Every finding on record at Medilodge of Zeeland

Based on observation, interview, and record review, the facility failed to provide sufficient staff to timely meet the needs for seven facility residents (R2, R15, R14, R95, R13, R48, and R6) and failed to respond effectively to the concern of the members of the Resident Council. Findings include.R48 Review of the Electronic Medical Record (EMR) reflected that R48 has pertinent diagnosis that includes absence of left leg below the knee, adjustment disorder w/ mixed anxiety and depressed mood, constipation, dependence on wheelchair and PTSD (Post Traumatic Stress Disorder). Review of the Minimum Data Set (MDS – a tool used to determine a resident's status) revealed R48 was cognitively intact. Section GG (functional Abilities and Goals) of this MDS reflected the Resident was dependent on staff for transfers, and bed mobility. During an interview on 05/04/2026 at 12:22 PM, R48 stated they don't have enough staff (especially on 3rd shift) I can't always choose when I want to go to bed because there are not enough staff. They try to accommodate us, but it is hard. R48 explained, I was tired and wanted to go to bed last night but was unable to because there wasn't enough staff. I didn't end up getting in bed until almost 2. We had one aide last night for 2 hallways and they had to pull an aide off the memory care unit to help. They just don't have enough staff at night for over 100 of us. R6 Review of the Minimum Data Set (MDS – a tool used to determine a resident's status) revealed R6 was cognitively intact. Section GG (functional Abilities and Goals) of this MDS reflected the Resident was dependent on staff for transfers, bed mobility. During an interview on 5/05/26 at 9:21 AM, R6's Guardian O revealed staffing has been short. Guardian O stated R6 has called me at night because staff were not answering his call light and it has been over an hour. I've tried to call the facility at night, but their phone system is a mess, and I've had to drive up (to the building) and ring the front door and wait for them to answer before I could get him help. During an interview on 05/06/2026 at 12:19 PM, NHA revealed they were working on staffing and states they can't control call ins. During the interview this surveyor revealed that many of the residents had complaints about call light (times), care and concerns with 3rd shift including concerns with Sunday night staffing (5/3/26). NHA revealed that 3rd shift was rough and stated we recently termed (terminated) 2 Aides together. These Aides' rode together and would show up late. They would leave/be gone from the building for periods of an hour to an hour half at a time during their shift. Review of the staff scheduled for 5/3/26 revealed for 3rd shift they had 3 nurses and 6 aides working from 10PM to 6AM for approximately 115 residents. R2 Review of the Electronic Medical Record (EMR) reflected R2 admitted to the facility 10/7/2025 with pertinent diagnoses that included bilateral below knee amputation and limitation of activities due to disability, Review of the Minimum Data Set (MDS – a tool used to determine a resident's status) dated 4/8/2026 revealed R2 was cognitively intact. Section GG (functional Abilities and Goals) of this MDS reflected the Resident was dependent on staff for transfers. On 5/4/2026 at 12:06 PM an interview was conducted with R2 in his room. R2 reported he required the use of a mechanical lift to transfer from his wheelchair to his bed. R2 reported he often had to wait, sometimes for an hour while sitting in his wheelchair for staff to transfer him back to his bed. R2 reported a spot on his bottom opened up a few days ago and a dressing had been applied. R15 Review of the Electronic Medical Record reflected R15 admitted to the facility 7/20/2025 with pertinent diagnoses that included: Paraplegia (loss or impaired use of extremities), Multiple Sclerosis (a chronic neurological disorder that affects the brain and spinal cord), Overactive bladder, and Repeated Falls. Review of the MDS dated [DATE] reflected R15 was cognitively intact. Review of the Activities for Daily Living (ADL's) Care Plan for R15 reflected two caregivers in room for ADLs and all contact. However, the Care Plan further reflected R15 had ongoing physical needs and required staff assistance with dressing, personal hygiene, transfers, and toileting. The ADL Care Plan reflected an intervention to Encourage resident to use call light when assistance is needed. The At Risk for Falls/Injury Care Plan reflected an intervention to Encourage resident to use call light. The episodes of incontinence Care Plan reflected Assist resident with toileting needs. On 5/5/2026 at 8:47 AM an interview was conducted with R15 in his room. E15 reported sometimes when he must use the bathroom staff tell him they must pick up meal trays instead. R15 reported this made him feel like he was the last priority. R15 stated that the facility was hurting for staff. R15 reported incidents when he initiated his call light that it was not unusual for staff to respond, turn off the call light, and tell him they would be back. R15 stated sometimes they come back. When asked how that made him feel R15 stated, like why a baby cries. R15 asked if he could be provided a catheter and indicated it would be for his convivence. R15 reported he preferred to wear two briefs because staff were not good about changing him. R15 added that he did not like it when he was changed and staff only put one brief back on him, R14 Review of the EMR Face Sheet reflected R14 originally admitted to the facility 5/12/2025 with pertinent diagnoses that included: Visual Loss Both Eyes (blind) Review of the Minimum Data Set (MDS) dated [DATE] reflected R14 was cognitively intact. This MDS reflected R14 was occasionally incontinent of bowel and bladder and required supervision with toileting and transfers. On 5/4/2026 at 9:00 AM an interview was conducted with R14 in his room. It was observed that his call light was on, and the Resident was asked about staff's response to his call light. R14 stated I ain't going to say'. Then R14 reported that call light response was frequently 'forty-five minutes to an hour. R14 declined to discuss this further at this time. On 5/6/2026 at 12:40 PM a follow up interview was conducted with R14 in his room. The Resident was observed to be in a wheelchair at the side of his bed. R14 was prompted to revisit the call light issue previously reported. R14 reported that most of the time delayed call light response was at nighttime. R14 again reported that call light response times were often forty-five minutes to an hour. R14 was asked how he knew the time of the wait as he was blind? R14 reported he had a phone that told him the time, R14 was asked if staff ever gave him a reason for their delayed response. R14 reported staff said they were busy. R14 was asked how that made him feel when he had to wait so long. R14 stated it made him feel like how you don't want to feel. R14 reported he was supposed to be assisted with transfers, but he had self-transferred often. R14 indicated this was related to extended call light response waiting times. R14 reported. But they don't like it when I do . sometimes I fall. R95 Review of the EMR reflected R95 originally admitted to the facility 4/24/2025 and had current pertinent diagnoses that included Foot Drop, left Foot, and Abnormality of Gait and Mobility. Review of the dated 3/6/26 reflected R95 was cognitively intact. On 5/5/2026 at 9:58 AM during an interview conducted in her room, R95 reported she experienced extended call light response waiting times that can be an hour. R95 reported the waiting times for assistance were worse during the night. R95 reported she was a fall risk and was not supposed to go to the bathroom without help. R95 reported she has had accidents (wet herself) and indicated this was due to the extended wait times. R95 reported she didn't want to get anyone in trouble, that the staff were working hard but that the facility just needs more people. R13 Review of R13's face sheet dated 5/4/26 revealed he was [AGE] years old, admitted on [DATE] with diagnoses that included: diabetes mellitus, pressure ulcer right hip, stage 4, lack of coordination, and reduced mobility. R13 was his own responsible party. During an interview with R13 on 5/4/26 at 1:54 PM, in his room he complained about not having enough staff and having to wait a long time for his call light to be answered. R13 put on his call light for help with the Surveyor in the room. The staff responded in 8 minutes. However, 2 staff walked by the room and did not respond to the call light. The light was verified to be on and visible in the hall. When the Certified Nurse Aide responded she apologized and reported she had just returned from her lunch. During an interview with R13 in his room on 5/5/26 at 2:31 PM with Unit Manager (UM) J present R13 complained about staff not assisting him routinely turning in bed and coming into his room saying things about not getting paid enough and not having enough help. UM J side she would complete a concern form for R13. Review of R13's Grievance and Satisfaction Form dated 5/5/26 at 2:30 PM, revealed, UM J completed the form. Concerns with staff reporting short staffed and complaining about two person assist. Resolution, Explained to him staff will be educated on customer service. Resolution was dated 5/6/26 as satisfied. Review of the facility Resident Council Minutes for 2/10/26 revealed, Current Situation/Concern. There has been a long wait time for call-lights later in the evening. Review of the facility Resident Council Minutes for 3/10/26 revealed, Old Business Review: There has been a long wait time for call-lights later in the evening. Outcome: not resolved action needed. Review of the facility Resident Council Minutes for 4/14/26 revealed, New Business Review/Action Plan: Call-light response time is long for third shift, action taken grievance form. Review of Grievance and Satisfaction From dated 4/14/26 at 11:00 AM revealed, Call light response time longer at night (third shift) Administrator Notification section was dated 4/17/26, scheduler relooked at the 3rd shift schedule and revised based off acuity. Resolution revealed, restructured cna's to have a float aide between halls. Date Resident Notified of Resolution was 4/24/26 and it was marked as Resident was satisfied. No resident name or readable signature of a resident was provided. During the quality assurance (QA) review on 5/6/26 at 2:03 PM, the Nursing Home Administrator (NHA) was asked if she had the call light response time in QA and if she was resident council has listed this as a concern for February 2026, March 2026, and April 2026. The NHA said she was aware of the concerns and was aware none of the interventions/actions the facility has taken have resolved the concern.

Based on observation, interview, and record review, the facility failed to implement a skin care plan for 1 Resident (R13) of 1 resident reviewed for skin care.Findings included: Review of R13's face sheet dated 5/4/26 revealed he was [AGE] years old, admitted on [DATE] with diagnoses that included: diabetes mellitus, pressure ulcer right hip, stage 4, lack of coordination, and reduced mobility. R13 was his own responsible party.R13 was observed in bed on 5/4/26 at 1:54 PM. He had an electrical motor attached to his mattress with the setting on firm. R13 did not know what his mattress setting should be. He knew he had sores on his butt and back but was not aware if they were healing. R13 was on his back in bed and there were no extra pillows visible to use for side to side turning. R13 was frustrated with his attempts to get staff to help get cleaned up and turned in bed. He complained about long-call light waits and staff complaining about being short staffed. R13 put on his call light for help at this time and it took 8 minutes for staff to respond. The Certified Nurse Aide (CNA) that responded apologized for the delay and reported she had been at lunch.During an interview with R13 in his room on 5/5/26 at 2:31 PM with Unit Manager (UM) J present, R13 complained about staff not assisting him routinely turning in bed and coming into his room saying things about not getting paid enough and not having enough help. R13 was on his back and reported he was on his back all day and only got turned one time at night. R13 could not roll in bed independently when asked to move himself. R13's motor to his mattress was unplugged and set at firm. UM J discovered the mattress had been unplugged and was not sure what setting the mattress needed. UM J said her expectation was for staff to turn him every two hours and place a pillow under one side of his back.During an interview with CNA N on 5/5/26 at 3:30 PM, he denied turning R13 and placing pillows under his side during care today. CNA N said he provided a bed bath after lunch on 5/5/26 around 1:30 PM and left him on his back.Review of R13's ADL (Activities of Daily Living) care plan dated 7/24/26 revealed, Bed Mobility: 2 person assist.Review of R13's impaired skin integrity care plan dated 7/18/25 revealed, Pressure Reducing Mattress (APM) initiated 7/29/26 (no setting indicated). Encourage resident to reposition self if able initiated 7/18/25, Assist resident with turning and repositioning at least every 2-3 hrs (hours) initiated 7/18/25.

Based on observation, interview, and record review, the facility failed to formulate and implement a plan of action to monitor, treat, and prevent the worsening of impaired skin for one Resident (R2) of two residents reviewed for impaired skin. Findings include:Review of the Electronic Medical Record (EMR) reflected R2 admitted to the facility 10/7/2025 with pertinent diagnoses that included bilateral below knee amputation and limitation of activities due to disability, Review of the Minimum Data Set (MDS - a tool used to determine a resident's status) dated 4/8/2026 revealed R2 was cognitively intact. Section GG (functional Abilities and Goals) of this MDS reflected the Resident was dependent on staff for transfers.On 5/4/2026 at 12:06 PM, an interview was conducted with R2 in his room. R2 reported he required the use of a mechanical lift to transfer from his wheelchair to his bed. R2 reported he often had to wait, sometimes for an hour while sitting in his wheelchair for staff to transfer him back to his bed. R2 reported a spot on his bottom opened up a few days ago and a dressing had been applied.Review of the EMR document titled Skin Assessment dated 4/23/2026 reflected no to new abnormal skin areas.Review of the Skin Assessment dated 4/30/2026 reflected yes to new abnormal skin areas. The document reflected Red area noted on upper coccyx. Skin is blanchable, appears to be related to shearing. The documented reflected Area cleaned, a foam border dressing applied. The document reflected yes to treatment initiated. The documentation did not reflect measurements were obtained of the Red area.Review of the EMR Progress Notes for R2 did not reflect the Medical Provider has been contacted and informed about the newly identified impaired skin. Review of the Doctor's Orders for R2 did not reflect a treatment had been implemented for dressing changes or monitoring of the impaired skin on the coccyx.Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for April and May 2026 did not reflect routine dressing changes or monitoring of the coccyx area of R2 had been implemented.Review of the Care Plan for R2 did not reveal any revisions that alerted staff that a focus area of impaired skin had been identified or that new interventions were implemented to improve or prevent worsening of the area.On 5/6/2026 at 12:57 PM an observation and interview were conducted in the room with R2 and Unit Manager (UM) J. The coccyx area of R2 was exposed and revealed a round dressing dated 5/4. UM J removed the dressing to reveal purulent drainage approximately the size of a quarter was observed on the dressing. The non-blanchable reddened area appeared as an abrasion and was photographed, measured (1.92 centimeters (cm) x 1.96 cm), and redressed using a hydrocolloid dressing. Following the observation UM J reported she would update the Doctor's Orders for care of the wound. UM J was asked how nurses would have known to change the dressing as no prior Doctor's Order had been in place. UM J confirmed that no Doctor's Order for dressing changes had been in the EMR and stated, I can't answer that. UM J was informed that the Care Plan for R2 had not been revised to include the area identified on 4/30/2026. UM J indicated the Care Plan would be revised to reflect current care and that the Medical Provider would be contacted.

Based on observation, interview, and record review, the facility failed ensure the safety of 2 two residents (R40) for safe bed mobility and for (R7) to prevent numerous falls, of 12 reviewed for accident hazards.Findings include:R7 Review of Face Sheet revealed Resident #7 re-admitted to the facility on [DATE], with pertinent diagnoses of Parkinson's Disease with Dyskinesia, anemia, bipolar disorder and encounter for palliative care. A review of R7's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 4/29/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 99 which revealed R7 was unable to complete the assessment/interview. Review of R7's Electronic Medical Record (EMR) reflected Resident had fallen from his bed seven times in the last 6 months. Review of R7's Care Plan Interventions for falls included, Utilize positioning devices such as pillows and wedges for safe positioning. Date Initiated: 04/13/2026. - Low bed Date Initiated: 07/24/2025 Revision on: 04/13/2026. - Mat to floor next to bed Date Initiated: 07/24/2025 Revision on: 04/13/2026. -Monitor my position to reduce the risk of sliding/falling Date Initiated: 07/24/2025 Revision on: 01/26/2026 - Observe for changes in mobility Date Initiated: 07/18/2025 - Perimeter overlay mattress to assist with positioning. Date Initiated: 07/24/2025 Revision on: 05/05/2026 - Place the call light within reach, though the resident may not be cognitively intact to use it. Date Initiated: 07/18/2025 Revision on:04/23/2026 - Quarter side rails Date Initiated: 05/03/2026 Revision and Resolved on 5/05/26. Review of Fall dated 10/21/2025 at 14:00 reflected, resident was getting up to go to the bathroom. Resident was found on the floor next to his bed and bedside table in close proximity to the bed. Noted no injuries. Review of Fall dated 1/20/2026 at 01:00, revealed, Resident observed lying face down on the floor between the bed and wall. Incont. (incontinent) of bowel. Indwelling Foley cath (catheter) was pulled taut causing pain/bleeding d/t position of resident. Resident stated he was on the floor but did not know how he got there. C/O pain at indwelling foley site. Balloon deflated and large amount of bright red blood instantly noted flowing into tubing and bag. Foley removed. Bleeding continued for approximately 5-10 minutes. Review of Fall dated 2/27/26 at 22:30, revealed aide came to this nurse as resident was on floor. When this nurse came to the room resident was lying on their back, on the floor facing the doorway. This nurse assessed resident vitals stable (104/61p,97 O2, 72p, 18r, 97.9 t) no injuries noted. Was able to move all extremities. Hoyer used to get resident up from the floor. Resident placed back in bed. On call nurse notified, . Resident description: I slid out of bed. Review of Fall dated 3/08/2026 at 04:30, revealed CNA notified this nurse that the resident was found on the floor. Upon arrival, resident observed lying facedown on the floor next to the bed. Resident rolled out of bed. Resident Description: I just fell it happens. Immediate Action Taken, Skin assessment completed. No skin issues noted. Bilateral knees slightly red; no bruising observed. No open areas or swelling noted. Bed placed in lowest position, call light within reach. Fall precautions reinforced. Review of the Nurses' Note dated 3/08/2026 at 05:33, reflected, CNA notified this nurse that the resident was on the floor. Upon arrival resident observed lying face-down on the floor next to the bed. Skin assessment completed. No new skin issues noted. Bilateral knees slightly red; no bruising observed. No open areas or swelling noted. Resident assisted back to bed using Hoyer lift with the assistance of 3 CNAs and this nurse to ensure safe transfer. Safety mattress straps adjusted, bed placed in lowest position, call light in reach. On call nurse and NP (Nurse Practitioner) notified. Family to be notified by first shift nurse for better hours to call for non-emergency. Review of Nurses' Note dated 3/08/2026 at 16:42 reflects, Res. Guardian/Conservation (Name of) was called and updated of Res. crawling out of bed last night and was Thankful. Review of Fall dated 3/08/2026 at 20:44, revealed resident had, small lump to back left of head. Interventions listed in the 3/08/2026 fall document included Collaborate with Hospice regarding routine medication (Ativan). Review of Nurses Progress Notes dated 3/08/2026 at 23:48 reflects, Resident roommate wheeled over to this nurse and informed that resident was on the floor in their room. At the same time a CNA also came to notify this nurse of same incident. Together we entered room observed resident on the floor next to his bed laying on his back with his head in the direction of the foot of the bed. Hoyered into bed. Difficult to get true assessment of ROM (Range of Motion) due to extremities movements. Initially, small lump felt to back of head, however not felt when reassessed. Per hospice, unless change of condition, okay to not due routine VS (Vital Signs) or neuro checks. Review of Physician Progress Note dated 3/9/2026 at 15:03, . Recurrent falls. (3/8 x2) has scoop mattress, unclear how he is rolling OOB (Out of Bed) No injury. Medications are reviewed. No prn morphine prior to fall, but noted prn Ativan prior to 2044 fall 3/8. Review of 4/09/2026 at 09:13, Interdisciplinary Progress Note Late Entry reflected, Review fall out of bed, bed low, perimeter mattress, continues to be physically active in bed with no purposeful movement. Assist with bed mobility to keep pulled up in bed. Mat on floor. Assist with positioning. Review of 4/9/2026 at 09:31, Interdisciplinary Progress Note reflected, Ativan increase due to constant body movement, causing him to be all over his bed, mat on floor, perimeter mattress. Assist with bed mobility. Noted increase in Ativan has decreased his uncontrolled movements. Care plan updated. Review of 4/9/2026 at 09:43, Interdisciplinary Progress Note reflected perimeter mattress, floor mat and mattress secured. Ativan has been changed to routine, noting decrease in his unvoluntary movements causing him to move in bed. Care Plan updated. Review of R7's Revised Care Plan failed to reflect any fall interventions/changes to care plan between 4/4 - 4/12/2026. Review of 4/10/2026 16:19 Nurses' Notes reflected, (Name of Resident) is very active today in his bed, needing to be repositioned frequently as he gets to the end of the bed, or cross ways. Perimeter on mattress, doesn't utilize the call light. He is answering back by just repeating what was said to him. He has been removing his brief at times, which is a new behavior. Review of Fall dated 4/11/2026 at 16:53, reflects the resident was, In bed, restless. Review of intervention revealed, When he is restless, will bring him out by nurses' station in gerichair. Review of Nurses' Notes dated 4/11/2026 at 17:03, reflected, Roommate of resident notified staff that the resident was on the floor. Resident observed lying diagonally on floormat next to bed, with his head under the bed. Assessed for injury and pain, none found observed. Used Hoyer to get patient back in bed, he had bm (bowel movement) and was very restless. A review of Fall dated 5/3/2026 at 01:55, reflected resident was Lying in bed. He had told CNA that his roommate wanted the TV off, but resident wanted it on. He was attempting prior to this fall to get up to play soccer (what he stated to CNA). He also requested CNA to help him have a BM at last interaction prior to fall. Review of Nurses' Notes dated 5/03/2026 at 03:31 revealed, While rounding on floor, CNA found resident lying on his stomach on the floor on the Mat beside his bed, naked, and having a BM. This nurse went into room and observed resident on floor as stated above with head where head of the bed would be. VSS, no visible sign of injury. Resident stated he did not hit his head and that he has no new pain present from fall. Resident is able to move all extremities. Resident was lifted off floor using two CNA's and a Hoyer lift. Resident was then laid back in bed. Review of Nurses' Notes dated 5/05/2026 at 09:51 revealed, IDT: review fall out of bed, refused change call light to touch pad, bed repositioned in room, NP reviewed medications, continue check and change for incontinence with repositioning. Perimeter mattress on bed with mat on floor. During an observation of R7's on 05/05/2026 at 3:19 PM, reflected the resident's bed was pushed up against the wall with a fall mat next to the bed no quarter rails observed. R7 states he is locked in bed and needs to get out. This surveyor asks resident to push his call button so his aide would come. R7's mattress at the foot of the bed on his right side was angled, smushed, and slumped towards the floor. Resident had slid down in his bed, and both of his legs were angled off the right side towards the floor. Perimeter overlay was not observed on resident's mattress. In an interview on 5/05/2026 at 3:22 PM, R7 stated he needs to get out of bed. On 5/05/2026 at approximately 3:26 PM, DON walked-in to answer R7's call light. This surveyor asked DON if residents sloped mattress could be contributing to his falls? DON stated she would check on it and would go find assistance to help get resident out of bed. On 5/05/2026 at approximately 3:50PM, R7 was dressed and staff were assisting resident into a wheelchair. Observation of R7's bed on 05/06/2026 at 3:00 PM revealed a new mattress had been provided. Further observation revealed the sides/edges around the perimeter were built-up approximately 3 inches to assist in preventing the resident from slipping out of bed. During an interview on 05/06/2026 at 4:14 PM, DON stated for (Name of R7) We provided a new mattress w/ perimeter overlay, keeping his bed low. R40 Review of R40's face sheet dated 5/5/26 revealed she was admitted to the facility on [DATE] and diagnoses included: Hemiplegia and hemiparesis following nontraumatic intercranial hemorrhage (brain injury causing lack of movement), seizures and gastrostomy status (tube fed). R40 was not her own responsible party. On 5/5/26 at 11:47 AM Certified Nurse Aide (CNA) I was observed providing incontinence care for R40. CNA I did not have any assistance providing R40 with the incontinence care which required her to roll R40 from side to side in the bed to clean her, change her brief and the pad in bed. Every time R40 was rolled to her left side it was away from CNA I and no one was on the other side of the bed to provide safety or assistance. When CNA I completed care for R40 she was asked when she was trained as a CNA was, she provided education about rolling dependent residents away from her in bed. CNA I responded it is not allowed and confirmed it was a safety concern as the resident can roll out of bed. Review of R40's Activities of Daily Living (ADL) last revised on 3/4/26 revealed, bed mobility 2 person assist, Resident is dependent on staff for mobility. During an interview with the Director of Nursing (DON) on 5/6/26 at 11:59 AM, the DON was informed of the observation when CNA I provided incontinence care for R40 independently and rolled R40 away from her in bed during care. The DON reviewed R40's care plan and said R40 required assistance of 2 staff with bed mobility. The DON confirmed it was not safe to provide care alone with the potential of the resident rolling out of bed. The surveyor questioned if this was covered during the CNA training and competency. The DON believed it was and commented it was just understood. Review of the facility, Nursing Assistant Orientation/Competency Skills Checklist did not reveal anything about the bed mobility for dependent residents. There was no indication in the safety portion of document there was a concern about safety or that 2-person assistance was required with bed mobility for dependent residents Review of the Michigan Nurse Aide Candidate Handbook effective April 1, 2022, revealed, page 43, position a dependent resident in bed on side: 6. Directs RN (Registered Nurse) Test Observer to stand on the side of the bed opposite working side of the bed to provide safety.

Based on observation, interview, and record review, the facility failed to keep an accurate tube feeding record for 1 resident (R40) of one resident reviewed for tube feeding.Findings included: Review of R40's face sheet dated 5/5/26 revealed she was admitted to the facility on [DATE] and diagnoses included: Hemiplegia and hemiparesis following nontraumatic intercranial hemorrhage (brain injury causing lack of movement), seizures and gastrostomy status (tube fed). R40 was not her own responsible party.R40 was observed in bed on 5/4/26 at 11:30 AM. R40's tube feeding was running at 65 ml(milliliters)/hour (hr). The bottle was dated 5/3/26. The tube feed bottle held 1000 ml. There was approximately 950 ml still in the bottle. (There was no indication what time the feeding started).During an interview with Licensed Practical Nurse (LPN) H on 5/5/26 at 11:39 AM, LPN H said the 2nd shift nurse started R40's tube feeding and the 1st shift nurse turned off the pump and disconnected the tube feeding. LPN H reported R40's feeding was competed earlier today, and she had already disconnected it. LPN H had no idea why R40's pump was still running on 5/4/26 at 11:30 AM with the bottle almost full. LPN H did not provide care for R40 on 5/4/26 and was not given any information in the shift report.R40 was observed in bed on 5/6/26 at 8:01 AM with her tube feeding running. The bottle was dated 5/5/26, starting time 20:00 (8:00 PM). The bottle held 1000 ml and approximately 550 ml was remaining. LPN H was at the bedside and when asked about the inconsistency of the end times for R40's tube feeding she reported there are days when she must let the tube feed run all day and LPN H reported she thought the tube feeding was just started late. LPN H said she reported this to her supervisors but denied documenting the late feedings in R40's medical record.During an interview with Registered Dietitian (RD) F on 5/6/26 at 8:30 AM, RD F reviewed R40 enteral feeding monthly notes and confirmed R40 had a 10.7-pound weight loss in March 2026 and R40's April weight was stable. RD F was not aware the nurses were not documenting when R40's tube feeding was not being completed on time or if they received the full amount. RD F did not know why R40 had a 10.7-pound weight loss in March 2026.During an interview with the Director of Nursing (DON) on 5/6/26 at 8:43 AM, the observations and interviews of the inconsistent tube feedings for R40 were reviewed. The DON said Licensed Practical Nurse (LPN) F documented on the Medication Administration Record (MAR) that he did the tube feeding on 5/3/26 at 8:00 PM. The DON had no idea why the tube feeding bottle that was dated 5/3/26 would still have 950 ml still in it on 5/4/26 at 11:30 AM if it had been started as documented on 5/3/26 at 8:00 PM.The Surveyor attempted to call LPN F on 5/6/26 at 8:47 AM and left a voice message to return the call. LPN F did not return the call prior to exit.Review of R40's May 2026 MAR (Medication Administration Record) revealed an order for, Enteral Feed Order at bedtime related to GASTRSTOMY STATUS Cyclic Enteral Feeding: Formula: Jevity 1.2; rate; 65ml/hr; start at 2000 (8:00 PM) and run until 1000 ml's has infused; Flush with water: Amount 55ml q (every) hour while running. LPN F documented his initials in the boxes for May, 2,3, and 4th.Durning an interview with the DON on 5/6/26 at 3:05 PM, the DON said she spoke to LPN F, and he said he started R40's tube feeding around 10:15 PM on 5/3/26 and he was not aware of the tube feeding not being competed on time. LPN F did report that the tube feeding does get paused sometimes. The DON confirmed she could not locate any documentation related to run time issues for R40's tube feeding.

Based on interview and record review, the facility failed to have a contract and followed the policies and procedures to coordinate hospice services and care for 1 (R 39) of 2 residents reviewed for hospice services. Findings include: Review of a Face Sheet Revealed R39 had received hospice services. Review of an Order Summary for R39 revealed an order for hospice dated 7/11/25. In an interview on 5/4/26 at 11:44 AM, the Power of Attorney (POA) for R39 reported the resident was on hospice and was having some depression since her husband died and not eating well. R39 was on hospice and not sure when hospice would come out to visit R39. The POA for R39 reported that the resident could be strong willed at time and hard to deal with because of her cognitive decline. Review of the Electronic Medical Records (EMR) for R39 revealed the last scanned in document dated 3/18/26 was from the Chaplain for spiritual care. The last Hospice Nurse visit was documented on 3/10/26 in the progress notes. Review of the Order Summary for R39 revealed on 3/18/26 an order for Hydroxyzine 100 mg by mouth at bedtime. (Different than the Hospice medication list.)-Nitrostat sublingual, every 5 hours as needed for chest pain. (Not on the Hospice medication list.)-Lidocaine Pain Relief Patch 4%, once a day for pain in lower back. (Not on the Hospice medication list.)-Lisinopril (blood pressure medication) 2.5 mg, once a day for hypertension. (Not on the Hospice medication list.)-Med Pass 2.0 (nutritional supplement), one time a day. (Not on the Hospice medication list.) Review of the Hospice Medication list with a printed date of 4/27/26 for R39 revealed the following:-Hydroxyzine 50 mg (milligrams), 2 tablets, 3 times daily for anxiety. Total dose 100 mg.-Bio freeze 4% topical gel, 2 inches, every 4 hours as needed, apply to back and right shoulder. (Not on the facility MAR.)-Levsin 0.125 mg, 1 tablet every 2 hours as needed for secretions. (Not on the facility MAR).-Nystatin (antifungal) 100,000 unit/gram topical powder, apply twice daily to affected area under breast. (Not on the facility MAR.)-Promethazine 25 mg, every 6 hours as needed for nausea or vomiting. (Not on the facility MAR.) Review of the Hospice IDG (Inner Development Goals) Comprehensive Assessment and Plan of Care Update Report dated 4/10/26 and signed as acknowledged on 5/1/26 for R39 revealed the Hospice Physician reviewed the Medication profile for effectiveness of drug therapy, drug side effects, drug interactions, and duplicate drug therapy. -Visit frequency from a Registered Nurse was once a week, the Social Worker visit was once a month, the Chaplain visit was 1-2 times a month. Review of a Physician Progress Note dated 4/7/26 for R39 revealed the Practitioner acknowledged R39 was on hospice and had dementia with behavioral disturbances. On high sedative burden with polypharmacy. [Quetiapine (antipsychotic), Trazodone (antidepressant), Sertraline (antidepressant), Mirtazapine (antidepressant), and Hydroxyzine ((Non-[NAME] Antihistamine FDA (Food and Drug Administration) approved for anxiety)] . Reassess need for multiple sedating nighttime agents. Monitor behaviors with hospice collaboration. 3/18 Consent obtained to GDR (gradual dose reduction) hydroxyzine. 4/7 Will attempt to obtain consent for continued GDR on hydroxyzine 2/2 high anticholinergic burden. Did well with previous GDR. During an interview on 5/6/26 at 2:45 PM, the Assistant Director of Nursing/Registered Nurse (RN) K could not locate a hospice schedule for the residents receiving hospice services on the locked unit. RN K stated that hospice nurses are expected to check in with the facility nurse upon arrival and use the EMR to document their visits. RN K confirmed she could not find any recent hospice documentation showing when hospice staff visited or whether they identified changes, concerns, or cares provided for R39. During an interview on 5/6/26 at 2:50 PM, Licensed Practical Nurse (LPN) L stated that the hospice staff check in with him when they arrive to coordinate resident care and review medications and any changes that need attention. LPN L added that he does not document their visits but signs an electronic acknowledgement from the hospice staff. Review of the Hospice Care Plan for R39 revealed: Administer medications as ordered and observe for effectiveness (7/10/25), Notify [Hospice Facility] of any changes of condition or updates (7/10/25).During an interview on 5/6/26 at 3:20 PM, the Nursing Home Administrator (NHA) stated that the Hospice Nurse is responsible for documenting directly in the facility's EMR and confirmed the last documented visit occurred on 3/10/26. The NHA also reported that the Social Worker serves as the facility's Hospice Care Coordinator. Review of a Hospice Policy last reviewed/revised dated 10/26/23 revealed: When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being.The facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the resident's care.The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the resident's needs, goals, and recognized standards of practice in consultation with the residents attending physician/practitioner and resident's representative, to the extent possible. The plan of care will identify the care and services that each entity will provide in order to meet the needs of the resident and his/her expressed desire for hospice care.The facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility.The facility will monitor and evaluate the resident's response to the hospice care plans.The facility will maintain communication with hospice as it relates to the resident's plan of care and services to ensure each entity is aware of their responsibilities. The plan of care will include directives for managing pain and other uncomfortable symptoms and will be revised and updated as necessary. The facility will monitor for medications and medical supplies to ensure they are provided by hospice as indicated in the plan of care for palliation and management of the terminal illness. Review of the Facility Hospice Contract provided by the NHA dated 4/30/24 revealed that this facility was not listed as a participating facility in the contract agreement.

This citation pertains to intake #2735204Based on interview and record review, the facility failed to provide dignified care to one Resident (R105) of four residents reviewed for quality of care. Findings include Review of the admission record for R105 reflected the Resident originally admitted to the facility 9/23/2015 and had current pertinent diagnoses that included: quadriplegic (paralysis of all four limbs), Traumatic Brain Injury, and Hydronephrosis (urine cannot properly drain from the kidneys). Review of the Minimum Data Set (MDS) (a tool used to assess a resident's care needs) dated 2/12/2026 reflected a Brief Interview for Mental Status (BIMS) (a scale used to assess a resident's cognitive status) score of 11 out of 15 which indicated R105 was moderately cognitively impaired.During an interview conducted 3/3/2026 at 1:45 PM, Unit Clerk (UC) I reported R105 was transported by facility staff to the hospital every two weeks for a routine procedure.On 3/4/2026 at 8:30 AM, an interview was conducted with Transportation Nurse Aide (TNA) J who reported the hospital is a seventeen minute drive from the facility. TNA J reported residents are prepared for transportation by floor staff and usually are ready to leave timely.Review of the medical records obtained from the hospital dated 2/3/2026 reflected that R105 arrived at the hospital for a routine urinary procedure that was scheduled for 9:00 AM. The documentation reflected an entry by Hospital Registered Nurse (HRN) G that on arrival R105 was very upset. The documentation reflected R105 reported to HRN G that facility staff made him sit in his wheelchair all night. The entry reflected R105 had multiple pressure injury wounds to his buttocks and was Found to have old and new stool saturating the dressings and the wounds. The hospital medical record from this appointment reflected a different hospital staff member changed three dressings that were Soiled (with) stool and that R105 presented with Entire buttocks area bilaterally very red.On 3/2/2026 at 10:41 AM, an interview was conducted with R105. R105 reported that the night prior to the regular procedure at the hospital facility staff refused to put him in bed and he had to sleep in his power chair. R105 reported the next morning he had asked staff several times to be cleaned up as he had soiled himself. R105 reported facility staff did not provide the care requested prior to leaving for his appointment and remained soiled until hospital staff cleaned him.On 3/3/2026 at 3:27 PM, a telephone interview was conducted with HRN G who reported she was present on 2/3/2026 for the procedure for R105. HRN G reported that R105 smelled strongly of stool and that R105 reported he had slept in his chair the night before. HRN G reported that R105 had stated that facility staff refused to put him into his bed or to change and clean him prior to leaving for the appointment. HRN G reported she and other staff cleaned the Resident of old and new stool and removed and replaced the stool-saturated dressings on the wounds on the Residents backside. HRN G reported the smell permeated the hospital unit and indicated R105 expressed embarrassment and frustration at the situation.During an interview conducted 3/3/2026 at 1:53 PM, Licensed Practical Nurse (LPN) O reported a transport log is provided for residents who have off-site appointments scheduled. LPN O reported he passes the information onto the Certified Nurse Aides (CNA) who make sure the resident is ready when Transportation staff come to take the resident. LPN O reported he does not remember anything unusual of the appointment of R105 on 2/3/2026. LPN O reported R105 is incontinent of stool and often does not know if he has soiled himself. LPN reported at times R105 had refused to get out of his chair and into the bed.On 3/4/2026 at 10:21 AM, an interview was conducted with Nurse Practitioner (NP) K. NP K reported that approximately one to two months ago R105 was refusing to sleep in his bed claiming the mattress was uncomfortable. NP K indicated the issue has since been resolved. NP K acknowledged that R105 was incontinent of stool and must be placed in his bed using a mechanic lift to be changed. NP K reported that R105 might not have been checked if soiled prior to leaving for the appointment but that he was capable of letting staff know he was soiled.Review of the EMR Progress Notes did not reflect documentation that R105 had left the facility for an appointment on 2/3/2026 or that the Resident had refused to go to bed or refused care on 2/2 or 2/3/2026. Further review of the EMR revealed a Bed Hold Policy (a document associated with an offsite transfer) had been issued on 2/3/2026 but no documentation of the transfer. Review of the EMR document titled Task B&B Bowel Elimination reflected R105 had a bowel movement on 2/2/2026 at 8:55 PM and a bowel movement on 2/3/2026 at 5:59 PM. The documentation does not reflect a bowel movement was documented between those times or around the time R105 was transferred to the hospital for an appointment. Review of the EMR document for R105 titled Task: Monitor Behavior Symptoms that included the behaviors of Transferring Behaviors and Rejection of Care reflected No Data Found.On 3/4/2026 at 12:09 PM, a follow up interview with R105 was conducted. R105 was asked if he had asked to be cleaned up before going to the hospital for his appointment on the day in question. R105 stated Yes, I always ask. R105 reported he was in the hall in his chair and had asked two different staff members to clean him but that he went to his appointment soiled. R105 reported that hospital staff were upset that he was sent dirty and stated he had sat in his stool for a long time.

This Citation pertains to intake # 2714532 and 2725669Based on interview and record review, the facility failed to promptly identify a change in condition and act upon those changes for 1 resident (Resident #1) out of 3 residents reviewed for quality of care, resulting in continued deterioration and subsequent death. Findings:Resident #1 (R1)Review of an admission Record revealed R1 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: stroke and palliative care. R1 was not his own responsible party and had a guardian in place.Review of the facility admission Agreement signed by R1's guardian on 5/2/25 revealed, VII. ADVANCE DIRECTIVE A resident has the right to formulate an advance directive with respect to the resident's desire to accept or refuse medical treatment.Review of R1's Advance Directives dated/signed by the guardian on 5/2/25 revealed R1 was a full code and was to receive cardiopulmonary resuscitation, a respiratory ventilator, artificial hydration, tube feeding, TPN, antibiotic therapy for infections, dialysis, maximum pain control, major surgery, and chemotherapy. R1 was to be transferred to an acute care hospital for inpatient treatment as well as the emergency department if necessary. Confirming that R1's wishes were to receive all avenues of care and treatment.Review of R1's communication Care Plan revealed, Resident is at risk for impaired communication related Dementia, Cambodian. Understands some English. Can answer simple questions with nod of head. Date Initiated: 07/18/2025. Request feedback, when needed, to ensure understanding.Use simple and direct communication (i.e., yes/no questions) to promote understanding, use gestures or pictures if necessary.Review of R1's urinary Care Plan revealed, Observe for signs/symptoms of UTI and report to Physician/PA (physicians assistant)/NP (nurse practitioner) (pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.) Date Initiated: 07/18/2025.Review of R1's August and September Medication Administration Record (MAR) and Pain Level Summary revealed only values of 0 (out of 10) indicating R1 did not typically experience pain or display symptoms of pain (a positive pain assessment would be abnormal for R1.)Review of R1's Hospice Note dated 9/4/25 at 11:20 PM revealed, .CHIEF COMPLAINT/REASON FOR PRN (as needed) VISIT: CHANGE IN MENTAL STATUS-GENITOURINARY (abnormal findings)-SIGNS AND SYMPTOMS OF INFECTION. URINE STRONG SCENTED AND DARK COLORED.UA (urinalysis) STRIP ABNORMAL, POSITIVE PROTEIN AND ELEVATED PH.INCREASED AGITATION AND BEHAVIORS, NOT EATING MUCH, SPITTING FOOD OUT.PATIENT CONTINUES TO HAVE INCREASED BEHAVIORS AND HAS BEEN SPITTING OUT HIS FOOD AND NOT EATING MUCH WHEN HE TYPICALLY EATS VERY WELL. UPON MY ASSESSMENT (R1) HAD A LOW GRADE FEVER OF 99.4 AND HIS PULSE WAS 102. WHEN PALPATING HIS ABDOMEN HE WHINCED AND PULLED MY HAND AWAY WHEN PALPATING HIS BLADDER. STAFF REPORTS HIS URINE HAS BEEN (sic) HAD A STRONG ODOR THE LAST FEW DAYS AND HAS BEEN DARK IN COLOR. UA (urinalysis) STRIP INDICATES A SMALL AMOUNT OF BLOOD IN HIS URINE IN ADDITION TO AN ABNORMAL SPECIFIC GRAVITY. SPOKE WITH DR. (name omitted) AND LEVAQUIN (antibiotic) 500MG 1 TIME DAILY FOR 7 DAYS HAS BEEN PRESCRIBED. DISCUSSED WITH FACILITY STAFF AND UNDERSTANDING WAS VERBALIZED. Confirming the facility staff were aware of a change in (R1's) condition for a few days and Levaquin has been prescribed.Review of R1's Electronic Medical Record (EMR) revealed no documentation that the practitioner or the guardian had been notified of the change in R1's condition prior to the hospice assessment on 9/4/25 despite identifying his symptoms a few days before.During an interview via email on 01/23/2026 2:53 PM, the Nursing Home Administrator (NHA) stated the facility staff follow McGeer Criteria for infections and would dip urine if residents are showing s/s (signs and symptoms) of infection. Check vitals, encourage fluids. Discuss with provider.On 01/22/2026 at 4:21 PM, a request for R1's UTI symptom tracking was requested. There was no documentation that the licensed nurses had been monitoring R1's symptoms. The NHA was unable to provide documentation of R1's symptom tracking.During an interview on 01/23/2026 at 3:41 PM, the Director of Nursing (DON) reported that their EMR did not prompt licensed nurses to complete symptom charting/UTI charting, and the licensed nurses were expected to complete physical assessments for residents following professional standards of practice. The DON reported that the facility CNAs had a habit of not charting on their residents until the end of their shift which may have been why there was no documentation for the last time R1 was observed responsive.Review of R1's Hospice Current Ordered Medication dated 9/4/25 at 3:28 PM revealed, PROBLEM: NEW NAUSEA.START ONDANSETRON (Zofran) 4 MG TABLET-1 TABLET, 4 TIMES DAILY PRN (as needed).Reason: For Nausea and vomiting with a start dated of 9/4/25.Review of R1's Hospice Current Ordered Medication dated 9/4/25 at 11:51 PM revealed, .Levaquin 500mg 1x per day x7 days for UTI symptoms. Goals: Improve patient behaviors and decrease UTI symptoms. with a start date of 9/5/25.During an interview on 01/22/2026 at 3:16 PM, Registered Nurse (RN) A reported that when hospice prescribed a medication it was then transcribed by the licensed nurses in the EMR Order Summary and the pharmacy would deliver it. If medications were ordered late in the day, pharmacy may not deliver them that same day, but the medications would be delivered by the next morning. RN A reported that some antibiotics were immediately available in the facility's medication storage but was unsure if Levaquin and Zofran were included. RN A confirmed that if R1's Levaquin and Zofran were ordered late on 9/4/25 they should have been delivered the morning of 9/5/25.Review of R1's Order Summary and Medication Administration Record revealed the Levaquin and the Zofran had not been transcribed or administered from the time it was prescribed by hospice on 9/4/25 until his death. There was no documentation for a rationale for the delay in treatment or provider notification that it had not been administered as ordered.During an interview via email on 01/23/2026 at 12:00 PM, the NHA stated, For the orders, they were not received by the facility until 9/5. I was the one who found them on the fax on 9/6. Since then, we have been able to give hospice providers access to chart in (the EMR) and able to input orders for our providers to review and approve.During an interview on 01/23/2026 at 3:41 PM, the DON confirmed the Levaquin had not been administered and the order had been delayed. The DON reported that the licensed nurse should have transcribed the antibiotic once the order was received or at least notified the oncoming nurse or the Unit Manager that hospice was prescribing an antibiotic to ensure there was follow through with the orders.A request for a printout of medications available in the facility's medication storage was requested on 01/23/2026 at 2:25 PM. The document was not received prior to survey exit.Review of R1's Nurses' Note dated 9/5/25 at 5:28 AM revealed, Hospice nurse in last night (9/4/25) to see resident.Had T (temperature) 99.4 and acknowledged pain with palpitation (sic) . Indicating the information documented in the note was obtained from the hospice assessment approximately 6 hours prior. There was no documentation that the nurse had completed a physical assessment to ensure R1's condition had not deteriorated at that time.Review of R1's EMR revealed no documentation that the nurse obtained updated vital signs or that they had completed a comprehensive physical assessment to ensure R1's condition had not deteriorated at that time There was no documentation that R1's guardian was notified of the resident's change of condition or included with his care and treatment by providing translations services in order to complete an accurate and comprehensive assessment despite the known communication barrier.Review of R1's pain Care Plan revealed, Resident pain threshold is 0 (zero) Date Initiated: 08/06/2025. Administer medications per orders and observe for side effects and effectiveness. Notify the Physician/NP/PA if current pain medication is ineffective or if the resident is experiencing side effects. Date Initiated: 07/18/2025Review of R1's EMR and Medication Administration Record revealed no documentation that R1 was administered Tylenol 650mg which was ordered every 4 hours as needed for pain following the hospice assessment. Indicating R1's pain was identified and documented but not acted upon.Review of R1's Medication Administration Record revealed R1 received a dose of Ativan 0.5 mg (every 4 hours as needed for anxiety) on 9/5/25 at 3:06 PM. R1's Orders - Administration Note revealed that at 3:58 PM the medication was effective. There was no documentation describing a physical assessment or follow-up from his identified pain. Additionally, there was no documentation of the behaviors and/or anxiety symptoms R1 was displaying that required the use of Ativan or if the behaviors were related to increased pain.Review of R1's behavior Care Plan dated 7/18/25 revealed, Resident has behavior(s) related to Dementia, GAD (generalized anxiety disorder). Will refuse cares.Approach resident in a calm manner to avoid frustration and behavior escalation; If resident becomes agitated and shows signs of escalation, reapproach later.Evaluate for verbal and non-verbal signs and symptoms relating to pain: grimacing, guarding, crying, moaning, increased anxiety.Review of R1's Nurses' Note dated 9/5/25 at 9:58 PM revealed, Resident refused assessments. T.98.3. Although the nurse was able to obtain R1's temperature, there were no additional assessments completed for R1 on 9/5/25 (the assessment could have included visual cues that R1 was experiencing continued pain and/or decline by observing him guard an area of discomfort, grimace, cry, display increased/new behaviors, the presence of vomiting, diaphoresis, change of baseline physical abilities/function, etc. A focused assessment can be performed using nursing observations and clinical judgement until a comprehensive assessment can be completed).Review of R1's EMR revealed no documentation that a facility nurse attempted to reapproach and complete an assessment to ensure there was no further deterioration in his health. There was no documentation that R1's guardian was notified of his refusal of care/assessment or that she was included in his care (translation services) or treatment options (transfer to hospital, comfort care, etc). There was no documentation that the licensed nurses ensured R1 received a dose of Levaquin as ordered.Review of R1's incontinence Care Plan dated 7/18/25 revealed, Check at regular intervals and change as needed.During an interview via email on 01/23/2026 at 2:53 PM, the NHA stated the facility staff complete rounds on residents and the best practice is every 2 hours. Review of R1's CNA Task documentation revealed there was no CNA documentation of care provided to R1 on 9/5/25 from 6:00 PM through 9/6/25 6:00 AM.Review of R1's Nurses' Note dated 9/6/2025 at 4:46 AM revealed, CNAs (Certified Nursing Assistants) were doing rounds and found resident deceased at 0420. Hospice (name omitted), Provider and Manager on call notified. Hospice will call family and funeral home. Hospice nurse (name omitted) will be arriving after 6am. Review of R1's EMR revealed no documentation that R1's had been assessed by a licensed nurse or observed by the CNAs for approximately 6 hours and 45 minutes prior to finding him unresponsive.Review of R1's Nurses' Note written by RN A and dated 9/6/2025 revealed, CNAs were doing rounds when the (sic) observed the resident unresponsive and cold to the tough (sic), No pulse. I immediately assessed the resident showing signs of irreversible death, including no pulse, yellow skin and cold to the touch, mottling and blood pooling and eyes fixed and dilated. When laid flat to evaluate, resident has large amounts of dark rust colored liquid draining out of his mouth all over the bed. When turned onto his side the resident projected the fluid onto the wall and all over the bed. Hospice, Unit Manager and Provider notified. Hospice notified family and funeral home. The last documentation where R1 was observed responsive was on 9/5/25 at 9:58 PM.During an interview on 01/23/2026 at 10:30 AM, the DON and NHA reported that following R1's death it was identified that RN A did not perform CPR due to the presence of signs of irreversible death. (Per the State Operations Manual obvious clinical signs of irreversible death are rigor mortis, dependent lividity, decapitation, transection, or decomposition.)During an interview on 01/23/2026 at 11:43 AM, CNA B reported that she was working for the first time on R1's unit and was on orientation at the time R1 was found unresponsive. CNA B stated when they were performing post-mortem care and rolled him to his side his back was purple. It wasn't red.it was purplish.During an interview on 01/22/2026 2:52 PM, CNA D reported that R1's unit was her assigned unit and she worked from 6PM on 9/5/25 to 6AM on 9/6/25. CNA D reported that at the start of her shift, when she was receiving report, CNA F reported to her that R1 was declining. CNA D reported that prior to his death he was displaying more symptoms of pain and had become more behavioral. CNA D stated, We had a concern because he wasn't eating. He wouldn't let us help feed him and we reported that to the nurses. CNA D reported that the expectation was to assess the residents during rounds every 2 hours. CNA D reported that he would sleep with a sheet over his head and because he had a history of behaviors, they would carefully check his brief for incontinence without disturbing him. She believed she last checked on R1 around 1:00 AM on 9/6/25. CNA D reported that on her next round she found R1 unresponsive in his bed and he was cold to the touch and was covered in dark colored fluid that had come from his mouth and stated, it was a gruesome scene. CNA D reported that during postmortem care she noted that his back was a deep dark purple color. Indicating he had not been rounded for more than 3 hours despite reporting she was aware of his deteriorating health status.During an interview on 01/22/2026 at 3:16 PM, RN A reported that she assumed care of R1 around 10:00 PM on 9/5/25 but had not been notified of any order changes or a decline in his health or newly identified pain. RN A reported that R1 mostly stayed in his room and was unsure when he went to bed as the CNAs had already assisted him to bed by the time she arrived to the unit. RN A reported that she would periodically check in on residents, but the CNAs monitor residents during their rounds. RN A reported she was unsure when the CNAs last observed him/rounded on him but was told by CNA D that she went in to check and change R1 but she didn't want to disturb him or wake him, so she quickly checked his brief to see if it was wet and crept out.RN A reported the CNAs had called for her to assess R1 and she could tell he had passed and stated, he was way gone.he was gone for a while. RN A reported that R1's eyes were fixed and dilated, his skin was waxy in appearance, and he was covered in brown liquid that had been coming from his mouth. RN A reported that when they (RN A, CNA B, and CNA D) rolled R1 to his side a significant amount of additional brown liquid came spewing from his mouth, and she observed his back with pooled blood. RN A reported a code was not called and CPR was not initiated because R1 was way beyond resuscitation.During an interview on 01/23/2026 at 10:47 AM, RN A clarified that she documented blood pooling in her nursing note regarding the identification of lividity. RN A reported R1's back was dark red in color and there was significant pooled blood observed on his back underneath his skin. RN A reported she did not know when R1 passed but it had been quite some time prior to finding him at 4:20 AM.Review of the National Library of Medicine article Evaluation of Postmortem Changes dated 5/1/23 revealed, Livor mortis, also known as postmortem hypostasis or postmortem lividity, is a passive process of blood accumulating within the blood vessels in the dependent parts of the body as a result of gravity, causing a discoloration of the skin that varies from pink to dark purplish. It begins to be apparent about an hour after death, is well-formed in about 3 to 4 hours after death, and gets fixed in about 6 to 8 hours after death. Almulhim AM, [NAME] RG. Evaluation of Postmortem Changes. 2023 May 1. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. PMID: 32119351.Review of the facility policy Notification of Changes last reviewed/revised 8/29/24 revealed, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. Circumstances requiring notification include. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment .Additional considerations.2. Residents incapable of making decisions: a. The representative would make any decisions that have to be made. b. The resident should still be told what is happening to him or her.

This citation pertains to intake #2666838Based on interview and record review, the facility failed to timely report allegations of abuse/neglect for 5 (R4, R5, R7, R9, and R10) of 10 residents reviewed.Findings include: F609 Resident #4 (R4)Review of a Face Sheet revealed R4 originally admitted to the facility on [DATE] and has pertinent diagnoses of Alzheimer's disease, dementia in lack of coordination. Resident #5 (R5)Review of a Face Sheet revealed R5 originally admitted to the facility on [DATE] and has pertinent diagnoses of alcohol induced dementia, Alzheimer's disease, psychotic disorder with delusions, and major depressive disorder. Resident #7 (R7)Review of a Face Sheet revealed R7 originally admitted [DATE] and has pertinent diagnoses of Alzheimer's disease, dementia with psychotic disturbances, and generalized anxiety disorder. Resident #9 (R9)Review of a Face Sheet for R9 revealed she originally admitted to the facility on [DATE] and has pertinent diagnoses of dementia with behavioral disturbances, major depressive disorder, and anxiety disorder. Resident #10 (R10)Review of a Face Sheet for R10 revealed she originally admitted to the facility on [DATE] and has pertinent diagnoses of Alzheimer's disease, dementia with mood disturbances, and generalized anxiety disorder. R5 and R10In an interview on 1/6/26 at 3:15 PM, CNA D reported she worked the day she documented R5 was sexually inappropriate and went on to describe walking into R5's room and saw R10 laying down in R5's bed with her pants slightly down to her hips and R5 was standing by her head with his pants lowered and his buttocks were exposed. CNA D reported she went to tell the nurse who then reported it to the Administrator. In an interview on 1/6/26 at 3:45 PM, the Nursing Home Administrator (NHA) reported she is aware of the incident between R5 and R10 but did not report it because she was at the facility within 30 minutes after being informed of the incident and was able to rule out any concerns right away. At this time, the Unit Manager/RN E entered the room and reported she remembered the incident between R5 and R10 at this time. There were no incident reports, statements, assessments or documentation in the EMR to show any incident had occurred or any notifications were sent to the physician or guardians. R4 and R5Review of a complaint reported to the State Agency revealed R5 entered R4's room and climbed into bed with her and did not want to leave the room. R4 was able to get out of bed to get help when the nurse came to her room and had to forcefully remove the resident. R5 has behaviors that staff cannot control. In an interview on 1/6/26 at 5:00 PM, the NHA reported she already provided any incident reports she had. When questioned about the incident of R5 climbing into R4's bed, the NHA reported that she had a soft file on that and did not report it to the State Agency. Review of the soft file regarding the incident between R4 and R5 revealed on 10/22/25 the NHA missed a call from the facility at 1:42 AM and again at 1:57 AM. The NHA returned the phone call at 2:46 AM and was notified of the incident between R4 and R5. It was reported that R5 climbed into bed between the wall and R4 and was pushing his back up against her moving her closer to the edge of the bed. R4 was worried about him potentially suffocating her baby doll and pushing her out of the bed. So, she got up and got the nurse. Review of two staff statements revealed R4 reported R5 called her a two-bit whore and then climbed into her bed. In an interview on 1/7/26 at 7:30 AM, the NHA reported she did not do an investigation regarding the incident between R4 and R5 but typed up a summary of the event the day before. In an interview on 1/8/25 at 9:13 AM, the NHA reported on 10/22/25 that the incident between R4 and R5 was relayed to her at 2:30 AM and was not fully informed of all the information regarding the verbal abuse and denied any physical abuse. The NHA reported she was looking for a willful intent and R4 was just fine and not upset. The NHA reported that she thinks the verbal abuse should have been reported. R5 and R9In an interview on 1/7/26 at 11:16 AM, RN H reported R5 walks aimlessly all-day night and can get aggressive when redirected by staff. One night RN H reported she called the guardian of R9 to inform her of a skin tear when the guardian questioned RN H about an incident on Christmas Eve when she was told by R9 that R5 grabbed her by the neck and had her head against the wall and it hurt her neck. The guardian reported R9 told the same story to several family members. RN H reported she looked into the EMR to find any incident reports or documentation regarding the incident and could not find any. R5 was in the hallway talking about the incident to staff with tears in her eyes and reported LPN B put cream on her neck after the incident. RN H reported she told the NHA about it and the NHA told her they already knew about the incident and dealt with it. RN H reported there are too many behaviors on that unit and not enough staff. RN H reported a Risk Management form should have been completed and In an interview on 1/8/25 at 9:13 AM, the NHA reported she was not aware of any incident between R5 and R9. In an interview on 1/7/26 at 11:16 AM, RN H reported that she completed a Risk Management document when R7 had a scratch on her forearm after R9 walked past her. RN H documented it as a resident-to-resident incident and was later changed to an injury of unknown origin by management. RN H was told she could not document the incident as a resident-to-resident incident because she did not actually see R9 scratch R7 even though she was close by. RN H reported when she looked at the Risk Management report later, it was documented that R9 lost her balance and accidentally scratched R7. When asked if she did any other documentation regarding the incident, RN H reported she did not put in a witness statement because R7 and R9 were arguing back and forth and was waiting for her to calm down and that LPN B was closer to the situation trying to separate the residents and should have actually been the one to complete the Risk Management documentation. In an interview on 1/8/25 at 9:13 AM, the NHA reported she was not aware of any contact made R7 and R9 but is aware that R9 was getting worked up about having a roommate and that is when they made a room change for R7. Review of a policy titled Abuse, Neglect and Exploitation last reviewed/revised on 10/24/22 revealed: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.VII. Reporting/ResponseA. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.2. Assuring that reporter are free from retaliation or reprisal.3. Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. This facility will post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if the employee believes the facility has retaliated against him/her for reporting a suspected crime and how to file such a complaint.4. Reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service.5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following:a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences.b. Defining how care provision will be changed and/or improved to protect residents receiving services.c. Training of staff on changes made and demonstration of staff competency after training is implemented.d. Identification of staff responsible for implementation of corrective actions.e. The expected date for implementation; andf. Identification of staff responsible for monitoring the implementation of the plan.B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

This citation pertains to intake #2666838Based on interview and record review, the facility failed to timely and thoroughly investigate allegations of abuse for 5 (R4, R5, R7, R9, and R10) of 10 residents reviewed.Findings include:Resident #4 (R4)Review of a Face Sheet revealed R4 originally admitted to the facility on [DATE] and has pertinent diagnoses of Alzheimer's disease, dementia in lack of coordination. Resident #5 (R5)Review of a Face Sheet revealed R5 originally admitted to the facility on [DATE] and has pertinent diagnoses of alcohol induced dementia, Alzheimer's disease, psychotic disorder with delusions, and major depressive disorder. Resident #7 (R7)Review of a Face Sheet revealed R7 originally admitted [DATE] and has pertinent diagnoses of Alzheimer's disease, dementia with psychotic disturbances, and generalized anxiety disorder. Resident #9 (R9)Review of a Face Sheet for R9 revealed she originally admitted to the facility on [DATE] and has pertinent diagnoses of dementia with behavioral disturbances, major depressive disorder, and anxiety disorder. Resident #10 (R10)Review of a Face Sheet for R10 revealed she originally admitted to the facility on [DATE] and has pertinent diagnoses of Alzheimer's disease, dementia with mood disturbances, and generalized anxiety disorder.R5 and R10Review of a Behavior Symptoms Task documentation by the Certified Nursing Assistants (CNA's) for R5 revealed on 12/28/25 he was documented as being sexually inappropriate. The document reveals other documented behaviors for 6 days out of the 30 day look back period that included behaviors of wandering, abusive language, threatening behavior, grabbing, pushing, yelling and screaming. In an interview on 1/6/26 at 3:15 PM, CNA D reported she worked the day she documented R5 was sexually inappropriate and went on to describe walking into R5's room (12/28/25) and saw R10 laying down in R5's bed with R10's pants slightly down to her hips and R5 was standing by her head with his pants lowered and his buttocks were exposed. CNA D reported she went to tell the nurse who then reported it to the Administrator. CNA reported the only body part she saw was R5's buttocks. In an interview on 1/6/26 at 3:30 PM, Unit Manager/Registered Nurse (RN) E reported she was not aware of any incidents of R5 being sexually inappropriate. When informed of the CNA documentation on 12/28/25, UM E was not aware of that being a documented task. UM E reported she was not aware of any incidents with R5 and R10 as described by CNA D. RN E did report she is aware of R5 wandering into other resident rooms and does expect staff to document behaviors in the electronic medical records (EMR). In an interview on 1/6/26 at 3:45 PM, the Nursing Home Administrator (NHA) reported she is aware of the incident between R5 and R10 but did not report it because she was at the facility within 30 minutes after being informed of the incident and was able to rule out any concerns right away. At this time, the Unit Manager/RN E entered the room and reported she remembered the incident between R5 and R10 at this time. There were no incident reports, statements, assessments or documentation in the EMR to show any incident had occurred or any notifications were sent to the physician or guardians. In an interview on 1/8/26 at 9:13 AM, the NHA reported R10 was in R5's bed and both of their pants were partially down on 12/28/25. The NHA reported she takes full responsibility for staff not documenting incidents on the computer and that it should have also reflected that the physician and guardians were notified. The NHA agreed that there was no documentation of interventions on the computer.R4 and R5Review of a complaint reported to the State Agency revealed R5 entered R4's room and climbed into bed with her and did not want to leave the room. R4 was able to get out of bed to get help when the nurse came to her room and had to forcefully remove the resident. R5 has behaviors that staff cannot control. In an interview on 1/6/26 at 5:00 PM, the NHA reported she already provided any incident reports she had. When questioned about the incident of R5 climbing into R4's bed, the NHA reported that she had a soft file on that and did not report it to the State Agency. Review of the soft file regarding the incident between R4 and R5 revealed on 10/22/25 the NHA missed a call from the facility at 1:42 AM and again at 1:57 AM. The NHA returned the phone call at 2:46 AM and was notified of the incident between R4 and R5. It was reported that R5 climbed into bed between the wall and R4 and was pushing his back up against her moving her closer to the edge of the bed. R4 was worried about him potentially suffocating her baby doll and pushing her out of the bed. So, R4 got out of bed to get the nurse. Review of two staff statements revealed R4 reported R5 called her a two-bit whore and then climbed into her bed. In an interview on 1/7/26 at 7:30 AM, the NHA reported she did not do an investigation regarding the incident between R4 and R5 but typed up a summary of the event the day before. During an observation on 1/7/26 at 8:00 AM, R5 was in bed with a sitter at his side for 1:1 supervision. The CNA did not know why R5 needed 1:1 supervision. LPN F reported she did not know why R5 required 1:1 supervision this day and reported it started the night before. LPN F reported it would be helpful to know why R5 required a 1:1 supervision and could not find any documentation in the EMR to clarify it. In an interview on 1/7/26 at 9:00 AM, CNA G reported she did work the night R5 climbed in bed with R4. CNA G remembered R4 came out of her room and yelled help me, help me, there is a man in my room and won't get out of my bed! He is calling me a f*ing whore and a little bitch. The nurse and another aide went to R4's room to address the situation. R5 had to be forcefully removed from her room. CNA G reported she was told by the nurse not to document anything about the incident as instructed by the NHA. In an interview on 1/8/25 at 9:13 AM, the NHA reported on 10/22/25 that the incident between R4 and R5 was relayed to her at 2:30 AM and was not fully informed of all the information regarding the verbal abuse and denied any physical abuse. The NHA reported she was looking for a willful intent and R4 was just fine and not upset. The NHA reported that she thinks the verbal abuse should have been reported.R5 and R9In an interview on 1/7/26 at 11:16 AM, RN H reported R5 walks aimlessly all-day and night and can get aggressive when redirected by staff. One night RN H reported she called the guardian of R9 to inform her of a skin tear when the guardian questioned RN H about an incident on Christmas Eve when she was told by R9 that R5 grabbed her by the neck and had her head against the wall and it hurt her neck. The guardian reported R9 told the same story to several family members. RN H reported she looked into the EMR to find any incident reports or documentation regarding the incident and could not find any. R9 was in the hallway talking about the incident to staff with tears in her eyes and reported LPN B put cream on her neck after the incident. RN H reported she told the NHA about it and the NHA told her they already knew about the incident and dealt with it. RN H reported there are too many behaviors on that unit and not enough staff. RN H reported a Risk Management form should have been completed. In an interview on 1/7/26 at 4:00 PM, LPN B reported he was on break on 12/24/25 when he was informed by the CNA that R9 made allegations that R5 grabbed her by the neck but the CNA did not witness it. LPN B reported he texted the NHA at 7:57 PM to inform her of the incident. The NHA asked him if R9 had any marks on her and he said no. The NHA then told LPN B she will investigate it in the morning. In an interview on 1/8/25 at 9:13 AM, the NHA reported she was not aware of any incident between R5 and R9. R7 and R9In an interview on 1/7/26 at 11:16 AM, RN H reported that she completed a Risk Management document when R7 had a scratch on her forearm after R9 walked past her. RN H documented it as a resident-to-resident incident and was later changed to an injury of unknown origin by management. RN H was told she could not document the incident as a resident-to-resident incident because she did not actually see R9 scratch R7 even though she was close by. RN H reported when she looked at the Risk Management report later, it was documented that R9 lost her balance and accidentally scratched R7. When asked if she did any other documentation regarding the incident, RN H reported she did not put in a witness statement because R7 and R9 were arguing back and forth and was waiting for her to calm down and that LPN B was closer to the situation trying to separate the residents and should have actually been the one to complete the Risk Management documentation. In an interview on 1/8/25 at 9:13 AM, the NHA reported she was not aware of any contact made R7 and R9 but is aware that R9 was getting worked up about having a roommate and that is when they made a room change for R7. Review of a policy titled Abuse, Neglect and Exploitation last reviewed/revised on 10/24/22 revealed: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:1. Identifying staff responsible for the investigation.2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence).3. Investigating different types of alleged violations.4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and6. Providing complete and thorough documentation of the investigation.

This citation pertains to intake #2666838Based on observation, interview and record review, the facility failed to develop individualized interventions, review and revise care plans, and provide adequate supervision for 5 residents (R4, R5, R7, R9, and R10) of 10 residents reviewed for dementia care.Findings include:Resident #4 (R4)Review of a Face Sheet revealed R4 originally admitted to the facility on [DATE] and has pertinent diagnoses of Alzheimer's disease, dementia and lack of coordination. Resident #5 (R5)Review of a Face Sheet revealed R5 originally admitted to the facility on [DATE] and has pertinent diagnoses of alcohol induced dementia, Alzheimer's disease, psychotic disorder with delusions, and major depressive disorder. Resident #7 (R7)Review of a Face Sheet revealed R7 originally admitted [DATE] and has pertinent diagnoses of Alzheimer's disease, dementia with psychotic disturbances, and generalized anxiety disorder. Resident #9 (R9)Review of a Face Sheet for R9 revealed she originally admitted to the facility on [DATE] and has pertinent diagnoses of dementia with behavioral disturbances, major depressive disorder, and anxiety disorder. Resident #10 (R10)Review of a Face Sheet for R10 revealed she originally admitted to the facility on [DATE] and has pertinent diagnoses of Alzheimer's disease, dementia with mood disturbances, and generalized anxiety disorder. R5 and R10In an interview on 1/6/26 at 3:15 PM, CNA D reported she worked the day she documented R5 was sexually inappropriate and went on to describe walking into R5's room and saw R10 laying down in R5's bed with her pants slightly down to her hips and R5 was standing by her head with his pants lowered and his buttocks were exposed. CNA D reported she went to tell the nurse who then reported it to the Administrator. During an observation on 1/6/26 at 9:38 AM, R5 was observed walking around inside room [ROOM NUMBER] (a resident's room that was not his). He then came out into the hallway and walked down the hall to the common area wandering around unsupervised. The resident whose room he had entered was not in the room. During an observation on 1/6/26 at 12:01 PM, R5 was observed wandering inside another resident's room [ROOM NUMBER], and then walked out the door. He then went to the nurse's medication cart and started shuffling through papers before he was redirected to the dining room. R5 was not being supervised before this. Review of a Behavior Symptoms Task documentation by the Certified Nursing Assistants (CNA's) for R5 revealed on 12/28/25 he was documented as being sexually inappropriate. The document reveals other documented behaviors for 6 days out of a 30 day look back period that included behaviors of wandering, abusive language, threatening behavior, grabbing, pushing, yelling and screaming. There was not any documentation in the Nursing Progress notes that addressed these behaviors and there were not any changes to R5's care plan. In an interview on 1/6/26 at 3:10 PM, Licensed Practical Nurse (LPN) B reported R5 was on 15-minute checks as far as he knew on 1/4/26 and came off the 15 minutes checks on 1/5/26 but did not know why he was being monitored for frequent checks. LPN B was not aware of R5 having any sexually inappropriate behaviors with any other residents. LPN B did say if there were any incidents, the NHA (Nursing Home Administrator) and family/guardians should be notified. No documentation in the EMR (electronic medical record) indicating why R5 was on 15-minute checks. In an interview on 1/6/26 at 3:15 PM, CNA D reported she worked the day she documented R5 was sexually inappropriate. CNA D reported she walked into R5's room and saw R10 laying down in R5's bed with her pants slightly down to her hips. R5 was standing by R10's head with his pants lowered and his buttocks were exposed. CNA D reported she went to tell the nurse who then reported it to the Administrator. No changes or updates to the care plan were made for R5 or R10 regarding the incident and no documentation was made in the EMR. In an interview on 1/6/26 at 3:30 PM, Unit Manager/Registered Nurse (RN) E reported she was not aware of any incidents of R5 being sexually inappropriate. When informed of the CNA documentation on 12/28/25, RN E was not aware of that being a documented task. RN E reported she was not aware of any incidents with R5 and R10 as described by CNA D. RN E did report she was aware of R5 wandering into other resident rooms and does expect staff to document behaviors in the EMR. In an interview on 1/6/26 at 3:45 PM, the Nursing Home Administrator (NHA) reported she was aware of the incident between R5 and R10. At this time, the RN E entered the room and reported she remembered the incident between R5 and R10 at this time. There were no incident reports, statements, assessments or documentation in the EMR to show any incident had occurred. Review of a Risk Management report provided by the NHA for R10 revealed on 12/28/25 there was an incident where R10 was in R5's room where his pants were down. Document shows it is not part of the medical records. In an interview on 1/8/26 at 9:13 AM, the NHA reported R10 was in R5's bed and both of their pants were partially down on 12/28/25. The NHA reported she takes full responsibility for staff not documenting incidents in the computer and that it should have also reflected that the physician and guardians were notified. The NHA agreed that there was no documentation of interventions in the computer. The NHA understood the importance of documentation as a way of communication of resident behaviors for staff. When questioned about good communication and the effects on resident care, the NHA agreed that good communication could result in better care, outcomes, and meaningful interventions. R4 and R5 Review of a complaint reported to the State Agency on 11/12/25 revealed R5 entered R4's room (date not specified) and climbed into bed with her and did not want to leave the room. R4 was able to get out of bed to get help when the nurse came to her room and had to forcefully remove the resident. R5 has behaviors that staff cannot control and are told not to document resident behaviors. In an interview on 1/7/26 at 9:00 AM, CNA G reported she did work the night R5 climbed in bed with R4. CNA G remembered R4 came out of her room and yelled help me, help me, there is a man in my room and won't get out of my bed! He is calling me a f*ing whore and a little bitch. The nurse and another aide went to R4's room to address the situation. R5 had to be forcefully removed from R4's room. CNA G reported she was told by the nurse not to document anything about the incident by the NHA. Review of the soft file (not part of the medical records) provided by the NHA regarding the incident between R4 and R5 revealed on 10/22/25, R5 climbed into R4's bed and laid between the wall and R4. R5 was pushing his back up against her, moving her closer to the edge of the bed. R4 was worried about him potentially suffocating her baby doll and pushing her out of the bed. So, R4 got out of bed to get the nurse. Review of two staff statements revealed R4 reported R5 called her a two-bit whore and then climbed into her bed. This information was not documented in the EMR, and no care plan interventions were made. During an observation and an interview on 1/7/26 at 8:00 AM, R5 was in bed with a sitter at his side for 1:1 supervision. The CNA did not know why R5 needed 1:1 supervision.In an interview on 1/7/26 at 8:05 AM, LPN F reported she did not know why R5 required 1:1 supervision this day and reported it started the night before. LPN F reported it would be helpful to know why R5 required a 1:1 supervision and could not find any documentation in the EMR to clarify it. R5 and R9Review of a complaint reported to the State Agency on 11/12/25 revealed R5 entered another resident's room that belonged to 2 female residents and held the door closed so staff could not enter. It took 4-5 staff members to get the resident out of the room and the police were called to assist. In an interview on 1/7/26 at 9:00 AM, Certified Nursing Assistant (CNA) G reported sometime between November and December, R5 barricaded himself in R9's room, who also had a roommate, by putting a chair up against the door and sat in the chair for a long time. Staff were not able to get into the room and the police were called. The door had to be forcefully pushed open. R9 did not want to go back to her room for a long time. There was no documentation in the EMR regarding this incident. In an interview on 1/7/26 at 11:16 AM, RN H reported R5 walks aimlessly all-day and night and can get aggressive when redirected by staff. One night RN H reported she called the guardian of R9 to inform her of a skin tear when the guardian questioned RN H about an incident on Christmas Eve. The Guardian reported R9 accused R5 of grabbing her by the neck and had her head against the wall and it hurt her neck. The guardian reported R9 told the same story to several family members. RN H reported she looked in the EMR to find any incident reports or documentation regarding the incident and could not find any. RN H reported then R9 was in the hallway talking about the incident to staff with tears in her eyes and reported LPN B put cream on her neck after the incident. RN H reported she told the NHA about it and the NHA told her they already knew about the incident and dealt with it. RN H reported there are too many behaviors on that unit and not enough staff. RN H reported a Risk Management form should have been completed. In an interview on 1/7/26 at 4:00 PM, LPN B reported he was on break on 12/24/25 when he was informed by the CNA that R9 made allegations that R5 grabbed her by the neck, but the CNA did not witness it. LPN B reported he texted the NHA at 7:57 PM to inform her of the incident. The NHA asked him if R9 had any marks on her and he said no. The NHA then told LPN B she will investigate it in the morning. The EMR did not reflect any documentation or acknowledgement of the alleged incident. In an interview on 1/8/25 at 9:13 AM, the NHA reported she was not aware of any incident between R5 and R9. Review of the Care Plan for R5 with a focus of Resident has behaviors related to alcohol dependence with alcohol induced persisting dementia, psychotic disorder with delusions due to known physiological condition as evidenced by: exit seeking, wandering throughout the facility with no sense of direction initiated on 10/13/25 revealed no meaningful, person centered interventions or revisions to address behaviors or wandering.Review of the Care Plan in its entirety for R5 revealed no person-centered interventions or provisions to care addressed R5's behaviors and the resident-to-resident incidents.In an interview on 1/8/26 at 9:13 AM, the NHA reported she was not fully informed of all the information regarding the incidents with R5 and R9 and was not able to provide the documentation indicating that R5 was being frequently monitored after the incidents. The NHA agreed that appropriate documentation and investigation could drive the plan of care. R7 and R9In an interview on 1/7/26 at 11:16 AM, RN H reported that she completed a Risk Management document when R7 had a scratch on her forearm after R9 walked past her. RN H documented it as a resident-to-resident incident and was later changed to an injury of unknown origin by management. RN H was told she could not document the incident as a resident-to-resident incident because she did not actually see R9 scratch R7 even though she was close by. RN H reported when she looked at the Risk Management report later, it was documented that R9 lost her balance and accidentally scratched R7. When asked if she did any other documentation regarding the incident, RN H reported she did not put in a witness statement because R7 and R9 were arguing back and forth and was waiting for them to calm down. RN H reported that LPN B was closer to the situation trying to separate the residents and should have actually been the one to complete the Risk Management documentation. Review of a Nursing Progress note dated 10/27/25 for R7 revealed: Many behaviors during night shift. Resident in and out of bed (complaining of) having a roommate and roommate's TV being too loud. Asking who are the idiots that make these decisions in her life. Asking why staff is treating roommate better than she is being treated. Refused to take (nighttime) meds because resident claimed she already took them because she takes care of her own medications. Unable to redirect. Review of a Psychiatry Progress note dated 11/16/25 for R7 revealed she struck another resident telling them to leave her room. She reported that her roommate was yelling when it was time to sleep. Another resident tried to take her walker and (R7) tried to take her walker and (R7) resisted and was struck in the face by another resident. Facility staff report angry outburst and fixating on trying to leave. Review of the Care Plan for R7 revealed no person-centered revisions documented reflecting the scratching incident or behaviors since admission. In an interview on 1/8/25 at 9:13 AM, the NHA reported she was not aware of any contact made R7 and R9 but was aware that R9 was getting worked up about having a roommate and that is when they made a room change for R7.

This citation pertains to intake #2666838Based on interview and record review, the facility failed to implement and maintain a system for complete and accurate medical records for 5 (R4, R5, R7, R9, and R10) of 10 residents reviewed for medical records.Findings include:Review of the electronic medical records (EMR) for R4, R5, R7, R9 and R10 revealed a lack of documentation regarding the following incidents: R4Review of a Risk Management document dated 12/28/25 for R4 revealed No documentation regarding the incident on 12/28/25 when R4 was observed in R5's room laying on his bed exposing himself to her. No documentation indicating the physician or the guardian was notified or what interventions were put into place. R5Review of the EMR for R5 revealed no daily behavior documentation or documentation regarding resident-to-resident incidents on 10/22/25, 12/24/25, 12/28/25. Review of a Behavioral Health progress note dated 12/24/25 for R5 revealed: Previously, patient demonstrated significant behavioral disturbances including yelling/screening, kicking/hitting, pushing, grabbing, wandering, abusive language, threatening behavior, and sexually inappropriate behavior. No documentation on the facilities behalf in the EMR to reflect any of these behaviors. Review of a Behavior Symptoms Task documentation by the Certified Nursing Assistants (CNA's) for R5 revealed on 12/28/25 he was documented as being sexually inappropriate. The document reveals other documented behaviors for 6 days out of the 30-day look back period that included behaviors of: wandering, abusive language, threatening behavior, grabbing, pushing, yelling and screaming. No Nursing documentation or follow up to the CNA documentation documented. In an interview on 1/6/26 at 3:15 PM, LPN B reported he was unaware of any sexual inappropriateness regarding R5 and that he would document in the EMR if there were any inappropriate behaviors and inform the guardian. In an interview on 1/6/26 at 3:30 PM, Unit Manager/Registered Nurse (RN) E reported she was not aware of any incidents of R5 being sexually inappropriate. When informed of the CNA documentation on 12/28/25, UM E was not aware of that being a documented task. UM E reported she was not aware of any incidents with R5 and R10 as described by CNA D. RN E did report she is aware of R5 wandering into other resident rooms and does expect staff to document behaviors in the electronic medical records (EMR). During an observation on 1/7/26 at 8:00 AM, R5 was in bed with a sitter at his side for 1:1 supervision. The CNA did not know why R5 needed 1:1 supervision. LPN F reported she did not know why R5 required 1:1 supervision this day and reported it started the night before. LPN F reported it would be helpful to know why R5 required a 1:1 supervision and could not find any documentation in the EMR to clarify it. In an interview on 1/7/26 at 11:16 AM, RN H reported R5 walks aimlessly all-day night and can get aggressive when redirected by staff. One night RN H reported she called the guardian of R9 to inform her of a skin tear when the guardian questioned RN H about an incident on Christmas Eve when she was told by R9 that R5 grabbed her by the neck and had her head against the wall and it hurt her neck. The guardian reported R9 told the same story to several family members. RN H reported she looked into the EMR to find any incident reports or documentation regarding the incident and could not find any. R9 was in the hallway talking about the incident to staff with tears in her eyes and reported LPN B put cream on her neck after the incident. RN H reported she told the NHA about it and the NHA told her they already knew about the incident and dealt with it. RN H reported there are too many behaviors on that unit and not enough staff. RN H reported a Risk Management form should have been completed. R9In an interview on 1/7/26 at 11:16 AM, RN H reported that she completed a Risk Management document when R7 had a scratch on her forearm after R9 walked past her. RN H documented it as a resident-to-resident incident and was later changed to an injury of unknown origin by management. RN H was told she could not document the incident as a resident-to-resident incident because she did not actually see R9 scratch R7 even though she was close by. RN H reported when she looked at the Risk Management report later, it was documented that R9 lost her balance and accidentally scratched R7. When asked if she did any other documentation regarding the incident, RN H reported she did not put in a witness statement because R7 and R9 were arguing back and forth and was waiting for her to calm down and that LPN B was closer to the situation trying to separate the residents and should have actually been the one to complete the Risk Management documentation. Review of a Nursing Progress noted dated 12/29/25 for R9 revealed: Res Observed standing in her doorway of her room with a skin tear to her right forearm. Area cleaned and Band-Aid applied. Res Stated it was from a scratch. No follow up assessment/documentation. In an interview on 1/8/25 at 9:13 AM, the NHA reported she was not aware of any contact made R7 and R9 but is aware that R9 was getting worked up about having a roommate and that is when they made a room change for R7. R7Review of the Monitor Behavior Symptoms task documentation with a 30-day look back revealed no behaviors documented on 12/29/25 as indicated in the above incident with R7. No behaviors documented for the 30-day time period. Review of the Nursing Progress notes for R7 revealed no documentation indicating R7 had any behaviors or concerns on 12/29/25. R10Review of the EMR for R10 revealed no documentation on 12/28/25 regarding the incident when R10 was in another resident room in his bed sleeping when another male resident was inappropriately dressed standing in front of her.

This citation pertains to intake #: MI00153297 Based on interview and record review, the facility failed to ensure sufficient supervision and safety measures were in place to prevent an elopement for 1 of 4 residents (Resident #1) reviewed for accidents, safety, and supervision. Findings: Resident #1 (R1) Review of an admission Record revealed R1 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's Disease and psychotic disorder with delusions. Review of R1's Facility Reported Incident dated 3/27/25 (from R1's previous facility) revealed R1 had eloped .Resident exited the facility unsupervised at 0510 am. She exited the building through the left exit doors in the main dining room . Review of R1's Nursing admission Screening/History dated 3/27/25 revealed the reason for admission was elopement. Review of R1's baseline care plan section C revealed, MAY WANDER OR ATTEMPT TO LEAVE FACILITY UNATTENDED . Review of R1's Patient admission Information dated 3/27/25 revealed, Transfer from (name omitted) due to increase in elopement risk and need for secured memory care unit. She has had increased attempts to leave the facility .She has been able to be redirected but has been focused on going home leaving the building. Review of a Physician Assessment dated 3/28/25 revealed, .Lately, she has been exit seeking and has eloped .She was transferred from (name omitted) to (facility) to be placed in secure dementia unit . Review of R1's Wandering Scale dated 3/27/25 revealed R1 was at risk to wander and was not high risk to wander. Review of a maintenance work order dated 5/14/25 revealed an order for R1's room for hole in screen. The work order did not indicate the window lock system had broken. Review of R1's General Progress Note dated 5/14/25 revealed, Reception stated a neighbor saw a woman who looked confused in our courtyard. Upon investigation, we found the window in the residents' room (number omitted) open and the screen torn. Resident was found by staff in the courtyard . Review of the Facility Reported Incident revealed, Incident Summary On 05/14/2025, resident (R1) exited unattended through her bedroom window into the courtyard. The facility staff were notified through nearby neighbors at 6:15 pm and called a Code Yellow immediately. (Licensed Practical Nurse [LPN] C) located (R1) still within the enclosed courtyard fence on the property . Investigative Summary / Timeline: (Certified Nursing Assistant [CNA] D) was interviewed stating, The last time I saw (R1) was around 5 pm 5:30 pm because we had sat and got the residents together for them to eat dinner. She was walking around talking with the staff. I did not notice any exiting seeking, just making comments talking about the military, making comments about the staff and walking up and down the hall. I am not one-hundred percent sure that she ate her meal because she likes to get up and down and doesn't really sit still .During a second interview with (CNA D) she stated that she recalled observing the window open in (R1's) room during her shift on 5/14/2025 around her lunchtime, and she thought in hindsight it may have been fully ajar beyond the 4 inches. She communicated to the Maintenance Assistant that there was a hole in the window screen needing repair, but did not inform the Maintenance Assistant that the window was fully open or also in need of repair . Conclusion: Verified Through witness statements and physical evidence, it can be verified that (R1) exited out of her window unattended into the facility enclosed courtyard. As she exited through the window, there was no alarm to sound to notify of her exit. (R1) was last observed inside the facility around 6:00 pm on 5/14/2025. At 6:15 pm, staff responded to a notification through a nearby neighbor, indicating a woman was in the enclosed courtyard. Staff initiated a Code Yellow and responded immediately. (R1) was located and attended to by staff still inside the enclosed courtyard and was redirected successfully inside the facility at 6:25 pm with no concerns of injury or distress . Review of CNA D's Disciplinary Action Record revealed, On 5/14/25 around 1:45 pm, you discovered a residents window was open & unsecured. A work order was placed regarding the rip in the screen, but it was not indicated to the maintenance team that the window was unsecured/opened in the verbal interaction & work order. This resulted in a residents elopement from the unit . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: The Quality Assessment and Assurance Committee met on 05/14/2025 and 05/15/2025 to review the incident and determined the following: This serves as the Facility's Plan of Correction in response to the allegation. The following action plan has been implemented: Action taken for residents involved: A code yellow was immediate initiated with a head count of residents to ensure no other resident were affected. (R1) was assisted back inside by staff; vital signs were taken, and a head-to-toe assessment completed by the nurse. There were no signs of injury, distress, no skin alterations and vital signs were stable. A new wandering risk assessment was completed, and resident was coded as High Risk to wander. Upon returning to the facility, the window in her room was repaired, and resident was placed on a 1:1 safety attendant until her room was secured and .15-minute checks were initiated thereafter . Areas identified requiring quality improvement: Elopement policy was reviewed by the QAPI Committee, and determined Elopement policy was followed by facility staff. Through investigation and root cause analysis, it was identified that (R1's) window was observed by a CENA to be unsecured and a hole in the window screen prior to the incident. The hole in the window screen was communicated by the CENA to the Maintenance Assistant, however did not communicate the window being unsecured to maintenance. The Maintenance Assistant did not assess the hole in the window screen that was reported earlier in the shift prior to the incident. Area identified requiring quality improvement includes timely and thorough reporting, assessment, and repair of potential damage to windows, window screens, and exit doors. How facility identified resident(s) affected and residents with potential to be affected: An audit was completed by the Director of Nursing/designee on 5/16/2024 to ensure an elopement assessment for all current residents and new admissions. All residents have assessments in place. Like Residents were identified as residents residing in the facility at high risk for wandering. All residents identified as High Risk for wandering were reviewed by the DON/designee on 5/16/2025 to ensure Wandering Risk Assessments are up to date, and care plans and orders reviewed/revised as needed to ensure appropriate interventions and safety precautions were in place by 5/16/2025. Elopement Books were reviewed and updated by the Administrator/designee on 5/16/2025, and ensured books updated at each nurse station & reception. Quality Improvement measures or systemic changes made: The Maintenance Director/designee completed an audit of all secured dementia unit windows for appropriate locking and security on 5/14/2025. All secured unit windows were properly locked and secured during audit. The Maintenance Director/designee completed an audit of all Main Unit windows for appropriate locking and security on 5/15/2025. All main unit windows properly locked and secured during the audit. The Elopement Policy was reviewed by the Administrator on 5/14/2025 and deemed appropriate. The Maintenance Director/designee completed an audit of all alarmed doors and panels to ensure appropriate labeling and sounding on 5/15/2025. All alarmed doors were properly function with appropriate identification during alarmed door during audit. Education was initiated by the Administrator/designee on 5/15/2025 for all facility staff on the Elopement Policy and Procedure, and on timely and thorough reporting, assessment, and repair of potential damage to windows, window screens, and exit doors. As of 5/21/2025, 129 out of 148 employees have been educated, and post-quiz completed. Any remaining staff will be educated prior to the start of their next shift. An Elopement Drill code yellow was conducted by the Maintenance Director/designee on 05/16/2025 and 05/21/2025. The Administrator/designee issued a disciplinary action to (CNA D) on 5/21/2025 due to failure to report the window being open earlier in the shift when notifying the Maintenance Assistant of the need to repair a hole in the residents window screen. The Maintenance Assistants were issued 1:1 Teachable Moment regarding any potential damage reported to windows, window screens, or exit doors. Maintenance will consider high priority and assess reported damage to any of these areas immediately upon receipt of request and will triage work required after thorough visual inspection. How facility monitors the effectiveness of its quality improvement measures (sustained compliance): Audits will be completed by the DON/designee on at least 5 residents weekly x4 weeks then monthly x2 months as directed by the QAA committee to ensure that the elopement policy remains implemented to assess resident risk for wandering, ensure appropriate interventions in place to reduce risk for elopement. Any concerns will be forwarded to the QAA committee for further review and recommendations as needed. Elopement Drills will be conducted by the Administrator/designee weekly x4 weeks then monthly x2 months as directed by the QAA committee to ensure appropriate staff response to potential elopement/missing resident. Any concerns will be forwarded to the QAA committee for further review and recommendations as needed. Security audits of windows will be conducted by the Maintenance Director/designee weekly x4 weeks then monthly x2 months as directed by the QAA committee to ensure windows are appropriately secured. Any concerns will be forwarded to the QAA committee for further review and recommendations as needed. Date of Completion: 5/19/2025 The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting the following areas: Findings include: Rooms 409/411 During an observation on 2/25/25 at 9:52 AM and 12:17 PM, room [ROOM NUMBER] had a shared bathroom with room [ROOM NUMBER]. Inside the bathroom was a dirty exhaust fan and an oxygen concentrator with a nasal canula connected to it stored under the sink. During observations on 2/26/25 at 7:34 AM and 9:22 AM rooms 409/411 still had the oxygen concentrator in the bathroom with the nasal cannula attached to it. During an observation and an interview on 2/27/25 at 9:30 AM, Certified Nursing Assistant (CNA) B accompanied this surveyor to the connected bathroom for rooms 409/411 and saw the oxygen concentrator with the nasal cannula attached, stored under the sink next to the toilet. The toilet was grossly soiled with stool splatters all over the seat and rim. A bedside commode pan was stored on the floor between the toilet and under the sink next to the oxygen concentrator, with a used brief inside. CNA B reported that the oxygen concentrator belonged to the resident in room [ROOM NUMBER] and confirmed the bathroom should not look like that and the concentrator should not be stored there. The CNA also confirmed the bathroom exhaust fan was very dusty. Rooms 404/406 During an observation on 2/25/25 at 12:38 PM, room [ROOM NUMBER] had a shared bathroom with room [ROOM NUMBER] for four residents. Several mixed toiletries and personal items in the bathroom were gathered on the sink and the shelf above the sink. No labels on any of the items observed. During observations on 2/26/25 at 7:34 AM and 9:24 AM rooms 404/406 had several personal mixed toiletries in the shared bathroom on the sink and the shelf above the sink. During an observation and an interview on 2/27/25 at approximately 9:45 AM, CNA B went with this surveyor to the shared bathroom for rooms 404/406. Several toiletries were on the sink and shelf above it, including 3 opened and used packets of ointment, deodorants, lotions, soaps, and various other items. One large bottle of lotion had a resident's name on it. CNAs B and C stated that residents' toiletries should be stored in their designated areas after use. Both CNAs mentioned the bathroom should not appear as it did and that the ointment packets should have been discarded. They also confirmed that the bathroom exhaust fan was very dusty. 38905 During a tour of the Gilead Pantry, at 9:55 AM on 2/25/25, an odor of sewer gas was present upon entering the room. Further evaluation found a floor drain in the back right corner of the room tucked behind the fridge that was allowing sewer gas to flow back into the space due to an evaporated pee-trap. Evaluation of the sink found a residential spray wand on the back. The spray wand has the potential the be pulled out and lay below the overflow rim of the sink creating a cross connection between the potable and wastewater supply. During a tour of the facility, at 1:01 PM on 2/25/25, it was observed that supplies from the activity department were stored underneath the wastewater line of the sink in the cafe. Observation found debris and staining from an old leak as well as a vase fake flowers stored. During a tour of the facility, at 1:22 PM on 2/25/25, observation underneath the dining room sink found stored activity supplies. These items were stored under and around the wastewater line of the sink. vases, fake flowers, sponges. During a tour of the Gilead dining room, at 2:08 PM on 2/25/25, it was observed that numerous items were stored underneath the sink's wastewater line. These items were vases, a bag of cookie cutters, totes of supplies and containers of decorations. 45410 Resident #89 In an observation and interview on 2/25/2025 at 10:35 AM in room [ROOM NUMBER], Resident #89 (R89) reported staff never cleaned his room. R89 stated, I have to clean my own room. During this interview the floor was littered with food crumbs and scattered sticky areas where liquids had dried, including what appeared to be dried drops of blood scattered around the entire room. In an observation and interview on 2/26/2025 at 8:49 AM in room [ROOM NUMBER], the floor was littered with food crumbs and the same dried red areas that were present on 2/25/2025. R89 reported his room had not yet been mopped. In an observation and interview on 2/27/2025 at 9:18 AM in room [ROOM NUMBER], the floor was littered with crumbs and the same dried red substance was on the floor from the previous two days. Housekeeping Aide K observed the floor with this surveyor and confirmed the presence of the dried red substance on the floor. The spots disappeared immediately as Housekeeping Aide K used a wet mop to clean the floors.

Based on interview and record review, the facility failed to promote resident dignity for 1 (R21) of two residents reviewed for dignity. Findings include: Review of an Admission Record revealed R21 admitted to the facility on [DATE] with pertinent diagnoses which included hemiparesis (muscle weakness or partial paralysis on one side of the body) and psoriasis (a skin condition in which skin cells build up and form scales and itchy, dry patches). Review of a Minimum Data Set (MDS) assessment for R21, with a reference date of 1/22/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R21 was cognitively intact. Further review revealed R21 required staff assistance with toileting. In an interview on 2/27/2025 at 8:22 AM, R21 reported she had a bowel movement the previous morning at 8:10 AM and pushed her call light. R21 reported Certified Nursing Assistant (CNA) J entered her room and she told him that she had soiled herself and needed to be changed. R21 reported CNA J instructed her she would have to wait until 8:30 or 8:45 to be changed because she had been changed at 6:30 and it had not been two hours yet. R21 reported she pressed her call light again and at 9:00 AM two CNAs entered her room to provide care. R21 reported she had been crying all day and the event made her feel like nobody cares. R21 reported being left in a soiled brief caused pain because of her chronic skin condition. In an interview on 2/26/2025 at 3:25 PM, CNA J reported he responded to R21's call light that morning at 8:00 AM and R21 told him that she was soiled and needed to be changed. CNA J reported he instructed R21 that she was on a two-hour schedule and not due to be changed yet and then left her room. CNA J reported that he discussed the incident with a unit manager at approximately 9:00 or 9:30 AM and the unit manager instructed him that residents needed to be changed immediately if they reported being soiled and could not be told to wait until later. In an interview on 2/27/2025 at 8:43 AM, Licensed Practical Nurse (LPN) E reported he had a discussion with CNA J the previous morning and instructed him that staff must check residents if they reported being soiled and could not wait two hours from the last time the resident was changed. In an interview on 2/26/2025 at 3:38 PM, the Director of Nursing (DON) reported staff should not tell residents who reported being soiled that they have to wait 2 hours from the last time they were changed. The DON reported residents should be checked and changed at the time they reported being soiled. Review of facility policy/procedure Resident Rights, dated 7/11/2018, revealed .It is the policy of this facility that all residents be treated with kindness, dignity and respect . The staff shall display respect for Residents when speaking with, caring for, or talking about them .

Based on observation, interview, and record review, the facility failed to implement dermatology recommendations in a timely manner for one resident (R21) of two residents reviewed for skin conditions. Findings include: Review of an Admission Record revealed R21 admitted to the facility on [DATE] with pertinent diagnoses which included hemiparesis (muscle weakness or partial paralysis on one side of the body) and psoriasis (a skin condition in which skin cells build up and form scales and itchy, dry patches). Review of a Minimum Data Set (MDS) assessment for R21, with a reference date of 1/22/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R21 was cognitively intact. In an observation and interview on 2/25/2025 at 11:56 AM in room [ROOM NUMBER], R21 reported she had a rash, itching, and burning under her right breast that staff were not treating. R21 reported this was an ongoing issue and she had recently been to a dermatologist. This surveyor observed a large area of skin under R21's right breast to be bright red. Review of R21's Physician Orders active 2/26/2023 at 11:21 AM revealed no medicated creams, powders, or lotions were ordered to treat the rash under her right breast. Review of R21's offsite dermatology documentation dated 2/6/2025 revealed R21 was evaluated for psoriasis and given the following recommendations .Zinc Oxide Diaper Cream . Apply to groin, buttocks, and thighs . nystatin . topical powder . apply to affected areas under breast crease . Review of R21's Practitioner Short Progress Note, dated 2/14/2025 revealed dermatology recommendations were reviewed by Nurse Practitioner (NP) Q for zinc and nystatin. Further review revealed R21 was noted to have an allergy to zinc and the facility would follow up with dermatology to request alternative recommendations. In an observation and interview on 2/26/2025 at 12:10 PM, NP Q observed R21's skin with this writer and reported her psoriasis was flaring up. NP Q and this writer observed redness and inflammation of R21's skin under her breasts, between her legs, and on her buttocks. In the hallway, NP Q reported the resident saw dermatology a couple weeks ago and reviewed the dermatology documentation. NP Q stated the nystatin order was not placed and that nursing staff usually places these orders. NP Q stated R21 needed the nystatin and that it would be ordered. NP Q reported facility staff should have contacted the dermatology office to request alternative recommendations for the zinc when the recommendations were initially reviewed on 2/14/2025. In an interview on 2/27/2025 at 12:36 PM, the Director of Nursing (DON) reported she could not find documentation that R21's dermatology recommendations from 2/6/2025 had been addressed by the facility prior to this surveyor's conversation with NP Q on 2/26/2025. Review of facility policy/procedure Skin Monitoring and Management-Non-PU, dated 7/11/2018, revealed .It is the policy of this facility that a resident having areas of skin breakdown . receive necessary treatment and services to promote healing, prevent infection, and prevent new non-pressure sores from developing .

Based on observation, interview, and record review, the facility failed to ensure proper tube feeding precautions were implemented and maintained for one resident (R37) of two residents reviewed for enteral feeding. Findings: Review of the Electronic Medical Record (EMR) reflected R37 originally admitted to the facility on [DATE] with diagnoses that included a history of stroke, dementia, and was receiving nutrition through a feeding tube. Review of the Doctor's Orders dated 2/14/25 for R37 reflected an enteral feed order and the Medication Administration Record (MAR) reflected or Glucerna 1.5 to be delivered at 100 cubic centimeters (cc) per hour. On 2/25/25 at 9:28 AM, a dressing change for R37 was observed in the Resident's room with Licensed Practical Nurse (LPN) R and Unit Clerk (UC) T. It was observed that the head of the bed was elevated approximately ten degrees and R37 was turned onto his left side during the dressing change that lasted approximately fifteen minutes. It was observed that the enteral feeding pump was infusing at the prescribed rate of 100 cc per hour during the wound dressing change. Following the dressing change the head of the bed of R37 was not increased from the lowered position The policy provided by the facility titled Subject: Enteral Nutrition-Resident. Dated 7/11/2018 was reviewed. The review reflected Policy: It is the policy of this facility that the nurse, in cooperation with other health team members, must carefully monitor the resident's response to the feedings and feeding techniques to assure the attainment of therapeutic goals. And Procedure: General monitoring of nursing care should include: 1. Head of bed should be elevated at a 30-45 degree angle during feeding and for at least one (1) hour after feedings completed to prevent gastric reflux and possible aspiration. On 2/26/25 at 11:59 AM an interview was conducted with LPN R in her office. The dressing changed observed 2/25/25 at 9:28 AM was reviewed. LPN R was asked why the tube feeding was not suspended during the dressing change when the head of the bed was lowered, and the Resident was turned on his side. LPN R stated Is that policy? The proper angle of the bed for tube feeding was discussed. LPN R reported that R37 has remotes (bed controls) and the Resident can adjust the angle of his bed on his own. The undated document titled Job Title (job description) Charge nurse-RN/LPN provided by the facility was reviewed. The document reflected Principal Duties and Responsibilities: which included: Provide care to Residents by performing a variety of treatments, including changing dressing, cleansing and/or irrigating wounds and incisions, performing Foley Catheter irrigations, IV therapy, and administering tube feedings, chest tubes and peritoneal dialysis. And Know and support facility philosophy, standards, policies, and procedures

Based on observation, interview, and record review, the facility failed to ensure infection control measures were maintained during a dressing change for one resident (R37) of three residents reviewed for infection control. Findings: Review of the Electronic Medical Record (EMR) reflected R37 originally admitted to the facility on [DATE] with diagnoses that included a history of stroke and dementia, Review of the EMR Progress Notes entry dated 1/28/25 at 2:32 AM reflected a three-centimeter (cm) lump was identified at the hairline of the neck of R37 and the medical provider was notified. On 2/5/25 the Progress Note entry at 3:39 PM reveal a change in the lump and R37 was transported to the hospital for evaluation. On 2/13/25, R37 returned from the hospital with a wound vac dressing (also known as vacuum assisted closure (VAC), a medical device sealed over a wound that uses negative pressure to pull fluid and debris out of the wound promoting granulation tissue growth). The entry reflected R37 was referred to a wound care provider for wound management. Review of the Doctor Orders dated 2/24/25 for R37 reflected the wound vac dressing system was ordered to be changed and to cleanse the wound with Dakins solution prior to wound vac placement every Tuesday, Thursday, and Saturday. On 2/25/25 at 9:28 AM a dressing change for R37 was observed in the Resident's room with Licensed Practical Nurse (LPN) R and Unit Clerk (UC) T. It was observed that the head of the bed was elevated approximately ten degrees and R37 was turned onto his left side to expose the wound vac dressing. UC T supported R37 as the Resident lay on his left side. Wound re-dressing supplies were assembled on a small tray on an over- the- bed table. No barrier was on the over-the-bed table and a pair of scissors, and a large piece of wound film lay directly on the table. LPN R was observed preparing the wound for redressing by cleaning the wound and the perimeter with the prescribed solution and wiping with 4 x4 inch gauze then discarding the blood-tinged gauze. LPN R retrieved the large piece of adhesive film from the unprotected table and used the un-sanitized scissors to cut a piece of adhesive film to size to cover the wound. The cut piece was placed on the small tray next to a piece of black foam that was be inserted in the wound bed. At this point UC T prompted a glove change as LPN R had not degloved after cleaning and wiping the wound area. LPN R donned new gloves without hand sanitizing and retrieved the black foam from the small tray and placed it inside the open the wound. LPN R then covered the wound with the cut film and used the un-sanitized scissors to poke a hole in the film for the wound vac device and placed the scissors back on over-the-bed table. The procedure required another piece of film to be cut from the remaining sheet of film that also rested on the undraped table. Without changing gloves, a newly cut piece of adhesive film was placed over the wound site to complete the dressing change. On 2/26/25 at 11:59 AM an interview was conducted with LPN R in her office. In review of the dressing change observed 2/25/25 at 9:28 AM, LPN R acknowledged that UC T had prompted her to change her gloves. LPN R reported this was because one of the gloves had ripped and did not acknowledge degloving was indicated after irrigating and cleansing the wound with wet gauze. LPN R acknowledge the scissors should have been sanitized and placed in a different location during the dressing change. The undated document titled Job Title (job description) Charge nurse-RN/LPN provided by the facility was reviewed. The document reflected Principal Duties and Responsibilities: which included Understands Infection Control and follows the Company's Infection Control guidelines, such as hand washing principles, understanding of isolation and standard precautions, recognizing signs and symptoms of infection, demonstrating and understanding of the process for identifying and handling infectious waste and cross contamination .

This citation pertains to intake MI00148411 Based on observation, interview, and record review, the facility failed to assess timely, monitor, treat and adequately control pain for 1 Resident (R1) of 3 Residents reviewed for pain. Review of R1's face sheet dated 2/6/25 revealed she was a [AGE] year old female admitted to the facility on [DATE] and had diagnoses that included: 11/28/24 encounter for other orthopedic, polyneuropathy (peripheral nerve disorder that affects multiple nerves throughout the body simultaneously), pain in right shoulder, generalized anxiety disorder, hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), Pseudobulbar affect (inappropriate involuntary laughing or crying due to nervous system disorder) and mild cognitive impairment. R1 was listed as her own responsible party. Review of R1's progress note dated 1/20/25 at 12:44 PM revealed R1 had a mental evaluation, and she score 15 out of 15 on her Brief Interview of Mental Status (BIMS). Normal cognitive function. Review of the facility reported incident for R1 dated incident occurred 12/3/24 at 4:30 AM, revealed R1's Family Member (FM) K called the Administrator on 12/3/24 at 7:57 PM accusing Licensed Practical Nurse (LPN) C of not giving her pain medications timely or transferring her to the hospital when she requested to go to the hospital. Review of the facility reported incident for R1 dated incident occurred 12/3/24 at 4:30 AM, revealed LPN C provided the following statement in the investigation, This issue started around 4 am this morning (12/3/24). I had every med (medication) written out in advance of what was due for R1 and when because of her behaviors surrounding her pain meds (medication). She asks way ahead of time every night and does not sleep at all at night, this is a battle every night with her. Around 4-4:15 am was the Flexeril (medication for muscle spasms), I said you have couple minutes left before I can give you this. She was laughing, we were talking have a good conversation, ands she said Im [sic] kind of achy in my chest. I took her vitals they were stable; she had no tingling or numbness. I asked her if she would be OK with giving her Flexeril a try and seeing if that makes a difference for her. She agreed to taking the Flexeril and giving that a try before we take other measures. She never rang her call light again between 4:15 and 4:30 am and did not request to see me or to go to the hospital. Around 4:30 am, I was getting ready to check blood sugars, I could hear R1 on the phone with 911 from the hall, so I came over to her room. I could hear the operator asking her if it was an emergency and she said multiple times that this is not an emergency. She said it is not any emergency, I want to go to the hospital because I want more pain meds. (Record review revealed Flexeril was given at 2:58 AM not 4:00 AM as indicated in this interview and R1's pain medication was due again at 4:11 AM, R1 had been taking her as needed pain medication every 4 hours and her was 10/10 (indicating severe pain) since 12/2/24 at 7:24 PM, record review did not reveal any physician notification of increased pain or any timely reassessment of her pain after she reported severe pain on 12/2/24 at 7:24 PM). Review of the facility reported incident for R1 indicated incident occurred 12/3/24 at 4:30 AM and revealed Certified Nurse Aide (CNA) I made the following statement, R1 is frequently turning her call light on to ask for medication, on 12/3/24 I know that she was given her cup of pills after she rang her call light. One of the times R1 turned on her light she said she was going to call 911 because she hasn't had her pills yet. I told this to the nurse. She did not have any physical signs of pain, she was just expressing that she needed her pain meds even though everything that was available had already been administered to her by the nurse, and her Flexeril (not pain medication, used for muscle spasms) was up next, but it was not time to be given. (Record review revealed R1 reported severe pain on 12/2/24 at 7:24 PM and continued to report pain. Flexeril was given on 12/3/24 at 2:58 AM R1's next dose of pain medication was due prior to her calling 911). Review of R1's progress noted dated 12/2/24 at 12:36 PM revealed, Writer spoke with resident regarding pain management and skin concerns. Writer educated resident on PRN (as needed) pain medications. Resident stated being aware of the schedule, but that she [is] still in pain. She was reminded of her follow up appointment with the surgeon today. She stated that she will tall [sic] to the surgeon for more pain meds. Review of R1's progress noted dated 12/3/24 at 4:30 AM revealed, At the time of resident's c/o (complaint of) chest pain resident denies any numbness or tingling to either arm or hand and continued to have a conversation without any s/s (signs or symptoms) of pain or discomfort. Also stated, I just want to go to the Hospital because I know they will give me more pain meds. Review of R1's progress note dated 12/3/24 at 5:29 AM revealed, At 4:30 am staff entered resident's room and resident was on the phone with the 911 operator telling him that she was having chest pain but that it was not an emergency. 911 operator then stated that they would be there shortly to pick her up. VS (vital signs) at that time were 136/72, (blood pressure), 97.3 (temperature), 75 (heart rate), 16 (respirations) 100% (oxygen level) on RA (room air). No s/s (signs or symptoms) of pain or discomfort noted. Percocet (narcotic pain medication) offered to resident at that time and resident stated, No I take too many pills right now. Name of emergency medical services arrived and assessed resident and also obtained VS (vital signs) WNL (within normal limits) except for slightly elevated pulse. Resident then stated that she was anxious. Name of emergency medical services left facility with resident and paperwork for [name of hospital]. Review of R1's progress note dated 12/3/24 at 10:02 AM revealed, Hospital called, and resident admitted to the hospital. Dx (diagnoses) of Bronchitis. Review of R1's progress note dated 12/4/24 at 22:30 (10:30 PM) revealed, Resident returned to facility per ambulance on stretcher. Review of R1's emergency room report dated 12/3/24 revealed, Patient started to experience chest pain across the center of her chest around 22:00 (10:00 PM). Symptoms lasted through the night until EMS (emergency medical services) was called. She was given aspirin and nitroglycerin, patient states her chest pain has resolved at this time. She noted a little shortness of breath. Of note, patient recently had orthopedic surgery at (name of hospital) for Achillies tendon lengthening. Surgery was on November 27. She has been bedridden, and leg has been wrapped ever since the procedure. Review of systems: Respiratory: positive for shortness of breath. Cardiovascular positive for chest pain. Gastrointestinal positive for nausea. Negative for vomiting. Review of R1's Percocet (narcotic pain medication) orders revealed on 12/3/24, Percocet 5-325 MG every 4 hours as needed for pain was discontinued after the last dose was given at 12:11 AM. Percocet 10-325 MG every 4 hours as needed for pain was ordered when she returned from the hospital. (increase in pain medication). R1 was observed on 2/6/25 at 12:45 PM receiving care. Certified Nurse Aides (CNA's) E and J, changed R1's brief and dressed her for an outside appointment. R1's buttock and peri area were bright pink. R1 and CNAs said her buttock had been excoriated for a long time. R1 had several creams and lotions in the room and sign on the wall indicating she was allergic to creams with zinc. R1 was hoping the dermatologist she was going to today would start a new treatment. R1 complained that she is incontinent and when she urinates it burns her buttock. R1 said her shoulder was a pain level of 4 out of 10, and her left arm and leg were both a 6 out of 10. R1 said she is always in pain and has never provided a pain score of zero. R1 talked about activities she used to like to do but said she can't sit up that long anymore. The CNA's confirmed R1 used to get out of bed more often and always reports being in pain. During a private interview with R1 in her room on 2/6/25 at 1:10 PM, R1 could not recall any specific details of the event on 12/3/24 at 4:30 AM when she called 911. R1 said she has called 911 more than one time because she doesn't feel she is getting her care timely and when she complains things only get worse. R1 was very focused on needing to get back into bed after physical therapy. R1 reported she had to stay out of bed for 4 hours or more on Friday January 31, 2025, and Monday February 3, 2025. R1 said she just spoke to the Therapy Director (TD) L, and he assured her next time he will help her get back into bed after therapy. R1 said she just can't sit in a wet diaper that long. R1 said she really wanted to be able to stand again so she would not have to use the mechanical lift to get into her wheelchair. She said she stood for 10 seconds in therapy twice and believed she would get stronger but was considering stopping physical therapy because it was too painful to stay up in her wheelchair that long. Review of R1's Medication Administration Record (MAR) for December 2024, revealed R1's pain was assessed by a nurse on 12/2/24 at 19:24 (7:24 PM) and her pain was recorded at 10 out of 10 (severe pain) that nurse provided R1 with a Fentanyl Transdermal Patch 72 hour/25mcg/hour.(narcotic pain medication). LPN I provided R1 with her Percocet Oral Tablet 5-325 MG on 12/3/24 at 12:11 AM and rated R1's pain at 8 out of 10 (severe pain). LPN I provided R1 with her Flexeril 5 mg table on 12/3/24 at 2:58 AM (not around 4 am as indicated in her facility statement) LPN I rated R1's pain as 8 out of 10 at 1:58 AM one hour prior to giving the Flexeril. LPN I did not confirm in her investigation statement that R1 had any complaints of pain on 12/3/24 prior to R1 calling 911, however LPN I documented twice prior to 4:30 AM that R1 had severe pain. LPN I documentation in R1's medical record did not match her statement she provided for the facility investigation. LPN I did document R1 has severe pain when she provided the Flexeril at 2:58 AM and she did not provide the as needed pain medication at 4:11 AM when she could have. LPN I did not offer additional pain medication until R1 called 911. Review of R1's pain assessments for R1 on 12/3/24 revealed that, LPN I rated R1's pain again on 12/3/24 at 2:33 AM and this time it was 6 out of 10 (moderate pain) This information was not located in the facility investigation. During a telephone interview with LPN I on 2/6/25 at 11:03 AM, LPN I recalled the event on 12/3/24 at 4:30 AM when R1 called 911 and complained of severe pain. LPN I recalled being interviewed by the facility and making a statement. The surveyor read her statement and LPN I confirmed that was her statement. LPN I did not recall assessing R1 earlier that evening as having pain scores of 8, and 6. LPN I could not recall which nurse was on when she arrived and denied being aware R1 had a pain score on 12/2/24 at 7:24 PM of 10 out of 10. LPN I was not sure about the timeline of events that evening. LPN I said she was aware R1 could have her Oxycodone every hour and she did not recall offering to provide R1 with another dose of Oxycodone until R1 had called 911 and R1 refused to take the Oxycodone at that time. (Oxycodone could have been given at 4:11 AM. R1 called 911 at 4:30 AM). During an interview with the Therapy Director (TD) L on 2/6/25 at 1:24 PM he confirmed that R1 attended therapy last Friday January 31 and Monday February 3, 2025. He confirmed that she was able to stand, and she seemed motivated to continue therapy. TD L said he just found out today that R1 was upset about not getting back to bed right after therapy and he did assure her next time he would assist staff getting back to bed after therapy. TD L was asked if R1 ever had a day where she was pain free and TD L said, no. he said he treated her shoulder earlier today and she reported it was a score of 7 out of 10 to start and after treatment she reported it was 4 out of 10. During a telephone interview with R1's Family Member (FM) K, on 2/6/25 at 2:17 PM she recalled reporting to the Nursing Home on 12/3/24 that R1 was not getting her pain medication timely. FM K expressed frustration because she feels like when they complain things get worse. FM K said R1 has been in the hospital several times since that event. FM K said she has talked with R1 about hospice care because she does not have any quality of life there. FM K said R1 called her one of the days after therapy crying because staff would not put her to bed. She told her to put her call light on and when staff came in, they were very rude to R1, FM K said she knows her mom gets mad and is rude to the staff too. FM K said they talked and if staff will not get her back to bed after therapy she will have to stop because it is just too painful to sit up that long. FM K said she will decide to go into hospice if she can't get better care, she just can't live like this. Review of R1's pain care plan dated 11/11/19 with revision on 12/13/24 revealed, The resident has acute/chronic pain r/t arthritis and muscle spasms, will refuse all other intervention other than pain med (medication). Resident is reporting increased pain due to recent surgical procedure to lengthen Achilles tendon LLE (left lower extremity). Resident will describe horrible: pain to nursing staff and ask for pain medication, when staff returns, she has been asleep in bed, and on occasion has been difficult to arouse. Strained right shoulder ligament. Refused Sling. Goal: The resident will verbalize and/or exhibit that pain is at a tolerable level and not have pain interfere with daily routine through the review dated: target dated 4/15/25. (no indication of what level pain is tolerable). During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 2/7/25 at 10:30 AM, R1's pain assessments for 12/2/24 and 12/3/24 and her Medication Administration Records (MAR) were reviewed. They confirmed that LPN M had assessed R1 to have pain at 10 out 10 on 12/2/24 at 7:19 PM and no follow up pain assessment was completed until LPN I assessed her at 12:11 AM on 12/3/24 and she still was at a pain level of 8 out of 10. The NHA confirmed that she did not interview LPN M for the investigation related to R1's pain complaints and calling 911 on 12/3/24 at 4:30 AM. LPN M was the nurse that rated R1's pain as 10 out of 10 on 12/2/24 at 7:19 PM. They confirmed that LPN I also assessed R1's pain 12/3/24 at 1:59 AM to still be 8 out 10 and 12/3/24 at 2:33 AM to be 6 out of 10. They confirmed that LPN I did not indicate in her statement that R1 was experiencing severe pain the night of 12/3/24 when R1 called 911 at 4:30 AM. They confirmed that staff did not contact R1's provider when her pain was 10/10 and did not reassess her pain in a timely manner. The pain assessments also revealed several pain assessments that rated R1 as having zero pain. When asked to explain this documentation as the resident and multiple staff interviews indicated R1 is never pain free. The DON said if the resident is sleeping, they can use the nonverbal scale and document zero, if she reports she is comfortable they can document zero and the DON said as a nurse she has heard R1. The DON said she is heard R1 say she is comfortable and has reported to her she is not in pain. When asked what is R1's tolerable pain level the DON reviewed the pain care plan from 2019 and said R1 could tolerate pain levels of 8 and 10. The DON was not sure who completed that assessment or where it was located. The Surveyor requested all information related to pain assessments and her pain tolerance. Upon exit no evaluations indicating R1 could tolerate pain at 8 and 10 were provided. During the interview with the DON and NHA on 2/7/25 at 10:30 AM, the NHA said they were educated today on doing a thorough investigation and started educating nurses on pain.

This citation pertains to intake #MI00145408. Based on interview and record review, the facility failed to prevent significant medication errors for 1 resident (Resident #101) of 3 residents reviewed for medication use, resulting in the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an Admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included seizures, fibromyalgia, and hypertension. In a telephone interview on 7/16/2024 at 9:05 AM, Hospital Case Manager B reported it was learned while preparing Resident #101 for discharge from the hospital back to the facility on [DATE] that Resident #101 had not been taking all the medications according to discharge orders the last time she was discharged from the hospital back to the facility on [DATE]. Review of Resident #101's local hospital Hospitalist Discharge Summary, dated 6/28/2024, revealed .Patient well known with multiple hospitalization s in 2024, last 6/14-6/16 . Review of medication performed by Pharm Technician revealed that majority of patients medications were discontinued per facility RN. Call was placed by this provider as well to verify medications and patient was not on antihypertensives or bowel routine, these medications were noted to be on her list on all of her admits this year . In an interview on 7/15/2024 at 3:19 PM, Licensed Practical Nurse (LPN) G reported he spoke to an employee at the hospital on 6/18/2024 when Resident #101 was discharged back to the facility and reviewed medication lists. LPN G reported he performed the admission assessment and reviewed medication orders upon Resident #101's return from the hospital that evening, and the third shift nurse was to perform the second check of the orders. LPN G reported a second nurse and the unit manager are required to double check admission orders. LPN G reported management later instructed him that he missed two medications, Miralax (a laxative) and Senna (a stool softener) and was given written counseling. Review of LPN G Disciplinary Action Record, dated 7/10/2024, revealed .issued on 7/10/24 . Written Warning #1 . Date of Infraction 7/1/2024 & 6/16/24 . On 6/16/24 you failed to correctly enter readmission orders for resident . You had errors in the transcription & placement of orders . Review and comparison of Resident #101's hospital discharge orders dated 6/16/2024 and facility physician's orders and Medications Administration Record revealed LPN G failed to activate several medication orders upon Resident #101's re-admission to the facility on [DATE] including the following . Amlodipine 10mg daily (hypertension medication), not started again until after Resident #101's 6/27/2024 to 6/28/2024 hospitalization on [DATE]- Baclofen 15MG three times a day (skeletal muscle relaxant that can cause withdrawals if stopped abruptly), not started gain until after Resident #101's 6/27/2024 to 6/28/2024 hospitalization on [DATE]- Senna S 8.6/50mg, two twice a day (laxative), not started gain until after Resident #101's 6/27/2024 to 6/28/2024 hospitalization on [DATE]- Miralax 17g daily (laxative), not started gain until after Resident #101's 6/27/2024 to 6/28/2024 hospitalization on [DATE]- Metoprolol Succinate 25mg twice a day (hypertension medication), not started gain until after Resident #101's 6/27/2024 to 6/28/2024 hospitalization on [DATE]- Lisinopril 40mg daily (hypertension medication), not started gain until after Resident #101's 6/27/2024 to 6/28/2024 hospitalization on [DATE]- In an interview on 7/16/2024 at 8:30 AM, the Nursing Home Administrator (NHA) reported she was not aware until yesterday afternoon that Resident #101 went without these medications. The NHA reported they originally thought Resident #101 only went without a couple bowel medications. Regional Consultant A reported LPN G failed to accurately reconcile Resident #101's medications during the admission process, the paper admission checklist was not completed as required for the 6/16/2024 or 6/28/2024 admission, Prior Nurse E failed to perform the second check of the admission orders, the unit manager failed to check the admission orders, and the medical provider failed to check the admission orders. Regional Consultant A reported the facility is working on a plan of correction to address this. Review of facility policy/procedure Admissions, dated 7/11/2018, revealed .Licensed Nurse Procedure . Inform physician of admission and verify transfer and admission orders . order medications from pharmacy . Review of a facility Admission Checklist, dated 7/15/2024, revealed the admission nurse is to confirm admission orders with a physician, have a 2nd nurse verify the admission orders, and ensure the pharmacy has the medication orders. This process is then checked by a nurse manager.

This citation pertains to intakes #: MI 481, MI 243, MI 497, and MI 931 Based on interview and record review, the facility 1.) failed to ensure a comprehensive facility-wide assessment that included an assessment of the staffing needs, resident behaviors (wandering), resident acuity, and staff training and education requirements was complete and accurate, 2.) failed to evaluate the effectiveness of the interventions in place for residents with known behaviors, 3.) failed to identify increased behaviors and revise a care plan and 4.) failed to ensure there was sufficient staffing to supervise residents and prevent resident to resident abuse for 7 residents (Resident #9, #107, #32, #79, #24, #36, #1), resulting in a pattern of systemic neglect leading to resident to resident abuse and the decline in mental and psychosocial well-being. Findings: Resident #9 (R9) Review of an Admission Record revealed R9 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for R9, with a reference date of 9/2/22 revealed R9 was cognitively impaired. Resident #107 (R107) Review of an Admission Record revealed R107 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R107, with a reference date of 7/28/22 revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated R107 was severely cognitively impaired. Review of R107's Care Plan for behaviors revealed, Focus-Resident has a behavior concern r/t (related to) dementia & depression. Has the potential to wander and may be friendly toward females (asks staff if they are married or make inappropriate/vulgar comments) Resident may touch female. May ask them for sex or make inappropriate gestures toward them (fondled self). May refuse to keep clothing and brief on. Date Initiated: 08/10/2021 . Indicating inappropriate sexual behavior was known and ongoing since the time of admission (greater than 1 year). Review of R107's Care Plan for behaviors revealed, Interventions-Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Put up stop barriers on the doors of female rooms on the same hallway. Date Initiated: 10/11/2021 .Redirect/distract res. from rooms and carts and offer assistance. Date Initiated: 11/17/2021 . Review of R107's Care Plan for wandering/elopement revealed, Resident is an elopement risk and/or exhibits wandering behavior r/t dementia. Per wife, has a history of wander halls and rooms. May go into other resident rooms with or without clothing on (a sexually inappropriate behavior). Date Initiated: 08/09/2021 . Indicating behavior was known and ongoing since the time of admission (greater than 1 year). Review of R107's Progress Note dated 9/3/22 revealed, Behaviors all shift. Coming out of room and taking food from people and eating it. Unable to redirect or to stop behavior. Becomes aggressive with attempts to stop. Asking for multiple drinks, etc. Seems unable to notice when he has had sufficient food. Review of R107's Progress Note dated 9/7/22 revealed, Resident had multiple behaviors all shift. Looking for cigarettes and coffee. Became angry and striking out at staff with redirection. Resident required close supervision t/o (throughout) shift. Cena (CNA-Certified Nursing Assistant) was able to redirect resident to his bed at this time. Review of R107's Progress Note dated 9/12/22 revealed, resident very combative last night. Needed to be redirected several times. Verbally aggressive with room mate (sic). Moved to new room for the night so there was no confrontation with room mate (sic). R107's Care Plan was not updated to reflect verbal aggression with roommate/room change. Review of R107's Progress Note dated 9/14/22 revealed, Resident was up multiple times through out (sic) the night, seeking drinks and food. Very difficult to redirect, yelling and combative with staff. Required close supervision through out (sic) shift. Review of R107's Progress Note dated 9/18/22 revealed, Intrusive behavior in early morning . Review of R107's Progress Note dated 9/19/22 at 9:17 PM revealed, Resident was intrusive going into other resident rooms, looking for food and drinks. Angry and striking out at staff with redirection. Resident given food and drinks from pantry. But behaviors continues (sic). Required close supervision through night. Review of R107's Progress Note dated 9/20/22 at 2:00 PM revealed, Resident was intrusive going into other resident rooms, looking for food and drinks. Resident given food and drinks. Behaviors continue. Required close supervision throughout shift . Review of R107's Progress Note dated 9/23/22 at 1:56 AM revealed, Resident up walking in hallway since beginning of shift .Resident aggressive toward staff and making inappropriate statements, putting his fists up as if to hit staff. Demanding more drinks and snacks. Angry facial expression . Review of R107's Progress Note dated 9/23/22 at 9:37 PM revealed, Resident was walking up and down hallways and going into other residents rooms looking for food and drinks. Resident was very difficult to redirect. Angry with redirection. Striking out at staff and verbally abusive. Resident given food and drinks but behaviors continues (sic). Resident required close supervision due to intrusive behaviors . Review of R107's Progress Note dated 9/24/22 at 2:43 PM revealed, Restlessness, seeking food and drinks throughout shift. Going into other resident rooms and taking med pass, applesauce, and pudding off med carts. Continuously hungry. Redirected with activities with little effect. Review of R107's Social Service note dated 9/15/22 revealed, IDT (Interdisciplinary Team) reviewed res. (resident) in behavior/[CONDITION(S)] committee meeting today 9.15.22. This is a follow up from previous meeting 9.8.22 when res. Was started on [MEDICATION(S)]. IDT reviewed medications and behaviors. No further concerns noted, therefore no further recommendations made by IDT at this time . Review of R107's Social Service note dated 9/22/22 revealed, IDT reviewed res. in behavior/[CONDITION(S)] committee meeting today 9.22.22. This is a follow up from previous meeting 9.15.22 when resident had some increased appetite. IDT reviewed medications and behaviors. No further concerns noted, therefore no further recommendations made by IDT at this time . On 9/7/22, 9/14/22, 9/19/22, and 9/20/22 nursing staff documented in R107's Progress Notes that R107 required close supervision for his behaviors and on 9/12/22 R107 was verbally aggressive with his roommate which resulted in him moving to another room. The IDT met on 9/15/22 and 9/22/22 to review R107's medications and behaviors. There were no concerns noted and no recommendations made indicating the IDT team did not identify R107's escalating behaviors now required close supervision and a room change. R107's Care Plan was not updated with interventions to keep himself and/or other residents safe from his behaviors. Review of R107's Care Plan revealed, Encourage res. (resident) to be close to staff and/or eye sight (sic) when able (or when out of room). Date Initiated: 09/27/2022 . Indicating the Care Plan for his increase in behaviors was updated after the Resident to Resident incident occurred. Review of a Witness Statement written by Activity Assistant (AA) Q revealed, At the request of nursing, this is my account of (R107) behaviors 9/24/22. (R107) was very disruptive from morning up until the incident with (R9). Stealing res (resident) beverages. Entering res rooms + startling them . Review of the Facility Reported Incident revealed that on 9/24/22 at 4:00 PM, (R107) was witnessed with his pants pulled down on top of (R9) while she was laying in her bed fully clothed (gown and brief on and not tampered with) her bed sheets were pulled up covering her body . (R107) was sent out to the hospital for evaluation . Through the investigation it was determined that prior to this event, (R107) did not display sexually inappropriate behavior toward other residents, he had historically directed his comments toward staff members and had been making comments throughout the day to staff members . Administrator spoke with (Family Member FM O), wife/guardian on 9/24/22 to inform her of the incident that occurred and his transfer to the hospital for further evaluation. At this time (FM O) stated that (R107) had no history of sexual behaviors towards other residents in the past and was surprised to hear of the incident . CONTRIBUTING FACTORS/ROOT CAUSE ANALYSIS: The primary root cause of (R107) sexually inappropriate behavior is due to his dementia and impaired ability to control impulsive behavior. In addition to the root cause, there are multiple contributing factors relating to the allegations: (R107) is diagnosed with schizophreniform disorder, dementia with behavioral disturbance, major depressive disorder, and restlessness/ agitation. (R107) had a medication change on 8/25/2022 and started on [MEDICATION(S)] for major depressive disorder, which was a new medication for him. (R107) recently had moved rooms . Indicating the facility identified possible agitators that caused an increase in R107's behaviors and no new interventions were implemented prior to the incident. During an interview on 12/01/22 at 04:07 PM, FM O reported that the incident never should have occurred. FM O reported that the facility wasn't paying attention to this particular (dementia) unit and she could not understand how there were no staff supervising the residents, with known wandering behaviors, to prevent this type of situation. FM O stated, if they had been paying attention this wouldn't have happened. Review of the staffing schedule dated 9/24/22, the Gilead Unit had 1 support aide, 2 nurses, and 3 CNA's (Certified Nursing Assistant) scheduled at the time of the incident between R107 and R9. A 4th CNA was scheduled to work from 5-9 PM. Resident #32 (R32) Review of an Admission Record revealed R32 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R32, with a reference date of 11/3/22 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated R32 was cognitively impaired. Review of R32's behavior Care Plan revealed, Resident has a behavior concern r/t Depression, anxiety, and Dementia (memory issues). He may exhibit refusals of care (showers/clothes changes), may become combative/aggressive (grab staff arm/hand, swat at staff, chest bump, push staff out of room). Res. may have boundary issues and/or walk up to another res. and/or talk to them while tapping or placing hand on their shoulder/arm. Resident may wander into other resident's rooms touch their belongings, stand over them while they sleep, lay in empty beds. Patient wanders, and may paces and rummage in his room, and at times in his roommate's personal space, putting him at risk for intruding on the privacy of others. Date Initiated: 06/11/2021 . Resident #79 (R79) Review of an Admission Record revealed R79 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R79, with a reference date of 10/25/22 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated R79 was moderately cognitively impaired. Review of the Staffing Schedule dated 11/20/22 for the shift 10 PM-6 AM revealed there were 2 CNA's and 1 nurse working on the Gilead Unit at the time of the incident. Review of R79's Witness Statement dated 11/21/22 revealed, Last night around 2am-3am, I was lying down in bed on my back, he came in and said them are mine referring to my breasts. He grabbed my breasts over the top of my pajama shirt and bra. I screamed for the nurse, she came in and got him out. Then he came back about 20 min later. I yelled at him you can't touch me, and I hit him on the head. I yelled for the nurse again and they took him out again .(R32) has been here too long, he goes in/out of rooms, he could rough anyone up at any time (interview with police officer) he came into my room [ROOM NUMBER] times last night. That man. (Could not provide a name or description after prompting from the officer). He said I want to feel you up and grabbed my breasts. I yelled Nurse, Nurse. Then he came back a second time and he grabbed them again and I yelled at him to get out and called for the Nurse. He didn't say anything the second time when he grabbed me. Then he came in another time and I yelled at him to get out. Review of CNA R's Witness Statement dated 11/21/22 revealed, (R32) walked into her room [ROOM NUMBER] times last night. The first time it was around 1:30am and I was in the middle of doing my rounds actively changing someone when I heard (R79) yell Nurse, nurse. The minute I could, I went in the room and directed (R32) out of the room. It took me maybe 1-2 minutes to get there from the time (R79) yelled for help, I was in the room next door .When I entered the room (R79) was lying in bed and (R32) was standing next to the recliner which is in the middle of the room. All (R79) said was if he comes in again I am going to kick his ass. From what I could see he was at least 10' away from her and not close enough to touch her .I went to change another person and again he went to her room and she got angry again. Less than 10 minutes had passed. He barely made it through the threshold of the door the 2nd time and I caught him immediately and redirected him .(R32) has a history of wandering and there were no allegations made last night . Review of CNA S's Witness Statement dated 11/21/22 revealed, I saw CNA R redirecting (R32) in the hallway last night and she (R79) came out and told me that the next time he came in her room I will beat his ass, or something to that effect. I said (R79) you aren't going to do that, he doesn't know any better . Review of LPN T's Witness Statement dated 11/21/22 revealed, .As far as I know I thought (R32) was in bed for the majority of my shift last night. The facility investigation indicated a lack of supervision for R32 when it was known he was entering R79's room. There were no immediate interventions put in place for R32's behaviors after he entered R79's room the first time causing R79 to be fearful and threaten physical violence against R32 when he attempted to enter her room the 2nd time. The FRI did not reflect that increased supervision or other interventions were implemented that would avoid psychosocial harm or physical abuse between R32 and R79. Additionally, the facility failed to affirm R79's fearfulness resulting in mental anguish despite the nature of the allegation (unwitnessed sexual assault). Review of R79's Police Report dated 11/22/22 revealed, .(R79) stated that she wanted (R32) out of the unit because she doesn't feel safe when he wanders . Review of a Facility Reported Incident between R79 and R32 revealed, On 11/21/2022 around 3:30pm Administrator was notified of potential abuse allegation between (R79) and (R32). It was reported that (R32) entered (R79's) room and attempted to touch her. Facility to initiate investigation.(R79) was likely startled by (R32) wandering into her room and it caused her to change her story in various ways in hopes that it would cause him to be removed from the facility. (R79) has a history of making false accusations which are a part of her preexisting mood and behavior care plans. Her decision making and impulse control are both impaired due to her dementia diagnosis. (R32) also has an impairment in decision and impulse control, with a history of wandering, this likely caused him to wander into her room at various points throughout the evening. Both residents reside on the memory care unit, and both have diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . DETERMINATION OF FINDINGS/CONCLUSION: Based on the findings of the investigation including interviews with the residents, review of the clinical record and interviews with staff members identified above, a decisive conclusion was made the occurrence was NOT the result of abuse, neglect, misappropriation, or harm. The event is determined to not have occurred. The abuse policy was followed . The facility determined the allegation did not occur although there were no witnesses present when R32 was alone in R79's room unsupervised. Review of the Quality Assessment and Assurance Committee minutes dated 11/22/22 revealed, Review & discuss outcomes of investigation of Abuse: 11/21/2022 (R32) vs. (R79) Abuse-Root Cause-(R32) entered (R79's) room and it startled her. she changed her story numerous times throughout the day in hopes that it would cause (R32) to get kicked out of the facility after talking with her friend (R36). She also changed her story again after speaking to administration and the police. *Immediate intervention-stop sign on (R79's) door, 15 minute checks for (R32) and (R79), encourage (R79) to sleep with her bedroom door shut in the evening. The Quality Assessment and Assurance Committee minutes did not address R32's wandering behaviors, staffing (required to redirect wandering behavior that impacts other residents), or supervision to prevent further abuse and/or allegations. Review of R79's mood Care Plan revealed, .Offer support visits to assist with any upset mood/behavior. Offer stop signs for doorway and suggest door is closed to reduce other resident's entering Date Initiated: 07/23/2021 Revision on: 09/27/2022 . prior to the facility reported incident of alleged resident to resident sexual assault. Review of R79's mood Care Plan revealed, .Offer support visits to assist with any upset mood/behavior. Offer stop signs for doorway and suggest door is closed to reduce other resident's entering Date Initiated: 07/23/2021 Revision on: 11/21/2022 . Indicating R79's Care Plan was not updated with new interventions following the incident. R79's Care Plan did not have an intervention related to 15 minute checks, invalidating the facility report to the state agency claiming meaningful changes to the plan of care had been implemented. Review of R32's behavior Care Plan revealed, .15-minute checks during the night x72 hours Date Initiated: 11/21/2022 . despite the fact that CNA R reported that R32 attempted to reenter R79's room when less than 10 minutes had passed. Resident #24 (R24) Review of an Admission Record revealed R24 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R24, with a reference date of 8/31/22 revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated R24 was severely cognitively impaired. Review of R24's behavior Care Plan revealed, Resident has a behavior concern d/t (due to) [CONDITION(S)] (Post Traumatic Stress Disorder), Dementia, Psychotic disorder w/ delusions. He may push/grab staff, use abusive/vulgar language (swear/use the F word), use hand gestures, slap at staff, May be physical with staff and/or others. May also have aggressive/threatening behavior and/or reject care (incontinence). Often above behaviors occur when he is rejecting care. May use tray tables or walkers inappropriately and throw things. May swing wet floor signs at others or throw walker. May try to stab at staff with pens May go into other resident's rooms when wandering the unit. Res. may also retaliate when feeling threatened. May be affectionate with female residents Date Initiated: 08/31/2021 Revision on: 11/21/2022 . Resident #36 (R36) Review of an Admission Record revealed R36 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for R36, with a reference date of 8/24/22 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated R36 was moderately cognitively impaired. Review of the Facility Reported Incident for R36, R24, and R32 revealed, .On 10/13/2022 at 4:25 PM, staff witnessed resident (R36) in his room, using a walker to push resident (R32) away from him. Another resident, (R24) was also in the room at the time. (R36) stated when staff came in to assist, that he was trying to get (R32) and (R24) out of his room. (R36) said that (R24) took a swing at him .(R32) and (R24) have a history of wandering behavior due to their dementia diagnosis .(R36) was interviewed and gave an account for what happened in his room. He stated that (R24) took a swing at me and (R32) came down too, they were both in my room. He said that when (R24) took a swing at him, he said had no choice but to defend himself. He said he told them two times that they have to get out of here, that is when (R24) took a swing at him. (R36) said that he got (R24) away from him and then grabbed the walker that was in his room to put between himself and (R32) so he would not come near him .The root cause of the incident was (R24) and (R32) entering (R36's) room. This caused (R36) to become upset with the gentlemen. When he asked (R36) to get out of his room that is what triggered (R24's) response of, reportedly swinging at him. (R24's) cognitive status caused him to respond to (R36's) request to leave his room, in the manner in which he did. When (R32) started walking toward (R36), (R36) felt as though he had to protect himself, so his immediate response was to grab the walker and place it between them. Conclusion: Based on the findings of the investigation including interviews with the residents, review of the clinical record and interviews with staff members identified above, a decisive conclusion was made the occurrence was NOT the result of abuse, neglect, misappropriation or harm. It can not be substantiated that (R24) took a swing at (R36) as (R36) does have impaired cognition and the event was not witnessed. However, it was witnessed that (R36) did use a walker to push between himself and (R32). (R36) did not take this action with intent to cause harm to others, but with an intent to encourage (R32) to leave his room and to defend himself. The event did not result in harm, pain, or mental anguish and all three residents remain at their baseline. It is not substantiated that an intent to cause harm or intent for any [MEDICATION(S)] negative impact exists . R32's Care Plan was not updated following this altercation that resulted from his wandering behavior. Resident #1 (R1) Review of an Admission Record revealed R1 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R1, with a reference date of 8/19/22 revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated R1 was cognitively impaired. Review of the Facility Reported Incident for R1 and R24 revealed, .On 10/16/2022 at 5:45 AM, facility administrator was notified of a potential resident to resident altercation. Staff witnessed (R1) yelling at (R24) to get out of her room. As he was wandering out (R1) hit (R24) .(R24) is independent with ambulation using a front wheeled walker, and frequently wanders throughout the unit . (R1) was heard yelling at (R24) to get out of her room. As he was leaving the room, she was seen hitting (R24) and losing her balance, in which point she fell . Root Cause Analysis/Contributive Factors: The investigation determined the event occurred and is likely related to (R24) wandering into (R1) room. (R24) wandered into (R1) room, this startled her and caused her to respond by yelling. As he was leaving her room, she hit him which was due to her lack of impulse control and poor decision-making abilities related her dementia diagnosis. Both residents have dementia and impairment related to decision making. DETERMINATION OF FINDINGS/CONCLUSION: Based on the findings of the investigation including interviews with the residents, review of the clinical record and interviews with staff members identified above, a decisive conclusion was made the occurrence was NOT the result of abuse, neglect, misappropriation or harm. The event is determined to have occurred but due to the residents impaired cognition, they were unable to form a willful intent to cause harm. (R1) was responding to (R24) wandering into her room, causing her to yelling and hit him. The IDT with input from frontline staff and developed new meaningful interventions for (R24). Both residents remain unchanged from baseline . R24's Care Plan was not updated following the altercation on 10/13/22 that resulted from his wandering behavior. There were no interventions implemented to prevent additional occurrences of resident to resident abuse due to R24's wandering behaviors. Review of R24's behavior Care Plan revealed, .Monitor/distract as able away from other rooms. Date Initiated: 10/16/2022 . Review of R24's behavior Care Plan revealed, .Monitor/distract as able from other rooms. Try to keep in common areas of the unit. Revision on: 10/17/2022 . During an interview on 11/28/22 from 10:31 AM-11:24 AM with R79 and R36, R36 reported that there are 2 residents that wander the units and like to go through people's rooms. R36 reported that the 2 residents that wander the halls and enter resident rooms are R32 and R24. R36 reported that both residents had recently entered his room without invitation (intake 1). R36 reported that he raised my voice to get them to leave and R24 took a swing at me. R36 reported fear with 2 men trying to accost me. R36 reported that he pushed him away with my leg and then R32 came at me. R36 reported that he had to use his walker to protect himself and it took everything I could to get away from them. R36 reported that R24 and R32 are left unsupervised and they are dangerous together. R36 reported that residents that require supervision are not supervised. R36 reported that the facility had a couple other (residents) that were bad news. R36 reported that a few months ago R107 sexually assaulted a female resident (R36 was able to name R107 and R9-intake 3). R36 stated the Gilead Unit is a vulnerable area. These women can't protect themselves from the residents with known behaviors. R79 reported that approximately 2 weeks prior she was in bed sound asleep and (R32) grabbed my boobs. I screamed! (intake 1) R79 reported fear when she woke to a man standing over her and ongoing fear and anxiety that there have been no changes made to prevent another occurrence. R79 stated the facility needs to hire one person as a pair of eyes to watch the guys (R32 and R24). R79 reported that there were not enough staff to meet the needs of the residents and the staff can't keep up. R79 reported that there was recently a night shift where there was only 1 CNA for all of the residents on the Gilead Unit. R79 reported that there are 2 CNAs scheduled for 3rd shift and there's no way they can have 2 staff at night to watch those 2 guys (R24 and R32). It's not enough. They try hard but they can't do it (their jobs) with 2 guys that are extra trouble. R36 reported that they try to get R24 and R32 to stay out of other rooms by putting up stop signs (Velcro mesh across resident doorways) but R24 will remove the stop sign from the doors and enter the room. R36 reported that R32 recently went around peeing in garbage and sinks but not the toilet because of the lack of staff/supervision. R79 reported that she is fearful of R24 and if you say something (R24) doesn't like he (punching motion) and the nurses are scared of him. R79 stated, there's not enough staff to give care and attention to residents. If they could bring more staff on it would be perfect. During an interview on 11/29/22 at 08:45 AM, LPN A reported that the Gilead (name of locked dementia unit) Unit had a lot of residents that have wandering behaviors which require supervision and a locked unit. During an interview on 11/29/22 at 09:07 AM, CNA W reported that there was not sufficient staff to meet the physical and behavioral needs of the residents. CNA W reported that 2nd shift is scheduled to have 3 CNAs on the floor and 1 support CNA to monitor residents in the main area. CNA W reported that there are times when 2nd shift only has 2 CNAs on the floor and that is not enough to control (R32) and (R24) specifically. CNA W reported that there are many residents on the Gilead Unit that wander and there is no way to manage behaviors, prevent resident to resident altercations, and/or wandering in and out of the rooms. CNA W reported that R32 and R24 have wandering tendencies that need direction. During an interview on 11/29/2022 at 3:00 PM, LPN M reported that the Gilead Unit was staffed with 3 CNAs at that time and 1 CNA was pulled to another unit. LPN M reported that it was difficult to monitor residents that wander in and out of rooms, especially (R32) and (R24) and reported R32 and R24 were often involved in resident-to-resident altercations. LPN M reported that dinner time to bedtime was the most difficult time of the shift because the CNA's had to assist with feeding, changing, nighttime care, and getting residents to bed. LPN M reported the Gilead Unit needed additional staff to supervise residents that wander in and out of rooms and upset other residents. During an interview on 11/30/2022 at 12:40 PM, CNA X reported that residents were not receiving the care they required because of the lack of staff. CNA X reported that there were many residents on the Gilead Unit that required extensive assist or 2 assist with cares and the staff were expected to monitor and supervise (R32) and (R24). CNA X reported that when a resident that requires 2 persons assist for care is being helped, it takes 2 CNAs off the floor which results in even less supervision for R32 and R24. CNA X reported that because of the lack of staff available on the Gilead Unit she has seen an increase in resident falls and resident to resident altercations. CNA X reported that if there is a call off on another unit, they pull from the Gilead Unit. CNA X reported that second shift is the most difficult because they are expected to monitor R32 and R24 while also providing care to all the residents (incontinence care, toileting, repositioning), assisting with dinner (passing trays, feeding, picking up trays), monitoring residents that are sundowning (increased behaviors that occur in the evening), and putting the residents to bed. CNA X reported that there were many residents that required 2-person assistance to get to bed because of their use of a hoyer lift. CNA X stated it's not reasonable to expect that ADL care and supervision can be completed with the number of staff availabl[TRUNCATED]

Based on interview and record review the facility failed to fully implement its established Quality Assurance Process Improvement (QAPI) plan and adequately and appropriately address known deficiencies resulting in 1.) The inability to sustain substantial compliance with federal regulations, 2.) the potential for unrecognized and incompletely evaluated systems leading to physical and psychosocial harm and diminished quality of life for residents living at the facility. Findings: Review of a facility policy Quality Assessment & Assurance Program revised 9/18/2019 reflected Quality Assurance and Performance Improvement (QAPI) builds upon traditional quality assurance methods by emphasizing the organization and systems. QAPI incorporates systems, programs, clinical practice, and clinical development driving system integrations and inter-program coordination through organized leadership oversight. The policy included a discussion of Root Cause Analysis (RCA). RCA is predicated on the belief that issues are best resolved by eliminating or correcting root causes, as opposed to addressing obvious symptoms or popular assumptions. By directing corrective action to the underlying cause, it is likely reoccurrence will be minimized. RCA can be used for both reactive post occurrence problem analysis and as a proactive method to forecast likelihood of reoccurrence. Review of facility survey history revealed that an annual recertification survey event KWWU11 dated 9/24/2021 found the facility non-compliant with federal regulations including but not limited to pressure ulcer prevention and treatment resulting in an immediate jeopardy (IJ), abuse and neglect as well as staffing. An abbreviated survey event IZON11 exited on 8/23/2022 found the facility non-compliant with regulations pertaining to abuse and neglect, pressure ulcer prevention and treatment and quality of care. A survey exited on 11/3/2022 identified non-compliance pertaining to quality of care. On 11/28/2022, the current annual recertification survey and a review of several Facility Reported Incidents (FRI) and complaints was commenced. Current non-compliance was identified in numerous areas including pressure ulcer prevention and treatment, quality of care, staffing, abuse and neglect, facility assessment, and staff training, among others. Throughout the survey, observations, interviews and records were reviewed to clarify concerns and make compliance determinations. Compliance determinations were communicated in general terms to the facility related to investigations at which time the facility provided information related to attempts to correct known deficient practices. Review of the Quality Assessment & Assurance Committee-AD HOC MINUTES dated 10/19/22 revealed, Plan of Correction-Wound & Skin Management Program (from previous F-Tag 686 citation issued on 8/23/22) .Education *Licensed Nurses and CENAs (Certified Nursing Assistant) were educated by the DON (Director of Nursing)/designee on the policies and procedures for Skin Monitoring and Management program, specifically assessment of wounds, communication from providers, updating and implementing plans of care, turning and repositioning, and appropriate physician orders for treatments .Chief Nursing Officer will educate DON and Administrator on the IDT (Interdisciplinary Team) Skin Committee Weekly meeting. *DON and Administrator educated the IDT on the IDT Skin Committee Weekly meeting expectations. Monitoring *Audits will be completed on 5 random residents with wounds weekly x4 weeks then monthly x2 months, or until substantial compliance has been achieved, by ensuring appropriate assessment of wounds, communication from providers, updating and implementing plans of care, turning and repositioning, and appropriate physician orders for treatments. Any concerns will be corrected immediately. *The results will be presented to the QAA committee for review and consideration of further corrective actions. Alleged Compliance- The Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 10/19/2022 and for sustained compliance. During the survey started on 11/28/2022 the facility failed to 1.) provide care following professional standards of practice and facility policy to prevent the development/worsening of avoidable pressure ulcers, 2.) assess, monitor, and provide ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .) promptly notify the physician of a change in condition for 2 residents (Resident #21 and #9), reviewed for alterations in skin integrity/pressure ulcers, resulting in unrecognized changes and the worsening of skin impairments, a delay in treatment and the potential for prolonged wound healing, infection, and overall deterioration in health status. This current/ongoing non-compliance highlighted the facility's failed attempt to implement comprehensive action plans/plans of correction to maintain sustained compliance at F-686. Review of a Facility Reported Incident (FRI) intake 6 revealed that Resident #108 was discovered with a severe [CONDITION(S)] 4 days after having a [CONDITION(S)] despite a change in behavior and new onset immobility. The survey identified non-compliance at Quality of Care (F-684) pertaining to identifying a change in condition and timely physician notification and subsequent treatment. During an interview on 12/01/2022 at 9:39 AM, NP P reported that he was likely in the facility on 10/24/2022 and would have been made aware of R108's [CONDITION(S)] at that time. NP P said he was not made aware R108 had a change in condition after 10/24/2022 until he was told R108 had a severe [CONDITION(S)]. NP P reported that the facility staff are very good at documenting when a resident is doing well or are doing very poorly but that identifying and reporting changes in condition as they occur needs improvement. NP P said that he has hired a nurse to conduct independent audits of the Electronic Medical Record (EMR) to be sure the provider group is not missing critical changes in condition due to the facility's failure to report pertinent changes in condition. Review of a document Facility Past Non-Compliance dated 11/01/2022 pertaining to FRI 6 reflected Areas identified requiring quality improvement: Recognition, response and monitoring of change in condition and response to significant medical event. The document detailed plans for identifying and reviewing like residents, educating licensed nurses and random resident audits periodically until sustained compliance is achieved. The document noted that the alleged date of compliance was 11/01/2022. The document specified that all licensed nurses would be educated by 11/01/2022, any nurse not educated by then would be educated prior to their next scheduled shift. Review of the documentation related to staff education revealed that nurses were not educated until 11/21/2022 and did not reflect that all nurses had been in serviced, despite having worked since the stated date of compliance. Review of resident audits reflected that not all residents were reviewed to identify changes in condition. No incorporation of Certified Nurse Aide (CNA) education or partnership with reporting pertinent observations was identified. The facility also provided Past Non-Compliance documentation related to a resident-to-resident sexual abuse allegation that was reported to the State Agency (Intake 3). The state agency investigation into the FRI revealed lack of properly trained staff were available to provide supervision for known wandering and sexual behaviors contributed to a male resident (R107) being discovered with his pants down and lying on top of a female resident (R9). The focus of the education to staff was on recognizing and responding to sexual behaviors. No evidence the facility reviewed the circumstances that created the environment that allowed for the resident-to-resident abuse to occur was noted. Review of FRI intake #'s MI 599, MI 243, MI 497, and MI 499 revealed the facility failed to identify that abuse occurred due to the facility failure to understand the term willful. Because of the facility failure to identify that abuse occurred, no root cause was identified, no corrective action was implemented, and no preventative measures were implemented to prevent ongoing abuse. Review of the facility policy Facility assessment dated [DATE] revealed, It is the policy of this facility to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies .The facility will use the facility assessment to assist with the following: Understand the nature of its resident population and the resources (human, physical, contractual and electronic, among others) that it will need to care for those residents competently during day to day emergency operations. This will include how those resources will be managed (e.g. staffing assignments, oversight of third party contracts, etc.) .2. Determine the number, competencies and skill sets of nursing staff needed to provide high quality care to its residents. 3. Determine the number, competencies and skill sets of its behavioral health staff needed to provide high quality care to its residents .7. Determining what clinical services, the facility is capable of providing (e.g. specialized Alzheimer's care, [CONDITION(S)] care, ventilator care, etc.). 8. Determine what policies and procedures are needed in order to best implement the resources and services identified in the facility assessment .12. Determine the content, type and frequency of training for staff, independent contractors and volunteers, including, but not limited to, training for CNAs and training in behavioral health services . Review of the Facility Assessment received on 11/28/202 revealed the assessment was last updated on 10/4/2022. The facility assessment did not reflect the assessment had been completed as directed by the facility policy outlined above that included comprehensive evaluation of staffing levels, staff training needs, an evaluation of resident conditions, diseases, physical or cognitive status, behavioral needs or resident acuity. The facility assessment did not include provisions for the review and maintenance of policies and procedures to ensure care and services provided met professional standards. During an interview on 12/5/2022 at 12:54 PM the Nursing Home Administrator (NHA) reported that she became the administrator on record at the facility in September 2022. According to the NHA, in the last year, there have been three (3) administrators and four (4) Directors of Nursing as well as departures in other areas of nursing management which has contributed to systemic instability. The NHA reported the QAPI Committee gathers information for review from a variety of sources including incident and accident or unusual occurrence reports. If a situation calls for prompt action an ad-hoc QAPI meeting is held, an RCA is conducted, plans are developed with ongoing review and revision as needed until the matter is resolved. The NHA stated that prior to the current survey, the facility assessment had not been accurate and was being updated. The NHA reported she was not clear about the definition of willful related to ongoing resident to resident abuse. The NHA reported the facility could have done better with the RCA and development of action plans (attestations of past non-compliance) related to the reported injury of unknown origin, resident to resident abuse/sexual abuse and the skin and wound care program monitoring.

This citation pertains to intake #: MI 243 Based on interview and record review, the facility failed to 1.) allow a resident to return to the facility after an emergency room (ER) evaluation and 2.) notify the residents DPOA (Designated Power of Attorney) in writing of their appeal rights for 1 resident (Resident #107) reviewed for facility initiated transfers, resulting in Resident #107 being denied return to the facility, the inability of Resident #107's DPOA to appeal the involuntary discharge, and the decline in R107's psychological wellbeing. Findings: Resident #107 (R107) Review of an Admission Record revealed R107 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R107, with a reference date of 7/28/22 revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated R107 was severely cognitively impaired. Review of the Facility Reported Incident revealed that on 9/24/22 at 4:00 PM, (R107) was witnessed with his pants pulled down on top of (R9) while she was laying in her bed fully clothed (gown and brief on and not tampered with) her bed sheets were pulled up covering her body . (R107) was sent out to the hospital for evaluation . Through the investigation it was determined that prior to this event, (R107) did not display sexually inappropriate behavior toward other residents, he had historically directed his comments toward staff members and had been making comments throughout the day to staff members . Administrator spoke with (Family Member FM O), wife/guardian on 9/24/22 to inform her of the incident that occurred and his transfer to the hospital for further evaluation. At this time (FM O) stated that (R107) had no history of sexual behaviors towards other residents in the past and was surprised to hear of the incident . CONTRIBUTING FACTORS/ROOT CAUSE ANALYSIS: The primary root cause of (R107) sexually inappropriate behavior is due to his dementia and impaired ability to control impulsive behavior. In addition to the root cause, there are multiple contributing factors relating to the allegations: (R107) is diagnosed with schizophreniform disorder, dementia with behavioral disturbance, major depressive disorder, and restlessness/ agitation. (R107) had a medication change on 8/25/2022 and started on [MEDICATION(S)] for major depressive disorder, which was a new medication for him. (R107) recently had moved rooms (Indicating the facility identified possible agitators that caused an increase in R107's behaviors). On 9-26-2022 QAPI committee reviewed the incident and investigation .There was no deficient practice identified .DETERMINATION OF FINDINGS: Based on interviews with staff and like residents, families, schedule review, clinical record review, a decisive conclusion has been made the occurrence was NOT a result of abuse, neglect or misappropriation. (R107) and (R9) are both significantly cognitively impaired and are unable to consent to sexual activity. Neither resident has a prior history of sexual tendencies towards other residents, and neither resident has had negative interactions with one another in the past. Per staff interviews, neither resident has previously intentionally sought out the other. Neither resident was able to develop a willful intent to cause harm. The incident did not result in harm, pain or mental anguish towards either resident. Review of R107's Hospital Social Work Progress Notes dated 9/24/22 at 7:46 PM revealed, Case discussed with (physician name omitted). Per his information, patient is from (facility) Memory Care Unit. He was found on top of a female resident, allegedly attempting to sexually assault her. Per the doctor's information, (facility) is refusing to have this pt (patient) return. I have sent a text the (facility) liaison, (name omitted) with no success . Review of R107's Hospital Social Work Progress Notes dated 9/24/22 at 10:21 PM revealed, .Patient was sent to the ED (emergency room ) from (facility) for allegedly attempting to sexually assault a female resident. I have attempted to talk with the patient via Telemed. He is able to tell me his name and birthdate but that he doesn't know how old he is or give any other details at all. He has a hx (history) of dementia with behavioral disturbances. No family in the ED. I was able to speak with (NHA). Initially she said that he needed to be seen by psychiatry before he could return to the facility. She said that they have a psych team that sees him in their facility and that he's had increased behaviors recently and that there were med changes but she didn't know what they were. She states this is the first time that he's attempted to sexually assault another resident. When I called (NHA), back to talk further about it, she told me that they would never be able to have him return to the facility and he needed to go to a different long term care facility. She states she has told the wife. I did request that his records indicating his behaviors and the meds/changes be faxed to the ED. She said that she would have the (sic) done .I did talk with (physician name omitted), psychiatrist who initially stated that he would be willing to evaluate the patient on Sunday but that he really had no interventions that would change the situation, and that he could not guarantee that the patient wouldn't have behaviors again. He has also been told that the patient is no longer able to return to the facility .At this time, there is no indication that he'd need to go to inpt (inpatient) psych placement. Pt is pleasant and calm in the ED tonight . Review of R107's Emergency Department Progress Notes dated 9/24/22 at 6:58 PM revealed, This is a [AGE] year-old male presenting today with behavioral disturbance with reports of sexual assault at his care facility. They do not feel comfortable taking him back at this time. On my exam, he seems to be at his baseline, he is alert and oriented . Review of R107's Hospitalist Progress Note dated 9/26/22 revealed, .Continue [MEDICATION(S)] (increased from 5 to 10mg). Review of R107's Hospitalist Progress Note dated 9/27/22 revealed, .Facility will not allow patient to return .Continue [MEDICATION(S)] 10mg . Patient is currently calm and redirectable, food motivated .Medically stable for discharge when facility and bed secured . Review of R107's Hospitalist Progress Note dated 10/5/22 revealed, .Patient allegedly attempted to sexually assault another resident at his facility-Facility will not allow patient to return-Social work consulted, in the process of finding new placement (>500 referrals sent)-Telemdicine Psychiatry evaluation noted, medications optimized Patient is currently calm and redirectable, food motivated Medications as per psych recommendation . Review of R107's Hospital Records revealed no documented evidence that the resident's return would endanger the health or safety of the resident or other individuals in the facility during the appeal process. During an interview on 12/01/22 at 04:07 PM, FM O reported that she was never given appeal paperwork and was not aware there was an appeal process. FM O reported that had she known she had a right to appeal the involuntary discharge she would have done so. FM O reported that she was not notified that R107 was being sent to the hospital due to the incident that occurred on 9/24/22. FM O reported that she had contacted the facility to see if we (family) could visit and they told me he was in the hospital. FM O reported that she wanted R107 to return to the facility. FM O stated he doesn't know what he's doing because of his advanced dementia. FM O reported that she had never agreed with the NHA to have him sent to another facility. FM O reported that she contacted the facility to see if he would be allowed to return and was told by the NHA that they would not allow R107 to return to the facility. FM O reported that she was told he would not be permitted to return for the safety of the other residents. FM O stated what about his safety? What about his mental wellbeing. How do you think his mind is feeling right now? He doesn't know what's going on. FM O reported that even after R107 had a psychiatric evaluation completed in the hospital, and he was at his baseline, the facility would not allow him to return. FM O reported that she had visited him while he was in the hospital, and he was not combative or inappropriate and he was the same as when he was at (facility.) FM O reported that prior to the incident R107 seemed to be doing alright and was at his baseline. FM O reported that family was able to visit him while at the facility. FM O reported that he was sent to a facility in Detroit after he was not permitted to return to the facility and family can no longer visit because of the distance. FM O reported that she works night shift and cannot drive 3 hours each way to visit him in Detroit often. FM O reported that since his transfer to Detroit her visits with R107 have decreased significantly. FM O reported that it did not benefit him moving across the state and the new environment has caused him fear. FM O stated, all these transfers (to hospital and then to new facility) is messing with his head and because of the transfers she has noted a decline is his psychosocial wellbeing. FM O stated it's not doing his disease any good to not see family at all. FM O reported that between the transfers and the inability for him to see his family, he has had increased confusion, increased fear, and a decline in his mental health. FM O reported that the incident never should have occurred. FM O reported that the facility wasn't paying attention to this particular (dementia) unit and she could not understand how there were no staff supervising the residents, with known wandering behaviors, to prevent this type of situation. FM O stated, if they had been paying attention this wouldn't have happened. During an interview via email on 12/1/22 at 1:22 PM, NHA reported that R107's DPOA and the LTC Ombudsman were not given notification of appeal rights regarding R107's transfer that occurred on 9/24/22. Review of R107's Electronic Medical Record revealed no documentation of the specific resident needs that could not be met at the facility to allow R107 to return, facility attempts to meet those needs, or the services available at the receiving facility to meet those needs. Review of R107's Care Plan for behaviors revealed, Focus-Resident has a behavior concern r/t (related to) dementia & depression. Has the potential to wander and may be friendly toward females (asks staff if they are married or make inappropriate/vulgar comments) Resident may touch female. May ask them for sex or make inappropriate gestures toward them (fondled self). May refuse to keep clothing and brief on. Date Initiated: 08/10/2021 . Indicating inappropriate sexual behavior was known and ongoing since the time of admission (greater than 1 year). Review of R107's Care Plan for behaviors revealed, Interventions-Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Put up stop barriers on the doors of female rooms on the same hallway. Date Initiated: 10/11/2021 .Redirect/distract res. from rooms and carts and offer assistance. Date Initiated: 11/17/2021 . Review of R107's Care Plan for wandering/elopement revealed, Resident is an elopement risk and/or exhibits wandering behavior r/t dementia. Per wife, has a history of wander halls and rooms. May go into other resident rooms with or without clothing on. Date Initiated: 08/09/2021 . Indicating behavior was known and ongoing since the time of admission (greater than 1 year). Review of the State Operations Manual revealed, The facility must not evaluate the resident based on his or condition when originally transferred to the hospital. If the facility determines it will not be permitting the resident to return, the medical record should show evidence that the facility made efforts to .Ascertain an accurate status of the resident's condition (or) . Find out from the hospital the treatments, medications, and services the facility would need to provide to meet the resident's needs upon returning to the facility . Review of the facility policy Discharge or Transfer dated 1/28/20 revealed, It is the policy of this facility to provide the Resident with a safe organized structured transfer and or discharge from the facility to include but not limited to hospital, another healthcare facility or home that will meet their highest practical level of medical, physical and psychosocial well-being. Expiration of Resident within facility is known as a Discharge. A transfer and or discharge shall be considered for the following reasons as regulated by Federal, State and other Regulatory Agencies. 1. Transfer/Discharge: Emergency .e. Provide Transfer Notice and Bed Hold Policy to the resident and/or an immediate family member or legal representative f. Document entire process in Nursing Progress Note.

This citation pertains to intake MI 2486 Based on interview and record review, the facility failed to assess, monitor, and notify the physician of new onset behavioral changes (refusing care, crying, screaming/yelling), immobility and difficulty transferring for one resident (Resident #108), resulting in a 4 day delay in care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Resident #108 (R108) Review of an Admission Record reflected R108 originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R108 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3/15. Section E-Behavior indicated R108 did not exhibit behavioral symptoms and did not reject care. Section G - Functional Status reflected R108 needed supervision and one-person physical assistance for bed mobility, walking in room and in the corridor as well as for locomotion on and off the unit. R108 needed extensive assistance from one person for toilet use, personal hygiene and dressing, did not have functional limitations in Range of Motion (ROM) and did not use mobility devices (cane, walker, wheelchair). Review of a Nurse Practitioner 60 Day mandatory visit progress note dated 10/5/2022 reflected Pt (patient, R108) seen today sitting in the common room. Pt is without any acute concerns and does not appear to be in any distress. Pt is a poor historian and the bulk of this history of presenting illness was deferred to nursing staff and chart review. Nursing staff denies any concerns for the patient. They state that he has been content and easily directed by staff with a calm approach. They deny any clinical concerns for the patient at this time. In terms of ADLs (activities of daily living), pt. does require assistance with bathing and grooming. He is able to ambulate independently. He has maintained adequate intake with food and fluids and is both continent and incontinent of bowel and bladder. We will continue with this plan and follow up with him periodically. Review of a General Progress Note dated 10/24/2022 at 3:30 PM reflected 3:30 - Loud scream heard. Resident (R108) having Grand Mal [CONDITION(S)] while sitting in recliner. Muscles became rigid, loss of consciousness, breathing was slow and labored, [CONDITION(S)] lasted approximately 5 minutes. 4:40 - Breathing normal, VS (vital signs) 125/50 (blood pressure), 69 (heart rate), 98% (oxygen saturation). Talking with staff. DPOA (durable power of attorney) and NP (Nurse Practitioner) notified. A full physical assessment to of R108 after the [CONDITION(S)] was not documented. On 11/29/2022 at 4:05 PM, Incident and Accident/Unusual Occurrence reports pertaining to R108 for the month of October were requested from the Director of Nursing (DON). An incident report was not completed for R108 after the [CONDITION(S)] on 10/24/2022. Review of a Documentation Survey Report v2 (a Certified Nurse Aide (CNA) task and resident functional status documentation) for the month of October 2022 reflected that prior to 10/24/2022, R108 was typically independent with transfers and required only supervision and/or limited support to complete transfers occasionally. On 10/25/22 and 10/26/2022 R108 was coded as being totally dependent on two people for transfers. On 10/27/22 R108 needed extensive assistance from one person to transfer and was again totally dependent on two people for transfers on 10/28/2022. R108 was independent with walking in his room or in the corridor the majority of the time during the month of October until 10/24/2022 when it was documented R108 was either totally dependent of two staff members for locomotion or did not walk at all between 10/24-10/28/2022. Behavior documentation reflected that R108 exhibited yelling/screaming and rejected care on 10/25/22, had frequent crying and rejected care on 10/26/22 and had frequent crying, yelling/screaming and rejection of care on 10/27/2022. Review of a General Progress Note dated 10/28/2022 at 12:06 PM reflected Complaining of pain in Right hip. Screaming in pain when being turned. NP notified N.O. (new order) for Xray of right and left hip and abdomen. [MEDICATION(S)] ([MEDICATION(S)]) given for constipation. Review of a General Progress Note dated 10/28/2022 at 7:12 PM reflected Xray results showing R (right) hip fx (fracture). Notified on call (name of on call provider), receiving order to send to the ED (Emergency Department) for eval and further tx (treatment). Guardians notified and will meet him there. On call manager notified. Report called to (name of local hospital), all necessary documentation sent with resident and (ambulance company). Further review of progress notes from 10/24/2022 -10/28/2022 did not reflect evidence of a nursing assessment or physician notification related to the documented change in R108's behavior, transfer or mobility status as noted in the CNA charting. Review of R108's hospital records from 10/28/2022-10/31/2022 reflected the Chief Complaint: HIP PAIN (Patient had [CONDITION(S)] 4 days ago and has been unable to ambulate since. Xray of right hip was completed and fracture of right hip was found.) The History of Present Illness reflected [AGE] year-old male with history of Down syndrome and a [CONDITION(S)] disorder presents (to) emergency department with hip pain after a fall. Patient had [CONDITION(S)] 4 days ago. Since that time has been refusing to walk. X-rays obtained at the facility showed a right-sided acetabular fracture. Patient was sent to the emergency department for evaluation. Patient's cousins are here with him for his power of attorney. They are not aware of any other recent illness. They saw him last week and he was doing well. When the patient is in bed at rest, he has no complaints of pain. The final result from the CT Abdomen and Pelvis Without IV Contrast reflected 1. Complex comminuted and displaced fractures of the right acetabulum involving both the anterior and posterior columns. Extension of the anterior column fracture into the iliac wing with a displaced fracture fragment into the iliacus muscle resulting in a small volume intraperitoneal hemorrhage. Additional fracture extension into the superior pubic ramus. The hospital record indicated that R108 was not a good surgical candidate and family was planning on hospice care. Review of Progress Notes from 11/01/2022-11/14/2022 reflected that R108 readmitted to the facility and elected hospice care. R108 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/01/2022 at 9:39 AM, NP P reported that he was likely in the facility on 10/24/2022 and would have been made aware of R108's [CONDITION(S)] at that time. NP P said he was not made aware R108 had a change in condition after 10/24/2022 until he was told R108 had a severe [CONDITION(S)]. NP P reported that the facility staff are very good at documenting when a resident is doing well or are doing very poorly but that identifying and reporting changes in condition as they occur needs improvement.

Based on observation, interview and record review, the facility failed to 1.) provide care following professional standards of practice and facility policy to prevent the development/worsening of avoidable pressure ulcers, 2.) assess, monitor, and provide ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .) promptly notify the physician of a change in condition for 2 residents (Resident #21 and #9), reviewed for alterations in skin integrity/pressure ulcers, resulting in unrecognized changes and the worsening of skin impairments, a delay in treatment and the potential for prolonged wound healing, infection, and overall deterioration in health status. Findings: Review of the Quality Assessment & Assurance Committee-AD HOC MINUTES dated 10/19/22 revealed, Plan of Correction-Wound & Skin Management Program (from previous F-Tag 686 citation issued on 8/23/22) .Education *Licensed Nurses and CENAs (Certified Nursing Assistant) were educated by the DON (Director of Nursing)/designee on the policies and procedures for Skin Monitoring and Management program, specifically assessment of wounds, communication from providers, updating and implementing plans of care, turning and repositioning, and appropriate physician orders for treatments .Chief Nursing Officer will educate DON and Administrator on the IDT (Interdisciplinary Team) Skin Committee Weekly meeting. *DON and Administrator educated the IDT on the IDT Skin Committee Weekly meeting expectations. Monitoring *Audits will be completed on 5 random residents with wounds weekly x4 weeks then monthly x2 months, or until substantial compliance has been achieved, by ensuring appropriate assessment of wounds, communication from providers, updating and implementing plans of care, turning and repositioning, and appropriate physician orders for treatments. Any concerns will be corrected immediately. *The results will be present to the QAA committee for review and consideration of further corrective actions. Alleged Compliance- The Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 10/19/2022 and for sustained compliance. Resident #21 (R21) Review of an Admission Record revealed R21 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for R21, with a reference date of 9/16/22 revealed R21 was severely cognitively impaired. Review of the Functional Status revealed that R21 required extensive 1 person assist for bed mobility, toileting, and personal hygiene, and extensive 2 person assist for transferring. Review of the Skin Conditions revealed R21 did not have a pressure ulcer but was at risk for the development of pressure ulcers. Review of R21's Physician Order dated 11/10/21 revealed, Apply border foam dressing to coccyx every 3 days and prn (as needed) for protection. Review of R21's Physician Order dated 2/8/22 revealed, [MEDICATION(S)] Paste ([MEDICATION(S)]) Apply to buttock topically every shift for incontinence [CONDITION(S)]. Review of R21's ADL (Activities of Daily Living) Care Plan revealed, Turn and reposition frquently (sic) Date Initiated: 11/02/2021 . Review of R21's Skin Observation Tool dated 11/16/22 revealed no alterations in skin integrity. Review of R21's Skin Observation Tool dated 11/22/22 revealed, .MASD (Moisture Associated Skin Damage), continue zinc as ordered .Res is turned and repositioned Q (every) 2 HRS and PRN (as needed). R21's Care Plan was not updated to reflect repositioning every 2 hours). Review of R21's Skin Observation Tool dated 11/23/22 revealed, .Resident has MASD on bilateral buttocks and her coccyx area, continuing zinc as ordered. Resident has pressure area on coccyx, continuing with treatment order for [MEDICATION(S)] dressing. Resident is turned and repositioned Q2hrs and PRN. No other skins (sic) concerns for resident at this time . Review of R21's Progress Notes revealed no documentation that the provider was notified of R21's skin breakdown on 11/22/22 or 11/23/22. Review of R21's Progress Notes revealed no documentation that the Unit Manager or Director of Nursing were notified of R21's skin breakdown on 11/22/22 or 11/23/22. Review of the Provider Communication Book located in the Gilead (name of locked dementia unit) Unit Nursing Station revealed no documentation/communication of R21's skin breakdown on 11/22/22 or 11/23/22. Review of R21's Physician Orders revealed no new orders or order changes regarding R21's MASD or Pressure Area identified on 11/22/22 or 11/23/22. Review of R21's Care Plans revealed no new interventions were implemented and/or no changes made regarding R21's MASD or Pressure Area identified on 11/22/22 or 11/23/22. During an observation and interview on 11/30/2022 at 12:40 PM, Certified Nursing Assistant (CNA) X reported that R21's buttocks had skin breakdown that had been worsening over the week. CNA X reported that she had notified the facility nurse of the worsening of R21's skin breakdown. R21 was turned to her left side and her coccyx area had a border gauze that was heavily soiled (unable to determine if it was drainage from the wound or stool/urine) with the edges of that dressing rolled up/not secure to skin (falling off). The border gauze did not have a date to indicate when it was applied and did not have initials to indicate the facility nurse that placed the border gauze on R21. CNA C removed the dressing. R21's skin was red approximately 2-2.5 inches in diameter. Inside the area of redness there were 3 open areas, with bright pink wound beds exposed, indicating a measurable length and width. CNA C and CNA X verified that there were 3 open areas and they both reported those open areas were new for R21. There was an unused border gauze dressing with a handwritten date of 11/30 and initials of Registered Nurse (RN) I on R21's nightstand. CNA C placed zinc barrier cream on R21's coccyx area/skin breakdown and then placed the border gauze over the zinc barrier cream/skin breakdown. CNA C was not a licensed nurse and performing wound care and/or treatment administration was outside CNA C's scope of practice. (Reference 4) CNA X reported that residents were not receiving the care they required from licensed nurses or support staff because of the lack of facility staff. CNA X reported that there were many residents on the Gilead Unit that required extensive assist or 2 assist with cares. CNA X stated it's not reasonable to expect that ADL care and supervision can be completed with the number of staff available. Review of R21's Treatment Administration Record (TAR) immediately following R21's skin injury observation on 11/30/2022 at 12:40 PM revealed an order Apply border foam dressing to coccyx every 3 days .for protection and was documented as being completed by RN I. Review of R21's Progress Notes revealed no documentation of R21's skin injury or that R21's treatment had been performed by CNA C. During an interview on 11/30/2022 at 1:42 PM, RN I verified that the girls did it (R21's dressing change) and reported that CNA C and CNA X reported that there were 3 areas but not open (on R21's coccyx). RN I reported that she had not done a skin assessment on R21 but would document the pressure injury concern. Review of R21's Electronic Health Record revealed no documentation that RN I documented R21's pressure injury or that she notified the R21's provider of the pressure injury. Review of R21's Skin Observation Tool dated 11/30/22 (lock time 8:23 PM) revealed Section 1 was completed with no new skin issues identified. Section II ALTERATIONS IN SKIN INTEGRITY and Section III ADDITIONAL INFORMATION were blank. Review of the Provider Communication Book on 12/1/22, located in the Gilead Unit Nursing Station, revealed no documentation/communication of R21's pressure injury identified on 11/30/22. During an interview on 12/01/2022 at 10:15 AM, Nurse Practitioner (NP) P reported that he was not aware of any skin integrity concerns (MASD/pressure ulcer) for R21. NP P reported that the expectation is to notify the provider immediately if there are concerns with a resident's skin integrity. NP P reported that he would want to be notified of the smallest area; even redness so he could order an intervention and/or treatment to prevent the worsening of the condition. NP P reported that if a resident has MASD he would not order border gauze as a treatment because removing the border gauze could cause the fragile skin to tear and worsen the condition of the wound. NP P reported that he would assess R21's skin and modify/implement a treatment today. An interview on 12/01/2022 at 12:45 PM with Licensed Practical Nurse (LPN) K and the DON highlighted aspects of the skin/wound monitoring program's ineffectiveness. LPN K reported that he was the Unit Manager as well as the nurse responsible for wound monitoring/care. LPN K reported that he was not Wound Care Certified. DON reported that the wound care program was new and started because of the citation that the facility had recently been issued (citation issued 8/23/22 with alleged compliance date of 10/19/22). DON reported that LPN K had been responsible for the wound care program for approximately 1 month. DON reported that the IDT (Interdisciplinary Team) met weekly regarding identified skin integrity concerns for all residents in the facility. LPN K reported that he was aware of MASD that was identified and documented approximately 1 week prior on a Skin Assessment. LPN K reported that (contracted wound care agency) was providing care to R21's roommate and consulted with LPN K concerning R21's documented MASD at that time (there was no order for consultation with the contracted wound care agency). LPN K reported that (contracted wound care agency) reported that if there was MASD on R21's buttocks, zinc topical cream and border gauze was okay to treat R21 (this recommendation conflicts with the recommendation for treatment made by NP P). Review of R21's Electronic Health Record (EHR) revealed no consultative notes/documentation regarding R21's skin breakdown and/or treatment recommendations. LPN K reported that he was under the impression that R21's provider was aware of R21's skin breakdown based on R21's active treatment orders. LPN K was not aware that R21's border foam dressing (ordered for protection) and [MEDICATION(S)] topical was ordered on 11/10/21 and 2/8/22 respectively, and not because of the newly documented skin breakdown on R21's 11/22/22 and 11/23/22 Skin Assessments. LPN K and DON reported that R21 was not being followed by the IDT Weekly Skin Committee (despite the Plan of Correction outlined above). DON reported that she was made aware of R21's skin breakdown this morning (more than a week after the development of actual skin breakdown) and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R21's Physician Provider Note dated 12/1/22 at 1:40 PM revealed: .(R21) is seen today as concerns expressed by the state surveyor regarding an open wound on her coccyx area. The patient is seen with the nursing staff and the state surveyor in her room. The patient was turned on to her left lateral position and the patient's coccyx area is noted and she has a superficial thin layer of skin is eroded and there are three small open areas that are hard to measure, has a second layer eroded, in fact it could be classified as not open as the patient has not had third layer of the skin is not open as subcutaneous tissue is not exposed. The patient does have a delicate skin and occlusive dressing would be difficult to manage so we will not use occlusive dressing and we will only use a barrier cream to protect the delicate skin and I have notified the staff to not wipe and only pat dry the area and keep it clean and dry as much as possible. We will continue to monitor. She was treated with antibiotic for pneumonia recently and she does not appear toxic. We will continue to monitor. She has recovered very well from pneumonia. She is dependent on staff for all ADL. Remains incontinent of bowel and bladder. Physical Exam- SKIN: Skin over sacral/coccyx area examined with ancillary nursing staff and state surveyor. Pt is thin with no subcutaneous tissue. She has a small area of erosion of superficial layer of skin measuring approximately about 2 inches in diameter. with in (sic) that area, there are 3 small spots that is too small to measure has lost next layer of skin and still does not appear to have lost full thickness loss. It started as Started as (sic) MASD .Instructed nursing to treat with barrier cream and to avoid occlusive dressing. Assessment / Plan- 1. Open wound of sacroiliac region - erosion of superficial layer of skin with out (sic) damage to all layer of skin .Unspecified open wound of lower back and pelvis without penetration into retroperitoneum, initial encounter . (References 1-I, 2, and 3). Review of R21's Progress Note written by DON revealed, LATE ENTRY (written on 12/2/22 at 2:49 PM) Resident wound assessed/evaluated by (NP P). No concerns noted. Superficial area breakdown (3 small pinpoint areas clustered together) noted to coccyx. Orders to apply barrier cream q (every) shift and prn. Also, staff educated on not wiping with wash cloth to avoid further disruption of fragile skin. Will continue to monitor. DON's late entry note does not correlate with NP P's documented assessment and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Unspecified open wound of lower back and pelvis without penetration into retroperitoneum . Review of R21's Progress Note dated 12/2/22 at 4:05 PM, written by DON revealed, Full head to toe assessment completed by nursing staff. No new areas of concern. There is a noted reddened area to coccyx that is blanchable. There is also a noted chronic scar to left hip. Care plan updated as needed. Orders reviewed. Indicating R21's no longer had an Open wound of sacroiliac region - erosion of superficial layer of skin without damage to all layer of skin as documented by NP P approximately 26 hours prior. (Reference 3) Review of R21's Physician Order dated 12/2/22 at 4:04 PM revealed, [MEDICATION(S)] Paste ([MEDICATION(S)]) Apply to buttock topically every shift for incontinence [CONDITION(S)] apply every shift and with all peri care. Do not wipe with washcloth. Indicating NP P's order was not completed/processed until approximately 26 hours later. Review of R21's Physician Order dated 12/1/22 revealed, Border foam discontinued. Indicating NP P's order was not completed/processed until approximately 26 hours later. Review of R21's skin integrity Care Plan revealed, Do not wipe fragile skin on sacrum/coccyx with wash cloth until area is healed Date Initiated: 12/02/2022 . Indicating provider-initiated intervention was not immediately updated on R21's Care Plan following his assessment and recommendation. Review of R21's Care Plan revealed turning/repositioning was not updated with a turn schedule and remained unchanged from 11/02/2021. Resident #9 (R9) Review of an Admission Record revealed R9 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for R9, with a reference date of 9/2/22 revealed R9 was severely cognitively impaired. Review of the Functional Status revealed that R9 required extensive 1 person assist for bed mobility and personal hygiene, and extensive 2 person assist for transferring and toileting. Review of the Skin Conditions revealed R9 did not have a pressure ulcer but was at risk for the development of pressure ulcers. During an observation on 11/30/2022 at 9:16 AM, R9 was sitting up in her broda chair leaning towards the left in the main activity/dining area on the Gilead Unit. During an observation on 11/30/2022 at 12:00 PM, R9 was sitting up in her broda chair leaning towards the left in the main activity/dining area on the Gilead Unit. During an observation on 11/30/2022 at 12:20 PM, R9 was sitting up in her broda chair leaning towards the left in the main activity/dining area on the Gilead Unit. CNA C reported that she was going to bring R9 back to her room to provide incontinence care and lay R9 down in her bed. CNA C asked another CNA to assist her with getting R9 to bed (R9 utilized a hoyer lift for transferring which required 2 staff assistance) but the CNA was assisting another resident on the unit and was unable to help at that time. CNA stated it'll (R9's incontinence care and chair to bed transfer) have to wait until I can get help. At 12:30 PM, CNA X and CNA C transferred R9 to her bed. CNA C reported that R9's routine is to be transferred to her broda chair prior to breakfast and transferred to her bed after lunch and incontinence care is provided prior to breakfast and after lunch CNA C reported that R9 required full feeding assistance and had to be sitting upright in her broda chair for all meals which was why she remained in her broda chair until after lunch. Review of the Dining Cart Order Schedule revealed breakfast on the Gilead Unit for residents that are assisted begins at 8:30 AM and lunch begins at approximately 12:30 PM with a 15-minute variable, resulting in R9 being in her broda chair for approximately 4-5 hours at a time. R9's bilateral lower extremities were contracted (inability to straighten legs due to shortening and tightening of the muscles) and her knees were rubbing together. R9 had mild redness between her knees and CNA C reported R9 should have a pressure relieving device in place to prevent a pressure injury. R9 was placed in her bed and incontinence was provided. R9's brief was saturated/heavy with urine and stool. R9 had a dressing on her right hip that did not have a date it was applied or the initials of the licensed nurse that completed the dressing change. CNA X reported that the area on R9's right hip was a new area of skin breakdown and CNA C agreed and stated that the skin breakdown was like a blister that popped. R9's sacral wound was uncovered/no dressing in place. CNA C completed pericare on R9 and covered R9's open sacral wound with skin protectant barrier cream. CNA C then placed a clean brief on R9 and repositioned her for comfort. CNA C and CNA X reported that R9 was to be repositioned at least every 2 hours to prevent skin breakdown. CNA C reported that because of the lack of facility staff, R9 would not receive timely incontinence care or repositioning because R9 required 2 staff assistance with hoyer transfers. CNA C reported that when the other CNAs were assisting other residents, there are no additional staff to assist her with transferring R9 to her bed. Review of R9's Progress Note Details from the contracted wound care agency dated 11/22/22 revealed, .Location: Sacrum .Date of Onset: Reported August 2022. Context: Pressure. Associated Signs and Symptoms: Increased pain noted .Nursing staff report patient developed a wound to her sacrum. Patient is dependent on staff for cares and repositioning .Wound Assessment .Sacral is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed .There is no change noted in the wound progression .Slightly larger SA (Surface Area) but wound clinically unchanged . Wound Orders .Cleanse wound with Normal Saline or Wound Cleanser. Wound Dressing: Apply [MEDICATION(S)]-change dressing 3 times per week; Change dressing as needed for soiling, saturation, or accidental removal. Additional orders: Pressure Relief/Offloading .turn in bed at least once every 2 hours if able-check and change every 2 hours (and PRN) with repositioning . Coordination of Care .Education provided to LPN K on offloading, repositioning, and the importance of dressing remaining in place . Review of R9's November Treatment Administration Record (TAR) revealed, [MEDICATION(S)] dressing right hip and coccyx for protection. change every 3 days and PRN when soiled. every 72 hours for protect right hip. R9's November TAR did not include the contracted wound care agency's wound care order for Cleanse wound with Normal Saline or Wound Cleanser. Review of R9's skin impairment Care Plan revealed, The resident is at risk for impaired skin r/t Disease process dementia, Immobility, Impaired nutritional status, incontinence. Stage 2 pressure ulcer of right coccyx Date Initiated: 08/07/2022 Revision on: 10/21/2022. R9's Care Plan was not revised to reflect R9's sacral Stage III pressure injury nor the pressure injury on her right hip. R9's Care Plan did not include interventions to relieve pressure between R9's knees. (Reference 8) Review of R9's Activities of Daily Living Care Plan revealed, .Check and Change (incontinence care) with AM/HS (morning and bedtime) care and before/after meals .Revision on: 11/03/2021. R9's Care Plan did not reflect the contracted wound care agency pressure relief orders. Review of R9's Skin Care Plan revealed, .Resident on an up and down schedule. Turn frequently, Float heels. Date Initiated: 08/07/2022. R9's Care Plan did not reflect the contracted wound care agency pressure relief orders. REFERENCES: 1.Review of the facility policy Skin Monitoring and Management-Pressure Ulcer dated 7/11/18 revealed, POLICY: It is the policy of this facility that: *A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and *A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing. PURPOSE: The purpose of this policy is that the resident does not develop pressure ulcers unless clinically unavoidable, and that the facility provides care and services to: *Promote the prevention of pressure ulcer development; *Promote the healing of pressure ulcers that are present (including prevention of infection to the extent possible); and *Prevent the development of additional, avoidable pressure ulcers .This policy acknowledges that, in certain circumstances, the development of pressure ulcers is an unavoidable occurrence. In accordance with the guidance issued by the National Pressure Ulcer Advisory Panel (March 2010), the facility recognizes that an unavoidable pressure ulcer is one which developed even though the provider evaluated the individual's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with individual needs goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. Facility nursing staff is expected to identify and document the resident's clinical condition and pressure ulcer risk factors related to the development of unavoidable pressure ulcers at the time of admission and thereafter as appropriate. PROCEDURE: RESIDENT ASSESSMENT The nurse responsible for assessing and evaluating the resident's condition on admission and readmission and is expected to take the following actions: A. Complete an admission assessment/evaluation and skin risk assessment to identify risk and to identify any alterations in skin integrity noted at that time . F. Assessment of wounds identified after admission: * A licensed nurse (which may be the facility Wound Nurse) must assess/evaluate a resident's skin at least weekly. All areas of breakdown, excoriation, or discoloration, or other unusual findings must be documented in the resident's clinical record. G. A licensed nurse (which can be the facility Wound Nurse) must assess/evaluate at least weekly each wound, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include but not be limited to: *Measuring the wound *Staging the wound *Describing the nature of the wound (e.g., pressure, stasis, surgical wound) *Describing the location of the wound *Describing the characteristics of the wound *Describing the progress with healing, and any barriers to healing which may exist *Identifying any possible complications or signs/symptoms consistent with the possibility of infection. I. Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's Order. *All wound or skin treatments should be documented in the resident's clinical record at the time they are administered. Stages/Description/Further Description . Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. o DOCUMENTATION- A. If the clinical assessment/evaluation indicates a change in condition or decline in the wound, the assessing/evaluating nurse will notify the physician and create a narrative nurse's note documenting that notification. B. Licensed Nurse should document skin evaluations in accordance with this policy in the resident's clinical record. o MONITORING- A. Daily via medication administration and treatment administration records *Ensure all orders have been implemented as ordered. B. Weekly via Weekly Skin Committee *Prepare and maintain Skin Committee review notes and recommendations in the resident's clinical record. *Document and implement recommended additions or changes to care plan in resident clinical record. C. Skin Inspection on Showering *On shower days, CNAs to observe resident skin. *Identify any areas of skin breakdown, discoloration, tears or redness. *Communicate findings to licensed nurse .*Licensed nurse to acknowledge findings, document pertinent information in resident's clinical record, and respond/obtain and implement treatment order as appropriate. D. Weekly skin check conducted by a facility licensed nurse *All residents will have a head to toe skin check performed at least weekly by a facility licensed nurse. *The licensed nurse should document the performance of the skin check in the resident's clinical record. *Any skin issues identified as a result of the weekly skin check should be documented and responded to as outlined above. F. Comprehensive skin review should occur on an as needed basis through the activity of the Interdisciplinary Team *The assessment/evaluation and recommendations of the IDT shall be documented in the resident's clinical record. o COMMUNICATION OF CHANGES A. Any changes in the condition of the resident's skin as identified daily, weekly, monthly, or otherwise, must be timely communicated to: *The resident's physician . o QUALITY ASSESSMENT AND ASSURANCE A. Incidences of skin breakdown which develop after a resident is admitted to the facility, whether the skin breakdown is avoidable or unavoidable, will be reviewed on a monthly basis, at a minimum, by the facility Quality Assurance Committee. B. Resident response to preventive measures and treatment designed to minimize skin breakdown or facilitate healing will be reviewed on a monthly basis, at a minimum, by the facility Quality Assurance Committee. C. The Quality Assurance Committee should, among other things, evaluate strategies to reduce the development and progression of pressure ulcers as well as monitoring the incidence and prevalence of skin breakdown in the facility. D. The activities and work product of the Quality Assurance Committee relative to the evaluation and assessment of skin breakdown, and the incidence and prevalence of skin breakdown in the facility, are protected from discovery or disclosure in accordance with the State Quality Assurance privilege. 2. Review of the National Pressure Injury Advisory Panel (NPIAP) Pressure Injury Stages revealed, .Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions) . Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. The National Pressure Injury Advisory Panel (NPIAP) is an independent not-for-profit professional organization dedicated to the prevention and management of pressure injuries 3. Review of the National Pressure Injury Advisory Panel (NPIAP) National Quality Forum dated 8/23/19 revealed, .Stage 2 pressure injuries, as partial thickness wounds heal as a result of [MEDICATION(S)] repair. Partial thickness wounds heal through resurfacing of the wound ([MEDICATION(S)] proliferation and migration and the reestablishment of [MEDICATION(S)] layers to restore the barrier function of the outer skin ([MEDICATION(S)]) layers. Unlike full thickness pressure injuries, shallow Stage 2 pressure injuries often heal without long term consequences, loss of skin function or scar tissue formation. Healing occurs in a more predictable manner and depending on the underlying comorbidities, occurs in a shorter timeframe than full thickness wounds. The median time for healing in long term care facilities is 46 days, with longer healing times required for larger Stage 2 pressure injuries . 4. Review of Fundamentals of Nursing (Potter and Perry) 10th edition revealed, Delegation and Collaboration-The skill of treating pressure injuries and wounds cannot be delegated to assistive personnel (AP). Instruct the AP to: o Report immediately to the nurse pain, fever, or any wound drainage. o Report immediately to the nurse any change in skin integrity. o Report any potential contamination to existing dressing, such as patient incontinence or dislodgement of the dressing. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 1276). Elsevier Health Sciences. Kindle Edition. 5. Review of Fundamentals of Nursing (Potter and Perry) 10th edition revealed, Continually assess a patient's skin for breakdown and color changes such as pallor or redness. Consistently use a standardized assessment tool such as the Braden Scale. The screening tool identifies patients with a high risk for impaired skin integrity or early changes in the condition of patients' skin. Early identification allows for early intervention. Observe the skin often during routine care (e.g., when the patient is

This citation pertains to intake #: MI 971, MI 278, MI 243, MI 497, MI 931 and MI 481 Based on observation, interview, and record review, the facility failed to provide sufficient staffing to 1.) prevent resident to resident abuse for 7 residents (Resident #9, #107, #32, #79, #24, #36, and #1), 2.) prevent the development/worsening of facility acquired pressure injuries for 2 residents (Resident #21 and #9), 3.) provide timely incontinence care for 2 residents (Resident #74 and #32), and 4.) provide adequate supervision for residents with known behavioral needs (wandering). This deficient practice places all residents residing in the facility at risk for unmet care needs and impaired physical, mental, and psychosocial well-being. Findings: On 11/28/2022, the current annual recertification survey and a review of several Facility Reported Incidents (FRI) and complaints commenced. It was identified during the onsite survey that the facility did not ensure there was adequate direct care staffing which resulted in the following deficiencies: 1. The facility failed to prevent resident to resident physical and sexual abuse, and protect residents from continued abuse, due to widespread system failures beginning with the failure to complete an annual facility assessment to determine direct care staffing needs, resident acuity, and staff competency and education requirements to meet the needs of residents with known behaviors and protect vulnerable residents. (Refer to noncompliance cited at F600-Abuse and F838-Facility Assessment). F600 Based on interview and record review, the facility . 3.) failed to identify increased behaviors and revise a care plan and 4.) failed to ensure there was sufficient staffing to supervise residents and prevent resident to resident abuse for 7 residents (Resident #9, #107, #32, #79, #24, #36, #1), resulting in a pattern of systemic neglect leading to resident to resident abuse and the decline in mental and psychosocial well-being. F838 Based on interview and record review, the facility failed to complete a comprehensive facility-wide assessment that included an assessment of the staffing needs, resident acuity, and staff training and education requirements, resulting in insufficient staffing to meet the needs of the residents, inadequate knowledge of the facility population and inadequate resources to care for residents and the potential for unmet care needs and physical and psychosocial harm for residents residing in the facility. 2. The facility failed to provide an adequate number of staff to meet the basic needs of the residents related to pressure ulcer prevention/healing, (Refer to noncompliance cited at F686-Treatment and Services to Prevent/Heal Pressure Ulcers) F686 Based on observation, interview and record review, the facility failed to 1.) provide care following professional standards of practice and facility policy to prevent the development/worsening of avoidable pressure ulcers, 2.) assess, monitor, and provide ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .) promptly notify the physician of a change in condition for 2 residents (Resident #21 and #9), reviewed for alterations in skin integrity/pressure ulcers, resulting in unrecognized changes and the worsening of skin impairments, a delay in treatment and the potential for prolonged wound healing, infection, and overall deterioration in health status. Incontinence Care Resident #74 (R74) Review of an Admission Record revealed R74 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for R74, with a reference date of 10/14/22 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated R74 was severely cognitively impaired. During an observation on 11/28/22 at 09:59 AM, R74 was sitting in a chair in the common area of the Gilead Unit (locked dementia unit). R74 stood up from the chair and was visibly agitated and tearful. R74's pants and shirt were saturated with urine extending from her thighs to her midback with a strong odor of urine noted. At 10:02 AM, R74 sat back down sitting at the edge of the chair, appeared restless and shifting her weight back and forth (indicating discomfort). At 10:09 AM, R74 stood up from her chair and began pulling at her saturated pants with continued tearfulness and agitation. R74 began ambulating down the hallway towards the main dining/activity room and the chair she had been using was visibly wet with urine. During an observation on 11/28/22 at 10:14 AM, CNA Y brought R74 to her bathroom and assisted R74 with incontinence care. R74's brief was bulky and excessively saturated with urine. The entirety of R74's buttocks was erythemic (bright red) from prolonged exposure to urine in a heavily saturated brief. Resident #32 (R32) Review of an Admission Record revealed R32 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R32, with a reference date of 11/3/22 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated R32 was severely cognitively impaired. Review of R32's bladder Care Plan revealed, Resident has occasional bladder incontinence r/t (related to) Confusion, Dementia, Poor toileting habits Date Initiated: 05/11/2021 . Review of R32's Skilled Nursing note dated 11/17/22 revealed, Resident has been identified as having declines in dressing, toileting, and hygiene . During an observation on 11/29/22 at 08:40 AM, R32 was walking down the hall saturated with urine. Urine was observed on the buttock area of his pants and up to the lower back area of his shirt with a strong odor of urine noted. At 08:44 AM surveyor notified Licensed Practical Nurse (LPN) A that R32 was saturated with urine. LPN A walked R32 down to his room and had him sit in his cloth recliner on top of a thin blanket. LPN A then left the room without assisting R32 with incontinence care and a clothing change. LPN A returned to the medication cart to continue morning medication administration. During an observation on 11/29/22 at 08:44 AM-09:06 AM, R32 was left sitting in his recliner saturated with urine until Certified Nursing Assistant (CNA) W was finished providing care for another resident on the unit. During an interview on 11/29/22 at 09:07 AM, CNA W reported that there was not sufficient staff to meet the physical and behavioral needs of the residents. CNA W reported that 2nd shift is scheduled to have 3 CNAs on the floor and 1 support CNA to monitor residents in the main area. CNA W reported that there are times when 2nd shift only has 2 CNAs on the floor and that is not enough to control (R32) and (R24) specifically. CNA W reported that there are many residents on the Gilead Unit that wander and there is no way to manage behaviors, prevent resident to resident altercations, and/or wandering in and out of the rooms. CNA W reported that R32 and R24 have wandering tendencies that require frequent redirection. Resident Supervision During an observation and interview on 11/29/22 at 08:45 AM, a female resident in the Gilead Unit dining room ambulated down the hall to R32's room, entered his room, and used his bathroom. Shortly after the female resident entered R32's room/bathroom, LPN A and R32 entered his room so R32 could receive incontinence care. LPN A observed the female resident exit R32's bathroom and reported it was not uncommon for that female resident to wander into resident rooms to use the bathroom. LPN A stated, she gets lost, we redirect her. LPN A reported that the Gilead Unit had a lot of residents that have wandering behaviors which require supervision and a locked unit. During an observation on 11/29/2022 at 2:55 PM, R24 entered R32's room, opened R32's nightstand, removed an item of food from the nightstand and began eating it. A female resident then entered R32's room while R24 was still in there. While R24 and the female resident were in R32's room, a second female resident attempted to enter R32's room. During an interview on 11/29/2022 at 3:00 PM, LPN M reported that the Gilead Unit was staffed with 3 CNAs at that time and 1 CNA was pulled to another unit. LPN M reported that it was difficult to monitor residents that wander in and out of rooms, especially (R32) and (R24) and reported R32 and R24 were often involved in resident-to-resident altercations. LPN M reported that dinner time to bedtime was the most difficult time of the shift because the CNA's had to assist with feeding, changing, nighttime care, and getting residents to bed. LPN M reported the Gilead Unit needed additional staff to supervise residents that wander in and out of rooms and upset other residents. During an observation on 11/30/2022 at 12:01 PM, R24 was observed ambulating up and down the hallway. R24 walked past a resident in the hallway and was less than 6 inches away from the resident. There were no staff observed on the Gilead Unit at that time. R24 has been the aggressor in multiple recent FRI's regarding resident-to-resident abuse. During an observation on 11/30/2022 at 1:05 PM, R32 was ambulating up and down the hall, smiling and talking nonsensically, and stopped in front room [ROOM NUMBER] (female room). A female resident residing in room [ROOM NUMBER] observed R32 standing in her doorway facing into her room. The female resident ambulated down the hall appearing anxious and concerned that R32 would enter. The female resident (able to make needs known with a BIMS of 9/15) used hand motions (pointing and wrist flicking) to prompt/encourage R32 to step away from her doorway and then stood in her doorway to block R32 from entering her room. The female resident and R32 were within arm's reach with no staff observed on the Gilead Unit during the encounter (no physical or verbal aggression was noted during their interaction). R32's Electronic Health Record revealed documentation that R32 would become angry with redirection, agitated and combative with attempted assist, and combative with staff at times during encouragement placing residents that attempt to redirect R32 out of and/or away from their room at risk for physical/verbal abuse. R32's known behavior of wandering into resident rooms has resulted in recent FRI's regarding resident-to-resident physical and sexual abuse. During an observation on 11/30/2022 1:10 PM, R2 was in her wheelchair in the common area on the Gilead Unit. R2 reported she wanted to go to her room but was unable to self-propel herself in the wheelchair. R2 appeared agitated and frustrated, repeatedly attempted to stand, and demanded an ambulatory resident push her to her room. There were no staff observed on the Gilead Unit at that time. During an observation on 11/30/2022 at 1:24 PM, R32 walked closely past R74 in the common area on the Gilead Unit. R74 angrily shouted, get away from me you creep. Indicating residents on the Gilead Unit require close supervision to prevent resident to resident abuse. Resident and Staff Interviews During an interview on 11/28/22 from 10:31 AM-11:24 AM with R79 and R36, R36 reported that there are 2 residents that wander the units and like to go through people's rooms. R36 reported that the 2 residents that wander the halls and enter resident rooms are R32 and R24. R36 reported that both residents had recently entered his room without invitation (intake 1). R36 reported that he raised my voice to get them to leave and R24 took a swing at me. R36 reported fear with 2 men trying to accost me. R36 reported that he pushed him away with my leg and then R32 came at me. R36 reported that he had to use his walker to protect himself and it took everything I could to get away from them. R36 reported that R24 and R32 are left unsupervised and they are dangerous together. R36 reported that residents that require supervision are not supervised. R36 reported that the facility had a couple other (residents) that were bad news. R36 reported that a few months ago R107 sexually assaulted a female resident (R36 was able to name R107 and R9-intake 3). R36 stated the Gilead Unit is a vulnerable area. These women can't protect themselves from the residents with known behaviors. R79 reported that approximately 2 weeks prior she was in bed sound asleep and (R32) grabbed my boobs. I screamed! (intake 1) R79 reported fear when she woke to a man standing over her and ongoing fear and anxiety that there have been no changes made to prevent another occurrence. R79 stated the facility needs to hire one person as a pair of eyes to watch the guys (R32 and R24). R79 reported that there were not enough staff to meet the needs of the residents and the staff can't keep up. R79 reported that there was recently a night shift where there was only 1 CNA for all of the residents on the Gilead Unit. R79 reported that there are 2 CNAs scheduled for 3rd shift and there's no way they can have 2 staff at night to watch those 2 guys (R24 and R32). It's not enough. They try hard but they can't do it (their jobs) with 2 guys that are extra trouble. R36 reported that they try to get R24 and R32 to stay out of other rooms by putting up stop signs (Velcro mesh across resident doorways) but R24 will remove the stop sign from the doors and enter the room. R36 reported that R32 recently went around peeing in garbage and sinks but not the toilet because of the lack of staff/supervision. R79 reported that she is fearful of R24 and if you say something (R24) doesn't like he (punching motion) and the nurses are scared of him. R79 stated, there's not enough staff to give care and attention to residents. If they could bring more staff on it would be perfect. During an interview on 11/30/2022 at 12:40 PM, CNA X reported that residents were not receiving the care they required because of the lack of staff. CNA X reported that there were many residents on the Gilead Unit that required extensive assist or 2 assist with cares and the staff were expected to monitor and supervise (R32) and (R24). CNA X reported that when a resident that requires 2 persons assist for care is being helped, it takes 2 CNAs off the floor which results in even less supervision for R32 and R24. CNA X reported that because of the lack of staff available on the Gilead Unit she has seen an increase in resident falls and resident to resident altercations. CNA X reported that if there is a call off on another unit, they pull from the Gilead Unit. CNA X reported that second shift is the most difficult because they are expected to monitor R32 and R24 while also providing care to all the residents (incontinence care, toileting, repositioning), assisting with dinner (passing trays, feeding, picking up trays), monitoring residents that are sundowning (increased behaviors that occur in the evening), and putting the residents to bed. CNA X reported that there were many residents that required 2-person assistance to get to bed because of their use of a hoyer lift. CNA X reported that it was not reasonable to expect that ADL care and supervision can be completed with the number of staff available. During an interview on 12/01/2022 at 12:45 PM, DON reported that only she and LPN K were part of the nursing management team. DON reported that LPN K was working as the Unit Manager as well as the Wound Care Program nurse. DON reported that the Infection Preventionist/Assistant Director of Nursing had abruptly quit on 11/30/22 at 7:30 PM.

This citation pertains to intakes MI00127897 and MI00128815 Based on observation, interview, and record review, the facility failed to provide quality care to 6 residents, (Resident #7, Resident #20, Resident #8, Resident #13, Resident #15, Resident #21) out of 21 resident's sampled, resulting in lack of available fluids, delays in staff response to care needs, increased risk for infection, undetected neurological changes after a fall, decreased feelings of self-worth when not provided regular bathing, and unrelieved pain. Findings: Resident #7 (R7) Review of an Admission Record revealed R7 was a [AGE] year old male, most recently admitted to the facility from the hospital on 05/13/22, with pertinent diagnoses of a stroke, contractures of the right hand and wrist and both knees and ankles, Diabetes Mellitus type 2, Chronic Kidney Disease-stage 2, blindness in one eye and low vision in the other eye (see's only shadows), moderate protein calorie malnutrition, and retention of urine and use of a foley catheter. R7 is his own responsible person and primary language is Spanish. Review of a Kardex (a quick reference bedside care guide) for R7 reflected the following instructions for care: (1) showers on Saturday, (2) keep frequently used items within reach, (3) encourage resident to be up in wheelchair for all meals, (4) liquids in a cup with handle and lid, (5) elevate heels off bed surface while at rest in bed, and (6) long pillow against wall by knees when in bed. Review of a Care Plan for R7 (in addition to the above referenced Kardex care instructions) revealed the following directions for the residents plan of care: (1) place positioning wedge under right side of residents trunk and left arm for support at all times when resident is resting in bed, (2) encourage resident to sit on toilet to evacuate bowels if possible, (3) protective boots on while in bed to protect heels, (4) priority frequent assisted repositioning, (5) apply splint to right hand for 3 hours every day, and (6) follow established plan of care within the facility to assist resident in maintaining optimal levels of strength, function, and medical status. During an observation on 11/01/22 at 8:15 AM, R7 sat in bed, flat on his back, the head of the bed at 30 degrees, and watching tv. R7 was malodorous, with a strong smell of urine. R7 did not have protective boots on, did not have a positioning wedge under the right side of R7's trunk and arm, did not have a cup with a handle for fluids, did not have a splint on his right hand, and did not have a long pillow against the wall by his knees. The styrofoam cup of water was dated 10/31/22- 2nd shift. R7 indicated that he had moved his bowels earlier this morning and asked to be changed but was told that he would have to wait until after he had breakfast. As of this interview, staff had not been back to change him. R7 stated that staff do not attempt to get him up to the toilet to move his bowels. They tell me to use the brief. R7 also stated that staff do not get him up in the wheelchair for meals and that he just stays in bed all day. When asked when the last time R7 has a shower, R7 responded a very long time and stated that staff clean him up in bed a little when they do come and check him. During an observation on 11/01/22 at 10:49 AM, R7 sat in bed, flat on his back, the head of the bed at 30 degrees, and watching tv. R7 was malodorous, with a strong smell of urine. R7 did not have protective boots on, did not have a splint on the right hand, did not have a positioning wedge under the right side of R7's trunk and arm, did not have a cup with a handle for fluids, and did not have a long pillow against the wall by his knees. The styrofoam cup of water was dated 10/31/22- 2nd shift. R7 indicated that staff had come in and changed his brief. During an observation on 11/01/22 at 2:20 PM, R7 sat in bed, remained flat on his back, the head of the bed at 30 degrees, and watching tv. R7 was malodorous, with a strong smell of urine. R7 did not have protective boots on, did not have a splint on the right hand, did not have a positioning wedge under the right side of R7's trunk and arm, did not have a cup with a handle for fluids, and did not have a long pillow against the wall by his knees. The styrofoam cup of water was dated 10/31/22- 2nd shift. R7 indicated that staff have not repositioned him since the morning. During an observation on 11/01/22 at 4:26 PM, R7 sat in bed, remained flat on his back, the head of the bed at 30 degrees, and watching tv. R7 was malodorous, with a strong smell of urine. R7 did not have protective boots on, did not have a splint on the right hand, did not have a positioning wedge under the right side of R7's trunk and arm, did not have a cup with a handle for fluids, and did not have a long pillow against the wall by his knees. R7 indicated that staff have not repositioned him since the morning. During an observation on 11/02/22 at 1:21 PM, R7 sat in bed, remained flat on his back, the head of the bed at 30 degrees, and watching tv. R7 was malodorous, with a strong smell of urine. R7 did not have protective boots on, did not have a splint on the right hand, did not have a positioning wedge under the right side of R7's trunk and arm, did not have a cup with a handle for fluids, and did not have a long pillow against the wall by his knees. R7 indicated that his brief had not been checked or changed since last night. During an observation on 11/03/22 at 8:32 AM, R7 sat in bed, remained flat on his back, the head of the bed at 30 degrees, and watching tv. R7 was malodorous, with a strong smell of urine. R7 did not have protective boots on, did not have a splint on the right hand, did not have a positioning wedge under the right side of R7's trunk and arm, did not have a cup with a handle for fluids, and did not have a long pillow against the wall by his knees. The styrofoam cup of fluids sat on the over bed table out of reach of R7, still had the paper covering the end of the straw, and was dated 11/02/22- 3rd shift. Resident #20 (R20) Review of an Admission Record revealed R20 was a [AGE] year old female, last admitted to the facility from the hospital on 09/04/22, after receiving care for an acute GI (gastrointestinal) bleed. R20 had pertinent diagnoses of left sided paralysis and weakness following a stroke, seizure disorder, low back pain, other chronic pain issues, and a history of migraine headaches. R20 was dependent on staff for activities of daily living. During an observation on 11/03/22 at 8:20 AM, R20 sat up in bed with glasses on and the tube feed pump was empty and beeping. R20's left arm was contracted and in a splint. The call light touch pad sat on top of the blanket between R20's legs. When asked if R20 could reach the call light where it was sat, R20 responded no. R20 stated that she had no use of the left arm. R20's bed was positioned in the room in such a manner that R20's dominant and useable arm and hand ( the right side) were closest to the wall and not toward the room where fluids and personal items were kept on the over bed table. R20 had a styrofoam cup of fluids on the bedside table, out of reach, and dated 11/02/22-3rd shift. The cup of fluids had a paper covering on the end of the straw. R20 reported terrible pain this morning, facial grimacing observed, and reported the pain to be at 10/10 and located in the stomach and left arm. During an observation on 11/03/22 at 10:15 AM, R20 again reported I have terrible pain and was not sure if she received any pain medications recently. A styrofoam cup of fluids sat on the over the bed table out of reach of the resident. During an interview on 11/03/22 at 10:25 AM, Licensed Practical Nurse (LPN) G indicated that at the time R20 received pain medication around 8 AM, R20 had reported pain at 10/10. At the time of this interview, LPN G indicated that she had not gone back to check on R20 or re-assess R20's pain. Review of a Physician Order Summary for R20 reflected an order for Lisinopril ( a medication used to treat high blood pressure) one tab daily via PEG tube ( the tube feed) and to hold the medication if R20's systolic (top number) blood pressure was less than 120. During the above interview with LPN G on 11/03/22 at 10:25 AM, LPN G reported giving R20 a dose of Lisinopril this morning without having a blood pressure. Review of blood pressures for R20 in the EHR (electronic health record) reflected: that only 1 blood pressure on 9/4/22 had been checked for the month of [DATE], that only one blood pressure on 10/10/22 had been checked for the month of [DATE], and that no blood pressures had been obtained for R20 thus far during the month of [DATE]. The Emar (electronic medication administration record) for R20 in the months of Sept, Oct, and [DATE] revealed R20 was given the ordered dose of Lisinopril daily without blood pressure monitoring. Review of a Physician Progress Note dated 09/13/22, indicated that lab work for R20 would be ordered. Review of a Physician Order reflected that labs for R20 had been ordered on 09/13/22. Review of the EHR for R20 did not reflect any lab results since 09/13/22. During an interview on 11/03/22 at 11:58 AM, the Administrator stated that the labs ordered on 09/13/22 for R20 had not yet been completed. Resident #8 (R8) Review of an Admission Record revealed R8 was a [AGE] year old female in a persistent vegetative state from an anoxic (no oxygen) brain injury requiring a tracheostomy and use of a tube feed for all nutrition and hydration intake. R8 had contractures of both hands and wrists and both knees and feet. R8 is completely dependent on staff for all activities of daily living. During an observation on 11/01/22 at 8:53 AM, R8's outer cannula of the trach was coated in a thick brownish-yellow substance and the trach was not properly secured as it was protruding out of the stoma (the opening in the skin on the neck where the plastic trach is inserted into the trachea) one inch. There were multiple 4x4 dressings tucked under the collar. The bedside 3 tier plastic tower, which held supplies for staff to access easily and quickly, had only 3 oral sponges (used to swab the mouth) in the bottom drawer. No oral swabs were located in the bedside table (which held other supplies) nor on R8's side of the room. During an observation on 11/01/22 at 4:40 PM, R8's outer cannula of the trach was coated in a thick brownish-yellow substance. During an observation on 11/02/22 at 1:25 PM, the bedside plastic 3 tier tower near R8's bed contained only 3 oral sponges in the bottom drawer. No oral sponges were located in the bedside table nor on R8's side of the room. During an interview on 11/03/22 at 10:04 AM, Unit Manager (UM) M indicated that the oral swabs used for R8 were kept in the plastic 3 tier supply tower located next to R8's bed. Upon checking, the only oral swabs located in the tower or anywhere in R8's room, were the 3 oral swabs in the bottom drawer of the plastic tower. Review of a Care Plan intervention for R8 reflected .oral care twice daily and swab mouth frequently. Resident #13 (R13) Review of an Admission Record reflected R13 was an [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses of diabetes mellitus, chronic kidney disease, high blood pressure, and dementia. Review of a Brief Interview for Mental Status (BIMS) dated 10/21/22, revealed a score of 11 out of 15, indicating R13 had slight cognitive impairment. During an observation on 11/01/22 at 8:41 AM, R13 sat in a recliner, recently finished breakfast, and was watching tv. R13 indicated not getting enough to eat for breakfast and was still hungry. When it was suggested that R13 could ask for more food, R13 recoiled, upper body stiffened, eyes opened wide and R13 stated no you can't they will get mad. R13's hair is greasy and R13 cannot recall when her last shower was. A styrofoam water cup dated 10/31/22- 3rd shift, sat empty on the over the bed table. During an observation on 11/01/22 at 10:59 AM, R13 sat in the recliner resting with eyes closed. The styrofoam cup dated 10/31/22- 3rd shift, sat empty on the over the bed table. During an observation on 11/01/22 at 1:01 PM, R13 sat in the recliner resting with eyes closed. The styrofoam cup dated 10/31/22- 3rd shift, sat empty on the over the bed table. During an observation on 11/01/22 at 2:26 PM, R13 sat in the recliner resting with eyes closed. The styrofoam cup dated 10/31/22- 3rd shift, sat empty on the over the bed table. During an observation on 11/02/22 at 1:16 PM, R13 sat in the recliner, awake, and watching TV. Her hair was very greasy and actually looked wet. When asked if she had been given a shower today, R13 responded no shower today, no shower yesterday. Review of a Kardex for R13 revealed showers were scheduled to be given on Thursdays. Review of a task monitor for documenting showers reflected that as of 11/1/22, R13 had one bed bath in the past 30 days. Review of an Emar for R13, dated October 1 2022 through October 31st 2022, revealed an order for Humolog insulin, inject 1 unit in the evening and hold is blood sugar is less than 100. Review of the same Emar for R13 reflected that R13 received the injection of insulin on 10/04/22 despite having a blood sugar of 92 and on 10/17/22 despite a blood sugar reading of 90. Resident #15 (R15) Review of an Admission Record reflected R15 was a [AGE] year old male, admitted to the facility on [DATE], with pertinent diagnoses of dementia, high blood pressure, unsteadiness on feet, weakness, and disorientation. Review of facility Incident/Accident reports revealed R15 sustained 2 unwitnessed falls during his admission. Review of a facility Policy/Procedure-Falls reflected the following .initiate neurological checks for any fall where a resident hit their head or for any unwitnessed falls. During an interview on 11/03/22 at 1:35 PM, the Administrator indicated that neurological checks for R15's two unwitnessed falls, could not be located. Resident #21 (R21) Review of an Admission Record revealed R21 was an [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses of dementia, high blood pressure, and over active bladder. During an observation on 11/03/22 at 8:39 AM, R21 asked the surveyor, can you help me, I'm moving my bowels and I need help. R21's call light was out of reach. The surveyor handed R21 the call light and it was activated. Staff entered R21's room within 2 minutes after the call light was activated and asked R21 what she needed. R21 told staff she needed to be changed, staff turned off the call light and told R21 that (the staff person) would find someone to get her changed. During an observation on 11/03/22 at 10:12 AM, staff were in R21's room getting her changed. During an interview on 11/03/22 at 10:46 AM, the Administrator, after hearing about the above incident involving R21, stated that an hour and a half was too long for someone to have to wait to get cleaned up after having a bowel movement. The Administrator went on to say that the call light should have been left on until R21's needs were met.

Based on interview and record review, the facility failed to identify a COVID-19 outbreak and properly prevent and/or contain the spread of COVID 19, resulting in a pattern of transmission that sickened 56 residents, contributed to the hospitalization of 1 resident and was highly likely to have been the cause of death for 2 residents. This deficient practice resulted in an immediate jeopardy beginning on [DATE] when the facility failed to recognize and respond appropriately to a COVID-19 outbreak at the facility with the high likelihood of causing serious harm and or death for all residents living at the facility. Findings: Review of a facility policy COVID19 Core Practices updated [DATE] reflected 13. The facility will evaluate and manage residents with suspected or confirmed [CONDITION(S)]-CoV-2 infections-Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an NIOSH approved N95 or equivalent or higher-level respirator, eye protection (eye goggles or a face shield that covers the front and sides of the face), gloves, and gown. Residents with suspected COVID-19 should be prioritized for testing. Residents with known or suspected COVID-19 do not need to be placed in an airborne infection isolation room (AIIR) but should ideally be placed in a private room with their own bathroom. Residents with suspected COVID-19 will be moved to a private room with their own bathroom while test results are pending; it is recommended the door to the room remain closed to reduce transmission of [CONDITION(S)]-Co-V-2-in some circumstances (e.g. memory care units), keeping the door closed may pose resident safety risks and the door might need to remain open, a. If doors must remain open, the facility will work to implement strategies to minimize airflow into the hallway. If limited single rooms are available or if numerous residents are simultaneously identified to have known [CONDITION(S)]-CoV-2 exposures or symptoms concerning for COVID-19, residents should shelter in place at their current location pending return of test results. Residents should only be placed in a COVID-19 unit if they have confirmed [CONDITION(S)]-CoV-2 infection. Roommates of residents with [CONDITION(S)]-CoV-2 infection should be managed as described in Section: Manage Residents who have had Close Contact with someone with [CONDITION(S)]-CoV-2 Infection. Increase monitoring of COVID-19 positive and COVID-19 suspected residents including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infection. 14. How the facility will manage residents with close contact with someone with [CONDITION(S)]-CoV-2 Infection: Residents who are not up to date with all recommended COVID-19 vaccine doses who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine for 10 days after their exposure, even if [CONDITION(S)] testing is negative. Residents in quarantine should be placed in a single-person room. If limited single rooms are available or if numerous residents are simultaneously identified to have known [CONDITION(S)]-CoV-2 exposures or symptoms concerning for COVID-19, residents should shelter in place at their current location .16. How the facility will respond to newly infected [CONDITION(S)]-CoV-2 infected staff members and residents: When performing an outbreak response to a known case, the facility will defer to the recommendations of the local health department. Respond to Newly Identified [CONDITION(S)]-CoV-2 infected staff member or resident-because of the high risk of unrecognized infection among residents, a single new case of [CONDITION(S)]-CoV-2 infection in any staff member or resident should be evaluated as a potential outbreak. The policy specified If additional cases are identified, testing should continue on affected unit(s) or facility-wide every ,d+[DATE] days in addition to room restrictions and full PPE use for care of unvaccinated residents, until there are no new cases for 14 days, a. If antigen testing is used, more frequent testing (every 3 days), should be considered. Review of the facility policy COVID-19 CMS Facility Testing Requirements updated [DATE] reflected a table summarizing when COVID-19 testing should be completed as follows: Any staff or resident that is symptomatic, regardless of vaccination status should be tested for COVID-19. If there is a Newly identified COVID-19 staff or resident in a facility that can identify close contacts-all staff should be tested regardless of vaccination status, that had a higher risk exposure with a COVID-19 positive individual. Test all residents, regardless of vaccination status, that had a close contact with a COVID-19 individual. For Newly identified COVID-19 positive staff or resident in a facility that is unable to identify close contacts, test all staff, regardless of vaccination status, facility wide or at a group level if staff are assigned to a specific location where the new case occurred (e.g. unit, floor, or other specific area(s) of the facility). Test all residents, regardless of vaccination status facility-wide or at a group level (e.g. unit, floor, or other specific area(s) of the facility.) The policy also specified Testing Staff and Residents During an Outbreak Investigation-A new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection triggers an outbreak investigation. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. The facility has the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility wide) testing. If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. If the facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-wide or group-level. Broader approaches might also be required if the facility is directed to do so by the local health department, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission. An unannounced on-site investigation was started on [DATE] and it was confirmed during the entrance conference that the facility was currently experiencing a COVID-19 outbreak with 2 residents currently positive for COVID-19. The facility COVID-19 policies, testing logs, vaccine matrix, resident vaccine status and outbreak investigation were requested via email on [DATE]. During an interview on [DATE] beginning at 10:16 AM, the Nursing Home Administrator (NHA) reported that she and the Director of Nursing (DON) were responsible for tracking the COVID-19 outbreak investigation. The NHA provided a document titled Quality Assurance Performance Improvement Action Plan initiated [DATE] as evidence of an outbreak investigation. No supporting documentation was provided. Review of the form Quality Assurance Performance Improvement Action Plan initiated [DATE] reflected Facility received notification that a resident(s) and/or staff member(s) tested positive for COVID-19. Action steps included If a resident requires a higher level of care or the facility cannot fully implement all recommended infection control precautions, the facility will transfer the resident to another facility that is capable of implementation .Roommate(s) (if applicable) of the identified resident that are unvaccinated or not up to date with vaccine doses will be placed in Transmission Based Precautions for 10 day quarantine .Quarantine unvaccinated residents and residents who are not up to date with vaccine doses who have been identified as having close contact with a person with a COVID-19 positive person for 10 days .The facility IP (Infection Prevention)/DON will track any respiratory illnesses, especially any suspected/confirmed COVID-19 cases for both staff members and residents utilizing the CDC (Centers for Disease Control and Prevention) Long Term Care (LTC) Respiratory Surveillance Line List Instructions a. LTC Respiratory Surveillance Line List b. LTC Respiratory Surveillance Outbreak Summary. The facility will complete a root cause analysis and contact tracing on all positive resident(s) and/or staff member(s) to quickly determine if universal use of recommended PPE, which includes use of an N95 or higher level respirator (or facemask if a N95 or respirator is not available), eye protection (eye goggles or a face shield that covers the front and sides of the face), gloves, and gown, is indicated for the care of all residents on an affected unit or facility wide. During a follow up interview on [DATE] at 10:22 AM, the DON and NHA provided a list of Residents who tested positive for COVID-19 as of [DATE]. When asked, the DON and NHA reported they did not have specific information about contact tracing and resident placement decisions based on vaccination status or exposure or staffing considerations that would reflect an outbreak investigation had been done. The NHA confirmed her credentials did not include infection control and prevention. The DON reported she had completed the CDC Infection Preventionist training. The DON reported that a COVID-19 outbreak consisted of multiple COVID-19 positives (staff or residents) at the same period of time and continues to spread. According to the NHA when the first resident tested positive on [DATE] she focused on the QAPI plan as described above but did not conduct contact tracing. The DON reported the COVID-19 outbreak began on [DATE] on the dementia unit and it was reasonable to expect that residents living there were exposed to COVID-19. Review of a [DATE] Employee COVID-19 testing log reflected that staff members tested positive for COVID-19 on [DATE], [DATE] and [DATE]. Despite evidence the facility was in a COVID-19 outbreak, all staff were not tested per facility policy and contact tracing and an outbreak investigation were not completed. Review of a [DATE] Resident testing log reflected no COVID-19 positive residents. Review of a [DATE] Employee COVID-19 testing log reflected that facility staff members tested positive for COVID-19 on [DATE], [DATE], [DATE], [DATE] and [DATE]. Despite evidence the facility was in an ongoing COVID-19 outbreak (less than 14 days between COVID-19 positive test results), all staff were not tested per facility policy and no evidence an outbreak investigation or contact tracing had been completed were provided to the surveyor. Review of a [DATE] Resident COVID-19 testing log reflected one resident tested positive for COVID-19 on [DATE]. Review of a [DATE] Employee COVID-19 testing log reflected that facility staff members tested positive for COVID-19 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The 29 employees that tested positive in [DATE] held positions in nursing, dietary, laundry, maintenance and office/administrative staff and represented a facility wide spread of infection amongst staff. Despite evidence of an ongoing outbreak of COVID-19, the facility did not have evidence of an outbreak investigation or contact tracing. Review of a [DATE] Resident COVID-19 testing log reflected that between [DATE] and [DATE], 36 residents tested positive for COVID-19. 23 of the 36 residents who tested positive in [DATE] usually lived on the dementia unit, 12 residents usually lived on the 300 hall and one lived on the 400 hall at the facility. Review of the [DATE] Employee Covid-19 testing log reflected incomplete results (the results reported began on [DATE]) and did not reflect any new COVID-19 positive staff. Review of a document (undated) provided by the NHA and DON reflected employee names, testing dates, testing location, 7th day test, results of test (7th day) and a return to work date (implying the employees listed had tested positive for COVID-19). The document indicated that between [DATE] and [DATE], 11 more staff had tested positive for COVID-19. Review of the [DATE] Resident COVID-19 testing log reflected that one resident tested positive for COVID-19 on [DATE]. Review of a COVID-19 Resident Line Listing document provided to the surveyor by the NHA, updated [DATE] reflected that between [DATE] and [DATE], 19 residents tested positive for COVID-19. Resident #14 (R14) Review of the electronic health record reflected that R14 was a [AGE] year-old person who lived on the dementia unit. R14's Immunization record did not reflect a second booster shot had been offered to them and was diagnosed with COVID-19 on [DATE]. Review of Progress Notes indicated that as recently as [DATE] R14 had been observed repeatedly getting into a food service cart (used to transport multiple resident meal trays) and was difficult to redirect. Resident #15 (R15) Review of the electronic health record reflected that R15 was a [AGE] year old person who lived on the dementia unit. R15's immunization record did not reflect a second booster shot had been offered to them. Review of R15's progress notes reflected that on [DATE] R15 was moved to a room on the 300 unit (the room of R13) due to a COVID-19 outbreak. Progress notes indicated that on [DATE] R15 tested positive for COVID-19. Resident #13 (R13) Review of the electronic health record reflected that R13 was a [AGE] year old person that lived in the room where R15 was moved to related to the COVID-19 outbreak on the dementia unit. R13's immunization record indicated the resident completed the primary series of the COVID-19 vaccine but was not boosted. Review of the progress notes indicated that R13 tested positive for COVID-19 on [DATE] (two days after R15 was diagnosed with COVID-19). R13 refused to be moved onto the COVID-19 unit for isolation/quarantine. On [DATE] R13 defied the COVID-19 isolation precautions, leaving their room without a mask on, traveling down corridors exposing other residents and staff to COVID-19 and to the outside of the facility leading to law enforcement being called. Resident #10 (R10) Review of the electronic health record reflected that R10 was a [AGE] year old person with Multiple [CONDITION(S)] who lived on the 300 hall at the facility. Review of R10's immunization record reflected they completed their primary COVID-19 vaccination but was not boosted a first or second time. Review of Progress Notes reflected that R10 tested positive for COVID-19 on [DATE] and would be moved to the dementia unit for isolation/quarantine, permission from the guardian to administer a COVID-19 antiviral medication was given. Further review of progress notes reflected that R10 was discovered deceased on [DATE] at 5:53 AM. Review of a Death Record dated [DATE] reflected R10's Cause of Death was COVID-19. Resident #11 (R11) Review the facility electronic health record reflected R11 was an [AGE] year old person who normally lived on the 300 unit. Review of R11's vaccine record reflected they had not been offered a second booster shot therefore was not fully vaccinated. Review of R11's progress notes reflect they tested positive for COVID-19 on [DATE] and was moved to the COVID-19 unit for quarantine/isolation and treatment with the COVID-19 antiviral medication. Further review of the progress notes indicated R11 had a huge decline as of [DATE] and hospice care was initiated on [DATE]. The progress notes reflected that R11 passed away on [DATE] at 6:33 PM. Resident #12 (R12) Review of the electronic health record reflected that R12 was an [AGE] year old person who normally lived on the 300 hall. Review of R12's immunization record reflected R12 received the primary series of COVID-19 vaccine but was not boosted once or twice. According to the Progress Notes, R12 tested positive for COVID-19 on [DATE], complained of chest pain and was sent to the hospital. Progress notes dated [DATE] reflect that R12 was diagnosed at the hospital with chest pain and COVID-19 hypoxemia without respiratory failure. R12 returned from the hospital on [DATE] (still COVID-19 positive) and was not moved to the COVID-19 unit at the facility until [DATE] (two days after return from the hospital). During an interview on [DATE] at 11:06 AM, the facility NHA and DON reported that the decision had been made to move residents off the dementia unit into rooms with residents living on the 300 hall in an attempt to mitigate the spread of COVID-19. The DON and administrator did not consider residents who were not roommates of COVID-19 positive residents as exposed and/or vulnerable due to vaccination status, and therefore require quarantine, nor did they consider a resident's vaccination status prior to room changes. The NHA confirmed that since February 2022, a vaccine booster clinic had not been offered at the facility. On [DATE] at 3:00 PM, the facility NHA and DON were informed of the Immediate Jeopardy (IJ) that was identified on [DATE] and began on [DATE] when the facility failed to recognize and respond appropriately to a COVID-19 outbreak at the facility. On [DATE] the surveyor confirmed the facility implemented the following to remove the immediacy: 1. On [DATE] all residents are at a potential risk. The two residents that reside in the facility with COVID19 have been reviewed to ensure their contact tracing has been completed, they are in isolation and under the appropriate TBP precautions. 2. A 100% audit was started on [DATE] on the 57 remaining residents that have not had COVID19 in the past 90 days. -The residents had a respiratory screen completed by a licensed nurse, which included an assessment of COVID19 symptoms, vital signs, oxygen saturations and a respiratory exam. -At this time 0 out of 57 residents have been identified with concerns related to COVID19. 3. On [DATE], the Facility Administrator and Director of Nursing were educated by the regional nurse consultant on COVID-19 Core Practices Policy and Procedures, including but not limited to outbreak testing, contact tracing, TBP and isolation/quarantine requirements and monitoring. 4. On [DATE], 44 out of 148 staff members have been educated on the following items: Guidance- COVID-19 Core Practices Any staff member that has not been educated will be educated prior to the start of their shift. 5. The DON/designee will complete 5 resident medical record audits/observations of the COVID unit/isolation rooms to ensure all COVID19 and Infection Control Policy and Procedures are implemented and being followed weekly times 4 weeks then monthly times 3 months. 6. The medical director was notified of these findings on [DATE]. Although the Immediate Jeopardy (IJ) was removed on [DATE], the facility remained out of compliance at a scope of Pattern and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the COVID-19 infection control policies and sustained compliance has not been verified by the state agency.

This citation pertains to intakes M 0137 and M 0026. Based on observation, interview and record review, the facility failed to properly assess, monitor, document, notify the physician timely, have staff provide care within their practice, and best infection control practices for 2 (Resident #1, Resident #2), resulting in worsening/untreated conditions, a fractured knee, hospitalization s, and [CONDITION(S)]. Findings include: Resident #1 (R1) Review of a Face Sheet revealed R1 is an [AGE] year-old female who originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed R1 was severely cognitively impaired and required extensive assistance of one staff for cares. She had a feeding tube and no pressure ulcers and had verbal behaviors. Review of a Change in Condition document dated [DATE] for R1 revealed her feeding tube was displaced and had an open area on her coccyx. She was sent to the hospital. Review of Hospital Records dated [DATE] for R1 revealed the facility reported to the hospital that the resident pulled out her feeding tube. The hospital replaced her feeding tube. Review of the Hospital Records dated [DATE] for R1 revealed she was transferred to the hospital for an evaluation of a newly founded femur fracture. R1 had contractures in all extremities, is nonverbal and bed bound. The hospital determined the fracture appeared to be two weeks old and the facility reported there were no falls or injuries. The hospital noted an 8 centimeter (cm) erythematous and bulge on the medial superior aspect of the right knee that had a central puncture that drained bloody fluid and tender to touch. R1 appeared to have dyskinesia movements of the tongue. Bruising of the right medial knee with [CONDITION(S)] and deformity were noted. R1 was diagnosed with open fracture of distal end of femur, [CONDITION(S)] of the right knee, [CONDITION(S)], dilated rectum due to fecal impaction, urinary tract infection ([CONDITION(S)]), stage II pressure injury, obstructive [CONDITION(S)], protein calorie malnutrition, metabolic acidosis, elevated liver function tests likely related to infection, [CONDITION(S)], and covid-19 infection. [MEDICATION(S)] was listed as an allergy. The hospital acknowledged R1 had a bruise on the left side of her face about 1.5 weeks ago and the facility denied her falling at that time. Her son reported the facility was not certain how she sustained the bruise. Her feeding tube was replaced, and the notes reported the Resident pulled her feeding tube out, but given her contractures, seems unlikely. R1 expired on [DATE]. Review of a Nursing Progress note dated [DATE] for R1 revealed she had a 2.0 x1.0 maroon discoloration on her forehead. Her bed is up against a wall and combative with cares. A pillow was to be put up against the wall to protect her head when doing care. No signs or symptoms of pain. Review of the Nursing Progress notes for R1 revealed on [DATE] a non-blanchable redness to her bilateral buttocks measuring 1x1 cm was noticed and new treatment orders were initiated and a consent for wound care was obtained. On [DATE] during wound rounds a new order put in place. On [DATE] the guardian was notified of a COVID-19 outbreak in the facility. On [DATE], the resident had a reddened/purple area to her right knee that was visualized to be 2 inches in diameter and not clear if it is a bruise or red from an irritant. Reported to the Unit manager on duty and notified the NP (Nurse Practitioner). On [DATE] at 7:20 AM, the reddened area to the right knee was bleeding. It was cleansed and a pressure dressing was applied. The doctor was notified in the book and report was given to the oncoming shift. On [DATE] at 1:40 PM, R1 was sent to the hospital. Review of a Skin assessment dated [DATE] for R1 was documented she had no new alterations in skin integrity but documented she did have a bruise on the outer aspect of her right knee. No further descriptions, measurements or assessments noted. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Her allergy to [MEDICATION(S)] was noted and listed as a medication she is taking since [DATE]. Her stage II pressure wound is followed by wound care. She has lost 14 pounds in six months while receiving a tube feeding. Today nursing reports the patient has redness and discoloration to her right knee. Nursing denies any recent falls or trauma. On exam, her right knee is beefy red, warm, and swollen to the medial aspect of her knee. A STAT Xray and labs were ordered. Review of the [DATE] MAR/TAR for R1 revealed an order a 2-view right knee Xray STAT (as soon as possible) and a serum laboratory order on [DATE] was documented done on [DATE]. Review of a Lab Result report for R1 revealed serum labs were drawn on [DATE] at 5:51 AM, received at 5:09 PM and reported at 6:14 PM. Review of a Nursing Progress note dated [DATE] at 2:35 PM for R1 revealed an Xray was completed on the right knee and showed a transverse supracondylar fracture of the femur. Review of the [DATE] MAR/TAR for R1 revealed an order to monitor behavior tracking and no documented behaviors are noted. An order to monitor the side effects of [CONDITION(S)] medications does not list symptoms such as dyskinesia, and 2 days were not documented. She is on [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] 25 milligrams (mg) twice a day for schizophreniform. [MEDICATION(S)] is not listed as an allergy in the electronic medical records. No COVID screening was documented since [DATE] when the family was notified of a COVID outbreak. Review of the last Behavioral Health progress note for R1 dated [DATE] revealed she has an allergy to [MEDICATION(S)]. She had no new or worsening concerns at that time but did have a list of several symptoms including but not limited to aggression during care, agitation, and anxiety. She was not considered a danger to herself or others. The follow up included continuing psychiatric services and report any new or worsening behaviors, including medication side effects. This is the last progress note for Behavioral Health Care. Review of the overall Care Plan for R1 revealed she had a stage 1 pressure ulcer initiated on [DATE] and revised on [DATE] with no new interventions. The care plan does not address and/or have updated and meaningful interventions including but not limited to pressure ulcers, behaviors, tube feeding, and weight loss. In an interview on [DATE] at 12:11 PM, the Director of Nursing (DON) reported R1 was combative with everyone and resisted everything people would do, but sometimes she was calm. At this time Behavioral Health Care notes and behavior logs requested. In an interview on [DATE] at 12:48 PM, Social Worker 'B reported R1 had verbal behaviors and would reject care. If she were confused or having delusions, she would tell people to get out of her room, but if she was reapproached, she could be receptive to care. She would pinch staff sometimes during care. SW B that the resident did not get Behavioral Health Care Services because she was so severely demented. They addressed her behaviors in the morning meetings with the facility's Physician Assistant. SW B reported that R1's normal baseline for behaviors was a couple times a week. In an interview on [DATE] at 1:48 PM, Licensed Practical Nurse (LPN) L reported R1 was bedridden and could be combative and verbally abusive to all people no matter who they were and that was her baseline. LPN L reported some of the Certified Nursing Assistants (CNA's) would take it personal until they began to know her. LPN L advised the CNAs to reapproach her if she had behaviors. R1 had a roller coaster of emotions. LPN L reported he did not see R1 hit her head on [DATE] but did see the discoloration on her forehead and notified the Unit Manager that was on call. LPN L does not recall anyone witnessing her hitting her head but is aware that she was combative that morning. The resident cannot reposition herself but thinks it could have happened when she was being repositioned, and then it would have been witnessed. In an interview on [DATE] at 2:38 PM, Unit Manager (UM) J reported R1 had dementia and was nonsensical. She could kick things or knock things out of your hands and was able to pinch people. The resident had behaviors almost every day and would expect the nurses to chart the behaviors. On [DATE] R1 had a discoloration on her forehead but not sure if it was a bruise and concluded it was from her being combative but did not witness it. When she was informed on [DATE] of R1's knee being red, she thought it may be bursitis or gout. When asked if the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] her knee was bleeding. UM J reported she would expect the nursing staff do monitor, assess, and document wounds or any changes regarding a resident's care and did not know why there was limited documentation. In an interview on [DATE] at 12:12 PM, Licensed Practical Nurse (LPN) O reported on [DATE] the CNAs notified her of R1's knee and the CNAs did not know how it could have happened. LPN O reported she notified the physician by writing down the concern in the 24-hour physician notification book so when the physician made their rounds, they can see it in the book. LPN O reported she then told UM J who said she would look at it. LPN O reported she did palpate her knee, but it did not look abnormal and there was no pain from it. If it were more serious, LPN O reported she would then call the physicians. LPN O reported R1 had mostly verbal behaviors, but the staff worked well with her. LPN O reported she would document it in the Treatment Administration Record (TAR). LPN O did not know how R1 could have fractured her knee unless she hit the wall when the staff were taking care of her. In an interview on [DATE] at approximately 2:00 PM, Nurse Practitioner (NP) K reported she was not aware of R1 having a reddened knee but would expect to call the practitioners for an acute or change in condition and not just write it in the communication book. In an interview on [DATE] at 10:30 AM, CNA N reported R1 had days when she was combative and days when she was not, and the residents' behaviors were more verbal than combative. The resident seemed to be more behavioral towards people of color. CNA N reported she worked with the day of [DATE] and told the nurse about the redness she observed on R1's knee. She did not recall seeing the knee red the day before and is not sure how or what it was from. R2 Review of a Face Sheet revealed R2 is a [AGE] year-old female who admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS for R2 dated [DATE] revealed a cognitive assessment was not done and is totally dependent on one staff for cares. During several observations on [DATE] at 8:25 AM, 10:48 AM, 2:07 PM, and 3:00 PM, R2 was in bed on her back with a pillow under her left arm with the tube feeding infusing with a [CONDITION(S)] delivering oxygen. She was in the same position during all observations. During an observation on [DATE] at 3:08 PM, CNA M when queried about the last time R2 was repositioned, she reported it was around 1:00 PM then changed her story when asked if she personally repositioned her. CNA M said she was sure the other CNA who had went home at 2:00 PM repositioned her and changed her because they are supposed to do that every 2 hours. The CNA went to R2's room at this time to reposition and check and change her. CNA M put R2's tube feeding on hold and started to change the residents brief that was soaked with urine. She tucked the brief between the residents' legs and began to turn the resident to her side but the tube feeding line limited how far she could move the resident. With the same gloved hand, she disconnected the feeding tube line from the resident and hung the uncapped tubing over the machine and continued to provide care. She reached inside her pocket with the same gloved hands she provided pericare with and applied a Periguard cream on her buttocks and applied a new brief. The CNA continued to reposition the resident touching her clothing and sheets with the same gloves. When she was done, she changed her gloves, used hand sanitizer, and reconnected the tube feed line to the resident. CNA M said the resident can take ,d+[DATE] staff to reposition her, but it depended on how many staff were available. The resident was repositioned with pillows on her right side. Review of a Nurse Practitioner Progress note dated [DATE] for R2 revealed the resident has a pressure injury on her coccyx and brown scabbing noted. The resident was soiled with stool, cleaned and the wound was observed. Wound care to address pressure injury and wound on the shin. In an interview on [DATE] at 2:54 PM, UM J reported R2 went to the hospital this day for respiratory distress and thick sputum. UM J reported she had not done a respiratory assessment earlier this day but found the resident to be absent of lung sounds on one side and implemented [CONDITION(S)] suctioning before she went to the hospital. Confirmed R2 had a stage II pressure ulcer on her coccyx and a wound on her right shin that started as a blister from when her leg boot was caught on a strap. Said the resident is to be repositioned every two hours and not sure if the CNAs are able to put the tube feeding on hold but did say they should not disconnect the line. When queried about pericare and infection control observations, UM J reported it sounded like they needed to reeducate the staff. Review of the [DATE] MAR/TAR ([DATE] to [DATE]) for R2 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Palm protectors not applied as ordered for 4 days. Skin prep to right inner foot/bunion daily not done for 4 days. An order to ensure additional cannulas are at bedside for airway management not documented for 5 opportunities. Pulse oximetry (oxygen saturations) every shift was ordered and not documented as done for 6 entries. Check the function of the oxygen concentrator ordered for every shift is missing 6 entries. Check tube feeding placement every shift is missing 5 days of care. Elevate the head of the bed ,d+[DATE] degrees during feeding and flushed every shift for minimizing risks is not documented as done for 5 opportunities. Oxygen ,d+[DATE] liters per minute via [CONDITION(S)] mask every shift is documented as not done for 6 entries.

This citation has two Deficient Practice Statements (DPS). DPS A Based on observation, interview, and record review, the facility failed to properly care for one dependent resident (Resident #9) known to have compromised skin integrity resulting in an Immediate Jeopardy when on 02/19/21, the facility failed to prevent, identify, and treat a pressure sore resulting in the deterioration of the sore to a stage 4 (bone and tendon exposed) wound with [CONDITION(S)] and [CONDITION(S)]. This deficient practice resulted in harm to the resident and inhibited the ability of Resident #9 to reach the highest practicable health and well-being, and has the high likelihood to place all dependent residents at risk for deteriorating skin integrity. Findings: Resident #9 (R9) was originally admitted to the facility 7/24/20 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] reflected R9 required extensive assistance with bed mobility. Section M of this MDS titled Skin Conditions reflected R9 had a Stage 4 pressure sore that was present on admission to the facility which indicated the condition was acquired outside the facility. Review of the Electronic Medical Record (EMR) revealed a Progress Note dated 2/8/21 that indicated R9 was readmitted to the facility following extended treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . No further description of the MASD identified in the Progress Notes from 2/8/21-2/19/21. A Progress Note dated 2/19/21 at 10:30 PM reflected R9 was sent to the hospital and diagnosed with Septic Shock. A Progress Note dated 2/25/21 reflected R9 returned to the facility with a dressing on the sacrum. Progress Note entries dated 2/26/21, timed 2:07 PM, 2:09 PM, and 2:11 PM revealed three wound evaluations of the sacrum and the left and right buttocks with measurements. All three wound assessments described R9's wounds as MASD. Review of the hospital documentation dated 2/19/21 reflected R 9 arrived at the Emergency Department (ED) from the facility with a sacral decubitus ulcer that included a photograph taken in the ED on 2/19/21 of a decubitus ulcer and a large area of possible MASD. The hospital documentation reflected that the sacral decubitus ulcer and surrounding [CONDITION(S)] as a possible source of [CONDITION(S)]. Despite the hospital physician documentation and photograph of 2/19/21 of R 9 having a decubitus ulcer facility documentation after 2/25/21 consistently reflect R 9 wounds are referred to as MASD in the EMR Progress Notes (3/9/21, 3/12/21, 3/19/21, 3/26/21, 3/29/21, 4/7/21, 4/15/21, 4/20/21) The medical record Progress Note dated 4/29/21 at 3:09 PM reflected R9 was admitted to the hospital again for [CONDITION(S)] and returned to the facility on [DATE]. The EMR Progress Notes revealed a wound assessment dated [DATE] at 9:20 PM, Wound location is Sacrum. Wound measurements .Length-5.4 centimeters (cm), Width -3.7 cm, Depth - 4.5 cm (approx. 1 ½ inches in depth). Another EMR Progress Note on that same day, 5/5/21, at 11:16 PM reflected a wound assessment that R9 had: sacrum , stage 4, undermining present, slough . hanging off ., Bones and tendons are exposed. Review of the EMR reflected Medical Provider documentation dated 5/12/21 at 1:45 PM that R 9 was hospitalized [DATE] for [CONDITION(S)] probably related to his stage IV sacral wound, . prognosis for (R 9) is poor. Review of the Wound Clinic documentation dated 5/24/21 reflected R9's sacral wound had deteriorated, Large amount of visible/palpable bone. The documentation reflected the wound measured 6.5 centimeters (cm) long, 4 cm wide, and 4 cm in depth (approx. 1 ½ inches deep). The documentation reflected the Medical Provider recommended imaging to rule out [CONDITION(S)]. Review of the Wound Clinic documentation dated 6/14/21 reflected the Medical Provider had reviewed consultation notes and recommended intravenous (IV) antibiotics with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The documentation reflected R9 left the clinic with a PICC line (peripherally inserted central catheter, used for longer term intravenous access) in place and antibiotics were scheduled. The industry Standard of Care for turning and repositioning of all Long-Term Care residents is every two hours. It was observed that R9 has a Blue Dot turning protocol in place which facility staff reported this means repositioning every two hours (standard of care). Review of an email communication sent by the DON on 9/22/21 at 11:21 a.m. reflected an explanation of the Blue Dot protocol, Blue Dot - is a tool we use to identify those who are at highest risk and need frequent assisted repositioning. No formal protocol for the facility's Blue-Dot protocol was provided. Review of a Therapy Status Communication form dated 6/7/21 reflected, [R9] to lay toward L and R (left and right) side (with) 2 wedges under hips and trunk throughout the day to decrease the risk of further skin breakdown. However, review of the Care Plan did not reveal this recommendation had been added to the comprehensive Care Plan as an intervention. Observations made on 9/21/21 at 9:33 AM, 10:52 AM, 11:45 AM, 1:08 PM, and 3:00 PM revealed R 9 was not turned or repositioned off his back. It was noted that during each observation over the course of five and a half hours, three pillows on the bed of R9 had not moved or had been repositioned during any of these times. No positioning wedges were observed in the room of R9. On 9/21/21 at 1:20 PM a request was submitted to the Director of Nursing (DON) for a timeline of the skin condition on the buttock of R9. On 9/22/21 at 8:54 AM the DON provided a timeline of the wounds for R9. The documentation of the timeline reflected, 2/19/21 Transfer out - No wounds. This is inconsistent with the hospital documentation and photograph of 2/19/21. On 9/22/21 at 1:27 PM the Administrator and Director of Nursing were notified of an Immediate Jeopardy related to F-686, that began on 02/19/21, when the facility failed to prevent, identify, and properly treat a stage IV pressure sore for R9. On 9/22/21 at 8:54 AM the DON provided a timeline asserting a wound on the buttocks of R 9 developed in the hospital between 2/19/21 and 2/25/21. However, hospital documentation and photo dated 2/19/21 reflected R 9 arrived to the ED with a large sacral decubitus ulcer that included a photograph of a large decubitus ulcer and a large area of possible Moisture Associated Skin Damage (MASD). The hospital documentation reflected that the sacral decubitus ulcer and surrounding [CONDITION(S)] as a possible source of [CONDITION(S)]. Observations during the current survey reveal R 9 is on a Blue Dot turning protocol (every two hours). Observations documented on 9/21/21 revealed R 9 was not turned or repositioned off of his back throughout five observations made by surveyors from 9:33 AM to 3:00 PM. The identified risk of serious injury, serious harm, serious impairment and/or death was evidenced by: Despite hospital documentation of R 9 having a decubitus ulcer facility documentation after 2/25/21 consistently reflect R 9 wounds are referred to as MASD. R 9 was admitted to the hospital again on 4/29/21 and returned to the facility on [DATE]. Facility documentation reflected R 9 was admitted to the hospital on 4/29/21 for [CONDITION(S)]. On 5/5/21 facility documentation reflected an assessment of the wounds of R 9 had: sacrum , stage 4, undermining present, slough . hanging off ., Bones and tendons are exposed. The Physician documentation of 5/12/21 reflected the Resident was hospitalized [DATE] for [CONDITION(S)] probably related to his stage IV sacral wound, . prognosis for (R 9) is poor. On 9/23/21 at 12:08 PM the facility plan to remove the Immediate Jeopardy was accepted and the State Agency validated the removal plan which included: 1. On 09/22/21 the facility immediately initiated skin assessments of the at risk residents. Skin sweep assessments will be completed by a licensed or registered nurse. 2. On 09/22/21 the facility initiated review of the skin sweep assessments and updated wound type if necessary. 3. On 09/22/21 the facility updated R9's wound type and the care plan was reviewed and updated with the appropriate interventions as necessary. 4. On 09/22/21 the facility initiated review and update of identified at risk residents care plans with appropriate interventions as necessary. 5. On 09/22/21 the facility initiated review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. On 09/23/21 the facility initiated completion of a new Braden Scale Assessment on all current residents to ensure risk of pressure ulcer development is accurately assessed. 7. On 09/23/21 the facility initiated notification of the primary care physician, responsible party/guardian of residents with newly identified skin concerns, change in treatments, change in wound severity, and/or plan of care. 8. Medical provider will receive and review the skin monitoring and management program to ensure program meets professional standards of practice. 9. On 09/23/21 education was started with all licensed and registered nurses and certified nursing assistants to be educated in person on the skin monitoring and management program including but not limited to assessment, correct identification, and implementation of interventions to monitor and treat the development or worsening of pressure wounds. Any staff no present during the education started on 09/23/21, will be educated prior to starting the next scheduled shift. Competency will be validated by a written competency test. On 9/23/21 at 10:53 AM an interview was conducted with the DON and Nurse Practitioner (NP) LL. The DON reported the timeline she provided of the wounds on R9 did not accurately explain the wound's history and treatment. The DON reported she had developed the timeline based on the medical record of R9 and an alternative timeline would be provided. Both the DON and NP LL reported they understood how the conclusions were drawn by the survey team of the progression of R9's wounds in reviewing the facility's medical record. NP LL reported medical records that the surveyors were not privy to would be provided and should be considered. NP LL reported every time the wound was seen by a different person each would give a different description. NP LL reported that MASD topical is an appropriate description and that the wound did not start out as pressure related. NP LL reported that wound progression was unavoidable. NP LL reported moisture on the skin from urine and fecal material is only one factor and that R9 is nutritionally and medically compromised. NP LL reported a urinary catheter was put in place (4/17/21) to remove urine from the area and R9 had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . NP LL was asked if keeping pressure off the area is important. NP LL stated, yes. NP LL reported that R9 resists position change. The DON reported that R9 was on the Blue Dot program which gives a higher priority to frequent assisted position changes. Review of the EMR Progress Notes for R9 from 2/8/21 to 4/29/21 reflected one entry on 3/9/21 that R9 was resistive to repositioning. No other documentation was found that indicated R9 was non-compliant with the Blue Dot Protocol of frequent assisted repositioning as described by the DON or with the staff's described understanding of the Blue Dot Protocol of repositioning every two hours (standard of care). The Care Plan titled Resident has potential/actual impairment to skin integrity (related to) old ([CONDITION(S)]) site to neck . MASD both buttock . was reviewed. The Care Plan reflected the intervention of the Blue Dot Protocol that was initially implemented 3/11/21. The Care Plan reflected the revision that R9, Will refuse or decline assistance with repositioning was added to the Blue Dot Protocol intervention on 5/5/21. This revision was not added to the Blue Dot Protocol until after the hospitalization of 4/29/21 when the wound had progressed to a documented Stage 4 wound. Review of the EMR task document titled Bed Mobility dated 8/24/21 to 9/22/21 (30 days) reflect R9 was Total Dependence on staff for bed mobility which was documented as completed two to four times a day (far less than the standard of care). The documentation of 9/21/21 reflected no bed mobility task was completed from 7:52 AM to 9:14 PM consistent with the observations made 9/21/21 of R9 not being repositioned between 9:33 AM to 3:00 PM as previously noted. On 9/23/21 at 2:27 PM the DON provided a second timeline. This timeline reflected open areas on the right buttocks were first noted on 10/28/20 prior to R9's admission to a facility for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The documents appeared to be from the facility where R9 was admitted during the care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Although the Immediate Jeopardy was removed on 9/23/21, the facility remained out of compliance at a scope of Actual harm that is not immediate jeopardy due to sustained compliance has not been verified by the state agency. DPS B Based on observation, interview, and record review, the facility failed to provide coordinated monitoring and treatment for 2 residents with skin breakdown (Resident #83 and Resident #105), resulting in the potential for undetected and untreated worsening pressure ulcers. Resident #83 (R83) Review of an Admission Record reflected Resident #83 (R83) originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R83 had short- and long-term memory problems and required limited assistance from one person for transfers, walking, toilet use and personal hygiene. The assessment also indicated R83 was not steady moving from a seated to standing position and moving off the toilet. Section H - Bowel and Bladder reflected R83 did not use a catheter, did not require intermittent catheterization, was not on a toileting program (such as scheduled toileting, prompted voiding or bladder training) and was only occasionally incontinent of urine and never incontinent for bowel movements. Section M-Skin Conditions reflected R83 was at risk for developing pressure ulcers but did not have any pressure sores. Review of an Incident Report dated 7/23/21 at 12:51 p.m. reflected R83 had an unwitnessed fall in the bathroom and was sent to the hospital after an x-ray revealed a right [CONDITION(S)]. Review of hospital Discharge Instructions dated 7/24/21 specified R83 was non-weight bearing on the right leg and Foley catheter until no longer painful for bed rolls. Review of Braden Scale for Predicting Pressure Sore Risk assessments dated 7/25/21, 8/12/21 and 8/20/21 reflected that R83 had a moderate risk for developing a pressure sore. Review of a Care Plan Report reflected that when R83 admitted to the facility on [DATE] a care plan focus area read Resident has potential to skin integrity r/t dementia, DM2 (type 2 diabetes), PVD ([CONDITION(S)]), self-transfers, failure to thrive. The goal of the care plan was Resident will maintain intact skin with no breaks in skin through the next review date. Interventions to reach the goal of maintaining intact skin were: (a) Educate resident/family/caregivers of causative factors and measures to prevent skin injury, (b) Encourage good nutrition and hydration in order to promote healthier skin, (c) Observe skin daily with care activities, report any changes in coloration/integrity etc., to nurse, (d) Resident needs pressure reduction interventions: (SPECIFY-mattress type, specialty bed, wheelchair cushion, etc.). The care plan did not specify any pressure reducing interventions. Further review of the entire Care Plan Report revealed facility staff had identified focus areas that included: Resident has limited physical mobility r/t (related to) dementia, failure to thrive, prostate cancer, DM2, and hearing loss; None (sic) weight bearing with the goal of keeping R83 comfortable and an intervention to reposition for comfort. The Care Plan Report did not reflect that facility nursing staff had care planned R83's assessed risk for pressure ulcers due to his lack of mobility and being completely bed bound with new bowel incontinence. Review of a document reflecting a task charted on by Certified Nurse Aides (CNA's) BED MOBILITY: SELF-PERFORMANCE-How resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture for the dates 8/23/21-9/20/21 reflected staff documented EXTENSIVE ASSISTANCE-Resident involved in activity; staff provide weight bearing support 58% of the time, with staff documenting R83 was TOTAL DEPENDENCE-Full staff performance 6% of the time in the 30 days look back period. Review of a Skin Observation Tool dated 8/1/21 reflected R83 had excoriation on his coccyx. No other skin abnormalities were documented on the form. Review of a General Progress Note dated 8/1/21 at 10:13 p.m. reflected Resident had bed bath this evening. Observed scab to left forearm related to previous fall, purpura to left forearm and excoriation to bilateral buttock. Notified (hospice group) of excoriation, waiting for new orders of [MEDICATION(S)] treatment to be applied every shift . During a telephone interview on 9/13/21 at 1:54 p.m., R83's wife, Family Member (FM) XX reported that she had just come from the facility after having assisted R83 with his noon meal. FM XX said that she would like to see R83 get out of bed, explaining that he has been bed-bound ever since he broke his hip in a fall at the facility on 7/23/21. FM XX said she had made the suggestion to the hospice staff that see R83 but had not told staff at the facility because they are so busy. FM XX said it was concerning to her because he had a little bedsore on the top of his tailbone, and she would like that treated. During an observation and interview on 9/14/21 at 12:09 p.m., Licensed Practical Nurse (LPN) L said she was not aware of any open areas on R83's coccyx and agreed to assess R83's skin. CNA I assisted in positioning R83 and reported she was aware of an open area on R83's coccygeal area and had reported it to another nurse (LPN J) a few weeks ago. Upon entering the room, R83 agreed to the observation and CNA I pointed to individual packets of ointment the CNAs were putting on the open area on R83's coccygeal area. LPN L reported the area was indeed open and measured a 1.0 cm x 0.5 cm area. Additional assessment of R83's skin revealed a small, reddened area on the left second toe, the skin on R83's feet was very dry. Review of General Progress Notes from 9/14/21-9/21/21 did not reflect the nurse had documented the open area measured on R83 during the observation and interview conducted on 9/14/21 at 12:09 p.m. Review of an Order Recap Report for R83 reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Skin Observation Tool dated 8/23/21 and 8/30/21 reflected R83 had no new skin issues. Skin Observation Tools dated 9/7/21 and 9/12/21 were blank, indicating no new areas or changes in R83's skin condition. No Skin Observation Tool was completed after the assessment of R83's skin by LPN J on 9/14/2021. Review of a Nurse Practitioner (NP) progress note dated 9/15/21 documented by NP LL reflected R83 was seen for a skin check. The note revealed Patient seen at the request of nursing staff for the evaluation of skin regarding concerns of open area over buttock. Pt is alert awake and hard of hearing. He has been bed bound due to the fact that he has a non-surgical fracture of the right femur. He is dependent on staff for all ADL (activities of daily living). He states his pain is well controlled. He has a Foley catheter and draining clear urine with some slight sediments. Pt has a history of prostate cancer and was under the care of the oncology until he went on hospice care. He has dementia, but he is pleasant and cooperative with care. He has no exhibited behavior so far, he is sleeping well, PO (per mouth) intake is good, he is cooperative with care. The note specified that R83 has no strength for bed mobility. The physical exam revealed His skin over the sacral area is clear and no open areas noted. The coccyx is slightly discolored. It is slightly red and blanchable. No open area noted, no pain or discomfort on palpation. He is incontinent on bowel and needed to be cleaned up while being examined, pt did not show any signs of pain while being cleaned. The Assessment/Plan specified that R83 did not have skin breakdown and no change in treatment was indicated. Resident #105 (R105) Review of an Admission Record revealed R105 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment, completed 07/26/21, reflected R105 required extensive assistance from staff for bed mobility, transfers, and going to the bathroom. Review of a Brief Interview for Mental Status (BIMS) revealed a score of 15 out of 15, which indicated that R105 was cognitively intact. Review of a Nursing Admission Screen for R105, dated 08/19/21 at 12:10 P.M., reflected that R105 did not have any skin concerns at the time of admission. Also noted was that R105 had bilateral lower extremity [CONDITION(S)]. Review of a Skilled Charting note for R105, dated 08/20/21 at 7:09 A.M., reflected the following information (a) R105 required substantial/maximal assistance to change positions from sitting to lying, (b) resident did not have any skin conditions or impairments, and (c) the resident did not have any [CONDITION(S)]. Review of a Skin & Wound Evaluation for R105, dated 08/20/21 at 9:12 A.M., reflected the following information: (a) R105 was admitted with a pressure type wound, (b) stage- deep tissue injury, (c) location- sacrum, (d) wound measurements- length 10.4 cm x width 7.4 cm (centimeters), (e) goal of care- slow to heal: wound healing is slow or stalled but stable, little/no deterioration, and (f) Additional Care- cushion, incontinence management, mattress with pump, repositioning devices, and turning/repositioning program. The evaluation did not indicate that the dietician nor the facility practitioner were notified. The above mentioned skin evaluation did not indicate that R105's [MEDICATION(S)] infection was evaluated and did not mention a plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a General Progress Note, dated 08/20/21 at 9:19 A.M. and noted as a late entry, revealed the following information regarding R105 .hospital record indicates a sacral wound, allowed care this am .mood calm .pitting [CONDITION(S)] to bilateral shins and feet .is jaundice, ascites present, [MEDICATION(S)] areas under bilateral arm pits and under abdominal pannus .deep tissue injury is noted entire sacral area .skin looks as if it will peel. Review of a Skilled Charting note for R105, dated 08/20/21 at 5:48 P.M., reflected the following information (a) R105 required substantial/maximal assistance to change positions from sitting to lying, (b) resident did not have any skin conditions or impairments, and (c) the resident did not have any [CONDITION(S)]. Review of a Skilled Charting note for R105, dated 08/21/21 at 12:54 A.M., reflected the following information (a) R105 required substantial/maximal assistance to change positions from sitting to lying, (b) resident did not have any skin conditions or impairments, and (c) the resident did not have any [CONDITION(S)]. Review of a Skilled Charting note for R105, dated 08/21/21 at 2:36 P.M., reflected the following information (a) R105 required substantial/maximal assistance to change positions from sitting to lying, (b) resident did not have any skin conditions or impairments, and (c) the resident did not have any [CONDITION(S)]. Review of Skin Observation Tool dated 08/22/21 for R105 did not provide a description of the sacral area nor any measurements, and only indicated that the resident had no new areas of skin concern. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Skin Observation Tool dated 08/29/21 for R105 did not provide a description of the sacral area nor any measurements, and only indicated that the resident had no new areas of skin concern.

This citation pertains to MI 1396 & MI 2658) This citation has two deficient practice statements. Statement A. Based on observation, interview and record review the facility failed to comprehensively assess residents and develop and implement person centered care plans to meet medical and nursing needs for 3 residents (Resident #83, Resident #104 and Resident #113) resulting in (a) harm from avoidable falls, and (b) the potential for serious harm when staff failed to implement interventions based on known risk factors (falls and pressure injuries). Findings: Resident #83 (R83) Review of an Admission Record reflected Resident #83 (R83) originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R83 had short and long-term memory problems and required limited assistance from one person for transfers, walking, toilet use and personal hygiene. The assessment also indicated R83 was not steady moving from a seated to standing position nor moving off the toilet. Section H - Bowel and Bladder reflected R83 did not use a catheter, did not require intermittent catheterization, was not on a toileting program (such as scheduled toileting, prompted voiding or bladder training) and was only occasionally incontinent of urine and never incontinent for bowel movements. Section M-Skin Conditions reflected R83 was at risk for developing pressure ulcers but did not have any pressure sores at the time of the assessment. All policies and procedures pertaining to Falls, Fall Prevention/Fall Program and related protocols, including the Yellow Dot protocol etc. were requested from the Director of Nursing (DON) on 9/22/21 at 9:56 A.M. Review of an email communication sent by the DON on 9/22/21 at 11:21 A.M. reflected an explanation of the Yellow Dot protocol, Yellow Dot - is a tool we use to identify those who are at highest risk for falling when left up in a chair unsupervised. No formal protocol for the facility's Yellow-Dot protocol was provided. Review of incident and accident reports for R83 for the date range 5/13/21-7/23/21 reflected the following: -On 5/13/21 at 10:30 A.M., R83 had an unwitnessed fall in the resident's room without injury. According to the report, R83 had been lying in bed and appeared to be sleeping 30 minutes prior to the fall. The resident told staff he was trying to take himself to the bathroom. A General Progress Note dated 5/17/21 detailed an IDT (interdisciplinary team) Fall review and reflected Resident impulsive and will not ask for assistance. A therapy screen was requested as an intervention to prevent future falls. -On 5/14/21 at 7:29 A.M., R83 had an unwitnessed fall in his room without injury and was found kneeling on the floor, with the rest of his body on his bed. The resident was unable to state what happened. A General Progress Note dated 5/26/21 detailed an IDT Fall review and reflected Had grippys on. Resident will self-transfer. Grippy Strips to be applied to the floor as an intervention to prevent future falls. -On 6/12/21 at 2:50 P.M., R83 had an unwitnessed fall in the doorway of his room without injury. R83 reported he was trying to unplug something. Review of a General Progress Note dated 6/17/21 detailed an IDT fall review and reflected [R83] had been sitting in his chair prior. Floor was dry, resident had grippy socks on . increased confusion this shift . R83 was encouraged to come out into common area, in addition to having STAT (urgent) labs drawn related to R83's increased confusion. -On 7/4/21 at 4:40 P.M., R83 had an unwitnessed fall in his room without injury. R83 was unable to state what happened. Review of a General Progress Note dated 7/13/21 detailed an IDT fall review and reflected R83 had apparently attempted to self-transfer from his bed to his recliner chair. The IDT review indicated R83 Had shoes on. Resident did not use his walker. Self-transferred to his recliner and lost balance. A soft touch call light was to be placed next to R83 to alert staff of attempts to get up unassisted. -On 7/23/21 at 12:51 P.M., R83 had an unwitnessed fall in the bathroom and sustained a right [CONDITION(S)]. Review of a General Progress Note dated 7/28/21 reflected an IDT fall review that indicated Resident can be confused and impulsive at times .x-ray ordered and showed right [CONDITION(S)]. Was sent out to hospital. [R83] readmitted under hospice care . The intervention added to the plan of care was for R83 to wear grippy sock at all times. -On 7/29/21 at 5:45 A.M., R83 had an unwitnessed fall in his room. R83 was unable to describe what happened. Review of a General Progress Note dated 8/3/21 detailed an IDT fall review that indicated Resident has a recliner next to his bed. Roommate sitting in recliner. Resident was confused and attempted to get up. Resident is under hospice care. Is impulsive. Has a right [CONDITION(S)]. All interventions were in place. Intervention was to remove recliner from resident's room. Mat added next to bed. Bed in ultra-low position. Review of a Care Plan Report initiated on 3/9/21 reflected [R83] is at risk for falls r/t failure to thrive, new environment, dementia, DM2, self-transfers/ambulates, hearing loss, OSA (obstructive sleep apnea). Resident is impulsive and will not wait for assistance. Will refuse at times to come out of room, will move call light. The goal of the care plan focus area was for R83 to remain free from fall related injury. Some active interventions were contradictory, as evidenced by the following: (a) Be sure call light is within reach, provide cueing and reminders for use as appropriate due to level of cognition, Resident has standard call light, able to use-initiated on 3/9/21; (b) soft-touch call light next to resident (no further instructions provided)-initiated on 7/4/21. Further review of the Care Plan did not reflect any interventions or approaches were in place to address R83's impulsive nature or cognitive impairments. The care plan did not specify R83's assessed high risk for falling nor mention the Yellow Dot protocol described by the DON, despite all falls occurring while in his room/chair and unsupervised. Review of a Care Plan Report reflected [R83] had an ADL self-care performance deficit r/t (related to) dementia, failure to thrive, [CONDITION(S)], DM2 (type 2 diabetes), and hearing loss . initiated on 3/9/21, revised on 9/13/21. The goals of the Care Plan, initiated on 3/9/21 and revised on 8/3/21 were for R83 to maintain his current level of function and participate in ADL tasks with therapy services as ordered to maintain prior level of functioning. Interventions to meet the stated goals included Ambulation with 1 assist RW (rolling walker); Transfers: 1 assist with R/walker needs encouragement and were not initiated until after R83 returned from the hospital with a fractured right hip on 7/25/21 and were Resolved on 7/28/21. There was an intervention added on 5/18/21 PTV (prompt to void) but did not elaborate on how frequently R83 would need prompting. Review of a Care Plan Report reflected that on 3/9/21 R83 was assessed as having Limited physical mobility related to dementia, failure to thrive, [CONDITION(S)], diabetes and hearing loss. The goal of the care plan was for R83 to maintain his current level of mobility with increases as able, with participation in therapy and/or nursing with interventions that included Transfer: 1 assist with 2WW (2-wheeled walker) and gait belt. The intervention was not resolved until 7/28/21 after R83 sustained right [CONDITION(S)] after a fall at the facility. Review of Braden Scale for Predicting Pressure Sore Risk assessments dated 7/25/21, 8/12/21 and 8/20/21 reflected that R83 had a moderate risk for developing a pressure sore. Review of a Care Plan Report reflected that when R83 admitted to the facility on [DATE], a care plan focus area read Resident has potential to skin integrity r/t dementia, DM2 (type 2 diabetes), PVD ([CONDITION(S)]), self-transfers, failure to thrive. The goal of the care plan was Resident will maintain intact skin with no breaks in skin through the next review date. Interventions to reach the goal of maintaining intact skin were: (a) Educate resident/family/caregivers of causative factors and measures to prevent skin injury, (b) Encourage good nutrition and hydration in order to promote healthier skin, (c) Observe skin daily with care activities, report any changes in coloration/integrity etc., to nurse, and (d) Resident needs pressure reduction interventions: (SPECIFY-mattress type, specialty bed, wheelchair cushion, etc.). The care plan did not specify any pressure reducing interventions. Further review of the entire Care Plan Report revealed facility staff had identified focus areas that included: Resident has limited physical mobility r/t (related to) dementia, failure to thrive, [CONDITION(S)], DM2, and hearing loss; None (sic) weight bearing with the goal of keeping R83 comfortable and an intervention to reposition for comfort. The Care Plan Report did not reflect that facility nursing staff had care planned R83's assessed risk for pressure ulcers due to his lack of mobility and being completely bed bound with new bowel incontinence. During a telephone interview on 9/13/21 at 1:54 P.M., R83's Family Member (FM) XX reported that she had just come from the facility after having assisted R83 with his noon meal. FM XX said that she would like to see R83 get out of bed, explaining that he has been bed-bound ever since he broke his hip in a fall at the facility on 7/23/21. FM XX said she had made the suggestion to the hospice staff that see R83 but had not told staff at the facility because they are so busy. FM XX said it was concerning to her because he had a little bedsore on the top of his tailbone, and she would like that treated. During an observation and interview on 9/14/21 at 12:09 P.M., Licensed Practical Nurse (LPN) L said she was not aware of any open areas on R83's coccyx and agreed to assess R83's skin. CNA I assisted in positioning R83 and reported being aware of an open area on R83's coccygeal area and had reported it to another nurse (LPN J) a few weeks ago. Upon entering the room, R83 agreed to the observation and CNA I pointed to individual packets of ointment the CNAs were putting on the open area on R83's coccygeal area. LPN L reported the area was indeed open and measured a 1.0 cm x 0.5 cm area. Additional assessment of R83's skin revealed a small, reddened area on the left second toe, the skin on R83's feet was very dry. Resident #104 (R104) Review of an Admission Record reflected R104 originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS assessment dated [DATE] reflected R104 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 2/15. R104 needed extensive assistance from two people for bed mobility, transfers, walking in a room or in a corridor, toilet use and personal hygiene. Review of a Care Plan Report initiated on 6/22/2019, last revised 6/29/21, reflected R104 had an ADL self-care performance deficit related to weakness, dementia, [R104] can be combative with cares, R104 was 1 assist with bathing and dressing, was independent with transfer and assist as needed and toileting with staff cueing and supervision. Will get combative when staff attempt to assist . The goal of the care plan was for R104 to participate in ADL tasks with interventions that specified AMBULATION: Extensive 2 assist with walking; resident able to ambulate with 2 assists to the dining room. An active care plan intervention conflicted with the Care Plan Focus area statement that the resident was independent with transfers and reflected TRANSFERS: 2 assist tires easily was initiated on 6/23/2019 and revised 4/07/2021. Review of a hospice Care Plan P070: Safety/Fall Prevention reflected the goal was to have R104's safety maintained as evidenced by patient free from injury due to fall through 10/9/2021. An intervention to attain the goal was for Staff to provide 2 person assist with gait belt for ambulation and transfers. During an observation on 9/22/21 at 8:52 A.M., LPN K and CNA I transferred/ambulated R104 from her room to a chair located down the hall several yards away, across from the main dining room. LPN K and CNA I did not use a gait belt, instead, supported/lifted the resident under her arms while the resident did not bear full weight on her legs and feet. Resident #113 (R113) Review of an Admission Record reflected R113 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS report dated 8/26/2021 reflected R113 was cognitively intact as evidenced by a BIMS score of 15/15 and needed extensive assistance from two people for bed mobility, transfers, dressing and personal hygiene. During a telephone interview on 9/24/21 at 10:24 A.M., LPN OO reported helping an unknown CNA with transferring R113 from the bed to the commode using a slide board. LPN OO said that at no time did R113 fall but did describe R113 not being any assistance during the transfer and having to literally drag R113 across the slide board to the commode. LPN OO said R113 was care planned to transfer using the slide board as far as LPN OO was aware but did not look at the care plan to confirm R113's transfer status. During a telephone interview on 9/24/21 at 10:36 A.M., CNA D reported that an unknown CNA had come to her asking for assistance with transferring R113, but another call light went off and was unable to help, so the unknown CNA requested the assistance of LPN OO. According to CNA D, LPN OO did assist the unknown CNA in transferring R113 from her bed to the commode and after completing that transfer, LPN OO asked CNA D to complete the transfer of R113 from the commode back to bed because the first transfer did not go well. According to CNA D, a gait belt was used for the second slide board transfer back to bed because without it, (R113) could have fallen. CNA D indicated the transfer status was reflected on the Kardex (care guide), but that the transfers with R113 were very rough because the resident would not help at all, and staff would have to use a lot of muscle. Review of PT-Therapist Progress & Updated Plan of Care, dated 8/29/21 for R113 for review dates 8/01/2021-8/30/2021 and signed by Physical Therapist (PT) RR, reflected R113's prior level of functioning for transfers from bed to chair was minimal assistance (1-25% assist). According to the form, R113's current level of functions as of 8/29/21 was dependent (100% assist). During an interview on 9/24/21 at 10:51 A.M., Occupational Therapist (OT) QQ indicated completing an initial therapy transfer status evaluation for R113 on 7/30/21, the day R113 admitted to the facility. According to OT QQ, R113 was able to complete the slide board transfer with one assist but was under the impression that staff had downgraded R113's transfer status to Hoyer (full mechanical lift) a few months ago due to her refusal to assist with slide board transfers. OT QQ said that in the times that she worked with R113 since the initial assessment, R113 had been using the bed pan for elimination. During an interview on 9/24/21 at 10:55 A.M., PT RR reported not working the day R113 admitted to the facility and that the times she worked with the resident, R113 was using a bed pan for elimination and said it was her understanding that staff had downgraded her from a slide board transfer to a Hoyer transfer, but a communication had not been made about it. PT RR reported that in any case, anytime a staff assists a resident with a transfer or with ambulation a gait belt is to be used. PT RR said that R113 would often refuse to complete slide board transfers with nursing staff but would do it for therapy staff. Review of a Care Plan Report that included resolved/discontinued focus areas and interventions reflected R113 Had an ADL self-care performance deficit r/t BKA (below the knee amputation) of left leg. I will refuse care, treatment, assessments, and therapy at times despite education and encouragement from staff. The goal of the care plan was for R113 to participate in ADL tasks with therapy services as ordered to attain and maintain prior level of function. Interventions included, TOLIET USE: 2 assist with Hoyer, initiated on 5/24/21 and revised on 8/27/21. No evidence R113 was ever a slide board for transfers was found anywhere in the care plan. Statement B. Based on observation, interview, and record review the facility failed to implement the comprehensive care plan for a deconditioned and medically compromised resident (Resident #9 ) and implement measures to improve or maintain mobility, resulting in degradation of a sacral skin condition which progressed to a stage 4 pressure sore, further preventing the resident from obtaining the highest practicable level of well-being and the potential for all facility residents dependent on staff for mobility from reaching their highest practicable well-being. Findings: Resident #9 (R9) was originally admitted to the facility 7/24/20 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Section M titled skin conditions dated 2/19/21 reflected R9 did not have a Stage 1 or greater pressure sore. The Braden Scale assessment (an industry method of predicting pressure sore risk) dated 3/4/21 reflected a score of 13 which indicated R9 was at moderate risk for developing pressure sores. Review of the medical record revealed a Progress Note entry dated 2/8/21 at 2:42 P.M. that reflected R9 was readmitted following an extended admission for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Note did not reflect measurements. The Progress Notes later reflected R9 was admitted to the hospital on 2/19/21 and returned to the facility on [DATE] with a dressing on the sacrum. On 2/26/21 three Progress Note entries (2:07 PM, 2:09 PM, and 2:11 PM) reflected three wound evaluations on the sacrum and left and right buttocks with measurements. All entries described the wounds as MASD. Review of the hospital documentation dated 2/19/21 reflected R9 arrived at the ED with a large sacral decubitus ulcer that included a photograph of the ulcer and a large area of possible MASD. The hospital documentation reflected that the sacral decubitus ulcer and surrounding [CONDITION(S)] as a possible source of [CONDITION(S)]. Despite the hospital physician's documentation and photograph on 2/19/21 of the decubitus ulcer, facility documentation after 2/25/21 consistently reflected that R9 wounds are MASD. The EMR (electronic medical record) Progress Notes reflect R9 was transferred to the hospital on 4/29/21 and returned to the facility on [DATE]. The EMR Progress Notes revealed a wound assessment, dated 5/5/21 at 9:20 PM, Wound location is Sacrum. Wound measurements .Length-5.4 centimeters (cm), Width -3.7 cm, Depth - 4.5 cm (approx. 1 ½ inches in depth). A Progress Note entry on 5/5/21 at 11:16 PM further describes the wound on the sacrum as, sacrum , stage 4, undermining present, slough . hanging off ., Bones and tendons are exposed EMR Medical Provider documentation of 5/12/21 at 1:45 PM reflected that R9 was hospitalized [DATE] for [CONDITION(S)] probably related to a stage IV sacral wound, . prognosis for (R9) is poor. The following Care Plan and EMR Progress Note review was confined to the dates from 2/8/21 to 4/29/21 during which time degradation of the sacral wound is documented. On 2/26/21 total sacral wound area was documented as 2.8 cm2 with a depth of 0.2 cm . On 4/20/21 the total area was documented at 7.8 cm2 and 1.3 cm in depth. Review of the care plan titled, Resident has limited mobility related to . was reviewed with a goal of Resident will maintain current level of mobility with increase as able with participation in therapy and/or nursing through review date. Initiated on 2/10/21, canceled on 2/22/21, and reinstated on 2/25/21 and canceled again on 4/29/21. The Care Plan reflects interventions that R9 was full weight bearing, with a transfer status of Dependent with Hoyer (lift) and two staff assist, provide mobility assistive devices for mobility; Geri chair implemented on 2/10/21 with cancellations and reinstated as listed above. Review of the EMR Progress Notes from 2/8/21 to 4/29/21 did not reveal R9 was transferred out of the bed or that attempts were made to promote full weight bearing or use of the Geri chair despite Care Planned interventions to do so. The Progress Notes did not reveal efforts were implemented to, maintain current level of mobility with increase as able, nor was documentation found in the Progress Notes that the interventions were attempted or why it had not be implemented. Review of the Care Plan titled Resident has potential/actual impairment to skin integrity (related to) old ([CONDITION(S)]) site to neck . MASD both buttock . initiated 2/10/21, canceled 2/22/21, reinstated on 2/25/21, and canceled on 4/29/21. Interventions included Resident needs pressure reduction interventions: wheelchair cushion and pressure reduction mattress with similar revision and cancellation dates as above. And Blue Dot Protocol: Frequent assisted repositioning, initiated 3/11/21 and canceled 4/29/21. An observation was conducted 9/22/21 at 7:28 AM of a common area room next to the room of R9. The room appeared to be as being used as storage room for several wheelchairs and walkers. One Geri-type chair was observed to be tagged with the name of R9. A Roho- type (pressure reducing) cushion lay in the seat of the chair labeled for R9. The industry Standard of Care for turning and repositioning of all Long-Term Care residents is every two hours. It was observed that R9 has a Blue Dot turning protocol in place, which facility staff reported meant repositioning every two hours (standard of care). Review of an email communication sent by the DON on 9/22/21 at 11:21 AM reflected an explanation of the Blue Dot protocol, Blue Dot - is a tool we use to identify those who are at highest risk and need frequent assisted repositioning. No formal protocol for the facility's Blue-Dot protocol was provided. On 9/23/21 at 10:53 AM an interview was conducted with the DON and Nurse Practitioner (NP) LL to discuss the progression of R9 wounds. NP LL acknowledged that keeping pressure off a compromised area was important. NP LL reported that R9 resists position change. The DON indicated that the Care Plan of R9 had been revised to achieve a goal regarding repositioning. Review of the Care Plan that contained the intervention of the Blue Dot Protocol reflected the revision that R9, Will refuse or decline assistance with repositioning. However, the medical record reflected this was not initiated as part of the Blue Dot Protocol intervention until 5/5/21 which was after the focus area of 2/8/21 to 4/29/21 and after the hospitalization of 4/29/21. Review of the EMR Progress Notes for R9 from 2/8/21 to 4/29/21 reflected one entry on 3/9/21 that R9 was resistive to repositioning. No other documentation was found that indicated R9 was non-compliant with the Blue Dot Protocol of frequent assisted repositioning as described by the DON. Observations documented on 9/21/21 revealed R9 was not turned or repositioned off his back from 9:33 AM to 3:00 PM with observations documented at 9:33 AM, 10:52 AM, 11:45 AM, 1:08 PM, and 3:00 PM. It was observed that the three pillows on the bed of R9 had not moved or had been repositioned during any of these times. While these observations were made outside of the 2/8/21 to 4/29/21 time frame it is reflective of the diligence of the implementation of the Blue Dot Protocol for R9. The focus time frame ended on 4/29/21 followed by the hospital admission that day for [CONDITION(S)] related to the documented stage 4 wound. The wound measurements described in the EMR Progress Note of 5/5/21 on readmission to the facility, reveal the severity of treatment that required hospitalization . The documentation of the medical record did not reflect adherence and diligent implementation of the Care Plan for a dependent and compromised Resident.

Based on observation, interview, and record review, the facility (A) failed to prevent the spread of COVID 19 on the 500 hall for six Residents (Resident #85, Resident #43, Resident #41, Resident #117, Resident #109, and Resident #7) resulting in multiple residents testing positive for COVID 19 and potential for all residents on that unit to become COVID 19 positive, (B) Failed to maintain a clean urinary drainage system for one Resident (Resident #105) resulting in the potential for the transmission of fecal matter to frequently used resident equipment, and (C) Failed to provide sanitary dining services for one Resident (Resident #104), resulting in the potential for contaminated food. Findings include: COVID 19 Outbreak 500 hall According to the facility COVID 19 Contact Tracing Questionnaire Tool-Resident, dated 9/9/21, a resident became positive when staff tested them as part of an outbreak. This resident was moved from room [ROOM NUMBER] to 512. Two days later, on 9/11/21, Resident #7 (R7) tested positive for COVID 19. R7's room (room [ROOM NUMBER]) was located diagonally from room [ROOM NUMBER]. R7 was moved to room [ROOM NUMBER] on 9/11/21. During an observation on 9/12/21 at 10:00 AM, Certified Nursing Assistant (CNA) VV reported that they were just told by management staff that full Personal Protective Equipment (PPE) needed to be worn in every room. CNA VV exited room [ROOM NUMBER] wearing full PPE, including N95 mask, face shield, plastic gown, and gloves. No signage was located near room [ROOM NUMBER] (the room that Resident #117 occupied) that noted what PPE was required to enter the room. The door to room [ROOM NUMBER] was left open, which located across from room [ROOM NUMBER] (a COVID 19 positive room). During an interview on 9/12//21 at 10:05 AM, Licensed Practical Nurse (LPN) V confirmed that staff had received notice from the facility management team that full PPE was required when entering all resident rooms on the 500 hall. During an observation made on 09/12/21 at 11:39 AM, STOP SPECIAL DROPLET/CONTACT PRECAUTIONS signs were noted outside some resident rooms on the 500 hall. The signs instructed the reader to perform hand hygiene, wear a face mask and eye protection and to gown and glove prior to entering the resident room. This sign read, KEEP DOOR CLOSED. There was no sign outside room [ROOM NUMBER] indicating which PPE was required to safely enter the resident room. During an interview on 9/12/21 at 12:09 PM, Licensed Practical Nurse (LPN) P stated that all residents testing negative on 500 hall were moved to Rooms 500 to 507 and those testing positive were placed in Rooms 509 and above, to keep them distanced. Resident #41 in room [ROOM NUMBER], and Resident #109 in room [ROOM NUMBER], had not tested COVID positive. LPN P confirmed this observation. According to the facility COVID 19 Contact Tracing Questionnaire Tool-Resident, dated 9/13/21, Resident #85 tested positive for COVID 19 and was moved from room [ROOM NUMBER] to 510. room [ROOM NUMBER] was next to and shared a bathroom with the first COVID 19 positive resident from four days earlier. Observations on 9/13/21 at 7:44 AM revealed Resident #7's (COVID 19 positive resident) door (room [ROOM NUMBER]) was open to the hallway, Resident #7 was observed from the hall to be in bed and a deep, dry cough was noted. Doors to rooms [ROOM NUMBERS] and located across the hallway from room [ROOM NUMBER], were also open. A sign was on the doorways to rooms [ROOM NUMBER], that indicated the doors should be kept shut. An observation made on 9/13/21 at 8:02 AM, LPN V entered room [ROOM NUMBER] without donning gown or performing hand hygiene, exited the room, and grabbed the medication cart to move it down the hall. LPN V was then observed to use hand sanitizer. That same day according to a COVID 19 Contact Tracing Questionnaire Tool-Resident, dated 9/13/21, Resident #41 tested positive for COVID 19. Resident #41 resided in room [ROOM NUMBER] and across the hall from COVID 19 positive rooms [ROOM NUMBERS]. Observations on 9/13/21 at 7:53 AM revealed Resident #43 in room [ROOM NUMBER] with a deep, dry cough, the door was open to the hallway. This room was located directly across the hall from the first COVID 19 positive resident from four days earlier. Resident #43 was sent to the emergency roiagnom on [DATE] and returned to the facility the next day with a COVID 19 diagnosis. On 9/13/21 at 1:56 PM a deep, dry cough was noted coming from Resident #7 (R7) in room [ROOM NUMBER]. R7's door was open to the hallway. Staff had posted a sign on the door indicating that it should be shut. Resident #117 resided in room [ROOM NUMBER] on 9/12/21 when a COVID 19 positive resident was moved across the hall, staff later moved Resident #117 to the other end of the unit, to room [ROOM NUMBER]. When Resident #117's COVID 19 test came back positive on 9/16/21, staff moved Resident #117 to room [ROOM NUMBER] (and across from original room). During an interview with the Director of Nursing (DON) on 9/13/21 at 4:45 PM, when asked about open doorways to COVID 19 positive room, the DON reported staff were leaving them open due to residents being a high fall risk and to keep room temperatures lower. During an observation on 9/15/21 at 7:27 AM, staff had left Resident #85's and R7's (both COVID 19 positive) doors open to the hallway. room [ROOM NUMBER] did not have a sign on the door indicating staff were required to wear additional PPE (gown and gloves) when entering the room. rooms [ROOM NUMBERS] had signs on the door indicating they should be shut; however, the doors were open. On 9/21/21 Resident #109 in room [ROOM NUMBER] tested COVID 19 positive. room [ROOM NUMBER] was diagonal from room [ROOM NUMBER] which had COVID 19 positive residents since 9/13/21. During an interview on 9/23/21 at 3:47 PM, the Infection Control Nurse (also DON), when discussing the above outbreak pattern and concerns with doors left open, the DON stated that the doors were left open when residents are a high fall risk and to keep the rooms cooler when residents complained of room being too warm (R 7). The DON also stated that the curtains should have been pulled and that there was still more than 6 foot physical distancing between residents. The DON also reported that all doors should have signs indicating what PPE was necessary for each room and claimed that one reason for missing signs are that they may fall off doors. R7 According to the Minimum Data Set (MDS) assessment, dated 6/12/21, R7 admitted to the facility with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This same assessment indicated R7 required assistance of staff for moving in bed, transferring, and hygiene needs including using the bathroom. Staff assessed R7 as cognitively intact, and R7 made their own health care decisions. R7 admitted to the facility on [DATE]. During an interview on 9/12/21 at 12:01 PM, R7 reported that she was scared. She reported receiving the vaccine for COVID 19 and was fully vaccinated and now as of last Friday, test positive for COVID 19. R7 stated it felt like a head cold but reported she was otherwise asymptomatic. R7 further reported that she was admitted to the facility for physical therapy and was supposed to be going home soon. R7 expressed concerns about how this COVID 19 infection would impact her ability to return home as planned. During a follow up interview on 9/15/21 at 2:35 PM, R7 was teary and anxious. R7 reported the facility was transferring her to a facility in (another city almost 3 hours away) and that she needed to pack her stuff. R7 became short of breath and was encouraged to relax and breath. After several moments R7 remained tearful and stated that facility management staff told her that she was being transferred and R7 stated that she told them she did not want to go. R7 asked this surveyor if she had to go if she did not want to and claimed she had been sick for five days already in this facility. R7 questioned if she would have to start the quarantine over once arriving to the new facility. This surveyor queried the DON and reported back to R7 that she would not have to start quarantine over and that she would return to this facility once her 10 days were over. R7 counted the days and claimed she would return to this facility on 9/20/21. R7 became less tearful but remained anxious regarding the transfer to a different facility. During on observation on 9/21/21 at 7:30 AM, R7 was not located in the building. That same day at 11:00 AM the DON reported that R7 would not be returning to the facility until the following Monday (9/27/21) due to transportation availability. Social Service progress notes dated 9/14/21 and located in R7's electronic medical record (EMR) read, Late entry from yesterday 9.13.21. This SW (Social Worker) meet with res. (resident) to talk over the plan r/t (related to) COVID positive and needed to transfer to COVID CRC (covid receiving center) unit for quarantine days then return. SW shared when/where this will likely occur Wednesday/(name of facility)). She was upset/sad and tearful. SW stayed with res. And talked through options as she was considering going home ASAP, even AMA alone. SW talked her through why this was a bad idea, another note read that same day from Social Services indicated that R7 would be leaving the facility on 9/15/21 at 4:00 PM. That same afternoon, another note read, SW meet up with res again today to monitor mood and anxiety related to upcoming transfer. She shared she is doing a little better. Then was tearful and anxious, SW documented following up with the Nurse Practitioner following this encounter. Social Services progress notes dated 9/15/21 indicated that R7 was notified of [MEDICATION(S)] (a medication for anxiety) was increased because of increased anxiety. Notes read, She was thankful, but still shared she is struggling. She was tearful again. Then she shared she wanted it noted that she does not what(sic) to go, support was provided and resident asked if she could refuse to go. Clarification was provided on quarantine period of 14 days from positive COVID 19 test and that because the facility did not meet criteria to retain own COVID positive residents, R7 wound need to be transferred to another facility for the remainder of the quarantine period. Another progress note dated 9/21/21 indicated R7 would be leaving to return to the facility 9/27/21 at 2:00 PM (12 days). Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/15/21 [MEDICATION(S)] 50 mg was ordered every 8 hours, and per the September 2021 Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #105 Review of an Admission Record revealed R105 was a [AGE] year-old male, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R105 had a foley urine collection system in place. A Minimum Data Set (MDS) assessment, completed 07/26/21, reflected R105 required extensive assistance from staff for bed mobility, transfers, and going to the bathroom. Review of a Brief Interview for Mental Status (BIMS) revealed a score of 15 out of 15, which indicated that R105 was cognitively intact. During an observation on 09/14/21 at 11:47 A.M., R105 laid in bed, resting with eyes closed. The urine collection bag for the foley catheter laid on the floor. Fecal matter was visible on the white back portion of the urine collection bag. During an observation on 09/14/21 at 3:24 P.M., R105's urine collection bag had smeared fecal matter on the white back portion of the bag. During an observation on 09/15/21 at 4:07 P.M., R105's urine collection bag sat in a privacy cover and upon inspection, fecal matter was smeared on the back white portion of the bag. During an observation on 9/22/21 at 8:52 A.M., Certified Nurse Aide (CNA) I leaned over R104 while assisting the resident with food set up. CNA I offered unwrapped sandwiches with bare hands to R104 while standing over the resident.

This citation is related to intake #MI00- 8 and will have 2 deficiency practice statements. DPS #1 Based on observation, interview, and record review, the facility failed to provide coordinated quality care for 1 resident (Resident #69), resulting in, (a) the development of increased swelling and blisters in both legs,when staff were not available to assist R69 back to bed, (b) the need for steroid use and an increased dose of an already prescribed diuretic, to treat the increased swelling and newly formed blisters, (c) administering the increased dose of diuretics outside physician ordered parameters, and (d) lack of monitoring and treatment orders for the blisters acquired Resident #69 (R69) Review of an Admission Record revealed R69 was an [AGE] year old male, admitted to the facility on ,d+[DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R69 did not have a guardian and was cognitively intact. During an interview on 09/15/21 at 9:20 A.M., R69 reported the following information related to an incident on 08/03/21: (a) was up in the electric wheelchair around 11:00 A.M., while therapy made adjustments, (b) therapy completed the adjustments and evaluation and R69 remained up in the wheelchair until approximately 2:00 P.M., (c) at that time (2 P.M.) R69 asked to be put back into bed because both legs were unsupported, just hanging free with no support, (d) R69 did not receive assistance to get back to bed until approximately 7:00 P.M., and (e) developed several large [CONDITION(S)] blisters during the time when both legs were hanging down and unsupported. During an interview on 09/15/21 at 9:10 A.M., Occupational Therapist (OT) QQ indicated that on 08/03/21 around 11:00 A.M., the following occurred: (a) OT QQ wanted to get R69 out of bed and into the electric wheelchair to evaluate positioning in the new wheelchair and no staff were available to help with the 2 person hoyer transfer, (b) OT QQ finally got help from another therapy staff person and transferred R69 into the electric wheelchair, (c) OT QQ completed the evaluation, made some needed adjustments and spent approximately 1 hour with R69, (d) R69 remained in the wheelchair (per the request of R69) when OT QQ exited the room, and (e) OT QQ contacted the wheelchair company after the evaluation with R69, because the wheelchair did not provide adequate support for R69 and additional adjustments would need to be made. Review of a Care Plan for R69 reflected the following intervention related to decreased mobility: Encourage and assist resident to change position throughout the day to prevent respiratory complications, dependent [CONDITION(S)], flexion deformity and skin pressure areas. Review of a Progress Note for R69, dated 08/04/21 at 9:55 A.M., reflected: Teds (compression stockings worn to help reduce swelling in the lower legs) on at AM and off at HS (bedtime) everyday and evening shift for [CONDITION(S)], off today due to fluid filled blister on leg. MD aware. Review of a Progress Note for R69, dated 08/04/21 at 11:51 A.M., revealed Late entry, during care conference resident (R69) expressed delay in receiving assistance back into bed from the wheelchair. Review of a Progress Note for R69, dated 08/04/21 at 1:14 P.M., revealed R69's blisters on right lower leg and left foot are intact at this time. Nurse Practitioner (NP) YY aware and observed the blisters. Review of a Progress Note for R69, dated 08/04/21 at 1:25 P.M. reflected that [MEDICATION(S)] was ordered for the blisters on right lower leg and left foot. Review of a facility Incident Report for R69, dated 08/04/21 at 4:00 P.M. and completed by Licensed Practical Nurse-Unit Manager (LPN-UM) AA, revealed the following: (a) during care conference resident alleged delay in care when requesting to be laid down, (b) no injuries were observed at time of the incident, (c) no injuries were observed post incident, (d) it was determined that the alleged delay in care occurred, and (e) summary- R69 up in chair at 11 A.M., rang at 2 P.M. to get into bed, staff were assisting other residents, and R69 was laid down around 6 P.M. No documentation of the [CONDITION(S)] or blisters were located in the Incident Report. Review of a Progress Note for R69, dated 08/04/21 at 6:11 P.M. revealed R69 continues to have fluid filled blisters to bilateral lower extremities. RLE (right lower extremity) has 6 blisters in total, one large, 1 medium and 4 small. Right foot has 1 large blister. Left foot has three blisters in total with 2 medium blisters and 1 large blister. Review of an Electronic Treatment Administration Record (Etar) for R69, dated 08/01/21 to 08/31/21, did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A treatment order was put in place for one blister, located on R69's right shin, after it ruptured on 08/17/21. Review of an Electronic Medication Administration Record (Emar) for R69, dated 08/01/21 to 08/31/21, reflected the following changes in medication orders needed to treat R69's increase in bilateral lower extremity [CONDITION(S)] and the new onset of blisters: (a) discontinue routine dose of [MEDICATION(S)] (diuretic) 20 mg (milligrams) once daily on 08/05/21 at 3:30 P.M., (b) discontinue routine dose of [MEDICATION(S)] (a potassium supplements often administered with [MEDICATION(S)], a loop diuretic) 10 meq (milliequivalants) daily on 08/05/21 at 3:41 P.M., (c) start [MEDICATION(S)] (a steroid) taper for 12 days, ordered 08/05/21 for blisters, (d) start [MEDICATION(S)] 40 mg twice daily for lower extremity [CONDITION(S)] (4 x's the previous dose ordered), and (e) on 08/06/21, start [MEDICATION(S)] 10 meq two tabs twice daily (4 x's the previous dose ordered) for lower extremity [CONDITION(S)]. Review of a Nursing Skin Observation Tool dated 08/08/21, reflected that R69 did not have any new alterations in skin integrity since last review on 08/01/21. The blisters were not mentioned. Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Emar, dated 08/01/21 to 08/31/21, reflected that on 08/14/21 in the morning, R69's blood pressure was 99/59 and the [MEDICATION(S)] 40 mg tablet was administered to the resident. Also noted, on 08/27/21 in the morning, R69's blood pressure was 100/48 and the [MEDICATION(S)] 40 mg tablet was administered to the resident. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M., reflected that the resident continued to have 3+ [CONDITION(S)] to BLE, a blister to the right foot was intact, and scabbing was noted to RLE where a ruptured blister was. Review of a Progress Note dated 08/27/21 at 10:22 A.M., revealed (R69) has blisters on legs that would burst if Ted hose were put on. Review of a Skilled Nursing Note, dated 08/28/21 at 3:15 A.M., reflected the following nursing assessment for R69: (a) Does resident have skin condition or impairment- No, and (b) Did resident display any [CONDITION(S)] this shift- No. Review of an Emar, dated 09/01/21 to 09/30/21, reflected that on 09/01/21 in the morning, R69's blood pressure was 103/59 and the [MEDICATION(S)] 40 mg tablet was administered to the resident. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M., reflected that the resident continued to have quite edematous legs and some leg wounds. Review of a Progress Note dated 09/11/21 at 5:00 P.M. revealed (R69) has too much [CONDITION(S)] in BLE (bilateral lower extremities) for TED hose at this time. This citation pertains to intake MI 506 DPS #2 Based on observation, interview and record review, the facility failed to provide the necessary care and services to maintain the highest practical physical level of wellbeing for two residents (R 85 and 107) out of 34 sampled residents. This deficient practice resulted in unmet care needs when; 1. R 85 was left in wet bedding and developed skin impairments, and 2. staff did not prevent and/or treat constipation for R 117. Findings include: R 85 According to the Minimum Data Set (MDS) assessment, dated 8-9-21, R 85 had multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This same assessment indicated R 85 required extensive assistance of two staff members for moving in bed, transferring, and incontinence care. Staff assessed R 85 as severely cognitively impaired. R 85 was enrolled in Hospice services. During a care observation on 9-14-21 at 3:15 PM, with Hospice Aide O, R 85 was rolled onto her side and a reusable bed pad located under the resident had been wet and now had darkened edges indicating the pad was drying. R 85's coccyx and buttocks were varying shades of purple with areas of pink tissue. A border gauze dressing, undated and located on R 85's bottom, was loosened on the bottom edge and it was soiled with stool. On 9-14-21 at 6:15 PM, Confidential Informant (CI) Q stated that they had found R 85 laying on a wet pad with darkened edges in the past. CI Q stated that the darkened edges indicated that the pad had been wet long enough for it to begin drying. On 9-22-21 at 10:45 AM, R 85 was yelling out for help, no staff was observed in the hall. R 85 was laying on the bed and was heard clearly from the hallway. On 9-22-21 at 12:38 PM, R 85 was yelling out, help me, help me and was clearly heard from the hallway. Housekeeper R was in the hallway outside R 85's room and then entered another resident room without answering R 85's call for help nor obtaining assistance for R 85. When this surveyor asked from the doorway what was needed, R 85 stated that she needed to be cleaned up. During an interview on 9-22-21 at 12:42 PM, Certified Nursing Assistant (CNA) S stated that R 85 only refuses care when in pain and that if R 85 gets something for pain prior to cares then R 85 tolerates them better. Following this interview, Licensed Practical Nurse (LPN) P entered R 85's room to perform a dressing change. During this dressing change R 85 was incontinent of a large amount of urine and R 85 stated that she had been that way for four hours. The brief under R 85 was saturated. There were three open areas, one located on each of R 85's buttocks and one on R 85's coccyx, each approximately the size of a quarter. R 85 required multiple attempts to find a comfortable position following cares. Immediately following the observation, LPN P was interviewed. LPN P confirmed this assessment and had agreed R 85 was more alert and orientated today. Review of R 85's Skin Assessments dated 9-11-21 and 9-18-21 indicated R 85 had no new alteration in skin integrity. Review of R 85's September 2021 Treatment Administration Record (TAR) indicated on 9-12-21 afternoon staff began the following treatment: Apply Periguard (a medicated ointment) to buttock every shift for incontinent [CONDITION(S)]. Review of R 85's progress notes indicated on 9-16-21 R 85 had continued excoriation on buttock and required encouragement from staff to change wet brief. On 9-17-21 staff documented R 85's buttocks are peeling from moisture and [CONDITION(S)]. R 117 According to the MDS assessment, dated 9-2-21, R 117 was admitted with cardiac arrhythmias (irregular heart rate), heart failure, high blood pressure, end stage renal disease, and diabetes. Staff assessed R 117 as requiring extensive assistance of one staff member for moving in bed, transferring, and using the bathroom. R 117 was assessed as cognitively intact. R 117 was admitted to the facility on Hospice care. According to the Electronic Medical Record (EMR) Task: Bowel continence, R 117 did not have a bowel movement for 11 days, between early morning 9-4-21 until early morning on 9-15-21. Review of R 117's September 2021 Medication Administration Record (MAR) revealed R 117 was taking [MEDICATION(S)] (a constipating pain medication) three times daily and then every four hours beginning September 8th. That same day, [MEDICATION(S)] and Milk of Magnesia (medications to treat constipation) was discontinued. On September 7th, another medication to treat constipation, Senna-S, was discontinued for R 117. The physician did not order any medications or treatments to replace these discontinued medications. On 9-14-21, R 117 received a suppository and Milk of Magnesia to promote a bowel movement. On 9-15-21 at 11:00 AM and again on 9-21-21 at 8:21 AM, a request was made of the Director of Nursing (DON) for additional documentation related to R 117's bowel routine. No new information was received. Review of R 117's Care plans revealed a Resident at risk for Constipation care plan revised on 9-8-21. R 117's goal was to have a normal bowel movement at least every three days. Listed interventions included, Follow facility bowel protocol for bowel management and Monitor medication for side effects of constipation. Keep physician informed of any problems. In a follow up email on 9-21-21 at 8:24 to the DON, clarification was asked regarding facility protocol for bowel management. The DON replied that same day at 11:00 AM, We do not have a bowel management policy. We watch alerts (messages on the computer), assess (Resident's) for change in condition, and communicate with (the) provider as needed. On 9-21-21 at 3:15 PM, Hospice staff U reported that even though appetite may be poor, Hospice staff encourage patients to have a bowel movement every three days.

This citation pertains to intakes MI- 6, MI- 6 and MI- 8 Based on observation, interview and record review, the facility failed to ensure staff provided adequate supervision to prevent accidents, identify hazards, and safely transfer and ambulate residents for 4 residents (Resident #83, Resident #104, Resident #113 and Resident #123) resulting in (a) Resident #83 sustaining a fall and an inoperable right [CONDITION(S)] after being left alone in the bathroom, (b) Resident #104 being ambulated without a gait belt resulting in the potential for a fall and/or serious injury and (c) Resident #113 and #123 being transferred incorrectly by staff resulting in pain and emotional distress. Findings: Resident #83 (R83) Review of an Admission Record reflected Resident #83 (R83) originally admitted to the facility on [DATE] with pertinent diagnoses of unspecified dementia, adult failure to thrive, diabetes, sleep apnea, high blood pressure, weakness, hearing loss and cognitive communication deficit. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R83 had short- and long-term memory problems and required limited assistance from one person for transfers, walking, toilet use and personal hygiene. The assessment also indicated R83 was not steady moving from a seated to standing position and moving off the toilet. Section H - Bowel and Bladder reflected R83 did not use a catheter, did not require intermittent catheterization, was not on a toileting program (such as scheduled toileting, prompted voiding or bladder training) and was only occasionally incontinent of urine and never incontinent for bowel movements. Review of fall risk assessments completed for R83 upon his admission on 3/8/21, after falls occurring on 5/13/21, 5/14/21, 6/12/21, 7/4/21, and 7/23/21, upon readmission on 7/25/21 and after another fall on 7/29/21, reflected R83 was a High Risk for Falling. All policies and procedures pertaining to Falls, Fall Prevention/Fall Program and related protocols, including the Yellow Dot protocol etc. were request from the Director of Nursing (DON) on 9/22/21 at 9:56 a.m. Review of an email communication sent by the DON on 9/22/21 at 11:21 a.m. reflected an explanation of the Yellow Dot protocol, Yellow Dot - is a tool we use to identify those who are at highest risk for falling when left up in a chair unsupervised. No formal protocol for the facility's Yellow-Dot protocol was provided. Review of the facility policy Fall adopted 7/11/2018, reflected, It is the policy of this facility to evaluate extent of injury after a fall, prevent complications and to provide emergency care. The policy specified 6. Evaluate for cause of fall, e.g., wet floor, obstructed pathway etc. The policy did not address fall risk assessment, interventions and strategies to reduce a resident's risk for falling or conducting a meaningful evaluation of falls to identify interventions most appropriate to prevent future falls. Review of a facility policy Gait Belt-Transfer Belt dated 7/11/2018, reflected, It is the policy of this facility to: (a) Provide safety for the unsteady and/or confused resident. (b) Aid in the transfer of the dependent resident. (c) Prevent injuries to employees and residents (i.e., back strain or potential for chronic disability, resident falls or fractures). (d) Allow the resident and aide to feel more secure during a transfer. Review of incident and accident reports for R83 for the date range 5/13/21-7/23/21 reflected the following: -On 5/13/21 at 10:30 a.m., R83 had an unwitnessed fall in his room without injury. According to the report, R83 had been lying in bed and appeared to be sleeping 30 minutes prior to the fall. The resident told staff he was trying to take himself to the bathroom. A General Progress Note dated 5/17/21 detailed an IDT Fall review and reflected Resident impulsive and will not ask for assistance. A therapy screen was requested as an intervention to prevent future falls. -On 5/14/21 at 7:29 a.m., R83 had an unwitnessed fall in his room without injury and was found kneeling on the floor, with the rest of his body on his bed. The resident was unable to state what happened. A General Progress Note dated 5/26/21 detailed an IDT Fall review and reflected Had grippys on. Resident will self-transfer. Grippy Strips to be applied to the floor as an intervention to prevent future falls. -On 6/12/21 at 2:50 p.m., R83 had an unwitnessed fall in the doorway of his room without injury. R83 reported he was trying to unplug something. Review of a General Progress Note dated 6/17/21 detailed an IDT fall review and reflected [R83] had been sitting in his chair prior. Floor was dry, resident had grippy socks on . increased confusion this shift . R83 was encouraged to come out into common area, in addition to having STAT (urgent) labs drawn related to R83's apparent increased confusion. -On 7/4/21 at 4:40 p.m., R83 had an unwitnessed fall in his room without injury. R83 was unable to state what happened. Review of a General Progress Note dated 7/13/21 detailed an IDT fall review and reflected R83 had apparently attempted to self-transfer from his bed to his recliner chair. The IDT review indicated R83 Had shoes on. Resident did not use his walker. Self-transferred to his recliner and lost balance. A soft touch call light was to be placed next to R83 to alert staff of attempts to get up unassisted. -On 7/23/21 at 12:51 p.m., R83 had an unwitnessed fall in the bathroom and sustained a right [CONDITION(S)]. Review of a General Progress Note dated 7/28/21 reflected an IDT fall review that indicated Resident can be confused and impulsive at times . x-ray ordered and showed right [CONDITION(S)]. Was sent out to hospital. [R83] readmitted under hospice care . The intervention added to the plan of care was for R83 to wear grippy sock at all times. Review of a Care Plan Report initiated on 3/9/21 reflected [R83] is at risk for falls r/t failure to thrive, new environment, dementia, DM2, self-transfers/ambulates, hearing loss, OSA (obstructive sleep apnea). Resident is impulsive and will not wait for assistance. Will refuse at times to come out of room, will move call light. The goal of the care plan focus area was for R83 to remain free from fall related injury. Some active interventions were contradictory, as evidenced by the following: (a) Be sure call light is within reach, provide cueing and reminders for use as appropriate due to level of cognition, Resident has standard call light, able to use-initiated on 3/9/21; (b) soft-touch call light next to resident (no further instructions provided)-initiated on 7/4/21. Further review of the Care Plan did not reflect any interventions or approaches were in place to address R83's impulsive nature or cognitive impairments. The care plan did not specify R83's assessed high risk for falling or mention the Yellow Dot protocol described by the DON, despite all falls occurring while in his room/chair and unsupervised. Review of a Care Plan Report reflected [R83] has an ADL self-care performance deficit r/t (related to) dementia, failure to thrive, [CONDITION(S)], DM2 (type 2 diabetes), and hearing loss . initiated on 3/9/21, revised on 9/13/21. The goals of the Care Plan, initiated on 3/9/21 and revised on 8/3/21 was for R83 to maintain his current level of function and participate in ADL tasks with therapy services as ordered to maintain prior level of functioning. Interventions to meet the stated goals included Ambulation with 1 assist RW (rolling walker); Transfers: 1 assist with R/walker needs encouragement and were not initiated until after R83 returned from the hospital with a fractured right hip on 7/25/21 and were Resolved on 7/28/21. There was an intervention added on 5/18/21 PTV (prompt to void) but did not elaborate on how frequently R83 would need prompting. Review of a Care Plan Report reflected that on 3/9/21 R83 was assessed as having Limited physical mobility related to dementia, failure to thrive, [CONDITION(S)], diabetes and hearing loss. The goal of the care plan was for R83 to maintain his current level of mobility with increases as able with participation in therapy and/or nursing with interventions that included Transfer: 1 assist with 2WW (2-wheeled walker) and gait belt. The intervention was not resolved until 7/28/21 after R83 sustained right [CONDITION(S)] after a fall at the facility. Review of a General Progress Note dated 7/23/21 at 1:00 p.m., documented by Licensed Practical Nurse (LPN) J reflected, Observed resident sitting on floor between toilet and wall. CNA (Certified Nurse Aide) was in the room and resident just slipped off the toilet. Neuro checks and FROM (Full Range of Motion) done. No internal rotation or shortening to either leg. Denied pain or discomfort. Unable to get Hoyer (mechanical lift) into bathroom and resident assisted with three staff members to a standing position. Intervention is to ensure that resident have grippy socks on. Resident returned to chair and resident had breakfast. Review of a General Progress Note dated 7/28/21 at 12:41 p.m., documented by Registered Nurse (RN) N reflected an IDT fall review: Fall huddle was done. Nurse observed resident sitting on floor between toilet and wall. CNA was in the room doing cares with resident. Resident was sitting on the toilet. Had no grippy socks on due to getting washed up and ready. CNA went to get clothes and resident attempted to stand up and slipped off the toilet. Floor was dry. Resident with dx (diagnosis) of dementia, and [CONDITION(S)]. Resident can be confused and impulsive at times. Resident did complain of pain to right hip and head. Xray was ordered and showed fractured right hip. Was sent out to hospital. Resident readmitted under Hospice care. Resident remains comfortable. Will continue to anticipate resident's needs and collaborate with Hospice and change POC (plan of care) as needed. Grippy socks on at all times also added to POC. During an interview on 9/21/21 at 11:53 AM, Certified Nurse Aide (CNA) I reported she did not use a gait belt when she walked with R83 into the bathroom while R83 used a walker. CNA I said she left R83 in the bathroom sitting on the toilet, the walker was in the bathroom, with the door ajar as she went to get a brief from his closet. According to CNA I, R83 stood and fell in just a few seconds. CNA I said R83 was pretty confused that day-making comments about poison and aliens. According to CNA I, the day R83 fell and fractured his hip was her first day caring for him. CNA I reported she was told that R83 could transfer himself. When asked if it was alright to leave R83 alone in the bathroom, CNA I said that it was just common sense not to leave a resident in the bathroom alone. Review of hospital Imaging Results dated 7/24/21 at 1:50 a.m. reflected Findings: There is an acute displaced fracture present involving the basicervical right femoral neck with potential intertrochanteric component. The femoral head appears otherwise intact without significant [CONDITION(S)] changes. Left hip is unremarkable. Chronic changes of the right hemi pelvis noted. It is unclear whether not nondisplaced fractures of the right pubic rami are demonstrated, versus old, healed fractures. Impression: Acute displaced fracture involving the basicervical right femoral neck with potential intertrochanteric component. Discharge instructions specified R83 was non-weight bearing on the right leg and Foley catheter until no longer painful for bed rolls. Review of a hospital record dated 7/25/21 reflected Hospital Course: [R83] with a history of dementia and metastatic prostate CA (cancer) who resides in long term care presented to the ER (emergency room ) after a fall and right hip pain. His imaging noted a displaced right femoral neck fracture. He met SIRS (Systemic [CONDITION(S)] Response Syndrome, can be caused by trauma) criteria but had no source of infection. He was admitted for pain management and orthopedic consultation. His wife met with ortho and opted for a non-surgical management. A foley was placed for comfort and she met with hospice. He will return to his long-term care facility with hospice care for symptom management. Review of an Incident Report dated 7/29/21 at 5:45 a.m. reflected R83 had another unwitnessed fall in his room. The report reflected This nurse was in common area with other residents when heard a noise then resident talking, went to resident's room and observed him sitting on the floor at the bedside. Head resting against mattress and frame of bed. A General Progress Note dated 8/3/21 at 1:44 p.m. reflected IDT review: Fall huddle done. Resident was observed sitting on the floor at bedside. No injuries noted, Resident was last seen after 5:00 a.m. when catheter bag was emptied. He was asleep at that time in bed. Resident had his night clothes on. Floor was dry, Resident has a recliner next to his bed. Roommate was sitting in recliner. Resident was confused and attempted to get up. Resident under hospice care. Is impulsive. Has fx right hip. All interventions were in place. Intervention was to remove recliner from resident's room. Mat added next to bed. Bed in ultra low position. Will continue to anticipate resident's needs and collaborate cares with hospice. Will continue to change poc as needed. Resident #104 (R104) Review of an Admission Record reflected R104 originally admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, delusional disorders, heart failure, adjustment disorder, pain, overactive bladder and unsteadiness on feet. Review of a quarterly MDS assessment dated [DATE] reflected R104 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 2/15. R104 needed extensive assistance from two people for bed mobility, transfers, walking in a room or in a corridor, toilet use and personal hygiene. Review of a Care Plan Report initiated on 6/22/2019, last revised 6/29/21, reflected R104 had an ADL self-care performance deficit related to weakness, dementia, [R104] can be combative with cares, she is 1 assist with bathing and dressing, is independent with transfer and assist as needed and toileting with staff cueing and supervision. Will get combative when staff attempt to assist her . The goal of the care plan was for R104 to participate in ADL tasks with interventions that specified AMBULATION: Extensive 2 assist with walking; resident able to ambulate with 2 assists to the dining room. An active care plan intervention conflicted with the Care Plan Focus area statement that the resident is independent with transfers and reflected TRANSFERS: 2 assist tires easily was initiated on 6/23/2019 and revised 4/07/2021. Review of a hospice Care Plan P070: Safety/Fall Prevention reflected the goal was to have R104's safety maintained as evidenced by patient free from injury due to fall through 10/9/2021. An intervention to attain the goal was for Staff to provide 2 person assist with gait belt for ambulation and transfers. During an observation on 9/22/21 at 8:52 a.m., LPN K and CNA I transferred/ambulated R104 from her room to a chair located down the hall several yards away, across from the main dining room. LPN K and CNA I did not use a gait belt, instead, supported/lifted the resident under her arms while the resident did not bear full weight on her legs and feet. Resident #113 (R113) Review of an Admission Record reflected R113 admitted to the facility on [DATE] with diagnoses that included acquired absence of the left leg below the knee, end stage renal disease, dependence on renal [CONDITION(S)], chronic fatigue, low back pain, lack of coordination and cognitive communication deficit. Review of a quarterly MDS report dated 8/26/2021 reflected R113 was cognitively intact as evidenced by a BIMS score of 15/15 and needed extensive assistance from two people for bed mobility, transfers, dressing and personal hygiene. Review of an incident report dated 8/27/2021, documented by the DON, reflected Resident reported that night shift nurse and CNA dropped resident during a slide board transfer to the floor. Resident stated that the nurse and CNA stood over her laughing for 5 minutes taunting her to get herself up. Resident stated that she was crying and begging them to assist her up. Resident stated that they finally assisted her off the floor but didn't state if it was to her w/c (wheelchair), the bathroom or back to bed. Resident stated she did not incur any new injuries during the episode and no new skin injuries. Further review of the incident report and subsequent investigation revealed that staff assigned to care for R113 on the night of the alleged occurrence denied R113 fell but admitted there had been a difficult transfer. The DON documented According to staff interviews, [R113] was being assisted with a transfer from her bed to the commode using 2 assist with slide board. Staff report [R113] was not cooperating well and provided little to no assistance. About halfway through the transfer, while on the slide board she was fearful she was going to fall. The two staff, assisted by boosting her over from the slide board and onto the commode, avoiding a fall. Review of a facility Nursing Daily Attendance Report dated 8/26/2021 reflected LPN OO, LPN TT, and CNA D were working at the time of the incident reported to the DON by R113 on 8/27/21. During a telephone interview on 9/24/21 at 10:24 a.m., LPN OO reported she was helping an unknown CNA with transferring R113 from the bed to the commode using a slide board. LPN OO said that at no time did R113 fall but did describe R113 not being any assistance during the transfer and having to literally drag R113 across the slide board to the commode. LPN OO said R113 was care planned to transfer using the slide board as far as she was aware but did not look at the care plan to confirm R113's transfer status. LPN OO said she and the unknown CNA did not use a gait belt because the resident would refuse it. LPN OO said CNA D was not the aide involved with the incident. During a telephone interview on 9/24/21 at 10:36 a.m., CNA D reported that an unknown CNA had come to her asking for assistance with transferring R113, but another call light went off and she was unable to help, so the unknown CNA requested the assistance of LPN OO. According to CNA D, LPN OO did assist the unknown CNA in transferring R113 from her bed to the commode and after completing that transfer, LPN OO asked CNA D to complete the transfer of R113 from the commode back to bed because the first transfer did not go well. According to CNA D, she did use a gait belt for the second slide board transfer back to bed that shift because without it, (R113) could have fallen. CNA D said she thought the transfer status was reflected on the Kardex (care guide), but that the transfers with her were very rough because R113 would not help at all, and staff would have to use a lot of muscle. Review of a Care Plan Report that included resolved/discontinued focus areas and interventions reflected R113 Had an ADL self-care performance deficit r/t BKA (below the knee amputation) of left leg. I will refuse care, treatment, assessments, and therapy at times despite education and encouragement from staff. The goal of the care plan was for R113 to participate in ADL tasks with therapy services as ordered to attain and maintain prior level of function. Interventions included, TOLIET USE: 2 assist with Hoyer, initiated on 5/24/21 and revised on 8/27/21. No evidence R113 was ever a slide board for transfers was found anywhere in the care plan. Review of PT-Therapist Progress & Updated Plan of Care, dated 8/29/21 for R113 for review dates 8/01/2021-8/30/2021 and signed by Physical Therapist (PT) RR, reflected R113's prior level of functioning for transfers from bed to chair was minimal assistance (1-25% assist). According to the form, R113's current level of functions as of 8/29/21 was dependent (100% assist). During an interview on 9/24/21 at 10:51 a.m., Occupational Therapist (OT) QQ said that she completed an initial therapy transfer status evaluation for R113 on 7/30/21, the day she admitted to the facility. According to OT QQ, R113 was able to complete the slide board transfer with one assist but was under the impression that staff had downgraded R113's transfer status to Hoyer (full mechanical lift) a few months ago due to her refusal to assist with slide board transfers. OT QQ said that in the times that she worked with her since the initial assessment, R113 had been using the bed pan for elimination. During an interview on 9/24/21 at 10:55 a.m., PT RR reported she was not working the day R113 admitted to the facility and that the times she worked with her she was using a bed pan for elimination and said it was her understanding that staff had downgraded her from a slide board transfer to a Hoyer transfer, but a communication had not been made about it. PT RR reported that in any case, anytime a staff assists a resident with a transfer or with ambulation a gait belt is to be used. PT RR said that R113 would often refuse to complete slide board transfers with nursing staff but would do it for therapy staff. Review of a facility policy Transfer Board adopted 7/11/2018 reflected It is the policy of this facility to transfer an individual with lower extremity weakness from bed to wheelchair. The policy specified a gait belt was required and detailed the following: 9. Assist resident to edge of bed; apply gait belt. 10. Instruct and/or assist resident to lift buttocks away from wheelchair and slide one end of the board under their buttocks. Put the other end of the board on the wheelchair seat. Roll the resident onto his side away from you and place board under him. Then roll him back onto the board. 11. Standing close to the resident, steady his trunk by holding on to gait belt. 12. Instruct resident to push against bed and board with arms while sliding across to wheelchair. Resident #123 (R123) Review of an Admission Record reflected R123 admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], acquired absence of the left leg below the knee, end stage renal disease, dependence on renal [CONDITION(S)], high blood pressure, and lack of coordination. Review of a Therapy Communication dated 6/22/21 reflected R123 required the assistance of 1 person for bed mobility and was totally dependent on a Hoyer lift for transfers. Review of a Therapy to Nursing Communication-Initial form dated 6/23/21 did not reflect a transfer status had been identified. Review of a Therapy to Nursing Communication-Update form dated 7/4/21, reflected R123's transfer status was a 1 Assist; mobility device Wheelchair. Directions on the bottom of the form specified Hold w/c (wheelchair) to have patient perform scoot transfer. During a telephone interview on 9/24/21 at 8:27 AM, R123 reported that on 7/4/21, a CNA (R123 did not know her name) was attempting to transfer her from her bed to her wheelchair. According to R123, the CNA did not have a good hold on her, and she slipped out of the chair and was halfway on the floor, halfway on the chair. R123 reported the CNA said she was going to get help, left her alone in the room and returned with a young guy (R123 did not know who the male helper was). R123 said that the young guy was smaller than the CNA and they both struggled to get her up. R123 said nobody bothered to make report about it and ask if she was OK and that made her very upset. R123 said it took 3 days to get a portable x-ray to be sure she didn't get injured in the incident. Review of a facility Nursing Daily Attendance Report July 4, 2021 reflected CNA S and RN UU were assigned to work on the unit where R123 lived. During a telephone interview on 9/24/21 at 8:53 a.m., CNA S recalled assisting R123 to transfer to her wheelchair from the bed using a slide board. According to CNA S, therapy had just okayed transferring R123 via the slide board with 1 assist/supervision. CNA S reported that a cushion was on the seat of R123's wheelchair was higher than R123 was used to and that threw R123 off. CNA S said R123 never fell on to the floor and was between the bed and the wheelchair, hanging onto the bed when she got help from Registered Nurse (RN) UU who helped boost R123 into her chair. When asked, CNA S said she did not use a gait belt during the transfer and that RN UU placed his arms under R123's shoulders to complete the transfer. CNA S said that she heard R123 complained of pain after the transfer and that an x-ray was obtained. According to CNA S, she started the transfer with R123 because she needed to get her weight and offered to use the Hoyer to obtain R123's weight instead of the wheelchair. CNA S said, The cushion in her wheelchair made a huge difference, I just wish that therapy had worked with me and the resident (when assessing her ability to complete the slide board transfer). During a telephone interview on 9/24/21 at 11:59 a.m., RN UU recalled being asked to assist CNA S transfer R123 on 7/4/21. RN UU said he came into the room and found R123 balancing between CNA S, the wheelchair, and the bed. According to RN UU the slide board had not been placed correctly and R123 was not helping due to R123 was holding something in her hand. RN UU confirmed that CNA S had left the room and R123 to get his attention to help with the transfer. Review of a [CONDITION(S)] Communication Form for R123 dated 7/6/21, reflected Resident complications during [CONDITION(S)]: Back pain-tx (treatment) ended early. Review of Progress Notes for R123 from 6/21/2021-7/8/2021 did not reflect a progress noted had been written for R123 on 7/4/2021 or 7/6/2021. Review of a General Progress Note dated 7/7/21 at 7:24 a.m. reflected Resident (R123) c/o (complained of) rib and back pain, PRN (as needed) [MEDICATION(S)] (a narcotic pain reliever) given and on call Dr called and ordered STAT (urgent) chest and [MEDICATION(S)] spine X-RAY 2 views, (name of mobile x-ray company) was called and everything was set up. Review of a Radiology Results Report dated 7/7/2021 reflected that an XRAY CHEST 2 VIEWS was obtained on R123 for Chest Pain, unspecified. The report revealed Conclusion: No gross fracture in the diagnostic portions of the images provided. [CONDITION(S)] intervertebral disc space narrowing. Limited exam, Recommend diagnostic images or CT. On 9/24/21 at 10:00 a.m., incident and accident reports and grievance reports pertaining to R123 were requested from the DON. The DON reported that there were no incident or accident reports for R123 but that she would find any grievances that may have been completed. Review of a Grievance and Satisfaction Form dated 7/8/21 at 3:00 p.m., received by the Nursing Home Administrator (NHA) on behalf of R123 reflected (R123) stated she attempted to self-transfer on 7/4 but was unable to complete transfer and aide came in to help prevent fall. Aide unable to by herself so called nurse. Nurse and aide assisted with transfer. Alleged that her back and ribs hurt afterwards . The form, completed by the NHA also reflected in the section Investigation, a notation per ADON (name of RN UU) was stuck out. The narrative following reflected X-ray showed no injuries. She (R123) was on pain meds and more added. When she complained of rib pain, x-ray ordered. No fracture, showed intervertebral disc space narrowing .stated nurse was (male name, not RN UU) but it was not (male name). The Resolution revealed Resident has been stating she wanted to leave and decided to leave AMA (against medical advice). Reported investigation results to resident but still not ok with this. The Grievance and Satisfaction Form was not accompanied by witness statements or additional information to suggest the alleged incident was thoroughly investigated to prevent future unsafe transfers.

This citation is related to intake #MI00- 9 Based on observation, interview and record review, the facility failed to 1.) carry out a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .) notify the physician that the referral was not made, when a registered nurse unilaterally and outside the scope of nursing practice, decided the referral did not need to be made 3.) and immediately report eye concerns to a physician, that was identified by a family member, for 1 of 1 residents (Resident #9) reviewed for quality of care, resulting in an immediate jeopardy when, beginning on 10/05/20, facility staff did not follow a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice may have likely resulted in the enucleation (surgical removal of an eye) of R9's left eye and placed all residents who have orders for a referral at risk for serious harm, injury and/or death. Findings include: Resident #9 (R9) Review of an Admission Record revealed R9 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment, completed 03/19/21, revealed that R9 required the extensive assistance from 2 staff persons for bed mobility, transfers, getting dressed, using the bathroom, and for all hygiene needs. A Brief Interview for Mental Status (BIMS) revealed a score of 5 out of 15 which indicated severe cognitive impairment for R9. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .HPI (history of present illness) R9 has been evaluated today for follow up of pain and dryness in left eye. The patient does have a history of dementia, but she is able to answer my questions. Upon evaluation, she is sitting in her chair, she admits left eye pain at 7/10. She states that it feels like there is a lot of pressure on her left eye. She admits that there is some blurriness on that eye. She denies any sensitivity to light. Staff has been using eye drops without much relief. Eye continues to reddened and swollen. (the) left pupil is fixed and is not reactive to light.ROS (review of systems) Patient reports dry eyes, irritation, and vision change .Physical Exam .EENT (ears,eyes, nose, throat) : EENT: Left eye protruding and red. Pupil fixed. Right eye reactive. Assessment / Plan 1. Pain of left eye - will send referral to ophthalmology H57.12: Ocular pain, left eye. Review of an Order Summary Report, with active orders for R9 as of 03/30/21, reflected the following order: please send referral for ophthalmology-eye pain and swelling, dated 10/05/20. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient has been previously seen for left eye pain and swelling. A referral was put out for an ophthalmologist. Upon evaluation, the patient states that she has still some pain. She does have dementia, but is able to answer some of my questions. There does not appear to be any eye drainage at this time. The eye does appear to be swollen as previous assessment. Staff states that patient has not been complaining as much regarding the eye pain. The patient is awaiting the ophthalmologist referral for further evaluation. The patient denies any other concerns at this time. Staff states that otherwise patient is doing well. ROS (review of systems): Patient reports dry eyes, irritation, and vision change. Physical Exam .EENT (ears,eyes,nose, throat): Left eye protruding and red. Pupil fixed (not reactive). Right eye reactive. Assessment / Plan 1. Pain of left eye - awaiting ophthalmology referral. Continue current treatment H57.12: Ocular pain, left eye. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . (R9) is seen today for 90 day regulatory visit . does have a history of dementia, but answers many questions appropriately. Some information obtained from nursing staff .(R9) states that (the) left eye continues to bother her, although she feels that it has slightly improved .states that it is no longer constantly itchy and painful, but still is intermittently itching and painful . eyelid is slightly drooped, and pupil is fixated . states in general, she has poor vision and does not feel that the left eye is worse than baseline currently . has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . was given a course of [MEDICATION(S)], which may have improved (the) eye as she states it has improved since she first noticed an issue . currently uses artificial tears and [MEDICATION(S)]-[MEDICATION(S)] drops .ROS: Patient reports dry eyes; vision waxes and wanes. Patient denies acute visual changes. Physical Exam .EENT: Left eye slightly reddened. Pupil fixed. Right eye reactive. No drainage .Assessment / Plan 2. Pain of left eye -Continue eye drops. Awaiting ophthalmology appt. H57.12: Ocular pain, left eye.( 17 days after ophthalmology referral was ordered) Review of an physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon evaluation, the patient does have dementia, so assessment is difficult at times and she is able to answer some of my questions .ROS: Patient reports dry eyes, irritation, and vision change .Physical Exam .EENT: Left eye slightly reddened. Pupil fixed. Right eye reactive. No drainage. Status of the ophthalmology referral was not addressed in this progress note. During an interview on 03/30/21 at 4:45 P.M., Unit Manager, Registered Nurse (UM-RN) C indicated that the order for a referral to ophthalmology for R9 was received in October 2020 and stated I checked her eye, there was nothing wrong with it. (R9) must have been rubbing her eye. The eye doctor was only taking cases that were emergencies. UM-RN C reported not calling an ophthalmologist to try to obtain an appointment, as ordered, and not reviewing the prescriber's progress notes related to the order for the referral. UM-RN C went on to state (R9) would need to be seen eventually, it just couldn't be done at that time due to Covid . (R9) had no symptoms .with all that Covid crap last year it was such a pain to get people into appointments. During a telephone interview on 03/31/21 at 11:30 A.M., the front desk receptionist EEE with eye center DDD reported that they had continued to take referrals during Covid, we still took urgent and emergent cases, and that same day appointments were available during Covid. Eye Center DDD was very familiar with R9 and had treated R9's left eye concerns starting in January 2021. Eye Center DDD had not received a referral for R9 in October of 2020. During an interview on 03/31/21 at 8:50 A.M., facility provider (NP-C) Z indicated knowing R9 very well, remembered the eye concerns in October, and making a referral for an ophthalmologist. Provider Z also did not recall anyone reporting that the referral was not made and would expect to have a conversation with any registered nurse who felt the order was not necessary. Orders can't just be canceled by a nurse. Review of a facility Policy/Procedure: Physician Orders, adopted 07/11/2018, with no reviewed or updated date listed, reflected; It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 03/30/21 at 11:15 A.M., complainant V reported that there was a zoom call on 01/15/21 involving the complainant, R9, and then Assistant Activities Director (AAD) GG. Complainant V recalled noticing something wrong with R9's left eye and R9 had indicted during the zoom call that the eye itched, hurt, and couldn't see so good. The complainant requested that AAD GG let someone know about the eye, something isn't right. During a telephone interview on 03/30/21 at 3:45 P.M., the previous AAD GG recalled the zoom call in January, attended by AAD GG, R9, and complainant V. AAD GG indicated that complainant V had voiced concerns related to the condition of R9's left eye, that R9 had concerns about the left eye, and that UM-RN C was notified of the concerns. Review of a Grievance and Satisfaction Form, dated 01/15/21, reflected the following: Describe Grievance or Satisfaction: while on zoom call with (complainant V), (AAD GG) heard resident express concerns about care related matters. Investigation: (which was assigned to UM-RN C) reflected, UM-RN C discussed concerns with (R9) and (complainant V) and guardian. (Complainant V) had no concerns. During a follow-up interview on 03/31/21 at 10:00 A.M., Complainant V reported that the facility did not call, at any time, to discuss the concerns about R9's eye, that were noticed and reported to staff on the zoom call from 01/15/21. Review of a General Progress Note, dated 01-17-21 at 21:33 reflected the following assessment . Also crying majority of evening shift difficult to console and unable to tell staff why she is upset. Review of a General Progress Note, dated 01-18-21 at 02:26 reflected the following assessment for R9 . Awake multiple times throughout the evening hollering, snacks given, changed and repositioned. Review of a General Progress Note, dated 01-19-21 at 23:15 reflected the following nursing assessment for R9 . Res (resident) sitting on edge of bed calling out. Snack offered and accepted. CENA (certified nurse aide) reported that res not sleeping well tonight. Review of a General Progress Note, dated 01-20-21 at 05:43 reflected the following nursing assessment for R9 . Res up in broda chair at about 0300 and out in common area with staff. Res tearful at times, unable to tell staff why. Review of a General Progress Note, dated 01-20-21 at 11:44 reflected the following nursing assessment for R9 . Resident noted to have a bright red left eye. Also observed yellow drainage and resident reports that she has pain and burning. Resident also states that she can not see out of that eye today. Facility physician assessed and stated to send her out to the ER as it might be an ulcer or a type of infection. Review of an physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On evaluation, the patient is resting in her wheelchair, sleeping. She does awaken with voice. Her left eye does appear to be swollen. Her corneas are red. She has opacity over her pupil. She states that she is unable to see out of that eye, which is new to her. She states that it is painful intermittently. She does have a history of dementia, but is able to answer my questions appropriately .Regarding the patients' eye, she will be sent to the emergency department for further evaluation. Review of a new patient office note from the eye center AAA, that evaluated R9 on 1/20/2 after being treated at the ER, and dictated by eye doctor CCC, who had examined R9 on 1/20/21, reflected the following: Chief Complaint/History of Present Illness-(R9) presents for evaluation of painful in the left eye. It started about 2 days ago. Throbbing OS (left eye) .brought in by EMT on stretcher, unable to transfer to exam chair .1. Impression- Acute angle-closure [CONDITION(S)], left eye .IOP (intraocular pressure) 75 for unknown period of time (normal range varies but standard range with [CONDITION(S)] is approximately 20-30) .Has not seen eye care provider recently. Goal is comfort care .2. Impression-Corneal ulcer, left eye .due to VA (visual acuity) NLP (no light perception) OS (left eye) from angle closure [CONDITION(S)] .K ulcer (corneal ulcer) may be secondary to epi erosion from severely elevated IOP. Referral made to University of Michigan, for further evaluation, on 1/22/21. During a telephone interview on 04/07/21 at 3:30 P.M., eye doctor CCC, who had examined R9 on 01/20/21 at eye center AAA, stated the following: It was impossible to say, with 100% certainty, whether or not R9's left eye concerns in October were related to the findings in January. The only way to know that for sure would have been to have R9 seen in October. Increased intraocular pressure can slowly build over time and if that were the case, it was possible that October was related to R9's eye concerns in January. R9's cognitive state (dementia) also made it difficult to know exactly what was happening; patients with dementia have an altered perception of pain and often times have trouble expressing it. Review of an office visit physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Severe Corneal ulcer OS(left eye)- Patient with hx (history) of HZO (herpes [MEDICATION(S)] ocular) 18 mos (months) prior, after which she has continued to have worsening eye vision- likely neurotrophic component from prior HZO. Patient now presents with 2 month history for acute-on-chronic worsening of vision and eye yellowing, but no pain- Examination today notable for large area of stromal infiltrate spanning the inferior corneal hemisphere, and small ?infra central endothelial plaque- I discussed the diagnosis, prognosis, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .- patient and her family understand the guarded prognosis for rectum of vision - goal is to save the eye .Plan: [MEDICATION(S)] and [MEDICATION(S)] every hour, left eye. Review of the After Visit Summary, dated 1/22/21, from the University of Michigan eye center, reflected the following: Pick up these medications from any pharmacy with your printed prescriptions: [MEDICATION(S)]-[MEDICATION(S)] .start [MEDICATION(S)] 95mg (milligrams) / 7 ml (milliliters) fortified ophthalmic solution 1 drop in left eye every hour .start [MEDICATION(S)] 25mg / ml ophthalmic solution 1 drop in the left eye every hour (24/7 was handwritten in) .Instruction: start fortified [MEDICATION(S)] and [MEDICATION(S)] every hour, left eye ( around the clock was hand written in). During a telephone conversation on 4/7/21 at 4:45 P.M., pharmacy technician GGG, who works for pharmacy FFF, indicated that the prescriptions for R9, which were for compounded medications, were received at pharmacy FFF on 1/25/21 and were picked up on 1/29/21. The prescriptions received at pharmacy FFF were not the prescriptions written by University of Michigan on 1/22/21, rather they were called in by eye center DDD on 1/25/21 (the same day R9 was seen at eye center DDD for the first time). Pharmacy technician GGG indicated that compounded medications are specially made at the pharmacy and can take 2-3 business days to make. The two ophthalmic prescription eye drops for R9 were given in a 14 day supply. During a telephone conversation on 4/8/21 at 9:45 A.M., complainant V reported being at the University of Michigan eye appointment on 1/22/21 and was given two prescriptions to take back to the facility to have filled. They had to be made special. Complainant V stated that the paperwork and prescriptions were returned to the facility and given to a nurse. Review of an established patient visit progress note at eye center DDD, dated 1/29/21, revealed the following for R9: Pt (patient) instilling fortified [MEDICATION(S)] and fortified [MEDICATION(S)] q hr (every hour) OS (left eye). Pt states assisted living not instilling (medications) during bedtime. Review of an EMR (electronic medication administration record), dated January 1, 2021 to January 31, 2021, revealed the following order for R9: [MEDICATION(S)] 0.3% 1 drop in left eye every hour for infection. Per the EMR, this medication was administered from midnight on 1/23/21 through 6 P.M. on 1/25/21. Review of the same EMR revealed another order for R9: [MEDICATION(S)] Solution, Instill 1 drop in left eye every hour for 13.6 mg/ ml. vial, for infection med provided through Watkins'. Per the EMR, this medication was administered from 7 P.M. on 1/25/21 through 8 P.M. on 1/30/31. During a telephone interview on 04/09/21 at 1:45 P.M. Administrator HH and the Director of Nursing indicated that there had been a transcription error and R9 had been getting the compounded [MEDICATION(S)] antibiotic eye drops, however, the EMR listed the eye drops as [MEDICATION(S)] 0.3% instead of the correct dose of 13.6 mg/ml. The [MEDICATION(S)] eye drops were administered every hour for 48 hours, by nursing staff, without the incorrect dose on the EMR having been called to attention. On 03/31/21 the Administrator was verbally notified and received written notification of the immediate jeopardy that was identified on 3/30/21 and began on 10/05/20 due to the facility's failure to follow a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A written plan for removal for the immediate jeopardy was received on 03/31/21 and the following was verified on 04/01/21: The (facility) submits the following Credible Allegation of Compliance outlining the measures it has completed to remove the findings of immediate jeopardy to resident health and safety identified by the survey team regarding the facility's alleged (1) failure to carry out a physician order, (2) allowing a registered nurse to practice outside the scope of an RN's practice, and (3) failure to promptly follow up on identified eye concerns made by a family member. 1. Response to Cited Areas: The facility failed to follow up with an ophthalmologist, as ordered by physician on 10/05/2020, for 1 resident (R9) with left eye pain, swelling and loss of vision. Facility Response: -R9 received left eye emergency care on 1/20/21. -R9 had surgery on 3/19/21 for left eye enucleation. -Education has been initiated to the facility nurses on 03/31/21 regarding change of condition monitoring and reporting and following physician orders. 2. Other Residents at Potential Risk: -An audit was initiated on 3/31/21 by the facility nurse management team back to 10/1/2020. -The audit consisted of verification of all current residents to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Process Implemented to prevent further incidence: -On 03/31/21 the education has been initiated on the following items: -Physician Orders -Change in Resident Condition Status- Monitoring and Reporting -Any staff member that has not been educated will be educated prior to the start of their shift Although the immediate jeopardy was removed on 03/31/21, the facility remained out of compliance at a scope of isolated and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency.

This citation pertains to intakes # MI00- 3, MI00- 8, MI000- 2, MI00- 9 Based on observation, interview and record review, the facility failed to ensure staff responded to resident needs in a timely manner for 4 residents ( Resident #9, Resident #15, Resident #16, and Resident #2), resulting in psychosocial harm from feeling neglected, abandoned, cold, wet, soiled, and hungry for extended periods of time. Findings include: Resident #9 (R9) Review of an Admission Record revealed R9 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment, completed 03/19/21, revealed that R9 required the extensive assistance from 2 staff persons for bed mobility, transfers, getting dressed, using the bathroom, and for all hygiene needs. A Brief Interview for Mental Status (BIMS) revealed a score of 5 out of 15 which indicated severe cognitive impairment for R9. During an observation on 03/26/21 at 3:17 A.M., the touch pad call light was half way down the bed, on the floor next to the bed. R9 was in bed with no covers on, in a hospital gown, nothing covering the legs. Eye patch covered the left eye. R9's room had a strong BM (bowel movement) odor. No staff visible on the hall. During an observation on 03/26/21 at 4:01 A.M., R9 was in bed, uncovered, legs exposed, and the touch pad call light was on the floor next to the bed. The room smelled of BM and R9 could be heard calling out, please cover me up. No staff were visible on the unit. For the observations listed below, from 4:56 A.M. to 6:15 A.M. on 03/26/21, this surveyor, with the permission of R9, remained in the residents room to accurately document any staff to resident interactions. During an observation on 03/26/21 at 4:56 A.M., R9 laid in bed, call light touch pad on the floor, patch over left eye, the room had a strong odor of BM. R9 yelled out I'm hungry. No staff located on the unit. During an observation on 03/26/21 at 5:20 A.M., R9 yelled out, please cover me up, I'm cold. Call light touch pad remained on the floor next to the bed. R9 called out again, Please. During an observation on 03/26/21 at 5:36 A.M., R9 called out I'm cold. During an observation on 03/26/21 at 5:40 A.M., R9 yelled Can I have something to eat? During an observation on 03/26/21 at 6:00 A.M., R9 yelled out, please cover me up. An unidentified staff person looked into R9's room, both hands were visible on door and a shadow was noted from the light in the hallway. The staff person did not enter the room and respond to R9's requests for help. At 6:02 A.M., R9 again yelled out, can I have something to eat, maybe a peanut butter and jelly sandwich. During an observation on 03/26/21 at 6:10 A.M., Registered Nurse, Unit Manager (RN-UM) B opened R9's door, did not enter the room, and told R9 to hold on, someone is coming. During an observation on 03/26/21 at 6:15 A.M., Certified Nurse Aide (CNA) S entered R9's room to get the resident cleaned up for the day. During peri care it was noted that R9 had loose watery stools that had soaked through the brief and into the blue pad. R9 complained of pain when CNA S cleaned her genitalia, I'm not even having sex and you are hurting me worse. CNA S stated you look a little red and sore down there, I will tell the nurse. During an interview on 03/30/21 at 11:15 A.M., complainant V reported attending multiple eye appointments with R9 during the months of January, February, and March of 2021. Complainant V indicated that at several of the appointments, R9 was very upset, crying, and stated, they treat me like an animal .they leave me in my room for hours . why do they treat me that way. Complainant V also indicated that R9 got so upset, that R9 would require time to settle down and stop crying so that R9 could participate in the eye appointments. Resident #15 (R15) Review of an Admission Record revealed R15 was a [AGE] year old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment, completed 02/12/21, revealed that R15 required the extensive assistance from 2 staff persons for bed mobility, transfers, bathing, and using the bathroom. A Brief Interview for Mental Status (BIMS) revealed a score of 14 out of 15 which indicated R15 was cognitively intact. During an observation on 03/26/21 at 3:12 A.M., R15's call light was on. During an observation on 03/26/21 at 3:25 A.M., R15's call light was off. This surveyor asked if needs had been met. R15 stated no, that staff came in and turned off the call light, and stated they would be back. They usually make me wait for first shift to get cleaned up, they let me lay here wet. During an interview on 03/26/21 at 3:40 A.M., R15 reported that staff had not been back to get him cleaned up. I'm soaked. During an interview on 03/26/21 at 3:55 A.M. R15 again reported that staff had not been back to get him cleaned up. During an interview on 03/26/21 at 4:40 A.M., R15 indicated that staff had come back and got him cleaned up at 4:30 A.M. Resident #16 (R16) Review of an Admission Record revealed R16 was a [AGE] year old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment, completed 02/19/21, revealed that R16 required the extensive assistance from 2 staff persons for transfers, bathing, and getting dressed. A Brief Interview for Mental Status (BIMS) revealed a score of 15 out of 15 which indicated R16 was cognitively intact. During a telephone interview on 04/01/21 at 4:15 P.M., complainant U reported receiving a text message from R16 at 7:30 P.M.(exact date unknown but believed it was early February sometime), that indicated that R16 had a bowel movement at 6:15 P.M. and staff had not yet answered the call light to help get cleaned up. Complainant U reported calling the facility and having difficulty getting staff to answer the phone. R16 had sent another text message indicating that staff answered the call light and assisted with clean up at 8:30 P.M. Complainant U also reported speaking with the Administrator the next day and (a) the Administrator apologized, (b) did not know the facility had been short staffed, (c) would write up a grievance form on the matter so it could be investigated, and (d) would speak with R16 about the matter. Three phone calls and messages were made to complainant U prior to the telephone conversation on 04/01/21 at 4:15 P.M. During an interview on 04/01/21 at 4:45 P.M., R16 sat up in the wheelchair playing video games and stated remembering the day in question. R16 reported waiting and sitting in[OBSCENITY]for two hours. I was so mad. R16 stated that the Administrator never came to the the room to speak about the matter and indicated that the average wait time for the call light to be answered was 30 minutes to 1 hour. The surveyor requested all grievance forms for R16 in past 4 months, received 2 forms, and neither were related to the above complaint. Review of the facility policy/procedure Call Light, adopted 07/11/2018 with no reviewed or updated date listed, reflected: POLICY: It is the policy of this facility to provide the resident a means of communication with nursing staff. PROCEDURE: (1) All facility staff must be aware of call lights at all times. (2) Facility shall answer call lights in a timely manner. (3) Answer all call lights in a prompt, calm, courteous manner; turn off the call light as soon as you enter the room and attend to the residents needs. (7) Be sure that call lights are placed within reach of residents who are able to use it at all times. There is no reason to place the call light within reach of a resident who is physically and cognitively unable to use the call light. During an interview on 04/02/21 at 10:47 A.M., Cheif Operating Officer (COO) NN Resident #2 Review of an Admission Record reflected Resident #2 (R2) admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) quarterly assessment dated [DATE] reflected R2 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14/15 and needed extensive assistance from two people for bed mobility, transfers, dressing, toileting and personal hygiene. The assessment indicated R2 had functional limitations in Range of Motion (ROM) on one side in both the upper and lower extremities. During an interview on 3/30/21 at 1:30 PM, R2 reported she felt that staff were not properly trained to take care of her. R2 said that an unknown CNA had transferred her with the EZ stand a few days ago and that it didn't go well, resulting in pain to her right knee that was pushed into the lift. According to R2 the facility did not make an incident report about the occurrence and that she felt frustrated. During a telephone interview on 3/30/2021 at 4:20 PM, a Family Member (FM RR) of R2 reported she had repeatedly reported several care concerns on behalf of R2 to the facility without resolution. FM RR described an incident that occurred on 1/12/2021 when R2 called her in tears because she was not able to get anyone to answer her call light and R2 was asking FM RR to call the facility nurse station to try and get help for her. FM RR said she called repeatedly without getting an answer until she was finally able to reach Certified Nurse Aide (CNA SS) who was working on a different unit who agreed to go and assist R2 with incontinence care. FM RR also reported a separate incident that occurred on 1/28/2021 when she had been on the telephone with R2 again due to lack of staff assistance. FM RR said R2 had requested a bed bath and incontinence care during the second shift and allegedly a CNA told her she would not provide the care. FM RR said R2 had to bang on the wall with an assistive device and on the trapeze over her bed before a third shift CNA finally helped clean her up, allegedly three hours later. FM RR said she detailed similar situations in an email to a CEO of the facility who forwarded the details to the unit manager (RN E) and to the Administrator. During an interview on 3/30/2021 at 4:45 PM, CNA SS recalled the incident from 1/12/2021 and validated he received a phone call from FM RR asking if anyone could help R2 because staff were not answering her call light. CNA SS said that he was working on the locked dementia unit at the time of the call but made arrangements to leave his post and assist R2 whom he discovered had been incontinent. CNA SS said that he did not observe any staff on the unit R2 lived on when he went to her room and did not observe staff on the unit after he finished providing care some 15-20 minutes later. CNA SS said he reported his activities and observations to the charge nurse he was being supervised by on the dementia unit but never heard any more about it. During a follow-up interview on 3/31/2021 at 12:15 PM, R2 confirmed the reports made on her behalf by FM RR. R2 said that having to wait so long for staff to assist her and not knowing where any of the staff were at made her feel abandoned and angry. Review of an email sent by FM RR to the Administrator and RN E dated 2/3/2021 reflected FM RR was reinforcing her frustration with the lack of resolution to ongoing delays in the provision of care that are frustrating to R2 and FM RR. FM RR documented a detailed example with names and times when R2 was actively seeking assistance with personal care that were allegedly ignored for over an hour and resulted in the loss of an opportunity to go outdoors to smoke. FM RR reiterated a report of an allegedly stolen purse and questioned why the facility never assisted the resident with reporting the matter to the police or helping her to replace missing social security card, debit card and medical cards. During an interview on 3/31/2021 at 12:45 PM, the Administrator reported that she would have reported a missing or stolen purse to the police but did not have any evidence that R2's missing purse was reported to either the police or State Agency as stolen. The Administrator also indicated she was aware of the alleged neglect reported by FM RR on behalf of R2 in writing and said she investigated the claims but did not report the alleged neglect to the State Agency. The Administrator was not able to provide any evidence of having conducted an investigation into the alleged concerns and also indicated she was never made aware of the incident validated by CNA SS as reported by FM RR as having occurred on 1/12/2021. During an interview on 4/1/2021 at 10:20 AM, Physical Therapist (PT) JJ reported she recalled R2 coming to her in tears on 3/26/2021 because of an incident that transpired during a transfer just prior to their meeting. According to PT JJ, R2 reported an unknown CNA had gotten her up in the EZ stand lift, then the CNA sat in R2's electric wheelchair and proceeded to push R2 around her room from the electric wheelchair while R2 was attached to the EZ stand. PT JJ said she immediately took R2 to RN E for assistance and considered that a report of abuse. During an interview on 4/1/2021 at 10:27 AM, the acting Director of Nursing (DON) A reported she had no knowledge of an allegation of abuse made by anyone on behalf of R2 on 3/26/2021. During an interview on 4/1/2021 at 11:00 AM, acting Administrator HH denied any facility reported incidents had been made on behalf of R2, nor had an investigation been conducted for an incident occurring on 3/26/2021. Incident and accident reports were requested pertaining to R2, and no incident report pertaining to the abuse/mistreatment alleged to have taken place on 3/26/2021 was provided.

This citation pertains to intakes M 5502 and M 5746 Based on observation, interview and record review, the facility failed to prevent neglect when the facility did not promptly and thoroughly address injuries of unknown origin for 2 residents (Resident #1 and Resident #3) of 3 residents reviewed for abuse and neglect, resulting in pain and [MEDICAL CONDITION] due to ongoing significant bruising and hematoma injuries sustained by Resident #1 and the potential for ongoing, unrecognized abuse and/or neglect for Resident #3 who was discovered with suspicious bruising. Findings include: Review of a policy titled Abuse and Neglect last revised 6/17/10 revealed: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Neglect is the failure to provide necessary and adequate (medical, personal, or psychological) care. Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional. IV. Identification: Have procedures to: Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. An injury should be classified as an injury of unknown source when both of the following conditions are met: a. The source of injury was not observed by any person or the source of injury could not be explained by the resident; and bathe injury is suspicious because of the extent of the injury or the location of the injury (example: the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at a particular point in time or the incidence over time. Documentation within a client medical record is a vital aspect of nursing practice. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track (resident) outcomes, and reflect current standards of nursing practice .Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors .The record is a means by which health care team members communicate (resident) needs and progress .The record should be the most current and accurate source of information about a client ' s health care status .High-quality documentation .(is) necessary to enhance efficient, individualized (resident) care. Quality documentation .(has) five important characteristics: they are factual, accurate, complete, current, and organized (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). According to the Fundamentals of Nursing, 6th Edition (Mosby, Patricia A. Potter, Anne G. Perry, 2005 page 481) High quality documentation and reporting are necessary to enhance efficient, individualized client care. Quality documentation and reporting have five important characteristics: they are factual, accurate, complete, current, and organized, The use of inferences without supporting factual data is not acceptable because it can be misunderstood. Review of a policy titled Charting and Documentation adopted on 7/11/18 revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Resident #1 Review of a Face sheet revealed Resident #1 is an [AGE] year old female originally admitted to the facility on [DATE] with pertinent diagnoses of neuromuscular dysfunction, dementia, and diabetes. No diagnoses for [MEDICAL CONDITION] noted. Review of the Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed a Brief Interview for Mental Status (BIMS) indicated she is severely cognitively impaired and required extensive assistance of 2 staff for transfers and toileting and unsteady on feet. No history of falls, skin conditions, or bruising noted. Review of a Facility Reported Incident (FRI) submitted online on 10/6/20 at 12:43 p.m. revealed: Incident Summary on 10/6/20, the Administrator (NHA) and Director of Nursing (DON) received a call from Medical Director concerning bruising noted to resident that appears to be new and worsening. On 10/5/2020 the bruising was assessed and was thought to be related to decline in transfer status using EZ stand lift from the belt positioning and declined positioning in wheelchair. Her transfer status had already been downgraded to Hoyer lift and a Broda Chair was put into use for improved positioning. Resident is in bed and appears comfortable. There have been no allegations of abuse at this time. Due to the significance of the bruising, a full investigation has been initiated for possible injury of unknown origin. On 10/5/20, (Resident #1) was sent to the hospital for what appeared to be a sudden onset of increased bruising along with abnormal lab results. After speaking with the Unit Manager and reviewing clinical records, it was thought that the bruising was likely related to a recent decline in transfer status. Staff was using EZ stand lift, and bruising matched the belt-positioning. (Resident #1) was also noted to have had a noted decline in wheelchair positioning and trunk control over the weekend. On the morning of 10/06/2020, the Administrator and Director of Nursing were made aware that the bruising that was initially reported on 10/5/20 had worsened. Due to the bruising's significance, a full investigation was initiated for possible injury of unknown origin. The Director of Nursing and Administrator completed a full clinical review. On 9/3/2020, a Nursing Assistant noted a purple bruise on (Resident #1) anterior armpit, a pink area to the left outer breast, and a light purple bruise on the inner left upper arm. Poor positioning was discussed with IDT as caregivers observed increase lateral leaning while seated in w/c despite current interventions over the weekend. Transfer status was downgraded from EZ stand to Hoyer lift, Broda Chair and stat labs were ordered. Nurse reported significant bruising in addition to hemoglobin level of 7.0 to on call provider and an order was given to send (Resident #1) to the hospital for further evaluation of bruising and abnormal labs. Upon returning from the hospital, the new interventions were in place including transfer status downgrade from an EZ stand to a Hoyer lift with 2 assist, and a Broda Chair to increase comfort when up for meals. Root Cause Analysis/Contributive Factors: The investigation determined that the event was substantiated to have occurred, due to visible bruising. Bruising was concluded to have been caused from an acute onset of increasingly worsened positioning, posture, and trunk control due to her [DIAGNOSES REDACTED]. Actions taken based on investigative findings: · Resident was downgraded from EZ stand lift to Hoyer · Broda chair in use to increase comfort when up for meals. (sic) Review of questionnaires from staff regarding Resident #1's bruising, several staff reported the resident was in pain, noticed new and old bruising and told the nurses. One nurse reported she saw the new bruising and noted in provider communication. Another CNA reported on 10/6/20 that the resident was vomiting in bed, leaning to right side, increased the head of the bed and reported to the nurse. No documentation noted in electronic health records of the resident vomiting. Staff who reported new bruising did not indicate when or where they were when they saw the bruising and when they reported it to the nurse. Review of a Complaint reported to the State Agency on 10/7/20 regarding Resident #1 revealed: . (Resident #1) needs full assist for everything. (Resident #1) has labs done and she is anemic (low hemoglobin). (Resident #1) is currently at the hospital (10/06/20) but will be discharged back to the facility. (Resident #1) has bruising, blood from her bruising just around her breast and nipples. (Resident #1) ' s bi-lateral chest and nipples seemed to be bruised with old bruises and new bruises. This could be occurring from (Resident #1) or some other trauma. It is unknown what has occurred. (sic) Review of Hospital Records dated 10/6/20 revealed Resident #1 arrived at the emergency roiagnom on Tuesday, 10/6/20 at 5:41 a.m. revealed: I suspect acute blood loss [MEDICAL CONDITION] secondary to blood loss into the soft tissues. bruising, it appears to be primarily around the nipples and flanks, and based on this pattern, I do have some suspicion, or at least and concern for elder abuse. hemoglobin of 7.9. Unfortunately, EMS (emergency medical services) was not able to get much report from the (Nursing Facility), but they do know that she had abnormal lab work and has had abnormal bruising over the past couple months. Physical Exam: Skin: Bruising (Significant ecchymosis (large, bruise like lesion caused by collection of extravascular blood in dermis and subcutaneous tissue caused by trauma or bleeding disorders) in varying degree of healing along the chest. The bruising appears to be most noticeable around bilateral nipples. No obvious hematoma. No tenderness.) present. Bruising as noted previously around bilateral breast as well as bilateral flanks. Bruises are of varying ages. There is concern that she may have been injured in some way . CT (computerized tomography) scan revealed: 1. Significant soft tissue swelling involving the left pectoralis muscles, probably related to diffuse intramuscular hemorrhage. Small measurable intramuscular hematoma also present in the left pectoralis major. 2. Minimally buckled fractures of the anterior left fourth and fifth ribs, age indeterminate. I spoke with her primary care provider . I relayed to him the findings of our scans and the history. He will see her tomorrow at her care facility. Review of an Incident Report dated 9/3/20 for Resident #1 revealed: CENA (Certified Nursing Assistant (CNA)) reported bruise noted when cares given. Purple bruise on anterior armpit, pink rubbed area left outer breast, and light purple inner left, upper arm. CENA that did her cares day prior did not observe any bruising. Immediate Action Taken: Towel placed in gap between bolster on w/c (wheelchair) arm and back of w/c. Notes: Anterior armpit purple bruise 3x2.5 cm (centimeters), 2x1 cm inner upper left arm light bruise, 4.5 x 7, left outer breast pink rubbed area. Predisposing factors: Using Wheelchair. Other info: Bolster on w/c sliding forward leaving a gap between bolster and back of w/c. Notes: (Staff)- I did (Resident #1's) a.m. care on 9/2/20 and did not see any bruising. I do often see (Resident #1 leaning in her chair to the left. (Staff) I was unaware of (Resident #1) bruising under left arm but have noticed (Resident #1) leaning over left side of wheelchair, hanging over left side of wheelchair. Resident tends to favor leaning to left side Privileged and Confidential- Not part of the Medical Record. No further documentation provided with this incident report. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed: No redness, bruising, or open areas. Review of a nursing Progress Note dated 9/1/20 for Resident #1 revealed: Bed bath given. No redness, bruising, or open areas noted. Denies any pain or discomfort. Review of a nursing Progress Note dated 9/3/20 for Resident #1 revealed: Bruises noted during a.m. cares. Anterior armpit purple bruise 3 x 2.5 cm, 2 x 1 cm, inner upper left arm light bruise, 4.5 x 7 cm, left outer breast pink rubbed area. Bruising not noted with cares yesterday per aide. Leans to left side often and is repositioned. PT (Physical Therapy) evaluation . Review of an Occupational Therapy (OT) Plan of Care document dated 9/7/20 for Resident #1 revealed: Pt (patient) referred to OT services 2/2 bruising on L (left) underarm armpit and L breast area per nursing staff. Nurse states may have been from bolster sliding forward and pt leaned over left side of w/c (wheelchair) armrest, causing increased pain. Therapy necessity: Therapy necessary for decreasing L arm pain, bruising and increased participation with ADL (activities of Daily Living) routine. Without therapy patient at risk for functional decline and falls. Pt resides in this LTC (long term care) facility with ext. (extensive) assist for ADL routine. Patient previously utilized EZ stand for transfers. Previous Therapy: Pt received PT (physical therapy) last month for transfer training. Pt states pain in L underarm, armpit, and L side breast area at 5/10 with shoulder flexion and ROM (range of motion) with self-feeding. No numbness stated on BUE (bilateral upper extremities), however pt's BUE hands were cold to the touch with some bruising noted on B dorsal (back) side of hands. The patient reports pain in L upper arm of moderate. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. Review of a Skin Observation Shower sheet dated 9/10/20 for Resident #1 which is not part of the medical record revealed the outline of a body shows no skin alterations or locations and not marked for alterations. The Licensed Nurse comments revealed: Continues with fading and healing bruises to left anterior armpit, inner upper left arm. Review of a Medical Practitioner Progress note dated 9/10/20 for Resident #1 revealed: . She has had some generalized bruising noted documented, but no open areas. She is having PT (physical therapy) see her to provide a bolster for better seating in her wheelchair so that the chair does not cause any areas of potential pressure points and bruising. Review of a Skin Observation Shower sheet dated 9/17/20 for Resident #1 which is not part of the medical record revealed the body outline diagram has an oval outline reaching from the left armpit down the left side of the resident and the box for bruises is checked off. The Licensed Nurse comments revealed: Continues with healing bruises to left breast and under left arm. Review of a Nurse Practitioner Note dated 9/17/20 for Resident #1 revealed no acknowledgement of bruising on Resident #1. Resident #1 is seen today for evaluation and management of multiple, complex, chronic medical problem that requires frequent monitoring to maintain stability and to prevent further decline. She is also specifically seen for transition of care and follow up of vitamin D deficiency. Skin: Skin is warm and dry, afebrile. (sic) Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. Review of a Skin Observation Shower sheet dated 9/24/20 for Resident #1 which is not part of the medical record revealed the body outline diagram has an oval outline reaching from the left armpit down the left side of the resident and the box for bruises is checked off. The Licensed Nurse comments revealed: Continues with healing bruises to left breast and under left arm. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. Review of a Skin Observation Shower sheet dated 10/1/20 for Resident #1 which is not part of the medical record revealed the body diagram outline had no marks and the box for bruises is checked off. Licensed Nurse comments revealed: Fading bruising to left breast and under left arm. No Skin Observation Shower records provided to this surveyor after 10/1/20 to 10/22/20. Review of a Late Entry Nursing Progress Note back dated 10/4/20 and created on 10/9/20 for Resident #1 revealed: old yellow bruising to left breast and flank, bruising extended to right breast and flank appearing dark in color, resident had no complaints of pain until being repositioned for check and change whiled rolled onto side, pain subsided once in neutral position, VS (vital signs) stable, physician note made. Review of a Weekly Skin assessment dated [DATE] and entered into the Electronic Health Record (EHR) on 10/9/20 for Resident #1 revealed a New alteration in skin integrity. It should be noted that pt (patient) has [MEDICAL CONDITION], type II diabetes, hypertension, [MEDICAL CONDITION] and Dementia as major medical problems, among others. It is noted that pt has been declining slowly and has been unable to hold her posture erect as a result of progressive neurological disorder [MEDICAL CONDITION]. Pt has been leaning forward and to right or left. Pt is also dependent on staff for all ADL (activities of daily living) including transfers. Pt's posture, leaning on arm rest either left or right as she is unable to hold posture erect may have exacerbated. First bruising was noted on 9/3 and since then therapy has evaluated for maintain pt's posture. In addition being on ASA (aspirin) did not help, as it may have contributed to bleeding in muscles and subcutaneous tissues leading to a larger bruise. Pt was observed to be comfortable with staff and no fear or concern noted. (sic) No measurements, location, or descriptions noted. Review of a Nursing Progress note dated 10/5/20 for Resident #1 revealed: Pt was observed throughout weekend to slouch and lay to either side in her wheelchair. Was frequently assisted to sit up and repositioned but this am (Monday) bruising to left flank and chest was increased and now bruising to right flank. Manager notified, Dr. notified. Family called and message left requesting call back. Broda chair ordered for comfort and intervention. Awaiting any additional order from Dr. Review of a Nursing Progress Note dated 10/6/20 for Resident #1 revealed: STAT lab results call in to Nurse on call (Nurse Practitioner) and order noted to send resident to hospital for eval. hemoglobin 7.0 (normal value is 12.0 to 16.0). Review of a laboratory result dated 7/8/20 revealed Resident #1 had a hemoglobin of 12.9. Review of an eInteract Transfer Form dated 10/6/20 at 4:08 a.m. and locked dated of 10/12/20 at 10:40 p.m. for Resident #1 revealed she was discharged to Hospital. Review of a Nurse Practitioner Note dated 10/6/20 at 3:00 p.m. for Resident #1 revealed: Pt seen at the request of nursing staff for eval of Bruising and F/U (follow up) ER (emergency room ) visit. She was noted to have extensive bruising recently. Blood work was done including coagulation studies which were mostly with in acceptable range with the exception of low (hemoglobin). Subsequently she was sent to ER for Eval. she was transferred from chair to commode and chair to bed using EZ stand/Sit to stand. It is my understanding that the strap that supports patient while on EZ stand is applied behind the back, passed under the axilla and stabilized in front. When pt is raised in EZ stand, pressure applied to areas on the chest and fragile nature of her skin has caused bruising. Pt's posture, leaning on arm rest either left or right as she is unable to hold posture erect may have exacerbated. First bruising was noted on 9/3 and contributed to bleeding in muscles and subcutaneous tissues leading to a larger bruises. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed the resident had a new alteration to her skin integrity. Bruising to chest and bilateral sides appear to be dissipating and to be healing well. (Resident #1) denied pain and stated she felt comfortable during this assessment. (Resident #1) is able to accurately answer Yes/No questions. When asked if she felt safe - yes. Asked if she enjoys living here - yes. Asked if we take good care of her - yes. Asked if anyone has ever hurt her here - no. (Resident #1) appeared comfortable, is being assisted with frequent repositioning with no new skin concerns. (sic) Review of a Nurse Practitioner Note dated 10/12/20 for Resident #1 revealed: (Resident #1) has been evaluated today at request of nursing staff for elevated blood pressure. Upon evaluation, the patient is resting in bed. Staff also had concerns of an episode low oxygenation with the O2 (oxygen) sat of 88 (normal is 92 to 100%). Her lungs did demonstrate crackles in the bases. She has not been out of bed. The patient was recently hospitalized with a hemoglobin of 7 with excessive bruising on the chest and flank. Last hemoglobin demonstrated with 7.8. Bruising appears to be dissipating. Review of a Late Entry General Progress Note back dated 10/5/20 and created by the Director of Nursing (DON) on 10/12/20 at 4:51 p.m. for Resident #1 revealed: Bruising noted to chest and bilateral sides of trunk. It should be noted that pt has [MEDICAL CONDITION], type II diabetes, hypertension, [MEDICAL CONDITION], and dementia as major medical problems among others. It is noted that pt has been declining slowly and has been unable to hold her posture erect as a result of progressive neurological disorder [MEDICAL CONDITION]. Pt has been leaning forward and to right or left. Pt is also dependent on staff for all ADL including transfers. Pt's posture, leaning on arm rest either left or right as she is unable to hold posture erect may have exacerbated. First bruising was noted on 9/3 and since then therapy has evaluated, for maintaining pt's posture. In addition being on ASA did not help, as it may have contributed to bleeding in muscles and subcutaneous tissues leading to a larger bruises. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alteration in skin integrity. No documentation of past bruising noted. Review of a Skin Observation Shower sheet dated 10/22/20 for Resident #1 which is not part of the medical record revealed the body outline diagram had an oval outline that encircled the left underarm and down the left side and a small circular outline of the right underarm. The check box for bruises is marked. Licensed Nurse comments revealed: yellow light purple bruising to left breast and under left arm. Small yellow bruise to right arm and chest. Both of which are not new and are fading. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. No documentation of past bruising noted. Review of a Skin Observation Shower sheet dated 10/29/20 for Resident #1 which is not part of the medical record revealed the body outline diagram had an oval outline surrounding the left underarm and down the left side. The Licensed Nurse Comments revealed: Light purple bruising under left breast and on left flank continues to heal. Review of a Hospice document dated 11/2/20 revealed Resident #1 was admitted to Hospice. During an observation and an interview on 11/4/20 at 10:55 a.m., Resident #1 observed in the dining room sitting in a Broda Chair (special chair for positioning) with puff boots on both feet and reported her sister got mad at her and hit her when queried about her bruising. Licensed Practical Nurse (LPN) B reported the resident had large bruising on the right side of her body and across her chest. In an interview on 11/4/20 at approximately 11:15 a.m., LPN C reported Resident #1 used to reside in room [ROOM NUMBER] when she took care of her and recently transferred to room [ROOM NUMBER]. LPN C did remember a Certified Nursing Assistant (CNA) told her the resident had some bruising but could not remember when or any of the details of the bruising. The nurse could not remember if she documented measurements of bruising. In an interview on 11/4/20 at 2:30 p.m., CNA D reported Resident #1 used to be in room [ROOM NUMBER] and then transferred to room [ROOM NUMBER]. The CNA remembered she took care of Resident #1 on a Monday and noticed bruising when she pulled back the blanket when the resident was in bed and saw bruising that was black and purple in color on her whole top half of her body including her breasts, sides, and stomach. CNA D reported she told Registered Nurse (RN) E and he went to the room to look at the resident and said it was from her positioning. RN E told the CNA to still get the resident up who was wincing in pain when the CNA moved her. CNA D reported she did not work on this unit much and had not seen the resident in a long time before this day. CNA D reported RN E knew about the bruising and told him he needed to fill out an incident report and then told UM A about the bruising on Resident #1. CNA D did not recall the facility getting any statements from her and did not understand why they did not ask any more questions. In an interview on 11/4/20 at 2:45 p.m., CNA F reported she noticed the bruising on Resident #1 when she worked the weekend prior to her going to the hospital on [DATE]. CNA F reported she noticed the bruising when she went to put her to bed and described the bruising looking like the resident got hit by a semi and the bruising looked like it had been there for a while. CNA F reported she told RN E who thought the bruising may have been from transferring the resident using a Sit to Stand device. CNA F reported the resident is supposed to transfer using a Hoyer lift. CNA F reported she did not understand why she seemed to be the only person shocked by the extensive bruising on Resident #1 and why other staff were oblivious to the bruising. CNA F reported she felt heartbroken for the resident. CNA F then clarified she may have seen the bruising on Resident #1 the Monday before the resident went to the hospital, but recalled the resident went to the hospital a couple days later after she took care of her and noticed the bruising. In an interview on 11/4/20 at 3:00 p.m., CNA G reported Resident #1 had bruising a while ago and reported it to RN E. CNA G reported the bruising she saw was not bad and on Resident #1's left side under her arm which was an old one then had newer bruising on the other side that came later. The bruising came across Resident #1's chest, under her breast. CNA G reported it was on a Sunday which was her weekend to work and that Monday she came in to work and Resident #1's bruising was much worse. CNA G reported that Monday RN E and UM A looked at Resident #1's bruising. In an interview on 11/5/20 at 8:49 a.m., LPN B reported the nursing Skin Assessments in the computer only address the New findings and a progress note should be made addressing the skin shower sheets initiated by the CNA's and completed by the nurses. UM A does weekly skin measurements on wounds. If a resident had a new skin concern LPN B would initiate a new nursing Skin Assessment, but if a resident already had a nursing Skin assessment initiated, there is nothing to prompt a continuing assessment if it already exists. In an interview on 11/5/20 at 8:57 a.m., RN E reported Resident #1 had bruising on the left flank and across her chest when she was on the 200 hall. Then she transferred to the 100 hall and the bruising was dark in color and yellow on the edges. RN E reported he knew about the bruising on the residents right side on a Monday and notified UM A as soon as she came in the door on that Monday, filled out an incident report and notified the physician of the left flank and chest bruising. RN E reported he saw bruising on that Sunday and saw more yellowing, the following Monday he recalled seeing bruising on the right side which was new. RN E did not recall Resident #1 having any pain. RN E said he was told that the bruising was from leaning over in her wheelchair and confirmed Resident #1 leaned over a lot but is doing better in her Broda chair. Not sure why it took so long for the resident get a Broda chair. RN E reported the UM A documents any wound measurements on residents. During an observation and an interview on 11/5/20 at 1:15 p.m., CNA H demonstrated how the Sit to Stand device works to transfer residents. The padding gets secured across the back and under the arm pits and a thinner belt like strap fastens across the chest, the resident is to then grab a hold of the handles and gets lifted to a standing position and then moved to where she needs to go. CNA H reported she took care of Resident #1 when she had a large bruise on her left side and chest and reported it to the nurse who reported she already charted it. In an interview on 11/5/20 at 1:20 p.m., Certified Occupational Therapy Assistant (COTA) J reported she did therapy for Resident #1 after she was referred on 9/7/20 for wheelchair positioning. The resident already had a bolster in place on the left side and implemented bolsters for the right side. COTA J is only aware of bruising across her chest and below her breasts and did not complain of pain during therapy. COTA J is not aware of any residents having bruising from poor positioning. In a telephone interview on 11/5/20 at approximately 2:00 p.m., The Director of Nursing (DON) reported Resident #1 had [MEDICAL CONDITION] (MS) and would slump over in her wheelchair and when a table was in front of her she would slump over the top of it. The bruising lined up across her chest with the table and the bruising on her flanks lined up with the wheelchair. The resident received therapy for positioning. In September, the resident was able to self-propel in her wheelchair and started to decline rapidly. The second bruising in October is much better now. The resident was using an EZ Stand (Sit to Stand) for transfers but many staff were already using the Hoyer lift. The significant bruising caused her to have a low hemoglobin (low blood level). The first bruise in September was milder compared to the second bruise in October and not clear where it came from. The DON reported they are not required to measure bruises. In a second interview on 11/5/20 at approximately 3:15 p.m., CNA F reported she only worked one weekend a month and reported she is not sure if she noticed the bruising on Resident #1 over that weekend but does remember the resident went to the hospital a couple days after she noticed the bruising on both breasts, and both sides of her flank and described the her chest being black and blue and remembered she told another nurse about it but is not sure what she did with the information. The resident is supposed to transfer using a Hoyer lift for about the last 6 months and has not seen anyone using the Sit to Stand to transfer the resident. In an interview on 11/9/20 at approximately 10:30 a.m., UM A reported Resident #1 had a bruise in September that seemed to be from a regular wheelchair with no bolsters and she just leaned over that way causing bruising based on her positioning. So the resident received therapy for positioning. Then in October UM A reported she came in to work on a Monday morning when RN E showed her that Resident #1 had bruising across her chest and toward the right side of her upper body. The Nurse Practitioner came in right after that to see the resident. The facility reported the incident to the State Agency. UM A thinks the bruising came from her MS [DIAGNOSES REDACTED]. The resident was self-propelling before this but observed leaning over a lot. Review of a Care Plan for Resident #1 revealed on 1-23-19 the resident was a Hoyer lift with 2 assist due to not always hanging on to the handles of the Sit to Stand transfer device. Several nonsensical revisions noted for transferring expectations and dates implemented. On 10/5/20 a Focus of Bruising t (TRUNCATED)

This citation pertains to intakes M 5502 and M100 6 Based on interview and record review, the facility failed to implement its abuse policy for two ( Resident #1 and Resident #3) of three residents reviewed for abuse/neglect. This deficient practice resulted in Resident #1 and Resident #2 having unexplained, repeated, suspicious, and painful injury/bruising from improper care and the potential to identify and respond to other continuous injuries and possible abuse and neglect with all other vulnerable residents. Findings include: Review of a policy titled Abuse and Neglect last revised 6/17/10 revealed: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Neglect is the failure to provide necessary and adequate (medical, personal, or psychological) care. Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional. IV. Identification: Have procedures to: Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. An injury should be classified as an injury of unknown source when both of the following conditions are met: a.The source of injury was not observed by any person or the source of injury could not be explained by the resident; and b.The injury is suspicious because of the extent of the injury or the location of the injury (example: the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at a particular point in time or the incidence over time.V.Investigation: Have procedures to: Investigate all allegations of abuse, neglect, misappropriation of property and incidents such as injuries of unknown source. All allegations will be investigated by the Administrator or Designee immediately. The initial and final reporting of the allegations will be done by the Administrator or Designee. VI. Protection: Have procedures to: Protect residents from harm during the investigation. 2.Affected residents will be assessed for injury. 3.Attending physician will be notified. a.This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation, etc. 1.If the alleged perpetrator is an employee, the employee will be immediately suspended from working pending the result of the investigation. The alleged staff will not be allowed to go back to work until the final investigation is forwarded to the appropriate State Agencies. If the alleged perpetrator is a visitor or a family member, the visitor will be denied unsupervised visitation. VII.Reporting/Response: Have procedures to: All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. All allegations of abuse will be reported to the appropriate State Agencies immediately after the initial allegation is received. A final investigation report will be submitted to the appropriate State Agencies within 5 working days. Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. Take all necessary corrective actions depending on the results of the investigation. Documentation within a client medical record is a vital aspect of nursing practice. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track (resident) outcomes, and reflect current standards of nursing practice .Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors .The record is a means by which health care team members communicate (resident) needs and progress .The record should be the most current and accurate source of information about a client ' s health care status .High-quality documentation .(is) necessary to enhance efficient, individualized (resident) care. Quality documentation .(has) five important characteristics: they are factual, accurate, complete, current, and organized (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). According to the Fundamentals of Nursing, 6th Edition (Mosby, Patricia A. Potter, Anne G. Perry, 2005 page 481) High quality documentation and reporting are necessary to enhance efficient, individualized client care. Quality documentation and reporting have five important characteristics: they are factual, accurate, complete, current, and organized, The use of inferences without supporting factual data is not acceptable because it can be misunderstood. Review of a policy titled Charting and Documentation adopted on 7/11/18 revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of a Face sheet revealed Resident #1 is an [AGE] year old female originally admitted to the facility on [DATE] with pertinent diagnoses of neuromuscular dysfunction, dementia, and diabetes. No diagnoses for [MEDICAL CONDITION] noted. Review of the Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed a Brief Interview for Mental Status (BIMS) indicated she is severely cognitively impaired and required extensive assistance of 2 staff for transfers and toileting and unsteady on feet. No history of falls, skin conditions, or bruising noted. Review of a Facility Reported Incident (FRI) submitted online on 10/6/20 at 12:43 p.m. revealed: Incident Summary on 10/6/20, the Administrator (NHA) and Director of Nursing (DON) received a call from Medical Director concerning bruising noted to resident that appears to be new and worsening. On 10/5/2020 the bruising was assessed and was thought to be related to decline in transfer status using EZ stand lift from the belt positioning and declined positioning in wheelchair. Her transfer status had already been downgraded to Hoyer lift and a Broda Chair was put into use for improved positioning. Resident is in bed and appears comfortable. There have been no allegations of abuse at this time. Due to the significance of the bruising, a full investigation has been initiated for possible injury of unknown origin. On 10/5/20, (Resident #1) was sent to the hospital for what appeared to be a sudden onset of increased bruising along with abnormal lab results. After speaking with the Unit Manager and reviewing clinical records, it was thought that the bruising was likely related to a recent decline in transfer status. Staff was using EZ stand lift, and bruising matched the belt-positioning. (Resident #1) was also noted to have had a noted decline in wheelchair positioning and trunk control over the weekend. On the morning of 10/06/2020, the Administrator and Director of Nursing were made aware that the bruising that was initially reported on 10/5/20 had worsened. Due to the bruising's significance, a full investigation was initiated for possible injury of unknown origin. The Director of Nursing and Administrator completed a full clinical review. On 9/3/2020, a Nursing Assistant noted a purple bruise on (Resident #1) anterior armpit, a pink area to the left outer breast, and a light purple bruise on the inner left upper arm. Poor positioning was discussed with IDT as caregivers observed increase lateral leaning while seated in w/c despite current interventions over the weekend. Transfer status was downgraded from EZ stand to Hoyer lift, Broda Chair and stat labs were ordered. Nurse reported significant bruising in addition to hemoglobin level of 7.0 to on call provider and an order was given to send (Resident #1) to the hospital for further evaluation of bruising and abnormal labs. Upon returning from the hospital, the new interventions were in place including transfer status downgrade from an EZ stand to a Hoyer lift with 2 assist, and a Broda Chair to increase comfort when up for meals. Root Cause Analysis/Contributive Factors: The investigation determined that the event was substantiated to have occurred, due to visible bruising. Bruising was concluded to have been caused from an acute onset of increasingly worsened positioning, posture, and trunk control due to her [DIAGNOSES REDACTED]. Actions taken based on investigative findings: · Resident was downgraded from EZ stand lift to Hoyer · Broda chair in use to increase comfort when up for meals. (sic) Review of questionnaires from staff regarding Resident #1's bruising, several staff reported the resident was in pain, noticed new and old bruising and told the nurses. One nurse reported she saw the new bruising and noted in provider communication. Another CNA reported on 10/6/20 that the resident was vomiting in bed, leaning to right side, increased the head of the bed and reported to the nurse. No documentation noted in electronic health records of the resident vomiting. Staff who reported new bruising did not indicate when or where they were when they saw the bruising and when they reported it to the nurse. Review of a Complaint reported to the State Agency on 10/7/20 regarding Resident #1 revealed: . (Resident #1) needs full assist for everything. (Resident #1) has labs done and she is anemic (low hemoglobin). (Resident #1) is currently at the hospital (10/06/20) but will be discharged back to the facility. (Resident #1) has bruising, blood from her bruising just around her breast and nipples. (Resident #1) ' s bi-lateral chest and nipples seemed to be bruised with old bruises and new bruises. This could be occurring from (Resident #1) or some other trauma. It is unknown what has occurred. (sic) Review of Hospital Records dated 10/6/20 revealed Resident #1 arrived at the emergency roiagnom on Tuesday, 10/6/20 at 5:41 a.m. revealed: I suspect acute blood loss [MEDICAL CONDITION] secondary to blood loss into the soft tissues. bruising, it appears to be primarily around the nipples and flanks, and based on this patter, I do have some suspicion, or at least and concern for elder abuse. hemoglobin of 7.9. Unfortunately, EMS (emergency medical services) was not able to get much report from the (Nursing Facility), but they do know that she had abnormal lab work and has had abnormal bruising over the past couple months. Physical Exam: Skin: Bruising (Significant ecchymosis (large, bruise like lesion caused by collection of extravascular blood in dermis and subcutaneous tissue caused by trauma or bleeding disorders) in varying degree of healing along the chest. The bruising appears to be most noticeable around bilateral nipples. No obvious hematoma. No tenderness.) present. Bruising as noted previously around bilateral breast as well as bilateral flanks. Bruises are of varying ages. There is concern that she may have been injured in some way . CT (computerized tomography) scan revealed: 1. Significant soft tissue swelling involving the left pectoralis muscles, probably related to diffuse intramuscular hemorrhage. Small measurable intramuscular hematoma also present in the left pectoralis major. 2. Minimally buckled fractures of the anterior left fourth and fifth ribs, age indeterminate. I spoke with her primary care provider . I relayed to him the findings of our scans and the history. He will see her tomorrow at her care facility. Review of an Incident Report dated 9/3/20 for Resident #1 revealed: CENA (Certified Nursing Assistant (CNA)) reported bruise noted when cares given. Purple bruise on anterior armpit, pink rubbed area left outer breast, and light purple inner left, upper arm. CENA that did her cares day prior did not observe any bruising. Immediate Action Taken: Towel placed in gap between bolster on w/c (wheelchair) arm and back of w/c. Notes: Anterior armpit purple bruise 3x2.5 cm (centimeters), 2x1 cm inner upper left arm light bruise, 4.5 x 7, left outer breast pink rubbed area. Predisposing factors: Using Wheelchair. Other info: Bolster on w/c sliding forward leaving a gap between bolster and back of w/c. Notes: (Staff)- I did (Resident #1's) a.m. care on 9/2/20 and did not see any bruising. I do often see (Resident #1 leaning in her chair to the left. (Staff) I was unaware of (Resident #1) bruising under left arm but have noticed (Resident #1) leaning over left side of wheelchair, hanging over left side of wheelchair. Resident tends to favor leaning to left side Privileged and Confidential- Not part of the Medical Record. No further documentation provided with this incident report. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed: No redness, bruising, or open areas. Review of a nursing Progress Note dated 9/1/20 for Resident #1 revealed: Bed bath given. No redness, bruising, or open areas noted. Denies any pain or discomfort. Review of a nursing Progress Note dated 9/3/20 for Resident #1 revealed: Bruises noted during a.m. cares. Anterior armpit purple bruise 3 x 2.5 cm, 2 x 1 cm, inner upper left arm light bruise, 4.5 x 7 cm, left outer breast pink rubbed area. Bruising not noted with cares yesterday per aide. Leans to left side often and is repositioned. PT (Physical Therapy) evaluation . Review of an Occupational Therapy (OT) Plan of Care document dated 9/7/20 for Resident #1 revealed: Pt (patient) referred to OT services 2/2 bruising on L (left) underarm armpit and L breast area per nursing staff. Nurse states may have been from bolster sliding forward and pt leaned over left side of w/c (wheelchair) armrest, causing increased pain. Therapy necessity: Therapy necessary for decreasing L arm pain, bruising and increased participation with ADL (activities of Daily Living) routine. Without therapy patient at risk for functional decline and falls. Pt resides in this LTC (long term care) facility with ext. (extensive) assist for ADL routine. Patient previously utilized EZ stand for transfers. Previous Therapy: Pt received PT (physical therapy) last month for transfer training. Pt states pain in L underarm, armpit, and L side breast area at 5/10 with shoulder flexion and ROM (range of motion) with self-feeding. No numbness stated on BUE (bilateral upper extremities), however pt's BUE hands were cold to the touch with some bruising noted on B dorsal (back) side of hands. The patient reports pain in L upper arm of moderate. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. Review of a Skin Observation Shower sheet dated 9/10/20 for Resident #1 which is not part of the medical record revealed the outline of a body shows no skin alterations or locations and not marked for alterations. The Licensed Nurse comments revealed: Continues with fading and healing bruises to left anterior armpit, inner upper left arm. Review of a Medical Practitioner Progress note dated 9/10/20 for Resident #1 revealed: . She has had some generalized bruising noted documented, but no open areas. She is having PT (physical therapy) see her to provide a bolster for better seating in her wheelchair so that the chair does not cause any areas of potential pressure points and bruising. Review of a Skin Observation Shower sheet dated 9/17/20 for Resident #1 which is not part of the medical record revealed the body outline diagram has an oval outline reaching from the left armpit down the left side of the resident and the box for bruises is checked off. The Licensed Nurse comments revealed: Continues with healing bruises to left breast and under left arm. Review of a Nurse Practitioner Note dated 9/17/20 for Resident #1 revealed no acknowledgement of bruising on Resident #1. Resident #1 is seen today for evaluation and management of multiple, complex, chronic medical problem that requires frequent monitoring to maintain stability and to prevent further decline. She is also specifically seen for transition of care and follow up of vitamin D deficiency. Skin: Skin is warm and dry, afebrile. (sic) Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. Review of a Skin Observation Shower sheet dated 9/24/20 for Resident #1which is not part of the medical record revealed the body outline diagram has an oval outline reaching from the left armpit down the left side of the resident and the box for bruises is checked off. The Licensed Nurse comments revealed: Continues with healing bruises to left breast and under left arm. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. Review of a Skin Observation Shower sheet dated 10/1/20 for Resident #1 which is not part of the medical record revealed the body diagram outline had no marks and the box for bruises is checked off. Licensed Nurse comments revealed: Fading bruising to left breast and under left arm. No Skin Observation Shower records provided to this surveyor after 10/1/20 to 10/22/20. Review of a Late Entry Nursing Progress Note back dated 10/4/20 and created on 10/9/20 for Resident #1 revealed: old yellow bruising to left breast and flank, bruising extended to right breast and flank appearing dark in color, resident had no complaints of pain until being repositioned for check and change whiled rolled onto side, pain subsided once in neutral position, VS (vital signs) stable, physician note made. Review of a Weekly Skin assessment dated [DATE] and entered into the Electronic Health Record (EHR) on 10/9/20 for Resident #1 revealed a New alteration in skin integrity. It should be noted that pt (patient) has [MEDICAL CONDITION], type II diabetes, hypertension, [MEDICAL CONDITION] and Dementia as major medical problems, among others. It is noted that pt has been declining slowly and has been unable to hold her posture erect as a result of progressive neurological disorder [MEDICAL CONDITION]. Pt has been leaning forward and to right or left. Pt is also dependent on staff for all ADL (activities of daily living) including transfers. Pt's posture, leaning on arm rest either left or right as she is unable to hold posture erect may have exacerbated. First bruising was noted on 9/3 and since then therapy has evaluated for maintain pt's posture. In addition being on ASA (aspirin) did not help, as it may have contributed to bleeding in muscles and subcutaneous tissues leading to a larger bruise. Pt was observed to be comfortable with staff and no fear or concern noted. (sic) No measurements, location, or descriptions noted. Review of a Nursing Progress note dated 10/5/20 for Resident #1 revealed: Pt was observed throughout weekend to slouch and lay to either side in her wheelchair. Was frequently assisted to sit up and repositioned but this am (Monday) bruising to left flank and chest was increased and now bruising to right flank. Manager notified, Dr. notified. Family called and message left requesting call back. Broda chair ordered for comfort and intervention. Awaiting any additional order from Dr. Review of a Nursing Progress Note dated 10/6/20 for Resident #1 revealed: STAT lab results call in to Nurse on call (Nurse Practitioner) and order noted to send resident to hospital for eval. hemoglobin 7.0 (normal value is 12.0 to 16.0). Review of a laboratory result dated 7/8/20 revealed Resident #1 had a hemoglobin of 12.9. Review of an eInteract Transfer Form dated 10/6/20 at 4:08 a.m. and locked dated of 10/12/20 at 10:40 p.m. for Resident #1 revealed she was discharged to Hospital. Review of a Nurse Practitioner Note dated 10/6/20 at 3:00 p.m. for Resident #1 revealed: Pt seen at the request of nursing staff for eval of Bruising and F/U (follow up) ER (emergency room ) visit. She was noted to have extensive bruising recently. Blood work was done including coagulation studies which were mostly with in acceptable range with the exception of low (hemoglobin). Subsequently she was sent to ER for Eval. she was transferred from chair to commode and chair to bed using EZ stand/Sit to stand. It is my understanding that the strap that supports patient while on EZ stand is applied behind the back, passed under the axilla and stabilized in front. When pt is raised in EZ stand, pressure applied to areas on the chest and fragile nature of her skin has caused bruising. Pt's posture, leaning on arm rest either left or right as she is unable to hold posture erect may have exacerbated. First bruising was noted on 9/3 and contributed to bleeding in muscles and subcutaneous tissues leading to a larger bruises. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1revealed the resident had a new alteration to her skin integrity. Bruising to chest and bilateral sides appear to be dissipating and to be healing well. (Resident #1) denied pain and stated she felt comfortable during this assessment. (Resident #1) is able to accurately answer Yes/No questions. When asked if she felt safe - yes. Asked if she enjoys living here - yes. Asked if we take good care of her - yes. Asked if anyone has ever hurt her here - no. (Resident #1) appeared comfortable, is being assisted with frequent repositioning with no new skin concerns. (sic) Review of a Nurse Practitioner Note dated 10/12/20 for Resident #1 revealed: (Resident #1) has been evaluated today at request of nursing staff for elevated blood pressure. Upon evaluation, the patient is resting in bed. Staff also had concerns of an episode low oxygenation with the O2 (oxygen) sat of 88 (normal is 92 t0 100%). Her lungs did demonstrate crackles in the bases. She has not been out of bed. The patient was recently hospitalized with a hemoglobin of 7 with excessive bruising on the chest and flank. Last hemoglobin demonstrated with 7.8. Bruising appears to be dissipating. Review of a Late Entry General Progress Note back dated 10/5/20 and created by the Director of Nursing (DON) on 10/12/20 at 4:51 p.m. for Resident #1 revealed: Bruising noted to chest and bilateral sides of trunk. It should be noted that pt has [MEDICAL CONDITION], type II diabetes, hypertension, [MEDICAL CONDITION], and dementia as major medical problems among others. It is noted that pt has been declining slowly and has been unable to hold her posture erect as a result of progressive neurological disorder [MEDICAL CONDITION]. Pt has been leaning forward and to right or left. Pt is also dependent on staff for all ADL including transfers. Pt's posture, leaning on arm rest either left or right as she is unable to hold posture erect may have exacerbated. First bruising was noted on 9/3 and since then therapy has evaluated, for maintaining pt's posture. In addition being on ASA did not help, as it may have contributed to bleeding in muscles and subcutaneous tissues leading to a larger bruises. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alteration in skin integrity. No documentation of past bruising noted. Review of a Skin Observation Shower sheet dated 10/22/20 for Resident #1 which is not part of the medical record revealed the body outline diagram had an oval outline that encircled the left underarm and down the left side and a small circular outline of the right underarm. The check box for bruises is marked. Licensed Nurse comments revealed: yellow light purple bruising to left breast and under left arm. Small yellow bruise to right arm and chest. Both of which are not new and are fading. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. No documentation of past bruising noted. Review of a Skin Observation Shower sheet dated 10/29/20 for Resident #1 which is not part of the medical record revealed the body outline diagram had an oval outline surrounding the left underarm and down the left side. The Licensed Nurse Comments revealed: Light purple bruising under left breast and on left flank continues to heal. Review of a Hospice document dated 11/2/20 revealed Resident #1 was admitted to Hospice. During an observation and an interview on f 11/4/20 at 10:55 a.m., Resident #1 observed in the dining room sitting in a Broda Chair (special chair for positioning) with puff boots on both feet and reported her sister got mad at her and hit her when queried about her bruising. Licensed Practical Nurse (LPN) B reported the resident had large bruising on the right side of her body and across her chest. In an interview on 11/4/20 at approximately 11:15 a.m., LPN C reported Resident #1 used to reside in room [ROOM NUMBER] when she took care of her and recently transferred to room [ROOM NUMBER]. LPN C did remember a Certified Nursing Assistant (CNA) told her the resident had some bruising but could not remember when or any of the details of the bruising. The nurse could not remember if she documented measurements of bruising. In an interview on 11/4/20 at 2:30 p.m., CNA D reported Resident #1 used to be in room [ROOM NUMBER] and then transferred to room [ROOM NUMBER]. The CNA remembered she took care of Resident #1 on a Monday and noticed bruising when she pulled back the blanket when the resident was in bed and saw bruising that was black and purple in color on her whole top half of her body including her breasts, sides, and stomach. CNA D reported she told Registered Nurse (RN) E and he went to the room to look at the resident and said it was from her positioning. RN E told the CNA to still get the resident up who was wincing in pain when the CNA moved her. CNA D reported she did not work on this unit much and had not seen the resident in a long time before this day. CNA D reported RN E knew about the bruising and told him he needed to fill out an incident report and then told UM A about the bruising on Resident #1. CNA D did not recall the facility getting any statements from her and did not understand why they did not ask any more questions. In an interview on 11/4/20 at 2:45 p.m., CNA F reported she noticed the bruising on Resident #1 when she worked the weekend prior to her going to the hospital on [DATE]. CNA F reported she noticed the bruising when she went to put her to bed and described the bruising looking like the resident got hit by a semi and the bruising looked like it had been there for a while. CNA F reported she told RN E who thought the bruising may have been from transferring the resident using a Sit to Stand device. CNA F reported the resident is supposed to transfer using a Hoyer lift. CNA F reported she did not understand why she seemed to be the only person shocked by the extensive bruising on Resident #1 and why other staff were oblivious to the bruising. CNA F reported she felt heartbroken for the resident. CNA F then clarified she may have seen the bruising on Resident #1 the Monday before the resident went to the hospital, but recalled the resident went to the hospital a couple days later after she took care of her and noticed the bruising. In an interview on 11/4/20 at 3:00 p.m., CNA G reported Resident #1 had bruising a while ago and reported it to RN E. CNA G reported the bruising she saw was not bad and on Resident #1's left side under her arm which was an old one then had newer bruising on the other side that came later. The bruising came across Resident #1's chest, under her breast. CNA G reported it was on a Sunday which was her weekend to work and that Monday she came in to work and Resident #1's bruising was much worse. CNA G reported that Monday RN E and UM A looked at Resident #1's bruising. In an interview on 11/5/20 at 8:49 a.m., LPN B reported the nursing Skin Assessments in the computer only address the New findings and a progress note should be made addressing the skin shower sheets initiated by the CNA's and completed by the nurses. UM A does weekly skin measurements on wounds. If a resident had a new skin concern LPN B would initiate a new nursing Skin Assessment, but if a resident already had a nursing Skin assessment initiated, there is nothing to prompt a continuing assessment if it already exists. In an interview on 11/5/20 at 8:57 a.m., RN E reported Resident #1 had bruising on the left flank and across her chest when she was on the 200 hall. Then she transferred to the 100 hall and the bruising was dark in color and yellow on the edges. RN E reported he knew about the bruising on the residents right side on a Monday and notified UM A as soon as she came in the door on that Monday, filled out an incident report and notified the physician of the left flank and chest bruising. RN E reported he saw bruising on that Sunday and saw more yellowing, the following Monday he recalled seeing bruising on the right side which was new. RN E did not recall Resident #1having any pain. RN E said he was told that the bruising was from leaning over in her wheelchair and confirmed Resident #1 leaned over a lot but is doing better in her Broda chair. Not sure why it took so long for the resident get a Broda chair. RN E reported the UM A documents any wound measurements on residents. During an observation and an interview on 11/5/20 at 1:15 p.m., CNA H demonstrated how the Sit to Stand device works to transfer residents. The padding gets secured across the back and under the arm pits and a thinner belt like strap fastens across the chest, the resident is to then grab a hold of the handles and gets lifted to a standing position and then moved to where she needs to go. CNA H reported she took care of Resident #1 when she had a large bruise on her left side and chest and reported it to the nurse who reported she already charted it. In an interview on 11/5/20 at 1:20 p.m., Certified Occupational Therapy Assistant (COTA) J reported she did therapy for Resident #1 after she was referred on 9/7/20 for wheelchair positioning. The resident already had a bolster in place on the left side and implemented bolsters for the right side. COTA J is only aware of bruising across her chest and below her breasts and did not complain of pain during therapy. COTA J is not aware of any residents having bruising from poor positioning. In a telephone interview on 11/5/20 at approximately 2:00 p.m., The Director of Nursing (DON) reported Resident #1 had [MEDICAL CONDITION] (MS) and would slump over in her wheelchair and when a table was in front of her she would slump over the top of it. The bruising lined up across her chest with the table and the bruising on her flanks lined up with the wheelchair. The resident received therapy for positioning. In September, the resident was able to self-propel in her wheelchair and started to decline rapidly. The second bruising in October is much better now. The resident was using an EZ Stand (Sit to Stand) for transfers but many staff were already using the Hoyer lift. The significant bruising caused her to have a low hemoglobin (low blood level). The first bruise in September was milder compared to the second bruise in October and not clear where it came from. The DON report (TRUNCATED)

This citation pertains to intakes M 5502 and M 5746 Based on observation, interview and record review, the facility failed to meaningfully investigate, correct, and prevent injuries of unknown origin for two (Resident #1 and Resident #3), of 3 residents reviewed, resulting in continued and repeated suspicious injuries to Resident #1 and bruising in a suspicious area to Resident #3 and the potential for abuse and neglect to go undetected, not investigated, not corrected, and injuries to continue. Findings include: Review of a policy titled Abuse and Neglect last revised 6/17/10 revealed: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Neglect is the failure to provide necessary and adequate (medical, personal, or psychological) care. Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional. IV. Identification: Have procedures to: Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. An injury should be classified as an injury of unknown source when both of the following conditions are met: a. The source of injury was not observed by any person or the source of injury could not be explained by the resident; and bathe injury is suspicious because of the extent of the injury or the location of the injury (example: the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at a particular point in time or the incidence over time.V. Investigation: Have procedures to: Investigate all allegations of abuse, neglect, misappropriation of property and incidents such as injuries of unknown source. All allegations will be investigated by the Administrator or Designee immediately. The initial and final reporting of the allegations will be done by the Administrator or Designee. VI. Protection: Have procedures to: Protect residents from harm during the investigation. 2. Affected residents will be assessed for injury. 3. Attending physician will be notified. a. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation, etc. 1. If the alleged perpetrator is an employee, the employee will be immediately suspended from working pending the result of the investigation. The alleged staff will not be allowed to go back to work until the final investigation is forwarded to the appropriate State Agencies. If the alleged perpetrator is a visitor or a family member, the visitor will be denied unsupervised visitation. VII. Reporting/Response: Have procedures to: All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. All allegations of abuse will be reported to the appropriate State Agencies immediately after the initial allegation is received. A final investigation report will be submitted to the appropriate State Agencies within 5 working days. Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. Take all necessary corrective actions depending on the results of the investigation. Documentation within a client medical record is a vital aspect of nursing practice. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track (resident) outcomes, and reflect current standards of nursing practice .Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors .The record is a means by which health care team members communicate (resident) needs and progress .The record should be the most current and accurate source of information about a client ' s health care status .High-quality documentation .(is) necessary to enhance efficient, individualized (resident) care. Quality documentation .(has) five important characteristics: they are factual, accurate, complete, current, and organized (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). According to the Fundamentals of Nursing, 6th Edition (Mosby, Patricia A. Potter, Anne G. Perry, 2005 page 481) High quality documentation and reporting are necessary to enhance efficient, individualized client care. Quality documentation and reporting have five important characteristics: they are factual, accurate, complete, current, and organized, The use of inferences without supporting factual data is not acceptable because it can be misunderstood. Review of a policy titled Charting and Documentation adopted on 7/11/18 revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Resident #1 Review of a Face sheet revealed Resident #1 is an [AGE] year old female originally admitted to the facility on [DATE] with pertinent diagnoses of neuromuscular dysfunction, dementia, and diabetes. No diagnoses for [MEDICAL CONDITION] noted. Review of the Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed a Brief Interview for Mental Status (BIMS) indicated she is severely cognitively impaired and required extensive assistance of 2 staff for transfers and toileting and unsteady on feet. No history of falls, skin conditions, or bruising noted. Review of a Facility Reported Incident (FRI) submitted online on 10/6/20 at 12:43 p.m. revealed: Incident Summary on 10/6/20, the Administrator (NHA) and Director of Nursing (DON) received a call from Medical Director concerning bruising noted to resident that appears to be new and worsening. On 10/5/2020 the bruising was assessed and was thought to be related to decline in transfer status using EZ stand lift from the belt positioning and declined positioning in wheelchair. Her transfer status had already been downgraded to Hoyer lift and a Broda Chair was put into use for improved positioning. Resident is in bed and appears comfortable. There have been no allegations of abuse at this time. Due to the significance of the bruising, a full investigation has been initiated for possible injury of unknown origin. On 10/5/20, (Resident #1) was sent to the hospital for what appeared to be a sudden onset of increased bruising along with abnormal lab results. After speaking with the Unit Manager and reviewing clinical records, it was thought that the bruising was likely related to a recent decline in transfer status. Staff was using EZ stand lift, and bruising matched the belt-positioning. (Resident #1) was also noted to have had a noted decline in wheelchair positioning and trunk control over the weekend. On the morning of 10/06/2020, the Administrator and Director of Nursing were made aware that the bruising that was initially reported on 10/5/20 had worsened. Due to the bruising's significance, a full investigation was initiated for possible injury of unknown origin. The Director of Nursing and Administrator completed a full clinical review. On 9/3/2020, a Nursing Assistant noted a purple bruise on (Resident #1) anterior armpit, a pink area to the left outer breast, and a light purple bruise on the inner left upper arm. Poor positioning was discussed with IDT as caregivers observed increase lateral leaning while seated in w/c despite current interventions over the weekend. Transfer status was downgraded from EZ stand to Hoyer lift, Broda Chair and stat labs were ordered. Nurse reported significant bruising in addition to hemoglobin level of 7.0 to on call provider and an order was given to send (Resident #1) to the hospital for further evaluation of bruising and abnormal labs. Upon returning from the hospital, the new interventions were in place including transfer status downgrade from an EZ stand to a Hoyer lift with 2 assist, and a Broda Chair to increase comfort when up for meals. Root Cause Analysis/Contributive Factors: The investigation determined that the event was substantiated to have occurred, due to visible bruising. Bruising was concluded to have been caused from an acute onset of increasingly worsened positioning, posture, and trunk control due to her [DIAGNOSES REDACTED]. Actions taken based on investigative findings: · Resident was downgraded from EZ stand lift to Hoyer · Broda chair in use to increase comfort when up for meals. (sic) Review of questionnaires from staff regarding Resident #1's bruising, several staff reported the resident was in pain, noticed new and old bruising and told the nurses. One nurse reported she saw the new bruising and noted in provider communication. Another CNA reported on 10/6/20 that the resident was vomiting in bed, leaning to right side, increased the head of the bed and reported to the nurse. No documentation noted in electronic health records of the resident vomiting. Staff who reported new bruising did not indicate when or where they were when they saw the bruising and when they reported it to the nurse. Review of a Complaint reported to the State Agency on 10/7/20 regarding Resident #1 revealed: . (Resident #1) needs full assist for everything. (Resident #1) has labs done and she is anemic (low hemoglobin). (Resident #1) is currently at the hospital (10/06/20) but will be discharged back to the facility. (Resident #1) has bruising, blood from her bruising just around her breast and nipples. (Resident #1) ' s bi-lateral chest and nipples seemed to be bruised with old bruises and new bruises. This could be occurring from (Resident #1) or some other trauma. It is unknown what has occurred. (sic) Review of Hospital Records dated 10/6/20 revealed Resident #1 arrived at the emergency roiagnom on Tuesday, 10/6/20 at 5:41 a.m. revealed: I suspect acute blood loss [MEDICAL CONDITION] secondary to blood loss into the soft tissues. bruising, it appears to be primarily around the nipples and flanks, and based on this patter, I do have some suspicion, or at least and concern for elder abuse. hemoglobin of 7.9. Unfortunately, EMS (emergency medical services) was not able to get much report from the (Nursing Facility), but they do know that she had abnormal lab work and has had abnormal bruising over the past couple months. Physical Exam: Skin: Bruising (Significant ecchymosis (large, bruise like lesion caused by collection of extravascular blood in dermis and subcutaneous tissue caused by trauma or bleeding disorders) in varying degree of healing along the chest. The bruising appears to be most noticeable around bilateral nipples. No obvious hematoma. No tenderness.) present. Bruising as noted previously around bilateral breast as well as bilateral flanks. Bruises are of varying ages. There is concern that she may have been injured in some way . CT (computerized tomography) scan revealed: 1. Significant soft tissue swelling involving the left pectoralis muscles, probably related to diffuse intramuscular hemorrhage. Small measurable intramuscular hematoma also present in the left pectoralis major. 2. Minimally buckled fractures of the anterior left fourth and fifth ribs, age indeterminate. I spoke with her primary care provider . I relayed to him the findings of our scans and the history. He will see her tomorrow at her care facility. Review of an Incident Report dated 9/3/20 for Resident #1 revealed: CENA (Certified Nursing Assistant (CNA)) reported bruise noted when cares given. Purple bruise on anterior armpit, pink rubbed area left outer breast, and light purple inner left, upper arm. CENA that did her cares day prior did not observe any bruising. Immediate Action Taken: Towel placed in gap between bolster on w/c (wheelchair) arm and back of w/c. Notes: Anterior armpit purple bruise 3x2.5 cm (centimeters), 2x1 cm inner upper left arm light bruise, 4.5 x 7, left outer breast pink rubbed area. Predisposing factors: Using Wheelchair. Other info: Bolster on w/c sliding forward leaving a gap between bolster and back of w/c. Notes: (Staff)- I did (Resident #1's) a.m. care on 9/2/20 and did not see any bruising. I do often see (Resident #1 leaning in her chair to the left. (Staff) I was unaware of (Resident #1) bruising under left arm but have noticed (Resident #1) leaning over left side of wheelchair, hanging over left side of wheelchair. Resident tends to favor leaning to left side Privileged and Confidential- Not part of the Medical Record. No further documentation provided with this incident report. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed: No redness, bruising, or open areas. Review of a nursing Progress Note dated 9/1/20 for Resident #1 revealed: Bed bath given. No redness, bruising, or open areas noted. Denies any pain or discomfort. Review of a nursing Progress Note dated 9/3/20 for Resident #1 revealed: Bruises noted during a.m. cares. Anterior armpit purple bruise 3 x 2.5 cm, 2 x 1 cm, inner upper left arm light bruise, 4.5 x 7 cm, left outer breast pink rubbed area. Bruising not noted with cares yesterday per aide. Leans to left side often and is repositioned. PT (Physical Therapy) evaluation . Review of an Occupational Therapy (OT) Plan of Care document dated 9/7/20 for Resident #1 revealed: Pt (patient) referred to OT services 2/2 bruising on L (left) underarm armpit and L breast area per nursing staff. Nurse states may have been from bolster sliding forward and pt leaned over left side of w/c (wheelchair) armrest, causing increased pain. Therapy necessity: Therapy necessary for decreasing L arm pain, bruising and increased participation with ADL (activities of Daily Living) routine. Without therapy patient at risk for functional decline and falls. Pt resides in this LTC (long term care) facility with ext. (extensive) assist for ADL routine. Patient previously utilized EZ stand for transfers. Previous Therapy: Pt received PT (physical therapy) last month for transfer training. Pt states pain in L underarm, armpit, and L side breast area at 5/10 with shoulder flexion and ROM (range of motion) with self-feeding. No numbness stated on BUE (bilateral upper extremities), however pt's BUE hands were cold to the touch with some bruising noted on B dorsal (back) side of hands. The patient reports pain in L upper arm of moderate. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. Review of a Skin Observation Shower sheet dated 9/10/20 for Resident #1 which is not part of the medical record revealed the outline of a body shows no skin alterations or locations and not marked for alterations. The Licensed Nurse comments revealed: Continues with fading and healing bruises to left anterior armpit, inner upper left arm. Review of a Medical Practitioner Progress note dated 9/10/20 for Resident #1 revealed: . She has had some generalized bruising noted documented, but no open areas. She is having PT (physical therapy) see her to provide a bolster for better seating in her wheelchair so that the chair does not cause any areas of potential pressure points and bruising. Review of a Skin Observation Shower sheet dated 9/17/20 for Resident #1 which is not part of the medical record revealed the body outline diagram has an oval outline reaching from the left armpit down the left side of the resident and the box for bruises is checked off. The Licensed Nurse comments revealed: Continues with healing bruises to left breast and under left arm. Review of a Nurse Practitioner Note dated 9/17/20 for Resident #1 revealed no acknowledgement of bruising on Resident #1. Resident #1 is seen today for evaluation and management of multiple, complex, chronic medical problem that requires frequent monitoring to maintain stability and to prevent further decline. She is also specifically seen for transition of care and follow up of vitamin D deficiency. Skin: Skin is warm and dry, afebrile. (sic) Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. Review of a Skin Observation Shower sheet dated 9/24/20 for Resident #1 which is not part of the medical record revealed the body outline diagram has an oval outline reaching from the left armpit down the left side of the resident and the box for bruises is checked off. The Licensed Nurse comments revealed: Continues with healing bruises to left breast and under left arm. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. Review of a Skin Observation Shower sheet dated 10/1/20 for Resident #1 which is not part of the medical record revealed the body diagram outline had no marks and the box for bruises is checked off. Licensed Nurse comments revealed: Fading bruising to left breast and under left arm. No Skin Observation Shower records provided to this surveyor after 10/1/20 to 10/22/20. Review of a Late Entry Nursing Progress Note back dated 10/4/20 and created on 10/9/20 for Resident #1 revealed: old yellow bruising to left breast and flank, bruising extended to right breast and flank appearing dark in color, resident had no complaints of pain until being repositioned for check and change whiled rolled onto side, pain subsided once in neutral position, VS (vital signs) stable, physician note made. Review of a Weekly Skin assessment dated [DATE] and entered into the Electronic Health Record (EHR) on 10/9/20 for Resident #1 revealed a New alteration in skin integrity. It should be noted that pt (patient) has [MEDICAL CONDITION], type II diabetes, hypertension, [MEDICAL CONDITION] and Dementia as major medical problems, among others. It is noted that pt has been declining slowly and has been unable to hold her posture erect as a result of progressive neurological disorder [MEDICAL CONDITION]. Pt has been leaning forward and to right or left. Pt is also dependent on staff for all ADL (activities of daily living) including transfers. Pt's posture, leaning on arm rest either left or right as she is unable to hold posture erect may have exacerbated. First bruising was noted on 9/3 and since then therapy has evaluated for maintain pt's posture. In addition being on ASA (aspirin) did not help, as it may have contributed to bleeding in muscles and subcutaneous tissues leading to a larger bruise. Pt was observed to be comfortable with staff and no fear or concern noted. (sic) No measurements, location, or descriptions noted. Review of a Nursing Progress note dated 10/5/20 for Resident #1 revealed: Pt was observed throughout weekend to slouch and lay to either side in her wheelchair. Was frequently assisted to sit up and repositioned but this am (Monday) bruising to left flank and chest was increased and now bruising to right flank. Manager notified, Dr. notified. Family called and message left requesting call back. Broda chair ordered for comfort and intervention. Awaiting any additional order from Dr. Review of a Nursing Progress Note dated 10/6/20 for Resident #1 revealed: STAT lab results call in to Nurse on call (Nurse Practitioner) and order noted to send resident to hospital for eval. hemoglobin 7.0 (normal value is 12.0 to 16.0). Review of a laboratory result dated 7/8/20 revealed Resident #1 had a hemoglobin of 12.9. Review of an eInteract Transfer Form dated 10/6/20 at 4:08 a.m. and locked dated of 10/12/20 at 10:40 p.m. for Resident #1 revealed she was discharged to Hospital. Review of a Nurse Practitioner Note dated 10/6/20 at 3:00 p.m. for Resident #1 revealed: Pt seen at the request of nursing staff for eval of Bruising and F/U (follow up) ER (emergency room ) visit. She was noted to have extensive bruising recently. Blood work was done including coagulation studies which were mostly with in acceptable range with the exception of low (hemoglobin). Subsequently she was sent to ER for Eval. she was transferred from chair to commode and chair to bed using EZ stand/Sit to stand. It is my understanding that the strap that supports patient while on EZ stand is applied behind the back, passed under the axilla and stabilized in front. When pt is raised in EZ stand, pressure applied to areas on the chest and fragile nature of her skin has caused bruising. Pt's posture, leaning on arm rest either left or right as she is unable to hold posture erect may have exacerbated. First bruising was noted on 9/3 and contributed to bleeding in muscles and subcutaneous tissues leading to a larger bruises. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed the resident had a new alteration to her skin integrity. Bruising to chest and bilateral sides appear to be dissipating and to be healing well. (Resident #1) denied pain and stated she felt comfortable during this assessment. (Resident #1) is able to accurately answer Yes/No questions. When asked if she felt safe - yes. Asked if she enjoys living here - yes. Asked if we take good care of her - yes. Asked if anyone has ever hurt her here - no. (Resident #1) appeared comfortable, is being assisted with frequent repositioning with no new skin concerns. (sic) Review of a Nurse Practitioner Note dated 10/12/20 for Resident #1 revealed: (Resident #1) has been evaluated today at request of nursing staff for elevated blood pressure. Upon evaluation, the patient is resting in bed. Staff also had concerns of an episode low oxygenation with the O2 (oxygen) sat of 88 (normal is 92 to 100%). Her lungs did demonstrate crackles in the bases. She has not been out of bed. The patient was recently hospitalized with a hemoglobin of 7 with excessive bruising on the chest and flank. Last hemoglobin demonstrated with 7.8. Bruising appears to be dissipating. Review of a Late Entry General Progress Note back dated 10/5/20 and created by the Director of Nursing (DON) on 10/12/20 at 4:51 p.m. for Resident #1 revealed: Bruising noted to chest and bilateral sides of trunk. It should be noted that pt has [MEDICAL CONDITION], type II diabetes, hypertension, [MEDICAL CONDITION], and dementia as major medical problems among others. It is noted that pt has been declining slowly and has been unable to hold her posture erect as a result of progressive neurological disorder [MEDICAL CONDITION]. Pt has been leaning forward and to right or left. Pt is also dependent on staff for all ADL including transfers. Pt's posture, leaning on arm rest either left or right as she is unable to hold posture erect may have exacerbated. First bruising was noted on 9/3 and since then therapy has evaluated, for maintaining pt's posture. In addition being on ASA did not help, as it may have contributed to bleeding in muscles and subcutaneous tissues leading to a larger bruises. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alteration in skin integrity. No documentation of past bruising noted. Review of a Skin Observation Shower sheet dated 10/22/20 for Resident #1 which is not part of the medical record revealed the body outline diagram had an oval outline that encircled the left underarm and down the left side and a small circular outline of the right underarm. The check box for bruises is marked. Licensed Nurse comments revealed: yellow light purple bruising to left breast and under left arm. Small yellow bruise to right arm and chest. Both of which are not new and are fading. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. No documentation of past bruising noted. Review of a Skin Observation Shower sheet dated 10/29/20 for Resident #1 which is not part of the medical record revealed the body outline diagram had an oval outline surrounding the left underarm and down the left side. The Licensed Nurse Comments revealed: Light purple bruising under left breast and on left flank continues to heal. Review of a Hospice document dated 11/2/20 revealed Resident #1 was admitted to Hospice. During an observation and an interview on 11/4/20 at 10:55 a.m., Resident #1 observed in the dining room sitting in a Broda Chair (special chair for positioning) with puff boots on both feet and reported her sister got mad at her and hit her when queried about her bruising. Licensed Practical Nurse (LPN) B reported the resident had large bruising on the right side of her body and across her chest. In an interview on 11/4/20 at approximately 11:15 a.m., LPN C reported Resident #1 used to reside in room [ROOM NUMBER] when she took care of her and recently transferred to room [ROOM NUMBER]. LPN C did remember a Certified Nursing Assistant (CNA) told her the resident had some bruising but could not remember when or any of the details of the bruising. The nurse could not remember if she documented measurements of bruising. In an interview on 11/4/20 at 2:30 p.m., CNA D reported Resident #1 used to be in room [ROOM NUMBER] and then transferred to room [ROOM NUMBER]. The CNA remembered she took care of Resident #1 on a Monday and noticed bruising when she pulled back the blanket when the resident was in bed and saw bruising that was black and purple in color on her whole top half of her body including her breasts, sides, and stomach. CNA D reported she told Registered Nurse (RN) E and he went to the room to look at the resident and said it was from her positioning. RN E told the CNA to still get the resident up who was wincing in pain when the CNA moved her. CNA D reported she did not work on this unit much and had not seen the resident in a long time before this day. CNA D reported RN E knew about the bruising and told him he needed to fill out an incident report and then told UM A about the bruising on Resident #1. CNA D did not recall the facility getting any statements from her and did not understand why they did not ask any more questions. In an interview on 11/4/20 at 2:45 p.m., CNA F reported she noticed the bruising on Resident #1 when she worked the weekend prior to her going to the hospital on [DATE]. CNA F reported she noticed the bruising when she went to put her to bed and described the bruising looking like the resident got hit by a semi and the bruising looked like it had been there for a while. CNA F reported she told RN E who thought the bruising may have been from transferring the resident using a Sit to Stand device. CNA F reported the resident is supposed to transfer using a Hoyer lift. CNA F reported she did not understand why she seemed to be the only person shocked by the extensive bruising on Resident #1 and why other staff were oblivious to the bruising. CNA F reported she felt heartbroken for the resident. CNA F then clarified she may have seen the bruising on Resident #1 the Monday before the resident went to the hospital, but recalled the resident went to the hospital a couple days later after she took care of her and noticed the bruising. In an interview on 11/4/20 at 3:00 p.m., CNA G reported Resident #1 had bruising a while ago and reported it to RN E. CNA G reported the bruising she saw was not bad and on Resident #1's left side under her arm which was an old one then had newer bruising on the other side that came later. The bruising came across Resident #1's chest, under her breast. CNA G reported it was on a Sunday which was her weekend to work and that Monday she came in to work and Resident #1's bruising was much worse. CNA G reported that Monday RN E and UM A looked at Resident #1's bruising. In an interview on 11/5/20 at 8:49 a.m., LPN B reported the nursing Skin Assessments in the computer only address the New findings and a progress note should be made addressing the skin shower sheets initiated by the CNA's and completed by the nurses. UM A does weekly skin measurements on wounds. If a resident had a new skin concern LPN B would initiate a new nursing Skin Assessment, but if a resident already had a nursing Skin assessment initiated, there is nothing to prompt a continuing assessment if it already exists. In an interview on 11/5/20 at 8:57 a.m., RN E reported Resident #1 had bruising on the left flank and across her chest when she was on the 200 hall. Then she transferred to the 100 hall and the bruising was dark in color and yellow on the edges. RN E reported he knew about the bruising on the residents right side on a Monday and notified UM A as soon as she came in the door on that Monday, filled out an incident report and notified the physician of the left flank and chest bruising. RN E reported he saw bruising on that Sunday and saw more yellowing, the following Monday he recalled seeing bruising on the right side which was new. RN E did not recall Resident #1 having any pain. RN E said he was told that the bruising was from leaning over in her wheelchair and confirmed Resident #1 leaned over a lot but is doing better in her Broda chair. Not sure why it took so long for the resident get a Broda chair. RN E reported the UM A documents any wound measurements on residents. During an observation and an interview on 11/5/20 at 1:15 p.m., CNA H demonstrated how the Sit to Stand device works to transfer residents. The padding gets secured across the back and under the arm pits and a thinner belt like strap fastens across the chest, the resident is to then grab a hold of the handles and gets lifted to a standing position and then moved to where she needs to go. CNA H reported she took care of Resident #1 when she had a large bruise on her left side and chest and reported it to the nurse who reported she already charted it. In an interview on 11/5/20 at 1:20 p.m., Certified Occupational Therapy Assistant (COTA) J reported she did therapy for Resident #1 after she was referred on 9/7/20 for wheelchair positioning. The resident already had a bolster in place on the left side and implemented bolsters for the right side. COTA J is only aware of bruising across her chest and below her breasts and did not complain of pain during therapy. COTA J is not aware of any residents having bruising from poor positioning. In a telephone interview on 11/5/20 at approximately 2:00 p.m., The Director of Nursing (DON) reported Resident #1 had [MEDICAL CONDITION] (MS) and would slump over in her wheelchair and when a table was in front of her she would slump over the top of it. The bruising lined up across her chest with the table and the bruising on her flanks lined up with the wheelchair. The resident received therapy for positioning. In September, the resident was able to self-propel in her wheelchair and started to decline rapidly. The second bruising in October is much better now. The resident was using an EZ Stand (Sit to Stand) for transfers but many staff were already using the Hoyer lift. The significant bruising caused her to have a low hemoglobin (low blood level). The first bruise in September was milder compared to the second bruise in October and not clear where it came from. The DON repor (TRUNCATED)

This citation pertains to intakes M 5502 and M 5746 Based on interview and record review, the facility failed to report immediately suspicious injuries of unknown origin for potential abuse, neglect, or mistreatment for 2 (Resident #1 and Resident #3) of 3 residents reviewed for abuse and neglect, resulting in the delay of treatment and investigation by administration and of notification for the State Agency. Findings include: Review of a policy titled Abuse and Neglect last revised 6/17/10 revealed: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Neglect is the failure to provide necessary and adequate (medical, personal, or psychological) care. Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional. IV. Identification: Have procedures to: Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. An injury should be classified as an injury of unknown source when both of the following conditions are met: a. The source of injury was not observed by any person or the source of injury could not be explained by the resident; and bathe injury is suspicious because of the extent of the injury or the location of the injury (example: the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at a particular point in time or the incidence over time.V. Investigation: Have procedures to: Investigate all allegations of abuse, neglect, misappropriation of property and incidents such as injuries of unknown source. All allegations will be investigated by the Administrator or Designee immediately. The initial and final reporting of the allegations will be done by the Administrator or Designee. VI. Protection: Have procedures to: Protect residents from harm during the investigation. 2. Affected residents will be assessed for injury. 3. Attending physician will be notified. a. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation, etc. 1. If the alleged perpetrator is an employee, the employee will be immediately suspended from working pending the result of the investigation. The alleged staff will not be allowed to go back to work until the final investigation is forwarded to the appropriate State Agencies. If the alleged perpetrator is a visitor or a family member, the visitor will be denied unsupervised visitation. VII. Reporting/Response: Have procedures to: All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. All allegations of abuse will be reported to the appropriate State Agencies immediately after the initial allegation is received. A final investigation report will be submitted to the appropriate State Agencies within 5 working days. Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. Take all necessary corrective actions depending on the results of the investigation. Documentation within a client medical record is a vital aspect of nursing practice. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track (resident) outcomes, and reflect current standards of nursing practice .Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors .The record is a means by which health care team members communicate (resident) needs and progress .The record should be the most current and accurate source of information about a client ' s health care status .High-quality documentation .(is) necessary to enhance efficient, individualized (resident) care. Quality documentation .(has) five important characteristics: they are factual, accurate, complete, current, and organized (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). According to the Fundamentals of Nursing, 6th Edition (Mosby, Patricia A. Potter, Anne G. Perry, 2005 page 481) High quality documentation and reporting are necessary to enhance efficient, individualized client care. Quality documentation and reporting have five important characteristics: they are factual, accurate, complete, current, and organized, The use of inferences without supporting factual data is not acceptable because it can be misunderstood. Review of a policy titled Charting and Documentation adopted on 7/11/18 revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Resident #1 Review of a Face sheet revealed Resident #1 is an [AGE] year old female originally admitted to the facility on [DATE] with pertinent diagnoses of neuromuscular dysfunction, dementia, and diabetes. No diagnoses for [MEDICAL CONDITION] noted. Review of the Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed a Brief Interview for Mental Status (BIMS) indicated she is severely cognitively impaired and required extensive assistance of 2 staff for transfers and toileting and unsteady on feet. No history of falls, skin conditions, or bruising noted. Review of the Intake M 5502 revealed on 10/6/2020 at 12:43 p.m., the facility reported to the State Agency an injury of unknown origin for Resident #1 and the investigation submitted on 10/13/20. DETERMINATION OF FINDINGS/CONCLUSION: Based on the interviews with staff, residents, and review of the clinical record, a decisive conclusion was made the occurrence was substantiated due to bruising. The staff implemented various interventions for positioning including frequent repositioning. Pain, and skin assessments have been completed. The transfer status has been downgraded from EZ stand to Hoyer lift and a Broda chair was implemented for increased comfort. Once these new interventions were put into place, the bruising is healing with no new areas of concern. Staff plan to continue to promote her independence with meals along with increased comfort during transfers and when out of bed. Change explanation: Bruising was concluded to have been caused from an acute onset of increasingly worsened positioning, posture, and trunk control due to her [DIAGNOSES REDACTED]. Staff was noted to be frequently repositioning resident due to slouching forward and to the left and right side when up in wheelchair over the weekend that the bruising was worsening. Review of a Facility Reported Incident (FRI) submitted online on 10/6/20 at 12:43 p.m. revealed: Incident Summary on 10/6/20, the Administrator (NHA) and Director of Nursing (DON) received a call from Medical Director concerning bruising noted to resident that appears to be new and worsening. On 10/5/2020 the bruising was assessed and was thought to be related to decline in transfer status using EZ stand lift from the belt positioning and declined positioning in wheelchair. Her transfer status had already been downgraded to Hoyer lift and a Broda Chair was put into use for improved positioning. Resident is in bed and appears comfortable. There have been no allegations of abuse at this time. Due to the significance of the bruising, a full investigation has been initiated for possible injury of unknown origin. On 10/5/20, (Resident #1) was sent to the hospital for what appeared to be a sudden onset of increased bruising along with abnormal lab results. After speaking with the Unit Manager and reviewing clinical records, it was thought that the bruising was likely related to a recent decline in transfer status. Staff was using EZ stand lift, and bruising matched the belt-positioning. (Resident #1) was also noted to have had a noted decline in wheelchair positioning and trunk control over the weekend. On the morning of 10/06/2020, the Administrator and Director of Nursing were made aware that the bruising that was initially reported on 10/5/20 had worsened. Due to the bruising's significance, a full investigation was initiated for possible injury of unknown origin. The Director of Nursing and Administrator completed a full clinical review. On 9/3/2020, a Nursing Assistant noted a purple bruise on (Resident #1) anterior armpit, a pink area to the left outer breast, and a light purple bruise on the inner left upper arm. Poor positioning was discussed with IDT as caregivers observed increase lateral leaning while seated in w/c despite current interventions over the weekend. Transfer status was downgraded from EZ stand to Hoyer lift, Broda Chair and stat labs were ordered. Nurse reported significant bruising in addition to hemoglobin level of 7.0 to on call provider and an order was given to send (Resident #1) to the hospital for further evaluation of bruising and abnormal labs. Upon returning from the hospital, the new interventions were in place including transfer status downgrade from an EZ stand to a Hoyer lift with 2 assist, and a Broda Chair to increase comfort when up for meals. Root Cause Analysis/Contributive Factors: The investigation determined that the event was substantiated to have occurred, due to visible bruising. Bruising was concluded to have been caused from an acute onset of increasingly worsened positioning, posture, and trunk control due to her [DIAGNOSES REDACTED]. Actions taken based on investigative findings: · Resident was downgraded from EZ stand lift to Hoyer · Broda chair in use to increase comfort when up for meals. (sic) Review of questionnaires from staff regarding Resident #1's bruising, several staff reported the resident was in pain, noticed new and old bruising and told the nurses. One nurse reported she saw the new bruising and noted in provider communication. Another CNA reported on 10/6/20 that the resident was vomiting in bed, leaning to right side, increased the head of the bed and reported to the nurse. No documentation noted in electronic health records of the resident vomiting. Staff who reported new bruising did not indicate when or where they were when they saw the bruising and when they reported it to the nurse. Review of a Complaint reported to the State Agency on 10/7/20 regarding Resident #1 revealed: . (Resident #1) needs full assist for everything. (Resident #1) has labs done and she is anemic (low hemoglobin). (Resident #1) is currently at the hospital (10/06/20) but will be discharged back to the facility. (Resident #1) has bruising, blood from her bruising just around her breast and nipples. (Resident #1) ' s bi-lateral chest and nipples seemed to be bruised with old bruises and new bruises. This could be occurring from (Resident #1) or some other trauma. It is unknown what has occurred. (sic) Review of Hospital Records dated 10/6/20 revealed Resident #1 arrived at the emergency roiagnom on Tuesday, 10/6/20 at 5:41 a.m. revealed: I suspect acute blood loss [MEDICAL CONDITION] secondary to blood loss into the soft tissues. bruising, it appears to be primarily around the nipples and flanks, and based on this patter, I do have some suspicion, or at least and concern for elder abuse. hemoglobin of 7.9. Unfortunately, EMS (emergency medical services) was not able to get much report from the (Nursing Facility), but they do know that she had abnormal lab work and has had abnormal bruising over the past couple months. Physical Exam: Skin: Bruising (Significant ecchymosis (large, bruise like lesion caused by collection of extravascular blood in dermis and subcutaneous tissue caused by trauma or bleeding disorders) in varying degree of healing along the chest. The bruising appears to be most noticeable around bilateral nipples. No obvious hematoma. No tenderness.) present. Bruising as noted previously around bilateral breast as well as bilateral flanks. Bruises are of varying ages. There is concern that she may have been injured in some way . CT (computerized tomography) scan revealed: 1. Significant soft tissue swelling involving the left pectoralis muscles, probably related to diffuse intramuscular hemorrhage. Small measurable intramuscular hematoma also present in the left pectoralis major. 2. Minimally buckled fractures of the anterior left fourth and fifth ribs, age indeterminate. I spoke with her primary care provider . I relayed to him the findings of our scans and the history. He will see her tomorrow at her care facility. Review of an Incident Report dated 9/3/20 for Resident #1 revealed: CENA (Certified Nursing Assistant (CNA)) reported bruise noted when cares given. Purple bruise on anterior armpit, pink rubbed area left outer breast, and light purple inner left, upper arm. CENA that did her cares day prior did not observe any bruising. Immediate Action Taken: Towel placed in gap between bolster on w/c (wheelchair) arm and back of w/c. Notes: Anterior armpit purple bruise 3x2.5 cm (centimeters), 2x1 cm inner upper left arm light bruise, 4.5 x 7, left outer breast pink rubbed area. Predisposing factors: Using Wheelchair. Other info: Bolster on w/c sliding forward leaving a gap between bolster and back of w/c. Notes: (Staff)- I did (Resident #1's) a.m. care on 9/2/20 and did not see any bruising. I do often see (Resident #1 leaning in her chair to the left. (Staff) I was unaware of (Resident #1) bruising under left arm but have noticed (Resident #1) leaning over left side of wheelchair, hanging over left side of wheelchair. Resident tends to favor leaning to left side Privileged and Confidential- Not part of the Medical Record. No further documentation provided with this incident report. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed: No redness, bruising, or open areas. Review of a nursing Progress Note dated 9/1/20 for Resident #1 revealed: Bed bath given. No redness, bruising, or open areas noted. Denies any pain or discomfort. Review of a nursing Progress Note dated 9/3/20 for Resident #1 revealed: Bruises noted during a.m. cares. Anterior armpit purple bruise 3 x 2.5 cm, 2 x 1 cm, inner upper left arm light bruise, 4.5 x 7 cm, left outer breast pink rubbed area. Bruising not noted with cares yesterday per aide. Leans to left side often and is repositioned. PT (Physical Therapy) evaluation . Review of an Occupational Therapy (OT) Plan of Care document dated 9/7/20 for Resident #1 revealed: Pt (patient) referred to OT services 2/2 bruising on L (left) underarm armpit and L breast area per nursing staff. Nurse states may have been from bolster sliding forward and pt leaned over left side of w/c (wheelchair) armrest, causing increased pain. Therapy necessity: Therapy necessary for decreasing L arm pain, bruising and increased participation with ADL (activities of Daily Living) routine. Without therapy patient at risk for functional decline and falls. Pt resides in this LTC (long term care) facility with ext. (extensive) assist for ADL routine. Patient previously utilized EZ stand for transfers. Previous Therapy: Pt received PT (physical therapy) last month for transfer training. Pt states pain in L underarm, armpit, and L side breast area at 5/10 with shoulder flexion and ROM (range of motion) with self-feeding. No numbness stated on BUE (bilateral upper extremities), however pt's BUE hands were cold to the touch with some bruising noted on B dorsal (back) side of hands. The patient reports pain in L upper arm of moderate. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. Review of a Skin Observation Shower sheet dated 9/10/20 for Resident #1 which is not part of the medical record revealed the outline of a body shows no skin alterations or locations and not marked for alterations. The Licensed Nurse comments revealed: Continues with fading and healing bruises to left anterior armpit, inner upper left arm. Review of a Medical Practitioner Progress note dated 9/10/20 for Resident #1 revealed: . She has had some generalized bruising noted documented, but no open areas. She is having PT (physical therapy) see her to provide a bolster for better seating in her wheelchair so that the chair does not cause any areas of potential pressure points and bruising. Review of a Skin Observation Shower sheet dated 9/17/20 for Resident #1 which is not part of the medical record revealed the body outline diagram has an oval outline reaching from the left armpit down the left side of the resident and the box for bruises is checked off. The Licensed Nurse comments revealed: Continues with healing bruises to left breast and under left arm. Review of a Nurse Practitioner Note dated 9/17/20 for Resident #1 revealed no acknowledgement of bruising on Resident #1. Resident #1 is seen today for evaluation and management of multiple, complex, chronic medical problem that requires frequent monitoring to maintain stability and to prevent further decline. She is also specifically seen for transition of care and follow up of vitamin D deficiency. Skin: Skin is warm and dry, afebrile. (sic) Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. Review of a Skin Observation Shower sheet dated 9/24/20 for Resident #1 which is not part of the medical record revealed the body outline diagram has an oval outline reaching from the left armpit down the left side of the resident and the box for bruises is checked off. The Licensed Nurse comments revealed: Continues with healing bruises to left breast and under left arm. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. Review of a Skin Observation Shower sheet dated 10/1/20 for Resident #1 which is not part of the medical record revealed the body diagram outline had no marks and the box for bruises is checked off. Licensed Nurse comments revealed: Fading bruising to left breast and under left arm. No Skin Observation Shower records provided to this surveyor after 10/1/20 to 10/22/20. Review of a Late Entry Nursing Progress Note back dated 10/4/20 and created on 10/9/20 for Resident #1 revealed: old yellow bruising to left breast and flank, bruising extended to right breast and flank appearing dark in color, resident had no complaints of pain until being repositioned for check and change whiled rolled onto side, pain subsided once in neutral position, VS (vital signs) stable, physician note made. Review of a Weekly Skin assessment dated [DATE] and entered into the Electronic Health Record (EHR) on 10/9/20 for Resident #1 revealed a New alteration in skin integrity. It should be noted that pt (patient) has [MEDICAL CONDITION], type II diabetes, hypertension, [MEDICAL CONDITION] and Dementia as major medical problems, among others. It is noted that pt has been declining slowly and has been unable to hold her posture erect as a result of progressive neurological disorder [MEDICAL CONDITION]. Pt has been leaning forward and to right or left. Pt is also dependent on staff for all ADL (activities of daily living) including transfers. Pt's posture, leaning on arm rest either left or right as she is unable to hold posture erect may have exacerbated. First bruising was noted on 9/3 and since then therapy has evaluated for maintain pt's posture. In addition being on ASA (aspirin) did not help, as it may have contributed to bleeding in muscles and subcutaneous tissues leading to a larger bruise. Pt was observed to be comfortable with staff and no fear or concern noted. (sic) No measurements, location, or descriptions noted. Review of a Nursing Progress note dated 10/5/20 for Resident #1 revealed: Pt was observed throughout weekend to slouch and lay to either side in her wheelchair. Was frequently assisted to sit up and repositioned but this am (Monday) bruising to left flank and chest was increased and now bruising to right flank. Manager notified, Dr. notified. Family called and message left requesting call back. Broda chair ordered for comfort and intervention. Awaiting any additional order from Dr. Review of a Nursing Progress Note dated 10/6/20 for Resident #1 revealed: STAT lab results call in to Nurse on call (Nurse Practitioner) and order noted to send resident to hospital for eval. hemoglobin 7.0 (normal value is 12.0 to 16.0). Review of a laboratory result dated 7/8/20 revealed Resident #1 had a hemoglobin of 12.9. Review of an eInteract Transfer Form dated 10/6/20 at 4:08 a.m. and locked dated of 10/12/20 at 10:40 p.m. for Resident #1 revealed she was discharged to Hospital. Review of a Nurse Practitioner Note dated 10/6/20 at 3:00 p.m. for Resident #1 revealed: Pt seen at the request of nursing staff for eval of Bruising and F/U (follow up) ER (emergency room ) visit. She was noted to have extensive bruising recently. Blood work was done including coagulation studies which were mostly with in acceptable range with the exception of low (hemoglobin). Subsequently she was sent to ER for Eval. she was transferred from chair to commode and chair to bed using EZ stand/Sit to stand. It is my understanding that the strap that supports patient while on EZ stand is applied behind the back, passed under the axilla and stabilized in front. When pt is raised in EZ stand, pressure applied to areas on the chest and fragile nature of her skin has caused bruising. Pt's posture, leaning on arm rest either left or right as she is unable to hold posture erect may have exacerbated. First bruising was noted on 9/3 and contributed to bleeding in muscles and subcutaneous tissues leading to a larger bruises. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed the resident had a new alteration to her skin integrity. Bruising to chest and bilateral sides appear to be dissipating and to be healing well. (Resident #1) denied pain and stated she felt comfortable during this assessment. (Resident #1) is able to accurately answer Yes/No questions. When asked if she felt safe - yes. Asked if she enjoys living here - yes. Asked if we take good care of her - yes. Asked if anyone has ever hurt her here - no. (Resident #1) appeared comfortable, is being assisted with frequent repositioning with no new skin concerns. (sic) Review of a Nurse Practitioner Note dated 10/12/20 for Resident #1 revealed: (Resident #1) has been evaluated today at request of nursing staff for elevated blood pressure. Upon evaluation, the patient is resting in bed. Staff also had concerns of an episode low oxygenation with the O2 (oxygen) sat of 88 (normal is 92 to 100%). Her lungs did demonstrate crackles in the bases. She has not been out of bed. The patient was recently hospitalized with a hemoglobin of 7 with excessive bruising on the chest and flank. Last hemoglobin demonstrated with 7.8. Bruising appears to be dissipating. Review of a Late Entry General Progress Note back dated 10/5/20 and created by the Director of Nursing (DON) on 10/12/20 at 4:51 p.m. for Resident #1 revealed: Bruising noted to chest and bilateral sides of trunk. It should be noted that pt has [MEDICAL CONDITION], type II diabetes, hypertension, [MEDICAL CONDITION], and dementia as major medical problems among others. It is noted that pt has been declining slowly and has been unable to hold her posture erect as a result of progressive neurological disorder [MEDICAL CONDITION]. Pt has been leaning forward and to right or left. Pt is also dependent on staff for all ADL including transfers. Pt's posture, leaning on arm rest either left or right as she is unable to hold posture erect may have exacerbated. First bruising was noted on 9/3 and since then therapy has evaluated, for maintaining pt's posture. In addition being on ASA did not help, as it may have contributed to bleeding in muscles and subcutaneous tissues leading to a larger bruises. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alteration in skin integrity. No documentation of past bruising noted. Review of a Skin Observation Shower sheet dated 10/22/20 for Resident #1 which is not part of the medical record revealed the body outline diagram had an oval outline that encircled the left underarm and down the left side and a small circular outline of the right underarm. The check box for bruises is marked. Licensed Nurse comments revealed: yellow light purple bruising to left breast and under left arm. Small yellow bruise to right arm and chest. Both of which are not new and are fading. Review of a nursing Weekly Skin assessment dated [DATE] for Resident #1 revealed no New alterations in skin integrity. No documentation of past bruising noted. Review of a Skin Observation Shower sheet dated 10/29/20 for Resident #1 which is not part of the medical record revealed the body outline diagram had an oval outline surrounding the left underarm and down the left side. The Licensed Nurse Comments revealed: Light purple bruising under left breast and on left flank continues to heal. Review of a Hospice document dated 11/2/20 revealed Resident #1 was admitted to Hospice. During an observation and an interview on 11/4/20 at 10:55 a.m., Resident #1 observed in the dining room sitting in a Broda Chair (special chair for positioning) with puff boots on both feet and reported her sister got mad at her and hit her when queried about her bruising. Licensed Practical Nurse (LPN) B reported the resident had large bruising on the right side of her body and across her chest. In an interview on 11/4/20 at approximately 11:15 a.m., LPN C reported Resident #1 used to reside in room [ROOM NUMBER] when she took care of her and recently transferred to room [ROOM NUMBER]. LPN C did remember a Certified Nursing Assistant (CNA) told her the resident had some bruising but could not remember when or any of the details of the bruising. The nurse could not remember if she documented measurements of bruising. In an interview on 11/4/20 at 2:30 p.m., CNA D reported Resident #1 used to be in room [ROOM NUMBER] and then transferred to room [ROOM NUMBER]. The CNA remembered she took care of Resident #1 on a Monday and noticed bruising when she pulled back the blanket when the resident was in bed and saw bruising that was black and purple in color on her whole top half of her body including her breasts, sides, and stomach. CNA D reported she told Registered Nurse (RN) E and he went to the room to look at the resident and said it was from her positioning. RN E told the CNA to still get the resident up who was wincing in pain when the CNA moved her. CNA D reported she did not work on this unit much and had not seen the resident in a long time before this day. CNA D reported RN E knew about the bruising and told him he needed to fill out an incident report and then told UM A about the bruising on Resident #1. CNA D did not recall the facility getting any statements from her and did not understand why they did not ask any more questions. In an interview on 11/4/20 at 2:45 p.m., CNA F reported she noticed the bruising on Resident #1 when she worked the weekend prior to her going to the hospital on [DATE]. CNA F reported she noticed the bruising when she went to put her to bed and described the bruising looking like the resident got hit by a semi and the bruising looked like it had been there for a while. CNA F reported she told RN E who thought the bruising may have been from transferring the resident using a Sit to Stand device. CNA F reported the resident is supposed to transfer using a Hoyer lift. CNA F reported she did not understand why she seemed to be the only person shocked by the extensive bruising on Resident #1 and why other staff were oblivious to the bruising. CNA F reported she felt heartbroken for the resident. CNA F then clarified she may have seen the bruising on Resident #1 the Monday before the resident went to the hospital, but recalled the resident went to the hospital a couple days later after she took care of her and noticed the bruising. In an interview on 11/4/20 at 3:00 p.m., CNA G reported Resident #1 had bruising a while ago and reported it to RN E. CNA G reported the bruising she saw was not bad and on Resident #1's left side under her arm which was an old one then had newer bruising on the other side that came later. The bruising came across Resident #1's chest, under her breast. CNA G reported it was on a Sunday which was her weekend to work and that Monday she came in to work and Resident #1's bruising was much worse. CNA G reported that Monday RN E and UM A looked at Resident #1's bruising. In an interview on 11/5/20 at 8:49 a.m., LPN B reported the nursing Skin Assessments in the computer only address the New findings and a progress note should be made addressing the skin shower sheets initiated by the CNA's and completed by the nurses. UM A does weekly skin measurements on wounds. If a resident had a new skin concern LPN B would initiate a new nursing Skin Assessment, but if a resident already had a nursing Skin assessment initiated, there is nothing to prompt a continuing assessment if it already exists. In an interview on 11/5/20 at 8:57 a.m., RN E reported Resident #1 had bruising on the left flank and across her chest when she was on the 200 hall. Then she transferred to the 100 hall and the bruising was dark in color and yellow on the edges. RN E reported he knew about the bruising on the residents right side on a Monday and notified UM A as soon as she came in the door on that Monday, filled out an incident report and notified the physician of the left flank and chest bruising. RN E reported he saw bruising on that Sunday and saw more yellowing, the following Monday he recalled seeing bruising on the right side which was new. RN E did not recall Resident #1 having any pain. RN E said he was told that the bruising was from leaning over in her wheelchair and confirmed Resident #1 leaned over a lot but is doing better in her Broda chair. Not sure why it took so long for the resident get a Broda chair. RN E reported the UM A documents any wound measurements on residents. During an observation and an interview on 11/5/20 at 1:15 p.m., CNA H demonstrated how the Sit to Stand device works to transfer residents. The padding gets secured across the back and under the arm pits and a thinner belt like strap fastens across the chest, the resident is to then grab a hold of the handles and gets lifted to a standing position and then moved to where she needs to go. CNA H reported she took care of Resident #1 when she had a large bruise on her left side and chest and reported it to the nurse who reported she already charted it. In an interview on 11/5/20 at 1:20 p.m., Certified Occupational Therapy Assistant (COTA) J reported she did therapy for Res (TRUNCATED)

Based on observation, interview, and record review, the facility failed to promptly provide emergency dental services for the removal of decayed, painful teeth in 1 of 9 residents (Resident #6) reviewed for accommodation of needs, from a total sample of 23, resulting in a delay in care and services for oral health, difficulty eating, difficulty speaking, and ongoing oral pain. Findings include: Review of a Face Sheet revealed Resident #6 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 10/15/17, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated that Resident #6 was cognitively intact. Review of a MDS assessment, with a reference date of 10/15/17, revealed Resident #6 had .No natural teeth or tooth fragment(s) . and .obvious or likely cavity or broken natural teeth . Review of a MDS assessment, with a reference date of 7/30/17, revealed Resident #6 was totally dependent on staff for hygiene (which includes oral care), and had .no natural teeth or tooth fragment(s) .obvious or likely cavity or broken natural teeth .inflamed or bleeding gums or loose natural teeth .mouth or facial pain, discomfort or difficulty with chewing . Review of a Care Area Assessment (CAA) for Mood State, completed 8/1/17, revealed Resident #6 .is having trouble sleeping and trouble concentrating due to the pain in his mouth. He has been out to an oral surgeon and plans to have all his teeth extracted. He will then get dentures. (Resident #6) is looking forward to this happening to be free of the pain and states he will then have straight teeth . Review of a CAA for Dental Care, completed 8/1/17, revealed Resident #6 .has very poor dentition with broken teeth, stubs, and decay. He has a hx (history) of poor oral hygiene and often refuses oral hygiene .(Resident #6) has oral pain and discomfort and is in the process of making an appointment with an oral surgeon to have his teeth removed and eventually get dentures. His mom, who is his guardian, is in charge of filling out paperwork and setting up the appointment as (Resident #6) will need to receive some anesthesia for this procedure. He receives [MEDICATION NAME] for the oral pain as well as Tylenol III. Currently await for his mom to complete the paperwork process .to have his teeth pulled .proceed to care plan . Review of the October 2017 Physician order [REDACTED].#6, printed 10/31/17, revealed an order for [REDACTED].as needed . with a start date of 9/2/17. Review of the October 2017 Physician order [REDACTED].#6, printed 10/31/17, revealed an order for [REDACTED].as needed every six hours . with a start date of 9/2/17. Review of the October 2017 Physician order [REDACTED].#6, printed 10/31/17, revealed a standing order for .Dental care as needed . Review of a current Care Plan Report, printed 10/31/17, revealed Resident #6 .is at risk for pain r/t (related to) Bladder Spasms. (Resident #6) has very poor dentition and oral pain and needs to have his teeth surgically removed. Await for Guardian to proceed with Dental office for paperwork and setting up appointment . Review of a current Care Plan Report for Resident #6, printed 10/31/17, revealed an update on 8/1/17 .(Resident #6) denied feeling sad or down. His main concern is the pain in his mouth. He is looking forward to having his teeth pulled and getting dentures . Review of a dental visit summary for Resident #6, dated 4/18/17, revealed .Patient is having pain with his teeth. #3 and #14 need to be extracted at an Oral Surgeons office. Patient has multiple non restorable decayed teeth and root tips. Patient stated he wants to have all teeth extracted and dentures made. There are two options (1) have only #3 and #14 extracted. or (2) have all remaining teeth extracted and have a denture evaluation .Treatment indicated at this time: Referring out to the Oral Surgeon for extractions .Treatment plans to be discussed with POA (power of attorney) and social worker . Review of an oral surgeon consultation report for Resident #6, dated 5/30/17, revealed .(Resident #6) has been experiencing pain in the left facial region. It was thought that tooth number 13 and 14 were problematic causing him the pain that he has been experiencing .There was a recommendation to have teeth numbers 13 and 14 removed with consideration of full mouth extractions and denture placement .(Resident #6) indicated that the left mandibular quadrant was his area of concern. This was most notable with a carious tooth number 19. Percussion of this tooth seemed to highlight his source of pain .I indicated to (Resident #6) that full mouth extractions and subsequent placement of a maxillary and mandibular prosthesis is an option for him .I also discussed the fact that removal of teeth in the office setting would be challenging because of his physical presentation .I indicated to (Resident #6) that we would discuss his case with his general dentist and his mother and contact him regarding the options discussed to form a final treatment plan . Review of a dental service Resident Canceled Visit Report, dated 10/4/17, revealed Resident #6's dental services were canceled on this date, as the resident had been referred to the oral surgeon. Review of a Clinical Note for Resident #6, dated 5/27/17, revealed .Resident c/o (complained of) tooth pain at beginning of shift, stating that we needed to call 911 to send him to the hospital. Educated patient on the use of 911 and the ER (emergency room ). Examined lower teeth on left side and unable to identify any trauma to the area. PRN (as needed) Tylenol #3 given per patients request . Review of a Clinical Note for Resident #6, dated 7/4/17, revealed .He requested additional PRN pain medication this evening due to a complaint of pain from a broken tooth (left lower jaw). Pain medication decreases the pain but does not resolve it . Review of a Clinical Note for Resident #6, dated 7/15/17, revealed .c/o mouth pain beginning of the shift, good oral care done, no other complaints r/t to the mouth . Review of a Clinical Note for Resident #6, dated 7/31/17, revealed .(Resident #6) reported that he was having 'severe tooth pain' .This was addressed by the Doctor . Review of a Clinical Note for Resident #6, dated 7/31/17, revealed a new order for .[MEDICATION NAME] PRN for tooth/mouth pain or discomfort . Review of a Clinical Note for Resident #6, dated 8/1/17, revealed .Resident c/o mouth pain, writer offered softer foods which resident declines. States he is getting 'all of my teeth pulled' and he will consider soft food then . In an interview on 10/30/17 at 8:58 a.m., Resident #6 reported ongoing mouth pain and that one of his teeth is broken, which causes discomfort. Resident #6 reported that he was unable to receive dental care for his tooth pain concerns due to his insurance. In an interview on 10/31/17 at 9:05 a.m., Resident #6 stated he experiences tooth pain .all the time . primarily in his left lower jaw. Resident #6 reported that one of his teeth is .sharp . and hurts his mouth. In an observation on 10/31/17 at 9:05 a.m., observed Resident #6's oral cavity. Noted teeth appeared dark/discolored and in poor condition. In an interview on 10/31/17 at 11:04 a.m., Unit Manager O reported that in regard to Resident #6's dental concerns, there are .not many places he can go . because of his insurance, and that the facility is currently waiting for insurance authorization and for his .mom to do her part . before they proceed. Unit Manager O reported that the .ultimate goal . for Resident #6 is dentures. Unit Manager O reported that Resident #6 has .[MEDICATION NAME] . and PRN pain medications for tooth pain, but prefers not to take certain PRN pain medications because they cause constipation. In an interview on 10/31/17 at 11:10 a.m., Unit Clerk II reported that the delay in dental care for Resident #6 was due to an .insurance approval issue . Unit Clerk II reported that Resident #6's dental concerns were initially identified in April of 2017. Unit Clerk II reported that Resident #6 was then referred to an oral surgeon in May of 2017. Unit Clerk II reported that she had contacted the oral surgeon last on 10/13/17, and insurance approval was still pending. In an interview on 11/1/17 at 9:16 a.m., Resident #6 stated in regard to his tooth pain .it's bad . Resident #6 reported he has difficulty eating due to the tooth pain, which has been an issue .for months . In an interview on 11/1/17 at 9:21 a.m., Licensed Practical Nurse (LPN) GG reported that Resident #6 has .[MEDICATION NAME] . for tooth pain and stated the medication helps Resident #6's oral pain .for a little bit . LPN GG reported that Resident #6 needs to have dental work done, but that the procedure is .held up due to insurance . In an interview on 11/1/17 at 10:18 a.m., Resident #6 reported that in regard to his broken tooth .it's cutting my tongue . Noted that Resident #6 was difficult to understand with hoarse, unclear speech. Resident #6 stated .When I get my tooth fixed I'll be able to talk . In an interview on 11/1/17 at 8:19 a.m., Family Member KK stated Resident #6 .has rotten teeth .we are waiting on the oral surgeon .it has been forever . Family Member KK reported that Resident #6 has one damaged tooth that .makes his tongue raw . Family Member KK reported that Resident #6's dental issues have been a concern .since May . and care has been delayed .due to insurance . In an interview on 11/1/17 at 12:14 p.m., Director of Nursing (DON) B reported Resident #6 initially complained of tooth pain in April, and had a visit with the dentist and was referred to the oral surgeon. DON B reported that Resident #6's dental procedures need to be completed in a hospital setting, and that the facility has been in contact with the oral surgeon for the past several months.

Based on observation, interview, and record review, the facility failed to implement functioning bed/chair alarms for 2 of 4 residents (Resident #104 and Resident #102) reviewed for falls, from a total sample of 4 residents, resulting in a fall with a wrist fracture for Resident #104 and the potential for falls for Resident #102 due to a nonfunctional chair alarm system. Findings include: Review of the policy and procedure for Falls Reduction, revised 6/6/16, revealed (The facility) works in partnership with clients and families to maintain client's independence and enhance the quality of client lives by managing the risk for falls and fall related injuries .goals include: 1. Identifying and promoting fall reduction strategies .Fall precautions are established by each facility based on their client population but may include .a fall management plan recommending safety measures such as bed or chair alarms . Resident #104 Review of a Face Sheet revealed Resident #104 was an [AGE] year-old female, originally admitted on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment, with a reference date of 1/19/17, revealed Resident #104 had moderately impaired cognition, with cognitive symptoms of inattention and disorganized thinking, and required extensive assist with transfers, ambulation, and bed mobility. Review of the February 2017 Physician order [REDACTED].#104 revealed an order for [REDACTED]. Review of a Client Care Guide for Resident #104, dated 1/23/17, revealed interventions for safety which included .Bed Sensor Alarm . Review of a Skilled Nursing General Progress note for Resident #104, dated 1/31/17, revealed .resident found sitting in rocker chair bleeding from right forehead. Drips of blood on floor and on floor mat. Bed alarm not sounding . Review of an occurrence report for a fall on 1/31/17 at 7:45 a.m., revealed Resident #104 was found by Certified Nursing Assistant (CNA) K .sitting in rocker chair bleeding from right forehead .Bed alarm not sounding . In the report, it was concluded that Resident #104 .got herself out of bed, and self transferred to a nearby chair .ROM (Range of Motion) to all extremities assessed, noted facial grimacing with movement to right wrist. The right wrist appeared slightly swollen with noted bruising .a right wrist x-ray was ordered . Under Preventative measures at time of fall the alarm details listed Not Sounding. In an interview on 2/22/17 at 1:17 p.m., Licensed Practical Nurse (LPN) J reported that prior to the incident on 1/31/17, she had observed Resident #104 in bed and that she appeared to be asleep. LPN J reported that after CNA K found the resident in the rocking chair, she went in to assess the resident and stated that the alarm .wasn't sounding .wasn't working .it was just not plugged right. In an interview on 2/22/17 at 1:37 p.m., CNA L reported that on 1/31/17 she had been assigned to Resident #104. CNA L explained that her shift began at 6:00 a.m., and that prior to the incident she had observed Resident #104 in her bed and that she appeared to be asleep. CNA L reported that she was unsure if she had checked the alarm, and explained that it order to check the alarm functionality the alarm unit makes noise, and that she .didn't want to wake her. In an interview on 2/22/17 at 2:08 p.m., CNA K reported that on 1/31/17 at 7:45 a.m. she walked past Resident #104's room and observed the resident in her rocking chair. CNA K reported that she entered the resident's room and noticed a laceration above her eye and a bruise on her right wrist. CNA K explained that she called for LPN J to assist and assess Resident #104 for injury. CNA K reported that the resident's bed alarm had not sounded, and stated .it was not plugged in . In an interview on 2/22/17 at 5:08 p.m., Director of Nursing (DON) B reported that the CNA's should be checking alarms with every transfer and that if a resident has an alarm in place, it should be functional. DON B reported that after the incident the bed alarm for Resident #104 was checked and it .was unplugged . Review of a the right wrist x-ray report for Resident #104, dated 1/31/17 at 12:15 p.m., revealed .Early degenerative changes in the small joints of the right wrist and right hand .A tiny bone fragment is seen along the dorsal aspect of the wrist opposite the carpal bones, likely representing a tiny avulsion fracture, likely originating in the triquetrum bone this is of mild overlying soft tissue swelling . Resident #102 Review of a Face Sheet revealed Resident #102 was a [AGE] year-old female, originally admitted on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 1/8/17, revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated severe cognitive impairment, as well as cognitive symptoms which included inattention and disorganized thinking. Review of a Skilled Nursing .General Progress note for Resident #102, dated 2/9/17, revealed .Chair and bed alarms in use at all times . Review of a Skilled Nursing .General Progress note for Resident #102, dated 1/26/17, revealed .Bed and chair alarms in use at all times. In an observation on 2/22/17 at 8:41 a.m., observed Resident #102 as she ate breakfast in the activity/dining area of the locked unit. Noted a wheelchair alarm unit which hung from the back handle of her wheelchair, with no lights visible to indicate that the alarm was functional. In an observation on 2/22/17 at 8:44 a.m., Certified Nursing Assistant (CNA) C moved the switch on the bottom of the alarm unit to the On position, the alarm unit beeped, and a green light began to blink intermittently to indicate that the alarm was On and functional. In an interview on 2/22/17 at 8:44 a.m., CNA C stated, I don't think they had it on. CNA C reported that the facility has several different styles of chair alarms, some that can be turned off, and some that are always on and only have a switch for high or low volume. In an interview on 2/22/17 at 9:02 a.m., Unit Manager D reported that an upgrade to the chair alarms is in progress to switch all alarms to a version that has No off switch. Unit Manager D explained that the staff switch out the alarms as the new ones are delivered. Unit Manager D reported that the chair alarms should be checked .every time someone sits down . to verify that the alarms are functional.

This citation pertains to intake number MI 542. Based on observation, interview, and record review, the facility failed to provide adequate supervision in the bathroom, for 1 of 4 residents (Resident #702) reviewed for accidents/hazards and supervision, from a total sample of 4, resulting in an unwitnessed fall with a right distal femur fracture and decreased ability to perform activities of daily living/impaired range of motion. Findings include: Review of the policy/procedure for Falls Reduction, revised 6/6/16, revealed Fall precautions are established by each facility based on their client population but may include .identification of the client at risk for falls, a fall management plan recommending safety measures such as bed or chair alarms, close monitoring . Review of a Face Sheet revealed Resident #702 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the Care Plan Report for Resident #702, dated 7/19/16, revealed the resident had a history of [REDACTED].does not always remember self-care limitations and safety issues and may be impulsive with attempting to self transfer. Interventions to prevent falls include Bed and chair alarms-check function and placement (every) shift and Yellow dot protocol-resident not to be unattended while in room unless in bed, both with an effective date of 8/31/15. Review of a Client Care Guide for Resident #702, dated 6/7/16, revealed .Yellow Dot Protocol-resident may not be left unattended in her room unless in bed . Review of a fall report for Resident #702 revealed the resident had an unwitnessed fall on 6/23/16 in her bathroom. An injury was noted to the resident's right knee, with the statement .Knee pain awaiting x-ray results . Per the report, Resident #702 was discovered seated on the floor of the bathroom by Certified Nursing Assistant (CNA) O. Review of a facility investigation into the fall that occurred on 6/23/16 revealed On 6/23/16 at 1:40 p.m., Resident #702 was assisted to the bathroom and placed on the toilet by Registered Nurse (RN) N. Resident #702 was asked to utilize the call light when she was done and staff would assist her accordingly .CNA O stated that she responded to the bathroom call light and visualized Resident #702 sitting upright on the floor in front of the toilet . Per the facility investigation, the resident was sent to the hospital, where it was discovered that she had a right distal femur fracture. Further review of the facility investigation revealed a documented interview performed by Director of Nursing (DON) B and Administrator A with RN N. RN N stated .that she took Resident #702 to the bathroom and physically assisted her onto the toilet and left the room. In an interview on 7/20/16 at 11:30 a.m., RN N declined to comment on the fall that occurred on 6/23/16, and stated, I don't think it's in my best interest to say anything. In an interview on 7/20/16 at 11:40 a.m., CNA O reported that on 6/23/16 she answered the call light and found Resident #702 sitting upright in the bathroom on the floor, unsupervised. CNA O stated, She wasn't supposed to be by herself. She was a two person transfer . CNA O reported that she .assumed someone was with her . and that the resident was on the Yellow Dot Protocol and was not supposed to be in the restroom by herself. Per CNA O, the facility completed an in-service training following the incident, and RN N no longer works at the facility. Review of a Diagnostic Radiology Report for Resident #702, dated 6/23/16, revealed .3 views of the right knee were obtained .There is a fracture of the distal right femur. The fracture fragments override slightly. The distal fracture fragment is displaced posteriorly one shaft width and approximately one half shaft width medially. The proximal tibia and fibula are intact . Review of a physician progress notes [REDACTED].for surgical repair .then returned .for rehab. Is progressing satisfactorily, minimal pain at present. In an interview on 7/20/16 at 9:32 a.m., CNA K reported that residents on the Yellow Dot Protocol are not to stay in their room or bathroom alone, unless in bed, because they are a high fall risk. In an interview on 7/20/16 at 9:33 a.m., CNA L reported that residents on the Yellow Dot Protocol should never be left in a bathroom unsupervised, and explained Only a person who is totally independent . could be left in the bathroom unsupervised. In an interview on 7/20/16 at 9:35 a.m., CNA M reported that residents on the Yellow Dot Protocol are at high risk for falls and should never be left unsupervised in their rooms or bathrooms, unless in bed. Review of a Minimum Data Set (MDS) assessment for Resident #702, dated 5/16/16 (prior to the residents fall with fracture), revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicates severe cognitive impairment. Further review of this MDS assessment revealed Resident #702 required extensive assist with transfers, walking, wheelchair locomotion, bathing, toileting, and bed mobility, with no noted impairments in range of motion. Review of a MDS Assessment for Resident #702, dated 7/4/16 (after the residents fall with fracture), revealed a BIMS score of 3, out of a total possible score of 15, which indicates severe cognitive impairment. Further review of this MDS assessment revealed Resident #702 was totally dependent on staff for transfers, wheelchair locomotion, bathing, toileting, and bed mobility, was unable to walk, and had impaired range of motion on one side of her lower extremities. This was a noted decline in her overall Activities of Daily Living (ADL) performance. On 7/20/16 at 2:13 p.m., observed Resident #702 in her room, in bed. Noted was a bed alarm in place and a leg brace worn on the resident's right leg. Two CNA's assisted Resident #702 from her bed to her wheelchair, using a slide board. The resident reported no pain at this time. In an interview on 7/20/16 at 2:23 p.m., Unit Manager Q reported that Resident #702 should not have been left alone in the bathroom on 6/23/16. Unit Manager Q reported that RN N was an agency nurse and had gone through the standard facility training for fall prevention. Unit Manager Q explained that following the fall on 6/23/16, RN N was removed from the schedule and no longer works at the facility. The nursing staff were then retrained on supervision of residents at high risk for falls. In an interview on 7/20/16 at 3:10 p.m., RN U reported that residents on the Yellow Dot Protocol need to be supervised in their rooms unless they are in bed. RN U stated that this information would be found on the resident's Care Guide and care plan. RN U reported that the nursing staff was recently given a refresher training about fall prevention and supervision of residents at high risk for falls. Further review of the facility investigation revealed an in-service training on Unusual occurrence and Client Care Guides was completed with the nursing staff on 6/25/16 and 6/26/16, with sign in sheets attached. Training materials revealed, Client care guides are individualized resident care information provided to direct care staff to maximize safety (for you and each resident); to prevent decline and provide the highest possible level of well-being .It is MANDATORY for the direct care staff to review and follow each individual plan of care prior to providing care or assisting any resident . Further review of the training materials for fall prevention revealed, .Always refer to the Client Care Guide prior to assisting with transfer or ambulation .If resident is not independent, NEVER leave alone in the bathroom .Yellow dot- HIGH FALL RISK. Must be supervised when out of bed. Not to be left in room alone unless in bed. In an interview on 7/20/16 at 3:29 p.m., DON B reported that RN N had assisted the resident to the toilet and then left her unsupervised in the bathroom. DON B reported that RN N had been trained on fall prevention and the Yellow Dot Protocol on 3/14/16. DON B explained that after the incident, RN N was pulled off of the floor and no longer works at the facility. DON B reported that the staffing agency she worked for was notified of the incident, and all of the nurses and CNA's were retrained on fall prevention and the Yellow Dot Protocol. DON B reported that there have been no further falls due to lack of supervision. The facility was granted a Past Non-Compliance at the time of exit due to no further like incidents had occurred, the facility re-trained pertinent staff, the fall policy was reviewed and deemed appropriate, and the facility had achieved sustained compliance. Therefore, no plan of correction will be required.

This citation pertains to intake MI 006 Based on observation, interview and record review, the facility failed to maintain a medication pass error rate rate less than 5% (five percent) in 3 of 5 sampled residents (Resident #101, #102, & #104,) reviewed for medication administration, from a total sample of 5 residents, resulting in the potential for reduced medication effectiveness and increased risk of adverse reactions and or side effects. Findings include: Review of a Facility Policy dated 10/95 with a revision date of 5/15 and labeled Medication Administration revealed : Medications are prepared, administered, as prescribed, in accordance with good nursing principles and practices and only be persons legally authorized to do so. Personnel authorized to administer medications may do so only after they have familiarized themselves with the medication. Further review revealed: Medications are administered in accordance with written or telephone orders from the prescriber. Personnel administering medications should refer to the Physicians Desk Reference (PDR), the Nursing Drug Handbook or other reference material when unfamiliar with the pharmacology of the drug, its potential toxic effects, contraindications, etc., as well as the specific indications and use for each drug. Review of Lippincott's Nursing Drug Handbook 2014 appendix 6, page 1471 revealed Age related changes can alter the way older people absorb, distribute, metabolize and eliminate medications compared to younger adults and children. Medication dosages and routes may need adjustment to optimize the patients response to medication and help prevent adverse reactions. Understanding how age related factors can alter how an older patient's body uses the medication will help you and implement your patients medication regimen and monitor his response appropriately. Resident #101 Review of a facility Face Sheet revealed Resident #101 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #101 was an extensive assist with one (1) staff assistance with dressing, hygiene, bathing, and independent/set up help with eating. A BIMS assessment score of 09/15 indicated Resident #101 was mildly cognitively impaired. Review of a facility investigation 24 hour report Incident Summary dated 12/25/15 revealed On 12/25/15 at approximately 0630 Licensed Practical Nurse (LPN) C prepared 5 ml (milliliters) of [MEDICATION NAME] lotion for Resident #101 and placed it in a med cup and set on Resident #101's night stand or the Certified Nurse Aide (CNA) F. At about 0730, CNA F was providing am care to Resident #101 when she saw a med cup with what she thought was remaining medication that the resident had not fully consumed. At this time CNA F gave Resident #101 the medicine cup and asked her to finish taking it. About an hour later, CNA F stated that Resident #101 had an emesis (vomiting). CNA F then went and informed LPN C of this fact. LPN C immediately assessed Resident #101, LPN C placed a call to the on-call practitioner and informed them of what had happened. LPN C was instructed to give Resident #101 water and crackers as well as call poison control. LPN C called poison control and was instructed to continue the water and crackers as that will help to quickly flush it out of her system. During an interview on 1/12/16 at 10:10 LPN C indicated on 12/25/15 she was working a unit she was unfamiliar with, LPN C had filled a med cup with [MEDICATION NAME] lotion and left it at Resident #101's bedside for the CNA caring for Resident #101 to apply to her back for itching, LPN C stated she had set up the [MEDICATION NAME] lotion prior to looking at the Medication Administration Record [REDACTED]. Review of Resident #101's physicians order dated 8/27/15 revealed Discontinue [MEDICATION NAME] Lotion. During an interview and observation on 1/12/16 at 11:10 a.m., Resident #101 was seated in room in wheelchair, Resident #101 was asked about an incident that recently made her sick, Resident #101 stated I've never been so sick in my life, I vomited, had nausea and diarrhea for 2 (two) days, I threw up all day long. During an interview on 1/13/16 at 1:00 p.m., CNA F indicated on 12/25/15 she approached Resident #101 at her bedside about 6:30 a.m., Resident #101 needed to be toileted at this time, CNA F noticed a med cup with a liquid pink substance which CNA F thought was pepto bismal (anti-diarrheal) medication, she asked Resident #101 to finish the medication, Resident #101 drank what was in the cup and about an hour later started vomiting, CNA F went to LPN C to report vomiting, and at that time CNA F asked LPN C what medication was in the cup, and LPN C responded that is was [MEDICATION NAME] lotion. Review of a facility investigation Meeting Summary dated 12/28/15 at 8:15 a.m. revealed Resident #101's family member was in the facility and wanted to meet with the Nursing Home Administrator (NHA). The summary revealed in the family members opinion there was an egregious breach in protocol for this to happen and that is has shaken their confidence in the facility. Resident #102 Review of a facility Face Sheet revealed Resident #102 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] indicated Resident #102 was an extensive assist with one (1) staff assistance with dressing, hygiene, bathing, and supervision/set up help with eating. A BIMS assessment score of 05/15 indicated Resident #102 was cognitively impaired. During an observation of a medication pass on 1/12/16 at 9:10 a.m. revealed Resident #102 was ordered [MEDICATION NAME] extended release (ER) 500 milligram (mg) Take 2 (two) tablets by mouth 1 (one) time daily for convulsions), Tylenol Arthritis (ER) 625 (mg) Take 2 (two) tablets by mouth 2 (two) times daily (for pain). It was observed that Licensed Practical Nurse (LPN) B crushed the [MEDICATION NAME] and Tylenol despite the packaging labeled Do Not Crush. Resident #104 Review of a facility Face Sheet revealed Resident #104 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] indicated Resident #104 was a total assist with 1 (one) staff assistance with dressing, hygiene, bathing, and extensive assist with 1 (one) staff with eating. A BIMS assessment score of 05/15 indicated Resident #104 was cognitively impaired. During an observation of a medication pass on 1/12/16 at 11:08 a.m. revealed Resident #104 was ordered [MEDICATION NAME] HCL 50 mg (narcotic pain medication) Take 1 (one) tablet by mouth 4 (four) times daily. It was observed that LPN B crushed the [MEDICATION NAME] 50 mg despite the package labeled Do Not Crush. During an interview with the Director of Nursing (DON) on 1/12/16 at 12:30 p.m., when asked if a nurse passing medications crushed medications that were labeled Do Not Crush as well as listed on the pharmacy list of non-crushable medications was following proper medication administration technique, and professional standards of quality, the DON stated No, that would be a medication error. During an interview on 1/12/16 at 12:40 p.m., LPN B was asked if she was aware that [MEDICATION NAME] ER, Tylenol Arthritis, and [MEDICATION NAME] HCL should not be crushed, LPN Bstated I had no idea these medications should not be crushed when asked if LPN B had a physicians order to crush Resident #102 and Resident #104's medications, LPN B indicated she had been crushing them for as long as she can remember.

This citation pertains to intake MI 006 Based on observation, interviews, and record review, the facility failed to maintain a medication administration free of significant error in 1 of 5 sampled residents (residents # 101) reviewed for medication administration, from a total sample of 5 residents, resulting in nausea, vomiting and diarrhea for 1 resident (Resident #101) and the potential for stomach upset, reduced medication effectiveness and increased risk of serious adverse reactions and or serious side effects. Findings include: Review of a Facility Policy dated 10/95 with a revision date of 5/15 and labeled Medication Administration revealed : Medications are prepared, administered, as prescribed, in accordance with good nursing principles and practices and only be persons legally authorized to do so. Personnel authorized to administer medications may do so only after they have familiarized themselves with the medication. Further review revealed: Medications are administered in accordance with written or telephone orders from the prescriber. Personnel administering medications should refer to the Physicians Desk Reference (PDR), the Nursing Drug Handbook or other reference material when unfamiliar with the pharmacology of the drug, its potential toxic effects, contraindications, etc., as well as the specific indications and use for each drug. Review of Lippincott's Nursing Drug Handbook 2014 appendix 6, page 1471 revealed Age related changes can alter the way older people absorb, distribute, metabolize and eliminate medications compared to younger adults and children. Medication dosages and routes may need adjustment to optimize the patients response to medication and help prevent adverse reactions. Understanding how age related factors can alter how an older patient's body uses the medication will help you and implement your patients medication regimen and monitor his response appropriately. Resident #101 Review of a facility Face Sheet revealed Resident #101 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #101 was an extensive assist with one (1) staff assistance with dressing, hygiene, bathing, and independent/set up help with eating. A BIMS assessment score of 09/15 indicated Resident #101 was mildly cognitively impaired. Review of a facility investigation 24 hour report Incident Summary dated 12/25/15 revealed On 12/25/15 at approximately 0630 Licensed Practical Nurse (LPN) C prepared 5 ml (milliliters) of [MEDICATION NAME] lotion for Resident #101 and placed it in a med cup and set on Resident #101's night stand or the Certified Nurse Aide (CNA) F. At about 0730, CNA F was providing am care to Resident #101 when she saw a med cup with what she thought was remaining medication that the resident had not fully consumed. At this time CNA F gave Resident #101 the medicine cup and asked her to finish taking it. About an hour later, CNA F stated that Resident #101 had an emesis (vomiting). CNA F then went and informed LPN C of this fact. LPN C immediately assessed Resident #101, LPN C placed a call to the on-call practitioner and informed them of what had happened. LPN C was instructed to give Resident #101 water and crackers as well as call poison control. LPN C called poison control and was instructed to continue the water and crackers as that will help to quickly flush it out of her system. During an interview on 1/12/16 at 10:10 LPN C indicated on 12/25/15 she was working a unit she was unfamiliar with, LPN C had filled a med cup with [MEDICATION NAME] lotion and left it at Resident #101's bedside for the CNA caring for Resident #101 to apply to her back for itching, LPN C stated she had set up the [MEDICATION NAME] lotion prior to looking at the Medication Administration Record [REDACTED]. Review of Resident #101's physicians order dated 8/27/15 revealed Discontinue [MEDICATION NAME] Lotion During an interview and observation on 1/12/16 at 11:10 a.m. Resident #101 was seated in room in wheelchair, Resident #101 was asked about an incident the recently made her sick, Resident #101 stated I've never been so sick in my life, I vomited, had nausea and diarrhea for 2 (two) days, I threw up all day long. During an interview on 1/13/16 at 1:00 p.m. CNA F indicated on 12/25/15 she approached Resident #101 at her bedside about 6:30 a.m., Resident #101 needed to be toileted at this time, CNA F noticed a med cup with a liquid pink substance which CNA F thought was Pepto bismol (anti-diarrheal) medication, she asked Resident #101 to finish the medication, Resident #101 drank what was in the cup and about an hour later started vomiting, CNA F went to LPN C to report vomiting, and at that time CNA F asked LPN C what medication was in the cup, and LPN C responded that is was [MEDICATION NAME] lotion. Review of a facility investigation Meeting Summary dated 12/28/15 at 8:15 a.m. revealed Resident #101's family member was in the facility and wanted to meet with the Nursing Home Administrator (NHA) the summary revealed in the family members opinion there was an egregious breach in protocol for this to happen and that is has shaken their confidence in the facility.

Based on observation, interview and record review the facility failed to prevent sexual abuse in 6 of 22 residents (Resident #2, Resident #20, Resident #41, Resident #42, Resident #43 and Resident #44) reviewed for abuse from a total sample of 22 residents, resulting in the dehumanizing and humiliation based on the reasonable person concept for Resident #2, Resident #20, Resident #41, Resident #42, Resident #43 and Resident #44. Findings include: CMS Center for Medicaid and State Operations Survey & Certification Group Reasonable Person Concept. The absence of a reaction from a cognitively impaired resident who lacks the ability to understand and react to most stimuli, including those affected by the situation, does not make the deficiency any less serious. In this case, the survey team should use the "reasonable person" concept to determine the severity level of psychosocial outcome for that person. CMS introduced the reasonable person concept in 1995 in Task 6E of the SOM, Appendix P. The reasonable person concept is described as follows: In cases where residents are unable to speak for themselves, the survey team should assess how most people would react to the situation in question. For example, a female resident who is unable to express herself is wheeled down the hall in a wheelchair on the way to her shower with only a towel partially covering her body. The team will decide whether this incident is inappropriate because the resident is unable to express herself. The Preceptor Manual further defines the reasonable person concept as follows: There must be a standard, which can be used by all to achieve some uniformity and consistency in the application of regulations. The "reasonable person" standard has been used by our judicial system as a standard to apply principles on a consistent basis. Use of this standard will help evaluate the impact of deficiencies, such as resident rights, on such intangibles as self-esteem, dignity and comfort. Resident #7: Review of the Face Sheet revealed Resident #7 was a [AGE] year old male admitted to the facility on [DATE]. Review of the [DIAGNOSES REDACTED].#7 was diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated he had severely impaired cognition. Resident #20 Review of the Face Sheet revealed Resident #20 was an [AGE] year old female admitted to the facility on [DATE] and was diagnosed with [REDACTED].#20 had moderately impaired cognition. During the survey Resident #20 was not in the facility. Review of the Mood/Behavior Tracking Tool dated 7/12/14 revealed documentation of Resident #7 "holding her (Resident #20) hand and stroking her (Resident #20) breast." In an interview on 9/11/14 at 9:20 a.m., CNA "E" stated she observed Resident #7 in the doorway to his room and Resident #20 was "in her wheelchair". CNA "E" stated, "I seen him holding her (Resident #20's) hand and stroking her breast with the back of his other hand." CNA "E" stated she thought to herself "hey, that's not right" and "I separated (the residents)." CNA "E" stated, "it happens so often, you can tell he's (Resident #7) stalking them, he's (Resident #7) always watching to see if we are watching him (Resident #7)." CNA "E" stated she then told the nurse about the sexual abuse. In a interview on 9/11/14 at 9:30 a.m., Licensed Practical Nurse (LPN) "G" stated, "I was told he (Resident #7) was rubbing her arm and the back of his hand was rubbing her (Resident #20) breast." LPN "G" stated, "we always have to watch him closely for any inappropriate behaviors." LPN "G" was asked by the surveyor if Resident #7 touching the breast of Resident #20 was sexual abuse. LPN "G" stated, "I didn't feel that it was (sexual abuse), I didn't feel it (rubbing Resident #20's breast) was something purposeful." LPN "G" was asked by the surveyor if she reported the incident to anyone else. LPN "G" stated,"I didn't do anything with it further." Resident #41: Resident #41 was an unidentified female resident who resided in the closed dementia unit. Review of the Mood/Behavior Tracking Tool dated 7/18/14 revealed "resident was touching female residents inappropriately during activities, he (Resident #7) put his hand in female residents peri area (Resident #41). In dining room after dinner he (Resident #7) was pinching a female resident's breasts (Resident #41), In common area he touched another female resident's breasts. Each time I (CNA "F") told him it was not appropriate." In an interview on 9/11/14 at 1:55 p.m., CNA "F" stated, on 7/18/14, Resident #7 "was in an activity" when she observed him inappropriately touch a female resident (Resident #41). CNA "F" stated, "you watch him (Resident #7) because he touches (the female residents)." CNA "F" stated, "that's not appropriate" for Resident #7 to touch female residents. CNA "F" stated she did not remember the name of the female residents and "what was charted" was her observations (touching female resident breasts) but she "can't remember everything." Resident #42: Resident #42 was an unidentified female resident who resided in the closed dementia unit. Review of the Nurses Notes dated 7/27/14 at 9:15 a.m., revealed LPN "J" was notified by activity aide "resident (Resident #7) was noted to be touching other resident inappropriately, other resident was unaware of surroundings, other resident was moved..." In an interview on 9/12/14 at 11:10 a.m., Activity Aide (AA) "O" stated, on 7/27/14, "I had witnessed Resident #7 put his hand on a (female) resident's thigh (Resident #42)." AA"O" stated, "it is not appropriate for him (Resident #7) to touch female residents. AA "O" stated she did not remember the name of Resident #42. In an interview on 9/11/14 at 3:15 p.m., LPN "J" stated Resident #7 was "regularly inappropriate" with female residents. LPN "J" stated, "I do remember that" incident "but it was a long time ago". LPN "J" stated Resident #7 "tries to pursue other women" in the closed dementia unit (where Resident #7 and Resident #42 resided in the facility). LPN "J" stated she could not remember the name of the female resident (Resident #42) who was sexually abused by Resident #7. LPN "J" stated, "it's important (to report the sexual abuse) because we need to protect our residents." LPN "J" was asked by the surveyor if the residents in the closed dementia unit could consent to sexual contact. LPN "J" stated, "no." Resident #43: Resident #43 was an unidentified female resident who resided in the closed dementia unit. Review of the Mood/Behavior Tracking Tool dated 8/7/14 revealed Resident #7 was "standing next to a female resident bumping himself into her arm, He (Resident #7) was also trying to rub up on other female residents." In an interview on 9/12/14 at 2:20 p.m., CNA "P" stated, on 8/7/14, she observed Resident #7 had walked up to a female resident (Resident #43) and was "bumping his crotch into her arm." CNA "P" stated, "no" the behavior was not appropriate and "I wasn't just going to stand there and let him (Resident #7) do that" to Resident #43. CNA "P" stated she did not remember the name of Resident #43. Review of the Nurses Notes dated 8/7/14 revealed no documentation of the sexual abuse by Resident #7. Resident #44: Resident #44 was an unidentified female resident who resided in the closed dementia unit. Review of the Nurses Notes dated 8/9/14 at 9:09 p.m., revealed Resident #7 asked a female resident if they "wanted to touch him...left (the) environment upset with staff..." The Nurses Notes revealed Resident #7 "then proceed to go back to activity room shortly after and sat next to another female putting his hand on her arm rubbing it, resident was asked to stop and res(ident) became upset again leaving activity room." In an interview on 9/11/14 at 3:15 p.m., LPN "J" was asked by the surveyor if she documented the nurses note (as stated above). LPN "J" stated, "yes" she heard Resident #7 state he wanted Resident #44 to touch him to a female resident on 8/9/14. LPN "J" stated, "I told my supervisor (Manager of Closed Dementia Unit "D")" of the statement made by Resident #7. LPN "J" stated she did not recall the name of Resident #44. In an interview on 9/12/14 at 11:10 a.m., AA "O" stated, on 8/9/14, Resident #7 "was rubbing the breast with the back of his hand" of Resident #2 (indicated 2nd sexual abuse incident charted in nurses notes on 8/9/14)." AA "O" stated Resident #7 was "kind of sneaky, he just slowly tries to sneak a touch" of female residents. AA "O" stated when she witnessed Resident #7 touch the breast of Resident #2 she knew it was "not good" and "I (AA"O") would feel very intimidated by it (touching by Resident #7)." Resident #2 Review of the Face Sheet revealed Resident #2 was an [AGE] year old female admitted to the facility on [DATE]. Resident #2 was diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had severely impaired cognition. In an observation and interview on 9/11/14 at 4:10 p.m., Resident #2 was noted to be seated in her wheelchair in the dining area watching television. Resident #2 was asked by the surveyor how long she had been at the facility. Resident #2 stated, "I live up the road, I just come down here for the TV (television)." Review of the facility incident report dated 9/10/14 revealed Resident #2 was "a long term resident on the (closed dementia unit)." The facility incident report revealed, "on 9/3/14 (Resident #2) was sitting in dining room when Resident #7 walked up to her (Resident #2)and she reached out her hand which he (Resident #7) held and directed to his crotch through clothing." The incident report further revealed Resident #2 and Resident #7 "have significant dementia and score as severely impaired on the BIMS (brief interview for mental status)...this appears to be consensual between both Resident #2 and Resident #7." In an interview on 9/12/14 at 2:20 p.m., CNA "P" stated Resident #7 went over to Resident #2 and "was rubbing her (Resident #2) arm. CNA "P" stated Resident #7 "grabbed her (Resident #2) and he (Resident #7) started rubbing her (Resident #2) hand on his crotch." In an interview on 9/10/14 at 2:55 p.m., Director of Social Services (DSS) "C" stated she was not aware of any sexual abuse involving Resident #7 until 9/3/14. DSS "C" stated Resident #7's medical record was reviewed for behaviors (sexual behaviors) on 7/9/14 but not after 7/9/14. DSS "C" stated Resident #7's behavior after 7/9/12 was "...sexually inappropriate." DSS "C" was asked by the surveyor if Resident #7's behavior was sexual abuse. DSS "C" stated, "oh definitely." DSS "C" stated, "these women...need to be protected because... (Residents of the closed dementia unit) can't give consent" for sexual contact. DSS "C" stated, "if we (social services) would have known" about the sexual abuse then an intervention would have been done to prevent further instances of sexual abuse. In an interview on 9/10/14 at 3:25 p.m., Manager of Closed Dementia Unit (MCDU) "D" stated she was not aware of the sexual abuse by Resident #7 until 9/3/14. MCDU "D" stated, "if I'd have known about it (sexual abuse) I would have reported it to my supervisor." MCDU "D" was asked by the surveyor if residents in the closed dementia unit could consent to sexual contact. MCDU "D" stated, "we should not let them engage (in sexual contact) because they (residents) are impaired (impaired mentally)." MCDU "D" stated, "most of them (residents in the closed dementia unit) do not" make their own decisions and "a lot of them (residents in the closed dementia unit) are severely impaired." MCDU "D" was asked by the surveyor if she considered the sexual abuse by Resident #7 was abuse. MCDU "D" stated, "if he (Resident #7) just touched her probably not." MCDU "D" was asked by the surveyor if any interventions had been placed to protect the female residents from sexual abuse after the sexual abuse on 7/12/14. MCDU "D" stated, "I was not aware of it (sexual abuse) so no" interventions were placed to prevent sexual abuse of female residents in the closed dementia unit. MCDU "D" stated no new interventions to prevent sexual abuse of female residents by Resident #7 were placed until the incident on 9/3/14. In an interview on 9/10/14 at 1:00 p.m., Administrator "A" stated, "there's a system (reporting/investigating abuse) we (facility) need to correct." Administrator "A" stated, "...I didn't know about it (sexual abuse)." ( )

Based on observation, interview and record review, the facility failed to maintain an updated and correct policy regarding reporting requirements for abuse, neglect and misappropriation of property and follow its abuse and neglect policy for 10 (#3, #8, #24, #25, #26, #27, #28, #29, #30, #31), of 12 residents reviewed for abuse, from a total sample of 23 residents, resulting in an immediate jeopardy when Residents #3, #26, #30, and #31 sustained injuries of unknown origin which were not investigated or reported to the State Agency, and Residents #8, #24, #25, #27, #28, and #29 had allegations of abuse that were not investigated or reported to the State Agency, resulting in continued abuse and injuries and the potential for further abuse and injuries of unknown origin to not be investigated or reported to the State Agency. These deficient practices place all 111 residents in the facility at high risk for physical harm and/or injury. Findings include: Resident #8 According to the face sheet, dated 9/23/13, Resident #8 was an [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment, dated 6/3/13, indicated that Resident #8 was cognitively intact and required extensive assistance of one person for dressing and hygiene. In a confidential group interview on 11/6/13 at 10:45 am, Resident #8 stated she requested not to have CNA "D" in her room because he was rough with her. Resident #8 stated CNA "D" jerked her clothes off in a rough way, which caused her hearing aids to be pulled out of her ears. Resident #8 stated since she has requested CNA "D" not come in her room, when her call light is on, CNA " D " would come into her room and ask her what she wanted. Resident #8 stated she would tell CNA "D" she wanted her aide and CNA "D" would turn off her call light, leave the room and not inform other staff that Resident #8's call light had been on. During a private interview with Resident #8 on 11/6/13 at 2:00 pm, she stated she reported to her aide and nurse that CNA "D" was rough with her, by shoving her around on the lift and toilet. Resident #8 was able to name CNA "L" as the nurse aide she reported her complaints about CNA "D" to. While explaining the incidents to the surveyor, Resident #8 became tearful. Resident #8 stated a nurse with gray, short hair and glasses came into her room and begged her to give CNA "D" one more chance, so she did. Resident #8 stated the next night, CNA "D" was so rough pulling her shirt and bra off from her that she cried. During the interview, CNA "D" walked by Resident #8' s room and Resident #8 stated, "There he is. Do you see him? He just walked by. "Resident #8 appeared fearful and stated CNA"D" better stay out of her room. In an interview on 11/6/13 at 2:15 pm, CNA "L" stated Resident #8 did report to her a few months ago that CNA "D" was rough with her. CNA "L" stated she reported it to her nurse, Licensed Practical Nurse (LPN) "M". In an interview on 11/6/13 at 2:20 pm, LPN "M" stated she couldn't recall if CNA "L" had reported the allegation Resident #8 had made against CNA "D". LPN "M" stated she had not filled out an incident report about Resident #8 reporting CNA "D" being rough with her. LPN "M" stated if CNA "L" reported Resident #8 making an allegation about CNA "D" being rough with her, she (LPN "M" ) would have reported it to Unit Manager "N" . LPN "M" stated multiple residents had voiced complaints against CNA "D" and had requested CNA "D" not provide care to them. LPN "M" stated Director of Nurse Aides (DNA) "C" asked her (LPN "M") to make a list of residents who had complained about the care CNA "D" provided. LPN "M" stated she did make the list and gave the list to UM "N". In an interview on 11/6/13 at 2:10 pm, Unit Manager (UM) "N" stated Resident #8 never reported to him that CNA "D" was rough with her. UM "N" stated he did talk with Resident #8 one day to ask her how her night went with CNA "D" , just because he (CNA "D") was new to the unit. The surveyor asked UM "N" if he did that with all staff that was new to the unit and UM "N" stated no. UM "N" was observed to have short gray hair and to be wearing glasses. UM "N" stated LPN "M" did give him a list of residents she had written, who had complained about CNA "D" and did not want CNA "D" to provide care to them anymore. UM "N" stated he gave the list to DNA "C". In an interview on 11/6/13 at 1:00 pm, Director of Nursing (DON) "B" stated there was no incident report regarding an allegation from Resident #8 against CNA "D". DON "B" stated she was not aware Resident #8 had made a complaint about CNA "D" . In an interview on 11/6/13 at 2:25 pm, the Director of Nurse Aides (DNA) "C" stated she recalled that LPN "M" notified her there were residents on the 300 Hall that did not want CNA "D" to take care of them. DNA "C" stated she had LPN "M" make a list of residents who had made complaints about CNA "D" . After multiple requests by the surveyor, for the list of residents who had made complaints about CNA "D" , no list was provided by the facility. During observations on 11/6/13 from 2:05 pm to 3:00 pm, the surveyor observed CNA "D" working as a direct care giver for Residents on the 300 Hall of the facility. Resident #26: Review of Resident #26's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set ((MDS) dated [DATE] indicated Resident #26 required extensive assistance of two persons for transfers, dressing and toilet use. Per facility incident report dated 7/11/13, at 4:30 pm, RN "F" saw certified nurse aide "D" (CNA "D") pushing Resident #26 into the dining room and Resident #26 was crying and upset. The incident report indicated Resident #26 reported to RN "F" her leg hurt in the knee area and that it got bumped on the way down the hall. The follow up section of the incident report indicated Resident #26 was sent to the emergency room and a CT scan (computer generated image of the bones), report showed a displaced cortical [MEDICAL CONDITION] femoral shaft (end of the upper leg bone). According to the Nursing Note dated 7/11/13, "at approximately 4:30 PM, I (RN "F" ) saw CNA "D" pushing this resident (Resident #26) into the dining room, resident was upset and crying. I asked her what was the matter and she said her left leg hurt in the knee area and that it got bumped on the way down the hall. Resident continued crying and complained of left leg pain." Resident #26 was then transferred to the Hospital. Upon review of the emergency Physician Note dated 7/11/13, Resident #26 grimaced with palpation (touched) of the left knee and had effusion (swelling caused by fluid) around her left knee. With a [DIAGNOSES REDACTED]. In an interview on 11/6/13 at 1:10 pm, Director of Nursing (DON) "B" stated she talked to CNA "D" and CNA "D" didn't know what happened, that he may have bumped Resident #26's leg and he may not have bumped Resident #26's leg. DON "B" stated she did not document the interview and concluded it was not abuse from, "knowing her residents and knowing her staff ". In an interview on 11/7/13 at 1:40 PM with RN "F" , RN "F" indicated, the Resident #26 sometimes is a little confused, but can answer yes and no questions. RN "F" reported that she did remember Resident #26's fracture and on the day that it happened, I (RN "F" ) remembered passing medications from the cart by the activity room. RN "F" indicated Resident #26 was very upset shaky and crying. RN "F" stated she asked CNA "D" who was pushing Resident #26 in the wheelchair what had happened. CNA "D" replied to RN "F" that he did not know. Resident #26 was holding her knee. Resident #26 reported to RN "F" that her knee hurt. RN "F" reported that she asked CNA "D" again what happened to her, CNA "D" said that he bumped her foot on the wall. RN "F" explained that foot petals were on the wheelchair. CNA "D" replied to RN "F" that he wasn't sure where he bumped her foot in the wall. RN "F" then stated that she asked LPN "P" and DON "B" to look at Resident #26's knee. Resident #26 was holding her leg up and would not put her leg down to rest on the foot petal. RN "F" then stated "by the way Resident #26 was aching and the way it looked I thought we should have it checked out. We called the doctor to have it checked out. "RN "F" then explained that the facility called the doctor to have it checked out. RN "F" explained that the x-ray was done while she was on shift and was done in house. At that time DON "B" was asked for the radiology results from the in house results that were done 7/11/13, DON "B" stated that no in house x-ray was done. In a phone interview on 11/7/13 at 2:55 PM with CNA "D" , CNA "D" was asked about the incident with Resident #26. CNA "D" explained that when he went into Resident #26 's room to get her up for dinner, "everything was fine" . CNA "D" reported again that after getting Resident #26 up in her wheelchair "everything was fine" . CNA "D" then explained that he was pushing Resident #26 in her wheelchair in the hall, and Resident #26 then stated, "oh my knee, oh my knee" . CNA "D" then explained that he didn't know what happened, and he continued to push her into the dining room. CNA "D" was asked if he stopped before getting to the dining room, and he stated "no" . CNA "D" reported that once he got Resident #26 into the dining room, he told the nurse that she had pain. In an interview on 11/13/13 at 11:30 am, CNA "H" stated on the day Resident #26 sustained her broken leg, she witnessed CNA "D" pushing Resident #26 out of her room in her wheelchair right before dinner. CNA "H" stated Resident #26 was shaking, crying and had a look on her face like she was terrified. CNA "H" stated shortly after that, Resident #26 was sent to the hospital. CNA "H" stated she was never asked any questions or interviewed by any administrative staff regarding Resident #26's injury to her leg. In an interview on 11/8/13 at 9:40 am, facility Director of Nursing "B"(DON "B") stated she did not get a written statement from CNA "D" regarding the fracture of Resident #26's leg because she knew what happened. The surveyor asked DON "B" what happened and DON "B" stated CNA "D" reported "he may have bumped her leg". DON "B" stated there was no further investigation into the fracture of Resident #26's leg. Resident #30 Review of Resident #30's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set ((MDS) dated [DATE] indicated she required extensive assistance of two persons for transfers and extensive assistance of one persons for dressing. Review of Resident #30's falls plan of care (undated), which was provided to the surveyor by the director of nurse aides "C", indicated Resident #30 required the use of an "EZ stand with two persons" for transfers. Per facility incident report dated 7/25/13, at 3:30 pm, a nurse was called to Resident #30's room by a CNA and informed of a skin tear to her lower forearm. The incident report indicated Resident #30 had a skin tear 8 to 9 centimeter in length and 0.1 centimeter in width. The follow up section of the incident report indicated CNA "D" was attempting to transfer Resident #30 with an EZ stand (lift used to transfer a resident), and Resident #30 bumped her arm. Per a typed statement by CNA "H" dated 7/26/13, CNA "H" heard Resident #30 crying more than she normally did and went into Resident #30's room. CNA "H" observed CNA "D" with Resident #30 and her sleeves pulled down with blood on the sleeves. CNA "D" told CNA "H" that Resident #30 had a bruise and he pulled Resident #30's sleeve up. CNA "H" statement indicated she told CNA "D" that was not a bruise, he needed to get a nurse and he could not leave Resident #30 like that. The statement indicated when CNA "H" entered Resident #30's room she heard Resident #30 crying and CNA "D" was brushing her hair like nothing was happening. In a phone interview on 11/7/13 at 2:55 PM with CNA "D" , he (CNA "D") stated he put Resident #30 in the lift and the sling cut her arm. CNA "D" stated he had to yell out of the room for another aide because he couldn't leave the room. CNA "D" stated he was alone in the room with Resident #30 when he lifted her with the lift. CNA "D" stated the nurse came to the room and accused him (CNA "D") of trying to hide the incident. In an interview on 11/13/13 at 11:30 am CNA "H" stated she heard Resident #30 screaming more than usual from the room she was in across the hall, so she walked into Resident #30's room to see what was happening. CNA "H" stated she observed Resident #30 in her wheelchair with CNA "D" standing near her, and Resident #30 had blood on her sleeve. CNA "H" stated she asked CNA"D" what happened as she pushed the sleeve up and CNA "D" stated he didn't know. CNA "H" stated she observed the largest skin tear she had ever seen, which extended about half the length of Resident #30's lower arm, and it was bleeding badly. CNA "H" stated she went to get the nurse and told CNA "H" he couldn't just leave Resident #30 that way. CNA "H" stated DON "B" came to the room and she (CNA "H") went back to work. During a interview on 11/6/13 at 1:30 PM, DNA "C" said that CNA "D" was suspended for three days because of the skin tear, " ...we wanted to investigate if there was anything else with him we should be concerned about ...he was suspended for his roughness ". DNA "C" stated she did not report any allegations of roughness by CNA "D" to the State Agency, that she reviewed it with her superiors. During an interview on 11/6/13 at 1:30 PM, DNA "C" stated abuse was defined as something causing physical pain or injury. DNA "C" also stated that when she becomes aware of an allegation of abuse she goes to her superior (the Director of Nursing, DON "B"). In an interview on 11/13/13 at 11:30 am CNA "H" stated she had reported to her Unit Manager after Resident #30 had her skin tear in July of 2013, that she (CNA "H") wasn't comfortable working with CNA "D" because he wasn't "safe". CNA "H" stated CNA "D" kept hurting the residents. CNA "D" stated at no time did a staff member follow up with her regarding her statement to her unit manager about CNA "D" and CNA "D" continued to work in the facility as a direct care giver. CNA "H" stated CNA "D was moved to another part of the building to work. # Resident #24: According to a face sheet, undated, Resident #24 is a [AGE] year-old woman, who was admitted to the facility on [DATE]. According to a BIMS Brief Interview for Mental Status (BIMS), Resident #24 was cognitively intact. During an interview on 11/6/13 at 9:30 AM, Resident #24 was asked if she felt safe with staff. Resident #24 replied, she had an incident with an aide who swung her around and put her in her wheelchair " ...that ' s how this happened... " , Resident #24 then exposed her right lower leg to the surveyor and a significantly large bandage was observed. Resident #24 explained that the wound on her leg bled terribly. When asked who the aide was, Resident #24 explained that she didn ' t know. Resident #24 stated that she reported the incident to her nurse. An incident/accident report documented the event on 9/17/13, but did not contain a statement from the resident about the incident. The nurse ' s aide involved in the incident was identified as CNA " D " . When DON " B " was asked why the facility did not get a statement from the resident, DON " B " explained, " I did not get a statement from the resident because I felt the statement from the aide explained everything. I have to trust my staff. " During an interview on 11/8/13 at 1:35 PM Resident #24 was tearful and said she just did not know why she swung her around and " plumped " her in her wheelchair like she did. Resident #27: Resident #28: According to the face sheet, dated 8/2/13, Resident #28 was a [AGE] year-old female, who was admitted to the facility on [DATE]. According to the MDS dated [DATE], Resident #28 had a BIMS of 9 out of 15, indicating she was moderately cognitively impaired. During the survey Resident #28 was not in the facility. According to the face sheet, dated 4/4/13, Resident #27 was an [AGE] year-old male, who was admitted to the facility on [DATE]. According the MDS dated [DATE], Resident #27 had a BIMS of 6 out of 15, indicating that he was severely cognitively impaired. During an interview on 11/6/13 at 4:00 PM, Unit Manager, LPN "I", stated that there had been occurrences of sexual behavior in the facility and residents were still fearful of further sexual abuse. On 11/6/13 at about 5:00 PM CNA "Q" was asked about resident-to-resident sexual behaviors in the facility. CNA "Q" explained that Resident #28 had been extra "touchy feely" approximately 4 months ago and was found in Resident #27's room performing oral sex on him. CNA "Q" stated that Resident #28 was then transferred to a Psychiatric Treatment facility. On 11/6/13 at about 6:00 PM, DON "B" was asked to provide incident/accident reports for the incident between Resident #27 and Resident #28. DON "B" stated that the incident was consensual sexual behaviors. When asked how the facility came to that conclusion and for the documentation about the incident, DON "B" explained that she would need to contact Director of Nurse Aides (DNA) "C". On 11/6/13 at about 6:10 PM, DNA "C", explained that there was no documentation for the resident to resident sexual incident. On 11/6/13 at about 6:30 PM, Resident #27's Power of Attorney (POA) was called and asked about the sexual incident that occurred on 6/4/13. Resident #27's POA explained that the facility called to explain the sexual behavior incident. Resident #27's POA also reported that the facility stated "They were not going to report it or put documentation into the records. It will be like it never happened." Resident #27's POA was then asked if the facility asked about reporting this incident to the police. Resident #27's POA stated that the facility never mentioned the word "police" in the meeting. An interview was conducted on 11/8/13 at 1:20 PM with DNA "C". DNA "C" stated she was contacted by DON "B" and was told "there was an instance of oral sex" between Residents #27 and #28. DNA "C" stated she was told she "did not need to do anything about reporting an 'internal investigation'" . In an interview on 11/7/13 at 9:27 a.m., Resident #28's Durable Power of Attorney (DPOA) stated Administrator "A" called her and reported Resident #28 had an "inappropriate behavior with another gentleman on the unit" and reported that it was "sexual in nature." Resident #28's DPOA stated Administrator "A" stated "it was their policy to contact the responsible party" of the residents involved. Resident #28's DPOA stated Administrator "A" "did not" talk about reporting the incident to the police". Resident #28's DPOA stated she was told, not asked, that the incident "would go under lock and key" and "that not everyone at the nursing facility would know" of the incident. Resident #28: Resident #29: According to the "Face Sheet" (Run Date 5/29/13), Resident #29 was a [AGE] year old male, admitted to the facility on [DATE]. Resident #29's "physician's orders [REDACTED]. Resident #29's Minimum Data Set (MDS) assessment dated [DATE], reflected that resident #29 had a Brief Interview for Mental Status (BIMS) Score of 11 out of 15, which indicated mild cognitive impairment. During the initial tour of the facility on 11/5/13 with Director of Nurses Aides (DNA) "C", beginning at 9:30 am, Resident #29's name was observed on a name plate outside one of the rooms on the "Gilead" locked unit. When DNA "C" was asked a question pertaining to Resident #29, DNA "C" responded that he was not currently a resident at the facility as he was receiving psychiatric treatment at a psychiatric hospital. DNA "C" was interviewed on 11/7/13 at 1:15 pm. DNA "C" was asked if Resident #29 had been making his own decisions about care in the facility to which she replied "He was not making his own decisions. I believe it was his daughter." DNA "C" later stated that Social Worker "S" would be able to explain who was making decisions for Resident #29 while in the facility. Social Worker "S" was interviewed on 11/8/13 at 3:30 pm. Social Worker "S" revealed that the facility had been working with Adult Protective Services since June 12, 2013 in regards to getting guardianship granted for Resident #29 as the facility was "not getting infor from his family and because he needed some help with decisions." Social Worker "S" also revealed that Resident #29's daughter had applied for guardianship on 10/10/13, and provided documentation that reflected this. ( ) Review of the face sheet, dated 8/2/13, revealed Resident #28 was a [AGE] year-old female, admitted to the facility on [DATE]. According to the MDS dated [DATE], Resident #28 had a BIMS of 9 out of 15, indicating she was moderately cognitively impaired. During the survey Resident #28 was not in the facility. Review of the witness statements dated 9/24/13 at 7:00 p.m. signed by CNA "R", revealed Resident #29 "walked over to the chair" where Resident #28 was located and "began to kiss" Resident #28. The witness statement continued and revealed Resident #31 "had his (Resident #31) hand down" Resident #28's pants. In an interview on 11/13/13 at 11:55 a.m., CNA "R" stated, "I witnessed Resident #29 going over to Resident #28" and "he (Resident #29) started making out with her (Resident #28)." CNA "R" stated Resident #29 "stuck his hand down her (Resident #28) pants." CNA "R" stated no management staff questioned her about the sexual behavior between Resident #28 and Resident #29. In an interview on 11/13/13 at 9:30 a.m., DON "B" was shown the witness statements by the surveyor. DON "B" stated, "I have not" seen these witness statements before. DON "B" stated she did not conduct the interviews which produced the witness statements. DON "B" stated the witness interviews were conducted by DNA "C". In an interview on 11/13/13 at 9:35 a.m., DNA "C" was shown the witness statements by the surveyor. DNA "C" stated, "I don't recall seeing them (witness statements)." DNA "C" stated, "no, there isn't" an investigation for the sexual incident (hand down pants and kissing of Resident #28) mentioned in the witness statement. DNA "C" stated the incident was not abuse because "neither (Resident) was injured, neither (Resident) were distressed" and "there was no injury" to either Resident (#28 and #29). DNA "C" stated after the sexual incident between Resident #28 and Resident #29 that Resident #29 was moved to another room in the facility. DNA "C" stated, "they (Resident #28 and Resident #29) were inappropriate" and "we (facility) didn't want the behavior to continue." Resident #31: Review of the Face Sheet, dated 4/18/11, revealed Resident #31 was admitted to the facility on [DATE]. According to the MDS, dated [DATE], Resident #31 was severely cognitively impaired and needed extensive assistance of 2 staff for transfers. In a phone interview on 11/7/13 at 1:40 PM., CNA "D" explained that when he pulled back the covers on Resident #31, he saw a large bruise. Review of nursing notes dated 10/29/13 (untimed), reflected, "Large hematoma present on Resident right lower extremity (outside calf) .....dark purple with raised area, irregular shape ....bruise appears to be related to bumping leg on wheelchair or .... during transfer." In an interview on 11/8/13 at 12:45 PM, UM "N" stated he was aware of the injury to Resident #31 "on the morning of 10/29/13." UM "N" stated "I did not look at the bruise on the 10/29/13." UM "N" stated "the first day I observed the bruise" was on 11/5/13. UM "N" stated he did not investigate the bruise to Resident #31's leg until 11/5/13 and stated "no" when asked by the surveyor if he interviewed any staff involved in the injury to Resident #31. UM "N" stated he had completed the conclusion (to the internal investigation) that the injury "was of undetermined cause." UM "N" agreed that the bruise was an injury of unknown origin. When asked if an injury of unknown origin would be reported to the state agency UM "N" stated "I couldn't tell you." In an interview on 11/13/13 at 11:15 a.m., DON "B" stated there was an incident and accident report for the injury to Resident #31 but not an investigation reported to the State agency. DON "B" stated, "I am responsible for the investigation." DON "B" stated she did not conduct any interviews related to the injury to Resident #31's leg. DON "B" stated UM "M" told her what he thought had happened to cause Resident #31's injury. Resident #3's "Face sheet" (undated) reflected she was an [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's "Nursing Admission Assessment" (Dated 9/17/13) reflected that Resident #3 was re-admitted to the facility on [DATE] and had a "Fall Risk Assessment" score of 16 "(Total score of 10 or above deems resident at risk; initiate precautions)" which indicated Resident #3 was not at a high risk for falls. Resident #3's careplan (Reviewed by Director of Nursing Assistants (DNA) "C" on 8/15/13) reflected "(Resident #3) at risk for falls R/T dementia & her inability to understand her safety needs..." Resident #3's Incident and Accident report (dated 8/5/13, 7:00 am) reflected "Bruise, Right Forearm, 9x9 (centimeters - cm) ecchymotic (bruise) area on right outer forearm." The section "General Follow up Procedures" reflected "Written by (DNA "C") on 8/13/13 11:00 am Incident discussed with interdisciplinary team and this is not a result of abuse. (Resident #3's name) skin is very thin and frail. Geri sleeves have been initiated and currently effective. Her dementia is at a stage where she still understands the importance of them and is compliant with wearing them." No additional documentation could be provided by the facility regarding any interviews done with any staff working with the resident at the time of, or before the incident. Resident #3's Incident and Accident report (dated 8/21/13) reflected "Bruise, Left Side of Chin, 3 cm dk. (dark) purple bruise on left chin/cheek." The section "General Follow up Procedures" reflected "Written by ( DNA "C") ... This was discussed with interdisciplinary team and not a result of abuse. While sleeping it was noted that her hand with her ring was up against her face. Reported to family and they voiced that she does have a history of bruising easily. (Resident #3) voiced that there is not pain. Staff did not wake her when this was noted because it looked harmless at the time. The bruise appeared after she was up for awhile in the morning. Now when they check on her they reposition her and take her hands away from her face if needed." No additional documentation could be provided by the facility regarding any interviews done with any staff working with the resident at the time of, or before the incident. The Incident and Accident report (dated 9/7/13) reflected "Assigned Care giver, CNA "O" ... R/O (Rule Out) Fracture, Right Shoulder, Resident with complaint of Right arm pain, swollen area noted at the deltoid. Nurse's Note of what happened written by (Nurse "K") ... I was in the medication room. I saw the resident turn to follow the CNA and her walker got caught on the lazy boy chair in the hallway. Resident unable to state what happened." The section "General Follow up Procedures" reflected "Written by (DNA "C") Incident discussed with falls committee and this is not a result of abuse. (Resident #3) has dementia and is unable to recall her safety needs. She also has [MEDICAL CONDITION]. Resident was restless during devotions and activities asked CNA if she could take her out of activity. She was walked to a chair and CNA sat next to her. Another resident from the other side of the room stood up, CNA responded, during this time (Resident #3) stood also. Chair alarms have been put in place. Also sling per physician's orders [REDACTED]." No additional documentation could be provided by the facility regarding any interviews done with any staff working with the resident at the time of, or before the incident. Resident #3's "Radiology Report" (dated 9/7/13) reflected " ...Swelling Post Fall RO FX (rule out fracture) ..>.Right shoulder, 2 views 1. Acute comminuted humeral neck and greater tuberosity fracture, with mild displacement ... Right Humerus, 2 views 1. Acute comminuted humeral neck and greater tuberosity fractures, with mild displacement." On 11/6/13 DNA "C" and Director of Nursing "B" were asked at 1:40 pm whether there was any more documentation from Resident #3's incident on 9/7/13 regarding staff interviewed about the incident. DON "B" indicated she would look to see if there was anymore available documentation. On 11/6/13 at 1:40 pm DON "B" revealed that there was no other documentation available regarding Resident #3's incident on 9/7/13 where she fractured her shoulder. DON "B" then revealed that she, DNA "C", and Administrator "A" performed the investigation on the incident. Administrator "A", DON "B", and DNA "C", were interviewed on 11/6/13 at approximately 3:00 pm. Administrator "A", DON "B", and DNA "C" were all asked whether they had observed Resident #3's incident on 9/7/13 where she fell and fractured her shoulder. All 3 answered they had not. All 3 were then asked how they determined that the incident on 9/7/13 was not a result of abuse and Administrator "A" responded "(DNA "C") did investigate. She talked to the 3 staff there. It was not reported to the State because the aid, activity aid (this activity aid was not identified in the incident and accident report (dated 9/7/13)), and Nurse were interviewed and we were not able to identify that it was abuse. I feel we were following the guidelines ..." DNA "C" was then asked if any of the interviews she performed for the investigation to the incident on 9/7/13 were documented. DNA "C" responded that she had not documented them. Administrator "A" then asked this surveyor "you have a copy of the incident and accident report?" This surveyor responded "Yes." Administrator "A" then stated "That's our investigation then." DON "B" then stated "Sounds like we would have to write down everything we talk to anyone about. We have to document it and keep a file, even if we feel no one did anything wrong." DNA "C" was again interviewed on 11/6/13 at 4:25 pm regarding Resident #3's Incident and Accident reports dated 8/5/13 and 8/21/13. DNA "C" stated that she did talk to staff members involved with both incidents but could not remember who, and did not document any of the information from the interviews regarding the investigations. CNA "O" was interviewed on 11/6/13 at 4:50 pm regarding the incident she observed on 9/7/13 where Resident #3 broke her shoulder. CNA "O" stated that she had been asked by an activity aid to help remove Resident #3 from an activity on the "Gilead" unit as Resident #3 was anxious and restless and not able to participate in the activity. CNA "O" stated that she then removed resident #3 from the activity and brought her out near the main hallway on the "Gilead" unit where she was assisting Resident #3 to sit down. At that time another resident's alarm began to sound as that resident was attempting to stand up, so CNA "O" turned to assist that resident "and then turned back

Based observation, interview and record review, the facility administration failed to use its resources to effectively and efficiently maintain the highest practicable physical, mental and psychosocial well-being for all 111 resident in the facility from a total sample of 23 residents, resulting in an immediate jeopardy when the administrative staff failed to prevent the abuse of Resident #8 and #25, investigate injuries of unknown origin for Residents #3, #26, #30, and #31, and investigate allegations of abuse for Residents #24, #27, 28, and #29 resulting in fear and emotional distress for Resident #8, and the potential for further abuse and injuries of unknown origin to not be investigated or reported to the State Agency. These deficient practices place all 111 residents in the facility at high risk for physical harm and/or injury. Findings include: Resident #8 According to the face sheet, dated 9/23/13, Resident #8 was an [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment, dated 6/3/13, indicated that Resident #8 was cognitively intact and required extensive assistance of one person for dressing and hygiene. In a confidential group interview on 11/6/13 at 10:45 am, Resident #8 stated she requested not to have CNA "D" in her room because he was rough with her. Resident #8 stated CNA "D" jerked her clothes off in a rough way, which caused her hearing aids to be pulled out of her ears. Resident #8 stated since she has requested CNA "D" not come in her room, when her call light is on, CNA " D " would come into her room and ask her what she wanted. Resident #8 stated she would tell CNA "D" she wanted her aide and CNA "D" would turn off her call light, leave the room and not inform other staff that Resident #8's call light had been on. During a private interview with Resident #8 on 11/6/13 at 2:00 pm, she stated she reported to her aide and nurse that CNA "D" was rough with her, by shoving her around on the lift and toilet. Resident #8 was able to name CNA "L" as the nurse aide she reported her complaints about CNA "D" to. While explaining the incidents to the surveyor, Resident #8 became tearful. Resident #8 stated a nurse with gray, short hair and glasses came into her room and begged her to give CNA "D" one more chance, so she did. Resident #8 stated the next night, CNA "D" was so rough pulling her shirt and bra off from her that she cried. During the interview, CNA "D" walked by Resident #8' s room and Resident #8 stated, "There he is. Do you see him? He just walked by. "Resident #8 appeared fearful and stated CNA"D" better stay out of her room. In an interview on 11/6/13 at 2:15 pm, CNA "L" stated Resident #8 did report to her a few months ago that CNA "D" was rough with her. CNA "L" stated she reported it to her nurse, LPN "M". In an interview on 11/6/13 at 2:20 pm, LPN (Licensed Practical Nurse) "M" stated she couldn't recall if CNA "L" had reported the allegation Resident #8 had made against CNA "D". LPN "M" stated she had not filled out an incident report about Resident #8 reporting CNA "D" being rough with her. LPN "M" stated if CNA "L" reported Resident #8 making an allegation about CNA "D" being rough with her, she (LPN "M" ) would have reported it to Unit Manager "N" . LPN "M" stated multiple residents had voiced complaints against CNA "D" and had requested CNA "D" not provide care to them. LPN "M" stated DNA (Director of Nurse Aides) "C" asked her (LPN "M") to make a list of residents who had complained about the care CNA "D" provided. LPN "M" stated she did make the list and gave the list to UM "N". In an interview on 11/6/13 at 2:10 pm, Unit Manager (UM) "N" stated Resident #8 never reported to him that CNA "D" was rough with her. UM "N" stated he did talk with Resident #8 one day to ask her how her night went with CNA "D" , just because he (CNA "D") was new to the unit. The surveyor asked UM "N" if he did that with all staff that was new to the unit and UM "N" stated no. UM "N" was observed to have short gray hair and to be wearing glasses. UM "N" stated LPN "M" did give him a list of residents she had written, who had complained about CNA "D" and did not want CNA "D" to provide care to them anymore. UM "N" stated he gave the list to DNA "C". In an interview on 11/6/13 at 1:00 pm, DON (Director of Nursing) "B" stated there was no incident report regarding an allegation from Resident #8 against CNA "D". DON "B" stated she was not aware Resident #8 had made a complaint about CNA "D" . In an interview on 11/6/13 at 2:25 pm, the Director of Nurse Aides (DNA) "C" stated she recalled that LPN "M" notified her there were residents on the 300 Hall that did not want CNA "D" to take care of them. DNA "C" stated she had LPN "M" make a list of residents who had made complaints about CNA "D" . After multiple requests by the surveyor, for the list of residents who had made complaints about CNA "D" , no list was provided by the facility. During observations on 11/6/13 from 2:05 pm to 3:00 pm, the surveyor observed CNA "D" working as a direct care giver for Residents on the 300 Hall of the facility. Resident #26: Review of Resident #26's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set ((MDS) dated [DATE] indicated Resident #26 required extensive assistance of two persons for transfers, dressing and toilet use. Per facility incident report dated 7/11/13, at 4:30 pm, RN "F" saw certified nurse aide "D" (CNA "D") pushing Resident #26 into the dining room and Resident #26 was crying and upset. The incident report indicated Resident #26 reported to RN "F" her leg hurt in the knee area and that it got bumped on the way down the hall. The follow up section of the incident report indicated Resident #26 was sent to the emergency room and a CT scan (computer generated image of the bones), report showed a displaced cortical [MEDICAL CONDITION] femoral shaft (end of the upper leg bone). According to the Nursing Note dated 7/11/13, "at approximately 4:30 PM, I (RN "F" ) saw CNA "D" pushing this resident (Resident #26) into the dining room, resident was upset and crying. I asked her what was the matter and she said her left leg hurt in the knee area and that it got bumped on the way down the hall. Resident continued crying and complained of left leg pain." Resident #26 was then transferred to the Hospital. Upon review of the emergency Physician Note dated 7/11/13, Resident #26 grimaced with palpation (touched) of the left knee and had effusion (swelling caused by fluid) around her left knee. With a [DIAGNOSES REDACTED]. In an interview on 11/6/13 at 1:10 pm, Director of Nursing (DON) "B" stated she talked to CNA "D" and CNA "D" didn't know what happened, that he may have bumped Resident #26's leg and he may not have bumped Resident #26's leg. DON "B" stated she did not document the interview and concluded it was not abuse from, "knowing her residents and knowing her staff ". In an interview on 11/7/13 at 1:40 PM with RN "F" , RN "F" indicated, the Resident #26 sometimes is a little confused, but can answer yes and no questions. RN "F" reported that she did remember Resident #26's fracture and on the day that it happened, I (RN "F" ) remembered passing medications from the cart by the activity room. RN "F" indicated Resident #26 was very upset shaky and crying. RN "F" stated she asked CNA "D" who was pushing Resident #26 in the wheelchair what had happened. CNA "D" replied to RN "F" that he did not know. Resident #26 was holding her knee. Resident #26 reported to RN "F" that her knee hurt. RN "F" reported that she asked CNA "D" again what happened to her, CNA "D" said that he bumped her foot on the wall. RN "F" explained that foot petals were on the wheelchair. CNA "D" replied to RN "F" that he wasn't sure where he bumped her foot in the wall. RN "F" then stated that she asked LPN "P" and DON "B" to look at Resident #26's knee. Resident #26 was holding her leg up and would not put her leg down to rest on the foot petal. RN "F" then stated "by the way Resident #26 was aching and the way it looked I thought we should have it checked out. We called the doctor to have it checked out. "RN "F" then explained that the facility called the doctor to have it checked out. RN "F" explained that the x-ray was done while she was on shift and was done in house. At that time DON "B" was asked for the radiology results from the in house results that were done 7/11/13, DON "B" stated that no in house x-ray was done. In a phone interview on 11/7/13 at 2:55 PM with CNA "D" , CNA "D" was asked about the incident with Resident #26. CNA "D" explained that when he went into Resident #26 's room to get her up for dinner, "everything was fine" . CNA "D" reported again that after getting Resident #26 up in her wheelchair "everything was fine" . CNA "D" then explained that he was pushing Resident #26 in her wheelchair in the hall, and Resident #26 then stated, "oh my knee, oh my knee" . CNA "D" then explained that he didn't know what happened, and he continued to push her into the dining room. CNA "D" was asked if he stopped before getting to the dining room, and he stated "no" . CNA "D" reported that once he got Resident #26 into the dining room, he told the nurse that she had pain. In an interview on 11/13/13 at 11:30 am, CNA "H" stated on the day Resident #26 sustained her broken leg, she witnessed CNA "D" pushing Resident #26 out of her room in her wheelchair right before dinner. CNA "H" stated Resident #26 was shaking, crying and had a look on her face like she was terrified. CNA "H" stated shortly after that, Resident #26 was sent to the hospital. CNA "H" stated she was never asked any questions or interviewed by any administrative staff regarding Resident #26's injury to her leg. In an interview on 11/8/13 at 9:40 am, facility Director of Nursing "B"(DON "B") stated she did not get a written statement from CNA "D" regarding the fracture of Resident #26's leg because she knew what happened. The surveyor asked DON "B" what happened and DON "B" stated CNA "D" reported "he may have bumped her leg". DON "B" stated there was no further investigation into the fracture of Resident #26's leg. Resident #30 Review of Resident #30's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set ((MDS) dated [DATE] indicated she required extensive assistance of two persons for transfers and extensive assistance of one persons for dressing. Review of Resident #30's falls plan of care (undated), which was provided to the surveyor by the director of nurse aides "C", indicated Resident #30 required the use of an "EZ stand with two persons" for transfers. Per facility incident report dated 7/25/13, at 3:30 pm, a nurse was called to Resident #30's room by a CNA and informed of a skin tear to her lower forearm. The incident report indicated Resident #30 had a skin tear 8 to 9 centimeter in length and 0.1 centimeter in width. The follow up section of the incident report indicated CNA "D" was attempting to transfer Resident #30 with an EZ stand (lift used to transfer a resident), and Resident #30 bumped her arm. Per a typed statement by CNA "H" dated 7/26/13, CNA "H" heard Resident #30 crying more than she normally did and went into Resident #30's room. CNA "H" observed CNA "D" with Resident #30 and her sleeves pulled down with blood on the sleeves. CNA "D" told CNA "H" that Resident #30 had a bruise and he pulled Resident #30's sleeve up. CNA "H" statement indicated she told CNA "D" that was not a bruise, he needed to get a nurse and he could not leave Resident #30 like that. The statement indicated when CNA "H" entered Resident #30's room she heard Resident #30 crying and CNA "D" was brushing her hair like nothing was happening. In a phone interview on 11/7/13 at 2:55 PM with CNA "D" , he (CNA "D") stated he put Resident #30 in the lift and the sling cut her arm. CNA "D" stated he had to yell out of the room for another aide because he couldn't leave the room. CNA "D" stated he was alone in the room with Resident #30 when he lifted her with the lift. CNA "D" stated the nurse came to the room and accused him (CNA "D") of trying to hide the incident. In an interview on 11/13/13 at 11:30 am CNA "H" stated she heard Resident #30 screaming more than usual from the room she was in across the hall, so she walked into Resident #30's room to see what was happening. CNA "H" stated she observed Resident #30 in her wheelchair with CNA "D" standing near her, and Resident #30 had blood on her sleeve. CNA "H" stated she asked CNA"D" what happened as she pushed the sleeve up and CNA "D" stated he didn't know. CNA "H" stated she observed the largest skin tear she had ever seen, which extended about half the length of Resident #30's lower arm, and it was bleeding badly. CNA "H" stated she went to get the nurse and told CNA "H" he couldn't just leave Resident #30 that way. CNA "H" stated DON "B" came to the room and she (CNA "H") went back to work. During a interview on 11/6/13 at 1:30 PM, DNA "C" said that CNA "D" was suspended for three days because of the skin tear, " ...we wanted to investigate if there was anything else with him we should be concerned about ...he was suspended for his roughness ". DNA "C" stated she did not report any allegations of roughness by CNA "D" to the State Agency, that she reviewed it with her superiors. During an interview on 11/6/13 at 1:30 PM, DNA "C" stated abuse was defined as something causing physical pain or injury. DNA "C" also stated that when she becomes aware of an allegation of abuse she goes to her superior (the Director of Nursing, DON "B"). In an interview on 11/13/13 at 11:30 am CNA "H" stated she had reported to her Unit Manager after Resident #30 had her skin tear in July of 2013, that she (CNA "H") wasn't comfortable working with CNA "D" because he wasn't "safe". CNA "H" stated CNA "D" kept hurting the residents. CNA "D" stated at no time did a staff member follow up with her regarding her statement to her unit manager about CNA "D" and CNA "D" continued to work in the facility as a direct care giver. CNA "H" stated CNA "D was moved to another part of the building to work. # During an interview on 11/06/13 at 11:30 AM, Confidential Informant (CI) "Z" said that she believed the staff should be a part of all potential concerns (related to alleged abuse & neglect). CI "Z" went on to report that the Nursing Home Administrator (NHA) "A" and DON "B" made it very clear to the interdisciplinary team who were concerned for all the residents at the facility, during a meeting, that it would be determined by them (NHA "A" and DON "B" ) whether or not an alleged abuse would be investigated. During the same interview CI "AA" went on to explain that they were told they could not possibly be expected to be kept aware of all alleged abuse or neglect. During an interview on 11/06/13 at 11:30 AM, CI "Z" told this surveyor about a very recent State Agency complaint investigation where physical and verbal abuses were anonymously reported and were substantiated in the facility (see Form CMS-2567 dated 10/07/13). CI "Z" knew nothing about the abuse prior to the State Agency coming in to investigate and questioned the NHA "A" and DON "B" about being able to tell a state surveyor she didn't know anything about the incident and NHA "A" told her it was ok to tell a surveyor she didn't know anything about an alleged abuse because " ...we (NHA "A" and DON "B") decided it was not abuse. CI "Z" and CI "AA" both said they had a huge problem with the NHA "A" and DON "B" making those decisions without an investigation to validate the conclusion. Both confidential informants worried about the security of their positions if they spoke out against NHA "A" and DON "B". Resident #24 According to a face sheet, undated, Resident #24 is a [AGE] year-old woman, who was admitted to the facility on [DATE]. According to a BIMS Brief Interview for Mental Status (BIMS), Resident #24 was cognitively intact. During an interview on 11/6/13 at 9:30 AM, Resident #24 was asked if she felt safe with staff. Resident #24 replied, she had an incident with an aide who swung her around and put her in her wheelchair " ...that ' s how this happened... " , Resident #24 then exposed her right lower leg to the surveyor and a significantly large bandage was observed. Resident #24 explained that the wound on her leg bled terribly. When asked who the aide was, Resident #24 explained that she didn ' t know. Resident #24 stated that she reported the incident to her nurse. An incident/accident report documented the event on 9/17/13, but did not contain a statement from the resident about the incident. The nurse ' s aide involved in the incident was identified as CNA "D". When DON "B" was asked why the facility did not get a statement from the resident, DON "B" explained, "I did not get a statement from the resident because I felt the statement from the aide explained everything. I have to trust my staff. " During an interview on 11/8/13 at 1:35 PM Resident #24 was tearful and said she just did not know why she swung her around and " plumped " her in her wheelchair like she did. Resident #25 According to the face sheet dated 1/23/12, Resident #25 was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS), an assessment tool, Resident #25 was cognitively intact. During a confidential group interview on 11/6/13 at 10:45 am, Resident #25 stated CNA "D" was not supposed to be in his room. Resident #25 stated CNA "D" was rough with him during care a couple of months ago and he (Resident #25) did report it to facility staff. Resident #25 stated CNA "D" still comes into his room to deliver his meal tray even though he isn't supposed to be in his room. Resident #25 stated CNA "D" grabbed him so hard around his ribs it felt like he (CNA "D") broke his (Resident #25) ribs. On 11/6/13 at 11:50 am, the surveyor requested all incident reports involving CNA "D" from DON "B" . No incident report involving Resident #25 was provided to the surveyor. At 2:00 pm, DON "B" stated to the surveyor that all incident reports involving CNA "D" had been provided to the surveyor. In an interview on 11/6/13 at 2:25 pm, Director of Nurse Aides "C" stated she met with Resident #25 in September in attempt to find out what was going on with CNA "D". Director of Nurse Aides "C" stated Resident #25 informed her that CNA "D" was rough. ( ) On 11/6/13 at approximately 1:00 PM, Resident # 25 was interviewed in his room. Resident #25 was asked to explain the incident that happened on 10/11/13. Resident #25 explained that he uses a fireman's pole in his room to transfer from his wheelchair to his bed. Resident #25 reported that when he was transferring, Certified Nursing Assistant (CNA) "D" came into Resident #25's room and squeezed Resident #25. Resident #25 reported that he may have been a little unsteady, but he always transfers himself. Resident #25 also reported that he felt that CNA "D" broke his ribs because he squeezed so hard. Resident #25 stated "I don't trust him." Resident #25 proceeded to explain that CNA "D" was not allowed to come into his room to care for him anymore, but CNA "D" still comes in to bring in Resident #25's dinner tray. On 11/7/13 at 1:15 PM DNA "C" clarified that she first met with Resident #25 in September because of hearsay from staff. DNA "C" then reported that Resident #25 complained again about CNA "D" so DNA "C" reported that she met with Resident #25 again. Review of CNA "D"'s personnel file did not reveal a disciplinary action or education with regards to his care of Resident #25. On 11/6/13 at 1:28 PM, Director of Nurse Aides (DNA) "C" was interviewed, with the Director of Nursing (DON) "B" present. DNA "C" was asked to explain what her process was, if a resident complained of abuse by a nurse's aide. DNA "C" stated that residents have complained (CNA "D" ) was rough with them. DNA "C" explained that she started talking with residents who complained about the abuse, interviewed staff that had worked with CNA "D" and brought CNA "D" into office to talk. DNA "C" then stated that she reviewed the investigation with her superior (DON "B"). When asked if the nurse aide was suspended, DNA "C" reported "no" . DNA "C" was then asked if being "rough" was an allegation of abuse. DNA "C" stated, only if the resident was harmed or had increased pain. When asked what constituted harm, DNA "C" stated "physical injury" . DNA "C" explained that she had talked with CNA "D" about slowing down. When asked for documentation for the education, DNA "C" could not produce the documentation. According to CNA "D"'s personnel file, CNA "D" was suspended on 7/26/13. DNA "C" was asked what prompted the facility to suspend CNA "D". DNA "C" explained that CNA "D" was suspended because there was an injury. When asked if this was reported, DON "B" replied "no". When asked why the facility did not report the incident, DON "B" stated "We knew what happened." Incident/accident reports for residents, who complained that CNA "D" was rough, were requested. DON "B" and DNA "C" explained that there was no documentation for the allegations or the investigations. ( ) Resident #27: Resident #28: According to the face sheet, dated 8/2/13, Resident #28 was a [AGE] year-old female, who was admitted to the facility on [DATE]. According to the MDS dated [DATE], Resident #28 had a BIMS of 9 out of 15, indicating she was moderately cognitively impaired. During the survey Resident #28 was not in the facility. According to the face sheet, dated 4/4/13, Resident #27 was an [AGE] year-old male, who was admitted to the facility on [DATE]. According the MDS dated [DATE], Resident #27 had a BIMS of 6 out of 15, indicating that he was severely cognitively impaired. During an interview on 11/6/13 at 4:00 PM, Unit Manager, LPN "I", stated that there had been occurrences of sexual behavior in the facility and residents were still fearful of further sexual abuse. On 11/6/13 at about 5:00 PM CNA "Q" was asked about resident-to-resident sexual behaviors in the facility. CNA "Q" explained that Resident #28 had been extra "touchy feely" approximately 4 months ago and was found in Resident #27's room performing oral sex on him. CNA "Q" stated that Resident #28 was then transferred to a Psychiatric Treatment facility. On 11/6/13 at about 6:00 PM, DON "B" was asked to provide incident/accident reports for the incident between Resident #27 and Resident #28. DON "B" stated that the incident was consensual sexual behaviors. When asked how the facility came to that conclusion and for the documentation about the incident, DON "B" explained that she would need to contact Director of Nurse Aides (DNA) "C". On 11/6/13 at about 6:10 PM, DNA "C", explained that there was no documentation for the resident to resident sexual incident. On 11/6/13 at about 6:30 PM, Resident #27's Power of Attorney (POA) was called and asked about the sexual incident that occurred on 6/4/13. Resident #27's POA explained that the facility called to explain the sexual behavior incident. Resident #27's POA also reported that the facility stated "They were not going to report it or put documentation into the records. It will be like it never happened." Resident #27's POA was then asked if the facility asked about reporting this incident to the police. Resident #27's POA stated that the facility never mentioned the word "police" in the meeting. An interview was conducted on 11/8/13 at 1:20 PM with DNA "C". DNA "C" stated she was contacted by DON "B" and was told "there was an instance of oral sex" between Residents #27 and #28. DNA "C" stated she was told she "did not need to do anything about reporting an 'internal investigation'" . In an interview on 11/7/13 at 9:27 a.m., Resident #28's Durable Power of Attorney (DPOA) stated Administrator "A" called her and reported Resident #28 had an "inappropriate behavior with another gentleman on the unit" and reported that it was "sexual in nature." Resident #28's DPOA stated Administrator "A" stated "it was their policy to contact the responsible party" of the residents involved. Resident #28's DPOA stated Administrator "A" "did not" talk about reporting the incident to the police". Resident #28's DPOA stated she was told, not asked, that the incident "would go under lock and key" and "that not everyone at the nursing facility would know" of the incident. Resident #28: Resident #29: According to the "Face Sheet" (Run Date 5/29/13), Resident #29 was a [AGE] year old male, admitted to the facility on [DATE]. Resident #29's "physician's orders [REDACTED]. Resident #29's Minimum Data Set (MDS) assessment dated [DATE], reflected that resident #29 had a Brief Interview for Mental Status (BIMS) Score of 11 out of 15, which indicated mild cognitive impairment. During the initial tour of the facility on 11/5/13 with Director of Nurses Aides (DNA) "C", beginning at 9:30 am, Resident #29's name was observed on a name plate outside one of the rooms on the "Gilead" locked unit. When DNA "C" was asked a question pertaining to Resident #29, DNA "C" responded that he was not currently a resident at the facility as he was receiving psychiatric treatment at a psychiatric hospital. DNA "C" was interviewed on 11/7/13 at 1:15 pm. DNA "C" was asked if Resident #29 had been making his own decisions about care in the facility to which she replied "He was not making his own decisions. I believe it was his daughter." DNA "C" later stated that Social Worker "S" would be able to explain who was making decisions for Resident #29 while in the facility. Social Worker "S" was interviewed on 11/8/13 at 3:30 pm. Social Worker "S" revealed that the facility had been working with Adult Protective Services since June 12, 2013 in regards to getting guardianship granted for Resident #29 as the facility was "not getting infor from his family and because he needed some help with decisions." Social Worker "S" also revealed that Resident #29's daughter had applied for guardianship on 10/10/13, and provided documentation that reflected this. ( ) Review of the face sheet, dated 8/2/13, revealed Resident #28 was a [AGE] year-old female, admitted to the facility on [DATE]. According to the MDS dated [DATE], Resident #28 had a BIMS of 9 out of 15, indicating she was moderately cognitively impaired. During the survey Resident #28 was not in the facility. Review of the witness statements dated 9/24/13 at 7:00 p.m. signed by CNA "R", revealed Resident #29 "walked over to the chair" where Resident #28 was located and "began to kiss" Resident #28. The witness statement continued and revealed Resident #31 "had his (Resident #31) hand down" Resident #28's pants. In an interview on 11/13/13 at 11:55 a.m., CNA "R" stated, "I witnessed Resident #29 going over to Resident #28" and "he (Resident #29) started making out with her (Resident #28)." CNA "R" stated Resident #29 "stuck his hand down her (Resident #28) pants." CNA "R" stated no management staff questioned her about the sexual behavior between Resident #28 and Resident #29. In an interview on 11/13/13 at 9:30 a.m., DON "B" was shown the witness statements by the surveyor. DON "B" stated, "I have not" seen these witness statements before. DON "B" stated she did not conduct the interviews which produced the witness statements. DON "B" stated the witness interviews were conducted by DNA "C". In an interview on 11/13/13 at 9:35 a.m., DNA "C" was shown the witness statements by the surveyor. DNA "C" stated, "I don't recall seeing them (witness statements)." DNA "C" stated, "no, there isn't" an investigation for the sexual incident (hand down pants and kissing of Resident #28) mentioned in the witness statement. DNA "C" stated the incident was not abuse because "neither (Resident) was injured, neither (Resident) were distressed" and "there was no injury" to either Resident (#28 and #29). DNA "C" stated after the sexual incident between Resident #28 and Resident #29 that Resident #29 was moved to another room in the facility. DNA "C" stated, "they (Resident #28 and Resident #29) were inappropriate" and "we (facility) didn't want the behavior to continue." Resident #31: Review of the Face Sheet, dated 4/18/11, revealed Resident #31 was admitted to the facility on [DATE]. According to the MDS, dated [DATE], Resident #31 was severely cognitively impaired and needed extensive assistance of 2 staff for transfers. In a phone interview on 11/7/13 at 1:40 PM., CNA "D" explained that when he pulled back the covers on Resident #31, he saw a large bruise. Review of nursing notes dated 10/29/13 (untimed), reflected, "Large hematoma present on Resident right lower extremity (outside calf) .....dark purple with raised area, irregular shape ....bruise appears to be related to bumping leg on wheelchair or .... during transfer." In an interview on 11/8/13 at 12:45 PM, UM "N" stated he was aware of the injury to Resident #31 "on the morning of 10/29/13." UM "N" stated "I did not look at the bruise on the 10/29/13." UM "N" stated "the first day I observed the bruise" was on 11/5/13. UM "N" stated he did not investigate the bruise to Resident #31's leg until 11/5/13 and stated "no" when asked by the surveyor if he interviewed any staff involved in the injury to Resident #31. UM "N" stated he had completed the conclusion (to the internal investigation) that the injury "was of undetermined cause." UM "N" agreed that the bruise was an injury of unknown origin. When asked if an injury of unknown origin would be reported to the state agency UM "N" stated "I couldn't tell you." In an interview on 11/13/13 at 11:15 a.m., DON "B" stated there was an incident and accident report for the injury to Resident #31 but not an investigation reported to the State agency. DON "B" stated, "I am responsible for the investigation." DON "B" stated she did not conduct any interviews related to the injury to Resident #31's leg. DON "B" stated UM "M" told her what he thought had happened to cause Resident #31's injury. Resident #3's "Face sheet" (undated) reflected she was an [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's "Nursing Admission Assessment" (Dated 9/17/13) reflected that Resident #3 was re-admitted to the facility on [DATE] and had a "Fall Risk Assessment" score of 16 "(Total score of 10 or above deems resident at risk; initiate precautions)" which indicated Resident #3 was not at a high risk for falls. Resident #3's careplan (Reviewed by Director of Nursing Assistants (DNA) "C" on 8/15/13) reflected "(Resident #3) at risk for falls R/T dementia & her inability to understand her safety needs..." Resident #3's Incident and Accident report (dated 8/5/13, 7:00 am) reflected "Bruise, Right Forearm, 9x9 (centimeters - cm) ecchymotic (bruise) area on right outer forearm." The section "General Follow up Procedures" reflected "Written by (DNA "C") on 8/13/13 11:00 am Incident discussed with interdisciplinary team and this is not a result of abuse. (Resident #3's name) skin is very thin and frail. Geri sleeves have been initiated and currently effective. Her dementia is at a stage where she still understands the importance of them and is compliant with wearing them." No additional

Based on observation, interviews, and record review, the facility failed to investigate and report allegations of abuse and injuries of unknown origin for 10 sampled residents (#3, #8, #24, #25, #26, #27, #28, #29, #30, #31), of 12 residents reviewed for abuse, from a total sample of 23 residents, resulting in an immediate jeopardy when Residents #3, #26, #30, and #31 sustained injuries of unknown origin which were not investigated or reported to the State Agency, and Residents #8, #24, #25, #27, #28, and #29 had allegations of abuse that were not investigated or reported to the State Agency, resulting in continued abuse and injuries and the potential for further abuse and injuries of unknown origin to not be investigated or reported to the State Agency. These deficient practices place all 111 residents in the facility at high risk for physical harm and/or injury. Resident #8: According to the face sheet, dated 9/23/13, Resident #8 was an [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment, dated 6/3/13, indicated that Resident #8 was cognitively intact and required extensive assistance of one person for dressing and hygiene. In a confidential group interview on 11/6/13 at 10:45 am, Resident #8 stated she requested not to have CNA "D" in her room because he was rough with her. Resident #8 stated CNA "D" jerked her clothes off in a rough way, which caused her hearing aids to be pulled out of her ears. Resident #8 stated since she has requested CNA "D" not come in her room, when her call light is on, CNA " D " would come into her room and ask her what she wanted. Resident #8 stated she would tell CNA "D" she wanted her aide and CNA "D" would turn off her call light, leave the room and not inform other staff that Resident #8's call light had been on. During a private interview with Resident #8 on 11/6/13 at 2:00 pm, she stated she reported to her aide and nurse that CNA "D" was rough with her, by shoving her around on the lift and toilet. Resident #8 was able to name CNA "L" as the nurse aide she reported her complaints about CNA "D" to. While explaining the incidents to the surveyor, Resident #8 became tearful. Resident #8 stated a nurse with gray, short hair and glasses came into her room and begged her to give CNA "D" one more chance, so she did. Resident #8 stated the next night, CNA "D" was so rough pulling her shirt and bra off from her that she cried. During the interview, CNA "D" walked by Resident #8' s room and Resident #8 stated, "There he is. Do you see him? He just walked by. "Resident #8 appeared fearful and stated CNA"D" better stay out of her room. In an interview on 11/6/13 at 2:15 pm, CNA "L" stated Resident #8 did report to her a few months ago that CNA "D" was rough with her. CNA "L" stated she reported it to her nurse, (Licensed Practical Nurse) LPN "M". In an interview on 11/6/13 at 2:20 pm, LPN "M" stated she couldn't recall if CNA "L" had reported the allegation Resident #8 had made against CNA "D". LPN "M" stated she had not filled out an incident report about Resident #8 reporting CNA "D" being rough with her. LPN "M" stated if CNA "L" reported Resident #8 making an allegation about CNA "D" being rough with her, she (LPN "M" ) would have reported it to Unit Manager "N" . LPN "M" stated multiple residents had voiced complaints against CNA "D" and had requested CNA "D" not provide care to them. LPN "M" stated Director of Nurse Aides (DNA) "C" asked her (LPN "M") to make a list of residents who had complained about the care CNA "D" provided. LPN "M" stated she did make the list and gave the list to UM "N". In an interview on 11/6/13 at 2:10 pm, Unit Manager (UM) "N" stated Resident #8 never reported to him that CNA "D" was rough with her. UM "N" stated he did talk with Resident #8 one day to ask her how her night went with CNA "D" , just because he (CNA "D") was new to the unit. The surveyor asked UM "N" if he did that with all staff that was new to the unit and UM "N" stated no. UM "N" was observed to have short gray hair and to be wearing glasses. UM "N" stated LPN "M" did give him a list of residents she had written, who had complained about CNA "D" and did not want CNA "D" to provide care to them anymore. UM "N" stated he gave the list to DNA "C". In an interview on 11/6/13 at 1:00 pm, DON (Director of Nursing) "B" stated there was no incident report regarding an allegation from Resident #8 against CNA "D". DON "B" stated she was not aware Resident #8 had made a complaint about CNA "D" . In an interview on 11/6/13 at 2:25 pm, the Director of Nurse Aides (DNA) "C" stated she recalled that LPN "M" notified her there were residents on the 300 Hall that did not want CNA "D" to take care of them. DNA "C" stated she had LPN "M" make a list of residents who had made complaints about CNA "D" . After multiple requests by the surveyor, for the list of residents who had made complaints about CNA "D" , no list was provided by the facility. During observations on 11/6/13 from 2:05 pm to 3:00 pm, the surveyor observed CNA "D" working as a direct care giver for Residents on the 300 Hall of the facility. Resident #26: Review of Resident #26's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set ((MDS) dated [DATE] indicated Resident #26 required extensive assistance of two persons for transfers, dressing and toilet use. Per facility incident report dated 7/11/13, at 4:30 pm, Registered Nurse (RN) "F" saw certified nurse aide "D" (CNA "D") pushing Resident #26 into the dining room and Resident #26 was crying and upset. The incident report indicated Resident #26 reported to RN "F" her leg hurt in the knee area and that it got bumped on the way down the hall. The follow up section of the incident report indicated Resident #26 was sent to the emergency room and a CT scan (computer generated image of the bones), report showed a displaced cortical [MEDICAL CONDITION] femoral shaft (end of the upper leg bone). According to the Nursing Note dated 7/11/13, "at approximately 4:30 PM, I (RN "F" ) saw CNA "D" pushing this resident (Resident #26) into the dining room, resident was upset and crying. I asked her what was the matter and she said her left leg hurt in the knee area and that it got bumped on the way down the hall. Resident continued crying and complained of left leg pain." Resident #26 was then transferred to the Hospital. Upon review of the emergency Physician Note dated 7/11/13, Resident #26 grimaced with palpation (touched) of the left knee and had effusion (swelling caused by fluid) around her left knee. With a [DIAGNOSES REDACTED]. Review of radiology report for Resident #26's left lower extremity dated 7/11/13 revealed findings to include undisplaced cortical fracture involving the medial distal femoral shaft (fracture left upper leg). In an interview on 11/6/13 at 1:10 pm, Director of Nursing (DON) "B" stated she talked to CNA "D" and CNA "D" didn't know what happened, that he may have bumped Resident #26's leg and he may not have bumped Resident #26's leg. DON "B" stated she did not document the interview and concluded it was not abuse from, "knowing her residents and knowing her staff ". In an interview on 11/7/13 at 1:40 PM with RN "F", RN "F" indicated, the Resident #26 sometimes is a little confused, but can answer yes and no questions. RN "F" reported that she did remember Resident #26's fracture and on the day that it happened, I (RN "F" ) remembered passing medications from the cart by the activity room. RN "F" indicated Resident #26 was very upset shaky and crying. RN "F" stated she asked CNA "D" who was pushing Resident #26 in the wheelchair what had happened. CNA "D" replied to RN "F" that he did not know. Resident #26 was holding her knee. Resident #26 reported to RN "F" that her knee hurt. RN "F" reported that she asked CNA "D" again what happened to her, CNA "D" said that he bumped her foot on the wall. RN "F" explained that foot petals were on the wheelchair. CNA "D" replied to RN "F" that he wasn't sure where he bumped her foot in the wall. RN "F" then stated that she asked LPN "P" and DON "B" to look at Resident #26's knee. Resident #26 was holding her leg up and would not put her leg down to rest on the foot petal. RN "F" then stated "by the way Resident #26 was aching and the way it looked I thought we should have it checked out. We called the doctor to have it checked out. "RN "F" then explained that the facility called the doctor to have it checked out. RN "F" explained that the x-ray was done while she was on shift and was done in house. At that time DON "B" was asked for the radiology results from the in house results that were done 7/11/13, DON "B" stated that no in house x-ray was done. In a phone interview on 11/7/13 at 2:55 PM with CNA "D" , CNA "D" was asked about the incident with Resident #26. CNA "D" explained that when he went into Resident #26 's room to get her up for dinner, "everything was fine" . CNA "D" reported again that after getting Resident #26 up in her wheelchair "everything was fine". CNA "D" then explained that he was pushing Resident #26 in her wheelchair in the hall, and Resident #26 then stated, "oh my knee, oh my knee". CNA "D" then explained that he didn't know what happened, and he continued to push her into the dining room. CNA "D" was asked if he stopped before getting to the dining room, and he stated "no". CNA "D" reported that once he got Resident #26 into the dining room, he told the nurse that she had pain. In an interview on 11/13/13 at 11:30 am, CNA "H" stated on the day Resident #26 sustained her broken leg, she witnessed CNA "D" pushing Resident #26 out of her room in her wheelchair right before dinner. CNA "H" stated Resident #26 was shaking, crying and had a look on her face like she was terrified. CNA "H" stated shortly after that, Resident #26 was sent to the hospital. CNA "H" stated she was never asked any questions or interviewed by any administrative staff regarding Resident #26's injury to her leg. In an interview on 11/8/13 at 9:40 am, facility Director of Nursing "B"(DON "B") stated she did not get a written statement from CNA "D" regarding the fracture of Resident #26's leg because she knew what happened. The surveyor asked DON "B" what happened and DON "B" stated CNA "D" reported "he may have bumped her leg". DON "B" stated there was no further investigation into the fracture of Resident #26's leg. Resident #30 Review of Resident #30's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set ((MDS) dated [DATE] indicated she required extensive assistance of two persons for transfers and extensive assistance of one persons for dressing. Review of Resident #30's falls plan of care (undated), which was provided to the surveyor by the director of nurse aides "C", indicated Resident #30 required the use of an "EZ stand with two persons" for transfers. Per facility incident report dated 7/25/13, at 3:30 pm, a nurse was called to Resident #30's room by a CNA and informed of a skin tear to her lower forearm. The incident report indicated Resident #30 had a skin tear 8 to 9 centimeter in length and 0.1 centimeter in width. The follow up section of the incident report indicated CNA "D" was attempting to transfer Resident #30 with an EZ stand (lift used to transfer a resident), and Resident #30 bumped her arm. Per a typed statement by CNA "H" dated 7/26/13, CNA "H" heard Resident #30 crying more than she normally did and went into Resident #30's room. CNA "H" observed CNA "D" with Resident #30 and her sleeves pulled down with blood on the sleeves. CNA "D" told CNA "H" that Resident #30 had a bruise and he pulled Resident #30's sleeve up. CNA "H" statement indicated she told CNA "D" that was not a bruise, he needed to get a nurse and he could not leave Resident #30 like that. The statement indicated when CNA "H" entered Resident #30's room she heard Resident #30 crying and CNA "D" was brushing her hair like nothing was happening. In a phone interview on 11/7/13 at 2:55 PM with CNA "D" , he (CNA "D") stated he put Resident #30 in the lift and the sling cut her arm. CNA "D" stated he had to yell out of the room for another aide because he couldn't leave the room. CNA "D" stated he was alone in the room with Resident #30 when he lifted her with the lift. CNA "D" stated the nurse came to the room and accused him (CNA "D") of trying to hide the incident. In an interview on 11/13/13 at 11:30 am CNA "H" stated she heard Resident #30 screaming more than usual from the room she was in across the hall, so she walked into Resident #30's room to see what was happening. CNA "H" stated she observed Resident #30 in her wheelchair with CNA "D" standing near her, and Resident #30 had blood on her sleeve. CNA "H" stated she asked CNA"D" what happened as she pushed the sleeve up and CNA "D" stated he didn't know. CNA "H" stated she observed the largest skin tear she had ever seen, which extended about half the length of Resident #30's lower arm, and it was bleeding badly. CNA "H" stated she went to get the nurse and told CNA "H" he couldn't just leave Resident #30 that way. CNA "H" stated DON "B" came to the room and she (CNA "H") went back to work. During an interview on 11/6/13 at 1:30 PM, DNA "C" said that CNA "D" was suspended for three days because of the skin tear, " ...we wanted to investigate if there was anything else with him we should be concerned about ...he was suspended for his roughness ". DNA "C" stated she did not report any allegations of roughness by CNA "D" to the State Agency, that she reviewed it with her superiors. During an interview on 11/6/13 at 1:30 PM, DNA "C" stated abuse was defined as something causing physical pain or injury. DNA "C" also stated that when she becomes aware of an allegation of abuse she goes to her superior (the Director of Nursing, DON "B" ). In an interview on 11/13/13 at 11:30 am CNA "H" stated she had reported to her Unit Manager after Resident #30 had her skin tear in July of 2013, that she (CNA "H") wasn't comfortable working with CNA "D" because he wasn't "safe". CNA "H" stated CNA "D" kept hurting the residents. CNA "D" stated at no time did a staff member follow up with her regarding her statement to her unit manager about CNA "D" and CNA "D" continued to work in the facility as a direct care giver. CNA "H" stated CNA "D was moved to another part of the building to work. According to the State Operations Manual, Section 43.13 (c) (2) " The facility must ensure that all alleged violations involving mistreatment, neglect or abuse including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with state law with established procedures (including the state survey and certification agency). " Section 483.13 (c) (3) reads " The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. " # Resident #24 According to a face sheet, undated, Resident #24 is a [AGE] year-old woman, who was admitted to the facility on [DATE]. According to a BIMS Brief Interview for Mental Status (BIMS), Resident #24 was cognitively intact. During an interview on 11/6/13 at 9:30 AM, Resident #24 was asked if she felt safe with staff. Resident #24 replied, she had an incident with an aide who swung her around and put her in her wheelchair " ...that's how this happened... " , Resident #24 then exposed her right lower leg to the surveyor and a significantly large bandage was observed. Resident #24 explained that the wound on her leg bled terribly. When asked who the aide was, Resident #24 explained that she didn ' t know. Resident #24 stated that she reported the incident to her nurse. An incident/accident report documented the event on 9/17/13, but did not contain a statement from the resident about the incident. The nurse ' s aide involved in the incident was identified as CNA " D " . When DON " B " was asked why the facility did not get a statement from the resident, DON " B " explained, " I did not get a statement from the resident because I felt the statement from the aide explained everything. I have to trust my staff. " During an interview on 11/8/13 at 1:35 PM Resident #24 was tearful and said she just did not know why she swung her around and " plumped " her in her wheelchair like she did. Resident #27: Resident #28: According to the facility roster, both Resident #27 and Resident #28 were not residing in the facility. According to the face sheet, dated 8/2/13, Resident #28 was a [AGE] year-old female, who was admitted to the facility on [DATE]. According to the MDS dated [DATE], Resident #28 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated she was moderately cognitively impaired. According to the face sheet, dated 4/4/13, Resident #27 was an [AGE] year-old male, who was admitted to the facility on [DATE]. According the MDS dated [DATE], Resident #27 had a BIMS of 6 out of 15, indicating that he was severely cognitively impaired. During an interview on 11/6/13 at 4:00 p.m., Unit Manager, LPN "I", stated that there had been occurrences of sexual behavior in the facility and residents were still fearful of further sexual abuse. On 11/6/13 at about 5:00 p.m. CNA "Q" was asked about resident-to-resident sexual behaviors in the facility. CNA "Q" explained that Resident #28 had been extra "touchy feely" approximately 4 months ago and was found in Resident #27's room performing oral sex on him. CNA "Q" stated that Resident #28 was then transferred to a Psychiatric Treatment facility. On 11/6/13 at about 6:00 p.m., DON "B" was asked to provide incident/accident reports for the incident between Resident #27 and Resident #28. DON "B" stated that the incident was consensual sexual behaviors. When asked how the facility came to that conclusion and for the documentation about the incident, DON "B" explained that she would need to contact Director of Nurse Aides (DNA) "C". On 11/6/13 at about 6:10 p.m., DNA "C", explained that there was no documentation for the resident to resident sexual incident. On 11/6/13 at about 6:30 p.m., Resident #27's Power of Attorney (POA) was called and asked about the sexual incident that occurred on 6/4/13. Resident #27's POA explained that the facility called to explain the sexual behavior incident. Resident #27's POA also reported that the facility stated "They were not going to report it or put documentation into the records. It will be like it never happened." Resident #27's POA was then asked if the facility asked about reporting this incident to the police. Resident #27's POA stated that the facility never mentioned the word "police" in the meeting. An interview was conducted on 11/8/13 at 1:20 p.m. with DNA "C". DNA "C" stated she was contacted by DON "B" and was told "there was an instance of oral sex" between Residents #27 and #28. DNA "C" stated she was told she "did not need to do anything about reporting an 'internal investigation'" . In an interview on 11/7/13 at 9:27 a.m., Resident #28's Durable Power of Attorney (DPOA) stated Administrator "A" called her and reported Resident #28 had an "inappropriate behavior with another gentleman on the unit" and reported that it was "sexual in nature." Resident #28's DPOA stated Administrator "A" stated "it was their policy to contact the responsible party" of the residents involved. Resident #28's DPOA stated Administrator "A" "did not" talk about reporting the incident to the police". Resident #28's DPOA stated she was told, not asked, that the incident "would go under lock and key" and "that not everyone at the nursing facility would know" of the incident. / Resident #28: Resident #29: Review of the face sheet, dated 8/2/13, revealed Resident #28 was a [AGE] year-old female, admitted to the facility on [DATE]. According to the MDS dated [DATE], Resident #28 had a BIMS of 9 out of 15, indicating she was moderately cognitively impaired. During the survey Resident #28 was not in the facility. According to the "Face Sheet" (Run Date 5/29/13), Resident #29 was a [AGE] year old male, admitted to the facility on [DATE]. Resident #29's "physician's orders [REDACTED]. Resident #29's Minimum Data Set (MDS) assessment dated [DATE], reflected that resident #29 had a Brief Interview for Mental Status (BIMS) Score of 11 out of 15, which indicated mild cognitive impairment. During the initial tour of the facility on 11/5/13 with Director of Nurses Aides (DNA) "C", beginning at 9:30 am, Resident #29's name was observed on a name plate outside one of the rooms on the "Gilead" locked unit. When DNA "C" was asked a question pertaining to Resident #29, DNA "C" responded that he was not currently a resident at the facility as he was receiving psychiatric treatment at a psychiatric hospital. DNA "C" was interviewed on 11/7/13 at 1:15 pm. DNA "C" was asked if Resident #29 had been making his own decisions about care in the facility to which she replied "He was not making his own decisions. I believe it was his daughter." DNA "C" later stated that Social Worker "S" would be able to explain who was making decisions for Resident #29 while in the facility. Social Worker "S" was interviewed on 11/8/13 at 3:30 pm. Social Worker "S" revealed that the facility had been working with Adult Protective Services since June 12, 2013 in regards to getting guardianship granted for Resident #29 as the facility was "not getting infor from his family and because he needed some help with decisions." Social Worker "S" also revealed that Resident #29's daughter had applied for guardianship on 10/10/13, and provided documentation that reflected this. ( ) Due to the interview that occurred with Unit Manager, LPN "I" on 11/6/13 at 4:00 p.m., DON "B" was asked on 11/6/13 at about 6:00 p.m. to provide incident/accident reports for the incident between Resident #28 and Resident #29. DON "B" stated that the incident was consensual sexual behaviors. Copies of "Witness Statements" were provided but no incident and accident report was provided by the facility regarding the sexual incident that occurred between Resident #28 and Resident #29. Review of the witness statements dated 9/24/13 at 7:00 p.m. signed by CNA "R", revealed Resident #29 "walked over to the chair" where Resident #28 was located and "began to kiss" Resident #28. The witness statement continued and revealed Resident #31 "had his (Resident #31) hand down" Resident #28's pants. In an interview on 11/13/13 at 9:30 a.m., DON "B" was shown the witness statements by the surveyor. DON "B" stated, "I have not" seen these witness statements before. DON "B" stated she did not conduct the interviews which produced the witness statements. DON "B" stated the witness interviews were conducted by DNA "C". In an interview on 11/13/13 at 9:35 a.m., DNA "C" was shown the witness statements by the surveyor. DNA "C" stated, "I don't recall seeing them (witness statements)." DNA "C" stated, "no, there isn't" an investigation for the sexual incident (hand down pants and kissing of Resident #28) mentioned in the witness statement. DNA "C" stated the incident was not abuse because "neither (Resident) was injured, neither (Resident) were distressed" and "there was no injury" to either Resident (#28 and #29). DNA "C" stated after the sexual incident between Resident #28 and Resident #29 that Resident #29 was moved to another room in the facility. DNA "C" stated, "they (Resident #28 and Resident #29) were inappropriate" and "we (facility) didn't want the behavior to continue." In an interview on 11/13/13 at 11:55 a.m., CNA "R" stated, "I witnessed Resident #29 going over to Resident #28" and "he (Resident #29) started making out with her (Resident #28)." CNA "R" stated Resident #29 "stuck his hand down her (Resident #28) pants." CNA "R" stated no management staff questioned her about the sexual behavior between Resident #28 and Resident #29. Resident #31: Review of the Face Sheet, dated 4/18/11, revealed Resident #31 was admitted to the facility on [DATE]. According to the MDS, dated [DATE], Resident #31 was severely cognitively impaired and needed extensive assistance of 2 staff for transfers. ( ) In a phone interview on 11/7/13 at 1:40 PM., CNA "D" explained that when he pulled back the covers on Resident #31, he saw a large bruise. ( ) Review of nursing notes dated 10/29/13 (untimed), reflected, "Large hematoma present on Resident right lower extremity (outside calf) .....dark purple with raised area, irregular shape ....bruise appears to be related to bumping leg on wheelchair or .... during transfer." In an interview on 11/8/13 at 12:45 PM, UM "N" stated he was aware of the injury to Resident #31 "on the morning of 10/29/13." UM "N" stated "I did not look at the bruise on the 10/29/13." UM "N" stated "the first day I observed the bruise" was on 11/5/13. UM "N" stated he did not investigate the bruise to Resident #31's leg until 11/5/13 and stated "no" when asked by the surveyor if he interviewed any staff involved in the injury to Resident #31. UM "N" stated he had completed the conclusion (to the internal investigation) that the injury "was of undetermined cause." UM "N" agreed that the bruise was an injury of unknown origin. When asked if an injury of unknown origin would be reported to the state agency UM "N" stated "I couldn't tell you." In an interview on 11/13/13 at 11:15 a.m., DON "B" stated there was an incident and accident report for the injury to Resident #31 but not an investigation reported to the State agency. DON "B" stated, "I am responsible for the investigation." DON "B" stated she did not conduct any interviews related to the injury to Resident #31's leg. DON "B" stated UM "M" told her what he thought had happened to cause Resident #31's injury. ( ) Resident #3 Resident #3's "Face sheet" (undated) reflected she was an [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's Minimum Data Set (MDS) assessment (dated 8/11/13) reflected a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which indicated severe cognitive impairment. Resident #3's "Nursing Admission Assessment" (Dated 9/17/13) reflected that Resident #3 was re-admitted to the facility on [DATE] and had a "Fall Risk Assessment" score of 16 "(Total score of 10 or above deems resident at risk; initiate precautions)" which indicated Resident #3 was not at a high risk for falls. Resident #3's Fall's careplan (Reviewed by Director of Nursing Assistants (DNA) "C" on 8/15/13) reflected "(Resident #3) at risk for falls R/T (Related To) dementia & her inability to understand her safety needs..." Resident #3's Incident and Accident report (dated 8/5/13, 7:00 am) reflected "Bruise, Right Forearm, 9x9 (centimeters - cm) ecchymotic (bruise) area on right outer forearm." The section "General Follow up Procedures" reflected "Written by (DNA "C") on 8/13/13 11:00 am Incident discussed with interdisciplinary team and this is not a result of abuse. (Resident #3's name) skin is very thin and frail. Geri sleeves have been initiated and currently effective. Her dementia is at a stage where she still understands the importance of them and is compliant with wearing them." No additional documentation could be provided by the facility regarding any interviews done with any staff working with the resident at the time of, or before the incident. Resident #3's Incident and Accident report (dated 8/21/13) reflected "Bruise, Left Side of Chin, 3 cm dk. (dark) purple bruise on left chin/cheek." The section "General Follow up Procedures" reflected "Written by ( DNA "C") ... This was discussed with interdisciplinary team and not a result of abuse. While sleeping it was noted that her hand with her ring was up against her face. Reported to family and they voiced that she does have a history of bruising easily. (Resident #3) voiced that there is not pain. Staff did not wake her when this was noted because it looked harmless at the time. The bruise appeared after she was up for awhile in the morning. Now when they check on her they reposition her and take her hands away from her face if needed." No additional documentation could be provided by the facility regarding any interviews done with any staff working with the resident at the time of, or before the incident. The Incident and Accident report (dated 9/7/13) reflected "Assigned Care giver, CNA "O" ... R/O (Rule Out) Fracture, Right Shoulder, Resident with complaint of Right arm pain, swollen area noted at the deltoid. Nurse's Note of what happened written by (Nurse "K") ... I was in the medication room. I saw the resident turn to follow the CNA and her walker got caught on the lazy boy chair in the hallway. Resident unable to state what happened." The section "General Follow up Procedures" reflected "Written by (DNA "C") Incident discussed with falls committee and this is not a result of abuse. (Resident #3) has dementia and is unable to recall her safety needs. She also has [MEDICAL CONDITION]. Resident was restless during devotions and activities asked CNA if she could take her out of activity. She was walked to a chair and CNA sat next to her. Another resident from the other side of the room stood up, CNA responded, during this time (Resident #3) stood also. Chair alarms have been put in place. Also sling per physician's orders [REDACTED]." No additional documentation could be provided by the facility regarding any interviews done with any staff working with the resident at the time of, or before the incident. Resident #3's "Radiology Report" (dated 9/7/13) reflected " ...Swelling Post Fall RO FX (rule out fracture) Right shoulder, 2 views 1. Acute comminuted humeral neck and greater tuberosity fracture, with mild displacement ... Right Humerus, 2 views 1. Acute comminuted humeral neck and greater tuberosity fractures, with mild displacement." On 11/6/13 DNA "C" and Director of Nursing "B" were asked at 1:40 pm whether there was any more documentation from Resident #3's incident on 9/7/13 regarding staff interviewed about the incident. DON "B" indicated she would look to see if there was anymore available documentation. On 11/6/13 at 1:40 pm DON "B" revealed that there was no other documentation available regarding Resident #3's incident on 9/7/13 where she fractured her shoulder. DON "B" then revealed that she, DNA "C", and Administrator "A" performed the investigation on the incident. Administrator "A", DON "B", and DNA "C", were interviewed on 11/6/13 at approximately 3:00 pm. Administrator "A", DON "B", and DNA "C" were all asked whether they had observed Resident #3's incident on 9/7/13 where she fell and fractured her shoulder. All 3 answered they had not. All 3 were then asked how they determined that the incident on 9/7/13 was not a result of abuse and Administrator "A" responded "(DNA "C") did investigate. She talked to the 3 staff there. It was not reported to the State because the aid, activity aid (this activity aid was not identified in the incident and accident report (dated 9/7/13)), and Nurse were interviewed and we were not able to ident

Based on observation, interviews, and record review, the facility failed to ensure 2 (#8, #25), of 12 residents reviewed for abuse, from a total sample of 23 residents were free from abuse, resulting in an immediate jeopardy when Resident #8 was shoved on a lift and the toilet and had her clothing roughly pulled off her by CNA (certified nurse aide) "D", and Resident #25 was grabbed roughly by CNA "D" around the chest, resulting in pain, emotional distress and fear for Resident #8 and Resident #25 when CNA "D" continued to work in the facility and enter their rooms regularly. These deficient practices place all 111 residents in the facility at high risk for physical harm and/or injury. Resident #8: According to the face sheet, dated 9/23/13, Resident #8 was an [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS (minimum data set) assessment, dated 6/3/13, indicated that Resident #8 was cognitively intact and required extensive assistance of one person for dressing and hygiene. In a confidential group interview on 11/6/13 at 10:45 am, Resident #8 stated she requested not to have CNA "D" in her room because he was rough with her. Resident #8 stated CNA "D" jerked her clothes off in a rough way, which caused her hearing aids to be pulled out of her ears. Resident #8 stated since she has requested CNA "D" not come in her room, when her call light is on, CNA "D" would come into her room and ask her what she wanted. Resident #8 stated she would tell CNA "D" she wanted her aide and CNA "D" would turn off her call light, leave the room and not inform other staff that Resident #8's call light had been on. During a private interview with Resident #8 on 11/6/13 at 2:00 pm, she stated she reported to her aide and nurse that CNA "D" was rough with her, by shoving her around on the lift and toilet. Resident #8 was able to name CNA "L" as the nurse aide she reported her complaints about CNA "D" to. While explaining the incidents to the surveyor, Resident #8 became tearful. Resident #8 stated a nurse with gray, short hair and glasses came into her room and begged her to give CNA "D" one more chance, so she did. Resident #8 stated the next night, CNA "D" was so rough pulling her shirt and bra off from her that she cried. During the interview, CNA "D" walked by Resident #8' s room and Resident #8 stated, "There he is. Do you see him? He just walked by. "Resident #8 appeared fearful and stated CNA"D" better stay out of her room. In an interview on 11/6/13 at 2:15 pm, CNA "L" stated Resident #8 did report to her a few months ago that CNA "D" was rough with her. CNA "L" stated she reported it to her nurse, (Licensed Practical Nurse) LPN "M". In an interview on 11/6/13 at 2:20 pm, LPN "M" stated she couldn't recall if CNA "L" had reported the allegation Resident #8 had made against CNA "D". LPN "M" stated she had not filled out an incident report about Resident #8 reporting CNA "D" being rough with her. LPN "M" stated if CNA "L" reported Resident #8 making an allegation about CNA "D" being rough with her, she (LPN "M" ) would have reported it to Unit Manager "N". LPN "M" stated multiple residents had voiced complaints against CNA "D" and had requested CNA "D" not provide care to them. LPN "M" stated Director of Nurse Aides (DNA) "C" asked her (LPN "M") to make a list of residents who had complained about the care CNA "D" provided. LPN "M" stated she did make the list and gave the list to UM "N". In an interview on 11/6/13 at 2:10 pm, Unit Manager (UM) "N" stated Resident #8 never reported to him that CNA "D" was rough with her. UM "N" stated he did talk with Resident #8 one day to ask her how her night went with CNA "D", just because he (CNA "D") was new to the unit. The surveyor asked UM "N" if he did that with all staff that was new to the unit and UM "N" stated no. UM "N" was observed to have short gray hair and to be wearing glasses. UM "N" stated LPN "M" did give him a list of residents she had written, who had complained about CNA "D" and did not want CNA "D" to provide care to them anymore. UM "N" stated he gave the list to DNA "C". In an interview on 11/6/13 at 2:25 pm, the Director of Nurse Aides (DNA) "C" stated she recalled that LPN "M" notified her there were residents on the 300 Hall that did not want CNA "D" to take care of them. DNA "C" stated she had LPN "M" make a list of residents who had made complaints about CNA "D" . After multiple requests by the surveyor, for the list of residents who had made complaints about CNA "D", no list was provided by the facility. During observations on 11/6/13 from 2:05 pm to 3:00 pm, the surveyor observed CNA "D" working as a direct care giver for Residents on the 300 Hall of the facility. # Resident #25 According to the face sheet dated 1/23/12, Resident #25 was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS), an assessment tool, Resident #25 was cognitively intact. During a confidential group interview on 11/6/13 at 10:45 am, Resident #25 stated CNA (Certified Nursing Assistant) "D" was not supposed to be in his room. Resident #25 stated CNA "D" was rough with him during care a couple of months ago and he (Resident #25) did report it to facility staff. Resident #25 stated CNA "D" still comes into his room to deliver his meal tray even though he isn't supposed to be in his room. Resident #25 stated CNA "D" grabbed him so hard around his ribs it felt like he (CNA "D") broke his (Resident #25) ribs. On 11/6/13 at 11:50 am, the surveyor requested all incident reports involving CNA "D" from DON (Director of Nursing) "B". No incident report involving Resident #25 was provided to the surveyor. At 2:00 pm, DON "B" stated to the surveyor that all incident reports involving CNA "D" had been provided to the surveyor. In an interview on 11/6/13 at 2:25 pm, Director of Nurse Aides "C" stated she met with Resident #25 in September in attempt to find out what was going on with CNA "D". Director of Nurse Aides "C" stated Resident #25 informed her that CNA "D" was rough. ( ) On 11/6/13 at approximately 1:00 PM, Resident # 25 was interviewed in his room. Resident #25 was asked to explain the incident that happened on 10/11/13. Resident #25 explained that he uses a fireman's pole in his room to transfer from his wheelchair to his bed. Resident #25 reported that when he was transferring, Certified Nursing Assistant (CNA) "D" came into Resident #25's room and squeezed Resident #25. Resident #25 reported that he may have been a little unsteady, but he always transfers himself. Resident #25 also reported that he felt that CNA "D" broke his ribs because he squeezed so hard. Resident #25 stated "I don't trust him." Resident #25 proceeded to explain that CNA "D" was not allowed to come into his room to care for him anymore, but CNA "D" still comes in to bring in Resident #25's dinner tray. On 11/7/13 at 1:15 PM DNA "C" clarified that she first met with Resident #25 in September because of hearsay from staff. DNA "C" then reported that Resident #25 complained again about CNA "D" so DNA "C" reported that she met with Resident #25 again. Review of CNA "D"'s personnel file did not reveal a disciplinary action or education with regards to his care of Resident #25. ( ) On 11/12/13 at 2:50 p.m., Administrator "A" was notified that the facility was placed in Immediate Jeopardy that was identified on November 7, 2013 and began on July 26, 2013, as a result of the facility's failure to implement their own abuse policy and thoroughly investigate, report, and protect residents from the potential for further abuse to occur. On 11/14/13, this surveyor confirmed the facility implemented the following to remove the Immediate Jeopardy: 1. Immediate steps for residents involved Resident #24, #25, #8, #31, will be interviewed by Social Services starting 11/13/13 regarding any concerns with facility staff and their cares. Resident #27, #28 are no longer residents of the facility. 2. Identification of others at risk Social Services began interviewing on 11/13/13 all residents who are able to convey their thoughts regarding any concerns with facility staff and their cares. Unit managers began conducting on 11/13/13 a full skin/body assessment of those residents unable to be interviewed for any signs/symptoms of abuse. 3. Systematic changes to ensure the practice does not recur Nurse Aide D was suspended by the facility on 11/6/13 after resident complaints were brought to the attention of the Administrator. Nurse Aide D was terminated from the facility for rough cares on 11/11/13. Nurse Aide E was suspended by the facility on 11/12/13 after a complaint was brought to the attention of the Administrator and an allegation of abuse was reported to the BHCS. Nurse Aide E will be off the schedule pending the results of the investigation. The abuse prevention plan was reviewed and updated by the corporate policy team on 11/13/13 to ensure all CMS abuse prevention standards were being met. Under #1, the word significantly was removed to read only injury of unknown origin. Under #3, the word immediately was added to reporting standards to local law enforcement. 4. Education The Vice President of Clinical Services for Providence Life Services will begin providing in-service education to all staff on 11/13/13 regarding abuse prevention and the abuse reporting and investigation policy including the obligation to start an investigation upon receipt of an allegation. All staff will be in-services starting on second shift 11/14/13 prior to working their next scheduled shift. The Vice President of Clinical Services began providing in-service education on 11/13/13 to DCA (B), DON (B), Administrator (A), and the unit managers on the abuse reporting and investigation policy and procedure responsibilities. 5. Monitoring System The Director of nursing or Administrator will review each incident/accident report immediately as reported by facility staff. Any allegations of abuse/neglect will be immediately reported to the State of Michigan and abuse prevention protocols will be implemented. The Director of Nursing will report all audits to QA monthly for 6 months. The Director of Nursing is responsible to ensure compliance with this standard. The Director of Social Services will interview 10 residents monthly to ensure that all concerns brought to staff have been appropriately followed up on. The Director of Social Services will report these interviews to QA monthly for 6 months. The Director of Social Services is responsible to ensure compliance with this standard. Although the Immediate Jeopardy was removed on 11/13/13, the facility remained out of compliance as a scope of actual harm that is not immediate jeopardy and severity of isolation due to the fact that psychosocial harm had occurred and compliance had not yet been verified by the State Agency. ( )

Based on interview and record review, the facility failed to prevent accidents for 2 (#26, #30) of 10 sampled residents reviewed for accidents, from a total sample of 23 residents, resulting in Resident #26 sustaining a fractured left leg and Resident #30 sustaining an 8 centimeter (cm) to 9 cm skin tear on her left forearm which required 12 steri strips to close the wound. Resident #26: Review of Resident #26's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set ((MDS) dated [DATE] indicated Resident #26 required extensive assistance of two persons for transfers, dressing and toilet use. Per facility incident report dated 7/11/13, at 4:30 pm, RN "F" saw certified nurse aide "D" (CNA "D") pushing Resident #26 into the dining room and Resident #26 was crying and upset. The incident report indicated Resident #26 reported to RN "F" her leg hurt in the knee area and that it got bumped on the way down the hall. The follow up section of the incident report indicated Resident #26 was sent to the emergency room and a CT scan (computer generated image of the bones), report showed a displaced cortical fracture of the distal femoral shaft (end of the upper leg bone). According to the Nursing Note dated 7/11/13, "at approximately 4:30 PM, I (RN "F" ) saw CNA "D" pushing this resident (Resident #26) into the dining room, resident was upset and crying. I asked her what was the matter and she said her left leg hurt in the knee area and that it got bumped on the way down the hall. Resident continued crying and complained of left leg pain." Resident #26 was then transferred to the Hospital. Upon review of the emergency Physician Note dated 7/11/13, Resident #26 grimaced with palpation (touched) of the left knee and had effusion (swelling caused by fluid) around her left knee. With a [DIAGNOSES REDACTED]. Review of radiology report for Resident #26's left lower extremity dated 7/11/13 revealed findings to include undisplaced cortical fracture involving the medial distal femoral shaft (fracture left upper leg). In an interview on 11/6/13 at 1:10 pm, Director of Nursing (DON) "B" stated she talked to CNA "D" and CNA "D" didn't know what happened, that he may have bumped Resident #26's leg and he may not have bumped Resident #26's leg. DON "B" stated she did not document the interview and concluded it was not abuse from, "knowing her residents and knowing her staff ". In an interview on 11/7/13 at 1:40 PM with RN "F" , RN "F" indicated, the Resident #26 sometimes is a little confused, but can answer yes and no questions. RN "F" reported that she did remember Resident #26's fracture and on the day that it happened, I (RN "F" ) remembered passing medications from the cart by the activity room. RN "F" indicated Resident #26 was very upset shaky and crying. RN "F" stated she asked CNA "D" who was pushing Resident #26 in the wheelchair what had happened. CNA "D" replied to RN "F" that he did not know. Resident #26 was holding her knee. Resident #26 reported to RN "F" that her knee hurt. RN "F" reported that she asked CNA "D" again what happened to her, CNA "D" said that he bumped her foot on the wall. RN "F" explained that foot petals were on the wheelchair. CNA "D" replied to RN "F" that he wasn't sure where he bumped her foot in the wall. RN "F" then stated that she asked LPN "P" and DON "B" to look at Resident #26's knee. Resident #26 was holding her leg up and would not put her leg down to rest on the foot petal. RN "F" then stated "by the way Resident #26 was aching and the way it looked I thought we should have it checked out. We called the doctor to have it checked out. "RN "F" then explained that the facility called the doctor to have it checked out. RN "F" explained that the x-ray was done while she was on shift and was done in house. At that time DON "B" was asked for the radiology results from the in house results that were done 7/11/13, DON "B" stated that no in house x-ray was done. In a phone interview on 11/7/13 at 2:55 PM with CNA "D" , CNA "D" was asked about the incident with Resident #26. CNA "D" explained that when he went into Resident #26 's room to get her up for dinner, "everything was fine" . CNA "D" reported again that after getting Resident #26 up in her wheelchair "everything was fine" . CNA "D" then explained that he was pushing Resident #26 in her wheelchair in the hall, and Resident #26 then stated, "oh my knee, oh my knee" . CNA "D" then explained that he didn't know what happened, and he continued to push her into the dining room. CNA "D" was asked if he stopped before getting to the dining room, and he stated "no" . CNA "D" reported that once he got Resident #26 into the dining room, he told the nurse that she had pain. In an interview on 11/13/13 at 11:30 am, CNA "H" stated on the day Resident #26 sustained her broken leg, she witnessed CNA "D" pushing Resident #26 out of her room in her wheelchair right before dinner. CNA "H" stated Resident #26 was shaking, crying and had a look on her face like she was terrified. CNA "H" stated shortly after that, Resident #26 was sent to the hospital. CNA "H" stated she was never asked any questions or interviewed by any administrative staff regarding Resident #26's injury to her leg. In an interview on 11/8/13 at 9:40 am, facility Director of Nursing "B"(DON "B") stated she did not get a written statement from CNA "D" regarding the fracture of Resident #26's leg because she knew what happened. The surveyor asked DON "B" what happened and DON "B" stated CNA "D" reported "he may have bumped her leg". DON "B" stated there was no further investigation into the fracture of Resident #26's leg. Resident #30 Review of Resident #30's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set ((MDS) dated [DATE] indicated she required extensive assistance of two persons for transfers and extensive assistance of one persons for dressing. Review of Resident #30's falls plan of care (undated), which was provided to the surveyor by the director of nurse aides "C", indicated Resident #30 required the use of an "EZ stand with two persons" for transfers. Per facility incident report dated 7/25/13, at 3:30 pm, a nurse was called to Resident #30's room by a CNA and informed of a skin tear to her lower forearm. The incident report indicated Resident #30 had a skin tear 8 to 9 centimeter in length and 0.1 centimeter in width. The follow up section of the incident report indicated CNA "D" was attempting to transfer Resident #30 with an EZ stand (lift used to transfer a resident), and Resident #30 bumped her arm. Per a typed statement by CNA "H" dated 7/26/13, CNA "H" heard Resident #30 crying more than she normally did and went into Resident #30's room. CNA "H" observed CNA "D" with Resident #30 and her sleeves pulled down with blood on the sleeves. CNA "D" told CNA "H" that Resident #30 had a bruise and he pulled Resident #30's sleeve up. CNA "H" statement indicated she told CNA "D" that was not a bruise, he needed to get a nurse and he could not leave Resident #30 like that. The statement indicated when CNA "H" entered Resident #30's room she heard Resident #30 crying and CNA "D" was brushing her hair like nothing was happening. In a phone interview on 11/7/13 at 2:55 PM with CNA "D" , he (CNA "D") stated he put Resident #30 in the lift and the sling cut her arm. CNA "D" stated he had to yell out of the room for another aide because he couldn't leave the room. CNA "D" stated he was alone in the room with Resident #30 when he lifted her with the lift. CNA "D" stated the nurse came to the room and accused him (CNA "D") of trying to hide the incident. In an interview on 11/13/13 at 11:30 am CNA "H" stated she heard Resident #30 screaming more than usual from the room she was in across the hall, so she walked into Resident #30's room to see what was happening. CNA "H" stated she observed Resident #30 in her wheelchair with CNA "D" standing near her, and Resident #30 had blood on her sleeve. CNA "H" stated she asked CNA"D" what happened as she pushed the sleeve up and CNA "D" stated he didn't know. CNA "H" stated she observed the largest skin tear she had ever seen, which extended about half the length of Resident #30's lower arm, and it was bleeding badly. CNA "H" stated she went to get the nurse and told CNA "H" he couldn't just leave Resident #30 that way. CNA "H" stated DON "B" came to the room and she (CNA "H") went back to work. During an interview on 11/6/13 at 1:30 PM, DNA "C" said that CNA "D" was suspended for three days because of the skin tear, " ...we wanted to investigate if there was anything else with him we should be concerned about ...he was suspended for his roughness ". DNA "C" stated she did not report any allegations of roughness by CNA "D" to the State Agency, that she reviewed it with her superiors. During an interview on 11/6/13 at 1:30 PM, DNA "C" stated abuse was defined as something causing physical pain or injury. DNA "C" also stated that when she becomes aware of an allegation of abuse she goes to her superior (the Director of Nursing, DON "B"). In an interview on 11/13/13 at 11:30 am, CNA "H" stated she had reported to her Unit Manager after Resident #30 had her skin tear in July of 2013, that she (CNA "H") wasn't comfortable working with CNA "D" because he wasn't "safe". CNA "H" stated CNA "D" kept hurting the residents. CNA "D" stated at no time did a staff member follow up with her regarding her statement to her unit manager about CNA "D" and CNA "D" continued to work in the facility as a direct care giver. CNA "H" stated CNA "D was moved to another part of the building to work. #

This citation pertains to MI 730. Based on interview and record review the facility failed to prevent physical and verbal abuse in 1 of 4 residents (Resident #102) reviewed for abuse, from a total sample of 6 residents, resulting in the dehumanization and humiliation based on the reasonable person concept for Resident #102. Findings include: Review of the anonymous complaint revealed Resident #102 was "held down" by Certified Nurse Aide (CNA) #13 while changing Resident #102's incontinence brief. The anonymous complaint revealed CNA #13 placed her knee on Resident #102's chest and used derogatory language regarding the color of Resident #102's skin color (Resident #102 is African American). Review of the Face Sheet revealed Resident #102 was a [AGE] year old male admitted to the facility on [DATE]. Review of the [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 was modified independence for cognition and was an extensive assist of 2 persons for toilet use. In an interview on 10/1/13 at 4:40 p.m., CNA #12 stated she, CNA #13 and CNA #11 were attempting to change Resident #102 around "9 p.m." on 9/10/13. CNA #12 stated Resident #102 was agitated and was refusing to have his soiled brief changed. CNA #12 stated Resident #102 was "pretty upset" and was combative with CNA #13. CNA #12 stated CNA #13 "was holding his (Resident #102) hands down." CNA #12 stated CNA #13 "was just so angry that he (Resident #102) was fighting us." CNA #12 stated CNA #13 then placed Resident #102's "hands across his chest, holding his wrists and pulling them (wrists) together" then "put her (CNA #13) knee on" Resident #102's "hands to keep him still and hold him down." CNA #12 stated Resident #102 "was struggling" with CNA #13 but CNA #13 "had pinned him down" to the bed. CNA #12 reported that CNA #13 stated, "when it comes to black people, if they bruise you can't see it". In an interview on 10/2/13 at 9:00 p.m., CNA #11 stated she, CNA #12 and CNA #13 were attempting to change Resident #102 in the evening of 9/10/13. CNA #11 stated CNA #13 took Resident #102's "hands, crossed them across his chest, put her knee on his arms and all of her body weight" on Resident #102's chest. CNA #11 stated she heard CNA #13 call Resident #102 a 'stupid n*#@ger' under her breath. CNA #11 stated Resident #102 was "pushing on her (CNA #13)" attempting to get her off his chest. CNA #11 stated, "I don't' think he (Resident #102) wanted to be restrained like that." CNA #11 stated Resident #102 "stopped fighting when (CNA #13) got off of him." CNA #11 reported that CNA #13 said 'it's all right if we bruise him because he's black and you won't see the bruise.' CNA #11 stated she, CNA #12 and CNA #13 finished changing Resident #102 and left the room. CNA #11 stated Resident #102 was left in bed after the incident. Multiple attempts were made by the surveyor to interview CNA #13. The surveyor was not able to reach CNA #13 for interview. In an interview on 10/2/13 at 2:00 p.m., Director of Nursing (DON) #2 stated she was made aware of the incident on 9/14/13 (4 days after the alleged abuse). DON #2 stated, "no, it wasn't abuse, the girls (CNA #11, CNA #12) were uncomfortable with how" CNA #13 restrained Resident #102. DON #2 was asked by the surveyor if she was aware of any comments made by her staff regarding skin color during the incident with Resident #102. DON #2 stated, "CNA #12 said she heard something under her (CNA #13) breath" about skin color. DON #2 was asked by the surveyor if this statement was abuse of Resident #102? DON #2 stated due to Resident #102's "cognition and his disease (dementia), he couldn't process it (statement made by CNA #13 regarding skin color and derogatory term of skin color) if he heard it, I don't feel it had done him any harm." Review of the facility witness statement dated 9/10/13 signed by CNA #13 revealed, "I (CNA #13) was holding his (Resident #102) arms and hands to his body." Review of the facility witness statement (un-dated) at 9:00 p.m. signed by CNA #11, revealed CNA #13 "was rough, crossed his (Resident #102) arms, placed her knee on arms to restrain him." The facility witness statement by CNA #11 revealed CNA #13 "was angry at time of incident" and CNA #13 "voiced did not have to worry about bruises he is colored (Resident #102 is African American)." Review of the facility witness statement dated 9/10/13 signed by CNA #12, revealed CNA #13 "held his (Resident #102) hands" and "proceeded to cross his arms and placed her knee on his arms to restrain him." The facility witness statement by CNA #12 revealed CNA #13 "was irritated and mad while holding him (Resident #102) down." ( )

This citation pertains to complaint investigation MI 839 Based on interview, and record review the facility failed to provided adequate supervision to prevent an fall for 1 (Resident #101) out of 4 residents out of a total sample of 4 residents reviewed for falls, when Resident #101 stood up without assistance and fell resulting in a fractured hip. Findings: Per the facility "Face Sheet" dated [DATE], Resident #101 was an [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the "Minimum Data Set" ((MDS) dated [DATE], Resident #101 required supervision for walking and transfers, was steady at all times, and did not use assistive devices. Resident #101 scored an 8 out of 15 during a Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The MDS indicated Resident #101 had fallen prior to admission. Per the facility "Falls Reduction" policy dated ,[DATE], it is the goal of the facility to enhance the quality of client lives by reducing falls and fall injuries. The policy classifies a fall that could have been prevented as avoidable when "..an accident occurred because the facility failed to: 1. Identify environmental hazards and individual client risk of accident, including the need for supervision." Per a "Nurse's Note" dated [DATE] at 10:00 a.m., "(Resident #101) is ...restless at times, 1:1 very helpful..." Per "Nurses's Notes" dated [DATE] at 12:00 noon, "Resident (#101) restless, trying to do 1:1 care." An untimed "physician progress notes [REDACTED].#101 as extremely anxious, difficult to get resident to sit for any length of time and "Needing 1:1 nursing to prevent himself from hurting self or falling." Review of a "Nurses Note" dated [DATE] at 1:30 p.m., indicated the physician had been in to see Resident #101 during rounds and increased Resident #101's Xanax (a medication used to treat anxiety) due to "extreme" anxiety and to "keep safe" and prevent hospitalization . The nurses note did not characterize Resident #101's behaviors or nursing interventions utilized to ensure the residents safety. Review of a "Nurse's Note" dated [DATE] at 1:30 p.m., indicated Resident #101 had been a 1:1 and was to stay on 1:1. Further review of nursing notes did not indicate a change in status until an entry on [DATE] documenting Resident #101's fall. During an interview on [DATE] at 12:47 p.m., Physician #8, who treated Resident #101 at the facility, said 1:1 was appropriate because Resident #101 had "absolutely no safety awareness". When the surveyor asked Physician #8 if it would be appropriate to observe Resident #101 from several feet away, Physician #8 said you would need to be right beside him in order to keep him safe due to his impulsivity. Review of the "Care Plan Report" dated [DATE], Resident #101 was at risk for falls because of his dementia and his inability to recognize his own safety needs, psychotropic med use, occasional urinary incontinence, a [DIAGNOSES REDACTED]. Resident #101 was not able to remember how to use a call light. Staff were to remind Resident #101 to ask for assistance prior to transferring, provide reminders to use ambulation devices, apply "hipsters all times" (pads worn by the resident to protect the hip area from injury in the event of a fall) and use bed alarm and chair pad alarm to monitor attempts to rise. No new interventions were added that reflected Resident #101 had any change in status which required increased supervision. Review of an undated "Assignment Sheet ,[DATE]", a guide for second shift aides listing all the resident care needs for the unit Resident #101 lived on, indicated he was to use stand by assistance and a walker for assistance with ambulation. No mention of close supervision is made or that Resident #101 has a very high risk of falling despite several safety precautions and transfer assistance needs. Review of Resident #101's "Client Care Guide" (placed in each resident room for staff to reference listing resident care needs) dated [DATE], indicated Resident #101 had moderate cognitive impairment, was independent with ambulation, toileting, and eating. Resident #101 was identified as an elopement risk and wore a "Wander Guard" (a sensor alarm alerting staff to attempts to exit through doors). No modifications had been made to the care guide to alert staff to Resident #101's status, increasing his risk for falls. During a telephone interview on [DATE] at 1:00 p.m., Certified Nursing Assistant (CNA) #3 stated she had been assigned to Resident #101 on [DATE] and had been queuing him to eat and recalled Resident #101 as having been "good the whole time and didn't stand up once." CNA #3 was never told to increase Resident #101's supervision and toward the end of the meal got up and walked four or five steps across the room toward CNA #4 to report Resident #101's food acceptance when she heard a chair alarm. CNA #3 said it happened very quickly. CNA #3 said Resident #101 was wearing hipsters. During an interview on [DATE] at 2:30 p.m., CNA #4 said she had been charting food acceptance in the dining room at the time Resident #101 fell on [DATE]. CNA #4 said she was facing in the direction of Resident #101 across the room, but wasn't specifically looking at him or aware of any need to increase supervision. Per a written statement submitted for the investigation by the facility into the incident, dated [DATE], CNA #4 indicated she was approximately 20 ft away, "...too far away to intervene". Review of a written statement dated [DATE], CNA #9 indicated she witnessed the incident from approximately 100 feet away, "...too far away to intervene..." as she was returning to the dining room to assist residents. Per the hospital "Discharge Summary", dated [DATE]. Resident #101 was admitted with a right femoral neck fracture (hip fracture). Resident #101's course of hospitalization after his fall at the facility was followed by surgery to repair his broken hip once he was medically cleared. After the surgery Resident #101 developed "...progressive hypoxemia (low oxygen in his blood) and evidence of sepsis (systemic infection)." Resident #101 died on [DATE].

This citation pertains to intake MI 203 Based on observation, interview, and record review the facility failed to prevent an accident and ensure the safety of 1 (#102) of 3 sampled residents, out of a total sample of 3 residents when a staff member failed to follow a care guide and a resident was transferred without proper assistance resulting in a fracture. Findings include: Per a facility "Face Sheet" Resident #102 was a [AGE] year old woman originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Minimum Data Set ((MDS) dated [DATE], indicated she was cognitively intact, and required extensive assistance from two people for transfers, walking in her room and toileting. Per documents included with the facility investigation dated 4/2/12, the Nursing Home Administrator #1 interviewed Nurse Aide (CNA) #5 and asked CNA #5 if she knew Resident #102 was a 2 person assist with transfers. CNA #5 admitted that she did know Resident #102's transfer status and knew she should not have transferred her by herself. Per the facility investigation summary, written by Director of Nursing (DON) #2, dated 4/5/2012 , "CNA #5 was terminated for knowingly transferring Resident #102 without a second person as the assignment sheet stated, and CNA #5 admitted she did wrong." During an interview on 4-19-2012 at 11:30 AM, Resident #102 reported that she had called for assistance with a transfer when CNA #5 responded. Resident #102 recalled feeling nervous and asking CNA #5 if she should have another helper with the transfer. Resident #102 also stated she told CNA #5 her "grippy socks" (socks with non-skid soles) were not gripping and without the support of a second staff member slipped and fell , injuring her knee. Resident #102 stated she did not feel secure with the transfer and is now very limited due to the fracture. Resident #102 reported she is now transferred with a mechanical lift which makes her feel scared but understands she needs it due to her inability to transfer safely otherwise. During a telephone interview on 4-19-12 at 1:15 PM, CNA #5 reported Resident #102 was in the bathroom screaming that she wanted to get off the toilet. CNA #5 stated she decided to get her off the toilet without help and confirmed Resident #102 stated her "grippy socks" weren't gripping. CNA #5 said she wanted to keep Resident #102 calm but that Resident #102 "freaked out" in the middle of the room and fell . Per a "Radiology Report" dated 3/31/12, the day Resident #102 was inappropriately transferred by CNA #5, an examination of the left knee revealed an acute fracture of the medial femoral condyle and moderate joint effusion. Per "Consultation Notes" for Resident #102 dated 4/09/12, Resident #102 had a fracture of the femur, specifically the distal medial femoral condyle.