Every finding on record at Harmony Village of Beverly Hills

Based on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in foodborne illness and cross-contamination for all residents that consume food from the kitchen. Findings include:On 6/1/26 at 8:42 AM, during an initial tour of the kitchen with the Certified Dietary Manager (CDM 'G'), the following concerns were observed:There was a table just outside the dish room that had several plates, bowls and silverware stored right side up and were observed soiled with various food debris. When asked about the storage of the items, CDM 'G' reported those items should've been stored face down and proceeded to turn the soiled items face down on the shelving unit. When asked if those items were going to remain in use, CDM 'G' offered no response and began to remove the items.According to the 2022 FDA (Food and Drug Administration) Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) .cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.There was a bottle of heavy-duty degreaser that was observed stored directly between the juice and coffee machine. When asked about the storage of the chemicals, CDM 'G' reported the chemical bottle should not have been stored there.According to the 2022 FDA Food Code section 7-201.11 Separation Poisonous or toxic materials shall be stored so they cannot contaminate food, equipment, utensils, linens, and single-service and single-use articles by: (A) Separating the POISONOUS OR TOXIC MATERIALS by spacing or partitioning; and (B) Locating the POISONOUS OR TOXIC MATERIALS in an area that is not above FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE or SINGLE-USE ARTICLES.The reach in cooler behind the meal prep area was observed to have a container of food with a blue lid and small piece of pie in a clear plastic container stored next to other food items in the cooler that had no label to indicate what the food item was, or any dates of when prepared or to be used by. When asked about the containers, CDM 'G' reported that was an employee's food. When asked if employees should be storing their food in with facility food/drink items, they reported they shouldn't and there was a cooler in the employee breakroom but that was not working. There was an opened gallon container of whole milk that was about half full with a best by date of 5/31/26. There was a large white <name brand foam> cup that contained an unidentifiable dark jelly-like substance. There was no label or date to identify what the substance was, when it was prepared, or when to discard. When CDM 'G' was asked about the cup, they reported that was <name brand gelatin> and should've been labelled appropriately.The walk-in cooler was observed to have two large bags of fresh parsley. Some of the parsley was observed brown in color and there were visible droplets that clung to the inside clear packaging. One bag had a label that indicated it had been delivered on 5/14/26 and was Best By 5/18/26. Another bag indicated it had been delivered on 5/4/26 with a Best By 5/12/26. There was a large clear container with clear plastic wrap that had illegible dates that contained a large amount of fresh parsley that was submerged in water. When CDM 'G' was asked to identify the date on the plastic wrap, they reported 5/20 to 5/30/26. There was an unopened gallon of whole milk that had a label with a best by date of 5/31/26.When asked why these food items were still in circulation and intended for use, CDM 'G' reported they had not worked this past weekend and usually would've caught that in the morning.According to the 2022 FDA Food Code section 3-302.12 Food Storage Containers, Identified with Common Name of Food, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD.According to the 2022 FDA Food Code section 3-501.17: .(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section, and: 1. The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and 2. The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety .On 6/1/26 at 11:25 AM, an observation of the lunch meal prep was conducted with CDM 'G' and [NAME] 'E'. While [NAME] 'E' obtained the food temperatures they were observed placing the thermometer into the food in which the top portion of the thermometer (base which was held with bare hand) also went into the food. Although the probe part of the thermometer was cleaned before and after each food item checked, the upper portion of the thermometer was not.According to the 2022 FDA Food Code section 3-101.11 Safe, Unadulterated, and Honestly Presented. FOOD shall be safe, unADULTERATED, and, as specified under S 3-601.12, honestly presented.According to the facility's policy titled, Food Safety Requirements dated 8/2025: .Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.Preparation of food.Equipment used in the handling of food, including dishes, utensils.that comes in contact with food.Employee hygienic practices.Facility staff shall inspect food, food products.and ensure timely and proper storage.Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date.All equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination.Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects.

Based on observation and interview, the facility failed to maintain the exterior dumpster area in a clean manner. This deficient practice had the potential to affect all residents, staff and visitors. Findings include:On 6/1/26 at 9:05 AM, an observation of the dumpster area was conducted with Certified Dietary Manager (CDM 'G'). At that time, both dumpsters were observed to have the doors on the sides opened, and one of the dumpsters had a top lid that was opened. There were birds observed actively going in and out of the opened lid and doors. The area just outside of the dumpsters was observed to have multiple hospital beds, chairs, debris and containers labelled for shredding materials stored directly on the ground. There was an additional large open topped dumpster that was stored on the parking lot near to the designated dumpster area. When asked about who was responsible to maintain the garbage/refuse area, CDM 'G' reported they were responsible for the smaller dumpsters and the maintenance department handled the area that had the resident equipment and the other large dumpster. When asked how the garbage/refuse containers should be maintained, CDM 'G' reported the doors should be closed and proceeded to close the side doors but reported they were unable to reach opened lid on the top.On 6/1/26 at 3:15 PM, an observation of the dumpster area was conducted with Maintenance & Environmental Services Director (Staff 'A'). The same furniture/equipment that was observed earlier remained stored on the ground to the right of the dumpsters. Additionally, upon further observation of the bins labelled for shredding materials, several were observed to have been there for some time as their wheels were buried/covered in dirt and contained various branches and debris. The ground area just in front of these bins and the equipment stored on the ground also revealed there was a large hole/burrow that appeared to be an animal/rodent nest. When asked about how long these items had been stored in this manner, Staff 'A' reported they didn't know about the bins but reported the furniture/equipment had been put there this past Friday and there was a guy that comes out to pick up those items. They further reported the large dumpster was due to be picked up tonight or tomorrow and they didn't put those items (bins/furniture/equipment) in the large dumpster because someone was coming to get them.When asked who was responsible to maintain the dumpster area, and how it should be maintained, they reported normally their staff made sure the doors were closed on the regular dumpsters and when informed of the observation from earlier with CDM 'G', Staff 'A' reported dietary staff should've maintained that as well.On 6/2/26 at 1:32 PM, the facility was requested to provide a facility policy regarding maintenance of the garbage/refuse, however there was no documentation provided by the end of the survey.

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 two (R1 and R19) of three residents 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:On 6/2/26 at 2:02 PM, the facility was requested to provide documentation of the required documents which included the SNFABN notice. (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.) R1:Review of the documentation provided for R1 revealed the resident started Medicare Part A benefits on 3/2/26 and their last covered day was 4/30/26. R1 remained in the facility, and their legal guardian was not provided with a SNFABN notice. R19:Review of the documentation provided for R19 revealed the resident started Medicare Part A benefits on 1/14/26 and their last covered day was 3/29/26. R19 remained in the facility, and their financial representative was not provided with a SNFABN notice.On 6/3/26 at 9:15 AM, an interview was conducted with the Business Office Manager (Staff 'I') who reported they had been in this role for about a month. When asked about the documentation provided for beneficiary notifications, Staff 'I' confirmed the residents did not have a SNFABN completed and further reported they should have. When asked what their process was currently to provide the required notices, Staff 'I' reported they met as an interdisciplinary team every Thursday to determine eligibility for those residents on skilled services and they would issue the documentation which included the SNFABN at least two days prior to their last covered Medicare A day.On 6/3/26 at 9:27 AM, the facility was requested to provide a facility policy for SNFABN notices and at 10:21 AM, the Administrator reported they didn't have a policy and were supposed to follow the guidelines from CMS (Centers for Medicare & Medicaid Services).

This citation pertains to intakes 2738135 and 2738724.Based on interview and record review, the facility failed to provide supervision for one (R603) of five residents reviewed for accidents, resulting in R603, with a history of severe mental illness, homelessness and frost bite, exiting the facility. This resulted in an Immediate Jeopardy when R603 exited the facility unbeknown to the facility staff, was picked up by Police on 2/8/26 at 1:33 AM and not identified as missing by facility staff until 2/8/26 at approximately 2:50 PM (approximately 13 hours later). Due to the deficient practice, R603 and additional residents at risk for elopement had the increased likelihood for serious harm, serious injury, and/or death including hypothermia, frost bite, hand other health hazards related to being outside in extreme cold weather unsuprevised. Findings include:The Immediate Jeopardy (IJ) started on 2/8/26 when it R603 exited the building without the facility's knowledge. The IJ was identified on 2/17/26.The Administrator was notified of the Immediate Jeopardy on 2/17/26 at 2:46 PM, and a plan to remove the immediacy was requested.The Surveyor confirmed the immediacy was removed on 2/18/26 following acceptance of the facility's removal plan via record review and interviews.Review of the facility's documentation of the Facility Reported Incident (FRI) included: On 2/7/2026 at 7:28 PM, [R603] consumed 100% of his HS (evening) snack. At approximately 10:15 PM, scheduled bedtime medications were administered.At approximately 12:30 AM on 2/8/2026, [R603] was observed by multiple staff members within the facility. He had been in the dining room, sitting alone as he routinely chooses to do during these hours, and was later seen ambulating toward his room. At that time, based on interviews, staff reported no observable distress, agitation, behavioral escalation, verbalization of dissatisfaction, or desire to leave.Based on police documentation, the resident had exited the building on 2/8/26 prior to 1:33 AM. [Local] Police Department documentation confirms that [R603] was encountered walking down the road. He communicated an intention to go to a local casino and was transported by a police officer to an enclosed heated bus shelter to await transportation. Law enforcement documentation indicates the resident was left at the bus shelter shortly after 1:33 AM.At approximately 2:00 PM on 2/8/2026, staff were unable to locate [R603] during a routine attempt to escort him for his customary smoke break. A house-wide sweep and full census head count were completed, confirming all other residents were accounted for.The facility Missing Resident Procedure was activated. The Administrator, law enforcement, the guardian, Medical Director, corporate support and attending provider were notified. Facility staff searched facility grounds and traveled to local vendors, gas stations, and stores questioning the resident's presence and providing contact information to be reached at if they happen to see him. Local hospitals were contacted, [County] Search & Rescue was engaged, and [NAME] (Licensing and Regulatory Affairs) was notified of the event. Local news assisted in broadcasting the resident's description to support search efforts.On 2/9/26 09:57 AM, the Administrator was notified by the police that [R603] was located again outside a [Local Fast Food] a couple miles from the facility, very near the bus shelter where he had initially been dropped off by the police and was being transported to the hospital for evaluation. Resident was wearing tennis shoes, pants, a grey sweatshirt and a grey hoodie.The facility NHA (Nursing Home Administrator), DON (Director of Nursing) and MDS (Minimum Data Set) Coordinator met [R603] at the hospital when he arrived. During the interview, [R603] stated that he left the facility because he was upset about his shoes and reported exiting through a window in the dining room. The resident stated that he was able to manipulate the window to open and reported closing it behind him. During this hospital interview, the resident was alert, able to articulate reasons for leaving, and demonstrated understanding of his actions.Review of the closed clinical record revealed R603 was initially admitted into the facility on 7/14/23 and had a stop billing date of 2/9/26. According to the facility staff, R603 has remained hospitalized since 2/9/26. Diagnoses included: unspecified disorder of psychological development, adjustment disorder with mixed anxiety and depressed mood, paranoid schizophrenia, unspecified protein-calorie malnutrition, insomnia, unsheltered homelessness, other hyperlipidemia, and acquired absence of left and right toes.According to the Minimum Data Set (MDS) assessment dated [DATE], R603 had moderate cognitive impairment and was independent with mobility without an assistive device.Review of R603's care plans included several for identified behaviors towards staff which included physical behaviors (hitting self in face, tearing up items, urinating in garbage cans, removing sheets on bed, screaming at staff, and throwing water on floor).A new care plan was initiated on 2/8/26 that included, I am at elopement risk r/t (related to) history of attempts to leave facility unattended, I am independent with mobility with/without device, I have impaired safety awareness, mental illness and choose not to take my ordered medications.Review of the elopement risk assessments identified that R603 had been an elopement risk from 2/14/24 - 1/25/25. Since 1/25/25, R603 was not assessed as being an elopement risk.Review of a community mental health assessment dated [DATE] documented, in part: .Guardian reports that (R603) has a history of homelessness, which caused him to have his toes amputated on both feet due to frostbite and gangrene. She said that his mental illness is severe and interferes with his ability to take care of himself.In the winter of 2021, he experienced frostbite and gangrene, resulting in amputation of all of his toes on both feet. Due to the severity of his mental illness and chronic homelessness he needs to remain in the nursing facility for long-term care.According to the website www.timeanddate.com, the weather at the time and location when R603 was found by police on 2/8/26 High:19 Low:18 (Fahrenheit).On 2/17/26 at 8:40 AM, an interview was conducted with the Administrator. When asked about the details of R603's elopement and when they first became aware the resident was missing, the Administrator reported staff discovered he was missing when getting the residents ready for smoking and he wasn't present. When asked if any door alarms had been identified as activated and shut off, the Administrator reported no staff reported hearing or responding to alarms. When asked if the facility utilized any video surveillance, the Administrator reported they did not. When asked how it was determined the resident left the facility unsupervised, the Administrator reported the resident reported they went through the window in the center dining room, and they also had picture of a set of footprints in the snow just outside the window. The Administrator further reported allegations that staff were asleep but that was unable to be confirmed.When asked about what care was given to the resident, including any medications, the Administrator reported they were able to confirm R603 received their evening medication on 2/7/26 but that was another issue they were investigating with the Nurse (Registered Nurse/RN 'A') who on day shift for 2/8 documented the resident had refused medications that morning and reported they had last seen the resident at 2:00 AM. The Administrator further reported that was determined to not be truthful since local police picked up the resident at 1:33 AM and when RN 'A' was further questioned by the Police, they acknowledged they didn't actually see the resident as initially reported to Administrator and Police.When asked about what care the direct care staff should've provided and how they didn't identify the resident was missing until approximately 13 hours later, the Administrator reported there were concerns about the Certified Nursing Assistants (CNAs) as well and they were able to verify that the day shift CNA (CNA 'D') had delivered R603's meal trays for breakfast and lunch and did not identify the resident was missing.On 2/17/26 at 2:00 PM, an observation was made with the Administrator of the alleged window R603 had exited from. There were three large windows in the dining room, with each window having two smaller windows on the right and left sides that could be slide open horizontally. Two of these large windows were observed to directly exit into an external cement stairwell that led to the basement. It should be noted that the smaller side windows that could be slid open contained a screw that prevented the windows from opening beyond approximately four to five inches.When asked how it was possible an adult body (R603 was documented in the FRI as 73 inches tall and approximately 150 pounds) could fit through the window opening that was only four to five inches, the Administrator reported they weren't sure, but the resident reported that and there were footprints. It should be noted that the area outside this window was also a courtyard that was utilized during the facility's smoking activity which included multiple residents. The Administrator acknowledged although they weren't sure how the resident exited the facility, the concern was ultimately with the lack of supervision by facility staff in which R603 left unsupervised without staff's knowledge and not identified until many hours later.On 2/17/26 at approximately 3:25 PM, RN 'B' was queried regarding R603's elopement. RN 'B' reported the last time they had seen R603 was early in the morning at around 12:30 AM, and they were in their room. RN 'B' indicated they did not check on them again for the rest of their shift which ended at approximately 7:00AM that morning (2/8/26). RN 'B' was asked what the standard of care was for monitoring residents and they stated they check on residents every two hours. RN 'B' reported they did not check on R603 due to the resident having a history of becoming physically aggressive of anyone going go into their room. On 2/17/26 at 3:35 PM, a phone interview was conducted with RN 'A'. They confirmed they were the Nurse assigned to R603 on the day shift on 2/8/26 which started at 7:00 AM. When asked if they had conducted any rounds with the nurse going off-shift from midnights, RN 'A' reported they had with RN 'B'. RN 'A' further reported when they got to R603's room that resident is aggressive and a psych patient and doesn't let you open his door, so his door was closed and they thought he was in his room. RN 'A' further reported they finished passing the morning medications around 12:00 PM to 1:00 PM and R603 was a smoker so when it was time to go smoke they started looking for the resident and couldn't find him. RN 'A' further reported they had asked another resident if they had seen R603 and that resident said they had and RN 'A' thought they recalled seeing the resident in the hallway earlier.RN 'A' further reported they searched everywhere and couldn't find him so around 2:30 PM they called the Administrator and DON. We drove to gas stations, stores to search around and then called 911. RN 'A' reported the only thing R603 talks about is going out to smoke and he was independent with everything else. Additionally, RN 'A' reported the Police called them the next day around 10:00 AM and said they found the resident and was taken to the hospital.On 2/17/26 at 3:48 PM, a phone interview was conducted with CNA 'D' who confirmed they were assigned to R603 on the night shift (2/7/26 into 2/8/26). When asked if they had provided any care to R603 or observed them while working, CNA 'D' reported they had seen R603 in their room about 12:00 or 12:30 AM to pull the garbage and saw him seated up on the bed. They further reported that was the only thing the resident would let them do and doesn't allow them to go into the room other than to pull out the garbage and they didn't go back into the room for the remainder of their shift which ended at 7:30 AM.On 2/18/26, an attempt to reach CNA 'C' was not successful by the end of the survey.Past noncompliance: The Immediate Jeopardy that began on 2/8/26 was removed on 2/8/26 when the facility completed the following to remove the immediacy:Completed full-house head count confirming all other residents were accounted for and safe.Implemented immediate one-to-one monitoring at the primary exit. This monitoring remained in place until door codes were changed and the door push-button (behind nursing station) was disabled.Completed elopement risk assessments on all residents and updated care plans as indicated.Suspended involved staff pending investigation.Implemented mandatory purposeful rounding with Nurses and CNAs.Implemented CNA walking rounds / shift-to-shift handoff documentation reviewed by charge nurses.Completed facility-wide education on elopement prevention, supervision expectations, abuse and neglect prevention, shift to shift reporting and rounding in a timely fashion, purposeful rounding, and documentation of integrity. Any staff who did not receive the education on 2/8/26 received the education on their next scheduled workday.The deficient practice was corrected on 2/8/26 after the facility completed the following: [Facility] Elopement - Past Non-Compliance (PNC)Implementation Date: 02/08/2026Applicable F-Tags: F689 - Free of Accident Hazards / Adequate Supervision F600 - Freedom from Abuse, Neglect, and Exploitation F658 - Services Provided Meet Professional Standards of Quality F842 - Medical Records: Complete, Accurate, AccessibleHow the Facility Identified Those Residents Affected or Likely to Be Affected: Immediately upon identification of the event, facility leadership activated the elopement response per policy. The resident's legal guardian was notified in accordance with facility policy. Local law enforcement was notified and responded to the facility to assist with an interior and exterior search. Local businesses and surrounding hospitals were alerted to the search.All exit doors, alarms, and window securements were inspected and validated, with no system failures identified. The resident directly involved in the elopement had their care plan reviewed and updated by the Director of Nursing (DON) or designee to reflect current elopement risk and individualized interventions.The Elopement binders were reviewed to ensure they were current and complete.What Corrective Action Was Taken for Those Residents Found to Have Been Affected by the Deficient Practice: The facility reviewed staff assignments and performed staff interviews to identify the last observed interaction with the resident prior to elopement to evaluate supervision expectations and response timeliness.On 02/08/2026, four (4) staff members identified as potentially involved based on shift assignments were suspended pending investigation, and associated HR (Human Resource) files were reviewed and validated.All residents identified as at risk for elopement during reassessment had their care plans reviewed and updated by the DON or designee to ensure appropriate supervision and safety interventions were implemented.Interviewable residents were interviewed regarding unmet needs, missed medications, or care concerns. Residents with a BIMS (Brief Interview for Mental Status) score of 10 or below received a head-to-toe skin assessment to evaluate for any signs of neglect or injury. No trends related to elopement, supervision, or unmet needs were identified, and any individual concerns expressed were addressed through the facility grievance process.A secondary inspection of doors, windows, and alarm systems was completed on 02/09/2026. Additional reinforcement was added to select windows as a precautionary measure.The facility completed a review of resident council meeting minutes and grievance logs for the previous three (3) months to evaluate for concerns related to elopement risk, supervision, or unmet resident needs. No trends, patterns, or related concerns were identified.The facility reviewed the most recent quarterly elopement drill (performed January 2026) to assess staff response, timeliness, communication, and adherence to established procedures. No missed opportunities or performance concerns were identified during the drill review.The facility completed a review of routine door and window inspection logs for the previous twelve (12) months to evaluate consistency and completeness. All required checks were completed as scheduled, with no missing or undocumented inspections identified.The Medical Director and the affected resident's attending physician were notified of the event and the determination of past non-compliance.Documentation Review and Findings:As part of the investigation, a focused review of documentation identified that one licensed nurse inaccurately documented medication refusals on 02/08/2026 (AM), later acknowledging the resident was not asked if medications were desired. Additionally, a day-shift CNA failed to document required Plan of Care (POC) interventions for the same assigned shift.An expanded documentation review for both staff members did not identify patterns or trends. The RN documented no additional refusals during the 3-day lookback period, and the CNA demonstrated substantial completion of required documentation for other assigned residents during the same and surrounding shifts.An additional concern related to medical record integrity was identified when the RN accessed the electronic medical record after suspension pending investigation via company Wi-Fi using a personal device and modified prior documentation (striking out previously entered documentation in the MAR (Medication Administration Record) and progress note). This activity was identified through system Page 3 of 4 access review and addressed through administrative reeducation regarding the need to disable EHR (Electronic Health Record) access upon suspension.During the investigation, it was also identified that the assigned CNA delivered both breakfast and lunch trays to the resident's room on 02/08/2026 without removing the untouched breakfast tray prior to placement of the lunch tray. This observation was addressed through education regarding purposeful rounding expectations and timely observation of resident needs. This finding was not determined to be a contributing factor to the elopement event.Interdisciplinary Team Root Cause Analysis (RCA):As part of the interdisciplinary team (IDT) review, a root cause analysis was conducted to evaluate the circumstances surrounding the elopement event.The IDT reviewed the resident's recent clinical status, behaviors, and medication profile and did not identify acute changes that would have altered the resident's baseline elopement risk.The IDT determined that the elopement was not related to equipment malfunction, environmental failure, or inadequate staffing levels, as all doors, alarms, and securements were functioning as designed and staffing was appropriate for the shift. Night shift staffing consisted of two (2) nurses, three (3) CNAs, and two (2) additional 1:1 staff members, for a total of seven (7) staff supporting a census of forty-five (45) residents. Staffing assignments and workload were reviewed and were determined to be appropriate for the census and acuity of the shift.The primary root cause was identified as a breakdown in consistent resident supervision, specifically the failure to complete purposeful rounding and timely checks on the involved resident, which delayed recognition of the resident's absence from the unit.During the course of the investigation, additional concerns unrelated to the cause of the elopement were identified, including documentation inaccuracies and medical record access issues. These findings were addressed through targeted education, administrative controls, and leadership oversight but were not determined to be contributing factors to the elopement itself.What Measures Were Put Into Place or Systemic Changes Made to Ensure the Deficient Practice Will Not Recur: The Nursing Home Administrator (NHA) reviewed the Elopement and Wandering Residents Policy and the Abuse, Neglect, and Exploitation Policy and determined both policies remain appropriate and consistent with regulatory requirements.CNAs are now required to turn in a signed walking rounds shift report sheet to their assigned Charge Nurse with shift changes.Facility-wide education was provided by the DON or designee to all staff on all shifts addressing wandering and elopement prevention, resident supervision expectations, shift/shift report, purposeful rounding, abuse and neglect prevention, professional standards of practice, and documentation accuracy and integrity. Staff not present received education upon return to work prior to their next assigned shift.How the Facility Will Monitor Its Corrective Actions to Ensure the Deficient Practice Is Being Corrected and Will Not Recur:The facility initiated this Quality Assurance Performance Improvement (QAPI) Past NonCompliance to monitor compliance related to elopement risk identification, resident supervision, professional standards, and medical record documentation practices. The facility will monitor EHR (Electronic Health Record) documentation compliance through daily EHR Dashboard review during morning stand-up meetings. Identified discrepancies will be investigated and addressed with the applicable staff members. The Administrator or designee will audit all suspended or terminated employees weekly to ensure the employee's EHR access was disabled. The facility will continue utilizing their Guardian Angel Program to perform weekly resident interviews to offer routine opportunities for residents to disclose concerns with any of the above noted situations or care concerns. Any identified concerns will be addressed through the facility grievance process. The DON or designee will retain the signed CNA walking rounds documents to validate compliance. Employees identified to not comply with this expectation may be subject to disciplinary action. The facility will complete a minimum of five purposeful rounding observations across various shifts weekly for four weeks, followed by monthly monitoring for two additional months. Employees identified to not comply with this expectation may be subject to disciplinary action.Results will be reviewed at monthly QAPI meetings. Monitoring will continue for a minimum of three months or until sustained compliance is achieved.The Administrator is responsible for sustained compliance with this PNC.Ad Hoc QAPI Meeting: 02/09/2026.

This citation has two deficient practice statements (DPS).DPS #1 Based on observation, interview, and record review, the facility failed to prevent a fall with significant injury for one (R39) of two residents reviewed for falls, which resulted in a head injury, sutures, and ongoing pain and discomfort. Findings include: On 12/02/25 at 11:55 a.m., R39 was observed lying on their back in their bariatric hospital bed. Enabler bars were observed on both sides of their bed. The bed was mid-height. Large crescent shaped bruises were observed under their eyes. On 12/02/25 at 11:58 a.m., R39 reported they fell out of their bed about a week prior and hit their head on the floor. R39 stated they rolled out of the hospital bed in the night, hit their head on the floor, and had to go to the hospital to get stitches. R39 said their bed was about mid-height and explained their mobility bars were taken off their bed by facility staff, which they had used for safe bed mobility (rolling). R39 clarified they had ongoing pain in the back of their head since the falls, and they felt the mobility bar would have prevented the fall, as they used it for bed mobility (rolling). R39 shared they had asked staff for new bars, as they felt unsafe when being rolled during cares, and had worried about falling out of bed prior to the incident. Review of R39's ADL (Activities of Daily Living) Care Plan, revised 10/20/25, prior to their fall, revealed they required one-person extensive assistance for bed mobility, although sometimes they could perform bed mobility by themselves per the Care Plan. Review of R39's Kardex (Nurse Aide Care Directive), accessed 12/04/25, revealed R39 needed a wider bariatric bed to assist them with turning and positioning, one-person extensive assistance with bed mobility (it was noted the mattress was replaced immediately same day of fall), and bilateral assist bars to assist R39 with positioning while in bed. Review of R39's profile sheet, accessed 12/04/25, revealed they were their own responsible party. Review of the Electronic Medical Record (EMR) showed R39 was admitted to the facility on [DATE], with diagnoses including osteoarthritis, sciatica (nerve pain traveling from the back down their legs), history of falls, lung disease, morbid obesity, depression, and adjustment disorder with anxiety. Review of R39's physician orders, accessed 12/04/25, revealed, bilateral assist bars to aide in (bed) mobility, initiated (active order) 10/17/24. It was noted the order was never discontinued and remained current during their stay. Review of R39's Care Conference Summary, by facility Social Worker E, dated 10/14/25 at 2:49 p.m., revealed, .(R39) does not like (their) bed and (their) assist bars are missing. Writer will complete concern form. It was noted R39 fell out of bed without assist bars on 11/19/25, over one month after R39 raised concerns. Review of R39's grievances, provided by the facility, revealed no grievances related to bed mobility or mobility bars, when requested via email twice. Review of R39's weight logs revealed R39 weighed 282 pounds on 11/05/25, the last facility weight obtained by the facility near the time of their fall. On 12/04/25 at 10:11 a.m., the Rehabilitation Director, Certified Occupational Therapy Assistant (COTA) J, and Physical Therapist, (PT) T, reported they had been attempting to obtain new bedrails for R39's bariatric hospital bed when R39's fall out of bed occurred. On 12/04/25 at 10:50 a.m., R39 reclarified they had a bariatric bed prior to their fall; however, it was not wide enough. R39 reported they had told nursing staff who assisted them they were afraid of rolling out without the bedrails which had been taken away, and they had not understood why. R39 reported the wide bariatric bed they currently were using was provided after they fell out of bed on 11/19/25 and said the bedrails (enabler bars observed) came with the new bed, which were observed. Review of R39's progress note, dated 11/20/25 at 10:14 a.m., showed the root cause of the fall, which said R39 rolled out of bed during a dream. This note further revealed, .Staff noted issues with (R39's) current mattress and immediately replaced the mattress.New interventions: New wider bed and mattress It was noted the mattress was defective when R39 fell out of bed. Review of R39's nursing progress note, dated 11/20/25 at 1:26 p.m., showed, (R39) observed laying on the floor on her right side next to the bed around 2010 (8:10 p.m. – on 11/19/25). Abrasion on right forehead with minimal bleeding noted on the floor. 911 called and took resident to hospital. Review of R39's progress note, dated 11/20/25 at 5:58 (a.m.) showed, .Event occurred at 11/19/2025. 8:10 p.m. Resident returned to facility at around 0440 (4:40 a.m.) transport via (Company name) ambulance. Bandage on resident forehead noted. Review of R39's progress note dated 11/20/25 at 18:54 (6:54 p.m.), revealed, First day post fall for resident.(R39) did complain (of) headache and back ache. (R39) was given prn (as needed) Norco (narcotic pain medication).(R39) did complain of second headache in PM (afternoon) and given Motrin (non-narcotic pain medication) for headache. Review of R39's nursing post fall documentation note, dated 11/23/25 at 6:29 (a.m.), revealed, Date of fall: 11/20/2025.Injuries: Bruising to face with 4 sutures.Follow-up/subsequent communication: (left blank). On 12/04/25 at 11:38 a.m., Licensed Practical Nurse, (LPN) S, was called as they worked on 11/19/25 on the midnight shift and completed the Accident report documentation and a progress note. No call was returned by survey exit. Review of R39's Accident and Incident report, by LPN S, dated 11/19/25 at 22:10 (10:10 p.m.) revealed, .Immediate Action Taken: Resident mattress on bed replaced; wider bed/mattress ordered.Level of Pain: 5 (of 10, with 10 the highest pain). Review of R39's grievances provided by the facility upon request revealed no grievances respective to R39 requesting mobility bars or a wider mattress, as described in SW E's progress note. Review of R39's Hospital After Visit Summary, dated 11/20/25, revealed a diagnosis of head injury adult.Fall: Laceration of forehead.Injury of head. The summary revealed R39 was 5'1 tall and weighed 313 lb (pounds), 11.4 oz (ounces), significantly more than their last facility weight of 281 pounds on 11/05/25. On 12/04/25 at 11:47 a.m., the Unit Manager, LPN H, who had completed some of the post-fall documentation, was asked about the Root Cause of R39's fall out of bed on 11/19/25, when R39 was sent out emergently, and returned to the facility on [DATE]. LPN H confirmed R39 did not have mobility bars on their bed when they fell out of bed on 11/19/25. LPN H clarified the mobility bars did not fit their bed so they were removed and said therapy was working to try to find assist bars which were compatible with R39's bed when they fell out of bed. LPN H continued the facility ordered R39 a new, wider bariatric bed with attached rails after R39's fall out of bed with injury (sutures) and increased pain. LPN H concurred R39's fall would have been avoidable had they received the proper bed prior, as a bariatric bed with attached rails was found and provided to R39 after they fell of their bed on 11/19/25. On 12/04/25 at 11:52 a.m., LPN H was asked if R39 should have had assist bars on their bed when R39 fell out of bed on 11/19/25 and responded, Yes. LPN H was asked about R39's mattress being replaced per facility documentation immediately after R39's fall with injury out of bed. LPN H confirmed R39's midnight nurse, LPN N, had reported to them R39's mattress had malfunctioned and deflated on one side, which contributed to R39's fall out of bed, and confirmed the air mattress was defective. LPN H also confirmed R39 had sutures on their head after they fell and had increased pain after the fall but said they were not aware they were still having headaches after their fall. Review of R39's Medication Administration Record (MAR) for the month of November 2025 revealed six of seven days they received narcotic (opioid) prn (as needed) pain medication after their fall on 11/19/25. LPN H concurred after record review with Surveyor this was not typical for them, and this was more narcotic pain medication than R39 usually received. On 12/04/25 at approximately 2:00 p.m., Surveyor reviewed concerns related to R39's fall out of bed with the Nursing Home Administrator (NHA). The NHA reported they had been aware R39 needed new assist bars and the wrong assist bars came, per the Rehab Director, COTA J. Surveyor conveyed concerns were also related to R39 wanting a wider mattress, expressing fearfulness during turning and cares on their prior mattress, and facility documentation and interviews showing their mattress malfunctioned when they fell, and was replaced after their fall with injury. Surveyor also reviewed concerns related to increased pain and R39 requiring sutures after they fell. The NHA conveyed they had worked on getting R39 alternate rails but were not made aware of bed concerns and R39's increased pain. The NHA acknowledged they did not fully investigate the incident, and had no witness statements or other investigation available, other than the progress note with RCA and the Accident and Incident report and progress notes. The NHA had no additional comment at that time. Review of the policy, Incident Reporting – Accidents and Supervision, Revised 8/24, revealed, Policy: The resident environment remains as free of accidents hazards as is possible, and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring effectiveness and modifying interventions when necessary. Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks – the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff (e.g. professional, administrative, maintenance) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. c. Various sources provide information about hazards and risks in the resident environment.2. Evaluation and Analysis. The process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. b. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. c. Evaluations also look at trends such as time of day, location, etc 3. Implementation of Interventions – using specific interventions to try to reduce a resident's risks from hazards in the environment. 4. Monitoring and Modification – Monitoring is process of evaluating the effectiveness of care plan interventions and making modifications. 5. Supervision – Supervision is an intervention and a means of mitigating accident risk. The faciltiy will provide adequate supervision to prevention accidents. Adequacy of supervision: a. defined by type and frequency. 6. Documentation. The purpose of the Incident/Accident report is to provide a standardized, systematic process to ensure that all accidents and incidents are promptly identified, reported and investigated and that measures addressing causes are implemented to prevent recurrence. An Accident/Incident report is any situation that involves harm or potential harm which is outside the usual or expected. These include: but are not limited to: a. Falls (any unintended movement from one surface to a lower surface).g. Unsafe Conditions. DPS #2 This citation pertains to intake #2640057. Based on observation, interview and record review, the facility failed to ensure an environment free from accident hazards related to resident smoking and storage of smoking paraphernalia for two (R26 and R46) of three residents reviewed for smoking. Findings include: Review of a complaint submitted to the State Agency included allegations that R26 was smoking in their room and staff are overheard talking about R26's smoking in the facility and a resident was told by staff that R26 does what he wants and that the administrator is aware of the issue but felt nothing had been done and they did not feel safe. According to the facility's policy titled, Resident Smoking dated 2/25:It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents .Smoking is prohibited in all areas except the designated smoking area.Residents who smoke will be further assessed to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all Electronic cigarettes (e-cigarettes/vape/vapor pen) can catch on fire and/or explode if not handled and stored safely.Use of e-cigarettes in designated smoking areas only.Don't use the device around flammable gasses or liquids, such as oxygen.Loose e-cigarette batteries and extra cartridges will be stored away from coins, keys, or other metal objects.Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan.If a resident or family does not abide by the smoking policy or care plan (e.g. smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional safety measures.Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. On 12/2/25 at 9:42 AM, R26 was observed seated in a motorized wheelchair in room, wearing winter jacket and hat. An ashtray with ashes was observed on a table near the resident's dresser and a pack of cigarettes. When asked about the smoking materials, R26 reported they smoked cigarettes and kept the cigarettes and lighter on themselves. When asked where they smoked, R26 reported they usually went outside but also stated I do smoke in my room I won't lie to you. When asked if anyone had addressed the safety concerns with smoking in the facility, R26 acknowledged they had but further reported they had been in prison for 34 years and don't like locked doors. On 12/2/25 at 11:55 AM and 12/3/25 at 9:00 AM, the pack of cigarettes and ashtray remained on the table in the resident's room. Review of the clinical record revealed R26 was initially admitted into the facility on 9/13/23 and readmitted on [DATE] with diagnoses that included: nicotine dependence unspecified uncomplicated. According to the annual Minimum Data Set (MDS) assessment dated [DATE], R26 had no communication concerns, had intact cognition, and exhibited no mood or behavior concerns during this assessment period of seven days. Review of the care plans as of 12/2/25 included several non-compliance care plans, including one for smoking that documented: Smoking: I have been assessed by the IDT (Interdisciplinary Team) and I am allowed to smoke/able to smoke independently, I have a potential for injury related to smoking there are times when I will not give my smoking paraphernalia to staff. I have been educated on following smoking policy. I choose to smoke in my room while in bed. I have been educated on smoking policy LOA (Leave of Absence) process and I choose to not follow this policy I will sit at the front entrance and smoke in non-designated smoking area. This was initiated 2/26/25 and most recently revised on 10/17/25 by Nurse 'E'. Interventions included: I will allow staff to search my room if staff smell cigarette smoke and remove them <sic> my room. Initiated 4/18/25 by Social Services Manager (SS 'F'). Document any behaviors related to not smoking on my behavior task/progress note. Initiated 2/26/25 by Nurse 'E'. Smoking paraphernalia will be stored at the nurse's station. Initiated 2/26/25 by Nurse 'E'. There were no interventions identified/implemented on how to specifically address the resident's non-compliance with smoking in the room. It should be noted that additional interventions were implemented on 12/3/25 after concerns were identified during the survey. Further review of the clinical record revealed multiple progress notes of R26 found smoking in their room, including while in bed. The facility's responses to some of these instances included documentation that the resident had been re-educated and provided with copies of the facility's smoking policy. There were no other interventions identified within the clinical record and in accordance with facility policy which addressed the resident's continued non-compliance and/or identified what other safety measures had been implemented following these multiple smoking incidents in the facility. Documentation of the progress notes included: An entry on 11/19/25 at 10:42 AM by Nurse Manager (NM 'H') read: .discussed resident in risk.Resident noted smoking in his room he was reissued a copy of smoking policy and informed he is expected to adhere to policy at all times. An entry on 11/13/25 at 7:25 AM by Physician 'L' documented, in part: .The patient was evaluated today for a routine regulatory assessment. He is alert and cooperative, able to follow commands, and oriented to person and place. He is electric-wheelchair dependent due to a left above-knee amputation (AKA) and chronic right lower-extremity (RLE) contracture.Chart review reveals a pattern of non-compliance, including.smoking in his room, both documented repeatedly by nursing. Patient was again counseled on smoking cessation, fire risk.Plan.Smoking prohibition reinforced. An entry on 11/9/25 at 7:54 PM by Nurse 'B' read: Writer observed resident smoking in room. Writer educated the resident on the risk of smoking inside room. Resident still noncompliant. Writer asked resident multiple times to put the cigarette out resident refused. An entry on 9/8/25 at 9:26 AM for 9/4/25 at 00:00 by Nurse Practitioner (NP 'O') read: .Patient was seen today for regulatory visit. Patient today alert and following commands. He is electric wheelchair bound.Patient notes reviewed, showing non-compliance, refusing medication and smoking in room. Patient educated on importance of smoking cessation. Patient and nursing staff without any other concerns at this time An entry on 9/2/25 at 5:25 AM for 9/1/25 at 21:10 by Nurse 'P' read: .Resident was observed smoking in the room and was instructed not to smoke in the room because of the risk it might cause fire, resident became very angry yelling, cursing at the nurse using profanity. Resident refused to give the cigarette and lighter to the nurse, DON and administrator were both notified by phone . There was no additional follow-up documented in the clinical record following this incident. A care plan note on 8/29/25 at 10:23 AM by Nurse 'E' read: .Focus: Smoking: I have been assessed by the IDT and I am allowed to smoke/able to smoke independently, I have a potential for injury related to smoking there are times when I will not give my smoking paraphernalia to staff. I have been educated on following smoking policy. I choose to smoke in my room while in bed. I have been educated on smoking policy LOA process and I choose to not follow this policy I will sit at the front entrance and smoke in non designated smoking area. Effective Date:8/29/2025. An entry on 7/15/25 at 7:58 AM by Nurse 'Q' read: .Staff alerted writer that resident was smoking in bed again. Writer educated resident on the dangers of smoking in bed. He said he dose <sic> not care and is careful. Writer did convince resident to put that cigarette out. An entry on 7/12/25 at 6:38 AM by Nurse 'P' read: .Resident was smoking in his room and was instructed to stop smoking in the room, then resident became angry, loud using profanity and was still smoking and said no body can do him anything. DON and administrator was notified and resident was closely monitored until he stop smoking. An entry on 7/11/25 by Nurse 'Q' read: .Resident was smoking while in bed. Resident was educated on the risk of smoking in bed and he refused to put out cigarette. An entry on 7/11/25 at 11:11 AM by SS 'F' read: .Writer met with resident. Resident stated he is good.No psychosocial concerns at this time. There was no documentation the social worker had been informed of the resident's continued behaviors of smoking addressed and/or documented. An entry on 7/11/25 at 4:51 AM by Nurse 'R' read: .Resident smoked in his room, when confronted, he said I feel like smoking and I cannot go outside now. An entry on 6/24/25 at 6:56 AM by Nurse 'P' read: .Resident was caught smoking in the room and was instructed not to smoke in the room and explained to resident of danger of smoking in the room. Resident became very agitated using profanity and said we cannot do him <sic> anything. DON (was notified by phone and instructed to make sure we collect the cigarette and the lighter from him, but resident refused and said he does not have cigarette or lighter with him.Resident was in bed in the room. On 12/3/25 at 11:53 AM, an interview was conducted with SS 'E'. When asked about who conducted with resident's smoking assessments, SS 'E' reported that would usually be nursing or activity staff. When asked if they had been notified this week of any concerns with smoking paraphernalia for R26, SS 'E' reported they had not. They further reported R26 was non-compliant with smoking and reported they had recently been seeking alternate placement. When asked if resident should have any smoking paraphernalia on them, SS 'E' reported all smoking materials should be locked up, including vapes and further stated Everything should be locked up. When asked if they were aware R26 had an ashtray in their room and had been observed since the first day of the survey, SS 'E' reported they did not. At that time, SS 'E' was requested to accompany to R26's room. On 12/3/25 at approximately 12:00 PM, SS 'E' approached R26 and confirmed the ashtray in the resident's room. When asked about what safety measures had been implemented following the multiple incidents of R26 smoking in their room, including while in bed, SS 'E' reported they always explained risk verse benefit and explained we have oxygen in the building and putting everybody at risk of being blown up. They reported they were actively looking for alternate placement for the resident.On 12/3/25 at 12:25 PM, an interview was conducted with the Administrator. When asked about whether residents were allowed to keep smoking paraphernalia on themselves, the Administrator deferred to their smoking policy and further reported those items were kept locked on a smoking cart managed by the Activity Director. When asked if they were aware of any residents not following the facility's smoking policy, the Administrator reported they began at the facility end of December last year and took over on June 30, 2025. They further reported that for about three weeks or so they had been working with their legal and corporate team to work on a discharge plan for R26. They were not aware of any other residents that had smoking paraphernalia. The Administrator was informed that during the survey, there was an additional resident observed with this and also reported that they smoked in their room as well. The Administrator reported they were not aware of that. When asked other than re-issuing a copy of the facility's smoking policy and encouraging smoking cessation after each occurrence, what was being done to address the safety concerns, the Administrator reported finding alternate placement. It should be noted that after this concern had been brought to the facility's attention during the survey, the facility implemented a staff person for R26 on a one to one basis for increased supervision. However further review of the progress notes included an entry on 12/3/25 at 8:57 PM by Nurse 'A' that read, .At about 1900 (7:00 PM) the CENA assigned to resident for 1:1 notified writer that resident was bringing a bottle of liquor, a lighter, and a cigarette out of his drawer and attempting to light a cigarette. R46 Clinical record review revealed R46 was admitted to the facility on [DATE] with a history of schizophrenia, substance abuse, and was a current smoker. Clinical record review of the Safe Smoking assessment dated [DATE], evaluated R46 may smoke with supervision. R46 had a self-care performance deficit related to bilateral above the knee amputations and used a wheelchair. A Brief Interview Mental Status assessed on 10/20/25 scored 15/15 indicating R46 was cognitively intact. On 12/2/25 at 10:32 AM, R46 was observed lying in bed parallel to a wall with a large sliding window. The sill of window was observed as personal storage area containing pictures of nude women, a purple vape pen, a cigarette with brown colored filter, and a package of Zig-Zag papers (brand of rolling papers for hand rolling tobacco). On 12/2/25 at 12:40 PM, when asked how they get outside to smoke, R46 replied I don't go outside. When asked how they smoked, they replied they could open the window and smoke from their bed. When asked if this was performed because of how cold it is outside, R46 replied it was not due to the weather, they just don't like to go outside. A purple vape pen, cigarette with brown colored filter, and package of Zig-Zag paper remained in reach at bedside windowsill. On 12/3/25 at 9:08 AM, the package of Zig-Zag papers remained at bedside. On 12/3/25 at 10:09 AM, R46 was observed in a wheelchair wearing a winter style coat, waiting near exit to smoking area and was observed holding what appeared a hand rolled cigarette. On 12/3/25 at 1:12 PM, the Nursing Home Administrator was informed of the findings and comments made by R46. Per the NHA, smoking paraphernalia is not to be stored at bedside. When asked why after multiple observations of the paraphernalia, why it remained at bedside. The NHA acknowledged staff should have removed and locked in the smoking box.

Based on observation and interview, the facility failed to provide a safe, clean, homelike environment resulting in odors (R42) and equipment that does not work properly. Findings include:Findings include: 12/02/2025 08:40 AM -Initial entrance into the facility starting at room [ROOM NUMBER], the entire corridor profoundly smelled of urine. On 12/3/25 at 9:00 AM, the social room with vending machine, was observed with the entire floor including perimeters of room was unkempt giving the appearance the floor was not cleaned. Popcorn and kernels were observed on scattered across the floor. Five of six floor vents were observed with moderate amounts of accumulated dust and dead insects. The six-floor vent located to the right of the exit door was corroded with black grime and rusted into the tile flooring. The windowsills were dusty and multiple dead insects were lying inside the interior window tracts. The blinds hanging from the window closest to the television were bent, broken and being held up by a plastic frame-like object. Three cardboard boxes were observed pushed into the corner of the floor storing books and magazines. The floor vented outside of rooms [ROOM NUMBERS] were observed with hairlike debris entangled in the grate and moving when the heat was on. On 12/3/25 at 9:35 AM, an interview with Rehabilitation Manager (RM) J was asked who maintains the cleaning of the floors and equipment, RM J acknowledged housekeeping is responsible for the floors and equipment is maintained by the rehab staff and cleaned in between resident use. While observing the room, in front of the SCIFIT Recumbent Stepper (exercise machine) a pile of black colored ash like dust was collected in front of a dirty rusted floor vent. The SCIFIT foot pedals and heel cups of (oversized foot beds with safety edges) were observed to contain moderate amounts of a [NAME], crumb like debris. A portable cylinder oxygen tank was stored next to the equipment covered in dust and insect webs. All three of the floor vents floors were dirty, bent and rusted. The entire flooring and perimeters of room were unkempt and upswept, giving the appearance the floors were not cleaned. The physical therapy blue foam mat on the treatment table with two Roho cushions (cushions to prevent pressure sores), a foam wedge and foam pillow were observed dirty and worn out. During review of the rehabilitation room a strong smell of urine was noted around the SCIFIT machine and in the front area of the floor with the three floor vents. Physical Therapy Assistant (PTA) K recognized the strong urine odor and recognized was more noticeable when the heat is on. RM J concurred. On 12/3/25 at 10:50 AM, Environmental Services Manager (ESM) I confirmed that housekeeping is responsible for daily dusting, cleaning the floors in the common areas and rehabilitation room. When shown the floor heat vents throughout the areas observed, ESM I acknowledged they were not clean, rusted, and should not contain the dust, grime, and dead insects. The floor inspected in the social room and rehabilitation was also acknowledged they were unkempt. ESM I also concurred the within the hallway starting at room [ROOM NUMBER] up to the rehabilitation room and within the rehabilitation room had a strong odor of urine. On 12/4/25 at 10:30 AM- the odor of urine in the hallway started at room [ROOM NUMBER] up to the rehabilitation room and within the rehabilitation room was intensified then the day before. Upon entrance into the rehabilitation room it was observed the sun was coming into the windows provided a warmer temperature amongst the room. RM J remarked housekeeping had cleaned the floors and was uncertain why the urine smell still permeated within the room. On 12/4/25 at 11:30 AM, Certified Nurse Assistant (CNA) N was asked to permit entry into the east shower room. CNA N confirmed there was one shower bed in the facility and a few of the residents require it. A blue colored shower bed mattress was observed with various sized rips and tears exposing the interior tan colored foam like material. On 12/4/25 at 11:45 AM, room [ROOM NUMBER] was observed with an Enteral Nutrition (tube feed) pole, pump, and hanging tan colored tube feed nutrition. The electronic feeding pump was observed with dried spilled tube feed matter on the face and sides of the pump. The pole and stand were also observed with moderate amounts of tan colored dried stained tube feed. On 12/4/25 at 11:50 AM, room [ROOM NUMBER] was observed with a tube feed pole, pump, and hanging tan colored tube feed nutrition. The electronic feeding pump was observed with dried spilled tube feed matter on the face and sides of the pump. The pole and stand were also observed with moderate amounts of tan colored dried stained tube feed. Splashes of the same dried tan colored matter were also observed splashed onto a black portable oxygen concentrator and on the floor around the equipment. Observations throughout the survey from 12/2/25 – 12/4/25 revealed multiple instances of lingering urine odors and stagnant air throughout room [ROOM NUMBER] and 119, the center hallway and therapy gym. On 12/4/25 at 11:20 AM, R42 was observed laying in bed. Upon entering the room, there was an extremely strong urine odor. The overbed light pull cord chain was only about a foot in length and the resident was not able to reach to utilize. The three-drawer bedside dresser was observed to have two of the three drawer handle pulls missing. On 12/4/25 at 11:25 AM, an observation of the west and center hall was conducted with the Environmental Services Manager (Staff 'I'). Upon entering room [ROOM NUMBER], it was observed that the built-in dresser was missing the top drawer hardware drawer pulls. Upon entering room [ROOM NUMBER], Staff 'I' confirmed the missing drawer pulls. When asked about the missing drawer pulls for the dressers, Staff 'I' reported they had not noticed those and would look for replacements. On 12/4/25 at 12:12 PM, the Administrator was requested to provide a policy for overbed light pull cords. At 2:06 PM, the Administrator reported there was no specific policy.

Based on observation, interview, and record review, the facility failed to ensure pain medications were administered as ordered for one resident (R31), of one resident reviewed for pain, resulting in repeated complaints of pain and discomfort. Findings include: On 12/2/25 at 10:02 AM, R31 was observed in their wheelchair in the doorway of their room leading out to the hallway. They were observed to be moaning and complaining of pain in their neck. Nurse 'B' was at the medication cart in the hallway adjacent to R31 and was overheard to tell R31 they just received Tylenol and asked them if they could give the Tylenol time to work. R31 replied by saying the Tylenol has not been working and their neck hurt, real bad describing the pain as moving down the middle of their neck. At that time, R31 told Nurse 'B' they wanted to go to the hospital. Nurse 'B' again asked R31 if they could give the Tylenol more time to, kick in. On 12/2/25 at 10:11 AM, Nurse 'A' was observed to assess R31 and asked R31 to give the Tylenol administered by Nurse 'B' another hour to begin working. R31 protested to Nurse 'A' and requested Nurse 'A' call their physician.On 12/2/25 at 10:14 AM, Nurse 'A' was overheard talking to R31 and telling them they phoned the physician, and the physician ordered oxycodone (narcotic pain reliever) for pain. A review of a progress note entered into the record by Nurse 'A' on 12/2/25 at 10:22 AM, was reviewed and read, .Resident reported pain on his back of neck, NP (Nurse Practitioner) .notified, ordered Oxycodone 5mg (milligram) PRN (as needed) for 5 days. Order noted and carried out .On 12/2/25 at 11:21 AM, a review of R31's physician's orders was reviewed and revealed an order dated 12/2/25 for oxycodone 5 mg every twelve hours as needed. R31's medication administration record (MAR) was also reviewed, however; the MAR did not document any administration of the oxycodone medication.On 12/3/25 at 8:55 AM, R31 was observed in the hallway seated in their wheelchair in the doorway of their room. They were asked how their neck felt and said, It still hurts.On 12/3/25 at 9:56 AM, a second review of R31's MAR was conducted and revealed no documented administrations of oxycodone on 12/2/25, the day R31 complained of the pain and the day the medication had been ordered. On 12/3/25 at 10:02 AM, a review of a controlled substance log sheet for R31's oxycodone was reviewed and did not document any removals of the medication from their supply on 12/2/25. At that time, an interview was conducted with Nurse 'A'. Nurse 'A' said they removed 5 mg of oxycodone from the facility's back-up medication supply and administered it on 12/2/25. They were asked why it was not documented on the MAR and reported the MAR would not allow them to document an administration because the physician had not signed the order for the controlled substance. Nurse 'A' was then asked to provide any type of proof the medication had been pulled from the back-up medication supply. Nurse 'A' left the unit and returned approximately 10 minutes later without any evidence the medication had been pulled from the back-up medication supply on 12/2/25. They were asked again if they administered the medication on 12/2/25 and gave no confirmation or denial of administering the medication.A review of R31's clinical record was conducted and revealed they admitted to the facility on [DATE] with diagnoses that included: spinal stenosis, heart attack, diabetes, bipolar disorder, epilepsy, osteoarthritis, delusional disorder, schizoaffective disorder, and dementia. R31's most recent Minimal Data Set (MDS) assessment dated [DATE] indicated R31 had moderately impaired cognition. A review of R31's care plans was conducted and read, .Care Plan Focus I may experience pain 2/2; Spinal Stenosis .Interventions/Tasks .Anticipate my need for pain relief and respond immediately to any complaint of pain .On 12/3/25 at 10:32 AM, an interview was conducted with the facility's Director of Nursing. They were asked if a medication pulled from the back-up medication supply could be documented on the MAR without the physician's signature on the order and they indicated it could. They were made aware of the incident on 12/2/25 when Nurse 'A' said they pulled 5 mg of oxycodone for R31 but did not sign it out on the MAR and could provide no evidence it had been pulled from the back-up supply, and they said the medication should have been given and documented in the record. A review of a facility provided document titled, Pain Management revised 7/2025 was conducted and read, .The facility must ensure pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences .

Based on observation, interview, and record review, the facility failed to ensure pain medication was administered per physician's orders and documentation in the record was accurate in accordance with nursing professional standards for one resident (R31), of one resident reviewed for nursing professional standards. Findings include: On 12/2/25 at 10:02 AM, R31 was observed in their wheelchair in the doorway of their room leading out to the hallway. They were observed to be moaning and complaining of pain in their neck. On 12/2/25 at 10:11 AM, Registered Nurse (RN) 'A' was observed to assess R31. R31 requested RN 'A' to call their physician due to their pain. On 12/2/25 at 10:14 AM, RN 'A' was overheard talking to R31 and telling them they phoned the physician, and the physician ordered oxycodone (narcotic pain reliever) for pain. A review of a progress note entered into the record by RN 'A' on 12/2/25 at 10:22 AM, was reviewed and read, .Resident reported pain on his back of neck, NP (Nurse Practitioner) .notified, ordered Oxycodone 5mg (milligram) PRN (as needed) for 5 days. Order noted and carried out .On 12/2/25 at 11:21 AM, a review of R31's physician's orders was reviewed and revealed an order dated 12/2/25 for oxycodone 5 mg every twelve hours as needed. R31's medication administration record (MAR) was also reviewed, however; the MAR did not document any administration of the oxycodone medication.On 12/3/25 at 8:55 AM, R31 was observed in the hallway seated in their wheelchair in the doorway of their room. They were asked how their neck felt and said, It still hurts.On 12/3/25 at 9:56 AM, a second review of R31's MAR was conducted and revealed no documented administrations of oxycodone on 12/2/25, the day R31 complained of the pain and the day the medication had been ordered. On 12/3/25 at 10:02 AM, a review of a controlled substance log sheet for R31's oxycodone was reviewed and did not document any removals of the medication from their supply on 12/2/25. At that time, an interview was conducted with RN 'A'. RN 'A' said they removed 5 mg of oxycodone from the facility's back-up medication supply and administered it on 12/2/25. They were asked why it was not documented on the MAR and reported the MAR would not allow them to document an administration because the physician had not signed the order for the controlled substance. RN 'A' was then asked to provide any type of proof the medication had been pulled from the back-up medication supply. RN 'A' left the unit and returned approximately 10 minutes later without evidence the medication had been pulled from the back-up medication supply on 12/2/25. It is noted there was no evidence R31 received the oxycodone on 12/2/25 despite RN 'A's note on 12/2/25 at 10:22 AM that documented they, carried out the physician's order. RN 'A' was asked again if they administered the oxycodone pain medication on 12/2/25 and gave no confirmation or denial of administering the medication. They further went on to say R31 had received Tylenol earlier in the morning on 12/2/25 and if R31 had received the oxycodone medication, they still would complain of pain. On 12/3/25 at 10:32 AM, an interview was conducted with the facility's Director of Nursing (DON). They were asked if a medication pulled from the back-up medication supply could be documented on the MAR without the physician's signature on the order and they said it could. The DON was then made aware of the incident on 12/2/25 when RN 'A' said they pulled 5 mg of oxycodone for R31 but did not sign it out on the MAR and could provide no evidence it had been pulled from the back-up supply despite their note indicating they gave the medication. The DON said the medication should have been given and documented on the MAR. They were further informed of Nurse 'A's comment regarding R31 still complaining of pain whether they had received the oxycodone or not and said, The resident's pain is what the resident says it is and they should have gotten the medication. A review of a facility provided document for the expectations of a Registered Nurse was reviewed and read, .The Registered Nurse is responsible for performing a variety of duties to provide quality nursing care .Accurately record resident observations .Administer medications to residents according to the Public Health Code, Nursing Department Policies, and standards and procedures as prescribed by the physician .

Based on observation and interview, the facility failed to maintain mechanical ventilation, resulting in lingering odors and uncirculated air, affecting four residents that share a bathroom in room [ROOM NUMBER] and 119, and throughout the center hallway and therapy gym. Findings include:Observations throughout the survey from 12/2/25 - 12/4/25 revealed multiple instances of lingering urine odors and stagnant air throughout room [ROOM NUMBER] and 119, the center hallway and therapy gym.On 12/2/25 at 10:45 AM, room [ROOM NUMBER] and 119 were observed to have an extremely strong urine odor which was acknowledged by the residents. The shared bathroom exhaust vent of resident room [ROOM NUMBER] and 119 was tested using a piece of toilet paper to test the exhaust function and no suction was observed.On 12/4/25 at 11:25 AM, on observation of the west and center hall was conducted with the Environmental Services Manager (Staff 'I'). When asked about lingering urine odor and stagnant air on the center hall, Staff 'I' acknowledged the same odors and deferred to nursing for room [ROOM NUMBER].On 12/4/25 at 11:35 AM, Nurse Manager (NM 'H') who also functioned as the facility's Infection Preventionist was asked to observe the resident in room [ROOM NUMBER]. Upon entering the resident's room, NM 'H' confirmed the strong urine odor and reported that maybe the resident had messed with their urostomy (a surgical opening on the abdomen to redirect urine from the urinary tract to an external collection pouch) and it leaked. Within a few minutes, the resident's assigned Certified Nursing Assistant (CNA 'G') entered the room and when asked about the urine odor, CNA 'G' checked the resident's urostomy area and reported it was dry.On 12/4/25 at 11:45 AM, Staff 'I' was requested to evaluate the facility's bathroom ventilation and they reported that was done on their rounds routinely. When asked how they checked to make sure the system was functioning properly, Staff 'I' reported they checked if the blades were moving. At that time, they were requested to hold a piece of toilet paper to the ventilation grid and upon doing so, the toilet paper did not suction to the grid, despite the sound of a fan motor. Continued observations of other rooms throughout the center hallway revealed they were functional (toilet paper suctioned to exhaust vent).On 12/4/25 at 12:12 PM, the Administrator was requested to provide a policy for ceiling/bathroom ventilation. At 2:06 PM, the Administrator reported there was no specific policy.

Based on observation, interview, and record review, the facility failed to ensure the call light was accessible to the resident for one (R32) of three residents reviewed for accommodation of needs. Findings include:On 12/2/25 at 1:48 PM, R42 was observed lying in bed. The call light was observed laying on the floor mat out of reach of the resident. When asked if they needed to summons assistance, how would they do that, R42 reported they would Yell for help. They further reported they could not reach the call light from where it was currently placed on the floor.At 1:50 PM, the assigned Certified Nursing Assistant (CNA 'D') entered the room and when asked about the placement of the call light on the floor, CNA 'D' reported He pushed that off.On 12/4/25 at 11:20 AM, R42 was observed lying in bed. The call light was observed placed around the bedside dresser approximately four feet away from the resident while in bed. The resident was asked if they could reach the call light if they needed to ask for assistance and they stated they could not.On 12/4/25 at 11:35 AM, during an observation of R42's room with Nurse Manager (NM 'H'), they confirmed the placement of the call light and reported that should be kept within reach and proceeded to place next to the resident on the bed. At that time, R42's assigned CNA 'G' entered the room and when asked about the call light being placed out of reach, around the bedside dresser, CNA 'G' reported they had placed the call light on the bedside dresser when they were pulling the resident up in bed for breakfast earlier and acknowledged it had been out of reach since then.On 12/4/25 at 12:12 PM, the Administrator was requested to provide a policy for call light placement.According to the policy titled, Call Lights Accessibility & Timely Response Policy dated 3/2025: .With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secure, as needed.

Based on observation, interview, and record review, the facility failed to ensure chemical restraints were not utilized for staff convenience, and without identification of non-pharmacological approaches attempted for one (R42) of one resident reviewed for psych/opioid medication side effects. Findings include:On 12/02/2025 at 10:45 AM, R42 was observed lying in bed, asleep. They did not awaken upon verbal stimuli.Review of the clinical record revealed R42 was admitted into the facility on 1/12/24 and readmitted on [DATE] with diagnoses that included: cognitive communication deficit, adult failure to thrive, other psychotic disorder not due to a substance or known physiological condition, delusional disorders, Alzheimer's disease with early onset, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, insomnia, and malignant neoplasm of bladder.According to the Minimum Data Set (MDS) assessment dated [DATE], R42 had no communication concerns, had moderately impaired cognition, had no signs/symptoms of delirium, delusions, or hallucinations, had no mood or behavioral concerns, and received antianxiety medication.Review of R42's medications included two orders for Lorazepam (Ativan) an antianxiety medication.One order was for scheduled Lorazepam 1 MG (Milligram) give one tablet by mouth at bedtime for anxiety or restless (to be given at 9:00 PM) was started on 11/23/25.Another order for Lorazepam 0.5 MG give one tablet by mouth every six hours as needed (PRN) for anxiety and restlessness for 12 days was started on 11/25/25.According to the Medication Administration Records (MARs) and corresponding controlled substance records, R42 received their scheduled Lorazepam and two doses of the as needed Lorazepam on 11/26/25 at 8:00 AM and on 12/1/25 at 7:51 AM. Both MAR entries were documented as administered by Nurse 'C'. The section of the MAR to enter notes for the 12/1/25 7:51 AM administration was left blank.Further review of the documentation available in the clinical record revealed there was no identification of distressing behaviors or any non-pharmacological approaches attempted prior to giving these two as needed Lorazepam administrations.Review of the available documentation included:An entry on 12/1/25 at 8:51 AM by Nurse 'C' read:Resident was attempting to get out of bed talking about going back to work They are waiting for him outside there. PRN anxiety med given with good effect. Currently eating food from lunch tray. Calm down now.A late entry on 12/1/25 at 12:24 PM for 11/26/25 at 9:08 AM by Nurse 'C' read: Resident was talking to self, looking up straight to air like yes you are right am still working here I will see you soon when you come. I am getting out of bed now to see you ok. PRN Ativan given earlier with good effect. MD aware. Safety maintained. On 12/3/25 at 2:07 PM, Nurse 'C' was attempted to be contacted by phone and a message was left to return the call.On 12/3/25 at 3:35 PM, an interview was conducted with the Director of Nursing (DON). When asked to explain the facility's process for administering as needed psychotropic medication, the DON reported the nurses should try other non-pharmacological interventions first. When asked where that would be documented, the DON reported in the progress notes or on the MAR. The DON further reported they had previously had discussions with Nurse 'C' about this same concern. The DON reviewed the documentation by Nurse 'C' for both administrations, and they reported the documentation as written did not capture what actually happened. The DON reported R42 gets extremely restless and agitated but acknowledged the documentation as written did not reflect that, nor did it include the non-pharmacological approaches attempted prior to administration.According to the facility's policy titled, Psychotropic Medication Policy dated 3/1/2025: . Chemical restraint refers to any drug used for discipline or that makes it more convenient (i.e., less effort) for staff to care for a resident, and not required to treat medical symptoms. This includes instances when a psychotropic medication may be approved to treat certain symptoms, however, nonpharmacological interventions should be used or attempted, unless clinically contraindicated, because they are less dangerous to a resident's health and safety.Non-pharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications.

This citation relates to Intake 1291048. Based on observation, interview, and record review, the facility failed to protect one Resident's (R204) right to be free from abuse mistreatment of two residents reviewed for abuse, when R204 was intimidated by a former staff member (witnessed by R203) with verbal aggression and a threatening gesture. Findings include: A facility-reported incident report was received by the State Agency on 6/27/25, which showed on 6/26/25 at approximately 3:30 p.m., R203 reported to the facility Social Worker, SW A, they witnessed an incident several days prior on the afternoon shift when R204 was observed swearing at Certified Nurse Aide (CNA) C . The report further revealed CNA C left the building and returned with a bat (baseball bat). The report described CNA C threatened R204 by approaching them and pursuing them with the bat. The staff member was suspended, and no physical contact was noted. It was reported that law enforcement was notified and stated R204 was not harmed. The staff member did not return to work and was terminated by the facility. The facility investigation determined the incident occurred on 6/22/25 between 3:00 p.m. to 4:00 p.m. The investigation showed R204 was unable to recall the incident, and denied any fear, pain, or distress. Review of the facility's investigation report revealed Maintenance Employee, Staff E observed they witnessed R204 tell CNA C to Shut the f* up and then saw CNA C retrieve a bat from their car and reenter the facility. The investigation conclusion revealed CNA C was separated from employment for failing to meet expectations regarding professional conduct and de-escalation practices. Review of R204's Accident and Incident report, dated 6/27/25, showed on 6/26/25 at 5:00 p.m., a resident (R203) made writer (nurse) aware of an incident which occurred on 6/22/25, when (R203) observed a worker (later identified as CNA C) making a threat towards another resident. (R203) stated they didn't like it and told some of the other residents about it. The writer asked the resident (R203) if they felt safe, who said yes. Writer interviewed R204 who said they were ok and did not recall any incident. The writer confirmed R204 had no injuries and no pain was found. The report showed the management and guardian were made aware an incident occurred. Review of R204's nursing assessment, dated 6/27/25 at 3:32 p.m. revealed a resident informed staff R204 was threatened by a worker on Sunday (6/22/25), the proper authorities were notified, and they assessed R204, and found no injuries.Review of Staff E's witness statement, dated 6/22/25, described on 6/22/25, The resident (R204) told the employee (CNA C) to, Shut the f* up. I witness (sic) employee (CNA C) went outside to her car and retrieved a bat out of the trunk of her car and entered the building on 6/22/25. There was no further description of what occurred when CNA C reentered the building with the bat, or if they followed up.Review of the Electronic Medical Record (EMR) showed R204 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, schizophrenia (mental disorder which may include psychosis), and an anxiety disorder. When the incident occurred, R204 was ambulatory and had moderate cognitive impairment. On 9/03/25 at 12:20 p.m., R204 was observed standing in the doorway of their room, dressed, and well groomed. On 9/03/25 at 12:22 p.m., R204 reported they had no concerns or recalled any incidents. R204 declined further interview. On 9/03/25 at 12:24 p.m., R203 was observed dressed and seated in a wheelchair in their room. On 9/03/25 at 12:25 p.m., R203 reported they recalled an incident between CNA C and R204, which occurred at the front door of the facility in front of the nurse's station, on the [NAME] end of the building. R203 stated CNA C got in (R204's) face and told (R204) 'I am not the person to mess with; I will f*** you up, intimidating (R204) and then stormed out to her car 'all heated' and came back with a big canvas bag. There was a Little League (smaller) aluminum bat.and (CNA C) hit it on the ground, like intimidation.It just surprised me.Yes, I was upset. When asked how R204 responded, R203 said, (R204) didn't really respond. R203 denied R204 was harmed. R203 was alert and oriented x four spheres and could tell time. R203 reported they felt safe at the facility. On 9/03/25 at 1:37 p.m., SW A confirmed the incident occurred as described by R203 during a phone interview. SW A explained R203 shared with them an employee pursued R204 with an object, and it had happened a few days before they reported the incident and said they had not told their nurse or a manager the incident occurred. SW A reported they immediately reported the incident to the Nursing Home Administrator (NHA) and the Regional Director of Operation (RDO), NHA F. SW A stated R203 was alert and oriented fully and said they were an accurate reporter and said R203 was concerned about R204's well-being. SW A clarified they understood CNA C pursued R204 in the facility with an object per the investigation findings but R204 was not harmed. SW A reported they did psychosocial follow-up with R204, and no concerns were found. On 09/03/25 at 1:47 p.m., Staff E reported during a phone interview they saw a verbal incident between R204 and CNA C, when they observed CNA C go to their car, followed them out, and saw CNA C obtain a bat, and said, You can't come (in) here with that bat. And then they observed CNA C re-enter the building and showed R204 the baseball bat. Staff E said to CNA C, Why are you showing them the bat? Staff E said CNA C had a metal bat, and she hit it on the floor firmly and then CNA C walked away and said, I am done. Staff E reported CNA C was in and out; one minute she was alright and another minute you just don't know. CNA 'C did not chase that man (R204). She was by the (front lobby) door and (CNA C) never went towards him with the bat. It got everyone's attention and (CNA C) should not have had the bat, period. (CNA C) put it in the car and came back in. (R204) did not understand what was happening. Staff E denied any reaction by R204 and confirmed no contact or harm occurred to R204 and said R204 did not appear fearful. On 9/03/25 at 2:52 p.m., the NHA and NHA F confirmed the mistreatment incident occurred on 6/22/25, when CNA C was observed getting upset with R204, and substantiated CNA C brought a bat into the facility during the incident. Both confirmed the bat was stomped on the ground in the presence of R204. The NHA and NHA F reported they were not immediately made aware of the incident, and they terminated CNA C once they found out about the incident. NHA F reported they confirmed CNA C demonstrated intimidating behavior and verbal aggression towards R204, and the NHA reported they concurred with these conclusions. Review of the policy, Abuse, Neglect, and Exploitation, revised 6/24, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. 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. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.

This citation relates to Intake 1291048. Based on interview and record review, the facility failed to report an abuse mistreatment incident for one Resident (R204) of two residents reviewed for abuse. Findings include:Review of the Facility Reported Investigation Summary/Actions Taken revealed, Reported Event: On 6/26/25, the Abuse Coordinator was informed by Social Worker (SW) A, of an alleged incident of staff-to-resident physical intimidation, involving R204 and Certified Nurse Assistant (CNA) C. The incident was reported to have occurred on 6/22/25, between 3:00 - 4:00 p.m. and allegedly involved the staff member retrieving an object from her car and reentering the building to confront the resident after a verbal altercation.Background: Upon notification, the facility suspended the staff member (CNA C) pending investigation, contacted the (Name of) Police Department, and initiated a full investigation . Further review of the report further revealed, (Staff E) submitted a statement dated 6/27/25, stating he witnessed (R204) tell (CNA C) to 'shut the f* up ** and then saw (CNA C) retrieve a bat from her car and reenter the facility.On 09/03/25 at 1:47 p.m., Staff E reported during a phone interview they saw incident between R204 and CNA C, when they observed CNA C go to their car, followed them out, and saw CNA C obtain a bat, and (Staff E) said, You can't come (in) here with that bat. And then they observed CNA C reenter the building, who showed R204 the baseball bat. Staff E said, Why are you showing them the bat? Staff E stated CNA C had a metal bat, and she hit it on the floor and then CNA C walked away and said, I am done. Staff E denied any reaction by R204 and confirmed no contact, or harm occurred to R204 and said they did not appear fearful. Staff E acknowledged they did not report the incident when it occurred to the facility. Review of the policy, Review of the policy, Abuse, Neglect, and Exploitation, revised 6/24, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. 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. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.VII. Reporting/Response: A. The facility will implement the following: 1. Reporting/Response: A. The facility will implement the following: 1. Reporting of all alleged violations to the facility Administrator (Abuse Coordinator) immediately after ensuring resident safety. 2. Reporting of all alleged violations to the State Agency, Adult Protective Services, and to all other required agencies (e.g. law enforcement when applicable) withing specified timeframes. a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in bodily injury, or b. not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included immediate action, education, and monitoring prior to the onsite survey on 9/03/25. The facility was able to demonstrate monitoring of the correction action and sustained compliance by 7/03/25. -

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices, hand hygiene, during medication administration observations for five (R4, R6, R10, R25, R27) of five residents resulting in the increased likelihood for the spread of infection. Findings include: On 6/10/25 at 9:12 AM, Registered Nurse (RN) A was observed for medication administration for R27 and was not observed performing hand hygiene prior to the preparation of the medications and prior to administering the medication. At 9:23 AM, Unit Manger Licensed Practical Nurse (LPN) C was observed whispering into RN A's ear at which time RNA made an audible comment to R27 that they need to do hand hygiene and proceeded into the residents restroom. On 6/10/25 at 9:25 AM, RN A provided a medication pass to R25 and was observed entering the room without performing hand hygiene. R25 placed a cup of medications on the side table, then proceeded to readjust the resident pressing the controls of the electronic control pad, call light, bedside table, and blankets with bare hands. RN A was observed placing the cup of medications into the resident's mouth and providing water without performing hand hygiene. RN A was observed exiting the room, and no hand hygiene performed. RN A commented R25 required another medication that was in the medication room and was observed removing a Band-Aid from their pointer finger and pressing onto the computer screen (biometric security), RN A retrieved the medication, exited the medication room, and proceeded to administer the medication to R25 without performing hand hygiene. On 6/10/25 at 3:46 PM RN A was observed providing a medication to R4 in the television activity room and was observed not performing hand hygiene before and after administering. On 6/10/25 at 3:49 PM, RN A was observed providing a medication to R6 and was observed not performing hand hygiene before and after administering. On 6/11/25 at 8:00 AM RN M was observed providing morning medications to R10 and was observed not performing hand hygiene before and after administering. On 6/11/25 at 8:37 AM RN M was observed providing an additional morning medication to R10 and was observed not performing hand hygiene before and after administering. On 6/11/25 at 9:06 AM, the Director of Nursing (DON), Licensed Practical Nurse (LPN) Manager C and Infection Control Nurse (ICN) E were informed of the concern that Nursing did not perform hand hygiene consistently with the Residents during medication administration and they said would follow up with Nursing staff. The facility acknowledged the concerns of not performing hand hygiene practices and reeducated staff while the survey was still in progress on 6/11/25. Review of the Policy titled; Medication Administration dated 2/2025, documented: Medications are administered .in a manner to prevent contamination or infection .Wash or sanitize hands prior to administering medication .

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent. Two medication errors were observed for R10 from a total of 30 opportunities reviewed during medication administration, resulting in an error rate of 6.67%. Findings include: On 6/11/25 at 8:29 AM, record review of a medication reconciliation was conducted for R10 and two medications: Metoprolol (medication for lowering blood pressure and heart rate) 25 milligram (mg) and Thiamine (Vitamin B1, essential nutrient for brain, heart, and nervous system function) 100 mg were documented as administered at 9:00 AM and were not observed prepared or administered. On 6/11/25 at 8:37 AM, RN M was questioned if the two medications in question were administered after the survey observation, at which time they reviewed the Electronic Medical Record (EMR) for R10 and apologized I am sorry for that and acknowledged they documented the Thiamine was given but it was not and RN M was observed providing Thiamine to R10. RN M was questioned about the Metoprolol medication and RN M commented they administered it and probably forgot to show the medication card and the blister pack being opened during the survey observation. On 6/11/25 at 9:06 AM, the Director of Nursing (DON) and Licensed Practical Nurse (LPN) Manager C were informed of the concern with the Metoprolol not being observed as prepared and administered. Both acknowledged they would follow up and obtain vital signs for R10. The DON and LPN C were also informed the admission by RN M of documenting R10's Thiamine was administered, and it was not given.

Based on record review and interview, the facility failed to ensure laboratory services for a urine culture/sensitivity test were received timely resulting in administering a resistant antibiotic for a Urinary Tract Infection in one resident (R27) of one reviewed for laboratory services. Findings include: A clinical record review revealed R27 was admitted to the facility on [DATE] with a sacral (base of the spine) ulcer and osteomyelitis (infection in the bone) of the sacral region. As a result of a stroke, and intracerebral hemorrhage (brain bleed) R27 was incontinent of urine and stool, resulting in high risk for a Urinary Tract Infections (UTI). R27 had impaired mobility and was unable to communicate their needs and their Brief Interview for Mental Status (BIMS) score was 4/15 indicating severe cognitive impairment. On 2/21/25 at 11:10 AM, a Nursing progress note documented a Urinalysis and Urine Culture and Sensitivity (C/S) was obtained and sent to the lab. On 2/26/25 at 10:45 AM, Interdisciplinary Team (IDT) Review Note documented R27 had a large amount of WBC (White Blood Cells) in their urine based on the urinalysis and the MD (Medical Doctor) was going to start them on an antibiotic and was prescribed Nitrofurantoin Macro crystal (Macrobid) Capsule 100 milligram (mg) every eight hours for UTI for seven days. On 3/5/25 at 7:09 PM, record review of the Practitioner Progress notes documented R27 was seen for evaluation of urine culture (collected 2/21/25) and was resistant to present antibiotic (Macrobid) had to be changed to a different antibiotic (Levaquin). On 6/11/25 at 9:36 AM, Infection Control (IC) E was questioned why was R27's antibiotic changed from Macrobid to Levaquin and was the C/S reviewed prior to starting the Macrobid. IC E indicated the Urinalysis results were obtained from the outside lab as it is integrated into their Electronic Medical software, however, the C/S is obtained via another software portal, and the facility was unable to obtain the C/S results. When questioned if the lab was contacted for the results, IC E replied they did not call, but mentioned maybe the Director of Nursing (DON) followed up. On 6/11/25 at 10:13 AM, the DON acknowledged there have been concerns with the facility's current lab and not receiving timely results. The DON indicated they had been in contact with lab about the concern and recalled this situation but was unable to confirm details of the delay. The DON further acknowledged R27's C/S results collected on 2/21/25 should have been resulted within 2-3 days and had not resulted until 3/5/25, confirming the originally ordered antibiotic was resistant to the infection and required a change in antibiotic therapy to treat R27's UTI. Review of the policy titled; Laboratory, Radiology, and other Diagnostic Services dated 11/2016, documented: .The facility is responsible for the timeliness of the services .

Based on observation and interview, the facility failed to ensure appropriate medication storage and labeling for medications in two of two medication carts reviewed and one residential room. Findings include: On 6/10/25 at 9:12 AM, while observing a medication administration in room [ROOM NUMBER], a white round pill was observed lying on the floor along the baseboard near the bathroom. Attention to the pill was brought to Unit Manager Licensed Practical Nurse (LPN) C at which time they were observed picking it off the floor with their bare hand. They were inquired if any identifiers were on the pill and LPN C confirmed there was nothing to identify the pill and it should not be on the floor. On 6/10/25 at 9:55 AM, a medication storage observation was conducted with Registered Nurse (RN) N for Medication Cart East and revealed in drawer one, one green colored oval shaped pill and one small peach colored pill both unidentifiable and not stored in containers and unidentified. Drawer two revealed one small green oval pill, one small white round pill, one partial white pill, one white oval pill, and one round yellow pill, not stored in containers and unidentified. On 6/10/25 at 10:13 AM, a medication storage observation was conducted with LPN C for Medication Cart Gold and revealed one white round pill, one capsule colored blue and pink, and two white round pills not stored in containers and unidentified. On 6/10/25 at 2:39 PM, the Director of Nursing (DON) and LPN C both acknowledged the concerns of loose medications observed within both medication carts not stored in containers and unidentified, and the concern of medication found on the floor of a resident's room. A request for the facility policy for medication storage was made via email on 6/11/25 at 9:27 AM and was not provided by end of the survey.

Based on observation, interview and record review, the facility failed to ensure that one (R25) of one resident reviewed for nutrition received nutritional supplements as ordered, resulting in the potential for weight loss and overall decline in their condition. Findings include: Record review revealed R25 was a long-term resident of the facility admitted to the facility on [DATE]. R25 was most recently re-admitted to the facility after hospitalization on 6/7/25. Review of R25's admission history revealed that R25 had multiple hospitalizations between 1/12/25 and 6/10/25. R25's admitting diagnoses included stroke, bladder cancer, difficulty swallowing, left ankle pressure ulcer and malnutrition. Based on the Minimum Data Set (MDS) assessment dated [DATE], R25 had a Brief Interview for Mental Status (BIMS) score of 4/15, indicative of significant cognitive impairment. An initial observation was completed on 6/10/25 at approximately 9:30 AM. R25 was observed laying on their bed. R25's bed on the right side was close to the wall and they had low air loss mattress. R25 was able to answer simple questions. When questioned if they had breakfast they stated yes when asked how they were doing, they stated OK. A follow up observation was completed during dinner time at approximately 4:20 PM. At approximately 4:30 PM, the dinner cart for the front end of the hall (where R25 was residing) arrived on the unit and staff started serving the trays. Approximately 10 minutes later this surveyor checked from the hallway,R25 was in their bed, the bedside table was on the left side of the bed. There was no dinner tray in their room. At approximately 4:45 PM the dinner cart for the back hall arrived and staff were serving the dinner trays. Staff members who finished serving the meal tray on the front end of the hall and were observed walking down the halls and engaged with other tasks. An unknown resident from the front end of hall brought out their finished dinner tray to the doorway to hand it to staff. At approximately 4:55 PM, Registered Nurse (RN) A, who assigned to care for R25 was observed in the hallway. This surveyor asked RN A about the tray arrival and serving process. They reported that the trays arrived in two carts, one cart for the front end and one cart for the back end and reported that the tray pass for the front hall was done. This surveyor asked if R25 had received their dinner tray. RN A reported that they would go and check in the back cart. This surveyor accompanied RN A to the back hall. When arrived at the back hall, a staff member was pushing the cart past the nurses' station towards the north end of the hall. RN A asked the staff member who was a Certified Nursing Assistant (CNA), if R25's tray was on the cart. The CNA reported that R25 did not get their tray and staff went to kitchen to get their tray. RN A asked the CNA to check the cart. The CNA started to check the cart and pulled R25's tray. RN A walked back to the room and started assisting R25. R25 received a regular diet with a dessert and a glass of pink drink. RN A started to assist R25 with their dinner. The ticket read regular diet, large portions, and health shakes. There was no health shake on R25's meal tray. When RN A was queried about the health shake, they reported that it should come with the dinner tray. They were not sure why it did not come with dinner tray and stated that they would get one. RN A left the room and returned after a few minutes with a health shake and started assisting R25. When queried on the process on who/how they ensured resident received appropriate supplements as ordered, RN A reported that kitchen should have checked and added that floor staff also should double check. They agreed R25 was high risk resident and understood the concern. Review of R25's Electronic Medical Record (EMR) revealed that R25 had a guardian (brother) and was a 'full code (wished to receive all life sustaining measures as needed). R25 also had significant weight loss during hospitalization. R25 was re-admitted with a pureed diet and they were changed to a regular diet on 6/9/25. Review of R25's physician orders revealed an order dated 6/7/25 that read House supplement - two times a day 4 OZ health shake with lunch and dinner-dietary to provide. Another order dated 6/7/25 read Patient requires 1:1 assist during meals. Review of R25's care plan read, I have a potential for nutritional/hydration problem. The care plan also revealed that R25 was receiving supplements (initiated on 5/20/25) prior to their recent hospitalization. A Registered Dietician (RD) note dated 6/10/25, read in part, My MNA (Mini Nutritional Assessment) score is 6. I am at nutritional risk due to dementia, hydronephrosis (urine backing up into kidneys) .SLP (Speech Language Pathologist) evaluated resident and upgraded to regular textures .upon return my supplements were put back into place . An interview with Unit Manager (UM) E was completed on 6/11/25 at approximately 8:50 AM. They were asked about R25 and they agreed they were a nutritional risk, had recent weight loss during hospitalization and they needed staff assistance with eating. They were queried about the tray pass process to ensure every resident received a meal tray with appropriate supplements as ordered. UM E reported that it was the responsibility of the kitchen team and floor staff to ensure that every resident their meal trays as ordered. This surveyor shared the observations and the concern and UM E reported that they agreed with the concern and they would follow up with their team. An interview with Dietary Manager (DM) M was completed on 6/11/25 at approximately 9 AM. They were asked about the tray assembly process and what their expectation for their staff to ensure that residents received the diets/supplements as ordered. DM M: reported that every resident had a ticket based on their order, staff followed the ticket and reached out to them if anyone had a question. When questioned about R25 and why they did not receive their supplement they reported R25's diet was recently changed and staff were in a rush when the nurse came and asked for the dinner tray on 6/10/25 and missed it. DM G was notified RN A picked up the dinner tray that was already assembled and was sent in the back hallway cart. They reported that they must have misunderstood and agreed on the concern. They stated that it was an oversight on their end. An interview with the Director of Nursing (DON) was completed on 6/11/25 at approximately 9:45 AM. The DON was queried about the tray pass process and how did the staff ensure that everyone received a meal tray with supplements as ordered. The DON reported that it was their team's responsibility to ensure that everyone received a meal tray as ordered. The observation and concerns for R25 were shared with the DON. The DON added that R25 would have received their tray and they added that staff should have made sure that R25 received their supplements as ordered. They added that they agreed with the concern and they had already followed up with their staff. A facility provided document titled Weight Monitoring with a revision date of 1/21 read in part, Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors b. Evaluating/analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revising them as necessary. 2. A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss/gain or compromised nutritional status. Assessments should include the following information: a. General appearance (e.g., robust, thin, obese or cachectic) b. Height c. Weight d. Food and fluid intake e. Fluid loss or retention f. Laboratory/Diagnostic Evaluation 3. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. 4. Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status .

This citation related to Intake #: MI00150321. This citation has two deficient practice statements. Deficient Practice Statement #1 Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent two physical resident-to-resident incidents for three Residents (R7, R13, R23) of three residents reviewed for incidents. Findings include: Review of a Facility Report Investigation (FRI) report, dated 2/11/25 through 2/13/25, revealed there was a resident-to-resident incident which occurred on 2/10/25. The incident began as a verbal altercation when R7 removed a chair from the hallway for their guest to be seated, which R13 believed was their own personal chair. There was a subsequent disagreement between R7 and R13, with an exchange of words, which resulted in R13 kicking R7 in the left ankle. The report conveyed R7 initially reported pain and was later found not injured. Review of R7's Minimum Data Set (MDS) assessment, dated 1/14/25, revealed R7 was admitted to the facility on [DATE] with diagnoses including stroke, anxiety, and depression. The assessment showed R7 required supervision for transfers and toileting. The Brief Interview for Mental Status (BIMS) assessment showed a score of 14/15, which showed R7 was cognitively intact. Review of R13's MDS assessment, dated 12/27/24, revealed R13 was admitted to the facility on [DATE], with diagnoses including atrial fibrillation (heart rhythm irregularity), bipolar (mood) disorder, and schizophrenia (a chronic mental health disorder which may affect one's perceptions). The assessment revealed R13 toileted themselves and transferred and walked short distances with set-up. The sensory assessment showed R13 was able to make themselves understood and could understand others, with clear speech. Review of R7's Accident and Incident report, dated 2/10/25 at 9:02 (a.m.), revealed, Writer (Licensed Practical Nurse) LPN D was called to hallway by a resident saying, They (R7 and R13) are about to fight. Writer along with medical records (staff) noticed residents (R7 and R13) arguing in hallway. Both residents were separated and asked to go to their rooms. At that time, (R7) said that resident (R13) kicked (them) in the ankle. Resident (R7) was assessed for injury. No injury found .(R7) says, I went and got a chair from the hallway because I was having company. I got the chair and took it to my room. At that time (R13) tried to enter my room to get the chair; (R13) said the chair was (theirs). I explained that the chair was in the hallway and not (theirs). (R13) has a chair in (their) room. (R13) began to swear at me and (R7) swore back . This incident was brought to staff attention by a resident, not by a staff member. Review of R7's progress note, by Physician L, dated 2/11/25 at 19:03 (6:03 p.m.), revealed R7 was kicked in the ankle by another resident and had developed some mild pain/swelling in the left ankle. The note further revealed an x-ray was taken of the left ankle, which was negative for a fracture or soft tissue swelling. Review of R7's nursing assessment narrative, dated 2/11/25 at 18:03 (6:03 p.m.), revealed, (R7) was kicked by (R13) because (R13) would not allow (R7) to remove a chair from (their) room that (R7) had put there for a visiting guest. (R13) felt that the chair that was sitting outside (their) door was (their) chair . Review of R13's Accident and Incident report, dated 2/10/25 at 16:35 (4:35 p.m.), by LPN D, revealed, Writer (LPN D) was called to hallway by a resident (not discovered by staff). Writer and medical records clerk witnessed two resident's fussing (sic) in hallway and making threats. Both residents were stopped and asked to go to their rooms. (R7) informed writer (LPN D) that (they were) kicked by (R13) in the Lt. (left) ankle .(R13) informed writer that (they were) in (their) room when (they) noticed (R7) taking (their) chair from the hallway. (R13) went to get (their) chair back and (R7) would not let (them) get the chair. They started yelling at each other and (R13) kicked (R7) because (they were) mad .Immediate action taken .(R13) was educated on not putting (their) hand or feet on (R7) and to let staff handle things of that nature . On 6/12/25 at 12:20 p.m., LPN D was asked about the verbal and physical altercation between R7 and R13 on 2/10/25. LPN D confirmed they were the nurse working and discovered the incident. LPN D clarified the incident occurred on the East Hall, and they understood R13 kicked R7, because R7 took a chair outside R13's room, which R13 believed was their own personal chair. LPN D was asked if they believed this was a deliberate act by R13. LPN D reported they believed when R13 kicked R7 there was some deliberateness, since R13 kicked R7 in anger because R13 took a chair which they believed was theirs. Review of R13's Care Plan, accessed 6/13/25, revealed an intervention after the incident occurred, which showed they have behaviors of physical aggression when I get upset or provoked by others. The intervention, dated initiated 2/12/25, revealed, Please give me time and the ability to talk thru my aggression or when I'm upset. There was no mention of R13 believing the chair in the hallway was their own personal chair, or a follow-up intervention. Review of R13's progress note, dated 2/18/25 at 16:57 (4:37 p.m.), revealed a second resident-to-resident incident, when R13 was walking to their room and a second resident (R23) attempted to make physical contact with them. R13 responded by making physical contact with the left arm of R23 and apologized to staff for their actions after staff education. Review of R13's behavioral care provider psychiatry note, dated 1/28/25, revealed R13 had been living in several nursing homes for the past several years, and they had been in an ALF (Assisted Living Facility) immediately prior to the last hospitalization, but the ALF homeowner said they would not take R13 back due to their aggression. The visit note confirmed R13 had schizophrenia and bipolar disorder, and a history of alcoholism and symptoms of alcohol inducted dementia. On 6/11/25 at 12:30 p.m., LPN D continued to describe the second resident-to-resident incident about a week later, between R13 and R23, when asked. LPN D reported on 2/18/25 after 3:00 p.m., they observed R23 walking down the East Hall and R13 was walking on the hall also, and they saw R23's hand touch R13 on their shoulder, which they believed was a caring touch. LPN D described R13 did not like R23's hand on their shoulder, and moved their hand, and they said, Don't do that; don't touch me, and R13 made contact with R23's arm with their hand. LPN D reported they were able to separate the residents and there were no injuries. LPN D reported R13 was upset with R23 about an hour prior, when R23 sat in a chair outside R13's room which staff used for charting, which R13 believed was their own personal chair. LPN D clarified R13 liked their own space and their room a certain way, and they were particular about their personal items. LPN D confirmed the chair outside R13's room door was related to both resident-to-resident physical incidents by R13, and remained outside R13's room for staff use. LPN D confirmed they called the Nursing Home Administrator (NHA) when the incident occurred. Review of R23's progress note, dated 2/18/25 at 16:06 (4:06 p.m.), revealed, (R23) was trying to touch another .resident (R13) in hallway and that resident (R13) reached (their) right hand and hit this .resident (R23) on (their) left arm. not hard, per witness . It was later clarified by the NHA the witness was a resident who no longer resided in the facility. No injury was described for R23 or R13. Review of R23's Accident and Incident report, dated 2/18/25 at 15:30 (3:30 p.m.) revealed, When (R23) was walking in the hallway and trying to touch (R13), (R13) reached back using (their) right hand and hit (R23) on (their) left arm. A third resident witnessed what happened . No pain, injuries, or distress was found per the report. Review of R23's MDS assessment, dated 1/28/25, revealed R23 was admitted to the facility on [DATE], with diagnoses including dementia, anxiety, and PTSD (Post Traumatic Stress Disorder). R23 was dependent for toileting, and independent with transfers and walking. The BIMS assessment showed a score of 0/15, showing severe cognitive impairment. Review of R23's behavioral management program review note, dated 2/07/25, revealed, .Behavior assessment. Behavior #1. 1a. Type of Behavior: I will invade other resident personal space . Review of R23's behavioral care psychiatry note, dated 11/04/24, revealed, .(R23) is well-known to have significant behavioral and emotional disturbances associated with (their) dementia. (R23) displayed wandering, emotional lability, and frequently gets close in other resident's personal space which puts (R23) at high risk for physical conflict . Review of R23's Care Plan, accessed 6/11/25, showed no mention of R23 invading other residents' personal space, or a related intervention. On 6/11/25 at approximately 1:30 p.m., this Surveyor observed R23 walking by R13 in a facility hallway. R13 agreed to be interviewed and headed towards their room. On 6/11/25 at approximately 1:34 p.m., R23 was observed walking by R13's open door of their room to the end of their hallway and standing there talking to themselves. There were no staff present observed on the hall. On 6/11/25 at 1:35 p.m., R13 stated they observed R23 walked by and stated, (R23) is a headache; (they) get on my nerves .I slapped (them) a little bit, as (they were) just driving me crazy and everything, but I am not doing it anymore . When asked why, R13 said they felt frustrated with R23. R13 confirmed R23 did not go in their room but walked on their hallway. R13 was asked about any incidences or concerns with other facility residents and denied any, including with R7. When asked about the black padded chair outside their room, R13 reported this was their own personal chair, and the staff could sit there. When asked about residents sitting in the chair, R13 stated the residents could not sit in their personal chair outside their room in the hallway, as it was their chair. It was observed there was a similar chair in R13's room, so it was unclear why R13 identified the chair staff used in the hallway for charting as their own personal chair. R13 was alert and oriented to themselves, their room (which they easily found), and to their surroundings. On 6/11/25 at 1:42 p.m., a black padded chair was observed outside R13's room, approximately five feet away from their room outer door. It was observed R7's room was on the same hall, a few doors down from R13's room. The chair was not labeled in any way, for staff or resident use. On 6/11/25 at 1:46 p.m., R23 approached this Surveyor on the hallway outside R7's room, walking ad lib, wearing casual sweat clothes. R23 began speaking non-sensically and attempted to follow this Surveyor into R7's room. No staff were observed on the hall or intervened. This Surveyor softly verbally redirected R23 out of R7's doorway, and they walked down the hall. R23 was oriented to their name only. On 6/11/25 at 1:48 p.m., R7 agreed to be interviewed in their room. R7 was in their bed, dressed, and a power wheelchair was observed next to their bed. R7 was alert and oriented x 4 spheres (to person, situation, time, and place). R7 was asked about any concerns with facility residents. R7 reported there was one concern, when they (R7) took a chair from their facility hall, and said R13 did not like it. R7 reported they (and R13) were doing fine now and declined to discuss it further. R7 stated, (R13) is my friend. this Surveyor asked if R23 or any residents were coming into their room. R7 responded, No. On 6/11/25 at approximately 1:53 p.m., this Surveyor was exiting R7's room, standing in the doorway, when R23 approached this Surveyor a second time, walking rapidly up to this Surveyor. Despite a computer table being in front of the Surveyor, R23 quickly leaned forward and grasped this Surveyor by both upper arms, just below the shoulders. R23 was pleasant and conversational however was in the Surveyor's personal space. No staff were observed to intervene, or in line of sight, R23 was verbally redirected to release their grasp by this Surveyor, with R23 complying and letting go. R23 followed Surveyor up to the nurse's station, where a nurse was seen around the corner coming out of a room, not in line of sight of R23, and was asked to redirect R23. On 6/11/25 at approximately 1:55 p.m., this Surveyor was standing in view of the facility elevator near the first-floor resident dining room. R13 was observed standing nearby. R23 walked from around the corner quickly and approached R13, who was near/across from the elevator, invading their personal space. R23 was heard to call R13 fat @ss loudly from a few feet away. R13 was observed to appear frustrated. The Activity Director, Staff F, walked up to R13 after and removed them from the situation by escorting them into the dining room. R23 next walked rapidly towards this Surveyor and again grasped this Surveyor's upper arms tightly, just below the shoulders, invading Surveyor's personal space, and took three loud grunting breaths, sounding unsettled and appearing angry. No staff came to intervene during this occurrence. This Surveyor softly verbally asked R23 to let go, which they did, and this Surveyor removed themselves from the situation. On 06/11/25 at approximately 1:57 p.m., this Surveyor asked to speak with R13 if they agreed. R13 agreed to a brief interview. This Surveyor asked R13 how they were doing, and they said, I'm ok. Everything's going to be ok. On 06/11/25 at 1:58 p.m., Staff F was asked about their observations of the verbal altercation. Staff F acknowledged R23 called R13 a fat @ss, a few minutes earlier, as observed by this Surveyor as well, and said R23 says this all day. Staff F stated they tried to redirect the other residents when this occurred, and said staff tried to keep R13 and R23 apart. Staff F explained R23 liked to touch people, but it was in a caring way typically. Staff F was asked if R23 attempted to go into other resident rooms or was targeting R13 in any way. Staff F denied both and reported this was R23's typical presentation, saying swear words under their breath. Review of R23's Care Plan, accessed on 6/11/25, revealed R23's PTSD/trauma diagnoses with triggers unknown, given their pronounced cognitive impairment. One intervention was to respect their personal space, and another was to provide soft redirection, structured routines, and a low stimulation environment. There was no targeted behavior or intervention for swearing under their breath or at facility residents or staff. Review of R23's behavioral tracking logs, accessed on 6/11/25, under tasks in the Electronic Medical Record (EMR), showed no targeted behavior tracking. The logs were blank without documentation during the 30-day look back period. Review of R13's behavioral tracking logs, accessed on 6/11/25, under tasks in the EMR, also showed no targeted behavior tracking. The logs were blank without documentation during the 30-day look back period. On 6/11/25 at 2:53 p.m., the NHA, with Regional Consultant K present, was notified of the verbal altercation observed by the elevator between R23 and R13, which was described. This Surveyor shared that Staff F corroborated the incident occurred when the NHA asked if the incident was witnessed. The NHA was asked if they had camera footage this Surveyor could review with them and their team, and the NHA responded, No. This Surveyor shared an unnamed staff member had earlier reported R23's typical behavior was saying fat b@ or fat @ss to residents and staff under their breath frequently. The NHA planned to review the incident further with their staff and denied being aware of this behavior for R23. This Surveyor shared concerns related to the two resident-to-resident incidences both involving R13's belief the black chair outside their room was their own personal chair. This Surveyor explained R13 said (on 6/11/25) facility residents could not sit in the black chair outside their room in the hallway, as it was their own personal chair. This Surveyor shared this appeared to be a contributing cause of both physical incidents perpetrated by R13, as this had not been addressed, and remained a potential risk factor. The NHA acknowledged they had not been made aware. The NHA reported they understood this concern and planned to follow up. On 6/11/25 at approximately 4:42 p.m., this Surveyor shared with the NHA, with Regional Consultant K present, supervision concerns for the involved residents related to the incidents, including direct observations on this date of a verbal altercation between R13 and R23, with R23 not being adequately supervised, given unwarranted physical contact with this Surveyor twice. This Surveyor shared R13 reporting they hit R23 out of frustration with the NHA, as well as staff reporting R13 seemed to deliberately kick R7 in anger when the black chair in the hallway outside their room was taken by R7. This Surveyor explained how the chair being related to both incidents was corroborated in facility documentation and by staff. The NHA reported they had done follow-up, and R13 had denied hitting R23 to them, and they interviewed staff involved in the concern today, and understood R23 was yelling into the air, not at R13. The NHA reported they had not been made aware or heard R23 saying swear words under their breath to residents. The NHA was asked if there was any camera footage anywhere in the building to review the observations of R23 with this Surveyor (and R13) and responded No. The NHA made further clarification their investigation into the incident today (on 6/11/25) with R13 and R23 was continuing, as they reported the verbal incident to the State Agency, and the State Manager. The NHA further clarified they had just discussed the black chair in the hallway with R13, and corroborated R13 said they believed the black chair was their own personal chair, and R13 did not want any residents sitting in the chair, including R23. The NHA explained they labeled the chair as R13's chair and moved this same black chair into R13's resident room, per R13's wishes. The NHA was asked if they understood the concerns regarding physical aggression (behaviors) which R13 perpetrated towards two facility residents (R7 and R23) during two verbal/physical incidents in February 2025, on 2/10/25 and 2/18/25, which may have been avoidable, given appropriate supervision and the chair perception concerns being addressed. The NHA indicated with any resident-to-resident incidences, their staff would immediately intervene and follow-up, which had occurred. The NHA respectfully disagreed with the supervision concerns, as they believed they had more than adequate staffing, and they respectfully declined to comment further. Review of the Policy, Incident Reporting: Accidents and Supervision, revised 8/2024, revealed, Policy: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring effectiveness and modifying interventions when necessary. Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks .2. Evaluation and Analysis . 3. Implementation of Interventions .4. Monitoring and Modification . 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency, b. Based on the individual resident's assessed needs and identified hazards in the resident environment. 6. Documentation- The purpose of the Incident/Accident report is to provide a standardized, systematic process to ensure that all accidents and incidents are promptly identified, reported and investigated, and that measures addressing causes are implemented to reduce recurrence. An Incident/Accident is any situation that involves harm or potential harm, which is outside of the usual and expected. These include but are not limited to: d. Resident altercation with staff/family/visitor/other . i. Resident to resident altercations (including inappropriate and or unwanted touching) . References: Centers for Medicare & Medicaid Services, Department of Health and Human Services. State Operations Manual (SOM): Appendix PP Guidance to Surveyors for Long Term Care Facilities . Deficient Practice Statement #2 Based on observation, interview, and record review facility failed to consistently implement fall prevention interventions as ordered/recommended for one (R29) of two (with history of multiple falls) Residents reviewed for falls. This deficient practice has the potential to result in further falls with/without injuries. Findings include: R29 Record review revealed R29 was a long-term resident of the facility admitted on [DATE]. R29's admitting diagnoses included dementia, muscle weakness, high blood pressure, narrowing of carotid artery (blood vessel to brain) with history of falls. Based on the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12/15, indicative of moderate cognitive impairment. An initial observation was completed on 6/10/25 at approximately 9:40 AM. R29 was observed sitting in their wheelchair and moving around in the hallway. The wheelchair had an antiroll back mechanism (a device that prevents the wheelchair from rolling back during transfers) attached to the wheelchair when a resident is not compliant or forgetful with locking the wheelchair brakes. The left arm/lever for the antiroll back device was turned inward and not in alignment to lock the left wheel/function appropriately. At approximately 10:15 AM, R29 rolled down the hallway and went into their room. The left lever for anti-roll back mechanism was in the same nonfunctional position. A brief interview was completed with R29. R29 reported that they wanted to walk like their roommate and added that they were not allowed to stand because of their falls. Later that day at approximately 3:20 PM, R29 was observed in their bed with their eyes closed. The wheelchair was parked next to the bed and the brakes were not locked. The left lever for the anti-roll back device was turned inward, in the same position. When this surveyor checked the wheelchair it moved freely and the anti-roll back mechanism was not functional. At approximately 4:30 PM, R29 was on their bed and the wheelchair was parked next bed and with left lever in the same position. Throughout the day, on multiple occasions, staff members including the nurse, Certified Nursing Assistants (CNAs) and leaders were observed going in and out of the room and speaking with the R29 in the hallway. On 6/11/25, at approximately 8 AM, R29 was sitting up in their wheelchair, in their room, facing the window and back of the wheelchair was visible from the hallway. The left arm of the anti-roll back device was in the same position. R29 stated that they were waiting to see someone from therapy. At approximately 8:10 AM, this Surveyor was speaking with Unit Manager (UM) E in the hallway, outside R29's room and R29 was observed self-transferring back to bed from their wheelchair. Review of R29's Electronic Medical Records (EMR) revealed that R29 had falls during their stay in the facility. Review of R29's fall risk assessment dated [DATE] revealed a score of 18, indicative of high risk for falls. Review of R29's nursing progress notes revealed a note dated 2/12/25 at 14:33 that read in part, Resident was observed sitting on his butt next to bed .missed the bed and slipped down to the floor . An interdisciplinary progress notes dated 12/13/25 titled anti-gravity team note read, Root cause of fall: Resident forgot to lock his wheelchair prior to attempting to get in to bed. New interventions: Anti-wheel back to be placed on wheelchair. Progress notes dated 2/27/25 revealed that R29 was observed sitting on the floor next to their bed. There were no follow-up interdisciplinary progress notes or root cause analysis and interventions in the EMR. Review of the care plan did not reveal any additional/change in interventions. A progress note dated 3/16/25 revealed that R29 had fall while they were attempting to self-transfer from wheelchair to bed. An anti-gravity team note dated 3/17/25 at 10:34 read, Root cause of fall: Resident attempted to self-transfer from chair to bed and did not lock the wheelchair. New interventions: Adjustment to anti-roll backs. A request for incident and accident reports/investigations for R29 from admission to current date was requested via e-mail to the facility administrator on 6/10/24 at 10:49 AM via e-mail, however were not received prior to survey exit. An interview with UM E was completed on 6/11/25 at approximately 8:20 AM. During the interview UM E reported that they were familiar with R29 and agreed that they were a high fall risk. They reviewed the EMR and confirmed the interventions that were in place. When queried about the fall on 3/16/25 and the intervention that read adjustment to anti-roll back (dated 3/17/25), UM E reported that the therapy team had checked after the fall and it had to be adjusted. When queried about the expectation for their team to ensure appropriate interventions are in place and functioning they reported that it was the responsibility of their team. They were shared the observation from 6/10/25 and 6/11/25. At approximately 8:30 AM, UM E went to R29's (with this surveyor) and R29 was in bed. The wheelchair was parked next to bed and the lever was in the same position as before and they checked the wheelchair and confirmed that the device was not working. They reported that it needed to be fixed and asked a staff member to take the wheelchair to therapy. An interview with the Director of Nursing (DON) was completed on 6/11/25 at approximately 9:30 AM. The DON was queried about the facility process to ensure that the ordered/recommended interventions were in place consistently and they reported that they had a running list of all the safety devices and they expected all staff and leaders to make sure that they were in place and functioning during their rounds. the DON was shared observations for R29 and they reported that they did not have the anti-roll back device on their list and they were going to add them for future. They agreed on the concern and reported that they were addressing it with their staff. A facility provided document titled Incident Reporting - Accident and Supervision with revision date of 8/24 read in part, Policy: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring effectiveness and modifying interventions when necessary. Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. c. Various sources provide information about hazards and risks in the resident environment. d. These sources may include, but are not limited to: i. quality assessment and assurance (QAA) activities ii. environmental rounds iii. MDS/CAA (care area assessment) data medical history iv. physical exam v. facility assessment vi. individual observation e. This information is to be documented and communicated across all disciplines. 2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. b. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. c. Evaluations also look at trends such as time of day, location, etc. 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. 4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions and making modifications as needed. 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency, b. Based on the individual resident's assessed needs and identified hazards in the resident environment .

Based on observation, interview and record review the facility failed to prevent the development of a pressure ulcer, ensure the facility accurately assessed/identified the wound timely and accurately implemented treatment for one (R27) of two residents reviewed for pressure ulcers, resulting in the development of a Stage IV (full-thickness skin and tissue loss) pressure ulcer to the bilateral buttocks that required an extensive hospital stay and a diagnosis of osteomyelitis (bone infection). Findings include: On 6/10/25 at approximately 10:12 AM, R27 was observed lying in bed. The resident was resting and did not answer questions asked. Prior to the observation, the facility provided information that noted R27 was the only Hospice resident at the facility. A review of R27's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Cerebral Infarction, Dysphasia, Adjustment Disorder and Moderate Protein-Calorie Malnutrition. A review of R27's Minimum Data Set (MDS) noted that the resident had a Brief Interview for Mental Status (BIMS) score of 4/15 (severely cognitively impaired) and required extensive one to two person assist for most Activities of Daily Living (ADL). A contract to begin Hospice services was signed by R27's representative on 5/10/25. Continued review of R27's record documented, in part, the following: 10/25/24: Practitioner Progress Note: .admitted from another facility .patient does not respond appropriately .HAD a PEG (percutaneous endoscopic gastrostomy) tube .he is eating orally .SKIN .generally intact .Patient was seen by video . 10/26/24: Order: .Clean coccyx (area just above center buttocks) area with soap and water, apply triad paste every shift for excoriation .Start date 10/26/24 .D/C (discontinue) date 11/12/24 . 10/30/24: Nutrition Summary Note: .My appetite is fair to good. Eating 50-100% of meals . 11/1/24: Braden Scale for Determining Pressure Ulcer Risk: .R27 .Category: Moderate Risk .Score 13 .Moisture .Occasionally Moist Activity:Bedfast .Nutrition: Probably Inadequate .Friction and Shear .Potential Problem . Care Plan: Focus: .I am at risk for impaired skin integrity (10/26/24) .Interventions: .Assist me to moisturize my skin as needed (initiated 11/7/24) .Assist me to turn &/or reposition routinely .while in bed and redistribute .when I am up in my chair (11/7/24) .Cleanse area and apply zinc oxide cream barrier to buttock/peri area after incontinence episodes .(Initiated 10/26/24) .Standard pressure relieving mattress to bed (Initiated 11/7/24) .Focus: I have history of skin impairment d/t (due to) excoriation and healed old scar on buttocks Intervention: Keep skin clean and dry .apply triad paste to buttocks area . 11/4/24: Weekly Skin Sweep: R27 .Please choose the skin condition that was observed: Discoloration .Site: Right buttock (excoriation-wearing off or abrading the skin resulting in a possible lesion or sore) .Left buttock (excoriation) . 11/11/24: : Weekly Skin Sweep: R27 .Please choose the skin condition that was observed: Non-skin intact .Site: old healed red area . *On 11/11/24, R27 stopped receiving any treatments to his buttocks. 11/21/24: Weekly Skin Sweep: R27 . Please choose the skin condition that was observed: Discoloration .Site: Right buttock (excoriation-wearing off or abrading the skin resulting in a possible lesion or sore) .Left buttock (excoriation) . 11/22/24: Order: .Provide skin barrier ointment after each incontinent episode and PRN (as needed) . *It should be noted that this order was not transferred to the Medication/Treatment Administration Record (MAR/TAR) and there was no documentation in R27's record that they received the treatment. A review of R27's MAR/TAR from 10/26/24-11/30/24 noted that the only treatments provided to the coccyx area were as follows: Clean coccyx area with soap and water, apply triad paste every shift for excoriation. This treatment was provided starting 10/26/24 and ended on 11/11/24. No additional treatments, including skin barrier ointment, were provided to the coccyx area through November 2024. 11/28/24: Weekly Skin Sweep: .R27 .Discoloration .Right buttock (excoriation) . Left buttock (excoriation) . 12/5/24: Progress Note Details: .R27 .12/5/24 .Established pt New Wound Resident .is being seen by wound care for assessment of skin breakdown bilateral buttock .Wound #1 Bilateral Buttock is a Partial Thickness MASD (Moisture Associated Skin Damage) and has received a status of Not Healed. There is a small amount of Sero-sanguineous drainage (a type of wound drainage that is a combination of fluid and blood) noted .Area appears to as multiple superficial open areas .Wound Orders: Wound Cleansing: Normal Saline or Wound Cleanser .Primary Dressing .Stock Calmoseptine or Chamosyn paste .Change frequently 2x per day and as needed . (Authored by Nurse Practitioner (NP) B). 12/11/24: Practitioner Progress Note: Late Entry .Seen for eval sacral ulcer .Opening per staff .sacral area open/excoriation . 12/12/24: Progress Note Details: .R27 .12/12/24 .Wound Assessment: .Bilateral Buttock is a Full Thickness MASD .status of not Healed .Small amount of sanguineous drainage .The wound is worsening .Orders .Primary dressing Medi honey .Apply Medi honey to slough following triad paste to perimeter of wounds .Secondary - apply Medi honey to abd pad, in center of pad, apply triad paste on to ABD pad surrounding Medi honey and place on area of skin break down BID and as needed . (Authored by NP B). 12/19/24: Progress Note Details: .R27 .12/19/24 . is being seen by wound care for reassessment of bilateral buttock skin breakdown .Wound #1 Bilateral Buttock is a Full Thickness MASD and has received a status of Not healed. Subsequent .measurements are 6cm (centimeters) length x 5.5cm width, with an area of 33 .Small amount of Sero-sanguineous drainage .wound margin is undefined wound bed has 76-100% granulation, 1-25% slough .Pressure Ulcer Unavoidable Evaluation . (Authored by NP B). 12/27/24: Weekly Skin Sweep: .Open area .Coccyx . 12/28/24: Progress Note Details: .R27 .12/28/24 (resident is being seen today instead of 12/26) .Wound #1 Bilateral Buttock Coccyx is an unstageable Pressure Injury Apply Medi honey to slough followed by ½ strength moist Dankins gauze, lightly fill to depth of wound Imaging Radiology .x-ray of Sacrum/coccyx to r/o (rule out) osteomyelitis ( a bone infection that develops from a wound) .Pressure ulcer: Unavoidable . (Authored by NP B). *It should be noted there was no order for the x-ray of sacrum/coccyx until 1/1/25. However, the X-ray order was never completed. In addition, the treatment Dankins was not ordered for R27 and thus the resident did not receive the treatment recommended by NP B starting on 12/28/24. 1/1/25: Nursing Progress Note: .resident wife and daughter came to check on their loved one .Wife stated that resident did not look right, and she would like to speak to doctor .PA (physician assistant) spoke with wife at length and agreed for resident to be sent to the Hospital . 1/1/25 (5:25 PM) Ambulance Service: .R27 .Incident Location: Facility .Destination: Hospital .Bed Confined (yes) .Last known well : 4 days ago .Primary Complaint: Sacral Wound . Hospital Records: 1/1/25 Emergency Department (ED): .ED notes Stage IV pressure injury to coccyx .malodorous .concerning for sepsis secondary to sacral osteomyelitis from a Stage IV decubitus ulcer .There is minimal history provided but it was reported the symptoms have been going on for 3-4 days .current medication information was not provided by the nursing facility at the time of transfer to the hospital .CT .Order Date (1/1/25) Reason for Exam: Sepsis, Sacral decubitus ulcer .Routine axial images .Impression: .Large sacral decubitus ulcer extending into the dorsal perineum to the anal verge .Focal examination of wounds: Sacrum to bilateral buttock- stage 4 pressure injury .Measurements 7.5 x 9.5x 3.6 cm .Base: Moist, tan necrotic tissue open would base with palpable bone, with open pink and tan necrotic tissue at wound edge. Full thickness tissue loss with depth to bone .Plan: Moisten Kerlix with Dankin's solution (ring out excess) and loosely pack into open wound on the sacrum q12 hours .Specialty Mattress- Striyker .Antibiotics per Infectious Disease .maintain vancomycin . 1/10/25: Admisison Note: Resident arrived at facility .Skin assessment done with large wound at sacrum area . 1/10/25: Practitioner Progress Note: late entry .R27 .sacral wound was sent to the hospital for worsening sacral wound concerning for infection .started on Dakins dressing changes daily and broad-spectrum ABX (antibiotics) .continue IV (intavenous) Vancomycin and Zosyn for 30 days . On 6/11/25 at approximately 9:55 AM, an interview and record review were conducted with Wound Nurse (WN) C. WN C reported that they had worked for the facility in the past, took a break from July 2024 and started again as the wound nurse in February 2025. They indicated that they are not yet wound certified but work along with NP B and Wound Physician N. WN C noted that prior to their employment as the wound nurse, Nurse A served as the facility wound nurse. WN C was queried as to R27's wounds. WN C noted that R27's wounds are currently healing and noted the resident is on Hospice and receives tube feeding. WN C was further asked if they were aware that R27 developed a facility acquired Stage IV pressure ulcer while at the facility. WN C again reported that they were not employed at the time the resident developed the pressure ulcer(s). While WN C was not able to specifically answer questions about R27's wound development they were able to confirm that orders, including treatments and radiology should be followed by staff. On 6/11/25 at approximately 12:01 PM, a phone interview was conducted with NP B. NP 'B reported that they started working at the facility in December 2024 and work generally on Thursdays. NP B reported that they do not work with all the facility residents, just those brought to their attention by nursing staff. NP B was specifically asked about R27, and they noted that the resident required total care, was a two person assist and recalled that he was admitted to the hospital for wounds in early 2025. NP B was asked if prior to seeing R27 on or about 12/5/24 where they aware that the resident's skin sweeps frequently noted they had excoriation to both the left and right buttock. NP B noted they could not recall as it was prior to their initial visit. However, NP B reported that residents with excoriated skin, are bedridden/chairbound and are incontinent must be turned and repositioned frequently. In addition, they require that the area at risk is cleaned, remains dry and barrier creams like triad paste should be applied as ordered. NP 'B was not aware R27's record indicated they received no treatment to their buttocks from 11/22/24-12/1/24. When asked if the recalled whether the resident had a low air loss mattress on or about 12/5/24, as an order could not be found, NP B reported they believed the resident did have one, but noted it was on the wrong setting and was too firm. During the continued interview with NP 'B they were asked as to their first visit (12/5/24) with R27 and what made them determine R27's bilateral buttocks as MASD as it was noted in their documents that there was superficial open areas and sanguineous drainage. NP 'B reported that they waivered between calling it a Stage II or MASD and went with MASD. NP B was asked about their note from 12/28/24 that indicated the resident's wound was noted as unstageable and whether they were aware that the required Dakins treatment was never ordered and never administered to R27's wound. NP B stated that they were not aware. When asked if they were aware that the recommendation for an X-ray to determine osteomyelitis dated 12/28/24 was never completed, NP B noted that it should have been completed. NP B was asked as to the current state of R27's wound and they reported it was showing signs of improvement. NP B was asked as to why they noted the wound was unavoidable as it was noted as improving. NP B reported that R27 in late December 2025 was showing quick deterioration of their skin that could have been prevented. On 6/11/25 at approximately 2:33 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked if they were familiar with R27 and their facility acquired wound to their left/right buttock. The DON noted they recalled the resident was having some weight loss and was not doing well. The DON reported that to their knowledge R27's wound was never considered open until they went to the Hospital with an unstageable diagnosis and returned with a Stage IV pressure ulcer. When asked if they were aware that R27 never received interventional treatment from 11/12/24 through 12/1/24, did not have an order for a low-air loss mattress, did not receive a timely x-ray pertaining to osteomyelitis and did not receive the treatment order for Dakins as noted 12/28/24, the DON reported they again could not recall and noted they would take a look at R27's electronic record. The DON did return following the interview but only provided a documented dated 1/2/25 that related to the Hospital records and provided no further information. The facility policy titled, Skin and Pressure Injury Risk Assessment and Prevention (Revised 2/24) was reviewed and documented, in part: Policy: It is our policy to perform a skin assessment and pressure injury risk assessment as part of our systematic approach to pressure injury and prevention .Residents determined at risk for developing pressure injuries will have interventions documented in plan of care based on specific factors identified in the risk assessment .Evidenced based interventions will be implemented for residents who are assessed at risk and/or who have a pressure injury present .interventions could include, but are not limited to: .Redistribute pressure .minimize exposure to moisture and keep skin dry .provide appropriate pressure-redistributing, support surfaces .Treatment decisions will be based on the characteristics of the wound, including the state, size, amount of exudate and presence of pain, infection or non-viable tissue .

This citation pertains to Intake Number(s): MI00138219. Based on observation, interview, and record review, the facility failed to thoroughly investigate multiple substantiated incidents of resident to resident sexual abuse involving five (R916, R907, R924, R923, and R903) of 15 residents reviewed for abuse, resulting in actual sexual abuse perpetrated by R916 that consisted of unwanted touching of R907, R923, R924, and R903's genitals. Findings include: Review of a Facility Reported Incident (FRI) submitted to the State Agency on 5/25/23 revealed a reported allegation that R916 groped the genitals of R907 while R907 was lying in bed. Review of the State Sex Offender Registry revealed R916 was an active sex offender who was Non-Compliant and Incarcerated as of 7/13/23. R907 On 7/19/23 at 11:23 AM, R907 was observed sitting on the side of the bed. R907 was pleasant and able to participate in an interview. When queried about any sexual incidents with other residents, R907 reported their previous roommate (R916) touched their genitals while R907 was lying in bed sleeping. R907 stated, He was demented and apparently that lowered his inhibitions. R907 reported the facility moved R916 to another room, but heard they touched other residents, male and female, in a sexual manner. Review of R907's clinical record revealed R907 was admitted into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic kidney disease, and bipolar disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R907 had intact cognition. Review of R907's progress notes revealed a late entry progress note written by the Director of Nursing (DON) on 5/26/23 that read, Resident reported that another resident touch near his private area while lying in bed with a brief on .Immediate intervention implemented: Accused resident removed from room . R916 Review of R916's clinical record revealed R916 was admitted into the facility on [DATE], readmitted on [DATE], and discharged to the hospital on 7/12/23 with diagnoses that included: type 2 diabetes mellitus (DM), COPD, and hypertension. A diagnoses of dementia was added on 6/22/23. Review of a MDS assessment dated [DATE] revealed R916 had moderately impaired cognition and no behaviors in the past 10 days of the assessment period (It should be noted that R916 touched R907's genitals on 5/24/23). The previous MDS assessment dated [DATE] revealed R916 had no behaviors. Review of R916's care plans revealed the following: A care plan initiated on 3/16/23 that noted, I will touch staff inappropriately .redirect me if I try to touch you inappropriately . This care plan was resolved on 7/6/23. A care plan initiated on 3/17/23 that noted, I have the potential to exhibit behaviors touching people inappropriately that appear sexual in nature related to dementia. All interventions were initiated on 7/6/23 and included: I will not share a room with another resident, If I am living in a different reality than yours, please join mine as I am unable to join yours, Please do not react emotionally to my behavior, Provide me with Psychiatric/Psychogeriatric consults as indicated, Redirect me if you see me about to touch someone inappropriately. Review of an investigation conducted by the facility as a result of R907's allegation of R916 touching their genitals revealed the following: Investigation Summary/Actions Taken: On 05/25/23, (R907) stated that (R916) groped his genitals. (R907) states that he was lying in bed in his brief alone when (R916) made contact with him via his hands .Like residents were interviewed and it was identified that one additional resident was touched by (R916) .(R916 has a BIMS/Brief Interview of Mental Status score of 10 indicating moderately impaired cognition) and requires frequent reminders of not touching other residents. Staff have been educated on keeping a visual eye on (R916) while awake .The incident has been substantiated as identified by an additional resident . A typed statement signed by the Administrator, dated 5/25/23, documented, (R907) approached Administrator and stated that (R916) touched his genitals while he was laying down. (R907) stated that he is doing fine. There were no additional statements from staff who worked that shift to determine if there were any other behaviors exhibited by R916 prior to the incident. A statement signed by the Administrator, dated 6/1/23, documented, While conducting like resident interviews, it was noted that (R924) stated that (R916) also touched her inappropriately. She stated that (R916) took her hand and placed it on her vagina while she was in the dining room. There was no indication that residents who were unable to be interviewed were assessed for potential abuse. R924 Review of R924's clinical record revealed R924 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: arthritis and COPD. Review of a MDS assessment dated [DATE] revealed R924 had intact cognition. Review of R924's progress notes revealed no documentation that they had been touched inappropriately as documented by the facility. Review of a FRI investigation conducted by the facility revealed the following: Investigative Summary/Actions Taken .On 6/1/23, DON(Director of Nursing) .informed Administrator .that (R924) stated that (R916) touched her .grabbed her own hand and placed it on her genitals .stated the incident happened on Monday 05/29/23 .The incident is substantiated as verified by a prior resident . A typed signed statement signed by the Administrator on 6/1/23 documented, DON .notified writer that (R924) was inappropriately touched by (R916). (R924) stated that (R916) placed his hand on top of her hand and placed it on her vagina .(R916) has a prior allegation of touching a resident (R907) . There were no additional statements from staff who worked that shift to determine how the incident may have happened and if there were any other behaviors exhibited by R916 prior to the incident. There was no indication that residents who were unable to be interviewed were assessed for potential abuse. R923 On 7/19/23 at 10:46 AM, an interview was conducted with R923 who was observed seated in a wheelchair inside of their room. When queried about any unwanted sexual contact that occurred, R923 reported a male resident touched my privates and explained it happened in the hallway. R923 reported they felt disgusting and reported it to the Administrator. R923 further reported that they heard the resident had touched other residents in a sexual manner. Review of R923's clinical record revealed R923 was admitted into the facility on [DATE] with diagnoses that included: hemiplegia, aphasia, and anemia. Review of a MDS assessment dated [DATE] revealed R923 had intact cognition. Review of R923's progress notes did not reveal any documentation that R923 had been touched inappropriately by another resident. Review of a FRI investigation conducted by the facility revealed the following: On 6/19/23, (R923) informed Administrator that she was inappropriately touched. She stated he did that and pointed at her vagina. Administrator inquired of who she was referring to and she pointed to (R916) .Reminded (R916) that he was not allowed to touch other people's genitals. He seemed to understand. (R916) allegedly touches other residents inappropriately despite the presence or supervision of another individual .Incident is substantiated as (R916) had a past history of touching other residents inappropriately . A typed statement signed by the Administrator on 6/19/23 documented, (R923) approached writer and said 'he did that' and pointed to her vagina. Writer asked resident who she was referring to and she pointed to (R916) . A hand written statement signed by another resident on 6/22/23 documented, I came out the room and seen (description of R916) pulling back his hand from (R923's) body. This happened on Tuesday after dinner in the middle hallway . A hand written statement signed by another resident on 6/22/23 documented, (R923) stated, 'he done it, he done it. I didn't know what she was talking about. I just say the after affect <sic>. I didn't see the actual act. This happened on Tuesday around 6 or 7 PM. There were no statements taken from staff members to determine how the incident may have happened. There was no indication that residents who were unable to be interviewed were assessed for potential abuse. R903 On 7/19/23 at approximately 10:30 AM, R903 was observed in the hallway, repeatedly standing up from the wheelchair. R903 said hello, but was unable to answer any further questions. On 7/20/23 at approximately 11:00 AM, R903 was observed seated in a wheelchair behind the nurses station. Review of R903's clinical record revealed R903 was admitted into the facility on [DATE] with early onset Alzheimer's Disease. Review of a MDS assessment dated [DATE] revealed R903 had severely impaired cognition. Review of a FRI reported to the State Agency on 7/12/23 revealed, Incident Summary: On 07/12/23, (Nurse 'E') notified Administrator .that she witnessed (R903) sitting on the lap of (R916). (R903's) pants were down to his ankle and (R916's) hand was in the brief of (R903) . On 7/19/23 at 11:30 AM, an interview was conducted with Social Worker 'B'. When queried about what was known about R916 prior to the sexual encounters with R907, R924, R923, and R903, Social Worker 'B' reported they were not aware of any previous sexual behaviors. On 7/19/23 at 12:15 PM, an interview was conducted with the Administrator. When queried about any investigation into R916's history of sexual behaviors and whether the facility was aware they were a registered sex offender, the Administrator stated, Well we know that now. The Administrator reported they did not look into R916's sexual history as part of the facility's investigations. When queried about whether knowing that information could have assisted with implementing effective interventions, the Administrator reported the facility believed their interventions were effective and working. On 7/20/23 at 9:27 AM, police reports regarding R916, R907, R924, and R923 were requested from the local police department. Officer 'D' provided the reports and wished to speak about the incidents. On 7/20/23 at 10:11 AM, a telephone interview was conducted with Officer 'D'. Officer 'D' explained that the police were contacted on 6/30/23 (37 days after the first incident of sexual abuse occurred between R916 and R907, 30 days after the DON was notified by R924 that R916 touched them inappropriately, and 11 days after R923 reported they were touched inappropriately by R916). Officer 'D' explained that all three incidents were reported at the same time as one report. Officer 'D' reported that on or around 7/7/23, the police department notified the facility's Administrator that they had contacted the county prosecutor and R916 would be arraigned the following week. At that time, Officer 'D' notified the Administrator that R916 was a registered sex offender/convicted felon and that until they were arraigned, the facility must keep a very close eye on R916. Five days later, the police department received a report of a fourth sexual abuse incident involving R916 and R903. (It should be noted that in the interview with the Administrator documented above, it was reported the facility was not aware of R916's sex offender status). The above information was not included in the facility's investigations. Review of the police reports provided by Officer 'D' revealed the following: A Case Report that documented, .Report Date/Time 06/30/2023 18:32 (6:32 PM) .Verified Offense .CSC (criminal sexual conduct) 4th Degree - Forcible Contact (unwanted sexual touching with another person) . The suspect was listed as R916 and the victims were listed as R907, R923, and R924. The following was documented, .I was dispatched to the above location (facility name) .for the report of a male resident touching other residents inappropriately. Upon arrival I spoke to the administrator .who stated a resident by the name of (R916) had multiple reports against him for unwanted touching. (The Administrator) had already taken statements from each of the victims and had them printed out of <sic> me. Each resident of the facility who had this issue with (R916) reported it to staff. All incidents occurred in the month of May/June . .Forwarded to the DB (Detective Bureau) for further . A follow up dated 7/3/23 was documented on the above mentioned police report by Officer 'D' that read, A (law enforcement information network) check of (R916) showed that he is a Lifetime Sex Offender Registry ([NAME]) member. (R916) also has a CCH (computerized criminal history) with two guilty convictions of CSC 1st with multiple variables (1st degree CSC is the highest level of CSC and involves sexual penetration with aggravating circumstances). (R916) CCH / [NAME] status is attached to this report. (R916) was discharged from parole on 12/26/1998 for the CSC convictions . .I also did a CLEMIS (Court and Law Enforcement Management Information System) check of (R916) which showed a recent contact with (police department from another city) September 2022, where a similar incident was both witnessed and reported at a nursing home (R916)previously resided at. The victim was non-verbal and due to that, the guardian did not wish to seek prosecution against (R916) . .Case sent to (County Prosecutor's Office) on 07/06/2023 for review and assigned (case number) . .FOLLOW-UP 07/10/2023: (County Prosecutor's Office) reviewed the case and issued a warrant for 3 counts of CSC 4th - 2 year high court misdemeanor. The warrant, subpoena, and complaint have been attached to this report . .FOLLOW-UP 07/11/2023: An arraignment has been set for 07/19/2023, with (medical transportation) (R916) from (facility to local police department) at 07:30 hours . .FOLLOW-UP 07/12/2023: Another incident similar in nature was reported on 07/12/2023 involving (R916) sexually touching another resident at (facility). (Facility) requested that he be transported to (local hospital)for psychiatric evaluation following the incident. Due to the threat he still presented to the residents, the arraignment was moved to 07/12/2023 . Review of a Case Report that documented, .Report Date/Time 07/12/2023 19:52 (7:52 PM) .Suspicious Circumstances .dispatched to the listed address (facility) for an employee reporting a patient touching another patient inappropriately . .INTERVIEW WITH EMPLOYEE (Nurse 'E'): (Nurse 'E') stated that when doing her medical rounds at approximately 1930 (7:30 PM) Hrs.(hours) an incident occurred between two patients in (room number). (Nurse 'E') witnessed (R903) sitting in (R916's) lap with his pants down to his knees. (Nurse 'E') witnessed that (R916's) right hand was reaching down into (R903's) diaper, where (R903's) genitals were located. At this time, (Nurse 'E') stated that she instructed (R916) to stop his actions. (Nurse 'E') stated that she then grabbed (R903's) hands and assisted him to his feet, taking him away from the situation. (Nurse 'E') stated that she asked (R916) what he was doing, and he said, 'Nothing.' (name redacted) advised me that (room number) is not being used at this time by any patients .(Nurse 'E') stated that both patients are not completely aware of their surroundings and continually will wander the halls of the facility . .After further investigation it was noted that (R916) is an uncompliant <sic> sex offender . .FOLLOW-UP 07/14/2023: (Administrator) had been advised of the warrant that was issued for (R916) on 07/07/2023 for 3 counts of CSC 4th degree, with an upcoming arraignment scheduled for 07/19/2023. (Administrator) had been advised to keep (R916) separated and supervised until he was arraigned. Due to the assaults ongoing, his arraignment was moved to 07/13/2023 . .(R916) was arraigned on 3 counts of CSC 4th degree on 07/13/2023 and lodged in (county jail), stemming from a warrant issued for similar incidents reports on 06/30/2023 . On 7/20/23 at 4:30 PM, an interview was conducted with the Administrator. When queried about the facility's investigations into the sexual abuse incidents perpetrated by R916 toward, R907, R924, and R923 and what they did to look into R916's history of sexual behaviors and why the facility did not evaluate cognitively impaired/non-interviewable residents to determine if further abuse happened, the Administrator reported they did not know about R916's history of being a sex offender and they only reviewed like-residents as part of the investigation because the residents who reported sexual abuse were interviewable. It should be noted that it was documented on the police report that the police department informed the Administrator of R916's status of being a sex offender and that they would be arraigned prior to the sexual abuse of R903 on 7/12/23. When queried about why the facility did not interview any staff members who worked during the shifts where the sexual abuse occurred, the Administrator reported because R907, R924, and R923 all reported the abuse directly and they would only interview staff it was unknown or without a witness. When queried about how the facility determined appropriate interventions for R916 if they did not evaluate what was going on with the resident prior to the sexual abuse incidents, the Administrator did not offer a response. Review of a facility policy titled, Abuse, Neglect and Exploitation, revised 4/2023, revealed, in part, the following: .Investigation .Investigations may include but not limited to: .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Providing complete and thorough documentation of the investigation .

This citation pertains to intake #MI00131483, MI00131513, MI00132356, MI00136470, MI00134873, MI00136407. Based on observation, interview and record review, the facility failed to protect R704's right to be free from physical and verbal abuse. This deficient practice resulted in an Immediate Jeopardy to the health and safety of R704 when staff members witnessed a Certified Nursing Assistant (CNA) abusing R704 physically and verbally (which included slapping R704's rear end, pressing hand on R704's neck and squeezing while threatening, punching R704's hand, placing their foot on R704's hand and bending the residents right thumb while repeatedly saying stop f****** playing with me; while attempting to get R704 off the ground into a sling the CNA began punching R704's hand twice, then placed their foot on R704's hand and bending R704's right thumb while repeating keep f****** playing with me). The physical and verbal abuse resulted in serious harm and/or injury to the resident using the reasonable person concept for a resident with impaired cognition. Additionally, the facility failed to ensure that resident to resident physical abuse did not occur for four (R's 730, 731, 713 and 723) of 14 residents reviewed for abuse. Findings include: Immediate Jeopardy (IJ): The IJ began on 9/12/22. The IJ was identified on 6/7/23. The Administrator was notified of the IJ on 6/7/23 at 4:07 PM and a plan to remove the immediacy was requested. The immediacy was removed on 6/7/23 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 potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. Review of a facility policy titled, Abuse, Neglect and Exploitation dated 4/2023 documented: .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .Verbal Abuse means the use or oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents .regardless of their age, ability to comprehend, or disability .Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment .Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . Review of a Facility Reported Incident (FRI) submitted to the State Agency revealed on 9/12/22 at 4:30 PM, .(Name of Nurse 'AA') informed (Name of Administrator) of an alleged event that includes CNA 'A' and (Name of R704). Per Nurse 'AA': CNA 'B' informed her that while assisting R704 from a floor mat, the resident was holding really tight to the floor mat. CNA 'A' placed her foot on the hand of R704 in order for the resident to release his hand. CNA 'B' further stated (per Nurse 'AA') that CNA 'A' pulled back the fingers of R704 due to him holding on tightly to release his grasp . Review of a complaint submitted to the State Agency by local Law Enforcement (Officer 'BB') included, .On 9/12/2022, (R704) had fallen to the floor. An employee of (Facility Name), CNA 'A', placed her right hand on R704's neck, squeezed, pressed his face to the floor mattress, punched R704 twice in the hand (to make him let go of an object), and she bent his thumb backwards . Review of a police report documented: .Report of: Vulnerable Adult Abuse .FOLLOW UP ON 9/29/2022 I followed up with (Name of Administrator) .who stated that she was conducting her own investigation into the matter to send to the State of Michigan. Additionally, I spoke to (R704), who stated the alleged events documented in this report, did in fact happen. I asked if (CNA 'A') had pressed his face into the mat and he shook his head yes; I asked if she had punched his hand, and he shook his head yes; I asked if she had pulled his thumb back and he shook his head yes .I asked (Name of Administrator) if there was an issue between (CNA 'A', CNA 'B' and CNA 'E') and she stated that (CNA 'A') said the other two were upset with her because she reported them for not doing their work. When I asked (CNA 'B') if this could be the case, she stated that would be impossible because they hadn't worked together previously. (Name of Administrator) stated that there is no record or (CNA 'E' and CNA 'B') making such a complaint. FOLLOW UP ON 10/4/2022 I spoke to (CNA 'A'), who stated that she wanted to talk to me regarding the issue .stated she would come in to talk with me at 12:00 pm. She did not show up or answer my phone calls afterward. I spoke to (CNA 'E') who stated she would take a poly if asked to. She stated everything she said in her statement is correct and she would not mind assisting in the investigation. (CNA 'B') stated she would come to the station to complete a witness statement (hers was deleted by [Facility Name] staff). FOLLOW UP ON 10/5/2022 I spoke to (CNA 'A') who stated she would be at the station at five to give her statement on today's date, however she never showed up again for the meeting. (CNA 'B') came into the station to make a statement. She stated the same details that (CNA 'E') said. She stated that (R704) is now afraid of (CNA 'A') and would not talk to staff and would only talk to staff after dark because he knows that (CNA 'A') does not work at night. She said (R704) is verbal and probably did not want to speak because he was afraid that he would be hurt again. SUMMARY On 9/19/2022 [local police department] PD was notified of an assault that had taken place at [Facility Name] nursing home .Upon arrival, officers spoke to the facility manager (Name of Administrator) who stated an employee, (CNA 'A') had been accused of assaulting a patient named (R704) on 9/12/2022. Witnesses to the incident (CNA 'E' and CNA 'B') stated they were walking by (R704's) room .when they observed him on the ground face down on a mat next to his bed. They stated that they went to get (CNA 'A') to assist him off the ground. When (CNA 'A') arrived to (R704's) room, it was observed that (R704) had a bowel movement while on the floor. (CNA 'A') proceeded to change (R704's) clothes, but left him without new clothes on, leaving him exposed on the ground. While exposed, (CNA 'A') continuously slapped (R704) on the rear end. (CNA 'B', CNA 'E' and CNA 'A') attempted to lift (R704) off the ground but were not able to because (R704) was too heavy. They went to get more help to try and lift (R704) off the ground and as they came back into the room, they observed (CNA 'A') placing her right hand on (R704's) neck pressing down and squeezing his neck while saying stop f****** playing with me. A lift assist tool (sling) was brought in to help get (R704) off the ground at this time. While attempting to get (R704) off the ground and into the sling, he began grabbing the sling strap and not letting go. (CNA 'B' and CNA 'E') state that (CNA 'A') began punching (R704's) hand attempting to get him to let go of the sling. They state (CNA 'A') punched his hand twice. (CNA 'A') then placed her left foot on (R704's) right wrist and pulled the sling from his hand. Once they rolled (R704) over (CNA 'A') had (R704's) right thumb in her hand and she was bending it back, while she kept repeating keep f****** playing with me. (R704) asked (CNA 'A') if she was going to break his finger and (CNA 'A') stated yes. Both (CNA 'E' and CNA 'B') stated that (R704) is afraid to talk to staff in fear of being hurt again by someone, and that could be the reason he did not speak to me and only used head and hand signs during the conversation. They stated that they believed (R704) denied any abuse allegations because he was fearful for retribution. (CNA 'A') was asked several times to come in for an interview and she stated yes she would like to come and talk to me however every time I would set an interview time, she would not show up for the appointment . FOLLOW UP ON 11/9/2022 Warrant was received . Included with this police report were handwritten statements from CNA 'B' and CNA 'E' and a warrant for CNA 'A' dated 10/6/22 which read, .being a person who directly cares for or has physical custody of a vulnerable adult, did intentionally cause physical harm to (R704), a vulnerable adult .VULNERABLE ADULT ABUSE - THIRD DEGREE . The statement from CNA 'E' dated 9/13/22 read, On Sept. 12, 2022 towards the end of the shift (CNA 'B') and I we're <sic> doing rounds. I was heading to a room with (CNA 'B') when the housekeeper seen that room (R704's room) was on the floor on his mattress face down. She told (CNA 'B') and I , I went into the room and (CNA 'B') called out for (CNA 'A'), because she was his CNA. We all prepared to get him off the floor, but I noticed his sheet was soild <sic> she (CNA 'A') cleaned him up. (CNA 'B', CNA 'A' and myself) tried to pick him up, but he was too heavy. I don't remember which one went out to get more help, but before going to get help (CNA 'A') placed her right hand on (R704's) neck and pressed as she squoze <sic> his neck and face down in the materss <sic>, as she was this she saying to him stop f****** playing with me (CNA 'D') came into the room after one of them wen <sic> to get help, (CNA 'A') was the help. (CNA 'A') left out the room to get the hoyer sling, because all four of us tried to get him up, and he still was too heavy. (R704) was grabbing the matterss <sic> and (CNA 'A') was punching his hand, she punched his hand twic <sic> and was his right hand. Once we started to put the sling in place (R704) grabbed it and wouldn't let go (CNA 'A') placed her left foot on (R704's) right wrist and pulled very hard the sling from out of his hand. Once we rolled him over (CNA 'A') had (R704) right thumb in her hand and she was bending it back, (CNA 'A') kept repeating Keep f****** playing with me, (R704) asked are you going to break my finger, and (CNA 'A') said yes. We finally got him safe into the bed using the hoyer. He gave me a thumbs up and thanked me for helping him. Also when waiting on (CNA 'D') to bring the hoyer lift and sling (CNA 'A') was smacking (R704) on the behing <sic> repeatedly. (R704) kept covering himself with the cover. The statement from CNA 'B' dated 10/5/22 read, .I was working it was almost the end of shift me and (CNA 'E') was walking down the hall and I seen (R704) on the floor I called (CNA 'A') because he was her resident me and (CNA 'E') told (CNA 'A') we will help you put him back in bed. When we go in the room (R704) had his cover I asked him to let it go and he did. (CNA 'A') put her hand on the back of (R704) neck and pushed his face in mattress and told him to stop f****** playing with her. She left out the room and came back (CNA 'D') came back in with (CNA 'A'). (CNA 'A') took her foot and stomp (R704) hand then took her hand and punched his hand. As we got (R704) turned over on his back to get him up (CNA 'A') bent his finger back and (R704) asked (CNA 'A') are you breaking my finger and she said yes. Me and (CNA 'E') went and told the unit manager. Then I told the DON and wrote a stament <sic> as well. An unannounced, onsite investigation was conducted from 6/6/23 through 6/9/23. On 6/7/23 at approximately 1:25 PM, R704 was observed laying in bed leaning to the right side of the bed with part of their right torso over the edge of the bed. When queried if they were comfortable, R704 stated they were and they preferred to be positioned like that. When asked if they could recall an incident with staff being rough during care, swearing, or making threats, R704 reported oh you mean with (Name of CNA 'A'). R704 reported that incident was probably reported by Nurse 'C' and CNA 'E'. R704 started to report staff went to change their adult brief, became visibly upset and did not want to continue the interview or review any further details. When asked if there had been any further issues since the alleged incident with CNA 'A', R704 shook their head no. Review of the clinical record revealed R704 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: encephalopathy, acute kidney failure, psychotic disorder with delusions, other seizures, dysphagia, contracture of muscle left hand, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic pulmonary edema, major depressive disorder single episode mild, and delirium. According to the Minimum Data Set (MDS) assessment dated [DATE], R704 had no communication concerns, had moderately impaired cognition (scored 11/15 on brief interview for mental status exam), required extensive assistance with two or more people with bed mobility, transfers, dressing, and toilet use; was occasionally incontinent of bladder, and was always incontinent of bowel. Review of the progress notes included: An entry on 9/12/22 at 9:37 PM read, Cena reported to administrator of an alleged fall/abuse event. Writer assessed resident and found no injuries. Writer noted a small old bruise on the base of the index finger of the left hand . An entry on 9/12/22 at 9:35 PM, by Physician 'W' read, .Patient was seen by video conferencing-with help of the nurse on duty .small abrasions noted on left hand - associated tenderness / partially contracted at baseline .Assessment and plan Lt (Left) hand injury/Fall/gait disturbance-fall .X-ray of the left hand to rule out any occult fracture . An entry on 9/18/22 at 12:57 AM, X-Ray Result: Hand 2 views, Left Scapholunate ligament disruption (when the scaphoid and lunate bones in your wrist move apart). No acute fracture identified . An entry on 9/18/22 at 12:52 AM from Physician 'W' read, .Left hand x-ray/changes in the scapholunate ligament noted likely chronic .Assessment and plan Scapholunate subluxation - radiologically but clinically without any problems/patient does not use the left arm/hand due to paralysis . It should be noted that the statements from staff identified concerns regarding R704's right hand, but there was no evaluation of the right hand, only the left. Attempts to contact CNA 'A', CNA 'D', and CNA 'E' were unsuccessful by the end of the survey. On 6/7/23 at 1:01 PM, a phone interview was conducted with Nurse 'C' who reported they no longer worked at the facility since 4/27/23. When asked what they could recall regarding the alleged incident with R704 and CNA 'A', they reported it was reported to them by one of the CNAs that had been providing care to R704. Nurse 'C' reported they had reported it to the Administrator. They reported at that time, they were kinda in charge since there were many DON (Director of Nursing) changes, so they were kind of like the Unit Manager, DON, and Wound Manager. They reported the CNA 'A' had been suspended immediately and had not been allowed to return to work following that day. On 6/7/23 at 1:30 PM, an interview was conducted with the Administrator and Regional Director of Operations (Staff 'F'). When asked about the FRI with allegations of physical abuse, the Administrator reported the facility had not substantiated R704's allegation since the resident denied it initially. When asked what they had done when they received additional information in the police report (noted as Created on 12/14/2022 12:14 PM per the documentation included in the facility's investigation file under Police Report in which documentation identified law enforcement's interviews with staff and R704 had substantiated and matched R704's initial allegations, the Administrator did not offer any further explanation other than they had kept in contact with police, but were not aware of anything further yet. When asked if the facility had reported CNA 'A's certification to the appropriate licensing department, the Administrator reported they had included that with the initial FRI which they had unsubstantiated. When asked once they received the police report with substantiated allegations, was anything else done, such as notifying appropriate licensing department, they reported nothing further had been done. The Administrator further reported they kept in contact with police, but was not aware of any other details. It was reported that the facility believed the warrant was issued due to CNA 'A' not cooperating with law enforcement. On 6/8/23 at 12:10 PM, a phone interview was conducted with the Director of Public Safety (Chief 'I'). Chief 'I' provided additional investigation details which included a warrant issued for CNA 'A' for vulnerable adult abuse. Chief 'I' reported CNA 'A' had not been arrested as of this time and continued to evade interaction with law enforcement. When asked to clarify if the warrant issued was due to CNA 'A's lack of cooperation with law enforcement, Chief 'I' reported it was not, it was for suspected criminal act and was the reason for issuance of a criminal bench warrant. Removal Plan for IJ for Abuse: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 09/16/22) On 9/12/22, a nursing assessment, including a skin assessment was completed on R704 - no identified deviations from the baseline. On 9/12/22 the facility Medical Director performed a video conference with R704. Neurochecks and an x ray of the left hand was ordered. X-ray results returned on 09/17 and did not reveal any fractures related to abuse per MD (Medical Doctor). On 9/16/22 neurochecks were completed - no identified abnormalities. The guardian was notified of the event. On 09/16/22, the police was notified of the incident.by the NHA. On 09/12/22, the identified CNA was suspended pending investigation. The identified CNA has not had access to the resident since 09/13/22 and was terminated on 09/16/22. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 06/07/23) On 06/07/23, the Regional Director of Operations reviewed the Abuse, Neglect and Exploitation policy and deemed it appropriate. On 06/07/23, the NHA was re-educated on reporting abuse allegations and the subsequent follow-up of all like residents. The NHA (nursing home administrator) was educated previously on 11/16/22. On 06/07/23, the NHA was educated on reporting staff licensures to the license agency for substantiated abuse accusations. On 06/07/23, The NHA reported the CNA certification to the licensing agency for the substantiated abuse allegation. On 06/07/23, like residents were interviewed for abuse. All facility reported incidents will be brought to QAPI (Quality Assurance Process Improvement) for review. The facility asserts the likelihood of immediate harm has been mitigated since 06/07/23. 41415 Review of a Facility Reported Incident (FRI) reported to the State Agency (SA) documented in part, . Incident Summary on 02/09 . (R723 name) made contact with Resident (R713 name) via her right hand to the right side of Resident (R713 name) face . (R723 name) was attempting to turn off Resident (R713 name) overhead light however (R713 name) told (R723 name) no. (R723 name) then proceeded to make contact with Resident (R713 name) via her right hand . On 6/8/23 at 11:27 AM, a telephone interview was conducted with R713 (who no longer resided in the facility). When asked about the incident that involved R723, R713 replied in part . it was daytime, and I was reading my stuff and she (R723) was turning off my light. I was shaking my head no and said you don't have to. She opened up her hand and slapped me. The person came in to help me and I told him (name of staff), and he asked the resident (R723) and she said yes she did slap me . Review of the medical record revealed R713 was admitted to the facility on [DATE], with diagnoses that included: multiple sclerosis, contracture of left and right hands, and quadriplegia. Review of the census revealed R713 was moved into the room with R723 on 1/31/23 only a few days before the alleged incident on 2/9/23. Review of the medical record revealed R723 was admitted to the facility on [DATE] with diagnoses that included: developmental disorder of speech and language, deaf nonspeaking and difficulty walking. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 9 (indicating moderately impaired cognition). On 6/9/23 at 10:38 AM, R723 was observed sitting in their wheelchair tending to their plant on their windowsill. Communication was conducting via pen and paper. When asked, R723 admitted to slapping R713. When asked why, R723 pointed to the light above their roommate's bed. R723 denied having any other incidents or concerns with any residents in the facility. Review of a facility policy titled Abuse, Neglect and Exploitation reviewed/revised 4/23, documented in part . It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . Abuse means the willful infliction of . intimidation, or punishment with resulting physical harm, pain, or mental anguish . 34275 R730 and R731 A FRI was reported to the SA on 5/1/23. The facility indicated that on 2/11/22, R730 struck R731 on the head. A review of the facility Incident/Accident report documented, in part: .Date of Alleged Event: 2/11/23 .Facility incident report received via online submission on: 5/1/23 .Incident Summary in review of R730's record, it was noted R730 made contact with R731 via his hand on 2/11/23. Administrator interviewed Nurse N. Nurse N stated that she was informed by Certified Nursing Assistant (CNA) P that R730 made contact with R731 on 2/11/23 .CNA P informed the Administrator that the event occurred and she immediately reported it to Nurse N .Administrator interviewed Nurse N who stated she was informed by CNA P of the event . A review of R730's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: psychotic disorder, anxiety disorder and Alzheimer's Disease. Review of the residents MDS indicated the resident was severely cognitively impaired. Continued review of the resident's clinical record documented, in part: 2/10/23 -Psychiatric Service Progress Note: New admission .is noted to have profound confusion .throwing self out of chair unsafely . 2/10/23 - Behavior Notes (11:03 PM): Please describe the behavior that was observed .Agitation, restlessness, constantly getting up to work with instability .Prior History of Aggression or Violence? YES . 2/11/23 - Nursing Progress Note (7:49 PM): Mistaken Entry .Resident very violent. Hitting R731 in the head three times. Trying to get out of chair and swinging at RCS's refusing to take his medication and swinging at nurse.(Authored by NurseN) *This progress note was struck out. There were no further notes regarding the incident. R731 A review of R731's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: cerebrovascular disease, osteoarthritis and Alzheimer's Disease. Review of R731's MDS noted the resident was severely cognitively impaired. A review of R731's clinical record revealed no documentation that indicated R730 struck the resident. There was no assessment completed on 2/11/23 to determine R731's medical status. On 6/8/23 at approximately 11:45 AM, R730 was observed sitting near the Nurse's station. The resident was alert, but not able to answer most questions asked. R731 was also sitting near the Nurse's station. R731 was not able to answer most questions asked. Nurse N was then asked as to whether they were aware of any incident involving R730 and R731. Nurse N stated they had no recollection of the incident. On 6/8/23 at approximately 1:42 PM, an interview was conducted with CNA P. CNA P was queried as to the incident involving R730 and R731 on or about 2/11/23 or 2/12/23. They reported that R731 was sitting in the hallway near the nurse's station eating dinner and R730 was walking nearby and struck R731 in the head. CNA P reported that R731 was pretty shook up after the incident. When asked if they were familiar with R730, CNA P reported that the resident was fairly new to the facility but showed signs of anxiety, irritation and was not easily directed. On 6/8/23 at approximately 1:43 PM, an interview and record review were conducted with the Administrator/Abuse Coordinator. When queried as to the reporting of the incident that occurred between R730 and R731, the Administrator reported that the incident did occur on 2/11/23. They noted that they were doing audits of the resident's charts and discovered that the incident occurred. When asked if any assessments were completed for R731, they reported not on that date.

This citation has three deficient practice statements. Deficient Practice #1 This citation pertains to intake #s: MI00132356, MI00132528 and MI00133994. Based on observation, interview and record review, the facility failed to provide adequate supervision, effective monitoring and effective search procedures to prevent the elopement of two residents (R707 and R720) of six residents reviewed for elopement, resulting in an Immediate Jeopardy when R707 (who was identified just prior to admission as having exited out of a window from a previous facility and identified as an elopement risk with severe cognitive impairment) exited the building from a window in their room, left the premises and was picked up by local law enforcement, and R720 (who was identified as having moderately impaired cognition and had a legal guardian) exited through a door to the patio area that had been alarming but was shut off by an unknown person, left the premises and was notified by a concerned [NAME] that (R720) they were at the local market on the corner of a highly trafficked six lane road. These deficient practices placed all residents at high risk for further undetected elopements, significant harm, injury and/or death. Findings include: Immediate Jeopardy (IJ): The IJ began on 10/30/22. The IJ was identified on 6/7/23. The Administrator was notified of the IJ on 6/7/23 at 11:10 AM and a plan to remove the immediacy was requested. The immediacy was removed on 6/8/23 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 potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. R707: Review of an allegation reported to the state agency on 11/3/22 documented, .Last week a new female admission, Room (occupied by R707), got out the window in her room, which didn't have a screen on it. Complainant doesn't know what happened to the resident. There is no protocol for when a resident gets out of the facility . Review of a Facility Reported Incident (FRI) on 10/30/22 reported the resident (R707) eloped from the facility. Documentation of the facility's Investigation Summary/Actions Taken included: .On 10/30/22, at approximately 7am, Administrator .was informed by Nurse 'CC' that new resident (R707) could not be located at approximately 600am. (R707 was admitted to the facility at approximately 9pm on 10/29). Nurse 'CC' stated he was in communication with R707 at approximately 430am at the nurse's station. At approximately 5am, R707 received ADL (Activities of Daily Living) care from CNA (Certified Nursing Assistant 'DD'). At approximately 6am, Nurse 'CC' stated he went into the resident's room to change the wound dressings and the resident could not be located. Nurse 'CC' noted that the window was open. The emergency elopement code search was initiated to locate R707. Staff searched the surrounding areas, inside and outside the facility, and the resident could not be immediately found. Police and family were notified. The administrator called the daughter at approximately 745am to gather more information about a potential location, a recent photo, etc. However, during the call, the daughter informed the administrator that they received a call from the [local police] that her mother was located and was in police custody. The daughter was in route to pick up the resident. At this time, the daughter also informed the Administrator that her mother has a history of jumping out of windows. The Administrator called the [local police] department and spoke with a dispatcher. The dispatcher stated, I have (R707) right in front of me. Staff were updated that (R707) Was located . The Maintenance Director assessed the window in R707's room. Per his assessment, the Maintenance Director stated that the window's stop lock presented as if someone hit it with force multiple times, forcing it back, causing damage, which loosened the stop lock causing the window to open an additional (approximately) 3 inches. A head count was performed during the emergency elopement code search. All other residents were accounted for. All windows in the resident rooms were assessed by the Maintenance Director to ensure an opening of no larger than 6 inches. All windows were confirmed with an opening of no larger than 6 inches. Two window stop locks were replaced, as they were noted with normal wear and tear. room [ROOM NUMBER], where R707 resided was repaired, ensuring a window opening of no greater than 6 inches. Updated elopement assessments for current residents were updated. Three residents were identified for elopement risk, in which care plans with interventions were reviewed and updated as deemed appropriate. Elopement binders were updated at each nurses station with resident photos and information. Staff were re-educated on the Elopement and Wandering policy. The Admissions Director was educated on identifying elopement risk residents via pre-screening and referral documents . Review of the hospital documentation provided to the facility prior to admission included: .The patient is a [AGE] year old Female .questionable dementia who presented to the ED (Emergency Department) <sic> after being petitioned by her daughter. Patient states that she is in the hospital for high blood pressure and leg pain which she sustained trying to chase after her dog. Patient states that she lives at home with her daughter .however IM (Internal Medicine) H+P (History & Physical), the patient lives in AFC (Adult Foster Care) nursing home and was found trying to jump out of a window which ishow <sic> she fell and injured her legs .Date of Service: 10/23/2022 .ER (emergency room ) consult re: (regarding) petition .pt (patient) with no psych history is petitioned by caregiver who says <sic> pt needs a med adjustment, he also says she has severe dementia, is constantly yelling, jumping from windows, escapingand <sic> fleeing the facility . Review of the clinical record revealed R707 was admitted into the facility on [DATE] and discharged on [DATE] with diagnoses that included: end stage renal disease, dependence on renal dialysis, and dementia in other diseases classified elsewhere, severe, with other behavioral disturbance. According to the discharge return not anticipated Minimum Data Set (MDS) assessment dated [DATE], the staff assessment for mental status was noted as short-term memory was ok with independent cognitive skills for daily decision making (which conflicted with hospital documentation) and had wandering behavior which occurred 1 to 3 days. Bed mobility/transfers, personal hygiene were not assessed, walking in room and corridor, dressing, eating, toilet use and bathing were noted as Activity did not occur. R720: Review of a FRI on 1/9/23 reported the resident (R720) eloped from the facility. Documentation of the facility's Investigation Summary/Actions Taken included: On 1/8/23 at approximately 445pm, Nurse 'L', notified Administrator .that (R720) left the facility without supervision or notice to staff. (R720) was last seen in the facility around 420pm and was located at approximately 435pm. Nurse 'M' stated a lady arrived to the facility and notified her that a man with missing legs was next door at the market inquiring on how to get to [name of local hospital]. Nurse 'M' immediately walked next door and brought Resident back to the inside of the facility. (R720) was properly dressed for the weather with a winter coat and clothing. Nurse 'M' inquired with (R720) of his reasoning for leaving the facility without notification. (R720) stated that he is ready to discharge. The physician, Guardian, and DON (Director of Nursing) were also notified. The [NAME] Hills Police arrived to ensure the resident arrived inside the facility safely. (R720)'s prior elopement risk assessment was on 10/30/22 and was not identified as an elopement risk. Upon return to the facility, Nurse 'M' did not note any injuries. Nurse 'D' stated that she heard the alarm on the rear door of the facility, however, it was quickly silenced. The doors were verified as working properly with alarms intact. Interview with staff members working in the facility at the time of the incident did not reveal any person(s) that shut the alarm off when it sounded. Staff members are being educated on the elopement policy and the importance of checking outside of the facility when an alarm sounds to ensure a resident has not left the facility unsupervised . On 01/09/23 Administrator .interviewed (R720) about the incident. (R720) was found in a jovial mood with smiles and laughter. He stated that he just wanted some fresh air. (R720) has 4 supervised visits per day, is currently on 30 minute checks, has resumed his normal daily activities and continues to be followed by psych and social services. A head count was provided to ensure all other residents were present inside the facility. Investigation Summary/Actions Taken: .On 1/8/23 at approximately 445pm, Nurse 'L', notified Administrator .that (R720) left the facility without supervision or notice to staff. (R720) was last seen in the facility around 420pm and was located at approximately 435pm. Nurse 'M' stated a lady arrived to the facility and notified her that a man with missing legs was next door at the market inquiring on how to get to [name of local hospital]. Nurse 'M' immediately walked next door and brought Resident back to the inside of the facility. (R720) was properly dressed for the weather with a winter coat and clothing. Nurse 'M' inquired with (R720) of his reasoning for leaving the facility without notification. (R720) stated that he is ready to discharge. The physician, Guardian, and DON (Director of Nursing) were also notified. The [Local Police] arrived to ensure the resident arrived inside the facility safely. (R720)'s prior elopement risk assessment was on 10/30/22 and was not identified as an elopement risk. Nurse 'M' stated that she heard the alarm on the rear door of the facility, however, it was quickly silenced. The doors were verified as working properly with alarms intact. Interview with staff members working in the facility at the time of the incident did not reveal any person(s) that shut the alarm off when it sounded. Staff levels were reviewed and determined to be sufficient. Staff members were educated on the elopement policy and the importance of checking the perimeters or an alarming door before silencing the alarm to ensure a resident has not left the facility unsupervised. An elopement drill has also been conducted since the incident and staff have been instructed on the tasks to be fulfilled in the event of an actual elopement. (R720) has been closely followed by Social Services and psych services since the incident. Social Services has been in contact with [guardian of resident] to start the process of securing safe housing outside of the facility. On 01/09/23 Administrator .interviewed (R720) about the incident. (R720) was found in a jovial mood with smiles and laughter. He stated that he just wanted some fresh air. (R720) has 4 supervised visits per day, has remained on increased supervision and has resumed his normal daily activities and will continue to be followed by psych and social services. A head count was initiated to ensure all other residents were present inside the facility. Doors and alarms have been verified to be in working order. Codes to the doors has also been changed and updated. The elopement event has been substantiated; however (R720) has not sustained any major injuries. Securing safe housing for the resident remains a top priority. (R720) has multiple supervised cigarette breaks per day, has increased supervision and continues to be followed by social services and psych services . Review of the clinical record revealed R720 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: type 2 diabetes mellitus with unspecified complications, long term use of insulin, acquired absence of left leg and right leg above knee, essential hypertension, benign prostatic hyperplasia with lower urinary tract symptoms, adjustment disorder, schizoaffective disorder, depressive type, and COVID-19. According to the MDS assessment dated [DATE], R720 had clear speech, had moderately impaired cognition (scored 12/15 on the brief interview for mental status exam; also had a legal guardian), had no behavioral concerns, required extensive assistance of one person physical assist for transfers, bed mobility, dressing, locomotion on/off unit required only supervision with setup help only, and used a wheelchair for mobility. Review of the care plans included: I have potential to demonstrate behaviors verbally 2/2 (secondary to) adjustment disorder, schizophrenia I will often yell out stating I want to get out of here, or at times I will call the police to get out. I will threaten to elope. I will engage in elopement behavior. This care plan had been initiated on 9/30/22, last revised on 1/9/23. Interventions included: Document my observed behavior and attempted interventions on my POC (Plan of Care). This had been initiated on 9/30/22. Review of the progress notes included: A late entry on 1/8/23 at 5:29 PM from Nurse 'L' read, writer noticed cigarette odor coming from residents room. Writer entered room with cena and addressed resident and removed a half smoked cigarette from his room. Writer then went to the west hall to speak with nurse. At that time we were informed by a bystander who believed one of our residents was outside in the adjourning parking lot. When myself and another nurse went outside, we saw R720 approaching southfield road. We were able to retrieve him an bring him into the building with no further incident . An entry on 1/8/23 at 5:29 PM from Physician 'W' read, Patient was seen by video conferencing .Eloped and ended up in a nearby store? Got out of the door an went in the wheelchair - thinks that he is his own guardian and makes own decision and can go wherever he wants (NOTE: patient has a COURT APPOINTED guardianship .also has been smoking in his room as not allowed to go out due to the low temperatures . An entry on 1/12/23 at 12:34 PM from psych read, .Continues to be easily agitated and angered. When asked how he was doing he replied I want to he there <sic> f-k out of here and go to a shelter. Unable or unwilling to discuss any realistic plans . An entry on 2/6/23 at 10:26 PM from Physician 'EE' read, .He eloped earlier today and as <sic> found in nearby store and brought back to the facility. He has a court-appointed guardian and can not make his own decisions. He states that he wants to go live somewhere else. D/w (Discussed with) pt (patient) that he could do so once he discusses this w/ (with) his guardian and they agree to his request. D/w SW (Social Work) to reach out to his guardian to this regard .Very high risk of elopement . (Per facility, although this note identified R720 eloped earlier today on 2/6/23, there was not another elopement, but is reflective of the elopement from 1/8/23.) An entry on 3/27/23 at 3:38 PM from SW 'T' read, Ombudsman called regarding resident wanting to discharge to less restrictive setting. SW informed her that resident has a guardian, and they are aware of his wishes . On 6/6/23 at 1:27 PM, an interview was conducted with CNA 'K' who reported they had been working at the facility since March 2023. When asked if they were aware of any residents on 1 East that were identified as being at risk for elopement, CNA 'K' reported they were not. When asked specifically about R720, CNA 'K' reported no and that R720 was able to independently wheel his wheelchair and went on smoke breaks. On 6/6/23 at 1:50 PM, an interview was conducted with the Maintenance Director (Staff 'O') who reported they had worked at the facility for about a year. When asked about whether the facility utilized a wanderguard alarm system for residents that eloped, they reported they did not. Staff 'O' further reported all of the doors were locked and could be released within 15 seconds or if staff let you out. When asked if a door alarm could be turned off on the outside of the exit door, they reported No. They were requested to provide all elopement drills that had been completed since 10/30/22. Staff 'O' was asked to observe multiple resident rooms, including the room that had been occupied by R707 and currently occupied by R720. Both rooms were located all the way at the end of the hallway on 1 East. Further observation of R720's room revealed there was no screen in the window and the window was opened several inches. Staff 'O' reported they had not been aware of the missing window screen and would replace. When asked who was responsible to monitor the windows as that was identified as an issue when R707 eloped on 10/30/22, Staff 'O' reported staff should've notified them it was missing but had not. When asked if that was something that would've been picked up on room rounds, or if that was part of an environmental audit, Staff 'O' offered no further response. When asked if there were any cameras utilized by the facility, Staff 'O' reported no. On 6/6/23 at 2:10 PM, an interview was conducted with CNA 'P' who reported they had worked at the facility for about eight months. When asked if they were aware of anyone who was an elopement risk on the 1 east wing, CNA 'P' reported they were not and that only the people that could walk would be at risk. CNA 'P' reported the people over here were mostly confused. When asked what they knew about R720, they reported he was alert and having a battle now with pop. On 6/6/23 at 2:15 PM, R720 was observed seated in a wheelchair watching television in the hallway on 1 east. CNA 'P' was observed talking to the resident about not drinking soda pop. R720 was observed to get agitated and began to yell. Further review of the documentation provided by the facility regarding R720's elopement on 1/8/23 revealed several concerns which included: The elopement assessment completed on 1/8/23, 2/5/23 and 5/7/23 revealed conflicting documentation and assessment of R720's risk factors such as diagnoses, other medical conditions, assessment of mobility, and whether the resident made statements regarding desire to leave/wish to go home. Although the assessment on 5/7/23 indicated R720 was not considered an elopement risk, had the assessment been completed as previous assessments with correct indicators, R720 would've been identified as an elopement risk on this assessment. Regardless of this most recent elopement assessment, review of the facility binder at the 1 East Nursing Station identified R720 was currently one of four residents identified as an elopement risk. There was only one elopement drill completed by the facility on 1/12/23 at 2:00 PM which identified concerns with .Problems noted during drill and corrective action taken: No one called Police and it took to <sic> long for them to notice Resident was missing . There were signatures from staff that participated in this drill, however there was no follow-up documentation from the facility on whether any additional elopement drills/education were completed and/or provided to ensure staff responded appropriately. On 6/7/23 at 8:36 AM, a phone interview was conducted with the Southfield Police Department. Although R707 had been picked up by their patrol, there was no documentation as to the details of where R707 was found/picked up. Their facility was approximately four miles from the facility. On 6/7/23 at 8:45 AM, an interview was conducted with the Administrator. When asked to recall the events for R707 and R720, they reviewed the documentation provided by the facility and recounted the same events. The Administrator was asked about whether the facility had identified where R707 had been picked up and they reported the did not. The Administrator reported they had an Admission Director and reported they found out after the elopement incident that the information was in the admission documentation and was ignored by Admissions staff. When asked what information the nurse reviewed as part of their admission assessment since the information about R707's history of jumping out of windows, and history of elopement was available for review, the Administrator reported usually for nursing they would review any orders or treatments. When asked if the facility considered where residents that were elopement risk were placed as both R707 and R720 were placed at the end of the hallway, and they reported Someone like that (R707) would not have been admitted to our facility. When asked about R720's current room placement at the end of the hallway, near the exit door, they offered no further response. When asked about the facility's process for how they identified residents were an elopement risk and how direct care staff would be aware, the Administrator reported there were two binders at the nursing station with photos as an extra precaution. If a major elopement risk for instance, the resident would attempt to be sent to a locked facility. The Administrator reported the residents that were currently in the facility were a lower risk. When asked about details of how it had been determined R720 eloped, the Administrator reported R720 got out from the door from the patio (smoking area). When asked about the door alarm and if it had alarmed, how did R720 get out, the Administrator reported it was sounding and he may have already departed before they got it because it was silenced after some time. The Administrator reported if staff silenced a door alarm, the were supposed to go out and check perimeters. When asked if that had been done, they offered no response. When asked if they used any cameras to verify what happened and who may have silenced the alarm, they reported the facility did not use any cameras and they had immediate education with the staff. When asked if all staff were re-educated, or only the staff on duty on 1/8/23, they reported it was done with staff that were involved with the elopement drill. When asked to explain more about the elopement drill, the Administrator reported there was a drill done on 1/12/23 and they were a part of the team to conduct that. They further reported you have the drill, and go through formalities of what went well and what went wrong. When asked if that was done for the employees who were not working that day, or if any additional elopement drills should have been completed since there were concerns identified and that was done only four days following R720's elopement, they reported they would conduct another drill at another time, but that had not been done. The Administrator was informed of current concern in regard to staff's lack of awareness of R720's elopement risk, inaccurate/consistent elopement risk assessments and acknowledged the concerns. On 6/7/23 at 9:36 AM, the Administrator provided documentation of a past non-compliance (PNC) for R707's elopement and was informed that due to ongoing, current concerns, there was no sustained compliance to consider an acceptance of a PNC. On 6/7/23 at 10:36 AM, a phone interview was conducted with R707's daughter. When asked if they could provide any additional information as to where R707 was found/picked up, or what the resident had been wearing at the time of the elopement, they reported they were unable to provide any details and R707 remained living with them since then. Removal Plan for IJ for Elopements: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 10/30/22 and 01/08/23) R720 1/8/23 On 1/8/23, a nursing assessment including a Skin Sweep was completed on R720 upon return to the facility - no identified deviations from baseline. On 1/8/23, the facility Medical Director performed a video conference with R720. On 1/8/23, a licensed nurse reevaluated R720 for risk for elopement and revised resident care plan, as applicable related to identified risk areas. Social Services performed wellness checks on the days following the event for R720. On 01/8/23, the Administrator verified all doors were in working order and would alarm if the appropriate code was not entered. R707 10/30/22 As of 10/31/22 R707 discharged from the facility (resident did not return to facility warranting further resident interventions) On 10/30/22, all windows were checked to verify openings of no larger than 6 inches. New window locks were purchased for rooms [ROOM NUMBERS], as the locks were identified with normal wear and tear. Upon review of the window lock in room [ROOM NUMBER] (where the elopement of R707 occurred), it was noted as having intentional-appearing damage. The window lock in room [ROOM NUMBER] has been replaced. On 10/30/22, the Admissions Director was re-educated on necessary efforts to identify elopement risk residents at pre-screening. The facility Medical Director was notified of the event. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 06/08/23) For both identified events, the DON/designee(s) re-evaluated all residents for risk for wandering/elopement using an elopement risk assessment tool to identify any updated residents for elopement/wander risk. For the incident involving R707, all residents were assessed on the date of the incident 10/30/2022. For the incident involving R720, all residents were assessed on the day of the incident on 1/8/2023. Current residents will be evaluated for elopement risk quarterly beginning on 6/7/2023, and as needed, new residents will begin assessment for elopement risk at the time of receiving the pending admission paperwork. The initial assessment and reassessment for all residents is deemed appropriate to capture any other residents that could potentially be at risk for elopement; implementation of possible interventions to reduce occurrence. All nurses have begun receiving education on completing the elopement assessment properly on 6/8/2023. The Admission Director employed during the 10/30/22 elopement event is no longer employed at [Nursing Facility]. The new Admission Director has been trained at hire on 3/20/2023 regarding the red light process of denying potential high risk elopement admissions to [Nursing Facility]. Potential high risk elopement admissions are referred to sister facilities with a separate secured unit. The facility communicates with the hospital liaison for the potential admission and assists with providing other facility options. Care plans will be updated quarterly, at minimum, and information communicated on the Kardex beginning on 6/8/2023. Elopement risk binders were reviewed on 06/07/23 and are current. For both identified events, staffing levels were reviewed by the NHA (Nursing Home Administrator) and deemed not to have contributed to the events. For both identified events, the NHA reviewed the Elopement and Wandering Residents Policy on 10/30/2022 and 1/9/2023 and deemed it appropriate. Beginning on 6/7/2023, staff will be educated on the Elopement and Wandering Residents policy bi-annually, at minimum, with an emphasis of checking the perimeter of the facility grounds for residents when an alarm sounds. Education originally began on 10/30/2022, as well as 6/7/2023 and is currently ongoing until all staff members have been educated. The Maintenance Director/designee continues to monitor the security of the doors weekly, at minimum, which was compliant before the first identified event. Ad Hoc QAPI (quality assurance process improvement) meeting was held on 01/09/23. The facility asserts the likelihood of immediate harm has been mitigated since 06/08/23. 34275 Deficient Practice #2 Based on observation, interview and record review, the facility failed ensure an open container of flammable charcoal lighter fluid was properly stored and secured to protect all 75 residents from possible fire and/or inhalation. Findings include: On 6/6/23 at approximately 2:05 PM, a tour of the outside smoking area was conducted with Maintenance/Housekeeping Director (MHD) O. The smoking area was set up in an enclosed courtyard space for both residents and staff. There were several chairs available for residents and staff to sit. Two staff employees were observed outside smoking. A charcoal and gas grill were also observed in the smoking area. Next to the gas grill was a container of charcoal lighter fluid lying on its side. *It should be noted that MHD O did not remove the container during the observation. On 6/6/23 at approximately 2:26 PM, a second tour of the outside smoking area was conducted with the Administrator. The charcoal lighter fluid was again observed lying on the ground near the gas grill. The Administrator picked up the container of lighter fluid and it was observed that the top of the container was not closed, and the container was half full. The Administrator noted that the last time they believed the grills were used was during Memorial Day Weekend (5/27/23-5/29/23) and that the container should not have been left open and on the ground. A review of the facility policy titled, Fire Safety and Prevention (Revised May 2011 ) documented: Policy Statement- All personnel must learn methods of fire prevention and must report conditions(s) that could result in potential fire hazard .Policy Interpretation and Implementation .1. Fire prevention is the responsibility of all personnel, residents, visitors and the general public .2. Whoever identifies a fire hazard .that could develop into a fire hazard, must report the situation .Flammable items .i. Store chemicals, cleaners, etc. as instructed on the containers .7. The Safety Coordinator and Administration will identify and document any hazardous or explosive materials that are stored in locked areas .8. The facility will train personnel on fire prevention methods . Deficient Practice #3 Based on observation, interview and record review the facility failed to ensure extension cords were not used in resident's rooms and ensure sharp and exposed items did not remain in resident room for four (R726, R729 and R727) residents out of five residents reviewed for environment concerns. Findings include: A review of the facility policy titled, Electrical Safety (1/11/21) documented, in part: Policy: It is our policy to provide a safe and healthful environment .Only qualified maintenance personnel are permitted to service, repair, or perform any operation on energized electrical lines or equipment .4. Extension Cord Safety: a. Extension cords shall be used for temporary use only by maintenance personnel. B. Extension cords shall not be used as a substitute for fixed wiring of a structure .g. Extension cords shall be removed immediately upon completion of the purpose for which they were used . On 6/6/23 at approximately 8:32 AM, observations were made in R726 and R729's room. On the wall was a red emergency outlet. Plugged into the outlet was a green extension cord. The cord ran out of the wall and two small fans were plugged into the extension cord. Television cords were also observed plugged into the emergency outlet. On 6/6/23 at approximately 1:50 PM a tour of the facility was conducted with MHD O. MHD O was queried as to the facility policy pertaining to extension cords in resident's rooms. MHD O reported that that extension cords should not be used in resident's room. MHD O reported that they conduct sweeps of resident's rooms to ensure extension cords [TRUNCATED]

This citation pertains to intake(s): MI00131088, MI00132356, and MI00134852. Based on interview and record review the facility failed to accurately complete Braden assessments, complete accurate weekly wound assessments, timely identify and report the development and/or worsening of wounds, implement appropriate and adequate treatment and interventions for wounds (R722) and consistently implement timely treatment (R701) for two (R's 722 & 701) of three residents reviewed for wounds, resulting in R722 to have developed multiple wounds which included a stage IV coccyx wound with osteomyelitis. Findings include: Review of a complaint submitted to the State Agency reported neglect of care and multiple pressure wounds identified on R722 including a stage IV on their sacrum. An unannounced survey was conducted at the facility to investigate the complainant's concerns. Review of the medical record revealed R722 was admitted to the facility on [DATE] and remained in the facility until 2/12/23 when the resident was transferred to the hospital. R722 was admitted with diagnoses that included: contracture of the right hand, muscle weakness, heart failure, chronic obstructive pulmonary disease, and blindness to the left eye. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of an admission MDS Skin Conditions assessment dated [DATE] documented the resident admitted with no pressure ulcers/injuries, however, was at risk of developing pressure ulcers/injuries. Review of an admission skin assessment dated [DATE] at 3:15 AM, documented no pressure ulcers identified upon admission. Further review of the skin assessment documented a Braden Assessment however failed to generate a Braden score for the resident. The assessment documented a At Risk for Falls score of 1.0 instead of a Braden score. Review of R722's care plan titled I am at risk for impaired skin integrity . documented the following intervention, . INCONTINENT: Cleanse area and apply barrier cream to buttock/peri area after incontinence episodes, per my preference and as I permit . Date initiated 2/3/22. Review of the medical record revealed this intervention was not implemented on 2/3/22 as the care plan documented. The first time this order was implemented was on 3/10/22, more than a month after admission into the facility. This order was not implemented timely to protect R722's skin and to prevent impairment skin for the buttock area. Review of a wound consultation dated 3/10/22 documented in part, . I am here to manage a wound located on the coccyx . RISK FACTORS: Limited Mobility . INCONTINENCE: Urine & fecal incontinent . Moisture Associated Skin Damage (MASD) . Review of the May 2022 MAR and TAR documented the following treatment orders: Triad Hydrophilic wound dressing paste, apply to coccyx/buttocks topically every shift for wound care. (Start date 3/21/22) This order was signed off by staff as completed for the entire month twice a day. Cleanse coccyx with wound cleaner, pat dry, apply triad, cover with border foam. (Start date 5/17/22) This is a secondary order which was discontinued on 5/26/22. Apply barrier cream to coccyx and bilateral buttocks with brief changes every shift (start date 5/26/22). This order was being applied to the coccyx area twice a day with the Triad treatment. These treatments continued to be applied to the coccyx area until 8/15/22, with no clarification documented by staff on why two different treatments were being applied to the coccyx area for this resident. Review of a wound consultation dated 5/17/22 documented in part, . Consultation for a wound on the coccyx . DRESSING USED: Barrier cream, Bordered Foam . EXUDATE: Scant, Serosanguineous . Length (cm- centimeters) 2.5, Width 1.8, Depth 0.1, Wound Area 4.5 . Wound has increased in size . Review of a wound consultation dated 5/26/22, documented the coccyx wound was epithelialized. Review of the wound consultations revealed R722 was seen by the wound practitioner on 11/8/22, 11/22/22, 12/20/22, 1/3/23, 1/10/23, & 1/17/23 for other skin concerns. The coccyx area was not assessed on the wound consultation dates noted above. Review of the November and December 2022 MAR and TARs revealed no treatment or barrier cream implemented to prevent and protect the coccyx area. Review of a wound consultation dated 1/24/23 documented in part . I was asked to see this patient for my opinion on how to manage their wounds at the left buttock, left medial heel, and right sole foot . Multiple new wound identified . Left Buttock . EXUDATE: Scant, Serosanguineous . 5.9 Length, 9.9 Width, UTD (unable to determine) Depth, 58.41 Wound area . WOUND PROGRESS: Undetermined: First Visit . Left Medial Heel . 2.0 Length, 1.0 Width, UTD Depth, 1.00 Wound area . Right Sole Foot . 2.0 Length, 3.5 Width, UTD Depth, 2.00 Wound area . The patient has wounds found on the left buttock, left medial heel, and right sole foot. The patient is also at risk for developing a pressure injury because of the risk factor of Limited Mobility . A low air loss mattress is recommended However DON (Director of Nursing) will evaluate patient to ensure risks of fall do not outweigh benefits . Review of the weekly skin assessments revealed no documentation of identification by the facility staff of any of the wounds identified by the wound practitioner on 1/24/23. A second review of the care plan titled I am at risk for impaired skin integrity . documented the following interventions: Assist me to turn &/or reposition routinely during CNA (Certified Nursing Assistant) rounds while in bed and frequently redistribute my weight if/when I am up in my chair (Initiated 4/25/22). Please keep my bed as flat as possible to reduce shear (Initiated 4/25/22). Please lift, do not slide me, Utilize an assistive device as applicable to decrease friction (Initiated 2/3/22). Further review of the interventions did not document a specific time frame for the staff to turn and reposition the resident. The care plan did not have adequate interventions in place to prevent the development of the wounds identified on the resident who had limited mobility. The barrier cream was not consistently implemented to prevent wound impairment on the coccyx and a low air loss mattress was not implemented timely nor was protective devices implemented to the feet area. Review of a Braden scale assessment completed 2/6/23 documented the resident as categorized as a Moderate Risk with a score of 14.0. Further review of the Braden assessment revealed the Nutrition section to be completed incorrectly as R722 was documented to have very poor nutrition in the medical record. Review of a wound consultation dated 2/7/23 documented in part, . RISK FACTORS: Limited Mobility . Left Buttock . EXUDATE: Moderate, Serosanguineous . Discussed with medical team that this wound has worsened and likely will need debridement when eschar (dead or devitalized tissue that is hard or soft in texture; usually black .) softens up . 20% slough (non-viable yellow, tan, gray, green or brown tissue that may be adherent to the base of the wound or present in clumps throughout wound bed) . 60% Eschar . 5.5 Length . 6.5 Width . UTD Depth . 35.75 Wound area . Left Medial Heel . 100% Eschar . 2.0 Length, 1.2 Width, UTD Depth, 2.40 Wound area . Right Sole Foot . Wound is epithelialized . Right Heel . Pressure injury/ulcer . Deep Tissue Pressure Injury . 100% Necrotic (slough or eschar) Tissue . 3.3 Length, 4.5 Width, UTD Depth, 14.85 Wound area . Left Lateral Heel . Pressure injury/ulcer . Deep Tissue Pressure Injury . 100% Necrotic Tissues . 1.5 Length, 1.0 Width, UTD Depth, 3.00 Wound area . Review of the medical record revealed no documentation of the staff to have identified and to have reported the worsening of the coccyx wound, prior to the wound practitioner identification of the wounds worsening on the 2/7/23 wound consultation. Review of a Nursing note dated 2/12/23 at 12:01 PM, documented the transfer of R722 to the hospital for respiratory distress and an elevated temperature. Review of the hospital records dated 2/12/23 at 10:41 AM, documented the following in part, . Started on ABT (antibiotics) and admitted to ICU (Intensive Care Unit) . was intubated . Left mid back - deep tissue injury . 2.5 X 3 cm . Left lower back - suspected deep tissue injury . 3 X 2.5 cm . Left elbow - unstageable/DTI (deep tissue injury) . 2.5 X 2 cm . Left medial elbow - deep tissue injury . 1 X 2 cm . Left hip - deep tissue injury . 0.5 X 1.5 cm . Sacrococcygeal (coccyx) (with extension to left buttock) - stage 4 pressure injury . 7 X 10 cm in total (1 cm skin bridge in between) . tan slough at sacrococcygeal center . surrounding tan/brown necrotic slough at wound left buttock. Full thickness tissue loss with depth of injury to muscle . Moderate amount of serous/tan mixed drainage to old dressings . Left lateral ankle - deep tissue injury . 2 X 2 cm . Right medical foot - deep tissue injury . 1.2 X 1.5 cm . Right fifth metatarsal head - deep tissue injury . 1.5 X 2 cm . Right lateral heel - deep tissue injury . 1 X 2.6 cm . Right heel - deep tissue injury . 6 X 4.5 cm . Left later heel - deep tissue injury . 1 X 3 cm . Left medial heel - unstageable pressure injury . 0.8 X 2 cm . black eschar open wound base. Full thickness tissue loss with depth to unknown depth of in jury due to black eschar obscuring the base . Left heel - deep tissue injury . 2.2 X 3 cm (inferior) and 2 X 1 cm (superior) . Further review of the hospital records contained photographs of all of the wounds identified at the hospital, which included the photograph of the coccyx wound to have revealed a stage IV wound. Review of a hospital Infectious Diseases consultation dated 2/15/23 at 10:42 AM, documented in part . Admission imaging . left decubitus ulcer with evidence of underlying osteomyelitis and soft tissue gas extending into the sacral epidural space . (R722) did not have the issues with skin breakdown prior to his entering the nursing home per the sister . Febrile on arrival 103 Fahrenheit . Impressions . Septic shock secondary to #2 and potentially #3 and #4 contributing . 2. Acute hypoxic respiratory failure . 3. Stage IV decubitus ulcer with likely chronic sacral osteomyelitis: Superficial wound culture showing Proteus and Strep dysgalactiae (bacteria) . 4. Concern for UTI (urinary tract infection) . Recommend debridement of sacral ulcer by surgery; send tissue for culture. Will not treat for osteomyelitis as to do so successfully would take full debridement with muscle flap, likely a diverting colostomy, and the ability to offload pressure from the flap, none of which is likely possible in this patient. Instead, will treat for acute wound infection and allow the dead bone to be colonized by bacteria that hopefully will not make him ill . Further review of the hospital medical record documented the resident was transitioned to hospice care. The hospital record revealed the facility staff failed to identify multiple wounds on the resident and failed to identify, report, and adequately treat the worsening stage IV coccyx wound. On 6/7/23 at 2:07 PM, the DON was interviewed and asked about the inaccurate Braden assessment, the timely implementation of adequate interventions, the application of accurate treatment to the coccyx area and the failure of the facility staff to timely identify worsening of the coccyx wound, identify the development of new wounds, report and obtain adequate treatment for the wounds. The DON explained the facility had concerns with the wound practitioner at that time and has since terminated services with that wound practitioner and hired a new wound team for the facility. The DON stated they would look into the concerns and follow back up. On 6/9/23 at 9:55 AM, the DON returned and stated they identified the same concerns with R722's wounds after review of their record. The DON stated they were unable to provide any additional explanation or documentation regarding the concerns. The DON however stated the facility was out of compliance with wounds around the time of R722's care. No further explanation or documentation was provided before exit. R701 Review of a complaint submitted to the SA documented concerns of the facility staff to have failed to provide adequate and appropriate care to prevent and/or treat pressure sores. Review of the medical record revealed R701 was admitted to the facility on [DATE], with a readmitted [DATE] and diagnoses that included: history of cardiac arrest, tracheostomy, gastrostomy, acute respiratory failure, and chronic obstructive pulmonary disease. A MDS assessment dated [DATE] documented severely impaired cognition skills for daily decision making and required staff assistance for all ADLs. Review of a readmission skin assessment dated [DATE] at 2:04 PM, documented impaired skin on the left buttock. Review of a Nursing admission note dated 7/29/22 at 2:52 PM, documented in part . open area on left buttock . Review of the physician orders and July MAR and TAR revealed no treatment implemented for the open area identified on the left buttock. Review of a readmission skin assessment dated [DATE], documented impaired skin to the right buttock. Review of the medical record revealed treatment was not implemented until 9/13/22, a week later. On 6/7/23 at 9:35 AM the DON was interviewed and asked the facility's protocol on the identification of a skin impairment and the DON replied staff are expected to notify the physician and obtain treatment. The DON was then asked why treatment was not implemented for R701 on 7/29/22 and 9/6/22 when staff identified abnormal skin changes to the resident's buttock area. The DON stated they were not the acting DON at the time R701 was inpatient at the facility, however, would look into the concerns and follow back up. On 6/9/23 at 9:55 AM, the DON returned and stated they identified the same concerns for R701 wound care and could not provide any further explanation or documentation on the concerns. No further documentation was provided before exit.

Based on observation, interview, and record review, the facility failed to ensure an environment free from neglect for nine (R29, R35, R36, R58, R59, R61, R64, R266, and R268) of nine residents reviewed for neglect. This resulted in an Immediate Jeopardy (IJ) to the health and safety of the residents when these residents were not assigned a licensed or registered nurse for eight and a half hours (7:42 AM until 4:15 PM) and did not receive multiple physician ordered medications needed to treat medical conditions, such as, seizures, diabetes, blood clots, [CONDITION(S)], neurological and psychiatric disorders, and pain; did not provide treatments including [CONDITION(S)] care, wound care, and PEG tube care; complete nursing assessments for pain and blood sugar monitoring; provide supervision; and respond to potential crisis/medical complications. This increased likelihood of serious injury, serious harm, and/or death to these nine residents. Findings include: On 8/29/22 at 9:40 AM, an interview was conducted with Nurse 'K' regarding their assignment. Nurse 'K' said their assignment was the entire West Wing and they believed they were splitting the center Gold Hall with Nurse 'M' until another nurse arrived to take the Gold Hall assignment. On 8/29/22 at approximately 9:45 AM, the Director of Nursing (DON) was observed counting controlled medications with the oncoming nurse (Nurse 'K') at the West Wing medication cart. At that time, the DON was observed informing Nurse 'K' they would have West Wing and a portion of the Gold Hall. On 8/29/22 at 10:25 AM, an interview was conducted with Nurse 'M' and they reported their assignment was the East Wing and half of the Gold Hall. On 8/29/22 at 10:35 AM, an interview was conducted with Unit Manager, Nurse 'A' regarding the staff assignments. They reported Nurse 'K' had the West Wing, and half of the Gold Hall, and Nurse 'M' had the East Wing and the other half of the Gold Hall until 11:00 AM when a third nurse was scheduled to arrive. Nurse 'A' explained when the third nurse arrived, their assignment would be the entire Gold hallway. On 8/29/22 at approximately 11:47 AM, R268 was heard yelling for help. When interviewed as to why she was yelling, R268 reported that she was still waiting for her medication that was not provided earlier. R268 stated that she has been asking for a Nurse all morning, had pain in her back and was not feeling well. The resident pointed to a list of medications that was taped on the wall of her room and stated those are all the medications I did not receive. The resident pressed her call light and CNA QQ entered the room. CNA QQ told R268 that she was looking for a nurse but was not able to locate anyone working on the floor. At approximately 12:47 PM, Nurse M was asked about who was responsible for providing R268's medication and they reported they believed Nurse J was assigned to the resident but had never met the Nurse and was not sure where they were. On 8/29/22 at 2:45 PM, R61 was observed and did not respond when asked if they received their morning medications. On 8/29/22 at approximately 2:58 PM, R268 reported that they still had not received their morning medications and the dressings to their legs had not been changed. On 8/29/22 at 3:15 PM, R59 was observed entering her room in a wheelchair. R59 asked, Can I please have my medications? When asked if she received medication that day, R59 reported she did not. R59 explained they took a medication that helped them to not urinate as frequently and reported she was uncomfortable because I have been going (urinating) so much all day today! On 8/29/22 at 3:16 PM, R266 was observed slouched in a chair in her room, shaking and crying. When addressed R266 was difficult to understand and spoke about aliens and needing help, but was unable to articulate what she needed. On 8/29/22 at approximately 3:17 PM, R64 reported she did not receive medications that day. On 8/29/22 at approximately 3:18 PM, R36 was lying in bed. R36's mother was in the room and noted that they had been with the resident since 11:00 AM and reported that no medication had been given to the resident and she was concerned that R36 did not receive his necessary [CONDITION(S)] medication. On 8/29/22 at 3:20 PM, a follow-up interview was conducted with Nurse 'K'. Nurse 'K' said they were informed a nurse arrived from the staffing agency at 11:00 AM and now their current assignment was limited to the West Hall minus R29, R35, and R58. Nurse 'K' reported they arrived for their shift at approximately 8:30 AM or 9:00 AM. R35 Review of R35's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Tablet (a diuretic used to prevent fluid overload in patients with [CONDITION(S)] - CHF) 1 MG Give 1 mg by mouth in the morning for [MEDICATION(S)] Take 1 tab daily, scheduled at 9:00 AM and was not administered (no nurse's signature was documented on the MAR and no progress note was written to indicate this medication was given or the provider was notified of the missed medication). Insulin [MEDICATION(S)] Solution 100 UNIT/ML Inject 10 unit subcutaneously one time a day for diabetes, scheduled at 8:00 AM and was not administered. [MEDICATION(S)] Solution (insulin) 100 UNIT/ML Inject as per sliding scale .two times a day for DM, scheduled at 9:00 AM and 9:00 PM. The 9:00 AM dose was not administered and R35's blood sugar was not monitored. [MEDICATION(S)] Tablet (a medication used to prevent blood clots) 2.5 MG Give 2.5 mg by mouth every 12 hours for [MEDICATION(S)] Take 2.5 mg every 12 hours, scheduled at 9:00 and 9:00 PM. The 9:00 AM dose was not administered on 8/29/22. [MEDICATION(S)] Tablet (a medication used to treat high blood pressure) 24-26 MG Give 1 tablet by mouth every 12 hours, scheduled at 9:00 AM and 9:00 PM. The 9:00 AM dose was not administered on 8/29/22. [MEDICATION(S)] Tablet (a medication used to treat diabetes) Give 0.5 mg by mouth with meals, scheduled at 8:00 AM, 12:00 PM and 6:00 PM. The 8:00 AM and 12:00 PM doses were not administered. Further review of R35's MAR on 8/30/22 revealed the 6:00 PM dose was not administered. Review of the clinical record revealed R35 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] noted R35 had intact cognition. Review of R35's progress notes revealed the following documentation regarding the missed medication on 8/29/22: An entry on 8/29/22 at 11:55 PM from Physician 'BB read, .Pt (patient) seen for increasing swelling in his legs and scrotum. States the am nurse did not give him his meds. Has hx (history) of ischemic CMP ([CONDITION(S)]) EF (Ejection Fraction - heart failure measurement) 20-25%. Pt was asking to go to the hospital .+ Scrotal [CONDITION(S)] mild, no drainage, no [CONDITION(S)] or warmth .Assessment and Plan: 1. Legs [CONDITION(S)]/scrotal [CONDITION(S)]/volume overload 2/2 (secondary to) acute decompensated CHF likely 2/2 meds and diet noncompliance. -Pt states he did not receive meds this an<sic> including [MEDICATION(S)] ([MEDICATION(S)])-d/w (discussed with) RN (Registered Nurse) to give [MEDICATION(S)] dose now (around 4:30 PM) and to inc (increase) [MEDICATION(S)] to 1 mg BID (twice a day) and give 2nd dose tonight around 9 PM. -if no improvement in the next couple days or worsening in symptoms, will send pt to the ER/Hosp (emergency room /Hospital) for IV (intravenous) diuretics . On 8/31/22 at 9:08 AM, Physician 'BB' was attempted to be reached by phone. There was no return call prior to the end of the survey. R29 Review of R29's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Provide [CONDITION(S)] care and replace inner cannular each morning every day. Further review of R29's MAR revealed this was not completed on 8/29/22 between the hours of 7:00 AM and 7:00 PM. [MEDICATION(S)] (a medication used to treat underactive [CONDITION(S)]) Tablet 137 MCG (micrograms) - Give 137 mcg by mouth one time a day for low [CONDITION(S)] hormone, scheduled at 9:00 AM and was not administered. Enteral Feed Order two times a day for NPO (nothing by mouth) Glucerna 1.5 1200ml (milliliters) @ 75ml/hr (milliliters per hour) x 16 hrs (run from 6PM-10AM.) Bolus flush 150ml ac/pc (before and after) feeding administration, with auto flush of 50ml/hr x 16 hrs for duration of infusion. 1200ml formula, 1800kcals (kilocalories), 2000ml free H2O (water). This was not administered on 8/28/22 at 6:00 PM and 8/29/22 at 9:00 AM. Further review of R29's MAR on 8/30/22 revealed he did not receive tube feeding on 8/29/22 at 6:00 PM. [MEDICATION(S)] (a medication used to treat seizures) Solution 100 MG/ML (milligram per milliliters) Give 15 ml via G-Tube two times a day, scheduled at 9:00 AM and was not administered. [MEDICATION(S)] Sodium (a medication used to prevent blood clots) PF Solution 5000 Unit/ml Inject 1 ml subcutaneously every 8 hours, scheduled at 2:00 PM and was not administered. Insulin [MEDICATION(S)] Solution 100 Unit/ml Inject as per sliding scale .subcutaneously every 8 hours, scheduled at 6:00 AM, 2:00 PM and 10:00 PM and was not administered on 8/29/22 at 2:00 PM. [MEDICATION(S)] Suspension (a medication used to prevent seizures) 125 MG/5ML Give 7.5 ml via G-Tube three times a day, scheduled at 8:00 AM, 1:00 PM and 9:00 PM and was not administered on 8/29/22 at 8:00 AM and 1:00 PM. Enteral Feed Order every 4 hours for NPO Flush 10 ml H2O ac/pc each medication administration and 5ml between each medication, scheduled at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. This was not administered on 8/29/22 at 8:00 AM and 4:00 PM. Oxygen at 5L/min (liters per minute) via [CONDITION(S)] continuously every shift related to [CONDITION(S)] status, scheduled to be done on the 7A-7P shift. Further review of R29's MAR revealed this was not completed on 8/29/22 between the hours of 7:00 AM and 7:00 PM. Further review of the clinical record revealed R29 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R29 had severe cognitive impairment. Review of the progress notes since 8/29/22 revealed documentation that the practitioner was not notified of the delayed/missed medications until 8/30/22 at 9:49 AM by Nurse Manager 'A'. R58 Review of R58's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (a medication used to treat gout) Tablet 100 MG Give 1 tablet by mouth one time a day, scheduled at 9:00 AM and was not administered. Aspirin Tablet Give 81 mg by mouth one time a day, scheduled at 9:00 AM and was not administered. [MEDICATION(S)] Tablet (a medication used for [CONDITION(S)]) 5 MG Give 5 mg by mouth one time a day, scheduled at 9:00 AM and was not administered. [MEDICATION(S)] Capsule (a medication used for [CONDITION(S)]) 0.4 MG Give 0.4 capsule by mouth in the morning, scheduled at 8:00 AM and was not administered. [MEDICATION(S)] ([MEDICATION(S)] - a medication used to treat fluid retention/[CONDITION(S)] in people with CHF) 80 MG Give 1 tablet by mouth one time, scheduled at 9:00 AM and was not administered. [MEDICATION(S)] - Acetaminophen Tablet (a narcotic pain medication) 7.5 -325 MG Give 2 tablet orally every 6 hours for Moderate Pain, scheduled at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM and not administered on 8/29/22 at 12:00 PM. Further review of R58's MAR on 8/30/22 revealed the 6:00 PM dose was not administered. Insulin [MEDICATION(S)] Solution 100 UNIT/ML Inject 6 unit subcutaneously one time a day, scheduled at 8:00 AM and was not administered and R58's blood sugar was not monitored. Insulin Regular Human Solution Inject as per sliding scale .subcutaneously before meals, scheduled at 6:30 AM, 11:30 AM and 4:30 PM and not administered on 8/29/22 at 11:30 AM and 4:30 PM. [MEDICATION(S)] ER (a medication used to treat cardiac and circulatory disorders) Tablet Extended Release 24 Hour 90 MG Give 1 tablet by mouth one time a day, scheduled at 9:00 AM and was not administered. Potassium Tablet (Potassium - a medication used for low potassium) Give 10 mEq (milliequivalents) by mouth one time a day, scheduled at 9:00 AM and was not administered. [MEDICATION(S)] Tablet (a medication used to treat high blood pressure and heart failure) 12.5 MG Give 1 tablet by mouth two times a day, scheduled at 9:00 AM and 9:00 PM and not administered on 8/29/22 at 9:00 AM. [MEDICATION(S)] Tablet 500 MG Give 500 mg by mouth two times a day, scheduled at 9:00 AM and 9:00 PM and not was not administered on 8/29/22 at 9:00 AM. [MEDICATION(S)] Tablet (a medication used to treat [CONDITION(S)] with hallucinations) 25 MG Give 1 tablet orally every 12 hours, scheduled at 8:00 AM and 8:00 PM and not administered on 8/29/22 at 8:00 AM. [MEDICATION(S)] Tablet (a medication used to treat high blood pressure) 50 MG Give 50 mg by mouth three times a day, scheduled at 6:00 AM, 1:00 PM and 9:00 PM and not administered on 8/29/22 at 1:00 PM. [MEDICATION(S)] Pain Relieving Patch 4% ([MEDICATION(S)]) Apply to Right shoulder topically one time a day for pain, scheduled at 9:00 AM and was not administered. Review of the clinical record revealed R58 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R58 had intact cognition. R268 A review of R268's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's MDS indicated the resident was cognitively intact. Review of R268's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physicians orders revealed R268 was scheduled to receive the following medications, treatments, and assessments: [MEDICATION(S)] (a medication used for High Blood Pressure) 10 MG one time per day, scheduled at 9:00 AM and was not administered on 8/29/22. [MEDICATION(S)] 40 MG one time per day, scheduled at 9:00 AM and was not administered on 8/29/22. [MEDICATION(S)] XL (a medication used to treat diabetes). 2.5 MG tablet, scheduled at 9:00 AM and was not administered on 8/29/22. A Blood Sugar check scheduled for 8:00 AM on 8/29/22 was not administered. [MEDICATION(S)] Patch 5% (Apply to lower back topically one time a day for pain), scheduled at 9:00 AM and was not administered on 8/29/22. [MEDICATION(S)] (a medication used to treat [CONDITION(S)]) Release 24 Hour 25 MG, scheduled at 9:00 AM was not administered on 8/29/22. [MEDICATION(S)] (a medication used to treat depression) XL Tablet Extended Release 24 Hour 300 MG, scheduled for 9:00 AM and was not administered on 8/29/22. [MEDICATION(S)] ([MEDICATION(S)]) Tablet 5MG, scheduled for 8:00 AM and 5:00 PM. The 8:00 AM dose was not administered on 8/29/22. Further review on 8/30/22 noted that the 8/29/22 5:00 PM dose was not administered. [MEDICATION(S)] Tablet (a medication used to treat high blood pressure) 5 MG, scheduled for 9:00 AM and 5:00 PM. The 9:00 AM dose was not administered. Further review of the MAR on 8/30/22 noted that the 5:00 PM dose on 8/29/22 was not administered. [MEDICATION(S)] Tablet (a medication used to treat anxiety) 0.5 MG, scheduled for 9:00 AM, 3:00 PM and 9:00 PM. The 9:00 AM and 3:00 PM dose was not administered on 8/29/22. Further review of the MAR on 8/30/22 noted that the 8/29/22 9:00 PM dose was not administered. [MEDICATION(S)]-[MEDICATION(S)] (a medication used for [CONDITION(S)] Disease) Tablet 25-100MG, scheduled for 9:00 AM, 3:00 PM and 9:00PM. The 9:00 AM and 3:00 PM doses were not administered on 8/29/22. [MEDICATION(S)] Capsule (a medication used to treat nerve pain) 300 MG, scheduled for 6:00 AM, 4:00 PM and 10:00 PM. The 4:00 PM dose was not administered on 8/29/22. Tylenol Tablet (pain medication) 325 MG, scheduled for 9:00 AM, 3:00 PM and 9:00 PM. The 9:00 AM and 3:00 PM dose was not administered on 8/29/22. [MEDICATION(S)] Suspension 1% -Instill 1 drop in both eyes four times a day for post-op eye surgery. The drops were schedule for 9:00 AM, 3:00 PM and 5:00 PM. The 9:00 AM and 3:00 PM doses/drops were not administered on 8/29/22. Further review of the MAR on 8/30/22 noted that the scheduled 5:00 PM dose on 8/29/22 was not administered. Left Lower leg treatment (xeroform to open area on anterior leg). Wrap with kerlix and Coban every day shift every other day, scheduled for 8/29/22 day shift. The treatment was not administered on 8/29/22. It should be noted that the treatment was also not administered on 8/27/22. Right lower leg: wrap with kerlix and Coban for [CONDITION(S)] every day shift every other day. The treatment was not administered on 8/29/22. It should be noted that the treatment was also not administered on 8/27/22. Further review of R268's MAR revealed medications for constipation, [CONDITION(S)], and supplements were also not given on 8/29/22, per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] R36 A review of R36's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R36's MDS noted the resident was severely cognitively impaired. Review of R36's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (a medication used to treat [CONDITION(S)] Disease) 10ml via PEG-Tube, scheduled for 9:00 AM and 9:00 PM. The 9:00 AM dose was not administered on 8/29/22. [MEDICATION(S)] (a medication related Diffuse Traumatic Brain Injury ) 5 MG- Give 1 tablet via G-Tube, scheduled for 9:00 AM and 5:00 PM. The medication was not administered at 9:00 AM on 8/29/22. [MEDICATION(S)] ([MEDICATION(S)]) Solution Give 10 ml via G-Tube for [CONDITION(S)] precaution, scheduled for 9:00 AM and 9:00 PM. The medication was not administered at 9:00 AM on 8/29/22. [MEDICATION(S)] (a narcotic pain medication) HCL Tablet 5 MG, scheduled for 8:00 AM and 8:00 PM. The medication was not administered at 8:00 AM and R36's pain level was not assessed at that time on 8/29/22. [MEDICATION(S)] ( a medication used to prevent seizures) Tablet 25 MG, scheduled for 9:00 AM and 5:00 PM. The medication was not administered at 9:00 AM on 8/29/22. R61 Review of R61's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS revealed the resident had moderately impaired cognition. Review of R61's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (an antipsychotic medication) 2 MG, scheduled for 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM. The medication was not administered at 12:00 PM on 8/29/22. Further review of the MAR on 8/30/22 noted the resident additionally did not receive that medication on 8/29/22 at 6:00 PM. [MEDICATION(S)] (an antipsychotic medication) 2MG/ML, scheduled for 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM. The medication was not administered at 12:00 PM on 8/29/22. Further review of the MAR on 8/30/22 noted the resident did not receive that medication on 8/29/22 at 6:00 PM. R59 Review of R59's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] ER (extended release) 5 MG (milligrams) by mouth one time a day for UI (urinary incontinence) which was scheduled for 11:00 AM. The 11:00 AM dose and was not administered on 8/29/22. [MEDICATION(S)] (a medication used to treat tremors) 0.5 MG two times a day, scheduled at 10:00 AM and 5:00 PM. The 10:00 AM dose was not administered on 8/29/22. [MEDICATION(S)] (a medication used to treat anxiety) 0.5 MG two times a day, scheduled at 10:00 AM and 5:00 PM. The 10:00 AM dose was not administered on 8/29/22. [MEDICATION(S)] ER (a medication used to treat [CONDITION(S)] disorder or [CONDITION(S)] disorder) 500 MG two times a day. The 10:00 AM dose was not administered on 8/29/22. Further review of R59's clinical record revealed R59 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a MDS assessment dated [DATE] revealed R59 had intact cognition. R64 Review of R64's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (a diuretic) 25 MG one time a day, scheduled at 9:00 AM and was not administered on 8/29/22. [MEDICATION(S)] (a medication used to treat diabetes) 10 MG one time a day, scheduled at 9:00 AM was not administered on 8/29/22. [MEDICATION(S)] ER 24 Hour Sprinkle (a medication used to treat high blood pressure) 100 MG one time a day, scheduled at 9:00 AM, was not administered on 8/29/22. [MEDICATION(S)] (a medication used to treat depression) 100 MG one time a day, scheduled at 9:00 AM, was not administered on 8/29/22. Blood sugar monitoring two times a day, scheduled at 6:00 AM and 8:00 PM, was not completed at 6:00 AM (or any time between 7:00 AM and 7:00 PM) on 8/29/22. [MEDICATION(S)] 2.5 MG two times a day, scheduled at 9:00 AM and 9:00 PM. The 9:00 AM dose was not administered on 8/29/22. [MEDICATION(S)] 24-26 MG two times a day, scheduled at 9:00 AM and 9:00 PM. The 9:00 AM dose was not administered on 8/29/22. [MEDICATION(S)] 40 MG two times a day, scheduled at 9:00 AM and 9:00 PM. The 9:00 AM dose was not administered on 8/29/22. Further review of R64's clinical record revealed R64 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a MDS assessment dated [DATE] revealed R64 had severely impaired cognition. R266 Review of R266's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 2.5 MG in the morning, scheduled at 10:00 AM, was not administered on 8/29/22. [MEDICATION(S)] (a medication used to treat [CONDITION(S)]) 5 MG give 0.5 tablet one time a day, scheduled at 10:00 AM, was not administered on 8/29/22. [MEDICATION(S)] [MEDICATION(S)] 50 MG two times a day, scheduled at 10:00 AM and 5:00 PM. The 10:00 AM dose was not administered on 8/29/22. Tylenol Extra Strength 1000 MG three times a day, scheduled at 10:00 AM, 2:00 PM, and 6:00 PM. The 10:00 AM and 2:00 PM doses were not administered the resident's pain level was not assessed. [MEDICATION(S)] (a medication used to treat seizures and [CONDITION(S)] disorder) 200 MG four times a day, scheduled at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. The 9:00 AM and 1:00 PM doses were not administered. On 8/29/22 at 3:42 PM, an interview was conducted with the DON. When queried about why R29, R35, R36, R58, R59, R61, R64, R266, and R268 did not receive medications, treatments, and nursing assessments that day, the DON reported she was unaware they did not receive medications or treatments. When queried about who the assigned nurse was for R29, R35, R36, R58, R59, R61, R64, R266, and R268, the DON reported it was Nurse 'J'. When queried about whether Nurse 'J' was still at the facility, the DON reported she was. At that time, the DON was asked to locate Nurse 'J'. On 8/29/22 at 4:00 PM, the DON returned with Nurse 'K' and the Unit Manager, Nurse 'A'. Nurse 'K' was queried about who she provided nursing services to that day (medication administration, treatments, assessments) and reported room numbers from the West Hall and did not include R29, R35, R36, R58, R59, R61, R64, R266, and R268 who resided on the Gold Hall. When queried about where Nurse 'J' was, Nurse 'A' reported Nurse 'J' arrived at the facility at approximately 12:00 PM and was assigned to the Gold Hall medication cart. Nurse 'A' reported she tried to locate her about 20 minutes later and could not find her. Nurse 'A' reported at that time she notified Scheduler 'S' so that she could find someone to replace Nurse 'J'. Nurse 'A' reported she did not notify the DON. At that time, the DON was asked when they were observed counting narcotic medication with Nurse 'K' on the morning of 8/29/22 at approximately 9:45 AM, who received the keys to that medication cart. The DON reported she did (the DON). When asked who the nurse was on the midnight shift, they reported that was Nurse 'H'. When asked who took control of the medication cart for the Gold Hall and West Wing when Nurse 'H' left, the DON reported they did not take control, but received the keys. The DON was asked what time they took the keys and they stated, Took the keys around 8:30 or 8:45 (AM). When asked about what time Nurse 'H' left, the DON reported, Left little after 9 or 9:30 (AM). On 8/29/22 at 4:16 PM, an interview was conducted with Scheduler 'S'. When queried about the nurses who worked in the facility that day (8/29/22) from 7:00 AM until the current time, Scheduler 'S' reported there were three nurses scheduled to work the 7:00 AM-7:00 PM shift. Two nurses scheduled called off according to Scheduler 'S' and she found replacements, Nurse 'K' who arrived at approximately 9:00 AM and Nurse 'J' who arrived at approximately 12:00 PM. Scheduler 'S' explained that around 1:00 PM, Nurse 'A' notified her that Nurse 'J' left the building and a replacement was needed. Scheduler 'S' further reported that she was unable to find a replacement for Nurse 'J' and notified Nurse 'A'. When queried about whether she notified the DON or Administrator, Scheduler 'S' reported she only told Nurse 'A'. On 8/29/22 at 5:13 PM, an interview was conducted with Nurse 'A'. When queried about the last time R29, R35, R36, R58, R59, R61, R64, R266, and R268 received any nursing services to include medication administration, treatments, and/or assessments, Nurse 'A' stated, Prior to 7:00 AM when the midnight nurse left. Nurse 'A' reported no nursing services were provided to R29, R35, R36, R58, R59, R61, R64, R266, and R268 between 7:00 AM and approximately 4:15 PM when she took control of the medication cart. When queried about whether Nurse 'J' provided any nursing services when she was in the building, Nurse 'A' reported she did not. On 8/30/22 at approximately 8:00 AM, the Administrator was asked to provide verification of Nurse 'H' and Nurse 'J''s time details for 8/28/22 and 8/29/22. On 8/30/22 at 8:20 AM, the Administrator reported Nurse 'H' was done with work at 7:42 AM. On 8/30/22 at 8:50 AM, the Administrator provided the time details for Nurse 'J' which revealed on 8/29/22 they were logged into the agency application as working from 12:31 PM to 12:37 PM (6 minutes). On 8/30/22 at approximately 9:10 AM a phone interview was conducted with Nurse J. Nurse J reported that she responded to an electronic notification from her Agency employer that the facility needed a nurse for the day shift on 8/29/22. She entered the building at approximately 12:30 PM and started a medication count on a cart placed near the front of the nurse's station (herein after gold cart). When doing the count with another nurse (Nurse K) she determined that the narcotic count was off as there were supposed to be 34 narcotic packages, but only 27 were noted. Nurse K stated that she informed the DON and was told that Nurse A would reconcile the count with her. Nurse J reported that she waited for Nurse A, but she never came and then she left the building as she did not feel comfortable passing medication. Nurse J reported that she never contacted the Agency to report why she left the facility. On 8/30/22 at 9:34 AM, the Administrator, in the presence of the DON, was interviewed. When queried about her knowledge of multiple residents not having an assigned nurse and as a result did not receive medications, treatments, or assessments between the time of 7:42 AM and approximately 4:15 PM, the Administrator reported she heard Nurse 'J' left the building and did not return and Nurse 'A' assumed duties of those residents. The Administrator explained that Physician 'CC' was contacted early that day to let him know that medications would be administered late and he said it was okay to give the once-a-day medications late. When queried about who was assigned to R29, R35, R36, R58, R59, R61, R64, R266, and R268 from 7:42 AM (when Nurse 'H' left) until 12:31 PM (when Nurse 'J' arrived), the Administrator reported she was not sure. When queried about how the Administrator became aware of the set of residents who did not have an assigned nurse and did not receive nursing services between 7:42 AM and 4:15 PM, the Administrator responded by saying Physician 'CC' was aware and she witnessed Regional Clinical Director of Operations 'U' contact him. On 8/30/22 at 1:51 PM, a telephone interview was conducted with Physician 'CC', the facility's Medical Director. When queried about when he was made aware that R29, R35, R36, R58, R59, R61, R64, R266, and R268 did not receive medications, treatments, or assessments on 8/29/22, Physician 'CC' checked his phone and reported that Regional Clinical Director of Operations 'U' contacted him at 4:00 PM on 8/29/22 (after it was identified by the survey team that the residents were not receiving nursing services and did not have an assigned nurse), approximately eight hours after the residents did not receive nursing services. When queried about when he should be contacted if it was known that a resident was not going to receive medications or treatments, Physician 'CC' stated, Facilities seem to call me after a concern is identified instead of when it actually happens. On 8/30/22 at approximately 10:43 AM, the DON was asked if she contacted the Agency that Nurse J was employed by to report that she had left the building without performing her assignment. The DON stated that never talked with the Agency but was waiting for a follow-up call from an e-mail tha

Based on observation, interview, and record review, the facility failed ensure orders for Total [MEDICATION(S)] Nutrition (TPN - all nutrition is received intravenously) were obtained and implemented for one (R216) of one residents reviewed for admission. This resulted in an immediate jeopardy (IJ) to the health and safety of the resident when R216 had not received TPN since their admission into the facility five days prior, resulting in the likelihood of serious harm due to malnutrition and electrolyte imbalance. Findings include: On 8/28/22 at 12:50 PM, R216 was observed seated at the side of the bed. R216 was pleasant and able to participate in conversation. An IV (intravenous) pole was observed at the resident's bedside with a bag of dextrose (a form of sugar solution infused intravenously to provide fluids and carbohydrates) hung, but not infusing at that time. An IV port was observed in the left side of R216's chest. When queried about their care in the facility, R216 reported she was admitted into the facility the previous Thursday and was supposed to receive TPN for nutrition, but had not received it since admission. When queried about the reason she had not received TPN, R216 reported the TPN was formulated based on laboratory results and blood had not been drawn yet. On 8/28/22 at 4:09 PM, R216 was further interviewed. When queried about whether she ate anything by mouth, R216 reported she took medications by mouth, but no food. R216 explained her medical condition which included multiple surgeries and an abdominal fistula (connection of two body cavities that do not typically connect) and that the TPN was required in order to heal the opening in her abdomen. R216 reported concern that in the hospital her blood was drawn weekly to formulate the TPN. R216 reported at the moment she felt okay, but would go to the hospital if she started to decline, but hoped that would not occur. Review of R216's clinical record revealed R216 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Discharge Summary from the hospital revealed the following documentation: Physician Discharge Summary .Primary Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Nutrition Continuous 3-in-1 by total volume (QS base) Intravenous Continuous (HS - at night) .65 mL/hr (milliliters per hour) .Active Issues Requiring Follow-Up: Enterocutaneous fistula output .TPN .Discharge instructions: .Diet: TPN .Sips of water for medications and ice chips .Medication List Given to patient as of 8/25/22 8:38 AM .Amino Ac Elect-Calc in D10W ([MEDICATION(S)] Nutrition Infusion for discharge) See most recent [MEDICATION(S)] Nutrition formula . Review of an After Visit Summary (with missing pages) from the hospital revealed R216 was admitted in the hospital from 6/3/22 through 8/25/22 at which time they were placed at the facility. The summary documented, Diet Instructions .Nutrition Recommendations: Ice chips and sips with meds .TPN via CVC (central venous catheter - tunneled catheter). The Medication List documented to TAKE these medications: [MEDICAL RECORD OR PHYSICIAN ORDER] .See most recent [MEDICATION(S)] Nutrition formula . Review of a Continuity of Care Document provided by the hospital revealed the following: .Active Lines .CVC Single Lumen Tunneled 5 Right [MEDICATION(S)] .Dressing change due 8/30/22 .Wound Care Instructions .Wound Location .Abdominal Fistula .Cleanse Normal Saline .Prep with skin prep and allow to dry .Cover Wound Management System (a pouch that adheres to the skin and ensures skin is protected from drainage from the fistula) .Change/PRN (as needed): Dressing no longer intact .Dressing damp, moist or saturated . Review of a section titled, TPN Medication Recent History which was continued from a previous page that was not included in the medical record revealed R216 received the following dose of TPN Continuous 3-in-1 by total volume on 8/24/22 at 10:00 PM in the hospital (the last dose given prior to admission into the facility) and documented all ingredients included in that dose which included macro ingredients (amino acids, dextrose), electrolytes, additives (insulin regular), sterile water, lipids (fats), and proteins. Review of R216's Admission/Readmission assessment dated [DATE] and completed by Nurse 'Y', documented See Diet Order in chart in the Nutrition section and it was checked that R216 received TPN. The admission skin assessment noted R216 had an implanted port (IV) in her chest and an abdominal fistula. It was documented R216 had a [CONDITION(S)]. Review of R216's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was an order dated 8/26/22 for cmp/cbc/tsh/hba1c next draw ordered by Physician Assistant (PA) 'NN'. No laboratory results were located in R216's medical record. Review of R216's progress notes revealed the following: A Practitioner Progress Note dated 8/25/22, written by Physician 'CC' that noted, .Adm (admit) for subacute rehab (rehabilitation)/wound care .Adm (admit) at (facility) from (inpatient rehab hospital), where pt (patient) was sent from Hosp (hospital) after intervention for recurrent enterocutaneous fistula - currently being treated with TPN to allow bowel rest and helping the closer <sic> of fistula - Has tunneled Central line in RT (right) SCV ([MEDICATION(S)]) or IJ (internal jugular) vein for TPN. [CONDITION(S)] is functional and she also has a bag for collection of the EC fistula discharge .Assessment and plan .Enterocutaneous fistula - recurrent - currently being treated conservatively with TPN to give 'bowel rest' - avoiding any food debris, load to intestines to help heal/close the fistula .May require surgical closure once nutritionally improved .TPN - orders to be filled by TPN pharmacy - start <sic> labs to be ordered to guide the pharmacy and then labs to be done weekly . A Practitioner Progress Note dated 8/26/22, written by PA 'NN' noted, .seen for eval (evaluation) pain control .on TF (tube feeding), NPO (nothing by mouth) due to fistula with ice chips .to start TPN on IVF today .abd (abdominal) pain/large fistula .TPN/NPO with ice chips, local care .check labs . As of 8/29/22 at 8:00 AM, there were no progress notes that explained why R216 had not yet received TPN. On 8/29/22 at 9:49 AM, Registered Dietitian (RD) 'X' was interviewed. When queried about why R216 had not yet received TPN when she was admitted on [DATE], RD 'X' reported he did not know and explained the pharmacy dosed TPN backed on blood work, but was not sure why R216 had not received it. Regional Dietician 'Z' was interviewed at that time and reported the dietary department would not enter an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Regional Dietician 'Z' reported what would typically happen was the hospital order would be faxed to the pharmacy so that it could be formulated specifically for that resident. When queried about what could happen if a resident did not receive TPN for five days, Regional Dietician 'Z' reported it would be an emergent situation and would require an emergency order from the pharmacy. On 8/29/22 at 10:13 AM, the Director of Nursing (DON - started working in the facility on 8/18/22) was interviewed. When queried about the facility's protocol for residents newly admitted into the facility, the DON reported the facility received a referral through the admissions department that would be communicated to the DON and Administrator, the resident would be assigned to a nurse to do the admission. The DON further explained the assigned nurse assessed the resident, added medications into the electronic medical record that were obtained from the orders that came from the hospital. When queried about any other information reviewed besides medications, the DON reported the nurse reviewed the entire discharge summary from the hospital and contacted the physician to approve the orders and receive any clarifications. The DON reported nursing management double checked all admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When queried about whether she reviewed R216's admission from 8/25/22, the DON reported she did not start the process to double check admissions yet. The DON reported Unit Manager, Nurse 'A' would be able to answer questions regarding R216. On 8/29/22 at 10:24 AM, Nurse 'A' was interviewed. Nurse 'A' explained they were the unit manager for the whole facility. When queried about why R216 was not receiving TPN, Nurse 'A' reported the admitting nurse should have put an order in and gone over the medications with the physician for any clarification. When queried about whether R216's provider was aware she had not yet received any doses of TPN since her admission on 8/25/22, Nurse 'A' reported the physician was not notified to her knowledge. On 8/29/22 at 10:56 AM, Physician 'CC' was interviewed via the telephone. When queried about why R216 had not yet received TPN, Physician 'CC' reported he put an order in for STAT labs the day of R216's admission. Physician 'CC' reported he was unaware that she had not yet received TPN. Physician 'CC' reported R216 received dextrose while waiting for the labs to be drawn and the TPN to arrive at the facility, but he would have expected to be notified within 24 hours if the resident could not receive the TPN in that frame. When queried about what should be done if TPN was unable to be obtained, Physician 'CC' reported he should be contacted so that the resident could be sent back to the hospital or other plans/orders be made. Physician 'CC' reported STAT labs typically were done and results received within one night or day and then they would be sent to the pharmacy for TPN formulation. On 8/29/22 at 11:06 AM, PA 'NN was interviewed via the telephone. When queried about whether she was aware on 8/26/22 that R216 had not yet received TPN, PA 'NN' reported she saw R216 on 8/26/22 but did not review all of her medical records. PA 'NN' reported she was aware R216 was receiving IV fluids and dextrose because it would take 24 hours to get the TPN from the pharmacy, but was unaware that the TPN never came. PA 'NN' reported a provider should have been contacted. PA 'NN' explained the nurses reported to her that TPN was going to arrive that day (8/26/22). On 8/29/22 at 12:18 PM, Nurse 'Y' (the nurse who completed R216's admission assessment on 8/25/22) was interviewed via the telephone. When queried about the facility's admission process, Nurse 'Y' reported when the resident arrived at the facility, an assessment was completed, admission paperwork was reviewed, diet orders were reviewed, orders were entered into the electronic medical record, and the provider was contacted to inform of the resident's admission and orders confirmed. Nurse 'Y' reported sometimes Physician 'CC' requested to do a video call so that he could see the resident. When queried about R216's admission on 8/25/22, Nurse 'Y' reported she was not R216's assigned nurse, but helped out another nurse who was overwhelmed and behind. Nurse 'Y' reported the other nurse (Nurse 'C') entered the orders and she (Nurse 'Y') assessed R216. When queried about R216's TPN orders, Nurse 'Y' reported herself nor Nurse 'C' could figure out the TPN orders so Physician 'CC' was contacted. Nurse 'Y' explained Physician 'CC' instructed them to provide the pharmacy with R216's most recent laboratory results from the hospital if they were drawn within the past 48 hours so the pharmacy could formulate the TPN. Nurse 'Y' reported she called the pharmacy who instructed her to contact a third-party company that compounded TPN. Nurse 'Y' explained she left a message with the specialty pharmacy and did not receive a call back. Nurse 'Y' reported Nurse 'C' contacted Physician 'CC' to inform him about the TPN and he instructed her to continue giving IV fluids and dextrose and ordered STAT labs. Nurse 'Y' entered the STAT lab order and instructed Nurse 'C' to follow up. Nurse 'Y' explained she did not enter a progress note because she was not the assigned nurse and Nurse 'C' said she would document what occurred. On 8/29/22 at 12:30 PM, any laboratory tests completed and any associated results since R216 was admitted into the facility were requested from the DON. On 8/29/22 at 1:15 PM, the DON reported she had to contact the laboratory to have them send the lab results to the facility. DON had to call the laboratory to get the labs. When queried about who was responsible to follow up on ordered labs, the DON reported the nurse who was assigned to the resident and the provider who initiated the order. If they were not completed on that shift, then it would be endorsed to the next shift. The DON reported that any communication should be documented in a progress note. At that time, the laboratory results for R216 were requested from the DON. The DON reported Nurse 'A' had them and would provide them. On 8/29/22 at 1:36 PM, Nurse 'A' was interviewed. Nurse 'A' reported she contacted the pharmacy and they said they did not receive any lab results for R216 and therefore they did not make the TPN. When queried about whether the STAT labs ordered by Physician 'CC' on 8/25/22 were drawn, Nurse 'A' reported she did not know and that the pharmacy did not have any record of labs for R216. Review of a Prehospital Care Report Summary from EMS (Emergency Medical Services), dated 8/29/22, revealed EMS contacted R216 at 11:28 PM, and included the following documentation: .PT (patient) requires EMS transport due to monitoring required due to 5 days of no nutrition administration by facility .Pt states she was admitted 5 days prior to EMS arrival. EMS crew confirmed the pt admitted [DATE]. She reports in that time, she has received absolutely no TPN. She has only received dextrose 10% (D10). In the last almost 14 hours since she last had any D10. She reports her last treatment (of D10) was 450ML approximately 45 grams of dextrose .Pt states she has had to resort to sneaking candies and graham crackers because he <sic> has been so hungry for the last 5 days and received nothing of nutritional value in the last 5 days .Pt was placed on cardiac monitor and 12 lead performed. 12 lead showed sinus rhythm with suppressed and prolonged T waves indicative of [CONDITION(S)] (low potassium) and [CONDITION(S)] (low calcium) likely due to the fact the pt has received nothing with any nutritional value in the last 5 days . Review of R216's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A policy regarding the facility's admission process was requested from the Administrator on 8/30/22 at 12:03 PM. The following was received: A document titled, (Facility name) New Admission/Readmission Checklist. Review of the document revealed the following information: Admission Process: .Verify orders printed on the 'Discharge Instructions' with physician/extender .Enter eMAR (electronic medication administration record)/eTAR (electronic treatment administration record) applicable and standing orders .Fax .full medication list to the pharmacy asap (as soon as possible) upon entry .Enter diet order and communicate new order with dietary department . .Within 24 Hours: .Schedule ordered and standing order labs. NOTE: It is acceptable in most cases to utilize recent hospital labs as admission labs [unless indicated otherwise] .Ensure order/tasks present for catheter, wound IV, splint, contracture, fistula, and post-op cares, etc. as applicable . The IJ began on 8/25/22, it was identified by the survey team on 8/29/22 and the facility was notified of the IJ on 8/29/22. On 8/29/22, the State Agency completed onsite verification that the Immediate Jeopardy was removed on 8/30/22, 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. The immediacy was removed on 8/29/22 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team, as follows: One resident residing in the facility is on TPN. The resident ' s admission TPN medication orders were reviewed and processed. The TPN medication orders were sent to the pharmacy for processing. The physician has been notified of the delay of TPN administration. No further orders were given. All resident's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

This citation has two deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to implement care planned interventions and develop effective and timely interventions based on accurate root cause analysis to prevent falls for one (R19) of two residents reviewed for falls, resulting in R19 falling seven times between July 6, 2022 and August 11, 2022 and sustaining injuries including abrasions to the chin and lip, a hematoma to the forehead, swelling of the hand, bruising to the arm, and a skin tear to the forearm. Findings include: On 8/28/22 at 12:33 PM, R19 was observed seated in a wheelchair near the nurse's station on the East Wing visiting with a family member. R19 appeared lethargic and her family member helped her eat. On 8/28/22 at approximately 1:00 PM, an interview was conducted with R19's family member. R19's family member reported R19 was supervised less and received less attention during the weekends, was paralyzed on the left side of her body, and experiences strong emotional reactions due to a head injury. R19's family member explained R19 had a [CONDITION(S)], but seizures were under control at that time. On 8/28/22, multiple observations were made of R19 between approximately 1:30 PM and 6:00 PM seated in the same spot near the East Wing nurse's station with minimal interaction from the staff. R19 was tearful, sobbing, and restless, crying out to Let me go! On 8/28/22 at 5:09 PM, R19 was seated near the East Wing nurse's station which was also near the Director of Nursing's (DON) office. R19 was screaming loudly and crying and plate of food was observed on the table in front of the resident. Nurse 'B' walked by R19 without addressing her. R19 repeated, They just leave me. They leave me alone. I can't do it!. The DON and a Certified Nursing Assistant approached R19 and said, Let's eat (R19) and walked away. R19 began crying when the staff walked away and continued to yell, I can't do it! I can't do it! I want to go! At 5:12 PM, the DON told R19 to let the staff finish passing meal trays and the CNA told R19 she would be right back. R19 continued screaming and sobbing and stated, I can't do it! I can't do it! Help me! Help me! At 5:16 PM, Nurse 'B' was observed seated behind the nurse's station desk and the DON was inside her office. At 5:20 PM, Nurse 'B' sat down next to R19, 20 minutes later, and assisted her with eating and R19 calmed down. On 8/29/22 at 9:01 AM, R19 was observed in bed with a breakfast tray. The door to the room was closed. R19 was sobbing and said she wanted to be up in the wheelchair outside of the room. R19 started screaming and crying. At 9:09 AM, the DON entered R19's room (the door remained closed) and asked R19 to eat her breakfast and left the room. R19 continued to yell, They leave me! They leave me alone! At 9:20 AM, a CNA entered R19's room and R19 calmed down. On 8/29/22 at 1:58 PM and 3:24 PM, R19 was seated in a wheelchair across from the nurse's station yelling, sobbing, and restless with minimal interaction from the staff. CNA 'SS' was observed to tell R19 that she would get her some cake or take her to a birthday party that was being held in the main dining room, but did not do either task. On 8/30/22 from 5:00 PM until 5:18 PM, R19 was observed seated in a wheelchair inside her room with the door open only a crack. R19 was near the door and was yelling and crying. At 5:30 PM, R19 was observed in her room in a wheelchair yelling and crying. R19's dinner plate was observed to be placed on the bed. On 8/31/22 at 2:42, R19 was observed lying in bed with the door closed. R19 was crying. Review of R19's clinical record revealed R19 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: metabolic [CONDITION(S)], seizures, major depressive disorder, expressive language disorder, [CONDITION(S)], [CONDITION(S)] (difficulty speaking), dysphagia (difficulty swallowing), psychotic disorder, nontraumatic subdural hemorrhage, and pseudobulbar affect. Review of R19's Minimum Data Set (MDS) assessments revealed the most recent MDS assessment was not yet completed and was due on 8/2/22. Review of the previous MDS assessment completed on 5/2/22 did not assess R19's cognition or behavior symptoms and revealed R19 required extensive assistance for bed mobility, was totally dependent on staff for transfers and eating, and was always incontinent of bowel and urine. It was documented R19 did not fall during the assessment period. Review of Fall Incidents (progress notes, incident reports, post-fall reviews, and care plans) for R19 from July 2022 and August 2022 revealed the following: 1. R19 fell on [DATE] at 4:00 PM and was observed laying on the floor on left side of her body. It was documented R19 complained of new pain to her left shoulder. There were no witnesses to the fall. A Post-Fall/Fall Risk Assessment completed on 7/6/22 documented R19's call light was not within reach and floor mats were in place. The assessment documented, State immediate intervention (new or revised) implemented to help prevent additional accidents: Floor mat in place . It should be noted that it was documented that the floor mat was in place at the time of the fall. A care plan initiated on 5/23/22 documented, I am at an increased risk of falls. Review of the care planned interventions for falls revealed the following interventions: Be sure my call light is within reach (initiated 5/23/22) (Please note that the post-fall assessment noted the call light was not in reach) and Floor mat was initiated on 6/27/22 and therefore was an intervention already in place at the time of the fall. Further review of the care plan revealed no new interventions. 2. R19 fell on [DATE] at 1:47, three days after the previous fall, and was observed on the floor in the hallway. R19 complained of pain in her left shoulder and head. There were no witnesses to the fall and R19 was not able to explain what happened. Review of a progress note written by Physician 'CC' revealed R19 sustained a small hematoma, complains of pain in the left shoulder from a previous fall and was more irritable than usual. R19 was later sent to the emergency room for an X-ray due to unrelieved pain and returned with negative results of the X-rays. An Antigravity Team Note (Interdisciplinary Team Note for Falls) dated 7/11/22 documented, Root Cause(s) of Fall: Resident is very spontaneous and becomes agitated at times. Will yell out or moan for attention, repeating over and over .she attempts to rise from the chair on her own and is physically unable to do so .Prior Interventions: Mat at bedside, call light in reach, place in high traffic areas, offer diversional activities .New Interventions: (this was left blank) . Review of R19's care plans revealed a new intervention initiated on 7/12/22 to place in high traffic area for monitoring when up in wheelchair. However, R19 was in the hallway near the nurse's station when the fall occurred on 7/9/22. 3. R19 fell on [DATE] at 11:54 PM and was observed lying partly on the floor mat and the floor. Resident was observed lying partly on the floor mat and on the floor. R19 sustained a small abrasion on the chin according to an evaluation by Physician 'CC' on 7/19/22. It was documented on the incident report that R19 had increased agitation. A care plan intervention initiated on 7/19/22 noted, I need a specialty wheelchair High back to help reduce my risk for falls. It was not mentioned if R19 was previous up in a wheelchair or in bed in their room. Review of a Post-Fall/Fall Risk Assessment completed on 7/19/22 revealed R19's call light was within reach, the bed was in the lowest position and they had a low bed. The immediate interventions implemented to help prevent additional accidents were noted as bed in lowest position, call-light within reach, educated on how to use the call light to call. 4. R19 fell on [DATE] at 5:52 PM and was observed on the floor mat in their room. It was documented on the incident report that Resident stated she rolled on the mat .intentionally rolls onto mat. According to Physician 'CC's evaluation conducted on 7/23/22, R19 .fell again, tries to move and get off the bed leading to falls .restlessness/fall as a result, worsened by old left [CONDITION(S)], poor bed mobility, PT (physical therapy) has not been of help. Continued fall precautions . A care planned intervention initiated on 7/25/22 noted, place in high traffic area when up in wheelchair. However, that intervention was initially added to the care plan on 7/12/22. Review of an Antigravity Team Note dated 7/26/22 to address R19's fall on 7/23/22 documented, .attempting to get out of bed .Prior interventions: move room near nurses station, place in active area, remind to ask for assistance, call light in reach .New Interventions: ask pharmacist to review meds . Review of R19's Pharmacy Progress Notes revealed the pharmacist did not review R19's medications until 8/23/22, one month later. Review of the Post-Fall/Fall Risk Assessment completed on 7/23/22 revealed n/a (not applicable was documented in the section to state immediate intervention . It was documented R19 was in bed prior to the fall and was agitated prior to the fall. 5. R19 fell on [DATE] at 4:45 PM and was observed on the floor in the hallway with a blister noted to the right hand. A progress note dated 7/29/22 noted R19 had a bruise on arm from fall. An evaluation documented by Physician 'CC' on 7/29/22 noted, screaming all morning, fell again, new right forehead hematoma, swelling to right hand, tender .blister .Xray .continue precautions Review of a Post-Fall/Fall Risk Assessment completed on 7/29/22 revealed R19 was agitated at the time of the fall and an evaluation by psychiatric services was ordered. R19 was seen by psychiatry on 8/4/22 and some medication changes were made. 6. R19 fell on [DATE] at 6:50 PM. Nurse 'B' heard a loud noise when they were walking down the hallway and R19 was observed lying on the floor face down in front of her w/c (wheelchair) in the hallway. R19 complained of pain to their left knee, left eye, and mouth and an abrasion was noted to R19's upper lip and a skin tear to the left forearm. R19's pain level was documented to be nine out of 10 with 10 being the highest level of pain. It was documented there were no witnesses to the fall. A progress note written by Physician 'CC' on 8/5/22 documented, .Fall. Pain in forehead apparently 'jumped' off the bed sustained injury to upper lip/left upper arm . It should be noted that the incident report documented R19 was found face down in the hallway and that the incident was not witnessed. Review of an Antigravity Team Note dated 8/10/22 for R19's fall that occurred on 8/5/22 revealed, .prior interventions: call light w/in reach, mattress next to bed, place in common area, med review .new interventions: 1:1 as needed . Review of R19's care plan revealed 1:1 as needed was initiated on 8/8/22. 7. R19 fell on [DATE] at 7:13 PM while Nurse 'H' was standing at the medication cart counting medications with the oncoming nurse. The incident report documented R19 fell out of the wheelchair and onto the floor in the hallway. It was documented there were no witnesses to the incident. A progress note written by Physician 'CC' documented R19 reported to have fallen and found on the floor apparently has been trying to fall on purpose as per nursing reports .Fall recurrent likely because of left [CONDITION(S)] - trying to get out of bed and unable to control herself. Precautions to be maintained .steps in place with low bed and floor mattress . Review of an Antigravity Team Note dated 8/10/22 documented, .root cause, resident placed self on floor .prior interventions: perimeter mattress, mattress next to bed, proper foot wear, psych eval, med review, UA, bed in low position. 1:1 as needed . It should be noted that R19 fell while in the hallway in the presence of staff. A new intervention was initiated on R19's care plan on 8/11/22 for mattress next to bed. It should be noted that R19 did not fall in her room on 8/10/22. Review of a Post-Fall/Fall Risk assessment dated [DATE] revealed it was documented that R19 was up in a wheelchair and placed herself on the floor. It was documented the incident was witnessed and R19 was agitated and restless at the time of the fall. There was no documented evidence that R19 was placed on 1:1 when she was agitated and restless as that was the previous care planned intervention implemented on 8/8/22. It was documented that resident would remain in bed for safety as an immediate intervention and it was also initiated on the care plan on 8/11/22. On 8/31/22 at 3:31 PM, the Director of Nursing (DON) was interviewed. When queried about how residents who were at high risk for falls were prevented from falling, the DON reported if a resident was assessed to be at high risk for falling it was shared with staff and care planned interventions would be developed and implemented. The DON reported falls were discussed at the daily IDT meetings to determine the root cause of the fall and to figure out appropriate interventions to prevent future falls. When queried about who monitored residents to ensure staff were implementing the care planned interventions to prevent falls, the DON reported nurses, the unit manager, or the DON. When queried about what was in place to prevent falls for R19, the DON reported she did not know who that resident was. The above observations were discussed with the DON and the incident reports and care plans for R19 were discussed. The DON reported all care planned interventions should be implemented and appropriate interventions based on the root cause of the fall should be added after falls occurred. Review of R19's care plan conducted on 8/29/22 revealed the falls care plan was initiated on 5/23/22 and documented, I am at an increased risk for falls r/t (related to). It should be noted that there was no specific focus or root cause identified on the care plan when reviewed on 8/29/22. Review of the care plan on 8/30/22 revealed the care plan was updated and noted, I am at an increased risk for falls 2/2 (secondary to) hx (history) of falls with major injury, decreased awareness, incontinence. The care plan did not document that R19 jumped out of bed or threw self on floor. The care plan documented the following interventions: 1:1 as needed initiated on 8/8/22 - This intervention was not observed throughout the survey when R19 was observed to be restless and in emotional distress. R19 was observed on multiple occasions in their room, in bed, with the door closed, while crying and distressed. Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility, initiated on 6/28/22. This intervention was not observed. Frequent monitoring, initiated on 8/8/22. There were multiple observations throughout the survey of R19 in a restless, distressed state both in the hallway by the nurse's station and in their room with the door closed for extended periods of time. I need strategies that minimize the potential for falls while providing diversion and distraction, initiated on 7/28/22 and revised on 7/28/22. This intervention did not include any individualized or specific strategies to attempt with R19. Place in high traffic area for monitoring when up in wheelchair, initiated on 7/12/22 and revised on 7/25/22. R19 was observed multiple times throughout the survey in their room with the door closed or near the nurse's station in a restless and distressed state with minimal engagement from the staff. Resident to remain in bed for safety, initiated on 8/11/22. There were multiple observations of R19 in bed with the door closed, crying and in distress. It should be noted that R19 had multiple unwitnessed falls in their room from their bed in the months of July 2022 and August 2022. Review of a facility policy titled, Fall Reduction Policy, revised 8/2021, revealed, in part, the following: .Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care .Interventions will be monitored for effectiveness .The plan of care will be revised as needed .When any resident experiences a fall, the facility will: .IDT review of the resident's care plan and update as indicated .obtain witness statements as needed . Deficient Practice #2 Based on observation, interview and record review, the facility failed to ensure a timely safe smoking assessment for one (R47) of four residents reviewed for accidents, resulting in the increased likelihood for unidentified supervision needs. Findings include: On 8/28/22 at 1:35 PM, R47 was observed seated in a wheelchair in their room. When asked about whether they smoked, R47 reported they used to have cigarettes that were kept in the nursing cart and recently had their family provide them with a CBD pen ([MEDICATION(S)] - vaping pen) recently. When asked if anyone had ever evaluated them for safe smoking, they reported the Administrator said they had to take the CBD pen and that no-one had assessed them for anything like that. Review of the clinical record revealed R47 was admitted in the facility on 6/30/22 with diagnoses that included: [CONDITION(S)] of vertebra sacral and sacrococcygeal region, attention to [CONDITION(S)], [CONDITION(S)], major depressive disorder recurrent, neuromuscular dysfunction of bladder, anxiety disorder, protein-calorie malnutrition, other chronic [CONDITION(S)], acquired absence of right and left leg below knee, assault by shotgun and retained metal fragments. According to the Minimum Data Set (MDS) assessment dated [DATE], R47 had intact cognition. Further review of the clinical record revealed there was no assessment for safe smoking completed until 8/28/22 (during the survey) by Nurse Manager 'A'. This assessment identified the resident may smoke with supervision. On 8/30/22 at 3:40 PM, the Administrator was asked about who was responsible for completing the smoking assessments for the residents and they reported those should be done by the floor nurses upon admission into the facility. When asked about R47's CBD pen, they reported they had just gotten approval from the physician and educated R47 about the facility's policy on use of cigarettes and smoking. When asked why the resident's safe smoking assessment was not completed until 8/28/22 (once survey started) and they reported they were not sure and were not aware other than the CBD pen that the resident smoked. The Administrator reported they were not aware R47 smoked cigarettes and would have to follow up. The Administrator was requested for a facility policy which addressed resident smoking, but there was no further documentation provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure ongoing and timely monitoring and treatment/intervention for one resident (R54), of two residents reviewed for nutrition, resulting in a resident that received total nutrition via enteral feeding (delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) having severe weight loss (8.83% in less than one month) and the potential for further clinical compromise. Findings include: According to the facility's policy titled, Nutrition at Risk and Review dated 2/2021, It is the practice of this facility to identify residents at nutritional risk and intervene to minimize decline in nutritional status .Residents at nutritional risk will be identified through the nutrition assessment, and observation .Residents reviewed will be a collaborated effort of an interdisciplinary team .Residents with unplanned significant weight changes .5% in 30 days .7.5% in 90 days .tube fed residents that do not have stable weight .The dietary manager or dietitian with the support of the Director of Nursing or designee will be responsible for seeing that all residents meeting the above criteria are identified .The Physician will be notified if a resident is not responding to current interventions .The dietitian, dietary manager or designee will document the review of the IDT members. This policy did not address severe weight loss, or weight monitoring process. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The current diet was NPO (nothing by mouth). The current enteral feed order dated 8/25/22 read, Enteral Feed Order two times a day Administer [MEDICATION(S)] 1.5 @78ML/hr x 16 hrs = total 1248mL. Autoflush: 50ml/hr x 16 hrs = total 800mL/h2o. Up at 6PM, down at 10AM or until dose complete. On 8/31/22 at 9:43 AM, R54 was observed lying in bed with a thin bedsheet covering their body. The resident appeared thin and a tube feeding pump was on and administering tube feeding. Further observation revealed the tube feeding bag was labeled with a date of 8-30-22, a time of 1800 (6:00 PM), and a rate of 78. There was approximately 100 ml (milliliters) of tube feeding remaining in the bag that was in use. The tube feeding pump itself was set to a rate of 75 (not 78 - see physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/31/22 at 10:04 AM, Nurse 'Y' was asked about R54's use of tube feeding and reported that was due to come down at 10:00 AM. When asked to confirm R54's tube feeding rate, Nurse 'Y' reviewed the order via the electronic medical record (EMR) and reported the rate was to be set at 78. Nurse 'Y' was asked to observe R54's tube feeding pump and confirmed the rate on the pump was set to 75 and not 78. Nurse 'Y' was asked about the total ML's R54 should've received to be completed with their feeding and reported R54's tube feeding container held only 1000 ml total so a second bag should be hung to complete the total enteral nutrition of 1250 ml's. When asked about the incorrect tube feeding rate, Nurse 'Y' reported they were not sure why the previous nurse did that, but someone didn't put the rate high enough. Nurse 'Y' further reported that the order calls for the tube feeding to be down at 10 AM or until full dose completed, so they would need to hang another bag of tube feeding and whoever hung it on midnight shift should've put the correct rate in. Review of the clinical record revealed R54 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R54 had unclear speech, had severe cognitive impairment, required extensive assistance of one person for bed mobility, was total dependent upon two or more people for transfers, weighed 133 lbs, had no weight changes, and received 51% or more total calories from the tube feeding and 501 cc/day or more for fluid intake per day by IV or tube feeding. Review of the nutritional care plans revealed they were initiated on 5/3/21 and last reviewed/revised on 5/17/22. I have the potential for a nutritional/hydration problem r/t (related to) dx (diagnosis) of dysphagia, dementia, mood disorder, anxiety, [CONDITION(S)] (Hypertension), GERD (Gastro-[CONDITION(S)] reflux disease), [CONDITION(S)], muscle weakness, subdural hemorrhage, [CONDITION(S)]. I am dependent on enteral feeding and hydration to meet 100% of my estimated nutrition needs. My diet order is NPO (nothing by mouth). Interventions included: Feeding Techniques I require: provide my TF (Tube Feeding) and water flushes as ordered. Monitor my weight. Report any significant weight changes I have to my physician and Me/DPOA/Guardian. Review of R54's documented weights revealed since February 2022 revealed the following: - 8/2/22 at 11:51 AM = 120.8 lbs (This was a severe loss of 11.7 lbs/8.83% in less than 30 days).) - 7/5/22 at 11:06 AM = 132.5 lbs - 6/7/22 at 10:47 AM = 133.8 lbs - 5/13/22 at 10:03 AM = 139.5 lbs - 2/15/22 at 2:59 PM = 125.1 lbs. There were no weights obtained for March, April, or upon R54's readmission on 7/15/22 following a peg-tube replacement. There were no additional weights obtained since 8/2/22 (such as a re-weight to determine accuracy or other factors). Review of the nutritional progress notes revealed: RD 'X' completed an assessment on 7/20/22 upon the resident's readmission which read, .My weight history is. <sic> Current BMI (Body Mass Index) of 21.4, indicating normal range, Wt (weight) stable x 180 days .I am at nutritional risk d/t (due to): S/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] .CBW: 132.5 lbs (pounds), BMI 21.4 indicating normal range .per RN (Registered Nurse) staff is tolerating TF (Tube Feeding) .No reports of .TF intolerance, Current TF: [MEDICATION(S)] 1.5 1000 ml @63ml/hr x 16 hrs .Current regimen likely meeting nutritional needs aeb (as evidenced by) wt stability x 180 days. Rec (Recommend) to continue w/POC (with plan of care). Monitor wt, skin, labs & TF tolerance, RD to follow . The next nutritional assessment was not until 8/25/22 which read, .CBW: 120.8 lbs, BMI 19.5 indicating normal range. Triggered for sig (significant) wt loss of -5% x 30 days (-11lbs) .Per RN, resident is tolerating TF .Res has hx (history) of wt fluctuating x 1 year: (approximately) 120-130lbs. Per RN, recommended increasing TF to 1250ML .Monitor wt .RD to follow. (The resident had severe weight loss, not significant as identified in this assessment.) There was no documentation of any evaluation of R54's severe weight loss from 8/2/22, until 8/25/22. Additionally, although the practitioner increased the resident's tube feeding rate on 8/25/22, their evaluation notes from 8/5/22 and 8/29/22 did not address the severe weight loss, or address any resident specific nutritional concerns. On 8/31/22 at 9:25 AM, an interview and record review were conducted with RD 'X'. When asked if there were any re-weights obtained that might not be in the EMR, RD 'X' reported there were none as R54's weights were done monthly. When asked about the delay in nutritional assessment and monitoring following the severe weight loss on 8/2/22, RD 'X' was unable to offer any explanation. When asked what their process was for weight discrepancies, RD 'X' reported they would have to follow up, but at a minimum should be once a month. When asked if weight changes or discrepancies were discussed in interdisciplinary meetings, they reported they had just done that on 8/25/22. When asked if they had been notified or aware of R54's weight loss on 8/2/22 and if there was any alert in the electronic record, they indicated there was an alert and they addressed it on 8/25/22. When asked why it took until 8/25 to address the resident's severe weight loss, especially for a resident that received all their nutritional via enteral feeding, they were not able to provide any explanation. When asked if the practitioner had addressed the weight/nutritional needs, RD 'X' reported they saw the resident on 8/29/22. Upon review of the physician note on 8/29/22, RD 'X' confirmed there was no mention of any nutritional concerns. RD 'X' was asked to obtain a current weight and reported they would arrange. On 8/31/22 at 9:45 AM, an observation of R54's weight was completed with Nurse 'Y' and Certified Nursing Assistant (CNA 'W'). R54's weight was obtained via use of a Hoyer lift that had a built-in weight scale. Prior to obtaining the weight, the nursing staff did not ensure the scale was set to zero (to ensure accurate weight was obtained). The weight observed was 124.9 lbs. When asked about the process for using the digital scale prior to getting the resident's weight, CNA 'W' reported it should have been completely zero' d out. On 8/31/22 at 10:37 AM, an interview was conducted with the Regional RD (RD 'Z') and RD 'X'. RD 'Z' reported they came to the facility on ce weekly to provide oversight. When asked about how the weights should be obtained, RD 'Z' reported an in-service would have to be done as the scale should've been set to zero to begin with. RD 'Z' also reported that the resident should have been placed on weekly weights and was unable to offer any explanation as to why this had not been done. Additionally, RD 'Z' was asked about if they were able to identify a severe weight loss if there was no documentation of any issues with the resident tolerating the tube feeding, and if it were possible the wrong rate of tube feeding could also contribute, they reported that could and confirmed they had concern with the delay in identification of the resident's weight loss, and delayed interventions and would have to follow up. A request was made for the facility's documentation on monitoring weights and nutritional status, however there was no further documentation provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to provide medically related social services to address behavior and mood management and coordinate ancillary services for two (R19 and R54) of three residents reviewed for Social Services, resulting in R19 being in a continuous state of distress, sobbing, and yelling; R54's documented statements of wanting to die being unaddressed, and a delayed audiology appointment for R19. Findings include: Review of a facility policy titled, Behavior Management Program, revised 12/2020, revealed, in part, the following: Residents who display mental disorder .psychosocial adjustment difficulty .should receive appropriate services as indicated to optimize the resident's overall wellbeing .Identified behaviors should be evaluated for frequency, duration, intensity and pattern .The Interdisciplinary Team should decide which residents need a behavior management program by evaluating the documented behaviors .The plan of care should be reviewed at least quarterly and as needed for continued need of behavior management and appropriate interventions .Behaviors should be identified and approaches for modification or redirection should be included in the plan of care . R19 On 8/28/22 at 12:33 PM, R19 was observed seated in a wheelchair near the nurse's station on the East Wing with a family member. At that time, the family member was concerned about R19 being lethargic and a call was made to the physician who evaluated R19 via a video call and reported she appeared over sedated. On 8/28/22 at 1:08 PM, R19 remained seated in a wheelchair near the nurse's station calling another resident vulgar names. R19 stated, We call each other [expletives] for fun. On 8/28/22 at 4:14 PM, R19 was observed seated in the same spot on the East Wing, sobbing uncontrollably with tears running down her cheek, yelling Let me go! Just let me go! Conversation was attempted with R19, but she was inconsolable. Staff were not observed to do anything to attempt to calm R19 down. On 8/28/22 at 5:09 PM, R19 was seated near the East Wing nurse's station which was also near the Director of Nursing's (DON) office. R19 was screaming loudly and crying and a plate of food was observed on the table in front of the resident. Nurse 'B' walked by R19 without addressing her. R19 repeated, They just leave me. They leave me alone. I can't do it!. The DON and a Certified Nursing (CNA) Assistant approached R19 and said, Let's eat (R19) and walked away. R19 began crying when the staff walked away and continued to yell, I can't do it! I can't do it! I want to go! Let me go! At 5:12 PM, the DON told R19 to let the staff finish passing meal trays and the CNA told R19 she would be right back. R19 continued screaming and sobbing and stated, I can't do it! I can't do it! Help me! Help me! At 5:16 PM, Nurse 'B' was observed seated behind the nurse's station desk and the DON was inside her office. Staff was not observed to address R19's distress. At 5:20 PM, Nurse 'B' sat down next to R19, 20 minutes later, and assisted her with eating and R19 calmed down. On 8/28/22, multiple observations were made of R19 between approximately 1:30 PM and 6:00 PM seated in the same spot near the East Wing nurse's station with minimal interaction from the staff. R19 remained tearful with almost continuous sobbing, crying, and yelling out for her family throughout this time frame, repeating the phrase, Let me go! On 8/29/22 at 9:01 AM, the door to R19's room was observed to be closed (it would not stay open). R19 was observed positioned poorly in bed, slouched down under an over the bed table that contained a breakfast tray. Food was observed to be all over R19's clothing and bed sheets and she was having difficulty eating it. R19 was sobbing and said she wanted to be up in the wheelchair outside of the room. R19 started screaming and crying, stating, Just let me go! R19 continued crying and reported various things about family members, that they were mean and she did not like them and to just let me go! At 9:09 AM, the DON entered R19's room (the door remained closed) and stated, Eat your breakfast sweetie. You are doing a good job. The DON left the room and did not address R19's crying. R19 continued to yell after the DON left the room stating, They leave me! They leave me alone! At 9:20 AM, a CNA entered R19's room and R19 calmed down while the CNA was in the room. On 8/29/22 at 1:58 PM, R19 was heard yelling and sobbing loudly (it was heard from another wing of the facility). Upon entrance to the East Wing, R19 was observed seated in a wheelchair near the nurse's station of the East Wing. CNA 'QQ' was observed seated at the nurse's station while R19 screamed. On 8/29/22 at 2:10 PM, R19 was observed yelling, sobbing, and nonsensically repeating, Let me go!. CNA 'RR' was observed on the unit. When queried about R19's distressing emotional behavior at that time, CNA 'RR' reported R19 just wanted to go home. When queried about what should be done to address her distressed mood, CNA 'RR' reported she would get her some crayons and the proceeded to place crayons, a coloring book, and word search puzzle book in front of R19. R19 continued to cry uncontrollably, yelling out for another staff member (CNA 'SS'). When queried about what should be done if R19 could not be consoled, CNA 'RR' reported she could report it to the nurse but she did not know where the nurse was. On 8/29/22 at 2:24 PM, R19 continued to yell out for CNA 'SS' and continued to cry. R19 was asked if she was able to do the word search puzzle that was placed in front of her and she responded, No! and continued to cry and state, Let me go! On 8/29/22 at 2:35 PM, CNA 'SS' arrived on the unit. R19 continued to call out her name over and over. When CNA 'SS' approached R19, she asked the resident if she wanted to attend the birthday party and have some cake. R19 stopped yelling and stated, Birthday party? CNA 'SS' explained to R19 that she had to remain calm and she could attend the party located in the dining room. R19 remained calm at that time. At 2:37 PM, CNA 'SS' told R19 that she would go get her some cake and did not take her to the birthday party. No cake was provided to R19 and she was not taken to the birthday party. On 8/29/22 at 3:24 PM, R19 remained seated near the nurse's station on the East Wing, yelling, crying, and restless. Activities Director 'AA' was present nearby R19 on the East Wing and was not observed to engage with R19 or offer an activity. On 8/30/22 from 5:00 PM until 5:18 PM, R19 was observed seated in a wheelchair inside her room with the door open only a crack (the door would not stay open). R19 was near the door and was yelling and sobbing. At 5:30 PM, R19 was observed in her room in a wheelchair yelling and sobbing. R19's dinner plate was observed to be placed on the bed. On 8/31/22 at 2:42 PM, R19 was observed lying in bed sobbing. The door was closed and the television was on. R19 could be observed from the hallway crying while in bed. Review of R19's clinical record revealed R19 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: metabolic [CONDITION(S)], seizures, major depressive disorder, expressive language disorder, [CONDITION(S)], [CONDITION(S)], psychotic disorder, nontraumatic subdural hemorrhage, and pseudobulbar affect. Review of R19's Minimal Data Set (MDS) assessments revealed the most recent MDS due on 8/2/22 had not yet been completed. Review of the last MDS assessment completed on 5/2/22 revealed R19's cognition and behavior symptoms were not assessed. On 8/31/22, a review of R19's progress notes was conducted. There was no documentation from nursing, social services, or a medical provider regarding the distressing emotional symptoms R19 had on 8/28/22, 8/29/22, 8/30/22, and 8/21/22. Review of the last documented social services progress note revealed on 8/2/22 R19 expressed wanting to die and wanting to go home. On 8/31/22 at 3:00 PM, Social Services Assistant (SSA), who was also the Activities Director in the facility, SSA 'AA', was interviewed. When queried about what was in place to address R19's mood and behaviors, SSA 'AA' reported there was currently nothing in place to address R19's mood and behaviors and stated, There is one staff person, but I'm not sure of her name, who can calm her down. Review of R19's care plans revealed the following: A care plan initiated on 6/3/22 and revised on 6/23/22 that documented, I use anti-psychotic medications r/t (related to) Behavior management, DX: psychotic disorder with delusions, resident yells out, and will place self onto floor . Documented interventions included: Administer medications as ordered .AIMS per policy .Educate .about risks, benefits and the side effects and/or toxic symptoms of the medication I am on .I am followed by (behavioral health provider) for psychoactive medication management) .keep resident from obtaining a major injury .Mattress placed at bedside . A care plan initiated on 6/3/22 that documented, I use Antidepressant or Mood Stabilizer medication r/t Depression. Documented interventions included: Document on (CNA electronic documentation system) and report to social work PRN (as needed) s/sx (signs and symptoms) of depression (initiated 6/3/22), Give antidepressant medications ordered by physician . There was no care plan developed that included individualized specific goals and interventions for R19's mood and behaviors. Review of CNA documentation for the past 30 days revealed one documentation on 8/6/22 of R19 being Verbally Aggressive. There was no additional documentation of any mood or behavior symptoms for R19. Review of a Behavior Management Program Review and Symptoms Analysis assessment dated [DATE] revealed, .Behavior Review Necessity .Does this Resident have any targeted behaviors and/or symptoms of depression that require being on the Behavior Management Program or Receiving ANY psychoactive medications, including PRN doses? Yes .Behavior Assessment Behavior #1 .Type of Behavior: yelling out .daily .Possible root cause: Disease process .Identified patterns/comments: Dx: psychotic disorder with delusions, mood disorder (It should be noted that the assessment did not document any identified patterns) .Behavior #2 .throwing self on floor .quantity: 0 .identified patterns/comments: Dx: psychotic disorder with delusions, mood disorder .Mood symptoms: .Mood swings .Crying .Statements of depression .Quantity/Frequency: Sometimes .Interventions: Varies .Possible Root Cause: Disease Process .Identified patterns/comments: Dx: psychotic disorder with delusions, mood disorder . It was documented the antipsychotic medication and antidepressant medication effectiveness was very good and that care plans were in place. Review of the CNA Kardex revealed the following interventions for Behavior/Mood: keep resident from obtaining major injury, psych eval. On 8/31/22 at 3:35 PM, the DON was interviewed. When queried about what was in place to address R19's distressed mood and behaviors, the DON initially reported she did not know who the resident was (she began working in the facility approximately one week prior). When the above observations were shared with the DON and SSA 'AA's explanation that there was no plan in place to address R19's mood and behavior symptoms, the DON reported that was unacceptable and there should be individualized interventions in place. At that time, the DON was given an opportunity to provide any additional information. No additional information was provided prior to the end of the survey. Further review of R19's clinical record revealed an active Physician's Order dated 8/5/22 for an audiology consult. Review of R19's progress notes revealed the following: A Practitioner Progress Notes dated 8/5/22, written by PA 'NN', documented, .seen per request for ear pain and decreased hearing .abrasion noted to back of right ear .left ear pain/abrasion/decrease hearing .audiologist to see . On 8/31/22 at 3:00 PM, SSA 'AA' was interviewed. When queried about whether R19 had been seen by the audiologist, SSA 'AA' reported they only came to the facility every few months. SSA 'AA' was not sure if R19 was on the list to be seen. When queried about whether any arrangements were made for R19 to go to an audiologist outside of the facility, SSA 'AA' reported none were made. On 9/6/22 at 1:04 PM, Regional Clinical Director of Operations 'LL', who was filling in for the DON on that day, was interviewed. When queried about why R19 had not yet seen an audiologist, Regional Clinical Director of Operations 'LL' reported he would look into it. Regional Clinical Director of Operations 'LL' followed up and reported no appointment had been made for R19 and she should have been sent to an outside audiologist since she had pain. A policy regarding ancillary services was requested from the Administrator on 8/31/22 at 3:24 PM. The policy was not received prior to the end of the survey. R54: On 8/31/22 at 9:43 AM, R54 was observed lying in bed with a thin bedsheet covering their body. The resident did not respond upon approach. Staff in the hallway outside the room reported this was common for the resident to pull the sheet up over their face. Review of the clinical record revealed R54 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: [CONDITION(S)] disease, anxiety disorder, mood disorder due to known physiological condition with major depressive-like episode, and dementia in other diseases classified elsewhere without behavioral disturbance. According to the MDS assessment dated [DATE], R54 had unclear speech, had severe cognitive impairment, had mood concerns such as feeling down, depressed, or hopeless, for 2-6 days during this assessment period of seven days. Review of the care plans included a mood care plan initiated 3/7/21, last revised on 10/1/21 which read: There are times when I may demonstrate sad effect/mood secondary to remaining in the nursing home currently and my medical condition. I receive psych meds for my DX (Diagnosis): anxiety, mood disorder, major depression. Review of the most recent social service assessment included a quarterly review dated 8/1/22 which read, .What is their Mood? .feels down .Behaviors .anxiousness, depressed .Areas <sic> Social Services will be monitoring mood and behavior . Review of the most recent social services assessment was on 8/1/22 from former Social Services Staff (SS 'II') which noted, .Statements of depression .varies .DX: mood disorder with major depressive like episodes, Anxiety . The section for review of behaviors only noted care plans in place. Review of the most recent psychiatric note included an entry on 7/28/22 at 11:19 AM which included, .Has history of depression and self injurious actions due to confusion and agitation .He was awake but confused an overall though process reduced from baseline. He mumbled a brief single word in response to simple questions. Otherwise he was confused and offered no spontaneous comments. Mood was bland with dull affective range . Review of R54's progress notes included an entry from an unidentifiable agency nurse (only noted as RN/LPN Agency 2022) on 8/28/22 at 7:12 AM which read, .resident verbalized wanting to die. states, I am sorry for what i did. (The earlier entry noted the resident pulled out their feeding tube.) Review of the behavior documentation in the clinical record (which was noted as being a behavior for Question 1 in most resident records asked staff, Did the resident exhibit signs or symptoms of wishing for death/wanting to die? revealed there was no documentation. The review noted No Data Found. There was no documentation that social services, or a practitioner had been notified of R54's expression of wanting to die as noted in the progress notes. On 8/31/22 at 10:30 AM, Social Services Assistant (Staff 'AA') was asked if they had been notified that R54 was making statement about wanting to die on 8/28/22 and they reported no one had mentioned anything to them. When asked what should've happened, they reported they should've been notified immediately and followed up. When asked if they were aware of the resident's history of self-injurious actions, they reported they were not.

Deficient Practice #1 Based on interview and record review, the facility failed to implement their policy and ensure accurate tracking and adminstration of the pneumococcal vaccinations for residents residing in the facility for three (R66, R69 and R70) of ten residents reviewed for pneumococcal vaccinations resulting in facility acquired pneumonia and hospitalization . Findings include: Review of a facility policy titled, Pneumococcal Vaccine (Series) revised 12/2020 read in part, .It is our policy to offer our resident immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations . Each resident will be assessed for pneumococcal immunization upon admission . Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders . Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization .The individual receiving the immunization, or the resident representative, will be provided with a copy of CDC's current vaccine information statement relative to that vaccine .The resident/representative retains the right to refuse the immunization. A consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record. The type of pneumococcal vaccine (PCV13 - pneumococcal conjugate vaccine, PPSV23/PPSV - pneumococcal polysaccharide vaccine) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations .The resident's medical record shall include documentation that indicates at a minimum, the following: .The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization .The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. Review of the CDC publication titled, Pneumococcal Vaccination: What Everyone Should Know read in part, .Pneumococcal disease is common in young children, but older adults are at greatest risk of serious illness and death . CDC recommends pneumococcal vaccination for all children younger than 2 years old and all adults [AGE] years or older. In certain situations, older children and other adults should also get pneumococcal vaccines . PCVs (Pneumococcal conjugate vaccine): CDC recommends PCV13 for: All children younger than 2 years old; Children 2 through [AGE] years old with certain medical conditions. For those who have never received any pneumococcal conjugate vaccine, CDC recommends PCV15 or PCV20 for: Adults [AGE] years or older; Adults 19 through [AGE] years old with certain medical conditions or other risk factors . PPSVs (Pneumococcal polysaccharide vaccine): CDC recommends PPSV23 for: Children 2 through [AGE] years old with certain medical conditions; Adults [AGE] years or older who receive PCV15 . There are 4 pneumococcal vaccines licensed for use in the United States by the Food and Drug Administration . On 8/31/22 at 8:44 AM, as part of a review of the facility's infection control program Licensed Practical Nurse (LPN) A, who was an Infection Control Preventionist (ICP) and served as the Infection Control Nurse (ICN) was interviewed and asked how it was determined which pneumococcal vaccine each resident received. ICN A explained she did not know, but would check the resident's chart and look at their policy to determine what vaccine should be given. When informed there were four different pneumococcal vaccines, and the vaccine given was dependent on the resident's age and medical conditions, ICN A explained she was not aware of the different pneumococcal vaccines or the requirements for each vaccine. ICN A was asked if any pneumococcal vaccinations had been given at the facility. ICN A explained did not know of any that had been given, but would check to see when any had been given to a resident. On 8/31/22 at 1:08 PM, ICN A provided documentation that the last pneumococcal vaccination had been given at the facility on 7/27/21. On 8/31/22 at 1:10 PM, three residents (R66, R69 and R70) were selected to review for screening and assessment for eligibility to receive the pneumococcal vaccination, education about risks and benefits of receiving the pneumococcal vaccination, and evidence of administration of the vaccination, if eligible and consent or refusal was given to be immunized. R66 Review of the clinical record revealed R66 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R66's progress notes revealed a Practitioner note dated 7/25/22 at 9:15 PM that read in part, .Pt seen for f/u (follow up) on . pneumonia . CXR (chest x-ray) showed RLL infiltrate. Pt reports worsening cough from baseline w/ yellowish sputum . A Practitioner note dated 7/26/22 at 8:45 read in part, .Assessment and plan: .To be sent to the ER at (Local Hospital) for evaluation . Review of R66's immunization record revealed no documentation of any pneumococcal vaccine. Review of R66's consents revealed no consent or refusal for any pneumococcal vaccine. R69 Review of R69's clinical record revealed R69 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R69's progress notes revealed a Practitioner note dated 1/10/22 at 6:35 PM that read in part, .pt seen and examined for f/u on recent dx (diagnosis) of LLL (left lower lobe) pneumonia .On evaluation pt is [CONDITION(S)] (elevated heart rate) . Pulse ox (measure of oxygen level in the blood) 74% (normal range 95-100%) on my exam, re-checked on different finger 75% . pt will be sent to the ER for [CONDITION(S)] and [CONDITION(S)] and to R/O (rule out) [CONDITION(S)] . Review of R69's immunizations revealed no documentation of any pneumococcal vaccine. Review of R69's consents revealed no consent or refusal for any pneumococcal vaccine. R70 Review of R70's clinical record revealed R70 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R70's progress notes revealed a Practitioner note dated 3/30/22 at 5:11 AM that read in part, .Altered/ mental status and resp distress -recently started on antibiotics for right bronchopneumonia/ oxygenating adequately but breathing at a rate of 40 per minute (normal rate 8-16) . Respiratory distress - Pneumonia likely a urgent Iso [sic] now causing [CONDITION(S)]/ ? PE (pulmonary embolism) - needs more active interventions . To be transferred to (Local Hospital) ER immediately . Review of R70's immunizations revealed no documentation of any pneumococcal vaccine. Review of R70's consents revealed no consent or refusal for any pneumococcal vaccine. On 8/31/22 at 3:04 PM, ICN A was asked to confirm that no residents at the facility had received a pneumococcal vaccine since 7/27/21. ICN A confirmed the date. When asked why, ICN A explained she had no idea of why as she had only been the ICN for a couple of weeks. ICN A was asked how consents for vaccinations were obtained. ICN A explained it was the admitting nurse who got the consents, but it depended on the nurse doing the admission whether they got them or not. When asked who was responsible for ensuring consents were obtained and vaccines given, ICN A explained she did not know. On 8/31/22 at 3:47 PM, Regional Clinical Director of Operations (RCDO) U was interviewed and asked why no pneumococcal vaccinations had been given at the facility since 7/27/21. RCDO U explained it was a big concern that no vaccines had been given, but she could not say why they had not been given. When asked who was responsible for ensuring consents were obtained and vaccines given, RCDO U explained the admitting nurse gets the consent then gives the consent to the Director of Nursing (DON) who puts in the order for the vaccine. On 8/31/22 at 4:20 PM, the DON was interviewed and asked if she was aware no pneumococcal vaccines had been given since 7/27/21. The DON explained she had not known because she had only been DON for a week, but that it was a big concern especially due to the time of the year. It should be noted that pneumococcal vaccines can be given any time of the year, there is no season. On 8/31/22 at 4:47 PM, RCDO U provided a Vaccine Consent Form Influenza/Pneumonia/Covid-19 for R66 from their admission packet. The form was not filled out except for R66's name, birth date and admitted , all the choices were blank, nor was it signed. RCDO U explained it was not the admitting nurse, but the Admissions Department that would obtain the consents, but she had not even been physically at the facility, she had been in a different building. RCDO U was asked how someone who had no clinical background provided education of risks versus benefits of the vaccine and answer questions about vaccinations, and get a signed consent if they were not physically there. RCDO U had no answer. Deficient Practice #2 Based on interview and record review the facility failed to provide the influenza vaccinations to one (R15) of five residents reviewed for influenza vaccinations. Findings include: Review of a facility policy titled, Influenza Vaccination revised 12/2020 read in part, .It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza . Influenza vaccinations will be routinely offered annually during flu season unless such immunization is medically contraindicated . following assessment for potential medical contraindications, influenza vaccinations may be administered in accordance with physician-approved standing orders . Review of R15's immunizations revealed on 10/27/20, R15 had received the Influenza vaccination. There was no documentation for 2021. Review of R15's consents revealed a Pneumococcal and Influenza Immunization Consent Form marked Accept and dated 7/19/21. On 8/31/22 at 8:44 AM, ICN A was interviewed and asked why R15 did not receive their Influenza vaccination when there was a signed consent. ICN A explained she did not know and would look into the matter. On 8/31/22 at 1:08 PM, ICN A confirmed R15 did not receive an Influenza vaccine after signing the consent to get one. When asked why R15 did not get the vaccine, ICN A had no answer.

This citation has two deficient practice statements (DPS). DPS #1 Based on interview, and record review, the facility failed to ensure Hospice Services were provided per plan of care for one resident, (R61) of one resident reviewed for Hospice Services, resulting in R61 not receiving the provision of Hospice Care. Findings include: A review of a facility provided policy titled, Hospice Services Facility Agreement with a revision date of 12/2021 was conducted and read, Policy: It is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence .3. If hospice care is furnished in the facility through an agreement, the facility will: a. ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services . On 8/28/22 at 1:02 PM, R61 was observed in their room lying in a fetal position in a low bed. R61 had the covers pulled over their head, and was not responsive to attempts at verbal conversation. On 8/31/22 at 9:23 AM, a review of R61's Hospice Service binder was reviewed and a document that named R61's Hospice Team. The document named Registered Nurse (RN) 'WW' as the Primary Nurse, Social Worker 'XX', Chaplain 'YY, and RN 'ZZ' as the Team Director. It was noted no one had been named as R61's Certified Health Aide. It was also noted there was no schedule in the binder that indicated hospice staff visits. that A review of the progress notes in the binder was conducted and revealed the only visits documented were a one time weekly visit from RN 'WW'. A review of a HOSPICE TEAM VISIT CALENDAR was contained in the binder and noted to be blank. A review of a Plan of Care Update Report dated 7/27/22 was reviewed and read, Client Orders .HOME HEALTH AIDE SERVICE FOR ASSISTANCE WITH PERSONAL CARE, HYGIENE, AND ACTIVITIES OF DAILY LIVING . On 8/31/22 at 9:36 AM, it was reported the Director of Nursing (DON) was the staff member responsible for coordinating the care between the facility and the Hospice Company. At 9:39 AM, the DON was informed the only documented hospice visits were a one time weekly visit by RN 'WW'. They were asked if they knew about a Hospice Aide, Social Worker, or any Spiritual Care coming in and said they would reach out to the Hospice company to see if they had any additional information. On 8/31/22 at 9:51 AM, the DON reported R61 came from a sister facility on Hospice Services. They further reported the Nurse comes one time a week and the Hospice company would only send an aide if there were five or more patients receiving their services in the building. On 8/31/22 at 10:21 AM, a review of R61's clinical record revealed they admitted to the facility on Hospice Services on 7/21/22 from a sister facility. R61's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R61's Minimum Data Set assessment dated [DATE] indicated R61 had moderately impaired cognition and needed total assistance from staff for activities of daily living. On 8/31/22 at 4:31 PM, the DON provided additional information faxed from the Hospice company. The Information provided included a document titled, FACILITY INTEGRATION TOOL that indicated R61 was to have a Hospice nurse visit once weekly and a Hospice aide visit once weekly. The additional documentation also indicated a Hospice Aide had been in the facility on 8/30/22, but no evidence was provided the aide had seen the patient between their admitted [DATE] and 8/30/22. It was further noted the document provided indicated a Social Worker had seen the resident on 8/11/22, but no progress note addressing the visit was provided. DPS #2 Based on observation, interview, and record review, the facility failed to ensure wound care treatments and leg wraps were provided per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: On 08/28/22 at 12:49 PM, R268 was observed in their room in their chair. R268 was asked about their stay in the facility and verbalized complaints about staff not changing the dressings on their legs and not knowing how to properly wrap their legs. R268 said they had [CONDITION(S)] and wounds. With R268's permission their legs were observed. The right leg was observed wrapped with a white bulky wrap and the left leg was observed wrapped with a flesh-colored self-adherent wrap. It was observed neither wrap was dated. R268 was asked the last time the wraps had been changed and said it had been three days. On 8/29/22 at 8:51 AM and 8/30/22 at 11:30 AM, R268's leg wraps were observed. It was observed the right remained with undated white bulky wrap and the left with undated self-adherent wrap. R268 was asked if the dressings had been changed and said they had not. On 8/29/22 at 2:15 PM, a review of R268's clinical record was conducted and revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R268's Minimum Data Set assessment dated [DATE] had not yet been completed but Section C. Cognition had been completed and documented intact cognition. On 8/30/22 3:52 PM a review of R268's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It was noted the treatment had not been documented as completed on 8/27/22 or 8/29/22. Continued review of the TAR revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . It was noted the treatment to the right leg had also not been signed off as completed on 8/27/22 or 8/29/22. On 8/30/22 at approximately 4:00 PM the facility's Director of Nursing was made aware of the concerns with R268 and acknowledged the concern.

This citation pertains to intake #MI 225 Based on observation, interview, and record review, the facility failed to follow the Center for Disease Control (CDC) protocol for COVID-19 ensuring that current infection control principles/CDC protocols were practiced including appropriate personal protective equipment (PPE) use, and ensuring staff were knowledgeable of residents requiring isolation precautions for COVID-19 rooms which resulted in an Immediate jeopardy (IJ). This deficient practice caused the outbreak of COVID-19 in the facility, the need to transfer a resident to an acute care setting and the likelihood for serious harm, injury, and or death. The IJ began on 5/2/22. The IJ was identified on 5/3/22. The facility was notified of the IJ on 5/3/22 at 12:46 p.m., A plan to remove the immediacy was requested. The immediacy was removed on 5/3/22 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 5/2/22 at approximately 9:00 AM, the facility's Administrator and Director of Nursing (DON) reported the facility was experiencing a COVID-19 outbreak and had several active cases in their building. They reported the 1 East Unit (Rooms 136-150) had been designated for COVID-19 positive residents and those residents were placed on transmission-based precautions. They further reported some rooms in the Center Hallway (Rooms 117-135) were designated for new admissions who had not been vaccinated for COVID-19 and those residents were also placed on transmission-based precautions. On 5/2/22 at approximately 11:00 AM, a review of a facility provided list of staff and residents positive for COVID-19 was reviewed and revealed the following: LPN 'D' tested positive on 4/12/22 R728 tested positive 4/12/22 LPN 'X' tested positive 4/16/22 Staff Member 'Y' tested positive 4/18/22 Registered Nurse 'O' tested positive 4/19/22 R721 tested positive 4/21/22 R722 and R725 tested positive 4/25/22 R#'s 720, 723, 726, and 727 tested positive 4/28/22 R724 tested positive 4/30/22 R719 tested positive 5/1/22 On 5/2/22 at 11:20 AM, room [ROOM NUMBER] was observed to have signs posted that indicated the room was a transmission-based precaution room and personal protective equipment (PPE) including: an N95 face mask, eye protection, isolation gown, and gloves were required for entry. At that time, Receptionist 'F' was observed outside of the room wearing a black, ear loop style surgical mask. Receptionist 'F' was then observed to don an isolation gown, eye protection, and gloves and entered the room, but was not observed to don an N95 face mask prior to entering the room. On 5/2/22 at 2:45 PM, R719's room was observed to have signs posted that indicated the room was a transmission-based precaution room and personal protective equipment (PPE) including: an N95 face mask, eye protection, isolation gown, and gloves were required for entry. At that time, Housekeeper 'N' was observed to exit room [ROOM NUMBER] wearing a blue, ear loop style surgical mask, an isolation gown, eye protection, and gloves. Housekeeper 'N' was observed to remove their used PPE in the hallway and place it in the garbage can on the housekeeping cart. On 5/22/22 at 2:50 PM, R722 and R723's room was observed to have signs posted that indicated the room was a transmission-based precaution room and personal protective equipment (PPE) including: an N95 face mask, eye protection, isolation gown, and gloves were required for entry. At that time, Certified Nursing Aide (CNA) 'J' was observed outside of the room wearing a blue, ear loop style surgical mask, preparing to enter the room. CNA 'N' donned the eye protection, gown, and gloves and entered the room. CNA 'N' was not observed don an N95 mask prior to entry. On 5/2/22 at 3:50 PM, a review of R#'s 719, 720, 721, 722, 723, 724, 726, 726, and 727 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at approximately 4:20 p.m., Family Member A (FM A) was queried regarding their concerns pertaining to infection control in the facility. FM A indicated the facility has a problem with COVID-19. FM A indicated they were concerned about the way staff were wearing their masks and indicated they have seen COVID-19 positive residents out of their room and wheeling up and down the hallway. On 5/3/22 at 8:35 AM, R720 and R721's room was observed to have signs posted that indicated the room was a transmission-based precaution room and personal protective equipment (PPE) including: an N95 face mask, eye protection, isolation gown, and gloves were required for entry. From the hallway CNA 'L' and CNA 'M' were observed in the room assisting R721. CNA 'L' and CNA 'M' were not observed to be wearing isolation gowns, gloves, or N95 masks while in the room. When the staff exited the room CNA 'L' was asked what PPE should be worn in the room. CNA 'L' reported they were supposed to wear an N95 mask, isolation gown, eye protection, and gloves. They were then asked why they were not observed wearing the N95 mask, isolation gown, or gloves and said, I forgot. On 5/3/22 at 11:20 AM, R726 and R727's room was observed to have signs posted that indicated the room was a transmission-based precaution room and personal protective equipment (PPE) including: an N95 face mask, eye protection, isolation gown, and gloves were required for entry. From the hallway, Housekeeper 'P' was observed in the room wearing an N95 mask with two straps, the bottom strap intended for the back of the neck and the top strap intended to be worn on the crown of the head. Housekeeper 'P's mask was observed to be secured to their face by the top strap and the bottom strap was observed hanging under their chin. On 5/3/22 at 11:32 AM, Nurse Extern 'A' was observed wearing a blue, surgical, ear-loop style mask with a white N95 mask over the surgical mask, preventing a proper seal of the N95 mask. On 5/3/22 at 1:50 PM, Registered Occupational Therapist (OTR) 'Q' was observed preparing to enter a transmission-based precaution room wearing a blue, surgical, ear-loop style mask with a white N95 mask over the surgical mask, preventing a proper seal of the N95 mask. It was also noted the N95 mask was only secured by the top strap, while the bottom strap hung under OTR 'Q's chin. At that time, OTR 'Q' was asked about wearing an N95 mask over a surgical mask and said, It's for safety. They were then asked if they were educated about the proper use of N95 masks and ensuring a good seal to the face, and utilizing both straps, OTR 'Q' had no response, but said they would fix it when they went in the room. On 5/4/22 at 1:57 PM, Housekeeper 'P' was observed preparing to enter a transmission-based precaution room wearing a blue, surgical, ear-loop style mask with a white N95 mask over the surgical mask, preventing a proper seal of the N95 mask. At that time, they were asked if it was appropriate to wear a surgical mask under an N95 mask and said they did not know. On 5/4/22 at 2:01 PM, an interview was conducted with the facility's DON/Infection Control Preventionist regarding proper wearing of N95 masks. They were asked if it was appropriate to wear a surgical mask under an N95 mask and said they didn't see why staff couldn't wear two masks. They were then asked if an N95 mask would properly seal with a surgical ear-loop style mask underneath and said they did not know. At that time, they were requested to provide the package insert for the N95 masks used in the facility, however; it was not provided by the end of the survey. On 5/5/22 at 9:20 AM, CNA 'K' was observed donning PPE to enter a transmission-based precaution room. CNA 'K' was observed to don an N95 mask with only the top strap securing the mask to their face. The bottom strap was observed dangling underneath CNA 'K's chin as they entered the room. An interview with the facility's DON/Infection Control Preventionist was conducted on 5/3/22 at 10:02 AM regarding their COVID-19 outbreak. The DON reported that on 4/12/22 Licensed Practical Nurse (LPN) 'D' tested positive for COVID-19 and on 4/16/22 R728 tested positive. The DON said they did not know how R728 contracted the virus. At that time, the DON was asked what PPE staff were supposed to wear in the transmission-based precaution rooms and said staff were to wear an N95 mask, eye protection, an isolation gown, and gloves. The DON was then asked if staff should doff used PPE in the hallway and said they should not. They were then asked when staff other than nursing staff were last educated on PPE use and said, Probably December. The interview with the DON continued and they were then asked if residents on transmission-based precautions should have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/5/22 at 12:00 PM, a review of the facility's monthly infection control program documentation was conducted and revealed the following: January 2022: There was no monthly summary that indicated the type of infections, calculated infection rate, or month-to-month comparisons. The monthly infection control log (line listing) indicated all infections met the definition of infections, however; the line list did not include any information about resident symptoms of infection or laboratory diagnostics. The documentation indicated R732 admitted to the facility on [DATE] (had not been discharged ) and had a dental infection identified on 1/8/22. This infection was documented as a hospital acquired infection, not a nursing home acquired infection. The January documentation also indicated R730 admitted to the facility on [DATE] (had not been discharged ) and had a wound infection identified on 1/20/22. This infection was documented as a hospital acquired infection, not a nursing home acquired infection. The data did not include any pharmacy reports or laboratory/diagnostic results. February 2022: There was no monthly summary that indicated the type of infection, calculated infection rate, or month-to-month comparisons. The monthly infection control log (line listing) did not indicate whether all infections met or did not meet infection criteria and did not include any information about resident symptoms of infection or laboratory diagnostics. It was noted there was no departmental surveillance, pharmacy reports, or laboratory/diagnostic results. The documentation indicated R731 admitted to the facility on [DATE] (had not been discharged ) and had a urinary tract infection identified on 2/1/22. This infection was documented as a hospital acquired infection, not a nursing home acquired infection. The February documentation also indicated R725 admitted to the facility on [DATE] (had not been discharged ) and had a wound infection identified on 2/9/22. This infection was documented as a hospital acquired infection, not a nursing home acquired infection. March 2022: There was no monthly summary that indicated the type of infection, calculated infection rate, or month-to-month comparisons. The monthly infection control log (line listing) did not indicate whether all infections met or did not meet infection criteria and did not include any information about resident symptoms of infection or laboratory diagnostics. It was noted there was no departmental surveillance, pharmacy reports, laboratory/diagnostic results, or in-service or education provided. On 5/5/22 at 12:37 PM, an interview was conducted with the facility's DON/Infection Control Preventionist. They were asked how they determined an infection met criteria for definition of an infection and reported they used McGeer's Criteria (a set of criteria based on symptoms and laboratory/diagnostics to define an infection). They were asked why no evidence of infections meeting McGeer's criteria was present with the documentation, and they had no explanation. They were then asked about calculating a monthly infection control rate and admitted they did not know how to calculate the rate. They further reported the facility was challenged for staff and they taught themselves how to run the facility's Infection Control Program. Lastly, they were asked if there was any corporate support to assist them with the program and they reported there was not. A facility document titled Infection Prevention and Control Program was reviewed and revealed the following: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases, ectoparasites and infections .4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. d. Licensed staff shall adhere to safe injection and medication administration practices .All staff have responsibilities related to the cleanliness of the facility and are to report problems outside of their scope to the appropriate department .5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection communicable disease, or ectoparasite infestation shall be placed on isolation precautions as recommended by current CDC guidelines. b. Residents will be placed on the least restrictive isolation precaution for the shortest duration possible under the circumstances. c. When a resident on isolation precautions must leave the resident care unit/area the charge nurse on that unit shall communicate to all involved departments the nature of the isolation and shall prepare the resident for transport in accordance with current isolation precaution guidelines . The immediacy was removed when the facility implemented the following: -All current residents were assessed by a licensed nurse for signs and symptoms of respiratory illness. -All residents were re-tested for COVID-19 per outbreak protocol. 3. Staff members identified as not wearing proper PPE received written counseling and completed a PPE competency evaluation by the DON (Director of Nursing) on 5/3/22. -Education was provided to all working staff by the DON/Designee regarding appropriate utilization of PPE, Transmission Based Precautions, and Hand Hygiene. Employees who did not receive the education on 5/03/22 will received it via email and will receive in-person training before their next scheduled shift. -The Infection Preventionist and Administrator were educated by the Regional Clinical Director on the Infection Outbreak Response policy & Infection Prevention and Control Program.

This citation pertains to intake #MI 854 Based on observation, interview, and record review, the facility failed to ensure three unlicensed personnel (UP A, B and C) were appropriately qualified of 38 Nursing departmental staff reviewed for qualified personnel, had an active Nursing license to practice as a Licensed Practical Nurse (LPN) in the State of Michigan. This resulted in an Immediate Jeopardy (IJ) to the health and safety of the residents when UP A, B and C provided nursing services (including: medication administration, wound care, PEG (percutaneous endoscopic gastrostomy) care and [CONDITION(S)] care to six residents (R's 703, 713, 715, 717, 718 and 719) of six residents reviewed for qualified personnel. This had the likelihood to result in serious injury, serious harm, and/or death due to the potential risk of PEG tube complications, malfunction and/or dislodgement, Respiratory complications (from the [CONDITION(S)]), wound infections and medication errors. Findings include: The IJ began on 3/1/22. The IJ was identified on 5/3/22. The facility was notified of the IJ on 5/3/22 at 11:23 a.m., A plan to remove the immediacy was requested. The immediacy was removed on 5/4/22 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 with no actual harm with potential for more than minimal harm that is not immediate jeopardy. A review of the staffing credentials for UP A, UP B and UP C was reviewed and revealed the following: UP A had completed a Licensed Practical Nurse program on 4/27/21 but was not currently licensed to practice Nursing in the State of Michigan. UP B had completed a Licensed Practical Nurse program on 3/26/20 but was not currently licensed to practice Nursing in the State of Michigan. UP C had completed a Licensed Practical Nurse program on 4/27/21 but was not currently licensed to practice Nursing in the State of Michigan. Resident #713 On 5/2/22 the medical record for R713 was reviewed and revealed the following: R713 was initially admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R713's MDS (minimum data set) with an ARD (assessment reference date) of 1/21/22 indicated R713 needed extensive assistance from facility staff with most of their activities of daily living. R713's BIMS score (brief interview of mental status) was 15 indicating intact cognition. A review of R713's March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . UP A administered approximately 11 medications on 3/14/22 including [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. UP B administered approximately 15 medications on 3/10/22 including the [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. A review of R713's April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . UP A administered approximately 15 different medications to R713 on 4/17/22, 19 different medications on 4/22/22, 15 medications on 4/26, and 15 medications on 4/30. UP B administered approximately 15 different medications on 4/4, 16 medications on 4/20 and 15 medications on 4/28. Resident #715 On 5/2/22 the medical record for R715 was reviewed and revealed the following: R715 was initially admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R715's MDS (minimum data set) with an ARD (assessment reference date) of4/5/21/22 indicated R715 needed extensive assistance from facility staff with most of their activities of daily living. R715's BIMS score (brief interview of mental status) was 14 indicating intact cognition. A review of R715's March, April, and May 2022 treatment administration records (TAR) revealed the following: UP C completed would care dressings on 3/10, 4/14, 4/19, 4/21 and 4/29. UP A had documented as having completed wound care on 4/26. On 5/4/22 at approximately 11:04 a.m., The facility Medical Director was queried regarding their knowledge of UP A, B and C administering medications and completing treatments in the facility without an active Nursing license. The Medical Director indicated that it was not their responsibility to ensure staff are appropriately licensed to practice Nursing. On 5/5/22 at approximately 9:45 a.m., UP A was queried regarding the education of the supervision component that was required of them. UP A indicated that the facility educated them that they could no longer independently administer medications or do any blood work UP A indicated they now must be directly supervised by a Registered Nurse. UP A was queried if they have their own cart and assignments previously and they indicate they did and that they were permitted to administer medications. On 5/5/22 at approximately 10:21 a.m., Nurse W was queried regarding the education that they were provided regarding their responsibilities in providing supervision to UP A, B and C. Nurse W indicated that the unlicensed personnel are no longer permitted to do any blood work or administer any medications on their own. Resident #713 Review of the clinical record revealed R703 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) dated [DATE], R703 had moderate cognitive impairment, was usually able to make self-understood and sometimes understands others, was independent with setup help only for locomotion on and off the unit and used a wheelchair for mobility. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The entry at 12:00 PM was noted as initialed by Nurse Extern 'B'. Review of the electronic MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no further explanation as to whether the medication was not available for administration, or whether the physician had been notified of the missed administration for either entries above. On 5/3/22 at 2:30 PM, an interview was conducted with Registered Nurse (RN 'O'). They reported they were assigned to the middle hall. When asked who the nurse was that was assigned to the west hall, RN 'O' reported that was Nurse Extern 'B'. When asked to speak with Nurse Extern 'B', RN 'O' reported they thought they were in a room with a resident, but they were on a break outside of the facility without RN 'O' knowledge. When asked who the nurse was providing supervision for Nurse Extern 'B', RN 'O' reported they were the nurse assigned, but they had their own assignments and if they needed help, Nurse Extern 'B' knew to come to them. On 5/3/22 at 2:39 PM, an interview was conducted with Nurse Extern 'B'. When asked about their documentation for R703 on 5/2 regarding the antibiotic medication, Nurse Extern 'B' reported they were not assigned to R703. When asked how that could be when their initials were documented on R703's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if that was how medications should be administered and documented, Nurse Extern 'B' declined to offer any further explanation. When asked about their experience and education background, Nurse Extern 'B' reported they began working at the facility in August (2021) and finished the practical nursing program but had not taken the boards yet. When asked if they had a supervisor, they reported currently that was Registered Nurse (RN 'O'). When asked what type of supervision they were provided such as if they were side by side right there, or just in the building, Nurse Extern 'B' reported, As long as the RN supervisor is in the building, the former DON (Staff 'CC') explained this to me when I hired in August. On 5/3/22 at 2:55 PM, an interview was conducted with the DON. When informed of the discussion with Nurse Extern 'B' and whether that followed standards of professional practices, the DON reported that should never have occurred, staff were not to share medication carts and use same computer logins. When asked about their use of graduate nurses and what specifically that meant regarding nursing care provided, the DON reported, Was informed they were graduate nurses when I came so I didn't look at their credentials. Was told during COVID they had allowances by the Governor, and a graduate nurse was allowed as long as they had RN supervision. When asked what they meant by RN supervision, the DON reported Been very vague I was looking for specifics, but it didn't specify they needed to be one to one, it was very vague .But I was not aware it was rescinded until today. It was rescinded April 30th (2020) .I should've been notified. I am very upset today it was rescinded April 30th, how am I supposed to know that, why didn't they (corporate) tell me? When asked what was being done since they now became aware of that information and Student Nurses were still working on the floor, the DON reported She's coming off at 3 (3:00 PM). I'm going to pull all of them off. It should be noted that prior to the survey team bringing these concerns to the attention of the facility, it was reported the three unlicensed personnel were performing nursing duties without the direct supervision of a Registered Nurse. R718 On 5/2/22 at 3:30 PM, R718 was observed in their bed. R718 was not responsive to attempts at verbal communication. It was observed R718 had a [CONDITION(S)] with oxygen delivered via [CONDITION(S)]-tube, and a feeding tube used for delivery of enteral nutrition. A review of R718's MARs and TAR's was conducted and revealed the following: March 2022: UP 'C' performed [CONDITION(S)] care and replaced R718's inner cannula on 3/3/22, performed assessments for tube feeding function, anticoagulant medications, pain, oxygen status, and COVID 19, as well as administered eight medications including: [MEDICATION(S)], [MEDICATION(S)], insulin, and [MEDICATION(S)] on 3/3/22. April 2022 UP 'C' performed [CONDITION(S)] care and replaced R718's inner cannula on 4/3/22 and 4/4/22. UP 'C' administered R718's tube feeding nutrition on 4/3/22 and 4/4/22. UP 'C' performed assessments for feeding tube function, anticoagulant medications, pain, oxygen status, and COVID-19 on 4/3/22 and 4/4/22. UP 'C' administered eight medications on 4/3/22 and eight medications on 4/4/22. The medications administered by UP 'C' included: [MEDICATION(S)] ([CONDITION(S)] medication), [MEDICATION(S)] (injected anti-coagulant), insulin injections, and [MEDICATION(S)] ([CONDITION(S)] medication). UP 'B' performed [CONDITION(S)] care and replaced R718's inner cannula on 4/20/22, 4/21/22, and 4/22/22. UP 'B' administered R718's tube feeding nutrition on 4/14/22, 4/20/22, 4/21/22, and 4/22/22. UP 'B' performed assessments for tube feeding function, anticoagulant medications, pain, oxygen status, and COVID-19 on 4/14/22, 4/20/22, 4/21/22 and 4/22/22. UP 'B' administered eight medications on 4/14/22, 4/20/22, 4/21/22, and 4/22/22. The medications administered by UP 'C' included [MEDICATION(S)], [MEDICATION(S)], insulin, and [MEDICATION(S)]. UP 'C' performed [CONDITION(S)] care and replaced R718's inner cannula, administered R718's tube feeding nutrition, performed assessments for tube feeding function, anticoagulant medications, pain, oxygen status, and COVID-19 as well as administered eight medications including: [MEDICATION(S)], [MEDICATION(S)], insulin, and [MEDICATION(S)] on 4/25/22. May 2022 UP 'B' performed [CONDITION(S)] care and replaced R718's inner cannula on 5/1/22, performed assessments for tube feeding function, anticoagulant medications, pain, oxygen status, and COVID 19 as well as administered eight medications including: [MEDICATION(S)], [MEDICATION(S)], insulin, and [MEDICATION(S)] on 5/1/22. R719 A review if R719's MAR's and TAR's was conducted and revealed the following: March 2022 UP 'A' provided suprapubic catheter care, performed assessments for R719's suprapubic catheter, performed pain assessments and assessments for COVID-19 as well as administered six medications including [MEDICATION(S)] on 3/5/22, 3/6/22, 3/22/22, and 3/25/22. UP 'B' performed pain assessments, COVID-19 assessments, and administered six medications including [MEDICATION(S)] on 3/17/22 and 3/18/22. April 2022 UP 'A' performed pain assessments, COVID-19 assessments, and administered six medications including [MEDICATION(S)] on 4/5/22, 4/8/22, 4/11/22, 4/14/22 and 4/16/22. UP 'C' provided suprapubic catheter care, performed assessments for R719's suprapubic catheter, performed pain assessments and assessments for COVID-19 as well as administered six medications including [MEDICATION(S)] on 4/6/22, 4/9/22, 4/10/22 4/13/22, 4/18/22, 6/19/22, 4/23/22, and 4/24/22. UP 'B' performed pain assessments, COVID-19 assessments, and administered six medications including [MEDICATION(S)] on 4/15/22, 4/19/22, 4/24/22, and 4/30/22. It was noted UP 'B' administered medications on those dates, but assessment and care for R719's suprapubic catheter were all left blank on the TAR on 4/15/22 and 4/19/22. May 2022 UP 'C' provided suprapubic catheter care, performed assessments for R719's suprapubic catheter, performed pain assessments and assessments for COVID-19 as well as administered six medications including [MEDICATION(S)] on 5/1/22. UP 'B' performed pain assessments, COVID-19 assessments, and administered six medications including [MEDICATION(S)] on 5/2/22. It was noted the assessments and care for R719's suprapubic catheter were blank on the TAR on 5/2/22. UP 'A' administered six medications including [MEDICATION(S)] on 5/3/22. R717 A review of R717's MAR's and TAR's was conducted and revealed the following: March 2022 UP 'B' performed pain and COVID-19 assessments as well as administered six medications including two blood pressure medications ([MEDICATION(S)] and [MEDICATION(S)]) to R717 on 3/17/22, 3/18/22, and 3/31/22. It was further noted UP 'B' performed a wound care treatment on R717 on 3/31/22. UP 'A' performed COVID-19 assessments, pain assessments, administered eight medications, and performed wound care treatments on 3/22/22 and 3/25/22 for R717. It was further noted UP 'A' administered a narcotic pain medication to R717 on 3/25/22. UP 'C' performed pain and COVID-19 assessments as well as administered eight medications and performed a wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] April 2022 UP 'A' performed pain assessments, COVID-19 assessments, administered eight medications including several cardiac medications and performed wound care treatments for R717 on 4/5/22, 4/8/22, 4/11/22, 4/14/22, and 4/16/22. UP 'B' performed pain assessments, COVID-19 assessments, administered nine medications including several cardiac medications and a narcotic pain medication, and performed wound care treatments for R717 on 4/15/22, 4/19/22, 4/24/22, and 4/30/22. UP 'C' performed pain assessments, COVID-19 assessments, administered seven medications, and performed wound care treatments for R717 on 4/5/22, 4/8/22, 4/11/22, 4/14/22, and 4/16/22. May 2022 UP 'C' performed pain assessments, COVID-19 assessments, administered eight medications (including [MEDICATION(S)]) and performed wound care treatments for R 717 on 5/1/22 and 5/2/22. It was further noted UP 'C' administered a narcotic pain medication to R717 on 5/2/22. UP 'B' performed pain assessments, COVID-19 assessments, administered nine medications (including a narcotic pain medication), and performed wound care treatments for R717 on 5/2/22. The immediacy was removed when the facility implemented the following: -Re-education is completed by the administrator to the Director of Nursing to ensure resident assessments, medication administration, and treatments are performed by a licensed nurse. -Unlicensed personnel A and B were immediately removed from the medication carts on 05/03/22 at 3pm. -Unlicensed personnel A, B, and C were educated on the principal duties and responsibilities outlined in the Nurse Extern job description and permanently removed from all responsibilities outside these parameters. -The Nurse Extern job description/policy will be revised to reflect that the nurse extern can only work under the supervision of a registered nurse. -Unlicensed personnel A, B and C will only work under the supervision of a Registered Nurse. -All working nurse (RN/LPN) staff were educated on the principal duties and responsibilities of the Nurse Extern. Nursing staff who did not receive the education will receive the education via email and in person at the start of their next shift. -HR has completed an audit to ensure all nurses hired by the facility have a current, up-to-date license per the state of Michigan.

Based on observation, interview and record review the facility failed to ensure professional standards of quality care were followed while providing Activity of Daily Living care for one (R701) of three residents reviewed for abusive care resulting in R701 feeling broken and violated. Findings include: Review of R701's hospital records dated 7/26/21 at 8:37 PM, documented in part .Reports that last night her nurse/aid was cleaning her up and posterior and appropriately <sic> the vaginal and rectal area. States that the parents <sic> used Tylenol <sic> and was cleaning up and was forceful. She states she wanted her to stop but she continued. Denies any other injuries. Denies any instrumentation or other sexual contact. Denies any other complaints at this time. Police Department .was called . Review of the clinical record revealed R701 was admitted into the facility on [DATE], and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the admission Minimum Data Set (MDS) assessment dated [DATE], R701 was able to speak and understand others without difficulty, was cognitively intact, was occasionally incontinent of bowel and bladder, and required extensive assistance of two people for bed mobility. On 8/3/21 at 8:30 AM, an interview was conducted with the Director of Nursing (DON) who reported they had been in that position as interim since 7/14/21. The DON reported the Administrator who was also the facility's Abuse Coordinator was not currently in the facility, but was on their way. The DON reported they were aware of R701's abuse allegation which involved Certified Nursing Assistant (CNA 'A') and their investigation was still in progress. On 8/3/21 at 8:50 AM, an interview was conducted with R701. At that time, the resident was laying in bed on their back watching television. Oxygen was being administered via nasal cannula. When asked about the care and treatment from staff, R701 stated in part, .it was two ladies (Certified Nursing Assistant (CNA) A & B) that came in to change me, the younger lady (CNA A kept jugging in me in my vagina and buttocks and it hurt so bad, (resident started to cry) it violated me. I was so sore .I told her it hurt and the lady said sorry. It wasn't the first time that she cleaned me but it was the first time that she was heavy handed, she was trying to go in me. I told her it hurt like three times and she flipped me over and she kept doing it again and I had to tell her again I said why you spooning me? and she said she was sorry again .I no make boo boo (bowel movement). When I say spooking like when dry boo boo (made digging motion with hand) .It came into Monday and I told the nurse .I was shocked and it actually made me cry .The older lady (CNA B) came back in the room and said why would you tell her that she didn't say that she was sorry? So, I shut my mouth .My vagina hurted <sic> so bad and the top of my butt. I told her (CNA A) to stop because it was hurting me and she kept plunging in me and I was so hurt, so hurt .I went to (hospital name redacted) and they took pictures and ran a test .I want it to be known for those that it may happen to here and can't speak for themselves .It makes me feel broken and violated and broken to the bone .I felt the pain for three days after .There are certain things in life that you will never forget .I will never forget it . R701 requested to look at their window and stated, Not sure if rock went into window but I'm starting not to feel safe. On 8/3/21 at 9:16 AM, the glass window was observed to be broken with several long splintered pieces. R701 was asked if there was any further information they would like to share and stated, I told her to stop at least three times, but kept going. On 8/3/21 at 9:57 AM, an interview was conducted with the Administrator. When asked about their investigation into the resident's allegations, the Administrator reported they were aware of the incident from the resident on 7/26/21. The Administrator reported they had planned to complete their investigation later today and Was going to do a customer service education and clear (CNA 'A') today. When asked about the lack of further protection of R701 when CNA 'B' had questioned their allegation following this incident, the Administrator reported, She got an on the spot (training) for that. On 8/3/21 at 11:12 AM, a telephone interview was conducted with Licensed Practical Nurse (LPN) F. When asked about having any knowledge of the allegation of the CNA A providing rough care to R701, LPN F stated in part, .She (R701) asked me for medication. She said the CNA A was rushing while wiping her private area .and needed pain medication for it .I believe I have her a PRN (as needed) [MEDICATION(S)] for pain .I said that I would talk to the CNA A about that, but she left a little earlier than normal that day . Review of a Controlled Substance Proof Of Use documented in part, .[MEDICATION(S)]-Acet 5-325 tab, give 1 tablet by mouth every 4 hours as needed . On 7/25/21 at 2:00 PM LPN F administered the pain medication to R701. Review of a care plan implemented by Social Worker (SW E) documented in part, .There may be times when I may misperceive a situation. Date Initiated: 07/30/2021 .Goal .I will be receptive toward staff's interventions when I misperceive a situation. Will review every 90 days .Interventions .Allow me to perform ADLS that I am able .Refer to Psych Services .Report/ document any situations that I may have exhibited/ verbalized while providing care .Use Buddy System when providing care . This care plan was implemented before the investigation was concluded on the incident & before the facility staff obtained and reviewed the behavioral consultation report. The care plan documented that R701 misperceived the rough care and pain that they verbalized to the facility staff, police, hospital staff and behavioral consultant. The facility Care Planning policy revised 12/20 documented in part, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care . The implementation of the misperceived care plan, did not provide an effective and person-centered care for the resident that met professional standards of quality of care. A review of R701's clinical record revealed the behavioral consultation conducted on 7/29/21 was not obtained by the facility staff. On 8/3/21 at 9:58 AM, a request was made to the Administrator and Social Worker (SW) E to provide the behavioral consultation report conducted on 7/29/21. On 8/3/21 at At 12:17 PM, the behavioral consultation report conducted on 7/29/21 was provided by SW E. A review of the behavioral consultation report documented in part .Complaint: Anxious mood, report of problematic interactions with staff .Psychology was asked by the facility social services to follow up with her regarding her emotional status .She had made a complaint that staff had touched her inappropriately. She reported that a police report had been filed over the matter and she had spoken to the police. She was unsure if there was any further police involvement. She was alert and oriented. She was willing to speak with psychology. She reported feeling calm today but acknowledged that staff had interacted in a way that I'll never forget. She described being assisted by staff for hygiene and grooming. She stated that staff used a towel near her genital area that was too rough. She added I think it was a cleaning that went too far. She stated she did not believe there was any sexual nature involved but her private area was sore from the event. She added that she felt safe in the facility but did not want such an action to occur again. She stated she would be willing to continue meeting with the psychologist in the future but felt alright at this time .Denied any troubling pain other than soreness in her genital area .The patient was agreeable to, and will be seen for follow-up . Shortly after 12:17 PM, an interview was conducted with SW E. When asked about the incident with R701, SW E stated in part, .I believe the Administrator asked me to speak to (R701) on Monday and I did visit (R701) and allowed her to verbalize her concerns and spoke to her and talked to her and the first thing I asked her is if she felt safe and she said she did .(CNA A) and another lady (CNA B) who was present while she was giving her care and she was performing ADLs, specifically washing her body up and she was being too rough while providing care and verbalized that to (CNA A) and CNA A apologized to her while the other staff was in the room .she went to the hospital and spoke to the police .she was seen by the psychologist . When asked why the decision was made that R701 misperceived the incident before the investigation into the incident was concluded and before the facility obtained and reviewed the psychologist consultation, SW E stated they were doing what they were told to do. When asked who told them to implement the care plan, SW E could not recall. On 8/3/21 at 1:15 PM, the Administrator was asked about their investigation and earlier statement that they were unable to substantiate abuse and reported I'm determining there's no sexual abuse. Did substantiate need to be more gentle. When asked if they had considered rough care as a potential allegation of abuse or mistreatment during their investigation, the Administrator reported they had not, and they had only focused on the sexual part of the allegation. When asked when a resident states something during care is hurting them, what should staff do, the Administrator reported they should stop and they could've got the nurse. Review of the facility's policy title, Abuse, Neglect and Exploitation dated Revised 12/2020, documented, .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .

Based on observation, interview and record review the facility failed to complete accurate weekly skin assessments, identify and report worsening of wounds timely, ensure adequate wound physician follow up, coordinate follow up with the vascular surgeon (R52) and delayed implementation of interventions (R54) for two (R's 52 and 54) of two residents reviewed for pressure ulcers, resulting in the development of and/or worsening of wounds. Findings include: Resident #52: A review of the clinical record revealed the following: A review of the hospital record dated 5/10/21 revealed initial documentation and photographs of the following in part, .Skin: Left foot- necrotic toes, Left heel: PI (Pressure Injury) unstageable, Left later leg- black red with 3 open blisters, Right heel: PI DIT (Pressure Injury Deep Tissue Injury), Sacrum/Left Ischium: Skin intact Evidence chronic friction aeb (as evidence by) skin ridging, deformation and lichenification (secondary skin lesion, characteristic features of skin thickening, hyperpigmentation and exaggerated skin lines), everything blanching . The facility's weekly skin assessments and clinical progress notes failed to identify the unstageable left heel, blisters on the left later leg and right heel pressure injury. A hospital clinical note (dated- Adm (Admission) 5/10/21, D/C (discharge) 5/21/21) documented in part, .Plan of Care: IV (Intravenous) Vanco (antibiotic) ordered .Preliminary results of LLE (left lower extremity) indicates occlusion at the superficial femoral artery and down with no flow detected .Per general surgery: No acute intervention, - May require amputations in the future, - Can follow up in our clinic .Conservative supportive therapy is recommended to prevent progression. With any wound progression, discomfort, or infection, consideration for bilateral above-knee amputation would be best one-step option for management, decision on which can be undertaken in the outpatient setting . R52 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6 (indicating severely impaired cognition) and required staff assistance for all activities of daily living, had no pressure ulcers and was at risk of developing pressure ulcers. A wound consult dated 2/24/21 documented in part, .Wound #2 Left First Toe (Great Toe) Tip of Toe is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1.2cm (centimeters) length x 1.9cm width with no measurable depth, with an area of 2.28 sq (square) cm .Wound #3 Left Ischium is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status Not Healed. Initial wound encounter measurements are 4cm length x 2cm width with no measurable depth, with an area of 8 sq cm .Plan .Wound #2 Left First Toe .Wound needs sharp debridement for optimal wound healing but before I can safely perform this, I request that a bilateral lower extremities vascular study, venous and arterial is obtained in order to assess patients vascular status . A wound consult dated 3/10/21 documented in part, .Wound dressed with same dressing place on wound last week, re-emphasized plan (indicating that staff did not change the wound dressing as directed by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Arterial Doppler shows moderate diffuse atherosclerosis with biphasic wave form and normal-moderate systolic velocity so it's safe to perform sharp debridement .Wound #2 Left First Toe (Great Toe) Tip of Toe is an acute Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 1.8cm length x 2.3cm width with no measurable depth, with an area of 4.14 sq cm .Wound bed has 50% eschar .Painful, stable eschar. 25% fluid filled dark blister .Wound #3 Left Ischium is an acute Stage 2 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 1.2 cm length x 0.7cm width x 0.5cm depth, with an area of 0.84 sq cm and a volume of 0.42 cubic cm . Two new additional wounds found on the Left Gluteal Region (stage 2 Pressure Injury Ulcer), measurements 7.5cm length x 1.4cm width x 0.3cm depth, with an area of 10.5 sq cm and a volume of 3.15 cubic cm. The second wound found was on the Right Gluteal fold (Stage 2 Pressure Injury Pressure Ulcer) and measurements 7.2cm length x 2.5cm width x 0.1 cm depth, with an area of 18 sq cm and a volume of 1.8 cubic cm . R52 was assessed again by the wound physician on 3/24/21 for an assessment of all of their wounds. Further review of the clinical record revealed no wound physician consultation notes from 3/24/21 until 5/10/21 when the resident was transferred to the hospital for further evaluation of their wounds. Weekly wound assessments noted the following in part: .4/7/21 .Left gluteal fold (description left blank) .Right gluteal fold (description left blank) .left ischium .lt (left) big toe tip . .4/14/21 .Lt big toe pressure wound .Lt ischium pressure .Left gluteal fold- Pressure .Right gluteal fold- Pressure . .4/21/21 .Left gluteal fold- Excoriation .Right gluteal fold- Excoriation .Other .Left big toe wound . .4/28/21 .Left gluteal fold- Resolving excoriation .Right gluteal fold- Resolving excoriation .Resolving area on left great toe . .5/2/21 .Left lower leg (rear)- Pressure/deep tissue injury at the back of left lower leg above the heel . There are no other documented wounds noted on this assessment. .5/9/21 .Left toe(s)- Degeneration of left big toe, deep pressure injury on left lower leg (back). Treatment in progress . There are no other documented wounds noted on this assessment. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Patient was seen by video conferencing .seen for black-appearing toes of his left foot .perfusion to toes poor especially left foot all toes show gangrenous changes-dry at this time .dark dry skin of all distal toes of the left foot and lateral left foot near the fifth toe base .needs urgent evaluation in the ER (emergency room )/vascular studies and evaluation to see if the reperfusion is possible and or further management of gangrenous toes . The weekly assessments completed by the nursing staff failed to identify the worsening of the resident toe wounds and failed to assess, describe, and document the description of all of the resident wounds. A facility policy titled Skin and Pressure Injury Risk Assessment and Prevention (Revised 12/20) documented in part .A skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter .Documentation of skin assessment: Document observations .type of wound .Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain) .Document if resident declined assessment and why .Assessments may also be conducted after a change of condition or after any newly identified pressure injury . A review of the hospital After Visit Summary paperwork provided to the facility documented it part, .Follow up & future appointments .Follow up with (doctor name redacted) in 1 month .Specialty: Vascular Surgery, General Surgery. Follow up for lower extremity wounds . the doctor address and number was documented on the summary for the facility to follow up. On 6/17/21 at 4:18 pm, a request was made to the Director of Nursing (DON) and Administrator regarding the date of the resident's follow up appointment with the vascular surgeon (as directed by the hospital upon discharge). At 4:37 pm, the DON returned and stated, there is no appointment scheduled. On 6/17/21 at 8:03 am, an observation completed with the facility's Wound Care Nurse (WCN) D was conducted of R52's wounds. The Right Distal Medial Anterior Shin revealed a quarter size healing abrasion. The Left Gluteal Region had a 3-to-4-inch opening and the Right Gluteal Fold had an opening noted as well. The Right and Left heels were observed with black discoloration covering both heels. All 5 toes on the left foot were observed with total black discoloration (to the total anterior and posterior aspect of the left top foot), shriveled, with dried flakes. An open area (the size of a pea) was seen on the Great toe. The Left Shin had a noticeable 6 to 7 inches of an open area that was black in color and dry. It was about 2 inches in width and looked as if black, dried muscle was exposed. When compared to the hospital pictures taken on 5/10/21, all areas had worsened. There was no clinical documentation noted that staff identified the worsening of these wounds. A care plan titled I have potential for alteration in skin integrity . (Revised 3/19/21) documented in part, .Monitor my skin daily and prn (as needed) during care and notify my nurse immediately of any changes to my skin .Skin checks weekly per facility protocol, document findings and notify my physician of any noted changes .reddened areas, discoloration, rashes, open areas . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .patient does have bilateral lower extremities wound left toe from first toe, second toe, third toe fourth .toe appears black and necrotic .right heel has 4 cm x 5 cm unstageable eschar, left heel has 6.3 cm x 7.2 cm unstageable ulcer . The physician failed to assess and document on the sacrum and Ischium wounds. On 6/4/21 at 7:40 am, a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .wound left toe from first toe, second toe, third toe, fourth .toe appears black and necrotic .right heel has 4 cm x 5 cm unstageable eschar, left heel has 6.3 cm x 7.0 cm unstageable ulcer does have . eschar . The physician failed to assess and document on the sacrum, Ischium, Gluteal/gluteal fold, and left shin wounds. On 6/17/21 at 9:24 am, WCN D was queried regarding the inaccurate weekly wound assessments and the lack of the wound physician examinations and stated the facility staff have been consistently in-serviced and educated on the accuracy of the weekly assessments. WCN D also stated the facility's previous wound doctor was let go in May of this year and another doctor is basically covering until we get a new wound doctor. When asked why the doctor failed to assess all of the resident wounds when completing a wound visit, WCN D acknowledged that he is supposed to, but he does not assess all of the wounds when he consults with a resident. When asked how the physician and facility staff are able to determine if the treatment is effective if the areas are not being assessed by the wound physician when they visit, WCN D could not provide any further explanation. WCN D was asked to provide any further documentation regarding R52's wounds and wound care. WCN D provided InService education titled low air loss mattress, Critical Element Pathways and Wound Treatment Management & Documentation. No further documentation was provided by the end of survey. Resident #54: Review of the admission MDS assessment dated [DATE] revealed R54 admitted to the facilty on 9/14/20, had no pressure ulcers, but was at risk for the development of pressure ulcers. Further review of the medical record failed to reveal the facilty had put into place any interventions to prevent the development of pressure ulcers until 4/9/21. Review of the weekly skin sweep dated 4/6/21, revealed R54's skin was intact. Review of the Weekly Skin Sweep note dated 4/13/21 revealed, Open Area .Right toe(s) .Right heel .Resident has a small sore on the R (right) heel and R great toe. Discoloration of the ball of left foot. Review of the Wound Assessment note dated 4/13/21 revealed R54 had a new wound on the right heel with a date of onset of 4/13/21 and was Acquired in-house. The wound was first identified as a vascular wound, but was later assessed to be a Pressure Ulcer. Further review of this document revealed, Site Right Heel .length 7(centimeters (cm)) Width 6 (cm) . Review of the Wound Assessment note dated 4/21/21 revealed, .Wound #1 Right heel .Pressure .5.7 (Length/L) .6.5 (Width/w) .utd (unable to determine) (Depth/D) .Stage Unstageable .%Eschar 50 .50% maroon .Additional skin issue? a. Yes .Is this a new skin condition? .b. No .Wound #2 .Rt 1st toe .Pressure .(L) 0.9 .(W) 0.8 .(Depth) utd .Unstageable .100% dry exudate .Wound #3 .Lt planter 1st toe Pressure (L) 1.2 .(W) 0.7 .(Depth) 0.1 .Stage III . (This assessment was completed with Wound Nurse 'D' and Physician 'J' (who no longer provides services at the facility.) On 6/15/21 at 11:34 AM, R54 was observed lying in bed on their back wearing protective boots to both feet which were covered by a blanket. The head of the bed was raised slightly, and the resident's head was leaning slightly to the left. There were no positioning wedges or pillows observed in use. The mattress was observed to be a regular mattress (not a pressure relieving mattress). Continued observations on 6/15/21 at 2:15 PM, 3:29 PM, 5:30 PM and on 6/16 from 8:09 AM to 10:20 AM, R54 remained in the same position at each observation without the use of any positioning devices (wedges or pillows). Additionally, during the observations of R54 on 6/16, no staff were observed to enter the room to attempt to reposition the resident. Although the resident had the protective boots on their feet, there was no repositioning of the feet observed at any of these observations. R54 responded to simple questions but due to significant mumbled speech, was very difficult to understand. On 6/15/21 at 2:17 PM, a phone interview was conducted with R54's family. When asked about the resident's pressure ulcers, family reported concerns that they had last spoken to the wound nurse on Thursday 6/10/21 and was told at that time the facility would have the wound physician see R54 and call back with an update. As of this interview, they had not yet heard back from anyone at the facility regarding R54's wounds. The family reported concerns that although the resident has a history of vascular wounds, they were not aware of any pressure ulcers since admission to the facility in May 2020 until the care conference after readmission in May 2021. On 6/17/21 at 10:29 AM, during an observation of R54's wounds, Wound Nurse 'D' removed a dressing dated 6/16/21 from R54's left foot and lifted R54's left leg up off the mattress. R54 began to breath in deeply and then yell that their leg hurt. R54's left foot appeared to have large flakes of dry skin, a thin, linear opening in the skin, approximately 5 cm (centimeters) in length, was observed in a crease on the bottom of the left foot between the great and second toes. R54's left heel appeared to have bruising to the bottom surface of the heel obscured by dry skin. Wound Nurse 'D removed the dressing from R54's right foot, the dressing was observed to be saturated with serosanguineous (blood mixed with serum) drainage. Wound Nurse 'D' lifted R54's right leg off the mattress, R54 again yelled that their leg hurt. The inside of the foam boot was observed to be stained with serosanguineous drainage where R54's right heel would be when in the boot. An open area on the lateral (outside) part of R54's right heel was approximately 5-6 cm in diameter. It appeared to have a pale base with a large amount of slough (non-viable yellow, tan, gray, green or brown tissue) around the wound and throughout the wound bed. R54's right foot had large flakes of dry skin also observed. R54 was asked if their legs hurt all the time, or only when lifted. R54 explained their legs hurt when touched. Review of the clinical record revealed R54 was hospitalized on [DATE] due to concerns with a heel wound, and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R54's medical record revealed the following care plans for skin care: I have actual impaired skin integrity r/t (related to) moisture 2/2 (secondary to) incontinence, decreased activity, chairfast most of the time, decreased mobility, [CONDITION(S)], PAD (Peripheral Artery Disease) initiated on 4/21/21, revised last on 5/20/21. Interventions included: Added 4/9/21: Assist me to position body with pillows/support devices, protect bony prominences as I allow. Added 4/9/21: Assist me to turn &/or reposition routinely during CNA (Certified Nursing Assistant) rounds while in bed and frequently redistribute my weight if/when I am up in my chair. Added 4/9/21: Assist/encourage me to elevate my heels off the bed. Added 4/9/21: Inspect skin daily with care - Report any concerns to nurse IE: Discoloration, rashes, reddened areas, open areas. Added 4/21/21, revised 5/20/21: Licensed Nurse skin assessment per protocol. Pressure injury, Poor circulation (vascular) initiated 5/20/21 (upon readmission). Interventions included: Added 5/20/21: revised 5/24/21: Keep skin clean and dry. Use lotion on dry skin. Do not apply on wound. Added 5/20/21: Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD. An incomplete care plan included: (left blank) I have a Pressure Injury, Stage: _____; (left blank) Location: _____. (left blank) This wound was (present on admission / developed in facility). initiated 5/20/21. Interventions included: Added 5/20/21: (left blank) Administer wound and skin treatments as ordered and monitor for effectiveness. Notify physician if wound stalls (no change in 2 weeks) or worsens. Added 5/20/21, revised 5/24/21: Avoid positioning me on my back for more that <sic>2 hours. Review of R54's skin assessments from 4/6/21 to 6/14/21 revealed the following inconsistencies with the types of wounds identified (vascular vs. pressure ulcer), the location and descriptions of the wounds identified, and what treatment interventions were reviewed and/or revised following these assessments. Additionally, review of the physician wound documentation revealed similar inconsistencies as to the types of wounds, lack of identification/evaluation of all wounds during their assessments and changes to interventions. Review of the resident's skin assessments following 4/6/21 included: On 4/14/21 an eINTERACT Change in Condition Evaluation noted, Skin wound or ulcer .This started on: 4/14/2021 .Afternoon .Right lateral foot .This condition, symptom or sign has occurred before .No .Summarize your observations, evaluations and recommendations (left blank) .Were the change in condition and notifications reported to primary care clinician Yes .4/14/2021 12:00 PM .Recommend resident sees vascular surgeon .Skin prep to bilateral feet. Sheepskin shoes as tolerated .Resident Representative Notification (left blank) . (This assessment was completed by Wound Nurse 'D'). On 4/20/21 a weekly skin sweep noted, .discoloration .open area .Right heel open area and rt great toe and left heel discoloration/redness . On 4/27/21 a weekly skin sweep noted, .Discoloration .Open Area .Right heel .Right Toe (s) .(description left blank) . (There was no identification or further mention of the left foot/toe pressure ulcer as identified on 4/21/21.) On 4/28/21 a wound assessment noted, .Wound #1 .Right heel pressure (measurements and stage left blank) .Wound #2 .Right toe(s) pressure .(measurements and stage left blank) . (There was no identification or further mention of the left foot/toe pressure ulcer as identified on 4/21/21.) On 5/4/21, a weekly skin sweep noted, .Discoloration .Open Area .Rt heel, rt great toe open area and left heel skin discoloration . (There was no description for any of these wounds noted.) On 5/11/21, a weekly skin sweep noted, .Discoloration .Open Area .Rt heel, rt big toe wound .Bilateral dry foot with discoloration and bilateral [CONDITION(S)] .Buttocks redness . On 5/13/21 an eINTERACT Change in Condition Evaluation noted, .Skin wound or ulcer .This started on: 5/13/2021 .Morning .Sent to (name of local hospital) for heel wound evaluation .Right heel .Left heel .Wound .Resident was sent to (name of local hospital) at about 5:00pm per (name of Physician 'K') for heel wound evaluation . On 5/20/21 a nursing admission/readmission assessment noted, .Skin/Braden Assessment .Right heel Pressure .Right toe(s) Vascular .Left toe(s) Vascular .Coccyx Pressure . On 5/20/21 a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Readm (readmitted ) from (name of local hospital) - was recently admitted there for worsening right heelwound-evaluated by-vascular surgery and podiatry. Also peripheral arterial disease-without requiring any interventions vasc surgery. also seen by podiatry who did not feel there was any need for further debridement of the heel wound .Skin: RT HEEL ULCER .SKIN .old scar to coccyx, dry flaky BLE (bilateral lower extremities) otherwise generally intact -right heel with large wound with necrotic areas .Right heel ulcer/wound-seen by podiatry and vascular, while in the hospital- no immediate interventions continue with current treatment/chemical debridement . On 5/24/21, a weekly skin sweep noted, .Discoloration .Open Area .Right heel Vascular Pressure wound present on admission .Right toe(s) Vascular Pressure wound present on admission .Left toe(s) Vascular Pressure wound present on admission .Coccyx Pressure wound present on admission . On 5/31/21, a weekly skin sweep noted, .Open Area .Right heel .Stage III pressure injury . (There were no other wounds identified and/or documented.) On 6/4/21, a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Patient seen for the wound management, he has right heel unstagable <sic> ulcer and left planter DTI (Deep Tissue Injury) He has been getting santyl to the right heel, and dry dressing to the left planter region He has heel protector shoes, and does have low air loss matress <sic>, he does gets turn frequently .SKIN .old scar to coccyx, dry flaky BLE otherwise generally intact -right heel measuring 4.5x3.0 cm, has mild bleeding, central region has slough, surrounding skin has good granulation, Left planter DTI,MEASURING 1X0.5 CM, NO DISCHARGE .Right heel unstageable <sic> ulcer, will use Santyl to the slough region, with 4x4 dressing and kerlix, change daily, continue to use protective boots Left planter has a DTI, keep protective boots on Keep tyrning <sic> patient frequently, while in bed to reduce the pressure to the bony prominence. On 6/7/21, a weekly skin sweep noted, .Rash/excoriation .Resident has a resolving excoriation on coccyx, and also resolving pressure wounds to both heels . On 6/14/21, a weekly skin sweep noted, .Rash/excoriation .Suspected Deep Tissue Injury . (This electronic document prompted the writer to put a site and description which were left blank.) On 6/14/21 a second weekly skin sweep noted, .Rash/excoriation .Suspected Deep Tissue Injury .Right heel unstageable pressure .Lt planter DTI .MASD (moisture-associated skin damage) Buttocks . On 6/16/21 at 2:24 PM, an interview and record review was conducted with Registered Nurse (RN) (Wound Nurse 'D') who also reported they were functioning as the facility's east unit nurse manager, clinical care coordinator and wound nurse. When asked about the R54's wounds and review of the conflicting documentation and what was provided to prevent further breakdown and/or improvement, Wound Nurse 'D' reported there were concerns with the care and treatment provided by Physician 'J' which was why they no longer treating residents at the facility and that Physician 'K' was temporarily covering as they also followed residents at the facility as their attending physician. Upon review of the above documentation for R54, Wound Nurse 'D' confirmed similar concerns with conflicting documentation. When asked what the facility's process was for assessing the residents' skin, Wound Nurse 'D' reported the nurses that worked on the floor were responsible for completing the weekly skin sweep assessments. Wound Nurse 'D' reported the skin assessments were conducted and details of the wounds were reported by Physician 'J' (previously) and Physician 'K' (currently). When queried about the lack of identification of all wounds/skin concerns during these assessments and as reflected from their documentation as well as the conflicting identification of vascular vs pressure ulcer, Wound Nurse 'D' reported they had similar concerns as well but offered no further explanation. When asked to review the documentation from 4/6/21 which identified there were no skin issues for R54 and what interventions were in place at that time, Wound Nurse 'D' reported R54 had readmitted to the facility the end of March 2021 but had not been identified correctly on the nursing readmission assessment. When asked to clarify why that had not been identified on the assessment then on 4/6/21, or the MDS assessment on 5/25/21, Wound Nurse 'D' offered no further response. When about what interventions were in place to promote healing or prevent further skin breakdown, Wound Nurse 'D' reported the resident wore protective boots and should be repositioned frequently. When asked what they meant by frequently, Wound Nurse 'D' reported less than every two hours. At that time, Wound Nurse 'D' was informed of the observations of lack of repositioning on 6/15 and 6/16. When asked about if even though R54 had protective boots, would that still put additional pressure to the heel areas if not being repositioned frequently, Wound Nurse 'D' confirmed that would which was why staff should be repositioning frequently and utilizing the pillows and wedge cushions. When asked if there was any consideration for a specialty mattress such as a low air loss mattress as identified in the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound Nurse 'D' was asked about the delay in identification of R54's skin changes on 4/13 and why the physician and family had not been notified until the next day and they reported they were unable to offer any explanation for that. Wound Nurse 'D' was unable to explain why there were no changes to the care plan interventions since 5/20/21. Wound Nurse 'D' was requested to provide additional documentation in regard to R54's wounds since 4/6/21, what interventions were implemented and/or changed and reported they would follow up. The only additional documentation provided by the Director of Nursing (DON) on 6/16/21 at 5:00 PM was Physician 'J's consultations from 4/19/21 to 5/10/21. A facility policy titled Wound Treatment Management and Documentation (revised 12/20) documented in part, .To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence- based treatments in accordance with current standards of practice and physician orders. The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment .Treatment decision will be based on etiology and characteristics of the wound .The effectiveness of treatments will be monitored through ongoing assessment of the wound. Consideration for needed modifications include: Lack of progression towards healing, Changes in the characteristics of the wound .The following element are documented as part of a complete wound assessment .Type of wound .Stage of wound .Measurements .Description of wound characteristics .

Based on observation, interview and record review the facility, which is an identified hub for placement of COVID positive residents from the community, failed to institute and operationalize appropriate infection control principles and practices per the Centers for Disease Control Prevention (CDC) safety measures to prevent the exposure/transmission of residents to 2019 Novel Coronavirus (COVID-19) for: 1) three residents (R#s 711, 713 and 715) that were reviewed for cohorting (sharing a room) and/or being potentially exposed (R# 713) with COVID-19 positive residents (R#'s 710, 712, 714, and 716); 2) implementing CDC guidance on the discontinuation of precautions for positive COVID-19 residents (R#'s 710, 712, 714 and 716); 3) ensuring staff utilized the recommended Personal Protective Equipment (PPE) per CDC guidance during the recommended monitoring phase; and 4) implement CDC guidance on implementing precautions on residents that were readmitted (R#'s 717, 718 and 719). The failure to follow current CDC recommendations for COVID-19 resulted in an Immediate Jeopardy (IJ) to the health and safety of all residents, many of whom were at high risk due to age and co-morbidities, to be exposed and/or develop COVID-19, given the high risk of spread once COVID-19 enters a nursing home, facilities must take immediate action to protect residents, families, and healthcare personnel (HCP) from resulting in the likelihood of serious health complications from COVID-19 hospitalization s, and death. Findings include: The IJ began on 7/11/20. The IJ was identified on 7/29/20. The Administrator was notified of the IJ on 7/29/20 at 2:47 PM and a plan to remove the immediacy was requested. Although the IJ was removed on 7/30/20, the facility remained out of compliance at a scope of widespread and a 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. Resident #710 and Resident #711: R#710 A review into the clinical record revealed the following: R#710 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A COVID-19 Test Result Summary dated as reported to the facility on [DATE] documented a positive test result for R#710. CDC guidance for COVID-19 in the nursing homes documented in part, .If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit . The facility's census report revealed R#'s 710 and 711 shared a room until 7/13/20 (despite R# 710 testing positive for COVID- 19 on 7/11/20.) R#710 was moved onto the COVID unit on 7/13/20. A COVID-19 Test Result Summary dated as reported to the facility on [DATE] documented a negative test result for R#710. Further review of the census report revealed R# 710 was moved back into a shared room with R#711 on 7/19/20 (6 days after being transferred to the COVID-19 unit). A facility's COVID-19 protocol/guidance form (dated July 1, 2020) documented in part .Residents with laboratory-confirmed COVID-19 who have not had any symptoms (Asymptomatic) should remain in Transmission-Based Precautions until either: Time-based strategy - 10 days have passed since the date of their first positive COVID-19 diagnostic test, assuming they have not subsequently developed symptoms since their positive test .Test-based strategy Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of [DIAGNOSES REDACTED]-CoV-2 RNA from at least two consecutive respiratory specimens collected (more than or equal to) 24 hours apart (total of two negative specimens) . On 7/28/20 at 2:25 PM, a request to the Administrator was made for any further COVID test results for R#710 after the dates of 7/17/20 and no further results were provided by the end of survey. A physician order [REDACTED].Droplet precautions, every day and night shift for COVID Positive .Discontinued on 7/21/20 . Despite R#710 being put back into the room with R#711 on 7/19/20 (before the recommended time frame), which potentially exposed R#711 for a second time. R#711 A review into the clinical record revealed the following: R#711 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A COVID-19 Test Result Summary dated as reported to the facility on [DATE] documented a negative test result for R#711. However, R#711 remained sharing a room with their COVID positive roommate until 7/13/20. Further review of the physician orders, care plans and progress notes in the clinical record revealed R#711 was not considered as exposed or potentially infected. CDC guidance for COVID-19 in the nursing homes documented in part .Roommates of residents with COVID-19 should be considered exposed and potentially infected .HCP (Health Care Providers) should use all recommended COVID-19 PPE for the care of all residents on affected units .this includes both symptomatic and asymptomatic residents . This allowed staff to provide care to R#711 without the recommended PPE per CDC guidance, while providing care for other non-exposed residents on that unit. A facility's COVID-19 protocol (dated July 15, 2020) documented in part, . As of May 14, full PPE is recommended in the following areas: Admission units, Observations units . On 7/28/20 at 3:40 PM, the Director of Nursing (DON) who also serves as the facility's Infection Control Nurse (ICN) was queried on why R#710 was not initially moved out of the room with R#711 on 7/11/20 and moved onto the COVID-19 unit and stated in part .We didn't get the report until 7/13/20 . When asked why precautions weren't ordered for R#711 after having been in a room for two days with their COVID-19 positive roommate, the DON stated in part .We didn't put her on precautions because she was in a room by herself and asymptomatic and COVID-19 test was negative .She was on Enhanced Precautions . The DON was then asked to clarify the Enhanced Precautions and stated It's a mask for staff. Either a N95 or K95, we have the real masks here . An observation of a signage on the facility's wall documented Enhanced Droplet - Contact precautions which directed the staff to perform hand hygiene, utilize a N95/surgical face mask, eye protection, gown, gloves and guidance for a private room and keep door closed. Resident #717, Resident #718 and Resident #719: R#717 On 7/29/20 at 10:29 am, an observation was made of R# 717's room door. There was no signage posted to direct staff on what PPE to don on, nor was there PPE (gloves, gown, eye protection etc) located on or near the door. On 7/29/20 at 10:37 am, Licensed Practical Nurse (LPN) C (the nurse providing care for R#717) was queried regarding R#717 and if there was any further PPE required for HCP other than a mask and stated in part, .No, she isn't on precautions. We just wear a mask . A review of the clinical record revealed the following: R#717 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The residents census report revealed R#717 room placement as the following: 7/23/20 admitted into a private room; 7/26/20 moved into a room with R#'s 718 & 719; 7/27/20 moved into a private room; 7/28/20 moved back into a room with R#'s 718 & 719; 7/29/20 moved back to a private room; CDC's COVID-19 guidance for nursing homes document in part, .a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE . A facility's COVID-19 protocol/guidance form (no date) documented in part, .Re-Admissions .Residents who return with symptoms that test negative will remain in isolation on our admission unit for 14 days and will be monitored closely using droplet precautions outlined in our toolkits. Residents will be tested at Day 12 of their stay. Based on negative Day 12 test results, improvement or resolution of symptoms, and completion of 14 days of isolation, these residents can be moved off of isolation and droplet precautions to the broader resident population . After being readmitted , R#717 was moved out of a private room and into a room with R#718 and R#719 (potentially exposing these residents) and again on 7/28/20 ( a potential second exposure). A review of R#717's physician orders, progress notes and care plans revealed no orders/interventions for precautions since being readmitted back into the facility on [DATE]. Which could have potentially exposed all HCP caring for the resident upon readmission and all of the resident's that the HCP were providing care for. On 7/29/20 at 11:28 am, the DON was queried on why R#717 was moved out of a private room three days after admission and cohorted with roommates and replied Because she was tested and it was negative . When queried on the facility's policy and CDC guidance to monitor readmissions for 14 days, the DON repeated She was tested and it was negative . When asked why R#717 was placed back into a private room on 7/27, then on 7/28 placed back into the room with R#'s 718 and 719 and then back into isolation on 7/29 the DON replied Her wheelchair didn't fit into the three bedroom. On 7/28 because she had a shared bathroom with a male, so the resident was moved back in the three bedroom and again the wheelchair couldn't fit so we put her back into a private room . The DON was then queried on R#718 and R#719, being that they were exposed twice to a recently readmitted resident and if any precautions were placed on the residents for the HCP to follow and the DON replied The roommates weren't put on precautions and their was no additional PPE required, other than a mask . CDC guidance for COVID-19 in the nursing homes documented in part .Roommates of residents with COVID-19 should be considered exposed and potentially infected .HCP should use all recommended COVID-19 PPE for the care of all residents on affected units .this includes both symptomatic and asymptomatic residents . A facility's COVID-19 protocol (dated July 15, 2020) documented in part, .As of May 14, full PPE is recommended in the following areas: Admission units, Observations units . On 7/29/20 at 11:47 am, LPN C was queried regarding a signage that was posted outside of a resident's room (an observation room) that documented Enhanced Droplet - Contact Precautions and asked what PPE was required for the staff to don on prior to entering the room and the LPN C replied in part .He was just moved to this room .there are no precautions, just a mask. The DON was then queried on that residents precaution status and stated No, he is on precautions. The DON was then observed instructing the LPN C of the signage on the door and informing them that if the sign is on the outside of the door then that resident is on precautions. LPN C was then queried on if they donned on the correct PPE while providing AM care or medications and stated in part .I haven't went into his room yet .We are doing the morning medications now. Resident 712 and Resident 713 Review of the census record revealed R712 and R713 had shared a room beginning on 5/26/20. Review of the clinical record revealed R712 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the COVID-19 test results for R712 revealed a positive test with a collection date of 7/9/20 and a report date of 7/11/20. Review of the census record revealed R712 was moved to a room on the COVID positive unit on 7/13/20, two days after the report date on the positive test results. Review of the clinical record revealed R713 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record for R713 did not reveal an order for [REDACTED]. On 7/28/20 at 2:35 PM, an interview was conducted and the DON was queried about R713 not being placed on droplet precautions after R713's roommate, R712, tested positive for COVID-19. The DON explained that because the facility tested all residents and staff weekly, and since there were no visitors allowed in the facility, there was no way for R713 to have been exposed to the COVID-19 virus, so there was no need for droplet precautions. R707 Review of the census record revealed R707 was moved into the same room as R713 on 7/17/20, four days after R713's last date of exposure to R712 who had tested positive for COVID-19. Review of the clinical record revealed R707 was originally admitted into the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. On 7/29/20 at 10:26 AM, an interview was conducted and the DON was queried about R707 being moved into R713's room on 7/17/20. The DON explained R707 was in a different room, but did not get along with their roommate, so R707 was moved to R713's room as there was an empty bed. When asked about the results of the COVID-19 tests and the timing of the room changes for R712, R713 and R707, the DON explained the facility used the collected date (7/9/20) for their timing. The DON stated, I know the regs (CDC guidelines) say 10 days, but we use symptom management. When asked how test results were used to determine if a resident could be cohorted with another resident, the DON explained only one negative test result was needed to move a resident if the resident was staying in the facility, if the resident was leaving the facility, two negative tests were required. Resident 714, Resident 715 and Resident 716: A review of the census record revealed R714, R715 and R716 had shared the same room beginning on 6/12/20. R714 A review of the clinical record revealed R714 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of COVID-19 test results for R714 revealed a positive test with a collection date of 7/9/20 and a report date of 7/11/20. A review of the census record revealed R714 was moved to a room on the COVID positive unit on 7/13/20, two days after the report date of the positive test results. R714 was then moved to a designated observation room (off of the facility's COVID unit) on 7/17/20, and then moved back to the original room on 7/21/20. R715 A review of the clinical record revealed R715 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of COVID-19 test results for R715 revealed an error with the collection for the test dated 7/9/20 and a negative test with a collection date of 7/13/20 and a report date of 7/15/20. A review of the census record revealed R715 was moved to an observation room (with enhanced precautions) on 7/13/20, then moved back to the original room on 7/16/20. Upon return to the original room, R715 was no longer on enhanced precautions (only five days following being exposed to R714 and R716 that tested positive for COVID-19). R716 Review of the clinical record revealed R716 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the COVID-19 test results for R716 revealed a positive test with a collection date of 7/9/20 and a report date of 7/11/20. Review of the census record revealed R716 was moved to a room on the COVID positive unit on 7/13/20, two days after the report date of the positive test results. R716 was then moved to a designated observation room (off the facility's COVID unit) on 7/17/20, and then moved back to the original room on 7/21/20. On 7/28/20 at 2:35 PM, the DON was asked to explain about the delay in transfer to a room on the facility's COVID unit once test results were reported as positive. The DON reported the facility had been having issues with obtaining lab results timely from the lab that was processing the COVID tests and reported the facility had not been aware of the positive results until 7/13/20, at that time the residents were moved. When asked about whether there had been any documentation of discussion with the lab regarding these concerns, the DON reported she would follow up. There was no documentation provided by the end of the survey. When asked why R714 and R716 had been taken off the COVID unit after only 5 days following positive COVID tests, then only observation with enhanced precautions for five days, then returned to original room which was shared with R715, the DON indicated all the residents COVID tests had come back negative and upon review with Medical Director and Epidemiologist, were given the okay to return. (The clinical records were reviewed and there was no documentation to reflect any discussion and/or clinical justification to reflect this decision.) Removal Plan: This Removal Plan in response to the findings of immediate jeopardy on July 29, 2020 @ 2:47 PM. The facility submits response to abate the findings of immediate jeopardy associated with the recent COVID IC Survey. The Facility was made aware by State Surveyor on July 29, 2020 @ 2:47 PM of their decision to cite a deficiency at the level of immediate jeopardy related to following: Failure to follow CDC (Center for Disease Control) recommendations for monitoring residents who are positive for COVID-19 related to cohorting, Discontinuation of precautions, Donning appropriate PPE for residents who have been exposed to COVID-19, Monitoring residents admitted and readmitted to the facility. Plan of removal as follows: On July 29, 2020 all current Residents have been assessed to assure COVID-19 positive residents are not cohorted with COVID-19 negative Residents. On July 29, 2020 any resident who was not recovered per the CDC (Center for Disease Control) recommendations will not be cohorted and they will be retested for COVID-19. On July 29, 2020 the facility reviewed current residents to ensure contact precautions for COVID-19 positive residents were removed per the CDC (Centers for Disease Control) recommendations. On July 29, 2020 the facility reviewed all current residents to ensure contact precautions are in place per CDC (Center for Disease Control) recommendations. On July 29, 2020 The District Director of Clinical Services has reviewed and re-educated the Administrator, Director of Nursing and Medical Director on the CDC (Center for Disease Control) recommendations related to the following: Admissions policy related to monitoring of residents admitted and readmitted to the facility, discontinuation of precautions for COVID-19 positive residents, not cohorting COVID-19 residents and non COVID-19 residents and wearing appropriate PPE for residents who have been potentially exposed to COVID-19.

This citation refers to Intake #MI 603 Based on observation, interview and record review, the Facility failed to ensure a hoyer lift transfer was provided in a safe and proper manner for one Resident (#704) of three residents reviewed for falls, from a total sample of six, resulting in Resident #704 sustaining multiple rib fractures, pain, bruising, hematoma to the head and a seven day hospital stay. Findings include: On 5/23/18 a Complaint was filed with the State Agency alleging that Resident #704 fell and sustained an injury during transfer with a Hoyer lift. On 6/5/18 at 8:00 AM, Resident #704 was observed lying in bed. The Resident was alert and able to answer questions asked. When queried about the fall, Resident #704 stated, This happened a few weeks ago at around 9:30 in the morning. I was in bed and the aides were trying to get me out of bed with the Hoyer lift and into a wheelchair. They put the sling on me and were lifting me up. When I was up in the air, I heard a pop. I think the straps were not properly hooked or secured. I fell to the floor on my right side. I hit the right side of my head. I hurt my whole right side. It bruised my thighs, my arm and a I had a big bump on my head. My middle are was hurting. I still have bruises and a bump on my head. (At that time Resident #704 pointed to the bruises to the right arm and right leg) Later that day everything was hurting me. At around 7:00 PM a person came in and took X-rays of my body while I was sitting in the wheelchair. I guess the X-ray couldn't find anything wrong, but the next day, I was still in a lot of pain, especially across my middle area and they sent me to the Hospital. I found out that I had fractured my ribs. I stayed there for a week. It still hurts me. They are using a new lift to transfer me and I have a new room. On 6/5/18 at 9:30 AM a review of Resident #704's clinical record was conducted and revealed that the Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) dated [DATE] documented that Resident #704 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitely intact) and required extensive two person assist for all transfers. A review of the Resident's care plan for Falls documented, in part, the following: Focus: Resident has potential/actual safety and fall risk related to decreased safety awareness for falls (initiated 11/1/17 .) Interventions: Educate staff on mechanical lifts (5/15/18) . A progress note dated 5/14/18 and authored by Nurse L documented, in part, the following: Resident had a fall around 10:00 AM off the Hoyer lift, one of the straps slipped off the hook and resident fell to the floor . Continued review revealed Hospital records that documented, in part, the following: History .presented to (name redacted) Hospital via EMS (emergency medical service) after a mechanical fall on 5/14/18 at the facility. Per EMS report, the nursing home staff were trying to transfer her from bed to her wheelchair and the patient was dropped on the floor. The patient did hit the right side of her head she also states that she fell on her right side of her body .on 5/15/18 she reported worsening rib pain .the CT (cat scan) .revealed right rib fractures (9-11) .due to her rib injuries the patient was admitted to (name redacted) for respiratory monitoring and pain control. A review of the Investigation and Incident form contained a typed, undated, unsigned and incomplete document detailing the incident that occurred. The document noted, Certified Nursing Assistant (CNA) D and CNA J were the aides providing the transfer for Resident #704 using the Hoyer lift on 5/14/18. On 6/5/18 at 10:54 AM a phone interview was conducted CNA D . CNA D was queried as to the incident involving Resident #704. CNA D stated, We were transfering the Resident from the bed to the wheelchair. We put the sling under her. The sling for some reason came off. We had been telling (name redacted) Former DON (director of nursing) S that the strings on the sling are too old and too thin, but she never ordered anything. I don't think the sling was the right size either. Now they ordered a new lift and we have been using that. On 6/5/18 at 12:00 PM an interview was conducted with CNA J. When queried as to the incident/fall involving Resident #704's on 5/14/18, CNA J stated, CNA D came to get me to help transfer Resident #704 from the bed to the wheelchair. We hooked up the sling. When she was up in the air, I was turned around trying to get the wheelchair. I heard a pop sound and then I saw her on floor and she (Resident #704) was yelling that she knew she was going to fall. On 6/6/18 at approximately 12:30 PM an interview was conducted with Nurse L. Nurse L was queried as to the incident pertaining to Resident #704. Nurse L stated, I remember the incident. I did not witness the fall. The CNA(s) came to get me. They told me that something snapped off and she fell . I assessed her for pain and then she got an x-ray. On 6/5/18 at approximately 3:00 PM an interview was conducted with the Maintenance Director . The Maintenance Director was queried as to the Facility policy on maintaining its Hoyer lifts. The Maintenance director reported that the lifts are checked once a month with an outside company. The lift that was used when the accident occurred for Resident #704 on 5/14/18 had been checked on 5/10/18 with no concerns. When queried as to the sling, the Maintenance Director stated, I checked a sling the day after the incident and it appeared okay, but I really could not verify that it was the sling actually used by staff and how it was applied. On 6/5/18 at approximately 2:30 PM, an interview and record review was conducted with the interim Administrator Aand Corporate Support Nurse (CSN) C. Administrator A reported that he was not employed at the time of the incident and was not familiar with the incident. CSN C stated, Former Administrator R notified corporate and a corporate staff determined that something happened with the lift. The Resident was relocated to a different room and was provided a new bed. On 6/6/18 at approximately 2:00 PM the following documentation was provided by the Facility: One-to-One Inservice Form: Date: 5/15/18 . Employee Name (CNA D) .Subject: Proper Hoyer repositioning .Instructions: Ensure resident is in proper alignment with the sling prior to lifting- Ensure the sting-straps are properly connected prior to lifting the resident- select proper size sling. A second One-to-One Inservice Form .Date: 5/15/18 .Employee Name: (CNA J) documented the same instructions as documented above. On 6/6/18 at approximately 2:30 PM a review of the Facility Competency: Use of Mechanical Lifts (s) was reviewed and documented, in part, the following: The Full Body Mechanical lift is used for transferring dependent and semi-dependent residents who cannot bear weight 5. Identify and Define Correct Lift and Sling Types, Sizes, and Uses for the resident .resident size, cognition, comfort, special needs .6. Inspect sling and equipment for safety per inspection criteria: all safety devices such as gates, clips, rubber discs, etc. must be in place. At least two trained staff are required for all mechanical lifts/transfers .

This citation refers to Intake #MI 646 Based on interview and record review the Facility failed to ensure blood glucose (sugar) levels were monitored for one diabetic Resident (#706) with a history of hypoglyemia (low blood sugar) and falls out of three Residents reviewed for falls out of a total sample of 12 resulting in Resident #706 falling and sustaining multiple facial fractures, a hypoglyglycemic episode (blood sugar level 60 mg) and a three day stay in the hospital. Findings include: On 8/22/17 the Facility reported to the State Agency that Resident #706 sustained a fall on 8/13/17 that resulted in multiple facial bone fractures. On 12/20/17 at 1:00 p.m a review of a Facility Incident/Accident Report (I&A) dated 8/13/17 documented that Resident #706, Resident was running and tripped over her own feet and fell flat on face causing nose to bleed profusely .Resident Outcome: Possible Fracture Transfer to Hospital . A review of the Residents Hospital Records (dated 8/14/17) documented, in part, the following: The patient was at her assisted living facility yesterday when she had a fall around 7pm. The fall was witnessed by the RN (registered nurse) who saw that Resident (name redacted) was walking quickly and had a fall She has a history of previous falls which her daughter associates with low blood sugars. At the time of this incident the patients BG (blood glucose) was found to be *66 EMS report it at 60 mg when she arrived in the ED (emergency department) . *A blood sugar level below 70 is considered low and can cause harm including, but not limited to, dizziness, poor coordination and weakness. On 12/20/17 at 1:30 p.m., a review of Resident #706's clinical record was conducted and revealed that the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Resident Minimum Data Set ((MDS) dated [DATE] documented that the Resident had a Brief Interview for Mental Status (BIMS) score of 7 (moderately cognitively impaired) and required limited assistance for transfers. Continued review of the Residents clinical record revealed a Fall Risk assessment dated [DATE] that documented that the Resident had a score of 16 (high risk for falls). A care plan initiated 8/8/2016 documented, in part, the following: Focus: Resident has Potential/Actual Safety and/or Fall Risk related to: History of falls, Decreased Safety Awareness, DM (diabetes mellitus) with episodes of [DIAGNOSES REDACTED]. Actual Fall: 7/15/17, 7/30/17, 8/12/17, 8/13/17) Interventions/Tasks: Encourage adequate food intake during meals, observer for s/s [DIAGNOSES REDACTED] (date initatied 11/07/16) Monitor blood glucose readings as ordered. Inform MD of hypoglycemic episodes for possible adjustment of insulin regimen (date initiated 11/07/2016) A physician order(s) dated 6/14/17 documented: (Brand name) pen injection 100 unit/ml (milliliter) (Insulin [MEDICATION NAME]) inject 10 units subcutaneously at bedtime related to diabetes mellittitus due to underlying condition with [DIAGNOSES REDACTED] . (Brand name) pen injection 100 unit/ml (milliliter) (Insulin [MEDICATION NAME]) inject 9 units subcutaneously 6:00 am related to diabetes mellitus due to underlying condition with [DIAGNOSES REDACTED] . The Resident's MAR indicated [REDACTED]. A review of the Residents Weights and Vital records showed no documentation that the Resident's blood sugar levels were checked from 6/23/17 to 8/13/17. On 12/21/17 at 12:20 p.m., an interview and record review was conducted with the Director of Nursing (DON). The DON was queried as to the Facility's Policy and nursing practice pertaining to resident who are diabetic and receive insulin. The DON stated that prior to giving insulin a Resident's blood sugar levels should be checked by a nurse. When queried as to the lack of recorded blood sugar levels in the Resident's record, the DON responded, I saw nurses checking it sometimes, they probably just forgot to document it. Maybe they noted it in the nursing notes. A review of the Resident's nursing notes indicated that documentation of the Resident's blood sugar levels from 7/1/17 to 8/13/17 was noted only four times (7/7/17, 7/8/17, 8/1/17 and 8/10/17). A nursing progress note dated 8/10/17 indicated that the Resident's blood sugar level was 100 and her insulin was not given. Further review of the Resident's nursing notes documented the resident sustained [REDACTED]. When queried as to the Resident's falls including the fall with injury on 8/13/17 and and the Fall care plan that documented fall interventions that included monitoring glucose levels and checking for [DIAGNOSES REDACTED], the DON provided no response. On 12/21/17 at 1:00 p.m., a phone interview was conducted with Physician F. Physician F was queried about Resident #706's fall and history of [DIAGNOSES REDACTED]. Physician F was queried as to the protocol for Residents receiving insulin including Resident #706. Physician F reported that blood sugar levels should be checked at meal times and/or before administering insulin. Physician F reported that Resident #706 often didn't eat meals and recalled being notified of low blood sugars and insulin being held. When queried as to what the Facility should do if a Resident's blood sugar levels were low. Physician F stated that insulin should be held. When queried as to whether low blood sugar levels could put the Resident at risk for falls, Physician F replied, Yes, it could put a Resident at risk for falls. On 12/21/17 at 1:30 p.m. an interview was conducted with the Administrator pertaining to the lack of blood glucose monitoring for Resident #706. The Administrator reported that the Facility Nurses had been educated on monitoring blood glucose results. Documentation provided by the Administrator documented: On 8/21/17 through a chart audit it was discoved that nursse were not following the facility Diabetic Management Policy regarding blood glucose results were not being documented in the clinical records. On 12/21/17 at 3:00 p.m., a review of the Facility's Diabetic Management Policy dated April 2005 and revised June 2008 was conducted and documented, in part, the following: Diabetic Management involves both preventative measures and treatment of [REDACTED]. Assessments: 'Upon admission the interdisciplinary team evaluates the diabetic resident and implements a plan of care to ensure: orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow and when to notify physician Routine Care: Blood glucose measurements are taken per the physician order. Results outside parameters are communicated to the physician immediately . [DIAGNOSES REDACTED]- Low Blood Sugar Levels: .weakness, dizziness or faintness, .blurred or impaired vision 2. Test the resident's blood glucose (BG) with a blood glucose monitoring device .if BG level is below 70 mg and the resident is presenting with signs/symptoms of [DIAGNOSES REDACTED] and can swallow, administer 4 ounces of fruit juice .

This deficiency practice is related to Intake #MI 970. Based on interview and record review, the facility failed to prevent skin breakdown and the formation of wounds for one resident (#917) out of 4 residents reviewed for wounds out of a total sample of 20 residents resulting in the formation of additional pressure wounds and the need for hospitalization . Findings include: Resident #917 was an [AGE] year old female who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A record review of the Minimum Data Set (MDS) revealed this resident had a Brief Survey for Mental Status (BIMS) score of 15 out of 15 potential points which indicated this resident had no difficulties with her mental thought process. Due to her [MEDICAL CONDITION], this resident needed extensive assistance with all of her activities of daily living. On 3/22/17 at 11:00 AM, a record review of the care plan for this resident revealed an entry, dated 12/2/16, that stated Resident 917 was admitted with one wound to her right buttock. Interventions, added on 12/10/16, listed included: notify MD of changes in wound or emerging wound, observe wound healing, provide wound care/preventive skin care, skin checks weekly per facility protocol, document findings, turn and reposition frequently to decrease pressure. On 3/22/17 at 11:10 AM, a record review of wound care notes, dated 12/8/16, indicated Resident 917 had one stage 4 wound to the right gluteal fold which measured 4.4 X 4.1 X 3.7 cm. There was undermining of 2.7 cm, necrotic base, moderate yellow slough and heavy serous drainage. On 3/22/17 at 11:20 AM, the Administrator was asked for copies of all skin assessments per the care plan documentation for weekly skin checks. One skin assessment by the external wound care team was provided which was dated 12/21/16. The documentation stated this resident had the following wounds: #1. a wound to the right gluteal fold - Stage 4 with a status of not healed. Measurement was 5.3 cm length x 2.3 cm width x 3 cm depth . Tunneling has been noted at 12:00 with a maximum distance of 5.7 cm. There is a large amount of sero-sanguiness drainage noted. #2. Coccyx is a Stage 3 pressure ulcer with a status of ''not healed.'' Measurements are 4.5 cm length x 3.5 cm width x 0.3 cm depth . There is a moderate amount of sero-sanguiness drainage noted. Wound bed is yellow necrotic base [MEDICATION NAME]. #3. Left Paralumbar is a stage 3 pressure ulcer and has a status of ''not healed.'' Measurements are 1.7 cm length x 6 cm width x 0.01 cm depth . There is a moderate amount of sero-sanguiness drainage noted. Wound bed is yellow necrotic base [MEDICATION NAME]. No skin assessments done by the facility staff were provided. On 3/22/17 at 2:00 PM, a record review of the progress notes, dated 12/27/16 by Licensed Practical Nurse (LPN) G was done. the notes stated: During wound care observed open area on lumbar spine area, open area on left hip and open area distal to left hip um (unit manager) in room during skin assessment states she will report to DON will continue to monitor. On 3/22/17 at 2:30 PM, a record review of a change in status note, dated 12/27/16, by LPN G indicated the resident has wounds to the sacral and gluteal area. Each wound has necrotic tissue with tunneling, foul order and pus filled discharge noted on the bandages. The resident was admitted with a [DIAGNOSES REDACTED]. B/P 76/52 Hr 94. SP02 94% on room air. Wounds are infected and patient could be septic. Physician notified. On 3/23/17 at 12:30 PM, an interview with Licensed Practical Nurse (LPN) G was done. LPN G cared for Resident #917 while she was a resident in the facility. Initially, LPN G stated she did not remember how many wounds Resident #917 had on admission. After LPN G thought about this resident, she recalled Resident #917 had one wound to her back. LPN G stated that, on discharge, resident #917 had a number of wounds to the buttocks and to the back. She stated the initial wound got worse.

This citation refers to Intake Number (s) M#I 202 Based on interview and record review, the Facility failed to ensure resident care was provided in a safe manner for one (#505) of two residents reviewed for falls/injuries, from a total sample of five, resulting in Resident #505 falling out of bed and sustaining a hematoma and laceration to the top of his head requiring hospitalization . Findings include: An incident was reported to the State Agency by the Complainant on 12/24/16 that documented Resident #505 had sustained a fall out of bed at the Facility on 12/23/16 resulting in a laceration to the apex of his head requiring hospitalization . Additional documentation provided indicated that Resident #505 was a two person assist with severe contractions and could not roll himself over in bed. On 1/5/17 at 10:50 a.m., Resident #505's clinical record was reviewed and revealed the following: Resident #505 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 12/16/16 documented that Resident #505 had severely impaired cognition and required total physical dependence of two staff members for assistance with transfers and bed mobility. An fall risk assessment completed on 12/9/16 documented that Resident #505 was a High Fall risk. A Fall Care Plan initiated 12/14/16 documented the following: R is at risk for FALLS/injury. impaired cognition, decreased physical mobility with decreased ROM (range of motion) to all extremities. He requires total assistance for transfers and repositioning . Interventions: Observe for appropriate positioning in bed. Keep resident centered in bed. Position with pillows as needed for comfort. On 1/5/17 at 1:00 p.m.,a Facility Incident and Accident Report revealed the following: Person Involved: Resident #505 Date of Incident: 12/23/16 Time: 9:20 p.m. Location of Incident: Resident's Room Findings: Resident on the floor with blood coming from head with CNA (certified nursing assistant) standing next to the resident. Further review of the Facility Investigation revealed the following. A written statement from CNA G dated 12/23/16 documented that CNA G was asked to by Nurse H to clean Resident #505 who had had bowel movement. CNA G reported that Resident #505 was lying on his back in bed. CNA G went to get a towel from the bedside table to clean Resident #505 that and when she turned around she saw him on the floor. She screamed for Nurse H for assistance who was treating Resident #505's roommate behind a curtain. On 1/5/17 at 3:25 p.m. a phone interview was conducted with Nurse H regarding the incident that occurred on 12/23/16. Nurse H stated, I was working the evening shift of 12/23/16. Resident #505 had returned via ambulance from the Hospital. I remember that he had a bowel movement when he returned and he needed to be changed. I asked CNA G to change him. I was on the other side of the room caring for the roommate. The curtain was pulled between the two Residents. I heard a loud noise and CNA G asking for help. I pulled the curtain and Resident #505 was lying on the floor. There was blood on the floor and we asked for help. We put him back in bed and called 911. He was transferred out of the Facility to the local Hospital. Nurse H was further queried as to Resident #505 mobility and whether he was able to roll on his own. Nurse H stated, I'm not sure. I can't say what happened. I did not observe it. Nurse H was asked about injuries sustained. Nurse H stated, I'm not sure about the injury, there was blood on the floor and he had a laceration on top of his head, we tried to take vitals, but he refused. We sent him to the hospital. On 1/5/17 at 3:40 p.m., the Administrator was queried about the incident and CNA G. The Administrator stated, I was out on leave at the time of the incident. CNA G was not employed by the Facility. She worked under contract from another Agency. She has not worked at the Facility since the incident. As to whether Resident #505 was able to move on his own in bed, you could talk with Physical Therapist Manager F regarding his mobility status. On 1/5/17 at 3:30 a.m., an interview and record review was conducted with Physical Therapist Manager F. PT F was queried as to the Resident's bed mobility and whether in his opinion Resident #505 would be able to turn on his own while in bed. PT F stated, His records show that he received physical therapy 12/8/16 -12/21/16. He was a total assist with everything. He was limited in moving his limbs. He came back from the hospital on [DATE] and was never reassessed because he fell and went back to the hospital. PT F was further queried as to whether Resident #505 could have moved or turned on the bed to the floor. PT F stated, He could not do a complete turn on his own. He would have needed assistance for turning. He could not have rolled out of bed on his own. On 12/6/16 at 9:00 a.m., a review of Resident #505's Hospital records was conducted and revealed, in part, the following: ED (emergency department) Notes 12/23/16 22:46): Chief Complaint: Fall R presents to the ED on 12/23/16 with chief complaint of fall Resident lived at Facility and fell out of bed tonight. EMS (emergency medical services) reports he hit his head and has an abrasion over the top of his head.PT (patient) is not answering questions and keeps repeating my neck is broken. EMS reports his blood pressure is 196/97 .PT was in hospital recently .had IVC (inferior vena cava filter) placed yesterday. He was discharged today .is limited secondary to dementia. Physical Exam: Quarter shaped Hematoma 5 cm (centimeter) laceration. History of Present Illness 12/24/16: R .presented from Facility the day he was discharged from Hospital .presents now after his family states that the personal at the NH (nursing home) dropped him on his head from a Hoyer lift. Discharge: Resident discharged from hospital on [DATE]. On 1/5/17 at 4:40 p.m., the Facility Policy titled FALL MANAGEMENT (revised August 2012) was reviewed and documented, in part, the following: 1. Facilities will take a proactive approach for new residents and will consider new admissions at risk for falls until the resident is reviewed by the IDT (inter-disciplinary team). 6. If determined by the IDT that the resident is at risk, the Falling Star will be continued and interventions in the Plan of Care will be updated . ( )

This citation refers to intake # MI 632 and MI 022. Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to provide care and services to residents in accordance with physicians' orders and plans of care for 83 residents in the facility who were without adequate services of a registered nurse on any shift from 9/2/16 through 9/6/16, and adequate nursing staff for the month of September (including no licensed nurse during the midnight shift on 9/10/16 and no certified nurse aide on the midnight shift on 9/10/16 between 2:30 A.M. and 7:00 A.M.), resulting in an immediate jeopardy when medications were not administered to three (#801, #802, and #803) of six residents reviewed for medications, from a total sample of six ([MEDICAL CONDITION], antibiotics, insulin, high blood pressure medications); medical treatments were not completed for two (#802 and #803) of three residents reviewed for treatments, from a total sample of six (including wound, [DEVICE], skin treatments, and treatment of [REDACTED].#801, #802, and #803) of three residents reviewed for activities of daily living, from a total sample of six (including showers, transfers to bed, and toileting). This deficient practice placed all 83 facility residents, who receive care and services per physicians' orders and plans of care, at risk for serious harm and/or death. The immediate jeopardy was identified on 9/22/16 at 10:45 A.M. and the administrator was asked for a plan of removal of the immediacy at 12:59 P.M. Although the IJ was removed on 9/27/16, the facility's deficient practice was not corrected and remained at widespread with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 9/21/16 at 7:00 A.M., a complaint submitted to the State Agency was reviewed. It was alleged by the complainant that on 9/9, 9/10, 9/11, and 9/12/2016 there were no CNAs (certified nursing assistant) from 2 AM to 6 AM to deliver care to the residents and on 9/9 from 3 PM to 11 PM, there was no nurse to administer medications. The complainant reported that the resident was never put to bed on 9/10 and had to stay in his chair for 42 hours and, on 9/12, the resident wet his bed because there was nobody available to give him the urinal. It was alleged that the resident had not received a shower in 17 days because the facility was short of staff and not hiring staff. On 9/21/16 at 7:15 A.M., a complaint submitted to the State Agency was reviewed and documented allegations of inadequate staff and lack of staffing in the facility. On 9/21/16 at 9:00 A.M., an unannounced on-site investigation was initiated. The actual daily schedule worked for all shifts and all units for September 2016 was requested from the Director of Nursing (DON) and Administrator. It was requested that the schedule included the staff who actually worked. A list of all nursing staff who currently worked in the facility and their titles were requested An interview with Resident #802 was conducted on 9/21/16 at 10:45 A.M. Resident #802 reported that there were a couple of times when nobody received medications. Resident #802 stated, I think there was a nurse in the building, but not assigned to the East hall. There was a, I think it was a Friday, Saturday and Sunday, where there were no aides in the building .I think it was last weekend when there were only two aides in the whole building. That's not enough to take care of all the residents .Last night, my nurse was my aide .Sometimes they mandate the aides (who work until 11 P.M.) to work an extra four hours until 2 or 3 A.M. and there will be no aide until 7 A.M. I have to get out of bed before 7 A.M. or else I become uncomfortable . Resident #802 reported there was one night when he had to stay up in his wheelchair because there was no one to put me to bed. On 9/21/16 at 9:30 A.M., a report titled, (corporate and facility name) date range schedule . was received. The DON was asked to explain the report and she reported that if there was a number entered under the date and shift, that indicated that the staff member worked that number of hours on that particular day. The daily nursing staffing hours for September 2016 was requested at this time. At 11:00 A.M., the DON provided the following information. The .date range schedule . and Daily Staffing was reviewed for the midnight shift (11 P.M. to 7 A.M.) for 9/9/16, 9/10/16, 9/11/16, and 9/12/16 and revealed the following: On 9/9/16, there were two nurses on the afternoon shift. There was a documented resident census of 82 residents. On 9/10/16 and 9/11/16, there was no nurse on the midnight shift and one nurse on the afternoon shift (3 P.M. to 11 P.M.). There was a documented resident census of 83 residents. On 9/10/16 and 9/11/16, there was one CNA (to 83 residents) on the midnight shift. On 9/12/16, there was no CNA on the midnight shift (for 83 residents). Resident #801 On 9/21/16 at 11:45 A.M., the clinical record for Resident #801 was reviewed and revealed the following: Resident #801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 7/1/16 documented that Resident #801 had intact cognition, required total physical assistance from one staff member for bathing, extensive assistance for transfers, toilet use, dressing, and hygiene, and limited assistance for bed mobility and ambulation. physician's orders [REDACTED].#801 did not receive the following medications on the afternoon shift: 9:00 P.M. dose of Alzheimer's medication (order for [MEDICATION NAME] 10 milligrams, give 0.5 tablet by mouth at bedtime) 4:30 P.M. finger stick blood sugar before meals 9:00 P.M. dose of insulin (order for [MEDICATION NAME] Flextouch 100 units/ml, inject 15 units subcutaneously at bedtime). 9:00 P.M. dose of an anti-parkinsonian medication ([MEDICATION NAME] HCL) related to [DIAGNOSES REDACTED]. 5:00 P.M. dose of an oral diabetic medication ([MEDICATION NAME]) (order for 500 mg, give 1 tablet by mouth two times a day). Further review of the MAR for September 2016 revealed the following: Accuchecks (blood sugar measuring system) were not completed before breakfast meals (6:30 A.M.) on 9/1/16, 9/3/16, 9/6/16, 9/7/16, 9/10/16, 9/12/16, 9/14/16, 9/15/16, and 9/16/16. [MEDICATION NAME] was not given at 9:00 P.M., per physician's orders [REDACTED]. Finger blood sticks were not completed before dinner meals (4:30 P.M.) on 9/2/16, 9/3/16, 9/5/16, 9/16/16. [MEDICATION NAME] (a medication to treat diabetes - ordered 5 mg, give 0.5 tablet by mouth in the morning) was not given on 9/1/16, 9/3/16, 9/6/16, 9/7/16, 9/10/16, 9/12/16, 9/14/16, 9/15/16, 9/16/16. Insulin ([MEDICATION NAME]) was not given on 9/3/16, 9/5/16, 9/16/16, 9/19/16, 9/20/16. 9:00 A.M. dose of high blood pressure medication ([MEDICATION NAME]) was not given on 9/3/16 and 9/20/16 (order for 10 mg, give 1 tablet by mouth one time a day). 9:00 P.M. dose of [MEDICATION NAME] was not given on 9/3/16, 9/5/16, 9/16/16, and 9/19/19. 9:00 A.M. dose of [MEDICATION NAME] was not given on 9/3/16 and 9/20/16 and the 5:00 P.M. dose was not given on 9/2/16, 9/3/16, 9/6/16, and 9/19/16. There was no documentation that Resident #801 refused the above medications. Resident #802 On 9/21/16 at 12:00 P.M., the clinical record for Resident #802 was reviewed and revealed the following: Resident #802 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment, dated 9/4/16, documented that Resident #802 had intact cognition and required total physical assistance from two staff members for transfers and toilet use, and extensive to total physical assistance from one staff member for bed mobility, dressing, eating, hygiene, and bathing. physician's orders [REDACTED].#802 did not receive the following afternoon shift medications (as indicated by no nurse's signature on the MAR): 6:00 P.M. dose of anti-diarrheal medication (order for [MEDICATION NAME] HCL 2 mg via PEG tube every 12 hours) 6:00 P.M. blood pressure check and anti-hypertensive medication (order for [MEDICATION NAME] 25 mg 1 tablet via PEG tube every 12 hours) 5:00 P.M. dose of a tear producing eye drop (order for [MEDICATION NAME] instill one drop in both eyes two times a day for dry eyes) 5:00 P.M. dose of sinus rinse (order for 1 spray alternating nostrils two times a day) 5:30 P.M. dose of a saliva producing medication (order for [MEDICATION NAME] HCL to give 1 tablet via PEG tube three times a day for Sjogre[DIAGNOSES REDACTED] - sicca syndrome 2 tabs at 6 A.M., 1 tab at 12 P.M., 1 tab at 6 P.M.) 6:00 P.M. dose of cough syrup for congestion (order for [MEDICATION NAME] Syrup to give 100 mg/ml via PEG tube every 6 hours) 5:00 P.M. and 9:00 P.M. doses of lubricant eye drops (order for Polyethyl [MEDICATION NAME]-Propyl [MEDICATION NAME] to instill 1 drop in both eyes four times a day for dry eyes). There was no documentation that Resident #802 refused the above medications. Further review of Resident #802's MAR for September 2016 revealed the following: On 9/3/16, 9/7/16, 9/12/16, 9/14/16, 9/15/16, and 9/16/16, Resident #802 did not receive any 12:00 A.M., 5:30 A.M., or 6:00 A.M. medications. On 9/5/16, Resident #802 did not receive any afternoon (5:00 P.M., 5:30 P.M., and 6:00 P.M.) medications. On 9/1/16, 9/2/16, 9/6/16, 9/11/16, 9/13/16, 9/14/16, 9/15/16, and 9/20/16, Resident #802's PEG site dressings were not treated, as ordered (every night shift cleanse peg site with normal saline and cover with DD (dry dressing) daily and as needed). Resident #803 On 9/21/2016 at 2:00 PM, a record review of Resident #803's electronic medical record was done. Resident #803 was a fifty-five year old female who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A record review of the Initial Minimum Data Set (MDS), dated [DATE], indicated this resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points indicating she was cognitively intact. Resident #803 was dependent on staff for transfers, dressing, hygiene and bathing. Because Resident #803 had paralysis of her lower limbs, she was dependent on staff for ambulation. On 9/21/2016 at 2:15 PM, a record review of Resident #803's wound care plan was reviewed. The focus of the plan stated Resident #803 has 2 stage 4 pressure ulcers present on admission. R hip, sacrococcyx/buttocks. r/t (related to) Hx (history) of ulcers, immobility. The goal was stated as Resident #803 will show signs of healing and remain free of infection by/through review date. (target date 11/30/2016) Interventions included: administer medications as ordered. Observe/document for side effects and effectiveness. Administer treatments as ordered. Change wound Vac as ordered. On 9/21/2016 at 2:30 PM, a record review of the MARs and TARs indicated Resident #803 had a wound vac (a therapeutic technique using a vacuum dressing to promote healing) in place to her right hip and to her sacral coccyx wounds. The physician orders, dated 8/26/2016, indicate the wound vac was to be changed at both locations every three days and PRN (as needed). According to the TAR, there was no documentation that the two wound vac's were changed on 9/7/16, 9/10/16 and 9/16/16. On 9/21/2016, a record review of the medication administration record (MAR) was done. On 9/3/2016, 9/7/2016 and 9/11/2016, the following medications were not given on the day shift at 9 am as ordered : Abacavir-Dolutegravir-Lamividine 600-50-300 milligrams (mg) [MEDICAL CONDITION] Tenofovir Disoproxil [MEDICATION NAME] 300 mg [MEDICAL CONDITION] [MEDICATION NAME] 10 mg for high blood pressure There was no documentation that Resident #803's blood sugar was checked for a blood sugar level on those dates and times. In addition,[MEDICATION NAME] mg, a medication used to treat a urinary tract infection, was ordered on [DATE]. The order read as follows: Cipro Tablet 500 mg ([MEDICATION NAME] HCl) Give 500 mg by mouth two times a day for infection for 7 days. Resident #803 should have received fourteen (14) doses of this antibiotic but only received 8. There was no documentation that the medication was given on the following dates and times: 9/3/16 at 9 am; 9/5/16 at 9 PM, 9/6/16 at 9 PM, 9/7/16 at 9 am and 9 PM, and on 9/3/16 at 9 PM the medication was not given because the resident was sleeping (11 = sleeping according to the chart codes). On 9/21/16 at approximately 3:00 P.M., the DON was asked for shower/bath sheets for Resident #s 801, 802, and 803. On 9/21/2016 at 3 PM, a record review of the staffing at the facility (Daily Staffing reports from 9/1/16 through 9/21/16 and staffing hours completed by the facility for 9/1/16 through 9/9/16) revealed there was no Registered Nurse (RN) hours documented for the following dates: 9/2/16, 9/3/16, 9/4/16, 9/5/16, 9/6/16, 9/8/16, 9/9/16, 9/16/16, 9/17/16, 9/18/16, 9/19/16, and 9/20/16 during any shift on those dates. The only scheduled staff were licensed practical nurses and certified nursing assistants. The resident census ranged from 82 to 84 residents residing in the facility on the above dates. A list of facility nursing staff was provided by the DON and Administrator and reviewed with the staffing coordinator (Staff A) on 9/21/16 at 3:15 P.M., who indicated the list had not been updated and some of the staff no longer worked in the facility. Staff A updated the list (and signed it to indicate the changes were made) which included only three RNs were currently employed by the facility, Nurse E, Nurse JJ and the Director of Nursing (DON). On 9/21/16 at 3:09 P.M., during a phone call with the State Ombudsman, it was revealed that the Ombudsman received, A lot of complaints lately. When asked if any complaints were received from residents regarding staffing at the facility, the Ombudsman stated, Oh yes. A lot and the floor staff say there is no management in the building. On 9/22/16 at 8:30 A.M., Staff A was interviewed. Staff A was asked if she was aware that the facility was short of nursing staff on 9/9/16, 9/10/16, 9/11/16, and 9/12/16 as mentioned above. Staff A stated, Yes. We are trying to hire people. People aren't showing up for interviews or orientation. We brought in agency staff (nurses). When queried about the date range schedule and daily staffing that documented two nurses on the afternoon shift on 9/9/16 with a resident census of 82, no nurse documented for 9/10/16 and 9/11/16 on the midnight shift and one nurse on the afternoon shift (3 P.M. to 11 P.M.) with a resident census of 83. Staff A reported that the reports reviewed did not document who actually worked on those days/shifts. Staff A stated, We would have to look at the sign-in sheets. When queried about the CNA coverage for the midnight shift of 9/10/16 and 9/11/16, and no CNA working on the midnight shift for 9/12/16, Staff A reported that it would be on the sign-on sheets. On 9/22/16 at 9:30 A.M., time sheets and sign-in sheets for all nursing staff were requested from the Administrator for the month of September 2016. On 9/22/16 at 10:00 A.M., an interview and review of the sign-in sheets and time sheets was conducted with the Administrator, DON, and Staff A. It was explained by Staff A that any staff member that was scheduled would write their signature on the sign-in sheets at the nurse's station. Staff A was asked, in the presence of the DON and the Administrator, to verify that the time sheets matched with the sign-in sheets. The following was revealed: On 9/1/16, there was a census of 82 residents in the facility. It was noted that one CNA (CNA B) was in the facility on 9/2/16 (on the 9/1/16 midnight shift) between 3:00 A.M. and 4:51 A.M. There were two nurses, identified by Staff A as agency nurses (Agency Nurse C and Agency Nurse D) on the sign in sheet. There was a signature next to Agency Nurse D and no signature next to Agency Nurse C. Nurse E stayed from the afternoon shift until 1:00 A.M. When queried about how it was known that Agency Nurse C and Agency Nurse D worked the midnight shift, Staff A reported that the agency staff do not use the facility's time clock and they would have to get the time sheets from the agency. On 9/2/16, there was a census of 83 residents in the facility. There were two CNAs (CNA F and CNA G) and two nurses (Nurse H and Nurse J) on the afternoon (3 P.M. to 11 P.M.) shift . On the midnight shift (11 P.M. to 7 A.M.), there was one CNA (CNA K) and one nurse (Nurse L). Agency Nurse C was on the sign-in sheet with no signature and no time sheet. On 9/3/16, the resident census was 83. There were two nurses (Nurse M and Nurse N) on the day shift, two CNAs (CNA B and CNA F) on the midnight shift from 11:00 P.M. until 3:00 A.M., and one CNA (CNA B) on the midnight shift from 3:00 A.M. until 7:00 A.M. CNA F clocked out at 3:09 A.M., leaving CNA B as the only CNA in the building from 3:09 A.M. to 7:00 A.M. On 9/7/16, the resident census was 83. The sign in sheet and time sheets indicated that CNA S and CNA T clocked out at 7:00 P.M., leaving CNA G as the only CNA in the building from 7 P.M. until 11 P.M. There were two nurses (Nurse E and Nurse H) on the afternoon shift. Nurse U did not have a signature next to her name and no time sheet. On 9/9/16, Resident census was 82. The sign in sheet indicated that two nurses (Nurse O and Nurse Q) signed in on the afternoon shift. Agency nurse P was listed under the afternoon shift, but there was no signature and no time sheet. On the midnight shift, it was documented that CNA B left at 12:00 A.M., returned at 5:00 A.M. with permission from Nurse for ER. CNA B's timesheet did not document that he clocked out for five hours. The DON was queried about the above note and reported that she had not yet looked into it. The DON was queried about the lack of RNs working in the facility in September 2016. The DON reviewed all the steps taken by the facility to recruit, interview and hire new staff. In addition, the DON indicated the facility was using three outside agencies to staff the facility. There was no explanation for the lack of RNs being used in the facility. The Administrator (who indicated she had been in the position since 9/2/16) was asked if the amount of nursing staff was adequate for the facility and she reported that it was not. When queried about what the facility had done to ensure adequate nursing staff was present in the facility, the Administrator stated, We are interviewing, calling, begging weekly. Asking people to come in. Bonuses are in place. We are met with challenges getting good quality staffing. The DON reported that the facility lost three nurses since she started on 6/27/16. Staff A was asked how long staffing had been an issue in the facility and stated, About 2-3 months. It's been a problem. The Administrator was asked if the facility stopped admitting residents. The Administrator stated, Admissions have slowed up .but, if they come to us, we admit them. Time sheets were requested from the Administrator, DON, and Staff A for agency nurses at this time to verify hours worked for September 2016. The DON was interviewed on 9/22/16 at approximately 11:00 A.M. regarding Resident #801 and #802 and the MARs were reviewed. When queried about the medications not given in September 2016, including insulin and oral diabetic medications for Resident #801, and medications and treatment for [REDACTED].#802 (indicated by a blank on the MAR and no corresponding progress note or documentation of refusal by the resident), the DON reported that It may have been an agency nurse. I will have to check into it. The DON was asked about the shower/bath sheets requested on 9/21/16 for Resident #s 801, 802, and 803 and stated, I found one, but haven't found the others yet. No shower sheets were provided by the facility by the end of the survey. On 9/22/2016 at 12:00 noon, an interview with the Director of Nursing (DON) was done. The DON was shown the copies of Resident #803's MAR and TAR for September 2016 and asked why the medications and wound treatments were not documented. She stated that sometimes the agency nurses could not be added to their electronic medical record so the agency nurses had to use a paper MARs and TARs for documentation purposes. The DON said she would look for these documents. At the time of exit, these paper documents were not provided. The sign in sheet for 9/10/16 was reviewed with Staff A on 9/22/16 at 11:15 A.M. Staff A was asked if a nurse worked the midnight shift and indicated that two agency nurses (Agency Nurse V and Agency Nurse W) worked the midnight shift (no signatures) and that there was no CNA between 2:30 A.M. and 6:55 A.M. Verification of Agency Nurse V and W's time sheets were requested. On 9/22/16 at 12:06 P.M., the DON was further interviewed about the MARs and TARs for Resident #801, #802, and #803 and the days where there were no signatures by the nurses for medications and treatments, [MEDICAL CONDITION], antibiotics, insulin, diabetic medications, and pressure ulcer treatments. The DON stated, I went through them, and there was an explanation for some of the missing medications and treatments, but I don't have an explanation for the rest. The DON stated, (Name of electronic medical record software) allows codes if a medication is not given or if the resident refused and the code generates a progress note to explain what happened. The DON stated, I'm going to have to talk to the agency nurses. Just because you are an agency nurse doesn't mean you don't utilize the same process. The DON was asked if she reviewed the MARs and TARs and physician's orders [REDACTED]. There is no ADON (Assistant Director of Nursing) or unit managers to help out. When queried about whether or not the DON was aware that medications and treatments were not being done, the DON reported that she did not know before today (9/22/16). On 9/22/16 at 2:45 P.M., Corporate Staff FF, the DON, and the Administrator, later joined by Corporate Staff GG, provided an Invoice from a staffing agency that documented Agency Nurse W worked on 9/10/16 from 3 P.M. to 7:15 A.M. and Agency Nurse V worked at the facility on 9/10/16 from 11 P.M. to 7:45 A.M. When queried about other shifts that were short of nursing staff, such as the dates when there was no CNA in the building for several hours, Corporate Staff FF stated, There should never not be a CNA. No other time sheets for agency nurses were received prior to the end of the survey. On 9/22/16 at 3:00 P.M., the following was revealed when reviewing the additional sign-in sheets, time sheets, and daily staffing reports for 9/4/16, 9/5/16, 9/6/16, 9/8/16, 9/11/16, 9/12/16, 9/13/16, 9/14/16, 9/15/16, 9/16/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, and 9/21/16: On 9/4/16, there were three CNAs on the day shift between 12:00 P.M. and 3:00 P.M., three CNAs on the afternoon shift to care for 82 residents (approximately 28 residents per CNA), and no CNA in the building between the hours of 3:00 A.M. and 7:00 A.M. on the midnight shift. On 9/5/16, there were three CNAs on the afternoon shift for 82 residents. On 9/6/16, there were two nurses on the afternoon shift for 84 residents. Nurse X was on the sign in sheet for the afternoon shift (with no signature), but punched out at 3:30 P.M. according to the time sheet. There was one nurse (Nurse Y) on the midnight shift. Nurse Z did not sign in and did not have a time sheet. On 9/8/16, there were three CNAs on the afternoon shift for 82 residents and one CNA (CNA AA) to care for all 82 residents in the facility on the midnight shift. CNA K signed the sign in sheet, but did not work, as evidenced by no time clocked in or out on the time sheet for this date. On 9/11/16, there was one CNA (CNA G) to care for 83 residents between 7:00 P.M. and 11:00 P.M. and two nurses (Nurse H and Agency Nurse D) to care for approximately 41 residents each until 4:45 P.M. After 4:45 P.M., Agency Nurse D was the only nurse in the building. There were two other nurses on the sign in sheet with no signature and no time sheet. There was one CNA (CNA K) in the building on the midnight shift between 11:00 P.M. and 4:45 A.M. On 9/12/16, there was one nurse (Nurse H) for the day shift, who arrived at 9:30 A.M. There was a signature next to Nurse X, but no punch in or out on the time sheet. There were three CNAs on the afternoon shift and no CNA on the midnight shift between 3:00 A.M. and 5:28 A.M. CNA BB and CNA CC punched out at 3:00 A.M. The resident census was 83. On 9/13/16, there were three CNAs on the afternoon shift and three CNAs on the midnight shift with one nurse (Nurse L) for a census of 83 residents. Nurse DD was written on the sign in sheet with no signature and no time sheet. On 9/14/16, there were three CNAs on the day shift and one nurse (Nurse O) on the day shift. There were two nurses without a sign in or time sheet. There were two CNAs (CNA BB and CNA G) on the afternoon shift. CNA F signed in on the sign in sheet, but there was no time clocked in or out on the time sheet. CNA B signed in on the sign in sheet for the 3 to 11 P.M. shift, but did not punch in until 11:00 P.M. according to the time sheet. The resident census was 83. On 9/16/16, there were three CNAs on the afternoon shift for 85 residents (approximately 28 residents assigned to each CNA). On 9/17/16, there were three CNAs for 84 residents on the day shift and afternoon shift, and only one CNA from 3:42 A.M. to 7:00 A.M. on the midnight shift. On 9/18/16, there were two CNAs on the day shift, three CNAs on the afternoon shift, and two CNAs on the midnight shift for a census of 84 residents. On 9/19/16, there were only two CNAs in the building from 6:30 P.M. until 11:00 P.M. and two CNAs from 12:30 A.M. until 7:00 A.M. There was a resident census of 83. On 9/20/16, there were two CNAs in the building on the midnight shift from 11:00 P.M. until 7:00 A.M. for a census of 82 residents (approximately 41 residents assigned to each CNA). The facility's policy, titled, Nursing Staffing Schedule was reviewed on 9/22/16 at 5:35 P.M. and documented the following: The Nursing department employs sufficient and competent employees to carry out the functions of the department and meet resident's needs . .The Director of Nursing Services or their designee is responsible for developing the work schedule taking into account the resident's care needs .At least one licensed nurse must be on duty at all times . The facility submitted an acceptable immediacy removal plan including supporting documentation on 9/27/16: Facility to Provide Sufficient Nursing Staffing: Element #1 The following recruiting practices are in place: online listing (Indeed, Career Builder, Craig's list, Sava Senior Care website, Glassdoor, Oodle, JuJu, Monster), Sign on bonuses of $5000 for RNs, $2500 for LPNs, and $500 for CNAs, and Open Interviews are scheduled Mon-Fri from 11 AM to 1 PM and as needed. We also have a relationship with local schools that offer training programs so that we can speak with students and recent graduates to recruit them to work for us. See attached Craig's List line listing of postings for the last 6 months and the ad from the website with this information. The facility has current contracts with three agencies to provide per diem nurses as needed. See attached copies of contracts with Elite Medical, Maxim, and Vibrus The facility will provide adequate services of a Registered Nurse at least one 8 hour shift per day, seven days per week. The facility will provide adequate Nursing Staff; Licensed Nurses and Certified Nursing Assistants on every shift seven days per week in order to provide medications, treatments, and activities of daily living. All nursing staff will document services provided in the medical record. Systemic changes will ensure that adequate staffing patterns will be consistent on a daily basis on each shift for each 24 hour period. Element #2 The facility has identified that all residents in the facility have the potential to be affected by the deficient practice. Element #3 On 9-22-16 the facility conducted an assessment of all residents in the facility to determine any residents who may be affected by the deficient practice. This audir was completed on 9-22-16. Assessment included a review of physician's orders [REDACTED]. These assessments were completed by the DON and other Corporate nursing support. Facility wide assessment of residents also consisted of visual observations of residents to ensure that care needs are being provided for each individual resident as needed per their individual plan of care. These visual observations were conducted by members of the facility interdisciplinary team. No [MEDICATION NAME] effects were noted. Any concerns identified related to care and services have been resolved. Element #4 On 9-22-16 facility began staff education on the requirement that adequate Nursing Staff is required on a consistent basis, every shift, seven days per week in order to provide care and services per physician's orders [REDACTED]. Staff education and training includes: procedures for providing adequate staffing, following each individual residents plan of care, following physician's orders [REDACTED]. All employees present on 9-22-16 after 6 PM were educated that evening. All oncoming staff have been educated at the start of their shift. On 9-23-16 the following audits will be completed to insure sustained compliance: Staffing will be audited daily, Provision of ADL care will be audited for 10 residents 3 times weekly, and Medications and Treatments for 10 Residents 3 tims weekly. Issues identified in the audits will be corrected. These audits will continue until the QAPI committee deems sustained compliance has been acheived. All audits will be presented to the Administrator and brought to the facility Quality Assurance Committee meeting for review and recommendations. Element #5: The facility alleged t

This citation refers to intake #MI 566. Based on interview and record review, the facility failed to provide wound vac treatment and repositioning per the physician's orders [REDACTED].#803) out of 3 residents reviewed for wound care out of a total sample of 6 residents resulting in a delay in wound healing and the formation of a new wound. Findings include: On 9/21/16 at 1:40 P.M., a complaint submitted to the State Agency was reviewed and documented an allegation from a complainant that the facility failed to provide her with adequate care and the staff was not adequately trained to provide wound vac (vacuum) care. Resident #803 was a fifty-five year old female who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 9/21/2016 at 1:45 PM, the Director of Nursing (DON) was asked when the wound care team would be at the facility to review all the residents with wounds in the facility. The DON stated the wound team was expected to be in the facility later today. The DON was asked to inform the survey team when the wound care team arrived in order to observe the wounds as well as wound care. The DON indicated she would let the survey team know when the wound care team entered the facility. On 9/21/2016 at 2:00 PM, a record review of Resident #803's electronic medical record was done. A record review of the Initial Minimum Data Set (MDS), dated [DATE], indicated this resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points indicating she was cognitively intact. Resident #803 was dependent on staff for transfers, dressing, hygiene and bathing. Because Resident #803 had paralysis of her lower limbs, she was dependent on staff for ambulation. On 9/21/2016 at 2:15 PM, a record review of Resident #803's wound care plan was reviewed. The focus of the plan stated Resident #803 has 2 stage 4 pressure ulcers present on admission. R hip, sacrococcyx/buttocks. r/t (related to) Hx (history) of ulcers, immobility. The goal was stated as Resident #803 will show signs of healing and remain free of infection by/through review date. (target date 11/30/2016) Interventions included: administer medications as ordered. Observe/document for side effects and effectiveness. Administer treatments as ordered. Change wound Vac as ordered. On 9/21/2016 at 2:22 PM, a record review of the Medication Administration Record (MAR) revealed Resident #803 had a physician's orders [REDACTED]. The Protein liquid was not given, as noted by a blank box in the MAR, on 9/3/16 at 9 AM; on 9/5/16 at 5 PM; on 9/6/16 at 5 PM; on 9/7/16 at 9 AM and 5 PM; and on 9/11/16 at 9 AM. Another physician order [REDACTED]. The House Supplement was not given on 9/3/16 at 9 AM and 1 PM and held at 9 PM because the resident was sleeping (coded as 11 which was noted in the chart codes to mean sleeping); on 9/5/16 at 9 AM (resident refused) and 9 PM; on 9/6/16 at 9 PM; on 9/7/16 at 9 am, 1 PM and 9 PM; and on 9/11/16 at 9 AM and 1 PM. Although the physician's orders [REDACTED]. On 9/21/2016 at 2:30 PM, a record review of the Treatment Administration Record (TAR) indicated Resident #803 had a wound vac (a therapeutic technique using a vacuum dressing to promote healing) in place to her right hip and to her sacral coccyx wounds. The physician orders, dated 8/26/2016, indicate the wound vac was to be changed at both locations every three days and PRN (as needed). According to the TAR, there was no documentation that the two wound vac's were changed on 9/7/16, 9/10/16 and 9/16/16. At 3:00 PM, the DON was again asked if the wound care team had entered the facility and she said they were on their way. On 9/21/2016 at 4:10 PM, an interview with Nurse Practitioner (NP) II was done. NP II stated she had just completed the wound care in the facility and was unaware that the surveyor wanted to observe wound care. According to NP II, she had just completed her wound care rounds for Resident #803 and, because there was no positive progress with Resident #803's wounds, she removed both [DEVICE] from Resident #803's wounds and changed some of the orders for care. NP II stated there was no consistency with staffing at the facility and wound care would work better if they (the facility) had the same nurse providing wound care to the residents. On 9/21/2016 at 3:30 PM, a record review of the wound care documentation for the previous 6 weeks was done. The following information was documented: 8/17/2016: Wound to right hip measured 9 x 6.5 x 1.6 cm; Wound care notes state pink base, heavy serosanguinous drainage, irregular edges, bony exposure noted. Wound to the buttocks measured 9.5 x 4.0 x 1.5 cm; pink base, heavy serosanguinous drainage, irregular edges. Pressure ulcer stage IV to right hip and bilateral buttocks. NP recommended wound vac q (every) 48 hours/PRN (as needed) to right hip. Hydrogel impregnated gauze daily/PRN sacrococcyx/bilateral buttocks. Frequently reposition. 8/24/2016: Wound to right hip measured 9.8 x 7.2 x 2.0 cm; pink base with bony exposure noted to mid core, heavy serous drainage. Wound to the buttocks measured 11.0 x 4.0 x 2.0 cm; pink base, heavy serous drainage with irregular edges. Diagnosis: [REDACTED]. Wound vac q 48 hours/PRN right hip, hydrogel impregnated gauze qd/PRN sacrococcyx/bilateral buttocks. Frequently reposition. 8/31/2016: Wound to right hip measured 7 x 6 x 0.8 cm ; pink base, heavy serosanguinous drainage, irregular edges, improvement noted. Wound to the buttocks measured 10.0 x 4.5 x 1.0 cm; pink base, heavy drainage irregular edges, Wound vac q 48 hours/PRN right hip. hydrogel impregnated gauze qd/PRN sacrococcyx/bilateral buttocks. Frequently reposition. 9/8/2016: Wound to right hip - resident #803 refused to have the wound measured Wound to the buttocks measured 10.5 x 3.7 x 1.0 cm; pink base with heavy serous drainage and irregular edges. [MEDICATION NAME] Ag q 2 d/PRN to sacrococcyx/bilateral buttocks. Wound vac q 48 hours/PRN right hip. Frequent reposition. 9/14/2016: New wound to left hip measured 1.7 x 1.4 x .01 cm; Pink base with minimal serous drainage. Wound to right hip - 7.4 x 6.0 x 1.0 cm; pink base, heavy serosanguinous drainage, irregular edges. Wound to the buttocks measured 6.5 x 3.0 x .7 cm; Pink base with moderate serosanguinous drainage and irregular edges. [MEDICATION NAME] Ag q 2 d/PRN to sacrococcyx/bilateral buttocks, wound vac q 48 hours/PRN to right hip, Allevyn Life q 3 days/PRN to left hip. Frequent reposition. 9/21/2016: New wound to left hip measured 1.0 x 0.4 x .01 cm; Pink base minimal serous drainage and irregular edges. Wound to right hip - 8.5 x 6.5 x 1.3 cm; Pink base with minimal necrosis (dead tissue) noted to distal wound edge, heavy serous drainage. Wound to the buttocks measured 8.8 x 3.0 x 2.4 cm; pink base with heavy serosanguinous drainage, irregular edges. Wound to left lumbar spine 2.0 x 2.0 x 0.01 cm; pink base minimal serous drainage with (unable to read) edges, Pressure ulcer Stage IV to sacrococcyx/bilat. buttocks and right hip. Skin tear left lumbar spine. Abrasion left hip. [MEDICATION NAME] AG qd (every day)/PRN to sacrococcyx/bilateral buttocks, right hip. D/C (discontinue) wound vac. Allevyn Life q 3 days/PRN to left lumbar spine, left hip. Frequent reposition. On 9/22/2016 at 11:05 AM, Resident #803 was observed in her bed in her room. Resident #803 was lying on a black mattress which was not covered with a sheet. Resident #803 was wrapped in a blanket. Resident #803 was noted to have an unpleasant odor about her body. When asked about receiving showers, she stated she needed assistance from the certified nursing assistants (CNAs) but they were not available to assist her. On 9/22/2016 at 12:00 PM, an interview with the Director of Nursing (DON) was done. The DON was shown the copies of the MAR and TAR for September 2016 for Resident #803 and asked why treatments were not documented. She stated that sometimes the agency nurses could not be added to their electronic medical record so the agency nurses had to use a paper TAR for documentation purposes. The DON said she would look for these documents. At the time of exit, these paper documents were not provided. ( )