Every finding on record at Hickory Ridge of Temperance

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings Include:On 4/19/2026 beginning at 8:39 AM a tour of the kitchen was conducted with [NAME] B serving as kitchen supervisor.On 4/19/2026 at 9:06 AM observed spots of build up on multiple shelves of the metal storage racks in the walk in cooler. An interview with [NAME] B at this time found the dietary manager usually has someone clean the racks but they are unsure how often.On 4/19/2026 at 9:09 AM observed black accumulation along the outer edge of the air duct in the kitchen dry storage area.On 4/19/2026 at 9:15 AM observed the meat slicer covered with a plastic bag. Upon removal of the bag, water was observed dripping from the blade onto the base of the unit. Further observation revealed an accumulation of dried brown residue in the area above the blade and moist meat debris along the back side of the slicer. An interview at this time with [NAME] B found the meat slicer is used a few times a week and is cleaned after use. At this time, Dietary Manager (DM) A arrived and acknowledged the buildup on the slicer. DM A stated they would get it cleaned.On 4/19/2026 at 9:23 AM observed a stack of cutting boards placed on top of each other on the bottom shelf of the storage rack. When removed from the stack, the white cutting board had brown discolored spots on the surface. When DM A wiped the surface of the cutting board a brown residue was observed on the white towel. DM A indicated they would have it cleaned.On 4/19/2026 at 9:26 AM observed juice residue caked on the upper backsplash of the juice machine. An interview at this time with DM A found the juice machine is cleaned weekly on Mondays.On 4/19/2026 at 9:28 AM observed brown debris floating in a pool of water at the bottom of the removable ice scoop insert in the kitchen ice machine. DM A indicated it is cleaned daily and removed the insert to be cleaned.On 4/19/2026 at 9:30 AM observed red splattered residue on the back interior wall of the microwave in the kitchen. Further observation found an area of missing paint on the front interior wall making it rough. An interview with DM A at this time found this microwave is used to heat residents' food and it is cleaned daily or immediately after a spill.On 4/19/2026 at 9:36 AM observed metal shavings accumulated next to the blade of the can opener, and a red sticky substance on the blade. When touched with a paper towel, small metal fragments were transferred onto the paper towel. DM A acknowledged the metal shavings and cleaned the can opener at this time. On 4/19/2026 at 9:39 AM observed dust and debris accumulated on the surface of the rack holding the scoops in the kitchen.On 4/19/2026 at 9:56 AM observed an accumulation of black spots along the inside wall of the ice machine in the kitchenette. When wiped with a paper towel, black residue transferred onto the paper towel. DM A acknowledged the residue. On 4/19/2026 at 10:58 AM observed yellow residue accumulated in the crease of the adaptive utensil bin spoon slot.On 4/19/2026 at 2:26 PM an interview with maintenance Director D found they had cleaned the ice machines the previous night and it was possible they had missed some areas on the interior.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 4/19/2026 at 9:11 AM observed stacked quarter pans on the dry storage rack. Upon removal of the top pan, water droplets were observed accumulated on the interior surface and running down the edges in four pans. An interview with [NAME] B at this time found pans should be dry before being stacked.According to the 2022 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining.On 4/19/2026 at 10:00 AM observed the drain line leading from the ice machine in the kitchenette resting directly on the grate of the floor drain, creating an improper air gap.According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 4/19/2026 at 11:04 AM observed Dietary Aid C carrying plates to the plate warmer while wearing a bandage on their finger and no gloves. When asked at this time Dietary Aid C indicated they had cut themselves.On 4/19/2026 at 11:22 AM observed Dietary Aid C in tray line assembly during lunch service. Dietary Aid C was observed grabbing trays and placing napkins, utensils, and dessert bowls with no covering over their bandaged finger onto the trays. According to the 2022 Food Code section 2-401.13 Use of Bandages, Finger Cots, or Finger Stalls, If used, an impermeable cover such as a bandage, finger cot or finger stall located on the wrist, hand or finger of a FOOD EMPLOYEE working with exposed FOOD shall be covered with a single-use glove.

Based on observation, interview, and record review the facility failed to properly dispose of refuse and maintain cleanliness of garbage and refuse areas resulting in the potential harborage of pests. This deficient practice has the potential to affect all 79 residents in the facility. Findings include: On 3/04/25 at 10:10 a.m., during an observation of the environment with Dietary Manager (DM) A, the following observations at the garbage area located near the kitchen door of the facility were made: 1. Left and right side of the garbage dumpster was observed with trash that consisted of soiled gloves, paper, plastic cups and lids, straws, salt and pepper packs, and condiment packs. 2. Left and right-side doors to dumpster were open. 3. Raw onion top was on the ground in front of the dumpster. 4. A broom was propped against the dumpster. 5. Behind the dumpster was more soiled gloves, plastic cups and lids, straws, food wrappers, condiment packs, plastic ware (spoons), paper, and wet cardboard. DM A was queried about the condition of the garbage area and said it was used by the entire building. DM A was uncertain the department responsible for maintaining the garbage area cleanliness, It may be maintenance or housekeeping. On 3/5/25 at 3:10 p.m. the Director of Nursing (DON) reported the following: the housekeeping department was responsible for cleaning the garbage area especially after the garbage is picked up. The garbage truck dumps the can and leave garbage on the ground each time it's picked up. The Maintenance department assist at times, but the responsibility is primarily housekeeping's. The garbage area is supposed to be cleaned six days a week except Sunday. The DON was queried should the garbage bags be closed properly to prevent garbage from falling out of them. The DON stated, I don't go there and check, so I don't know. The DON said the facility did not have a Garbage Disposal policy however is addressed in the Housekeeping policy. Review of the facility's policy titled Housekeeping Services last revised 2/28/25 documented in part the following: Trash: The area surrounding the dumpster will be kept free from debris. When transporting garbage to the dumpster staff will ensure the area is clean and free from debris.

Based on observation, interview, and record review, the facility failed to obtain a complete order for the application and removal of a topical pain patch for one resident (R57) of 29 residents observed during Medication Administration (med pass), resulting in the potential of causing the resident to be overly medicated and skin breakdown. Findings include: On 3/4/2025 at 9:34 a.m., an observation was made with Licensed Practical Nurse (LPN) B during morning Med Pass to R57 on the South (100's Hallway). LPN B' was observed walking out of R57's room and said, I just remove the other patch. LPN B was asked what part of the body the other patch was applied. LPN B said the patch was removed from R57's right hip. R57 was observed lying in bed and alert. LPN B was observed applying a topical patch (Salonpas pain patch) to R57's right hip. On 3/4/2025 at 9:50 a.m. LPN B was asked during an interview what were the instructions for applying and taking off the patch. LPN B said, I follow the physician's orders when applying and removing the patch. LPN B reviewed R57's medication administration record (MAR) and explained the order documented to apply to right hip topically one time a day for pain and remove per schedule and LPN B explained the patch is taken off at 9:59 a.m. and the new patch is applied at 10:00 a.m. LPN B was asked the length of time R57 goes without the patch. LPN B said, One minute. LPN B was asked should the patch be on for twenty-three hours and fifty-nine minutes without resting the affected area? LPN B said I have seen some patches stay on for twelve hours and some twenty-four hours, it just depends on the physician's orders. According to the electronic medical record, R57 was admitted to the facility on [DATE] with diagnoses of effusion to right hip, Bursitis of right hip, and unilateral primary osteoarthritis. R57's quarterly' Minimum Data Set (MDS) with a reference date of 2/26/2025 indicated R57 had intact cognition with a BIMS (brief interview for mental status) score of 15/15. Physician's orders revealed, Salonpas pain relief patch external (Menthol-Methyl Salicylate) Apply to right hip topically one time a day for pain and remove per schedule with the start date of 2/8/2025. Review of R57's care plans with last review date of 2/24/2025 had the following: -R57 is at risk for pain and has chronic pain related to a stage four pressure injury, right hip bursitis, and right hip effusion. -R57 is at risk for impaired skin integrity/pressure injury .risk for further skin breakdown due to protruding hip bones . On 3/5/2025 at 3:00 p.m. the Director of Nursing (DON) was informed of the concern regarding the application of the pain patch. The DON said I will review and follow up with the manufacturer directions. On 3/5/2025 at 3:26 p.m. the DON entered the conference room and read the pain patch Manufacturer's insertion instructions which stated, Remove patch from the skin after the most eight hours application. The DON stated, with the instructions on the insert from the manufacturer, the patch should not have been left on over eight hours at a time. The DON added the doctor would not have ordered this order this way if the nurse had notified the physician and had the order changed. On 3/5/2025 at 3:35 p.m. a medication administration policy was requested from the DON. The medication administration policy was not provided prior to exiting the facility on 3/5/2025 at 4:15 p.m.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for anticoagulant therapy for one resident (R330) of 25 reviewed for comprehensive care plans, resulting in the potential for lack of assessment of skin and mucus membranes. Findings include: On 1/23/24 at 11:09 AM during observation and interview of R330, both hands were noted to be discolored on the anterior side covering the entire surface. R330 said It's been that way for years because of the blood thinners. Review of resident's MDS (minimum data set) record revealed, R330 admitted to the facility on [DATE] with pertinent diagnosis of renal failure and was receiving dialysis. Upon record review of MAR (medication administration record): Eliquis Oral Tablet 2.5 MG (blood thinner) 2.5 mg administer two times each day. Clopidogrel Bisulfate Oral Tablet 75 MG (blood thinner). Give 75 mg by mouth each morning for blood clot. Review of R330 EHR (electronic health record) did not include a care plan regarding anticoagulant (blood thinner). On 1/25/24 at 03:17 PM during interview the Director of Nursing (DON) explained there should be a specific anticoagulant care plan for R330 to monitor for skin issues and there were none. On 1/25/24 at 3:20 PM the DON presented a policy which indicated residents on an anticoagulant should have an anticoagulant care plan because the skin needs to be monitored. Review of the facility's policy titled Anticoagulant Therapy dated September 18, 2023, documented the following: Anticoagulant therapy is utilized ss a prophylaxis and treatment of venous thrombosis, pulmonary embolism, thrombolytic disorders, atrial fibrillation with embolism, and prophylaxis of systemic embolism after myocardial infarction. They inhibit the development of a thrombus. Throughout anticoagulant therapy monitor the resident for signs and symptoms of bleeding. If signs and symptoms of bleeding are noted hold anticoagulant medication and notify physician immediately. Documentation: 1. Physician order 2. Progress notes 3. Coumadin flow sheet, if applicable 4. Medication administration record 5. Resident care plan.

This citation pertains to intake MI00136764. Based on interview and record review the facility failed to provide interventions to prevent the development of a heel pressure ulcer for one resident (R277) out of five residents reviewed for pressure ulcers resulting in R277 developing a deep tissue pressure ulcer injury to the left heel. Findings include: The State Agency received a complaint that the resident developed a pressure ulcer of the left heel that required hospitalization while residing in the facility. Record review of R277's closed Electronic Health Record (EHR) revealed R277 admitted to the facility on [DATE] with diagnoses that included dementia, encephalopathy, muscle weakness, and altered mental status. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed R277 had severely impaired cognition and required extensive two person assistance with bed mobility. The MDS indicated R277 did not have any pressure sores and/or wounds upon admission. A Braden Scale assessment on 3/30/23 revealed a score of 18 which indicated a low risk for developing pressure ulcers. An initial skin assessment on 3/29/23 revealed R277 had no wounds upon admission. A nursing progress note dated 4/12/23 revealed, Writer asked to assess resident's left heel. Posterior left heel is open, draining clear pink fluid. Base of heel is dark purple, tender to touch per resident. Left lateral ankle is swollen with light blue discoloration. On call contacted, New orders for wound care is in PCC, (EHR) and to follow up with wound care. A wound care practitioner note dated 4/13/23 revealed, Left heel blister with DTI length 8.5 width 8.5 wound bed moist, color pink/maroon, wound edges attached, drainage moderate, surrounding skin intact. Deep tissue injury is defined: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury. (npuap, 2016). Review of the physician orders dated 4/12/23 documented to cleanse left heel normal saline pat dry, apply adaptic, abd wrap (gauze pad) with kerlix, cleanse left heel cleans left heel with normal saline, pat dry. Apply triple antibiotic ointment to open area of left heel. Cover with xeroform, and foam dressing daily and as needed, med boot at all times, check for placement every shift, apply betadine-soaked gauze to left heel. Cover with ABD pads, wrap with rolled gauze and secure with tape daily and as needed. Record Review of the Care Plan revealed the following Focus: (R277) is at risk for impaired skin integrity/pressure injury R/T: incontinence, decreased mobility, initiated 3/29/23 and revised on 4/5/23 for care refusals . document and report abnormal findings to physician initiated 3/29/23, cue to reposition self as needed initiated 3/29/23, educate resident/family/caregivers as to cause of impaired skin integrity, including transfer/position requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning initiated 3/30/23 follow facility policies /protocols for the prevention/treatment of impaired skin integrity initiated 3/29/23, observe sliding down in the chair and assist to reposition in chair as needed initiated 3/30/23 . use draw sheet or pad to assist with positioning initiated 3/30/23. However, none of the interventions listed on the care plan addressed R277's heels. On 1/25/24 at 10:54 AM the facility's wound care nurse, Licensed Practical Nurse (LPN) A and Director of Nursing (DON) reviewed R277's EHR and stated the left heel wound was open on 4/12/23 but was not staged since the wound had a blister cap on it. LPN A and the DON agreed R277 did not have any wounds upon admission to the facility and discharged to the hospital on 4/16/23 due to R277's family member's concern regarding the left heel wound. When queried if the interventions on the care plan were effective for preventing R277's heel wound neither LPN A nor the DON provided an answer. On 1/25/24 at 2:00 PM the DON provided a timeline of interventions initiated for R277 on 4/12/23 once the wound was identified but explained that the current interventions were not in place prior to the development of R277's heel pressure ulcer. Review of the facility policy titled Skin Management origination date of 5/1/2010, revised 7/14/2021 revealed in part It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan. The interdisciplinary team considers whether the guest/resident exhibits conditions or is receiving treatments that may place the guest/resident at higher risk of developing pressure injury or complicate their treatment. Such conditions may include: Cognitive impairments. Impaired/decreased mobility and decreased functional ability Bowel and or bladder incontinence Guest refusal of some aspect of care and /or treatment The DON/designee will document any changes in the care plan/Kardex.

Based on observation, interview, and record review the facility failed to follow the standards of infection control for (1) proper hand hygiene, (2) glove use, and (3) proper storage of a nebulizer mask (used for breathing tratments), for one resident (R15) out of 24 residents reviewed for infection control, resulting in the potential for placing a vulnerable population at high risk for cross-contamination and infection. Findings include: Review of an Admission Record revealed, R15 admitted to the facility on [DATE] with pertinent diagnoses which included Dementia, Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease (COPD). Review of a Minimum Data Set (MDS) assessment, with a reference date of 11/18/23 revealed R15 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15 and required oxygen therapy. In an observation on 1/23/24 at 10:04 a.m., Certified Nursing Assistant (CNA) B exited a resident's room while wearing gloves. CNA B took off the gloves, entered R15's room, and put on new gloves without performing hand hygiene. A bag of soiled linen sat on the floor next to R15's bed. In an observation on 1/23/24 at 10:06 a.m., R15's nebulizer mask with a small amount of liquid in the bottom of the mask attachment hung off a lamp shade and was not in stored in a bag. In an interview on 1/23/24 at 10:10 a.m., CNA B reported when you remove gloves, hand sanitizer should be used. In an observation on 1/23/24 at 10:39 a.m., CNA B exited a resident's room, removed gloves, and did not perform hand hygiene. In an observation on 1/23/24 at 1:04 p.m., R15's nebulizer mask with a small amount of liquid in the bottom of the mask attachment hung off a lamp shade and was not stored in a bag. In an observation on 1/24/24 at 11:26 a.m., R15's nebulizer mask with a small amount of liquid in the bottom of the mask attachment hung off a lamp shade and was not stored in a bag. In an interview on 1/24/24 at 11:27 a.m., Licensed Practical Nurse (LPN) C reported R15 receives a breathing treatment every six hours as needed. LPN C reported nebulizer mask should be stored in a bag when not in use. In an interview on 1/25/24 at 9:06 a.m., the Director of Nursing (DON) reported the policy for oxygen use pertains to nebulizer mask. The DON then reported the nurse should clean, dry, and place a nebulizer mask in a bag after use. In an observation on 1/25/24 at 9:41 a.m., CNA B and D prepared to perform ADL (activities of daily living) care for R15. R15 had a large bowel movement. CNA B cleaned R15's peri area and buttocks. CNA B did not perform hand hygiene or change gloves before the application of new brief or clean linen to R15's bed. In an observation on 1/25/24 at 9:53 a.m., CNA B removed gloves and did not perform hand hygiene. Review of Physicians order revealed, R15 had an order Ipratropium-Albuterol Inhalation Solution (breathing treatment) 3 ml inhale orally every 6 hours as needed for SOB (shortness of breath)/wheezing with a start date of 11/14/23. In an interview on 1/25/24 at 2:09 p.m., Infection Control Preventionist E reported hand hygiene should be performed before going in a room, before and after contact with a resident, and before and after glove use. Review of an Hand Hygiene policy revised 10/11/23 revealed, Policy: To decrease the risk of transmission of infection by appropriate hand hygiene . Hand hygiene should be performed: Before and after contact with the resident; Before performing an aseptic task; After contact with blood, body fluids, visibly contaminated surfaces or after contact with objects in the resident's room; After removing personal protective equipment (e.g., gloves, gown, facemask): After using the restroom; and Before meals Staff involved in direct resident contact must perform hand hygiene (even if gloves are used) . Review of an Use of Oxygen policy revised 8/17/21 revealed Policy: To promote guest/resident safety in administering oxygen. The following guidelines will be observed in oxygen administration . III. The O2 cannula or mask, when not in use, should be stored in a clean bag. Bag should be changed weekly .

Based on interview and record review the facility failed to initiate a base line care plan for falls upon admission, affecting one resident (610) out of three residents reviewed for baseline care plans (interventions), resulting in the potential for injury during a fall and unmet needs. Findings include: Record review revealed R610 was admitted into the facility on [DATE] with a pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) dated [DATE], R610 had impaired cognition and was extensive assist with most Activities of Daily Living (ADLS). Record review of hospital provider discharge paperwork After Visit Summary dated 10/29/22, documented R610, Reason for visit- Fall from bed. Record review revealed resident had a fall on 10/29/22 and was sent to nearby hospital. Further review revealed resident had no base line care plan and no current care plan interventions to prevent falls until 11/2/22. On 11/3/22 at 1:22 PM with Director of Nursing (DON), when asked if a baseline care plan should be implemented after admission to the facility, DON said Yes. After reviewing fall care plans for R610 it was confirmed that the resident did not have a baseline care plan for falls. When asked the reason for implementing base line care plans after admission, she said, To meet the resident's potential needs. Record review of policy titled Care Planning last revised on 6/24/21 documented the following: .A Baseline Care Plan will be developed within 48 hours identifying any immediate needs, initial goals and interventions needed to provide effective and person-centered care .

Citation pertains to MI 964 Based on interview and record review the facility failed to 1. Assess and monitor a resident after an admission 2. Administer antibiotics as ordered by a physician, effecting two residents (602 and 610) out of 14 residents reviewed for quality of care, resulting in the potential for a change in condition and decreased therapeutics of antibiotics. Findings include: R602 A complaint was made to the State Agency that R602 had missed a dose of antibiotics. Record review revealed R602 was admitted to the facility on [DATE] with a pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) dated [DATE], R602 had intact cognition and needed extensive assistance with most Activities of Daily Living (ADLS). Record review of Medication Administration Record (MAR) dated for March 2022 revealed R602 was ordered [MEDICATION(S)] Chloride Solution (antibiotic) Infuse 1 gram/100 ml (milliliters) two times a day, it was to be given at 600 (6:00AM) and 1800(6:00PM). Further review revealed no documentation of the antibiotic being administered at 1800 on March 3, 2022. Record review of R602's Nursing Progress Notes for the Month of March revealed no documentation that the physician was made aware of the missed dose. R610 Record review revealed R610 was admitted into the facility on [DATE] with a pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) dated [DATE], R610 had impaired cognition and was extensive assist with most Activities of Daily Living (ADLS). Record review of R610's Progress Notes and Vital Signs revealed no documentation of R610's vital signs until 10/29/22 at 6:13 PM. Record review revealed that Nursing assessment dated [DATE] had not been completed as of 11/2/22. During interview on 11/2/22 at 1:22 PM with Director of Nursing (DON), when asked if resident's vital sign should be monitored upon admission and each shift, DON said, Yes. When asked the purpose of assessing and monitoring the vital signs of residents, DON said, To see if there is a change in the residents' condition. After reviewing documents for R610 it was confirmed that vitals were not taken until the following day. When asked if medications should be administered as the physician orders, DON said, Yes. After reviewing the MAR and Nursing progress notes it was confirmed that R602 had missed a dose of antibiotics. When asked how nursing verified that a dose has been given, DON said, The nurse will sign the MAR.

This citation has two deficient practices. Deficient practice number 1. Based on interview and record review, the facility failed to respond to call lights timely in multiple resident rooms (Rooms 118, 120, 121,122, 127, 144, 145, 146, 148, 156, 172, 173, 174, 175, 177, 181,197, and Therapy Room Bathroom) resulting in complaints of slow staff call light response times for one resident (R30) from a total of 19 residents reviewed for accommodation of needs and the potential for long wait times and resident frustration. Findings Include: On 10/12/22 at 12:18 PM R30 complained that his call light was not answered last Tuesday for almost 4 hours. R30 said, They do not answer the call lights timely. There is no light or bell that alerts them that I need assistance. The call light goes to the desk or someplace else. Review of R30's alarm event report dated 10/4/22 at 9:26 AM, revealed R30 to room (staff responding to an activated call light) response was 3 hours and 5 minutes. Review of the alarm event report dated 10/12/22 to 10/13/22 (2 days of the survey) revealed the following staff to room response times: 10/12/22; Room (Rm) 145B- 1 hour (hr) 01 minutes (min) Rm 156B-1 hr 10 min Rm 148B-1 hr 06 min Rm 173B-1 hr 06 min Therapy Room Bathroom-1 hr 23 min Rm 146-1 hr 00 min Rm 144-1 hr 35 min Rm 122B-1 hr 57 min Rm 172B-1 hr 34 min Rm 197-1 hr 37 min Rm 121B-1 hr 28 min Rm 177B- 1 hr 20 min Rm 127B- 1 hr 27 min Rm 118B-1 hr 26 min 10/13/22; Rm 148A- 2 hr 17 min Rm 146- 1 hr 00 min Rm 175- 2 hr 7 min Rm 120B- 1 hr 28 min Rm 181A- 1 hr 06 min Rm 148B- 1 hr 02 min Rm 144- 1 hr 20 min Rm 174B- 1 hr 24 min Review of the Resident Council meeting minutes dated 9/22/22 documented, Nursing: call lights not answered timely (especially evenings). During an interview on 10/14/22 at 12:57 PM, with the Director of Nursing (DON) and Maintenance Director (MD) C, the MD reported when the call light is activated it sends a page to all employees via a pager system. MD C reported that staff have to hold the call light button down, once it's addressed to have light turn off, otherwise it stays on. MD C confirmed that if the call light it not turned off/reset, the resident cannot reactivate it. When asked about the alarm event report documenting long call light activation times, the DON said, It's a mixture of staff not responding timely and not turning off call light when addressing residents needs. The DON stated that a reasonable call light response time should be As quickly as possible. Approximately 15-20 minutes. During an interview on 10/14/22 at 3:30 PM, the Resident Council President confirmed call lights not being answered timely was discussed in the September 2022 meeting. In an interview on 10/14/22 at 3:42 PM, the DON indicated the call light concern from Resident Council had not been discussed with the Interdisciplinary Team Members. Review of the facility's Call Light policy dated 4/1/22 documented, 3. Go to the location of the call light, and turn off the light if you are able to meet the guest/resident request . Review of the facility's Guest/Resident Rights and Facility Responsibilities policy dated 5/1/22 documented, 3. Reasonable Accommodation. The right to reside and receive services in the facility with reasonable accommodation of guest/resident needs and preferences except when to do so would endanger the health and safety of the guest/resident or other guests/residents. Deficient practice number 2. Based on observation, interview, and record review the facility failed to accommodate the needs of one resident (R60) of two residents reviewed for accommodation of needs when the facility declined to provide a bedside commode for the resident after several requests and a fall during toileting that resulted in the resident expressing fear of falling again and frustration with the preference to use a bedside commonde being unmet. Findings include: On 10/13/22 at 8:48 AM R60 was observed in her room sitting up in bed. R60 said she was upset and wanted to leave the facility because they declined to provide her with a bedside commode. R60 said, I fell yesterday after trying to use the toilet with the assistance of a Physical Therapist. I told him that I was not ready to walk 20 feet to the toilet on my first time out of bed. I asked if we could try a bedside commode that was closer to the bed and he said 'no'. I can't even put weight on my left leg yet. I am a bigger lady, and I don't have the arm strength to use the walker to hold my body up and hop on my right leg 20 feet to use the toilet. I kept telling him this and he insisted I walk to the toilet anyway. I did try but ended up falling on the way back to the bed. I asked them for a bedside commode again and they won't do it. They say I must walk all the way to the toilet or use a bed pan. I'm not trying that again just yet, so now I use a bedpan. I'm not refusing to get therapy I'm just asking for a bedside commode that is closer to the bed. According to the Electronic Medical Record (EMR) R60 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the hospital's admission notes dated 10/11/22 at 9:50 AM revealed the following Physical Therapist notes; Gait distance: patient was able to stand, but unable to take any steps while maintaining NWB status of the Left lower leg, limiting factors to gait is weakness. According to the facility's therapy notes dated 10/12/22 at 5:29 PM, Patient is struggling to follow NWB ., provided education and used knee support walker to train walking to the bathroom and back .Due to fatigue the patient was unable to weight bear with UE (Upper Extremities) and her RLE (Right Lower Extremity) . and was assisted to go on her knees. On 10/13/22 at approximately 9:15 AM during an interview with Therapy Director (TD) K and unit manager Registered Nurse (RN) J, TD K confirmed that R60 had a controlled dissent during therapy on 10/12/22 when the resident's knees hit the floor after returning from the toilet. TD K acknowledged that R60 had requested a bedside commode but that was not recommended and would not be provided even though the toilet was 20 feet away from the resident's bed. TD K said, We don't want the CNAs (certified nursing assistants) doing pivot transfers with her (R60) from the bed to a bedside commode. We took the walker away too. TD K could not explain why a bedside commode could not be used during therapy with therapy staff assistance. On 10/14/22 at 12:28 PM R60 was observed in bed without a walker or bedside commode in her room. R60 said she did not understand why she could not have a bedside commode for toileting. I'm not going to try to get up without assistance. I want to get better, not worse. At this point I should just go home to recover. The toilet is closer to my own bed and couch than it is in here. On 10/14/22 at 1:47 PM, TD K confirmed that a bedside commode would not be provided for R60, despite several requests from the resident.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices by ensuring staff properly used PPE (Personal Protective Equipment) for one resident(R203) of one resident reviewed for Infection Control, potentially resulting in the spread of a highly contagious virus which could affect residents residing on the unit. Findings include: In an observation on 10/12/22 at 10:15 a.m., R203 had a sign on the room door which read DROPLET & CONTACT PRECAUTIONS . Wash hands before entering and when leaving. Required: Gown and Gloves put on before entry and discard before exit. Eye Protection on & Masks: Make sure the eyes, nose and mouth are covered before entry, and remove before room exit. A box with PPE (Personal Protective Equipment) hung on the door. R203's family member was observed entering the room and wore only a mask. In an interview on 10/12/22 at 10:16 a.m , Occupational Therapist (OT) P reported staff does not need to wear additional PPE (gloves, gown) unless they are providing care. In an interview on 10/12/22 at 10:18 a.m., Infection Control Nurse C reported everyone entering the room must wear a gown and gloves for protection due to R203 having C-Diff (highly contagious disease with germs that cause diarrhea and inflammation of the colon). In an observation on 10/12/22 at 10:30 a.m., Licensed Practical Nurse (LPN) Q entered R203's room with medication. LPN Q did not put on a gown or gloves before entering the room. LPN Q stood near R203's bed and administered medication. In an interview on 10/12/22 at 10:33 a.m., LPN Q reported staff should wear gown and gloves when entering R203's room. Review of an Admission Record revealed, R203 admitted to the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Progress Note with a date of 10/5/22 at 3:06 p.m. revealed, . Resident placed on isolation precautions for C-Diff, resident taking oral antibiotics . In an interview on 10/14/22 at 2:43 p.m., Director of Nursing (DON) B reported when entering a droplet/contact precaution room staff must wear full PPE which included face shield, gown, gloves, and a mask. Review of a Droplet Precautions policy with a revised date of 9/9/22 revealed, Policy: Droplet Precautions shall be used in addition to Standard Precautions for guests/residents with infections that can be transmitted by droplets .PPE A. A mask should be worn when entering the guest's/resident's room or cubicle. B. Eye protection is goggles or face shield . Review of a Contact Precautions policy with a revised date of 9/9/22 revealed, Policy: It is the intent of this facility to use contact precautions in addition to Standard Precautions for guests/residents known or suspected to have serious illnesses easily transmitted by direct guest/resident contact or by contact with items in the guest's/resident's environment . Gloves, Gowns, and Hand Hygiene A. Health care personnel caring for guests/residents on Contact Precautions should wear gloves and a gown for all interactions that may involve contact with the guest/resident or potentially contaminated areas in the guest's/resident's environment .

Based on interview and record review, the facility failed to ensure an Advanced Directive was in place timely for two (R50 and R203) of three residents reviewed for Advance Directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility or other healthcare providers. Findings Include: Resident #50 Review of an Admission Record revealed, R50 admitted to the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment, with a reference date of 10/4/22, revealed R50 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 13 out of a total possible score of 15. Review of Electronic Health Record (EHR) revealed, R50 did not have an Advance Directive. In an interview on 10/12/22 at 3:07 p.m., Social Services (SS) E reported R50 was a full code by default. SS E then reported R50 does not have a completed Advance Directive. SS E reported Advance Directives should be completed within 72 hours of admission. In an interview on 10/13/22 at 1:08 p.m., Social Worker (SW) F reported Advance Directives should be completed with admission. SW F then reported the form is completed by the nurse and the Social Worker ensures it was completed. Resident #203 Review of an Admission Record revealed, R203 originally admitted to the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Electronic Health Record (EHR) revealed, R203 did not have an Advance Directive. In an interview on 10/12/22 at 3:07 p.m., SS E reported R203 was a full code by default. SS E confirmed R203 did not have an completed Advance Directive in the code status book on the unit. Review of a Resident Code Status form provided by the facility revealed, R203 elected code status Do-Not-Resuscitate Order (DNR) with a signed date of 10/13/22. Review of a Do-Not-Resuscitate Order with a signed date of 10/13/22 revealed, R203 and a witness signed the order. The order was not signed by the Physician. In an interview on 10/13/22 at 1:22 p.m., SW F reported R50 and R203 should have completed an Advance Directive prior to 10/13/22. In an interview on 10/14/22 at 11:09 a.m., Licensed Practical Nurse (LPN) G reported the Advance Directive is in the admission packet. LPN G then reported that the Social Worker is responsible for completing the Advance Directive form. In an interview on 10/14/22 at 11:17 a.m., Director of Nursing B reported the nurses were responsible for Advance Directives on admission. Review of a Code Status policy with a revised date of 11/1/17 revealed, Policy: All residents upon admission and/ or re-admission will have a Resident Code Status Form completed to determine whether to initiate a Full Code Status or a Selective Code Status. Procedure: 1. All residents upon admission will be asked if they have a Advance Directive. 2. A Resident Code Status Form is to be completed within 24-72 hours of admission .

Based on interview and record review, the facility failed to monitor the fistula site and failed to consistently complete post [CONDITION(S)] assessments for one (R5) of one resident reviewed for [CONDITION(S)] services, resulting in the potential for undetected complications associated with receiving [CONDITION(S)], including bleeding, infection, and site failure. Findings include: Review of an Admission Record revealed, R5 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, with a reference date of 7/8/22 revealed R5 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 3 out of a total possible score of 15 and required [CONDITION(S)]. Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Care Plan with focus (R5) is at risk for complications R/T (related to) needs [CONDITION(S)] due to : [CONDITION(S)] (End Stage Renal Disease) . with a revised date of 8/10/21. Interventions included, check and change [CONDITION(S)] access daily per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Hemodialysis Communication Form from August 2022 through October 2022 revealed, the facility did not assess R5's [CONDITION(S)] access site consistently on return from [CONDITION(S)]. The access site was not assessed on the following dates: August- 8/1, 8/5, 8/8, 8/10, 8/12, 8/15, 8/17, 8/22, 8/26, 8/29 September- 9/2, 9/5, 9/7, 9/12, 9/13, 9/16, 9/19, 9/21, 9/23, 9/26, 9/28, 9/30 October-10/5, 10/7, 10/11 In an interview on 10/14/22 at 11:05 a.m., Licensed Practical Nurse (LPN) G reported R5's fistula site should be checked before and after [CONDITION(S)]. LPN G then reported [CONDITION(S)] communication forms are completed prior to [CONDITION(S)] and on return. R5's access site should be checked and documented on the communication form. In an interview on 10/14/22 at 11:12 a.m., Director of Nursing (DON) B reported [CONDITION(S)] fistula monitoring should be on the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B reported it is important to check the [CONDITION(S)] site to ensure there are no issues after [CONDITION(S)]. Review of Hemodialysis policy with a revised dated of 10/1/19 revealed, Guest/residents receiving hemodialysis will be assessed pre and post treatment and receive necessary interventions . Guidelines 1. Obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility completes the appropriate section of the hemodialysis communication form prior to guest/resident receiving each [CONDITION(S)] session and again when the guest/resident returns from hemodialysis. 5. Evaluate the guest/resident daily for [CONDITION(S)] access site and possible complications including . b. Thrill- palpation of fistula site, it can be described as a purring vibration. c. Bruit- a continuous, machine-like sound that can be heard during auscultation with a stethoscope. It can also be described as a 'whooshing' or a high pitched 'whistling' .

Based on interview and record review, the facility failed to ensure 2 of 4 Certified Nurse Assistants (CNA's) had annual (yearly) Competency evaluations (to determine whether the CNA was able to demonstrate the skills necessary for resident care), resulting in the potential for unmet care needs. Findings Include: Record review of a document titled, CNA Competency Evaluation with Staff Development Nurse Registered Nurse (RN) C on 10/13/22 at 2:12 PM , RN C, reported that a competency evaluation was conducted annually for all CNA's due the month of hire. Review of CNA H with a date of hire(DOH) of 5/28/21 CNA Competency Evaluation form documented that CNA H's last competency evaluation was 6/3/21. Review of CNA I with a hire date of 8/9/14 did not have CNA competency evaluation for years 2021 or 2022. RN C confirmed the competency evaluations were past due and reported working on getting caught up. In an interview on 10/14/22 at 12:15 PM, the Director of Nursing (DON) reported having alot of work to do with training. Review of the facility's policy titled, Staff Development dated 5/1/22 documented, 1. The Staff Development Coordinator provides training and orientation to assist staff in performing their assigned functions .9. A competency evaluation will be completed annually for all certified nurse aides/state tested nursing assistants. Training will be added to the calendar based on the weakness identified.

Based on interview and record review, the facility failed to ensure 12 hours of in-service education was provided for 3 of 4 Certified Nurse Assistance (CNA's H, I, and O) reviewed for annual training, resulting in the potential for care performance concerns. Findings Include: Record review of the CNA's transcript training with Staff Development Nurse, Registered Nurse (RN) C, it was reported that resident abuse prohibition and dementia care training was provided annually and included in 12 in-service education for all CNA's, due the month of hire. 1. CNA H with a date of hire (DOH)- 5/28/21. Transcript Training documented CNA H had .5 in-service hours over the 12 month look back service training time period. CNA H had no abuse or dementia training since hire date. 2. CNA I with a DOH- 8/9/14. Transcript Training documented CNA I had 7.5 in-service hours over the 12 month look back service training time period. CNA I's last abuse and dementia training was 9/15/21. 3. CNA O with a DOH- 7/19/19. Transcript Training documented CNA O had 2.5 in-service hours over the 12 month look back service training time period. CNA O's last abuse training was 9/13/21. RN C confirmed the training hours and content were past due and reported working on getting caught up. In an interview on 10/14/22 at 12:15 PM, the Director of Nursing (DON) reported having alot of work to do with training, but the new In-service Director (RN C) is trying to catch up. Review of the facility's policy titled, Staff Development dated 5/1/22 documented, 1. The Staff Development Coordinator provides training and orientation to assist staff in performing their assigned functions .5. The annual training schedule should include programs relating to but not limited to: .Abuse Prohibition; Elder Justice Act, Dementia Care 8. Nurse aides are provided no less than 12 hours of in-service education per year from the employees date of hire.

This citation pertains to MI 177. Based on interview and record review, the facility failed to demonstrate professional standards of practice by failing to notify the physician and report low blood pressure and reassess blood pressure for one resident (#609) of six residents reviewed for change in condition, resulting in the missed opportunity for physician participation in resident care and [CONDITION(S)] (low blood pressure) to go untreated. Findings include: A review of the Face Sheet and clinical record for Resident #609 (R609) documented an initial admitted [DATE], readmitted [DATE], and death in the facility on [DATE]. A Minimum Data Set, dated dated dated [DATE] documented moderate cognitive impairment. R609's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R609's care plans documented in part the following: Focus: (R609) is at risk for complications related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Report significant changes in .blood pressure .immediately Focus: (R609) is at risk for cardiac complications related to multiple cardiovascular diseases: [CONDITION(S)], [CONDITION(S)], hypertension, coronary artery disease, [CONDITION(S)], congestive heart failure, and [CONDITION(S)]. Interventions included: vital signs as ordered. Notify physician of abnormal readings as needed. A review of R609's blood pressure values documented the following: [DATE] at 7:50 AM: ,d+[DATE] [DATE] at 9:39 PM: ,d+[DATE] [DATE] at 5:17 AM: ,d+[DATE] [DATE] at 11:47 AM: ,d+[DATE] [DATE] at 1:43 PM: ,d+[DATE] [DATE] at 12:14 AM: ,d+[DATE] [DATE] at 6:28 AM: ,d+[DATE] [DATE] at 11:23 AM: ,d+[DATE] Progress note of [DATE] at 5:49 PM, written by Licensed Practical Nurse (LPN) J, documented in part the following: At 1710 (5:10 PM) writer entered room and observed resident was unresponsive with no pulse or respirations present. Writer called for help and started CPR (cardiopulmonary resuscitation) until rescue team arrived. EMTS (emergency medical technicians) performed CPR for approximately 25 minutes. Calling time of death 1744 (5:44 PM). Writer informed Dr. (Physician K) . During an interview on [DATE] at 3:46 PM, LPN C stated he would call the physician for a systolic blood pressure less than 100. During an interview on [DATE] at 3:47 PM, LPN D stated she would call the physician for a systolic blood pressure less than 100. During an interview on [DATE] at 3:49 PM, Registered Nurse (RN) E stated if the resident's blood pressure tended to run low, he would call the physician for a systolic blood pressure less than 90 or 95 because the doctor may want to start a new order; maybe order a vasopressor to bring the pressure up. We are to notify the physician of changes (in the resident). During an interview on [DATE] at 9:56 AM, LPN J stated, If the resident's blood pressure is usually ,d+[DATE], I would give [MEDICATION(S)]. I would recheck the blood pressure. If it does not come up, I would call the physician. Usually, [MEDICATION(S)] has parameters for when to contact the physician. If there are no parameters, I use ,d+[DATE]. Interviews and review of R609's clinical record were conducted with Director of Nursing (DON) B on [DATE] at 3:54 PM, [DATE] at 12:42 PM, and [DATE] at 2:40 PM. DON B stated, I wouldn't be concerned about a blood pressure of ,d+[DATE] for someone normally hypotensive. DON B stated, There are no specific facility standing orders for hypertension (or [CONDITION(S)]). It is resident specific. If there are no orders, it is the nurse's judgment (for when to call the physician). A review of R609's Weights and Vitals Summary printed on [DATE] documented a Warning of Systolic Low of 90 exceeded on [DATE] for a blood pressure of ,d+[DATE]. This was the first time a warning was generated due to a low systolic reading. R609's clinical record revealed that R609's blood pressure was not rechecked, nor his physician notified of the warning systolic blood pressure reading. DON B stated the purpose of contacting the physician regarding a change in condition was to ensure guidance on how to proceed with resident's care. In reference to R609's blood pressure reading of ,d+[DATE], DON B stated, I don't know if I would have notified the physician. I don't know if I would have rechecked his blood pressure. The Warnings (on the Weights and Vitals Summary document) are there because you may want to call the physician. During an interview and review of R609's clinical record on [DATE] at 11:00 AM, Physician K stated, If the (systolic) blood pressure goes below 90, I should be notified. We are worried about [CONDITION(S)] ([CONDITION(S)] or passing out), low perfusion to the kidneys (decrease in fluid passage through kidneys), falls, and weakness. Usually, we have standing med orders for when to notify the physician for [CONDITION(S)]. I don't see parameters. The current order (for [MEDICATION(S)]) did not have parameters for when to call the physician. That's concerning. I would have wanted to be called for a (blood pressure of) ,d+[DATE]. A facility document titled, Change in status, identifying and communicating, long term care, revised [DATE], was reviewed and revealed the following: -A resident is more likely to return to baseline status and avoid complications when a condition is recognized early so that it can be treated. When a nurse recognizes a potentially life-threatening condition or significant change in a resident's status, the nurse must communicate with other health care providers to meet the resident's needs. -The nurse .must communicate a resident's change in status, including assessment findings, to the practitioner. On [DATE] at 3:50 PM during the exit conference, Nursing Home Administrator A and DON B were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

This citation pertains to intake MI 177. Based on interview and record review, the facility failed to provide baths/showers as scheduled and according to resident's preference for one resident (#600) of four residents reviewed who were dependent on staff for performance of activities of daily living (ADLs), resulting in resident dissatisfaction and potential for unmet care needs. Findings include: A review of the Face Sheet for Resident #600 (R600) documented an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set, dated dated dated [DATE] documented intact cognition and extensive, two-plus persons physical assistance for bathing and hygiene. A review of R600's care plans documented in part the following: Focus: (R600) has an ADL self care performance deficit and requires assistance with ADL's and mobility related to weakness, right tibia fracture, and respiratory failure. Interventions included: Resident requires max assistance with transfers with two staff assistance and mechanical lift. Interviews and review of R600's clinical record were conducted with the Director of Nursing (DON) B on 12/2/2021 at 12:35 PM and 2:40 PM. A review of documentation of the shower/baths given to R600 revealed her first shower/bath was provided on 10/19/2021. Considering R600 was admitted to the facility on [DATE], DON B acknowledged that 12 days had passed before R600's first shower. DON B stated, This is not acceptable. It is the practice of this facility and my expectation, that residents are showered at least twice a week. The purpose of showering is to maintain hygiene and good infection control practice. (People) like to shower and be clean. It's good for resident morale. DON B indicated there might be documentation that R600 had refused shower/baths. Documentation of care refusals was not provided by the end of the survey. The facility document titled, Routine Guest/Resident Care, dated June 2021, was reviewed and revealed the following: -Guest/residents receive the necessary assistance to maintain good grooming and personal/oral hygiene . -Showers, tub baths, and/or shampoos are scheduled according to person centered care or state specific guidelines .Additional showers are given as requested. On 12/2/2021 at 3:50 PM during the exit conference, Nursing Home Administrator A and DON B were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and they reported there was not.

This citation pertains to intake MI 177. Based on observation, interview and record review, the facility failed to ensure fresh water was passed in a timely manner to one residents (#607) out of four residents reviewed for hydration, resulting in the potential for dehydration, and a medically decline in the resident's status. Findings include: Review of an Oral Hydration policy with a revised date of 2/15 revealed, Policy: It is the policy of this facility to assist residents to maintain adequate hydration whenever possible. Nutrition and hydration interventions will be pursued until the resident and/or family have opted for comfort measures only and attempting more aggressive methods of hydration are contrary to the resident's Quality of Life, comfort, and requests .5. Each resident will be provided bedside water unless contraindicated . Review of an Admission Record revealed, Resident #607 admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, with a reference date of 9/28/21 revealed Resident #607 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 3, out of a total possible score of 15. Review of a Care Plan revealed focus, (Resident #607) is at risk for infection related to frequent bladder and bowel incontinence and hx of UTI's (urinary tract infections). Interventions included, Encourage fluid intake and adequate rest to bolster the immune system . In an observation on 12/2/21 at 1:33 p.m., Resident #607 laid in bed with eyes close. A full cup of water with a date of 12/1 3rd sat on the edge of Resident #607's bedside table and was not within reach. In an interview on 12/2/21 at 1:56 p.m., Certified Nursing Assistant (CNA) L reported the water on Resident #607's bedside is from the night shift. CNA L then reported she did not pass water to the residents during her shift. CNA L reported water is passed in the morning and once a shift. CNA L then stated, Let me gone ahead and pass it before I leave. In an interview on 12/2/21 at 2:08 p.m., CNA M reported fresh water is passed every shift. In an interview on 12/2/21 at 2:15 p.m., Director of Nursing (DON) B reported fresh water is given to the residents once a shift.

Based on interview and record review, the facility failed to develop a comprehensive Water Management Plan (WMP) to address the control and spread of Legionella bacteria pathogen in the facility water system, in accordance with QSO 17-30 Hospitals/CAHs/NH, Revised 7-6-2018, and failed to Develop and implement a water management program that considers the ASHRAE 188 (American Society of Heating, Refrigerating and Air-Conditioning Engineers) and the CDC (Centers for Disease Control) tool kit. The failure to develop a comprehensive Water Management Plan has the potential to allow for the proliferation and transmission of the bacteria in the circulating water of the building and the spread of Legionella infections in all 60 residents. Findings include: On 08/10/21 at 03:20 PM, an interview with the Maintenance Director (MD) E was conducted to review the facility's WMP for the control of Legionella in the water supply system. An undated document titled Water Management Plan was presented as the facility's plan to control the growth and spread of Legionella. During the interview, it was learned that the review of the policy by the Quality Assurance and Assessment Committee, did not include the maintenance director. MD E also advised the facility staff listed as the water management team is no longer present in the facility. The following components were absent from the facility WMP : A. The water management team listed; current plan consisted of facility staff who are no longer present in the facility. B. Identification of defined effective control measures and locations related to risk and the critical limits which are set. Control measures generally consist of temperature and disinfectant levels that are known to limit the growth and transmission of the pathogen. No corrective was defined and the critical limit, one set for scalding risk, is not a limit which is known to control the Legionella pathogen. C. Identification of critical limits related to the risk areas identified and which can be utilized to control the growth and spread of Legionella D. Identification of interventions/procedures to follow when critical limits are not met. E. An evaluation process to determine how the WMP is functioning.

This citation is linked to Intake #MI 512. Based on observation, interview, and record review, the facility failed to prevent mistreatment and verbal abuse for two Residents (#3 and #4) of nine residents reviewed for abuse, resulting in multiple verbal abuse and mistreatment events for Resident #4, and contributed to Resident #4's physical, emotional, and psychosocial decline, as well as feelings of frustration for Resident #3. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 5/19/21, revealed Resident #3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 required two-person assistance for bed mobility, transfers, and toileting, one-person assistance for dressing and pushing his wheelchair, and supervision for eating. He demonstrated range of motion impairment on one side of his upper and lower extremities. The Brief Interview for Mental Status (BIMS) revealed a score of 9/15, indicating Resident #3 demonstrated moderate cognitive impairment. The BIMS assessment from the prior quarter, 2/18/21, revealed a score of 15/15, indicating no cognitive impairment. Review of Resident #4's MDS assessment, dated 1/23/21, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4 required supervision with bed mobility, transfers, and eating, and was independent with walking, one-person assistance with dressing and toileting. The assessment revealed Resident #4 was usually understood and could usually understand others. The BIMS score was 5/15, indicating Resident #4 had marked cognitive impairment. Review of the MDS assessment, dated 4/26/21, revealed Resident #4 required one-person assistance for bed mobility, transfers, dressing, and toileting, and supervision for eating and walking in her room. The assessment revealed Resident #4 was usually understood and could usually understand others. The BIMS score remained 5/15. The assessment showed Resident #4 had a decline in bed mobility, transfers, walking, and newly demonstrated wandering behavior. Resident #3 and Resident #4 were married long term care residents who shared the same room upon survey entry on 6/21/21. Review of Resident #3's and Resident #4's progress notes revealed five resident-to-resident incidences of mistreatment and/or verbal abuse by Resident #3, towards his wife, Resident #4, on 1/17/21, 3/13/21, 5/22/21, 6/11/21, and 6/20/21. During an interview on 6/22/21 at 11:25 a.m., Certified Nurse Aide (CNA) C described a resident-to-resident incident between Resident #3 and his wife, Resident #4, in the past month. CNA C stated recently when they returned from their break they found the Resident #3's and Resident #4's shared room had water all over the floor, and Resident #4 was observed with the nurse outside the room, soaked in water from her head to her feet. The nurse said, Change her, as [Resident #3] poured water on [Resident #4], and they changed Resident #4's clothes. Surveyor asked who was aware of the incident, and CNA C responded, I think everybody [all the staff] knows, and the managers know. [LPN E] said it was emotional abuse. During an interview on 6/22/21 at 12:00 p.m., the Nursing Home Administrator (NHA) was asked about this resident-to-resident incident. The NHA reported when the Resident (#3) threw water on Resident #4, the nurse [unspecified] brought Resident #4 to the NHA who observed Resident #4's hair was wet, and they went down the residents' hall to see what happened. The NHA reported the residents said, We were just goofing around . and reported Resident #3 denied throwing the water on Resident #4. The NHA stated the facility management called the son/POA [Power of Attorney] and the regional Ombudsman to request assistance to resolve the marital conflict, as they did not know how to prevent these incidents from recurring. The NHA stated Resident #4 was not injured in any way, so they did not report to the State Agency (S.A.). The NHA acknowledged Resident #3 did yell at Resident #4 at times, and this was also why they had involved the POA and the Ombudsman. The NHA was asked about any other incidences between the residents, and reported this March (2021) there was an incident when Resident #3 sprayed Resident #4 with a water bottle. Surveyor asked for any investigation reports for resident-to-resident incidents which involved Resident #3 and Resident #4 since January, 2021. The NHA soon after showed Surveyor a resident-to-resident physical abuse incident report between Resident #3 and Resident #4 which had been reported to the State Agency, when Resident #4's nail was torn in a physical altercation with Resident #3 on 3/13/21. No other incidents were reported. During an interview on 6/22/21 at 2:30 p.m., CNA B was asked if they were aware of any incidents between these two residents. CNA B reported they saw Resident #3 trying to shower' Resident #4 with a water bottle, and they stopped the incident, earlier this month. They recalled reporting this to an unnamed nurse, but not to the NHA. CNA B reported sometimes Resident #3 yelled at his wife, Resident #4, and they did not report this to the NHA, as they did not know if this was verbal abuse. An observation on 6/22/21 at 2:45 p.m. revealed Resident #3's and #4's door was closed. Surveyor knocked on the door and observed them both alone in their room. Resident #3 was seated in a manual wheelchair, and Resident #4 was seated on her bed. Surveyor left the room and returned at 2:49 p.m. to interview Resident #3, and the door remained closed. During an interview on 6/22/21 at 2:49 p.m., Resident #3 stated, I had a water bottle to dampen the hair. If you just turn where it comes out [the spout] you can get it to a spray, and if you turn it more it would be like a squirt gun. When I couldn't get [Resident #4] to calm down I didn't know what to do so I squirted [Resident #4] .It worked and that was my main idea .I don't see anything wrong with it. It causes no harm . Resident #3 was asked if he had done this more than once, and responded, Yes, It's always been the squirt thing [using the spray bottle towards his wife], or I would take this [showed Surveyor a clear Coke 16 oz bottle on the ledge in [Resident #3's] room, half filled with water, and I put my finger in it. Resident #3 reported they use the water bottle as the spray bottle was removed from their room. Next he demonstrated how he flicked the water with his right arm and hand with the opening partly covered towards Resident #4 often. Resident #3 stated, That's [the water] what would come [land] on [Resident #4]. So the bottle doesn't go flying and hit her. I have threatened [to spray Resident #4] too when it's [the plastic bottle] empty. [Resident #4] reacts like it's full of water .The nurses say I'm picking on her. They must have seen her after she got squirted once. [Resident #4] definitely knew it [the water] was on her. The way she was acting, it was a fair thing to do. I can't sit there and scream at [Resident #4] all day. My stomach gets all upset and nervous. I cannot tell her [what to do] louder, and I figured it ain't hurting nothing .There is confusion there; [Resident #4] has dementia; that's what it's all about. [Resident #4] got upset, yeah, and said, 'Why are you doing that?' It [the water] was all over her on her head and chest. I'm here 24 hours [in the shared room with Resident #4]. These people [staff] will come in and be with her 15 minutes and they can't take anymore. I don't yell unless if it gets very bad .The threat of doing something is just like when you're a little kid as that's what [Resident #4] is Resident #3 then explained he was responsible for Resident #4's supervision as the staff don't stay long enough. He stated just before the Surveyor came in Resident #4 was crooked in her bed, so he pushed [Resident #4] to the middle of the bed. Resident #3 was interviewable and fully oriented to himself, situation, surroundings, and time/schedule. This interview revealed Resident #3's willfulness/intention with mistreatment/verbal abuse towards his wife, Resident #4. This was immediately reported to the S.A., and then disclosed to the NHA and DON. Surveyor attempted to interview Resident #4 at 3:05 p.m. Resident #4 appeared calm, and reported she was fine when asked, but was unable to answer any specific questions due to cognitive impairment and was unable to participate further in the interview. During an interview on 6/22/21 at 3:10 p.m. LPN Q was asked if Resident #3's and Resident #4's door should remain closed with both residents in the room. LPN Q reported to keep the door closed as Resident #3 liked the door closed to keep the room warm LPN Q was unable to visually supervise either resident with the door closed. During a telephone interview on 6/22/21 at 4:10 p.m., LPN E was asked if they recalled any resident to resident incidents between Resident #3 and Resident #4. LPN E reported were several incidences with the squirt bottle which involved Resident #3 as the perpetrator, and described the most recent incident. LPN stated, The one [incident] in June [2021], I believe they [staff] called me in there as [Resident #4] was very upset. When I came in there [into their room] me and [CNA C] found the whole room was covered in water. It was all over the floor. [Resident #4] was soaked from head to toe. [Resident #4] was just over the top upset; [Resident #4] couldn't get the words out and kept saying, '[Resident #3] did this, now look at me and now I'm wet'. LPN E reported [Resident #3] poured a cup of water on [Resident #4]. LPN C stated they took [Resident #4] out of the room to separate the two and took [Resident #4] to the Administrator to show the management staff what happened. LPN C explained they and nursing staff had done this previously when they reported the other incidents involving Resident #3 and Resident #4 to the Administrator. LPN C reported Resident #3 said he had to squirt Resident #4 to get Resident #4 to do what Resident #3 wanted Resident #4 to do, and added Resident #3 was constantly raising his voice to Resident #4 and was frustrated with Resident #4's dementia. LPN C clarified Resident #3 told Resident #4, 'There's no point in telling you anything as you don't understand anything.' .and Resident #4 said, '[Resident #3] is being mean; he's an a**.' Review of Resident #3's progress notes revealed the following: 1/17/2021 17:12 (5:12 p.m.): Behavior note: Resident [#3] heard from outside the [room] door, loudly [sic] voices frustrations to roommate [Resident #4]. Resident [#3] heard using foul language with roommate, telling roommate she is a f****** [expletive] idiot and a dumb [B****] [expletive]'. Writer removed roommate from room to hallway . There was no follow up regarding this incident documented in Resident #3's or Resident #4's progress notes, including nursing, physician, or social worker's notes. 2/12/2021 14:53 (2:53 p.m.): Spoke with son (POA - Power of Attorney) about res [#3's] aggression toward his wife (roommate) .Writer [Social Worker (SW R)] also addressed res [#3] talking down to res [#4] and name calling . 2/19/2021 09:31 (9:31 a.m.): Res [#3] continues at [facility] for LTC [Long Term Care]. [Resident #3] is [sic] currently shares a room with [#3's] wife, [Resident #4], who [#3] argues with at times . 3/13/2021 14:42 (2:42 p.m.): Resident [#3] was witnessed by housekeeper [unnamed] squirting resident [Resident #4] with a water and arguing and pushing each other at approximately at 140 pm [1:40 p.m.], writer [LPN E] interviewed, resident [#3] and asked what happened during the interview and resident [#3] said that [#3] has to squirt resident [#4] to make [Resident #4] listen and do what [#4] is supposed to do, [sic] when asked what caused the pushing incident [Resident #3] said [Resident #4] wasn't doing what [#4] was supposed to do so [#3] was spraying [#4] and [#4] tried to grab the bottle and they were just horseplaying .[Resident #3] said [sic] [#3] uses the squirt bottle all the time to make resident [Resident #4] behave right as [#4] doesn't know how to act right. Writer separated the resident [#3] and resident [#4] and notified the appropriate people of behaviors and room changes. Will continue to monitor. 3/13/2021 15:56 p.m. (3:56 p.m.): Writer [Social Worker - SW R] met with res. [#3] who fist [sic] stated [Resident #3] and his wife were horeplaying'[sic - horseplaying] but went on to say that [Resident #3] didn't like the way [Resident #4] was behaving and that [Resident #3] squirt [sic] her with the water bottle which [Resident #3] referred to as a squirt gun; [Resident #3] then said that 'I'll tell [Resident #4] that if [#4] doesn't stop something or act right that I'm going to squirt [#4]' .Writer explained the difference to resident [#3] between horseplay and a threatening remark; we discussed the need to treat everyone with respect as well as notifying the staff when [Resident #3] becomes frustrated with [#3's] wife so that staff can remove one of them from the room for a cool down time . 4/21/2021 17:50 p.m. (5:50 p.m.): Writer (LPN E) heard resident [#3] screaming and cussing from out in hallway, writer entered room and asked why [#3] was yelling and [#3] replied, 'Because I have to do your f**ing [expletive] job and keep an eye on [Resident #4] all day,' referring to resident [#4], and 'I have to yell because [Resident #4] can't hear anything.' [sic] Resident [#4] was standing up in front of [Resident #3] and said, 'I can hear everything!' [sic] . 5/22/2021 18:05 (6:05 p.m.): Writer [LPN E] walked into resident's room to give resident 5 pm med [medication] when writer witnessed [Resident #3] using a squirt bottle on [Resident #4] which [sic] was laying in bed, [#3] was squirting [#4] directly in the face and resident [#4] was attempting to cover [#4's] face to block the water, writer told [Resident #3] to quit and asked him what he was doing it for, he said that resident [#4] wouldn't listen so this was the only way to get [#4] to do what he wants her to do and that he does it all the time, writer explained to [Resident #3] that squirting someone is not tolerated and is considered abuse, [Resident #3] replied, 'As much as I pay here I can do whatever I want to do, so what are you gonna do about it [sic] you guys are not able to take care of [Resident #4].' I asked resident [#3] if he would want to be moved to a different room than resident [#4] and he said, 'That could never happen because [#3] has to take care of resident [#4]' .I told resident .I cannot have [#3] squirting anyone with the squirt bottle and that it would be taken if [#3] were to continue, [#3] said, 'I will use it if I want to to [sic] squirt [Resident #4] or you or whoever the hell I want to, or to wet down my hair when it's sticking up, you won't be taking anything from me .' There was no follow up regarding this incident documented in Resident #3's or Resident #4's progress notes, including nursing, physician, or social worker's notes. 6/05/2021 18:10 (6:10 p.m.): Writer [SW S] heard resident [#3] yelling at staff. Nurse was speaking to him kindly reminding [Resident #3] that if [#3] needs a break from his spouse (roommate) to tell stay [sic - staff] instead of yelling at [Resident #4] and throwing objects. Started yelling at writer and writer explained that if this was to cont [continue] we would have to separate the two [Residents #3 and #4]. [Resident #3's] response was 'Well you will be giving the stay a 24/7 job because [#4] won't do well without me.' Writer also has to remove a spray bottle from room as [#3] had mentioned [#3] was going to spray [Resident #4] . 6/11/2021 13:52 (1:52 p.m.) Writer [SW S] was informed by staff that res [#3] had thrown water all over [#3's] rom [sic - room] and roommate [Resident #4]. Writer approached the resident [#3], [who] was very call [sic - calm] and denied just [sic] actions. Writer again discussed that if [Resident #3] needed assistance with his roommate/spouse [Resident #4] that [Resident #3] needed to ask instead of throwing [sic] or become upset. He denied it in this instance. There was no follow up in the progress notes regarding this incident for Resident #3 or Resident #4, including nursing, physician, or social worker notes. An investigation report was provided upon request during the survey. 6/20/2021 22:56 [10:56 p.m.] Resident [#3] frequently raised his voice at his wife, [Resident #4] this evening. [Resident #3] was overheard telling [Resident #4] to 'shut up, lay [#4's] lazy a** down,' etc. Writer [DON] intervened and asked resident to not speak to [Resident #4] that way. [Resident #3] proceed [sic] to state [#3] will talk to [Resident #4] any way [#3] chooses too . 6/22/2021 17:29 [5:29 p.m.] Resident [#3] spoke to son [name] via phone with NHA [Nursing Home Administrator] present. We discussed the incident on Sunday evening [6/20/21]. We [staff and POA] also discussed that [Resident #3] told a Surveyor today of some of things [Resident #3] does to threaten his wife .At this time, it was agreed that temporarily the two of them should be separated to allow [Resident #3] the opportunity to de-stress and work on positive coping mechanisms, as able, in dealing with his wife [Resident #4] . 6/22/2021 18:24 [6:24 p.m.] Coke bottle [referenced earlier] containing water was removed from room [Resident #3's room]. Res [#3] at first objected but then stated, I guess that's what I get for telling the truth, go ahead and take it. by LPN Q. Review of Resident #3's Care Plan, accessed 6/23/21 and provided by the DON, revealed no new interventions to address Resident #3's mistreatment and verbal abuse towards Resident #4. Review of Resident #4's progress notes revealed the following: 3/13/2021 14:33 [1:33 p.m.] Writer [LPN E] was notified that resident [#4] and resident [#3] were arguing and that resident [#4] had broken her finger nail and was bleeding by the housekeeper [unnamed] at approximately 1:40 pm [sic] the housekeeper was in the room cleaning when she saw the residents arguing and resident [#3] squirting the resident [#4] with a squirt bottle, resident [#4] became agitated and tried to get the bottle from resident [#3] and during the struggle they began pushing each other and . [Resident #4] broke her left index finger nail, [sic] writer asked resident what happened after bandaging [#4's] finger .but resident [#4] only said that resident [#3] threw water at [#4] and [Resident #3] was being mean to [#4] .resident [#4] continues to be agitated from the incident . 3/15/21 10:30 [a.m.] After phone meeting with son [POA] writer [LPN K] asked resident [#4] if [#4] was ready to return to their room and see [Resident #3], [sic] resident [#4] stated [sic], 'Is [Resident #3] going to be nice to me? I think I will stay here for a while .' 6/05/2021 18:13 [6:13 p.m.]: SW S noted, Resident [#4] wandering the hallways and in and out of rooms. Resident [#4] looks distraught and asking where [#4] should go and what to do. Staff have been redirecting her but visually upset that spouse was ridiculing [#4] . 6/11/2021 13:55 [1:55 p.m.] by SW S noted, Res [#4] presented in wet clothing, [#4] reports, '[Resident #3] threw something on me.' Res was assisted by aid [sic] in changing [clothes] and then sat in ac's [activities] to eat lunch with assistance . 6/11/2021 13:13 [1:13 p.m.] by SW S noted, Per administrator res [#4] was brought to [the NHA] regarding this incident, when admin (administrator) asked what had happened [#4] then responded, 'We were just messing around.' This is inconsistent of what [Resident #4] had reported to other staff. As of today, 6/14/21, Admin has called the (county/regional) Ombudsman for a potential family meeting. SS [social services staff) to assist as needed for emotional support. There was no documentation in the social services progress notes of any additional psychosocial support provided after this incident. 6/11/2021 22:40 [10:40 p.m.], Resident [#4] has been wandering up and down hall this shift [sic] no short term recall, comes up to staff asking 'What do you want me to do what do you want me to do?' At times cursing at staff, [who] redirects [sic] to bed then get back up going in other residents rooms . 6/12/2021 07:53 [a.m.] Resident [#4] wandering in hallway and attempting to enter resident's rooms. staff redirects [Resident #4] to room as tolerated and resident keeps stating, what am I suppose to be doing? . 6/14/2021 15:18 [3:18 p.m.], Summary for Providers: Situation: The change of condition reported on this .evaluation are/were: Altered mental status. Other change in condition Positive findings reported on the resident/patient evaluation for this change of condition were: - Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy, but easily aroused, difficult to arouse), memory loss .needs more assistance with ADLs Nursing observations, evaluation, and recommendations are resident [#4] is having increase in confusion, she needs redirecting more throughout shift, she is wandering into other residents rooms in nighttime hours . by LPN U. 6/14/2021 23:40 [11:40 p.m.] Aide [unnamed] called this writer [nurse] into patient's [Resident #4's] room. Noted the patient [Resident #4] was laying on the floor facing the bed in between the bed and the bedside table. Patient was unable to explain what had happened .Note patient had a reddened area above the right eyebrow . No suspicion of abuse was noted. [The change of condition was noted before this fall.] 6/16/2021 18:10 [6:10 p.m.], .[Resident #4] has needed extra assistance with meals and with toileting, neuro checks continue with all vitals withing normal limits, resident has discoloration noted to right eyebrow and right elbow .[from the unwitnessed fall]. 6/20/2021 17:38 p.m. [5:38 p.m.] [LPN K noted] resident [#4] is in need on [sic] increased assistance with meals, [#4] needs to be redirected constantly to sit up instead of trying to lay down while eating, staff try to encourage [#4] to eat meals while sitting in wheelchair .but as soon as staff leave the room resident [#4] will push the tray away from [#4] and lay back down, when staff stay in the room with [#4] and try to encourage [#4] to eat or feed herself they have to remind [#4] what/how to do so with every bite and remind [#4] cannot lay back down in bed while eating .[#4] has begun to forget how to use utensils with meals and tries to use fingers often, if staff does not help eat resident [#4] tends to try to eat meal while laying down in bed or will not attempt to eat at all . 6/22/2021 18:25 [6:25 p.m.] Writer [Director of Nursing - DON] spoke with resident [#4] in room, approximatley 1630 [4:30 p.m.] . [Resident #4] indicated [#4] was doing fine and was ok. Resident [#4] noted to have decline in feeding self, attention span, and following directions. Labs were completed and no significant findings noted. Writer referred therapy for screening. Son [POA] made aware . Review of Resident #4's Care Plan, accessed 6/23/21 and provided by the DON revealed no new interventions to protect/address Resident #3's mistreatment and verbal abuse towards Resident #4. Observations during the survey on 6/21/21 and 6/22/21 revealed Resident #3 and #4 shared the same room, and at times their door was closed. Observations on 6/23/21 revealed Resident #3 had been relocated to a different room on another hall, and Resident #4 remained in the same room where they both had resided. Review of the facility census, accessed 6/23/21, for Resident #3 and Resident #4 revealed they resided in the same room until 6/23/21, with the exception of 3/14/21, when Resident #4 was moved to another room, and returned to share her former room with her spouse on 3/15/21. During an interview on 6/23/21 at 1:15 p.m. without [Resident #4's] spouse present, Resident #4 did not recall any concerns with her husband or express fearfulness when [Resident #3's] name was mentioned. She said yes when asked if she felt safe at the facility. She did not say anything about the room change, and appeared calm. She was oriented to her name only. Resident #4 was observed with 1:1 supervision throughout the day, including by activities staff. Surveyor asked the NHA and DON on 6/22/21 if there were any investigations for the mistreatment/physical abuse and verbal abuse incidents which involved Residents #3 and #4. Review of the investigation report provided by the DON upon request, Date of incident: 6/11/2021 .Summary of Resident Interview, revealed, .[unnamed nurse] brought [Resident #4] to NHA to report resident's husband [Resident #3] had thrown water at resident stated [Resident #4] was upset visibly so and there was water all over floor in room. [Resident #4] said, [Resident #3] threw it on me .[Resident #3] states nothing happened and [#3] didn't know how [Resident #4] got wet; [stated] '[Resident #4's] hard to control' Indicated water on floor because [#4] spilled it [sic] [Resident #3] became very agitated when [writer] asked if he threw water [on Resident #4] .Conclusion: It is obvious by [Resident #4's] wet hair and water on the floor that [Resident #4] got wet. It was unwitnessed and was thought to be [Resident #3] [as the perpetrator] after [Resident #4] told the nurse that [Resident #3] threw it [water] at me. Review of the investigaton report provided by the DON upon request, .Summary of Resident Interview, revealed, Date of incident: 6/20/2021. Summary: Resident [#3] stated [#3]called [Resident #4] a lazy a** because all [#4] does is lay around and that [#3] also called [#4] a pig because when [#4] does it [sic] [#3] just shoves it [unspecified] in [#4's] face. [Resident #3] also stated that it's [#3's] right to talk to [#4] any way [#3] wants .[Interim DON] overhead [Resident #3] telling [Resident #4] to shut up and lay [#4's] lazy ass down . During an interview on 6/23/21 at 8:50 a.m. with Resident #3, Surveyor observed resident in his new room. Resident #3 stated, Why did you take my water [Coke] bottle away? It wasn't hurting anything. [Nursing staff on 6/22/21 had removed his plastic Coke soda bottle.] Resident #3 added, I was just flicking it at her [Resident #4] when [#4] needed it as [#4] doesn't know anything. [Resident #3] picked up [#3's] plastic juice cup and stated, It's not like I was hitting [Resident #4] with anything plastic. [Resident #3] stated [#3] wanted the water bottle back. Resident #4 was not in the room with Resident #3. Review of Resident #3's [company name] psychiatric visit note, dated 3/19/2021, revealed, Spoke to SW [unnamed] and Medicine MD [unnamed]. I directly asked about the spraying his spouse with water incident, [sic] 'We were just horsing around and they [facility staff] blew it out of proportion.' Both Medicine MD and SW said that was not the case . Review of additional psychiatric visit notes requested from the facility revealed no psychiatric referral or mention of recent resident-to-resident incidents in May or June, 2021 being addressed by the psychiatric staff. Review of Resident #3's physician note, dated 3/19/21, revealed, On March 13 [2021] there was episode of altercation between the patient and his wife, observed by the staff, patient [Resident #3] was mad at his wife [Resident #4] and squirting her with a water [sic] .This is not a new issue; she [sic- he] gets easily frustrated with the spouse because of her dementia and at times inappropriate and confused behavior .With episodes of agitation and inappropriate behavior, especially towards his wife [Resident #4] who is very demented and depends on patient [#3] in many instances. No signs of [CONDITION(S)] in fact blood work was unremarkable .no clinical signs of UTI. His behavior has history of similar pattern . Review of physician visit notes requested from the facility revealed no mention of resident-to-resident incidents during May and June, 2021. Review of Resident #4's psychiatric visit note, dated 4/16/21, revealed, Nurse [unnamed] says she thinks patient may be a bit more depressed, [Resident #4] is staying in bed more, maybe wetting the bed more. [Resident #4] says spouse still speaks to [#4] harshly at times .[Resident #4] does look a bit more blunted but this could be from cognitive decline and not emotional distress. We decide no new meds were needed at this time . Review of additional psychiatric visit notes requested from the facility revealed no psychiatric referral or mention of recent resident-to-resident incidents in May or June, 2021 being addressed by the psychiatry staff. During interviews on 6/22/2021 at 3:46 p.m. and 4:35 p.m., the NHA and DON were asked about these resident-to-resident incidents, including Resident #3's reports to Surveyor and nursing staff regarding his mistreatment, verbal abuse, and willfulness (intention) to commit abuse towards his wife, Resident #4. The NHA acknowledged Resident #3's verbal aggression towards Resident #4, and concerns related to the water squirting/pouring incidences. The NHA reported they did not know what to do to prevent it from occurring as they [Resident #3 and Resident #4] were married and roommates [at the time of the interview]. Both the NHA and DON denied any outcome for Resident #4. The DON denied Resident #3's mistreatment and verbal abuse towards his wife, Resident #4, yet reported they were aware of the 3/13/21, 6/11/21, and 6/20/21 resident-to-resident incidents. The DON reiterated they had found no abuse or outcome for Resident #4, despite Surveyor reviewing the related progress notes with both the NHA and DON during the interview. Both denied awareness of any other resident-to-resident incidences for Resident #3 and Resident #4. The NHA and DON reported they had involved the Ombudsman for their region, Resident Advocate T, regarding verbal aggression incidents and what they deemed as marital conflict. Surveyor clarified any suspicion of abuse including mistreatment or verbal abuse would need to be reported to the S.A., and reviewed their policy which provided definitions of mistreatment and verbal abuse, and when to report abuse. During an interview on 6/22/21 at 4:57 p.m, the regional Ombudsman, Resident Advocate T, was asked if they had met with the facility regarding concerns with Resident #3's and #4's marital conflict and reported verbal aggression towards each other. Resident Advocate T reported they educated the facility when they were there on 6/21/21 to report any verbal abuse or any other type of abuse to the S.A., if they believed verbal or any other type of abuse had occurred. Resident Advocate T reported the facility did not report verbal abuse or other abuse to them. Resident Advocate T confirmed they had called the resident's son/POA on 6/21/21 twice in the facility with the NHA, without reaching him, as the facility had asked them for assistance. Surveyor was also unable to reach Resident #3's and Resident #4's son/POA via phone despite two attempts during the survey. Review of the policy, Abuse Prohibition Policy, revised 07/2019, provided by the NHA, revealed, Each resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment .Allegations of resident abuse, exploitation, neglect, misappropriation of properly, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies (S.A.), physician, families, and/or representative .Abuse (definition) means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, o [TRUNCATED]

This citation is linked to Intake #MI 512. Based on interview and record review, the facility failed to implement their abuse policy for reporting and investigating two incidents of abuse/mistreatment and two verbal abuse incidents (one not reported timely) for two Residents (#3 and #4) of nine residents reviewed for abuse. This deficient practice resulted in abuse not being reported to the state survey agency, allegations of abuse not being thoroughly investigated, the potential for abuse to go undetected, and the potential for residents not being protected from abuse. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 required two-person assistance for bed mobility, transfers, and toileting, one-person assistance for dressing and pushing his wheelchair, and supervision for eating. He demonstrated range of motion impairment on one side of his upper and lower extremities. The Brief Interview for Mental Status (BIMS) revealed a score of 9/15, indicating Resident #3 demonstrated moderate cognitive impairment. The BIMS assessment from the prior quarter, 2/18/21, revealed a score of 15/15, indicating no cognitive impairment. Review of Resident #4's MDS assessment, dated 1/23/21, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4 required supervision with bed mobility, transfers, and eating, and was independent with walking, one-person assistance with dressing and toileting. The assessment revealed Resident #4 was usually understood and could usually understand others. The BIMS score was 5/15, indicating Resident #4 had marked cognitive impairment. Resident #3 and Resident #4 were married long term care residents who shared the same room upon survey entry on 6/21/21. During an interview on 6/22/21 at 11:25 a.m., Certified Nurse Aide (CNA) C described a resident-to-resident incident between Resident #3 and his wife, Resident #4, in the past month. CNA C stated recently when they returned from their break they found the Resident #3's and Resident #4's shared room had water all over the floor, and Resident #4 was observed with the nurse outside the room, soaked in water from her head to her feet. The nurse said, Change her, as [Resident #3] poured water on [Resident #4], and they changed Resident #4's clothes. Surveyor asked who was aware of the incident, and CNA C responded, I think everybody [all the staff] knows, and the managers know. [LPN E] said it was emotional abuse. During an interview on 6/22/21 at 12:00 p.m., the Nursing Home Administrator (NHA) was asked about this resident-to-resident incident. The NHA reported when the resident (#3) threw water on Resident #4, the nurse [unspecified] brought Resident #4 to the NHA who observed Resident #4's hair was wet, and they went down the residents' hall to see what happened. The NHA reported the residents said, We were just goofing around . and reported Resident #3 denied throwing the water on Resident #4. The NHA stated the facility management called the son/POA [power of attorney] and the regional Ombudsman to request assistance to resolve the marital conflict, as they did not know how to prevent these incidents from recurring. The NHA stated Resident #4 was not injured in any way, so they did not report to the State Agency (S.A.). The NHA acknowledged Resident #3 did yell at Resident #4 at times, and this was also why they had involved the POA and the Ombudsman. The NHA was asked about any other incidences between the residents, and reported this March (2021) there was an incident when Resident #3 sprayed Resident #4 with a water bottle. Surveyor asked for any investigation reports for resident-to-resident incidents which involved Resident #3 and Resident #4 since January, 2021. The NHA soon after showed Surveyor a resident-to-resident physical abuse incident report between Resident #3 and Resident #4 which had been reported to the S.A. when Resident #4's nail was torn in a physical altercation with Resident #3 on 3/13/21, which was reported as desk reviewed. No other incidents were reported. During an interview on 6/22/21 at 2:30 p.m., CNA B was asked if they were aware of any incidents between these two residents. CNA B reported they saw Resident #3 trying to shower' Resident #4 with a water bottle, and they stopped the incident, earlier this month. They recalled reporting this to an unnamed nurse, but not to the NHA. CNA B reported sometimes Resident #3 yelled at his wife, Resident #4, and they did not report this to the NHA, as they did not know if this was verbal abuse. During a phone interview on 6/22/21 at 4:10 p.m., LPN E was asked if they recalled any resident to resident incidents between Resident #3 and Resident #4. LPN E reported were several incidences with the squirt bottle which involved Resident #3 as the perpetrator, and described the most recent incident. LPN stated, The one [incident] in June [2021], I believe they [staff] called me in there as [Resident #4] was very upset. When I came in there [into their room] me and [CNA C] found the whole room was covered in water. It was all over the floor. [Resident #4] was soaked from head to toe. [Resident #4] was just over the top upset; [Resident #4] couldn't get the words out and kept saying, '[Resident #3] did this, now look at me and now I'm wet'. LPN E reported [Resident #3] poured a cup of water on [Resident #4]. LPN C stated they took [Resident #4] out of the room to separate the two and took [Resident #4] to the Administrator to show the management staff what happened. LPN C explained they and nursing staff had done this previously when they reported the other incidents involving Resident #3 and Resident #4 to the Administrator. LPN C reported Resident #3 said they had to squirt Resident #4 to get Resident #4 to do what Resident #3 wanted Resident #4 to do, and added Resident #3 was constantly raising their voice to Resident #4 and was frustrated with Resident #4's dementia. LPN C clarified Resident #3 told Resident #4, 'There's no point in telling you anything as you don't understand anything.' .and Resident #4 said, '[Resident #3] is being mean; he's an ass.' Review of Resident #3's progress notes revealed: 1/17/2021 17:12 (5:12 p.m.): Behavior note: Resident [#3] heard from outside the [room] door, loudly [sic] voices frustrations to roommate [Resident #4]. Resident [#3] heard using foul language with roommate, telling roommate [Resident #4] 'is a f****** [expletive] and a dumb [B****] [expletive]' Writer removed roommate from room to hallway . This incident was not reported to the S.A. The Electronic Medical Record (EMR) revealed no evidence of investigation or follow-up by any staff for an outcome, or anything being done to protect Resident #4 from further abuse. 5/22/2021 18:05 (6:05 p.m.): Writer [LPN E] walked into resident's room to give resident 5 pm med [medication] when writer witnessed [Resident #3] using a squirt bottle on [Resident #4] which [sic] was laying in bed, [#3] was squirting [#4] directly in the face and resident [#4] was attempting to cover [#4's] face to block the water, writer told [Resident #3] to quit and asked him what he was doing it for, he said that resident [#4] wouldn't listen so this was the only way to get [#4] to do what he wants her to do and that he does it all the time, writer explained to [Resident #3] that squirting someone is not tolerated and is considered abuse, [Resident #3] replied, 'As much as I pay here I can do whatever I want to do, so what are you gonna do about it [sic] you guys are not able to take care of [Resident #4].' I asked resident [#3] if he would want to be moved to a different room than resident [#4] and he said, 'That could never happen because [#3] has to take care of resident [#4]' .I told resident .I cannot have [#3] squirting anyone with the squirt bottle and that it would be taken if [#3] were to continue, [#3] said, 'I will use it if I want to to [sic] squirt [Resident #4] or you or whoever the hell I want to, or to wet down my hair when it's sticking up, you won't be taking anything from me .' This incident was not reported to the S.A. The EMR revealed no evidence of investigation or follow-up by any staff for an outcome, or anything being done to protect Resident #4 from further abuse. 6/11/2021 13:52 (1:52 p.m.) Writer [SW S] was informed by staff that res [#3] had thrown water all over [#3's] rom [sic - room] and roommate [Resident #4]. Writer approached the resident [#3], [who] was very call [sic - calm] and denied just [sic] actions. Writer again discussed that if [Resident #3] needed assistance with his roommate/spouse [Resident #4] that [Resident #3] needed to ask instead of throwing [sic] or become upset. He denied it in this instance. There was no follow up in the progress notes regarding this incident for Resident #3 or Resident #4, including nursing, physician, or social worker notes. This incident was not reported to the S.A. An investigation report was provided upon request during the survey. 6/20/2021 22:56 [10:56 p.m.] Resident [#3] frequently raised his voice at his wife, [Resident #4] this evening. [Resident #3] was overheard telling [Resident #4] to 'shut up, lay [#4's] lazy ass down,' etc. Writer [DON] intervened and asked resident to not speak to [Resident #4] that way. [Resident #3] proceed [sic] to state [#3] will talk to [Resident #4] any way [#3] chooses too . This incident was reported to the S.A. late, on 6/22/21, once Surveyor reviewed this nursing progress note during the survey and asked the facility if they had reported the incident. An investigation report was provided upon request during the survey, once the incident was reported to the S.A. Review of the policy, Abuse Prohibition Policy, revised 07/2019, provided by the NHA, revealed, Each resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment .Allegations of resident abuse, exploitation, neglect, misappropriation of properly, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies (S.A.), physician, families, and/or representative .Abuse (definition) means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or 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. Verbal abuse is defined as the use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families .regardless of their age, ability to comprehend, or disability. Examples: Threats of harm; saying things to frighten a resident .yelling or hovering over a resident, mocking, insulting, ridiculing, harassing a resident .neglect is the failure of the facility, it's employees .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .Mistreatment means inappropriate treatment or exploitation of a resident. Exploitation means taking advantage of a resident for person gain through the use of manipulation, intimidation, threats, or coercion. Examples: .domestic violence and abuse .D. Identification. The facility Quality Assurance Performance Improvement Committee will investigate occurrences, patterns, and trends that may indicated the presence of abuse, neglect .and to determine the direction of the investigation .The Behavior Committee meets as needed to review residents with difficult or aggressive behaviors that may escalate into an abusive situation and determine appropriate interventions .E. Investigation. Allegations by anyone who becomes aware of verbal, physical, mental, sexual or emotional abuse and mistreatment, neglect, exploitation .must immediately report it to his/her Administrator. The DON or designee will complete an assessment of resident(s) and document findings in the medical record .An incident report will be completed .The licensed nurse will a. Notify the physician if required, b. Notify the family member/responsible party .A preliminary on-site investigation will be initiated within twenty-four (24) hours of any report .social services will provide follow-up counseling if abuse occurred. F. Protection of Residents during the Investigation .When a resident displays behavior against another resident that is suspected abuse, the residents will be separated from each other. A. Try to identify the incident or cause of the behavior. B. Attempt to remove the cause and calm the resident. c. If the resident is combative or aggressive, do not handle the resident in order to protect the resident and staff member form harm. D. Try to engage the resident in other activities away from the area where the behaviors occur .G. Reporting abuse and facility Response to the allegation. 1. The staff will report any allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property, injuries of unknown source to the Administrator and DON immediately. The Administrator or designee will notify the resident's representative. Also, any State of Federal agencies of allegations per state guidelines (2 hours if abuse allegation or serious injury; all others not later than 24 hours .).

This citation pertains to intake number MI 848. Based on interview and record review, the facility failed to properly assess, monitor and implement timely, appropriate care and treatment for one (#301) of four sampled residents reviewed for bowel management and hydration, resulting in development of fecal impaction, lethargy, confusion, dehydration, septic shock, emergency hospital treatment and death. Findings include: The complainant reported to the State agency that resident #301's (R301) bowel movements and fluid intake were not monitored leading to fecal impaction, bowel infection,[MEDICAL CONDITION] and death. Per the complainant, She complained a lot of being thirsty. She was weak when she got there (the facility) and needed help. The doctor at the hospital said that they pulled out a foot of stool and that she had an infection in her abdomen and was dehydrated. They said something was dying inside. They took her down to do surgery but could not do it because of the blood thinners she was taking. On [DATE] at 3 PM, the clinical record for R301 was reviewed. R301 was admitted into the facility on [DATE] following hospitalization for femoral artery occlusion and thrombectomy (removal of a blood clot). Other [DIAGNOSES REDACTED]. Constipation and dehydration were not listed in the record as [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted R301 was cognitively intact, was independent with eating but otherwise required extensive assistance for care, occasionally incontinent of urine and continent of bowel. R301 was prescribed the following medications on admission: Apixaban (blood thinner) 5 milligrams (mg) scheduled twice a day, [MEDICATION NAME] (nerve pain) 75 mg scheduled twice a day, [MEDICATION NAME] (iron for [MEDICAL CONDITION]) 325 mg scheduled once a day, [MEDICATION NAME] (diuretic for [MEDICAL CONDITION]) 20 mg scheduled once a day and [MEDICATION NAME] (opioid narcotic for pain) ,[DATE] mg every 4 hours PRN (as needed) for 7 days then changed to every 6 hours PRN. According to R301's ,[DATE]-,[DATE] Medication Administration Records (MAR), the medications were given every day during admission, including [MEDICATION NAME] most days. Two additional diuretics, [MEDICATION NAME] 50 mg scheduled daily and [MEDICATION NAME] 50 mg scheduled twice daily, were given until [DATE]. Per review of the website, Drugs.com: Common side effects of [MEDICATION NAME] and [MEDICATION NAME] included hard stools/constipation. Regarding [MEDICATION NAME]: side effects you are more likely to experience include: Dry mouth, thirst, weakness, muscle pains or cramps [MEDICATION NAME]'s effect is very strong. It can lead to a significant depletion of electrolytes which may lead to side effects such as muscle cramps severe renal impairment may affect laboratory test results. Older people may not respond as well to the initial diuretic effect of [MEDICATION NAME]. (MONTH) not be suitable for some people including those who are already electrolyte depleted or dehydrated. [MEDICATION NAME] (stool softener) tablets were also prescribed on admission every 12-hours PRN for constipation. The MAR indicated [REDACTED]. Nurses noted the following: [DATE]-Resident complains of constipation, requests PRN medication. [DATE] at 5:14 AM-PRN [MEDICATION NAME] given for constipation and was: Ineffective small bowel movement. At 1:23 PM--Skin turgor: 'Good' elasticity. [DATE] at 10:23 PM-Resident requests stool softener. [DATE] at 5:41 AM-PRN [MEDICATION NAME] given for constipation and was: Ineffective. Resident states that 'It hasn't worked yet but I think it will later today.' [DATE] at 9:22 PM-PRN [MEDICATION NAME] given for constipation. [DATE]-PRN [MEDICATION NAME] given for constipation and was: Ineffective. (This dose was not on the MAR.) On [DATE], Milk of Magnesia was prescribed every 24-hours PRN for constipation. There was no indication in nursing notes or the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Per a nursing note that day, Resident reports constipation. There were no available recorded bowel movements for R301 in the clinical record prior to [DATE]. When asked where the information was located, the Director of Nursing (DON) said it would be in the clinical record. Further progress notes for R301 were as follows: Physician note [DATE]-Chief complaint Complaining of rectal pain which is constant and not associated with bowel movements like a spasm Rectal pain with no history of hemorrhoids, but patient is relatively constipated, I will start [MEDICATION NAME] twice daily and rectal corticosteroids ([MEDICATION NAME] suppositories) for [MEDICAL CONDITION] control. There was no documented indication a rectal exam was performed. Per the MAR, R301 started receiving the suppositories each night and [MEDICATION NAME] was then scheduled twice a day instead of PRN. Physician note [DATE]-Patient has been complaining of rectal pain with no hematochezia (rectal bleeding) or severe constipation suppository was started. There was no documented indication a rectal exam was performed. Nursing note [DATE]-Skin turgor: 'Poor' elasticity (a sign of fluid loss/dehydration). Per a lab report of R301's electrolyte levels and kidney function dated [DATE]: Sodium low at 133 (normal range ,[DATE]), Chloride low at 91 (normal range ,[DATE]), BUN (blood urea nitrogen, amount of waste product in the blood determining kidney function) high at 56 (normal range ,[DATE]). These levels represented signs of possible dehydration. There were no other documented levels conducted by the facility in the clinical record. R301's Dehydration/potential fluid deficit due to diuretic use care plan, dated [DATE] noted: Goal-Will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor Interventions included: Encourage resident to drink fluids of choice, Observe and document intake and output as per facility policy, Observe and report to physician PRN signs/symptoms of dehydration: decreased or no urine output tenting skin (poor skin turgor) new onset confusion thirst, Obtain labs and diagnostics as ordered, report abnormal findings to the physician. There was no documented indication the physician was notified of the abnormal lab report on [DATE] or poor skin turgor and no indication in R301's care plans or notes of non-compliance or refusal to take in fluids. Bowel records noted on [DATE], R301 had one small, normal bowel movement. Physician note [DATE]-Chief complaint Patient has difficulty with urination, (at) times she does not void for ,[DATE] hours, and had difficult time voiding even at that time. She says this is new to her because usually she is having urinary urgency Rectal pain improved significantly Urinary hesitancy. Medications reviewed At this time post void residual (PVR-amount of urine left in the bladder after an attempt to empty it completely) will be checked in ,[DATE] occasions and we will go from that. No signs of urinary tract infection. Absence of urine output represented a sign of possible dehydration. There were no further documented physician progress notes [REDACTED]. Nursing note [DATE]-Resident examined by (physician), new order received PVR every shift times 2 shifts, notify physicians if PVR is greater than 200 (milliliters-ml) Skin turgor: 'Poor' elasticity. PVRs were checked on ,[DATE] and [DATE]. The MAR indicated [REDACTED]. Bowel records noted on [DATE] at 2:29 PM, R301 had one medium, normal bowel movement. At 5:23 PM, per a note by nurse 'A', a dose of Milk of Magnesia was given for constipation. The MAR indicated [REDACTED]. Nursing note [DATE] at 2:17 AM-Resident sent to hospital per Dr called for transportation at 10:58 (PM on [DATE]). Resident was lethargic, not appropriate with responses, pale, cold to the touch, blood pressure could not be obtained. 99.9 temperature, 115 pulse The MAR indicated [REDACTED]. On [DATE] at 3 PM, when asked what happened to R301, the DON said, She was transferred to the hospital and she died and said that she did not know the circumstances of death. She said, I would have to go through the record to figure it out. Hospital records were then requested from the DON. On [DATE] at 4 PM, nurse 'A' was asked about the Milk of Magnesia she had given R301 on [DATE]. Nurse 'A' said, She was pretty constipated. I noticed she hadn't had a bowel movement for a few days. I usually check, so I gave her something. The protocol is to give Milk of Magnesia after three days, wait 24-hours then give a suppository if that doesn't work, then an enema. On [DATE] at 4:30 PM, when asked about R301's bowel movement on [DATE] and her usual bowel pattern, the assigned nurse aide that day ('B') said, Her bowel movements were pretty small and had no further specific recall regarding R301. At 4:45 PM, the hospital records were reviewed and revealed the following: Death Discharge Summary Primary Discharge Diagnosis-Septic shock secondary to possible urinary tract infection versus significant colonic distention, stool burden (large amount of stool present), acute kidney injury (damage) Oliguria (inadequate fluid intake) Hypovolemic (fluid loss), [MEDICAL CONDITION] (low sodium level) Severe constipation, stool impaction Presenting problem altered mental status, septic shock Blood pressure dropped as low as ,[DATE] CAT scan of abdomen and pelvis showed a large stool burden and constipation Patient was severely dehydrated on exam and was given a significant amount of fluid resuscitation, due to impending [MEDICAL CONDITION], she was also intubated Nephrology performed [MEDICAL TREATMENT] however there was no significant change in renal function General surgery had performed a manual disimpaction (removal of stool by hand), and had planned for subsequent surgery on [DATE] however due to worsening INR of 10 (a test to determine how long it took for blood to clot, target range of ,[DATE]), significant change from prior INR of 3.2, surgery was deferred Patient continued to clinically deteriorate patient expired at 4:52 (PM on [DATE]) According to R301's Certificate of Death provided by the complainant, signed by a physician on [DATE]: Immediate cause of death: Colonic Ischemia (blocked blood flow to the colon); Conditions leading to immediate death: Colonic Obstruction; Disease or injury that initiated events resulting in death: Constipation. At 5 PM, when the DON was asked how and why R301 became impacted and dehydrated and asked what should have been done to prevent it, she said, If it were me, as a nurse, I would have checked into it and implemented something in three days and offered no further comments or information by survey exit at 5:30 PM. The physician was not available for comment. A bowel protocol policy was requested from the DON. She said there was no policy and provided a list of Physician's Standing Orders for bowels that noted: Milk of Magnesia 30 ml daily PRN for constipation. Ducolax Suppository daily PRN for constipation. Fleets enema daily PRN for constipation. Per review of the website, Mayoclinic.org: Risk factors for constipation include: ·Being an older adult ·Being a woman ·Being dehydrated ·Getting little or no physical activity ·Taking certain medications, including sedatives, narcotics, some antidepressants or medications to lower blood pressure. Complications include: ·Swollen veins in your anus (hemorrhoids). Straining to have a bowel movement may cause swelling in the veins in and around your anus. ·Torn skin in your anus (anal fissure). A large or hard stool can cause tiny tears in the anus. ·Stool that can't be expelled (fecal impaction). Chronic constipation may cause an accumulation of hardened stool that gets stuck in your intestines. Prevention to avoid development of constipation include: ·Drink plenty of fluids.

THIS CITATION PERTAINS TO INTAKE #: MI 420. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT MIStreatment of [REDACTED].#102 SUSTAINING A FRACTURED WRIST AND ELBOW AND RESIDENT #105 HAVING A TOWEL THROWN AT HER WHILE IN THE SHOWER, BEING LEFT ALONE TO PROVIDE CARE TO HERSELF. FINDINGS INCLUDE: RESIDENT#102: ACCORDING TO THE FACILITY'S INCIDENT REPORT AND NURSING PROGRESS NOTES, BOTH DATED 8/23/13, IT WAS DOCUMENTED THAT ON 8/22/13 AT 11:30 A.M., RESIDENT #102 WAS OBSERVED TO BE GUARDING HER RIGHT ARM; SAYING "OUCH" WHEN HER RIGHT ARM WAS TOUCHED; AND YELLOW BRUISING ON THE BACK OF HER RIGHT HAND. AN X-RAY WAS DONE ON RESIDENT #102'S RIGHT ARM ON 8/22/13 AND REVEALED RESIDENT #102 SUSTAINED AN ACUTE (NEW) DISPLACED [MEDICAL CONDITION] DISTAL ULNA (WRIST), AND INCOMPLETE FRACTURES OF THE RIGHT DISTAL RADIUS AND OLECRANON PROCESS (ELBOW). THE REPORT INDICATED RESIDENT #102 WAS DETERMINED TO HAVE MILD [MEDICAL CONDITION] AND MILD [MEDICAL CONDITION] IN THAT AREA. DURING AN INTERVIEW ON 9/4/13 AT 4:30 P.M., THE PHYSICIAN SAID HE EXAMINED RESIDENT #102 AND REVIEWED THE X-RAY REPORT FROM 8/22/13 AND "STRONGLY BELIEVED" THERE WAS NO WAY RESIDENT #102 COULD HAVE SUSTAINED THOSE TYPES OF INJURIES SPONTANEOUSLY AND IT "MOST LIKELY OCCURRED DURING A TRANSFER OR SPLINT APPLICATION BY A STAFF MEMBER THAT WAS FORCEFUL WITH RESIDENT #102'S CONTRACTED RIGHT ARM". DURING THE MEDICAL RECORD REVIEW ON 9/4/13 AT 11:00 A.M., IT WAS REVEALED RESIDENT #102 WAS admitted INto the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #102 WAS APHASIC (NOT ABLE TO SPEAK) AND HAD VERY LIMITED ABILITY TO VERBALLY EXPRESS HER NEEDS. RESIDENT #102 WAS ASSESSED TO BE TOTALLY PHYSICALLY DEPENDENT ON STAFF FOR ALL ASPECTS OF DAILY LIVING, AND HAD SEVERELY LIMITED RANGE OF MOTION WITH HER RIGHT ARM DUE TO CONTRACTURES. BENT UP TOWARD HER CHEST A REVIEW OF THE PHYSICIAN'S PROGRESS NOTES AND NURSING NOTES FROM 1/26/13 - 9/4/13, REVEALED THAT RESIDENT #102'S RIGHT ARM WAS SEVERELY CONTRACTED AT THE SHOULDER, ELBOW AND WRIST JOINTS SINCE THE TIME OF ADMISSION AND SHE WAS UNABLE TO MOVE IT VOLUNTARILY. THE CONTRACTURE DISTORTED THE RESIDENT'S RIGHT ARM AND WRIST, WITH THE WRIST FLEXING INWARD AND THE FOREARM FLEXED AND PULLED CLOSE TO THE BODY. RESIDENT #102 HAD THE FOLLOWING ORDERS DATED 7/2/13: RIGHT HAND SPLINT (A DEVICE USED TO GRADUALLY STRETCH THE CONTRACTURE) ON 2 HOURS AND THEN OFF 2 HOURS. A REVIEW OF THE MEDICATION ADMINISTRATION RECORDS FROM 7/1/13 - 9/4/13 REVEALED THAT RESIDENT #102'S SPLINT WAS APPLIED EVERY AND REMOVED EVERY TWO HOURS AS INSTRUCTED BY THE PHYSICIAN. DURING AN OBSERVATION ON 9/4/13 AT 9:30 A.M., RESIDENT #102 WAS FOUND RESTING ON HER BED WITH HER RIGHT WRIST/FOREARM WRAPPED IN AN ACE WRAP. RESIDENT #101 COULD NOT BE VERBALLY INTERVIEWED, BUT APPEARED ALERT AND WAS ABLE TO NOD HER HEAD AND APPROPRIATELY TRACKED MOVEMENT IN THE ROOM WITH HER EYES. RESIDENT #102'S RIGHT HAND AND FOREARM DID NOT HAVE ANY VISIBLE BRUISING AT THIS TIME. DURING AN INTERVIEW ON 9/5/13 AT 11:30 A.M., THE DIRECTOR OF NURSING REPORTED THAT DURING HER INVESTIGATION OF RESIDENT #102'S FRACTURES THAT WERE IDENTIFIED AND CONFIRMED WITH X RAY REPORT ON 8/23/13, THAT CNA "Q" REPORTED TO THE ADMINISTRATOR THE DAY BEFORE THE FRACTURES WERE IDENTIFIED (8/22/13) SHE HEARD CNA "F" HAD BEEN ROUGH AND INAPPROPRIATE WITH OTHER RESIDENTS. THE DIRECTOR OF NURSING SAID THAT DURING THIS INVESTIGATION INFORMATION SURFACED THAT ON 8/14/13 AT APPROXIMATELY 11:45 P.M., CNA "Q" NOTICED RESIDENT #102 WAS "GUARDING HER RIGHT ARM" AND IN VISIBLE PAIN AS EVIDENCED BY FACIAL GRIMACING. NURSING PROGRESS NOTES WERE REVIEWED AND THERE WAS NO ENTRY WRITTEN BY THE NURSING STAFF ON THAT DAY. THE DON REPORTED IT WAS DETERMINED THROUGH INVESTIGATION THAT CNA "F" PROVIDED CARE TO RESIDENT #102 ON 8/14/13 DURING THE 1ST SHIFT (7:00 AM - 3:00 P.M.). CNA "Q" WAS INTERVIEWED ON 9/6/13 AT 3:40 P.M. AND REPORTED THAT ON 8/14/13, RIGHT AT THE BEGINNING OF HER SHIFT (APPROXIMATELY 11:15 P.M.), SHE NOTICED THAT RESIDENT #102 WAS "OBVIOUSLY AND VISIBLY IN PAIN". RESIDENT #102 WAS GUARDING HER RIGHT ARM WITH HER LEFT HAND AND PULLED THE RIGHT ARM AWAY WHEN CNA "Q" ATTEMPTED TO TOUCH IT (THE RIGHT ARM). CNA "Q" FURTHER REPORTED RESIDENT #102 WAS ACTING COMPLETELY DIFFERENT THAN NORMAL AND WAS CLEARLY EXPRESSING PAIN BY WAY OF FACIAL GRIMACING AND NODDING HER HEAD WHEN ASKED IF HER ARM WAS HURTING. CNA "Q" SAID THAT SHE HAS CARED FOR RESIDENT #102 FOR OVER A YEAR AND KNEW THE RESIDENT'S MANNERISMS VERY WELL. CNA 'Q' SAID THAT SHE IMMEDIATELY NOTIFIED NURSE 'R' OF THE RESIDENT'S PAIN AND WAS TOLD TO JUST PUT THE SPLINT ON BECAUSE IT WAS JUST ARTHRITIS. CNA "Q" SAID SHE DID NOT PLACE THE SPLINT ON RESIDENT #102'S RIGHT ARM BECAUSE SHE DID NOT FEEL COMFORTABLE ABOUT IT. CNA "Q" WAS UNABLE TO RECALL WHETHER NURSE "R" CAME IN TO ASSESS RESIDENT #102 BECAUSE SHE (CNA 'Q') WENT TO CARE FOR ANOTHER RESIDENT. DURING AN INTERVIEW ON 9/9/13 AT 9:00 A.M., LICENSED PRACTICAL NURSE "R", WHO WAS ON DUTY THE MIDNIGHT SHIFT OF 8/14/13 SAID THAT SHE COULD NOT RECALL IF CNA "Q" TOLD HER THAT RESIDENT #102 WAS ACTING DIFFERENTLY OR HAD ANY BRUISING OR PAIN IN HER RIGHT ARM. THE DIRECTOR OF NURSING SAID THAT CNA 'F' WAS UNABLE TO BE DIRECTLY INTERVIEWED REGARDING THE FRACTURE INCIDENTS BECAUSE CNA 'F' HAS NOT SHOWN UP TO WORK SINCE THE DAY THE X-RAY REPORT REVEALED RESIDENT #102 SUSTAINED A FRACTURED WRIST AND ELBOW. THE DON SAID MESSAGES WERE LEFT FOR CNA "F" TO CONTACT THE FACILITY; HOWEVER, CNA "F" HAD NOT RETURNED PHONE CALLS. RESIDENT #105: DURING AN INTERVIEW ON 9/4/13 AT 1:35 P. M WITH RESIDENT #105, SHE SAID THAT A COUPLE WEEKS AGO, A CNA WAS RUDE TOWARDS HER AND THREW A TOWEL ON HER WHILE SHE WAS IN THE SHOWER ROOM. RESIDENT #105 SAID THAT AN UNIDENTIFIED CNA WAS ASSISTING HER IN THE SHOWER ROOM WHEN SHE (RESIDENT #105) ASKED THE CNA TO STOP WAVING THE TOWEL AROUND BECAUSE SHE WAS CAUSING A COOL BREEZE TO BLOW ON HER (THE RESIDENT). RESIDENT #105 SAID THE CNA THREW THE TOWEL ON THE RESIDENT AND SAID, "WELL YOU CAN JUST DO IT YOURSELF" AND WALKED OUT OF THE SHOWER ROOM. RESIDENT #105 ALSO SAID THE SAME CNA WAS ROUGH WITH HER DURING TRANSFERS FROM THE WHEELCHAIR TO THE BED AND ALWAYS PULLED ON HER LEFT ARM DURING TRANSFERS. RESIDENT #105 SAID, "IT SEEMED LIKE SHE DID NOT KNOW WHAT SHE WAS DOING". RESIDENT #105 SAID THAT SHE REPORTED THIS INCIDENT TO SOMEONE (UNIDENTIFIED) IN AN OFFICE AND THEN THE DIRECTOR OF NURSING CAME IN TO ASK HER ABOUT THE INCIDENT. RESIDENT # 105 SAID THAT THE CNA HAD NOT WORKED AT THE FACILITY VERY LONG AND HAS NOT BEEN SEEN SINCE SHE REPORTED THE INCIDENT. A MEDICAL RECORD REVIEW CONDUCTED ON 9/5/13 AT 3:00 P.M., REVEALED THAT RESIDENT #105 WAS AN [AGE] year OLD FEMALE WHO admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE] IDENTIFIED THE RESIDENT TO HAVE FULL COGNITIVE ABILITIES AND SCORED A 15 OUT OF 15 IN THE BIMS (BRIEF INTERVIEW FOR MENTAL STATUS). DURING AN INTERVIEW ON 9/5/13 AT 11:30 A.M., THE DIRECTOR OF NURSING SAID RESIDENT #105 WAS INTERVIEWED IN REGARD TO THE ALLEGATION AND THAT IT WAS SUBSTANTIATED THAT CNA 'F' HAD THROWN A TOWEL ON RESIDENT #105 AND THEN WALKED OUT OF THE SHOWER ROOM, LEAVING RESIDENT #105 UNATTENDED IN THE SHOWER ROOM. THE DIRECTOR OF NURSING SAID THAT CNA 'F' WAS INTERVIEWED REGARDING THE INCIDENT OVER THE TELEPHONE, BUT HAS NOT COME INTO THE FACILITY SINCE THAT TIME. ( )