Every finding on record at Lenawee Medical Care Facility

This Citation Pertains to Intake 2997912.Based on observation, interview and record review the facility failed to ensure one resident (resident #2) was free from physical restraints, resulting in anger frustration. Findings include:Review of Resident #2's (R2) clinical record, including the Minimum Data Set, dated [DATE] revealed R2 was an [AGE] year old male admitted to the facility on [DATE] with diagnoses of dementia, heart failure and adult failure to thrive. R2 scored 99 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and received hospice care. Review of R2's behavior care plan that was in place on 4/18/26, dated 01/02/26 identified R2 was resistant to care and could be combative with caregivers. R2's behavior care plan interventions in place on 4/18/26 included: approach slowly and identify yourself prior to initiating care, provide calming sensory interventions such as music, hand fidget, comfort items. Use calm, respectful and reassuring communication. Use non-verbal cues (smiling, nodding, gentle gestures). Use short simple, one step at a time directions. Review of the resident hospice care plans and hospice resident notes did not reflect any interventions that physical restraint was to be utilized when providing cares. Due to R2's cognition and inability to be interviewed, the reasonable person standard will be used for this citation. Physical restraints are defined as: The right to be free from any physical . restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with S483.12(a)(2). S483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. S483.12(a) The facility must- S483.12(a)(2) Ensure that the resident is free from physical . restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. Review of the facility reported incident dated 4/18/26 at 06:50 pm, revealed that Licensed Practical Nurse (LPN) I notified Quality Assurance Manager (QAM) D via phone about an allegation of abuse that occurred at 10:40 am that day. It was reported that Certified Nursing Assistant (CNA) G was in training and was paired with CNA E and F. CNA G made the allegation that CNA E and CNA F held R2 down and gave him Titty Twisters. A Titty Twister is known to the general public as the act of pinching and twisting a person's nipple roughly to inflict pain. Review of the witness statement dated 4/20/26 with CNA G conducted by Director of Nursing (DON) B, Human Resources (HR) J and QAM D. CNA G stated that on 4/18/26 at approximately 10:30 am, prior to entering R2's room, CNA E warned her that R2 was combative with care and upon entering the room R2 was lying in bed in preparation to have a brief change, and CNA F was already in the room. CNA G reported CNA E pushed on R2's shoulders to position R2 and that was when he began to get combative and refused to open his legs for care. CNA G then stated CNA E restricted R2's arms and CNA F held R2's legs. CNA G elaborated that she questioned CNA E about their methods of restraining R2 while providing care in which the CNA E replied that is how we have to do it. Review of the witness statement dated 4/20/26 with CNA E, conducted by DON B, HR J and QAM D, CNA E reported that on 4/18/26 at 10:30 am CNA F was already in the room and R2 needed his brief changed. The written statement reflected R2 was combative during care despite explaining care and that in her experience staff often have to hold him down to complete care due to R2's combative behavior. CNA E elaborated holding R2 down was for R2s safety and staff safety. Review of the witness statement dated 4/20/26 with CNA F, conducted by DON B, HR J and QAM D, CNA E reported that on 4/18/26 at 10:30 am she reported R2 became combative during care, but care was required to provide care so she held R2's legs while CNA E restricted R2's arms.On 5/12/26 at 1:00 pm, during an interview with QAM D she reported she conducted the investigation in collaboration with other management staff such as DON B and HR J and the facility's Abuse Prevention Coordinator /Nursing Home Administrator A. QAM D stated the facility did confirm that abuse had occurred. When queried what type of abuse was verified, QAM D stated physical and humiliation/mental. At this time, facility camera/video footage was viewed, the footage was dated 4/18/2026 and showed R2, and CNA E and CNA G sitting at the Nurses station. The footage showed CNA E fondling R2's right breast. Due to the angel of the camera and the fact that R2 wore a cowboy hat, R2's facial expression was difficult to read. Of note, there was no audio to the video. QAM D provided an untitled packet of papers that alleged the facility was in compliance as of 5/01/26, however the packet provided did not determine what the facility's deficient practice was. On 5/13/26 an updated and untitled packet of papers was provided and alleged a compliance date of 5/13/26 with F tag 600 though the written packet did not determine what type of abuse was inflicted upon R2. The information in part reflected CNA E and F were suspended pending investigation and prior to returning to work, the staff directly involved (CNA E and CNA F) were educated on professional boundaries, abuse prevention, resident rights, and appropriate management of combative residents without the use of force or restraint. On 5/12/26 at 1:49 pm, during an interview with CNA E she readily admitted that it was routine practice to restrain R2 during care. CNA E reported this was a normal standard and it was how everybody takes care of R2. CNA E elaborated on how terrible R2's behaviors are. Stating that management knows about R2's behaviors and nobody does anything, thus they (staff) have no other choice but to hold R2 down. CNA E elaborated she was familiar with all the federal regulations and that staff are required to provide care and that is what they do. CNA E went on to say that she knows her rights and she has the right to work in an abuse free environment. Stating that the staff only restrain R2's arms and legs to protect themselves, again CNA E repeated staff had the right to work in a safe environment and in CNA Es opinion it was not safe and management was not doing anything about it. When queried if staff enlisted assistance from the Nurse, CNA E stated no. When queried if they tried leaving R2 alone and reapproaching him after R2 settled down, CNA E stated no. CNA E reiterated she knew the federal regulations and if she left R2 alone that would be neglect. When queried if CNA E referenced R2's care plan or Kardex for approaches, CNA E stated R2 did not have any behavior interventions in place on 4/18 or today. At this time CNA E and this surveyor went to R2's room. R2 was observed resting in bed, made eye contact but did not speak upon approach. CNA E went to R2's closet and there was a Kardex in place that listed approaches on how to care for and what approaches to try when/if R2 becomes combative. When queried about the Kardex again, CNA E stated someone must have just put it in R2's closet. When queried about restraining R2 for care, CNA E again reverted back to that was how staff provided care to R2 based on R2's actions/behavior and CNA E had the right to work in a nonviolent atmosphere. When queried if CNA E thought it was ok to restrain R2 to provide care, CNA E stated it was absolutely ok and reverted back to her right to have violent free workplace. The reasonable person would find it unacceptable to being forcibly held down during care. During an interview with CNA G on 5/12/26 at 2:31pm, CNA G stated 4/18/26 was her third day in orientation and she was shadowing CNA E, CNA G stated while on the way to R2's room CNA E was complaining about how hard it was to take care of him and how R2 always fights them. CNA G stated upon entering the room, R2 was on the bed and CNA F was already in the room and CNA E started the interaction being aggressive as if she were preparing for R2 to be aggressive in return. CNA G said she was there to observe and learn but instead observed CNA E stern fully and forcefully take R2 by the shoulders and push down on R2 on the bed. CNA G stated after that interaction R2 became angry and was yelling, cussing and trying to hit and kick at them. CNA G stated CNA E held R2's arms down while CNA F held R2's legs. CNA G stated the interaction was crazy and she did not know what to do. On 5/13/26 at 9:53am during an interview with CNA F she reported she barely remembered anything about 4/18/26 aside from being suspended. CNA F stated it was a normal day, and her partner (CNA E) had an orientee with her (CNA G). CNA F stated they got transferred to the dementia unit unwillingly a few months ago and R2 was his normal aggressive self that day. CNA F elaborated they have to hold R2 down because R2 fights, kicks and spits at them. When queried if they asked the Nurse for assistance, CNA F stated no, there was no reason to get the nurse. Stating she and CNA E worked well together, and they were always able to handle R2 without enlisting the nurse's help. Using the reasonable person standard, a cognitively intact resident would not accept being held down, have their arms and legs held constricting their movement. On 5/13/26 at 3:00 pm during a phone interview with Director of Nursing (DON) B, she reported the facility was working on learning R2's preferences for care which included R2 being an active participant and offered no additional information. Based on interviews conducted on 5/12 and 5/13 with both CNA E and CNA F it was evident CNA E and CNA F had previously completed dementia care training however they failed to apply, implement and demonstrate an understanding of what was taught regarding professional boundaries, abuse prevention, resident rights, and appropriate management of combative residents without the use of force or restraint. The reasonable person would expect to receive care without the use of physical force and being held down. Review of the facility policy titled Restraint Free Environment dated 02/2022 reviewed 02/2026. Policy Statement: It is the policy of this facility that each resident shall attain and maintain his/her practical wellbeing in an environment that prohibits the use of restraints for discipline or convenience and limits the use of restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. The policy defined physical restraint as refers to any manual method or physical or mechanical or material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access of one's body. Physical restraints include but are not limited to .holding down a resident in response to a behavior symptom, or during a provision of care if the resident is resistive or refusing care.

This Citation Pertains to Intake 2997912.Based on observations/interviews and record review, the facility failed to protect the resident's right to be free from of physical and mental abuse perpetrated by staff for one resident (Resident #2) of three reviewed. Resulting in R2 being abused by staff. Findings include:Review of Resident #2's (R2) clinical record, including the Minimum Data Set, dated [DATE] revealed R2 was an [AGE] year old male admitted to the facility on [DATE] with diagnoses of dementia, heart failure and adult failure to thrive. R2 scored 99 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and received hospice care. Review of R2's behavior care plan that was in place on 4/18/26, dated 01/02/26 identified R2 was resistant to care and could be combative with caregivers. R2's behavior care plan interventions in place on 4/18/26 included: approach slowly and identify yourself prior to initiating care, provide calming sensory interventions such as music, hand fidget, comfort items. Use calm, respectful and reassuring communication. Use non-verbal cues (smiling, nodding, gentle gestures). Use short simple, one step at a time directions. Review of the resident hospice care plans and hospice resident notes did not reflect any interventions that physical restraint was to be utilized when providing cares. Due to R2's cognition and inability to be interviewed, the reasonable person standard will be used for this citation. Abuse, is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Neglect, as defined at S483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Sexual abuse, is defined at S483.5 as non-consensual sexual contact of any type with a resident. Willful, as defined at S483.5 in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Review of the facility reported incident dated 4/18/26 at 06:50 pm, revealed that Licensed Practical Nurse (LPN) I notified Quality Assurance Manager (QAM) D via phone about an allegation of abuse that occurred at 10:40 am that day. It was reported that Certified Nursing Assistant (CNA) G was in training and was paired with CNA E and F. CNA G made the allegation that CNA E and CNA F held R2 down and gave him Titty Twisters. A Titty Twister is known to the general public as the act of pinching and twisting a person's nipple roughly to inflict pain. The allegation became reported due a group chat amongst new employees, the group chat reflected CNA G was disturbed by a series of events that she witnessed on 4/18/26 that involved R2, CNA E and CNA F. Review of the witness statement dated 4/20/26 with CNA G conducted by Director of Nursing (DON) B, Human Resources (HR) J and QAM D. CNA G stated that on 4/18/26 at approximately 10:30 am, prior to entering R2's room, CNA E warned her that R2 was combative with care and upon entering the room R2 was lying in bed in preparation to have a brief change, and CNA F was already in the room. CNA G reported CNA E pushed on R2's shoulders to position R2 and that was when he began to get combative and refused to open his legs for care. CNA G then stated CNA E restricted R2's arms and CNA F held R2's legs. CNA G elaborated that she questioned CNA E about their methods of restraining R2 while providing care in which the CNA E replied that is how we have to do it. The written interview statement then reflected that at approximately 1:00 to 1:30 pm while sitting at the nurses' station with R2 and CNA E , CNA E said Titty Twister then performed the action on R2. CNA G statement revealed R2 looked surprised by CNA E's action. Review of the witness statement dated 4/20/26 with CNA E, conducted by DON B, HR J and QAM D, CNA E reported that on 4/18/26 at 10:30 am CNA F was already in the room and R2 needed his brief changed. The written statement reflected R2 was combative during care despite explaining care and that in her experience staff often have to hold him down to complete care due to R2's combative behavior. CNA E elaborated holding R2 down was for R2s safety and staff safety. According to the written statement when CNA E was question about the Titty Twister CNA E stated that was clearly a joke and denied making physical contact. Review of the witness statement dated 4/20/26 with CNA F, conducted by DON B, HR J and QAM D, CNA E reported that on 4/18/26 at 10:30 am she reported R2 became combative during care, but care was required so she held R2's legs while CNA E restricted R2's arms.Review of witness statement dated 4/20/26 with Housekeeper H she reported she witnessed CNA E and CNA G at the nurses' station with R2. Housekeeper H stated while cleaning a room she could hear laughing at the nurses' station and overheard a comment, she then exited the room and asked about the comment that was made and CNA E replied Titty Twister.On 5/12/26 at 1:00 pm, during an interview with QAM D she reported she conducted the investigation in collaboration with other management staff such as DON B and HR J and the facility's Abuse Prevention Coordinator /Nursing Home Administrator A. QAM D stated the facility did confirm that abuse had occurred. When queried what type of abuse was verified, QAM D stated physical and humiliation/mental. At this time, camera/video footage was viewed, the footage was dated 4/18/2026 and showed R2, and CNA E and CNA G sitting at the Nurses station. The footage showed CNA E fondling R2's right breast. Due to the angel of the camera and the fact that R2 wore a cowboy hat, R2's facial expression was difficult to read. Of note, there was no audio to the video. QAM D provided an untitled packet of papers that alleged the facility was in compliance as of 5/01/26, however the packet provided did not determine what the facility's deficient practice was. On 5/13/26 an updated and untitled packet of papers was provided and alleged a compliance date of 5/13/26 with F tag 600 though the written packet did not determine what type of abuse was inflicted upon R2. The information in part reflected CNA E and F were suspended pending investigation and prior to returning to work, the staff directly involved (CNA E and CNA F) were educated on professional boundaries, abuse prevention, resident rights, and appropriate management of combative residents without the use of force or restraint.On 5/12/26 at 1:49 pm, during an interview with CNA E she readily admitted that it was routine practice to restrain R2 during care. CNA E reported this was a normal standard and it was how everybody takes care of R2. CNA E elaborated on how terrible R2's behaviors are, that management knows about R2's behaviors and nobody does anything, thus they (staff) have no other choice but to hold him down. CNA E elaborated she was familiar with all the federal regulations and that staff are required to provide care and that is what they do. CNA E went on to say that she knows her rights and she has the right to work in an abuse free environment. Stating that the staff only restrain R2's arms and legs to protect themselves, again repeating staff has the right to work in a safe environment. Stating in CNA Es opinion it was not safe and management was not doing anything about it. When quired if staff enlisted assistance from the Nurse, CNA E stated no. When queried if they tried leaving R2 alone and reapproaching him after R2 settle down, CNA E stated no. CNA E reiterated she knew the regulations and if she left R2 alone that would be neglect. When queried if she referenced R2's care plan or Kardex for approaches, CNA E stated R2 did not have any behavior interventions in place on 4/18 or today.At this time CNA E and this surveyor went to R2's room. R2 was resting in bed, made eye contact but did not speak upon approach. CNA E went to R2's closet and there was a Kardex in place that listed approaches on how to care for and what approaches to try when/if R2 becomes combative. When queried about the Kardex again, CNA E stated someone must have just put it in R2's closet. When queried about restraining R2 for care, CNA E again reverted back to that was how they provided care to R2 based on R2's actions/behavior. CNA E stated she had the right to work in a nonviolent atmosphere. When CNA E was queried about giving R2 a Titty Twister CNA E reported she never touched R2. When it was explained this surveyor watched the video from 4/18/26, CNA E then stated Well it was just a joke! When queried if CNA E thought it was acceptable to restrain a resident to provide care, CNA E stated absolutely. Again, CNA E reiterated how she needed to keep herself safe and had no other alternative. Using the reasonable person standard, a cognitively intact person would not find it acceptable to be held down during care, nor would the reasonable person find it funny or a joke to have their breast fondled and then laughed at by staff. During an interview with CNA G on 5/12/26 at 2:31pm, CNA G stated 4/18/26 was her third day in orientation and she was shadowing CNA E, CNA G stated while on the way to R2's room CNA E was complaining about how hard it was to take care of R2 and how R2 always fights them. CNA G stated R2 was on the bed and CNA F was already in the room and CNA E started the interaction being aggressive as if she were preparing for R2 to be aggressive in return. CNA G said she was just there to observe and learn and she the witnessed CNA E stern fully and forcefully take R2 by the shoulders and push down on R2 on the bed. CNA G stated after that interaction R2 became angry and was yelling, cussing and trying to hit and kick at them. CNA G stated CNA E held R2's arms down while CNA F held his legs. CNA G stated the interaction was crazy and she did not know what to do. CNA G said then a few hours later while sitting at the nurses' station with R2 and CNA E you could feel the tension between R2 and CNA E. CNA G stated R2 and CNA E were across from CNA G. CNA G stated at this time out of nowhere CNA E started laughing and yelled Titty Twister and then completed the action. CNA G stated CNA E was laughing and R2 looked shocked and then smiled. CNA G stated she gave a nervous laugh because the whole day CNA G felt confused and awkward. CNA G elaborated that later that day R2 went into another resident room and took their scarfs, at which time she reported she observed CNA E yank the scarfs out of R2's hands, R2 in turn replied Give me my s**t back and CNA E responded It's not your s**t and walked away. CNA G stated all of this was reported to a panel of people whom she had already given a statement to. The reasonable person would not expect items to be yanked out of their hands, or the use of profanity foul language from a caregiver.On 5/13/26 at 9:53am during an interview with CNA F she reported she barely remembered anything about 4/18/26 aside from being suspended. CNA F stated it was a normal day, and her partner (CNA E) had an orientee with her (CNA G). CNA F stated they got transferred to the dementia unit where R2 resides, unwillingly a few months ago and R2 was his normal aggressive self that day. CNA F elaborated they have to hold R2 down because R2 fights, kicks and spits at them. When queried if they asked the Nurse for assistance when R2 becomes combative or resistant to care, CNA F stated no, there was no reason to get the nurse. Stating she and CNA E worked well together and could handle it. When queried about interventions CNA F stated one of the interventions was to wear a face shield because R2 spits at them, but they don't do those interventions. When asked why, CNA F reported the afternoon shift asked her a few days ago about the interventions and CNA F stated she told them not to bother, they don't work and, in her opinion, may possibly trigger R2. CNA F elaborated management was aware of R2's behavior and did nothing about it. When queried if CNA F documented R2's behaviors for 4/18/26 or reported to the Nurse or management that she felt the behavior interventions listed for R2 were not effective or may trigger R2, CNA F stated Well I mean, don't know that was a long time ago. Of note, the behavior tracking for R2 on 4/18/26 had no documented behaviors. When queried if the facility provided dementia care training and abuse prevention training, CNA F stated yes, but it's all online and there was nothing offered for in person for training/education on dementia care and behaviors. The reasonable person would expect to be treated with dignity and respect and not be held down. During a phone interview on 5/13/26 at 10:17 am, with Housekeeper H she reported she observed R2, CNA E and CNA G sitting at the nurses' station on 4/18/26, while entering a nearby room she was going to clean. Housekeeper H stated she thought she overheard CNA E say something pretty inappropriate followed by laughter, Housekeeper H stated she stepped out of the room and asked CNA E what did you say?' and CNA E replied Titty Twister and erupted in laughter again. Housekeeper H stated I guess I did hear it right the first time. Based on interviews conducted on 5/12 and 5/13 with both CNA E and CNA F it was evident CNA E and CNA F received some training on dementia care however, they failed to apply, implement and demonstrate an understanding of what they had been taught regarding professional boundaries, abuse prevention, resident rights, and appropriate management of combative residents without the use of force or restraint.On 5/13/26 at 12:25 pm during an interview with NHA A identified herself as the abuse prevention coordinator, QAM D participated in the interview. The facility reported incident was reviewed. NHA A and QAM D agreed abuse had occurred.

This Citation Pertains to Intake 2997912.Based on observations/interviews and record review, the facility failed to preserve the dignity and right to make choices including the refusal of care for one resident (Resident #2) of three reviewed. Findings include:Review of Resident #2's (R2) clinical record, including the Minimum Data Set, dated [DATE] revealed R2 was an [AGE] year old male admitted to the facility on [DATE] with diagnoses of dementia, heart failure and adult failure to thrive. R2 scored 99 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and was receiving hospice care. Review of R2's behavior care plan that was in place on 4/18/26, dated 01/02/26 identified R2 was resistant to care and could be combative with caregivers. R2's behavior care plan interventions in place on 4/18/26 included: approach slowly and identify yourself prior to initiating care, provide calming sensory interventions such as music, hand fidget, comfort items. Use calm, respectful and reassuring communication. Use non-verbal cues (smiling, nodding, gentle gestures). Use short simple, one step at a time directions. Due to R2's cognition and inability to be interviewed, the reasonable person standard will be used for this citation. Review of the facility reported incident dated 4/18/26 at 06:50 pm, revealed that Licensed Practical Nurse (LPN) I notified Quality Assurance Manager (QAM) D via phone about an allegation of abuse that occurred at 10:40 am that day. It was reported that Certified Nursing Assistant (CNA) G was in training and was paired with CNA E and F. CNA G made the allegation that CNA E and CNA F held R2 down and gave him Titty Twisters. A Titty Twister is known to the general public as the act of pinching and twisting a person's nipple roughly to inflict pain. Review of the witness statement dated 4/20/26 with CNA G conducted by Director of Nursing (DON) B, Human Resources (HR) J and QAM D. CNA G stated that on 4/18/26 at approximately 10:30 am, prior to entering R2's room, CNA E warned CNA G that R2 was combative with care and upon entering the room R2 was lying in bed in preparation to have a brief change, and CNA F was already in the room. CNA G reported CNA E pushed on R2's shoulders to position R2 and that was when he began to get combative and refused to open his legs for care. CNA G then stated CNA E restricted R2's arms and CNA F held R2's legs. CNA G elaborated that she questioned CNA E about their methods of restraining R2 while providing care in which the CNA E replied that is how we have to do it. The written interview statement then reflected that at approximately 1:00 to 1:30 pm while sitting at the nurses' station with R2 and CNA E, CNA E said Titty Twister then performed the action on R2. CNA G statement revealed R2 looked surprised by CNA E's action. Review of the witness statement dated 4/20/26 with CNA E, conducted by DON B, HR J and QAM D, CNA E reported that on 4/18/26 at 10:30 am CNA F was already in the room and R2 needed his brief changed. The written statement reflected R2 was combative during care despite explaining care and that in her experience staff often have to hold him down to complete care due to R2's combative behavior. CNA E elaborated holding R2 down was for R2s safety and staff safety. According to the written statement when CNA E was question about the Titty Twister CNA E stated that was clearly a joke and denied making physical contact. Review of the witness statement dated 4/20/26 with CNA F, conducted by DON B, HR J and QAM D, CNA E reported that on 4/18/26 at 10:30 am she reported R2 became combative during care, but care was required so she held R2's legs while CNA E restricted R2's arms.Review of witness statement dated 4/20/26 with Housekeeper H she reported she witnessed CNA E and CNA G at the nurses' station with R2. Housekeeper H stated while cleaning a room she could hear laughing at the nurses' station and overheard a comment, she then exited the room and asked about the comment that was made and CNA E replied Titty Twister.On 5/12/26 during an interview with QAM D she provided an untitled packet of papers that alleged the facility was in compliance as of 5/01/26, however the packet provided did not determine what the facility's deficient practice was. On 5/13/26 an updated and untitled packet of papers was provided and alleged a compliance date of 5/13/26 with F tag 600 though the written packet did not determine what type of abuse was inflicted upon R2. The information in part reflected CNA E and F were suspended pending investigation and prior to returning to work, the staff directly involved (CNA E and CNA F) were educated on professional boundaries, abuse prevention, resident rights, and appropriate management of combative residents without the use of force or restraint. On 5/12/26 at 1:49 pm, during an interview with CNA E she readily admitted that it was routine practice to restrain R2 during care. CNA E reported this was a normal standard and it was how everybody takes care of R2. CNA E elaborated on how terrible R2's behaviors are, that management knows about R2's behaviors and nobody does anything, thus they (staff) have no other choice but to hold him down. CNA E elaborated she was familiar with all the federal regulations and that staff are required to provide care and that is what they do. CNA E went on to say that she knows her rights and she has the right to work in an abuse free environment. Stating that staff only hold R2's arms and legs to protective themselves, again repeating staff has the right to work in a safe environment. Adding, in CNA Es opinion it was not safe and management was not doing anything about it. When quired if staff enlisted assistance from the Nurse, CNA E stated no. When queried if they tried leaving R2 alone and reapproaching him after R2 settle down, CNA E stated no. CNA E reiterated she knew the regulations and if she left R2 alone that would be neglect. When queried if R2 had the right to refuse care, CNA E said she had to provide care, and it was R2 right to not to be neglected. When CNA E was queried about giving R2 a Titty Twister CNA E reported she never physically touched R2. When it was explained this surveyor watched the video, CNA E then stated Well it was just a joke! When quired if using the reasonable person standard if touching another person's breast, male or female without consent then laughing would be as humiliating or degrading? CNA E repeated it was just a joke. Using the reasonable person standard, having your breast fondled, being laughed at by your caregivers is not promoting dignity, respect or a joke.During an interview with CNA G on 5/12/26 at 2:31pm, CNA G stated 4/18/26 was her third day in orientation and she was shadowing CNA E, CNA G stated while on the way to R2's room CNA E was complaining about how hard it was to take care of R2 and how R2 always fights them. CNA G stated R2 was on the bed and CNA F was already in the room and CNA E started the interaction being aggressive as if she were preparing for R2 to be aggressive in return. CNA G said she was just there to observe and learn and she the witnessed CNA E stern fully and forcefully take R2 by the shoulders and push down on R2 on the bed. CNA G stated after that interaction R2 became angry and was yelling, cussing and trying to hit and kick at them. CNA G stated CNA E held R2's arms down while CNA F held his legs. CNA G stated the interaction was crazy and she did not know what to do. CNA G said then a few hours later while sitting at the nurses' station with R2 and CNA E you could feel the tension between R2 and CNA E. CNA G stated R2 and CNA E were across from CNA G. CNA G stated at this time out of nowhere CNA E started laughing and yelled Titty Twister and then completed the action. CNA G stated CNA E was laughing and R2 looked shocked and then smiled. CNA G stated she gave a nervous laugh because the whole day CNA G felt confused and awkward. CNA G elaborated that later that day R2 went into another resident room and took their scarfs, at which time she reported she observed CNA E yank the scarfs out of R2's hands, R2 in turn replied Give me my s**t back and CNA E responded It's not your s**t and walked away. CNA G stated all of this was reported to a panel of people whom she had already given a statement to a few days after this happened. Using the reasonable person standard, it would not be acceptable behavior for a caregiver to yank items from a resident and use profanity foul language with a resident. On 5/13/26 at 9:53am during an interview with CNA F she reported she barely remembered anything about 4/18/26 aside from being suspended. CNA F stated it was a normal day, and her partner (CNA E) had an orientee with her (CNA G). CNA F stated they got transferred to the dementia unit unwillingly a few months ago and R2 was his normal aggressive self. CNA F elaborated they have to hold R2 down because he fights, kicks and spits at them. When queried if the asked the Nurse for assistance, CNA F stated no, there was no reason to get the nurse. Stating her and CNA E could handle it. When queried why they didn't stop the interaction, since R2's was trying to refuse services, CNA F stated they had to provide care and that was how they always did it. During a phone interview on 5/13/26 at 10:17 am, with Housekeeper H she reported she observed R2, CNA E and CNA G sitting at the nurses' station on 4/18/26, while entering a nearby room she was going to clean. Housekeeper H stated she thought she overheard CNA E say something pretty inappropriate followed by laughter, Housekeeper H stated she stepped out of the room and asked CNA E what did you say?' and CNA E replied Titty Twister and erupted in laughter again. Housekeeper H stated I guess I did hear it right the first time. On 5/12/26 at 1:00 pm, during an interview with QAM D she reported she conducted the investigation in collaboration with other management staff such as DON B and HR J and the facility's Abuse Prevention Coordinator /Nursing Home Administrator A. QAM D stated the facility did confirm that physical abuse had occurred. At this time, camera/video footage was viewed, the footage was dated 4/18/2026 and showed R2, and CNA E and CNA G sitting at the Nurses station. The footage showed CNA E touching and tickling R2's breast. Due to the angel of the camera and the fact that R2 wore a cowboy hat, R2's facial expression was difficult to read. Of note, there was no audio to the video. QAM D was queried about the video she agreed using the reasonable person standard it would be humiliating to be touched like that and laughed at. QAM D also acknowledged that R2 had the right to refuse care. Although record review of CNA E and CNA F files reflected education on professional boundaries, abuse prevention, resident rights, and appropriate management of combative residents without the use of force or restraint. CNA E and CNA F have failed to apply, implement and demonstrate an understanding of what they had been taught. On 5/13/26 at 12:25 pm during an interview with NHA A identified herself as the abuse prevention coordinator, QAM D participated in the interview the facility reported incident was reviewed. NHA A and QAM D agreed abuse had occurred.

This Citation Pertains to Intake 2997912.Based on observations, interviews and record review, the facility failed to develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.for one resident (Resident #2) of three reviewed.Findings include:Review of Resident #2's (R2) clinical record, including the Minimum Data Set, dated [DATE] revealed R2 was an [AGE] year old male admitted to the facility on [DATE] with diagnoses of dementia, heart failure and adult failure to thrive. R2 scored 99 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and received hospice care. Thus, the reasonable person standard will be used for this citation. Review of the facility reported incident dated 4/18/26 at 06:50 pm, revealed that Licensed Practical Nurse (LPN) I notified Quality Assurance Manager (QAM) D via phone about an allegation of abuse that occurred at 10:40 am that day. It was reported that Certified Nursing Assistant (CNA) G was in training was in paired with CNA E and F. CNA G made the allegation that CNA E and CNA F held R2 down and gave him Titty Twisters. A Titty Twister is known to the general public as the act of pinching and twisting a person's nipple roughly to inflict pain. Review of the witness statement dated 4/20/26 with CNA G conducted by Director of Nursing (DON) B, Human Resources (HR) J and QAM D. CNA G stated that on 4/18/26 at approximately 10:30 am, prior to entering R2's room, CNA E warned her that R2 was combative with care and upon entering the room R2 was lying in bed in preparation to have a brief change, and CNA F was already in the room. CNA G reported CNA E pushed on R2's shoulders to position R2 and that was when he began to get combative and refused to open his legs for care. CNA G then stated CNA E restricted R2's arms and CNA F held R2's legs. CNA G elaborated that she questioned CNA E about their methods of restraining R2 while providing care in which the CNA E replied that is how we have to do it. The written interview statement then reflected that at approximately 1:00 to 1:30 pm while sitting at the nurses' station with R2 and CNA E , CNA E said Titty Twister then performed the action on R2. CNA G statement revealed R2 looked surprised by CNA E's action. Review of the witness statement dated 4/20/26 with CNA E, conducted by DON B, HR J and QAM D, CNA E reported that on 4/18/26 at 10:30 am CNA F was already in the room and R2 needed his brief changed. The written statement reflected R2 was combative during care despite explaining care and that in her experience staff often have to hold him down to complete care due to R2's combative behavior. CNA E elaborated holding R2 down was for R2s safety and staff safety. According to the written statement when CNA E was question about the Titty Twister CNA E stated that was clearly a joke and denied making physical contact. Review of the witness statement dated 4/20/26 with CNA F, conducted by DON B, HR J and QAM D, CNA E reported that on 4/18/26 at 10:30 am she reported R2 became combative during care, but care was required so she held R2's legs while CNA E restricted R2's arms.Review of witness statement dated 4/20/26 with Housekeeper H she reported she witnessed CNA E and CNA G at the nurses' station with R2. Housekeeper H stated while cleaning a room she could hear laughing at the nurses' station and overheard a comment, she then exited the room and asked about the comment that was made and CNA E replied Titty Twister.On 5/12/26 at 1:00 pm, during an interview with QAM D she reported she conducted the investigation in collaboration with other management staff such as DON B and HR J and the facility's Abuse Prevention Coordinator /Nursing Home Administrator A. QAM D stated the facility did confirm that physical abuse had occurred. On 5/13/26 at 12:25 pm during an interview with NHA A and QAM D the facility reported incident was reviewed. The facility reported incident dated 4/18/26 read in part, Type of alleged incident: Abuse Was the alleged incident verified (substantiated): Yes Suspected Crime: No Was law enforcement contacted: No. During the interview NHA A and QAM D each agreed abuse was inflicted upon R2. When queried why the local Police Department was not notified of the abuse neither NHA A or QAM D responded.

This Citation Pertains to Intake 2997912Based on observation, interview and record review, the facility failed to ensure the protection of residents from abuse for one (Resident #2) of three residents reviewed, resulting in the potential for continued abuse. Findings include:Review of Resident #2's (R2) clinical record, including the Minimum Data Set, dated [DATE] revealed R2 was an [AGE] year old male admitted to the facility on [DATE] with diagnoses of dementia, heart failure and adult failure to thrive. R2 scored 99 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and received hospice care. Thus, the reasonable person standard will be used for this citation. Review of the facility reported incident dated 4/18/26 at 06:50 pm, revealed that Licensed Practical Nurse (LPN) I notified Quality Assurance Manager (QAM) D via phone about an allegation of abuse that occurred at 10:40 am that day. It was reported that Certified Nursing Assistant (CNA) G was in training was in paired with CNA E and F. CNA G made the allegation that CNA E and CNA F held R2 down and gave R2 a Titty Twisters. A Titty Twister is known to the general public as the act of pinching and twisting a person's nipple roughly to inflict pain. Review of the witness statement dated 4/20/26 with CNA G conducted by Director of Nursing (DON) B, Human Resources (HR) J and QAM D. CNA G stated that on 4/18/26 at approximately 10:30 am, prior to entering R2's room, CNA E warned her that R2 was combative with care and upon entering the room R2 was lying in bed in preparation to have a brief change, and CNA F was already in the room. CNA G reported CNA E pushed on R2's shoulders to position R2 and that was when he began to get combative and refused to open his legs for care. CNA G then stated CNA E restricted R2's arms and CNA F held R2's legs. CNA G elaborated that she questioned CNA E about their methods of restraining R2 while providing care in which the CNA E replied that is how we have to do it. The written interview statement then reflected that at approximately 1:00 to 1:30 pm while sitting at the nurses' station with R2 and CNA E , CNA E said Titty Twister then performed the action on R2. CNA G statement revealed R2 looked surprised by CNA E's action. Review of the witness statement dated 4/20/26 with CNA E, conducted by DON B, HR J and QAM D, CNA E reported that on 4/18/26 at 10:30 am CNA F was already in the room and R2 needed his brief changed. The written statement reflected R2 was combative during care despite explaining care and that in her experience staff often have to hold him down to complete care due to R2's combative behavior. CNA E elaborated holding R2 down was for R2s safety and staff safety. According to the written statement when CNA E was question about the Titty Twister CNA E stated that was clearly a joke and denied making physical contact. Review of the witness statement dated 4/20/26 with CNA F, conducted by DON B, HR J and QAM D, CNA E reported that on 4/18/26 at 10:30 am she reported R2 became combative during care, but care was required so she held R2's legs while CNA E restricted R2's arms.Review of witness statement dated 4/20/26 with Housekeeper H she reported she witnessed CNA E and CNA G at the nurses' station with R2. Housekeeper H stated while cleaning a room she could hear laughing at the nurses' station and overheard a comment, she then exited the room and asked about the comment that was made and CNA E replied Titty Twister.On 5/12/26 at 1:00 pm, during an interview with QAM D she reported she conducted the investigation in collaboration with other management staff such as DON B and HR J and the facility's Abuse Prevention Coordinator /Nursing Home Administrator A. QAM D stated the facility did confirm that abuse had occurred. When queried what type of abuse was verified, QAM D stated physical and humiliation/mental. At this time facility camera/video footage was viewed, the footage was dated 4/18/2026 and showed R2, and CNA E and CNA G sitting at the Nurses station. The footage showed CNA E fondling R2's right breast. Due to the angel of the camera and the fact that R2 wore a cowboy hat, R2's facial expression was difficult to read. Of note, there was no audio to the video. QAM D provided an untitled packet of papers that alleged the facility was in compliance as of 5/01/26, however the packet provided did not determine what the facility's deficient practice was. On 5/13/26 an updated and untitled packet of papers was provided and alleged a compliance date of 5/13/26 with F tag 600 though the written packet did not determine what type of abuse was inflicted upon R2. The information in part reflected CNA E and F were suspended pending investigation and prior to returning to work, the staff directly involved (CNA E and CNA F) were educated on professional boundaries, abuse prevention, resident rights, and appropriate management of combative residents without the use of force or restraint.On 5/12/26 at 1:49 pm, during an interview with CNA E she readily admitted that it was routine practice to restrain R2 during care. CNA E reported this was a normal standard of practice and it was how everybody takes care of R2. CNA E elaborated on how terrible R2's behaviors are, that management knows about R2's behaviors and nobody does anything about R2, thus they (staff) have no other choice but to hold R2 down. CNA E elaborated she was familiar with all the federal regulations and that staff are required to provide care and that is what they do. CNA E went on to say that she knows her rights and she has the right to work in an abuse free environment and the staff only restrain R2's arms and legs to protect themselves. Again, repeating staff has the right to work in a safe environment and in CNA Es opinion, the facility was not a safe work environment due to R2 and facility management was not doing anything about it. When quired if CNA E enlisted assistance from the Nurse, CNA E stated no. When queried if staff tried leaving R2 alone and reapproaching later giving R2 time to settle down, CNA E stated no. CNA E reiterated she knew the federal regulations and if she left R2 alone that would be neglect. When queried if she referenced R2's care plan or Kardex for approaches, CNA E stated R2 did not have any behavior interventions in place on 4/18 or today. At this time CNA E and this surveyor went to R2's room. R2 was resting in bed, made eye contact but did not speak upon approach. CNA E went to R2's closet and there was a Kardex in place that listed approaches on how to care for and what approaches to try when/if R2 becomes combative. When queried about the Kardex again, CNA E stated someone must have just put it in R2's closet. When queried about restraining R2 for care, CNA E again reverted back to that was how they provided care to R2 based on R2's actions/behavior and she had the right to work in a nonviolent atmosphere. When CNA E was queried about giving R2 a Titty Twister CNA E reported she never touched R2. When it was explained this surveyor watched the video from 4/18/26, CNA E then stated Well it was just a joke! CNA E reported she was suspended after her shift that day 4/18 but returned to work a few days later. CNA E reported still being assigned to care for R2 and works full time on the facility's dementia unit. During an interview with CNA G on 5/12/26 at 2:31pm, CNA G stated 4/18/26 was her third day in orientation and she was shadowing CNA E, CNA G stated while on the way to R2's room CNA E was complaining about how hard it was to take care of him and how R2 always fights them. CNA G stated R2 was on the bed and CNA F was already in the room and CNA E started the interaction being aggressive as if she were preparing for R2 to be aggressive in return. CNA G said she was just there to observe and learn and she the witnessed CNA E stern fully and forcefully take R2 by the shoulders and push down on R2 on the bed. CNA G stated after that interaction R2 became angry and was yelling, cussing and trying to hit and kick at them. CNA G stated CNA E held R2's arms down while CNA F held his legs. CNA G stated the interaction was crazy and she did not know what to do. CNA G said then a few hours later while sitting at the nurses' station with R2 and CNA E you could feel the tension between R2 and CNA E. CNA G stated R2 and CNA E were across from CNA G. CNA G stated at this time out of nowhere CNA E started laughing and yelled Titty Twister and then completed the action. CNA G stated CNA E was laughing and R2 looked shocked and then smiled. CNA G stated she gave a nervous laugh because the whole day CNA G felt confused and awkward. CNA G elaborated that later that day R2 went into another resident room and took their scarfs, at which time she reported she observed CNA E yank the scarfs out of R2's hands, R2 in turn replied Give me my s**t back and CNA E responded It's not your s**t and walked away. CNA G stated all of this was reported to a panel of people whom she had already given a statement to. On 5/13/26 at 9:53am during an interview with CNA F she reported she barely remembered anything about 4/18/26 aside from being suspended for a few days. CNA F stated it was a normal day, and her partner (CNA E) had an orientee with her (CNA G). CNA F stated they got transferred to the dementia unit, where R2 resides, unwillingly a few months ago and R2 was his normal aggressive self that day. CNA F elaborated they have to hold R2 down because R2 fights, kicks and spits at them. When queried if they asked the Nurse for assistance, CNA F stated no, there was no reason to get the nurse, she and CNA E could handle it. When queried about interventions CNA F stated one of the interventions was to wear a face shield because he spits at them, but they don't do those interventions. When asked why, CNA F reported the afternoon shift asked her a few days ago about the interventions and CNA F stated she told them not to bother, they don't work and, in her opinion, may trigger R2. CNA F elaborated management was aware of R2's behavior and did nothing about it. When queried if the facility provided dementia care training and abuse prevention training, CNA F stated yes but it's all online and there was nothing offered for in person for training/education on dementia care and behaviors. When queried if CNA F documented R2's behaviors for 4/18/26 or reported to the Nurse or management that she felt the behavior interventions listed for R2 were not effective or may trigger R2, CNA F stated Well I mean, don't know that was a long time ago. Of note, the behavior tracking for R2 on 4/18/26 had no documented behaviors. During a phone interview on 5/13/26 at 10:17 am, with Housekeeper H she reported she observed R2, CNA E and CNA G sitting at the nurses' station on 4/18/26, while entering a nearby room she was going to clean. Housekeeper H stated she thought she overheard CNA E say something pretty inappropriate followed by laughter, Housekeeper H stated she stepped out of the room and asked CNA E what did you say?' and CNA E replied Titty Twister and erupted in laughter again. Housekeeper H stated I guess I did hear it right the first time. On 5/13/26 at 12:25 pm during an interview with NHA A who identified herself as the facility's abuse coordinator and QAM D the facility reported incident was reviewed and acknowledged by NHA A and QAM D that abuse had occurred. When queried what was done to ensure the protection of R2 and other at-risk residents who received care from CNA E and CNA F NHA A reported they had been re-educated. Based on interviews conducted on 5/12 and 5/13 with both CNA E and CNA F it was evident CNA E and CNA F had failed to apply, implement and demonstrate an understanding of what was taught regarding professional boundaries, abuse prevention, resident rights, and appropriate management of combative residents without the use of force or restraint.

Based on interview and record review, the facility failed to maintain record of successful completion of a State-approved paid feeding assistant training course for 6 of 12 paid feeding assistants. Review of the lists provided by the facility, the facility had 12 staff who were Paid Feeding Assistants and 9 residents who were approved for the Paid Feeding Assistant program. In an interview on 03/19/26 at 12:55 PM, Director of Nursing (DON) B reported the facility was only able to locate the documentation of completion of a State-approved paid feeding assistant training course for 6 of the 12 staff who worked as Paid Feeding Assistants. DON B reported Life Enrichment Coordinator W, Dining Room Assistant (DRA) X, DRA Y, DRA Z, DRA AA, and DRA BB all completed the Paid Feeding Assistant training and had assisted with feeding, however the facility was unable to locate the documentation that the training had been completed.

Based on observations during medication administration the facility failed to provide hand hygiene for one resident (R121) out of three residents observed during medication administration.Findings IncludeResident #121 (R121)Review of the medical record reflected that R121 was admitted to the facility on [DATE]. Diagnoses of Chronic Obstructive Pulmonary Disease, pain in her right and left shoulders, Heart Failure, Acute Kidney Failure, Anxiety, Depression and shortness of breath.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2026 revealed R121 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R121 needed minimum assistance with showering, personal care, getting dressed and putting on footwear, however, was not completed at this time.During an observation and interview on 03/18/2026 at 8:25 AM, Registered Nurses (RN) I was pulling the medications out of the medication cart to administer to R121. RN I did not perform hand hygiene before leaving the medication cart. RN I walked into R121's room with her medications. RN I did not perform hand hygiene before handing R121 her medications. RN I stated she had to go get the blood pressure machine to check her blood pressure before giving her the blood pressure medication. RN I left medications and inhaler on the over the bed table with the R121 and left the room to go get the blood pressure machine. RN I brought BP machine into the room, next to resident. RN I did not perform hand hygiene before taking her vital signs, BP 151/92. R121 stated to RN I she used her inhaler on her own. RN I stated ok and went to get R121 blood pressure pill, no hand hygiene observed before getting in the medication cart or after getting the medication and handing that med cup to R121.During an interview on 03/19/26 at 9:45 AM, Director of Nursing (DON) B stated it was the expectation for the medication pass nurse to do hand hygiene before and after passing medications.

Based on observation, interview, and record review the facility failed to ensure the medication rate was less than 5% when two medication errors were observed form a total of 30 opportunities for one resident (#121) of three reviewed for medication administration, resulting in a mediation error rate of 6.67 %.Findings IncludeResident #121 (R121)Review of the medical record reflected that R121 was admitted to the facility on [DATE]. Diagnoses of Chronic Obstructive Pulmonary Disease, pain in her right and left shoulders, Heart Failure, Acute Kidney Failure, Anxiety, Depression and shortness of breath.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2026 revealed R121 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R121 needed minimum assistance with showering, personal care, getting dressed and putting on footwear, however, was not completed at this time.During an observation and interview on 03/18/2026 at 8:25 AM, Registered Nurses (RN) I was pulling the medications out of the medication cart to administer to R121. RN I walked into R121's room with her medications. RN I did not perform hand hygiene before handing R121 her medications. RN I stated she had to go get the blood pressure machine to check her blood pressure before giving her the blood pressure medication. RN I left the medications in the med cup and inhaler on the over the bed table with R121 and left the room to go get the blood pressure machine. RN I brought blood pressure machine into the room, next to resident, BP 151/92. R121 stated she used her inhaler on her own. RN I stated ok and went to get R121 blood pressure medication.The inhaler R121 self-administered was Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG/ACT 2 puff inhale orally two times a day for COPD. Rinse mouth out with water after use. RN I did not give R121 a cup of water to swish and spit. During this same medication administration, (RN) I pulled a Lidoderm External Patch 4% to put on R121 shoulders topically for pain. R121 made comment that the Lidocaine 4% External Cream that was used yesterday may or may not have helped much. Oral medications, Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG/ACT inhaler and the Lidoderm External Patch 4% were set on R121's over the bed table.Record review revealed the Lidoderm External Patch 4% was discontinued on 03/17/26 at 6:00 PM. A new order dated 03/18/26 for Lidocaine 4% External Cream, apply to shoulders topically two times a day for pain, written by License Practical Nurse (LPN) G. There was not an active order for Lidoderm External Patch 4%.During an interview on 03/18/26 at 3:00 PM, R121 stated the nurses usually stay in her room when she is taking her medication. R121 added that she cannot always take them at once so the nurses lets her take as many as she wants to take at a time. Writer asked R121 if RN I offered her water to rinse and spit after she administered her own inhaler. R121 stated no, but she took water when she swallowed her pills. No observation of nurse handing her a glass of water to swish and spit during the med pass.Record review did not reveal an assessment giving the R121 permission to self-administer her medications independently. During an interview on 03/19/26 at 9:45 AM, Director of Nursing (DON) B stated the expectation for medication pass would be, to ensure the medication cart is clean, applesauce used to administer some medications would be dated, have fresh water, pull the Medication administration record (EMR) pulled up on the computer, pull the medications from the drawer, confirm the order, check the allergies, triple check the medication to order and resident. Writer asked DON B if an order was discontinued, should RN I notice that? DON B stated yes. During this same interview, writer asked DON B if it was the expectation of the nurse to leave meds at the bedside. DON B stated no, unless they had an assessment giving them permission to self-administer. Writer reported to DON B did not find one in R121's EMR. Writer asked DON B if R121 self-administered her own inhaler, would she expect the RN I to give the resident water to rinse and spit after she returned to the resident's room? DON B stated yes, she would expect the nurse to provide water to rinse and spit.

Based on observation, interview and record review, the facility failed to implement a restorative maintenance program for one (R3) of one reviewed. Findings include: Review of the medical record reflected R3 admitted to the facility on [DATE], with diagnoses that included non-pressure chronic ulcer of the left thigh with necrosis of muscle, displaced intertrochanteric fracture of the left femur and presence of a left artificial knee joint. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/1/26, reflected R3 scored eight out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had lower extremity impairment on one side that interfered with daily functions or placed them at risk of injury in the last 7 days. On 03/17/2026 at 11:06 AM, R3 was observed seated in a wheelchair, in their room, watching TV. The footrests of the wheelchair were elevated, to approximately seat level height. R3's legs were extended on the footrests, and their left leg was bent laterally (to the outside), at the knee. R3 did not verbally respond when spoken to but shook their head to indicate no, when asked if they had any new joint stiffness. On 03/18/2026 at 11:02 AM, R3 was observed seated in a wheelchair, in their room, minimally self-propelling the wheelchair with their arms. The footrests of the wheelchair were elevated, to approximately seat level height. R3's legs were extended, and their left leg was bent laterally, at the knee. In an interview on 03/18/2026 at 11:32 AM, Therapy Director (TD) L reported R3 discharged from Physical Therapy (PT) and Occupational Therapy (OT) services on 2/18/26. TD L reported R3's left leg was turned outward, and their left hip was weaker than their right. According to TD L, a recommendation was made for a restorative nursing program for R3, which was to include range of motion (ROM), but the facility could only have a specific number of residents on restorative services at a time. Each resident on restorative services could have two programs, so R3 would have range of motion and bed mobility programs. When residents were taken off restorative services, the facility could add other residents from the waiting list. TD L stated R3 was not on the restorative program list, but a referral had been placed. A PT Discharge summary, dated [DATE], reflected a recommendation for R3 to be placed on a restorative program to address lower extremity strengthening, passive ROM, active assisted ROM and active ROM. An OT Discharge summary, dated [DATE], reflected a recommendation for a restorative ROM program. On 03/19/2026 at 10:53 AM, Registered Nurse (RN) U reported there were two restorative aides, plus one as needed aide to provide coverage if one of the two aides was off. RN U reported that on 2/17/26, therapy did a referral for restorative for R3, but they were not yet on a restorative program due to the caseload being too large to add R3. RN U reported there were 25 residents on restorative services at the time of the interview, and there were typically two programs for each resident. There was a waiting list for restorative services, according to RN U.

Based on observation, interview and record review, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) Assessment timely for one (R13) of 23 reviewed.Findings include: Review of the medical record reflected R13 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included Multiple Sclerosis. The Significant Change in Status MDS, with an Assessment Reference Date (ARD) of 2/5/26, reflected R13 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and received hospice services. The MDS was completed on 2/19/26. On 03/17/2026 at 10:21 AM, R13 was observed seated in a high-back wheelchair, watching TV, in their room. A Progress Note for 1/30/26 reflected R13 admitted to hospice services. In a phone interview on 03/19/2026 at 11:33 AM, MDS Nurse V reported the significant change in status occurred on 1/30/26, when R13 was enrolled in hospice services. In a follow-up phone interview on 03/19/2026 at 12:18 PM, MDS Nurse V reported they had looked into the timing of R13's Significant Change in Status MDS and stated the MDS should have been locked (completed) by 2/12/26. According to the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025, .Significant Change in Status Assessment (SCSA) .An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than) .The MDS completion date (item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met. This date may be earlier than or the same as the CAA(s) completion date, but not later than .

Based on observation, interview and record review the facility failed to protect personal, private and confidential information for one resident (R121) of three resident's protected information.Findings Include:Resident #121 (R121)Review of the medical record reflected that R121 was admitted to the facility on [DATE]. Diagnoses of Chronic Obstructive Pulmonary Disease, pain in her right and left shoulders, Heart Failure, Acute Kidney Failure, Anxiety, Depression and shortness of breath.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2026 revealed R121 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R121 needed minimum assistance with showering, personal care, getting dressed and putting on footwear, however, was not completed at this time.During an observation and interview on 03/18/2026 at 8:25 AM, Registered Nurses (RN) I was pulling the medications out of the medication cart to administer to R121. RN I walked into R121's room with her medications, leaving the computer screen open with R121 person and protected information showing as well as the list of resident names and daily report visible faced up on the cart. RN I did not perform hand hygiene before handing R121 her medications. RN I stated she had to go get the blood pressure machine to check her blood pressure before giving her the blood pressure medication. RN I left medications and inhaler on the over the bed table with the R121 and left the room to go get the blood pressure machine. RN I brought BP machine into the room, next to resident. BP 151/92, R121 stated she used her inhaler on her own. RN I stated ok and went to get R121 blood pressure pill, no hand hygiene observed before getting in the medication cart or after getting the medication and handing that med cup to R121. The computer screen remained open with R121's personal and protected information was visible to anyone walking by.During an interview on 03/19/26 at 9:45 AM, Director of Nursing (DON) B stated the expectation would be to close the computer screen prior to leaving the medication cart unattended in the hallway before going into a resident's room. DON B stated yes. Writer asked DON B if the expectation was the same when leaving the daily schedule/list of residents names/ laying face up on the medication cart. DON B stated yes.

Based on interview, observation and record review the facility failed to assess one resident (R121) out of three to self-administer her medications safely and independently.Findings IncludeResident 121 (R121)Review of the medical record reflected that R121 was admitted to the facility on [DATE]. Diagnoses of Chronic Obstructive Pulmonary Disease, pain in her right and left shoulders, Heart Failure, Acute Kidney Failure, Anxiety, Depression and shortness of breath.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2026 revealed R121 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R121 needed minimum assistance with showering, personal care, getting dressed and putting on footwear, however, this portion was not completed at this time.During an observation and interview on 03/18/2026 at 8:25 AM, Registered Nurses (RN) I was pulling the medications out of the medication cart to administer to R121. RN I walked into R121's room, leaving the computer screen open with R121 person and protected information showing as well as the list of resident names and daily report visible faced up on the cart. RN I did not perform hand hygiene before handing R121 her medications. RN I stated she had to go get the blood pressure machine to check her blood pressure before giving her the blood pressure medication. RN I left medications and inhaler on the over the bed table with the R121 and left the room to go get the blood pressure machine. RN I brought BP machine into the room, next to resident. BP 151/92, R121 stated she used her inhaler on her own. RN I stated ok and went to get R121 blood pressure pill, no hand hygiene observed before getting in the medication cart or after getting the pill and handing that med cup to R121. The inhaler R121 self-administered was Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG/ACT 2 puff inhale orally two times a day for COPD. Rinse mouth out with water after use. RN I did not give R121 a cup of water to swish and spit.During an interview on 03/18/26 at 3:00 PM, R121 stated the nurses usually stay in her room when she is taking her medication. R121 added that she cannot always take them at once so the nurses lets her take as many as she wants to take at a time. Writer asked R121 if RN I offered her water to rinse and spit after she administered her own inhaler. R121 stated no, but she took water when she swallowed her pills. No observation of nurse handing her a glass of water to swish and spit during the med pass.Record review did not reveal an assessment giving the R121 permission to self-administer her medications independently.During an interview on 03/19/26 at 9:45 AM, Director of Nursing (DON) B stated the expectation for medication pass would be, to ensure the medication cart is clean, applesauce used to administer some medications would be dated, have fresh water, pull the Medication administration record (EMR) pulled up on the computer, pull the medications from the drawer, confirm the order, check the allergies, triple check the medication to order and resident. Writer asked DON B if an order was discontinued, should RN I notice that? DON B stated yes. During this same interview, writer asked DON B if it was the expectation of the nurse to leave meds at the bedside. DON B stated no, unless they had an assessment giving them permission to self-administer. Writer reported to DON B did not find one in R121's EMR. Writer asked DON B if R121 self-administered her own inhaler, would she expect the RN I to give the resident water to rinse and spit after she returned to the resident's room? DON B stated yes, she would expect the nurse to provide water to rinse and spit.

Based on interviews and record reviews, the facility failed to thoroughly investigate the alleged sexual abuse on one resident (R2) of one resident investigated for abuse.Linked to intake 2645136Findings IncludeResident #2 (R2)Review of the medical record reflected that R2 was admitted to the facility on [DATE]. Diagnoses of Congestive Heart Failure, Stroke, Traumatic Brain Injury, Dysphagia (difficulty swallowing), Major Depression, High Blood Pressure, Bi-Polar, weakness and unsteady on her feet.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/11/2025 revealed R2 had a Brief Interview of Mental Status (BIMS) of 07 (Moderate to severe cognition impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R2 needed assistance of 1 person with personal care.Resident #3 (R3)Review of the medical record reflected that R3 was admitted to the facility on [DATE]. Diagnoses of Congestive Heart Failure, Adjustment disorder with mixed disturbance of emotions and conduct, Vascular Dementia without behavioral disturbance, unsteady on his feet and abnormalities of gait and mobility.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/2025 revealed R3 had a Brief Interview of Mental Status (BIMS) of 03 (severe cognition impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R3 needed assistance of 1 person with personal care. Record review revealed an incident of sexual abuse that took place on 09/25/2025 between R3 and R2 at this facility. The incident report also reported this abuse was witnessed by Certified Nursing Assistants (CNA) H. It was alleged the abuse was verified, by the facility, not only by staff witness but also by reviewing the hallway camera footage. Incident report included the timeline of events.Camera footage was reviewed to verify the timeline of events from 09/25/2025.2125 pm. R3 approached R2 in the hall near the nurse's station. They were both in their wheelchairs.2126pm. R3 gets even closer to R2 and touches her wheelchair arm. R2 appears to be consoling R2 as she was crying. R3 reaches and touches R2's face. They were talking and then R3 rubs R2's back.2127pm. R3 attempted to hug R2.2127:07pm. R3 reached over and touched R2's right breast.2127:09pm. R3 removed his hand from touching R2's right breast.2127:15pm. R3 places his hand back on R2's right breast.2127:17pm. R3 moved his hand to R2's left breast.2127:18pm. R3 moved his hand back to the wheelchair.2127:19pm. RSA H approached R3 and R2.2127:21pm. RSA H reached R3 and R2 and separated them.2127:24pm. R3 self-propels backwards.2128pm. RSA H took R2 into her room.2155pm. RSA H reported this event to LPN D. Record review revealed the facility completed two witness statements, from CNA H and CNA I on 09/25/25 at 9:45pm. CNA I stated she did not witness that incident on her hall.Record review revealed LPN D followed up with R2 regarding the incident who was sitting on her bed crying.Record review revealed Social Service Coordinator (SSC) C followed up with R2 regarding the incident, R2 could not recall the incident.During an interview on 02/04/26 at 1:07 PM, SSC C stated she followed up with R2 after the incident and R2 had some confusion and difficulty finding words during conversation, however appeared pleasant. SSC C also stated R2 had a fall on 09/29/25. Stated R3 had a room change from the first-floor household to the second-floor household related to this incident.During an observation on 02/04/26 at 3:00 PM, R3 was sleeping in his bed with his head covered with a white sheet, TV on in the background.During an interview on 02/05/26 at 9:35 AM, CNA G stated she had cared for R3, he sleeps all day like a second shifter, he was a little hands on with staff, sometimes he would make comments like hey baby, why don't you crawl in to bed with me. CNA G stated she never felt unsafe with him.The alleged perpetrator continues to have access to the alleged victim and/or othervulnerable residents.State Operations ManualDuring an interview on 02/05/26 at 9:45 AM, CNA F stated R3 was flirty with the female residents and staff. CNA F stated R3 never bothered men, just the females.A resident who continually fondles other residents is moved to another unit, where he/shecontinues to exhibit the same behaviors to other residents. State Operations Manual.Assurance that ongoing safety and protection is provided for the alleged victim and, as appropriate, other residents. State Operations ManualDuring an observation and interview on 02/05/26 9:55 AM, R2 was resting in her bed with her eyes closed, stated she didn't want to talk to anyone, she was sleeping.During an observation on 02/05/26 at 9:22 AM, R3 was sleeping in his bed with his head covered.During an interview on 02/05/26 at 11:07 AM, LPN D, stated CNA H told him of the incident the night of 09/25/25, he was coming down the hall, separated the residents and called Nursing Home Administrator (NHA) A. LPN D stated they came to the conclusion to keep them separated for the night, and they would change rooms the next day. LPN D stated he talked to R3 that night and he could not remember the incident, nor could R2 remember the incident.During an interview on 02/05/26 at 10:55 AM, Registered Nurse (RN) E stated R3 was moved to her hallway, due to having less residents on the floor. RN E stated R3 made comments that were charted and not very nice, but only to staff that she recalled. RN E stated she usually told the RSAs to tell R3 that it is inappropriate, and he cannot talk like this. RN E stated R3 liked to sleep and would get up late afternoon or early evening. RN E stated if R3 repeats the behavior, the RSAs go to her, and she would go to NHA A for directions.During an interview on 02/05/26 at 11:30 AM, NHA A and Quality Assurance Manager (QAM) H stated they reported the incident to QAPI and had minutes under the board meeting minutes. Writer asked NHA A if other residents on that household were interviewed. NHA A stated whatever is in the folder is what they did. Writer asked NHA A if any other staff had been interviewed the night of the incident regarding R3's behaviors. NHA A asked QAM H if SWC C had interviewed any other residents, QAM H stated she could not remember, as NHA A was looking through the folder. NHA A stated there wasn't anything in the folder.Writer asked to view the camera recording of the incident, QAM H was looking through her cell phone for it then stated she didn't have it anymore. Writer asked NHA A if they called the police for this abuse allegation. NHA A stated they were not called because both residents were cognitively impaired. No other explanation. Writer asked NHA A what education was provided and to whom was it provided to regarding the sexual abuse? NHA A stated she wasn't sure what education would be provided, residents were impaired, the staff knew what to do as this worked. Writer asked NHA A how they were tracking R3's repeated behaviors since this was not a new behavior. QAM H stated he wasn't abusive to any other residents, just the staff.They have a stop and watch program and a monitoring program in place. QAM H stated staff tell R3 that it was inappropriate and if he is safe, they can leave him in his room.Record review of the conclusion revealed the facility observed and reviewed the camera footage of the incident and verified R3 did touch both of R2s breast. Shortly after the incident, neither R3 nor R2 could recall the occurrence. Both residents' care plans were updated to reflect new interventions. R3 had a room change from one alert hallway to another alert hallway. Stated R3 was adjusting well to his new private room and household. SSC C followed up with R3 for 4 weeks to ensure he was adjusting to his new household and did not experience any psychosocial changes. R2 continued to not remember the incident and did not experience any psychosocial changes. Psychosocial services for R2 will continue for 4 weeks as well. Record review did not reveal any interviews with other residents living in that same household about R3's inappropriate behaviors, inappropriate comments and touching of female residents.Record review did not reveal any interviews with staff working on that household/hall regarding R3's inappropriate behaviors, inappropriate comments and touching of female residents or staff.Record review revealed R3 was moved to a household/hall were other vulnerable female residents lived.Record review revealed there was no education provided to staff regarding this sexual abuse situation when this was not the first time R3 had inappropriate behaviors, inappropriate comments to female residents and staff and inappropriate touching of female residents.Record review revealed the facility failed to call the police as mandated with any abuse, including a sexual abuse that was witnessed, recorded and reviewed on camera footage and substantiated it as abuse by this facility.Record review revealed the facility failed to do a thorough investigation of this reportable incident after verifying it substantiated as abuse by this facility.Per the State Operations Manual, the facility failed to follow their regulations .For any alleged violation of sexual abuse, the facility must: Immediately implement safeguards to prevent further potential abuse. Immediately report the allegation to appropriate authorities. Conduct a thorough investigation of the allegation. Thoroughly document and report the result of the investigation of the allegation.

This citation pertains to Intake 2621377. Based on observation, interview, and record review, the facility failed to respect the right to privacy for one (R1) of three reviewed. Findings include:Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, vascular dementia, and major depressive disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/2/25 revealed R1 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the facility's investigation revealed Witness G showed Human Resources Assistant (HRA) D videos that Certified Nursing Assistant (CNA) E recorded while in resident rooms and sent to CNA F. The investigation revealed The second video [Witness G] showed [HRA D] was of the same staff member [CNA E] recording one of our residents in Windsor Ridge while her back was to the camera and resident was on the phone with someone. At the end of the video, the staff member turns the camera on herself, and I [HRA D] was able to verify the second video was also recorded by [CNA E]. On 9/22/25 at 10:52 AM, the above-mentioned video was observed with Corporate Compliance & Quality Assurance Manager (CCQAM) C. The video was recorded from behind a resident as she sat in her wheelchair in front of her television, while talking on the telephone in her room. At the end, the video turns to CNA E's face. CCQAM C reported the resident in the video was R1 who was not aware that she had been recorded. On 9/22/25 at 9:18 AM, R1 was observed in a wheelchair in her room. R1 was not aware of any instances of being recorded. When asked how she would feel about being recorded, R1 stated it would depend on what it would be. In a telephone interview on 9/22/25 at 10:47 AM, CNA F reported they received one video via social media messenger from CNA E. CNA F reported CNA E recorded a video while in a resident's room and the back of a resident's head was seen in the video. CNA F reported herself and Witness G shared a social media account and that is how Witness G acquired the video. In a telephone interview on 9/22/25 at 11:14 AM, CNA E reported they recorded a video in R1's room as a way of their own complaining and documentation of false allegations that were happening against us at that time. CNA E reported R1 turned her call light on, she responded, and R1 shooed her away because she was on the telephone. CNA E reported she then took a video and sent it to CNA F In an interview on 9/22/25 at 10:26 AM, HRA D reported CNA E was terminated from employment due to violating the facility's policy of no photography or video recordings on the property, not treating R1 with respect, and violating R1's right to privacy.

This citation pertains to intake MI00153332. Based on observation, interview and record review, the facility failed to ensure a transfer was performed according to the plan of care for one (R3) of three reviewed, resulting in R3 being lowered to the floor and sustaining a fracture. Findings include: Review of the medical record reflected R3 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included fracture of unspecified part of neck of right femur and Multiple Sclerosis. The Significant Change in Status/Medicare 5 day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/12/25, reflected R3 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and was dependent for transfers. On 6/25/25 at 11:23 AM, R3 was observed seated in a wheelchair, with a mechanical lift sling beneath them. R3's legs were resting on a heel elevation cushion, which was positioned on the footrests of the wheelchair. R3 reported they had fallen really hard during a transfer and fractured their femur. R3 reported having x-rays, which initially did not show a fracture. Approximately two days after the fall, R3 reported being really miserable. R3 reported having surgery after their fracture was identified. An Incident Report, dated 4/22/25 at 6:35 PM, reflected R3 was lowered to the floor during a transfer with Certified Nurse Aide (CNA) E. According to the report, while R3 was attempting to stand with the lift, their bad leg gave out. As CNA E was attempting to assist R3 to sit back down, the wheelchair, which was noted to be locked, moved backwards, away from R3. R3's legs slid from beneath them, and they sat down hard on the floor. After an assessment by the nurse, R3 was transferred to bed via hoyer lift (mechanical lift which does not require weight-bearing by the patient). Once R3 was transferred via hoyer lift, they complained of level eight out of ten pain in their right thigh. X-rays of the right knee, right hip and pelvis on 4/23/25 did not show any obvious fractures. During a phone interview on 6/25/25 at 9:39 AM, CNA E reported they were attempting to transfer R3 from their wheelchair to bed when R3's right leg gave out during the transfer. CNA E reported that although R3's wheelchair was locked, it moved backwards, and they were unable to hold R3 up and move the wheelchair at the same time. R3 was lowered to the floor. CNA E stated when R3 was six to twelve inches from the floor, their right leg shot out in front instead of bending, and R3 plopped down on their buttocks. During the same interview, CNA E stated their report sheet indicated R3 transferred via one to two person assistance with the sit to stand lift, although their Care Plan and Kardex (CNA care guide) had been updated to reflect two person assistance with transfers using the sit to stand lift. CNA E reported they had not seen R3's updated Care Plan or Kardex and had been using the information on the report sheet. R3's Care Plan included an intervention with a revision date of 10/25/24 which reflected R3 required the assistance of two people to transfer via sit to stand lift. The April 2025 Medication Administration Record (MAR) reflected Oxycodone (opioid pain medication) 5 milligrams (mg) by mouth every eight hours, as needed for pain, for seven days was started on 4/24/25. The MAR reflected the medication was administered on 4/24/25 at 10:36 AM and 6:30 PM for level eight out of ten pain. A correlating Progress Note for 4/24/25 at 10:36 AM reflected Oxycodone was administered per request of R3 for complaints of right leg pain. A correlating Progress Note for 4/24/25 at 6:30 PM reflected Oxycodone was administered for R3's complaint of pain to the right upper thigh. The April 2025 MAR further reflected Oxycodone was administered on 4/25/25 at 7:02 AM and 7:07 PM for complaints of level eight out of ten pain. Correlating Progress Notes reflected the medication was administered for right leg pain. Oxycodone was administered on 4/26/25 at 7:20 AM for level eight out of ten pain and at 4:30 PM for level three out of ten pain. A correlating Progress Note for 4/26/25 at 7:20 AM reflected Oxycodone was administered for complaints of pain to the right leg. A correlating Progress Note for 4/26/25 at 4:30 PM reflected Oxycodone was administered for right hip pain. According to the April 2025 MAR, Tylenol 1000 mg every eight hours, as needed, for pain or fever was administered on 4/23/25 at 5:39 PM for level eight out of ten pain and on 4/24/25 at 7:12 AM for level eight out of ten pain. A correlating Progress Note for 4/24/25 at 7:12 AM reflected Tylenol was administered per R3's request due to right leg pain. Progress Notes reflected R3 was transferred to the hospital on 4/27/25 due to experiencing lethargy, decreased responsiveness and hallucinations. R3 readmitted to the facility on [DATE]. A Physician Progress Note for 5/7/25 reflected R3 reported knee pain since their fall (on 4/22/35), and their imaging did not show fractures. According to the note, x-rays of the knee, hip and pelvis were reviewed and were unremarkable. The note reflected R3 would restart Physical Therapy. A Physical Therapy note for 5/7/25 reflected R3's transfer orders were changed to reflect the use of a hoyer lift. According to the note, R3 did not want the therapist to move their leg, as R3 had not yet received pain medication. R3 reported level seven out of ten pain with movement and no pain at rest. An Occupational Therapy note for 5/8/25 reflected R3 was unable to sit on the edge of the bed due to significant pain in their right leg when attempting to move the leg. According to the notes, R3 continued with Physical and Occupational Therapy services through 5/14/25. Progress Notes for 5/8/25, 5/9/25, 5/10/25, 5/11/25, 5/12/25, 5/13/25 5/14/25 and 5/15/25 reflected R3 continued to experience right thigh pain, documented as aching and sharp. The May 2025 MAR reflected an order, dated 5/6/25, for a Lidoderm 5% patch (helps treat pain) to be applied topically, to the right hip, daily. Pain Relieving External Cream topically to affected area every eight hours as needed for pain was started on 5/6/25. The medication was used on 5/8/25 for right lower extremity pain, on 5/13/25 for right leg pain and 5/14/25 for right hip pain. Naproxen Sodium (used to treat pain and inflammation) 220 mg by mouth three times daily for pain was started on 5/14/25. A Medication Administration Note for 650 mg of Acetaminophen (Tylenol) on 5/13/25 at 7:50 PM reflected R3 reported they did not have pain with sitting or lying still. R3 reported when care was performed or when being moved in the hoyer lift, it was extremely painful and a 10/10 [ten out of ten level pain]. A Progress Note for 5/13/25 at 11:30 PM reflected R3 continued to report pain to the right thigh, stating it felt like the pain was deep. The note reflected R3 experienced pain when their leg was moved, even slightly. R3 refused to get out of bed that day and reported pain with care and bed mobility. R3 reported it hurt their leg to get into the hoyer lift. A Nurse Practitioner (NP) Progress Note for 5/14/25 reflected R3 was seen for complaints of continued and worsening pain. The note referenced an incident a couple weeks prior, when R3 was lowered to the floor, landed on their buttocks, then turned onto their right hip. According to the note, R3 did not have issues with pain in their hip or leg prior to or immediately following the incident. It was not until staff started to move R3 again that they had pain in their hip. R3 described their pain as sharp and deep, ranging from level two to nine out of ten pain. The note reflected the NP would order x-rays of the right hip, pelvis and lumbosacral spine. A right hip and pelvis x-ray, dated 5/14/25, reflected, .Fracture of upper shaft of femur with callus formation and internal fixation in situ .As compared to previous X-ray dated 04/23/2025, no interval changes seen . R3 was transferred to the hospital on 5/15/25 and underwent surgery for the fracture on 5/16/25. R3 readmitted to the facility on [DATE]. In an interview with Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and Corporate Compliance and Quality Assurance Manager C on 6/25/25 at 1:40 PM, it was reported they believed R3 sustained the femur fracture during the fall on 4/22/25. It was reported the facility requested to have R3's original x-rays from 4/23/25 reviewed again, and it was noted that there had in fact been a fracture at that time that, which was not initially identified. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included removal of transfer status from all report sheets; education on the importance of reading the Care Plans and Kardex; education to Clinical and Therapy staff regarding pain management, recognizing pain, continued monitoring and reporting to the provider; CNA E competency evaluation with return demonstration for sit to stand lift use and on-going transfer and positioning audits for R3. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake MI00153420 Based on observation, interview and record review the facility failed to ensure that three residents (R4, R6, R7) were free from non-physician ordered chemical restraints imposed for purposes of staff convenience of five residents reviewed. Findings include: Review of the Facility Reported Incident(FRI), dated 5/26/25, reflected, The facility investigation revealed that Licensed Practical Nurse(LPN) L administered medication (Benadryl), which she bought while on the clock, which was not ordered by the physician, to at least two residents. During the review of the camera footage and documentation, [named LPN L] also left her medication cart unlocked, walked in the halls with gloves on, administered medication in public places, picked up pills off the floor and attempted to administer, administered medications outside of physician ordered times, documented she administered medication which was found in trash, spent much time on her personal cell phone, and frequented the bathroom [ROOM NUMBER] times on her shift. Resident #4(R4) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R4 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease, dementia with other behavioral disturbances, adjustment disorder with mixed anxiety and depressed mood and restlessness and agitation. The MDS reflected R4 had a BIMS (assessment tool) score of 00 which indicated her ability to make daily decisions was severely impaired. During an observation on 6/25/25 at approximately 12:40 p.m., R4 observed sitting in chair located by nurse station and appeared calm and well groomed. Review of R4 Nurse Progress Note, dated 5/27/25, reflected, Phone call placed to facility administrator on 5/26/25 at approx 2130[9:30 p.m.] reporting that this resident received a dose of Benadryl. Vital signs and monitoring implemented upon notification of administration of Benadryl. Writer placed call to facility provider. No new orders at this time. Writer spoke to POA/niece on the phone at noon on today's date updating on administration of Benadryl . Review of R4 Physician Progress Note, dated 5/27/25, reflected, Chief Complaint / Nature of Presenting Problem: Benadryl administration History Of Present Illness: Patient is being seen today by the request of nursing due to receiving a dose of Benadryl not prescribed to her on 5/26/2025. Patient seen sitting in wheelchair in no acute distress, responding appropriately, at her baseline, with no adverse reactions noted from receiving medication.Plan: Inappropriate Benadryl administration-continue monitoring patient for any adverse effects, encouraged to increase her water intake . Review of R4's May 2025 Medication Administration Record (MAR) did not reflect Benadryl as being an ordered medication for R4. Resident #6 (R6) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R6 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease, vascular dementia, depression, cognitive communication deficit and repeat falls. The MDS reflected R6 had a BIMS (assessment tool) score of 00 which indicated her ability to make daily decisions was severely impaired. During an observation on 6/23/25 at 2:46 p.m. R6 was observed by sitting in wheel chair located at Nurse Station. R6 appeared calm and well groomed with staff located nearby. Review of R6 Nurse Progress Note, dated 5/27/25, reflected, Phone call placed to facility administrator on 5/26/25 at approx 2130 reporting that this resident received a dose of Benadryl. Vital signs and monitoring implemented upon notification of administration of Benadryl. Writer placed call to facility provider . Review of R6 Physician Provider Note, dated 5/27/25, reflected, Chief Complaint / Nature of Presenting Problem: Inappropriate Benadryl administration History Of Present Illness: Patient is being seen today by the request of nursing due to receiving a dose of Benadryl not prescribed to her on 5/26/2025. Patient seen sitting in recliner in her room, in no acute distress, responding appropriately, at her baseline, with no adverse reactions noted from receiving medication. Patient denies any hallucinations. At times patient was noted to be having conversations with people from the TV show, which was verified by staff baseline for patient. Per staff no unusual behavior has been noted throughout the shift since receiving this medication Plan: Inappropriate Benadryl administration-continue monitoring patient for any adverse reactions from medications, encouraged patient to increase water intake . Review of R6's May 2025 Medication Administration Record (MAR) did not reflect Benadryl as being an ordered medication for R6. Review of the FRI investigation witness statement, dated 5/26/25 at 10:45pm, reflected Resident Assistant (RSA) N completed a written statement that included, Agency nurse [named LPN L] told myself & rsa [named RSA O] that she gave [named R6, R4 and R7] Benadryl she bought from dollar general. She stated she left and went to dollar general when she got to work. She stated that she already worked 3 days in a row and she wasn't putting up with the three Bam Bams tonight. Stated she told us a secret. She told myself & [named RSA O] all of this and stated if we told she would know. [named RSA O] stated she did not want to tell because she, did not see big deal. [named LPN L] stated that she gave them benadryl & melatonin. The statement was signed by RSA N. During an interview with Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and Corporate Compliance and Quality Assurance Manager(CC) C on 6/25/25 at 2:18 PM, it was reported the FRI from 5/25/25 related to staff administering non physician ordered benadryl to three residents was substantiated. NHA A reported was first made aware of incident 5/26/25 at about 9:30 p.m. CC C reported she completed a thorough investigation, contacted the agency company, reported LPN L licence and contacted local law enforcement, provided education to staff, continued monitoring for effected residents and discussed in Quality Assurance meeting and have continued to audits. CC C reported alleged compliance 6/13/25. CC C reported was expect staff to administer medications as ordered by physician and verified residents involved did not have orders for benadryl. Resident #7 (R7) Review of the medical record reflected R7 admitted to the facility on [DATE], with diagnoses that included Alzheimer's and anxiety. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/9/25, reflected R7 scored zero out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 6/23/25 at 2:18 PM, R7 was observed seated in a standard chair, at the nurse's station, near their room. R7 was reading a Bible storybook out loud. An Incident Report for 5/26/25 at 9:30 PM reflected a phone call was placed to the Nursing Home Administrator (NHA), reporting the nurse attempted to administer Benadryl to R7, which was not prescribed by the provider. The report reflected R7 did not accept their medications and spit them on the floor. A facility investigation file included a witness statement from Certified Nurse Aide (CNA) N, which reflected Licensed Practical Nurse (LPN) L told them and CNA O that she administered Benadryl, which she had purchased at a local store, and Melatonin to R4, R6 and R7. The witness statement reflected LPN L had stated she already worked three days in a row and was not putting up with the three Bam Bam's tonight. The facility investigation file included a witness statement from CNA O, which reflected she (the nurse) sat at the nurse's station and asked if they could keep a secret. The nurse told them she administered Benadryl and Melatonin to R4, R6 and R7 to help them sleep better. An additional witness statement from CNA O reflected on the way to the dining room to assist with feeding residents, they observed the nurse attempting to administer medications to R7. The statement reflected R7 got mad and spit the pills out. One of the pills observed by CNA O was dissolved and pink in color. R7's May 2025 Medication Administration Record (MAR) did not reflect Benadryl as being an ordered medication for R7. Witness statements from CNA P and CNA Q reflected LPN L asked if they were ready to have a good night. LPN L stated she was going to a local store at 3:00 PM. The statement reflected LPN L asked staff to let her know when R7 was eating so she could administer their medication, and R7 would be ready to go to bed as soon as she did. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included termination of LPN L post verified administration of benadryl (sedating medication) for staff convenience; education to Clinical staff regarding appropriate medication administration, medication errors, abuse and reporting; Clinical staff competency evaluation improvements and ongoing audits. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to Intake # MI00143838 Based on observation, interview, and record review, the facility failed to protect resident property in 1 of 3 residents reviewed for misappropriation of property (Resident #2), resulting in feelings of sadness and potential mistrust. Findings include: Resident #2 (R2) Review of the Face Sheet revealed that Resident #2 (R2) was admitted to the facility on [DATE] with diagnoses including Parkinson's, atrial fibrillation, and anxiety. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/2/24 showed that R2 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating cognitive intactness. On 7/31/24 at 11:29 AM, R2 was observed in her room speaking with a family member (FM) R. R2 was well-groomed, seated in a recliner, and was easily conversant. Numerous photographs and colored pictures were observed on R2's wall. R2 explained that she had a favorite aide (certified nursing assistant) who colored pictures for her. However, another aide had entered R2's room one day, removed the colored pictures from her wall, and discarded them without R2's permission. R2 stated that this incident upset her, as she did not understand why it had happened. The colored pictures were replaced with new ones shortly afterward, and the aide responsible for removing and discarding the originals was terminated. During the same interview, FM R mentioned that R2 had an aide identified as CNA F whom she greatly valued. CNA F had colored pictures for R2 and displayed them on R2's wall at her request. FM R noted that there appeared to be competition between two CNAs working on the hall, which may have been a reason why CNA G removed the colored pictures from R2's wall when R2 was not present and without her permission. A review of the Facility Reported Incident investigation revealed that on 4/3/24, CNA F asked Social Worker (SW) K if she had seen the colored pictures on R2's wall. CNA F stated that the pictures had been removed from R2's room. The facility reviewed camera footage and discovered that CNA G had entered R2's room when she was absent and discarded the pictures in the community trash room. The investigation summary indicated that R2 noticed the colored pictures were missing upon returning to her room from an activity. R2 was upset and tearful at the discovery. A family member followed up with SW K about the concern, reporting that three pictures/drawings were removed from [R2's] room today . when [R2] returned, she noticed right away that the pictures/drawings were missing. Video footage revealed that CNA G exited R2's room with a crumpled piece of paper in her hand, entered the community trash room, and exited with no contents in her hand. During an interview, CNA G admitted to removing and discarding the pictures from R2's room. In a telephone interview on 8/1/23 at 10:32 AM, CNA F reported that she would sit and color with R2. CNA F displayed the pictures on R2's wall at R2's request. CNA F noted that other staff members reported that R2 would often look at the pictures, read CNA F's name written at the bottom of the pictures, and then call out for CNA F at all hours. In a telephone interview on 8/1/24 at 2:38 PM, CNA G reported that she removed and discarded the colored pictures from R2's wall because she believed the pictures caused R2 distress. CNA G claimed that R2 would read the name at the bottom of the pictures and call out for CNA F, which CNA G felt was disruptive. In an interview on 8/1/24 at 12:36 PM, Social Worker K stated that she was informed about the pictures being removed from R2's room and reported the incident to Nursing Home Administrator (NHA) A. SW K discussed the matter with R2's family, the facility reviewed the video footage, and confirmed the concern. SW K expressed that the removal of the pictures upset R2. In an interview on 8/1/24 at 3:58 PM, NHA A reported that the facility investigated the concern and confirmed that CNA G had removed and discarded the colored pictures from R2's room. The facility substantiated the misappropriation and CNA G was terminated.

Based on interview and record review, the facility failed to ensure staff had proper certification for Cardiopulmonary Resuscitation (CPR- medical interventions used to restore circulatory and/or respiratory function that has ceased), including 2 (Nurses K and I) of 6 reviewed for CPR certification, resulting in the likelihood of residents not receiving adequate life sustaining treatments in the event of a sudden change in condition, potentially affecting all residents choosing to receive CPR. Review of the medical record reflected Resident #111 (R111) was admitted to the facility on [DATE], with diagnoses that included essential hypertension, Type 2 diabetes with diabetic neuropathy, sleep apnea, and acute respiratory failure. The Minimum Data Set (MDS) history reflected R111 died in the facility on [DATE]. Review of a Nurses Note dated [DATE] at 02:14 AM revealed Staff was in doing care with resident prior to bed when residents legs became weak and buckled while staff was assisting resident transferring from recliner to wheelchair. Staff lowered resident to the ground and notified writer @ [at] approximately 2145 [9:45 PM]. Writer went to residents room to assess resident for any injuries or pain and obtain VS [vital signs]. No injuries were noted and resident denied any new pain or concerns since lowered to the ground. Staff went to retrieve hoyer machine (patient lift) and sling to safely transfer resident from floor to his bed. Staff was able to safely hoyer resident from ground, when staff was assisting resident to the bed from hoyer resident started to become blue and unresponsive @ [at] approximately 2155 [9:45 PM]. RSA [Resident Service Aide] stayed with resident while writer called code blue on PA system and other RSA [Resident Service Aide] went to retrieve crash cart and AED (automated external defibrillator). Staff called 911. Nurse supervisor for shift and other nurses came to assist with code, staff placed board under resident and began compressions @2200 [10:00 PM] .EMS [Emergency Medical Services] stooped [sic] compressions and calledtime [sic] of death for resident @ 2253 [10:53 PM] on [DATE] . The author of the Nurses Note was Licensed Practical Nurse (LPN) K. Review of the medical record reflected R111 was a full code (full resuscitation and life sustaining treatment). The Physician's Orders reflected the code status document was effective [DATE]. Review of the Incident Report dated [DATE] created by LPN K reflected a brief summary of R111's fall and stated that the writer (LPN K) assessed R111 for injuries, pain, obtained vital signs, and assessed R111's neurological status immediately. No evidence of any assessment was located on the incident report. On [DATE] at 2:58 PM, Resident Service Aide (RSA) G reported that she was R111's RSA on the night that he passed ([DATE]). RSA G reported that R111 was not at his normal baseline that night, R111 was falling asleep while consuming his dinner and could not grasp his cups and utensils while self-feeding. R111 had requested to go to bed so RSA G and RSA H placed a gait belt on R111 and attempted to stand him. While attempting to stand and transfer to the bed, R111's knees buckled and R111 was lowered to the floor by RSA G and RSA H. RSA H left the room to retrieve LPN K so she could assess R111 after he sustained the fall. RSA G stated that when R111 was in the Hoyer sling being lifted to his bed, his face turned blue and it appeared that he was foaming at the mouth. RSA G said she immediately knew something was wrong. RSA G reported that she tried to get R111 out of the sling and onto the bed as quickly as possible. LPN K left the room, meanwhile RSA G was screaming R11's name and rubbing his chest in attempt to elicit a response with no avail. When LPN K didn't return, RSA H left the room in attempt to get staff assistance. While RSA G was waiting in the room she overhead a page from LPN K which stated all nurses report to [unit R111 resided on]. RSA G stated that R111 did not appear to be breathing and was staring at the ceiling, not blinking. LPN K did not immediately return to the room to render care to R111. On [DATE] at 3:19 PM, Resident Service Aide (RSA) H stated that he was present when R111 fell and experienced a medical emergency. RSA H stated that R111 seemed a little out of it that night and witnessed R111 shaking, dropping items, and not wanting to eat his dinner. RSA H was assisting RSA G with transferring R111 to the bathroom before bed when R111 appeared to be shaking, unable to ambulate, and unable to hold his body weight. RSA G and H lowered R111 to the floor and retrieved LPN K. RSA H left the room to obtain the Hoyer lift so R111 could be lifted from the floor and into bed. RSA H returned with the Hoyer lift and while transferring him to the bed with the Hoyer lift, RSA H recalled looking at R111's face and noticed him turning blue. RSA H quickly attempted to get R111 onto the bed and LPN K rushed out of the room. RSA H stated that after some time, he had to leave the room and tell LPN K that the situation was serious and R111 was not breathing. RSA H stated that he left to retrieve the crash cart and when he returned, there were more staff present in the room including LPN K. RSA H stated that the staff removed the back board from the crash cart, placed it underneath R111 and then started chest compression. In a telephone interview on [DATE] at 12:49 PM, RSA N stated that she was across the hallway providing care when she exited the room into the hallway and observed RSA G in the doorway asking where LPN K was. RSA N stated that R111 was motionless on the bed and had a grey appearance. RSA N stated she observed RSA H obtaining the crash cart which prompted her to run to obtain the AED. RSA N stated that LPN K was not in the room with RSA G initially but did state that LPN K came back into R111's room but left again. In a telephone interview on [DATE] at 2:09 PM, Licensed Practical Nurse I stated that she was working on [DATE] and responded to R111's medical emergency. LPN I stated she was working on a different unit that night and heard a page overhead which stated, all nurses go to [unit R111 resided on]. LPN I stated that she walked that way unsure which room to report to but observed a few staff outside of R111's room. When LPN I arrived to R111's room, LPN K and a few RSA's were in the room. She noticed that R111 was on the bed and not breathing. LPN I instructed a staff member to call 911 and the asked the RSA's to retrieve the AED. LPN I stated that when the crash cart arrived, staff removed the backboard, place it under R111 and LPN I started chest compressions. When asked where LPN I obtained her Basic Lifesaving Support (BLS) certification, LPN I stated that she took an online class for her BLS certification and did not have to provide any hands-on demonstration. In a telephone interview on [DATE] at 4:15, Licensed Practical Nurse (LPN) J reported she was working on [DATE]. LPN J reported hearing a page overhead and responded to the unit R111 resided on. When she arrived at the room LPN K and I were present and standing in the room. LPN J reported R111 appeared pulseless and blue/gray in color. LPN J stated that someone came with the crash cart, the backboard was removed, and R111's shirt was cut before starting chest compressions. In a telephone interview on [DATE] at 4:39 PM, Licensed Practical Nurse K confirmed that she was working on [DATE] and was the nurse assigned to R111. LPN K stated that in report it was mentioned that R111 was not feeling well that day and struggled with abnormally high blood glucose levels and had poor food acceptance. LPN K stated that upon hearing that R111 was lowered to the floor, she came in and assisted with RSA G and H. LPN K stated that she obtained a set of vital signs while R111 was on the floor and recalls that the blood pressure was a little high and the oxygen saturation reading was down to 86%. LPN K stated that RSA G and H proceeded to place R111 in the Hoyer lift and transfer his bed when she noticed that he started to go blue and not respond when she yelled his name. When asked why LPN K left the room she stated that she left to check and ensure R111 was a code blue (full code), announce a code blue on the overhead paging system, and look for oxygen. When asked why LPN K left the room a second time, LPN K stated she left the room to call the family. When LPN K returned to the room after leaving it the second time, staff members were beginning to respond and bring the crash cart and AED. LPN K stated that upon entry to the room the second time, R111 was still blue and cardiopulmonary resuscitation efforts still had not been started. When asked if any vitals were obtained after the fall and during the code, LPN K stated that the assessment and vitals should be documented on the Incident Report. When asked what method was used to obtain her Basic Life Support (BLS) certification, LPN K stated that she took an online class for her BLS certification and did not have to provide any hands-on demonstration. Review of the Physician Order set for R111 revealed an order which stated Standing Orders okay. Review of the policy titled Standing Orders with an origination date of ,d+[DATE] and a revised date of ,d+[DATE] reflected the Standing Orders approved by the Medical Director. One of the Standing Orders in the facilities policy stated Oxygen per nasal cannula or mask 2LPM PRN [2 liters per minute as needed] for breathing difficulty and O2 SAT [oxygen saturation] below 90. Notify provider for further orders . LPN K reported that R111's oxygen saturation was 86% after the fall, however, there was no documentation provided that reflected oxygen was administered to R111 as ordered. Review of the Video Surveillance footage from [DATE] revealed the following observations: 9:44:40 PM: RSA G and H enter the room together to provide care to R111 9:59:38 PM: LPN K enters the room with the vitals machine 10:05:46 PM: LPN K quickly exits the room and runs toward the nurses station 10:07:02 PM: RSA H exits room pushing a wheelchair towards nurse direction. RSA H stops and appears to shout something toward the direction that LPN K went. RSA H reenters room. Moments later, RSA H exits the room pushing the Hoyer lift out of the room and walks down the hallway toward the direction of LPN K. 10:08:21 PM: RSA N exits room across from R111's room and looks down hall toward LPN K. RSA G exits the room and speaks to RSA N prompting her to urgently enter the room of R111. 10:08:48 PM: LPN K appears and is running down the hallway with an oxygen concentrator 10:08:56 PM: LPN I enters the room of R111 10:09:13 PM: LPN K exits the room, holding onto the vitals machine and faces the room. LPN K is pointing down the hallway. RSA N exits the room and appears to be speaking to LPN K. LPN I also exits the room. The vitals machine remains in the hallway. 10:09:21 PM: LPN K exits the room and runs down the hallway toward nurses station 10:09:23 PM: LPN I reenters the room 10:09:35 PM: RSA H enters the room with the crash cart 10:09:42 PM: LPN J enters the room 10:09:56 PM: LPN K reenters the room 10:10:03 PM: RSA H exits the room 10:10:22 PM: RSA G exits the room 10:20:38 PM: Emergency Medical Services arrive In an interview on [DATE] at 10:11 AM, Licensed Practical Nurse (LPN) L stated that he is a unit manager for the facility, and also helps reviews falls. When inquiring about the fall and medical emergency for R111, LPN L stated that he would be responsible for reviewing the fall but there was not a lot to go off of for the investigation because there was no documentation of an assessment including vital signs from the fall R111 sustained prior to going unresponsive. When queried what the protocol would be if he encountered a situation in which a resident went blue and unresponsive, LPN L stated that the procedure would be to conduct an assessment to include breathing and pulse. If the resident was pulseless, LPN L would call for help and start chest compressions immediately. In an interview on [DATE] at 9:11 AM, Registered Nurse and Clinical Nurse Educator (RN) M stated that she has been conducting mock code blue exercises in the building recently, the first one being held on [DATE]. When asked what the proper procedure is for code blue situations, RN M stated that when staff see someone that is turning blue and unresponsive, they need to check for a pulse, start compression, yell at an RSA or other staff member to call code blue overhead, and call 911. All staff need to come that can but typically it's one RSA from the hallways that grab the crash cart and go to that area. The first nurse on scene is the charge nurse . have someone confirm they are full code, the nurse will verify no pulse, no respirations, call for help and begin CPR (cardiopulmonary resuscitation) .a RSA or nurse can be the clinical recorder. RN M explained that the crash carts have a code blue sheet on them which is to be utilized in the event a code blue situation arises, and code documentation needs to be obtained. RN M stated that all nurses were required to have a current and proper Basic Life Support (BLS) certification which included the course and hands-on demonstration. When queried if LPN K and LPN I had their BLS certification RN M stated that they received their BLS certification outside of the facility. RN M later confirmed that LPN K and LPN I had not completed their hands-on BLS demonstration which meant their current BLS certification was invalid. In an interview on [DATE] at 10:02 AM, Director of Nursing (DON) B reported that if an unresponsive resident needs help, whoever the first one to respond stays with patient, and use light or call out in hallway for help and ask for them to get code cart and AED. The nurse should stay with the patient and start compressions. The staff that goes to get the equipment should call overhead as well for more help . DON B stated that it would not be appropriate to wait for the backboard to arrive before starting chest compressions. DON B stated that the code involving R111 was discussed, and some concerns were identified. When queried what concerns were identified, DON B stated that LPN K should not have left the room and that the RSA should have been sent to gather more help. DON B also stated that the lack of documentation was also an identified concern, so the facility recently started implementing Mock Code Blue training. DON B also acknowledged that the two LPN's (K and I) did not have their proper Basic Life Support (BLS) certification which meant that they were unqualified to perform proper Cardiopulmonary Resuscitation on R111.

Based on interview and record review the facility failed to ensure a comprehensive care plan was in place for one out of 22 residents (Resident 313), resulting in the potential for care needs to not be met. Findings Included: Resident #313 (R313) no longer resided at the facility. Per R313's Electronic Medical Record (EMR) R313 was [AGE] years old with a diagnosis of dementia. Review of a Facility Reported Incident (FRI) revealed Resident Service Aid (RSA) P reported to RN M that on 1/11/2023 she was sitting at the nurses' station when she overheard RSA Q say to R313, (R313) you stop that shit; there is no cat in there. So annoying, and then walk out of R313's room. In an interview on 11/14/2023 at 3:59 PM, RSA P said while she was sitting at the nurses' station she heard RSA Q, who was in R313's room, loudly say the R313 that there was no cat in here, and then said stop that shit there are no cats. In an interview on 1/15/2023 at 9:33 AM, RSA Q stated that R313 was afraid of cats. RSA Q said the facility had cats but the cats did not usually come into the hall R313 resided on. Review of a progress note dated 9/6/2022 revealed, RSA and Nurse both noted elder asking about a cat and requesting it not be on her bed or in her room. Staff has not noted a cat in this elders room, nor a cat in her bed when she requests for it to be taken off her bed . Review of a written witness statement from RSA Q dated 1/19/2023, revealed RSA Q stated that R313 was afraid of cats, and would put her call light on several times regarding cats being in her room. Review of an incident summary revealed RSA Q had made a statement that R313 was always afraid of cats being in her room, would put her call light on several times about a cat in her room, and had caught R313 going to her closet to chase cat out. Review of R313's care plans revealed there was no care plan in place that identified the concern R313 had with a fear cats, nor were there any interventions in place that addressed R313's fear of cats and thinking cats were in her room.

This citation pertains to intake numbers MI00136522 and MI00135497. Based on interview and record review the facility failed to ensure for two out of six residents (Residents 312 and 313) allegations of abuse were reported immediately to the abuse coordinator and state agency resulting in the potential for alleged and/or actual abuse to not be reported. Findings Included: Resident #313 (R313): R313 no longer resided at the facility. Per R313's Electronic Medical Record (EMR) R313 was [AGE] years old with a diagnosis of dementia. Review of a Facility Reported Incident (FRI) revealed Resident Service Aid (RSA) P was attending a training class on 1/19/2023, and when abuse and neglect were discussed RSA P recalled an incident that had occurred on 1/11/2023. The FRI revealed that RSA P reported to Registered Nurse (RN) M, who was the staff educator, that she witnessed abuse that she did not report. Further review of the FRI revealed RSA P reported to RN M that on 1/11/2023 she was sitting at the nurses' station when she overheard RSA Q say to R313, (R313) you stop that sh*t; there is no cat in there. So annoying, and then walk out of R313's room. Review of RSA P's EMPLOYEE IN-SERVICE TRAINING dated 10/20/2022, revealed RSA P had received training in an in-service on, .Abuse Prevention and Intervention Program . In an interview on 11/14/2023 at 3:59 PM, RSA P stated that she did not report the abuse she witnessed, because she was not fully aware of the facility's process for reporting alleged or actual abuse. RSA P said while she was sitting at the nurses' station she heard RSA Q, who was in R313's room, loudly say the R313 that there was no cat in here, and then said stop that shit there are no cats. RSA P said she had forgotten to tell the nurse she was working with. During the same interview RSA P said she was going to ask two other employees what she should do, but got to busy and forgot before she ended her shift. In an interview on 11/16/2023 at 08:20 AM, RN M stated that she was talking about abuse at the beginning of the training class. RN M said at the break RSA P told her about the abuse allegation that occurred on 1/11/2023. RN M said RSA P told her that she did not want to get anyone in trouble, and did not know what to do. RN M said RSA P had full abuse training upon her hire. In an interview on 1/15/2023 at 9:33 AM, RSA Q stated that nothing happened on 1/11/2023 when she cared for R313. RSA Q said she did not say anything to R313 regarding cats, and said R313 was afraid of cats. RSA Q said the facility had cats but the cats did not usually come into the hall R313 resided on. RSA Q said she did not recall what she said to R313 on 1/11/2023, but stated that she must have said that the R313 because the facility said she did. Review of RSA Q's education on abuse revealed that on 3/11/2022 RSA Q had received training on abuse that included recognizing, reporting, and prevention. Also on 6/25/20222 RSA Q was educated again on abuse. Review of the incident reported to the state agency revealed that the incident occurred on 1/11/2023, but was not reported to the state agency until 1/19/2023. Review of the facility policy and procedure dated 5/2021 and revised 8/2023, revealed on page six and seven, The facility will have written procedures that include: a. Reporting of all alleged violations to the Administrator or designee, state agency, adult protective services, and all other required agencies (e.g., law enforcement when applicable) within specified time frames: i. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Abuse, Neglect and Exploitation. ii. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 46955 Resident #312 (R312) Review of the medical record revealed that Resident #312 (R312) was admitted to facility 4/18/2017 with diagnoses including severe vascular dementia with mood disturbance, major depressive disorder, and anxiety disorder. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/20/23 reflected that R312 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 3 (severe cognitive impairment). Further review of the medical record reflected that R312 was discharged to the hospital on 8/7/23 and did not return. Review of the Facility Reported Incident reflected Date/Time Incident Occurred: 3/18/23, Date/Time Incident Discovered: 3/20/2023 8:15 AM. Incident Summary within same report revealed According to resident service aide, [Resident Service Aide (RSA) E], [RSA E] and another resident service aide, [RSA F] was in resident [R312's] room providing care. [R312] was being aggressive with [RSA F]. [RSA F] stated to [R312], If you are going to be mean to me, I am going to be mean to you. Once care was finished, as the two aides were exiting the room, [RSA F] said, You're so mean to me. I hope your cat (stuffed cat) pees on you. [RSA F] then hit [R312's] stuffed cat. In a telephone interview on 11/14/23 at 11:18 AM, RSA E stated that she had been employed at the facility from the beginning of January 2023 to approximately the end of March 2023, confirmed familiarity with R312, and stated that R312 was one that had to be talked to in a certain way as she was a little hesitant with cares, resistant with changing and dressing and had to be a little cautious with as she would strike out and swear when being changed. RSA E stated that on the 3/17/23 night shift she was being trained by RSA F and that toward the end of that same shift, on 3/18/23 at approximately 4:00 AM, while she and RSA F were trying to change R312, R312 began swearing, grabbing, and scratching at RSA F. RSA E stated that RSA F began taunting R312 by sticking her tongue out at her, telling her that she was mean, saying that if she hit her again she would hit her stuffed cat and that she hoped her cat would pee on her, and stated that from what she could recall, RSA F did end up hitting her cat. RSA E stated that she initially thought that RSA F was joking with R312 but as RSA F repeatedly taunted R312, said mean things to her, verbally insulted her, and then hit her cat, she realized that what she witnessed could be considered abuse. RSA E stated that she distracted and redirected R312 so that she would focus on her instead of RSA F and that they were then able to finish R312's care. RSA E stated that both she and RSA F exited R312's room and that she made a mental note to herself to report what she had witnessed as she didn't know exactly what to do as she was newer, didn't know if she could tell the nurse, as thought that she had to tell the boss so as not to involve the floor nurse. RSA E stated that the end of the shift was hectic, she left work without reporting the potential abuse that she had witnessed, returned home, and went to bed. RSA E stated that later that same day (3/18/23), although she could not recall a specific time frame, she either sent a text or an email to Human Resource Specialist (HRS) D to inquire what she should do if she witnessed abuse on a weekend. RSA E stated that she then received a phone call from HRS D on the following Monday (3/20/23) morning, that she went to the facility to complete a report about what she had witnessed, and that she received training regarding identifying and reporting abuse a few days later. RSA E stated that from that training she learned something that she had not known and that she had messed up as she should have reported the abuse that she had witnessed on 3/18/23 immediately to whomever was in charge at that time. RSA E stated that she thought she had received training regarding abuse identification and reporting upon hire to the facility in January 2023 and then again in March but that the education was brief and she couldn't recall the exact training provided but stated that she thought she had to take a quiz regarding abuse reporting with both training's. Review of email correspondence dated March 18, 2023, at 5:55 PM, from RSA E to HRS D stated, I need to report something about witnessing a coworker use abuse towards an elder. How do I go about doing that on a weekend? Review of email correspondence dated March 20, 2023, at 7:30 AM, from HRS D to RSA E stated, You need to report any type of abuse to your nurse immediately no matter when it is. Please call me ASAP [as soon as possible] so that I can get the information from you regarding what you witnessed as this is very important. In a telephone interview on 11/14/23 at 3:20 PM, HRS D stated that she did not work weekends, did not always check her emails on the weekends and that from what she could recall, upon arriving to work on Monday, 3/20/23, she had received a potential allegation of abuse from RSA E via email dated 3/18/23. HRS D stated that she immediately reported the allegation to Corporate Compliance & Quality Assurance Director (CC/QAD) C, responded back to RSA E regarding the proper channels to report abuse, and requested that RSA E come to the facility to provide a written report of the allegation. HRS D stated that she did not normally receive abuse allegations via email and that staff knew to report any suspected abuse immediately to nurse or Nursing Home Administrator (NHA) A so that immediate follow up could be completed. In an interview on 11/14/23 at 4:20 PM, CC/QAD C stated that NHA A was the abuse coordinator but that if NHA A was unavailable for any reason, that any allegation of abuse would be reported directly to her, and that she would coordinate with NHA A, if needed, and begin an investigation. CC/QAD C stated that that per the facility's abuse policy that if any staff identified anything that could be potential abuse, resident safety would first be assured, a supervisor would be notified and then NHA A would be immediately notified for further direction. CC/QAD C further stated that all staff were able to call NHA A directly to report potential abuse but that frequently the RSA's reported directly to the nurse supervisor and then the supervisor reported to NHA A which was acceptable as long as the potential abuse was reported immediately upon identification. Upon review of the Facility Reported Investigation, CC/QAD C stated that she was alerted to the potential allegation of abuse on 3/20/23 upon arrival to work by HRS D, that HRS D communicated with RSA E via phone to obtain an initial statement and that RSA E then came to the facility that same date to provide a written statement. CC/QAD C stated that an investigation was initiated immediately based on HRS D's telephone interview with RSA E and that the incident was submitted to the State Agency. CC/QAD C confirmed that the alleged abuse incident occurred 3/18/23 and as was reported via email was not discovered until 3/20/23 at 8:15 AM and was not submitted to the State Agency until 3/20/23 at 8:42 AM. CC/QAD C acknowledged that RSA E had received education regarding the facility's abuse policy upon hire and follow up education on 3/14/23 but that RSA E may have hesitated to report the alleged abuse as she was timid and potentially intimated by more experienced RSA F. In an interview on 11/14/23 at 4:59 PM, NHA A acknowledged that the expectation would be that any potential allegation of abuse be reported immediately to the direct supervisor and/or the abuse coordinator so that an investigation could be promptly initiated and any needed follow up completed. NHA A further stated that RSA E and all staff received reeducation regarding abuse identification and reporting following the 3/18/23 incident. Review of RSA E's personnel file indicated a date of hire of 1/4/23. A form tilted Abuse Policy Acknowledgement signed and dated by RSA E on 1/4/2023 stated, I have read and understand the facilities abuse policy as it was presented to me in orientation. I acknowledge my immediate concern is for the safety of the elder/resident and removing them from potential harm. I will immediately inform the household nurse of the potential abuse and then contact the Abuse Coordinator, [Nursing Home Administrator (NHA) A]. I understand I will need to fill out a Witness Statement containing the facts of the potential abuse. A separate quiz titled Abuse and Neglect dated 1/4/2023 was noted to be completed by RSA E. A form titled Human Resources Department Employee General Orientation Checklist within RSA E's file was also noted to include Employee In-Service Training .[Facility Name's] Abuse Prevention and Intervention Program - 1 Hour initialed by RSA E as completed and signed/dated by RSA E on 1/5/2023. Document titled Education regarding reportable incident on 1-18-2023 & 1-19-2023 Education for All Staff stated, Any suspicion of abuse must be reported immediately to a supervisor/nurse with associated Quiz for the Reporting abuse education noted to be completed and signed by RSA E with a date of 3/14/22 (date clarified as 3/14/23 by RSA E and by CC/QAD C during separate interviews). Despite the receipt of abuse education and reporting by RSA E at facility hire and again just 4 days prior (on 3/14/23) to the witnessed alleged abuse on 3/18/23, RSA E reported the allegation of potential abuse via email greater than 12 hours after the event had been witnessed. Review of the facility policy titled, Abuse, Neglect and Exploitation with an 8/2023 revised date stated, Policy Statement: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .G. Reporting/Response .1. The facility will have written procedures that include: a. Reporting of all alleged violation to the Administrator or designee, state agency .within specified time frames: i. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .

This citation pertains to intakes MI00136626 and MI00140194. Based on observation, interview, and record review the facility failed to protect the residents' right to be free from sexual abuse by a resident for two residents (Resident #6 and Resident #3) of six reviewed, resulting in Resident #6 being sexually abused by Resident #5 which caused increased tearfulness, anxiety, and emotional distress and Resident #3 being sexually abused by Resident #4. Findings include: Resident #5 (R5) and Resident #6 (R6) Review of the medical record revealed R5 admitted to the facility on [DATE] with diagnoses that included diabetes, anxiety disorder, and major depressive disorder. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/23 revealed R5 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record revealed R6 admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, generalized anxiety disorder, and major depressive disorder. The MDS with an ARD of 8/7/23 revealed R6 was severely cognitively impaired. Review of the Facility Reported Incident revealed Incident Summary On 10/7/23 at approximately 7:15 p.m., resident service aide [Certified Nursing Assistant (CNA)] D heard resident [R6] yelling no, no, no from the dining room in Windsor Ridge. [R6] often states, no, no, no, but her voice was elevated. [CNA D] entered the dining room and found that resident [R5] had [R6] pinned against the wall in her wheelchair and was rubbing her vagina. [CNA D] immediately separated [R6] and [R5]. She asked [R5], What are you doing? He stated, I was pleasuring her. [CNA D] told [R5] that he cannot do that. She immediately [R6] back to her household and room. She returned and took [R5] to his room. She informed her nurse. [R5] was placed on a 1:1 while out of his room. The double doors to the household were closed to deter [R6] from entering Windsor Ridge. The nurses [Licensed Practical Nurse (LPN) O] and [LPN S] completed a skin assessment of [R6]. She has 1 x 1 cm raised red area that appears like a scratch on her labia. [R6] is rarely/never understood. At this time, [R6] has not displayed any reaction to the above incident and is currently resting in bed. Law enforcement has been contacted. The facility's investigation revealed the camera footage was reviewed on 10/9/23 and revealed the following: 6:40 PM R5 was in the Windsor Ridge dining room by himself 6:41 PM Dietary Aide approached R5 and spoke to him, continued cleaning up the dining room 6:42 PM the Dietary Aide walked out of the dining room 6:47 PM R5 propels his wheelchair in the dining room, moving a cart around 6:48 PM R6 enters the dining room. R5 continues to move the cart, not looking at R6. R6 moves around a table 6:49 PM R5 shuts the back of the dining room light off and sees R6 6:50 PM R6 moves closer to R5 and around the table. She is face to face with R5, touching her leg and hand 6:50 PM R6 backs away 6:52 PM R6 is moving around 6:53 PM R6 reapproached R5 and reaches out to him. She grabs his hand. R5 is holding R6. R5 begins to touch her vaginal area of clothing. 6:54 PM R6 backs away. R6 moves around the table, pulling at her shirt sleeve. R5 continues to sit at the same place in the dining room 6:55 PM R5 moves towards R6. R5 fixes R6's shirt sleeve. 6:56 PM R6 backs away 6:56 PM R6 wheels forward and then back. R6 appears stuck and trying to move. She continues to wheel back and forth. Her legs are up and moving. Her left pant leg is up. 6:59 PM R6 continues to be stuck near R5 7:05 PM R6 and R5 are together 7:06 PM R6 and R5 are in close contact and R5 is touching R6's vaginal area over her clothes 7:07 PM CNA D enters and separates R5 and R6 by removing R6 from the dining room 7:08 PM R5 remains in the dining room sitting in his wheelchair, leaning his head back 7:09 PM R5 propels out of the dining room and stops to interact with a housekeeper 7:11 PM R5 continues to propel down the hall towards his room 7:13 PM R5 enters his room On 10/18/23 at 9:05 AM, R6 was observed sitting in a wheelchair at a dining room table with her eyes closed. A staff member was feeding R6. On 10/18/23 at 9:31 AM, R5 was observed sitting in a wheelchair in his room. R5 reported he had been in the facility for one year and recently moved to the first floor from the second floor. When asked why he moved to a new room, R5 stated I was a bad guy. I molested a woman. R5 was able to identify R6 by stating her first name and reported R6 was still upstairs and that's why he moved to a different floor. R5 reported he had since learned that R6 had dementia and he did not know that when the incident occurred. R5 reported he had previous interactions where the same thing happened and he molested R6. R5 reported these previous incidents happened once in his room and once in the community room. R5 stated apparently they saw it, but I didn't know they saw it. Review of the Nurse Practitioner Note dated 10/9/23 revealed R6 was found in dining room being assaulted by a male resident rubbing her peri area. She is seen today to examine for any injuries. She is very agitated, tears running down her face, grinding her teeth, saying No, No, No. In a telephone interview on 10/18/23 at 1:50 PM, CNA D reported the day of the incident, she heard R6 sounding distressed. CNA D reported she went to assist R6 and found R5 sexually assaulting R6 in the dining room. CNA D reported R5 had one hand holding the arm of R6's wheelchair and the other hand rubbing her vagina. CNA D stated, He was right in front of her. She couldn't move in any direction. CNA D reported she asked R5 what he thought he was doing and R5 reported he was trying to get R6 excited. CNA D reported since the incident, it's heartbreaking caring for R6 because R6 becomes more tearful, doesn't wander down the hall as much, and doesn't want staff to touch her anymore. CNA D reported R6 also calls for Momma often and she never did that before. In an interview on 10/18/23 at 12:51 PM, CNA J reported R6 usually grabs her clothes and clenches during care but was able to be calmed down. CNA J reported since the incident, staff has not been able to calm R6 down as easily. CNA J reported R6 has been more resistive, more tearful, and looks like she is zoning out. In an interview on 10/18/23 at 1:08 PM, CNA K reported she has worked full time with R6 for one year. CNA K reported since the incident with R5, R6 grabs herself and tries to prevent staff from helping her, has been more difficult with any care, and has been more resistive. CNA K reported R6 has had a lot more tearfulness every day and that R6 zones out a lot more now too. CNA K reported one day since the incident, she was assisting R6 with toileting and R6 pointed behind CNA K and said, Get him, get him! and started bawling. CNA K reported another night she was checking R6 in bed and R6 yelled out Momma, Momma and stated R6 has never done that before. CNA K reported she tells R6 that He's not here, he's gone and then R6 will nod her head and wipe her tears away. In an interview on 10/19/23 at 11:01 AM, CNA R reported he cares for R5 all the time. CNA R reported there have been frequent incidents of R5 touching nursing assistants and making moaning noises when nurses perform a straight catheterization on him. CNA R reported he assists R5 with his showers because the female staff are uncomfortable due to R5 making sexual comments and asking for sexual favors from staff. CNA R reported sometimes R6 would pick up her pant leg and R5 would comment that R6 had sexy legs. In a telephone interview on 10/19/23 at 11:54 AM, CNA N reported she has worked with R6 a few times since the incident with R5. CNA N reported she has noticed a huge difference with R6 being more tearful, more anxious, and more resistive with care. CNA N reported approximately two days after the incident, she was performing R6's peri care and R6 was very resistive with moving her legs or spreading her knees, crying, and screaming. CNA N reported when finished with care, she assisted R6 into her wheelchair, apologized and explained she was just taking care of her. CNA N reported she asked R6 if she was ok and R6 looked me dead in the eyes and said, No. CNA N reported she had never seen R6 do anything like that. In a telephone interview on 10/19/23 at 12:35 PM, CNA M reported after the incident between, the nurse assessed R6 and found a cut on her private area. CNA M reported since the incident, R6 had not been the same, she is very withdrawn, cries a lot now .very detached, just stares into space. CNA M reported R6 did not do those things before the incident. In a telephone interview on 10/19/23 at 3:58 PM, LPN O reported at the time of the incident between R5 and R6, she was downstairs assisting another nurse. LPN O reported she performed a full body assessment on R6 and found a small cut approximately one to three centimeters on R6's left labia. LPN O reported R6 was pretty agitated after the incident, kept saying no, no, no and guarding her private area. LPN O reported she had to have another nurse hold R6's legs open to perform the skin assessment. LPN O reported for the first few days following the incident, R6 was more agitated, had more anxiety, was more difficult to move, and more timid with care. Review of the facility's investigation revealed staff interview questions included: 1. Have you ever witnessed [R5] and [R6] interacting? If so, please explain 2. Has [R5] ever been sexually inappropriate? If so, how did you handle it? The responses to question 1 included: Yes, [R6] came down to Windsor and was down in the dining area and [R5] said hi to [R6] and touched her hand, in a friendly like manner. [R5] would just talk about [R6]. Say she is pretty or how she would roam. Just talking and mocking her. She said no, no, he would say yes, yes. Yes, [R5] would mock her no, no, no and say yes, yes, yes. multiple statements saying he would mock her when she repeatedly said no, no, no. Responses to question 2 included: Told him it was inappropriate and making staff uncomfortable. Only one time [R5] made a moaning sound when I was doing [his] straight cath [catheter]. I educated him it was not appropriate and he apologized. Have heard from co-workers afterwards that yes. For me he talked about Lizard Lot. Something about women at a truck stop. He would talk about his wife being a sexaholic. I would tell him all that is inappropriate. He makes [comments] to staff, will [purposefully] drop stuff so us ladies have to bend over to grab it. Or when you wash him up he will ask how's it look. When giving him a shower in Windsor he made multiple comments about getting me to play with his balls and I keep asking people to and no one will. I told him that we would not do that, we don't offer those services here and maybe he should find something online. He made similar comments the following day. I deferred his care to [male CNA's name] whenever possible after that. Staff Interview Questions related to R6 included: Have you noticed a change in [R6's] baseline? If yes, what has changed? Please explain in detail. Answers included: Sleeping more, resistive [with] care (even more than before), seems scared. Yes, sleeping more-increase in her meals-not as resistive with changes. She has cried more and more often. Yes. Zoning off. Cried a single tear while RSA [CNA] fed her breakfast. Resisting taking pants off for brief changes and calling for her mother during any peri care. Sleeping all day, decreased FAR [food acceptance record]. A little more resistive with care, will hold her legs more closed, holds onto her pants/brief. More resistive with care. Doesn't wander as much. Yes. She has been more tearful when care is being done and when it isn't being done. She's been calling out for her mother and saying no. She has had a vacant expression in her face and eyes. Yes. [R6] has been more tearful during personal care, and is resistive with spreading her knees apart. She has been yelling out more during and not during peri care. She has been more tearful and staring off into space. She hasn't been going down the other halls as much as she used to. Yes, not as talkative with us or communicating with us like normal more resistive with care, more tearful when giving care. Yes. [R6] is not as communicative as she was on Friday. She is either zoned-out, crying or sleeping. She is not as responsive to us trying to talk to her, she used to answer or have some sort of reaction to me. She's being more resistive [and] tearful with any care. Sleeping more, don't see her much in the hallways. Doesn't roam the halls as much. Elder has been more anxious/agitated when roaming the halls & getting stuck in things (wall, lift, BP machine). During care elder is more resistive with [CNAs] changing brief, more difficult to get her legs open. In an interview on 10/19/23 at 8:46 AM, Nursing Home Administrator (NHA) A reported after the incident, R5 was charged with second degree criminal sexual conduct and a warrant had been served on 10/18/23. ON 10/19/23 at 12:38 PM, NHA A and Corporate Compliance & Quality Assurance Director (CCQAD) C reported they were not aware of any previous sexually inappropriate incidents between R5 and R6, but that R6 was now reporting previous incidents. Resident #3 (R3) and Resident #4 (R4) Review of the medical record revealed R3 admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease. The MDS with an ARD of 9/22/23 revealed R3 was severely cognitively impaired. Review of the medical record revealed R4 admitted to the facility on [DATE] with diagnoses that included dementia, psychotic disorder with delusions, restlessness and agitation. The MDS with an ARD of 6/13/23 revealed R4 scored 4 out of 15 (severe cognitive impairment) on the BIMS. On 10/18/23 at 9:12 AM, R4 was observed sitting in his wheelchair at the nurses' station. On 10/18/23 at 9:13 AM, R3 was observed sitting in a geri chair in her room. R3's doorway had a swinging gate. Review of R4's Nurse's Note dated 4/27/2023 revealed At 0745 [7:45 AM], RSA [CNA] notified writer that when RSA walked into the dining room she observed elder with his hands under another elders shirt. Elders were immediately separated, no distress noted to either elder. Review of R3's Nurse's Note dated 4/27/2023 09:23 revealed At 0745, RSA notified writer that when RSA walked into the dining room, she observed another elder had his hands under this elder's shirt. Elders were immediately separated, no distress noted to either elder. Writer assessed under elder's shirt, no redness or bruising noted. In an interview on 10/19/23 at 9:18 AM, CNA P reported on 4/27/23, she entered the dining room and observed R4 with his hands up R3's shirt and caressing her breasts.

Based on observation, interview and record review, the facility failed to prevent a severe weight loss over three and six months, in 1 (Resident #2) of 3 residents reviewed for weight loss, resulting in a pressure ulcer, unmet nutrition needs and decreased quality of life. Findings include: Resident #2 (R2) On 10/14/20 at 11:45 AM, R2 was observed lying in bed with his lunch next to him on an over the bed table, his sandwich was untouched. In review of tasks, R2's food acceptance for lunch on 10/14/20 was 0 to 25 percent (%) intake. R2's Admission Nutrition assessment dated [DATE], indicated he was at moderate risk for nutrition-related problems. R2's current body weight, at the time of the assessment, was 126.8 pounds (lbs.); his discharge weight from a previous admission in 2014 was around 150 lbs., and his usual body weight was around 160 lbs. R2's estimated calorie needs were 1800 calories and his protein needs were calculated at 60 to 70 grams (gm) a day. R2's goal was for weight stability with no significant weight changes. Registered Dietitian Admission Note dated 4/01/20 indicated a past history of falls with recent hospitalization due to a fall with multiple rib fractures resulting in a small pneumothorax (collapsed lung, air enters the space around lungs), dementia, [DIAGNOSES REDACTED] (pockets form in the walls of digestive tract), [MEDICAL CONDITIONS] reflux disease (GERD, liquid content of the stomach refluxes into the esophagus), and depression. The same note indicated R2 was on a regular diet, regular texture with thin liquids. R2 reported he had a poor appetite and was eating about 50 % of his meals. R2's goal was for intakes to be at least 75%. R2 reported that he enjoyed cookies, mashed potatoes gravy, and ice cream, and would offer fortified foods (magic cup) with meals to help him meet his estimated nutrition needs. The same note revealed R2 was able to eat independently with setup help and he requested a dark colored plate due to a visual impairment. R2's Admission Minimum Data Set (MDS) 3.0 assessment, with an assessment reference date (ARD) of 4/06/20, introduced the Brief Interview for Mental Status (BIMS), a short-performance-based cognitive screener for nursing home (NH) residents, score was 10 (scale: 08-12 Moderate Impairment). The same MDS assessment indicated R2 was independent (no help or staff oversight at any time) with set-up help only, for eating and drinking. The same MDS assessment indicated R2 required extensive assistance (staff provided weight bearing support) of two staff for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). R2's same MDS indicated he did not have pressure ulcers and was at risk for pressure ulcers. R2's weight documented on this same assessment was 127 pounds (lbs.). R2's care plan dated 4/01/20 indicated he would take a magic cup, mighty shake or high calorie juice with his meals. R2's care area assessment (CAA) for pressure ulcers, dated 4/08/20, revealed [DIAGNOSES REDACTED]. The same CAA indicated medication's that increase risk of pressure ulcer injury/development included R2's use of opioids for pain management. R2's Nurses Notes dated 5/16/20 at 9:17 AM revealed a facility acquired pressure ulcer (localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) with a red, non-blanchable area that measured 5.0 centimeter (cm) by 6.0 cm's, with a grey area in the center, measuring 1.0 cm by 1.0 cm. The same note indicated the pressure ulcer was tender to the touch. Nurses Notes dated 5/18/20 at 1:11 PM indicated R2's pressure ulcer was located on his left heel. Physician's Progress Notes dated 5/26/20 at 9:31 AM reflected R2 was medically stable excluding the development of a pressure ulcer. The same note indicated would maintain current pain management strategies especially since now R2's heel appeared to be a source of discomfort in addition to the arthritis. The same note indicated R2's rib fractures and [MEDICAL CONDITION] were resolved. R2's care plan on 6/03/20 reflected his goal was to accept 4 ounces (oz) of med pass supplement three times a day between meals with medication pass times. According to the Medline website at https://www.medline.com/product/Med-Pass-20-Nutritional-Supplement/Oral-Supplements/Z05-PF #:~:text=Med%20Pass%202.0%20Fortified%20Nutritional%20Shake%20by%20Hormel,Vanilla%2C%20Butter%20Pecan%20%2011%20more%20rows%20, 4 ounces of supplement contains 240 calories, and three 4 oz supplements a day would provide 720 calories. R2's electronic Weight Summary indicated on 6/09/20 his weight was 123.4 lbs. R2 Nutrition CAA, ARD 7/05/20, reflected the CAA triggered for nutritional status due to being on a mechanically altered diet while a resident and presence of pressure areas to skin; currently on a regular diet, regular texture with mechanical soft meats only and thin liquids. The same note indicated R2 had poor food acceptance and often refused meals; sometimes accepted fortified foods and 4 oz med pass supplement three times a day in between meals. 7/7/20 weight is 122.2 lbs. (BMI 23.9) and reflects a stable weight over the last month. Weight has been maintained between 120-125 lbs. since mid-April. Will continue to encourage foods in order to ensure adequate nutrition and hydration status; will continue to monitor skin, intakes, weight, and food acceptance in order to ensure adequate nutrition and hydration status. R2's electronic Weight Summary revealed on 7/28/20 his weight was 120.2 lbs. R2's August 2020 electronic food acceptance documentation revealed he refused breakfast 24 out of 31 times, and he ate 0 to 25 % 3 times. R2's lunch intake in August 2020 indicated he refused lunch 21 times and ate 0 to 25 % on his lunch 7 times. R2's August 2020's dinner documentation revealed he refused dinner 15 times and ate 0 to 25 % for 14 meals. R2's August 2020 Medication Administration Record [REDACTED]. R2's weight summary revealed on 9/01/20 his weight had dropped to 113.2 lbs., an 8.2% severe weight loss over 3 months. There were no new nutrition interventions added to R2's care plan in September 2020. R2 weight loss over 5 months was 15.6 lbs., 12.13 %. R2's September 2020 eating task coding revealed he refused meals the entire day; breakfast, lunch and dinner; on 6 of the days during the month. R2's September 2020 eating task coding revealed he refused breakfast 17 times during the month; he ate 0 to 25 % of breakfast 11 times during the month of September; and ate 26 to 50 % of his breakfast 2 days during the same month. R2's September 2020 Medication Administration Record [REDACTED]. R2's Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed his cognitive skills for daily decision making was moderately impaired (decisions poor, cues/supervision required). The same MDS assessment revealed R2 had a weight loss of 5 percent (%) or more in the last month or loss of 10% or more in last 6 months and was not on a physician-prescribed weight loss regimen. R2's Weight Summary report indicated on 10/06/20 his weight was 112.6 lbs.; on 10/20/20 his weight was 107.7 lbs. R2's care plan on 10/07/20 goal was changed to accept 4 oz med pass supplement three times a day between meals with medication pass times and pro-stat supplement, 30 milliliters (ml) twice a day. According to the Healthfully website at https://healthfully.com/ 6-pro-stat-101-nutrition-information.html#:~:text=Pro-Stat% %20is%20a%20protein-based%20nutrition%20supplement%2C%20manufactured,shown%20to%20promote%20wound%20healing%2C%20according%20to%20MayoClinic.com; Pro-stat had 101 calories per ounce, and 2 oz.'s per day would provide 202 calories. Registered Dietitian W was interviewed on 10/21/20 at 12:52 PM and stated R2's protein needs should have increased with the development of a pressure ulcer. RD W stated she did recommend pro-stat supplement on 10/07/20 for R2 due to the pressure ulcer. RD W stated in the same interview she would calculate R2's protein needs at 1.4 grams per kilogram. RD W stated they had not addressed option of a tube feeding yet with R2's family. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.17.1, October 2019, indicated unrelieved pain adversely affected function and mobility contributing to dependence, skin breakdown, contractures, and weight loss. If significant weight loss was noted, the interdisciplinary team should review for possible causes of changed intake, changed caloric need, change in medication (e.g., diuretics), or changed fluid volume status.

Based on observation, interview, and record review, the facility failed to address medication interactions in 1 of 5 residents reviewed for medication review (Resident #61), resulting in unnecessary medication and weight loss. Findings include: Resident #61 (R61) On [DATE] at 10:23 AM, R61 was observed sitting in a recliner chair with his feet up. R61's admission Minimum Data Set (MDS), with assessment reference date (ARD) of [DATE], introduced the Brief interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, was 03 (scale ,[DATE] Severe impairment). The same assessment indicated R61 did not have any verbal, physical or other behaviors; and did not wander during the look-back period. The same assessment revealed R61 did not receive antipsychotic medication during the look-back period. R61 was admitted to the facility on [DATE]. According to R61's February 2020 Medication Administration Record [REDACTED]. Progress Notes dated [DATE] at 4:03 PM revealed R61 called out help me frequently throughout day. R61 reported pain during urination and orders were received for a urine analysis and to push fluids. R61's [DATE] MAR indicated [REDACTED]. physician progress notes [REDACTED]. and restlessness were not effective. Despite having dementia, being blind, then losing wife and home, it was believed there was an element of [MEDICAL CONDITION]. Then same note indicated the plan included to initiate [MEDICATION NAME] (antipsychotic) 0.25 mg twice daily. Consent for Chemical Restraint Use dated [DATE] for [MEDICATION NAME] (antipsychotic) did not include moderate interactions with [MEDICATION NAME]. Progress Notes dated [DATE] at 3:02 PM revealed yelling behaviors continued. Progress Notes dated [DATE] at 11:56 AM indicated a new order to Increase [MEDICATION NAME] to 0.5 mg twice daily was obtained. According to Drugs.com website at https://www.drugs.com/drug_interactions.html, interactions between [MEDICATION NAME] and [MEDICATION NAME]; [MEDICATION NAME] and [MEDICATION NAME]; and [MEDICATION NAME] and [MEDICATION NAME] medications had moderately clinically significant interactions and were usually avoided with exception of special circumstances. The same website indicated common side effects of [MEDICATION NAME] included nausea, decreased appetite, visual distrubance, [MEDICAL CONDITION], and anxiety. The same website revealed taking [MEDICATION NAME] together with [MEDICATION NAME] may increase side effects such as dizziness, drowsiness, confusion, and difficulty concentrating. Some people, especially the elderly, may also experience impairment in thinking, judgment, and motor coordination. Taking [MEDICATION NAME] along with [MEDICATION NAME] increase the effects of [MEDICATION NAME] and can cause development of extrapyramidal symptoms resulting in tremor, shuffling of feet, drooling, a mask-like face, tongue stiffness, muscle spasms or rigidity, and involuntary movements. The same website revealed use of [MEDICATION NAME] together with [MEDICATION NAME] may increase side effects such as dizziness, drowsiness, confusion, and difficulty concentrating. The American Geriatric Society, A POCKET GUIDE TO THE 2019 AGS BEERS CRITERIA®, website at http://files.hgsitebuilder.com/hostgator 2/file/ags_2019_beers_pocket_printable_rh.pdfl.; indicated any combination of 3 of these active central nervous system (CNS) drugs: Antidepressants, Antipsychotics, Benzodiazepines, Opioids; Increased risk of falls and of fracture. physician progress notes [REDACTED]. A variety of pharmacologic interventions have been attempted all with discussion with daughter. Unfortunately, none have been really effective and as a result recently [MEDICATION NAME] has been added. It may have reduced marginally the amount of time he spends screaming but when he does, he is just as loud and disruptive. Staff are reporting that he continues to shout and has been threatening to punch them. Screams help but cannot tell staff what he wants help with. Frequently screams he cannot see, or he needs to pee. Transferring back and forth between the wheelchair and recliner chair all day long without a clear purpose. The same note indicated he was increasing R61's [MEDICATION NAME]. would taper off [MEDICATION NAME], and in the future may be able to taper off [MEDICATION NAME]. Progress Notes dated [DATE] at 2:18 AM, revealed R61's behaviors continued, and he was found sitting on the floor in front of his recliner chair at 10:35 PM, after hearing a loud thud. R61's [DATE] MAR indicated [REDACTED]. There was no update made to the Consent for Chemical Restraint Use to include the addition of [MEDICATION NAME] and/or [MEDICATION NAME]. On [DATE], R61's power of attorney gave consent for gene testing as indicated on a gene testing (analyzes individual's genetic makeup and how their genetics may affect their reactions and responses to certain medications or drug treatments) consent form. The same consent indicated the test may be used by the resident's clinician to assist in medication treatment decision making. According to a gene test report dated [DATE], [MEDICATION NAME] was included in a list of medications that were a significant gene-drug interaction; serum level may be too high, lower doses may be required; genotype may impact drug mechanism of action and result in reduced efficacy; use of this drug may increase risk of side effects; FDA label identifies a potential gene-drug interaction for this medication. The same report identified [MEDICATION NAME] as a significant gene-drug interaction; serum level may be too high, lower doses may be required; use of this drug may increase risk of side effects; and FDA label identifies a potential gene-drug interaction for this medication. Progress note dated [DATE] revealed R61 had not met his fall goal I will have not have any injurious falls through next review; he has had 5 falls during the assessment period and falls of [DATE] and [DATE] resulted in complaints of pain. Progress notes reviewed a revealed additional fall occurances on [DATE], [DATE], [DATE], [DATE] and [DATE]. Quarterly Assessment of Psychopharmacologic Medication Use assessment dated [DATE] at 10:15 AM revealed R61 continued to yell out at times and can be physically and verbally aggressive with staff at times. When yelling out, will ask what he needs and will respond I don't know. Staff state he can be easily redirected, however, sometimes will continue to yell out. R61's verbally and physically aggressive behavior continues, however, these incidents have decreased. In an interview on [DATE] at 11:26 AM, with R61's resident representative (RR), expressed concerns regarding his weight loss, and remarked on how thin he looked during a video chat. R61's RR stated she didn't know why he lost weight. R61's RR stated she was tested for COVID-19 so she could come in the facility and assist him with his meals. RR #61 stated she came in for the first time the night before, for supper and he ate and drank everything. R61's RR stated they keep him fairly sedated because he was anxious and yelled out. RR #61 explained right before he was admitted his wife died , then COVID-19 hit, so the isolation must have been difficult. [DATE] at 10:49 AM, physicians progress note indicated R61's assessment showed no facial asymmetry but masklike face and some temporal and periorbital wasting was noted. The same note indicated R61's [MEDICATION NAME] was increased to 30 mg daily. R61's electronic weight summary indcated on [DATE] his weight was 198.2 lbs. and on [DATE] his weight was 177 lbs. physician progress notes [REDACTED]. Last evaluated on [DATE] for accelerated behaviors described as yelling without apparent reason and at times using profanity. At that time [MEDICATION NAME] was increased to 30 mg daily, in addition to previously prescribed [MEDICATION NAME] 0.5mg three times a day and [MEDICATION NAME] 1 mg by mouth twice a day. Staff reporting significantly increased sedation and worsening oral intake. Weight is down 21 lbs. between September and October, down 43 lbs. since March. On [DATE] [MEDICATION NAME] was reduced to twice daily with no noted reduction in sedation/lethargy. R61 was responsive today but is quite sedate and delayed in his reactions. R61 was unable to provide any meaningful information given advanced dementia. Gene site testing was completed with significant gene drug interactions noted with [MEDICATION NAME] and [MEDICATION NAME]. There does not appear to be any significant gene drug interaction with [MEDICATION NAME]. The same note indicated the plan was to Stop [MEDICATION NAME], start [MEDICATION NAME] (antidepressant) 5 mg daily tomorrow [DATE]. Reduce [MEDICATION NAME] to 0.5 mg twice daily. Update on lethargy, food acceptance, and behaviors on Monday [DATE]. Increased lethargy had been noted since the last increase in [MEDICATION NAME] dose. Because there is a significant drug Gene interaction will discontinue this altogether. [MEDICATION NAME] has a moderate gene to drug interaction with the following clinical considerations, serum level may be too high, lower doses may be required and genotype may impact drug mechanism of action resulted in reduced efficacy. Will initiate [MEDICATION NAME] at 5 mg daily hoping to impact his anxiety while not provoking sedation. [MEDICATION NAME] is also identified as having significant gene drug interaction, will reduce the dose by 50 %. If needed may be consider the addition of [MEDICATION NAME] and elimination of [MEDICATION NAME]. Will have staff update in 4 days and likely will continue to gradual dose reduction (GDR) [MEDICATION NAME]. Continue [MEDICATION NAME] twice daily with discretionary doses available if needed. According to Speech Therapy Plan of Care note dated [DATE], R61 had a 22 lbs. weight loss from [DATE] to [DATE]. Social Worker (SW) X was interviewed on [DATE] at 10:13 AM and stated she was not sure why it took so long to address R61's gene test results. SW X stated she used to only give the Director of Nursing (DON) a copy, but now gives both the DON and physician a copy of the gene test results. On [DATE] at 12:18 PM, Director of Nursing (DON) B stated R61's physician should have been aware of R61's gene study on [DATE]. DON B stated during the same interview that they finally received orders to change R61's [MEDICATION NAME] on [DATE].

Based on observation, interview and record review, the facility failed to prevent pressure ulcers in 1 of 4 residents reviewed for pressure ulcers (Resident #2), resulting in pain, infection (Resident #2) and decreased quality of life. Findings include: Resident #2 (R2) On 10/14/20 at 11:45 AM, R2 was observed in bed with his lunch next to him on an over the bed table, his sandwich was untouched. On 10/15/20 at 9:07 AM, R2 was observed in bed in his room, awake and appeared to have difficulty attempting to pull back his bedspread. Braden skin assessment dated [DATE] indicated R2's score was 18 (total scores range from 6-23, a lower Braden score indicates higher levels of risk for pressure ulcer development), he was at risk for skin breakdown. physician progress notes [REDACTED]. As a result of the trauma and internal hemorrhage it appeared that he had a small to moderate hemothorax (blood collected between chest wall and lungs) on the right and hematoma (collection of blood outside of blood vessel) involving the right flank. This resulted in a drop in his hemoglobin. R2 was sent to the nursing home hoping to get back on his feet. The same note revealed R2 had significant dementia and was being supported at home with a caregiver coming in for a portion of every day and oversight from his brother. The same note indicated he had the [DIAGNOSES REDACTED]. Nutrition assessment dated [DATE] indicated R2 was a moderate risk for malnutrition. R2's estimated calorie needs were 1800 calories and 60 to 70 grams (gm's) of protein daily. R2's oral food intake on this assessment indicated he accepted 76 to 100 percent (percent) of his daily meals. Registered Dietitian Admission Note dated 4/02/20 indicated R2 had a past history of [DIAGNOSES REDACTED] (pockets form in the walls of digestive tract), [MEDICAL CONDITIONS] reflux disease (GERD, liquid content of the stomach refluxes into the esophagus), and depression. The same note indicated R2 was on a regular diet with a regular texture and thin liquids. R2 reported he had a poor appetite and was eating about 50 % of his meals. R2's goal was for intakes to be at least 75%. The same note indicated would offer R2 fortified foods (magic cup) with meals to help him meet his estimated nutrition needs. R2 was able to eat independently with setup help. R2's Admission Minimum Data Set (MDS) 3.0 assessment, with an assessment reference date (ARD) of 4/06/20, introduced the Brief Interview for Mental Status (BIMS), a short-performance-based cognitive screener for nursing home (NH) residents, score was 10 (scale: 08-12 Moderate Impairment). The same MDS assessment indicated R2 required extensive assistance (staff provided weight bearing support) of two staff for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). R2's same MDS indicated he did not have pressure ulcers; however, he was at risk for pressure ulcers. R2's care area assessment (CAA) for pressure ulcers, dated 4/08/20, revealed [DIAGNOSES REDACTED]. The same CAA indicated medication's that increase risk of pressure ulcer injury/development included R2's use of opioids for pain management. R2's care plan, dated 4/08/20, revealed his skin care goal was to not have any skin breakdown related to pressure through the next review. The care plan did not instruct to offload heels when in bed. R2's Nurses Notes dated 5/16/20 at 9:17 AM revealed a facility acquired pressure ulcer (localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) with a red, non-blanchable area that measured 5.0 centimeters (cm) by 6.0 cm's, with a grey area in the center (slough tissue: non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture, may be adherent to base of wound or present in clumps throughout wound bed), measuring 1.0 cm by 1.0 cm. The same note indicated the pressure ulcer was tender to the touch but did not indicate the location on the pressure ulcer. R2's May 2020 Medication Administration Record [REDACTED]. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.17.1, October 2019, defined an unstageable pressure ulcer as obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer could not be confirmed because the wound bed was obscured by slough or eschar (dead or devitalized tissue, hard or soft in texture, usually black, brown, or tan in color, may appear scab-like). The same source indicated unrelieved pain adversely affected function and mobility contributing to dependence, skin breakdown, contractures, and weight loss. Progress Note dated 5/16/20 at 5:18 PM indicated a Heels-up cushion (intervention to off-load heels) was initiated for R2. Progress Note dated 5/26/20 at 8:54 AM revealed dressing changes to R2's left heel was increased to every 3 days and as needed. The same noted indicated a moderate amount red drainage was noted in R2's old dressing and he continued to complain of tenderness when dressing change was completed. Physician's Progress Notes dated 5/26/20 at 9:31 AM reflected R2 was medically stable excluding the interval development of a pressure ulcer. The same note indicated would maintain current pain management strategies especially since now R2's heel appeared to be a source of discomfort in addition to the arthritis. The same note indicated R2's rib fractures and [MEDICAL CONDITION] were resolved. R2's care plan on 6/03/20 reflected his goal was to accept 4 ounces of med pass supplement three times a day between meals with medication pass times. physician progress notes [REDACTED].sleeping on my arrival and continue to fall back asleep throughout the exam. His primary complaint is regarding pain in his left heel, foot, and lower leg. Has developed an unstageable pressure ulcer to his left heel which is being cared for by staff with pressure alleviating interventions in place. He is receiving routinely scheduled [MEDICATION NAME] twice daily with 2 discretionary doses available. It appears that he is taking at least 1 extra dose of [MEDICATION NAME] regularly every day. Also receiving [MEDICATION NAME]. Staff continue to report poor appetite at most meals; however, he does eat supper well . The same note indicated [MEDICATION NAME] pain medication was increased, scheduled three times a day with one discretionary dose available. R2's June 2020 MAR indicated [REDACTED]. Progress Note dated 6/30/20 at 11:08 AM reflected R2's pressure ulcer on his left heel was unstageable and very painful with redness and dark necrotic tissue. The same note indicated R2 frequently takes off his heels up pillow. No additional interventions were put into place to off-load the left heel until 8/14/20, when a heel protector was added to R2's care plan. July 2020 MAR/Treatment Administration Record (TAR) instructed as of 7/01/20, to irrigate R2's wound to left heel with normal saline or wound cleanser, Apply [MEDICATION NAME] foam dressing over wound then allevyn heel dressing to left heel and secure with [MEDICATION NAME] dressing; change every 3 days and as needed. R2's same record indicated the treatment continued through 10/09/20. Progress Noted dated 7/03/20 at 4:00 PM reflected a BIMS assessment was completed with R2 that reflected a score of 4, indicating his cognition was severely impaired (scale 0-7 severe impairment). R2 Nutrition CAA, ARD 7/05/20, reflected the CAA triggered for nutritional status due to being on a mechanically altered diet while a resident and presence of pressure areas to skin; R2 was on a regular diet, regular texture with mechanical soft meats only and thin liquids. The same note indicated R2 had poor food acceptance and often refused meals; sometimes accepted fortified foods and 4 oz med pass supplement three times a day in between meals. Significant Change Nutrition Assessment date 7/13/20, revealed R2's weight was 122.2 lbs., a 3.6 percent weight loss in 3 months. R2's protein needs remained the same as before the development of the pressure ulcer, 60 to 70 gm's per day. R2's electronic Weight Summary revealed on 7/28/20 his weight was 120.2 lbs. R2's Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed his cognitive skills for daily decision making was moderately impaired (decisions poor, cues/supervision required). The same MDS assessment revealed R2 had a weight loss of 5 percent (%) or more in the last month or loss of 10% or more in last 6 months and was not on a physician-prescribed weight loss regimen. R2's care plan on 10/07/20 reflected his goal was to accept the med pass supplement, as ordered since June 2020 and drink a pro-stat supplement, 30 milliliters (ml) twice a day. Registered Dietitian W was interviewed on 10/21/20 at 12:52 PM and stated R2's protein needs should have increased with the development of a pressure ulcer. RD W stated she did recommend pro-stat supplement on 10/07/20 for R2 due to the pressure ulcer. RD W stated in the same interview she would calculate R2's protein needs at 1.4 grams per kilogram. RD W stated they had not addressed option of a tube feeding yet with R2's family. Registered Nurse (RN)/Wound Nurse H was interviewed on 10/21/20 at 9:00 AM and stated R2 had been using a pressure-reducing mattress since he was admitted to the facility and was non-compliant at time with care planned interventions. RN/Wound Nurse H stated in the same interview she had not considered a low air loss mattress for R2. Wound Evaluation Flow Sheet dated 10/07/20 revealed R2's left heel pressure ulcer measured 4 cm by 3 cm, the wound bed consisted of dark eshar, with scant amount of drainage, and was painful. Following the interview with RN/Wound Nurse H, Progress Note dated 10/21/20 at 1:38 PM, revealed a request for an air mattress to be placed on R2's bed for pressure reduction. According to the 2018 article titled Pressure Ulcer and Nutrition (Saghaleini SH, Dehghan K, Shadvar K, Sanaie S, Mahmoodpoor A, Ostadi Z. Pressure Ulcer and Nutrition. Indian J Crit Care Med. 2018 Apr;22(4):283-289. doi: 10.4103/ijccm.IJCCM_277_17. PMID: 767; PMCID: PMC 32); Nutritional deprivation and insufficient dietary intake are the key risk factors for the development of pressure ulcers and impaired wound healing. Unplanned weight loss is a major risk factor for malnutrition and pressure ulcer development.

This Citation Pertains to Intake #MI 380 and MI 489 Based on interview and record review, the facility failed to identify, thoroughly investigate, and implement corrective action for alleged and/or actual abuse for five out of twelve residents (#1, 2, 10, 11 and 12), resulting in Immediate Jeopardy when the facility failed to ensure abuse investigations were investigated thoroughly, ensure prevention of further verbal and physical abuse of residents, and put corrective action into place to prevent further incidents of abuse placing all 101 residents who reside at the facility at risk for serious harm, injury, impairment and or death. Findings include: Resident 2 According to the clinical record including the Minimum Data Set ((MDS) dated [DATE], Resident 2 (R2) was an [AGE] year old female, admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Further review of the clinical record reflected Administrator A was the daughter and Durable Power of Attorney of R2. Review of R2's nurses notes dated 2/17/2019 reflected Elder was very confused and irritable during writers shift. Elder went into two other elders rooms yelling at them to be quiet and get out of her house, elder told one of the elders family members she was going to get her gun and shoot them. Redirected elder back to her room and gave her warm towels. Elder was difficult to redirect all shift. ( Name redacted) ( Assistant Director of Nursing (ADON) N) and (name redacted) (Administrator A notified.) Review of R2's nurses notes dated 3/11/2019 reflected RSA (certified nursing assistant) reports that during dinner another resident was propelling wheelchair toward this elder. This elder then raised hand and said to other elder 'you better get away'. Other elder was redirected away from this elder. No signs of distress from either elder was reported. Will continue to monitor. DON ( Director of Nursing B) and administrator notified. Review of R2's nurses notes dated 3/15/2019 reflected Elder overheard a conversation between another elder and an RSA. The other elder was concerned that she might accidentally bump her with her foot at the dining room table. This elder then stated, sometimes I'd like to smack the s**t out of you. The other elder did not hear this comment and did not respond. RSA encouraged elder to eat her dinner. She did not make any further negative comments during the meal. Review of nurses notes dated 4/12/2019 reflected RSA stated that elder opened her gate to her room and hit another elder on the hand with her gate as elder was passing her room in the hallway. Both elders assessed, both elders denied pain. DON and administrative director notified. Will continue to monitor. Review of nurses notes dated 4/29/2019 reflected RSA reported to writer few hours after incident happened on first shift that elder grabbed another elder around the neck of her shirt and said she needs to stop talking to me before I hit her. RSA went to move elder away and elder got her fist up and was was ready to swing at other elder. RSA moved elder to her room to cool down while she check on other resident. Review of nurses notes dated 5/05/2019 reflected Stop and watch filled out by RSA stating that Elder was being rude to other elders and their family members. Will continue to monitor for behaviors during AM shift. Review of the nurses notes dated 6/16/2019 reflected Elder was verbal abusive about another elder. Elder was talked to and redirected easily and stated she wouldn't do anything to harm anyone. Will continue to monitor. ADON notified. Review of the nurses notes dated 8/05/2019 reflected RSA reports that this elder told another elders family to shut their mouths then told that elder to watch out b/c she was going to break her nose. Other elder and family went to community room to visit and that elder and family shows no signs of distress. (Name redacted) Administrator A notified and suggested elder eat in room tonight. Review of the nurses notes dated 8/09/2019 reflected RSA reports that when they were walking another resident, this elder wheeled past and said f**k you, and kept going. Review of the nurses notes dated 9/28/2019 reflected RSA reported seeing this elder reach out and grab at another elder's hair while they were conversing in the hall. Staff separated the two of them. DON notified and SW followed up with elders. Neither seem distressed or otherwise agitated following incident. A follow up nurses note to the 9/28/2019 incident, dated 11/14/2019 reflected video footage was reviewed, and the conclusion was R2 was not aggressive. Review of the nurses notes dated 10/04/2019 reflected At 1500, elder was sitting at nurse's station, another elder reached for a paper sign, then reached over to (name redacted) (R2) . (name redacted) (R2) swatted other elder in the right arm. Elders were immediately separated, PCP, POA notified. Review of nurses notes dated 12/08/2019 Around 1800, RSA took elder to her room, then reported to writer that she had made a comment towards another elder, stating I will shoot you. during dinner. Elder immediately taken from dinning room. Writer called DON. DON said to chart on it, and to not let those elders sit together at meals anymore. Information passed onto RSAs, and will continue to be passed onto the oncoming shift. Elder has been in room, relaxing peacefully. Staff will continue to monitor. On 03/03/2020 at 11:50 AM, during an interview with Director of Nursing B, Assistant Director of Nursing N and Corporate Compliance Director C, DON B stated she served as the facility's abuse coordinator. A review of R2's abusive behaviors from the nursing notes was completed, at that time and a request was made to review the each of the above listed incidents entire investigations, including but not limited to witness statements and corrective measures. DON B stated the only incident from the above list that was investigated was the facility reported incident that was submitted to the State Agency on 10/04/2019 . When queried why the remaining incidents were not investigated or corrective measures implemented DON B offered no explanation. When DON B, ADON N and Corporate Compliance Director C were queried if they were aware of R2's verbal and physical abuse towards other residents. All three reported R2's behavior was well known throughout the facility. Review of R2's behavior care plan, dated 11/02/2018 reflected R2 was verbally and physically aggressive at times, with a goal of maintaining behavioral stability without showing an increase in behavioral symptoms from the previous assessment. An intervention dated 01/08/2019 was to encourage R2 to use a sewing box of materials in her room if she becomes anxious and provide a 1:1 if becomes anxiety increases and use [MEDICATION NAME] lotion Intervention dated 2/18/2019 was to be agreeable with R2 and not to rationalize, and if delusional go along with it if R2 was safe. Intervention dated 2/18/2020 was to provide her with meaningful activities, and provide reassurance. Review of the facility care guide, utilized by the certified nursing assistants reflected Behavior: My visual hallucinations often times are distressful to me. Please reassure me. On 3/04/2020 at 11:20 am, during an interview with Director of Nursing (DON) B she reported there was no special behavior program, or intervention used when R2 becomes physically and verbally aggressive. DON B stated they just try to separate from other residents. On 3/04/2020 at 1:20 PM, during an interview with Certified Nursing Assistant (CNA) M, she reported the CNA's use the care guide to learn what each residents needs were. CNA M reported she has never been given instruction or specialized training on how to handle R2's abusive behaviors or how to protect the other residents. I just have to figure it out by trial and error. On 3/05/2020 at 2:30 PM, during an interview with CNA H she reported she also used the facility's care guide for instruction on how to care for residents, not the care plan. On 03/04/2020 at 10:00 am, during an interview with Administrator A she stated she was R2's daughter and Durable Power of Attorney. Administrator A further reported she was aware of R2's verbal and physical abuse directed at other residents, as she is at the facility daily, her staff keep her informed as she is also the daughter and durable power of attorney. Review of the events from the nurses notes were reviewed with Administrator A, she acknowledge again that she was aware of all of the events though could not recall specific details. When Administrator A was queried why there was no evidence that any investigations excluding the 10/04/2019 incident had been investigated thoroughly or corrective action to prevent further abuse were in place. Administrator A stated all investigations surrounding her mother (R2) and abuse were a conflict of interest and she instructed Assistant Administrator D to handle all R2's abuse investigations and reporting to the State Agency. When Administrator A was queried if she followed up with the DONB/ abuse coordinator or Assistant Administrator D as to the results and corrective measures to be implemented from the investigations Administrator A stated no, it was a conflict of interest. When queried what had the facility implemented to prevent R2 from verbally and physically abusing other residents, Administrator A reported they started her on medication. Record review revealed R2 had been prescribed [MEDICAL CONDITION] medication since 11/02/2018. On 03/04/2020 at 10:30 AM, during an interview with Assistant Administrator D she stated she had been asked by Administrator A one time to investigate an allegation of abuse related to R2. Assistant Administrator A further stated the one incident she was asked to investigate, was the incident on 10/04/2019 which was then reported to the State Agency. According to the facility policy titled Abuse Prevention and Intervention Program Reviewed/Revised 5/02/19 reflected Verbal Abuse defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to elders or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Physical Abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. On page 4. under the heading Procedure reflected 2.The Director of Nursing, Administrator or designee shall thoroughly investigate all allegations. 3. The Director of Nursing, Administrator or designee will notify the elder's representative, and any state or federal agencies of allegations immediately and investigation within 5 days. 4. The Director of Nursing, Administrator or designee will take steps to ensure and prevent further potential abuse while the investigation is in process. On page 6. under the heading Elder to Elder reflected 11. All incidents are to be documented in each elder's medical record with intense monitoring to continue for at least 24 hours. On 03/06/2020 this surveyor verified that the facility implemented the following to remove the Immediate Jeopardy that began on 2/17/2019, and was identified on 03/04/2020: Beginning 3/4/2020, The Abuse Coordinator and/or Designee will review progress notes daily of all Elders to determine if there have been allegations of Abuse that were not reported to the Abuse Coordinator or Administrator. On 3/4/2020 at 3:45 p.m. the Abuse Coordinator, Administrator, Assistant Administrator & Corporate Compliance were educated via telephone regarding the requirements of Abuse reporting under Regulation F610 by (name redacted) RN, LNHA (Registered Nurse and Licensed Nursing Home Administrator) with (name redacted) Consulting. The Abuse Coordinator and/or designee will thoroughly investigate all allegations of abuse after they have first been reported through the MI-Login online portal by the Administrator or designee. The Facility will also register the Abuse Coordinator through the MI-Login allowing her access to reporting. A comprehensive [MEDICAL CONDITION] medication review including all mood and behavioral symptoms and interventions for Resident #2 is being completed. Resident #2 will be discussed at the Facility's IDT meeting today 3/5/2020 with the Administrator & Assistant Administrator also in attendance and care plan updated to prevent future occurrences of verbal or physical abuse. Administrator has implemented and will maintain a log at all times (24 hours a day) of phone calls & notifications received regarding allegations of Abuse and the action taken. Log will begin today 3/5/2020. Beginning 3/5/2020 the Administrator and Assistant Administrator will attend all IDT meetings at the Facility to ensure that any allegations of Abuse have been reported. On 3/5/2020 the Facility will place posters at all nursing stations within the building outlining the forms of abuse and who to notify for any potential incidents of abuse. The Facility began re-educating staff on 3/4/2020 at 4:00 p.m. regarding the Facility's Abuse policy and Abuse reporting guidelines as well as immediately protecting other residents from potentially abusive peers. This education will be completed by 3/5/2020 at 5:00 p.m. Any employees who are on leaves of absence or are scheduled on a casual basis will be reeducated via telephone prior to them returning to work. The Administrator, Assistant Administrator, Abuse Coordinator & Corporate Officer reviewed the Abuse Policy on 3/4/2020 & 3/5/2020. The result of the review is that our current policy lacks specific language as described in Regulations 609 & 610. The Facility will revise its policy by 3/6/2020. Although the Immediate Jeopardy was removed on 3-6-2020 non compliance continued at no actual harm with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance could not be verified by the state agency.

This citation pertains to intake MI 520. Based on observation, interview and record review the facility failed to ensure that 2 of 17 residents reviewed for medications (#2 and #21) from a total sample of 24 were free of significant medication errors resulting in Resident #2 receiving insulin that was not prescribed requiring hospitalization for treatment of [REDACTED].#21 having a [MEDICATION NAME] (applied to skin) medication patch applied incorrectly and not receiving medication to control excess saliva resulting in nausea and vomiting. Findings include: Resident #2 The facility policy Standard for Drug Administration, reviewed/revised 8/16/11 and 10/2/17, reflected .Procedure .4. Medications will be administered at the time they are prepared. Doses will not be pre-poured, or preset .5. All medication errors will be reported to the Attending Physician and Director of Nurses (or designee). A medication incident report will be completed by the nurse who made the error or the nurse who discovered the error .17. The 6 rights of medication administration will always be followed . Clinical Nursing Skills and Techniques, Perry and Potter, 6th edition, 2006, page 618 states the six rights of medication administration are the right; medication, dose, client, route, time and documentation. Item 19 was added on 10/2/17 and reflected Once medications are prepared, they cannot be returned/stored in medication carts. Based on observation of a TB ([MEDICATION NAME]) syringe and an insulin syringe used in the facility the following describes the differences; 1) the TB syringe had a brown needle cap and the barrel of the syringe had markings in 1/10 ml increments (marked as 0.1, 0.2, etc) up to 1 ml. 2) the insulin syringe had a bright orange cap and the syringe barrel had markings in unit increments (marked with lines for each unit and numbers every 5 units) up to 100 units. The syringes are not interchangeable i.e. insulin cannot be accurately measured in a TB syringe and TB solution cannot be accurately measured in an insulin syringe. Insulin is administered into the subcutaneous fat by placing the needle straight into the skin. TB solution is placed under the skin by placing the needle just under the skin at a horizontal angle and creating a bubble under the skin when 1/10 ml of solution is injected. Based on the manufacturer's information in Specialized Long Term Care Nursing drug Handbook 2008, pages 509-510, 518 and 1115-1121. Insulin is an antidiabetic medication that lowers blood sugar levels in the body of residents with diabetes. The most common side effect is low blood sugar with symptoms such as [MEDICAL CONDITION](heart rate >100), anxiety, hunger, tremor, pallor, headache, motor dysfunction, speech disturbances, sweating, palpitations (feels like heart fluttering), coma and death. The treatment is 15-20 grams of glucose (juice, candy) and [MEDICATION NAME] (a drug that raises blood sugar), if necessary. [MEDICATION NAME] is a long-acting form of insulin with an onset of action of 3-4 hours after administration, a peak effect in 6-8 hours, and the duration of action of 12-24 hours. Fasting (no calorie intake for 8 hours) blood sugar normal range is 70-100 mg/dl with levels less than 140 mg/dl after meals. Treatment with food and/or glucose is required at blood sugar levels less than 70 mg/dl. Based on the electronic medical record (EMR) face sheet Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Based on the Medication Review Report, dated 9/30/17, Resident #2's admission physician orders [REDACTED].hypertension .[MEDICATION NAME] Solution 5 unit/0.1 ml ([MEDICATION NAME] PPD) Inject 0.1 ml intradermally (under the skin) one time a day for screening for TB Vitamin B Complex Tablet .Give 1 tablet by mouth one time a day .Vitamin C Tablet 500 MG .Give 1 tablet by mouth one time a day . The Medication and Treatment Incident Report, dated 9/30/17, with no time or identification of the writer documented, reflected .(Registered Nurse L's name) gave 36 units of [MEDICATION NAME] to a nondiabetic Pt (patient) instead of a tb shot. DON (Director of Nursing) notified . The notified: yes and no boxes next to the physician's name were blank. The Date/Time of Notification under the physician name reflected 1900 (7:00 PM) and the Treatment Orders: No box was checked. Under Medication Error Type: 1. Administration Error the box for wrong drug was checked and section 2. Failure to follow Procedure: left syringe in cart was hand written. Under Medication Error Classification: the box Error occurred, resulted in initial or prolonged hospitalization , temporary harm was checked. The form was signed by the Registered Nurse (RN) L, The Director of Nursing (DON) B and the Administrator A on 10/1/17. The Medical Director signed the form on 10/3/17. Review of the EMR for Resident #2 reflected a blood sugar level of 249 mg/dl at 7:00 PM on 9/30/17 in the Weights and Vitals Summary. The next documented blood sugar levels were in the Progress Notes, dated 10/1/17 at 2:47 AM by LPN G, that reflected critically low levels of 33 mg/dl at 12:30 AM and 38 mg/dl at 12:40 AM. A blood sugar of 71 mg/dl was documented at 12:50 AM after [MEDICATION NAME] was administered and Resident #2 had eaten peanut butter crackers and orange juice. The Statement of Witness, hand written and signed by RN L on 10/1/17, reflected Writer was admission nurse on duty the day of 9/30/17. New Admit, stated above (Resident #2's name), arrived to the facility via family vehicle at 1330 (1:30 PM). Shortly after, writer drew up TB to be administered. writer explained to CB (Canterbury) nurse on duty (identified by facility as Licensed Practical Nurse (LPN) J) that writer (RN L) was placing TB syringe in top drawer of med (medication) cart for later administration. At 1845 (6:45 PM) writer pulled only syringe from top of med cart for administration. Writer administered (R) (right) arm. When writer returned to med cart Nurse there (identified by the facility as LPN G), asking if writer (RN L) had seen insulin syringe. It was at that moment writer realized insulin was administered. DON notified immediately. Family not present during administration. There was no documentation found in the medical record related to the medication error. RN L was no longer employed at the facility at the time of the investigation. The Statement of Witness related to Resident #2, hand written and signed by LPN G on 10/1/17, reflected When I came onto my shift (6:00 PM-6:00 AM) there was a TB syringe in the top drawer of my (medication) cart. I put it in the sharps container. Further into my shift I got together another residents (sic) medication and insulin (identified by the facility as Resident #4) and noticed a change in her medication and didn't feel comfortable giving it without another set of eyes. I locked the medication in my cart and walked down to Green Gables (adjacent unit) for 1 minute to double check my narc (narcotic) with the nurse. I walked back down to CB and (RN L's first name) came to me with (Resident #4's first name) insulin syringe gone and told me she gave (Resident #2's first name) her TB shot. I then told her that was insulin and she then followed (sic) with (DON's first name). According to (RN L's first name) I was to monitor (Resident #2's first name) and check her blood sugar at midnight. I checked it that moment and it was 250. I continued to monitor (Resident #2's first name). At 1230 (12:30 AM) her BS (blood sugar) was 33, dyphoretic (sic) and [MEDICAL CONDITION] fell ow nurse (LPN H's first name) got [MEDICATION NAME] and administered, called DON and gave OJ (orange juice) and PB (peanut butter) crackers. 1240 (12:40 AM) BS 38. Dr. (Doctor) was called and V.O. (verbal order) to send PT to ER. Family notified. Ambulance came. LPN G was interviewed by telephone on 10/18/17 and confirmed the above statement. In addition, LPN G stated the physician was not notified of the medication error at the time it occurred and the direction to monitor Resident #2 and check her blood sugar at midnight when the insulin was to reach its peak action time came from RN L after RN L's telephone conversation with DON B. LPN G stated In my head I knew I should call the Doctor and I wanted to tell the family but RN L stated DON B would handle the situation on Monday. LPN G stated she checked on Resident #2 often during the evening and the Resident was not diaphoretic until midnight when the blood sugar was 33. LPN G stated the Resident was conversing with LPNs G and J and did not appear confused at 12:30 AM. LPN G stated she was not aware any other nurse had keys to the Canterbury medication cart. On 10/18/17 at 12:50 PM DON B stated that at the time of the medication error for Resident #2 the admission nurse on duty had keys to the medication carts on the Canterbury and Green Gables units in addition to the nurse assigned to the unit. The Statement of Witness related to Resident #2, hand written and signed by LPN J on 10/1/17, reflected (RN L's name) informed me that she drew up elder's (Resident #2) TB shot and placed it in the top drawer of my med cart, that she would give it to the elder later. When I opened the med cart, there was a TB syringe in the top drawer, it was unlabeled. On 10/18/17 at 1:35 PM during an interview LPN J confirmed the above statement. In addition, LPN J stated the TB syringe had a brown needle cap which was usual for that type of syringe. On 10/18/17 at 2:44 PM LPN H was interviewed by telephone. LPN H stated she was working the 6:00 PM-6:00 AM shift on the Green Gables unit on 9/30/17. LPN H stated LPN G had told LPN H about Resident #2 receiving a dose of insulin intended for another resident. LPN H stated she told LPN G the type of insulin Resident #2 received had its peak effect in 5-7 hours after administration so LPN G should check the Resident's blood sugar level during that time. LPN H stated she went with LPN G to check Resident #2's blood sugar at midnight and found the Resident sweaty (diaphoretic) and the Resident was speaking to them. LPN H stated she obtained the [MEDICATION NAME] injection for the Resident then notified the on-call medical staff, Physician's Assistant (PA) N, while LPN G stayed with the Resident. LPN H stated PA N directed Resident #2 be sent to the hospital emergency room (ER) for monitoring and treatment. LPN H stated she also notified the family that the Resident's blood sugar had dropped and Resident #2 was being sent to the ER for treatment. LPN H stated she did not inform the family the Resident had received insulin in error but was aware the family had not been informed of the medication error. On 10/18/17 at 12:50 PM DON B was interviewed related to Resident #2 receiving insulin not prescribed for the Resident. DON B confirmed the following video surveillance timeline documented in the facility investigation for the 9/30/17-10/1/17 incident involving Resident #2; 1) 6:46 PM RN L enters Resident #2's room. Gave injection (insulin), removed supper tray. 2) 7:06 PM LPN G to room to assess elder and check blood sugar. 3) 7:16 PM Family returned with snacks for elder. 4) 7:39 PM LPN G enters Resident's room with a vital signs machine. 5) 7:51 PM Family left. 6) 8:15 PM LPN G enters Resident's room. 6) 8:59 PM LPN G enters Resident's room. 7) 10:47 PM LPN G enters Resident's room. 8) 11:29 PM Nursing aide (not identified) enters Resident's room. 9) 12:15 AM LPN G enters Resident's room. 10) 12:20 AM LPN G enters Resident's room. Additional documentation reflected; 1) RN L notified DON B by telephone of the medication error at 7:23 PM on 9/30/17 and RN L was told to assess the elder and monitor her blood sugar at the time of the peak effect of the insulin. RN L was asked by DON B if the family was present when the error occurred and stated yes but the family had now left. RN L was asked by DON B if the Resident had eaten supper and stated yes. 2) At 12:27 AM on 10/1/17 LPN H notified DON B by telephone that Resident #2 was symptomatic, diaphoretic and tachcardic with a blood sugar of 33 and had been given a dose of [MEDICATION NAME]. 3) DON B called LPN H and asked to have Resident #2 checked, encouraged to eat a snack and juice, and have the physician notified. DON B told LPN H Resident #2 would need more monitoring for blood sugar and possibly an IV (needle in a vein to give fluids) of [MEDICATION NAME] (sugar) to maintain her blood sugar. DON B asked how the Resident was and LPN H stated she was sleepy. DON B instructed LPN H to have Resident #2 eat and drink as able and call the physician for further treatment recommendations. 4) LPN H notified PA N who was on-call for the attending physician and received an order to send the Resident to the hospital for monitoring. 5) at 12:42 AM LPN H called the ambulance. 6) At 12:46 AM DON B was notified of the order for transport to the ER. 7) At 12:49 AM LPN H notified the family (of the transfer). 8) At 1:18 AM DON B called LPN H for an update and was informed Resident #2 had been transported to the hospital and her last blood sugar was 71. DON B was informed the family was notified of the transfer. DON B spoke with LPN G and was informed of the TB syringe found in the medication cart and discarded by LPN G. DON B was informed of the events as written in LPN G's statement above. During the above interview DON B stated there was no discussion between she and RN L during the 7:23 PM telephone conversation related to notifying the physician. DON B stated she assumed the family had been notified of the error as RN L stated the family was present at the time the insulin was given. DON B stated RN L never went back into the room to assess Resident #2 after administering the insulin and RN L told LPN G not to tell the family. DON B stated RN L had told DON B during an interview on 10/1/17 that there was nothing about the insulin syringe that made RN L question that it was not the TB solution syringe RN L had prepared earlier for Resident #2 despite the fact that the TB syringe would have had a brown needle cap and the insulin syringe would have had a bright orange needle cap. In addition, the amount of fluid in the filled insulin syringe would have been three times the amount in the TB syringe based on the 1/10 ml dose of the TB solution and the 36 units of [MEDICATION NAME] insulin. Injecting the 36 unit volume of insulin under the skin would have created a very large bubble, not the small bubble created by the 1/10 ml TB solution. A letter to RN L from the facility and signed by Assistant Administrator O, dated 10/4/17, reflected RN L's employment at the facility was terminated on 10/2/17 for failing to follow facility nursing procedures. Resident #21 Review of the face sheet and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #21 had unclear speech, was rarely/never understood, rarely/never understands and was moderately impaired cognitively. Review of the Medication and Treatment Incident Report dated 2/5/17 reveals, (Resident #21) been having N/V (nausea and vomiting) for 2 days. (Name of nurse) and I (Registered Nurse (RN) K) went to look at scope patch ([MEDICATION NAME]-[MEDICATION NAME], a medication administered via a stick on patch that is used to decrease secretions). Back was still on (preventing the absorption of the medication). (Resident #21) received and IV (intravenous) and [MEDICATION NAME] (medication used to prevent nausea and vomiting) per PCP (primary care physician) on 2-4-17. Per the Director of Nursing, RN K is no longer employed at the facility. Review of the physician order [REDACTED]. ([MEDICATION NAME]) Apply 1.5 mg [MEDICATION NAME] (using a patch that touches the skin and passes medication across the skin) one time a day every 3 day(s) for Excessive secretions r/t (related to)[MEDICAL CONDITION] and dysphagia. Review of the medical record revealed that on 2/3/17 at 6:00 a.m., RN K documented on the Medication Administration Record that a new [MEDICATION NAME] 1.5 mg patch was placed on Resident #21. Review of the nurses note dated 2/3/17 at 8:36 p.m. revealed, (Resident #21) had 4 med-large (medium to large) emesis (vomiting) this evening .(Resident #21) is not able to verbally express if he is still nauseous .Head of the bed is raised, [MEDICATION NAME] is in place on the right side of the neck. Will continue to monitor. Review of the nurses note dated 2/4/17 at 12:04 p.m. revealed, New Orders received from (physician) for Saline IV @ 125 cc/hr (cubic centimeters per hour) [MEDICATION NAME] 4 mg (Every 8 hours) .Elder having episodes of emesis. Unable to keep food, liquid, or medication down .Will continue to monitor. Review of the medical chart revealed that on 2/5/17, after it was discovered that the [MEDICATION NAME] was placed on Resident #21 improperly and then corrected, the physician order [REDACTED]. Review of the nurses note dated 2/5/17 at 1:58 p.m. revealed, (Resident #21) ate around 75% of breakfast later in the morning. (Resident #21) got up in (wheelchair) for lunch eating a jello cup and peaches. Went with wife down the hall. (Resident #21) in good spirits today .When writer asked (Resident #21) if he was feeling better, (Resident #21) nodded head yes and smiled .

This citation pertains to intake MI 520. Based on observation, interview and record review the facility failed to notify the attending physician and the family of a significant medication error for 1 of 14 residents reviewed for medications (#2) from a total sample of 24 resulting in a delay in the initiation of treatment to prevent the development of a critically low blood sugar level for Resident #2 which required hospitalization . Findings include: The facility policy Standard for Drug Administration, reviewed/revised 8/16/11 and 10/2/17, reflected .Procedure .4. Medications will be administered at the time they are prepared. Doses will not be pre-poured, or preset .5. All medication errors will be reported to the Attending Physician and Director of Nurses (or designee). A medication incident report will be completed by the nurse who made the error or the nurse who discovered the error .17. The 6 rights of medication administration will always be followed . Clinical Nursing Skills and Techniques, Perry and Potter, 6th edition, 2006, page 618 states the six rights of medication administration are the right; medication, dose, client, route, time and documentation. Item 19 was added on 10/2/17 and reflected Once medications are prepared, they cannot be returned/stored in medication carts. Based on observation of a TB ([MEDICATION NAME]) syringe and an insulin syringe used in the facility the following describes the differences; 1) the TB syringe had a brown needle cap and the barrel of the syringe had markings in 1/10 ml increments (marked as 0.1, 0.2, etc) up to 1 ml. 2) the insulin syringe had a bright orange cap and the syringe barrel had markings in unit increments (marked with lines for each unit and numbers every 5 units) up to 100 units. The syringes are not interchangeable i.e. insulin cannot be accurately measured in a TB syringe and TB solution cannot be accurately measured in an insulin syringe. Insulin is administered into the subcutaneous fat by placing the needle straight into the skin. TB solution is placed under the skin by placing the needle just under the skin at a horizontal angle and creating a bubble under the skin when 1/10 ml of solution is injected. Based on the manufacturer's information in Specialized Long Term Care Nursing drug Handbook 2008, pages 509-510, 518 and 1115-1121. Insulin is an antidiabetic medication that lowers blood sugar levels in the body of residents with diabetes. The most common side effect is low blood sugar with symptoms such as [MEDICAL CONDITION](heart rate >100), anxiety, hunger, tremor, pallor, headache, motor dysfunction, speech disturbances, sweating, palpitations (feels like heart fluttering), coma and death. The treatment is 15-20 grams of glucose (juice, candy) and [MEDICATION NAME] (a drug that raises blood sugar), if necessary. [MEDICATION NAME] is a long-acting form of insulin with an onset of action of 3-4 hours after administration, a peak effect in 6-8 hours, and the duration of action of 12-24 hours. Fasting (no calorie intake for 8 hours) blood sugar normal range is 70-100 mg/dl with levels less than 140 mg/dl after meals. Treatment with food and/or glucose is required at blood sugar levels less than 70 mg/dl. Based on the electronic medical record (EMR) face sheet Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Based on the Medication Review Report, dated 9/30/17, Resident #2's admission physician orders included [MEDICATION NAME] Tablet 5 MG Give 1 tablet by mouth one time a day related to essential .hypertension .[MEDICATION NAME] Solution 5 unit/0.1 ml ([MEDICATION NAME] PPD) Inject 0.1 ml intradermally (under the skin) one time a day for screening for TB Vitamin B Complex Tablet .Give 1 tablet by mouth one time a day .Vitamin C Tablet 500 MG .Give 1 tablet by mouth one time a day . The Medication and Treatment Incident Report, dated 9/30/17, with no time or identification of the writer documented, reflected .(Registered Nurse L's name) gave 36 units of [MEDICATION NAME] to a nondiabetic Pt (patient) instead of a tb shot. DON (Director of Nursing) notified . The notified: yes and no boxes next to the physician's name were blank. The Date/Time of Notification under the physician name reflected 1900 (7:00 PM) and the Treatment Orders: No box was checked. Under Medication Error Type: 1. Administration Error the box for wrong drug was checked and section 2. Failure to follow Procedure: left syringe in cart was hand written. Under Medication Error Classification: the box Error occurred, resulted in initial or prolonged hospitalization , temporary harm was checked. The form was signed by the Registered Nurse (RN) L, The Director of Nursing (DON) B and the Administrator A on 10/1/17. The Medical Director signed the form on 10/3/17. Review of the EMR for Resident #2 reflected a blood sugar level of 249 mg/dl at 7:00 PM on 9/30/17 in the Weights and Vitals Summary. The next documented blood sugar levels were in the Progress Notes, dated 10/1/17 at 2:47 AM by LPN G, that reflected critically low levels of 33 mg/dl at 12:30 AM and 38 mg/dl at 12:40 AM. A blood sugar of 71 mg/dl was documented at 12:50 AM after [MEDICATION NAME] was administered and Resident #2 had eaten peanut butter crackers and orange juice. The Statement of Witness, hand written and signed by RN L on 10/1/17, reflected Writer was admission nurse on duty the day of 9/30/17. New Admit, stated above (Resident #2's name), arrived to the facility via family vehicle at 1330 (1:30 PM). Shortly after, writer drew up TB to be administered. writer explained to CB (Canterbury) nurse on duty (identified by facility as Licensed Practical Nurse (LPN) J) that writer (RN L) was placing TB syringe in top drawer of med (medication) cart for later administration. At 1845 (6:45 PM) writer pulled only syringe from top of med cart for administration. Writer administered (R) (right) arm. When writer returned to med cart Nurse there (identified by the facility as LPN G), asking if writer (RN L) had seen insulin syringe. It was at that moment writer realized insulin was administered. DON notified immediately. Family not present during administration. There was no documentation found in the EMR related to the medication error and no documentation on the Medication Administration Record [REDACTED]. RN L was no longer employed at the facility at the time of the investigation. The Statement of Witness related to Resident #2, hand written and signed by LPN G on 10/1/17, reflected When I came onto my shift (6:00 PM-6:00 AM) there was a TB syringe in the top drawer of my (medication) cart. I put it in the sharps container. Further into my shift I got together another residents (sic) medication and insulin (identified by the facility as Resident #4) and noticed a change in her medication and didn't feel comfortable giving it without another set of eyes. I locked the medication in my cart and walked down to Green Gables (adjacent unit) for 1 minute to double check my narc (narcotic) with the nurse. I walked back down to CB and (RN L's first name) came to me with (Resident #4's first name) insulin syringe gone and told me she gave (Resident #2's first name) her TB shot. I then told her that was insulin and she then followed (sic) with (DON's first name). According to (RN L's first name) I was to monitor (Resident #2's first name) and check her blood sugar at midnight. I checked it that moment and it was 250. I continued to monitor (Resident #2's first name). At 1230 (12:30 AM) her BS (blood sugar) was 33, dyphoretic (sic) and [MEDICAL CONDITION] fell ow nurse (LPN H's first name) got [MEDICATION NAME] and administered, called DON and gave OJ (orange juice) and PB (peanut butter) crackers. 1240 (12:40 AM) BS 38. Dr. (Doctor) was called and V.O. (verbal order) to send PT to ER. Family notified. Ambulance came. LPN G was interviewed by telephone on 10/18/17 and confirmed the above statement. In addition, LPN G stated the physician was not notified of the medication error at the time it occurred and the direction to monitor Resident #2 and check her blood sugar at midnight when the insulin was to reach its peak action time came from RN L after RN L's telephone conversation with DON B. LPN G stated In my head I knew I should call the Doctor and I wanted to tell the family but RN L stated DON B would handle the situation on Monday. LPN G stated she checked on Resident #2 often during the evening and the Resident was not diaphoretic until midnight when the blood sugar was 33. LPN G stated the Resident was conversing with LPNs G and J and did not appear confused at 12:30 AM. LPN G stated she was not aware any other nurse had keys to the Canterbury medication cart. On 10/18/17 at 2:44 PM LPN H was interviewed by telephone. LPN H stated she was working the 6:00 PM-6:00 AM shift on the Green Gables unit on 9/30/17. LPN H stated LPN G had told LPN H about Resident #2 receiving a dose of insulin intended for another resident. LPN H stated she told LPN G the type of insulin Resident #2 received had its peak effect in 5-7 hours after administration so LPN G should check the Resident's blood sugar level during that time. LPN H stated she went with LPN G to check Resident #2's blood sugar at midnight and found the Resident sweaty (diaphoretic) and the Resident was speaking to them. LPN H stated she obtained the [MEDICATION NAME] injection for the Resident then notified the on-call medical staff, Physician's Assistant (PA) N, while LPN G stayed with the Resident. LPN H stated PA N directed Resident #2 be sent to the hospital emergency room (ER) for monitoring and treatment. LPN H stated she also notified the family that the Resident's blood sugar had dropped and Resident #2 was being sent to the ER for treatment. LPN H stated she did not inform the family the Resident had received insulin in error but was aware the family had not been informed of the medication error. On 10/18/17 at 12:50 PM DON B was interviewed related to Resident #2 receiving insulin not prescribed for the Resident. DON B confirmed the following video surveillance timeline documented in the facility investigation for the 9/30/17-10/1/17 incident involving Resident #2; 1) 6:46 PM RN L enters Resident #2's room. Gave injection (insulin), removed supper tray. 2) 7:06 PM LPN G to room to assess elder and check blood sugar. 3) 7:16 PM Family returned with snacks for elder. 4) 7:39 PM LPN G enters Resident's room with a vital signs machine. 5) 7:51 PM Family left. 6) 8:15 PM LPN G enters Resident's room. 6) 8:59 PM LPN G enters Resident's room. 7) 10:47 PM LPN G enters Resident's room. 8) 11:29 PM Nursing aide (not identified) enters Resident's room. 9) 12:15 AM LPN G enters Resident's room. 10) 12:20 AM LPN G enters Resident's room. Additional documentation reflected; 1) RN L notified DON B by telephone of the medication error at 7:23 PM on 9/30/17 and RN L was told to assess the elder and monitor her blood sugar at the time of the peak effect of the insulin. RN L was asked by DON B if the family was present when the error occurred and stated yes but the family had now left. RN L was asked by DON B if the Resident had eaten supper and stated yes. 2) At 12:27 AM on 10/1/17 LPN H notified DON B by telephone that Resident #2 was symptomatic, diaphoretic and tachcardic with a blood sugar of 33 and had been given a dose of [MEDICATION NAME]. 3) DON B called LPN H and asked to have Resident #2 checked, encouraged to eat a snack and juice, and have the physician notified. DON B told LPN H Resident #2 would need more monitoring for blood sugar and possibly an IV (needle in a vein to give fluids) of [MEDICATION NAME] (sugar) to maintain her blood sugar. DON B asked how the Resident was and LPN H stated she was sleepy. DON B instructed LPN H to have Resident #2 eat and drink as able and call the physician for further treatment recommendations. 4) LPN H notified PA N who was on-call for the attending physician and received an order to send the Resident to the hospital for monitoring. 5) at 12:42 AM LPN H called the ambulance. 6) At 12:46 AM DON B was notified of the order for transport to the ER. 7) At 12:49 AM LPN H notified the family (of the transfer). 8) At 1:18 AM DON B called LPN H for an update and was informed Resident #2 had been transported to the hospital and her last blood sugar was 71. DON B was informed the family was notified of the transfer. DON B spoke with LPN G and was informed of the TB syringe found in the medication cart and discarded by LPN G. DON B was informed of the events as written in LPN G's statement above. During the above interview DON B stated there was no discussion between she and RN L during the 7:23 PM telephone conversation related to notifying the physician. DON B stated she assumed the family had been notified of the error as RN L stated the family was present at the time the insulin was given. DON B stated RN L never went back into the room to assess Resident #2 after administering the insulin and that RN L told LPN G not to tell the family. A letter to RN L from the facility and signed by Assistant Administrator O, dated 10/4/17, reflected RN L's employment at the facility was terminated on 10/2/17 for failing to follow facility nursing procedures. Review of the facility investigation summary of the medication error for Resident #2, reflected DON B notified Administrator A of the above incident at 10:55 AM on 10/1/17. DON B spoke with Resident #2's family member by telephone at 12:45 PM on 10/1/17. The family requested a meeting with the facility on Monday (10/2/17). On 10/18/18 at 12:50 PM DON B confirmed the above and stated the family was informed by the hospital staff that Resident #2 had received insulin in error and the facility had not informed the Resident or the family. A progress note in the EMR, dated 10/2/17 at 2:35 PM by Administrator A, reflected .Family was notified that she (Resident #2) was transferred (to the hospital). They were not informed by the nurse that the insulin was given on 9/30/17 at 1846 (6:46 PM).