Every finding on record at Harmony Village of Clinton

This citation pertains to intakes: 2684900,2686660,2687810, and 2689521.Based on observation, interview, and record review, the facility failed to prevent financial exploitation for one resident (R700) out of two reviewed for misappropriation of funds, resulting in mental anguish and emotional distress. Findings include:A review of a Facility Reported Incident (FRI) noted the following, . Findings: Misappropriation of Resident Funds, Substantiated Psychological abuse, Substantiated Conclusion: An investigation was initiated on 11/25/2025 after [R700] reported concerns involving the Business Office Manager, [Business Office Manager (BOM) B. Through multiple interviews and review of documentation and phone messages voluntarily presented by the resident, the facility identified information suggestive of financial exploitation, misappropriation of resident funds, and violations of professional boundaries. As [R700] is under full guardianship and legally incapacitated, [R700] does not have the authority to consent to financial transactions or personal interactions of an intimate or influential nature with staff. Transfers of funds to the employee occurred without guardian authorization, and resident trust funds were moved without required oversight.A review of the medical record revealed R700 re-admitted into the facility on 8/1/2025 with the following medical diagnoses, Anxiety disorder, Bi-Polar, Narcissistic Personality disorder, and adjustment disorder. A review of the most recent Minimum Data Assessment set revealed a Brief Interview for Mental Status score of 15/15, indicating an intact cognition. R700 also required staff assistance with bed mobility and transfers.Further review of the medical record revealed the following progress notes, Date:11/26/2025.Description of what occurred: Patient observed to have increased anxiety, paranoid, lack of sleep, and suicidal ideation. Staff member had unprofessional conduct with resident. Employee suspended, psych (psychiatry) to F/U (follow up), like resident interviews held, psychosocial assessments, police report, pain and skin assessments.Immediate intervention implemented 1:1 monitoring, behavior progress notes, psych to eval (evaluate) and treat. Date:11/26/2025.Resident observed with (2) open areas proximal L (Left) wrist. Open areas #1 and #2 observed small amount of bleeding. Open areas #1 approximate measurement 2.0cm (centimeters) x 0.1cm. Open area #2 approximate measurement 3.0 cm x 0.1cm .New orders received to transfer to ER (Emergency Room) at [Hospital] for psychiatric assessment R/T (Related To) attempting self-harm with suicidal ideations.A review of the inpatient psychiatry note dated 11/26/2025 noted the following, Patient presented to the ED (Emergency Department) via ambulance for hypoxia (shortness of breath) and suicidal ideation. Patient resides at an ECF (Extended Care Facility) and reportedly has been on 1:1 for agitation. Patient made suicidal statements today,,.per staff. Patient reports [they] had multiple blades from razors stored. Leaving one in the bed which [they] reports [they] rolled over and cut [their] left wrist .Patient became more uncooperative after a staff member was terminated for having an inappropriate relationship with patient.On 12/10/2025 at 10:18 AM, an interview was conducted with R700. R700 was noted to have a 1:1 sitter in the room with them. R700 reported that they were not financially exploited by BOM B. R700 reported the Nursing Home Administrator (NHA) is upset they can not control them and that they believe the NHA stole all their money. R700 reported that BOM B is the only person in the facility that cares about me and helps me. R700 reported that BOM B did have control over their money but would buy them items such as Dr. Pepper and bathroom items. R700 was asked about their suicide attempt and reported that it was an accident. R700 reported they slipped and fell on a razor and did not need a 1:1 sitter anymore.On 12/10/2025 at 10:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) C. CNA C was the current 1:1 sitter for R700. CNA C reported R700 had a 1:1 sitter for all shifts and that they usually work midnights. CNA C reported that R700 has named a teddy bear after BOM B, and they are distraught over BOM B no longer working in the facility.On 12/10/2025 at 10:49 AM, an interview was conducted with the Legal Guardian (LG) D for R700. LG D reported they were informed by the facility that an employee was misusing R700's funds and entered into an inappropriate relationship with them. LG D reported R700 has a debit card that they provided for them and puts funds on there for R700. LG D reported they were informed by the facility that another debit card was opened for R700 and the funds from their resident trust fund were transferred there without their consent. LG D reported they were sending approximately $1800 per month because they thought R700 had a patient pay amount and was not informed that R700 did not have to send any money to the facility, so the money was being put into a resident trust fund that was being managed by the facilities BOM B. LG D reported BOM B did call their office and ask could the funds be used to obtain dentures for R700, to which they agreed, however the funds were not used for that purpose. LG D reported they are unsure what the funds were used for, but they were informed that approximately $10,000 is unaccounted for. LG D reported that they recently found out that BOM B acquired a lawyer for R700 to get their guardianship terminated, and they were also unaware of this, as was the facility. LG D reported R700 has petitioned the court to get their guardianship terminated in the past, and it was determined that R700 needed a legal guardian. LG D reported that they wanted to get a Personal Protection Order against BOM B so they could not contact R700 anymore, however there has not been enough to get one granted at this time. A review of electronic transactions from R700's resident trust fund showed money transfers on the following dates, 10/15, 10/21, 10/23,10/29,10/30, and 11/10, totaling in the amount $10,465.94 unauthorized transactions.On 12/10/2025 at 11:30 AM, a phone interview was conducted with BOM B. BOM B reported they started working with R700 in May of 2025. BOM B reported R700's guardian was not helping them and R700 needed help with many things, so they started to help them. BOM B reported that in July of 2025, R700 reported they could not get in touch with the guardian and R700 wrote out a letter saying they wanted BOM B to help them obtain things, such as clothes and they would put the money on a debit card because it would take to long for the NHA to give them the funds. BOM B reported they did help R700 obtain a lawyer but did not go through Social Work because they wouldn't get involved. BOM B reported they did not use R700's funds for personal use and did not have an inappropriate relationship with them, and that they were just trying to help.On 12/10/2025 at 12:58 PM, an interview was conducted with the NHA. The NHA stated they were notified of the incident when R700 came into their office on 11/25/2025, asking to see a box that they had been holding from them. The NHA reported they showed R700 the box and asked why they thought it wasn't there anymore. The NHA stated R700 then said that BOM B kept telling them to ask about the box and that they were helping them with some financial things. The NHA stated they asked R700 more about BOM B helping R700 financially and they told them BOM B was handling their finances for them. The NHA reported R700 showed them their text messages on their own because they stated they had nothing to hide and was telling the truth. The NHA reported they read some of the messages and determined that they were inappropriate and immediately suspended BOM B pending an official investigation. The NHA stated it was reported to the State Agency, as well as the police. The NHA reported they are aware that R700 is still in contact with BOM B and that they sent a cease and desist to BOM B to cut off contact with R700. The NHA reported they do not ask to see R700'S phone, but that R700 gives them their phone because they have nothing to hide even though they keep telling them it's not necessary. The NHA reported when R700 had the injury to their wrist, they had a 1:1 sitter at the time for suicidal ideations, but requested privacy to use the urinal. The NHA reported R700 was seen by psych on 12/9/2025 and it was recommended that they continue with the 1:1 sitter.On 12/10/2025 at 1:18 PM, an interview was conducted with Regional Business Office Manager (RBOM) A. RBOM A reported if a resident has money in their resident trust fund account, then they can give them up to $100 in physical cash, same day. RBOM A reported that if it is greater than $100, then approval is needed from the resident's legal guardian if the resident has one. RBOM A reported that BOM B was making electronic transfers to a green dot card which is like a money card and there were no approvals from the guardian for the transfers. RBOM A reported BOM B should have informed the guardian that there was no PPA (Patient Pay Amount) so they would not send that large amount of money monthly and received permission for the electronic transfers. RBOM A reported they have implemented the two-signature process for cash withdrawals, and that they are personally overseeing all electronic withdrawals at this time. RBOM A reported there have not been any request for electronic withdrawals at this time.A review of a facility policy titled, Resident Trust Find Noted [NAME] following, .14. Withdrawals from the president's personal funds may be made only under written direction of the resident, resident's legal representative, or designated representative.PNC StatementDuring the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:Element I-The suspected perpetrator was immediately removed from the facility and suspended pending investigation; employment was subsequently terminated on 11/26/2025. The incident was reported to the State Agency, law enforcement, corporate compliance, facility Medical Director, and the residents' representative on 11/25/2025.-A comprehensive review of R1 and R2's complete trust fund histories was completed by the [NAME] Business Office Manager (RBOM).-Social Services completed wellbeing assessments including psychosocial evaluation and PHQ-9 (depression) screening to determine emotional impact.-Protective measures were implemented to prevent further access to resident funds.-The facility will continue to cooperate with law enforcement to determine the extent of the misappropriation and any potential restitution.Element II-The Regional BOM completed a 10-month audit of all current resident trust fund accounts on 12/5/2025. Any additional discrepancies identified will be investigated and reported in accordance with policy and regulation.-HR (Human Resources) validated background checks and personnel files for all business office and administrative staff with financial access.Element III-The Administrator reviewed the Resident Trust Policy, After-Hours Trust Procedure, and Abuse/Neglect/Exploitation Policy; all were deemed appropriate.-The QAPI (Quality Assurance Program Initiative) Committee approved a systemic change requiring mandatory dual signatures on all withdrawals and enhanced monthly reconciliation oversight.-The RBOM provided reeducation to interim BOM support (Anha) ( Assistant Nursing Home Administrator) and the Administrator regarding RFMS procedures, trust funds, and documentation requirements.-All facility staff were reeducated on: 12/5/2025 F602 Misappropriation/Exploitation Resident Rights Abuse, Neglect, and Exploitation policy Mandatory reporting obligations-Staff training was completed by 12/5/2025. Any staff member who did not receive training by this date will receive it prior to their next scheduled shift.-ADHOC QAPI meeting: 12/4/2025Element IV-The Administrator or designee will conduct weekly audits of all trust fund transactions to verify dual signatures for 8 weeks, then monthly for 2 months.-The RBOM will conduct monthly RFMS audits to identify discrepancies for 8 weeks, then monthly for an additional 2 months.-Audit results wiIl be reviewed in QAPI to ensure ongoing oversight, timely identification of issues, and sustained compliance.Element VThe facility asserts substantial compliance as of 12/5/25, the date on which al corrective actions were implemented, and the deficient practice fully corrected.The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review, the facility failed to ensure nurse staffing postings were completed and readily accessible for all 74 residents, families, and visitors in the facility. Findings include: On 6/4/25 at 2:02 PM, the Nursing Home Administrator (NHA) was requested to provide the daily staff postings for the past 18 months. The NHA provided a 2024 binder and explained they were gathering the 2025 postings. A review of the binder revealed forms dated 11/3/24, 11/6/24, and 7/2/2024 that were incomplete, missing dates, and staffing information. On 6/4/25 at 2:21 PM, the staffing coordinator acknowledged the forms were incomplete. On 6/4/25 at 2:58 PM, the facility provided the 2025 postings for the months of March through June. The postings for January 2025 and February 2025 were not provided by the end of the survey. On 6/4/25 at 2:58 PM, after a review of the postings the NHA was asked about the missing and incomplete forms. The NHA confirmed, the forms were not completed correctly. A review of the facility's policy titled Nurse Staffing Posting Information dated, 3/24, revealed, Policy: It is the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The nurse staffing information will be posted on a daily basis and will contain the following information: a. Facility name b. The current date c. Facility ' s current resident census d. The total number and the actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides 2. The facility will post the nurse staffing data at the beginning of each shift . 5. Nursing schedules and posting information will be maintained in the facility for review for at least 18 months or according to state law, whichever is greater .

Based on observation, interview, and record review, the facility failed to properly store nebulizer masks and a bi-pap mask for three residents (R15, R17, and R25) out of ten reviewed for infection control. Findings include: R15 On 6/2/2025 at 9:53 AM, R15's nebulizer mask was observed sitting on the nightstand with no barrier noted between the mask and the nightstand. R15 explained they use their nebulizer everyday. A review of the medical record revealed that R15 admitted into the facility on 7/9/2024 with the following medical diagnoses, Epilepsy and Personal History of Covid-19. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status assessment score of 14/15 indicating an intact cognition. R15 also required staff assistance with bed mobility and transfers. R17 On 6/2/2025 at 9:39 AM, R17 was observed in the bed. R17's nebulizer mask and bi-pap mask were observed sitting on the nightstand, no barrier noted between the masks and the nightstand. R17 was asked how often they use the nebulizer and the bi-pap and they replied quite often. A review of the medical record revealed that R17 admitted into the facility on 3/15/2024 with the following medical diagnoses, Hypotension and Anemia. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status assessment score of 12/15 indicating an intact cognition. R17 also required staff assistance with bed mobility and transfers. R25 On 6/2/2025 at 10:06 AM, R25's nebulizer mask was observed sitting on the nightstand with no barrier noted between the mask and nightstand. A review of the medical record revealed that R25 admitted into the facility on 4/28/2023 with the following medical diagnoses, Dysphagia and Obstructive Sleep Apnea. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R25 also required staff assistance with bed mobility and transfers. On 6/4/2025 at 10:44 AM, an interview was conducted with the Infection Control Preventionist (ICP) A. ICP A reported that all nebulizer masks should be properly stored in a bag and that bi-pap masks should be cleaned weekly and stored properly in a bag. A review of a facility policy titled, Nebulizer Therapy noted the following, Care of The Equipment .2.Store dry nebulizers mesh bags, clear plastic bag or proper clean storage per the facility's preference.

Based on interview and record review, the facility failed to ensure updated and accurate advance directive (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for one resident (R57) of one resident reviewed for advance directives. Findings include: A review of R57's medical record revealed they were admitted into the facility on [DATE] with diagnoses which included Cerebral Infarction, Major Depressive Disorder, and Dysphasia. Further review revealed the resident was dependent on staff for transfers and toileting. Upon reviewing the resident's medical record, the resident's code status which was displayed at the top of their medical record revealed the code status of DNR (do not resuscitate). Further review of R57's medical record revealed a document dated and signed by the resident on [DATE] and titled Medical Treatment Decision Form noting a check mark by CPR full resuscitation. I request that in the event my heart and breathing stop, I am given resuscitating measures. On [DATE] at 12:11 PM, an interview was completed with the Nursing Home Administrator (NHA) and was asked about R57's conflicting code status in which the NHA explained the resident changed their mind. On [DATE] at 3:19 PM, an interview was completed with the Director of Nursing (DON) regarding the conflicting code status for R57, and explained the social worker uploaded the new form and failed to notify the nurses so they could update it in the medical record. A review of the facility's Residents' Rights Regarding Treatment and Advance Directives policy revealed the following, .8. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care .

Based on observation, interview, and record review, the facility failed to provide a clean and safe environment for one resident (R18) of two residents reviewed for homelike environment. Findings include: On 6/02/25 at 10:00 AM, R18 was observed sitting in the wheelchair watching television in their room. A large approximately 12 inch round dark brown stain was noted on the ceiling tile directly above the head of the bed. R18 was asked about the stain and stated that stain was there when he moved there. R18 stated it needs to be fixed and they had mentioned it to someone but nothing had been done. A record review revealed that R18 was admitted on [DATE] with the following medical diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction and Chronic Obstructive Pulmonary Disease. A review of the Minimum Data Set assessment (MDS) dated [DATE] noted Brief Interview in Mental Status (BIMS) score of 15/15 which indicates intact cognition. On 06/04/25 at 1:40 PM, an observation of R18's room occurred with the Maintenance Director (MD). When asked about the brown stain on the ceiling tile the MD revealed that there was audit ongoing about rooms with concerns. MD stated that their expectation was that resident rooms are in good shape to provide a home like environment. A review of the policy titled Safe and Homelike Environment implemented on 1/21/21 revealed that the facility will provide a safe, clean comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on observation, interview, and record reviews the facility failed to follow the recommendation of a OBRA (Omnibus Budget Reconciliation Act) Level II Evaluation for one (R61) of five residents reviewed for PASARRs (Preadmission Screen Resident Review). Findings include: A review of R61's medical record revealed they were admitted into the facility on 4/17/23 with diagnoses which included Type II Diabetes, Depression and Hypertension. Further review of the medical record revealed the resident was cognitively intact and independent for transfers. Further review of R61's medical record revealed an OBRA evaluation dated 8/27/24 revealing the following, .O. Recommendations .[R61] would like to move to a senior apartment type setting where [they] could have medical assistance/home healthcare to come in assist [them] with [their] diabetic issues. [R61] appears to have gained insight into the importance of successfully managing [their] diabetes. [R61] wants to live in a less restrictive setting and feels that [they] have gained the skills to be successful. [R61] requires minimal assistance for ADLs (activities of daily living). Lastly, it is recommended that NF (nursing facility) social work staff assist [R61] in searching for a least restrictive setting if the medical team agrees with this plan . Further review of R61's medical record did not reveal documentation that the OBRA recommendations had been addressed or followed up on. On 6/4/25 at 1:25 PM, an interview was completed with R61 regarding their independence and explained that they asked social work about discharging from the facility, and potentially living a more independent life where they would have more freedom. R61 explained that they were, Shot down. R61 explained they feel like everything has been taken from them and would like to experience more joy. On 6/4/25 at 3:21 PM, the Director of Nursing (DON) was asked about the lack of follow-up on the OBRA evaluation recommendations and explained that corporate staff would be looking further into it. No further information was received by the end of the survey. A review of the facility's Resident Assessment - Coordination with PASARR Program policy revealed the following, .b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD (mental disability), ID (intellectual disability), or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs .7. Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care .

Based on interview and record review, the facility failed to revise a care plan to reflect the resident's current status for one resident (R61), of one resident reviewed for care plan revision. Findings include: On 6/2/25 at 11:02 AM, R61 was observed sitting up in bed and asked about any concerns they've had in the facility. R61 explained they had a pair of dentures when they first admitted into the facility however, they didn't fit properly. R61 explained they had been seen by the dentist last year in June, in which the dentures were to be realigned however, that has yet to be completed and, they no longer have the dentures. A review of R61's medical record revealed they were admitted into the facility on 4/17/23 with diagnoses which included Type II Diabetes, Depression and Hypertension. Further review of the medical record revealed the resident was cognitively intact and independent for transfers. A review of R61's care plan revealed the following, Focus: I have an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) dx (diagnoses) of mood disorder, DM (Daibetes Mellitus) . type 2, Date Initiated: 04/18/2023 .Inteventions/Tasks: Dentures: I have dentures, please assist me to ensure they fit properly and are securely in place. Date Initiated: 04/18/2023. A review of R61's dental records reveal the following dental exam note dated 6/19/24, .Full impressions taken of ULCD (upper and lower complete dentures) for lab reline .denture was taken to laboratory. Adjust diet PRN (as needed). A review of R61's medical record did not reveal any information regarding the resident's dentures. On 6/4/25 at 3:22 PM, The Director of Nursing (DON) was asked about the resident's dentures, and indicated they had reached out to the previous dental provider and are awaiting a return call. The DON was also asked about the resident's care plan indicating they had dentures but did not, the DON acknowledged the care plan should reflect the resident's current status. A review of the facility's Care Planning policy revealed the following, .5. The comprehensive care plan is developed from the RAI (resident assessment instrument) scheduled and is reviewed and revised by the IDT (interdisciplinary team) as necessary.

Based on observation, interview, and record review, the facility failed to provide 1:1 feeding assistance for one resident (R47) out of two reviewed for feeding assistance. Findings include: On 6/2/2025 at 12:08 PM, R47 was observed eating lunch, unassisted. R47 was observed leaning to their right side and food was on their gown. A review of the meal ticket stated 1:1 feeding assistance. A review of the medical record revealed R47 admitted into the facility on 4/23/2025 with the following medical diagnoses, Multiple Sclerosis and Dysphagia. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental status score of 3/15 indicating an impaired cognition. R47 also required staff assistance with bed mobility and transfers. Further review of the diet order revealed R47 required 1:1 feeding assistance. On 6/3/2025 at 1:14 PM, R47 was noted to be eating lunch unassisted. On 6/4/2025 at 8:56 AM, an interview was conducted with Registered Dietitian (RD) D. RD D indicated that R47 is a 1:1 feed and that they are being followed by Speech Therapy. RD D indicated R47 can feed themselves but does better with 1:1 assist and encouragement. On 6/4/2025 at 9:55 AM, an interview was conducted with the Director of Nursing (DON). The DON reported R47 sometimes eats in the dining room and sometimes in their room. The DON reported the staff pass trays for people that need to be assisted eating last and then assist them with eating. A review of a facility policy titled, Activities of Daily Living noted the following, .3.A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to implement pressure ulcer (PU) interventions to prevent pressure ulcer reoccurance for one resident (R43) out of two reviewed for pressure ulcers. Findings include: On 6/2/2025 at 9:48 AM, R43 was observed in the bed sleeping. R43 was observed laying on their back, heels laying flat on the mattress, no positioning wedges or pillows were noted in the bed. On 6/2/2025 at 11:48AM, R43 was observed to be laying on their back with no positioning devices in place. On 6/2/2025 at 2:03 PM, R43 was observed with their head of bed (HOB) elevated, in a sitting position and sleeping. A review of the medical record revealed R43 admitted in the facility on 11/15/2024 with the following medical diagnoses, Moderate Protein-Calorie Malnutrition and Pressure ulcer of Left Buttock, Stage IV (4- Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status assessment of 3/15 indicating an impaired cognition. R43 also required staff assistance for bed mobility and transfers. Further review of the most recent wound care note dated 5/28/2025 noted the following, Category: Pressure. Ulcer/Problem Site: Sacral. MDS (Minimum Data Set) Stage:4. Place Acquired. Size in CM (Centimeters) (LXWXD). 2x1.5x1.5 .Preventative Measure in Place .Heels-Offload with heel protectors or Pillow .Repositioning-in the bed and w/chair (wheelchair) as needed, or per facility protocol, if patient cannot do it. On 6/3/2025 at 9:14 AM, 11:06 AM, 12:02 PM, 1:40 PM, R43 was noted to be laying in bed with a positioning wedge on their right side. R43's heels were noted to be laying flat on the mattress. On 6/4/2025 at 9:44 AM, an observation of the wound was completed. On 6/4/2025 at 10:07 AM, an interview was conducted with Unit Manager (UM) B who was also oversaw the wound care program. UM B reported the wound started off as red and when they admitted they put R43 on an air mattress. UM B reported the wound declined rapidly and they put in supplements and have wedges and pads to assist with turning and repositioning. UM B reported they implemented interventions such as turning and repositioning every two hours and wearing heel boots or floating their heels. UM B was informed of the observations of R43 not being turned and repositioned. UM B indicated their expectation is R43 is repositioned frequently depending on the time of day and meals. UM B reports heels should be elevated as tolerated. A review of the facility policy titled, Wound Treatment Management and Documentation noted the following, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with the current standards of practice and physician orders .

Based on observation, interview, and record review, the facility failed to implement dietary restrictions for one resident (R45) out of two reviewed for nutrition. Findings include: On 6/1/2025 at 9:51 AM, R45 was observed laying in bed a water cup with a straw was observed next to them dated 6/1/2025 NTL (Nectar Thickened Liquids). A review of the medical record revealed R45 admitted into the facility on 4/29/2025 with the following medical diagnoses, Dysphagia (difficulty swallowing), and Muscle Wasting and Atrophy. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 9/15 indicating an impaired cognition. R45 also required staff assistance with bed mobility and transfers. A review of the diet order revealed R45 was not to have straws related to Dysphagia. On 6/2/2025 at 10:15 AM, R45 was noted to have a straw in their water cup. On 6/2/2025 at 11:57 AM, R45 was noted to still have a straw in their water cup. A review of their diet ticket also noted no straws. Unit Manager (UM) B was queried as to if R45 should have a straw in their cup. UM B reported they would have to look at the speech orders. On 6/4/2025 at 9:08 AM, an interview was conducted with Occupational Therapist (OT) C. OT C reported R45 is on NTL and can not have a straw and reported if R45 has a straw then they will cough and it's safer to not have a straw to reduce the risk of aspiration (choking). On 6/4/2025 at 9:30 AM, a straw was observed in R45's cup of water. On 6/4/2025 at 9:52 AM, an interview was conducted with the Director of Nursing (DON) and was informed R45 was observed with a straw in their cup. The DON reported they print daily diets and put them on the water carts and they expect for diet orders to be followed. A request for a facility policy addressing special dietary instructions was requested, but not received by end of survey.

Based on observation, interview, and record review, the facility failed to safely secure an oxygen cylinder/tank for one sampled resident (R54) of four review for accidents. Findings include: On 6/02/25 at 12:15 PM, R54 was observed sitting up in their bed, observed next to the bed was a wheelchair. The wheelchair had an oxygen cylinder/tank that sat in the seat of the wheelchair and leaned on the back of the chair. The oxygen cylinder/tank was observed to have a layer of dust and cobwebs (abandoned spider webs) on it. R54 was asked how long the oxygen cylinder/tank had been in the wheelchair as observed. R54 reported that it has been there a while. R54 was asked to explained a while and R54 was unable to provide a timeline. On 6/4/25 at 9:00 AM, the Director of Nursing (DON) was asked if they were aware of the oxygen cylinder/tank that was in R54's wheelchair. The DON stated, Yes. The DON was asked how oxygen cylinders/tank are to be stored, and explained the tank is to be stored secured in a carrier and once done placed in the oxygen storage room. A review of the facility's policy titled, Oxygen Safety - Gas Storage and Handling dated, 2/25, revealed, Policy: It is the policy of this facility to provide a safe environment for residents, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment. Policy Explanation and Compliance Guidelines: 4. Oxygen Storage - a. Oxygen storage locations shall be in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors or gates that can be secured against unauthorized entry. b. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier. Empty cylinders shall be segregated from full cylinders. Empty cylinders will be marked to avoid confusion. c. Cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty .

Based on interview and record review, the facility failed to attempt a Gradual Dose Reduction (GDR) for an Antipsychotic (Seroquel) for one resident (R32) out of one reviewed for GDRs. Findings include: A review of the medical record revealed that R32 admitted into the facility on [DATE] with the following diagnoses, Vascular Dementia and Adjustment Disorder with Anxiety. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 3/15 indicating a severely impaired cognition. R32 also required staff assistance with bed mobility and transfers. Further review of the active physician orders revealed the following, Seroquel (Antipsychotic) 25 mg (milligrams) by mouth one time a day and Seroquel 50 mg by mouth at bedtime. On 6/4/2025 at 9:22 AM, an interview was conducted with the Nursing Home Administrator (NHA) and a request for any documented GDR attempt was requested but not received by the end of survey. A review of a facility policy titled, Gradual Dose Reduction of Psychotropic Drugs noted the following, Resident's who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to be managed at a lower dose or to discontinue these drugs.

Based on observation, interview, and record review, the facility failed to timely follow-up on dental services related to dentures for one resident (R61) of one resident reviewed for dental services. Findings include: On 6/2/25 at 11:02 AM, R61 was observed sitting up in bed and asked about any concerns they've had in the facility, and explained they had a pair of dentures when they first admitted into the facility however, they didn't fit properly. R61 explained they had been seen by the dentist last year (2024) in June, in which the dentures were to be realigned however, that has yet to be completed and, they no longer have the dentures. R61 explained they were told that a follow-up would occur but hasn't received an update. R61 further explained their jaw has been hurting, making it difficult to chew. A review of R61's medical record revealed they were admitted into the facility on 4/17/23 with diagnoses which included Type II Diabetes, Depression and Hypertension. Further review of the medical record revealed the resident was cognitively intact and independent for transfers. A review of R61's dental records reveal the following dental exam note dated 6/19/24, .Full impressions taken of ULCD (upper and lower complete dentures) for lab reline .denture was taken to laboratory. Adjust diet PRN (as needed). A review of R61's medical record did not reveal any information regarding the resident's dentures. On 6/4/25 at 3:22 PM, the Director of Nursing (DON) was asked about the resident's dentures and indicated they had reached out to the previous dental provider and are awaiting a return call. A review of the Dental Services policy revealed the following, 5. For residents with lost or damaged dentures, the facility will refer the resident for dental services within three days. 6. In the case of an acute dental condition or loss/damage of dentures, the facility will take measures to ensure residents are still able to eat and drink while awaiting dental services. Interventions include, but are not limited to: a. Notifying physician of pain or other needs. b. Modifying diet consistency (i.e. chopped meats). c. Referring to dietician for food preferences during the interim. d. Referral to speech therapist for chewing or swallowing problems .

This citation pertains to intake MI00145809. Based on interview and record review the facility failed to ensure the care plan was updated to reflect the wandering and related fall and bowel and bladder behaviors and document interventions for them. Findings include: A review of an incident report for R901 documented a fall on 06/21/24 and was found at 6:40 AM with a last seen time of 5:30 AM. R901 was sent out to the hospital with a head injury. A physical (rehab) medicine note dated 04/16/24 documented, .evaluated secondary to fall and decline in function . A review of a psychiatric note dated 05/23/24 documented, .Dementia with Behaviors .Last seen by writer 01/31/24, Patient was seen and evaluated and discussed with staff. (R901) is reported to have increased confusion and restlessness .will start risperdal .3/12/24 increased risperdal .noted to wander and can be quite intrusive with peers .per staff the increase in risperdal has not helped .requires constant redirection reported to continue to be impulsive and wanders and intrusive with peers .will initiate depakote (anti seizure medication used for manic episodes in bipolar disease) . A review of the practitioner note dated 06/17/24 documented, .baseline is wandering in particular at night .patient did not answer any questions for examiner . On 08/13/24 at 8:58 AM, a former roommate of R901 reported, R901 had attempted to eat rolled up toilet paper, would go into roommate's closet and take out stuff, walked while in the room, wandered all the time, did have falls, staff would bring resident back to room and not ten minutes later R901 was back out again, did wake up one time with R901's butt hovering over them, R901 often walked around with their pants down and often had pulled up R901's pants. The roommate was asked about incidents with other residents and reported an incident where R901 had a bowel movement all over the bed and laid in it. The roommate further noted R901 had done the same across the hall in another resident's room just before they went out to the hospital on 06/21/24. On 08/13/24 at 8:44 AM, Licensed Practical Nurse (LPN) A was asked about R901 and reported, R901 was demented, confused and wandered a lot. LPN A reported R901 was sometimes easy to redirect, often went into other resident rooms taking items and was unsteady when walking. It was also reported R901 would use a wheelchair but sometimes would just get up and walk around and most of residents were familiar, so would they would just tell the staff. On 08/13/24 at 10:03 AM, a visitor reported via the phone that R901 was not monitored well enough and was told different stories by staff and residents about the fall on 06/21/24.The visitor commented they did not feel staff were attentive to R901. On 08/13/24 at 10:58 AM, Certified Nursing Assistant (CNA) B reported R901 had been declining and wandering for months. CNA B reported R901 was a wanderer and would go into other resident's rooms and was sitting on their beds and went into their bathrooms. CNA B reported they had not witnessed this but had heard of incidents of R901 having had bowel incontinence in their own bed. CNA B reported R901 would grab people's stuff and roommates things. CNA B also noted R901 wandered the length of the hall and staff would have to run to catch R901 so they did not fall. On 08/13/24 at 11:00 AM, CNA C reported R901 was a wanderer but easily redirected. On 0/13/24 at 11:05 AM, CNA D reported they had not witnessed any falls and was not aware of any resident to resident incidents that involved R901. CNA D did report R901 was confused and they saw R901 wander into other rooms but was easily redirected. On 08/13/24 at 12:04 PM, Therapy staff F was asked about R901 and reported R901 was often in the hall without a brief on or naked during the evenings and would walk independently and had been on the rehab caseload. Staff F noted R901 would use the furnititure to walk. On 08/13/24 at 1:40 PM, CNA G reported they had worked with R901 off and on and recalled that R901 was confused and wandered but easy to redirect. On 08/13/24 at 3:25 PM, CNA H reported that around 6 AM on 06/21/24, R901 was found next to their bed, seated on the floor with their pants down. CNA reported R901 did not use their call light and that R901's reason for walking around was generally due to the need to use the bathroom. CNA H further reported R901 does roam into other rooms, and gets confused may go out the wrong door of the bathroom and may sit on another resident in their bed. CNA H commented they do try to monitor R901 but that it was kind of hard to be with R901 all the time. On 08/13/24 at 3:45 PM, Social Worker I was asked about R901 and reported they wound see R901 every day. SW I reported R901 was very confused and did have behaviors of getting into their own feces and putting it everywhere. SW I reported R901 just needed eyeballs on them. SW I reported that planning had started for transfer of R901 to a facility with a locked dementia unit but R901 had the fall and was discharged to the hospital. On 08/13/24 at 3:58 PM, the resident involved with R901's defecation on their bed reported R901 had wandered into their room before and they had to direct them back out, but on that day they were out on an appointment. On 08/13/24 at 4:13 PM, the Director of Nursing (DON) was asked about R901 and reported the dementia and roaming had become worse before the incidents and reported they had started to put signs in bathroom to help redirect R901 and put their name in big letters on the door to help R901 find their room. The DON was asked about the fall and reported they think it was related to R901's underlying disease process. The DON was asked about the use of a one to one and reported it had not been considered and that planning had started to have R901 transferred to a locked dementia unit at another facility. A review of the record for R901 revealed R901 was admitted into the facility 01/27/22. Diagnoses on admission included Alzheimer's Disease, Dementia, Muscle Weakness, Difficulty Walking and Hearing Loss. Delirium (per Mayoclinic.org - a serious change in mental abilities resulting in confused thinking and a lack of awareness of ones surroundings) was added 02/09/24. A review of the Minimum Data Set (MDS) assessments revealed, the wandering was not captured on prior assessments. The 05/06/24 nor the 07/04/24 MDS assessments had wandering documented as being present. Cognition was documented as severely impaired. The 05/06/24 MDS documented partial/moderate assitance for toileting hygiene and supervison for transfers and bed mobility. The 07/04/24 MDS documented toileting hygiene, transfer and bed mobility as dependent A review of the active and resolved care plans revealed the care plan Alzheimer's, am at risk for elopement initiated 01/27/22, revised 06/19/24 had Elopement risk assessment on admission, then quarterly and PRN (as needed) as the only intervention and dated 01/27/22. The I am at risk for falls related to unsteady gait . care plan initiated 01/27/22 and revised last 03/07/24 did not documented the wandering behavior. The I use Antidepressant or Mood stabilizer related to Dementia care plan initiated 11/12/23 and last revised 03/07/24 was noted with no new interventions. The care plan did not represent the changes in mobility, wandering and intrusive behaviors identified. On 08/13/24 at 5:37 PM, a care plan and interventions for the indentified wandering and bowel/bladder concerns was requested. The bladder incontinence care plan provided did not identify the inapproriate use of other resident rooms for bowel and bladder needs. The Administrator and DON reported there was not a care plan for the identified concerns. A review of the policy titled, Care Planning implemented 11/2016, revealed, 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 .The comprehensive care plan is developed from the (resident assessment instrument) RAI (MDS) scheduled and is reviewed and revised by the (interdisciplinary team) IDT as necessary.

This citation pertains to Intake M100143094. Based on interview and record review, the facility failed to provide adequate, meaningful weekend activities for facility residents including eight anonymous group participants. Findings include: On 04/24/24 at 2:29 PM, eight anonymous group participants indicated the facility no longer had activities department staff working on the weekends and no organized or meaningful activities were being provided or facilitated. The group participants reported being bored and having nothing to do on weekends. Review of the facility Activities calendar for March and April 2024 revealed all Saturdays stated Independent leisure activities can be found in the dining room and all Sundays stated 10 AM Independent activity and 1:30 PM Afternoon Worship. On 04/25/24 at 9:37 AM, the facility Activities Director (AD) reported the facility no longer employed Activities aides. The AD reported they work a full time day shift schedule and therefore there are no dedicated Activities department employees scheduled on weekends. The AD reported they set up items (board games, coordination games, etc.) in the dining room for residents to use on weekends and the Certified Nursing Assistants (CNAs) and other staff can assist residents to access these items. On 04/25/24 at 1:30 PM, the facility Administrator (NHA) reported the facilities Activities aides positions were eliminated and verified that there are no dedicated Activities department staff scheduled on weekends. The NHA reported in response to these staffing changes the facility has instructed other facility staff such as CNAs and nurses to assist in facilitating activities on the weekends. On 04/25/24 at 2:29 PM, the NHA reported their expectation was non-Activities department staff such as CNAs and nurses would be able to satisfactorily assist residents to participate in meaningful weekend activities in a manner that was not insufficient compared to weekday Activities programming. Review of the facility policy Activities dated 01/01/24 revealed the Policy statement It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 4/23/24 between 8:45 AM-9:30 AM, during an initial tour of the kitchen, the following items were observed: There was a personal cell phone on the food preparation counter. On 4/23/24 at 11:15 AM, Dietary Manager (DM) P confirmed the cell phone should not have been left on the food preparation counter. According to the 2017 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination, FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. The flour bin located inside the dry storage room was observed with the scoop stored inside the bin, with the handle resting in the flour. On 4/23/24 at 11:17 AM, DM P confirmed the scoop should not have been stored inside the flour. According to the Food & Drug administration (FDA) 2017 Model Food Code, Section 3-304.12 In-Use Utensils, Between-Use Storage, During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .(B) In FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD with their handles above the top of the FOOD within containers or EQUIPMENT that can be closed, such as bins of sugar, flour, or cinnamon; There was a box of orange juice concentrate stored on the floor, being utilized to prop open the dry storage room door. According to the 2017 FDA Food Code section 3-305.11 Food Storage, 1. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: 1. (1) In a clean, dry location; 2. (2) Where it is not exposed to splash, dust, or other contamination; and 3. (3) At least 15 cm (6 inches) above the floor. The top surface of the Southbend steamer was observed with a buildup of grease and crumbs. According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surface, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. There was a wet wiping cloth lying on the food preparation counter. The rag was not stored inside sanitizer bucket, and there were no prepared sanitizer buckets anywhere in the kitchen. According to the 2017 FDA Food Code, Section 3-304.14 Wiping Cloths, Use Limitation, .(B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114; There was dried food splatter on the inside surface of the microwave. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The shelf at the front of the steam table was warped, with large cracks and exposed, porous particle board. The surface of the shelf was no longer smooth and easily cleanable. When queried on 4/23/24 at 11:25 AM, DM P stated a new shelf would be ordered. According to the 2017 FDA Food Code section 4-101.19 Nonfood-Contact Surfaces, NonFOOD-CONTACT SURFACES of EQUIPMENT that are exposed to splash, spillage, or other FOOD soiling or that require frequent cleaning shall be constructed of a CORROSION-RESISTANT, nonabsorbent, and SMOOTH material. Dietary staff members Q and R were observed using the dish machine. When queried about how to check the dish machine for adequate sanitization, Dietary Staff Q stated she was new and did not know. Dietary Staff R stated she would check the dial for the wash and rinse temperature. When queried about checking the chemical sanitizer level for the low temperature, chemical sanitizing dish machine, Staff R stated she did not know how to do that. The log for documenting the sanitization of the dish machine was blank on 4/22 dinner and 4/23 breakfast. According to the 2017 FDA Food Code section 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration, Concentration of the SANITIZING solution shall be accurately determined by using a test kit or other device. Pf

Based on interview and record review, the facility failed to ensure the Activities Director met the required professional qualifications. Findings include: On 04/25/24 at 9:37 AM, the facility Activities Director (AD) was interviewed and reported they had been in the AD position for approximately one month. The AD reported they are a Physical Therapy Assistant (PTA) and they had been working in the facilities therapy department prior to accepting the AD position. The AD reported they planned to take college classes to pursue Therapeutic Recreation-related credentialing but they were not currently participating in this training/education. On 04/25/24 at 1:06 PM, the AD reported they transitioned directly from the therapy dept. to the AD position and they did not have recent/previous experience in an Activities department. On 04/25/24 at 1:30 PM, the facility Administrator (NHA) acknowledged the current AD did not meet the required professional qualifications. The NHA reported the facility had provided the AD with the resources to pursue their credentialing for the position and arranged for the AD to receive mentoring from the AD from a sister facility, however these processes were not completed prior to the AD assuming the positions role and responsibilities in the facility. Review of the facility policy Activities Director Qualifications dated 01/01/24 revealed the Policy statement This facility ' s activities program is directed by a qualified professional. The Policy Explanation and Compliance Guidelines included the following entries: 1. The Activity Director, at a minimum, shall meet the following qualifications: a. Licensed or registered, if applicable, by the State in which practicing; and b. One or more of the following: i. Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; ii. Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; iii. Is a qualified occupational therapist or occupational therapy assistant; or iv. Has completed a training course approved by the State. 2. Qualifications shall be verified prior to hire as Activity Director.

Based on interview and record review, the facility failed to ensure an Advanced Directive was in place timely for one (R73) of four residents reviewed for Advance Directives (AD-legal documents that allows a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility or other healthcare providers. Findings Include: Review of electronic health record (EHR) on [DATE] at 1:23 p.m. revealed R73 did not have a code status in the banner or a signed advance directive form. Review of an Admission Record revealed, R73 originally admitted to the facility on [DATE], and readmitted on [DATE] with pertinent diagnosis which included End Stage Renal Disease and Type 2 Diabetes. Review of a Minimum Data Set (MDS) assessment dated of [DATE] revealed R73 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15 out of 15 and required dialysis. On [DATE] at 8:48 a.m., an Advance Directive was requested for R73. Review of an advance directive dated [DATE] revealed, R73 elected CPR (Cardiopulmonary resuscitation) and yes to all treatment. In an interview on [DATE] at 1:52 p.m., Social Worker (SW) L reported an advance directive should be completed by day three of admission. SW L the reported the AD for R73 was completed today ([DATE]). SW L then reported R73 should have had an advance directive completed prior to today. Review of an Resident's Rights Regarding Treatment and Advance Directives policy revised ,d+[DATE] documented the following: Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive . 1. On admission, the facility will determine if the resident has executed an advance directive . and if not, determine whether the resident would like to formulate an advance directive .

Based on observation, interview, and record review, the facility failed to initiate a care plan for a newly identified facility acquired pressure ulcer for one resident (R441) of four residents reviewed for pressure ulcers. Findings include: On 4/23/24 at 9:26 AM, R441 was observed in bed lying on their backside, face grimacing and indicating that they were in pain. On 4/23/24 at 11:37am and 2:23pm, R441 was observed in the same position as they had been earlier that morning. A review of R441's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Paroxysmal Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, and Depression. Further review of the medical record revealed that the resident was severely cognitively impaired and required total dependence for Activities of Daily Living. Further review of the wound doctor's Visit report for 4/12/24 revealed the following, Wound #1 Sacral is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not healed.Sequela wound encounter measurements are 2.2cm (centimeters) length x 2cm width x 0.5cm depth, with an area of 4.4 sq cm (square centimeters) and a volume of 2.2 cubic cm A review of R441's care plan revealed the following, Focus: I am at risk for impaired skin integrity r/t (related to) incontinence. Date initiated: 03/05/2024 . Interventions/Tasks: Assist me to moisturize my skin as needed. Date Initiated: 03/05/2024. Incontinent: Cleanse area and apply barrier cream to buttock/peri area after incontinence episodes, per my preference and as I permit. Date initiated: 03/05/2024 . Further review of the care plan did not reveal a care plan addressing R441's newly acquired pressure ulcer. On 4/25/24 at 2:04 PM, an interview was completed with the Director of Nursing (DON) regarding the lack of implementation of care planned interventions, and she explained that the care plan should reflect the resident's current status. A review of the facility's Skin and Pressure Injury Risk Assessment and Prevention policy revealed the following, 12. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors indemnified in the risk assessment, skin assessment, and any pressure injury assessment .

Based on observation, interview and record review the facility failed to ensure one resident (R441) of four residents reviewed were repositioned timely and appropriately resulting in an acquired pressure ulcers (damage to skin and underlying tissue over bony areas). Findings include: On 4/23/24 at 9:26 AM, R441 was observed lying on their back. R441 heels were on bed surface with a small foam boot around her right ankle and another small foam boot lying under the left calf. A review of the facility's electronic medical record (EMR) revealed that R441 was admitted on [DATE]. Diagnoses include Atrial Fibrillation, Myocardial Infarction (heart attack), Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Chronic Kidney Disease, Morbid Obesity (severe), Dysphagia, Low Back Pain, and Dementia. R441's Minimum Data Set (MDS) revealed severe cognitive impairment. On 4/23/24 at 11:37 AM and 2:30 PM, R441 was observed lying on their back with heels on surface of bed. No heel protection in place On 4/24/24 at 9:04 AM, R441 was observed lying mostly on their back, slightly turned to the side with a flat pillow partially under left upper body. R441's small foam boots were around lower calf with heels on bed surface. On 4/25/24 at 10:10 AM and 2:15 PM, R441 was observed lying on the right side with a wedge holding R441 off their buttocks. There was no heel protection in place. On 4/25/24 at 10:05 AM, Nurse C was queried regarding R441. Nurse C, when queried about repositioning schedules, documentation of repositioning, or documentation of refusal to reposition could be found, they replied that they did not know where refusal to reposition was documented. Nurse C was asked how they know if resident needs assisted repositioning and if it is being done. Nurse C stated, I would look at the resident as I am passing meds or doing treatments to see if residents are in different positions. On 4/25/24 at 11:19 AM, an interview with Certified Nursing Assistant (CNA), A revealed that she is not a regular on the floor but works on this unit often. CNA A was queried as to how she knows when a resident should be repositioned. CNA A indicated a schedule attached to their ID badge that has a picture for the position assigned when residents are repositioned every 2 hours. On 4/25/24, at 1:04 PM, CNA B was queried regarding where they document refusal to reposition. CNA B stated they were not sure. Then offered to demonstrate the Kiosk documentation where charting is done. They related they tell the nurse when a resident refuses to reposition after a few times. Review of the Electronic Medical Record (EMR) Nurse Practitioner O on 4/3/24, revealed .a stage three pressure ulcer on coccyx today. The note further revealed an order for z-guard (protective cream) and every two hour turns with a follow up for wound care on Friday. Review of the EMR, dated 4/5/24, revealed Wound Care Practitioner H (WCP) evaluated R441's sacral wound as follows: revealed a referral for developed ulcer on the sacrum (buttock area). R441 wanted to be left alone. R441 is on a foam pressure reducing mattress. WCP G documented the following findings: Sacral is a Stage three Pressure Injury Pressure Ulcer (full thickness tissue loss) and has received a status of Not Healed. Initial wound encounter measurements are two-point-five centimeters (cm) length by two centimeters (cm) in width by zero-point-three centimeters (cm) in depth, with an area of five square cubic centimeters. There is a small amount of sero-sanguineous drainage noted. The patient reports a wound pain of level five of a possible 10 on a scale of one to ten, with one being no pain, to ten being excruciating pain. The wound margin is well defined. Wound bed is 26-50% granulation (healthy tissue), 26-50% slough (non-healthy). The periwound (area surrounding the open area of the wound) skin texture, moisture and color is normal. Periwound skin does not exhibit signs and symptoms of infection. Review of the EMR, dated 4/6/24, the weekly Skin Sweep identified a discoloration that was on R441's forehead from a previous fall. The sacral wound was not identified. On 4/25/24, a review of the EMR, dated 4/8/24, a Braden Scale Score (risk prediction for wound development covering six areas, with scores of one to four) of 16 indicating that the resident was at Mild Risk for development of a wound. On 4/2/24, a review of the EMR for R441 revealed a Treatment Administration Record (TAR) indicated the first wound treatment order occurred on 4/11/24. Review of R441's EMR revealed that there was not a care plan for pressure wound care or prevention and there is no care plan addressing floating the heels. Review of R441's Kardex (a document used by certified nursing assistants to guide the care required) required documentation for floating heels as care planned. The document has three areas for documentation daily. Between 4/12/24 and 4/25/24, there are three incidents of documentation that indicated that the heels were not floated. Those incidents are 4/13/24 at 10:30 PM, 4/14/24 at 2:19 AM and 4/22/24 at 6:09 PM. On 4/25/24 at 1:35 PM, an interview with Director of Nursing (DON) was conducted, and she was inquired about her expectation for repositioning changes. She explained that repositioning should occur regularly based on the residents' needs. When queried regarding documentation of repositioning, the DON revealed that the repositioning schedule indicated by CNA A is not a (facility) practice. When queried further about R441, DON indicated that R441 could stand so did not see the need for this type of care plan. Further query as to where refusals for repositioning are documented, she did not respond. A review of the facility policy titled Skin & Pressure Injury Risk Assessment and Prevention revealed the following, Residents determined as at risk for developing pressure injuries will have the interventions documented in plan of care based on specific factors identified in the risk assessment . Evidence based interventions for prevention will be implemented for residents who are assessed at risk and/or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: Redistribute pressure, provide appropriate, pressure-redistributing, support surface. Evidence-based treatment in accordance with standards of practice will be provided for all residents who have a pressure injury present.

This citation pertains to intakes MI00140142 and MI00139650. Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one resident (R602) of three reviewed for abuse resulting in R602 being choked by R603, causing small scratch around R602's neck. Findings include: A review of the intake allegation noted, Details: It was reported there was a resident to resident physical abuse incident that did not result in injury. A review of R603's progress notes revealed, 8/14/2023 06:11 Nursing Progress Note Text: Patient is being combative with assigned CNA (Certifed Nursing Assistant). CNA was completing morning rounds and attempted to change patient's clothes, but patient began to become aggressive toward CNA and CNA notified writer. 8/14/2023 20:17 (9:17 PM), Nursing Progress Note Text: Resident came out of room and became physical with another resident (R602). Resident would not let go until staff had to grab [R603]. Resident then became aggressive with CNA. Resident was assisted back to room and Physician notified. ADON (Assistant Director of Nursing) was notified and requested resident be petitioned out. Resident is a one on one until EMS (Emergency Medical Systems) arrives. Family notified that resident cannot return without contacting administrator. On 11/06/23 at 3:08 PM, CNA A was called and asked about the incident with R603 and R602. CNA A stated, I was coming out of a resident's room and I saw (R603) in front of (R602). (R603) grabbed (R602) by the throat, (R603) was close to (R603's) ear saying something, I don't know what (R603) was saying. I took (R603's) hands from around (R602's) throat. CNA A was asked if R603 had a history of being aggressive towards residents or staff. CNA A stated, I don't know, I had not been there long enough, but (R603) did have a foul mouth. CNA A was asked how was R602 after the incident, CNA A explained, R602's face and neck were red. Nurse B was asked about the incident and stated, I was sitting at the desk, and I looked up and saw (R603) with (R602) in a choke hold. I separated them and the CNA took (R603), I took (R602) to assess (R602). Nurse B was asked how was R602 after the incident and stated, (R602) had some redness that was all. A review of R603's care plan revealed, Focus: I [R603] has Potential Safety Risk related to: Decreased Safety Awareness, wandering behavior, impaired cognition, impulsive behavior; current pharmacological interventions. Date Initiated: 02/06/2018. Goal: I will be observed for wandering and elopement behavior and other safety concerns and remain safe within the facility thru next review. Date Initiated: 02/06/2018. Interventions: I will be observed for exit seeking behaviors and provide diversion activities. Date Initiated: 02/06/2018. I will be observed frequently during increased wandering to ensure safety. Date Initiated: 02/06/2018. Further review of R603's medical record noted, 8/14/2023 20:52 (8:52 PM) eINTERACT . Evaluation are/were: Altered mental status Behavioral symptoms (e.g. agitation, psychosis) . Primary Diagnosis is: Relevant medical history is: Dementia . Behavioral Status Evaluation: Physical aggression Verbal aggression Danger to self or others Other behavioral symptoms . Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse)Nursing observations, evaluation, and recommendations are:Resident will be petitioned to hospital. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Resident will be petitioned to hospital . A review of the facility's investigation summary revealed that, after a total body skin assessment R602's neck was noted with a small scratch on the left side of the neck. Continued review of the facility's summary noted, Interview with R603 revealed, [R603] was interviewed as to why [R603] did this and stated [R602] stole [their] energy drink. [R603] admitted to putting [their] hands on [R602's] neck and stated [R602] will do it again. [R603] became combative towards the staff and [R603] was petitioned out to the hospital for mental health evaluation and treatment . A review of R603 medical record noted, R603 was admitted to the facility on [DATE] and discharged on [DATE] with diagnosis of Encephalopathy. A review of R602 medical record noted R602 was admitted to the facility on Diagnosis of encephalopathy, epilepsy, generalized anxiety disorder. On 11/06/23 at 3:20 PM, the Nursing Home Administrator was asked about the incident and explained they completed a Past Noncompliance (PNC) for this incident. stated that they have a PNC. The identified concern was that the staff failed to recognize behaviors. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included (interventions/actions to correct the past noncompliance). The facility was able to demonstrate monitoring of the corrective action and maintained compliance. A review of the facility's PNC revealed, Date of Report: 09/15/2023 . Residents Involved: [R603], [R602] Description of Incident: [R603] was combative with his assigned CNA on 8/14/2023 at 6:11am. The resident then had a physical altercation with another resident, [R602] on the same day at approximately 8:30pm. The facility failed to address resident's behaviors which led to resident to resident altercation. An Ad Hoc QAA (Quaility Assessment and Assurance) meeting was conducted on 9/15/23 to review and make any recommendations for the on-going investigation. This serves as the Facility's Plan of Correction in response to the allegation. The following action plan has been implemented. Following review for Quality Improvement: All staff will be educated on identifying resident behaviors and the potential for adverse events. Action taken for resident involved: The resident involved (R602) was evaluated for injury, pain, and psychosocial needs. The resident's care plan has been reviewed and updated. The other resident involved (R603) was petitioned out to the hospital for a psychological evaluation and then placed at another facility. Action taken for the employee involved: N/A Areas identified requiring quality improvement: The DON (designee) will monitor compliance with timely identification of resident behaviors. How facility identified resident(s) affected and residents with potential to be affected: All residents residing in the facility. Quality Improvement measures or systemic changes made: Daily staff huddles during shift change to ensure any/all resident behaviors have been identified and communicated to the assigned nurse. How facility monitors the effectiveness of its quality improvement measures (sustained compliance): The DON/Designee will audit 10% of residents for behavior management weekly X 4 weeks and monthly X 2 months to ensure sustained compliance. The results of the audits will be forwarded to the Quality Assurance and Process Improvement Committee monthly for review and follow up as indicated. The Administrator is responsible for ensuring substantial compliance. Date of completion: 9/19/2023

This citation pertains in part to intake MI 944. Based on observation, interview, and record review, the facility failed to effectively coordinate additional dental services for one of eight residents (R902) reviewed for dental care, resulting in on-going tooth pain, delayed services and treatment, and the potential for infection. Findings include: On 9/20/22 at 8:58 AM, during an interview with R902. R902 was lying in bed and complained that his teeth were hurting, and stated that he needs them pulled. R902 stated, I've been able to bear it but it's at the point where it's got to be done. R902 indicated that last Friday he relayed this information to his assigned nurse but has not heard anything since. R902 further explained that he had a dental exam (dental hygienist) about three weeks ago, but it had been a while since he had seen a dentist. R902 stated he takes pain medication and indicated that the teeth on the left side of his mouth were hurting. A significant number of R902's teeth were observed to be missing. On 9/20/22 at 2:58 PM, R902 was queried further regarding his tooth pain. R902 stated when he saw the hygienist a few weeks ago all she did was clean his teeth. R902 stated that he informed the hygienist that he was having tooth pain. A review of R902's progress notes revealed: -8/4/2022 18:44 (6:44 PM) Practitioner Progress Notes .Chief Complaint: Oral abscess .Positive for dental abscess with swelling noted to left side of face .Patient with history of dental extractions, positive for very poor dentition. Recurrent oral infections. Antibiotic therapy was initiated for R902's dental abscess. -8/12/2022 02:36 (AM) Infection Note Text: ABT (antibiotic therapy) continues for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . -8/14/2022 06:58 (AM) Infection Note Note Text: Pt continue on [MEDICATION(S)] Capsule 500 MG by mouth every 8 hours for bacterial infection abscess for 10 Days .Pt has c/o (complaints of) pain. -8/15/2022 01:17 (AM) eMar -Medication Administration Note Note Text: [MEDICATION(S)] Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for pain, Prn (as needed) [MEDICATION(S)] requested and received for oral pain 4/10. -8/24/2022 08:38 (AM) eMar -Medication Administration Note Note Text: Ibuprofen Tablet 800 MG (milligrams) Give 1 tablet by mouth every 8 hours as needed for inflammation, 3/10 mouth pain; requested med prior to dental appointment. -8/27/2022 21:04 (9:04 PM) eMar -Medication Administration Note Note Text: Ibuprofen Tablet 800 MG (milligrams) Give 1 tablet by mouth every 8 hours as needed for inflammation, Pt requested for ear/tooth pain 7/10. -8/29/2022 20:11 (8:11 PM) eMar -Medication Administration Note Note Text: Ibuprofen Tablet 800 MG (milligrams) Give 1 tablet by mouth every 8 hours as needed for inflammation, Pt requested for tooth pain 8/10. A review of R902's record and dental documentation provided from the Director of Nursing (DON) revealed that the resident was seen by a dental hygienist on 8/31/22. The documentation read, Pt (patient) states in pain ULQ and would like DDS (dentist) to eval (evaluate) and poss exts (possibly extract) .Pt in pain eval (evaluate) .#14 #15 (tooth numbers on upper left side) . No additional documentation was found indicating that R902 had been seen by a dentist. No further exams were found or provided. On 9/20/22 at 3:50 PM, Social Worker (SW) J was interviewed and unable to provide information as to why R902 was not seen by the dentist after the hygienist noted dental pain. SW J stated that the resident's annual exam was scheduled for November 2022 and he would be seen by the dentist at that appointment. On 9/21/22 at 9:42 AM, R902 was interviewed along with Nurse G. R902 pointed to three teeth in his mouth and indicated to Nurse G that those teeth were hurting. R902 stated it seemed like the pain was getting worse. Nurse G informed the resident that she would let the doctor know. When interviewed about the resident, Nurse G indicated that R902 is reliable in terms of indicating when he has pain and doesn't over-exaggerate. Nurse G stated, If [R902] says something is hurting, then it is. On 9/21/22 at 11:00 AM, the Director of Nursing (DON) was interviewed but directed this surveyor to speak with Unit Manager H regarding R902's dental situation. On 9/21/22 at 12:05 PM, Unit Manager H was interviewed about R902's dental situation. Manager H explained that R902 tried to go see a dentist at the VA (Veterans Affairs) but didn't have an appointment, so they wouldn't see him, and also wouldn't see the resident anyway because he is wheelchair-bound. Manager H stated this information was in her appointment book. Manager H indicated that social work is typically responsible for compiling the list of residents to be seen by the dentist. Manager H indicated she did not know about R902's tooth pain until today. A review of R902's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] and had medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed that the resident is cognitively intact and requires limited to extensive assistance from staff for activities of daily living (ADLs). A review of the facility's policy/procedure titled, Dental Services, dated 12/20, revealed, It is the policy of this facility, in accordance with residents' needs, to assist residents in obtaining routine .and emergency dental care .Referrals to .dental provider shall be made as appropriate .The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location .All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record.

This Citation Pertains to Intakes 6 and 2. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to prevent willful Resident to Resident sexual assault and failed to identify and thoroughly assess and monitor psychosocial distress for three (#'s 701, 702, and 703) of six Residents reviewed, resulting in Resident #701, who has severe limitations in physical mobility, being sexually assaulted by Resident #702 including Resident #702 entering Resident #701's room, pinning them down on their bed, ripping their gown, kissing and biting their breasts, ripping their brief open and penetrating them repeatedly with two fingers while Resident #703 was present in the room and witnessed the assault. This deficient practice resulted in immediate jeopardy, physical injury, unnecessary pain, and psychosocial distress. On 9/22/20, Resident #701 reported unwanted attention and communication from a male Resident (Resident #702) to a Nursing Assistant, Psychiatrist, and the Social Worker A. Resident #701 reported the attention and communication made them feel uneasy and gave them the heebie-jeebies. Resident #703 (Resident #701's roommate) disclosed they had observed Resident #702 bothering Resident #701 several times prior to the sexual assault on 9/30/20. Per Resident #703 revealed they saw Resident #702 enter their room multiple times when Resident #701 was sleeping. Resident #703 revealed Resident #702 had sat their wheelchair, next to Resident #701's bed, and stared at them while they slept. Resident further revealed another instance in which Resident #701 was sleeping and Resident #702 entered the room and placed their hand on (Resident #701's) arm. Resident #703 was unable to provide specific date of the occurrences. The Administrator was notified of the Immediate Jeopardy on 10/1/20 at 3:00 PM. A plan to remove the immediacy was requested. The IJ began on 9/22/20 and was removed on 9/30/20 based on the facility's implementation of the plan removal as verified onsite on 10/2/20. Although the IJ was removed, the facility's deficient practice remained at isolated. Actual harm that is not immediate jeopardy. Findings include: Review of intake documentation revealed Resident #702 (male) entered Resident #701's (female) room on 9/30/20 at approximately 3 AM and began to kiss (Resident #701) on the lips and breasts. (Resident #702) also fondle (Resident #701's) breasts and penetrated their vagina with . finger sexual acts were not warranted nor consented . (Resident #702) . verbalize that they kissed and used fingers to penetrate (Resident #701) . An entrance conference was completed with the facility Administrator and Director of Nursing (DON) on 10/1/20 at 9:00 AM. During the entrance conference, the Administrator stated, We were expecting someone (from the State) to show up today regarding the sexual assault that occurred in the facility. When asked what had occurred, the Administrator revealed Resident #702 had sexually assaulted Resident #701 during the midnight shift on 9/30/20. When queried how the assault occurred, with staff present in the facility, the Administrator stated, There was about 15 minutes when no one (staff) was in the hallway. The Administrator continued, (Resident #701) has MS (Multiple [CONDITION(S)]) and couldn't scream loud. When asked how and when the assault was identified, the Administrator revealed, The Aides (Nurses Assistants) didn't catch (Resident #702) doing it but one saw them going back to their room. The Administrator and DON were then asked about the proximately of Resident #701 and Resident #702's rooms in the facility and revealed the Residents resided on the same hall. The DON continued, (Resident #701) is in 128-1 and (Resident #702) is in 117-3. When asked, the Administrator revealed the rooms on are opposite ends of the hall with Resident #702 being closest to the nurses' station. When queried if there were other female Residents between Resident #702 and Resident #701's rooms, both the Administrator and DON replied, Yes. When queried why Resident #702 went to Resident #701's room when other females were in rooms closer to their room, the Administrator and DON were unable to provide an explanation. The Administrator and DON were then asked if the facility had video monitoring/recording in the hall of the facility where the Residents resided and assault occurred and the Administrator replied, No. When queried if call light reports were available for the hall, the Administrator replied, No. On 10/1/20 at 9:45 AM, an observation of Resident #701 occurred. The Resident's room was near the end of the hall, not in close proximately to the nurses' station. Resident #701 shared a room with Resident #703 and Resident #701's bed was closest to the entrance door of the room. Resident #701 was in bed, positioned on their left side with a wedge pillow. An upper extremity brace was present on the overbed table next to the Resident and the Resident's legs were bent at their knees at approximately a 45-degree angle. An interview was completed at this time. When queried regarding the brace and mobility, Resident #701 revealed they have Multiple [CONDITION(S)] and have contractures in both their arms/hands and legs. Resident #701 stated, I can't really move or roll myself in bed at all. With further inquiry, Resident #701 stated, They (staff) use a lift (Hoyer- mechanical lift utilized to move individuals) to get me up. I have a wound (pressure ulcer- wound created by pressure) on my tailbone and I have to be on the wedge on my side. I can't move my legs at all and I just have really bad spasms. When queried regarding interactions with other Residents in the facility, Resident #701 stated, I just want to forget about it. It was awful. With further conversation, Resident #701 stated, I woke up to this man kissing my face. Resident #701 was asked if they knew the man or if they had ever seen them before and replied, Yes, when I was in my chair (electric wheelchair) he would go by in his chair and ask my name and if he could come in. When asked for clarification regarding their location when this occurred, Resident #701 revealed they were in their room. Resident #701 then stated, I wouldn't go in the hall because (Resident #702) gave me the heebie-jeebies. With further inquiry regarding Resident #702 giving them the heebie-jeebies, Resident #701 revealed the hair went up on the back of my neck when Resident #702 was around. When asked if they were scared of Resident #702 prior to the assault, Resident #701 stated, Yes. Resident #701 then stated, I told (Social Worker A) about (Resident #702) too and how they were saying things to me. Resident #701 was asked what occurred after they voiced their concerns to Social Worker A and replied, (Social Worker A) said they would take care of it. At this time, Resident #701 continued to describe the assault. Resident #701 stated, When I woke up, (Resident #702) had my arms pinned back and they were kissing me. I was yelling and they stuck their tongue in my mouth. I tried to bite them (to get them off me) but I think it turned (Resident #702) on (sexually). Resident #702 continued, Then (Resident #702) pulled my gown down so my breasts were exposed and was kissing and like biting at them. (Resident #702) kept going down. (Resident #702) ripped my brief and put two fingers in me and thrusting with his fingers. (Resident #702) kept thrusting. It was gross, it was awful. At this time, Resident #701 became visibly distressed and tearful. Resident #701 continued, Then (Resident #702) climbed on top of me. I said I think he is going to rape me. Resident #701 revealed they yelled to their roommate (Resident #703), (Resident #702) is inside of me and stated (Resident #703) pushed the call light. Resident #701 revealed they tried to stop the assault and stated, (Resident #702) had me pinned with their upper body, they were pushing down. I was trying to hit (Resident #702) with my arm and yelling for them to stop. Resident #701 was asked if staff responded when they were yelling and revealed Resident #702 got off of them and left their room after they yelled that they were going to rape them. Resident #701 continued, I have a wedge under the right side of me (in bed) and (Resident #702) pulled it out so I was lying flat. It was so gross. When asked, Resident #701 revealed Resident #703 (Roommate) had pushed their call light for assistance and stated, But no one ever came. Resident #701 continued, I was hoping (Nursing Assistant B) would come in and pull (Resident #702) off of me. Resident #701 was asked when staff entered the room and who came in and replied, They all seemed to come at one because they heard me screaming. They couldn't believe what happened. Resident #701 expanded, I want to move on. I am just glad that (Resident #702) never got their pants off but I still feel like I got raped. My breasts were exposed and (Resident #702) had their fingers in me. They (facility staff) said (Resident #702) had a stroke but that doesn't excuse them. They knew what they were doing. That is why I reported it (to Social Worker A) when (Resident #702) started bugging me. I was nervous. Resident #701 then stated, To be honest, I wish (Resident #702) would just drop dead for what they did to me. I can't do anything, I am helpless. I never want to see them again. Resident #701 stated, I thought I was supposed to be safe here. I am just stressed. When asked about assessment following the assault, Resident #701 stated, The (Forensic) nurse did an exam from the hospital yesterday to do DNA testing. They said there was damage and bleeding inside of me. Resident #701 was asked how they are feeling now and replied, Yesterday, I couldn't eat at all. I couldn't sleep at all the night before last, I slept during the day. If I hear a noise when I am sleeping, I jump. I am scared. My (child) wants me out of here but I am scared I will have to go through it all again somewhere else. If I go somewhere else, it could be good, but it could happen again. Resident #701 was asked if they are scared now and replied, Yeah, but I know (Resident #702) isn't here now. I just want move on. Resident #701 was asked if they recalled what time Resident #702 entered their room and replied, (Resident #702) woke me up around 3:00 AM from what I remember between the TV and the clock and finally left about 3:30 AM. An interview was conducted with Resident #703 on 10/1/20 at 10:21 AM. Resident #703 was asked if they recalled an incident that occurred during the night involving their roommate, Resident #701, and they revealed they did. When queried what occurred, Resident #703 stated, (Resident #701) said (Resident #702) was in the room and to press the call light so I did. Resident #703 continued, I could hear (Resident #701) telling me what (Resident #702) was doing. (Resident #70!) kept yelling 'Get away,' 'Don't do it, and 'Go away.' (Resident #702) was touching (Resident #701's) breasts and (Resident #701) said (Resident #702) was biting. (Resident #701) kept yelling, Get away, don't do that. Resident #703 stated, (Resident #701) said something about (Resident #702's) fingers touching them. When asked what happened after that, Resident #703 stated, (Resident #702) finally left and the Nurse's Aide (Nursing Assistant) say then in the hall. When asked how they felt after what occurred, Resident #703 indicated hearing/seeing the assault on their roommate shook them. When asked if they had been scared, Resident #703 replied, Yeah. Resident #703 then stated, (Resident #702) always bothered (Resident #701). When asked what they meant, Resident #702 stated, One time (Resident #702) came in here (room shared with Resident #701) but left. One time I saw (Resident #702) sitting on the chair staring at (Resident #701) when they were sleeping. Resident #703 was then asked how that made them feel and replied, Scared me. Resident #703 proceeded, (Resident #702) came back a couple of other times. One time, (Resident #702) put his hand on (Resident #701's) arm and then left. With further conversation regarding what had occurred, Resident #703 stated, (Resident #701) was pretty shook up. Just kept telling (Resident #702), 'Don't do it. On 10/1/20 at 10:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) C. When queried regarding Resident #702 including the Resident's behaviors, LPN C replied, (Resident #702) had [CONDITION(S)] but did not provide further explanation. When queried if the Resident had wandering behaviors, LPN C replied, Yes. A review of Social Services progress note documentation in Resident #701's medical record did not reveal documentation related to Resident #701 verbalizing concerns related to Resident #702. At 10:45 AM on 10/1/20, an interview was completed with the facility Administrator. When queried regarding the location of the Social Worker in the facility, the Administrator revealed Social Worker A was off work due to a family emergency. The Administrator stated, I am a Social Worker and indicated they were filling the role for the day. The Administrator was then queried regarding Resident #701 stating they verbalized concerns about Resident #702 to Social Worker A prior to the sexual assault and lack of documentation in the Residents medical record and replied, I don't know anything about that. I will call (Social Worker A). Social Worker A's contact information was requested at this time and the Administrator reiterated the Social Worker was not available related to a family emergency and a death in their family. An interview was completed with Nursing Assistant D on 10/1/20 at 11:20 AM. When queried, Nursing Assistant D revealed they are frequently assigned to care for Resident #701. When queried regarding the Resident's sleeping patterns, Nursing Assistant D stated, (Resident #701) is a VERY sound sleeper. When asked if they were aware of the incident that had occurred in the facility involving Resident #701, Nursing Assistant D indicated they were not aware of any specifics. Nursing Assistant D was then asked if they had observed any change in the Resident's sleeping patterns since the incident and revealed they had not observed them sleeping since the assault occurred. When asked if Resident #701 normally confides in them about things that are bothering them and/or talks to them about how they feel, Nursing Assistant D stated, No. (Resident #701) had never told me personal things and further indicated they do not ask Residents any personal questions. Nursing Assistant D was asked if they had worked with Resident #701 on 9/30/20 and they revealed they had. When queried regarding Resident #701's behavior and oral intake during their shift, Nursing Assistant D revealed Resident #701 ate nothing at breakfast. On 10/1/20 at 11:38 AM, an interview was conducted with Station One Unit Manager LPN F. When queried regarding the sexual assault that occurred in the facility on 9/30/20 involving Resident #701 and Resident #702, LPN F indicated they were not aware of the specifics of what had occurred and stated, When I came in, I just saw police cars and the Administrator and DON (Director of Nursing). LPN F continued, The police were down the hall. When queried if they assessed and/or saw Resident #701 after that, LPN F replied, No. At 11:45 AM on 10/1/20, the Administrator revealed they had located a Concern Form pertaining to Resident #701 and Resident #702 in the Social Services office. Review of provided Concern Form dated 9/22/20 revealed, To Social Work. Department Social Services . Description of Concern: At noon, I was sitting in (Resident #701's) room feeding them lunch. (Resident #701) told me that an unknown male Resident was sitting outside of their room and they felt uncomfortable with him sitting out there . See typed report . Attached typed report authored and signed by Social Worker A detailed, SW (Social Worker) was brought into a conversation that (Resident #701) was having with (Psychiatrist) on 9/22/20 at approximately 1:30 PM. Resident did inform (Psychiatrist) and myself that they were having a concern with a male Resident sitting outside their door . SW did discuss with Resident putting on call light if continued to feel uncomfortable . Later that afternoon, SW did receive a concern form (from Nursing Assistant) at approximately 2:00 PM that when they were feeding (Resident #701) . did indicated to them the same complaint. SW did inquire to (Nursing Assistant) if they were aware of any unknown makes that were seen down the hallway near (Resident #701's) door. (Nursing Assistant did indicate that the only make that was possibly down that way was (Resident #702) . Resident #702 is very confused and alert and orientated X 2 (person and place) . Review of facility provided Incident documentation included: -Sexual Assault . (Resident #701) . Location: Resident's Room . Nursing Description: Resident observed lying in bed with sheets pulled down and chest exposed, at 3:30 am. A small amount of blood was also observed in the brief and on sheets. Wedge (positioning device) was no longer under resident . Resident Description: Resident informed writer that they were sleeping at the time incident stated . was woken up by (Resident #702) kissing face. (Resident #702) pinned their arms close to their head and made attempts to stick tongue in their mouth. (Resident #701) kept mouth closed and tried hitting (Resident #702's) head with left arm. (Resident #702) pulled their gown down exposing chest and kissing it. (Resident #702) then pulled brief down and stuck their fingers inside of them. From there, (Resident #702) laid on top of them briefly. (Resident #701) told their roommate (Resident #703), '(Resident #702) is going to rape me.' (Resident #702) responded, 'No, I'm not. (Resident #702) began kissing them again, all while staying fully clothed. (Resident #702() then reinserted their fingers a second time into their vagina. (Resident #701) told (Resident #703), 'Hit the call button.' (Resident #702) stopped and got back in their wheelchair saying, 'I will see you.' During this time, (Resident #702) continued to ask (Resident #701) what their name was . Immediate Action Taken . DON, Administrator, Police . notified . Mental Status: Orientated to Person . Place . Situation . Time . -Resident #701's SBAR Communication Form and Progress Note dated 9/30/20 at 4:03 AM detailed, The change in condition, symptoms, or signs . Resident observed lying in bed with sheets pulled down and chest exposed, at 3:30 AM. A small amount of blood was also observed in the brief and on sheets. Wedge (for positioning) was no longer under resident. Skin assessed, no new issues to report . ' -Sexual Assault . (Resident #702) . Location: Resident's Room . Nursing Description: Resident entered another Resident's room in the middle of the night and made physical contact . Act was done without the other Resident's permission. Resident was kissing, forcing themselves on (Resident #701). (Resident #702) also placed fingers inside of (Resident #701). Resident stating, 'Nothing happened, nothing happed.' Resident finally admitting to writer, I kissed (Resident #701) and put my fingers in (Resident #701) Immediate Action Taken . DON, Administrator, Police . notified . Mental Status: Orientated to Person . Place . Time . -Resident #702's SBAR Communication Form and Progress Note dated 9/30/20 at 4:15 AM revealed, Resident entered another residents' room in the middle of the night and made physical contact with that Resident. Act was done without the other residents' permission. Resident was kissing, forcing himself on (Resident #701) and placing his fingers inside of (Resident #701) . -Resident #702 Discharge Plan and Summary Documentation revealing the Resident was discharged home -Typed statement signed by Nursing Assistant H (no date): I am usually assigned to work unit 2 for the midnight shift. On 9/29/20, I was assigned to work unit one from 11 PM until approximately 7 AM on 9/30/20. When I do my charting, I always sit in the middle of the hallway so I can monitor the rooms. Around 3 AM on 9/30/20, I was sitting in hallway between rooms [ROOM NUMBERS] charting. room [ROOM NUMBER] call light went off. I went into that room . was in the room for approximately 15-20 minutes. I came out of the room and (Resident #702) up in wheelchair coming from the opposite end of hallway . I immediately asked (Resident #702) where they were coming from and what they were doing. (Resident #702) stated, 'nothing, I'm doing nothing. I asked again . (Resident #702) stopped answering, and began propelling wheelchair really fast and went into their room . About three minutes later, (Resident #701's) call light went off. (Nursing Assistant B) went to answer the light . (Nursing Assistant B) yelled for (Licensed Practical Nurse [LPN] I) to come . (LPN I) and myself ran right into the room. I observed (Resident #701) laying in bed with chest exposed . (Resident #701) started to tell us what happened . Said (Resident #702) was over them, kissing their mouth, kept trying to put their tongue in their mouth and then started messing with their chest. (Resident #701) said (Resident #702) got on top of them and put their hand in their vagina . I went to (Resident #702's) room, they were laying in bed . Nursing Assistant H was attempted to be contacted by phone on 10/1/20 at 3:30 PM. A return call was not received by the conclusion of the survey. -Typed statement signed by Nursing Assistant J (no date): I was assigned to work unit one midnight shift from 11 PM until approximately 7 AM on 9/30/20. On Wednesday morning 9/30/30 sometime around 3 AM, I was at the nurses station charting with the charge nurse (LPN I) . (Nursing Assistant B) came to desk and stated they were going to get supplies Resident room [ROOM NUMBER] call light went off, (Nursing Assistant H) went into answer it . Nursing Assistant B was returning with the supplies and as they did (Resident #701's) room light came on . (Nursing Assistant B) went to answer the light, immediately yelled for (LPN I) to come to room. (LPN I) ran to room immediately . Nursing Assistant H was attempted to be contacted by phone on 10/1/20 at 3:31 PM. A voicemail with return phone number was left but a return call was not received by the conclusion of the survey. -Typed statement signed by LPN I (Dated 9/30/20): I was charge nurse assigned to care for unit one Went on 9/28 from approximately 7 PM until 7:30 AM on 9/30/30 . I administered (Resident #702's) medication sometime after 9:30 PM. (Resident #702) was lying in bed . I went back in (Resident) room before 11 PM and offered snacks . I observed (Resident #701) around 10:30 PM . Around 3 AM, I was at the desk completing charting . (Nursing Assistant H) was stationed in the hallway charting and (Nursing Assistant B) was collecting supplies when a call light went off. I think it was for room [ROOM NUMBER] . another call light went off for (Resident #701's) room. I heard (Nursing Assistant B) calling for me . I went right to the room and observed (Resident #701) with the top of their gown completely unbuttoned. Both breasts were exposed. The wedge that is usually positioned hind was at the foot of their bed . sheets were pulled down to feet and bunched up . (Resident #701) stated they were sleeping and was woken up to (Resident #702) kissing their face . very close to their face. (Resident #701) stated they told (Resident #702) very specifically, stop, get out of here but (Resident #702) had a hold of both of their wrists and put them close to their face and (Resident #702's) chest was pressed up against theirs. (Resident #701) tried to talk and communicate with (Resident #703) roommate for help . (Resident #701) stated they were able to hit (Resident #702) with their left hand . (Resident #702) then pulled gown down and started kissing their chest. (Resident #702) then pulled their brief down and put their fingers into their vagina and began thrusting fingers into vagina . I completed a physical exam on (Resident #701) and noted there to be a small amount of blood in brief and on sheets . Suprapubic (surgically inserted urinary catheter) had slight drainage . (Resident #701) initially said they wanted to go to the hospital. (Resident #701) asked me to wash their hands because said they smelled like (Resident #702). I did that . I was providing care when (Resident #701) said they knew what they were going to do in the ER and who knew how long that was going to take . said I know exactly what happened and there isn't anything that are going to do form me there . I went to (Resident #702's) room . lying in bed fully dressed. I asked them where they were and what there were doing two times. He kept saying nothing. I told (Resident #702) that I know what happened and I needed to hear their version. (Resident #702's) version was very short; said 'I kissed (Resident #701). I asked what else, (Resident #702) said, 'I put my fingers in (Resident #701).' (Resident #701) then said it was our fault, we were showing movies both Residents were placed on close monitoring . LPN I was contacted with phone on 10/1/20 at 3:27 PM and 6:39 PM. A voicemail message with return phone number was left but a return call was not received by the conclusion of the survey. A phone interview was conducted with Police Detective G on 10/1/20 at 12:11 PM. When queried regarding Resident #701 and Resident #702 on 9/30/20, Detective G revealed police were contacted and were investigating the sexual assault. When asked about investigation, Detective G stated, (Resident #702) admitted what they did to the Police Officers. Police Detective G also revealed they had coordinated care with an organization who came into the facility to complete an exam on Resident #701. Documentation pertaining to the investigation was requested at this time. Review of Resident #701's medical record revealed Resident #701 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive to total assistance to complete Activities of Daily Living (ADLs). Review of Resident #701's care plans revealed the Resident's care plan had not been updated after the sexual assault and the Resident did not have a care plan in place related assessment and/psychosocial well-being related to the sexual assault. Review of Resident #701's progress note documentation revealed the following: -9/30/20 at 7:43 AM: Provider Note . exam secondary to incident . Patient states . did wake up today from a nap and . could still see (Resident #702's) face. After discussions that (Resident #702) was no longer resident at (facility) stated . feels safe . Will contact psychiatric services . -9/30/20 at 3:53 PM: Social Services Note . SW (Social Worker) did visit resident in room to discuss any further concerns and assess for any behavioral changes and resident did indicate that (Resident) does continue to play the incident in head. SW did discuss with (Resident) agreeing to participate in the Domestic Violence Counseling Services (External Company) . Review of Resident #701's health care provider orders revealed an order dated, 8/11/20 for Psyche to eval and treat . but did not include an updated order. No documentation of communication with Psychiatric/Mental Health services was noted in Resident #701's medical record. The most recent Behavioral Health Services documentation for Resident #701 was dated 9/22/20. The documentation detailed, (Resident #701) She did report a concern regarding another male peer. Discussed concern with SW . Review of Resident #701's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #703's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 6/25/20, revealed the Resident was cognitively intact and required supervision to extensive assistance to perform Activities of Daily Living (ADLs). Review of Resident #703's medical record, including progress notes and assessments, revealed no documentation of psychosocial assessment following the sexual assault that transpired in their room and which they heard/observed on 9/30/20. An interview was completed with Forensic Registered Nurse (RN) E on 10/1/20 at 1:29 PM. When queried, Forensic RN E revealed they had completed an exam on Resident #701 following the sexual assault. Forensic RN E was asked about Resident #701's mental state and physical status during their exam and revealed Resident #701 had signs and symptoms of injury. Forensic RN E stated, (Resident #701) had internal and external (vaginal) tearing. Forensic RN E continued, (Resident #701) was still almost in the shock phase yesterday, almost numb. Review of Criminal Investigation documentation related to the sexual assault to Resident #701 on 9/30/30 perpetuated by Resident #702 revealed the following: -Police Department Field Case Report . Reported Date 9/30/20 0411 (4:11 AM) . Occurred Date: 9/30/20 0300 (3:00 AM) . Occurred Through: 9/30/20 0330 (3:30 AM) . Description: Sexual Penetration/Object- CSC (Criminal Sexual Conduct) 1st Degree . Subject: (Resident #702) . Victim: (Resident #701) . -Michigan State Police (Medical Examination Documentation) . (Resident #701) . 9/30/20 0830 (8:30 AM) . Medical Note . Spoke with (Resident #701's) nurse (LPN C) regarding medication for discomfort and monitoring for signs and symptoms of infection . (Resident #701) discharged . to facilities care . Relationship of Assailant: Another Resident in the facility, 'I keep seeing (Resident #702's) stupid face' . Symptoms Since Assault . (Resident #701) making occasional remarks such as 'Their stupid,' 'At first I couldn't believe it happened.' 'Just their face makes me uneasy.' 'I still cant believe this happened, Especially in a facility like this' . Trauma (during vaginal exam) . #1. Approximately 2.5 cm (centimeter) area of red-purplish bruising and abrasion to labia minoria at 12 o'clock position. Small amount of bright red bleeding . During vaginal swabbing pt (patient) reported 'sharp pain 8/10.' Blood noted on vaginal swabs . Review of Resident #702's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively impaired and required limited to extensive assistance to perform Activities of Daily Living (ADLs). Review further revealed Resident #702 remained in the facility for 13 hours after sexually assualting Resident #701. They were discharged home, with family, on 9/30/20 at 4:17 PM. Review of Resident #702's most recent Behavioral Health Services documentation, dated 8/27/20 revealed, Patient was admitted to (Hospital) from June 15 through June 26 due to auditory hallucinations . speaking clearly and making good eye contact . reports . thinking is clear. Writer did ask SW if patient was responding to internal stimuli when (they were) approaching and did say yes (Resident #702) was . Level of Consciousness: Alert . Demeanor: +Resistant; Orientation: oriented to time, place, and person. Attention/Concentra[TRUNCATED]

Based on interview and record review, the facility failed to initiate CPR (Cardiopulmonary Resuscitation) on a resident (R111) who was a full code. This deficient practice resulted in an Immediate Jeopardy when staff found the resident to be unresponsive and pronounced the resident dead on [DATE] at 10:35 PM without attempting life-saving measures per the resident's documented wishes. The Immediate Jeopardy (IJ) started on [DATE] and was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] and was asked for a plan to remove the immediacy. The IJ was removed on [DATE], based on the facility's implementation of the removal plan as verified onsite on [DATE]. Although the immediacy was removed the facility's deficient practice remained isolated with actual harm that is not immediate jeopardy. Findings include: A review of R111's Minimum Data Set (MDS) assessment dated [DATE] and medical record revealed that the resident was admitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was cognitively impaired and required extensive assistance from staff for activities of daily living (ADLs), mobility, and transfers. The resident was noted to be marked on the MDS as receiving hospice services while in the facility. Further review of R111's electronic medical record revealed that the code status (whether the resident wished for live-saving measures, such as CPR) for the resident on the main screen was listed as a Full Code. A review of R111's facesheet also noted, ADC: Full Code. Review of the resident's physician orders [REDACTED]. Active [DATE]. Additional review of documentation in R111's hard copy chart and electronic medical record revealed the following advance directive document titled, Life-Sustaining Treatment, signed and dated [DATE]th, 2020 (uploaded into the electronic medical record on [DATE]), which read: Some people do not wish to have certain life sustaining treatments under any circumstance, even if a recovery is a possibility. With each treatment listed below, please indicate either yes or no. Yes means that you agree to and want to have this treatment. Or No, that you do not wish to have this treatment under any circumstances. Cardiopulmonary Resuscitation (CPR): Yes Ventilation (breathing machine): No Feeding tube: No [MEDICAL TREATMENT]: Yes Blood Transfusion: Yes This will provide peace of mind to be able to choose healthcare decisions when you no longer can communicate your wishes. Further review of R111's medical record revealed the following progress notes: [DATE] 19:42 (7:42 PM) Provider Note, Encounter Date: [DATE], Chief Complaint: Initial visit .Per discussion with family as interpreters for patient patient does not wish for intubation however does wish for CPR. Discussed with hospice team CODE STATUS will need to be further discussed with family if patient is to remain on hospice care .Code Status: Full code with no intubation. [DATE] 18:58 (6:58 PM) Social Services Note, Note Text: resident (family) provided Patient Advocate forms for resident chart today, scanned and uploaded, resident (family) continues to visit daily through window .brought resident some snacks, writer asked if full code status to remain with hospice care resident (family) responded yes full code to remain in place. Effective Date: [DATE] 22:35 (10:35 PM) Type: Nursing Note Resident expired [DATE] at 10:35 pm. Family and hospice notified. Remains picked up by (Funeral Home). Author: (LPN F) - Licensed Nurse (e-SIGNED). Effective Date: [DATE] 22:38 (10:38 PM) Type: Nursing Note Resident expired at 10:35 p. Resident observed for heart and lung sounds; no heart or lung sounds observed at that time. Physician and hospice notified. Author: (RN E) - Registered Nurse (e-SIGNED). Effective Date: [DATE] 17:16 (5:16 PM) Type: Discharge Note, Note Text: .Encounter Date: [DATE], Code Status: Full code with no intubation, Disposition: Patient expired [DATE]:35 PM .Per discussion with family as interpreters for patient patient does not wish for intubation however does wish for CPR. Discussed with hospice team CODE STATUS will need to be further discussed with family if patient is to remain on hospice care . The note did not mention administration of CPR on the day R111 expired. No additional progress notes dated [DATE] were present in R111's record along with no progress notes dated [DATE] or [DATE]. The following vital signs were noted in R111's medical record, entered by LPN F: (Blood pressure) [DATE] 20:44 (8:44 PM): 115 / 78 mmHg Lying r/arm (right arm). (Pulse) [DATE] 20:44 (8:44 PM): 108 bpm (beats per minute). (Temperature) [DATE] 20:44 (8:44 PM): 98.5 °F Oral. (Oxygen Saturation) [DATE] 20:44 (8:44 PM): 96.0 % Room Air. The most recent set of vital signs prior to [DATE] on R111 were noted to be taken last on [DATE]. On [DATE] at 3:50 PM, Registered Nurse (RN) E was interviewed regarding their note entered into R111's record on [DATE]. RN E stated, I was working station 1. (LPN F) came down and asked me to pronounce the resident (deceased ). I went to see (R111) with my stethoscope in hand, I did not see breathing or pulse, the resident was pale with mucus coming out of their mouth. Their arms were still a little warm, hands were cool. I assessed hardened lung sounds and pronounced (R111) at the time I wrote in my note. (LPN F) notified hospice and the family. I had to talk to the family about the policy and procedure regarding seeing the resident. Prior to that, (LPN F) had informed me (R111) was a full code. That was about 20 minutes after the fact that I had pronounced (them deceased ). When asked who saw the resident initially, RN E stated, (LPN F). (LPN F) didn't mention anything about the resident other than I needed to pronounce them. When queried if they would have done CPR if they had known the resident's code status, RN E stated, If it seemed like (R111) had recently passed and I knew (their) code status then yes. On [DATE] at 3:55 PM, an attempt to interview LPN F via phone call was made. A voicemail was left for call back. On [DATE] at 3:57 PM, an attempt to interview Resident Care Aide (RCA) G via phone call was made. A voicemail was left for call back. On [DATE] at 5:05 PM, the Director of Nursing (DON) was queried what the expectation of staff is if a resident is listed as a full code and replied, The expectation of staff if listed as a full code and attempt CPR is for staff to perform or attempt to perform (CPR) if (the resident) is found unresponsive. When queried if staff is expected to follow resident advance directives, the DON stated, My expectation is for staff to follow advance directives. When queried if advance directives through hospice and through the facility were the same, the DON stated, Hospice and our advance directives are combined. When queried regarding R111's advance directive, the DON confirmed that the facility's advance directive on file for R111 dated [DATE] was what was to be followed. When queried regarding R111 passing away in the facility on [DATE], the DON stated, I asked the nurses who were on that night what happened and they gave their statements and gave them to me. On [DATE] at 5:26 PM, a second attempt to interview LPN F via phone call was made. A voicemail was left for call back. On [DATE] at 8:55 AM, LPN F was interviewed via phone call. When queried regarding what happened before and during R111's passing away in the facility on [DATE], LPN F stated, I was in another room, passing meds. Came on shift, started at 7 PM. An hour or two later the aide had called me, (R111) was receiving [MEDICATION NAME] every 2 hours. I had given [MEDICATION NAME] for that timeframe. When queried if that was why they had documented vital signs on the resident on [DATE] at 8:44 PM, LPN F stated, I believe so, I might have given it a little sooner. I gave [MEDICATION NAME] and was in another room on the east side, (R111) was on the west side. The aide came and called me and told me it looks like the resident was gone and the resident wasn't doing anything. I yelled for help from my co-worker. I assessed (R111) didn't have a pulse, did sternal rub. Looked like (they were) completely gone. Not sure how long. Then my coworker was in the room we checked there was no pulse. Not sure how long (R111 was gone). I called the RN (RN E) that was there, the RN confirmed (R111) passed. When asked if they were aware of R111's code status, LPN F stated, I thought (R111) was a DNR (do not resuscitate). When asked if they had seen the code status after the resident had been pronounced as deceased , LPN F stated, Yes. Not like hours after, but yes. When asked if the aide knew if the resident was a full code, LPN F stated, The aide wouldn't know that. I don't think they would know that I'm not sure. When asked the name of the aide, LPN F indicated that it was RCA G. On [DATE] at 9:11 AM, a second attempt to interview Resident Care Aide (RCA) G via phone call was made. A voicemail was left for call back. No call back from RCA G was received prior to survey exit. On [DATE] at 9:15 AM, LPN F called back and stated they wanted to add a piece of information. LPN F stated, Vital signs - I took them at the time (I found R111) but didn't get numbers. When asked if they documented that, LPN F stated, Yes I think in the progress note. Upon review of the progress note, no information related to vital signs was found. The only set of vital signs recorded for R111 on [DATE] were entered by LPN F at 8:44 PM. On [DATE] at 9:30 AM, LPN J was asked where nurses check for code status in the medical record. LPN J stated, In PCC (electronic medical record) right on the face page or look in the paper chart. And it's in the physician orders. When queried what the procedure is if a resident is found unresponsive, LPN J stated, If full code, start CPR and if DNR, make comfortable. But a full code, definitely CPR. When asked if they checked code status for hospice residents, LPN J stated, I will check because we have had residents here who were hospice who have been full code or request that CPR be done. On [DATE] at 9:41 AM, Social Worker (SW) H was interviewed regarding R111's code status. SW H stated, When (R111) first came in, (there was discussion regarding the resident) being a full code but their culture doesn't allow them to do DNR. So, (R111) came in on hospice and was a full code. They had no POA (Power of Attorney) but because there was no POA, (the resident) was a full code. There was a language barrier. I asked the (family member) to translate how the resident felt. The (family member) was outside the window for a conversation with the resident .and asked the resident, 'Do you want CPR?' (R111) nodded their head (yes), asked 'Do you want to be DNR?' (R111) gestured no. (The resident) talked with family when they came, the resident trusted them and I trusted those were (R111's) wishes based on the family. It was a collaborative effort to determine the resident's wishes. I can't push people on what to do, I have to be on the side of the resident and their wishes, and (R111's) wish was full code. When queried regarding education given on following advance directives, SW H stated, Yes. We did a full audit. Made sure everyone understands the location of (the advance directive). As a nurse or anyone you can't just assume (code status), you need to be careful and look at everything. We did every code status in the system 100%, we are becoming [MEDICATION NAME]. Everyone was educated, (aides) are required to know and they should. We educate everyone to know the process. A review of the facility's policy/procedure titled, Medical Emergency Management, revised February 2017, revealed: The facility ensures residents receive timely and appropriate interventions in the event of a medical emergency. The staff takes actions to ensure that the resident's airway, breathing, and circulation are maintained until emergency personnel arrive. Staff is aware of each resident's physician orders [REDACTED].Once a medical emergency is identified, qualified staff assesses the resident, initiates the appropriate emergency procedure(s) in accordance with physician's orders [REDACTED]. The staff continues to provide care and monitor the resident until the emergency personnel arrive. A review of the facility's policy/procedure titled, Advance Directives, Revision Date: February 2017, revealed: The resident has a right to accept or refuse medical or surgical treatment and to formulate an advance directive in accordance with State and Federal law. The facility uses its best efforts to comply with the wishes of a resident as expressed in an advance directive and will not condition the provision of care or otherwise discriminate against an individual based on whether the individual has executed an advance directive .3. If a resident has executed an advance directive the facility must obtain a copy from the resident or the legal representative which is stored in the resident's medical record file. Nursing notifies the physician of the resident's or the legal representative's wishes, obtains orders as appropriate, and enters the information in the Electronic Health Record .7. The facility's copy of the advance directive must be filed in the resident's clinical record .1. Copies of any advance directives are maintained in the resident's clinical record. 2. The facility must document in a prominent part of the resident's clinical record whether the resident has issued an advance directive. F678 Immediate Jeopardy - Plan for Removal The preliminary fact analysis demonstrates that the facility failed to initiate CPR on a resident who was a full code. The resident was pronounced dead on [DATE] at 10:35 PM without initiation of CPR or notification of 911. -Resident (R111) expired on [DATE] while receiving hospice services. -DON interviewed staff involved and provided immediate education to RN and LPN involved on [DATE]. -Interdisciplinary team meeting held [DATE] to review all current advance directives. Facility leadership educated on Advance Directive policy. -The Medical Director was notified of the failure to initiate CPR [DATE] and of Immediate Jeopardy on [DATE]. -All residents that are residing in the facility with a full code status have the potential to be affected in a similar manner. -A facility audit was completed on [DATE] to ensure appropriate code status orders for all residents who currently reside in the facility. -Education with specific focus on acquiring and following advanced directives including initiating CPR and notifying 911 for all licensed staff has been initiated and will be completed prior to the start of their next shift. The Administrator is responsible for attaining and maintaining compliance. Completion date: [DATE].

Based on observation, interview, and record review, the facility failed to ensure a safe transfer for one sampled resident (R26), resulting in a fall, broken femur with hospitalization and surgical repair, decrease in functioning, and resident feelings of frustration. Findings include: On 9/22/20 at 9:18 AM, during the initial tour, R26 was queried regarding the care received in the facility. R26 was observed lying in bed and stated, They broke my femur! Staff put me in the shower room. They were supposed to stay with me but left me. I fell and broke my left femur. It was an aide .still works here. I was getting pretty good at getting up and dressed now they don't want me to get up in my chair. They don't trust me getting up by myself. The resident indicated they were currently receiving therapy services and had started the services after breaking their leg. R26 continued, I had to go to the hospital and get it fixed. They put a metal pipe in from knee to hip. (The aide - Resident Care Aide (RCA) O) went out into the hallway to talk to somebody. I said, 'Help me I'm ready to fall.' (The aide) couldn't keep me up. I was standing up. But (the aide) wasn't supposed to leave at all! On 9/22/20 at 11:50 AM, upon further interview with R26, the resident indicated they are blind in their left eye and have partial sight in their right eye. When queried if staff had asked about what had happened in the shower room, R26 stated, I told staff that I was left in the shower room when I fell but they didn't say anything. When queried how long the aide stepped out of the room, R26 stated, I don't know. When queried what they were doing, R26 stated, I was holding onto the bar on the wall standing in the bathroom. I had already taken a shower. (The aide) completely left the room. R26's roommate, R25, was present at the time of the interview and stated, That's what (R26) told me, too. They (aide) left to talk to some staff in the hallway. A review of R25's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating an intact cognition. A review of R26's MDS assessment dated [DATE] revealed the resident had a BIMS score of 15/15, indicating an intact cognition, with medical [DIAGNOSES REDACTED]. Further review revealed the resident requires extensive assistance from two or more staff for transfers. A the time of the fall, R26's MDS assessment dated [DATE] indicated the resident required extensive assistance from one staff for transfers. A review of R26's medical record revealed the following progress note written by Licensed Practical Nurse (LPN) Q: 3/1/2020 15:08 (3:08 PM), SBAR (Situation, Background, Assessment, Recommendation) Summary: .RN Assessment/LPN Appearance of resident - What I think is going on with the resident is: crying in pain .Additional Nursing Notes as applicable: CNA (Certified Nursing Assistant/RCA) reported to nurse that resident fell on the floor writer summoned into the shower room observed (R26) lying on (their) back LLE (left lower extremity) twisted knee area red and swollen crying in pain EMS (emergency medical service) called for transport . On 9/23/20 at 10:45 AM, RCA P was queried regarding R26's fall that occurred on 3/1/20. RCA P stated, I do remember (R26) falling and fracturing their femur but I wasn't working with (the resident) that day. I believe it was (RCA O). On 9/23/20 at 10:52 AM, an attempt to interview RCA O was made via phone call. A voicemail was left for call back. On 9/24/20 at 10:45 AM, LPN Q was interviewed regarding R26's fall on 3/1/20 that resulted in a fractured femur. LPN Q was queried what happened and stated, I was in the hallway, the aide called for me to go to the shower room. The aide put (R26) in there on the toilet. For some reason (R26's) knees buckled up and (they) ended up on the floor. LPN Q was queried who the aide was and indicated they believed it was RCA O. LPN Qcontinued and stated, The aide called me to go in there and I actually observed (R26) on the floor. When I talked to (RCA O) they said they were in the room trying to get the resident off the toilet and (R26's) knees buckled up and they fell . When queried if RCA O had left the shower room, LPN Q stated, I don't think so .I don't know if (RCA O) left (R26) on the toilet and went to a different section of the shower room. When queried regarding R26's appearance when they saw the resident on the floor, LPN Q indicated the resident was wearing clothing and stated, I saw (R26's) knees were swollen and they were calling my name. I knew it was broken. When queried regarding R26's transfer status, LPN Q stated, Right now, (R26) is a hoyer, at that time I'm not certain, I think maybe extensive one person assist. When queried if they observed a gait belt around the resident and queried regarding RCA O using the gait belt and the resident still falling, LPN Q stated, It happened so quick, when I talked to (RCA O) I didn't personally see the gait belt but (RCA O) was saying that they had it. I just don't remember. On 9/24/20 at 11:04 AM, a second attempt to interview RCA O was made via phone call. A voicemail was left for call back. No call back from RCA O was received prior to survey exit. On 9/24/20 at 12:14 PM, R26 was interviewed to confirm the details surrounding the fall they sustained on 3/1/20. R26 was asked if RCA O had been assisting them when they fell and if they had a gait belt on. R26 replied, They broke my femur! (RCA O) went out and talked to some girls in the hall. I told (RCA O) I was falling, they had helped me stand up, then I held onto the bar. My wheelchair was back against the wall. Then (the aide) went out into the hallway. I was standing when they went to the hallway. I said 'I'm falling!' (RCA O) came and tried to help me when I was falling I said, 'Grab my wheelchair!' The aide didn't grab the wheelchair (they) held onto me. And I fell . No gait belt. I ended up on the floor breaking my femur bone. I can't figure out why (RCA O) left me! It's frustrating. I don't know why. On 9/24/20 at 12:45 PM, RCA T and RCA P were seen walking in the hallway. Neither RCA was observed to have a gait belt with them. On 9/24/20 at 12:46 PM, RCA S was observed in the hallway with no gait belt. When queried if they had been provided with one, RCA S stated, Yes it's in my locker in the locker room. I'll go get it. RCA D was observed in the hallway at this time with no gait belt. On 9/24/20 at 12:49 PM, RCA U was observed in the hallway with no gait belt. When queried if they had been provided with one, RCA U stated, It's in my bag. RCA U then went into the clean utility room on the unit and stated, Oh, it's gone. On 9/24/20 at 12:55 PM, the Director of Nursing (DON) was interviewed and indicated they had done the investigation on R26's fall on 3/1/20. When queried what was found, the DON stated, The resident was in the shower room with an RCS (RCA). The resident felt a pain in their leg and lost their footing. They found that the resident had a complete occlusion at the hospital. The resident was alert and oriented the entire time. I know the aide was in the room with (R26) and (the resident) was an extensive one assist so (they) followed the care plan. When queried regarding the resident's statement about the event, the DON stated, fell trying to transfer to the wheelchair. When asked if that was all the resident stated happened, the DON stated, That's all the resident said. When asked how the resident was able to fall hard enough to the ground to break their leg if they were being assisted by the aide and a gait belt, the DON stated, (RCA O) said they were trying to help transfer (R26) when (the resident) moved very fast, and tried to get the wheelchair. When asked if R26 stated that their wheelchair was not near them at the time of the fall, the DON stated, No, (R26) said their leg hurt and they fell trying to get to the wheelchair. That's what (R26) told the hospital as well. When queried regarding gait belts in the facility, the DON stated, (Staff) is encouraged to keep them on their person. All staff have been provided with gait belts and they are available on the units. A review of the facility's investigation into R26's fall on 3/1/20 revealed the following: Provide detailed description of event/allegation: (R26) was being transferred from the toilet to .wheelchair with the assistance of (RCA O), Resident care specialist when (R26) fell on to the floor. Assessment of resident/describe injury: Closed fracture of shaft of left femur. Resident interview summary: (R26) stated that (they) 'fell trying to transfer to wheelchair.' (No further details provided). Immediate resident protection initiated: Resident was transferred to (hospital) for further evaluation. Causal/Contributing factors and observations (May include information from witness interviews, medical record review, environmental observations, equipment, etc.): Left sided [MEDICAL CONDITION] and [MEDICAL CONDITION], Occlusion of the left common and external iliac artery. Three witness statements were included in the investigation. The statements were reviewed and revealed: I was the charge nurse for one east on 3/1/20 from 7 AM until 3 PM I was charting at the nurse's station when I heard (RCA O) calling for help. I got up immediately and went into the shower room. I observed (R26) laying on (their) back on the floor. I could visibly see deformity to (their) left leg. I instructed (RCA O) not to leave (R26) and not to move (them) and I called for help. The nurse caring for (R26) called 911. (R26) was alert and crying. I asked (R26) what had happened, (they) said that (they were) trying to transfer into the wheelchair and that (they) just didn't make it . Signed by LPN V. .I seen the resident care specialist (RCA O) take (R26) into the bathroom to change (them) .At 2:10 PM I heard (RCA O) calling for help. Another nurse (LPN V) and I entered the shower room and witnessed (R26) lying on the floor on (their) back .left leg was twisted and I could see swelling and redness. I immediately called 911 . Signed by LPN Q. .I helped (R26) into the bathroom around 2:10 PM. Once (they were) done using the toilet, I helped (them) get dressed and began to assist (R26) with transferring from the toilet to the wheelchair. (R26) was fully dressed and had on .tennis shoes. I had (their) wheelchair positioned in close proximity and the gait belt on .(R26) is weak on (their) left side. I began to help (R26) transfer when all of a sudden (they) just started moving very fast. I tried my best to get (them) into the wheelchair but (they) only got onto a part of the seat and started falling to the floor. I called out for help, the charge nurses came in . Signed by RCA O. A review of the facility's policy/procedure titled, Fall Management, revised July 2017, revealed, POLICY: The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs, as appropriate, to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident ' s fall risks. A Care Plan is developed and implemented, based on this evaluation, with ongoing review .When a resident is found on the floor, the facility is obligated to investigate to determine how the resident got there and put into place an intervention to minimize it from recurring. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred . A review of the facility's policy/procedure titled, Physical Function, revised June 2008, revealed, Residents' abilities in activities of daily living do not diminish unless circumstances of their clinical condition demonstrate the decline is unavoidable. These activities include the resident's ability to: Transfer and ambulate, Feed themselves, Dress themselves, Perform personal hygiene; and use the toilet, move freely in bed .Guidelines: .Staff uses gait belts for safety during transfers .

This Citation Pertains to Intake MI OOO . Based on observation, interview and record review, the facility failed to ensure timely care plan interventions in a resident at risk for skin break down, prevent the development of pressure ulcers, identify appropriate treatment to heal an existing pressure ulcer in 2 (#'s 702 and 704) of 2 sampled residents reviewed for pressure ulcers, from a total sample of 24 residents, resulting in the worsening of a stage 4 pressure ulcer and the development of avoidable unstageable pressure ulcers. Findings include: Resident #704 During the initial tour on 11/6/17 at 9:00 am, Resident #704 was observed lying in bed waiting for assistance with eating. Nurse J said the resident had an unstageable coccyx wound that wasn't new and Was seen weekly by the Wound Care Doctor. A record review on 11/6/17 at 4:00 PM revealed, Resident #704 was admitted to the facility on [DATE] and readmitted on [DATE] and 10/26/17 with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had cognitive dysfunction and needed extensive to total assistance with all care. On 11/7/17 at 9:00 am, a record review revealed the following: Weekly Skin Assessments- there were no Nursing skin assessments completed in July, 2017. Wound Care Physician Notes: 4/10/17-11/6/17, not completed weekly. 11/6/17: Coccyx Wound measurements-7.3 centimeters (cm) length by (x) 6.1 cm width x 4.0 cm depth. Treatment Dakin's Soak with 4 x 4 gauze and [MEDICATION NAME]. 10/30/17: Coccyx Wound- 5.2 x 4.0 x 3.3 (Resident hospitalized ,[DATE]-[DATE]) 10/9/17: Coccyx Wound- 4.6 x 3.8 x 3.3 Dakins Soak 10/2/17: Coccyx Wound- 4.6 x 4.0 x 3.5 Dakins Soak 9/18/17: Coccyx Wound- 4.9 x 4.5 x 4.0 Dakins Soak 8/28/17: Coccyx Wound- 6.3 x 5.0 x 4.0 Dakins Soak began again on 8/21/17. 8/21/17: Coccyx Wound- 6.7 x 5.5 x 4.0 Wound VAC discontinued 8/14/17: Coccyx Wound- 7.3 x 6.1 x 4.0 Treatment- Wound VAC began 8/7/17: No Assessment 7/31/17: Coccyx Wound- 5.3 x 4.5 x 3.0. Treatment Santyl and 4 x 4 gauze. 7/17/17: Coccyx Wound- 4.5 x 2.0 x 2.2 Treatment Santyl and 4 x 4 gauze. 6/19/17: Coccyx Wound- 3.0 x 1.5 x 0.7 Dakins Soak 6/2/17: Coccyx Wound- 1.5 x 1.4 x 0.6 Dakins Soak 5/22/17: Coccyx Wound 1.5 x 1.0 x 0.6 with 100% granular base. Treatment Dakins Soak From 5/22/17- 11/6/17 the Wound had dramatically increased in size. From 8/21/17 until 11/6/17 the only treatment applied was a Dakins Soak with 4 x 4 gauze and [MEDICATION NAME] dressing. Wound Care Physician I, wrote the same documentation in every note from 8/28/17-10/30/17, . The base is 80% granular, 20% necrotic tissue. Moderate serosanguinous drainage. No odor, no [DIAGNOSES REDACTED], no [MEDICAL CONDITION] around. No more maceration around like last week. We will cleanse the wound with saline, dry, apply skin prep around the wound, pack the wound with Kerlix gauze, damp on Dakin's solution then cover with dry 4 x4 and [MEDICATION NAME] to change daily and as needed. There was no mention of maceration since 8/21/17, in reference to use of the Wound VAC. No new interventions had been mentioned or implemented and Wound Care Physician I documented the same Treatment, note every visit since 8/28/17, We will do the dressings as mentioned above. Continue to reposition the patient every two hours. Continue to keep (the resident) clean and dry with the diapers. Foam boots bilaterally. Foley care. Help the patient with the feedings. Dietitian continue to monitor the patient regarding supplementations and nutritional status. Pain Control. Multiple comorbidities, advanced disease and advanced age and very high risk of complications. I coordinated care with the nurse in the facility and I will follow up with the patient in a week. The Skin Care Plan for Resident #704 had not been updated since 8/22/17, and then on 11/8/17, during the survey and stated, Turn and reposition using foam wedge frequently while in bed for comfort and pressure reduction. On 11/8/17 at 10:28 am, Nurse E was observed completing the dressing change to Resident #704's coccyx. The area was completely open to the bone with a small area with yellow slough. The resident repeatedly said, Ow, during the dressing change. An interview with the Director of Nursing (DON) on 11/8/17 at 3:50 PM provided, You would usually change the treatment if the wound wasn't healing. On 11/8/17 at 4:15 PM, a review of the facility policy titled, Skin Management, dated July 2017 provided, Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers .defined and implemented interventions that are consistent with resident needs, goals and recognized standards of practice, monitored and evaluated the impact of the interventions and revised the approaches as appropriate . Resident 702: On 11/6/17, at 3:10 PM, Resident #702 sitting in wheelchair in the room having speech therapy. On 11/6/17, at 3:45 PM, a record review revealed that resident #702 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 10/16/17, revealed that the resident had a severe memory problem and required extensive assistance with Activities of Daily Living (ADL's) including bed mobility. On 11/6/17, at 4:00 PM, a review of Resident #702's skin issues care plan revealed the following skin issues related to: potential breakdown due to Alzheimer's, muscle weakness, incontinence . Created 7/22/16. Residents skin will remain intact without signs of breakdown by next review . Revision 10/23/17. There were no new interventions updated to Resident #702's care plan. On 11/7/17, at 3:00 PM, Resident #702 was observed resting in bed on their back with bilateral heel pads on. On 11/8/17, at 12:05 PM, Nurse A was interviewed regarding Resident #702's new skin breakdown and Nurse A stated, I rounded with the doctor this Monday, that's when it was brought to our attention. Nurse A was further queried to what interventions the facility has put into place for Resident #702's new skin breakdown and Nurse A stated, heel pads. On 11/8/17, at 12:20 PM, a review of Resident #702's medical record revealed the following nursing admission assessment . bruising to BUE (bilateral upper extremities) . dated 10/9/17, signed by Nurse P, skin-head to toe skin checks . intact skin . dated 11/2/17, signed by Nurse A; Skin-head to toe skin checks . new other issue . right heel, blackened heel, left heel large water blister noted . dated 11/5/17, signed by Nurse K. On 11/8/17, at 1:15 PM, during a wound observation on Resident #702's heels, Nurse A was queried if the wound was a result from pressure and Nurse A stated Yes it is. Oh it didn't look like this Monday it was a fluid filled blister. Nurse A was asked to measure Resident #702's black right heel pressure ulcer. Nurse A measured Resident #702's right heel to reveal 3.5 centimeters wide by 3 centimeters long. This area was dark purple/black in color. Resident #702 was on their back in bed during wound treatment. Nurse A failed to measure left heel wound which was black in color also. Nurse A was queried as to how often the facility measures pressure ulcers and Nurse A stated weekly. There were no wound measurements available in Resident #702's medical record. On 11/8/17, at 1:45 PM, The Director of Nursing (DON) was queried regarding Resident #702's new pressure ulcer. The DON stated I will have to talk to (Nurse A) about that. The DON offered nothing further on facility acquired pressure ulcers. On 11/8/17, at 2:30 PM, Nurse A was furthered interviewed on what stage Resident #702's pressure ulcers are and Nurse A stated, Unstageable and then Nurse A added I'm not that good at pressure ulcers, when asked if they were the result of deep tissue injury from on going pressure. On 11/8/17, at 3:00 PM, a review of facility's policy, titled, Skin Management, dated July 2017 revealed the following; Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infections, and prevent new ulcers from developing . A pressure ulcer is defined as any [MEDICAL CONDITION] caused by unrelieved pressure resulting in damage of underling tissue. Pressure ulcers are usually over bony prominence's and are staged to determine the degree of tissue damage observed . Suspected Deep Tissue Injury . Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister .

Based on observation, interview, and record review, the facility failed to ensure appropriate care and management of an indwelling suprapubic catheter (catheter inserted into the bladder by means of a surgically placed incision in the abdomen) for 1 ( # 710) of 1 sampled residents reviewed for catheter care, from a total sample of 24 Residents, resulting in pain and discomfort, lack of catheter assessment, documentation, and replacement, and the potential for urinary tract infections and decline in overall health status. Findings include: During the initial tour of the facility on 11/6/17 beginning at 8:45 AM, Resident #710 was observed in their room in the facility lying in bed. Urinary catheter drainage bag was observed hanging on the side of the Resident's bed. Large amounts of sediment and a white colored substance were observed in the catheter tubing. When queried regarding the catheter, Resident #710 stated, I have been here almost two months and they (facility) staff haven't even changed it. I took better care of it at home by myself. With further inquiry, Resident #710 stated, It's a suprapubic catheter. When queried regarding the catheter insertion site, Resident's #710 stated, It hurts. I'm sure I got an infection. I know, I've had them. When asked if they had spoken to facility nursing staff regarding their catheter, Resident #710 replied, Yeah, I have but that don't make a damn bit of difference. They don't give a[***] Record review on 11/6/17 at 11:45 AM revealed Resident #710 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, required extensive assistance to perform Activities of Daily Living (ADL's), and had both a [MEDICAL CONDITION] (surgical procedure in which an opening or stoma is created to allow stool to exit the body) and a suprapubic catheter. On 11/7/17 at 8:45 AM, Resident #710 was observed lying in their bed, positioned on their back. The Resident's suprapubic catheter tubing had cloudy, dark off white colored drainage with large amounts of sediment. The Resident's catheter tubing was not secured with a device to prevent pulling. When queried, Resident #710 stated, It (catheter) has been bothering me. It hurts. On 11/7/17 at 12:00 PM, record review of Resident #710's medical record revealed no documentation that the catheter had been changed while at the facility. Review of Physician orders did not reveal an order for [REDACTED]. Review of the Resident's care plans revealed a care plan entitled, I, (Resident #710), has (Indwelling Suprapubic) Catheter r/t (related to) [MEDICAL CONDITION] bladder (Initiated: 10/10/17). Care plan interventions included: -Anchor catheter to prevent excess tension (Initiated: 10/10/17) -Observe/document for pain/discomfort due to catheter (Initiated: 10/10/17) -Observe/record/report to MD for s/sx (signs/symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns (Initiated: 10/10/17) On 11/8/17 at 8:45 AM, observation occurred of Resident #710's catheter. The catheter tubing had cloudy, dark off-white colored drainage with large amounts of sediment. The Resident's catheter tubing was not secured with a device to prevent pulling. When queried, Resident #710 stated, It (catheter) ain' t right. Record review on 11/8/17 at 9:45 AM of Resident #710 paper and electronic medical records revealed no documentation of laboratory testing, including urine testing, completion and/or results while at the facility. On 11/8/17 at 11:10 AM, observation of Resident #710's catheter and an interview was conducted with Nurse O. The catheter tubing was observed to have a large amount of sediment. The catheter was draining a cloudy, dark off-white colored urine. The Resident's catheter tubing was not secured with a device to prevent pulling. When queried regarding the catheter, Nurse O stated, I think (Resident #710) has a history of UTI's. Nurse O then stated, (The Resident) was on an antibiotic when they were admitted . It might have been for a UTI. When asked about facility policy/procedures for suprapubic catheters, Nurse O replied, Cleaned every day. On 11/8/17 at 12:00 PM, an interview was completed with the Director of Nursing (DON). When queried regarding the policy/procedure for suprapubic catheter management, the DON stated, They are changed monthly or per Physician order. When queried regarding Resident #710's catheter, the DON reviewed the Resident's medical record. After reviewing the medical record, the DON stated, There is no order and no documentation that it has been changed. It was missed. When queried regarding the Resident stating they have told nursing staff about the catheter, the Resident verbalizing concerns related to infection and complaints of pain, the DON was unable to provide an explanation. A policy pertaining to suprapubic catheter care and maintenance was requested but not received by the conclusion of the survey.

Based on observation, interview and record review, the facility failed to implement a planned Restorative Nursing Program for 1 (#712) of 4 sampled residents reviewed for Restorative Nursing, from a total sample of 24, resulting in experiencing a functional decline, lack of monitoring and documentation of Resident contractures, decreased independence, and Resident feelings of sadness and frustration. Findings include: Record review on 11/6/17 at 12:30 PM revealed Resident #712 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive assistance to perform Activities of Daily Living (ADL's). The MDS further indicated the Resident had no impairment in their upper extremity Range of Motion (ROM). On 11/6/17 at 2:15 PM, Resident #712 was lying bed in their room. Both of the Resident's hands were observed to be contracted. Resident #712's left wrist and hand appeared to be at a 70 to 80 degree angle with their fingers pointed inward toward the palm of their hand. The Resident's right wrist was observed to be at a 60-70 degree angle with their fingers positioned inward towards the palm of their hand. An interview was completed with Resident #712 at this time. When queried, Resident #712 stated My right used to be the worse one, now it is the left. With further inquiry regarding the contractures, Resident #712 stated, They (hands) have gotten worse since I have been here. Resident #712 then stated, Would you please give me a drink, I have a hard time grabbing the cup. The Resident then demonstrated how they were unable to grab the Styrofoam cup sitting on their over-bed table. Observation revealed Resident #712 was unable to grab the cup due to the contractures in their hands and the inability to move their fingers far enough apart to effectively grasp the cup. With additional inquiry, Resident #712 stated, I move my bed so I can get to it. Resident #712 proceeded to demonstrate raising the head of their bed and moving their whole body in order to reach the straw of the cup with their mouth. The Resident then stated, It isn't easy. When queried regarding ROM exercises for their hands, Resident #712 indicated Therapy staff had provided a small rectangular block of foam for the Resident to squeeze with their hands. When queried, Resident #712 stated, That's all they gave me but that was a while ago and I can't really even grab it anyway. With further inquiry, Resident #712 stated, It's depressing just laying here but I can't even do any activities because of that chair (Resident #712 indicated the wheelchair in their room). I have to depend on somebody to bring me back, I can't even wheel myself now. Review of Resident #712's active care plans on 11/6/17 at 4:00 PM did not reveal a current or resolved care plan pertaining to Restorative nursing, ROM exercises, and/or interventions pertaining to the Resident's contractures. No documentation of ROM exercises was located within the Resident's medical record. On 11/8/17 at 2:00 PM, an interview was completed with Physical Therapist L. When queried regarding Resident #712, Physical Therapist L. When queried regarding Resident #712, Physical Therapist L indicated the Resident was being treated by Occupational Therapy but further revealed the Occupational Therapist was not currently at the facility nor available for interview. When queried regarding Resident #712's hands, Physical Therapist L replied, I believe (the Resident) has contractures. I think we are going to get a brace. Therapy documentation for Resident #712 was reviewed with Physical Therapist L at this time. Review revealed the Resident was discharged from skilled occupational therapy services on 10/13/17 and readmitted on [DATE] due to functional decline. Review of Occupational Therapy notes for Resident #712 with Physical Therapist L at this time revealed the following documentation. 10/13/17: Occupational Therapy: OT Discharge Summary, authored by Occupational Therapist R: -Discharge Recommendations: discontinue OT services to continued nursing care with referral to restorative UE (Upper Extremity) ROM (Range of Motion) program. -Restorative Programs: Restorative Program Established / Trained = Restorative Range of Motion Program . AAROM (Active Assistive Range of Motion) at (Bilateral shoulders) two sets of 10 reps (repetitions) each. AAROM at bilateral elbows and wrists with 1 lb. (pound) weight, two sets of 10 reps each. AAROM bilat (bilateral) hands as tolerated, two sets of 10 reps each. Left hand contracted at 3rd - 5th digits, and bilateral hands deformed with arthritis. 11/14/17: Occupational Therapy: OT (Occupational Therapy) Evaluation & Plan of Treatment, authored by Occupational Therapist Q: -Short-Term Goals #2.0: Patient will improve bilateral hand functions to Fair . to improve patients ability to perform self-feedings talks with SBA (Stand By Assist) with use of AE (Assistive Equipment) as appropriate . -Additional Abilities/Impairments/Needs . UE (Upper Extremities) Tone: UE Muscle Tone = Other (Tightness in bilateral hands, especially in left hand noted) . Fine Motor: Fine Motor Coordination = Impaired. -Current Referral . Referred to skilled OT services . d/t (due to) increased tightness in BUE's (Bilat Upper Extremities) . decrease in functional mobility, decrease in Range of Motion (ROM), decrease in strength, decreased coordination . increased need for assistance from others, pain, . and reduced ADL participation . Prior Level of Function (PLOF): During previous d/c (discharge) from skilled OT services on 10/13/17, patient required SBA with self-feeding, min assist with hygiene/grooming tasks, toileting with max assist, UB (Upper Body) bathing with max assist and LB bathing with TD (Total Dependence). -Musculoskeletal System Assessment . Contracture: Functional Limitations Present d/t (due to) Contracture = Yes . Clinical Impressions: Patient . referred to skilled OT d/t bilateral hand contractures . -Assessment Summary: Clinical Impressions: . Referred to skilled OT d/t bilateral hand contractures . Patient presents with decreased ROM in BUE's, decreased strength in BUE's, . decreased ability to complete ADL's and ADL transfers, and pain in bilateral hands . Patient currently with a decrease in functional status from baseline . When queried regarding documentation of Restorative Nursing services as recommended following Resident #712's discharge from Therapy on 10/13/17, Physical Therapist L replied, Restorative Nurse Y would have that (documentation). Physical Therapist L proceeded to contact Restorative Nurse Y at this time to Request Restorative Nursing documentation for Resident #712. On 11/8/17 at 3:40 PM, an interview was conducted with Restorative Nurse Y. When queried regarding Restorative therapy for Resident #712, Restorative Nurse Y stated, We never got a referral for therapy for (Resident #712). With further inquiry, Restorative Nurse Y stated, The ball got dropped. It was never done. (The Resident) did not get Restorative. On 11/8/17 at 3:45 PM, an interview was completed with Physical Therapist L. When queried, Physical Therapist L stated, I found the referral form. It was not followed up on. Physical Therapist L then stated, It (referral form) was in the Therapists binder. The form entitled, Rehab to Restorative Transition Record for Resident #712 was reviewed at this time. The Rehab to Restorative Transition Record indicated: -Goals of intervention: To maintain ROM in BUE. -Activities to be performed with Resident: ROM Program- AAROM at Bilateral shoulders two sets, 10 reps each. AAROM bilateral elbows and wrists with 1 lb. (pound) weight, two sets, 10 reps each. AAROM at bilat hands as tolerated, two sets of 10 reps each. -Problems/Precautions: Left hand contracted at 3rd - 5th digits, and bilateral hands deformed with arthritis. The Rehab to Restorative Transition Record for Resident #712 was not dated or signed by the Therapist. When asked why the Rehab to Restorative Transition Record was not completed and why care coordination did not occur, Physical Therapist L replied, That Therapist (Occupational Therapist R) is no longer employed here. No further explanation was provided. When queried regarding facility documentation that indicated Resident #712 had a decline in function from the time of discharge from therapy on 10/13/17 to resumption of therapy on 11/4/17 and when the Resident had not received Restorative Nursing as planned, Physical Therapist L stated, It was not long before (Resident #712) started back on therapy. When queried if Restorative Nursing services would have prevented the Resident's functional decline, Physical Therapist L did not provide a response. On 11/8/17 at 4:30 PM, an interview was completed with the facility Administrator. When queried regarding Restorative Nursing not being implemented as planned for Resident #712 and documentation of the Resident's decline in function, the Administrator stated, I am not going to argue. It was missed. Review of facility provided documentation entitled, Module One: Restorative Care Program Overview (no date) on 11/8/17 at 6:30 PM, revealed, It is the Facility's philosophy that all Residents receive care and services that help them to adapt and adjust to living as independently as possible . Restorative Care are Nursing Interventions that assist or promote the Resident's ability to gain or maintain functionality . have measurable goals and objectives, are evaluated regularly . The documentation further indicated Restorative Care services are provided to maintain, improve or prevent decline in the Resident's ability to function and to perform self-care activities as independently as possible .

This citation pertains to Intake # Based on observation, interview and record review, the facility failed to prevent an elopement from a doctor's office for a scheduled appointment for one (# 901) of five residents reviewed for the risk of elopement, from a total sample of five residents, resulting in an Immediate Jeopardy (IJ) when the resident was not accompanied by a facility staff member to the 10/24/16 scheduled appointment and the resident left at the doctor's office on 10/24/16 and was found the morning of 10/25/16 at the bus stop by a family member, cold and hungry. Findings include: This deficient practice had the potential to result in serious harm and/or injury and required immediate corrective actions. The Administrator was notified of the IJ on 10/27/16 at 4:18 PM. A plan of correction to remove the immediacy was requested. The IJ was removed on 10/27/16 based on the facility's implementation of the plan removal as verified onsite by the survey team on 10/28/16. Although the IJ was removed, the facility's deficient practice was not corrected and remains at isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 10/27/16 at 10:45 AM Resident #901 was observed dressed and lying in bed. The resident was interviewed regarding the physician's office visit on 10/24/16 where left the physician's office. Resident #901 was confused and could not remember leaving the facility or that he had visited the physician's office. Resident #901 stated: I was round and about Mt Clemens. When asked if he was transported by the facility's van to a doctor's appointment, Resident #901 shook his head to indicate no and repeated that he had been round and about in Mt Clemens. Resident #901 did not answer when asked where he had been in Mt Clemens. On 10/27/16 at 11:00 AM record review revealed that Resident #901 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13 out of 15 which indicated cognitively intact. The MDS further indicated Resident #901 required supervision and limited assistance of staff for all Activity Of Daily Living. On 10/27/16 at 11:15 AM, review of the Care Conference Note dated 10/7/16 documented: IDT (interdisciplinary) team met with resident and resident does not remember what sent him to the hospital. Nor does he know why he is here. A review of Physician's 'B' progress note dated 10/10/16 documented for History of Present Illness: PMH (past medical history) of alcohol abuse who was found by family members at home with increased confusion; was taken to ED (emergency department) where MRI of brain done on 10-1-16 showed acute hemorrhagic stroke. General : Alert and oriented times 1. Neurologic: Alert and oriented to self only. A review of Resident #901's Safety and Falls care plan dated 10/6/16 , documented: Has potential safety and/or fall risk related to decreased safety awareness. Interventions: 1. Initiate safety checks as indicated. 2. Observe for exit seeking behaviors and provide diversion activities. On 10/27/16 at 11:30 AM, the Director of Nursing (DON) was interviewed regarding the appointment for resident #901. The DON indicated that Resident (#901) had a Nephrologist appointment on 10/24/16 at 11:30 AM and he (referring to the resident) was transported there by van. He was not accompanied by another staff. He signed into the physician's office and left. He has a BIMS score of 13 and is his own responsible party. When transport went to pick him up, he was not there (referring to physician's office). I was informed by the resident's aunt, that he was with his brother. The DON was queried regarding Resident #901 not being accompanied to the physician's office with a staff member and that he had been assessed to be alert and orientated to self only. The DON indicated that the facility's physician determines if the resident is able to continue with planned appointments. On 10/27/16 at 12:30 PM. Social Worker 'A' was interviewed regarding the 10/24/16 doctor's appointment for resident # 901. Social Worker A stated, I got a report from my unit manager that the resident was nowhere to be found. I immediately called the doctor's office to see if he was still there and the girl at the office said no he is not here. I was told by the DON on 10/25/16, that his family had found him and his brother had him. On 10/27/16 at 2:50 PM, a telephone interview was conducted with the brother of resident #901. Resident #901's brother indicated that Resident #901's daughter thought that she had seen him on the street. I told her that he (referring to Resident #901) was supposed to be in the facility. Resident #901's brother stated: I was taking my grandson to school the morning of 10/25/16 and something told me to ride down the street at about 9 mile road or 10 mile road. He (referring to Resident #901) was at a bus stop where I picked him up. I brought him to my house. He was cold. I got him a jacket and warm clothes. I fed him some sandwiches. He was so cold that he could not talk. He was out there all night. He was supposed to be at the facility. On 10/27/16 at 3:20 PM, Physician 'B' was interviewed per telephone and was asked about the documented assessment dated [DATE] of Resident #901's mental status as alert and orientated to self only. Physician 'B' stated: If a resident is alert and oriented to self only, they cannot make their own decisions and should be accompanied to appointments. If he is confused and has a doctor's appointment, he will be accompanied by staff that will stay with him the whole time. The administrator was not in the facility at the time of interviews. On 10/27/16 at 3:45 PM, review of the facility's policy titled, Resident Transport revised in July 2014 indicated, A facility employee in addition to the driver should accompany the resident to and from the appointment unless the following conditions exist: 1. An assessment of the resident has been conducted and the resident is found to be capable of managing the appointment on his or her own; or 2. A family member/friend of the resident will accompany the resident. The facility submitted the following plan to remove the IJ: Element #1: Resident #901 remains in the facility and has been assessed by attending physician and a licensed nurse and no adverse outcomes have been identified based on the physical assessment. Upon return to the facility, care conference was held with resident, residents' brother, and social work, which included cognition status and general appearance. The resident ' s Doctor has been notified and has ordered a new Elopement Assessment to be completed and a Brief Interview for Mental Status (BIMS) tool to be completed by the facility. The facility has completed the assessment tools. Element #2: The facility has conducted Elopement Risk Assessments on all residents in the facility to identify if any other residents have the potential to be affected by the same alleged deficient practice. No additional residents have been identified that were not previously identified by the facility. Previously identified residents who were considered elopement risks have had their care plans reviewed and have been deemed appropriate. The facility has conducted a Brief Interview of Mental Status (BIMS) assessment tool for all residents that have scheduled appointments outside of the facility through the end of the month. Residents who are determined to need assistance during trips to outside providers will be accompanied by a staff member or family member. Element #3: The facility has put measures into place to ensure that the deficient practice does not recur. Residents that require an appointment that is to occur outside of the facility will have Elopement Risk Assessments and BIM assessment tools completed in accordance with the facility policy. The facility will notify each resident ' s attending physician of the results of each assessment, and a physician's order [REDACTED]. The physician's order [REDACTED]. Each resident is to be re-assessed with [REDACTED]. The licensed nursing staff and facility scheduler will be educated regarding these measures, as well as the facility Elopement Assessment Tool and the facility policies and procedures for identifying and reporting any changes of condition. Education for licensed nursing staff in the building began immediately and all additional nursing staff are being educated prior to the start of their shift. Element #4: The facility has conducted an Ad Hoc QAPI committee meeting on 10/27/2016 at 5 P.M. to include the facility Medical Director to determine how to monitor its corrective actions to ensure that the alleged deficient practice has been corrected and will not recur. Nursing Management will audit all residents scheduled to have outside appointments weekly, to ensure that assessments have been completed and a physician's order [REDACTED]. Results of the audits will be forwarded to the facility Administrator for review and then forwarded to the monthly facility Quality Assessment Performance Improvement Committee for discussion during the monthly meeting. The administrator is responsible for sustained compliance. This Plan of Correction has been completed on 10/27/16 and the facility is requesting that the findings of immediate jeopardy be removed. ( , , )

This citation has two deficient practices. Deficient Practice Practice #1; Based on observation, interview and record review, the facility failed to ensure smoking implements including cigarette lighters were secured in a safe manner based on the resident's assessed abilities resulting in an Immediate Jeopardy ( IJ) for five (#'s 703, 713, 721, 725 and 726) sampled residents and three (#'s 17, 27 and 64) supplemental sampled residents of 18 residents who smoke having a potential to affect all 119 residents in the facility for serious harm, injury or death, including but not limited to resident burns and fire, related to lack of supervision and monitoring of residents who possess cigarette lighters. The Immediate Jeopardy was identified on 9/29/16 at 9:30 am. The Administrator was notified of the IJ on 9/29/16 at 12:35 PM and was informed to submit a plan of correction to remove the immediacy. The IJ was removed on 9/29/16 based on the providers implementation of corrective actions as verified onsite during the completion of the extended survey. Although the IJ was removed, the facility remained at no actual harm with potential for more than minimal harm that is not immediate jeopardy at a pattern. On 9/27/16 at 2:15 p.m., record review revealed that Resident #703 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #703 needed extensive assist with transfers, dressing, bed mobility, hygiene and toileting needs. Resident #703 had intact cognition with no impairments. Observations on 9/28/16 at 8:50 a.m., revealed that resident #703 was anxiously shuffling thru items in her purse. Resident #703's hands and arms were shaking and had spastic, involuntary movements. Resident #703 stated, My roommate decided to keep me up all night so I am going outside to have a smoke. On 9/28/16 at 3:30 p.m., review of the Safe Smoking Evaluation dated 5/4/16 revealed that Resident #703 was to wear a smoking apron while smoking, considered to be safe, but needing frequent supervision (with smoking). On 9/28/16 at 3:40 p.m., review of the Current Smokers Updated 09/22/2016 list provided by the facility revealed that Resident #703 was supervised during smoking. On 9/28/16 at 4:00 p.m., Resident #703 was observed awake, dressed in bed. Resident #703 stated, I always keep my cigarettes in my zipper pouch. Resident #703 pointed to her black zipper waist pouch lying on her wheelchair. Resident #703 pointed to a clear, empty plastic box on her bedside table and stated, I am not going to use that box, I can't fit it in my pouch. On 9/28/16 at 8:25 a.m., Resident #703 was observed awake, dressed in bed eating breakfast. Resident #703 was interviewed about where she keeps her cigarette lighter. Resident #703 stated, I still keep it in my black zipper pouch. Resident #703 grabbed her pouch off of her wheelchair. While grabbing it, Resident #703's hands were tremoring uncontrollably causing difficulty opening her bag. After a few minutes, Resident #703 was able to open her bag and remove a black lighter from her pouch. Once she had a hold of the lighter, it flung out of her hands (due to her spastic hand tremors) and landed on to the floor next to her bed. Resident #703 stated, That is my lighter. Resident #721 On 9/28/16 at 2:55 p.m., record review revealed that Resident #721 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed that Resident #721 had an intact cognition with no impairments. On 9/28/16 at 4:15 p.m., Resident #721 was observed dressed in her wheelchair sitting outside and stated, I keep my lighter in this little zip up change purse all the time; I do not lock it up in my room. On 9/28/16 at 4:30 p.m., review of Resident #721's care plan revealed that a Smoker care plan was initiated on 1/29/16. The goal states, .will not suffer from unsafe smoking practices through the review date. The interventions state, The resident's smoking supplies are stored with person in room in locked boxes. Resident #726 On 9/29/16 at 11:00 a.m., record review revealed that resident # 726 was admitted into the facility on [DATE] with the [DIAGNOSES REDACTED]. On 9/29/16 at 11:15 a.m., review of the MDS assessment dated [DATE] revealed that Resident #726 needed extensive assist with transfers, hygiene, bathing, toileting, bed mobility and had an intact cognition with no impairments. On 9/28/16 at 4:45 p.m., Resident #726 was observed sitting in her wheelchair on the back patio smoking. Resident #726 stated, I keep my lighter and cigarettes here (pointing to her tote); I'm not going to use a little plastic box (provided by facility to hold cigarettes and lighters)! Resident # 27 On 9/28/16 at 4:15 p.m., Resident #27 was queried while outside in regards to where he stored his cigarettes and lighter. Resident #27 stated, I keep mine in my wheelchair pouch, I don't use the plastic box they gave me. Resident #17 On 9/29/16 at 11:00 a.m., Resident #17 was queried at bedside in regards to where he keeps his cigarettes and lighter. Resident #17 pointed to his pack of cigarettes and opened up the pack to reveal a lighter. Resident stated that he did not use a lock box to store his lighter or cigarettes. On 9/29/16 at 1:00 p.m., the Administrator was interviewed in regards to residents' who smoke and the storing of their supplies. The Administrator stated, Where exactly do they carry their lighters; I don't see any harm here? On 9/29/16 at 9:00 a.m., a record review of the policy titled, Safe Smoking Policy June 2015 revealed the following: Purpose-To help ensure the safety of all residents, staff and visitors at facilities which permit smoking. Safe Smoking Determination-Interview the resident to determine their ability to verbalize and understand the smoking rules;and Observed the resident's ability to smoke in a safe manner. Procedure-6. Staff members maintain all smoking materials for unsafe smokers .Staff members distribute smoking materials to residents at smoking times. Safe smokers with lock boxes in their rooms may maintain their own smoking materials. ( ) According to the electronic medical record (emr) that was reviewed on 9-29-2016 at 1:00 p.m., Resident #713 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] reflected Resident #713 had a brief interview mental status of 15 indicating no cognitive impairment. The Safe Smoking Evaluation dated 7-19-2016 reflected Resident #713 was a safe smoker and required no supervision from staff while smoking. On 9-29-2016 at 11:10 a.m., Resident #713 was interviewed in her room and reported that she smoked cigarettes several times a day. When queried where her smoking material was kept she removed an empty pencil box from her nightstand drawer and reported, They gave me this 2 or 3 days ago. Resident #713 then opened her purse and removed a blue lighter and package of cigarettes stating I keep that stuff in my purse. When queried if she ever used the container that was provided by the facility she reported no and reiterated that they gave it to her 2 or 3 days ago. On 9-29-2016 at 2:00 p.m., Resident #713's undated smoking care plan was reviewed and revealed, the resident smoking supplies are stored with resident inside a locked box. On 9-29-2016 at 11:00 a.m., Resident #64 was interviewed at bedside. Queried regarding smoking materials. Resident #64 stated he does not use the facility to store his smoking materials. Then he pointed to his pouch that was connected to his wheelchair and stated, I keep them here. ( ) Resident #725; On 9/29/16 at 1:00 p.m., a record review of the face sheet for Resident #725 revealed that she was admitted on [DATE] with the following Diagnoses: [REDACTED]. On 9/29/16 at 1:30 p.m., a record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #725 required extensive assist with transfers, dressing, bed mobility, hygiene and toileting needs. Resident #725 had intact cognition with no impairments. The document titled Safe Smoking Evaluation for Resident #725 dated 7/14/16 revealed that the resident was Safe Smoker. No supervision required. The Care Plan titled (Resident #725's name) is a smoker dated 7/14/16 had an intervention of The resident's smoking supplies are stored with resident inside a lock box. On 9/29/16 at 2:05 p.m., observed resident #725 dressed, in the beauty shop up in her wheelchair. Resident #725 was asked where she secured her smoking items (lighter, cigarettes) and stated, I don't use that stupid box they gave me. I keep my smoking items right here (pointed to bag next to her in the wheelchair) in my string bag all the time. ( ) The facility's Plan of Correction to remove the Immediacy: Element #1 - On 9-29-16 Resident #s 703, 713, 721, 725, 726, 17, 27, and 64 have been re-assessed for smoking and the smoking policy has been reviewed with all residents identified. Specific to storage of smoking materials in provided lock boxes . Residents smoking materials will remain in lock boxes when residents are not smoking or are in route to or from smoking. All residents identified will be placed on supervised smoking schedule until 10-3-16 at which time they will be re-assessed for supervision needs. Element #2 On 9-29-16 all remaining smokers will be re-assessed for safe smoking and re-educated to the smoking policy. Any resident identified with supervisory needs will be placed on supervised smoking. Signed smoking policies have been obtained for all smokers. Smoking assessments have been completed for all residents that smoke with no concerns or negative outcomes noted. Element#3 - On 9-29-16 education with all staff regarding our safe smoking policy has been implemented and will continue until all staff have been educated prior to the start of their shift. Element#4 - The Administrator is responsible for compliance. On 9-29-16 The Administrator held AD HOC QAPI meeting with the IDT Team and Medical Director. The Administrator/Designee will conduct audits three times per week of 5 residents who smoke to monitor for compliance with storage of smoking materials. The Administrator will report findings to the QAPI committee for review and recommendation. ( / / ) Deficient Practice Statement 2; Based on observation, interview and record review the facility failed to properly secure 1 portable oxygen tank for 1 Resident (#709) of 4 Residents reviewed for oxygen use from a total sample of 26, resulting in the potential for injury. Findings include. According to the electronic medical record (emr) that was reviewed on 9-27-2016 at 1:00 p.m. Resident #709 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] reflected a brief interview mental status of 15, which indicated no cognitive impairment. A review of the signed monthly physician orders [REDACTED]. On 9-28-2016 at 9:20 a.m., during an interview that was conducted with Resident #709 in his room, he was observed to have his nasal cannula in place that provided oxygen from an oxygen concentrator. Two large boxes were observed behind the door of the room and were stacked on top of each other. On top of the second box a portable oxygen (O2) tank was observed propped against the wall at a 90 degree angle without a cylinder or stand to secure it. Resident #709 reported that the O2 tank was kept there and he used it only when he goes on a leave of absence from the facility. When queried when his last outing was he reported about a week or 10 days ago. On 9-28-2016 at 9:45 a.m., Licensed Practical Nurse (LPN) Unit Manager D was interviewed in Resident #709's room and observed the unsecured portable O2 tank. When LPN Unit Manager D was queried about the storage of portable O2 tanks she reported That definitely should not be stored there, I will take care of it now. According to the facility policy titled Oxygen Storage & Assembly with a release dated of April 2005, under the heading Oxygen Storage Page 4. 1. Place cylinder in stand or cart. ( )

Based on observation, interview and record review, the facility failed to investigate and conduct pertinent interviews with all direct nursing staff for injuries of unknown origin (tibia-leg bone and humerus-arm bone fractures) for one ( # 705) sampled resident of eight residents reviewed for injuries of unknown origin out of a total sample of 26, resulting in the potential for actual abuse and unknown cause (s) for injury/fracture. Findings Include: On 9/27/16 at 11:50 a.m., Resident #705 was observed sitting in a wheel chair with a sling noted supporting the residents right arm. On 9/27/16 at 11:59 a.m., record review revealed that Resident #705 was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Quartey Minimum Data Set assessment dated [DATE] indicated the resident's cognition was severely impaired and required supervised one person assistance with bed mobility and transfers. The clinical record revealed a (Resident name) language barriercare plan dated 9/22/16 indicating the resident was unable to speak English (Bosnian and Arabic were primary language spoken). Review of a nurses progress note dated 7/11/16 documented the Resident #705 had swelling of the right lower extremity and a venous doppler (test to check for blood clot) was ordered. On 7/12/16 the results of the venous doppler study was negative. Review of a radiology report dated 7/13/16 revealed an Acute comminuted (multiple bone splinters) impacted proximal (right) tibia fracture. On 9/27/16 at 1:35 p.m., review of the facility provided document titled Verification of Investigation revealed a Date of Finding: 7/13/16 with the coinciding investigation summary of Noted swelling to resident's right lower extremity on 7/11/16, physician and family notified and orders were obtained to have venous doppler. Doppler negative, physician and family notified, orders obtained to have x-rays taken . There was no documented evidence of the investigation dating back to 7/11/16 when the initial swelling of the right lower extremity was identified. The investigation revealed no direct nursing staff interviews. On 9/27/16 at 2:45 p.m., review of a hospital transfer sheet dated 8/14/16 documenting Post fall. Laceration to left forehead. Review of the hospital records revealed a radiology (x-ray) report dated 8/14/16 documenting, Right shoulder impression: There is a nondisplaced oblique fracture through the right proximal humeral metaphyses ([MEDICAL CONDITION] close to the shoulder area). The hospital discharge instructions dated 8/15/16 documented, Follow up on right arm fracture with Orthopedic Surgeon, until then, keep in sling and nonweightbearing bearing. Review of a second right humerus x-ray (obtained at the facility) dated 8/16/16 revealed, Conclusion: Intact right humerus. On 9/28/16 at 10:20 a.m., Resident #705's Orthopedic Physician was interviewed and asked about the fractures that Resident #705 had sustained in July and August 2016. The physician stated, It is difficult to determine the exact reason for the fractures because the resident is unable to communicate and can only speak in puffs (through the mouth) or gestures. I rely on the nursing staff to figure that out. The physician was asked about the discrepancy between the right humerus x-ray obtained at the hospital (revealing a humerus fracture) and the one obtained at the facility (revealing the humerus was intact) and said that the x-rays taken at the hospital were much more reliable. The physician went on the say his treatment of [REDACTED]. On 9/28/16 at 12:50 p.m., the facility's Director of Nursing (DON) was queried regarding the fractured right tibia for Resident #705 (determined on 7/13/16). The DON said that she did an investigation of the fracture on 7/13/16 and concluded her results on 7/14/16. The DON stated, The resident daughter came in and interpreted for us. The daughter stated 'the resident indicated she did not hurt her leg from falling, she hit it on the assist bars on her bed'. The DON was asked why her investigation did not date back to 7/11/16 when the swelling of the leg was first noted or why direct nursing staff interviews were not conducted to which she responded, Because we believed the fracture was from hitting her leg on the assist bars. At 1:15 p.m., the DON was queried regarding Resident #705's right humerus fracture. The DON said she did not investigate the fracture, conduct direct nursing staff interviews because, We thought the right humerus was intact. On 9/28/16 at 3:00 p.m. review of the facility's Abuse and Neglect Prohibition Policy dated June 2013 documented, The facility will conduct an investigation of any alleged mistreatment, abuse, neglect, injuries of unknown origin, or misappropriation of resident property in accordance with the facility's General Investigation policy .( )

This citation pertains to intake #MI 743 & MI 535 Based on interview and record review the facility failed to: 1.) assess, monitor and document the skin condition change in 2 (#501 and #502) of 3 sampled residents reviewed for impaired skin integrity, from a total sample of 4 residents and 2.) pursue immediate medical evaluation and treatment for [REDACTED].#502 developing a left heel ulcer while in the facility. Findings include: Resident #501 On [DATE], review of clinical records for Resident #501 revealed that the resident was a [AGE] year old female who was admitted into the facility on [DATE]. The resident had been transferred to the facility from another facility as a result of a fire evacuation. Resident #501 only resided in the facility from [DATE] until [DATE], when she was transferred to a different Long Term Care facility at the request of the residents Legal Guardian. Resident #501 was admitted into the facility with [DIAGNOSES REDACTED]. According to the Minimum Data Set Assessment, Resident #501 was totally dependent on staff for all activities of daily living including bed mobility, transfers, and hygiene. Review of the Nursing Admission assessment dated [DATE] revealed, "...multiple blisters on left hip, multiple open skin tears ..." (localized blisters in hip area) However the Resident Transfer Form dated [DATE] revealed, "blisters over entire body due to skin disease, multiple skin tears." On [DATE] at 3:30 p.m., an interview was conducted with Unit Manager #3 who explained that Resident #501 had an [DIAGNOSES REDACTED] disorder that caused skin blistering. The Unit manager was asked to describe the way that the resident skin appeared while she was in the facility and the Unit Manager stated, "she had blisters all over her body...I was scared about them transferring her and breaking the blisters." Unit Manager #3 explained that Resident #501's daughter telephoned the facility and "gave specific instructions on how to take care of her mother's skin care in order to prevent a severe breakout of the blister. I wasn't familiar with the skin condition. I had to look it up." The unit manager explained that the residents daughter did not visit the facility often because it was far from her home, and that was the reason she wanted the resident moved to a facility closer to her home. "I actually never saw her visit her mother." The unit manager was asked to show the surveyor the documentation of the telephone call with the instructions on how to care for the resident skin. The Unit manager was unable to find documented information reflecting the telephone call that was made by the resident's daughter that provided instructions to the nursing staff. The unit manager was queried as to whether the resident's daughter was informed when her mother's condition changed and she developed blisters all over her body. The unit manager said, "I assumed that she knew." I was unclear how the resident's daughter would have known if she didn't visit the facility to see it for herself. An interview was conducted with the Physician Assistant #4 on [DATE] at 4:00 p.m. who explained that when the resident was first admitted into the facility, "the blisters were on her hip and she had [MEDICAL CONDITION] on her lower extremities." Documentation of the PA #4's progress notes dated [DATE] confirmed that she noted that blisters were localized to one area of the resident's body. Record review revealed a care plan entitled "Non-pressure ulcer skin impairment" dated [DATE] which was a generic care plan with interventions that included: 1. Observe skin weekly and document findings as indicated, 2. Observe for safety needs with transfer, and 3. Wound care as ordered. There were no specific instructions for the staff on care and treatment of [REDACTED]. Review of nurses notes revealed: On [DATE] "resident resting at bedside no signs of pain or discomfort." On [DATE] ,[DATE]p.m., "resident A and O X 1. No signs or symptoms of distress noted ...Spoke with guardian regarding care of resident, all questions answered ... On [DATE] "Patient alert and non- verbal. On tube feeding ...well tolerate. Dressing change to left hip ... No signs of pain noted. On antibiotics ..." On [DATE] " Patient continues on antibiotics. Pulse 94, Respiration 19, Blood Pressure ,[DATE], SPO2 91%, Temperature 98.9. BP medication held ..." On [DATE] " Resident alert and oriented times one. Non-verbal, no signs or symptoms of distress..." On [DATE] 11:30 a.m., "Patient alert and non-verbal. No distress noted. Peg tube site intact and peg tube patent. No distress or shortness of breath noted ..." There was no documentation related to the resident's skin. There were no noted observations of the resident's skin condition, there were no assessments documented (except the initial admission assessment) of the skin nor was there documentation of care provided to the skin. Further review of the residents medical record did not reveal any head to toe skin sheets noted that assessed Resident #501's skin condition during showers. Review of a physician's order written by the treatment nurse on [DATE] revealed, "Cleanse blisters to left hip with wound cleanser, apply 4 x 4 soaked with boric acid for ten minutes. Pat dry and apply TAO [MEDICATION NAME] and ABD pad and tape (2 pieces) daily and PRN until healed." On [DATE] at 4:15 p.m. an interview was conducted with the facility wound treatment nurse who was unable to provide any written documentation on skin assessments or wound care documentation for Resident #501. The treatment nurse stated, "I provided treatment to the resident twice, but didn't do a skin assessment on her." The treatment nurse explained that she was behind on her documentation. The treatment nurse also explained that she did notice that the number of blisters on the resident's skin did increase over the time that Resident #501 resided there, but she did not notify the physician or the family of the change in condition. During an interview, on [DATE] at 10:00 a.m., the Medical director stated that Resident#501 had a [DIAGNOSES REDACTED]. The MD explained that he was not familiar with the resident before she was admitted and he could not tell if the blisters on the resident skin were a new flair up or if they were healing blisters. "I treated her with [MEDICATION NAME] and Bactrim DS." A telephone interview was conducted with Resident 501's legal guardian on [DATE] at 12:4 p.m. "I didn't have an opportunity to visit my mom at the facility much because I live far from that location but I did visit my mother at the facility on her birthday, [DATE] th and I noticed two blisters on her elbow. She did not have blisters all over her body on that day. I told the wound care nurse that I noticed the blisters and I told her that they needed to stay on top of that so that her condition doesn't worsen. I also spoke to the administrator. I was devastated to see my mother's condition when they transferred her to the other nursing home. She was covered in open blisters. Her skin was red and raw and my mom was in extreme pain. The facility sent my mom out to the hospital as soon as she got there. The (transferring) facility should not have transferred my mom to a nursing home; they should have sent her straight to the hospital. They dumped my mom in that nursing home without even telling them about her condition. The facility didn't even inform me of her change in condition." During an interview with the facility administrator on [DATE] who confirmed that he spoke with Resident 501's daughter about the blisters that she noted on her mother's elbow, and he then spoke to the treatment nurse about addressing the resident's skin. A telephone interview was conducted with the Director of Nursing at the facility Resident #501 was transferred to. "I was familiar with the skin disorder but I never saw a case that bad. It was so severe. Her blisters had ruptured. Her skin was reddened and raw across her stomach near her peg tube. The biggest area of blisters were in her hip area, but she was covered with blisters including her arms and legs, breasts and genitals. Her daughter had not seen her, nobody from the transferring facility called her to inform her (the Legal Guardian) of the change in condition. We sent her to the hospital immediately after she got here." Resident #502 Review of Medical records for Resident #502 on [DATE] at 3:00 p.m. revealed that the resident was a [AGE] year old female who was readmitted into the facility on [DATE] with multiple medical problems including [DIAGNOSES REDACTED]. According to the Minimum Data Set Assessment Resident #502 was cognitively intact for decision making. According to the clinical record, Resident #502 had frequent recent hospitalization s. Resident #502 did not reside in the facility at the time of the investigation. According to hospital records, Resident #502 expired on [DATE]. An interview was conducted with the facility treatment nurse on [DATE] at 4:20 p.m. and the treatment nurse was queried about wounds that the resident had while she was in the facility. The treatment nurse stated, "she had [MEDICAL CONDITION] on her lower extremities when she frist got in the facility, but that cleared up near the end of her stay." Wound treatment records were reviewed which noted that many of the wounds that the resident developed were first observed on admission. However, a left heel wound was noted to be observed on [DATE]. Wound treatment documentation revealed "[DATE] size 4.1 x 3.1 centimeters, initial evaluation blood filled blister observed to left heel. Treatment hydrogel ABD pad, keflex daily." the wound information was documented by the treatment nurse. Review of the Head to Toe Skin check documentation did not reveal any alteration on the residents heel on [DATE] and there was no additional skin assessment completed until [DATE]. The wound was noted on the assessment on [DATE]. Review of the facility policy and procedure entitled "Skin Management" dated February 2012 revealed "Skin assessments: weekly skin check will be transcribed onto the treatment record including the day and shift on which the check will be conducted. Completion of the weekly skin assessment will be noted on the Treatment Administration Record (TAR)...Skin assessment findings will be documented weekly on the Head to Toe Skin Check form. A change of Condition form is to be completed and new physician's order obtained for new alterations noted as needed." ( )