Every finding on record at Hartford Nursing & Rehabilitation Center

This citation pertains to intake 3051101.Based on interview and record review, the facility failed to ensure emergency Physician services were provided in a timely manner for one resident (R101) of three residents reviewed for a change of condition.Findings include:On 7/9/2026 at 8:46 AM, Family Member C was interviewed and said that R101 had a fall with head injury on 4/11/2026 at the facility and wasn't sent to hospital until 10 hours later once a doctor responded to the nurse's call.Record review of R101's Progress note dated 4/10/2026 at 23:57 revealed, Resident was observed sitting on the floor in her room and bleeding from the skin tear she sustained from falling at her left eyebrow. Resident stated that she was trying to get up to sit on the floor and she stated that she was trying to go to the bathroom. She was put back in bed and offered bedpan. Dry pressure dressing was applied to her left eyebrow and the bleeding stopped. She is alert and oriented X2, disoriented to situation with occassional periods of forgetfulness. Vital signs at time of fall was BP 182/91, temp 97.2f, pulse 88, resp 16, SpO2 93% room air, and pain 5. tylenol was given for pain, Blood pressure started trending down to 164/78, 132/69. Attening (sic) physician (Medical Doctor D) was notified via paging, daughter (Family Member C) was notified and she came to stay with her mum at 0100 am, and on call managr (manager) notified via voicemail. Neuro checks initiated, awaiting further orders. Resident was frequestly (sic) offered bedpan and reminded of using her call light for assistance. She is in bed and in no acute distress at this time. Will continue with plan of care.According to the [NAME] Scale (0-10), a pain level of 5 is indicative of moderate pain.Record review of R101's progress note dated 4/11/2026 revealed, Writer received report that resident expeirenced (sic) a fall overnight. The midnight nurse was unable to raeach (sic) the oncall physician, and follow up was endoresed (sic) to the day nurse. Following the fall, the resident was placed in the activity room for close monitoring. The resident family arrived and transported the resident back to her room, stating the resident does not like being in the activity room. Writer informed the family that the placement was for safety and observation following the fall. A second family member later approached the nurse station, appeearing (sic) upset and requesting information regarding the next steps in resident care. Writer explained that contact had been attempted with the in call physician, and that further actions would be determined once a response was received. The family then became increasingly agitated, expressing concern that someone should have been called earlier, and that the resident may have sustained a concussion. Writer reassured the family that the resident condition wa (sic) being monitored and that appropriate steps were being taken to ensure her care. On call finally reached out to writer, examined resident and ordered to send resident out to r/o concussion and possibly get stiches. Writer informed family of the doctor orders, and the ETA time for pick up. Writer continued to preovide (sic) care per care plan for pt until transportation showed up.On 7/9/2026 Licensed Practical Nurse (LPN) B was interviewed and said the on-call doctor did not respond to LPN A during the midnight shift. LPN B further said she assessed R101 around 7 AM and paged Medical Doctor D and received a response around 11:00 AM when the provider ordered the resident to the hospital. LPN B stated, Usually the on-call physician responds in around 20 minutes.On 7/9/2026 LPN A was interviewed and said she assessed R101 after the fall on 4/11/2026 at around 1:00 AM. LPN A said she notified Medical Doctor D but did not get a response. LPN A stated, The doctor is supposed to respond in 20-30 minutes to give us instructions. The doctor did not respond by shift change so I gave my report to the oncoming nurse.On 7/9/2026 at 2:00 PM, Medical Doctor D was telephoned for an interview. Ther was no response by survey exit.Review of R101's Electronic Health Record revealed she was admitted to the facility on [DATE] and sent to the hospital on 4/11/2026 with diagnoses that included Encounter for surgical aftercare following surgery on the circulatory system, Repeated Falls, and Ataxic gait.Review of R101's physician orders revealed, Clopidogrel Bisulfate Tablet 75 mg (blood thinner), Aspirin Oral Tablet Chewable 81 mg (blood thinner).Review of R101's transfer order dated 4/11/2026 at 11:38 AM revealed, Transfer to Emergency department.Review of R101's care plan revealed, (R101) is at risk for abnormal bleeding/bruising R/T (related to) medication use. Antiplatelet, post-surgical. Date initiated 3/28/2026. Interventions observe and report to physician PRN s/sx(sign symptoms) of complications lethargy, bruising, sudden changes in mental status. Date initiated 3/28/2026.On 7/9/2026 at 2:15 PM, the Director of Nursing (DON) was interviewed and said the expectation is for the on-call doctor to respond to the nurse within 20 minutes. If the on-call doctor does not respond, then the nurse should call the medical director. The DON said that at the time of R101's fall the attending doctor, and medical director was Medical Doctor D. The DON further said since Medical Doctor D was both the attending and facility medical director for R101 there were no other medical doctors for the nurses to notify. Review of the facility's policy titled, Physician Services revised 3/12/2025 revealed in part.All residents shall be provided with emergency and/or alternative physician care. 6. Emergency physician care is available to all residents. A. if the resident's attending physician is not available when an emergency occurs, the covering physician on call must be contacted. B. the facility maintains a listing of physicians, alternate physicians, and their phone numbers. Each attending physician will provide the facility with this contact information for his or her coverage group.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings Include:On 1/27/2026 at 9:59 AM, observation of the walk-in cooler found an increased accumulation of black spotted debris on the top surfaces of the hard plastic shelving used to store food product. When asked how often the storage shelves get cleaned, Dietary Manager (DM) F stated they get power washed, but it's been so cold we have not been able to take them outside.On 1/27/2026 at 10:19 AM, an interview with DM F found that the clean utensil bin is cleaned weekly. Observation inside of the bin found an assortment of clean utensils stored among food crumbs and debris. Upon wiping the inside of the bin, it was found to be greasy. DM F stated that they will get it cleaned. On 1/27/2026 at 10:21 AM, an interview with DM F found that the tabletop slicer is used once or so a week to slice meat. When asked what the plastic cover over the slicer meant to kitchen staff, DM F stated that it's to keep the unit clean between uses. Upon removing the plastic cover, observation of the slicer found accumulation of dried meat debris on the backside bottom and top portions of the blade. On 1/27/2026 at 10:30 AM, observation of the back corner of the kitchen found a stand-up floor mixer covered with a plastic bag. An interview with DM F found that they only have one cook who uses the mixer, and that it only gets used about once a month. Observation of the mixer found yellow and white debris caked on the surface of the under arm of the unit. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 1/27/2026 at 10:03 AM, observation of the three door Traulson cooler, in the serving room, found the ambient air thermometer in the back of the unit read 50F. An interview with DM F found that they don't usually keep a lot of products in the cooler. At this time, a container of Tuna Salad and a packet of cream cheese was taken and found to be 47.3F when measured with a rapid read thermometer. An interview with DM F found that she was going to toss the items in the unit. On 1/27/2026 at 11:10 AM, an observation of the C unit nourishment room found a refrigeration unit with an internal temperature of 50F.According to the 2022 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above. or (2) At 5C (41F) or less.On 1/27/2026 at 10:35 AM, observation of the high temperature dish machine data plate found that it requires 160F minimum temperature for the wash water and an initial rinse temperature of 180F from the manifold of the machine. A review of the Dish Machine Log found that staff only track the rinse temperature of the unit. Observation of the dish machine over the course of five loads of dishes found the wash gauge range between 148F-152F. An interview with DM F found that she was going to reach out to the vendor. On 1/28/2026 at 11:58 AM, observation of the high temperature dish machine, over three racks of dishes, found that the wash gauge was around 140F. According to the 2022 FDA Food Code section 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than.(3) For a single tank, conveyor, dual temperature machine, 71oC (160oF).On 1/27/2026 at 11:01 AM, observation of the A and B nourishment room refrigeration unit found the following items: a takeout container of chicken wings with no date to indicate discard, a leftover container of pizza with a receipt dated 1/21/26, and a yogurt container with a best by date of 1/22/26.On 1/28/2026 at 11:48 AM, observation of the walk-in cooler found two containers of whipped topping with a best by date of 1/21/26. Further review found an open package of sliced smoked ham with no date to indicate discard. On 1/28/2026 at 11:12 AM, observation of the Homebound nourishment room found the following items: a container of rice not dated, leftover sub not dated, peanut butter and jelly sandwich not dated. Further review of the unit found a nutritional supplement with manufacturer's directions that state the item is good for 14 days after thaw. An interview with DM F found that she was unaware when the items would have thawed. A record review of the facility provided document entitled Food From Outside Sources, revised 11/12/2021, found that All food brought in is to be checked by the Nurse, Dietary Manager, or Dietitian. It must be placed in a seal container and labeled for the content, the guest's/residents's name and date the food was received, and an expiration date of 3 days after the food was brought in. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) .On 1/27/2026 at 11:02 AM, observation of the A and B nourishment room found packed disposable cups stored underneath the wastewater line to the hand sink. On 1/27/2026 at 11:12 AM, observation of the Homebound nourishment room found a package of thickened juices stored underneath the wastewater line to the hand sink. According to the 2022 FDA Food Code section 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD:.(2) Where it is not exposed to splash, dust, or other contamination;.According to the 2022 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.On 1/27/2026 at 11:10AM, observation of the C unit nourishment room microwave found the unit with bubbled and peeling surfaces on the inside of the unit. Portions of the unit were found with brown and rusted surfaces. According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.On 1/28/2026 at 10:22 AM, observation of the Cardiac nourishment room found that the ice machine drain line was found directly connected to the wastewater line of the sink via a condensate pump. The current set up allows for the potential contamination of ice due to wastewater from the nourishment room sink. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed.On 1/28/2026 at 12:04 PM, observation of the walk-in cooler found two large zip lock bags, sealed, with ground turkey sausage dated for 1/28. When asked what the sausage was from, DM F stated that they must have saved it from breakfast this morning. When asked if there was a log or tracking for the cooling sausage, DM F stated they don't keep a cooling log. When asked what time the sausage would have started the cooling process, DM F was unsure, but agreed that the item would have started to cool prior to 10:00 AM. At this time, the temperature of the product was taken with a rapid read thermometer and found to be 74.5F. DM F stated she would discard the product. According to the 2022 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less.According to the 2022 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD.

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility.Findings include:On 1/27/26 at 10:25 AM observation of the kitchen serving room revealed a possible stagnant water line coming from the hand sink area down the wall near the steam tables. An interview with the Maintenance Director (MD) H found that he was unaware of the water line. An interview with the Dietary Manager G found she was unaware of what the water line was for and stated it was not something that kitchen staff use.On 1/27/26 at 1:11 PM observation of the Homebound unit soiled linen room revealed the hopper had brownish yellow water coming from the hot and cold-water fixtures on the over hopper faucet. Further observation found discolored water coming from the hopper sprayer.On 1/27/26 at 1:35 PM observation of the soiled linen room in unit C revealed a sink and hopper fixture with no water flow and possible stagnant water.On 1/27/26 at 1:57 PM observation of soiled utility room (near room [ROOM NUMBER]) revealed water level low in the hopper bowl, indicating infrequent use of the water fixture. When the hopper faucet was turned on the water flow was slow and discolored. The hopper spray was observed with brownish yellow water coming out.On 1/28/26 at 9:08 AM observation of the soiled utility room in the New Center unit found a hopper. An interview with housekeeping manager (HM) G found the hopper was not used. When asked if he had responsibilities for the Water Management Plan (WMP) he indicated he did not.On 1/28/26 at 9:20 AM observation of B unit janitor closet sink noted that the handle for the cold-water side was missing which indicates a possible stagnant water line. On 1/28/26 at 9:32 AM observation of B unit hallway found an inoperable water fountain with possible stagnant water.On 1/28/26 at 9:45 AM observation of B unit soiled utility room found debris in hopper bowl and an inoperable utility sink not allowing for lines to be flushed indicating possible stagnant water. An interview with Certified Nursing Aide (CNA) E indicated the hopper unit was not used by staff.On 1/28/26 at 9:58 AM observation of A unit hallway found an inoperable water fountain with possible stagnant water. On 1/28/26 at 10:11 AM, observation in Homebound unit A hallway found a water line with shut off valve extended through the wall. Interview with HM G found that the water line was for a drinking fountain that had been removed and this water line was shut off. When the valve was opened, the water was collected in a clear plastic cup and found to be milky and discolored.On 1/28/26 at 12:15 PM an interview with MD H indicated that he was in the process of creating a Water Management Program (WMP) binder with documentation that had existed electronically, but much had been lost. Further, he described the following processes related to the WMP:MD H showed the packet of test strips that he uses to monitor for free chlorine. He tests cold water at Point of Use ([NAME]) in resident rooms using WaterWorks(tm) 5-Way Water Check test strips. As the strips do not detect/indicate free chlorine in the 0-0.5 parts per million (ppm) range, the results he was able to detect were consistently 0.5 ppm (the minimum amount detectable by use of the color change test strip). The current testing method is insufficient for the stated control level they are monitoring for (minimum of 0.2 ppm).- MD H described a monthly water flushing procedure, indicating that flushing took place at various points of use including sinks, showers and storage tanks.On 1/28/26 at 2:00 PM An interview with Nursing Home Administrator (NHA) took place to follow up on WMP documentation. When asked for WMP documentation, NHA indicated that MD H would have that information.On 1/28/26 at 1:30 PM an observation of the basement vending/staff lounge area revealed a potentially stagnant water line extension off the line running to a small wall mounted hand sink. Interview with MD H found he was unaware of the water line. A record review of the facility-provided Water Management Program policy, last revised 2/1/24, stated that The facility will implement measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems with a water management program that is based on nationally accepted standards and will include: An assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread; and measures to prevent the growth of opportunistic waterborne pathogens, and how to monitor them. The assessment will include a description of the building water systems using text and flow diagrams for identification. No such assessment or water systems description with flow diagrams was provided upon request.The policy further states that an effective water management program include: preventing water stagnation. The Water Management Team Meeting Minutes dated 11/13/25 and 12/19/25 section 8 addresses Review and validate flush schedule completion and the box marked is other frequency, explain in minutes section. In 11/13/25 minutes section there is no reference of a flushing schedule. In 12/19/25 minutes section it is stated: sinks are flushed twice a month at low point. No detail is provided about which sinks, fixtures, or dead end piping are flushed.

Based on observation and interview the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting all residents.Findings include: On 1/27/26 starting at 1:17 PM, an environmental tour was conducted in the homebound unit with the following observations:The faucet in resident room [ROOM NUMBER] was observed with only a pencil thin stream of hot water when in use. The faucet was loose to mount and was able to be moved around. The shower room found eight razors stacked on the sink basin. Further observation revealed spots of black accumulation on underside of the shower bed mat, and a wet washcloth on the floor.An observation of the janitor closet revealed that a chemical pre-dispensing system was in place and that staff leave the faucet on when not in use. This set up puts undue back pressure on the faucets internal atmospheric vacuum breaker (AVB) of which will ruin the integrity of the mechanism.On 1/27/26 starting at 1:20 PM, an individual tour was conducted in the C unit and found the following observations:The tub room revealed a toilet loose to mount on the floor, and unattached to the floor caulk. The shower room found a brown smear on the underside of the shower bed mat as well as an accumulation of moisture and black spots on the shower bed plastic surface.On 1/28/26 starting at 8:24 AM, a tour of the laundry department was conducted with Housekeeping Manager (HM) G with the following observations:Clean sorting bins, used to transport clean linen from the washers to the dryers, revealed a layer of excess debris under the inside support floor (used to help bring linen near the top of the bin). Debris included packaged cookies, plastic wrappers, used gloves, a metal hanger, and dirty socks and gloves. Observations of the laundry bulk storage room revealed two of four lights inoperable and one light unshielded. Further observation found numerous tiles loose on the floor.On 1/28/26 starting at 9:00 AM, a tour of the New Center unit was conducted with HM G with the following observations:The nursing supply storage closet was found with a liquid nebulizer product stored in a box on the floor. Buildup of dust and debris was observed on the floor under and around the shelving unit. The clean utility closet revealed a buildup of dust, straws, and gloves on the floor under the storage unit. Observation of the spa revealed a brown smear on a shower chair. When asked, HM G stated it looked like a bowel movement and that Certified Nursing Aides (CNAs) are responsible for cleaning shared equipment in shower room. Further observation found lint balls and a loose screw near the drain of the shower. An observation of the janitor closet found the mop sink faucet left on leaving undue pressure on the faucet's internal AVB. The nourishment room revealed a package of napkins stored beneath the sink with visible brown and black wastewater on the packaging. The Campus Martius enrichment center revealed food crumbs beneath the chair cushion. Additionally, a green lounge chair was observed to have a red stain on the back edge of the cushion and backrest.On 1/28/26 starting at 9:28 AM, a tour of the Homebound B unit was conducted with HM G with the following observations:Observation of the janitor closet found the mop sink faucet left on leaving undue pressure on the faucets internal AVB. Shower room two revealed four broken and crumbled two by two-inch floor tiles at the entrance of the shower room. [NAME] smear marks were observed on the shower bed mat, along with dried white crumbs and pooled water in the crease of the mat. The exhaust air vent was visibly soiled with an accumulation of dust. Additional observations found an accumulation of dust and debris along the perimeter and corners of shower room. An observation of shower room one found the shower curtain hanging low and touching the floor, with black residue along the bottom portion of the curtain. Further observations found an accumulation of debris along the perimeter and corners of the shower room. The soiled utility room revealed a hand sink fixture with a crack in the back leaking heavily when turned on. The storage closet on unit B revealed an accumulation of debris on the floor including dust, dirt, razors, and used gloves.On 1/28/26 starting at 10:01 AM, a tour of Homebound A unit was conducted with HM G with the following observations:The janitors closet found a mop sink faucet left on with an AVB as the backflow prevention device under undue back pressure. The shower room found the soap dispenser leaking onto the floor creating a pool of soap. A chunk of donut with chocolate frosting was observed on the shower floor as well as a brown 1 inch smear on the floor. A cookie and wrapper was observed on the floor as well as a damp washcloth hanging on the handrail. The wastewater line that was previously used to drain the drinking fountain in unit A- Homebound was observed open and exposed with no cap. A thick black substance on the inside of the pipe was found.On 1/28/26 at 10:27 AM, an observation of the janitor closet on cardiac unit revealed the mop sink faucet left on leaving undue pressure on the faucets internal AVB.On 1/28/26 at 2:36 PM, an observation of resident room [ROOM NUMBER] revealed the hot water faucet releasing a trickle of hot water when turned on.

This citation pertains to intake 2720882.Based on observation, interview, and record review the facility failed to pass water in a timely manner to ensure adequate hydration for five residents (R94, R76, R18, R156, and R33) of seven residents reviewed for hydration, resulting in the potential for increased risk for dehydration.Findings include:During the initial screening process on 1/27/2026 between 10:00 a.m. and 2:00 p.m. multiple residents were observed with no water in their rooms or at bedside. These residents are as follows:R94.R94 was observed to be alert and was able to be interviewed. During an interview, R94 said there was no fresh water passed by the staff since about nine P.M. on the midnight shift. R94 pointed to a small, iced tea bottle and stated, I am glad I kept this tea bottle so I can get me some water out of the sink. I don't understand why they have not passed fresh water yet.According to the electronic medical record (EMR), R94 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and hypertension. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R94 was cognitive intact with a BIMS (brief interview for mental status) score of 14/15. Review of R94 Nutritional/Hydration care plan revised on 1/28/2026 had the following: (R94) has alteration in nutritional and/or hydration status related to dementia and hypertension.R76.R76 was observed alert, lying in bed with an empty white Styrofoam cup on the bedside table not in reach. During an interview, R76 said there was no cold water passed since midnight shift and would like to have a drink of cold water.According to the electronic medical record (EMR), R76 was admitted on [DATE] with diagnoses that included cerebral infarction, hypertension, and venous insufficiency. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R76 was cognitive intact with a BIMS (brief interview for mental status) score of 15/15. Review of R76 Nutritional/Hydration care plan revised on 1/18/2024 had the following: R76 has alteration in nutritional and/or hydration related to diagnoses CVA (Cerebral vascular accident), history of falls, pain, CAD (Carotid artery disease).R18R18 was observed in room alert and was able to be interviewed. During an interview R18 stated, No one brought in any fresh water at all today (1/27/2026) and I would like to have some cold water.According to the electronic medical record (EMR), R18 was admitted on [DATE] with diagnoses that included hypertension, severe protein-calorie malnutrition, dementia, anemia, type two diabetes mellitus, and cerebral infarction. According to the significant change Minimum Data Set (MDS) assessment dated [DATE] indicated R18 was severely cognitively impaired with a BIMS (brief interview for mental status) score of 03/15. Review of R18 Nutritional/Hydration care plan revised on 12/10/2025 had the following: (R18) has alteration in nutritional and/or hydration related to diagnoses UTI (urinary tract infection), dementia, and prostate cancer.R156R156 was observed resident lying in bed alert and oriented. During an interview, R156 stated, They (the staff) came in and picked up my water cup I believe at breakfast time and just have not brought anymore fresh water back yet.According to the electronic medical record (EMR), R156 was admitted on [DATE] with diagnoses that included congestive heart failure, chronic respiratory failure, diabetes mellitus type two, and chronic obstructive pulmonary disease. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R156 was cognitively intact with a BIMS (brief interview for mental status) score of 15/15. Review of R156 Nutritional/Hydration care plan revised on 11/29/2025 had the following: (R156) has alteration in nutritional and/or hydration status related to diagnoses H, pylori (a stomach bacteria), hypertension, and morbid obesity.R62On 1/27/2026 at 1:30 p.m. R62 was observed with no water cup in the room or at bedside. R62 did not want to be interviewed.According to the electronic medical record (EMR), R62 was admitted on [DATE] with diagnoses that included ETOH, Left femur fracture, hypertension, history of falls, Carotid artery disease, and chronic obstructive pulmonary disease. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R62 was cognitively intact with a BIMS (brief interview for mental status) score of 15/15. Review of R62 Nutritional/Hydration care plan revised on 1/22/2026 had the following: (R62) has alteration in nutritional and/or hydration status related to diagnoses of adjustment disorder, BPH and schizophrenia.On 1/27/2026 at approx. 2:00 p.m. the unit's daily assignment was requested and provided. Review of the daily assignment revealed Certified Nursing assistant (CNA) T was R62's R76's, and R18's assigned CNA for the dayshift (7:00 a.m. thru 3:00 p.m.).On 1/27/2026 at 3:00 p.m. CNA T was interviewed regarding providing water to the residents. CNA T acknowledged that water had not been passed but was going to pass water later. CNA T stated, the residents should have had water at the start of the shift at 7:00 a.m.On 1/27/2026 at 4:16 p.m. CNA U was the assigned CNA (was working an additional four hours) for residents R156, and R94. CNA U was asked was water passed for the shift. CNA U stated, I was really busy, but I am passing the resident's water now. The residents should have received fresh water before now.On 1/29/2026 at 2:23 p.m. the Director of Nursing (DON) was interviewed regarding the appropriate time staff should pass water to residents. The DON was asked should the staff pass water before 3:00 p.m. and 4:00 p.m. for the shift. The DON stated, Absolutely. The twelve-hours shift CNAs should pass water multiple times and the eight hours shift should pass fresh water before 3:00 p.m. and 5:00 p.m. usually by 10: 00 a.m. fresh water should be pass because midnight usually pass the resident fresh water before leaving their shift, but regardless fresh water should be pass before 3:00 p.m.According to the facility's 1/29/2026 Oral Hydration policy: It is the policy of this facility to assist residents to maintain adequate hydration whenever possible. Procedure: 5. Each resident will be provided bedside water.

This citation pertains to intakes 2656662 and 2661216Based on observation, interview, and record review, the facility failed to ensure meals were served at palatable temperatures in two of two records reviewed, resulting in decreased food consumption and potential nutritional decline.Findings Include:It was reported to the State Agency that food served to the residents was not at palatable temperatures.On 1/27/2025 at 11:57 AM, an interview with Dietary Manager F found that the facility has heated bases, but they are not in use for today's meal. Further observation found plates between 75F-85F with no visible plate warmer being utilized. When asked what she expects for hot food on the steam table, DM F stated that it should be at least 150F so that residents can get their food at 135F or higher.On 1/27/2025 at 12:09 PM, a regular test tray was plated and placed as one of the first meals on the C unit cart. On 1/27/2025 at 12:20 PM, the meal cart arrived on C unit with roughly 25 meal trays present. On 1/27/2025 at 12:37 PM, all trays were delivered, and the test tray was back in the conference room. The following temperatures were found using a rapid read thermometer: Pot pie 127.6F and mixed vegetables 104F.

Based on observation, interview, and record review the facility failed to give information for Advance Medical Directives (AMD, the written instruction relating to the provision of health care) to one (R2) of two residents or their representatives reviewed for code status, resulting in R2's code status being changed to a full code (all possible life saving measures will be provided if the person's heart stops or they stop breathing).Findings include: On [DATE] at 2:30 PM, R2 was observed up in recliner chair watching TV. R2 was unable to be interviewed due to cognition status. On [DATE] at 2:50 PM, during interview with R2's Representative (RR1) they said they were not being included in decision making for R2. RR1 said they were not R2's Legal Guardian (LG) at this time and was currently trying to obtain it through the court system. RR1 said they did not know R2's code status had been changed to a 'full code' by the facility. According to R2's Electronic Health Record (EHR) RR1 was identified as R2's emergency contact and representative. R2 had resided in the facility since [DATE] with multiple diagnoses that included vascular dementia. The Annual Report of Guardian on condition of Legally Incapacitated Individual indicated that R2 had a LG company assigned as their LG, and a Do-Not-Resuscitate Order had been executed. The Report indicated that Guardianship was in effect from [DATE] through [DATE]. R2's AMD form dated [DATE] indicated that R2 was a DNR Do-Not-Resuscitate - No Cardiopulmonary Resuscitation. The form was signed by the LG Company representative. A second AMD form dated [DATE] identified R2 as a full code and was not signed by a LG or resident representative. The form was signed by Social Worker (SWQ) and noted that R2 was unable to sign and had a diagnosis of dementia with confusion. A review of R2's progress notes and social service notes did not reveal any documentation to support R2's representative was provided information regarding formulating an AMD. On [DATE] at 11:24 AM, during an interview with SW Q they said that R2's LG paperwork had expired on [DATE] and there had been no information to determine who was R2's LG. There was no documentation to support that R2's representative was provided information on how to formulate advanced directives or that R2's code status was changed. SW Q stated, That Guardian company went out of business in 2024, and we haven't found another one to replace it. The family has not provided us with any LG paperwork, so the resident doesn't have a legal guardian now. By default, the resident goes back to a full code. SW Q could not explain why R2's representative was not provided information on R2's AMD. On [DATE] at 11:39 AM, the Nursing Home Administrator (NHA) said R2 hasn't had a LG since [DATE] and by default had to go back to a full code. The NHA could not provide any documentation to support that R2's representative had been given any information of the AMD. There was no documentation to support that the facility had petitioned for another LG for R2. According to the facility's Advance Directive-Michigan last revised on [DATE] in part read:A. Identify. On admission, the Facility will determine whether the Resident has executed advance directives (e.g., a DPOA-HC, or Living Will), and if not, whether the Resident would like to execute advance directives-The Facility will also determine whether there was a DNR Order signed in another setting (e.g., hospital, home) and whether the Resident would like a DNR Order issued while in the facility. A Code Status Form will be signed to reflect the decision regarding CPR/DNR under the guidance provided below.B. Obtain Documents. Copies of all advance directives will be obtained from the Resident and/or family and placed in the medical record. If applicable, a DNR Order will be signed and placed in the medical record G. Advise on Right to Establish Advance Directives. If the Resident has not executed an advance directive (i.e., a Living Will or DPOA-HC), the Resident and the Resident's family will be advised of the right to establish an advance directive and assistance will be offered regarding the same. If the initial facility cognitive evaluation (Nursing Comprehensive Evaluation and/or BIMS) indicates a level of cognition that questions the Resident's ability to participate in medical treatment decisions, the facility will initiate a capacity evaluation form as also stated above.

Based on interview and record review, the facility failed to transmit a Minimum Data Set (MDS) assessment for one (R173) of three residents reviewed for MDS assessment transmittal requirements.Findings include:During the MDS Assessment task R173 was identified to have a MDS assessment that was due over 120 days. On 1/28/26 a review of R173's Electronic Heath Record (EHR) revealed R173 discharged from the facility on 8/27/25. The MDS assessment for discharge status had not been transmitted to the CMS system at this time. On 1/28/2026 at 11:06 AM, during an interview with MDS coordinator (staff Q) R173's EHR was reviewed. Staff Q stated, We did not transmit the MDS yet. It's late. I will send it today. Staff Q said that the facility had undergone staff changes and some transmittals had been missed. On 1/29/26 at 2:10 PM the Nursing Home Administrator said the expectation is that MDS assessments will be sent timely in accordance with the federal regulations.

Based on observation, interview, and record review, the facility failed to accurately complete Minimum Data Set (MDS) assessments for two (R2 and R4) of three residents reviewed for MDS assessments. Findings include:R2 According to R2's MDS assessment dated [DATE] section P, R2 used a limb restraint less than daily. Review of R2's Electronic Health Record (EHR) did not reveal any orders, care plans, or documentation to support R2 used a limb restraint. 01/27/2026 11:06 AM R2 was observed lying in bed on left side using wedge bolster. There were no visible restraints on R2. There were no restraint devices in R2's room. At 2:30 PM R2 was observed up in recliner chair. There were no visible restraints on R2 or in the room. R2 was unable to be interviewed due to cognition status. At approximately 2:35 PM unit manager Licensed Practical Nurse (LPN) R was asked if there were any restraints in the facility. LPN R stated, There are no restraints in the facility. We do not use them. LPN R confirmed that R2 had never had restraints. LPN R reviewed R2's MDS dated [DATE] and stated, This is wrong. The resident doesn't have restraints. There are no restraints in this building. On 1/28/2026 at 11:06 AM, during an interview with the MDS Director (staff Q) R2's MDS dated [DATE] section P was reviewed. Staff Q stated, This is an obvious mistake. The resident has been here for 10 years and has never had a restraint. I'll correct it and re-send. Staff Q said that the facility had undergone staff changes. R4 According to R4's MDS assessment dated [DATE] section O. R4 receives Hemodialysis (HD). Review of R4's EHR did not reveal any orders or documentation to support R4 was receiving HD. On 1/27/2026 at 11:33 AM, R4 was observed seated up in bed watching TV. R4 was interviewed and reported they do not get dialysis. R4 confirmed they never had dialysis. On 1/28/2026 at 11:13 AM Staff Q reviewed R4's MDS assessment dated [DATE] section O. Staff Q confirmed the MDS was inaccurate and stated, The resident did not receive dialysis. I'll correct it today.

Based on observation, interview and record review, the facility failed to refer one (R158) of two residents reviewed, with a serious mental disorder, to the state designated authority for review of the pre-admission screening and resident review (PASARR) program. This resulted in the likelihood of decline related to unidentified needs. Findings include: Record Review of the Electronic Health Record (EHR) revealed no Level II PASARR completed by the facility since R158's admittance date on 8/1/25. On 01/27/2026 at 11:39 A.M., R158 was interviewed and reported that he does not receive behavior or psychiatric supports at this facility. On 01/27/2026 at 2:20 P.M., R158's record review revealed a diagnosis of PARANOID SCHIZOPHRENIA with no evidence of a Level II PASARR. Review of a Level I PASARR dated 8/1/25 which was completed by the referring hospital which denoted the following: a diagnosis of Schizophrenia, a history of previous mental health treatment and the routine prescription of the antipsychotic medication Invega (antipsychotic, a long-lasting injection used to treat schizophrenia). Record review also revealed R158 was admitted on [DATE] with the following diagnosis: Paranoid Schizophrenia, Alcohol Abuse, Hypothyroidism, Type 2 Diabetes, Hypertension, Hyperlipidemia, Rhabdomyolysis, Prostatic Hyperplasia, Ischemic Attack. The Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 -indicating R158 as cognitively intact. On 01/28/2026 at 3:36 P.M., Social Worker (SW) S was interviewed regarding PASARR screenings. SW S said that staffing changes over the summer caused the Social Work Department to fall behind on their PASARR processes and stated, To be completely transparent, it (R158's Level II PASARR) wasn't done! On 01/29/2026 at 1:17 P.M., Record Review revealed an order dated 8/1/25- Psych services to eval and treat as indicated. On 01/29/2026 at 2:05 P.M., the Nursing Home Administrator (NHA) was queried as to who is responsible for ensuring PASARR screenings are completed. NHA stated, It's the job of our Social Services Department and we are reviewing records with our social services team to catch up on these things. NHA also confirmed that R158 has not received psychiatric services or medication for Schizophrenia since admission on [DATE]. Record review of Care Plan dated 11/08/2025 revealed: Focus-(R158) is at risk for pain Rhabdomyolysis, BPH, schizophrenia, decubitus ulcer, and AKI . and Intervention-Observe for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls.Review of the facility's policy titled Pre-admission Screening and Guest/Resident Review-PASRR Michigan dated for last revision on 11/21/2021, documented in part: . the PASRR process is to screen all individuals admitted for nursing care to ensure that needs are met to assist the individual in reaching their highest potential . If the responses to the Level I/3877 screening indicate the presence of a mental illness and/or intellectual/developmental disability, or related condition, the person is referred to the local community mental health program for a comprehensive screening, Level II. Review of the Level I screening criteria- Section II dated 8/1/25 identified 3 of 6 areas that meet the requirement for mental Illness with instruction to contact the local community mental health services program (CMHSP) for Level II screening.1.The person has a current diagnosis of mental illness- yes2. The person has received treatment for mental illness- yes3. The person has routinely received one or more prescribed antipsychotic or antidepressant medications with the last 14 days- Yes

Based on observation, interview, and record review, the facility failed to follow standards of practice for medication administration for one resident (R183) of four residents reviewed for medication administration. Findings include:On 01/27/2026, at approximately 10:05 AM, R183 was observed in their room. Three pills in a medication cup were observed on R183's bedside table. Upon inquiry, R183 said the nurse leaves them since they cannot swallow the pills all at once. R183 further said they are not sure what the pills are taken for, or what they are. A record review was completed on 1/28/2026 which revealed R183 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right side, muscle wasting and atrophy, hyperlipidemia, hypertension, gastro-esophageal reflux disease, depression, and insomnia. Section C of the Minimum Data Set with an Assessment Reference Date of 1/6/2026, revealed R183 scored a 15/15 on the Brief Interview for Mental Status assessment - indicative of no cognitive impairment. A review of physician orders in the electronic medical record revealed no orders allowing for self-administration of medications. On 1/28/2026 at approximately 11:09 AM, Licensed Practical Nurse (LPN) D was interviewed regarding the process of medication administration. LPN D confirmed that R183 did not have an order to self-administer medications. LPN D further said that professional standards include observing the resident take the medication and that it is not safe or appropriate to leave medications at the bedside. On 1/28/2026 at approximately 1:40 PM, the Director of Nursing (DON) was interviewed regarding medication administration standards. When asked if it was appropriate to leave medications at the bedside, the DON stated, We do not leave pills at the bedside - that is not our process. A policy titled, Medication Administration last revised on 10/17/2023 documented, Resident medications are administered in an accurate, safe, timely, and sanitary manner . #7. Observe that the resident swallows the oral medications. Do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication.

Based on observation, interview, and record review, the facility failed to ensure two residents (R118 and R33) out of four residents reviewed for accidents had wheelchair footrests in place during wheelchair mobility.Findings include: R33 On 1/27/2026 at 10:25 a.m. R33 was observed sitting in a wheelchair and unable to answer questions about care. Observed both of R33's leg lifted off the floor with intervals of the left leg dropping to the floor while Licensed Practical Nurse (LPN) V propelled R33 without any footrest into the hallway. There was no footrest in the room or the closet. On 1/27/2026 at approximately 10:35: a.m. LPN V was interviewed regarding R33's footrest. LPN V was asked did the resident have footrests for the wheelchair for safety? LPN V stated, the resident do not have leg rests but I will call therapy to get some for her. The resident should have them for safety reasons. According to the electronic medical record (EMR), R33 was admitted into the facility on 2/10/2017 and readmitted on [DATE] with diagnosis that included sequelae of cerebral infarction, sensorineural hearing loss bilateral, dementia, hypertension, osteoarthritis of left and right shoulder, R33's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R33 was moderately cognitively impaired with a BIMS (brief interview for mental status) score of 09/15. Review of the 11/6/2025 Activity Daily Living (ADL) care plan revealed, R33 had a functional ability deficit and requires assistance with self-care/mobility related to fatigue/weakness, impaired balance, impaired cognition, and impaired mobility. R118 On 1/28/2026 at 8:25 AM, R118 was observed sitting in the rehab wing day room in a wheelchair without footrests feet resting directly on the floor. R118 was unable to answer questions about care. Licensed Practical Nurse (LPN) I was asked how R118 was transported to the day room. LPN I said Certified Nursing Assistant (CNA) J pushed R118 in a wheelchair. On 1/28/2026 at 9:25 AM, R118 was observed sitting outside of the rehab wing nurses' station in a wheelchair without footrests, feet resting directly on the floor. On 1/28/2026 at 12:52 PM, R118 was observed pushed by CNA K from R118's room to the rehab wing day room approximately 250 feet in a wheelchair without footrests with R118's feet sliding directly on the floor. When CNA K was asked about R118's wheelchair CNA K said R118's wheelchair should have footrests. On 1/29/2026 at 9:39 AM, LPN L was interviewed and said R118 should have leg/footrests and that R118 was dependent for wheelchair mobility. LPN L further said all residents that are dependent should have footrests for wheelchair mobility, it was a potential accident. On 1/29/2026 at 11:54 AM, the Director of Nursing (DON) was interviewed and said the expectation for staff is to make sure dependent residents have footrests/leg rests on the wheelchair prior to transport to reduce the risk for accidents. On 1/29/2026 at 2:16 PM, Rehab Manager M was interviewed and said dependent residents should not be pushed in a wheelchair without footrests. They would be at risk of an injury or fall. Record review of R118's Electronic Health Record (EHR) revealed R118 admitted to the facility on [DATE] with diagnoses that included pneumonia, and adult failure to thrive. Review of R118's Brief interview for Mental Status assessment performed on 1/15/2026 revealed a BIMS of 6/15 severe cognitive impairment. Review of R118's mobility rating dated 1/21/2026 revealed dependent for wheelchair transfers and mobility. Review of the facility policy titled Wheelchairs undated revealed in part.Assisting a patient to safely achieve mobility is a goal of all the members of the interdisciplinary rehabilitation team. The patient's cognition, vestibular function, judgment, physical endurance and strength play a part in selecting the appropriate equipment. After selection of an appropriate wheelchair and accessories, nurses play an important role in assisting the patient to use the equipment safely.

Based on observation, interview, and record review, the facility failed to follow physician's orders to apply oxygen for one resident (R118) out of four residents reviewed for oxygen use.Findings include:On 1/28/2026 at 8:25 AM, R118 was observed sitting in the rehab wing day room in a wheelchair with a portable oxygen tank with Certified Nursing Assistant (CNA) actively assisting R118 with breakfast. R118 was observed not wearing the oxygen canula. R118 was observed coughing. R118 was unable to answer questions regarding care. Licensed Practical Nurse (LPN) I was asked how R118 was transported to the day room. LPN I said Certified Nursing Assistant (CNA) J pushed R118 in a wheelchair. When LPN I was asked if R118 should be on oxygen LPN I stated, Yes she just got out of isolation for Covid-19 and acknowledged R118 was not wearing the oxygen canula. LPN I checked R118's portable oxygen tank and said R118's tank was empty and proceeded to get R118 a new portable oxygen tank and applied R118's oxygen canula. On 1/28/2026 at 8:57 AM, CNA J was interviewed and stated, I brought R118 to the day room this morning. The portable oxygen was out, I should have told the nurse, but I got distracted.On 1/29/2026 at 9:39 AM, LPN L was interviewed and said R118 should have been wearing the portable oxygen, staff should know because it should be care planned and resident care is discussed in morning meetings. LPN L said R118 could become short of breath without the oxygen.Record review of R118's Electronic Health Record (EHR) revealed admitted to the facility on [DATE] with diagnoses that included pneumonia, and adult failure to thrive.Review of R291's Brief interview for Mental Status assessment performed on 1/15/2026 revealed a BIMS of 6/15 severe cognitive impairment. Review of R118's physician orders revealed O2 (oxygen) per nasal cannula @ 2L/min (at two liters per minute) continuously dx: SOB start date 1/8/2026.Review of R118's care plan did not reveal oxygen use.Review of R118's Kardex did not reveal oxygen use.On 1/29/2026 at 11:56 AM, the Director of Nursing (DON) was interviewed and said the expectation for staff is to follow physician orders and check the portable oxygen tanks prior to transporting residents. The DON further said oxygen use should be on the care plan and Kardex and agreed oxygen use was not care planned for R118.Review of the facility policy titled Oxygen Administration undated, revealed in part.Inspect all equipment and supplies. Implementation verify the practitioner's order for oxygen administration via humidified high-flow nasal cannula. Make sure the order contains the prescribed flow rate and oxygen level.

Based on observation, interview, and record review the facility failed to obtain a Legal Guardian (LG) for one (R2) of one legally incapacitated resident resulting in R2 not having a court appointed legal guardian since 2024. Findings include:On [DATE] at 2:30 PM, R2 was observed up in recliner chair watching TV. R2 was unable to be interviewed due to cognition status. On [DATE] at 2:50 PM during interview with R2's Representative (RR1) they said they were not being included in decision making for R2. RR1 said they were not R2's Legal Guardian (LG) at this time and was currently trying to obtain it through the court system. RR1 said they had not been assisted by the facility to assist with Legal Guardianship paperwork. RR1 stated, I was told because I did not live in the same county as the facility, they had no way to help me. According to R2's Electronic Health Record (EHR) RR1 was identified as R2's emergency contact and representative. R2 had resided in the facility since [DATE] with multiple diagnoses that included vascular dementia. The Annual Report of Guardian on condition of a Legally Incapacitated Individual indicated that R2 had a LG company as their LG until [DATE]. There was no further information to determine if R2 had a current LG. R2's Advance Medical Directive (AMD) form dated [DATE] identified R2 as a full code and was not signed by a LG or resident representative. The form was signed by Social Worker (SWQ) and noted that R2 was unable to sign and had a diagnosis of dementia with confusion. R2's progress notes and social service notes did not reveal any documentation to support R2 had a LG. There was no documentation to indicate the facility had made attempts to acquire a LG for R2. On [DATE] at 11:24 AM, during an interview with SW Q they said that R2's LG paperwork had expired on [DATE] and there had been no information to determine who was R2's LG. SW Q stated, That Guardian company went out of business in 2024, and we haven't found another one to replace it. The family has not provided us with any LG paperwork, so the resident doesn't have a legal guardian now. SW Q could not provide any documentation to support the facility had attempted to obtain a LG for R2. SW Q stated, The family was supposed to apply for guardianship, but we haven't heard back from them. On [DATE] at 11:39 AM the Nursing Home Administrator (NHA) said R2 hasn't had a LG since [DATE]. The NHA could not provide any documentation to support the facility had attempted to acquire a LG for R2. The NHA stated, We do not have a specific policy for social services to obtain legal guardianship for legally incapacitated residents, but it is the expectation that they do.

Based on observation, interview, and record review, the facility failed to ensure the physician ordered diet was provided to one resident (R203) of two residents reviewed for diet and nutrition, resulting in the potential for the resident to aspirate or choke.Findings include: On 1/27/2026 at approximately 1:40 PM, R203 was observed in their room with their lunch meal tray. The meal ticket on the tray listed the diet order as a regular diet with a pureed texture. The following food was observed on the tray: chicken pot pie, bread roll, peas and carrots, and applesauce. The food was not in a pureed form. R203 began to remove the plastic wrap from the bread roll to consume it. At approximately 1:45 PM, the surveyor notified LPN A of the concern. Upon entering the resident's room, the nurse was asked to verify the diet order on the meal ticket and stated, it's pureed, but that's not pureed food. I'll remove it and get (R203) the correct food. A record review revealed that the resident was admitted to the facility on [DATE] with a diagnosis of dysphagia. A Brief Interview for Mental Status assessment was completed on 1/24/2026. The resident scored a 7, indicative of severe cognitive impairment. A physician order dated 1/24/2026 in the electronic medical record identified the diet as a regular diet with pureed texture and thin liquids. Section GG of the Minimum Data Set with an Assessment Reference Date of 1/26/2025 revealed the resident needed supervision or touching assistance with eating. A care plan focus dated 1/26/2026 revealed: Ord'd Reg diet, Puree texture, thin consistency. 1/26 Tray set up for meals. An interview with Speech Language Pathologist (SLP B) was conducted on 1/28/2026 at 11:35 AM via phone with the facility Rehabilitation Director present. During this interview, SLP B said that R203 admitted to the facility from the hospital with a diet order of mechanical soft. Nursing then downgraded the diet to pureed after observing R203 with chewing and swallowing difficulties. The resident was provided with speech language therapy services with the goal of returning R203's diet to mechanical soft. SLP B confirmed that during current treatments, R203 has been observed with continual difficulty chewing and swallowing and stated, it would be concerning if the resident received a regular textured diet. An interview with Registered Dietitian (RD C) was conducted on 1/28/2026 at approximately 1:45 PM. RD C said they work with the kitchen staff to ensure each resident receives the correct diet as ordered. RD C said it would be concerning if R203 received the incorrect diet because it would put them at-risk for aspiration. An interview with the Nursing Home Administrator (NHA) conducted on 1/28/2026 at approximately 2:25 PM. The NHA said it was their expectation that each resident receives the correct diet and meal, and that multiple things could happen to the resident should the wrong diet and meal be provided to a resident, including adverse health effects. A facility document titled, Diet Orders with a revision date of 12/10/2024 revealed: The goal for each diet order is to be the least restrictive to effectively manage the resident's medical condition and to assist the resident in reaching their highest functioning potential. Further, #6 – The facility will adhere to therapeutic diet parameters during food preparation and when dispensing condiments. On 1/27/2025 at 3:03 PM, an interview with Dietary Manager F found that during meal service there are two dietary aides that check tickets and ensure proper diets are given. One of the aides is receiving the plates and putting together the tray, and the other dietary aid checks over the tray and meal before placing it on the cart.

Based on interview and record review, the facility failed to ensure one resident (R33) out of five residents reviewed for immunizations, was provided influenza and pneumococcal vaccination and education resulting in the potential for development and spread of influenza and pneumonia among vulnerable residents in the facility. Findings include:On 1/29/2026 at 10:00 AM, the Infection Preventionist (IP) O was interviewed and reported R33 did not have documentation of a current influenza or pneumococcal immunizations or refusals signed by the guardian.Review of the Electronic Health Record (EHR) for R33 revealed R33 admitted on [DATE] with diagnosis of transient cerebral ischemic attack, dementia and Alzheimer's disease. R33 did not have documentation to indicate that the influenza or pneumococcal vaccines were declined by the guardian or were contraindicated.On 1/29/2026 at 11:59 AM the Director of Nursing (DON) was interviewed and said R33's guardian should have been contacted to obtain consent or declination.Review of the facility policy titled Immunizations: Influenza Vaccination of Residents dated 4/17/2025, revealed in part.It is the policy of this facility that, annually residents will be offered immunization against influenza. Document resident refusal and education of risk vs. benefit. Review of the facility policy titled Immunizations: Pneumococcal Vaccination of Residents dated 11/4/2024, revealed in part.Informed consent in the form of a discussion regarding risks and benefits of vaccination will occur prior to vaccination. (This may be with the resident's authorized representative when appropriate. If signed consent were required according to state law, it would occur at this procedural step.)

Based on interview and record review, the facility failed to ensure one resident (R33) out of five residents reviewed for immunizations, was provided Covid-19 vaccination and education resulting in the potential for development and spread of Covid-19 among vulnerable residents in the facility. Findings include:On 1/29/2026 at 10:00 AM, the Infection Preventionist (IP) O was interviewed and reported R33 did not have documentation of a current Covid-19 immunization or refusal signed by the guardian.Review of the Electronic Health Record (EHR) for R33 admitted on [DATE] with diagnosis of transient cerebral ischemic attack, dementia and Alzheimer's disease. R33 did not have documentation to indicate that the Covid-19 vaccine was declined by the guardian or was contraindicated.On 1/29/2026 at 11:59 AM the Director of Nursing (DON) was interviewed and said R33's guardian should have been contacted to obtain consent or declination.Review of the facility policy titled Resident Covid-19 Vaccination dated 10/6/2025, revealed in part.The facility will obtain a signed consent form for the administration of the Covid-19 vaccine from the resident or the resident's designated health care representative. A declination will be signed if consent is not given.

This citation pertains to intakes 1227387 and 1227390.Based on interview and record review the facility failed to implement fall prevention interventions for one (R101) of three residents reviewed for accidents, hazards, and adequate supervision, resulting in multiple falls with the potential for injuries. Findings include:This citation pertains to intakes 1227387 and 1227390.Based on interview and record review the facility failed to implement fall prevention interventions for one (R101) of three residents reviewed for accidents, hazards, and adequate supervision, resulting in multiple falls with and without injury.Findings include:On 8/4/25 at 10:30 a.m. R101 was contacted via telephone regarding the allegations reported to the state agency. R101 said they experienced several falls when trying to get something off the floor, when needing to go to the bathroom independently, and after putting on and waiting for the call light to be answered. R101 said the nurses put the resident at the nurse's station all day because of the multiple falls, I tried to get whatever fell off the floor and the nurses took too long to help me, so I did it myself and fell. I hurt my head, my shoulders, legs and back. Review of the clinical record documented R101 was admitted into the facility on 2/2/25 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Parkinson's disease, and history of falling. R101 was discharged to another facility and no longer resides at the facility. According to the quarterly Minimum Data Set assessment dated [DATE], R101 was cognitively intact (BIMS-13), and required one person assistance with activities of daily living. Review of the Risk for Falls care plan, dated 2/2/25 documented:R101 is at risk for falls related to injury and falls related to: history of falls, hemiparesis, impaired cognition, decreased transfer and locomotion mobility.Goal: Will be free from injury and related to falls through the review date.Interventions: Keep the residents' environment as safe as possible with: even floors free from spills and/or clutter; adequate lighting; call light within reach, commonly used items within reach, avoid repositioning furniture and keep the bed in the appropriate position. 2/2/25Staff to ensure that all items are in reach and accessible (i.e. remote control, cell phone, water cup, books, ink pens, etc.). 2/20/25Put the call light within reach and encourage him/her to use it for assistance as needed. 2/2/25Staff to locate a different room, closer to the nurse's station. 5/30/25 Review of the following Incident and Accident reports documented in part for following falls:-2/3/25 16:00- Incident Description: .In room, observed resident lying on floor, on the right side, near the bed. I was reaching for my call light and the end table moved and I rolled out of bed.Immediate Action taken: . Resident complained of pain in right shoulder.-2/18/25 12:09- Incident Description: .Observed resident on floor in bathroom in room with back against the wall facing the toilet. Resident stated trying to grab onto the rail with the weak hand and slid onto the floor. No injury observed.-2/20/25 00:00- Incident Description: The resident was observed on the floor unwitnessed on the left side. No injuries observed.There was no statement from resident about the fall. -2/26/25 05:55- Incident Description: CNA observed resident on the floor in room. observed laying on back in front of the wheelchair. Resident stated trying to get call light off the floor. No injury observed.-3/13/25 00:00- Incident Description: The resident was observed in the bedroom on buttocks and pillow near the bedroom door trying to get remote control. No injury observed.-3/26/25 00:00- Incident Description: Observed resident on buttocks on the floor in front of the wheelchair. The Resident was trying to get remote off floor. No injury observed.-5/17/25 14:00- Incident Description: Called in the room due to the patient's fall and bruising around the eye. Resident was trying to get the bed remote on the side of the bed.-5/29/25 15:45- Incident Description: Resident was observed sitting on buttocks. Resident said was trying to go to the bathroom. No injury observed.-6/10/25 11:15- Incident Description: The resident was observed on the floor on side of the bed on buttocks trying to obtain eyeglasses. No injury observed. 0n 8/4/25 at 4:25 p.m. CENA A was interviewed and queried about implementing interventions to residents that are at risk for falls. CENA A said the aides are supposed to ask the resident or look in the resident's chart to know their status. Any changes to the resident are reported to the nurse so the care guide can be updated. The aides are supposed to read the care guide to know if the resident has fall precautions. A lot of the time, residents drop their call lights and remotes on the floor. But if the rounds are done regularly or call lights answered, then residents would probably not fall. On 8/4/25 at 4:40 p.m. the Director of Nursing (DON) was interviewed. The DON said the resident was reviewed in Fall Risk meetings and recalled the number of times the resident (R101) fell and would be better to be close to the nurse's station. The reason for the residents' falls were identified. We tried to put frequently used items within reach. Nursing staff are supposed to check on residents at least every two hours. The resident fell a lot while in the room due to the resident not wanting to come out of the room so the staff should have done visual checks. According to the DON,visual checks are not documented, and therefore no review could be completed. Review of the facility's policy titled Fall Management dated 7/8/25 documented in part the following: The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls.

This citation pertains to intake #MI00151498. Based on observation, interview and record review, the facility failed to utilize a two-person assist while turning and reposition a resident while performing care for one resident (R903) of three residents reviewed for accidents, resulting in a fall with injury. R903 sustained a right hip fracture that required surgical repair. Findings include: Review of an allegation received through the State Agency revealed the following: (R903) has a history of stroke and is paralyzed from the waist down. (R903) has been in a nursing/rehab facility for the past two years . On or about 3/21/25, (R903) brief was being changed by an employee, and (R903) fell out of the bed. (R903) was left on the floor for an unknown period of time and was yelling for help when the staff member ran out of the room to get help. (R903) fell when (R903) was being turned over to change, but it is believed there was only one staff member present when she was being changed, and (R903) should have two since (R903) is a fall risk. (R903) was taken to the hospital . (R903) fractured her hip . (R903) has to have surgery. On 3/31/2025 at 9:34 am, R903 was observed in bed on their back, wearing a hospital gown. R903 was able to communicate her needs. R903 was interviewed and asked about how they were injured. R903 stated, A girl (Certified Nurse Aide, CNA C) rolled me over and I fell out of bed .I hurt my hip. R903 was asked the number of staff that usually assisted with care and R903 said, It depends on how much staff they have. R903 described that they had a lot of pain after the fall. R903 said that they never had a fall that resulted in a fracture. R903 said it took several staff to assist them back to bed. R903 was asked if they have gotten out of bed for activities. R903 reported not been able to get out of bed. R903 said that they missed all of the activities, especially playing BINGO. R903 stated that BINGO was their favorite game and they missed going. R903 said, This makes me feel terrible. I want to start back doing the things I used to do. R903 had three days without activities since readmission to the facility. A review of R903's electronic medical record revealed admission to the facility on [DATE] with the diagnoses of Chronic Foot Ulcer, Stroke, Neuropathy, Ventral Hernia, and Incontinence. A review of R903's Brief Interview for Mental Status (BIMS) dated 2/25/2025 revealed a score of 15/15 (cognitively intact). A review of R903's care plan revealed the following: Focus: (R903) is at risk for fall related injury and falls R/T (Related To): Stroke, history of falls, medications, discomfort, weakness, impaired bed, transfer, toilet, gait, balance, and locomotion mobility Revision date on 2/4/2023 . Focus: (R903) requires Physical Therapy r/t decline in function or to maintain/slow decline secondary to MS Wasting: Decline in bed positioning, decline in gait/ambulation, decline in transfer skills .Decreased LLE (Left Lower Extremity) strength .Decreased RLE (Right Lower Extremity) .Patient/Caregiver education . Revision date on 2/4/2023 . Focus: has a functional ability deficit and requires assistance with self-care/mobility R/T: Fatigue/Weakness, Impaired Balance, Impaired Mobility, Impaired ROM (Range of Motion) . Revision date on 10/13/2023 .Interventions: Observed/document/report to Nurse as needed any changes in functional ability-CNA .Bed Mobility: Resident requires extensive to maximum assistance with two staff assistance to reposition and turn in bed . A review of R903's Kardex ((a reference guide that summarizes key resident information, resident care, Activities of Daily Living (ADL), Safety, Toileting, and care plans, to aid nurses and CNAs in providing efficient and personalized care)) dated 10/2/2024 revealed the following: Bed Mobility: Resident requires extensive to maximum assistance with two staff assistance to reposition and turn in bed . A review of the inpatient hospital orthopedic surgery note dated 3/24/2025 by Hospital Physician D, revealed the following: Patient (R903) endorses the following history Patient is non-ambulatory at baseline ever since (R903's) CVA (Stroke-Cerebrovascular Accident) .(R903) was getting turned and fell off the bed . A review of R903's inpatient hospitalization hip x-ray report, dated 3/23/2025, revealed the following: Findings: Right hip: Acute intertrochanteric fracture of the right femur with mild varus angulation ((a break in the bone (femur) just below the hip joint, between the greater and lesser trochanters)) . A review of R903's inpatient hospitalization hip x-ray report, postoperative dated 3/23/2025 revealed a screw was surgically implanted to repair R903's fracture. On 3/31/2025 at 12:52 pm, Certified Nurse Aide (CNA C) was interviewed and queried about the care that was provided to R903 on 3/22/2025. CNA C stated, I was giving a 'Check and Change' (checking residents for incontinence briefs for wetness or soiling) .(R903) had a bowel movement .I took the covers off and rolled (R903) on the side and cleaned (R903). As I walked to the other side of the bed (R903) rolled out of bed and fell on the floor. CNA C was asked if they took their hands off R903. CNA C answered Yes and explained that R903 was stable but then loss their balance and fell out of bed onto the right side. CNA C further explained that after R903 fell out of bed, CNA C called for help. CNA C reported about five staff members came to assist R903 off of the floor and placed R903 back into bed. CNA C was then queried if they reviewed the Kardex prior to providing care. CNA C stated, I did not know that the Kardex had information on it about the resident care. CNA C then added they received training after the resident fell out of bed. CNA C was asked how they knew what care the resident needed and CNA C stated, I've taken care of (R903) by myself in the past and did not have any problems .I did not know (R903) was supposed to have two people. CNA C said that they received report from the previous shift CNA. CNA C was asked how do you know that the information was accurate from the previous shift. CNA C stated, That's a good question. Sometimes we are short staffed. On 3/31/2025 at 3:50 pm, an interview was conducted with the Administrator (NHA) and the Director of Nursing (DON) about CNA C not following R903's care plan/Kardex, by performing bed mobility without another staff and stating that they were not aware of the Kardex. The DON stated, (CNA C) received training so maybe they was nervous . But now we are re-educating all staff. (CNA C) did not follow the policy.

Based on observation, interview and record review the facility failed to ensure resident equipment was cleaned and sanitized sanitary equipment for 14 of 14 residents that resided on the third floor. Findings Include: On 11/22/24 at 9:00AM, a shower chair was observed in the hallway with visible dried feces. In addition, the sit to stand machine (device used for positioning residents) was noted to be soiled with dirt and food particles. On 11/22/24 at 9:10 AM, LPN A was queried concerning who was responsible for cleaning the resident's equipment. LPN A indicated the equipment should have been cleaned by the midnight shift. LPN A further indicated the equipment should have been cleaned after each use to prevent cross contamination. On 11/22/24 at 9:20 AM, the Nursing Home Administrator, (NHA) was shown the shower chair while she was rounding on the unit. The Administrator reiterated after observing the shower chair the facility was responsible for cleaning the equipment and the equipment should be cleaned after each use and on the midnight shift. A request for the facility's policy on cleaning equipment was made at this time. On 11/22/24, record review of the facility's policy entitled Cleaning and Disinfecting Multi-Use Resident Equipment dated 10/11/23 documented in part: Cleaning and disinfection are essential for ensuring that multi-use medical equipment does not transmit infectious pathogens to residents . Noncritical items are resident care items that come in contact with intact skin but not mucous membranes and include, but are not limited to: .wheelchairs . Noncritical resident care items carry very little risk of transmitting infectious agents to residents even when they come in contact with non-intact skin or mucous membranes. However, these items may contribute to secondary transmission by contaminating the hands of health care workers . Thus, reusable noncritical resident care items should undergo cleaning and disinfection when they're visibly soiled and on a regular schedule (for instance, after each use, daily or weekly), as determined by the health care facility

This citation pertains to intake MI00135760. Based on interview and record review, the facility failed to adequately supervise Resident #101 (R101) when on 4/6/23 at 10:16 PM R101 left the facility through the front door without the knowledge of the facility staff. The facility staff was unaware of R101's disappearance until 4/7/23 at 7:50 AM, approximately 10 hours later. R101 was found by local police on 6 Mile Road and Telegraph Road, approximately five miles away from the facility. Local police took R101 to the local hospital on 4/7/23 at 3:08 AM. This deficient practice resulted in the likelihood of all independent ambulatory residents to have serious injury, serious harm, serious impairment, or death when R101 left the facility unsupervised and without staff knowledge. The Immediate Jeopardy started on 4/6/23. A review of the Facility Report Incident dated 4/7/23 documented the following: On 4/7/23, staff noticed that (R101) was not in his room at 7:50 AM .The Afternoon CNA (Certified Nurse Assistant) observed (R101) in their room while passing trays between 6:30 PM to 6:45 PM and again when collecting dinner trays at 7:15 PM. The Nurse administered medication to (R101) at approximately 8:50 PM (R101) was observed in their room during nursing rounds at 9:45 PM . During morning med (medication) pass the nurse noted that (R101) was not in their room. A review of the Facility Investigation Summary dated 4/12/23 documented, At, approximately 9:28 PM (R101) left his room, walking down the main hall and going in or near the conference room behind the receptionist desk. When the receptionist left the desk at 9:55 PM, (R101) emerged from in or near the conference room and exited via the front door at 9:56 PM. At approximately 10:16 PM, (R101) left the premises going west (on nearby street). A review of R101's medical record revealed an admitted [DATE] with medical diagnoses that included: Repeated Falls, Dementia, Difficulty Walking, and Anoxic Brain Injury (a lack of oxygen going to the brain resulting in injury). R101's Minimum Data Set (MDS) dated [DATE] revealed, R101 had a Brief Interview for Mental Status (BIMS) a score that indicated intact cognition. R101 required extensive one person assistance with walking and toileting. On 5/1/23 at 11:38 AM CNA B was interviewed regarding supervising the front desk while covering for Receptionist A the night R101 exited the facility. CNA B explained that she did not monitor the desk between 9:55 PM and 10:00 PM. R101 was observed via facility camera to have exited the front door at 9:56 PM. On 4/27/23 at 4:01 PM, Receptionist A was queried regarding R101's elopement on 4/6/23. Receptionist A said she went on break at 9:55 PM. R101 exited the facility at 9:56 PM. On 4/27/23 at 4:28 PM CNA D was asked about when they had last seen R101 during their shift on the day R101 exited the facility. CNA D said between the hours of 8 PM and 9 PM they recalled seeing R101. But CNA D did not remember seeing R101 any time after 9 PM, during their shift. On 5/1/23 at 1:10 PM Licensed Practical Nurse (LPN) F was queried regarding what happened on the night of 4/6/23 into 4/7/23 when R10 exited the facility. LPN F said she was the assigned nurse for R101 but didn't realize he was missing until approximately 8:15 AM. On 5/1/23 at 9:18 AM the Nursing Home Administrator (NHA) was queried about the facility cameras and R101 exiting the facility. The NHA explained that R101 was last seen on camera at 10:16 PM going in the direction of the back parking lot. On 5/1/23 at 9:41 AM Family Member E was interviewed regarding the elopement. Family Member E stated they received a call from R101's neighbor (house) at 2:45 AM on 4/7/23 regarding R101. Family Member E said the unidentified neighbor explained that the police called and said R101 was seen wandering around 6 Mile Rd. and Telegraph Rd. and that R101 was taken to the local hospital. Family Member E reported the police saw R101 on the side of the road looking like he was about to fall. On 5/1/23 at 11:06 AM the NHA and Director of Nursing (DON) were interviewed about their expectations on supervision of residents and the front desk. The NHA and DON said they identified there being a problem regarding staff not being present at the front desk and that the CNAs were not doing rounds consistently to check on the R101. The NHA and DON acknowledged that it is the facility's expectation that CNAs do routine rounds on their shift to make sure residents are accounted for and that there should always be someone at the front desk to monitor residents. A review of the policy titled Standards of CNA/STNA Practice dated 9/7/2021 revealed in part The CNA/STNA makes routine rounds to check each assigned guest's/resident's condition and ensures their needs are being met. A review of the policy titled Elopement Policy dated 5/1/22 revealed in part, Rounds of all guests/residents are made at the beginning of the shift, at mealtimes, and at the end of the shift at a minimum by direct care staff and licensed nurses. CNA/STNA or nurse can achieve this through the medication administration pass, mealtime passes, and during care rounds. A policy regarding monitoring the front desk was requested on 4/27/23. However, the requested policy was not provided by exit on 5/1/23. On 5/1/23 the past non-compliance was received and reviewed. Review of the past non-compliance verified the removal of the Immediate Jeopardy on 4/7/23. The facility removal plan documents the following: Description of deficient practice: The facility failed to prevent a resident, who requires supervision, from going outside the facility doors independently. The resident was able to exit the front entrance of the rehab unit and exited the facility through a door that did not have an alarming system in place when the receptionist took a break. Staff did not round adequately during shift. A QAPI meeting was held to review the Elopement policy, ADL care and Nursing and CNA's standards. How facility identified resident affected and residents having potential to be affected by the same deficient practice. The Administrative Nurses reviewed the residents in the facility last Elopement Risk Assessment to identify the residents who are at risk for elopement. Corrective action taken for the resident affected: * Resident was assessed at the hospital. * The resident chart was reviewed. * Residents were interviewed and or observed to ensure care was provided to the residents. * Upon readmission the resident will be re-assessed for Elopement Risk. * The elopement care plan was reviewed and revised as needed. * Upon return resident will be assessed and given a wander guard device. * Resident room placement was reviewed and will be revised upon return. Measures of systemic changes made to ensure the deficient practice will not occur and affect others. * A QAPI meeting was held to review the elopement, rounds, ADL care, door alarms, and desk coverage on 4/7/23. * Rounds were made on all doors in the facility that exit to the outside to validate alarms are functioning, if the door is not alarmed a screamer door alarm was placed on the door. * The entrance door to the rehab unit has a screamer alarm added. * Administrative Nurses and or the Social Worker reviewed the residents identified at risk for elopement to and completed a new Risk for Elopement evaluation the care plans for elopement are up to dare and the wander guard is in place and functioning. * Residents were interviewed and or observed to ensure care was provided to the residents. * The Elopement policy was reviewed and deemed appropriate. All staff were educated on elopement policy. ADL care, Standards of practice for Nurses and CNAs with emphasis on rounds policy re-education began on 4/7/23. *The receptionists were educated on getting coverage when leaving the desk. * Screamer door alarm added to front door on the rehab center. How facility monitors its corrective actions to ensure same deficient practice is corrected and will not recur. * The Maintenance Staff or designee will complete rounds on all doors in the facility that exit to the outside to validate alarms are functioning 7 days a week for 4 weeks and then monthly for 2 months, any concerns will be addressed. Findings will be reported to the QAPI committee monthly for 3 months for recommendations. * Maintenance Staff or designee will make rounds to validate the entrance door to the rehab unit has screamer alarm and cover. Findings will be reported to the QAPI committee monthly for 3 months for recommendations. * The Licensed Nurses or designee will make frequent random rounds on the residents identified at Risk of Elopement on the weekly x 4weeks and then monthly for 2 months, any concerns will be addressed. Findings will be reported to the QAPI committee monthly for 3 months for recommendations. * DON or Staff designee will conduct random audits to ensure that staff are completing ADL care and Standards of Practice with emphasis on rounds with for nursing according to the policy weekly x 4 weeks. Findings will be reported to QAPI committee monthly for 3 months for recommendations.

Based on observations, interview and record review the facility failed to monitor and evaluate the impact of pressure ulcer prevention measures for one sampled resident (#41) out of five residents reviewed for pressure ulcers from a total sample of 29, resulting in the development of left gluteal (buttocks) Stage III (full thickness tissue loss) pressure ulcer. Findings include: Resident #41 Pressure Ulcer/Injury On 02/19/18 at 08:43 AM, during the initial tour of the first floor nurses station observation was made of R#41 laying in bed. R#41's head of bed (HOB) was up 90 degrees, and the resident was eating 50-75% of the breakfast foods. Notation was made of the resident leaning to left side. TV noted at foot of the residents bed. Many necklaces noted around the resident neck. Low air loss mattress was in place. On 02/19/18 at 10:23 AM, Observed R#41 in bed. HOB remains elevated. TV remained on, resident watching TV. Able to answer simple questions. Observed slouching to his left side. On 02/19/18 at 12:45 PM, observed resident in bed. Continues to lean toward his left side. Pressure relieving device on wheelchair located in the room was noted. On 02/19/18 at 2:10 PM, observation was made of R#41 laying on his back. HOB was up 90 degrees. On 02/20/18 at 08:30 AM, observation was made of R#41 in bed leaning onto his left side. The HOB was at a 45 degree level. The TV was on, but the resident was sleeping. On 02/20/18 at 12:20 PM, observation was made of R#41 up in a high back wheelchair in his room. Pressure relieving device in use. Dressed for the day. On 02/20/18 02:31 PM, Record review revealed that R#41 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] documented that R#41 required extensive one person physical assistance for bed mobility, two person physical assistance with toilet use, was frequently incontinent of bowel and bladder and was cognitively intact. The MDS documented that the resident was at risk for developing pressure ulcers, but coded for 0 (zero) pressure ulcers at the time of the assessment. Review of the Nursing Admission assessment dated [DATE] documented, sacral coccyx 2 areas pink in color not opened. Review of a Braden Scale (Tool for predicting pressure sore risk) dated 10/19/17, had a score of 15-Low risk for pressure sore development. Review of an undated Kardex Report (a guide the Certified Nurse Assistant (CNA) used to render individualized resident care) documented, Resident (#41) requires extensive assistance to reposition and in bed. Turn/reposition resident at least every 2 hours, more often as needed or requested. The care plan titled, Alteration in Self care dated 9/26/17 had interventions of Bed Mobility: Resident requires extensive assistance to reposition and in bed . Toilet use: resident requires extensive assistance to use toilet with assistance of two . There was no care plan with goals or interventions in the current medical record focusing on the potential for alteration in skin integrity related to the [MEDICAL CONDITIONS], artery disease, impaired mobility, and incontinence issue. A Nursing Weekly (Head-To-Toe) Skin assessment dated [DATE] documented, Skin condition: Is the resident skin intact with no problems? 'No' (was marked). Skin Alteration: Identify site of skin alteration and type-Site #54 was marked (a corresponding numbered diagram of the front and back of a figure of the body that identified #54 was the left buttock). Description: (Right) AKA. Review of a dietary progress noted dated 11/27/17 documented R#41's weight was 108# +6.7# up 6.6% x 30 days significant weight gain. Review of a physician's orders [REDACTED]. Review of the Nursing progress notes dated 1/2/18 through 2/15/18 revealed documentation of the pressure ulcer on the left gluteal was on 1/10/18 (eight days after the nursing weekly skin assessment) Wound care physician in to visit today. Left gluteal is a Stage III pressure injury measuring 3.0 centimeters (cm) x 0.7 cm x , 0.01 cm; pink base with moderate scattered yellow necrotic (death of cells or tissue from severe injury of disease, especially in localized area of the body) tissue; moderate serous drainage noted; irregular edges noted . On 02/21/18 at 09:15 AM Observed R#41 laying flat in bed with wedge under right mid back propping resident onto his left side. On 02/21/18 at 10:11 AM Wound care observation was performed with Wound Care Nurse E. R#41 was laying on his left side. The Left gluteal pressure ulcer measured 2.6 cm x 1.5 cm x .02 cm. There is moderate amount of sero-sanguineous drainage noted. Wound bed has a pale pink base [MEDICATION NAME] (formation of granulation tissue). Santyl ointment (a [MEDICATION NAME] ointment) was applied and 4 x 4 gauze dressing covered the wound. Nurse E said that the left gluteal treatment was changed to Santyl on 2/7/18. On 02/22/18 10:37 AM during an Interview with Nurse E she was asked about skin care plans. Nurse E' indicated that residents that are admitted into the facility have potential for skin breakdown care plan put into place upon admission. After reviewing R#41's current clinical record she stated, I'm looking for a care plan for potential skin breakdown prior to the left buttock wound development. I don't see anything. Nurse E was asked about the 1/2/18 Nursing Weekly (Head-to- Toe) Skin Assessment which documented Site #54 left gluteal fold identified as an area of concern, with a description; (R) AKA to which she responded, that is confusing, I'm not sure what that is suppose to mean. I know the wound care team did not become aware of left gluteal area until 1/10/18. Nurse E was asked how preventative measures to prevent the development of pressure ulcers was evaluated (in R#41's case turning and repositioning) to which she responded, The care plan has the approaches on them, and the approaches are evaluated quarterly with with the MDS assessment, or as needed. Nurse E was not sure how preventative approaches/interventions could be evaluated when there was no plan of care for skin integrity with approaches/interventions in the clinical record. On 02/22/18 01:41 PM, during an interview with the Director of Nursing (DON) she said the R#41's Potential for Skin breakdown care plan was resolved on 1/3/18, the interventions that were in place on 1/3/18 were the same interventions that should have been in place when pressure ulcer developed. The DON was asked about the 1/2/18 Nursing Weekly (Head-to- Toe) Skin Assessment which documented Site #54 left gluteal fold identified as an area of concern, with a description; (R) AKA to which she responded, the resident had a left gluteal fold on his (R) AKA. There was no documented wound description that the right AKA stump had a left gluteal fold. The DON was able to provide documented evidence on Point of Care (P[NAME]-electronic record where the CENA's document resident care provided) the R#41 was turned and repositioned regularly. The DON could not provide evidence if that single intervention was evaluated to determine the impact to prevent left gluteal pressure ulcer development. The DON stated the pressure ulcer was unavoidable because of the resident [DIAGNOSES REDACTED]. Review of the facility's Skin Management policy dated 5/2010, revised 8/16 documented, Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes . #3. Appropriate preventative measures will be implemented on residents identified at risk (a score of 18 or less on the Braden Scale) and the interventions are documented on the care plan.

THIS CITATION REFERS TO INTAKE NUMBER MI 401. BASED ON INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE OR APPROPRIATE SUPERVISION TO PREVENT A FALL FOR 1 (#101) RESIDENT OF 4 RESIDENTS SAMPLED FOR FALLS IN A TOTAL SAMPLE OF 11 RESIDENTS, RESULTING IN RESIDENT #101 ROLLING OUT OF BED DURING CARE, HITTING HER HEAD SUSTAINING A HEMATOMA (A LOCALIZED SWELLING FILLED WITH BLOOD) OVER HER RIGHT EYE, AND FRACTURED RIGHT CLAVICLE. FINDINGS INCLUDE: ACCORDING TO THE SBAR (PHYSICIAN COMMUNICATION) FORM ON 12/22/2012 AT 1:45 PM, NURSE #12 REPORTED TO THE PHYSICIAN THAT RESIDENT #101"fell OUT OF BED" AND HIT HER HEAD. THE PHYSICIAN GAVE AN ORDER TO TRANSFER RESIDENT #101 TO A LOCAL emergency room FOR EVALUATION AND TREATMENT. THE FACILITY FACE SHEET INDICATED RESIDENT #101 WAS A [AGE] year OLD WOMAN INITIALLY admitted to the facility on [DATE] AND MOST RECENTLY ON 12/10/2012. THE HISTORY AND PHYSICAL DATED 12/12/12 REVEALED [DIAGNOSES REDACTED]. A MINIMUM DATA SET (MDS) assessment dated [DATE] INDICATED RESIDENT #101 WAS UNABLE TO UNDERSTAND OR MAKE HER NEEDS KNOWN. A BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) THAT WAS UNABLE TO BE COMPLETED INDICATED RESIDENT #101 WAS SEVERELY COGNITIVELY IMPAIRED. RESIDENT #101 WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADLS). THE FACILITY INCIDENT AND ACCIDENT REPORT DATED 12/22/2012 INDICATED RESIDENT #101 ROLLED OVER THE BOLSTERS AND fell on THE FLOOR, HITTING HER HEAD ON THE EDGE OF THE NIGHT STAND. THE DOCUMENTATION INDICATED THAT NURSE #12 HAD LEFT THE BEDSIDE TO OBTAIN GLOVES AND WHILE CERTIFIED NURSE ASSISTANT (CNA) #13 WAS MOVING FROM ONE SIDE OF THE BED TO THE OTHER, AND WAS UNABLE TO REACH THE RESIDENT IN TIME TO PREVENT THE FALL. INITIAL OBSERVATION OF THE RESIDENT IDENTIFIED A HEMATOMA AND BLACKENED AREA OVER HER RIGHT EYE. NURSING PROGRESS NOTES DATED 12/22/12 (3-11 PM) INDICATED RESIDENT #101 RETURNED TO THE FACILITY FROM A LOCAL ACUTE CARE HOSPITAL AT 8:30 PM WITH "HEMATOMA ABOVE HER R (RIGHT) EYE, BROKEN COLLARBONE, AND EAR INFECTION." HOSPITAL RECORDS OBTAINED ON 2/28/2013, REVEALED AN X-RAY RESULT, DATED 12/22/2012 FROM THE emergency room ADMISSION POST FALL AT NURSING FACILITY, OF "NONDISPLACED FRACTURE OF THE RIGHT DISTAL CLAVICLE." ON 12/26/2012 THE PHYSICIAN ORDERED "STAT CLAVICLE XRAY RT (RIGHT) AND LT (LEFT). THE RADIOLOGY REPORT OF RIGHT CLAVICLE DATED 12/26/2012 INDICATED "SLIGHTLY DISPLACED FRACTURE OUTER END OF THE CLAVICLE, PROBABLY RECENT." LEFT CLAVICLE RADIOLOGY REPORT DATED 12/26/2012 INDICATED "NO DEFINITE RADIOGRAPHIC EVIDENCE OF ACUTE FRACTURE OR DISLOCATION OF CLAVICLE." ACCORDING TO THE DIRECTOR OF NURSING (DON) #2, DURING AN INTERVIEW ON 2/19/2013 AT 4:00 PM, A MESSAGE WAS LEFT FOR NURSE #12 TO EXPLAIN THE CIRCUMSTANCES SURROUNDING RESIDENT #101'S FALL. NURSE #12 NEVER RETURNED THE CALL AND DID NOT SHOW UP FOR ANY FURTHER SCHEDULED SHIFTS. ATTEMPTS TO CONTACT NURSE #12 WERE UNSUCCESSFUL. CNA #13 WAS SUSPENDED DURING THE INVESTIGATION. ON 12/26/2012 CNA #13 SIGNED A "DISCIPLINARY ACTION RECORD FOR FAILED TO FOLLOW PROPER POLICY/ PROCEDURE AS IN-SERVICED ON 9/7/12 ON TURNING AND REPOSITIONING FOR SAFETY, COMFORT, ROLLING RESIDENT TOWARD YOU FOR SAFETY TO PREVENT INCIDENT/ACCIDENT." ON 2/26/2013 AT 4:50 PM, CNA #13 SAID THAT SHE (#13) HAD ALREADY CLEANED RESIDENT #101 AND WAS ASSISTING NURSE #12, WHO WAS GETTING SUPPLIES TO COMPLETE THE WOUND CARE. CNA #13 SAID THAT NURSE #12 LEFT THE BEDSIDE TO GET GLOVES AND HAD HER BACK TO RESIDENT #101. CNA #13 SAID SHE WAS MOVING FROM ONE SIDE OF THE BED TO THE OTHER (TO HOLD THE RESIDENT OVER FOR NURSE #12) AND WHEN SHE GOT TO THE END OF THE BED, SHE (CNA #13) SLIPPED ON DEBRIS ON THE FLOOR AND BARELY CAUGHT HERSELF FROM FALLING. AT THAT TIME, RESIDENT #101 BECAME AGITATED AND ROLLED HERSELF OVER THE BED BOLSTER ONTO THE FLOOR. CNA #13 SAID SHE COULDN'T GET THERE FAST ENOUGH TO PREVENT THE FALL. CNA #13 SAID SHE SHOULD NOT HAVE LEFT THE SIDE OF THE BED WHEN THE NURSE WAS NOT ON THE OTHER SIDE. SHE SAW THE RESIDENT ROLL OUT AND HIT HER HEAD ON THE OPEN DRAWER OF THE NIGHTSTAND. CNA #13 SAID SHE GOT A DISCIPLINE AND 3 DAY SUSPENSION BECAUSE OF THE INCIDENT.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONSISTENTLY ASSESS, MONITOR AND IMPLEMENT INTERVENTIONS TO PREVENT AVOIDABLE PRESSURE SORES FOR THREE (#'S 652, 654, AND 667) OF TEN RESIDENTS REVIEWED FOR PRESSURE SORES FROM A TOTAL SAMPLE OF 26 RESIDENTS, RESULTING IN FACILITY ACQUIRED PRESSURE SORES AND THE INCREASED POTENTIAL FOR UNIDENTIFIED AND/OR UNMONITORED PRESSURE SORES. FINDINGS INCLUDE: ON 8/21/12 FROM 9:20 A.M. UNTIL 1:20 P.M., RESIDENT #652 WAS OBSERVED SEATED IN THE SAME POSITION, UPRIGHT IN A WHEELCHAIR, WEARING AN ORTHO SHOE WITH A VELCRO FASTENER SECURED TO HIS LEFT FOOT. ON 8/21/12 AT 2:35 P.M., REVIEW OF CLINICAL RECORDS REVEALED THE FOLLOWING: RESIDENT #652 WAS INITIALLY admitted INto the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE ADMISSION MINIMUM DATA SET ((MDS) dated [DATE] REVEALED THAT THE RESIDENT WAS COGNITIVELY INTACT, UNABLE TO AMBULATE, REQUIRED EXTENSIVE ASSISTANCE OF ONE PERSON FOR TRANSFERS, BATHING, DRESSING, HYGIENE AND TOILETING. THE MDS DOCUMENTED THAT RESIDENT #652 WAS AT RISK FOR PRESSURE SORES BUT DID NOT HAVE A PRESSURE SORE. REVIEW OF RESIDENT #652'S "ADMISSION NURSING COMPREHENSIVE EVALUATION" DATED 7/31/12, REVEALED THE SKIN WAS INTACT ON HIS LEFT HEEL. THERE WERE NO DOCUMENTED AREAS OF PRESSURE SORES. THE BRADEN SCALE (TOOL THAT DETERMINES RISK FOR PRESSURE SORES) WAS DOCUMENTED AS "17", INDICATING THAT THE RESIDENT WAS AT LOW RISK FOR THE DEVELOPMENT OF PRESSURE SORES. REVIEW OF THE "NURSE NOTES" FROM 8/1/12 - 8/17/12, REVEALED BLANK ENTRIES FOR THE SECTION LABELED "SKIN CONDITION". THERE WERE NO ADDITIONAL DESCRIPTIONS OF THE SKIN CONDITION. ADDITIONALLY, FOR THE "MEDICARE DAILY NURSE NOTES" FROM 8/19 - 8/20/12, THE SKIN CONDITION WAS NOT ADDRESSED AS EVIDENCED BY BLANK ENTRIES. REVIEW OF "NURSE PROGRESS NOTES" READ: 8/1/12, "L (LEFT) HEEL MISSING, AREA DRY WITH OLD, HEALED WOUND..." 8/11/12, "LT (LEFT) HEEL WITH DRY FLAKEY SKIN SURROUNDING MACERATED TISSUE IN THE MIDDLE SM (SMALL) AMT (AMOUNT) OF SEROSANG (SEROSANGUINEOUS - FLUID SUBSTANCE THAT CONTAINS BLOOD AND SERUM) DRAINING..." 8/14/12, "RESIDENT OBSERVED WITH OPEN AREA TO LEFT HEEL. MEASURES 5.5 X 6.8 CM (CENTIMETERS), SURROUNDING SKIN DRY AND FLAKEY, MACERATED TISSUE IN THE MIDDLE OF WOUND. SCANT AMOUNT OF SEROSANGUINOUS DRAINAGE PRESENT. ORDER FOR WOUND TEAM-CONSULT WRITTEN..." 8/22/12, "ORDER CHANGE FOR LEFT HEEL. ST. (STAGE) III (PARTIAL THICKNESS SKIN LOSS), 6.0 X 6.8 CM. ORDER NOW CLEANSE WITH WOUND CLEANSER, PAT DRY, APPLY HYDROGEL, COVER WITH 4 X 4'S, ABD, WRAP WITH KERLIX Q (EVERY) DAY AND PRN (AS NEEDED). LEFT HEEL DESCRIPTION, ST III, SURROUNDING SKIN DRY. PALE PINK BASE WITH SCANT YELLOW DRAINAGE." REVIEW OF THE "ALTERATION IN SKIN INTEGRITY CARE PLAN" DATED 8/1/12, WAS NOT UPDATED TO REFLECT THE CHANGE IN SKIN CONDITION WHEN THE PRESSURE SORE WAS IDENTIFIED ON 8/11/12 UNTIL 8/14/12. THE APPROACH/PLAN READ, "SKIN ASSESS WITH SHOWERS, TX NURSE TO ASSESS WKLY (WEEKLY), FLOAT HEALS". REVIEW OF RESIDENT #652'S "physician progress notes [REDACTED]." REVIEW OF THE "MDS DOCUMENTATION PROGRESS NOTE" DATED 8/8/12, READ..."SKIN: TWO SUTURED SITES RIGHT GROIN, RIGHT ARM...". THERE WAS NO DOCUMENTATION ABOUT A CONCERN IN THE SKIN CONDITION OF RESIDENT #652'S LEFT HEEL. ADDITIONALLY, THE "MDS DOCUMENTATION PROGRESS NOTE" DATED 8/13/12, DID NOT REFLECT ANY DOCUMENTATION ABOUT RESIDENT #652'S PRESSURE SORE OR THAT THERE WAS A CONCERN WITH RESIDENT #652'S SKIN CONDITION. ON 8/21/12 AT 3:30 P.M., AN INTERVIEW AND RECORD REVIEW WITH THE ASSISTANT DIRECTOR OF NURSING (ADON) WAS CONDUCTED AND CONFIRMED THERE WERE NO SKIN ASSESSMENTS COMPLETED FOR RESIDENT #652 OTHER THAN THE INITIAL NURSING EVALUATION ON 7/31/12 WHICH SHOWED NO OPEN AREA ON THE LEFT HEEL. THE ADON WAS QUERIED ABOUT THE FACILITY'S PROTOCOL FOR MONITORING AND REPORTING CHANGES IN SKIN CONDITIONS AND STATED, "IF ANY CHANGES ARE NOTED THEY (CERTIFIED NURSING ASSISTANTS) WOULD REPORT IT TO THE NURSES." ON 8/23/12 AT 2:10 P.M., A WOUND OBSERVATION OF RESIDENT #652'S LEFT HEEL WAS CONDUCTED WITH TREATMENT NURSE "I" AND CERTIFIED NURSING ASSISTANT "S" AND REVEALED A STAGE III PRESSURE SORE ON HIS LEFT HEEL WITH ESCHAR AND YELLOW SLOUGH. ON 8/24/12 AT 8:50 A.M., AN INTERVIEW WITH TREATMENT NURSE "I" AND THE ADON CONFIRMED RESIDENT #652 HAD NOT YET BEEN EVALUATED BY THE WOUND CARE PHYSICIAN. THERE WAS NO DOCUMENTATION THAT A WOUND CARE CONSULTATION HAD BEEN COMPLETED. ON 8/24/12 AT 10:00 A.M., THE ADON PROVIDED A SKIN assessment dated [DATE], WHICH INDICATED NO CONCERN TO THE LEFT HEEL PRESSURE SORE AND READ, "SKIN ALTERATION: EXISTING AREA (MARKED AS AN X)." THE ONLY DOCUMENTATION ABOUT THE FEET WAS MARKED AS "DRY SKIN". ) ON 8/23/12 AT 2:00 P.M., A REVIEW OF THE ADMISSION FACESHEET AND CLINICAL RECORD, DOCUMENTED RESIDENT #667 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (M.D.S.) DATED 7/19/12, DOCUMENTED RESIDENT #667 WAS MODERATELY IMPAIRED FOR DECISION MAKING SKILLS AND REQUIRED EXTENSIVE ASSISTANCE WITH BED MOBILITY, AND ACTIVITIES OF DAILY LIVING. FURTHER REVIEW OF THE M.D.S. DOCUMENTED THE RESIDENT DID NOT HAVE PRESSURE SORES, BUT WAS AT RISK FOR PRESSURE SORES. REVIEW OF AN ADMISSION NURSING assessment dated [DATE] AT 6:30 P.M., DOCUMENTED THE RESIDENT HAD LEFT HIP AND LOWER LEFT LEG STAPLES AND SUTURES. (THERE WERE NO PRESSURE SORES DOCUMENTED). REVIEW OF RESIDENT #667's "BRADEN SCALE" (PRESSURE ULCER RISK TOOL) DATED 7/12/12, DOCUMENTED A SCORE OF "17" (MILD RISK). REVIEW OF NURSING WEEKLY (HEAD-TO-TOE) SKIN ASSESSMENTS DOCUMENTED AS FOLLOWS: 1. ON 7/12/12, "5 STAPLES LEFT OUTER KNEE, 12 STAPLES OUTER THIGH, 7 STAPLES HIP, LEFT KNEE [MEDICAL CONDITION], BILATERAL LOWER EXTREMITY [MEDICAL CONDITION], UPPER BILATERAL [MEDICAL CONDITION]." (THERE WERE NO PRESSURE SORES DOCUMENTED). 2. ON 7/19/12, "5 STAPLES LEFT OUTER KNEE, 12 STAPLES OUTER THIGH, 7 STAPLES HIP, LEFT KNEE [MEDICAL CONDITION], BILATERAL LOWER EXTREMITY [MEDICAL CONDITION], UPPER BILATERAL [MEDICAL CONDITION]." (THERE WERE NO PRESSURE SORES DOCUMENTED). 3. ON 7/26/12, "SUTURES 3 SITES LEFT LEG, HIP AND THIGH." (THERE WERE NO PRESSURE SORES OR OTHER SKIN ALTERATIONS, DOCUMENTED). 4. ON 8/2/12, "OPEN AREA ON LEFT BUTTOCKS." (THERE WAS NO NURSE'S SIGNATURE DOCUMENTED). 5. ON 8/9/12, "TREATMENT CONTINUED ON LEFT BUTTOCK." 6. ON 8/16/12, "TREATMENT IN PROGRESS." 7. ON 8/23/12, "NEW OPEN AREA NOTED, TREATMENT IN PROGRESS." REVIEW OF "WOUND" NURSE'S NOTES DOCUMENTED: 1. ON 7/23/12, "RESIDENT OBSERVED WITH OPEN AREA TO LEFT BILATERAL BUTTOCK, 3.0 X 1.5 CENTIMETERS, PINK BASE, MODERATE YELLOW SLOUGH, ROLLING , IRREGULAR EDGES...WOUND TEAM CONSULT WRITTEN." (HOWEVER, THE SKIN assessment dated [DATE] (3 DAYS FOLLOWING), DOCUMENTED THE RESIDENT HAD NO PRESSURE SORES). 2. ON 7/25/12, "SEEN BY WOUND TEAM COCCYX/LEFT BUTTOCK STAGE III (PARTIAL THICKNESS SKIN LOSS), 1.5 X 2.5 X 0.2 CM." 3. ON 8/1/12, "SEEN BY WOUND TEAM. LEFT BUTTOCK PRESSURE STAGE III 0.7 X 1.8 X 0.3 CM...COCCYX RESOLVED. 4. ON 8/8/12 "...LEFT BUTTOCK PRESSURE ULCER STAGE III. 0.6 X 1.5 X 0.2 CM..." 5. ON 8/15/12, "SEEN BY WOUND TEAM LEFT BUTTOCK STAGE III 0.5 X 1.2 CM..." 6. ON 8/22/12, "SEEN BY WOUND TEAM. LEFT BUTTOCK STAGE III 0.4 X 1.3..." REVIEW OF WOUND PHYSICIAN CONSULT DOCUMENTED THE FOLLOWING: ON 7/25/12, "COCCYX/LEFT BUTTOCK 1.5 X 2.5 X 0.2 CM, MODERATE SEROUS DRAINAGE, IRREGULAR EDGES... DIAGNOSES. PRESSURE ULCER STAGE III COCCYX/LEFT BUTTOCK. (2). DM (DIABETES MELLITUS). RECOMMENDATIONS: (1). SANTYL EVERY DAY AND AS NEEDED COCCYX/LEFT BUTTOCK, (2). LOW AIR LOSS MATTRESS, (3). FREQUENTLY REPOSITION, (4). FLOAT BILATERAL LOWER EXTREMITIES, (5). LOW AIR LOSS SEAT CUSHION. ON 8/23/12 AT 1:30 P.M., DURING AN INTERVIEW WITH RESIDENT #667 WHEN QUERIED REGARDING THE PRESSURE SORE, STATED "I THINK I GOT THE SORE BECAUSE WHEN I GOT HERE THEY TOLD ME I HAD TO STAY ON MY BACK BECAUSE OF MY HIP (FRACTURE). I COULDN'T TURN I HAD TO LAY LIKE THIS (THE RESIDENT WAS OBSERVED LAYING ON HER BACK IN BED, THERE WAS NO LOW AIR LOSS MATTRESS NOTED AT THAT TIME). ON 8/23/12 AT 1:50 P.M., DURING A WOUND CARE OBSERVATION WITH TREATMENT NURSE "I" REVEALED THAT RESIDENT #667 HAD A STAGE III (THREE), PRESSURE SORE TO THE LEFT BUTTOCK. THE WOUND MEASURED 0.4 X 1.3 CM (ON 8/22/12 BY THE WOUND CARE PHYSICIAN). THERE WAS A MODERATE AMOUNT OF SEROUS DRAINAGE NOTED. (THERE WAS NO LOW AIR LOSS MATTRESS NOTED FROM 8/21/12-8/24/12 BETWEEN 9:00 A.M., AND 4:00 P.M.). ON 8/24/12 AT 10:30 A.M., DURING A TELEPHONE FAMILY INTERVIEW FOR RESIDENT #667 WHEN QUERIED REGARDING THE DEVELOPMENT OF THE PRESSURE SORE, THE FAMILY MEMBER STATED, "WHEN I WAS VISITING ONE DAY OVER THREE WEEKS AGO MY GRANDMOTHER (THE RESIDENT) TOLD ME HER BOTTOM WAS HURTING AND SHE SAID, IT FELT LIKE SHE WAS LYING ON SOMETHING HARD. SHE HAD AN AIR MATTRESS ON HER BED AT THAT TIME. THE NURSE CAME IN TO CHECK THE MATTRESS. WHEN THE NURSE AND I CHECKED THE MATTRESS WE FELT A HARD COIL WITHIN THE MATTRESS. THAT WAS WHAT MY GRANDMOTHER HAD FELT AND HAD BEEN LYING ON. THE NURSE SAID THE AIR MATTRESS WAS NOT WORKING RIGHT. THE NURSE HAD SOMEONE FROM MAINTENANCE TO REMOVE THAT MATTRESS. THEY REPLACED IT WITH A REGULAR MATTRESS NOT AN AIR MATTRESS. ON 8/24/12 AT 11:30 A.M., DURING AN INTERVIEW AND RECORD REVIEW WITH THE ASSISTANT DIRECTOR OF NURSING (A.D.O.N.) WHEN QUERIED REGARDING RESIDENT #667'S PRESSURE SORE STATED "I DON'T KNOW HOW THE RESIDENT GOT THE PRESSURE SORE.", "I DON'T KNOW ANYTHING ABOUT THE AIR MATTRESS NOT WORKING." ON 8/24/12 AT 1:15 P.M., DURING AN INTERVIEW WITH TREATMENT NURSE "I" WHEN QUERIED REGARDING THE RESIDENT #667'S PRESSURE SORE STATED "THE RESIDENT'S FAMILY MEMBER TOLD US, THAT THE RESIDENT HAD A PRESSURE SORE. WHEN FURTHER QUERIED TREATMENT NURSE "I" COULD NOT EXPLAIN WHY THE RESIDENT WAS NOT ON A LOW AIR LOSS MATTRESS. TREATMENT NURSE "I" COULD NOT EXPLAIN WHY THE WEEKLY SKIN SHEET DATED 7/26/12, DID NOT INDICATE THAT THE RESIDENT HAD A PRESSURE SORE (THREE DAYS AFTER THE TREATMENT NURSE'S WOUND NOTE DOCUMENTED THE RESIDENT HAD A PRESSURE SORE ON 7/23/12). REVIEW OF THE FACILITY'S POLICY TITLED "SKIN MANAGEMENT" DATED. 5/2010, DOCUMENTED AS FOLLOWS: " IF A NEW AREA OF SKIN IMPAIRMENT IS IDENTIFIED, NOTIFY THE RESIDENT, RESPONSIBLE PARTY, ATTENDING PHYSICIAN, DIRECTOR OF NURSING AND TREATMENT TEAM, IF APPLICABLE, AND PLACE THE RESIDENT ON THE 24-HOUR REPORT. ( ) ON 8/22/12 AT 10:00 A.M., REVIEW OF THE ADMISSION FACESHEET AND CLINICAL RECORD DOCUMENTED RESIDENT #654 WAS ORIGINALLY admitted INto the facility on [DATE] AND REadmitted on [DATE] TO HOSPICE WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (M.D.S.) DATED 7/12/12, DOCUMENTED RESIDENT #654 WAS SEVERELY IMPAIRED FOR DECISION MAKING SKILLS AND TOTALLY DEPENDENT ON STAFF FOR BED MOBILITY AND ALL ACTIVITIES OF DAILY LIVING. FURTHER REVIEW OF THE M.D.S. DOCUMENTED THE RESIDENT HAD ONE STAGE IV PRESSURE SORE THAT MEASURED 4.5 X 1.8 X 1.6 CM (CENTIMETERS). REVIEW OF "WOUND", NURSING NOTES DOCUMENTED THE FOLLOWING: -7/11/12, "SEEN BY WOUND TEAM... PRESSURE ULCER STAGE IV, 4.5 X 1.8 X 1.6... -8/1/12, "SEEN BY WOUND TEAM...SACRAL STAGE IV 3.2 X 2.4 X 1.0 CM. (THERE WERE NO WEEKLY SKIN ASSESSMENTS OR MEASUREMENTS FOR THE RESIDENT'S PRESSURE SORES BETWEEN 7/11/12-8/1/12, NOR AFTER 8/1/12 BY THE FACILITY NOR THE WOUND PHYSICIAN). ON 8/22/12 FROM 9:00 A.M., UNTIL 3:15 P.M., AND ON 8/23/12 FROM 8:30 A.M., UNTIL 11:00 A.M., RESIDENT #654 WAS OBSERVED IN BED LYING ON HER RIGHT SIDE. ON 8/23/12 FROM 12:00 P.M., UNTIL 3:45 P.M., RESIDENT #654 WAS OBSERVED IN BED LYING ON HER RIGHT SIDE. ON 8/24/12 FROM 8:45 A.M., UNTIL 1:30 P.M., RESIDENT #654 WAS OBSERVED IN BED LYING ON HER RIGHT SIDE. (THE RESIDENT'S HEELS WERE NOT FLOATED AND HER RIGHT LEG WAS OBSERVED LYING DIRECTLY ON THE AIR MATTRESS). ON 8/23/12 AT 11:00 A.M., RESIDENT #654 WAS AWAKE LYING IN BED ON HER RIGHT SIDE. THE RESIDENT'S RIGHT LEG WAS LYING DIRECTLY ON THE AIR MATTRESS. THE RESIDENT'S HEELS WERE NOT FLOATED. THERE WAS A PILLOW BETWEEN THE RESIDENT'S KNEES. AT THAT TIME, DURING A WOUND CARE OBSERVATION WITH TREATMENT NURSE "I" REVEALED THAT RESIDENT #654 HAD A STAGE IV SACRAL PRESSURE SORE. THE WOUND BASE WAS PINK. THERE WAS A MODERATE AMOUNT OF SEROSANGUINEOUS DRAINAGE NOTED ON THE OLD DRESSING. ON 8/23/12 AT 11:45 A.M., DURING AN INTERVIEW AND RECORD REVIEW WITH TREATMENT NURSE "I" WHEN QUERIED REGARDING RESIDENT #654'S SACRAL PRESSURE SORE AND WEEKLY ASSESSMENTS AND MEASUREMENTS, TREATMENT NURSE "I" STATED "SHE (THE RESIDENT) IS HOSPICE, SHE IS NOT SEEN BY THE WOUND TEAM." AT THAT TIME DURING RECORD REVIEW, TREATMENT NURSE "I" WAS UNABLE TO EXPLAIN WHY THERE WERE NO WEEKLY NURSING ASSESSMENT NOTES FOR THE RESIDENT'S SACRAL PRESSURE SORE. WHEN FURTHER QUERIED REGARDING THE RESIDENT'S SACRAL PRESSURE SORE MEASUREMENTS, TREATMENT NURSE "I" STATED, "I DON'T MEASURE WOUNDS." REVIEW OF THE FACILITY'S "SKIN MANAGEMENT" POLICY, DATED 5/2010, DOCUMENTED THE FOLLOWING: #5. "THE LICENSED NURSE WILL INITIATE THE APPROPRIATE SKIN FORM, WHICH INCLUDES A DESCRIPTION OF THE ULCER AS FOLLOWS; -USE THE WOUND/SKIN HEALING RECORD FOR ALL IDENTIFIED PRESSURE ULCER AREAS. -PLACE THE FORM IN THE CURRENT TREATMENT BOOK, AND DOCUMENT WEEKLY UNTIL THE AREA IS HEALED." ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 942 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SAFE AND APPROPRIATE SAFETY MEASURES TO PREVENT A FALL FOR ONE (#501) OF 5 SAMPLED RESIDENTS AT RISK FOR FALLS FROM A TOTAL SAMPLE OF FIVE RESIDENTS, RESULTING IN HEAD TRAUMA, A THORACOABDOMINAL INJURY (PERFORATION OF THE DIAPHRAGM) AND ESOPHAGEAL RUPTURE. FINDINGS INCLUDE: ACCORDING TO THE FACILITY INCIDENT REPORT DATED [DATE] AT 11 P.M., "CENA (CERTIFIED NURSE AIDE) STATES WHEN SHE TURNED RESIDENT TO PROVIDE CARE, RESIDENT ROLLED OUT OF BED LANDING ON RIGHT SIDE OF BODY." RESIDENT #501 DID NOT RESIDE IN THE FACILITY AT THE TIME OF THE INVESTIGATION. ACCORDING TO THE DIRECTOR OF NURSES (DON), RESIDENT #501 WAS TRANSFERRED TO A LOCAL HOSPITAL EMERGENCY DEPARTMENT ON [DATE]. SHE WAS THEN TRANSFERRED TO AN IN-PATIENT HOSPICE PROGRAMS AND died on E WEEK AFTER THE INCIDENT. A CLINICAL RECORD REVIEW ON [DATE] AT 12:30 P.M., REVEALED THAT RESIDENT #501 WAS AN [AGE] year OLD FEMALE admitted INto the facility on [DATE] AND REadmitted on [DATE]. HER [DIAGNOSES REDACTED]. THE RESIDENT WAS ON HOSPICE. THE MINIMUM DATA SET ASSESSMENT (MDS) REVEALED A BIMS SCORE OF 8 WHICH SUGGESTED THAT RESIDENT #501 HAD MODERATELY IMPAIRED COGNITION. THE RESIDENT WAS TOTALLY DEPENDENT ON STAFF FOR BED MOBILITY AND TRANSFERS AND REQUIRED ASSISTANCE FROM TWO PEOPLE. ON [DATE] AT 12:10 P.M., AN INTERVIEW WAS CONDUCTED WITH CERTIFIED NURSE AIDE (CNA) #6. THE CNA REPORTED THAT SHE WAS ASSIGNED TO CARE FOR RESIDENT #501 ON THE DAY OF THE INCIDENT. CNA #6 WAS ASKED ABOUT THE FALL INCIDENT WITH RESIDENT #501 AND SHE EXPLAINED THAT ON [DATE], "IT HAPPENED NEAR THE END OF THE SHIFT. I MADE HER THE LAST PATIENT. I WAS TIRED AND EXHAUSTED. I TURNED HER OVER, AWAY FROM ME, SHE JERKED AND HER BODY fell . WHEN SHE fell on THE FLOOR SHE HIT HER HEAD. THERE WERE NO MATS ON THE FLOOR." THE CNA WAS ASKED WHY SHE DID NOT HAVE SOMEONE ASSIST HER WITH REPOSITIONING RESIDENT #501 AND CNA #6 STATED, "THE PAPERWORK SAID THAT SHE WAS A FALL RISK. I ALWAYS USE TWO PEOPLE WHEN I PROVIDE CARE TO HER. I LOOKED AROUND FOR ABOUT 30 MINUTES TO FIND SOMEONE TO HELP ME WITH HER, BUT I COULDN'T FIND ANYONE. THERE WERE ONLY TWO AIDES WORKING THAT DAY. I HAD 16 PATIENTS ASSIGNED TO ME. WHEN I DIDN'T FIND ANYONE TO ASSIST ME, I PROVIDED CARE FOR THE RESIDENT BY MYSELF." FURTHER REVIEW OF RESIDENT #501'S CLOSED RECORD DID NOT REVEAL A CNA CARE GUIDE (INSTRUCTIONS FOR CNAS FOR PROVIDING CARE TO RESIDENTS). ON [DATE] AT 11:15 P.M., WHEN THE DIRECTOR OF NURSES (DON) WAS QUERIED ABOUT THE CNA CARE GUIDE, SHE (DON) STATED, "I LOOKED FOR THE CNA CARE GUIDE ON THE DAY OF THE INCIDENT AND IT WAS NOT IN THE ROOM. IT COULD NOT BE FOUND." ON [DATE], AT APPROXIMATELY AT 4:00 P.M., THE DON LOCATED AN (UNDATED) CNA CARE GUIDE, WHICH INDICATED THAT RESIDENT #501 REQUIRED A TWO PERSON ASSIST WITH BED MOBILITY. ON [DATE] AT 12:30 P.M., DURING AN INTERVIEW WITH THE FACILITY ADMINISTRATOR, SHE (ADMINISTRATOR) STATED, "THERAPY SAID THAT THE RESIDENT WAS A TOTAL ASSIST (FOR BED MOBILITY)." ACCORDING TO THE "THERAPY COMMUNICATION FORM TO NURSING," DATED [DATE], RESIDENT #501 REQUIRED A TWO PERSON ASSIST WITH BED MOBILITY. REVIEW OF THE ACTIVITY OF DAILY LIVING (ADL) SHEETS FOR THE MONTH OF [DATE] REVEALED THAT CNAS DOCUMENTED THAT THEY PROVIDED BED REPOSITIONING USING ONLY ONE PERSON. REVIEW OF RESIDENT #501'S "FALLS" CARE PLAN REVEALED FLOOR MATS WERE ADDED AS A FALL SAFETY INTERVENTION ON [DATE] (AFTER THE INCIDENT). ON [DATE] AT 12:00P.M., THE DON WAS QUERIED ABOUT THE INCIDENT AND REPORTED THAT THE CNA INVOLVED WAS DISCIPLINED AND WAS IN-SERVICED ON REPOSITIONING. THE DON STATED, "WE DID A COMPETENCY ON THE CNA AND GAVE HER A FINAL WARNING BECAUSE OF THE SEVERITY OF THE INJURY." REVIEW OF NURSE'S NOTES REVEALED THE FOLLOWING ENTRIES: ON [DATE] AT 11:00 P.M., "CALLED TO RESIDENT ROOM BY ASSISTANT CENA. RESIDENT OBSERVED LYING ON FLOOR IN FRONT OF BED ON RIGHT SIDE. CENA STATED WHILE PROVIDING CARE SHE TURNED RESIDENT AND SHE ROLLED OUT OF BED...HEMATOMA NOTED ON RIGHT FOREHEAD, ICE APPLIED. (DOCTOR) NOTIFIED, NEW ORDERS WRITTEN AND NOTED. NEUROCHECKS X 48 HOURS, NO XRAY'S..." ON [DATE] AT 6:00 A.M., "STAT SKULL X-RAY ORDERED..." THERE WAS NO DOCUMENTATION NOTED AS TO WHY THE X-RAY WAS ORDERED. ON [DATE] AT 12:15 P.M., "RESIDENT HAD COFFEE GROUND EMESIS...DOCTOR NOTIFIED, GAVE ORDERS TO TRANSFER TO HOSPITAL FOR A CT (COMPUTED TOMOGRAPHY) SCAN RELATED TO FALL ON THE PREVIOUS NIGHT..." ON [DATE] AT 1:10 P.M., A TELEPHONE INTERVIEW WAS CONDUCTED WITH NURSE #17 WHO EXPLAINED THAT SHE WAS THE NURSE ON DUTY ON UNIT A THE NIGHT OF THE INCIDENT INVOLVING RESIDENT #501. NURSE #17 WAS QUERIED ABOUT THE INCIDENT AND SHE STATED, "IT WAS AT THE END OF THE SHIFT. THE ASSIGNED CNA CAME TO ME AND SAID THE RESIDENT fell . WHEN I WENT INTO THE ROOM, THE RESIDENT WAS ON THE FLOOR ON HER RIGHT SIDE. SHE HAD A HEMATOMA ON HER FOREHEAD. I TALKED TO THE DOCTOR AND BECAUSE THE RESIDENT WAS ON HOSPICE, THEY ORDERED NO X-RAYS. THEY JUST WANTED NEUROCHECKS. WHEN I CAME BACK TO WORK THE FOLLOWING DAY, AT 3 P.M., I NOTICED THAT an order for [REDACTED]." NURSE #17 WAS UNABLE TO EXPLAIN WHY THE X-RAY ORDER WAS WRITTEN, OR WHAT CAUSED THE HOSPITAL TRANSFER. ON [DATE] AT APPROXIMATELY 12:30 P.M., A TELEPHONE INTERVIEW WAS CONDUCTED WITH THE FORMER UNIT MANAGER #15 OF UNIT A. THE FORMER UNIT MANAGER EXPLAINED THAT SHE WAS STILL EMPLOYED AT THE FACILITY AT THE TIME OF THE FALL INCIDENT WITH RESIDENT #501. WHEN UNIT MANAGER #15 WAS QUERIED ABOUT THE INCIDENT WITH RESIDENT #501, SHE STATED, "IT HAPPENED ON MIDNIGHTS. I CAME IN ON THE FOLLOWING MORNING AND WAS INFORMED ABOUT IT. THE RESIDENT HAD A HEMATOMA ON THE RIGHT SIDE OF HER FACE. SHE WAS EXPERIENCING PROJECTILE VOMITING WHICH PROMPTED US TO SEND HER TO THE HOSPITAL. SHE WAS SUPPOSED TO HAVE A CT SCAN AND THEN SHE WAS TO BE SENT BACK TO THE FACILITY, BUT SHE NEVER CAME BACK." NURSE #18 WAS INTERVIEWED ON [DATE] AT 1:40 P.M., AND SHE EXPLAINED THAT SHE WAS IN ORIENTATION ON [DATE], BUT CONFIRMED THAT THE RESIDENT WAS VOMITING DURING THE DAY PRIOR TO HER HOSPITAL TRANSFER. THROUGHOUT THE SURVEY, STAFF WHO PROVIDED DIRECT CARE FOR RESIDENT #501 WERE INTERVIEWED AND REPORTED THAT THEY WOULD TURN THE RESIDENT TOWARD THEM WHEN PROVIDING CARE, NOT AWAY FROM THEM. ONE STAFF MEMBER WHO REQUESTED TO REMAIN ANONYMOUS STATED, "THE RESIDENT HAD NO REFLEX ABILITY AND WAS NOT ABLE TO EXTEND HER ARMS TO BREAK HER FALL. WE ALL KNEW THAT ABOUT HER. I BELIEVE THAT THE CNA CARING FOR THE RESIDENT ON THE NIGHT OF THE INCIDENT WAS RUSHING AND WAS NOT BEING CAREFUL." ACCORDING TO THE PATIENT TRANSFER DATED [DATE] THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL FOR A "CT SCAN AND THEN PATIENT CAN BE SENT BACK." THE PHYSICIAN ORDERS [REDACTED]." ACCORDING TO THE HOSPITAL emergency room REPORT DATED [DATE], THE FINAL IMPRESSION [DIAGNOSES REDACTED]. THE REPORT FURTHER STATED, "THIS PATIENT WHO LIKELY SUFFERED SOME SERIOUS THORACOABDOMINAL INJURY GIVEN THE REPORTED HEMATEMESIS...WE HAVE TO INCLUDE ESOPHAGEAL RUPTURE, PULMONARY CONTUSION, GREAT VESSEL INJURY AND HOLLOW VISCOUS PERFORATION...THE PATIENT HAS LIKELY SUFFERED WHAT IS GOING TO BE A FATAL INJURY." ACCORDING TO THE "FALL MANAGEMENT" POLICY DATED ,[DATE], "...RESIDENTS IDENTIFIED AT RISK FOR FALLS WILL HAVE A CARE PLAN DEVELOPED AND IMPLEMENT APPROPRIATE FALL PREVENTION INTERVENTIONS..." REVIEW OF RESIDENT #501'S "BED MOBILITY" CARE PLAN REVEALED THAT STAFF WERE TO "...ROLL (RESIDENT) TOWARD THE STAFF MEMBER..." ( )

REFERS TO INTAKE MI 843. BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT PHYSICAL ABUSE AND THEFT OF A GOLD COLORED CHAIN FOR 1 (#500) OF 4 RESIDENTS SAMPLED FOR ABUSE IN A TOTAL SAMPLE OF 15 RESIDENTS RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #500 WHEN A FORMER EMPLOYEE GAINED ACCESS TO THE RESIDENT'S ROOM, ASSAULTED HER AND STOLE HER NECKLACE. AS A RESULT OF THE FACILITY'S FAILURE TO PREVENT ABUSE AND THEFT, ALL RESIDENTS WERE PLACED AT RISK FOR ABUSE AND THEFT. FINDINGS INCLUDE: RESIDENT #500 WAS A [AGE] year OLD FEMALE WHO, ACCORDING TO A 12/19/11 HISTORY & PHYSICAL (H&P) REPORT, HAD MANY DIAGNOSES, INCLUDING HYPERTENSION, [MEDICAL CONDITION] REFLUX DISEASE, ARTHRITIS, AND [MEDICAL CONDITION]. THE H&P DOCUMENTED A SPEECH IMPEDIMENT AND RIGHT UPPER EXTREMITY PARALYSIS. A MINIMUM DATA SET (MDS) REPORT, DATED 4/23/12, INDICATED THAT RESIDENT #500 WAS ALERT AND ORIENTED TO PERSON, PLACE, AND TIME. SHE WAS INDEPENDENT IN ALL OF HER ACTIVITIES OF DAILY LIVING (ADLS). RESIDENT #500 WAS INTERVIEWED ON 5/3/12 AT 8:45 A.M. THE RESIDENT WAS DIFFICULT TO UNDERSTAND, BUT THE FOLLOWING INFORMATION WAS REPEATED BACK TO THE RESIDENT, AND SHE CONFIRMED THE INFORMATION. RESIDENT #500 SAID A FORMER EMPLOYEE (FEMALE) VISITED HER ON THURSDAY, 4/26/12. ON FRIDAY, 4/27/12, THE FORMER EMPLOYEE RETURNED TO THE RESIDENT'S ROOM ABOUT 10 P.M. RESIDENT #500 SAID SHE WAS STANDING AT HER CLOSET WHEN THE FORMER EMPLOYEE GRABBED HER AROUND THE CHEST WITH ONE ARM. RESIDENT #500 SAID SHE TRIED TO TURN AROUND, BUT THE PERSON WAS TOO STRONG. THE FORMER EMPLOYEE HELD HER HAND OVER THE RESIDENT'S MOUTH, AND MADE A LITTLE GRUNTING SOUND. RESIDENT #500 SAID SHE WAS UNABLE TO MAKE ANY NOISE WITH THE HAND OVER HER MOUTH. THE FORMER EMPLOYEE RIPPED OFF THE RESIDENT'S TWO CHAIN NECKLACES, AND RESIDENT #500 fell on TO THE BED ON HER KNEES. WHEN THE FORMER EMPLOYEE LEFT, THE RESIDENT SAID SHE YELLED FOR HELP. RESIDENT #500 SAID SHE TOLD THE NURSE (NURSE #10) WHAT HAPPENED, BUT HE JUST SAID, "BYE, SEE YOU TOMORROW." RESIDENT #500 SAID THE ATTACK LEFT A RED MARK AT THE RIGHT SIDE OF HER NECK. CERTIFIED NURSING ASSISTANT (CNA) #11 WAS INTERVIEWED ON 5/4/12 AT 3 P.M. CNA #11 SAID SHE WAS ASSIGNED TO RESIDENT #500 ON 4/27/12 DURING THE AFTERNOON SHIFT. CNA #11 SAID SHE HEARD RESIDENT #500 YELL, "HELP, HELP." ACCORDING TO CNA #11, RESIDENT #500 TOLD THE SAME STORY TO HER (#11) AS THE ONE SHE (#500) TOLD THE SURVEYOR. CNA #11 SAID THE RESIDENT WAS HOLDING HER NECK, WHICH WAS RED. CNA #11 SAID SHE SAW RESIDENT #500 WEAR THE SAME TWO GOLD CHAINS EVERY DAY, AND AT 10 P.M. ON 4/27/12, THE CHAINS WERE GONE. THE CNA SAID RESIDENT #500 WAS ABLE TO NAME HER ATTACKER AND IDENTIFIED BY NAME THE FORMER FACILITY EMPLOYEE WITHOUT ANY HELP. CNA #11 SAID SHE (#500) HAD SEEN THE ATTACKER IN THE FACILITY ON DAYS PRIOR TO THE INCIDENT ON 4/27/12. CNA #11 SAID SHE (#11) DID NOT KNOW THIS PERSON BECAUSE SHE (THE ATTACKER) HAD WORKED IN THE FACILITY AT ONE TIME BUT HAD BEEN FIRED. CNA #11 FURTHER STATED THAT SHE (#11) HAD SEEN THIS FORMER EMPLOYEE, IN THE FACILITY ON 4/23/12, 4/24/12, 4/25/12, AND 4/26/12. CNA #11 SAID IT WOULD BE EASY FOR THE FORMER EMPLOYEE TO ENTER THE BUILDING THROUGH THE EMPLOYEE'S ENTRANCE BECAUSE THE CODE PROBABLY HAD NOT CHANGED. THE CNA SAID SHE BELIEVED EVERYTHING THE RESIDENT SAID. "(NAME OF RESIDENT) NEVER STEERS ME WRONG." CNA #11 SAID SHE TOLD NURSE #10 IMMEDIATELY ABOUT THE INCIDENT, BUT HE DIDN'T PAY ANY ATTENTION. THE CNA SAID SHE WENT TO THE OTHER NURSING STATION ON THE FLOOR AND TOLD NURSE #17, THE NURSE ON-DUTY THERE, ABOUT THE ATTACK. THAT NURSE TOLD HER (#11) TO DOCUMENT IT ON THE BEHAVIOR LOG. CNA #11 SAID SHE WENT BACK TO RESIDENT #500'S ROOM. RESIDENT #500 SAID SHE WAS STILL AFRAID. THE CNA SAID SHE WAS OFF WORK ON THAT WEEKEND, BUT WHEN SHE RETURNED TO WORK ON MONDAY, 4/30/12, RESIDENT #500 WAS STILL TELLING THE SAME STORY. NURSE #10 WAS INTERVIEWED BY TELEPHONE ON 5/3/12 AT 12:30 P.M. HE SAID CNA #11 TOLD HIM ABOUT THE INCIDENT ON 4/27/12. NURSE #10 SAID HE WENT TO RESIDENT #500'S ROOM BUT DIDN'T SEE ANYTHING AMISS. HE SAID HE THOUGHT MAYBE THE RESIDENT HAD A NIGHTMARE AND TOLD HER TO GO BACK TO SLEEP. NURSE #10 SAID HE WAS BUSY THAT NIGHT WITH ANOTHER RESIDENT IN DISTRESS. THE NURSE SAID HE DIDN'T TELL ANYONE ABOUT THE INCIDENT, "BECAUSE I DIDN'T THINK IT WAS ANYTHING." NURSE #17 WAS INTERVIEWED BY PHONE AT 2 P.M. ON 5/8/12. NURSE #17 SAID THAT SHE DID NOT RESPOND TO THE CNA #11'S REPORT OF THE INCIDENT BECAUSE SHE (#17) DID NOT THINK IT WAS HER RESPONSIBILITY. NURSE #14, INTERVIEWED ON 5/15/12 BY TELEPHONE, SAID SHE STOPPED TO TALK WITH RESIDENT #500 IN THE MORNING, JUST PRIOR TO HER SHIFT ENDING ON 4/28/12. NURSE #14 SAID RESIDENT #500 SAID SHE (#500) DIDN'T SLEEP WELL DURING THE NIGHT, AND TOLD HER (#14) ABOUT THE ATTACK THAT OCCURRED ON THE PREVIOUS EVENING AND THE THEFT OF THE NECKLACES. THE NURSE SAID THAT SHE (#14) NOTICED THE RESIDENT'S NECKLACES, WHICH SHE WORE ALL THE TIME, WERE NOT VISIBLE. NURSE #14 SAID SHE FOUND ONE NECKLACE INSIDE THE RESIDENT'S NIGHTGOWN, BUT THE SECOND NECKLACE WAS GONE. THE NURSE SAID THERE WAS A FINE CUT ON THE SIDE OF THE RESIDENT'S NECK. RESIDENT #500 TOLD NURSE #14 THAT SHE (#500) WAS NOT GOING INTO HER CLOSET AGAIN AT NIGHT BECAUSE SHE WAS TOO AFRAID. SHE SAID, "I'LL GO INTO THE CLOSET DURING THE DAY, BUT NOT AT NIGHT, IT'S TOO DARK." ACCORDING TO NURSE #14, RESIDENT #500 SAID SHE KNEW THE SUSPECT; IT WAS SOMEONE WHO HAD WORKED IN THE FACILITY, AND WHO HAD BEEN IN THE FACILITY RECENTLY. NURSE #14 SAID THE RESIDENT WAS "ADAMANT" ABOUT CALLING THE POLICE. CNA #16 WAS INTERVIEWED ON 5/8/12 AT APPROXIMATELY 10 A.M. SHE SAID SHE TOOK CARE OF RESIDENT #500 ON SATURDAY, 4/28/12, DURING THE DAY SHIFT AND THE AFTERNOON SHIFT. CNA #16 SAID SHE COULD TELL SOMETHING WAS TROUBLING THE RESIDENT BECAUSE SHE (#500) TOLD EVERYONE ABOUT THE ATTACK WHICH HAD OCCURRED ON 4/27/12. THE RESIDENT, ACCORDING TO THE CNA, WAS UPSET BECAUSE SHE (#500) DIDN'T THINK PEOPLE BELIEVED HER WHEN SHE SAID SHE HAD BEEN ATTACKED. CNA #16 SAID THAT SHE (#16) SHOWERED THE RESIDENT THAT DAY AND FOUND A SCRATCH ON THE SIDE OF HER NECK AND A SCRATCH ON HER THUMB. CNA #16 SAID THE RESIDENT WORE TWO CHAINS ALL THE TIME, BUT, ON THAT DAY, ONE OF THE CHAINS WAS GONE. CNA #16 SAID THE RESIDENT DESCRIBED HER ATTACKER AND CALLED HER (THE ATTACKER) BY NAME. CNA #16 SAID THAT THE FORMER EMPLOYEE, THE ALLEGED ATTACKER, COULD HAVE ENTERED THE BUILDING THROUGH THE EMPLOYEES' DOOR BECAUSE THE CODE TO ENTER HADN'T BEEN CHANGED IN SEVERAL YEARS. THE ADMINISTRATOR (#42) AND THE DON (DIRECTOR OF NURSING) (#43) WERE INTERVIEWED ON 5/3/12 AT 7:45 A.M. THE ADMINISTRATOR SAID RESIDENT #500 SAID SHE WAS ATTACKED AND A NECKLACE WAS STOLEN ON 4/27/12. THE ADMINISTRATOR SAID THERE WAS A SMALL RED SPOT ON THE RESIDENT'S NECK, BUT COULD NOT EXPLAIN WHY THIS HAD NOT BEEN DOCUMENTED IN THE NURSING NOTES OR THE INCIDENT REPORT. BOTH THE ADMINISTRATOR AND DON SAID RESIDENT #500 COULD NOT IDENTIFY THE ATTACKER. ACCORDING TO #42 AND #43, WHEN "SOMEONE" MENTIONED THE NAME OF A FORMER EMPLOYEE, THE RESIDENT STARTED SAYING THAT PERSON HAD BEEN HER ATTACKER, BUT THEY (#42 AND #43) DID NOT THINK IT WAS CREDIBLE. ACCORDING TO THE ADMINISTRATOR, THERE WERE SECURITY CAMERAS AT ALL ENTRANCES, AND SHE (#42) DID NOT SEE ANYONE SHE DID NOT KNOW ENTERING OR EXITING THE BUILDING ON 4/27/11. ALSO, VISITORS WERE REQUIRED TO SIGN IN, AND THE PERSON IDENTIFIED BY THE RESIDENT DID NOT SIGN IN TO ENTER THE BUILDING. THE ADMINISTRATOR DID NOT SAY WHY THIS FORMER EMPLOYEE COULD NOT HAVE GAINED ENTRANCE BY THE EMPLOYEES' DOOR. WHEN THE ADMINISTRATOR WAS ASKED WHY THIS INCIDENT HAD NOT BEEN REPORTED TO THE STATE AGENCY, THE ADMINISTRATOR STATED SHE DID NOT KNOW SHE (#42) WAS OBLIGATED TO REPORT AN ALLEGED ASSAULT AND THEFT. IN AN INTERVIEW ON 5/10/12 AT 2:30 P.M., THE MAINTENANCE DIRECTOR SAID THE DOOR CODE TO ENTER THE EMPLOYEE ENTRANCE HAD NOT CHANGED IN THE TWO YEARS SINCE HE HAD STARTED WORKING AT THE FACILITY. TWO RELATIVES OF RESIDENT #500 WERE INTERVIEWED. RELATIVE #12 WAS INTERVIEWED BY TELEPHONE ON 5/7/12 AT 7:38 A.M. ACCORDING TO RELATIVE #12, THE FACILITY ADMINISTRATOR (#42) HAD ASSURED THE FAMILY THAT THE FACILITY HAD SECURITY CAMERAS, AND THAT THEY (THE FACILITY) WERE DOING AN INVESTIGATION INVOLVING RESIDENT #500, SO THERE WOULD BE NO REASON TO CONTACT THE POLICE. "I WENT ALONG WITH IT," SAID THE RELATIVE. RELATIVE #13 WAS INTERVIEWED BY TELEPHONE ON 5/7/12 AT 7:45 A.M. RELATIVE #13 SAID THAT THE RESIDENT'S STORY ABOUT THE INCIDENT NEVER CHANGED. RELATIVE #13 SAID RESIDENT #500 CALLED THE MORNING OF 4/28/12, VERY UPSET, AND DESCRIBED THE INCIDENT. ACCORDING TO RELATIVE #13, THE FACILITY LEFT A MESSAGE ON HER TELEPHONE ABOUT THE ATTACK OF HER MOTHER WHICH SHE RECEIVED ON 4/29/12. RELATIVE #13 SAID THE POLICE WERE UNFORTUNATELY NOT CALLED AT THE TIME OF THE INCIDENT, AND THERE HAD BEEN NO INFORMATION ABOUT THE INCIDENT FROM THE ADMINISTRATOR SINCE THE FIRST MEETING WITH HER. "MY MOTHER SAID SHE COULD IDENTIFY THE ATTACKER. WHY NOT SHOW THE SECURITY TAPES TO HER?" THE RELATIVE SAID THE MOTHER WAS UNABLE TO SLEEP FOR SEVERAL NIGHTS. RELATIVE #13 DESCRIBED THE BRUISE ON THE RIGHT SIDE OF RESIDENT #500'S NECK. ACCORDING TO THE FACILITY "ABUSE PROHIBITION POLICY", DATED 6/20/11, "1. ANY PERSON(S) WITNESSING OR HAVING KNOWLEDGE OF POTENTIAL, ACTUAL OR ALLEGED ABUSE, MISTREATMENT, MISAPPROPRIATION OF PROPERTY, EXPLOITATION, OR NEGLECT OF A RESIDENT MUST BE REPORTED TO THE CHARGE NURSE WHO WILL EXAMINE RESIDENT AND DOCUMENT FINDINGS IN THE MEDICAL RECORD AND INTERNAL ABUSE REPORTING SYSTEM. 2. THE ADMINISTRATOR AND/OR DESIGNEE WILL BE NOTIFIED IMMEDIATELY." NURSE #10 FAILED TO EXAMINE THE RESIDENT AND DOCUMENT HIS FINDINGS IN THE MEDICAL RECORD. HE ALSO FAILED TO NOTIFY THE ADMINISTRATOR OF AN ALLEGATION OF ABUSE. ON 5/11/12 AT 12:40 P.M. THE ADMINISTRATOR WAS INFORMED OF THE IMMEDIATE JEOPARDY AS A RESULT OF THE FACILITY'S FAILURE TO PREVENT PHYSICAL ABUSE AND THEFT OF A GOLD COLORED CHAIN WHICH WAS REPORTED BY RESIDENT #500 ON 4/27/12 AT APPROXIMATELY 10 P.M. RESIDENT #500 SUSTAINED A BRUISE ON HER NECK AND PSYCHOLOGICAL DISTRESS AS A RESULT OF THE INCIDENT. ON 5/17/12 THE SURVEYOR CONFIRMED THAT THE FACILITY HAD IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. RESIDENT WAS ASSESSED ON 4/28/12 BY THE DON (DIRECTOR OF NURSING) AND THERE WAS AN ABRASION ON THE RIGHT SIDE OF THE NECK WHICH DID NOT REQUIRE TREATMENT. THE SOCIAL WORKER SAW THE RESIDENT ON 4/28/12, 5/3/12, AND 5/17/12 AND DOCUMENTED THAT THE RESIDENT WAS FINE AND CONCERNS WERE TAKEN CARE OF. 2. THE POLICE WERE NOTIFIED ON 5/8/12 OF THE ALLEGED EVENT. 3. ON 5/9/12 AND 5/10/12 130 RESIDENTS CONSIDERED AT RISK FOR ABUSE WERE INTERVIEWED AND/OR OBSERVED FOR SIGNS OF DISTRESS. 4. NURSE #10 WAS SUSPENDED ON 5/3/12, 5/4/12, AND 5/7/12 PENDING THE INVESTIGATION AND IN-SERVICED PRIOR TO THE START OF HIS SHIFT ON 5/8/12. 5. THE NURSING HOME ADMINISTRATOR WAS INSERVICED BY THE STAFF DEVELOPMENT DIRECTOR ON THE ABUSE PROHIBITION POLICY ON 5/8/12. 6. INSERVICING FOR ALL STAFF ON THE ABUSE PROHIBITION POLICY BEGAN ON 5/8/12. THE INSERVICE IS ONGOING TO CAPTURE 100% OF THE EMPLOYEES. 7. AN AUDIT TOOL WAS IMPLEMENTED ON 5/9/12 BY SOCIAL WORKERS OR DESIGNEE TO ENSURE THAT ALL CONCERNS OF ABUSE ARE ADDRESSED. 8. AN AUDIT TOOL WAS IMPLEMENTED ON 5/9/12 BY SOCIAL WORKERS TO INTERVIEW STAFF ABOUT ALLEGATIONS OF ABUSE WEEKLY FOR 4 WEEKS. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON 4/27/12 WAS REMOVED ON 5/9/12. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED. ( )

REFERS TO INTAKES MI 843 AND MI 592. BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEW, THE FACILITY FAILED TO REPORT AN ALLEGATION OF ABUSE AND THEFT IMMEDIATELY TO THE ADMINISTRATOR OF THE FACILITY, FAILED TO REPORT TO THE STATE AGENCY AND OTHER OFFICIALS, AND TO THOROUGHLY INVESTIGATE THE ALLEGATION OF ABUSE FOR 1 (#500) OF 4 SAMPLED RESIDENTS FOR ABUSE IN A TOTAL SAMPLE OF 15 RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #500 WHO SUSTAINED PHYSICAL AND PSYCHOLOGICAL HARM AS WELL AS THE THEFT OF A GOLD COLORED CHAIN BY AN ATTACKER IDENTIFIED BY THE RESIDENT, PLACING ALL RESIDENTS AT RISK FOR ABUSE AND THEFT OF PERSONAL BELONGINGS. THE FACILITY ALSO FAILED TO REPORT TO THE STATE AGENCY THE ELOPEMENT OF 1 (#501) OF 5 SAMPLED RESIDENTS REVIEWED FOR ELOPEMENT FROM A TOTAL SAMPLE OF 15, AND TO THOROUGHLY INVESTIGATE THIS ELOPEMENT, IN RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #501, WHO ELOPED FROM THE FACILITY ON 4/6/12, PLACING RESIDENT #501 AND 3 ADDITIONAL RESIDENTS IDENTIFIED AS AN ELOPEMENT RISK, IN DANGER OF PHYSICAL HARM OR DEATH. FINDINGS INCLUDE: RESIDENT #500, [AGE] years OLD, HAD MANY DIAGNOSES, INCLUDING HYPERTENSION, [MEDICAL CONDITION] REFLUX DISEASE, ARTHRITIS AND [MEDICAL CONDITION], ACCORDING TO A 12/19/11 HISTORY & PHYSICAL (H&P) REPORT. THE H&P DOCUMENTED A SPEECH IMPEDIMENT AND RIGHT UPPER EXTREMITY PARALYSIS. AN MDS (MINIMUM DATA SET) REPORT, DATED 4/23/12, INDICATED THAT RESIDENT #500 WAS ALERT AND ORIENTED TO PERSON, PLACE, AND TIME. SHE WAS INDEPENDENT IN ALL HER ACTIVITIES OF DAILY LIVING. RESIDENT #500 WAS INTERVIEWED ON 5/3/12 AT 8:45 A.M. THE RESIDENT WAS DIFFICULT TO UNDERSTAND, BUT THE FOLLOWING INFORMATION WAS REPEATED BACK TO THE RESIDENT, AND SHE CONFIRMED THE INFORMATION. RESIDENT #500 SAID A FORMER EMPLOYEE (FEMALE) VISITED HER ON THURSDAY, 4/26/12. ON FRIDAY, 4/27/12, THE FORMER EMPLOYEE RETURNED TO THE RESIDENT'S ROOM ABOUT 10 P.M. RESIDENT #500 SAID SHE WAS STANDING AT HER CLOSET WHEN THE FORMER EMPLOYEE GRABBED HER AROUND THE CHEST WITH ONE ARM. RESIDENT #500 SAID SHE TRIED TO TURN AROUND, BUT THE PERSON WAS TOO STRONG. THE FORMER EMPLOYEE HELD HER HAND OVER THE RESIDENT'S MOUTH, AND MADE A LITTLE GRUNTING SOUND. RESIDENT #500 SAID SHE WAS UNABLE TO MAKE ANY NOISE WITH THE HAND OVER HER MOUTH. THE FORMER EMPLOYEE RIPPED OFF THE RESIDENT'S TWO CHAIN NECKLACES, AND RESIDENT #500 fell on TO THE BED ON HER KNEES. WHEN THE FORMER EMPLOYEE LEFT, THE RESIDENT SAID SHE YELLED FOR HELP. RESIDENT #500 SAID SHE TOLD THE NURSE (NURSE #10) WHAT HAPPENED, BUT HE JUST SAID, "BYE, SEE YOU TOMORROW." RESIDENT #500 SAID THE ATTACK LEFT A RED MARK AT THE RIGHT SIDE OF HER NECK. CERTIFIED NURSING ASSISTANT (CNA) #11 WAS INTERVIEWED ON 5/4/12 AT 3 P.M. CNA #11 SAID SHE WAS ASSIGNED TO RESIDENT #500 ON 4/27/12 DURING THE AFTERNOON SHIFT. CNA #11 SAID SHE HEARD RESIDENT #500 YELL, "HELP, HELP." ACCORDING TO CNA #11, RESIDENT #500 TOLD THE SAME STORY TO HER (#11) AS THE ONE SHE (#500) TOLD THE SURVEYOR. CNA #11 SAID THE RESIDENT WAS HOLDING HER NECK, WHICH WAS RED. CNA #11 SAID SHE SAW RESIDENT #500 WEAR THE SAME TWO GOLD CHAINS EVERY DAY, AND AT 10 P.M. ON 4/27/12, THE CHAINS WERE GONE. THE CNA SAID RESIDENT #500 WAS ABLE TO NAME HER ATTACKER AND IDENTIFIED BY NAME THE FORMER FACILITY EMPLOYEE WITHOUT ANY HELP. CNA #11 SAID SHE (#500) HAD SEEN THE ATTACKER IN THE FACILITY ON DAYS PRIOR TO THE INCIDENT ON 4/27/12. CNA #11 SAID SHE (#11) DID NOT KNOW THIS PERSON BECAUSE SHE (THE ATTACKER) HAD WORKED IN THE FACILITY AT ONE TIME BUT HAD BEEN FIRED. CNA #11 FURTHER STATED THAT SHE (#11) HAD SEEN THIS FORMER EMPLOYEE, IN THE FACILITY ON 4/23/12, 4/24/12, 4/25/12, AND 4/26/12. CNA #11 SAID IT WOULD BE EASY FOR THE FORMER EMPLOYEE TO ENTER THE BUILDING THROUGH THE EMPLOYEE'S ENTRANCE BECAUSE THE CODE PROBABLY HAD NOT CHANGED. THE CNA SAID SHE BELIEVED EVERYTHING THE RESIDENT SAID. "(NAME OF RESIDENT) NEVER STEERS ME WRONG." CNA #11 SAID SHE TOLD NURSE #10 IMMEDIATELY ABOUT THE INCIDENT, BUT HE DIDN'T PAY ANY ATTENTION. THE CNA SAID SHE WENT TO THE OTHER NURSING STATION ON THE FLOOR AND TOLD NURSE #17, THE NURSE ON-DUTY THERE, ABOUT THE ATTACK. THAT NURSE TOLD HER (#11) TO DOCUMENT IT ON THE BEHAVIOR LOG. CNA #11 SAID SHE WENT BACK TO RESIDENT #500'S ROOM. RESIDENT #500 SAID SHE WAS STILL AFRAID. THE CNA SAID SHE WAS OFF WORK ON THAT WEEKEND, BUT WHEN SHE RETURNED TO WORK ON MONDAY, 4/30/12, RESIDENT #500 WAS STILL TELLING THE SAME STORY. NURSE #10 WAS INTERVIEWED BY TELEPHONE ON 5/3/12 AT 12:30 P.M. HE SAID CNA #11 TOLD HIM ABOUT THE INCIDENT ON 4/27/12. NURSE #10 SAID HE WENT TO RESIDENT #500'S ROOM BUT DIDN'T SEE ANYTHING AMISS. HE SAID HE THOUGHT MAYBE THE RESIDENT HAD A NIGHTMARE AND TOLD HER TO GO BACK TO SLEEP. NURSE #10 SAID HE DID NOT EXAMINE THE RESIDENT FOR INJURY. NURSE #10 SAID HE WAS BUSY THAT NIGHT WITH ANOTHER RESIDENT IN DISTRESS. THE NURSE SAID HE DIDN'T TELL ANYONE ABOUT THE INCIDENT, "BECAUSE I DIDN'T THINK IT WAS ANYTHING." NURSE #17 WAS INTERVIEWED BY PHONE AT 2 P.M. ON 5/8/12. NURSE #17 SAID THAT SHE DID NOT RESPOND TO THE CNA #11'S REPORT OF THE INCIDENT BECAUSE SHE (#17) DID NOT THINK IT WAS HER RESPONSIBILITY. NURSE #14, INTERVIEWED ON 5/15/12 BY TELEPHONE, SAID SHE STOPPED TO TALK WITH RESIDENT #500 IN THE MORNING, JUST PRIOR TO HER SHIFT ENDING ON 4/28/12. NURSE #14 SAID RESIDENT #500 SAID SHE (#500) DIDN'T SLEEP WELL DURING THE NIGHT, AND TOLD HER (#14) ABOUT THE ATTACK THAT OCCURRED ON THE PREVIOUS EVENING AND THE THEFT OF THE NECKLACES. THE NURSE SAID THAT SHE (#14) NOTICED THE RESIDENT'S NECKLACES, WHICH SHE WORE ALL THE TIME, WERE NOT VISIBLE. NURSE #14 SAID SHE FOUND ONE NECKLACE INSIDE THE RESIDENT'S NIGHTGOWN, BUT THE SECOND NECKLACE WAS GONE. THE NURSE SAID THERE WAS A FINE CUT ON THE SIDE OF THE RESIDENT'S NECK. RESIDENT #500 TOLD NURSE #14 THAT SHE (#500) WAS NOT GOING INTO HER CLOSET AGAIN AT NIGHT BECAUSE SHE WAS TOO AFRAID. SHE SAID, "I'LL GO INTO THE CLOSET DURING THE DAY, BUT NOT AT NIGHT, IT'S TOO DARK." ACCORDING TO NURSE #14, RESIDENT #500 SAID SHE KNEW THE SUSPECT; IT WAS SOMEONE WHO HAD WORKED IN THE FACILITY, AND WHO HAD BEEN IN THE FACILITY RECENTLY. NURSE #14 SAID THE RESIDENT WAS "ADAMANT" ABOUT CALLING THE POLICE. NURSE #14 SAID SHE (#14) IMMEDIATELY CALLED THE DIRECTOR OF NURSING (DON #43) AND REPORTED THE ABUSE AND THEFT. NURSE #14 SAID THAT THE DON RESPONDED THAT SHE (DON #43) WOULD DOCUMENT THE INCIDENT AND HAVE NURSE #14 SIGN SOMETHING LATER. NURSE #14 SAID SHE HAD NOT SIGNED ANYTHING OR DOCUMENTED THE INCIDENT AS OF 5/15/12. CNA #16 WAS INTERVIEWED ON 5/8/12 AT APPROXIMATELY 10 A.M. SHE SAID SHE TOOK CARE OF RESIDENT #500 ON SATURDAY, 4/28/12, DURING THE DAY SHIFT AND THE AFTERNOON SHIFT. CNA #16 SAID SHE COULD TELL SOMETHING WAS TROUBLING THE RESIDENT BECAUSE SHE (#500) TOLD EVERYONE ABOUT THE ATTACK WHICH HAD OCCURRED ON 4/27/12. THE RESIDENT, ACCORDING TO THE CNA, WAS UPSET BECAUSE SHE (#500) DIDN'T THINK PEOPLE BELIEVED HER WHEN SHE SAID SHE HAD BEEN ATTACKED. CNA #16 SAID THAT SHE (#16) SHOWERED THE RESIDENT THAT DAY AND FOUND A SCRATCH ON THE SIDE OF HER NECK AND A SCRATCH ON HER THUMB. CNA #16 SAID THE RESIDENT WORE TWO CHAINS ALL THE TIME, BUT, ON THAT DAY, ONE OF THE CHAINS WAS GONE. CNA #16 SAID THE RESIDENT DESCRIBED HER ATTACKER AND CALLED HER (THE ATTACKER) BY NAME. CNA #16 SAID THAT THE FORMER EMPLOYEE, THE ALLEGED ATTACKER, COULD HAVE ENTERED THE BUILDING THROUGH THE EMPLOYEES' DOOR BECAUSE THE CODE TO ENTER HADN'T BEEN CHANGED IN SEVERAL YEARS. THE ADMINISTRATOR (#42) AND THE DON (DIRECTOR OF NURSING) (#43) WERE INTERVIEWED ON 5/3/12 AT 7:45 A.M. THE ADMINISTRATOR SAID RESIDENT #500 SAID SHE WAS ATTACKED AND A NECKLACE WAS STOLEN ON 4/27/12. THE ADMINISTRATOR SAID THERE WAS A SMALL RED SPOT ON THE RESIDENT'S NECK, BUT COULD NOT EXPLAIN WHY THIS HAD NOT BEEN DOCUMENTED IN THE NURSING NOTES OR THE INCIDENT REPORT. BOTH THE ADMINISTRATOR AND DON SAID RESIDENT #500 COULD NOT IDENTIFY THE ATTACKER. ACCORDING TO #42 AND #43, WHEN "SOMEONE" MENTIONED THE NAME OF A FORMER EMPLOYEE, THE RESIDENT STARTED SAYING THAT PERSON HAD BEEN HER ATTACKER, BUT THEY (#42 AND #43) DID NOT THINK IT WAS CREDIBLE. ACCORDING TO THE ADMINISTRATOR, THERE WERE SECURITY CAMERAS AT ALL ENTRANCES, AND SHE (#42) DID NOT SEE ANYONE SHE DID NOT KNOW ENTERING OR EXITING THE BUILDING ON 4/27/11. ALSO, VISITORS WERE REQUIRED TO SIGN IN, AND THE PERSON IDENTIFIED BY THE RESIDENT DID NOT SIGN IN TO ENTER THE BUILDING. THE ADMINISTRATOR DID NOT SAY WHY THIS FORMER EMPLOYEE COULD NOT HAVE GAINED ENTRANCE BY THE EMPLOYEES' DOOR. WHEN THE ADMINISTRATOR WAS ASKED WHY THIS INCIDENT HAD NOT BEEN REPORTED TO THE STATE AGENCY, THE ADMINISTRATOR STATED SHE DID NOT KNOW SHE (#42) WAS OBLIGATED TO REPORT AN ALLEGED ASSAULT AND THEFT. ON 5/11/12 THE ADMINISTRATOR GAVE THE SURVEYOR A COPY OF THE POLICE REPORT THAT HAD BEEN CALLED TO THE POLICE DEPARTMENT ON 5/8/12. THE REPORT INDICATED THAT THE FACILITY ADMINISTRATOR WAS MAKING THE REPORT. THE REPORT READ; "(ADMINISTRATOR) STATES RESIDENT, (NAME OF RESIDENT #500) B/F/11-6-24/86 YRS, STATES SOMEONE CAME INTO HER ROOM AND REMOVED HER GOLD NECKLACE FROM HER NECK ON ABOVE DATE, TIME AND LOCATION. (ADMINISTRATOR) STATES RESIDENT STATES SHE DOES NOT KNOW WHO TOOK SAID NECKLACE. (ADMINISTRATOR) STATES FAMILY OF RESIDENT VALUED SAID NECKLACE AT $1200, BUT ALSO STATES SAID NECKLACE WAS NEVER ON THE INVENTORY OF POSSESSIONS." THE DATE AND TIME OF THE ATTACK ENTERED ON THE POLICE REPORT WAS 4/28/12, 12:00 P.M. IN AN INTERVIEW ON 5/10/12 AT 2:30 P.M., THE MAINTENANCE DIRECTOR SAID THE DOOR CODE TO ENTER THE EMPLOYEE ENTRANCE HAD NOT CHANGED IN THE TWO YEARS SINCE HE HAD WORKED AT THE FACILITY. TWO RELATIVES OF RESIDENT #500 WERE INTERVIEWED. RELATIVE #12 WAS INTERVIEWED BY TELEPHONE ON 5/7/12 AT 7:38 A.M. ACCORDING TO RELATIVE #12, THE FACILITY ADMINISTRATOR (#42) HAD ASSURED THE FAMILY THAT THE FACILITY HAD SECURITY CAMERAS, AND THAT THEY (THE FACILITY) WERE DOING AN INVESTIGATION INVOLVING RESIDENT #500, SO THERE WOULD BE NO REASON TO CONTACT THE POLICE. "I WENT ALONG WITH IT," SAID THE RELATIVE. RELATIVE #13 WAS INTERVIEWED BY TELEPHONE ON 5/7/12 AT 7:45 A.M. RELATIVE #13 SAID THAT THE RESIDENT'S STORY ABOUT THE INCIDENT NEVER CHANGED. RELATIVE #13 SAID RESIDENT #500 CALLED THE MORNING OF 4/28/12, VERY UPSET, AND DESCRIBED THE INCIDENT. ACCORDING TO RELATIVE #13, THE FACILITY LEFT A MESSAGE ON HER TELEPHONE ABOUT THE ATTACK OF HER MOTHER WHICH SHE RECEIVED ON 4/29/12. RELATIVE #13 SAID THE POLICE WERE UNFORTUNATELY NOT CALLED AT THE TIME OF THE INCIDENT, AND THERE HAD BEEN NO INFORMATION ABOUT THE INCIDENT FROM THE ADMINISTRATOR SINCE THE FIRST MEETING WITH HER. "MY MOTHER SAID SHE COULD IDENTIFY THE ATTACKER. WHY NOT SHOW THE SECURITY TAPES TO HER?" THE RELATIVE SAID THE MOTHER WAS UNABLE TO SLEEP FOR SEVERAL NIGHTS. RELATIVE #13 DESCRIBED THE BRUISE ON THE RIGHT SIDE OF RESIDENT #500'S NECK. ACCORDING TO THE FACILITY "ABUSE PROHIBITION POLICY", DATED 6/2011, "1. ANY PERSON(S) WITNESSING OR HAVING KNOWLEDGE OF POTENTIAL, ACTUAL OR ALLEGED ABUSE, MISTREATMENT, MISAPPROPRIATION OF PROPERTY, EXPLOITATION, OR NEGLECT OF A RESIDENT MUST BE REPORTED TO THE CHARGE NURSE WHO WILL EXAMINE RESIDENT AND DOCUMENT FINDINGS IN THE MEDICAL RECORD AND INTERNAL ABUSE REPORTING SYSTEM. 2. THE ADMINISTRATOR AND/OR DESIGNEE WILL BE NOTIFIED IMMEDIATELY." NURSE #10 FAILED TO EXAMINE THE RESIDENT AND DOCUMENT HIS FINDINGS IN THE MEDICAL RECORD. HE ALSO FAILED TO NOTIFY THE ADMINISTRATOR OF AN ALLEGATION OF ABUSE. RESIDENT #501 RESIDENT #501, [AGE] years OLD, HAD THE FOLLOWING DIAGNOSES; DEMENTIA, HYPERTENSION, DEPRESSION, [MEDICAL CONDITION], AND [MEDICAL CONDITION], ACCORDING TO AN H&P, DATED 4/5/12. IN A TELEPHONE INTERVIEW ON 5/6/12 AT 10 P.M., VISITOR #3 SAID SHE LEFT THE NURSING UNIT WHERE RESIDENT #501 RESIDED AT APPROXIMATELY 9 P.M. ON 4/6/12. ACCORDING TO VISITOR #3, AS SHE WAS LEAVING THE UNIT, SHE OVERHEARD A NURSING INSTRUCTOR TELL THE STAFF THAT ANOTHER RESIDENT SAW RESIDENT #501 LEAVE THE NURSING UNIT. VISITOR #3 SAID SHE WENT DOWN THE ELEVATOR AND OUT THE FRONT DOOR OF THE BUILDING. AS SHE APPROACHED HER TRUCK IN THE FACILITY PARKING LOT, SHE SAW SOMEONE COME FROM THE PASSENGER SIDE OF THE TRUCK TO THE FRONT OF THE TRUCK. VISITOR #3 SAID THE PERSON WAS WEARING A BONNET ON HER HEAD THAT ALL THE RESIDENTS HAD BEEN WEARING THAT DAY AS PART OF AN EASTER CELEBRATION. VISITOR #3 SAID SHE HAD SEEN RESIDENT #501 ON THE UNIT THAT DAY, BUT SHE DID NOT KNOW HER NAME. VISITOR #3 SAID SHE ASKED THE RESIDENT WHERE SHE WAS GOING. THE RESIDENT SAID SHE WANTED TO GO TO CHURCH. VISITOR #3 SAID SHE TOLD THE RESIDENT, "COME AND GO BACK WITH ME INTO THE BUILDING," AND OFFERED RESIDENT #501 HER ARM. THE VISITOR SAID RESIDENT #501 TOOK HER ARM AND WALKED WITH HER, SLOWLY, INTO THE BUILDING. VISITOR #3 SAID SHE TOOK THE RESIDENT BACK TO THE NURSING UNIT AND HAD HER SIT DOWN. VISITOR #3 SAID THAT NURSING STAFF SAID TO THE RESIDENT, "WE WERE LOOKING FOR YOU. WE WERE LOOKING FOR YOU." VISITOR #3 SAID SHE THEN LEFT THE UNIT. IN A TELEPHONE INTERVIEW ON 5/4/12 AT 2 P.M., RECEPTIONIST #5 SAID SHE DID SEE VISITOR #3 LEAVE THE FACILITY ABOUT 9:30 P.M. OR 9:40 P.M. ON 4/6/12 AND THEN BRING A FEMALE WITH HER INTO THE FACILITY SHORTLY THEREAFTER. RECEPTIONIST #5 SAID SHE DID NOT KNOW THE PERSON (RESIDENT #501) BROUGHT IN BY THE VISITOR. SHE DESCRIBED THE SAME CLOTHING WORN BY RESIDENT #501 AS DID THE VISITOR IN THE TELEPHONE INTERVIEW ON 5/6/12 AT 10 P.M. SHE (#5) SAID THE VISITOR TOOK THE RESIDENT TO THE SECOND FLOOR AND THEN LEFT AGAIN. NURSE #6 WAS INTERVIEWED BY TELEPHONE ON 5/4/12 AT 2 P.M. SHE SAID SHE WORKED THE 7 A.M. TO 7 P.M. SHIFT ON 4/6/12 AND THEN WORKED TWO ADDITIONAL HOURS, UNTIL 9 P.M. NURSE #6 SAID RESIDENT #501 WAS WANDERING THE HALLS, BUT WAS NOT EXIT SEEKING UNTIL 5 P.M. AT 5 P.M. RESIDENT #501 BECAME COMBATIVE. AT 7 P.M. THE BEHAVIORS ESCALATED, THE RESIDENT WAS LOUD AND WAS SWINGING HER CANE. NURSE #6 SAID SHE HAD ADMINISTERED [MEDICATION NAME] (ANTI-ANXIETY MEDICATION) WITHOUT EFFECT. NURSE #6 SAID RESIDENT #501 DID NOT ELOPE ON HER SHIFT. CERTIFIED NURSING ASSISTANT (CNA) #2 WAS INTERVIEWED ON 5/4/12 AT 3 P.M. SHE SAID SHE WAS ASSIGNED TO RESIDENT #501 ON 4/6/12 DURING THE AFTERNOON SHIFT. RESIDENT #501 WAS WANDERING ALL SHIFTS AND WAS CONSTANTLY EXIT SEEKING. THE RESIDENT HAD TO BE REDIRECTED FROM THE DOORS AND THE ELEVATOR. CNA #2 SAID SHE TRIED TO WATCH THE RESIDENT CLOSELY, BUT SHE HAD TEN OTHER RESIDENTS ASSIGNED TO HER. CNA #2 SAID RESIDENT #501 WAS NOT ASSIGNED ONE PERSON WHOSE ONLY RESPONSIBILITY WAS TO MONITOR THE WHEREABOUTS OF RESIDENT #501 THAT SHIFT, SO ALL THE CNAS TRIED TO HELP WATCH HER. CNA #2 SAID SHE WAS NOT SURE WHETHER RESIDENT #501 LEFT THE UNIT THAT EVENING. SHE SAID RESIDENT #501 WAS NOT WEARING HER WANDERGUARD (A DEVICE THAT TRANSMITS A SIGNAL WHICH ACTIVATES AN ALARM WHEN THE SIGNAL IS RECEIVED, USUALLY AT A DOORWAY) SHE (#2) CHECKED THE RESIDENT AT THE END OF THE EVENING. NURSE #4 WAS INTERVIEWED BY TELEPHONE ON 5/4/12 AT 4:15 P.M. NURSE #4 SAID THAT SHE PROVIDED CARE FOR RESIDENT #501 ON 4/6/12 FROM 9 P.M. AND SENT RESIDENT #501 TO THE HOSPITAL AT 12:15 A.M. ON 4/7/12. NURSE #4 SAID THE RESIDENT WAS VERY COMBATIVE THAT EVENING. NURSE #4 SAID, "SHE MENTIONED A BUS, I KNEW SHE WANTED TO GO." ACCORDING TO NURSE #4, RESIDENT #501 WAS TRYING TO GET ON THE ELEVATOR. WHEN ASKED WHETHER RESIDENT #501 LEFT THE UNIT, NURSE #4 SAID SHE DIDN'T SEE HER (#501) GO ANYWHERE. WHEN QUESTIONED WHETHER ANYONE TOLD HER THAT RESIDENT #501 LEFT THE UNIT, NURSE #4 SAID THAT A VISITOR MENTIONED THAT RESIDENT #501 WAS TRYING TO LEAVE, SAYING, "YOU NEED TO WATCH HER (#501)." NURSE #4 SAID SHE COULD NOT REMEMBER THE NAME OF THE VISITOR. NURSE #4 SAID WHEN SHE CHECKED FOR THE WANDERGUARD NEAR THE END OF THE SHIFT, SHE DID NOT SEE ONE ON THE RESIDENT. RESIDENT #501 WAS INITIALLY admitted to the facility on [DATE], PER THE FACILITY ADMISSIONS RECORD. ON 3/26/12 A "WANDERGUARD" WAS ADDED TO THE INITIAL CARE PLAN FOR COGNITIVE LOSS DEVELOPED ON 3/23/12. A NURSE'S NOTE, DATED 3/25/12 DOCUMENTED THE RESIDENT "TRYING TO OPEN EXIT DOORS STATING I HAVE TO GO TO WORK." A NURSES NOTE ON 3/26/12 DOCUMENTED, "SEVERAL ATTEMPTS TO GO OUT THE EXIT DOORS AND ONTO ANOTHER UNIT." A 3/27/12 NURSE'S NOTE INDICATED THAT THE RESIDENT WAS REMOVING THE WANDERGUARD. A NURSE'S NOTE ON 3/28/12 INDICATED THAT RESIDENT #501 WAS TRANSFERRED TO THE HOSPITAL FOR AGGRESSIVE BEHAVIORS. ACCORDING TO THE ADMISSION RECORD, RESIDENT #501 RETURNED to the facility on [DATE]. NURSES' NOTES ON 4/6/12 DESCRIBED RESIDENT #501'S BEHAVIORS AS "COMBATIVE ...YELLING OUT ... RESISTING CARE ... WANDERING HALLWAY ...AGGRESSIVE." THERE WAS NO DOCUMENTATION THAT RESIDENT #501 HAD TRIED TO EXIT THE UNIT. THERE WAS NO DOCUMENTATION THAT RESIDENT #501 HAD ELOPED FROM THE FACILITY. AN INCIDENT REPORT, DATED 4/6/12, DOCUMENTED THE FOLLOWING, "RES (RESIDENT #501) OBSERVED EXIT SEEKING TOWARD DOOR, FAMILY MEMBER BROUGHT RES (RESIDENT) BACK TO NURSING STATION." THE ADMINISTRATOR (#42) WAS INTERVIEWED ABOUT THE ELOPEMENT ON 5/4/12 AT 9 A.M. SHE SAID RESIDENT #501 HAD MANY BEHAVIORS. SHE PULLED FIRE ALARMS. SHE WAS EXIT SEEKING. THE ADMINISTRATOR SAID SHE HAD NO EVIDENCE THE RESIDENT LEFT THE BUILDING ON 4/6/12. SHE SAID THE VISITOR, WHO SAID SHE RETURNED THE RESIDENT to the facility on [DATE] FROM OUTSIDE THE BUILDING, WAS SEEN ON THE SECURITY TAPES LEAVING THE BUILDING THAT EVENING; HOWEVER, THE VISITOR WAS NOT SEEN RETURNING TO THE BUILDING WITH THE RESIDENT. THE ADMINISTRATOR SAID SHE COULD NOT REMEMBER THE NAME OF THE VISITOR. ACCORDING TO ADMINISTRATOR #42, RESIDENT #501 DID NOT ELOPE FROM THE FACILITY. ON 5/4/12, ADMINISTRATOR #42 PROVIDED A HANDWRITTEN SHEET OF PAPER TO THE SURVEYOR. SHE SAID IT WAS PART OF THE DON'S INVESTIGATION, BUT SHE (#42) WAS NOT SURE WHAT "IT ALL MEANT." ON THE HANDWRITTEN PAPER WAS DOCUMENTED, "EXIT STAIRWAY ON HOMEBOUND (NURSING UNIT WHERE RESIDENT #501 RESIDED) DOWN TO LOWER LEVEL DOOR/DOOR NOT ALARMED." THE PAPER INDICATED THAT ALL EXITS WERE CHECKED, WANDERGUARD DOORS WERE CHECKED, AND WANDERGUARDS ON RESIDENTS ASSESSED AS EXIT SEEKING WERE CHECKED. IT WAS DOCUMENTED THAT A "FAMILY MEMBER" WAS CALLED AND INTERVIEWED. THE NAME OF THE FAMILY MEMBER WAS NOT DOCUMENTED. AT THE BOTTOM OF THE PAGE WAS WRITTEN: "EXIT DOORS - 4 BROKEN, EXIT DOORS - 3 NO ALARM, 3 DOORS (EXIT ALARMS) WORKING." THERE WERE NO DATES OR TIMES THAT THE ABOVE WERE COMPLETED. THE DON (#43) WAS NOT AVAILABLE FOR INTERVIEW. THERE WAS ONE INTERVIEW CONDUCTED, WITH A DATE AND TIME, PROVIDED TO THE SURVEYOR, AS PART OF THE INVESTIGATION FOR THE ELOPEMENT. THE INTERVIEW WAS WITH CNA #2 ON 4/7/12 AT 3 P.M. NURSE #4, IN A TELEPHONE INTERVIEW ON 5/14/12 AT 9 A.M., SAID SHE WAS INTERVIEWED FOR THE FIRST TIME ON 5/14/12. MAINTENANCE STAFF MEMBER #36 COMPLETED A SERVICE LOG ON 4/6/12 AT 4:58 P.M. INDICATING THAT HE CHECKED ALL DOORS AND FOUND THAT ALL ALARMS WERE FUNCTIONING PROPERLY. ON 4/7/12 (NO TIME SPECIFIED) MAINTENANCE MEMBER #36 DOCUMENTED ON A SERVICE LOG THAT ALL DOOR ALARMS WERE WORKING EXCEPT FOR THE DINING ROOM DOOR ON THE HOMEBOUND UNIT THAT WAS NOT ACTIVATED. ON 5/11/12 AT 12:40 P.M. THE ADMINISTRATOR WAS INFORMED OF THE IMMEDIATE JEOPARDY AS A RESULT OF THE FACILITY'S (1) FAILURE TO REPORT AN ALLEGATION OF ABUSE AND THEFT IMMEDIATELY TO THE ADMINISTRATOR OF THE FACILITY, FAILED TO REPORT TO THE STATE AGENCY AND OTHER OFFICIALS, AND TO THOROUGHLY INVESTIGATE THE VIOLATION OF ABUSE FROM RESIDENT #500 PLACING ALL RESIDENTS AT RISK FOR ABUSE AND THEFT, AND (2) FAILURE TO REPORT TO THE STATE AGENCY AND THOROUGHLY INVESTIGATE AN ELOPEMENT OF RESIDENT #501, PLACING THREE ADDITIONAL RESIDENTS AT RISK FOR ELOPEMENT AND POSSIBLE SERIOUS PHYSICAL HARM, INJURY, OR DEATH. ON 5/17/12 THE SURVEYOR CONFIRMED THAT THE FACILITY HAD IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. RESIDENT #500 WAS ASSESSED ON 4/28/12 BY THE DON, AND THERE WAS AN ABRASION ON THE RIGHT SIDE OF THE NECK WHICH DID NOT REQUIRE TREATMENT. THE SOCIAL WORKER SAW THE RESIDENT ON 4/28/12, 5/3/12, AND 5/17/12 AND DOCUMENTED THAT THE RESIDENT WAS FINE AND CONCERNS WERE TAKEN CARE OF. RESIDENT #501 NO LONGER RESIDES AT THE FACILITY. 2. THE POLICE WERE NOTIFIED ON 5/8/12 OF THE ALLEGED EVENT. 3. NURSE MANAGERS RE-ASSESSED 130 RESIDENTS FOR ELOPEMENT RISK. CARE PLANS AND CARE GUIDES WERE UPDATED, AND A PLAN FOR CHECKING AND DOCUMENTING FUNCTIONALITY OF WANDERGUARDS FOR 4 RESIDENTS AT RISK FOR ELOPEMENT WAS IMPLEMENTED. AUDIT TOOLS WERE IMPLEMENTED ON 5/9/12 TO MONITOR ELOPEMENT AND WANDERGUARD USE. 4. ON 5/9/12 AND 5/10/12 130 RESIDENTS CONSIDERED AT RISK FOR ABUSE WERE INTERVIEWED REGARDING ABUSE, MISSING ITEMS, OR THEFT. 5. NURSE #10 WAS SUSPENDED ON 5/3/12, 5/4/12, AND 5/7/12 PENDING THE INVESTIGATION AND INSERVICED PRIOR TO THE START OF HIS SHIFT ON 5/8/12. 6. ON 5/8/12 THE NURSING HOME ADMINISTRATOR WAS INSERVICED ON THE ABUSE PROHIBITION POLICY AND THE IMPORTANCE OF REPORTING ALLEGATIONS TO THE STATE AGENCY IN ACCORDANCE WITH STATE GUIDELINES BY THE STAFF DEVELOPMENT DIRECTOR, BEGINNING 5/9/12. THE NURSING HOME ADMINISTRATOR WAS INSERVICED BY THE REGIONAL CLINICAL COORDINATOR ON REPORTING RESPONSIBILITIES WITH THE ELDER JUSTICE ACT ON 5/8/12. 7. INSERVICING FOR ALL STAFF ON THE ABUSE PROHIBITION POLICY AND THE ELOPEMENT POLICY BEGAN ON 5/8/12. THE INSERVICES ARE ONGOING TO CAPTURE 100% OF EMPLOYEES. 8. ALL INCIDENT & ACCIDENT REPORTS WILL BE REVIEWED AND DISCUSSED WITH THE IDT (INTERDISCIPLINARY TEAM) AT THE STANDUP MEETINGS BEGINNING 5/8/12 TO DETERMINE IF IT IS REPORTABLE IN ACCORDANCE WITH STATE GUIDELINES. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON 4/6 /12 (ELOPEMENT) AND THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON 4/27/12 (ABUSE/THEFT) WAS REMOVED ON 5/9/12. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED. ( )

REFERS TO INTAKES MI 592 AND MI 843 AND CONTAINS MULTIPLE DEFICIENT PRACTICE STATEMENTS. BASED ON OBSERVATION, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE SUPERVISION TO PREVENT ELOPEMENT FOR 1 (#501) OF 4 SAMPLED RESIDENTS REVIEWED FOR ELOPEMENT FROM A TOTAL SAMPLE OF 15, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #501 WHO WAS MISSING FROM THE FACILITY ON 4/6/12 SOMETIME BETWEEN 9 P.M. AND 10 P.M. UNBEKNOWNST TO STAFF, PLACING THE RESIDENT AT RISK FOR PHYSICAL HARM OR DEATH. AS A RESULT OF THE FACILITY'S FAILURE TO SUPERVISE AND IMPLEMENT APPROPRIATE INTERVENTIONS TO ADDRESS ESCALATING BEHAVIOR, 4 OTHER RESIDENTS IDENTIFIED AS WANDERERS WERE PLACED AT RISK FOR ELOPEMENT WHICH COULD RESULT IN PHYSICAL HARM OR DEATH. FINDINGS INCLUDE: RESIDENT #501 WAS AN [AGE] year OLD FEMALE WHO, ACCORDING TO A HISTORY & PHYSICAL (H&P) DATED 4/5/12, HAD THE FOLLOWING Diagnoses: [REDACTED]. IN A TELEPHONE INTERVIEW ON 5/6/12 AT 10 P.M., VISITOR #3 SAID SHE LEFT THE NURSING UNIT WHERE RESIDENT #501 RESIDED AT APPROXIMATELY 9 P.M. ON 4/6/12. ACCORDING TO VISITOR #3, AS SHE WAS LEAVING THE UNIT, SHE OVERHEARD A NURSING INSTRUCTOR TELL THE STAFF THAT ANOTHER RESIDENT SAW RESIDENT #501 LEAVE THE NURSING UNIT. VISITOR #3 SAID SHE WENT DOWN THE ELEVATOR AND OUT THE FRONT DOOR OF THE BUILDING. AS SHE APPROACHED HER TRUCK IN THE FACILITY PARKING LOT, SHE SAW SOMEONE COME FROM THE PASSENGER SIDE OF THE TRUCK TO THE FRONT OF THE TRUCK. VISITOR #3 SAID THE PERSON WAS WEARING A BONNET ON HER HEAD THAT ALL THE RESIDENTS HAD BEEN WEARING THAT DAY AS PART OF AN EASTER CELEBRATION. VISITOR #3 SAID SHE HAD SEEN RESIDENT #501 ON THE UNIT THAT DAY, BUT SHE DID NOT KNOW HER NAME. VISITOR #3 SAID SHE ASKED THE RESIDENT WHERE SHE WAS GOING. THE RESIDENT SAID SHE WANTED TO GO TO CHURCH. VISITOR #3 SAID SHE TOLD THE RESIDENT, "COME AND GO BACK WITH ME INTO THE BUILDING," AND OFFERED RESIDENT #501 HER ARM. THE VISITOR SAID RESIDENT #501 TOOK HER ARM AND WALKED WITH HER, SLOWLY, INTO THE BUILDING. VISITOR #3 SAID SHE TOOK THE RESIDENT BACK TO THE NURSING UNIT AND HAD HER SIT DOWN. VISITOR #3 SAID THAT NURSING STAFF SAID TO THE RESIDENT, "WE WERE LOOKING FOR YOU. WE WERE LOOKING FOR YOU." VISITOR #3 SAID SHE THEN LEFT THE UNIT. IN A TELEPHONE INTERVIEW ON 5/4/12 AT 2 P.M., RECEPTIONIST #5 SAID SHE DID SEE VISITOR #3 LEAVE THE FACILITY ABOUT 9:30 P.M. OR 9:40 P.M. ON 4/6/12 AND THEN BRING A FEMALE WITH HER INTO THE FACILITY SHORTLY THEREAFTER. RECEPTIONIST #5 SAID SHE DID NOT KNOW THE PERSON (RESIDENT #501) BROUGHT IN BY THE VISITOR. SHE DESCRIBED THE SAME CLOTHING WORN BY RESIDENT #501 AS DID THE VISITOR IN THE TELEPHONE INTERVIEW ON 5/6/12 AT 10 P.M. SHE (#5) SAID THE VISITOR TOOK THE RESIDENT TO THE SECOND FLOOR AND THEN LEFT AGAIN. NURSE #6 WAS INTERVIEWED BY TELEPHONE ON 5/4/12 AT 2 P.M. SHE SAID SHE WORKED THE 7 A.M. TO 7 P.M. SHIFT ON 4/6/12 AND THEN WORKED TWO ADDITIONAL HOURS, UNTIL 9 P.M. NURSE #6 SAID RESIDENT #501 WAS WANDERING THE HALLS, BUT WAS NOT EXIT SEEKING UNTIL 5 P.M. AT 5 P.M. RESIDENT #501 BECAME COMBATIVE. AT 7 P.M. THE BEHAVIORS ESCALATED, THE RESIDENT WAS LOUD AND WAS SWINGING HER CANE. NURSE #6 SAID SHE HAD ADMINISTERED XANAX (ANTI-ANXIETY MEDICATION) WITHOUT EFFECT. NURSE #6 SAID RESIDENT #501 DID NOT ELOPE ON HER SHIFT. CERTIFIED NURSING ASSISTANT (CNA) #2 WAS INTERVIEWED ON 5/4/12 AT 3 P.M. SHE SAID SHE WAS ASSIGNED TO RESIDENT #501 ON 4/6/12 DURING THE AFTERNOON SHIFT. RESIDENT #501 WAS WANDERING ALL SHIFTS AND WAS CONSTANTLY EXIT SEEKING. THE RESIDENT HAD TO BE REDIRECTED FROM THE DOORS AND THE ELEVATOR. CNA #2 SAID SHE TRIED TO WATCH THE RESIDENT CLOSELY, BUT SHE HAD TEN OTHER RESIDENTS ASSIGNED TO HER. CNA #2 SAID RESIDENT #501 WAS NOT ASSIGNED ONE PERSON WHOSE ONLY RESPONSIBILITY WAS TO MONITOR THE WHEREABOUTS OF RESIDENT #501 THAT SHIFT, SO ALL THE CNAS TRIED TO HELP WATCH HER. CNA #2 SAID SHE WAS NOT SURE WHETHER RESIDENT #501 LEFT THE UNIT THAT EVENING. SHE SAID RESIDENT #501 WAS NOT WEARING HER WANDERGUARD (A DEVICE THAT TRANSMITS A SIGNAL WHICH ACTIVATES AN ALARM WHEN THE SIGNAL IS RECEIVED, USUALLY AT A DOORWAY) SHE (#2) CHECKED THE RESIDENT AT THE END OF THE EVENING. NURSE #4 WAS INTERVIEWED BY TELEPHONE ON 5/4/12 AT 4:15 P.M. NURSE #4 SAID THAT SHE PROVIDED CARE FOR RESIDENT #501 ON 4/6/12 FROM 9 P.M. AND SENT RESIDENT #501 TO THE HOSPITAL AT 12:15 A.M. ON 4/7/12. NURSE #4 SAID THE RESIDENT WAS VERY COMBATIVE THAT EVENING. NURSE #4 SAID, "SHE MENTIONED A BUS, I KNEW SHE WANTED TO GO." ACCORDING TO NURSE #4, RESIDENT #501 WAS TRYING TO GET ON THE ELEVATOR. WHEN ASKED WHETHER RESIDENT #501 LEFT THE UNIT, NURSE #4 SAID SHE DIDN'T SEE HER (#501) GO ANYWHERE. WHEN QUESTIONED WHETHER ANYONE TOLD HER THAT RESIDENT #501 LEFT THE UNIT, NURSE #4 SAID THAT A VISITOR MENTIONED THAT RESIDENT #501 WAS TRYING TO LEAVE, SAYING, "YOU NEED TO WATCH HER (#501)." NURSE #4 SAID SHE COULD NOT REMEMBER THE NAME OF THE VISITOR. NURSE #4 SAID WHEN SHE CHECKED FOR THE WANDERGUARD NEAR THE END OF THE SHIFT, SHE DID NOT SEE ONE ON THE RESIDENT. RESIDENT #501 WAS INITIALLY admitted to the facility on [DATE], PER THE FACILITY ADMISSIONS RECORD. ON 3/26/12 A "WANDERGUARD" WAS ADDED TO THE INITIAL CARE PLAN FOR COGNITIVE LOSS DEVELOPED ON 3/23/12. A NURSE'S NOTE, DATED 3/25/12 DOCUMENTED THE RESIDENT "TRYING TO OPEN EXIT DOORS STATING I HAVE TO GO TO WORK." A NURSES NOTE ON 3/26/12 DOCUMENTED, "SEVERAL ATTEMPTS TO GO OUT THE EXIT DOORS AND ONTO ANOTHER UNIT." A 3/27/12 NURSE'S NOTE INDICATED THAT THE RESIDENT WAS REMOVING THE WANDERGUARD. A NURSE'S NOTE ON 3/28/12 INDICATED THAT RESIDENT #501 WAS TRANSFERRED TO THE HOSPITAL FOR AGGRESSIVE BEHAVIORS. ACCORDING TO THE ADMISSION RECORD, RESIDENT #501 RETURNED to the facility on [DATE]. THE READMISSION NURSING EVALUATION ON 4/4/12 FOR RESIDENT #501 INCLUDED AN ELOPEMENT RISK ASSESSMENT. THE NURSE COMPLETING THE EVALUATION SCORED THE RESIDENT'S RISK AS "9". ACCORDING TO THE TOOL, A TOTAL SCORE OF 10 OR ABOVE INDICATES "AT RISK." THE NURSE, HOWEVER, FAILED TO INDICATE ON THE TOOL THAT THE RESIDENT WAS TAKING MULTIPLE MEDICATIONS, INCLUDING A PSYCHOACTIVE MEDICATION (SEROQUEL), WHICH WOULD HAVE ADDED AN ADDITIONAL 10 POINTS. ALSO, THE NURSE FAILED TO INCLUDE AN ATTEMPT AT ELOPEMENT IN THE PAST 6 MONTHS, WHICH WOULD HAVE ADDED ANOTHER 10 POINTS. A CARE PLAN FOR WANDERING FOR THE 4/4/12 ADMISSION WAS ADDED ON 4/5/12. IT STATED THAT "WANDERGUARD (WAS) PLACED ON RESIDENT. PLACEMENT TO BE CHECKED EVERY SHIFT & FUNCTION DAILY." THERE WERE NO INTERVENTIONS RELATED TO DEALING WITH EXIT SEEKING BEHAVIOR OR ESCALATING BEHAVIORS. NURSES' NOTES ON 4/6/12 DESCRIBED RESIDENT #501'S BEHAVIORS AS "COMBATIVE ...YELLING OUT ... RESISTING CARE ... WANDERING HALLWAY ...AGGRESSIVE." THERE WAS NO DOCUMENTATION THAT RESIDENT #501 HAD TRIED TO EXIT THE UNIT. THERE WAS NO DOCUMENTATION THAT RESIDENT #501 HAD ELOPED FROM THE FACILITY. AN INCIDENT REPORT, DATED 4/6/12, DOCUMENTED THE FOLLOWING, "RES (RESIDENT #501) OBSERVED EXIT SEEKING TOWARD DOOR, FAMILY MEMBER BROUGHT RES (RESIDENT) BACK TO NURSING STATION." THE ADMINISTRATOR (#42) WAS INTERVIEWED ABOUT THE ELOPEMENT ON 5/4/12 AT 9 A.M. SHE SAID RESIDENT #501 HAD MANY BEHAVIORS. SHE PULLED FIRE ALARMS. SHE WAS EXIT SEEKING. THE ADMINISTRATOR SAID SHE HAD NO EVIDENCE THE RESIDENT LEFT THE BUILDING ON 4/6/12. SHE SAID THE VISITOR, WHO SAID SHE RETURNED THE RESIDENT to the facility on [DATE] FROM OUTSIDE THE BUILDING, WAS SEEN ON THE SECURITY TAPES LEAVING THE BUILDING THAT EVENING; HOWEVER, THE VISITOR WAS NOT SEEN RETURNING TO THE BUILDING WITH THE RESIDENT. THE ADMINISTRATOR SAID SHE COULD NOT REMEMBER THE NAME OF THE VISITOR. ACCORDING TO ADMINISTRATOR #42, RESIDENT #501 DID NOT ELOPE FROM THE FACILITY. ON 5/4/12, ADMINISTRATOR #42 PROVIDED A HANDWRITTEN SHEET OF PAPER TO THE SURVEYOR. SHE SAID IT WAS PART OF THE DON'S INVESTIGATION, BUT SHE (#42) WAS NOT SURE WHAT "IT ALL MEANT." ON THE HANDWRITTEN PAPER WAS DOCUMENTED, "EXIT STAIRWAY ON HOMEBOUND (NURSING UNIT WHERE RESIDENT #501 RESIDED) DOWN TO LOWER LEVEL DOOR/DOOR NOT ALARMED." THE PAPER INDICATED THAT ALL EXITS WERE CHECKED, WANDERGUARD DOORS WERE CHECKED, AND WANDERGUARDS ON RESIDENTS ASSESSED AS EXIT SEEKING WERE CHECKED. IT WAS DOCUMENTED THAT A "FAMILY MEMBER" WAS CALLED AND INTERVIEWED. THE NAME OF THE FAMILY MEMBER WAS NOT DOCUMENTED. AT THE BOTTOM OF THE PAGE WAS WRITTEN: "EXIT DOORS - 4 BROKEN, EXIT DOORS - 3 NO ALARM, 3 DOORS (EXIT ALARMS) WORKING." THERE WERE NO DATES OR TIMES THAT THE ABOVE WERE COMPLETED. THE DON (#43) WAS NOT AVAILABLE FOR INTERVIEW. DURING A TOUR WITH THE MAINTENANCE DIRECTOR ON 5/10/12 AT 2 P.M., THE EXIT DOOR IN THE DINING ROOM ON HOMEBOUND UNIT HAD A SIGN INDICATING THAT IT WAS FOR EMERGENCY EXIT ONLY. WHEN tested , OBSERVATION REVEALED THAT THIS DOOR HAD BEEN LEFT UNSECURED. SOMEONE HAD EXITED THROUGH THE DOOR, AND THE ALARM HAD NOT BEEN RESET. ACCORDING TO THE MAINTENANCE DIRECTOR, THIS ALLOWED INDIVIDUALS TO EXIT THE DOOR WITHOUT AN ALARM SOUNDING. ON 5/17/12 THE DOOR WAS tested WITH THE MAINTENANCE DIRECTOR AND FOUND TO BE WORKING. ON 5/14/12 AT 3 P.M. THE SURVEYOR FOUND THE SECOND FLOOR ALARMED DOOR (EXIT TO THE STAIRWELL) BETWEEN THE ELEVATOR AND THE NURSE'S STATION OPEN. THE MAINTENANCE DIRECTOR WAS NOTIFIED BY THE SURVEYOR IMMEDIATELY. ON 5/17/12 THE MAINTENANCE DIRECTOR SAID A NEW DOOR HAD BEEN ORDERED. A FACILITY EMPLOYEE WAS MONITORING THE DOOR TO MAKE SURE RESIDENTS DID NOT EXIT OR ENTER THE UNIT. ON 5/11/12 AT 12:40 P.M. THE ADMINISTRATOR WAS INFORMED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 4/6/12 AS A RESULT OF THE FACILITY'S FAILURE TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY FOR RESIDENT #501, PLACING FOUR OTHER RESIDENTS AT RISK FOR ELOPEMENT AND THE RISK OF SERIOUS HARM, INJURY, OR DEATH. ON 5/17/12 THE SURVEYOR CONFIRMED THAT THE FACILITY HAD IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY ON 5/14/12. 1. RESIDENT #501 WAS RE-admitted to the facility on [DATE] AND WAS NOT FOUND TO BE AN ELOPEMENT RISK. BASED ON THE FINDING OF RESIDENT #501 AS AN ELOPEMENT RISK ON A PRIOR ADMISSION, A WANDERGUARD WAS PLACED ON THE RESIDENT DURING THE 4/4/12 READMISSION. 2. ON 5/9/12, NURSE MANAGERS RE-ASSESSED 130 RESIDENTS FOR ELOPEMENT RISK. CARE PLANS AND CARE GUIDES WERE UPDATED, AND A PLAN FOR CHECKING AND DOCUMENTING FUNCTIONALITY OF WANDER GUARDS FOR 4 RESIDENTS AT RISK FOR ELOPEMENT WAS IMPLEMENTED. 3. THE ENVIRONMENTAL SERVICES DIRECTOR/DESIGNEE CHECKED ALL DOORS ON 4/6/12 AND 4/7/12 FOR FUNCTIONING OF ALL ALARMS, AND ALL WERE FOUND FUNCTIONING APPROPRIATELY. ON 5/17/12 ONE DOOR WAS BEING MONITORED CONTINUALLY BY A FACILITY STAFF MEMBER BECAUSE OF A MALFUNCTION. THIS DOOR HAD BEEN FOUND OPENED ON 5/14/12. MONITORING WOULD CONTINUE UNTIL A NEW DOOR COULD BE PLACED. A NEW SECURITY SYSTEM WAS PLANNED FOR THE FORMER EMPLOYEE ENTRANCE DOOR, WHICH HAD BEEN LOCKED AS AN ENTRANCE AND CHANGED TO AN EMERGENCY EXIT DOOR. 4. ON 5/1/12, STAFF WERE INSERVICED REGARDING A MALFUNCTION OF DOORS AND THE NEED FOR CONTINUOUS MONITORING BY A FACILITY STAFF MEMBER. THE IN-SERVICE IS ON-GOING TO CAPTURE 100% OF EMPLOYEES. 5. AN ELOPEMENT BOOK WAS UPDATED FOR NEW ADMISSIONS WHO ARE ELOPEMENT RISKS AS OF 5/9/12. ON 5/9/12 INFORMATION REGARDING FOUR RESIDENTS IDENTIFIED AS ELOPEMENT RISKS WERE PLACED IN THE ELOPEMENT BOOKS AT THE RECEPTIONIST'S DESK AND ON ALL NURSING UNITS. AS OF 5/17/12 THE THIRD FLOOR NURSING UNIT DID NOT HAVE CURRENT INFORMATION IN AN ELOPEMENT BOOK. 6. THE FRONT DESK WAS STAFFED WITH A RECEPTIONIST AND/OR A SECURITY GUARD 24 HOURS DAILY, 7 DAYS A WEEK AS OF 5/8/12. 7. IN-SERVICING ON THE ELOPEMENT POLICY BEGAN ON 5/8/12. THE IN-SERVICE IS ON-GOING TO CAPTURE 100% OF EMPLOYEES. NEWLY HIRED EMPLOYEES WILL RECEIVE EDUCATION ON THE ELOPEMENT POLICY BEGINNING 5/9/12. 8. ON 5/8/12, A NEW SECURITY CAMERA WAS INSTALLED AT THE EMPLOYEE ENTRANCE AT THE BACK OF THE FACILITY. AN EXISTING FIRST FLOOR CAMERA LOCATED IN THE HALLWAY BY THE CONFERENCE ROOM WAS REPOSITIONED ON 5/8/12 TO CAPTURE PEOPLE ENTERING THE FACILITY FROM THE LOBBY. 9. BEGINNING 5/8/12 WANDERGUARDS ON RESIDENTS WERE CHECKED DAILY FOR FUNCTIONALITY AND DOCUMENTED IN THE MAR (MEDICATION ADMINISTRATION RECORD) BY LICENSED NURSES. 10. NEW ADMISSIONS, BEGINNING 5/8/12, WERE ASSESSED FOR ELOPEMENT RISK BY LICENSED NURSES, AND CARE PLANS, CARE GUIDES, AND THE ELOPEMENT BOOK WILL BE UPDATED. RESIDENTS WITH ESCALATING BEHAVIORS WILL BE ASSESSED, THE PHYSICIAN WILL BE CONTACTED, AND APPROPRIATE INTERVENTIONS WILL BE IMPLEMENTED. 11. BEGINNING 5/9/12 NEW ADMISSION CHARTS WILL BE REVIEWED DAILY IN THE MORNING STAND-UP MEETING TO ENSURE THAT RESIDENTS IDENTIFIED AS AN ELOPEMENT RISK HAVE INTERVENTIONS IN PLACE. 12. ON 5/8/12, ELEVATORS LOCATED BY NURSING STATIONS OR IN HIGH TRAFFIC AREAS ARE MONITORED BY FACILITY STAFF AND HAVE A SEQUENCE CODE SYSTEM TO OPERATE THE ELEVATOR. 13. THE KEY PAD AT THE EMPLOYEE BACK DOOR (PREVIOUS EMPLOYEE ENTRANCE) WAS DEACTIVATED ON 5/4/12, AND STAFF CAN NO LONGER ENTER THROUGH THAT DOOR. ON 5/4/12 THE DOOR WAS CHANGED TO AN EMERGENCY EXIT ONLY. 14. BEGINNING 5/8/12, THE NHA OR DESIGNEE WILL RANDOMLY VIEW THE VIDEO FOOTAGE WEEKLY AND AS NECESSARY TO ENSURE THAT RESIDENT SAFETY IS MAINTAINED. 15. DAILY AUDITS OF ALARMED DOORS WILL BE DONE DAILY BY THE ENVIRONMENTAL SERVICES DIRECTOR/DESIGNEE AND REPORTED TO THE NHA, BEGINNING 5/9/12. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON 4/6/12 WAS REMOVED ON 5/14/12. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "PATTERN" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED. ( ) BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEWS, THE FACILITY FAILED TO PROVIDE SUPERVISION AND ASSISTIVE DEVICES TO PREVENT FALLS AND TO THOROUGHLY INVESTIGATE THE CAUSE OF FALLS TO DETERMINE POSSIBLE FALL INTERVENTIONS FOR 5 (#502, #507, #508, #509, #514) OF 5 RESIDENTS SAMPLED FOR FALLS FROM A TOTAL SAMPLE OF 15, PLACING THE RESIDENTS AT RISK FOR CONTINUED FALLS AND INJURY. FINDINGS INCLUDE: RESIDENT #502, [AGE] years OLD, WAS REadmitted to the facility on [DATE], PER A NURSES ADMISSION EVALUATION. A 3/5/12 CARE CONFERENCE FORM INDICATED THAT RESIDENT #502 WAS ALERT WITH CONFUSION AND REQUIRED ASSISTANCE WITH ADLS (ACTIVITIES OF DAILY LIVING). SHE WAS INCONTINENT OF BOWEL AND BLADDER. THERE WERE NO NEGATIVE BEHAVIORS. A THERAPY COMMUNICATION FORM, DATED 3/12/12, INDICATED THAT RESIDENT #502 WAS A MAXIMUM 2 PERSON ASSIST WITH TRANSFERS. RESIDENT #502 USED A WHEELCHAIR FOR MOBILITY. ACCORDING TO AN INCIDENT REPORT, ON 4/28/12, AT 8:05 A.M., RESIDENT #502 EXITED THE FIRST FLOOR NURSING UNIT WHERE SHE RESIDED, WHEELED INTO THE LOBBY AND fell DOWN THE THREE STEPS TOWARD THE LOBBY EXIT DOOR. THE DOORS FROM THE NURSING UNIT INTO THE LOBBY WERE OPEN. THE INCIDENT REPORT STATED THAT THE RESIDENT HAD A WANDERGUARD IN PLACE WHICH DID NOT ALARM WHEN SHE WENT THROUGH THE DOORS. THE DOORS WERE EQUIPPED WITH A WANDERGUARD ALARM SYSTEM. RECEPTIONIST #41WAS INTERVIEWED ON 5/10/12 AT 1 P.M. ACCORDING TO RECEPTIONIST #41, ON 4/28/12, SHE (#41) WAS SEATED AT THE BOTTOM OF THE THREE STEPS AND ACROSS FROM THE LOBBY EXIT DOOR. RECEPTIONIST #41 SAID THAT SHE (#41) DID NOT HEAR THE WANDERGUARD ALARM SOUND WHEN RESIDENT #502 ENTERED THE LOBBY AREA. SHE SAID SHE DID NOT KNOW THE RESIDENT WAS EVEN IN THE LOBBY UNTIL THE RESIDENT SCREAMED AND LANDED AT THE BOTTOM OF THE STAIRS. ACCORDING TO RECEPTIONHIST #41, THE RESIDENT LANDED ON HER (#502) SIDE, STILL IN THE WHEELCHAIR. THE RECEPTIONIST SAID THERE WERE HOUSEKEEPERS IN THE LOBBY THAT MORNING WHO SAID THEY DID NOT HEAR ANY WANDERGUARD ALARMS WHEN THE RESIDENT ENTERED THE LOBBY AREA. THE RECEPTIONIST SAID SHE HEARD THE WANDERGUARD ALARM WHEN NURSES RETURNED RESIDENT #502 TO THE NURSING UNIT. CNA #15 WAS INTERVIEWED ON 5/9/12 AT 1:55 P.M. CNA #15 SAID SHE WAS ASSIGNED TO RESIDENT #502 ON 4/28/12 DURING THE DAY SHIFT. CNA #15 SAID SHE SAW THE RESIDENT AT THE NURSES' STATION WHEN SHE MADE HER INITIAL ROUNDS SHORTLY AFTER 7 A.M. CNA #15 SAID SHE WAS PASSING BREAKFAST TRAYS WHEN THE RECEPTIONIST CAME AND SAID A RESIDENT fell DOWN THE LOBBY STAIRS. CNA #15 SAID SHE WAS NOT AWARE THAT THE RESIDENT HAD GONE INTO THE LOBBY. ACCORDING TO THE CNA, RESIDENT #502 WAS WEARING A WANDERGUARD. NURSE #29 WAS INTERVIEWED BY TELEPHONE ON 5/12/12 AT 3:45 P.M. NURSE #29 SAID THAT ON 4/28/12, RESIDENT #502 HAD A WANDERGUARD ATTACHED TO THE WHEELCHAIR. THE NURSE SAID NURSING STAFF ON THE UNIT, HOUSEKEEPERS, AND A RECEPTIONIST IN THE LOBBY DID NOT HEAR A WANDERGUARD ALARM SOUND WHEN THE RESIDENT EXITED THE NURSING UNIT. SHE SAID THE WANDERGUARD ALARM ON THE EXIT DOORS FROM THE UNIT TO THE LOBBY SOMETIMES ALARM WHEN THERE WERE NO RESIDENTS IN THE AREA. SHE SAID THIS HAD HAPPENED 2 OR 3 TIMES SINCE 4/28/12. RESIDENT #502 DID NOT HAVE A CARE PLAN IN PLACE FOR EXIT SEEKING BEHAVIOR OR FOR USE OF A WANDERGUARD PRIOR TO 4/28/12. A CARE PLAN FOR "THE POTENTIAL TO WANDER/ELOPE" WAS INITIATED ON 5/8/12. ON 4/28/12 THERE WAS AN ENTRY ON THE RESIDENT'S TREATMENT RECORD TO CHECK THE FUNCTION AND PLACEMENT OF THE WANDERGUARD EVERY SHIFT. NURSE #7, INTERVIEWED ON 5/9/12 AT 9:20 A.M., SAID SHE WAS A RESTORATIVE NURSE AND WAS RESPONSIBLE FOR INVESTIGATING FALLS IN THE FACILITY. SHE SAID SHE AND THE ADON (ASSISTANT DIRECTOR OF NURSING) (#44) EVALUATED ALL RESIDENTS FOR ELOPEMENT RISK ON 4/8/12, AND RESIDENT #502 WAS NOT IDENTIFIED AS AN ELOPEMENT RISK AT THAT TIME. SHE COULD NOT EXPLAIN WHY OR WHEN THE WANDERGUARD WAS PLACED. ACCORDING TO NURSE #7, THERE WAS NO DOCUMENTATION ON RESIDENT #502'S TREATMENT RECORD ABOUT THE WANDERGUARD PRIOR TO 4/28/12. NURSE #7 FURTHER SAID THAT THE FALLS COMMITTEE DID NOT DETERMINE WHY THE RESIDENT'S WANDERGUARD DID NOT FUNCTION PROPERLY ON 4/28/12. ( ) RESIDENT #507 RESIDENT #507, [AGE] years OLD, WAS admitted to the facility on [DATE], PER THE ADMISSION RECORD. A HOSPITAL H&P REPORT FOR RESIDENT #507, DATED 4/19/12, DOCUMENTED THE FOLLOWING DIAGNOSES; DEMENTIA, ANEMIA, AND DEEP VEIN THROMBOSIS (CLOTS). AN MDS (MINIMUM DATA SET) ON 2/8/12 INDICATED THAT RESIDENT #507 REQUIRED LIMITED TO EXTENSIVE ASSISTANCE FOR MOST ACTIVITIES OF DAILY LIVING. A PHYSICAL THERAPY PROGRESS NOTE, DATED 12/23/11, INDICATED THE RESIDENT REQUIRED MODERATE ASSISTANCE (AVERAGE AMOUNT OF PHYSICAL ASSISTANCE TO COMPLETE TRANSFER) OF ONE PERSON AND VERBAL CUING FOR TRANSFERS. A PHYSICAL THERAPY PROGRESS NOTE ON 1/11/12, INDICATED THAT RESIDENT #507 REQUIRED STANDBY ASSISTANCE (NO DIRECT CONTACT WITH PATIENT)/CONTACT GUARD (DIRECT CONTACT WITH PATIENT FOR SAFETY BUT NO PHYSICAL ASSISTANCE) AND VERBAL CUING (SHORT DIRECT INSTRUCTIONS) FOR TRANSFERS. RESIDENT #507 HAD MULTIPLE FALLS, RECORDED IN VARIOUS LOCATIONS. THERE WERE INCIDENT REPORTS, DATED 11/1/11, 11/3/11, 12/23/11, AND 1/14/12. physician progress notes [REDACTED]. A 12/20/11 physician progress notes [REDACTED]. . .IMPULSIVE - GETTING UP ON HER OWN - USUALLY TO TOILET. . .COMPLAINS OF 'MENTAL PAIN' AND POSSIBLY DEPRESSION. . . POSSIBLE URGENCY - CHECK UA (URINALYSIS), C&S (CULTURE & SENSITIVITY TO RULE OUT URINARY TRACT INFECTION), NEEDS FORMAL BOWEL PROGRAM. . .CLOCK VOIDING HAS BEEN INITIATED. . .BED & CHAIR ALARM ALREADY INITIATED, LOW BED & MAT INITIATED. . . MAY BENEFIT FROM A ROOM CLOSER TO NURSING STATION. . .KEEP PATIENT IN ACTIVITIES ALL DAY." THE PHYSICIAN DOCUMENTED THAT HE DISCUSSED THIS WITH THE RESIDENT'S PRIMARY PHYSICIAN, A NURSING SUPERVISOR, AND TWO FLOOR NURSES. ACCORDING TO A 12/22/11 FOLLOW-UP PROGRESS NOTE, WRITTEN BY THE SAME PHYSICIAN, "DISCUSSED WITH NURSING - PATIENT FOUND IN BATHROOM ON HER OWN AGAIN. IS NOT STAYING IN ACTIVITIES. CLOCK VOIDING BEING DONE (ONLY) IN AFTERNOON. UA, C&S WAS SENT <24 HOURS AGO. LAB DOES NOT HAVE THE URINE. WILL ATTEMPT TO RESEND." THERE WERE TWO CARE PLANS FOR ACTIVITIES FOR RESIDENT #507, ONE INITIATED ON 10/26/11 AND THE SECOND ONE INITIATED ON 11/2/11. THE CARE PLANS DID NOT IDENTIFY THE ACTIVITIES APPROPRIATE FOR RESIDENT #507 AND A SPECIFIC SCHEDULE FOR THE RESIDENT TO MEET THE GOAL IDENTIFIED BY THE PHYSICIAN IN THE 12/20/11 PROGRESS NOTE. IT DID NOT ADDRESS THE ISSUE THAT THE RESIDENT WAS NOT STAYING IN ACTIVITIES. RESIDENT #507 HAD A CARE PLAN FOR BOWEL INCONTINENCE, INITIATED ON 11/7/11. IT DID NOT DISCUSS A SPECIFIC BOWEL PROGRAM OR ITS EFFECTIVENESS. THERE WAS A CARE PLAN FOR BLADDER INCONTINENCE, INITIATED ON 11/7/11. THERE WAS AN INTERVENTION TO TOILET THE RESIDENT IN THE "A.M.", AT BEDTIME, AFTER MEALS, AND UPON REQUEST. IT DID NOT OFFER A SPECIFIC TIME FOR VOIDING OR DISCUSS THE EFFECTIVENESS OF A SCHEDULED VOIDING PROGRAM. RESIDENT #507 HAD A FALLS CARE PLAN, INITIATED ON 11/7/11. THERE WAS AN INTERVENTION FOR CNAS TO "ENCOURAGE RESIDENT TO ASK FOR ASSIST WITH TRANSFER WHEN FEELING WEAK OR UNABLE TO BALANCE SELF," EVEN THOUGH PHYSICAL THERAPY INDICATED THAT THE RESIDENT NEEDED ASSISTANCE FOR ALL TRANSFERS. ON 1/18/12 A NEW PROBLEM WAS ADDED. IT STATED THAT RESIDENT #507 CONTINUED TO GET OUT OF HER WHEELCHAIR WITHOUT ASSISTANCE AND WAS REMOVING HER WHEELCHAIR ALARM. ALL THE PREVIOUS INTERVENTIONS FROM 11/7/11 REMAINED ON THE CARE PLAN. THERE WERE NO NEW INTERVENTIONS ON 1/18/12 TO ADDRESS THE NEW PROBLEM ADDED ON 1/18/12. ( ) RESIDENT #508 RESIDENT #508, [AGE] years OLD, WAS REadmitted to the facility on [DATE], PER THE ADMISSION RECORD. ACCORDING TO A NURSING COMPREHENSIVE EVALUATION ON ADMISSION (5/5/12), RESIDENT #508 WAS BLIND, ALERT TO PERSON ONLY, REQUIRED ONE PERSON ASSISTANCE FOR BED MOBILITY AND TRANSFERS. THE RESIDENT WAS DETERMINED TO BE AT RISK FOR FALLS, ACCORDING TO THE FALLS RISK ASSESSMENT, DATED 5/5/12. ON 5/6/12, PER AN INCIDENT REPORT, RESIDENT #508 fell OUT OF BED AT 3:15 P.M. ACCORDING TO THE INCIDENT REPORT, THE resident sustained [REDACTED]. INTERVENTIONS TO BE IMPLEMENTED INCLUDED; ONE-ON-ONE MONITORING, NEUROLOGICAL CHECKS PER PROTOCOL, ROOM TRANSFER CLOSER TO THE NURSE'S STATION, AND A CONCAVE MATTRESS. DURING A TOUR WITH NURSE #7 ON 5/10/12 AT 10:05 A.M., OBSERVATION REVEALED THAT RESIDENT #508'S BED WAS LACKING THE CONCAVE MATTRESS. WHEN ASKED ABOUT THE ABSENCE OF THE CONCAVE MATTRESS, NURSE #7 SAID THE RESIDENT'S ROOM HAD CHANGED AND GAVE THAT AS THE REASON THAT RESIDENT #508 DID NOT HAVE THE INTERVENTION THAT HAD BEEN ASSESSED TO ADDRESS HER FALLS. ( ) RESIDENT #509 RESIDENT #509. [AGE] years OLD, WAS admitted to the facility on [DATE], ACCORDING TO THE ADMISSION RECORD. ACCORDING TO A HOSPITAL DISCHARGE SUMMARY ON 4/24/12, RESIDENT #509 WAS hospitalized for [REDACTED]. AN H&P REPORT ON 4/29/12 INDICATED THAT RESIDENT #509 WAS "PLEASANTLY DEMENTED . . . DOES GET CONFUSED AND DOES TEND TO WANDER." RESIDENT #509 HAD TWO FALLS DOCUMENTED IN A NURSE'S NOTE ON 4/26/12 AT 7 P.M. AND 4/27/12 AT 8:30 A.M. ACCORDING TO THE NURSES' NOTES ON BOTH DATES, THE RESIDENT WAS ATTEMPTING TO USE THE BATHROOM INDEPENDENTLY RATHER THAN CALL FOR ASSISTANCE. RESIDENT #509 WAS OBSERVED IN THE THERAPY DEPARTMENT ON 5/10/12 AT 11:40 A.M. DURING A TOUR WITH NURSE #7. THE RESIDENT WAS IN HER WHEELCHAIR, WAITING FOR HER THERAPY. THE SURVEYOR NOTED THAT THE RESIDENT'S PERSONAL ALARM WAS NOT ATTACHED TO THE RESIDENT. WHEN NURSE #7 WENT TO TEST THE ALARM, THE ALARM DID NOT INITIALLY SOUND. THE ALARM DID NOT SOUND UNTIL AFTER NURSE #7 OPENED THE PERSONAL ALARM DEVICE AND REPOSITIONED THE BATTERIES. ( ) RESIDENT #514 RESIDENT #514, [AGE] years OLD, WAS REadmitted to the facility on [DATE], ACCORDING TO THE FACILITY ADMISSION RECORD. ACCORDING TO A 3/30/12 H&P REPORT, RESIDENT #514 HAD MANY [DIAGNOSES REDACTED]. RESIDENT #514 HAD TWO FALLS, ACCORDING TO INCIDENT REPORTS. ON 4/9/12 AT 1:15 P.M. THE RESIDENT WAS FOUND ON THE FLOOR IN FRONT OF HER WHEELCHAIR IN THE HALLWAY. THE RESIDENT SAID SHE WAS TRYING TO GO HOME. INTERVENTIONS INCLUDED A WHEELCHAIR ALARM, AND THE WHEELCHAIR SEAT WAS DROPPED. ACCORDING TO A PHYSICIAN'S PROGRESS NOTE, DATED 4/9/12, RESIDENT #514 WAS EVALUATED AFTER A FALL ON 4/9/12. AT THAT TIME THE RESIDENT WAS ALERT BUT "VERY CONFUSED." THE NOTE INDICATED THAT AN OLD CEREBRAL INFARCTION MAY "EXPLAIN RESIDENT FALL RISK. VISUAL SENSORY AND SPATIAL SENSE IS IMPAIRED. NONE OF THE CHANGES ARE ACUTE." THE PLAN WAS TO MONITOR THE RESIDENT FOR CHANGES, ENCOURAGE ORAL INTAKE, AND EVALUATE THE RESIDENT'S ANEMIA. ON 5/5/12 AN INCIDENT REPORT INDICATED THAT RESIDENT #514 WAS IN BED AND THEN FOUND ON THE FLOOR MAT NEXT TO HER BED AT 9:20 A.M. CNA #40 WAS INTERVIEWED BY TELEPHONE ON 5/18/12 AT 8:10 A.M. SHE SAID SHE WAS INITIALLY ASSIGNED TO RESIDENT #514 ON 5/5/12 DURING THE DAY SHIFT. THE CNA SAID THE RESIDENT WAS "AGGRESSIVE" ON 5/5/12, WHICH WAS NOT AT ALL LIKE HER. THE CNA SAID THE RESIDENT PUSHED HER BREAKFAST TRAY ON THE FLOOR AND THREW SOME BLANKETS. WHEN THE RESIDENT WAS WASHED AND DRESSED, CNA #40 SAID SHE PLACED HER AT THE NURSE'S STATION "BECAUSE I HAD OTHER RESIDENTS TO CARE FOR". THE CNA SAID THREE NURSES WERE AT THE NURSE'S STATION, AND SHE TOLD THEM SOMETHING WAS WRONG WITH THE RESIDENT. THE CNA SAID ONE NURSE TOLD HER THE DEMENTIA WAS PROGRESSING. ONE OF THE NURSES TOLD THE CNA TO PUT HER BACK INTO BED. THE CNA SAID, "I TRIED TO TELL THEM (THE NURSE ON DUTY) SHE WASN'T SAFE IN BED." BUT THEY (THE NURSE) INSISTED. ACCORDING TO CNA #40, "THAT IS WHEN THE RESIDENT fell OUT OF BED." NURSE #36 WAS INTERVIEWED BY TELEPHONE ON 5/17/12 AT 2:15 P.M. NURSE #36 SAID SHE WORKED 7 A.M. TO 7 P.M. ON 5/5/12. SHE SAID RESIDENT #514 HAD BEEN AGITATED AND TRYING TO GET OUT OF HER WHEELCHAIR ALL NIGHT. THE NURSE SAID THE RESIDENT NEVER WANTED TO GET UP IN THE MORNING, SO THIS BEHAVIOR WAS VERY UNUSUAL. NURSE #36 SAID SHE CALLED STAFFING FOR A 1:1 SITTER AND CALLED A FRIEND OF THE RESIDENT TO COME SIT WITH HER, BUT BEFORE ANYONE WAS AVAILABLE THE RESIDENT fell OUT OF BED. ACCORDING TO THE NURSE, IT WAS AN UNWITNESSED FALL. THE NURSE SAID SHE CALLED THE PHYSICIAN, AND THE PHYSICIAN ORDERED A URINALYSIS WITH CULTURE AND SENSITIVITY AND SOME HALDOL (ANTIPSYCHOTIC). NURSE #36 DID NOT EXPLAIN WHY CNA #40 WAS INSTRUCTED TO PUT RESIDENT #514 BACK INTO HER BED WHEN IT WAS NOT SAFE TO DO SO. RESIDENT #514 HAD NO VISIBLE INJURY FROM THE FALL ON 5/5/12. A NURSE'S NOTE ON 5/5/12 DOCUMENTED THAT THE RESIDENT BECAME UNRESPONSIVE AT 9:18 P.M. AND THE NURSE WAS UNABLE TO OBTAIN VITAL SIGNS. CARDIOPULMONARY RESUSCITATION WAS INITIATED. A HOSPITAL PHYSICIAN'S NOTE, DATED 5/5/12 AT 9:54 P.M., INDICATED THE RESIDENT SUFFERED A CARDIOPULMONARY ARREST AND WAS DEAD ON ARRIVAL. ( ) BASED ON INTERVIEWS, FACILITY STAFF FAILED TO MAINTAIN LOCKED DOORS DURING THE NIGHT, PERMITTING A PERSON WITHOUT AUTHORITY TO ENTER THE FACILITY PLACING ALL RESIDENTS AT RISK FOR PSYCHOLOGICAL OR PHYSICAL TRAUMA. FINDINGS INCLUDE: A POLICE COMMUNICATIONS EMPLOYEE (#35) WAS INTERVIEWED BY TELEPHONE ON 5/15/12 AT 10:55 A.M. SHE SAID A CALL CAME IN TO 911 (EMERGENCY SERVICES) ON MONDAY, 3/5/12 AT 12:39 A.M., REPORTING THAT "A MAN CAME INTO THE FACILITY SAYING HE HAD BEEN STABBED." EMERGENCY MEDICAL SERVICES (EMS) AND THE POLICE WERE DISPATCHED TO (ADDRESS) IN (NAME OF CITY). THIS WAS THE FACILITY ADDRESS. TWO EMPLOYEES WHO WISHED TO REMAIN ANONYMOUS CONFIRMED THAT POLICE WERE DISPATCHED TO THE FACILITY. EMPLOYEE "G" SAID ADMINISTRATION KNEW THE FRONT LOBBY DOOR WAS BROKEN FOR THREE DAYS AND COULD NOT BE SECURED. THE EMPLOYEE SAW THE MAN IN THE FACILITY LOBBY, WITH BLOOD ON HIS PERSON. EMPLOYEE "H" SAID, "ABSOLUTELY I KNEW ABOUT THIS." THE EMPLOYEE SAID A MAN WALKED FROM THE STREET INTO THE FACILITY AND DOWN THE "A" HALLWAY. THE FRONT DOOR TO THE LOBBY HAD BEEN BROKEN SINCE FRIDAY (3/2/12). TAPE HAD BEEN PLACED OVER THE LOCKING MECHANISM SO THE DOOR WOULD NOT LOCK. IF IT HAD LOCKED, NO ONE WOULD HAVE BEEN ABLE TO ENTER OR EXIT THE DOOR. ADMINISTRATION SAID IT WOULD BE FIXED ON MONDAY (3/5/12). ON 5/9/12 AT 3 P.M. THE ADMINISTRATOR AND THE DIRECTOR OF MAINTENANCE WERE QUESTIONED ABOUT THE FRONT LOBBY DOOR BEING OPEN ON THE WEEKEND. BOTH INDIVIDUALS DENIED KNOWING ANYTHING ABOUT THE UNSECURED DOOR. ( )

REFER TO INTAKES MI 843 AND MI 592. BASED ON OBSERVATIONS, INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO ADMINISTER STAFFING RESOURCES EFFECTIVELY AND EFFICIENTLY AND FAILED TO RECOGNIZE REPORTABLE EVENTS TO THE STATE AGENCY AND LAW ENFORCEMENT WHICH AFFECTED THE SAFETY OF 1 (#500) OF 4 RESIDENTS SAMPLED FOR ABUSE IN A TOTAL SAMPLE OF 15 RESIDENTS AND WHICH AFFECTED THE SAFETY OF 1 (#501) OF 4 SAMPLED RESIDENTS FOR ELOPEMENT IN A TOTAL OF 15 SAMPLED RESIDENTS. THIS RESULTED IN IMMEDIATE JEOPARDY FOR RESIDENT #500 WHO REPORTED ABUSE ON 4/27/12 AT APPROXIMATELY 10 P.M., SUSTAINING A BRUISE ON HER NECK, PSYCHOLOGICAL DISTRESS, AND THE THEFT OF A NECKLACE AND IMMEDIATE JEOPARDY FOR RESIDENT #501 WHO WAS MISSING FROM THE FACILITY ON 4/6/12 SOMETIME BETWEEN 9 P.M. AND 10 P.M. UNBEKNOWNST TO STAFF PLACING THE RESIDENT AT RISK FOR PHYSICAL HARM OR DEATH. AS A RESULT OF THE FACILITY'S FAILURE TO ADMINISTER STAFFING RESOURCES EFFECTIVELY AND EFFICIENTLY AND FAILURE TO RECOGNIZE REPORTABLE EVENTS, 4 RESIDENTS CURRENTLY WERE PLACED AT RISK FOR ELOPEMENT WHICH COULD RESULT IN INJURY OR DEATH AND ALL RESIDENTS WERE PLACED AT RISK FOR ABUSE AND THEFT. FINDINGS INCLUDE: RESIDENT #500 RESIDENT #500 WAS INTERVIEWED ON 5/3/12 AT 8:45 A.M. THE RESIDENT SAID SHE CALLED FOR HELP AFTER BEING PHYSICALLY ATTACKED IN HER ROOM ON 4/27/12 AT APPROXIMATELY 10 P.M. CNA (CERTIFIED NURSING ASSISTANT) #11, INTERVIEWED ON 5/4/12 AT 3 P.M., SAID SHE FOUND RESIDENT #500 WITH A REDDENED NECK, VISIBLY UPSET, IN A ROOM WITH HER BELONGINGS SCATTERED ABOUT. RESIDENT #500 TOLD THE CNA THAT A FORMER EMPLOYEE CAME INTO HER ROOM, HELD HER AGAINST HER WILL AND STOLE HER NECKLACE. CNA #11 SAID SHE BELIEVED THE RESIDENT BECAUSE RESIDENT #500 "NEVER STEERS ME WRONG." THE CNA SAID SHE TOLD THE NURSE ON DUTY (#10); HOWEVER, THE NURSE IGNORED HER. CNA #11 TOLD A NURSE ON ANOTHER UNIT. THE SECOND NURSE (#17) TOLD CNA #11 TO WRITE THE INCIDENT ON THE BEHAVIOR LOG. AN "ABUSE PROHIBITION POLICY", DATED 6/2011, INCLUDES THE FOLLOWING DIRECTIONS FOR REPORTING ABUSE. "THE STAFF WILL REPORT ANY ALLEGATIONS OF MISTREATMENT, ABUSE, NEGLECT, MISAPPROPRIATION OF PROPERTY, AND INJURIES OF UNKNOWN SOURCE TO THE ADMINISTRATOR IMMEDIATELY. THE FACILITY WILL REPORT ALL ALLEGATIONS AND SUBSTANTIATED OCCURRENCES OF MISTREATMENT, ABUSE, NEGLECT, MISAPPROPRIATION OF PROPERTY, OR INJURIES OF UNKNOWN SOURCE PER STATE GUIDELINES. . . OTHER AGENCIES SUCH AS THE POLICE OR FAMILY PROTECTION AGENCY WILL BE NOTIFIED BASED UPON THE CIRCUMSTANCE OF THE CASE. THE ADMINISTRATOR OR DIRECTOR OF NURSING WILL INFORM THE RESIDENT OR HIS/HER REPRESENTATIVE OF THE FINDINGS OF THE INVESTIGATION AND CORRECTIVE ACTION TAKEN." THE "ABUSE PROHIBITION POLICY" ALSO STATES, "ANY PERSON(S) WITNESSING OR HAVING KNOWLEDGE OF POTENTIAL, ACTUAL OR ALLEGED ABUSE, MISTREATMENT, MISAPPROPRIATION OF PROPERTY, EXPLOITATION, OR NEGLECT OF A RESIDENT MUST BE REPORTED TO THE CHARGE NURSE WHO WILL EXAMINE RESIDENT AND DOCUMENT FINDINGS IN THE MEDICAL RECORD AND INTERNAL ABUSE REPORTING SYSTEM. . .THE ADMINISTRATOR OR DESIGNEE SHALL THOROUGHLY INVESTIGATE ALL ALLEGATIONS USING THE INCIDENT AND ACCIDENT INVESTIGATION FORM AND THE QUALITY ASSURANCE INTERVIEW SUMMARY FORM." NURSE #10 WAS INTERVIEWED BY TELEPHONE ON 5/3/12 AT 12:30 P.M. HE SAID CNA #11 TOLD HIM ABOUT THE INCIDENT ON 4/27/12. NURSE #10 SAID HE WENT TO RESIDENT #500'S ROOM BUT DIDN'T SEE ANYTHING AMISS. HE SAID HE THOUGHT MAYBE RESIDENT #500 HAD A NIGHTMARE AND TOLD HER TO GO BACK TO SLEEP. NURSE #10 SAID HE DID NOT CONDUCT A PHYSICAL EXAMINATION OF THE RESIDENT. NURSE #10 SAID HE WAS BUSY THAT NIGHT WITH ANOTHER RESIDENT IN DISTRESS. HE SAID HE DIDN'T TELL ANYONE ABOUT THE INCIDENT "BECAUSE I DIDN'T THINK IT WAS ANYTHING." NURSE #17 WAS INTERVIEWED BY PHONE AT 2 P.M. ON 5/8/12. NURSE #17 SAID THAT SHE DID NOT RESPOND TO THE CNA #11'S REPORT OF THE INCIDENT BECAUSE SHE (#17) DID NOT THINK IT WAS HER RESPONSIBILITY. NURSE #14, INTERVIEWED ON 5/15/12 BY TELEPHONE, SAID SHE STOPPED TO TALK WITH RESIDENT #500 IN THE MORNING, JUST PRIOR TO HER SHIFT ENDING ON 4/28/12. NURSE #14 SAID RESIDENT #500 SAID SHE (#500) DIDN'T SLEEP WELL DURING THE NIGHT, AND TOLD HER (#14) ABOUT THE ATTACK THAT OCCURRED ON THE PREVIOUS EVENING AND THE THEFT OF THE NECKLACES. ACCORDING TO NURSE #14, RESIDENT #500 SAID SHE KNEW THE SUSPECT; IT WAS SOMEONE WHO HAD WORKED IN THE FACILITY, AND WHO HAD BEEN IN THE FACILITY RECENTLY. NURSE #14 SAID THE RESIDENT WAS "ADAMANT" ABOUT CALLING THE POLICE. NURSE #14 SAID SHE (#14) IMMEDIATELY CALLED THE DIRECTOR OF NURSING (DON #43) AND REPORTED THE ABUSE AND THEFT. NURSE #14 SAID THAT THE DON RESPONDED THAT SHE (DON #43) WOULD DOCUMENT THE INCIDENT AND HAVE NURSE #14 SIGN SOMETHING LATER. NURSE #14 SAID SHE HAD NOT SIGNED ANYTHING OR DOCUMENTED THE INCIDENT AS OF 5/15/12. RELATIVE #13, INTERVIEWED BY TELEPHONE ON 5/7/12 AT 7:45 A.M., SAID SHE DID NOT FIND OUT ABOUT THE INCIDENT UNTIL THE NEXT MORNING WHEN HER MOTHER, VERY UPSET, CALLED HER AND TOLD HER ABOUT THE ATTACK. RELATIVE #13 SAID SHE HAD NOT YET RECEIVED ANY INFORMATION ABOUT THE PERSON WHO ATTACKED RESIDENT #500 BASED ON THE INVESTIGATION CONDUCTED BY THE ADMINISTRATOR. ( ) RESIDENT #501 RESIDENT #501, BASED ON AN INTERVIEW WITH VISITOR #3 ON 5/6/12 AT 10 P.M., ELOPED FROM THE FACILITY ON 4/6/12 BETWEEN 9 P.M. AND 10 P.M. VISITOR #3 SAID SHE FOUND RESIDENT #501 NEAR HER TRUCK ON THE FACILITY GROUNDS AND ESCORTED THE RESIDENT BACK INTO THE FACILITY. THE VISITOR ASKED RESIDENT #501 TO BE SEATED IN A CHAIR ON THE UNIT, AND THE VISITOR LEFT THE UNIT. WHEN QUESTIONED DURING AN INTERVIEW ON 5/4/12 AT 4:15 P.M., NURSE #4 SAID ONLY THAT SHE DID NOT SEE RESIDENT #501 LEAVE THE UNIT AT ANY TIME ON 4/6/12. WHEN ASKED WHETHER ANYONE TOLD HER THAT RESIDENT LEFT THE UNIT, NURSE #4 SAID THAT A VISITOR MENTIONED THAT RESIDENT #501 WAS TRYING TO LEAVE, SAYING, "YOU NEED TO WATCH HER." NURSE #4 SAID SHE DID NOT REMEMBER THE NAME OF THE VISITOR WHO RETURNED RESIDENT #501 TO THE UNIT. CNA #2 WAS INTERVIEWED ON 5/4/12 AT 3 P.M. SHE SAID SHE WAS ASSIGNED TO RESIDENT #501 ON 4/6/12 DURING THE AFTERNOON SHIFT. SHE SAID RESIDENT #501 WAS WANDERING THE HALLS AND TRYING TO EXIT THE UNIT ALL AFTERNOON AND EVENING. CNA #2 SAID SHE TRIED TO WATCH THE RESIDENT CLOSELY, BUT SHE HAD TEN OTHER RESIDENTS TO CARE FOR. ACCORDING TO CNA #2, NO STAFF PERSON WAS ASSIGNED ONLY TO MONITOR THE WHEREABOUTS OF RESIDENT #501 THAT SHIFT. CNA #2 SAID ALL THE CNA'S TRIED TO HELP WATCH THE RESIDENT. THE "ELOPEMENT POLICY AND PROCEDURE", DATED 9/2010, INCLUDES THE FOLLOWING RESPONSIBILITIES FOR THE DIRECTOR OF NURSING OR THE CHARGE NURSE UPON RETURN OF THE RESIDENT TO THE FACILITY. A) CONTACT THE ADMINISTRATOR, B) EXAMINE THE RESIDENT FOR INJURIES AND DOCUMENT FINDINGS, C) CONTACT THE ATTENDING PHYSICIAN, REPORT FINDINGS AND CONDITIONS OF THE RESIDENT, AND FOLLOW THE physician's orders [REDACTED]. PLAN AND CARE GUIDE WITH INTERVENTIONS FOR ELOPEMENT PREVENTION. THERE WAS NO DOCUMENTATION IN THE NURSE'S NOTES THAT THE RESIDENT WAS EXIT SEEKING ON 4/6/12 OR THAT SHE ELOPED ONTO FACILITY GROUNDS. THERE WAS NO DOCUMENTATION IN THE NURSE'S NOTES THAT THE ADMINISTRATOR, THE PHYSICIAN, OR THE LEGAL REPRESENTATIVE HAD BEEN NOTIFIED. AN INCIDENT REPORT DOCUMENTED THAT "RES (RESIDENT) OBSERVED EXIT SEEKING TOWARDS DOOR. FAMILY MEMBER BROUGHT RES BACK TO NURSING STATION." THE STATE AGENCY HAD NO RECORD OF THE ELOPEMENT WHICH OCCURRED WITH RESIDENT #501 ON 4/6/12 BETWEEN 9 P.M. AND 10 P.M. THE ADMINISTRATOR, IN AN INTERVIEW ON 5/4/12 AT 9 A.M., SAID SHE HAD NO EVIDENCE THAT THE RESIDENT LEFT THE BUILDING ON 4/6/12. SHE SAID THE SECURITY TAPES SHOWED VISITOR #3 LEAVING THE BUILDING ON 4/6/12, BUT THEY DID NOT SHOW VISITOR #3 RETURNING RESIDENT #501 TO THE FACILITY AS DESCRIBED BY VISITOR #3. THE RECEPTIONIST, ON DUTY 4/6/12 DURING THE AFTERNOON AND EVENING SHIFT, SAID SHE SAW VISITOR #3 RETURN TO THE BUILDING WITH RESIDENT #501. BOTH DESCRIBED THE RESIDENT'S CLOTHING AND DEMEANOR IN THE SAME WAY. THE STATE AGENCY HAD NO RECORD OF THE ABUSE REPORTED BY RESIDENT #500 ON 4/27/12 BETWEEN 9 P.M. AND 10 P.M. THE ADMINISTRATOR (#42) SAID SHE DID NOT SEE ANYONE SHE DID NOT KNOW ENTERING OR EXITING THE BUILDING ON 4/27/12. SHE SAID VISITORS WERE REQUIRED TO SIGN IN AT THE RECEPTIONIST'S DESK, AND THE PERSON IDENTIFIED BY RESIDENT #500 AS THE ALLEGED PERPETRATOR DID NOT SIGN IN THAT DAY. THE POLICE WERE NOT CALLED TO INVESTIGATE THE INCIDENT. A FAMILY MEMBER OF RESIDENT #500, INTERVIEWED ON 5/7/12 AT 7:35 A.M., SAID THE ADMINISTRATOR SUGGESTED THAT POLICE WOULD NOT BE NEEDED BECAUSE THE FACILITY WOULD BE DOING AN INVESTIGATION AIDED BY INFORMATION ON THEIR SECURITY TAPES. IN AN INTERVIEW ON 5/3/12 AT 10:45 A.M., THE ADMINISTRATOR SAID FAMILY OF RESIDENT #500 ASKED THAT THE POLICE NOT BE INVOLVED. ON 5/11/12 AT 12:40 P.M. THE ADMINISTRATOR WAS INFORMED OF THE IMMEDIATE JEOPARDY AS A RESULT OF THE FACILITY'S FAILURE TO ADMINISTER STAFFING RESOURCES EFFECTIVELY AND EFFICIENTLY AND FAILED TO RECOGNIZE REPORTABLE EVENTS TO THE STATE AGENCY AND LAW ENFORCEMENT AS A RESULT OF RESIDENT #500 REPORTING PHYSICAL ABUSE AND THEFT OF A GOLD COLORED CHAIN ON 4/27/12 AT 10 P.M. RESULTING IN A BRUISE ON HER NECK AND PSYCHOLOGICAL DISTRESS, PLACING ALL RESIDENTS AT RISK FOR PHYSICAL ABUSE AND THEFT; AND AS A RESULT OF RESIDENT #501 MISSING FROM THE FACILITY ON 4/6/12 SOMETIME BETWEEN 9 P.M. AND 10 P.M. UNBEKNOWNST TO STAFF, PLACING HER AT RISK FOR PHYSICAL HARM AND DEATH AS WELL AS PLACING FOUR ADDITIONAL RESIDENTS AT RISK FOR ELOPEMENT AND POTENTIAL PHYSICAL HARM OR DEATH. ON 5/17/12 THE SURVEYOR CONFIRMED THAT THE FACILITY HAD IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. RESIDENT #501 NO LONGER RESIDES AT THE FACILITY. RESIDENT #500 WAS SEEN BY THE SOCIAL WORKER ON 4/28/12, 5/3/12, AND 5/7/12 AND STATED SHE FELT SAFE AND WAS SATISFIED THAT HER CONCERNS WERE TAKEN CARE OF. 2. POLICE WERE NOTIFIED BY THE ADMINISTRATOR ON 5/8/12 REGARDING THE ATTACK OF RESIDENT #500. 3. NURSE MANAGERS RE-ASSESSED 130 RESIDENTS FOR ELOPEMENT RISK ON 5/8/12 AND 5/9/12. FOUR RESIDENTS, FOUND TO BE AT RISK, HAD THEIR CARE PLANS AND CARE GUIDES REVIEWED AND UPDATED BY LICENSED NURSES. 4. THE MAINTENANCE DEPARTMENT CHECKED DOORS FOR FUNCTIONING ALARMS ON 4/6/12 AND 4/7/12 AND BATTERIES WERE CHANGED. 5. RESIDENTS WITH WANDERGUARDS WERE CHECKED FOR PLACEMENT AND FUNCTIONALITY BEGINNING 5/8/12 BY THE LICENSED NURSES. BEGINNING 5/8/12 LICENSED NURSES CHECK PLACEMENT AND FUNCTIONALITY OF WANDERGUARDS DAILY AND DOCUMENT FINDINGS IN THE CLINICAL RECORD. 6. ON 4/28/12 THE SOCIAL WORKER INTERVIEWED 13 OF THE INTERVIEWABLE RESIDENTS ON A UNIT TO ENSURE THERE WERE NO ADDITIONAL REPORTS OF MISSING ITEMS OR THEFT AND TO DETERMINE CONCERNS. FINDINGS WERE REPORTED TO THE ADMINISTRATOR ON 4/28/12. 7. BEGINNING ON 5/9/12, 130 RESIDENTS WITH THE POTENTIAL TO BE AFFECTED WERE INTERVIEWED BY THE SOCIAL WORKERS REGARDING CONCERNS OF ABUSE, NEGLECT, OR MISAPPROPRIATION OF PROPERTY. FINDINGS WERE REPORTED TO THE ADMINISTRATOR ON 5/9/12. 8. ALL EMPLOYEES ARE REQUIRED TO SIGN IN AT THE RECEPTION DESK AS OF 5/4/12 TO PREVENT EX-EMPLOYEES FROM ENTERING THE BUILDING. 9. EX-EMPLOYEES ARE NO LONGER ABLE TO ENTER THE FACILITY AS OF 5/4/12 AND THE 4 RECEPTIONISTS WERE INSERVICED ON 5/4/12. 10. INSERVICING FOR ALL STAFF ON THE ABUSE PROHIBITION POLICY AND THE ELOPEMENT POLICY BEGAN ON 5/8/12. THE INSERVICES ARE ONGOING TO CAPTURE 100% OF EMPLOYEES. 11. THE FACILITY'S CONTRACTED SECURITY COMPANY INSTALLED AN ADDITIONAL SECURITY CAMERA WHICH WAS PLACED AT THE EMPLOYEE ENTRANCE AT THE BACK OF THE BUILDING. AN EXISTING CAMERA ON THE FIRST FLOOR NEAR THE CONFERENCE ROOM WAS REPOSITIONED TO CAPTURE PERSONS ENTERING THE FACILITY THROUGH THE LOBBY. THE NHA OR DESIGNEE WILL VIEW THE VIDEO FOOTAGE AS NECESSARY TO ENSURE RESIDENT SAFETY. 12. NURSE #10 WAS SUSPENDED ON 5/3/12, 5/4/12, AND 5/7/12 PENDING THE INVESTIGATION AND WAS INSERVICED ONE ON ONE ON THE ABUSE PROHIBITION POLICY ON 5/8/12. 13. THE NURSING HOME ADMINISTRATOR WAS INSERVICED BY THE STAFF DEVELOPMENT DIRECTOR ON THE ABUSE PROHIBITION POLICY AND ON THE GUIDELINE FOR REPORTING TO THE STATE AGENCIES IN ACCORDANCE WITH THE GUIDELINES ON 5/8/12. 14. ON 5/8/12 THE REGIONAL CLINICAL CONSULTANT REVIEWED THE GUIDELINE FOR REPORTING AND PROPER DOCUMENTATION ON ALLEGATIONS OF ABUSE, NEGLECT, AND MISAPPROPRIATION OF PROPERTY AND NOTIFYING THE POLICE IN ACCORDANCE WITH THE ELDER JUSTICE ACT. 15. AN AUDIT TOOL WAS IMPLEMENTED ON 5/9/12 BY SOCIAL WORKERS OR DESIGNEE TO ENSURE THAT ALL CONCERNS OF ABUSE ARE ADDRESSED. 16. AN AUDIT TOOL WAS IMPLEMENTED ON 5/9/12 BY SOCIAL WORKERS TO INTERVIEW STAFF ABOUT ALLEGATIONS OF ABUSE WEEKLY FOR 4 WEEKS. 17. THE NURSING HOME ADMINISTRATOR WILL REVIEW EMPLOYEE SIGN IN SHEETS TO ENSURE NO EX-EMPLOYEES ENTER THE FACILITY BEGINNING 5/9/12. 18. THE NURSING HOME ADMINISTRATOR WILL REVIEW ENVIRONMENTAL TEST AND SERVICE LOGS THREE TIMES WEEKLY BEGINNING 5/9/12. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON 4/27/12 WAS REMOVED ON 5/9/12. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND SEVERITY OF "NO ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 820 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY NEGLECTED TO PROVIDE GOODS AND SERVICES (WATER, SHIELDING FROM DIRECT SUNLIGHT, ELECTRIC FANS AND OPERATIONAL COOLING SYSTEMS) FOR 10 OF 40 SAMPLED RESIDENTS (RESIDENTS #4, #5, #12, #13, #24, #25, #31, #32, #33, #39), WHO WERE EXPERIENCING HIGH AMBIENT ROOM AIR TEMPERATURES, RESULTING IN IMMEDIATE JEOPARDY BY PLACING THESE RESIDENTS AT HIGH RISK FOR SEVERE HARM, SERIOUS IMPAIRMENT, AND/OR DEATH FROM HEAT EXHAUSTION OR HEAT STROKE. FINDINGS INCLUDE: ON 7/6/11, A COMPLAINT WAS MADE THAT ALLEGED THAT THERE WERE ROOMS IN THE FACILITY WITH VERY HOT AMBIENT TEMPERATURES. THE FACILITY WAS ASKED TO BEGIN HOURLY TEMPERATURE MONITORING, WITH THE FIRST REPORT DATED 7/6/2011. AS OF 5 P.M. ACCORDING TO THIS REPORT, THERE WERE 81 RESIDENT ROOMS OF 82 RESIDENT ROOMS THAT HAD TEMPERATURES RECORDED. OUT OF THESE 81 RESIDENT ROOMS, 62 HAD TEMPERATURES GREATER THAN 81 DEGREES FAHRENHEIT AND 5 ROOMS WERE EXACTLY 81 DEGREES FAHRENHEIT. ON 07/07/11 FROM 10:45 AM TO 11:40 AM, ON 07/07/11 FROM 1:15 PM TO 2:55 PM AND ON 07/08/11 FROM 8:35 AM TO 9:05 AM, THE SURVEYOR, IN THE PRESENCE OF MAINTENANCE STAFF MEMBERS #4, #7 AND/OR #9 (AT VARIOUS TIMES), AND NURSING STAFF MEMBER #5 OBSERVED RESIDENTS AND THEIR ROOMS, INTERVIEWED RESIDENTS AND STAFF AND OBTAINED ROOM TEMPERATURES FROM 82 SEPARATE RESIDENT ROOMS. OBSERVATION REVEALED THAT RESIDENTS #4, #5, #12, #13, #24, #25, #31, #32, #33, AND #39, IN ADDITION TO BEING SUBJECTED TO EXTREMELY HIGH AMBIENT ROOM TEMPERATURES, WERE NOT PROVIDED WITH GOODS AND SERVICES (PROVIDE WATER, AIR TEMPERATURES AT A SAFE AND COMFORTABLE LEVEL, RESIDENTS SHIELDED FROM DIRECT SUNLIGHT, AND OPERATIONAL COOLING SYSTEMS) THAT COULD MITIGATE THE AMBIENT ROOM TEMPERATURES. FOR READING CLARITY, WHEN TWO TEMPERATURES ARE LISTED, THE FIRST TEMPERATURE REPRESENTS THE FACILITY ' S FAHRENHEIT DEGREE READING OBTAINED FROM AN INFRARED TEMPERATURE SENSOR AND THE SECOND TEMPERATURE REPRESENTS THE SURVEYOR'S FAHRENHEIT DEGREE READING OBTAINED FROM A PROBE THERMOMETER. RESIDENT #4, room [ROOM NUMBER].1: DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT # 4'S ROOM AS HAVING AN AMBIENT TEMPERATURE OF 82.0/81.4. THE ROOM HAD NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. RESIDENT #4'S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/22/11, THAT SAID RESIDENT #4 WAS AN [AGE] year OLD FEMALE WITH DIAGNIOSES OF SENILE DEMENTIA AND MUSCULAR WASTING/DISUSE/ATROPHY, AMONG OTHER MEDICAL DIAGNOSES. RESIDENT #5, room [ROOM NUMBER].2: DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #5'S ROOM AS HAVING AN AMBIENT TEMPERATURE OF 82.0/81.4. THE ROOM HAD NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. RESIDENT #5'S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 06/06/11, THAT SAID RESIDENT #5 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. RESIDENT #12, room [ROOM NUMBER].1: DURING ROOM OBSERVATIONS ON 07/07/11 FROM 10:45 AM TO 11:40 AM WITH FACILITY STAFF #4, #5, #6, #7 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #12 ' S ROOM AS HAVING AN AMBIENT TEMPERATURE OF 85.5/85.4. THERE WAS NO OPERATING AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #12 WAS NON-VERBAL AND NON-RESPONSIVE TO THE SURVEYOR'S ATTEMPTS TO COMMUNICATE. RESIDENT #12'S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/22/11, THAT SAID RESIDENT #12 WAS AN [AGE] year OLD FEMALE WITH DIAGNOSOES OF [MEDICAL CONDITION], GASTROSTOMY, MUSCULAR WASTING/DISUSE/ATROPHY, AND [MEDICAL CONDITION], AMONG OTHER MEDICAL DIAGNOSES. RESIDENT #12'S MEDICAL RECORD CONTAINED PHYSICIANS ORDERS, DATED FROM 07/01/11 TO 07/31/11, WHICH STATED UNDER TUBE FEEDING ORDERS, RESIDENT #12 WAS ORDERED 450 CC OF WATER FLUSH EVERY SHIFT INCLUDING MED PASS. RESIDENT #12'S MEDICAL RECORD CONTAINED A MEDICATION OBSERVATION RECORD, DATED FROM 07/01/11 TO 07/31/11, THAT SAID RESIDENT #12 WAS ORDERED 450 CC OF WATER FLUSH EVERY EIGHT HOURS INCLUDING MED PASS. THIS MEDICATION OBSERVATION RECORD SAID RESIDENT #12 HAD NOT BEEN PROVIDED WITH 450 CC OF WATER ON 07/07/11 DURING THE 3-11 PM WORK SHIFT BASED ON NO CLINICIAN'S INITIALS BEING CHARTED DURING THAT TIME FRAME. THE SPACE RESERVED FOR THE CLINICIANS CHARTING WAS LEFT BLANK WITH NO FURTHER EXPLANATION CHARTED ON THE MEDICATION OBSERVATION RECORD. RESIDENT #12'S MEDICAL RECORD CONTAINED A STAT DIAGNOSTIC LAB RESULT DATED 07/07/11 THAT SAID RESIDENT #12'S BLOOD UREA NITROGEN (BUN) LEVEL WAS 21 MG/DL (ELEVATED). RESIDENT #13, room [ROOM NUMBER].2: DURING ROOM OBSERVATIONS ON 07/07/11 FROM 10:45 AM TO 11:40 AM WITH FACILITY STAFF #4, #5, #6, #7 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #13 ' S ROOM AS HAVING AN AMBIENT TEMPERATURE OF 85.5/85.4. THERE WAS NO OPERATING AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #13 WAS OBSERVED LYING IN BED HAVING DIRECT SUNLIGHT SHINING ON HER UPPER BODY THROUGH THE WINDOW. THE WINDOW HAD A RAISED BLIND WHICH ALLOWED THE SUNLIGHT TO SHINE DIRECTLY ON RESIDENT #13. RESIDENT #13 WAS NON-VERBAL AND NON-RESPONSIVE TO THE SURVEYOR'S ATTEMPTS TO COMMUNICATE. RESIDENT #13'S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, THAT SAID RESIDENT #13 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. RESIDENT #13'S MEDICAL RECORD CONTAINED PHYSICIANS ORDERS, DATED FROM 07/01/11 TO 07/31/11, WHICH STATED UNDER TUBE FEEDING ORDERS, RESIDENT #13 WAS ORDERED 400 CC OF WATER FLUSH EVERY EIGHT HOURS INCLUDING MED PASS. RESIDENT #13'S MEDICAL RECORD CONTAINED A MEDICATION OBSERVATION RECORD, DATED FROM 07/01/11 TO 07/31/11, THAT SAID RESIDENT #13 WAS ORDERED 400 CC OF WATER FLUSH EVERY EIGHT HOURS INCLUDING MED PASS. THIS MEDICATION OBSERVATION RECORD SAID RESIDENT #13 WAS NOT PROVIDED WITH 400 CC OF WATER ON 07/07/11 DURING THE 3-11 PM WORK SHIFT BASED ON NO CLINICIAN'S INITIALS BEING CHARTED DURING THAT TIME FRAME. THE SPACE RESERVED FOR THE CLINICIANS CHARTING WAS LEFT BLANK WITH NO FURTHER EXPLANATION CHARTED ON THE MEDICATION OBSERVATION RECORD. RESIDENT #13'S MEDICAL RECORD CONTAINED A STAT DIAGNOSTIC LAB RESULT DATED 07/07/11 THAT SAID RESIDENT #13 ' S BLOOD UREA NITROGEN (BUN) LEVEL WAS 30 MG/DL (ELEVATED). RESIDENT #24, room [ROOM NUMBER].1: DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #24 ' S ROOM AS HAVING AN AMBIENT TEMPERATURE OF 84.5/84. THE ROOM HAD NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. RESIDENT #24 ' S MEDICAL RECORD CONTAINED A FACE SHEET DATED 06/14/11 THAT SAID RESIDENT #24 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. RESIDENT #25, room [ROOM NUMBER].2: DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #25 ' S ROOM AS HAVING AN AMBIENT TEMPERATURE OF 84.5/84. THE ROOM HAD NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. RESIDENT #25 ' S MEDICAL RECORD CONTAINED A FACE SHEET DATED 05/25/11 THAT SAID RESIDENT #25 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. RESIDENT #31, room [ROOM NUMBER].2: DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #31'S ROOM AS HAVING AN AMBIENT TEMPERATURE OF 81.5/82. THE ROOM HAD NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. ON 07/08/11 AT 8:48 AM, DURING OBSERVATION AND INTERVIEW, THE SURVEYOR MEASURED RESIDENT #31 ' S ROOM AS HAVING AN AMBIENT TEMPERATURE OF 82.4 WITH NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. RESIDENT #31 SAID, "I NEED SOME WATER. IT'S WARM IN HERE." THE SURVEYOR DID NOT OBSERVE ANY AVAILABLE DRINKING WATER IN RESIDENT #31'S ROOM. RESIDENT #31'S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 06/15/11, THAT SAID RESIDENT #31 WAS AN [AGE] year OLD MALE WITH [DIAGNOSES REDACTED]. RESIDENT #32, room [ROOM NUMBER]: DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #32'S ROOM AS HAVING AN AMBIENT TEMPERATURE OF 81.5/82.4. THE ROOM HAD NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. RESIDENT #32'S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 06/14/11, THAT SAID RESIDENT #32 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. RESIDENT #33, room [ROOM NUMBER]: DURING ROOM OBSERVATIONS ON 07/07/11 FROM 10:45 AM TO 11:40 AM WITH FACILITY STAFF #4, #5, AND #7 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #33 ' S ROOM AS HAVING AN AMBIENT TEMPERATURE OF 83.5/82.9. THE ROOM HAD NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. DURING AN INTERVIEW WITH RESIDENT #33 ON 07/07/11 AT 11:20 AM, RESIDENT #33 MADE MOTIONS WITH MOUTH AS IF TRYING TO SPEAK BUT COULD NOT PRODUCE UNDERSTANDABLE LANGUAGE. RESIDENT #33 WAS ABLE TO MOVE HER HEAD UP AND DOWN IN A CLEAR "YES" MOTION WHEN ASKED IF SHE WAS TOO HOT. RESIDENT #33'S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, THAT SAID RESIDENT #33 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. RESIDENT #39, room [ROOM NUMBER]: DURING ROOM OBSERVATIONS ON 07/07/11 FROM 10:45 AM TO 11:40 AM WITH FACILITY STAFF #4, #5, AND #7 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #39'S ROOM AS HAVING AN AMBIENT TEMPERATURE OF 85/85.2. THE ROOM HAD NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. CERTIFIED NURSE AIDE (CNA) #5 (FACILITY STAFF) SAID THIS WAS RESIDENT #39'S PREFERENCE. RESIDENT #39'S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, THAT SAID RESIDENT #39 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. ON 7/7/11, AT 1:10 PM, MAINTENANCE EMPLOYEE #7 WAS INTERVIEWED REGARDING WHY SOME OF THE ROOMS HAD NEITHER A FUNCTIONING FAN NOR AIR CONDITIONING. EMPLOYEE #7 WAS NOT ABLE TO GIVE AN EXPLANATION, OTHER THAN "SOME RESIDENTS DON'T WANT ANYTHING." THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED ON 7/8/11, AT 10:50 A.M. THE SURVEYOR ASKED THE DON WHY RESIDENTS #4, #5, #24 #25, #31 #32, #33 AND #39 DID NOT EVEN HAVE A FUNCTIONING FAN IN THEIR ROOMS. THE DON WAS ASKED WHY RESIDENT #31 DID NOT HAVE WATER AVAILABLE IN THE ROOM. THE DON WAS ASKED WHY WHY RESIDENTS #12 AND #13 DID NOT HAVE THEIR WATER FLUSHES CHARTED. THE DON WAS ASKED WHY RESIDENT #13 WAS LEFT WITH DIRECT SUNLIGHT SHINING ON HER BODY. THE DON WAS NOT ABLE TO EXPLAIN THE SURVEYOR'S FINDINGS. DURING AN INTERVIEW WITH DIETITIAN (DT) #10 ON 07/08/11 AT 11:00 AM, DT #10 SAID RESIDENT #12 ' S CURRENT FLUID NEEDS WERE 2619 CC ' S (CUBIC CENTIMETERS) DAILY AS OF 06/08/11 AND RESIDENT #13 ' S CURRENT FLUID NEEDS ARE 2482 CC ' S DAILY AS OF 06/03/11. DT #10 SAID RESIDENT FLUID NEEDS ARE REVIEWED AT LEAST MONTHLY AND FREE WATER NEEDS ARE FACTORED INTO THE DAILY FLUID INTAKE AMOUNT. DT #10 SAID THE DAILY FLUID CC COUNT INCLUDES WATER FLUSHES VIA GASTROSTOMY TUBES. THE FACILITY PROVIDED A POLICY ENTITLED HAZARDOUS HOT WEATHER POLICY, DATED NOVEMBER 2010, THAT SAID, UNDER POLICY STATEMENT, "THE FACILITY STRIVES TO MAINTAIN SAFE AND/OR COMFORTABLE RESIDENT ROOM TEMPERATURE LEVELS." THIS POLICY ALSO SAID, UNDER POLICY INTERPRETATION, "THE RECOMMENDED TEMPERATURE RANGE IS 71 TO 81 DEGREES FAHRENHEIT." UNDER RECOMMENDED MEASURES, THE POLICY SAID, "KEEP RESIDENTS COMFORTABLE DURING HAZARDOUS HOT WEATHER, KEEP WELL HYDRATED WITH A PARTICULAR ATTENTION TO DEPENDENT RESIDENTS, USE FANS AS APPROPRIATE, ROOM TEMPS WILL BE TAKEN WEEKLY AND/OR AS NEEDED, AND ALL CONCERNS ARE TO BE DIRECTED TO THE DON AND/OR ADMINISTRATOR." THE FACILITY PROVIDED A POLICY ENTITLED MAINTENANCE ROOM TEMPERATURE POLICY AND PROCEDURE, DATED MAY 2011, THAT SAID "ROOM TEMPS WILL BE TAKEN WEEKLY AND/OR AS NEEDED." THE FACILITY PROVIDED A POLICY ENTITLED HYDRATION POLICY, REVISED 08/10/09, THAT SAID, UNDER POLICY, "RESIDENTS WILL BE OFFERED AND ENCOURAGED TO CONSUME ADEQUATE FLUIDS WHICH WILL MEET OR EXCEED THE MINIMAL NEEDS, UNLESS CLINICALLY CONTRAINDICATED." THIS POLICY ALSO SAID, UNDER PROCEDURE, "(5) EACH RESIDENT WILL BE PROVIDED BEDSIDE WATER UNLESS CONTRAINDICATED" AND "(7) RESIDENTS RECEIVING MEDICATIONS VIA A PEG TUBE WILL HAVE THE PEG TUBE FLUSHED WITH WATER BEFORE ADMINISTRATION OF MEDICATIONS, IN BETWEEN MEDICATIONS AND AFTER THE LAST MEDICATION." THE FACILITY PROVIDED A HANDOUT ENTITLED HEAT AND HUMIDITY, UNDATED. THIS HANDOUT IS POSTED AT VARIOUS HIGH VISIBILITY LOCATIONS THROUGHOUT THE FACILITY. THIS HANDOUT SAID "(2) DRAW ALL SHADES, BLINDS ETC WHEN EXPOSED TO DIRECT SUNLIGHT, (3) REMOVE RESIDENTS FROM AREAS OF DIRECT SUNLIGHT," AND "(6) PROVIDE AMPLE FLUIDS...OFFER FREQUENTLY." ADM #2 WAS NOTIFIED ON 07/11/11 AT 12:15 PM OF THE IMMEDIATE JEOPARDY, WHICH BEGAN ON 07/06/11, WHEN THE FACILITY NEGLECTED TO PROVIDE WATER, AIR TEMPERATURES AT A SAFE AND COMFORTABLE LEVEL, RESIDENTS SHIELDED FROM DIRECT SUNLIGHT, AND OPERATIONAL COOLING SYSTEMS FOR RESIDENTS #4, #5, #12, #13, #24, #25, #31, #32, #33, #39 PLACING THEM AT HIGH RISK FOR SEVERE HARM, SERIOUS IMPAIRMENT, AND/OR DEATH FROM HEAT EXHAUSTION OR HEAT STROKE. THE SURVEYOR VERIFIED ON 07/15/11 AT 2:00 PM THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON 07/08/11 THE FACILITY HAD THREE PORTABLE AIR CONDITIONING UNITS OPERATING IN THE FACILITY. 2. ON 07/15/11 THE SURVEYOR VERIFIED THAT, STARTING ON 07/06/11 AT 5:00 PM, THE FACILITY BEGAN MEASURING AND FAXING ROOM TEMPERATURES TO THE STATE AGENCY, INCLUDING SOME RESIDENT BODY TEMPERATURES. 3. ON 07/15/11 RESIDENT #12 ' S ROOM TEMPERATURE WAS LESS THAN 81 DEGREES FAHRENHEIT, HAD OPERATING AIR CONDITIONING AND FLUID NEEDS WERE PROVIDED FOR. THE CLINICIAN, RESPONSIBLE FOR NOT PROVIDING FLUID NEEDS, WAS REMOVED FROM THE WORK SCHEDULE FOR ONE DAY. 4. ON 07/15/11 RESIDENT #13 ' S ROOM TEMPERATURE WAS LESS THAN 81 DEGREES FAHRENHEIT, HAD OPERATING AIR CONDITIONING, FLUID NEEDS WERE PROVIDED FOR AND DIRECT SUNLIGHT WAS BLOCKED BY APPROPRIATE WINDOW TREATMENTS. THE CLINICIAN, RESPONSIBLE FOR NOT PROVIDING FLUID NEEDS, WAS REMOVED FROM THE WORK SCHEDULE FOR ONE DAY. 5. ON 07/15/11, RESIDENT ' S #4, #5, #24, #25, #31, #32, AND #33 HAD ROOM TEMPERATURES LESS THAN 81 DEGREES FAHRENHEIT, HAD OPERATING CLIMATE CONTROL DEVICES IN THEIR ROOMS, HAD FLUID NEEDS PROVIDED FOR AND DIRECT SUNLIGHT WAS BLOCKED BY APPROPRIATE WINDOW TREATMENTS. RESIDENT #39 DID NOT HAVE ANY OPERATING FAN OR AIR CONDITIONING PER CHOICE. FACILITY CLINICIANS ASSESSED RESIDENT #39 AS NEEDED PER HOT WEATHER POLICY AND CHARTED SUCH VIA NURSING NOTES. 6. ON 07/15/11 THE SURVEYOR VERIFIED THAT, ON 07/06/11, 3 OF 3 MAINTENANCE EMPLOYEES WERE RE-EDUCATED ON THE ROOM TEMPERATURE POLICY. 7. ON 07/15/11 THE SURVEYOR VERIFIED THAT, ON 07/07/11, 6 OF 6 ACTIVITY DEPARTMENT EMPLOYEES WERE IN-SERVICED ON THE HAZARDOUS HOT WEATHER AND THE HYDRATION POLICIES. 8. ON 07/15/11 THE SURVEYOR VERIFIED THAT, BY 07/07/11, 95 OF 100 NURSING DEPARTMENT EMPLOYEES WERE IN-SERVICED ON THE HAZARDOUS HOT WEATHER AND THE HYDRATION POLICIES. CERTIFIED LETTERS WERE SENT TO REMAINING NURSING STAFF IDENTIFYING EDUCATIONAL EXPECTATIONS NEEDED TO RETURN TO WORK. NEW EMPLOYEES WILL RECEIVE TRAINING ON ABOVE POLICIES STARTING 07/07/11. 9. ON 07/15/11 RESIDENTS WERE ASSESSED AS NEEDED PER THE HAZARDOUS HOT WEATHER AND THE HYDRATION POLICY PROTOCOLS. 10. ON 07/15/11 ROOM AUDITS WERE VERIFIED AS COMPLETED BY MAINTENANCE, DATED 07/07/11 THROUGH 07/12/11. 11. ON 07/15/11 NURSING AUDITS WERE VERIFIED AS COMPLETED BY DIRECTOR OF NURSING/DESIGNEE, DATED 07/07/11 THROUGH 07/12/11. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON 07/7/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND A SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO INCOMPLETE IN-SERVICE TRAINING FOR STAFF ON THE HAZARDOUS HOT WEATHER AND THE HYDRATION POLICIES AND BECAUSE SUSTAINED COMPLIANCE HAS NOT BEEN VERIFIED BY THE STATE AGENCY.

THIS CITATION PERTAINS TO INTAKE NUMBER MI 820 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE COMFORTABLE AND SAFE TEMPERATURES FOR 40 OF 40 SAMPLED RESIDENTS (#1 THROUGH #40), RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENTS #1 THROUGH #40 BY PLACING THEM AT HIGH RISK FOR SEVERE HARM, SERIOUS IMPAIRMENT, AND/OR DEATH FROM HEAT EXHAUSTION OR HEAT STROKE. FINDINGS INCLUDE: ON 7/6/11, A COMPLAINT WAS MADE THAT ALLEGED THAT THERE WERE ROOMS IN THE FACILITY WITH VERY HOT AMBIENT TEMPERATURES. THE FACILITY WAS ASKED TO BEGIN HOURLY TEMPERATURE MONITORING, WITH THE FIRST REPORT DATED 7/6/2011. AT 5:00 P.M., ACCORDING TO THIS REPORT, THERE WERE 81 RESIDENT ROOMS OF 82 RESIDENT ROOMS THAT HAD TEMPERATURES RECORDED. OUT OF THESE 81 RESIDENT ROOMS, 62 HAD TEMPERATURES GREATER THAN 81 DEGREES FAHRENHEIT AND 5 ROOMS WERE EXACTLY 81 DEGREES FAHRENHEIT. ON 07/07/11 FROM 10:45 AM TO 11:40 AM AND ON 07/07/11 FROM 1:15 PM TO 2:55 PM AND ON 07/08/11 FROM 8:35 AM TO 9:05 AM, THE SURVEYOR, IN THE PRESENCE OF MAINTENANCE STAFF MEMBERS #4, #7 AND/OR #9 (AT VARIOUS TIMES), OBSERVED RESIDENTS AND THEIR ROOMS, INTERVIEWED RESIDENTS AND STAFF, AND OBTAINED ROOM TEMPERATURES FROM 82 SEPARATE RESIDENT ROOMS. 24 OF THE 82 RESIDENT ROOMS HAD ROOM TEMPERATURES GREATER THAN 81 DEGREES FAHRENHEIT, WHICH DIRECTLY AFFECTED 40 RESIDENTS (#1 THROUGH #40). FOR READING CLARITY, WHEN TWO TEMPERATURES ARE LISTED, THE FIRST TEMPERATURE REPRESENTS THE FACILITY ' S FAHRENHEIT DEGREE READING OBTAINED FROM AN INFRARED TEMPERATURE SENSOR AND THE SECOND TEMPERATURE REPRESENTS THE SURVEYOR'S FAHRENHEIT DEGREE READING OBTAINED FROM A PROBE THERMOMETER. RESIDENT #1, room [ROOM NUMBER].1: RESIDENT #1 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 06/01/11 WHICH SAID RESIDENT #1 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #1 ' S ROOM AS HAVING A TEMPERATURE OF 84.5/83.6. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #2, room [ROOM NUMBER].2: RESIDENT #2 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 07/05/11, WHICH SAID RESIDENT #2 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #2 ' S ROOM AS HAVING A TEMPERATURE OF 84.5/83.6. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #3, room [ROOM NUMBER].3: RESIDENT #3 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, WHICH SAID RESIDENT #3 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #3 ' S ROOM AS HAVING A TEMPERATURE OF 84.5/83.6. THE ROOM HAD A FAN BLOWING AND NO OPERATING AIR CONDITIONING. RESIDENT #4, room [ROOM NUMBER].1: DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT # 4'S ROOM AS HAVING AN AMBIENT TEMPERATURE OF 82.0/81.4. THE ROOM HAD NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. RESIDENT #4'S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/22/11, WHICH SAID RESIDENT #4 WAS A [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. RESIDENT #4 ' S MEDICAL RECORD CONTAINED PHYSICIANS ORDERS, DATED FROM 07/01/11 TO 07/31/11, THAT SAID RESIDENT #4 WAS PRESCRIBED FUROSEMIDE 40 MG ONE TABLET BY MOUTH DAILY. ACCORDING TO THE DRUG INFORMATION HANDBOOK FOR NURSING 2007, THE MEDICATION FUROSEMIDE WAS IN THE PHARMACOLOGIC CATEGORY OF DIURETIC, LOOP. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) WEBSITE (<HTTP://WWW.BT.CDC.GOV/DISASTERS/EXTREMEHEAT/FAQ.ASP>) THE RISK FOR HEAT-RELATED ILLNESS AND DEATH MAY INCREASE AMONG PEOPLE USING THE FOLLOWING DRUGS: (4) DIURETIC MEDICATIONS OR "WATER PILLS" THAT AFFECT FLUID BALANCE IN THE BODY. RESIDENT #5, room [ROOM NUMBER].2: DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #5'S ROOM AS HAVING AN AMBIENT TEMPERATURE OF 82.0/81.4. THE ROOM HAD NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. RESIDENT #5'S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 06/06/11, WHICH SAID RESIDENT #5 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. RESIDENT #6, room [ROOM NUMBER].1: RESIDENT #6 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 06/02/11, WHICH SAID RESIDENT #6 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. RESIDENT #6 ' S MEDICAL RECORD CONTAINED PHYSICIANS ORDERS, DATED FROM 07/01/11 TO 07/31/11, THAT SAID RESIDENT #6 WAS PRESCRIBED FUROSEMIDE 40 MG ONE TABLET BY MOUTH DAILY. ACCORDING TO THE DRUG INFORMATION HANDBOOK FOR NURSING 2007, THE MEDICATION FUROSEMIDE WAS IN THE PHARMACOLOGIC CATEGORY OF DIURETIC, LOOP. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) WEBSITE (<HTTP://WWW.BT.CDC.GOV/DISASTERS/EXTREMEHEAT/FAQ.ASP>) THE RISK FOR HEAT-RELATED ILLNESS AND DEATH MAY INCREASE AMONG PEOPLE USING THE FOLLOWING DRUGS: (4) DIURETIC MEDICATIONS OR " WATER PILLS " THAT AFFECT FLUID BALANCE IN THE BODY. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #6'S ROOM AS HAVING A TEMPERATURE OF 82.0/80.9. THE ROOM HAD A FAN BLOWING AND NO OPERATING AIR CONDITIONING. RESIDENT #7, room [ROOM NUMBER].2: RESIDENT #7 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 06/14/11, WHICH SAID RESIDENT #7 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #7 ' S ROOM AS HAVING A TEMPERATURE OF 82.0/80.9. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #8, room [ROOM NUMBER].3: RESIDENT #8 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/22/11, WHICH SAID RESIDENT #8 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #8'S ROOM AS HAVING A TEMPERATURE OF 82.0/80.9. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #9, room [ROOM NUMBER].1 RESIDENT #9 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/22/11, WHICH SAID RESIDENT #9 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #9' S ROOM AS HAVING A TEMPERATURE OF 82.5/82. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #10, room [ROOM NUMBER].2: RESIDENT #10 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, WHICH SAID RESIDENT #10 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #10' S ROOM AS HAVING A TEMPERATURE OF 82.5/82. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #11, room [ROOM NUMBER].3: RESIDENT #11 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, WHICH SAID RESIDENT #11 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. RESIDENT #11' S MEDICAL RECORD CONTAINED physician's orders [REDACTED].#11 WAS PRESCRIBED FUROSEMIDE 20 MG ONE TABLET BY MOUTH DAILY. ACCORDING TO THE DRUG INFORMATION HANDBOOK FOR NURSING 2007, THE MEDICATION FUROSEMIDE IS IN THE PHARMACOLOGIC CATEGORY OF DIURETIC, LOOP. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) WEBSITE (<HTTP://WWW.BT.CDC.GOV/DISASTERS/EXTREMEHEAT/FAQ.ASP>) THE RISK FOR HEAT-RELATED ILLNESS AND DEATH MAY INCREASE AMONG PEOPLE USING THE FOLLOWING DRUGS: (4) DIURETIC MEDICATIONS OR " WATER PILLS " THAT AFFECT FLUID BALANCE IN THE BODY. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #11' S ROOM AS HAVING A TEMPERATURE OF 82.5/82. THE ROOM HAD A FAN BLOWING AND NO OPERATING AIR CONDITIONING. RESIDENT #12, room [ROOM NUMBER].1: RESIDENT #12 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/22/11, WHICH SAID RESIDENT #12 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 10:45 AM TO 11:40 AM WITH FACILITY STAFF #4, #5, #6, #7 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #12 ' S ROOM AS HAVING A TEMPERATURE OF 85.5/85.4. THE ROOM HAD A FAN BLOWING AND NO OPERATING AIR CONDITIONING. RESIDENT #12 WAS NON-VERBAL AND NON-RESPONSIVE TO THE SURVEYORS ATTEMPTS TO COMMUNICATE. RESIDENT #13, room [ROOM NUMBER].2: RESIDENT #13 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, THAT SAID RESIDENT #13 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 10:45 AM TO 11:40 AM WITH FACILITY STAFF #4, #5, #6, #7 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #13' S ROOM AS HAVING A TEMPERATURE OF 85.5/85.4. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #14, room [ROOM NUMBER]: RESIDENT #14 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11,WHICH SAID RESIDENT #14 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. RESIDENT #14 ' S MEDICAL RECORD CONTAINED physician's orders [REDACTED].#14 WAS PRESCRIBED FUROSEMIDE 20 MG ONE TABLET BY MOUTH DAILY. ACCORDING TO THE DRUG INFORMATION HANDBOOK FOR NURSING 2007, THE MEDICATION FUROSEMIDE IS IN THE PHARMACOLOGIC CATEGORY OF DIURETIC, LOOP. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) WEBSITE (<HTTP://WWW.BT.CDC.GOV/DISASTERS/EXTREMEHEAT/FAQ.ASP>) THE RISK FOR HEAT-RELATED ILLNESS AND DEATH MAY INCREASE AMONG PEOPLE USING THE FOLLOWING DRUGS: (4) DIURETIC MEDICATIONS OR " WATER PILLS " THAT AFFECT FLUID BALANCE IN THE BODY. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #14' S ROOM AS HAVING A TEMPERATURE OF 84.5/83.1. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. DURING OBSERVATIONS ON 07/09/11 AT 4:00 PM, THE SURVEYOR MEASURED RESIDENT #14 ' S ROOM (162) AS HAVING A TEMPERATURE OF 81.1 DEGREES FAHRENHEIT. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #15, room [ROOM NUMBER]: RESIDENT #15 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 07/08/11, WHICH SAID RESIDENT #15 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. RESIDENT #15 ' S MEDICAL RECORD CONTAINED physician's orders [REDACTED].#11 WAS PRESCRIBED CARBIDOPA-LEVODOPA 10-100 MG ONE TABLET THREE TIMES DAILY FOR PARKINSON'S. ACCORDING TO THE DRUG INFORMATION HANDBOOK FOR NURSING 2007, THE MEDICATION CARBIDOPA-LEVODOPA IS IN THE PHARMACOLOGIC CATEGORY OF ANTI-PARKINSON ' S AGENT. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) WEBSITE (<HTTP://WWW.BT.CDC.GOV/DISASTERS/EXTREMEHEAT/FAQ.ASP>) THE RISK FOR HEAT-RELATED ILLNESS AND DEATH MAY INCREASE AMONG PEOPLE USING THE FOLLOWING DRUGS: (2) MEDICATIONS FOR PARKINSON ' S DISEASE, BECAUSE THEY CAN INHIBIT PERSPIRATION. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #15 ' S ROOM AS HAVING A TEMPERATURE OF 83.5/83.6. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #16, room [ROOM NUMBER]: RESIDENT #16 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/22/11, WHICH SAID RESIDENT #16 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 10:45 AM TO 11:40 AM WITH FACILITY STAFF #4, #5, AND #7 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #16 ' S ROOM AS HAVING A TEMPERATURE OF 90/89.9. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. DURING AN INTERVIEW WITH RESIDENT #16 ON 07/07/11 AT 11:00 AM, RESIDENT #16 SAID, " IT FEELS WARM IN THE ROOM...IT BE HOT " . DURING AN INTERVIEW WITH RESIDENT #16 ON 07/09/11 (2 DAYS LATER,) AT 4:10 PM, RESIDENT #16 SAID FACILITY STAFF " JUST PUT " AIR CONDITIONING IN HER ROOM (165). RESIDENT #17, room [ROOM NUMBER]: RESIDENT #17 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 5/25/11, WHICH SAID RESIDENT #17 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #17 ' S ROOM AS HAVING A TEMPERATURE OF 85.5/85.2. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. DURING OBSERVATIONS ON 07/08/11 AT 9:00 AM, THE SURVEYOR MEASURED RESIDENT #17 ' S ROOM (166) AS HAVING A TEMPERATURE OF 82 DEGREES FAHRENHEIT. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #18, room [ROOM NUMBER].1: RESIDENT #18 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/22/11, WHICH SAID RESIDENT #18 WAS A [AGE] year OLD MALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #18 ' S ROOM AS HAVING A TEMPERATURE OF 84/84.3. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #19, room [ROOM NUMBER].2: RESIDENT #19 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, WHICH SAID RESIDENT #19 WAS A [AGE] year OLD MALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #18 ' S ROOM AS HAVING A TEMPERATURE OF 84/84.3. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #20, room [ROOM NUMBER].1: RESIDENT #20 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/22/11, THAT SAID RESIDENT #20 WAS A [AGE] year OLD MALE WITH [DIAGNOSES REDACTED]. RESIDENT #20 ' S MEDICAL RECORD CONTAINED physician's orders [REDACTED].#20 WAS PRESCRIBED FUROSEMIDE 40 MG ONE TABLET BY MOUTH TWICE DAILY. ACCORDING TO THE DRUG INFORMATION HANDBOOK FOR NURSING 2007, THE MEDICATION FUROSEMIDE IS IN THE PHARMACOLOGIC CATEGORY OF DIURETIC, LOOP. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) WEBSITE (<HTTP://WWW.BT.CDC.GOV/DISASTERS/EXTREMEHEAT/FAQ.ASP>) THE RISK FOR HEAT-RELATED ILLNESS AND DEATH MAY INCREASE AMONG PEOPLE USING THE FOLLOWING DRUGS: (4) DIURETIC MEDICATIONS OR " WATER PILLS " THAT AFFECT FLUID BALANCE IN THE BODY. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #20 ' S ROOM AS HAVING A TEMPERATURE OF 85/85.6. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #21, room [ROOM NUMBER].2: RESIDENT #21 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, THAT SAID RESIDENT #21 WAS AN [AGE] year OLD MALE. RESIDENT #21 ' S MEDICAL RECORD CONTAINED physician's orders [REDACTED].#21 HAD HYPERTENSION, END STAGE RENAL DISEASE, AND DYSPHAGIA, AMONG OTHER MEDICAL DIAGNOSES. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #21' S ROOM AS HAVING A TEMPERATURE OF 85/85.6. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #22, room [ROOM NUMBER].1: RESIDENT #22 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/22/11, WHICH SAID RESIDENT #22 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #22 ' S ROOM AS HAVING A TEMPERATURE OF 82/82.4. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #23, room [ROOM NUMBER].2: RESIDENT #23 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, WHICH SAID RESIDENT #23 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #23 ' S ROOM AS HAVING A TEMPERATURE OF 82/82.4. THE ROOM HAD BOTH AN OPERATIONAL FAN AND AIR CONDITIONER. NONE OF THE MAINTENANCE STAFF PRESENT AT VARIOUS TIMES WERE ABLE TO EXPLAIN WHY THE AIR CONDITIONER WAS ONLY ABLE TO KEEP THE AMBIENT ROOM TEMPERATURE AT A MINIMUM OF 82 DEGREES FAHRENHEIT. RESIDENT #24, room [ROOM NUMBER].1: RESIDENT #24 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 06/14/11, WHICH SAID RESIDENT #24 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #24 ' S ROOM AS HAVING A TEMPERATURE OF 84.5/84. THE ROOM HAD NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. RESIDENT #25, room [ROOM NUMBER].2: RESIDENT #25 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, WHICH SAID RESIDENT #25 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #25 ' S ROOM AS HAVING A TEMPERATURE OF 84.5/84. THE ROOM HAD NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. RESIDENT #26, ROOM 177: RESIDENT #26 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/22/11, WHICH SAID RESIDENT #26 WAS AN [AGE] year OLD MALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #26 ' S ROOM AS HAVING A TEMPERATURE OF 84.5/82.9. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #27, room [ROOM NUMBER]: RESIDENT #27 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 06/06/11, WHICH SAID RESIDENT #27 WAS AN [AGE] year OLD MALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #27 ' S ROOM AS HAVING A TEMPERATURE OF 82/83.4. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #28, room [ROOM NUMBER].1: RESIDENT #28 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/20/11, WHICH SAID RESIDENT #28 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #28 ' S ROOM AS HAVING A TEMPERATURE OF 81.5/81.6. THE ROOM HAD OPERATIONAL AIR CONDITIONING, BUT NO FAN. NONE OF THE MAINTENANCE STAFF PRESENT AT VARIOUS TIMES WERE ABLE TO EXPLAIN WHY THE AIR CONDITIONER WAS ONLY ABLE TO KEEP THE AMBIENT ROOM TEMPERATURE AT A MINIMUM OF 81 DEGREES FAHRENHEIT. RESIDENT #29, room [ROOM NUMBER].2: RESIDENT #29 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/22/11, WHICH SAID RESIDENT #29 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #29 ' S ROOM AS HAVING A TEMPERATURE OF 81.5/81.6. THE ROOM HAD OPERATIONAL AIR CONDITIONING, BUT NO FAN. NONE OF THE MAINTENANCE STAFF PRESENT AT VARIOUS TIMES WERE ABLE TO EXPLAIN WHY THE AIR CONDITIONER WAS ONLY ABLE TO KEEP THE AMBIENT ROOM TEMPERATURE AT A MINIMUM OF 81 DEGREES FAHRENHEIT. RESIDENT #30, room [ROOM NUMBER].3: RESIDENT #30 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 06/10/11, WHICH SAID RESIDENT #30 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #30 ' S ROOM AS HAVING A TEMPERATURE OF 81.5/81.6. THE ROOM HAD OPERATIONAL AIR CONDITIONING, BUT NO FAN. NONE OF THE MAINTENANCE STAFF PRESENT AT VARIOUS TIMES WERE ABLE TO EXPLAIN WHY THE AIR CONDITIONER WAS ONLY ABLE TO KEEP THE AMBIENT ROOM TEMPERATURE AT A MINIMUM OF 81 DEGREES FAHRENHEIT. RESIDENT #31, room [ROOM NUMBER].2: RESIDENT #31 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 06/15/11, WHICH SAID RESIDENT #31 WAS A [AGE] year OLD MALE WITH [DIAGNOSES REDACTED]. RESIDENT #31 ' S MEDICAL RECORD CONTAINED physician's orders [REDACTED].#31 WAS PRESCRIBED ZYPREXA 20 MG ONE TABLET BY MOUTH ONCE DAILY (SCHIZOPHRENIA). ACCORDING TO THE DRUG INFORMATION HANDBOOK FOR NURSING 2007, THE MEDICATION ZYPREXA (OLANZAPINE) IS IN THE PHARMACOLOGIC CATEGORY OF ANTI-PSYCHOTIC, ATYPICAL. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) WEBSITE (<HTTP://WWW.BT.CDC.GOV/DISASTERS/EXTREMEHEAT/FAQ.ASP>) THE RISK FOR HEAT-RELATED ILLNESS AND DEATH MAY INCREASE AMONG PEOPLE USING THE FOLLOWING DRUGS: (1) PSYCHOTROPICS, WHICH AFFECT PSYCHIC FUNCTION, BEHAVIOR, OR EXPERIENCE (E.G. HALOPERIDOL OR CHLORPROMAZINE). DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #31 ' S ROOM AS HAVING A TEMPERATURE OF 81.5/82. THE ROOM HAD NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. ON 07/08/11 AT 8:48 AM, DURING OBSERVATION AND INTERVIEW, THE SURVEYOR MEASURED RESIDENT #31 ' S ROOM AS HAVING A TEMPERATURE OF 82.4 WITH NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. DURING AN INTERVIEW WITH RESIDENT #31 ON 07/09/11 AT 4:20 PM, (2 SAYS LATER) RESIDENT #31 SAID FACILITY STAFF HAD INSTALLED A FAN AND AIR CONDITIONING IN HIS ROOM (251). RESIDENT #32, room [ROOM NUMBER]: RESIDENT #32 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 06/14/11, WHICH SAID RESIDENT #32 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #32 ' S ROOM AS HAVING A TEMPERATURE OF 81.5/82.4. THE ROOM HAD NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. RESIDENT #33, room [ROOM NUMBER]: RESIDENT #33 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, WHICH SAID RESIDENT #33 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. RESIDENT #33 ' S MEDICAL RECORD CONTAINED physician's orders [REDACTED].#33 WAS PRESCRIBED ZYPREXA 2.5 MG GIVE ONE TABLET BY MOUTH AT BEDTIME. ACCORDING TO THE DRUG INFORMATION HANDBOOK FOR NURSING 2007, THE MEDICATION ZYPREXA (OLANZAPINE) IS IN THE PHARMACOLOGIC CATEGORY OF ANTI-PSYCHOTIC, ATYPICAL. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) WEBSITE (<HTTP://WWW.BT.CDC.GOV/DISASTERS/EXTREMEHEAT/FAQ.ASP>) THE RISK FOR HEAT-RELATED ILLNESS AND DEATH MAY INCREASE AMONG PEOPLE USING THE FOLLOWING DRUGS: (1) PSYCHOTROPICS, WHICH AFFECT PSYCHIC FUNCTION, BEHAVIOR, OR EXPERIENCE (E.G. HALOPERIDOL OR CHLORPROMAZINE). DURING ROOM OBSERVATIONS ON 07/07/11 FROM 10:45 AM TO 11:40 AM WITH FACILITY STAFF #4, #5, AND #7 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #33 ' S ROOM AS HAVING A TEMPERATURE OF 83.5/82.9. THE ROOM HAD NO OPERATING FAN AND NO OPERATING AIR CONDITIONING. DURING AN INTERVIEW WITH RESIDENT #33 ON 07/07/11 AT 11:20 AM, RESIDENT #33 MADE MOTIONS WITH HER MOUTH AS IF TRYING TO SPEAK BUT COULD NOT PRODUCE UNDERSTANDABLE LANGUAGE. RESIDENT #33 WAS ABLE TO MOVE HER HEAD UP AND DOWN IN A CLEAR " YES " MOTION WHEN ASKED IF SHE WAS TOO HOT. RESIDENT #34, room [ROOM NUMBER].1: RESIDENT #34 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, WHICH SAID RESIDENT #34 WAS AN [AGE] year OLD MALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 10:45 AM TO 11:40 AM WITH FACILITY STAFF #4, #5, AND #7 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #34 ' S ROOM AS HAVING A TEMPERATURE OF 83.5/81.6. THE ROOM HAD OPERATIONAL AIR CONDITIONING, BUT NO FAN. NONE OF THE MAINTENANCE STAFF PRESENT AT VARIOUS TIMES WERE ABLE TO EXPLAIN WHY THE AIR CONDITIONER WAS ONLY ABLE TO KEEP THE AMBIENT ROOM TEMPERATURE AT A MINIMUM OF 81 DEGREES FAHRENHEIT. RESIDENT #35, room [ROOM NUMBER].2: RESIDENT #35 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, WHICH SAID RESIDENT #35 WAS AN [AGE] year OLD MALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 10:45 AM TO 11:40 AM WITH FACILITY STAFF #4, #5, AND #7 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #35 ' S ROOM AS HAVING A TEMPERATURE OF 83.5/81.6. THE ROOM HAD OPERATIONAL AIR CONDITIONING, BUT NO FAN. NONE OF THE MAINTENANCE STAFF, PRESENT AT VARIOUS TIMES, WERE ABLE TO EXPLAIN WHY THE AIR CONDITIONER WAS ONLY ABLE TO KEEP THE AMBIENT ROOM TEMPERATURE AT A MINIMUM OF 81 DEGREES FAHRENHEIT. RESIDENT #36, room [ROOM NUMBER].1: RESIDENT #36 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 06/21/11, WHICH SAID RESIDENT #36 WAS AN [AGE] year OLD MALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #36 ' S ROOM AS HAVING A TEMPERATURE OF 82.5/84. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. DURING AN INTERVIEW WITH RESIDENT #36 ON 07/07/11 AT 1:40 PM, RESIDENT #33, WHO HAD SOME DIFFICULTY PRODUCING LANGUAGE, STATED, " IT ' S TOO HOT. " WHEN ASKED IF HE WAS COMFORTABLE, RESIDENT #36 ALSO MADE A FANNING MOTION WITH HIS HAND IN FRONT OF HIS FACE WHICH THE SURVEYOR INTERPRETED AS THE RESIDENT INDICATING HE WAS TOO HOT. RESIDENT #37, room [ROOM NUMBER].2: RESIDENT #37 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, WHICH SAID RESIDENT #37 WAS AN [AGE] year OLD MALE WITH [DIAGNOSES REDACTED]. DURING ROOM OBSERVATIONS ON 07/07/11 FROM 1:15 PM TO 2:55 PM WITH FACILITY STAFF #5, #7, AND #9 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AND FACILITY STAFF MEASURED RESIDENT #37 ' S ROOM AS HAVING A TEMPERATURE OF 82.5/84. THERE WAS NO AIR CONDITIONING IN THE ROOM, BUT A FAN WAS RUNNING. RESIDENT #38, room [ROOM NUMBER]: RESIDENT #38 ' S MEDICAL RECORD CONTAINED A FACE SHEET, DATED 05/25/11, WHICH SAID RESIDENT #38 WAS AN [AGE] year OLD MALE WITH [DIAGNOSES REDACTED]. RESIDENT #38 ' S MEDICAL RECORD CONTAINED physician's orders [REDACTED].#38 WAS PRESCRIBED RISPERIDONE 1 MG GIVE ONE TABLET BY MOUTH THREE TIMES DAILY. ACCORDING TO THE DRUG INFORMATION HANDBOOK FOR NURSING 2007, THE MEDICATION RISPERIDONE (RISPERDAL) IS IN THE PHARMACOLOGIC CATEGORY OF ANTI-PSYCHOTIC AGENT, ATYPICAL. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) WEBSITE (HTTP://WWW.BT.CDC.GOV/DISASTERS/EXTREMEHEAT/FAQ.ASP) THE RISK FOR HEAT-RELATED ILLNESS AND DEATH MAY INCREASE AMONG PEOPLE USING THE FOLLOWING DRUGS: (1) PSYCHOTROPICS, WHICH AFFECT PSYCHIC FUNCTION, BEHAVIOR, OR EXPERIENCE (E.G. HALOPERIDOL OR CHLORPROMAZINE). DURING ROOM OBSERVATIONS ON 07/07/11 FROM 10:45 AM TO 11:40 AM WITH FACILITY STAFF #4, #5, AND #7 PRESENT (AT VARIOUS TIMES), THE SURVEYOR AN

THIS CITATION PERTAINS TO INTAKE NUMBER MI 820 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADMINISTRATE EFFECTIVELY AND PROVIDE FOR RESIDENT AMBIENT ROOM TEMPERATURE CONTROL NEEDS IN A TIMELY MANNER FOR 40 OF 40 SAMPLED RESIDENTS (#1 THROUGH #40), RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENTS #1 THROUGH #40 ,PLACING THEM AT HIGH RISK FOR SEVERE HARM, SERIOUS IMPAIRMENT, AND/OR DEATH FROM HEAT EXHAUSTION OR HEAT STROKE. FINDINGS INCLUDE: ON 07/06/11, A COMPLAINT WAS MADE THAT ALLEGED THAT THERE WERE ROOMS IN THE FACILITY WITH VERY HOT AMBIENT TEMPERATURES. THE FACILITY WAS ASKED TO BEGIN HOURLY TEMPERATURE MONITORING, WITH THE FIRST REPORT DATED 07/06/11. AT 5:00 PM., ACCORDING TO THIS REPORT, THERE WERE 62 ROOMS WITH AMBIENT ROOM TEMPERATURES GREATER THAN 81 DEGREES FAHRENHEIT. ON 07/07/11 FROM 10:45 AM TO 11:40 AM AND ON 07/07/11 FROM 1:15 PM TO 2:55 PM, OBSERVATION REVEALED THAT THERE WERE 24 OUT OF THE 82 TOTAL RESIDENT ROOMS THAT HAD ROOM TEMPERATURES GREATER THAN 81 DEGREES FAHRENHEIT WHICH DIRECTLY AFFECTED 40 RESIDENTS (SEE F-257). THE FACILITY PROVIDED A FORM ENTITLED RESIDENT ROOM AIR TEMPERATURE CHECK DATED 07/02/11 (NO TIME INDICATED) THAT SAID 19 RESIDENT ROOMS OF 82 RESIDENT ROOMS HAD TEMPERATURES RECORDED. OUT OF THESE 19 RESIDENT ROOMS, 9 HAD TEMPERATURES GREATER THAN 81 DEGREES FAHRENHEIT AND 2 ROOMS WERE EXACTLY 81 DEGREES FAHRENHEIT. IT WAS UNCLEAR WHY ALL RESIDENT ROOMS IN THE FACILITY DID NOT HAVE THE ROOM TEMPERATURE CHECKED AT THIS TIME. THE FACILITY PROVIDED A POLICY ENTITLED HAZARDOUS HOT WEATHER POLICY. DATED NOVEMBER 2010, WHICH SAID, UNDER POLICY STATEMENT, "THE FACILITY STRIVES TO MAINTAIN SAFE AND/OR COMFORTABLE RESIDENT ROOM TEMPERATURE LEVELS." THIS POLICY ALSO SAID, UNDER POLICY INTERPRETATION, "THE RECOMMENDED TEMPERATURE RANGE IS 71 TO 81 DEGREES FAHRENHEIT." UNDER RECOMMENDED MEASURES, THE POLICY SAID, "KEEP RESIDENTS COMFORTABLE DURING HAZARDOUS HOT WEATHER, KEEP WELL HYDRATED WITH A PARTICULAR ATTENTION TO DEPENDENT RESIDENTS, USE FANS AS APPROPRIATE, ROOM TEMPS WILL BE TAKEN WEEKLY AND/OR AS NEEDED, AND ALL CONCERNS ARE TO BE DIRECTED TO THE DON AND/OR ADMINISTRATOR." THE FACILITY PROVIDED A POLICY ENTITLED MAINTENANCE ROOM TEMPERATURE POLICY AND PROCEDURE, DATED MAY 2011, WHICH SAID "ROOM TEMPS WILL BE TAKEN WEEKLY AND/OR AS NEEDED." THE FACILITY PROVIDED A FORM ENTITLED FACILITY ACTION PLAN, DATED AND SIGNED BY THE ADMINISTRATOR (ADM) #2 ON 06/30/11 WHICH SAID, UNDER RECOMMENDED PLAN OF CORRECTION, "TO DECREASE AND/OR IMPLEMENT MEASURES TO PREPARE FOR SUMMER MONTHS." UNDER METHODS USED TO IMPLEMENT THE PLAN OF CORRECTION, THE FORM SAID, "OFFER WINDOW AIR CONDITIONERS TO RESIDENT, OFFER FANS TO RESIDENT, PUT FANS IN AREA OF BUILDING THAT HAS A HISTORY OF BEING HOT, GET QUOTES FOR MINI-SPLIT UNITS AND PTAC UNITS (DEVICES USED TO CONTROL CLIMATE), AND MAINTENANCE TO TAKE ROOM TEMPS WEEKLY." UNDER RESULTS OF PLAN OF CORRECTION, THE FORM SAID, "WINDOW AIR HAS BEEN INSTALLED IN REQUESTED ROOMS, FANS PUT OUT, AND STILL AWAITING FOR QUOTES." DURING AN INTERVIEW WITH MAINTENANCE STAFF (MTS) #7 ON 07/07/11 AT 1:10 PM, MTS #7 SAID, "I'M JUST THE MAINTENANCE TECH. THE MAINTENANCE DIRECTOR WALKED OUT (QUIT) 3 WEEKS AGO." WHEN ASKED ABOUT THE AIR CONDITIONING SYSTEM, MTS #7 SAID THAT THE LONG TERM PLAN WAS TO INSTALL NEW EQUIPMENT. ACCORDING TO MTS #7, THE FACILITY HAD OBTAINED QUOTES, BUT IT WOULD TAKE AT LEAST 30 DAYS TO ORDER AND RECEIVE THE ACTUAL EQUIPMENT. ADDITIONAL TIME WOULD BE NEEDED FOR INSTALLATION. THE FACILITY PROVIDED A QUOTE FROM AN OUTSIDE HEATING AND COOLING COMPANY, DATED 07/05/11, THAT ESTIMATED THE COSTS TO FURNISH AND INSTALL NEEDED CLIMATE CONTROL DEVICES WITHIN THE FACILITY. THE TOTAL PRICE FOR THE PROJECT, INCLUDING THE ELECTRICAL, WAS $122,022.90. THE ACCEPTANCE LINE ON THIS QUOTE WAS BLANK AND UNSIGNED BY THE FACILITY. THE FACILITY PROVIDED AN UNDATED AND UNSIGNED TYPED RECORD OF EVENTS ATTACHED TO THE QUOTE DATED 07/05/11 THAT SAID, "THESE QUOTES REQUESTED FIRST WEEK OF JUNE. . .ADMINISTRATOR AND MAINTENANCE IN BUILDING JULY 2- PTAC UNITS REPAIRED AND SWITCHED OUT. . .ADDITIONAL FANS OFFERED AND/OR PUT OUT. . .NO REQUEST FOR ADDITIONAL WINDOW AIR CONDITIONS (CONDITIONING). . .EMAIL SENT TO RDO (REGIONAL DIRECTOR OF OPERATIONS) ON 07/2/11 FOR ASSISTANCE TO EXPEDITE QUOTES. . .QUOTES RECEIVED ON 7/5/11." THE FACILITY PROVIDED A LETTER FROM AN OUTSIDE HEATING AND COOLING COMPANY, DATED 07/07/11, THAT SAID THE OUTSIDE HEATING AND COOLING COMPANY WOULD BE INSTALLING 3 EMERGENCY RENTAL COOLING UNITS IN THE FACILITY WITH AN ESTIMATED DELIVERY OF MID-DAY 07/07/11. DURING AN INTERVIEW WITH THE ASSISTANT ADMINISTRATOR (AADM) #1 AND DIRECTOR OF NURSING (DON) ON 07/07/11 AT 3:00 PM, AADM #1 SAID MTS #7 WAS THE DIRECTOR OF MAINTENANCE SINCE THE PREVIOUS DIRECTOR QUIT APPROXIMATELY 3 WEEKS AGO. AADM #1 SAID THE FACILITY POLICY IS TO CHECK ALL ROOM TEMPERATURES WEEKLY. AADM #1 WAS NOT ABLE TO EXPLAIN WHY ONLY 19 OF 82 ROOMS HAD BEEN CHECKED FOR AMBIENT AIR TEMPERATURES ON 7/2/11. THE FACILITY ADMINISTRATOR (EMPLOYEE #2) WAS INTERVIEWED ON 07/08/11 AT 9:40 AM; 07/09/11 AT 5:30 PM; 07/11/11 AT 9:20 AM; AND 07/11/11 AT 9:45 AM. DURING THESE INTERVIEWS, THE ADMINISTRATOR WAS ASKED TO EXPLAIN HOW THE FACILITY HAD PLANNED TO HANDLE EXCESSIVELY HIGH AMBIENT ROOM TEMPERATURES AND THE RISK FOR HEAT-RELATED ILLNESS IN THE FACILITY. ACCORDING TO THE ADMINISTRATOR, THE FACILITY HELD MONTHLY QUALITY ASSURANCE (QA) MEETINGS WITH THE MEDICAL DIRECTOR PRESENT. AS A RESULT OF QA REGARDING AMBIENT AIR TEMPERATURES IN RESIDENT ROOMS, ADM #2 STATED THAT IN THE FIRST WEEK OF JUNE 2011, SHE REQUESTED QUOTES FOR NEW AIR CONDITIONING UNITS AND SENT THESE QUOTES TO THE CORPORATE REGIONAL DIRECTOR OF OPERATIONS (RDO). ADM #2 SAID THE MAINTENANCE DEPARTMENT PROVIDED FANS, HYDRATION CARTS WERE PLACED ON THE UNITS, ADDITIONAL FLUIDS WERE OFFERED TO RESIDENTS, STAFF CHECKED RESIDENTS FREQUENTLY, AND THE FACILITY FOLLOWED THE HOT WEATHER POLICY. ADM #2 SAID SHE REQUESTED ADDITIONAL AIR CONDITIONING UNITS BASED ON RANDOM TEMPERATURES IN THE BUILDING AND IN PREPARATION FOR THE HOT SEASON. ADM #2 EXPLAINED THAT THE BUILDING DID NOT HAVE AIR CONDITIONING IN ALL AREAS. ADM #2 WENT ON TO SAY THAT SOME RESIDENTS DID NOT WANT AIR CONDITIONING UNITS AND COMPLAINED OF BEING COLD. ADM #2 STATED THAT ON SATURDAY, 07/02/11 SHE WAS NOTIFIED THAT TEMPERATURES IN THE FACILITY WERE EXCESSIVELY ELEVATED AND SO SHE CAME INTO THE FACILITY WITH MAINTENANCE STAFF TO MONITOR. THE ADMINISTRATOR WAS NOT ABLE TO SAY WHY THEY HAD WAITED UNTIL 7/7/11 TO REQUEST THE EMERGENCY RENTAL COOLING UNITS. ADM #2 WAS NOTIFIED ON 07/11/11 AT 12:15 PM OF THE IMMEDIATE JEOPARDY, WHICH BEGAN ON 07/06/11, WHEN THE FACILITY FAILED TO ADMINISTRATE EFFECTIVELY AND PROVIDE FOR RESIDENT AMBIENT ROOM TEMPERATURE CONTROL NEEDS IN A TIMELY MANNER FOR 40 OF 40 SAMPLED RESIDENTS (#1 THROUGH #40), RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENTS #1 THROUGH #40, PLACING THEM AT HIGH RISK FOR SEVERE HARM, SERIOUS IMPAIRMENT, AND/OR DEATH FROM HEAT EXHAUSTION THE SURVEYOR VERIFIED ON 07/15/11 AT 2:00 PM THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON 07/08/11 THE FACILITY HAD THREE PORTABLE AIR CONDITIONING UNITS OPERATING IN THE FACILITY. 2. ON 07/15/11 THE SURVEYOR VERIFIED THAT, STARTING ON 07/06/11 AT 5:00 PM, THE FACILITY BEGAN MEASURING AND FAXING ROOM TEMPERATURES TO THE STATE AGENCY, INCLUDING SOME RESIDENT BODY TEMPERATURES. 3. ON 07/15/11 RESIDENT #12 ' S ROOM TEMPERATURE WAS LESS THAN 81 DEGREES FAHRENHEIT, HAD OPERATING AIR CONDITIONING AND FLUID NEEDS WERE PROVIDED FOR. THE CLINICIAN RESPONSIBLE FOR NOT PROVIDING FLUID NEEDS WAS REMOVED FROM THE WORK SCHEDULE FOR ONE DAY. 4. ON 07/15/11 RESIDENT #13 ' S ROOM TEMPERATURE WAS LESS THAN 81 DEGREES FAHRENHEIT, HAD OPERATING AIR CONDITIONING, FLUID NEEDS WERE PROVIDED FOR AND DIRECT SUNLIGHT WAS BLOCKED BY APPROPRIATE WINDOW TREATMENTS. THE CLINICIAN RESPONSIBLE FOR NOT PROVIDING FLUID NEEDS WAS REMOVED FROM THE WORK SCHEDULE FOR ONE DAY. 5. ON 07/15/11, RESIDENT ' S #4, #5, #16, #24, #25, #31, #32, #33, #36, AND #38 HAD ROOM TEMPERATURES LESS THAN 81 DEGREES FAHRENHEIT, HAD OPERATING CLIMATE CONTROL DEVICES IN ROOM, HAD FLUID NEEDS PROVIDED FOR AND DIRECT SUNLIGHT WAS BLOCKED BY APPROPRIATE WINDOW TREATMENTS. RESIDENT #39 DID NOT HAVE ANY OPERATING FAN OR AIR CONDITIONING PER CHOICE. FACILITY CLINICIANS ASSESSED RESIDENT #39 AS NEEDED PER HOT WEATHER POLICY AND CHARTED SUCH VIA NURSING NOTES. 6. ON 07/15/11 THE SURVEYOR VERIFIED THAT, ON 07/06/11, 3 OF 3 MAINTENANCE EMPLOYEES WERE RE-EDUCATED ON THE ROOM TEMPERATURE POLICY. 7. ON 07/15/11 THE SURVEYOR VERIFIED THAT, ON 07/07/11, 6 OF 6 ACTIVITY DEPARTMENT EMPLOYEES WERE IN-SERVICED ON THE HAZARDOUS HOT WEATHER AND THE HYDRATION POLICIES. 8. ON 07/15/11 THE SURVEYOR VERIFIED THAT, BY 07/07/11, 95 OF 100 NURSING DEPARTMENT EMPLOYEES WERE IN-SERVICED ON THE HAZARDOUS HOT WEATHER AND THE HYDRATION POLICIES. CERTIFIED LETTERS WERE SENT TO REMAINING NURSING STAFF IDENTIFYING EDUCATIONAL EXPECTATIONS NEEDED TO RETURN TO WORK. NEW EMPLOYEES WILL RECEIVE TRAINING ON ABOVE POLICY ' S STARTING 07/07/11. 9. ON 07/15/11 RESIDENTS WERE ASSESSED, AS NEEDED, PER THE HAZARDOUS HOT WEATHER AND THE HYDRATION POLICY PROTOCOLS, INCLUDING THOSE CHOOSING NOT TO HAVE AIR CONDITIONING. 10. ON 07/15/11 ROOM AUDITS WERE VERIFIED AS COMPLETED BY MAINTENANCE DATED 07/07/11 THROUGH 07/12/11. 11. ON 07/15/11 NURSING AUDITS WERE VERIFIED AS COMPLETED BY DIRECTOR OF NURSING/DESIGNEE DATED 07/07/11 THROUGH 07/12/11. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON 07/7/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND A SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO INCOMPLETE IN-SERVICE TRAINING FOR STAFF ON THE HAZARDOUS HOT WEATHER AND THE HYDRATION POLICIES AND BECAUSE SUSTAINED COMPLIANCE HAS NOT BEEN VERIFIED BY THE STATE AGENCY.