Every finding on record at Maple Valley Nursing Home

Based on interview and record review, the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all residents residing in the facility.Findings include:Review of the CMS PBJ Staffing Data Report FY (fiscal year) Quarter 1 2026 (October 1-December 31) revealed the metric Failed to have Licensed Nursing Coverage 24 Hours/Day Triggered with infraction dates being: 10/4, 10/5, 10/16, 10/18, 10/19, 10/21, 11/02, 11/29, 12/14.A request was made for licensed nursing timecards for those infraction dates was requested on 5/5/26 to the Nursing Home Administrator (NHA).Review of the licensed nursing timecards was completed on 5/6/26. This Surveyor was able to verify that the facility did have 24/7 nursing coverage on those infraction dates, however, the data missing was due to not entering travel nursing data into the PBJ system.An interview was conducted with the NHA on 5/6/26 at 12:30 PM. The NHA stated that the business office manager was responsible for entering data into the CMS PBJ system, but was unavailable at the time of the survey due to entering payroll for their employees.

Based on interview and record review, the facility failed to ensure Medication Regimen Reviews were completed and addressed by the attending physician in the medical records of four Residents (#8, #2, #3, & #7) of five residents reviewed for unnecessary medications. Findings include:Resident #7 (R7) The EMR of R7 indicated a pharmacist conducted a MRR on 2/7/26. The pharmacist documented in the EMR, in part: .See report for any noted irregularities and/or recommendations. The pharmacist's report for the 2/7/26 MRR was not located in the EMR. The EMR of R7 did not include documentation by the attending physician indicating the MRRs of 2/7/26 had been reviewed nor was there documentation by the attending physician on actions taken to address the pharmacist's recommendations. Review of the facility's policy [Facility Name] Statement of Policy for Facility Pharmacy Services, reviewed 1/16/26 read, in part, .Monthly visits by a licensed pharmacist to document drug regimen reviews for each resident.Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physical, medical director, director of nursing and lists, at a minimum, the resident's name, relevant drug, and the irregularity the pharmacist found. These reports will be addressed by physician, or physician extender during weekly visits at facility but no later than 10 days. Resident #8 (R8) The electronic medical record (EMR) of R8 indicated a pharmacist conducted a Medication Regimen Review (MRR) on 2/6/26. The pharmacist documented in the EMR, in part: .See report for any noted irregularities and/or recommendations. The pharmacist's report for the 2/6/26 MRR was not located in the EMR. The EMR of R8 included a pharmacist's MRR for R8 on 3/1/26. The pharmacist documented the following in the EMR, in part: .See Report – Lab Request. The pharmacist's report for the MRR of 3/1/26 was not located in the EMR. The EMR of R8 did not include documentation by the attending physician indicating the MRRs of 2/26/26 and 3/1/26 had been reviewed nor was there documentation by the attending physician on actions taken to address the pharmacist's recommendations. On 5/5/26 at 11:40 AM, the Director of Nursing (DON) said the facility was unable to locate the absent MRRs for R8. Resident #2 (R2) The EMR of R2 revealed an admission date to the facility on 4/13/26. The EMR did not contain an admission MRR. On 5/5/26 at 11:40 AM, the DON was asked if an MRR had been completed for R2. The DON said the pharmacist had not yet completed an MRR for R2. According to The American Society of Consultant Pharmacists (ASCP) guidelines titled GUIDANCE COMPONENTS OF A MEDICATION REGIMEN REVIEW IN LONG-TERM CARE FACILITIES found at www.ascp.com/page/policystatements?&hhsearchterms=admission&#rescol_4849366: .MRR is a process conducted by a pharmacist, either upon admission, during routine monthly visits, or if a resident experiences a change in condition. The guidelines define admission MRR as follows: admission MRR: MRR that is performed at the point of admission of a resident to a facility to identify clinically significant medication issues which can affect the resident positively by preventing a condition or reducing risk or avoiding an issue that may exacerbate, cause, or contribute to a symptom, illness, or decline in status . Resident #3 (R3) The pharmacist completed an MRR for R3 on 3/1/26. The pharmacist documented the following in the EMR of R3, in part: .See Report – Lab Request. The pharmacist's report for the MRR of 3/1/26 was not located in the EMR of R3. The EMR of R3 did not include documentation by the attending physician indicating the MRR of 3/1/26 had been reviewed nor was there documentation by the attending physician on actions taken to address the pharmacist's recommendation. On 5/5/26 at 11:40 AM, the DON said the facility was unable to locate the 3/21/26 MRR for R3.

Based on interview and record review, the facility failed toMaintain documentation in the clinical record to support a new diagnosis of schizophrenia, Care plan and provide interventions for schizophrenia, Monitor for behaviors associated with schizophrenia consistent with Diagnostic and Statistical Manual of Mental Disorders criteria, andMonitor for antipsychotic side effects and adverse reactionsfor one Resident (#3) of five residents reviewed for unnecessary medications. Findings include:Resident #3 (R3)A Minimum Data Set (MDS) assessment dated [DATE], prior to the acute care hospitalization of R3, documented active psychiatric diagnoses of bipolar disorder and anxiety disorder. The MDS indicated R3 did not have an active psychiatric diagnosis of Schizophrenia prior to the hospitalization on 10/1/25.Review of the EMR did not reveal documentation of psychiatric review while R3 was hospitalized , nor did the EMR contain behavior monitoring documentation for schizophrenia.The EMR for R3 did not include a care plan for schizophrenia and there was no documentation found indicating the facility was monitoring for side effects or adverse reactions related to the administration of antipsychotic medications.Social Worker (SW) E was interviewed on 5/5/26 at 3:19 PM, and confirmed R3 returned to the facility after an acute care hospitalization with new diagnosis of schizophrenia and a new antipsychotic medication prescription for risperdal. When asked if there was documentation to support a diagnosis of schizophrenia, SW E said, I don't think so. SW E was asked where behavior documentation for symptoms of schizophrenia was located in the EMR of R3. SW E stated she did not know.Certified Nurse Aide (CNA) C was interviewed on 5/6/26 at 7:06 AM. CNA C said behavior monitoring and tracking is documented by the CNAs and entered in the Resident Tasks in the EMR.Review of behavior monitoring documentation revealed R3 was being monitored for crying/sadness, isolating behaviors, and repetitive anxious complaints. R3 was not monitored for delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, other symptoms of schizophrenia, and/or side effects of the new medication prescribed.MDS nurse D was interviewed on 5/6/26 at approximately 9:00 AM, and was asked for any supporting documentation in the EMR for the diagnosis of schizophrenia for R3. MDS nurse D confirmed the facility only had the diagnosis of schizophrenia for R3 and did not have any documentation from the hospitalization to indicate how the diagnosis was received. MDS nurse D said she would review hospital information to see if psychiatric consultations were completed while R3 was hospitalized .On 5/6/26 at 12:25 PM, MDS nurse D provided her laptop computer for review. MDS nurse D said there was documentation from a psychiatrist contained in the hospital's separate EMR system. MDS nurse D said she had view-only access and was unable to print the information for the medical record of R3. MDS nurse D said she would submit a medical records request to the hospital to obtain the information for placement in the facility's EMR of R3.The hospital psychiatrist's report, dated 10/1/25, read, in part: . [Name of R3 redacted] is a 65 yo [year old] female with a longstanding history of bipolar disorder and more recent diagnosis of 'schizophrenia' who is admitted due to altered mental status/an episode of unresponsiveness yesterday. I am suspicious for the recent diagnosis of 'schizophrenia' at such a late age; it's more likely that either [R3's name redacted] psychotic symptoms went unnoticed/undiagnosed when she was younger, or have just come on in the past couple years in the context of potential new neurocognitive disorder [a condition characterized by a decline in cognitive function that interferes with daily life, caused by medical or neurological conditions rather than psychiatric illness]. Son reports that [R3's name redacted] has been showing signs of declining cognition, but has not yet been diagnosed with dementia.MDS nurse D was asked if any documentation was found indicating who gave the diagnosis of schizophrenia if the psychiatrist at the hospital was suspicious of the diagnosis and questioned the authenticity and accuracy of the diagnosis. MDS nurse D said she did not know and could not locate hospital documentation indicating what provider gave a diagnosis of schizophrenia. According to the DSM (Diagnostic and Statistical Manual of Mental Disorders) at American Psychiatric Association, DSM-5 Task Force. (2013). Diagnostic and statistical manual of mental disorders: DSM-5(tm) (5th ed.). American Psychiatric Publishing, Inc https://doi.org/10.1176/appi.books.9780890425596, the diagnostic criterion for schizophrenia includes:Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):1. Delusions.2. Hallucinations.3. Disorganized speech (e.g., frequent derailment or incoherence).4. Grossly disorganized or catatonic behavior.5. Negative symptoms (i.e., diminished emotional expression or avolition). B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences)D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. The Director of Nursing (DON) was interviewed on 5/6/26 at 8:58 AM. The DON confirmed R3 was transferred to the hospital in October 2025 with a medical condition and returned to the facility with a psychiatric diagnosis. The DON was uncertain how the resident was diagnosed with schizophrenia.An annual MDS assessment dated [DATE] coded R3 with a Brief Interview for Mental Status (BIMS) score of 15 which is indicative of fully intact cognition. The MDS documented R3 did not have concerns with inattention or disorganized thinking.R3 was interviewed on 5/6/26 at 9:13 AM. R3 said she was never previously diagnosed with schizophrenia. R3 said she had bipolar disorder, anxiety disorder, and depression. R3 accurately verbalized from memory the medications she was prescribed. R3 said she had never taken Risperdal until she was hospitalized in October. She stated she was receiving Risperdal twice daily but did not know why she was prescribed the medication in the hospital.The Behavior Management policy dated as updated 12/10/25 read, in part: .Residents with behavior problems will be treated by [name of facility redacted] using both non-medication interventions and medication as appropriate.Areas for review during behavior management meetings:.Plan of care review.Medication review including diagnosis & adverse reactions.Review of Behavior Monitoring records.All psychotropic medication use will be monitored closely for effectiveness and adverse reactions.

This deficiency pertains to Intake #2792749Based on interview and record review, the facility failed to protect a resident from misappropriation of resident property for one Resident (#21) of one resident reviewed for misappropriation of property. Findings include:Resident #21 (R21)An admission Minimum Data Set (MDS) assessment dated [DATE] indicated R21 was admitted to the facility on [DATE]. The MDS coded R21 with a Brief Interview for Mental Status (BIMS) score of 15 indicating R15 had intact cognition. The MDS documented R21 had intact short-term memory and long-term memory and had no mood or behavioral conditions.During an interview on 5/4/26 at 10:47 AM, R21 said Certified Nurse Aide (CNA) stole over $500.00 from his cash app account (a mobile app money transfer service that allows users to send and receive money) in February 2026. The alleged perpetrator was identified by R21 as CNA F, who worked the night shift.R21 said he wanted to transfer funds from a credit card but did not know the process to do it, so R21 said CNA F told him she could assist him if he provided her with his Cash App sign-in information. R21 said he provided CNA F with his Cash App sign-in information so she could help him with the money transfer.According to R21, he was reviewing his Cash App transactions shortly after Valentine's Day (2/14/26) and noted two suspicious transactions he had not authorized. R21 said the two transactions reflected CNA F had accessed his account and withdrew funds totaling over $500.00.R21 said he notified the facility social worker (SW) E and the Director of Nursing (DON) who notified the police of the theft. R21 said a police officer visited him, but he was unaware of the current status of the investigation.When asked how he felt about the theft of his funds, R21 said the facility had reimbursed the money, but at the time it occurred he was upset and angry. R21 said, I was upset - I was mad and hurt. That's what I get for letting my guard down and being friendly.The electronic medical record (EMR) of R21 contained a progress note dated 2/19/26 at 7:10 PM. The progress note was authored by SW E and read: Resident reported that he had $$520.49 [sic] taken from his account from the cash app and that it was [name of CNA F redacted] that completed two transactions taking this money from him. SW reviewed the transactions with resident on his cash app and made copies of them in the team office with resident present. SW also phoned [name of DON] and the [name of police department redacted]. Deputy [name of deputy redacted] interviewed resident in my presence in the team office. Resident is pressing charges against [name of CNA F redacted]. The deputy is calling [name of CNA F redacted], APS [Adult Protective Services] and will turn the case over to the prosecuting attorney for charges to be pressed. [Name of CNA F redacted] was a CENA [Competency Evaluated Nursing Assistant] with [name of staffing agency redacted]. [name of DON redacted] is reporting this to the state today. Copies of the deputy report number and cash app transactions scanned into resident's chart. Plan to follow.A progress note dated 2/28/26 at 12:49 PM documented, in part: Collaborated with [name of DON redacted], and she reports that [name of nursing facility redacted] will reimburse resident the #520.49 [sic] that was stolen from him by the [name of staffing agency redacted] CENA.During an interview with SW E on 5/5/26 at 3:04 PM, SW E was asked about the allegation of misappropriation of R21's money. SW E said on 2/19/26, R21 showed her his Cash App interactions from his cell phone and told her CNA F had stolen his money. SW E said the transactions to which R21 were referring documented the initials of CNA F. SW E said she contacted the police and the DON, and the DON reported the theft and CNA F to the state agency. SW E said, [R21] was upset she [CNA F] took his money. SW E said the facility had not received a police report because the investigation was still open.The DON was interviewed on 5/6/26 at 1:10 PM. The DON provided an investigation file of the misappropriation. The file included a photo of a cell phone displaying Cash App transactions. The cell phone reflected two transactions: one occurring on 2/1/26 for $500.26 and one occurring on 2/5/26 for $20.23, totaling $520.49. The first four letters of the recipient of the funds were the same first four letters of the first name of CNA F.The DON said she was contacted by SW E on 2/19/26 and made aware CNA F had stolen money from R21. The DON said she spoke with R21 who said he shared his Cash App information with CNA F. The DON said she contacted the contracted agency who suspended CNA F. The DON confirmed she notified the state agency to report the allegation against CNA F and report the misappropriation of money from R21 by CNA F.Attempts to contact CNA F via telephone were made on 5/5/26 and 5/6/26, but the attempts were futile.The policy Missing Items dated as reviewed and updated 3/21/16 read, in part: .It is the policy and responsibility of the facility to safeguard resident property to the extent possible to assure there is no misappropriation of resident property.

Based on interview and record review, the facility failed to ensure the Long-Term Care Ombudsman was notified of a resident's discharge from the facility for one Residents (#25) of one resident reviewed for discharge practices.Findings include:Review of R25's Electronic Medical Record (EMR) revealed the resident was discharged from the facility on 4/6/26. Review of the documentation provided to the Long-Term Care Ombudsman in April 2026 indicated they were not notified of the resident's discharge from the facility. An email to the Long-Term Care Ombudsman on 5/5/26 at 11:22 AM confirmed no notification of R25's discharge.On 5/6/26 at 12:21 PM, an interview was conducted with the Nursing Home Administrator (NHA) regarding R25's discharge and notification to the Long-Term Care Ombudsman. The NHA stated they have never sent notification of discharges.Review of the facility's policy titled Discharge of Resident, updated on 2/17/26 read, in part, Purpose: to provide safe departure from the facility, provide continuity of care, and to provide appropriate documentation.She/he will notify Michigan Long Term Care Ombudsman.

Based on interview and record review, the facility failed to:Document wound monitoring and assessments for one Resident (#21) of two residents reviewed for skin conditionsMaintain documentation in the facility reflecting ongoing collaboration and communication between the facility and hospice provider and ensure an updated hospice plan of care was retained in the facility for one Resident (#12) of three residents reviewed for hospice care.Findings include:Resident #21 (R21):An admission Minimum Data Set (MDS) assessment dated [DATE] indicated R21 was admitted to the facility on [DATE] with a primary medical condition of orthopedic aftercare following an amputation. The MDS coded R21 with a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented R21 had an infection of a surgical wound on the foot and received antibiotic medication.During an interview on 5/4/26 at 10:47 AM, R21 was noted to have a wound VAC (Vacuum-Assisted Closure - a medical device that uses negative pressure to promote wound healing) at bed side. The wound VAC tubing was lying atop the bed and was not connected to the wound dressing on the right foot of R21. The wound VAC pump was noted to be turned off.When asked about the disconnected wound VAC, R21 said he occasionally turned the pump off and disconnected the tubing from the wound dressing on his foot because the noise and feeling of the wound VAC on the wound of his foot aggravated him. When asked if the wound was worsening, R21 said he did not know.The electronic medical record (EMR) of R21 was reviewed and revealed the following physician's orders:Order dated 4/15/26: Wound vac to R[right] ft [foot] wound continuously at 125 mmhg [millimeters of mercury, a unit of pressure], Change Q [every] M-W-FR [Monday, Wednesday, and Friday] and PRN [as needed] if needed. Order dated 4/23/26: If Wound Vac fails or resident declines reapplication of Vac, cleanse wound to Rt foot with Wound Cleanser, pat dry, apply a N/S [normal saline] wet to dry [dressing] using sterile 4x4's [4 inch by 4 inch - size of gauze pads] and Kerlex [sic, Kerlix - woven gauze dressing]. Daily PRN per [name of physician redacted]. No [name of antiseptic redacted].The care plan for the surgical site wound on the right foot of R21 did not include wound VAC information nor did the care plan interventions address wound assessment documentation and frequency.The electronic medical record (EMR) of R21 was reviewed for wound assessment documentation. Two wound assessments were identified: a progress note entry on 1/16/26 and a progress note on 4/21/26.A progress note on 1/16/26 at 2:47 PM documented, in part: . Right foot, 4th and 5th toe amputated, incision site remains closed with sutures, approximately 4 cm [centimeter] x [by] 1 cm, no drainage. Right foot 2nd toe has 2 circular scabs on top, both under 0.5 cm in diameter, both closed with no s/s [signs or symptoms] of infection.A progress note dated 4/21/26 at 3:36 PM documented, in part: .Open wound measures 6.5 cm x 2.0 cm wide and 0.3 cm deep. Approximately 1/2 of the wound bed is covered with slough like [non-viable tissue that can impede healing and increase infection], dry, tissue. The remainder of the wound bed is pink granulation [newly formed connective tissue] tissue. Scant bleeding upon cleansing.The progress notes of 1/16/26 and 4/21/26 were the only wound assessments located in the EMR of R21.On 5/5/26 at 9:01 AM The Director of Nursing (DON) was queried regarding wound assessments. The DON said all wounds were assessed at least weekly and documented in the EMR, including surgical site wounds. The DON said all wound assessments were in progress notes or in the Consults portion of the EMR under the Miscellaneous tab.The Consult portion of the Miscellaneous tab in the EMR of R21 contained consultations with a podiatrist. The podiatrist consultations included medication and treatment orders but did not document wound assessments.On 5/6/26 at 1:08 PM, the DON said wound assessments were expected to be documented every time the wound VAC was changed. The DON said wound assessments were expected to include measurements and assessments of the wound appearance.The policy Wound Care Protocol dated as revised 2/3/26 read, in part: .Chart in progress notes length, width, and depth in millimeters [sic], drainage, odor, appearance.Resident #12 (R12)R12 was admitted to the facility on [DATE]. The EMR of R12 contained a physician's order dated 11/5/25 that read: Admit to hospice services [name of hospice redacted].An MDS assessment dated [DATE] documented R12 had a primary medical condition of non-traumatic brain dysfunction. The MDS indicated R12 received hospice care services and was dependent on staff for most activities of daily living (ADL).On 5/5/26 at 1:58 PM, the DON and MDS nurse D were asked the location of hospice documentation and hospice plans of care. MDS nurse D provided a binder and said hospice documentation was maintained in the binder.The hospice information in the binder for R12 was reviewed and contained one document dated 1/21/26. There was no other documentation in the binder. The EMR of R12 did not contain an updated hospice care plan, documentation of visits, assessments, or recommendations by the hospice provider.On 5/6/26 at approximately 9:30 AM, MDS nurse D was asked if hospice documentation was available in the facility for R12. MDS nurse D said the facility was unable to locate an updated hospice care plan or hospice documentation for R12. MDS nurse D said the hospice provider was contacted on 5/5/26 and an updated hospice care plan and documentation of visits from hospice were requested.A hospice Plan of Care Update Report was provided by MDS nurse D on 5/6/26 at approximately 10:15 AM. The date and time stamp in the upper right portion of the document was dated 5/5/26 at 3:15 PM indicating the document was issued to the facility on that date and time.MDS nurse D said she had notified hospice on 5/5/26 regarding missing documentation for R12. MDS nurse D said hospice visited several times a week, but they did not have any progress notes or information in the facility for hospice visits for R12.When asked the reason for the delay in receiving updated hospice plans of care and hospice visit documentation, MDS nurse D said, It's not very collaborative. MDS D reiterated she had contacted hospice on 5/5/26 to request hospice visit notes and was still waiting for them to send the notes.The DON was interviewed on 5/6/26 at 1:03 PM. The DON said she oversaw hospice services in the facility but did not know why progress notes, an updated hospice care plan, and hospice documentation was not available in the facility. The DON said she assumed hospice personnel left copies of documentation in the facility when they visited. The DON confirmed the hospice provider was expected to provide timely visit documentation and updated plans of care.On 5/6/26 at 1:33 PM, MDS nurse D provided 24 pages of hospice documentation. The date and time stamp in the upper right corner indicated the documentation was generated on 5/6/26 at 10:49 AM. The documentation included visit notes from 11/3/25 through 5/4/26.

Based on observation, interview, and record review, the facility failed to obtain a physician's order for supplemental oxygen and ensure respiratory equipment was changed and labeled for one Resident (#12) of two residents reviewed for oxygen therapy. Findings include:On 5/4/26 at 12:27 PM, R12 was observed wearing a nasal cannula (flexible tube that delivers supplemental oxygen). The nasal cannula was attached to an oxygen concentrator set to deliver supplemental oxygen at the rate of 3.5 liters per minute (LPM). The nasal cannula tubing was not labeled with a date to indicate when the tubing had last been changed.On 5/5/26 at 8:20 AM, the oxygen concentrator was noted be set to deliver 2 LPM of oxygen. The nasal cannula tubing remained unlabeled with a date.On 5/5/26 at 10:52 AM, the oxygen concentrator was set at 3.5 LPM. The nasal cannula tubing remained unlabeled.According to the electronic medical record (EMR), R12 was admitted to the facility 6/1/22. The diagnoses of R12 included a diagnosis of hypoxemia (low blood oxygen levels).A Minimum Data Set (MDS) assessment dated [DATE] documented R12 had a primary medical condition of non-traumatic brain dysfunction. The MDS indicated R12 utilized oxygen therapy as a respiratory treatment and received hospice care services.Review of physician's orders revealed R12 did not have a physician's order indicating the flow rate of supplemental oxygen. A physician's order dated 9/13/25 read: Replace oxygen tubing, nasal cannula and plastic storage bag at bedside weekly on Saturday during MN [midnight] shift. Label with resident name and date. Clean concentrator filter.Progress notes in the EMR of R12 included a nurse's progress note dated 1/30/26 at 12:36 AM that documented, in part: . O2 via NC [nasal cannula] @ [at] 4L [liters] . A nurse's progress note dated 4/28/26 at 11:48 PM documented, in part: . Oxygen via nasal cannula @ 2L/[per] min .The EMR included a care plan for Ineffective Breathing Pattern AEB [as evidenced by] Hypoxemia, adventitious [abnormal] breath sounds, sudden weight gain and increased edema dated as initiated 6/20/23 and revised 9/24/23 contained intervention that read: O2 via N/C 1-6L to maintain O2 [oxygen] sats [saturation] >90% and monitor my Pulse Ox [pulse oximetry or SPO2 - peripheral oxygen saturation] as ordered to titrate my oxygen needs.There were no orders found to monitor SPO2 as directed by the care plan intervention. There were no SPO2 readings documented on the medication administration record (MAR) or the treatment administration record (TAR). A review of the vitals portion of the EMR revealed no SPO2 documentation since 1/31/26.A hospice document dated 1/21/26 documented R12 had chronic respiratory failure with hypoxia and was dependent on continuous supplemental oxygen. The list of hospice orders included an order dated 11/6/25 that read: Oxygen gas for inhalation at 4 liters by inhalation continuous. The hospice document included SPO2 levels. The nursing assessment read, in part: .O2 screening [SPO2] at 87% on room air, nasal cannula placed back on patient. Vitals signs are stable on 4L nasal cannula.Licensed Practical Nurse (LPN) A was interviewed on 5/5/26 at 11:24 AM. LPN A said R12's oxygen concentrator should be always set between 2-3 LPM. LPN A said the nurses have not obtained SPO2 levels for R12 because the resident received hospice services.An interview with LPN B was conducted on 5/6/26 at 8:05 AM. LPN B said the supplemental oxygen for R12 was to be delivered at 1-2 LPM. LPN B said oxygen tubing was changed on the midnight shift weekly and the facility expectation was to write the date on a piece of medical tape and wrap the tape around the nasal cannula tubing, so staff know when the tubing was changed. When asked the date the nasal cannula tubing was changed for R12, LPN B said she did not know.During an interview with the Director of Nursing (DON) on 5/6/26 at 1:05 PM, the DON said a physician's order was required to use supplemental oxygen therapy, and she expected nurses to obtain SPO2 levels.The undated document Policy & Procedure Oxygen Therapy read, in part: .Oxygen is used only on the order of a physician, except in the case of emergency.Residents with orders for O2 will have documentation on treatment record for flow administered, rate of flow, frequency of administration and reason.The undated policy and procedure Oxygen Concentrator & Oxygen Cylinder Usage & Cleaning in a Nursing Home read, in part: .All customers using oxygen require a prescription signed by a physician. If there are any changes in oxygen flow rate or hours of usage, there will be available a prescription signed by the physician indicating the change.[name of supplier of supplemental oxygen redacted] will change the nasal cannula or mask on the concentrator and oxygen tanks being used at least weekly and place a dates ticker on the cannula identifying the change.The undated policy Pulse Oximetry read, in part: .Many of our resident have physician orders for monthly oximetry. Unless otherwise ordered - remove O2 for 5 minutes - record findings in resident record.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and served food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 21 residents of the facility. Findings include: On 4/8/25 at 10:50 AM, an initial tour of the kitchen was conducted, and the following was identified: a.) In the upright refrigerator/freezer, in the freezer section was three English muffin breakfast sandwiches with sausage, cheese, and egg wrapped in saran wrap without a label or date. b.) In the walk-in large cooler, a bag of chicken breast without a label or date. On 4/8/25 at 10:55 AM, an observation was made of a sign posted to the right of the walk-in cooler that read in part, .Date foods that are taken out of the freezer to thaw with a Th and then the date . On 4/8/25 at 11:00 AM, an interview was conducted with the [NAME] J and Kitchen Staff D, who were asked about the undated and unlabeled food items observed. [NAME] 'J stated he just took of the chicken this morning from the freezer and was unaware it needed to be dated and labeled. Kitchen Staff D stated she was unsure of why the breakfast sandwiches were in the upright refrigerator / freezer and so was [NAME] J who also mentioned he had never seen them used. 3-302.12 Food Storage Containers, Identified with Common Name of Food. - Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. - 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 On 4/8/25, the following observations were made of the kitchen staff: a.) At 11:06 AM, [NAME] F was not wearing a beard net and had a beard that was approximately 3/4 of an inch long. [NAME] F was preparing biscuits from scratch. b.) At 12:13 PM, Kitchen Staff D was preparing beverages for residents and did not wear gloves or sanitize her hands. There was also a plastic bun bag where Kitchen Staff D was putting her dirty used gloves in the bag on the clean prep counter. c.) At 12:30 PM, [NAME] F wore gloves that he had been serving with, used the ice scoop, and then prepared a sandwich with the now contaminated gloves. d.) At 12:41 PM, Kitchen Staff D was delivering meal trays with gloves on, returned to the kitchen, removed the top of a sandwich bun with the same dirty gloves, and then delivered another tray with the same dirty gloves. On 4/8/25 at 1:00 PM, an observation was made of a sign above the ice machine that read in part, Wash hands before using the ice scoop . On 4/9/25, the following observations were made of the kitchen staff: a.) At 7:46 AM, Kitchen Staff D washed her hands at the sink for only ten seconds and then turned the water off with bare hands. b.) At 8:03 AM, Kitchen Staff D delivered a drink to a resident, touch the resident, returned to the kitchen to get another drink and delivered the drink, returned to the kitchen and flipped an egg, went to the refrigerator, and then delivered another resident a drink while she was not wearing any gloves and failed to complete any hand hygiene. c.) At 8:17 AM, Kitchen Staff D washed her hands at the sink for only seven seconds and then turned the water off with bare hands. d.) At 8:43 AM, Kitchen Staff D was gathering dirty linen napkins, added them to the laundry cart, and then washed hands at the sink for ten seconds and turned the water off with her bare hands. e.) At 8:48 AM, Certified Nurse Aide (CNA) C delivered trays to two separate rooms (3, 6) and then went to the women's bathroom for residents and never performed any kind of hand hygiene. f.) At 8:55 AM, CNA C was with the meal tray cart in the hallway, removed a meal tray, entered room one, delivered and set up the tray, left room one without hand sanitization, removed another tray from the cart, delivered the tray to room five, left room five without hand sanitization, and then returned the cart to the kitchen. g.) At 10:15 AM, [NAME] F was preparing food in the kitchen for lunch without wearing a beard net. h.) At 11:35 AM, Kitchen Staff D washed her hands at the sink for ten seconds and then turned the water off with her bare hands. i.) At 11:45 AM, Kitchen Staff D was delivering food to three different residents wearing the same gloves, removed the gloves, did not use any hand hygiene, put something in the upright refrigerator, and then went to roll up silverware in cloth napkins. j.) At 11:50 AM, Kitchen Staff D grabbed a mug for coffee without gloves on, touched her face, poured the coffee, touched her face two more times, delivered the coffee with bare hands by grabbing the handle, and did not perform any type of hand hygiene. k.) At 11:54 AM, [NAME] F was preparing mechanical soft meals without a beard net on. l.) At 11:58 AM, [NAME] F touched several spices, washed his hands for ten seconds, and then turned the water off with bare hands. On 4/10/25, the following observations were made of the kitchen staff: a.) At 8:30 AM, Kitchen Staff D was flipping an egg with gloved hands, removed her gloves, no hand hygiene was performed and poured two cups of coffee, then removed the egg from the stove, put on gloves, made toast, delivered the egg and toast to a resident, returned to the kitchen with dirty items, removed her gloves, washed her hands for only ten seconds and turned the water off with bare hands, put on gloves, served a tray, removed gloves and again washed her hands for only ten seconds and turned the water off with bare hands. b.) At 8:34 AM, Kitchen Staff D was adjusting her clothing with bare hands, then grabbed three bowls to prepare mechanical soft meals, and did not perform hand hygiene. c.) At 8:40 AM, Kitchen Staff D washed her hands for ten seconds and turned the water off with bare hands. d.) At 11:45 AM, [NAME] F and Dietary Manager (DM) J were preparing lunch in the kitchen and neither one had a beard net on. DM J had a beard that was an inch and a half long. e.) At 12:04 PM, [NAME] F washed his hands at the sink for ten seconds and turned the water off with bare hands. f.) At 12:12 PM, Kitchen Staff D washed her hands for ten seconds and turned the water off with bare hands. g.) At 12:14 PM, DM J washed her hands for ten seconds and turned the water off with bare hands. h.) At 12:15 PM, Activities Aide M entered the dining room, did not perform hand hygiene, and passed out meal trays to two residents. The FDA Food Code 2017 states: 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (E) After handling soiled EQUIPMENT or UTENSILS (I) After engaging in other activities that contaminate the hands. On 4/10/25 at 12:25, an interview was conducted with the DM J, who was asked if he felt dietary staff changed gloves and performed hand hygiene enough during meal services. DM J replied, No, they don't change their gloves enough. They should be changing their gloves between each plate and each task. DM J was asked what the process for hand washing was. DM J replied, I don't know it by heart. I can't honestly tell you. DM J was asked if there were instructions near the kitchen hand washing sink on how the hand washing procedure should be completed. DM J replied, I think so. DM J was asked if beard nets should be worn in the kitchen. DM J replied, Yes (while he grabbed his own beard). On 4/10/25 at 12:30 PM, an observation was made of the kitchen hand washing sink and there were not instructions on the hand washing procedure near the kitchen hand washing sink. Review of policy titled, Food Storage, dated 2019, read in part, Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure .12. Refrigerated food storage .f. All foods should be covered, labeled and dated . Review of policy titled, Food Safety: Ice, dated 2019, read in part, Policy: Ice will be produced and handled in a manner to keep it free from contamination. Procedure .4. Staff will wash hands prior to handling ice . Review of policy titled, Hand Washing, dated 2019, read in part, Policy: Employees will wash hands as frequently as needed throughout the day using proper hand washing procedures .If chemical sanitizing gels are used, staff must first wash hands as outlined below. Procedure: Hands and exposed portions of arm .should be washed immediately before engaging in food preparation. 1.When to wash hands .b. After touching bare human body parts other than clean hands and clean, exposed portions of arms .f. After handling soiled equipment or utensils. g. During food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks .i. Before donning disposable gloves for working with food and after gloves are removed .2. How to wash hands: a. Turn on the faucet using a paper towel to avoid contaminating the faucet. b. Wet hands and forearms with warm water .and apply an antibacterial soap. c. Scrub well with soap and additional water as needed, scrubbing all areas thoroughly .Scrub for a minimum of 10 to 15 seconds within the 20-second hand washing procedure .d. Rinse thoroughly. e. Dry hands with paper towel .f. Use the paper towel to turn the faucet off and open the door if needed and then discard it. Review of policy titled, Food Safety and Sanitation, dated 2019, read in part, Policy: All local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. Procedure .Employees .c. Employees are required to have their hair styled so that it does not touch the collar, and to wear clean aprons, clothes and shoes .Beard nets are required when facial hair is visible . Review of policy titled, Bare Hand Contact with Food and Use of Plastic Gloves, dated 2019, read in part, Policy: Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. Procedure .3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task .used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 4. Hands are to be washed when entering the kitchen and before putting on the single-use gloves (before beginning work with food) and after removing single use gloves

This deficiency contains two deficient practices: Deficient Practice #1 Based on interview and record review, the facility failed to establish and/or implement an Infection Prevention and Control Program (IPCP) and update IPCP policies annually. This deficient practice had the potential to affect all 21 residents residing in the facility. Findings include: The facility IPCP was reviewed with the Infection Preventionist (IP) on 4/9/25 at 12:45 PM. The IPCP was noted to be without infection surveillance for symptomatic residents for whom an infection had not been diagnosed , and methods for investigating infections. The IP was asked how symptomatic residents who do not meet the criteria for infections are monitored. The IP said there was no list of symptomatic residents and no method for monitoring or tracking symptomatic residents. When asked about infection surveillance, the IP said a line listing was posted in the medication room and the names of residents who were prescribed antibiotics were placed on the list. The IP presented a form titled Antibiotic Listing Report that contained dates, residents' names, and prescribed antibiotics. The IP was asked where symptoms were documented but did not provide an answer. The IP said the residents on the Antibiotic Listing Report were considered to have infections because they were placed on antibiotics regardless of meeting criteria for infections. When asked the criteria used for determining infections, the IP said the facility utilized McGeer Criteria (guidelines for infection surveillance) and produced a document for McGeer Criteria dated the year 2012 (month/date not indicated). The most recently published McGeer Criteria was in the year 2024. When asked how infections were investigated to track origin of infections, analyze clusters, and determine the organism and source of infection, the IP said, We don't do that. Review of the IPCP binder revealed employee illnesses were not tracked prior to January 2025. The IP was asked how correlation of illnesses and potential contagious diseases between residents and employees were monitored prior to January 2025. The IP said, I just learned I was supposed to be doing that. The policy titled Infection Control Program dated as updated (revised) 4/12/22 read, in part: . [name of facility] has established an Infection Control Committee . with responsibility for overall infection control in the facility. All representatives of the I.C.C. [Infection Control Committee] shall meet quarterly and shall prepare and maintain an agenda, minutes of meetings, and shall annually review same as well as policies and procedures for compliance. The policy documented the I.C.C. was responsible for the establishment, oversight, monitoring, and review of the facility's IPCP. Facility IPCP policies and procedures were reviewed with the IP in the presence of the Director of Nursing (DON) on 4/10/25 at 10:40 AM. The IP was asked about the I.C.C. The IP said they did not have an infection control committee or have infection control meetings. The DON explained the IP was new in the role and still learning. The IP said she required additional training on the expectations of the IPCP and how to conduct an effective IPCP. The DON and IP confirmed an effective IPCP was not implemented. The DON said, We know infection control isn't where it needs to be - we have a lot of work to do. The policy Infection Investigation and Control dated 4/22/13 read, in part: . [name of facility] investigates, and controls to [sic] transmission of infections in the facility through their Infection Control Program. Procedure: 1. Monitor and investigate causes of all infections . A. The infection control nurse will review the information given and fill out an Individual Resident Infection Worksheet. The IP provided a copy of the Individual Resident Infection Worksheet. The document contained information regarding infection source, date of onset, infection site, signs and symptoms of infection, culture results, isolation if indicated, and treatment plan. The IP said the worksheet had not been utilized as indicated in the policy. Review of the IPCP policies and procedures revealed the following outdated policies that had not been updated annually: Infection Control Program dated as updated 4/12/22 Infection Investigation and Control dated 4/22/13 Infection Control Laundry Services dated 3/17/14 Handwashing dated 3/12/13 Hand Hygiene Alcohol Based Hand Cleansing Products was undated Employee Absence dated as revised 3/9/20 Employee Health Policy dated 11/2/16 Isolation Precaution Policy was undated Standing Orders for Administering Pneumococcal Vaccine to Adults dated 8/15/17 Antibiotic Stewardship Program was undated Immunization of Residents dated 2/25/21 Prevention and Control of Influenza dated 4/12/23 41978 Deficient Practice Statement #2 Based on observation, interview and record review, the facility failed to ensure implementation of enhanced barrier precautions (EBP) during resident care for one Resident (#72) of one resident reviewed and appropriate hand hygiene during medication administration for five Residents (#14, #18, #6, #8 and #1) of five residents reviewed. Findings include: Resident #72 (R72) Review of the Minimum Data Set (MDS) assessment, dated 3/26/2025, revealed R72 was admitted to the facility from an acute care hospital on 3/21/2025 and had diagnoses including surgical amputation of left great toe. R72 was assessed as having four unhealed Stage Two (partial thickness tissue loss) pressure injuries and one unhealed surgical wound. R72 was dependent on staff for all care and had severe cognitive impairment. An observation on 4/8/2025 at 2:16 p.m., revealed a sign attached to the door of R72's room alerting staff to use EBP. Further review of the sign revealed staff were to don gown and gloves during high-contact care activities including transferring, providing hygiene, changing briefs or assisting with toileting, and wound care. Further observation revealed Registered Nurse (RN) A and Activity Aide/Certified Nursing Assistant (CNA) K enter the room to transfer R72 from her wheelchair to her bed using a total mechanical lift. It was noted neither RN A or CNA K wore a protective gown during the transfer. On 4/9/2025 at 11:00 a.m., R72 was observed being cared for by Occupational Therapist (OT) O, Physical Therapist (PT) P and CNA G. CNA G donned gloves and provided incontinence care for R72 by removing R72's brief and cleansing the resident's peri-area with foam cleanser and a washcloth. PT P stood on the right side of R72 and OT O stood to the left of the bed to assist in positioning for R72 while CNA G provided care. After placing a clean brief on R72, CNA G proceeded to apply lotion to R72's back and arms. CNA G, PT P and OT O were observed not wearing protective gowns. Review of R72's care plan on 4/9/25 at 11:31 a.m., revealed the following: Skin/Risk for Infection: Orthopedic aftercare following surgical amputation & other wound care . Enhanced barrier precautions. Review of R72's physician order, dated 3/31/2025 at 1:23 p.m., revealed the following: Enhanced Barrier Precautions until wounds are healed. During an interview on 4/9/2025 at 4:15 p.m., Licensed Practical Nurse (LPN) B reported R72 had open wounds on her buttocks and left heel. On 4/9/2025 at 2:09 p.m., CNA G was asked about the use of EBP during high-contact care activities for R72. CNA G was alerted to the sign on R72's door informing staff of the need to utilize EBP during care of R72. CNA G stated she was unsure why the sign was attached to the door of R72's room as she had not worked for an extended period, but she believed the sign to be left over from when the facility had a Covid-19 outbreak. When asked if she knew the difference between Transmission-based Precautions (TBP) and EBP, CNA G could not offer an answer. Review of the facility policy titled, Enhanced Barrier Precautions, dated 4/5/2024, revealed the following: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes . involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., resident with wounds or indwelling medical devices). Residents #14 (R14), #18 (R18), #6 (R6), #8 (R8) and #1 (R1) On 4/10/2025 at 7:18 a.m., LPN B was accompanied into R14's room and was observed donning gloves to administer R14's oral medications. LPN B did not perform hand hygiene prior to donning gloves. After administration, LPN B removed the gloves, left R14's room and returned to the medication cart. No hand hygiene was performed by LPN B after removing the gloves or when returning to the medication cart. On 4/10/2025 at 7:51 a.m., R18 approached the medication cart and requested administration of an albuterol inhaler. LPN B donned gloves and proceeded to administer R18's inhaled medication by holding the inhaler to R18's mouth for inhalation. After administration, LPN B returned to the medication cart, cleansed the mouthpiece of the inhaler and returned the inhaler to the cart. LPN B removed the gloves and proceeded to prepare the remainder of R18's scheduled medication. LPN B was then accompanied to R18's room where she was observed donning gloves and administered R18's oral medications. Upon completion, LPN B removed the gloves and without performing hand hygiene returned to the medication cart and began preparing R6's medication for administration. On 4/10/2025 at 8:06 a.m., LPN B was accompanied to R6's room and was observed donning gloves to administer R6's oral medications. LPN B did not perform hand hygiene prior to donning gloves. Upon completion LPN B removed the gloves, returned to the medication cart without performing hand hygiene and proceeded to prepare R8's medications for administration. On 4/10/2025 at 8:10 a.m., LPN B was accompanied to R8's room and observed donning gloves to administer R8's oral medications. LPN B did not perform hand hygiene prior to donning gloves. Upon completion, LPN B removed the gloves, returned to the medication cart without performing hand hygiene and proceeded to prepare R1's medications for administration. On 4/10/25 at 8:20 a.m., LPN B was accompanied and observed donning gloves to administer R1's oral medications. LPN B did not perform hand hygiene prior to donning gloves. Upon completion, LPN B removed the gloves and returned to the medication cart without performing hand hygiene. An interview was conducted immediately following the medication administration observations. When asked about missed opportunities for hand hygiene during medication administration, LPN B confirmed she forgot to perform hand hygiene during the medication passes. LPN B stated I made sure I had it [hand sanitizer] on the cart yesterday. LPN B reported she should have been sanitizing her hands before and after each medication administration. Review of the facility policy titled, Medication Administration, dated 5/19/2023, revealed the following: Procedures for passing medications: Oral Medications . 1. Wash hands . 4. Place pills in mouth or instruct resident to place in mouth and swallow while giving fluids for ease of swallowing. 5. Wash hands.

This citation pertains to intake MI00151466. Based on observation, interview and record review, the facility failed to ensure the safe administration of medications for one Resident (#10) of six reviewed, resulting in a significant error when R10 was administered another resident's medications, leading to lethargy and confusion. Findings include: Resident #10 (R10) Review of the Minimum Data Set (MDS) assessment, dated 1/22/2025, revealed R10 was admitted to the facility on [DATE] and had diagnoses including hypertension, diabetes, stroke, and depression. R10 was assessed as cognitively intact and independent with most ADLs (activities of daily living) and ambulation. On 4/8/2025 at 3:06 p.m., R10 was observed standing at the sink in her room washing her hands, unassisted. R10 walked unassisted to her bed and sat down. During an interview at the time of the observation, R10 was asked about care in the facility, including medication management. R10 reported an occasion when she was administered another resident's medications leading to her feeling loopy and missing out on her shower day. R10 was unsure of the exact date of the occurrence or what medications she was administered. Review of R10's electronic medical record (EMR) revealed the following progress note: 1/28/2025 08:01 [8:01 a.m.]. Incident Note . Writer administered wrong medication to resident . Resident lethargic . Review of R10's, Medication Related Incident Report, provided by the Director of Nursing (DON) and dated 1/28/2025, revealed the following: I administered the wrong medications to this resident. I was pulling medications for one administration, multiple residents at med cart asking questions and I gave this resident [R10] the incorrect meds . Resident was lethargic . At lease one dose administered with a change in vital signs or other noticeable changes . Resident was lethargic for the majority of shift. It was noted the incident report did not include information regarding what medications R10 was incorrectly administered. On 4/10/2025 at 10:52 a.m. the DON was queried about the incident and asked what medications R10 were incorrectly administered. The DON reported R10 incorrectly received the following: Depakote (anti-convulsant medication used to treat seizures and bi-polar disorder) 125 milligrams (mg); Seroquel (anti-psychotic medication) 50 mg; and vitamin D3 25 micrograms (mcg). The DON stated the nurse was distracted, leading to administration of another resident's medications to R10. Review of the facility policy titled, Medication Administration, dated 5/19/2023, revealed the following: Keep in mind the Five Rights when giving medicines . 1. Right resident. 2. Right medication . Exercise care in giving medicine because there is an element of danger in every pill or drop of medicine . Pass medicines as quickly as possible without interruptions. It is the nurses' responsibility to ensure a safe and accurate medication pass .

Based on interview and record review, the facility failed to ensure that Medication Regimen Reviews (MRR's) and pharmacy recommendations were reviewed timely for one Resident (R18) out of five residents reviewed for MRR's. This deficient practice resulted in the potential for unnecessary medications or inappropriate durations of treatments. Findings include: Resident #18 (R18) A review of R18's medical record revealed they admitted to the facility on [DATE] with medical diagnoses including diabetes mellitus type II, bipolar disorder, and anxiety. A review of their 12/20/24 Minimum Data Set (MDS) assessment revealed they scored 15/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. A review of a Pharmacy Consultation Report dated 10/24/24 revealed in part, (R18) Consider adding lab draws for A1C and Magnesium levels .Physician agrees and signed on 11/5/24. Review of R18's Medications and Treatment Administration Records and progress notes, dated October through December 2024, revealed no labs were ordered to be drawn, and no progress notes documented labs were drawn for R18. Review of R18's physician order, dated 11/30/24, revealed an order for: Routine Labs: A1C (If last A1C <8 Q6 mos., if >8 Q 3 mos.) (MAR, JUNE, SEPT, DEC). Directions: No directions specified for order. Active as of: 11/30/24. R18's last A1C was drawn in March of 2024 with a result of 6.3 and R18 should have had an A1C scheduled / drawn in September 2024 but it was never ordered. On 4/10/25 at 9:06 AM, an interview was conducted with the Director of Nursing (DON), who stated that lab draws are an issue related to orders being put in for only three days and then travel nurses not wanting to draw the labs and then not letting her know they weren't drawn and then they get missed. The DON admitted to the lab being missed was her fault and acknowledged there needs to be a better system. A review of Pharmacy Consultation Report, dated 12/26/24, revealed a note to nursing to please consider obtaining updated lab value. Review of policy titled, Consultant Pharmacist Monthly Reports, Documentation and Communication of Consultant Pharmacist Recommendations, undated, read in part, Policy: The consultant pharmacist will submit a compete (sic) written report documenting all aspects of that month's consultation within ten (10) business days of exit date. The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapy are communicated to those with authority and / or responsibility to implement the recommendations and respond in an appropriate and timely fashion. Procedures .3. All procedural irregularities should be corrected as soon as possible by the facility staff or prescriber and note documenting that correction should be made in the DON's copy of the final report .

Based on interview and record review, the facility failed to ensure laboratory results were obtained and reviewed to monitor for adverse effects of anti-psychotic medications for one Resident (#4) of five residents reviewed. Findings include: Resident #4 (R4) Review of the Minimum Data Set (MDS) assessment, dated 1/19/2025, revealed R4 was admitted to facility on 4/18/2016 and had diagnoses including dementia, seizure disorder and schizophrenia. R4 was rated as having severe cognitive impairment. Review of R4's active medication orders revealed the following: Clozapine oral tablet 100 MG [milligram], give 1 tablet by mouth in the morning related to paranoid schizophrenia. Order date: 12/01/2023. Clozapine oral tablet 100 MG, give 3 tablets by mouth at bedtime related to paranoid schizophrenia. Order date: 12/01/2023. Further review of R4's electronic medical record (EMR) revealed the following active physician's order for laboratory testing, dated 11/4/2024: CBC with diff [complete blood count with differential] q [every] 30 days. The EMR for R4 revealed the most recent laboratory results, including CBC with diff were dated 12/27/2024. Review of R4's, Psychiatric Progress Note, dated 7/18/2024, revealed the following: . there was a period of time when she was unresponsive. They were instituting hospice. For that reason, I believe her CBCs were discontinued. The last one that was done was in May . [R4] is now much more responsive and doing well, so the hospice may be re-evaluated . if she graduates hospice, this should return to monthly monitoring. During an interview on 4/9/2025 at 12:48 p.m., Licensed Practical Nurse (LPN) B reported R18 was no longer receiving hospice services as of January 2025. Review of R4's physician progress noted, dated 2/28/25, revealed the following: . continues with clozapine, depakote, risperdal. continue clozapine monitoring with cbc and diff . Monitor labs . During an interview on 4/9/2025 at 4:15 p.m., the Director of Nursing (DON) was asked why there were no laboratory results found in R4's EMR since 12/27/2024. The DON presented laboratory results, included CBC with diff, dated 1/28/2025 and 4/03/2025. When asked for the results for February 2025 and March 2025, the DON reported R4's testing was missed due to staff failure to acquire R4's blood sample for testing. The DON reported when staff are too busy or just don't want to do it, the task is not completed and after three days the task no longer remains on the TAR. The DON reported when left uncompleted, the staff do not report the samples were never obtained. The DON reported she is working on a new system for ordering the laboratory samples, so the orders are not missed.

Based on interview and record review, the facility failed to ensure residents' code status was communicated and readily available for staff in the event of an emergency for three Residents (R17, R12, and R16) of six residents reviewed for advanced directives. Findings include: Resident #17 (R17) R17 was admitted to the facility on [DATE] with a primary medical diagnosis of Huntington's Disease. R17 was deemed totally incapacitated and had a court-appointed guardian. A document titled Out of Hospital Do-Not-Resuscitate [DNR] Order was signed by R17's guardian, physician, and two witnesses on [DATE]. The document read, in part: .In the event of an emergency or critical situation where a decision about immediate medical intervention is required, appropriate clinical decisions will be made in light of the directive below that you have signed and dated . No Resuscitation. Illnesses will be treated aggressively, including hospitalization if indicated, but in the event of cardiac or respiratory arrest, CPR and emergency transportation to the hospital will not [sic] be carried out . The DNR document was filed under the miscellaneous tab in R17's Electronic Medical Record (EMR). The DNR code status was not entered electronically as a physician's order in R17's EMR nor was the DNR order entered in R17's informational data on the status bar of the EMR. The code status bar of the EMR was blank for the advanced directive. Resident #12 (R12) R12 was admitted to the facility on [DATE] with primary medical diagnoses of vascular dementia and adult failure to thrive. R12 was deemed totally incapacitated and had a court-appointed guardian. The document Out of Hospital Do-Not-Resuscitate [DNR] Order under the miscellaneous tab in the EMR was signed by R12's guardian, physician, and two witnesses on [DATE]. The DNR code status was not entered into R12's informational data on the status bar of the EMR. The code status bar of the EMR was blank for the advanced directive. Resident #16 (R16) R16 was admitted to the facility on [DATE] with a primary diagnosis of encephalopathy (disease or disorder that affects the brain's function or structure). The document Out of Hospital Do-Not-Resuscitate [DNR] Order under the miscellaneous tab in the EMR was signed by R16 and two witnesses on [DATE]. The EMR reflected the form was scanned into the record on [DATE]. The DNR code status was not entered electronically as a physician's order in R16's EMR nor was the DNR order entered into R16's informational data on the status bar of the EMR. The code status bar of the EMR was blank for the advanced directive. On [DATE] at 7:57 AM, Licensed Practical Nurse (LPN) B was asked the code status of R17. LPN B opened the EMR and checked the information data status bar and said, It [code status] should be right here and pointed to the code status bar of the informational data. LPN B reviewed physician's orders and said there wasn't an order for code status. LPN B then reviewed R17's dashboard in the EMR, the face sheet, the Medication Administration Record (MAR), and the profile before saying the code status wasn't found. After searching the EMR for approximately two minutes, LPN B found the document Out of Hospital Do-Not-Resuscitate [DNR] Order under the miscellaneous tab. LPN B was asked about the amount of time that had passed to find R17's code status. LPN B said, This would absolutely be way too long in the case of an emergency. It needs to be where the nurses can find it. LPN B was asked about the code status for R12. LPN B referenced the informational data on the status bar of the EMR and said, This is the same problem. It's not where it should be. I really need to tell [the Director of Nursing (DON)] about this because a lot of nurses wouldn't know the code status if there was an emergency, and it took me too long to find it and I've been working with [name of EMR system] for the seven years I've been a nurse. LPN B was asked the code status for R16. LPN B opened the miscellaneous tab in the EMR of R16, but the tab did not populate categories and LPN B said she did not know how to filter to get the categories to populate. LPN B was asked if there were any additional methods to obtain code status information in the event of an emergency. LPN B said there was a binder in the DON's office, and said she would find the key and get the binder. Approximately four minutes later, LPN B produced a binder with paper copies of Out of Hospital Do-Not-Resuscitate [DNR] Order documents for each resident, including R16's DNR document. The DON was interviewed on [DATE] at 9:17 AM. The DON said LPN B had made her aware of the concern with code status communication and lack of immediate availability of each resident's code status information. The DON said, The nurses should be aware of the code statuses, and they [code status] should be in the electronic record so the nurses can find the information immediately. The DON said each resident's code status should be under the Advanced Directive portion on the informational status bar in the EMRs. The undated, untitled policy for DNR contained the procedure for documenting DNR orders. The policy read, in part: . 6. [Name of facility] will document in the residents' chart [sic] if the resident has a Do Not Resuscitate (DNR) order so all staff are aware.

Based on observation, interview and record review, the facility failed to ensure the assessment of respiratory status prior to the administration of an inhaled medication and according to professional standards for one Resident (#18) of five resident reviewed for medication administration. Findings include: Resident #18 (R18) Review of the Minimum Data Set (MDS) assessment, dated 12/20/2024, revealed R18 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD). R18 was assessed as cognitively intact. On 4/10/2025 at 7:51 a.m., during an observation, R18 approached the medication cart where Licensed Practical Nurse (LPN) B was reviewing resident medication needs for the morning. R18 reported feeling short of breath to LPN B and requested to use her inhaler. LPN B was observed removing an albuterol (short-acting inhaled medication used to open the airway, commonly called rescue inhalers) inhaler from the medication cart to administer to R18. LPN B administered two puffs of the medication to R18 in the hallway near the medication cart without performing a respiratory assessment to assess base line lung sounds for later use to determine effectiveness of the medication. After administration of the inhaler, R18 walked to her room and LPN B returned the inhaler to the cart and began preparing the remainder of R18's morning medications. LPN B was accompanied and observed administering the remainder of R18's scheduled medications. LPN B did not conduct a respiratory assessment, including obtaining R18's oxygen saturations (O2 sats-measures blood oxygen percentage) prior to administration of the inhaler or in response to R18 reporting she felt short of breath. LPN B did not perform a respiratory assessment following administration of the inhaler to R18 to assess for the effectiveness of the medication administered. On 4/10/2025 at 8:30 a.m., LPN B was asked if a respiratory assessment should be completed for a resident reporting shortness of breath and requiring use of as needed (prn) inhaled medication. LPN B reported she should have done an assessment prior to administration of the inhaler to determine necessity and after to determine response to treatment. Review of R18's electronic medication record (EMR) on 4/10/2025 at 9:35 a.m., including the Medication and Treatment Administration Records (MAR/TAR), revealed no respiratory assessment or O2 sat documented for R18 on 4/10/2025. On 4/10/2025 at 10:52 a.m., the Director of Nursing (DON) reported nursing staff were expected to conduct respiratory assessments for residents reporting shortness of breath and prior to the administration of prn inhaled medications as well as after administration to assess the effectiveness of the treatment. The DON stated, it's a nursing standard. Review of the facility policy titled, Medication Administered by Inhaler, provided by the Director of Nursing (DON) and dated 7/28/2018, revealed the facility policy did not include instructions for obtaining respiratory assessments, including baseline lung sounds or O2 sats, prior to or after administering as needed inhaled medications to treat shortness of breath.

Based on observation, interview, and record review, the facility failed to provide a dignified dining experience for three Residents (R5, R7, and R18) of twenty-one residents reviewed for dining experience. This deficient practice resulted in frustration and helplessness for those residents who were waiting for their meal to arrive. Findings include: On 4/8/25 between 11:30 AM and 1:00 PM, an observation was made in the main dining room where residents were eating lunch. Three staff members requested a lunch tray and kitchen staff made a lunch tray for them. After observing the three staff members receiving a lunch tray a tour was made of the facility where some remaining residents were observed in their rooms and the following observations and interviews were made. Resident #5 (R5) A review of R5's medical record revealed they admitted to the facility on [DATE] with medical diagnoses including Huntington's disease (neurogenerative disease that results in the lack of coordination and involuntary body movements), aphasia (inability to use spoken language), and dysphasia (impairment in the production of speech). A review of their 1/19/26 Minimum Data Set (MDS) assessment revealed they were dependent on staff for all activities of daily living (ADL's). On 4/8/25 at 1:02 PM, an observation was made of R5 lying in his bed in his room. An attempt was made to interview R5, but they were unable to speak related to their medical condition. R5 was observed moving his mouth open and closed and motioning with his right hand when asked if they were hungry. R5 did not received his meal until 1:45 PM, over two hours after lunch started to be served. On 4/8/25 at 1:50 PM, an interview was conducted with Certified Nurse Aide (CNA) C, who was asked if R5 received their lunch yet or if they were going to get them up to eat lunch. CNA C replied, No, (R5) did not get lunch yet. We need to get them up. We have been busy with other residents and had not been able to get to them yet. Resident #7 (R7) A review of R7's medical record revealed they admitted to the facility on [DATE] with medical diagnoses including diabetes mellitus type II, anxiety, and muscle wasting. A review of their 11/11/24 MDS assessment revealed they scored 8/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderate cognitive impairment. On 4/8/25 at 1:05 PM, an observation was made of R7 in their room and lying in bed. R7 was asked if they ate lunch or if they had gone to the dining room to eat lunch yet. R7 replied, No, but I am hungry. I hope they bring it soon! Resident #18 (R18) A review of R18's medical record revealed they admitted to the facility on [DATE] with medical diagnoses including diabetes mellitus type II, bipolar disorder, and anxiety. A review of their 12/20/24 Minimum Data Set (MDS) assessment revealed they scored 15/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. On 4/8/25 at 1:10 PM, an observation was made of R18 in their room, sitting on their bed. R18 was asked if they ate lunch or if they had gone to the dining room to eat lunch yet. R18 replied, No and I am hungry. Why haven't they brought me lunch yet? On 4/9/25 at 1:20 PM, an interview was conducted with the Director of Nursing (DON), who was asked about meal tray pass and staff being served prior to all residents' being served meal trays. The DON replied, It is our policy that all residents' are served before staff get a meal tray. Staff should be waiting until all the residents are served to get a meal. They all know that! On 4/10/25 at 12:25 PM, an interview was conducted with the Dietary Manger (DM) J, who was asked about meal service and if it was appropriate for staff to get a meal tray before all the residents were served a meal tray. DM J replied, No, and it would be helpful if management staff would come and assist during mealtimes with tray passes especially with the few residents' that choose to eat in their rooms. Review of the policy titled, Timely Meal Service, dated 2019, read in part, Policy: Food will be delivered promptly to assure safe, palatable, and high-quality food served at the proper temperature .

Based on interview and record review, the facility failed to: 1. Educate residents/resident representatives on the pneumonia vaccines currently available and recommended by the CDC for two residents (R10 and R72) of five residents reviewed for immunizations. 2. Administer a pneumococcal vaccination or document the clinical reasons for withholding the pneumococcal vaccination for one resident (R17) of five residents reviewed for immunizations. 3. Update vaccine consent forms and immunization policies with the pneumococcal vaccines (PCV15, PCV20 or PCV21) currently available and recommended by the Centers for Disease Control (CDC). Findings include: Resident #10 (R10) R10 was admitted to the facility on [DATE] with a primary diagnosis of diabetes with circulatory complications. A vaccination report from the [State] Care Improvement Registry (MCIR - State Agency Immunization Record) was reviewed on 4/10/25 and revealed R10 was overdue for pneumonia vaccination. The MCIR documented, in part: .Pneumococcal High Risk (HR)/Adult . Status: PCV15/PCV20/PCV21 - DUE NOW [sic] . A document titled Immunization Consent Form was signed by R10's resident representative on 10/15/24. The form included the statement: I have received a copy of the most current Vaccination Information Sheet (VIS) as published by the CDC. I have read or have had explained to me information of the above vaccines . The consent form did not indicate which VIS had been provided to the legal representative of R10. The consent form did not include the PCV15/PCV20/PCV21 vaccines. Documentation by R10's physician was not located in the Electronic Medical Record (EMR) regarding any contraindications of pneumococcal vaccination. No documentation could be found in the EMR by the physician or Infection Preventionist (IP) regarding vaccination discussions or education provided to the resident or resident representative on the benefits or risks of pneumococcal vaccination. Resident #72 (R72) R72 was admitted to the facility on [DATE] with a primary diagnosis of orthopedic aftercare following surgical amputation. A MCIR for R72 was reviewed on 4/10/25. The MCIR read, in part: . Pneumococcal High Risk (HR)/Adult . Status: Due 9/4/24. An Immunization Consent Form document was signed by the Resident Representative of R72 on 3/21/25. The form included the statement: I have received a copy of the most current Vaccination Information Sheet (VIS) as published by the CDC. I have read or have had explained to me information of the above vaccines . The consent form did not indicate which VIS had been provided to R72. The consent form did not include the PCV15/PCV20/PCV21 vaccines. Further review of the consent form for R72 revealed outdated recommendations for pneumococcal vaccination. The form erroneously stated the CDC recommended the use of the PCV13 and PPSV23 vaccines. The PCV13 vaccine ceased being recommended by the Centers for Disease Control (CDC) for routine use among adults aged 65 and older as of 11/22/19 (www.cdc.gov/mmwr/volumes/68/wr/mm6846a5.htm). Documentation by R72's physician was not located in the Electronic Medical Record (EMR) regarding contraindications of pneumococcal vaccination. No documentation could be found in the EMR by the physician or Infection Preventionist (IP) regarding vaccination discussions or education provided to the resident or resident representative on the benefits or risks of pneumococcal vaccination. On 4/10/25 at 10:40 AM, the Infection Preventionist (IP) was asked regarding the Vaccine Information Statement (VIS) provided to the Resident Representatives of R10 and R72. The IP provided a VIS for PPSV23 dated 10/30/19 that included the use of PPSV23 and PCV13. The IP confirmed no additional VIS were provided to R72 or the legal representatives of R10. The most current VIS published by the CDC was on 5/12/23 and included the recommendation for PCV15 and PCV20. The Representatives for R10 and R72 were not provided with the most current, updated recommendations and information to make informed decisions on pneumococcal vaccinations nor were the Representatives provided education on the benefits and potential side effects of these vaccinations. Resident #17 (R17) R17 was admitted to the facility on [DATE] with a primary diagnosis of Huntington's Disease. A MCIR for R17 was reviewed on 4/10/25 and revealed the resident had not received pneumococcal vaccination. A review of an Immunization Consent Form signed by R17's court-appointed legal guardian on 2/5/25 revealed the guardian requested and consented to pneumococcal vaccination for R17. On 4/10/25 at 10:40 AM, a progress noted dated 4/7/25 at 3:22 PM was reviewed with the IP. The note read: Consent obtained from resident's guardian [name of guardian] to give the current vaccinations that are due: Tetanus, COVID booster, and pneumonia. The Immunization Consent Form signed by R17's guardian on 2/5/25 was reviewed with the IP. The IP was asked if R17 received the pneumococcal vaccination. The IP said, I'm still working on it and confirmed R17 was not provided the pneumonia vaccination as requested despite R17's guardian consenting to the vaccination more than two months previously. No clinical consideration of contraindication of the vaccine was documented by R17's physician. The IP produced a document Standing Orders for Administering Pneumococcal Vaccine to Adults dated as revised 8/15/17 read, in part: Purpose: to reduce morbidity and mortality from pneumococcal disease by vaccinating all patients who meet the criteria established by the Centers for Disease Control . The CDC recommendations for adults ages 19 through [AGE] years read, in part: .The following guidance applies to adults younger than [AGE] years who have a risk condition. Never received any pneumococcal vaccine: Give 1 dose of PCV15, PCV20, or PCV21 . (www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/risk-indications.html). The facility policy titled Immunization of Residents dated as updated 2/25/21 read, in part: .3. Residents without proof of previous pneumococcal vaccination should receive one (1) dose only of Pneumovax 23 .If under age [AGE] years and has been six years since last immunization, then repeat immunization .

This deficiency pertains to Intake MI00149589. Based on interview and record review, the facility failed to conduct regular skin assessments for one Resident (#1) of three residents reviewed for quality of care resulting in the potential for untreated skin conditions. Findings include: Resident #1 (R1) Review of R1's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including ischemic cardiomyopathy (a condition that reduces the heart's ability to pump blood due to decreased blood supply) and type two diabetes. Review of R1's most recent Minimum Data Set (MDS) assessment, dated 10/22/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. On 1/22/25 at 11:25 AM, a telephone interview was conducted with R1's Guardian [A] regarding the care she received at the facility. Guardian A stated R1 had consistent redness and irritation in her skin folds around her stomach and groin area. Guardian A stated the facility was not addressing the concern. On 1/22/25 at 10:51 AM, an interview was conducted with R1 who verified redness and irritation in her skin folds. R1 stated the facility was not doing anything to address the discomfort. Review of R1's Plan of Care revealed a focus titled, Skin Breakdown, revised 10/16/24, which read, I have a history of skin breakdown near my coccyx area and red areas in skin folds. The following interventions were listed: Apply protective or barrier ointment after incontinence or in skin folds if they become red . CNA's to inspect skin daily and report any changes (redness, rashes, wounds .) to charge nurse . On 1/22/25 at 12:01 PM, an interview was conducted with Registered Nurse (RN) F regarding facility expectations with skin assessments. RN F stated each resident undergoes a skin assessment at least once per week, usually on shower days, which is documented in the Treatment Administration Record (TAR) and an associated progress note in the EMR. On 1/22/25 at 12:46 AM, an interview was conducted with Certified Nursing Assistant (CNA) D who verified she assisted R1 on four of her last six shower days. CNA D confirmed R1 frequently had redness and irritation near her underwear line. CNA D stated if skin integrity issues or abnormalities were noted, the facility protocol is to report the concern to the floor nurse. When asked if the skin redness and irritation for R1 was reported to the nurse, CNA D stated she was unable to recall. Review of R1's EMR revealed the only skin and wound progress note was written on 10/26/24, 11 days after her initial admission, which read, in part: Inflamed reddened macerated [broken down skin resulting from prolonged exposure to moisture] right groin rash . No other skin assessments were noted in the EMR. On 1/22/25 at 1:12 PM, an interview was conducted with the Director of Nursing (DON) regarding facility skin assessment expectations. The DON confirmed all residents should have a skin assessment performed at least once per week which should be documented in the TAR with a corresponding progress note. The DON confirmed R1 had a history of yeast infections in her skin folds and no documented skin assessment since 10/26/24. Review of the facility policy titled, Skin Integrity, dated 1/14/14, read, in part: .weekly skin assessments will be done on all residents .

This deficiency pertains to Facility Reported Incident (FRI) MI00145634. Based on observation, interview, and record review, the facility failed to prevent a serious burn injury for one Resident of 3 residents reviewed for accidents and hazards. This deficient practice resulted in a second-degree burn sustained to the upper torso of Resident #1. Findings include: Resident #1 (R1): Review of R1's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including dementia and fibromyalgia (a syndrome causing chronic widespread pain). Review of R1's most recent Brief Interview for Mental Status (BIMS) assessment, dated 5/26/24, revealed a score of 9, indicative of moderate cognitive impairment. Review of the facility investigation summary submitted to the State Agency (SA) read, in part: Date of Alleged Event: 7/1/24 .I was informed by [Certified Occupational Assistant (COTA) C] that [R1] had spilled soup on herself and was burned. I immediately went into [R1's] room. She was in bed lying at a 45-degree angle with her eyes closed and her bowl upside down on her upper abdomen. Her shirt was rolled up away from her skin. I noted a reddened area approximately 3 inches long x 4 inches wide .I interviewed [Certified Nursing Assistant (CNA) B] who delivered the tray. She told me that she brought tray in and left it, because [R1] seemed sleepy. She planned on coming back after she delivered the other trays . [Dietary Director (DD) F] stated that the soup was held at temperature of 173 f [Fahrenheit] in [the] steam table .Investigation determined resident was served soup that was hot enough to burn skin and was left unattended that was in reach of resident who was drowsy and grabbed the bowl to feed herself . On 8/19/24 at 10:30 AM, R1 was observed lying in bed, positioned to toward the right side. CNA D and CNA G were observed re-positioning R1 toward the center of the bed, as R1 was unable to complete the task independently. An interview was attempted and R1 was unable to answer specific questions related to the incident but was able to state, Yes when asked if she experienced a burn on her torso. Review of an incident report, dated 7/1/24, written by CNA B read, in part: I delivered [R1's] dinner .which was soup. I set up her soup to cool, but she was sleepy, so I left to deliver other trays . About five minutes later, the DON [Director of Nursing] grabbed me to inform me that [R1] got burnt by the soup. When we walked back into the room, she [R1] was still very sleepy and lethargic . On 8/19/24 at 12:14 PM, an interview was conducted with COTA C who verified she was treating R1's roommate at the time of the incident. COTA C stated, I was working with [R1's] roommate and the curtain was pulled between the beds, but I heard her [R1] yelling. She was shouting, 'It's hot!' COTA C stated she observed R1 in a reclined position, approximately 45 degrees, with a bowl of soup spilled on her upper torso. On 8/19/24 at 12:14 PM, an interview was conducted with CNA D regarding the proper position to place a resident when choosing to eat in bed. CNA D stated, The resident should be as close as possible to 90 degrees .you want them sitting all the way up. Review of a Skin/Wound Note, dated 7/2/24, written by Registered Nurse (RN) A read, in part: Wound to upper abdomen caused by hot liquid burn today assessed. Pain assessment completed - resident c/o [complains of] 6/10 pain at area, described as burning.Blistering present . On 8/19/24 at 12:21 PM, an interview was conducted with RN A who verified she assessed R1's burn following the incident. RN A confirmed blistering was present upon her assessment which classified the burn as a second-degree [a burn causing damage to the first and second layer of skin]. When asked about positioning expectations for meal consumption in bed, RN A stated, The angle of the bed should be upright to reduce risk of aspiration [choking] or spills. On 8/19/24 at 12:26 PM, an interview was conducted with the DON regarding the burn incident. The DON verified R1 was in a reclined position and a bowl of hot soup was left on a tray table placed over the bed. The DON stated the tray table should have been moved off to the side of the bed before CNA B left the soup unattended. The DON indicated her expectation is to place residents in an upright position should they chose to consume a meal in bed to reduce the risk of accidents. The DON confirmed the presence of blistering classified the burn as second-degree. Review of R1's EMR did not reveal any assessment for burn potential prior to the incident. Review of facility policy titled, Burns, revised 8/7/24, read, in part: [Facility Name] will prevent a burn from occurring . on admission and quarterly an assessment for burn potential will be done for all residents . Review of facility policy titled, Facility Safety Hazards P&P [Policy and Procedures], dated 3/28/24, read, in part: .Foods will be served at safe temperatures to prevent burns .

This Deficient Practice Statement (DPS) has two parts: A and B. DPS A: Based on observation, interview, and record review, the facility failed to prevent the unauthorized removal of a resident from the facility for approximately 16 hours resulting in the likelihood for serious injury, serious psychosocial harm, or death for one Resident #9 (R9) of one resident reviewed for abuse. Findings Include: The Immediate Jeopardy began on 9/18/23 at 6:07 PM when the facility failed to prevent R9's unauthorized leave from the facility by two former terminated Certified Nurse Aides (CNAs). Former Registered Nurse (RN) M failed to ensure Former CNA/Perpetrator I and J had permission to take R9 from the facility to an unknown location for approximately 16 hours without any medication provided, including potentially necessary hospice medications, or a thickening agent for R9's prescribed therapeutic diet. The Director of Nursing (DON) was notified of the immediate jeopardy on 4/22/24 at 4:37 PM. At that time, a written removal plan was requested from the facility. This surveyor confirmed by interview and record review that the immediacy was removed on 4/22/24 at 11:30 AM, however, noncompliance remains at the potential for more than minimal harm due to sustained compliance which has not been verified by the State Agency (SA). Resident #9 (R9): Review of R9's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including Huntington's disease (a progressive, fatal genetic disorder that affects the brain and causes involuntary movements, cognitive decline, and emotional problems), aphasia (difficulty processing, using, and/or understanding language), dysphagia (difficulty or inability to swallow), contracture of unspecified hand (a permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult), and alcohol abuse. Record review of R9's Minimum Data Set (MDS) assessment immediately preceding the unauthorized leave of absence (LOA) on 7/20/23, indicated R9 had severely impaired cognition - unable to complete BIMS [Brief Interview for Mental Status]. R9 was admitted to hospice services on 7/20/23. On 4/22/24 at 10:27 AM, R9 was observed sitting in a specialized wheelchair with anti-tip bars, a Velcro lap buddy, back leg rests, and a pressure reducing cushion. A pressure reducing mattress was noted in R9's room. On 4/22/24 at 11:47 AM, a phone interview was conducted with R9's Guardian [H], who disclosed two former facility staff members had taken R9 out overnight without his permission at some point the previous fall. Guardian H indicated the facility called him the morning following the LOA to ask if facility staff that worked the previous evening had asked him for consent prior to R9's departure. Guardian H indicated he did not give approval and was unaware of R9's exit from the facility. On 4/22/24 at 1:04 PM, a follow-up phone interview was conducted with Guardian H who stated the morning following R9's leave of absence, he received a call from the facility informing him that R9 was missing. Guardian H indicated the facility informed him Perpetrator I and Perpetrator J (later identified as former terminated Certified Nursing Assistants [CNAs] at the facility) had taken him out of the facility the previous night and had not returned. Guardian H stated, I was freaking out. I asked if we should file a report with the police. Guardian H reiterated the facility had not called him prior for permission for R9's departure, stating, I was upset with the nursing home and their lack of calling me. The nurse who called me the morning he was missing wasn't sure where [R9] was. I was shocked .shocked that the facility would let somebody out on hospice care and not even call to even verify if it was okay. Guardian H stated that since R9 signed with hospice on 7/20/23, nobody was authorized to take R9 from the facility due to his deteriorating physical and mental condition. Review of R9's progress notes revealed the following entries: 1. 9/18/23 at 18:07 [6:07 PM] written by former Registered Nurse (RN) M: LOA with [Perpetrator J] and [Perpetrator I] to [Perpetrator J's] house at 1807 [6:07 PM]. 2. 9/18/23 at 22:24 [10:24 PM] written by RN D: Resident's responsible party for LOA was called and did not answer. 3. 9/18/23 at 23:44 [11:44 PM] written by RN D: This writer attempted to call [Perpetrator J] and [Perpetrator I] and [Guardian H]. None of them answered. DON aware. 4. 9/18/23 at 23:49 [11:49 PM] written by RN D: This writer attempted to call [Perpetrator J] and [Perpetrator I] and [Guardian H] each multiple times. None of them answered. 5. 9/19/23 at 09:48 [9:48 AM] written by RN K: LOA Returned from [Perpetrator J's] house driven by [Perpetrator J] and [Perpetrator I]. On 4/22/24 at 1:55 PM, a phone interview was conducted with RN D who was asked why R9's responsible party was not called for approval of an LOA until after R9 had already exited the building for approximately 4.5 hours. RN D stated, I think I was expecting him to be back that night and that's why I called the responsible guardian [H] .or I wasn't certain if he was supposed to return so I was trying to figure it out. RN D was asked why he attempted several subsequent phone calls to Perpetrator J, Perpetrator I, and Guardian H as documented at 11:44 PM and 11:49 PM. RN D stated, I wasn't getting through to people, and I wasn't sure if [R9] was coming back at that time. RN D was asked the protocol for a resident going on a leave of absence. RN D indicated the responsible party would sign the resident out in the Release of Responsibility for Leave of Absence binder and the charge nurse would document the departure in the EMR. When RN D was asked if the process would differ for a resident with a guardian, he stated, If somebody were to want to take a resident and they weren't the guardian, I would contact the guardian to get permission .I'm not sure of the exact protocol, but I would put it into my LOA note [in the resident's EMR]. On 4/22/24 at 2:30 PM, a phone interview was conducted with former Director of Nursing (DON) RN M who verified that Perpetrator J and Perpetrator I came to the facility around 6:00 PM on 9/18/24. RN M stated Perpetrator J and Perpetrator I informed her that they were taking R9 out for a brief leave. RN M stated, They [Perpetrator J and Perpetrator I] had taken him out in the past and they would take him to [Perpetrator J's] house. They would take him over for dinner and bring him back. That's what I would have expected . I got a call from [Perpetrator J] saying that they got him [R9] back to the facility at 9:00 AM the next morning .I was furious. RN M was asked if Perpetrator J and Perpetrator I were authorized to take R9 on a LOA. RN M stated, I didn't look at it [the approved list of responsible parties] that day. When they [Perpetrator J and Perpetrator I] took him out of the facility, I just assumed they were on the approved list. RN M stated no necessary medications, equipment, or supplies per R9's plan of care or physician orders were sent upon his departure. On 4/22/24 at 2:54 PM, an interview was conducted with the Nursing Home Administrator (NHA) and the DON. The NHA verified that former CNAs, Perpetrator J and Perpetrator I, took R9 out of the facility on an unauthorized LOA and did not bring him back until the following morning. The NHA stated that although Perpetrator I did have permission at one time, Guardian H had since stopped anybody from removing R9 the facility following his admission to hospice (on 7/20/23) due to his declining condition. The NHA and DON both confirmed they were unaware of R9's absence from the building until arriving to the facility for work on the morning of 9/19/23. The NHA indicated they called local law enforcement after learning of the situation. The NHA stated, I didn't know what to do .What's the process for this? They basically kidnapped a resident. The NHA and DON stated they did not know why they were not contacted by RN D or former RN M on 9/18/23 after R9 left the facility and did not return. The NHA was asked if Perpetrator J or Perpetrator I had any previous history with R9. The NHA stated Perpetrator I had received disciplinary action in early 2021 after she shaved R9's legs, shaved a letter in the back of R9's hair, and drew inappropriate pictures and phrases on his skin with permanent marker. The NHA did not indicate Perpetrator I had any limited or altered contact with R9 following the incident as part of the remedial action. Review of CMS-2567 form dated 6/10/21 indicated Perpetrator I was, educated on resident's right, abuse and other policies regarding this type of behavior following the incident. The NHA verified Perpetrator I was subsequently terminated on 3/8/23 following a separate incident with a different resident per form CMS-2567 dated 7/3/23. The NHA confirmed Perpetrator J quit working as a CNA on 12/8/21 for reasons related to her vaccination status. Review of, [County Name] County Dispatch - Call Detail Report indicated Business Officer Manager (BOM) L filed a report on 9/19/23 at 9:24 AM that read, in part: Patient missing, two people came last night around 1800 HRS [6:00 PM], said they had paperwork to take him [R9] out . [Perpetrator I] .[Perpetrator J] . On 4/22/24 at 3:50 PM, a phone interview was conducted with Perpetrator J who stated, We just took him [R9] out for a good time . Me and [Perpetrator I] took him to my house for dinner and gave him a shower. Perpetrator J stated she informed the nurse on duty, RN M, that they were taking R9 on a LOA. Perpetrator J stated she didn't take any required medications, supplies, or equipment prior to departure besides a couple incontinence briefs. Perpetrator J indicated that she and Perpetrator I transferred R9 into her private vehicle without using the care-planned transfer technique and drove to her private residence. Once there, Perpetrator J indicated R9 ate some ground up stir fry, drank some water, and then she assisted him into the shower. Perpetrator J stated R9 slept in a recliner, propped up so he could breathe. Perpetrator J was asked if she had permission to take R9 on a LOA to which she replied, I had permission before he [R9] was on hospice. Since he was on hospice, the process was different, and I wasn't aware of that. Apparently, I was no longer cleared [to take R9 on a LOA]. Perpetrator J was asked if she was contacted by the facility after leaving with R9. Perpetrator J stated, Yes, that night the facility called me and asked what time R9 was going to be home. I told them, 'He'll be there when we get him there.' On 4/22/24 at 4:19 PM, a phone interview was conducted with Perpetrator I who stated she and Perpetrator J arrived at the facility around dinner time and notified RN M they were taking R9 on a LOA. Perpetrator I stated that CNA R packed R9 an overnight bag. Perpetrator I stated they took R9 to Perpetrator J's personal residence. Perpetrator I stated that R9 ate some pudding, tried a beer, but didn't like it, so he was switched to drinking pop. Perpetrator I verified R9 was given a shower at the residence because, he was covered in food and slop and slept in a recliner. Perpetrator I stated around 10:00 AM on the morning of 9/19/23, she received at text message from RN K asking when R9 was returning to the facility. Perpetuator I indicated to RN K that they were planning on returning R9, in a little bit until RN K stated that we had to bring him back immediately. Perpetrator I indicated that shortly after dropping R9 back off at the facility, she received a call from local law enforcement stating she was being charged with felony kidnapping. However, Perpetrator 'I stated the police officer ended up calling Perpetrator I back, stating R9's family no longer wished to press charges, and that they were instead upset at the facility for not knowing his whereabouts. On 4/22/24 at 4:58 PM, an interview was conducted with RN K who stated he arrived at the facility at the start of his shift around 6:30 AM on 9/19/23. RN K stated he received report from the midnight nurse, former RN M, who indicated R9 was not in the building. RN K stated, She [former RN M] seemed concerned. I don't think she was aware that R9 was going to be out overnight. RN K stated he tried calling Perpetrator J and Perpetrator I several times with no answer. RN K indicated he eventually got in contact with the NHA and BOM L who notified the police. Review of R9's MDS Assessment completed 7/20/23, revealed the following care area requirements: 1. Eating, toilet hygiene, upper body dressing, bed-to-chair transfer, toilet transfer, and car transfer: substantial/maximal assistant - helper does more than half the effort. 2. Shower/bathe self, lower body dressing: Dependent. Review of R9's Plan of Care revealed the following focuses: 1. TOILET USE, revised 3/29/23: 2 staff assist with gait belt, grab bar, place transport commode chair behind resident & assist to toilet. I am continent of bowel and occasionally incontinent of bladder. I need help with hygiene to prevent complications/infection. I am unsteady with poor balance coordination and require 2 staff CGA [contact guard assist] + gait belt with toileting. 2. TRANSFER, revised 3/15/23: I require 2 person extensive assist with gait belt during transfer to wheelchair. 3. FALL RISK - HIGH, revised 11/27/23. a. Scoop mattress to define edges of bed. Revision on: 2/6/2019 4. Nutrition Goal: Reduce my risk of aspiration, by following protocol for pureed food and (pudding) moderately thick liquids. Use small spoon and divider plate for my meals. a. Family and staff educated to provide me with pureed foods and moderately thick liquids, (Pudding consistency) for pureed food and drinks. Serve my meals in divided plate using smaller feeding spoons, and my drinks in nosey cups. Nurse to check to ensure fluids are Moderately thick. My liquids will be spooned to me. (Initiated 11/7/17). b. I am on a puree diet, HONEY thick liquids. Mouth must be kept clean. Pop and beer must be thickened (HONEY) and need to be given with supervision. Nursing staff to test consistency of liquids to ensure correct thickness prior to serving resident. (Initiated 6/28/18). Review of R9's Physician Orders revealed the following: 1. Monitor for use of Gait belt when transferring to and from wheelchair (Initiated: 3/16/23). 2. Adaptive equipment/Small feeding spoon as recommended by ST [speech therapy] to facilitate smaller bites due to dysphagia (Initiated: 3/3/23). 3. Prior to ANY consumption of liquids, nurse needs to verify it is thickened to HONEY consistency (Initiated: 2/28/23). On 4/22/24 at 5:11 PM, an interview was conducted with CNA R who stated Perpetrator J and Perpetrator I arrived at the facility around dinner time and stated they would return R9 to the facility around 8:00 PM. CNA R stated, 8:00 PM came around, and he [R9] didn't come back. Then it turned to 9:00 PM and everybody wanted to know, 'where is [R9]?' I tried calling both [Perpetrator J and Perpetrator I] with no answer. It turned to 11:00 PM .I left the facility after my shift but kept calling and texting with no response .I came back [to the facility] the next morning and he still wasn't there. CNA R stated she had not packed R9 an overnight bag because he was supposed to return to the facility that night. CNA R stated R9 was sent on the LOA with two briefs and approximately 6 wash cloths. CNA R stated R9 did not have food, liquid, a food/liquid thickener powder, a gait belt, eating adaptive equipment, medications, or any other medical supplies necessary per R9's plan of care when he left the building on 9/18/23. On 4/23/24 at 9:03 AM, a phone interview was conducted with former DON, N who verified she was the Director of Nursing at the time of R9's unauthorized LOA (9/18/23-9/19/23). DON N recalled she received a text message from RN D around midnight on 9/19/23 which indicated R9 left the previous evening and had not returned. Former DON N stated she arrived for work the next morning and was informed that R9 was still not at the facility. Former DON N was asked if she notified the NHA after she received the text message from RN D around midnight on 9/19/23 indicating R9 was not in the facility. Former DON N replied, I don't think I did because I was repeatedly told not to bother them .when [the NHA] arrived that morning, he was upset. He told me that this could be kidnapping, and he should have been notified immediately. Former DON N was asked if Perpetrator J and Perpetrator I had obtained permission to take R9 on a LOA. Former DON N stated, I know that the guardian in the past had given them permission to take him [R9] out, but I think that was an old, in-the-past type of deal. I think it was assumed by other staff that it was okay. Former DON N was asked if there was a protocol for residents going on a LOA to which she replied, There's a sign-out book. I'm sure there was a protocol, but I don't know if off-hand .if a resident had a guardian, I know the guardian needed to give permission . Former DON N stated she contacted R9's guardian the morning of 9/19/23 to inform him that the police had been notified of R9's unauthorized LOA. Former DON N stated, [R9's] guardian was not happy . he specifically said he did not give permission [to leave the facility]. Former DON N stated Perpetrator J and Perpetrator I were aware of R9's specialized diet but did not take thickener or any other necessary medical supplies with them. When former DON N was asked if either Perpetrator J or Perpetrator I received disciplinary action in the past regarding R9, she stated, I think the one did . I think she shaved his head or drew on him .it was something just bizarre. I believe she got reprimanded for that. On 4/23/24 at 11:01 AM, an interview was conducted with R9 who was able to answer some yes or no questions. R9 confirmed Perpetrator J and Perpetrator I took him on an overnight LOA in September 2023. R9 confirmed he drank pop on the LOA. When R9 was asked if the pop was thickened per his diet orders, he stated, No. When R9 was asked if Perpetrator J and Perpetrator I gave him a shower, he stated, Yes. A follow-up interview was attempted with Guardian H on 4/25/24 at 9:30 AM. A voicemail was left with no return call upon survey exit. Review of facility policy titled, Resident Leave of Absence dated 2/29/23 read, in part: Protocol: Residents may enjoy a leave of absence from the facility with a physician's order. The type and length of leave of absence (LOA) will be in accordance with the resident's assessed physical, mental and emotional ability and with resident and/or resident representative in involvement in requesting/obtaining the LOA . Physician's order should include type of LOA . No physician order for a LOA was identified in R9's EMR. Review of facility policy titled, Incident/Accident Report Policy and Procedure revised 4/27/23 read, in part: .An incident/accident report will be filled out completely by the charge nurse for any incident/accident involving a resident, employee, or visitor . Fill out incident/accident report on [EMR System] to include: a. Name of person involved in incident/accident. b. Date, hour, place of incident/accident. c. Name of person who observed incident/accident. This person shall be interviewed by CHARGE NURSE, DON, OR ADON [assistant director of nursing] for description of what occurred. d. Narrative of the incident and/or accident. Ask resident what happened and document their response or lack of response. e. Document results of initial exam. Include a full set of vital signs . Incident and Accident reports for R9 were requested on 4/23/24 at 11:30 AM. BOM L indicated there was no record for incident or accidents for R9 on 4/23/24 at 1:15 PM. Review of facility policy titled, Resident Abuse, Neglect Mistreatment or Misappropriation Prevention Program reviewed 3/20/24 read, in part: .The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Resident will not be subjected to abuse by any volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, vendors or other individuals . abuse can be resident-to-resident, staff-to-resident, family-to resident, visitor-to-resident .suspected or substantiated cases of resident abuse, neglect, misappropriation of property, mistreatment, exploitation, involuntary seclusion, or any other adverse event shall by thoroughly invested and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representatives . The Immediate Jeopardy which began on 9/18/23 was removed on 4/22/24 when the facility submitted an acceptable removal plan and took the following actions to remove the immediacy. The Facility Removal Plan read as follows: 1. The facility will ensure that all persons requesting to take a resident out on LOA from facility will have a. Authorization either by resident or if deemed incompetent, the resident's guardian or DPOA [durable power of attorney]. b. Necessary medications, equipment, supplies, and instructions will be provided to person signing resident out to ensure the resident will be safe in the environment. c. Charge nurse will assess for appropriateness of LOA and resident's condition at time that request is made to facility. 2. This has the potential to effect [sic] all residents with ability to be taken out on LOA. 3. For resident involved facility no longer has approval by guardian for LOA's due to residents' deteriorating condition. To prevent reoccurrences, facility will write a policy and procedure to clarify what has to happen before a resident is allowed to go on LOA. This will include the items, meds [medications], supplies, and equipment that must be sent. It will include direction for checking and ensuring signed consent from resident or responsible party has been obtained. Procedures on assessing resident's condition before LOA is granted by Charge Nurse. It also will include instructions on assessing resident on return to facility. All charge Nurses will be trained on new Policy and Procedure on 4/22/24 and 4/23/24. Prior to their shift current DON [sic]. All other nursing staff will be trained individually during their current shift or if not scheduled, by 4/24/24. All training's will be done be current DON. A mandatory in-service will be held this month to explain our new policy to all staff. All staff not able to attend in-service will be instructed individually. Signed consents will be scanned into resident's electronic record. 4. The plan of correction will be monitored by DON daily times 2 wks [weeks] then monthly. This will be added to our QAPI [Quality Assurance and Performance Improvement] process. 5. Immediacy will be removed when all staff currently in working in building today are trained on new process. All staff coming in for their next shift will be educated prior to the start of their shift, all other staff will be required to be educated prior to working their next shift. 34568 DPS B: Based on observation, interview, and record review, the facility failed to prevent further resident to resident altercations for two residents (R17, R18) of three residents reviewed for abuse. This deficient practice resulted in R18 feeling helpless with her current living situation, and the potential for further incidents to occur amongst R17 and R18. Findings include: Review of R17 and R18 Facility Reported Incident dated 4/2/24 read, in part, Date/Time Incident Occurred 4/2/24 10:30 AM, Resident 1 (R17) was upset and yelled at her roommate Resident 2 (R18) because (R18) was trying to get into her own closet. (R17) believes it is her room and owns all of the belongings. (R17) started pushing (R18) and (R18) reacted and pushed back resulting in (R17) losing her balance and falling to the floor .Corrective actions, continue to work with [Community Mental Health Care Provider] and Medical Director for psychiatric assessment and recommendations, implement as ordered. When (R17) becomes agitated, separate her from other residents and provide diversional activities. On 4/22/24 at approximately 12:10 p.m. an observation was made of R17 attempting to elope from the facility front doors. R17 was noted to be agitated at staff trying to redirect her from the front door, stating that she was on her way to the bank. R17 became upset when she was told she was required to stay at the facility after she requested this Surveyor provide transportation to the bank. An interview was conducted with Social Services Director/Staff G on 4/24/24 at 2:57 p.m. Staff G was asked about the resident-to-resident altercation and stated, (R18) was still threatening (R17) after follow-up of the incident. (R18) would tell me that she would think about smashing (R17's) head against the wall. They (R17, R18) still argue with each other over the situation of the room set up, and how overwhelming it is. I did ask if either one wanted a room move and they both stated no. I felt that it was safe after discussion with both of them. An observation and interview with R18 were conducted on 4/24/24 at 3:05 p.m. R18 was observed to be sitting in a recliner chair in a small sitting room. During this interview, when R18 was asked about an incident between her and R17, R18 stated, I do not like her! She gets crazy and her eyes get really big! Today she yelled at me for no reason, and I had to tell her to back off. My room isn't my room anymore, it's hers and staff just cater to her and her demands! They brought her in a new chair and pushed all my things to the side. When asked if she is afraid of R17, she stated, I'm not afraid of her. I'm afraid of myself. I'm going to hurt her one day, I won't be able to stop myself. Review of the facility's Resident Abuse, Neglect, Mistreatment or Misappropriation Prevention Program - Facility Prevention Program reviewed 3/20/24, read, in part, .Resident will not be subjected to abuse by an volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, vendors or other individuals .

DPS A: Based on interview and record review, the facility failed to implement appropriate interventions to prevent a fall for one Resident (R24) of one resident reviewed for falls. This deficient practice resulting in R24 sustaining a fall with subsequent injuries requiring staples. Findings include: R24 A review of R24's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including dementia, history of Urinary Tract Infections (UTI), and osteoarthritis. R24 scored an ,d+[DATE] on the [DATE] Brief Interview for Mental Status (BIMS) score indicative of moderate cognitive impairment. R24 did not have a completed Fall Risk Assessment during her stay at the facility. Review of R24's Progress Notes revealed the following entries: [DATE] 22:35 (10:35 p.m.) Resident called out from her room at this time and staff entered. Resident was on floor and stated that she fell and hit her head. Unwitnessed falls protocol initiated. After initial set of vitals, staff attempted to assist her into a seated position to take a seated blood pressure. With very slight movement, she winced and stated that it hurt really bad in her back and neck. Staff did not continue attempt to move her. Resident stated that she felt very dizzy. [DATE] 22:45 (10:45 p.m.) This writer dialed on-call provider number and (Nurse Practitioner (NP) P) ordered ED (Emergency Department) send out. No visible injury, though full assessment was not possible at this time to prevent unnecessary movement after resident's pain response. [DATE] 23:05 (11:05 p.m.) Resident left [facility name] with [name of county] fire and rescue at this time to transport to [hospital name] ED. [DATE] 2:19 a.m. Call received from [hospital name] ER. Resident was evaluated and [hospital name] staff determined pain not related to acute injury, resident was given Tylenol, x-ray was WNL (within normal limits). They will be sending her back to [facility name]. [DATE] 6:30 a.m. She requires up to one assist with ADLs (Activities of Daily Living) due to new required supplemental oxygen .She reports dizziness with some movements and with quick movements . [DATE] 1:45 a.m. She requires assistance of one for transfers, ambulation, toileting, dressing, bathing, and hygiene . [DATE] 18:15 (6:15 p.m.) Resident was assessed by this nurse after falling in the women's common bathroom. Pressure applied to posterior scalp where bleeding occurred, which did stop. Swelling on posterior head observed. Vitals/neuro [neurological] were initiated per fall protocol. Mentation and vitals were at baseline. Resident was able to move her head/neck and all limbs without any c/o (complaint of) pain or discomfort. Resident was assisted into a wheelchair by two staff. NP P notified at 1820 (6:20 p.m.) of incident and gave the okay for the resident to be sent out to [hospital name]. Residents' son was notified of incident at 1824 (6:24 p.m.) and stated that he would like his mother to be sent out to [hospital name] to be evaluated. Ambulance was called at 1835 (6:35 p.m.). Resident left facility at 1850 (6:50 p.m.) . Review from R24's [hospital name] discharge summary revealed the following, in part, This is an [AGE] year-old female who presents after a fall .She was noted to have laceration with bleeding .occipital scalp laceration .3 cm (centimeters) in length, repaired by 4 staples .assessment/plan: fall, closed head injury, scalp laceration . Review of R24's Incident and Accident report dated [DATE] read, in part, This nurse was urgently called to the women's common bathroom by a staff member that was assisting resident. Upon entering the bathroom, the resident was lying flat on her back with her head in front of the toilet. Moderate amount of blood was observed by her posterior head. Resident description: I was backing up toward the toilet and I fell and clunked my head. A witness statement dated [DATE] (incorrect date as the incident had not happened yet) from Certified Nurse Aide (CNA) C read, On February 6th, 2024, I was getting (R24) ready for bed in the women's restroom after dinner. I helped her get into a nightgown, fresh socks, and a new brief before putting her shoes back on. She then stood up so we could pull her brief up, and I asked how she was feeling, to which she replied that she was feeling grand. We then walked out of the stall, and I was in front of her. I handed her a warm washcloth so she could wash her face, and right after she grabbed the washcloth (R24) fell straight backwards and hit her head . Review of R24's Fall/Safety Care Plan read, I am a moderate risk for falls r/t (related to) occasional confusion, R/T impulsiveness due to my diagnosis of dementia. I am unsteady on my feet. I have poor safety awareness and do not remember that I am no longer able to walk or transfer alone. I have recently had anesthesia and have residual effects causing confusion and need for O2 (oxygen) date initiated: [DATE] revision on [DATE] .Assist of one to ambulate and transfer. Date initiated: [DATE] .Provide me with a safe environment .personal items within reach. Date Initiated:[DATE]. CNA C's witness statement did not state if a gait-belt was being used at the time of the incident, nor why CNA C was not providing physical assistance on to R24 per the resident's care plan interventions. DPS B: Based on observation, interview, and record review the facility failed to prevent elopements for one Resident (R17) of one resident reviewed for elopement. This deficient practice resulted in R17's elopement from the facility, with the risk for falls and injury. Findings include: Review of R17's EMR revealed admission to the facility on [DATE] with diagnoses including vascular dementia with agitation. R17's [DATE] MDS assessment revealed she scored a ,d+[DATE] on the BIMS score, indicating she was cognitively intact and had no behaviors of wandering during the look back period. R17 was observed on [DATE] at approximately 12:30 p.m. finishing her lunch meal in the main dining room. R17 then stood up and exited the main dining room towards the front entrance door. R17 held the door handle, and the front door began to alarm. A staff member stated to this surveyor, Oh, that's just (R17) trying to leave again. We go through this almost every day. Review of R17's progress notes revealed the following entries: [DATE] Resident continues to be verbally abusive to staff and continues to go in and out of resident rooms, it is very difficult to redirect this patient at this time . [DATE] Resident went out of the facility via the facility entrance way. Facility activities director attempted to redirect the resident. Resident was very hesitant with attempts of redirecting but did agree to go for a ride with the activity's driver .Resident rode around. With the activity's director and then did return back to the facility. Resident was calm for a few minutes but then started attempting to exit seek once again. [DATE] Resident attempted to break facility windows and alarm keypads by hitting it with a staff bathroom key/stick. Attempts to redirect resident have been unsuccessful . [DATE] Resident outside of the facility through the front entrance and was observed by a staff member. That staff member informed this nurse and other staff members of this occurrence. This nurse and another nurse immediately went outside with the resident and attempted to redirect back inside. The resident was not easily redirected for this nurse. The resident stated, 'I'm not a prisoner. I should make it easy for you and go in the road.' Another nurse was also unsuccessful with redirecting the resident. Resident eventually did agree to go for a ride with the activity's director/facility driver. An interview was conducted with Registered Nurse (RN) K on [DATE] at 10:41 a.m. RN K stated that R17 is still able to read and can read the signs at the keypad and the door alarm. RN K stated that R17 will hold the door handle for 15 seconds and the door will release to open. RN K stated that R17 has gotten out of the facility prior without staff knowledge but she, Doesn't go far. RN K stated that there are no incident or accident reports related to R17 exiting the facility. Review of R17's Safety/Wander/Elopement High Risk Care Plan read, I get confused and agitated in afternoon and evening. I may try to leave facility. Date Initiated: [DATE] Revision on: [DATE] .I wear a Wander-guard ankle bracelet. Check for proper fit, placement, and function Q (every) shift Date Initiated [DATE]. Monitor for attempts to leave facility Date initiated: [DATE] Please remind me that I cannot go outside unsupervised and offer to take me out on occasion Date Initiated: [DATE]. 45123 DPS C: Based on observation, interview, and record review, the facility ensure residents were safe to smoke, supervised, and smoking paraphernalia was kept in a secure location for two Residents (R21 and R11) of five sampled residents reviewed for accidents, hazards, and supervision. Findings include: Resident #21 (R21) Review of R21's face sheet, revealed an original admission into the facility on [DATE] with medical diagnoses of the following, in part: depression, bipolar disorder, paraplegia, and pressure ulcers. Review of R21's Minimal Data Set (MDS) assessment, dated [DATE], revealed that R21 was cognitively intact. Review of R21's physician order, dated [DATE], revealed the following, in part: attempt resuscitation/CPR [cardiopulmonary resuscitation]. Review of R21's hospital discharge summary, dated [DATE], revealed the following allergies, in part: bee stings - anaphylactic reaction. On [DATE] at 10:30 AM, an interview was conducted with R21 in his room and was asked about smoking and his allergies and replied, I have been going outside to smoke by myself since I was admitted here back in November. I am allergic to bee stings. I was stung when I was younger a bunch of times and I had a sever reaction. R21 was observed to have a lock box in his room and inside the lock box was a set of keys for the lock box. R21 was asked where he kept his cigarettes and lighter and replied, They are in my jacket pocket. I don't know why I have that box because I never use it. Review of R21's progress note, dated [DATE] at 3:06 PM, read in part, Resident's brother came for a visit. Resident's brother brought in the following items: $50 cash .2 packs of Marlboro Menthol 100's, 2 Breeze Blueberry Vape pens . Review of R21's progress note, dated [DATE] at 4:25 PM, read in part, .Resident outdoors smoking. Resident had removed his patch and has given it to this nurse. Review of R21's complete EMR, smoking assessment, dated [DATE], was the first and only initial smoking assessment and R21 was smoking prior to this assessment on the facility property. Review of R21's physician order, dated [DATE], read in part, Perform smoking assessment . Review of R21's physician order, dated [DATE], read in part, Smoking assessment one time a day every 3 months .Start date [DATE]. On [DATE] at 10:00 AM, an observation was made of R21 outside of the facility siting in his wheelchair near the [NAME] entrance, between the pole barn and the garbage dumpster, and was unsupervised by facility staff. R21 was observed smoking during the following dates and times in the same designated smoking area on: [DATE] at 1:50 PM, [DATE] at 7:25 AM, and [DATE] at 12:15 PM. During the time of the survey and observation was made of the [NAME] entrance, between the pole barn and the garbage dumpster, and the pole barn was noted to have two bee nests located around the main door frame. On [DATE] at 2:05 PM, and observation was made of R21's lock box in his room and was observed to have the same set of keys as the prior observation of the lock box and no smoking paraphernalia was found within the lock box. R21's cigarettes and lighter were observed on top of a chair in his room. On [DATE] at 3:57 PM, an interview was conducted with RN K who was asked how long R21 had been smoking at the facility and replied, Pretty much since he has been here. He used to have a nicotine patch, but it was discontinued because he continued to smoke and refused the patch. On [DATE] at 5:00 PM, an observation was made of R21 outside of the facility siting in his wheelchair near the [NAME] entrance, between the pole barn and the garbage dumpster, and was unsupervised by facility staff. 49302 Resident #11 (R11) Review of R11's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, mild cognitive impairment, and nicotine dependence. Review of R11's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicative of moderate cognitive impairment. On [DATE] at 10:16 AM, an entrance conference was conducted with the Director of Nursing (DON). The DON stated there were two current smokers who resided at the facility (R11 and R21). When the DON was asked about designated smoking locations and times, she stated there are no official smoking locations but R11 and R21 preferred to smoke out by the garage or in the arbor. The DON stated there were no designated smoking times or direct staff supervision. On [DATE] at 11:13 AM, an interview was conducted with R11 during the initial tour of the building. R11 confirmed that he smoked cigarettes. R11 stated there are no designated smoking times and he prefers to smoke in the arbor near the entrance of the building. R11 was asked the protocol for staff notification prior to leaving the building to smoke to which he replied, I don't tell them [nursing staff] or sign out unless I'm leaving the property. On [DATE] at 11:17 AM, R11 was observed entering the door code at the exit on the west wing and exiting the building without staff observation or knowledge. R11 was subsequently observed sitting in the arbor in a patio area, smoking without supervision. On [DATE] at 10:46 AM, R11 was again observed sitting in the arbor, smoking without supervision. Review of R11's Plan of Care revealed the following focus imitated [DATE]: I am aware that it is not good for me, but do wish to continue smoking with the following interventions: 1. Cigarettes and lighter kept in lockbox inside resident's room, initiated [DATE]. 2. Resident will let staff know when he is going outside and staff will observe from afar that he is safe and in the designated smoking area, initiated [DATE]. 3. Smoking assessment will be completed quarterly, initiated [DATE]. Review of R11's orders revealed the following, initiated [DATE]: Cigarettes and light to be locked in lock box in his room AT ALL TIMES when not in use. Please verify he is using the lock box q [every] shift and prn [as needed]. Review of R11's EMR revealed an initial smoking assessment was conducted on [DATE]. A subsequent smoking assessment was conducted on [DATE], nearly a year after the original assessment. On [DATE] at 2:14 PM, this surveyor attempted to view the preferred smoking areas from the entrance/exit of the building. This surveyor was unable to visualize either the arbor patio area due to a tree and other vegetation obscuring the view nor the side of the garage which was blocked from view by support pillars to the entryway as well as a parked vehicle. On [DATE] at 8:24 AM, R11 was observed walking back into the facility from outside where he had just finished smoking a cigarette unsupervised. Upon entrance to R11's room, no lock box could be visualized. When asked if he had a lock box, R11 was unable to locate it and stated, I think it's around here somewhere. R11 demonstrated that he stored his cigarettes and lighter in the pocket of his coat when not in use. R11 confirmed he did not utilize a lock box and stated, I sleep with my feet on top of my coat so nobody can steal my cigarettes or lighter. On [DATE] at 2:45 PM, an interview was conducted with the DON who confirmed that smoking assessments were supposed to be completed upon admission as well as quarterly. The DON was asked why R11 went nearly a year without a smoking re-assessment. The DON stated this was brought to her attention and she began to educate staff in [DATE]. The DON confirmed R11's next smoking assessment was due [DATE] to reach compliance with the quarterly re-assessment requirement but it somehow, was missed. The DON was asked how it was determined R11 was safe to smoke unsupervised without regular assessments to evaluate. The DON stated, [R11] goes all over the place . he hasn't been deemed incompetent, but we're [facility staff] seeing things that probably should indicate it . When [R11] first got here, we monitored him for signs of elopement, and he wasn't .I can't remember if he's an elopement risk right now. I know they [nursing staff] watch him from the back door. The DON was asked if it was possible to visualize R11 from the back door to which she replied, I guess it depends on which part of the arbor he's in .there is probably areas we can't watch him. When asked about cigarette and lighter storage the DON said, They're [smoking paraphernalia] supposed to be in a lock box in his drawer, but there's times when we catch him when they're not in the lock box and we have to remind him. Review of facility policy titled, Smoking Assessment Policy and Procedure read, in part: .Residents will not be permitted to engage in smoking activity unless they are assessed during the admission process, ongoing quarterly assessments and as needed to determine the level of supervision required . .Residents who are assessed as requiring supervision for smoking, will be provided with scheduled smoking times in a designated supervised area . .All smoking material or paraphernalia (including cigarettes, cigars, pipes, tobacco, matches, lighters, etc.) must be stored at the nurse's station at all times unless they have been approved for a lock box . DPS E: Based on interview and record review, the facility failed to provide adequate supervision to prevent an unauthorized leave of absence from the facility for one Resident (#9) of five residents reviewed for safety/supervision. This deficient practice resulted in two Former Certified Nursing Assistants (CNAs)/Perpetrator I and J removing R9 from the facility to an unknown location for approximately 16 hours without guardian approval or any potentially necessary hospice medications or medical supplies. Findings include: Review of R9's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including Huntington's disease (a progressive, fatal genetic disorder that affects the brain and causes involuntary movements, cognitive decline, and emotional problems), aphasia (difficulty processing, using, and/or understanding language), dysphagia (difficulty or inability to swallow), contracture of unspecified hand (a permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult), and alcohol abuse. Record review of R9's Minimum Data Set (MDS) assessment immediately preceding the unauthorized leave of absence (LOA) on [DATE], indicated R9 had severely impaired cognition - unable to complete BIMS [Brief Interview for Mental Status]. R9 was admitted to hospice services on [DATE]. On [DATE] at 11:47 AM, a phone interview was conducted with R9's guardian, Guardian H who disclosed two former facility staff members had taken R9 out overnight without his permission at some point the previous fall. Guardian H indicated the facility called him the morning following the LOA to ask if facility staff that worked the previous evening had asked him for consent prior to R9's departure. Guardian H indicated he did not give approval and was unaware of R9's exit from the facility. On [DATE] at 1:04 PM, a follow-up phone interview was conducted with Guardian H who stated the morning following R9's leave of absence, he received a call from the facility informing him that R9 was missing. Guardian H indicated the facility informed him Perpetrator I and Perpetrator J (later identified as formerly terminated CNAs] at the facility) had taken him out of the facility the previous night and had not returned. Guardian H stated, I was freaking out. I asked if we should file a report with the police. Guardian H reiterated the facility had not called him prior for permission for R9's departure, stating, I was upset with the nursing home and their lack of calling me. The nurse who called me the morning he was missing wasn't sure where [R9] was. I was shocked .shocked that the facility would let somebody out on hospice care and not even call to even verify if it was okay. Guardian H stated that since R9 signed with hospice on [DATE], nobody was authorized to take R9 from the facility due to his deteriorating physical and mental condition. Review of R9's progress notes revealed the following entries: 1. [DATE] at 18:07 [6:07 PM] written by former Registered Nurse (RN) M: LOA with [Perpetrator J] and [Perpetrator I] to [Perpetrator J's] house at 1807 [6:07 PM]. 2. [DATE] at 22:24 [10:24 PM] written by RN D: Resident's responsible party for LOA was called and did not answer. 3. [DATE] at 23:44 [11:44 PM] written by RN D: This writer attempted to call [Perpetrator J] and [Perpetrator I] and [Guardian H]. None of them answered. DON aware. 4. [DATE] at 23:49 [11:49 PM] written by RN D: This writer attempted to call [Perpetrator J] and [Perpetrator I] and [Guardian H] each multiple times. None of them answered. 5. [DATE] at 09:48 [9:48 AM] written by RN K: LOA Returned from [Perpetrator J's] house driven by [Perpetrator J] and [Perpetrator I]. On [DATE] at 1:55 PM, a phone interview was conducted with RN D who was asked why R9's responsible party was not called for approval of an LOA until after R9 had already exited the building for approximately 4.5 hours. RN D stated, I think I was expecting him to be back that night and that's why I called the responsible guardian [H] .or I wasn't certain if he was supposed to return so I was trying to figure it out. RN D was asked why he attempted several subsequent phone calls to Perpetrator J, Perpetrator I, and Guardian H as documented at 11:44 PM and 11:49 PM. RN D stated, I wasn't getting through to people, and I wasn't sure if [R9] was coming back at that time. RN D was asked the protocol for a resident going on a leave of absence. RN D indicated the responsible party would sign the resident out in the Release of Responsibility for Leave of Absence binder and the charge nurse would document the departure in the EMR. When RN D was asked if the process would differ for a resident with a guardian, he stated, If somebody were to want to take a resident and they weren't the guardian, I would contact the guardian to get permission .I'm not sure of the exact protocol, but I would put it into my LOA note [in the resident's EMR]. On [DATE] at 2:30 PM, a phone interview was conducted with former Director of Nursing (DON) RN M who verified that Perpetrator J and Perpetrator I came to the facility around 6:00 PM on [DATE]. RN M stated Perpetrator J and Perpetrator I informed her that they were taking R9 out for a brief leave. RN M stated, They [Perpetrator J and Perpetrator I] had taken him out in the past and they would take him to [Perpetrator J's] house. They would take him over for dinner and bring him back. That's what I would have expected . I got a call from [Perpetrator J] saying that they got him [R9] back to the facility at 9:00 AM the next morning .I was furious. RN M was asked if Perpetrator J and Perpetrator I were authorized to take R9 on a LOA. RN M stated, I didn't look at it [the approved list of responsible parties] that day. When they [Perpetrator J and Perpetrator I] took him out of the facility, I just assumed they were on the approved list. RN M stated no necessary medications, equipment, or supplies per R9's plan of care or physician orders were sent upon departure. On [DATE] at 2:54 PM, an interview was conducted with the Nursing Home Administrator (NHA) and the DON. The NHA verified that former CNAs, Perpetrator J and Perpetrator I, took R9 out of the facility on an unauthorized LOA and did not bring him back until the following morning. The NHA stated that although Perpetrator I did have permission at one time, Guardian H had since stopped anybody from removing R9 the facility following his admission to hospice (on [DATE]) due to his declining condition. The NHA and DON both confirmed they were unaware of R9's absence from the building until arriving to the facility for work on the morning of [DATE]. The NHA indicated they called local law enforcement after learning of the situation. The NHA stated, I didn't know what to do .What's the process for this? They basically kidnapped a resident. The NHA and DON stated they did not know why they were not contacted by RN D or former RN M on [DATE] after R9 left the facility and did not return. The NHA was asked if Perpetrator J or Perpetrator I had any previous history with R9. The NHA stated Perpetrator I had received disciplinary action in early 2021 after she shaved R9's legs, shaved a letter in the back of R9's hair, and drew inappropriate pictures and phrases on his skin with permanent marker. The NHA did not indicate Perpetrator I had any limited or altered contact with R9 following the incident as part of the remedial action. Review of CMS-2567 form dated [DATE] indicated Perpetrator I was, educated on resident's right, abuse and other policies regarding this type of behavior following the incident. The NHA verified that Perpetrator I was subsequently terminated on [DATE] following a separate incident with a different resident per form CMS-2567 dated [DATE]. The NHA confirmed Perpetrator J quit working as a CNA on [DATE] for reasons related to her vaccination status. Review of, [County Name] County Dispatch - Call Detail Report indicated Business Officer Manager (BOM) L filed a report on [DATE] at 9:24 AM that read, in part: Patient missing, two people came last night around 1800 HRS [6:00 PM], said they had paperwork to take him [R9] out . [Perpetrator I] . [Perpetrator J] . On [DATE] at 3:50 PM, a phone interview was conducted with Perpetrator J who stated, We just took him [R9] out for a good time . Me and [Perpetrator I] took him to my house for dinner and gave him a shower. Perpetrator J stated she informed the nurse on duty, RN M, that they were taking R9 on a LOA. Perpetrator J stated she didn't take any required medications, supplies, or equipment prior to departure besides a couple incontinence briefs. Perpetrator J indicated that she and Perpetrator I transferred R9 into her private vehicle without using the care-planned transfer technique and drove to her private residence. Once there, Perpetrator J indicated R9 ate some ground up stir fry, drank some water, and then she assisted him into the shower. After showering R9, Perpetrator I stated she cut his fingernails and cut his hair. Perpetrator J stated R9 slept in a recliner, propped up so he could breathe. Perpetrator J was asked if she had permission to take R9 on a LOA to which she replied, I had permission before he [R9] was on hospice. Since he was on hospice, the process was different, and I wasn't aware of that. Apparently, I was no longer cleared [to take R9 on a LOA]. Perpetrator J was asked if she was contacted by the facility after leaving with R9. Perpetrator J stated, Yes, that night the facility called me and asked what time R9 was going to be home. I told them, 'He'll be there when we get him there.' On [DATE] at 4:19 PM, a phone interview was conducted with Perpetrator I who stated she and Perpetrator J arrived at the facility around dinner time and notified RN M they were taking R9 on a LOA. Perpetrator I stated that CNA R packed R9 an overnight bag. Perpetrator I stated they took R9 to Perpetrator J's personal residence where they, sang karaoke and just kind of hung out. Perpetrator I stated that R9 ate some pudding, tried a beer, but didn't like it, so he was switched to drinking pop. Perpetrator I verified R9 was given a shower at the residence because, he was covered in food and slop and slept in a recliner. Perpetrator I stated around 10:00 AM on the morning of [DATE], she received at text message from RN K asking when R9 was returning to the facility. Perpetuator I indicated to RN K that they were planning on returning R9, in a little bit until RN K stated that we had to bring him back immediately. Perpetrator I indicated that shortly after dropping R9 back off at the facility, she received a call from local law enforcement stating she was being charged with felony kidnapping. However, Perpetrator 'I stated the police officer ended up calling Perpetrator I back, stating R9's family no longer wished to press charges, and that they were instead upset at the facility for not knowing his whereabouts. On [DATE] at 4:58 PM, an interview was conducted with RN K who stated he arrived at the facility at the start of his shift around 6:30 AM on [DATE]. RN K stated he received report from the midnight nurse, former RN M, who indicated R9 was not in the building. RN K stated, She [former RN M] seemed concerned. I don't think she was aware that R9 was going to be out overnight. RN K stated he tried calling Perpetrator J and Perpetrator I several times with no answer. RN K indicated he eventually got in contact with the NHA and BOM L who notified to the police that R9 had not returned from a LOA. On [DATE] at 5:11 PM, an interview was conducted with CNA R who stated Perpetrator J and Perpetrator I arrived at the facility around dinner time and stated they would return R9 to the facility around 8:00 PM. CNA R stated, 8:00 PM came around, and he [R9] didn't come back. Then it turned to 9:00 PM and everybody wanted to know, 'where is [R9]?' I tried calling both [Perpetrator J and Perpetrator I] with no answer. It turned to 11:00 PM .I left the facility after my shift but kept calling and texting with no response .I came back [to the facility] the next morning and he still wasn't there. CNA R stated she had not packed R9 an overnight bag because he was supposed to return to the facility that night. CNA R stated R9 was sent on the LOA with two briefs and approximately 6 wash cloths. CNA R stated R9 did not have food, liquid, a food/liquid thickener powder, a gait belt, eating adaptive equipment, medications, or any other medical supplies necessary per R9's plan of care when he left the building on [DATE]. On [DATE] at 9:03 AM, a phone interview was conducted with former DON, N who verified she was the Director of Nursing at the time of R9's unauthorized LOA ([DATE]-[DATE]). DON N recalled she received a text message from RN D around midnight on [DATE] which indicated R9 left the previous evening and had not returned. Former DON N stated she arrived for work the next morning and was informed that R9 was still not at the facility. Former DON N was asked if she notified the NHA after she received the text message from RN D around midnight on [DATE] indicating R9 was not in the facility. Former DON N replied, I don't think I did because I was repeatedly told not to bother them .when [the NHA] arrived that morning, he was upset. He told me that this could be kidnapping, and he should have been notified immediately. Former DON N was asked if Perpetrator J and Perpetra[TRUNCATED]

Intake # M100143193 Based on interview and record review, the facility failed to protect one Resident (#1) of three residents reviewed for the right to be free from mental and/or potential sexual exploitation resulting in the potential for mental anguish and pain. Findings include: Resident #1(R1) Review of the quarterly MDS for R1 dated 2/28/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. Diagnoses included quadriplegia, bipolar depression and traumatic brain injury. On 3/13/24 at 9:10 AM, a phone interview was conducted with the Guardian (A) for R1, who indicated there was concern for possible sexual exploitation. Guardian A stated he observed an ongoing messaging stream on (social media messenger service), between R1 and a facility staff member, who at the time of the interview, Guardian A believed to be a nurse. On 3/13/24 at 9:30 AM, a staff list received from the facility, identified the staff member named by Guardian A, as a member of the housekeeping staff (Housekeeper I). On 3/13/24 at 10:47 AM, a follow-up phone interview was conducted with Guardian A, at which time picture evidence was requested of the alleged sexual/mental exploitation of R1 by Housekeeper I. On 3/13/24 at 11:00 AM, an interview was conducted with RN C who stated R1 fluctuated with his wanting to come out of his room because of a bipolar diagnosis. On 3/13/24 at 11:15 AM, an interview was conducted with R1, who denied having a girlfriend or anyone trying to initiate anything of a sexual nature with him since admission to the facility. On 3/13/24 at 11:45 AM a phone interview was attempted with Housekeeper I, but the number provided on the staff listing was disconnected. On 3/13/24 at 12:10 PM, an interview was conducted with Housekeeping Supervisor E, who was asked if the facility had a current phone number for Housekeeper I. Supervisor E stated she did have the current phone number for Housekeeper I and provided the number. On 3/13/24 at 12:30 PM, a text message was received from Guardian A with several screen shots of messages between R1 and Housekeeper I. The screen shot messages started with R1 initiating a conversation with Housekeeper I as follows: 2:03 PM on 2/24/24 R1- hello. 3:09 PM Housekeeper I- Helloooo (sic) lol (laugh out loud). 3:22 PM R1- No sending pics (pictures) now your BF (boyfriend) wouldn't like that lol. (Screen Name) is my ( another social media messaging service) name. 3:46 PM Housekeeper I- I think I added the right one lol and wat (sic) bf lol and I swear I won't send any lol. Less you ask joking lol R1 Don't say that last part. Housekeeper I- ? The whole last message lol I apologize. R1 No need to. Just know I wanna ask. Housekeeper I- lol oh you want to ask to see pics lol good to know lol. R1 Yes I do Housekeeper I- Lol to be honest I could tell you wanted to ask lol. R1 **** yes February 29 approximately 7:00 AM Housekeeper I- Good morning. R1- Morning. What you wearing? Housekeeper I- Tank top and shorts wby (what about you) R1- A sweatshirt, getting turned on because of your pics. (Implied private explicit/revealing pictures had already been shared via social media messaging services.) Housekeeper I- Awe and mmmmm I like them don't u (you). R1- Yes Housekeeper I- Oooo so wat (sic) u gonna do now lol. R1- Thinking of (sexual act) if I can. Housekeeper I- Oooo to bad I'm not there to help. R1- Wished you were. R1 then sent a picture of his private parts to this message. On 3/13/24 at 12:39 PM, a phone interview was attempted with Housekeeper I and there was no answer. A voicemail could not be left as the mailbox was full. On 3/13/24 at 1:28 PM, an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON). Both the NHA and DON indicated staff are not permitted to have relationships with residents. On 3/13/24 at 2:42 PM, an interview was conducted with Financial Officer F, who confirmed the picture on the messages was Housekeeper I. Financial Officer F proceeded to pull Housekeeper I's (social media profile) account up and confirmed the identity of Housekeeper I.

This deficient practice pertains to intake MI#00130116: Based on observation, interview, and record review, the facility failed to provide fluids in the prescribed texture/consistency for one Resident (#9) of two residents reviewed for food/beverages served in proper form. This deficient practice resulted in the delivery of fluid of inappropriate consistency which resulted in episodes of choking and aspiration (accidental breathing of food/fluid into the lungs, which can cause pneumonia), and the likelihood of aspiration pneumonia and potential for death. Findings include: Review of Resident #9's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including Huntington's Disease, aphasia, dysphagia, abnormal weight loss, and esophageal obstruction. His 10/27/22 Minimum Data Set (MDS) assessment revealed a moderately impaired cognition and required extensive one person assist for eating. Section K: Swallowing/Nutritional Status revealed that Resident #9 was not marked as having a swallowing disorder or marked as receiving a mechanically altered diet. On 2/7/23 at 11:40 a.m., Dietary Manager (DM) Y was observed preparing the lunch meal service. DM Y stated that Resident #9 receives a puree diet with honey thick liquids. At this time Dietary Aide/Staff DD was observed preparing a Pepsi for Resident #9 using a thickening powder, Staff DD was observed adding the powder to the drink, but it was not thickening to the correct consistency. Staff DD left the Pepsi on the counter and walked away. DM Y confirmed that the Pepsi for Resident #9 was 8 fluid ounces. On 2/7/23 at approximately 12:00 p.m., Certified Nurse Aide (CNA) D began to wheel Resident #9 into the dining room and placed him near a table in the far-right corner. CNA D came over to the kitchen counter, grabbed a nosey cup (an adapted drinking cup with a u-shaped cut out on one side), filled the cup with apple juice and grabbed the canister of thickening powder used to thicken Resident #9's drinks. CNA D then placed a tablespoon into the powder, dumped the powder into the drink and began to stir. CNA D repeated the same procedure one more time using the same tablespoon, then walked the drink over to Resident #9 and set it in front of him. This Surveyor asked CNA D what consistency of drink Resident #9 was to have, in which she replied thickened when asked to what consistency, CNA D replied, honey. When asked how many scoops of powder it takes to make a honey thick liquid, CNA D replied, Two scoops. It's on the can. This Surveyor again attempted to confirm with CNA D that this was the correct consistency for Resident #9 but was ignored. Resident #9 began to drink his juice and was noted to be coughing and turning red in the face. Resident #9 was also given the Pepsi drink that was not in the correct honey thicken consistency. Review of the thickening powder can read, in part, .Thickener Mixing Chart .Moderately Thick Honey Like .8 Fl (fluid) oz (ounces) .3T .T=Tablespoon . On 2/7/23 at 3:30 p.m., a telephone interview was conducted with Speech Language Pathologist (SLP) L. SLP L stated that Resident #9 had been receiving therapy services one time a week from 1/6/23 through 2/3/23. SLP L stated that Resident #9's diet continued to be puree consistency with honey thick liquids. SLP L stated that Resident #9 aspirates frequently during meals, and frequently coughs, tongue thrusting, not placing the food all the way into the back of the mouth, spilling, and inadequate lip seal. SLP L stated that each time she came into the facility to provide treatment to Resident #9 his drinks continued to not be made to the correct honey thick consistency that was required and stated that staff did not want to make the drinks to that consistency because Resident #9 would not be able to drink them by himself. SLP L stated that she provided education each time she came into the facility to the dietary staff, which included the syringe demonstration, and provided a handout that was to be hung in the staff lounge for other CNA's to be educated on. SLP L stated that she also requested the facility use a gel thickener instead of powder to ensure the proper mixture and consistency for Resident #9's drinks, and at the time of Resident #9's discharge, the facility had not purchased or discussed the benefits of the gel thickener. When asked if Resident #9 was at continued risk for aspiration because staff were not thickening his drinks to the correct consistency, SLP L responded, Yes. On 2/7/23 at 4:03 p.m. DM Y was asked how to mix Resident #9's drink to a honey thick consistency. DM Y stated that she did not know, and that nursing staff were responsible for making Resident #9's drinks. On 2/7/23 at 5:30 p.m., the dinner meal was observed in the main dining room. Resident #9 was brought down into the dining room and placed at a table in the far-right corner. CNA E then grabbed a blue nosey cup from the kitchen counter and placed two scoops of thickening powder into the cup, then began to add Resident #9's Pepsi and stir using a regular tablespoon. CNA E was observed to be only stirring the top of the drink and not placing the spoon all the way into the nosey cup. When asked how to make Resident #9's drink into a honey thick consistency, CNA E stated, I used to work in the dietary, I don't know how many scoops to put in, but I just know what it is supposed to look like. CNA E also began to prepare Resident #9 a nosey cup with water, by adding two scoops of thickening powder into the water, and only stirring the top of the cup. CNA E then took the canister of thickening powder, the Pepsi and the water to Resident #9's table to continue to thicken both drinks. While at the table, CNA E added a total of 5 scoops of thickening powder to Resident #9's water, and 7 scoops of thickening powder to Resident #9's Pepsi. However, neither beverages were at the correct consistency. This Surveyor again asked CNA E if this was the correct thickened liquid for Resident #9, and she stated, Yes. Resident #9 was handed his Pepsi, began to drink the Pepsi at a very quick quickly and began to cough and choke. Resident #9 was observed to be turning red, was unable to catch his breath, and was visibly seen with sputum coming out of his mouth and nose. There were a total of 14 exacerbated coughs counted during this observation, while CNA E attempted to comfort Resident #9 and place his food farther away from him. Registered Nurse (RN) V was in the dining room during this event and did not attempt to intervene or assess Resident #9 during this time but told CNA E to help feed Resident #9 at a slower pace. On 2/7/23 at 6:00 p.m., the Director of Nursing (DON) was notified of the concern of Resident #9's inappropriately thickened liquids. The DON verbalized understanding and stated that they would take care of it. On 2/8/23 at 11:35 a.m., Dietary Aide/Staff DD was observed preparing Resident #9's Pepsi beverage for the lunch meal. Staff DD stated that she had already added four scoops of the thickening powder to the Pepsi, but that it was not thickening correctly. Staff DD could not demonstrate how much or what a honey thick liquid drink was supposed to look like. Certified Dietary Manager (CDM) Z came into the dining room and stated that she heard there was an issue with Resident #9's drinks and advised Staff DD to leave his drink alone to see if it would thicken up. Resident #9 entered the dining room and was given his Pepsi during the lunch meal service which was not the correct honey thickened consistency. Review of Resident #9's care plans, read, in part, Neuro: Huntington's. I have an alteration in neurological status r/t (related to) the disease process of Huntington's .Monitor for signs and symptoms of aspiration, choking, and difficulty swallowing date initiated:10/27/16 .Nutrition: I am currently able to make my needs, likes and dislikes know. I have a dx (diagnoses) of Huntington's disease. As this is a disorder that progressively limits my abilities, and I have chosen not to be treated, I can expect eventual decline .I have a tendency to eat too fast this puts me at risk for choking/aspiration .I have had choking incidents .swallow study on 6/27/18 shows that I silently aspirate on regular liquids .I am needing more assistance with my meals, as I have greater difficulty feeding myself .Interventions: Follow recommendations by the speech therapist regarding my intakes. I require constant supervision while eating due to risk for choking. I need frequent cues to slow down, small bites, alternate solids and liquids, and reduce talking Date Revision 12/27/22. I am on a puree diet, honey thick liquids revision on 8/11/22 .monitor me for s/s (signs/symptoms) of swallowing problems, choking, and aspiration. Encourage me to eat slowly revision on 8/11/22 . Review of Resident #9's Speech Therapy: Outpatient Clinic SLP Eval (evaluation) and Plan of Treatment dated 1/6/23 and written by SLP L read, in part, .the patient is a [AGE] year-old male who has been diagnosed with Huntington's Disease .Staff reports that patient has been coughing during meals .clinical bedside assessment of swallowing: thick liquids - thin liquids teaspoon = severe; clinical s/s (signs/symptoms) dysphagia. Pt (patient) given think liquid by spoon and displayed watery eyes. Nectar thick liquids - nectar liquids = mild; clinical s/s dysphagia: Pt with water eyes with intake of mildly thick liquids. Honey thick liquids .pt. appeared to have no s/s of aspiration. Pt able to bring cup to mouth; however, took too big of a sip. Unable to seal lips to swallow across trials .Patient is recommended to receive ST (Speech Therapy) services 1/2x(times)/wk. (week) for 30 days in order to assess and evaluate least restrictive diet, provide staff with safe swallowing strategies, and meet hydration/nutrition needs. Without skilled services, pt. is at risk for aspiration, compromised general health, weight loss, and malnutrition. Date of Service: 1/13/23 .Patient was seen in nursing home for swallow dysfunction services from ST. St saw patient during a meal in the dining room. Patient is currently on a puree texture and moderately thick liquids. Upon arrival, nursing reports that he is doing better. Nursing also states that the swallow recommendations that ST provided in eval session were helpful. During meal, pt. had puree fish and moderately thick Pepsi. St needed to thicken Pepsi more due to its thinner consistency. No CNA staff were available to watch ST complete recommended swallow techniques with patient this session. St also wanted to see how the CNA staff assist pt. with feedings in order to give recommendations. Patient showed x1 instance of s/s of aspiration during meal. Date of Service 1/20/23 .Patient was seen in nursing home for swallow dysfunction services. ST provided services in the dining room when patient was eating lunch. Upon arrival, patients' liquid was not moderately thick. St provided education to kitchen staff/available nursing staff with handout and explanation on the flow test for moderately thick liquids. St also provided a syringe to test if facility does not carry them. St assessed patients' tolerance of puree texture and moderately thick liquids (after thickness was corrected.) Pt displayed no s.s of aspiration/penetration this session, however CNA that joined ST reported that pt. has been having coughing episodes recently. This may be due to the liquids not being thickened correctly, but not known. St had CNA demonstrate how she usually assists him with feedings and provided her with safe swallowing strategies. She states she did not see the safe swallowing handout from previous session. Date of Service: 1/27/23 .Patient was seen in nursing home for swallow dysfunction services. St. provided services in the dining room when patient was eating lunch. Nursing reports that he was coughing a lot during breakfast and that the family signed off on not receiving a feeding tube for the patient, despite aspiration concerns. Nursing also reports that the patient is coughing throughout the day, however, states it is drainage. Trials of MO3 (moderately 3) via nosey cup. Pt has difficulty tipping it up in order to drink it. CNA in dining stated they make it less thick, so he can tip it up. However, ST educated her on the importance of sticking to MO3. St suggested spoon feeding the MO3 if he is unable to drink via nosey cup. Pt likes to drink pop, so the carbonation can make it thicker and harder to sip . An Immediate Jeopardy (IJ) began on 2/8/23 at 12:00 p.m., when facility staff were unable to demonstrate ability to properly thicken Resident #9's liquids to the correct consistency. The IJ notification was communicated verbally to the Administrator, and Director of Nursing on 2/8/23 at 12:00 p.m. and was followed with an email copy with request for a removal plan. The removal plan was accepted on 2/9/23. An onsite verification of immediacy removal was made on 2/9/23. Facility Removal Plan 2/9/23 - Immediate training will be done by Certified Dietary Manager and will be done with all dietary staff and CENA's before next administration or preparation of liquids. Dietary staff member will prepare thickened liquid and CENA will verify that consistency is correct prior to intake by R9 (Resident #9) 2/9/23 - Each individual dietary staff or CENA will be tested prior to their next feeding or dietary assignment. Staff educated on for test and syringe test and have demonstrated correct and consistent thickness with both. Staff will be shown what thickened liquid should look like 2/9/23 - The CDM was trained through Certifying Board. International Dysphagia Diet Standardization Initiative (IDDSI) provided the information for training on levels of thickened liquids. 2/9/23 - Facility will provide training for all dietary staff and nursing staff and anyone who is trained to feed residents. This training will include written education along with hands on visual training. Written education will be posted in kitchen for reference. 2/9/23 The Certified Dietary Manager will continue monitoring Resident 9's liquids for consistency daily times four weeks. If CDM is not available, the charge nurse will be checking liquids for correct consistency. PRN (as needed) audit will be done every quarter. 2/9/23 - An in depth Inservice will be conducted by the speech therapist on February 17th and February 22nd, 2023, for all dietary staff and nursing staff and anyone who is trained to feed. The speech therapist will include more on the anatomy of swallowing and mechanics and why liquids must be thickened. The speech therapist will be able to answer questions that are beyond the scope of the CDM. 2/9/23 - CDM reviewed IDDSI training through iddsi.org on January 23, 2023. CDM has been trained and tested today (February 9, 2023) by contracted RD (registered dietitian). 2/9/23 - CDM began training direct care staff as of February 9, 2023 and will continue all direct care staff is trained and can return demonstration adequately. CDM and Dietary manager have been trained Thursday am February 9, 2023, by RD. 2/9/23 - New dietary and nursing staff will appropriately train and tested as part of new employee orientation to ensure competency. Based on observation, interview, and record review on 2/9/23, the facility demonstrated removal of the immediacy via observation of staff properly thickening liquids to the correct consistency onsite. Although the IJ was removed on 2/9/23, the facility remained out of compliance at a scope and severity the potential for more than minimal harm at an isolated level. 35103 During an interview on 2/8/23 at 4:20 p.m., RN V was asked if the facility had provided education on 2/7/23 following the evening meal potential aspiration of improperly thickened (not honey thick as ordered) beverages by Resident #9. RN V said they had not received any education since the previous day (2/7/23) when staff were told they needed to ensure the correct thickness of Resident #9's liquid beverages. RN V stated, I was told there was going to be some more formal education. RN V did not know when the education was going to be provided to facility staff who routinely provided dietary assistance to Resident #9. RN V confirmed he was present in the dining room the previous evening when Resident #14 appeared to have aspirated while consuming liquids that were not thickened to honey consistency. RN V said the facility did have access to mobile x-rays, but none had been ordered for Resident #9 following what appeared to be an episode of aspiration at dinner on 2/7/23.

This deficient practice pertains to intake MI#00134067: Based on interview and record review, the facility failed to monitor for change in condition and timely send to the emergency roiagnom on e Resident (#7) out of 18 residents reviewed for quality of care. This deficient practice resulted in a delay in timely transfer for Resident #7, with the potential for a decline in function. Findings include: Resident #7 (R7) A review of R7's medical record revealed he admitted to the facility on [DATE] and had diagnoses including Down Syndrome, mood disorder, chronic respiratory failure, and recent tibia and fibula fractures. A review of his 1/1/23 Minimum Data Set (MDS) assessment revealed he was assessed as severely cognitively impaired and was totally dependent on one staff person for locomotion and extensive assistance of one staff for hygiene. This MDS also showed that R7 required limited assistance of one staff for eating. A review of a 12/12/22 Nurse Practitioner (NP) R note revealed, Nurses reported patient had a generalized tonic-clonic seizure lasting about a minute when he was transferred via Hoyer lift from the bed to the chair this morning upon waking . He has had 1 other known seizure which occurred on 7/16/2022. Her was taken to the emergency room following the event . He has not had any seizures in the interim other than the one this morning . We will start patient on Keppra (an anti-convulsant medication) 500 mg (milligrams) p.o. (by mouth) twice daily . A review of R7's record revealed no tapering of the Keppra. The only documentation of monitoring the discontinuation of the Keppra was on a New/Changed Medication Log which revealed documentation regarding R7's behaviors from 12/28/22 through 12/31/22 with no notation regarding seizures. The 1/1/23 documentation revealed: day shift noted, Acting strange, 'hallucinating', tired ., the afternoon shift noted, happy, wakeful after supper, and the night shift noted only, Awake, impulsive in recliner all NOC. A review of R7's nursing progress notes revealed the following: 1/1/23 at 11:40 p.m., This RN heard a yell/high pitch screech coming from resident's room- upon entering, resident was noted to be in bed, lying on his left side, convulsing- witnessed convulsions for approximately 10 seconds. NC (nasal canula) O2 (oxygen) turned up .Resident quickly became postictal for approximately 4 mins (minutes) with snoring respirations; . will monitor closely. This note was written by Registered Nurse (RN) N. 1/2/23 5:05 a.m., . During care, resident loudly and quickly yelled out x3 (three times) with nothing precipitating it. No abnormal behaviors otherwise. Approximately 3 minutes after staff was done with care and walked out of his room, resident was heard yelling/screeching- upon arrival to room he had his hands clenched up on his neck with violent muscle contractions noted. He was quickly turned up on his left side, head and airway protected . Convulsions lasted (witnessed) for approximately 10 seconds, postictal stage approximately 4 minutes . Scratch noted on right neck area from his fingernail . Will notify guardian and physician of overnight seizure activity x2 (times two) this am. This note was also written by RN N. 1/2/23 at 11:16 a.m., Resident had another Tonic Clonic seizure approx. (approximately) 0820 (8:20 a.m.) lasting approx. 15-20 sec. He drew his arms rigidly up to his chin and began jerking vigorously. Post Ictal phase lasted approx 4-5 min . Discussed and updated (Name of Nurse Practitioner (NP) R) who states send to ER for Eval (evaluation), guardian . aware of transfer to (Name of hospital) order . This note was written by Licensed Practical Nurse (LPN) H. A review of R7's hospital notes dated 1/2/23 revealed, Pt (patient) coming from (Name of Facility) after having 3 seizures, per ems and guardian pt was removed from his Keppra due to increased aggression and has been without seizure meds 2-3 days . evidently they (the Facility) felt that the Keppra he was on was contributing to his aggression. They stopped his Keppra 2-3 days ago. Patient had a full tonic-clonic seizure activity today . It is my opinion the patient's seizure is related to him stopping his Keppra. I have reinstituted Keppra with a Keppra Bolus and load here in the emergency department. I recommend that the facility reinstitute his Keppra daily dosing. Should they wish to stop the Keppra, they should do this in discussion with the primary care provider or neurologist . A review of R7's physician orders revealed the Keppra medication was discontinued on 12/27/22. A review of a 1/11/23 NP R note for R7 revealed, The patient is seen today for follow-up of seizures. He was sent to (name of Hospital) on 1/2/2023 after having 3 seizures at the nursing facility. Patient was previously on Keppra for seizures for about 3 weeks prior to his hospital admission but this was discontinued due to irritability and agitation thought to be a side effect of the Keppra . Seizures. Continue Keppra 500 mg BID (twice per day) . A review of the SNF/NF to Hospital Transfer Form for the 1/1/23 transfer to the hospital was not fully filled out. The vitals section showed vitals taken on 1/1/23 and 1/2/23, but the date of transfer was listed as 10/10/2022 16:30 incorrectly instead of 1/2/23. It noted that LPN H had notified the responsible party and Physician K but did not document a date or a time. On 2/16/23 at approximately 11:00 a.m., the DON was asked to provide documentation that the Physician or Nurse Practitioner was notified for each of the three seizures. On 2/16/23 at 12:12 p.m., the DON reported she could only find documentation that the 3rd seizure was reported and asked if that would be sufficient. The DON was asked to provide documentation that the provider and family had been notified of the first two seizures. On 2/16/23 at 11:32 a.m., a phone call was made to RN N who did not answer. A message was left with contact information, reason for call, and a request for a call back. By the time of the exit on 2/17/23 at 10:30 a.m., RN N had not returned the call. At the time of exit on 2/17/23 at 10:30 a.m., no documentation was provided to show that RN N had informed the Physician of R7's first two seizures to determine if hospital transfer was necessary. A review of the facility policy titled, Change of Condition revised 2/4/19 revealed, Policy: Resident changes of condition will be assessed to determine, if possible, the reason for the change. The attending Doctor and responsible party will be notified . Call: Doctor and responsible party. Chart: . What doctor was informed and what he/she was informed of. Who else notified and the time . A review of the Centers for Disease Control and Prevention (CDC) document titled Types of Seizures reviewed on 9/30/20 revealed the following, .Tonic-clonic seizures, also called grand mal seizures, can make a person: Cry out. Lose consciousness. Fall to the ground. Have muscle jerks or spasms . (https://www.cdc.gov/epilepsy/about/types-of-seizures.htm) A review of the package insert documentation for the anti-seizure medication Keppra from the website www.drugs.com revealed, .Discontinuation of Keppra. Avoid abrupt withdrawal of Keppra in order to reduce the risk of increased seizure frequency and status epilepticus .

This deficient practice pertains to intake MI#00130116: Based on observation, interview, and record review, the facility failed to ensure that assistance was provided for eating and drinking for two Residents (#11 and #14) out of five residents reviewed for meal assistance. This deficient practice resulted in R11 not being assisted with meals, inadequate intake, and a significant weight loss of -7.8% in 15 days. Findings include: Resident #11 (R11) A review of R11's medical record revealed he admitted to the facility on [DATE] with diagnoses including dementia, major depression, dysphagia (swallowing impairment), and tremors. A review of his 11/7/22 Minimum Data Set (MDS) assessment revealed he scored 5/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating severely impaired cognition. This MDS showed he required supervision and setup help only for meals. This MDS was reviewed as the most recent MDS was still in progress and not completed. On 2/7/23 at 12:15 p.m., R11 was observed sitting at dining room table with a small bowl of tamale pie in front of him. R11 was observed to have a tremor while trying to bring a cup with apple juice and a straw to his mouth. R11 made multiple attempts to grab his fork, but due to the tremors was not able to reach his mouth. No staff were observed helping R11 with his meal. On 2/7/23 at 6:03 p.m., R11 was observed during the dinner meal. R11 was not observed to be feeding himself, nor was he assisted by staff. On 2/8/23 at 5:31 p.m., R11 was observed in the dining room with a small bowl of beef barley soup with no liquid. A spoon was sitting on the top of the food in the bowl, but R11 was making no attempts to feed himself. No staff were observed assisting R11 with his meal despite Certified Nurse Aide (CNA) E sitting next to him feeding another resident. On 2/8/23 at 5:35 p.m., R11 was asked how his food was but he did not respond. CNA E then asked R11 how his food was and R11 proceeded to shake his fist at CNA E. CNA E then asked R11 if he wanted his dessert to which he did not respond. A review of R11's progress notes revealed the following: 1/24/23 .Resident has had a need to be assisted (fed) with meals at dinner. Staff assisting as needed. Continue to monitor . No weight loss but potential for . A review of R11's weight log revealed the following: 8/31/22 167 pounds 11/30/22 171 pounds 12/30/22 170.4 pounds 1/31/23 171 pounds A review of R11's care plan revealed the following: .Self Care Deficit . Eating. I am a choke risk because I eat too fast . (2/24/21) .I am able to eat independently; set up assistance only if needed (revised 2/6/19) .Nutrition. I only have a few teeth I have not been feeding myself at dinner and may need more assist (revised 1/24/23) . On 2/15/23 at 11:42 a.m., R11 was observed being weighed by CNA F. CNA F read out and it was visualized on the scale that R11 weighed 157.6 pounds. This would indicated a 13.4 pound weight loss in 15 days, or -7.8% in 15 days, indicating a significant weight loss. On 2/15/23 at 2:00 p.m., Certified Dietary Manager (CDM) Z and Dietary Manager Y were notified that R11 had not been helped at meals by staff and had also had a 13.4 pound weight loss in 15 days. Neither CDM Z or Dietary Manager Y provided any comments as to why R11 was not receiving adequate assistance with his meals. 34568 Resident #14 On 2/7/23 at 11:50 a.m., an observation was made of the lunch meal being served in the main dining room. During this observation, Resident #14 was observed to be sitting at a dining room table with three other Residents with his meal placed in front of him. Resident #14 stared at his meal and was not assisted by staff to eat. At 12:15 p.m., Certified Nurse Aide (CNA) D placed three green beans on Resident #14's fork and said, Do you want to take a bite? while standing over top of him and placed the fork forcefully in Resident #14's mouth. Resident #14 began to chew the green beans in his mouth while CNA D then went back over to another Resident (later identified as Resident #9) to assist with his juice. CAN D did not return over to Resident #14. At 12:20 p.m. CNA S began to assist Resident #14 with his meal and continued to stand over him while assisting. CNA S continued to stand overtop of Resident #14 until approximately 12:30 p.m. On 2/8/23 at 5:30 p.m., an observation was made of the dinner meal being served in the main dining room. During this observation, Resident #14 was observed to be sitting at a dining room table with three other residents with his dinner meal placed in front of him. Resident #14's eyes were closed and he appeared to be asleep. During the meal service, Resident #14 continued to not be assisted with meals and only one staff member attempted to wake him, but quickly moved on to pass meal trays to other residents entering the dining room. Review of Resident #14's EMR revealed admission to the facility on [DATE] with diagnoses including dementia with behavioral disturbance and Alzheimer's disease with late onset. Resident #14's 1/22/23 MDS assessment noted him to have severely impaired cognition and requiring extensive one person assist for eating. Review of Resident #14's care plans read, in part, .self-care deficit and physical mobility .interventions: Eating: Feed .Nutrition: I am able to feed myself, make my likes/dislikes known. I can make simple decisions .interventions: Resident is a feed, can occasionally take a bite unassisted, let me do what I can for myself, assist me as needed when I am having difficulty. Date initiated: 11/11/2022 Revision on 1/20/2023 .

This deficient practice pertains to intake MI#00130116: Based on observation, interview and record review, the facility failed to obtain therapy services as documented and ordered for one Resident (#7) out of five residents reviewed for therapy services. This deficient practice resulted in Resident #7 not receiving physical therapy after a fall with fracture requiring surgical repair with a decline in functional ability. Findings include: Resident #7 (R7) On 2/10/23 at 1:50 p.m., R7 was observed sitting in a recliner in the common area by the TV in the hallway. R7 was holding onto his wheelchair in front of him and attempting to self transfer into it. CNA G was observed to talk up to the area, observe R7, get some hand sanitizer from the wall dispenser and continue on her way down the hall. CNA G did not intervene when she witnessed R7 trying to self-transfer to his wheelchair without staff assistance. A review of R7's medical record revealed he admitted to the facility on [DATE] and had diagnoses including Down Syndrome, mood disorder, chronic respiratory failure, and recent tibia and fibula fractures. A review of his 1/1/23 Minimum Data Set (MDS) assessment revealed he was assessed as severely cognitively impaired and was totally dependent on one staff person for locomotion and extensive assistance of one staff for hygiene. This MDS also showed that R7 required limited assistance of one staff for eating. A review of a facility reported incident for R7 dated 10/10/22 revealed that R7 had fallen in the morning and later in the day was sent to the hospital where it was found that he had sustained tibia and fibula fractures of the left leg. R7 underwent surgical revision for these fractures on 10/12/22. A review of an Occupational Therapy Evaluation/Care Plan for R7 completed by the OT on 10/19/22 and signed by the Nurse Practitioner (NP) R on 11/1/22 revealed, .Long Term Goals: . return to prior level of function . Treatment plan: Self care PT (patient) education. Therapeutic exercise. Therapeutic activities. Frequency: 1-2 times per wk (week) for 30 days . There were no further Occupational Therapy (OT) notes, orders, or discharge summary for R7. A review of a Physical Therapy Evaluation/Care Plan assessment for R7 revealed the following, . Treatment plan: Therapeutic exercise. Gait training. Bed mobility/transfer training . other: manual therapy. Frequency: 5 times per wk for 30 days . This evaluation was completed on 10/19/22 and signed off by the NP R on 11/1/22. A review of a Progress Report/Discharge Summary for R7 for Physical Therapy (PT) was reviewed and revealed, . Discharge summary. From 10/19/22 to 10/20/22 .Pt (patient) unable to follow any instructions to participate in any therapeutic exercises or activities at this time secondary to severity of cognitive deficits and non-weight bearing status . A review of an untitled document for therapy tracking revealed documentation of Physical Therapy on 10/19/22 for 60 minutes and 10/20/22 for 38 minutes. This document showed documentation of only 60 minutes of Occupation Therapy on 10/19/22. There were no further Occupational Therapy (OT) notes, orders, or discharge summary for R7. There were no further Physical Therapy notes, orders, or discharge summaries for R7. A review of a Therapy Orders document for R7 from the orthopedic surgery center dated 10/28/22 revealed, . Left closed displaced tibial [NAME] fracture . Treatment: PT evaluate & treat. Therapy: Range of Motion, Stretching. Other: Please work on L (left) ankle passive ROM (range of motion) to pain tolerance. Duration: 6 week therapy order . A review of an Orthopedic Surgery progress note revealed, November 28, 2022 . Pt (patient) progressing normally. Please continue fracture boot except for hygiene and exercises x (times) 4 more weeks. WBAT (weight bearing as tolerated). Skin checks BID (twice per day). Start PT (Physical Therapy) as prescribed . There was no evidence to show that the 10/28/22 orthopedic surgery orders for PT evaluation and treatment were ever completed, nor evidence to show he received any therapy services after 10/20/22. On 2/16/23 at 11:20 a.m., the DON was asked about R7's fall on 2/15/23 and she reported she was just handed the incident report at 10:47 a.m. that morning. The DON was asked to show evidence of CNA E receiving education for not following R7's care plan resulting in a fall. On 2/16/23 at 12:01 p.m., an email was received from the DON that revealed, I spoke with (name of RN I) 02/16/2023 at 1149 regarding the above. She stated that she verbally educated staff and did not hold an in-service. I verified with (Name of RN V) that (Name of CNA E) was the CENA on that did not use the gait belt. (Name of RN V) also told me that he educated the staff based on the resident's care plan . On 2/16/23 at 1:55 p.m., an interview was conducted with the DON and Owner A. When asked how CNA E was educated or disciplined for failing to following the care plan for R7, Owner A reported that RN V had written a progress note that education was done and he should have brought the issue to the DON which he did not. When asked if there was no record of in-services or one-to-one educations when staff fail to provide the correct care, Owner A reported that they just do verbal education and don document anything. When asked then how they could determine if the same staff member was failing to follow the care plan on multiple occasions if there was no documentation of the education, Owner A reported she understood how that could be helpful. The DON was notified that R7 had orders from the orthopedic surgeon on 10/28/22 for physical therapy, and a screen indicated therapy was warranted. The DON and Owner A were not able to provide any evidence that R7 received any therapy services for this certification period. A review of R7's ADL care plan initiated on 1/18/2018 revealed the intervention of . Ambulation: supervision only; uses walker . revised on 2/6/2019. At the time of the survey R7 had declined and was no longer ambulating independently, but the care plan was not revised. A review of R7's care plan for his left leg fracture initiated 11/2/22 revealed, Fracture. I fractured my Fibula and Tibia r/t a fall .Follow-up appointment at (name of Orthopedic Provider) as ordered . PT and OT to evaluate and treat if indicated. A review of R7's MDS 7/3/22 from prior to the 10/10/22 fall compared with the most recent 1/1/23 MDS revealed the following: R7 required only limited assistance of one staff with transfers prior to the 10/10/22, but as of the 1/1/23 MDS he required the extensive assistance of two or more staff for transfers. R7 required only the limited assistance of one staff for locomotion prior to the 10/10/22 fall, but as of the 1/1/23 MDS was totally dependent on one staff member for all locomotion On 2/16/23 at 11:20 a.m., the DON was asked about R7's fall on 2/15/23 and she reported she was just handed the incident report at 10:47 a.m. that morning. The DON was asked to show evidence of CNA E receiving education for not following R7's care plan resulting in a fall. On 2/16/23 at 12:01 p.m., an email was received from the DON that revealed, I spoke with (name of RN I) 02/16/2023 at 1149 regarding the above. She stated that she verbally educated staff and did not hold an in-service. I verified with (Name of RN V) that (Name of CNA E) was the CENA on that did not use the gait belt. (Name of RN V) also told me that he educated the staff based on the resident's care plan . On 2/16/23 at 1:55 p.m., an interview was conducted with the DON and Owner A. When asked how CNA E was educated or disciplined for failing to follow the care plan for R7, Owner A reported that RN V had written a progress note that education was done and he should have brought the issue to the DON which he did not. When asked if there was no record of in-services or one-to-one educations when staff fail to provide the correct care, Owner A reported that they just do verbal education and don document anything. When asked then how they could determine if the same staff member was failing to follow the care plan on multiple occasions if there was no documentation of the education, Owner A reported she understood how that could be helpful. The DON was notified that R7 had orders from the orthopedic surgeon on 10/28/22 for physical therapy, and a screen indicated therapy was warranted. The DON and Owner A were not able to provide any evidence that R7 received any therapy services for this certification period.

Based on interview and record review, the facility failed to develop an individualized care plan and to implement clear and explicit care plan interventions, including adequate monitoring, for 1 Resident (#400) (with a history of [MEDICAL CONDITION] and [DIAGNOSES REDACTED]), of 3 residents reviewed for care planning with implementation, from a total sample of 3 residents. This deficient practice resulted in the lack of recognizing and monitoring for [MEDICAL CONDITION] and hydocephalus symptoms, lack of appropriate individualized care plan interventions, and a delay in emergency treatment for [REDACTED]. Findings Include: A record review of Resident #400's face sheet dated 7/11/17 revealed on 7/11/17, a [AGE] year old female was admitted to the facility with [DIAGNOSES REDACTED]. A review of Resident #400's Minimum Data Set (MDS) Assessment, dated 7/17/17, revealed she had moderately impaired cognition, clear speech, understands and is easily understood, can feed self without help, . There was no mention of Resident #400 having a history of [DIAGNOSES REDACTED], [MEDICAL CONDITION], or meningitis. A review of Resident #400's cognition assessment by Social Worker Aon 7/24/17 revealed her cognition was intact, Resident #400 was her own person (made her own decisions). Resident #400 was coded 'Do Not Resuscitate'. A review of Resident #400's comprehensive care plans dated 7/21/17, revealed there was no care plan in place which addressed the [DIAGNOSES REDACTED].#400 should have been monitored. ([DIAGNOSES REDACTED] (Hakim's Triad) is a brain disorder in which excess cerebrospinal fluid accumulates in the brain's ventricle.) The classic symptoms include urinary incontinence, gait disturbance, and progressive cognitive loss. Other related symptoms may include: headache, poor coordination, lethargy, drowsiness, irritability, other changes in personality, vomiting, and nausea. (Source: alz.org) A review of Resident #400's progress notes from 7/11/17 through 9/01/17 (including ambulance transfer sheet) revealed: 7/15/17 - alert and oriented X 3 (for person, place and time - her own person) 7/23/17 - alert and oriented, refused assistance with cares, shower independently (7/24/17 - Aggression Assessment completed with behaviors of complaining, consistently wanted request for attention/help, screaming, cursing, verbal aggression) 7/25/17 - resident fell (from wheelchair) - unwitnessed 7/29/17 - last two days cooperative with staff 8/08/17 - (Resident #400) .in standing position with sit to stand .(she) let go of handles .Resident said, let go because her arm hurt 8/16/17 - alert and oriented X 1, full transfer due to knees buckling, happily confused, (contacted physician) 8/16/17 - Geriatric Nurse Practitioner B visited resident, suggested psyche visit, ordered labs for next week 8/24/17 - updated (FM C), labs results .dehydrated, fluids pushed, vital signs every shift, more like herself tonight, conversation clear and appropriate, mood better 8/25/17 - could hold glass without spilling water, 8/27/17 - fed self part of both meals 8/30/17 - GNP B visited with resident, new orders, (2 - 500 milligrams of extra strength Tylenol 3 times a day ordered for headache), daughter informed 8/31/17 - alert and oriented X 1, small emesis 9/01/17 - 5:21 am - alert and oriented to self, distant look, arm hanging off the bed, total assistance needed 4:03 pm - oriented to self and family, vital signs, daughter asked for resident to go to ER (emergency room ) 9/01/17 - SW A note - unable to make decisions, speech garbled, face flushed 9/01/17 - 6:15 pm - per Ambulance Transfer sheet, Resident #400 left for the hospital Reviewed Resident #400's Intake and Output (I & O) Record for 7/11/17 - 9/01/17. Documentation showed when Resident #400's intake declined, GNP B assessed Resident #400, labs were drawn, dehydration was found and an order to push fluids had been given. The I & O Record revealed her intake had increased following the hydration order. A Reviewed Medication Administration Record [REDACTED]. On 8/23/17, a routine order for 2 pills of 500 milligrams of extra strength Tylenol 3 times a day was written for headaches versus the original order of As Needed. Per interview with RN J (9/18/17 at 3:15 pm) Resident #400's pain level, when asked was usually 3 - 5 on a 10 scale. A review of the MAR for 8/24/17 through 9/01/17 revealed Resident #400 was receiving the 8/23/17 Tylenol order, but there was no documentation of a pain scale showing if the medication was working to relieve the headaches. On 9/21/17 at 1:00 p.m.,an interview was conducted with Registered Nurse (RN) Q. RN Q said she worked for Area for Aging and on 8/21/17 met with Resident #400 and FM C in the facility to decide if Resident #400 could move into an apartment by herself. RN Q said there was a nurse from the facility, RN F, who brought Resident #400 to the meeting. RN Q stated, .(FM C) and I were surprised by how (Resident #400) looked .slumped in her wheelchair, groggy .her hand was curled up and arm against her chest .stiffly shaking .(RN F) took her (Resident #400's) hand and started opening and spreading her fingers, pulling her arm down .(RN F) told us (Resident #400) has behavioral [DIAGNOSES REDACTED].after seeing (Resident #400's) condition I suggested to (FM C) maybe she should talk to someone about getting (Resident #400) a CT (computed tomography scan) .could tell (FM C) was upset .knew (Resident #400) wasn't a candid for her own apartment. On 9/21/17 at 1:35 p.m. an interview was conducted with RN F about the meeting she attended with RN Q, Resident #400 and FMC. RN F said she just wheeled Resident #400 into the room. RN F stated she saw Resident #400's arm up, fist clenched and shaking a little, which she thought was strange and had never seen her arm like that before or after the meeting. She wasn't in the room very long, then wheeled Resident #400 out when the meeting was finished. RN F said she couldn't remember exactly what went on, and didn't hear anyone say anything about a CT scan to be done This Surveyor asked her if she had documented the meeting. RN C said, No, I didn't think about it. On 9/21/17 at 1:00 p.m. an interview was conducted with the Director of Nursing (DON) concerning Resident #400. The DON was not happy the meeting was not documented. The DON said, I wish (RNQ) would have come to see me and told me what she thought about the CT scan .I was on vacation during the end (last week of Resident #400 being at the facility) . I agree the documentation is lacking . we are going to discuss this at our nurses meeting being held this afternoon . A review was conducted of the Hospital Summary dated 9/03/17, dictated by Doctor D: .(Resident #400) initially admitted with altered mental status/[MEDICAL CONDITION] with a know history of recurrent UTI (urinary tract infection) and chronic [DIAGNOSES REDACTED] due to remote (history of) meningitis .[MEDICAL CONDITION] is multifactorial .CT scan of the head done on admission showed marked [DIAGNOSES REDACTED] .the report included mention that this [DIAGNOSES REDACTED] had progressed significantly since 2014 and was concerning for fourth ventricular obstruction . (Neurology Physician E) did review outpatient records and noted that this patient had been seen in 2014 and follow up imaging was suggested to make sure there was no fourth ventricular obstruction and progressive hydroocephalus .He noted that the patient never returned for follow-up. A review of the CT scan taken on 9/01/17 showed, .marked [DIAGNOSES REDACTED] is present with significant worsening since prior scan three years ago. There is marked dilatation of the fourth ventricle and the appearance is highly suspicious for fourth ventricular obstruction . A review was conducted of Resident #400's Death Certificate dated 9/02/17, which read, Enter the chain of events, diseases or complications that directly caused the death: Obstructive [DIAGNOSES REDACTED] due to (or as consequences of) Remote (history of)Meningitis .

Based on interview, observation and record review, the facility failed to notify the physician and call Emergency Medical Services (EMS) in a timely manner to transfer a resident to the emergency room after a severe head injury for one Resident (#101) out of four residents reviewed for assessment and treatment post injury in a total sample of four residents. This deficient practice resulted in a delay in assessment by the hospital and a delay in treatment of [REDACTED]. Findings include: A review of Resident #101's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 7/4/16 Minimum Data Set (MDS) assessment revealed Resident #101 scored a 3/15 on the Brief Interview of Mental Status (BIMS) assessment, indicating severely impaired cognition and she required assistance of one person for transfers and bed mobility. A review of progress notes for Resident #101 written by Licensed Practical Nurse (LPN) I dated 8/25/16 revealed, 02:45 (a.m.) .Resident (#101) lying face down on floor at end of bed. Blood noted from head . face [MEDICAL CONDITION] (swollen, fluid filled), left eye swollen and closed. Producing bloody discharge from mouth . A second note dated 8/25/16 read, Addendum for fall 8/25/16 . blood noted from nasal passages . complains of nausea small bloody emesis (vomit) . 03:40 (a.m.) (PhysicianE) called new order .transfer to (local Medical Center) ER (emergency room ) . 03:45 (a.m.) daughter (of Resident #101) notified of fall. 04:30 (a.m.) 911 called. 04:45 (a.m.) (Local transport) EMS arrived . This documentation revealed, per LPN I, she waited 55 minutes to call the Physician after finding Resident #101 on the floor, and then waited 50 minutes more to call the EMS to transport Resident #101 to the hospital emergency department. Review of Resident #101's Medication Administration Record [REDACTED]. Resident #101 was taking 2 mg of [MEDICATION NAME] on Monday, Wednesday, and Friday. [MEDICATION NAME] prevents the blood from clotting which can cause excessive bleeding. ( ) Review of Resident #101's local hospital History and Physical dated 8/25/16 reads, Chief complaint is found down after likely fall .(Resident #101) was down for an unknown length of time .She was noted to have swelling over her left periorbital (around the eye) region .found to have a retrobulbar hematoma (blood around the eye) on the left (eye) with impingement on the optic (eye) nerve .patient was also found to have a left subdural hemorrhage (bleeding into the brain) .she has extensive left facial [MEDICAL CONDITION] (swelling) with slight shift to the right noted to her nose and mouth region .fracture of left orbital floor (bottom of eye socket) .bilateral (both sides) nasal bone fractures . ( ) Review of the facility's Incident Accident Report dated 8/25/16 reads, .L (left) eye swollen and bruised (and) closed, L face [MEDICAL CONDITION] (swelling) ?deformity, blood from nose, nausea, coughing up bloody secretions, L hand 4 cm (centimeter) skin tear, L elbow 2 cm skin tear, R (right) elbow 2 cm skin tear . ( ) On 9/1/16 at 11:20 a.m., the Director of Nursing (DON) was asked if she had reported any events to the State Agency in the last two months and the DON reported, No. The DON reported that there had been one fall recently that the facility had looked into and education was provided on pulling documents from the electronic medical record. The DON stated, She (Resident #101) had fallen and we looked into how long to get her to the hospital. It took longer than it should have. On 9/1/16 at 4:22 p.m., an interview was conducted with Registered Nurse (RN) B. When asked what she would do if she found a resident on the floor with a severe head injury, like Resident #101 had, RN B stated, The head injury was pretty severe. She (Resident#101) should have been sent out immediately. On 9/2/16 at 9:20 a.m., Resident #101 was observed up in a wheelchair in the hallway with staff. Resident #101 was observed to have deformity to her left eye area, and extensive bruising to her face and neck. Her left eye appeared abnormal in comparison to her right eye and was watering extensively. When asked how she was doing, Resident #101 stated, Just so-so. On 9/2/16 at 9:38 a.m., a phone interview was conducted with Physician E who, when asked about the call from LPN I on 8/25/16 stated, I told her you need to send her (Resident #101) over (to the emergency room ). She had fallen and hit her head. There was no question. When asked about whether the nurse should have waited as long as she did when there had been facial deformity and swelling, Physician E stated, If there was some deformity probably the first thing I'd have done was calling (911). On 9/2/16 at 1:04 p.m., an interview was conducted with LPN I regarding the event that occurred on 8/25/16 and reported, She (Resident #101) was laying at the foot of the bed. She was laying on her abdomen face down. There was blood on the floor around her head. I went to get assistance from the CNA (Certified Nurses Aide H) . We decided to to lift her with the mechanical lift. When asked how long it took them to get Resident #101 back into bed, LPN I stated, About 20 minutes. I'm not in a hurry because once they are on the floor there's no further down (that they can go). When asked what happened after the Resident was back in bed, LPN I stated, We took vitals on her. She was nauseated. She had a little emesis. Then I went to get an ice pack, then I just proceeded to have the CNA stay with her . I called the doctor (Physician D). When asked what Physician D instructed her to do, LPN I stated, He said 'You just better send her (to the hospital)'. I told him it looked like abnormalities to her face and I was concerned about fractures. It (her left eye) looked deformed to me. When asked about a neurological assessment of Resident #101's status, LPN I stated, I couldn't do eye checks because her eyes were swollen shut. We checked blood pressure, hand grips, and such. When asked if she had taken into account that Resident #101 was on an anticoagulant medication, LPN I stated, I was immediately aware that she was on [MEDICATION NAME]. I was not surprised to see bleeding because of that. When asked whether Resident #101 could tell her what had happened, LPN I stated, I don't know that she couldn't have answered (the question of what had happened), I don't know that I asked her. I could have done a lot of things different. When asked if Resident #101 should have been sent out sooner than two hours after being found with severe injuries, LPN I stated, I guess she should have. When asked how Resident #101 was acting during the two hour wait, LPN I stated, She told me she wanted to go to the hospital. When asked if Resident #101 was in pain during this time, LPN I stated, Yes. I think it was pretty bad. She couldn't really see. She was holding her face, and stating she wanted to go to the hospital . On 9/2/16 at 1:42 p.m., an interview was conducted with CNA H who had assisted LPN I with Resident #101 on 8/25/16. When asked about what had happened, CNA H stated, It was one of the worst nights that I remember . I walked out of a room with a brief and (LPN I) says, 'We got someone on the floor. (Resident #101) is on the floor.' I did what she (LPN I) told me to do. I seen her face down. (There was) blood from her head to he shoulder area (on the floor). When asked how the Resident was acting after they found her on the floor, CNA H stated, She said she hurt . I think she had blood in her nose. Her face - holy moly. Her left eye was huge and black and blood everywhere . She said she wanted to go to the hospital and we told her she was going. When asked if there was something else that was going on that night that would have prevented LPN I from sending Resident #101 to the hospital in a timely manner, CNA H stated, I don't know. On 9/2/16 at 2:10 p.m., the DON when asked why LPN I had delayed sending Resident #101 out to the hospital for evaluation on 8/25/16, stated, That's not normal procedure. I don't know what happened with (LPN I) that night. When asked what should have been done, the DON reported, I would have called the ambulance right away and gotten her in (to the hospital). On 9/2/16 at 2:40 p.m., an interview was conducted with LPN G who, when asked what she would do if she found a resident on the floor with excessive bleeding and facial deformity, stated, I would try to stop the bleeding if I could and call (911) right away. On 9/2/16 at 2:51 p.m., an interview was conducted with Registered Nurse (RN) F who when asked what she would do if she found a resident on the floor with excessive bleeding and facial deformity stated, Call 911 immediately. A review of the facility policy titled Emergency Medical Care written 5/19/13 and reviewed on 1/17/16 read in part, 1. Assess resident and provide immediate nursing care. 2. Call Physician to notify and obtain orders. 3 .Emergency care that residents must be transported to hospital for are Fractures, severe head injuries . Review of the facility policy titled Incident/Accident Report Policy and Procedure dated and reviewed 1/26/16 read, 1. After an incident/accident has occurred, assess for injuries, deliver any first aid that is required. 2. If injuries are of serious nature notify Doctor and transport. Call emergency personnel at (Emergency Center). Telephone number is 911 . ( )

Based on observation, interview, and record review, the facility failed to ensure safety measures were followed per care plan and prevent a second degree burn for 1 Resident (#200) of 5 residents reviewed for accidents/hazards, from a total sample of 5 residents. This deficient practice resulted in Resident #200's multiple second degree burns from a coffee spill, increased pain from the burns, and the potential for infection. Findings include: An abbreviated survey was conducted on 5/27/16 to address the facility reported incident of Resident #200's burn which occured while he was drinking hot coffee. A review of the facility Investigation File dated 5/24/16 through 5/27/16 revealed: On 5/24/16, at 7:00 a.m., Cook/Kitchen Staff C served Resident #200 a covered insulated 8 ounce mug of hot coffee to which cold water had been added. Staff C went back into the kitchen, heard a noise in the dining room, and saw Resident #200's coffee mug sideways in his lap. Staff C took the clothing protector and the coffee mug off of his lap. Staff C then went down the hallway and told Certified Nurse Aide (CNA) H, Resident #200 needed attention because he spilled coffee on himself and his pants were wet. The Investigation Report dated 5/24/16, also indicated Resident #200 received a burn blister to his anterior/medial left thigh 3.0 cm (centimeters) x 3.0 cm from coffee which was too hot. Per the interview statements, investigation, and Resident #200's progress notes, Resident #200's pants did not get changed nor did he get any treatment for [REDACTED]. On 5/27/16 at 10:25 a.m., Cook/Kitchen Aide C reenacted the obtaining of coffee for Resident #200. She put 8 ounces of coffee in an insulated mug, put in cold water, and then took the temperature of the coffee - 140 degrees (°F). Staff C said, I told (CNA H), the coffee had added cold water .but was still hot . A review conducted of Resident #200's Minimum Data Set (MDS) Assessment, dated 3/22/16, revealed a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment revealed Resident #200 had moderate cognitive decline with confusion and needed set up and supervision when eating. A review of his Activities of Daily Living (ADL) Care Plan (dated 1/13/16) showed written, I have been experiencing difficulty in not spilling my drinks at meals, sometimes I doze off or tip the glass too much . A review of the staff interviews revealed a miscommunication between staff on whether the spill on Resident #200 was from a hot or cold beverage, which delayed the immediate treatment Resident #200 should have received. On 5/27/16 at 9:15 a.m., an interview was conducted with Resident #200 pertaining to the burn he received from his coffee. During the interview he seemed to nod off and then come back to the conversation. Resident #200 wore a brief and had a privacy sheet over his lap as he sat in his wheelchair. When Resident #200 was asked if he remembered spilling his coffee and getting burned a couple of days ago, he stated, .Yes .spilt my coffee .hurt some .not as much as it does now .drink hot coffee everyday .like it (coffee) hot .have tipped (my coffee) cup before but don't remember ever spilling coffee (getting burned) on me .we (wife (Resident #205) and Resident #200) like to go into the dining room early in the morning . On 5/27/16 at 9:45 a.m. an interview was conducted with the Director of Nursing (DON) pertaining to Resident #200's coffee burn. The DON stated, .We (staff) all feel awful .he shouldn't have been in the there (dining room) without supervision .early in the morning there is no supervision .(he) should have been given a cold drink .will not happen again .she (Staff C) didn't know he shouldn't have been given hot coffee .cold water has always been added to everyone's coffee (prior to handing it out to the residents) .now ice cubes are being put in the coffee and (coffee) is tempted (temperature taken of coffee before given to residents) . On 5/27/16 at approximately 10:30 a.m., Physician B and this Surveyor observed Resident #200 on his bed with covers removed to expose 4 open blistered burn areas (anterior, medial, lateral and posterior) wrapping down and under his left inner thigh. Registered Nurse (RN) F measured the open areas which ranged from 4 cm x 1 cm (centimeter) down under the leg at the groin area to the largest being 7 cm x 8 cm. on the top (anterior) of the thigh. Some of the areas had hardened top blister skin covering the areas. There were also a couple of tiny blisters intact. The wounds looked clean and dry with no infection, ranging in color from dark red to pink. On 5/27/16, interviews were conducted with Activity Director A at 9:30 a.m., CNA D at 10:10 a.m., LPN E at 10:48 a.m., RN F at 11:05, and CNA G at 11:15 a.m., pertaining to Resident #200 being in the dining room unsupervised, and what to do if someone has hot beverage spilt on them. All five of the staff interviewed knew prior to the incident, Resident #200 needed supervision in the dining room, needed a top on all liquid containers and if he was not immediately supervised, could be given a cold drink. The above interviews also revealed, if one of the residents did accidentally get hot liquid spilled on them, every resident is given ice water on the table, and to dump the cold water immediately over the area of the spill. This had been the protocol prior to the incident. A message was left with CNA H (the CNA who was told Resident #200 had spilled hot coffee on his lap) at 12:45 p.m., but she never returned the phone call. On 5/27/16, during the interview with LPN E at 10:48 a.m., LPN E said, she saw (on 5/24/16, at 7:20 a.m.) Resident #200 being wheeled back to his room to get his pants changed. LPN E reiterated (what she had written in her statement dated 5/24/16), .I felt his pants which were cool and asked him if he was ok .he stated 'yes, I just want to finish my breakfast' .I said that's fine and we'll assist you in the bathroom after breakfast .at 10:00 a.m. the CNAs changed his pants and reported the blister .I then talked to (Staff C explaining the importance of notifying the charge nurse immediately, following a glass of water to the coffee spill(site) . On 5/27/16 at 12:10 p.m., this Surveyor took the temperature of the coffees being removed from the kitchen. They were 110 degrees. Just after the coffee temperature was taken, observations were conducted of Residents #202 and #204. They were sitting at a table located at the back of the dining room getting ready for lunch. They each had a juice, a coffee, and a water, along with their plate of food. They were both interviewed. They said they liked their coffee hot. Resident #200 was then wheeled into the dining room, given hot coffee in a regular coffee cup and then supervised. At 12:15 p.m., Resident #201, care planned for supervision, was given his drinks with supervision. Resident #204 was interviewed just after lunch, at 2:00 p.m. She said she wondered why the coffee was not hot like usual, but had asked for it to be warmed up and it was made hotter for her. On 5/27/16 at 1:47 p.m. an interview was conducted with the DON about any new interventions put in place. The DON said, in the kitchen, all kitchen personal were in-serviced on who can get hot liquids and which residents needed to be supervised. The coffee is cooled with ice, cold water, or just by waiting a little longer before giving it to the residents. All coffee at this time is temped prior to taking it to a resident. The facility staff had all been reeducated on the immediacy of reacting to any hot liquid spill and what to do. All residents were reassessed and individual care plans were reviewed to prevent this from happening again. After reading the staff interview statements, the DON said there could have been a communication problem between the staff. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION FOR 1 (#1) COGNITIVELY IMPAIRED RESIDENT, WHO HAD BEEN IDENTIFIED AS AN ELOPEMENT RISK, OF 4 SAMPLED RESIDENTS IDENTIFIED WITH WANDERING BEHAVIORS, FROM THE TOTAL FACILITY POPULATION OF 19. THE FACILITY'S DEFICIENT PRACTICE RESULTED IN RESIDENT #1 ELOPING FROM THE FACILITY, IN THE WINTER TIME, PLACING HIM IN IMMEDIATE JEOPARDY TO HIS HEALTH AND SAFETY. FINDINGS INCLUDE: THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 12/13/11 AT 12 P.M. THE IMMEDIATE JEOPARDY BEGAN ON 12/12/11 AT APPROXIMATELY 2 P.M., WHEN RESIDENT #1 EFFECTIVELY LEFT THE FACILITY THROUGH AN EXIT DOOR, ON A COLD DAY. ACCORDING TO WWW.W(WEATHER)UNDERGROUND.COM, THE AREA TEMPERATURE ON 12/12/11 AT APPROXIMATELY 3 P.M., WAS RECORDED AS 46 DEGREES FARENHEIT WITH A WIND CHILL OF 42.5 DEGREES FARENHEIT. THE RESIDENT (#1) WAS RETURNED TO THE FACILITY AT APPROXIMATELY 3 P.M., "SHIVERING FROM THE COLD", BY A PERSON WHO HAD FOUND RESIDENT #1 SITTING BY A POND OF WATER ON THE PROPERTY ADJACENT TO THE FACILITY. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 12/13/11 AT 2 P.M. ON 12/13/11 AT 4 P.M., THE IMMEDIATELY JEOPARDY WAS REMOVED WHEN THIS SURVEYOR VERIFIED THE FOLLOWING: - ON 12/13/11 FROM 9:40 A.M. TO APPROXIMATELY 9:55 A.M., THE ADMINISTRATOR AND THIS SURVEYOR OBSERVED THE FOUR EXIT DOORS AND DETERMINED DOORS WERE SECURED BY A PUSH BUTTON ENTRY SYSTEM WHICH WOULD DISENGAGE THE LOCKED DOOR FOR ENTRY INTO THE FACILITY AND THE KEY PAD SYSTEMS ON THE INSIDE WALL, ALLOWING EXIT ONLY BY ENTERING THE KEY PAD CODE BEFORE THE LOCKED DOOR WOULD RELEASE. IT WAS DETERMINED THE KEY PAD CODE SYSTEM WOULD RELEASE IF FIRE ALARMS WERE ACTIVATED. THE EXIT DOOR OBSERVATIONS ALSO DETERMINED ONLY THE FRONT EXIT DOOR AND THE WEST EXIT DOOR WERE USED BY INDIVIDUALS TO EXIT THE FACILITY AND LEAVE THE GROUNDS. AT THE NORTH EXIT AND SOUTH EXIT DOORS, THE FACILITY GROUNDS WERE FENCED WITH A SECURED GATE. - THE ADMINISTRATOR AND/OR DON MET WITH ALL STAFF ON DUTY IMMEDIATELY AFTER THE INCIDENT AND ALL ADDITIONAL STAFF AS THEY CAME ON DUTY. THEY INFORMED STAFF OF THE FACILITY'S NEW INTERVENTIONS REGARDING THE EXIT SEEKING RESIDENTS AND ADDITIONAL SECUREMENT METHODS TO BE USED WITH THE TWO EXIT DOORS. THIS WAS VERIFIED THROUGH PHONE OR DIRECT INTERVIEWS WITH THE STAFF THAT WORKED AFTER 3 P.M. ON 12/12/11 AND ALL ADDITIONAL DIRECT CARE STAFF WHO WORKED 12/13/11 ON THE FIRST AND SECOND SHIFTS. - AFTER THE INCIDENT, THE TWO EXIT DOORS WERE IMMEDIATELY VISUALLY MONITORED AT ALL TIMES BY STAFF. THIS INTERVENTION WAS VERIFIED BY OBSERVATIONS ON 12/13/11 AT 9 A.M., 9:30 A.M. 10:45 A.M., 1:20 P.M. AND 3:45 P.M. - THE TWO RESIDENTS (#1 AND #2) IDENTIFIED AS HAVING EXIT SEEKING BEHAVIORS RECEIVED ONE-ON-ONE SUPERVISION AFTER THE INCIDENT. THE SUPERVISION WILL CONTINUE UNTIL THE NEW EXIT DOOR ALARM SYSTEM IS IN PLACE. DURING THE NIGHT SHIFT, SENSOR ALARMS ARE PLACED ON THEIR BEDS AND IF THE RESIDENTS RISE FROM THEIR BEDS, ONE-ON-ONE SUPERVISION WILL BE INITIATED OR THE RESIDENT WILL BE REDIRECTED BACK TO BED. RESIDENTS #1 AND #2 WERE OBSERVED HAVING ONE-ON-ONE SUPERVISION ON 12/13/11, IN THE DAY ROOM AT 9:20 A.M. AND 1:20 P.M., IN THE RESIDENT HALL AT 10:45 A.M. AND SITTING IN THE RESIDENT LOUNGE AREA AT 3:45 P.M. - UNTIL THE NEW EXIT DOOR ALARM SYSTEM IS IN PLACE, THE EXIT DOOR KEY PAD CODES WERE CHANGED AND STAFF WILL ENTER CODES FOR VISITORS AND DELIVERY PERSONNEL. STAFF WERE REMINDED OF THE INTERVENTION ALREADY IN EXISTENCE MAKING SURE THE EXIT DOORS ARE SECURE AS THEY EXIT THE FACILITY AND A RESIDENT IS NOT BEHIND THEM READY TO EXIT. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT AN ISOLATED LEVEL, WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM, DUE TO: - AWAITING COMPLETION OF REASSESSMENTS OF ALL RESIDENTS AND ANY NEEDED CARE PLAN ADJUSTMENTS REGARDING WANDERING/EXIT SEEKING BEHAVIORS. - AWAITING THE INSTALLMENT OF THE WANDERGUARD DOOR ALARM SYSTEM, DEMONSTRATION OF ITS USE AND DOCUMENTATION ALL STAFF HAVE BEEN TRAINED ON THE NEW SYSTEM. - AWAITING MANAGEMENT REVIEW OF THE FACILITY'S ELOPEMENT POLICY AND TRAINING OR RETRAINING OF ALL STAFF ON THE POLICY. - ALTHOUGH AN 11/17/11 ELOPEMENT DRILL WAS PERFORMED WITH SOME OF THE STAFF, DOCUMENTATION IS NEEDED TO SHOW ALL ADDITIONAL STAFF PARTICIPATED IN AN ELOPEMENT DRILL. FINDINGS INCLUDE: AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSING (DON) ON 12/13/11 AT 9:15 A.M. SHE EXPLAINED HER INITIAL INVESTIGATION DETERMINED RESIDENT #1, AN IDENTIFIED EXIT SEEKING RESIDENT, WAS LAST SEEN IN THE FACILITY ON 12/12/11 AT APPROXIMATELY 2:05 P.M. BY ACTIVITY STAFF "A". THE DON SAID, RESIDENT #1 WAS RETURNED TO THE FACILITY AT APPROXIMATELY 3 P.M., AFTER BEING FOUND BY A PERSON WHO SAW RESIDENT #1 SITTING BY A POND OF WATER. SHE STATED RESIDENT #1 RETURNED "SHIVERING FROM THE COLD" AND HAVING A TEMPERATURE APPROXIMATELY TWO DEGREES LOWER THAN HIS NORMAL 97.5 DEGREES. THE DON EXPLAINED RESIDENT #1 WAS THEN PUT TO BED AND WRAPPED IN WARM BLANKETS AND OBSERVED UP AND AROUND "WITHIN THE HOUR" LAUGHING AND BEING HIMSELF. WHEN ASKED IF THE FACILITY'S INITIAL INVESTIGATION DETERMINED HOW RESIDENT #1 LEFT THE FACILITY WITHOUT STAFF AWARENESS, SHE STATED, "WE BELIEVE HE FOLLOWED A VISITOR OR DELIVERY PERSON OUT THE DOOR...HE CAN BE VERY QUICK...IT WAS SHIFT CHANGE, STAFF WERE PASSING INFORMATION AND LOST TRACK OF HIM..." THE DON ALSO SAID RESIDENT #1 COULD BE MISTAKEN AS A VISITOR BECAUSE "...HE WALKS VERY WELL AND SOMETIMES DOESN'T LOOK LIKE HE'S CONFUSED..." RESIDENT #1'S CLINICAL RECORD WAS REVIEWED. THE 12/12/11 NURSES NOTES VERIFIED THE INFORMATION GIVEN BY THE DON DURING THE INTERVIEW ON 12/13/11 AT 9:15 A.M. RESIDENT #1'S FACE SHEET DOCUMENTED HE IS [AGE] years OLD AND admitted INto the facility on [DATE]. HIS [DIAGNOSES REDACTED]. HIS 10/29/11 MINIMUM DATA SET (MDS) ASSESSMENT AND 11/07/11 CARE PLAN DOCUMENT HE HAS had a history of [REDACTED]. THE MDS AND CARE PLAN SHOW HE RARELY UNDERSTANDS WHAT IS SAID TO HIM, HAS DISORGANIZED THINKING AND HAS LONG AND SHORT TERM MEMORY PROBLEMS. PER THE MDS, RESIDENT #1 IS INDEPENDENT WITH AMBULATION. THE CARE PLAN DOCUMENTS, "MONITOR WANDERING BEHAVIOR THROUGHOUT YOUR SHIFT...MONITOR ACTIVITY AROUND EXIT DOORS...TAKE CAUTION FOR ANY VERBALIZATION ABOUT LEAVING THE BUILDING...MUST BE DIRECTLY SUPERVISED BY STAFF IF OUTSIDE THE BUILDING (LIKES TO TAKE WALKS)." ON 12/13/11 AT 10:30 A.M., RESIDENT #1 WAS OBSERVED SITTING IN THE DAY ROOM IN A ROCKING CHAIR, WITH A STUFFED DOG ON HIS LAP. ACTIVITY PERSON "A" WAS SITTING CUTTING COUPONS WITH RESIDENT #2, ANOTHER EXIT SEEKING RESIDENT. RESIDENT #1 SMILED AND SAID HELLO TO THIS SURVEYOR. INTERVIEWS WERE CONDUCTED WITH ACTIVITY AIDE "A", LICENSED PRACTICAL NURSE (LPN) "B", CERTIFIED NURSE AIDE (CNA) "C", CNA "D", LPN "E", CNA "F" AND CNA "G" AT 10:35 A.M., 11 A.M., 11:12 A.M., 1 P.M., 5 P.M., 5:15 P.M. AND 5:30 P.M. RESPECTIVELY. THEY ALL STATED THEY WERE AWARE OF RESIDENT #1'S ELOPEMENT AND THE DIRECTIVES GIVEN BY THE DON IMMEDIATELY AFTER HIS RETURN TO THE FACILITY. THE ACTIVITY AIDE "A" STATED SHE WAS THE STAFF PERSON WHO THE DON BELIEVES WAS THE LAST ONE TO SEE RESIDENT #1 PRIOR TO THE ELOPEMENT. SHE EXPLAINED SHE WAS WITH HIM IN THE DAY ROOM, "MOST OF THE DAY..." ACTIVITY AIDE "A" SAID SHE WAS WITH RESIDENT #1 UNTIL ABOUT 2:05 P.M., EXPLAINING SHE HAD TO LEAVE THE DAY ROOM TO ASSIST ANOTHER "ACTING OUT RESIDENT". LPN "B", CNA "D" AND CNA "C" STATED THEY SAW RESIDENT #1 WANDERING THE TWO FACILITY HALLS "AS USUAL". THEY STATED HE WAS EASILY REDIRECTED AND MADE NO ATTEMPTS TO LEAVE THROUGH THE EXIT DOORS. DURING THE INTERVIEW WITH LPN "E" AND CNA "G", THEY EXPLAINED THEY WERE THE STAFF THAT ASSISTED RESIDENT #1 UPON HIS RETURN TO THE FACILITY. LPN "E" SAID THE INFORMATION IN THE 12/12/11 NURSES NOTE WAS CORRECT AND RESIDENT #1'S VITAL SIGNS WERE WITHIN HIS NORMAL LIMITS WITH HIS BODY TEMPERATURE RETURNING FROM 95.5 TO RESIDENT #1'S NORMAL OF 97.5 BOTH STAFF SAID "WITHIN A FEW MINUTES", RESIDENT #1 STOPPED SHIVERING, SMILED AND "WAS HIMSELF". AN INTERVIEW WAS HELD WITH THE ADMINISTRATOR ON 12/13/11 AT 4 P.M. HE STATED, HE HAS OBSERVED RESIDENT #1'S ABILITY TO WALK QUICKLY WHEN HE, RESIDENT #1, WANTED TO. THE ADMINISTRATOR SAID, HE "THINKS" RESIDENT #1 FOLLOWED A VISITOR OR DELIVERY PERSON OUT THE DOOR WITHOUT THEM REALIZING HE WAS BEHIND THEM. HE TOO STATED, RESIDENT #1 COULD BE MISTAKEN AS A VISITOR. ( )