Every finding on record at Helen Newberry Joy HLTCU Golden Leaves Living Cent

This deficiency pertains to Intake #2694753Based on observation, interview, and record review, the facility failed to implement interventions consistent with recognized standards of practice to promote the healing of a pressure injury for one Resident (R1) of three residents reviewed for pressure injury. This deficient practice resulted in the worsening of stage 3 pressure injury on the right heel of R1. Findings include:Intake #2694753 was submitted to the state agency on 12/10/25. The intake alleged the facility failed to prevent worsening of a pressure injury (PI) to the heel of Resident #1 (R1).On 1/2/26 at 10:32 AM, 11:17 AM, and 12:19 PM, R1 was observed in her room sitting in her wheelchair at bedside with both feet placed directly on the floor without a support surface or pressure-reducing device.R1 was interviewed on 1/2/26 at 12:19 PM. A wound dressing was observed on her right lateral posterior calf. R1 said she had a wound on her calf but could not recall how long the wound on the calf had been present. R1 confirmed she also had a wound on her right heel. When asked if she had been provided with a pressure-reducing boot or similar device to offload pressure from the wound, R1 disclosed she did not wear any devices for her feet and said staff had never offered her any boots. When asked if she elevated her heels off the mattress when in bed, R1 said she had multiple sclerosis and was dependent on staff. R1 said staff did not elevate her feet on a pillow or use a heel wedge to elevate her heels off the mattress while in bed.Review of the electronic medical record (EMR) revealed R1 was admitted to the facility 2/22/25 with a primary diagnosis of multiple sclerosis. A Minimum Data Set (MDS) assessment dated [DATE] coded R1 with a Brief Interview for Mental Status (BIMS) score of 15 indicating R1 had fully intact cognition. The MDS indicated R1 had no impairment of short-term memory or long-term memory. Further review of the MDS divulged R1 had functional limitation in range of motion of the bilateral lower extremities. R1 was documented as being non-ambulatory and utilized a wheelchair for locomotion. R1 was identified as being at risk for developing PI but did not have identified or documented PI at the time of the MDS assessment.The EMR documented a stage 3 PI (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) was initially identified on 11/28/25. The most recent measurements of the PI were obtained on 12/26/25 and documented the PI measurements as 1.61 centimeters (cm) x (by) 1.24 cm x 0.2 cm (length, width, and depth respectively).A physician's order dated 11/28/25 read: Float heels at all times while in bed and assess resident while up in wheelchair to ensure pressure relief to right heel. A physician's order dated 12/5/25 read in part: Resident to dangle foot and offload heel while in wheelchair in room.A care plan focus dated as revised 11/28/25 read: I have a stage III [3] pressure ulcer [injury] to right heel. The care plan interventions included the following: Check resident every 2 hours to ensure pressure relief on right heel. Encourage resident to sit in recliner during the day to assist with off loading pressure from right heel. Float heels while in bed.The care plan did not include interventions to reduce pressure on the heel while R1 was in the wheelchair. The Kardex (a quick-reference guide that provides staff with pertinent information and interventions for a resident) did not include the PI or direct staff to provide any pressure reducing interventions to implement to alleviate pressure from the heel.The EMR contained a report from a consultant physician dated 12/11/25. The report documented the reason for the consultation was Right foot - pain wound. The consultant's report documented, in part: .[R1 name redacted] is a [AGE] year-old female that is wheelchair-bound with multiple sclerosis that has developed a pressure wound at the bottom of her right heel. she would benefit from a [brand name of a pressure-eliminating boot redacted] to remove all pressure at the bottom of the heel which she should wear at all times.A progress notes in the EMR dated 12/4/25 at 6:00 AM read: Note text: wound to RIGHT [sic] heel dressing was saturated, changed dressing. wound is worse than my previous evaluation of wound. odor [sic] from wound. wound [sic] size has also increased from my previous evaluation of wound with maceration [breakdown of the skin due to prolonged exposure to moisture] extended. Cleansed areas. Applied [antimicrobial wound dressing] as ordered to wound bed. Covered with foam dressing.A progress note dated 12/14/25 at 9:25 AM read, in part: . [name of consultant physician redacted] is ordering resident a brace.orders include. continuous offloading.A progress noted dated 12/22/25 at 6:02 AM read, in part: . wound has again progressively worsening [sic], dressing was saturated as it was last changed by myself at prior shift. Her socks were saturated as well. There is slough [non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture]. Odor present after cleansing wound. blanching [temporary whitening when pressure applied] surrounding significant amount of area . I am fearing this wound to become quite large.Licensed Practical Nurse (LPN) A and the Director of Nursing (DON) completed a dressing change to the right heel of R1 on 1/2/26 at 1:29 PM. Upon entry into the room, R1 was lying on her back in bed with both heels resting directly on the mattress.LPN A was asked about the dressing on R1's right latero-posterior calf. LPN A said there was no wound under the dressing and the dressing was only present to provide protection from a previous wound that had healed. The surveyor requested to have the dressing removed to visualize the skin beneath the dressing. The DON removed the dressing from the calf to reveal an open area with irregular edges approximately 1.0 cm x 0.5 cm x < (less than) 0.1 cm. The DON said, Oh, she does have a wound under there.The DON removed the dressing to the right heel to reveal a stage 3 pressure injury. The dressing was saturated with serosanguineous drainage (pink, clear, thin fluid). The wound was measured at 2.0 cm x 4.0 cm x 0.4 cm. The wound measurements revealed the PI to be larger than the previous measurement on 12/26/25 of 1.61 cm x 1.24 cm x 0.2 cm.After completing the treatment, the DON asked R1 if she had any boots for her heels. R1 told the DON she had never been offered any boots. The DON asked R1 if the staff were elevating her heels off the mattress on pillows when she was in bed. R1 replied, No one ever puts my feet up off the bed.The DON was interviewed on 1/2/26 at 10:37 AM and 1:51 PM. The DON confirmed the PI developed while R1 resided in the facility and said R1 did not have a history of pressure injuries.When asked why the wound measurement assessment on 1/2/26 revealed the PI to have worsened in size since the previous measurement obtained on 12/26/25, the DON said there were discrepancies in wound measurements due to inaccurate data provided by the software program the facility utilized to measure wounds. When queried regarding the reason the facility would continue to utilize the program if inaccuracies in data were suspected, the DON replied, We will have to go back to measuring them manually like we used to until the software is corrected.When asked about the boot referenced in the consulting physician's report of 12/11/25, the DON said she was unaware the consulting physician had ordered a boot for R1. The DON was asked if any pressure-reducing devices were put in place to reduce the pressure on R1's heel. The DON said, The staff should be putting her foot up when she's in bed. The DON admitted the resident should have had pressure-reduction boots or a similar pressure-reducing device in place.The Kardex of R1 and the consultant report of 12/11/25 were reviewed with the DON. The DON said there should have been a physician's order and care plan intervention for the boot as ordered by the consultant physician. The DON said the Kardex should have included pressure-reducing interventions for staff to follow to promote healing of the existing PI and to prevent new PI from developing.After the interview, the DON went to her office and returned with the boot for R1 as referenced by the physician consultant on 12/11/25. The DON said she did not know how long the boot had been in her office. She said she first noticed the boot in her office on 12/31/25 but did not know who it was for. The DON was asked what pressure-reducing devices or interventions were put in place until the boot was received. The DON said, They [staff] should have been putting her foot up when she's in bed, and she should have had soft booties.The manufacturer's insert in the package with the boot contained the following information, in part: . [Brand name of boot redacted] eliminates pressure on the heel and toes, while dynamically positioning the foot in a neutral position for the treatment of foot and ankle contractures. The floating heel design of the [brand name of boot redacted] eliminates pressure or friction on the heel, enhancing circulation vital to healing. The manufacturer's warning list on the insert included: .1. [brand name of boot redacted] requires a physician order.The policy Wound Care Guidelines dated as revised 7/16/2024 read, in part: . Elevate heels off mattress and support calves and ankles with a pillow or protective device float.The policy Skin and Wound Assessment dated as revised 1/14/2025 read, in part: .ALL [sic] residents that do have skin breakdowns and/or pressure ulcers receive necessary treatment and services to promote healing. Avoidable Pressure Ulcer: Means that the resident developed a pressure ulcer and that the facility did not do one or more of the following:Evaluate the resident's clinical condition and pressure ulcer risk factors;Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice;Monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. The National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide Recommendations, 4th edition, 2025 [https://npiap.com/page/InternationalGuidelines?hhsearchterms=2025] recommends, in part: .It is good practice to frequently reposition individuals at risk of pressure injuries who are seated out of bed. position seated individuals in such a way that reduces pressure, shear and friction. This includes: . position in which the individual's legs are elevated and supported so the heels are free from the support surface. It is good practice to elevate the heels of individuals at risk of pressure injuries, so the heels are not in contact with the support surface. We suggest using a heel offloading device that is appropriate to the individual's mobility and activity level. It is good practice to elevate the heels of individuals at risk of pressure injuries using standard pillows or cushions with sufficient height to ensure the heels are not in contact with the support surface.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by:- Failing to ensure labeling of food.- Failing to ensure expired food was discarded.- Failing to ensure proper hand sanitization when serving food.This deficient practice had the potential to result in food borne illness among any or all 29 residents in the facility who receive meals.Findings include:During an observation on 8/26/25 at 10:12 a.m., the #9 walk in refrigerator contained:1. 1 bag of opened celery with a use by date of 8/23/25.2. 1 large bag of sliced green peppers that appeared to be mushy and slimy with no had no use by date.3. 1 opened bag of diced onions with a use by date of 8/24/25.4. 1 opened bag of sliced onions with a use by date of 8/25/25.During an observation on 8/26/25 at 10:25 a.m., the #3 refrigerator had a small plastic container of cultured buttermilk with an open date of 8/19.During an observation on 8/26/25 at approximately 10:27 a.m., the #7 walk in freezer contained:1. 1 large bag of frozen fish nuggets out of the original box with no use by date.2. 2 bags of frozen broccoli that had been opened with no open date or use by date.3. 1 bag of frozen cauliflower that had been opened with no open date or use by date.4. 1 bag of diced celery that had been opened with no open date or use by date.5. 1 bag of crinkled carrots that had been opened with no open date or use by date.During an observation on 8/26/25 at 10:50 a.m., there was one container of sliced tomatoes, and one container of lettuce left uncovered near the tray line.During an observation on 8/26/25 at approximately 11:00 a.m., the dry food storage area contained:1. 1 bin of rice with no open or use by date.2. 1 bin of sugar with no open or use by date.3. 1 bin of flour with no open or use by date.Review of policy titled Food Storage last reviewed 2/26/24, read in part .Food is stored.to prevent contamination.plastic containers with tight fitting covers must be used for.flour, sugar.and bulk foods. All containers must be legible and accurately labeled.Food should be dated as it is placed on the shelves.Refrigeration.all foods should be covered, labeled, and dated.Frozen foods.foods should be covered, labeled and dated.During an observation the dining room refrigerator contained the following:1. On 8/26/25 at 11:19 a.m., 2 plastic bags with slices of deli turkey with a use by date of 8/25/25.2. On 8/27/25 at 8:11 a.m., 2 plastic bags with slices of deli turkey with a use by date of 8/25/25.3. On 8/28/25 at 7:23 a.m., 2 plastic bags with slices of deli turkey with a use by date of 8/25/25.During an interview on 8/28/25 at 7:36 a.m., the Director of Nursing (DON) acknowledged that the deli meat is outdated and reported she is not sure whose job it is to look for dates in the dining room refrigerator.Review of policy titled kitchenettes and pantries last reviewed 7/15/25, read in part .Supplies of food and beverage items will be available around the clock in the kitchenette or pantry areas.nursing staff shall.rotate stock and remove outdated items.During an observation on 8/27/25 at 8:05 a.m., Certified Nurses Aide (CNA) B served a resident breakfast, did not use hand sanitizer and then walked to the kitchen window to get a tray of glasses. CNA B filled up a glass with juice and gave it to another resident.During and observation on 8/27/25 at 11:33 a.m., CNA K served a resident the lunch tray and did not use hand sanitizer before serving another resident a lunch tray. CNA F walked up to a resident that needed assistance with her meal, leaned over to unlock her brakes with her hand, moved the resident closer to the table, adjusted the resident's wheelchair, and then locked the wheelchair with her hand. CNA F did not use hand sanitizer or wash her hands, sat down in a chair, and began to feed the resident her meal.A policy for hand washing was requested multiple times and was not provided prior to exit from the facility.

Based on observation, interview, and record review, the facility failed to provide a comfortable temperature level in the dining room, and maintain the wheelchairs of three Residents (R5, R19, and R24) in clean and sanitary conditions.Findings include:Findings include: Resident #19 (R19) On 8/27/2025 at 8:45 AM, an observation was made of an unoccupied wheelchair belonging to R19 in the hallway leading to the main dining room. The wheelchair was observed with a large amount of food particles of various shapes, colors, and sizes underneath the cushion and along the sides of the seat. On 8/27/25 at 8:50 AM, an observation was made of a second wheelchair in R19's room. The wheelchair was identified as R19's unoccupied and had food crumbs on the seat of the wheelchair. On 8/27/25 at 9:00 AM, an observation was of Resident #5 and Resident #24's unoccupied wheelchairs in the hallway. They were observed with multiple old food crumbs and drink stains on them and debris of food on the seats. On 8/27/25 at 9:15 AM, an interview was conducted with The Director of Nursing (DON), who was asked about the uncleanliness of the wheelchairs and how they looked. The DON went to see the wheelchairs with this Surveyor and stated, The Certified Nurse Aides (CNA's) are supposed to wash them on night shift the day of residents' scheduled showers. They look disgusting and there is a lot of food debris on them all. The DON then went to talk with Registered Nurse (RN) A regarding the dirty wheelchairs. On 8/27/25 at 9:27, an interview was conducted with RN A who stated, There is a sign-up sheet in the break room, so they [CNA's] know which resident's wheelchair was washed or not. It is also on the weekly skin check sheets that ask specifically about the wheelchair evaluation for condition and cleanliness and if it was cleaned. I guess I am going to have to have a talk with the night shift CNA's again. Review of document titled, Weekly Skin Assessment Record, undated or filled out, revealed a spot for CNA's to document regarding resident's wheelchair evaluation for working condition and cleanliness. Review of document for R19 titled, Weekly Skin Assessment Record, dated 8/25/25, revealed that CNA C checked off on the document that R19's wheelchair was evaluated and found to be in good working condition and cleaned. During an observation on 8/27/25 at 7:23 a.m., the dining room felt cold, and a cool breeze could be felt coming from the overhead vents. The residents in the dining room had their arms crossed and were shivering in their chairs. During an interview on 8/27/25 at 7:25 a.m., Resident #12 stated It is always cold in the morning, it is like this every day .I don't think that it is right that it is this cold in here. During an interview on 8/27/25 at 7:46 a.m., Residents #3, #12, and #21 reported that it was cold in the dining room. During an interview on 8/27/25 at 7:51 a.m., Resident #6 stated It's cold in here. During and interview on 8/27/25 at 7:55 a.m., Resident #11 stated We are freezing. On 8/27/25 at 7:56 a.m., Licensed Practical Nurse LPN B reported that its cold in the dining room because the facility is trying to cool the kitchen down. On 8/27/25 at approximately 7:58 a.m., Resident #16 stated I am going to get my sweater and come back to finish my breakfast. During an observation on 8/27/25 at 7:59 a.m., Maintenance staff H used an infrared thermometer to measure the temperature of the room. The temperature recorded was 63 degrees Fahrenheit. On 8/27/25 at 8:07 a.m., Resident #16 came into the dining room with her sweater and a hat on her head and reported that she wished she had ear flaps on her hat to keep warm.

Based on interview and record review, the facility failed to provide information to formulate an advance directive for two Residents (#4 and #21) of two residents reviewed for advanced directives.Findings include:Resident #4 (R4)Review of the Minimum Data Set (MDS) assessment, dated 6/11/25, revealed admission to the facility on [DATE].Review of the Electronic Medical Record (EMR) did not reveal that the resident/responsible party had received advanced directive information or formulated an advanced directive.Resident #21 (R21)Review of the MDS assessment, dated 6/5/25, revealed admission to the facility on 2/22/25.Review of the EMR did not reveal that the resident/responsible party had received advance directive information or formulated and advanced directive.During an interview on 8/27/25 at 11:45 a.m., Licensed Practical Nurse (LPN) D reported she had been providing information for residents/responsible parties for advanced directives. LPN D reviewed the EMR for #4 and #21 and acknowledged the residents were not provided advance directive information or formulated an advanced directive.During an interview on 8/27/25 at 12:12 p.m., Registered Nurse (RN)/Nursing Supervisor A acknowledged R4 and R21 were not given advanced directive information and did not formulate advanced directives.Review of policy titled Resident Right Durable Power of Attorney last revised 1/14/25, read in part .It is the policy of the Long Term Care facility to provide a consistent and orderly method of notifying resident of their rights.including the right.to formulate advanced directives.at the time each individual is admitted as a resident, the resident shall be provided with information regarding advanced directives.the resident will be assisted to complete and advanced directives.

Based on interview and record review, the facility failed to investigate resident-to-resident altercations for two Residents (R12 and R6) of two residents reviewed for abuse. Findings include: Resident #12 (R12) was admitted to the facility on [DATE] with a primary medical diagnosis of chronic obstructive pulmonary disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R12 had no functional limitations in range of motion, was independent for activities of daily living, and was independently ambulatory utilizing a walker. Further review of the MDS disclosed R12 had fully intact cognition. During an interview on 8/26/25 at 1:22 PM, R12 said another resident had recently struck her in the head and grabbed her by the wrist and twisted it resulting in a sore wrist. R12 indicated it was the same resident with whom she had previous altercations – Resident #4 (R4). A progress note in the electronic medical record (EMR) of R12 dated 8/6/25 at 9:47 AM read, in part: Spoke with resident today.regarding small incident between her and [R4] yesterday evening [8/5/25]. Per [R12], [R4] came up to her in the hallway with a large pillow. [R12] told [R4] that the pillow was not hers. Staff was already on theirway [sic] down when they had seen [sic]the 2 pass in the hallway. After [R12] had told [R4] the pillow was not hers, [R4] had grabbed onto [R12]'s wrist to lead her somewhere. [R12] yanked her arm away and left the situation. The progress note was authored by Registered Nurse (RN) A. There were no progress notes or documentation in R4's EMR regarding the incident that occurred with R12 on 8/5/25. A care plan in R4's record contained a focus with a revision date on 6/18/25 that read: I have a behavior problem r/t [related to] wandering, aggressive behavior, and entering other residents room. The care plan contained an intervention dated as initiated on 3/15/25 that read: Keep me away from residents [R12] and [another resident]. We do not get along at times. The EMR of R12 contained a care plan dated 6/18/25 that read: I feel nervous around resident (R4) d/t [due to] a past altercation. An intervention dated 6/18/25 read: If resident [R4] and I are in the hallways at the same time, please redirect her away from me. R12 was re-interviewed on 8/27/25 at 8:49 AM. R12 said she was frightened of R4 and indicated the door to her room had signage and barriers as a deterrent to prevent R4 from entering the room. The door to R12's room was observed with a mesh barrier that contained a red-colored octagon with the word STOP written on the octagon. The mesh barrier had Velcro on each end to attach to each side of the doorway when extended across the doorway. A posting on the door read Private and pictured a red-colored, open hand. Additional signage was posted that read: PRIVATE PROPERTY KEEP OUT. R12 said she is afraid R4 will enter her room, and she does not feel safe even in her room. On 8/27/25 at 8:25 AM, The Director of Nursing (DON) was asked for the investigation regarding the resident-to-resident altercation between R12 and R4. The DON indicated RN A addressed the concern the day after the occurrence. The DON said an investigation was not completed for the altercation. RN A was interviewed on 8/27/25 at 9:44 AM. RN A confirmed previous altercations between R12 and R4. RN A said she spoke with R12 on 8/6/25 and R12 told her that R4 had grabbed her by the wrist and yanked on her arm. RN A was asked if staff was interviewed and the medical records of R12 and R4 were reviewed along with care plan reviews with new or revised interventions to minimize the risk of recurrence or protect other residents and RN A said, No. RN A was asked if the altercation was reported to the physician or if R12 received support visits or if any kind of corrective action was implemented. RN A said, No. RN A was asked if a pain assessment or skin assessment was conducted on R12 after the occurrence, RN A said, No. When asked what was being done to protect R12 from the repeated assaults by R4, RN A said the staff just keep reminding R12 that she is safe after the altercations occur. RN A was asked the names of the staff members who witnessed the altercation between R12 and R14 on 8/5/25. RN A said the responding staff members were Certified Nurse Aide (CNA) E, CNA G, and CNA B. RN A was asked if R12's care plan was updated and said no. CNA E was interviewed on 8/27/25 at 12:09 PM. CNA E said she could not recall the date the altercation occurred but said the event between R12 and R5 occurred around lunch. CNA E said she was at the nurses' station down the hall and observed R12 sitting on the seat of her 4-wheeled walker outside of the dining room doors at the end of the hall waiting for the dining room to open for lunch. CNA E said R4 was in front of R12 with a pillow in her hands. CNA E said, [R12] had a panicked look on her face and was backing up against the wall telling [R4] to get away from her. CNA E said R12 was frightened of R4 and she (CNA E) headed down the hall to assist because R12 had such a panicked look on her face. CNA E said she reported the situation to the DON after it occurred. CNA E said the DON was present in the facility when the altercation occurred. CNA B was interviewed on 8/27/2025 at 3:45 PM. CNA B said she did not remember the occurrence and said she was unable to recall if she worked on 8/5/25. CNA G was interviewed on 8/27/2025 at 3:49. CNA G said he did not work on 8/5/25. The schedule for 8/5/25 was provided by the DON on 8/27/25 at 3:59 PM. The schedule documented CNAs E, B, and G worked the day shift on 8/5/25. During an interview on 8/28/25 at 7:27 AM, RN A said the altercation between R12 and R4 occurred on 8/5/25 at approximately 3:00 PM – 3:30 PM. RN A said she was not present in the facility when the altercation occurred, but the DON was in the facility at the time. The DON was interviewed on 8/28/25 at 7:39 AM. The DON said she was exiting the facility on 8/5/25 when CNA E informed her of the altercation between R12 and R4. The DON said, I went to talk to [R12] but by the time I got down there she was lying down in bed, and I didn't want to bother her. The DON admitted she had not spoken with R12 after the occurrence with R4. The DON said she had RN A speak with R12 the following day, and RN A confirmed through interview with R12 that R4 had pulled on the wrist of R12. The DON was asked why the altercation was not investigated. The DON said, because I don't think it happened. The policy Abuse Policy dated as revised 6/1/24 read, in part: .Each resident has the right to be free from all types of abuse. The types of physical contact, which may constitute physical abuse, include, but are. Pulling or tugging on any part of the resident's body. The Charge Nurse is to do a thorough assessment of all residents involved. This will be done to evaluate for any injuries . A progress note will be entered to document the findings of this assessment. The primary doctor will be notified by the Charge Nurse. The Director of Nursing or designee will do a thorough investigation which includes interviewing all the people involved in the allegation, other residents, other staff members and any other pertinent people who may have knowledge of the allegations. A review of the patient's medical record will be included in the investigation. The Social Worker Director of Nursing or designee will assess any resident that is involved in allegations of abuse, neglect, exploitation, misappropriation or mistreatment. The Social Worker Director of Nursing or MDS Coordinator/RN Supervisor will make changes to the care plan as needed. Review of the MDS assessment, dated 5/21/25, revealed admission to the facility on 2/5/25, with active diagnoses that included dementia, and cerebrovascular accident (CVA)/Transient Ischemic Attack (TIA) or stroke. R6 scored a 7 of 15 on the BIMS assessment reflective of severe cognitive impairment. Resident #9 (R9) Review of the MDS assessment, dated 7/2/25, revealed admission to the facility on 6/18/25, with active diagnoses that included dementia. R9 scored a 3 of 15 on the BIMS assessment reflective of severe cognitive impairment. Review of R9's behavior note dated 7/3/25 at 9:47 p.m., read in part .Resident had been talked to multiple times this evening about inappropriately touching of another resident, myself and other staff and have asked him nicely to keep his hands to himself.he keeps looking at staff to see if watching and when not looking he gets closer to the resident and tries to touch and rub her leg and towards her private area. Review of R9's behavior note, dated 7/6/25 at 10:04 a.m. read in part .Resident was witnessed by staff this morning attempting to touch another resident inappropriately on the leg. Review of R9's behavior note, dated 7/10/25 at 10:40 a.m., read in part .Resident has been gravitating toward the female residents attempting to hold their hands and bring them to his room, rubbing their arms. Review of R9's behavior note, dated 7/16/25 at 3:18 p.m., read in part .Certified Nurse's Aide (CNA) F reported to writer that resident [R9] had his hand up the shirt of resident [R6]. During an interview on 8/28/25 at 10:47 a.m., Registered Nurse (RN)/Nursing Supervisor A reported that she had not completed any investigation, attained any witness statements, and did not have a report of the resident-to-resident altercation on 7/16/25. During an interview on 8/28/25 at 10:53 a.m., CNA F reported that R6 and R9 were in the hallway on 7/16/25 and he was seeking out other female residents.I saw R9 put his hand up R6's shirt and his hand was by her waist and stomach . I was not asked to write a statement of what I saw but I did report it to RN/Nursing Supervisor A . Review of policy titled Abuse Policy last revised 6/1/24, read in part . Conducting Investigations.in the event of suspected about/neglect, resident to resident altercations and all events that require further investigation the Director of Nursing (DON), RN Supervisor or designee will conduct a formal investigation.when staff are present during a shift or have witness and event .they are to write up a written statement.the written statement should be written as soon as the resident is/are stabilized and there is no potential for abuse or neglect.

Based on observation, interview, and record review the facility failed to obtain physician orders for the use of a catheter for one Resident (#21) of three residents reviewed for catheters.Findings include:Resident #21 (R21)Review of the Minimum Data Set (MDS) assessment, dated 6/5/25, revealed admission to the facility on 2/22/25 with active diagnoses that included depression and multiple sclerosis. R21 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition.During an observation on 8/26/25 at 12:25 p.m., R21 had a catheter bag that was located in a privacy bag.During an interview on 8/26/25 at 12:28 a.m., R21 stated, I was going to the bathroom a lot and they needed to help me.I was getting up at night and they put the catheter in me.I drink a lot of fluids as I have had urinary tract infections in the past and I don't want to get another one.Review of the Electronic Medical Record (EMR) revealed there was no physician order for an indwelling catheter for R21.During an interview on 8/27/25 at 1:24 p.m., Registered Nurse (RN)/Nursing Supervisor A acknowledged there was no order for an indwelling catheter for R21.Review of policy titled Catheter Insertion and Removal, last reviewed 12/24, read in part .Insertion of a catheter must have a physicians order.

Based on observation, interview, and record review, the facility failed to administer supplemental oxygen according to physician orders, change and date respiratory tubing, and maintain clean respiratory equipment for one Resident (R19) of three residents reviewed for respiratory services. Findings include: Resident #19 (R19) was admitted to the facility 3/16/22. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed R19 had moderately impaired cognition and received supplemental oxygen for a primary medical diagnosis of congestive heart failure.On 8/26/25 at 11:31 AM, R19 was observed sitting in a recliner in her room wearing an unlabeled/undated nasal cannula (a tube used to deliver supplemental oxygen). The undated tubing was attached to an oxygen concentrator set to a flow rate of 3 LPM (liters per minute). The oxygen concentrator was observed to be visibly soiled with dust and visual debris was evident on and around the concentrator. A note was taped to the oxygen concentrator that read: oxygen is PRN [as needed] on day shift. Leave machine on & [and] O2 [oxygen] cannula in place/in reach at all times. It is scheduled at night, ensure it is applied & machine is on.When queried regarding the last time the nasal cannula tubing was changed or the last time the concentrator was cleaned, R19 indicated she did not know.On 8/27/25 at 7:57 AM, R19 was sitting in the recliner, wearing supplemental oxygen via nasal cannula. The cannula tubing remained undated. The concentrator was set to deliver a flow rate of 2.5 LPM of supplemental oxygen. The concentrator was observed to be littered with dust and debris.On 8/27/25 at 1:55 PM, R19's nasal cannula tubing remained undated, and the oxygen concentrator continued to be visually covered with dust and debris. The oxygen concentrator was set to deliver 2.5 LPM of supplemental oxygen. The electronic medical record (EMR) of R19 disclosed a care plan for altered cardiovascular status with an intervention for the supplemental oxygen that read: OXYGEN SETTINGS [sic]: O2 via nasal canula @ [at] 2L [liters] at night, PRN during day if SOB [short of breath] or sats [SpO2 - peripheral capillary oxygen saturation which measures the percentage of oxygen in the blood] below 88% on RA [room air]. The documented SpO2 results on the medication administration record (MAR) of R19 on day shifts for the month of August were reviewed on 8/26/25. SpO2 ranged from 95% - 97% every day in August 2025. Further review of the EMR revealed a physician's order dated 10/7/24 that read: Change/label O2 tubing and bag weekly. Clean concentrator and filter weekly.On 8/27/25 at 2:18 PM, the oxygen tubing was noted to be labeled with a date of 8/27/25. The oxygen concentrator remained visibly soiled with dust and debris. On 8/27/25 at 2:18 PM, The Director of Nursing (DON) was asked to accompany the surveyor to R19's room. Upon entering the room, the DON was directed to the oxygen concentrator. The DON was asked the last time the concentrator and filter had been cleaned. The DON responded, Obviously this hasn't been cleaned in quite a while. The DON said concentrators and filters should be cleaned weekly or when visibly soiled. The DON was asked the flow rate of R19's oxygen and said the flow rate should be at 2 LPM. The DON noted the flow rate on the concentrator was set at 2.5 LPM and adjusted the concentrator to deliver 2 LPM of supplemental oxygen.The policy Oxygen/Oxygen Administration dated as last revised 7/25/25 read, in part: .Check the physician order for flow rate.Turn flow rate on to prescribed liter flow.Mark tubing with tape and date tubing. The oxygen nasal cannula, tubing and storage bag will be changed dated every week.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5 percent, with 12 errors identified, out of 41 medication administration opportunities observed. This deficient practice resulted in a medication error rate of 29.27 percent.Findings include: Errors 1 - 12. Resident #7 (R7) - During observation of preparation of oral and inhalation medications for R7 on 8/27/25 at 10:24 AM, Licensed Practical Nurse (LPN) D dispensed aspirin 81 milligrams (mg) one chewable tab, ferrous sulfate 325 mg one tab, ascorbic acid 500 mg one tab, sennosides-docusate sodium 8.6 mg / 50 mg one tab, guaifenesin extended release (ER) 600 mg one tab, topiramate 50 mg one tab, oxcarbazepine 600 mg one tab, desvenlafaxine ER 100 mg one tab, metoprolol succinate ER 25 mg one tab, and isosorbide mononitrate ER 30 mg half tab (15 mg) one tab. LPN D also dispensed two inhalers; fluticasone furoate and vilanterol one puff, and tiotropium bromide two puffs. LPN D completed her preparation for morning medication pass for R7 which included 0800 (8:00 AM) medications. LPN D dispensed all R7's medications to R7 in their room. LPN D returned to the medication cart and signed out R7's medications at 10:28 AM. On 8/27/25 at 10:30 AM, an interview was conducted with LPN D who was asked if she had enough time to administer all 29 residents' morning medications and replied, Well obviously not if those [R7's] medications were just given. Plus, with all the interruptions while giving morning meds. On 8/27/25 at 11:30 AM, an interview was conducted with Register Nurse (RN) A who was asked to review the time stamp on R7's medication administration record (MAR) for the morning of 8/27/25 and what time R7's medications were administered. RN A confirmed LPN D had administered all R7's 0800 medications at 10:28 AM. RN A was asked about medication administration times and how long of a window the nurses had for before and after a scheduled physician order to administer residents medication and replied, They [nurses] have an hour before and an hour after the scheduled time to administer medications on time. Review of R7's August 2025 MAR, revealed that R7's morning medications were ordered by the facility physician to be given at 8:00 AM and LPN D was approximately one hour and twenty-eight minutes late with medication administration to R7 on 8/27/25. On 8/28/25 at 10:00 AM, an interview was conducted with the Director of Nursing (DON) who was asked about medication administration and replied, I have no idea what [LPN D] is doing with her medication pass. When I or [RN A] work the floor, we have the medications passed on time. There is no excuse that the medications were given late. The DON confirmed that nurses are to follow the five rights of medication administration, and they are to be given on time.

Based on observation, interview, and record review, the facility failed to ensure safe storage of medications and labeling for one medication cart of one medication cart reviewed for medication storage. Findings include: On 8/27/2025 at 7:30 AM, in the main dining room an observation was made of a round circular orange pill lying on the main dining room floor with the imprint on one side an Xa and on the other side 15 and an upside-down triangle and identified as a Rivaroxaban. At the time the pill was observed there were 14 unidentified residents sitting in the dining room. Licensed Practical Nurse (LPN) D confirmed that the identified pill was rivaroxaban and was an anticoagulant which is a blood thinner medication that belonged to Resident #4. On 8/27/2025 at 11:30 AM, an interview was conducted with the Registered Nurse (RN) A who was made aware of the observation of the rivaroxaban lying on the main dining room floor during residents' morning breakfast and stated, That's not good especially that medication a blood thinner. RN A asked this Surveyor if the nurse [LPN D] dropped it and this Surveyor replied, No, the nurse [LPN D] and I [Surveyor] just entered and walked in the main dining to start medication pass and the pill was observed [by this Surveyor] on the floor when entering the main dining room. Review of the facility form 671, dated 8/26/25, revealed the facility had 29 residents on 8/27/25 and 17 of the 29 residents have had a dementia diagnosis. Review of policy titled, Storage of Medications, dated 11/26/24, read in part, Policy: 1. All medications shall be kept under locked storage, with access limited to authorized nursing personnel.

This deficiency pertains to Intakes #MI00153229 and #MI00152446 Based on observation, interview, and record review, the facility failed to prevent one Resident (#3) of eight residents reviewed for homelike environment related to personal property from entering the rooms and taking personal possessions of other residents. This deficient practice resulted in Residents #2, #4, & #5 experiencing fear of continued resident to resident abuse, frustration, and emotional distress and items being taken from #7 and #8. Findings include: On 6/4/25 at 10:15 AM, the doorways to residents' room were observed with mesh-type barriers with stop sign notifications on the barriers. The barriers extended across the doorways and were secured with Velcro on each end to the doorframes. The Director of Nursing (DON) said the barriers were utilized to prevent Resident #3 (R3) from entering the rooms of other residents. Resident #2 (R2) On 6/4/25 and 6/5/25, the door to R2's room was observed with a sign indicating Do Not Enter. The door to the room was closed with a mesh barrier secured across the doorway. R2 was interviewed on 6/4/25 at 3:33 PM. R2 said the sign on the door and the barrier across the doorway was intended to prevent R3 from entering the room and taking R2's belongings. R2 said R3 constantly entered the rooms of other residents and either destroyed their belongings or removed their belongings. R2 said she was fearful of R3 due to R3 physically harming R2 by striking her in the head a couple months ago when R2 tried to prevent R3 from entering her room and taking her belongings. A progress note in R2's Electronic Medical Record (EMR), dated 4/14/25 at 3:27 PM read, in part: .Resident had an altercation with resident [R3] today. [R3] was attempting to get into resident's room. Resident then pushed her away. [R3] then went to hit resident in the right ear and made contact . A Minimum Data Set (MDS) assessment dated [DATE] documented R2 had a Brief Interview for Mental Status (BIMS - a test for cognitive status) of 15, signifying R2 was cognitively intact. The MDS indicated the short-term and long-term memory of R2 were intact, and R2 had no concern with memory or recall ability. An admission MDS dated [DATE] documented R2's preferences for customary routine in Section F0400.B. The question: How important is it to you to take care of your personal belongings had a documented response of being very important to R2. Resident #4 (R4) R4 was interviewed on 6/5/25 at 9:31 AM. R4 said she had difficulties with R3. When asked to provide an example, R4 said a few weeks prior she heard the resident in the next room calling out for help. She went to the room next door and observed R3 removing items from the room. R4 said she attempted to stop R3 from removing the items and R3 placed her hands around R4's neck and began choking her. R4 said the encounter shook her up. R4 said R3 entered her room on previous occasions and tried to take her personal items. R4 said R3 continually entered the rooms of other residents and took their belongings. A progress note in the EMR of R4 dated 5/18/25 at 6:35 PM read, in part: .Resident visibly shaken after (choking) [sic] altercation with resident [R3]. Resident states that she was 'trying to help.' Resident assessed for marks or bruises, none found . A progress note dated 5/18 at 7:35 PM read, in part: . She states she is nervous about going to sleep, she was reassured that she is safe. She voiced frustration .Stop sign was placed across her door . The EMR disclosed R4 was admitted to the facility 2/22/25. An admission MDS dated [DATE] documented a BIMS score of 14 indicating R4 had intact cognition. The MDS documented R4's preferences for customary routine in Section F0400.B. The question: How important is it to you to take care of your personal belongings had a documented response of being very important to R4. The most recent MDS dated [DATE] documented R4 had intact short-term and long-term memory and had no issues with memory or recall ability. Resident #5 (R5) R5 was interviewed on 6/5/25 at 9:42 AM. R5 said R3 came into her room and dumped her potted plants and began picking up her personal items. R5 said she began screaming and R4 came to the room to help by stopping R3 from taking the personal items. R5 said R3 started choking R4 so R5 started screaming again to gain staff assistance. R5 said, I'm so scared of [R3]! She got in here once and she can get in here again. She hurts people. I'm scared she's going to come in here at night when fewer people are around. A progress note in the EMR of R5 dated 5/18/25 at 6:35 PM read, in part: . Resident shaken after witnessing altercation between 2 residents. Resident states that [R3] came into her room and dumped out flowerpots and was scattering Kleenex . R5 was admitted to the facility 2/14/25. An admission MDS dated [DATE] documented a BIMS of 10 indicating R5 was moderately cognitively impaired. The MDS did not document concern with short-term or long-term memory impairment or R5's memory or recall ability. The MDS documented R5's preferences for customary routine in Section F0400.B. The question: How important is it to you to take care of your personal belongings had a documented response of being Very Important to R5. Resident #7 (R7) R7 was interviewed on 6/5/25 at 8:20 AM. R7 said R3 goes into residents' rooms and takes their things. R7 said R3 tried to enter her room previously but R7 was able to redirect R3 and deter R3 from removing items from their room. R7 was admitted to the facility 10/5/23. An annual MDS dated [DATE] documented a BIMS of 15. The MDS documented R7's preferences for customary routine in Section F0400.B. The question: How important is it to you to take care of your personal belongings had a documented response of being Somewhat Important to R7. A quarterly MDS dated [DATE] supported a BIMS of 15 and indicated R7 had no concern with short-term and long-term memory, and no concern with memory or recall ability. Resident #8 (R8) R8 was interviewed on 6/5/25 at 8:31 AM. R8 said, [R3] likes to come in my room and take my things. R8 said about a month ago, R3 entered her room and tried to take something from the room. When R8 tried to stop R3 from taking her belongings, R3 struck R8 in the head. R8 said she reported it, but nothing ever came of it aside from staff placing the barrier across the doorway of the room. R8 was admitted to the facility 8/27/24. An admission MDS dated [DATE] documented R8 was cognitively intact with a BIMS of 14. The MDS documented R8's preferences for customary routine in Section F0400.B. The question: How important is it to you to take care of your personal belongings had a documented response of being Somewhat Important to R8. An MDS dated [DATE] documented R8 had no concerns with short-term or long-term memory and had no concerns with memory or recall ability. Resident #3 (R3) An interview was attempted with R3 on 6/4/25 at approximately 11:00 AM. R3 became agitated and said, Why don't you go **** yourself! R3 was admitted to the facility 12/2/24. An MDS dated [DATE] documented a BIMS of 3, signifying R3 had severe cognitive impairment. The MDS documented R3 had behaviors including physical behaviors directed toward others, verbal behavioral symptoms directed toward others and other behavioral symptoms. The MDS coded R3 with wandering behaviors. Review of progress notes revealed 49 entries regarding R3 removing items from the rooms of other residents and/or wandering into the rooms of other residents: 12/4/24 at 11:30 PM, 12/5/24 at 12:42 AM, 12/5/24 at 8:49 PM, 12/6/24 at 8:00 PM, 12/8/24 at 5:07 PM, 12/9/24 at 1:55 AM, 12/9/24 at 10:04 PM, 12/10/24 10:12 PM, 12/12/24 at 1:11 AM, 12/13/24 at 12:54 AM, 12/14/25 at 9:16 PM, 12/22/24 at 8:34 AM, 12/25/24 at 5:56 PM, 12/30/24 at 6:42 PM, 1/6/25 at 6:46 PM, 1/10/25 at 2:35 AM, 1/1725 at 2:52 AM, 1/17/25 at 10:13 PM, 1/24/25 at 1:36 AM, 1/26/25 at 3:00 PM, 1/31/25 at 2:46 PM, 2/3/25 at 6:06 PM, 2/12/25 at 6:13 PM, 2/16/25 at 3:39 AM, 2/22/25 at 2:59 AM, 2/23/25 at 12:12 PM, 2/24/25 at 6:07 PM, 2/25/25 at 5:58 PM, 2/25/25 at 11:39 PM, 3/2/25 at 12:54 AM, 3/2/25 at 8:30 PM, 3/4/25 at 6:12 PM, 3/8/25 at 2:56 AM, 3/9/25 at 9:11 PM, 3/10/25 at 10:44 PM, 3/11/25 at 6:17 PM, 3/13/25 at 1:24 AM, 3/19/25 at 9:06 PM, 4/1/25 at 2:53 PM, 4/2/25 at 10:10 PM, 4/6/25 at 8:58 PM, 4/9/25 at 7:37 PM, 4/12/25 at 8:53 PM, 4/13/25 at 7:17 PM, 4/13/25 at 8:43 PM, 4/15/25 at 1:22 PM, 4/16/25 at 6:21 AM, 4/23/25 at 2:37 PM, and 5/18/25 at 6:35 PM. A behavior note in the EMR of R3 dated 4/13/25 at 7:17 PM read, in part: .resident is in and out of many resident rooms and is causing residents to be upset. She is taking things from residents rooms and walking out of rooms with them. She has upset a couple residents that (2) of them have swatted towards her to get out of their rooms and have yelled at her . A progress note dated 2/16/25 at 3:39 AM documented, in part: . Resident not sleeping tonight and if left by herself she goes straight into someone's room waking them, cursing them if they tell her to get out . A behavior note dated 2/12/25 at 6:13 PM documented, in part: . Resident has been wandering in/out of other residents [sic] room this shift, going through other residents [sic] belongings. Other residents are getting angry/frustrated with this resident and staff as well . A progress noted dated 1/24/25 at 1:36 AM read, Resident has been awake all night thus far. She is not sleeping and has been in and out of multiple residents' rooms and waking them up as well as startling them as it is late hours, and they are asleep. Multiple unsuccessful attempts to redirect resident. During an interview on 6/5/25 at 8:56 AM, Certified Nurse Aide (CNA) E said she witnessed R3 get verbally aggressive toward other residents, including raising her voice to them and using profanity loudly to other residents. CNA E said, Other residents [NAME] out of [R3's] way and keep their distance to try and avoid her. CNA E said it is almost impossible to keep R3 from going into other residents' rooms and taking their things because R3 wanders the halls almost constantly. Licensed Practical Nurse (LPN) G was interviewed on 6/5/25 at 10:08 AM. LPN G said R3 went into other residents' rooms at all times of the day and night. LPN G said, It's impossible to keep up with her. She [R3] takes their [other residents] things, and they [other residents] get mad. I can't blame them - I'd be mad too. LPN G said one resident threatened to hit [R3] because he was annoyed with R3 going into his room. The Director of Nursing (DON) was not available in the facility on 6/5/25. The Assistant Director of Nursing (ADON) was interviewed on 6/5/25 at 11:01 AM. When asked what was being done to keep R3 from going into residents' rooms and taking their belongings, The ADON said, I can't answer that - I don't have an answer. The ADON then said, Staff keep an eye on [R3] and get her out of residents' rooms when they see [R3] going into the rooms. When asked if residents in the facility have the right to maintain their personal possessions without fear of their possessions being destroyed or taken by another resident, the ADON replied, Yes - they absolutely have that right. The undated document issued by the Michigan Long Term Care Ombudsman Program My Rights as a Resident of a Nursing Home stated, in part: . My rights as a resident of a nursing home are guaranteed by both federal and state laws. The laws require nursing homes to promote and protect the rights of each resident and place a strong emphasis on individual dignity and choice. Living in a nursing home, I maintain all rights I had before becoming a resident of the home . I have the right to . privacy .live in a clean and safe space . Be free from verbal and physical abuse .

This deficiency pertains to Intakes #MI00152446 and #MI00153229 Based on interview and record review, the facility failed to ensure three Residents (#2, #4, and #7) of five residents reviewed for abuse were free from physical abuse by another Resident (#3) with a documented history of physical abuse of others. This deficient practice resulted in R2 and R4 experiencing fearfulness, frustration, and emotional distress, and R7 experiencing fear, pain and sustaining reddened areas on the neck after a choking event. Findings include: Two facility-reported incidents (FRI) regarding resident-to-resident altercations were reported to the state agency. #MI00152446 was reported on 4/14/25 and #MI00153229 was reported on 5/18/25. Both FRI listed Resident #3 (R3) as being involved in physical altercations with other residents. Intake #MI00152446 reported, in part: . DON [Director of Nursing] received call from RN [Registered Nurse] Supervisor that there was a resident-to-resident altercation. [Resident #2 (R2)] was sitting outside her room on her walker by her door. [R3] attempted to get into [R2] room. [R2] pushed [R3] away from door, RN Supervisor saw [R3] swing and hit [R2] in the side of head . R2 An interview was conducted with R2 on 6/4/25 at 3:33 PM. R2 said a couple of months ago she was sitting on the seat of her walker in the hallway outside her room waiting for the dining room to open. R2 said R3 tried to enter R2's room. R2 said when she tried to stop her, R3 hit her in the head with a closed hand and pulled on her arm which resulted in pain. R2 said she was afraid of R3 and feared she could be physically harmed again by R3. A progress note in R2's Electronic Medical Record (EMR), dated 4/14/25 at 3:27 PM read, in part: .Resident had an altercation with resident [R3] today. [R3] was attempting to get into resident's room. Resident then pushed her away. [R3] then went to hit resident in the right ear and made contact . A Minimum Data Set (MDS) assessment dated [DATE] documented R2 had a Brief Interview for Mental Status (BIMS - a test for cognitive status) of 15, signifying R2 was fully-cognitively intact. The MDS indicated the short-term and long-term memory of R2 were intact, and R2 had no concern with memory or recall ability. During an interview with Certified Nurse Aide (CNA) I on 6/5/25 at 11:48 AM, CNA I said he was present when R3 hit R2 in the hallway on 4/14/25. CNA I said R2 was sitting in the hallway outside her room and R3 tried to go into R2's room. R2 tried to stop R3 from entering the room and R3 hit R2. CNA I said, [R2] was pretty shaken up. CNA I said there were residents who were afraid of R3 because R3 was difficult to redirect. CNA I denied receiving resultant education after the resident altercations involving R3. When asked how staff knew what interventions to implement when R3 had increased behaviors, CNA I admitted there were no specific instructions or guidelines for staff to follow when R3 posed behavioral difficulties. Intake #MI00153229 reported, in part: . staff members were finishing up report and heard [Resident #5 (R5)] yelling for help. [Name of nurse redacted] and both NOC [night] shift CNAs went to her room to see what was going on. Upon entering room [R3] was seen with her hands on [Resident #4 (R4)] neck. [CNA] redirected [R3] out of room. It was noted that there were flowerpots dumped out in sink and tissues scattered on floor . R4 R4 was interviewed on 6/5/25 at 9:31 AM. R4 said a few weeks prior she heard R5 screaming for help from the room next door to R4's room. R4 went to R5's room and observed R3 removing items from the room. R4 said she attempted to stop R3 from removing the items and R3 placed her hands around R4's neck and began choking her. R4 said the encounter shook her up. A progress note in the EMR of R4 dated 5/18/25 at 6:35 PM read, in part: .Resident visibly shaken after (choking) [sic] altercation with resident [R3] . A progress note in the EMR of R4 dated 5/18/25 at 7:35 PM read, in part: . She states she is nervous about going to sleep, she was reassured that she is safe. She voiced frustration .Stop sign was placed across her door . The EMR disclosed R4 was admitted to the facility 2/22/25. An admission MDS dated [DATE] documented a BIMS score of 14 indicating R4 had intact cognition. The MDS revealed R4 had intact short-term and long-term memory and had no issues with memory or recall ability. R5 R5 was interviewed on 6/5/25 at 9:42 AM. R5 confirmed the statement provided by R4. R5 said R3 came into her room and dumped her potted plants then began picking up her personal items. R5 said she began screaming and R4 came to the room to help by stopping R3 from taking the personal items. R5 said R3 started choking R4 so R5 started screaming again to gain staff assistance. R5 said, I'm so scared of [R3]! She got in here once and she can get in here again. She hurts people. I'm scared she's going to come in here at night when fewer people are around. A progress note in the EMR of R5 dated 5/18/25 at 6:35 PM read, in part: . Resident shaken after witnessing altercation between 2 residents. Resident states that [R3] came into her room and dumped out flowerpots and was scattering Kleenex . CNA H was interviewed on 6/5/25 at 11:30 AM. CNA H said she was the CNA who responded to the event with R3 choking R4. CNA H said she heard R5 yelling for help and went immediately down the hall to the room and saw R3 choking R4. CNA H said she had to remove R3's hands from around R4's neck and then removed R3 from the room. CNA H said R4 and R5 were very upset by the incident. CNA H said she did not receive staff education after the altercation. Resident #7 (R7) R7 was interviewed on 6/5/25 at 8:20 AM. R7 said she was assaulted by R3 in the cafeteria when R3 approached her and started choking her. R7 said she had to pry R3's fingers off her neck. She said her neck hurt and she had red marks across her neck from R3's hands squeezing her neck. R7 said the attack was unprovoked. R7 said she was shocked by the incident but denied being fearful of R3. A progress note in the EMR of R3 dated 4/16/25 at 3:27 PM documented, in part: I was in the resident dining room .my back was to [R7] . I turned around and saw [R3] standing by [R7] and saying something I could not understand, but I could see the mad expression on [R3] face. I went over and told [R3] to be nice and not to touch anyone . I asked [R7] what had happened, and she stated that she had told [R3] to get away from her and then [R3] put her hands around [R7] neck . [R7] stated it hurt when [R3] squeezed her neck .I looked at [R7] neck and did see a red mark on each side of her neck. [R7] stated that she had tried to pull [R3] hands away, but it was hard to do . Activity Aide (AA) F was interviewed on 6/5/25 at 9:21 AM. AA F said R3 was aggressive with a lot of residents at certain times because R3 doesn't like to be told no and does not like to be redirected from the rooms of other residents. AA F said she was the employee in the dining room on 4/16/25 when R3 choked R7, and authored the progress note in R3's medical record on 4/16/25 at 3:27 PM. When asked regarding R7's reaction to the choking, AA F said R7's neck had reddened marks on both sides of her neck and R7 verbalized pain after the incident. AA F admitted there were residents in the facility who were afraid of R3 but said R7 told her she was not frightened of R3. AA F said she did not recall receiving education after the resident altercation. Resident #8 (R8) On 6/4/25 at 10:15 AM, the doorway to R8's room was observed with a mesh-type barrier with a stop sign notification on the barrier. The barrier extended across the doorway and was secured with Velcro on each end to attach each end of the barrier to the doorframe. R8 was interviewed on 6/5/25 at 8:31 AM. R8 said, [R3] likes to come in my room and take my things. R8 said about a month ago, R3 entered her room and tried to take something from the room. When R8 tried to stop R3 from taking her belongings, R3 hit R8 in the forehead. R8 said she reported it, but nothing ever came of it aside from staff placing the barrier across the doorway of the room. R8 denied being fearful of R3 and said she was not injured when she was struck by R3. There were no progress notes or mention in R8's EMR of R3 striking R8. On 6/5/25 at 8:40 AM, the Assistant Director of Nursing (ADON) was asked about the allegation conveyed by R8 that R3 had hit her. The ADON said nursing leadership had not been made aware of R8 saying she was hit by R3. R3 On 6/4/25 at approximately 10:15 AM, R3 was observed ambulating in the hallway. A staff member accompanied R3 with a hand around R3's arm to redirect the resident when R3 attempted to enter the rooms of other residents. An interview was attempted with R3 in her room on 6/4/25 at approximately 11:00 AM. R3 became agitated and said, Why don't you go **** yourself! Review of the EMR of R3 revealed an admission date of 12/2/24. The diagnoses of R3 included a diagnosis of severe vascular dementia with agitation. The most recent MDS, dated [DATE], documented a BIMS score of 3, signifying R3 had severe cognitive impairment. The MDS documented R3 had behaviors including physical behaviors directed toward others, verbal behavioral symptoms directed toward others, wandering and other behavioral symptoms. Further review of the EMR disclosed instances of physical altercations toward other residents perpetrated by R3. A behavior note in R3's EMR on 1/31/25 at 1:09 AM documented, in part: .resident to resident .where this resident smacked other said resident across LEFT [sic] side face .both residents need to be kept away from each other as best to avoid further altercations. An Alert Note in the EMR dated 2/18/25 at 9:30 AM read: Resident approached another resident this AM and started talking to her, she then put both her hands around her neck and began choking her. The two residents had to be separated by staff. This resident was escorted to the Day Room so that she could calm down. A progress note dated 4/14/25 at 3:29 PM reported, in part: . Resident was attempting to get into [R2] room, [R2] pushed resident away. This aggravated [R3] and she hit [R2] on the right side of the head . A behavior note of 5/18/25 at 6:35 PM documented, in part: This writer heard yelling and witnessed resident with her hands around another resident's neck. Resident taken out of room by CNA x 2 and multiple attempts to redirect were unsuccessful, resident was becoming verbally aggressive and trying to enter other residents' rooms. Resident became aggressive with CNA and multiple attempts to redirect were unsuccessful, resident was becoming verbally aggressive and trying to enter other residents' rooms. Resident became aggressive with CNA. Resident currently 1 on 1 [1:1 - oversight by a dedicated caregiver] in her room A report by the facility's contracted provider of psychiatric services dated 3/28/25 documented, in part: . [R3] poses a threat to herself and others due to her behavior . During an interview on 6/5/25 at 8:56 AM, CNA E said she witnessed R3 get verbally aggressive toward other residents, including raising her voice to them and using profanity loudly to other residents. CNA E said, Other residents just [NAME] out of [R3] way and keep their distance to try and avoid her. CNA E said it was almost impossible to keep R3 from going into other residents' rooms and taking their things because R3 wandered the halls almost constantly. Licensed Practical Nurse (LPN) G was interviewed on 6/5/25 at 10:08 AM. LPN G said R3 went into other residents' rooms at all times of the day and night. LPN G said, You can't keep up with her. She [R3] takes their [other residents] things, and they [other residents] get mad. I can't blame them - I'd be mad too. LPN G said one resident threatened to hit [R3] because he was annoyed with R3 going into his room. LPN G admitted there were residents who were afraid of R3 and specifically mentioned R4 was frightened of R3. LPN G said R3 could pose a danger to other residents. LPN G said R3 only received 1:1 care a few hours a day 5 days per week and R3's behaviors were ramping up and worsening. CNA J was interviewed on 6/5/25 at 11:59 AM. CNA J said, [R3] always goes into other people's rooms and takes things. She is excessive and gets upset when we tell her she can't go into their rooms and taking their stuff. She for sure needs somebody with her all the time. CNA J said the 1:1 was not working because R3 doesn't always have 1:1 care. CNA J said R3 yelled and swore at the other residents and a lot of residents were frightened of R3. CNA J said residents appeared to cower when R3 walked near them. CNA J said, Someone would need to be with [R3] all the time to keep the residents safe. CNA J said they did not have access to specific resident-centered interventions when R3 had increased behaviors. An interview statement was provided by Confidential Employee (CE) K on 6/5/25 at a time not disclosed to protect confidentiality as requested. CE K said, The only reason [R3] is on 1:1 supervision with staff right now is because the state is here. CE K said, [R3] gets triggered just by looking at her, and asserted the residents in the facility were afraid of R3. The Director of Nursing (DON) was not available in the facility on 6/5/25. The ADON was interviewed on 6/5/25 at 11:01 AM. The ADON said she was the nurse who witnessed the altercation between R3 and R2 on 4/14/25. The ADON said she was in the hallway and witnessed R3 try to get into R2's room. When R2 pushed R3 away from the door of the room, R3 hit R2 in the head. The ADON said she ran down the hall and broke up the altercation and R3 was placed on 1:1 care. The ADON said R2 was upset and crying and a CNA sat with R2 to calm her down. The ADON was asked how R3 choked R7 in the dining room on 4/16/25 if R3 was 1:1 with personal oversight by a staff member after physically hitting R2 on 4/14/25. The ADON said she didn't know but employees who provided oversight through 1:1 were required to document resident activity on a facility form. The ADON was asked to provide the form. The ADON left the interview to obtain the form but returned and said there was no documentation and the 1:1 ended before the choking event of R7 on 4/16/25. The ADON said a care plan was developed by the DON after the choking event of R7. The care plans of R3 were reviewed with the ADON. A care plan focus dated as created and initiated 4/16/25 read: I have the potential to be physically aggressive towards other residents and staff r/t anger, dementia, history of harm to others, poor impulse control. An intervention initiated 5/19/25 read [R5] is nervous when I am around d/t [due to] verbal altercation, please keep me out of her room. Another intervention dated 5/19/25 read: I have become physically aggressive with [R4], please monitor me when I am out and about and ensure that I am not entering her room. A care plan dated 12/19/24 had a focus that read: I have a behavior problem r/t [related to] wandering and entering other residents' rooms. The care plan had an intervention dated as initiated 2/19/25 for 15-minute checks continuously. The care plan was dated as resolved 3/16/25. When the ADON was asked the reason 15-minute checks were discontinued, the ADON said she wasn't sure and said the checks were probably discontinued because they weren't working. When asked what interventions were put in place on 3/16/25 to protect the residents in the facility if the 15-minute checks weren't working, the ADON responded, I don't have an answer to that. A care plan dated 12/19/25 had a focus that read: I have an ADL self-care performance deficit r/t confusion had an intervention dated as initiated 3/1/25 that read: Keep me away from residents [R2] and [R7]. We do not get along at times. The ADON was asked how interventions were evaluated and revised after each alleged or verified abuse occurrence. The ADON said R3's care plans were updated to keep R3 away from residents with whom R3 had altercations. The ADON was asked what was done proactively to protect all the residents in the facility from physical abuse by R3. The ADON said staff was expected to keep redirecting R3. When asked if redirection was successful in protecting the residents, the ADON said, Sometimes it is. The ADON said R3 was currently on continuous 1:1. The care plans for R3 did not document continuous 1:1, rather the care plan for physical aggression contained an intervention dated 4/16/25 that read, in part: Provide me with 1:1 during hours that I'm feeling more agitated, which is typically between 1500-2100 [3:00 PM - 9:00 PM] . The investigations submitted to the state agency (#MI00152446 and #MI00153229) were reviewed with the ADON. The investigation for #MI00152446 related to R3 hitting R2 on 4/14/25 documented, in part: .All staff have been educated on updates to care plans for both resident . The investigation for #MI00153229 regarding R3 choking R4 documented, in part: .All staff continue to be educated on behaviors and if they see any change in [R3] mood or increase wandering, they are to provide 1:1 until behaviors resolve . The ADON was asked for the education referenced in #MI00152446 and #MI00153229. An education document dated 4/16/25 was provided and reviewed. The document reflected required attendees were All Staff. There were 11 signatures on the document. The ADON was asked if 11 individuals constituted all staff. ADON said, No. When asked if there was additional documentation of all staff education, the ADON said, No. An education form dated 5/21/25 was reviewed with the ADON. The required attendees' section of the form listed LPN's and CNA's. The section of the form for participant attendance contained the signatures of six employees. The ADON was asked if the facility had a total of six LPNs and CNAs. The ADON said, No, there's a lot more than that. An employee schedule titled Long Term Care Bi-Weekly Schedule dated 5/25/25 through 6/7/25 contained the names of licensed nurses and CNAs in the facility. The ADON confirmed all nurses and CNAs employed by the facility were listed on the schedule. There were a total of 27 nurses and CNAs listed as current employees excluding the DON and ADON. The policy titled Abuse Policy dated as revised 6/1/24 documented, in part: . Each resident has the right to be free from all types of abuse . The [name of facility redacted] has a great interest in protecting residents and patients from abuse, neglect, exploitation, misappropriation or mistreatment no matter who is responsible for the harm . The [facility] is responsible for protecting all residents from nonemployees whenever it has or should have reasonably had a warning of the potential problem . All employees will be trained through orientation and on-going sessions on issues related to abuse prohibition practices such as: i. appropriate interventions to deal with aggressive and/or catastrophic reactions of residents . The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation is more likely to occur. i. Including an analysis of . 4. the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms .

Based on interview and record review, the facility failed to provide written notification of the facility bed hold policy for four Residents/Resident Representatives (R1, R4, R8, and R16) of four residents reviewed for notice of bed hold policy. Findings include: Review of the facility Electronic Medical Record (EMR) confirmed that R1 was discharged from the facility on 8/19/24 Review of the facility EMR confirmed R4 was discharged from the facility on 8/9/24 to acute care Review of the facility EMR confirmed R8 was discharged from the facility on 8/19/24 to acute care Review of the facility EMR confirmed R16 was discharged from the facility on 8/9/24 to acute care During an interview on 10/25/24 at 7:48 a.m., the Chief Nursing Officer A stated, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) B take care of all .discharges, we do not have a social worker. During an interview on 9/25/24 at approximately 10:20 a.m., Administrative Assistant F stated, we have not given or sent a bed hold policy letter to residents or families since July of 2022 .I mail out all the information. During an interview on 9/26/24 at 8:33 a.m., the Chief Nursing Officer A stated, I don't believe we have completed notifications of bed hold policy or transfers in quite some time .I doubt we will be able to find anything. During an interview on 9/26/24 at 9:42 a.m., the Assistant Director of Nursing (ADON) B stated, we do not have any bed hold or transfer forms, we didn't know we had to do that .we do not have a bed hold policy. Review of facility policy titled Discharge and Transfer - Resident last revised on 7/21/24, read in part . purpose .transfer to medical surgical unit . to another facility other than an acute care hospital .for discharge .LPN/Social work designee notifies the family and/or guardian of the facility bed holding policy . The facility did not provide this Surveyor a bed hold policy before exit.

Based on observation, interview, and record review, the facility failed to ensure freedom from physical restraints for one Resident #10 (R10) of one resident reviewed for restraints. This deficient practice resulted in the restriction of freedom of movement, physical discomfort, and psychosocial distress. Findings include: Resident #10 (R10) Review of R10's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: Parkinson's disease, hypertension, dementia, and hyperlipidemia. R10 scored a 15 of 15 on the Brief Interview of Mental Status (BIMS) reflective of intact cognition. Review of R10's care plan last revised 5/4/24, read in part .Wander guard to left ankle to alert staff when I am near an exit door. During an interview on 9/26/24 at approximately 9:15 a.m., R10 stated, I don't know why that thing is on my ankle .it is tight on my ankle though and uncomfortable. During a review of R10's Elopement Risk Evaluation dated 8/30/24 revealed R10 scored a 1 out of 11 on the risk assessment, reflective of R10 being a low risk for elopement. During an interview on 9/26/14 at 9:42 a.m., Assistant Director of Nursing (ADON) B stated, R10 has the wander guard on her ankle to turn her around when she is by the door at the end of the hallway . she has never tried to leave .I cannot find a policy on wander guard's or a restraint policy . we don't have one. Review of facility policy titled Abuse Policy, read in part .the following actions or omissions constitute neglect whenever they result in a noticeable deterioration of the residents physical, mental or emotional wellbeing .leaving a resident restrained.

Based on observation, interview, and record review, the facility failed to implement appropriate interventions to prevent unsafe wandering and elopement for two Residents (#R9 and #R7) of two residents reviewed for elopement. This deficient practice resulted in continued unsafe supervision and two elopements from the facility. Findings include: This citation pertains to the intake #MI00147126 Resident #9 (R9) Review of R9's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: dementia, anxiety, depression, and hypertension. R9 scored a 14 of 15 on the Brief Interview of Mental Status (BIMS) reflective of intact cognition. Review of the Facility Reported Incident (FRI) dated 9/17/24, revealed that a Licensed Practical Nurse (LPN) who was backing up out of parking spot at 7:30am and saw resident in the parking lot. Further review of the FRI revealed that the door alert system did not alarm due to R9 removing her tether. The doors leading to the dining room were open for breakfast. R9 was seen by a LPN at 7:20 a.m. Review of the video footage revealed resident exited to the outside at 7:30 and remained near the door until 7:33a.m. Video footage revealed that R9 was being escorted back into the facility at 7:34 a.m. Review of the facility document titled Incident Report dated 9/17/24, revealed that R9 is independent in ambulatory status. The incident had occurred at 7:30a.m. and the incident was discovered at 7:34 a.m. There were no witnesses. During an interview on 9/24/24 at approximately 1:20p.m., The Chief Nursing Officer A demonstrated where the resident had eloped. The Chief Nursing Officer A stated, if the resident was wearing a tether, then alarm would have gone off .I don't know why the two exit doors down the hallway would not alarm when opened. During an observation on 9/25/24 at 11:48 a.m., revealed two doors opened at the end of the hallway with no staff present. R9's bedroom door was located two rooms away from the opened doors. When exiting the opened doors and turning left there was a short hallway that led to an exit door. When turning to the right from the exit door there was another short hallway that led to a second exit door that when opened led to the parking lot. During an interview on 9/25/24 at 11:56 a.m., R9 stated, I was trying to get out of the facility, and I made it . I know how to get out of here again because I can shut the alarm off on my door, it's just a little switch .I left because I wanted to go outside and see the flowers .I told them I chewed that bracelet off, but I used clippers . During an observation at 12:05 p.m., R9 opened her bedroom door and reached for the alarm at the top of her door to shut it off. This citation pertains to MiFri #57798 Resident #7 (R7) Review of R7's MDS assessment dated [DATE] revealed admission to the facility on [DATE], with active diagnoses that included dementia, diabetes mellitus, and renal insufficiency/renal failure/end stage renal disease (ESRD). R7 scored a 00 on the BIMS assessment reflective of severe cognitive impairment. Review of facility document titled Incident Report dated 9/25/24, revealed that at 5:26 p.m., R7 was found down a hallway near the emergency room (ER) doors of the hospital adjacent to the facility. The double doors at the end of the hallway leading to the dining room were opened and the resident exited during mealtime. One of the facility staff was in the dining room and the other staff were in resident rooms providing care. During an interview on 9/26/24 at approximately 8:00 a.m., Chief Nursing Officer A and Assistant Director of Nursing (ADON) B revealed that R7 had eloped from the facility. Chief Nursing Officer A stated, R7 went out the same doors as R9 did but turned to the right and walked down the hallway and was found by hospital staff . he had a tether, and the alarm was going off. During an observation on 9/26/24 at approximately 9:00 a.m., R7 had walked approximately 150 steps and passed 5 exits from the building before being observed by hospital staff walking down the hallway. During an interview on 9/26/24 at 9:44 a.m., Certified Nurse Aide (CNA) H stated, I didn't hear the alarms from the room I was in .the pager would alert me when the alarms go off .I keep the pager in the office as it doesn't work down the hallway anyway . I heard the alarm go off when I stepped in the hallway and saw someone bringing R7 back . I don't know how long R7 was gone. Review of Facility Policy titled Safety last revisited 6/1/24, read in part . exit door leading out of the facility are equipped with an alarm for residents who wear a tether.

Based on interview and record review, the facility failed to ensure behavioral health services were provided for one Resident #9 (R9) of three residents reviewed for behavioral health services. Findings include: Resident #9 (R9) Review of R9's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: dementia, anxiety, depression, and hypertension. R9 scored a 14 of 15 on the Brief Interview of Mental Status (BIMS) reflective of intact cognition. Review of R9's behavior notes with the following dates: read in part . 7/29/24, resident made several statements about her extreme guilt she was feeling, regarding certain events in her life .wanting to remain in her room and not come out. 7/30/24, resident has remained in her room today and refused to come out or turn on her tv, which she enjoys watching. Resident normally comes to the dining room for two meals a day. 8/3/24 resident came to nurses station agitated and having racing thoughts, requesting to call the police related to an incident that happened years ago . 8/5/24 resident continues with self-punishment related to her description of herself as I am a liar, I have done bad things and I cannot look anyone in the eye . 8/11/24 resident states, I don't deserve to live 8/20/24 resident pointing to multiple residents telling them, you are going to die . 8/22/24 resident up in hallway yelling we are all going to die because of her and saying she is coming out of her skin. 8/29/24 resident has been up and down all night yelling out in the hallways HELP! HELP! 8/30/24 R9 is very anxious and restless. 9/8/24 Resident started to go into other resident's rooms just before shift change. Resident started yelling out help help .everyone is going to die. During an interview on 9/25/24 at 7:48 a.m., the Chief Nursing Officer A stated, we do not have a social worker/designee for the residents here . we do not have any contract with any behavioral support agency . During an interview on 9/25/24 at 12:29 p.m., the Assistant Director of Nursing (ADON)B stated, R9's moods an behaviors have changed so much .we have not looked into a change of condition, reassessed her BIMS, we haven't added any new interventions into her care plan when her moods and behaviors changed, and we have not sent a referral to Behavioral Care Solutions (BCS) or any outside agencies to assess the change in behaviors . Review of Facility Assessment (FA) read in part .facility resources needed to provide competent support care for our resident population .behavioral and mental health providers, referrals to outlying providers . Review of facility policy titled Behavioral Program last reviewed 1/18/23, read in part . to ensure that residents with increased behaviors are identified and have interventions in place to prevent episodes of verbal or physical aggression .behavioral plan will be reviewed as needed.

Based on interview, and record review the facility failed to provide social services for two Residents #3 (R3) and #9 (R9) of three residents reviewed for social services. This deficient practice resulted in the potential for psychosocial decline. Findings include: Resident #3 (R3) Review of R3's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included depression, anxiety disorder, malnutrition, and hypertension. R3's mood interview revealed R3 had little interest or pleasure in doing things nearly every day, R3 felt down, depressed, or hopeless nearly every day and R3 felt bad about their self or felt they were a failure or felt they have let their self or their family down nearly every day. During an interview on 9/23/24 at 3:48 p.m., R3 stated, I have fears about things .and no one has come to see me or talk about my fears .there are things that have happened to me in the past . no one has talked with me about wanting to live near my brother. Review of R3's social service notes revealed no social service assessment, no social service notes, and no plans for R3's discharge. Resident #9 (R9) Review of R9's (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: dementia, anxiety, depression, and hypertension. R9 scored a 14 of 15 on the Brief Interview of Mental Status (BIMS) reflective of intact cognition. Review of R9's behavior with the following dates: 7/29/24, read in part .resident made several statement about her extreme guilt she was feeling, regarding certain events in her life .wanting to remain in her room and not come out. 7/30/24 resident has remained in her room today and refused to come out or turn on her tv, which she enjoys watching. Resident normally come to the dining room for two meals a day. 8/3/24 resident came to nurses station agitated and having racing thoughts, requesting to call the police related to an incident that happened years ago . 8/5/24 resident continues with self-punishment related to her description of herself as I am a liar, I have done bad things and I cannot look anyone in the eye . 8/11/24 resident states, I don't deserve to live 8/20/24 resident pointing to multiple residents telling them, you are going to die . 8/22/24 resident up in hallway yelling we are all going to die because of her and saying she is coming out of her skin. 8/29/24 resident has been up and down all night yelling out in the hallways HELP! HELP! 8/30/24 R9 is very anxious and restless. 9/8/24 Resident started to go into other resident's rooms just before shift change. Resident started yelling out help help .everyone is going to die. During an interview on 9/25/24 at 7:48 a.m., the Chief Nursing Officer A stated, we do not have a social worker/designee for the residents here . Review of facility policy titled Social Service Procedure last reviewed 12/5/22, read in part .the social service designee will complete the admission assessment within one week of the residents admission .interview the resident and inform the resident of the social services that are available .on going assessment of the residents adjustment to the facility and therapeutic intervention if problems arise .the social worker designee may assist the resident .in finding and utilizing .mental health services .in addition to the social history, the social work designee will maintain progress notes in the residents medical record .if resident is able to be discharged from the facility, the social work designee will assist in planning alternative living arrangements.

Based on interview, and record review, the facility failed to obtain informed consent for psychotropic medications for two Residents (#7 and #9) out of three residents reviewed for unnecessary psychotropic drug use. Findings include: Resident #7 (R7) Review of R7's face sheet, printed on 9/25/24, revealed admission to the facility on [DATE] with medical diagnoses including diabetes mellitus, dementia, and insomnia. R7's face sheet and medical records revealed a Durable Power of Attorney (DPOA) was activated and was not their own person. Review of R7's Minimum Data Set (MDS) assessment, dated 7/11/24, section C - cognition, revealed R7 had a Brief Interview for Mental Status (BIMS) that was unable to be completed and a score of 00 which indicated severe cognitive impairment. Review of physician order, read in part, Risperidone oral tablet 0.5 mg (milligram), give 1 tablet by mouth at bedtime related to dementia ., started on 4/3/24. Review of physician order, read in part, Risperidone oral tablet 1 mg, give 1 tablet by mouth two times a day related to dementia ., started on 5/28/24. On 9/26/24 at 11:35 AM, an interview was conducted with the (Assistant Director of Nursing) ADON. The ADON was asked if she had obtained informed consent from the family for R7 being placed and or increased risperidone. The ADON replied, I do not have a signed consent for R7 and was not aware that one needed to be obtained. The ADON confirmed that the facility did not have an acting Social Services Director at the time of the abbreviated survey. Resident #9 (R9) Review of R9's face sheet, printed on 9/25/24, revealed admission to the facility on [DATE] with medical diagnoses including hypertension, dementia, and depression. R9's face sheet and medical records revealed they were their own person. Review of R9's MDS assessment, dated 7/14/24, section C - cognition, revealed R7 had a Brief Interview for Mental Status (BIMS) that was unable to be completed and a score of 14 which indicated intact cognition. Review of physician order, read in part, haloperidol injection solution 5 mg, give 2.5 mg intramuscularly one time only related to anxiety disorder for one day ., started on 9/17/24. Review of physician order, read in part, lorazepam oral tablet 0.5 mg, give 1 tablet by mouth two times a day for anxiousness/restlessness ., started on 9/17/24. On 9/26/24 at 10:45 AM, an interview was conducted with the ADON. The ADON was asked if she had obtained informed consent from the resident R9 before being placed/given lorazepam or haloperidol. The ADON replied, I do not have a signed consent for R9 and was not aware that one needed to be obtained. The ADON confirmed that the facility did not have an acting Social Services Director at the time of the abbreviated survey. Review of policy, titled Psychotropic Medication Use, dated 8/6/24, read in part, Purpose: Physicians and providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring .Notify family/responsible party of any changes in medications .

Based on interview and record review, the facility failed to implement rehab services for one Resident #3 (R3) of three residents reviewed for rehab services which resulted in a delay in assessment, treatment and a decline in physical mobility. Findings include: Resident #3 (R3) Review of R3's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included depression, anxiety disorder, malnutrition, and hypertension. Review of MDS Section O-Special Treatments and Programs revealed zero minutes from Occupational Therapy (OT) and zero minutes from Physical Therapy (PT). Review of Discharge Summary from UP Health Systems [NAME] dated 8/26/24, read in part . Discharge Plan . physical deconditioning continue PT/OT. Review of facility Progress note dated 8/27/24, read in part . History and Physical (H & P) [Resident] continues to have weakness and gait difficulties and is quite deconditioned. [Resident] needs aggressive PT and OT. During an interview on 9/23/24 at 3:48p.m., R3 stated, I have not been seen by rehab, I want to walk and I need more assistance .I can't sit up by myself and I know I am getting weaker .I am afraid I will end up in a wheelchair and never improve .the staff said I can do more for myself but I can't. I have fallen because I am getting weaker. During a follow-up interview R3 stated, My balance is getting worse .I wobble when I walk .I am afraid of falling and hurting myself. During an interview on 9/24/24 at 2:08p.m, The Assistant Director of Nursing (ADON) B stated, The physical therapist and occupational therapist are on off and cannot be reached. During an interview on 9/24/24 at approximately 3:00p.m., Administrative Assistant F stated, I cannot find any therapy notes or assessment regarding R3 .I cannot find her admission paperwork. During an interview on 9/24/24 at 4:13 p.m., Chief Nursing Office A stated, There are standing orders for PT/OT .the Director of Nursing (DON) reviews the admission paperwork to ensure the Doctors orders are followed up on . I don't know where the admission paperwork is for R3 .there was a delay in therapy services for R3. During a phone interview on 9/25/24 at 8:03a.m., the DON stated, I don't remember when R3 was first admitted or if I reviewed her paperwork .I don't know what happened to the paperwork from the hospital .I couldn't tell you where R3's admission paperwork is located. During a phone interview on 9/25/24 at 8:13 a.m., this surveyor called UP Health Systems hospital for R3's paperwork sent to the facility. During an interview on 9/25/24 at 9:05 a.m., Licensed Practical Nurse (LPN) G stated, I was the admitting nurse for R3, and I did not ask the doctor to order PT/OT for R3 .PT and OT are not on the list of standing orders when residents are first admitted . I may have a copy of the standing orders somewhere. Review of facility policy titled Physicians Standing Orders last revised 3/23, read in part . Standing Orders: Physical Therapy, Occupational Therapy .evaluation and treatment as indicated. Review of facility policy titled Rehabilitative and Restorative Programs last revised 3/19/24, read in part . Residents receive a functional assessment on admission that serves as a basis for a formulation of resident care plan .those residents those PT and OT assessment reveals a need for a specific restorative program will be placed in one or more programs .

Based on observation, interview, and record review, the facility failed to assess and monitor pressure injuries, develop and implement a plan of care for pressure injuries, and maintain infection control practices during dressing changes for One Resident (R14) of One resident reviewed for pressure injuries. This deficient practice resulted in harm when R14 experienced worsening of wounds and the development of three stage 3 pressure injuries. Findings include: Resident #14 (R14) was interviewed on 6/24/24 at 12:56 p.m. R14 was noted to be lying on his back in bed with the sides of his body pressed against the side rails on the bed. R14 said, they ordered me a new bed - it should have been here by now. R14 said a new bed had been ordered due to wounds on his buttocks. On 6/24/24 at approximately 2:00 p.m., the Director of Nursing (DON) said there were no pressure injuries in the facility. When asked for clarification, the DON reiterated the facility did not have any residents who had pressure injuries. When asked regarding wounds for R14, the DON responded, those are areas of shearing (skin damage that results when tissue layers laterally shift in relation to each other). R14 was readmitted to the facility on [DATE] after eight days of hospitalization due to Sepsis (a potentially life-threatening condition due to infection). A form Skin Observation Tool - Licensed Nurse dated 4/28/24 documented R14 had three pressure injuries when he was readmitted to the facility from the hospital: a stage 2 pressure injury (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) on the posterior right thigh, a stage 2 pressure injury on the left posterior thigh, and a pressure injury to the gluteal area. The documentation did not indicate which side the pressure injury to the gluteal area was located or the stage of the pressure injury in the gluteal area. An admission Minimum Data Set (MDS) assessment dated [DATE] coded R14 as having one or more unhealed pressure injuries at Stage 1 or higher (skin with a localized area of non-blanchable redness). The MDS coded R14 as scoring 15 on a Brief Interview for Mental Status examination indicating R14 was cognitively intact. R14's medical record did not contain any documentation of wound assessments for the month of June 2024. The form Wound - Weekly Observation Tool (Licensed Nurses) was completed weekly for the month of May 2024. The last wound assessment in the medical record was completed on 5/30/24 and documented communication to update the physician on 5/31/24, the day after the document was completed. The assessment documented the wounds as shearing wounds. A wound assessment dated [DATE] described the wounds as shearing. The assessment of 5/3/24 documented the presence of granulation tissue and slough and documented 30% of the shearing was covered with necrosis and/or slough. On 6/25/24 at approximately 1:50 p.m., a different bed was observed in R14's room. The bed was a bariatric bed with a low air loss mattress. R14 said the new bed arrived earlier in the day. On 6/25/24 at 2:06 p.m., the nurse supervisor, Registered Nurse B (RN B), was observed completing wound care and dressing change to R14's wounds. RN B cleansed her hands and donned gloves before removing the existing dressing from R14's bilateral upper buttocks area. When the dressing was removed, three wounds were observed: one on the left intergluteal cleft adjacent to the inferior coccyx (tailbone), and two on the right intergluteal cleft lateral to the coccyx. The wounds were open with adipose (fat) tissue visible in the bases of the wounds. RN B said, this is much worse than the last time I saw [R14] and said R14's wounds had worsened to three stage 3 pressure injuries (full-thickness skin loss with visible subcutaneous fat and granulation tissue). RN B was asked to measure the wounds but responded, We don't measure - only the wound consultant measures. RN B cleansed the wounds wearing the same gloves she had on when removing the soiled dressing, patted the wounds dry, applied skin prep around the wounds then applied an absorbent dressing across the wounds without cleansing her hands or changing her gloves during these tasks. RN B was asked regarding the treatment and responded she would report to the wound care consultant so the consultant would assess the wounds and determine the appropriate treatment. On 6/25/24 at 2:26 p.m., RN B was asked about cleaning her hands and changing gloves when completing treatments. RN B responded she washed her hands after she set up the wound supplies and when she was finished with the treatment. RN B said, I didn't think about it (washing hands and changing gloves) while I was doing it (completing the treatment). The DON was interviewed on 6/25/24 at approximately 4:00 p.m. The DON said RN B had informed her about the worsening of R14's wounds. The DON was asked about wound measurements and assessment. The DON said, There's no reason we can't measure wounds - we're registered nurses. The DON said she did not know why there were no documented wound assessments for June 2024 and said the wound consultant had been in the facility and should have documented on R14's wounds. The DON said she had assessed R14's wounds and determined the wounds were not shearing. The DON said the wounds had advanced to three stage 3 pressure injuries but admitted she did not know when the three pressure injuries were initially identified. The DON said she had contacted R14's physician to change the treatment order due to necrotic tissue in the wound beds. When asked why a low air loss mattress had not been provided to R14 prior to today, the DON said she had not been made aware of the wound consultant's recommendation for a low air loss mattress until the previous week. She said the bed and mattress were immediately ordered when it came to her attention, and it was delivered on 6/25/24. The DON said the wound consultant would be in the facility to assess R14's wounds the following day, on 6/26/24. The DON was asked to inform the surveyor when the wound consultant arrived so the surveyor could interview the consultant. R14's care plan included a care plan for being at risk for skin breakdown but did not include actual skin breakdown or mention of pressure injuries. The care plan documented I am at risk for skin breakdown d/t (due to) previous history of cellulitis and diabetic ulcers. The bariatric bed was not included in the care plan interventions nor were a low air loss mattress or related interventions to prevent the development of pressure injuries or promote the healing of existing pressure injuries. On 6/26/24 at approximately 9:00 a.m., the DON conveyed the wound consultant would not be in the facility due to being on sick leave. The DON produced an email chain between herself and the wound consultant. An email from the DON to the wound consultant on 6/25/24 at 3:01 p.m. read in part: .the wounds have deteriorated. Now stage III. Are you or anyone else able to come today and assess? . The response from the wound consultant dated 6/25/24 at 6:11 p.m. read, in part: .I am out for several weeks due to injury, meaning no wound services to LTC (long term care) during that time . On 6/26/24, a weekly wound assessment was noted in R14's medical record dated 6/11/24. The assessment documented shearing to the buttocks with epithelial tissue, granulation tissue, and odor. The form was dated 6/11/24 but displayed as created and locked on 6/25/24. On 6/26/24, skin assessments were observed in R14's record dated 6/24/24 and 6/25/24. The assessment dated [DATE] documented two stage 2 sacral pressure injuries measuring 2.5 cm x 2.0 cm x 0.1 cm. The skin assessment on 6/25/24 documented three stage 3 pressure injuries: a stage 3 on the proximal right buttock measuring 2.7 cm x 1.0 cm x 0.1 cm, a stage 3 on the distal right buttock measuring 2.0 cm x 0.5 cm x (no depth documented), and a stage 3 on the left buttock measuring 4.5 cm x 4.0 cm x 0.1 cm. A nursing progress note dated 6/25/24 at 2:22 p.m. documented, Wound care performed today per orders. Resident's wounds classified as sheer [sic] in OT/WC (occupational therapy/wound consultant) documentation. Upon assessment, res has 1 stage 3 decub (pressure injury) on his left inner buttock and 2 stage 3 decubs on his right buttock. Wounds have slough to > (greater than) 90% of wound bed . A skin and wound progress note dated 6/25/24 at 7:02 p.m. documented No formal wound care services will be provided this week (6/24 - 6/28) as staff member out of office. Do not anticipate staff return until week of 7/15/24. Nursing staff to continue wound care management plan. The policy Skin and Wound assessment dated ,d+[DATE] [sic] read, in part: .Purpose: 1. To maintain and/or improve the skin integrity of all residents .b. ALL [sic] residents that do have skin breakdowns and/or pressure ulcers receive necessary treatment and services to promote healing, prevent infection, and prevent the breakdown from recurring . A preventative care plan will be developed .4. All ulcers will be measured weekly and PRN (as needed) .

Based on observation, interview, and record review, the facility failed to accurately assess, develop and revise care plan interventions, provide adequate supervision, and investigate falls for root cause, to minimize the risk of fall recurrence for one Resident (R23) of two residents reviewed for falls. This deficient practice resulted in R23 experiencing multiple falls with numerous injuries including transfer to the emergency department for facial suturing. Findings include: Resident #23 (R23) was admitted to the facility on [DATE] with a diagnosis of severe Dementia with agitation. An admission Minimum Data Set (MDS) assessment dated [DATE] documented R23 as having a history of falls prior to admission to the facility. Section J1700 of the MDS documented R23 had a fall within the month prior to admission to the facility and had falls within 2-6 months prior to admission to the facility. On 6/24/24 at 2:10 p.m., a position change alarm box was observed on the head of R23's bed. R23 was observed ambulating in the hallway, occasionally leaning into the wall as he walked and entering other residents' rooms. An incident report dated 4/3/24 at 11:04 p.m. documented R23 fell in his room. There were no interventions documented on the incident report, baseline care plan, or nursing progress notes to identify and minimize risk of fall recurrence. An admission nursing assessment was not found in the medical record of R23. According to nursing progress notes on 4/4/24, R23 experienced another fall on 4/4/24 at 1:15 p.m. The fall resulted in multiple injuries including lacerations to the left eyebrow and left cheek, skin tears to the left elbow and left wrist, and a swollen, painful right ankle. R23 was sent to the emergency department and received 5 sutures to the facial laceration on the left eyebrow. An incident report was not located for the fall on 4/4/24. The baseline care plan was not updated with fall hazards or interventions to minimize the risk of fall recurrence. Documentation regarding causal factors or the root-cause of the fall was not located in the medical record. A care conference progress note on 4/10/24 at 3:09 p.m. documented R23 was at low risk for falls despite having 2 falls with injury within the previous 7 days and a history of falls prior to admission to the facility. The note read, in part: .Res low fall risk but subsequently had 2 falls days 1 and 2 after admission . A Physician progress note dated 5/8/24 at 11:46 a.m. documented, in part: .He is at high risk for falls, which he has had 2 since admission to LTC (long term care). One of which required stitches to his forehead . R23 fell again on 5/17/24 at 1:15 a.m. According to the incident report, R23 was found by staff on the floor in the bathroom of another resident. The incident report documented R23 sustained an abrasion injury to the top of the scalp. No other injuries were documented on the incident report. Nurses' notes on 5/17/24 at 1:13 p.m. documented R23 sustained an abrasion to the center of the forehead as a result of the fall. There were no nurses notes to clarify the location(s) of the injuries. Documentation regarding the causal factors of the fall was not located in the medical record. A fall re-assessment using a Morse Fall Scale was completed on 5/17/24. R23 scored 75 indicating high risk for falls. R23 had an unwitnessed fall in his room on 5/18/24 at 3:52 a.m. According to the incident report, the fall resulted in a skin tear injury to the left elbow. The incident report documented R23 was in bed sleeping when staff heard the bed alarm go off. The incident report read, in part: . Resident fell earlier this day shift, he has some bruising to his face/head. Writer observed a bruise earlier in his hair line. After the fall on night shift he had a bruise to his R [right] side of face and his nose . There was no incident report located for a fall on day shift on 5/17/24 or 5/18/24. Documentation regarding the potential hazards or causal factors of the fall was not located in the medical record. R23 fell in his room on 5/19/24 at 1:40 p.m. The incident report documented the resident was observed attempting to sit down and lost his balance. A care plan intervention was added on 5/20/24 for (brand name) alarm to bed to alert staff when I am up out of bed. The intervention was resolved on 5/27/24 with no other intervention implemented, and no documentation explaining the rationale for the discontinuance of the intervention on the care plan. R23's care plan was reviewed on 6/25/24 and documented, in part: I am at low risk for falls (Morse 15) r/t (related to) confusion. The care plan was not updated with the completion of the fall risk assessment on 5/17/24 to reflect R23's high fall risk. The falls care plan was dated as developed on 4/11/24. The interventions on the care plan for falls were all dated 4/11/24 except for an intervention initiated on 5/20/24 for a position change alarm. The Director of Nursing (DON) was interviewed on 6/25/24 at 9:23 a.m. The DON said a Risk Management Report (incident report) is completed after each fall, and care plans are updated after fall occurrences. The DON was asked if any investigations had been conducted for R23's falls. The DON admitted investigations had not been completed for R23's falls. The DON was asked if there was an incident report for the fall with injury requiring transfer to the emergency department on 4/4/24. The DON reviewed R23's medical record and said an incident report had not been completed. The DON was asked if there was an incident report for the day shift on 5/17/24 or 5/18/24 as referenced in the incident report of 5/18/24. The DON reviewed the record and said there were no additional incident reports on 5/17/24 aside from the fall on 5/17/24 at 1:15 a.m., and there were no additional incident reports on 5/18/24 aside from the one at 3:52 a.m. The DON was asked why a position change alarm box was on the head of R23's bed despite being discontinued on 5/27/24. The DON replied, There shouldn't be an alarm box. The DON explained R23 was a prison guard for years and responds quickly to the sound of alarms. The DON said the sound of an alarm is more likely to increase the chance of R23 falling. The DON was told the incident report of 5/18/24 documented the resident had a bed alarm, but the bed alarm wasn't added to the care plan until 5/20/24. When asked when the bed alarm was placed on the bed, the DON said, I'm not really sure. When asked about care plan updates, interventions, and root-cause of fall occurrences, the DON reviewed R23's record and said the care plans and interventions were not updated after falls. The DON and Nursing Supervisor (RN B) were interviewed on 6/26/24 at 10:45 a.m. RN B said she enters a progress note from the Fall Committee into a resident's medical records when a resident falls to document the cause of falls and the interventions implemented for the resident. A response was not received when asked why there was no documentation for root-causes or interventions for R23. The DON was asked the location of R23's admission nursing assessment. The DON looked in R23's medical record and said an admission nursing assessment had not been completed for R23. The DON said an admission nursing assessment is expected to be completed for all residents when admitted to the facility. The policy Falls and Suspected Falls dated as revised 12/5/23 read, in part: .Purpose: Establish care plans that provide a safe environment that minimizes risk for falls .A Care Plan will be developed with goals and interventions to decrease the potential for falls . The Fall Team Committee (FTC) will review all falls on a weekly basis. Falls with injuries requiring hospitalization will be reviewed by the Fall Team Subcommittee within 24 hours of the fall. Interventions and recommendations will be addressed by the attending physician and care plan will be reviewed and revised as needed .Investigation includes implementing any interventions deemed necessary to prevent recurrence. The Supervisor will investigate the fall .the Supervisor will update the care plan . A Care Plan will be developed with goals and interventions to decrease the potential for falls. Areas of focus will include, but are not limited to fall history, external factors, and internal factors that may contribute to falls and/or potential falls .The Nurse/LPN (Licensed Practical Nurse) shall complete a Clarity Report and Accidents & Injuries Report and Risk Management Assessment for each fall or suspected fall .Investigation includes implementing any interventions deemed necessary to prevent recurrence .The Supervisor will investigate the fall .Based on that review, the Supervisor will update the care plan and notify staff of changes and / or trends in falls .

This citation pertains to Intake MI 890. Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors for one Resident (#16) of one resident reviewed for medication errors. This deficient practice resulted in harm when Resident #16 received the wrong type of insulin, became unresponsive and required transfer for emergency treatment. Findings include: Resident #16 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #16 was cognitively intact. An observation on [DATE] at 3:19 p.m., revealed Resident #16 sitting on the edge of his bed. Resident #16 appeared thin with his face slightly sunken and collar bones protruding. When asked if he had any recent hospitalization s, Resident #16 reported he was recently sent to the emergency department (ED) after being administered the wrong insulin. Resident #16 stated he did not remember being transferred to the ED but he felt woozy for days, after the event. Resident #16 stated, I almost died . A review of Resident #16's ED Provider Assessment, dated [DATE] at 11:45, revealed the following, in part: Chief Complaint: Unresponsive . found in his room in an unresponsive state. He had eaten half of his breakfast and had been given his morning insulin, (point of care) glucose was reportedly less than 20 (normal range is ,d+[DATE]) per long-term care staff .Rapid response was called, and the ER staff/code team responded to the resident's room. Found to be unresponsive to verbal and tactile stimulus but breathing, with a dilated fixed left pupil, strong pulse, and adequate perfusion of his extremities. 1 mg (milligram) of [MEDICATION(S)] was administered subcu (subcutaneously), be he did not respond. He was subsequently brought to the emergency room for further evaluation and treatment, he remained unresponsive . Further review of Resident #16's ED Provider Assessment, dated [DATE] at 11:45 a.m., revealed the following, in part: IV was initiated and he was given D50W bolus with no response, (point of care) glucose increased to 100s and he had a transient moment of responsiveness, but remained confused and then was hyper somnolent for several hours. A nasopharyngeal airway was placed . Finally, nearly 4 hours after initial [MEDICATION(S)] injection, he become responsive . Since this episode was not totally explainable by a simple injection of 10 units of long-acting (brand name redacted) insulin, his medications were reviewed. It appears that he may have inadvertently received 20 units of rapid acting (brand name redacted) (rapid-acting insulin), which better explains his profound [CONDITION(S)] . Impression: 1. Profound [CONDITION(S)], possible due to inadvertent administration of rapid acting (brand name redacted) insulin instead of long-acting (brand name redacted) . A review of Resident #16's physician's orders revealed the following: Date ordered: [DATE], (brand name redacted, long-acting insulin), Insulin Pen, 100 unit/ml (milliliters): Inject 24 units . Subcutaneous 1 time per day at 10:00 (a.m.), for type 2 diabetes mellitus with diabetic neuropath . Date ordered: [DATE], blood sugars 4 times per day at 07:00. 11:00, 16:00, 20:00. Continue to monitor blood sugars as ordered. If stable after 1 week, may change to q a.m. (every morning) and hs (bedtime). During the review of Resident #16's physician's orders for [DATE] through [DATE], it was noted Resident #16 had never been prescribed a rapid-acting insulin. A review of Resident #16's Blood Sugar Recordings, on [DATE] at 9:00 a.m. with the Director of Nursing (DON), revealed no recorded blood sugar on the morning of [DATE], prior to Resident #16's insulin administration. The DON confirmed Resident #16's blood sugar should have been checked prior to administration of the Resident's 10:00 a.m. administration of insulin. The DON reported the facility confirmed Resident #16 had been administered a rapid-acting insulin instead of the long-acting insulin as ordered. The DON stated the nurse who administered the incorrect insulin was Licensed Practical Nurse (LPN) L. The DON reported LPN L was a contracted employee and no longer worked at the facility. The DON stated no contact information was available for LPN L. The DON stated nursing should be verifying they have the right medication for the right resident prior to administering any medications. A review of Resident #16's Life Event reported, dated [DATE] at 11:15 a.m., revealed the following : Event Type: Medication . Type of Medication Event: Wrong drug. Describe the Event: Writer walked past resident room and noticed resident hanging off bed. Writer then entered resident room and tried to get resident to respond . Resident was unresponsive. A review of the Root Cause Analysis, dated [DATE], and provided by the DON, revealed the following, in part: Incident Date: [DATE] . Rapid Response to (Resident #16's) room. Resident unresponsive . (point of care) blood sugar <20 (less than 20) . transported to ED for further care and evaluation. Once in ED (Physician M) raised concern that patient was not responding to interventions and inquired about possibility of him receiving a fast-acting insulin rather than the long acting (brand name redacted) he is prescribed. (Pharmacist N) interviewed (LPN L) who administered the insulin . Together, they walked to the medication cart. (LPN L) opened the cart and grabbed a (rapid-acting insulin) pen. (Pharmacist N) clarified with (LPN L) that she was certain that is what she administered to (Resident #16). (LPN L) was certain that it was the (rapid-acting insulin) and not (long-acting insulin). She also pointed out that the pens they were looking at belonged to a different resident with same first name but not last name. A review of Pharmacist N's statement, electronically signed on [DATE] at 12:55 p.m., revealed the following: I, (Pharmacist N), went to (facility) to determine what insulin and how much was administered to the patient. (LPN L) stated she gave 20 units of (long-acting insulin). I asked to see the medication, she then brought me to the medication cart and showed me a (rapid-acting insulin) pen. At that time, she realized that she did in fact administer the (rapid-acting insulin) instead of the (long-acting insulin). A review of Pharmacist N's statement, electronically signed and dated [DATE] A review of the facility policy titled Diabetic Policy - Insulin Administration/Documentation, last reviewed [DATE] and revised ,d+[DATE], revealed the following, in part: Purpose: Monitoring for hyper and [CONDITION(S)] to maintain consistent blood sugar results. Immediate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Procedure: 1. Obtain a blood sugar according to resident orders, signs/symptoms of hypo and [CONDITION(S)] . 3. Each med (insulin) should be checked by the nurse three times before administration. Compare the label to the emar (electronic medication administration record) when removing the med, compare the label when drawing the insulin, compare the label to the mar just before injection .

This citation has two Deficient Practice Statements, A and B: A. Based on observation, interview, and record review, the facility failed to implement COVID-19 (a highly transmissible [CONDITION(S)] disease) infection control practices to prevent the possible spread of COVID-19 by: a) Failing to quarantine a resident (#17) exposed to a COVID-19 positive staff member, Staff U, on 4/12/21, when Staff U's COVID-19 positive test results were received on 4/14/21. This potentially resulted in Resident #17's positive COVID-19 status on 4/20/21. b) Failing to immediately restrict from the facility two staff members exposed to a COVID-19 positive resident (#17) on 4/20/21, who were observed in the clinical area without appropriate Personal Protective Equipment (PPE) on 4/21/21. c) Failing to cease communal dining following a confirmed positive COVID-19 case in the facility. d) Failing to maintain adequate infection surveillance and mapping following a COVID-19 positive resident (#17) diagnosis. e) Failing to update the COVID-19 policy to include Centers for Disease Control (CDC) most recent infection control guidelines. f) Failing to ensure staff utilized appropriate PPE given facility COVID-19 outbreak of a COVID positive resident (#17). This deficient practice resulted in Immediate Jeopardy for the continued spread of COVID-19 in the facility, potentially affecting all 31 facility long-term care residents. The Immediate Jeopardy was identified on 4/21/21 at 1:43 p.m. during an annual recertification survey, and the notice was delivered at 4:20 p.m. to the Director of Nursing (DON), the Chief Nursing Officer (CNO), Registered Nurse (RN) V, and the Infection Control nurse for employee health, RN T. An Abatement Plan was requested, received, and approved on 4/21/21 at 5:22 p.m. The accepted Abatement Plan included the discontinuation of communal dining and communal activities, the tracking of staff members potentially exposed to the COVID positive resident (#17), the continuation of serial testing of exposed staff, staff education, and the quarantining of any additional staff exposed to Resident #17 . The Immediate Jeopardy continued at a level of no actual harm with the potential for more than minimal harm until confirmation of the entire plan of correction. The Immediate Jeopardy began on 4/14/21 with the identification of a COVID-19 positive staff (Staff U). This new infection outbreak was identified by the DON following receipt of Staff U's positive COVID-19 test results. Resident #17 was exposed to Staff U on 4/12/21, and was not placed in quarantine as a PUI (Person Under Investigation), until she was diagnosed as COVID-19 positive on 4/20/21. Findings include: An observation on 4/20/21 at approximately 11:00 a.m. revealed a sign in large red print posted on the facility entry door which indicated there was a COVID-19 positive staff member identified. An interview with the DON on 4/20/21 at approximately 11:15 a.m. revealed one positive staff member (Nurse Aide / Staff U) was identified as COVID-19 positive on 4/14/21, and was placed on medical leave. This was considered a new outbreak. An interview on 4/21/21 with the DON at 7:42 a.m. revealed the COVID positive staff member worked with Resident #17 on 4/12/21. Resident #17 was not vaccinated, and had tested positive for COVID-19 on 4/20/21. The DON reported Resident #17 was relocated to a COVID positive isolation unit in the long-term care facility on 4/20/21. Resident #17 was confirmed isolated on the COVID positive unit at 8:10 a.m. An observation on 4/21/21 at approximately 9:42 a.m. revealed two private duty aides (exposed to the newly COVID positive Resident #17 on 4/20/21) were observed in the facility without appropriate PPE, specifically an N-95 mask and a face shield or eye goggles. An observation on 4/20/21 beginning at 11:54 a.m. revealed Resident #17 dressed and well groomed, seated in the activity dining room holding a baby doll. Soon after, her private duty aide, Staff S, set Resident #17 up with her lunch tray. Resident #17 was observed in the facility halls throughout the day with her 1:1 staff. An interview on 4/21/21 at 12:56 p.m. with the Minimum Data Set (MDS) nurse, Licensed Practical Nurse (LPN) K, confirmed there was group dining on 4/21/21 in the large facility dining room with residents distanced at least 6' apart. During an interview on 4/21/21 at 1:02 p.m. with the DON and RN T, it was confirmed Staff U's infection was not tracked to see which residents were exposed when they worked on 4/12/21, and the two days prior. RN T reported they took responsibility for this as they went on vacation that week, and worked at the hospital and did not keep up on all the long-term care requirements (the federally mandated regulations for Long Term Care [LTC]). RN T reported they kept track of employee infections for the hospital and LTC, and the DON kept track of resident infections for LTC. RN T reported they should have gone beyond tracking Staff U's exposure to other staff, and instructed the DON to further track any residents who were exposed to Staff U and clarified which residents were vaccinated and unvaccinated. RN T stated, [Resident #17] should have been isolated .We will have to start testing every resident now weekly . RN T reported during this interview 44% of long term care employees had been vaccinated, which meant 56% of the long-term care employees were not vaccinated. During further interview, the DON was asked about the two private duty aides exposed to Resident #17 on 4/20/21 and observed in the facility on 4/21/21. The DON stated, They [these two staff] did come back in [to the LTC facility] when they found out they were negative [Covid test results] .I'm not sure of the regulation. I would have preferred them to go directly out the [facility] door. Regarding communal dining after the potential exposure, the DON reported they did not see a concern if the residents were seated 6' apart, and added 27 of 31 LTC residents were vaccinated (87%). During an interview on 4/21/21 at 3:33 p.m., RN V reported they were new to the Long Term Care regulations and asked where to look for them. RN V reported they understood the Immediate Jeopardy deficient practice concerns, and stated, We'll fix it. During a second request for current infection surveillance logs for staff and residents from the DON on 4/21/21 at 1:52 a.m., the DON provided a stack of employee COVID screening logs. This Surveyor reclarified the definition of surveillance logs as line listings or written logged tracking of resident infections, and specifically requested tracking for residents with respiratory symptoms and/or COVID-19 infections for the month of April (2021), at a minimum. At 2:45 p.m., the DON reported the surveillance logs and infection mapping had not been updated, and provided a blank surveillance log for April, 2021, and a facility mapping of infections for April, 2021, which did not show Resident #17's infection. This confirmed the facility was not tracking this new COVID-19 resident infection in 'real-time' (current), per the Centers for Disease Control (CDC) guidelines. The DON confirmed there was only one positive resident (#17) in the facility, which remained the case during the duration of the survey. Review of the employee surveillance log, provided by the DON from RN T, revealed Staff U tested positive for COVID-19 on 4/14/21, had symptom onset on 4/14/21, and would be eligible to return to work on 4/25/21. It was noted the log was difficult to read as it was a combined log of hospital and LTC employees, with the hospital employees blacked out for confidentiality. The log was absent type of symptoms and the duration of the illness. Review of a typed page on facility letterhead from the DON on 4/21/21 revealed, Positive COVID tests - staff, and showed, [Staff U], NA [nurse aide] 4/14/21. An interview on 4/26/21 at 10:39 a.m. with the DON revealed the facility had another new COVID-19 positive employee, CNA W, who was placed on medical leave, and two residents (Residents #20 and #6) who had exposure were placed in quarantine. The DON reported Resident #20 was directly exposed to CNA W, and Resident #6 was their roommate, and both residents were quarantined in different rooms. The DON reported all staff were now wearing full PPE including N 95, face shields or eye goggles, gloves, and gowns during resident care, and the facility had begun daily COVID-19 testing for residents and staff at least twice a week. The DON denied any residents newly testing positive, including Resident #6 and #20, and provided COVID-19 tests which confirmed this report. During this same interview, the LTC infection surveillance logs and facility mapping (which showed infections diagramed per resident room number) were reviewed. It was noted there was no mapping of resident infections on the October (2020), November (2020), December (2020), and January (2021) resident infection logs. The DON reported these logs should have been completed, and were not completed by the previous infection control nurse. It was earlier noted the April 2021 surveillance log and mapping did not note Resident #17 as COVID-19 positive, thus further infection details were unavailable. No updated April (2021) resident surveillance log was provided by the end of the survey. Observations on 4/26/21 at 11:19 a.m. revealed Resident #20's and Resident #6's rooms each had their doors closed and proper signage was posted on the door for infection precautions. Review of a handwritten document titled, Residents who have not been vaccinated as of 4/21/21, received from the DON on 4/21/21, revealed four LTC residents had not been vaccinated, including Resident #17. Review of the policy titled, Infection Control - Tracking Map, provided from the DON, reviewed 10/20(20), revealed, Purpose: To promote the health and well-being of residents, staff, and visitors, to prevent the staff and residents from exposure to diseases, to ascertain if there is a correlation in the disease processes with residents, staff, and visitors .3. All infections: Resident and Employee will be kept track on the Infection Control Log as they occur [in 'real time']. The RN Supervisor, charge nurse, or designee will record on the Infection Control Map the following: .Resident or employee, room, symptoms, onset of condition, duration of illness, pathogen, specimen date, prescription or antibiotic therapy .Each Infection will be followed by color-coding each Infection on the Infection Control Map . Review of the facility policy, COVID-19, reviewed April, 2021, provided by the DON, did not include when to quarantine a resident following COVID-19 exposure. The policy also stated, An HCP [health care practioner] should not come in to work if they present with any s/s [signs/symptoms] of COVID-19 . Review of the document, Interim Infection Prevention and Control Guidelines to Prevent [CONDITION(S)]-CoV-2 [COVID-19 infection] in Nursing Homes, last updated March 29, 2021, revealed, .Residents who have had close contact with someone with [CONDITION(S)]-Co-V-2 should be placed in quarantine 14 days after their exposure .Because of the high risk of infection among residents, a single new case of [CONDITION(S)]-CoV-2 infection in a resident should be evaluated as a potential outbreak.Implement facility wide testing along with the following infection control precautions: - HCP should care for residents using an N-95 respirator or eye protection .gloves, and gown. Residents should generally be restricted to their rooms and serial [CONDITION(S)]-CoV-2 testing performed .Consideration should be given to halting social activities and communal dining . On 4/26/21 at 9:46 a.m., disposable personal protective gowns were observed hanging on the outside of rooms [ROOM NUMBERS]. CNA C was distributing gowns to individual rooms and was asked about the gowns. CNA C said all staff were using the gowns for cares since a resident tested positive for COVID-19. During an interview on 4/26/21 at 9:50 a.m., the DON confirmed the hospital (attached to the facility) chief medical officer recommended the use of gowns with all cares. The DON confirmed gowns were not being conserved and should be disposed of with each use. When asked why the gowns were stored on the outside of rooms, exposing the hallways potentially, the DON stated, I'm not sure. The DON said gowns should be disposed of after each use, within the room in which it was worn. On 4/26/21 at 9:54 a.m., the disposable gowns were observed hanging on the outside of rooms 269, 271, 277, 279, 221, 212, 214, and 217. On 4/27/21 at 3:45 p.m., a disposable gown was observed hanging on the outside of room [ROOM NUMBER]. On 4/26/21 at 10:02 a.m., catheter care was observed with CNA G, who did not wear a protective gown during the care. At 10:44 a.m., CNA G confirmed the error. B. Based on interview and record review, the facility failed to develop a comprehensive Water Management Plan (WMP) to address the control and spread of Legionella bacteria pathogen in the facility water system, in accordance with QSO 17-30 Hopsitals/CAHs/NH, Revised 7-6-2018, and failed to Develop and implement a water management program that considers the ASHRAE 188 (American Society of Heating, Refrigerating and Air-Conditioning Engineers) and the CDC (Centers for Disease Control) tool kit. The failure to develop a comprehensive Water Management Plan has the potential to allow for the proliferation and transmission of the bacteria in the circulating water of the building and the spread of Legionella infections in all 31 residents. Findings include: On 4/21/21 at 9:30 AM, an interview with Maintenance Director/ Staff A was conducted to review the facility's WMP for the control of Legionella in the water supply system. A document with the subject Water Management Program, with a Reviewed Date 10/2020 was presented as the water management plan. The Document was a policy and procedure directing the facility to develop a water management plan, and did not constitute a plan to control the growth and transmission of the water borne pathogen Legionella. The document directed the following components to be included in the Water Management Program as listed in the facility's policy and procedure (numbers correspond to policy and procedure document): 5. Identify areas of each building where Legionella could grow and spread. 6. Develop control measures and corrective actions. 7. Decide where control measures should be applied. 8. Decide how to monitor your control measures. 9. Establish ways to intervene when control limits are not met. 10. Monitor program to assure it is running as designed and is effective. 11. Document and communicate all the activities of your Water Management Program The following components were absent from the facility WMP : A. A quantitative inventory and assessment of plumbing fixtures and the identification of high risk fixtures, which would correspond to item 5 above. B. Identification of defined control measures and locations related to risk and the critical limits which are set and correspond to item 6 above. C. Identification of set critical limits related to the risk areas identified and which can be controlled. D. Identification of interventions/procedures to follow when critical limits are not met, which would correspond to item 9 above. E. Implementation of regular scheduled mitigation program. F. An evaluation process to determine how the WMP is functioning , which would correspond to items 10 and 11 above.

Intake: MI 4556 Based on observation, interview, and record review, the facility failed to complete assessments to determine need for bed rails for one Resident (#76), resulting in immediate jeopardy (IJ) due to a fall from bed (Resident #76) and the likelihood of entrapment and serious harm for all 28 residents residing in the facility. This deficient practice resulted in the likelihood of entrapment, serious injury or harm, and/or death, for all facility residents using bed rails without assessment of safety and appropriateness for medical conditions. The immediate jeopardy began on 6/26/19 at 7:00 a.m. when Resident #76 sustained a fall from a bed with side rails resulting in serious bodily injury (right frontal sinus fracture). Immediate jeopardy was identified on 7/17/19 at 3:23 p.m. with notification to the Nursing Home Administrator (NHA) on 7/17/19 at 5:00 p.m. An abatement plan was requested from the facility at that time. The immediate jeopardy was removed on 7/17/19 at 6:15 p.m., when the facility received acceptance of, and began implementation of, its IJ Abatement Plan for removal of the immediate jeopardy, that included: The DON (Director of Nursing), RN (Registered Nurse) Supervisor, MDS (Minimum Data Set) Coordinator/SS (Social Service) Designee, Therapy will be responsible for assessing the use of bed rails for each resident beginning on 7/17/19, quarterly, annually, at admission and upon significant change of conditions. Each resident will have a risk vs benefit statement if bed rails are implemented/not implemented. The facility will assess potential interventions prior to putting bed rails in place. Each resident will be assessed for entrapment risk by the DON, RN Supervisor, MDS Coordinator/SS Designee, Therapy, Maintenance beginning on 7/17/19, quarterly, annually, upon admission and upon significant change of conditions. (Facility Name) will begin bed rail and entrapment risk assessments on 7/17/19, as soon as P[NAME] (Plan of Care) accepted. Assessments to be completed by 7/22/19. Maintenance will assist by using the gap measurement tool guidelines of device measurements beginning on 7/17/19. To be completed by 7/22/19. (Facility Name) to develop policy on bed rail requirements, and assessments to be completed on 7/17/19. Education to be provided to CNA (Certified Nurse Aide), Nursing, Maintenance, and Housekeeping Staff in regards to bed rail requirements, and assessments beginning on 7/17/19. Education will be provided to all staff upon their first shift after the P[NAME] (for Abatement) accepted and (Facility Name) will maintain documentation of education presented. Education to be completed by 7/22/19. Noncompliance remained at a widespread level of no actual harm with potential for more than minimal harm, until confirmation of completion of the abatement plan, and verification of the facility process to ensure resident assessment of bed rail need and safety has been completed. Findings include: Review of Resident #76's medical record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #76 was noted to need one person assist for transfers, independent in ambulation with a cane or a FWW (front wheeled walker), and independent with bed mobility on her 6/17/19 Mobility Care Plan. Resident #76 had an incomplete Minimum Data Set (MDS) assessment as of the survey date 7/17/19, but was noted to have severely impaired cognition and had an activated Power of Attorney - Health (POA - H) for decision making. Review of an Incident/Accident Report, dated 6/26/19, revealed Resident #76 was .found on the floor, by CNAs (Certified Nurse Aides) G and CNA H. Nursing staff notified immediately, and a Rapid Response was called. (Resident #76) transferred to the Emergency Department .(Resident #76) returned from the Emergency Department with a [DIAGNOSES REDACTED]. Review of the hospital X-ray Report - Final (dated 6/26/19 at 07:16 a.m.) read, CT (computed tomography) Head . female with an unwitnessed fall .impression: 1) there is a hairline nondisplaced [MEDICAL CONDITION] wall of the right frontal sinus with an air-fluid level in the right frontal sinus compatible with blood. There is an overlying scalp hematoma and preseptal periorbital (tissues surrounding the eye) [MEDICAL CONDITION] . Review of Resident #76's Post Fall Huddle Form (undated) did not note the current use of side rails, or include any new intervention to have side rails up or down while Resident #76 was in bed. An interview was conducted with the DON on 7/17/19 at 3:10 p.m. regarding Resident #76 being found on the floor on 6/26/19. The DON confirmed all beds in the facility had side rails attached to the bed. When asked if Resident #76 had an assessment completed for the proper use of side rails, the DON confirmed there was no side rail assessment conducted. When asked if the facility had considered the use of side rails contributing to prior falls, the DON stated, No. An interview was conducted with CNA G on 7/17/19 at 3:40 p.m., regarding Resident #76 being found on the floor in her room. CNA G and this Surveyor went into Resident #76's previous room to reenact the incident, CNA G stated, She (Resident #76) was found on the floor with her head facing the footboard of the bed and I saw there was blood on the footboard. When asked if Resident #76's left side of the bed was pushed up against the wall on 6/26/19, CNA G responded Yes. When asked if Resident #76's right side rail was up on 6/26/19, CNA G responded, Yes it was always up. When asked if Resident #76 ever used her right side rail for transfers or repositioning, CNA G responded She never used them (side rails) to my knowledge. CNA G confirmed Resident #76 was on 15 minute checks starting on 6/25/19 and was last seen in bed on 6/26/19 at 6:45 a.m. An interview was conducted with Licensed Practical Nurse (LPN) C on 7/17/19 at approximately 3:50 p.m. LPN C confirmed she was the first responding nurse to Resident #76 on 6/26/19. LPN C stated, (Resident #76) was laying on the floor at an angle with her head facing the headboard and feet out towards the middle of the room. Her glasses were found near the footboard. It did not look like she had taken any steps from bed. LPN C stated Resident #76's left side of the bed was against the wall and her right side rail was up when she was found on the floor on 6/26/19. When asked if Resident #76 used the right side rail for transfers or repositioning, LPN C stated, I don't know. An interview was conducted with the DON and Maintenance Director/Staff D on 7/17/19 at 4:09 p.m. regarding bed assessments. Staff D confirmed the maintenance department only checked beds in the facility for electricity and not for entrapment zones. When asked if the beds were still under warranty of the manufacture, Staff D stated, No, they are our (facility's) responsibility. When asked when the beds were assembled Staff D stated, 2005. Staff D confirmed that all 28 beds currently used in the facility had side rails which were assembled in house by the facility. Bed entrapment zone measurements were not provided for any resident bed in the facility. Review of the User-Service Manual (Brand Name) Bed Frames received from the facility on 7/17/19 revealed the following, .An optimal bed system assessment should be conducted on each resident by a qualified clinician or medical provider to ensure maximum safety of the resident. The assessment should be conducted within the context of, and in compliance with, the state and federal guidelines related to the use of restraints and bed system entrapment guidance, including the Clinical Guidance for the Assessment and Implementation of Side Rails published by the Hospital Bed Safety Workgroup of the U.S. Food and Drug Administration .locate mounting brackets for assist devices strictly according to instructions. Gap between head/foot panel and assist device must be small enough or large enough to prevent resident/patient from getting his/her head or neck caught in this location (see specific Assist Device Installation Instructions for more information.) The facility did not provide the Assist Device Installation Instructions to the Surveyors prior to the exit date on 7/23/19. Review of the facility's Restraint/Immobilization Policy dated 8/2015 and revised 3/19 read, .it is the policy of (facility) to use restraints only when medically necessary to assure the safety of our patients and others and after alternative methods have been tried .Initiation of Restraints may only be used to ensure the immediate physical safety of the patient .and must be discontinued at the earliest possible time .Care Planning - The use of restraints must be a written modification of the care plan .Side-rails: If side rails are used to restrict a patient's movement they constitute a restraint .

Based on observation, interview, and record review, the facility was placed in Immediate Jeopardy due to their failure to prevent resident to resident abuse involving two sampled Residents (#1 and #2) when on 9/12/18, Resident #2 threatened to kill Resident #1 and then on 9/30/18, was found in the hall by facility staff attempting to suffocate Resident #1. This deficient practice resulted in the potential to cause death. The Immediate Jeopardy had the potential to affect all residents in the facility. The Immediate Jeopardy began on 9/30/18 when Resident #2 attempted to suffocate Resident #1. The Chief Executive Officer (CEO), Chief Nursing Officer (CNO) and Director of Nursing (DON) were notified of Immediate Jeopardy on 10/12/18 at 4:02 p.m. The Notification to the Facility of Immediate Jeopardy was signed and returned electronically on 10/12/18 at 4:23 p.m. The IJ was removed on 10/12/18 at 5:00 p.m., but the noncompliance remained at the lower scope and severity level of actual harm that is not Immediate Jeopardy. The Immediate Jeopardy which began on 9/30/18 was removed on 10/12/18 at 5:00 p.m. when the facility presented an immediacy removal plan and began implementation of the following: 1. Resident #2 was placed on a one to one staff supervision. 2. All staff participating in Resident #2's one to one supervision will be educated on Standards of Care for Residents with Behavioral Problems prior to the start of their shift. The immediacy removal plan also included the following: 1. The facility identified this deficient practice affected Resident # 1 and had the potential to affect all residents. 2. Resident # 1 and #2 were referred for a Psychological Evaluation. Order was written on 10/12/18 at 12:00 p.m. 3. The DON review of the facility's Abuse/Neglect Policy and Procedure to ensure it included Resident to Resident Events, more specifically related to behaviors that have the potential to be harmful to other residents or themselves. Policy addition was completed by 10/15/18 with staff education. Education began on 10/15/18 with 17 staff educated. 4. All staff will be educated on Standards of Care for Residents with Behavioral Problems prior to their next shift. Staff will not be able to work or participate in the 1:1 unless they receive this education. Education began on 10/12/18. 5. Other residents having like behaviors, more specifically increased verbal/physical aggression, will be identified by reviewing daily Behavioral Notes. This will begin on 10/15/18. If there are noted behaviors, the physician will be contacted as soon as possible and staff will increase supervision immediately. 6. Prior to Social Service designee's next shift, on 10/15/18, DON will educate Social Services designee on Behavioral Program. Social Services designee will review daily progress notes, participate in scheduled Behavioral Meetings (will begin weekly on 10/16/18) with the Interdisciplinary Team. Review non pharmacological and pharmacological interventions, review and request gradual dose reductions and appropriate consults and evaluations as warranted. The Behavioral Care Team will ensure the recommendations/reviews will be documented in the medical record, beginning 10/15/18. In addition, the Social Work designee or alternate will make care plan changes/interventions to the care plan and notify staff via email and a sign off education sheet on changes to the care plan/interventions put in place. Findings include: Review of Resident #2's Minimum Data Set (MDS) assessment, reference date 9/10/18, revealed the following [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) reflected severely impaired cognition. Resident #2 displayed both physical and verbal behaviors directed toward others and wandered. The Functional Status showed Resident #2 needed supervision with ambulation in the room and corridor and the use of a wander/elopement alarm. Review of Resident #1's MDS assessment, reference date 7/3/18, revealed the following [DIAGNOSES REDACTED]. The BIMS reflected moderately impaired cognition. Resident #1 ambulated independently and used a wander/elopement alarm. On 10/11/18 at approximately 10:00 a.m., Resident #1 and Resident #2's rooms were noted to be located diagonally across from one another on the same hallway of the facility. Review of Resident #1's Progress Notes, dated 9/12/18, read, While in report staff heard resident yell help, when both LPNs (Licensed Practical Nurse) came out to see what was going on resident and another resident, (Resident #2), were in the hallway standing next to each other and she (Resident #1) was stating that (Resident #2) tried to kill her .Multiple times after this incident resident continues to walk by this same resident and ram her (Resident #1) walker at him (Resident #2), yell at him and call him names, staff was present and the other resident (Resident #2) was doing nothing to provoke this behavior . Review of Facility Investigation Summary, dated 9/30/18, read, .it was observed by staff members (Certified Nurse Aide {CNA} F and {CNA H}) that (Resident #2) had a hold of (Resident #1's) mouth and nose and shaking her head 'back and forth'. This event took place in the hallway. Review of Facility Investigation Summary, dated 9/30/18, included an interview with Resident #1 conducted by the DON on 9/30/18, which read, .(Resident #1) stated she was in her room and (Resident #2) came in and hit her in the face. She stated that she did not say anything to him .(Resident #1) stated that her face was sore at this time. During an interview on 10/12/18 at 10:40 a.m., the DON was asked about Resident #2's verbal threats to kill Resident #1. The DON stated, That's a common thing he says. They instigate each other. This Surveyor asked the DON to clarify her interview obtained with Resident #1 on 9/30/18 which described a different physical assault involving Resident #2. The DON responded, That event happened a year ago. She's confused. The DON was asked if additional details were provided by Resident #1 during the interview. The DON responded, Yes, she said her face hurt. The DON confirmed Resident #1's roommate was not interviewed as a possible witness. During an interview on 10/11/18 at 1:48 p.m., CNA E confirmed working on 9/30/18, the date of the incident involving Resident #1 and Resident #2. CNA E stated, They'll verbally go back and forth. And she'll ram into him with her walker and he'll respond by threatening to kill her. Review of Resident #1's Progress Note, dated 9/2/18, reads, attempted to run into (unidentified resident) .with her walker . On 10/11/18 at 2:41 p.m., a telephone interview with CNA G was attempted. The voicemail box was full; therefore, writer unable to leave a message. On 10/11/18 at 2:49 p.m., a telephone interview with LPN I was attempted. A voicemail was left with no return phone call to this Surveyor prior to exit date. On 10/11/18 at 3:15 p.m., during a telephone interview, CNA H said she worked the night shift (date of the incident) and was in the hallway when she heard a female's voice calling for help. CNA H recalled seeing Resident #2's hand covering Resident #1's mouth and nose while shaking her head head back and forth. CNA H remembered hearing Resident #2 say that he was going to 'shut her up.' CNA H stated Resident #2 slapped her (CNA H) in the face and spat in CNA F's face during the separation of Resident #2 from Resident #1. On 10/11/18 at 3:23 p.m., during an interview, CNA F recalled hearing a woman screaming for help. CNA F stated, He (Resident #2) had a hold of her (Resident #1's) face and nose. CNA F said she told (Resident #2) You're hurting her. CNA F and CNA H and to pry his hand off her nose and mouth. CNA F confirmed Resident #2 attempted to hit her and spat in her face. CNA F said that (Resident #2) had threatened to kill other residents. On 10/17/18 at 8:37 a.m., a telephone interview with LPN Y was attempted. The voicemail box was full; therefore, this Surveyor was unable to leave a message. Review of Resident #1's Incident and Accident Reports revealed an Incident on 7/16/18, which read in part, ' .resident in front of hallway and started yelling 'help help' resident (Resident #2) in front of resident with his fist raised .(CNA H) removed (Resident #2's) grasp from her (Resident #1's) wrist .(CNA P) had seen this resident pushing her walker into (Resident #2's) at the time of the incident. Review of Resident #2's Incident and Accident Reports revealed an Incident on 6/25/18 which read in part, .(staff) just broke up a physical altercation in the front lobby .residents punching each other . (Resident #2) came in here and said I'm going to to f***ing kill you and started punching me in the head , so I started punching him back in the stomach.' On 10/11/18 at 10:14 a.m., Resident #2 was not found in his room. Charge nurse LPN C and Graduate Nurse/LPN N indicated Resident #2 was attending church services in the Activity Room. This Surveyor, upon walking towards the Activity Room saw Resident #2 wandering in the hallway. The absence of any staff visible in either direction was noted. When asked if he enjoyed church services Resident #2 responded, I didn't go. I don't need that. Another observation of Resident #2 on 10/11/18 at 11:00 a.m., showed Resident #2 at the entrance door of the Activity Room. Resident #2 was heard asking where the bathroom was located. Resident #2 walked away from the Activity Room (around the corner) and was observed pulling on a locked mechanical room door. No staff were observed in either direction of the hallway. Resident #2 asked writer where the bathroom was located when this writer returned to the Activity Room and asked CNA F to assist Resident #2 to the bathroom. An observation of Resident #1 on 10/11/18 at 1:30 p.m. and 3:04 p.m. showed her seated in the lobby entrance without direct staff supervision. Review of facility's Abuse Policy, revised 6/18, read, . Prevention .The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation is more likely to occur . 4. the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents ' rooms . Review of Resident #'2 Care Plan (print date 10/4/18) read in part: *Staff to provide 1:1 observation if resident is not redirectable during periods of agitation. (11/30/17) . *Redirect me away from resident (Resident #1) as we know each other from the community and past altercations and are not fond of one another.(12/6/17) . *I have a tendency to get agitated with (unidentified resident). Intervene when needed and redirect me away from his vicinity. (11/30/17) . *Please observe me if I get early in the morning, as I may not be 'awake' and may engage in verbal/physical aggression. (6/28/18) . *Please redirect me from (unidentified resident). We have had resident to resident incidences .(3/15/18) . *Please direct me from (unidentified resident), as we get agitated when we are near each other in the hallway. (7/30/18) On 10/11/18 at 10:25 a.m. Resident #2 was observed walking in the main hallway of the facility. No other staff were present or visible. Later that morning, at 11:05 a.m., Resident #2 again was noted walking unattended in the same main hallway. No facility staff were visible.

Based on observation, interview, and record review, the facility was placed in Immediate Jeopardy due to their failure update Behavior Care Plans for two Residents (#1 and #2) to prevent resident to resident abuse when on 9/12/18, Resident #2 threatened to kill Resident #1 and then on 9/30/18, was found in the hall by facility staff attempting to suffocate Resident #1. This deficient practice resulted in the potential to cause death. The Immediate Jeopardy had the potential to affect all residents in the facility. In addition to the residents in immediate jeopardy, the facility failed to revise care plans for an additional two Residents (#3 and #4) out of four residents reviewed for appropriate care plans, resulting in the potential for unmet care needs. The Immediate Jeopardy (IJ) began on 9/30/18 when Resident #2 attempted to suffocate Resident #1. The Chief Executive Officer (CEO), Chief Nursing Officer (CNO) and Director of Nursing (DON) were verbally notified of Immediate Jeopardy on 10/12/18 at 4:02 p.m. The Notification to the Facility of Immediate Jeopardy was signed and returned electronically on 10/12/18 at 4:23 p.m. The IJ was removed on 10/12/18 at 5:00 p.m., but the noncompliance remained at the lower scope and severity level of actual harm that is not Immediate Jeopardy. The Immediate Jeopardy that began on 9/30/18 was removed on 10/16/18 at 5:00 p.m. when the facility presented an immediacy removal plan and began implementation of the following: The deficient practice affected Resident # 1 and had the potential to affect all residents. 1. Placement of a 1:1 supervision for Resident #2 on 10/12/18. 2. Resident # 1 and #2 referred for a Psychological Evaluation. Order was written on 10/12/18 at 1200. 3. DON review of Abuse/Neglect Policy and Procedure to ensure that it includes Resident to Resident Events, more specifically related to behaviors that have the potential to be harmful to other residents or themselves. Policy addition completed by 10/15/18 with staff education. Education began on 10/15/18 with 17 staff being educated. 4. All staff will be educated on Standards of Care for Residents with Behavioral Problems prior to their next shift. Staff will not be able to work or participate in the 1:1 unless they receive their education. Education began on 10/12/18. 15 staff members were educated on 10/12/18. 5. Other residents that have like behaviors, more specifically increased verbal/physical aggression will be identified by reviewing daily Behavioral Notes. This will begin on 10/15/18. If there are noted behaviors the physician will be contacted as soon as possible and staff will increase supervision immediately. 6. Prior to Social Service designee's next shift, on 10/15/18, DON will educate Social Services designee on Behavioral Program. Social Services designee will review daily progress notes, participate in scheduled Behavioral Meetings (will begin weekly on 10/16/18) with the Interdisciplinary Team. Review non pharmacological and Pharmacological Interventions, review and request gradual dose reductions and appropriate consults and evaluations as warranted. The Behavioral Care Team will ensure that the recommendations/reviews will be documented in the medical record, beginning 10/15/18. In addition, the Social Work designee or alternate will make care plan changes/interventions to the care plan and notify staff via email and a sign off education sheet on changes to the care plan/interventions put in place. Findings include: Review of Resident #2's Minimum Data Set (MDS) assessment, reference date 9/10/18, revealed the following [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) reflected severely impaired cognition. Resident #2 displayed both physical and verbal behaviors directed toward others and wandered. The Functional Status showed supervision with ambulation in the room and corridor and the use of a wander/elopement alarm. Review of Resident #1's MDS assessment, reference date 7/3/18, revealed the following [DIAGNOSES REDACTED]. The BIMS reflected moderately impaired cognition. Resident #1 ambulated independently and used a wander/elopement alarm. During an interview on 10/11/18 at 2:12 p.m Social Services designee, Registered Nurse (RN) A was asked if she had completed any care plan notes/changes to either Residents' #1 or #2 Care Plans as a result of their prior resident to resident abuse incidences which occurred in (MONTH) (YEAR). RN A reviewed each of their Care Plans and stated, I did not make any changes to their Care Plans and I wasn't asked too. RN A explained how her role was to only review Care Plans Quarterly/Annually when MDS assessments were scheduled. RN A said the DON was responsible for other needed Care Plan changes. During an interview on 10/12/18 at 10:40 a.m., the DON was asked what Care Plan interventions were put in place for (Resident #1) as a result of the repeated resident to resident incidences. The DON responded, I haven't put anything in place. I'm not sure what interventions I can use. She walks independently . This Surveyor followed with Resident #2 when the DON stated, I was waiting to hear back about a possible alarm I could use . The DON confirmed no changes made to either Resident #1's or Resident #2's Care Plans for behavior management. The DON was asked if Resident #2 had a referral for a mental health evaluation. The DON responded, No, we've tried that in the past. The DON was then asked if any new physician orders [REDACTED]. Review of Resident #1's and Resident #2's Care Plans confirm no new interventions were put in place as a result of the two separate resident to resident incidences which occurred on 9/12/18 and again on 9/30/18. Review of Resident #1's Care Plan revealed the following: PROBLEM: Start date: 6/1/17 read, .at risk for fear related to resident to resident incident . INTERVENTIONS: 1. (6/1/17) will follow (Resident #2) in the hallway. Please ensure that she is redirected to avoid confrontation . 2. (6/1/17) does not like (Resident #2) , and they had a physical alteration . 3. (8/6/17) allow resident to express concerns about a male resident who hit her . 4. (11/22/17) do not seat resident near (Resident #2) . 5. (12/6/17) I am known to elicit anger in (Resident #2) by sticking my tongue out at him or calling him names . 6. (12/6/17) I express my dislike towards (Resident #2) to other residents and visitor . 7. (5/11/18) I don't get along with resident ., and may initiate an argument. Review of Resident #2's Care Plan revealed the following: PROBLEM: Start date: 11/30/17 read, .history of resident to resident altercations . INTERVENTIONS: 1. (11/30/17) I have a tendency to get agitated with resident . 2. (12/6/17) redirect me away from resident (Resident #1) .and past altercations and are not fond of one another . 3. (3/15/18) Please redirect me from . We have had resident to resident incidences. Please watch me especially when I am walking to and from the Dining Room as .room is located near this area . 4. (6/28/18) Please observe me if I get up early .and may engage in verbal/physical aggression . 5. 7/30/18 Please direct me from ., as we get agitated when we are near each other in the hallway .' Resident #4 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The care plan dated 08/03/17 was written to address a problem of . [DIAGNOSES REDACTED]. The care plan included interventions of: Social Service visits as needed. Social worker will talk with (Resident #4) and provide reality statements. When I look distressed please direct me to Social worker, (Staff member T) as she will help me make sense of things. The Human Resource Director / Staff S was interviewed on 10/17/18 at approximately 9:00 a.m. and confirmed the facility's last Social Worker, Staff T, no longer worked at this facility as of 12/29/17. Another social worker had not been hired. The care plan was updated on 9/21/18 by RN A and no change had been made to this care plan to remove the social worker's name referenced, who no longer worked at the facility, or to add a Social Services designee. The record also revealed that Resident #4 had several behavioral incidents including: 9/12/18 at approximately 2 a.m. Resident #4 was yelling at his roommate who had woken him up. 9/14/18 Resident #4 was noted to be restless requesting to put that woman out 9/25/18 Resident #4 was pacing and became verbally aggressive toward his roommate and with staff threatening to punch the CNA. The care plan had not been updated to include interventions for verbal and physical aggressive behavior. Resident #3 was admitted [DATE] with a [DIAGNOSES REDACTED]. The Progress Notes for #3 revealed: 9/22/18 4:24 a.m. up for a brief time during this shift, stattin (sic) he was going to kill the aide if she tried to get him into bed. 9/25/18 7:02 a.m. Resident woke up very agitated, confused, combative and unable to redirect at approx 0345 (3:45 a.m.). Striking out and swearing at staff .unable to redirect, reason with, calm down in any way. 9/29/18 11:45 p.m. Yelling and threatening staff. Resident was not easily redirected .Resident was a danger to himself and staff. 10/2/18 4:45 a.m. res(ident) states 'get the hell out or I'll hit you' throwing walker and hitting staff 10/3/18 12:15 a.m. resident continued to threaten staff. 'Get the hell out of here' I'm going to punch you. 10/8/18 9:27 p.m. Resident with increased verbal and physical aggression towards staff, trying to rip clipboard out of their hands, threatening to know them on their ass. Staff attempted to redirect, with little effect. Record review indicated there was one care plan for Resident #3 entitled pyscho-social well-being. This care plan, dated 5/23/18, was written by the Minimum Data Set (MDS) Coordinator/Licensed Practical Nurse (LPN) B and listed a problem of Potential for psychosocial distress related to moderate impaired decision making. This care plan had two approaches added on 9/21/18 but had no updates had been made after the six events of verbal and physical aggression documented in the progress notes for Resident #3. During an interview with RN A on 10/11/18 at approximately 2:20 p.m. she stated that she had recently taken on the role of Social Services designee. She noted that she only updates the care plan with regards to the goals and does not change the interventions.