 and 205 121.9 218 and 219 125.5 220 124.0 The Maintenance Director was observed using his thermometer to measure the water temperature in room 219 (which is shared with 218), however he had not allowed the thermometer to remain positioned within the flow of running water of the faucet. The Maintenance Director was queried about why he did not allow the thermometer to remain in the flow of running water before the temperature fully registered and he did not offer an explanation. The temperature was retaken with the facility's thermometer at this time and registered at 125.5 degrees F. Maintenance Director 'O' was queried regarding the water temperatures which were found to exceed the maximum safe temperature of 120 degrees F. Maintenance Director 'O' indicated that the high water temperatures were due to the residents' rooms being positioned above the boiler room and stated: That's why temperature is so hot. The temperature adjusted for rooms on the end of hallway to prevent cooler water in those rooms (further from the boiler). On 8/31/16 at 12:25 pm through 12:32 pm, the following water temperatures were obtained on the 2 North unit in the shared hand sinks in adjoining resident restrooms. The following was observed: Room Number: Temperature: 208 and 209 122.0 degrees F 210 and 211 122.7 degrees F 214 and 215 122.0 degrees F 216 and 217 123.8 degrees F Unit manager (Nurse) B was interviewed on 8/31/16 at 1:00 P.M. Nurse B was asked to identify any residents on the 2 North unit who were able to ambulate (either on foot or in a wheelchair) and could access the hand sinks in the resident rest rooms independently. Nurse B identified the following residents: #'s 802, 810, 816, 72, 76, 77, 78, 79, 80, 82, 83, 85, 90 and 91. Resident #802 On 8/31/16 at 4:00 pm, review of Resident #802's clinical record revealed the resident was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's minimum data set (MDS) assessment dated [DATE] revealed the resident scored 3/15 on a brief interview for mental status exam, which indicated that the resident was cognitively impaired. Per this MDS assessment, the resident required limited assistance and one person physical assistance for locomotion on the unit. Resident #810 On 8/31/16 at 4:20 pm, review of Resident #810's clinical record revealed the resident was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's minimum data set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Per this MDS assessment, the resident required limited assistance and one person physical assistance for locomotion on the unit. Resident #816 On 8/31/16 at 4:30 pm, review of Resident #816's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's minimum data set (MDS) assessment dated [DATE] revealed the resident scored 11/15 on a brief interview for mental status exam, which indicated that the resident had moderate cognitive impairment. Per this MDS assessment, the resident was independent for locomotion on the unit. Resident #72 On 8/31/16 at 5:00 pm, review of Resident #72's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's minimum data set (MDS) assessment dated [DATE] revealed the resident scored 8/15 on a brief interview for mental status exam, which indicated that the resident was cognitively impaired. Per this MDS assessment, the resident required limited assistance and one person physical assistance for locomotion on the unit. Resident #76 On 8/31/16 at 5:10 pm, review of Resident #79's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's minimum data set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Per this MDS assessment, the resident required limited assistance and one person physical assistance for locomotion on the unit. Resident #77 On 8/31/16 at 5:15 pm, review of Resident #77's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's minimum data set (MDS) assessment dated [DATE] revealed the resident scored 9/15 on a brief interview for mental status exam, which indicated that the resident was cognitively impaired. Per this MDS assessment, the resident was independent for locomotion on the unit. Resident #78 On 8/31/16 at 5:20 pm, review of Resident #78's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's minimum data set (MDS) assessment dated [DATE] revealed the resident scored 3/15 on a brief interview for mental status exam, which indicated that the resident was cognitively impaired. Per this MDS assessment, the resident required limited assistance and one person physical assistance for locomotion on the unit. ( ) Resident #79: On 8/31/16 at 5:00 pm, review of Resident #79's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's minimum data set (MDS) assessment dated [DATE] revealed the resident scored 4/15 on a brief interview for mental status exam, which indicated that the resident was cognitively impaired. Per this MDS assessment, the resident required limited assistance and one person physical assistance for locomotion on the unit. Resident #80: On 8/31/16 at 5:05 pm, the clinical record for Resident #80 was reviewed and revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's MDS assessment dated [DATE] revealed the resident scored 5/15 on a brief interview for mental status exam, which indicated that the resident was cognitively impaired. Per this MDS assessment, the resident was able to ambulate independently. Resident #82: On 8/31/16 at 5:10 pm, the clinical record for Resident #82 was reviewed and revealed the resident was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's MDS assessment dated [DATE], the resident scored 15/15 on a brief interview for mental status exam, which indicated that the resident was cognitively intact. Review of this MDS assessment revealed the resident required limited assistance with one person physical assistance for locomotion on the unit. Resident #83: On 8/31/16 at 5:12 pm, the clinical record for Resident #83 was reviewed and revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per a review of the resident's MDS assessment dated [DATE], the resident scored 4/15 on a brief interview for mental status exam, which indicated that the resident was cognitively impaired. Per review of this MDS assessment, the resident required supervision only for locomotion on the unit. Resident #85: On 8/31/16 at 5:15 pm, the clinical record for Resident #85 was reviewed and revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's MDS assessment dated [DATE], the resident had severely impaired cognition. Review of this MDS assessment revealed the resident required limited assistance and one person physical assistance for locomotion on the unit. Resident #90: On 8/31/16 at 5:20 pm, the clinical record for Resident #90 was reviewed and revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #90 did not yet have a comprehensive MDS assessment completed to review. Resident #91: On 8/31/16 at 5:25 pm, the clinical record for Resident #91 was reviewed and revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's MDS assessment dated [DATE], the resident scored 3/15 on a brief interview for mental status exam, which indicated that the resident was cognitively impaired. Per review of this MDS assessment, the resident required limited assistance and one person physical assistance for locomotion on the unit. The administrator was interviewed on 8/31/16 at 4:10 P.M. regarding the proper technique to be used when measuring water temperatures and explained that the thermometer should be placed in the stream of water until the temperature stopped increasing. A review of the facility's Water Temperatures, Safety of Policy Statement (Revised April 2010) was reviewed on 8/31/2016 at 3:15 PM. The Policy Interpretation and Implementation documented: Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees F (48.9 degrees C), or the maximum allowable temperature per state regulation. The facility submitted the following plan to remove the immediacy on 8/31/16 at 5:30 P.M. Immediate Corrective Action: The hot water tank was immediately lowered to 118 degrees and at 3:30pm the temps in the sinks for resident number #72, 76, 77, 78, 79, 80,82, 83, 85, 90, 91, 802, 810, 816 were all below 120 Fahrenheit. The residents noted were all assessed from head to toe, no noted redness, swelling or complaints of burns identified. The residents identified did not have any negative outcomes from the hot water temps. Identification of others: At 3:43pm a temperature audit was taken for every resident room bathroom and shower rooms in the facility and found to be in compliance with temperatures between 105-120 degrees. At 5:06 rooms for resident # 72, 76 77, 78, 79, 80, 82, 83, 85, 90, 91, 802, 810, 816 and were all found to be within appropriate range of 105-120 degrees. Systemic changes: 1. Water temperatures for every resident room and shower room will be taken twice per day by the designated staff member. 2. Staff at the facility at 3:30pm and thereafter have received education on safe water temperatures for resident care. They were educated on assuring appropriate water temperatures by using the back of their hand or inner side of wrist to test the temperature before providing resident care and reporting any sinks/showers which seem to have increased temperatures. Staff was instructed not to use the water if temps appeared to uncomfortable upon testing. 3. Residents # 72, 76, 77, 78, 79, 80, 82, 83, 85, 90, 91, 802, 810, 816 who do not have cognitive deficit were educated on safe hot water temperatures and to notify staff immediately if they feel the temperature is too hot at 3:55pm. They were also instructed not to use the water if the temperatures seem to be uncomfortable. They were educated on using caution when using hot water, feeling the temperature of the water before using the sink, reporting any water temps that are hotter than normal to the charge nurse, cena, and/or any manager. The residents identified did not complain of excessive hot water temperatures. 4. All other resident in the facility that do not have cognitive deficits were provided with the same on safe hot water temperatures. They were also instructed not to use the water if the temperatures seem to be uncomfortable. They were educated on using caution when using water, feeling the temperature of the water before using the sink, reporting any water temps that are hotter than normal to the charge nurse, cena, and/or any manager. The residents identified did not complain of excessive hot water temperatures. Monitoring: 1. The Maintenance Director will assure that hot water temperatures are in compliance daily and will take hot water temperatures two times per day for the next 30 days. Findings will be reported to QA Committee 5 times per week by the maintenance director. 2. The Administrator will assure ongoing compliance. Completion of Immediate corrective action, Identification of other areas that may have been effected, systemic changes made, and implementation of monitoring all completed on 8/31/2016 . ( , , , , ) Deficient Practice #2 Based on observation, interview, and record review, the facility failed to assess and appropriately transfer one (Resident #801) following a fall of three residents reviewed for falls, out of a total sample of 25 residents, resulting in the potential for undetected injury and additional injuries. Findings include: On 8/30/16 at 9:49 am, Resident #801 was observed to have rolled over her winged mattress on her low bed and onto the fall mat next to her bed. At 9:52 am, Licensed Practical Nurse (LPN)/Unit Manager 'K' walked past Resident #801's room, observed Resident #801 on the fall mat and closed the door to the room, but did not enter. She proceeded to ask the nurse to tell the Certified Nursing Assistant (CNA) to go to the room. On 8/30/16 at 9:55 am, CNA 'L', CNA 'M', and Nurse 'A' entered the room, where Resident #801 remained on the floor mat. CNA 'L' and CNA 'M' prepared to put Resident #801 back in bed grabbing her by her arms and legs and swinging her up and over the bolsters and back into the bed. On 8/30/16 at 11:30 am, an interview with LPN 'K' was conducted. LPN 'K' was asked why she closed Resident #801's door when she observed her out of bed on the fall mat. LPN 'K' stated, She does that all the time, and I couldn't put her back to bed myself. LPN 'K' was then asked why she didn't assess the resident after the fall/roll out of bed she stated, I looked at her, she didn't look like she was in distress. LPN 'K' was then made aware of the way CNA 'L' and CNA 'M' transferred Resident #801 back to bed and stated, I don't think that's the way they should be transferring her. LPN 'K' was asked to clarify Resident #801's transfer status and indicated that she was a one or two person transfer and could sometimes stand and bear weight with maximum assistance. On 8/31/16 at 10:55 am an interview with the facility's Director of Nursing (DON) was conducted. During the interview, the DON was asked if LPN 'K' acted appropriately regarding Resident #801's fall. She indicated that an assessment should have been done, the door should not have been closed, and stated, We don't just leave our residents on the floor. The DON next was asked about the transfer of Resident #801 back to the bed and explained that they could have used a sheet or some other method to transfer her. On 8/29/16 at at 3:10 pm, a review of Resident #801's clinical record was conducted and revealed a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of Resident #801's Minimum Data Set assessment dated [DATE] indicated the resident was a extensive one person assist. On 8/31/16 at 4:45 pm, a review of the facility's policy titled Safe Lifting and Movement of Residents read, In order to protect the safety and well being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents .2. Manual lifting of residents shall be eliminated when feasible . The facility was asked if they had any additional information to provide regarding the concern and none was supplied by the end of the survey. ( )

Based on observation, interview and record review, the facility failed to assess the skin under a removable immobilizer, clarify physician's orders for cleaning and assessing the skin under the immobilizer for one (#402) of six residents reviewed for pressure sores out of a total sample of 20, and failed to consistently perform wound treatments per physician ' s orders for three (#401, #402, and #403) of six residents reviewed for pressure sores out of a total sample of 20, resulting in the development of a stage III (through all layers of skin, exposing muscle) pressure sore and the potential for delay in healing of pressure sores. Findings include: On 9/16/15 at 9:30 A.M., Treatment Nurse C was observed performing a wound treatment for [REDACTED]. Resident #402 was alert, nonverbal, with a percutaneous endoscopic Gastrostomy tube (PEG tube- a feeding tube surgically inserted through the skin into the stomach), and was unable to move independently. Treatment Nurse C removed a pressure reduction ankle foot orthotic (PRAFO) boot from the resident's right foot, and proceeded to remove the gauze dressing on the resident's heel. When queried, Treatment Nurse C stated that Resident #402 had had a fractured right ankle, and subsequently developed a pressure sore on the back of the heel of that foot. Resident #402's right heel wound was observed to be a dime sized circular depressed ulcer with a central area of dry brown eschar (dry dead tissue), surrounded by raised white curling edges. On 9/17/15 at 11:40 A.M., Resident #402's clinical record was reviewed, in the presence of the facility administrator, with the Assistant Director of Nursing (ADON), who was the facility Treatment Nurse at the time Resident #402 developed the right heel pressure sore.The following information was revealed: A face sheet documented that Resident #402 was admitted into the facility on [DATE], with readmission on 7/20/15 after a hospitalization . [DIAGNOSES REDACTED]. A Minimum Data Set Assessment ((MDS) dated [DATE] documented that Resident #402 had severely impaired cognition, severe communication impairments, needed extensive physical assistance of two staff for mobility in bed, and was dependent on staff for transfers to the wheelchair, and all activities of daily living (ADLs). A facility Incident and Accident Report (I & A) and investigation for Resident #402 documented that Resident #402 was transferred to the hospital on [DATE] for a pathological [MEDICAL CONDITION] ankle, and returned to the facility on [DATE] with a right leg immobilizer. When queired, ADON D stated that the resident's right leg immobilizer was an air cast with velcro strap closures. When queried, ADON D stated, The immobilizer was on 24/7 (24 hours a day, seven days a week). We didn't have any orders from the physician to release or remove it for skin assessments, or to clean his foot or leg. He didn't have it off until he went to the Orthopedic Physician to remove it on 6/4/15. It is a facility acquired pressure sore. They found it at the Doctor's office when they took the immobilizer off. Review of Braden Scale skin assessments for Resident #402 revealed no Braden Scale skin assessment was done on readmission to the facility after the ankle fracture. When queried, ADON D was unable to provide documentation of Braden Scale assessments for 2015, prior to development of the right heel pressure sore, but a Barden Scale on 8/4/14 and one on 7/22/15 documented that Resident #402 was at high risk for the development of pressure sores, with scores of 12 (12 or less indicates high risk). Review of Nursing Care Plans for Resident #402 in place at the time of the fractured ankle, revealed a care plan dated 5/1/14, entitled, At risk for the development of a pressure ulcer secondary to the following risk factors: Braden scale =12, History of pressure ulcers, Cerebral vascular Acident ([MEDICAL CONDITION]- stroke) right side weakness, fracture right ankle-air cast. Interventions included, (5/1/14) Complete weekly skin assessment by licensed nurse, and, (5/1/14) Daily Skin Check by CNA. An undated handwritten added intervention noted float heels. When queried, ADON D was unable to state whether this was added before or after development of Resident #402's right heel pressure ulcer. When queried at this time, ADON D stated that the skin under the immobilizer was not assessed, as care planned, because there were no orders or instructions provided by the Orthopedic Surgeon for removal of the immobilizer, or for release of the velcro closures, in order to provide cleaning of the feet and skin, or for skin assessments. A Physician's order monthly summary for Resident #402, signed by the physician on 4/28/15, noted, splint to right leg, but did not include any parameters for removal or release of the velcro straps, or for skin assessment or cleansing of the affected foot. Review of Nursing notes for Resident #402 revealed the following note dated 6/4/15 (no time indicated), Patient returned from Scheduled appointment with Orthopedic Surgeon. The leg brace was discontinued. When requested, the ADON D was unable to provide documentation that Resident #402's skin was assessed after the immobilizer was removed on 6/4/15, until the following day (6/5/15), when a suspected deep tissue injury (pressure damage that has not yet opened up into a wound) was noted. A Nursing note dated 6/5/15 for Resident #402 documented, 4.5 (centimenter -cm) by 6.0 (cm) area on distal plantar area of right foot which is non blancing red (suspected deep tissue injury). Right foot and lower extremity (leg) with [MEDICAL CONDITION] (swelling). splint removed 6/4/15. Review of a Nursing note dated 8/12/15 (no time indicated) for Resident #402 documented, Right heel eschar 2.0 by 1.9 cm, black. A nursing note for Resident #402 dated 8/17/15, no time indicated) documented, Seen by Doctor today. Right heel eschar edges lifting up. Eschar sharply debrided (surgical removal). Stage III ulcer. Wound measures 1.5 cm by 2.0 cm by 0.2 cm (deep). A Wound Care Physician Consultation report dated 9/10 15 for Resident #402 documented, Right heel pressure ulcer stage III. On 9/17/15 at 2:00 P.M., Resident #402's Treatment Administration Records (TAR) were reviewed with ADON D in the presence of the facility administrator, and revealed that wound care treatments for Resident #402's right heel pressure ulcer were not consistently performed on weekends. Review of Resident #402's TAR revealed the following treatments were not performed: June 1-30, 2015, Cleanse Right (r) heel eschar with normal saline and apply 4 by 4 (gauze square) and [MEDICATION NAME] (gauze wrap). Change every other day (QOD) and as needed (PRN). This was not done from 6/12/15 through 6/14/15 (4 days) , 6/20/15 through 6/21/15 (two days) or 6/27 -6/28/15 (two days). When queried about this, the Administrator stated, Those were all weekends. ADON D stated, The treatment nurse doesn't work on the weekends. I'm guessing they weren't done. July 1-31, 2015, Cleanse r heel ulcer with normal saline . Apply 4 by 4, abdominal pad (large thick dressing) and [MEDICATION NAME] QOD and PRN. This was not documented as done when due on 7/12/15. August 1-31, 2015, Cleanse R heel ulcer with wound cleanser . Apply [MEDICATION NAME] gel. (antimicrobial absorbent patch). cover with 4 by 4 and secure with [MEDICATION NAME]. Change every two to three days and PRN. When asked why the treatment was not scheduled at a routine interval, ADON D stated, I noticed that we were having a problem with missing treatments in the facility when they were ordered every other day (qod), so I had them all changed to give us some leeway. The treatment was not documented as done from 8/27/15 through 9/1/15 (six days). On 9/17/15 at 3:20 P.M., The Director of Nursing (DON) was interviewed and was unable to provide any additional information. When queried regarding skin assessments, skin cleansing and pressure sore prevention interventions for a resident at high risk for pressure sores, who is admitted into the faciity with a leg immobilizer with no wearing parameters from the Orthopedic Surgeon , the DON stated, The nurses would be afraid to remove or release the immobilizer without parameters. I guess nursing professional standards would be to call the Orthopedic Surgeon to clarify the orders, and get parameters. When queried at this time, the DON stated that the facility did not have a policy and procedure for immobilizers and braces. ( ) Resident #408 On 9/15/15 at 3:20 P.M., Treatment Nurse C was observed performing wound care for Resident #401 ' s stage III (wound extending through the skin, exposing muscle) pressure sore on the middle finger of the right hand. Resident #401 was alert and oriented, responded appropriately to questions, and reported that she was paralysed from the neck down, and unable to move independently. The right finger wound was observed to be a nickel sized circular moist beefy red wound on the second knuckle of the right hand middle finger. The resident ' s hand was contracted (joints fixed in bent position through disuse) into a tight fist. When queried, ADON D reported that Resident #401 ' s finger wound was acquired in the facility, and was first noted on 8/28/15. On 9/16/15 at 2:20 P.M., Resident #401 ' s clinical record was reviewed with the Assistant Director of Nursing (ADON) D , who was the facility' s treatment nurse prior to September 2015. The following was noted: A face sheet documented that Resident #401 was admitted into the facility on [DATE], with most recent readmission on 8/25/15 after hospitalization . [DIAGNOSES REDACTED]. A Minimum Data Set Assessment ((MDS) dated [DATE] documented that Resident #401 had intact cognition, and was physically dependent on staff for mobility in bed, and all activities of daily living. The MDS documented that Resident #401 had range of motion (ROM) limitations on both upper and lower body. A Wound Care Services Consultation Report for Resident #401, dated 9/10/15 documented, Right middle finger 1.4 centimeters (cm) by 1.4 cm by 0.01 cm deep. Pressure ulcer stage III. There was no readmission Braden Scale Assessment (scores risk of developing pressure sores) or readmission skin assessment for Resident #401 ' s readmission to the facility on [DATE], three days prior to the facility noting the new pressure sore on the resident ' s right middle finger on 7/28/15. When queried, ADON D stated, Everyone is supposed to get a readmission skin assessment and Braden Score on readmission. I know she should have one. I ' ll have to look for them in Medical Records to see if they got thinned from the chart. Physician ' s orders for Resident #401 included the following orders for treatment of [REDACTED]. Dated 8/28/15, cleanse right (R) third finger wound with wound cleanser. Apply [MEDICATION NAME] Silver (an absorbent antimicrobial patch). Cover with dry dressing and secure with [MEDICATION NAME] (gauze wrap) every (q) 2 to 3 days. When asked why the order was written with flexible treatment intervals, ADON D stated, I noticed that we were having a problem with missing treatments in the facility when they were ordered every other day (qod), so I had them all changed to give us some leeway. Review of Resident #401 ' s Treatment Administration Record (TAR) for August 2015 at this time revealed no treatments were done for this physician ' s order for four consecutive days, from 8/29/15 through 9/1/15. Review of Resident #401 ' s September TAR revealed that this treatment order was not done for four days, from 9/9/15 through 9/12/15. On 9/16/15 at 2:30 P.M., ADON D was queried about the missing treatments and stated, We' re aware we have had a problem with treatments being missed, especially on the weekend. On 9/17/15 at 10:15 A.M., The Director of Nursing (DON) was queried regarding Resident #401 ' s missing skin assessment, Braden Scale assessment, and missing wound treatments, and was unable to provide any additional information. ( ) On 9/15/15 at 9:15 a.m., during the initial tour, Resident #403 was observed lying in a low bed (right side of bed against wall) and full size mattress was noted on the left side on the floor next to his bed. A dressing/Kerlix to his left foot and ankle was half off and dangling. Resident #403 was alert and answered some simple questions. On 9/15/15 at 3:10 p.m., review of Resident #403's face sheet indicated an admission into the facility on [DATE] and a re-admission on 9/4/15 with [DIAGNOSES REDACTED]. Resident #403's admission Minimum Data Set (MDS) assessment, dated 7/29/15, indicated a slightly impaired cognition and he required extensive assistance with all activities of daily living (ADLs). On 9/16/15 at 9:30 a.m., During a medication pass observation with nurse B, Resident #403 was observed lying in bed with half of the dressing to his left heel and foot loosely fitting and part of the wound exposed (necrotic area). The date documented on the dressing was 9/14/15. Nurse B confirmed the date on the dressing was 9/14/15. Resident #403 was turned on his left side (left leg and arm were noted extended over the mattress) as he yelled out to use the bathroom. On 9/16/15 at 9:35 a.m., the Director of Nurses (DON) was shown Resident #403's dressing to his left foot and ankle that was dated 9/14/15. The DON reported that she had no explanation. The DON paged the facility's treatment nurse (nurse C). Nurse C stated, I was not able to change his (#403) dressing yesterday. Nurse C was asked if she passed the information on to the oncoming nurse, she stated, I passed it on to the next nurse. I can't remember her name. She is an agency/pool nurse. Review of Resident #403's Treatment Administration Record (TAR) was reviewed with the DON and the treatment nurse further revealed, not only was the treatment not done on 9/15/15, treatments were missed (not done) on 9/11/15, 9/12/15, and 9/13/15. The DON and treatment nurse (nurse C) were asked why the treatments were not done as ordered by the doctor. Nurse C stated, The treatments are done by the floor nurses on the weekends. There was no explanation as to why the treatment was not done on 9/11/15 (Friday). The DON offered no explanation. On 9/16/15 at 10:45 a.m., review of Resident #403 doctor's orders revealed an order, dated 9/10/15 at 3 p.m., that read: Cleanse left heel with NS (normal saline), pat dry, apply Santyl and cover with ABD (abdominal) and kerlix every day. Review of the Vascular and Wound Consultation, dated 9/18/15 at 10:40 a.m., revealed the following documentation: Left heel measurements: 6.0 X 8.8 X 10.0 centimeters (cm), dry base, edges lifting. Area is cleansed with [MEDICATION NAME]. Escharotomy (removal of eschar/necrotic skin) performed. Underlying tissue is necrotic. Per the consultation, the left heel was diagnosed as having a pressure ulcer stage III. The recommendation written on the wound consultation included float left heel. On 9/18/15 at 4:00 p.m., review of the facility's policy titled Pressure Ulcer Prevention & Skin Care Management Policy, revised 11/2012, revealed the following documentation: A resident who enters the facility without a pressure ulcer will not develop a pressure ulcer unless the resident's clinical condition demonstrates that they were unavoidable. A resident having a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection, and reduce the risk of a new pressure ulcer from developing. The treatment nurse will provide the necessary treatments on the day shift Monday through Friday. On the weekend, the day shift charge nurse will be responsible for providing treatments as ordered. ( )

This citation has two deficient practice statements. Deficient Practice Statement #1 Based on observation, interview and record review, the facility failed to assess for the ability to safely handle hot beverages, and failed to monitor the temperature of hot beverages served in the facility for one (#408) of eight residents reviewed for accidents out of a total sample of 20, resulting in blistering thigh burns. Findings include: On 9/15/15 at 12:40 P.M., Resident #408 was observed in the dining room, eating lunch while seated in a wheelchair. The resident was alert with confusion, and was eating rapidly and independently, spilling food on her lap with each bite. The resident had a large purse on the floor by the wheelchair. There were no beverages or cups provided for the resident during the meal. On 9/16/15 at 9:30 P.M., Review of Resident #408 ' s clinical record and facility Incident and Accident (I&A) reports revealed the following: A face sheet documented that Resident #408 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE], documented that Resident #408 had severely impaired cognition, impaired communication, undesirable behaviors, needed supervision for mobility in bed, and physical assistance for transfers to the wheelchair and toileting, needed extensive staff assistance for dressing, had impaired balance, and ate independently. An Eye Exam Progress note, dated 6/22/15, documented that Resident #408 had impaired vision, Total or Mature Cataracts both eyes (OU) - Moderate-dense. A Physical Medicine and Rehabilitation (PM & R) Physician ' s progress note dated 5/15/15 documented the at Resident #408 needed Occupational Therapy (OT- Skilled therapy for the upper body) for weakness, abnormal balance, confusion , and needed supervision for dressing, toileting and hygiene. The resident ' s ability to safely handle hot liquids, or eat independently were not addressed. A Rehabilitative screen dated 7/5/15 documented that Resident #408 had Limited safety awareness , and limited orientation and ability to understand others. The ability to safely handle hot beverages and the resident ' s ability to eat independently without supervision were not addressed. A Nursing Care Plan for Resident #408 entitled, visual Function , dated 4/2/15, documented, Resident has decreased vision , with an intervention (staff instruction), Assess the effect of Vision loss on resident ' s functional Status, and an updated intervention dated 7/13/15, OT to evaluate for use of cup. Review of Resident #408 ' s clinical record revealed no OT evaluation for the use of cup or for the ability to safely handle hot beverages. An I&A and post incident evaluation for Resident #408, dated 7/10/15 at 10:00 A.M, revealed Resident #408 sustained a burn with tea in the dining room, and noted the resident received an antidepressant medication and a psychotrophic medication (can impair balance and coordination). The I & A documented, Nurse recognized the patient ' s voice as she was crying. Assigned staff with the patient stated that the patient suffered burns with tea. Redness on both knees and thighs. Patient enjoys tea often at meal times or during activities. After the incident patient stated, ' No tea, No tea. . A statement from the assigned Certified Nursing Assistant (CNA) revealed that the CNA was not with the resident at the time of the incident, and stated, Patient always drinks tea and has never had a problem holding or handling her up. The I & A documented the witness to the incident as Activity Director G > The I&A summary of Conclusion , for Resident #408 ' s I & A dated 7/10/15, signed by the administrator (no date) noted, OT assessment/screen for use of cup holder Handled cup with lid, resident went to grasp her coffee cup and she dropped it on herself. Resident is alert with confusion and 100% independent with meals/utensils/cups etc. Resident said she accidently dropped her cup on herself. A post incident evaluation for Resident #408, dated for the 7/10/15 incident noted, Summary of Changes to the Resident ' s Plan of Care as, OT screen for use of two handled cup, cup holder. A 72 Hour Post Incident and Accident Reporting for for Resident #408 documented on 7/10/15 during the 3-11:00 PM shift, pain- evidence of by moaning, facial grimacing. physician's order [REDACTED]. burn treatment, Silvedene cream 1% to bilateral (both) knee/thigh burns twice daily and as needed (PRN) immediately (ASAP). There was no documentation to indicate that Resident #408 ' s burn was seen or assessed by the physician. When queried, ADON D stated, We aren ' t allowed to diagnose the degree level of a burn. The doctor has to do that. We don ' t have any documentation of what degree her burns were, because the doctor didn ' t note anything. A Nurse ' s Note for Resident #408, dated 7/11/15 at 4:00 P.M., one day after the burn occurred described five areas of burns as, left posterior distal anterior thigh with serous (tissue fluid) filled blisters. Proximal medial (upper middle) 3.0 by 2.0 centimeters (cm). Distal (lower) medial area 3.0 by 7.0 cm with opening in center 2.5 by 3.0 cm, pink, moist. Distal lateral thigh (lower, and to the side) 5.0 by 1.5 cm serous filled, and proximal lateral L shaped 4.0 by 1.0 serous filled. On 9/16/15 at 10:40 A.M., Activity Director G was interviewed regarding Resident #408 ' s burn with tea on 7/10/15, and stated, I was in the hallway outside of the dining room door when it happened. No staff were around at the time. It happened just before 9:00 AM. It happened during the time between whenstaff left the dining room after breakfast, and before my Activity Aide got here at 9:00 A.M. I heard her scream, and saw the cup land on her knee and the tea run down her leg. She had her purse on the table. She probably put the cup on top of the purse, or missed the table trying to put the cup down. On 9/17/15 at 10:55 A.M., Occupational Therapist (OT) H was interviewed regarding Resident #408, and Resident #408 ' s clinical record and Skilled Therapy documentation was reviewed. OT H was unable to provide any documentation that Resident #408 was assessed for the ability to handle hot beverages safely, upon request. When requested, OT H was unable to provide any documentation of an OT assessment or screen for cup use after the incident on 7/10/15. OT H stated, After this happened, we just started doing hot beverage assessments on new residents upon admission. We weren ' t doing this before. On 9/17/15 at 11:10 A.M., Certified Occupational Therapy Aide (COTA) I was interviewed regarding Resident #408 and stated, (Resident #408 s upper body strength and eating ability are normal. When asked how Resident #408 performed on fine motor skill/hand eye coordination tasks, such as fitting pegs into a peg board, COTA I stated, She had trouble, but it was because of her vision, not her motor skills. On 9/18/15 at 9:00 A.M., the facility Registered Dietitian (RD) was interviewed regarding beverage temperatures on 7/10/15. The RD stated, I don ' t have any temperatures for the hot beverages. We do not take the hot beverage temperature. I took a temperature this morning after you asked, and the water for the tea came out of the machine at 158 degrees farenheit (f). The machine is set to 165 f. On 9/18/15 at 10:00 A.M., the Director of Nursing (DON) was interviewed regarding Resident #408 ' s burn from hot tea, and stated, Anyone can have an accident. She eats independently. She does spill some food when she eats. We instituted a new policy after her accident. We bought lids for our cups. Hot beverages need a lid now. I didn ' t realize that Dietary wasn ' t monitoring the temperature of the tea and coffee. 165 f is just too hot. The DON was unable to provide additional information upon request. On 9/21/15 at 1:30 P.M., review of the U.S. National Institutes of Health website (<https://www.nlm.nih.gov/medlineplus/ency/imagepages/8601.htm>) , Second-degree burns affect both the outer and underlying layer of the skin, causing pain, redness, swelling, and blistering. On 9/21/15 at 1:40 P.M., review of the the NIH website link for information on care of burns, (http://familydoctor.org/familydoctor/en/prevention-wellness/staying-healthy/first-aid/first-aid-burns.printerview.all.html) Second-degree burns are thicker burns, are very painful and typically produce blisters on the skin. The skin is very red or splotchy, and may be very swollen. See a doctor if: A first- or second-degree burn covers an area larger than 2 to 3 inches in diameter.The burn is on your face, over a major joint (such as the knee or shoulder) On 9/18/15 at 11:00 A.M., the Administrator reported that prior to Resident #408 ' s burn on 7/10/15, the facility had no written Policy for assessment of residents for ability to safely handle hot beverages, or for temperature monitoring of hot beverages provided by the facility. ( ) Deficient Practice #2 Based on observation, interview, and record review, the facility failed to implement appropriate interventions to prevent falls, for three (#405, #406, and #414) of 12 sampled residents reviewed for falls, out of a total sample of 20 residents, resulting in falls with fractures, an abrasion and a bruise. Findings include: Resident #414 Clinical record review on 9/17/15 at 11:00 am, revealed that Resident #414 was originally admitted into the facility on [DATE], and was readmitted on [DATE] with [DIAGNOSES REDACTED]. According to a quarterly Minimum Data Set, dated dated [DATE], Resident #414 had moderately impaired cognition, and was independent for ambulation and transfers. Review of a Fall Risk Evaluation for Resident #414, dated 4/15/15 noted that the resident was a high risk for falls due to balance problems while walking, weakness, and the use of hypnotic medications. Review of a Falls care plan for Resident #414, initiated on 1/27/15, noted the following: Problem: Resident is at risk for falling r/t (related to) short of breath at times, osteoarthritis chronic pain, lower extremity edema history, risk of injury related to osteoporosis . Long Term Goal: Resident will have decreased likelihood of injury from fall. Residents fall risk will be minimized with reduction interventions . Approach: Provide with a cane for short distance assist prn (as needed), provide wheelchair for longer distances prn. Alert therapy of any decline .follow any recommendations. Assure resident is wearing eyeglasses. Encourage proper footwear. Restoril hypnotic for insomnia, observe for nighttime ambulation difficulty. Review of a Physical Therapy Evaluation and Plan of Treatment for Resident #414, dated 5/20/15, noted the following: Current Referral: Patient exhibits new onset of decrease in strength, decrease in functional mobility, decrease in transfers, decreased coordination, reduced balance, reduced ability to safely ambulate, increased need for assistance from others and reduced static and dynamic balance . Standing Balance: Static Standing = Poor, Dynamic Standing = Poor Gait Pattern: Unsteady Impressions: Resident shown decrease ble (bilateral lower extremity) muscle strength, balance, coordination, resident is at fall risk, shown decrease ability to perform safe transfers and ambulation . Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for falls. Review of the nurse's notes, the fall care plan, and the certified nurse assistant (CNA) care guide for Resident #414, revealed no documentation or new interventions that addressed the decline in ambulation, balance, and the increased risk for falls for Resident #414, which was identified on 5/20/15. Review of an Incident/Accident Report for Resident #414, dated 5/25/15 at 2:00 am, noted the following: Description: Resident asked for her dinner, was explained it was 2:00 am, offered her sandwich, she refused it. She was returning back to her room, I heard yelling, was then found on hallway floor, lying on her back .complained of pain to left groin area, has small raised area to left side of head . Summary of Conclusion: Resident was questioned about why she fell ambulating back to her room, she stated, I got dizzy and lost my balance. Review use of Restoril .may cause dizziness. Review of the physician's orders [REDACTED]. Review of a CT (computed tomography) scan of the pelvis for Resident #414, conducted at the hospital on [DATE], noted: Left superior pubic root fracture and sacral fracture. On 9/17/15 at 2:30 pm, Physical Therapist (PT) J was queried regarding Resident #414's decline in function, which was noted in May 2015. PT J stated that he had received a request from nursing for a therapy evaluation for Resident #414, due to the resident declining, with decreased strength and increased weakness. PT J stated that he conducted the evaluation on 5/20/15, and that the resident was scheduled to receive physical therapy services for 8 weeks. PT J stated that Resident #414 refused her physical therapy for the next 3 days (5/21/15-5/23/15), so therapy was discontinued. On 9/18/15 at 9:45 am, Nurse Manager A was queried regarding Resident #414. When queried about the therapy evaluation for Resident #414 that was done on 5/20/15, Nurse Manager A stated, I remember talking about her (Resident #414) increased weakness in the morning meeting. I think it was due to pain. Her level of assistance would vary with her pain. When queried about the 5/25/15 fall, Nurse Manager A stated that she was not working at the time, and that she does not really remember the details about what happened. Nurse Manager A stated that Nurse F was working at the time of the 5/25/15 fall, and would be able to answer any questions regarding the fall. Nurse Manager A was unable to provide an explanation for the lack of any new fall interventions after the 5/20/15 therapy evaluation, to address the increased weakness, decreased strength, balance, and the decreased ability to safely ambulate for Resident #414. On 9/18/15 at 11:30 am, Nurse F was queried regarding the 5/25/15 fall sustained by Resident #414. Nurse F stated, It was 2:00 am, I was in the hall, and she came to me asking for dinner. I told her she could have a sandwich or some crackers, but she didn't want that. She went back to her room. Then I heard her yell, and saw her on the floor. When queried about the recent decline in ambulation and increased weakness, which was detailed in the 5/20/15 physical therapy evaluation, Nurse F stated that she was unaware of any decline or weakness. Nurse F stated, I think she had been getting therapy, but had been refusing a lot. When asked if Resident #414 was using her cane on the night of the 5/25/15 fall, Nurse F stated, I know she (Resident #414) was supposed to use a cane, and you always had to remind her to use it. I really don't remember if she had her cane that night. Nurse F provided no explanation as to why Resident #414 was not provided assistance back to her room on 5/25/15, when it had been identified by physical therapy on 5/20/15 that the resident was exhibiting a decreased ability to perform safe transfers and ambulation. Resident #405 On 9/15/15 at 9:20 a.m., during the initial tour, accompanied by the Unit Manager (Nurse A), Resident #405 was observed lying in a low bed asleep. Bilateral fall mats were noted on the floor (one on each side of the bed on the floor). Nurse A reported that he was a high fall risk. On 9/16/15 at 1:55 p.m., review of Resident #405's face sheet indicated an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #405 was re-admtted into the facility on [DATE] with an additional [DIAGNOSES REDACTED]. Resident #405's quarterly Minimum Data Set (MDS) assessment, dated 4/12/15, indicated a severely impaired cognition and indicated he was dependent upon the staff for all activities of daily living (ADLs). Also, per the MDS, Resident #405's balance during transition and walking, was not steady. He was only able to stabilize with staff's assistance. On 9/18/15 at 11:05 a.m., the Unit Manager (Nurse A) was interviewed regarding Resident #405's fall on 4/18/15 at 8:00 a.m. Record review of Resident #405 with Nurse A revealed the following: TheIncident/Accident Report, revealed the following documentation: Resident was in bed having finished his breakfast. His bed alarm did not sound although resident was observed standing next to his bed. As the CENA (Certified Nursing Assistant) attempted to reach to him resident fell backward and onto his buttocks. Resident transported to a shower chair and showered. A two inch abrasion was on his right side of torso . The assigned CENA's written statement: Observed resident walking at the end of bed. Tried to get chair close enough to him but he stepped back and sat on the floor. Further review of the Incident/Accident Report, under the subtitle of Preventive measures and/or corrective actions revealed the following documentation: Resident is alert with confusion. He has an alarm in bed and w/c (wheelchair). He sits up in a 'rock n go.' Does not follow direction. will change batteries in bed alarm. The Post Fall Summary on the Incident/Accident report revealed the following documentation: Resident is alert with confusion. Does not follow commands or directions. Attempts to get up on his own. He has an alarm in bed and w/c. Will change batteries in alarm to bed. A nurse's note dated 4/22/15 (four days post fall) at 5:15 a.m., revealed the following documentation: Res. (resident) flinching up on turning onto left side. Left leg and knee area. X-ray ordered of left knee, left hip, left femur. The following nurse's note, dated 4/22/15, no time written, revealed the following documentation: X-ray revealed left hip fracture. Resident transferred to hospital via gurney at 9:30 a.m . Review of the Radiology Report, dated 4/22/15, revealed the following: There is a left intertrochanteric fracture with mild angulation .Acute appearing left hip fracture .new compared to prior exam dated 10/19/13. This is a fracture involving the proximal femur (thigh) with mild angulation .Conclusion: Acute appearing left femur as described. Resident #405's current Falls care plan revealed some of the following interventions: - Keep bed in lowest position (dated 10/13/14) - alarm to bed and chair (dated 10/13/14) During the clinical record review, Nurse A was queried as to why the nursing staff did not ensure the alarm to Resident #405's bed was not working. Nurse A was asked how does the staff ensure the functioning of the fall alarms each shift. Nurse A was unable to answer the questions. Nurse A provided no explanation. On 9/18/15 at 2:15 p.m., the Director of Nurses (DON) was queried regarding Resident #405's fall on 4/18/15 that resulted in a left femur fracture and why the fall alarm was not working at the time of the fall. The DON stated, I was not working here at that time. Resident #406 On 9/15/15 at 2:30 P.M., Resident #406 was observed seated in a wheelchair with a pommel cushion in the activity room. On 9/16/15 at 9:45 A.M., the clinical record for Resident #406 was reviewed and revealed the following: Resident #406 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE], documented that Resident #406 had severely impaired cognition, behaviors, and required extensive to total physical assistance from staff for all activities of daily living, including transfers. A Nurse's Note dated 9/11/15, documented that Resident #406 was found on her knees on the floor in her room. A Fall Risk Assessment dated 9/11/15, documented that Resident #406 was at high risk for falls and Pommel Cushion was documented as a post-fall intervention. A Nurse's Note dated 9/15/15 at 7:30 A.M., documented, Resident was observed sitting on her buttocks on the floor of her room under her geri-chair (a specialized chair that provides support and positioning) at 4:30 A.M. Resident was on the bed, tried to get up from bed .Nurse called assigned CENA to change resident and make (the) bed. Assigned CENA put resident on geri-chair to make a bed. Resident attempts to slide down from geri-chair .Reddened skin of L (left) back observed .I/A (incident/accident) report done . A nurse's note dated 9/15/15 at 9:00 P.M. documented that Resident #406's left back area was reddened with some bruising. A nurse's note dated 9/16/15 at 5:10 A.M. documented, .Small bruise development to left side mid-back . Incident/Accident Reports (I&A) were reviewed for Resident #406 on 9/16/15 at 2:30 P.M. and did not include an I&A for Resident #406 for the documented incident from 9/15/15. On 9/17/15 at 1:40 P.M., the DON was interviewed regarding Resident #406 and the above mentioned incident documented in the nurse's note on 9/15/15. The DON reported that she was unaware Resident #406 had fallen on that date. When queried about the facility's process for I&A's and falls, the DON explained that an I&A form would be completed and the incident would be discussed in morning meeting for the interdisciplinary team to make any necessary recommendations and interventions. The DON was asked if the fall was brought to morning meeting on 9/15/15. The DON stated, We didn't have morning meeting because you guys came (the state agency). On 9/17/15 at 2:00 P.M., the 2 North unit manager (Nurse A) was interviewed about the incident documented in the nurse's note on 9/15/15. Nurse A reported that she was aware of the incident and provided an I&A report completed by Nurse K. When queried about what was done with the I&A report after she became aware of the incident, Nurse K stated, Well you guys came that morning. The I&A report form completed by Nurse K, dated 9/15/15 was reviewed at this time and documented the following: Resident was observed sitting on her buttocks under her geri-chair. Assigned CENA put resident on the chair to change all her bed because of wetting. Resident attempts to slide down from geri-chair .L back redness. The I&A Report form was signed by Nurse K only. The spaces for signatures from the DON, Administrator and Physician were left blank. The Assigned Nurses Statement documented, The nurse observed resident sitting on her buttocks on the floor of her room at 4:30 A.M. Resident attempts to get up from her bed .Assigned CENA was called. CENA put resident on geri-chair. Result, resident was sitting on the floor .Reddened L back observed. The Assigned CENA Statement documented, I (CNA L) observed resident slide on to floor from her chair. She had been changed and placed in her chair about 25 min. before she was found sitting on the floor in front of her chair. The nurse saw her on the floor. She didn't fall and she wasn't hurt after assessing her body. The nurse observed her on floor and called me .to help put her to bed. The Post Fall Summary was not completed. A Post Incident Evaluation dated 9/15/15, completed by Nurse K, documented, Slid out of geri-chair . Nurse K was interviewed on 9/17/15 at 4:00 P.M. regarding the I&A and nurse's note completed on 9/15/15. Nurse K stated, The bed alarm was sounding and she (Resident #406) was sitting up on bed and the resident and bed was wet. I called nurse aide and she came to change her. The nurse aide put her in the geri-chair and changed the bed. She (Resident #406) slid down and we said 'sit down, sit down' and put her back in geri-chair. When she was calm, I went back to nurse's station. Later on, I went back to check on her and she was on the floor with the geri-chair behind her. Nurse K was queried about the type of chair Resident #406 was supposed to use and reported a wheelchair, but the aide put her in a geri-chair. When queried about whether or not Resident #406 had a wheelchair with a pommel cushion, Nurse K did not offer a response. Resident #406's clinical record was further reviewed on 9/18/15 at 9:30 A.M. A Falls care plan documented a fall on 9/11/15, an intervention on 9/14/15 that documented, Change to pommel cushion, and an intervention on 9/17/15 that documented, Assigned CENA will be educated on ensuring the resident is in proper chair. The DON and administrator were interviewed on 9/18/15 at 11:45 A.M. regarding the follow up on the I&A for Resident #406, dated 9/15/15. The DON reported that CNA L would be reeducated because Resident #406 was placed in the wrong type of chair. The DON reported that Resident #406's geri-chair was discontinued on 9/14/15 and changed to a wheelchair with a pommel cushion. Nurse A was also interviewed at this time and reported that CNA L grabbed the geri-chair and put the Resident #406 into it and she slid down. Nurse A stated, She (CNA L) did not follow the plan of care. When queried about whether or not the appropriate wheelchair with a pommel cushion was available in Resident #406's room, Nurse A did not offer an explanation. On 9/18/15 at 3:10 p.m., review of the facility's policy titled, Fall Prevention, last reviewed 1/20/15, revealed the following documentation: Residents identified as a high risk for falls utilizing the Fall Risk Assessment will have interventions identified and care planned . The facility's policy for the use of fall alarms was requested but was not received by the time of the survey's exit. Review of the facility's policy titled, Fall Prevention, last reviewed 1/20/15, revealed the following: Residents identified as a high risk for falls .will have interventions identified and care planned . ( ), ( ), ( )

This citation pertains to intake MI 297. Based on interview and record review the facility failed to assess, monitor and provide suctioning for one (#501) of one sampled resident with a tracheotomy stoma (an opening in the neck to facilitate breathing) from a total sample of six residents resulting in shortness of breath, difficulty breathing and an occluded airway. Findings include. On [DATE] at 12:30 pm, Family Member 'A' stated that he visited Resident #501 on [DATE]. Family Member 'A' described that Resident #501 was seated in a reclining chair in her room. According to Family Member 'A', she (#501) had [MEDICAL CONDITION] mask on because the humidifier was next to her bed and "the tubing was not long enough to reach over to where she was sitting. [MEDICAL CONDITION] was supposed to keep her secretions moist and they (the facility) said she was supposed to wear it all the time." Family Member 'A' reported that he observed dried mucous in (Resident #501's) stoma and that "when it gets like that (dried mucous), it needs to be flushed out (the stoma needs to be suctioned out to remove mucous plugs that impede breathing)." Family Member 'A' said that Resident #501 "was a neck breather" (obtained oxygen mostly through the tracheotomy stoma) and that she had the stoma for [AGE] years. "It never closed but she always made mucous plugs. We (family members) instructed the facility on how to suction (Resident #501). I expected them to put the saline water (normal saline) into the stoma and flush (suction) the mucous plugs out. The last day I saw her, I told (name of Nurse 'B') that (Resident #501) needed to be flushed out. I could see the dried mucous plug in the opening. (Nurse 'B') gave her some medicine. She went to sleep, but the nurse didn't flush her out while we (family) were there. Since she was asleep, I figured that she would be okay. Then I got a call later on that night and they told me she was dead. I don't think (Nurse 'B') flushed her out because the stoma still had that crusted mucous in the stoma when we returned to the facility to see her." On [DATE] at 1:45 pm, Resident #501's clinical record was reviewed and revealed the following. Resident #501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] documented that Resident #501 was able to understand others, able to make some of her needs known, had severely impaired cognition and that she required complete physical assistance from staff for all Activities of Daily Living. The MDS also noted that Resident #501 required suctioning and tracheotomy care. A form titled "Memo: Care Summary of (Resident #501)" dated [DATE] documented "Flushing her stoma is imperative! Whenever she shows signs of respiratory distress, such as raspy breathing, frequent coughing, trouble catching her breath - She needs to be suctioned out. As you are inserting the suction catheter please use saline water to moisten the area and loose the mucous in the stoma. She should be suctioned at least every two days, as preventive care from accumulating dried mucous in her stoma." On [DATE], according to an acute care facility note, Resident #501 was observed to have a "stoma site widely patent." The plan of care indicated was to deliver humidified oxygen. Upon return to the facility, a physician's orders [REDACTED]." A [MEDICAL CONDITION] medicine note dated [DATE] documented that Resident #501 was seen for Shortness of Breath and Difficulty Breathing secondary to mucous plugs with a medical plan to continue [MEDICAL CONDITION] with moisture. Review of physician's orders [REDACTED]. 1. Aerosolized water to stoma at all times. 2. Suction tracheotomy every shift and as necessary. A [MEDICAL CONDITION] medicine note dated [DATE] revealed that Resident #501 was seen for "thick bloody clots" and chronic mucous. There were no "Skilled Daily Nurses Note" for the month of [DATE] that documented any assessment, monitoring or care to Resident #501's stoma. There were no nursing notes from [DATE] to [DATE] that documented the assessment, monitoring or care to Resident #501's stoma. There was no plan of care for Resident #501's tracheotomy stoma. The "Transfer Form" dated [DATE] documented that the [DIAGNOSES REDACTED].#501) turned blue, respiratory distress. 911 called. CPR started." A nurse's note dated [DATE] revealed that Resident #501 "passed away" at 10:30 pm. On [DATE] at 9:30 am, Unit Manager Nurse 'C' was asked if Resident #501's stoma was assessed, monitored and suctioned every shift as ordered. Nurse 'C' reviewed Resident #501's Medication Administration Record (MAR), Treatment Administration Record (TAR) and Nurses Notes and could not find any documented evidence that Resident #501's respiratory status was assessed, evidence that the stoma was monitored for mucous plugs, and documented evidence that the stoma was suctioned as requested by the family or as ordered by the physician. The order for [MEDICAL CONDITION] to deliver aerosolized water to stoma at all times was written on [DATE], however there was no documented evidence that it was provided to Resident #501 at all times. Nurse 'C' then reviewed the clinical record and reported that there was no documented evidence of stoma care for Resident #501 during the month of July. The Unit Manager, Nurse 'C', was unable to describe the kind of care Resident #501 was to receive for her stoma since there was no plan of care. On [DATE] at 10:00 am, when Nurse 'B' was queried, she reported that she suctioned Resident #501 at least once per shift but was unable to explain why there was no documentation that she assessed Resident #501's respiratory status and monitored for the effectiveness of suctioning. On [DATE] Nurse 'B' stated that Family Member 'A' asked her to suction Resident #501 and stated, "I suctioned her around nine o'clock." However, review of the documentation written at 11:45 pm, after Resident #501 was pronounced dead, a nurse's note indicated that Nurse 'B' suctioned Resident #501's stoma at 8:00 pm which resulted in "thick, medium, white secretions." There was no documentation that indicated that Resident #501 was assessed prior to being suctioned and there was no documented evidence of the effectiveness of suctioning. On [DATE] at 10:05 am, Certified Nurse Assistant (CNA) 'E' was interviewed and reported that Resident #501 had [MEDICAL CONDITION] on at all times. On [DATE] at 10:30 am, Nurse 'F' was interviewed and reported that Resident #501 had "a really strong cough" and that she was suctioned at least once a shift. When queried, Nurse 'F' was unable to explain why stoma care for Resident #501 was not documented. When asked if she referred to a care plan regarding the care for Resident #501's stoma, Nurse 'F' stated that she was unaware of a plan of care for Resident #501's stoma and stated, "The orders for her stoma changed all the time." On [DATE] at 11:40 am, [MEDICAL CONDITION] Medicine Physician Assistant (PA) 'D' was queried regarding Resident #501. PA 'D' explained that Resident #501 had a history and was prone to develop mucous plugs that would block her airway. PA 'D' also reported that "(Resident #501) needed humidified air to thin secretions and needed to be suctioned on an as needed basis because she had a weak cough." When asked when Resident #501 was to be suctioned, PA 'D' explained that suctioning would be done based on nursing assessment. PA 'D' added that the humidified air was delivered through [MEDICAL CONDITION] at 28% and then stated that suctioning and humidified oxygen should have been administered as ordered and documented in the TAR and the MAR and that nursing assessments before and after suctioning should have been documented in the nurses' notes. On [DATE] at 12:15 pm the Administrator was queried regarding assessing, monitoring and providing stoma care for Resident #501. The Administrator reviewed Resident #501's clinical record and stated that the facility staff "did not assess (Resident #501) as they should have." On [DATE] at 9:00 am, Police Lieutenant 'G' was interviewed regarding the emergency run regarding Resident #501. Lieutenant 'G' verified that the EMS record noted that Resident #501's neck was very stiff and the stoma appeared to be closed. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT PRESSURE RELIEVING DEVICES TO PREVENT THE DEVELOPMENT OF A PRESSURE SORE FOR ONE ( # 702) OF TWO RESIDENTS REVIEWED FOR PRESSURE SORES FROM A TOTAL SAMPLE OF 21, RESULTING IN THE DEVELOPMENT OF AN AVOIDABLE FACILITY ACQUIRED STAGE THREE (III) PRESSURE SORE TO THE RESIDENT'S RIGHT KNEE. FINDINGS INCLUDE: DURING THE INITIAL TOUR OF THE 2 NORTH UNIT ON 9/25/12 AT 9:00 A.M., THE DIRECTOR OF NURSING (DON) REPORTED THAT RESIDENT (702) HAD A FACILITY ACQUIRED PRESSURE ULCER ON THE KNEE THAT WAS CAUSED WHEN STAFF POSITIONED THE BED AGAINST THE WALL AND THE RESIDENT'S KNEES WAS PRESSED AGAINST THE WALL. RECORD REVIEW REVEALED THAT RESIDENT #702 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE NURSING ADMISSION ASSESSMENT, DATED 4/28/11, INDICATED RESIDENT #702'S SKIN WAS INTACT WITH OLD SCARS TO THE BUTTOCK AND BACK. THE BRADEN SCALE (TOOL USED TO PREDICT PRESSURE SORE RISKS) DATED 4/28/11, 6/14/11, 8/23/11 AND 11/29/11, INDICATED RESIDENT #702 WAS AT A MILD RISK FOR THE DEVELOPMENT OF PRESSURE SORES. THE MOST RECENT MINIMUM (MDS) data set [DATE] INDICATED RESIDENT #702 WAS NON-AMBULATORY, TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING, INCLUDING BED MOBILITY, TRANSFERS AND WAS SEVERELY IMPAIRED IN COGNITIVE SKILLS FOR DECISION MAKING. REVIEW OF AN AT RISK FOR ALTERATION IN SKIN INTEGRITY RELATED TO DECREASED MOBILITY, INCONTINENCE OF BOWEL AND BLADDER CARE PLAN, DATED 5/11/11 AND REVISED ON 1/20/12 , INDICATED RESIDENT #702 WAS AT RISK FOR PRESSURE ULCER DEVELOPMENT AND REQUIRED STAFF ASSISTANCE WITH TURNING AND REPOSITIONING TO HELP PREVENT THE DEVELOPMENT OF PRESSURE SORES. REVIEW OF A "MONTHLY SKIN WOUND REPORT", DATED SEPTEMBER 2012, INDICATED A STAGE THREE (III) PRESSURE SORE WAS IDENTIFIED ON RESIDENT #702'S RIGHT KNEE ON 1/18/12. REVIEW OF A NURSING PROGRESS NOTE, DATED 1/20/12 STATED " ...RT (RIGHT KNEE WITH 4 X 5 CENTIMETER (CM) DRY HARD PURPLE YELLOW AREA WITH SMALL AMOUNT OF SEROUS DRAINAGE. REPORTED TO START OUT AT FLUID FILLED BLISTER. IT'S KNEE IS NEXT TO WALL. SUSPECT BUMPING ON WALL. RESIDENT MOVES ABOUT IN BED...BOTH LOWER EXTREMITIES CONTRACTED UP. NOTED LAYING IN BED WITH BOTH LEG DRAWN UP AND ADDUCTED TO BOTH SIDES...KEEP BED 6 INCHES FROM WALL..." ON 9/27/12 AT 2:25 P.M., DURING A WOUND CARE OBSERVATION WITH THE DIRECTOR OF NURSING (DON) AND TREATMENT NURSE (B), REVEALED A STAGE III (FULL THICKNESS TISSUE LOSS, SUBCUTANEOUS FAT MAY BE VISIBLE) PRESSURE SORE TO RESIDENT # 702 RIGHT KNEE THAT MEASURED 1.7 CENTIMETER(CM ) X 1.8 CM. WITH A MODERATE AMOUNT OF SEROSANGUINEOUS DRAINAGE. THE WOUND BED WAS PINK WITH A SCANT AMOUNT OF SCATTERED FAT TISSUE EXPOSED. AFTER THE WOUND CARE PROCEDURE, ON 9/27/12 AT 3:00 P.M. THE DON AND TREATMENT NURSE (B) WAS INTERVIEW REGARDING WHAT PREVENTATIVE DEVICES WERE PUT IN PLACE TO PREVENT THE DEVELOPMENT OF RESIDENT # 702 PRESSURE SORE. THE DON AND TREATMENT NURSE STATED THE PRESSURE SORE ON RESIDENT #702'S RIGHT KNEE WAS CAUSED, WHEN STAFF POSITIONED RESIDENT #702'S RIGHT KNEE DIRECTLY AGAINST THE WALL. THE DON WAS UNABLE TO EXPLAIN WHY PRESSURE RELIEF DEVICES HAD NOT BEEN PUT IN PLACE TO HELP PREVENT THE DEVELOPMENT OF THE STAGE III PRESSURE SORE ON RESIDENT #702'S KNEE. REVIEW OF THE FACILITY'S UNDATED POLICY, TITLED, "PRESSURE ULCER PREVENTION AND SKIN CARE MANAGEMENT POLICY", STATED, "...A RESIDENT WHO ENTERS THE FACILITY WITHOUT A PRESSURE ULCER WILL NOT DEVELOP A PRESSURE ULCER UNLESS THE RESIDENT'S CLINICAL CONDITION DEMONSTRATES THAT THEY WERE UNAVOIDABLE..." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ASSESS SIGNS AND SYMPTOMS OF PAIN FOR ONE (#504) OF 9 RESIDENTS REVIEWED FOR PAIN FROM A TOTAL SAMPLE OF 22 RESIDENTS, RESULTING IN CONTINUED AND ON-GOING DEMONSTRATIONS OF PAIN. FINDINGS INCLUDE: ON 10/18/11 AT 9:00 A.M., DURING THE INITIAL TOUR, RESIDENT #504 WAS OBSERVED IN A GERICHAIR IN HER ROOM INTERMITTENTLY "SHOUTING OUT." CERTIFIED NURSE ASSISTANT (CNA) 'E' WAS QUERIED REGARDING RESIDENT #504'S SHOUTING AND STATED, "THE RESIDENT IS IN PAIN." THE RESIDENT WAS THEN QUERIED AND DID NOT ANSWER. SHE BECAME "TEARFUL". AT 11:45 A.M., RESIDENT #504 WAS UP IN A GERICHAIR IN HER ROOM AND COULD BE HEARD YELLING. ON 10/20/11 AT 2:40 P.M. REVIEW OF THE CLINICAL RECORD REVEALED THE FOLLOWING: PER THE FACE SHEET, RESIDENT #504 WAS admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE ANNUAL MINIMUM DATA SET (MDS), dated [DATE], AND THE QUARTERLY MDS, dated [DATE], CODED THE RESIDENT AS HAVING "LIMITED ABILITY TO EXPRESS CONCRETE REQUESTS FOR BASIC NEEDS" AND THAT THE RESIDENT HAD "SOME DIFFICULTY RESPONDING ACCURATELY" TO STAFF. THE RESIDENT WAS CODED AS REQUIRING EXTENSIVE TO TOTAL PHYSICAL ASSISTANCE FROM STAFF FOR COMPLETION OF ALL ACTIVITIES OF DAILY LIVING (ADL'S). THE ANNUAL MDS (3/22/11), AND THE MOST RECENT QUARTERLY MDS (9/21/11), REVEALED THAT RESIDENT #504'S PAIN ASSESSMENT WAS NOT COMPLETED. THERE WAS NO EVIDENCE THE FACILITY UTILIZED A DIFFERENT ASSESSMENT TOOL TO ASSESS FOR PAIN. REVIEW OF THE CURRENT (10/11) MEDICATION ORDERS REVEALED THAT THE RESIDENT RECEIVED TYLENOL 325 MILLIGRAMS (MG) TWO TABLETS EACH NIGHT FOR PAIN AND TYLENOL 325 MG EVERY FOUR HOURS AS NEEDED FOR INCREASE IN TEMPERATURE (FEVER). THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THERE WAS NO INDICATION AS TO THE REASON THE TYLENOL WAS GIVEN AND THERE WAS NO EVIDENCE A PAIN ASSESSMENT WAS COMPLETED PRIOR TO AND AFTER THE ADMINISTRATION OF THE MEDICATION. THE CARE PLAN FOR PAIN, DATED 9/21/11, DOCUMENTED THE CONCERN AS, "POTENTIAL FOR ALTERATION IN COMFORT RELATED TO [DIAGNOSES REDACTED]." THE INTERVENTIONS DOCUMENTED INCLUDED THE FOLLOWING: 1. ASSESS EFFECTIVENESS OF PAIN MEDICATION/INTERVENTIONS. 2. OBSERVE RESIDENT FOR SIGNS AND SYMPTOMS OF DISCOMFORT SUCH AS VERBALIZATION OF PAIN, GRIMACING, DIAPHORESIS (SWEATING), GUARDING, CRYING, MOANING, ETC. ON 10/20/11 AT 5:00 P.M., RESIDENT #504 WAS OBSERVED IN BED. THE RESIDENT WAS GRIMACING AND SHOUTING OUT AT INTERVALS. STAFF MEMBERS WERE OBSERVED TO WALK PAST THE RESIDENT'S ROOM WITHOUT STOPPING. AT 10:00 A.M., RESIDENT #504 WAS OBSERVED IN BED. THE RESIDENT WAS TEARFUL. WHEN QUERIED, THE RESIDENT POINTED AT HER LEGS AND STATED, "MY LEGS HURT." AT 10:20 A.M. NURSE 'G' WAS QUERIED REGARDING RESIDENT #504'S YELLING OUT AND WHETHER THE RESIDENT WAS ON A PAIN MANAGEMENT PROGRAM. NURSE 'G' STATED, "SHE SCREAMS OUT LIKE THAT ALL THE TIME". NURSE 'G' ASKED RESIDENT #504, "WHAT'S GOING ON?" RESIDENT #504 BECAME TEARFUL AND BEGAN TO CRY. THE RESIDENT LIFTED HER RIGHT LEG AND STATED, "MY LEGS...THEY HURT...IT REALLY HURTS." ON 10/21/11 AT 12:00 P.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED REGARDING THE RESIDENT'S CONTINUED EXPRESSIONS (VERBAL AND GESTURES) OF PAIN. THE DON SAID THAT RESIDENT #504 SHOUTED OUT IN THIS MANNER WHEN IN DISCOMFORT. THE DON WAS QUERIED REGARDING THE INCOMPLETE MDS PAIN ASSESSMENTS AND WAS UNABLE TO EXPLAIN. THE DON WAS UNABLE TO IDENTIFY "HOW" RESIDENT #504 WAS ASSESSED FOR PAIN AND STATED, "...TYLENOL FOR PAIN CONTROL WOULD NOT BE SUFFICIENT". WHEN QUERIED REGARDING THE MANNER IN WHICH RESIDENT #504 WAS ASSESSED FOR PAIN, THE DON STATED, "WE CAN'T CONSISTENTLY BASE IT (PAIN LEVEL) ON WHAT SHE SAYS. WE SHOULD MONITOR HER FACIAL EXPRESSIONS." ON 10/21/11 AT 1:15 P.M., THE FACILITY POLICY TITLED, "PAIN ASSESSMENTS" DOCUMENTED THE FOLLOWING: "THE ASSESSMENT INCLUDES THE FREQUENCY AND INTENSITY OF SIGNS AND SYMPTOMS OF PAIN AND CAN BE USED TO IDENTIFY INDICATORS OF PAIN AS WELL AS TO MONITOR RESIDENT'S RESPONSE TO PAIN MANAGEMENT INTERVENTIONS... OBSERVE RESIDENT FOR INDICATORS OF PAIN....MOANING, CRYING, AND OTHER VOCALIZATIONS, WINCING OR FROWNING AND OTHER FACIAL EXPRESSIONS, BODY POSTURE SUCH AS GUARDING OR PROTECTING AN AREA OF THE BODY, OR LYING VERY STILL." ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 978. BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION TO PREVENT ELOPEMENT AND/OR FALLS FOR 2 OF 10 SAMPLED RESIDENTS (#101 AND #107), RESULTING IN (1) IMMEDIATE JEOPARDY FOR RESIDENT #101 WHO ELOPED FROM THE FACILITY WHEN STAFF TURNED THE ALARM OFF AND OPENED THE FRONT DOOR OF THE FACILITY, ALLOWING RESIDENT #101 TO EXIT THE FACILITY AND PLACING 7 RESIDENTS, WHO WERE IDENTIFIED AS AT RISK FOR ELOPEMENT, AT HIGH RISK FOR SERIOUS INJURY, HARM, OR DEATH, AND (2) MULTIPLE FRACTURES FOR RESIDENT #107 WHO fell FROM AN ELEVATED HOYER LIFT (A PORTABLE MECHANICAL LIFT) WHILE BEING TRANSFERRED UNASSISTED BY ONE STAFF MEMBER, PLACING 16 RESIDENTS, WHO WERE IDENTIFIED AS BEING AT RISK FOR FALLS, AT POTENTIAL RISK FOR PHYSICAL INJURY. FINDINGS INCLUDE: RESIDENT #101: AN INCIDENT AND ACCIDENT REPORT DATED 06/11/10 INDICATED RESIDENT #101 WAS OBSERVED ON 06/11/10 AT 7:00 AM WALKING OUT THE FRONT DOOR OF FACILITY INTO THE PARKING LOT. THIS REPORT SAID RESIDENT #101 WAS CARRYING HER HANDBAG AND VERBALIZED WANTING TO GO TO SON'S HOUSE. ACCORDING TO A COMPETENCY ASSESSMENT FOR RESIDENT #101, DATED 05/17/10 AND SIGNED BY A PHYSICIAN, RESIDENT #101 WAS INCOMPETENT TO MAKE DECISIONS REGARDING MEDICAL TREATMENT. A WANDERING ASSESSMENT/RISK FOR ELOPEMENT FORM DATED 05/17/10 IDENTIFIED RESIDENT #101 AS AT RISK FOR ELOPEMENT. ACCORDING TO THE MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #101 WAS A [AGE] year OLD FEMALE WITH MODERATELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION MAKING AND HAS DISPLAYED WANDERING BEHAVIORS THAT WERE NOT EASILY ALTERED. THE MDS INDICATED THAT RESIDENT #101 HAD MEDICAL [DIAGNOSES REDACTED]. A CARE PLAN DATED 05/28/10 IDENTIFIED RESIDENT #101 AS A RISK FOR ELOPEMENT. THIS CARE PLAN INSTRUCTED STAFF TO OBSERVE RESIDENT #101 OFTEN DURING EACH SHIFT AND TO LOCATE RESIDENT #101 IF SHE WAS NOT IN AREA(S) USUAL FOR HER. THE NURSE'S NOTES DATED 06/11/10 AT 7:30 AM, SIGNED BY REGISTERED NURSE #9, INDICATED RESIDENT #101 WAS OBSERVED IN THE FACILITY PARKING LOT CARRYING HER HANDBAG AND VERBALIZING THAT SHE WAS GOING TO HER SON'S HOUSE. THESE NURSE'S NOTES STATED AN ELOPEMENT MONITOR SHEET WAS CONTINUED. THE SOCIAL SERVICES PROGRESS NOTES DATED 06/11/10 (NO TIME NOTED) INDICATED RESIDENT #101 HAD AN INCIDENT OF ELOPEMENT FROM THE BUILDING. DURING AN INTERVIEW ON 10/05/10 AT 11:45 AM, LICENSED PRACTICAL NURSE (LPN) #6 SAID SHE WAS AWARE OF AN INCIDENT IN WHICH RESIDENT #101 HAD ELOPED FROM THE FACILITY BUT WAS UNABLE TO PROVIDE SPECIFIC DATES AND TIMES. IN AN INTERVIEW ON 10/06/10 AT 10:10 AM, THE ADMINISTRATOR SAID RESIDENT #101 ELOPED FROM THE FACILITY ON 06/11/10 AT APPROXIMATELY 7:00 AM. THE ADMINISTRATOR SAID HOUSEKEEPING STAFF (HSK) #10 TURNED ALARM OFF AND OPENED THE FRONT DOOR OF THE FACILITY, ALLOWING RESIDENT #101 TO EXIT THE FACILITY. IN AN INTERVIEW ON 10/06/10 AT 10:50 AM, HSK #7 SAID SHE OBSERVED RESIDENT #101 WANDERING OUTSIDE THE FACILITY NEAR THE ROCKS AT THE FAR END OF THE FACILITY PARKING LOT WHILE DRIVING TO WORK ON 06/11/10 AT APPROXIMATELY 7:00 AM. HSK #7 SAID SHE PULLED INTO THE PARKING LOT AND OBSERVED CERTIFIED NURSE AIDE (CNA) #8 SITTING IN CAR IN PARKING LOT AND HSK #11 IN THE PARKING LOT. HSK #7 SAID SHE REQUESTED THE ASSISTANCE OF CNA #8 AND HSK #11 TO ESCORT RESIDENT #101 BACK TO THE FACILITY. HSK #7 SAID CNA #8 AND HSK #11 ESCORTED RESIDENT #101 BACK TO THE FACILITY. SHE SAID RESIDENT #101 WAS NOT INJURED. HSK #7 SAID THE FACILITY VIDEO CAMERA SHOWED THAT HSK #10 KEYED THE ALARM TO TURN ALARM OFF AND OPENED THE FRONT DOOR OF THE FACILITY, ALLOWING RESIDENT #101 TO EXIT THE BUILDING. IN AN INTERVIEW ON 10/06/10 AT 11:20 AM, CNA #8 SAID SHE WAS SITTING IN A CAR IN THE FACILITY PARKING LOT ON 06/11/10 AT APPROXIMATELY 7:00 AM WHEN HSK #7 CALLED FOR HER TO HELP RESIDENT #101 BACK TO THE FACILITY. CNA #8 SAID SHE SAW RESIDENT #101 WANDERING IN THE FACILITY PARKING LOT AND HELPED ESCORT RESIDENT #101 BACK TO THE FACILITY WITH HSK #11. CNA #8 SAID RESIDENT #101 ELOPED FROM THE FACILITY FOR APPROXIMATELY 5 MINUTES BEFORE BEING ESCORTED BACK INTO THE BUILDING. IN AN INTERVIEW ON 10/06/10 AT 2:10 PM, HSK #11 SAID HE SAW RESIDENT #101 CARRYING A HANDBAG AND WANDERING NEAR THE ROCKS AND GATE IN THE FACILITY PARKING LOT. HSK #11 SAID RESIDENT #101 SAID "I WANT TO GO HOME" AND WAS HEADING TOWARD THE ROAD. HSK #11 SAID HSK #7 ASKED FOR HIS HELP TO ASSIST RESIDENT #101 BACK TO THE FACILITY. HSK #11 SAID HE AND CNA #8 ESCORTED RESIDENT #101 BACK TO THE FACILITY. HSK #11 SAID RESIDENT #101 ELOPED FROM THE FACILITY FOR APPROXIMATELY 5 MINUTES BEFORE BEING ESCORTED BACK INTO THE BUILDING. IN AN INTERVIEW ON 10/06/10 AT 2:20 PM, HSK #10 SAID HE KEYED THE ALARM TO TURN THE ALARM OFF AND OPENED THE FRONT DOOR OF THE FACILITY ALLOWING RESIDENT #101 TO EXIT THE FACILITY. HSK #10 SAID RESIDENT #101 ELOPED FROM THE FACILITY FOR APPROXIMATELY 5 MINUTES BEFORE BEING ESCORTED BACK INTO THE BUILDING. THE ADMINISTRATOR WAS NOTIFIED ON 10/08/10 AT 11:25 AM OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 06/11/10 AT 7:00 AM WHEN HOUSEKEEPING STAFF #10 TURNED THE ALARM OFF AND OPENED THE FRONT DOOR OF THE FACILITY, ALLOWING RESIDENT #101 TO LEAVE THE FACILITY UNSUPERVISED. ON 10/11/10, THE SURVEYOR VERIFIED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON 6/11/10, RESIDENT #101 WAS RETURNED TO THE FACILITY WITHOUT PHYSICAL HARM OR INJURY. 2. ON 10/11/10 AT 9:45 AM, SURVEYOR OBSERVED FACILITY STAFF MONITORING THE FACILITY FRONT DOOR, SIDE DOOR, AND DINING ROOM PATIO DOOR. FACILITY STAFF MEMBERS WERE SIGNING VISITORS IN AND OUT UPON ENTRANCE AND DEPARTURE FROM FACILITY. THE FACILITY SAID THERE WILL BE A STAFF MEMBER AT THIS POSITION MONITORING THE ABOVE LOCATIONS ON A 24 HOUR A DAY, 7 DAY A WEEK BASIS. 3. ON 10/11/10 AT 1:10 PM, SURVEYOR OBSERVED PHOTOS OF RESIDENTS IDENTIFIED AS HIGH RISK FOR ELOPEMENT PLACED INSIDE PRIVACY BINDERS LOCATED AT THE FRONT DESK, THERAPY DEPARTMENT, DIETARY DEPARTMENT, AND AT EACH NURSING UNIT. 4. ON 10/07/10 AND 10/08/10, 102 OF 130 STAFF WERE IN-SERVICED REGARDING ELOPEMENT POLICY AND PROCEDURE AND IDENTIFICATION OF RESIDENTS AT RISK FOR ELOPEMENT. THE SURVEYOR VERIFIED THAT THE REMAINDER OF THE STAFF WILL RECEIVE AN OVERNIGHT LETTER MAILED 10/11/10 TO REVIEW THE ELOPEMENT PREVENTION AND MISSING RESIDENT CODE POLICY. 5. AS OF 10/11/10, THE FACILITY HAS 7 RESIDENTS OF 101 RESIDENTS IDENTIFIED AS AT RISK FOR ELOPEMENT. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON 10/11/10 AT 2:00 PM, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND SEVERITY OF ACTUAL HARM NOT IMMEDIATE JEOPARDY (SEE RESIDENT #107 CITED BELOW) DUE TO NOT ALL STAFF MEMBERS HAD BEEN IN-SERVICED REGARDING THE FACILITY ELOPEMENT POLICY AND PROCEDURE AND BECAUSE SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. RESIDENT #107: REVIEW OF AN INCIDENT/ACCIDENT REPORT DATED 09/10/10 REVEALED RESIDENT #107 fell TO FLOOR DURING A TRANSFER VIA HOYER LIFT ON 09/10/10 AT 2:00 PM . THIS REPORT SAID CNA #13 WAS INVOLVED. THE FACILITY PROVIDED A POLICY WITH PROTOCOLS FOR SAFE LIFT/TRANSFER OF RESIDENTS DATED 10/01/07. THIS POLICY STATED "MECHANICAL LIFTS/STANDS REQUIRE TWO (2) PERSONS FOR TRANSFERS." REVIEW OF THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED RESIDENT #107 WAS A [AGE] year OLD FEMALE WITH MODERATELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION MAKING AND WHO WAS TOTALLY DEPENDENT FOR TRANSFERRING NEEDS AND REQUIRED ASSISTANCE FROM TWO OR MORE PERSONS. RESIDENT #107'S WEIGHT WAS 190 POUNDS. A CARE PLAN DATED 08/13/10 IDENTIFIED RESIDENT #107 AS A RISK FOR FALLS. THIS CARE PLAN SAID INSTRUCTED STAFF TO PROVIDE 2 PERSONS TO ASSIST WITH TRANSFERS USING A HOYER LIFT. A CARE PLAN DATED 08/13/10 IDENTIFIED RESIDENT #107 AS A RISK FOR SELF CARE DEFICITS. THIS CARE PLAN INSTRUCTED STAFF TO TRANSFER RESIDENT #107 WITH TWO PERSONS AND A HOYER LIFT. THE NURSE'S NOTES DATED 09/10/10 AT 2:00 PM THAT SAID A CNA (UNIDENTIFIED) WAS TRANSFERRING RESIDENT #107 TO A WHEELCHAIR VIA A HOYER LIFT WHEN RESIDENT #107 SLID OUT OF THE HOYER SLEEVE (SLING) AND HIT THE FLOOR. THE NOTES SAID RESIDENT #107 HAD A SMALL SKIN TEAR ON HER LOWER LEFT BACK AND COMPLAINTS OF EXTREME PAIN (10 OF 10 ON A 1-10 SCALE WITH 10 BEING THE WORST DEGREE OF PAIN). THE NURSE'S NOTES DATED 09/10/10 AT 3:05 PM INDICATED RESIDENT #107 HAD AN INCREASED PULSE RATE AND LOW SPO2 LEVELS (BLOOD OXYGENATION LEVEL). INTERIM PHYSICIAN ORDERS [REDACTED].#107 TO THE HOSPITAL FOR HER INCREASED PULSE RATE AFTER THE FALL. THE HOSPITAL INPATIENT FACE SHEET (UNDATED) SAID RESIDENT #107 WAS admitted TO THE hospital on [DATE] AT 4:25 PM WITH [DIAGNOSES REDACTED]. REVIEW OF A HOSPITAL DIAGNOSTIC TEST REPORT DATED 09/10/10 AT 5:30 PM REVEALED THAT RESIDENT #107 HAD FRACTURES TO THE LEFT 10TH AND 11TH RIBS AND THE LEFT T10 TRANSVERSE PROCESS (A BONE IN THE LOWER SPINE). IN AN INTERVIEW ON 10/07/10 AT 11:30 AM, REGISTERED NURSE (RN) #14 SAID ON RESIDENT #107 fell FROM AN ELEVATED HOYER LIFT STRIKING THE FLOOR DURING A TRANSFER FROM BED TO WHEELCHAIR BY CNA # 13 ON 09/10/10 AT 2:00 PM. RN #14 SAID RESIDENT #107'S TRANSFER ORDERS WERE FOR 2 PERSON ASSISTANCE VIA HOYER LIFT. RN #14 SAID CNA #13 CALLED FOR HELP AFTER THE FALL. RN #14 SAID WHEN SHE ENTERED RESIDENT #107'S ROOM, SHE SAW RESIDENT #107 ON HER BACK ON THE FLOOR WITH FEET STILL IN HOYER LIFT PAD AND COMPLAINING OF BACK PAIN. RN #14 SAID THERE WAS NO APPARENT MALFUNCTION OF EQUIPMENT. RN #14 SAID CNA #13 ATTEMPTED TO TRANSFER RESIDENT #107 VIA HOYER LIFT ALONE AND UNASSISTED. RN #14 SAID SHE IMMEDIATELY ASSESSED RESIDENT #107 AND NOTIFIED THE PHYSICIAN. IN AN INTERVIEW ON 10/07/10 AT 11:50 AM, CNA #13 SAID SHE ATTEMPTED TO TRANSFER RESIDENT #107 VIA HOYER LIFT ALONE AND UNASSISTED ON 09/10/10 AT 2:00 PM. CNA #13 SAID SHE PLACED RESIDENT #107 IN THE HOYER LIFT PAD FOR A TRANSFER FROM BED TO WHEELCHAIR. CNA #13 SAID SHE ELEVATED RESIDENT #107 INTO THE AIR VIA THE HOYER LIFT AND PULLED RESIDENT #107 OUT FROM THE BED. WHILE RESIDENT #107 WAS STILL ELEVATED, CNA #13 TURNED AWAY FROM RESIDENT #107 IN AN ATTEMPT TO MANEUVER THE WHEELCHAIR UNDERNEATH RESIDENT #107. CNA #13 SAID AT THE MOMENT SHE TURNED AWAY, RESIDENT #107 SLIPPED THROUGH THE RIGHT SIDE OF THE HOYER PAD AND fell TO THE FLOOR ON HER BACK WITH HER FEET STILL IN THE HOYER LIFT PAD. CNA #13 SAID RESIDENT #107 IMMEDIATELY BEGAN COMPLAINING OF BACK PAIN. IN AN INTERVIEW ON 10/07/10 AT 12:25 PM, THE ADMINISTRATOR SAID RESIDENT #107 WAS TRANSFERRED TO THE hospital on [DATE] FOR FURTHER MEDICAL ASSESSMENT. ( )