Every finding on record at Heritage Manor Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to: 1. Ensure the use of hair restraints of staff working in the kitchen; 2. Effectively clean multiple surfaces in the kitchen (walls, ice machine, ice scoop holder, reach-in cooler floor, reach-in cooler storage racks); 3. Ensure cleaned pans and dishes were allowed to air dry before stacking; 4. Ensure surfaces inside the kitchen were smooth and easily cleanable (insulated foam board); and 5. Ensure cleaned ladles were properly stored. Findings include: On 3/3/26 at 8:40 AM during a tour of the kitchen with Dietary Manager (DM) Q, the following items were noted: Dietary Aid (DA) U was observed operating the dish machine. DA U's facial hair was not covered with a beard guard. DM Q indicated DA U should have had on a beard guard that properly covered their facial hair. A ball of dust, approximately the size of a large marble, was protruding from a ceiling tile located above the prep handwashing sink. A panel inside of the ice machine was stained with a brown colored substance. When the panel was wiped with a clean paper towel, brown smears were observed on the paper towel. DM Q agreed that the panel was not properly cleaned. The ice scoop holder on the side of the ice machine was observed with standing, discolored water that contained loose brown sediment. A metal threshold strip was not securely fixed to the floor inside of the walk-in cooler. Part of the metal strip was missing. A predominately brown colored substance was observed around the missing and displaced metal strip. The residue on the floor smeared a clean paper towel when wiped. DM Q was unable to explain or describe the brown-colored substance on the floor of the walk-in cooler. Wire racks inside of the walk-in cooler were discolored. When one of the racks was wiped with a clean paper towel, brown-colored smears were observed on the paper towel. DM Q acknowledged that the racks did not pass the wipe test. Three ladles of varying sizes were hanging from a rack, bowl side up. Four 1/2-size pans, two full-size pans, and three 1/2-size sheet pans were stacked in the clean pot/pan storage and observed to have droplets of water. The top plate, stored in the plate dispenser, was observed to have droplets of water. A green colored insulation foam board, applied to the outside of the walk-in freezer, was chipped and crumbling. Broken pieces of the underlying white foam were observed on the floor. On 3/4/25 at 12:49 PM per DM Q, surfaces within the kitchen should be smooth and cleanable. DM Q indicated that maintenance was responsible for cleaning the inside of the ice machine and food service was responsible for cleaning the outside of the ice machine including the ice scoop bin. On 3/4/26 at 1:25 PM Corporate Maintenance Director, R said the insulation foam board was installed about four years ago because the freezer wall did not have enough insulation to maintain the proper temperature. The freezer condenser pump was replaced, the freezer is operating okay, and the foam insulation is no longer necessary. I never removed the foam. I guess it can come off today. On 3/5/26 at 3:14 PM, the Nursing Home Administrator (NHA) indicated the kitchen was to be up to par. The NHA added they were actively correcting the concerns. According to the 2013 FDA Food Code: Section 2-402, Hair Restraints. Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Section 4-602.11. Equipment Food-Contact Surfaces and Utensils. Equipment food-contact surfaces and utensils shall be cleaned (5) at any time during the operation when contamination may have occurred. Section 4-602.13, Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils shall be air-dried. Section 6-201.11 Floors, Walls, and Ceilings. Except as specified under 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable.

Based on observation, interview, and record review, the facility failed to ensure proper handling of clean linen resulting in the potential for infection among all residents in the facility.Findings include:On 3/5/2026 at approximately 8:20 AM, an observation and tour of the laundry room was conducted with the Housekeeping Manager (HM C). Two blue laundry barrels were observed near the washing and dryer machines. HM C said the barrels were used to transport washed linen to the dryer, and from the dryer to the clean linen area. Both barrels were observed to have paper tissue debris, dried corn kernels, and other unidentifiable debris. HM C confirmed these findings and stated, these barrels need to be kept clean. An undated policy titled, Laundry was provided and revealed the following: Linen can become contaminated with pathogens from contact with intact skin or body substances, or from environmental contaminants or contaminated hands.Separate carts will be used for transporting clean and contaminated linen. Carts will be cleaned when visibly soiled, and routinely according to facility schedule.

Based on observation, interview, and record review, the facility failed to ensure the reach-in juice cooler, the inside of the walk-in cooler and the walk-in freezer were properly maintained and in good working order. Findings include: On 3/3/26 at 8:40 AM during a tour of the kitchen with Dietary Manager (DM) Q, the following items were noted: The door gaskets of the reach-in juice cooler were damaged and loose in several places. A metal threshold strip was not securely fixed to the floor inside of the walk-in cooler. A significant build-up of ice and condensation was visible on the outside of the walk-in freezer door. DM Q said the freezer door does not fully close. On 3/4/26 at 12:50 PM, DM Q said the maintenance supervisor was supposed to check the dietary maintenance log at least once a week. The Maintenance/Dietary Service Log was reviewed with DM Q and revealed the following: 10/30/25 Problem: Freezer door cracked. Solution: Working on it 11/14/25.2/1/26 Problem: Freezer built up on door. Solution: (Area blank.) During an interview on 3/5/26 at 3:14 PM, the Nursing Home Administrator said they were actively correcting the kitchen related concerns presented. A review of the 2013 FDA Food Code documented the following:Section 4-501.11. Good repair and proper adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. Section 6-201.11 Floors, Walls, and Ceilings. Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. Section 6-501.11 Repairing. Physical facilities shall be maintained.

Based on observation, interview, and record review, the facility failed to ensure the walls and cove base outside of the walk-in cooler were in good condition and cleanable and the leak in the janitor's closet was repaired correctly and timely. Findings include: On 3/3/26 at 8:40 AM during a tour of the kitchen with Dietary Manager (DM) Q, the following items were noted: A metal baseboard, approximately eight by four inches, was missing on the outside of the walk-in cooler. The concrete floor in the janitor's closet (chemical closet) was observed to be damp and with standing water. Portions of the cinder block walls in the janitor's closet showed signs of peeling paint and moisture exposure. On 3/4/26 at 12:50 PM, DM Q said the maintenance supervisor was supposed to check the dietary maintenance log at least once a week. The Maintenance/Dietary Service Log was reviewed with DM Q and revealed the following: 12/1/25 Problem: Chemical closet still has leaks from 2nd floor. Solution: (Area blank.) 1/7/26 Problem: Chemical closet still leaking. Solution: (Area blank.) On 3/4/26 at 1:22 PM the Nursing Home Administrator (NHA) said that maintenance had fixed the ceiling leak more than once, but they were probably not fixing it right. On 3/4/26 at 1:25 PM Corporate Maintenance Director (CMD), R said the leak in the janitor's closet was coming from a supply line located inside the concrete. CMD R added they are getting quotes to replace the supply line in the closet. CMD R agreed it should not take months to get a quote. During an interview on 3/5/26 at 3:14 PM, the Nursing Home Administrator said they were actively correcting the kitchen related concerns presented. A review of the 2013 FDA Food Code documented the following:Section 4-501.11. Good repair and proper adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. Section 6-201.11 Floors, Walls, and Ceilings. Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. Section 6-501.11 Repairing. Physical facilities shall be maintained.

Based on interview and record review the facility failed to deposit the resident personal funds (resident trust fund) in an interest-bearing account that is separate from the facility's operating account and credit all interest earned on the resident funds to that account. This deficient practice has the potential to affect R90 and 27 of 36 residents that had over $100.00 in the facility's resident trust fund account in the month of January 2026.On 3/4/26 at 1:44 PM, R90 reported that they received their $60.00 a month but it is always late. According to R90's Electronic Health Record (EHR), R90 admitted on [DATE] with multiple diagnoses that included congestive heart failure. R90 had a court appointed Legal Guardian. R90's annual Minimum Data Set (MDS) dated [DATE] identified R90 to be cognitively intact and totally dependent on staff for all activities of daily living.On 3/5/26 at 10:09 AM during the facility task for resident's Personal Fund with the facility's Business Office Manager (BOM) G, the resident's trust fund account was reviewed for the months of 12/ 2025, 1/ 2026, and 2/2026. BOM G produced facility created excel spread sheets that detailed each resident's activity within their account. There was no credit or documentation to indicate there had been any interest accrued to the resident's trust fund. At this time 35 residents were consistently using the trust fund. BOM G could not produce actual banking statements and stated, The corporate accountant manages the resident's trust funds. I have the quarterly statements and resident's monthly deposits and withdrawals on an accounting sheet, but I don't know if the resident's trust fund is in an interest-bearing account. I'll have to call the accountant. On 3/5/26 at approximately 10:20 AM Corporate Accountant (CA) H was interviewed by phone and asked if the resident's trust fund was in an interest-bearing account. CA H said, Yes, it's in an interest-bearing account but it's in with the facility's account so we just deposit $1.00 per month into each resident's account. CA H was asked why there were no monthly $1.00 credits into the resident's trust fund account for the months of 12/2025, 1/2026, and 2/2026. CA H said, I will provide the updated spreadsheet.On 3/5/26 at 11:46 AM CA H sent over an updated spread sheet that indicated every resident had $1.00 deposited in their account for the months off 12/2025, 1/2026, and 2/2026. CA H could not explain how the previous reviewed spread sheets did not include any deposit for $1.00 to each resident. CA H said, It accumulates very little interest and it's difficult to determine how much each resident should be accruing. On 3/5/26 at 12:31 PM the Nursing Home Administrator (NHA) was asked about the resident's trust fund account and said, I don't have anything to do with it. The corporate accountant handles that. The NHA confirmed the corporate accountant is CA H.On 3/5/26 at 12:34 PM the Legal Guardian (LG) J for R90 was interviewed over the phone. LG J reported that they had received quarterly statements for R90's account from the facility but had not seen any interest accrued or deposited into that account. LG J confirmed that R90 does receive $60.00 per month on the 5th of every month, not the 1st of every month.On 3/5/26 at 2:35 PM, BOM G provided a third set of resident trust fund excel spreads sheet for 12/2025, 1/2026, and 2/2026. This set of spread sheets indicated that each of the 35 residents received a pro-rated amount of interest each month. The BOM did not produce any actual banking statements to indicate the resident's trust fund was in an interest-bearing account. When asked how each resident's interest was determined, BOM G replied, I received these from the corporate accountant.On 3/6/2026 at 10:06 AM during an interview with the NHA and BOM G they confirmed that the excel spread sheets do not match the trust fund account. A review of the actual bank statement for the resident's trust fund did not reveal how interest was determined and had significant amounts of money deposited and withdrawn weekly that did not match with the resident's activity on their personal facility statements. On 3/06/2026 at approximately 11:30 AM the facility's business owner (FBO) I was interviewed and said, The resident's trust fund was co-mingled with the facility's general bank account and interest had not been pro-rated accordingly. We will correct this going forward.According to the facility's Resident Personal Funds policy implemented 10/27/22 in part reads:Deposit of FundsThe facility will deposit any resident's personal funds in excess of S100 in an interest-bearing account (or accounts) separate from any of the facility's operating accounts and will credit all interest earned on resident funds to that account. (In pooled accounts, there must be separate accounting for each resident's share.)The facility will maintain a resident's personal funds that do not exceed $100 in a non-interest-bearing account, interest bearing account, or petty cash fund.Residents whose care is funded by Medicaid: the facility will deposit the resident's personal funds in excess of $50 in an interest-bearing account (or accounts) separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account, (In pooled accounts, there must be separate accounting for each resident's share.)

Based on interview and record review the facility failed to maintain a separate accounting system for the resident trust fund account and use generally accepted accounting principles for 35 residents utilizing the facility's resident trust fund account. This deficient practice has the potential for the misappropriation of resident's funds.Findings include:On 3/5/26 at 10:09 AM during the Personal Fund task with the facility's Business Office Manager (BOM) G, the resident's trust fund account was reviewed for the months of 12/2025, 1/2026, and 2/2026. BOM G produced facility created excel spread sheets that detailed each resident's activity within their account. At this time 35 residents were consistently using the trust fund. BOM G could not produce actual banking statements and stated, The corporate accountant manages the resident's trust funds. I have the quarterly statements and resident's monthly deposits and withdrawals on an accounting sheet, but I don't know if the resident's trust fund is in an interest-bearing account. I'll have to call the accountant. On 3/5/26 at approximately 10:20 AM Corporate Accountant (CA) H was interviewed by phone and asked to provide the actual banking statement for the resident's trust fund. CA H reported that the resident's trust fund account was in an interest-bearing account and bank statements would be provided. Upon further inquiry CA H said, We just deposit $1.00 per month into each resident's account. CA H was unable to provide any consistent banking statements to confirm there was interest deposited into the resident's trust fund account for 12/2025, 1/2026, and 2/2026. CA H said, I will provide the updated spreadsheet.On 3/05/26 at 11:46 AM CA H sent over an updated spread sheet that indicated every resident had $1.00 deposited in their account for the months of 12/2025, 1/2026, and 2/2026. CA H did not provide actual banking statements of the account at this time. On 3/5/26 at 12:31 PM the Nursing Home Administrator (NHA) was asked about the resident's trust fund account and said, I don't have anything to do with it. The corporate accountant handles that. The NHA confirmed the corporate accountant is CA H.On 3/5/26 at 2:35 PM, BOM G provided a third set of resident trust fund excel spreads sheet for 12/2025, 1/2026, and 2/2026. This set of spread sheets indicated that each of the 35 residents received a pro-rated amount of interest each month. The BOM did not produce any actual banking statements to indicate the resident's trust fund was in a separate interest-bearing account from the facility. On 3/6/26 at 10:06 AM during an interview with the NHA and BOM G the actual bank statements for the resident's trust fund was provided. BOM G confirmed that the amount in the excel spread sheets did not match the trust fund's amount. A review of the actual bank statement for the resident's trust fund did not reveal how interest was determined and had significant amount of money deposited and withdrawn weekly that did not match with the resident's activity on their personal facility statements. On 3/6/26 at approximately 11:30 AM the facility's business owner (FBO) I was interviewed and said, The resident's trust fund was co-mingled with the facility's bank account. We were withdrawing money out of the resident's trust fund account at the end of every month so it would not get levied (legal seizure of property of assets, such as bank accounts) by an outside entity. FBO I went on to say that the resident's trust fund would now be separated out from the corporation to prevent possible loss of resident's monies. According to the facility's policy for Resident Personal Funds implements on 10/27/2022 in part reads:Accounting and Records1. The facility will establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's person funds entrusted to the facility on the resident's behalf.2. The system will preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident.

Based on observation, interview, and record review, the facility failed to provide periodic reviews and to adequately update information on Advance Medical Directives (AMD- the written instruction relating to the provision of health care) for five (R5, R6, R55, R45, and R25) of thirteen residents reviewed for advanced directives. Findings include: On 3/3/25 at 1:27 PM, R25's face sheet indicated R25 was a full code (in the event the resident stops breathing, and/or heart stops beating, healthcare providers will use all available aggressive life-saving measures). A Resident Code Status form dated 11/18/24 indicated R25 was a 'full code'. This form had the resident's initials next to it, a physician signature, and undeterminable facility staff signature. However, a Code status/Do Not Resuscitate (DNR) Directive form with an earlier date of 5/16/23 indicated R25 was a 'Do Not Resuscitate (in the event the resident stops breathing, and/or heart stops beating, healthcare providers will not use any medical interventions). This form was signed by R25's Legal Guardian (LG), the physician, and two witnesses. Valid LG paperwork was verified in R25's EHR. At this time R25 was observed seated in his bed drinking coffee and was unwilling to be interviewed regarding this subject matter. On 3/4/26 at 2:20 PM during an interview with Social Worker (SW) K the two different code status forms were reviewed. SW K could not explain why there was a change in code status and said, That is not my signature on either form. I don't know who signed those code status forms. I will have to review it with resident's Legal Guardian. Further review of R25's EHR did not reveal any documentation to support the LG had been consulted regarding code status. On 3/4/26 at 2:45 PM R25's court appointed LG L for R25 was interviewed over the phone regarding code status and said that R25 was a DNR. LG L stated, I will email the Social Worker to clarify this. We email monthly and no one has asked me about this. I don't know why it would be changed. On 03/03/2026 at 3:03 PM, record review revealed R5 has a code status of Full Code with no documentation of information offered regarding the option of formulating an advanced directive. Further record review revealed no documentation to support a periodic review of an advanced directive. There was also no evidence of a periodic review of advance medical directives as part of the comprehensive care planning process. Record review of the admission record revealed R5 was admitted to the facility on [DATE] with a diagnosis of Anemia, Hypertension, Peripheral Vascular Disease, Renal Failure, Diabetes and Hyperlipidemia. The Minimum Data Set, dated [DATE] revealed R5 has a Brief Interview for Mental Status (BIMS) of 14 out of 15 which indicates cognitively intact. On 03/03/2026 at 2:35 PM, record review revealed R6 has a code status of Full Code with an Advance Directive signed by R6 on 03/08/24. Record review also revealed R6 has a legal guardian. Further record review revealed no documentation to support a periodic review of an advanced directive since 03/08/2024. Record review did not reveal documentation of a discussion with the legal representative regarding formulating an advanced directive or the provision of updating the current advanced directive. There was also no evidence of a periodic review of advance medical directives as part of the comprehensive care planning process. Record review of the admission record revealed R6 was admitted to the facility on [DATE] with a diagnosis of Hypertension, Reflux, Diabetes, Hyperlipidemia and Huntington's Disease. The Minimum Data Set, dated [DATE] revealed R6 has a Brief Interview for Mental Status of 7 out of 15 which indicates severe impairment. On 03/03/2026 at 2:00 PM, record review revealed R45 has a code status of Full Code. An advanced directive form, located in the electronic health record (EHR) was signed by R45 on 11/18/2024.Record review also revealed R45 has a legal guardian. Further record review revealed a lack of documentation supporting a discussion with the legal representative regarding formulating an advanced directive or the provision for periodically reviewing and/or updating an advanced directive. A record review revealed there was also no evidence of a periodic review of advance medical directives as part of the comprehensive care planning process. Record review of the admission record revealed R45 was admitted on [DATE] with a diagnosis of Schizoaffective Disorder, Bipolar Type, Major Depression, Generalized Anxiety Disorder. The Minimum Data Set, dated [DATE] revealed R45 has a Brief Interview for Mental Status of 12 out of 15 which indicates a moderate impairment. On 03/03/2026 at 2:10 PM, record review revealed R55 has a code status of Full Code with an advanced directive signed by R55 on 02/13/2023. Record review also revealed R55 has a legal guardian. Further record review revealed no documentation to support a periodic review of an advanced directive since 02/13/2023. Record review also did not reveal documentation of a discussion with the legal representative regarding formulating an advanced directive or the provision of updating the current advanced directive. There was also no evidence of a periodic review of advance medical directives as part of the comprehensive care planning process. Record review of the admission record revealed R55 was admitted on [DATE]. The Minimum Data Set, dated [DATE] revealed R55 has a Brief Interview for Mental Status of 15 out of 15 which indicates cognitively intact. On 03/04/2026 at 2PM, Social Worker (SW) K was interviewed and stated, Advanced Directives are reviewed at the time of admission and should be reviewed at least quarterly. On 03/05/2026 at 9AM, the Nursing Home Administrator (NHA) was queried on expectations of advance directives. The NHA said, Advance Directives should be reviewed quarterly and updated yearly. The resident and their guardian should sign, and the discussion should be documented. Reviewed policy on Advanced Directives entitled, Residents' Rights Regarding Treatment and Advance Directives date revised- 01/07/2026, which reads in part: . During the care planning process, the facility will identify, clarify and review with the resident or legal representative whether they desire to make any changes related to any advance directives.Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehension care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. Any decision making regarding the resident's choices will be documented in the medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. No further information provided for advanced directives.

This citation pertains to intake 2792738. Based on interview and record review, the facility failed to ensure money was safe from misappropriation for one resident (R110) of two residents reviewed for abuse, resulting in missing resident funds. Findings include: A review of a Facility Reported Incident (FRI) dated 1/29/26 documented in part the following: The Nursing Home Administrator (NHA) received a call from the corporate office on 1/29/26 that the social service employee (SSE) M was suspected of stealing money from R110. The NHA was informed by corporate office to speak with Business Office Manager (BOM) G to find out what happened. BOM G informed the NHA that R110 had been informed on 1/23/26 of a check that was returned due to insufficient funds. R110 informed BOM G that there was $4000.00 in the bank. R110 requested BOM G's assistance in a review of financial transactions. R110 did not have their bank card or wallet on them. R110 stated, The (SSE M) has it. BOM G went to the social service office and asked Social Worker K about the location of R110's wallet. SW K said that SSE M had it in their desk. When R110 reviewed the contents of the wallet in the presence of BOM G, the bank card was not in the wallet. The FRI continued and documented R110 called the bank and put the phone on speaker with BOM G present. The bank employee informed R110 that charges on their bank card were automatically paid off at the end of each month. R110's credit card payment on 12/20/25 was $6303.17. This payment put R110 in overdraft status and was the reason for the returned check for insufficient funds. The bank employee named several transactions that were disagreeable with R110. Per BOM G, the financial institution asked if they had any idea who would be using the card. BOM G identified SSE M. Per BOM G, the financial institution replied that was the person they have been tracking for a cash advance with invalid data. R110's bank card was cancelled immediately per BOM G. A document in the FRI investigative file, written by BOM G, revealed the following:On 1/23/26, telephone calls were made to two different financial institutions involving R110's bank card transactions. On this document, BOM G listed transactions with the following retailers allegedly made with R110's bank card: Target, [NAME], BP gas station, Oak Park Fuel cash advance, Dollar General, Southwest Airlines, Walmart, Best Buy, [NAME], Bath & Body Works, Sams Club, CVS, and Marshalls. A payment was made to R110's bank card on 12/20/25 in the amount of $6303.17. According to the FRI documentation, SSE M was immediately suspended via phone as they had left early for a personal emergent situation. The NHA spoke with R110 on 1/29/26. R110 was being discharged on the same day. R110 indicated being aware that someone allegedly stole their money. R110 stated, I think it was the social worker, I don't know. R110 was asked to stay long enough for the facility to call the police. R110 said no, my driver is here. R110 was informed that it was mandatory for the facility to report this allegation to the police. R110 stated, Go ahead but I'm leaving. According to the FRI, the allegation of abuse was inconclusive. A review of R110's clinical record documented an original admission date of 4/7/25 and readmission date of 9/2/25. R110's diagnoses included epilepsy, congestive heart failure, depressive disorder, and anxiety disorder. A Minimum Data Assessment (MDS) dated [DATE] documented intact cognition. During an interview on 3/4/26 at 9:00 AM, the Nursing Home Administrator (NHA) said SSE M did have R110's bank card. The Activity Director and SW K verified that SSE M assisted R110 with bill paying. On 1/29/26, SSE M was suspended immediately by the NHA. SSE M resigned from their position on February 1, 2026. During an interview on 3/4/26 at 9:13 AM, BOM G said an email was received on 1/23/26 from the corporate office that a check written out to the facility from R110, dated 1/13/26, had been returned due to insufficient funds. BOM G spoke to R110 who reported having over $4000.00 in their checking account. BOM G verified the speakerphone discussions held with R110 and their financial institutions on 1/23/26. BOM G said the MDS Coordinator was present in the office during these conversations. During an interview on 3/4/26 at 10:01 AM, MDS Coordinator/Licensed Practical Nurse (LPN) N said she witnessed BOM G speaking with R110. LPN N overheard the conversations with the financial institutions because the telephone calls were on speaker phone. R110 granted the financial institutions permission to speak with BOM G. The calls were about a bounced check. LPN N heard the person on the line report a list of transactions made on R110's bank card that included a cash advance at a gas station and a transaction with Southwest Airlines. LPN N indicated that someone was stealing from R110. A review of the facility document titled, Abuse, Neglect and Exploitation, dated July 2025, revealed in part the following:- It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit prevent abuse, neglect, exploitation and misappropriation of resident property.- Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.- Possible indicators of abuse include but are not limited to: Resident reports of theft of property, or missing property.

This citation pertains to intake 2792738. Based on interview and record review, the facility failed to ensure staff reported an allegation of misappropriation of resident property (MARP) to the State Agency in a timely matter for one resident (R110) out of two residents reviewed for abuse, which could result in additional missing resident funds. Findings include:On 1/29/26 the facility reported incident to the State Agency documented an allegation of misappropriation of resident property. A review of the facility's 5-Day abuse investigation summary dated 2/5/26 documented in part the following: The Nursing Home Administrator (NHA) received a call from the corporate office on 1/29/26 that the social service employee (SSE) M was suspected of stealing money from R110. The NHA was informed by corporate office to speak with Business Office Manager (BOM) G to find out what happened. BOM G informed the NHA that R110 had a check written out to the facility that was returned on 1/23/26 due to insufficient funds. Per BOM G, R110 requested their assistance to review banking transactions. R110 informed BOM G that there was $4000.00 in the bank. R110 did not have their bank card or wallet on them. R110 stated, The social worker has it. BOM G went to the social service office and asked Social Worker K about the location of R110's wallet. SW K said that SSE M had it in their desk. When R110 reviewed the contents of the wallet in the presence of BOM G, the bank card was not in the wallet. R110 called the bank and put the phone on speaker with BOM G present. The bank employee informed R110 that charges on their bank card were automatically paid off at the end of each month. R110's credit card payment on 12/20/25 was $6303.17. This payment put R110 in overdraft status and was the reason for the returned check for insufficient funds. The bank employee named several transactions that were disagreeable with R110. Per BOM G, the financial institution asked if they had any idea who would be using the card. BOM G identified SSE M. Per BOM G, the financial institution replied that was the person they have been tracking for a cash advance with invalid data. R110's bank card was cancelled immediately per BOM G. During an interview on 3/4/26 at 9:00 AM, the NHA was identified as the facility's abuse coordinator. The NHA stated, It did not make sense for (BOM G) to bypass me to report this concern. The NHA said that on 1/23/26 BOM G was aware of the possibility of MARP because R110's check to the facility was returned due to insufficient funds. The NHA reported to the State Agency the allegation of MARP on 1/29/26. During an interview on 3/4/26 at 9:13 AM, BOM G said they received an email on 1/23/26 from the corporate office that a check written out to the facility from R110, dated 1/13/26, had been returned due to insufficient funds. BOM G spoke to R110 who reported having over $4000.00 in the checking account. BOM G said they were unsure of an established protocol of what to do when a resident's check was returned due to insufficient funds. BOM G said they suspected fraudulent activity towards R110 on 1/23/26 because of the returned check. BOM G was aware that the NHA was the facility's abuse coordinator but decided to report the allegation of MARP to the company's owner (Owner V). On 1/23/26 BOM G sent the following text message to Owner V, The check that was returned was for a resident that had his information in the SW office. The resident stated that (they) received a call saying (their) card was used and if (they) authorized it. That is all the info the resident could give me. I am going to have (them) call the bank. BOM G said they spoke to Owner V on 1/27/26 regarding the suspected MARP. BOM G said they were aware of the facility's abuse policy. BOM G stated, I know I didn't follow the protocol when they failed to report the suspected MARP to the facility's abuse coordinator. BOM G said she did not report the allegations to the State Agency either. A review of R110's clinical record documented an original admission date of 4/7/25 and readmission date of 9/2/25. R110's diagnoses included epilepsy, congestive heart failure, depressive disorder, and anxiety disorder. A Minimum Data assessment dated [DATE] documented intact cognition. A review of the facility document titled, Abuse, Neglect and Exploitation, dated July 2025, revealed in part the following:- It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit the prevent abuse, neglect, exploitation and misappropriation of resident property.- Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.- Possible indicators of abuse include but are not limited to: Resident reports of theft of property, or missing property.- The facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. - Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

This citation pertains to intake 2792738. Based on interview and record review, the facility failed to conduct a thorough investigation of misappropriation of resident property (MARP) for one resident (R110), out of two residents reviewed for abuse. Findings include: A review of a Facility Reported Incident (FRI) dated 1/29/26 documented in part the following: The Nursing Home Administrator (NHA) received a call from the corporate office on 1/29/26 that the social service employee (SSE) M was suspected of stealing money from R110. The NHA was informed by corporate office to speak with Business Office Manager (BOM) G to find out what happened. BOM G informed the NHA that on 1/23/26, R110 had been informed of a check that was returned due to insufficient funds. Per BOM G, R110 requested their assistance to review banking transactions. R110 informed BOM G that there was $4000.00 in the bank. R110 did not have their bank card or wallet on them. R110 stated, The social worker has it. BOM G went to the social service office and asked Social Worker K about the location of R110's wallet. SW K said that SSE M had it in their desk. When R110 reviewed the contents of the wallet in the presence of BOM G, the bank card was not in the wallet. The FRI continued and documented R110 called the bank and put the phone on speaker with BOM G present. The bank employee informed R110 that charges on the credit card were automatically paid off at the end of each month. R110's credit card payment on 12/20/25 was $6303.17. This payment put R110 in overdraft status and was the reason for the returned check for insufficient funds. The bank employee named several transactions that were disagreeable with R110. Per BOM G, the financial institution asked if they had any idea who would be using the card. BOM G identified SSE M. Per BOM G, the financial institution replied that was the person they have been tracking for a cash advance with invalid data. R110's bank card was cancelled immediately per BOM G According to the FRI documentation, on 1/29/26, the NHA immediately suspended (SSE) M by phone as SSE M left early for a personal emergent situation. The NHA spoke with R110 on 1/29/26. R110 was being discharged on the same day. R110 indicated being aware that someone allegedly stole their money. R110 stated, I think it was the social worker, I don't know. R110 was asked to stay long enough for the facility to call the police. R110 said no, my driver is here. R110 was informed that it was mandatory for the facility to report this allegation to the police. R110 stated, Go ahead but I'm leaving. According to the FRI, the allegation of abuse was inconclusive. A review of R110's clinical record documented an original admission date of 4/7/25 and readmission date of 9/2/25. R110's diagnoses included epilepsy, congestive heart failure, depressive disorder, and anxiety disorder. A Minimum Data Assessment (MDS) dated [DATE] documented intact cognition. During an interview on 3/4/26 at 9:13 AM, BOM G said they received an email on 1/23/26 from the corporate office that a check written out to the facility from R110, dated 1/13/26, had been returned due to insufficient funds. BOM G spoke to R110 who reported having over $4000.00 in the checking account. BOM G confirmed the 1/23/26 conversations conducted with R110 and their financial institutions as documented in the FRI investigation. BOM G said the MDS Coordinator was present in the office during these conversations. During an interview on 3/4/26 at 10:01 AM, MDS Coordinator/Licensed Practical Nurse (LPN) N said she witnessed BOM G speaking with R110. LPN N overheard the conversations with the financial institutions because the calls were on speaker phone. R110 granted the financial institutions permission to speak with BOM G. The calls were about a bounced check. R110 heard the person on the line report a list of transactions made on R110's bank card that included a cash advance at a gas station and a transaction with Southwest Airlines. LPN N indicated that someone was stealing from R110. LPN N did not provide a statement to the NHA because they were not asked to. The FRI investigative file was reviewed and there was no interview from LPN N. SSE M, who was in possession of R110's bank card was unable to be interviewed because they resigned from their position. A review of the facility document titled, Abuse, Neglect and Exploitation, dated July 2025, revealed in part the following:- An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.- Written procedures for investigations include identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; and providing complete and thorough documentation of the investigation.

Based on observation, interview, and record review, the facility failed to develop and implement a supra-pubic (s/p, a tube inserted through the abdomen directly into the bladder to drain urine) indwelling urinary catheter care plan for one (R9) of two residents reviewed for urinary catheter.Findings include:On 3/4/26 at 9:35 AM R9 was observed seated on their bed in t-shirt and sweatpants. A urinary catheter tubing was observed pulling tightly downward from under R9's T-shirt. The catheter was attached to a collection bag resting on the floor. There was approximately 1 liter of urine in the collection bag. R9 was asked about the catheter and said, It's bothering me. R9 lifted up their T-shirt and lowered the waistband of their sweatpants to show the s/p catheter's insertion site. There was an anchoring device on the catheter, but it was not adhered to R9's body. The insertion site had no dressing over it and was open to air. A small shallow ulcer was observed around the stoma (surgically created hole the tubing goes through). The ulcer was pink, moist, and without visible drainage. There was some redness to the surrounding area. It appeared that the waistband of R9's sweatpants was directly resting over the s/p catheter's insertion site. Licensed Practical Nurse (LPN) A was present and stated, I'm going to call the doctor about the redness at the site, it (the catheter insertion site) should be covered. This (the collection bag) should be emptied out and picked up off the floor. LPN A confirmed that the anchoring device was not attached correctly. LPN A stated, It's not sticking to anything. It needs a new one. According to R9's Electronic Health Record (EHR) they admitted on [DATE] with multiple diagnoses that included neuromuscular dysfunction of the bladder and required a s/p catheter to drain urine. On 2/2/26 a Physician's order for urinary catheter care included: ensure the anchor is in place. The last annual Minimum Data Set (MDS) dated [DATE] indicated R9 had a supra-pubic catheter. Section 'V triggered urinary incontinence/indwelling catheter as a care area assessment, but there is no urinary or catheter care plan. R9 had a care plan for urinary tract infection initiated on 2/16/26, but there are no interventions for catheter care. On 3/6/26 at 10:40 AM the Director of Nursing (DON) was asked about R9's s/p catheter and lack of care plan and said, There are orders to cleanse and dress the site every day and as needed. A care plan has been started. I don't know why it wasn't done before. The DON was asked to provide a policy for resident care planning and stated, We don't have one. It's part of the MDS assessment that a care plan would be started.

Based on observation, interview, and record review, the facility failed to assist a wheelchair dependent resident (R35), reliant on the use of the elevator to smoke, of one resident reviewed for smoking resulting in missed opportunities for smoking.Findings include: On 3/3/2026 at approximately 1:00 PM, R35 was observed in their wheelchair at the 2nd floor elevator. R35 said they were waiting to go outside and smoke. On 3/3/2026 at approximately 1:20 PM, R35 was observed at the 1st floor elevator. When asked if they went outside to smoke, R35 stated, no, I missed it. On 3/3/2026 at approximately 1:45 PM, R35 said that they miss their smoke breaks often because there is only one elevator out of two elevators in the building that work. R35 further said that it can take up to 30 minutes to get on the elevator because so many residents and staff are waiting to use it. In addition, R35 stated, It is very upsetting to miss my smoke breaks. If you miss it, it's a non-negotiable - they close the door and won't let you smoke. It happens a lot. A record review was completed on 3/4/2026 and revealed that R35 was admitted to the facility on [DATE] with diagnoses that included seizures, hemiplegia and hemiparesis, heart disease, cerebral infarction, anxiety, and depression. Section C of the Minimum Data Set with an Assessment Reference Date of 12/4/2025 revealed R35 scored a 15/15 on the Brief Interview for Mental Status assessment - indicative of no cognitive impairment. Section GG of the Minimum Data Set with an Assessment Reference Date of 12/4/2025 revealed R35 needed partial moderate assistance from staff to transfer from their bed to wheelchair. A Smoking Risk Assessment was last completed on 3/4/2025 and revealed that R35 was safe to smoke. R35's care plan indicated they had the ability to smoke. On 3/4/2026 at approximately 3:00 PM, a sign posted on a bulletin board near the activity director office listed facility designated smoking times as 9:15 AM, 1:00 PM, and 5:15 PM. On 3/4/2026 at approximately 3:30 PM, Activity Director (AD B) was interviewed regarding the facility smoking procedures. AD B stated, once the smoke break is over, the activity staff go to other responsibilities, so the smoke break ends. On 3/5/2026 at approximately 3:30 PM, the Nursing Home Administrator (NHA) was interviewed regarding resident smoke breaks. The NHA stated, the resident should be allowed to smoke.A policy titled, Resident Smoking, Vaping, and Smokeless Tobacco, reviewed/revised 6/5/2025 revealed, Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan.

Based on observation, interview, and record review the facility failed to implement appropriate indwelling urinary catheter care for one (R9) of two residents reviewed for urinary catheter care resulting in discomfort and irritation at R9's supra-pubic catheter (s/p, a tube inserted through the abdomen directly into the bladder to drain urine) insertion site along with the potential for infection and catheter dislodgement.Findings include:On 3/4/26 at 9:35 AM R9 was observed seated on their bed in t-shirt and sweatpants. A urinary catheter tubing was observed pulling tightly downward from under R9's T-shirt. The catheter was attached to a collection bag resting on the floor. There was approximately 1 liter of urine in the collection bag. R9 was asked about the catheter and said, It's bothering me. R9 lifted up their T-shirt and lowered the waistband of their sweatpants to show the s/p catheter's insertion site. There was an anchoring device on the catheter, but it was not adhered to R9's body. The insertion site had no dressing over it and was open to air. A small shallow ulcer was observed around the stoma (surgically created hole the tubing goes through). The ulcer was pink, moist, and without visible drainage. There was some redness to the surrounding area. It appeared that the waistband of R9's sweatpants was directly resting over the s/p catheter's insertion site. Licensed Practical Nurse (LPN) A was present and stated, I'm going to call the doctor about the redness at the site, it (the catheter insertion site) should be covered. This (the collection bag) should be emptied out and picked up off the floor. LPN A confirmed that the anchoring device was not attached correctly. LPN A stated, It's not sticking to anything. It needs a new one. According to R9's Electronic Health Record (EHR) they admitted on [DATE] with multiple diagnoses that included neuromuscular dysfunction of the bladder and required a s/p catheter to drain urine. On 2/2/26 a Physician's order for urinary catheter care included: ensure the anchor is in place. The last annual Minimum Data Set (MDS) dated [DATE] indicated R9 had a supra-pubic catheter. Section 'V triggered urinary incontinence/indwelling catheter as a care area assessment, but there is no urinary or catheter care plan. R9 had a care plan for urinary tract infection initiated on 2/16/26, but there are no interventions for catheter care. On 3/4/26 at 11:00 AM LPN A said the physician ordered for wound care to consult and treat R9's s/p catheter site. On 3/6/26 at 10:40 AM the Director of Nursing (DON) was asked about R9's s/p catheter site and said, There are orders to cleanse and dress the site every day and as needed. It should have been done before. There are care plans in place now. According to the facility's Indwelling Catheter Use and Removal policy implemented on 11/1/2022, in part reads: It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice.4. If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to:f. Ongoing monitoring for changes in condition related to potential catheter-associated urinary tractinfections, recognizing, reporting and addressing such changes.7. Additional care practices include:a. Recognition and assessment for complications and their causes, and maintaining a record of anycatheter-related problems d. Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethraltears or dislodgement of the catheter; ande. Securement of the catheter to facilitate flow of urine, prevention of kinks in the tubing and positioningbelow the level of the bladder.

Based on observation, interview, and record review, the facility failed to prepare vegetables to the proper food consistency for four residents receiving pureed textured meals in the facility. Findings include: On 3/3/26 at 11:04 AM, during observations of the kitchen lunch service with Head [NAME] S and Dietary Manager (DM) Q, the steam table was set with pans of food ready to be served to facility residents. Due to a lack of space on the steam table, the pan of prepared pureed green beans, also ready to be served to the residents, was sitting in a pan of water on the hot stove. While taking food temperatures, the pureed green beans appeared lumpy. DM Q and the two State Surveyors present obtained and tasted a sample of the green beans. The consensus from the tasting was that the green beans contained lumps. DM Q said the green beans needed to be smoother. Head [NAME] S informed the staff on the tray line to put the meal tickets for the residents on pureed diets aside because the pureed green beans were being smooth out in the blender. On 3/4/26 at 12:34 PM, when Registered Dietitian, T was queried about the consistency of pureed food, they said, It should be smooth like pudding.

This citation pertains to intake number 2723282.Based on observation, interview, and record review, the facility failed to protect R201's right to be free from physical and mental abuse by Housekeeper D and Housekeeping Manager C, when Housekeeping Manager C sprayed a chemical (bleach cleaner) into the eyes of R201 while Housekeeper D held R201's wheelchair in place. This deficient practice caused chemical damage to R201's eyes and subsequent pain.Findings include: On 1/14/2026 at 8:51 AM, the State Agency (SA) received a Facility Reported Incident (FRI) with an allegation of staff to resident abuse.On 2/4/2026 at 10:00 AM, R201 was observed in bed and was interviewed about the reported incident to the SA. R201 stated, Some staff sprayed a chemical in my eyes. My right eye is still messed up, and I am having pain in it. R201 said the incident occurred in the sixth-floor hallway and said he was assaulted by several employees but could not identify the staff members. R201 stated, They also hit me with a broom. R201 was unable to describe which chemical was sprayed. R201 said he went to the hospital to get his eyes treated.On 2/4/2026 at 11:22 AM, the Nursing Home Administrator (NHA) was queried regarding the incident with R201 and provided a video recording and facility investigation. Review of the video dated 1/12/2026 with a time stamp of 14:33 with the NHA revealed Housekeeping Manager (HM) C spraying a spray bottle identified as Clorox bleach cleaner by the NHA directly at R201beginning at 41 seconds. There appeared to be a total of five sprays directed at R201 from HM C. When the NHA was asked to describe the incident on video the NHA stated, I saw (HM C) spray Clorox cleaning spray in R201's face in the hallway on the sixth floor. The NHA identified from the video recording Housekeeper D holding R201's wheelchair while HM C sprayed Clorox cleaning spray at R201. The NHA identified Certified Nursing Assistant (CNA) B in the video.On 2/24/2026 at 11:50 AM, CNA B was interviewed and said she was working on the sixth floor and witnessed the incident with R201. CNA B stated, I saw (HM C) spray Clorox cleaning spray in R201's face in the hallway. CNA B said HM C stated, I'm gonna fuck him up and sprayed more Clorox bleach spray in R201's face. CNA B stated, I knew it was bleach spray because of the smell.Record review of R201's Electronic Health Record (EHR) revealed original admission to the facility on 9/1/2023 with most recent readmission on [DATE] with diagnoses that included Schizoaffective disorder, Dementia, Acquired absence of left leg below knee, and Asthma. Review did not reveal a history of eye disease.The Minimum Data Set (MDS) dated [DATE], indicated that R201 had adequate vision (-sees fine details, such as regular print in newspaper/books), did not wear corrective glasses, had moderate cognitive impairment and was wheelchair bound.Review of the practitioner progress note dated 1/1/2026, revealed, HEENT (head, eyes, ears, nose, and throat) Normocephalic and atraumatic. Conjunctiva white, sclera non-icteric (normal sized head, no trauma, eyes white and healthy in appearance).Review of R201's progress note dated 1/12/2026 at 3:33 PM, revealed, Resident transferred to hospital at his request via Detroit Police Department.Review of R201's hospital after visit summary dated 1/12/2026 revealed, You were seen on Monday January 12th, 2026, for Eye Pain. The following issue was addressed: Chemical exposure of eye. Instructions -Preservative free artificial tears every hour during the day in both eyes. Erythromycin ointment four times per day while awake in both eyes. Pred forte four times per day in both eyes. Moxifloxacin four times per day in both eyes.Review of R201's progress note dated 1/13/2026 at 8:16 AM revealed, Resident was transported back to the facility from hospital at approximately 3AM.Review of R201's practitioner progress note dated 1/13/2026 revealed, Patient evaluated today following recent ED transfer (1/12/26) after allegation of chemical exposure to the eyes during a confrontation between patient and facility staff member. Patient returned to SNF (Skilled Nursing Facility) on 1/13/26. Today is the first day ophthalmic medications will be administered. Mild conjunctival redness noted on arrival and periorbital puffiness noted.Review of R201's ophthalmology report of consultation dated 1/14/2026, revealed, (R201) was seen for chemical exposure to the front of eyes. Initially had significant epithelial irritation (eye irritation) with corneal haze (a condition that affects the transparent outermost layer of the eye, the cornea) although improving today continues to have some haze. Overall improving, will adjust medications. Diagnosis: chemical exposure of eye, no limbal ischemia (inadequate blood supply to the limbus, the border between the cornea and the conjunctiva).Review of R201's after Visit Summary dated 1/14/2026 revealed, You have chemical damage to the front of your eyes which is improving.On 2/24/2026 at 1:00 PM, R201's previous eye examination records were requested.On 2/4/2026 at 2:00 PM, the Director of Nursing (DON) was interviewed and reviewed R201's EHR. The DON said R201 did not have a medical history of eye disease or any listed eye conditions other than dry eyes. The DON said there were no previous eye consultations for R201. The DON further said there wasn't a documented history of cornea haze or eye issues for R201.On 2/4/2026 at 3:30 PM, the NHA was interviewed and said all employees receive abuse training and how to deal with combative residents upon hire and at least yearly. The NHA said the expectation is for staff to de-escalate tense situations with residents, to walk away and not engage. The NHA said all employees associated with the incident with R201 were terminated for not following the abuse policy.Review of the facility policy titled Abuse, Neglect and Exploitation dated January 2026, revealed in part.It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm.

This citation pertains to 1220384, 1220412, and 2569363.Based on interview and record review the facility failed to ensure that one resident (R406) of five residents reviewed was free from abuse and exploitation of personal funds resulting in certified nursing assistant (CNA) A using a R406's debit card to make purchases totaling $1,900.Findings include:According to a facility reported incident, CNA A used R406's debit card to make a personal purchase.On 7/30/25 at 2:05 PM, R406 was interviewed regarding the incident. R406 acknowledged the incident and said that the facility had recovered some of the money taken from their debit card.On 7/31/25 at 11:00 AM, the Nursing Home Administrator (NHA) was interviewed regarding the incident and reported CNA A had taken R406's money and had made payments toward the $1,900 debit balance, reducing the amount owed to $570.42. The NHA said the facility provides education regarding abuse and expects staff to follow facility policies.Record reviewed noted that R406 was admitted on [DATE] with the following diagnosis including hypertension, fracture of right ulna, fracture of sixth cervical vertebra, protein malnutrition and physical disability.Review of Quarterly Minimum Data Set (MDS) dated [DATE] documented R406 Brief Interview for Mental Status (BIMS) score was 12 out of 15 indicating R406 was moderately cognitively impaired.Record review revealed the following:On 7/10/25, R406's debit card declined when the facility attempted to process a payment. R406 was advised to cancel the debit card.On 7/11/25, CNA A informed the facility they had obtained R406's debit card number and had made purchases totaling $1,900.On 7/16/25, CNA A acknowledged they had broken a nursing home rule and resigned.Review of a facility document, Abuse, Neglect, Exploitation with a revised date of July 2025, noted, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. In addition the policy defined exploitation as taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion.

This citation pertains to intake MI00153787 Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 107 residents who consume food products, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 06/25/25 at 11:52 A.M., A comprehensive tour of the food service was conducted with Dietary Manager A. The following items were noted: The 3-compartment sink sanitizer basin chemical concentration was tested and observed to be more than 500 parts-per-million (PPM) quaternary ammonia. Dietary Manager A indicated she would contact the contractual vendor for necessary adjustments to the chemical dispensing assembly as soon as possible. The 2022 FDA Model Food Code section 4-501.114 states: A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under §7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart; FDA Food Code 2022 Chapter 4 Equipment, Utensils, and Linens Chapter 4 - 19 CONCENTRATION RANGE (MG/L) MINIMUM TEMPERATURE PH 10 OR LESS °C (°F) MINIMUM TEMPERATURE PH 8 OR LESS °C (°F) 25 - 49 49 (120) 49 (120) 50 - 99 38 (100) 24 (75) 100 13 (55) 13 (55) (B) An iodine solution shall have a: (1) Minimum temperature of 20°C (68°F), (2) PH of 5.0 or less or a PH no higher than the level for which the manufacturer specifies the solution is effective, and (3) Concentration between 12.5 MG/L and 25 MG/L; (C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24oC (75oF), (2) Have a concentration as specified under § 7-204.11 and as indicated by the manufacturer's use directions included in the labeling, and (3) Be used only in water with 500 MG/L hardness or less or in water having a hardness no greater than specified by the EPA-registered label use instructions; (D) If another solution of a chemical specified under (A) - (C) of this section is used, the PERMIT HOLDER shall demonstrate to the REGULATORY AUTHORITY that the solution achieves SANITIZATION and the use of the solution shall be APPROVED; (E) If a chemical SANITIZER other than chlorine, iodine, or a quaternary ammonium compound is used, it shall be applied in accordance with the EPA-registered label use instructions; and (F) If a chemical SANITIZER is generated by a device located on-site at the FOOD ESTABLISHMENT it shall be used as specified in (A) - (D) of this section and shall be produced by a device that: (1) Complies with regulation as specified in §§ 2(q)(1) and 12 of the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA), (2) Complies with 40 CFR 152.500 Requirement for Devices and 40 CFR 156.10 Labeling Requirements, (3) Displays the EPA device manufacturing facility registration number on the device, and (4) Is operated and maintained in accordance with manufacturer's instructions The Manitowac ice machine interior stainless steel retention plate was observed heavily stained and corroded with rust scale deposits. Dietary Manager A indicated she would have maintenance remove and thoroughly clean and sanitize the retention plate assembly as soon as possible. The can opener assembly and mounting plate bracket were observed heavily soiled with accumulated and encrusted food residue deposits. The cutting blade surface was also observed black in color with excessive food residue build-up. Dietary Manager A indicated she would have staff thoroughly clean and sanitize the can opener assembly and mounting plate bracket as soon as possible. The Coffee Machine interior and exterior surfaces were observed soiled with accumulated and encrusted food residue deposits. Dietary Manager A indicated she would have staff thoroughly clean and sanitize the coffee machine as soon as possible. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The Amana commercial microwave oven exterior door handle was observed cracked and broken. The door handle could be moved completely around in a 360-degree circle. Dietary Manager A indicated she would contact maintenance for necessary repairs as soon as possible. The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. On 06/25/25 at 01:31 P.M., An interview was conducted with Dietary Manager A regarding specific Policies/Procedures for cleaning and maintaining food service equipment. Dietary Manager A stated: I will see what I have. On 06/26/25 at 08:00 A.M., Record review of the Policy/Procedure entitled: Sanitation Inspection dated 11/01/2022 revealed under Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations. Record review of the Policy/Procedure entitled: Sanitation Inspection dated 11/01/2022 further revealed under Policy Explanation and Compliance Guidelines: (1) All food service areas shall be kept clean, sanitary, free from litter, rubbish, and protected from rodents, roaches, flies, and other insects. On 06/26/25 at 08:15 A.M., Record review of the Policy/Procedure entitled: Manual Warewashing - 3 Compartment Sink dated 11/01/2022 revealed under Policy and Compliance Guidelines: (1) The facility utilizes a 3-compartment sink to wash, rinse, and sanitize pots, pans, and other utensils to prevent the spread of bacteria that may cause foodborne illness. (2) A 3-step process is used to manually wash, rinse, and sanitize dishware correctly: (a) First step: Thorough washing using hot water and detergent after food particles have been scraped off. (b) Second step: Rinsing with hot water to remove all soap residues. (c) Third step: Sanitizing with either hot water (at least 171 degrees Fahrenheit) for 30 seconds or a chemical sanitizing solution used according to manufacturer's instructions.

This citation pertains to intake MI00153787 Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 107 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 06/25/25 at 12:10 P.M., 6 of 9 first floor Main Dining Room Portable Terminal Air Conditioning (PTAC) unit filters were observed heavily soiled with accumulated and encrusted dust/dirt deposits. The interior and exterior (PTAC) cabinet surfaces were also observed soiled with accumulated and encrusted dust/dirt deposits. Maintenance Director C indicated he would have staff thoroughly clean the filters and cabinet surfaces as soon as possible. On 06/25/25 at 12:15 P.M., The first floor Main Dining Room flooring surface was observed soiled with accumulated and encrusted dust/dirt/food residue deposits. On 06/25/25 at 12:20 P.M, An interview was conducted with Director of Housekeeping and Laundry Services E regarding current staffing levels. Director of Housekeeping and Laundry Services E stated: I have ten housekeepers total. Director of Housekeeping and Laundry Services E also stated: I have six housekeepers on first shift. Director of Housekeeping and Laundry Services E additionally stated: I have one housekeeper on second shift. Director of Housekeeping and Laundry Services E further stated: The other three housekeepers cover the schedule during call offs and days off. On 06/25/25 at 01:52 P.M., An interview was conducted with Dietary Aide B regarding the food production kitchen floor drains. Dietary Aide B stated: The floor drain flooding is random. Dietary Aide B also stated: The floor drain sometimes floods daily and other times weekly. On 06/25/25 at 03:00 P.M., An interview was conducted with Corporate Life Safety and Maintenance/Environmental Director D regarding the floor drain flooding concern. Corporate Life Safety and Maintenance/Environmental Director D stated: The first time we experienced a wastewater issue was nine years ago. Corporate Life Safety and Maintenance/Environmental Director D also stated: I generally snake drains as needed. Corporate Life Safety and Maintenance/Environmental Director D additionally stated: I snaked drains in the basement last week (6-16-25). Corporate Life Safety and Maintenance/Environmental Director D further stated: The dietary grease traps were cleaned by (contractual service name) on 6-18-25. Corporate Life Safety and Maintenance/Environmental Director D also stated: The wastewater drain lines were cleaned on 11-6-24 for preventative measures. On 06/25/25 at 03:15 P.M., An interview was conducted with Corporate Life Safety and Maintenance/Environmental Director D regarding future plans for maintaining the facility wastewater drain system. Corporate Life Safety and Maintenance/Environmental Director D stated: Education of staff and continued monitoring. Corporate Life Safety and Maintenance/Environmental Director D also stated: The problem we continue to have is our dietary drain lines from excessive grease and solids/debris. On 06/26/25 at 08:45 A.M., Record review of the Policy/Procedure entitled: Sewage and Waste Disposal dated 01/2024 revealed under Policy: It is the policy of this facility to plan for safe and sanitary disposal of sewage and waste. Record review of the Policy/Procedure entitled: Sewage and Waste Disposal dated 01/2024 further revealed under Policy Explanation and Compliance Guidelines: (1) The facility sewer lines will be maintained to ensure that all sewage drains run freely at all times. (2) In the event that the facility encounters a drain that becomes blocked, the facility will contact its Director of Facilities to snake drains or contact vendor to clear the lines.

This citation pertains to intake MI00153011. Based on interview and record review the facility failed to document complete transfer and discharge information for one (R510) of two residents reviewed for the transfer/discharge process resulting in the potential for the receiving health care provider to be unaware of all the resident's healthcare needs. Findings include: The State agency received a complaint that R510 was improperly transferred. According to R510's Electronic Health Record the resident admitted to the facility on [DATE] with multiple diagnoses that included paraplegia and surgical repair of fractured right femur. A progress note dated 3/19/25 at 6:41 PM indicated R510 returned from the hospital and was then transferred to another long-term facility. There was no additional documentation. There was no transfer form to the hospital. There was no discharge plan, summary note or progress notes to indicate instructions had been given to either the receiving hospital or long-term care facility the resident was transferred to. On 5/15/25 during an interview with the Director of Nursing (DON) it was confirmed R510 had no transfer or discharge summary to indicate that instructions or a safe transfer/discharge had occurred for the resident. On 5/15/25 during an interview, the Nursing Home Administrator (NHA) said the facility should have included transfer information and a discharge summary to indicate the receiving healthcare providers had been informed of the resident's on-going healthcare needs. The NHA supplied the facility's policies for transfer and discharge procedures. According to the facility's Transfer and Discharge policy last revised 3/26/2025, read in part: 3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge. c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged . According to the facility's Discharge Planning Process policy last revised 2/26/2025, read in part: 11. The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record. 12. The results of the evaluation and final discharge plan will be discussed with the resident or the resident's representative. All relevant information will be provided in the discharge summary

This citation pertains to intake MI00148648. Based on observation, interview, and record review the facility failed to establish a record of receipt, disposition, or reconciliation of controlled drugs (a drug that the government regulates for possession and use, i.e. narcotics) in the facility's back-up box (secured storage unit of controlled drugs), resulting in the facility being unable to account for the receipt of, disposition of, or discrepancies of controlled drugs in the facility's back-up box with the potential for drug diversion and controlled drugs being unavailable to administer to residents as prescribed. Findings include: On 12/19/24 at 12:52 PM observation of the facility's narcotic back-up box with the Director of Nursing (DON) revealed there was no plastic lock on the narcotic drawer. The lack of a lock indicated that the narcotic drawer had been opened after pharmacy had delivered a fully restocked narcotic supply. There was no documentation to indicate when pharmacy last delivered the back-up-box or when narcotics had been removed. A sheet of paper with multiple undated entries indicated narcotics had been removed. The last dated entry was 11/18/24 (31 days earlier) and indicated that an oxycodone 5 milligrams (mg) had been removed leaving 5 in the back-up-box. Upon visual inspection of the oxycodone 5 mg box there were 3 tablets present. The DON was asked how the facility reconciles narcotics taken from the back-up-box. The DON could not determine when narcotics had last been delivered from pharmacy, the number of narcotics that were delivered from pharmacy, what facility nursing staff received the narcotics, or when narcotics had been removed from the back-up-box. The DON could not explain the facility's process for narcotic reconciliation, what the plastic locks on the narcotic drawer were used for or if any dispensing forms were utilized. At this time the number for the pharmacy was requested. On 12/19/24 at 2:40 PM during a phone interview the facility's pharmacist (PH) M said that the pharmacy delivers a fully stocked back-up-box every week with a numbered plastic lock on it. The last delivery was on 12/10/24 and according to the dispensing sheets the following number of narcotics should be present. -Oxycodone 5 mg should have 4 tablets available for dispensing. Upon visual inspection there were 3 tablets available. (one tablet unaccounted for) -Norco 5 mg should have 3 tablets available for dispensing. Upon visual inspection there were 4 tablets available. (one tablet extra) -Norco 10 mg should have 5 tablets available for dispensing. Upon visual inspection there were 3 tablets available. (two tablets unaccounted for) -Percocet 5 mg should have 5 tablets available for dispensing. Upon visual inspection there were 5 tablets available. PH M could not account for the discrepancy in numbers of narcotics and said, We only have what dispensing forms the nursing staff fax to us. That is all we have. I don't know why the numbers don't match up. I will send someone out there tomorrow to reconcile the back-up-box. According to the facility's Pharmacy Services implemented 2/19/24 in part read: The facility in coordination with the licensed pharmacist, will provide for: a. A system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications; b. Prompt identification of loss of or potential diversion of controlled medications; and c. Determination of the extent of loss or potential diversion of controlled medications.

This citation pertains to intake MI00143878. Based on interview and record review, the facility failed to implement interventions and provide sufficient staff for supervision to prevent falls for one (R921) of four residents reviewed for accidents and supervision resulting in R921 being found unresponsive on the floor with a pool of blood around the resident's head. Findings include: The State Agency received a Facility Reported Incident (FRI) on [DATE] for an incident that occurred on [DATE]. The FRI reported that R921, a Hospice patient (receiving palliative care) was observed on the floor by Certified Nursing Assistant (CNA) C on [DATE] at 7:50 AM with an injury of unknown source with serious bodily injury. An Event Report dated [DATE] indicated R921 was observed on the floor next to the bed. Assessments including X-rays revealed R921 did not sustain any injuries. Interventions that were to be immediately taken included a floor mat. A review of R921's care plans on [DATE] did not include 'falls' as a concern and there were no interventions as identiifed. On [DATE] a fall mat was not in place under R921 when found. The facility provided a paper version of the baseline care plan initiated [DATE] that had floor mat [DATE] written in next to a signature. On [DATE] at 1:25 PM, Licensed Practical Nurse (LPN ) H said, I responded to a code that was called. When I got there the nurse (LPN A) was already there trying to roll him over. There was blood on the floor around his head. I did not see a floor mat. 911 had arrived and they took over. According to R921's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] and expired in the facility on [DATE]. Diagnoses included history of a stroke with weakness/paralysis on the right side of the body. A fall risk assessment on [DATE] identified the resident as 'not at risk' for fall. 32220 A physician note dated [DATE] documented, .answered to name however is unable to communicate meaningfully . The physician note further indicated R921 required frequent turning related to a sacral/tailbone pressure ulcer. A physician order dated [DATE] indicated resident was on contact precautions which would have required staff to don personal protective equipment when care was provided. A review of the progress notes documented the last progress notes by the nurse or physician were on [DATE]. A review of the progress note dated [DATE] at 8:10 AM by LPN A revealed, Upon rounds resident found face down and unresponsive, (cardiopulmonary resuscitation) CPR started, 911 called, nurse sent cena to call code code (sic), assessment done no noted respirations or pulse 911 notified instructions to grab defib, 911 rescue in building to take over CPR. On [DATE] at 3:12 PM, LPN A was asked via the phone about R921 and the incident on [DATE]. LPN A reported the facility was short staffed when LPN A entered the building for the day shift. LPN A reported the night nurse was LPN B and had worked the second and sixth floors during the night shift with one aide (CNA F) when there were normally two aides. At the time of shift change CNA C reported R921 was down and mentioned something about blood and LPN A went and assessed R921. LPN A reported R921 was prone, head faced toward the exit, was cold, had no pulse, and the blood around the head had dried to a gel and separated. 911 was called and attempts were made to get R921 turned over but LPN could not get R921 turned over to attempt resuscitation. LPN A reported CNA C was asked to call the code and attempted to get help from CNA E to help turn R921 over. Additional staff arrived at about the same time 911 arrived in the room and the code was handed off to 911. LPN A also reported that a number of staff had left around the time of the incident related to management changes. LPN A was also asked about a floor mat and reported R921 was not on a floor mat when found. On [DATE] at 6:38 AM, LPN B was asked about their night shift on [DATE] into [DATE]. LPN B reported they arrived on the floor around 7:10 PM and did rounds. LPN B reported they made two trips to the second floor and were not aware they had to cover the second floor until two hours into their shift. LPN B reported they did rounds three times on their shift with the last check of R921 around 4:30 AM. LPN B reported the night was a little difficult as they had to answer problematic call lights and had a wanderer who required redirection away from exits multiple times. LPN B further noted that if one staff was in a room the other would have to be in the hall or at the nurse station to keep and eye on the wanderer. LPN B reported the day shift aide came on the sixth floor around 7:10 AM and LPN A arrived around 7:45 AM and was not made aware of any concerns with R921 until after they had arrived home. A review of a statement related to R921's fall on [DATE] by Certified Nursing assistant (CNA) F documented CNA F came on shift at seven PM on [DATE] and deferred checking on R921 until between 12:30 AM and 1:00 AM and reported R921 did not request assistance the remainder of the night. Attempts to reach CNA F were made via phone on [DATE] at 3:39 PM and [DATE] around noon. Messages were left. The calls were not returned. On [DATE] at 7:26 AM, CNA K reported last rounds are generally done around 6:30 AM for the night shift and that is was likely rounds were not done by the night CNA as they were missing two CNA's that night. CNA K further reported they believed the incident with R921 on [DATE] could have been avoided. On [DATE] at 10:45 AM, CNA C was interviewed about the incident with R921. CNA C confirmed they had found R921 on the floor next to the bed with blood around the head. CNA C reported the room door was partially open and R921 was on the far side of the bed on the floor. A review of the facility policy titled Fall Prevention Program implemented ,d+[DATE], revealed, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .5. Low/Moderate Risk Protocols: b. Implement routine rounding schedule .6. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. ii. Place Fall Prevention Indicator (such as star, color coded sticker) on the name plate to resident's room. iii. Place Fall Prevention Indicator on resident's wheelchair. b. Implement interventions from Low/Moderate Risk Protocols. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, status, or recent change in functional status. d. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices ii. Increased frequency of rounds . 9. When any resident experiences a fall, the facility will: e. Review the resident's care plan and update as indicated .

This citation pertains to intake: MI 567 Based on observation, interview, and record review, the facility failed to ensure pain medication was consistently available and administered in one of one resident (R115) reviewed for pain, resulting in R115 not having his pain consistently controlled as evidenced by moaning, facial grimacing, and clenching his fists during care. Findings include: During an observation on 11/15/21 at 10: 40 AM, R115 was being repositioned in bed by Certified Nursing Assistant (CNA) L. R115 was clenching his fists and moaning out loud. R115 was alert with facial grimacing but unable to coherently verbalize due to cognitive impairments. R115 had a feeding tube that was clean, dry and intact along with an indwelling urinary catheter that was not secured (anchored) to his thigh area that drained into a collection bag that was in a pink wash basin on the floor. CNA L could not say when R115 had last received pain medication. According to the 'face sheet' R115 had readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R115 had been admitted to hospice care on 10/18/21. A review of the November 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/15/21 at 11:00 AM, Licensed Practical Nurse (LPN) CC said R115 was not given his 6:00 AM dose of '[MEDICATION(S)] 5 mg - acetaminophen 325 mg' tablet because there wasn't any available for him in the medication cart. LPN CC confirmed that '[MEDICATION(S)] 5 mg - acetaminophen 325 mg' tablets were available in the 'back- up' medication box in the medication room, but neither she nor the midnight shift nurse had obtained it to administer to R115. LPN CC said R115 had been given his other scheduled pain medication, [MEDICATION(S)] 5 mg at 9:00 AM. During observation of R115, LPN CC confirmed that R115 was exhibiting signs of pain and would obtain the '[MEDICATION(S)] 5mg - acetaminophen 325 mg from the 'back-up' medication box, and notify the pharmacy to refill the resident's pain medication. LPN CC reviewed the electronic medical record and confirmed that the pharmacy had not been notified that R115's pain medication needed to be refilled. At approximately 12:00 PM R115 was administered '[MEDICATION(S)] 5 mg - acetaminophen 325 mg tablet via his feeding tube from the 'back-up' medication box. According to the 'significant change' Minimum Data Set ( MDS) dated [DATE], R115 had severe cognition impairment and required total assistance for all Activities of Daily Living (ADL) including bed mobility. On 10/18/21 R115 was placed on 'hospice services' and the following pain medications were ordered: 1) [MEDICATION(S)] 5 mg - acetaminophen 325 mg, 1 tablet every 8 hours at 6:00 AM, 2:00 PM, and 10:00 PM via feeding tube and 2) [MEDICATION(S)] 20.0 mg/ml concentrate, give 5.0 mg/0.25 ml every 6 hours at 3:00 AM, 9:00 AM, 3:00 PM, and 9:00 PM. A hospice note dated 10/25/21 written by Registered Nurse (RN) O had the following comments; The hospice nurse received the patient lying in bed during this visit . Patient is experiencing pain which contributes to elevated heart rate. Pain medication recently administered .Hospice nurse communicated the importance of pain management and its effect on the body to facility staff. A review of R115's October MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R115's November MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R115's electronic medical record was reviewed and revealed there were no corresponding progress notes to indicate any nursing staff communicated with the physician or pharmacy to determine why the pain medication was unavailable. There is no documentation to support that nursing staff obtained the pain medication from the 'back-up' medication box on any of those 'missed doses'. R115 was prescribed and administered [MEDICATION(S)] 20.0 mg/ml concentrate, 5.0 mg/.25 ml every 6 hours during these dates. Pain assessments revealed that R115 did have some intermittent pain that was being controlled with the [MEDICATION(S)]. During an interview with the Pharmacy Technician (PT) R on 11/15/21 at 2:45 PM she said that R115's pain medications were not available to the facility from 10/18/21 - 10/25/21 because it needed to be 're-ordered' when R115 transitioned to 'hospice care'. PT R said there were no 'requisitions' to indicate the facility nursing staff had utilized the '[MEDICATION(S)] 5 mg - acetaminophen 325 mg' medications from the back up box to administer to R115. During an interview with Registered Nurse (RN) O on 11/17/21 at 1:00 PM she said that the facility had difficulty consistently obtaining and administering R115's pain medications when hospice services were initiated, but that had improved. During an interview with Director of Nursing (DON) BB on 11/17/21 at 12:15 PM she said the facility's policy is for nurses to get missing medications from the 'back-up box' if applicable and administer to the residents as ordered. Then to notify pharmacy of the missing medications. DON BB could not provide any documentation to support that either pharmacy or hospice services were made aware that R115's '[MEDICATION(S)] - Acetaminophen medication' was not readily available from 10/18/21 through 10/25/21, until 10/25/21. The pharmacy had not been notifed that on 11/15/21 at 6:00 AM that R115's '[MEDICATION(S)] - acetaminophen' medications needed to be refilled until 11/15/21 at approximately noon. According to the facility's policy for 'Pain Assessment & Management'; last revised on 8/1/2016. The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident ' s goals and needs and that address the underlying causes of pain. 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain management is defined as the process of alleviating the resident ' s pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching of the jaw, etc. Implementing Pain Management Strategies: 6. Implement the medication regimen as ordered, carefully documenting the results of the interventions . If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated.

This citation pertains to Intake/FRI MI 0. Based on observation, interview, and record review the facility failed to ensure a resident's pain management was addressed prior to the receipt of personal care, affecting one sampled resident (# 806), resulting in verbalized pain, discomfort, and anxiety during personal care. Findings include: On 3/9/23 at 9 a.m. a review of an investigation and other pertinent documents regarding a Facility Reported Incident (FRI) revealed the incident occurred on 2/26/21 at 3:00PM. The resident reported two female CNAs was rough with her during care causing pain in both legs. Upon further investigation the pain concern involved two CNA's insisting on the need to change the resident's wet linen as opposed to honoring her request for pain medication prior to the linen change. The resident complained of crying in pain during the linen change. An interview was conducted with one of the CNA's (The other CNA no longer works at the facility) via the administrator. The CNA admitted the resident began crying and complaining of pain during care. The CNA stated, they obtained a nurse after care was completed to provide the resident with pain medication. On 3/9/21 at 11:33 a.m. the resident (806) was observed lying in her bed. The Resident was asked how she was doing. The Resident stated, I still get a little nervous about what happened about 2 weeks ago. There were two aides that came to my room to change my bed. They said it was wet. I told the aides I did not want it changed now because I was in too much pain in my legs. I told them I would rather have my pain medication. The aides said, Your bed is too wet, it must be changed now. According to resident (806) one of the aides then stated she would tell the nurse she wanted pain medication after her bed is changed. The resident stated she asked for pain medication again, but the CNA's refused and started repositioning her to change her bed. Resident (806) stated, They would not stop changing my bed, I cried out in pain every time they moved me. According to a record review conducted on 3/9/21, Resident (806) was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment with a reference date of 12/10/20 documented the resident scored 14/15 on the BIMS (Brief Interview for Mental Status), indicating intact cognitive (thought processes) functioning. The resident required total assistance with bed mobility and extensive assistance with bowel and bladder functioning due to incontinence (inability to control urine and bowels). The resident scored 4 (Very severe, horrible) on the MDS pain intensity scale. The resident's care plan dated 2/17/21 identified the resident at risk for pain due to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included administering medications as ordered, and providing pain medication ½ hour prior to treatments, activities, and prn. An interview was conducted with the Administrator on 3/10/21 at 10 a.m. The Administrator stated one of the CNAs have not returned to work due to personal issues and the other CNA was provided with a one-on-one education related to the importance of not prioritizing care over a resident's complaint of pain. An interview was conducted with CNA (G) on 3/9/21 at 3 p.m. CNA (G) stated, I was with another CNA in the room. The resident's bed was soaking wet and that is why we wanted to change the linen despite the resident stating (They) did not want the bed changed now. CNA (G) also stated, I went to tell a nurse the resident needed something for pain, right after we finished. The DON was interviewed on 3/10/21 at 3:30 p.m. regarding the resident's lack of pain management. The DON was informed the care plan of resident (806) included orders to provide the resident with pain medication ½ hour prior to activities/treatments. The DON stated, I have not seen the care plan but if it states that, I agree the resident's pain management should be the priority. An undated document was reviewed entitled Pain Assessment and Management: Nursing Procedures. The purpose of the procedure was to help staff identify pain in the resident and develop interventions. The pain interventions should be consistent with the resident's goals for treatment.

This citation pertains to intake number MI 917. Based on interview and record review the facility failed to provide resident supervision, as well as provide safe environment for one sampled resident (R#504) with a known history of ingesting foreign objects, out of a total sample of three, resulting in an Immediate Jeopardy for R#504 related to the actual ingestion of three batteries and hospitalization to remove the foreign objects by laparotomy (surgical incision into the abdominal cavity). Administrator was notified of the Immediate Jeopardy (IJ) on 10/22/19 at 5:50 PM. A plan to remove the immediacy was requested. The IJ was began on 10/2/19 when the facility created a care plan titled, The resident has a behavior problem of eating objects that have no nutritional value and are not food items. She is not redirectable and continues to ingest items even if it may cause her harm and disregards education, and subsequently 4 days later on 10/6/19 R#504 ingested three batteries. The IJ was removed on 10/6/19. Although the IJ was removed, the facility's deficient practice was not corrected and remained isolated with actual harm. Findings include: Record review revealed that R#504 was admitted into the facility following hospitalization on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted no cognitive deficits, non-ambulatory, independent to limited supervision required, delusions, care rejection and other adverse behaviors. A care plan titled, The resident has a behavior problem of eating objects that have no nutritional value and are not food items. She is not redirectable and continues to ingest items even if it may cause her harm and disregards education dated 10/2/19 (7 months after admission into the facility) had interventions of; Educate (which the resident was identified to disregard) the resident/family/caregivers on successful coping and interaction strategies such as behaviors .If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and or unacceptable to the resident. The care plan did not give examples of what strategies were successful for R#504. The care plan did not address measures for resident supervision or ensuring the resident's environment was free from harmful items that could be ingested. There was no documented evidence in the clinical record that R#504 was provided supervision/monitoring or sweeping of the environment to ensure safety. Review of a Unusual Occurrence Report dated 10/6/19 (4 days after the behavior problem of eating objects that have no nutritional value and are not food items care plan was created) documented; At approximately 6:00 PM, resident approached writer in hallway during 5:00 PM medication pass. Resident stated, 'Please don't be mad, I swallowed 2 batteries'. Was asked where she gotten the batteries she stated, 'from my TV remote' .911 called transported to (local hospital name) for further evaluation. Review of the hospital records dated 10/7/19 and 10/8/19 documented: -Chief complaint; Swallowed Foreign Body .multiple previous visits for foreign body ingestion (needles, screws, razor blades, broken antennae, plastic fork, surgical tweezers, safety pins, batteries) requiring multiple abdominal surgeries .present to Emergency Department complaining of epigastric abdominal pain s/p (status [REDACTED]. -Radiological summary; There are three cylindrical metallic opacities projecting over the expected region of the stomach fundus and one projecting over the left lower midabdomen which could be within small bowel, or less likely in a low projecting stomach body, consistent with clinical history of ingested batteries . -Laparotomy with removal of foreign body. -Plan; suicidal precautions, bed sitter, no access to portable objects, social work consult, psych consult . On 10/22/19 at 2:50 PM at 2:50 PM, during an interview the facility's Director of Nursing (DON), Administrator and Corporate Administrator, were asked how the facility kept R#504 safe from foreign body ingestion after the behavior was identified on 10/2/19 per the care plan, to which the DON stated, We put her on 1:1 supervision (close observation and surveillance) when she returned from the hospital on [DATE] (2 days after the batteries were ingested). No one could explain why R#504 had not receive increased supervision and/or was provided an environmentally safe environment prior to 10/8/19. Review of the facility's Enhanced Supervision (1-1 Monitoring) policy dated 2/1/18 documented, Residents who exhibit behaviors or concerns that could potentially result in harm to self or others will result in utilization of 1 to 1 monitoring until such time that the concerns is resolved to a level where normal monitoring can occur. Abatement: Heritage Manor believes that as of 10/06/2019, the measures it has implemented are sufficient to demonstrate that residents are receiving adequate interventions for behaviors that may result in serious injury, harm, impairment or death. 1. Resident identified to be affected by the alleged deficient practice. The identified resident # 504 has been discharged to the hospital on [DATE] following this event. Resident no longer resides at this facility. Residents with the potential to be affected by the alleged deficient practice. Residents who have a high risk for behaviors based on their medical/psychiatric history are at risk. The Licensed Social Worker has completed a facility wide assessment on every resident to identify this behavior risk. All identified residents care plans have been updated and implemented to provide safe behavior risk interventions and CNA care guides have been updated with this information. A QAPI was held with the IDT to discuss and make identified necessary changes with implementation of interventions for resident's with behaviors. Nursing Care Plans and C.E.N.A care guides will be reviewed and updated to reflect changes identified by IDT during weekly behavior meetings. Resident's identified as having increased at risk behavior will be seen by Psych services for interventions, Physicians will be involved with plan of care making changes as necessary, If resident is deemed unsafe 1:1 staff will be provided until appropriate placement can be obtained for the resident 2. Systemic Measures PRIOR TO ADMISSION: 1. Starting with the next admission, The Director of Nursing will screen residents preadmission information for evidence of unsafe behaviors to determine if resident can be safely admitted 2. New referral will be reviewed to identify any unsafe behaviors. 3. Once the decision to admit has been made, nursing leadership will meet with the receiving nursing team to give report on the expected need and risk factors of the new admission. 4. Quarterly and PRN the residents of the facility will be assessed for this type of behavior, and interventions will be put into place immediately. 5. The facility staff have been given on the spot education on documenting in the behavior log,and identifying hazards in the environment, the remaining staff will be educated prior to the start of their shift until complete. 6. Information will be noted on the 24 hour report to assure continuity of information shift to shift. FOLLOWING ADMISSION: 7. The receiving nurse will complete the baseline care plan to identify and document the risks and assure the care guide is updated to inform the assigned CN[NAME] 8. Interventions for unsafe behaviors will be reviewed during the daily clinical risk meeting DON/Nurse Manager to identify appropriate interventions are in place. ONGOING MONITORING: 1. A resident being identified as demonstrating unsafe behaviors, nursing staff will notify the physician and the assigned DON/designee. The assigned nurse will put interventions in place as needed for each individual. The care plan/care guide will be updated immediately. 2. Information will be noted on the 24 hour report to assure continuity of information shift to shift. 3. Psychiatric referrals will be initiated to assure the resident is seen at the next scheduled visit. 4. Leadership staff will convene as necessary to discuss and implement interventions to maintain the resident's safety. 5. Weekly behavior management meetings will be held no less than weekly to address and assure interventions are in place. 6. During the quarterly and PRN assessments if this type of behavior is noted alternate place will be sought immediately with resident being discussed in weekly behavior meeting. 7. The Administrator, DON, Admissions Coordinator, and Social Worker will be re-educated on this practice, given by corporate administrator. 8. The Social Worker/Nurse Manager will round on unsafe risk residents daily. 9. Guardian Angel rounds will continue with daily discussion, all findings will be brought to monthly Q.[NAME]based on findings adjustments will be made.

This citation pertains to intake #MI 88. Based on interview and record review, the facility failed to provide appropriate, timely interventions to ensure the health and well-being for two (#802, #803) of eight sampled residents reviewed for quality of care, resulting in one resident (#801) with a mood disorder, who exhibited on-going adverse behaviors of physical aggression towards others, attacking resident #802 by pushing the resident to the floor, causing a [MEDICAL CONDITION] requiring surgical repair and leading to the unexpected death of resident #802 due to the [MEDICAL CONDITION] as an underlying cause of death, according to the resident's death certificate, and the likelihood for continued acts of aggression toward the other 16 residents on the nursing unit at the time, placing them at risk. Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 2:30 PM. A plan to remove the immediacy was requested. The IJ began on [DATE] at 12 noon when physical aggression began with resident (#803), resulting in resident #801 pushing resident #803 to the floor and then pushing resident #802 to the floor, as the behaviors continued. The IJ was removed on [DATE], when resident #801 was transferred out of the facility to a hospital crisis center, based on the facility's implementation of the plan of removal as verified by the surveyor. Although the IJ was removed, the facility's deficient practice was not corrected and remained isolated with actual harm. Findings include: The complainant reported to the State agency that resident #801 behaved aggressively toward other residents, that resident #802 was pushed to the floor and injured and that resident #802 died after return to the facility following hospitalization , one week later. On [DATE] at 12 noon, the clinical record for resident #801 was reviewed. The resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) completed [DATE], noted severe cognitive impairment, independence with ambulation and mobility and adverse behaviors involving verbal/physical abuse, delusions and wandering. The resident's care plans noted the following: [MEDICAL CONDITION] Drug Use dated [DATE], last reviewed [DATE]-Resident receives antipsychotic, antianxiety and antidepressant medication related to [DIAGNOSES REDACTED]. Interventions included: Assess if the resident's behavioral symptoms present a danger to the resident and/or others. Intervene as needed Monitor resident's behavior and response to medication. Behavioral Symptoms dated [DATE]-I have a behavior problem related to my [DIAGNOSES REDACTED]. I sometimes interrupt my roommates during the night. My behavior sometimes also include combativeness as evidenced by my behavior towards my roommate Interventions included: Refer me to psych as needed. There were no documented physician progress notes [REDACTED]. When asked if the resident had been seen by mental health services, the Social Worker (SW)said yes and presented psychiatric evaluations, however the last documented psychiatric evaluation was dated [DATE] before the incidents with resident #802 and #803. Per the evaluation notes by a Nurse Practitioner: The evaluation was requested by staff following physical aggression that day toward another resident; The resident had a prior history of aggression or violence, displayed aggression towards: nursing facility staff, had irritable mood, impaired memory and concentration and poor fund of knowledge, judgement and insight. Plan: behavioral management Provide safety. Resident displays aggressive behaviors Notify (psychiatric) service of changes in mood or behavior, or with new concerns; The resident's current psychiatric condition and associated functional impairment may worsen without intervention at this time; Nature of the presenting problem: High severity or unstable or significant new problem requiring immediate attention. At the time of the evaluation, the resident was receiving [MEDICATION NAME] (mood stabilizer), [MEDICATION NAME] (anti-psychotic) and [MEDICATION NAME] (anti-depressant), per the ,[DATE] Medication Administration Records. There were no changes in treatment, other than to discontinue [MEDICATION NAME] on [DATE]. There were no further orders for anti-depressants or medication specifically for treatment of [REDACTED]. Unusual Occurrence (Incident) reports dated [DATE] at 12 noon for resident #801 and #803 noted: Patient (#801) throws and pushes resident (#803) on floor after taking lunch tray from resident (#803's) room preventive measures to prevent recurrence: Separate patients from each other. Suggest that resident (#801) have lunch near nurses station. According to a SBAR (acute change in condition) form dated [DATE] for resident #801: Increased agitation Writer observed patient (#801) pushing and shoving resident (#803) to floor after going in resident's room taking lunch tray New or worsening behavioral symptoms. The SW noted on [DATE], that when spoken to about the incident 20 minutes later, resident #801 had no recall of the incident and was very confused. Resident #803's clinical record noted: an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS completed [DATE] noted moderately impaired cognition, supervision required for ambulation and no adverse behaviors. (On [DATE] at 10:45 AM, resident #803 was observed isolated in his room in bed, with the door closed and a very disheveled appearance. When asked about the incident, he was confused and unable to answer questions. When queried, staff said that the resident usually stayed in his room.) After the incident with resident #803, nurses noted the following in resident #801's record: [DATE] at 1:30 PM-Resident exhibiting increased agitation. [DATE] at 7 PM-Encouraged not to enter other residents' room. [DATE] at 9 AM-Resident observed having verbal altercation with threats of physical harm noted (toward another resident). Writer intervened [DATE] at 6 PM-Resident kept out of other residents' rooms on unit. There were no further notes in the resident's record after [DATE] at 9 AM (when reviewed with the Director of Nursing (DON) on [DATE] at 4:20 PM). However, per Incident reports for resident #801 and #802 dated [DATE] at 10:20 AM, the following occurred: For resident #801-Resident (#801) walking up and down the hall. Spoke to resident (#802), touched her left shoulder. Resident (#802) stated 'Don't touch me (expletive).' Resident (#801) became aggressive and pushed (resident #802) Resident was moved from unit with 1 on 1 staffing (monitoring) until transfer to crisis center. For resident #802-The resident was waiting in front of the elevator when touched by resident #801. (Resident #801) got upset, started cursing and pushed resident (#802) down fall by being pushed right hip/leg complaining of pain, level 9 (on a scale of ,[DATE] with 10 being the worse) transfer to emergency room separated the aggressive resident. A SBAR for resident #802 noted: In pain post fall. Complaining of pain with mobility with movement Resident was in verbal altercation with another resident (#801) became upset and pushed (#802) fell to floor in front of elevator on right side pain with guarding and facial grimaces. Resident #802 returned to the facility on [DATE] following repair of a right hip (femur) fracture. The record further revealed: an original admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS completed [DATE] noted intact cognition, independence with ambulation and mobility, no adverse behaviors, [MEDICAL CONDITION] medication use and no history of falls. On [DATE], a Nurse Practitioner saw resident #802 and noted: The resident complained of pain to the right hip, had surgical staples in place and was prescribed [MEDICATION NAME] and Tylenol for pain and [MEDICATION NAME] (blood thinner to prevent development of blood clot, a cause of sudden death post hip surgery). Nurses noted the resident's pain level was at 9. ,[DATE]-[DATE] notes were uneventful. Per [DATE] notes, pain level ,[DATE], right lower extremity throbbing/aching and 16 staples to the wound were identified. On [DATE] at 1 PM, Resident denies pain at this time. Mood pleasant appetite good. Per notes for resident #802 dated [DATE]: At 1 AM-watching TV, was in pain at level 5, Tylenol given. At 1:45 AM-My pain is gone. I feel much better now. I can rest pain level now 1. At 3:55 AM- during walking safety rounds, primary nurse asked (resident #802), 'How you feeling, now (resident) did not respond. Primary nurse observed no chest rise or fall and immediately checked for carotid and radial pulses which were not present call a code blue to room and call 911. At approximately 3:55 AM, CPR was initiated by staff. Then approximately 4:05 AM, CPR was immediately taken over by 2 EMTs (emergency medical technicians). At 4:16 AM, the resident was pronounced dead by EMT via communication and direction of a physician by phone. A partially completed Death Certificate was in resident #802's clinical record, which noted the same date and time of death, but did not note the cause of death. A copy of the completed Death Certificate was then requested from the funeral home, which noted: Cause of Death- Enter the chain of events-diseases, injuries, or complications-that directly caused death. Sequentially list conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury that initiated the events resulting in death) LAST. Line a. [MEDICAL CONDITION] Cardiovascular disease Line b. [MEDICAL CONDITION] Line c. Fractured Femur On [DATE] at 4:20 PM, the interim Administrator said she was off on medical at the time of the incidents between residents #s 801, 802 and 803 (between ,[DATE]-[DATE]). She and the Director of Nursing did not explain why the incidents were not reported to the State agency and why resident #801 was not provided interventions, such as a psychiatric evaluation with [MEDICAL CONDITION] medication review and increased supervision to protect residents on the unit, including residents #s 802 and 803, before the [MEDICAL CONDITION] occurred. Per review of the facility's policies on Dementia dated [DATE], Behavior Assessment and Monitoring (undated) and [MEDICAL CONDITION] Medication Use dated [DATE]: -Individuals with dementia can also have a personality disorder, mental illness, [MEDICAL CONDITIONS], depression, adverse drug reactions, or other conditions causing or contributing to impaired cognition and problematic behavior. As needed, the physician may obtain a psychiatrist or neurologist consultation to assist with diagnosis, treatment selection, monitoring of responses to treatment, and adjustment of medications. -Problematic behavior will be identified and managed appropriately If the resident is being treated for [REDACTED]. Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing [MEDICAL CONDITION] medication The facility submitted the following plan to remove the immediacy on [DATE]: Heritage Manor submits the following Credible Allegation of Compliance outlining the measures it has completed to abate the findings of immediate jeopardy to resident health and safety identified by the survey team regarding the facility failed to provide appropriate timely interventions to ensure the health and well being of resident #801 1. Resident identified to be affected by the alleged deficient practice. The identified resident #801 no longer resides in the facility. Residents with the potential to be affected by the alleged deficient practice. All residents on anti-psychotics will be monitored with levels ordered as necessary. the physician will be notified of any residents and any residents with sub-therapeutic levels immediately. All residents identified with behavior care plans, care guides were updated/reviewed, medication reviewed and behavior management meeting held. Staff in-serviced on behavior logs. Clinical meetings will discuss behavior logs and IDT will determine if psyche services should proceed. Staff in-servicing initiated immediately. Nurses in-serviced on obtaining the lab reports and notifying the physician 2. Systemic Measures 1. Starting with admission the social worker will be made aware of residents with noted psyche [DIAGNOSES REDACTED]. 2. Unit managers will review daily labs/orders and report findings to the physician 3. Behavior management meeting held during clinical to initiate interventions to have positive outcomes and make changes if needed. ONGOING MONITORING: 1. Managers will audit all residents on anti-psychotics with levels as necessary weekly for labs and adverse reactions. 2. Social Worker will identify residents with behaviors in morning meeting and monitor the behavior log. 3. Residents with noted behaviors care plans initiated. QAPI 1. Director of Nursing/ Manager will audit all residents on anti-psychotics levels/orders as necessary/ weekly 2. Social Services will audit behaviors, behavior logs and behavior mgt. meeting 3. QAPI committee will review findings at least quarterly to review data and assure benchmarks are being met. This information will be used to drive policy changes, staff

This pertains to intake #MI 88. Based on observation, interview and record review, the facility failed to provide appropriate, timely behavior management and proper monitoring of medication to stabilize mood for one (# 801) of three sampled residents reviewed for adverse behaviors, resulting in physical aggression toward resident #802, leading to resident #802 being pushed to the floor sustaining a [MEDICAL CONDITION] requiring surgical repair and the unexpected death of resident #802, due to the [MEDICAL CONDITION] as an underlying cause of death according to the resident's death certificate, and the likelihood for continued acts of aggression toward the other 16 residents on the nursing unit at the time, placing them at risk. Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 2:30 PM. A plan to remove the immediacy was requested. The IJ was began on [DATE] at 12 noon when physical aggression began toward another resident (#803), resulting in resident #801 pushing resident #803 to the floor and then pushing resident #802 to the floor as the behaviors continued. The IJ was removed on [DATE], when resident #801 was transferred out of the facility to a hospital crisis center, based on the facility's implementation of the plan of removal as verified by the surveyor. Although the IJ was removed, the facility's deficient practice was not corrected and remained isolated with actual harm. Findings include: The complainant reported to the State agency that resident #801 behaved aggressively toward other residents, that resident #802 was pushed to the floor and injured and that resident #802 died after return to the facility following hospitalization , one week later. On [DATE] at 12 noon, the clinical record for resident #801 was reviewed. The resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) completed [DATE], noted severe cognitive impairment, independence with ambulation and mobility and adverse behaviors involving verbal/physical abuse, delusions and wandering. The resident's care plans noted the following: [MEDICAL CONDITION] Drug Use dated [DATE], last reviewed [DATE]-Resident receives antipsychotic, antianxiety and antidepressant medication related to [DIAGNOSES REDACTED]. Interventions included: Assess if the resident's behavioral symptoms present a danger to the resident and/or others. Intervene as needed Monitor resident's behavior and response to medication. Behavioral Symptoms dated [DATE]-I have a behavior problem related to my [DIAGNOSES REDACTED]. I sometimes interrupt my roommates during the night. My behavior sometimes also include combativeness as evidenced by my behavior towards my roommate Interventions included: Refer me to psych as needed. There were no documented physician progress notes [REDACTED]. When asked if the resident had been seen by mental health services, the Social Worker (SW)said yes and presented psychiatric evaluations, however the last documented psychiatric evaluation was dated [DATE], before the incidents with residents #802 and #803. Per the evaluation notes by a Nurse Practitioner: The evaluation was requested by the SW following physical aggression that day toward another resident; The resident had a history of [REDACTED]. psychiatric condition and associated functional impairment may worsen without intervention at this time; Nature of the presenting problem: High severity or unstable or significant new problem requiring immediate attention. At the time of the evaluation, the resident was receiving [MEDICATION NAME] (mood stabilizer) 250 milligrams (mg) twice a day, [MEDICATION NAME] (antipsychotic) 25 mg twice a day and [MEDICATION NAME] (antidepressant) 10 mg daily, per the ,[DATE] Medication Administration Records. There were no changes in treatment, other than to discontinue [MEDICATION NAME] on [DATE] and start [MEDICATION NAME] (typically used for [MEDICAL CONDITION] and migraine headaches that works by decreasing abnormal excitement in the brain). There were no further orders for antidepressants or medication specifically for treatment of [REDACTED]. However, when nurse A looked in the resident's record (on [DATE] at 4 PM) for results, there were none. He then called the lab and requested copies of the levels, but the lab representative said there was no record of the testing being done, in order to see if the [MEDICATION NAME] was at an appropriate or therapeutic level or was in need of adjustment to be effective. Unusual Occurrence (Incident) reports dated [DATE] at 12 noon for resident #801 and #803 noted: Patient (#801) throws and pushes resident (#803) on floor after taking lunch tray from resident's room preventive measures to prevent recurrence: Separate patients from each other. Suggest that resident (#801) have lunch near nurses station. There was no nursing note documented in resident #801's record about the incident. According to a SBAR (acute change in condition) form dated [DATE] for resident #801: Increased agitation Writer observed patient (#801) pushing and shoving resident (#803) to floor after going in resident's room taking lunch tray New or worsening behavioral symptoms. The Social Worker (SW) documented the following note in both residents' records: [DATE]-SW was informed that (resident #803) had an incident with other resident (#801). The other resident walked into his room and took his meal tray. (#803) followed the resident to retrieve his tray. Both residents tugged on the tray until it fell on the ground. When (#803)went to pick the tray up the other resident pushed him down The residents were separated SW spoke with (#803) about the incident about 20 minutes after it occurred and he stated a lady came into his room and took his tray during lunch (#803) does not normally exhibit behavioral concerns. This was an isolated incident for him. The SW noted that resident #801 had no recall of the incident and was very confused when asked about it 20 minutes later. Resident #803's clinical record also noted: an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS completed [DATE] noted moderately impaired cognition, supervision required for ambulation and no adverse behaviors. (On [DATE] at 10:45 AM, resident #803 was observed isolated in his room in bed, with the door closed and a very disheveled appearance. When asked about the incident, he was confused and unable to answer questions. When queried, staff said that the resident usually stayed in his room.) After the incident with resident #803, nurses noted the following about resident #801: [DATE] at 1:30 PM-Resident exhibiting increased agitation. (Urine testing) ordered Writer attempted to obtain (urine sample). Resident could not urinate. Will encourage liquids and try again. There was no documented indication the sample was ever obtained to rule out a urinary tract infection, in which agitation is a common symptom in the elder population. [DATE] at 7 PM-Encouraged not to enter other residents' room. [DATE] at 9 AM-Resident observed having verbal altercation with threats of physical harm noted. Writer intervened, resident sent to participate in activities (off the unit); at 6 PM- Resident kept out of other residents' rooms on unit. There were no further notes in the resident's record after [DATE] at 9 AM (when reviewed with the Director of Nursing (DON) on [DATE] at 4:20 PM). However, per Incident reports for resident #801 and #802 dated [DATE] at 10:20 AM, the following had occurred: For resident #801-Resident (#801) walking up and down the hall. Spoke to resident (#802), touched her left shoulder. Resident (#802) stated 'Don't touch me (expletive).' Resident (#801) became aggressive and pushed (resident #802) Resident was moved from unit with 1 on 1 staffing (monitoring) until transfer to crisis center. For resident #802-The resident was waiting in front of the elevator when touched by resident #801. (Resident #801) got upset, started cursing and pushed resident (#802) down fall by being pushed right hip/leg complaining of pain, level 9 (on a scale of ,[DATE] with 10 being the worse) transfer to emergency room separated the aggressive resident. The SBAR for resident #802 noted: In pain post fall. Complaining of pain with mobility with movement fell to floor in front of elevator on right side pain with guarding and facial grimaces. Resident #802 returned to the facility on [DATE] following repair of a right hip (femur) fracture. The record further revealed: an original admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS completed [DATE], noted intact cognition, independence with ambulation and mobility, no adverse behaviors or psychoactive medication use and no history of falls. On [DATE], a Nurse Practitioner saw resident #802 and noted: The resident complained of pain to the right hip, had surgical staples in place and was prescribed [MEDICATION NAME] and Tylenol for pain and [MEDICATION NAME] (blood thinner to prevent development of blood clot, a cause of sudden death post hip surgery). Nurses noted the resident had a pain level of 9. ,[DATE]-[DATE] notes were uneventful; [DATE]-pain level ,[DATE], right lower extremity throbbing/aching, 16 staples to the wound identified; [DATE] at 1 PM-Resident denies pain at this time. Mood pleasant appetite good. Per notes dated [DATE] for resident #802: At 1 AM-watching TV, was in pain at level 5, Tylenol given. At 1:45 AM-My pain is gone. I feel much better now. I can rest pain level now 1. At 3:55 AM-resident found unresponsive, called a code blue and called 911, staff initiated CPR. At approximately 4:05 AM, CPR was taken over by 2 EMTs (emergency medical technicians). At 4:16 AM, the resident was pronounced dead by EMT via communication and direction of a physician by phone. A copy of the completed Death Certificate was requested from the funeral home, which noted: Cause of Death- Enter the chain of events-diseases, injuries, or complications-that directly caused death. Sequentially list conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury that initiated the events resulting in death) LAST. Line a. [MEDICAL CONDITION] Cardiovascular disease Line b. [MEDICAL CONDITION] Line c. Fractured Femur On [DATE] at 4:20 PM, the interim Administrator said she was off on medical at the time of the incidents between residents #s 801, 802 and 803 (between ,[DATE]-[DATE]). She and the Director of Nursing did not explain why the incidents were not reported to the State agency and why resident #801 was not provided interventions, such as a psychiatric evaluation with [MEDICAL CONDITION] medication review and 1 on 1 supervision to protect residents on the unit, including residents #s 802 and 803, before the [MEDICAL CONDITION] occurred. Per review of the facility's policies on Dementia dated [DATE], Behavior Assessment and Monitoring (undated) and [MEDICAL CONDITION] Medication Use dated [DATE]: -[MEDICAL CONDITION] may be especially problematic in individuals with underlying dementia. Prominent symptoms may include reduction in alertness, appetite, attention span, function, and responsiveness; alternating agitation and lethargy, fluctuation in level of consciousness, hallucinations, and delusions The staff and physician will evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes. -Problematic behavior will be identified and managed appropriately If the resident is being treated for [REDACTED]. Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing [MEDICAL CONDITION] medication The facility submitted the following plan to remove the immediacy on [DATE]: Heritage Manor submits the following Credible Allegation of Compliance outlining the measures it has completed to abate the findings of immediate jeopardy to resident health and safety identified by the survey team regarding the facility failed to ensure the health and well being for resident #802 AEB causing a [MEDICAL CONDITION] as an underlying cause of death. Heritage believes that as of [DATE], the measures it has implemented are sufficient to demonstrate that residents are safe. 1. Resident identified to be affected by the alleged deficient practice. The Identified resident #802 expired. Residents with the potential to be affected by the alleged deficient practice. All residents identified that have behaviors care plans, care guides were updated/reviewed, medication reviewed and behavior management meeting held. Staff in-serviced on behavior logs. Clinical meetings will discuss behavior logs and IDT will determine if psyche services should proceed. Staff in-servicing initiated immediately. Nurses in-serviced on obtaining the lab reports and notifying the physician 2. Systemic Measures 1. Starting at admissions the social worker will be made aware of residents with noted psyche [DIAGNOSES REDACTED]. 2. Behavior management meeting held during clinical to initiate interventions for positive outcomes and make changes if needed. 3. Monitor Daily acuity of residents ONGOING MONITORING: 1. Social Worker will identify residents with behaviors 2. Behavior management meeting held during clinical meeting 3. Social Worker will monitor behavior logs 4. Audit Daily staffing levels

This citation pertains to MI 302. Based on observation, interview and record review the facility failed to ensure that vulnerable residents were free from abuse and neglect for five (R#s 24, 27, 37, 79, 81) of seven sampled residents reviewed for abuse, resulting in resident to resident verbal abuse, staff to resident physical abuse and ingestion of accessible unsafe, inedible objects. Findings include: Abuse On 9/10/19 at 10:08 AM, during a tour of the 500 Nursing Unit a smell of bowel movement (BM) was pungent outside the room and into the hallway that R#24 and R#79 shared. R#24 was noted sitting up in his wheelchair in the room by himself. R#24's roommate (R#79) entered the shared room, yelling at the top of his voice obscenities toward R#24. R#79 then exited the room cussing loudly to himself while he paced down the hallway and back. R#79 then re-entered the room yelling loudly and directing his comments toward R#24 exclaiming over and over, You stinky, slimy Mother [***] ! .Get the [***] out of here .You stinky Mother [***] .You stink .You stinky Ass Hole .Don't touch my bed you slimy [***] [***] this[***]. The roommate then slammed the room door and continued to yell obscenities at R#24 behind closed doors, and then opened door, entered the hallway and stood anxiously outside the room. Afterward, R#24 quietly propelled himself toward the doorway of the room. Without urgency Nurse G arrived at the room and asked R#24 if he would like to come out of the room, to which the resident shook his head no. Nurse G then walked R#79 down the hallway toward the dayroom. At 10:19 AM, Nurse G was asked about the verbal abuse from R#79 toward R#24. The nurse said that (name of R#24) has grown accustom (accept something as normal) to his roommate yelling at him like that. Nurse G said the resident (R#79) is continent of bowel and bladder and the roommate (R#24) is incontinent, and it upsets the roommate when the room smells like BM and he yells at his roommate. Nurse G went on to say I asked him (R#24) if he wanted to come out of the room, but he declined. At 10:40 AM, an attempt was made to speak to R#24 regarding the verbal abuse. The resident looked blankly past the writer with a flat affect and did not speak. At 11:20 AM, observation was made of R#24 laying in his bed turned away from the doorway and withdrawn. R#79 periodically walked in and out of the shared room. At 5:15 PM, a second attempt was made to speak to R#24. Observation of the resident revealed he appeared very thin and sitting in a wheelchair. The resident appeared sad, did not make eye contact and spoke using few words in a soft spoken tone. When asked how he was doing, he looked frustrated and said , Not good because of him, pointing to his roommates empty bed. When asked what was wrong, he said, He's always talking. When asked what he meant, the resident indicated that the roommate frequently yelled and cursed at him and said, I feel bad. When asked what he would like to see happen, he threw his hand toward the door, raised his voice slightly and said angrily, I want him out of here. Record review revealed the R#24 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] indicated the residents cognition was severely impaired and required supervision with all activities of daily living. A Social Service Quarterly Note for R#24 dated 6/6/19 documented, Social worker visited resident in his room for quarterly review, he was open to conversation although he did not speak very much. Resident remains alert and oriented x 2-3 and can make his needs known. Per activity staff, he self directs his own activities and prefers to remain in his room . Social worker will continue to monitor resident for changes in his mood, behaviors and cognition and would refer to other services and departments as needed. Review of an Activities Care Plan dated 6/12/19 indicated the resident does not participate in large group activities, prefers one to one activities/on the unit activities. Record review revealed the R#79 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] indicated the residents cognition was intact and was independent with all activities of daily living. Review of a Patient transfer Form documented that on 4/2/19 R#79 was Petition and transferred to the hospital mental health treatment for [REDACTED]. A Behavior management note for R#79 dated 05/03/2019 documented, Social worker was informed that resident kicked a hole on the wall in his room during one of his outburst. Social worker met with resident on the first floor later that day. Resident stated he was sorry. Resident looked comfortable and showed no signs of pain or discomfort related to incident. Social worker informed resident to report to a staff when he feels the urge to harm or to hit an object. Resident verbalized understanding. Review of a physician's orders [REDACTED].#79 (a resident with documented violent behaviors) on 7/10/19 (9 weeks as roommates prior to event). A Psychiatrist note for R#79 dated 8/10/19 (4 weeks after R#24 was transfered into his room) indicated The patient has NOT been getting along fairly good with residents and staff. Review of the behavior log for (MONTH) 2019 revealed no documented behaviors for R#79. On 9/11/19 at 9:51 AM, During an interview the Administrator and the interim Director of Nursing (DON) they indicated that they both spoke with Nurse G who said she did not see anything wrong with the interaction that occurred the previous day between the two residents (R#24 and R#79). The interim DON stated that residents have been roommates for about 8-9 weeks. The Administrator stated that the Nurse had received inservicing on identifying and reporting abuse. On 9/11/19 at 12:45 PM, during an interview with Unit Manager, Nurse H she said that she was aware that R#79 had violent behaviors and has been trying to get him into a room by himself. Review of the facility's Resident Abuse/Neglect policy dated 7/1/16, reviewed 11/5/18 documented, Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain mental anguish .It includes verbal abuse, sexual abuse, physical abuse and mental abuse .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident #37 On 9/10/19 at 3:30 PM, the resident was observed sitting in a wheelchair talking with her family representative (Rep). The resident was alert, able to respond appropriately to most questions and had a contracted left hand. The resident and the Rep reported that about a month ago, the resident kept asking throughout the day shift to change her incontinence brief but was told that she would have to wait until the afternoon shift came on duty and that if she was put in bed and changed on the day shift, she would have to stay in bed. A total body mechanical lift was used to transfer the resident to and from bed. The Rep said that when she came to visit the resident that afternoon, she was still sitting in the wheelchair and noticed a puddle underneath the chair. They said that the resident was so wet that urine had leaked through the brief and onto the floor. The Rep said, Ask (nurse aide Q). She saw it and told me to get the (interim) DON. I got the (interim) DON and she came to the room and saw it. This is unacceptable. No one should be treated this way. The resident said, I was uncomfortable. It was embarrassing. It was stinking and smelling. At 3:55 PM, aide Q was queried and said, About two months ago, the day shift left her up in the chair and did not change her. She had been asking to be changed all day and was told to wait until the afternoon shift. By that time, there was urine on the floor underneath the chair that the (Rep) saw and she told me about it and the (Rep) got the (interim) DON to see. On 9/11/19 at 3:50 PM, a review of the resident's clinical record and a Concern Form revealed: an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted: moderate cognitive impairment, total assistance required for care, including hygiene, non-ambulatory and incontinent of bowel/bladder. The resident was prescribed [MEDICATION NAME] (water pill) 40 milligrams (mg) every morning and 20 mg every evening. Resident Concern Forms for the resident were requested for 2019. Two were presented, filed by the Rep. One dated 7/3/19 at 3 PM noted: Resident asked day shift (aide) to change her and was told to wait for afternoon shift and (aides) tell her she has to stay in the bed after she gets changed. The form asked, Have you contacted us in the past about this issue? Response-Yes, last year and this year. The second one dated 8/7/19 at 4:15 PM noted: (Rep) stated that resident has to ask to be changed and resident is told to ask (aide Q on afternoon shift) to change you It's an on-going issue (Rep) stated that she does not like how (resident) is being treated and how she is not happy that her concerns are never being addressed. The form asked, Have you contacted us in the past about this issue? Response-Yes, all the DONs. Since 1/1/2019, the facility has had three DONs plus the interim DON, who has had this role off and on from 6/2019 to present. On 9/11/19 at 5:30, the interim DON and aide Q were queried. The interim DON said, I saw her left wet in the chair but I didn't see urine on the floor. I did a 1 to 1 inservice (training) with the aide (assigned day shift aide M) and the nurse (nurse K) because the nurse is responsible for oversight. (Aide M) said she did not tell the resident to wait for the afternoon shift to be changed. Aide Q however, reiterated that she saw the urine on the floor under the wheelchair, saw the interim DON in the room while urine was on the floor and that she had to clean the resident up. The 1 to 1 inservice records for staff K and M, written by the interim DON noted: Employee is being educated related to family concerned residents are not being changed after lunch and being told if they are changed they can't get back out of bed they are not being cleaned up after meals and on several occasions have come in to find their family member soiled. The inservice records were dated 8/5/19. On 9/20/19 at 4 PM, per review of the facility's ADL (Activities of Daily Living), Functional Mobility and Resident Care policy dated 9/14/19: Check resident throughout the shift for care and hygiene needs. Provide incontinence care, peri-care and preventative skin care appropriately throughout the shift. Resident #81- On 9/10/19 at 9:40 AM, the resident was observed alert and lying on the bed in her room. When asked how she was doing, she said that she was having pain in her abdomen and had several holes there that were draining into a dressing. The clinical record was then reviewed and revealed the following: The resident was admitted into the facility following hospitalization on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted no cognitive deficits, non-ambulatory, independent to limited supervision required, delusions and other adverse behaviors. The resident was prescribed anti-psychotic, mood stabilizer and anti-anxiety medications. Records from the transferring hospital noted: an admission from 3/10-3/20/19 following ingestion of a plastic fork and a metal needle requiring open abdominal surgery for [REDACTED]. The resident was transferred to the facility with [DIAGNOSES REDACTED]. The Nursing Comprehensive Evaluation (admission assessment) dated 3/20/19, comprehensive [MEDICAL CONDITION] Drug Use care plan initiated 3/20/19 and an undated Initial Care Plan noted: [MEDICAL CONDITION], foreign body ingestion and a history of swallowing objects. The presence of these documents indicated that the facility was aware of the Pica [DIAGNOSES REDACTED]. The resident's clinical record noted: On 4/4, 4/11, 4/24, 4/30, 6/8, 7/30, 8/4, 8/15, 8/23 and 8/30/19, the resident was transported to the hospital emergency room for multiple procedures to remove ingested items: plastic forks, knitting needles, a pipe cleaner, tweezers, a metal bar, razor blades and screws at the facility. Per hospital records, on 8/31/19: Resident presents after ingestion of a razor blade approximately 6 hours ago. Abdominal x-rays showed a screw and razor present. On 9/3/19: The patient states at 11:30 PM on 8/30/19 she began hearing voices telling her to hurt herself. She then went to the bathroom and grabbed a razor blade and ingested it still feeling diffuse lower quadrant (abdominal) pain. The resident returned the facility on 9/4/19. A comprehensive Alteration in Behavior care plan dated 4/12/19 noted interventions that included: Room sweep, remove any loose items that may be ingested, Avoid sharp objects in room, Redirect behaviors, offer hard candy as feasible, Random room sweeps for non edible items, lotions, powders, deodorants, perfumes, etc., Promote activities. On several occasions, the physician ordered the resident's room swept and removed of objects that could be swallowed. There were no further documented care plan updates in the resident's paper and electronic record medical record and no mention of ensuring sharps, etc., were secured. There were no incident reports written when the objects were swallowed, incident investigations as to how resident got a hold of those items or corrective actions to prevent reoccurrence of and access to potentially unsafe facility items, such as proper storage of razors, pipe cleaners, screws and metal bars, other than periodically sweeping her room. On 9/11/19 at 10:05 AM, the resident was alert and in her room awaiting transport to a [MEDICATION NAME] appointment regarding further surgery. When queried about the objects she swallowed, she said, I heard voices when she swallowed two razors that she found in the shower room and screws she found on the (window) ledge by the window in her room. On 9/12/19 at 11:40 AM, the interim Director of Nursing (DON) was queried and said, She got razor blades from the linen room and screws from around the window in her room. On 9/13/19 at 4 PM, per review of the facility's Accidents and Incidents-Investigating and Reporting policy dated 7/1/2016: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises will be investigated and reported to the Administrator Data Included on Report of Incident/Accident Form The Charge Nurse and/or the department manager will promptly initiate and document investigation of the accident or incident The following data, as applicable, will be included on the Report of Incident/Accident form: .The circumstances surrounding the accident or incident; .Any corrective action taken; . The facility reported an incident of staff to resident physical abuse. Resident 27- On 9/10/19, review of an incident reported to the State Agency documented on 7/24/19 at 8:13 PM, Certified Nurse Aide (CNA) LL was trapped in a corner and punched by Resident #27 (R27); but, once the situation was defused and R27 was pulled off of CNA LL, CNA LL walked over to R27 and slapped her. Review of the clinical record for R27 documented an initial admission date of [DATE] and readmission date of [DATE]. R27's [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented severe cognitive impairment and four to six days of physical and verbal behaviors directed toward others during the seven-day look back period. R27 was independent and required no supervision for bed mobility, transfers, and walking around her room. The MDS indicated R27 required supervision for moving about the corridors on her housing unit. Review of R27's care plans documented the following: --Problem: I have a behavior problem related to my [DIAGNOSES REDACTED]. I sometimes interrupt my roommates during the night. My behavior sometimes also includes combativeness as evidenced by my behavior towards my roommate on 4/14/19, because my roommate called me the 'N' word.I continually have aggressive behaviors towards others, --Approach: Offer to listen to music when signs/symptoms of anxiousness. Praise for acceptable behavior. Approach me in a friendly, calm manner and console me when I cry. Smile at me often, do not argue or provoke me. Review of the facility's documentation of the incident included: --Interview of CNA LL conducted on 7/25/19. Did you slap the resident? No. What was the events leading up to this? (Resident #59) came out the room screaming that (R27) was in her room going through her belongings. That is when I entered and tried to redirect her. (R27) stated that these were her belongings and proceeded out of the room. She came out of the room and exchange words. Then she went back in. I then tried to redirect her and then she pushed me into the corner and start beating me and had her nails in my arm. (MDS Nurse R) entered the room and did nothing. Then the (Charge Nurse MM) pulled (R27) off of me. So, (you do) not remember hitting her? No, I just remember trying to protect my face, my hand was open, but I didn't hit her. --Interview of Resident #59 (R59) conducted on 7/26/19. When I pushed the door open, I saw (R27) with by belongings claiming that they were hers. I screamed for somebody to get her out of my room. (CNA LL) showed up to do so. She asked the resident to leave. (R27) left out but came right back. (R27) began cussing at me, and (CNA LL) told her this was not her room. (CNA LL) tried to lead her out of the room and she would not go. So, (R27) pushed (CNA LL) and started hitting her. The nurse, (Nurse R) came in and stood there. (Nurse MM) came in and moved (R27). I heard (Nurse R) say, You hit the resident. --Interview Charge Nurse MM conducted on 7/25/19. I heard a lot of commotion. I noticed that (CNA LL) was in the corner and (R27) had her pinned down. (R27) was beating (CNA LL). I removed (R27). Once I removed her, (CNA LL) walked straight towards (R27) and slapped her. (Nurse R) stated, You hit the resident. (CNA LL) replied, Well you didn't help me. On 9/12/19 at 10:53 AM, when the facility Administrator was interviewed about the facility reported incident, she said, The employee (CNA LL) was immediately terminated. When queried about the importance of protecting the facility's residents, she said, It is our responsibility.

Based on observation, interview and record review, the facility failed to document care, implement thorough and appropriate interventions, provide proper supervision, and secure sharps and undigestible items involving three (#s 23, 81, 143) of eight sampled residents reviewed for accidents, resulting in fall with laceration, pain and ingestion of numerous inedible objects requiring emergency hospital services and multiple surgical procedures. Findings include: Resident #81- On 9/10/19 at 9:40 AM, the resident was observed alert and lying on the bed in her room. When asked how she was doing, she said that she was having pain in her abdomen and had several holes there that were draining into a dressing. The clinical record was then reviewed and revealed the following: The resident was admitted into the facility following hospitalization on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted no cognitive deficits, non-ambulatory, independent to limited supervision required, delusions, care rejection and other adverse behaviors. The resident was prescribed [MEDICATION NAME] (anti-psychotic) 10 milligrams (mg) daily at 2 PM and 25mg at bedtime, [MEDICATION NAME] (mood stabilizer) 1,500 mg twice a day at 9 AM-5 PM and [MEDICATION NAME] (for anxiety) 0.5 mg every 8 hours PRN (as needed). Records from the transferring hospital noted: an admission there from 3/10-3/20/19 following ingestion of a plastic fork and a metal needle which had become impacted in the intestines. An exploratory laparotomy (open abdominal surgery) was performed on 3/11/19 for removal of the items with a [MEDICAL CONDITION] created. The resident was transferred to the facility with [DIAGNOSES REDACTED]. admission orders [REDACTED]. The Nursing Comprehensive Evaluation (admission assessment) dated 3/20/19 noted: surgery to remove foreign ingested items i.e., needle and plastic fork and 13 staples to the abdomen. The resident's undated Initial Care Plan noted problems of [MEDICAL CONDITION] and foreign body ingestion. A comprehensive [MEDICAL CONDITION] Drug Use care plan initiated 3/20/19 noted: Resident receives anti-psychotic medications related to some behaviors, she has a history of swallowing objects. She has swallowed plastic forks and pins. Interventions included: Assess if the resident's behavioral symptoms present a danger to the resident and/or others. Intervene as needed and Monitor resident's behavior and response to medication. The presence of these documents indicated that the facility was aware of the Pica [DIAGNOSES REDACTED]. The following transpired after admission to the facility: 4/4/19 progress note-Readmit from hospital with [DIAGNOSES REDACTED]. (Per a mental health note dated 5/28/19, the resident had swallowed a plastic fork on 4/4/19.) There was no further documentation regarding this incident. 4/11/19 order-Transfer to hospital, ingestion of foreign body; Patient (hospital) Transfer Form-Swallowed foreign body, nursing recommendations: Close monitoring, remove all plastic. Resident self mutilates when voices tell her. 4/12/19 progress note- Hospital nurse stated that the foreign object was successfully removed and resident would be returning that day; Order-Please make sure resident's room is free of any objects/items she can eat; The resident's room was swept and all items and objects that can be eaten or swallowed have been removed. A comprehensive Alteration in Behavior care plan dated 4/12/19 noted: Ingestion of none food items related to hallucinations and [MEDICAL CONDITION]. Interventions included: Room sweep, remove any loose items that may be ingested, Avoid sharp objects in room, Redirect behaviors, offer hard candy as feasible, Random room sweeps for non edible items, lotions, powders, deodorants, perfumes, etc., Promote activities. 4/15/19 order-Transfer to the hospital. The reason was not documented. Progress note-returned from the hospital with no documented reason as to why she went. 4/16/19 order-change [MEDICATION NAME] 500 mg twice a day to 1,000 mg twice a day. 4/24/19 order-Stat (immediate) abdominal x-ray swallowed foreign object. There was no further documented information about this incident. 4/30/19 progress note-received a call from a hospital physician stating the pain in resident's abdomen is due to the plastic fork that she ate a week ago. They performed a scan and found it in her small intestine. The surgical team feels it's unable to surgically remove so they feel it only can come out naturally and she will have pain The resident returned from the hospital that day. 5/30/19 progress note-The resident told a nurse on another floor that she wanted to harm herself, was then transported to a mental health crisis facility and returned on 5/31/19. 6/7/19 mental health note-[MEDICATION NAME] had been increased on 5/31/19 from 10 mg at bedtime to 10 mg during the day plus 15 mg at bedtime; command hallucinations to kill herself by swallowing objects to produce bowel obstructions. 3-11 PM shift progress note-Resident informed writer that she had swallowed a pair of tweezers The physician was notified and told staff to sweep the resident's room of items. 6/8/19 orders-Stat abdominal x-ray (it showed tweezers in the stomach); Send to emergency room for ingestion of foreign body. Requires removal by endoscopy. The resident returned on 6/10/19 following removal of the tweezers. 7/29/19 order-abdominal x-ray to rule out swallowing a screw. 7/30/19 progress note-States swallowed 2 foreign objects at 8 PM (on 7/29/18) 'hearing voices made me do it.' Stat abdominal x-ray done result, most likely foreign objects in abdomen. Resident stated she swallowed a screw and a knitting needle order to send resident to (hospital). She returned on 7/31/18; knitting needle removed from abdomen, screw still remains. 8/4/19 order-Transfer to hospital related to hearing voices and swallowing a metal bar. There was no further documentation about this incident. 8/12 and 8/14/19 orders-Stat and non-Stat x-rays of the abdomen rule out foreign objects. The 8/12/19 x-ray showed a 3.8 centimeter screw and a shorter 1.5 centimeter screw in the abdomen. 8/15/19 at 12:36 PM abdomen x-ray-Comparison to the 8/12/19 x-ray showed two metallic foreign bodies. 8/15/19 2:05 PM order-Transfer to hospital related to swallowing a pipe cleaner. The resident returned on 8/16/19 at 2:30 AM. There was no further documentation about this incident. 8/23/19 9 PM progress note-Patient informed (nurse aide) that she had swallowed 2 plastic razor blades Dr notified. Patient sent to hospital The resident returned on 8/25/19. There was no further documentation about this incident. 8/30/19 6 PM progress note-Resident alert and responsive rolled herself up to nurses station, handed writer blue plastic bottom piece of razor for shaving. Resident stated she felt (like) swallowing object so she swallowed razor part of shaver Dr notified order to transfer resident to emergency room . Hospital records noted the following: On 8/31/19-Resident presents after ingestion of a razor blade approximately 6 hours ago. Abdominal x-ray showed a screw in the right lower abdomen and a 4 centimeter long rectangular metallic object (razor) over the mid abdomen. On 9/2/19- X-ray showed screw in same location, the razor has moved further No surgical intervention at this time. On 9/3/19-The patient states at 11:30 PM on 8/30/19 she began hearing voices telling her to hurt herself. She then went to the bathroom and grabbed a razor blade and ingested it still feeling diffuse lower quadrant (abdominal) pain. The resident returned on 9/4/19. On 9/11/19 at 10:05 AM, the resident was alert and in her room awaiting transport to a [MEDICATION NAME] appointment regarding further surgery. When queried about the objects she swallowed, she said, I heard voices when she swallowed two razors that she found in the shower room and screws she found on the (window) ledge by the window in her room. There were no incident reports regarding the swallowed objects, incident investigations as to how resident got a hold of those items or corrective actions to prevent reoccurrence of the resident's access and ingestion of inedible items, other than periodically sweeping her room. On 9/12/19 at 11:40 AM and 09/13/19 at 11:32 AM, the interim Director of Nursing (DON) was queried and said, She got razor blades from the linen room and screws from around the window in her room. Most of her incidents are done on a SBAR (Change in Condition report), however, there were no documented SBAR reports found in the resident's paper or electronic clinical records. She then said, I don't know why they (staff) didn't do them (Incident Reports). They would just send her out to the hospital. It became a trend. On 9/13/19 at 4 PM, per review of the facility's Accidents and Incidents-Investigating and Reporting policy dated 7/1/2016: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises will be investigated and reported to the Administrator Data Included on Report of Incident/Accident Form The Charge Nurse and/or the department manager will promptly initiate and document investigation of the accident or incident The following data, as applicable, will be included on the Report of Incident/Accident form: .The circumstances surrounding the accident or incident; .Any corrective action taken; . Residents #23 and 143- On 9/11/19 at approximately 1 PM, resident #143 was observed pushing resident #5 down the hall in a wheelchair to the resident's room without incident. Just prior, resident #143 was observed pacing back and forth in the hallway periodically asking how to leave the nursing unit to go home, exit seeking by pulling on doors setting off the alarm and asking workers if she could help them in their duties. At 3:35 PM, nurse K was overheard telling someone by phone that resident #143 was pushing resident #23 in the wheelchair and that resident #23 had just fallen forward from the chair while being pushed and sustained a head injury. Upon entering the room, resident #23 was in bed with eyes closed and had a small gaping laceration above the right eyebrow with swelling. When asked what happened, the resident said, I don't know. I don't know if someone pushed me or I fell . When asked if she was okay, the resident said, My head hurts. On 9/12/19 at 9:10 AM, the Director of Nursing (DON) was asked to observed the resident and was asked about the incident. The DON said she was made aware that the resident fell , but did not know she fell while being pushed by another resident. After she saw the laceration and was told that resident #5 was also seen being pushed by resident #143, the DON indicated the resident should not have been transporting other residents. Per nurse K's notes about the incident dated 9/11/19 at 3:10 PM: Writer sitting at nurses station heard a thud. Resident fell forward out of her wheelchair and hit her head. Another resident was pushing her. Right side bleeding from cut above eye. There were no documented interventions in notes for resident #143 regarding interventions to prevent transporting residents. Nurse K was then asked how she knew what happened and if she had actually observed the fall. She said, I saw her (resident #143) pushing (resident #23) in front of the nursing station and when they passed, I heard her fall. At that time, when the DON was told that nurse K saw resident #143 transporting the resident and did not intervene, she said, That shouldn't have been allowed. Further review of resident #23's clinical record revealed: an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] noted, severe cognitive impairment, non-ambulation, extensive assistance required for care including mobility and transfers and unsteady balance. Fall Risk Evaluations dated 3/14, 6/12 and 9/11/19 noted high risk for falls. A review of resident #143's clinical record noted: an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] noted severe cognitive impairment, ambulatory, independent with most activities of daily living, delusions, resistance to care, wandering and physically/verbally abusive behaviors. On 9/13/19 at 4 PM, per review of the facility's undated Falls and Fall Risk, Managing policy: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling The staff will identify appropriate interventions to reduce the risk of falls staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

Based on interview and record review, the facility failed to thoroughly and completely investigate an allegation of sexual abuse and report the allegation to the State Agency when resident (#811) alleged to hospital personnel during a hospitalization that she had been raped at the nursing home. This allegation was identified during a review of the facility's internal investigation of alleged abuse incidents that had not been reported to the State Agency. The failure to thoroughly and completely investigate the allegation of rape and report the allegation to the State Agency had the potential for future unreported and uninvestigated abuse allegations and resulted in Immediate Jeopardy (IJ). This deficient practice had the potential to result in serious harm and/or injury for other residents and required immediate action. The IJ was identified at 2:15 p.m. on 10/19/16, and the Administrator was notified of the IJ at 4:00 p.m. A Plan of Correction was requested to remove the IJ. The IJ was removed on 10/20/16 at 1:00 p.m., based on the facility's implementation of the plan of removal as verified by the surveyor. Although the IJ was removed the facility's deficient practice was not corrected and remained isolated with no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: On 10/18/16 at 12:55 p.m., the Administrator was queried and asked to provide allegations of abuse that were investigated by the facility and not reported to the State Agency. At 1:15 p.m., the Administrator provided one file regarding an allegation of sexual abuse that involved Resident #811. On 10/19/16 at 8:00 a.m., review of Resident #811's admission Minimum (MDS) data set [DATE] revealed that Resident #811 was able to make her needs known and had moderately impaired cognition. On 10/19/16 at 8:30 a.m., review of the facility file for the alleged sexual abuse revealed the following: A face sheet dated 2/17/16, documented that Resident #811 was admitted into the facility on [DATE]. There were no diagnoses listed. An untitled, undated, unsigned piece of typing paper was reviewed and revealed multiple statements that included Resident #811's name and the following phrases 911, STD, she had been abused - was raped, and official investigation. Further review of the investigation packet included an incomplete facility form titled, Resident Abuse Investigation Report signed by the former Director of Nursing 'AA' on 4/8/16 (the day before Resident #811) was discharged to the hospital. The form documented that an unknown incident occurred allegedly at (Facility Name) that involved Resident #811. (Facility Marketing Director) received information that during the resident's hospitalization she alleged that she had been raped at the nursing home. The form also indicated that the type of abuse was listed as sexual, there was no witness, and no person was identified as the perpetrator. The summary included the following, Resident (#811) voiced to hospital staff that she was raped at (Facility Name). The findings noted the following, The abuse (sexual) was not substantiated, the Resident made reference to Foley (indwelling catheter) being placed with a 'baby.' This is the resident misinterpreting care of Foley being placed and a sexual incident. A review of the investigation packet revealed no interview with Resident #811 regarding the incident and no evidence that Resident #811 misinterpreted a Foley (indwelling catheter) for a sexual incident. There were no interviews of staff or potential witnesses as no timeframe of the reported incident had been established. Moreover, there was no complete and thorough investigation nor documented evidence, that supported whether the allegation of sexual abuse occurred or not. In addition, the State Agency was not informed of the alleged allegation of sexual abuse (rape). 10/19/16 at 10:30 am, during an interview with the Administrator and Director of Nursing (DON), Resident #811's clinical records prior to the discharge to the hospital on [DATE], were requested in order to determine Resident #811's history and disposition at the time of discharge. However, the Administrator and the Director of Nursing explained that the Medical Records Staff Person was on bereavement leave and that the Administrator and the DON were unable to locate Resident #811's clinical record. At 10:45 a.m., the Administrator (the Abuse Coordinator) and the DON were queried. When asked why Resident #811 was sent out to the hospital, the Administrator explained that she was not present during the time Resident #811 was sent to the hospital nor was she the Administrator at the time of the reported allegation of abuse. When asked if there was a completed investigation that included interviews from the resident, witnesses or staff, the Administrator stated, I wasn't here. I have no idea what happened. Since there was an incomplete investigation regarding the allegation of rape, another request was made to obtain Resident #811's clinical record at the time of discharge to the hospital. Additional information from the clinical record was needed to determine Resident #811's disposition at the time of discharge. The Administrator stated, We (she and the DON) are unable to locate the chart. At this time, the Administrator and the DON were asked why Resident #811's allegation of rape was not reported to the State Agency. The Administrator explained that she was unable to offer any additional information because This is the first time I looked at (#811's) investigation packet. The DON stated, We can't answer that because we were not here at the time. We just started working here. On 10/19/16 at 4:30 p.m., the facility's policy titled, Abuse Investigations revised 7/1/16 was reviewed. The policy noted, All reports of resident abuse, neglect and injuries of unknown source will be promptly and thoroughly investigated by facility management. The timeframe for reporting to the State Agency documented, It the incident or suspected incident of abuse resulted in serious bodily injury to the patient, it shall be reported immediately, but not more than two hours after forming the suspicion. If the incident or suspected incident did not result in serious bodily injury it shall be reported not longer than 24 hours after the incident. In regards to the Investigation Process, The individual conducting the investigation will, as a minimum: Review the resident's medical record to determine events leading up to the incident, interview the person(s) reporting the incident, interview any witnesses to the incident, interview the resident (as medically appropriate), interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, interview the resident's roommate, family members, and visitors, and review all events leading up to the alleged incident. The policy also noted, The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, initial report within 24 hours and follow up within five working days of the reported incident. On 10/20/16 at 1:00 p.m., the facility provided a removal plan for the immediate jeopardy regarding the failure to thoroughly and completely investigate an allegation of sexual abuse and report the allegation of sexual abuse to the State Agency when resident (#811) alleged she had been raped at the nursing home. IJ Removal Plan The facility failed to thoroughly and completely investigate and report an allegation of sexual abuse that occurred on 4/11/16 and immediately report an allegation of sexual abuse to the State Agency and other officials in accordance with federal regulatory requirements. Element 1 The identified resident #811 is no longer a resident of the facility. The resident was discharged home from the facility. All residents have the potential to be affected by this deficient practice. The facility failed to thoroughly and completely investigate and report an allegation of sexual abuse and report the allegation to the State Agency. Element 2 The Administrator and Director of Nursing reviewed the policies and procedures on investigating and reporting allegations of abuse on 10/19/16 at 7 p.m. and found them to be adequate with no changes required. The Administrator and Director of Nursing were not able on 10/19/16 at 7 p.m. to identify any other allegations of sexual abuse that were reported to the Abuse Coordinator. On 10/19/16 at 7 p.m., the Administrator and Director of Nursing reviewed the Resident Council minutes conducted during the months of April 2016 through October 2016 and found no indication of any sexual abuse not investigated and not reported. The Administrator and Director of Nursing reviewed seven resident concern forms from the months of January 2016 through October 2016 on 10/19/16 at 7:15 p.m. and found no evidence of any allegations of sexual abuse. No concerns were identified. Element 3 The Administrator, Director of Nursing and department heads will in-service the facility staff on the identification of alleged sexual abuse and the procedure for reporting any suspected or alleged sexual abuse and the consequences of not reporting suspected or alleged sexual abuse. The Administrator, Director of Nursing and departments heads will educate the facility staff to notify the abuse coordinator and local law enforcement agencies immediately when an allegation of suspected or alleged sexual abuse is known. The in-services will start on 10/19/16 and will be completed by 10/21/16. The Administrator and Director of Nursing will review Unusual Occurrence reports starting on 10/20/16 at morning stand-up meeting for any indication of suspected or alleged sexual abuse daily Monday through Friday. The weekend nursing supervisor will review Unusual Occurrence reports on Saturday and Sunday for any indication of suspected or alleged sexual abuse. The scheduled facility staff will be in-serviced on 10/19/16, 10/20/16, and 10/21/16 on day shift, afternoon and midnight shifts by Administrator, Director of Nursing, nursing supervisor and department heads. The facility staff on medical leave and contingent employees will be notified by phone and mail of abuse in-service. The staff will not be allowed to work until they completed the abuse in-service. Abuse investigations starting 10/19/16 will be thoroughly and completely investigated immediately by the Administrator and/or Director of Nursing. Any allegation of sexual abuse will be reported to LARA (State Agency) within the required time period of knowledge. Abuse investigations will be reported by the Administrator during monthly facility Quality Assurance and Process Improvement meeting. Element 4 The Administrator will be responsible for ongoing sustained compliance. Element 5 The POC will be implemented on 10/19/16 and will be completed by 10/21/16. On 10/20/16 at 8:45 p.m. the administrator was asked if there was any additional documentation or information that they would like to provide prior to the end of the survey and reported there was none. ( )

Based on observation, interview, and record review the facility failed to assess and provide pain management for acute and chronic pain for one (Resident #711) of four sampled residents reviewed for pain from a total sample of 19 residents, resulting in unrelieved pain. Findings include: On 10/6/15 at 10:45 am, wound care was observed on Resident #711. Prior to the start of wound care on Resident #711 the Wound Care Nurse/Unit Manager, Nurse 'K' revealed that Resident #711 received pain medication ([MEDICATION NAME]) at 9:30 am. At 10:50 am, prior to the start of the wound care, when Nurse 'K' asked Resident #711 if he was in any pain, Resident #711 stated, Yes. Nurse 'K' asked, Where is your pain? Resident #711 replied, The three parts on my butt. Nurse 'K' explained that Resident #711 was always in pain and stated, I think it is getting worse because he is guarding that right leg even more. He is getting more contracted. At this time Nurse 'K' pulled back the cover to expose Resident #711's body. The bones in Resident #711's legs and hips could be seen through his skin. Resident #711 was observed grimacing and holding his right leg up and toward his chest (approximately at more than 90 degree angle) preventing his heel from touching the mattress. Resident #711's left leg was stiff and he held it straight out. Nurse 'K' then asked Resident #711 to report his pain level. While taking deep breaths in and out, Resident #711 stated, It's a nine (of 10 pain level)! Nurse 'K' removed the bandage from Resident #711's left foot and Resident #711 shouted Ow, ow, ow, ow! Nurse 'K' removed a pillow from Resident #711's bed and accidently dropped it onto Resident #711's foot. Resident #711 yelled OW!! Nurse 'K' then began to cleanse Resident #711's left second toe and Resident #711 began to yell out loud, Oh, oh, oh, oh, oh, oh, Jesus Christ! Nurse 'K' then asked, What is your pain level now? Resident #711 yelled, A 10. It could only be worse if you tortured me. Nurse 'K' was then asked what kind of pain was Resident #711 experiencing and Nurse 'K' explained that she did not know. Nurse ' K ' then stated, People (staff) keep writing generalized pain on his assessments. As Nurse 'K' continued with the wound care, Resident #711 began to repeated strike the mattress with his hand, yelling, Please, please, please. Nurse 'K' then cleansed the wound to Resident #711's right posterior leg. Resident #711 shook his head 'no', verbalized complaints of pain, and taking deep breaths in and out. Resident #711's hands were observed to tremble. At 11:15 am Certified Nurse Assistant (CNA) 'M' entered Resident #711's room. When queried CNA 'M' explained that Resident #711 was not her resident to care for today but she has cared or Resident #711 in the recent past. When asked if Resident #711 complained of pain when she performed care on him or when she turned and repositioned him, CNA 'M' stated, (Resident #711) does not complain of pain when I reposition him. CNA 'M' and Nurse 'K' then proceeded to perform incontinence care on Resident #711. Resident #711 was observed to grimace upon being touched and moved by CNA 'M' and Nurse 'K'. CNA 'M' touched Resident #711's right leg and Resident #711 yelled Ouch. CNA 'M' then apologized to Resident #711 and stated, I didn't mean to touch your leg. CNA 'M' and Nurse 'K' returned Resident #711 to the same position he was in prior to wound care. During positioning, Resident #711's left leg was observed to slip off of the bed. When Nurse 'K' returned his left leg back onto the bed, Resident #711 stated, It hurts so bad. Don't touch it. Nurse 'K' then asked What is your pain level now? Resident #711 stated, Seven. It was an eight yesterday. On 10/6/15 at 11:40 am (two hours after the administration of pain medication), Nurse 'J' was asked if Resident #711's pain was reassessed after he received pain medication at 9:30 am. Nurse 'J' stated, I haven't done that yet. On 10/6/15 at 1:30 pm, Family Member 'O' who visited Resident #711 every other day was queried and expressed concerns with Resident #711's pain management. Family Member 'O' stated, I think (Resident #711) is on scheduled pain medications . (But) he still has a lot of pain. On 10/6/15 at 2:20 pm Nurse 'J' was interviewed regarding Resident #711's pain management. Nurse 'J' reported that she always asked Resident #711 and stated, I know that (Resident #711) has pain because he has a pressure ulcer, he does not move around. At that time, review of the Medication Administration Record [REDACTED]. When asked if Resident #711 had a pain consult (by a pain specialist) in order to address his complaints of pain, Nurse 'J' reviewed Resident #711's clinical record and found no pain consult. Resident #711 had a physician's orders [REDACTED]. Resident #711's pain Medication Administration Record [REDACTED]. According to the Controlled Drug Record, dated 8/8/15 through 10/6/15, Resident #711 did not receive any pain medication on 8/12/15, 8/26/15, 9/3/15, 9/17/15, 9/21/15, or 9/25/15. He received one dose of [MEDICATION NAME] 5-325 milligram tablet on 8/11/15, 8/15/15, 8/20/15, 8/21/15, 8/22/15, 8/23/15, 8/29/15, 8/30/15, 9/4/15, 9/8/15, 9/13/15, 9/26/15, 9/27/15, 10/5/15, and 10/6/15. He received two doses on 8/9/15, 8/14/15, 8/17/15, 9/1/15, 9/2/15, 9/7/15, 9/12/15, 9/14/15, 9/19/15, 9/23/15, 9/29/15, 9/30, 10/2/15 and three doses on 8/8/15, 8/10/15, 8/13/15, 8/18/15, 8/19/15, 8/24/15, 8/25/15, 8/27/15, 8/28/15, 8/31/15, 9/5/15, 9/6/15, 9/9/15, 9/10/15, 9/11/15, 9/15/15, 9/16/15, 9/18/15, 9/20/15, 9/22/15, 9/24/15, 9/28/15, 10/3/15, 10/4/15. There were no days that Resident #711 received all four doses of the [MEDICATION NAME] even though staff reported that Resident #711 was in constant pain. When asked if Resident #711's pain was assessed at some point on every shift, Nurse 'J' reviewed Resident #711's clinical record and revealed that there was no documentation that Resident #711's complaints of pain were consistently addressed, daily or otherwise. When asked how Resident #711's pain could be managed without regular pain assessments, Nurse 'J' was unable to provide an explanation. Further review along with Nurse 'J' revealed that Resident #711 had to be repositioned every two hours. Review of the Pain Flow Sheet for the month of October, 2015 revealed that Resident #711 complained of frequent pain in both legs and feet and that positioning and contractures are the aggravating factors causing the pain. However, there were no evidence that Resident #711 was medicated to prevent pain when he was repositioned every two hours. When queried, Nurse 'J' was unable to explain why Resident #711 did not receive regularly scheduled medications to address the frequent complaints of pain. On 10/6/15 at 3:00 pm, clinical record review revealed that Resident #711 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set ((MDS) dated [DATE], Resident #711 had moderately impaired cognition, however Resident #711 was able to make his needs known. Resident #711 required total physical assistance for all activities of daily living with the exception for eating where he required extensive physical assistance. Further review of Resident #711's clinical record revealed a Rehabilitation Screen dated 8/25/15, noting that nursing staff was notified that Resident #711 refused to participate for the rehabilitation screen and documenting, Resident refuses when he is in pain. Review of Facility Integrated Progress Report notes dated from 4/18/15 through 10/4/15 revealed the following entries related to pain were documented as follows: 4/19/15 (day shift) no pain verbalized; 6/11/15 at 7:00 pm Resident #711 was observed, guarding right knee 45 degrees bend flexion. [MEDICATION NAME] (pain medication) given by nurse per order; 7/16/15 (day shift), Resident complain of right knee pain. Medication given for pain. Resident continues to refuse physical therapy service daily; 8/16/15 (unable to determine time), Resident rest in bed denies any pain; 9/24/14 (day shift), no pain verbalized at this time; 10/1/15 at 4:00 am, no complaints of pain or discomfort voiced; and, 10/4/15 at 4:30 am no complaints of pain. There was no evidence that Resident #711's right leg pain was consistently addressed. There was no evidence that pain was assessed on 8/12/15, 8/26/15, 9/3/15, 9/17/15, 9/21/15, and 9/25/15 when Resident #711 did not receive any pain medication. Facility Pain Assessments dated 5/1/15, 6/23/15, 7/11/15, 7/28/15 revealed that Resident #711 complained of pain in feet and that Resident #711 wanted to have a pain level of one (no pain) out of ten (the worst pain experienced) at each assessment. There was no plan of care implemented to address Resident #711's complaints of pain. Facility Pain Assessments dated 8/1/15 and 9/2/15 documented that Resident #711 was on routine pain medication (Resident #711 did not have scheduled medications). The assessments did not reveal the location of Resident #711's pain or discomfort. In addition the assessments indicated that Resident #711 wanted a pain level of one (no pain). Documents titled Monthly Summary dated 7/11/15, 8/6/15, and 9/2/15, documented that Resident #711 complained of pain in the right leg. Other Facility documents titled Monthly Summary noted: (Undated) patient complains of generalized pain. (Undated) patient complains of right leg pain. (Undated) patient complains of right leg pain. On 10/7/15 at 11:15 am, the Director of Nursing (DON) was queried regarding Resident #711's frequent complaints of pain and why staff did not address the complaints of pain. The DON was unable to explain why staff did not address Resident #711 ' s pain even though he had frequent complaints of pain and had to be repositioned every two hours which caused him pain. When asked why Resident #711 did not have a care plan to address his pain the DON was unable to provide an explanation. When asked why Resident #711's pain was not assessed frequently due to his pressure ulcers, his refusal to move at times, and his guarding of his right leg, the DON explained that pain was assessed if Resident #711 requested pain medication. The DON further explained that she expected staff to assess for pain every shift. However, the DON was unable to provide documented evidence that Resident #711's pain was assessed every shift. When asked why Resident #711 had pain assessments that stated that Resident #711 was on routine pain medication when Resident #711 did not receive routine pain medications, the DON was unable to provide an explanation. When asked why staff did not address Resident #711's guarding of his left leg after multiple documented complaints and his refusal to participate in physical therapy, the DON was unable to provide an explanation. Review of the facility document titled, Policy and Procedure Pain Management date 9/2015, revealed, Policy: Improve and manage pain level of residents to maintain well-being and functioning of residents. Procedure: Assess/recognize pain, Investigate cause of pain. Implement plan to manage pain that is relevant to that resident's discomfort. Order pain medication as needed. Monitor results of pain interventions. Adjust treatment as necessary. Doctor, nursing, family, and resident are all to be involved in managing pain level. ( )

THIS CITATION CONTAINS 2 DEFICIENT PRACTICE STATEMENTS AND PERTAINS TO INTAKES MI 586 AND MI 409. DEFICIENT PRACTICE STATEMENT #1: BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION BY MONITORING THE WHEREABOUTS OF ONE (#700) OF 10 RESIDENTS IDENTIFIED BY THE FACILITY AS BEING AT HIGH RISK FOR ELOPEMENT, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #700 WHEN HE LEFT THE BUILDING UNNOTICED FOR 3 HOURS AND WAS FOUND THREE (3) MILES AWAY FROM THE FACILITY. RESIDENT #700 PRESENTED AT A LOCAL emergency room WITH AN ABRASION AND A CONTUSION TO HIS FOREHEAD, RESULTING IN THE POTENTIAL FOR HARM, SERIOUS INJURY AND/OR DEATH. THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON 9/11/13, AT 2:00 P.M., AND THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY AT 4:50 P.M., ON 9/11/13. A PLAN OF CORRECTIVE WAS REQUESTED TO REMOVE THE IJ. THE IMMEDIATE JEOPARDY WAS REMOVED ON 9/12/13, BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 9/12/13, AS VERIFIED ONSITE ON 9/13/13. ALTHOUGH THE IMMEDIATE JEOPARDY (IJ) WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE REMAINED AS ISOLATED WITH ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE: ON 9/11/13, AT 9:00 A.M., INTERVIEW WITH PHYSICIAN EMPLOYEE #1 REVEALED THAT ON 9/3/13, RESIDENT #700 ELOPED FROM THE FACILITY AND WAS readmitted FROM AN AREA hospital on [DATE]. EMPLOYEE #1 STATED THAT RESIDENT #700 WAS FOUND ON THE GROUND APPROXIMATELY 3 MILES FROM THE FACILITY AND TAKEN TO AN AREA HOSPITAL emergency room WHERE HE REQUIRED treatment for [REDACTED]. ON 9/11/13, AT 9:45 A.M., DURING THE INITIAL TOUR, OBSERVATION REVEALED THAT RESIDENT #700 PRESENTED WITH A RAISED SCABBED AREA ON THE RIGHT SIDE OF HIS FOREHEAD. WHEN QUERIED ABOUT THE INJURED AREA HE REPLIED, "I fell OUTSIDE." HOWEVER, RESIDENT #700 COULD NOT RECALL ANY SPECIFIC DETAILS REGARDING THE INCIDENT. REVIEW OF THE HOSPITAL RECORD DATED 9/4/13, REVEALED THAT RESIDENT #700 HAD A COMPUTERIZED TOMOGRAPHY (CT) SCAN COMPLETED ON 9/3/13, INDICATING THAT RESIDENT #700 HAD SUSTAINED A RIGHT FRONTAL SCALP HEMATOMA AND ABRASION. FURTHER DIAGNOSTIC TESTING REVEALED THAT RESIDENT #700 REQUIRED treatment for [REDACTED]. THE HOSPITAL RECORD INDICATED THAT FOLLOWING THE emergency room TREATMENT ON 9/3/13, RESIDENT #700 WAS hospitalized BEGINNING ON 9/4/13 AND WAS TRANSFERRED BACK TO THE NURSING HOME ON 9/10/13. RECORD REVIEW REVEALED RESIDENT #700 WAS ORIGINALLY admitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMAL DATA SET ( (MDS) dated [DATE], REVEALED THAT RESIDENT #700 WAS AMBULATORY AND USED A STRAIGHT CANE. ON 9/11/13, AT 10:15 A.M., INTERVIEW WITH ADMINISTRATOR (EMPLOYEE #2) VERIFIED THAT RESIDENT #700 ELOPED FROM THE FACILITY ON 9/3/13, AND AN INTERNAL INVESTIGATION WAS CONDUCTED, BUT THAT THE ELOPEMENT INCIDENT HAD NOT BEEN REPORTED TO THE STATE AGENCY. EMPLOYEE #2 FURTHER EXPLAINED THAT DURING THE FACILITY'S INTERNAL INVESTIGATION IT WAS ESTABLISHED THAT RESIDENT #700 HAD NEVER BEEN ASSESSED FOR ELOPEMENT RISK PRIOR TO HIS ELOPEMENT. EMPLOYEE #2 STATED THAT IF RESIDENT #700 HAD BEEN ASSESSED, HE WOULD HAVE BEEN CONSIDERED AS BEING AT HIGH RISK FOR ELOPEMENT AND THAT FACILITY STAFF WERE UNAWARE THAT RESIDENT #700 WAS MISSING FROM THE FACILITY. EMPLOYEE #2 STATED THAT ON 9/3/13, AT 9:58 P.M., SHE RECEIVED A PHONE CALL FROM NURSE SUPERVISOR EMPLOYEE #5, WHO REPORTED THAT RESIDENT #700 WAS TAKEN TO AN AREA HOSPITAL BY EMERGENCY MEDICAL TECHNICIANS AFTER HE WAS FOUND ON THE GROUND. EMPLOYEE #2 STATED THAT WHEN THE HOSPITAL STAFF CONTACTED FACILITY SECURITY STAFF AT 9:45 P.M., ON 9/3/13, THAT WAS THE FIRST NOTIFICATION TO FACILITY STAFF THAT RESIDENT #700 WAS MISSING AND HAD ELOPED. REVIEW OF THE FACILITY'S INTERNAL INVESTIGATION REPORT REVEALED THAT ON 9/3/13, AT APPROXIMATELY 6:45 P.M., RESIDENT #700 EXITED OUT THE FRONT ENTRANCE DOOR OF THE FACILITY. EMPLOYEE #2 STATED THAT THERE WERE TWO EMPLOYEES AT THE FRONT ENTRANCE DOOR WHO OBSERVED RESIDENT #700 EXIT THE BUILDING AND THOUGHT HE WAS A VISITOR. EMPLOYEE #2 STATED THAT FACILITY STAFF WERE UNAWARE THAT RESIDENT #700 ELOPED UNTIL HOSPITAL PERSONNEL CALLED THE NURSING HOME AT 9:45 P.M., AND INFORMED THE FACILITY SECURITY GUARD THAT RESIDENT #700 WAS BROUGHT TO THE emergency room BY EMERGENCY MEDICAL TECHNICIANS. EMPLOYEE #2 EXPLAINED THAT SHE REVIEWED VIDEO SURVEILLANCE AND ESTABLISHED THAT RESIDENT #700 ELOPED AT 18:44 MILITARY TIME (MT) OR 6:44 P.M. EASTERN STANDARD TIME( EST). EMPLOYEE #2 EXPLAINED THAT REVIEW OF THE VIDEO SURVEILLANCE VERIFIED THAT 2 HOUSEKEEPERS EMPLOYEES #3 AND #4 WERE PRESENT AT THE SECURITY DESK WHEN RESIDENT #700 EXITED FROM THE FRONT ENTRANCE OF THE FACILITY ON 9/3/13. ON 9/12/13, AT 9:30 A.M., THE VIDEO SURVEILLANCE WAS REVIEWED BY THE SURVEYOR WITH EMPLOYEE #2. REVIEW OF THE VIDEO VERIFIED THAT RESIDENT #700 EXITED THE FRONT ENTRANCE AT 18:44 MT OR 6:44 P.M. (EST), AS TIMED ON THE VIDEO SURVEILLANCE. THE VIDEO FURTHER REVEALED THAT TWO HOUSEKEEPERS KNOWN AS EMPLOYEES #3 AND #4 WERE PRESENT AT THE FRONT ENTRANCE SECURITY DESK AND OBSERVED RESIDENT #700 LEAVE THE BUILDING USING THE FRONT ENTRANCE OF THE FACILITY. ON 9/12/13, AT 1:05 P.M., INTERVIEW WITH EMPLOYEE #3 REVEALED THAT HE WAS PRESENT AT THE SECURITY DESK WHEN RESIDENT #700 EXITED THE FACILITY USING THE FRONT DOOR. EMPLOYEE #3 STATED THAT HE WAS UNAWARE THAT RESIDENT #700 WAS AN ELOPEMENT RISK AND STATED THAT HE HAD MISTAKEN RESIDENT #700 TO BE A VISITOR SINCE HE AMBULATED WITH A CANE. EMPLOYEE #3 FURTHER STATED THAT AFTER RESIDENT #700 EXITED THE BUILDING, HE (#3) LOOKED IN THE ELOPEMENT BINDER KEPT AT THE SECURITY DESK AND DID NOT SEE A PICTURE THAT RESEMBLED RESIDENT #700. ON 9/12/13 AT 3:45 P.M., INTERVIEW WITH THE AFTERNOON SHIFT NURSE SUPERVISOR KNOWN AS EMPLOYEE #5 REVEALED THAT AT APPROXIMATELY 9:45 P.M., SHE RECEIVED A PHONE CALL FROM THE HOSPITAL TO ALERT HER THAT RESIDENT #700 WAS IN THE emergency room . EMPLOYEE #5 STATED THAT UNTIL SHE RECEIVED THE CALL FROM THE HOSPITAL FACILITY STAFF WERE UNAWARE THAT RESIDENT #700 HAD ELOPED. EMPLOYEE #5 STATED THAT SHE IMMEDIATELY INITIATED CONTACT TO THE NURSING HOME ADMINISTRATOR. ON 9/11/13, AT 1:00 P.M., REVIEW OF THE FACILITY'S "ELOPEMENT POLICY AND PROCEDURES" REVISED AUGUST 2013, REVEALED THAT A PINK BINDER LABELED ELOPEMENT WAS LOCATED IN EACH DEPARTMENT AND AT EACH NURSING STATION AS WELL AS THE SECURITY DESK. FURTHERMORE, THE ELOPEMENT POLICY AND PROCEDURE INDICATED THAT THE FOLLOWING ACTIONS TO BE IMPLEMENTED WHEN IT HAD BEEN ESTABLISHED THAT A RESIDENT HAD THE POTENTIAL FOR ELOPEMENT: 1. IDENTIFICATION BAND (PINK) ON AT ALL TIMES, IF LOST OR REMOVED, OBTAIN NEW IDENTIFICATION BAND FROM ADMITTING OFFICE. IF RESIDENT REFUSED TO WEAR A WRIST BAND WILL BE PLACED AT THE SECURITY GUARD'S DESK AND ON THE RESIDENT'S MAR (MEDICAL ACCEPTANCE RECORD); 2. ALL DOORS LEADING IN/OUTSIDE THE FACILITY, AS WELL AS THE UNITS WILL BE MAINTAINED WITH ALARMS; 3. CARE PLANS WILL BE INSTITUTED TO INCLUDE AN APPROACH TO PROVIDE ACTIVITIES THAT WILL DETER WANDERING. THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THE FACILITY IMPLEMENTED THE FOLLOWING PLAN OF CORRECTION: 1. RESIDENT (#700) RETURNED FROM THE hospital on [DATE]. THE FOLLOWING INTERVENTIONS OCCURRED. THE RESIDENT WAS PLACED ON EVERY 30 MINUTE CHECKS TIMES 24 HOURS. THE RESIDENT WAS ASSESSED FOR ELOPEMENT RISK AND HIS SCORE TRIGGERED HIM AS A RISK FOR ELOPEMENT. A PINK ARM BAND WAS PLACED ON HIS WRIST. AN ELOPEMENT CARE PLAN WAS INITIATED. THE RESIDENT'S CARE CARD INDICATED THE RESIDENT IS AN ELOPEMENT RISK. A PICTURE OF THE RESIDENT WAS PLACED IN THE ELOPEMENT BINDERS IN ALL APPLICABLE AREAS: SECURITY,; ALL NURSING UNITS ' DIETARY; ACTIVITIES; LAUNDRY; BUSINESS OFFICE; HUMAN RESOURCES; THERAPY. 2. UPON RECEIVING THE NOTIFICATION THE FOLLOWING OCCURRED ELOPEMENT, THE FOLLOWING REMEDIES WERE IMMEDIATELY INSTITUTED: ON 9/11/13 THE RESIDENT WAS RE-assessed with [REDACTED]. HE WAS PLACED ON THE NEW ELOPEMENT SUPERVISION LOG FOR MONITORING EVERY ONE HOUR. A COPY OF "PINK FEET" WAS PLACED OVER HIS BED. THE RESIDENT'S CARE PLAN WAS UPDATED TO INDICATE THE "PINK FEET" WAS PLACED ON HIS CARE OVER HIS BED. THE RESIDENT'S CARE CARD WAS UPDATED TO INDICATE THE "PINK FEET" WAS PLACED OVER THE HEAD OF HIS BED. 3. ALL RESIDENTS IN THE FACILITY WERE RE-assessed with [REDACTED]. FOUR RESIDENTS WERE IDENTIFIED AS BEING POTENTIALLY AFFECTED BY THIS DEFICIENT PRACTICE. THE POTENTIALLY AFFECTED RESIDENTS WERE PLACE ON THE ELOPEMENT SUPERVISION LOG, CARE PLANS UPDATE TO INDICATE THE RESIDENTS HAVE "PINK FEET" PLACED OVER THEIR BEDS. 3. THE FACILITY ELOPEMENT POLICY WAS REVIEWED AND AN ADDENDUM WAS ADDED TO INDICATE THE INCORPORATION OF THE "PINK FEET" AS AN IDENTIFIER FOR POTENTIAL FOR ELOPEMENT RISK. UPON ADMISSION ALL RESIDENTS WILL BE ADDRESSED FOR ELOPEMENT. IF A RESIDENT SCORE 10 OR GREATER ON THE ELOPEMENT RISK ASSESSMENT THE ELOPEMENT SUPERVISION LOG WILL BE INITIATED. A CARE PLAN WILL BE IMPLEMENTED AND A PICTURE OF PINK FEET WILL BE PLACED ABOVE THEIR RESIDENT'S BED TO ENSURE THIS DEFICIENT PRACTICE DOES NOT RECUR. 4. THE FACILITY UNIT MANAGERS AND STAFF DEVELOPER CONDUCTED IN-SERVICES REGARDING THE NEW ELOPEMENT ASSESSMENT FORM AND ELOPEMENT SUPERVISION LOG. THE FACILITY STAFF WAS EDUCATED RELATED TO THE "PINK FEET." IN-SERVICES RELATE TO STAFF BEING ABLE TO PHYSICALLY IDENTIFY RESIDENT AT RISK FOR ELOPEMENT BASED ON POSSIBLE PHYSICAL APPEARANCE I.E. ANYONE USING A CANE, WALKER, QUAD CANE, IDENTIFICATION BRACELET ON, PINK IDENTIFICATION BRACELET SHOULD NOT BE PERMITTED TO SIGN OUT WITHOUT AUTHORIZATION 9/11/13. A SPECIAL RESIDENT COUNCIL MEETING WAS HELD REGARDING ELOPEMENT PRECAUTIONS 9/12/13. TO ENSURE THAT THIS DEFICIENT DOES NOT REOCCUR THE VISITORS ARE MONITORED. THE SECURITY AND RELIEF STAFF WAS EDUCATED ON THE PROTOCOL FOR RELIEVING THE MAIN ENTRANCE 9/11/13. TWO VENDORS HAVE BEEN CONTACTED TO PERFORM AN ASSESSMENT THE MAIN ENTRANCE FOR SECURITY ENHANCEMENT. (ONE ASSESSMENT HAS BEEN COMPLETED AND WAITING AN ESTIMATE THE OTHER ONE WILL BE COMPLETED IN TWO DAYS). THE COMPANY ' S TASKS WILL BE TO ALARM THE FRONT ENTRANCE. THIS WILL GIVE THE SECURITY STAFF OR RELIEF MORE CONTROL OVER THE INCOMING AND OUTGOING OF THE TRAFFIC. 5. UPON ADMISSION THE ADMITTING NURSE WILL RESPONSIBLE FOR PLACING COMPLETING THE ELOPEMENT ASSESSMENT FORM AND PLACING ALL RESIDENTS WHO TRIGGER AS A "HIGH RISK" FOR ELOPEMENT ON THE ELOPEMENT SUPERVISION LOG AND PLACING THE "PINK FEET" OVER THE RESIDENT'S BED AND INITIATE A CARE PLAN. IT WILL BE THE RESPONSIBILITY OF THE CHARGE NURSE TO COMPLETE THE HOURLY ELOPEMENT SUPERVISION LOG TO ENSURE THE WHEREABOUTS OF THE RESIDENT. THE UNIT MANAGERS WILL BRING ALL ELOPEMENT SUPERVISION LOGS TO THE DIRECTOR OF NURSING EVERY MORNING AT THE CLINICAL MEETING. ON THE WEEKEND THE NURSING SUPERVISORS WILL REVIEW THE LOGS. 6. THE ELOPEMENT SUPERVISION LOG WILL BE UTILIZED TO MONITOR THE WHEREABOUTS OF RESIDENTS WHO SCORED "HIGH RISK" FOR ELOPEMENT. RESIDENTS WHO SCORE: "HIGH RISK" FOR ELOPEMENT WILL HAVE COPY OF "PINK FEET" PLACE ABOVE THEIR BED. THE ADMITTING NURSE WILL BE RESPONSIBLE FOR PLACING THE "PINK FEET" OVER THE RESIDENT'S BED. IT WILL BE THE RESPONSIBILITY OF THE CHARGE NURSES TO PERFORM EVERY ONE HOUR ROUNDS AND DOCUMENT THE WHEREABOUTS OF THE RESIDENT. ANY CONCERNS WILL BE ADDRESSED IMMEDIATELY WITH THE INITIATION OF THE ELOPEMENT POLICY AND PROCEDURE. 7. FOR THE NEXT WEEK ALL STAFF WILL BE CONTINUOUSLY IN-SERVICED REGARDING THE NEW ELOPEMENT ASSESSMENT FORM THE NEW ELOPEMENT SUPERVISION LOG AND PINK FEET AND THE PROTOCOL FOR MONITORING THE MAIN ENTRANCE. ANY STAFF THAT HAS BEEN IN SERVICED WILL NOT BE ALLOWED TO WORK UNTIL THEY HAVE BEEN EDUCATED ON THE NEW PROCEDURE FOR MONITORING THE WHEREABOUTS OF THE RESIDENTS DEEMED "HIGH RISK" FOR ELOPEMENT. THE POLICY AND PROCEDURE WILL BECOME PART OF NEW HIRE ORIENTATION EFFECTIVE IMMEDIATELY. 8. THE DIRECTOR OF NURSING WILL REVIEW THE ELOPEMENT SUPERVISION LOGS AT THE CLINICAL MEETING ADDRESS ANY CONCERNS IMMEDIATELY. THE DIRECTOR OF NURSING AND OR THE ADMINISTRATOR WILL DO RANDOM AUDITS OF THE ELOPEMENT PROCESS DAILY TO ENSURE COMPLIANCE OF THIS DEFICIENCY. FINDINGS WILL BE REPORTED TO THE QUALITY ASSURANCE COMMITTEE. THE FACILITY IS CONFIDENT THAT THESE CORRECTIVE MEASURES WILL BE IMPLEMENTED BY 9/12/13. THE ADMINISTRATOR WILL BE RESPONSIBLE FOR SUSTAINED COMPLIANCE. ( , , ) DEFICIENT PRACTICE STATEMENT #2: BASED ON INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION FOR 1 (#701) OF 2 SAMPLED RESIDENTS REVIEWED FOR ELOPEMENT FROM A TOTAL SAMPLE OF 9, RESULTING IN THE POTENTIAL FOR ELOPEMENT. FINDINGS INCLUDE: ON 9/11/13, AT 9:30 A.M., INTERVIEW WITH RESIDENT #701 REVEALED THAT HE ELOPED FROM THE FACILITY DURING AN EVENING SMOKING ACTIVITY AT APPROXIMATELY 6:30 P.M. ON 8/24/13. RESIDENT #701 STATED THAT AFTER THE SUPPER MEAL, HE AND SEVERAL OTHER RESIDENTS WERE TAKEN OUTDOORS TO SMOKE. RESIDENT #701 FURTHER EXPLAINED THAT HE DECIDED TO WALK TO HIS MOTHER'S HOME WHEN THE STAFF PERSON MONITORING THE SMOKING ACTIVITY WENT BACK INSIDE THE FACILITY. RESIDENT #701 STATED THAT HE WAS UNCERTAIN HOW LONG HE WAS AWAY FROM THE NURSING HOME BUT STAFF FOUND HIM AND BROUGHT HIM BACK UNHARMED. ON 9/11/13, AT 9:55 A.M., REVIEW OF THE CLINICAL RECORD FOR RESIDENT #701 INDICATED ON THE "ADMISSION RECORD FORM" AN INITIAL admission date of [DATE], WITH [DIAGNOSES REDACTED]. THE MDS DATED 7/8/13, INDICATED THAT RESIDENT #701 WAS ORIENTED TO PERSON, PLACE, AND TIME AND AMBULATED WITH AN UNSTEADY GAIT. FURTHER REVIEW OF THE CLINICAL RECORD REVEALED THAT RESIDENT #701 HAD A COURT APPOINTED LEGAL GUARDIAN. THERE WAS DOCUMENTATION IN THE "NURSES PROGRESS NOTES" THAT INDICATED THAT RESIDENT #701 WANTED TO LEAVE THE FACILITY TO BE AT HOME WITH HIS MOTHER. ON 9/11/13, AT 10:00 A.M., INTERVIEW WITH EMPLOYEE #2 REVEALED THAT AN INTERNAL FACILITY INVESTIGATION WAS CONDUCTED REGARDING THE ELOPEMENT INCIDENT THAT INVOLVED RESIDENT #701. EMPLOYEE #2 STATED THAT THE EMPLOYEE WHO WAS RESPONSIBLE TO SUPERVISE THE RESIDENTS DURING THE EVENING SMOKING ACTIVITY ON 8/24/13, WAS TERMINATED DUE TO INCONSISTENCIES REPORTED REGARDING THE INCIDENT. ( )

THIS CITATION PERTAINS TO INTAKE # MI 822 BASED ON OBSERVATIONS, INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO ENSURE THAT 1 (#102) OF 4 RESIDENTS REVIEWED FOR WEIGHT LOSS, FROM A TOTAL SAMPLE OF 5, RECEIVED ADEQUATE NUTRITIONAL SUPPORT TO MAINTAIN HIS WEIGHT, RESULTING IN A SIGNIFICANT WEIGHT LOSS FOR RESIDENT #102, WITH THE POTENTIAL FOR NUTRITIONAL DEFICITS, [MEDICAL CONDITION] AND ASSOCIATED ILLNESSES. FINDINGS INCLUDE: RESIDENT #102 ACCORDING TO THE FACE SHEET DATED 8/18/2012, RESIDENT #102 WAS A [AGE] year OLD MALE, admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #102 HAD IMPAIRED DECISION MAKING, SHORT TERM MEMORY LOSS, A PRESCRIBED THERAPEUTIC DIET, RECENT SIGNIFICANT WEIGHT LOSS AND HE REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST HIM WITH EATING. A MONTHLY WEIGHT RECORD REVEALED RESIDENT #103 WEIGHED 193 POUNDS WHEN HE WAS admitted to the facility on [DATE]. THE ADMISSION NUTRITIONAL assessment dated [DATE] NOTED THAT RESIDENT #102 NEEDED A LOW SODIUM, LOW CHOLESTEROL DIET WITH 87 GRAMS OF DAILY PROTEIN, A DAILY GREEN VEGETABLE AND AN EVENING SNACK. A DIETARY CARE PLAN DATED 4/16/2012 IDENTIFIED RESIDENT #102 AT RISK FOR IMPAIRED NUTRITION, BUT DESPITE HIS NEED FOR 87 GRAMS OF PROTEIN DAILY, STAFF WAS REQUIRED TO SUPPLY ONLY 80 GRAMS DAILY. THE CARE PLAN DID NOT INCLUDE WEEKLY WEIGHTS OR DAILY MONITORING OF HIS FOOD ACCEPTANCE. A "COMMUNICATION BETWEEN THE CONSULTING DIETITIAN AND ATTENDING PHYSICIAN" DATED 4/17/2012 DOCUMENTED THAT THAT PHYSICIAN AGREED TO FOUR WEEKLY WEIGHTS AND A FOURTEEN DAY FOOD ACCEPTANCE LOG COMPLETED FOR RESIDENT #102. A COMPREHENSIVE REVIEW OF THE MEDICAL RECORD REVEALED THE FOOD ACCEPTANCE FOR 4/13, 4/14, 4/15, 4/16, 4/17, 4/18, 4/19, 4/20, 4/23, 4/24, 4/26, 4/27, 4/28, 4/29, 4/30 AND 4/31/2012 WERE INCOMPLETE. ADDITIONALLY, THE REVIEW FAILED TO IDENTIFY ANY DOCUMENTED EVIDENCE WEEKLY WEIGHTS HAD BEEN OBTAINED AFTER 4/11/2012. A MONTHLY WEIGHT RECORD REVEALED RESIDENT #102 WEIGHED 180.6 POUNDS ON 6/05/2012, A WEIGHT LOSS OF 12.4 POUNDS, OR 6% OF HIS TOTAL BODY WEIGHT, SINCE ADMISSION 4/11/2012. A COMPREHENSIVE REVIEW OF THE MEDICAL RECORD DID NOT REVEAL ANY DOCUMENTED EVIDENCE TO SUGGEST THAT THE REGISTERED DIETITIAN OR ANY OTHER NUTRITION PROFESSIONAL MONITORED, ASSESSED OR INTERVENED FOR RESIDENT #102 WHEN THIS WEIGHT LOSS WAS RECOGNIZED. ON 6/19/2012 THE PHYSICIAN RECOGNIZED RESIDENT #102 HAD WEIGHT LOSS AND ORDERED 400 MG OF DAILY [MEDICATION NAME] (ANTIEMETIC, ALSO USED FOR POOR APPETITE), TO STIMULATE HIS APPETITE. REVIEW OF THE JUNE 2012 MEDICATION ADMINISTRATION RECORDS REVEALED THE APPETITE STIMULANT WAS NOT ADMINISTERED TO RESIDENT #102 ON 6/24, 6/25, 6/26, 6/27, 6/28, 6/29 AND 6/30/2012. NURSING STAFF FAILED TO DOCUMENT WHY THEY DID NOT FOLLOW PHYSICIAN ORDERS [REDACTED]. A NUTRITIONAL assessment dated [DATE] REVEALED RESIDENT #102 HAD DEVELOPED LOWER EXTREMITY [MEDICAL CONDITION], YET STILL LOST 23 POUNDS, OR 11% OF HIS TOTAL BODY WEIGHT SINCE HE WAS admitted [DATE]. THE ASSISTANT DIETARY MANAGER (DMA) #1 REQUESTED WEEKLY WEIGHTS AND LOGS TO MONITOR THE RESIDENT'S DAILY FOOD ACCEPTANCE. THE "COMMUNICATION BETWEEN THE CONSULTING DIETITIAN AND ATTENDING PHYSICIAN" DATED 6/27/2012 DOCUMENTED THAT THE PHYSICIAN AGREED TO CHANGE THE DIET FOR RESIDENT #102. HE WAS PLACED ON A SOFT NO ADDED SALT, LOW CHOLESTEROL DIET, WITH SUPER FOODS, 4 OUNCES OF HEALTHSHAKES TWICE A DAY, AND A NUTRITIONAL SUPPLEMENT (MED PASS 2.0) THREE TIMES DAILY. THE PHYSICIAN AGREED RESIDENT #102 REQUIRED WEEKLY WEIGHTS AND DAILY LOGS FOR HIS FOOD ACCEPTANCE. A COMPREHENSIVE REVIEW OF THE MEDICAL RECORD FAILED TO IDENTIFY ANY DOCUMENTED EVIDENCE FOOD ACCEPTANCE RECORDS WERE EVER COMPLETED IN JUNE OR JULY 2012. ADDITIONALLY, THE REVIEW FAILED TO IDENTIFY ANY WEEKLY WEIGHTS OBTAINED BETWEEN 6/27/2012 AND 7/27/2012. A MONTHLY WEIGHT RECORD DATED 7/11/2012 REVEALED RESIDENT #102 LOST ANOTHER 4.6 POUNDS, WEIGHED ONLY 170.4 POUNDS AND CUMULATIVELY HAD LOST 13% OF HIS TOTAL BODY WEIGHT SINCE ADMISSION THREE MONTHS EARLIER. DESPITE KNOWING RESIDENT #102 HAD RECENT SIGNIFICANT WEIGHT LOSS AND LOWER EXTREMITY [MEDICAL CONDITION] THAT IN HER OPINION REQUIRED WEEKLY WEIGHTS AND DAILY FOOD ACCEPTANCE RECORDS, A COMPREHENSIVE REVIEW OF THE MEDICAL RECORD FAILED TO IDENTIFY ANY DOCUMENTED EVIDENCE THAT DMA #1 OR ANY OTHER NUTRITION PROFESSIONAL FOLLOWED-UP ON RESIDENT #102 AFTER 6/27/2012. A TRANSFER FORM DATED 7/18/2012 REVEALED RESIDENT #102 HAD MENTAL STATUS CHANGES AND WAS TRANSFERRED TO A LOCAL AREA HOSPITAL. ACCORDING TO LOCAL HOSPITAL RECORDS, RESIDENT #102 HAD A PACEMAKER INSERTED AND RETURNED TO THE FACILITY 7/27/2012. THE MONTHLY WEIGHT RECORD REVEALED RESIDENT #102 WEIGHED 163.6 POUNDS WHEN HE RETURNED to the facility on [DATE]. admission orders [REDACTED]. ADDITIONALLY, RESIDENT #102'S DIET WAS DOWN-GRADED FROM INCLUDING SUPER FOODS, HEALTH SHAKES AND NUTRITIONAL SUPPLEMENTS, TO A REGULAR NO ADDED SALT AND LOW CHOLESTEROL DIET. A READMISSION NUTRITIONAL ASSESSMENT COMPLETED 8/06/2012, 9 DAYS AFTER RESIDENT #102 RETURNED FROM THE HOSPITAL WITH AN ADDITIONAL 7 POUND WEIGHT LOSS, SUPER FOODS, BENE-PROTEIN AND SUPPLEMENTS (MED PASS 2.0) WERE REINTRODUCED INTO HIS DIET. A "COMMUNICATION BETWEEN THE CONSULTING DIETITIAN AND ATTENDING PHYSICIAN," DATED 8/06/2012 DOCUMENTED THAT THE PHYSICIAN ONCE AGAIN AGREED TO WEEKLY WEIGHTS AND DAILY FOOD ACCEPTANCE RECORDS WERE REQUIRED. A PHYSICIANS ORDER FOR 8/06/2012 REQUIRED RESIDENT #102 TO RECEIVE A NUTRITIONAL SUPPLEMENT (MED PASS 2.0) THREE TIMES A DAY. THE AUGUST 2012 MEDICATION ADMINISTRATION RECORDS REVEALED THE NUTRITIONAL SUPPLEMENT WAS NOT ADMINISTERED RESIDENT #102 ON BETWEEN 8/06/2012 AND 8/24/2012. ADDITIONALLY, THE SUPPLEMENT WAS ONLY GIVEN ONCE DAILY ON 8/24, 8/25, 8/26 AND 8/27/2012. NURSING STAFF FAILED TO DOCUMENT WHY THEY DID NOT FOLLOW PHYSICIAN ORDERS [REDACTED]. A COMPREHENSIVE REVIEW OF THE MEDICAL RECORD FAILED TO IDENTIFY ANY DOCUMENTED EVIDENCE FOOD ACCEPTANCE RECORDS WERE EVER COMPLETED IN AUGUST 2012. A WEEKLY WEIGHT RECORD DATED 8/15/2012 REVEALED RESIDENT #102 LOST ANOTHER 5 POUNDS, WEIGHED ONLY 158 POUNDS, AND CUMULATIVELY LOST 35 POUNDS, OR 18% OF HIS TOTAL BODY WEIGHT SINCE ADMISSION 4/11/2012. DESPITE THE WEEKLY WEIGHTS AND PROGRESSIVE WEIGHT LOSS, THE DMA#1 WAITED 16 DAYS, BEFORE SHE REASSESSED HIS NUTRITIONAL STATUS ON 8/22/2012. SHE DOCUMENTED RESIDENT #102 HAD A "GOOD" APPETITE, ADDED ONE CUP OF MILK TWICE TO HIS DAILY DIET AND REQUESTED A THREE DAY DIET DIARY. THE "RESIDENT FOOD INTAKE DIARY" DOCUMENTED THAT BETWEEN 8/23/2012 AND 8/25/2012, RESIDENT #102 ATE LESS THAN 25% OF HIS MEALS. A DIETARY PROGRESS NOTE DATED 8/27/2012 REVEALED DMA #1 KNEW THAT RESIDENT #102 CONSUMED 50% "OR LESS" OF HIS FOOD/FLUIDS, REFUSED FEEDING ASSISTANCE AND STILL DOCUMENTED THE CURRENT PLAN OF CARE WOULD BE FOLLOWED. A WEEKLY WEIGHT DATED 8/29/2012 REVEALED RESIDENT #102 HAD LOST AN ADDITIONAL 7.8 POUNDS AND WEIGHED ONLY 148.8 POUNDS. IN A DIETARY PROGRESS NOTE DATED 8/29/2012, DMA #1 WITNESSED RESIDENT #102 CONSUME ONLY 25% OF HIS MEAL AND DOCUMENTED THE SHE WOULD CONTINUED TO MONITOR THE RESIDENT. PHYSICIAN ORDERS [REDACTED]. THE DRUG HAD ORIGINALLY BEEN ORDERED IN JUNE 2012, BUT NEVER RESTARTED WHEN RESIDENT #102 RETURNED TO THE FACILITY FROM A LOCAL HOSPITAL 7/18/2012. DURING AN INTERVIEW ON 9/28/2012 AT 9:30 A.M., RESIDENT #102 SAID THE REASON HE LOST WEIGHT WAS BECAUSE HE HAS HAD NO APPETITE. RESIDENT #102 WORE A DARK BLUE PAIR OF OVERSIZED PANTS, KEPT IN PLACE ON RESIDENT #102'S BODY WITH A BELT. DURING AN INTERVIEW ON 9/28/2012, DM #1 (DIETARY MANAGER) SAID HER ASSISTANT DM (DMA #1) WAS REQUIRED TO COMPLETE WEEKLY DOCUMENTED ASSESSMENT ON ALL ASSIGNED RESIDENT diagnosed with [REDACTED]. DM #1 REVIEWED THE MEDICAL RECORD AND SAID IT WAS OBVIOUS DMA #1 DID NOT ADEQUATELY MONITOR THE NUTRITIONAL STATUS OF RESIDENT #102, AS EVIDENCED BY THE LACK OF WEEKLY WEIGHTS OBTAINED FOR REVIEW, THE LACK OF FOOD ACCEPTANCE RECORDS OBTAINED FOR REVIEW, THE LACK OF WEEKLY DIETARY PROGRESS NOTES IN THE MEDICAL RECORD, AND HER DELAYED RESPONSES TO THE RESIDENT'S ONGOING, SIGNIFICANT WEIGHT LOSS. DM #1 FAILED TO EXPLAIN WHY THE NUTRITIONAL CARE PLAN FOR RESIDENT #102 REQUIRED HE EAT 80 GMS OF PROTEIN WHEN HIS ASSESSED NEEDS WERE CONSISTENTLY HIGHER OR WHY HE DID NOT RECEIVE THE ORDERED [MEDICATION NAME] ON SEVEN CONSECUTIVE DAYS IN JUNE 2012. WHEN ASKED WHY THE RESIDENT #102 WAS discharged for SURGERY 7/11/2012 ON [MEDICATION NAME] AND AN ADVANCED NUTRITIONAL DIET, BUT RETURNED WITH CONTINUED WEIGHT LOSS 7/18/2012 ON A SIGNIFICANTLY DOWN-GRADED NUTRITIONAL DIET, WITHOUT [MEDICATION NAME], SHE SAID IT WAS AN OVERSIGHT NOT TO PICK IT "RIGHT BACK UP."

THIS CITATION PERTAINS TO INTAKE # MI 955. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT ACCIDENTS FOR 1 (#101) OF 4 SAMPLED RESIDENTS, ALL REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 4, WHEN RESIDENT #101 fell OUT OF BED, AFTER BEING LEFT IN AN UNSAFE POSITION UNSUPERVISED BY FACILITY STAFF, RESULTING IN A FALL WITH INJURY. FINDINGS: RESIDENT #101: ACCORDING TO THE FACE SHEET DATED 3/30/2012, RESIDENT #101 WAS admitted to the facility on [DATE]. THE RESIDENT #101 HAD SEVERAL DIAGNOSES, WHICH INCLUDED KIDNEY DISEASE, HIGH BLOOD PRESSURE, COLITIS, ARTHRITIS AND STROKE. ACCORDING TO PHYSICAL THERAPY PROGRESS NOTE DATED 4/9/2012 RESIDENT #101 REQUIRED THE MAXIMUM PHYSICAL ASSISTANCE OF TWO STAFF MEMBERS WITH BED MOBILITY. ACCORDING TO "INTRODUCTION TO PHYSICAL THERAPY FOR PHYSICAL THERAPIST ASSISTANTS," BY OLGA DREEBEN, PUBLISHED BY JONES & BARTLETT, 2006, MAXIMUM ASSISTANCE REQUIRES THE STAFF TO "CONSISTENTLY PROVIDE ASSISTANCE TO THE RESIDENT IN THE FORM OF ASSISTANCE WITH BALANCE, MOVING EXTREMITIES OR ASSISTIVE DEVICES, PROVIDE ASSISTANCE WITH APPROXIMATELY 75 TO 100 % OF THE TOTAL WORK INCLUDING WEIGHT BEARING, AND GUARD THE RESIDENT FROM ACCIDENTS THAT ARE PROBABLE." REVIEW OF THE CLINICAL RECORD REVEALED A PHYSICAL THERAPY EVALUATION DATED 4/2/2012, THAT EVALUATED RESIDENT #101'S PHYSICAL STRENGTH. RESIDENT #101'S LEFT ARM WAS RATED 3/5 FOR STRENGTH. RESIDENT #101'S RIGHT ARM WAS RATED 2-/5 FOR STRENGTH. BOTH OF RESIDENT #101'S LEGS WERE RATED 0/5 FOR STRENGTH. DURING AN INTERVIEW ON 5/22/2012 AT 11:55 A.M., THE PHYSICAL THERAPIST (PT #1) SAID RESIDENT #101 WAS "WEAK, VERY WEAK." PT #1 REFERRED TO THE PHYSICAL THERAPY EVALUATION AND SAID THAT RESIDENT #101'S LEFT ARM WAS 3/5 FOR STRENGTH AND THAT MEANT THAT RESIDENT #101 WAS JUST ABLE TO HOLD WEIGHT OF HER ARM AGAINST GRAVITY. PT #1 SAID RESIDENT #101'S RIGHT ARM HAD LESS STRENGTH THAN THE LEFT AND THAT SHE HAD NO STRENGTH IN HER LEGS. ACCORDING TO THE FALLS assessment dated [DATE], RESIDENT #101 WAS ASSESSED BY FACILITY STAFF AND WAS FOUND TO BE AT "HIGH RISK" FOR FALLS. ACCORDING TO THE NURSE'S NOTES DATED 4/26/2012 RESIDENT #101 WAS OBSERVED LYING ON THE FLOOR ON HER LEFT SIDE COMPLAINING OF PAIN TO HER LEFT HIP. ACCORDING TO THE FACILITY INCIDENT REPORT DATED 4-30-2012, ON 4-26-2012 AT APPROXIMATELY 10:30 A.M., RESIDENT #101 WAS LAST SEEN BY THE TREATMENT NURSE (LPN #1) AT 10:30 A.M. ACCORDING TO THE INCIDENT REPORT, LPN #1 ADMINISTERED CARE AND "...LEFT THE RESIDENT POSITIONED ON HER LEFT SIDE..." IN THE BED. IN AN INTERVIEW ON 2/22/2012 AT 11:358 A.M., LPN #1 SAID THAT ON 4-26-2012 HE WAS SERVING AS THE TREATMENT NURSE. LPN #1 SAID HE ASSESSED RESIDENT #101'S WOUNDS, AND LEFT RESIDENT #101 LYING ON HER LEFT SIDE IN THE BED FACING THE DOOR. LPN #1 SAID RESIDENT #101HAD A BED WITH AN AIR MATTRESS AND NO SIDE RAILS. LPN #1 SAID RESIDENT #101 WAS VERY WEAK, HAD UPPER EXTREMITY CONTRACTURES (A CONDITION OF SHORTENING AND HARDENING OF MUSCLES, TENDONS, OR OTHER TISSUE, OFTEN LEADING TO DEFORMITY AND RIGIDITY OF JOINTS) AND WAS UNABLE TO TURN HERSELF WITHOUT ASSISTANCE. LPN #1 SAID THAT DUE TO RESIDENT #101 WEAKNESSES, SHE WAS NOT STRONG ENOUGH TO STOP HERSELF FROM ROLLING OR FALLING. LPN #1 SAID THAT WHILE ASSESSING RESIDENT #101, HE FOUND THAT SHE HAD SOILED HERSELF WITH A BOWEL MOVEMENT. LPN #1 SAID HE LEFT RESIDENT #101 ON HER SIDE, CLOSED THE PRIVACY CURTAIN AND WENT TO THE DOORWAY. LPN #1 SAID HE WALKED TO THE DOORWAY, 3 FEET FROM RESIDENT #101'S BEDSIDE, AND CALLED THE CERTIFIED NURSE ASSISTANT (CNA) INTO THE ROOM. LPN #1 SAID THAT ONCE HE DETERMINED WHICH CNA WAS RESPONSIBLE FOR RESIDENT #101'S CARE, CNA #1 WALKED INTO THE ROOM. LPN #1 SAID CNA #1 WALKED PAST HIM TOWARDS RESIDENT #101 AS HE LEFT THE ROOM. LPN #1 SAID A FEW MINUTES LATER, "...COULD BE FIVE TO TEN MINUTES...LONG ENOUGH FOR ME TO CHART A FULL PAGE OF DOCUMENTATION," THE CNA YELLED OUT THAT RESIDENT #101 HAD ROLLED OUT OF THE BED. DURING AN INTERVIEW ON 5/22/2012 AT 11:40 A.M., CNA #1 SAID SHE WAS CALLED INTO THE ROOM BY THE TREATMENT NURSE WHO SAID RESIDENT #101 NEEDED TO BE CLEANED. CNA #1 SAID THE ROOM'S PRIVACY CURTAIN WAS CLOSED AS SHE WENT TO THE SINK TO RUN WARM WATER FOR RESIDENT #101. CNA #1 SAID A FEW MINUTES LATER HEARD A THUD, AS RESIDENT #101 HIT THE FLOOR. CNA #1 SAID SHE WAS NEVER TOLD RESIDENT #101 WAS LEFT ON HER SIDE. CNA #1 SAID, "...IF I HAD KNOWN I WOULD HAVE GONE STRAIGHT TO HER TO MAKE SURE SHE WAS SAFE BEFORE GETTING WATER..." CNA #1 BECAME TEARY EYED, SAID SHE WISHED SHE WOULD HAVE "...CHECKED BEHIND THE CURTAIN FIRST..." ACCORDING TO THE FACILITY INCIDENT REPORT DATED 4-30-2012, RESIDENT #101 WAS FOUND ON THE FLOOR AT 10:55 A.M. AND COMPLAINED OF RIGHT HIP PAIN. RESIDENT #101'S PHYSICIAN WAS CONTACTED AND AN X-RAY WAS ORDERED. ACCORDING TO THE RADIOLOGY REPORT DATED 4/26/2012 RESIDENT #101 SUFFERED AN IMPACTED INTERTROCHANTERIC FRACTURE OF THE PROXIMAL LEFT FEMUR (BROKEN HIP) WITH SOME VARUS DEFORMITY AT THE FRACTURE SITE. ACCORDING TO THE NURSE'S NOTES DATED 4/26/2012, RESIDENT #101 WAS TRANSFERRED TO A LOCAL AREA HOSPITAL FOR TREATMENT. IN AN INTERVIEW ON 2/22/2012 AT 12:06 P.M., THE ASSISTANT DIRECTOR OF NURSING (DON #1) SAID RESIDENT #101 SHOULD HAVE BEEN CENTERED IN THE BED WITH THE BED IN ITS LOWEST POSITION. DON #1 INSISTED RESIDENT #101'S SAFETY WAS BEING ASSURED BY LPN #1 AND CNA #1 ON 4/26/2012. DON #1 WAS ASKED HOW THE FACILITY ENSURED RESIDENT #101, A VERY WEAK RESIDENT UNABLE TO MOVE HERSELF OR STOP HERSELF FROM ROLLING, WAS SAFE WHEN SHE WAS LEFT IN THE BED ALONE ON HER SIDE, WITH THE CURTAIN CLOSED AND NOT VISIBLE TO STAFF, AFTER LPN #1 LEFT THE BEDSIDE AND BEFORE CNA #1 ARRIVED. DON #1 DECLINED TO ANSWER. WHEN DON #1 WAS ASKED TO EXPLAIN WHO WAS PROVIDING RESIDENT #101 WITH THE SUPERVISION REQUIRED TO ENSURE HER SAFETY, DON #1 AGAIN DECLINED TO ANSWER. ON 2/22/2012 AT 1:20 P.M., DON #1 SAID NO STAFF COULD HAVE BEEN SUPERVISING RESIDENT #101 SINCE NO ONE COULD SEE HER. DON #1 SAID SHE DID NOT KNOW HOW LONG RESIDENT #101 WAS LEFT UNSUPERVISED BEFORE SHE fell . ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT RAIN WATER FROM LEAKING INTO MULTIPLE AREAS OF THE KITCHEN. RAIN WATER WAS DRIPPING NEAR REFRIGERATION UNITS, FOOD PREPARATION AREAS, THE STEAM TABLE, AND TRAY LINE. RAIN WATER LEAKING FROM THE CEILING INTO THE KITCHEN RESULTED IN AN IMMEDIATE JEOPARDY (IJ) TO RESIDENT HEALTH AND SAFETY AND AFFECTED ALL (96 OF 96) RESIDENTS DUE TO THE POTENTIAL FOR SERIOUS HARM, INJURY OR DEATH FROM INGESTED CONTAMINATED FOOD AND WATER . THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON 11/29/11 AT 8:50 AM. THE ADMINISTRATOR WAS NOTIFIED OF THE IJ ON 12/01/11 AT 11:50 A.M. A PLAN OF CORRECTION WAS REQUESTED TO REMOVE THE IJ. THE IMMEDIATE JEOPARDY WAS REMOVED ON 12/02/11 BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 12/2/11 AS VERIFIED ONSITE ON 12/2/11, DURING THE COMPLETION OF THE EXTENDED SURVEY. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AS WIDESPREAD, WITH NO ACTUAL HARM, WITH A POTENTIAL FOR MORE THAN MINIMAL HARM THAT WAS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE. ON 11/29/11 AT 8:50 AM, DURING THE INITIAL TOUR OF THE KITCHEN, WITH THE CERTIFIED DIETARY MANAGER, WATER WAS OBSERVED STEADILY DRIPPING FROM THE CEILING TO THE RIGHT OF THE TRAY LINE AND FOOD PREPARATION AREAS. CEILING TILES HAD BEEN REMOVED AND WATER DRIPPED FROM THE CONCRETE ABOVE IT. WATER ALSO DRIPPED FROM A LOWER HANGING PORTION OF THE CEILING BESIDE IT. THE WHITE PAINT ON THE WALL HAD BUCKLED AND SAGGED. THE WALL WAS MOIST. THE DESSERT REFRIGERATOR AND ICE CREAM FREEZER REMAINED PLUGGED INTO THE ELECTRICAL SOCKET ALONG THAT WALL, UNDERNEATH THE DRIPPING CEILING. THE ICE CREAM FREEZER HAD BEEN PULLED OUT FROM THE WALL AND WATER RAN ONTO THE ELECTRICAL BOX THAT THE ICE CREAM FREEZER WAS PLUGGED INTO. FOUR CLOTHS (BED SPREADS) AND FOUR SQUARE PLASTIC PANS (USED TO COLLECT DISHES AFTER EATING) HAD BEEN PLACED ON THE FLOOR ALONG THE BASE OF THE WALL TO CATCH THE WATER. THE CERTIFIED DIETARY MANAGER WAS ASKED HOW LONG THE CEILING HAD BEEN LEAKING AND STATED, "THE LEAKING STARTED THIS YEAR". SHE FURTHER REVEALED THE MAINTENANCE DEPARTMENT HAD CHANGED THE CEILING TILES DUE TO STAINING. ON 11/29/11 AT 11:56 AM, DURING LUNCH PREPARATION ON THE TRAY LINE, THE CEILING, TO THE RIGHT OF THE TRAYLINE AND FOOD PREPARATION AREA, STEADILY DRIPPED WATER. THE CLOTHS AND PANS REMAINED IN PLACE TO CATCH THE WATER. IN ADDITION, WATER WAS OBSERVED DRIPPING TO THE FLOOR FROM THE CEILING ABOVE THE END OF THE COOK'S SINK, NEAR A FLORESCENT LIGHT. THE TABLE, USED BY THE COOK WAS STACKED WITH EMPTY RESIDENT PLATES, CUPS AND BOWLS HAD BEEN MOVED FROM THE AREA NEAR THE DRIPPING WATER AND UNDER THAT PART OF THE CEILING. ON 11/30/11 AT 4:35 P.M., WATER WAS OBSERVED TO BE LEAKING FROM SEVERAL PLACES IN THE KITCHEN CEILING INTO THREE SHALLOW PANS USED TO COLLECT THE WATER. SEVERAL BLUE BLANKET-LIKE CLOTHS WERE OBSERVED ON THE FLOOR AROUND THE SHALLOW PLASTIC PANS, SOAKING UP WATER. ON 12/1/11 AT 9:00 A.M., A TOUR OF THE KITCHEN WAS CONDUCTED WITH THE MAINTENANCE SUPERVISOR. WATER WAS OBSERVED TO BE LEAKING FROM THE CEILING, FLOWING DOWN A WALL WHICH WAS APPROXIMATELY FOUR FEET ADJACENT TO THE STEAM TABLE TRAY LINE. THERE WERE SHALLOW PLASTIC BUCKETS ON THE FLOOR, CATCHING THE FLOWING WATER STREAM. A SECOND WATER LEAK WAS OBSERVED DRIPPING DOWN FROM THE CEILING ONTO A STAINLESS STEEL COUNTER, ATTACHED TO A SINK LOCATED DIRECTLY ACROSS FROM THE OVEN. THERE WAS A RAG LOCATED ON THE COUNTER, SOAKING UP THE WATER FROM THE LEAK. A KITCHEN STAFF WORKER WAS AT THE STOVE PREPARING FOOD FOR THE LUNCH MEAL, APPROXIMATELY THREE FEET AWAY FROM THE DRIPPING WATER LEAK. ON 12/1/11 AT 9:30 A.M., THE DINING ROOM LOCATED DIRECTLY NEXT TO THE KITCHEN WAS ALSO OBSERVED TO HAVE WATER ACTIVELY LEAKING FROM THE CEILING. THERE WAS WATER LEAKING FROM THE CEILING AND INTO A SHALLOW CONTAINER PLACED ON THE FLOOR, NEAR THE STEAM TABLE USED IN THE MAIN DINING ROOM. THERE WAS A SECOND WATER LEAK OBSERVED DRIPPING FROM THE AREA OF THE CEILING SUPPORT BEAM IN THE DINING ROOM. THE PLASTER WHICH COVERED THE CEILING SUPPORT BEAM IN THE DINING ROOM, WAS SAGGING DOWN FROM THE WEIGHT OF THE POOLING WATER UNDERNEATH. ON 12/1/11 AT APPROXIMATELY 10:00 A.M., THE SAGGING CEILING PLASTER fell FROM THE CEILING ONTO THE FLOOR OF THE DINING ROOM. THE ENVIRONMENTAL SUPERVISOR STATED THAT THE LEAKING WATER IN THE KITCHEN AND THE DINING ROOM WAS COMING FROM A SECOND FLOOR ROOF-TOP PATIO, WHICH WAS LOCATED DIRECTLY ABOVE THE DINING ROOM. OBSERVATION OF THE SECOND FLOOR ROOF-TOP PATIO REVEALED THAT THERE WAS A LARGE DECK THAT HAD BEEN BUILT DIRECTLY FLUSH AGAINST THE ROOF TOP SURFACE. WATER WAS POOLING ON THE SURFACE OF THE ROOF, AROUND THE PERIMETER OF THE DECK. IN ADDITION, WATER WAS OBSERVED SQUIRTING OUT FROM UNDERNEATH THE MEMBRANE COVERING OF THE ROOF TOP SURFACE, WHILE IT WAS BEING WALKED ON. EVIDENCE OF LEAVES, DEBRIES AND BIRD FECES WAS OBSERVED IN THE DIRTY WATER. THE MAINTENANCE SUPERVISOR STATED THAT BECAUSE THE DECK HAD BEEN BUILT FLUSH AGAINST THE ROOF, THERE WAS NO WHERE FOR THE RAIN WATER TO DRAIN OFF THE ROOF. HE FURTHER STATED THAT THE TWO ROOF DRAINS HAD BEEN COVERED UP BY THE DECK, AND WERE NOT ACCESSIBLE. ON 12/1/11 AT 12:10 P.M., THE ADMINISTRATOR STATED THAT HE WAS AWARE OF THE WATER LEAKS IN THE KITCHEN AND DINING ROOM, BUT OFFERED NO ADDITIONAL INFORMATION. ON 12/01/11 AT 12:15 PM, DURING THE MEAL SERVICE IN THE KITCHEN, WATER WAS OBSERVED DRIPPING FROM THE CEILING OF THE SOUTH SIDE OF THE KITCHEN, ADJACENT TO THE TRAY LINE. THE CEILING TILES HAD BEEN REMOVED AND WATER WAS OBSERVED DRIPPING FROM CONCRETE BLOCKS. FOUR SHALLOW PLASTIC CONTAINERS, APPROXIMATELY 12" X 20," PLACED ALONG THE SOUTH WALL, WERE FILLED WITH THE DRIPPING WATER FROM THE CEILING. FOUR LARGE TOWELS, PLACED IN FRONT OF EACH PLASTIC CONTAINER, WERE USED TO ABSORB WATER OVERFLOW FROM THE PLASTIC PANS. THE SOUTH WALL WAS MOIST AND THE PAINT ON THE WALL HAD POCKETS OF WATER. THE CEILING AREA, TO THE SOUTH OF THE COOK'S SINK, HAD A DARK WATER STAIN AND WAS DRIPPING WATER WHICH WAS SPLASHING ON THE FLOOR. THE PAINTED AIR DUCT HANGING FROM THE CEILING ABOVE THE STEAM TABLE WAS COVERED WITH WATER STAINS AND BLISTERED PAINT WHICH fell AWAY WHEN TOUCHED BY THE DIETARY MANAGER. AT THAT TIME, DURING AN INTERVIEW, THE DIETARY MANAGER STATED THAT SHE WAS NOT AWARE THAT WATER WAS DRIPPING TO THE SOUTH OF THE COOK'S SINK, AND THAT THE PAINTED AIR DUCT HAD BLISTERED PAINT. REVIEW OF THE FACILITY'S POLICY ENTITLED, "POLICY AND PROCEDURE FOR MAINTAINING THE KITCHEN AND DINING AREA IN A DRY AND SANITARY MANNER", DATED 12/2/11, STATED: "THE DIETARY MANAGER WILL INSPECT THE CEILINGS AND WALLS IN THE KITCHEN, FOOD STORAGE AREA AND THE DINING ROOM DAILY FOR INDICATIONS OF WATER LEAKS. ANY BREACH IN THE WALL OR CEILING INTEGRITY WILL BE REPORTED TO THE MAINTENANCE SUPERVISOR AND THE ADMINISTRATOR IMMEDIATELY FOR REPAIRS. A ROUNDS/AUDIT TOOL HAS BEEN DEVELOPED TO VERIFY THESE DAILY INSPECTIONS. THE DIETARY MANAGER WILL REVIEW THE ROUND/AUDIT TOOL FINDINGS WEEKLY WITH THE ADMINISTRATOR OR HIS DESIGNATED PERSON ". THE IMMEDIATE JEOPARDY WAS REMOVED ON 12/02/11, WHEN THE FACILITY IMPLEMENTED THE FOLLOWING: "12:30 P.M., THE ADMINISTRATOR AND STAFF IMMEDIATELY CONDUCTED A TOUR IN ORDER TO ASSESS FOR DAMAGES AND TO DEVELOP A CORRECTIVE PLAN. THE AREAS OF CONCERN NOTED BY THE SURVEYORS WERE IDENTIFIED. THE DIETARY MANAGER DETERMINED THAT THE ENTIRE KITCHEN WORK AREA, TRAY LINE AND FOOD STORAGE AREAS HAVE BEEN COMPROMISED BY THE LEAKS, AND ARE NOT APPROPRIATE FOR FOOD PREPARATION AND STORAGE. THE KITCHEN HAS BEEN CLOSED. SERVICEMASTERS, A CLEANING SERVICE PROVIDER, HAS BEEN CONTACTED TO SANITIZE THE KITCHEN AND STORAGE AREA. ALL FOOD ITEMS STORED IN THE FOOD STORAGE AREAS, AND SHELVES WILL BE REMOVED. CANS AND PLASTIC CONTAINERS WILL BE WASHED AND CLEANED. PERISHABLES WILL BE DESTROYED. SERVICEMASTER'S a CLEAN ing services HAS INSPECTED THE KITCHEN AREAS AND WILL BE OUT ON THURSDAY DECEMBER 8 TH 2011 TO SANITIZE THE KITCHEN AREAS AND FOOD STORAGE AREAS. THEY HAVE BEEN CONTRACTED TO CLEAN THE SINKS, WALLS, FLOORS, STOVES, DISHWASHER AND THE REFRIGERATOR. THE ADMINISTRATOR AND MAINTENANCE SUPERVISOR NOTED THE CEILING TO BE LEAKING WITH DEBRIS FALLING IN THE 1 SOUTH DINING ROOM. THE RESIDENTS WERE IMMEDIATELY REMOVED FROM THE DINING AREA. NO RESIDENTS HAVE BEEN AFFECTED BY THE CITED INCIDENT. THE DIRECTOR OF NURSING HAS IDENTIFIED THAT ALL RESIDENTS ARE POTENTIALLY AT RISK FOR THE CITED OFFENSE. UPON ASSESSMENT OF THE DAMAGES IT WAS DETERMINED BY THE ADMINISTRATOR AND MAINTENANCE SUPERVISOR THAT A WOODEN DECK BELOW THE ROOF MUST BE REMOVED BEFORE REPAIRS CAN BE MADE ON THE ROOF. THE ADMINISTRATOR ORDERED DUMPSTERS WHICH ARE IN PLACE FOR THE REMOVAL OF THE DECK. THIS TASK WILL BE COMPLETED BY 7 PM TONIGHT. UPON THE REMOVAL OF THE DECK THE REPAIRS TO THE ROOF WILL BE MADE. BRUNELL ROOFING, A LICENSED CONTRACTOR HAS MET WITH THE STATE OF MICHIGAN HEALTH FACILITIES ENGINEER, WHO DETERMINED THE ROOF IS STRUCTURALLY SOUND AND THEY HAVE AGREED THAT THE CONTRACTOR MAY PROCEED WITH REPAIRS AS WEATHER AND MATERIALS PERMIT. THE ADMINISTRATOR HAS ARRANGED FOR RESIDENT MEALS TO BE OBTAINED FROM A LOCAL FOOD VENDOR ON 12-1 -2011 FOR DINNER AND 12-2-2011 FOR BREAKFAST THROUGH DINNER. NO FOOD PREPARATION WILL BE DONE FROM THE KITCHEN. ALL UTENSILS DISTRIBUTED TO RESIDENTS WILL BE DISPOSABLE. FOOD FOR RESIDENTS ON PUREED DIETS WILL BE SUPPLIED by SYSCO FOOD SERVICES. STARTING 12-03-2011 THE SALVATION ARMY WILL PROVIDE THREE WHOLESOME MEALS A DAY IN CAMBER CONTAINERS. THIS SERVICE WILL BE CONTINUED FOR AS LONG AS NEEDED. THE ADMINISTRATOR AND DON HAVE DETERMINED THAT RESIDENTS WILL HAVE THE OPTION OF HAVING THEIR MEALS IN THEIR ROOMS OR ON FLOORS 2-5. MEALS WILL ALSO BE MADE AVAILABLE IN THE DAY ROOM. THE 6 TH FLOOR DAY ROOM WILL SERVE AS THE DISTRIBUTION CENTER FROM WHERE THE MEALS WILL BE DELIVERED TO THE UNITS. THE KITCHEN STAFF HAS BEEN IN SERVICED ON THE EMERGENCY MEASURES THAT HAVE BEEN IMPLEMENTED. THE IN-SERVICES INCLUDE: HAND WASHING, FOOD DISTRIBUTION, AND ALL TEMPORARY MEASURES REGARDING THE STORAGE AND DISTRIBUTION OF FOOD, WATER, AND ICE. THE REGISTERED DIETICIAN AND DIETARY MANAGER HAVE IN SERVICED DIETARY EMPLOYEES TO DATE. EMPLOYEES IN ALL DEPARTMENTS WILL BE IN SERVICED THROUGHOUT THE SHIFT TODAY. TO DATE ALL 16 DIETARY EMPLOYEES HAVE BEEN INSERVICED. ANY STAFF MEMBER NOT SCHEDULED WITHIN THE NEXT 24 HOURS WILL BE SENT THE IN-SERVICE DATA FOR REVIEW, THEY WILL SIGN AND RETURN. EMPLOYEES SCHEDULED OFF OR ON LEAVE WILL NOT BE PLACED ON THE SCHEDULE UNTIL THEY RECEIVE THE IN-SERVICE. THE DIETARY MANAGER WILL INSPECT THE CEILINGS AND WALLS IN THE KITCHEN, FOOD STORAGE AREA AND THE DINING ROOM DAILY FOR INDICATIONS OF WATER LEAKS. ANY BREACH IN THE WALL OR CEILING INTEGRITY WILL BE REPORTED TO THE MAINTENANCE SUPERVISOR AND ADMINISTRATOR IMMEDIATELY FOR REPAIRS. A ROUNDS/AUDIT TOOL HAS BEEN DEVELOPED TO VERIFY THESE DAILY INSPECTIONS. THE DIETARY MANAGER WILL REVIEW THE ROUND/AUDIT TOOL FINDINGS WEEKLY WITH THE ADMINISTRATOR OR HIS DESIGNATED PERSON. THE MAINTENANCE SUPERVISOR WILL CONDUCT WEEKLY INSPECTIONS OF THE BUILDING, CEILINGS AND WINDOWS FOR WATER LEAKS, AND WILL REPORT ALL FINDINGS TO THE ADMINISTRATOR. THESE INSPECTIONS HAVE BEEN ADDED TO THE PREVENTIVE MAINTENANCE BOOK. WATER LEAKAGE IN THE KITCHEN, DINING AS WELL AS ANY OTHER NOTED AREAS HAS BEEN ADDED TO Q. A AND WILL BE REVIEWED MONTHLY BY THE QA COMMITTEE. THE MAINTENANCE SUPERVISOR WILL DISTRIBUTE BOTTLED WATER FOR RESIDENT CONSUMPTION. FRESH ICE WILL BE PURCHASED DAILY. SUPPLIES ARE IN SUFFICIENT QUANTITIES AND WILL BE REPLENISHED AS LONG AS NECESSARY. THE FACILITY FULLY EXPECTS TO ELIMINATE BREACHES TO THE CEILINGS AND ROOF BY 12-08-2011". ( , , , , , ,)

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE TREATMENTS, PRESSURE RELIEF DEVICES, REPOSITIONING, ASSESSMENT, MONITORING, DEVELOPMENT AND IMPLEMENTATION OF INTERVENTIONS TO PREVENT THE DEVELOPMENT OF NEW AND RECURRENT PRESSURE SORE/ULCERS AND TO PROMOTE HEALING FOR 2 (#503AND 510) OF 5 RESIDENTS REVIEWED FOR PRESSURE ULCERS/SORES FROM A TOTAL SAMPLE OF 22 , RESULTING IN THE DEVELOPMENT IN NEW PRESSURE SORES, AND A POTENTIAL FOR A DELAY IN HEALING OF AN EXISTING PRESSURE ULCERS/SORES. FINDINGS INCLUDE: DURING THE INITIAL TOUR OF THE SECOND FLOOR NURSING WITH NURSE (G), ON 11/29/11, AT 8:30 A.M., RESIDENT (#510) WAS OBSERVED IN BED. NURSE (G) STATED RESIDENT # 510 HAD RECENTLY ACQUIRED A NEW PRESSURE ULCER ON THE RIGHT BUTTOCK. NURSE (G) REPORTED THE NEW PRESSURE ULCER HAD BEEN CAUSED BY FRICTION AND SHEARING WHEN THE RESIDENT WAS REPOSITIONED, AND THE STAGE THREE (III) ON THE RESIDENT'S RIGHT BUTTOCK HAD REOPENED. THE RESIDENT WAS OBSERVED LYING ON AN INCONTINENCE PAD--THERE WAS NO DRAW SHEET. (DRAW SHEETS HELP TO MAINTAIN BODY ALIGNMENT, HELP TO PREVENT STRESS AND FRICTION TO RESIDENT SKIN WHEN REPOSITIONED (CLINICAL NURSING SKILLS AND TECHNIQUE, 6 TH EDITION 2006, ANNE GRIFFIN PERRY, AND PATRICIA A. POTTER). REVIEW OF THE ADMISSION RECORD DATED, 4/20/11, INDICATED RESIDENT #510 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE Minimum Data Set, dated dated dated , 9/08/11, INDICATED RESIDENT # 510 HAD SEVERELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION MAKING, WAS NON-AMBULATORY, AND TOTALLY DEPENDENT ON STAFF FOR BED MOBILITY AND TRANSFERS. THE ADMISSION NURSING ADMISSION ASSESSMENT, DATED 4/19/11, INDICATED RESIDENT #510 WAS admitted INTO THE FACILITY WITH A HISTORY OF PRESSURE ULCERS: A STAGE II ON THE LEFT UPPER BUTTOCK, A STAGE II ON THE RIGHT UPPER BUTTOCK, A STAGE II ON THE UPPER GLUTEAL FOLD, AND A STAGE II ON THE RIGHT OUTER BUTTOCK. THE CLINICAL RECORD INDICATED RESIDENT #510 HAD BEEN FOLLOWED BY THE WOUND CARE PHYSICIAN. A WOUND CARE physician progress notes [REDACTED]. THE BRADEN SCALE (TOOL USED FOR PREDICTING PRESSURE ULCER RISK) DATED 4/21/11 AND 10/14/11 INDICATED RESIDENT #510 REMAINED "AT RISK" FOR THE DEVELOPMENT OF PRESSURE ULCERS/SORES. A NURSING NOTE, DATED 10/30/11 INDICATED RESIDENT #510 HAD AN OPEN AREA ON THE RIGHT GLUTEAL "...STAGE II...". A WOUND physician progress notes [REDACTED]. THE NEXT PROGRESS NOTE FROM THE WOUND CARE PHYSICIAN, DATED 11/07/11, INDICATED THE STAGE III PRESSURE ULCER ON RESIDENT #510 ' S BUTTOCK HAD PROGRESSED TO 3.5 CM X 4.8 CM WITH MODERATE SEROSANGUINOUS DRAINAGE AND IRREGULAR EDGES. A DRESSING CHANGE AND WOUND CARE OBSERVATION WAS CONDUCTED ON 11/30/11 AT 9:30 A.M., WITH TREATMENT NURSE (E). IT WAS OBSERVED THAT RESIDENT #510 HAD A STAGE III PRESSURE ULCER ON THE RIGHT BUTTOCK THAT MEASURED 1.6 X 1.4 CM WITH A PINK BASE AND MODERATE SEROSANGUINOUS DRAINAGE. ON 12/01/11 AT 8:30 A.M., RESIDENT # 510 WAS OBSERVED RESTING IN BED, LYING ON THE BACK SIDE WITH HEAD SLIGHTLY ELEVATED. IT WAS OBSERVED THAT RESIDENT #510 WAS LYING ON AN INCONTINENT PAD. THERE WAS NO DRAW SHEET OBSERVED UNDERNEATH RESIDENT #510. CNA (F) DEMONSTRATED THE TECHNIQUE SHE USED TO REPOSITION RESIDENT #510, BY GRABBING THE INCONTINENCE PAD LOCATED UNDERNEATH RESIDENT # 510 AND PULLING IT TOWARD THE RIGHT SIDE OF THE BED. THE INCONTINENCE PAD SLID PART OF THE WAY FROM UNDERNEATH RESIDENT #510, WHICH CAUSED THE POTENTIAL FOR FRICTION AND SHEERING. RESIDENT #510 BARELY MOVED. CNA (F) PULLED AGAIN AT THE INCONTINENCE PAD, CAUSING THE INCONTINENT PAD TO SLIDE AGAINST RESIDENT #510, CREATING AN EXAMPLE OF FRICTION AND SHEERING AS THE INCONTINENCE PAD WAS PULLED AGAINST RESIDENT #510'S BACKSIDE. A REVIEW OF THE NURSING PLAN OF CARE FOR PRESSURE ULCERS FOR RESIDENT #510, DATED 4/21/11, INDICATED THERE WERE NO INTERVENTIONS FOR THE NEW STAGE III PRESSURE ULCER ON RESIDENT #510'S RIGHT BUTTOCK THAT WAS IDENTIFIED IN NURSING PROGRESS NOTES ON 10/30/11. IN ADDITION, THERE WERE NO INTERVENTION IN THE PLAN OF CARE TO REPOSITION RESIDENT #510 TO HELP PREVENT AND ALLEVIATE PRESSURE ON THE BUTTOCKS AND TO REPOSITION RESIDENT #510 IN A MANNER TO HELP PREVENT FRICTION AND SHEERING OF THE PRESSURE ULCER/SORE AND THE RESIDENT'S SKIN WHEN THE RESIDENT WAS TURNED OR REPOSITIONED. THE PLAN OF CARE FOR RESIDENT #510 HAD NOT BEEN UPDATED OR REVISED SINCE 4/21/11. THE FACILITY'S PREVENTATIVE SKIN MANAGEMENT FACILITY GUIDELINES DATED, SEPTEMBER 2011, WERE AS FOLLOWS: " ...A CARE PLAN IS DEVELOPED UPON ADMISSION AND ADDRESSES: IDENTIFYING THE CONTRIBUTING RISKS FOR BREAKDOWN, HYDRATION NUTRITION, PREVENTATIVE DEVICES, PHYSICAL ACTIVITY, POSITIONING REQUIREMENTS, PROPER BODY ALIGNMENT, EDUCATION, WHEN APPROPRIATE ... " DURING AN INTERVIEW ON 12/01/11 AT 2:00 P.M., TREATMENT NURSE (E) STATED IT WAS THE RESPONSIBILITY OF THE TREATMENT NURSE AND UNIT CHARGE NURSES TO ENSURE THAT PRESSURE RELIEF INTERVENTIONS AND PREVENTATIVE MEASURES WERE PUT IN PLACE AS PART OF THE RESIDENT'S PLAN OF CARE TO HELP PREVENT THE DEVELOPMENT OF NEW PRESSURE ULCERS, INCLUDING THOSE FROM FRICTION AND SHEERING. THE TREATMENT NURSE WAS UNABLE TO PROVIDE ANY EVIDENCE THAT PREVENTATIVES MEASURES WERE IN PLACE FOR RESIDENT #510 PRIOR TO THE DEVELOPMENT OF THE PRESSURE ULCER ON THE RIGHT BUTTOCK AND ALSO TO HELP PREVENT FRICTION AND SHEERING. ON 12/02/11 AT 11:00 A.M., AND INTERVIEW WAS CONDUCTED WITH BOTH THE DIRECTOR OF NURSING AND THE IN-SERVICE DIRECTOR. THE DIRECTOR OF NURSING AND THE IN-SERVICE DIRECTOR, BOTH CONFIRMED THAT THE USE OF AN INCONTINENCE PAD TO REPOSITION A RESIDENT WAS NOT THE FACILITY'S PROCEDURE AND THAT A DRAW SHEET SHOULD BE USED INSTEAD. NEITHER WERE ABLE TO PROVIDE ANY EVIDENCE THAT STAFF HAD RECEIVED EDUCATION TO PREVENT SKIN BREAKDOWN FROM FRICTION OR SHEERING. ( ) THE FACILITY'S CARE PLAN POLICY DATED SEPTEMBER 2011, REVEALED , "ALL RESIDENT NEEDS WILL BE MET AND ADDRESSED IN THE CARE PLAN..." THE CARE PLAN POLICY INDICATED THAT RESIDENTS PLAN OF CARE WOULD BE REVIEWED QUARTERLY AND AS CONDITIONS CHANGE AND AS NEEDED. ON 11/29/11 AT 3:30 PM, RESIDENT #503 WAS OBSERVED LYING ON THE LEFT SIDE IN BED. THE LOW AIR LOSS MATTRESS WAS VISIBLY UNDER-INFLATED. FLOOR NURSE "C" WAS ASKED WHETHER THE MATTRESS WAS INFLATED PROPERLY AND STATED, "I DON'T KNOW, BUT I WILL FIND OUT." AT 3:48 PM, NURSE "B" CAME AND STATED, "THE COMPANY BRINGS THE BED IN ALREADY BLOWN UP. THE NURSES CHECK THE POSITION. WE'VE NEVER HAD ONE THAT WAS NOT INFLATED; THE FACILITY DOES NOT CHECK THE PRESSURE ON THE MATTRESSES. WHEN I PUT MY WEIGHT ON IT, I FELT THE FRAME." RESIDENT #503'S HEELS WERE NOT FLOATED NOR WAS SHE WEARING HEEL PROTECTORS. AT 9:50 AM, THE WOUND CARE NURSE WAS OBSERVED DOING THE DRESSING CHANGE. RESIDENT #503'S HEELS WERE NOT FLOATED NOR WAS SHE WEARING HEEL PROTECTORS. WHEN THE WOUND CARE NURSE CLEANSED THE WOUND WITH NORMAL SALINE, RESIDENT #503 JUMPED AND PULLED AWAY. THE STAGE FOUR (IV) (STAGE IV--FULL THICKNESS TISSUE LOSS WITHEXPOSED BONE, TENDON, OR MUSCLE. SLOUGH OR ESCHAR MAY BE PRESENT ON SOME PARTS OF THE WOUND BED. OFTEN INCLUDES UNDERMINING AND TUNNELING- STATE OPERATION MANUAL, DATED 1/7/11) COCCYX WOUND MEASURED 2.6 CENTIMETERS (CM) LONG X 0.9 CM WIDE X 0.5 CM DEEP AND HAD A PINK BASE WITH A SMALL AMOUNT OF SEROSANGUINOUS DRAINAGE. THE SURROUNDING SKIN WAS DARKLY PIGMENTED AND FRAGILE. FOLLOWING THE TREATMENT OBSERVATION, THE WOUND CARE NURSE WAS ASKED ABOUT THE MATTRESS BEING UNDER INFLATED. HE STATED, "THE MATTRESS COMES FROM THE COMPANY ALREADY SETUP AND THE TECHNICIAN ADJUSTS IT ACCORDING TO THE PATIENT'S WEIGHT WHEN HE GETS INTO THE FACILITY. THE BED HAS TWO SETTINGS, NORMAL AND MAXIMUM. WE DON'T HAVE A CRITERIA ON HOW THEY ARE SET. NURSE "B" CALLED ME YESTERDAY TO TELL ME THE BED WAS FLAT, BUT IT SEEMED OK TO ME WHEN I GOT HERE. BUT I CALLED THE TECHNICIAN ANYWAY AND HE CAME OUT." THE WOUND CARE NURSE WAS ASKED WHAT THE TECHNICIAN HAD FOUND AND STATED,THE "SERVICE WORK ORDER FORM", DATED 11/29/11 AT 8:00 PM, INDICATED THE TECHINICIAN WAS "NOT ABLE TO FIX IN ACCOUNT HAD TO SWAP BED". NURSE "C" WAS ASKED IF SHE HAD EVER BEEN IN-SERVICED ON THE SPECIALTY BED. SHE STATED, "I'VE BEEN HERE THREE YEARS, NO". ON 11/30/11 AT 11:20 AM, A REVIEW OF THE FACE SHEET REVEALED THAT RESIDENT #503 HAD BEEN admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE QUARTERLY MINIMUM DATA SET (MDS), dated [DATE], INDICATED THAT RESIDENT #503 HAD SHORT AND LONG-TERM MEMORY PROBLEMS AND "SEVERELY IMPAIRED" COGNITIVE ABILITY FOR DAILY DECISION-MAKING. THE MDS FURTHER REVEALED THAT RESIDENT#503 WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING. THE BRADEN SCALE (USED TO ASSESS A RESIDENT'S RISK FOR THE DEVELOPMENT OF PRESSURE SORES) INDICATED THAT RESIDENT #503 WAS AT "HIGH RISK" FOR THE DEVELOPMENT OF PRESSURE SORES. THERE WAS NO NURSING CARE PLAN FOR AN ACTUAL PRESSURE SORE. THE NURSING CARE PLAN "PREVENTATIVE SKIN CARE: POTENTIAL FOR IMPAIRED SKIN INTEGRITY", INITIATED "3/21/08", INDICATED THAT RESIDENT #503 WAS readmitted INto the facility on [DATE]. THE PREVENTATIVE SKIN CARE POLICY STATED, "SYSTEMATIC SKIN ASSESSMENT WILL BE PERFORMED TWICE A WEEK WITH PARTICULAR ATTENTION TO BONY PROMINENCES, DOCUMENT...WHILE IN BED, REPOSITION EVERY 2 HOURS." THE CARE PLAN DID NOT DISCUSS PROTECTION FOR RESIDENT #503'S HEELS. THE UNDATED NURSE AIDE CARE PLAN FAILED TO INDICATE THAT RESIDENT #503 HAD A PRESSURE SORE OR PREVENTATIVE DEVICES WERE TO BE USED. THE "SKIN ASSESSMENT FORM", DATED 3/18/11, INDICATED THAT RESIDENT #503 WAS readmitted WITH A STAGE II PRESSURE SORE (PARTIAL THICKNESS LOSS OF DERMIS PRESENTING AS A SHALLOW OPEN ULCER WITH A RED-PINK WOUND BED WITHOUT SLOUGH. MAY ALSO PRESENT AS AN INTECT OR OPENED/REPTURED BLISTER..-STATE OPERATION MANUAL, DATED 1/7/11). ON THE COCCYX THAT MEASURED 1.2 CM LONG X 0.7 CM WIDE HAD MINIMAL SEROUS SANGUINOUS DRAINAGE, YELLOW BASE, AND FRAGILE SURROUNDING SKIN. ON 11/30/11 AT 3:00 PM, THE WOUND CARE NURSE WAS ASKED ABOUT THE PROGRESSION OF THE WOUND FROM A STAGE II TO A STAGE IV. THE WOUND CARE NURSE REVEALED THE WOUND WAS A STAGE IV WHEN HE STARTED AT THE FACILITY AROUND OCTOBER 2011. RESIDENT #503'S CHART RECORDS WERE REQUESTED TO REVIEW THE CARE PLAN, PHYSICIAN ORDERS, MEASUREMENTS, AND TREATMENT RECORDS. THE WOUND CARE NURSE REVEALED HE WAS UNABLE TO FIND ANY RECORDS FROM 3/19/11 - 4/1/11. THE "WEEKLY WOUND NOTES", DATED 4/1/11 - 8/8/11, INDICATED THE FOLLOWING CHANGES IN RESIDENT #503'S COCCYX WOUND: "5/12/11 - INCREASED TO 2.8 CM LONG X 1.9 CM WIDE 5/19/11 - INCREASED TO 5.1 CM LONG X 3.2 CM WIDE 5/21/11 - COCCYX WOUND BECAME A STAGE III (STAGE III-FULL THICKNESS TISSUE LOSS. SUBCUTATNEOUS FAT MAY BE VISIBLE BUT BONE, TENDON, OR MUSCLE IS NOT EXPOSED. SLOUGH MAY BE PRESENT BUT DOES NOT OBSCURE THE DEPTH OF TISSUE LOSS. MAY INCLUDE UNDERMINING OR TUNNELING-STATE OPERATION MANUAL, DATED 1/7/11 ) AND MEASURED 5.1 CM X 3.2 CM X 0.1 CM DEEP 8/8/11 - COCCYX WOUND BECAME A STAGE IV THAT MEASURED 4.8 CM LONG X 3.2 CM WIDE X 0.9 CM DEEP AND HAD YELLOW SLOUGH PINK FRAGILE EDGES AND WAS PAINFUL TO RESIDENT #503. THERE WERE NO OTHER "WEEKLY WOUND CARE DOCUMENTATION" FORMS PRESENTED WITH DATES BETWEEN 8/8/11 - 10/3/11. THE NURSING NOTES FOR THE TIME PERIOD OF 8/8/11 - 10/3/11 WERE REVIEWED. A NURSING NOTE, DATED 9/26/11 AT 4:30 PM, STATED, "WOUND CARE COCCYX WOUND WITH GRANULATION, SIZE DECLINING PAIN...MS SO4 ([MEDICATION NAME] SULFATE) GIVEN PER ORDER, CONT (CONTINUE) POC (PLAN OF CARE)." THERE WAS NO OTHER DOCUMENTATION RELATED TO CARE OF THE COCCYX WOUND. THERE WERE NO TREATMENT RECORDS, WEEKLY SKIN ASSESSMENTS, UPDATES TO THE NURSING CARE PLAN, PHYSICIAN ORDERS, OR PROGRESS NOTES. ON 11/30/11, A REVIEW OF THE WOUND CONSULT FORM REVEALED RESIDENT #503 WAS SEEN ON 10/4/11. THE "VASCULAR & WOUND CONSULTATION" FORM, STATED, "STAGE IV SACRAL 4.2 CM LONG X 2.4 CM WIDE X 0.8 CM DEEP WITH PINK BASE HEAVY SEROSANGUINOUS DRAINAGE, IRREGULAR EDGES, PERI-WOUND SKIN INTACT." ON 12/1/11 AT 4:43 PM, AN INTERVIEW WITH THE ASSISTANT DIRECTOR OF NURSING (ADON) STATED, "BASED ON OUR POLICY AND PROCEDURE WE DO FLOAT HEELS. EVERYONE DOES NOT HAVE BOOTS, BUT WE DO FLOAT HEELS. THERE IS A WARNING LIGHT ON THE BED. WE NOTIFY THE COMPANY WHEN THE WARNING LIGHT COMES ON. DAY SHIFT CALLS THE WOUND CARE NURSE, AFTERNOON AND MIDNIGHT SHIFTS CALL THE COMPANY. WHEN THE BED IS INFLATED I THINK THERE IS A LIGHT THAT IS GREEN WHEN IT IS WORKING PROPERLY. THE ADON WAS INFORMED THAT THE WOUND CARE NURSE HAD NOT BEEN ABLE TO IDENTIFY WHEN THE BED WAS NOT WORKING PROPERLY. THE ADON STATED, "I HEARD ABOUT THAT." ON 12/2/11 AT 9:41 AM, THE IN-SERVICE DIRECTOR WAS ASKED IF SHE HAD DONE ANY IN-SERVICES WITH THE NURSING STAFF ON THE MONITORING OF THE SPECIALTY BEDS. THE IN-SERVICE DIRECTOR STATED, "NO. I HAVEN'T DONE IT. I'M TRYING TO GET INFORMATION ON THEM RIGHT NOW." ON 12/2/11 AT 12:00 PM, THE DIRECTOR OF NURSING (DON) WAS ASKED ABOUT THE MISSING DOCUMENTATION AND STAFF'S LACK OF KNOWLEDGE ABOUT THE SPECIALTY BED. THE DON STATED, "THE MEASURES USED TO TRACK PRESSURE SORES WERE CHANGED IN SEPTEMBER. THE DON WAS ASKED ABOUT MARCH 2011 - OCTOBER 2011. SHE STATED, "I WASN'T HERE THEN. ALL OF THE SPECIALTY BEDS CAME AFTER HE (WOUND CARE NURSE) GOT HERE. WE WEREN'T USING PRESSURE RELIEVING MATTRESSES 'TILL HE GOT HERE. THE TREATMENT NURSE IS RESPONSIBLE FOR THE CARE PLANS AND MDS NURSES OVERSEES THAT." THE DON WAS ASKED ABOUT THE USE OF HEEL PROTECTORS AND PADS BEING PLACED BETWEEN THE RESIDENT AND THE SPECIALTY MATTRESS. THE DON STATED, "INCONTINENCE PADS. I DON'T THINK ITS IS RECOMMENDED, BUT I'M NOT SURE. HEELS ARE TO BE PROTECTED... " A REVIEW OF THE FACILITY POLICY, DATED 9/11, STATED, " PLACE EACH RESIDENT ON A WEEKLY HEAD-TO-TOES SKIN ASSESSMENT. ESTABLISH A DAY OF THE WEEK TO MEASURE ALL PRESSURE ULCERS AND COMPLETE THE LOG GOING FORWARD. AT LEAST MONTHLY, A SYSTEM AUDIT ON THE SKIN MANAGEMENT GUIDELINES IS CONDUCTED TO ENSURE ONGOING COMPLIANCE IN ALL AREAS." ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT WEIGHTS WERE MONITORED AND ACCEPTABLE PARAMETERS OF NUTRITIONAL STATUS WERE MAINTAINED FOR TWO (#s 503 & 505) OF SEVEN RESIDENTS REVIEWED FOR WEIGHT GAIN/LOSS, OUT OF A TOTAL OF 22 SAMPLED RESIDENTS, RESULTING IN RESIDENT#503 WITH A SIGNIFICANT WEIGHT GAIN OF 11 PERCENT (%) AND RESIDENT #505 A SEVERE WEIGHT LOSS OF 31.7%. FINDINGS INCLUDE: ON 11/29/11 AT ON 11/29/11 AT 9:00 AM, DURING THE INITIAL TOUR, RESIDENT #505 WAS OBSERVED SITTING UP IN HER WHEELCHAIR IN HER ROOM. SHE LOOKED VISIBLY UNDERWEIGHT. ON 12/1/11 AT 8:48 AM, A REVIEW OF THE FACE SHEET REVEALED THAT RESIDENT #505 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS), dated [DATE], INDICATED THAT RESIDENT #505 HAD SHORT AND LONG TERM MEMORY PROBLEMS, SEVERELY IMPAIRED COGNITIVE ABILITY, AND WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING. RESIDENT HAD BEEN admitted on HOSPICE, BUT THE - GUARDIAN FORM STATED, DATED 10/21/11, STATED, "GUARDIAN REFUSE...TO FOLLOW DR. (DOCTOR) ADVICE TO REMOVE FROM HOSPICE CARE, RESIDENT MEDICAL CONDITION IMPROVE." physician progress notes [REDACTED]. 6/21/11 - "REMAINS POORLY" 7/26/11 - "NICE TO SEE HER SMILE" 8/23/11 - "SURPRISINGLY IMPROVED" 9/20/11 - "CONTINUE TO LOOK BETTER" A REVIEW OF THE "WEEKLY WEIGHT RECORD" REVEALED THE FOLLOWING: 5/18/11 - 111.8 POUNDS 6/22/11 - 119.8 POUNDS 7/08/11 - 113.2 POUNDS 8/11/11 - 113 POUNDS 9/08/11 - 111 POUNDS 10 (DATE NOT COMPLETED) - 108 POUNDS 11/1/11 - 105 POUNDS ON 12/2/11 AT 1:53 PM, THE DIETITIAN CONSULTANT WAS ASKED ABOUT RESIDENT "505'S WEIGHT LOSS. THE DIETITIAN CONSULTANT REVIEWED THE CLINICAL RECORD. THE "NUTRITION ASSESSMENT", DATED 5/29/11, INDICATED THAT RESIDENT #505'S USUAL BODY WEIGHT WAS 115 POUNDS, CURRENT WEIGHT WAS 118 POUNDS, AND NEEDED 1749 CALORIES PER DAY. THE "ENTERAL FEEDING" (TUBE FEEDING) FORM INDICATED THAT RESIDENT #505 WAS TO RECEIVE "TWO CAL (CALORIE) HN" THREE TIMES A DAY. THE DIETITIAN CONSULTANT STATED, "SHE IS NOT GETTING WHAT I ORDERED. I NEVER CHANGED MY RECOMMENDATION. THE DIETITIAN CONSULTANT REVEALED SHE HAD RECOMMENDED 2 CAL FORMULA ON ADMISSION. A REVIEW OF THE PHYSICIAN ORDERS [REDACTED]. THE DIETICIAN WAS ASKED WHY SHE DID NOT KNOW RESIDENT #505'S FORMULA HAD BEEN CHANGED SINCE JULY. THE DIETITIAN MADE NO COMMENT. HOWEVER, FURTHER REVIEW OF THE PHYSICIAN ORDERS, DATED 7/14/11, DOCUMENTED THAT THE CHANGE FROM 2 CAL HN TO [MEDICATION NAME] 1.2 TUBE FEEDING ORDER HAD BEEN CLARIFIED BY THE DIETICIAN CONSULTANT ON 7/14/11 AT 5:14 PM AND DOCUMENTED IN THE DIETITIAN NOTE ON 7/28/11. THE DIETITIAN THEN REVEALED THAT RESIDENT #505 WAS ON HOSPICE AND SHE EXPECTED HER TO LOSE WEIGHT. THE DIETICIAN WAS SHOWN THE NOTE IN THE CHART THAT RESIDENT #505 HAD IMPROVED AND THAT IT WAS RECOMMENDED RESIDENT #505 BY REMOVED FROM HOSPICE CARE. THE DIETITIAN OFFERED NO FURTHER EXPLANATION. THE DIETITIAN WAS ASKED IF RESIDENT #505 HAD BEEN DISCUSSED IN WEIGHT MEETING. THE DIETITIAN STATED, "I DON'T KNOW, BUT I BELIEVE SO." HOWEVER, A REVIEW OF THE WEIGHT MEETING INFORMATION PRESENTED FOR 7/7/11, 7/28/11, 9/21/11, 9/28/11, 10/5/11, 10/12/11, 10/19/11, 10/26/11, 11/02/11, AND 11/9/11 DID NOT HAVE RESIDENT #505 LISTED AS BEING DISCUSSED IN THE MEETINGS. AT 2:16 PM, RESIDENT #505'S WEIGHT WAS OBTAINED WITH THE DIETITIAN CONSULTANT. RESIDENT #505'S WEIGHT WAS 78.5 POUNDS. THIS WAS A 26.6 POUNDS DROP FROM THE 11/1/11 WEIGHT AND A 36.5 POUNDS DROP FROM USUAL BODY WEIGHT. THE DIETITIAN CONSULTANT OFFERED NO EXPLANATION. ON 11/30/11 AT 11:20 AM, A REVIEW OF THE FACE SHEET REVEALED THAT RESIDENT #503 HAD BEEN admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE QUARTERLY MINIMUM DATA SET (MDS), dated [DATE], INDICATED THAT RESIDENT #503 HAD SHORT AND LONG-TERM MEMORY PROBLEMS AND SEVERELY IMPAIRED COGNITIVE ABILITY. THE MDS FURTHER REVEALED THAT RESIDENT #503 WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING. THE PHYSICIan order for [REDACTED]." THE "ALTERATION IN NUTRITION" CARE PLAN, DATED 5/17/11, DOCUMENTED THE FOLLOWING UNDATED INTERVENTION: REDUCE TUBE FEEDING TO 1500 CAL OF [MEDICATION NAME] 1.2 WITH 1250 CC EVERY 24 HOURS-10/20/11." THE 2011 MONTHLY WEIGHT RECORD LISTED THE FOLLOWING WEIGHTS: 6/2/11 146.2 POUNDS 7/8/11 153 POUNDS 8/11/11 161 POUNDS 9/8/11 163.2 POUNDS 10/12/11 167.8 POUNDS 11/1/11 178 POUNDS A REVIEW OF THE THE NUTRITIONAL ASSESSMENT, DATED 3/19/11, INDICATED THAT RESIDENT #503'S ADMISSION WEIGHT WAS 154 POUNDS, HER USUAL BODY WEIGHT (UBW) WAS 160 POUNDS, AND HAD A STAGE II PRESSURE SORE ON THE COCCYX. A REVIEW OF THE DIETARY PROGRESS NOTES REVEALED THE FOLLOWING: "8/5/11, STATED, "CURRENT DIET PLEASURE PUREE TRAY ONE ITEM ONLY AND RECEIVE TUBE FEEDING [MEDICATION NAME] 1.2 2000 CALORIES (CAL)/1667 CC (CUBIC CENTIMETERS)...CURRENT WEIGHT 161 POUNDS 8/11/11, 7/8/11 153 POUNDS, 6/2/11 146.2 POUNDS, 5/11/11 135.2 POUNDS. RESIDENT HAD 16% WEIGHT GAIN IN PAST 90 DAYS WILL ASK FOR RE-WEIGHT FOR ACCURACY." 8/31/11 DIETARY NOTE DOES NOT DISCUSS A RE-WEIGHT. "9/29/11 WEIGHT FOR THIS MONTH IS 163.2 POUNDS, AUGUST WEIGHT 161 POUNDS, JULY WEIGHT 153 POUNDS. UBW 160 POUNDS. SHE IS GAINING EACH MONTH...AT THIS POINT IT IS RECOMMENDED TO REDUCE THE TUBE FEEDING TO 1800 CAL/1500 CC OF [MEDICATION NAME] 1.2 TO RUN AT 93 CC/HR, START AT 4 P UNTIL THE 1500 CC DOSE IS COMPLETE. A RECOMMENDATION IS BEING LEFT FOR DOCTOR. 10/20/11 WEIGHT FOR THIS MONTH IS 167.8 POUNDS, A RECOMMENDATION TO REDUCE THE PEG (PERCUTANEOUS ENDOSCOPIC GASTROSTOMY - TUBE FEEDING) TUBE CALORIES IS BEING LEFT FOR THE PHYSICIAN. HER UBW IS 160 POUNDS. 11/27/11 NOVEMBER WEIGHT IS 178 POUNDS, OCTOBER WEIGHT 167.8 POUNDS, SEPTEMBER WEIGHT 163.2. SHE HAD A 6% WEIGHT GAIN IN ONE MONTH. HER DIET ORDER REMAIN 2000 CAL OF [MEDICATION NAME] 1.2 PUREED, LOW CHOLESTEROL, 2 GRAM SODIUM CARDIAC, HEALTHSHAKE TID (THREE TIMES A DAY) SUPERFOODS. RECOMMENDING TO D/C (DISCONTINUE) ALL SUPPLEMENTS AND REDUCE THE TUBE FEEDING TO 1500 CAL OF [MEDICATION NAME] 1.2..." ON 12/1/11 AT 8:30 AM, NURSE "C" WAS ASKED TO SHOW ON THE PUMP HOW MUCH TUBE FEEDING HAD BEEN INFUSED. NURSE "C" REVEALED THAT RESIDENT #503 HAD RECEIVED 1590 CC OF [MEDICATION NAME] 1.2 AND THAT SHE WOULD LET THE PUMP RUN UNTIL 1667 CC HAD BEEN INFUSED. AT 1:00 PM, THE REGISTERED DIETITIAN CONSULTANT WAS ASKED ABOUT RESIDENT #503'S WEIGHT GAIN AND THE RECOMMENDATION TO REDUCE THE TUBE FEEDING IN SEPTEMBER. THE DIETICIAN REVEALED SHE HAD COMPLETED A "COMMUNICATIONS BETWEEN THE CONSULTING DIETITIAN AND ATTENDING PHYSICIAN" FORM TO REDUCE THE TUBE FEEDING. THE DIETITIAN CONSULTANT REVIEWED THE CHART BUT WAS UNABLE TO LOCATE THE DIETARY RECOMMENDATION FORM. THE DIETITIAN CONSULTANT WAS ASKED WHY SHE HAD REDUCED THE TUBE FEEDING IN NOVEMBER. SHE STATED, "WHEN I REALIZED IT HAD NOT BEEN DONE, I REDUCED IT FURTHER." ON 12/2/11 AT 8:45 AM, RESIDENT #503 WAS OBSERVED LYING IN THE BED. THE TUBE FEEDING PUMP WAS RUNNING AT 93 CC/HR. NURSE "C" WAS ASKED HOW LONG THE TUBE FEEDING WAS TO RUN. SHE STATED, "UNTIL 1667 CC IS DELIVERED." NURSE "C" SHOWED THAT THE PUMP WAS SET TO DELIVER 1667 CC WHICH IS 2000 CALORIES OF TUBE FEEDING FORMULA. NURSE "C" WAS ASKED IF SHE HAD BEEN TOLD THE TUBE FEEDING AMOUNT HAD BEEN REDUCED. SHE STATED, "IT HAS." NURSE "C" CHECKED THE DOCTOR'S LOG BOOK AND FOUND A "COMMUNICATIONS BETWEEN THE CONSULTING DIETITIAN AND ATTENDING PHYSICIAN" FORM, DATED 10/20/11, THAT STATED, "RESIDENT #503 IS GAINING WEIGHT EACH MONTH. CURRENT WEIGHT IS 167.8 POUNDS...UBW 160 POUNDS...SUGGESTION: REDUCE THE TUBE FEEDING TO 1800 CAL/1500 CC [MEDICATION NAME] 1.2 TO RUN AT 93 CC/HR UP AT 4 P UNTIL 1500 CC DOSE IS COMPLETE..." THIS RECOMMENDATION HAD BEEN AGREED UPON AND SIGNED BY THE PHYSICIAN ON 10/25/11. NURSE "C" HAD NO EXPLANATION WHY THE ORDER HAD NOT BEEN WRITTEN AND THE TUBE FEEDING ADJUSTED. AT 2:30 PM, THE DIETITIAN CONSULTANT WAS INFORMED THAT RESIDENT #503 CONTINUED TO RECEIVE 2000 CALORIES OF TUBE FEEDING EVEN AFTER THE DISCUSSION YESTERDAY. THE DIETITIAN CONSULTANT MADE TO COMMENT. ON 12/2/11 AT 12:00 PM, THE DIRECTOR OF NURSING (DON) WAS ASKED ABOUT COMMUNICATION BETWEEN THE DIETITIAN AND NURSING. THE DON STATED, "THERE IS A TRIPLICATE FORM IS USED, BUT COMMUNICATION IS GOING TO HAVE TO BE BETTER BETWEEN DIETARY AND NURSING." A REVIEW OF THE UNDATED "DIETARY - PHYSICIAN COMMUNICATION TOOL" POLICY STATED, " THE COMMUNICATION SHEET WILL BE INITIATED BY THE DIETITIAN OR THE DIETARY MANAGER. PLACED IN THE PHYSICIAN'S LOG. ONCE IT IS SIGNED BY THE PHYSICIAN THE WHITE COPY WILL BE PLACED IN THE MEDICAL RECORD AND THE YELLOW WILL BE GIVEN TO THE DIETARY MANAGER. THE CHARGE NURSE IS RESPONSIBLE FOR WRITING IN ORDER IF THE PHYSICIAN DOES NOT." THE UNDATED "WEIGHT MANAGEMENT PROGRAM POLICY" STATED, "AT MINIMUM, EVERY RESIDENT IS WEIGHTED ON ADMISSION, A WEEK FOLLOWING ADMISSION AND AT LEAST EVERY MONTH. THE PURPOSE OF THE WEIGHT MANAGEMENT PROGRAM POLICY IS TO PROVIDE A METHOD BY WHICH EVERY RESIDENT'S WEIGHT IS MONITORED TO IDENTIFY SIGNIFICANT WEIGHT GAIN OR LOSS SO, IF NECESSARY, APPROPRIATE PERSONS ARE INFORMED AND INTERVENTIONS INITIATED. ( )