Every finding on record at Medilodge of Capital Area

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 115 residents who consume food products, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:On 06/23/2026 at 8:55 A.M., an initial tour of the food service was conducted with Account Manager (AM) J and Regional Registered Dietician (RRD) K. The following items were noted:The one-door reach-in cooler was observed without any interior racks or mounting clips to support racks for food storage.The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened.On 06/23/2026 at 9:21 A.M., an interview was conducted with (AM) J regarding the availability and location of the original interior storage racks. (AM) J stated: The racks are in my office.On 06/23/2026 at 9:50 A.M., the commercial toaster air inlet grill plate was observed heavily soiled with accumulated and encrusted dust/dirt deposits. (AM) J stated: I will place the toaster into (Electronic Maintenance Work Order System Name). (AM) J additionally stated: The toaster is cleaned daily. (AM) J further stated: I have never cleaned that part of the toaster.The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 06/23/2026 at 10:05 A.M., the janitor closet vinyl tile flooring surface was observed stained/soiled with accumulated and encrusted dust/dirt deposits. The vinyl flooring surface was additionally observed (etched, chipped, particulate). The metal entrance door frame edge between the door and door jamb was also observed heavily soiled with accumulated and encrusted dust/dirt deposits. The mop sink basin was further observed soiled with accumulated and encrusted dust, dirt, and corrosion deposits. The ceiling mounted return air exhaust ventilation grill was additionally observed soiled with accumulated and encrusted dust/dirt deposits.The 2022 FDA Model Food Code section 4-602.13 states: NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues.The 2022 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair.The 2022 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing.On 06/25/2026 at 9:30 A.M., record review of the Policy/Procedure entitled: Environment dated 06/2025 revealed under Policy Statement: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Record review of the Policy/Procedure entitled: Environment dated 06/2025 further revealed under Procedures: (1) The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 115 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:On 06/23/2026 at 2:14 P.M., an environmental tour of the facility Laundry Service was conducted with Account Manager (AM) M. The following items were noted:Clean Laundry Room:One of two commercial washing machines was observed non-functional. Laundry Aide O was queried: How long has the washing machine been down? Laundry Aide O stated: Two months at least. Laundry Aide O also stated: The machine was not working right, and we could only get three loads washed a day. (AM) M stated: The facility has purchased a new machine, and we are awaiting the install.The hand sink aerator was observed partially obstructed with mineral (lime and calcium) deposits restricting the water supply pressure.Four of four overhead clear protective light lens covers were observed heavily soiled with accumulated and encrusted dust/dirt deposits.Soiled Laundry Room:One of one overhead clear protective light lens covers was observed heavily soiled with accumulated and encrusted dust/dirt deposits.Two 6-inch-wide by 12-inch-long vinyl flooring tiles were observed missing, adjacent to the soiled laundry room entrance door. (AM) M stated: I will place a work order into (Electronic Maintenance Software System).Four commercial laundry carts and two large gray plastic bins were observed completely full and overflowing with soiled facility laundry. The soiled laundry was also observed to be mounded along one wall approximately 12-inches from the ceiling surface. (AM) M stated: The soiled laundry is backed up because we only have one washer.On 06/23/2026 at 3:17 P.M., an interview was conducted with Nursing Home Administrator (NHA) A regarding the failed commercial washing machine. (NHA) A stated: The new machine has been purchased, and the vendor has indicated the machine will be installed this week.On 06/23/2026 at 3:23 P.M., an interview was conducted with Director of Maintenance N regarding the failed commercial washing machine. (DM) N stated: The new machine will be installed tomorrow morning (6/24/26).On 06/24/2026 at 8:45 A.M., the contractual vendor was observed onsite dismantling and removing the failed commercial washing machine. The new commercial washing machine was scheduled to be installed once the old machine had been removed.On 06/24/2026 at 9:00 A.M., a common area environmental tour was conducted with Director of Maintenance (DM) N. The following items were observed during the tour.100 Hall (Memory Care Unit)Dining Room: The hand sink hot water supply faucet was observed leaking. (DM) N stated: I will have to replace the cartridge.Spa: 2 of 4 overhead light assemblies were observed non-functional. The over sink light assembly was also observed non-functional.500 HallActivity Room: The oscillating wall mounted fan was observed soiled with accumulated and encrusted dust/dirt deposits.On 06/25/2026 at 10:00 A.M., record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 3/12/2022 revealed under Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.On 06/25/2026 at 10:15 A.M., record review of the Policy/Procedure entitled: Routine Cleaning and Disinfection dated 2/1/2022 revealed under Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment, and to prevent the development and transmission of infections to the extent possible.On 06/25/2026 at 10:30 A.M., record review of the Electronic Maintenance Software System Work Orders for the last 90 days revealed no specific entries related to the aforementioned maintenance issues.

This citation pertains to intakes: 2969859, 2990774, 2999197, 2999242 Based on observation, interview and record review, the facility failed to protect and prevent abuse in four residents (R12, R34, R95, R101) of four residents reviewed for abuse and six residents (R12, R34, R61, R68, R95, R101) of six residents reported from facility reported incidents. Findings Include: Resident #12 (R12): Per the facility's face sheet R12 was admitted to the facility on [DATE] and re-admitted on [DATE]. Diagnoses included depression and anxiety. Review of a Brief Interview of Mental Status (BIMS) score dated 5/5/2026 revealed R12 scored a 15 out of 15 which indicated full mental cognition. Review of a facility reported incident (FRI), dated 4/11/2026, revealed Licensed Practical Nurse (LPN) II was witnessed by LPN JJ, Certified Nurse Aid (CNA) KK, CNA LL stating to R12 that she was going to mark all her medications as refused after having an argument with her about the medications she was receiving. The FRI revealed that LPN II was suspended from work on 4/11/2026. The facility performed a five-day investigation, dated 4/20/2026, which resulted in an interview with LPN JJ who stated that she heard LPN II state to R12 that she would not give R12 anymore medication. Another interview documented on the five-day with CNA KK revealed CNA KK heard R12 tell LPN II that the pill she was giving her was the wrong pill. Then R12 started to yell at LPN KK, and LPN KK started to argue loudly with R12. Then CNA KK heard LPN II state to R12, as she was walking away, that she was R12's nurse tomorrow and she was going to mark refused on all of R12's medications including her heart medication. The five-day investigation revealed an interview with CNA LL who stated that she heard LPN II state to R12 that she would not be giving R12 her medications for the rest of the day and was speaking loudly to R12. The five-day investigation revealed an interview with LPN II who stated that R12 told her she had given her the wrong medication, and R12 told LPN II she would not take any medication from her, so LPN II told R12 fine I will just mark them refused. In an interview on 6/26/2026 at 9:30 AM, LPN JJ stated that she witnessed R12 by the nurse's cart, and R12 asked her to verify if the pill in her hand was Tylenol. LPN JJ said she got another Tylenol and compared it. LPN JJ said it looked like maybe a Colace, then R12 said to LPN II I told you that was not the right pill. LPN JJ said LPN II then started pointing down at R12, who was sitting in her wheelchair, and raised her voice at her. LPN JJ said she could not recall what LPN II said, but she did recall LPN II saying to R12 that she was not getting any more meds from her today. In an interview on 06/26/2026 at 9:53 AM, CNA KK said LPN II went to give R12 her pills and R12 told LPN II it was the wrong pill. CNA KK said then she witnessed LPN II point her finger at R12 and yelled at her telling her that she did not give her the wrong pill. CNA KK said R12 said yes, you did, and LPN II kept yelling at R12 all the way down the hall and there were other residents present. CNA KK said LPN II told R12 that she was going to be her nurse tomorrow and she was going to put in that R12 refused all her FXXXXXX medications. CNA KK said that the incident went on for about 15-20 minutes. In an interview on 06/26/2026 at 9:15 AM, R12 stated that she recalled the incident. R12 said LPN II would not give her medications to her. R12 said LPN II never did give her medications to her, and after LPN II left her room, she never saw her again. R12 said LPN II was very mean to her. Review of LPN II's employee record revealed LPN II was terminated on 4/14/2026 because of the incident. The facility substantiated that verbal abuse occurred as documented in the facility's five-day investigation. Resident #61 (R61) Review of the medical record revealed R61 was admitted to the facility 04/03/2025 with diagnoses that included Dementia, Degeneration of Nervous System, Mood Disorders, Anxiety and Alcohol Dependence with Alcohol Induced Persisting Dementia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/31/2026, revealed R61 had a Brief Interview for Mental Status (BIMS) of 00 (severe cognitive impairment) out of 15. Resident #101 (R101) Review of the medical record revealed R101 was admitted to the facility 08/04/2025 with diagnoses that included mild neurocognitive disorder due to known physiological condition with behavior disturbance, adjustment disorder, vascular dementia, PTSD, and major depressive disorder. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/31/2026, revealed R101 had a Brief Interview for Mental Status (BIMS) of 04 (severe cognitive impairment) out of 15. Resident #95 (R95) Review of the medical record revealed R95 was admitted to the facility 07/10/2025 with diagnoses that included post procedural hemorrhage of skin and subcutaneous tissue following other procedure, mild neurocognitive disorder due to known physiological condition without behavioral disturbance, generalized anxiety disorder, major depressive disorder. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/16/2026, revealed R95 had a Brief Interview for Mental Status (BIMS) of 03 (severe cognitive impairment) out of 15. Resident #61 and Resident #101 Review of MI-FRI (Michigan Facility Reported Incident) #00064236 revealed R61 came out of main dining room after eating on the night of 04/10/2026. R61 walked into the day room and made contact with his right hand to R101's face. When R61 was asked what happened and then stated, what do I do? When R101 was asked what happened, R101 stated get him away from me! Staff immediately separated the residents and R61 was taken back to his room and a 1:1 staff supervision. According to the 24-hour MI-FRI report the incident occurred on 04/10/2026 at 6:15 p.m. Review of the facility 5-day investigation summary revealed the conclusion: The facility acknowledges that physical incident occurred. Review of the facility incident report revealed R101 did not have any physical injury, and pain scale was reported at 0 (no pain). During an interview on 06/23/2026 at 2:53 PM, Writer asked R101 about the incident when another resident (R61) slapped him across the face/jawline, R101 stated R61 isn't watched well enough or he would not do these things. Writer asked him if he had any additional interactions with R61 and he stated no, told them to keep him away from him. During an interview on 06/26/2026 at 1:07 PM, Nursing Home Administrator (NHA) A and Director of Nursing (DON) B Stated LPN BB notified her/ NHA A that R61 went into the TV room and made contact with R101. NHA A stated LPN BB separated the residents, skin assessment for both residents, placed R61 on a 1 to 1, notified the provider, skin assessments for R101 and R61 were completed, reported to the state, before moving R61 to 200 hall, and received no special supervision. During an interview on 06/26/2026 at 1:16 PM, LPN BB stated towards the ends of the evening, she went to get supplies and stopped at the nursing station and saw R61 punched R101 in the face. R101 tried to hit him back but didn't make contact. Certified Nursing Assistants (CNA's) separated the two residents, LPN BB called LHNA A and DON B along with the provider, she filled out a resident-to-resident incident report. R61 was then placed on a 1 to 1 staff supervision. During an observation and interview on 06/26/2026 at 2:23 PM, R101 stated he didn't remember if R61 had caused any issues with him or not. R101 was sitting in the activity room watching bird houses being made. Record review of progress notes revealed R61 was initially admitted to this facility on 04-03-2025 for long-term care due to requiring 24-hour assistance with Activities of Daily Living (ADL's) skilled nursing care, and medication management. Social Work requested evaluation to assess for increased symptoms of his ongoing anxiety, restlessness, and agitation related to dementia. R61 had an increase in physical aggression towards staff and his 1:1staff supervision, which is ongoing for safety. R61 was currently managed by Zoloft, Namenda, and Seroquel. Resident was evaluated while lying in his bed in his room with a 1:1 for safety. R61 continued to have restlessness and would wander the halls of the facility frequently. He had exhibited increased physical aggression towards staff with 10 episodes noted in the past 14 days. Cognitive Screening: Brief Interview of Mental Status (BIMS) score remains 0 of 15. R61 was alert and oriented x1 (self only). Baseline confusion with impaired impulse control and memory. Responds with minimal verbal responses, mainly head nods and occasionally answered with yes or no; when asked questions, shakes head and states I don't know.Safety Screening: Patient denies suicidal ideation. Patient denies homicidal ideation. Currently on 1:1 for safety due to episodes of physical aggression towards staff and peers. 10 episodes of physical aggression noted in past 14 days. R61 had become a danger to himself and others with multiple episodes of physical aggression. Resident #61 and Resident #95 Review of MI-FRI (Michigan Facility Reported Incident) #00064000 revealed resident to resident incident took place between R61 and R95 on 03/20/26, reported to the state on 03/20/26, 5 day follow up to the state on 03/30/26. According to the 24-hour MI-FRI report the incident occurred on 03/20/2026 at 12:20 p.m. Incident report revealed that staff heard yelling coming from a resident's room. Staff went into the resident's room and saw 95 holding R61 by arms. Staff separated residents. When asked by the nurse if he/R61 was hit by R95 stated, yes. R95 stated I was taking my trash to the cart and the weird guy hit me in the head with his walker. I did not hit him. He is always messing with me, and I do not like him. Staff interviews: LPN CC stated she was at the desk when CNA DD yelled that she needed help. RN EE and LPN CC went down to assess the situation. CNA DD had the residents separated. R95 stated he was going to hurt R61. LPN CC did not see R95 hit R61 LPN CC asked R61 if R95 hit him and he said, Yes. CNA DD was passing the dinner trays and was assisting a resident with dinner. CNA DD heard R95 yelling and cussing and went out and saw R95 holding R61by the arms. CNA DD attempted to separate them and yelled for help. After separating R95 from R61, R61 lifted his walker straight up with it pointed at R95. R95 grabbed a hold of the walker by the wheels. CNA DD had to keep re-directing R61 away from R95. LPN CC asked R61 if he got hit and he said, Yes. R61 had a lump forming on his forehead and red marks above his eyebrows. R95 said that he was trying to put his tray in the cart when R61 came out and pushed him. RN EE heard CNA DD yell that she needed help. When she got there, CNA DD had the residents separated. R61 tried to flip R95 off. R95 stated he was going to beat R61's butt. According to the 24-hour MI-FRI report the incident occurred on 03/20/2026 at 6:33 p.m. Review of the facility 5-day investigation summary revealed the conclusion: The facility investigation concluded that while there were not independent witnesses, the event between the two residents occurred resulting in injury. Skin Assessment V4- dated 03/25/26, no documentation of lump on his forehead or red above his eyebrows on R61.During an interview on 06/26/2026 at10:02 AM, LPN CC stated she was here during that particular incident, R61 has had multitude incidents, puts his hands into fist like he was going to punch someone. Stated R95 had walked past his room, R61 started to go after him, by the time she ran down R95 was in R61's doorway, R61 went out and hit/punch R95 in the chest. R61 was on the 100 hall, with him using his walker, if people were in his way, he would push through them and had falls. LPN CC stated other residents were falling because he push his way through. Stated she remember R95 telling R61 that I am fucking going to hit you. R61 can only say good, not good, hell, damn, doesn't remember his ever saying anything more than 1 word. R95 was moved to another room.During an interview on 06/26/2026 at10:29 AM, DON B and NHA A were together in NHA A office together. NHA A stated she was notified by LPN CC who stated R61 had a lump on his forehead from R95 in a resident-to-resident incident. Placed R95 on a 1 to 1 supervision, neuro checks and R61 on 15min checks. LPN CC called provider and sent R61 out to hospital for evaluation of the lump on his forehead and marks above his right eyebrow. DON B stated she was going to educate nurses to do assessments, open a new pain or skin assessment, they have to pull it over, does not show available without pulling it over. Stated put R95 on 1 on 1supervision, R65 on15 mins checks. Since R95 hit R61 and it was after the fact that R95 had a hold of R61's arm. R95 was on 1 on 1 from 03/20/26 to 04/16/26. R61 went 1 on 1 supervision on 05/10/26. DON B stated R61 was being aggressive with staff, so they started ongoing 1 on 1. DON B stated R61 and another gentleman had an altercation on the TV room. R61, moved to 200 hall, and had issues getting along with people in there, and they thought he could have more space to wander and burn off energy. DON B stated 100 hall to 300 hall R61 walked through the bathroom, and someone was using it and they were upset that R61 walked in on them. Resident #34 (R34) Review of the medical record revealed R34 was admitted to the facility on [DATE] with diagnosis that included Alzheimer's Disease, type 2 diabetes, hypertension, hyerlipidemia, stage 3 kidney disease, benign prostatic hyperplasis, atrial fibrillation, depression, dementia, osteoarthritis of right knee, and bilateral hearing loss. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04-18-2026, revealed R34 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. Resident #68 (R68) Review of the medical record revealed R68 was admitted to the facility 09/02/2025 with diagnoses that included stroke, hypertension, antiphospholipid syndrome (an autoimmune disorder that causes your immune system to produce abnormal antibodies), receptive-expressive language disorder (neurological condition that impairs your ability to understand or speak language), explosive disorder (mental health condition characterized by frequent, sudden outburst of impulsive anger or aggression), aphasia (difficulty swallowing), delusional order (mental illness where a person has fixed, false believed that are not rooted in reality), and anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/08/2026, revealed R68 had a Brief Interview for Mental Status (BIMS) of 11 (moderate cognitive impairment) out of 15. R68 was discharged from the facility 06/26/2026. Review of MI-FRI (Michigan Facility Reported Incident) #00063798 revealed R34 was in the main dining room eating his lunch in the back of the dining room. R68 was observed to approach R34. R68 was observed to close his fist and punch R34 under the right eye. Staff immediately separated the residents and R68 was taken back to his room and a 1:1 staff member was provided to R68. According to the 24 hour MI-FRI report the incident occurred on 03/05/2026 at 12:20 p.m. Review of the facility 5 day investigation summary revealed the conclusion: The facility acknowledges that physical incident occurred. Review of the facility summary revealed that the physical altercation between R34 and R68 had been witness by Certified Nurse Aide (CNA) P. Review of the facility incident report revealed R34 did not have any physical injury and pain scale was reported at 0 (no pain). During an interview on 06/25/2026 at 02:12 p.m. Nursing Home Administrator (NHA) A explained that a physical altercation had been witnessed between R34 and R68. NHA A explained that the R68 had been observed to punch R34 under his right eye. NHA A explained that she had concluded that the altercation had occurred but explained she had not substantiated abuse. When asked if punching someone would be defined as physical abuse NHA replied yes. NHA A could not explain why the altercation between R34 and R68 had not been substantiated as physical abuse. During an interview on 06/25/2026 at 02:20 p.m. Certified Nursing Aide (CNA) P explained that she had been passing lunch trays in the dining room on 03/05/2026. CNA P explained that while she was passing trays she had observed R68 pacing back and forth near R34. CNA P explained that she then witnessed R68 make a fist and cold cocked R34 in his face. CNA P was asked what cold cock meant and she explained that R68 punched R34 in the face and R34 had not seen it coming. CNA P explained that she yelled for R68 to stop and ran over and separated the residents. CNA P explained that R34 had made allegations that R68 had been stealing his cloths. CNA P explained that she had reported the allegation to NHA A prior to this altercation. During observation and interview on 06/26/2026 at 08:46 a.m. R34 was observed sitting up on the side of his bed. R34 was asked if he remembered an incident that occurred with another resident? R34 explained that the person who was stealing his clothes had just come up to him and punched him right under his right eye. R34 explained that the punch caused him pain. R34 explained that his pain level was a 10 (scale 1-10 :1 being least and 10 being most) at the time. R34 kept saying that he had told the facility staff that R68 had been stealing his clothes.

Based on interview and record review, the facility failed to develop and maintain a Quality Assistance and Process Improvement (QAPI) program which identified and prioritized quality deficiencies, systematically analyzed the underlying causes, and implemented effective corrective action or performance improvement activities to remedy those deficiencies. Findings Included:On 06/26/2026 at 02:07 p.m. an interview was conducted with Nursing Home Administrator (NHA) A regarding concerns identified during the current Recertification Survey. NHA A' explained that during the last year the QAPI committee had identified areas of concerns for Performance Improvement Plans (PIPS). NHA A explained that items are identified through Minimum Data Set (MDS) indicators, quality measures, return to hospitals, surveys for the month, risk management, trigger events (such as Facility Reported Incidents) and resident complaints. NHA A explained that PIPs are determined by the QAPI team and are monitored for compliance. NHA A explained that those PIPs are determined to be active until substantial compliance has been determined through monitoring. NHA A explained that the period of compliance was usually 6 months.NHA A was asked if the committee had identified that the facility had a pattern of abuse allegations involving resident to resident altercations? NHA A said that the committee had not identified resident to resident abuse as an area for a Performance Improvement Project. The abuse allegations that the survey team identified as area of concern during the current Recertification Survey, was discussed. NHA A could not explain why the committee had not identified a pattern of resident-to-resident altercations or why the committee had not sanctioned a PIP regarding the issue. NHA A explained that in hindsight a PIP should have been implemented regarding the pattern of resident-to-resident altercations. NHA A also explained that a root cause analysis had not been conducted to determine the cause of repeated resident to resident altercations.Review of facility policy entitled QAPI Plan, dated 10/24/2022 and last reviewed/revised 10/24/22, revealed, Purpose: . The goal is to create a process that ensures care and services delivered meet accepted standards of quality. The same policy lists key components:1. Tracking and measuring performance.2. Establishing goals and thresholds for performance improvements.3. Identifying and prioritizing quality deficiencies.4. Systematically analyzing underlying causes of systemic quality deficiencies.5. Developing and implementing corrective action or performance improvement. activities.6. Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revisiting as needed.

Based on observation, interview and record review, the facility failed to ensure two witness signatures were obtained when the Responsible Party signed a do-not-resuscitate (DNR) document for one (R100) of one reviewed. Findings include: Review of the medical record reflected R100 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cerebral atherosclerosis, Alzheimer's and unspecified dementia. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/31/26, reflected R100 scored zero out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). According to the medical record, R100 had a Guardian in place. On 06/24/2026 at 12:38 PM, R100 was observed seated in a standard chair, at the nurse's station, with a lunch tray in front of them. A staff member was seated across from R100, offering cueing with the meal. A DNR document reflected R100's Responsible Party signed the document on 10/14/24. The Physician signature was dated 10/15/24. Two witness signatures were dated 10/16/24. In an interview on 06/24/2026 at 12:46 PM, Social Service Assistant (SSA) E reported the process for completing a DNR document included obtaining witness signatures from two individuals that witnessed the signing of the document by the resident or their Responsible Party. SSA E was unsure of the reason the witness signatures on R100's DNR form were dated after the signature of the Responsible Party.

Based on observation, interview, and record review, the facility failed to ensure each resident's health information was kept private for one (R24) of one reviewed.Findings include:A review of the clinical record revealed R24 was admitted into the facility on [DATE] with diagnoses that included: cerebral infarction (stroke), hemiplegia (a form of paralysis that affects only one side of the body) and hemiparesis (partial weakness, numbness or loss of motor control affecting only one side of the body). According to the Minimum Data Set (MDS) assessment dated [DATE], R24 scored 14/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).On 6/23/26 at 11:20, R24 was observed to be sitting up in her manual wheelchair. R24 reported that she overhears a lot of HIPAA violations (Health Insurance Portability and Accountability Act-federal law that protects the privacy of personal medical information). R24 stated that staff (mostly nurses) speak about residents private patient information in the hallway, sometimes too loudly or in close proximity to resident's room.On 6/25/26 at 9:57 AM, R24 reported that she had overheard private information about multiple residents and could specifically recall information current information about R49. At this time R24 reported knowing that the resident (R49) was a diabetic (confirmed via MDS assessment), that she had a sore on her toe and that she had MS (Multiple sclerosis-which was confirmed via MDS assessment).On 6/26/26 at 9:35 AM, during an interview with Director of Nursing (DON) B, it was reported that private health information should not be shared outside of the workplace and not in the hallway where other residents can overhear.

Based on observation, interview, and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for three residents (R34, R68, R107) of six reviewed.Findings include: Resident # 107 (R107) A review of the clinical record revealed R107 was admitted into the facility on 9/26/25 with diagnoses that included: Bipolar disorder, adjustment disorder with mixed disturbance of emotions and conduct and depression. According to the Minimum Data Set (MDS) assessment dated [DATE], R107 scored 6/15 on the Brief Interview for Mental Status exam (which indicated severely impaired cognition). On 6/23/26 at 1:02 PM, R107 was observed sitting on his bed in his room. R107 reported that he kissed a staff member and that staff member kissed him back. He identified the staff member as CNA (certified nursing assistant) P and reported that facility staff are aware. R107 reported being fond of CNA P. A review of R107's Progress notes revealed the following: 6/24/26 1:51 pm Behavior Displayed: Per CNA statement, resident kept stating, you know I kissed you and you kissed me and you know I'm telling the truth. Resident was asked by the CNA to stop saying that, and resident continued to repeat it. CNA reported to writer after finishing the resident's roommate's VS (vital signs). Precipitating factors/events: UNK (unknown), Intervention(s) attempted: Redirection, Intervention results: Initially successful. Redirection will need to be done again, as resident has history of this behavior. Pharmacologic Intervention required: NA, Comments: Administrator and SW (social work) notified. 6/9/26 6:03 pm (R107) is a (age redacted) male with a complex medical and psychiatric history, residing in long-term care for supervision and management of behavioral disturbances. Over the past 72 hours, he has continued to make inappropriate sexual comments towards staff, with redirection proving ineffective. A review of R107's care plan revealed the following: (initiated on 9/29/25 and revised on 6/10/26) Resident at times attempts to show affection towards staff (i.e. trying to kiss on cheek and giving hugs); making sexual or suggestive comments regarding female staff (complimenting physical appearance, stating he wants staff to be his wife, or wants to shower with staff, etc). On 6/25/26 at 2:53 PM, during an interview with CNA P, she reported that R107 had stated that he was in love with her and tried to kiss her. CNA P reported that she told him no and re-directed him when it occurred earlier in her current shift. Additionally, CNA P reported that R107 had accused her of kissing him too. CNA P stated that she reported R107's behaviors to Unit Manager (UM) HH and that to her knowledge the allegations had not been investigated. On 6/26/26 at 9:57 AM, during a follow up interview with CNA P, she reported that about 1.5 weeks ago R107 tried to kiss her on the lips and she had reported it to UM HH at that time. CNA P stated that UM HH told her to re-direct the resident and that other staff members were also aware of R107's allegations. On 6/26/26 at 11:47 AM, during an interview with UM HH, when asked if he was aware of any incidents or allegations about kissing staff involving R107, he reported that R107 likes to go around and try to kiss some of the aides (CNA's). UM HH further reported that CNA P had informed him that R107 had said she kissed him and CNA P denied the allegation. When asked what UM HH did with the information about staff being kissed or kissing R107, he reported that the facility physician had prescribed the resident a medication to help with hypersexuality. When asked if the facility administrator had been made aware, he reported that it was his understanding that she was aware. When asked if it should have been investigated as an allegation of abuse, he reported that he would assume so if the allegation was that a staff member kissed him. UM HH reported that he was made aware a month or two ago but couldn't recall the exact date. On 6/26/26 at 1:01 PM, during an interview with Nursing Home Administrator (NHA) A, she reported that staff had notified her that R107 had been attempting to kiss them, staff had updated his care plan and he had been on every 15 minute checks to ensure he didn't move on to other residents. Both NHA A and Director of Nursing B denied being aware that R107 had also reported that he had been kissed by a staff member. NHA A reported had she been made aware that R107 had alleged he had been kissed by staff an investigation would have been initiated. Interviews with staff and R107's progress notes indicated NHA A had been made aware that R107 alleged he had been kissed by a staff member, however, the allegation had not been reported or investigated. iResident #34 (R34) Review of the medical record revealed R34 was admitted to the facility 10/12/2025 with diagnoses that included Alzheimer's Disease, type 2 diabetes, hypertension, hyperlipidemia (high fat volume in blood), stage 3 kidney disease, benign prostatic hyperplasia (non-cancer enlarged prostate), atrial fibrillation, depression, dementia, osteoarthritis of right knee (joint pain caused by wearing of padding between joints), and bilateral hearing loss. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2026, revealed R34 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. Resident #68 (R68) Review of the medical record revealed R68 was admitted to the facility 09/02/2025 with diagnoses that included stroke, hypertension, antiphospholipid syndrome (an autoimmune disorder that causes your immune system to produce abnormal antibodies), receptive-expressive language disorder (neurological condition that impairs your ability to understand or speak language), explosive disorder (mental health condition characterized by frequent, sudden outburst of impulsive anger or aggression), aphasia (difficulty swallowing), delusional order (mental illness where a person has fixed, false believed that are not rooted in reality), and anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/08/2026, revealed R68 had a Brief Interview for Mental Status (BIMS) of 11 (moderate cognitive impairment) out of 15. R68 was discharged from the facility 06/26/2026. Review of MI-FRI (Michigan Facility Reported Incident) #00063798 revealed R34 was in the main dining room eating his lunch in the back of the dining room. R68 was observed to approach R34. R68 was observed to close his fist and punch R34 under the right eye. Staff immediately separated the residents and R68 was taken back to his room and a 1:1 staff member was provided to R68. Review of the facility summary revealed that the physical altercation between R34 and R68 had been witness by Certified Nurse Aide (CNA) P. During an interview on 06/25/2026 at 02:20 p.m. Certified Nursing Aide (CNA) P explained that she had been passing lunch trays in the dining room on 03/05/2026. CNA P explained that while she was passing trays she had observed R68 pacing back and forth near R34. CNA P explained that she then witnessed R68 make a fist and cold cocked R34 in his face. CNA P was asked what cold cock meant and she explained that R68 punched R34 in the face and R34 had not seen it coming. CNA P explained that she yelled for R68 to stop and ran over and separated the residents. CNA P explained that R34 had made allegations that R68 had been stealing his cloths. CNA P explained that she had reported the allegation to NHA A prior to this altercation. During an interview on 06/25/2026 at 02:31 p.m. Nursing Home Administrator (NHA) A was asked if she had been made aware of the allegation that R68 had been stealing R34's clothing. NHA A explained that she had been made aware of the allegation during the investigation regarding the physical altercation between R34 and R68 that had occurred on 3/5/2026. NHA A explained that she had investigated the allegation. NHA A denied that she received the allegation prior to the resident-to-resident altercation that had occurred on 03/05/2026. When asked if the allegation of R68 stealing R34's clothing had been reported, NHA A explained that she had not reported the allegation to the appropriate state agency. NHA A could not explain why the allegation had not been report appropriate state agency. When asked for documentation regarding the investigation of R68 stealing R34's clothing NHA explained that she had not recorded any of the investigation. During observation and interview on 06/26/2026 at 08:46 a.m. R34 was observed sitting up on the side of his bed. R34 was asked if he remembered an incident that occurred with another resident? R34 explained that the person who was stealing his clothes had just come up to him and punched him right under his right eye. R34 explained that the punch caused him pain. R34 explained that his pain level was a 10 (scale 1-10 :1 being least and 10 being most) at the time. R34 kept saying that he had told the facility staff that R68 had been stealing his clothes. During an interview on 06/26/2026 at 09:21 a.m. Licensed Practical Nurse (LPN) S explained that R34 had been calling R68 a thief. LPN S could not recall if this had occurred before or after the altercation on 03/05/2026. LPN S explained that she had reported the allegation of R68 stealing R34's clothing to NHA A.

Based on observation, interview, and record review the facility failed to adequately investigate an allegation of neglect/abuse for two resident (#34, #107) of six residents reviewed for neglect/abuse.Findings Included: R107A review of the clinical record revealed R107 was admitted into the facility on 9/26/25 with diagnoses that included: Bipolar disorder, adjustment disorder with mixed disturbance of emotions and conduct and depression. According to the Minimum Data Set (MDS) assessment dated [DATE], R107 scored 6/15 on the Brief Interview for Mental Status exam (which indicated severely impaired cognition). On 6/23/26 at 1:02 PM, R107 was observed sitting on his bed in his room. R107 reported that he kissed a staff member and that staff member kissed him back. He identified the staff member as CNA (certified nursing assistant) P and reported that facility staff are aware. R107 reported being fond of CNA P. A review of R107's Progress notes revealed the following: 6/24/26 1:51 pm Behavior Displayed: Per CNA statement, resident kept stating, you know I kissed you and you kissed me and you know I'm telling the truth. Resident was asked by the CNA to stop saying that, and resident continued to repeat it. CNA reported to writer after finishing the resident's roommate's VS (vital signs). Precipitating factors/events: UNK (unknown), Intervention(s) attempted: Redirection, Intervention results: Initially successful. Redirection will need to be done again, as resident has history of this behavior. Pharmacologic Intervention required: NA, Comments: Administrator and SW (social work) notified.6/9/26 6:03 pm (R107) is a (age redacted) male with a complex medical and psychiatric history, residing in long-term care for supervision and management of behavioral disturbances. Over the past 72 hours, he has continued to make inappropriate sexual comments towards staff, with redirection proving ineffective. A review of R107's care plan revealed the following: (initiated on 9/29/25 and revised on 6/10/26) Resident at times attempts to show affection towards staff (i.e. trying to kiss on cheek and giving hugs); making sexual or suggestive comments regarding female staff (complimenting physical appearance, stating he wants staff to be his wife, or wants to shower with staff, etc). On 6/25/26 at 2:53 PM, during an interview with CNA P, she reported that R107 had stated that he was in love with her and tried to kiss her. CNA P reported that she told him no and re-directed him when it occurred earlier in her current shift. Additionally, CNA P reported that R109 had accused her of kissing him too. CNA P stated that she reported R107's behaviors to Unit Manager (UM) HH and that to her knowledge the allegations had not been investigated. On 6/26/26 at 9:57 AM, during a follow up interview with CNA P, she reported that about 1.5 weeks ago R107 tried to kiss her on the lips and she had reported it to UM HH at that time. CNA P stated that UM HH told her to re-direct the resident and that other staff members were also aware of R107's allegations. On 6/26/26 at 11:47 AM, during an interview with UM HH, when asked if he was aware of any incidents or allegations about kissing staff involving R107, he reported that R107 likes to go around and try to kiss some of the aides (CNA's). UM HH further reported that CNA P had informed him that R107 had said she kissed him and CNA P denied the allegation. When asked what UM HH did with the information about staff being kissed or kissing R107, he reported that the facility physician had prescribed the resident a medication to help with hypersexuality. When asked if the facility administrator had been made aware, he reported that it was his understanding that she was aware. When asked if it should have been investigated as an allegation of abuse, he reported that he would assume so if the allegation was that a staff member kissed him. UM HH reported that he was made aware a month or two ago but couldn't recall the exact date. On 6/26/26 at 1:01 PM, during an interview with Nursing Home Administrator (NHA) A, she reported that staff had notified her that R107 had been attempting to kiss them, staff had updated his care plan and he had been on every 15 minute checks to ensure he didn't move on to other residents. Both NHA A and Director of Nursing B denied being aware that R107 had also reported that he had been kissed by a staff member. NHA A reported had she been made aware that R107 had alleged he had been kissed by staff an investigation would have been initiated. Interviews with staff and R107's progress notes indicate NHA A was aware that R107 alleged he had been kissed by a staff member, however, the allegation had not been investigated. Resident #34 (R34) Review of the medical record revealed R34 was admitted to the facility 10/12/2025 with diagnoses that included Alzheimer's Disease, type 2 diabetes, hypertension, hyperlipidemia (high fat volume in blood), stage 3 kidney disease, benign prostatic hyperplasia (non-cancer enlarged prostate), atrial fibrillation, depression, dementia, osteoarthritis of right knee (joint pain caused by wearing of padding between joints), and bilateral hearing loss. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2026, revealed R34 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. Resident #68 (R68) Review of the medical record revealed R68 was admitted to the facility 09/02/2025 with diagnoses that included stroke, hypertension, antiphospholipid syndrome (an autoimmune disorder that causes your immune system to produce abnormal antibodies), receptive-expressive language disorder (neurological condition that impairs your ability to understand or speak language), explosive disorder (mental health condition characterized by frequent, sudden outburst of impulsive anger or aggression), aphasia (difficulty swallowing), delusional order (mental illness where a person has fixed, false believed that are not rooted in reality), and anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/08/2026, revealed R68 had a Brief Interview for Mental Status (BIMS) of 11 (moderate cognitive impairment) out of 15. R68 was discharged from the facility 06/26/2026. Review of MI-FRI (Michigan Facility Reported Incident) #00063798 revealed R34 was in the main dining room eating his lunch in the back of the dining room. R68 was observed to approach R34. R68 was observed to close his fist and punch R34 under the right eye. Staff immediately separated the residents and R68 was taken back to his room and a 1:1 staff member was provided to R68. Review of the facility summary revealed that the physical altercation between R34 and R68 had been witness by Certified Nurse Aide (CNA) P. During an interview on 06/25/2026 at 02:20 p.m. Certified Nursing Aide (CNA) P explained that she had been passing lunch trays in the dining room on 03/05/2026. CNA P explained that while she was passing trays she had observed R68 pacing back and forth near R34. CNA P explained that she then witnessed R68 make a fist and cold cocked R34 in his face. CNA P was asked what cold cock meant and she explained that R68 punched R34 in the face and R34 had not seen it coming. CNA P explained that she yelled for R68 to stop and ran over and separated the residents. CNA P explained that R34 had made allegations that R68 had been stealing his cloths. CNA P explained that she had reported the allegation to NHA A prior to this altercation. During an interview on 06/25/2026 at 02:31 p.m. Nursing Home Administrator (NHA) A was asked if she had been made aware of the allegation that R68 had been stealing R34's clothing. NHA A explained that she had been made aware of the allegation during the investigation regarding the physical altercation between R34 and R68 that had occurred on 3/5/2026. NHA A explained that she had investigated the allegation. NHA A denied that she received the allegation prior to the resident-to-resident altercation that had occurred on 03/05/2026. When asked if the allegation of R68 stealing R34's clothing had been reported, NHA A explained that she had not reported the allegation to the appropriate state agency. NHA A could not explain why the allegation had not been report appropriate state agency. When asked for documentation regarding the investigation of R68 stealing R34's clothing NHA explained that she had not recorded any of the investigation. During observation and interview on 06/26/2026 at 08:46 a.m. R34 was observed sitting up on the side of his bed. R34 was asked if he remembered an incident that occurred with another resident? R34 explained that the person who was stealing his clothes had just come up to him and punched him right under his right eye. R34 explained that the punch caused him pain. R34 explained that his pain level was a 10 (scale 1-10 :1 being least and 10 being most) at the time. R34 kept saying that he had told the facility staff that R68 had been stealing his clothes.

Based on observation, interview and record review, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment for two (R3 and R121) of 23 reviewed. Findings include: Resident #3 (R3) Review of the medical record reflected R3 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included type 2 diabetes. The Quarterly MDS, with an Assessment Reference Date (ARD) of 4/23/26, reflected R3 received one insulin injection in the prior seven days. On 06/23/2026 at 2:15 PM, R3 was observed self-propelling their wheelchair in the hallway, using their left foot. Review of R3's April 2026 Medication Administration Record (MAR) reflected they received an injection of Trulicity (glucagon-like peptide receptor agonist/GLP-1) 1.5 milligrams (mg) per 0.5 milliliters (mL) on 4/17/26. R3's MAR did not reflect that they received insulin. In an interview on 06/24/2026 at 2:34 PM, MDS Nurse D indicated she coded Trulicity as insulin on R3's Quarterly MDS, with an ARD of 4/23/26. MDS Nurse D reported Trulicity was classified as a GLP-1 medication and not an insulin. Resident #121 (R121) Review of the medical record revealed R121 was admitted to the facility 04/08/2026 with diagnoses that included urinary tract infection (UTI), congestive heart failure (CHF), hypertension, irritable bowel syndrome (chronic disorder of the large intestine causing pain, gas, bloating, changes in bowel habits like diarrhea, constipation, or both), myocardial infarction (heart attack), anxiety, and hyperlipidemia (high fat content in blood). R121's 5-day admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/14/2026, revealed R121 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15. R121 was discharged from the facility 04/23/2026. Review of R121's discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/23/2026, revealed section A2105 was coded as 01 (discharge to home/community). Review of R121's medical record revealed a progress note dated 04/23/2026 at 11:15 a.m. which stated, Resident PT/INR (blood coagulation test) results elevated and reviewed with (name of doctor) this morning. Order to send resident to the hospital. Sent to (name of hospital). Call . emergency contact and she plan to meet the at the hospital. EMS (ambulance) transported her via stretcher. In an interview on 06/24/2026 at 02:37 p.m. Minimum Data Set (MDS) Nurse D confirmed that R121's discharge MDS, with an Assessment Reference Date (ADR) of 04/23/2026, was coded that she had returned home/to community. MDS Nurse D also confirmed that R121's progress notes, dated 04/23/2026, revealed that she was discharged to the hospital. MDS Nurse D confirmed that R121 had not returned to the facility. MDS Nurse D explained that R121's discharge MDS, with an ARD of 04/23/2026, was coded incorrectly. MDS Nurse D explained R121's MDS, with an ARD of 04/23/2026 should have been coded 04-short Term General Hospital. MDS Nurse D could not explain why R121's discharge MDS was coded inaccurately.

Based on observation, interview and record review, the facility failed to ensure accuracy of comprehensive the care plan for 1 (Resident 12) of 23 reviewed. Findings include:On 6/23/26 at 4:41 PM, R12 was observed sitting up in her manual wheelchair with oxygen on via nasal cannula. R12 reported that she is not a current smoker and has not smoked in years.A review of the clinical record revealed R12 was admitted into the facility on [DATE] with diagnoses that included: dyspnea (difficulty breathing) and cardiomegaly (enlarged heart). According to the Minimum Data Set (MDS) assessment dated [DATE], R12 scored 14/15 on the Brief Interview for Mental Status exam (which indicated intact cognition) and was coded as a non-smoker in section J1300 of the same assessment.A review of the list of current smokers provided by the facility, revealed R12 was listed as a current smoker and it indicated that she was care planned as such.A review of R12's care plan revealed she was care planned as an active smoker which was initiated on 2/20/26 and revised on 6/12/26, Resident chooses to smoke. She has been educated on facility non-smoking policy, smoking items to be kept at front desk .Goal: Resident will follow and verbalize understanding regarding the facility rules for designated smoking areas and smoking material through next review ., with multiple interventions listed.A review of R12's progress notes revealed, 6/15/26 .The patient is a former cigarette smoker who successfully quit smoking in 2021.On 6/24/26 at 11:51 AM, during an interview with CNA P, she reported that R12 is not a current cigarette smoker and had not been for approximately 2 years.On 6/26/26 at 9:32 AM, during an interview with Director of Nursing (DON) B, she confirmed that R12 is not a current smoker. DON B later reported that she had seen R12 outside but had not necessarily seen her smoking. DON B reported the change from smoker to non-smoker was recent.

Based on interview and record reviews the facility failed to include one resident (R76) out of two residents reviewed for scheduled outings with the activity group with the potential of social isolation and not living her highest practicable, physical, mental, and psycho-social wellbeing. Findings Included;Resident #76 (R76)Review of the medical record revealed R76 was admitted to the facility 02/13/2026 with diagnoses that included Dementia, heart failure, diabetes mellitus 2, anxiety, and senile degeneration of the brain. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/19/2026, revealed R76 had a Brief Interview for Mental Status (BIMS) of 03 (severe cognitive impairment) out of 15.During an observation and interview on 06/25/2026 at 11:01 AM, R76 was sitting up in the front lobby looking out the window. R76 stated she would like to go to the local store to get some cookies. R76 then stated her daughter in law is unable to take her because of her fear she will fall and not able to get the wheelchair in their car.During an interview on 06/25/2026 11:51 AM, Activity Director (AD) FF was asked if R76 had participated in any of their activity outings to the store and other locations. AD FF stated not with her and Activity Aide GG wasn't aware of any reason R76 could not go out. AD FF stated there was absolutely no reason she could not go. AD FF stated she would pair well with her old roommate; they will get that set up.During the same interview AD FF stated they go out for outings two times a month. AD FF stated the business office handles the resident's money, if the residents didn't have any money in their account, they will call the family to see if they can give the resident money for an outing. AD FF stated the residents are still allowed to go on outings even if they do not have money. During an interview on 06/25/2026 at 2:08 PM, NHA A stated R76 was offered to go on outings but didn't go. Writer asked to have that documentation, NHA A stated she called the previous Activity Director, and she told NHA A that R76 was offered but didn't go. NHA A stated they didn't have anything in writing regarding resident being offered or refusing to go on outings. Record review of the activity task sheets revealed that R76 had participated in Bingo, visits and some current events. Outings were listed on the task sheet as an option, R76 did not go on any outings since being admitted to the facility.

Based on observation, interview, and record review, the facility failed to consistently provide restorative therapy services for one (Resident 24) of one reviewed.Findings include:A review of the clinical record revealed R24 was admitted into the facility on [DATE] with diagnoses that included: cerebral infarction (stroke), hemiplegia (a form of paralysis that affects only one side of the body) and hemiparesis (partial weakness, numbness or loss of motor control affecting only one side of the body). According to the Minimum Data Set (MDS) assessment dated [DATE], R24 scored 14/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).On 6/23/26 at 11:20, R24 was observed to be sitting up in her manual wheelchair. R24 reported that she had not been receiving her restorative therapy services as often as she was supposed to. She reported that it is provided sporadically and that she had started to get a contracture in her left hand/wrist which concerned her.A review of R24's physician's orders revealed an active order for Restorative Level 2: AROM (active range of motion): BLE (bilateral lower extremities sci-fit (machine used for comprehensive activity-based therapy for individuals with paralysis due to stroke) 15 mins or as tolerated, AROM LUE (left upper extremity)-extension with prolonged hold (10 seconds) 3 x 10 reps. 3 times per week. A review of the associated Task log (where staff document completion of prescribed services) revealed that R24 did not receive the Level 2 restorative services for 9 days, during the time span of 6/17/26 through 6/25/26.On 6/26/26 at 12:34 PM, during an interview with Assistant Director of Nursing (ADON) Q, it was reported that she is responsible for overseeing the restorative therapy program, which consisted of following the charts and completing monthly notes (explained to mean audits for completion and progress). ADON Q reported that typically the facility had 2 restorative aides and one per diem staff member that covers as needed. ADON Q reported that one of the restorative aides was off on maternity leave. ADON Q acknowledged the gap in services for R24 and stated that the per diem staff member had been utilized on the floor as a CNA (certified nursing assistant) during that time.A review of the facilities policy titled Restorative Nursing Programs documented in part The goal(s) of Restorative Nursing includes improving and/or maintaining independence in activities of daily living and mobility. A Restorative Nursing Program, when appropriate is based on a comprehensive assessment and resident. Level II Restorative Nursing-A reasonable expectation that improvement will continue to occur with resident participation and goal setting.The following types of residents could benefit from Restorative Program(s) but limited to: contracture prevention and/or management.Each facility should establish a monitoring program to assure success.

Based on observation, interview, and record review the facility failed to ensure infection control standards and manufacture recommendations were followed for disinfecting a glucometer (medical device used to measure the approximate concentration of sugar in blood) for one resident (#71) of one residents reviewed during medication administration.Findings Included:Resident #71 (R71)Review of the medical record revealed R71 was admitted to the facility 07/17/2025 with diagnoses that included atherosclerotic heart disease (fatty plaques build up in coronary arteries), type 2 diabetes, heart failure, dementia, aortic (valve) stenosis (abnormal narrowing), gastro-esophageal reflux, insomnia, hyperlipidemia (high fat content in blood), anemia (low red number of red blood cells), atrial fibrillation, and hypertension. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/23/2026, revealed R71 had a Brief Interview for Mental Status (BIMS) 05 (severe cognitive impairment) out of 15.On 06/25/2026 at 11:21 a.m. R71 was observed sitting up in a wheelchair at her bedside. Licensed Practical Nurse (LPN) AA was observed entering R71's room and explaining to R71 that it was necessary that she obtain her blood sugar level using a handheld glucometer. LPN AA was observed obtaining a blood sample form R71's finger and placing it one glucometer strip, which was already in the glucometer. LPN AA was observed then discarding the glucometer strip. LPN AA was observed taking off her gloves and then observed sanitizing hands. LPN AA then proceeded to the medication cart, located outside R71's room, and placed the soiled glucometer on the medication cart. On 06/25/2026 at 11:28 a.m. Licensed Practical Nurse (LPN) AA was observed preparing R71's Humalog insulin 100units/milliliter pen. LPN AA was then observed administering R71's 2 milliliters of Humalog insulin using acceptable infection control practices. On 06/25/2026 at 11:30 a.m. Licensed Practical Nurse (LPN) AA was observed returning the medication cart. LPN AA removed a Sani-Cloth from a purpled top container. LPN AA picked up the soiled glucometer, located on the top the medication cart, an proceed to wipe the glucometer with the Sani-Cloth. LPN AA then placed the glucometer in the top drawer of the medication cart.During an interview on 06/25/2026 at 11:32 a.m. Director of Nursing (DON) B was asked to verbally explain the facility policy/expectation for using and cleaning of a facility glucometer. DON B explained that a clean glucometer should be taken into a resident's room and placed on a barrier while the nurse obtained a blood sample. DON B explained that once the resident's blood sample was placed into the glucometer it would be read and the sample would then be discarded. DON B explained that the soiled glucometer would be taken back to the medication cart on a barrier and the nurse would sanitize the glucometer using a Super Sani-Cloth wiped. DON B explained that the glucometer would be left on the barrier wet and allowed to dry for 3 minutes. DON B explained that once the sanitization process had been completed the glucometer would be placed back into the medication cart.Review of policy Blood Glucose Machine Disinfection, dated 7/15/2020 and last revised 04/02/2026, revealed:1. The facility will ensure blood glucose machines will be disinfected after each use and according to manufacturer's instructions for multi-resident use.2. The facility will clean blood glucose machines when visibly soiled as needed and per manufacturer's instruction.3. The blood glucose machine should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus.Review of the owner's manual for the UltraTrak Pro- Blood Glucose Monitoring System (glucometer), used by the facility, revealed on page 53: Cleaning- 1. To clean the meter exterior, wipe with a cloth moistened with tap water or a mild cleaning agent, then dry the device with a soft and dry cloth. Do not flush with water.Review of Super Sani-cloth (germicidal disposable wipe) manufactures label revealed To Disinfect and deodorize hard, nonporous surfaces: . Allow surface to remain wet for two (2) minutes. Let air dry.

This citation pertains to Intake 2788552.Based on interview and record review, the facility failed to ensure a physician documented that transfer/discharge was necessary for one (R1) of three reviewed.Findings include:Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included fracture of left leg, epilepsy, anxiety disorder, depression, schizophrenia, and Post Traumatic Stress Disorder (PTSD). The Minimum Data Set (MDS) with an Assessment Reference Date of 1/30/26 revealed R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). In a telephone interview on 3/4/26 at 9:58 AM, R1 reported approximately four police officers, and a social worker came into his room with an order from the judge to send him to the hospital for evaluation. R1 reported that same night, he was ready to discharge from the hospital back to the facility. R1 reported the hospital called the facility, but the facility refused to take him back saying they would rather have a hit on their license than take him back. R1 reported the hospital then told him he had to leave so he discharged to the community with his significant other. Review of the Social Services Progress Note dated 2/26/26 revealed [Social Services Director (SSD)] attempted to issue Involuntary Discharge paperwork to resident with [Nursing Home Administrator]. Resident refused the paperwork but he requested to be given the appeal paperwork. SSD attempted to hand the paperwork to him, he stated he would not touch it, and paperwork was placed gently on his left knee with no physical body contact made between SSD and resident. Review of the Immediate Involuntary Discharge paperwork dated 2/26/26 revealed This letter is to inform You that you will be immediately discharged on February 28, 2026 to [name of a local motel], for the following reason(s): Sec. 21773(2)(a). You have been observed making repeated threats towards staff and other residents and continue to do so despite being counseled on your behavior. Review of the Notice of Involuntary Transfer or Discharge and Facility-Initiated Discharge for Nursing Homes revealed R1 was being transferred/discharged due to the safety of other individuals in the facility is endangered due to clinical or behavioral status of resident and health of other individuals in the facility is endangered. Review of the Nurses' Note dated 2/26/26 revealed Police came to facility [related to] resident calling 911 .Before the police left the facility [Director of Nursing (DON)] gave police residents letter of resident's involuntary discharge. Resident stated that he [is] unable to read. Even though he had read things of papers resident had. Resident is aware that he needs to leave tomorrow 2/27/26 as the police told him that. Review of the Nurses' Note dated 2/27/26 revealed resident was unexpectedly discharged via police car to [Emergency Department] [due to] a court appointed petition. In a telephone interview on 3/4/26 at 10:54 AM, Registered Nurse (RN) E reported she worked on 2/27/26 and R1 was sent to the hospital prior to her shift. RN E reported she was told in report that if the hospital called, the facility would not readmit R1. RN E reported the hospital called multiple times wanting to send R1 back to the facility, but the facility refused. In an interview on 3/4/26 at 11:16 AM, Assistant Director of Nursing (ADON) C reported the facility was trying to do an involuntary discharge for R1, but they had not received approval from the State Agency yet. ADON C reported the hospital called the facility to readmit R1, but facility staff were told R1 was to discharge to the local motel. ADON C reported R1 refused to discharge to the motel so the hospital discharged him to the community. In an interview on 3/4/26 at 11:35 AM, Social Services Director (SSD) G reported they had not heard one way or another if R1's involuntary discharge was approved by the State Agency. In an interview on 3/4/26 at 11:46 AM, Nursing Home Administrator (NHA) and Director of Nursing (DON) B reported R1 was given involuntary discharge paperwork on 2/26/26 and that he did not take it well. NHA A reported R1 asked for the appeal, but was not aware of him filing an appeal. NHA A reported on 2/27/26 they still had not heard from the State Agency if R1's involuntary discharge was approved or not. NHA A reported the police showed up on 2/27/26 around 4:00 PM with a court order to take R1 to the hospital. NHA A reported the hospital called the facility shortly after midnight wanting to send R1 back to the facility. NHA A reported the hospital was told that R1 could go to the local motel. NHA A reported R1 was not readmitted to the facility due to concerns with his behaviors and threatening other residents. Review of the medical record revealed a physician did not document that R1's transfer/discharge was necessary due to the safety of individuals in the facility was endangered due to the clinical or behavioral status of the resident and that the health of individuals in the facility would otherwise be endangered.

This citation pertains to Intake 2747733.Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by a vendor for one (R3) of three reviewed.Findings Include:Review of the medical record revealed R3 admitted to the facility on [DATE] with diagnoses that included major depressive disorder and history of traumatic brain injury. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/26/26 revealed R3 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R3 discharged from the facility on 2/19/26.Review of the incident investigation that the facility reported to the State Agency revealed Background: [R3] was admitted on [DATE]. On 2/8/26, the physician ordered an x-ray for [R3]. [Xray Technician (XT) E] .came into the facility. XT E entered [R3's] room. [XT E] stood over top of [R3] and began swearing at him while shaking a closed fist. Investigation: [R3], Administrator [Nursing Home Administrator (NHA) A] spoke with resident who stated that [XT E] came in room using profanity. [XT E] stood over me and got in my face while threatening me with a closed fist and using profanity towards me. [R3] stated that him and [XT E] exchanged words and staff stepped in and removed [XT E] from room and the facility .Conclusion: [R3] was ordered an x-ray. [Name of x-ray vendor] sent x-ray tech, [XT E], to come and provide service to [R3]. [XT E] came into [R3's] room; and used profanity towards [R3]. [XT E] and [R3] had a verbal altercation. The nursing staff intervened [sic] and removed [XT E] from the facility. The facility substantiated that the incident occurred but cannot substantiate that verbal abuse occurred.An attempt to contact R3 via telephone was made on 2/24/26 at 10:12 AM, but R3's phone number was out of service. Review of the Nurse's Note dated 2/8/26 revealed The resident was having an X-ray performed when this nurse heard yelling for help. Staff went into room and noted a verbal altercation with the resident and the x-ray technician.Review of the Social Services Progress Note dated 2/9/26 revealed [Social Services Director (SSD)] checked in with resident [related to] interaction with x-ray technician from 2/8/26. Resident reports he and x-ray tech exchanged pleasantries and called each other derogatory names.In a telephone interview on 2/24/26 at 10:53 AM, Licensed Practical Nurse (LPN) G reported while XT E was in R3's room, she heard R3 yell Help! Help!. LPN G reported herself and another nurse went into R3's room and witnessed XT E cursing at R3. LPN G reported XT E told R3 that he didn't give a f*ck who he told and that he was going to finish his job. LPN G reported XT E and R3 went back and forth, XT E 'was going off on R3. LPN G reported R3 said if his leg wasn't messed up, he would get out of bed at which point XT E said I would like to see you f*cking try and continued to antagonize R3 to get out of bed. LPN G reported staff had to get in between them and pull the privacy curtain shut, LPN G reported XT E grabbed the x-ray plate roughly, left the room, and yelled while going down the hallway. LPN G reported R3 was very scared after this incident. In a telephone interview on 2/24/26 at 11:24 AM, Registered Nurse (RN) F reported on 2/8/26 she heard yelling coming from R3's room. RN F reported herself, LPN G and Certified Nursing Assistant (CNA) H entered R3's room. RN F stated XT E was going back and forth, yelling at the resident. RN F reported it was all verbal exchanges which included statements such as XT E saying he was going to do his f*cking job and part of his f*cking job was to make sure he got the x-ray. RN F reported R3 alleged XT E got in R3's face and pulled his fist back like he was going to hit R3 but did not hit him. In an interview on 2/24/26 at 1:27 PM, CNA H reported while answering a call light in another room, she heard someone yelling Help! Help! CNA H reported she entered R3's room with two nurses and witnessed XT E talking aggressively to R3. CNA H reported R3 asked staff to remove XT E from his room because he was being threatening and disrespectful. CNA H reported XT E continued to yell at R3 and said things such as this is why you're in here and I wish you could get up and hit me. CNA H reported it was inappropriate and she got in between R3 and XT E and closed the privacy curtain. In a telephone interview on 2/25/26 at 3:44 PM, XT E reported when he arrived at the facility, R3 was not in his room so he had to wait for R3 to come back to his room and get into bed without staff assistance. XT E reported he took a couple images and about halfway through, things started to go left. XT E reported R3's ankle needed to be turned for the next image and R3 kicked the plate on the floor. XT E reported he picked up the plate and that's when the cursing started to go back and forth .It was all verbal. XT E reported R3 told him he needed to give better f*cking instructions to which XT E responded that R3 better watch his mouth or I was going to leave because I do not take disrespect from anyone. XT E stated the conversation was elevated the entire time. It definitely wasn't at the volume we are speaking right now. Everything about the conversation was extremely heated. XT E reported R3 called for staff and that he didn't stop working even when the verbal part started. XT E reported he was there to do a job and continued to do the x-rays. XT E reported staff responded and pulled the privacy curtain between him and R3 so he then left the room, completed his paperwork, and left the facility. In an interview on 2/25/26 at 12:03 PM, NHA A and Director of Nursing (DON) B reported the facility substantiated that there was yelling and words exchanged between R3 and XT E. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included interviews, skin, and pain assessments on all residents, all staff abuse education, weekly abuse audits. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review the facility failed to report allegations of abuse to the State Agency for four residents (#1,#6,#9,#10) of ten residents reviewed for abuse. This citation pertains to intake #2615129 Review of the medical record reflected R1 was admitted to the facility on [DATE], with diagnoses that included alcohol dependance and anxiety disorder. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/29/25, reflected R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). In an interview on 9/23/25 at 9:30 AM, Family Member (FM) D reported concerns that R1's debit card was removed from the facility by staff and used to purchase items. Additionally, the staff member had withdrew cash from the bank and kept some for themselves. The staff member was identified as CNA E. In an interview on 9/23/25 at 1:56 PM, Certified Nursing Assistant (CNA) H confirmed that R1 will regularly ask staff to take her debit card and purchase her items. CNA H stated that it was nothing that they would do and has educated R1 on several occasions about how staff is not permitted to do that. In an interview on 9/23/25 at 2:15 PM, CNA E voiced familiarity of R1. CNA E stated that R1 has requested CNA E to take her bank card on several occasions and purchase her items, including alcohol. CNA E denied doing so and reported the frequent requests to management. CNA E recalled an incident where R1's FM had accused CNA E of using R1's debit card, leading to a suspension and investigation regarding the accusation. Review of an undated Witness Statement completed by R1 revealed [CNA E] did take my card I gave it to him to purchase me alcohol and a joint. with my [family member] present. In the same witness statement, the handwritten paragraph below stated, after the daughter left the facility [R1] came to Administrator and DON (Director of Nursing] and stated that she felt pressured by [family member] to say [CNA E] did it and that [CNA E] has never purchased anything for her using her card. In an interview on 9/23/25 at 2:16 PM, DON B stated R1's family member came into the office and shared the concern that staff was taking R1's bank card. DON B stated that she went to R1's room and R1 reported the allegation to Nursing Home Administrator (NHA) A and DON B. After R1's family member left, R1 retracted her statement and denied the allegation that CNA E removed her bank card from her possession and used it. DON B confirmed that thought retracted after some time, R1's initial statement was still an allegation of misappropriation and should have been reported. In an interview on 9/23/25 at 2:27 PM, NHA A confirmed that R1's family member had reported that CNA E was using R1's bank card. NHA A spoke to R1 who confirmed the allegation. NHA A stated that she suspended CNA E. NHA A stated that after R1's family member left, R1 retracted the allegation. NHA A stated that she suspended CNA E pending the allegation of misappropriation and therefore, should have reported the allegation to the State of Michigan. Findings Included: Resident #6 (R6) Review of the medical record revealed R6 was admitted to the facility 08/07/2025 with diagnoses that included type 2 diabetes, chronic kidney disease, anemia (low red blood cells, hyperlipidemia (high fat content in blood), gastro-esophageal reflux, dementia and depression. The most recent Minimum Data set (MDS), with an Assessment Reference Date (ARD) of 08/13/2025, revealed R6 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. Resident #9 (R9) Review of the medical record revealed R9 was admitted to the facility 07/11/2025 with diagnoses that included dementia, epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), stage 3 kidney disease, chronic obstructive pulmonary disease (COPD), traumatic brain injury, gastro-esophageal reflux, hypertension, cognitive communication deficient, obstructive sleep apnea, lung cancer, intervertebral disc degeneration, and dysphagia (difficulty swallowing). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/17/2025, revealed R9 had a Brief Interview for Mental Status (BIMS) of 5 (sever cognitive impairment) out of 15. Resident #10 (R10) Review of the medical record revealed R10 was admitted to the facility 12/05/2022 with diagnoses that included cerebral atherosclerosis (condition where fatty deposits build up in the arteries in the brain, narrowing or blocking blood flow), type 2 diabetes, malnutrition, dementia, obesity, hyperlipidemia (high fat content in blood), hypertension, Alzheimer's disease, dysphagia (difficulty swallowing), insomnia, hypokalemia (low levels of potassium), adult failure to thrive, and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/14/2025, revealed R10 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. Review of facility incident report dated 08/22/2025 at 03:15 p.m. for R6 revealed: medical record number (medical record number of R9) poke very loudly stating, that's my hat, indicating resident. Resident replied, no it not, peer (medical record number of R9 came up an quickly removed the hat in question. Resident and peer began swinging at each other. It appeared that (medical record number of R9) made contact with resident's back. During an interview on 09/23/2025 at 02:28 p.m. Nursing Home Administrator (NHA) A explained that she was the facility abuse coordinator. NHA A explained that it was her responsibility to investigate and review all allegations of abuse. NHA A was asked to review incident report dated 08/22/25 between R6 and R9. NHA A explained that she had not been notified that R9 had contacted R6. NHA A explained that now that she had reviewed this incident report that it would be an allegation of abuse and should have been investigated. NHA A explained that she did not have an investigation related to this incident and the incident was not report to the appropriate state agency. Review of facility incident report dated 09/10/2025 at 03:45 p.m. for R6 revealed, this writer was given medication when I looked back heard 115A (R10) was getting agitated to this resident (R6) saying give that back to me! Grabbed this resident's arm, so I came in between tried separating both but resident grabbed my left fingers and pushed me and twisted them and tried to twist resident's arm, so this CNA (certified nursing aide) came in between and stopped resident, separated them and this resident scratched CNA's right arm. Assessment done to both resident, the resident's arm 103B (R6) right has pain 5/10, no open area. The residents right middle finger had pain 2/10 painad(sp). Called administrator, DON (Director of Nursing), nurse manager notified. Notified son. Therapeutic communicated done to both. Skin and pain monitored. The same incident report also revealed Resident Description: He hit me and grabbed my arm I was trying to us the ball. During observation and interview on 09/23/2025 at 03:34 p.m. R6 was observed lying in bed. R6 denied that she had any physical altercations with any other residents at the facility. During observation and interview on 09/23/25 at 03:44 p.m. R9 was observed sitting in the dinning room, at the end of the 100 hall. R9 could not recall any physical altercations with any other residents. R9 explained that she had a good relationship with all the residents at the facility. During an interview on 09/23/2025 at 04:15 p.m. Nursing Home Administrator (NHA) A was asked to review R6 incident report dated 09/10/2025 at 03:45 p.m. NHA A was asked if this incident had been reported to the appropriate state agency. NHA A explained that it had not been reported because she had not been notified on what was written on the incident report. NHA A explained that she had not known that R6 had any complaints of pain following this incident. NHA A was asked if she reviewed all incident reports and signed that incidents had been reviewed. NHA explained that she would have to check to see if R6's incident reports had been reviewed and signed by herself. NHA A agreed, after reviewing the incident report, that an investigation should have been initiated and the incident should have been reported to the appropriate state agency. During an interview on 09/23/2025 at 04:30 p.m. Nursing Home Administrator (NHA) explained that she had signed R6's incident reports. Review of the provided facility report that demonstrated when Nursing Home Administrator A had signed R6's incident reports revealed: the incident report for the date of 08/22/2025 was signed by NHA on 09/04/2025, and the incident report for the date of 09/10/2025 was signed by the NHA on 09/17/2025. During an attempted interview on 09/24/25 at 09:59 a.m. R10 was observed sitting in the 100 hall activity room sleeping. R10 appeared well groomed and was not disturbed to interview during this time. Review of policy titled Abuse, Neglect and Exploitation, implementation date 07/28/2020 and last revised date of 01/10/2024, revealed Abuse means the willful infliction of injury.which can include staff to resident abuse and certain resident to resident altercations. The same policy also revealed Physical abuse – includes, but is not limited to hitting, slapping, punching, biting, and kicking. The same policy revealed section entitled Investigation of Alleged Abuse. A. an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. The same policy also revealed Reporting 1. Reporting of alleged violation to the Administrator, state agency, adult protective services, and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes as required by state and federal regulations.

Based on observation, interview, and record review the facility failed to investigate allegations of abuse for three residents (#6,#9,#10) out of ten residents reviewed for abuse. Findings Included: Resident #6 (R6)Review of the medical record revealed R6 was admitted to the facility 08/07/2025 with diagnoses that included type 2 diabetes, chronic kidney disease, anemia (low red blood cells, hyperlipidemia (high fat content in blood), gastro-esophageal reflux, dementia and depression. The most recent Minimum Data set (MDS), with an Assessment Reference Date (ARD) of 08/13/2025, revealed R6 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. Resident #9 (R9)Review of the medical record revealed R9 was admitted to the facility 07/11/2025 with diagnoses that included dementia, epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), stage 3 kidney disease, chronic obstructive pulmonary disease (COPD), traumatic brain injury, gastro-esophageal reflux, hypertension, cognitive communication deficient, obstructive sleep apnea, lung cancer, intervertebral disc degeneration, and dysphagia (difficulty swallowing). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/17/2025, revealed R9 had a Brief Interview for Mental Status (BIMS) of 5 (sever cognitive impairment) out of 15. Resident #10 (R10)Review of the medical record revealed R10 was admitted to the facility 12/05/2022 with diagnoses that included cerebral atherosclerosis (condition where fatty deposits build up in the arteries in the brain, narrowing or blocking blood flow), type 2 diabetes, malnutrition, dementia, obesity, hyperlipidemia (high fat content in blood), hypertension, Alzheimer's disease, dysphagia (difficulty swallowing), insomnia, hypokalemia (low levels of potassium), adult failure to thrive, and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/14/2025, revealed R10 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. Review of facility incident report dated 08/22/2025 at 03:15 p.m. for R6 revealed: medical record number (medical record number of R9) poke very loudly stating, that's my hat, indicating resident. Resident replied, no it not, peer (medical record number of R9 came up an quickly removed the hat in question. Resident and peer began swinging at each other. It appeared that (medical record number of R9) made contact with resident's back. During an interview on 09/23/2025 at 02:28 p.m. Nursing Home Administrator (NHA) A explained that she was the facility abuse coordinator. NHA A explained that it was her responsibility to investigate and review all allegations of abuse. NHA A was asked to review incident report dated 08/22/25 between R6 and R9. NHA A explained that she had not been notified that R9 had contacted R6. NHA A explained that now that she had reviewed this incident report that it would be an allegation of abuse and should have been investigated. NHA A explained that she did not have an investigation related to this incident and the incident was not report to the appropriate state agency. Review of facility incident report dated 09/10/2025 at 03:45 p.m. for R6 revealed, this writer was given medication when I looked back heard 115A (R10) was getting agitated to this resident (R6) saying give that back to me! Grabbed this resident's arm, so I came in between tried separating both but resident grabbed my left fingers and pushed me and twisted them and tried to twist resident's arm, so this CNA (certified nursing aide) came in between and stopped resident, separated them and this resident scratched CNA's right arm. Assessment done to both resident, the resident's arm 103B (R6) right has pain 5/10, no open area. The residents right middle finger had pain 2/10 painad(sp). Called administrator, DON (Director of Nursing), nurse manager notified. Notified son. Therapeutic communicated done to both. Skin and pain monitored. The same incident report also revealed Resident Description: He hit me and grabbed my arm I was trying to us the ball.During observation and interview on 09/23/2025 at 03:34 p.m. R6 was observed lying in bed. R6 denied that she had any physical altercations with any other residents at the facility.During observation and interview on 09/23/25 at 03:44 p.m. R9 was observed sitting in the dinning room, at the end of the 100 hall. R9 could not recall any physical altercations with any other residents. R9 explained that she had a good relationship with all the residents at the facility. During an interview on 09/23/2025 at 04:15 p.m. Nursing Home Administrator (NHA) A was asked to review R6 incident report dated 09/10/2025 at 03:45 p.m. NHA A was asked if this incident had been reported to the appropriate state agency. NHA A explained that it had not been reported because she had not been notified on what was written on the incident report. NHA A explained that she had not known that R6 had any complaints of pain following this incident. NHA A was asked if she reviewed all incident reports and signed that incidents had been reviewed. NHA explained that she would have to check to see if R6's incident reports had been reviewed and signed by herself. NHA A agreed, after reviewing the incident report, that an investigation should have been initiated and the incident should have been reported to the appropriate state agency. During an interview on 09/23/2025 at 04:30 p.m. Nursing Home Administrator (NHA) explained that she had signed R6's incident reports.Review of the provided facility report that demonstrated when Nursing Home Administrator A had signed R6's incident reports revealed: the incident report for the date of 08/22/2025 was signed by NHA on 09/04/2025, and the incident report for the date of 09/10/2025 was signed by the NHA on 09/17/2025. During an attempted interview on 09/24/25 at 09:59 a.m. R10 was observed sitting in the 100 hall activity room sleeping. R10 appeared well groomed and was not disturbed to interview during this time. Review of policy titled Abuse, Neglect and Exploitation, implementation date 07/28/2020 and last revised date of 01/10/2024, revealed Abuse means the willful infliction of injury.which can include staff to resident abuse and certain resident to resident altercations. The same policy also revealed Physical abuse - includes, but is not limited to hitting, slapping, punching, biting, and kicking. The same policy revealed section entitled Investigation of Alleged Abuse. A. an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. The same policy also revealed Reporting 1. Reporting of alleged violation to the Administrator, state agency, adult protective services, and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes as required by state and federal regulations.

Based on observation, interview, and record review the facility failed to implement its own written policies and procedures for Abuse and Neglect for four residents (#6, #9, #10) of 10 residents reviewed. Findings Included:Resident #6 (R6):Review of the medical record revealed R6 was admitted to the facility 08/07/2025 with diagnoses that included type 2 diabetes, chronic kidney disease, anemia (low red blood cells, hyperlipidemia (high fat content in blood), gastro-esophageal reflux, dementia and depression. The most recent Minimum Data set (MDS), with an Assessment Reference Date (ARD) of 08/13/2025, revealed R6 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. Resident #9 (R9):Review of the medical record revealed R9 was admitted to the facility 07/11/2025 with diagnoses that included dementia, epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), stage 3 kidney disease, chronic obstructive pulmonary disease (COPD), traumatic brain injury, gastro-esophageal reflux, hypertension, cognitive communication deficient, obstructive sleep apnea, lung cancer, intervertebral disc degeneration, and dysphagia (difficulty swallowing). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/17/2025, revealed R9 had a Brief Interview for Mental Status (BIMS) of 5 (sever cognitive impairment) out of 15. Resident #10 (R10) Review of the medical record revealed R10 was admitted to the facility 12/05/2022 with diagnoses that included cerebral atherosclerosis (condition where fatty deposits build up in the arteries in the brain, narrowing or blocking blood flow), type 2 diabetes, malnutrition, dementia, obesity, hyperlipidemia (high fat content in blood), hypertension, Alzheimer's disease, dysphagia (difficulty swallowing), insomnia, hypokalemia (low levels of potassium), adult failure to thrive, and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/14/2025, revealed R10 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. Review of facility incident report dated 08/22/2025 at 03:15 p.m. for R6 revealed: medical record number (medical record number of R9) poke very loudly stating, that's my hat, indicating resident. Resident replied, no it not, peer (medical record number of R9 came up an quickly removed the hat in question. Resident and peer began swinging at each other. It appeared that (medical record number of R9) made contact with resident's back. During an interview on 09/23/2025 at 02:28 p.m. Nursing Home Administrator (NHA) A explained that she was the facility abuse coordinator. NHA A explained that it was her responsibility to investigate and review all allegations of abuse. NHA A was asked to review incident report dated 08/22/25 between R6 and R9. NHA A explained that she had not been notified that R9 had contacted R6. NHA A explained that now that she had reviewed this incident report that it would be an allegation of abuse and should have been investigated. NHA A explained that she did not have an investigation related to this incident and the incident was not report to the appropriate state agency. Review of facility incident report dated 09/10/2025 at 03:45 p.m. for R6 revealed, this writer was given medication when I looked back heard 115A (R10) was getting agitated to this resident (R6) saying give that back to me! Grabbed this resident's arm, so I came in between tried separating both but resident grabbed my left fingers and pushed me and twisted them and tried to twist resident's arm, so this CNA (certified nursing aide) came in between and stopped resident, separated them and this resident scratched CNA's right arm. Assessment done to both resident, the resident's arm 103B (R6) right has pain 5/10, no open area. The residents right middle finger had pain 2/10 painad(sp). Called administrator, DON (Director of Nursing), nurse manager notified. Notified son. Therapeutic communicated done to both. Skin and pain monitored. The same incident report also revealed Resident Description: He hit me and grabbed my arm I was trying to us the ball.During observation and interview on 09/23/2025 at 03:34 p.m. R6 was observed lying in bed. R6 denied that she had any physical altercations with any other residents at the facility.During observation and interview on 09/23/25 at 03:44 p.m. R9 was observed sitting in the dinning room, at the end of the 100 hall. R9 could not recall any physical altercations with any other residents. R9 explained that she had a good relationship with all the residents at the facility. During an interview on 09/23/2025 at 04:15 p.m. Nursing Home Administrator (NHA) A was asked to review R6 incident report dated 09/10/2025 at 03:45 p.m. NHA A was asked if this incident had been reported to the appropriate state agency. NHA A explained that it had not been reported because she had not been notified on what was written on the incident report. NHA A explained that she had not known that R6 had any complaints of pain following this incident. NHA A was asked if she reviewed all incident reports and signed that incidents had been reviewed. NHA explained that she would have to check to see if R6's incident reports had been reviewed and signed by herself. NHA A agreed, after reviewing the incident report, that an investigation should have been initiated and the incident should have been reported to the appropriate state agency. During an interview on 09/23/2025 at 04:30 p.m. Nursing Home Administrator (NHA) explained that she had signed R6's incident reports.Review of the provided facility report that demonstrated when Nursing Home Administrator A had signed R6's incident reports revealed: the incident report for the date of 08/22/2025 was signed by NHA on 09/04/2025, and the incident report for the date of 09/10/2025 was signed by the NHA on 09/17/2025. During an attempted interview on 09/24/25 at 09:59 a.m. R10 was observed sitting in the 100 hall activity room sleeping. R10 appeared well groomed and was not disturbed to interview during this time. Review of policy titled Abuse, Neglect and Exploitation, implementation date 07/28/2020 and last revised date of 01/10/2024, revealed Abuse means the willful infliction of injury.which can include staff to resident abuse and certain resident to resident altercations. The same policy also revealed Physical abuse - includes, but is not limited to hitting, slapping, punching, biting, and kicking. The same policy revealed section entitled Investigation of Alleged Abuse. A. an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. The same policy also revealed Reporting 1. Reporting of alleged violation to the Administrator, state agency, adult protective services, and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes as required by state and federal regulations.

Based on interview and record review, the facility failed to obtain a physician order an advanced directive/ Do Not Resuscitate, for one resident (resident #8) of one reviewed. Findings include: Review of the clinical record, including the Minimum Data Set, dated [DATE] revealed Resident #8 was admitted to the facility on [DATE]. R8 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Further record review revealed R8 had a full legal guardian in place to make health and medical care decisions. R8's advanced directives revealed the legal guardian signed an advanced directive form on [DATE] that reflected Do Not Resuscitate (DNR) / No CPR (cardiopulmonary resuscitation which is an emergency procedure that combines chest compressions and rescue breathing to restart a person's breathing and heartbeat. The form included 2 witnesses, and the Physician signature dated [DATE]. During a record review on [DATE] it was revealed there was no Physician order in place to implement the DNR. On [DATE] at 1:04 PM, during an interview with Social Services Assistant O she reported there should be a physician order that would reflect the wishes of the resident/guardian but could not comment any further as Social Worker P handles advanced directives.Social Woker P was not working during the survey time frame and unavailable to be interviewed. During an interview with Assistant Director of Nursing (ADON) E on [DATE] 2:50 PM reported the process was Social Worker P notifies her to have orders changed/updated, ADON E stated she did not recall Social Worker P notifying her that R8's guardian had signed any advanced directives.

Based on observation, interview and record review, the facility failed to complete a change in condition, Minimum Data Set (MDS) Assessment for two (Resident #6 and Resident #15) of two residents reviewed for pressure ulcers. Findings include: Review of the medical record reflected R6 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included muscle weakness and anxiety. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/27/25, reflected R6 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the MDS indictors revealed that R6 was coded as having a tracheostomy. On 08/04/2025 at 12:19 PM, R6 was observed in her room watching television. No tracheostomy equipment was observed at the bedside, no tracheostomy was observed on R6. R6 denied having a tracheostomy. Review of R6's Five-day MDS revealed under Section O- Special Treatments, Procedures, and Programs, R6 required Tracheostomy Care. On 08/05/2025 at 3:27 PM, MDS Licensed Practical Nurse A stated that R6 does not require tracheostomy care and that the MDS was incorrect. Review of the medical record reflected that R15 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Diagnoses of Traumatic Brain Injury, Schizoaffective Disorder, Dementia, Parkinson’s Disease, Muscle weakness, and Dysphagia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/02/2025 revealed R15 had a Brief Interview of Mental Status (BIMS) of 12 (cognitively impaired) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R15 needs moderate assistance with eating and oral care. Dependent on showers, getting dressed, and all hygiene care, sitting to laying, laying to sitting, chair to bed, tub/shower transfers. During an interview and observation on 08/05/2025 at 9:22 AM, R15 lifted his feet up off the bed so this writer could see his pressure ulcer on his left heel. During an interview on 08/05/2025 at 9:24 AM, Registered Nurse (RN) “G” stated R15 did have a pressure ulcer on his heel, added she had not changed the dressing yet this morning. RN “G” stated they ask R15 if he would like lotion on his legs and feet, and if he does, they will apply it on him. During an interview on 08/05/2025 at 12:14 PM, Wound Care Nurse/Licensed Practical Nurse “J” stated R15's left heel pressure ulcer was now healed. Wound Care Nurse/Licensed Practical Nurse “J” stated she would do daily skin sweep, using a new skin assessment/sweep, asking 3 questions, was there new skin breakdown, if so, was a risk management started, was treatment started. During an interview on 08/05/2025 at 3:23 PM, Minimal Data Set (MDS) nurse “L” stated that MDS had a schedule on which resident was due for an assessment on which day. Writer asked how she gathered information for this assessment, she stated she went down to talk to the nurse, then the resident and or family. MDS nurse “L” stated when the next assessment was due, she read nursing progress notes and talks to the resident while they are out walking in the hall, getting around on the unit, during use of the bathroom, etc. MDS nurse “L” stated she used the skin assessment and communicated with the wound care nurse or provider. Writer asked MDS nurse “L” when R15’s left foot pressure ulcer developed. MDS nurse “L” stated 04/07/2025. Writer asked MDS nurse “L” if that would be a change in condition for a new pressure ulcer developed. MDS nurse “L” stated it should have been, but one did not get done. MDS nurse “L” added that an MDS assessment had to be done within 7 days of the change in condition, there was not a change in condition assessment completed.

This citation pertains to Intake Numbers MI00148941, MI00148966 and MI00149186 Based on observation, interview and record review the facility failed to protect the resident's (R505) right to be free from sexual abuse by another resident (R501) of 7 sampled residents reviewed for abuse resulting in sexual assault of R505 who was cognitively impaired and also resulted in the likelihood of physical harm, infection, and emotional pain and suffering, based on the reasonable person concept. The Director of Nursing (DON) was interviewed on 12/18/2024 at 10:10 AM. and confirmed viewing the facility surveillance video captured on 12/12/24. The video taken on 12/12/24 at 7:42 PM showed R501 ushered R505 into R501's room. At 9:09 PM, R501 was seen on video looking up the hallway before ushering R505 back to her room. On 12/13/2024, R505 was sent to the emergency room for further examination due to soiled underwear and suspected sexual assault. The DON stated the video was no longer available for review. The facility did not save a copy nor had the facility recorded the incident's surveillance video on 12/12/24. Further interview with the staff revealed R501 barricaded the door of his room to prevent anyone from entering. The Immediate Jeopardy began on 12/12/2024 when the facility failed to prevent the sexual assault of R505 by R501. The Immediate Jeopardy was identified on 12/26/2024 at 3:30 PM. The facility Administrator was notified in writing of the Immediate Jeopardy on 12/26/2024 at 4:45 PM, and a plan for the removal was requested. It was confirmed by interview and record review on 12/30/24, that the Immediate Jeopardy was removed on 12/13/24, but non compliance remained at actual harm due to sustained compliance that had not been verified by the State Agency. Findings include: The DON was interviewed on 12/18/24 at 10:10 AM. The DON confirmed viewing the facility's surveillance video captured on 12/12/24. According to the DON, the incident had been reported to the state involving a resident-to-resident encounter for a possible sexual assault. The DON described the incident that occurred on 12/12/24, and the timeline was based on after they viewed the facility's video surveillance that was captured on 12//12/24. The DON indicated they first knew about the incident when the staff called them because they were concerned and suspected sexual abuse may have occurred. On 12/12/24 at approximately 7:42 PM to 9:09 PM, Staff noticed that R505 was not in her room for over an hour. After R505 returned to her room, the staff suspected she may have been in R501's room. It was later verified and confirmed, as seen via surveillance camera, that R505 went into R501's room for 1 hour and 27 minutes. The DON stated she watched the video and she saw R501 entered R505's room, but the conversation could not be heard because there was no audio. R501 approached R505's room, stood by the door, and gestured towards his room right across from R505's room. A few minutes later, R505 followed R501 to his room. The DON stated, after the Administrator and the DON watched the video, they immediately called the police and sent R505 to the hospital for a Rape Kit evaluation and further assessment. On 12/19/24 at approximately 10:00 AM, the surveyor requested to review the video footage pertaining to 12/12/24. The DON stated that the video was no longer available for review. The facility did not save a copy nor had they recorded the incident's surveillance video on 12/12/24. According to the daughter/POA (Power of Attorney), during an in-person interview at the facility on 12/18/24 at 3:45 PM, she revealed that she was at the hospital bedside during the hospital physical examination performed by the Forensic Nurse Examiner (FNE) and had asked for a consent to the examination because she was R505's POA. The POA indicated the FNE revealed to her that there was evidence of vaginal bleeding and apparent vaginal tearing present. The daughter/POA also revealed to the nurse, R505's medical history showed R505 had not had periods since about [AGE] years ago when R505 had a hysterectomy. The daughter mentioned, according to the police, they had assured R505's daughter there was enough evidence to implicate R501 for what he had done to her mother. When asked how her mother was doing, she said they would keep her until after the holiday and wouldn't return until the PPO (Personal Protection Order) was implemented against R501. An interview with the [NAME] Detective (LD) was conducted by phone on 12/19/24 at 10:11 AM. LD stated there was a 99.9% (percent) the sexual encounter occurred. There was enough evidence to incriminate this man (referring to R501). The Detective Investigation Report was reviewed on December 26, 2024, at 3:20 PM. It revealed the incident occurred on 12/12/2024 at approximately 1905 hours. It wrote: I (detective) reviewed the camera footage with the Administrator and CNA B. They advised the camera footage's time is one (1) hour ahead due to the system not accepting daylight saving time changes. With the correct time stamps, the incident occurred as follows: 1. At 1904 hours, both R505 and R501 are seen speaking with each other in the hallway. 2. At 1905 hours, both parties enter their respective rooms (room [ROOM NUMBER] and room [ROOM NUMBER]). 3. At 1942 hours, R501 exits his room, goes to R505's door, and gestures to his room. R501 is seen guiding R505 into R501's room. R501 is then seen closing R505's door and placing the stop sign back in place. 4. At 2011 hours, CNA B attempted to enter R501's room to take his vitals and finds it barricaded. 5. At 2020 hours, CNA B entered R505)'s room and advised she was not inside. 6. At 2105 hours, CNA B makes contact with R501 and does not observe R505 inside his room. 7. At 2106 hours, CNA B leaves. 8. At 2109 hours, R501 is seen guiding R505 out of his room and back into her room. 9. At 2111 hours, CNA B enters into R505's room, and R501 attempts to follow. The report by the detective further described: On 12/13/2024 at approximately 0100 hours, I (LD) was dispatched to the facility (name of the facility mentioned and address) in reference to a suspicious situation. Dispatch advised the male in room [ROOM NUMBER] (referring to R501) had barricaded himself and another resident in his room. Dispatch stated the other resident, [R505 (name mentioned)], who has Dementia, is mentally incapacitated, and is unable to make decisions for herself. Dispatch said that the staff was concerned a sexual assault took place. On 12/13/2024, at approximately 1215 PM, I (detective) spoke to the Administrator for the facility (facility name mentioned) via text and obtained her statement. Administrator's statement: I (detective) spoke to the Administrator (actual name mentioned) via TX (text). She explained last night at approximately 1942 hours, [R501 (mentioned resident's name)], the accused, coaxed [R505 (mentioned R505's name)] into coming into his room. The Administrator explained that he (R501) barricaded himself in the room with [R505 (resident's name mentioned)], but the staff did not know she was there with him. At 2105 hours, he left the staff to do his vitals at his bedroom door, but they did not go into the room and were unable to see [R505 (name mentioned)] in the room. At 2109 hours, [R501 (Resident's name mentioned)] was seen taking [R501(resident's name)] back to her room. She (Administrator) explained that [R505(name mentioned)] had a guardian and does want to prosecute charges. On 12/13/2024 at approximately 0100 hours, officers responded to the facility (facility named) in regards to a report of a possible sexual assault. I (detective) spoke with the accused, [R501 (name mentioned)], who denied the accusations. On 12/19/24 at 2:30 PM, a review of the nearby hospital emergency room (ER) records with the arrival date of 12/13/24 at 0157. Chief Complaint: The patient arrives via EMS from the facility, staff requesting a rape kit from the incident. Per staff, the patient was missing for 1 hour and found to be in a male resident's room. The patient has severe Dementia and does not know what happened or why she is at the hospital. Visit Diagnoses: Encounter for screening examination Z13.9 (primary), Assault Y09. On 12/13/24 at 3:49 AM: Forensic Nurse Examiner to bedside. Medical forensic exam completed w (with)/ pt's (patient's) daughter present as her support person. Pt (patient) is alert and oriented x (times) self only and is not able to provide a history. I reviewed the exam process w/ the pt at cognitively appropriate level. Pt assented to the exam. Pt reports no pain during the exam. Vaginal bleeding was noted during the exam. Pt. has a scant amount of bright red blood present on swabs and with tissue when wiping after using the restroom. No other injuries were noted. See the Medical forensic chart for all findings of the medical forensic exam. Clothing was collected by FNE except for socks and shoes. The patient was given new clothing, including undergarments . Pad applied to underwear due to vaginal bleeding.,.Clothing was collected by FNE except for socks and shoes. Pt was given new clothing, including undergarments and FNE assisted the pt with changing into new clothing. Pad applied to underwear due to vaginal bleeding. SANE (Sexual Assault Nurse Examiner) discharge instructions were reviewed with/ the patient's daughters, including the guardian. Pt to follow up with her Pt. for STI (Sexually Transmitted Infections)/HIV (Human Immunodeficiency Virus) testing and to reassess vaginal bleeding. The patient's family was advised to refer to the Primary MD (Medical Doctor) if the bleeding persists or worsens; they should seek care w/ PCP (Primary Care Physician) or return to the ED (Emergency Department). The family, including the guardian, verbalized understanding. The patient's daughter was given a SANE discharge pack. At 05:45 AM, (Resident 505) was discharged to the hospital emergency room . (Resident 505 guardian) decided to bring her home until after Christmas. ER (emergency room ) Physician and the Nurse Practitioner were notified, including STI/HIV prophylaxis and discharge planning were deferred to the Dr (Doctor) and NP (Nurse Practitioner). Resident #501 (R501) R501 was [AGE] years old and admitted to the facility on [DATE] with the diagnosis of Adjustment Disorder with Anxiety, Insomnia, Irritability and Anger, Bipolar Disorder, and Narcissistic Personality Disorder, in addition to other diagnoses. According to the PASARR (Preadmission Screening/Annual Resident Review) Level 1 dated 11/19/2024, R501 was not receiving any treatments and no current medications per his preference. R501 has a BIMS (Brief Interview for Mental Status) Score of 15/15, assessed on November 29, 2024, and was deemed his own responsible person. On 12/18/24, a review of R501's care plan did not reflect interventions in place for precautions or monitoring residents related to the past history of sexual activities and his conviction. R501 was independent with Activities of Daily Living (ADLs). R501 used a motorized wheelchair for mobility and ambulation, especially for long-distance ambulation but was independent during transfers to and from the toilet and bed transfers to the chair. He requires very minimal assistance from staff for ADLs. The Plan of Care does not include any monitoring or activity of intimacy or involvement with consensual sexual relationships/interactions with other residents or visitors/guests. An interview with R501 conducted on 12/18/24 at 9:36 AM. During this particular interview with R501, R501 denied touching R505 nor having sex with R505. R505 was [AGE] years old and admitted to the facility on [DATE] with a diagnosis of diverticulitis of the intestine, contact with and exposure to COVID-19, Alzheimer's disease, and dementia with other behavioral disturbance in addition to other diagnoses. R505's current BIMS Score of 03/15 (severe cognitive impairment) assessment was done on December 2, 2024. She is oriented to self only. Resident has a legal guardian, conservator, and Medical POA (Power of Attorney). She requires minimal assistance with ADLs and is independent with ambulation. R505 Care Plan printed on 12/19/24 was reviewed for impaired cognitive function related to Alzheimer's disease, Dementia and was at risk for falls. On 12/30/24 at 3:30 PM, the surveyor met with R505 in her room. She was pleasant and welcomed the surveyor to her room. R505 remained pleasant and did not show any emotional distress. R505 stated no when asked if she is afraid or felt harmed. An interview with the Administrator was conducted on 12/18/24 at 12:20 PM. They do have an Abuse Policy that covers detailed information about sexual assault or abuse. The Administrator also justified the provision of privacy and honoring residents' rights, which confused staff. The administrator asserted that because R501 was his own responsible party, R501 had the right to approve guests in his room or restrict entry. According to Certified Nurse Aide CNA B on 12/23/24 at 8:17 AM, He recalled he was doing his vitals at that time and noticed R501's room was barricaded. CNA B explained that he tried to push the door to open gently, but it felt like there was something heavy by the door, and the door would not open. CNA B stated, The door was stuck and shut. CNA B further revealed that he could only visualize an inch of R501's room and did not see R501 or anyone else inside. CNA B could hear R501 respond from inside the room and told him that he would come out and find him in about 15 minutes. CNA B noticed across the hall that R505 was not in her room but did not suspect anything because the stop sign was placed by her door until over an hour later when R505 had returned. CNA B expressed that he felt weird and disgusted and reported the suspicion to the nurse. That was when they called and reported it to the DON and Administrator. CNA B continued to recall that the nurse assessed and examined R505 later in her room. The nurse said that she saw the blood stain or what may appear to be a blood smear in R505's underwear during her physical and skin assessment right after R505 was missing for over one hour. CNA B stated, (R505) was not an elopement risk, so I did not think she was missing. I just thought she may have visited another hall to visit friends. Although I saw (R505) friendly to (R501) that day, I assumed they were friends for a while. When CNA B was asked when he reported R505 missing? He explained that he did not report her missing because she could be visiting her friends in other halls. CNA B also recalled that he had to get other resident's vitals that night. So he was looking for her but also tried to get to complete the vitals task that was due in his set. R501 also told him that she was last seen heading towards 200 Hall. It was not until after R505 returned to her room that he felt something was wrong. He reported to Nurse A immediately. CNA B said he did not pursue getting in R501's closed door because he was his own person and had the right to privacy. They did not have special instructions on what to do or a care plan specific for residents who are sex offenders. Nurse A was interviewed on 12/23/24 at 8:13 AM. She indicated that she was not notified that R505's whereabouts were unknown for 1 hour and 27 minutes. Nobody had reported to her that she was missing. CNA B only told her when R505 had returned to her room at 2109. Nurse A would have actively looked for R505. Nurse A immediately called the DON and Administrator, assessed R505, and sent her to the ER. R501 was a known sex offender but denied the sexual encounter and stated it did not happen. Nurse A admitted she found some stains in R505's underwear upon physical assessment but was not sure and was not further confirmed as R505 started to get agitated and did not want me to proceed with the examination. We decided to have R505 keep the clothes and underwear on her way to the ER to have her SANE/Rape Kit Test. R505 left at around 1:00 AM on 12/13/24. R501, on the other hand, was placed under one-on-one supervision. An interview by phone with Nurse C was conducted on 12/18/24 at 2:38 PM. Nurse C indicated she had not seen or heard anything. All she recalled on 12/12/24 was CNA B came to 200 Hall, where she was, and asked if she had seen R505. CNA B did not mention R505 was missing then. CNA B came twice, and then he went away. Nurse C recalled, when in 400 hall to do split jobs with medication pass, she did not notice seeing R501 or R505. Nurse C revealed Nurse A was assigned to the 400 Hall, where both R501 and R505 resided. Nurse C was asked how they monitor residents in the sex offender registry and what to monitor. She said they did not have a policy that she knew of. The Registered OT (Occupational Therapist) staff was interviewed on 12/18/24 at 2:15 PM, she indicated R501 used a motorized wheelchair for mobility to move around long distance in the community. His safety awareness is not a problem when he was evaluated in May 2024. He was evaluated and was independent with ADLs, especially during his transfers, walking going to the toilet, pivoting from bed to chair to toilet. He had no problems doing all these independently. Missing resident policy (undated) reviewed on 12/30/24 at 2:30 PM. Missing Person Policy Code Yellow .Nursing personnel must report and investigate all reports of missing residents. If the resident is discovered to be missing, a search shall begin immediately, per the missing person/s protocol. c The Nurse will assign a staff member to begin a headcount of all current residents. c The Nurse will designate a search leader c Assigning staff to conduct an interior search of the facility to also include closets, storage rooms, offices, and any other accessible interior area . According to Nurse A on 12/23/24 at 8:13 AM, during an interview conducted by phone, the Missing Resident Policy or Code Yellow was not activated because it was not reported to her that R505 was missing for over an hour on 12/12/24. Abuse Policy (date revised on 01/10/2024) was reviewed on 12/19/24 at 3:00 PM. Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident's property . . Sexual Abuse (definition) is non-consensual sexual contact of any type with a resident . Criminal Sexual Abuse (definition) is serious bodily injury/harm shall be considered to have occurred if the conduct causing the injury is conduct described in section 2241 (relating to aggravated sexual abuse) or section 2242 (relating to sexual abuse) of Title 18, United States Code, or any similar offense under the State Law. In other words, serious bodily injury includes sexual intercourse with a resident by force or incapacitation or through threats of harm to the resident who is incapable of declining to participate in the sexual act or lacks the ability to understand the nature of the sexual act . .Prevention of Abuse . The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact . B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and /or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms Immediate Jeopardy Removal: The Immediate Jeopardy that began on 12/12/24 was removed on 12/13/24 when the facility took the following actions to remove the immediacy: As a result of the finding of Immediate Jeopardy by the survey team on 12/12/24 related to Resident #501 and Resident #505 the facility has reviewed the below to determine causation. Findings include: Element #1 Resident #505 was transferred to hospital on 12/13/24 and was provided a SANE examination. This exam identified no external injuries with vaginal bleeding, scant blood present on tissue when wiping. She was discharged to care of DPOA on 12/13/24. Resident readmitted to the facility on [DATE]. Social Services/designee will complete wellness visits and offer psychosocial support and services. Resident #501 admitted to having resident #505 present in his room to watch a movie on 12/12/24. Beginning on 12/13/2024, he was placed on 1:1 supervision until discharged from the facility on 12/18/24. Element #2 Beginning on 12/12/2024, Female residents with a BIMS 10 or less had skin assessments completed with no concerns identified. Female residents with a BIMS 10 or higher were interviewed regarding any concerns with other residents in the facility and if they feel safe. On 12/13/2024 Social Services Director completed an audit of sex offender registry for residents in facility. Three additional residents were identified. These residents were placed on one to one supervision and assessed regarding risk factors (date of charges, degree of severity, any history of behaviors in facility, cognition and ADLS status or ability move independently throughout the facility). Resident's interventions/supervision updated as deemed appropriate based on risk factors. Care plans updated. These residents had sex offender registration audited to ensure current address was present, any discrepancies were reported to the registry. Element #3 Beginning on 12/12/2024 Facility staff were re-educated on the facility Abuse, Neglect and Exploitation Policy to include Criminal Sexual Abuse. Administrator, Director of Nursing and Social Services Director educated on ensuring that Active sex offenders within the facility have appropriate supervision and interventions initiated and have ongoing monitoring. Beginning on 12/13/2024 Facility staff were educated on signs of potential sexual abuse and also actions to take if sexual abuse is suspected or has occurred. Facility staff were also educated on following the kardex / care plan regarding interventions placed for resident who are active registered sex offenders. Systemic Changes Include: Sexual Abuse education will be completed during ongoing facility orientation. Residents who are on the sex offender list will be care planned with discussion and agreement, to allow entry when staff has a need to verify the whereabouts of another resident. Should a suspected or confirmed sexual abuse occur, the facility staff will: Immediately intervene and stop contact between residents Perpetrator will be placed on one to one supervision in the interim Notify the Administrator Notify Police as appropriate Nurse will complete a physical assessment Ad hoc QAPI initiated on 12/13/2024. Element #4 Beginning on 12/13/2024 Current residents in facility with a sex offender history will be reviewed by the Social Services Director or designee and IDT (Interdisciplinary Team) weekly for any new behaviors and to ensure current interventions remain in place and are appropriate. The Medical Director/designee was notified of the event on 12/13/2024 has been notified of the Immediate Jeopardy

Based on observation, interview, and record review the facility failed to prevent accidents, failed to adequately investigate accidents, determine root cause of accident for one resident (#75) resulting in death and to prevent potential accidents with harm in six residents (#22, #26, #29, #36, #46, #84) of seven residents reviewed, resulting in Immediate Jeopardy when resident #75 was using an unassessed electric scooter, fell , suffered a left hip fracture, and died related to complication of the fall and failed to prevent the potential of serious harm to other residents that are using electric wheelchairs and scooters in a current facility census of 83. Findings Include: Resident #75 (R75) Review of the medical record revealed R75 was admitted to the facility originally admitted to the facility [DATE] with diagnoses that included atherosclerosis of arteries of right leg, social phobia, gastroesophageal reflux, hyperparathyroidism of renal origin, acquired absence of left below the knee, anxiety, insomnia, multiple bilateral rib fractures, ascites, dependence on renal dialysis, chronic kidney disease, type 2 diabetes, end stage renal disease, depression. R75 was discharge to the hospital following a fall (resulting in left hip fracture) at the facility [DATE] and was readmitted to the facility [DATE] after receiving a closed reduction percutaneous pinning of left femoral neck fracture at the hospital. R75 died at the facility [DATE]. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R75 had a Brief Interview for Mental Status (BIMS) of 15 (intact cognition) out of 15. Review of the medical record revealed that R75 was transported to an appointment, outside the facility, on [DATE] and was transported by means of the facility transport van. R75 was using a four wheeled scooter as his mode of mobility to get on the facility transport van and attend the outside appointment. Review of the incident report dated [DATE] and timed 11:13 a.m. revealed that Resident getting off transport van. Backing up and went too far to one side and rolled out of electric wheelchair. Backing up while talking and did not pay attention. In the same incident report, documented as witness statement from Transportation Aide AA, stated Resident back wheel reversed over edge of ramp of the van causing tire to elevate and having resident fall out of electric wheelchair. Review of the medical record revealed R75 progress note (dated [DATE] at 06:30 p.m.) stated, Received results from x-ray to left hip. FX (fracture) femoral neck to left hip. The medical record revealed that R75 was then sent to the hospital. R75's medical record revealed that R75 returned to the facility [DATE]. Review of the discharge summary, dated [DATE], revealed that while at the hospital R75 had a closed reduction percutaneous pinning of left femoral neck fracture [DATE] closed left hip fracture. Review of the medical record revealed that on [DATE] at 06:25 a.m. R75 was observed laying on his back with his eyes closed. R75 was not responding and was absent of pulse, cardiopulmonary resuscitation (CPR) was started by the staff. 911 was called and upon arrival EMS continued with CPR. CPR was unsuccessful at reviving R75, and he was pronounced dead at 06:55 a.m. Review of R75's Certificate of Death revealed that the section listed as Manner of Death- Accident with a date of injury listed as [DATE]. The section listed as Describe how injury occurred was documented fell from electric scooter. R75's Certificate of Death also listed contributing factors of death complications of left hip fracture. In an interview on [DATE] at 09:38 a.m. Nursing Home Administrator (NHA) A was asked if she had knowledge of the fall on of R75 on [DATE]. She explained that she was aware of the fall. She was asked if she had knowledge of R75's cause of death and she explained that she could not speak to his cause of death. The investigation file regarding this incident on [DATE] was requested. In an interview on [DATE] at 10:10 a.m. Transportation Aide AA explained that he witnessed the fall of R75 on [DATE] and was the person that was transporting him to and from an appointment. Transportation Aide AA explained when R75 returned from his appointment, that R75 was setting on his electric four wheeled scooter while exiting the transportation van. He explained that R75 moved himself, while on the four wheeled scooter, onto the mechanical lift ramp of the transportation van. Once R75 was on the mechanical lift ramp, he lowered the mechanical lift ramp. Transportation Aide AA explained that he had told R75 that he could not exit the ramp. He explained that as R75 was navigating the electric four wheeled scooter independently and he was standing right beside R75 on the electric four wheeled scooter. He explained that R75 then started navigating the electric four wheeled scooter backwards of the ramp. Transportation Aide AA explained that during that time R75 turned the handlebars of his electric four-wheel scooter while backing up and the right tire went over the side guards of the ramp and R75 and the electric four-wheel scooter tipped to the left side. He explained that R75 then fell to the pavement, still sitting on the scooter and landing on his left side. Transportation Aide AA explained that he did not have time to prevent R75 or the scooter from tipping onto the pavement. During observation of the facility transportation van on [DATE] at 10:34 a.m., while Transportation Aide AA demonstrated operation of the mechanical lift, it was observed that the lift had a metal strip, along each side of the ramp platform. The metal strip was approximately 3 inches in height from the bottom of the platform and extended the entire length on both sides. In an interview on [DATE] at 12:23 p.m. Program Director for Therapy BB explained that she was an Occupational Therapist, as well as the Program Director of Therapy. She explained that this department included physical, occupational, and speech therapy for the facility. She explained that her department is responsible for completing wheelchair assessments for all residents at the facility. This assessment included the appropriateness of a resident with the use of a manual wheelchair, electric wheelchair, and electric scooter. Program Director for Therapy BB explained that the facility used a document entitled Power-Mobility Indoor Driving Assessment. That assessment included questions regarding driving the device safely both inside and outside of the facility. She also explained that the assessment included the use of a ramp on the facility transportation van. Program Director for Therapy BB explained that she was aware of R75's fall that occurred on [DATE]. She explained that R75 had ordered an electric power scooter from e-bay and that it was delivered to the facility. The power electric scooter was four wheeled scooter and was delivered to the Therapy gym once it had been assembled by the maintenance department. She explained that she conducted a Power-Mobility Indoor Driving Assessment for R75 on [DATE]. She explained that the assessment was not completed because it had been raining outside that day making it impossible to complete the outdoor or transportation ramp portion of the assessment. She also explained that the electric four wheeled scooter did not have a seat belt and that she had recommended that one be applied to the chair. She further explained that she had explained to R75 that he was unable to use the electric four wheeled scooter until the evaluation was completed and the seat belt was applied. Program Director for Therapy BB explained that she had removed the electric four wheeled scooter on [DATE] from R75's room and locked it in the therapy gym. She explained that she had not documented that the electric four-wheeled scooter was removed and locked in the therapy gym or that the use of the scooter was unsafe at that present time. Program Director for Therapy BB' explained that R75 was given back the scooter on [DATE] by the therapy staff that was working on the weekend. She explained that she was not aware that the scooter had been returned to R75 for use until after the fall had occurred on [DATE]. In an interview on [DATE] at 12:37 p.m. Program Director for Therapy BB explained that she and another occupational therapist had completed a Power-Mobility Indoor Driving Assessment on all residents that used an electric wheelchair or electric scooter. She explained that these assessments had been completed after the incident involving R75 on [DATE]. She could not provide dates in which they had been completed or the name of the residents completed. She explained that she gave all of the documents to Assistant Nursing Home Director G once the Power-Mobility Indoor Driving Assessment had been completed. In an interview on [DATE] at 01:46 p.m. Physical Therapist Assistant (PTA) CC explained that she was the therapy staff member that was working at the facility on [DATE]. She explained that on [DATE] that she was told by the Program Director of Therapy BB that R75 had a Power-Mobility Indoor Driving Assessment initiated on [DATE] but that it was not completed. She explained that Program Director of Therapy BB' told her that R75 would want to use the scooter on Saturday and that it was ok for her to give him the scooter. She also explained she was told to watch him during use and if she felt R75 was safe to let him continue using it. PTA CC explain that she watched R75 using the scooter and thought he was safe. PTA CC explained that she had not documented anything in R75's medical record. Review of the investigation file (provided by Nursing Home Administrator (NHA) A) revealed a typed and signed statement from Transportation Aide AA , which signature was not dated. The file also included a written statement by Director of Nursing (DON) 'B dated [DATE]. The file also included a census of resident, that appeared to be generated on [DATE]. The resident list demonstrated which resident at the facility used an electric wheelchair. Nine residents were listed as using an electric wheel chair on the census. In an interview on [DATE] at 01:57 p.m. Nursing Home Administrator (NHA) A reviewed the investigation file of the incident on [DATE] with this surveyor. She explained that a Power-Mobility Indoor Driving Assessment was to be completed on all resident that were currently using an electric wheelchair or scooter at the facility. NHA A was unable to produce any Power-Mobility Indoor Driving Assessment that had been completed at this time. She explained that Assistant Nursing Home Administrator G had not received the completed Power-Mobility Indoor Driving Assessment. NHA A was unable to provide any other witness statements, a timeline of the investigation, or a root cause analysis of the investigation. During observation on [DATE] at 02:40 p.m. in the Program Director of Therapy BB 's office it was observed that Nursing Home Administrator (NHA) A was talking with Program Director of Therapy BB. NHA A was requesting Power-Mobility Indoor Driving Assessment that had been completed following the incident with R75 on [DATE]. As Program Director of Therapy BB was looking for documentation in the computer NHA A picked up a pile of papers that were located to the left of Program Director of Therapy BB current location in the office. NHA A explained that these appear to be the requested Power-Mobility Indoor Driving Assessment. She further explained that she would need to verify these were completed. A copy of those Power-Mobility Indoor Driving Assessment was requested. All those documents (Power-Mobility Indoor Driving Assessment) were not provided by the time of exit. Resident #22 (R22) Review of the medical record revealed R22 was admitted to the facility [DATE] with diagnoses that included peripheral vascular disease (PVD), type 2 diabetes, Chronic Obstructive Pulmonary Disease (COPD), anemia (low volume of blood), acquired absence of left leg below the knee, acquired absence of right leg below the knee, hypotension, cognitive communication deficit, depression, insomnia, urinary retention, osteomyelitis (bone infection), osteoporosis (bone thinning), occlusion and stenosis of bilateral carotid arteries, osteoarthritis, chronic back pain, atherosclerotic heart disease, hypertension, hyperlipidemia (high fat levels in blood), gastro-esophageal reflux, anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R22 had a Brief Interview for Mental Status (BIMS) of 15 (intact cognition) out of 15. Review of the medical record revealed R22 had a plan of care intervention which stated, Resident uses a motorized wheelchair to get around the facility. Resident to use seatbelt while operating motorized wheelchair. That intervention was add to the plan of care [DATE]. An Power-Mobility Indoor Driving Assessment was not located in the medical record. During observation and interview [DATE] at 09:50 a.m. R22 was observed lying in bed. An electric wheelchair was observed to the right of R22's bed. R22 explained that she used her electric wheelchair to move around the facility. She explained that facility completed a wheelchair test the other day. She explained that the test consisted of mobility around cones, safe use of the wheelchair backing up, and even went outside and used the lift on the van. She could not identify the exact day that she received that evaluation. Resident #26 (R26) Review of the medical record revealed R26 was admitted to the facility [DATE] with diagnoses that included end stage renal disease, type 2 diabetes, acquired absence of right leg below the knee, acquired absence of left leg below the knee, anemia (low volume of blood), anxiety, depression, and sepsis (systemic infection). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R26 had a Brief Interview for Mental Status (BIMS) of 15 (intact cognition) out of 15. Review of the medical record revealed R26 had a plan of care intervention which stated Resident uses a motorized scooter to get around the facility. Resident to use seatbelt while operating motorized scooter. Resident uses standard wheelchair for attending appointments or transportation via facility van or other facility provided transportation. That intervention was added [DATE] and revised [DATE]. A Power-Mobility Indoor Driving Assessment was not located in the medical record. During observation and interview on [DATE] at 09:53 a.m. R26 was observed setting on a four wheeled scooter in the doorway of his room. R26 explained that he had just had to take a scooter test. He explained he thought the test was a week ago or last week. He explained that the scooter test' they made him go outside and use the lift on the van. R26 explained that he passed the test. Resident #29 (R29) Review of the medical record revealed R29 was admitted to the facility [DATE]with diagnoses that included type 2 diabetes, asthma, hyperlipidemia (high fat levels in blood), obstructive sleep apnea, osteoarthritis, pain in left knee, bipolar disorder, gout (buildup of uric acid in bone joints), Parkinson's disease, obesity, and major depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R29 had a Brief Interview for Mental Status (BIMS) of 15 (intact cognition) out of 15. Review of the medical record revealed R29 had a plan of care intervention which stated, Resident uses motorized wheelchair independently throughout the facility. This intervention was date [DATE]. The intervention was update [DATE] to state, resident uses motorized wheelchair independently throughout the facility. Resident to use seatbelt while operating motorized wheelchair. A Power-Mobility Indoor Driving Assessment was not located in the medical record. During observation and interview on [DATE] at 09:57 a.m. R29 was observed sitting at the side of bed in an electric wheelchair. She explained that she had taken a wheelchair test at 08:00 p.m. on [DATE]. It included going outside and using the ramp for the van. Resident #36 (R36) Review of the medical record revealed R36 was admitted to the facility [DATE] with diagnoses that included spastic quadriplegic cerebral palsy, dysarthria (difficulty speaking because of weak muscle), anarthria (inability to articulate speech), anoxic (lack of oxygen) brain damage, adjustment disorder, dysphagia (difficulty swallowing), contracture (shortening or hardening of muscle) of left knee, contracture of right knee, and osteoarthritis. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R36 had a Brief Interview for Mental Status (BIMS) of 15 (intact cognition) out of 15. Review of the medical record revealed R29 had a plan of care intervention which stated, Locomotion in Power Wheelchair independently. Encourage resident to keep his distance from other residents while driving w/c (wheelchair) independently. Staff assist prn (as needed). Resident to use seatbelt while operating motorized wheelchair. That intervention was initiated [DATE] and revised [DATE]. A Power-Mobility Indoor Driving Assessment was not located in the medical record. During observation and interview on [DATE] at 10:15 a.m. R 36 was observed lying in bed. An electric wheelchair was observed beside the bed. R36 did not respond to verbal questions. Resident #46 (R46) Review of the medical record revealed R46 was admitted to the facility [DATE] with diagnoses that included infective endocarditis (inflammation of the heart valve), displacement of intraocular (within the eye ball) lens, fracture of right orbital (forms the roof of the maxillary sinus) floor, congestive heart failure (CHF), urinary retention, obstructive sleep apnea, bullous pemphigoid (disease causing fluid filled blisters on the skin), insomnia, hyperlipidemia (high fat levels in blood), and abnormal posture. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R46 had a Brief Interview for Mental Status (BIMS) of 15 (intact cognition) out of 15. Review of the medical record revealed R46 had a plan of care intervention which stated, Resident uses electric w/c (wheelchair) for mobility throughout the facility. Resident will utilize seat belt on wheelchair at time per preference, is able to secure and unsecure seat belt independently on command. That intervention was initiated [DATE]. A Power-Mobility Indoor Driving Assessment was not located in the medical record. During observation and interview [DATE] at 10:03 a.m. R84 was observed lying in bed. An electric wheelchair was observed at the side of his bed. R84 explained the facility had given him a wheelchair test on [DATE]. He explained that he had to go outside and demonstrate using his electric wheelchair in the parking lot, on the sidewalks, going across the street, and using the van lift. During an interview on [DATE] at 2:33 PM, Director of Nursing (DON) B stated she did not know why R84's wheelchair evaluation was ordered on [DATE] and not completed until [DATE]. DON B stated she would investigate it but did not have a rational prior to or during survey exit on [DATE] at 4:00 PM. Resident #84 (R84) R84's Admission Minimum Data Set (MDS) assessment with assessment reference date (ARD) of [DATE], revealed he was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short cognitive screener for nursing home (NH) residents, score of 15 (,d+[DATE] Cognitively Intact). The same MDS assessment indicated it was very important to go outside to get fresh air weather the weather was good. R84's care plan indicated he had a diagnosis of right below-the-knee amputation (BKA), major depression disorder and diabetes mellitus. R84 was at risk for falls and required one person assist with slide board and gait belt for transfers between surfaces. R84's care plan indicated therapy was to evaluate for safety for use of electric wheelchair on [DATE]. Progress note dated [DATE] at 6:29 PM and incident report dated [DATE] at 2:20 PM, indicated R84 reported that between 1:00 PM and 3:00 PM, while he was off campus, he was crossing the street near a busy street, with his electric wheelchair and a truck cut him off. R84 stated that no contact was made with the truck. R84 stated he fell over and scraped his forehead and left knuckles. R84 stated good Samaritans stopped to help and assisted him back onto his wheelchair. R84 stated that they offered to call paramedics, but that he denied needing to go to the hospital. R84's wounds were treated, and intervention was to have therapy assess for safety with electric wheelchair. Physician's order dated [DATE] at 10:06 AM revealed therapy order to evaluate R84 for electric wheelchair. In an interview with Nursing Home Administrator (NHA) A on [DATE] at approximately 2:00 PM, the first electric wheelchair evaluation was on [DATE]. In review of R84's [DATE] electric wheelchair evaluation, it was recommended he decrease speed for safety. On [DATE] at 05:27 p.m. Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy that began on [DATE] and was identified on [DATE] due to the facilities failure to ensure that residents are free of accident hazards/supervision/devices. Immediate Jeopardy was removed on [DATE] when the facility had the following in place: As of [DATE] the Administrator educated the Director of Rehab on the completion of Power-Mobility Indoor Driving assessment mobility device and driver Experience check list for resident with electric scooter or electric wheelchairs. As of [DATE] the Director of Rehab began immediate education of the therapy department staff on the completion of Power-Mobility Indoor Driving assessment mobility device and driver experience check list for residents with electric scooters or electric wheelchairs. As of [DATE] the Therapist who removed the electric wheelchair/scooter from its locked up location in the therapy gym was educated on the completion of Power-Mobility Indoor Driving assessment mobility device and driver Experience check list, including the need to keep electric scooter/wheelchair in a locked location after training and until the completion of the Power-Mobility Indoor Driving assessments mobility device and driver Experience check list, and the resident has been deemed safe to drive As of [DATE] the facility van driver will be re-educated on the safety process of the facility vehicle (bus) prior to the start of his next shift. As of [DATE] the Director of Rehab completed 6 of 6 Power Mobility indoor driving assessment mobility device and driver experience check list for residents with electric scooters or electric wheelchairs and deemed safe for using an electric wheelchair or scooter. As of [DATE] the facility educated 3 of 3 contracted Licensed Physical Therapist/Occupational Therapist staff. As of [DATE] The facility Medical Director was notified. As of [DATE] The IDT (Interdisciplinary team) completed a chart audit on the 6 residents who use an electric scooter or electric wheelchair ensuring physician orders are complete, care plans reviewed to ensure resident care planned of the use of electric wheelchair or scooter and matches therapy Power-Mobility Indoor Driving assessment. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency. 30337

This citation pertains to intake MI00133592, MI00134607, MI00132301, and MI00134412. Based on observation, interview, and record review, the facility failed to monitor, provide care and treatments according to professional standards of practice, the care plan, and resident choice in 6 of 6 residents reviewed for care and services (Resident #2, #4, #5, #12, #14, & #17), resulting in the medications, treatments or care not provided (Resident #2, #4, #5, #12, #14,#17), emergency room transfers (Resident #4, #5, #17), a delay in treatment (Resident #5), and treatment for infection (Resident #5). Findings include: Resident #2 (R2) R2's hospital history and physical dated 2/09/23, indicated she was alert and oriented to person, place and time; had fallen at home at an assisted living facility and had a humeral (large bone of upper arm) fracture. R2's history and physical revealed she had the diagnoses of chronic back pain, heart failure and diabetes mellitus. R2's entry Minimum Data Set (MDS) assessment indicated she admitted to the facility on a Friday, 2/10/23. R2's discharge MDS indicated she was discharged on [DATE]. In review of R2's admission assessment, it was not completed until Monday, 2/13/23. R2's care plans were not initiated until 2/13/23. In review of R2's February 2023 Medication Administration Record (MAR), Aspart insulin, 7 units with meals not given on 2/10/23 at dinner and 2/11/23 at dinner. Aspart insulin was discontinued on 2/12/23 with no rapid acting insulin administered on 2/12/23, Aspart insulin was re-ordered on 2/13/23, but not administered on 2/13/23 and 2/14/23. R2 did not receive coumadin on 2/10/23. R2 did not receive Levemir insulin at night on 2/10/23. In review of R2's Inventory of Personal Effects dated 2/10/23, 2 insulin pens were given to the nurse. Director of Nursing (DON) B was interviewed on 4/13/23 at 2:40 PM and stated the facility had insulin in their back-up supply. Social Services director O was interviewed on 4/13/23 at 3:48 PM and stated R2 was transferred to a different facility. Resident #12 (R12) R12's MDS dated [DATE] revealed he admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), cognitive screener, score of 5 (00-07 severe cognitive impairment). In review of Medication Reconciliation Summary dated 11/01/22, active medications included Cyancoabalmin1000 milligrams (mg)daily (Vitamin B12) and Cholecalciferol 10 micrograms (mg) (D3 400 units). In review of R12's November 2022 Medication Administration Record (MAR) Cyanocobalamin 1000 mg was not transcribed to the MAR and Cholecalciferol 10 mcg (D3 400 units) was transcribed as Cholecalciferol 1000 units. Licensed Practical Nurse unit manager (LPN) P was interviewed on 4/13/23 at 4:11 PM and stated R12's medication list had active and suspended medications listed and caused confusion with her and the facility physician. LPN P stated she did not call the facility that sent the medication list for clarification. Nurse Consultant Q was interviewed on 4/13/23 at 3:59 PM and stated she talked to R12's spouse at one point regarding medication concerns and the physician changed the medications. R12's blood pressures ranged 139 to 179/70-104 from 11/24/22 to 1/03/23. Lisinopril-hydrochlorothiazide was listed on the Medication Reconciliation Summary dated 11/01/22 as suspended. Nurses Notes dated 1/11/23 at 2:44 PM indicated R12's Lisinopril-hydrochlorothiazide Tablet 10-12.5 MG was updated to twice daily per wife stating that he had previously taken it twice a day. Unit manager called and clarified with Physician and got the order updated. R12 was discharged from the facility on 1/04/23. Resident #14 (R14) During an observation on 4/12/23 at 4:30 PM, Nurse Assistant L assisted R14 turn from his back to his right side; R14's catheter bag was hooked on the bed frame on the left side of the bed. R14 did not have a catheter securement device and pulling was observed. NA L assist R14 to his back, removed the catheter from the bed frame, and then turned him back onto his right side to observe his wound dressing on his coccyx. R14's coccyx pressure ulcer dressing was observed and dated for 4/10/22. R14's April 2023's Treatment Administration Record (TAR) revealed a physician's order dated 4/06/23 for treatment for a coccyx wound: cleanse with wound cleanser, pat dry, apply Hydrofera Blue dressing cut to size of wound bed, cover with bordered foam dressing, change daily on day shift. R14's care plan initiated 1/17/23 revealed he was admitted to facility on 1/14/23 and had an existing stage IV pressure wound (full thickness tissue loss with extensive destruction; exposed bone, tendon or muscle) to his coccyx. R14 was at risk for pressure ulcer development related to diabetes mellitus, history of chronic wounds, bedbound, impaired mobility, and lymphedema (swelling in leg caused by lymphatic system blockage). Approaches included to provide foley catheter care and colostomy care. R14's indwelling catheter care plan revised on 2/08/23 indicated his goal was to remain free from catheter-related trauma through review date. R14's approaches did not include a catheter stabilization device to secure his catheter to eliminate chance of a sudden pull and accidental removal of the catheter. 46954 Resident #4 (R4) Review of an Admission Record revealed Resident #4 (R4) admitted to the facility on [DATE] with pertinent diagnoses which included osteomyelitis, multiple sclerosis, hypertension, anxiety, and major depressive disorder. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/2/22, reflected R4 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R4 required extensive assistance of two or more people person to toilet, transfer, dress and for bed mobility. R4 no longer resided in the facility. Review of R4's Wound assessment dated [DATE] revealed R4 admitted to the facility with a Stage 4 Sacral Pressure Ulcer that measured 32.57 centimeters (cm) x 7.62 cm x 5.91 cm with the depth of the wound measuring 2.2 cm. Treatment for the Pressure Ulcer included continuous wound vacuum therapy. Review of a Nurse's note dated 1/3/23 at 2:18 PM revealed Resident [R4] VS [vital signs] out of normal range today. NP [Nurse Practitioner] Nurse Practitioner (NP) D asked for VS [vital signs] to be monitored frequently. Resident wife arrived asking for resident to be sent out. Resident diaphoretic, Tachypneic, hypotensive and tachycardic. NP [nurse practitioner] notified of wife's request to send resident out to ER [emergency department] at 1350 [1:50 PM]. DON [Director of Nursing] notified at 1352 [1:52 PM] of same. [Local transportation service] notified of need for transfer at 1354 [1:54 PM]. Stated they had no units and would turn call over to [Local Emergency Medical Service] arrived at 1410 [2:10 PM] and departed at 1420 [2:20 PM] enroute to [Local Emergency Department] for eval [evaluation] and treatment . Review of a Physician Note dated 1/3/23 revealed a [AGE] year-old male with chronic medical conditions including MS [multiple sclerosis], sacral decubitus ulcer, overall decline since his most recent hospitalization . Staff notes patient had a temperature yesterday evening T-max 102.1. T-max today 101.1. Staff notes COVID negative. Staff reports patient is otherwise stable and patient continues to tolerate room air. Staff reports patient is tolerating Foley catheter. Patient is a questionable historian, however, he is able to respond to direct question. He reports he does not feel well. He notes he has a cough. He denies chills/fever. Staff notes poor oral intake .COVID negative. I will order stat labs CBC, CMP as well as stat radiology to do chest x-ray. UA pending .We will continue to monitor closely, q.[every] hour vital signs. Increase fluid if able. Patient is high risk for decompensation. Review of the Electronic Medical Record revealed the following vital signs: 1/2/23 7:21 PM 102.1 degrees Fahrenheit temperature; 146 / 100 Blood pressure 1/3/23 5:02 AM 101.1 degrees Fahrenheit temperature; 118/76 blood pressure 1/3/23 9:29 AM 98.0 degrees Fahrenheit temperature; 116/71 blood pressure The last set of vital signs was obtained at 9:29 AM which indicated no evidence of frequent monitoring of R4's vital signs as requested by Nurse Practitioner D. In an interview on 4/11/23 at 2:10 PM, Family Member (FM) E reported R4 went to the wound clinic about once a month for management of his sacral pressure ulcer. Family Member E reported that she visited R4 almost every day and at times she would come in and discover that R4's wound vacuum was not operating because the staff could not get the wound vacuum to seal so they wouldn't put it back on or she would observe the wound vacuum unplugged. FM E reported that the wound vacuum unit that R4 had could not hold a charge so in order to be functional, R4's wound vacuum had to be plugged in at all times. FM E reported that the day of 1/3/23 she had called the facility multiple times in an attempt to speak to R4 but did not get an answer from the facility, so FM E got around and went up to the facility to visit R4. Upon arrival to R4's room, FM E stated she recognized immediately that something was wrong with R4 because he was not able to answer FM E or recognize her, which was abnormal from his baseline. FM E inquired with the nurse in charge and was told that the nurse in charge was in contact with the doctor and the doctor reported to just monitor [R4] every half hour. I said absolutely not . send him to the hospital . FM E stated that the wound vacuum was not running when she arrived at the facility on 1/3/23 and that it had been off for a few days. FM E also stated that the reservoir on the wound vacuum had dark, dried blood in it and the wound smelled terrible, it made [R4'S] entire room smell terrible. Review of the Patient Care Record dated 1/3/23 at 2:09 PM obtained from the local Emergency Medical Service that assessed and transported R4 to the local Emergency Department revealed Upon arrival [staff] reports the patient is being sent to the ER (Emergency Department) because [R4'S] vital signs have been changing often which is abnormal for the patient. Staff reports the males wife (FM 'E') has requested he is sent out of the facility. Staff states the male has been diaphoretic today and is concerned this may be due to his changing vital signs. Upon making contact with the patient [R4], patients family reports that the patients [R4] wound vac (vacuum) has not been turned on as it is supposed to and feels that the patients wound now has an odor to it .Patient (R4) appears to be unbathed and appears to have dried vomit on his face. Patients (R4's) sheets are also saturated. Family reports the patient is in the facility for osteomyelitis of his vertebrae which is why the patient has a wound vac (vacuum). Family states the patient is usually alert and oriented x4 and has found today that he is not oriented and not acting like himself .Patient alert and not oriented. Patient displays stupor and is found to be diaphoretic, pale and with skin hot the the [sic] touch. Patient displays labored breathing .patients wound vac (vacuum) is found with a small amount of dried blood that is almost black in color inside of the vac (vacuum) reservoir . R4 was transported Priority 2. Review of the same Patient Care Record revealed R4 had the following vital signs: 2:25 PM- 151/128 Blood Pressure, 110 Pulse, 24 Respiratory Rate, 82 percent oxygen saturation on room air, 101.5 degrees Fahrenheit temperature 2:25 PM- 151/128 Blood Pressure, 110 Pulse, 24 Respiratory Rate, 101.5 degrees Fahrenheit temperature Review of the Medical Records from R4's 1/3/23 hospitalization revealed Upon arrival (to the Emergency Department) [R4] was hypertensive with the blood pressure of 170/120, a heart rate of 120 . and an oxygen saturation of 82 percent on room air . Patient has had a cough .also has a wound to his coccyx and is supposed to have a wound vac (vacuum) but has not been turned on for the last two days according to the [family member E] who was at the nursing home. She requested transfer to the hospital due to his altered mental status. The physical exam revealed mucous membranes dry, core temperature was obtained . and was 39.8 (103.6 degrees Fahrenheit) rectally after evaluation I (emergency room Physician) am most concerned about sepsis .his white (blood) cell count was over 26,000 .his chest x ray shows bilateral pneumonia . patient has acute kidney injury with a significantly elevated creatine (indicating that the kidneys were not working as well as they should) .also has this infected wound . R4 was admitted to the local hospital in critical condition with diagnoses that included Septic Shock, Urinary Tract Infection, Pneumonia, Acute Kidney Injury secondary to dehydration, acute encephalopathy (permanent or temporary brain damage, disorder, or disease), acute hypoxic respiratory failure (not enough oxygen in your body or too much carbon dioxide), and lactic acidosis. Review of the Wound Consultation Notes from the same Medical Records revealed R4 had new necrotic tissue in the wound bed that was not present in the photographs from the prior wound clinic visit that occurred on 12-29-22 and a foul odor coming from the wound. Upon arrival to the Emergency Department, it was noted that the wound was assessed and discovered fecal matter in the wound. R4 underwent a wound debridement of his sacral pressure ulcer during his hospitalization . Review of the same medical records revealed R4 became hemodynamically unstable shortly after arrival to the local Emergency department. R4 required vasopressor medications (medication to elevate blood pressure) and a central venous catheter (a long, flexible tube your provider inserts into a vein in your neck, chest, arm or groin. It leads to your vena cava, a large vein that empties into your heart) in an attempt to ensure R4 stabilized medically. In an interview on 4/12/23 at 11:15 AM, Registered Nurse F reported that R4's wound vacuum would often give staff members trouble with both battery issues and issues with getting the vacuum to seal over the sacrum wound. RN F reported that the wound vacuum would not hold a charge and required to be always plugged in to remain powered on. RN F reported that a couple of times R4 would return from his Wound Clinic appointments and staff would not notice it so the Wound Vacuum would not get plugged back in and powered on. This would go unnoticed for a few hours. RN F also reported that she observed fecal matter in R4's sacrum wound a couple of times. In an interview on 4/13/23 at approximately 11:30 AM, LPN G reported that R4's wound vacuum was difficult to keep in place .we had some newer nurses and some of them didn't know how to do them (wound vacuum). (R4) was bowel incontinent and the stool would go right up underneath the plastic which would loosen the seal . at times it lost suction and the staff would have to redo the dressing change. LPN F also reported that it would take up to 40 minutes to complete R4's dressing change. When asked if staff had any additional education regarding the wound vacuum, LPN F stated that she had gone through several classes specific to wound vacuums but none at the facility. No classes on wound vacuums or additional education were offered at the current facility. LPN F also reported that if she has a resident that looks like they are feeling ill, best practice is to send the resident out to the hospital. We can't diagnose them so send them out, I'm not going risk their lives because someone doesn't want to send them out . if the resident needs to be sent out emergent, I would not use (transportation ambulance service) them at all, I would call 911 . In an interview on 4/13/23 at 2:24 PM, Director of Nursing B was unsure if a head-to-toe assessment was performed on R4 the day he was requested to be sent out to the hospital or who may have performed the head-to-toe assessment. In an interview on 4/12/23 at 12:27 PM, Paramedic H reported that the local transportation service initially contacted when R4 was requested to be sent to the hospital on 1/3/23 is used just for transport, they can't do EMS (emergency medical services). [The local transport service] can be contacted for any kind of Priority 3 calls or scheduled transfers, but anything that requires urgent/emergent response, those types of calls would require EMS services. Review of the Tri-County Emergency Medical Control Authority Systems Protocol dated 3/1/13 revealed Priority One and Priority Two patients are for patients whose conditions could reasonable be expected to worsen without immediate intervention. Priority 3 would be reserved for non-life-threatening calls. Resident #5 Review of an Admission Record revealed Resident #5 (R5) admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included urinary tract infection, acute kidney failure, malignant neoplasm of bladder, personal malignant neoplasm of prostate, major depressive disorder, and restless leg syndrome. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/19/22, reflected R5 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R5 required extensive assistance of two or more people to toilet and transfer. R5 no longer resided in the facility. R5 was admitted to a local Hospice shortly after admission to the facility. Review of a Physician Note dated 9/16/2022 at 10:47 AM revealed Staff notes patient (R5) was found to have his suprapubic catheter (surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) dislodged. Staff notes patient is otherwise stable and afebrile. Staff notes Hospice is aware. Staff reports patient's nephrostomy tubes (drains urine directly from your kidney into a bag outside your body into a bag) appear to be functioning . Review of the Progress Notes revealed no other mention of an incident report and/or assessments regarding the dislodgment of the suprapubic catheter. Review of a Nurse's Note dated 9/20/23 at 6:53 AM revealed R5 was observed on the floor next to bed. Resident was assisted back into bed. No injuries . Review of the Progress Notes revealed no mention of an assessment to ensure the patency of the suprapubic catheter and/or the nephrostomy tubes. Review of a Physician Note dated 10/3/2022 at 12:34 PM revealed Patient (R5) was transferred to the hospital after his nephrostomy tube was dislodged. Patient was found to have lactic acidosis and leukocytosis, he was started on empiric antibiotics, he was also given blood transfusion for anemia. Patient is currently under Hospice care . His nephrostomy tube was replaced. He was transitioned to oral antibiotics and discharged back to our facility . Review of the Care Plan revealed that R5 had no Care Plan implemented for the nephrostomy tubes. Review of the Physician Orders revealed R4 had an order in place since admission to change the drain sponges on both nephrostomy tubes daily as well as an order to clean and change the split 4 x 4 dressings on R4's suprapubic catheter daily and as needed. In an interview on 4/10/23 at 12:23 PM, Hospice Nurse Practitioner (NP) K reported that the lack of care for R4 was very concerning. We attempted to have several care conferences with the facility, but we never actually ever were able to meet in person with the Director of Nursing (DON), I only spoke with her on the phone about wanting to set up a care conference but it never happened. We had several meetings with staff at the facility regarding providing adequate care for R4, especially his nephrostomy tubes. [R4] had multiple ER [Emergency Department] trips for dislodges tubes. Often times, we [Hospice NP and RN] would arrive and [R4] would have no dressing on his nephrostomy or suprapubic tubes and he would be sitting in stool with his bed saturated in urine. The urine would be there for so long that at times, the urine would be dried on the sheets. [R4] should not have been in this condition. On one occasion one nephrostomy tube was leaking and been pulled out and the aide [Certified Nursing Assistant] said she had notified the nurse a couple days ago. We evaluated it and at that time there was an actual dressing on it [the nephrostomy tube] because I put it on during a previous visit and dated it . I know one time I had the DON at the meeting, it was actually someone that was sitting in for the DON at the time, I had him come down and provided education on how to appropriately dress these nephrostomy tubes which was a daily clean and change, several days later that date was still on the dressing. It was saturated, the [nephrostomy] tube was pulled out and not in position. We had to send [R4] to the ER. I saw [R4] way more often than I typically do just because of everything that was going on. Before care conferences we [hospice staff] would have to come in and spend a good 20 to 30 minutes getting [R4] cleaned up to get him ready up for his wife. The bed linens were constantly soaked and [R4] would be sitting in soiled briefs. I spoke to the DON about doing check and changes, the additional visits that myself and the nurses made because the facility wasn't doing care and tried to educate the facility so we could collaborate to give him the best care. I've been in several facilities, and this is the worst I've ever seen. Review of the Hospice Notes for R4 dated 9/28/22 revealed had just left facility care conference with social worker, LPN (Licensed Practical Nurse) filling in for Nursing Manager, Activities Director, Hospice Social Worker, Hospice Nurse Practitioner, and patients wife along with two advocates .our concerns were addressed with patient not being given the care that he needs, especially with dressing changes for the suprapubic and the nephrostomy tubes. Multiple disciplines have all been in from hospice, all stating that patient was not clean, and dressings were not on the drain sites. After the care conference Nurse Practitioner .went to patients room. Patient looked drastically different than 10 days ago when [hospice] saw him last. Patient looks thinner, pale, a beard starting to grow. Hospice nurse assessed and found he was alert and oriented to self only, 10 days earlier he was alert and oriented x 3 .patients sheets, mattress, blankets, and clothing saturated with urine. Upon further assessment discovered that right nephrostomy tube was almost an inch out from sutures and coiled . there was a scant amount of urine in right nephrostomy tube drain bag but floor RN (Registered Nurse) .was unable to confirm the last time it was drained .[hospice staff] gave patient a full bed bath, cleaned the bowel from his bottom, and did complete clothing, dressing, and bed sheet change . Review of the same Hospice Note dated 9/28/23 revealed Care conference at facility .meeting was brief as facility stated they needed to get to another meeting. Concerns were expressed about the need for daily dressing changes on the nephrostomy tubes as hospice staff have found dressings almost a week old or no dressing at all .after care conference saw PT [patient] laying in bed with no shirt on hands dirty, hair disshelved, sitting in stool and bed linens with large amount of dried urine. Assessment of right nephrostomy tube revieled [sic] a saturated dressing, removed dressing and noted nephrostomy tube was out by atleast 1in. small amount of urine in bag of right nephrostomy tube. Per aide (certified nursing assistant) she noted bed was soaked yesterday too .explained to patient and [family member] that patient needed to go to the hospital to have the right nephrostomy tube replaced . PT [patient] is AAOX1 [only recognizable to self] today, was AAOX3 [alert and responsive to their environment, and knows who they are, where they are, and the approximate time] on admission. Has not received any PRN (as needed) doses of the Morphine or Ativan. Review of a Nurse Note dated 9/28/22 at 6:02 PM revealed R5 was transferred to the hospital. Review of the Hospital Record dated 9/28/22 revealed R5 had a dislodged right sided nephrostomy tube and endorsed being in a significant amount of pain. R5 could not recall how the nephrostomy tube was dislodged. R5 had an elevated white blood cell count (indicative of infection) and blood loss anemia. R5's computed tomography imaging scans confirmed that the right nephrostomy tube was nearly completed withdrawn from the skin and the left side of R5's abdomen had fluid collection under the skin consistent with urinoma (a collection of urine under the skin). Additionally, the left side of R5's abdomen was moderately distended with concern for left sided kidney hemorrhage (bleed). R5 was also diagnoses with an acute kidney injury secondary to obstruction with the right sided nephrostomy tube being dislodged. R5 received 4 grams of Zosyn (antibiotic) for the possible peritoneal fluid infection. R5 was given three units of packed red blood cells to correct the anemia. The same Hospital Note revealed R5 was not being cared for well at the facility and the Physician noted she would work with the hospital Case Manager to find different placement. In an interview on 4/12/23 at 1:54 PM, Family Member Q stated he [R5] wasn't getting good care .they let him lay in his poop . I would come in and see and smell that he wasn't cleaned up . In an interview on 4/11/23 at 2:10 PM, Registered Nurse (RN) F reported that staffing was an issue related to R5's dressing change. When asked if staffing shortages was the issue for ensuring dressing changes were completed as ordered, RN F reported absolutely I did not have enough time to do those [dressing change]. It was difficult enough trying to get medications done on top of everything else. I did not have enough time to do the dressing changes . I would always try to do dressing changes and they would be late or just not done and I had to pass the responsibility off to the next shift. When asked if the facility provided any additional education regarding the nephrostomy and suprapubic dressing changes, RN F stated no, In an interview on 4/13/23 at approximately 11:30 AM, LPN G reported that she was aware of the concerns with Hospice regarding care and dressing changes but did not receive additional education. In an interview on 4/13/23 at 4:00 PM, Former Director of Nursing (DON) R reported that she was aware of the care concerns that Hospice brought forward to the facility. DON R reported that staff was provided additional education and competencies regarding nephrostomy and suprapubic dressing changes. Personal files including education and competencies were requested and reviewed on 4/13/23 for Licensed Practical Nurses G, R, S, T, and U, nurses that commonly cared for R5. After review of the files, it was determined that none of the aforementioned employees received any additional education related to the care of R5, including dressing changes, suprapubic tube care, and nephrostomy tube care. Resident #17 Review of an Admission Record revealed Resident #17 (R17) admitted to the facility on [DATE] and readmitted to the facility on [DATE] with pertinent diagnoses which included hypertension, type two diabetes, quadriplegic, neuromuscular dysfunction of bladder, depression, and muscle weakness. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/27/23, reflected R17 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R17 required extensive assistance of two or more people person to toilet, and dress and total dependence to transfer. Review of the Electronic Medical Record revealed that R17 admitted to the facility with an indwelling urinary catheter related to the diagnosis of neuromuscular dysfunction of the bladder. Review of R17's Care Plan revealed that there was no Care Plan implemented for R17's indwelling Urinary Catheter. Review of a Nurses' Note dated 10/18/22 at 12:58 PM revealed Resident complained on [sic] burning upon urination, frequency, and has blood in urine. Contacted NP (Nurse Practitioner) Review of a Nurses' Note dated 10/18/22 at 10:37 PM revealed Resident [R17] c/o (complaining off) pain with urination. CNA (Certified Nursing Assistant) was putting resident to bed and noticed residents' penis was very swollen and notified writer. Upon examination writer noticed that the foley cath [catheter] balloon had been dislodged into the shaft of the penis. Resident did tell writer that when getting up for the day it was accidentally pulled on . Review of a Nurses' Note dated 10/20/22 at 5:02 AM revealed Resident c/o (complaining off) pain in the urethra. Observed blood in foley bag and large cloths in tubing. Urine unable to pass, changed catheter. Large clot observed in catheter that was removed . Review of a Nurses' Note dated 10/20/22 at 7:18 AM revealed resident presents with red blood in catheter, c/o (complained of) suprapubic pain, nurse from night shift changed catheter, after having no output .no output since 4am . notified doctor, advised to flush catheter again .resident requested to be sent out to the hospital. Review of the Hospital Records dated 10/20/22 revealed R17 presented to the hospital on 10/20/22 for [complaint] of hematuria (blood in urine) and anasarca ( severe and generalized form of edema, with subcutaneous tissue swelling throughout the entire body) of unknown etiology. Patient has a chronic foley catheter since February 2022 .patient states that he feels pain during urination and states that he had never had this problem in the past . R17 was ultimately diagnosed with hemorrhagic cystitis (bleeding and inflammation of the bladder) and underwent a procedure to have a suprapubic catheter placed (surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow). Review of a Nursing Evaluation Summary Note dated 11/8/22 at 2:17 AM revealed R17 returned to the facility. Review of R17's Care Plan revealed the Indwelling and Suprapubic Catheter Care Plan was initiated on 11/9/22. Interventions included having a catheter anchor in place and maintain patency of both catheter. Review of the Physician Order's revealed there was no order set pertaining to the surgical wound care and management for R17. Review of a NP/PA Progress Note dated 11/15/22 at 10:02 PM revealed .nurse reports patient [R17] has been becoming increasingly confused for the last few days. Nurse observed yellow and greed [sic] discharge around indwelling catheter. Oxygen sat [saturation] 81% (percent). Temp (temperature) 101.7 (degrees Fahrenheit) .send to ER (Emergency Department) to be further evaluated. Review of a Nurses' Note dated 11/15/22 at 11:16 PM revealed R17 had increased confusion and had some yellow/green drainage from R17's penis and suprapubic site. The Nurses' note also revealed that there was some odor with the drainage. R17 was transferred to the Emergency Department. Review of a Physician Progress Note dated 11/16/22 at 7:27 PM revealed that R17 was evaluated at the Emergency Department and discharged back to the facility with an antibiotic. Review of the Treatment Administration Record revealed R17 had an order to cleanse suprapubic insertion site with wound cleanser; apply split gauze dressing every evening shift that was not initiated until 11/22/22, 14 days after returning to the facility with a

This citation pertains to MI 282 and MI 7207. Based on observation, interview, and record review, the facility 1) failed to ensure adequate supervision for one out of five residents (Resident 12 (R12)), who had a Wanderguard bracelet (bracelet that is placed on a resident that alarms when resident approaches a door equipped with a Wanderguard alarm) on her person, resulting in Immediate Jeopardy when on 10/31/2019 at 5:48 PM, R12 exited the main entrance of the facility unbeknownst to facility staff, and was located in a nonfunctional vehicle in the facility's front parking lot two hours and 47 minutes later, placing 18 residents identified to have a Wanderguard bracelet in place at a high risk for serious harm, injury, and/or death; and 2) failed to implement appropriate interventions to prevent and/or reduce falls for two (Resident #1 and #4) of eight reviewed for falls, resulting in repeated falls and the potential for serious injury. Findings Included: Per the facility face sheet R12 was a [AGE] year old female admitted to the facility on [DATE], and had a [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) Assessment, dated 10/6/2019, revealed R12 scored a six on her Brief Interview for Mental Status (BIMS) which indicated a decline in her cognitive ability. The MDS revealed R12 had poor recall, was not oriented to time, and had delusions. Review of a Risk of Elopement/Wandering Review, dated 10/18/2019, revealed R12 had poor decision-making skills, could ambulate independently, had verbally expressed the desire to go home, packed her belongings to go home, or stayed near an exit door. The review also revealed R12 was at risk for elopement and had attempted to exit the facility several times on 10/18/2019. Review of R12's Physician orders, dated 10/18/2019, revealed a physician's orders [REDACTED]. Record review of R12's care plans revealed a care plan, dated 10/18/2019, in place related to, The resident (R12) is at risk for elopement .r/t (related too) history of attempts to leave the facility unattended, impaired safety awareness, dx (diagnosis) of dementia, [MEDICAL CONDITION] disorder, delusions. The care plan revealed R12 had delusions of husband/son/family coming to pick her up, but R12 did not have a husband, and thought they were waiting outside for her. The care plan also revealed R12 may state she wanted to catch the bus. Interventions in place on the care plan consisted of, Distract resident (R12) from wandering by offering pleasant diversion, structured activities, food, conversation, television, book etc., maintain daily routine ., observe for acute process which may increase wandering, redirect from wandering to get on the bus by letting resident (R12) know the bus isn't running right now, and wander alert: Wanderguard. Review of a Progress Note, dated 10/23/2019, documented by R12's Medical Provider revealed R12 had been more exit seeking lately. Review of R12's Progress Notes, dated 10/29/2019 revealed a notation that R12 had, Delusions that husband/son/family are coming to pick her up with attempts to exit facility unattended. Review of R12's Progress Notes, dated 10/31/2019, revealed a note, dated 11/1/2019, Resident (R12) observed walking out front door with family member. Upon returning resident in stable condition, Resident transferred to the memory care unit (secure unit). Another note, dated 11/1/2019, revealed that on 10/31/2019 R12 had ambulated with her walking to the door and verbalized she wanted to leave and go home. Review of a facility incident report, dated 10/31/2019, revealed R12 was observed walking out front door when another resident's family member turned off the alarm. The incident report revealed R12 went and sat in an unlocked car. Although, at the top of the incident report document a box was checked that revealed, Was incident witnessed, No. The report revealed R12 had a memory and decision-making impairment. Under Incident Type another box was checked that revealed the incident was unobserved. In an interview on 11/4/2019, at 2:19 PM, with a confidential staff member, it was stated R12 had eloped from the facility on Halloween night (10/31/2019) just prior to the dinner time. The confidential staff member stated R12 went out the front door undetected, in the bad weather, rain, snow and cold. Confidential staff member said R12 had gotten into a vehicle that was in the front parking lot and said the facility staff did not know she was gone for 3 hours. In an interview on 11/4/2019, at 2:53 PM, with another confidential staff member, it was stated that R12 was let out by another resident's family member and sat in a vehicle for a few hours. Confidential staff member stated that no staff knew she was gone. In an interview on 11/5/2019, at 11:38 AM, CNA T stated that it was her vehicle R12 got into, and said it was parked in the front of the facility in the employee of the month parking spot. CNA T said her car had been sitting there for about 2-3 days before Halloween and it would not start. CNA T said the vehicle had not been started since it had been sitting there. In an interview on 11/4/2019, at 3:31 PM, Administrator A stated R12 had spoken about leaving the facility, so on 10/18/2019 the Wanderguard bracelet was placed on her person, but also stated R12 had removed the Wanderguard bracelet on 10/26/2019 so another one was placed on her. Administrator A stated on Halloween night another resident's family member put in the code to unlock the front entrance door, and R12 had followed the family member outside, and got into a car that belonged to a staff member located in the front parking lot. Administrator A said per the video surveillance R12 was outside in the car for about one hour. Administrator A said it was about dinner time and R12 was walking the hall and when the Wanderguard code was disabled at 5:50 PM. Administrator A it was after dinner when staff noticed R12 was gone and had not returned from dinner. Observation on 11/5/2019, at 10:00 AM, of video surveillance of the facility's main front door revealed that on 10/31/2019, at 5:48 PM, a family member of another resident approached the front door entrance and put in the code to unlock the door, and then exit the facility, in which R12 followed her out the door at 5:48 PM. The family member was observed to reenter the facility and punch in a code again at the same code box. Administrator A stated that a different code number was used to disable the Wangerguard alarm, and said the only way that family member knew the code to disable the Wanderguard alarm was because she had to do it when she would take her mother out of the facility who also wore a Wanderguard bracelet. Further review of the video surveillance revealed R12 had on pants, shoes, long sleeve shirt, and a purse over shoulder. The video surveillance revealed that at 8:35 PM (two hours and 45 minutes later) R12 was escorted back into the facility by nursing, Social Services, her brother, and 3 police officers. The video revealed that at the time of R12 exiting the facility, sounding the Wanderguard alarm, and the family member returning inside to silence the Wandergaurd alarm, no staff member was observed on the video responding to the Wanderguard alarm sounding. In an interview at the time of the video surveillance review Administrator A, and Director of Nursing (DON) B, DON B said she was notified at 7:48 PM from Administrator A, and arrived at the facility at 8:30 PM. Administrator A said she received the call at approximately 7:26 PM. Admin A said R12 was located sitting in a white jeep that belonged to a CNA, and said the vehicle had been in the parking lot for 3 days. According to www.wunderground.com, at 4:00 PM on 10/31/19, the temperature outside was 36 degrees Fahrenheit. At 5:00 PM, the temperature was 34 degrees Fahrenheit. At 6:00 PM, 7:00 PM and 8:00 PM, the temperature was 33 degrees Fahrenheit. In an interview on 11/5/2019, at 9:33 AM, Certified Nurse Aid (CNA) S, who was R12's CNA on 10/31/2019 on the second shift, said she did not know what happened to R12, and she had not seen R12 for awhile which caused her to start looking for her. CNA S said R12 had a Wanderguard bracelet on. CNA S stated R12 was walking down the hall towards the main entrance and the main dining room at about 4:00 PM on 10/31/2019. CNA S said R12 told her that she was going to Arkansas, and said she then asked R12 if she would be back before dinner, in which R12 replied yes. CNA S said she figured there were other staff down in the area R12 was walking towards. CNA S further stated that she usually worked on the 500 hall and had seen R12 attempt twice on the 500 hall to open the back door the end of the 500 hall. CNA S further stated when R12 would wander to the 500 hall she would say she was going to the bus and would have her purse with her and her coat on. CNA S said when R12 went out of her view she assumed she was in the dining room and so she then began passing meal trays. CNA S said could not find R12 to give her meal tray to her, and stated R12 always ate her meals in her room. CNA S said she then sat R12's meal tray down in her room and went looking for her. CNA S said she went to all the nurses' stations and asked if anyone had seen R12. CNA S said a couple of nurses, who names she did not know, had not seen her. CNA S said CNA P, who was on the 200 hall, said R12 had just been sitting with her 30 minutes prior, but said CNA P did not state where R12 had gone off too. CNA S then stated she went to all halls, the dining room, and kitchen asking if anyone seen R12 and no one had, so all staff begun looking in every closet, room etc . CNA S said by that time an hour and one half had gone by since she has last seen R12, and stated a code yellow (called over head for a missing resident) was then called about 2 hours after she observed that R12 went missing. CNA S said all staff kept looking for R12, over and over in all places, and then some staff began to drive around looking outside for her, but no one could find her so the police was called at approximately 8:00 PM. While continuing the interview with CNA S she stated that it was not my fault, because she could not watch her (R12), and said staff knew she wandered. CNA S said R12 was found in a jeep by the police. CNA S said an ambulance was called because R12 was outside to long, and it was cold, raining and snowing. CNA S said when R12 returned inside the facility she asked her where she had been, and R12 said who are you. CNA S said R12 was always confused, and going to Arkansas. Further interview with CNA S, CNA S said the facility's protocol was that everyone was supposed to keep an eye on R12, and staff were always on alert to watch a resident who was trying to elope, and staff were to check an alarm when it sounded. CNA S said that was what the Wanderguard alarm was for, and stated the alarm went off at the front entrance so she went to the front door and looked, she said she saw a family member putting in the code for the Wanderguard alarm which turned it off, and so she went back to the 400 hall. CNA S said she was surprised a family member knew the code to turn off the alarm, and stated she did not even know the code herself. CNA S said she never saw R12 at the door but stated that she did not ask the other resident's family member who turned off the alarm if a resident had exited the facility. CNA S said had to go back to the 400 hall. CNA S said she was the first one to question where R12 was and felt no other staff member took her seriously when she could not locate R12, because R12 always wandered. CNA S said she first look around the facility by herself. CNA S said she had never been instructed to increase supervision of R12. CNA S stated that she had not ever been trained on what to do when a Wanderguard alarm went off. Record review of CNA S's employee file revealed she was hired on 9/17/2019, and completed an Elopement Test for wandering residents. In an interview on 11/6/2019, at 10:56 AM, Licensed Practical Nurse (LPN) V, who was R12's nurse on 10/31/2019 when she eloped from the facility, stated he was not made aware R12 had her purse and said she was going to Arkansas. LPN V said he did not find out R12 was missing until after he gave report to another nurse, who asked where R12 was. In an interview on 11/5/2019, at 1:06 PM, CNA P said on 10/31/2019 she was sitting at a computer halfway down the 300 hall when R12 walked up to her and sat down. CNA P said R12 had her walker, sat down for about 10 minutes at about 4:30 or 5:00 PM. CNA P R12 did not state a purpose for her sitting down next to her. CNA P said R12 then left her walker behind and walked toward the front lobby nursing station. CNA P said she then went in the main dining room about 5:15PM or 5:30 PM. CNA P said she did not hear the Wanderguard alarm sound, and stated that CNA Scame up to her and asked her if she had seen R12, in which she then instructed CNA S look room to room. CNA P said she began to help looking for R12. CNA P said all the staff began to search all resident's rooms, and said she went outside, and down the street driving around looking for R12. CNA P said she was outside searching for about 30 minutes. In another interview on 11/6/2019, at 10:00 AM, Administrator A stated that at the point of R12 stating she was going to Arkansas she expected CNA S to have followed R12, and if an alarm that was a Wanderguard alarm sounded and CNA S saw R12 walking down the hall she expected staff to go to the alarm because R12 was known to be exit seeking. Administrator A said R12 had a Wanderguard bracelet on her wrist because she had made previous comments about leaving the facility. Administrator A said on 10/26/2019, R12 had cut off her Wanderguard bracelet so then it was then put on her ankle. In an interview on 11/5/2019, at 1:33 PM, Visiting Family Member (VFM) [NAME] said was not aware that a resident had followed her out the door on 10/31/2019. VFM [NAME] said the front entrance Wanderguard alarm would sound if a resident with a Wanderguard bracelet on stood to close to the door, and said she thought the alarm had sounded as a result of other residents in the lobby. VFM [NAME] said the code to go out the front entrance was 1119, and to shut off the Wanderguard alarm the code was 1379. VFM [NAME] said she would routinely shut the Wanderguard alarm off when trigger mother, who was a resident, triggered it. VFM [NAME] said the code to shut off the alarm had been the same code since she had known it in the end of (MONTH) 2019. VFM [NAME] said this was the first she had learned about this. VFM [NAME] also stated that the facility staff would not respond to the Wandergaurd alarm at the front entrance very often, but occasionally they would, such as when the after the alarm been going off for awhile. Review of the facility's policy and procedure titled, Unsafe Wandering & Elopement Prevention Protocol Missing resident Protocol, dated (MONTH) (YEAR), revealed under #4, Should an employee discover that a resident is missing from the facility, he/she should: b. Notify the licensed staff in charge immediately of the possible missing resident. On 11/5/2019, at 4:09 PM, the Administrator was notified if the Immediate Jeopardy that was identified on 11/4/2019, and began on 10/31/2019 when R12 exited the main entrance of the facility unbeknownst to facility staff, and was located in a nonfunctional vehicle in the facility's front parking lot two hours and 47 minutes later. On 11/12/2019 this surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: 1.) On 10/31/2019, R12 guardian was contacted and the doctor notified of the cited event. 2). On 10/31/2019, the DON, Administrator, and facility staff members participated in a QAPI action plan addressing Unsafe wandering protocol. 3). On 10/18/2019, R12 had an elopement assessment completed and was determined to be at risk and care plan updated with interventions. 4). On 10/31/2019, R12 was assessed by the licensed nurse and EMS, and there was no new health concerns identified post cited event. 5). On 10/31/2019, the 18 resident residing in the facility who were identified as being at risk for elopement were reviewed by facility nursing leadership to review current elopement risk, care plan, and Kardex to ensure appropriate assessment and interventions were in place. 6). An audit was completed on 11/1/2019, of the elopement book to verify that all facility residents at risk for elopement had an elopement photo sheet in place. 7). On 10/31/2019, signs were placed before entering the front door, viewable upon entrance and exit, as well as at the nursing station alerting persons that exit the facility not to assist residents outside without validating they are safe to do so with the nurse/designee. to 8). On 11/6/2019, the Administrator, DON, and IDT were re-educated on the Unsafe Wandering and Elopement Prevention Protocol-Missing Resident Protocol and Accidents, monitoring of residents that express desire to leave and/or exit seeking behaviors, immediacy of implementing missing resident protocol, and Incidents-Investigating and Reporting. 9). The Unsafe Wandering and Elopement Prevention Protocol-Missing Resident Protocol and Accidents and Incidents-Investigating and Reporting was reviewed by the Administrator and DON on 10/31/2019, and deemed appropriate. 10). On 11/6/2019, the Unsafe Wandering and Elopement and Missing Resident Protocol was updated to reflect, if the resident had been assessed to be at risk for elopement and verbalizing wanting to leave the facility, staff shall immediately notify the on call clinical supervisor for further individualized interventions. If the clinical supervisor is unavailable, notify the Administrator and/or DON. 11). An Ad Hoc QAPI meeting was held on 10/31/2019 to review the Unsafe Wandering and Elopement Prevention Protocol-Missing Resident Protocol and Accidents, and Accidents and Incidents-Investigating and Reporting and this plan. The Medical Director reviewed the plan with the Administrator on 10/31/2019 via telephone and he agreed with the plan. 12). Beginning 11/5/2019, facility Wanderguard system bypass codes changed at all identified exits to ensure no residents at risk for elopement are inappropriately let out of the facility by resident families/visitors. 13). Beginning 11/6/2019, re-education was provided to staff including, nursing, housekeeping, dietary, maintenance, and therapy by the DON/designee related to the Unsafe Wandering and Elopement Prevention Protocol-Missing Resident Protocol, monitoring of residents that express desire to leave and/or exit seeking behaviors, immediacy of implementing missing resident protocol, no employee will be allowed to work without receiving education. 14). Beginning 10/31/2019, new admissions will have a risk for elopement assessment completed. Those determined to be at risk will have their care plans and Kardex updated with appropriate interventions. These assessments will be reviewed during the next scheduled clinical meeting, Monday through Friday to ensure that they are accurate and that interventions are in place to meet the resident's needs. 15). Beginning 11/6/2019, weekly elopement drills will be completed by the facility to ensure understanding of facility Unsafe Wandering and Elopement Prevention Protocol-Missing Resident Protocol. 16). Beginning 11/6/2019, all resident responsible parties have been notified of the updated facility protocols pertaining to elopement. Although the Immediate Jeopardy was removed on 11/6/2019, the facility remained out of compliance at a scope of pattern and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance had not yet been verified by the State Agency. Resident #1 (R1) Review of the medical record reflected that R1 was admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/5/19, reflected that R1 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected that R1 required supervision to limited assistance of one person for most Activities of Daily Living (ADL's). R1's medical record reflected that she was sent to the hospital on [DATE] and returned to the facility on [DATE]. On 10/28/19 at 10:30 AM, R1 was observed lying in bed with her eyes closed and a cervical collar in place. A stop sign was observed across R1's room door. Her bed was in the lowest position, and a floor mat was at the right bedside. R1's call light was clipped to her comforter. An orthotic boot was noted in R1's room, next to her nightstand. On 10/29/19 at 11:54 AM, R1 was observed at the dining table with a cervical collar in place and an orthotic boot on her right foot. On 10/30/19 at 9:16 AM, R1 was observed seated in her wheelchair in the 100 hall Day Room. She had a cervical collar in place, a gripper sock on her right foot and a standard sock on her left foot. R1 stated her first name and reported that she had not yet had breakfast. R1 then made a statement that was not understood before being approached by Nurse Practitioner (NP) K. Review of R1's Progress Notes reflected an Interdisciplinary Team (IDT) note for 9/27/19 that revealed R1 was reviewed due to [MEDICATION NAME] (anti-anxiety medication) orders and increased lethargy. The note reflected that orders for [MEDICATION NAME] 0.5 milligrams (mg) twice daily and to hold for lethargy were in place. An Incident Report reflected that on 9/29/19 at 5:20 AM, R1 was observed lying on her right side at the foot of the bed. R1 had gripper socks in place, and her walker was at the head of the bed. The Fall Investigation Report reflected that R1 was attempting to go to the bathroom just before she fell . Documentation for the task of .Bladder Elimination . reflected that R1 was incontinent at 1:21 AM. No further toileting was documented in the .Bladder Elimination . task prior to the fall. R1 was sent to the hospital on [DATE] and was readmitted on [DATE] with injuries of cervical (C3) fracture and right fibula fracture. An S[NAME]-Falls Progress Note for 9/30/19 reflected it was reasonable to conclude that the root cause of the fall on 9/29/19 was R1 ambulating in her room and losing her balance. Care Plan interventions, initiated on 9/29/19, included, Anticipate and meet the resident's needs based on nursing assessments, Bed in lowest position when not providing care and Offer resident toileting assistance upon awakening, before meals and before bed. R1 did not have a Care Plan that addressed incontinence at the time of the fall. An Incident Report reflected that on 10/2/19 at 11:05 PM, R1 was observed on the floor, rolling in her feces. No new injuries were documented on the Incident Report. The Incident Report reflected the action taken was for a floor mat at the bedside. The Fall Investigation Report reflected that R1 slipped in feces while she was alone. The Fall Investigation Report reflected that R1 was attempting to go to the bathroom just before the fall, she was last toileted at 9:45 PM and was wet at the time of the fall. The task documentation for .Bladder Elimination . did not reflect any documentation for 10/2/19. The S[NAME]-Falls Progress Note for 10/3/19 reflected that it was reasonable to conclude that the root cause of the fall on 10/2/19 was R1 getting up out of bed due to being incontinent. A Care Plan intervention, initiated on 10/3/19, reflected, Floor mats to floor around bed. In an interview on 11/6/19 at 3:54 PM, Unit Manager (UM) W was asked how floor mats would have been an effective intervention for a fall related to being soiled and getting up unassisted to use the bathroom. UM W replied that intervention would not have been effective, but they were just thinking at least the floor would be soft. UM W stated there were no additional interventions for the fall on 10/2/19. An Incident Report reflected that on 10/4/19 at 4:00 AM, R1 was observed on the bedside floor mat. No new injuries were documented on the Incident Report. The report reflected that R1 rolled out of bed, and the action taken was for a scoop mattress. The Fall Investigation Report reflected the root cause was R1 being anxious, distraught and a change in mental status. According to the report, an additional intervention was to have the Physician review R1's psychiatric medications. The S[NAME]-Falls Progress Note for 10/7/19 reflected that it was reasonable to conclude that the root cause of R1's fall on 10/4/19 was having an increase in confusion due to limited immobility due to the orthotic boot for her right leg and the neck collar for her fractures from a previous fall. R1's Care Plans were not updated with fall interventions, including a perimeter (scoop) mattress, until 10/7/19. In an interview on 11/6/19 at 3:54 PM, UM W reported that the nurses were responsible for updating the Care Plans and interventions. When asked why there was a delay in adding the perimeter mattress to the Care Plan, UM W reported that the facility may not have had the mattress and may have had to order it. When asked if R1 would have had an immediate intervention in place to prevent further falls, UM W replied, no. A Psychiatric Visit Progress Note for 10/9/19 at 3:01 PM reflected that R1's medications included [MEDICATION NAME] (antipsychotic medication) 1 mg twice daily and [MEDICATION NAME] 0.5 mg twice daily. The note further reflected, .Primary recently started [MEDICATION NAME] for agitation. She has had several falls recently, one resulted in a C3 and tibia fracture .Plan: unclear why [MEDICATION NAME] was increased, due to multiple falls would strongly recommend reducing dose. Also given falls, would recommend reduction of [MEDICATION NAME] to reduce risk of further falls and injury . Review of R1's medical record reflected the following physician's orders [REDACTED].>-[MEDICATION NAME] ([MEDICATION NAME]/anti-anxiety medication) 0.5 mg by every 8 hours as needed for anxiety. The order start date was 8/29/19, and the order end date was 9/12/19. -[MEDICATION NAME] 0.5 mg by mouth every 8 hours as needed for anxiety/agitation. The order start date was 9/18/19, and the end date was 9/23/19. -[MEDICATION NAME] 0.5 mg by mouth every 8 hours for anxiety. The order start date was 9/23/19, and the end date was 9/27/19. -[MEDICATION NAME] 0.5 mg by mouth every 12 hours for anxiety, hold if lethargic. The order start date was 9/27/19, and the end date was 9/30/19. -[MEDICATION NAME] 0.5 mg by mouth every 8 hours as needed for anxiety. The order start date was 10/2/19, and the end date was 10/3/19. -[MEDICATION NAME] 0.5 mg by mouth twice daily for anxiety. The order start date was 10/3/19. As of record review on 10/30/19, the order was active and without an end date. -[MEDICATION NAME] ([MEDICATION NAME]/antipsychotic medication) 0.5 mg by mouth at bedtime for [MEDICAL CONDITION]. The order start date was 8/29/19, and the end date was 9/30/19. -[MEDICATION NAME] 1 mg by mouth at bedtime for unspecified [MEDICAL CONDITION]. The order start date was 10/2/19, and the end date was 10/3/19. -[MEDICATION NAME] 1 mg by mouth two times a day for unspecified [MEDICAL CONDITION]. The order start date was 10/3/19. As of record review on 10/30/19, the order was active and without an end date. -[MEDICATION NAME] 1 mg by mouth one time only for increased restlessness. The order start date was 10/3/19, and the end date was 10/4/19. During an interview on 10/30/19 at 11:47 AM, NP K reported that he visited the facility Monday through Friday. NP K reported that there were communication books for staff to write in (to notify providers of pertinent matters). When asked if he had been asked to evaluate R1's medications, NP K stated they usually did that almost every time (they evaluated the resident). NP K reported that he did not believe anyone had notified him of any concerns with R1's medications. NP K stated, If they give me a note on anything, I usually put it at the top of my progress note, right in the subjective line. NP K reported that his first follow-up visit with R1 after she returned from the hospital was on 10/3/19. When asked why R1's [MEDICATION NAME] was increased on 10/3/19, NP K reported that was usually a psych (psychiatric services) request. NP K stated, There are some meds (medications) I do not like adjusting. NP K reported [MEDICATION NAME] was one of those medications. After NP K reviewed portions of R1's medical record, he stated that he personally entered R1's order for the [MEDICATION NAME] increase on 10/3/19. NP K reviewed R1's records from her most recent hospital stay and reported the recommendation to increase the [MEDICATION NAME] did not come from the hospital. NP K reviewed his visit note for 10/3/19 and stated he did not document why but noted the [MEDICATION NAME] was to be increased to 1 mg twice daily. NP K stated his note was not clear as to why that change was done or where the recommendation came from. When asked if anyone had communicated to him that psychiatric services made a recommendation to decrease the [MEDICATION NAME] and [MEDICATION NAME] doses, according to their visit on 10/9/19, NP K stated, Normally they are very good about talking to me while I am here, so I cannot say. NP K reported that he usually tried to read the psychiatric services notes and that they were very good about notifying him (of recommendations). NP K reported that quite often, the psychiatric provider would seek him out and give their recommendations. When asked if he would have agreed with the psychiatric provider recommendations to decrease the [MEDICATION NAME] and [MEDICATION NAME] if the recommendation had been presented to him, NP K reported that when psychiatric services made a recommendation, he very seldom over-rides it. NP K clarified that he would have likely adhered to the recommendations. When asked if he believed the [MEDICATION NAME] and [MEDICATION NAME] could have been contributing to R1's falls, NP K indicated that he did believe so. R1's Progress Notes reflected that following the 10/9/19 Psychiatric Visit, R1 was not evaluated by a Physician or NP until 10/25/19 at 10:02 AM. R1's Progress Notes, as documented through 10/30/19 at 9:27 AM, did not contain documentation from a Physician or NP that they had received or acknowledged the Psychiatric Services visit recommendations for decreasing [MEDICATION NAME] and [MEDICATION NAME] on 10/9/19. An Incident Report reflected that on 10/23/19 at 10:30 PM, R1 slid out of a chair in the Day Room while trying to get out of the chair unassisted. No new injuries were documented on the Incident Report. The action taken reflected every two hour toileting. The Fall Investigation Report reflected that R1 would have orthostatic blood pressures (blood pressures performed while lying, sitting and standing) for three days. The S[NAME]-Falls Progress Note for 10/24/19 reflected that it was reasonable to conclude the root cause of R1's fall on 10/23/19 was that R1 tried to stand up and slid from the chair to the floor. The same note reflected that R1 had a tendency to fall more between 4:00 AM and 5:00 AM and 10:00 PM to 11:00 PM. A Care Plan intervention with a date initiated of 10/24/19, reflected that R1 was to have orthostatic blood pressures from 10/24/19 to 10/27/19. An Incident Report reflected that on 10/28/19 at 8:30 PM, R1 was observed on her hands and knees, on the floor, behind the nurse's station. R1 reporte

This citation pertains to MI 290. Based on observation, interview and record review, the facility failed to prevent the development and worsening of pressure ulcers for two (Resident #2 and #5) of four reviewed for pressure ulcers, resulting in Immediate Jeopardy when Resident #2 developed a pressure ulcer that worsened to a stage IV (4-full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the ulcer) without physician notification or physician evaluation of the worsening wound, the likelihood for complications, including osteo[DIAGNOSES REDACTED] (bone infection), the likelihood for serious harm, serious injury, serious impairment or death and lack of timely treatment and evaluation for Resident #5's stage III pressure ulcer (3-full thickness loss of skin, subcutaneous fat may be visible in the ulcer) that worsened to a stage IV pressure ulcer. This deficient practice places all 102 residents whom reside in the facility at risk for serious harm, serious injury, serious impairment, or death. Findings include: Resident #2 (R2) Review of the Admission Record reflected that R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE], reflected that R2 had short-term and long-term memory impairments. R2 was non-ambulatory (did not walk) and required extensive assistance of one to two or more people for Activities of Daily Living (ADL's). The MDS reflected that R2 did not have pressure ulcers upon her admission to the facility. R2's medical record reflected that she was admitted to Hospice services on [DATE]. On [DATE] at 10:35 AM, R2 was observed lying in bed while Hospice Registered Nurse (RN) F and Hospice Certified Nurse Aide (CNA) G provided care. R2 was wearing oxygen via nasal cannula. An air mattress was observed on her bed. The air mattress pump on the foot of her bed had no illuminated lights or indication that the air mattress was powered on or functioning. When asked about the condition of R2's skin, RN F stated that R2 had an open blister to her back that the facility was treating. When R2 was turned onto her right side, a dressing to her buttocks was observed with a date of [DATE]. A dressing to R2's mid back region was observed to have a date of [DATE]. On [DATE] at 10:58 AM, Licensed Practical Nurse (LPN) H began performing wound care on R2, with RN F and CNA G assisting with R2's positioning. R2's coccyx wound was observed to have black (necrotic) tissue in the center with pink, open tissue around the wound edges. When the Surveyor inquired about the black tissue, LPN H stated that the black tissue probably needed to be debrided (removal of damaged tissue). After wound care was performed, the surveyor asked LPN H how they knew if R2's air mattress was on. LPN H stated that lights (on the pump) were usually on. LPN H and RN F both stated that air mattress had been on earlier that day. When RN F was asked if they had checked R2's air mattress during their visit, RN F stated they thought the mattress was on, as the mattress still had pressure in it. After CNA G readjusted the air mattress plug in the wall outlet, the lights for the air mattress pump turned on. Review of R2's Skin Assessment for [DATE] reflected there were new, abnormal skin areas, including an intact blister on the right buttock, measuring 2 centimeters (cm) by (x) 1 cm. The assessment also reflected that R2 had a black area, measuring 0.1 cm x 0.1 cm, on Left toe(s). R2's Skin Assessment for [DATE] reflected, blister popped skin not intact (sic). Area 5cm x 5cm . R2's Skin Assessment for [DATE] reflected that R2 had an open area to the right buttocks with treatment in place. The assessment reflected that the area showed signs of healing. R2's Skin Assessment for [DATE] reflected that R2 had an open area above the coccyx. R2's Skin Assessment for [DATE] reflected that R2 had an open coccyx wound and a previous fluid-filled area on the left mid-back and right back. A Wound Care Progress Note for [DATE] reflected that R2 had a stage II pressure ulcer (2-Partial-thickness loss of skin with exposed dermis that presents as a shallow, open ulcer), measuring 7.0 (cm in length) by 4.1 (cm in width). The wound was documented to have granulation tissue (pink/red tissue that forms when an ulcer starts to heal). The note reflected that the wound started as a blister on [DATE]. A Wound Care Progress Note for [DATE] reflected that R2 had a stage III pressure ulcer to the sacral region, measuring 12.3 (cm in length) x 5.4 (cm in width). The note reflected that the size of the wound had increased, and the tissue quality of the wound worsened. The wound bed was documented to have granulation tissue, 25% slough (non-viable tan, yellow, gray, brown or green tissue) and 10% eschar (dead tissue, usually brown, black or tan in color). A Wound Care Progress Note for [DATE] reflected that R2 had a stage IV sacral/coccyx wound, measuring 17.5 (cm in length) by 6 (cm in width) with a depth that was UTD (unable to determine). The documentation reflected that the size of the wound increased, and the tissue quality of the wound worsened. The wound bed was documented to have granulation tissue and 75% eschar. An alternate Wound Care Progress Note for [DATE] reflected that R2's stage IV pressure ulcer measured 0.1 (cm in depth). All of the additional documentation for the two Wound Care Progress Notes for [DATE] was the same. Both notes were authored by RN O. A Wound Care Progress Note for [DATE] reflected that R2 had a stage IV coccyx pressure ulcer, measuring 11.4 (cm in length) by 8.7 (cm in width) with a depth of 0.3 (cm). The documentation reflected that the size of the wound decreased, and the tissue quality of the wound worsened. The wound bed was documented to have 90% eschar. Review of R2's Progress Notes reflected a note on [DATE] at 1:30 AM, which revealed that R2 had an intact blister to the right buttock. The note reflected that Doctor of Osteopathic Medicine (DO) I was notified. Review of R2's medical record on [DATE], did not reflect that a Physician had been notified of her worsening wound after [DATE], nor was there documentation that a Physician evaluated R2's worsening wound. In an interview on [DATE] at 1:45 PM, Nurse Practitioner (NP) J reported that R2's name did not sound familiar. NP J looked up Progress Notes and reported that they had never seen R2, but Doctor of Medicine (MD) K had seen R2 on [DATE]. During a phone interview on [DATE] at 2:04 PM, DO I reported that he did not have a computer in front of him and asked for some background information on R2, which was provided to him by the Surveyor. DO I reported that he did not know of any skin conditions that R2 had. Additionally, DO I reported that he did not have knowledge of the pressure ulcer that R2 had. DO I reported that the facility communicated urgent issues by pager. Non-urgent issues were communicated via rounds with the NP. The Surveyor informed DO I that the facility had documented that R2 had a blister on their coccyx that had most recently been documented as worsened to a stage IV pressure ulcer. DO I stated he was sorry to hear that. On [DATE], DO I was at the facility, requesting to speak with the Surveyor. In an interview on [DATE] at 8:15 AM, DO I shared that he had been away from his computer in the last conversation with the surveyor (on [DATE] at 2:04 PM). DO I stated that seeing R2 was all MD K. DO I stated that he had no direct contact with R2, but he did have a role in approving and signing orders. DO I stated that the facility staff had 24 hour access to notify him of something urgent. He described urgent matters as someone pulling out a tube, pulling out a foley (catheter), falls or things that were catastrophic; something that needs a 4 to 20 minute response time, according to DO I. DO I stated the primary mode for notification was morning rounds or a book that staff could have made notes in. In regards to R2, DO I stated this was one of those swiss cheese cases. DO I stated that R2 admitted to the facility expected to die within days of her arrival, she had poor nutritional status and was very ill. DO I stated, .If there were things we missed, it was because she (R2) was terminal . DO I reported if they had done anything, it was flanked by R2's body working around it. DO I stated that the case was set up that R2 was expected to pass. DO I stated that he felt remorseful that a wound developed. In an interview on [DATE] at 12:28 PM, MD K reported that R2 admitted to the facility after a stroke, failure to thrive in the hospital, and a decision was made for Hospice. MD K reported R2 had an issue with a sacral pressure ulcer. MD K stated that he had seen R2 the week prior to the interview with the Surveyor, or even the week prior to that (2 weeks prior). He stated that he was starting to do rounds on wound care. MD K stated that he rounded with the wound nurse (RN O) the day prior to his progress note for [DATE]. He then stated that it was either [DATE] or [DATE] (when he rounded). MD K stated that he saw RN O each time he was at the facility and that he rounded every Monday, Wednesday and Friday ([DATE] was a Thursday). When asked if he ever saw R2's wound, MD K stated, physically measuring, I don't. MD K stated that he expected the wound care nurse to measure and manage the wound, I am not a wound doc (Doctor). He stated that the wound nurse was evaluating, but he did see the wound. It was progressing between a 3 or a 4 (stage III or stage IV). MD K acknowledged that his note for a visit on [DATE] was his first time evaluating R2's pressure ulcer. MD K stated that DO I was the Medical Director and was more proactive in the building and more of the wound person. When asked if he would have expected to be notified of R2's pressure ulcer before it worsened to a stage IV, MD K stated .they kind of give us a heads up on all the patients once a week to let us know what is going on. They could have told an on-call, but I'm not on-call all the time. I was not on-call that day .I would ask (DO I). He is more proactive on wounds, and I'm 100% sure he would have been notified. I am more the Attending Physician that sees them day to day. During an interview on [DATE] at 4:28 PM, RN O reported that she did weekly wound measurements and decided on wound care dressings and treatments. RN O stated she was doing that for all wounds, and it was too much because she was also a hall manager. If there was a change in a wound, RN O was called to evaluate, per her report. Regarding R2's wound, RN O stated that the progression was fast, and it started as a blister. RN O reported following the wound once the blister popped, and it became a stageable injury. When asked if she did the wound assessments alone, RN O stated she needed someone with her to have four hands for care. When asked if there was anyone else that evaluated the status of R2's wound with her, RN O stated, No, the doctor gets made aware. (NP J) was with me on Thursday ([DATE] to evaluate R2's wound) . When asked if any provider, NP or Physician, had ever evaluated R2's wound with her before NP J did on [DATE], RN O stated that NP J was the first provider to go in with her to evaluate R2's wound. When asked how the Physician was being notified of worsening wounds, RN O stated, They come here and we would discuss. RN O stated that a Physician did not talk to her about R2's wound, nor had the NP talked to her about it (prior to [DATE]). RN O stated, Her status was hospice. We knew unfortunately that the wound was going to progress . On [DATE] at 4:00 PM, Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were notified of the Immediate Jeopardy that was identified on [DATE] and began on [DATE], due to the facility's failure to ensure Physician notification and Physician evaluation of a pressure ulcer that worsened to a stage IV. A corrective action plan was requested from the facility to remove the Immediate Jeopardy. Immediate Jeopardy was removed on [DATE], when the facility had the following in place: -The Physician was notified on [DATE] of the condition of R2's wound status and had evaluated the wound. As part of the evaluation, orders were reviewed and deemed appropriate. -On [DATE], a Licensed Nurse conducted a full skin and pain assessment on R2 to ensure pain was being managed, wound was being treated appropriately, and there were no other affected areas of the skin. -On [DATE], R2's responsible party was notified of R2's current status and treatment plan. -On [DATE], all existing residents in the facility that had an existing pressure ulcer were identified. An audit was completed on those residents to ensure the Physician had been notified, collaborated with the Interdisciplinary Team (IDT) and deemed all treatments were appropriate. -On [DATE], all residents in the facility had skin assessments completed to ensure that all residents with existing wounds had Physician notification and appropriate treatment orders in place. -On [DATE], the DON, Nursing Management and all Licensed Nurses were educated regarding the facility policy and procedures on Pressure Ulcers and Physician/Representative Notification; Change in a Resident's Condition or Status. Education was provided to the Medical Director, Physician's and Practitioners regarding the policy and procedures regarding notifications, documentation and continued follow-up. -An adhoq QA (Quality Assurance) meeting was held on [DATE] with the IDT and Attending Physician team. The Medical Director was informed of the concern and agreed with the plan to correct. It was not until after the facility was notified of Immediate Jeopardy on [DATE], that MD K created a late entry Progress Note on [DATE], for a visit date of [DATE]. The late entry Progress Note was created by MD K on [DATE] at 9:01 AM, for an effective date of [DATE] at 9:32 AM. The note reflected, .Late Entry: .Ptalso (sic) (patient also) has a sacral/coccyx wound stage 4 per wound staff and hospice RN .SKIN: sacral/coccyx wound stage 4 Wound 17.5cm (centimeters) L (length) x 6cm W (width) x 0.1 cm D (depth) with minimal serosanguinous drainage .Wound unavoidable secondary to FTT (failure to thrive) and pt overall decline with terminal prognosis . The measurement and drainage described in MD K's note were reflective of the wound documentation from the RN O on [DATE]. The medical record reflected that R2 died in the facility on [DATE]. Althoough the Immediate Jeoparday was removed on [DATE] deficient practice continued at isolated actual harm that is not immediate jeopardy. Resident #5 (R5) Review of the Admission Record reflected that R5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission / 5 day Medicare MDS, with an ARD of [DATE], reflected that R5 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). She was non-ambulatory and required extensive assistance of one to two or more people for ADL's. The same MDS assessment had R5 coded for one stage III pressure ulcer present on admission and two unstageable pressure injuries presenting as deep tissue injuries on admission. On [DATE] at 11:48 AM, R5 was observed lying in bed, towards her right side. An air mattress was observed on R5's bed, and a pillow to elevate her heels was in place. R5 was not wearing socks. The skin to her feet was intact. RN O performed a dressing change to R5's coccyx pressure ulcer while RN N assisted with R5's positioning. The old dressing to R5's coccyx was dated for [DATE] at 0700 (7:00 AM). R5 was observed to have a large open ulcer to her coccyx. The tissue surrounding the ulcer was red. The wound bed had the appearance of both granulation tissue and eschar. R5's wound had a foul odor. During the treatment, RN O stated that she needed to change the type of dressing that was being used, but she needed to look in her book for what to use. R5's wound was cleansed, packed and a new dressing applied. Review of R5's (MONTH) 2019 Treatment Administration Record (TAR) on [DATE] at 12:22 PM, reflected that R5's coccyx dressing was last changed on [DATE] and signed out for Night. R5's order was for dressing changes twice daily, day and night, and as needed (wound care observation on [DATE] reflected a dressing dated for [DATE] at 7:00 AM). Review of R5's Admission Skin Assessment for [DATE] reflected that R5 had a stage III wound to the sacrum and pressure ulcers to the right and left heels. The medical record did not reflect documentation on the size or appearance of the wounds upon admission. Review of R5's TAR for (MONTH) 2019 reflected that a treatment for [REDACTED]. The (MONTH) 2019 TAR did not reflect a treatment order for the pressure ulcers to R5's heels. The (MONTH) 2019 TAR reflected that daily skin prep application to R5's heels was initiated on [DATE]. R5's Progress Notes reflected a note from MD K on [DATE] at 9:59 AM that R5's skin was within normal limits, without rashes or decubs (decubitus ulcer/pressure ulcer). A NP Progress Note on [DATE] at 2:21 PM reflected that there was .Excoriation to buttocks per nursing notes . Review of R5's Progress Notes reflected that on [DATE] at 11:00 PM, it was documented that R5's coccyx wound had foul odor and moderate drainage. A Progress Note for [DATE] at 7:00 AM reflected that R5's coccyx wound had slough. Progress Notes for [DATE] at 7:00 AM and [DATE] at 3:00 PM reflected that R5 had a stage III coccyx wound. Progress Notes for [DATE] at 7:00 AM and [DATE] at 3:00 PM reflected that R5's coccyx wound was not improving, was slightly deeper and had a thick yellow center. The note reflected that the author requested for the Physician to evaluate the wound. Progress Notes for [DATE] at 7:00 AM and [DATE] at 3:00 PM reflected that the coccyx wound was not improving. The note reflected that a thick scab was forming and that the practitioner assessed the site. The medical record did not contain documentation of the practitioner evaluation. A Progress Note for [DATE] at 4:12 PM was the first documented full assessment of R5's pressure ulcer on the coccyx. The note reflected that the ulcer was a stage IV, measuring 7.3 cm in length by 5.2 cm in width and 0.3 cm in depth. The wound bed was documented to have 50% slough and 35% eschar, with epitheilal tissue around the wound edges and a small amount of granulation tissue. A Progress Note for [DATE] at 12:02 PM reflected that R5's stage IV coccyx wound was 7.8 cm in length by 5.9 cm in width and 0.3 cm in depth. The wound bed was documented to have 10% slough and 40% eschar and granulation. A Progress Note for [DATE] at 11:00 AM reflected that R5's coccyx wound had an odor and necrotic tissue. A Progress Note for [DATE] at 11:00 PM reflected that R5's coccyx wound had purulent drainage (milky drainage that can be indicative of infection) and odor. A NP Progress Note for [DATE] at 2:45 PM reflected that there was stool in R5's coccyx wound at the time of examination. There was necrotic tissue through much of the wound, according to the note. A recommendation was made for a wound clinic evaluation and/or General Surgeon for debridement. A Progress Note for [DATE] at 11:00 PM reflected that there was a foul odor to R5's coccyx wound. A late entry Progress Note for [DATE] at 9:47 AM reflected that R5's stage IV pressure ulcer measured 8 cm in length by 9.3 cm in width and 0.3 cm in depth. The note reflected that the wound size increased, and the tissue quality worsened. A Progress Note for [DATE] at 11:00 PM reflected that R5's coccyx wound had a foul odor. A NP Progress note for [DATE] at 8:44 AM reflected that R5's coccyx wound was worsening. Stool was again noted in the wound, according to the note. There was necrotic tissue through much of the wound. .Again recommend evaluation by wound clinic and/or GS (General Surgeon) for debridement .After wound cleaned obtain culture . A Progress Note for [DATE] at 1:35 AM reflected that R5's coccyx wound continued to smell and did not show signs of healing. A Progress Note for [DATE] at 12:35 PM reflected that the wound culture was obtained (as recommended by the NP 4 days prior, on [DATE]). A Progress Note for [DATE] at 11:35 PM reflected that R5's coccyx wound had purulent drainage and foul odor. A late entry Progress Note for [DATE] at 9:49 AM reflected that R5's stage IV coccyx wound measured 8.2 cm in length by 11.7 cm in width and 0.4 cm in depth. The note reflected that the wound size increased, and the tissue quality worsened. A NP Progress Note for [DATE] at 9:40 PM reflected that R5's coccyx wound had areas of tunneling at the 7 to 9 o'clock positions and 2 to 4 o'clock positions. According to the note, there was necrotic tissue throughout much of the wound bed. New granulation tissue was documented from 5 to 7 (o'clock) and 9 to 12 (o'clock). A Progress Note for [DATE] at 5:35 PM reflected that R5's coccyx wound had moderate amounts of purulent drainage. A Progress Note for [DATE] at 6:21 AM reflected that R5's wound had purulent drainage and a very strong odor. The note reflected that the wound culture was still pending and that R5 was waiting for an appointment for wound debridement. A Progress Note for [DATE] at 9:12 PM reflected that R5 was started on antibiotics for a positive wound culture. A NP Progress Note on [DATE] at 9:10 AM reflected, .Worsening wound. Cultures obtained last week resulting with multiple organisms .Decub ulcer on coccyx, with stool again noted in wound at time of examination .Again recommend evaluationby (sic) wound clinic and/or GS for debridement . A Progress Note for [DATE] at 9:35 AM reflected that R5's wound measured 10 (cm in length) by 6.5 (cm in depth) by 2.5 (cm in depth). A Progress Note for [DATE] at 11:35 PM reflected that R5's wound had purulent drainage and foul odor. The area surrounding the wound was documented to have redness and increased skin temperature. R5's medical record did not reflect that a referral had been made to a wound clinic or General Surgeon, per recommendations by the NP. In an interview on [DATE] at 12:30 PM, RN O reported that R5's wound looked terrible. She stated that the wound was progressing fast and was much deeper and tunneling. She stated, There is a certain smell people get when they are dying, and she has that smell. When asked where things were with getting R5 an appointment to the wound clinic, RN O stated that R5 did not want to go to a wound clinic. RN O stated, she wants this to be over. She wants Hospice. RN O stated that there should have been a note that R5 didn't want to go to the wound clinic. RN O reported that R5's wound had worsened further between her evaluations on [DATE] and [DATE]. RN O reported that if she had known the wound changed that much, she would have changed R5's treatment sooner. RN O stated that the floor nurse should have communicated the worsening wound to her, and they did not. RN O stated that the wound documentation was too generic. She reported that the nurses should have been documenting the size of the wound, any odor, drainage, appearance of surrounding skin, if there had been or if there needed to be a change in treatment and who was notified. According to the facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, with a reviewed/revised date of (MONTH) 28, (YEAR), .Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing .1. An admission evaluation helps identify residents at risk of developing a pressure ulcer/pressure injury (PU/PI), and residents with existing PU/PIs. Because a resident at risk can develop a PU/PI within hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI. The admission evaluation helps define those initial care approaches .4. The interdisciplinary team (IDT) will assess and document and individual's significant risk factors for developing PU/PI's; for example immobility, recent weight loss, history of PU/PI, modifiable and non-modifiable risk factors .5. Initial Screen: .c. Complete the Nursing Data Evaluation and/or admission skin assessment upon admission to the facility (Skin assessment portion completed preferably within the first 8 hours of admission); d. All PU/PI or other skin related issues are measured and documented (electronic medical record in EMR facilities); e. Staging will be documented per National Pressure Ulcer Advisory Panel (NPUAP) and Resident Assessment Instrument (RAI) guidelines .8. Change of condition/New skin alteration: a. Notify Physician and Resident Representative of all new and/or non-healing/worsening PU/PIs .10. The physician will help the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of an ulceration as needed .11. The physician will help clarify relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, the impact of comorbid conditions on wound healing, etc. as needed .1. The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents .12. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. Treatment selection is based on what the wound bed looks like, if it is draining, signs of infection, tunneling, etc. Review the wound care formulary for guidance .15. As needed, the physician will help identify medical and ethical issues influencing wound healing; for example, because of end-stage [MEDICAL CONDITION] or because cause-specific treatment is not advisable, not feasible, or not desired by the resident or family .1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or non-healing wounds .16. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions .

This citation pertains to intakes MI 659 and MI 478. Based on observation, interview and record review, Immediate Jeopardy was identifed due to the facilities failure to assess resident safety in use of sit to stand lift, assess size of sling for sit to stand lift, and notify therapy of resident need for transfer assessment, in 2 of 4 residents reviewed for transfers (Resident #79 and Resident #80), resulting in fractures to the right clavicle and right shoulder blade (Resident #79), extensive bruising and swelling (Resident #79), difficulty lifting right and left arms (Resident #79) and the potential for injuries during transfers (Resident #80); and the facility failed to provide adequate supervision to prevent falls in one of one residents reviewed for fall with major injury (Resident #78), resulting in a fracture. Findings include: Findings include: Resident 79 On 10/9/18 at 1:25 PM, Resident #79 (R79) was observed sitting in a wheelchair next to the nurse's station with a sling on her right arm and stated she felt terrible. Admission Record dated 10/5/18 revealed R79 was an [AGE] year-old, admitted to the facility on [DATE] and had the [DIAGNOSES REDACTED]. R79's Minimum Data Set (MDS) assessment dated [DATE] introduced a Brief Interview of Mental Status (BIMS), a short performance-based cognitive screener, score was 04 (scale 00-07 indicated a severe impairment). The same MDS indicated R79 had physical and verbal behaviors that occurred 1 to 3 days during the 7 day look-back period. The same MDS assessment indicated R79 required extensive assistance of 2 persons for transfers. Skin assessment dated [DATE] at 5:30 PM indicated R79 had a bruise to her right shoulder that was 4 centimeters (cm) by 5 cm and bruising to right upper chest was 14 cm by 5 cm then 19 cm by 5 cm going down; purple in color. In review of R79's Pertinent Charting Initial Skin dated 10/2/18 at 3:40 PM, with event date of 9/28/18, indicated bruising on left and right shoulder with bruising on right arm and bruising on right and left arms and hands. On 10/9/18 at 1:35 PM, Licensed Practical Nurse (LPN) H stated the last time she remembered R79 was able to propel herself in her wheelchair was on (MONTH) 26, (YEAR). LPN H stated she thought she had made the unit manager aware in (MONTH) (YEAR) that R79 was combative when transferred with the sit to stand lift. LPN H stated she observed R79's bruising on her shoulders on 9/28/18 and was reported to the Director of Nursing (DON) the same day. DON B was interviewed on 10/9/18 at 2:50 PM and stated she was made aware of R79's bruises on 9/28/18 and did not know why the bruising was not reported to state agency. During the same interview, DON B stated she was aware of R79's issues with the sit to stand lift shortly before the bruises were noted, maybe a week; and stated she instructed the unit manager to evaluate her. On 10/10/18 at 9:30 AM Certified Nurse Assistant (CNA) M was interviewed and stated R79 screamed, let go of the sit to stand lift during transfers, and her knees would buckle that caused all of her weight to be supported by the sling under her arms. CNA M stated she had observed R79's behaviors during transfers since 9/1/17 and did not know if any staff reported R79's behaviors to the DON. On 9/28/18 physician's orders [REDACTED]. Progress Note dated 10/5/18 at 5:18 AM revealed R79 was resistant when right shoulder x-ray was being attempted to be obtained and only 1 view was obtained. On 9/29/18 at 5:09 AM, Radiology Report indicated x-ray of right shoulder negative for fracture. On 10/2/18 at 9:56 AM, Physician order [REDACTED]. On 10/2/18 Nurse Practioner's progress note dated 10/4/18 at 10:48 AM revealed R79 was seen for follow-up of for comfort, R79 was .found to have bruising noted on her left and right shoulders, further investigation pending possible cause may be from lift. The same note indicated R79 had discolorations on arms. R79's Transfer Safety Evaluation dated 7/23/18 at 4:00 PM revealed transfer required use of a walker and 1 person staff assist. This was the only transfer assessment completed by nursing in R79's medical record. In review of R79's Activities of Daily Living Care Plan dated 7/23/18 revealed transfer instructions were to use the sit to stand lift with 2 person to assist. On 9/29/18 the same care plan indicated R79 required a total lift and 2 person assist. There was no indication on what size sling to use in both of the above instructions on R79's care plan. Registered Nurse (RN) unit manager (UM) L was interviewed on 10/9/18 at 2:30 PM and stated she was notified of R79's bruising on 9/28/18 by the unit nurse. UM L stated she notified the DON immediately and started an investigation. UM L stated the same interview the only thing she could come up with for a possible cause for R79's bruising was from the sit to stand lift, in that R79's did not bear weight during the transfer and pressure from the sling was placed under her arms. UM L was not sure what size sling R79 was to use with the sit to stand lift at that time. On 10/10/18 at 11:55 AM UM L stated she re-created the sit to stand transfer on 10/2/18 and determined R79's bruising matched where the sling would have caused pressure. UM L was not sure what size lift sling she used during the re-enactment; but thought it was the sling with the green trim. UM L stated she did not measure R79 to determine sling size or observe staff transfer R79 with the sit to stand lift or the total lift. On 10/2/18 Interdisciplinary Progress Note (IDT) dated 10/2/18 at 1:54 PM revealed R79 complained of pain and had decrease in range of motion; x-ray completed of right shoulder; follow up to occur with physician for additional imaging orders. On 10/10/18 at 11:55 AM UM L stated she relayed to the nurse to follow-up with the physician regarding x-rays after the IDT meeting, but was not sure why order for x-rays were not obtained until 10/4/18. On 10/4/18 R79 received a physician order [REDACTED]. Addendum Radiology Report dated 10/4/18 11:43 PM indicated no fracture or dislocation of the left hand, and midshaft clavicle fracture from right shoulder view. Progress Note dated 10/5/18 at 4:22 AM revealed R79 had a [MEDICAL CONDITION] clavicle, right clavicle and right scapula (shoulder blade). On 10/5/18 at 4:53 AM A Physician note document titled Emergency Documentation revealed R79 had pain, swelling, and bruising to both shoulders; difficulty moving both arms; and extensive bruising and swelling over the left and right clavicles. The same note indicated according to staff, R79 had become uncooperative during a transfer with machine to help her stand for transfers and fell , injuring both shoulders. The same note revealed the facility performed an x-ray on the left shoulder that revealed midshaft clavicle fracture with slight comminution and angulation. The same note indicated assessment/plan included right clavicle fracture, fracture of left clavicle, and right scapula fracture. Preliminary Radiology Report dated 10/5/18 at 3:50 PM revealed fractures of the right clavicle and right scapula. The NHA A was interviewed on 10/9/18 at 4:20 PM and stated through his investigation he determined the staff had issues transferring R79 with the sit to stand lift was on 9/27/18. NHA stated he was not aware of R79's bruising that was observed by staff until 10/5/18. However, On 10/10/18 at 4:25 PM DON B stated she reported R79's bruising to the NHA on either 9/28/18 or 10/1/18. Immediate Jeopardy was identified: 10/10/18 and Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy (IJ) on 10/10/18 with deficient practice that had the potential to affect 35 residents that used mechanical lifts for transfers, out of a census of 102 residents, resulting in the potential for serious harm or injury and required immediate corrective action. A plan to remove the immediacy was requested. Resident #80 On 10/10/18 at 9:45 AM Resident #80 (R80) was observed during a transfer using the sit to stand lift from the wheelchair to toilet, with assistance from CNA E and CNA M. CNA E placed a gray sling with green trim, no size marked on the sling, around R80's waist, clipped the belt in the front, tightened the waist strap, instructed R80 to place her feet on the foot platform, secured a belt around each calf, clipped the waist sling on both sides of the lift machine, instructed R80 to place her hands on the lift machine handles, and instructed her to hold on. R80 was lifted from a seated position to a nearly standing position, R80 was not wearing a bra, and her breasts were exposed as lift sling slid up under her arms. CNA M stood behind R80 to observe the transfer. CNA E then turned R80 on the lift, 180 degrees and pushed her into the restroom, placed her over toilet, and lowered onto toilet. R80's weight on 10/3/18 was 137.4 (lbs.) pounds as noted in her electronic medical record under Weight Summary. R80's activities of daily living care plan, dated 9/17/16 instructed to transfer her with a sit to stand lift and did not specify sling size. Mechanical Lift policy, procedure revised 8/2016 instructed lift sling to be used per manufacture's instructions. On 10/10/18 at 10:15 AM, Rehabilitation Manager (RM) J stated in an interview the therapy department assesses residents for appropriate transfer device equipment but does not evaluate/assess appropriate sling lift size. On 10/10/18 at 12:30 PM, Central Supply (CS) K stated in an interview there were slings from 2 manufactures in the building, and he thought the sizing on the slings were the same for both manufactures. CS K stated one of the manufactures indicated the size on the sling and both used colored trim to indicate size. CS K was unable to determine the size of the sling with dark gray material and green trim observed in room [ROOM NUMBER] on 100 hall unit; he though it was size medium/large and confirmed there was no indication of the size on the actual sling. Following the sling inspection, during the same interview, in review of the document Sling Sizes dated (MONTH) 2008, CS K was unable to explain why green trim with dark gray material indicated size large bariatric sling for a weight range of 450 pounds (lbs.) to 555 lbs. CS K stated in the same interview he would contact the manufacture of the green trim sling observed to determine the actual size. Shortly following the same interview, at approximately 12:45 PM, CS K presented Sizing Guides for (manufacture) Sit to Stand Slings (Clip style). Sizing Guides for (name of manufacture) Sit to Stand Slings (Clip style), not dated, document indicated size medium sling was up to a 35-inch waist, yellow trim, and weight 75 lbs. to 180 lbs. The size large sling was up to a 45-inch waist, had green trim and weight of 150 lbs. to 300 lbs. The XX Large sling had purple trim, appropriate for up to a 65-inch waist, and weight of 370 lbs. to 600 lbs. R80's transfer observed earlier on 10/10/18 at 9:45 AM was with a size large sling size and based on the sling manufacturer's instructions, a size medium sling would have been recommended. Sling Size dated (MONTH) 2008, for slings made by the alternate manufacture revealed size medium sling had yellow trim and the weight range was 121 lbs. to 165 lbs. The size large sling had green trim and the weight range was 154 lbs. to 264 lbs. The XXL sling had terracotta trim, and the weight range was 440 lbs. to 500 lbs. Resident 78 On 10/5/18 at approximately 10:45 AM, Resident #78 (R78) was observed sitting in his room in his wheelchair, in front of an over-the-bed table eating breakfast. R78's Admission Record printed 10/5/18, indicated he was admitted to the facility on [DATE] and had the [DIAGNOSES REDACTED]. R78's Minimum Data Set (MDS) 3.0, dated 5/24/18 introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 10 (scale 08-12 indicated moderate impairment). The same MDS assessment revealed R78 required one person physical assist for transfers, toilet use and walking. R78's incident report (no title) dated 3/13/18 at 8:00 PM, revealed staff responded to his call light to find him on the floor in the bathroom near the toilet. The same report indicated R78 was attempting to pick a tissue off the floor, was alone and unattended. Fall Investigation Report indicated that prior to R78's fall, he had returned to his room following dinner. The same report reflected the root cause of R78's fall was the amount of assistance in effect and environmental factors/items out of reach. Fall Risk Evaluation dated 3/13/18 at 8:25 PM indicated R78 required assistance with toileting, had a history of [REDACTED]. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.15, (MONTH) (YEAR), section J, indicated a previous fall, especially a recent fall, recurrent falls, and falls with significant injury are the most important predictors of risk for future falls and injurious falls; and when planning for care, evaluate staffing needs for residents who are at risk for falls. R78's Risk for falls care plan dated 5/23/17 indicated to re-educate resident related to transferring with assist of staff. R78's incident report (no title) dated 5/14/18 at 10:20 AM revealed he was found on the floor on his left side in his bathroom. The same report indicated R78 was trying to plunge the toilet with a plunger and lost his balance. The same report revealed three abrasions were noted on his back. R78's Fall Investigation Report dated 5/14/18 at 10:20 AM, indicated R78 stated prior to the fall and plunging the toilet, he had to void. The same report included a statement from Certified Nursing Assistant (CNA) F that indicated prior to R78's fall he went to breakfast and the last time she saw him he was sleeping in his bed. The same report revealed R78 was alone and unattended at the time of the fall. The same report revealed the root cause of R78's fall was his medical status, amount of assistance in effect and environmental factors/items out of reach. Progress Notes dated 5/15/18 at 2:13 PM revealed R78 sustained a right clavicle (collarbone) fracture, follow-up x-rays were scheduled to monitor healing, and a pain regimen was ordered. The same progress note indicated R78 was a one person assist for transfers, noted to have poor safety awareness, poor judgement and did not recognize need for assistance at times. On 10/5/18 at 10:42 AM, during an interview, CNA F stated she did not remember toileting R78 after breakfast and prior to assisting him into bed, I probably should have toileted him. In an interview on 10/4/18 at 3:00 PM, Nursing Home Administrator (NHA) A stated someone had left a plunger in R78's bathroom, and determined the unknown person must had started a plunging job, did not finish, and left the plunger in R78's bathroom. During the same interview, NHA A stated the plunger was supposed to be locked in the soiled utility room. The Immediate Jeopardy was removed on 10-11-18 when the facility had the following in place: On 10/5/2018 an investigation was initiated by the Nursing Home Administrator and Director of Nursing related to Resident #79 bruising and Fracture. On 10/10/2018 resident #79 had a target behavior initiated related to behaviors occurring during lift transfers by Regional Director of Clinical. On 10/10/2018 resident #79 was assessed for proper total lift sling size and determined to require purple trimmed Arjo sling. On 10/11/2018 an audit was completed of x rays completed since 9/27/2018 was completed by Director of Nursing to verify orders were in place timely. On 10/10/2018 Maintenance checks were performed on the facility sit to stand and total lifts by the Maintenance Director. All were found to be functional according to manufacturer instructions. On 10/10/2018 current residents received skin assessments to identify any injuries of unknown origin. On 10/10/2018 the slings that are not Arjo brand being utilized with Arjo lifts have been removed from the facility. The slings in use match the brand of the lift. On 10/10/2018 the 17 residents utilizing sit to stand lift were assessed for proper sling size by the Director of Nursing. On 10/10/2018 the 18 residents utilizing total lift were assessed for proper sling size by the Director of Nursing. On 10/10/2018 the residents utilizing sit to stand and total lifts sling size was added to the Care Plan and Kardex by the Director of Nursing. On 10/10/2018 the residents utilizing sit to stand and total lifts had a transfer safety evaluation completed by the Director of Nursing . On 10/10/2018 Residents at risk for injury due to combative behavior during lift transfers were identified by the Unit Manager and Director of Nursing. The behavior and intervention was added to the care plan and included in the Transfer safety evaluation. 4 Residents were identified. On 10/10/2018 the Director of Nursing and the Nursing Home Administrator were educated on Centers of Medicare and Medicaid Services reporting requirements by the Regional Director of Operations. Beginning 10/10/2018 the Staff Development Coordinator/designee educated licensed nurses, and unit managers on the process for sizing slings following the Transfer safety evaluation completion. As of 10/11/2018, 14 of 38 scheduled nurses including nurse management have received education. Return demonstration was completed by Staff Development Coordinator/designee with the nursing staff to ensure proper technique is utilized when using mechanical lifts for transfers. Beginning 10/10/2018 the Nursing staff are being educated on identifying the proper size sling utilizing the Kardex and what to do if behaviors arise during a lift transfer. As of 10/11/2018, 14 of 38 scheduled nurses including nurse management have received education and 31of 46 Nursing assistants have received education. Beginning 10/5/2018 education for management and nursing staff was initiated by the Staff Development Coordinator specific to reporting and injuries of unknown origin. On 10/10 & 10/11/2018 Therapy (Director of Therapy) and the therapists completed transfer screening on residents utilizing sit to stand and total lifts. On 10/11/18 the director of therapy completed a transfer assessment and return demonstration of the transfer for R#79 at 11:55 am. Beginning 10/11/2018 no employees will work until their education is completed. On 10/11/2018 a Standards of Care meeting was held with the Interdisciplinary Team to review Resident #'s change in condition and update care plans. On 10/10/18 the Medical Director was notified of the immediate jeopardy and in agreement with the removal plan. On 10/11/2018 an Ad Hoc Quality Assurance Performance Improvement meeting was held to review the removal plan with the Medical Director present. Although the immediate jeopardy was removed on 10-11-18, the facility remained out of compliance at the scope of isolated and the severity of no actual harm with potential for no more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the state agency.

This citation pertains to intakes: MI 756, MI 758 and MI 783. Based on interview, and record review, the facility failed to provide an environment free from abuse for 4 residents (#4, #5, #6 and #7) of 6 reviewed for abuse from a total sample of 7 residents, resulting in the Resident #4 feeling uncomfortable around the staff member and Residents #5, #6 and #7 being physically abused by a staff member. Findings include: Review of the facility's Abuse Prevention Program policy, undated, revealed, Our residents have the right to be free from abuse, neglect, resident property, exploitation, corporal seclusion and any physical or chemical treat the resident's symptom .Our facility is committed to protecting our residents from abuse but not necessarily limited to: facility staff, consultants, volunteers, and staff from other services to our residents, family members, legal guardians, surrogates, sponsors, or any other individual .Our abuse prevention program provides policies and procedures that govern, at a minimum: Mandated annual staff training/orientation programs that topics as abuse prevention, identification and abuse, exploitation, mistreatment, neglect, management, dealing with violent behavior or reactions, etc .The reporting and filing of accurate documents relative to abuse; reporting to law enforcement, as required, in accordance with the Elder Justice Act .Our abuse prevention/intervention education program includes, Training and is not necessarily limited to, the following: .Helping staff to deal appropriately with stress and emotions; Training staff to understand and manage a resident's verbal or physical aggression .Monitoring staff on all shifts to identify inappropriate behaviors toward residents (e.g., using derogatory language, rough handling of residents .) .Expect all personnel, residents, family members, visitors, etc., to report any signs or suspected incidents of abuse to facility management immediately .All personnel, residents, family members, resident representatives, visitors, etc., are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff .Employees, facility consultants and/or attending Physicians must immediately report any suspected abuse or incidents of abuse to the Administrator. In the absence of the Administrator, such reports may be made to his/her designee . Abuse - The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families .Mental abuse is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services .Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing or designee .Staff members and persons affiliated with this facility shall not knowingly: Attempt, with or without threats or promises of benefit, to induce another to fail to report an incident of mistreatment or other offense; Fail to report an incident of mistreatment or other offense .Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information . Review of the Admission Record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #4 had clear speech, was understood, understands and was cogitatively intact. Review of the facility's indent report dated 1/7/18 revealed, (Resident #4) reported, 'The tall pregnant night shift aide (Certified Nursing Assistant (CNA) L) stated if you would stop eating your almonds you wouldn't have a problem with diarrhea. She told me she was taking my water and I asked why. I explained to her that I had the flue and that was causing the diarrhea. She argued with me and moved the almonds out of reach She also told me if you go to sleep you would not be sh*ting all over the place. I asked for water several times and she told me I did not need it. Review of the facility's Personnel Action Request (PAR) dated 1/30/18 revealed CNA L was , Separated from employment on 1/11/18; Reason for separation: Abuse. During an interview on 2/2/18 at 8:30 a.m., when asked about the incident Resident #4 stated, I think she (CNA L) was getting burnout and she had to take care of all of us that were 'sh*iting' as she liked to put it. (CNA L) said that I should stop eating the nuts and drinking water. I said that they are good for you, she responded, 'not when you are sh*ting'. Again she told me to stop drinking water and eating the nuts, 'I think you ought to stop drinking and eating and I am taking your water and nuts.' I told her that it was good to drink water while having diarrhea and she said, 'I'm taking it you're not having any more because I am not cleaning up anymore of your sh*t'. I was mad at her, she bullied me, I didn't like it .I thought she was over stepping her boundaries by telling me to stop drinking water and eating nuts. During an interview on 2/2/18 at 10:26, when asked about the incident between CNA L and Resident #4, Licensed Practical Nurse (LPN) M stated, I came in for my shift, when I got down to her to pass her medications I was trying to chit chat with her and as soon as I went in there she said, can you please not have that aide in here tonight. She described her as a tall pregnant girl, the tall pregnant girl is (CNA L). (Resident #4) said that she did not care for her and (CNA L) made her feel really bad about going to the bathroom. (Resident #4) stated that (CNA L) told her that if she wasn't eating so much crap she wouldn't be sh*ting all over. (Resident #4) said (CNA L) took her water and move it. When asked if she felt this action by CNA L was abuse, LPN M stated, Yes. When asked why, LPN M stated, Because she made her feel bad about herself .you cant take water and food from (the residents). An attempt to reach CNA L was unsuccessful. Residents #5, #6 and #7 Review of the Admission Record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was an [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #5 had clear speech, rarely/never understood, rarely/never understands and was severely impaired cognitively. Review of the Admission Record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #6 was rarely/never understood and was severely impaired cognitively. Review of the Admission Record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was an [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #7 had clear speech, was understood, usually understands and was severely impaired cognitively. Review of the facility's Investigation summary dated 1/15/18 revealed, (Certified Nursing Assistant (CNA) N) informed the DON (Director of Nursing B) that employees informed her they uncomfortable with working with (CNA J) because of the way she treats residents It was told to me that (CNA J) has been hitting residents by three different CNA's (CNA S), (CNA O) and (CNA T) .Based on employee interviews the facility is substantiating abuse. (Resident #5), (Resident #6) and (Resident #7) were reviewed by the physician and the IDT . Review of the facility's Personnel Action Request (PAR) dated 1/30/18 revealed that (CNA J) was separated from employment on 1/30/18, Reason for separation: Resident Abuse. Review of the Center's for Medicare and Medicaid, Psychosocial Outcome Severity Guide, Reveal that when determining severity of a deficient practice, The survey team should use the reasonable person concept when the resident's psychosocial outcome may not be readily determined through the investigative process: When there is no discernable response or when circumstances obstruct the direct evaluation of the resident's psychosocial outcome. Such circumstances may include, but are not limited to .cognitive impairments .or insufficient documentation by the facility. In this situation, the survey team may use the reasonable person concept to evaluate the severity (Level 2, Level 3, or Level 4) of the deficient practice. Further review of this guide reveals, Severity Level 3 Considerations: Actual Harm that is not Immediate Jeopardy. Severity Level 3 indicates noncompliance that results in actual harm, and can include but may not be limited to clinical compromise, decline, or the resident's inability to maintain and/or reach his/her highest practicable well-being. Examples of negative psychosocial outcomes as a result of the facility's noncompliance may include but are not limited to: Persistent depressed mood that may be manifested by verbal and nonverbal symptoms such as: Chronic or recurrent fear/anxiety that has compromised the resident's well-being and that may be manifested as avoidance of the fear-inducing situation(s) or person(s); preoccupation with fear; resistance to care and/or social interaction; moderate aggressive or agitated behavior(s) related to fear; sleeplessness due to fear; and/or verbal expressions of fear Dehumanization refers to the deprivation of human qualities or attributes such as individuality, [MEDICATION NAME], or civility. Dehumanization is the outcome resulting from having been treated as an inanimate object or as having no emotions, feelings, or sensations. Review of the written statements from the 3 CNAs that reported (CNA J) was abusing Residents #5, #6, and #7 reveal the following: CNA S statement, .we were changing (Resident #5) and she was resisting care. (CNA J) 'popped' her in the face. I has been a time or two with (Resident #6) as well. (CNA J) consistently picks with (Resident #6) and I feel she is provoking her. (CNA J) antagonizes her by saying, 'I'm sleeping with your man . CNA X statement, (CNA J) did it this last weekend I worked with herd. We were in the room with (Resident #6) and (Resident #5) and (CNA J) always antagonizes (Resident #6). If (Resident #6) talks about her boyfriend or wedding, (CNA J) will say, No, that's not your boyfriend that's my boyfriend and that makes (Resident #6) mad. (Resident #6) will get mad and hit (CNA J) and (CNA J) will hit her on the hand or flick her nose. I know (CNA J) antagonizes (Resident #7) too. CNA O statement, It was around (MONTH) when I first started (working here). I was mandated to work over on second shift on (CNA J)'s) hall. I wasn't in the room that long but (CNA J) was with (Resident #5) and (Resident #5) was being resistant to care. I saw (CNA J) hit (Resident #5) on the arm. Review of the facility's investigation dated 1/15/18 under the Follow up interviews section revealed, (CNA S)-During the follow up interview (CNA S) verbalized an understanding of abuse and the process of reporting abuse. When asked to demonstrate and explain the statement, (CNA J) popped her . (CNA S) tapped herself with an open hand. (CNA S) further indicated she thought the tap was abusive and did not report it because of fear of the employee knowing it would be her and contacting her. (CNA S) reported that (CNA J) makes comments about kissing (Resident #6's) boyfriend causing her to become upset and curse at her. Further review of this section revealed, (CNA O) verbalized an understanding of abuse and protocol for reporting abuse. (CNA O) re-enacted the interaction between (CNA J) and (Resident #5) and explained the physical contact as (CNA O) hit her hand quickly as if someone was trying to stop a child from doing something. When asked why she did not report what she seen she stated, l was fearful because I was a new employee and I wanted to be accepted by staff. When asked if she understood the importance of patient advocacy she stated, Yes, after (CNA X) reported that she had the same experience I knew I had to say something. Further review of this section revealed, (CNA X) verbalized an understanding of abuse and the protocol for reporting abuse. (CNA X) described the physical contact between (CNA J) and (Resident #5) as, Kind of like a tap or flick (thump) on her nose. When she did it I said, (CNA J)! Afterwards I decided to talk to (CNA O) about it. When asked to describe the antagonistic behavior (CNA J) has with residents (CNA X) stated, She jokes with (Resident #6) about her boyfriend and (Resident #6) gets mad. She does the same with (Resident #7) as well but I can't really explain it. When asked if she understood the importance of patient advocacy she stated l had a family member in one of our facilities and when I thought about someone doing something to them I understood why I should reported it sooner. During an interview on 2/2/18 at 11:00 a.m., when asked about the abuse of Resident #5, #6 and #7 by CNA J, CNA N stated, .I think it was (CNA S) that told me first about the abuse, it was over the weekend that (CNA S) told me, then (CNA O) told me the same thing .I was off work with (CNA S) told me (about the abuse), it was the next day that I worked that I told the DON (Director of Nursing B) I needed to talk to her, but it ended up being at the end of the day . During an interview on 2/2/18 at 11:30 a.m., CNA O read her statement and stated that is a correct statement. CNA O further stated, I started working here in (MONTH) .I saw (CNA J) slap (Resident #5's) arm because she was being resistant to cares, you know like you would slap a child's hand if they were reaching for an outlet. During an interview on 2/2/18 at 12:45 p.m., when asked about CNA J being abusive to residents, CNA S stated, It was back in (MONTH) and (CNA J) was antagonizing (Resident #6). I think (Resident #6) has mental issues and (CNA J) teases her about her boyfriend .and then we (CNA J and CNA S) were getting (Resident #5) ready for bed and was trying to get her changed and (Resident #5) was being resistive and bumped into (CNA J) and then (CNA J) did this to the (Resident #5's) fore head (CNA S demonstrated to this surveyor, an open hand slap using the fingers).

This citation pertains to intake MI 143. Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 (Resident #2) of 3 reviewed for falls, from a total sample of 7, resulting in Resident #2 sustaining a fall with fractures and was hospitalized for [REDACTED]. Findings include: Review of the Admission Record and Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #2 had clear speech, usually understood, usually understands, was severely impaired cognitively, required limited physical assistance of two people for ambulation, required extensive physical assistance of two persons for toileting and for transfers. Review of the incident form dated 12/11/17 at 10:15 a.m. revealed, (Resident #2) observed on floor of another resident's room. c/o (complain of) pain to Rt (right) hip and knee. Resident sent to (name of hospital) ER (emergency room ). Review of the SBAR (Situation, Background, Assessment, Recommendation) note dated 12/11/17 revealed, C/O (complain of) pain rt hop (right hip) after fall .H/O (history of) multiple falls .in pain with movement to Rt hip, sent to ER (emergency room ) .Resident observed on floor of another residents bathroom, with complaints of pain to rt hip and knee. No apparent bleeding noted. Resident was in therapy prior to being observed on the floor. Resident sent to ER. Review of the Transcribed Progress Note dated 12/11/17 at 11:12 a.m. reveals, Patient one-to-one care wandered off and fell in another resident's bathroom. Difficult to exam due to pain level; patient sitting on floor complaining of arm and hip pain. Patient with some significant pain upon palpation of the right shoulder area and right hip. Patient's with history of multiple falls here poor safety awareness, TBI ([MEDICAL CONDITION]) patient unsure of what occurred does not remember events. Secondary to mechanism will fall and injury 911 contacted to transfer out to Hospital .Treatment Notes: Patient with acute fall pain over right hip and shoulder due to mechanism of injury TBI and confusion, high risk for fracture will send out to emergency room for evaluation . Review of the hospital History and Physical dated 12/11/17 at 3:56 p.m. revealed, (Resident #2) is a [AGE] year old female with medical history significant for TBI (June (YEAR)) .fall in (MONTH) (YEAR) with right humerus fracture. (Resident #2) presented to the ER today from (name of facility) following a fall with complaint of right hip and arm pain .(Resident #2) was reportedly wheeling herself into another pts (patient's) room or bathroom with a wheel chair. She was found sitting on the ground with her right leg bent and complaining of right hip pain. It appeared that (Resident #2) was trying to self-transfer when she fell .(Resident #2) had another fall in (MONTH) (YEAR) that resulted in a comminuted proximal humerus fracture . Review of the hospital discharge summary dated 12/13/17 revealed, 2-part displaced fracture of surgical neck of right humerus .S/P (status/post) right [MEDICAL CONDITION] .S/P ORIF (open reduction internal fixation) right [MEDICAL CONDITION] (troch nail) 12/11/17 (resident had surgery on her right hip, a trochanteric femoral nail was used to stabilize the [MEDICAL CONDITION]). Review of Resident #2's Risk for falls related to: Gait/balance problems, Pain, Unsteady gait, TBI [MEDICAL CONDITIONS], hx of falls, hx of self transfers. Care Plan initiated 9/26/16, and last revised 12/20/17, revealed the intervention of !:1 at all times, initiated on 11/12/17. Review of the written statement by Certified Nursing Assistant (CNA) P, undated, revealed, I (CNA P) was doing one on one with (Resident #2) my nurse (Registered Nurse (RN) R) requested me to go and help CNAs on the hall because call lights were going on. So (RN R) started taking care of (Resident #2) at that moment. I was busy in getting up people. When I saw (RN R) without (Resident #2) I asked her where is (Resident #2)? (RN R) replied she was with the therapy. After a few minutes one of my co-workers called us to one of the resident rooms. The resident restroom was locked. When (RN R) came in and opened the door, (Resident #2) was lying on the floor. During an interview on 11:45 a.m., CNA P read her statement and confirmed that it was accurate. CNA P further stated, Yes, I was the 1:1 that was assigned to (Resident #2) that day. That day was my day off, so I picked up to do 8 hours to work with (Resident #2). I started the day with (Resident #2) in the a.m. It was about 9:15 a.m. and the nurse asked me to help with another CNA because of the call lights, I told (RN R) that I was a 1:1 for (Resident #2). Between 9:50 and 10:00 a.m., I saw the nurse (RN R) and I was scared and asked her where (Resident #2) was, she said she was with therapy .it was 10:15 a.m. when wee found (Resident #2) on the floor. Review of a written stated by RN R undated revealed, This nurse asked (Physical Therapy Assistant (PTA) Q) from therapy to watch (Resident #2) while (CNA P) helped another resident .at 10:15 am the Resident in (room) 506 reported that another resident went into there bathroom. (Resident #2) was observed on the floor next to toilet complaining of pin in the (right) hip and knee . During a telephone interview on 2/2/18 at 12:20 p.m., when asked to describe the day Resident #2 fell and had a fracture, RN R asked, Which fall, both falls she fell and had a fracture. When asked to describe the most recent fall, RN R stated, (Resident #2) was a 1:1, I had one of my CNAs doing the 1:1 and there was a lot of call lights going off so I took over the 1:1 and asked (CNA P) to answer call lights. Then I saw a therapy staff go by and I asked (PTA Q) if she could do the 1:1 so I could go and complete my med (medication) pass. (PTA Q) had her and then about 15 minutes later the call light in 506 was on, the resident in that room pulled the light and I went in and (Resident #2) was in the bathroom with the door locked, I used my key to open it up and (Resident #2) was on the floor and she said her hip hurt, so we called 911. When asked why she did not help with the call lights, RN R stated, Because there was about 5 lights going off, and I can stay with the 1:1 while I pull my meds, since I had to be next to desk anyway. When asked why she passed the 1:1 on to (PTA Q), RN R stated, Because I wanted to finish my med pass. When asked if she actually asked (PTA Q) to be Resident #2's 1:1, RN R stated, My exact words were 'can you watch (Resident #2)'. Review of a written statement by PTA Q, dated 12/11/17 revealed, (RN R) asked if (Resident #2) could stay in therapy while (CNA P) was pulled into a patient room. (Resident #2) had a magazine in hand so I put her up to tour table. I said to our staff in general, no one in particular, that (Resident #2) was going to stay with us for a while. As I was engaged in therapy treatment (with another resident) I looked over and saw (Resident #2) turned from the table facing the therapy treatments in progress. A few minutes later I saw (Resident #2) was gone and assumed the floor staff retrieved her. I went to the bathroom behind the nurses station, as I came out, I heard the I-Team (overhead call when a resident falls) called. (RN R) told me that (Resident #2) had fallen in someone's bathroom. During an interview on 2/2/18 at 12:10 p.m., PTA Q reviewed her written statement and stated, Yep, that is accurate. PTA Q further stated, (RN R) and (Resident #2) were sitting in the sitting area (right outside the door of the therapy room. (RN R) asked if (Resident #2) could stay with us for a little and stated that (CNA P) was her 1:1. I brought (Resident #2) into the therapy room. When asked who was performing the duties of Resident #2's 1:1 at this point, PTA Q stated, We were all in there, when (Resident #2) came in I told everyone that we needed to keep an eye on (Resident #2) until (CNA P) came back. When asked if any of the therapy staff members saw CNA P take the resident, PTA Q stated, I don't know, I was working with another resident, I was working with her and looking back at (Resident #2), I continued to work with the resident and when I looked back (Resident #2) wasn't there and I assumed (CNA P) came and got her, then when I came out of the bathroom I heard them call an I-team, which means fall, but it was not (Resident #2's) room. That is when (RN R) came and told me that it was (Resident #2) that had fallen. When asked if there was an actual handing off of the 1:1 responsibility, PTA Q stated, It was more everyone was in the room to keep an eye on her. At this point PTA Q and this surveyor walked to the therapy room. PTA Q indicated that (Resident #2) was sitting at that table. pointing at a table that was approximately 15 feet from the only entrance/exit door in the therapy room. PTA Q then pointed to where she was working with the other resident, it was about 10-15 feet away form where Resident #2 was sitting. PTA Q stated there were at least 3 therapy staff in the room at the time of the incident. During an interview on 2/2/18 at 1:50 p.m., when asked to supply a policy pertaining to 1:1 care, Nursing Home Administrator (NHA) A stated, We do not have a policy for the 1:1. When asked what the expectation was when a resident required 1:1 care, NHA A replied, Staff was instructed to say just stay with her at all time .that person (assigned as the 1;1) would be with the resident at all times. During an interview on 2/2/18 at 3:30 p.m., when asked if staff were to have other responsibilities when they were providing 1:1 cares for residents, Director of Nursing (DON) B stated, No. During this same interview, when asked what the recording of the camera showed during the time leading up to Resident #2 falling, DON B stated, it showed the resident wheeled herself out of the therapy gym and into the other room.

Based on observation, interview and record review, the facility failed to implement interventions to avoid a fall that resulted in a fractured left hip for 1 of 6 residents (#1) that were reviewed for falls from a total sample of 21; and the facility failed to properly transfer 2 residents (#21 and #23) resulting in a skin tear for resident #21 and a bruise for resident #23, from a total sample of 21. Findings include: According to the facility face sheet dated 8/16/2013, resident #1 was a [AGE] year old female originally admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The fall care plan dated 4/11/2013 reflected resident #1 required 1 person assist for transfers and ambulation. There had been multiple interventions in place such as gripper socks, perimeter mattress (which was discontinued 5/01/2013), bed and chair alarms (discontinued on 7/08/2013), matt to the floor (discontinued 5/06/2013), and to keep the room clutter free. No intervention had been added to the care plan such as to keep the bed in a low position, or to use Hipsters or other protective devices, despite the facility's attempts to ensure resident #1 was safe and to minimize injury. A review of the clinical record revealed resident #1 had a history of [REDACTED].#1 had 6 falls. According to the Incident Reports dated 4/14, 4/29, 5/5, and 7/6/2013, the 4 falls occurred in resident #1's room. Three of the 4 falls involved resident #1 attempting to get out of bed,. The 5/5/2013 incident report reflected resident #1 was trying to get into bed. The Incident Report dated 7/31/2013 reflected that on 7/31/2013 at 2:00 p.m. resident #1 was observed on the floor in her room. Prior to staff observation of resident #1 being on the floor, resident #1 had been in bed. When a pain assessment was conducted, resident #1 rated the pain in her left hip as being 10 out of 10. She was transferred to the hospital and underwent a surgical procedure to repair the left hip. On 11/21/2013 at 8:15 a.m., during an interview with the Director of Nursing staff "l", she reported that the floor mats were discontinued because the team felt they were more hazardous, the alarms were discontinued because the interdisciplinary team felt they startled resident#1, the perimeter mattress was discontinued because resident#1 was always trying to climb out of bed and the facility felt it posed more of a danger than a benefit. When staff "l" was asked if other interventions such as hipsters or a low bed had not been tried staff "l" stated "I thought she would fight against the hipsters." Staff "l" stated the facility had not tried a low bed because they were trying other interventions. The updated fall care plan for resident #1, dated 8/19/2013 with updates added 10/21/2013, included interventions to reduce the risk of fall such as a high/low bed, bilateral floor matts, a perimeter mattress and prompted toileting every 2 hours. ( ) Resident #21 According to Resident #21's physician orders [REDACTED]. On 11/21/13 at 3:00 pm, during review of personnel records, with Human Resource Manager "H" employee Certified Nurse Aide "G's" was noted to have no fingerprint information available. Resident care concerns were requested and revealed CNA "G'" had two disciplinary forms related to resident transfers with injuries and his orientation in-service for resident transfers which included mechanical lifts was incomplete. On 11/21/13 at 4:00 pm, Staff development director "F" reported CNA "Gs" orientation transfer competency was incomplete. According to the facility incident report dated 9/14/13 at 8:45 pm, Resident #21 sustained a skin tear on the left forearm measuring 1.5 x 4.0 cm (centimeters) with a skin flap hanging during a transfer off the toilet by the use of a arjo mechanical total lift, and was documented to not have used two people to help with the transfer. Resident #21 was documented to have been treated with Tylenol for pain. Review of Resident #21's "ADL (Activities of Daily Living) /Mobility Plan of Care," dated 6/28/13 revealed an intervention for a Sara lift (mechanical lift) with (2 PA) 2 person assist . Review of Resident #21's "Fall / Injury Assessment: Prevention and management Plan of Care," dated 6/28/13, revealed an intervention for a Sara lift (mechanical lift) with (2 PA) 2 person assist . Review of Resident #21's Care plan "Areas of Impairment," revealed "Skin tear L (left) upper arm 9/14/13 with an intervention of "Education to staff" dated 9/14/13. On 11/22/13 at 9:25 am, during an interview, CNA "G" was asked how he knew which lift to use for each resident and how to transfer the resident. CNA "G" reported "We carry the care guide with us." CNA "G" reported he used the Tempo lift. CNA "G" was questioned for clarification, Resident #21's transfer information was on your care guide? CNA "G" stated, "Yes." CNA "G" was questioned, did you transfer Resident # 21 by yourself and CNA "G" stated "Yes, the family were getting on me about getting her laid down in a timely manner, I had a lapse in judgement. Was there someone you could have gotten assistance from. "Yes, the nurse." CNA G was questioned if it was the facility policy to transfer with one person with the mechanical lift and responded, "no, I came in yesterday and trained on all the lifts and there are to be two people." On 11/22/13 at 10:20 am, Attending Physician "K" reported Resident #21 had very fragile skin, bruised very easily with a lot of fluid accumulation and was at risk for skin tears. ( )

THIS CITATION PERTAINS TO MI 665 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE USE OF SAFETY DEVICES (WHEELCHAIR FALL ALARM) IN 1 OF 11 SAMPLED RESIDENTS (RESIDENT #511) IN A TOTAL SAMPLE OF 11 RESIDENTS, RESULTING IN RESIDENT #511 FALLING OUT OF HER WHEELCHAIR FACE FIRST AND SUSTAINING A LACERATION REQUIRING SUTURES TO HER FOREHEAD AND A SKIN TEAR TO HER RIGHT FOREARM. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET IN THE MEDICAL RECORD 2/8/12 REVEALED RESIDENT #511 WAS [AGE] year OLD FEMALE admitted to the facility on [DATE]. REVIEW OF THE [DIAGNOSES REDACTED].#511'S [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED RESIDENT #511 HAD SEVERE COGNITIVE IMPAIRMENTS AND REQUIRED ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S). REVIEW OF THE FALL CARE PLAN DATED 3/1/12 REVEALED RESIDENT #511 WAS AT RISK FOR FALLS AND INTERVENTIONS INCLUDED LOW BED WITH FALL MATS, ALARMS IN BOTH WHEELCHAIR AND BED, FOOT REST ON AT ALL TIMES, AND NON-SKID SOCKS. IN AN INTERVIEW ON 4/30/12 AT 11:35 CNA #37 REPORTED ON 4/22/12 DURING FIRST SHIFT, RESIDENT #511'S BED AND WHEELCHAIR FALL ALARMS WERE IN PLACE AND FUNCTIONING PROPERLY. CNA #27 REPORTED AFTER LUNCH, SHE AND REGISTERED NURSE (RN) #15 TRANSFERRED RESIDENT #511 FROM THE WHEELCHAIR TO THE BED AND ENSURED THE BED ALARM WAS IN PLACE AND FUNCTIONING. IN AN INTERVIEW ON 4/30/12 AT 10:15 AM, CERTIFIED NURSING ASSISTANT (CNA) #11 REPORTED ON 4/22/12 AT APPROXIMATELY 6:00 PM, HE AND CNA #12 CLEANED HER UP AND TRANSFERRED HER FROM THE BED TO THE WHEELCHAIR AND DID NOT HEAR THE FALL ALARM GO OFF. CNA #11 REPORTED HE COULD NOT FIND THE FALL ALARM AND THOUGHT IT WAS DISCONTINUED. CNA #11 REPORTED HE PROPELLED RESIDENT #511 IN HER WHEELCHAIR WITHOUT A FALL ALARM TO THE ACTIVITY ROOM FOR DINNER. CNA #11 REPORTED HE DID NOT CHECK RESIDENT #511'S CARE GUIDE TO SEE IF THE FALL ALARM WAS DISCONTINUED AND DID NOT NOTIFY RN #15 THAT HE COULD NOT FIND RESIDENT #511'S FALL ALARM. IN AN INTERVIEW ON 4/30/12 AT 3:30 PM, RN #15 REPORTED SHE WAS UNAWARE CNA #11 AND CNA #12 COULD NOT FIND RESIDENT #511'S FALL ALARM. RN #15 REPORTED AFTER LUNCH, SHE AND REGISTERED NURSE (RN) #15 TRANSFERRED RESIDENT #511 FROM THE WHEELCHAIR TO THE BED AND ENSURED THE BED ALARM WAS IN PLACE AND FUNCTIONING. IN AN INTERVIEW ON 4/30/12 AT 10:40 AM, CNA #13 REPORTED HE WAS IN THE ACTIVITY ROOM ON 4/22/12 AT ABOUT 6:15 PM PROVIDING 1:1 SUPERVISION FOR ANOTHER RESIDENT WHEN HE HEARD A LOUD NOISE. CNA #13 REPORTED HE TURNED AROUND AND SAW RESIDENT #511 ON THE FLOOR FACE FIRST AND IMMEDIATELY CALLED FOR HELP. CNA #13 REPORTED HE DID NOT HEAR RESIDENT #511 FALL ALARM SOUNDING. REVIEW OF A NURSE'S NOTE DATED 4/22/12 REVEALED RESIDENT #511 WAS TRANSFERRED TO THE HOSPITAL FOR TREATMENT. REVIEW OF A NURSE'S NOTE DATED 4/23/12 REVEALED RESIDENT #511 RETURNED TO FACILITY ON 4/23/12 AT 11:00 PM. THE NOTE REVEALED RESIDENT #511 SUSTAINED A LACERATION TO HER FOREHEAD REQUIRING SUTURES AND A SKIN TEAR TO HER RIGHT FOREARM. IN AN INTERVIEW ON 4/30/12 AT 10:35 AM, DIRECTOR OF NURSING (DON) REPORTED NURSING STAFF SHOULD BE LOOKING AT THEIR RESIDENT CARE GUIDES EVERYDAY TO SEE IF THERE WERE ANY NEW CHANGES OR UPDATES. IN AN OBSERVATION ON 4/30/12 AT 12:02 PM, RESIDENT #511 WAS SITTING IN HER WHEELCHAIR WITH THE FALL ALARM IN PLACE AND FUNCTIONING, FOOT BOX/CUSHION IN PLACE, AND FOOT RESTS IN PLACE. RESIDENT #511 HAD BRUISES AND SUTURES TO HER FOREHEAD. RESIDENT #511 WAS UNABLE TO ANSWER QUESTIONS AT THAT TIME. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT A FALL FOR 1 OF 5 RESIDENTS (#41) REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 8 RESIDENTS, RESULTING IN SKIN INJURIES INCLUDING BRUISE, ABRASION TO THE LEFT KNEE AND EMOTIONAL TRAUMA. FINDINGS INCLUDE: ACCORDING TO THE MONTHLY PHYSICIANS ORDER SHEET DATED JUNE 2012 RESIDENT #41 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) assessment dated [DATE] REFLECTED RESIDENT #41 HAD BRIEF INTERVIEW FOR MENTAL STATUS (BIM) SCORE OF 15 FROM A TOTAL SCORE OF 15 (MEANING RESIDENT IS ALERT AND COHERENT). FOR THE MDS ( SAME DATE) UNDER THE FUNCTIONAL STATUS THE BED MOBILITY WITH SELF-PERFORMANCE WAS CODED AS "3" REPRESENTING THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE AND WITH SUPPORT CATEGORY SHE WAS CODED AS "3" REPRESENTING 2 PERSON PHYSICAL ASSIST. UNDER THE BALANCE DURING TRANSITIONS AND WALKING THE RESIDENT WAS CODED AS "2" REPRESENTING THE RESIDENT WAS NOT STEADY AND ONLY ABLE TO STABILIZE WITH STAFF ASSISTANCE. THE INCIDENT REPORT DATED 6/10/12 AT 2:15 A.M. REFLECTED RESIDENT #41 WAS OBSERVED "LYING ON LEFT SIDE OF BODY WITH BACK FACING THE WALL" IN THE RESIDENT'S BEDROOM. UNDER THE PHYSICAL EXAMINATION- INJURY SECTION OF THE SAME INCIDENT REPORT OF 6/10/12. RESIDENT #41 WAS DESCRIBED AS HAVING, " A BRUISE/SWELLING MEASURING 6 CM X 8 CM ON HER LEFT KNEE, REDDENED/DISCOLORED AREA MEASURING 10 CM X 7 CM ON HER LEFT POSTERIOR THIGH". THE RESIDENT WAS TAKEN TO emergency room FOR EVALUATION. THE LEFT KNEE CAT SCAN UNDER "PRELIMINARY RADIOLOGY REPORT" DATED 6/10/12 REFLECTED RESIDENT #41 HAD AN OLD HEALED FRACTURE OF THE FIBULA, NO ACUTE FRACTURES, SEVERE TRICOMPARTMENTAL DEGENERATIVE DISEASE, SMALL JOINT EFFUSION, OSTEOPENIA, ATHEROSCLEROSIS AND PREPATELLAR SOFT TISSUE SWELLING. THE CAT SCAN OF BRAIN REFLECTED RESIDENT #41 HAD NO ACUTE INTRACRANIAL HEMORRHAGE OR SKULL FRACTURES. ON 6/12/12 AT 10:30 A.M., RESIDENT #41 WAS OBSERVED LYING ON HER "BIG BOY" BED WITH OXYGEN RUNNING THROUGH A NASAL CANNULA. THE RESIDENT LOOKED TO BE OVERWEIGHT. HER WEIGHT WAS 248 LBS, HEIGHT 5' 2' AS QUOTED FROM RESIDENT LIFTING, TRANSFERRING AND REPOSITIONING DATA COLLECTION FROM DATED 6/11/12. THE RESIDENT LIFTED HER SHEET AND POINTED TO HER LEFT KNEE THAT WAS COVERED WITH ICE BAG. THE LEFT KNEE HAD EXTENSIVE PURPLE BLUISH BRUISE AND RED ABRASION. RESIDENT #41 STATED THAT SHE fell on THE FLOOR FACE DOWN FROM HER BED LAST SATURDAY. THE RESIDENT STATED, "I COULD NOT BREATHE, MY OXYGEN WAS OFF AND I WAS SCARED TO DEATH. I WAS JAMMED IN THE THE SPACE BETWEEN THE BED AND THE WALL. THEY HAD TO LIFT ME UP WITH A BIG MACHINE". RESIDENT #41 CONTINUED TO STATE, "I DO NOT KNOW THE AIDE WHO CAME IN TO CHANGE MY BRIEF. SHE WAS SHORT AND HAD BLACK HAIR. I TOLD HER I WAS NOT WET BUT SHE INSISTED THAT I HAD TO BE CHANGED". THE "CARE DELIVERY GUIDE," UTILIZED BY THE NURSING AIDES, UPDATED 6/12/12 (AFTER THE FALL) REFLECTED RESIDENT #41 REQUIRED 2 ASSIST POSITIONING, 2 ASSIST TRANSFER "TEMPO" LIFT AND 2 ASSIST FOR SHOWER. ON 6/13/12 AT 1:30 P.M., THE ASSISTANT DIRECTOR OF NURSING (STAFF "A") STATED THAT SHE HAD UPDATED THE CARE GUIDE YESTERDAY AND STATED THERE WAS NO CHECK MARKS ON HOW MANY ASSIST THE RESIDENT REQUIRED FOR BED MOBILITY. ON 6/13/12 AT 1:15 P.M., THE NURSING AIDE, (STAFF "B") STATED THAT SHE HAD KNOWN RESIDENT #41 SINCE HER ADMISSION, THE RESIDENT WAS NEVER A ONE PERSON ASSIST, THE RESIDENT DID NOT TURN HERSELF AND THE RESIDENT RARELY GOT OUT OF THE BED. THE CARE PLAN REGARDING THE FALL/INJURY DATED 11/23/11 AND UPDATED ON 2/22/12 AND 6/10/12 REFLECTED RESIDENT WAS AT RISK FOR FALLS RELATED TO UNSTEADY GAIT, POOR WEIGHT BEARING, [DIAGNOSES REDACTED]. UNDER THE INTERVENTIONS RESIDENT #41 WAS CHECKED FOR 2 ASSIST FOR AMBULATION, 2 ASSIST FOR TRANSFER WITH "TEMPO" LIFT AND ENABLER BAR WAS ADDED ON 6/10/12 (AFTER THE INCIDENT). ON 6/13/12 AT 2:00 P.M., THE DIRECTOR OF NURSING (DON) WAS ASKED WHAT MAY HAVE BEEN THE ROOT CAUSE OF THE RESIDENT'S FALL. THE DON STATED THAT THE FACILITY HAD IMPLEMENTED "ENABLER BARS" FOR SUPPORT. THE INVESTIGATIVE REPORT DATED 6/11/12 REFLECTED THE STAFF WAS NOT FOLLOWING PLAN OF CARE SPECIFIC TO 2 PERSON ASSIST FOR AMBULATION, TRANSFER WITH "TEMPO" LIFT. ON 6/13/12 AT 11:00 A.M., RESIDENT #41 WAS OBSERVED LYING IN HER BED. THERE WERE "GRAB" BARS ON EACH SIDE OF THE BED AND HAD PRESSURE RELIEVING AIR MATTRESS (NOT NEW) ON. THE RESIDENT WAS STILL SHAKEN BY THE FALL AND STATED," THE GIRL (AIDE) KEPT PUSHING ME FURTHER AND FURTHER TO THE EDGE WHERE THERE WAS NO ROOM, NOTHING TO GRAB ON TO AND I FINALLY ROLLED OUT OF THE BED". THE RESIDENT ADDED, "THEY WERE SUPPOSED TO TURN ME WITH 2 PEOPLE BUT SHE WAS DOING IT BY HERSELF. SHE EVEN TRIED TO LIFT ME UP BY HERSELF FROM THE FLOOR AFTER I fell ". THE SPACE BETWEEN THE BED AND THE WALL WAS MEASURED AND WAS NOTED TO BE 10 INCHES WIDE. RESIDENT #41'S FALL THAT OCCURRED ON 6/10/12 WAS PREVENTABLE. ( )

BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO REVISE THE FALL CARE PLAN INTERVENTIONS TO PREVENT FALLS FOR 1 OF 9 RESIDENTS REVIEWED FOR FALLS (#15) OUT OF A TOTAL OF 20 SAMPLED RESIDENTS , RESULTING IN THE POTENTIAL FOR CONTINUED FALLS WITH INJURY. FINDINGS INCLUDE: ACCORDING TO THE FACE SHEET DATED 1/20/12, RESIDENT #15 WAS A [AGE] year OLD FEMALE admitted [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE INCIDENT AND ACCIDENT REPORTS DATED FROM 1/15/12 THROUGH 1/29/12 RESIDENT #15 HAD 6 FALLS. THE ACCIDENT/INCIDENT REPORT DATED 1/15/12 REFLECTED RESIDENT #15 WAS OBSERVED FALLING TO FLOOR, LEANED TO HER RIGHT SIDE ON THE FLOOR WITH HAND ON RIGHT TEMPLE, THE NURSE AIDE TOOK VITAL SIGNS AND ASSISTED RESIDENT #15 BACK TO BED. THE RESIDENT'S ALARM WAS PLUGGED IN BUT NOT SOUNDING. THE IMMEDIATE ACTION TO PREVENT FURTHER INCIDENTS WAS TO INCREASE MONITORING, CHECKED ALARM AND THE BATTERIES WERE CHANGED. RESIDENT #15 HAD TWO FALLS ON 1/19/12, ONE FALL WAS AT 19:30 AND THE OTHER WAS 30 MINUTES LATER . THE ACCIDENT/INCIDENT REPORTS DATED 1/19/12 AT 19:30 REFLECTED RESIDENT #15 TRIPPED ON LOOSE SOCKS. THIRTY MINUTES LATER RESIDENT #15 WAS FOUND SITTING BESIDE HER BED ON THE FLOOR MAT. THE INVESTIGATIVE PORTION OF THE INCIDENT ON 1/19/12 AT 20:00 (10 PM) REFLECTED THE ALARM WAS NOT PLUGGED IN AND "ALARMS NOT PROPERLY USED". THIS SAME INCIDENT REPORT REFLECTED, "RESIDENT CONTINUES TO TRANSFER HERSELF WITH OUT USING THE CALL LIGHT ... REMOVED BILAT (BILATERAL) FLOOR MAT". THE ACCIDENT/INCIDENT REPORT DATED 1/20/12 AT 19:30 (9:30 PM) REFLECTED RESIDENT #15 WAS OBSERVED SITTING ON THE FLOOR IN HER ROOM NEXT TO HER BED, RESIDENT STATED THAT SHE WAS TRYING TO PICK UP SOMETHING OFF THE FLOOR. THIS SAME REPORT ALSO REFLECTED THE ALARMS IN BED WERE NOT WORKING. IN THE FINAL DISPOSITION PORTION OF THE REPORT THERE HAD BEEN A PHARMACY MEDICATION REVIEW, THE ALARM WAS REPLACED BUT THE RESIDENT HAD BEEN OBSERVED BY STAFF REMOVING AND UNPLUGGING HER ALARMS. THE ACCIDENT/INCIDENT REPORT DATED 1/22/12 REFLECTED RESIDENT #15 WAS AGAIN OBSERVED SITTING ON THE FLOOR, RESIDENT WAS HEARD YELLING OUT, RESIDENT WAS CONFUSED DROWSY AND DISORIENTED. THE IMMEDIATE ACTION TAKEN TO PREVENT FURTHER INCIDENTS WAS TO PUT RESIDENT #15 IN A "WHEELCHAIR FOR EASIER OBSERVATION BY STAFF". THE FINAL DISPOSITION WAS FOR RESIDENT#15 TO BE KEPT AT NURSE'S STATION AT TIMES FOR INCREASED ACTIVITY AND RESTLESSNESS AND AMBULATE WITH STAFF AS NEEDED FOR RESTLESSNESS. THE UNDATED ACCIDENT/INCIDENT REPORT SIGNED 1/29/12 REFLECTED THAT BRUISES WERE NOTED ON THE RESIDENT THAT MORNING, THE RESIDENT STATED SHE fell OUT OF WHEELCHAIR, THEN SAID SHE fell OUT OF BIG CHAIR AND FINALLY THE STAFF DETERMINED SHE WAS UNABLE TO REMEMBER. THE IMMEDIATE ACTION TO PREVENT FURTHER INCIDENTS WAS TO INCREASE MONITORING AND ACTIVITIES. THE FINAL DISPOSITION WAS THAT RESIDENT #15 WAS COGNITIVELY IMPAIRED AND THE BRUISES COULD HAVE OCCURRED FROM PREVIOUS FALLS. THE PROGRESS NOTES DATED 1/30/12 AND 2/1/12 REFLECTED RESIDENT #15 CONTINUES TO SELF TRANSFER. THE 2/1/12 PROGRESS NOTES REFLECT THE SAFETY MEASURES WERE IN PLACE AND THE CALL LIGHT WAS WITHIN REACH. THE PROGRESS NOTES DATED 2/6/12 REFLECTED "RES. (RESIDENT) CONTINUES TO SELF TRANSFER, AMBULATE IN ROOM, ATTEMPT TO STAND UP FROM WHEELCHAIR THROUGHOUT SHIFT! RES. CHAIR AND BED ALARMS ARE ACTIVATED WITH EACH ATTEMPT. RES. ESCORTED BACK TO BED, CHAIR, W/C (WHEELCHAIR) OR RES PREFERENCE EACH TIME. REMINDED RES TO USE CALL LIGHT FOR ASSIST AND TO MAKE NEEDS KNOWN. ..CALL LIGHT AND SAFETY MEASURES IN PLACE." ON 2/24/12 AT 12:30 PM THE ADMINISTRATOR STATED RESIDENT #15 LIKES TO SOCIALIZE SO THEY KEEP HER INVOLVED IN ACTIVITIES AS A WAY OF PREVENTING FALLS, SHE STATED THAT THIS NEW INTERVENTION HAS BEEN EFFECTIVE. SHE ALSO STATED SHE WAS AWARE OF NURSE AIDE COMPLAINTS ON THAT HALL THAT MORE STAFF WAS NEEDED TO EFFECTIVELY SUPERVISE AND ADDRESS RESIDENT #15'S BEHAVIOR AND TO PREVENT FALLS BECAUSE OF HER HALLUCINATIONS. HOWEVER, SHE FELT THAT CURRENT STAFF NUMBERS AND INTERVENTIONS WERE EFFECTIVE. ON 2/24/12 AT ABOUT 9;00AM, AN CONFIDENTIAL INTERVIEW WITH A STAFF STATED THAT RESIDENT #15 HAD A LOT OF BEHAVIORS AND NEEDED EXTRA SUPERVISION, THAT SHE FALLS ALL THE TIME AND HAS FREQUENT HALLUCINATIONS AND HAD EVEN THREATENED TO BLOW THE PLACE UP. SHE STATED THAT RESIDENT #15 DOES NOT USE HER CALL LIGHTS AND SOCIALIZING HER WITH OTHER RESIDENTS HAS NOT BEEN EFFECTIVE TO PREVENT FALLS. THE FALL PREVENTION PLAN OF CARE DATED 1/9/12 REFLECTED TO EDUCATE RESIDENT AND RESPONSIBLE PARTY AND STAFF AS NEEDED, TO KEEP THE CALL LIGHT IN REACH. IT IS UNCLEAR WHETHER THIS IS AN APPROPRIATE INTERVENTION SINCE THE FACILITY diagnosed RESIDENT #15 WITH COGNITIVE IMPAIRMENT. THIS CARE PLAN HAD NOT ADDRESSED ALL OF THE CHANGES AND INTERVENTIONS THAT WERE MADE AFTER THE FALL INVESTIGATIONS AND THE INTERMEDIATE DISCIPLINARY TEAM MEETING SO STAFF ARE ABLE TO CONSISTENTLY IMPLEMENT CURRENT INTERVENTIONS. EXAMPLES OF SUPPOSEDLY REVISIONS THAT WERE MADE BUT WERE NOT UPDATED IN THE CARE PLAN OF 1/9/12 MAY BE THE MONITORING OF THE ALARMS, ABILITY OF RESIDENT #15 TO REMOVE ALARMS AND ENHANCED PARTICIPATION FOR ACTIVITIES. RESIDENT #15'S FALLS FOR 1/15/12, 1/19 AND 1/20 WERE PREVENTABLE. ( )

THERE ARE TWO DEFICIENT PRACTICES RELATED TO THIS REQUIREMENT. 1) BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND INTERVENTIONS TO PREVENT BURNS WITH HOT LIQUIDS RESULTING IN IMMEDIATE JEOPARDY FOR 1 RESIDENT (#28) OUT OF A SAMPLE OF 13 RESIDENTS RELATED TO A SECOND DEGREE BURN TO RESIDENT #28'S THE LEFT HIP AREA (BLISTERING, SWELLING, AND REDNESS OF SURROUND AREA). RESIDENT #28 WAS ASSESSED TO HAVE DEMENTIA AND ASSESSED AS A "RISK WITH HOT LIQUIDS". THE FACILITY FAILED TO UPDATE RESIDENT #28'S CARE PLAN AND INTERVENTIONS TO INCLUDE THE FOLLOWING BEHAVIORS OF RESIDENT #28: REPEATEDLY TAKES OFF THE COFFEE LID, DOZES OFF WHILE WAITING TO BE SERVED AS VERBALIZED BY A DIETARY AIDE WHO KNOWS RESIDENT #28, AND WAS SHAKY WHEN ASSISTED FOR TRANSFERS BY DIRECT OBSERVATION. IN ADDITION, THE BURN INCIDENT WAS NOT REPORTED IMMEDIATELY TO NURSING AND MEDICAL STAFF FOR PROPER TREATMENT. THE IMMEDIATE JEOPARDY BEGAN ON 4/17/2012 BETWEEN 7:30 A.M. AND 8:00 A.M. ABOUT THE TIME THE INCIDENT OCCURRED. THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY SITUATION AT ON 4/19/2012 AT 10:55AM. THE IMMEDIATE JEOPARDY WAS REMOVED BUT NOT CORRECTED WHEN THE FACILITY ADMINISTRATOR PROVIDED THE CORRECTION PLAN TO REMOVE THIS IMMEDIATE JEOPARDY ON 4/19/2012 AT 4:00 P.M. THE CORRECTION PLAN TO REMOVE THE IMMEDIATE JEOPARDY CONSISTED OF THE FOLLOWING: 1) AN IN-SERVICE FOR HOT FOOD AND BEVERAGE SAFETY PROCEDURE TO THE ENTIRE FACILITY STAFF; 2) AN IN-SERVICE TO THE ENTIRE FACILITY STAFF FOR PROPER RESPONSE TO SPILLS INVOLVING RESIDENTS; 3) NOTIFY LICENSED NURSES TO ASSESS RESIDENT OR RESIDENTS WHO REMOVE THE ASSISTIVE DEVICES (LIDS) IN ORDER TO APPLY APPROPRIATE INDIVIDUALIZED INTERVENTIONS; 4) ASSIGN A LICENSED NURSE TO THE DINING ROOMS FOR ALL MEALS TO ASSIST IN SUPERVISION; 5) RE-ASSESSMENT OF RESIDENT 28'S RISK FOR HOT LIQUIDS. THE CARE PLAN WILL BE UPDATED TO REFLECT CURRENT STATUS; 6) RE-EVALUATION OF ALL RESIDENTS WHO ARE AT RISK FOR HOT LIQUIDS. THE CARE PLANS WILL BE REVISED ACCORDINGLY; 7) IN-SERVICE TO ALL STAFF RELATED TO ANY CHANGES TO CARE PLANS RELATED TO " RISK FOR HOT LIQUIDS " AND INJURY; AND 8) THE QUALITY ASSURANCE PROGRAM WILL INITIATE AND PERIODICALLY REVIEW ACTIONS TAKEN FOR SUSTAINED COMPLIANCE. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AT HARM WITH A SCOPE OF ISOLATED RELATED TO TWO RESIDENTS ( #17 AND 27) WHO HAD PREVENTABLE FALLS. IN ADDITION, THE FACILITY HAS TO COMPLETE REASSESSING ALL RESIDENTS WITHIN THE FACILITY WHO ARE AT RISK FOR HOT LIQUIDS, REASSESS THEIR USE OF ASSISTIVE DEVICES WHEN BEING PROVIDED LIQUID BEVERAGES, CONTINUE TRAINING FOR ALL CHANGES TO THE CARE PLANS AND FOR THEIR QUALITY ASSURANCE COMMITTEE TO MONITOR THE CORRECTIONS AND SUSTAIN COMPLIANCE. FINDINGS INCLUDE: THE FACILITY DOCUMENT TITLED "HISTORY & PHYSICAL EXAMINATION " DATED 12/28/2011 DESCRIBED RESIDENT #28 AS AN [AGE] year-OLD FEMALE admitted to the facility on [DATE] WITH THE FOLLOWING Diagnoses: [REDACTED]. ON 4/17/2012 AT ABOUT 10:40 A.M. DURING THE INITIAL TOUR WITH THE ASSISTANT DIRECTOR OF NURSING, STAFF "A" AN INTERVIEW WAS CONDUCTED WITH RESIDENT #28 IN HER ROOM. RESIDENT #28 COMPLAINED WITH FACIAL GRIMACING THAT SHE HAD SPILLED HER COFFEE AND WAS HAVING PAIN LAYING HER HAND OVER HER LEFT HIP AREA. STAFF "A" WAS ASKED IF THIS HAS BEEN REPORTED AND INDICATED THAT THIS IS THE FIRST THAT SHE HAD HEARD OF IT. STAFF "A" WAS REQUESTED TO ASSIST IN LIFTING THE CLOTHING GARMENT TO EXPOSE THE AFFECTED LEFT HIP AREA OF RESIDENT #28. STAFF "A" RETRIEVED A CERTIFIED NURSING ASSISTANT TO ASSIST. RESIDENT #28 ' S LEFT OUT HIP WAS EXPOSED AND REVEALED AN AREA WITH BLISTERING, SWELLING AND REDNESS TO THE SKIN. RESIDENT #28 WAS ASKED AGAIN IF THIS AREA CAUSED HER PAIN AND INDICATED THAT IT WAS PAINFUL, REPEATEDLY STATED, " YES" WITH FACIAL GRIMACING AND POINTING TO THE LEFT HIP AREA. THE SIGNS AND SYMPTOMS REVEALED A SECOND DEGREE BURN. REVIEW OF RESIDENT #28 ' S MEDICAL RECORD IDENTIFIED RESIDENT #28 TO BE AT RISK FOR HOT LIQUIDS WITH THE FOLLOWING NOTATIONS: THE DOCUMENT TITLED "PROGRESS NOTES" AN INTERDISCIPLINARY TEAM MEETING NOTE DATED 12/30/11 THAT SHOWED, " ...NEEDS LIDS ON HOT BEVERAGES "; A physician's orders [REDACTED]. HANDLING HOT BEVERAGES " AND AN INTERVENTION DATED 1/24/12 "LIDS ON HOT BEVERAGES"; A DOCUMENT TITLED "ADL (ACTIVITIES OF DAILY LIVING)/MOBILITY: PLAN OF CARE" A PROBLEM ENTRY DATED 3/29/12 OF "AT RISK FOR HANDLING HOT BEVERAGES" WITH AN INTERVENTION DATED 3/29/2012 AS "LID ON HOT BEVERAGES". HOWEVER, THE CARE PLAN DID NOT INCLUDE THE CURRENT STATUS THAT RESIDENT # 28 REPEATEDLY TAKES THE LID OFF HER COFFEE, DOZES OFF PRIOR TO HER MEALS AND IS REPORTED TO BE SHAKY. THE NURSING PROGRESS NOTES WERE REVIEWED BETWEEN 10:40 A.M. AND 11:40 A.M. ON 4/17/2012 AND THERE WAS NO MENTION OF ANY NOTES REGARDING HOT LIQUID SPILL THAT OCCURRED BETWEEN 7:40 A.M. AND 8:00 A.M. ON 4/17/2012. THERE WAS NO INCIDENT REPORT AVAILABLE FOR REVIEW DURING RECORD REVIEW BY THIS SURVEYOR ON 4/17/2012 AT 11:15 A.M. ON 4/17/2012 AT 11:40 A.M. AN INTERVIEW WAS CONDUCTED IN THE MAIN DINING ROOM WAIT AREA WITH DIETARY AIDE, STAFF "D" . STAFF "D" WAS ASKED ABOUT THE INCIDENT THAT OCCURRED WITH RESIDENT #28 EARLIER THIS MORNING AND INDICATED RESIDENT #28 WAS NOTED BY STAFF "D" TO BE DOZING OFF AT THE TABLE BEFORE BREAKFAST. RESIDENT #28 fell ASLEEP AND DROPPED HER COFFEE. STAFF "D" WAS ASKED IF A LID WAS APPLIED TO THE CUP OF COFFEE AND STAFF "D" REPLIED, "SHE ALWAYS TAKES HER LID OFF TO ADD CREAM AND SUGAR, I DON ' T KNOW, THE LID WAS ON THE FLOOR ALONG WITH THE CUP". "STAFF "D" WAS ASKED IF ANY STAFF ASSISTED IN PREPARING HER COFFEE OR SUPERVISED HER TO ASSURE THE LID IS SECURED ON THE COFFEE SINCE RESIDENT #28 REMOVES THE LID. STAFF "D" INDICATED THAT THE STAFF IN THE DINING ROOM JUST WATCHES EVERYONE BUT THE STAFF DO NOT MAKE SURE THE LIDS ARE ON TIGHT IF THE RESIDENTS REMOVE THEM. STAFF "D" WAS ASKED WHAT TOOK PLACE AFTER THE COFFEE SPILLED. STAFF "D" WENT OVER TO THE RESIDENT AND APPLIED A COLD WET PAPER TOWEL, THEN A CERTIFIED NURSING ASSISTANT (CNA), STAFF "E" WENT OUT INTO THE HALL AND STAFF "D" ASSUMED THAT CNA, STAFF "E" WAS GOING TO GET THE NURSE BUT CNA, STAFF "E" COULD NOT FIND A NURSE SO SHE TOLD THE CNA THAT WORKED IN RESIDENT #28 ' S HALLWAY WHAT HAPPENED. DIETARY AIDE, STAFF "D" STATED THAT CLOSE TO 8:00 A.M. INTERIM DIETARY MANAGER, STAFF "C" ARRIVED TO WORK AND QUESTIONED STAFF "D" WHO WAS SURPRISED SINCE SOMEHOW STAFF "C" WAS ALREADY AWARE OF THE ACCIDENT. STAFF "C" TOLD STAFF "D" TO START PUTTING AN ICE CUBE IN THE COFFEE CUPS SERVED TO RESIDENTS. ACCORDING TO THE FACILITY'S "FOOD-USAGE & TEMPERATURE REPORT" DATED 4/17/12 , THE START TEMPERATURE FOR COFFEE SERVED AT BREAKFAST WAS 160 DEGREES FAHRENHEIT, THE MORNING OF THE BURN INCIDENT. ON 4/19/2012 AT 1:15 P.M. AN INTERVIEW WAS CONDUCTED WITH CERTIFIED NURSE ASSISTANT (CNA), STAFF "E" IN THE HALLWAY ON THE 100 UNIT REGARDING THE BURN INCIDENT INVOLVING RESIDENT #28. STAFF "E" REPLIED, "I WAS BRINGING TOWELS INTO THE DINING ROOM AND SAW THE COFFEE ON THE FLOOR. I WENT TO THE HALL WHERE SHE (RESIDENT #28) LIVES AND I COULDN'T ' T SEE THE NURSE, SO I TOLD HER AIDE (CNA) THAT SHE (RESIDENT #28) SPILLED HER COFFEE". REVIEW OF RESIDENT #28 ' S MEDICAL RECORD REFLECTED A physician's order [REDACTED].M.) THAT INDICATED CLEAN BURNED, REDDENED SKIN ON LEFT HIP WITH WOUND CLEANSER, APPLY HYDROCORTISONE AND COVER WITH ABD (BULKY PAD) PAD ONCE DAILY AND AS NEEDED. REVIEW OF THE FACILITY DOCUMENT TITLED " RESIDENT INCIDENT " DATED 4/17/2012 REFLECTED RESIDENT #28 HAD SUSTAINED AN INJURY AND WAS DESCRIBED AS A 2ND DEGREE BURN MEASURING 9 CM (CENTIMETERS) X 5 CM TO THE LEFT ANTERIOR LATERAL THIGH. IT TOOK APPROXIMATELY 9-10 HOURS BEFORE A PHYSICIAN PRESCRIBED TREATMENT TO RESIDENT #28'S BURN. REVIEW OF THE FACILITY ' S POLICY AND PROCEDURE TITLED "HOT FOOD AND BEVERAGE SAFETY 6.6.1" DATED JULY 2008 REFLECTED "...FACILITIES WILL PROPERLY POSITION RESIDENTS FOR MEAL SERVICES TO PROMOTE INDEPENDENCE IN SELF FEEDING AND TO PREVENT SPILLAGE. RESIDENT AT RISK FOR A BURN INJURY WILL BE ASSISTED WITH TRAY SET UP OR WITH EATING TO PREVENT SPILLS OF HOT FOOD OR BEVERAGES. RESIDENTS AT RISK FOR A BURN INJURY MAY DEMONSTRATE SOME OF THE FOLLOWING: SLOW RESPONSE TIME; NEED FOR ASSISTANCE WITH TRAY SETUP; NEED FOR ASSISTANCE WITH EATING; COGNITIVE IMPAIRMENT (DEMENTIA)". 2) BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ENSURE ADEQUATE SUPERVISION AND INTERVENTIONS TO PREVENT FALLS FOR 2 RESIDENTS (#17 AND 27) OF 9 RESIDENTS ASSESSED FOR FALLS OUT OF A TOTAL OF 13 SAMPLED RESIDENTS SUSTAINING PAIN IN BOTH KNEES AND A SKIN TEAR TO THE LEFT UPPER EXTREMITY STUMP FOR RESIDENT #17, AND SUSTAINING SWELLING AND A LACERATION TO HEAD FOR RESIDENT #27. FINDINGS INCLUDE: RESIDENT #17 WAS AN ALERT AND ORIENTED [AGE] year-OLD FEMALE admitted to the facility on [DATE] TO REHABILITATE FROM A LEFT FOREARM AMPUTATION IN NOVEMBER 2011 AND DURING ADMISSION WAS ASSESSED FOR THE NEED TO CONTINUE WITH PHYSICAL THERAPY FOR DIFFICULTY AMBULATING AS REFLECTED IN A physician's order [REDACTED]. REVIEW OF AN INCIDENT REPORT DATED 4/16/2012 FOR A FALL REFLECTED RESIDENT #17 HAD TRIPPED OVER HER OWN SHOES WHILE AMBULATING IN THE HALLWAY ON 4/16/2012. SHE WAS USING A STRAIGHT CANE AND A GAIT BELT WITH CONTACT ASSIST. RESIDENT #28 SUSTAINED INJURY DESCRIBED AS PAIN TO BILATERAL KNEES AND LEFT UPPER EXTREMITY STUMP IN ADDITION TO A SKIN TEAR THAT MEASURED TO BE 1.5 CM (CENTIMETERS) X 1.2 CM TO THE TIP OF THE LEFT UPPER EXTREMITY STUMP. ON 4/19/2012 AT 3:00 P.M. AN INTERVIEW WITH RESIDENT #17 WAS CONDUCTED IN HER ROOM. RESIDENT #17 WAS ASKED ABOUT THE FALL THAT TOOK PLACE ON 4/16/2012. SHE INDICATED THAT SHE IS STILL EXPERIENCING PAIN IN BOTH HER KNEES AND THE LEFT UPPER EXTREMITY STUMP. SHE STATED THAT THE SKIN TEAR THAT OCCURRED FROM THE FALL WAS HEALING. RESIDENT #17 INDICATED THE PHYSICAL THERAPIST HAD DONNED A GAIT BELT ON HER AND HAD FELT THE THERAPIST'S HAND ON HER BACK WHEN RESIDENT #17 AND THE PHYSICAL THERAPIST, STAFF "H" WERE WALKING BACK TO RESIDENT #17'S ROOM AFTER THE THERAPY SESSION. ON 4/19/2012 AT 3:20 P.M. AN INTERVIEW WITH PHYSICAL THERAPIST, STAFF "H" WAS CONDUCTED IN AN EMPTY RESIDENT ROOM ON THE 500 UNIT REGARDING THE FALL THAT OCCURRED ON 4/16/2012 INVOLVING RESIDENT #17 . STAFF "H" INDICATED THAT RESIDENT #17 WAS CARE PLANNED TO BE A STAND BY ASSIST WHEN AMBULATING FROM HER ROOM TO THE PHYSICAL THERAPY ROOM PRIOR TO THERAPY SESSION. HOWEVER, RESIDENT #17 WAS CARE PLANNED TO BE CONTACT GUARD WHEN AMBULATING FROM THERAPY SESSION IN THE THERAPY ROOM BACK TO RESIDENT ' S ROOM. STAFF "H" WAS ASKED TO EXPLAIN THE TERM "CONTACT GUARD" AS DIFFERENTIATED FROM A STAND BY ASSIST. STAFF "H" DEFINED CONTACT GUARD AS ONE HANGS ONTO A GAIT BELT TO ASSIST THE RESIDENT WITH BALANCE AND HAVE A HOLD IN THE EVENT A RESIDENT NEEDS ASSISTANCE WITH CONTROL. STAFF "H" INDICATED PRIOR TO THE FALL RESIDENT #17 WAS AMBULATING WITH A CANE DOWN THE HALL TOWARD HER ROOM, STAFF " H " HAD A HOLD OF THE GAIT BELT WITH ONE HAND, AND WALKED A HALF STEP BEHIND AND TO THE SIDE OF RESIDENT, WHILE AN OCCUPATIONAL THERAPIST WALKED BEHIND RESIDENT #17 WITH A WHEELCHAIR TO AID THE RESIDENT IF RESIDENT #17 NEEDED TO REST. STAFF "H" FURTHER EXPLAINED THAT RESIDENT #17 HAD EXPERIENCED WEAKNESS IN HER ANKLE AND DID NOT LIFT HER RIGHT FOOT ENOUGH TRIPPING ON HER OWN SHOE, WENT FORWARD AND STAFF "H" LOST THE GRIP ON THE GAIT BELT WHICH THEN RESIDENT #17 LANDED ON THE FLOOR WITH BOTH KNEES , RIGHT HAND, AND LEFT UPPER EXTREMITY STUMP. STAFF "H" WAS ASKED IF THIS COULD HAVE BEEN AVOIDED AND REPLIED, " I SHOULD HAVE BEEN ANTICIPATING MORE TO PREVENT THE FALL, IT HAPPENED SO QUICKLY ". AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSING (DON) ON 4/20/2012 AT 8:35 A.M. IN THE CONFERENCE ROOM REGARDING THE FALL OF RESIDENT #17 ON 4/16/2012. THE DON CONFIRMED THE FALL WAS AVOIDABLE WHEN THE DON ACKNOWLEDGED THE PHYSICAL THERAPIST SHOULD HAVE BEEN MORE ALERT AND MAY ANTICIPATE THAT AN EVENT COULD HAPPEN ESPECIALLY AFTER A THERAPY SESSION WHEN MUSCLES ARE TIRED AND WEAK. IN ADDITION, RESIDENT #17 IS CURRENTLY EXPERIENCING PAIN AND DISCOMFORT RELATED TO THE FALL. A RECORD REVIEW OF THE FACILITY ' S DOCUMENT TITLED "history and physical examination [REDACTED]'S DISEASE, DEMENTIA, ANXIETY DISORDER WITH PSYCHOSIS AND BEHAVIORAL PROBLEMS, status [REDACTED]. REVIEW OF THE FACILITY DOCUMENT TITLED "RESIDENT INCIDENT" DATED 4/17/2012 THAT REFLECTED RESIDENT #27 HAD A FALL ON 4/16/2012 IN HER ROOM. RESIDENT #27 "WAS FOUND ON THE FLOOR BETWEEN WALL AND BED. SHE WAS IN A SITTING POSITION WITH THE CNA (CERTIFIED NURSING ASSISTANT) WITH HER. RESIDENT HAD A SMALL LACERATION ON TOP OF HER HEAD WITH A VERY SMALL AMOUNT OF BLOOD. CLEANSED WOUND, NO CONTINUOUS BLEEDING WAS NOTED". THE DOCUMENTATION OF THE WOUND ASSESSED REFLECTED A 1 CM (CENTIMETER) X 1 CM CUT ON TOP OF HEAD SURROUNDED BY SLIGHT SWELLING. REVIEW OF AN ATTACHED WITNESS STATEMENT WRITTEN FOR THE INVESTIGATION, NOT DATED REFLECTED " I (REFERRING TO WRITER) HAD THE 1:1 WITH RESIDENT #27 (REFERRED TO RESIDENT'S NAME) AND IT WAS AROUND 9:30 P.M. WHEN ANOTHER CNA (REFERRED TO NAME OF CNA) AND I CHANGED HER BRIEF AND PUT HER IN BED. I WAS JUST FINISHING TYING THE BAGS OF CLOTHES/LINEN AND TRASH UP AND I WENT TO TAKE OUT THE TRASH AND PUT IN A NEW TRASH BAG AND I LOOKED UP AND RESIDENT #27 (REFERRED TO RESIDENT'S NAME) HAD HER LEGS OVER THE BED AND I WENT OVER THERE AS QUICK AS POSSIBLE AND BEFORE I COULD GET THERE SHE fell OVER THE BED. SHE THEN PROCEEDED TO TRY AND GET UP AND HIT HER HEAD ON HER BEDSIDE TABLE .. " REVIEW OF RESIDENT #27'S MEDICAL RECORD REFLECTED A DOCUMENT TITLED " PROGRESS NOTES " WITH AN ENTRY DATED 4/16/12 AND TIMED 2200 (10:00 P.M.) "RESIDENT WAS ON SIDE OF BED AND fell FORWARD ONTO FLOOR. ACCORDING TO CNA HE COULD NOT GET TO HER QUICK ENOUGH. RESIDENT ATTEMPTED TO GET UP, WHICH RESULTED HER IN HITTING HER HEAD ON BEDSIDE TABLE. ANOTHER ENTRY DATED 4/13/12 REFLECTED " IDT (MEANING INTERDISCIPLINARY TEAM) MET TO DISCUSS RESIDENT SECONDARY INCREASED RESTLESSNESS AND INITIATION OF 1:1 ... " THE FACILITY DOCUMENT TITLED "FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE" REFLECTED AN ENTRY DATED 4/17/12 "RE-EDUCATION OF STAFF ON 1:1 RESPONSIBILITY". A REVIEW OF THE CARE PLAN FOR FALL/ INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE HAD ADDED INTERVENTIONS DATED 4/17/12 AND 4/10/12 BUT IT DID NOT INCLUDE AN UPDATE OF THE 1:1 FROM THE IDT RECOMMENDATION/INITIATION OF 4/13/12. AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) WAS CONDUCTED IN THE CONFERENCE ROOM ON 4/20/12 AT 8:35 A.M. REGARDING RESIDENT #27'S FALL ON 4/16/12. THE DON CONFIRMED THAT THE FALL WAS AVOIDABLE AND A 1:1 WAS NOT TO BE CLEANING AND LEAVING THE RESIDENT'S SIDE. A DOCUMENT TITLED, " 1:1 RESPONSIBILITIES WITH RESIDENT # 27" WITH A DATE OF 4/19/12 LISTED THE FUNCTIONS AND EXPECTATIONS OF 1:1 WITH A THE FIRST RESPONSIBILITY AS, " STAY AT RESIDENT # 27 'S SIDE AT ALL TIMES, EVEN WHEN SHE IS IN BED" . ( )

This citation pertains to intake MI 20. Based on observation, interview, and record review, the facility failed to provide adequate supervision and appropriate assistive devices to prevent falls in 2 of 6 sampled residents (Resident #101 and Resident #105) at risk for falls, from a total of 6 sampled residents, resulting in: 1.) Resident #101 tripping and falling causing a head injury after a facility staff member failed to use a gait belt, and 2.) Resident #105 rolled out of bed and hit his head when grab bars were not applied to the bed as care planned. Findings include: Resident #101 Per a hospital "Consultation regarding a neck fracture", dated [DATE], Resident #101 fell at home and sustained a non-displaced fracture of C 2 (neck bone)...Patient will be placed in Aspen collar (neck brace) which is to be worn at all times..." Per the "Minimum Data Set", dated [DATE], Resident #101 was admitted to the facility on [DATE], scored ,[DATE] on "Cognitive Patterns" (indication of memory problem), used a walker for ambulating (walking), and walked in her room with the assistance of staff. Per the facility "Accident/Incident Report", dated and signed by RN/Registered Nurse #22 on [DATE] at 2:35 AM, "Called to room. (Resident #101) observed lying on the floor on her right side. (Resident #101) had her neck brace on (secondary to) non-displaced C 2 (neck) fracture. (Resident #101) was bleeding from the back of her head, unable to assess wound to keep her still until EMS (Emergency Medical personnel) came to put her on a backboard. (Resident #101) c/o (complained of) pain from the back of her head; also complained of pain in lower back ...Alert and oriented to person, place, time and year. Handgrips were equal. (Resident #101) did complain of slight dizziness and was tired ...(Physician), family notified ...Section B-Final Disposition: (Nurse aide #20) neglected to use her gait belt to ambulate (walk) (Resident #101). Had (nurse aide #20) used it (gait belt), (nurse aide #20) could have steadied (Resident #101) and most likely avoided the fall..." Per the hospital "Database Form", dated [DATE], Resident #101 sustained an acute right temporal SAH (subarachnoid hemorrhage/bleeding in the area between the brain and the tissues covering the brain), frontal contusion (bruise). In an interview, on [DATE] at 8:55 AM, nurse aide #20 stated she was present on [DATE] at 2:15 AM when Resident #101 tripped, fell , and hit her head in her room. Nurse aide #20 said, "(Resident #101) was set on going to the nurses' station to sit in a chair. I went with her. A couple of hours later (Resident #101) wanted to go back to bed. I walked with (Resident #101); (Resident #101) was using her walker and had a hard time pushing the walker over the floor mats...started to trip and fall backwards. She had a neck brace on from a previous injury. She hit her head on the corner of the cabinet". Nurse aide #20 stated she was supposed to use a gait belt to assist Resident #101 from the chair at the nurses' station to Resident #101's bed. Nurse aide #20 said, "Usually, I wear it around me. I had left it at home, and I couldn't find one (a gait belt at the facility)". On [DATE] at 9:10 AM, in the presence of nurse aide #20, this Surveyor observed Resident #101, in her room, sitting in a wheelchair with a chair alarm, wearing a neck brace and a blue jacket. When this Surveyor asked Resident #101 about hitting her head, Resident #101 stated, "I don't remember anything about it. The scab is still there", and she touched the right side of her head. A quarter-sized scab was observed through Resident #101's thin gray hair. Per a "Disciplinary Action Report" dated [DATE], regarding nurse aide #20, "Serious violation of a safety rule ...(Nurse aide #20) ambulated a resident from the nurses station on the 500 wing to the resident's room. She did not use a gait belt as required. The resident fell , hitting her head, and required hospitalization ...". Per an in-service record entitled, "Gait Belt", dated [DATE] (2 days after Resident #101's fall), the list of signatures did not include nurse aide #20's signature. Per nurse aide #20's time card, she worked on [DATE], [DATE], [DATE], and [DATE]. In an interview, on [DATE] at 2:20 PM, Director of Nursing #23 told this Surveyor she educated nurse aide #20 about using a gait belt at all times on [DATE], but failed to record the education. In a telephone interview, on [DATE] at 7:45 AM, nurse aide #20 told this Surveyor, she couldn't remember when, but she thought the DON #23 told her to use wear and use a gait belt at all times or she would be fired a day or two before she signed the "Disciplinary Action Report" dated [DATE]. ( ) Resident #105 According to the "Minimum Data Set", dated [DATE], Resident #105 had dementia, was incontinent of bowel and bladder, and needed "extensive assistance" for bed mobility. Per Resident #105's "Fall/Injury Assessment: Prevention and Management Plan of Care", dated [DATE], "Environmental Modification/Additions" included "grab bar" to the bed. Per a facility "Accident/Incident Report", "(Resident #105) turned to side while in bed while (nurse aide #29) changed his brief. (Resident #105) over extended and rolled off bed (on to the floor)" on [DATE] at 6:15 AM. In a telephone interview, on [DATE] nurse aide #29 revealed there were no "grab bars" present on Resident #105's bed at the time of the incident. Nurse aide #29 said he turned Resident #105 on his side, "(Resident #105's) body weight shifted, he rolled," and he fell off the bed on to the floor and hit his head on the dresser. Nurse aide #29 stated, "(Resident #105) doesn't really use his upper arms. He lays there like a log, very still and doesn't move ...(Resident #105) bumped his head but he didn't have to go to the hospital..." When asked if he had ever been told to have two staff members present during Resident #105's cares, nurse aide #29 stated, "No. They put assist devices side rails (grab bars) on the bed right after the incident happened. You must place his hands on the rails, and sometimes remind him to do it (hang on)". When nurse aide #29 was asked if he had been in-serviced on bed mobility since the incident on [DATE], he stated, "No, not that I remember" . ( )

This citation pertains to MI# 905 Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent burns in 1 of 6 sampled (#101) residents, resulting in resident #101 sustaining burns with blisters when he spilled his hot chocolate onto his right thigh while in his room unsupervised. Findings include: Record review of facility accident/Incident report dated 3/7/11 at 10:15 AM, revealed that Resident #101 was in his room when certified nurse assistant observed resident #101 sitting in his wheelchair with some hot chocolate spilled on his pants over his right thigh. Cup of hot chocolate on bedside table and half of saltine cracker dipped in chocolate lying next to cup. Resident #101 was noted to state that he was fine. Denied pain or discomforts. Right thigh was noted to be pink, blanchable and had no blisters noted. Located under 'injury' on the form it was noted, "burn". Review of facility 'Hot Food and Beverage Safety', policy/procedure dated 7/08, revealed that residents at risk for burn injury will be assisted with tray set-up or with eating to prevent spills of hot food or beverage. Residents at risk for a burn injury demonstrate some of the following: Need for assistance with tray set-up, Cognitive impairment (Dementia) were noted, which resident #101 had been assessed for. Procedure recommended .1) Attend residents at risk for hot food injury when serving hot food or beverages. Review of facility 'Resident Supervision' policy/procedure dated 1/09, revealed that the facility will continually evaluate the level of supervision needed through assessment and observation of the resident's cognitive, behavioral, medical or other conditions that put them at risk to self or others. Observation on 3/24/11 at 2:00 PM of the entrance tour revealed that the resident of concern no longer resided at the facility. Observations revealed there to be 12 residents total living at the facility. Record review of resident #101's Initial Psychological Evaluation form dated 2/10/11 revealed that dementia symptoms were present. The psychologist noted that the client's primary symptoms seem to be mild to high, mild dementia. Symptoms included memory impairment, cognitive impairment, and disturbance of executive functioning. Record review of resident #101's minimum data set (MDS) 12/16/10 noted [AGE] year old male with [DIAGNOSES REDACTED]. Record review of Resident #101's significant change MDS dated [DATE] revealed in the cognitive section C- that the resident was experiencing altered level of consciousness coded at a 2- behavior present, fluctuates (comes and goes, changes in severity). Record review of resident #101's ADL (activity of daily living) functional Status V01 assessment notes dated 2/16/11 revealed that the resident was assessed for significant change status. Record review of the form revealed fluctuating ADL's due to over all decline in function. Physical limitations of weakness/limited ROM (range of motion)/poor coordination/poor balance/visual impairment/pain were noted on the assessment section 4. Record review of resident #101's dehydration/fluid maintenance V01 assessment notes dated 2/16/11 revealed that the resident was assessed for functional decline, recent changes in mental status, recent decline in ADLs including body or hand control problems, inability to sit up. There were notes that revealed the resident was being assessed for significant change due to overall decline in mental and physical changes. Record review of resident #101's progress notes dated 2/8/11 the facility IDT (interdepartmental team) met to discuss fluid intake and encouraged fluids at the bedside. The note did not state hot or cold beverages. Record review of IDT progress notes dated 2/21/11 revealed that the resident had been noted to lean to his right in his wheelchair. Record review of nurse notes dated 2/28/11 at 5:00 PM revealed, that the resident received an order for [REDACTED]. Record review of nurse note date 3/1/11 at 11:38 AM revealed the resident to be alert and oriented to person and time, but not to location. Record review of nurse note dated 3/7/11 at 10:00 AM revealed that the resident was sitting in wheelchair and noted to be leaning to the right. The resident was noted to request hot chocolate and crackers. Record review of 'Cognitive Assessment/Plan of Care', dated 2/15/11 revealed that the resident was assessed for short term memory problems and long term memory problems at times. Record review of the resident #101's 'Fall/Injury Assessment: Prevention and Management Plan of Care', dated 2/16/11 revealed that the resident had fall/injury risk assessment related to: Musculoskeletal unsteady, osteoarthritis, weakness, fatigue. Medical factors- exhaustion, weakness. Cognitive impairment factors- Mental status changes. Neurological factors- [DIAGNOSES REDACTED] related to pituitary [DIAGNOSES REDACTED]. Record review of 'Safety Device Plan of Care', dated 2/28/11 revealed safety issues related to falls and tab alarms due to medical [DIAGNOSES REDACTED]. Record review of resident #101's care plans dated prior to the hot liquid spill incident (3/7/11) revealed there to be no assessment or interventions for resident #101 for handling hot liquids, even though the resident was exhibiting dementia symptoms and was assessed for a significant change in mental and physical status. An interview on 3/25/11 at 8:00 AM with certified nurse assistant (CNA) #3 revealed that around 9 AM on 3/7/11 resident #101 put on his call light and requested hot cocoa and soda crackers. Staff #3 stated "I went to get it (cocoa) from the kitchen, (cocoa machine) it's like a cappuccino machine at a gas station, put it (cocoa) in a purple thermal cup and placed a white lid on it, got 2 packages of soda crackers. I took it into his room. I set it on the over bed table/tray. He (resident #101) was up in wheelchair. I asked if he needed anything else and he said no. I walked out of the room, went back to the nurse station and charted". CNA #3 revealed that she was at the nurse station writing when she heard "oh,[***] and then resident #101's call light came on, so she went to his room and there was hot chocolate on the resident and on the floor. CNA #3 stated that resident #101 had taken the lid off the cup to dunk the crackers in. CNA #3 stated, "When I got the hot chocolate and crackers I didn't think he would dunk the crackers. I just left the room. He had moments of unsteadiness, yes he had been declining, and he was on hospice". Record review of physician progress notes [REDACTED]. He stated he hold from the table and is trying to put it back on the table after taking a sip. While putting it back, he felt it on the table and then he could not place it properly because of his visual problem. The physician noted right thigh [DIAGNOSES REDACTED], possible first degree burn. Physician noted the resident may not be a good candidate to drink hot liquids in his room and that Resident #101 should be supervised while drinking them. Record review of the resident #101's physician orders [REDACTED]. Therapy multi-disciplinary therapy screening tool dated 3/7/11 recommended that the resident be supervised with all hot beverages due to risk of spilling. Record review of resident #101's skin grid dated 3/8/11 revealed there to be 4 blisters to the right thigh burn site that varied in size from 0.2 cubic centimeters (cc) X 2 cc up to 0.6 cc X 0.6 cc with dressing changes noted to area. #