Every finding on record at Medilodge of Lansing

Based on observations, interviews, and record reviews, the facility failed to clean and maintain the physical plant affecting 75 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:On 12/01/2025 at 2:18 P.M., An environmental tour of the facility Laundry Service was conducted with Director of Housekeeping and Laundry Services (DHLS) R. The following items were noted: Ten 24-inch-wide by 48-inch-long acoustical ceiling tiles were observed stained from previous moisture leaks. (DHLS) R stated: I will place a work order into TELS. Eight 12-inch-wide by 12-inch-long vinyl flooring tiles by eighteen 12-inch-wide by 12-inch-long vinyl flooring tiles were observed (etched, scored, stained, particulate), adjacent to the two commercial washing machines. The damaged flooring tile section measured approximately 8 feet-wide by 18-feet-long totaling 144 square feet. (DHLS) R stated: I will place a work order into TELS. An air gap was observed between the emergency exit double door metal threshold plate and door sweep assembly. The observed air gap measured approximately 1.5 inches-wide by 72-inches-long, creating a potential entrance for vermin. (DHLS) R stated: I will place a work order into TELS. On 12/2/2025 at 11:45 A.M., Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 3/12/22 revealed under Policy: A Preventative Maintenance Program shall be developed to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 3/12/22 further revealed under Policy Explanation and Compliance Guidelines: (1) The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. During an observation on 12/01/2025 at 9:45 AM R67's motorized wheelchair egg crate cushion and standard wheelchair black cushion was observed severely soiled with accumulated and encrusted dust and dirt deposits. During an observation on 12/01/2025 at 4:36 PM R67's wheelchair cushions continued to be very soiled During an observation and interview on 12/04/2025 10:42 AM R67's wheelchairs cushion located in room and in hall continued to be heavily soiled. Certified Nurse Aid V reported night shift staff was responsible for cleaning resident equipment including wheelchairs and as needed. During an interview on 12/04/2025 at 10:46 AM Director of Nursing B reported night shift staff were responsible for cleaning equipment and any staff as needed and facility had cleaning schedule that would expect staff to follow.

Based on observations, interviews, and record reviews, the facility failed to clean and maintain food service equipment affecting 75 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:On 12/01/2025 at 9:40 A.M., An initial tour of the food service was conducted with Dietary Manager I and District Manager Q. The following items were noted:The sole hand sink basin was observed draining very slowly. Dietary Manager I stated: I'll place a work order into TELS for maintenance repairs.The 2022 FDA Model Food Code section 5-205.15 states: A plumbing system shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.The True three-door reach-in cooler was observed with 1 of 2 interior lights non-functional. Dietary Manager I stated: I'll place a work order into TELS for replacement.The 2022 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor.The service area laminate countertop surface was observed (etched, scored, particulate), creating a porous surface. The damaged laminate surface measured approximately 4-inches-wide by 8-inches-long. District Manager Q stated: I will place a work order into TELS for repairs.The 2022 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair.The clear plastic (8-ounce) resin cups were observed severely clouded with accumulated and encrusted mineral (lime and calcium) deposits.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.C-Unit:On 12/01/2025 at 10:15 A.M., An initial tour of the C-Unit Kitchenette was conducted with District Manager Q. The following items were noted:The kitchenette hand sink basin was observed stained with accumulated and encrusted iron deposits. District Manager Q stated: I will have staff thoroughly clean and sanitize the hand sink as soon as possible.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.On 12/02/2025 at 11:00 A.M., Record review of the Policy/Procedure entitled: Equipment dated 9/2017 revealed under Policy Statement: All foodservice equipment will be clean, sanitary, and in proper working order. Record review of the Policy/Procedure entitled: Equipment dated 9/2017 further revealed under Procedures: (1) All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials.On 12/02/2025 at 11:15 A.M., Record review of the Policy/Procedure entitled: Warewashing dated 9/2017 revealed under Policy Statement: All dishware, service ware, and utensils will be cleaned and sanitized after each use.

Based on observation, interview and record review the facility failed to follow physician medication and wound treatment orders in accordance with professional standards of practice, implement care plans, and provide resident care choices for one resident (R70) of 18 reviewed for quality of care, resulting in wound decline, uncontrolled pain and overall feelings of anger and frustration.Review of the Face Sheet, dated 12/3/25, reflected R70 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included paraplegia (paralyzed below waist), multiple pressure ulcers up to stage IV(full thickness tissue/muscle loss), hypertension, pain, anxiety and depression. Review of the Progress Note, dated 11/11/25, reflected, Therapy: unable walk or do transfer she[R70] is dependent on that task max for lower dressing sock and shoes toilet hygiene is max mod assist for upper body dressing bed mobility set up for eating and personal care. Nursing: wound care pain management, medication management, labs super pubic cath. discharge plan go home with significant other.Review of R70 Progress Note, dated 11/28/25, reflected, Sensory Perception: No impairment. Moisture: Occasionally moist. Activity: Bedfast. Resident is Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Nutrition: Adequate. Friction and shear: Potential problem.BRADEN Score: 15.0.During an observation and interview on 12/01/2025 at 11:55 AM R70 was laying in bed, appeared calm and able to answer questions without difficulty. R70 had a bell on the bedside table along with the roommate and reported the facility call system did not function in that room since they arrived over one month ago, verified by no call lights in room. R70 reported staff often close door and do not respond to bell and often takes up to one hour to get assistance. R70 reported needs staff assist for almost everything including as needed pain medication, bed mobility, toileting and dressing and reported was paralyzed from the waist down. R70 reported has had several issues with controlled pain medications not available because of pharmacy deliveries. R70 reported if staff administer pain medications as prescribed by physician pain is usually controlled under 7 on scale of 0-10. R70 reported pain was mostly related to wounds that were present on admission.During an interview on 12/2/2025 at 10:13 AM Director of Maintenance DM S reported the resident call system in R70 room for both bed one and bed two was not functioning. DM S stated, The call system panel is old and we cannot get parts for repair. I am getting quotes to replace the entire call system. I have two quotes currently and need one other quote.During an observation on 12/01/2025 at 2:13 PM resident in R70's bathroom was ringing the bell. Certified Nurse Aid (CNA) E walked by room. During continued observation at 2:14 PM bell ringing again in R70 room and again at 2:15 PM when Registered Nurse (RN) F entered the room.During an observation and interview on 12/03/2025 at 12:25 PM R70's door was closed, surveyor was granted permission to enter. R70 was lying in bed, appeared anxious, crying and reported had been waiting on pain medications since that morning after three requests to staff and pain was currently 10 out of 10 on pain scale. R70 reported had requested door remain open but staff continue to shut door, and they do not hear and/or respond to bell provided in place of non-functioning call system in room. R70 reported was also waiting on staff to perform wound care that should have been done yesterday because dressing was saturated and starting to have an odor. R70 reported dressing was last changed 12/1/25 at wound clinic to sacral area and currently where pain was located. R70 reported had requested sacral dressing to be changed 12/2/25 evening but was not completed.Review of R70 Physician Order, dated 12/1/25, reflected treatment orders to cleanse sacral pressure ulcer with wound cleanser. Pat dry. Apply Aquacel Ag, cut to fit wound bed. Cover with Bordered Foam dressing. Skin barrier wipe to peri wound every night shift every three day(s) and as needed If soiled or displaced.During an observation on 12/03/2025 12:45 PM Licensed Practical Nurse (LPN) U entered R70 room and provided R70 with several oral medications including pain medications. R70 reported pain 10 out 10 on pain scale. RN G and two Certified Nurse Aids entered R70 room. RN G removed heavily soiled, undated, dressing from R70 sacral area, used wet wash cloths that were obtained from clear garbage bag to cleans peri wound. RN G told R70 had used warm water on wash clothes for comfort. Wound was about the size of small hand with beefy red wound bed, serosanguinous and slightly yellow drainage and peri wound appeared red with indentations from sheets noted in skin. RN G had unlabeled clear cups on bedside table with moistened gauze in each one that were not use for dressing change. Did not observe RN G clean wound bed. RN G cut Calcium Alginate to fit wound bed and covered with foam bordered dressing. R70 informed RN G that wound clinic changed treatment order to gray colored dressing material to wound bed on 12/1/25 and RN G informed R70 calcium alginate was similar color. This surveyor observed off white color of calcium alginate. R70 appeared to be painful with dressing change as evidenced by facial grimacing and verbalized pain with position changes. Observed heel dressing dated 12/2/25.During an interview on 12/03/2025 at 12:52 PM RN G verified R70 did not have a date on soiled dressing removed from sacral area and reported had thought had last been change the evening prior because overheard staff talking. RN G reported had completed R70 heel dressings on 12/2/25.Review of R70 Wound Clinic Consult, dated 12/1/25, reflected Aquacell AG to all wounds and cover with border foam, change three times per week or as needed for increased drainage. During an observation and interview on 12/03/2025 at 2:04 PM RN G verified used calcium alginate without silver over R70 wound bed and verified facility also had calcium alginate with silver available. RN G was asked what Ag meant in the treatment order, RN G responded, alginate. RN G reported did not know Ag indicated silver so had not used calcium alginate with silver for any of R70's wound treatments.During an interview on 12/03/2025 at 2:10 PM, Director of Nursing (DON) B reported would expect staff to follow physician orders.Review of R70 Pain Care Plan, dated 11/10/25, reflected, Evaluate for verbal and non-verbal signs of pain. Administer pain meds as ordered.[named R70] has pain related to.multiple pressure ulcers in buttocks, left hip, left heel and ankle pressure ulcer(s), complex regional pain syndrome of left upper limb Date Initiated: 11/07/2025 Revision on: 11/10/2025.Review of R70 Medication Administration Record and Controlled Substance Record, dated 11/8/25 through 12/4/25, reflected several discrepancies between Morphine Sulfate 15mg Extended Release and Immediate Release doses.Review of R70 Treatment Administration Record (TAR), dated 12/1/25 through 12/4/25, reflected R70 received a sacral dressing change treatment on 12/1/25 and not on 12/2/25. The TAR reflected no evidence of as needed dressing change completed on 12/2/25 to sacral area per R70 request.Review of R70 Nurse Progress Notes, dated 12/1/25, reflected, Resident had wound clinic appt.[appointment] today. Order change from hydra-lock and Bordered foam. New Order: aquacel Ag[silver] to all wounds cover with foam Change 3 times a week and prn [as needed] for increased drainage F/U [follow up] in 1 week.During an interview on 12/04/2025 at 8:32 AM, R70 reported pain well controlled at that time at 7/10 and reported it often depended on who the nurse was and reported RN G and current nurse do well with administering medications as ordered. R70 reported again the best the pain gets is about 6/10 on pain scale and verified they never reported 2/10 on pain scale yesterday after observed dressing change. R70 reported staff performed dressing changes again after observed by surveyor to add correct ordered treatment and verified pain was not lower than 7/10 after wound care on 12/3/25. R70 verified pain medications administered on 12/3/25, when surveyor was present, was an example of when staff had not been administering pain medications as ordered. During an interview and record review on 12/04/2025 at 8:55 AM, Director of Nursing (DON) B reported staff were expected to follow Physician orders and administer medications within one hour prior to or one hour after ordered time of administration. DON B reported after reviewing R70's, Controlled Substance Record dated 11/8/25 through 12/4/25 had identified issues with staff documenting on wrong Controlled Substance Record because R70 and scheduled and as needed medications. DON B verified R70 had scheduled Morphine Sulfate ER Tablet (Extended Release) 15 MG to be given 1 tablet by mouth two times a day and 10:00a.m. and 10:00p.m. DON G verified R70 also had order for Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for moderate to severe that was different from scheduled dose. DON B reported would follow up after reviewing R70's medications.During an interview on 12/04/2025 at 11:00 am, Unit Manager Registered Nurse (UM) D reported reviewed R70 Controlled Substance Records, dated 11/8/25 through 12/4/25 and determined four medication errors had occurred related to nursing staff administering wrong Morphine Sulfate 15mg to R70 by confusing Immediate Release and Extended-Release doses including on 12/3/25. UM D reported planned to educate staff and change process to better label medications. UM D verified medication errors had occurred with more than one staff member. Review of the facility, Wound Treatment Management Policy, revised 10/26/2023, reflected, Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change .Review of the facility, Controlled Substance Administration & Accountability Policy, revised 10/13/2025, reflected, Policy It is the policy of this facility to promote save, high quality patient care, compliant with state and federal regulation regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure .Review of the facility, Medication Errors Policy, revised 1/24/2024, reflected, .The facility shall ensure medications will be administered as follows: a. According to physician's orders .Medications administered not in accordance with the prescriber's order. Examples include, but not limited to: i. Incorrect dose, route of administration, dosage form, time of administration; ii. Medication omission; iii Incorrect medication .

Based on observation, interview and record review, the facility failed to accurately assess and ensure adequate pain management for one of 18 reviewed for pain (Resident #70), resulting in untreated and unnecessary pain for R70.Review of the Face Sheet, dated 12/3/25, reflected R70 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included paraplegia (paralyzed below waist), multiple pressure ulcers up to stage IV(full thickness tissue/muscle loss), hypertension, pain, anxiety and depression. Review of the Progress Note, dated 11/11/25, reflected, Therapy: unable walk or do transfer she[R70] is dependent on that task max for lower dressing sock and shoes toilet hygiene is max mod assist for upper body dressing bed mobility set up for eating and personal care. Nursing: wound care pain management, medication management, labs super pubic cath. discharge plan go home with significant other. During an observation and interview on 12/01/2025 at 11:55 AM R70 was laying in bed, appeared calm and able to answer questions without difficulty. R70 had a bell on the bedside table along with the roommate and reported the facility call system did not function in that room since they arrived over one month ago, verified by no call lights in room. R70 reported staff often close door and do not respond to bell and often takes up to one hour to get assistance. R70 reported needs staff assist for almost everything including as needed pain medication, bed mobility, toileting and dressing and reported was paralyzed from the waist down. R70 reported has had several issues with controlled pain medications not available because of pharmacy deliveries. R70 reported if staff administer pain medications as prescribed by physician pain is usually controlled under 7 on scale of 0-10. R70 reported pain was mostly related to wounds that were present on admission. During an interview on 12/2/2025 at 10:13 AM Director of Maintenance DM S reported the resident call system in R70 room for both bed one and bed two was not functioning. DM S stated, The call system panel is old and we cannot get parts for repair. I am getting quotes to replace the entire call system. I have two quotes currently and need one other quote. During an observation on 12/01/2025 at 2:13 PM resident in R70's bathroom was ringing the bell. Certified Nurse Aid (CNA) E walked by room. During continued observation at 2:14 PM bell ringing again in R70 room and again at 2:15 PM when Registered Nurse (RN) F entered the room. During an observation and interview on 12/03/2025 at 12:25 PM R70's door was closed, surveyor was granted permission to enter. R70 was lying in bed, appeared anxious, crying and reported had been waiting on pain medications since that morning after three requests to staff and pain was currently 10 out of 10 on pain scale. R70 reported had requested door remain open but staff continue to shut door, and they do not hear and/or respond to bell provided in place of non-functioning call system in room. During an observation on 12/03/2025 12:45 PM Licensed Practical Nurse (LPN) U entered R70 room and provided R70 with several oral medication including pain medications. R70 reported pain 10 out 10 on pain scale. RN G and two Certified Nurse Aids entered R70 room. RN G performed dressing change for sacral wound that was about the size of a small hand. R70 appeared to be painful with dressing change as evidenced by facial grimacing and verbalized pain with position changes. Review of R70 Pain Care Plan, dated 11/10/25, reflected, Evaluate for verbal and non-verbal signs of pain. Administer pain meds as ordered.[named R70] has pain related to.multiple pressure ulcers in buttocks, left hip, left heel and ankle pressure ulcer(s), complex regional pain syndrome of left upper limb Date Initiated: 11/07/2025 Revision on: 11/10/2025. Review of R70 Medication Administration Record (MAR) and Controlled Substance Record, dated 11/8/25 through 12/4/25, reflected several discrepancies between Morphine Sulfate 15mg Extended Release and Immediate Release doses including on 12/3/25. Continued review of the MAR reflected R70 had an order for Morphine Sulfate 15mg Immediate Release every six hours and scheduled dose of Morphine Sulfate 15mg Extended Release two times daily. Continued review of the MAR reflected, Ask the resident if their pain program is effective. Documentation reflected R70 was 1/10 on the morning of 12/3/25 and 2/10 pain on the afternoon of 12/3/25. (When this surveyor observed and heard resident report of 10/10 pain on pain scale to staff.) During an interview on 12/04/2025 at 8:32 AM, R70 reported pain well controlled at that time at 7/10 and reported it often depended on who the nurse was and reported RN G and current nurse do well with administering medications as ordered. R70 reported again the best the pain gets is about 6/10 on pain scale and verified they never reported 2/10 on pain scale yesterday after observed dressing change. R70 reported staff performed dressing changes again after observed by surveyor to add correct ordered treatment and verified pain was not lower than 7/10 after wound care on 12/3/25. R70 verified pain medications administered on 12/3/25, when surveyor was present, was an example of when staff had not been administering pain medications as ordered. During an interview and record review on 12/04/2025 at 8:55 AM, Director of Nursing (DON) B reported staff were expected to follow Physician orders and administer medications within one hour prior to or one hour after ordered time of administration. DON B reported after reviewing R70's, Controlled Substance Record dated 11/8/25 through 12/4/25 had identified a could issues with staff documenting on wrong Controlled Substance Record because R70 and scheduled and as needed medications. DON B verified R70 had scheduled Morphine Sulfate ER Tablet (Extended Release) 15 MG to be given 1 tablet by mouth two times a day and 10:00a.m. and 10:00p.m. DON G verified R70 also had order for Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for moderate to severe that was different from scheduled dose. DON B reported wound follow up after reviewing R70's medications. During an interview on 12/04/2025 at 11:00 am, Unit Manager Registered Nurse (UM) D reported reviewed R70 Controlled Substance Records, dated 11/8/25 through 12/4/25 and determined four medication errors had occurred related to nursing staff administering wrong Morphine Sulfate 15mg to R70 by confusing Immediate Release and Extended-Release doses including on 12/3/25. UM D reported planned to educate staff and change process to better label medications. UM D verified medication errors had occurred with more than one staff member.

Based on observation, interview, and record review the facility failed to honor dietary preferences for one (Resident #12) out of 3 reviewed for nutrition. Findings include: Review of the medical record reflected R12 was admitted to the facility on [DATE], with diagnoses that included muscle weakness. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/4/25, reflected R12 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/01/2025 at 10:42 AM, R12 was observed resting in bed. R12 reported difficulties with the facility honoring his meal preferences on his tray ticket. R12 explained that he requested two 8-ounce glasses of iced tea with ice and double portions at lunch and dinner. R12 stated that this preference is seldom honored. Review of R12's meal tray ticket reflected regular diet, double portion entree, vegetable and breakfast meat, no salt packet. Iced tea 16 oz add ice to both TEA 2% milk - 8 oz. (ounce). On 12/01/2025 at 12:44 PM R12's lunch meal was observed. R12 received a carton of one percent milk, one 8-ounce cup of iced tea with no ice, and R12's pork was not a double portion. Review of a Care Plan intervention dated 9/12/23 stated Provide meals/fluids based on resident food preferences and as ordered. In an interview on 12/3/25 at 11:26 AM, Dietary Manager I stated that the expectation would be to follow the tray ticket and honor preferences listed on the tray ticket.

Based on observation and interview, the facility failed to update the daily staff posting with a current facility census of 75 residents. Findings include: Upon initial entry to the facility at 12/01/2025 at 9:12 AM, the daily staffing post was observed with a last completed date of 11/19/25. On 12/01/2025 at 3:15 PM, the same daily staffing post was observed with the date of 11/19/25. On 12/02/2025 at 7:55 AM, the same daily staffing posting dated 11/19/25 was observed. In an interview on 12/03/2025 at 10:44 AM, Certified Nursing Assistant H stated that she was responsible for the daily staffing posting, however, had been off of work and thought the daily staffing posting had been delegated to another staff member. CNA H was not able to ascertain why the daily staffing post was not updated.

This citation pertains to Intake 2656668.Based on observation, interview and record review, the facility failed to report an allegation of abuse to the State Agency for one (R6) of three reviewed.Findings include:Review of the complaint received by the State Agency on 10/24/25 revealed, [R6] reported that staff, [Certified Nursing Assistant (CNA) E and CNA F] punched her in the face .This incident was reported to the supervisor and none of the staff was investigated or suspended.Review of the medical record revealed R6 was admitted to the facility on [DATE] with diagnoses that included moderate intellectual disabilities, dementia, and major depressive disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/5/25 revealed R6 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 11/19/25 at 9:45 AM, R6 was observed in bed with the bedroom door open. A sign on the door revealed Do not enter without permission. After knocking and asking permission to enter, R6 shook her head no and threw a cup of water across the room towards the doorway. A staff member entered R6's room to assist. R6 began yelling out but was easily calmed down by the staff member. On 11/19/25 at 9:49 AM, all incident reports and grievances for R6 in the last three months were requested. At 10:02 AM, Director of Nursing (DON) B reported R6 did not have any concern forms or risk managements in the last three months. In a telephone interview on 11/19/25 at 10:00 AM, CNA E reported approximately one to one and a half months ago, R6 reported that CNA E and CNA F hit R6. CNA E reported they were still at work when R6 reported the allegation. CNA E reported DON B took her verbal statement and then DON B called CNA F. CNA E reported since both themself and CNA F had the same verbal story, it was dropped. CNA E reported they were not suspended during an investigation. In a telephone interview on 11/19/25 at 11:01 AM, CNA F reported sometime last month, they received a call from Scheduler D stating there was an incident in R6's room and asked CNA F what happened. CNA F reported she was not aware of an incident. CNA F reported the next day, they came into work and asked CNA E what the phone call was about. CNA F reported CNA E told them that R6 made an allegation that they both hit R6. CNA F reported they were never asked for a statement. In a telephone interview on 11/19/25 at 11:41 AM, Registered Nurse (RN) G reported they recalled R6 reporting she was hit during night shift and it hurt. RN G reported the allegation was reported to them and Scheduler D. RN G reported Scheduler D and someone else went into R6's room to interview about the allegation. In an interview on 11/19/25 at 10:18 AM, Scheduler D reported they were not aware of any incident where R6 alleged being hit by staff. In an interview on 11/19/25 at 11:34 AM, DON B reported there was not an allegation reported to them that R6 was hit by CNA E and CNA F. In an interview on 11/19/25 at 12:15 PM, Nursing Home Administrator (NHA) A reported there was a recent allegation that two staff members hit R6. NHA A reported they were on their way to work when they received a phone call related to the allegation. NHA A reported she asked Scheduler D and Payroll Benefits Coordinator (PBC) I to speak to R6 together. NHA A reported they could not recall exactly what R6 said, but that R6 ended up telling them that she did not like one of the aides being in her room and that nobody hit her. When asked if the allegation was reported to the State Agency, NHA A reported it was not because they ended up feeling like it was not reportable due to R6 eventually reporting nobody hit her.

This citation pertains to Intake 2656668.Based on observation, interview, and record review, the facility failed to thoroughly investigate an allegation of abuse for one (R6) of three reviewed.Findings include:Review of the complaint received by the State Agency on 10/24/25 revealed, [R6] reported that staff, [Certified Nursing Assistant (CNA) E and CNA F] punched her in the face .This incident was reported to the supervisor and none of the staff was investigated or suspended.Review of the medical record revealed R6 was admitted to the facility on [DATE] with diagnoses that included moderate intellectual disabilities, dementia, and major depressive disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/5/25 revealed R6 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 11/19/25 at 9:45 AM, R6 was observed in bed with the bedroom door open. A sign on the door revealed Do not enter without permission. After knocking and asking permission to enter, R6 shook her head no and threw a cup of water across the room towards the doorway. A staff member entered R6's room to assist. R6 began yelling out but was easily calmed down by the staff member. On 11/19/25 at 9:49 AM, all incident reports and grievances for R6 in the last three months were requested. At 10:02 AM, Director of Nursing (DON) B reported R6 did not have any concern forms or risk managements in the last three months. In a telephone interview on 11/19/25 at 10:00 AM, CNA E reported approximately one to one and a half months ago, R6 reported that CNA E and CNA F hit R6. CNA E reported they were still at work when R6 reported the allegation. CNA E reported DON B took her verbal statement and then DON B called CNA F. CNA E reported since both themself and CNA F had the same verbal story, it was dropped. CNA E reported they were not suspended during an investigation. In a telephone interview on 11/19/25 at 11:01 AM, CNA F reported sometime last month, they received a call from Scheduler D stating there was an incident in R6's room and asked CNA F what happened. CNA F reported she was not aware of an incident. CNA F reported the next day, they came into work and asked CNA E what the phone call was about. CNA F reported CNA E told them that R6 made an allegation that they both hit R6. CNA F reported they were never asked for a statement. In a telephone interview on 11/19/25 at 11:41 AM, Registered Nurse (RN) G reported they recalled R6 reporting she was hit during night shift and it hurt. RN G reported the allegation was reported to them and Scheduler D. RN G reported Scheduler D and someone else went into R6's room to interview about the allegation. In an interview on 11/19/25 at 10:18 AM, Scheduler D reported they were not aware of any incident where R6 alleged being hit by staff. In an interview on 11/19/25 at 11:34 AM, DON B reported there was not an allegation reported to them that R6 was hit by CNA E and CNA F. In an interview on 11/19/25 at 12:15 PM, Nursing Home Administrator (NHA) A reported there was a recent allegation that two staff members hit R6. NHA A reported they were on their way to work when they received a phone call related to the allegation. NHA A reported she asked Scheduler D and Payroll Benefits Coordinator (PBC) I to speak to R6 together. NHA A reported they could not recall exactly what R6 said, but that R6 ended up telling them that she did not like one of the aides being in her room and that nobody hit her. When asked if the allegation was reported to the State Agency, NHA A reported it was not because they ended up feeling like it was not reportable due to R6 eventually reporting nobody hit her. When asked if there was an investigation, NHA A stated yes and provided the file. Review of the facility's investigation revealed five staff statements, but no statements or assessments of other residents who were cared for by CNA E and CNA F. The investigation did not include any documentation on whether R6 had any physical signs of injury or not. The investigation did not include a statement from RN G who was one to receive the initial reported allegation. A written statement by PBC I revealed Went to interview [R6] on 10/21/25 after she said she was hit and after [Scheduler D] and I interviewed her she said she was not hit, she just didn't want a boy in her room.

Based on observation, interview, and record review the facility failed to ensure that controlled medication was administered and documented according to professional practice for one medication cart (to include six residents #7, #8, #9,#10, #11, and #12) out of five medication carts reviewed. Findings Included:Resident #7 (R7)Review of the medical record revealed R7 was admitted to the facility 08/18/2022 with diagnoses that included Parkinsons Disease, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease (disease caused by plaque buildup in arterial walls), hyperlipidemia (high fat content in blood), emphysema (chronic lung disease with destruction and enlargement of the air sacs in the lungs), hypertension, orthostatic hypotension (low blood pressure on rising), anxiety, constipation, polyneuropathy (peripheral nerve damage), and chronic pain. Review of R7's most recent Minimum Data Set (MDS),with an Assessment Reference Date (ARD) of 08/24/2025, revealed a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15.Resident #8 (R8)Review of the medical record revealed R8 was admitted to the facility 11/02/2025 with diagnoses that included chronic kidney disease, low back pain, hypothyroidism (low thyroid hormone), osteoarthritis (chronic joint disease), hypertension, and muscle weakness. Review of R8's assessment entitled Interviews-BIMS/PHQ/Social Determinants of Health -V2, completed 11/03/2025, revealed a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15.Review of #9 (R9)Review of the medical record revealed R9 was admitted to the facility 08/07/2023 with diagnoses that included type 2 diabetes, peripheral vascular disease (PVD), chronic kidney disease, hypertension, anemia (low red blood cells) , acquired absence of right toes, hyperlipidemia (high fat content in blood), hypomagnesemia 9low magnesium levels in blood), chronic pain syndrome, atherosclerotic heart disease (disease caused by plaque buildup in arterial walls), gastro-esophageal reflux, and muscle weakness. Review of R9's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/29/2025, revealed a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15.Review of #10 (R10)Review of the medical record revealed R10 was admitted to the facility 10/04/2023 with diagnoses that included type 2 diabetes, aortic valve disease, legal blindness, hypertension, depression, hyperlipidemia (high fat content in blood), chronic viral hepatitis C, insomnia, dementia, cognitive communication deficit, chronic pain syndrome, gastro-esophageal reflux, low back pain, and chronic kidney disease. Review of R10's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/01/2025, revealed a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact) out of 15.Review of #11 (R11)Review of the medical record revealed R11 was admitted to the facility 11/11/2022 with diagnoses that included obesity, chronic venous insufficiency, osteoarthritis left knee, muscle spasms, insomnia, chronic pain, and depression. Review of R11's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/19/2025, revealed a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15.Review of #12 (R12)Review of the medical record revealed R12 was admitted to the facility 09/04/2025 with diagnoses that included type 2 diabetes, acquired absence of right above the knee, chronic obstructive pulmonary disease (COPD), asthma, gastro-esophageal reflux disease, gout (buildup of uric acid in joints), acquired absence of left leg above knee, peripheral vascular disease, cognitive communication deficit, bipolar disorder, and gastro-esophageal. Review of R12's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/09/2025, revealed a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15.On 11/10/2025 at 03:06 p.m. a review of medication cart A controlled medication was conducted and observed with Director of Nursing (DON) B and Registered Nurse (RN) K. The following was observed:A. R7's Control Substance Record for hydrocodone-APAP 5-325mg (milligrams) tablet revealed a total count of 7 tablets but only 6 tablets remained in the control mediation drawer. RN K stated that the medication had been given at 02:00 p.m. but had not been documented as being removed from the control drawer on the Control Substance Record. RN K explained that he had documented the mediation as given to the resident on the Medication Administration Record of R7's electronic medical record. B. R8's Control Substance Record for hydrocodone-APA 5-325mg tablet revealed a total count of 22 tables but only 22 tablets remained in the control medication drawer. RN K stated that the medication had been given at 10:00 a. but had not been documented as being removed from the control drawer on the Control Substance Record. RN K explained that he had documented the mediation as given to the resident on the Medication Administration Record of R8's electronic medical record. C. R9's Control Substance Record for Pregabalin 150mg capsule revealed a total count of 10 capsules but only 9 capsules remained in the control medication drawer. RN K stated that the medication had been given at 02:00 p.m. but had not been documented as being removed from the control drawer on the Control Substance Record. RN K explained that he had documented the mediation as given to the resident on the Medication Administration Record of R9's electronic medical record. D. R10's Control Substance Record for Tramadol 50mg tablet revealed a total of 5 tablets but only 4 tablets remained in the control mediation drawer. RN K stated that the medication had been given at 02:00 p.m. but had not been documented as being removed from the control drawer on the Control Substance Record. RN K explained that he had documented the mediation as given to the resident on the Medication Administration Record of R10's electronic medical record. E. R11's Control Substance Record for Tramadol 100mg tablet revealed a total of 24 tablets but only 23 tablets remained in the control medication drawer and the Control Substance Record for oxycodone IR 5 mg tablet revealed a total of 4 tablets but only 3 tablets remained in the control medication drawer. RN K stated that the medication had been given at 02:00 p.m. but had not been documented as being removed from the control drawer on the Control Substance Record RN K explained that he had documented that both mediations had been given at 09:00 a.m. to the resident on the Medication Administration Record of R11's electronic medical record. F. R12's Control Substance Record for oxycodone IR 5mg tablet revealed 18 tablets but only 17 tablets remained in the control medication drawer. RN K stated that the medication had been given at 09:00 a.m. but had not been documented as being removed from the control drawer on the Control Substance Record. RN K explained that he had documented the mediation as given to the resident on the Medication Administration Record of R12's electronic medical record.On 11/12/2025 at 08:39 a.m. during an interview with Registered Nurse (RN) K explained the professional practice of removing controlled medication from the controlled medication drawer. RN K explained that the residents' orders are reviewed in the resident computerized medical record, which was called Point Click Care (PCC). RN K explained that the controlled medication was then removed and documented on the Controlled Substance Record as being removed and a final count is documented. RN K explained that the mediation are then taken to the resident for administration and then recorded as given in the PCC system. RN K could not explain why this professional practice was not followed for the residents listed as above.On 11/12/2025 at 08:55 a.m. during an interview with Director of Nursing (DON) B explained the professional practice of removing controlled medication from the controlled medication drawer. DON B explained that the residents' orders are reviewed in the resident computerized medical record, which was called Point Click Care (PCC). DON B explained that the controlled medications are then removed and documented on the Controlled Substance Record as being removed and a final count is documented. DON B explained that the mediations are then taken to the resident for administration and then recorded as given in the PCC system. DON B could not explain why this professional practice was not followed for the residents listed as above.

This Citation Pertains to Intake # 2567245Based on interview and record the facility failed to ensure adequate care, follow up and documentation were in place regarding Advanced Directives, resident alleging fear of certain family members, and failure to assess, monitor and investigate allegations of unwanted visitors giving a resident medication that was not prescribed by facility physician and provided by facility pharmacy. Findings include: Resident #1 (R1) admitted to facility on [DATE] with diagnoses that includes heart disease, diabetes and dementia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview Status score of 9 (moderate) cognitive impairment. Review of R1's physician orders reflected R1 was a full code, further review of R1's electronic medical record reflected R1 that Niece P had durable power of attorney and signed a form titled Advanced Directives Acknowledgement/CPR Consent on [DATE] the box do not resuscitate in the event of a cardiac arrest was checked. Further review of medical record revealed on [DATE] family member N (whom has several alias's) came into the facility and signed an Advanced Directive for R1. The form listed facility employee Social Worker (SW)C and Registered Nurse (RN) Q as the witnesses to the signing. The acknowledgement of receipt for the signed advanced directive R1's family member N added as 'DPOA (Durable Power of Attorney) as their relationship to R1.On [DATE] at 10:25 am during an interview with SW C she reported Adult Protective Services (APS) came to the facility on [DATE] regarding concerns for R1. SW C stated she had little information as APS met with admission Director (AD) E . SW C stated she was waiting on correct paperwork from Niece P When queried how she knew who had the correct paperwork for Power of Attorney, SW C said the APS worker brought it in, but facility staff did not ask for a copy. SW C elaborated after being made aware that family members N didn't have legal authority to make decisions the Physician reverted the status and made R1 a full code. SW C stated she believed family member P had legal authority and was waiting for them to provide documentation. SW C elaborated that family member N and family member O have been banned from visiting because R1 reported he was fearful of family member O. There was no documentation in the clinical record from SW C about the Advanced Directives, what concerns APS had or that R1 was fearful of a particular visitor, or that any visitors had been banned from visiting. When queried more about APS, SW C suggested admission Director E be interviewed because SW C wasn't really involved. SW C offered no explanation for the lack of documentation for the above noted concerns. On [DATE] at 11:20am, during an interview with R1's nurse RN D, she reported there was a sign posted at the nurse's station that two of R1's family members with several aliases have been banned from visiting. When queried about the reason form the ban, RN D reported it was due to family member O bringing in and administering medications from the community. RN D did not know the specifics of when or what medications. The sign was only there for a few days then removed RN D was not sure why the sign was removed or if the situation resolved itself. On [DATE] at 12:30pm, during an interview with Director of Nursing (DON) B she reported not having any knowledge of R1 receiving mediations from an outside source. DON B stated that she knew some lady came in about concerns for R1 but assumed she was a case manager from the hospital, did not know she was from Adult Protective Services. DON B stated she was made aware that R1 was fearful of family member O and possibly afraid of family member N too but wasn't sure. When queried why R1 was afraid of family members DON B didn't know and should have followed up with R1. On [DATE] at 12:50pm, during an interview with admission Director E she reported family member N and O came in the facility with DPOA papers, but family member P signed the admission contract. admission Director E stated she asked for both of their ID's and both family member ID reflected the same first name but looked legitimate so they were allowed to sign the documents but then family P called from out of state and APS got involved about 6 weeks ago and family member N and O are now banned. When queried the reason for the ban, admission Director E stated that because R1 stated he was afraid of them and that family member O gave him pills. When queried about the pills admission Director E stated she met with R1 and asked about the pills being brought which R1 didn't know the names of the pills. admission Director E stated the Nursing Home Administrator (NHA) A was on vacation otherwise she would have called him but instead notified DON B. when queried why this was not documented in the medical record, admission Director E stated she did not have access/authorization to document in the medical record.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents who consume food from the kitchen with a current facility census of 62 residents. Findings include: During a tour of the kitchen, starting at 9:00 AM on 10/1/24, it was observed that the top portion of the gasket, on the left door of the Raetone three door refrigeration unit, was found to have an accumulation of spotted debris. During a tour of the kitchen, at 9:15 AM on 10/1/24, it was observed that the underside of the juice machine was found with fuzzy and sticky debris between the spouts of the unit, especially in and around areas where screws are located. When showed to Regional Dietary Manager (RDM) V, he stated they would get them cleaned. During a tour of the kitchen, at 9:17 AM on 10/1/24, observation under the single compartment preparation sink found water accumulation that spanned under the juice and coffee area, the hand sink, and under the three-door refrigeration unit. Further observation found that the air gap to the preparation sink was not installed in a manner that made it easy for staff to dispense the sink when finished and would routinely cause water to accumulate on the floor. At this time, observation of the dish machine air gap also found that it caused excess splash onto the floor. These air gaps should prevent contamination from backflow, but also be installed in a manner that causes minimal issues with general cleaning and environment of the kitchen. During a tour of the kitchen, at 9:20 AM on 10/1/24, it was found that accumulation of debris, dirt, and some stagnant water, had found its way behind the three large cold hold units along the back of the floor juncture. Observation found two of the units are on fitted legs and one unit has caster wheels. Observation of the three-compartment sink area, at 9:35 AM on 10/1/24, found a shelf above the three compartment sink, next to the cook line, that was used for storing half and quarter size stainless steel pans. Feeling the stacked pans, found that they were covered in a greasy substance and not clean. When asked why the pans were in this location, RDM V was unsure, and stated he would cleaned the area, and move the pans to the storage rack near the back of the kitchen with other pots and pans. Observation of the ice machine area, at 10:05 AM on 10/1/24, found accumulation of dust and dirt debris behind the ice machine as well as plastic wrapping and Styrofoam cups. During a revisit to the kitchen, at 11:35 AM on 10/1/24, it was observed that a 14-inch saucepan was on the stove top for cooking grilled cheese. Observation of the saucepan found heavy encrusted grease deposits which blackened most of the cooking surface of the pan, leaving minimal stainless steel visible. When asked if there were other pans that could be used, [NAME] X stated it was the only one they had to use. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. According to the 2017 FDA Food Code section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . Observation of Activities Aide Y at 10:07 AM on 10/1/24, found they used the hand wash sink faucet, near the ice machine, in order to fill a cup of water. An interview with RDM V found that staff should not use the hand sink for water pass and that the facility has a water dispenser right next to the ice machine. When questioned why the water dispenser wasn't used, staff had stated at this time that the water spigot for water pass comes out slow compared to the hand sink. According to the 2017 FDA Food Code section 5-205.11 Using a Handwashing Sink. (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use.(B) A HANDWASHING SINK may not be used for purposes other than handwashing . A revisit to the kitchen, at 12:06 PM on 10/1/24, observed staff plating meal service for lunch. As meals were being plated in the kitchen and passed through a window, Staff on the other side of the window were checking tickets and stacking meal trays on carts. At this time, some grilled cheeses were requested to be made and Dietary Manager in Training (DMT) W came from outside the kitchen, put on gloves, and started making two grilled cheese. No observation of hand sink use was found after entering the kitchen and starting food preparation. According to the 2017 FDA Food Code section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and . (H) Before donning gloves to initiate a task that involves working with FOOD; .

Based on observation and interview the facility failed to provide and maintain therapy equipment in a manner that would allow for safe and consistent operation that meets the needs of all residents. Findings Include: An interview with Physical Therapy Manager (PTM) U, at 2:50 PM on 10/1/24, found that some equipment in therapy has not been working properly for all residents. When asked what issues have been occurring, PTM U went on to state that the parallel bars are not wide enough to be used properly for our residents who are bariatric. When asked how they are used for those residents now, PTM U stated that those residents have to use the side of the parallel bars and that makes them unable to use both sides to stabilize as they walk down. When asked about any other equipment, PTM U stated that the ScitFit elliptical bike doesn't seem to be working properly and that the resistance doesn't increase sometimes as the dial gets turned up. PTM U stated that some residents have noticed that as they want to increase the resistance and work harder on their recovery, the bike doesn't seem to aid in a way that allows for those residents to achieve their goals. During a tour of therapy, at 2:55 PM on 10/1/24, an interview with Physical Therapy Aide Z, found that the therapy department uses the kitchenette area in therapy for residents. At this time, the stove top oven was able to be turned on with the dials on the back of the unit and was getting hot quickly. An interview with Maintenance Director S found that there is a control panel shut off for the stove and it should be locked out whenever it is not in use. At this time, Maintenance Director S went and shut off the breaker and stated he would be putting a lock on the breaker from now on.

Based on observation, interview and record review, the facility failed to prevent an elopement and respond timely to a door alarm for one (Resident #33) of one reviewed. Findings include: Review of the medical record reflected Resident #33 (R33) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included unspecified dementia, unsteadiness on feet and disorientation. The modified admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/9/24, reflected R33 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R33 was coded for wandering one to three days during the assessment look-back period that placed them at significant risk of getting to a potentially dangerous place, such as stairs or outside of the facility. On 10/01/24 at 10:10 AM, R33 was observed ambulating in the hallway, using a rolling walker. A wanderguard bracelet was observed on their left ankle. On 10/03/24 at 7:29 AM, R33 was observed lying in bed. A wanderguard bracelet was observed on their left ankle. R33's Care Plan, which was initiated on 5/3/24 and revised on 7/16/24, reflected they were at risk for elopement related to unsafe wandering and attempts of exiting a door at the end of a hall. An intervention, which was initiated on 5/3/24, reflected R33 wore a wanderguard device. An Incident Report for 6/10/24 at 11:40 PM reflected the nurse was notified by the Certified Nurse Aide (CNA) that R33 was not in their room and not accounted for in the facility. Staff began looking for R33 after discovering they were missing. A facility timeline reflected the following: -At 11:35 PM, R33 exited their room on D hall. -At 11:36 PM, R33 walked around the nurse's station and down B hall. -At 11:37:10 PM, the B hall door alarm went off, lights at the nurse's station began flashing and R33 exited the door. -At 11:37:26 PM, Licensed Practical Nurse (LPN) G walked to the nurse's station to check for the source of the alarm. CNA I met LPN G at the nurse's station and had a brief conversation. -At 11:37:50 PM, LPN G checked the B hall door with CNA I. -At 11:38 PM, the alarm was turned off by CNA I, but the flashing light alarm continued. -At 11:38:40 PM, LPN G notified the D hall CNA to check that residents were in the building. -At 11:39 PM, CNA H exited C hall. -At 11:40 PM, R33's room was checked, and it was noted they were not in bed. Staff ran down the hall to alert other staff. -At 11:41 PM, LPN G exited the facility to find R33. -At 11:42 PM, the remainder of the staff looked for R33 in the building. A CNA exited the facility to check the perimeter. -At 11:51 PM, the nurse and R33 entered the facility through the front door. A statement by CNA H reflected they last saw R33 when giving them water around 11:20 PM. R33 was in bed, sleeping, at that time. It was not long after when CNA H saw lights at the nurse's station blinking. CNA H went to check the panel, and it showed the alarm was from B hall. CNA H went to B hall immediately and met two other staff. A code yellow was called. CNA H went to R33's room and could not locate them. Staff went outside to look, and a nurse got in their car. During a phone interview on 10/03/24 at 8:02 AM, LPN G reported that when the door alarm went off, she immediately went to the panel at the nurse's station and saw that it was for the B hall exit door. LPN G reported she ran to the door and did not see anyone. A code yellow was called for everyone to check if any residents were gone. A CNA said R33 wasn't there. Staff checked the entire building and perimeter and could not locate R33. LPN G reported she got in her car, drove around and located R33 walking. R33 was on a road adjacent to the facility. LPN G reported R33 must have gone through the bushes on the facility's property to get to where they were, otherwise she would have seen R33 on the facility's road when she went to the exit door. According to a written statement by LPN G, the B hall exit door was open when staff approached it in response to the alarm. During an interview with former Nursing Home Administrator (NHA) R on 10/03/24 at 10:11 AM, she confirmed that R33 had a wanderguard at the time of the elopement, but the B hall exit door did not have a wanderguard alarm on it. She reported R33 was in the parking lot of a hotel behind the facility when located by staff. Former NHA R stated she did not know how long R33 was outside for, but her understanding was that it was not long. During an interview on 10/03/24 at 10:24 AM, Director of Nursing (DON) B stated staff checked the nurse's station first, rather than the door. She reported when an alarm sounded, you could hear where it was coming from without checking the panel first. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: -Residents who were at risk for elopement had elopement assessments completed. -An extra alarm was placed on the B hall door to alert staff to the location of a door alarm more quickly. All end exit hall doors have this alarm. -Staff were educated on the Elopement Prevention and Response policy and code yellow process prior to working their next shift. -An ad hoq QAPI meeting was completed on 6/11/24. -Code yellow drills were conducted weekly on each shift for four weeks, then monthly thereafter on different shifts. The facility was able to demonstrate monitoring of the corrective action and maintained compliance. 32064 An observation on 10/03/24 at 11:47 AM with Maintenance Director (MD) S revealed all hallway exit doors had two alarms. The first alarm was a 15 second delayed egress. The alarm sounded when the door bar was pushed. The alarm continued to sound for 15 seconds before the door could be opened. Once the door was opened, the alarm continued to sound and a second, louder, alarm sounded. Overhead lights flashed at the nurses' station and the monitor at the nurses' station indicated what door alarmed. In an interview on 10/03/24 at 12:06 PM, Director of Nursing (DON) B reported the second, louder alarms were the new alarms installed on the doors after R33 eloped from the facility.

Based on observation, interview and record review, the facility failed to ensure monitoring of an antipsychotic medication according to provider recommendations for one (Resident #58) of five reviewed. Findings include: Review of the medical record reflected Resident #58 (R58) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included mood disorder due to known physiological condition, major depressive disorder and anxiety disorder. The modified quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/24/24, reflected R58 had short-term and long-term memory impairments. On 10/01/24 at 1:34 PM, R58 was observed seated on their bed. R58's medical record reflected an order for 25 milligrams (mg) of Quetiapine Fumarate (Seroquel/antipsychotic medication) to be given in the morning for mood disorder due to known physiological condition. An additional order reflected R58 was to receive 100 mg of Quetiapine Fumarate at bedtime for mood disorder due to known physiological condition. A Psychiatric Services Progress Note for 5/2/24 reflected the risks of Seroquel included but were not limited to hyperglycemia (high blood sugar) and postural hypotension (orthostatic hypotension/low blood pressure when standing, after sitting or lying down). A Psychiatric Services Progress Note for 8/29/24 reflected recommendations to increase R58's Seroquel dose to 50 mg at bedtime for one week, then 75 mg at bedtime for one week, then 100 mg at bedtime, ongoing, for mood instability and impaired sleep. The note reflected Seroquel risks included but were not limited to hyperglycemia and postural hypotension. The note further reflected orthostatic blood pressures should be taken every shift when an antipsychotic medication was started or when the dose was increased. According to the note, hemoglobin A1C (blood test that reflects the average blood sugar level for the past two to three months) and a lipid profile (blood test to measure the amount of cholesterol and triglycerides (a type of fat) in the blood) should have been monitored every six months. An electrocardiogram (EKG/test that measures electrical activity of the heart) was also recommended, if not recently obtained. R58's medical record did not reflect that a lipid profile, hemoglobin A1C or an EKG had been performed. R58's medical record did not reflect that orthostatic blood pressures were being monitored. R58's medical record did not reflect documentation that their Physician declined the recommended tests. On 10/02/24 at 10:32 AM, an email was sent to Nursing Home Administrator (NHA) A for R58's EKG results, hemoglobin A1C results and lipid profile results, if available. Orthostatic blood pressures since the date of admission were also requested. The items were not received prior to the survey exit on 10/3/24. During an interview on 10/02/24 at 10:36 AM, Director of Nursing (DON) B reported orthostatic blood pressures should have been monitored monthly for residents that were receiving antipsychotic medications. DON B reported there was usually a physician's order for orthostatic blood pressures. She stated she did not see an order for orthostatic blood pressures for R58 since May 2024. DON B reported she did not locate hemoglobin A1C, lipid profile or EKG results for R58. DON B stated when Psychiatric Services providers recommended tests, the facility would typically order them, as the facility's Physician and Nurse Practitioner usually followed Psychiatric Services recommendations.

Based on observation, interview, and record review, the facility failed to revise care plans for three (Resident #34, #57, and #62) of 16 reviewed. Findings include: Resident #34 (R34) Review of the medical record revealed R34 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included Parkinson's Disease and unsteadiness on feet. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/24 revealed R34 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the fall care plan initiated on 2/1/24 revealed the following interventions: - Place walker within reach of bed on the left side - Resident often chooses to use four wheeled walker despite therapy recommendations and education of risks. Therapy gave resident standard front wheeled walker - Encourage resident to slow down with his motorized wheelchair - Dycem to wheelchair Review of the Activities of Daily Living (ADL) care plan initiated 2/1/24 revealed the following: - Ambulation: 1 person assist with 2ww [two wheeled walker]. Often chooses to ambulate independently. Please encourage [R34] to allow someone to be with him while using walker and not use 4ww [four wheeled walker] (as it is not safe at this time). - Transfers: 1 person assist with 2ww - Uses a motorized wheelchair for locomotion throughout the facility On 10/01/24 at 11:49 AM and 10/02/24 at 8:13 AM, R34 was observed in their bed. R34's standard (non-motorized) wheelchair was against the wall on the left side of the bed. There was no dycem in the wheelchair. R34's four wheeled walker was against the wall on the other side of the wheelchair. The walker was not in reach of the bed per the care plan. R34 did not have a two wheeled walker in his room per the care plan. On 10/02/24 at 8:50 AM, R34 was observed self-propelling his standard wheelchair throughout the hallway. In an interview on 10/02/24 at 11:12 AM, Director of Nursing (DON) B reported R34 was only able to safely use their motorized wheelchair outside, therefore the motorized wheelchair was stored in the lobby of the facility. DON B reported R34 was not safe to use the four wheeled walker but was unsure of where R34's two wheeled walker was located. DON B reported the dycem to wheelchair was for R34's motorized wheelchair. DON B agreed R34's care plans needed to be updated. Review of the Power-Mobility Indoor Driving assessment dated [DATE] revealed R34 had poor safety awareness with power w/c [wheelchair] indoors, at risk of causing harm to himself or others. Recommend manual w/c indoors, able to utilize power chair for outdoor mobility with supervision. On 10/02/24 at 5:00 PM, R34 was observed in the parking lot, driving their motorized wheelchair without staff supervision. 45135 Resident #62 (R62) Review of the medical record reflected R62 was admitted to the facility on [DATE]. Diagnoses of other fractures of lower end of right radius, multiple fractures of ribs, right side, bi-polar, and muscle weakness. Record review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated severe cognition impairment. Record review of a physician's orders dated 08/27/2020, revealed an order for Resident #62 to use a wheelchair. The order also clarified that physical therapy recommended skilled physical therapy (PT) 5-6 days a week for a duration of 8 weeks to provide therapeutic exercise, therapeutic activities, neuromuscular re-education, and wheelchair training in 1:1/group/concurrent settings as indicated due to unsteady gait. Record review of the care plan Intervention dated 08/09/24 revealed R62 used a walker for ambulation/transfer. R62 had an Activities of Daily Living (ADL) self-care performance deficit related to cognitive impairment, delirium, dementia, generalized weakness, history of falls, poor balance, psychoactive drug use, Bipolar, difficultly walking Date Initiated: 08/09/2024 Revision on: 08/13/2024. During an Observation of 10/02/24 at 08:25 AM, R62 was sitting at the table in the common area eating his breakfast while sitting in his wheelchair. During an interview and observation on 10/02/24 at 4:09 PM, R62 was sitting on his bed watching [NAME] on TV with a Certified Nursing Assistant (CNA) T sitting in a chair close to his bed watching TV with him. CNA T stated R62 needed one on one supervision at all times due to the right sided non-weight bearing from his fall on 08/20/2024. Observation of a large wheelchair sitting in his room, and no walker within site. During an interview and observation on 10/03/24 at 08:21 AM, R62 was in the physical therapy department using the sci-fit bike (a special exercise bike). Physical Therapy Assistant (PTA) K stated after his fall on 08/20/24, R62 is none weight bearing on the right side, and required a one on one CNA supervision at all times due to safety. PTA K also stated they stopped using the walker after his fall on 08/20/24. PTA K added that it is easier and safer for him to use wheelchair. During an interview on 10/03/24 at 08:26 AM, Physical Therapy Manager U stated they took away the walker when he fractured his right arm and ribs, and start using the wheelchair due to non-weight bearing on the right side. Physical Therapy Manager U also stated they updated R62 orders and recommendations within their department then it went to the unit manager M to update the care plan. During an interview and observation on 10/03/24 at 08:31 AM, Unit Manager M stated R62 used the walker on 08/20/24 when he fell . R62 was sent out to the hospital and due to multiple fractures, R62 was non- weight bearing on the right side. Unit Manager M also stated that when R62 came back to the facility, he was more unsteady. Unit Manager M also stated R62 was using the wheelchair for his safety as well as the one-on-one CNA supervision for safety reasons. During this same observation, Unit Manager M looked up R62's care plan, and stated that it did not have the use of the wheelchair on the care plan. Unit Manager M stated she removed the walker and added wheelchair to R62's care plan. 49103 Resident #R57 (R57) On 10/1/24 at 9:22 AM during observation and interview R57 was alert and able to participate in an interview. R57 was up independently in the room with a steady gait. R57 talked about interests such as going to the store which he does independently. Review of the electronic medical record (EMR) revealed R57 was admitted to the facility 4/17/24 with pertinent diagnoses of Memory Deficit following other Cerebral Vascular Disease (a disease which includes a variety of medical conditions that affect the blood vessels of the brain and cerebral circulation) and Schizoaffective Disorder, Bipolar type (a mental health condition that is marked by a mix of symptoms such as hallucinations, delusions, and mood disorder). According to a Minimum Data Set (MDS) report dated 7/27/24 R57 had a Brief Interview for Mental Status score of 09 indicating moderate cognitive impairment. R57 is listed as his own representative. Further review of the EMR revealed a note entered 9/16/24 by Physician Assistant (PA) AA which stated in part that R57 had an episode of . acute alcohol intoxication again. after drinking a bottle of Tequila. The note further said that R57 (at the time of the visit) did not . appear altered. but had . some upset stomach and nausea. PA AA discussed with R57 the importance of avoiding drinking and potential medication interactions with alcohol. On 10/2/24 at 3:33 PM during interview with the Director of Nursing (DON) B the care plan was reviewed. It was noted that there was no entry in the care plan concerning R57's risk related to alcohol consumption. The DON confirmed this and said there should be a care plan item in place addressing the problem. On 10/2/24 at 3:53 PM Social Worker (SW) C submitted a care plan item which addresses R57's history of substance abuse disorder. SW C explained this was previously a part of the main care plan and when the care plan was updated it did not come through but as of the day of survey had been added. The care plan states in part, Resident will remain free of substance abuse (unless physician prescribed) and will not have evidence of a relapse through the next review. Date initiated 10/2/24.

Based on observation, interview, and record review, the facility failed to ensure their medication error rate was below 5% when two medication errors were observed from a total of 25 opportunities for two residents (Resident #22 and Resident #36) of four reviewed resulting in a medication error rate of 8%. Findings include: Resident #36 (R36) Review of the medical record revealed R36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included urosepsis (urinary tract infection that leads to sepsis). Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/26/24 revealed R36 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Order dated 10/1/24 revealed ertapenem sodium solution (antibiotic) 1 gram intravenously (IV) every 24 hours for infection, complicated urinary tract infection, for four days. Review of the Medication Administration Record (MAR) revealed the last dose of ertapenem was administered on 10/1/24 at 6:01 PM. On 10/02/24 at 8:28 AM, Registered Nurse (RN) F was observed preparing and administering ertapenem 1 gram/100 milliliters IV over one hour through a peripherally inserted central catheter (PICC line). The dose was administered approximately 14.5 hours after the last dose. RN F reported R36's antibiotic was delivered late on 10/1/24 and therefore given after the scheduled time. RN F agreed R36 received the last dose the evening before and that it had not yet been 24 hours. In an interview on 10/02/24 at 10:36 AM, Director of Nursing (DON) B reported R36 was ordered to receive ertapenem every 24 hours. DON B agreed R36 received a dose on 10/1/24 at 6:01 PM and then again, the morning of 10/2/24, approximately 14.5 hours later. DON B reported they would expect the timing of the order to be changed after the first dose was administered late. 38383 Resident #22 (R22) Review of the medical record reflected R22 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included type 2 diabetes. On 10/02/24 at 07:38 AM, Registered Nurse (RN) D was observed to begin preparing medications for R22, including Tresiba FlexTouch 100 units per milliliter (u/mL) (long-acting insulin pen). Without placing a needle on the insulin pen, RN D turned the dose selector to two units, then pressed the injection button. RN D stated she always pushed two units of air out of the pen. She then applied a needle to the insulin pen and turned the dose selector to R22's prescribed dose of 55 units. On 10/02/24 at 08:36 AM, RN D reported she usually primed insulin pens without a needle on the pen. RN D could not recall if that was how she had been trained. In an interview on 10/02/24 at 10:36 AM, Director of Nursing (DON) B described that priming an insulin pen consisted of placing a needle on the insulin pen, setting the dose selector to two units and pressing the injection button. The insulin pen would then be set to the prescribed dose for administration. According to Cleveland Clinic, .Prime the insulin pen. Priming means removing air bubbles from the needle. It ensures that the needle is open and working. You must prime the pen before each injection. To prime the insulin pen, turn the dosage knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. You may need to repeat this step until a drop appears . (https://my.clevelandclinic.org/health/treatments/17923-insulin-pen-injections)

This citation pertains to intake: MI00143250, MI00143278 Based on observation, interview, and record review the facility failed to insure that one resident #1 (R1) was free from significant medications errors out of four residents reviewed for significant medication errors resulting in the potential for adverse physical reactions/outcomes to residents. Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility 03/17/2023 with diagnoses that included nontraumatic intracerebral hemorrhage (stroke), Schizoaffective Disorder Bipolar type, hemiplegia (paralysis) affecting right dominate side, post-traumatic stress disorder (PTSD), dysphagia (swallowing difficulties), depression, hypertension, adjustment disorder with mixed anxiety and depression, muscle weakness, cognitive communication deficit, and hypokalemia (lower than normal potassium in bloodstream). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/07/2024, demonstrated R1 had a Brief Interview for Mental Status (BIMS) of 6 (severe impaired cognition). Resident #9 (R9) Review of the medical record revealed R9 was admitted to the facility 01/12/2024 with diagnoses that included bipolar disorder with psychotic features, intellectual disabilities, intermittent explosive disorder (frequent episodes of impulsive anger), anxiety disorder, seizures, restlessness and agitation, irritability and anger, developmental disorder or speech and language, and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/2024, demonstrated R9 had a Brief Interview for Mental Status (BIMS) of 3 (severe impaired cognition). Review of R1's medical record demonstrated a progress note from 03/08/2024 at 07:21 a.m. which stated, Resident was given wrong medication and posin (sp) was notified with orders to do 1-hour vitals and neuro (neurological) checks for 8 hours then Q (every) 4 hours for 24 hours if any changes to send to hospital. R1's medical record also demonstrated a progress note from 03/08/2024 at 07:25 a.m. which stated, Writer accidentally passed the wrong medication from the wrong cup. The same note explains that the physician assistant and the nurse manager were notified of the incident. The same note also demonstrated orders are to watch for tremors and increased sedation, vitals Q 4 hours X (for) 24 hours. No c/o (complaint) pain or discomfort, Resident A&O (alert and orientated) x 1. R1's medical record demonstrated that he was sent to the hospital on 03/08/2024 at approximately 02:00 p.m. R1's medical record demonstrated that he returned to the facility on [DATE] at 02:25 a.m. and demonstrated a progress note that stated, .spoke with ER physician. The physician reported that (R1's) lab work, vital signs and monitoring was stable and that his cognition/neurological status had returned to base line. No further orders received at this time other than to continuous monitoring of neurological status/vital signs. In an interview on 04/10/2024 at 02:15 p.m. Nurse Manager (NM) C explained that she was aware of the incident involving R1, that occurred on 03/08/2024 and that R1 was given R9's medication. NM C explained that Registered Nurse L had prepared the medication for R1 and had also prepared medication for R9. Licensed Practical Nurse K then took both residents medication and proceeded to administer R9's medication to R1. NM C provided this surveyor with the facility incident report. Review of the facility incident report, 03/08/2024 at 07:15 a.m., demonstrated Writer administered incorrect medications to incorrect patient at AM morning pass. Medication that was incorrectly passed were as follows: Keppra 1500mg (milligrams), Lamotrigine 200mg, Oxcarbazepine 900mg, Seroquel 300mg, Topamax 100mg. The same incident report also demonstrated that R1's at 01:00 p.m. vital signs had become tachycardic (heart rate greater than 120 beats per minute) and he had become lethargic. At 02:00 pm. R1 became more lethargic and had a pulse rate of 40 beats per minute and he was taken to the hospital by Emergency Management Services (EMS). During a telephone interview on 04/11/2024 at 08:39 a.m. Licensed Practical Nurse (LPN) K explained that she was finishing her shift, on the morning of 03/08/2023, and explained that she was assisting the on-coming nurse (Registered Nurse (RN) K) with medication administration. She explained that RN L had prepared the medication that was to be given to R1 and to be given to R9. LPN K explained that she took both medication cups that contained R1's and R9's medication and went into R1's room to administer the medication. She explained that then came R1 the medication of R9 by accident. She explained that she immediately identified the error and proceeded to notify the physician assistant and the nurse manager. LPN K explained that she should not have administered medication that were provided by another nurse or have taken two different residents medications during the same time to administer. In an interview on 04/11/2024 at 12:13 p.m. Registered Nurse (RN) L explained that she had worked 03/08/2024 during the day shift. She explained that she had prepared the medication for R9 and had placed those medications in a medication cup. She explained that Licensed Practical Nurse (LPN) K was going to take those medication and provide them to R9. She further explained that LPN K did not immediately take those medication and walked away from the medication cart. She explained that continued preparing the medication for R1 by placing them in a different mediation cup. LPN K then returned to the medication cart and took both medication cups for R1 and for R9. She explained that shortly after LPN K returned and informed her that she had given R9 medication to R1. During observation and interview on 04/11/2024 at 12: 21 p.m. R1 was observed lying down in his bed. He explained that he was aware of receiving the wrong medication but could not recall the date that it had occurred. He explained that no medication errors had occurred since that time. In an interview on 04/11/2024 at 01:41 p.m. Director of Nursing (DON) B' explained that it was her expectation and a professional standard that medication be prepared and administered by the same nurse. Medication should not be prepared by one nurse and then provided to a resident by a different nurse. She explained that if medication is prepared and dispensed by a different nurse could place the resident at risk for a significant medication error. DON B explained that she was aware of the significant medication error that had occurred with R1 on 03/08/2024. She explained that the root cause was because one nurse prepared the medication, and a different nurse gave the medication. During onsite survey, past none compliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: 1). A root cause analysis of the deficient practice. 2). completed and audit of all residents on the same unit that could have been potentially impacted. 3). Immediate re-education of the two-nursing staff involved in the deficient practice. 4). All licensed nursing staff were re-educated regarding professional standards for medication administration. 5). The Director of Nursing/Designee completed observation of all licensed nursing staff during medication administration. 6). The facility Quality Improvement Committed implemented a quality assurance plan to correct the deficient practice and implemented on going monitoring of medication administration. 7). The Director of Nursing/designee will audit significant medication errors at least one time weekly for four weeks. After which the frequency of those audits will be one time weekly for three months. 8). The Director of Nursing/designee will audit licensed nursing staff for appropriate medication administration, by observation during medication administration, one time weekly for four weeks. After which, the frequency of those audits will be one time weekly for three months. Finding will be presented to the Quality Assurance Performance Improvement (QAPI) team for recommendations and follow-up. The Facility was able to demonstrate the correction action and maintained compliance as of 03/25/2024.

Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen, date mark potential hazardous foods, and maintain the ice machine, resulting in the potential biological contamination of food products, affecting all residents that consume food from the kitchen. Findings include: On 7/18/23 at 8:07 AM, during an inspection of the kitchen, the floor/wall juncture behind the stainless steel coffee table was observed to be soiled with soil and food debris. Additionally, the floor tile grout around the dish machine drain board and underneath the dish machine was observed to be dissolving, leaving gaps for water to accumulate. During an interview on 7/18/23 at 8:23 AM, Dietary Manager L was queried on how often the floor are cleaned and stated, I don't really keep track. According to the 2017 FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions. (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 7/18/23 at 8:12 AM, a container of tomato sauce was observed to be dated 7/17 - 8/17 in reach-in refrigerator #1. At this time, Dietary Manager L stated that the tomato sauce came from a can and hasn't been heated up yet. On 7/18/23 at 8:36 AM, almond based yogurt was observed in the resident food refrigerator, located in the dining room, without a date labeling when the container was opened. Additionally, a carton of almond milk and a carton of strawberry banana juice were observed with no open date label. At this time, Dietary Manager L discarded the unlabeled products. On 7/18/23 at 8:40 AM, excessive water was observed to be puddled on the floor between the ice machine and the hand sink. Dietary Manager L was not aware of the source of the standing water. Additionally, the ice machine deflector plate was observed to have pink staining. At this time, Dietary Manager L stated that the maintenance department is responsible for cleaning the ice machine. According to the 2017 FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils. (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: . (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. On 7/18/23 at 8:42 AM, the reach-in refrigerator, located in the dining room service area, was observed to not be provided with an internal ambient thermometer. At this time, Dietary Manager L could not located a thermometer. According to the 2017 FDA Food Code Section 4-204.112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of a TEMPERATURE MEASURING DEVICE shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot FOOD storage unit. On 7/18/23 at 8:45 AM, the resident refrigerator located in The Lakes hall, was observed to have a thickened liquid med pass beverage that was opened but did not contain an open date label. Additionally, a deli sandwich was observed to not have a date mark.

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for four (Resident #2, #26, #44 and #64) of 17 reviewed for MDS, resulting in the potential for inaccurate care plans and unmet care needs. Findings include: Resident #26 (R26): Review of the medical record reflected R26 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery, diabetes and vascular dementia. The Significant Change in Status (SCSA) MDS, with an Assessment Reference Date (ARD) of 4/21/23, reflected R26 had short-term and long-term memory problems and required limited to total assistance of one to two or more people for activities of daily living (ADLs). R26 was coded as receiving an anticoagulant (blood thinning medication) for seven days during the look-back periods of the SCSA MDS, with an ARD of 4/21/23, as well as the annual MDS, with an ARD of 1/19/23 and the SCSA MDS, with an ARD of 10/31/22. According to R26's physician's orders, she had not received an anticoagulant medication since 2021. R26 had an order for Clopidogrel (Plavix/anti-platelet medication) 75 milligrams daily. During an interview on 07/19/23 at 10:20 AM, MDS Coordinator G reported she had recently realized she made a mistake and had been coding Plavix as an anticoagulant. Resident #44 (R44): Review of the medical record reflected R44 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes and heart failure. The quarterly MDS, with an ARD of 5/26/23, reflected R44 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and required extensive to total assistance of one to two or more people for most ADLs. R44 was coded for daily bed rail use. According to Section P of the MDS, pertaining to Restraints and Alarms, P0100 .Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. On 07/19/23 at 11:34 AM, R44 was observed lying in bed with bed rails in place to both sides of the bed. A physician's order, with a revision date of 5/22/23, reflected R44 had enabler bars to both sides of the bed to assist with bed mobility. During an interview on 07/19/23 at 10:20 AM, MDS Coordinator G reported her understanding was that bed rails were a restraint. MDS Coordinator G reported R44's bed rails did not restrict her movement or access to her body, but she could not remove them easily. MDS Coordinator G reported R44 spent most of her time in bed. 32064 Resident #64 (R64) Review of the medical record revealed R64 was admitted to the facility on [DATE] and discharged [DATE] with diagnoses that included diabetes, lymphedema, major depressive disorder, acute kidney failure, hypertension, pain, and cellulitis. Review of the Nursing Admission Evaluation dated 8/26/22 revealed R64 had a right heel pressure ulcer. Review of the Skin & Wound Evaluation dated 8/30/22 revealed R64's wound was a diabetic ulcer. Review of the Physician's Progress Note dated 9/22/22 revealed R64 had a right heel diabetic wound. Review of the Physician's Progress Note dated 9/26/22 revealed R64 had a diabetic foot ulcer. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/1/22 revealed R64 had an unstageable pressure ulcer. Review of the discharge MDS with an ARD of 9/27/22 revealed R64 had an unstageable pressure ulcer. In an interview on 07/19/23 at 10:19 AM, MDS Coordinator G reported she coded R64's skin based on the admission skin assessment. MDS Coordinator G was unaware that R64's wound had been later diagnosed as a diabetic ulcer, even though the additional wound assessments were completed prior the MDS. 46955 Resident #2 Review of the medical record revealed that Resident #2 (R2) was admitted to facility on 4/12/2022 with diagnoses including mild protein-calorie malnutrition, schizoaffective disorder, and unspecified dementia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/11/23 revealed that R2 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 7 (severely impaired cognition). Section O of the same MDS indicated that R2 was receiving Hospice care. Review of R2's Significant Change MDS with an ARD of 11/8/2022 indicated that R2 had not received Hospice care in the prior 14-day assessment period. R2's Physician Order dated 11/2/2022 at 8:48 AM stated, Resident is a hospice resident of (name of Hospice Company) for DX (diagnosis): Mild Protein-Calorie Malnutrition effective 11/1/22 . In an interview on 7/19/23 at 12:26 PM, Licensed Practical Nurse/Minimum Data Set Coordinator/Unit Manager (LPN/MDS Coordinator/UM) G stated that a Significant Change MDS would be completed with a change in a resident's health status that impacted more than one area and when a resident enrolled or disenrolled from hospice services. Upon review of R2's medical record, LPN/MDS Coordinator/UM G confirmed that R2 was admitted to hospice care on 11/1/22 and that a Significant Change MDS was completed at that time to reflect hospice enrollment. Upon review of R2's Significant change MDS with an ARD of 11/8/22, LPN/MDS Coordinator/UM G confirmed that Section O of the MDS was coded incorrectly as did not reflect the hospice care that R2 was enrolled in effective 11/1/22 and was the reason that the Significant Change MDS had been completed. LPN/MDS Coordinator/UM G stated that she would be completing a Modification of Significant Change for the Significant Change MDS with an ARD of 11/8/22 to accurately reflect the Hospice care that R2 had received effective 11/1/22.

Based on observation, interview and record review, the facility failed to revise care plans for four (Resident #17, #26, #35 and #38) of 16 reviewed for Care Plans, resulting in inaccurate care plans and the potential for unmet care needs. Findings include: Resident #26 (R26): Review of the medical record reflected R26 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery, diabetes and vascular dementia. The Significant Change in Status (SCSA) Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/21/23, reflected R26 had short-term and long-term memory problems and required limited to total assistance of one to two or more people for activities of daily living (ADLs). On 07/20/23 at 7:44 AM, R26 was observed seated in a broda chair, watching TV in her room. R26 was non-verbal when spoken to. A Progress Note by the physician on 4/14/23, reflected, .I was requested to evaluate for capacity to consent to sexual activities. Patient answers questions with head nods but is nonverbal. I was asked to answer the following questions: 1. Is the resident aware of who is initiating sexual contact? -unable to determine as patient is nonverbal. 2. Does the reisdnet [sic] believe that the other person is a spouse and thus, acquiesces out of a delusional believer, or is she cognizent [sic] of the other's identity and intent? -Again, unable to determine with patient's nonverbal status. 3. Can the resident state what level of sexual intimacy she would be comfortable with? -No as patient is nonverbal. 4. Is the behavior consistent with formerly held beliefs? -Unable to determine due to nonverbal status. 5. Does the residnet [sic] have capcity [sic] to say no to any uninvited sexual contact? -No. 6. Does the resident realize that this relationship may be time limited (placement on unit is temporary)? -No 7. Can the resident describe how she will react whenthe [sic] relationship ends? -No .at this time patient does NOT have capcity [sic] to consent to sexual activities in my medical opinion . Resident #35 (R35) Review of the medical record reflected R35 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included bipolar disorder and dementia. The annual MDS, with an ARD of 5/25/23, reflected R35 scored nine out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was independent to extensive assistance for ADLs. A Provider Note for 4/14/23 reflected, .I was asked to evaluate his capacity to consent to sexual activities. He has been known to enter a specific resident's room, bringing beverages that the other resident is not to have and concern for possible advancement of their relationship. I was asked to answer the following questions. 1. Is the resident aware of who is initiating sexual contact? -No. He states that he is not aware of the other resident, has no plans for a relationshp. [sic] 2. Does the resident believe that the other person is a spouse and thus, acquiesces out of a delusional believer, or is he cognizent [sic] of the other's identity and intent? -No, states he does not know who the other resident is. 3. Can the residentstate [sic] what level of sexual intimacy she would be comfortable with? -Yes 4. Is the behavior consistent with formerly held beliefs? -Unclear. patient reports he has not had a relationship since his wife passed away. 5. Does the resident have capacityto [sic] say no to any uninvited sexual contact? -Yes 6. Does the resident realize that this relationship may be time limited (placement on unit is temporary)? -Yes. 7. Can the resident describe how he will react when the relationship ends? -No.At this time, patient does not have the capacity to consent to sexual activities in my medical opinion . During an interview on 07/19/23 at 12:15 PM, Director of Nursing (DON) B reported R26 and another resident liked to hang out. They held hands, which was not necessarily sexual, according to DON B. The facility had them evaluated in case they wanted to have that kind of relationship. DON B reported family was ok with the residents holding hands. During an interview on 07/19/23 at 2:23 PM, MDS Coordinator G reported assessments had to be done if anyone displayed behaviors of wanting to be around the opposite sex, and R26 was doing that. According to MDS Coordinator G, R26's family was aware that she was holding R35's hand and wanting to sit by him, and R26's family was ok with that. MDS Coordinator G stated the only thing they said was that they did not want R35 in R26's room alone. During an interview on 07/20/23 at 8:04 AM, Nursing Home Administrator (NHA) A reported there was a male resident that R26 liked to sit with, hold hands, kiss each others hands and try to kiss each other. She stated both residents had consent from family to hold hands. NHA A reported they liked to show affection towards each other, and their Guardians were ok with hand holding and kissing affection. If they were together, they were kept in a common area, with eyes on them, and were never alone. When asked how staff knew that information, NHA A stated it was a known fact and probably needed to be in their care plans, if it was not. R26 and R35's Care Plans were not reflective of behavior and interactions with one another that were reported to be acceptable versus unacceptable by their Guardians, such as R35 not being permitted to be in R26's room alone. 45038 Resident #38 (R38) Review of the medical record revealed R38 was admitted to the facility 11/17/2022 with diagnoses that included stage 4 pressure ulcer to right buttock, pressure ulcer of right upper back, stage 4 pressure ulcer of left elbow unstageable stage 2 pressure ulcer of sacral region, anemia (low red blood cells in blood), severe protein calorie malnutrition, quadriplegia (paralysis of all four limbs), cervical disc displacement at cervical 5 through cervical 6 level, hypotension, major depression, migraines, post-traumatic stress disorder, bradycardia (low heart rate), chronic pain, anxiety disorder, colostomy, and neuromuscular dysfunction of the bladder. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/26/2023, revealed R38 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. Section N (Medications) of the MDS, with the same ARD, demonstrated R38 had received 7 days of anti-anxiety medication during the seven days look back period of the MDS. During observation and interview on 07/20/2023 at 07:48 a.m. R38 was observed lying down in his bed. R38 explained that he had been in a car accident two years in the past. R38 explained that he was taking anti-anxiety medication on a routine basis and also takes more anti-anxiety medication on an as needed basis. R38 explained that when he needs the as needed anti-anxiety medication he has feeling of the walls closing in. R38 explained that the motor vehicle accident had changed his life totally and that he was still having a hard time with all the change in his life. R38 explained that he had tried non- pharmacological interventions, in the past, put could not explain what non-pharmacological interventions he had tried. Review of the R38's medical record demonstrated that he was receiving Buspirone HCL (hydrochloride) 5 milligrams (MG) one tablet three times a day. R38 had physician order, started 07/07/2023, for Ativan 0.5 mg every 6 hours as needed for anxiety for 14 days. R38's medical record also demonstrated past orders for Ativan 0.5mg for anxiety for 14 days, started on 6/7/2023 and 07/07/23. R38's medical record demonstrated that he had received regular contracted psychiatric services 06/08/2023, 06/09/2023, 06/22/2023, and 06/29/2023. None of those contracted psychiatric services records demonstrated why R38's anti-anxiety medication had been renewed for another 14 days for the dates of 6/07/2023 and 7/07/2023. No other physician progress notes could be located in the medical record that provided any rational for the renewal of the anti-anxiety medication. Review of R38's Point of Care (POC) behavior tracking since 03/28/2023. Review of R38's plan of care demonstrated a focus state of The resident has potential psychosocial well-being problem r/t (related to) age, depression, anxiety, PTSD (Post-Traumatic Stress Disorder). R38's plan of also demonstrated the resident uses anit-anxiety medications r/t anxiety. No non- pharmacological interventions were list in R38's plan of care. In an interview on 07/20/2023 at 08:04 a.m. Nursing Home Administrator (NHA) A confirmed that R38 did not have behavior monitoring completed since 03/28/2023. NHA A confirmed that there were not any non-pharmacological interventions included in R38's plan of care. She explained that non-pharmacological interventions should have been included on the plan of care. 46955 Resident #17 (R17) Review of the medical record revealed that Resident #17 (R17) was admitted to facility on 4/5/23 with diagnoses including schizophrenia, unspecified protein-calorie malnutrition, type 2 diabetes mellitus, unspecified dementia, and history of stage 3 pressure ulcer of left heel. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/23 revealed that R17 was rarely/never understood with staff assessment for mental status reflecting short and long-term memory problems and severely impaired cognitive skills for daily decision making. Section G of the same MDS indicated that R17 required two-person extensive assist with bed mobility and Section M indicated that R17 was at risk of developing pressure ulcers but was not on a turning/repositioning program. In an observation and interview on 7/18/23 at 9:40 AM, R17 was observed lying in bed, on back, with head of bed at an approximate 30-degree angle. R17 was dressed in a facility gown, observed to have legs extended straight out with two pillows positioned under lower legs with right heel observed to be hanging over the edge of the pillows and left heel resting on mattress to left of pillows. A white, bordered gauze dressing was observed to be securely adhered to R17's right heel. R17 responded to questions with unintelligible, garbled, rambling speech. In observations on 7/18/23 at 10:45 AM and 11:35 AM, R17 was again observed lying in bed, on back, with head of bed at an approximate 30-degree angle. R17's legs remained extended straight out with two pillows positioned under lower legs with right heel observed to be hanging over the edge of the pillows and left heel resting on mattress to left of pillows. In an observation on 7/18/23 at 4:34 PM, R17 was observed lying in bed, on back, with head of bed elevated at an approximate 15-degree angle. R17's legs were observed to be extended straight out with one pillow positioned under lower legs with both heels noted to be resting directly on mattress. Review of R17's medical record completed with the following findings noted: Skin Assessments dated 6/6/23 and 6/13/23 indicated that R17 was free from existing or new abnormal skin areas. Skin assessment dated [DATE] indicated that R17 had a new abnormal skin area described as right heel red and that a treatment was initiated with no additional assessment information noted. Skin assessment dated [DATE] indicated that R17 had existing abnormal skin areas at right heel described as an unstageable blister treatment in progress and at left heel described as an unstageable blister treatment in progress with no additional assessment information noted for either alteration. Skin assessment dated [DATE] indicated that R17 had existing abnormal skin areas at left heel described as a re absorbed blister, at right heel described as blister treatment in progress, and other described as rt (right) great toe, treatment in progress with no additional assessment information noted for any of the alterations. Skin assessment dated [DATE] indicated that R17 had existing abnormal skin areas at right and left heel with no additional assessment information noted for either alteration. Review of Physician Assistant Encounter Note dated 6/20/23 stated, .Chief Complaint/Nature of Presenting Problem: Diabetes, skin evaluation .History of Present Illness .Nursing requesting evaluation secondary to left heel issues possible early skin wound. No open areas no pain .Physical Exam .Skin .Left heel with area of boggy skin no open area .Plan .Skin left heel we will treat with Skin-Prep (a liquid that forms a transparent film over the skin to protect it) cover with border gauze encourage movement . Further review of note included no assessment information pertaining to R17's right heel. Braden Scale for Predicting Pressure Sore Risk dated 4/5/23, 4/12/23, 4/19/23, 4/26/23, 7/6/23 reflected scores of 11-12 which indicated that R17 had High Risk for skin breakdown. Review of R17's Comprehensive Care Plans was noted to include a Care Plan Focus which stated, (R17's name) has potential impairment skin integrity of the following location heels and bony prominence with a 4/5/23 initiated and 6/20/23 revised date and a Care Plan Goal which stated, (R17's name) will have no complications related to skin impairment through review date with a 4/5/23 initiated and 6/20/23 revised date. The only 2 associated Care Plan Interventions stated, Educate resident/family/caregivers of causative factors and measures to present skin injury and Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface with a 4/5/23 initiated date for both. No Care Plan Interventions noted pertaining to the repositioning of R17 or the offloading/floating (relief of pressure) of R17's heels. Further review of all Care Plans included no Care Plan Focus that identified the actual skin alteration noted to R17's right heel on 6/22/23. Review of R17's Kardex (tool used by the Certified Nurse Aide to guide them as to the care needs of a specific resident) indicated, BED MOBILITY: Total with assist of (2) staff members but provided no guidance as to frequency of repositioning and offloading/floating of R17's heels while in bed. Review of R17's Tasks included Task: MONITOR-Floating Heels with the follow up question, Were resident's heels floated while in bed? with multiple dates during the 6/20/23 through 7/19/23 period not noted to be signed out by the Certified Nurse Aide as completed each shift including 6/24/23 (signed out at 2:59 PM and 8:40 PM), 6/26/23 (signed out at 5:10 PM), 6/27/23 (signed out at 8:34 AM and 3:33 PM), 7/8/23 (signed out at 1:55 PM and 8:59 PM), 7/12/23 (signed out at 8:53 AM and 5:09 PM), and 7/18/23 (signed out at 11:44 AM and 4:54 PM). In an interview on 7/19/23 at 8:42 AM, Licensed Practical Nurse/Minimum Data Set Coordinator/Unit Manager (LPN/MDS Coordinator/UM) G stated that she was the facility's sole MDS Nurse, was the UM on C Unit, and helped to oversee both A and D wings. LPN/MDS Coordinator/UM G confirmed familiarity with R17, stated that she had a history of pressure ulcers at heels and buttocks prior to facility admission but denied knowledge of current alterations in R17's skin integrity. LPN/MDS Coordinator/UM G stated that upon R17's facility admission, implemented precautions included turning/repositioning in bed, pressure reducing mattress, and floating of heels while in bed and that these precautions would be listed as interventions on R17's potential for impaired skin integrity care plan. Upon review of R17's Care Plan Focus (R17's name) has potential impairment to skin integrity, LPN/MDS Coordinator/UM G stated that although these interventions were not indicated on R17's care plan, floating of heels and turning/repositioning in bed were every shift tasks that the assigned CNA needed to sign out when completed and that would be how the aides were alerted to R17's specific care needs. LPN/MDS Coordinator/UM G stated that the expectation was for R17's bilateral heels to be offloaded with pillows or a foam elevating device, at all times, while in bed. In an interview on 7/19/23 at 9:52 AM, LPN/Wound Nurse D stated that she was Wound Care Certified, had recently submitted her resignation as the facility wound nurse, but that was continuing to assist in the role of wound nurse until a new one was hired. LPN/Wound Nurse D stated that she was prompted to assess R17's right heel on 6/22/23 as was alerted by LPN/MDS Coordinator/UM G of a small open area to R17's right heel. LPN/Wound Nurse D stated that she recalled R17's right heel presenting with a small, superficial slit and that upon physician notification received an order for xeroform treatment. LPN/Wound Nurse D stated that she would generally complete a nurse's progress note to reflect right heel alteration, physician notification, and treatment order but upon review of R17's medical record, confirmed that she did not see any documentation. LPN/Wound Nurse D further stated that as the wound nurse, she would have generally completed a weekly wound assessment on R17's right heel wound but that she had routinely been assigned as a floor nurse on her normal wound assessment days and therefore R17's initial and weekly assessments were missed. Additionally, LPN/Wound Nurse D stated that upon identification of R17's right heel alteration that she would have generally updated R17's care plan to reflect an actual alteration in skin integrity as well as reviewed and revised interventions. Upon review of R17's current potential impairment in skin integrity care plan, LPN/Wound Nurse D stated that the potential impairment care plan generally contained preventative interventions and that she would have also included the interventions in the actual alteration in skin integrity care plan as stated that the certified nurse aides used the Kardex that was generated by the care plan as guidance to each individual resident's care needs. In an interview on 7/19/23 at 10:42 AM, Certified Nurse Aide (CNA) H confirmed that she was R17's assigned CNA along with a second CNA on the unit and that she wasn't real familiar with R17 as only worked C Unit, where R17 resided, about once per month. CNA H stated that R17 required assist with all aspects of care and that the nurse had provided instruction to her that morning to place pillows underneath her lower legs when she was in bed so that R17's heels were off the mattress. CNA H stated that she referenced a resident's Kardex for guidance as to the required care needs when not familiar with a resident and confirmed that she would not have known to offload R17's heels as there was no indication on the Kardex to guide staff to do that. In an interview on 07/19/23 at 10:57 AM, Registered Nurse/Regional Director of Clinical Services I stated that a facility wide skin sweep would be conducted to identify any additional skin alterations that were not currently being followed and a chart review to ensure that care plans were up to date. Review of the facility policy titled Comprehensive Care Plans with a 6/30/2022 revised date stated, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs .Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preference .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment .

This citation pertains to intake MI00132648, MI00132380, MI00132653, MI00131631, MI00132101 and MI00132397. Based on observation, interview, and record review, the facility failed to protect the resident ' s right to be free from abuse including sexual abuse by another resident in one of 20 residents reviewed for abuse (R1, R2 R3, R10), , resulting in Resident #2 observed visibly upset, anxious and required anti-anxiety medication following the incident. Findings include: Resident #1 (R1) On 12/06/22 at 11:45 AM R1 was observed sitting in a wheelchair, wearing pajamas, hair not combed, and eating lunch in the dining room. R1's significant change Minimum Data Set (MDS) dated [DATE] indicated he admitted to the facility on [DATE] and was readmitted from a psychiatric hospital on 11/08/22. The same MDS indicated R1's cognition was severely impaired, required limited assistance with eating and locomotion. Physician progress note dated 11/09/22 at 11:32 AM indicated R1 had a history of schizo-affective disorder (comination of symptoms), bipolar disorder, cognitive communication deficit, dementia, and anxiety. Resident #2 (R2) R2's admission MDS assessment dated [DATE] indicated she was admitted to the facility on [DATE] and had a Brief Interview for Mental Status for Mental Status (BIMS, a performance-based screening tool for cognition) score was 11 (08-12 indicated moderate impairment). Psychiatry notes dated 9/29/22 revealed R2 was seen for follow-up and the exam indicated she was alert, calm, attentive and not in acute distress. R2's judgement was impaired and was able to follow conversation. The assessment and plan included supportive therapy to help improve current mood and functioning. R2's MDS dated [DATE] revealed she was discharged to a community setting. Progress note dated 9/30/22 at 9:32 AM indicated R2 had diagnoses of schizo-affective disorder, bipolar, dementia, post-traumatic stress disorder (PTSD), and depression. In review of the facility's 5-day investigation of an allegation of resident-to-resident sexual abuse that occurred on 10/12/22 at 12:10 PM; the facility was notified by staff that they had reason to believe R1 had touched R2 in her private areas; R2 was visibly upset afterward, anxious and required medication. Witness statement dated 10/12/22, indicated Certified Nurse Assistant (CNA) K witnessed R1 grab R2's vagina from behind. In an interview on 12/06/22 at 2:20 PM, CNA K stated she witnessed the incident that occurred between R1 and R2 on 10/12/22. R2 was standing, facing the nurses' station; R1 came up behind R2 and grabbed her over her clothing and between her legs. R1 was re-directed and let go of R2. R2 was visibly upset. CNA K stated before this event, on a different day, she had witnessed R2 sitting on R1's lap, but the incident on 10/12/22 had taken her by surprise. In review of R1's progress notes dated 10/12/22, he was transferred to the hospital following the incident. Social Services Progress Note dated 10/13/22 at 2:45 PM indicated R2 was seen in follow-up to incident with another resident on the unit the day before. The same note indicated R2 was anxious on the same day as the note and was exit seeking. Ativan was administered by the nurse at 1:15 PM to help with anxiety. The same note revealed R2 was .unable to express appropriately to any great extent but just says it's not a good day. Plan was to refer to psychiatric services to address needs. There were no Social Services progress notes in R2's record to assess/address residual effects from the 10/12/22 incident on 10/14/22 or 10/15/22. Nurses' Notes dated 10/17/22 at 10:31 AM, revealed R2 was asked to use walker or take a seat for safety and R2 threw the walker against the wall. In review of R2's October 2022's Medication Administration Record, Ativan 0.5 milligrams (mg) was ordered every 8 hours, as needed (PRN), for 14 days on 10/05/22. R2 did not require PRN Ativan from 10/05/22 through 10/08/22 and did not need Ativan PRN on 10/10/22 and 10/11/22. Prior to the 10/12/22 incident R2 had used Ativan 2 times on 10/09/22 and at 4:35 AM on 10/12/22. Ativan was administered on 10/12/22 at 12:46 PM following the incident with R1, 10/13/22 at 4:46 AM and again at 1:16 PM, 10/14/22 at 9:40 AM, 10/15/22 at 10:45 AM, 10/17/22 at 2:43 PM, 10/18/22 at 1:26 PM, and 10/19/22 at 7:18 PM. Social Services Progress Note was dated 10/20/22 at 9:28 AM, indicated the Guardian requested R2 to be discharged the following Sunday. Facility investigation of incident that occurred on 10/12/22 at 10:10 PM, revealed R1 was sent to the hospital for a neuropsychiatric care. The same investigation indicated based on R1's dementia diagnosis and cognitive disabilities, they did not feel that it was willful and did not substantiate abuse. Director of Nursing (DON) B was interviewed on 12/06/22 at 2:15 PM and stated they were not able to review camera footage of the 10/12/22 incident between R1 and R2, because the cameras were not able to record and had needed to be fixed since July 2022. Nursing Home Administrator (NHA) A was interviewed on 12/13/22 at 11:19 AM and stated residents were followed for 72 hours after an incident for any behaviors and psychosocial distress and documentation was expected. 34705 Resident #2(R2) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R2 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, bipolar disorder, dementia, post-traumatic stress disorder, major depressive disorder, hypertension (high blood pressure), chronic obstructive pulmonary disease, and muscle weakness. The MDS reflected R2 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist with bed mobility, transfers, locomotion on unit, dressing, toileting, and two person physical assist with hygiene. The MDS reflected R2 had no behaviors including verbal or physical including discharge MDS, dated [DATE]. Resident #3(R3) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R3 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, bipolar disorder, traumatic brain injury, diabetes mellitus, congestive heart failure, anxiety disorder, hypertension (high blood pressure), chronic obstructive pulmonary disease, and lack of coordination. The MDS reflected R3 had a BIM (assessment tool) score of 8 which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist with transfers, walking, dressing, toileting, hygiene and bathing. Resident #10(R10) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R10 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included cerebral infarction, schizoaffective disorder, dementia, major depressive disorder, hypertension (high blood pressure), extrapyramidal and movement disorder. The MDS reflected R10 had a BIM (assessment tool) score of 00 which indicated her ability to make daily decisions was severely impaired, and she required two person physical assist with bed mobility, transfers, toileting, and hygiene and one person physical assist with locomotion on unit, dressing and showering. Continued review of the MDS reflected R10 vision was not impaired. The MDS reflected R10, dated 10/27/22, reflected death in facility. Review of the complaint, reported to the State Agency 10/20/22, reflected R2 had several bruises with unknown cause. Review of the witnessed Facility Reported Incident(FRI), dated 9/16/22 at 6:00 p.m., reflected R10 tightly grabbed R2 arm and dug nails into skin resulting in injuries that included bruising and two crescent shaped skin scratches. The FRI named R10 as the perpetrator. Review of the witnessed FRI, dated 10/14/22 at 6:40 a.m., reflected R2 and R3 had a verbal altercation that developed into physical altercation on the C hallway near the nurse's station. The FRI reflected named R3 as the perpetrator and indicated the incident was witnessed by Housekeeper (HK) M. The report reflected, type of alleged incident: Mistreatment . During an observation and interview on 12/6/22 at 11:25 a.m., C hall was noted to be a locked unit with one Nurse and one Certified Nurse Aid observed on the unit. Registered Nurse (RN) L, who was present, reported there was another CNA on break who was currently working on C hall. R3 was observed sitting in Dining Room with several other Residents and appeared anxious and asking why this surveyor was present. The medication cart was parked by entrance to Dining Room, across from Nurse Station door with items top of cart including heavy medal pill crusher, medication and drinking cups. Review of the requested FRI investigation, dated 10/14/22 at 6:40 a.m., reflected a witness statement written by HK M and signed by Nursing Home Administrator(NHA) A. The statement reflected, I was cleaning the C-hall dining room & [named R2] was sitting in a chair next to the med cart & [named R3] was sitting in the wheelchair near the door of the nurse's station. They were having some type of argument that I was not paying attention to, when thighs started to escalate. [Named R3] approached [named R2] and grabbed her by her feet & started hitting her & taking her shoes off. [Named R2] started kicking and flailing and ended up kicking [named R3] directly in the face. [Named R3] then grabbed a large metal object off the med cart and started hitting [named R2] with it. At this point I stepped in and tried to get them to stop & I took the metal object from [named R3] and set it back on the med cart. As soon as I turned around, they resumed fighting, which started with [named R3] grabbing at [named R2] breasts and squeezing & pulling tightly. When that happened I went to go find someone to help, which was [named Scheduler N]. They continued fighting until other arrived. Continued review of the same investigation indicated based on the dementia diagnosis and cognitive disabilities for the resident involved, they did not feel that it was willful and did not substantiate abuse. During an interview on 12/7/22 at 8:25 a.m., HK M witnessed resident to resident verbal and physical altercation on 10/14/22 at 6:40 a.m. HK M reported R3 and R2 were located by the C-hall nurse station and started yelling at each other and escalated to throwing punches. HK M reported did not recall who started verbal altercation and reported R3 had history of over reacting and R3 pushed R2 with hands and R2 started kicking then R3 picked up metal object from medication cart and hit R2 with it several times to front of left shoulder area. HK M reported no other staff present at the time and had to leave the locked unit to get help after failing to deescalate the situation. HK M reported Scheduler N was located at the Main Nurse Station, outside the locked c-hall, who assisted to separate R2 and R3. HK M reported both residents appeared upset. HK M verified witness statement. HK M reported did not recall nurse present on c-hall prior to altercation and reported was also working on d-hall at the time and reported was unsure who Certified Nurse was at the time. HK M reported usually worked the c-hall three to four times weekly. During an interview on 12/7/22 at 9:10 a.m., Scheduler N reported had worked at the facility for nine years and was currently the scheduler, medical records and also a CNA. Scheduler N verified assisted HK M separate R2 and R3 after a physical altercation on 10/14/22 on unit C. Scheduler N verified was sitting at the Main Nurse Station, outside of the locked c-hall, when HK M exited the unit and requested assistance. Scheduler N reported no other staff present at the time of the incident and verified residents were separated. During an interview on 12/7/22 at 9:15 a.m., HK M reported had worked at the facility for nine months after transferring from another facility in the area. HK M reported did not receive abuse training from current facility and was able to report 3 of 8 types of abuse. HK M reported not aware of any resources available to utilize. HK M reported 10/14/22 resident to resident altercation was an example of an allegation of abuse and was reported to management. During an interview on 12/7/22 at 9:25 a.m., Scheduler N reviewed the schedule and reported Unit Manager(UM) I was the nurse from 6:30 a.m. to 9:00 a.m. and CNA O was the aid on the C-hall. Scheduler N reported Director of Nursing (DON) B had been the night nurse for the entire facility until 6:30 a.m. and CNA P had been only night CNA on c-hall. During an interview on 12/7/22 at 9:35 a.m., UM I reported had worked at the facility for two months and verified worked 10/14/22 from 6:30 a.m. to 9:00 a.m. UM I reported was not aware of R2 and R3 verbal and physical altercation on c-hall at 6:40 a.m. UM I reported worked on d-hall from 6:30 a.m. to 9:00 a.m. and reported usually obtained two resident blood sugars around breakfast time on c-hall before breakfast. UM I reported unsure if she had been on c-hall prior to altercation and again reported had not knowledge of R2 and R3 physical altercation on 10/14/22 at 6:40 a.m. During an interview on 12/7/22 at 10:41 a.m., Payroll Staff (PR) Q provided missed punches for DON B on 10/13/22 at 6:30pm to 10/14/22 at 7:00am. PR Q provided missed punches for UM I on 10/14/22 at 6:30am to 10:50am. During a telephone interview on 12/7/22 at 10:52 a.m., CNA R reported was not involved in R2 and R3 altercation on 10/14/22 at 6:40 a.m. CNA R reported had worked d-hall night shift until 10/14/22 at 7:00 a.m. CNA R reported frequent resident altercation on, psych unit (hall c) that often occur in the morning hours and reported R3 had frequent history of provoking other residents. During a telephone interview on 12/7/22 at 11:12 a.m., CNA O reported was not present for R2 and R3 altercation on 10/14/22 at 6:40 a.m. CNA O reported had heard about incident after arriving for shift on 10/14/22 at 7:00 a.m. and did not recall any changes in interventions to prevent further altercations. During a telephone interview on 12/7/22 at 11:23 a.m., RN E reported was not working c-hall on 10/14/22 at the time of R2 an R3 altercation and recalled UM I present at Main Nurse Station who was just getting report related to a call in and reported was maybe her first day. RN E reported was present for day shift on another hall but had good rapport with R3 and assisted after the altercation with attempts to defuse R3. Review of R3 Electronic Medical Record, dated 5/28/22 to 10/14/22, reflected R3 had 10 documented physical altercations with other residents on c-hall. Review of R3 Care Plans, dated 5/28/22 to current(12/7/22), reflected, The resident has impaired cognition and difficulty making decisions r/t a TBI and Schizoaffective Disorder and Bipolar Disorder Revision on: 12/11/2020 . Cue, reorient and supervise as needed. Date Initiated: 12/11/2020 .The resident has potential to be physically aggressive or agitated r/t Anger, History of harm to others, Poor impulse control .Goal .The resident will not harm self or others through the review date. Date Initiated: 08/11/2021 Revision on: 04/05/2022 .Interventions .Resident given soft stuffed animal to hit with when upset. Date Initiated: 06/14/2022 . Continued review of the Care Plans reflected no evidence of revision of interventions or new interventions added with exception 6/14/22 intervention for R3's 11 documented physical altercations with other residents including R2 on 10/14/22. During a telephone interview on 12/7/22 at 4:06 p.m., R2 Case Worker(CW) S reported was R2 and R3 Case Worker for local mental health organization. CW S reported between her and another case worker they visit facility weekly. CW S reported they make several recommendations for residents but facility has had issues with no follow up related to implementing recommendations possibly related to staffing changes but continue to make recommendations. CW S reported activities for residents on c-hall had been a concern but getting slightly better. CW S reported aware of recent change in facility Social Worker and reported every consult visit sent to facility staff in PDF form after each visit. CW S verified 12 missing consult notes for R3 since September. R3 facility EMR reflected no evidence of (local mental health) consult since 9/7/22. During an observation on 12/8/22 from 8:20 a.m. to 10:00 a.m., on the locked c-hall, reflected one nurse, RN T and one aid, CNA D for day shift 6:30 a.m. to 2:30 p.m. Continued observation reflected UM/MDS H in and out of unit, Social Worker(SW) F in and out of unit, and male staff wearing street clothes assisted a resident back to room from Dining Room in wheelchair with no foot pedals at 8:35 a.m. and then exited unit. At 8:56 a.m. two residents noted wandering hall with one resident who appeared very anxious repeatedly asking if it was time to smoke. UM H, CNA D and RN T off the unit at that time for more than 5 minutes with SW F as only staff on the unit(not observed). CNA D returned to the unit at 9:03 a.m., Activity staff entered the unit at 9:04 a.m. with RN T and tended to resident who wanted to smoke. Housekeeping entered unit at 9:08 a.m. and UM H returned at about 9:25 a.m. During a telephone interview on 12/8/22 at 8:42 a.m., CNA P reported worked night shift 10/13/22 to 10/14/22 on c-hall as only cna staff and DON B was only nurse on night shift for entire facility. CNA P reported staff document behaviors in tasks. CNA P reported was unsure who she gave report to on the morning of 10/14/22 but was not present at time of R2 and R3 verbal and physical altercation. When ask how staff prevent resident to resident altercations CNA P reported she tried to keep residents apart and reported did not recall change in R2 or R3 interventions after 10/14/22. CNA P reported did care for R2 and R3 after the 10/14/22 altercation and reported R2 had scratches on chest. In review of the facility's 5-day investigation of an allegation of resident-to-resident sexual abuse that occurred on 10/12/22 at 12:10 PM; the facility was notified by staff that they had reason to believe male resident had touched R2 in her private areas; R2 was visibly upset afterward, anxious and required medication. Witness statement dated 10/12/22, indicated Certified Nurse Assistant (CNA) K witnessed male resident grab R2's vagina from behind. In review of R2's October 2022's Medication Administration Record, Ativan 0.5 milligrams (mg) was ordered every 8 hours, as needed (PRN), for 14 days on 10/05/22. R2 did not require PRN Ativan from 10/05/22 through 10/08/22 and did not need Ativan PRN on 10/10/22 and 10/11/22. R2 had used Ativan 2 times on 10/09/22 and at 4:35 AM on 10/12/22. Ativan was administered on 10/12/22 at 12:46 PM following the incident with male resident, 10/13/22 at 4:46 AM and again at 1:16 PM, 10/14/22 at 9:40 AM(after resident-to-resident physical altercation at 6:40 a.m.that day), 10/15/22 at 10:45 AM, 10/17/22 at 2:43 PM, 10/18/22 at 1:26 PM, and 10/19/22 at 7:18 PM. Review of R2 EMR, dated 10/14/22 through 10/18/22, reflected no evidence that SW assessed/address residual effects from the 10/14/22 incident including Progress Notes. Continued Review of EMR reflected no evidence of completed skin assessments between 10/14/22 and 10/17/22(included existing abnormal skin with no documentation). The EMR reflected no evidence of Pain assessment between 10/14/22 and 10/23/22(discharge). During an interview on 12/8/22 at 4:23 p.m., DON B reported had been DON at the facility for 18 months with three different Nursing Home Administrators. DON B reported behaviors reviewed daily Monday through Friday at morning meetings that consisted of clinical managers. DON B reported morning meetings were the same as IDT meetings and all events were reviewed and if any changes in immediate interventions were need they add IDT Progress Notes and add interventions including on Care Plans. DON B reported would expect interventions to be added to care plans and implemented after each altercation to prevent further altercations. This surveyor requested DON B provided evidence of what measures were taken by facility to prevent resident to resident altercation. DON B reported R3 had incentive program started but was unsure where it was documented with frequent changes. DON B would expect SW to follow up with residents after each allegation of abuse including resident to resident altercations for 72 hours and document in Progress Notes. DON B reported noticed yesterday SW had not completed 72 hour follow up assessments for residents after allegations of abuse when reviewing surveyor requested documents and education was provided to SW F. DON B reported SW F had worked at the facility for three months with no prior SW experience. DON B reported she was covering role of SW as well as DON with regional staff to cover behavior unit(c-hall). DON B verified had been working to relocate R3 per resident and POA request with documentation for at least past six months. Request for evidence of follow up. DON B reported would expect consulted mental health documents to be in resident EMR prior to next visit or 48 hours. DON B reported they have access to reports but had not educated new SW on how to obtain or if she knows she is responsible for obtaining records. DON B verified R3's last record of community mental health consult visit was 9/7/22 and reported R3 had been seen several times since then. DON B reported had provided all staff with Dementia training and would provide evidence. Review of provided Dementia Training Report, dated 12/8/22, reflected no evidence of Dementia Training for HK M. In review of the facility's 5-day investigation of an allegation of resident-to-resident physical abuse that occurred on 9/16/22 at 6:00 PM; R10 was moving through out the dining room and hall and R2 was sitting in the dining room who R10 rolled past R2 and then lounged and grabbed R2 arm. Skin and pain for R2 reflected pain of 4 to bilateral legs( residents normal pain) and R2 had 2 crest shaped scratches with bruising noted. Review of R2 Physician Progress Note, dated 9/19/22, reflected, CHIEF COMPLAINT: Resident-to-resident incident. HISTORY OF PRESENT ILLNESS: [AGE] year-old female here for long-term care, locked psych unit. Patient with known history of dementia, bipolar disorder, schizoaffective disorder, bipolar type, PTSD, major depressive disorder. Patient had a resident-to-resident incident, was grabbed on her right arm via fell ow resident which gouged arm pretty hard. Patient does not remember incident occurring. Patient confused at baseline .Skin: Warm and dry. Patient does have deep nail marks from another resident on her right forearm .IMPRESSION AND PLAN: 1. Schizoaffective disorder, bipolar type. 2. Fingernail gouging. 3. Bipolar disorder. 4. Major depressive disorder. Patient with resident-to-resident incident, had fingernail gouging from another resident on right forearm. We will monitor the site closely . Review of R2 Physician Progress Notes, dated 9/21/2022 at 11:58 a.m., reflected, HISTORY OF PRESENT ILLNESS .Patient is with recent injury to right arm, had nails scratched from another resident. Skin appears more red and tender . IMPRESSION AND PLAN: 1. Skin infection right forearm .Patient did have recent injury to right forearm from another resident ' s nails appears infected. We will start doxycycline 100 mg b.i.d. and monitor. Site red, swollen, tender. Injury with human nails, high risk for infection. We will start antibiotic and monitor . Review of R2 Skin assessment, dated 9/16/22 through 10/20/22, reflected on 9/16/22 R2 had two new abnormal skin areas to right hand purple discoloration with scab near thumb and right posterior forearm with 2 crescent shaped skin tears and purple discoloration. The Skin Assessment, dated 9/17/22, 9/24/22, 10/6/22, 10/10/22, reflected no existing abnormal skin areas. The Skin Assessments, dated 10/1/22 and 10/12/22, reflected R2 had bruising and discoloration right arm. The Skin Assessments, dated 10/12/22, and 10/17/22 and 10/20/22 reflected existing abnormal skin areas with no documentation completed. The Skin Assessments did not reflect increased redness and tenderness or signs of infection as indicated in Physician assessment dated [DATE]. Review of the Physician Orders, dated 9/21/22, reflected, Doxycycline Hyclate Tablet 100 MG Give 1 tablet by mouth two times a day for Skin infection for 7 Days. During an interview on 12/9/22 at 12:05 p.m., Regional staff V reported had been at facility for two months and had reviewed all FRI and tracked and identified need for full time activity staff on c-hall. During a telephone interview on 12/8/22 at 12:26 p.m., CNA W reported R10 and R2 had a resident-to-resident altercation on 9/16/22 at 6:04 p.m. CNA W reported there was another CNA on c-hall that was in another resident room. CNA W reported had her back turned and heard R2 scream for help from the Dining Room, turned and saw R10 grabbing at R2 arms. CNA W attempted to separate residents with moderate about of bleeding from R2 right arm from R10 nails that had gouged into skin and had to pry one finger off at a time. CNA W reported Nurse not on the unit at the time of the incident. CNA W reported only intervention implemented was R10 nails trimmed after incident. CNA W reported had never observed 1:1 for any residents on c-hall. CNA W reported times when she had to work c-hall by alone and nurse had to splits with d-hall. CNA W reported very stressful for one person related to residents with behaviors on c-hall. Review of the Nursing Working Schedule, dated 9/16/22, reflected one nurse split between c-hall and d-hall at time of resident-to-resident physical altercation between R10 and R2. During an interview on 12/8/22 at 3:20 p.m., Regional staff V and UM H reported aware increased, frequent FRI and reviewed with plan to add full time activity staff for 2023. UM H reported after creating surveyor requested time line for R3 noticed times and locations of resident-to-resident altercations that occurred mostly during meal time and discussed with team possible interventions to implement and possible plan to use both common areas for two Dining Rooms on c-hall instead of one. During a telephone interview on 12/8/22 at 4:51 p.m., RN X reported several residents on c-hall have manipulative behaviors and reported 12-15 residents on unit will gang up on you. RN X reported not safe for one staff to control entire c-hall on own and resident-to-resident altercation occur when nurse staff split between C and D halls. RN X reported nurses had been told they did not have document abnormal exiting skin on weekly assessments if it had been documented prior, only new skin issues. During a telephone interview on 12/8/22 at 5:30 p.m., RN T reported verbal cussing every day on c-hall and staffing had improved over past 30 days, however, times with one cna and nurse spilt between C and D hall. RN T reported medical event and resident-to-resident altercation occur at same time on both halls and impossible for nurse to be in two places at one time. RN T reported R2 son had questioned her related bruises and marks on R2 arms and reported she reassured him reports had been completed related to resident-to-resident incidents including when R10 grabbed R2 arm and dug her nails into R2 arm that caused open wounds and bruising. Review of R2 EMR dated, 7/25/22 through 10/23/22(admission to discharge), reflected R2 had no evidence of monthly behavioral meeting notes. During an interview on 12/13/22 at 9:10 a.m. SW F reported had worked at the facility about three months. SW F reported was familiar with R3 and reported R3 had behaviors that included cussing, yelling and often difficult to redirect and occasionally able to redirect with calls to sister. SW F reported did not have any involvement with R2 and R10 resident-to-resident altercation on 9/16/22 or R2 and R3 resident-to-resident altercation on 10/14/22. SW F reported received training from prior part time SW. SW F reported was informed by DON B within past week, need to follow up with residents for three days after an allegation of abuse or resident-to-resident altercation and document in Progress Notes to assess for both emotional and physical residual of event. SW F reported was not aware of that requirement prior to last week. SW F reported if community mental health involved in resident care facility has a monthly behavior meeting and should be documented. SW F verified no behavior meeting notes for R2 and reported prior SW was part time between another facility and may not of had time to complete. When SW F was quarried what was was being done to protect other resident on c-hall from R3 on-going physical altercations, SW F reported plan to continue to focus on R3 and DPOA request to transfer to another facility because nothing else had worked. SW F reported c-hall was not a homelike environment related to daily yelling, cussing and repeat resident-to-resident events. During an interview on 12/13/22 at 11:20 a.m., NHA A reported had worked at the facility since 7/18/22 and was also the facility Abuse Coordinator. NHA A reported R3 FRI were not substantiated because investigations did not reflect evidence of contact including staff eye witness events and recording devices have not been functioning. NHA A reported they have cleared congestion in c-hall at nurses station into dining room by removing medication cart one month ago. NHA A they have implemented mental health training for all staff, re-educated all staff on abuse, and continue to work on activity engagement. NHA A reported monthly meetings with consulting mental health groups and reported would expect facility to implement consulting mental health recommendation and have records of consults in resident records within 7 to days post visits. NHA A reported did not think meetings were happening on regular basis with current plans to have SW F and Medical Records N responsible for that task moving forward. During an interview on 12/13/22 at 1:15 p.m. DON B reported skin assessments should be completed through including existing skin alteration.

This citation pertains to intakes MI00132318, MI00132309, MI00130769, MI00130733, MI00132653, MI00131631, MI00132101 and MI00130749. Based on observation, interview, and record review the facility failed to effectively supervise residents and implement effective interventions in 6 of 20 residents reviewed for abuse (Resident #1, #2, #3, #5, #10, #16, #17), resulting in continued resident to resident altercations. Findings include: Resident #1 (R1) On 12/06/22 at 11:45 AM R1 was observed sitting in a wheelchair, wearing pajamas, hair not combed, and eating lunch in the dining room. R1's significant change Minimum Data Set (MDS) dated [DATE] indicated he admitted to the facility on [DATE] and was readmitted from a psychiatric hospital on 11/08/22. The same MDS indicated R1's cognition was severely impaired, required limited assistance with eating and locomotion. Physician progress note dated 11/09/22 at 11:32 AM indicated R1 had a history of schizo-affective disorder (combination of symptoms), bipolar disorder, cognitive communication deficit, dementia, and anxiety. Resident #2 (R2) R2's admission MDS assessment dated [DATE] indicated she was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS, a performance-based screening tool for cognition) score of 08 (08-12 Moderate Impairment). Progress note dated 9/30/22 at 9:32 AM indicated R2 had diagnoses of schizo-affective disorder, bipolar, dementia, post-traumatic stress disorder (PTSD), and depression. Investigation summary dated 8/13/22 at 3:24 PM indicated R1 [NAME] a glass of iced tea at R2, hitting her on the left side of her head. Resident #3 (R3) R3's MDS dated [DATE] revealed a BIMS score of 08 (08-12 Moderate Impairment). According to the facility 5-day investigation, date of incident 10/07/22 at 5:50 PM, R3 had diagnoses of schizoaffective disorder-bipolar Type, traumatic brain Injury, and generalized anxiety disorder. The same investigation revealed R1 hit R3 on top of her head at approximately 5:50 PM on 10/07/22 in the hallway, and there were not any witnesses. The same investigation indicated the nurse had responded to residents yelling. The incident report dated 10/07/22 at 5:50 PM, indicated predisposing environmental factors included crowding. Resident #5 (R5) R5's MDS dated [DATE] revealed she had a BIMS score of 08 (08-12 moderate cognitive impairment). Witness statement dated 10/11/22 indicated R5 yelled at R1 and R1 threw juice in R5's face. In review of R5's progress notes, there were no social services daily follow-up notes for 72 hours following the altercation. R5 was interviewed on 12/07/22 at 3:45PM and she recalled juice thrown in her face and stated there was a mean guy there. R5 became tearful and stated her nerves could not take much more. Resident #16 (R16) R16's MDS dated [DATE] revealed a BIMS score of 06 (00-07 severely impaired cognition). According to witness statement dated 12/01/22 at 9:30 AM, the nurse walked up to the nurse's station and was informed by residents, that R1 hit R16. The same statement indicated the nurse asked R16 she had been hit, and she replied yes and started crying. The same statement indicated R1 and R16 began kicking each other and were separated. The same statement indicated R16 was taken back to her room continued crying. In review of R16's progress notes, there were no 72-hour follow-up notes from social services. In review of R1's progress notes, there was not any follow-up from social services following the incident with R16 on 12/01/22. Social Services (SS) F was interviewed on 12/13/22 at 9:10AM and stated she had started in the position in September 2022. SS F stated she had not been trained to follow-up on resident-to-resident altercations for 3 days for assessment of residual effects until a couple of weeks prior to this interview. SS F stated she did not recall the incident between R1 and R3 on 10/07/22. Nursing Home Administrator (NHA) A was interviewed on 12/13/22 at 11:19AM and stated the facility cameras were not useful in investigations of resident-to-resident altercations because they were not able to record footage, the cameras still required more updates and they had been working on camera updates since July 2022. NHA A stated one of the trends they noted in resident-to-resident altercations, was congestion at the nurse's station, we removed the medication cart from the area last month. NHA A stated she had noticed the dining cart had taken the place of where the medication cart had previously been parked, thus not improving congestion in the nurses station/dining entrance area. 34705 Resident #2(R2) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R2 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, bipolar disorder, dementia, post-traumatic stress disorder, major depressive disorder, hypertension (high blood pressure), chronic obstructive pulmonary disease, and muscle weakness. The MDS reflected R2 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist with bed mobility, transfers, locomotion on unit, dressing, toileting, and two person physical assist with hygiene. The MDS reflected R2 had no behaviors including verbal or physical including discharge MDS, dated [DATE]. Resident #3(R3) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R3 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, bipolar disorder, traumatic brain injury, diabetes mellitus, congestive heart failure, anxiety disorder, hypertension (high blood pressure), chronic obstructive pulmonary disease, and lack of coordination. The MDS reflected R3 had a BIM (assessment tool) score of 8 which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist with transfers, walking, dressing, toileting, hygiene and bathing. Resident #10(R10) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R10 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included cerebral infarction, schizoaffective disorder, dementia, major depressive disorder, hypertension (high blood pressure), extrapyramidal and movement disorder. The MDS reflected R10 had a BIM (assessment tool) score of 00 which indicated her ability to make daily decisions was severely impaired, and she required two person physical assist with bed mobility, transfers, toileting, and hygiene and one person physical assist with locomotion on unit, dressing and showering. Continued review of the MDS reflected R10 vision was not impaired. The MDS reflected R10, dated 10/27/22, reflected death in facility. Resident #16(R16) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R16 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included dysphagia, aphasia, stroke, anoxic brain damage, vascular dementia, hypertension, and major depressive disorder. The MDS reflected R16 had a BIM (assessment tool) score of 6 which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with transfers, dressing, toileting, hygiene and bathing. Resident #17(R17) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R17 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, bipolar disorder, kidney disease, congenital malformation of brain, hypertension, major depressive disorder' The MDS reflected R17 had a BIM (assessment tool) score which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with transfers, locomotion, dressing, toileting, hygiene and bathing. Continued review of the MDS assessments reflected R17 was transferred to the hospital 11/22/22. Review of the witnessed Facility Reported Incident, date 7/5/22 at 10:00a.m., reflected R3 and R17 had been verbally arguing all morning including call each other names. Physical contact was made when R3 struck R17 in head with closed fist. Review of the witnessed Facility Reported Incident(FRI), dated 9/16/22 at 6:00 p.m., reflected R10 tightly grabbed R2 arm and dug nails into skin resulting in injuries that included bruising and two crescent shaped skin scratches. The FRI named R10 as the perpetrator. Review of the witnessed FRI, dated 10/14/22 at 6:40 a.m., reflected R2 and R3 had a verbal altercation that developed into physical altercation on the C hallway near the nurse's station. The FRI reflected named R3 as the perpetrator and indicated the incident was witnessed by Housekeeper (HK) M. The report reflected, type of alleged incident: Mistreatment . Review of R3 Electronic Medical Record(EMR) and requested incident reports for R3, dated 5/28/22 to 11/22/22, reflected R3 had 14 documented physical altercations with other residents on the c-hall. Continued review of the EMR reflected three of the physical altercations occurred with R16 that included; 9/16/22 at 2:30 p.m. when payroll staff observed R3 hitting R16 leg with hand near nurse station; 10/25/22 at 11:00a.m. when two staff from housekeeping/cota observed R3 strick R16 at least three timed with closed fists in arm and call names. The investigation reflected nurse was not on the unit at the time and was working both c and d hall; 11/22/22 at 535 p.m. when staff observed R3 punching R16 in back three to 4 times during the meal. Continued review reflected no Social work follow up after 14 of 14 resident-to-resident physical altercations. During an observation and interview on 12/6/22 at 11:25 a.m., C hall was noted to be a locked unit with one Nurse and one Certified Nurse Aid observed on the unit. Registered Nurse (RN) L, who was present, reported there was another CNA on break who was currently working on C hall. R3 was observed sitting in Dining Room with several other Residents and appeared anxious and asking why this surveyor was present. The medication cart was parked by entrance to Dining Room, across from Nurse Station door with items top of cart including heavy medal pill crusher, medication and drinking cups. During a telephone interview and record review 12/8/22 at 9:34 a.m., Prior DON U reported witnessed physical altercation between R3 and R17 on 7/5/22 and was reported as Facility Reported Incident because R3 made physical contact with R17's head with closed fist. Prior DON U reported immediate interventions was to separate residents and redirect and unable to recall if interventions added. Prior DON U reported they would attempt to separate residents and involve in activities and reported no activites at the time and R3 very impulsive. The facility incident report reflected action as residents educated and seeking activity staff. Review of the facility Working Schedule, dated 7/5/22, reflected one CNA on c-hall and one Nurse split between C and D hall at time of the resident-to-resident event. Review of the requested FRI investigation, dated 10/14/22 at 6:40 a.m., reflected a witness statement written by HK M and signed by Nursing Home Administrator(NHA) A. The statement reflected, I was cleaning the C-hall dining room & [named R2] was sitting in a chair next to the med cart & [named R3] was sitting in the wheelchair near the door of the nurse's station. They were having some type of argument that I was not paying attention to, when thighs started to escalate. [Named R3] approached [named R2] and grabbed her by her feet & started hitting her & taking her shoes off. [Named R2] started kicking and flailing and ended up kicking [named R3] directly in the face. [Named R3] then grabbed a large metal object off the med cart and started hitting [named R2] with it. At this point I stepped in and tried to get them to stop & I took the metal object from [named R3] and set it back on the med cart. As soon as I turned around, they resumed fighting, which started with [named R3] grabbing at [named R2] breasts and squeezing & pulling tightly. When that happened I went to go find someone to help, which was [named Scheduler N]. They continued fighting until other arrived. Continued review of the same investigation indicated based on the dementia diagnosis and cognitive disabilities for the resident involved, they did not feel that it was willful and did not substantiate abuse. During an interview on 12/7/22 at 8:25 a.m., HK M witnessed resident to resident verbal and physical altercation on 10/14/22 at 6:40 a.m. HK M reported R3 and R2 were located by the C-hall nurse station and started yelling at each other and escalated to throwing punches. HK M reported did not recall who started verbal altercation and reported R3 had history of over reacting and R3 pushed R2 with hands and R2 started kicking then R3 picked up metal object from medication cart and hit R2 with it several times to front of left shoulder area. HK M reported no other staff present at the time and had to leave the locked unit to get help after failing to deescalate the situation. HK M reported Scheduler N was located at the Main Nurse Station, outside the locked c-hall, who assisted to separate R2 and R3. HK M reported both residents appeared upset. HK M verified witness statement. HK M reported did not recall nurse present on c-hall prior to altercation and reported was also working on d-hall at the time and reported was unsure who Certified Nurse was at the time. HK M reported usually worked the c-hall three to four times weekly. During an interview on 12/7/22 at 9:10 a.m., Scheduler N reported had worked at the facility for nine years and was currently the scheduler, medical records and also a CNA. Scheduler N verified assisted HK M separate R2 and R3 after a physical altercation on 10/14/22 on unit C. Scheduler N verified was sitting at the Main Nurse Station, outside of the locked c-hall, when HK M exited the unit and requested assistance. Scheduler N reported no other staff present at the time of the incident and verified residents were separated. During an interview on 12/7/22 at 9:15 a.m., HK M reported had worked at the facility for nine months after transferring from another facility in the area. HK M reported did not receive abuse training from current facility and was able to report 3 of 8 types of abuse. HK M reported not aware of any resources available to utilize. HK M reported 10/14/22 resident to resident altercation was an example of an allegation of abuse and was reported to management. During an interview on 12/7/22 at 9:25 a.m., Scheduler N reviewed the schedule and reported Unit Manager(UM) I was the nurse from 6:30 a.m. to 9:00 a.m. and CNA O was the aid on the C-hall. Scheduler N reported Director of Nursing (DON) B had been the night nurse for the entire facility until 6:30 a.m. and CNA P had been only night CNA on c-hall. During an interview on 12/7/22 at 9:35 a.m., UM I reported had worked at the facility for two months and verified worked 10/14/22 from 6:30 a.m. to 9:00 a.m. UM I reported was not aware of R2 and R3 verbal and physical altercation on c-hall at 6:40 a.m. UM I reported worked on d-hall from 6:30 a.m. to 9:00 a.m. and reported usually obtained two resident blood sugars around breakfast time on c-hall before breakfast. UM I reported unsure if she had been on c-hall prior to altercation and again reported had not knowledge of R2 and R3 physical altercation on 10/14/22 at 6:40 a.m. During an interview on 12/7/22 at 10:41 a.m., Payroll Staff (PR) Q provided missed punches for DON B on 10/13/22 at 6:30pm to 10/14/22 at 7:00am. PR Q provided missed punches for UM I on 10/14/22 at 6:30am to 10:50am. During a telephone interview on 12/7/22 at 10:52 a.m., CNA R reported was not involved in R2 and R3 altercation on 10/14/22 at 6:40 a.m. CNA R reported had worked d-hall night shift until 10/14/22 at 7:00 a.m. CNA R reported frequent resident altercation on, psych unit (hall c) that often occur in the morning hours and reported R3 had frequent history of provoking other residents. During a telephone interview on 12/7/22 at 11:12 a.m., CNA O reported was not present for R2 and R3 altercation on 10/14/22 at 6:40 a.m. CNA O reported had heard about incident after arriving for shift on 10/14/22 at 7:00 a.m. and did not recall any changes in interventions to prevent further altercations. During a telephone interview on 12/7/22 at 11:23 a.m., RN E reported was not working c-hall on 10/14/22 at the time of R2 an R3 altercation and recalled UM I present at Main Nurse Station who was just getting report related to a call in and reported was maybe her first day. RN E reported was present for day shift on another hall but had good rapport with R3 and assisted after the altercation with attempts to defuse R3. Review of R3 Care Plans, dated 5/28/22 to current(12/7/22), reflected, The resident has impaired cognition and difficulty making decisions r/t a TBI and Schizoaffective Disorder and Bipolar Disorder Revision on: 12/11/2020 . Cue, reorient and supervise as needed. Date Initiated: 12/11/2020 .The resident has potential to be physically aggressive or agitated r/t Anger, History of harm to others, Poor impulse control .Goal .The resident will not harm self or others through the review date. Date Initiated: 08/11/2021 Revision on: 04/05/2022 .Interventions .Resident given soft stuffed animal to hit with when upset. Date Initiated: 06/14/2022 . Continued review of the Care Plans reflected no evidence of revision of interventions or new interventions added with exception 6/14/22 intervention for R3's 11 documented physical altercations with other residents including R2 on 10/14/22. During a telephone interview and record review on 12/7/22 at 4:06 p.m., R2 Case Worker(CW) S reported was R2 and R3 Case Worker for local mental health organization. CW S reported between her and another case worker they visit facility weekly. CW S reported they make several recommendations for residents but facility has had issues with no follow up related to implementing recommendations possibly related to staffing changes but continue to make recommendations. CW S reported activities for residents on c-hall had been a concern but getting slightly better. CW S reported aware of recent change in facility Social Worker and reported every consult visit sent to facility staff in PDF form after each visit. CW S verified 12 missing consult notes for R3 since September. R3 facility EMR reflected no evidence of (local mental health) consult since 9/7/22. During an observation on 12/8/22 from 8:20 a.m. to 10:00 a.m., on the locked c-hall, reflected one nurse, RN T and one aid, CNA D for day shift 6:30 a.m. to 2:30 p.m. Continued observation reflected UM/MDS H in and out of unit, Social Worker(SW) F in and out of unit, and male staff wearing street clothes assisted a resident back to room from Dining Room in wheelchair with no foot pedals at 8:35 a.m. and then exited unit. At 8:56 a.m. two residents noted wandering hall with one resident who appeared very anxious repeatedly asking if it was time to smoke. UM H, CNA D and RN T off the unit at that time for more than 5 minutes with SW F as only staff on the unit(not observed). CNA D returned to the unit at 9:03 a.m., Activity staff entered the unit at 9:04 a.m. with RN T and tended to resident who wanted to smoke. Housekeeping entered unit at 9:08 a.m. and UM H returned at about 9:25 a.m. During a telephone interview on 12/8/22 at 8:42 a.m., CNA P reported worked night shift 10/13/22 to 10/14/22 on c-hall as only cna staff and DON B was only nurse on night shift for entire facility. CNA P reported staff document behaviors in tasks. CNA P reported was unsure who she gave report to on the morning of 10/14/22 but was not present at time of R2 and R3 verbal and physical altercation. When ask how staff prevent resident to resident altercations CNA P reported she tried to keep residents apart and reported did not recall change in R2 or R3 interventions after 10/14/22. CNA P reported did care for R2 and R3 after the 10/14/22 altercation and reported R2 had scratches on chest. In review of the facility's 5-day investigation of an allegation of resident-to-resident sexual abuse that occurred on 10/12/22 at 12:10 PM; the facility was notified by staff that they had reason to believe male resident had touched R2 in her private areas; R2 was visibly upset afterward, anxious and required medication. Witness statement dated 10/12/22, indicated Certified Nurse Assistant (CNA) K witnessed male resident grab R2's vagina from behind. Review of R2 EMR, dated 10/14/22 through 10/18/22, reflected no evidence that SW assessed/address residual effects from the 10/14/22 incident including Progress Notes. Continued Review of EMR reflected no evidence of completed skin assessments between 10/14/22 and 10/17/22(included existing abnormal skin with no documentation). The EMR reflected no evidence of Pain assessment between 10/14/22 and 10/23/22(discharge). During an interview on 12/8/22 at 4:23 p.m., DON B reported had been DON at the facility for 18 months with three different Nursing Home Administrators. DON B reported behaviors reviewed daily Monday through Friday at morning meetings that consisted of clinical managers. DON B reported morning meetings were the same as IDT meetings and all events were reviewed and if any changes in immediate interventions were need they add IDT Progress Notes and add interventions including on Care Plans. DON B reported would expect interventions to be added to care plans and implemented after each altercation to prevent further altercations. This surveyor requested DON B provided evidence of what measures were taken by facility to prevent resident to resident altercation. DON B reported R3 had incentive program started but was unsure where it was documented with frequent changes. DON B would expect SW to follow up with residents after each allegation of abuse including resident to resident altercations for 72 hours and document in Progress Notes. DON B reported noticed yesterday SW had not completed 72 hour follow up assessments for residents after allegations of abuse when reviewing surveyor requested documents and education was provided to SW F. DON B reported SW F had worked at the facility for three months with no prior SW experience. DON B reported she was covering role of SW as well as DON with regional staff to cover behavior unit(c-hall). DON B verified had been working to relocate R3 per resident and POA request with documentation for at least past six months. Request for evidence of follow up. DON B reported would expect consulted mental health documents to be in resident EMR prior to next visit or 48 hours. DON B reported they have access to reports but had not educated new SW on how to obtain or if she knows she is responsible for obtaining records. DON B verified R3's last record of community mental health consult visit was 9/7/22 and reported R3 had been seen several times since then. DON B reported had provided all staff with Dementia training and would provide evidence. Review of provided Dementia Training Report, dated 12/8/22, reflected no evidence of Dementia Training for HK M. In review of the facility's 5-day investigation of an allegation of resident-to-resident physical abuse that occurred on 9/16/22 at 6:00 PM; R10 was moving through out the dining room and hall and R2 was sitting in the dining room who R10 rolled past R2 and then lounged and grabbed R2 arm. Skin and pain for R2 reflected pain of 4 to bilateral legs( residents normal pain) and R2 had 2 crest shaped scratches with bruising noted. Review of R2 Physician Progress Note, dated 9/19/22, reflected, CHIEF COMPLAINT: Resident-to-resident incident. HISTORY OF PRESENT ILLNESS: [AGE] year-old female here for long-term care, locked psych unit. Patient with known history of dementia, bipolar disorder, schizoaffective disorder, bipolar type, PTSD, major depressive disorder. Patient had a resident-to-resident incident, was grabbed on her right arm via fell ow resident which gouged arm pretty hard. Patient does not remember incident occurring. Patient confused at baseline .Skin: Warm and dry. Patient does have deep nail marks from another resident on her right forearm .IMPRESSION AND PLAN: 1. Schizoaffective disorder, bipolar type. 2. Fingernail gouging. 3. Bipolar disorder. 4. Major depressive disorder. Patient with resident-to-resident incident, had fingernail gouging from another resident on right forearm. We will monitor the site closely . Review of R2 Physician Progress Notes, dated 9/21/2022 at 11:58 a.m., reflected, HISTORY OF PRESENT ILLNESS .Patient is with recent injury to right arm, had nails scratched from another resident. Skin appears more red and tender . IMPRESSION AND PLAN: 1. Skin infection right forearm .Patient did have recent injury to right forearm from another resident ' s nails appears infected. We will start doxycycline 100 mg b.i.d. and monitor. Site red, swollen, tender. Injury with human nails, high risk for infection. We will start antibiotic and monitor . Review of R2 Skin assessment, dated 9/16/22 through 10/20/22, reflected on 9/16/22 R2 had two new abnormal skin areas to right hand purple discoloration with scab near thumb and right posterior forearm with 2 crescent shaped skin tears and purple discoloration. The Skin Assessment, dated 9/17/22, 9/24/22, 10/6/22, 10/10/22, reflected no existing abnormal skin areas. The Skin Assessments, dated 10/1/22 and 10/12/22, reflected R2 had bruising and discoloration right arm. The Skin Assessments, dated 10/12/22, and 10/17/22 and 10/20/22 reflected existing abnormal skin areas with no documentation completed. The Skin Assessments did not reflect increased redness and tenderness or signs of infection as indicated in Physician assessment dated [DATE]. Review of the Physician Orders, dated 9/21/22, reflected, Doxycycline Hyclate Tablet 100 MG Give 1 tablet by mouth two times a day for Skin infection for 7 Days. During an interview on 12/9/22 at 12:05 p.m., Regional staff V reported had been at facility for two months and had reviewed all FRI and tracked and identified need for full time activity staff on c-hall. During a telephone interview on 12/8/22 at 12:26 p.m., CNA W reported R10 and R2 had a resident-to-resident altercation on 9/16/22 at 6:04 p.m. CNA W reported there was another CNA on c-hall that was in another resident room. CNA W reported had her back turned and heard R2 scream for help from the Dining Room, turned and saw R10 grabbing at R2 arms. CNA W attempted to separate residents with moderate about of bleeding from R2 right arm from R10 nails that had gouged into skin and had to pry one finger off at a time. CNA W reported Nurse not on the unit at the time of the incident. CNA W reported only intervention implemented was R10 nails trimmed after incident. CNA W reported had never observed 1:1 for any residents on c-hall. CNA W reported times when she had to work c-hall by alone and nurse had to splits with d-hall. CNA W reported very stressful for one person related to residents with behaviors on c-hall. Review of the Nursing Working Schedule, dated 9/16/22, reflected one nurse split between c-hall and d-hall at time of resident-to-resident physical altercation between R10 and R2. During an interview on 12/8/22 at 3:20 p.m., Regional staff V and UM H reported aware increased, frequent FRI and reviewed with plan to add full time activity staff for 2023. UM H reported after creating surveyor requested time line for R3 noticed times and locations of resident-to-resident altercations that occurred mostly during meal time and discussed with team possible interventions to implement and possible plan to use both common areas for two Dining Rooms on c-hall instead of one. During a telephone interview on 12/8/22 at 4:51 p.m., RN X reported several residents on c-hall have manipulative behaviors and reported 12-15 residents on unit will gang up on you. RN X reported not safe for one staff to control entire c-hall on own and resident-to-resident altercation occur when nurse staff split between C and D halls. During a telephone interview on 12/8/22 at 5:30 p.m., RN T reported verbal cussing every day on c-hall and staffing had improved over past 30 days, however, times with one cna and nurse spilt between C and D hall. RN T reported medical event and resident-to-resident altercation occur at same time on both halls and impossible for nurse to be in two places at one time. RN T reported R2 son had questioned her related bruises and marks on R2 arms and reported she reassured him reports had been completed related to resident-to-resident incidents including when R10 grabbed R2 arm and dug her nails into R2 arm that caused open wounds and bruising. Review of R2 EMR dated, 7/25/22 through 10/23/22(admission to discharge), reflected R2 had no evidence of monthly behavioral meeting notes. During an interview on 12/13/22 at 9:10 a.m. SW F reported had worked at the facility about three months. SW F reported was familiar with R3 and reported R3 had behaviors that included cussing, yelling and often difficult to redirect and occasionally able to redirect with calls to sister. SW F reported did not have any involvement with R2 and R10 resident-to-resident altercation on 9/16/22 or R2 and R3 resident-to-resident altercation on 10/14/22. SW F reported received training from prior part time SW. SW F reported was informed by DON B within past week, need to follow up with residents for three days after an allegation of abuse or resident-to-resident altercation and document in Progress Notes to assess for both emotional and physical residual of event. SW F reported was not aware of that requirement prior to last week. SW F reported if community mental health involved in resident care facility has a monthly behavior meeting and should be documented. SW F verified no behavior meeting notes for R2 and reported prior SW was part time between another facility and may not of had time to complete. When SW F was quarried what was was being done to protect other resident on c-hall from R3 on-going physical altercations, SW F reported plan to continue to focus on R3 and DPOA request to transfer to another facility because nothing else had worked. SW F reported c-hall was not a homelike environment related to daily yelling, cussing and repeat resident-to-resident events. During an interview on 12/13/22 at 11:20 a.m., NHA A reported had worked at the facility since 7/18/22 and was also the facility Abuse Coordinator. NHA A reported R3 FRI were not substantiated because investigations did not reflect evidence of contact including staff eye witness events and recording devices have not been functioning. NHA A reported they have cleared congestion in c-hall at nurses station into dining room by removing medication cart one month ago. NHA A they have implemented mental health training for all staff, re-educated all staff on abuse, and continue to work on activity engagement. NHA A reported monthly meetings with consulting mental health groups and reported would expect facility to implement consulting mental health recommendation and have records of consults in resident records within 7 to days post visits. NHA A reported did not think meetings were happening on regular basis with current plans to have SW F and Medical Records N responsible for that task moving forw [TRUNCATED]

This citation pertains to intake number MI 132. Based on observation, interview, and record review, the facility failed to ensure [CONDITION(S)] (a tube placed into the trachea in the neck to create an alternative airway) supplies were available, nursing staff were trained and competent in [CONDITION(S)] ([CONDITION(S)]) care for three out of three residents (Resident #42, 48, and 357) resulting in Immediate Jeopardy when the facility did not have the needed [CONDITION(S)] supplies, and an observation of [CONDITION(S)] care revealed a staff nurse who was not competent to provide [CONDITION(S)] care attempted to remove R48's entire [CONDITION(S)] before being stopped by the State Surveyor, including an attempt by the Director of Nursing to insert the incorrect inner cannula (tube that goes into a [CONDITION(S)] tube that is either disposable or non-disposable) into R48's [CONDITION(S)]. Findings Included: Resident #48 (R48): Per the facility face sheet R48 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] shift and as needed. Another physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an observation on 6/15/2022, at 9:34 AM , R48 was observed to have [CONDITION(S)] tubing that was connected to an oxygen concentrator (machine that delivers oxygen) that supplied oxygen into his [CONDITION(S)] site. R48's oxygen was observed to be set at 2.5 liters per minute. In an observation on 6/16/2022, at 8:32 AM, R48 was observed to have oxygen via an oxygen concentrator delivered at 2.5 liters per minute. A box was observed on a bedside table that contained an Adult Flexible [CONDITION(S)] Tube with TaperGuard Cuff ([CONDITION(S)] tube), and an inner cannula (fits inside the [CONDITION(S)] tube and acts as a liner) which was a disposable size 7.5 millimeter (mm). No [CONDITION(S)] cleaning kits, and no ambu bag (bag used to manually breath for a person and supply oxygen in an emergency) was observed in R48's room, drawers or closet. Additionally R48 was observed to not have a dressing around his [CONDITION(S)] site. In an interview on 6/16/2022, at 8:41 AM, Registered Nurse (RN) FF was asked if R48 had [CONDITION(S)] supplies available, and when was R48's [CONDITION(S)] care performed and how often. RN FF asked what was meant by the question, and the question was asked again, in which RN FF then reviewed R48's Treatment Administration Record (TAR), and stated that at 7:39 AM on 6/16/2022 she did provide [CONDITION(S)] care which she stated consisted entirely of her wiping around R48's [CONDITION(S)] site with a sterile gauze and peroxide. RN FF stated she did not know anything about R48's [CONDITION(S)], then directed all further questions to RN EE, who was the Unit Manager (UM) and staff educator. RN FF stated to RN EE that she did not know anything about trachs. RN EE was not able to answer the questions, and only stated there were [CONDITION(S)] cleaning kits in the hall way closet on the D-hall (where R48 resided). In an observation on 6/16/2022, during the interview with RN EE, the D-hall closet observed with RN EE and revealed no [CONDITION(S)] cleaning kits in the D-hall closet. In an interview on 6/16/202, at 9:06 AM, Central Supply (CS) GG staff member stated the [CONDITION(S)] supplies were kept in the central supply closet that was located between the A and B halls. During the interview an observation of the central supply closet was made with CS GG which revealed no [CONDITION(S)] cleaning kits, and no disposable inner cannula's #8 or size 7.5 mm. CS GG stated she did not order [CONDITION(S)] cleaning kits or supplies, and the only way she would know to order those things was by the nursing staff telling her. CS GG was asked to provide an invoice of all [CONDITION(S)] supplies that were ordered and receipts of delivery of those items for the last two months. On 6/16/2022, at 12:00 PM, CS GG provided a document from from a supplier of [CONDITION(S)] supplies that was dated 6/16/ , which revealed five inner cannula's were ordered for R48, however CS GG was not able to provide the receipt for the date of delivery of the supplies, nor an invoice of supplies ordered for R48 prior to or at the time of R48's admission to the facility. In an observation on 6/16/2022, at 1:05 PM, RN FF was observed providing R48's [CONDITION(S)] care, which included changing R48's disposable inner cannula and replacing it with a new one, with Licensed Practical Nurse (LPN) AA, who was the UM of the A-hall. R48 was observed to not have a dressing around his [CONDITION(S)] site. Upon observation R48's disposable inner cannula was not in place. RN FF said R48's inner cannula had already been removed and disposed of prior to her beginning [CONDITION(S)] care. RN FF was then observed to open the box that contained a [CONDITION(S)] tube and a disposable inner cannula. RN FF then stated to LPN AA that she was ready to change R48's [CONDITION(S)], then took the [CONDITION(S)] out of the box, and placed the disposable inner cannula into the [CONDITION(S)] tube, then reached over and placed her hand on R48's [CONDITION(S)] tube to remove it, which would have resulted in the complete removal of R48's entire artificial airway. LPN FF was immediately stopped from continuing the [CONDITION(S)] care, and a request for the Director of Nursing (DON) A to be retrieved was made. On 6/16/2022, at 1:43 PM, DON B entered R48's room, and upon asking what the concern was it was brought to DON B's attention that RN FF and LPN AA were providing [CONDITION(S)] care and upon RN FF stating she was ready to replace R48's disposable inner cannula, that was stated by RN FF to have already been removed and disposed of prior to beginning the [CONDITION(S)] care, RN FF was observed to attempt to remove R48's entire [CONDITION(S)] tube which would have removed R48's entire artificial airway. DON B then proceeded to suction R48's secretions and clean R48's [CONDITION(S)] site. DON B removed a size 7.5 mm disposable inner cannula that was located in R48's bedside table, and the only one in R48's room. DON B was asked what size inner cannula was ordered for R48, in which she did not know, and therefore requested RN FF to check R48's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B was then observed to attempt to put the inner cannula in place inside R48's [CONDITION(S)] tube, however the inner cannula did not fit into R48's [CONDITION(S)] tube, and was not able to be all the way inserted to allow the side clips to snap into place. During the observation RN FF stated to DON B that the inner cannula she had removed prior to [CONDITION(S)] care did not have the clips on the side of it. DON B stated that R48's [CONDITION(S)] supplies would be located in the supply closet by B-hall, but when informed that no inner cannula's in the correct size were observed in the supply closet, DON B stated she would have to send an employee to another facility, which was approximately 20 miles round trip and 50 minutes to drive round trip, to retrieve the correct inner cannula for R48. DON B also confirmed that an ambu bag was required to be in R48's room for emergency purposes, which she then asked RN FF to retrieve. Review of a care plan, initiated 5/21/2022, and revised 6/8/2022 revealed, (R48) has a [CONDITION(S)], size 8, related to [CONDITION(S)] secondary to trauma. The care plan listed the interventions of OXYGEN SETTINGS: O2 via [CONDITION(S)] mask @ 6L 24 hours per day., and TUBE OUT PROCEDURES: Keep extra [CONDITION(S)] tube and obturator at bedside. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help IMMEDIATELY., however both interventions were not added to R48's plan of care until the dated of 6/16/2022 as indicated on the care plan. In an interview on 6/16/2022 at 2:20 PM, RN FF stated she had never been trained by the facility on [CONDITION(S)] care, nor had completed a competency on [CONDITION(S)] care. In an interview on 6/16/2022, at 3:26 PM, DON B stated the staff member who she sent the other facility to get the correct [CONDITION(S)] size for R48 was still in route, and at 4:13 PM DON B stated that the inner cannula's had arrived in which she was observed to have four size 7.5 mm inner cannula's, and then proceeded to go replace R48's inner cannula was not replaced until 4:15 PM, resulting in R48 not having an inner cannula in place for 3 hours and 8 minutes. On 6/16/2022, at 4:02 PM, a request was made to provide all nurse's competencies regarding [CONDITION(S)] care be provided. As of 6/16/2022, at 4:31 PM, no nursing competencies were received. DON B provided a sign in record for an inservice titled [CONDITION(S)] Care, which was dated 2/28/2022, however DON B, LPN AA, and RN FF were not one of the 10 staff member's names signed in on the inservice record. In an interview on 6/17/2022, at 1:00 PM, DON B stated no competency skills were performed after the inservice, and said the inservice was conducted because the facility was going to begin to admit residents with a [CONDITION(S)]. DON B provided two Annual Competency Checklist which revealed one was dated June of 2020, the other July of 2020, and did not include [CONDITION(S)] care as one of the competencies listed. DON B provided no other nurses's competency checklist, and stated that was because no nursing competencies had been conducted since 2020. Review of the facility's policy and procedure, titled [CONDITION(S)] Care, and dated 1/1/2021, revealed under, Policy: The facility will ensure that residents who need respiratory care, including [CONDITION(S)] care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Under Compliance Guidelines the policy revealed under #2, The facility will provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, [CONDITION(S)] care and/or suctioning, #3 .General considerations include: a. Perform [CONDITION(S)] care at least twice daily. b. Keep a suction machine, a supply of suction catheters, and correctly sized cannula's easily accessible for immediate emergency care, #5 The facility will ensure staff responsible for providing [CONDITION(S)] care including suctioning are trained and competent according to professional standards of practice, and #7 Procedure with Use of Disposable Cannula: a. Verify that the inner cannula is disposable. Verify correct size . Review of the facility's Census and Conditions of Resident report, dated 6/15/2022, revealed the facility had three residents who resided at the facility with a [CONDITION(S)] (an artificial airway through the neck into ones airway). Review of the Facility Assessment Tool, dated 6/6/2022, revealed the assessment did not an assessment of the need for nurses competent in providing care for [CONDITION(S)] residents. The assessment revealed the facility, under Respiratory Services provided [CONDITION(S)] care, however the assessment did not include under, Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and during Emergencies. the assessed need for nursing staff trained and competent in [CONDITION(S)] care. Review of the facility's MDS (Minimum Data Set) Resident Matrix, printed 6/15/2022, revealed the facility had three residents with a [CONDITION(S)], with two having admitted s of 5/10/2022 and 5/19/2022. Review of the previous Facility Assessment Tool revealed the assessment had been completed on 10/11/2021. No other assessment was provided or completed between 10/11/2021 and 6/6/2022, and no Facility Assessment Tool was completed or provided prior to the admission of a [CONDITION(S)] resident on 5/10/2022. In an interview on 6/22/2022, at 10:11 AM, Administrator A stated she did not include on the 6/6/2022 facility assessment the need of trained nursing staff competent in the care of [CONDITION(S)] residents, because she only included MDS data from January 2022 through March 2022. Administrator A said she did not assess what supplies were needed prior to the first [CONDITION(S)] resident who was admitted in May of 2022. On 6/16/2022, at 5:09 PM, the Administrator was notified of the Immediate Jeopardy that began on 6/16/2022, and was identified on 6/16/2022 when an observation of [CONDITION(S)] care revealed that staff attempted to remove Resident #48's entire [CONDITION(S)] before being stopped by the State Surveyor, attempted to insert a clipped inner cannula for Resident #48, however Resident #48 required an unclipped inner cannula, and the facility did not have an unclipped cannula and had to send staff to another facility (approximately 20 miles away and a 50-minute drive, round trip) to retrieve the correct inner cannula for Resident #48. On 6/17/2022 this surveyor verified that as of 6/17/2022 the facility implemented the following to remove the Immediate Jeopardy: 1). Beginning 6/16/2022, Resident R48 was assessed by the Director of Nursing and licensed Respiratory Therapist, 98.9 temperature, 124/82 blood pressure, pulse 114, respirations 18, oxygen level 97%, R48 remained at baseline. 2). Beginning 6/16/2022, 3 out of 3 residents requiring [CONDITION(S)] care have been assessed by a licensed nurse and remain at baseline. 3). Beginning 6/16/2022, 3 out of 3 resident bedside emergency supplies have been assessed and correct amount of supplies are present at the bedside. (this was not verified to be in place until 6/17/2022). 4). Beginning 6/16/2022, all supplies were reviewed and signed of by a licensed Respiratory Therapist. 5). Beginning 6/16/2022, Nurse Management team had verified that orders are correct for those residents receiving [CONDITION(S)] care. 6). Beginning 6/16/2022, 3 out of 3 residents [CONDITION(S)] care plans have been reviewed and updated as appropriate. 7). Beginning 6/16/2022, any residents admitted with a [CONDITION(S)] will be reviewed following this process. 8). Beginning 6/16/2022, the policy for [CONDITION(S)] care was reviewed by the Regional Director of Clinical and Regional Director of Operations and deemed appropriate. 9). Beginning 6/16/2022, at 10:45 PM, 10 out of 19 nurses had been re-educated on the policy for [CONDITION(S)] care including immediate notification to nurse management and central supply of [CONDITION(S)] supplies were not available. 10). Beginning 6/16/2022, Licensed Nurses who are educated but cannot successfully complete competency education will not be assigned to care for [CONDITION(S)] residents until they are able to successfully demonstrate competency and return demonstration of [CONDITION(S)] care. 11). Beginning 6/16/2022, any nurse not educated will receive education prior to their next scheduled shift. 12). Beginning 6/16/2022, random [CONDITION(S)] care observations will be started and conducted every shift for seven days. Each nurse working will be audited at a minimum of one time per working shift for 7 days. 13). Beginning 6/16/2022, upon observation if a nurse is found to not be completing care per [CONDITION(S)] policy, the nurse will be immediately educated on the spot regarding the concerns found at observation. The nurse will not be allowed to complete [CONDITION(S)] care until education is completed and return demonstration is successful. 14). Beginning 6/16/2022, an audit was started every shift for seven days to verify that the four out of four current residents [CONDITION(S)] supplies and emergency supplies are available and appropriate to the residents ordered [CONDITION(S)] supplies/size and need. Although the Immediate Jeopardy was removed on 6/17/2022, the facility remained out of compliance at a scope 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. Resident #357 (R357) Review of the medical record revealed R357 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R357 had a [CONDITION(S)] (a surgical procedure to create an opening in the windpipe to assist with breathing). Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/8/22 revealed R357 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-cognitive screening tool). R357's medical record revealed he was a Full Code. Review of R357's [CONDITION(S)] care plan initiated 6/5/22 revealed interventions that included TUBE OUT PROCEDURES: Keep extra [CONDITION(S)] tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs or respiratory distress. If able to breathe spontaneously, elevate HOB [head of bed] 45 degrees and stay with resident. Obtain medical help IMMEDIATELY. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/16/22 at 11:00 AM, the order was changed to reflect a size 4 [CONDITION(S)] with an ID of 5.0 mm and an outer diameter of 9.4 mm. On 6/16/22 at 11:40 AM, R357 was observed lying in bed. R357 reported his [CONDITION(S)] care was not being performed twice a day and was last performed a couple days ago. R357 reported his inner cannula was last changed a couple days ago and reported he did not have any more inner cannulas. R357 pointed to the garbage bag of supplies sitting on the floor in his room. Observation of the supplies in the bag revealed there were not any [CONDITION(S)] care/cleaning kits or inner cannulas. There was no ambubag or emergency equipment readily available. R357 reported he performed his own suctioning. R357 was observed with 4 liters of oxygen running through a [CONDITION(S)] mask. Review of R357's Treatment Administration Record (TAR) on 6/16/22 at 11:46 AM, revealed [CONDITION(S)] care was signed out as completed three times per day, including the morning of 6/16/22. On 06/16/22 at 12:18 PM, Registered Nurse (RN) R reported she was caring for R357 that day. When asked about the [CONDITION(S)] and emergency equipment at bedside, RN R entered R357's room. R357 was observed suctioning his [CONDITION(S)]. RN R emptied the garbage bag of supplies and located a Shiley ([CONDITION(S)] tube) 5.0 mm ID, 9.4 mm OD/size 4. When asked if she performed R357's [CONDITION(S)] care yet that day, RN R stated, No, not yet. RN R agreed there was no ambubag located in R357's room. When asked about his oxygen order, RN R stated, I believe its 4 to 5 [liters]. In a telephone interview on 6/17/22 at 5:14 PM, RN R reported she did not perform [CONDITION(S)] care for R357 on 6/16/22 but acknowledged that she signed it out as completed. When asked why, RN R reported because the care was scheduled for morning, but she did not usually complete it until later in the day. On 06/16/22 at 1:16 PM, R357 was observed in bed with his oxygen running at 4 liters. In an interview on 06/16/22 at 2:06 PM, Unit Manager (UM) AA reported R357 had a disposable inner cannula, performed his own [CONDITION(S)] care, suctioning, and replaced his own inner cannula. When asked where supplies were kept, UM AA stated, should be in the supply room. The supply room was observed with UM AA, but only size 6 tracheostomies were observed. UM AA then went into R357's room and was able to locate one size 4 [CONDITION(S)]. R357 was again observed on 4 liters of oxygen. When asked about his oxygen order, UM AA reviewed R357's orders and reported he should be on 6 liters of oxygen. In an interview on 6/16/22 at 4:23 PM, MDS Nurse BB reported she was working A hall and caring for R357. When asked about crash carts, MDS Nurse BB reported the facility had two crash carts: one outside of the Director of Nursing's office (outside of C hall) and another on C hall. MDS Nurse BB reported R357 did not have an ambubag in his room. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/17/22 at 1:00 PM, R357 held up a pad of paper which read can you change my inner cannula. R357 was observed on 4 liters of oxygen. His suction cannister was approximately 50% full of yellowish secretions. RN EE was notified of R357's request for an inner cannula change. RN EE searched R357's room and supply closet and was unable to locate the correct size inner cannula for R357. RN EE then asked UM AA who was also unable to locate the correct size inner cannula. As of 6/17/22 at 1:11 PM, staff were still unable to locate a replacement inner cannula for R357. In an interview on 06/17/22 at 1:13 PM, Director of Nursing (DON) B could not explain why the facility did not have any replacement inner cannulas for R357. DON B was also unaware that R357 had been on 4 liters of oxygen and reported the facility had 10 liter concentrators delivered last night. When asked how resident supplies were audited as their plan to remove the immediacy, DON B reported the facility focused on emergency equipment, replacement [CONDITION(S)], and inner cannulas for R48. On 06/17/22 at 1:35 PM, R357's emergency supply bag was observed in his room. Inside the bag was an ambubag and two different size tracheostomies. One was a 7.0 mm ID, 10.1 mm OD shiley adult flexible [CONDITION(S)] tube with taperguard cuff and the other was a 5.0 mm ID, 9.4 mm OD [CONDITION(S)] tube cuffless with disposable inner cannula. On 06/17/22 at 1:36 PM, DON B reported the facility obtained an order that it was okay for R357 to be without an inner cannula. DON B reported R357's [CONDITION(S)] order was changed back to a size 4 on 6/17/22. When asked why the size was changed to a 5 on 6/16/22, DON B reported she was unable to answer that. DON B reported the facility did not have any inner cannulas for R357. At approximately 1:46 PM, DON B was observed attempting to increase R357's oxygen from 4 liters to 6 liters, but the concentrator would not increase the rate. DON B reported R357 had a bad tank and she would order a new one. In a telephone interview on 06/17/22 at 2:07 PM, Physician's Assistant (PA) Y reported he was notified on 6/17/22 that R357 did not have any inner cannulas and he gave the order that it was okay for R357 to not have an inner cannula in place. Resident #42 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], R42 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Brief Interview for Mental Status (BIMS) reflected R42 scored 15 out of 15 (cognitively intact). Review of 5/10/22 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change [CONDITION(S)] ties with baths. Change [CONDITION(S)] ties every 3 days. Assess stoma site and under [CONDITION(S)] ties. Review of June 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/16/2022 a review of R42's current care plans reflected The resident has a Treacheostomy {sic} R/T (related to) Cancer of the Larynx. The goal was R42 to have clear and bilaterally equal breath sounds, was dated 5/11/22 with target date of 8/25/22, some of the interventions were [CONDITION(S)] care twice in a 24 hour period. Changing inner cannula one time in a 24 hour period or more as necessary. [CONDITION(S)] care every shift and as needed. On 06/16/22 at 11:40 AM during an interview at bedside, Resident # 42 resting in bed, she was observed to have an airway stoma, there were no emergency airway supplies including ambubag in room in plain sight. R42 stated there weren't any supplies including cleaning kits and granted permission to search room including night stand and closet for airway supplies. None were located. On 06/16/22 at 01:16 PM, during an interview with Registered Nurse (RN) R she stated Resident # 42 does her own [CONDITION(S)] care but she watches to ensure its done appropriately. RN R further stated supplies should be kept at bedside and it was the responsibility of R42 to let them know if supplies are low. Review of R42's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . It was requested [CONDITION(S)] care be observed , RN R requested surveyor return around 4:00PM, which was when she normally did R42's [CONDITION(S)] care. On 06/16/22 at 01:22 PM during a follow up interview with R 42 in the main dining room. R42 reported the facility did not provide [CONDITION(S)] supplies or cleaning kits and hadn't had any in a while and that she had been cleaning it rinsing it in the bathroom sink, velcro collar has not been changed since admission on 5/10/22. When queried the last time her airway care was done R42 reported she did it herself earlier that day, when queried if Nursing staff observed her do her airway care R42 stated no. There was no documentation that R42 was able to perform her airway care without staff supervision. On 6/16/22 at 4:13 pm in Licensed Practical Nurse (LPN) BB stated RN R had to leave early and that R42 did her own trachestomy care, when queried about the residents airway supplies and ambubag, LPN BB stated ambubag was kept on a crash cart, not in R42's room. In a telephone interview on 6/17/22 at 5:14 PM, RN R reported she did not perform or observe [CONDITION(S)] care for R42 on 6/16/22 but acknowledged that she signed it out as completed. When asked why, RN R reported because the care was scheduled for morning, but she did not usually complete it until later in the day. During an interview with Director of Nursing (DON) B on 06/17/22 01:19 PM it was queried Who/how decided if airway care was to be /can be self performed and how individual training, teaching and what oversight was inplace to assure resident self perform appropriately. DON B reported she was not aware that R42 was doing her own [CONDITION(S)] care until last night when she was working on a removal plan for the immediate jeopardy, at which time she had the Physician Assistant (PA) Y assess R42 to perform her own care. 06/17/22 at 01:43 PM , during an observation of R42's room and airway supplies, DON B stated she was educated last night and R42 did not have an actual [CONDITION(S)] but instead had a larytube. (A flexible silicone tube designed to maintain the stoma airway following laryngectomy). When queried if the facility had a back up or replacement larytube onsite, DON B stated No but one was ordered last night and should arrive today. DON B stated when she spoke with PA Y she was told R42 could go without her larytube for a while. DON B could not articulate what time frame a while was, and offered no explanation as to why there were no larytubes in backup since R42's admission on 5/10/22. In a telephone interview on 06/17/22 at 2:07 PM, PA Y reported he would expect the facility to have had an extra larytube on site for R 42.

This citation pertains to Intake: MI 065 Based on observation, interview, and record review, the facility failed to timely review a STAT radiology report and timely notify the physician of a displaced left greater tuberosity avulsion [MEDICAL CONDITION] for one resident (R12) of four residents reviewed for falls, resulting in ongoing pain, lack of ongoing care coordination, assessment, timely diagnosis, and a greater than 10 hour delay of treatment for [REDACTED]. Findings Include: According to the facility, Falls-Clinical Protocol, revised 6/2018, reflected, As part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling. This will be accomplished by the following task; a. The Falls Risk Evaluation is completed upon admission, quarterly, and with significant change in status. 1. Based on the assessment a care plan will be developed and implemented to address identified risk. This will be revised as necessary .For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall .Document findings in the resident's medical record per standard protocol . Resident #12(R12) Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected R12 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected R12 had a BIM (assessment tool) score of 10 which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist with bed mobility, transfers, walk in room, location on unit, dressing, toileting, hygiene, and bathing. The MDS reflected R12 was not steady with balance during transfers and required human assist to stabilize. The MDS reflected R12 did not have any behaviors including rejection of ADL assist. During a telephone interview on 1/27/21 at 1:28 p.m. an anonymous complainant reported R12 had three falls at the facility including a fall that resulted in left arm fracture and reported R12 was not sent to the hospital or seen by a physician for the fracture prior to leaving the facility. The complainant reported R12 contracted Covid-19 and facility staff planned to transfer R12 to another facility but complainant reported family refused and picked up R12 on 12/7/20 instead and reported R12 had not had any symptoms and remains at home. Review of the facility Progress Notes, dated 11/18/20 at 11:14 a.m., for R12 reflected, Pertinent Charting-Falls Note Text: Date of Fall: 11/18/2020 Situation Details: Resident tripped on her flip-flop sandals,lost her balance and fell to the floor . Review of the facility Progress Notes, dated 11/25/20 at 8:21 p.m. for R12 reflected, Pertinent Charting-Falls Note Text: Date of Fall: 11/25/2020 Situation Details: res witnessed laying on left side on the floor. Assessment: skin assessment completed, neuros started, pain eval done and fall packet and charting finished. res complained of pain 6/10 to left shoulder, 4cm x's 4cm bruise noted, with STAT x ray ordered and completed. Mitigating Factors: res seemed to loose her balance in room. Environmental Factors: res stated she was helping her roommate eat something as res was sitting on the commode( just using as a seat) got up and lost her balance. Interventions: commode has been taken out of res room MD Notification: Dr. (named physician) Responsible Party Notification: self Comments: The Progress Note was completed by Licensed Practical Nurse (LPN) PP. Request was made to the Administrator (ADM) A, on 1/27/21 at 2:29 p.m. for all of R12's complete incident accident investigations for past four months. Review of facility Incident/Accident Report, dated 11/18/20 at 9:15 a.m., reflected R12 had a witnessed fall after standing from wheelchair and loosing balance and falling on floor with no apparent injury. The investigation reflected R12 fell related to improper footwear and intervention implemented for R12 to wear gripper socks at all times. Review of the facility Incident/Accident Report, dated 11/25/20 at 7:20 p.m., reflected R12 had an unwitnessed fall in her room and was found laying on left side on the floor, R12 complained of pain 6/10 to left arm, hematoma/bruise and abrasion was marked on the Incident Report. The report reflected R12 had reported she was helping to feed roommate and was sitting on the commode, as a seat, stood up, lost balance and fell . Review of Occupational Therapy Notes, dated 11/9/20, reflected R12 had [DIAGNOSES REDACTED].Precautions/Prior Living .Precautions/Contraindications: repeat falls, dementia .Prior Living .Uses standard walker for functional mobility but has a lot of falls . Review of the Radiology Report, dated 11/25/20 reflected R12 had an X-Ray of the Left shoulder on 11/25/20. The Radiology Report reflected, Results: There is an acute avulsion fracture involving the greater tuberosity of the left humerus, with mild displacement of approximately 5 mm .There is mild soft tissue swelling. Conclusion: Acute left greater tuberosity avulsion fracture. The Radiology Report reflected, Report Date: 11/26/2020 12:15:18 AM The Report reflected it had been faxed to the facility on [DATE] at 12:19 a.m., as evidenced by date/time stamp at the top of the Radiology Report. Hand writing was noted at bottom of Radiology report that appeared to be Physician orders [REDACTED]. Review of facility Progress Notes, dated 11/26/20 at 10:41 a.m., for R12, reflected, Note Text: Notified On call provider of X-ray result. Results indicates acute avulsion fracture involving the greater tuberosity of the left humerus with mild displacement of approximately 5mm. No dislocation of the glonomhumral joint. Acrominocalvicular and coracoclavicular joints are intact. Mild soft tissue swelling noted. Conclusion: Acute left greater tuberosity avulsion fracture. Received order for arm sling, STAT orthopedic referral, ice qid to affected area, Start [MEDICATION NAME] 5/325mg qid for 7days. Hold [MEDICATION NAME] for 7days. On call manager, resident and resident family notified. The Progress Note was competed by Registered Nurse(RN) SS. Review of the facility, NP/PA Progress Note, dated 11/26/20 at 2:35 p.m. for R12, reflected, Note Text: (named physician group), PC Notified of a fall last night. (named R12) fell off of a stool in another residents room onto her L side. Complaining of severe L shoulder pain. X-ray was ordered. I was just notified of the results showing avulsion [MEDICAL CONDITION] tuberosity of L proximal humerous with mild displacement. No dislocation. Plan will be to treat as an outpatient due to risks associated during the COVID-19 pandemic. Ordered stat orthopedic consult, sling to wear for arm support. [MEDICATION NAME] was ordered for 3 days to help with the pain. [MEDICATION NAME] was placed on hold during this time. Given the fracture and patient report of increased pain, benefit of opioid pain med vs. [MEDICATION NAME] outweighs the risks. Also instructed to use ice often throughout the day to help with pain, swelling. Nurse read back orders to me and were correct. (Named Physician) was notified of plan and he agrees with outpatient treatment at this time. The Progress Note was written by Nurse Practitioner UU. Review of a facility, Order-Administration Note, dated 11/26/20 at 4:21 p.m., for R12, reflected, Text: [MEDICATION NAME] Tablet 5-325 MG Give 1 tablet by mouth four times a day for Pain for 7 Days Time change to 1800 Review of a facility, Order-Administration Note, dated 11/26/20 at 8:14 p.m., for R12, reflected, Note Text:[MEDICATION NAME] Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for Pain Given for left shoulder pain. Resting in bed. Review of the facility Electronic Medical Record including Progress Notes, dated 11/25/20 at 7:20 p.m. through 11/26/20 at 10:41 a.m. reflected no documentation of comfort measures offered to R12 including ice or elevation for R12 Left arm pain with exception of routine scheduled and PRN medications. During a telephone interview on 2/3/20 at 1:04 p.m., LPN PP reported R12 had a history of [REDACTED]. LPN PP reported was R12 nurse on 11/25/20 when R12 fell off R12's roommates commode she was using as a seat. LPN PP reported Certified Nurse Staff notified her R12 was laying on floor and immediately when to R12 room. LPN PP reported she assessed R12 on the floor and R12 was able to report commode shifted and lost balance and fell to floor. LPN PP reported R12 was able to get self back to bed after fall with assist. LPN PP reported R12 remained in bed the rest of shift after fall reported completed frequent neurological assessments as well as positioned R12 with pillow in bed for comfort. LPN PP reported R12 complained of 6/10 pain to left shoulder after fall and had bruise on left arm. LPN PP R12 had routine pain medication due at that time that appeared effective. LPN PP reported prior to R12 fall her shift started at 6:30 p.m. and got report on two halls because was only nurse for both C Hall and D Hall. LPN PP reported started on C Hall with medication pass and had not made it to D Hall prior to R12 fall at 7:20 p.m. LPN PP reported she completed fall assessment, fall risk survey, skin assessment, pain assessment, initial fall charting, neurological assessments, and notified Physician who ordered STAT X-Ray. LPN PP reported Nurse TT who was the other nurse working that evening found R12 Radiology results on the fax machine around shift change at 6:00 a.m. on 11/26/20 and notified Physician. LPN PP reported had looked prior but did not notice prior and stated, we always look prior to end of shift. Review of the facility Pain Evaluation, dated 11/26/20 at 1:44 a.m., reflected R12 was having moderate, stabbing, pain in shoulder with movement that has affected R12 sleep. The Pain Evaluation reflected R12 was receiving PRN medication. Review of the facility, Pain Level Summary, dated 11/23/20 to 12/6/20, reflected between 11/23/20 and 11/25/20(prior to fall with fracture of left arm), R12 pain level ranged from 0/10 to 3/10 and pain was assessed six times daily. According to the Log R12 developed 7/10 pain after the fall on 11/25/20 and had 7/10 pain level documented six additional times until 11/26/20 at 8:14 p.m.(24 hours after fall). During a telephone interview on 2/3/21 at 1:48 p.m. CNA Y reported working with R12 on 11/25/20 at the time of the fall. CNA Y reported did not complete a witness statement because R12's fall was not witnessed. CNA Y reported R12 was sitting on roommates commode seat feeding roommate prior to fall. CNA Y reported R12 was on the floor when she entered the room and R12 complained of left arm pain and was trying to get up off floor while nurse was asking R12 not to move. CNA Y reported nurse did assessment and three staff members transferred R12 off floor to bed and R12 tolerated well but did complain of arm pain. CNA Y reported mobile X-Ray performed at facility and nurse did frequent neuro assessments and CNA staff obtained frequent vitals after fall. CNA Y reported R12 complained of pain by left shoulder and pillows were used for comfort. This Surveyor asked CNA Y how she knows what kind of assistance each resident requires. CNA Y reported she knows her residents, however if she has a question she would ask the resident or may get from change of shift report and also will check Kardex when completing documentation after care is provided. During a telephone interview on 2/3/21 at 3:55 p.m. RN SS reported worked on 11/26/20 day shift starting at 6:30 a.m. with R12 after 11/25/20 fall. RN SS reported received report from LPN PP that R12 had fall the evening of 11/25/20 with left shoulder pain and had STAT X-Ray with no results yet. RN SS reported found R12 X-Ray results on fax machine that indicated acute fracture of left arm and called Physician who gave new orders that included frequent ice, orthopedic referral STAT, sling, [MEDICATION NAME] 5/325 qid x 7 days and hold [MEDICATION NAME] RN SS reported hand written notes on bottom of Radiology report were hers when call was placed to Physician about 10:30 a.m. RN SS reported informed Unit Manager DD to assist with STAT orthopedic appointment because of the holiday. RN SS reported R12 received sling same day and provided R12 with ice for comfort. RN SS reported R12 continued to have increased pain and Physician was contacted again and adjustments in pain medication was ordered. RN SS reported R12 was not sent to hospital. During a telephone interview on 2/3/21 at 4:30 p.m. Unit Manager(UM) DD reported was working as interim Director of Nursing at the time of R12 fall. UM DD reported received call from LPN PP at the time of R12 fall on 11/25/20. UM DD reported did not work next day 11/26/20 related to holiday. UM DD reported R12 fall was unwitnessed so there were no witness statements. UM DD reported IDT team responsible for fall investigation who consisted of department managers. UM DD reported unsure when R12 last seen prior to fall. UM DD reported would expect nurse to follow up after STAT X-Ray for results within two to three hours if no results. UM DD reported was unsure why there was over a 10 hr delay from receiving R12 STAT X-Ray results and physician notification the Physician of R12 acute left are fracture. UM DD reported was not aware of R12 delay Physician notification and treatment prior to this surveyor question. UM DD reported IDT team only reviewed fall and ways it could have been prevented. During a telephone interview on 2/4/21 at 7:57 a.m. Radiology Company staff VV reported prompt course of events from Radiology Company. Company performed X-Ray for R12 on 11/25/20 at 11:50 p.m. at the facility and results were faxed to the facility on [DATE] at 12:19 am.

This citation pertains to MI 908. Based on observation, interview and record review, the facility failed to appropriately assess and treat pressure ulcers for two (Resident #11 and #15) of two reviewed for pressure ulcers, resulting in missed treatments, lack of wound assessments and the potential for worsening pressure ulcers. Findings include: Resident #11 (R11) Review of the medical record reflected that R11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2020, reflected that R11 had one unstageable pressure ulcer that presented as a deep tissue injury and was present on admission. R11 discharged to the hospital on [DATE] and had not returned as of the time of the survey. R11's Care Plans included a focus of, The resident has diabetic ulcer of the right heel. The date initiated was 12/14/2020 with a revision date of 12/14/2020. Care Plan interventions included but were not limited to: -Monitor/document wound: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, [MEDICAL CONDITION], granulation, infection, necrosis, eschar, gangrene, Document progress in wound healing on an ongoing basis. Notify MD as indicated. Date Initiated: 12/14/2020 -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Date Initiated: 12/14/2020 -WOUND/DRESSING per MD order. Date Initiated: 12/14/2020 Revision on: 12/14/2020 R11's December 2020 and January 2021 Treatment Administration Records (TAR) reflected, NPWT (negative-pressure wound therapy) (a vacuum assisted wound closure system) for right heel wound: Cleanse wound with wound cleanser, pat dry, apply skin sealant (skin prep) to peri wound, fill dead space with black foam, cover with sealant cover film and apply NPWT tubing. Set at 125mmHg continuous every night shift every Mon (Monday), Wed (Wednesday), Fri (Friday) .Start Date .12/14/2020 . The TAR's reflected boxes to document Drain (drainage with yes or no response), Infec (infection with yes or no response), Necro (necrosis with yes or no response), Odor, Pain, Skin (with yes or no response). According to the December 2020 TAR, the treatment was to be provided during night shift on 12/14/2020, 12/16/2020, 12/18/2020, 12/21/2020, 12/23/2020, 12/25/2020, 12/28/2020 and 12/30/2020. The December 2020 TAR reflected the treatment was to be performed a total of eight days after the order start date but was only documented as being performed on 12/14/2020 and 12/21/2020. TAR documentation for 12/28/2020 reflected to refer to Progress Notes. A Progress Note, dated 12/29/2020, and in reference to the NPWT treatment order, reflected the wound vac (NPWT) was broken, and the providing company had been notified to deliver a new device. R11's medical record did not reflect a change in treatment orders that were to be carried out while the NPWT device was broken. According to the January 2021 TAR, the NPWT treatment was to be performed on the night shift of 1/1/21. The documentation reflected to refer to the Progress Notes. A Progress Note, dated 1/2/21 at 6:09 AM, in reference to the NPWT treatment, reflected, .not done. During a phone interview on 2/3/21 at 9:11 AM, Staff Member (SM) LL reported they went to assess R11 at shift change, between 6:30 PM and 7:00 PM on 1/1/21, and the NPWT device was not plugged in. SM LL was unsure of how long the device had been unplugged. They reported the dressing was clean and clear, so they did not perform the NPWT treatment on their shift that night. Review of R11's electronic medical record reflected the following skin assessments: -12/19/2020: No new abnormal skin areas. The document reflected there was an existing abnormal skin area, with notation of a surgical wound to the left heel with a wound vac (NPWT) in place. -12/26/2020: No new abnormal skin areas. The document reflected there was an existing abnormal skin area, with notation of an open area to the right heel with a wound vac in place. -1/2/21: No new abnormal skin areas. The document reflected there was an existing abnormal skin area, with notation of an open area to the right heel with wound a vac in place. The above skin assessments did not reflect any further documentation or assessments of the wound. On 2/1/21 at 2:08 PM, an email was sent to Nursing Home Administrator (NHA) A and Director of Nursing (DON) B to request all wound assessments for R11 for 12/12/2020 to 1/4/21. On 2/1/21 at 3:30 PM, and email was received from NHA A with the skin assessments for 12/19/2020, 12/26/2020 and 1/2/21, as referenced above. On 2/1/21 at 3:33 PM, the Surveyor sent an email inquiring if there were any additional assessments pertaining to R11's right heel ulcer. On 2/1/21 at 4:22 PM, and email was received from NHA A that they were unable to supply that information. On 2/2/21 at 4:21 PM, NHA A reported the reason they were unable to provide additional documentation of R11's right heel wound was because there was no additional documentation of the wound that she was aware of. On 2/2/21 at 4:27 PM, DON B reported they used an alternate system for documentation of wounds, but that system did not have anything pertaining to R11's right heel wound. During a phone interview on 2/3/21 at 11:02 AM, DON B reported R11's NPWT treatment should have been performed every Monday, Wednesday and Friday. When asked how often R11's wound should have been assessed, DON B reported they did a skin standard of care note weekly. When asked what they would expect to see documented with the wound assessments, DON B reported, measurements of the wound, a description of the wound, as well as any change in intervention, if anything changed and what had been going on in the past week. R11's medical record did not reflect documentation of thorough assessments of their right heel wound, including wound measurements, characteristics or wound progression. During the phone interview on 2/3/21 at 11:02 AM, DON B reported the facility had provided all of the documentation they had pertaining to R11's right heel wound. Resident #15 (R15) Review of the medical record reflected that R15 was admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 10/30/2020, reflected that R15 did not walk and required extensive assistance of one to two or more people for Activities of Daily Living (ADL's). On 2/2/21 at 11:37 AM, R15 was observed lying on their back, in bed, with their eyes closed. On 2/2/21 at 12:56 PM, R15 was observed in bed, with the head of the bed elevated. A staff member was at the bedside, providing R15 assistance with lunch. R15's medical record reflected they were transferred to an alternate facility (HUB) due to a [DIAGNOSES REDACTED]. A Nursing Readmission Evaluation, dated 1/22/21, reflected R15 had an open area/excoriation to the coccyx upon readmission. There was no additional assessment information pertaining to the open area on 1/22/21. A Progress Note for 1/24/21 reflected that R15's coccyx dressing was changed due to being saturated with a moderate amount of bright red blood. A Standard of Care (SOC) Skin Progress Note, dated 1/25/21 at 2:53 PM, reflected that R15 readmitted (on 1/22/21) with a stage three wound to the coccyx, which measured seven centimeters (cm) by five cm. The wound bed was pink and moist. There was an area of eschar approximately three cm by three cm at the top, middle of the wound. The note further reflected that R15 returned to facility with the wound, and the admitting nurse assessed it initially. The note reflected it was diagnosed as a stage three by the Nurse Practitioner (NP). An NP Progress Note for 1/25/21 at 3:30 PM reflected R15 returned to the facility with a stage three pressure ulcer to the left upper buttock, measuring seven cm by five cm. There was a small center island of eschar noted with a small amount of slough. A late entry SOC Skin Progress Note, dated 2/1/21 at 3:43 PM, reflected R15's wound measured 12.5 cm by 7.7 cm with an area of eschar at the top, middle of the wound. R15's medical record failed to show a thorough assessment of their coccyx wound upon readmission to the facility on [DATE]. According to the Progress Notes, as noted above, the wound was documented as a stage three on 1/25/21. During a phone interview on 2/3/21 at 11:02 AM, DON B reported she would have liked to see a more detailed assessment of R15's wound upon his readmission on 1/22/21. DON B reported she wanted to have the Doctor stage the wound on Monday (1/25/21). DON B reported she worked on 1/23/21 and should have entered a Progress Note regarding R15's pressure ulcer. According to DON B, the pressure ulcer looked very much the same on 1/25/21 as it did on 1/23/21. When asked if the facility had provided all of the documentation they had pertaining to R15's wound, DON B acknowledged that as long as the Surveyor had both of the SOC notes regarding the wound, then yes, that was all of the documentation. According to the facility policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, with a reviewed/revised date of 10/30/2020 and a date implemented of 1/1/21, .Initial Screen .All PU/PI or other skin related issues are measured and documented (electronic medical record in EMR facilities) .

This citation pertains to intake MI 825. Based on interview, and record review, the facility failed to provide an environment free from verbal abuse for one (#5) of two sampled residents reviewed for abuse resulting in Resident #5 feeling humiliated, embarrassed and fearful to ask staff for assistance. Findings include: Review of the facility's Abuse Prevention Program policy revised 2/22/18 revealed, Our facility is committed to protecting our residents from abuse by anyone .Our facility will not condone resident abuse by anyone, including staff members .Abuse-The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Verbal Abuse is defined as 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 . Review of the medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Cells in nearly any part of the body can [MEDICAL CONDITION], and can spread to other areas.) Review of the MDS revealed that Resident #5 had clear speech, was understood, understands and was cognitively intact. Review of the facility's Incident Summary which was submitted to the State Agency on 8/2/18 revealed, Allegation of Verbal/Emotional abuse. (Resident #5) states that he worries about asking for his medication because he doesn't want to be belittled. Review of the facility's Investigation Summary which was submitted to the State Agency on 8/8/18 revealed, Investigation Conclusion: The facility was able to substantiate the event occurred. (Licensed Practical Nurse (LPN) K's) employment was terminated on 8/8/2018 for inappropriate communication with this resident. Review of the facility's Complaint/Grievance Report dated 8/1/18 revealed, (Resident #5) feels (LPN K) makes him feel bad about himself to the point he is afraid to ask for his meds (medications) . During an interview on 9/6/18 at 9:43 AM, when asked about the incident that took place between Resident #5 and LPN K, Resident #5 stated, That was just an example of what would happen every day. I had received word that I was going to be going to (name of hospital'[MEDICAL CONDITION] center), I had all my stuff ready to go and (LPN K) looked into my room and said, 'what are you doing'? I told her that I was moving to [MEDICAL CONDITION] unit and she said, 'You ain't going nowhere.' She was following me down the hall and she kept saying this, it was quite loud and everyone was watching what she was doing. I asked her how she knew and she said, 'you ain't going nowhere', she kept saying it over and over and over while she kept following me. I was completely embarrassed, I wanted to crawl underneath a rock, she made me very embarrassed. Resident #5 continued, Other days, I would ask her if it was time for pain medication and (LPN K) would say, 'I'll tell you when it's time for your med (Medication).' So I would wait and then go ask her again, and she would tell me, 'What did I tell you, go away!'. (LPN K) would say this to me every day and after awhile I wouldn't ask, because I was afraid of being belittled. When asked if he ever missed pain medications because of this, Resident #5 stated, Yes, pain meds all of the time. I [MEDICAL CONDITION] and that pain is really bad. I was afraid to ask (LPN K) for meds, I felt like crawling under a rock, she would make me cry. Review of the Statement of Witness which was taken by Nursing Home Administrator (NHA) A, dated 8/1/18 revealed, (Resident #5) feels that he has to beg for his meds, to the point where he feels sometimes he is scared to ask for his medication because he doesn't want to be belittled. At the conclusion of this (statement), resident was emotional and became tearful. Humiliation is defined by the Centers for Medicare and Medicaid as, A feeling of shame due to being embarrassed, disgraced, or depreciated. During an interview on 9/5/18 at 2:35 PM, when asked about the abuse allegation that was submitted to the State Agency by the facility's Nursing Home Administrator, and asked if (LPN K's) license was reported to the State Licensing Board, NHA A stated, We substantiated that the event occurred, we could go either way whether it was abuse or not. When asked why was it not abuse, NHA A stated, Honestly, it was either or, we could go either way, we decided that the event occurred. When asked who we was, NHA A stated, the management team. When asked, so was it abuse, NHA A stated, The way I was coached/trained on this event was we could not establish that abuse took place, they, the higher ups said, 'let the state' (State Agency) come in and decide if it is abuse or not and then we can report the nurse. During the 9/5/18 at 2:35 PM interview, when asked to define abuse, NHA A stated, Physical, verbal calling them names, emotional or mental making them feeling bad, misappropriation, seclusion, neglect. When asked why was this not abuse, NHA A stated, (Resident #5) was saying that he was going to the hospital and told a CNA (Certified Nursing Assistant, CNA L). (CNA L) asked (LPN K) if she could help him. LPN K said don't believe him he is crazy, (LPN K) said this in public. My gut feeling leads me to believe that it was abuse, but at the time, at the whole situation, it was difficult to nail it down to what it was. Like I said it was how I was coached, we were very confident that the state (State Agency) was coming in on the event .then if the state comes in and they confirm abuse, then we would report (LPN K's) license then. Review of the Statement of Witness, which was taken by NHA A dated 8/2/18 revealed that CNA L stated that (Resident #5) was asking (CNA L) to assist him with packing a bag to go to the hospital. (CNA L) then asked (LPN K) if she was aloud (sic) to help him pack. (LPN K) responded with, 'Don't listen to him, he's crazy and he's not going anywhere.' . During an interview on 9/6/18 at 11:33 AM, when asked about the incident between LPN K and Resident #5, Activities Director (AD) H stated that she witnessed the event. AD H stated, I was walking near (Resident #5) he was asking me for help. He said 'They were holding a room for me at (Name of Hospital) and I need to get a hold of someone'. I went to the nurses station, and I asked (LPN K) what I should do and she said, 'you can't listen to him he is crazy.' I looked at her and then looked at him, he said, 'please do not listen to her, she is going to ruin this for me.' (Resident #5) looked sad and defeated. I took him into the front office and (CNA G) was there, and I asked her to help. (CNA G) and I assisted him in making the phone call, the receptionist at the office did say that they were saving a room for him. (Resident #5) got tearful, and he stated that he was afraid that (LPN K) was going to ruin this for him. The problem with this is it was out in front of everyone and in front of him. When asked if she felt that this was verbal abuse, AD H looked at the facility's abuse policy and stated, we as caregivers can appear to some that we hold a place of power and that is what I feel he was threatened by. I knew this wasn't right when it happened. I sit on the (name of the facility's) abuse task force that the ombudsman set up Yes, I would (say this is abuse), based on the definition that is clearly written here (pointing to the policy) and based on his reaction, he was crying and he was very scared that her words were going to influence me and his ability to get help. During an interview on 9/6/18 at 11:10 AM, when asked about the concerns between LPN K and Resident #5, CNA G stated, that she did witness the event that took place on 8/2/18. CNA G further stated, We had some issues with a nurse, (Resident #5) was asking for a medication and (LPN K) would argue with him about his time and he came to me and stated that he was afraid to ask (LPN K) for anything. (Resident #5) told me that every time he asked her for something she always played it off. When asked if she felt (LPN K) was abusive towards Resident #5, CNA G replied, Yes, he was asking for something and she wasn't providing him. He was very upset, I had to pull him into the office to calm him down, and then when he saw that she was gone and was told that she wont be back he was calmer. But he said, 'what if she comes back and is meaner?' When asked about the incident between LPN K and Resident #5, Staffing Coordinator I stated, I was in my office sitting at my desk. I could hear (LPN K) talking to (Resident #5) loudly .he was asking her to call the facility to help him with his room, and she was very loud and dismissive to him and was mocking him saying he does not have a room there and she wasn't going to help him and that he is crazy, and that is when I came out of my office .I stood back and observed what was happening, there were other staff members helping him, I know I went to the front office and told them I did not like the way the nurse was talking to him .he was like saying no, I do have a room here .he was frustrated .any other issues with her? No .verbal or emotional abuse? Yes, I would .both .I brought it up again that day at stand down at 3:30 .I let those know at that time the I felt it was verbal abuse .and everyone else came forward with what they saw .yes, they did agree with me that it was abuse .

This citation pertains to MI 168. Based on interview and record review, the facility failed to perform CPR on 1 of 2 sampled residents who were found without pulse or respirations and had a Full Code status (Resident #1), from a total of 5 sampled residents; resulting in Immediate Jeopardy to Resident #1 by not not receiving CPR (Cardiopulmonary Resuscitation) which was predetermined choice of Resident #1.Findings include: According to the Minimum Data Set, Resident #1 was a [AGE] year old male who had [DIAGNOSES REDACTED]. According to the Face Sheet, dated [DATE], Resident #1 lived at the facility since [DATE]. According to the Resident Request to Decline Life Prolonging Procedures document, signed by Resident #1 on [DATE], Resident #1 designated his choice to be: I want CPR to be Administered per facility policy. According to the facility Cardiopulmonary Resuscitation (CPR) Procedure, dated revised [DATE], .Unless a decision not to initiate CPR has previously been made by the resident and State guidelines are in place, CPR will be initiated on any resident that experiences a witnessed or unwitnessed cardiopulmonary arrest while in the center . Review of Resident #1's Determination of Inability to Participate in Medical Treatment Decisions form, first dated by a physician (signature illegible), revealed Resident #1 was deemed unable to participate in medical treatment decisions on [DATE], and an Acceptance of Designation by Patient Advocate document, dated [DATE] revealed he had been appointed a court appointed advocate, but no further updates to Resident #1's Code status were in Resident #1's Medical Record. According to a Clinical Progress Note, dated [DATE], Physician F documented, Staff asked me to address my opinion regarding code status regarding (Resident #1). Discussed with (Resident #1), he is feeling okay. No acute complaints . Looking back over the past year, his main problems are psychiatric problems with his [MEDICAL CONDITION] disorder, depression and past suicide ideation .Considering his baseline mental function, it would not be inappropriate of order a DNR (do not resuscitate), currently he has no pressing issue right now regarding addressing any imminent reason to consider hospice care . According to a Clinical progress note, dated [DATE], NP/Nurse Practitioner E documented, .stable BP (blood pressure) for (Resident #1) .TSH ([MEDICAL CONDITION] stimulating hormone) levels were drawn for lethargy and are elevated .(Resident #1) shows clear sings (signs) of decline; he refuses adequate food and fluid intake, although he is encouraged frequently .Treatment: 1. Major [MEDICAL CONDITION]; Notes: progressed, patient refusing food/fluid intake, weight loss, psych eval (evaluation ordered) .4. [MEDICAL CONDITION]; Notes: TSH ,[DATE], increase [MEDICATION NAME] from ,[DATE] mcg qd (every day). TSH levels in 8 weeks .Follow up: 1 week. According to a Clinical progress note, dated [DATE], NP E documented, (Resident #1) continues to state that he is sleepy. Staff reports that patient continues to sleep twice daily for extended periods of time. (Resident #1) denies CP (chest pain), SOB (shortness of breath), NVCD (nausea, vomiting, constipation, and diarrhea), although he is confused and a poor historian. (Resident #1) exhibits clear sings (signs) of severe decline; he continue to refuse adequate food and fluid intake although he is encouraged frequently. In an interview, on [DATE] at 9:35 AM, NP E reported she had been monitoring Resident #1's condition for the past few months and had ordered a psychological assessment because she could find no physiological reason why Resident #1's food and fluid intake had decreased and sleepiness had increased other than his [MEDICATION NAME] (medication to treat [MEDICAL CONDITION] disorder) levels being off. NP E reported she increased his [MEDICATION NAME] but, it takes 4 weeks to show results . NP E reported Resident #1 had dementia, but was not in the end stages of the disease. In a Witness Investigation Statement, dated [DATE], Nurse Aide D documented, (On [DATE] at 9:40 PM) Went in to check (Resident #1) and (Resident #1) appeared breathless and white. (Resident #1) looked dead so I went and got the nurse. I knew it was 9:40 (PM) because I looked at the clock before I went into (Resident #1's) room to do my last rounds. In an interview, on [DATE] at 2:30 PM, Nurse Aide D reported when she walked into Resident #1's room on [DATE] at 9:40 PM, (Resident #1's) knees were hanging off the bed. He didn't respond, but he's hard to wake up. I touched him; he was still warm .Only 1 ,[DATE] minutes passed from the time I saw him until (RN C) came in to (Resident #1's room) .I didn't see a blood pressure cuff go into the room. I stepped just outside the door and heard (RN C) say, He's dead, then she came out right away and went to the desk to make a phone call . In a Witness Investigation Statement, dated [DATE], RN/Registered Nurse C documented,(On [DATE] at 9:45 PM) I entered (Resident #1's) room approximately 9:45 PM. (Resident #1) appeared not to be breathing, was pale white, cool skin - BUE (both upper extremities)/BLE (both lower extremities), mouth and eyes fixed open. Upon my assessment, I noted that (Resident #1) indeed had no pulse or respirations. (Resident #1) did not respond when spoken to or shaken. Time of death was called by this RN at 2145 (9:45 PM) .This nurse checked (Resident #1) approx. (approximately) 9:15 PM; was sleeping soundly, snoring, and treatment completed. (Resident #1) was warm at the time. In an interview, on [DATE] at 10:17 AM, RN C reported she had been a Registered Nurse since [DATE], (had been hired by the facility as an LPN/Licensed Practical Nurse on [DATE]), and worked full time on second shift. RN C stated Resident #1 resided on A Hall, the unit she normally worked and she knew Resident #1 well, although RN C stated she did not know Resident #1's Code status prior to [DATE]. RN C stated Resident #1 did not wake up when she applied ointment to Resident #1's groin earlier in the evening, stating, Usually, he does wake up. RN C reported she immediately went to Resident #1's room when alerted by Nurse Aide D to come quickly because, It's (Resident #1). I think he's dead. RN C said,(Resident #1) appeared expired .fixed eyes, mouth open. Very apparently deceased . I announced him dead right then, at 9:45 PM. I did what we normally do. I didn't feel CPR was appropriate. CPR at this point isn't going to help him. Before this happened, no one ever told me it wasn't my nursing judgment to decide who not to give CPR to. After the fact, I found out our company still requires us to do CPR if they are a Full Code .I didn't know we were supposed to start CPR. When asked what a Full Code meant, RN C stated, It means they want CPR measures. RN C further stated, On (Resident #1's) chart, there was a boxed checked for Full Code. RN C stated she was certified to perform CPR and presented her current CPR certification card. Per Interim Orders, dated and signed by RN C on [DATE] at 2150 (9:50 PM/5 minutes after RN C stated she walked into Resident #1's room and found him without pulse or respirations), Okay to release body to (funeral home) per NP E. The Administrator B was notified, on [DATE] at 5:13 PM, of the Immediate Jeopardy that began on [DATE] at 9:45 PM due to failure to initiate CPR on Resident #1 who had a Full Code status and was found without pulse or respiration, resulting in death. On [DATE] at 9:00 AM, the Surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy as of [DATE]: 1). On [DATE], RN C was suspended pending investigation and determination of action. 2). Between [DATE] - [DATE] licensed nurses were reeducated regarding CPR and Code status policies including, but not limited to, reviewing the medical record for Code status and initiating CPR for residents with a resuscitation Code status. As of [DATE], 21 of 22 licensed nurses' education was completed, with the majority of facility licensed nurses educated by [DATE]. The remaining 1 licensed nurse, not educated, will be educated at the start of her next shift; as of [DATE], she is not scheduled to work. 3). On [DATE], Education was provided to Administrator and DON by Regional Director of Clinical Operations regarding the policy and procedure for CPR/DNR (do not resuscitate) including initiation of CPR for residents with a resuscitation code status. 4). On [DATE] an audit of 100% (22 of 22) of licensed nurses was completed to identify CPR certification; 7 of 22 certifications could not be validated. As of [DATE], 21 of 22 licensed nurses had verified, current CPR certification. 5). On [DATE], a process was implemented whereas the staffing schedule is to be reviewed in advance to ensure that there is always at least 1 CPR certified nurse on duty per shift. The CPR certified nurses are indicated on the schedule with a heart symbol next to their name. This process will remain in place until all nurses on staff have completed CPR certification. Should all identified CPR certified nurses call in, the DON will be notified and a CPR certified, on call manager will report to work. 6). On [DATE] an audit of 100% (80 of 80 residents on [DATE]) of all in house resident records was conducted and completed to validate the code status, orders, and advance directives were complete. 7). On [DATE], 2 of 2 attending physicians and 2 of 2 extenders were reeducated on the policies for CPR and Code status including requesting Code status upon death notifications. 8). On [DATE], 1 of 2 on call managers was educated on the policies for CPR and Code status, including requesting Code status upon death notifications. As of [DATE], 2 of 2 on call managers were educated. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to all in-services not completed and sustained compliance not verified by state agency. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IDENTIFY, PREVENT AND PROTECT 1 OF 5 SAMPLED RESIDENTS REVIEWED FOR ABUSE (#13) OUT OF A TOTAL SAMPLE 19 RESIDENTS, RESULTING IN PAIN, PHYSICAL, VERBAL, AND MENTAL ABUSE OF RESIDENT #13. FINDINGS INCLUDE: ACCORDING TO THE [MEDICAL CONDITION] MEDICATION USE CARE AREA ASSESSMENT (CAA) DATED 11/13/12, RESIDENT #13 WAS A "[AGE] year OLD FRAIL FEMALE WHO admitted INITIALLY TO THIS FACILITY FOLLOWING A BRIEF hospitalization S/P (status [REDACTED]. DUE TO SEVERAL OTHER CO-MORBIDITIES CONTRIBUTING TO HER CURRENT MENTAL STATE & HEALTH STATUS (RESIDENT #13) WAS PICKED UP BY (admitted TO) (NAME OF) HOSPICE 10/31/12. RESIDENT'S ABILITY TO MAKE SELF UNDERSTOOD IS LIMITED TO MAKING CONCRETE REQUESTS ONLY. RESIDENT'S ABILITY TO UNDERSTAND OTHERS IS IMPAIRED TO RESPONDING ADEQUATELY TO SIMPLE, DIRECT COMMUNICATION ONLY. RESIDENT'S ABILITY TO COMMUNICATE IS IMPAIRED BY DX (DIAGNOSIS) OF ALZHEIMER'S, DEMENTIA, & RECENT INTRACRANIAL TRAUMA.... RESIDENT IS AN EXTENSIVE ASSIST WITH USE OF SARA LIFT FOR TRANSFERS. RESIDENT'S MODE OF TRANSPORTATION IS WHEELCHAIR R/T (RELATED TO) BUT NOT LIMITED TO IMPROPER POSITIONING...POOR SAFETY AWARENESS... RESIDENT CONTINUES TO BE INCONTINENT OF BOWEL & BLADDER. ..RESIDENT IS CURRENTLY TAKING A ANTIDEPRESSANT MEDICATION PER physician's orders [REDACTED]. RESIDENT IS CURRENTLY TAKING A ANTIANXIETY MEDICATION AS NEEDED PER physician's orders [REDACTED]." ACCORDING TO BOTH THE QUARTERLY MINIMUM DATA SET (MDS) assessment dated [DATE] AND THE SIGNIFICANT CHANGE MDS dated [DATE] RESIDENT #13 SCORED 99 ON THE BRIEF INTERVIEW FOR MENTAL STATUS (BIMS), REFLECTING HER COGNITIVE AND COMMUNICATION LEVEL WAS TOO POOR TO CONDUCT AN INTERVIEW. HOWEVER, THE FACILITY'S 5-DAY INVESTIGATION REPORT DATED 3/4/13 REFLECTED THAT RESIDENT #13'S BIMS SCORE WAS 04 OUT OF A POSSIBLE 15, INDICATING SEVERE COGNITIVE IMPAIRMENT. ACCORDING TO THE FACILITY'S WRITTEN 5-DAY INVESTIGATION REPORT DATED 3/4/13, ON THE DATE OF 2/27/13 AT 9:30 PM, WITNESSES NURSE AIDE "L" AND NURSE AIDE "K" WERE IN RESIDENT #13'S ROOM WHEN THE NURSE AIDE "M" BEGAN ABUSING RESIDENT #13. NURSE AIDE "L" EXPLAINED TO THE DIRECTOR OF NURSING (DON) THAT SHE OBSERVED RESIDENT #13 VISIBLY SOILED AND ASKED NURSE AIDE "K" TO GO GET NURSE AIDE "M." WHEN NURSE AIDE "M" ENTERED THE ROOM SHE ASKED RESIDENT #13 "WHAT THE F**K DID THEY FEED YOU? NURSE AIDE "M" ALSO STATED "I DON'T HAVE TO PUT UP WITH THIS S**T" IN FRONT OF RESIDENT #13. WITNESSES NURSE AIDE "K" AND "L" NOTED THAT NURSE AIDE "M" WAS VISIBLY UPSET AND TRIED TO CALM NURSE AIDE "M" "STATING IT WAS NOT RIGHT HOW SHE WAS TALKING TO THE RESIDENT." THEN NURSE AIDE "M" "HELD (RESIDENT #13'S NAME) ARMS DOWN WHILE ATTEMPTING TO REMOVE SOILED CLOTHING AND BEDDING. (NURSE AIDE "M") WAS THEN NOTED TO GET BM (BOWEL MOVEMENT) ON HER HANDS AND THEN SWIPE THE RESIDENT'S (#13) DIRTY BED SHIRT ACROSS THE RESIDENT'S (#13) FACE. NURSE AIDE "M" THEN WIPED HER SOILED HANDS ON THE RESIDENT'S HAIR. WITNESSES NURSE AIDES "K" AND "L" STATED THEY NEEDED THE LIFT TO TRANSFER THE RESIDENT TO THE SHOWER ROOM TO CLEAN HER UP. NURSE AIDE "M" PROCEEDED TO MANUALLY LIFT THE RESIDENT FROM THE BED AND TRANSFER HER TO THE WHEELCHAIR. NURSE AIDE "L" DID NOT LEAVE THE RESIDENT ALONE WITH NURSE AIDE "M" AS SHE (RESIDENT #13) WAS TRANSPORTED TO THE SHOWER ROOM ... AND WHILE IN THE SHOWER." THIS SAME 5-DAY REPORT DATED 3/4/13 REFLECTED THE DIRECTOR OF NURSING OBSERVED RESIDENT #13 ON 2/27/13 AT APPROXIMATELY 21:30 (9:30 PM) BEING TRANSPORTED BY NURSE AIDES "L" AND "M" IN A WHEELCHAIR COVERED WITH A SHEET, THEN ASKED "WHAT THEY WERE DOING." NURSE AIDE "L" RESPONDED TO THE DON "PLEASE GO SEE (NURSE AIDE "K") ABOUT THIS SITUATION, NURSE AIDE "M" WAS NOT TREATING THE RESIDENT PROPERLY." ON 3/13/13 AT APPROXIMATELY 2:45 PM DURING AN INTERVIEW IN THE ACTIVITY ROOM, NURSE AIDE "K" ALSO EXPLAINED WHAT HAPPENED ON THE EVENING OF 2/27/13, NURSE AIDE "K" WITNESSED NURSE AIDE "M" ABUSING RESIDENT #13. NURSE AIDE "K" HAD AN OPPORTUNITY TO REPORT NURSE AIDE "M" WHILE NURSE AIDE "M" WAS VERBALLY ABUSING AND YELLING AT RESIDENT #13. NURSE AIDE "K" LEFT RESIDENT #13'S ROOM TO GET CLEAN TOWELS, BUT WHILE SHE WAS OUT OF THE ROOM, NURSE AIDE STATED SHE DID NOT TELL ANYONE WHAT WAS TAKING PLACE IN THE ROOM. NURSE AIDE "K" WAS ASKED WHY DIDN'T SHE TELL ANYONE ONE ABOUT HOW NURSE AIDE "M" WAS MISTREATING RESIDENT #13? NURSE AIDE "K" RESPONDED BECAUSE SHE HAD NOT STARTED ANY "PHYSICAL ABUSE" YET, AND SHE THOUGHT SHE WAS GOING TO CALM DOWN. NURSE AIDE "K" WAS THEN ASKED WASN'T NURSE AIDE "M'S" SWEARING AND YELLING AN INDICATION SHE WAS BEING ABUSIVE AND NOT IN ANY CONDITION TO CARE FOR A RESIDENT? NURSE AIDE "K" SAID, "NO BECAUSE (NAME OF NURSE AIDE "M") ACTS LIKE THAT ALL THE TIME, AND (NAME OF NURSE AIDE "M") ALSO COMPLAINED ABOUT DOING HER JOB." NURSE AIDE "K" GAVE AN EXAMPLE OF NURSE AIDE "M" EXPRESSING HER FRUSTRATION WITH A RESIDENT BY SAYING TO THEM "YOU WET AGAIN!" NURSE AIDE "K" STATED SHE HAD PREVIOUSLY REPORTED NURSE AIDE "M'S" ATTITUDE TO THE PRIOR DIRECTOR OF NURSING, AND WAS ASSURED THE DON HAD FOLLOWED UP WITH NURSE AIDE "M". ON 3/13/13 AT 2:45 PM DURING THIS SAME INTERVIEW WITH NURSE AIDE "K" SHE STATED SHE WANTED TO START AT THE BEGINNING AND NOT LEAVE ANYTHING OUT. NURSE AIDE "K" STATED SHE AND NURSE AIDE "L" WERE IN A DIFFERENT ROOM CARING FOR ANOTHER RESIDENT AND COULD SMELL AN ODOR. WHEN FINISHED CARING FOR THAT RESIDENT WE WENT DOWN "C" HALL LOOKING IN EACH ROOM, WHEN WE GOT TO RESIDENT #13'S ROOM SHE SAW HER HANGING OUT OF THE BED, SHE SAID TO NURSE AIDE "L" GIVE ME SOME GLOVES TO CLEAN UP, "IT'S A MESS." THEN NURSE AIDE "K" RAN AND GRABBED NURSE AIDE "M" WHO HAD BEEN CHARTING AND SAID "WE NEED YOU RIGHT NOW." THE FIRST "THING" NURSE AIDE "M" SAID WHEN SHE ENTERED THE ROOM WAS "WHAT THE F**K DID THEY FEED YOU?"NURSE AIDE "M" TOOK HER BM (BOWEL MOVEMENT) SOILED GOWN OFF SPLATTERING IT ON THE WALL AND RESIDENT #13'S FACE, THEN TOOK THE GOWN AND WIPED HER FACE WITH IT, AND PUT THE GOWN ON THE FLOOR. NURSE AIDE "K" STATED NURSE AIDE "M" HELD RESIDENT #13 BY HER WRISTS INTO HER CHEST AND YELLING AT THE SAME TIME. WHILE NURSE AIDE "M" WAS HOLDING RESIDENT #13 DOWN, RESIDENT #13 REPLIED "I'M GOING TO BITE YOU," AND NURSE AIDE "M" RESPONDED BY STICKING HER WRIST INTO RESIDENT #13'S MOUTH AND SAYING "BITE ME, BITE ME." WHILE NURSE AIDE "M" WAS HOLDING RESIDENT #13 DOWN, NURSE AIDE "L" TOOK HER BRIEF OFF. NURSE AIDE "K" STATED SHE TOLD NURSE AIDE "M" TO CALM DOWN, RESIDENT #13 REACTED SO SHE CALMED DOWN. THEN NURSE AIDE "M" STARTED SWEARING AGAIN USING THE WORD "S**T" A LOT. THEN NURSE AIDE "M" REPLIED TO NURSE AIDE "K" AND STATED "ARE YOU GOING TO TELL ME HOW TO DO MY JOB OR JUST YELL AT ME? NURSE AIDE "M" THEN PUT HER HAND UNDERNEATH THE BACK OF RESIDENT #13'S NECK AND THE OTHER ARM UNDERNEATH HER LEGS AND ROUGHLY PULLED RESIDENT #13 INTO A SITTING POSITION. NURSE AIDE "K" STATED SHE AND NURSE AIDE "L" INSISTED ON USING THE LIFT TO TRANSFER HER, NURSE "M" DID NOT RESPOND BUT WAS YELLING SHE DIDN'T LIKE BEING TOLD WHAT TO DO. RESIDENT #13 WAS IN A SITTING POSITION WHEN NURSE AIDE "M" SAID "I DON'T GIVE A S**T, JUST GET YOUR S**T ALL OVER ME, I'M GOING HOME ANYWAY. THEN NURSE AIDE "M" LIFTED RESIDENT #13 UNDERNEATH HER ARMS ROUGHLY, YANKED HER UP, AND SLAMMED HER INTO THE WHEELCHAIR." NURSE AIDE "K" STATED NURSE AIDE "M" SWORE, "ACTED LIKE SHE DIDN'T WANT TO DO HER JOB," ALL THE TIME, EVER SINCE SHE BEGAN EMPLOYMENT AT THIS FACILITY IN 9/12. SHE STATED SHE THOUGHT THIS WAS A PART OF NURSE AIDE "M'S" PERSONALITY. NURSE AIDE "K'S" INTERVIEW STATEMENTS WERE CONSISTENT WITH NURSE AIDE "K'S" WRITTEN STATEMENT COMPLETED ON THE "WITNESS INVESTIGATION STATEMENT" DATED 2/27/13 AT 21:30 (9:30 PM). ON 3/12/13 AT 3:50 PM, NURSE AIDE "L" WAS INTERVIEWED. NURSE AIDE "L" STATED SHE NOTICED NURSE AIDE "M" WAS IN A BAD MOOD BEFORE THE SHIFT BEGAN (ABOUT 2:30 PM). NURSE AIDE "L" STATED NURSE AIDE "M'S" FAMILY HAD MOVED IN WITH HER AND THEY WERE NOT PAYING ANY BILLS AND NURSE AIDE "M" WAS LOSING HER HOUSE. NURSE AIDE "L" STATED WHEN SHE WAS WALKING DOWN THE HALL SHE NOTICED RESIDENT #13 SITTING ON THE EDGE OF A LOW BED WITH FECES ON HER HANDS. NURSE AIDE "L" STATED SHE WENT TO TELL NURSE AIDE "M" BECAUSE RESIDENT #13 WAS HER ASSIGNED AIDE. NURSE AIDE "L" STATED SHE WAS IN THE ROOM WITH RESIDENT #13. AS SOON AS NURSE AIDE "M" ENTERED RESIDENT #13'S ROOM, SHE ASKED RESIDENT #13 "WHAT THE F**K DID THEY FEED YOU?" NURSE AIDE "L" STATED SHE (NURSE AIDE "L") PUT RESIDENT #13'S LEGS ON THE BED TO PULL HER BRIEF OFF, WHILE SHE WAS PULLING OFF RESIDENT #13'S BRIEF, RESIDENT #13 WAS FLINGING HER ARMS, NURSE AIDE "M" CROSSED RESIDENT #13'S ARMS AND HELD THEM INTO HER CHEST, WHILE NURSE AIDE "L" CONTINUED TO CHANGE HER BRIEF. NURSE AIDE "L" STATED NURSE AIDE "K" WAS WATCHING AND THEN WENT TO GET CLEAN TOWELS AND RETURNED ABOUT 1 1/2 MINUTES LATER. NURSE AIDE "L" STATED SHE HAD TRAINING ABOUT STRESS AND BURN OUT AND WHEN "A PERSON IS STRESSED YOU ARE SUPPOSED TO TAKE A BREAK." NURSE AIDE "L" WAS ASKED WHAT IF YOU RECOGNIZED SOMEONE ELSE WAS STRESSED, WHAT WERE YOU SUPPOSED TO DO? NURSE AIDE "L" REPLIED "I WOULD TELL THEM TO TAKE A BREAK AND IF THAT DOESN'T WORK I WOULD TELL THE NURSE." NURSE AIDE "L" WAS ASKED WAS THAT WHAT THE STAFF WAS TRAINED TO DO? NO REPLY. NURSE AIDE "L" WAS ASKED SUPPOSED THE NURSE AIDE SAID YOU CAN'T TELL ME WHAT TO DO YOU'RE NOT MY BOSS? NURSE AIDE "L" REPLIED "YEAH, THAT'S WHAT SHE (NAME OF NURSE AIDE "M") DID." NURSE AIDE "L" STATED SHE TOLD NURSE NURSE AIDE "M" "YOU CAN'T DO THAT" MEANING SHE CAN'T TRANSFER HER WITHOUT A LIFT. NURSE AIDE "M" INSISTED ON TRANSFERRING HER MANUALLY AND NOT USING THE LIFT. NURSE AIDE "L" EXPLAINED THE SLING WAS IN THE ROOM, BUT NURSE AIDE "M" WOULD NOT PUT IT UNDERNEATH HER. NURSE AIDE "L" STATED NURSE "M" GRABBED RESIDENT #13 UNDERNEATH HER LEGS WITH ONE ARM AND BY THE HEAD WITH THE OTHER ARM AND LIFTED HER OUT OF BED. AFTER WATCHING THE ABUSE OF RESIDENT #13 NURSE AIDE "L" STATED SHE IMMEDIATELY REPORTED IT. NURSE AIDE "L'S" INTERVIEW STATEMENT WAS CONSISTENT WITH NURSE AIDE "L'S" WRITTEN STATEMENT COMPLETED ON THE "WITNESS INVESTIGATION STATEMENT" DATED 2/27/13 AT 21:30 (9:30 PM). REVIEW OF NURSE AIDE "M'S" WRITTEN STATEMENT DATED 2/28/13 REFLECTED RESIDENT #13 DID SAY SHE WAS GOING TO BITE HER AND NURSE AIDE "M" REPLIED "GO FOR IT." NURSE AIDE "M" ALSO admitted TO IMPROPERLY TRANSFERRING RESIDENT #13 FROM THE BED TO THE CHAIR. NURSE AIDE "M" ALSO admitted IN HER WRITTEN STATEMENT THAT NURSE AIDE TOLD HER WHAT WAS WRONG AND HOW TO DO IT. NURSE AIDE "M'S" FINAL PARAGRAPH REFLECTED, "IF I SAID OR DID ANYTHING WRONG CNA SHOULD OF LEFT @ THAT TIME & TOLD A NURES (sic) OR SOMEONE, NOT STAY IN ROOM UNTIL THE WORK @ THAT TIME WAS DONE..." THE FACILITY INVESTIGATION REPORT COMPLETED BY THE ADMINISTRATOR DATED 3/4/13 REFLECTED, RESIDENT #13 WAS ASSESSED FOR SIGNS AND SYMPTOMS OF INJURY. FINDINGS INCLUDED A BRUISE TO THE LEFT FOREARM (2 CM X 1 CM), A BRUISE ON THE LEFT CALF (2.5 CM X 1.5 CM) AND A BRUISE TO THE RIGHT SCAPULA (2 CM X 1 CM)... RESIDENT DENIED PAIN AND HAD NO NON-VERBAL SIGNS OF PAIN. IT COULD NOT BE DETERMINED THAT THESE BRUISED WERE FROM THE INCIDENT THAT HAD JUST OCCURRED. THE FACILITY INVESTIGATION CONCLUSION REFLECTED, "THE ALLEGATION OF ABUSE WAS SUBSTANTIATED BASED ON THE WITNESS STATEMENTS...AT THAT TIME, SHE (NURSE AIDE "M") WAS TERMINATED FROM EMPLOYMENT." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO SECURE AN OXYGEN CYLINDER AND FAILED TO PROVIDE ADEQUATE SUPERVISION FOR TWO OF 8 SAMPLED RESIDENTS REVIEWED FOR FALLS AND (#5, #17) AND THREE OFF SAMPLED RESIDENTS WITH POTENTIAL BURNS (#20, #21, #24), AND PROVIDE A GRAB BAR IN THE BATHROOM FOR ONE RESIDENT (#24) FROM A TOTAL OF 17 SAMPLED RESIDENTS, RESULTING IN FEAR AND PAIN FOR RESIDENT #5, A FALL AND FRACTURE FOR RESIDENT #17 AND THE POTENTIAL FOR FALLS FOR RESIDENT #24, AND THE POTENTIAL FOR BURNS FOR RESIDENTS #20, #21 AND #22. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S [DIAGNOSES REDACTED]. ACCORDING TO THE HOSPITAL CONSULTATION REPORT DATED [DATE] (4 DAYS PRIOR TO ADMISSION) RESIDENT #17 SUSTAINED A FRACTURE OF THE PUBIC RAMUS ON THE RIGHT "THESE ARE NONDISPLACED." THIS SAME REPORT REFLECTED RESIDENT #17'S "...NEUROVASCULAR FUNCTION OF THE RIGHT LEG WAS INTACT. PATIENT IS A LITTLE FORGETFUL, OTHERWISE APPEARS TO BE HEALTHY." THE OCCUPATIONAL THERAPIST "PLAN OF CARE"AND INITIAL assessment dated [DATE] REFLECTED RESIDENT #17 HAD "COMPLIANT'S OF RIGHT HIP AND LEG PAIN/WEAKNESS WITH RESULTING IMPAIRMENTS IN ACTIVITIES OF DAILY LIVING, AMBULATION, AND TRANSFERS. THIS SAME ASSESSMENT REFLECTED SHE HAD SEVERE COGNITIVE IMPAIRMENT SHE WAS ORIENTED TO HERSELF, HER SAFETY JUDGEMENT WAS SEVERELY IMPAIRED" (CONSISTENTLY NEEDING DIRECTION). RESIDENT #17'S BALANCE AND DYNAMIC STANDING WAS "ACCEPTS MINIMAL CHALLENGE; UNABLE TO MAINTAIN BALANCE WHILE TURNING HEAD/TRUNK." THIS SAME INITIAL ASSESSMENT STATED COMMUNICATION WAS "RAMBLING, LACKS CONTENT, AND WORK FINDING PROBLEMS NOTED. SEVERELY IMPAIRED PROBLEM SOLVING SKILLS, ORIENT TO SELF ONLY AND EASILY DISTRACTED BY SELF IN A LOW STIMULUS ENVIRONMENT. TENDS TO LEAN BACKWARDS AND SITS AT WILL VS WHEN FURNITURE AVAILABLE." BOTH THE MONTHLY physician's orders [REDACTED].#17 SHOULD HAVE BED ALARM, WHEELCHAIR ALARM AND TO CHECK FUNCTION EVERY SHIFT. RESIDENT #17'S ACTIVITIES OF DAILY LIVING AND MOBILITY CARE PLAN DATED [DATE] REFLECTED FACILITY STAFF SHOULD "EXPLAIN ALL PROCEDURES, PROVIDE ASSISTIVE DEVICE AS NEEDED FOR TRANSFER: STAND BY ASSIST WITH GAIT BELT. RESIDENT #17'S FALL CARE PLAN DATED [DATE] REFLECTED A HISTORY OF FRACTURES INCLUDING HIP AND ARM. THE INTERVENTIONS WERE A PERIMETER WITH OPENING, CHAIR AND BED ALARMS, MAT TO FLOOR, LOCK BED WHEELS AND BED NEXT TO WALL." THE FACILITY'S "ACCIDENT/INCIDENT REPORT" DATED [DATE] REFLECTED "RES. OBSERVED ON HANDS AND KNEES IN FRONT OF WHEELCHAIR AND KLEENEX BOX. DENIES DROPPING THE BOX BUT STATES WAS TRYING TO GET OVER THE FIRE DOOR THRESHOLD. DID NOT HIT HEAD, DENIES PAIN. SKIN INTACT, 0 BRUISING, GAIT BELT AND STATIONARY CHAIR TO HELP RES I (INDEPENDENTLY) BACK TO HER WHEELCHAIR. WHEELCHAIR ALARMS PRESENT AND FUNCTIONING." THE IMMEDIATE ACTION THAT WAS TAKEN TO PREVENT FURTHER INCIDENTS WAS "RESIDENT EDUCATION ON PROPER POSTURE IN WHEELCHAIR WHEN SITTING OR PROPELLING ONESELF. VERBALIZED UNDERSTANDING. REMOVED TISSUE BOX FROM HANDS SO SHE CAN PROPERLY PROPEL." THE 'MULTI-DISCIPLINARY THERAPY SCREENING TOOL DATED [DATE] REFLECTED RESIDENT #17 HAD "POOR SAFETY AWARENESS, INCREASED CONFUSION, POOR RETENTION WITH TEACHING SAFETY, REQUIRES ASSISTANCE/VERBAL CUEING FOR TRANSFERS AND AMBULATION, INDEPENDENT WITH WHEELCHAIR MOBILITY MAY NEED VERBAL CUES WITH MANEUVERING." AN INCIDENT AND ACCIDENT REPORT DATED [DATE] REFLECTED THAT NURSE "U" WAS SUMMONED TO THE DINING ROOM WHERE RESIDENT (#17) WAS OBSERVED LYING ON THE FLOOR ON HER RIGHT SIDE. FALL WAS WITNESSED BY DIETARY AIDE "V" - WITNESS STATEMENT TAKEN DESCRIBING FALL." THE IMMEDIATE ACTION TAKEN TO PREVENT FURTHER INCIDENTS WAS TO "HAVE THERAPY ASSESS RESIDENT FOR SEATBELT ALARM." ON THIS SAME FORM UNDER "TRANSFERRING FROM" IT WAS NOTED THAT RESIDENT #17 "GOT UP OUT OF CHAIR IN DINING ROOM, WALKED, fell ." ACCORDING TO THE "WITNESS INVESTIGATION STATEMENT" DATED [DATE] AT 12:30 AM, DIETARY AIDE "V" STATED "I HEARD THE CHAIR ALARM GO OFF, AND (RESIDENT #25'S NAME) STARTED TO YELL AT RESIDENT #17 TO SIT DOWN. I WALKED AROUND THE WALL TO SEE THAT RESIDENT #17 WAS WALKING VERY FAST AND COULD SEE THAT SHE WAS WOBBLY SO I WAS RUSHING OVER TO HER AND THAT'S WHEN SHE TURNED AND CAUGHT ONE FOOT ON THE OTHER AND fell on HER RIGHT SIDE. I CALLED FOR A NURSE, AND NURSE (W) CAME RIGHT AWAY." ACCORDING TO THE "WITNESS INVESTIGATION STATEMENT" DATED [DATE] AT "11:00ISH AM "COMPLETED BY NURSE AIDE "F". RESIDENT #17 WAS "LAST TOILETED AFTER BREAKFAST AROUND 9:30 AM AND TOOK HER TO ACTIVITIES AFTERWARD. THERE WASN'T AN ACTIVITY STARTED SO I SET HER UP WITH A MAGAZINE TO LOOK AT. HER SENSOR ALARM WAS ON. AROUND 11 AM, THE NURSE CAME DOWN D-HALL AND TOLD ME (RESIDENT #17'S NAME) WAS ON THE FLOOR IN THE DINING ROOM. NURSE AIDE "X" GOT A TEMPO (MOBILE LIFT DEVICE) AND I GOT A SLING. ... NURSE AIDE "X", NURSE AIDE "Y" AND I GOT HER (RESIDENT #17) BACK INTO HER WHEELCHAIR: USING THE TEMPO. SHE LOOKED LIKE SHE WAS IN PAIN BUT SHE WASN'T SCREAMING..." "...SHE WAS IN A LOT OF PAIN, SO I TOLD THE NURSE "U". SHE SAID SHE CALLED THE DOCTOR AND SHE WILL GIVE HER SOME PAIN MEDICINE THE DOCTOR HAD JUST ORDERED. I ASKED HER - THE DOCTOR DIDN'T ORDER AN X-RAY? AND NURSE "U" SAID NO - SHE JUST ORDERED ULTRAM." NURSE AIDE "F" STATED "I WENT BACK TO (RESIDENT #17'S) ROOM AND WENT TO TAKE HER TO LUNCH. SHE (RESIDENT #17) STATED SHE NEEDED TO GO TO THE BATHROOM. I TRIED TO TAKE HER TO THE BATHROOM, SHE IS A STAND-BY ASSIST WITH GAIT BELT. SHE (RESIDENT #17) WAS NOT ABLE TO STAND UP AT ALL. SHE WAS IN SO MUCH PAIN. WE TRIED A COUPLE OF TIMES TO STAND WHEN I FINALLY DECIDED TO USE A SARA LIFT (SIT TO STAND DEVICE). SHE WAS UNABLE TO BEAR WEIGHT ON HER RIGHT LEG AND KEPT IT UP WHILE I WAS LIFTING HER ON THE LIFT. WHILE (RESIDENT #17) WAS ON THE TOILET, ON THE SARA, I WENT AND TOLD NURSE "U" THERE IS REALLY SOMETHING WRONG AND EXPLAINED WHAT SHE WAS DOING. I TOLD HER I THINK HER HIP IS BROKEN. SHE (NURSE "U") TOLD ME SHE JUST GAVE HER ULTRAM AND GIVE IT SOME TIME TO KICK IN. TIME WENT BY AND I TOLD NURSE "U" SHE WAS STILL IN PAIN AND SO SHE CALLED THE DOCTOR AGAIN AND NEXT THING I KNOW SHE (RESIDENT #17) WAS BEING SENT TO THE HOSPITAL." "LATER THAT NIGHT AFTER DINNER SOMETIME I ANSWERED THE PHONE AND IT WAS RESIDENT #17'S SON. HE TOLD ME HER RIGHT HIP WAS BROKEN AND THEY WERE SCHEDULING SURGERY..." AN INTERVIEW WITH THE DIRECTOR OF NURSING ON THE MORNING OF [DATE] CONFIRMED THAT RESIDENT #17 WAS LEFT UNATTENDED IN THE BATHROOM IN THE SARA LIFT BY NURSE AIDE "F" WHILE NURSE AIDE "F" WAS SEARCHING FOR THE NURSE. THE PROGRESS NOTE COMPLETED BY NURSE "U" DATED [DATE] AT 14:15 STATED, "AT APPROX. 1200 NOON, RES (RESIDENT) ATTEMPTED TO AMBULATE IN DR (DINING ROOM) AND fell on L (LEFT) HIP." THERE WAS NO DOCUMENTION IN THE CLINICAL RECORD THAT A COMPREHENSIVE ASSESSMENT OF THE RESIDENT WAS COMPLETED AFTER THE FALL. A DOCUMENT PROVIDED BY THE FACILITY ADMINISTRATOR (UNDATED) TITLED "ASSESSMENT AFTER A FALL" REFLECTED "CHARGE NURSE ON DUTY THAT DAY RECEIVED TRAINING ON ASSESSMENT OF RESIDENTS AFTER A FALL...CHARGE NURSE RECEIVED DISCIPLINARY ACTION ADDRESSING ISSUES REGARDING ASSESSMENT OF A RESIDENT AFTER A FALL." THE RIGHT HIP AND FEMUR PANEL X-RAY DATED [DATE] FROM THE HOSPITAL REFLECTED RESIDENT #17 HAD AN "ACUTE INTERTROCHANTERIC FRACTURE OF THE RIGHT HIP..." THE HOSPITAL RESIDENT TRANSFER FORM DATED [DATE] REFLECTED RESIDENT WAS "CONFUSED, NEEDS REDIRECTION AND REMINDERS CONSTANTLY FOR SAFETY." RECORD REVIEW OF RESIDENT #17'S CARE PLANS REFLECTED A CARE PLAN TITLED "FALL/INJURY: PREVENTION AND MANAGEMENT PLAN OF CARE" INITIATED UPON RESIDENT #17'S admitted D [DATE]. THERE WERE NO FURTHER UPDATES OR ADDITIONAL INTERVENTIONS ON THE CARE PLAN UNTIL [DATE], 4 DAYS AFTER THE RESIDENTS SECOND FALL ON [DATE] WHICH RESULTED IN A RIGHT HIP FRACTURE. A CARE PLAN TITLED "ADL/MOBILITY: PLAN OF CARE" INITIATED ON [DATE] DID NOT REFLECT ANY UPDATES OR ADDITIONAL INTERVENTIONS UNTIL [DATE]. RESIDENT #17'S FALL CARE PLAN UPDATED [DATE] AND [DATE] REFLECTED A ROOM CONFIGURATION AND PRESSURE SENSITIVE ALARM TO CARDIA CHAIR. THE MOBILITY CARE PLAN UPDATED [DATE] REFLECTED "2 ASSIST WITH TEMPO LIFT/SM SLING." THE "THERAPY COMMUNICATION TO NURSING" FORM DATED [DATE] REFLECTED RESIDENT #17 NOW HAD A GERI CHAIR ORDERED. RECORD REVIEW OF RESIDENT #17'S MINIMUM DATA SET (MDS) ASSESSMENT REFERENCE DATE [DATE] REFLECTED A SIGNIFICANT CHANGE IN CONDITION COMPARED TO RESIDENTS ADMISSION MDS ASSESSMENT REFERENCE DATE OF [DATE]. THE CARE AREA ASSESSMENT SECTON FOR NUTRITIONAL STATUS DATED [DATE] REFLECTED, "OVERALL DECLINE=NOT WANTING TO EAT, POOR PO INTAKE,V (VERY) CONFUSED, PAIN R/T FX (FRACTURE) HIP W (WITH) SURGERY...FAMILY CONSIDERING HOSPICE FOR COMFORT CARE." THE CARE AREA ASSESSMENT SECTON FOR PAIN DATED [DATE] REFLECTED, "PAIN OCCURS CONSTANTLY AND LASTS UNTIL FALLS ASLEEP...DOES HAVE NONVERBAL INDICATORS OF PAIN INCLUDING BUT NOT LIMITED TO FACIAL GRIMACING, MOANING, AND GUARDING R/T PAIN." THE FACILITY FAILED TO PROVIDE SUPERVISION AND COMPREHENSIVE INTERVENTIONS TO RESIDENT #17 WITH A KNOWN HISTORY OF FALLS WITH PREVIOUS FRACTURES RESULTING IN ADDITIONAL FALLS WITH A RIGHT HIP FRACTURE RESULTING IN HARM TO RESIDENT #17. NURSING NOTES REFLECT THAT RESIDENT #17 died on [DATE]. ( ) RESIDENT #5 WAS AN [AGE] year-OLD FEMALE admitted to the facility on [DATE] WITH THE [DIAGNOSES REDACTED]. ALZHEIMER'S, PREDIABETIC, URINARY INCONTINENCE, AND DEPRESSION. ACCORDING TO THE FACILITY DOCUMENT TITLED "FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE" DATED [DATE] REFLECTED RESIDENT #5 WAS CATEGORIZED TO BE A HIGH RISK FOR FALLS AND INTERVENTIONS OF BED AND WHEELCHAIR ALARMS WERE TO BE UTILIZED. ON [DATE] AT 2:45 P.M. RESIDENT #5 WAS OBSERVED IN HER ROOM LYING IN BED AND COMPLAINED OF HAVING TO GO TO THE BATHROOM. ON [DATE] AT 3:05 P.M. UPON RETURNING TO VISIT WITH RESIDENT #5 IN HER ROOM, A VOICE WAS HEARD STATING "GOD HELP ME, SOMEONE HELP ME, OH GOD HELP ME, OH GOD" IN A SOFT CALL OUT TONE. THE VOICE WAS COMING FROM RESIDENT #5 'S BATHROOM AND UPON OPENING THE DOOR RESIDENT #5 WAS OBSERVED TO BE POSITIONED LEANING TO THE LEFT ON THE TOILET AND STILL HARNESSED IN THE SLING WITH BOTH LEGS STRAPPED TO THE SHIN SUPPORT PAD OF THE SIT-TO-STAND LIFT. NO STAFF WERE PRESENT AND RESIDENT #5 WAS UNABLE TO REACH THE CALL LIGHT WHEN ASKED. RESIDENT #5 WAS COMPLAINING OF LEFT HIP PAIN. ON [DATE] AT 3:10 P.M. A CERTIFIED NURSING ASSISTANT, STAFF "F" WALKED INTO RESIDENT #5'S ROOM AND ASKED RESIDENT #5 IF SHE WAS FINISHED GOING TO THE BATHROOM. AN INTERVIEW AT THIS TIME WITH STAFF "F" WAS CONDUCTED. STAFF "F" WAS ASKED IF A RESIDENT WAS TO BE LEFT STILL HARNESSED TO A LIFT WHEN IN THE BATHROOM AND STAFF "F" REPLIED BY STATING "AS LONG AS THE BRAKES ARE ON SHE IS SAFE." THEN STAFF "F" WAS ASKED IF A RESIDENT IS CONSIDERED A HIGH RISK FOR FALLS IF THEY ARE TO BE LEFT UNATTENDED IN THE BATHROOM AND STAFF "F" REPLIED "NO, WHEN A RESIDENT HAS ALARMS FOR FALLS THEY ARE NOT TO BE LEFT UNATTENDED IN THE BATHROOM, I'M SORRY." AT THAT TIME CNA STAFF "E" ENTERED THE ROOM TO ASSIST CNA STAFF "F" WITH TRANSFERRING RESIDENT #5 FROM THE BATHROOM TO BED." CNA "E" WAS ASKED IF A RESIDENT WAS TO BE LEFT UNATTENDED IN THE BATHROOM IF THEY ARE CONSIDERED A HIGH RISK FOR FALLS AND CNA STAFF "E" REPLIED "NO, IF THE RESIDENT IS A HIGH RISK FOR FALLS WE ARE NOT TO LEAVE THEM ALONE." THEN CNA "E" WAS ASKED IF IT IS OKAY TO LEAVE A RESIDENT UNATTENDED IN THE BATHROOM AND STILL HARNESSED IN A SIT TO STAND LIFT AND CNA STAFF "E" REPLIED, "WELL, IT HELPS TO STABILIZE THEM, BUT PROBABLY NOT." ON [DATE] AT 2:50 P.M. AN INTERVIEW WITH THE EDUCATIONAL TRAINING DIRECTOR, STAFF "I" WAS CONDUCTED IN THE SITTING AREA JUST INSIDE THE MAIN DINING ROOM. WHEN ASKED IF IT WAS OKAY TO LEAVE A RESIDENT IN A SIT-TO-STAND LIFT WHILE ON THE TOILET IN THE RESTROOM UNATTENDED, STAFF "I" REPLIED, "ABSOLUTELY NOT!" STAFF "I" PRESENTED A FACILITY DOCUMENT TITLED "FALL PREVENTION EDUCATION" DATED [DATE] & 11, 2012 THAT REFLECTED "RESIDENTS WITH ALARMS MAY NOT BE LEFT UNATTENDED WHILE IN THE RESTROOM." IN ADDITION, STAFF "I" PRESENTED A FACILITY DOCUMENT USED FROM TRAINING CNAS REGARDING THE SAFE USE OF LIFTS (TRANSFERRING DEVICES) TITLED "ACUTE CARE RETURN DEMONSTRATION CHECK-OFF PACKET-ANSWER KEY" DATED [DATE] THAT REFLECTED, UNDER THE SECTION TITLED "RETURN DEMONSTRATION CHECK-OFF", "SHOULD YOU EVER LEAVE A PATIENT ROOM WHEN THEY ARE IN A LIFT" WITH THE POSTED ANSWER AS "NO". ON [DATE] AROUND 11:45 A.M. AN INTERVIEW WAS CONDUCTED WITH RESIDENT #5'S HUSBAND IN RESIDENT #5'S ROOM. WHEN RESIDENT #5'S HUSBAND WAS ASKED ABOUT THE TOILETING OF RESIDENT #5 HE REPLIED, "WHEN I AM HERE THEY WILL TAKE HER TO THE BATHROOM AND LEAVE HER-TELL HER TO PULL THE CORD WHEN SHE IS FINISHED. THEY LEAVE HER IN THE MACHINE ON THE TOILET." RESIDENT #5'S HUSBAND WENT ON TO STATE, "AND I AM HERE ALMOST EVERYDAY." ON [DATE] AT 9:30 A.M. DURING AN INITIAL TOUR OF THE FACILITY, AN OXYGEN CYLINDER WAS OBSERVED IN THE OXYGEN CLOSET AT THE BEGINNING OF C-HALL STANDING UP ON THE FLOOR AND NOT SECURED IN A RETAINER DEVICE. REVIEW OF THE FACILITY'S POLICY AND PROCEDURE TITLED "OXYGEN STORAGE" DATED [DATE] REFLECTED "KEEP CYLINDERS IN AN APPROVED OXYGEN CART OR STORAGE BIN; IF CYLINDERS ARE NOT IN A STORAGE CART OR STORAGE BIN, THEY MUST BE SECURED BY A CHAIN OR OTHER SUITABLE RETAINER DEVICE." RESIDENT #20 WAS AN [AGE] year-OLD MALE admitted to the facility on [DATE] WITH THE [DIAGNOSES REDACTED]. ON [DATE] FROM 8:30 A.M. TO 8:50 A.M. RESIDENT #20 WAS OBSERVED IN THE DINING ROOM, SITTING AT A TABLE DRINKING A CUP OF COFFEE THAT HAD STEAM ROLLING OFF THE TOP OF THE LIQUID INSIDE THE CUP WITHOUT A LID. RESIDENT #20 WOULD TAKE THE CUP WITH BOTH HANDS TO BRING IT TO HIS MOUTH AND THEN WOULD REST THE CUP ON HIS ROUNDED PROTRUDING ABDOMEN OR SET THE CUP ON THE TABLE NEAR THE EDGE CLOSEST TO THE RESIDENT NEAR THE PLATE OF FOOD. THE LID TO THE COFFEE CUP WAS SITTING ON THE TABLE NEAR THE COFFEE CUP. REVIEW OF RESIDENT #20'S MEAL TICKET REFLECTED THAT RESIDENT #20 WAS TO HAVE LIDS ON HOT LIQUIDS FOR SAFETY. REVIEW OF RESIDENT #20'S MEDICAL RECORD REFLECTED ON A FACILITY DOCUMENT TITLED "FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE" DATED [DATE] UNDER THE ASSESSMENT SECTION IT IS WRITTEN "AT RISK FOR HANDLING HOT BEVERAGES". UNDER THE INTERVENTIONS SECTION IT IS WRITTEN, "STAFF TO PROVIDE LIDS ON ALL HOT BEVERAGES" AND DATED [DATE]. RESIDENT #21 WAS A [AGE] year-OLD FEMALE admitted to the facility on [DATE] WITH THE [DIAGNOSES REDACTED]. ON [DATE] FROM 8:30 A.M. TO 8:50 A.M. RESIDENT #21 WAS OBSERVED IN THE DINING ROOM, SITTING AT A TABLE DRINKING A CUP OF COFFEE WITH CREAMER WITHOUT A LID. THE LID WAS SITTING ON THE TABLE NEXT TO THE COFFEE CUP. RESIDENT #21 WAS OBSERVED TO BE SIPPING COFFEE FROM THE CUP WITHOUT THE LID, HER HAND HAD A SLIGHT TREMBLE WHEN MANEUVERING THE COFFEE CUP. REVIEW OF RESIDENT #21'S MEAL TICKET REFLECTED THAT RESIDENT #21 WAS TO HAVE LIDS ON ALL HOT BEVERAGES FOR SAFETY. REVIEW OF RESIDENT #21'S MEDICAL RECORD REFLECTED ON A FACILITY DOCUMENT TITLED, "ADL/MOBILITY: PLAN OF CARE" DATED [DATE] UNDER THE SECTION TITLED PROBLEM, "AT RISK FOR HANDLING HOT BEVERAGES" AND UNDER THE SECTION TITLED INTERVENTIONS IT WAS WRITTEN, "HOT BEVERAGES WILL HAVE SIPPY LID" AND DATED [DATE]. RESIDENT #22 WAS AN [AGE] year-OLD FEMALE RE-admitted to the facility on [DATE] WITH THE [DIAGNOSES REDACTED]. ON [DATE] ABOUT 7:50 A.M. RESIDENT #22 WAS OBSERVED SITTING IN THE DINING ROOM AT A TABLE DRINKING A CUP OF COFFEE WITHOUT A LID. THE LID TO THE COFFEE CUP WAS LAYING ON THE TABLE BESIDE THE CUP. REVIEW OF RESIDENT #22'S MEDICAL RECORD REFLECTED ON A FACILITY DOCUMENT TITLED "PROGRESS NOTES" DATED [DATE] "IDT (INTERDISCIPLINARY TEAM) MET DAY #1, CHART REVIEW, RESIDENT AT RISK FOR HANDLING HOT BEVERAGES...". A FACILITY DOCUMENT TITLED "FOOD PREFERENCE RECORD" AND DATED [DATE] REFLECTED, "LID ON HOT BEVERAGE...". ( ) DURING THE ENVIRONMENTAL TOUR ON [DATE] STARTING AT 9:08 AM, THE BATHROOM SHARED BY ROOM A-9 AND A-11, USED BY 1 OF 3 RESIDENTS (#24) WAS OBSERVED TO BE WITHOUT ANY GRAB BARS. ATTACHED TO THE COMMODE (AND THE BACK OF THE TOILET SEAT) WAS A METAL FRAME APPARATUS USED TO ATTACH COMMODE RAIL HANDLE SUPPORT GRAB BARS. YET, THE HANDLE SUPPORT GRAB BARS WERE NOT ATTACHED TO THE TOILET. NOR WERE THERE ANY GRAB BARS AVAILABLE IN THE RESTROOM, TO PROMOTE SUPPORT/STABILITY FOR COMMODE USE. LATER THE SAME DAY AT 11:51 AM NURSING ASSISTANT (STAFF "T") REVEALED THAT RESIDENT #24 USED THE RESTROOM, VIA THE SARA LIFT FOR TRANSPORT. STAFF "T" STATED SHE WOULD LEAVE THE RESIDENT ON THE COMMODE WITH THE SARA LIFT AND STAY IN THE ROOM OUTSIDE THE DOOR. ALSO, THAT THE RESIDENT PUTS HIS HANDS ON SARA LIFT AND GRAB BARS IN THE BATHROOM. STAFF "T" WAS INFORMED THAT THERE WERE NO GRAB BARS IN THE REST ROOM. STAFF "T" REPLIED, THERE ARE SUPPOSED TO BE RAILS THERE ON THE TOILET, AND THAT THEY WERE THERE BEFORE SHE LEFT FOR VACATION. THE ADMINISTRATOR WAS PRESENT DURING THE INTERVIEW, AND STATED HE WAS NOT AWARE THAT THERE HAD BEEN GRAB BARS PRESENT THAT WERE MISSING. ( )

THIS CITATION PERTAINS TO MI 189 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY IN 1 OF 6 SAMPLED RESIDENTS FROM A TOTAL SAMPLE OF 8 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY (IJ) WHEN RESIDENT #501, WHO HAD BEEN IDENTIFIED AS AN ELOPEMENT RISK, ELOPED FROM THE FACILITY ON 7/25/11 AT APPROXIMATELY 4:25 AM UNBEKNOWNST TO FACILITY STAFF. RESIDENT #501 RETURNED TO THE FACILITY AT 5:25 AM AFTER ATTEMPTING TO CALL THE FACILITY ON HIS CELL PHONE TO INFORM THEM OF HIS IMMINENT RETURN. THIS DEFICIENT PRACTICE PLACES FIVE OTHER RESIDENTS, WHO ARE IDENTIFIED AS ELOPEMENT RISKS, AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET IN THE MEDICAL RECORD, DATED 7/17/11, REVEALED RESIDENT #501 WAS A [AGE] year OLD MALE admitted to the facility on [DATE]. REVIEW OF THE MINIMUM DATA SET (MDS), dated [DATE], REVEALED RESIDENT #501 HAD DIAGNOSES, WHICH INCLUDED VASCULAR DEMENTIA WITH DELUSIONS, STROKE, AND DEPRESSION. THE MDS REVEALED RESIDENT #501 HAD NO COGNITIVE IMPAIRMENTS. REVIEW OF THE "QUARTERLY NURSING DATA COLLECTION AND ASSESSMENT", DATED 6/2/11, REVEALED RESIDENT #501 WAS IDENTIFIED AS AN ELOPEMENT RISK AND HAD A WANDERGUARD BRACELET ATTACHED TO HIS WHEELCHAIR. RESIDENT #501 HAD LEFT ARM AND HAND CONTRACTURES AS WELL AS LEFT ARM AND LEG WEAKNESS AS A RESULT OF A STROKE. RESIDENT #501 HAD IMPAIRED RANGE OF MOTION ON HIS LEFT SIDE. REVIEW OF AN INCIDENT/ACCIDENT REPORT, DATED 7/25/11, WRITTEN BY LICENSED PRACTICAL NURSE (LPN) #3, REVEALED THAT SHOWER AIDE #11 CAME INTO THE HALLWAY AND TOLD LPN #3 THAT RESIDENT #501 WAS COMING DOWN THE 25 MILE PER HOUR (MPH) ROAD IN HIS WHEELCHAIR. THE REPORT REVEALED LPN #3 WENT DOWN THE HALLWAY AS RESIDENT #501 WAS COMING IN THROUGH THE FRONT DOOR. RESIDENT #501 TOLD LPN #3 HE HAD GONE TO THE GAS STATION. RESIDENT #501 WAS INTERVIEWED ON 8/3/11 AT 8:45 AM. RESIDENT #501 WAS IN AN OFFICE WITH THE SURVEYOR, SEATED IN HIS WHEELCHAIR. THE SURVEYOR OBSERVED THAT RESIDENT #501 WAS WEARING A HAT, SHIRT, SWEAT PANTS, AND TENNIS SHOES. RESIDENT #501 APPEARED WELL-GROOMED AND FREE FROM ANY UNEXPLAINED PHYSICAL INJURIES. RESIDENT #501'S WANDERGUARD BRACELET WAS ATTACHED TO HIS WHEELCHAIR. RESIDENT #501 REPORTED HE left the faciity on THE MORNING OF 7/25/11 BECAUSE HE NEEDED TO BUY COFFEE AND CIGARETTES FROM THE GAS STATION. RESIDENT #501 REPORTED HE DID NOT MAKE THE STAFF AWARE THAT HE WAS LEAVING THE FACILITY. RESIDENT #501 REPORTED THAT HE PROPELLED HIMSELF BACKWARDS IN HIS WHEELCHAIR, DOWN A 25 MPH ROAD, AND THEN ONTO THE SIDEWALK OF A FOUR LANE 40 MPH ROAD THAT WAS UNDER CONSTRUCTION. RESIDENT #501 REPORTED THAT HE TRIED CALLING THE FACILITY TO LET THEM KNOW HE WAS COMING BACK TO THE FACILITY, BUT NO ONE ANSWERED HIS PHONE CALL. REVIEW OF A VIDEO SURVEILLANCE FROM THE GAS STATION REVEALED RESIDENT #501 ENTERED THE GAS STATION AT 4:52 AM ON 7//25/11 AND LEFT AT 4:59 AM. RESIDENT #501 WAS WEARING A HAT, SHIRT, SWEAT PANTS, AND TENNIS SHOES. REVIEW OF THE GAS STATION'S TRANSACTION JOURNAL, DATED 7/25/11 AT 4:52 AM, REVEALED RESIDENT #501 PURCHASED COFFEE, CIGARETTES, AND A LIGHTER. ACCORDING TO THE SURVEYOR'S VEHICLE ODOMETER, THE DISTANCE FROM THE FACILITY TO THE GAS STATION WAS 0.3 MILES IN AN INTERVIEW ON 8/4/11 AT 9:16 AM, CERTIFIED NURSING ASSISTANT (CNA) #12 REPORTED ON 7/24/11 DURING THE DAY SHIFT, SHE CHECKED RESIDENT #501'S WANDERGUARD BRACELET FOR FUNCTIONALITY AND PLACEMENT. CNA #12 REPORTED ONE OF HER DAILY RESPONSIBILITIES WAS TO CHECK ALL ALARMED DOORS AND WANDERGUARD BRACELETS. CNA #12 REPORTED ALL ALARMED DOORS AND WANDERGUARD BRACELETS WERE FUNCTIONING PROPERLY ON 7/24/11. IN AN INTERVIEW ON 8/3/11 AT 9:30 AM, CNA #4 REPORTED ON 7/25/11 AT APPROXIMATELY 4:00 AM, SHE PROVIDED MORNING CARE FOR RESIDENT #501, DRESSED HIM, AND CHECKED HIS WANDERGUARD FOR PLACEMENT. CNA #4 REPORTED RESIDENT #501 DID NOT REQUEST COFFEE OR CIGARETTES AT THAT TIME. IN AN INTERVIEW ON 8/4/11 AT 7:18 AM AND IN A WRITTEN STATEMENT (UNDATED), LPN #3 REPORTED ON 7/25/11 AT APPROXIMATELY 4:25 AM, SHE GAVE RESIDENT #501 HIS MEDICATIONS AND THEN HE SELF-PROPELLED HIMSELF DOWN THE HALL. LPN #3 REPORTED RESIDENT #501 DID NOT REQUEST COFFEE OR CIGARETTES AT THAT TIME. LPN #3 REPORTED SHE INITIATED 15 MINUTE CHECKS AFTER RESIDENT #501 RETURNED TO THE FACILITY AT APPROXIMATELY 5:30 AM BUT DID NOT DO A HEAD-TO-TOE ASSESSMENT. IN AN INTERVIEW ON 8/4/11 AT 6:30 AM AND IN A WRITTEN STATEMENT, DATED 7/27/11, CNA #5 REPORTED ON 7/25/11 AT APPROXIMATELY 4:45 AM, HE WAS COMING OUT OF A RESIDENT'S ROOM AND HEARD THE DOOR ALARM SOUNDING. CNA #5 REPORTED HE TURNED OFF THE ALARM, CHECKED OUTSIDE, DID NOT SEE ANY RESIDENTS, THEN WENT BACK TO WORK. IN AN INTERVIEW ON 8/4/11 AT 8:28 AM AND IN A WRITTEN STATEMENT, DATED 7/26/11, SHOWER AIDE #11 REPORTED ON 7/25/11 AT APPROXIMATELY 5:25 AM, SHE OBSERVED RESIDENT #501 SELF-PROPELLING HIMSELF BACKWARDS IN HIS WHEELCHAIR ON THE 25 MPH ROAD HEADING TOWARDS THE FACILITY'S PARKING LOT. SHOWER AIDE #11 REPORTED RESIDENT #501 HAD A CUP OF COFFEE FROM THE GAS STATION IN HIS HAND. SHOWER AIDE #11 REPORTED SHE PARKED HER CAR, ENTERED THE FACILITY, CLOCKED IN FOR WORK AND THEN WENT TO INFORM LPN #3 THAT RESIDENT #501 WAS PROPELLING IN HIS WHEELCHAIR BACKWARDS INTO THE FACILITY'S PARKING LOT. SHOWER AIDE #11 REPORTED SHE AND LPN #3 WENT TO THE FRONT DOOR AND AS A RESIDENT #501 ENTERED THE FACILITY, THE WANDERGUARD ALARM SOUNDED. AN OBSERVATION ON 8/2/11 AT 2:00 PM, REVEALED ALL EXIT DOORS (7 EXIT DOORS) AND WANDERGUARD BRACELETS (6 WANDERGUARD BRACELETS) WERE FUNCTIONING PROPERLY. ON 8/5/11 AT 3:15 PM, THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 7/25/11 WHEN THE FACILITY FAILED TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY OF RESIDENT #501, WHO HAD BEEN IDENTIFIED AS AN ELOPEMENT RISK, AND WHO ELOPED FROM THE FACILITY ON 7/25/11 AT APPROXIMATELY 4:25 AM UNBEKNOWNST TO FACILITY STAFF. RESIDENT #501 RETURNED TO THE FACILITY AT 5:25 AM AFTER ATTEMPTING TO CALL THE FACILITY ON HIS CELL PHONE TO INFORM THEM OF HIS IMMINENT RETURN. THIS DEFICIENT PRACTICE PLACES FIVE OTHER RESIDENTS, WHO ARE IDENTIFIED AS ELOPEMENT RISKS, AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. ON 8/9/11 10:00 AM, THE SURVEYOR CONFIRMED THAT THE FACILITY STAFF IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON 7/26/11, ALL RESIDENTS WERE ASSESSED FOR ELOPEMENT AND SMOKING. RESIDENT CARE PLANS WERE UPDATED, AS NEEDED, AND REMAIN CURRENT. ALL SMOKERS SIGNED A NEW SMOKING POLICY ACKNOWLEDGEMENT AND HAD A SAFE SMOKING ASSESSMENT COMPLETED. 2. ON 7/27/11, MISSING PERSON DRILLS WERE CONDUCTED FOR FIRST AND SECOND SHIFTS. 3. ON 7/27/11, CARE DELIVERY GUIDES WERE UPDATED FOR RESIDENTS WITH ELOPEMENT RISK AND SMOKERS. ELOPEMENT BOOKS WERE REVIEWED AND RECOPIED/REDATED/UPDATED, AS NEEDED. 4. ON 7/27/11, THE SOCIAL SERVICES DIRECTOR INITIATED A CONVERSATION WITH RESIDENT #501 REGARDING ALTERNATIVE PLACEMENT AFTER SURGERY 5. ON 7/28/11, A MISSING PERSON DRILL WAS CONDUCTED FOR THIRD SHIFT. 6. AS OF 7/28/11, ELOPEMENT IN-SERVICING CONTINUES WITH 114 OUT OF 122 STAFF IN-SERVICED. THE IN-SERVICING BEGAN ON 7/26/11. NO STAFF WILL BE ALLOWED TO WORK UNTIL IN-SERVICING HAS BEEN ACCOMPLISHED. 7. AS OF 7/28/11, SMOKING IN-SERVICING CONTINUES WITH 101 OUT OF 122 STAFF IN-SERVICED. THE IN-SERVICING BEGAN ON 7/26/11. NO STAFF WILL BE ALLOWED TO WORK UNTIL IN-SERVICING HAS BEEN ACCOMPLISHED. 8. AS OF 7/28/11, IN-SERVICING BEGAN FOR ALL STAFF REGARDING SIGNAGE POSTED AT THE FRONT DOOR, STATING THAT VISITORS MUST CONSULT WITH A NURSE WHEN ASSISTING RESIDENTS OUTSIDE. ALTHOUGH IMMEDIATE JEOPARDY WAS REMOVED ON 7/28/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND A SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO THE FACT THAT IN-SERVICES HAD NOT BEEN COMPLETED FOR ALL STAFF AND SUSTAINED COMPLIANCE HAD NOT YET BEEN VERIFIED BY THE STATE AGENCY. ( )