Every finding on record at Mission Point Nursing & Physical Rehab Center Of L

Based on observation, interview, and record review, the facility failed to implement its Infection Control and Prevention policies and procedures during resident care and medication administration and have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility. Findings include: During an observation of medication administration beginning at 8:15 AM on 12/15/2025, Registered Nurse (RN) D was met at the medication cart on the east hall of the facility. An uncovered plastic cup of yellow carbonated liquid was observed to the right of the computer. An uncovered cup of clear liquid was observed to the left of the computer screen. When asked, RN D said the yellow liquid was their personal drink and that the other uncovered cup of clear liquid was water she had poured for another resident who was not yet ready for their medications. During an observation of medication administration on 12/15/2025 at 8:30 AM, RN D entered Resident #8's (R8), who required Enhanced Barrier Precautions (EBP), room and proceeded to remove a lidocaine patch from R8's back, apply a new lidocaine patch and administer medications without donning gloves or a gown for the high contact (patch removal and application) resident interaction. RN D then discarded the uncovered plastic cup containing yellow liquid in the adjacent shower room. RN D did not discard the uncovered cup of clear liquid intended for another resident. During an observation of medication administration for on 12/15/2025 at 8:40 AM, RN D gathered prescribed medications for Resident #27 (R27). As RN D was pushing a capsule of pantoprazole 40 milligram (MG) from a blister pack, the medication dropped onto the medication cart rather than into a plastic medication cup and RN D picked up the medication with bare hands and placed it in the medication cup. After administering the morning doses of medication to R27, RN D went back to the medication cart to obtain a piece of 2 MG Nicotine gum as requested by R27. Again, RN D pressed the prescribed dose of medication from a blister package, the piece of nicotine gum landed on the medication cart rather than in the medication cup and RN D used her bare hands to pick up the dose and place it in the medication cup. During an observation of incontinence care on 12/15/2025 at 2:22 PM, Resident #16 (R16) was lying in bed and required a brief change and perineal cleansing. Certified Nurse Aides (CNAs) I and J donned appropriate PPE and provided appropriate perineal care for R27. Throughout the process, both CNA's were observed changing gloves but did not implement hand hygiene between glove changes (the use of alcohol-based hand sanitizer or soap and water). Once the CNA's completed cares for R16, they proceeded to adjust the linens, utilize bed controls, open dresser drawers to replace supplies and recap supplies with soiled gloves. Review of the facility policy and procedure for Enhanced Barrier Precautions, dated 3/2024 reflects It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Review of the facility policy and procedure for Hand Hygiene dated 3/2024 reflected All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. On 12/14/2025 at 11:01AM, observed in the Soiled Utility room on East Hall, hopper in the soiled utility rooms, has a cold-water line that cannot be turned on at the faucet by hand. On 12/15/2025 at 8:35AM, Environmental Manager (EM) L says the lines for the hopper are not on the schedule for routine flushing and he is unsure if hopper is used routinely. The facility's Water Management Plan states water lines not in use are flushed weekly. On 12/14/2025 at 11:10AM, the East Hall Housekeeping Closet has a spigot with hot and cold-water lines, at the time the hot water handle was turned on, brown water came out of the spigot. 12/15/2025 at 8:40AM, interview with EM L indicates the spigot in the Housekeeping Closet is not in use and the water lines are not flushed weekly.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of staff access only areas and residents living areas. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living, among all the residents in the facility.Findings include: On 12/14/2025 at 10:58 AM, observed, in the Resident Care Supply room, the condenser cover of ice machine had a buildup of debris on the surface. On 12/15/2025 at 8:25AM, walkthrough of building with Environmental Manager (EM) L, during discussion regarding cleaning schedule EM L stated that their TELLs system automatically reminds his department of continuous cleaning and maintenance schedules, ice machine is scheduled to be wiped down monthly by housekeeping personnel. On 12/14/2025 at 11:01AM, observation of hopper in the Soiled Utility room on East Hall, the hopper had a buildup of brown film on the interior, the film was partially dislodged when sprayed with water. On 12/15/2025 EM L indicated cleaning of the hopper was a responsibility of the Housekeeping Department. On 12/15/2025 at 12:45PM, observed ventilation cover for the vent in the shared restroom, for rooms [ROOM NUMBERS], was not flush with ceiling, allowing an opening of over a half inch between the ceiling and vent cover. At that time, it was also noticed that the fan was operating and creating loud noise and could be heard in room [ROOM NUMBER] with the door to the restroom closed. EM L when asked, was unaware of the issue with the vent cover or the noise level of the fan when operating.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one (Resident #10) of seven resident's reviewed for call light placement. Findings:Resident #10 (R10)Review of an admission Record revealed R10 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses of anoxic (lack of oxygen) brain damage, unsteadiness on feet, muscle weakness, and adjustment disorder with anxiety. R10 required assistance from 1 staff person for most ADL's (activities of daily living).During an observation on 12/14/25 at 9:36 AM, R10 sat up in bed awake and stated that he did not know where his call light was. The call light laid on top of the heat vent, almost to the floor, between the wall and the resident's bed out of sight and out of reach. During an observation on 12/14/25 at 11:40 AM, the floor nurse went into R10's room and brought in his medications. After the nurse finished and exited R10's room, the call light remained on the vent between the bed and the wall, out of sight and out of reach of R10. During an observation on 12/14/25 at 1:41PM R10 laid in bed resting with his eyes closed. The call light remained on the vent between the bed and the wall out of sight and out of reach of the resident. During an observation on 12/15/25 at 8:30 AM, R10 laid in bed with his eyes open. The call light laid on the vent, near the floor, between the bed and wall out of sight and out of reach of R10. R10 stated no he had not had access to his call light throughout the night. R10 then stated that if he had needed something he would have had to yell for staff. When asked if R10 felt sure that staff would hear him yelling, he reported that he was not sure because his room was at the end of hall.Review of a safety Care Plan for R10 reflected the following intervention .be sure my call light is within reach.During an interview on 12/16/25 at 10:23 AM, Certified Nurse Aide (CNA) C indicated that staff check call light placement in each room with every 2 hour check.

Based on observation, interview, and record review, the facility failed to ensure licensed nurses followed The Five Rights (Right Resident, Right Drug, Right Dose, Right Route, and Right Time) of medication administration in accordance with professional standards for 2 residents (R8 and R27) out of 3 residents observed during medication administration. Findings Include: During an observation on 12/15/2025 at 8:20 AM, Registered Nurse (RN) D prepared medications for R8 including Lidocaine External Patch 4% (Lidocaine) and Cranberry Oral Tablet 500 MG (milligram) (Cranberry (Vaccinium macrocarpon)) Give 2 tablets by mouth in the morning for UTI (urinary tract infection) prevention. RN D discovered the only dosage form of the Cranberry supplement prescribed for R8 available in the facility was a 450 MG tablet, not the 500 MG dosage ordered. RN D reported she would obtain a clarification order from the prescriber before administering a dose lower than prescribed. During the same medication administration observation on 12/15/2025 at 8:30 AM, RN D discovered a Lidocaine patch was already present on R8's back. The Lidocaine patch did not have a date or nurse initials indicating when the patch was applied or by whom. RN D said she did not believe the resident was to wear the patch overnight and reported the concern to the Assistant Director of Nursing (ADON) K. During an interview on 12/15/2025 at approximately 8:35 AM, ADON K reported that she had contacted the physician who confirmed R8 was to wear the lidocaine patch during the day and remove it at night. During an observation on 12/15/2025 at 8:40 AM, RN D prepared medications for R27 which included Sertraline HCl (Hydrochloride) Tablet 100 MG, Give 200 MG by mouth in the morning for depression. RN D discovered the prescription medication was not available in the medication cart. ADON K was nearby and said it was available in the backup supply of medications in the medication room. As RN D was walking toward R27's room to administer the other medications ordered for R27, ADON K handed RN D a medication cup that allegedly contained 4 (four) 50 MG tablets of Sertraline HCl. RN D did not witness ADON K obtain the medication from the backup supply and did not verify the tablets were indeed the right dose of the right drug for the right patient. RN D proceeded to administer medications to R27, including the unverified antidepressant.On 12/15/2025 at 10:30 AM, Central Supply Clerk N reported she was in charge of ordering supplies for the facility, reviewed the supplier's ordering details online, and confirmed the facility had never stocked the cranberry supplement in a 500 MG dose. Review of R8's Medication Administration Record (MAR) for the month of December 2025 reflected that a licensed nurse documented the Lidocaine patch had been removed on 12/14/2025, despite the discovery of a lidocaine patch in place the morning of 12/15/2025. The MAR also reflected licensed nurses had been documenting the administration of Cranberry Oral Tablet 500 MG (milligram) (Cranberry (Vaccinium macrocarpon)) Give 2 tablets by mouth in the morning for UTI (urinary tract infection) prevention, every day in December 2025, despite the Right dose was never available in the facility. Review of R27's MAR for the month of December 2025 reflected RN D documented she administered Sertraline HCl (Hydrochloride) Tablet 100 MG, give 200 MG by mouth in the morning for depression, despite not conducting the Five Rights of medication administration. During an interview on 12/15/2025 at 2:44 PM, the Director of Nursing (DON) reported that licensed nurses are expected to adhere to professional standards during medication administration. The DON reported that an audit of residents who were prescribed Cranberry Oral Tablet 500 MG revealed that 5 (five) residents had been receiving doses lower than prescribed. The DON also reported that the ADON K and RN D did not adhere to professional standards of medication administration related to R27's prescription antidepressant. Review of the facility policy Medication Administration - General Guidelines dated June 2019 reflected Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The policy also specified 3) The Five Rights (Right Resident, Right Drug, Right Dose, Right Route, and Right Time) are applied for each medication being administered. A triple check of these Five Rights is recommended at three steps in the process of preparation of a medication for administration:a. When the medication is selected, the label, container, and contents are checked for integrity and compared against the Medication Administration Record (MAR) by reviewing the Five Rights.b. When the dose is removed from the container, it is verified against the label and the MAR by reviewing the Five Rights.c. Immediately after the dose is prepared and the medication is put away, the label is reverified against the MAR by reviewing the Five Rights.4) If the medication and/or dosage schedule on the label and the MAR are different, and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. When a medication order is changed, and the current supply may continue to be used, the container should be flagged, and the order change must be communicated to (name of pharmacy) so that the next supply of the medication is labeled with the current directions.The Medication Administration - General Guidelines policy also specified The person who prepares the dose for administration is the person who administers the dose. The nurse who administers the medication records the administration on the resident's MAR immediately after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the nurse who administered the medications report off-duty without first recording the administration of all medications.

Based on observation and interview, the facility failed to maintain cleanliness and general repair of equipment, plumbing, the onsite waste water system, and other aspects of the physical environment. This deficient practice has the potential to affect all residents in the facility. Findings Include: During a tour of the dry storage room, at 10:22 AM on 10/21/24, it was found that an odor resembling sewer gas was present upon entering the room. When asked if they knew what the odor was, Dietary Manager R and Regional Dietitian U were unsure. Upon further evaluation of the room, it was found that a slowly leaking sewer pipe was observed in the back left corner with totes underneath it to catch the leak. The sewer pipes were observed covered in duct and electrical tape in some spots, with no adequate fix to the line. No food storage was under this area. During a tour of the facility, at 1:40 PM on 10/21/24, observation of the Ice Machine room with Regional Dietitian U, found a black rubber insulated seal was dangling down on the backside of the white plastic shield that hangs over the bottom bin portion of the ice machine. Further observation of the unit found increased amounts of black debris accumulation on the side wall of the unit, between the plastic shield and the wall. Observation of the room found an accumulation of brown crusted debris on the underside of the ice machine with a dozen plastic lids that had fallen behind the unit onto the floor. The unit was observed draining water from three different water lines into the stainless steel preparation sink next to the ice machine. When asked if that is the sink where hydration pass is filled, Regional Dietitian U stated she believes so. The sink was found with heavy rust staining on the inside compartment and walls. Two of the three discharge lines, hanging over the sink, were from a water-cooled compressor, the third line was from the ice that melts in the bottom bin, drains to a condensate pump (where it stays stagnant in an enclosed container that doesn't get cleaned) until the pump fills to the level to be discharged into the sink (where residents receive hydration pass). During a tour of the east hall spa room, at 1:50 PM on 10/21/24, it was observed that one of the two light ballasts in the room was not working and left the shower area dim and hard to see. Observation of the central supply room, at 2:23 PM on 10/21/24, found a leaking sewer line in the back left corner of the room that was falling onto old files and records the facility had in storage. The files and records were observed with black spotted mold looking accumulation with numerous water lines and marks from consistent leaking and drying in this area. During an interview with Environmental Services Manager (ESM) G, at 2:40 PM on 10/21/24, it was found that he has been at this facility less than a month and has been trying to play catch up on some of the repairs that the facility needs. When asked about the sewer line in dry storage. ESM G stated that they have reached out to a vendor to fix the issues and are just waiting on them to come and complete the project. When asked about the leaking sewer line in central supply ESM G stated he was not aware about that leak. During a tour of the laundry room, at 3:30 PM on 10/21/24, it was found that one of two washers and one of two dryers were not operational. When asked if there was progress on getting repairs or new equipment, ESM G stated it has been going through the purchase order process, but he's not sure where it's at currently. When asked if staff can keep up with demand, ESM G stated that they have been, but it's harder on staff as they work longer hours in order to make it happen. ESM G wasn't sure how long the machines have been down, but mentioned staff told him its been this way for a while. Last annual survey, in December of 2023, these pieces of equipment were down and not operational. In an interview with ESM G, at 3:05 PM on 10/21/24, the surveyor questioned the operation of the facilities' onsite wastewater treatment plant and found that they have been having issues staying in compliance with the Michigan Department of Environment Great Lakes and Energy ([NAME]) regarding the wastewater treatment plant. ESM G stated that since coming on board the last few weeks he has started to take over ensuring their vendor wastewater operator is fulfilling the obligations of his position. Previously the reports and samples were not received by the facility and would just go to the vendor. ESM G stated that [NAME] was out last week and had discharge concerns with numerous violations.

Based on observation, interview, and record review, the facility failed to position a urinary catheter collection bag to facilitate drainage for 1 resident (Resident #20) of 2 residents reviewed for urinary catheter care. Findings include: Review of an Admission Record revealed Resident #20 (R20) admitted to the facility on [DATE] with pertinent diagnoses which included flaccid neuropathic bladder and retention of urine. Review of a Minimum Data Set (MDS) assessment for R20, with a reference date of 10/11/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R20 was cognitively intact. Review of a current urinary catheter Care Plan intervention for R20, initiated 4/16/2024, directed staff to position her urinary catheter bag below the level of the bladder. In an observation and interview on 10/21/2024 at 3:28 PM in R20's room, R20 was sitting in her wheelchair with her urinary catheter collection bag hanging from the back of her wheelchair level with her middle and upper back and above the level of her bladder. R20 reported her urologist instructed her at an appointment that same day that she needed to store the bag below the level of her bladder. In an observation on 10/22/2024 at 8:15 AM in the dining room, R20 was in her wheelchair with her urinary drainage tube going over the back of her wheelchair and the urinary catheter collection bag hanging from the back of her wheelchair level with her middle and upper back and above the level of her bladder. Urine was visible backed up in the drainage tube and unable to empty into the urinary catheter collection bag. In an interview on 10/22/2024 at 10:16 AM, Certified Nursing Assistant (CNA) P reported staff had been storing R20's urinary catheter collection bag on the back of her wheelchair for months because this was R20's preference. In an interview on 10/22/2024 at 10:20 AM, CNA T reported staff had been storing R20's urinary catheter collection bag on the back of her wheelchair for months because it was being pulled on when it was stored under the wheelchair. In an interview on 10/22/2024 at 10:26 AM, Registered Nurse (RN) E reported R20's urinary catheter collection bag was being stored on the back of her wheelchair because it was leaking when under her chair. RN E reported the bag should be placed under the wheelchair to prevent urine from going back into the bladder and causing possible infection. In an interview on 10/22/2024 at 10:41 AM, the Director of Nursing (DON) reported R20's urinary catheter collection bag was being stored on the back of her wheelchair because it was getting caught up under the wheelchair and leaking. The DON reported keeping the bag above the level of the bladder could cause urine to reflux back into the bladder. In an interview on 10/22/2024 at 4:05 PM, R20's community Urologist M reported he noticed R20's urinary catheter collection bag was on the back of her wheelchair and above the level of her bladder at her appointment with him the previous day. Urologist M reported he educated R20 that the bag and tubing must be below the level of the bladder to allow the bladder to empty and prevent reflux of urine back into the bladder. Urologist M reported the bladder remaining full of urine and urine reflux can cause urinary tract infections.

Based on observation, interview, and record review, the facility failed to date and discard an outdated-for-use biological medication and failed to discard two insulin pens kept in active storage past the manufacturer's recommended expiration date and after the medication had been discontinued. Findings: On [DATE] at 7:55 AM a review was conducted of the facility medication room with Licensed Practical Nurse (LPN) J. Review of the medication refrigerator revealed an opened and entered multidose vial of purified protein derivative (PPD) solution. It was observed that the vial was not dated when it had been placed in service. LPN J noted that the box in which the undated vial was contained was dated [DATE] but that the vial itself was not dated. LPN J indicated she did not know the date the vial had been placed into service and reported that the vial expiration date would be the manufacturer's expiration date on the vial. On [DATE] at 8:10 AM the North unit medication cart was reviewed with Registered Nurse (RN) E. Review of the top drawer revealed a [NAME] insulin pen dated as placed in service [DATE] and an Admelog insulin pen dated as placed in service [DATE] for Resident #15 (R15). RN E reported that all nurses are responsible for maintaining an orderly medication cart. RN E reviewed the electronic medical record for R15 and reported no current Doctor's Orders were in place for the insulin pens and that both should have been discarded. The policy provided by the facility titled Medication Storage in the Facility last revised [DATE] was reviewed. The document reflected, Policy. Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier . The policy reflected Procedures ., H. Outdated, contaminated or deteriorated medications .are immediately removed from inventory . And Expiration Dating, C .1).b. Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: 1. In a multidose injectable vial. 2. An item for which the manufacturer has specified a usable life after opening. And D. When the original seal of a manufacturer's vial is initially broken, the vial will be dated. 1) The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial will be 30 days unless the manufacturer recommends another date . G. All expired medication will be removed from the active supply .regardless of the amount remaining. Review of the Manufacturer's instructions for the Admelog insulin pen reflected Only use your pen for up to 28 days after its first use. Throw away .after 28 days even if it still has insulin in it. Review of the Manufacturer's package insert for the Lantus insulin pen reflected the device was to be discarded 28 days after it was placed in service. Review of the Manufacturer's package insert for the PPD solution reflected Storage . A vial of (PPD solution) which has been entered and in use for 30 days should be discarded. On [DATE] at 11:01 AM an interview was conducted with the Director of Nursing (DON) in her office. The DON acknowledged the PPD solution should have been discarded. The DON also reported that the insulin pens discovered in the North medication cart that were outdated and without a current order should have been tossed a long time ago.

Based on observation, interview, and record review, the facility failed to ensure proper use of Personal Protective Equipment (PPE) for residents in Enhanced Barrier Precautions (EBP) for 1 resident (Resident #22) of 12 residents reviewed for infection control. Findings include: Review of an Admission Record revealed Resident #22 (R22) admitted to the facility on [DATE] with pertinent diagnoses which included pressure ulcers. Review of R22's Physician's Orders, active 10/23/2024 at 9:00 AM, revealed he required multiple daily dressing changes. Further review revealed no order for EBP's. In an observation and interview on 10/23/2024 at 9:30 AM in R22's room, Registered Nurse (RN) E performed several dressing changes without donning a gown. There was no signage on the door indicating the need for PPE. RN E reported R22 should have EBP's in place because of his wounds. In an interview on 10/23/2024 at 10:04 AM, the Director of Nursing (DON) reported R22 should have had EBP's in place since admitting to the facility because of his wounds that required dressing changes. Review of facility policy/procedure Enhanced Barrier Precautions, reviewed 3/2024, revealed .EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous statis ulcers) . High-contact resident care activities include . Wound care: any skin opening requiring a dressing .

This citation pertains to intake # MI00145786 Based on observation, interview, and record review, the facility failed to effectively implement interventions for effective communication for one resident (R2) of four reviewed for care plans, resulting in the miscommunication of care needs. Findings include: Review of a Face Sheet for R2 revealed she originally admitted to the facility on [DATE] with pertinent diagnosis of hemiplegia and hemiparesis (one sided weakness), aphasia (may be unable to comprehend or unable to formulate language because of damage to specific brain regions), and cognitive communication deficit. In an interview on 7/24/24 at 8:28 AM, the Designated Power of Attorney (DPOA)/husband of R2 reported that R2 cannot speak or say words like that because she has expressive aphasia. He works with her every day using word cards and a computer program to encourage her to speak in the mornings. He said the facility staff does not know how to communicate with her like he does. In an interview on 7/24/24 at 12:37 PM, R2 had no communication board in her room or any other modes for R2 to communicate verbally, nonverbally, or any means to reinforce words she was trying to express. Review of the Electronic Medical Records for R2 revealed no communication board or communication devices were available and no baseline communication/cognitive status established. In an interview on 7/29/24 at 9:15 AM, the Director of Nursing (DON) reported R2's husband usually comes to visit 2-3 times a day and will work with her doing therapy in the gym, help work on her speech, and some gardening. The NHA (Nursing Home Administrator) and DON were not aware of any baseline communication or communication devices for R2. In an interview on 7/29/24 at 11:00 AM, Speech Therapist (ST) S reported he is not at the facility often and is not given the autonomy to screen the residents himself but does get referrals. He reported he has made several attempts to see R2, but she was either sleeping and difficult to arouse, or another time he tried, and she backed herself up in a corner. There was a time ST S thought R2 may have been sick when he attempted to see her approximately in May/June 2024 and was asked to not attempt to try at this time. When asked about R2 saying si (si, C, or see) when she communicated, ST S reported it could have been an utterance without any value to it. Like a pattern of talking and may not have communication value. Nonverbal communication may be more effective when she is nodding her head. ST S reported that knowing the communication pattern would be valuable. Based on her record review, ST S could not figure out what her baseline communication was. He would have to assess more for her ability to identify pictures from verbal commands, yes or no questions, or even a communication board. Review of a Secure Conversation note for R2 dated 4/12/24 revealed: husband/guardian is requesting a letter be written stating that (name of R2) is cognitively intact and can make decisions but has difficulty communicating due to aphasia. Will one or both of you please evaluate her cognition? Her BIMS has been a 14 or 15 since I started using a picture board so she can point to her answers (with the exception of the November assessment when she was not interacting with staff). Review of a Social Service Progress Note dated 5/20/24 for R2 revealed, During the resident's quarterly PHQ-9 assessment, the resident expressed she has thoughts of suicidal ideation/self-harm almost daily. A Columbia Suicide Screening assessment was completed. Social worker and administrator do not feel the resident is an immediate threat to herself. Will attempt communication device as resident is frustrated that she is not able to communicate after her stroke. Review of a Practitioner Progress note dated 5/23/24 for R2 revealed: Cognitive communication deficit, continue supportive care and monitoring. Could be contributing to anxiety and depression. Review of a Practitioner Progress note for R2 dated 6/10/24, 6/13/24, 6/20/24, and 7/2/24 revealed: Cognitive communication deficit, continue supportive care and monitoring. Could be contributing to anxiety and depression. Review of the Care Plan for R2 revealed: I will be able to communicate needs daily by Yes/No answers, initiated 5/17/22. Monitor/document communication skills. Document baseline. If resident is presenting problems with cognitive function and communication, obtain an order for Speech Therapy consult to evaluate and treat, initiated 5/17/22. Monitor/document mobility status. If resident is presenting with problems or paralysis, obtain order for Physical therapy and Occupational therapy to evaluate and treat, initiated 5/17/22. Reinforce any cognitive programs put in place by therapy services, initiated 5/17/2022. Discuss with me/Guardian concerns or feelings regarding communication difficulty, initiated 5/27/22. Encourage me to continue stating my thoughts even if I am having difficulty making sense. Focus on a word or phrase that makes sense and help me elaborate from that word/thought. Allow me time to try to formulate my thoughts without feeling rushed to do so, initiated 5/27/22. Help me to develop a communication tool that I can utilize to communicate my needs, initiated 5/27/22. Monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. Monitor/document frustration level. Allow me time before providing me with words. Review factors affecting underlying cause of communication deficit, recent onset, chronic or recurrent conditions, success of attempted remedial actions, ability to compensate with nonverbal strategies, understanding in particular situations etc. Validate my spoken message by repeating aloud, initiated 5/27/24. Record/report to MD for [signs and symptoms] of UTI: pain, burning, no output, increased pulse, increased temp, urinary frequency, fever, chills, altered mental status, change in behavior, change in eating patterns. Social worker will collaborate with therapy to develop a communication board to help ease my frustration with not being able to communicate, initiated 5/20/24. Review of the Care Plan for R2 revealed: I have the potential for impaired cognitive function [related to] history of cerebral infarction with residual deficits/communication problems initiated 11/30/22 and no revision date. Goal: Will maintain current level of cognitive function through the review date, initiated 11/30/22 and no revision date. Interventions: -Ask me yes/no questions in order to determine my needs. Date Initiated: 11/30/2022 -Report to Social Services and Nurse any changes in cognitive function, specifically changes in: decision making ability, memory, recall, or confusion. Date Initiated: 11/30/2022

This citation pertains to intake # MI00145786 Based on observation, interview, and record review, the facility failed to effectively manage care for one resident (R2) of four reviewed for quality of care, resulting in unmet care needs. Findings include: Review of a Face Sheet for R2 revealed she originally admitted to the facility on [DATE] with pertinent diagnosis of hemiplegia and hemiparesis (one sided weakness), aphasia (may be unable to comprehend or unable to formulate language because of damage to specific brain regions), and cognitive communication deficit. In an interview on 7/24/24 at 8:28 AM, the Designated Power of Attorney (DPOA)/husband of R2 reported he saw her Friday morning on 7/19/24 and she was timid and didn't want to communicate which was abnormal for her, because she is usually cheery. He left and came back in the afternoon and R2 was having some pain in her abdominal/vaginal area. He had the nurse assess R2 and did not see any concerns. The next morning on 7/20/24, the DPOA came to visit, and his wife still had pain in her vaginal area. He asked the nurse to do a urinalysis because she was having symptoms similar to a urinary tract infection as she had in the past. The nurse told him they would do it for R2. When he came back to the facility at 1:30 PM, the nurse told him the strip indicated there was bacteria in the urine and the doctor ordered the urine sample to be sent out to the lab. In an interview on 7/23/24 at 3:34 PM, the Nursing Home Administrator (NHA) said they are waiting for labs to be done. A urinalysis (U/A) was collected on Saturday but was not picked up or sent out and needed to be redone. She began to refuse medications which was not normal for her. She had recently been sent to the hospital for behaviors and was diagnosed with a UTI. During multiple observations on 7/23/24 at 1:43 PM, 2:56 PM, and 4:22 PM, R2 was in bed with the lights out and would not engage or acknowledge this surveyor, visitors, and had limited staff interaction. She would open her eyes briefly and quickly close them. Review of a Behavior Notes dated 7/19/24 at 1:04 PM for R2 revealed: Resident spent the entirety of this shift in bed. When asked if she wanted to get up, she refused. Resident very quiet and appears to be sad. Review of a Behavior Notes dated 7/19/24 at 9:40 PM for R2 revealed Registered Nurse (RN) D documented: At the start of this shift, resident's husband approached this staff and he said that his wife was in pain, and she was pointing at her genital area. Went to this resident's room and checked. This staff observed this resident was crying and she was pointing at her genital area. This staff assessed the area and her bottom. She did not have any skin condition. Her skin in the genital area and bottom was intact. Asked this resident if she wanted her pain medication. She nodded. This staff gave her (as needed) Tylenol and milk of magnesia for she was on the BM (bowel movement) list. After a few minutes, she was seen in bed and asleep. In an interview on 7/24/24 at 3:37 PM, RN D reported he was working second shift on Friday 7/19/24 when R2's husband approached him about 2:10 PM with concerns about his wife having complaints of pain in the general area of her lower abdomen and vaginal area. The day shift nurse thought her pain was from constipation, but the husband told them she had a bowel movement the previous day. R2 was observed laying flat on her back and visibly crying. RN D asked R2 if it hurt down there, and she said si and pointed to her vagina. RN D was thinking she may have a yeast infection. RN D assessed the resident's vaginal area and noticed a discharge similar to a yeast infection and thought that may be the problem. He pressed on her suprapubic area, and she grimaced. R2 could not communicate well so he asked her pertinent questions. RN D then said he did not have any assessment concerns and convinced R2 to take a Tylenol and she then went to sleep. R2 was fine the rest of the night. When asked if he documented the assessment, RN D reported he did not. When asked if he notified the physician, he reported he did not. In an interview on 7/24/24 at 11:42 AM, Licensed Practical Nurse (LPN) H reported R2s husband approached her in the morning of 7/20/24 with concerns his wife having complaints of burning in her genitals. LPN H asked the resident if it burns when she is dribbling urine and said yes or si. LPN H asked if she had a urinary tract infection (UTI) in the past and if it felt the same and she said yes. LPN H collected a urine sample after R2s husband left that morning via straight catheter collection method and noticed the edge of the outer vagina (labia majora) looked raw and the resident hurt when she moved positions. LPN H did not notice any concerns inside the labia (labia minora) when she straight cathed the resident. LPN H reported she did not document her assessment findings. LPN H did a urine dipstick that resulted in the resident having 70+ bacteria in her urine and called the physician who ordered a urinalysis with a culture. LPN H reported she is new and did not know how to send out a urinalysis (UA), so she put the urine on ice and talked to oncoming RN I who did not know how to send it out either but was going to find out and take care of it. LPN H reported she later found out it was not sent out. LPN H reported there was nothing abnormal about R2 this day and her behavior was normal, she was just in pain and uncomfortable. A thorough pain assessment was not completed or documented. In an interview on 7/24/24 at 7:00 PM, CNA M reported she was familiar with R2 and reported she could communicate her needs but not verbalize them. Staff could usually guess or figure out what R2 wanted or needed. On Saturday 7/20/24 R2 was checked to see if she needed incontinence care after dinner and R2 said no. CNA M reported she checked her brief anyway and it was dry. About 45 minutes later R2 put on her call light to be changed and her brief was wet. When CNA M put the head of the bed down, she was making noises like she was aggravated. CNA M reported she was told in report R2 was being checked for a UTI. R2 was breathing heavy and CNA M asked her if she hurt when she pees and R2 said no. When CNA M removed her brief R2 inhaled like it hurt and asked her if it hurt. She thought the brief grazed over the sore area. R2 replied no but si. CNA M noticed a bright red lump on her inner right labia similar to an abscess and a milky white fluid coming from her vagina. She folded R2s brief back up and got RN I. RN I came in and got some Nystatin cream and applied it to R2. In an interview on 7/24/24 at 3:20 PM, RN I reported she worked the second shift on 7/20/24 and started around 2:00 PM. She was told in report from the day shift nurse (LPN H) that R2 was having some abdominal pain and burning in her genital area. LPN H told her that she obtained a urine sample for a urinalysis to be sent out but did not know which lab to send it out to. RN I told LPN H she would take care of it. RN I reported she texted the DON (Director of Nursing) to find out which lab to send the urinalysis to and was instructed to find out when the urine was collected because it was at room temperature with no date or time of the collection marked on the sample. CNA M (Certified Nursing Assistant) approached RN I to tell her that R2 was having pain in her genital area and CNA M saw bruising. RN I said she assessed R2 and saw some redness and an abrasion inside her labia that was not real red and some discharge but did not document any assessment. RN I reported it could have been from her brief. RN I asked RN L to assess R2 because she thought there were abrasions, and she was the only nurse on duty from 2-6 PM and wanted a second opinion. In an interview on 7/25/24 at 1:33 PM, RN L reported she started her shift on 7/20/24 at 6:30 PM. When she arrived, RN I was the only nurse at the time and was passing medications to other residents. She was informed by CNA M about a rape allegation involving R2 and her husband. RN I then gave report that they were concerned earlier about R2 having a UTI, RN L did an assessment of R2's vaginal area and saw some bruising and redness. A circular abrasion was on her left inner labia and a small area was on her right. It was similar to a rug burn or an irritation with some inflammation that looked like it would have been from the last couple of hours. She did have some discharge and it could have been a yeast infection. R2 could scratch her genitals if she had any itching. R2 was incontinent. Review of a Practitioner Progress note dated 7/20/24 at 9:32 PM for R2 revealed: Nurse called [8:16 PM]. Pt had been complaining of pain around genitalia. I gave verbal order to transfer her immediately to ED (emergency department). Review of a Nurse Practitioner Note dated 7/22/24 for R2 revealed .ROS reveals concerns for potential UTI, reviewed with patient, she denied firmly to have straight cath (catheter) for eval of UTI. She denies any other concerns at this time. In an interview on 7/24/24 at approximately12:15 PM, LPN/Unit Manager J reported there has been some ups and downs with labs recently and named several labs the facility uses. She was not clear at first which labs and forms the facility is to use for a urinalysis then named a couple options. UM J reported she communicates with staff by cheat sheets in a binder that has snap shots of how to put in orders based on the lab. UM J said there is one lab that provides a urinalysis collection kit with instructions the staff could use. In an interview on 7/24/24 at 12:30 PM, LPN H reported she did not use the UA collection kit that the UM J reported was available. In an interview on 1/24/24 at 1:00 PM LPN C reported she was informed that week on where to send a urinalysis. In an interview on 7/29/24 at 9:15 AM the Director of Nursing (DON), reported they were able to collect another urine sample on 7/23/24 and sent to the lab. The urinalysis resulted on 7/26/24 and R2 was positive for a UTI.

Based on observation, interview, and record review the facility failed to: 1. Ensure sufficient hot water at the hand sink; 2. Properly datemark food product; 3. Properly store food product; and 4. Ensure cleanliness of food and non-food contact surfaces. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 30 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the kitchen, starting at 9:05 AM on 1/8/24, it was observed that the hand sink, located to the right of the dish machine, was not providing hot water to achieve the required 100F. At this time, the hot water was checked with a rapid read digital thermometer and found to only reach 61F. An interview with Dietary Aide F found that the hand sink never seems to get hot, but the one compartment wash sink (next to the hand sink on the dish machine line) gets hot. Further observation found that the hot water line under the hand sink passes through a mixing valve. According to the 2017 FDA Food Code section 5-202.12 Handwashing Sink, Installation. (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 38C (100F) through a mixing valve or combination faucet . 2. During the initial tour of the kitchen, at 9:15 AM on 1/8/24, an interview with Dietary Manager (DM) E found that food is dated for six days out. Observation of the three-door true cooler found an open thickened dairy beverage with no discard date (manufacture states the product is good for four days after opening), an open container of thickened lemon water with no discard date (manufacture states the product is good for seven days after opening). Further review of the cooler found a three-gallon container with a large ham wrapped in saran wrap and pieces of ham chunks stored in a plastic bag. When asked if there was a discard date on either of the ham items, DM E stated it was not dated. During the initial tour of the kitchen, at 9:28 AM on 1/8/24, observation of the two-door cooler found an open package of sliced ham with no discard date. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . 3. During the initial tour of the kitchen, at 9:30 AM on 1/8/24, it was observed an open container of less sodium soy sauce was found stored underneath the preparation table on the cook line. Further review of the product found that the manufacture states to Refrigerate After Opening. According to the 2017 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: .(2) At 5 C (41 F) or less . 4. During the initial tour of the facility, at 9:27 AM on 1/8/24, it was observed that the top gaskets of the two door cooler were found with an accumulation of debris. During the initial tour of the kitchen, at 9:35 AM on 1/8/24, an interview with DM E found that staff use the stand up mixer a couple times a week. The mixer was found covered in a plastic bag which DM E indicated meant it was clean and ready to be used. Observation of the underside arm of the mixer found an accumulation of white and yellow stuck on splatter debris. During the initial tour of the kitchen, at 9:37 AM on 1/8/24, observation of the underside corners of the juice machine found an accumulation of sticky orange, brown debris. During a tour of the North hall pantry, at 11:22 AM on 1/8/24, it was observed that a dried spill occurred on the top of the refrigeration unit and into the crevice of the top gasket seal. When asked if kitchen staff use this area, DM E stated the PM cook comes down daily. During the tour of the facility, at 11:25 AM on 1/8/24, it was observed that the ice machine was found with an accumulation of black debris on the corners and sides of the inside plastic lip. When asked who services the machine, DM E stated a vendor comes out and cleans it quarterly and they were here in December. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation, interview, and record review, the facility failed to provide a dignified dining experience for four residents who required assistance to be fed (Resident #10, Resident #14, Resident #18, and Resident #26), of 4 residents reviewed, resulting in staff standing over the residents to assist with feeding in an undignified manner and providing intermittent feeding assistance with the potential for the residents' food to get cold. Findings include: Resident #10 (R10) Review of the Care Plan for R10 revealed she has dysphagia with a general diet with 4-pureed textured foods, thin liquids and is allowed a regular texture meal when alert. Her independence with meals fluctuates and is to be provided assistance as needed. She does better with finger foods at meals, initiated 4/29/19. She is also care planned for being dependent for feeding initiated 2/3/22. Resident #14 (R14) Review of the Care Plan for R14 revealed she is dependent for eating, initiated on 1/27/21. The feeding techniques she requires is to be fed by staff, she has a history of pocketing food, initiated 2/3/22, and diet orders are a general diet, 4-pureed texture, and thin liquids, initiated 2/1/21. Resident #18 (R18) Review of the Care Plan for R18 revealed she requires the assistance of one-to-one feeding, at times independent cut up meals into small bites, initiated 11/25/20. She needs supervision, encouragement, and cueing to eat. Her husband will be in daily to assist with lunchtime feedings, initiated 2/23/21. Resident #26 (R26) Review of the Care Plan for R26 revealed her diet orders are pureed with mildly thickened liquids, I need to be fed, initiated 2/16/23. She is to be assisted with eating and offer cueing as needed, initiated 7/14/23. During an observation on 1/8/24 at 12:11 PM in the North Unit dining room, R10, R14, R18 and R26 were sitting at the dining room table with food trays sitting in front of them and were not able to feed themselves. Other residents in the room were eating their meals. Certified Nursing Assistant (CNA) C was the only staff member in the room meeting the needs of all the residents that were in the dining room. CNA C was observed providing beverages, utensils, cutting up residents' food, and satisfying meal change requests for the residents in the dining room. CNA C was walking to the different tables R10, R14, R18, and R26 were sitting at and stood over them while providing them 1-2 bites of food at a time while rotating between them and assisting the other residents in the dining room. After some time had passed by, CNA C sat down next to two of the residents who needed assistance. Other staff were observed entering the dining room and leaving and assisted briefly and intermittently. During an observation and interview on 1/9/24 at 8:26 AM, CNA C was observed assisting the residents with their breakfasts in the North Unit dining room. R4, R10, R14 and R18 were sitting at different tables waiting for assistance with their meals that was placed on the table in front of them. Other residents in the room were eating their meal. There were 13 residents total in the dining room and CNA C was the only staff member in the dining room assisting all the residents by providing coffee and other requests for the residents. CNA C was observed rotating between the four residents who required assistance with meals, standing over them when providing 1-2 bites at a time until their meal was finished. CNA C reported the other aides will usually come in and help when they get done with the needs on the floor. At this time a nurse came into the dining room to give medications to a resident who was eating independently. Another CNA brought a resident to dining room via wheelchair and left the resident at a table with her meal and no silverware and walked away. At 8:41 AM there was still no other staff in the dining room assisting the residents consistently. The atmosphere was not relaxing as CNA C kept trying to meet the needs of all the residents. One staff member observed randomly entering the dining room and would randomly assist residents who did not require feeding assistance for approximately a few minutes at a time and leave the room. .

Based on observation, interview and record review, the facility failed to ensure medications were stored and administered according to professional standards, resulting in the potential for significant medication errors and clinically adverse consequences. Findings include: Review of the Medication Administration policy dated June 2019 revealed, B. Administration: 3. Medications are administered at the time they are prepared. Medications are not pre-poured in advance of the medication pass or for more than one resident at a time. During an observation and an interview on 1/10/24 at 9:35 AM, Licensed Practical Nurse (LPN) I had two medication cups with medications in them for two different residents in her hand. LPN I reported the one resident was not ready for his medications yet, so she put his name on the cup and placed it back into the locked medication cart and proceeded to the other resident's room to administer his medications. This surveyor told her when she was done with that medication pass, the next medication pass will need to be observed from the beginning. When LPN I came back to her medication cart, the top drawer had 4 medication cups with preset medications. She reported they were for R1, R2, R15 and R186. One cup had crushed medications that LPN I reported there were two different medications in that cup. She said one resident was still on his CPAP when she went to see if he wanted them and could not administer them, another resident was busy with the aides and could not give medications, and another resident told her he was not ready for his medications. When queried if she asks or checks on the residents to see if they are ready for their medications before she prepares them, LPN I reported it would take all day to give them their medications if she did that. In an interview on 1/10/24 at 3:08 PM, the Director of Nursing (DON) reported her expectations from the nurses are to not preset medications without administering them right after.

This citation pertains to intake M100137229 Based on interview and record review, the facility failed to operationalize policies and procedures and implement measures for a wandering resident to prevent falls, thoroughly investigate for root causes of falls, and implement meaningful interventions for 1 (Resident #2), resulting in a fracture of unknown origin. Findings Include: Review of a policy titled Fall Reduction last revised 4/23 revealed: Our residents have the right to be free from falls, or to sustain no or minimal injury from falls. 4. When any resident experiences a fall, the facility will: a. Assess the resident. B. Complete a Post-Fall Assessment. C. Complete a Risk Management Incident Report. E. Review the event and an interdisciplinary team. F. Implement (or revise) new fall prevention intervention (s). G. Obtain witness statement, as applicable. Review of a policy titled Abuse, Neglect and Exploitation last revised 6/23 revealed: It is the policy of this facility to provide protection 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. Neglect: means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Prevention: C. The facility will assure that residents are free from neglect by having the structures and processes to provide needed care and serviced to all residents . D. The facility will identify by ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect (i.e., . wandering, communication barriers, .) Resident #2 (R2) Review of a Face Sheet revealed R2 admitted to the facility on [DATE] with pertinent diagnoses of vascular dementia, repeated falls, fractured ribs, and anxiety disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed R2 was severely cognitively impaired and required supervision while ambulating independently with a walker. She required extensive assistance of one staff for toileting and limited assistance of one staff for eating. The resident's preadmission fall history was incomplete and documented since admission of having 2 falls with no injury, one fall with injury and one fall with a major injury. The resident no longer resides at the facility. Review of a Facility Reported Incident (FRI) for R2 revealed on 5/21/23 at 3:48 PM, the resident was heard crying from the hallway and the resident was observed with a golf ball sized bump on her head. The resident was agitated, and evident pain noticed in her left arm with movement. R2 was sent to the hospital. No statements from staff who provided care this day or who were in the building. She was toileted 45 minutes prior to the injury but did not report who assisted her. The 5-day report summary concluded: Resident ambulates independently with four wheeled walker, has poor judgement and poor impulse control and safety awareness. It can be concluded that the injury was the result of a fall. Resident has a history of falls and reason for admission was fractured ribs due to a fall. Review of a Progress note (late entry) dated 5/22/23 for R2 revealed: Event occurred on 5/19/23 at 7:42 AM. Resident was seen walking across room to bathroom When I caught up to her at bathroom door, she began to grab grab bar and slipped and slid down the door onto left hip. I could not catch her in time. She landed on her buttocks and left hip. Review of a Hospital Emergency Department document dated 5/21/23 for R2 revealed she had a closed displaced spiral fracture of shaft of left humerus (left upper arm) and a closed head injury. Timeline of behaviors and falls: Review of an incident report dated 4/13/23 at 5:51 AM for R2 revealed the resident was observed lying on the floor next to her bed. No staff interviews provided to know who saw her last or provided care for the resident before she fell . The post fall assessment says she was last toileted at 4:00 AM. She had wandering behaviors at the time she fell . Immediate intervention was frequent checks for 7 days while adjusting to new medication. The care plan did not reflect this change and no documentation indicating frequent checks were implemented or how often. Review of a Nursing Progress Note dated 4/16/23 at 6:30 PM for R2 revealed: Event occurred on 4/16/23 3:30 PM. Resident was observed sitting on her buttocks in room [ROOM NUMBER]. Physician and responsible party notified. No incident report or investigation provided. No changes to the Care Plan. Review of a Behavior Note dated 4/16/23 at 8:37 PM for R2 revealed the resident continues to cry non-stop and wandering into other resident's rooms and lying in their beds. Resident did have a fall this shift in room [ROOM NUMBER] with no injuries. Redirection is not effective. Review of a Behavior Note dated 4/19/23 at 7:07 AM for R2 revealed she was crying, wandering, and attempting to elope. Review of a Behavior Note dated 4/22/23 at 8:39 PM for R2 revealed: Resident had been wandering and entering other resident's room multiple times. Agitated; restless and crying. Hard to redirect. (As needed) Ativan given- not effective. Review of a Behavior Note dated 4/23/23 at 1:42 PM for R2 revealed: wandering, also entering other residents' rooms repeatedly, crying and whining. Redirection and Ativan given but not effective. Review of a Behavior Note dated 4/25/23 at 8:30 PM for R2 revealed she had been crying and wandering, entering other resident's room. causes disturbances to other residents. Review of a Behavior Note dated 4/26/23 at 12:53 PM for R2 revealed: Resident has spent a good portion of this shift wandering aimlessly around the facility, she was observed entering other resident's rooms. No harmful behaviors but disruptive to other residents. Review of an Incident report dated 4/26/23 at 8:15 PM for R2 revealed: Resident was seen sitting on the floor in her bedroom and leaning on her bed. She was tangled by her blanket with a cut at her left outer lateral eyebrow. She appeared agitated. No staff statements or post fall/ risk management assessment. No documentation of what staff provided care or when she was provided care or seen last. Review of Behavior Notes dated 4/27/23 at 10:54 PM for R2 revealed: Resident had been wandering and entering other residents' room multiple times. Kept on following staff, unable to follow direction. it causes disturbances to other residents who are sleeping. Review of Behavior Notes dated 5/9/23 at 4:15 PM for R2 revealed: Resident set door alarm off on East Hall. Continues to wander aimless and is exit seeking. Review of a Nursing Progress Note dated 5/9/23 at 4:25 PM for R2 revealed the facility left a message asking if a family member could come sit with the resident. Review of a Behavior Note dated 5/11/23 at 9:35 PM for R2 revealed she had been wandering and entering other resident rooms multiple times and hard to redirect. Review of a Behavior Note dated 5/12/23 at 12:51 AM and at 3:39 PM for R2 revealed she had been wandering and entering other resident rooms multiple times and hard to redirect. Review of a Social Services Progress Note Quarterly Review dated 5/15/23 for R2 revealed she had behaviors of wandering 39 times and exit seeking 7 times. Interventions include re-direction, offering things to do, trying to have her lay down and rest, (as needed) Ativan and Tylenol if wandering is related to pain. Interventions vary in effectiveness. Review of an Incident Report dated 5/19/23 at 7:25 AM for R2 revealed: Resident fell unassisted in her bathroom. The nurse observed the resident walking to the bathroom without her walker and ran to assist her. The resident missed the grab bar and fell to the floor on her left side while sliding down the door of the other room. She did not hit her head or injure herself. She was last toileted 5/18/23 at 8:30 PM. Review of a Behavior Progress note dated 5/20/23 at 10:50 PM for R2 revealed she had been wandering and set off the alarm in the east hall door. She had been entering other resident's rooms and is hard to follow simple commands. She was redirected, staff walked with her and offered her snacks. Review of a Practitioner Note dated 5/22/23 for R2 revealed Per nursing: event occurred on 5/19/23 7:42 AM. Resident was seen walking across room to bathroom. When I caught up to her at bathroom door, she began to grab grab bar and slipped and slid down the door onto left hip. I could not catch her in time. She landed on her buttocks and left hip. Another fall occurred on 5/21/23 with right arm weakness and pain. Per nursing, patient to right arm suspected fracture noted. Advised ED evaluation due to no immobility resources at the facility. She was ultimately admitted for spiral fracture with surgery coming up. In an interview on 8/17/23 at 11:21 AM, the Nursing Home Administrator in Training and the Director of Nursing (DON) reported R2 did have excessive wandering and exit seeking behaviors. She walked fast with her walker. At odd times at night staff would just find her on the floor. She needed to be in a safer setting. She hit 4 doors in one day in a short time. The DON reported she just did some staff education for falls and did a fall audit to make sure staff are documenting accordingly. The incident on 4/13/23, R2 was typically steady on her feet and just implemented monitoring of her blood pressures. No care plan intervention was done. The 4/26/23 incident, the nurse did a progress note about the fall, but no post fall risk management documentation was done. The resident was in bed with a weighted blanket on that the family wanted her to use and she had her shoes on and tried to get out of bed and got wrapped up in the blankets. The DON did not see documentation when the resident was last seen or cared for prior to this incident and if the post fall assessment was done it would have been documented in it. The Care Plan implemented a fall mat at the bedside on 4/27/23. The incident on 5/19/23, the DON said the nurse was a new nurse and acknowledged she documented the fall on 5/22/23 which was 3 days later. When queried about how she remembered her vital signs 3 days later, she did not know and said she was educated about it. When queried about no documentation of the resident not being seen or supervised from 5/18/23 at 8:30 PM to 5/19/23 at 7:25 AM, the DON agreed that the documentation did not reflect the supervision or care provided for the resident. On 5/21/23 when the resident was found in her room at 3:48 PM, the DON verified that a post fall investigation or risk assessment was not completed. The NHA in training reported that their standards of care require staff to typically do checks on residents every 2 hours. Review of the Care Plan for R2 revealed a Fall/wandering Focus initiated 12/26/22 included to review information on past falls and attempt to determine cause of falls. Record possible root causes and remove any potential causes as applicable. New interventions on 4/27/23 for a floor matt next to the bed and on 4/14/23 to monitor vital signs for 4 days to rule out hypotension. The Follow my scheduled toileting program was resolved on 3/6/23.

Based on observation, interview, and record review, the facility failed to provide adequate nursing staffing to provide 1 Resident (R202) with care as needed, resulting in R202 sitting in urine past the standard 2-hour check and change and experiencing discomfort and potential for skin breakdown. Findings include: Review of R202's face sheet dated 9/28/23 revealed she was a [AGE] year old female admitted to the facility on [DATE] and had diagnoses that included: Schizoaffective disorder, epilepsy, chronic pain, anoxic brain damage (loss oxygen causing brain damage), aphasia (loss of the ability to understand or express speech caused by brain damage), bipolar disorder, anxiety disorder and muscle weakness, R202 was not her own responsible party and was currently in hospice care. On 9/28/23 at 12:35 PM R202 was up in her chair at the Nurse's Station and Registered Nurse (RN) E was feeding her ice cream. R202 was asked if she liked ice cream and she did not respond. R202 began sliding and lifting her buttock off the seat of her chair. R202 did not respond to questions of did she have pain or did her bottom hurt. RN E was asked if he saw her buttock or skin today and he responded, No. When asked how long she had been up in the chair and when she had last been changed, he responded, she had been up in her chair since she fell out of bed this morning and he was not sure when her brief had last been changed. R202 than began yelling she wanted her bottom checked. On 9/28/23 at 12:45 PM, RN E and Certified Nurse Aide (CNA) F transferred R202 back to bed with a canvas full body sling and an electronic lift. When R202 was lifted out her chair the canvas sling that had been in the chair was wet over the entire bottom and up past both hips. Her sweatpants and brief were totally saturated. CNA F said she had not provided any care for R202 today and thought CNA G had provided care. During an interview with CNA G on 9/28/23 at 1:05 PM, she confirmed she did R202's morning care around 9:00 AM and changed her incontinent brief at that time. CNA G said R202 wanted to get up at that time but someone else needed assistance to get another resident out of bed so she left and R202 fell before she could get back to her to assist her out of bed. CNA G said she did not change R202 since prior to the fall that morning. CNA G said 2 CNA's called in and she and CNA F were assigned to all 35 residents. CNA G said the nurses and other staff were assisting when they could, but she had not had time to get back to do incontinence care with R202. During an interview with the Nursing Home Administrator (NHA) on 9/28/23 at 2:00 PM, the Surveyor reported the observation and interviews that R202 had not received her incontinence care for the greater than 3 hours today and was found soaked in urine. The NHA said she would start investigating and verifying all residents were getting the care they needed. During an interview with UM (Unit Manager) B on 9/28/23 at 2:45 PM, UM B was asked who the CNA was that was assigned to R202 today. UM B said they had 2 CNA's call in and when that happens, she went to the nurse's station and pulled a resident list by room off the board. All but 3 residents listed were highlighted in yellow or green. R202 was in the yellow group. The yellow group had 16 residents and there were 3 residents that were not assigned to either group. UM B was not sure which CNA had the yellow group today. During an interview with the NHA at 3:45 PM the NHA confirmed that she spoke with the scheduler and there was confusion as to who was providing care for R202 and other residents. The NHA said the scheduler was a CNA and they had a driver that was also a CNA, both were doing some care, however, there was confusion as to who was responsible for which residents' care. The NHA said the driver had to leave and the scheduler was also doing her job duties along with assisting with care when she could.

Based on observation, interview, and record review, the facility failed to provide adequate nursing staffing to provide 1 Resident (R202) with care as needed, resulting in R202 sitting in urine past the standard 2-hour check and change and experiencing discomfort and potential for skin breakdown. Findings include: Review of R202's face sheet dated 9/28/23 revealed she was a [AGE] year old female admitted to the facility on [DATE] and had diagnoses that included: Schizoaffective disorder, epilepsy, chronic pain, anoxic brain damage (loss oxygen causing brain damage), aphasia (loss of the ability to understand or express speech caused by brain damage), bipolar disorder, anxiety disorder and muscle weakness, R202 was not her own responsible party and was currently in hospice care. On 9/28/23 at 12:35 PM R202 was up in her chair at the Nurse's Station and Registered Nurse (RN) E was feeding her ice cream. R202 was asked if she liked ice cream and she did not respond. R202 began sliding and lifting her buttock off the seat of her chair. R202 did not respond to questions of did she have pain or did her bottom hurt. RN E was asked if he saw her buttock or skin today and he responded, No. When asked how long she had been up in the chair and when she had last been changed, he responded, she had been up in her chair since she fell out of bed this morning and he was not sure when her brief had last been changed. R202 than began yelling she wanted her bottom checked. On 9/28/23 at 12:45 PM, RN E and Certified Nurse Aide (CNA) F transferred R202 back to bed with a canvas full body sling and an electronic lift. When R202 was lifted out her chair the canvas sling that had been in the chair was wet over the entire bottom and up past both hips. Her sweatpants and brief were totally saturated. CNA F said she had not provided any care for R202 today and thought CNA G had provided care. During an interview with CNA G on 9/28/23 at 1:05 PM, she confirmed she did R202's morning care around 9:00 AM and changed her incontinent brief at that time. CNA G said R202 wanted to get up at that time but someone else needed assistance to get another resident out of bed so she left and R202 fell before she could get back to her to assist her out of bed. CNA G said she did not change R202 since prior to the fall that morning. CNA G said 2 CNA's called in and she and CNA F were assigned to all 35 residents. CNA G said the nurses and other staff were assisting when they could, but she had not had time to get back to do incontinence care with R202. During an interview with the Nursing Home Administrator (NHA) on 9/28/23 at 2:00 PM, the Surveyor reported the observation and interviews that R202 had not received her incontinence care for the greater than 3 hours today and was found soaked in urine. The NHA said she would start investigating and verifying all residents were getting the care they needed. During an interview with UM (Unit Manager) B on 9/28/23 at 2:45 PM, UM B was asked who the CNA was that was assigned to R202 today. UM B said they had 2 CNA's call in and when that happens, she went to the nurse's station and pulled a resident list by room off the board. All but 3 residents listed were highlighted in yellow or green. R202 was in the yellow group. The yellow group had 16 residents and there were 3 residents that were not assigned to either group. UM B was not sure which CNA had the yellow group today. During an interview with the NHA at 3:45 PM the NHA confirmed that she spoke with the scheduler and there was confusion as to who was providing care for R202 and other residents. The NHA said the scheduler was a CNA and they had a driver that was also a CNA, both were doing some care, however, there was confusion as to who was responsible for which residents' care. The NHA said the driver had to leave and the scheduler was also doing her job duties along with assisting with care when she could.

This citation pertains to intake MI000131812 Based on observation, interview, and record review, the facility Governing Body failed to meaningfully engage in operational oversight of the facility to ensure all residents residing in the facility attained/maintained their highest practicable well-being as evidence by: 1.) failed to ensure a sufficient number of competent and qualified licensed nurses, nurse aides, and other nursing personnel to provide quality care and meet the resident's needs, 2.) failed to provide adequate resources to the facility to ensure resident safety when the Fire Monitoring System was disconnected due to non-payment unbeknownst to facility administration, and 3.) failed to ensure corporate policies and the Facility Assessment were reviewed, revised, and implemented to manage operations in the facility. This deficient practice resulted in the mismanagement of the facility, inadequate and incompetent direct care staff, and the potential for serious adverse physical, mental, and psychosocial harm for all residents residing in the facility. Findings: During an interview on 1/20/2023 at approximately 11:00 AM, the Nursing Home Administrator (NHA) reported the facility learned the fire alarm system was not communicating with the security/monitoring company when a routine fire drill was conducted on 10/27/2022. The reason for the system failure was due to non-payment to the fire monitoring/security company and was not known prior to the fire drill. According to the NHA, corporate accounts payable (AP) has been having issues with timely bill payment. When asked, the NHA said the cable television was shut off for approximately 3 days over the holiday season, confidential information/document shredding service was not paid timely in the past, trash removal was an issue in July 2022 and a supply company account was inaccessible until the day prior (1/19/2023) due to non-payment, making purchases of needed equipment and parts impossible. According to the NHA, a transportation company account was not paid timely which put residents who required transportation to outside appointments/dialysis at risk for missing critical access to services. The NHA reported that the AP manager was difficult to communicate with and in order to get financial matters resolved she would call or email COO L who would handle the matter. During an interview on 1/24/2023 at 8:52 AM, Chief Operating Officer (COO) L reported that the corporate body switched Accounts Payable systems 7-8 months ago due to recognition of the former accounting system not working. COO L reported that now all invoices are sent to a system that each facility administrator approves expenses and checks are cut according to terms of the contracts with each vendor. COO L emphasized that individual NHA administrators throughout the corporation have no direct control over AP other than to approve/validate expenses. It was identified during the onsite survey that the Governing Body, required to be involved in the Facility Assessment, did not ensure the Facility Assessment was comprehensive, accurate, complete, and implemented which resulted in the following deficiencies: 1. Based on observation, interview, and record review, the facility failed to ensure a sufficient number of competent staff to provide care and respond to each resident's basic needs and individual needs as required by the resident's diagnoses, medical condition, and plan of care. (Refer to noncompliance cited at F725-Sufficient Nursing Staff) 2. Based on observation and interview the facility failed to keep kitchen equipment in a state of repair that would allow for regular use and operation of the machines. (Refer to noncompliance cited at F908-Essential Equipment in Safe Operating Condition). 3. Based on interview and record review, the facility failed to ensure a fire monitoring system was functional for 15 days (10/25/2022-11/09/2022) without a report to the State Agency and without a Fire Watch implemented. (Refer to noncompliance cited at F689-Free of Accident Hazards/Supervision/Devices). It was identified during the onsite survey that the Governing Body, aware of the staffing concerns at the facility, failed to provide resources to ensure a sufficient number of Administrative/Managerial Nursing staff to 1.) monitor nursing staff for compliance with nursing standards of practice (medication administration, documentation) and complete evaluations, 2.) oversee and supervise development and delivery of in-service education, 3.) ensure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services and 4.) ensure the ICP (Infection Control Preventionist) had the time necessary to properly assess, develop, implement, monitor, and manage the Infection Prevention and Control Program resulting in the following deficiencies: 1. Based on interview and record review, the facility failed to complete a Comprehensive Significant Change Minimum Data Set (MDS) assessment for 1 resident (Resident #7) and failed to accurately complete Minimum Data Set (MDS) assessments for 1 resident (Resident #9). (Refer to noncompliance cited at F637-Comprehensive Assessment After Significant Change and F641-Accuracy of Assessments). 2. Based on interview and record review, the facility to ensure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs, resulting in medication errors for Resident #9, #14, #30, #17, #15, and #20 and incomplete/inaccurate medical records for R15. (Refer to noncompliance cited at F658-Services Provided Meet Professional Standards, F726-Competent Nursing Staff, and F842-Resident Records). 3. Based on interview and record review, the facility to implement an effective and current system of surveillance of resident and staff illnesses to identify possible communicable diseases and infections for all residents and staff to prevent the spread of an illness/outbreak and failed to ensure a complete and accurate outbreak investigation for a COVID-19 outbreak and document follow-up activity in response to the outbreak. (Refer to noncompliance cited at F880-Infection Prevention and Control).

Based on observation, interview, and record review, the facility failed to ensure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs, resulting in medication errors, and the potential for residents to receive inadequate care, ongoing medication errors, and to not attain or maintain their highest practicable level of physical, mental, functional and psychosocial well-being. Findings: Review of the facility Certified Nurse Aide (CNA) Position Summary last revised [DATE] revealed, .Required/Desired Qualifications: Education, Training, and Experience: Must possess a current Michigan Certified Nurse Aide Certification or have completed a Michigan approved CNA training program and are eligible to test. Must be certified within 4 months of hire . Review of the facility Initial Competency Checklist-Certified Nurse Aide (no date) revealed, This checklist outlines the information the employee needs to know to perform the responsibilities of the position of Certified Nurse Aide. As each item is completed, both the person providing orientation and the new employee should write their initials and the date in the space provided .This checklist should be signed by the employee and by the instructor and turned into Human Resources before working on the floor alone . Review of the facility Charge Nurse RN (Registered Nurse) Position Summary last revised [DATE] revealed, .Principal Duties and Responsibilities .Administer medications to residents according to the Public Health Code, Nursing Department Policies, and standards and procedures and as prescribed by the physician; notify appropriate clinical and/or nursing personnel of medication contraindications .Required/Desired Qualifications: Education, Training, and Experience .CPR (Cardio Pulmonary Resuscitation) certification required . Review of the facility Initial Competency Checklist-Certified Nurse Aide (no date) revealed, This checklist outlines the information the employee needs to know to perform the responsibilities of the position of Charge Nurse RN. As each item is completed, both the person providing orientation and the new employee should write their initials and the date in the space provided .This checklist should be signed by the employee and by the instructor and turned into Human Resources before working on the floor alone . During an interview on [DATE] at 01:32 PM, Director of Nursing (DON) reported that she was the Staff Educator for the facility. DON reported that during direct care and licensed staff evaluations, areas for improvement are identified and is what drives the yearly education and the education provided during the mandatory monthly meetings. DON reported that beginning January of 2023, licensed nurses were required to attend the monthly meetings. DON reported that mandatory monthly meetings were not yet required for CNAs. During an interview on [DATE] at 10:47 AM, [NAME] President of Human Resources (VPHR) J reported that new hire Initial Competency Checklists were completed by DON. VPHR J reported that because this is a smaller facility the DON was to observe the skills and sign off on each of the items listed in the Initial Competency Checklist for the licensed nurses and direct care staff and submit the completed form to the Human Resources Coordinator. During an interview on [DATE] at 10:34 AM, Human Resources (HR) F reported that she took over as the facility HR Coordinator in [DATE] (hire date [DATE]). HR F reported the previous HR Coordinator had left in July or [DATE] and the Regional/Corporate HR Coordinator was responsible for HR duties prior to HR F's hire. HR F reported she was left with a mess when she hired in (Initial Competency Checklist unavailable, CPR certification expired, missing education). HR F reported that she was working on ensuring all required certifications for licensed nurses were up to date and completed an audit on Friday ([DATE]) ensuring all licensed nurses and CNAs had active licenses/certifications. During an interview on [DATE] at 11:26 AM, HR F reported that DON signs off on all Initial Competency Checklists to ensure the new employees have met the requirements and then turns the completed Initial Competency Checklist to the facility's HR department to keep in the employee file. HR F reported that the Initial Competency Checklist is to be completed within 30 days of hire and reported it did not need to be completed prior to working independently/off orientation. The following employee files were reviewed with HR F at this time: RN E, CNA C, Non-Certified Nurse Aide (NCNA) D, RN U, CNA V, and RN A. Review of CNA C's employee filed revealed a hire date of [DATE]. CNA C did not have an Initial Competency Checklist on file to ensure CNA C had the knowledge and skills required to provide resident care. Review of the Staffing Schedule and Nursing Department Daily Staffing revealed CNA C was not on orientation and worked independently on [DATE], [DATE], [DATE], and [DATE]. Review of NCNA D's employee file revealed a hire date of [DATE]. NCNA D completed Abuse/Neglect training on [DATE] (nearly 5 months after hire). HR F reported no additional Abuse/Neglect education completed prior to [DATE] was available in NCNA D's employee file (indicating it was not completed upon hire). NCNA D did not have an Initial Competency Checklist on file to ensure NCNA D had the knowledge and skills required to provide resident care and did not have an active CNA certification (as of [DATE]). NCNA D was not eligible to work as of [DATE] (per NHA). Review of the Staffing Log and the Nursing Department Daily Staffing revealed NCNA D worked the following shifts in the capacity of a CNA on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of RN U's employee file revealed a hire date of [DATE]. RN U did not have an Initial Competency Checklist on file to ensure RN U had the knowledge and skills required to provide nursing care. Review of the Staffing Schedule and Nursing Department Daily Staffing from [DATE] to present revealed RN U was not on orientation and worked independently as an RN. Review of RN E's employee file revealed a hire date of [DATE]. RN E did not have a current CPR certification and did not have an Initial Competency Checklist on file to ensure RN E had the knowledge and skills required to provide nursing care. The RN Initial Competency Checklist includes an evaluation of Medication Administration and Reporting Systems (physician notification). Review of the Staffing Schedule and Nursing Department Daily Staffing from [DATE] to present revealed RN E was not on orientation and worked independently as an RN. (HR F verified that RN E did not have a current CPR certification). Review of RN A's employee file revealed an Employee Counseling Notice (write-up) dated [DATE] which revealed, Violation Date [DATE] .(RN A) did not follow orders as written for end of life comfort and did not document reason or notify hospice why medications were held .Resident fell later that day, possible root cause end of life restlessness not managed as ordered .(RN A) will follow doctor's orders as written and if have any concerns r/t (related to) orders or holding medications. Document notification of provider medications held .educated nurses on end of life medication s/s (signs and symptoms) of pain in dementia residents-notification of providers if med held .Follow Up Date (blank) .(RN A refused to sign the counseling notice). No documentation that Previous DON or current DON had completed a follow-up evaluation/medication administration competency after the identified medication administration error. Review of Resident #14, #30, #15, #9 and #20's December and January Medication Administration Records (MAR) reflected multiple medication administration errors (administering expired insulin, withholding medications without a physician order, and/or giving medications outside of physician ordered parameters) committed by RN A and RN E. (Refer to noncompliance cited at F658-Services Provided Meet Professional Standards related to medication administration.) Review of the Facility Assessment last revised/reviewed [DATE] revealed, .Staff training/education and competencies 3.4. (Healthcare training company name omitted) online learning system is used to track and provide all annual educations to facility staff at all levels, consistent with their roles. All departments as well as contracted services and volunteers receive abuse training on hire and annually. Licensed nurses receive annual skills check to verify clinical competencies . The Facility Assessment did not include a competency-based approach for Certified Nurse Aides to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. The Facility Assessment did not include or address an evaluation of the facility's training program to ensure training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles.

This citation has 2 Deficient Practice Statements (DPS) DPS 1 Based on interview and record review, the facility failed to ensure a sufficient number of Administrative/Managerial Nursing staff to 1.) monitor nursing staff for compliance with nursing standards of practice (medication administration, documentation) and complete evaluations, 2.) oversee and supervise development and delivery of in-service education, 3.) ensure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services and 4.) ensure the ICP (Infection Control Preventionist) had the time necessary to properly assess, develop, implement, monitor, and manage the Infection Prevention and Control Program. Findings: Director of Nursing Duties During an interview on 01/20/23 at 12:54 PM, Director of Nursing reported that she had assumed the DON role in October 2022. DON reported that she was the facility Wound Care Nurse and was responsible for weekly monitoring of wounds which included documentation of wound measurements, characteristics, and treatment decisions and ensuring treatment changes were reflected in the resident Treatment Administration Record. DON reported that if a resident wasn't being followed by the contracted wound consultants, she would consult with the facility provider and make treatment changes as need. DON reported she was not Wound Care Certified. DON reported that she was the Infection Control Preventionist for the facility. DON was responsible for surveillance (system for prevention, identifying, reporting, investigating, and controlling infections diseases for residents, staff, volunteers, and visitors), implementing isolation protocols, antibiotic stewardship (monitoring antibiotic use in the facility), resident/family/staff infection control education, and the immunization (flu/pneumonia/Covid) program for staff and residents. DON reported that Unit Manager (UM) V was working on becoming Infection Control certified to assist with the Infection Control Program duties, but had not yet completed the training. During an interview on 01/20/23 at 01:32 PM, DON reported that there was a recent change with the MDS Nurse (Minimum Data Set is a core set of screening, clinical & functional status elements that forms the foundation of the comprehensive assessment) and the new MDS Nurse's first day is today. DON reported that she was responsible for the in-person resident interviews in relation to the MDS assessments. DON reported that she was accountable for the oversight of the resident MDS assessments as well as ensuring that resident Care Plans were reviewed, revised, and implemented. DON reported that because of the licensed nurse shortage at the facility, she also worked as the direct care nurse when there were no other licensed nurses to cover a shift. Review of the January 2023 Staffing Schedule revealed the DON worked the following shifts: (1st shift) 1/6/23 and 1/9/23 (2nd shift) 1/3/23, 1/12/23, 1/16/23, 1/21/23, 1/22/23, and 1/23/23 During an interview on 01/20/23 at 01:32 PM, DON reported that she was the Staff Educator for the facility. DON reported that during direct care and licensed staff evaluations, areas for improvement are identified and is what drives the yearly education and the education provided during the mandatory monthly meetings. During an interview on 01/24/2023 at 11:26 AM, HR F reported that DON signs off on all Initial Competency Checklists to ensure the new employees have met the requirements and then turns the completed Initial Competency Checklist. During an interview on 01/24/2023 at 10:47 AM, [NAME] President of Human Resources (VPHR) J reported that new hire Initial Competency Checklists were completed by DON. VPHR J reported that because this is a smaller facility the DON was to observe the skills and sign off on each of the items listed in the Initial Competency Checklist for the licensed nurses and direct care staff and submit the completed form to the Human Resources Coordinator. VPHR J reported that weekly meetings were held to discuss staffing needs for all Mission Point facilities, and they had been working at the corporate level to fill these holes with the focus on CNA and licensed nurse positions. VPHR J reported that staffing needs were identified at the facility. VPRH J reported that the DON duties varied based on the facility census and the facility budget. VPHR J reported there was no designated Corporate/Regional Wound Care Nurse, Staff Educator, or MDS Nurse. VPHR J reported that the Regional/Corporate Nurse would educate on Infection Control and changes made with policies and procedures, however, there was no designated Regional/Corporate Infection Preventionist. Confirming that DON simultaneously served as the Director of Nursing, Infection Control Preventionist, Wound Care Nurse, Staff Educator (including new hire orientation competency evaluation), MDS oversight (including resident Care Plan revision and implementation), and as a direct care nurse. It was identified during the onsite survey that the facility did not ensure there were sufficient administrative and/or managerial staff which resulted in the following deficiencies: 1. Failed to complete a Comprehensive Significant Change Minimum Data Set (MDS) assessment for 1 resident (Resident #7) and failed to accurately complete Minimum Data Set (MDS) assessments for 1 resident (Resident #9). (Refer to noncompliance cited at F637-Comprehensive Assessment After Significant Change and F641-Accuracy of Assessments). 2. Failed to ensure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs, resulting in medication errors for Resident #14, #30, #15, #9 and #20 and incomplete/inaccurate medical records for R15. (Refer to noncompliance cited at F658-Services Provided Meet Professional Standards, F726-Competent Nursing Staff, and F842-Resident Records). 3. Failed to implement an effective and current system of surveillance of resident and staff illnesses to identify possible communicable diseases and infections for all residents and staff to prevent the spread of an illness/outbreak and failed to ensure a complete and accurate outbreak investigation for a COVID-19 outbreak and document follow-up activity in response to the outbreak. (Refer to noncompliance cited at F880-Infection Prevention and Control). 4. Failed to 1.) ensure a complete and comprehensive assessment was completed .3.) determine staff training, education, and competencies required to care for residents in the facility, and 4.) ensure the facility assessment was reviewed annually and updated to reflect administrative staff. (Refer to noncompliance cited at F838-Facility Assessment). Review of the State Operations Manual revealed, IP (Infection Preventionist) Hours of Work- Designated IP hours per week can vary based on the facility and its resident population. Therefore, the amount of time required to fulfill the role must be at least part-time and should be determined by the facility assessment, conducted according to S483.70(e), to determine the resources it needs for its IPCP, and ensure that those resources are provided for the IPCP to be effective. Based upon the assessment, facilities should determine if the individual functioning as the IP should be dedicated solely to the IPCP. A facility should consider resident census as well as resident characteristics, types of units such as respiratory care units, memory care, skilled nursing and the complexity of the healthcare services it offers as well as outbreaks and seasonality of infections such as influenza in determining the amount of IP hours needed. The IP must have the time necessary to properly assess, develop, implement, monitor, and manage the IPCP for the facility, address training requirements, and participate in required committees such as QAA. Review of the facility policy Antibiotic Stewardship Program last reviewed/revised December 2020 revealed, .1. The Infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the Antibiotic Stewardship Program: a. Infection Preventionist-coordinates all antibiotic stewardship activities, maintains documentation, and serves as a resource for all clinical staff. b. Director of Nursing-serves as back up coordinator for antibiotic stewardship activities, provides support and oversight, and ensures adequate resources for carrying out the program . Review of the facility policy Infection Prevention and Control Program last reviewed/revised December 2020 revealed, .6. Antibiotic Stewardship .The Infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the antibiotic stewardship program . Review of the facility Director of Nursing job description dated 4/27/20 revealed, .Principal Duties and Responsibilities: *Responsible for ensuring proper Policies, Procedures, and Protocols for care are in place to include the entire nursing process (assessment, plan, implementation, and follow up) for use of antibiotics in the care of the residents. The role of the DON includes adequate education and monitoring to ensure the process is implemented, communication, evidence-based standards of practice vs perceptions, and expectations of staff in their respective roles. *Develops, maintains, and implements nursing policies and procedures that conform to current standards of nursing practice, facility philosophy, and operational policies while maintaining compliance with state and federal laws and regulations. *Communicates and interprets policies and procedures to nursing staff, and monitors staff practices and implementation. *Participates in all admission decisions and may visit prospective residents before admission to assess overall health status. *Participates in daily or weekly management team meetings to discuss resident status, census changes, personnel, or resident complaints or concerns. *Evaluates the work performance of all nursing personnel, assists in the determination of wage increases, and implements discipline according to operational policies. *Ensures delivery of compassionate quality care and nursing supervision as evidenced by adequate services and staff coverage on unit, absence of odors, general cleanliness, prevention of pressure wounds, and apparent maintenance of optimal resident functions. *Demonstrates knowledge of and application of Key Clinical Quality Indicators, and proactively monitors and implements systems to achieve and/or surpass company thresholds. *Exercises overall supervision of resident assessments and care plans. Assures resident care conferences are conducted. *Reviews 24-hour report from every unit daily to monitor and ensure timely, effective responses to significant changes in condition, transfers, discharges, use of restraints, unexplained injuries, falls, behavioral episodes, and medication errors. *Collaborates with physicians, consultants, community agencies, and institutions to improve the quality of services and to resolve identified problems. *Coordinates nursing services with all other departments including Therapy and Pharmacy consultants. *Oversees nursing schedules to assure they meet resident needs and regulatory and budgetary standards. *Oversees and supervises development and delivery of in-service education to equip nursing staff with sufficient knowledge and skills to provide compassionate, quality care and respect for resident rights. *Proactively develops positive employee relations, incentives, and recognition programs. Promotes teamwork, mutual respect, and effective communication. *Performs rounds to observe care and to interview staff, residents, families or other interested parties. *Monitors staff for compliance with OSHA mandates and facility policies on workplace safety. *Proactively develops procedures and incentives to promote workplace safety and safe work practices. *Establishes, implements, and monitors the infection control program designed to provide a safe, sanitary, and comfortable environment designed to prevent the development and transmission of disease and infection. *Prepares or reviews infection control surveillance reports to identify trends and to develop effective actions to control and prevent infections. Submits an infection control report to the QA Committee. *Participates in budget development for the nursing department, and for medical, nursing, and central supplies. Assures nursing staff properly charges out ancillaries used. *Helps the Administrator prepare staff for inspection surveys, instructing staff on matters of conduct and disclosure, being interviewed by inspectors, immediate corrections of problems noted by surveyors, etc. *Reviews and reinforces important standards previously cited. *Participates in the preparation of the Plan of Correction response to an inspection survey and implements any follow-up QA required for any nursing allegations. *Communicates directly with residents, families, medical staff, nursing staff, interdisciplinary team members, and Department Heads to coordinate care and services, promote participation in care plans, and maintain a high quality of care and life for residents. *Promotes customer service and hospitality and responds to and adequately resolves complaints or concerns from residents or families about nursing services. *Monitors facility incidents and complaints daily to identify those defined as unusual occurrences by State policy and promptly reports such occurrences to Administrator for appropriate action. *Monitors complaint reports daily for allegations of potential abuse or neglect, or the loss or misappropriation of resident property, and participates in these investigations. *Promotes compliance with accident prevention procedures, safety rules, and safe work practices to prevent employee injury and illness and control worker's compensation costs. *Responsible for surveillance, infection definition based on standards of practice, education, tracking, data management, analysis of data, communication with the Medical Director and Consultant Pharmacist, and ongoing system review. *Responsible for ensuring proper Policies, Procedures, and Protocols for care are in place to include the entire nursing process (assessment, plan, implementation, and follow up) for use of antibiotics in the care of the residents. The role of the DON includes adequate education and monitoring to ensure the process is implemented, communication, evidence-based standards of practice vs perceptions, and expectations of staff in their respective roles. *Assures staff is trained in fire and disaster and other emergency procedures and evaluates performance during drills. *Acts in an administrative capacity in the absence of the Administrator. *Conduct staff meetings and in-services as requested. *Answer incoming calls when necessary and direct calls appropriately. *Assists in the dining room during assigned meals. *Perform other tasks as required . DPS 2 Based on observation, interview, and record review, the facility failed to ensure a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs and individual needs as required by the resident's diagnoses, medical condition, and plan of care, resulting in the potential for staff burnout, neglect, unmet care needs, and serious adverse physical, mental, and psychosocial harm. This deficient practice has the potential to affect all residents residing in the facility. Findings: Facility Assessment During an interview on 01/20/2023 at 9:11 AM, NHA reported that based on the Facility Assessment and the resident acuity level, the Certified Nursing Assistant (CNA) to resident ratio should be 1:10 to 1:12 (1 CNA for 10-12 residents) and a ratio of 1:8 would be ideal. NHA reported that staffing 3 CNAs on 1st shift, 2.5 CNAs on 2nd shift, and 2 CNAs on 3rd shift is the goal. NHA reported that the facility is not consistently staffed based on the Facility Assessment staffing plan. Review of the Facility Assessment last reviewed/revised on 10/26/22 revealed: Staffing plan 3.2. Our facility is relatively small in size making the staffing plans unique to ensure appropriate staffing is provided to meet the needs of all patients. The table listed below describes the basic facility staffing needs required to care for patients within our average census patterns. In relation to direct care staffing of nurses and nursing assistants, we staff with consideration of our daily census and flex staff up or down in relation to patient acuity. Our facility uses a basic guideline as below in relation to direct care staffing. Adjustments are made in relation to acuity and census. Licensed Nurses (LN): RN, LPN providing direct care- DON (Director of Nursing): 1 DON RN (Registered Nurse) full-time Days Clinical Care Coordinator/MDS: 1 RN full-time days RN or LPN (Licensed Practical Nurse) Charge Nurse: 2 for each shift am, pm, 1 nurse noc (night) shift 1:x 17 ratio Days and Evenings 1:x 35 ratio Nights An RN is scheduled 8/24 hours daily to meet the RN coverage requirement. Certified Nurse Aide (CNA): providing direct care- 1:8 ratio Days (total licensed or certified) 1:12 ratio Evenings 1:15 ratio Nights These numbers are baselines and are adjusted as needed in relation to patient acuity. During an interview on 1/20/2023 at 9:18 AM, the NHA reported that Corporate was aware of the staffing concerns at the facility but would not approve the use of agency CNAs and licensed nurses. 29073 During a confidential group interview on 1/18/2023 at 10:37 AM, 3 of 8 participants reported they feel like staffing at the facility could be improved. According to the residents, the facility counts the nurse in its staffing considerations but believe the nurse does not have time to answer call lights. Residents reported that the facility can't keep staff and that the afternoons are the worst time of day for call light response times. Residents reported having to wait for an hour and up to an hour and a half for staff to meet their needs. Residents reported staff are good about leaving the call light on until their need can be met. Residents also reported that there are not enough staff working in the kitchen. Review of Resident Council Meeting Minutes from August 2022 to December 2022 reflected the residents reported concerns with staff call light response times on the second shift during meetings held in September, October and November. In September 2022 residents specifically reported wanting more than one nurse aide on each hall. During an interview on 1/19/2023 at 7:50 AM, Staff R reported that one nurse is not enough for 33 (census at the time of the interview) residents. Staff R said they had a hard time getting treatments done and have to stay late. Staff R said Certified Nurse Aides (CNA's) are mandated frequently and it causes burnout and the facility does not use agency staff due to cost. During an interview on 1/19/2023 at 8AM, Staff S reported that there are only 2 CNAs on duty today (day shift), This is not enough help, the majority of residents are two person assist. Staff S said a shower needed to be completed later in the day and that would leave 1 CNA and 1 nurse to attend to residents. Review of a Resident Roster dated 1/19/2023 provided by the facility identified 15 of 33 residents required 2 people for transfers. When asked, the Nursing Home Administrator (NHA) reported that 3 residents were totally dependent on staff for feeding assistance. Review of PBJ (Payroll Based Journal) Staffing Data Report [NAME] Data Report 1705D FY (Fiscal Year) Quarter 4 2022 (July 1 - September 30) run on 1/5/2023 reflected the facility triggered for One Star Staffing Rating and Excessively Low Weekend Staffing. The staffing data report is used to identify areas requiring follow-up during the survey. During an interview on 1/20/2023 at 9:18 AM the NHA reported that she was not aware the facility had triggered for exceptionally low weekend staffing. According to the NHA, the facility did a bed reduction plan to decrease staff to resident ratios by 5 beds from July-December 2022. The NHA said the facility is running one CNA short for the first shift and one licensed nurse (RN/LPN) short for second shift. During a telephone interview on 1/24/23 2:25 PM Staff T reported a lot of staff are burned out. Staff T said that 3rd shift CNA's are not mandated like 1st and 2nd shift staff. Staff T said there are only two CNA's typically during days and that is not enough; on weekends there are only 3 staff-2 CNA's and 1 nurse and no management on duty to help take care of patients. Staff T said that they have been told by management over and over again that agency cannot come in to help and when staff do ask management for help with passing trays they don't come out and pass trays. According to Staff T, with two aides and one nurse on floor there is not enough people to look after wandering residents,It's unsafe for them (residents) and unsafe for us.

This citation pertains to intake MI000131812 Based on interview and record review, the facility failed to ensure a fire monitoring system was functional for 15 days (10/25/2022-11/09/2022) without a report to the State Agency and without a Fire Watch implemented, resulting in the potential for serious harm, injury and/or death from smoke and fire. Findings: Review of a fire monitoring system audit/activity report for the date range 1/01/2022-1/24/2022 reflected the following: 10/20/22 at 14:11:31 (3:11:31 PM) Account was set inactive on 10/20/2022 out of service-pending cancellation 14:11:33 (3:11:33 PM) Audit details for Subscriber Information ACTIVATE FLAG CHANGED FROM Y (Yes) to N (No) Out of Service - Pending Cancellation Inactive date changed from (space left blank) to 10/20/2022 10/21/22 at 12:31:26 From: (email address of employee at fire monitoring company); Reply to: no-reply@ (name of fire monitoring company); To: (email address of employee at fire monitoring company); Subject: CANCEL; Message:; Attachment: email12210211230.doc 7279 bytes. 10/25/2022 at 10:55:37 AM Account number changed to CANCxxxxx (cancelled/account number). Further review of the report reflected 11/09/22 16:19:36 (4:19 PM) Account was set Active on 11/09/22. During an interview on 1/20/2023, the Nursing Home Administrator (NHA) reported the facility learned the fire alarm system was not communicating with the security/monitoring company when a routine fire drill was conducted on 10/27/2022. The reason for the system failure was due to non-payment to the fire monitoring/security company and was not known prior to the fire drill. The NHA reported she did not call the State Agency to report the outage and a Fire Watch was not implemented nor was she directed to do so by corporate environmental services staff. Review of an educational document (Name of fire monitoring company) Security System Outage/Disconnection dated 10/27/2022 reflected the Issue Identified: Fire Alarm System not communicating with our (name of monitoring company). Need for manual Emergency (911) communication in the event of a fire. The education indicated All residents at risk. The Root Cause Analysis: Communication Outage/Disconnect of (fire monitoring system) with (name of community) fire system. The process implemented to prevent further occurrence was In the event of an emergency where the fire alarm sounds, a designated employee must call 911 to alert first responders there is a need for assistance. Once 911 had been called, designee is to call Administrator immediately following. The section of the form for Monitoring indicated Manual call to 911 until further notice as long as the outage of the (fire monitoring company) system continues. Review of NFPA 101 Life Safety Code 9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. A.9.6.1.6A A fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. Such individuals should be specially trained in fire prevention and in occupant and fire department notification techniques, and they should understand the fire safety situation for public education purposes. (Also see NFPA601, Standard for Security Services in Fire Loss Prevention.) The term out of service in 9.6.1.6 is intended to imply that a significant portion of the fire alarm system is not in operation, such as an entire initiating device, signaling line, or notification appliance circuit. It is not the intent of the Code to require notification of the authority having jurisdiction, or evacuation of the portion of the building affected, for a single nonoperating device or appliance.

Based on interview and record review, the facility failed to implement the bowel protocol for one resident (Resident #12), out of one resident reviewed for bowel and bladder, resulting in hospitalization for an ileus (inactive bowel) due to a bowel impaction (feces blockage of the colon), and [MEDICAL CONDITION] with [MEDICAL CONDITION] (lack of oxygen). Findings include: According to a facility face sheet dated 2/7/19, Resident #12 was a [AGE] year old readmitted into the facility on [DATE]. The original admitted was 8/30/10. The readmission [DIAGNOSES REDACTED]. Resident #12 was also diagnosed with [REDACTED]. Resident #12 was hospitalized from [DATE] to 1/25/19. Review of Resident #12's Bowel documentation reflected: 1/13/19 at 6:58 PM to 1/18/19 at 4:47 AM, Resident #12 did not have a bowel movement, 14 shifts. From 1/18/19 at 1:33 PM until 1/23/19 at 1:31 PM Resident #12 had anywhere from a few soft semi-formed stools to loose/diarrhea. Review of the facility printed bowel protocol reflected, If no BM for 3 days, the 9th shift is to assess bowel sounds, distension, complaints of pain, nausea, vomiting, and call doctor if indicated. Review of the progress notes revealed no documentation on 1/13/19 to 1/18/19 about an assessment of Resident #12's abdomen such as the bowel sounds and if the physician was contacted. Review of hospital discharge notes dated 1/30/19 reflected, Acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (difficulty breathing resulting in lack of oxygen), ileus secondary to heavy stool burden (constipation), [MEDICATION NAME] (inability to fully inflate lungs) volume loss secondary to an elevated left hemidiaphragm from ileus (stool filled colon pushed up on the diaphragm and impeded breathing). A CT (Computed Tomography) scan of the abdomen and pelvis reflected, .Bowel: Very large amount of desiccated (dry) stool in rectum measuring approximately 97 mm (millimeters, or 3.8189 inches) with [MEDICATION NAME] dilatation descending colon and hepatic flexure . This documentation also reflected that Resident #12 was taking [MEDICATION NAME] 75 mg (milligrams, an antidepressant that can cause constipation), [MEDICATION NAME] 5/325 mg 1 nightly (a narcotic that can cause constipation), and [MEDICATION NAME] 150 mg twice a day (a stomach acid medication that can cause constipation). Progress notes reflected, 1/31/2019 13:14 (1:14 PM) Secure Conversation Note Note Text: (name of Licensed Practical Nurse K) Sent: 01/29/2019 12:56 PM When (Resident #12) came back from the hospital they put him on Calcium [MEDICATION NAME], The phamacy (sic) does not carry this, can we put him back on the oyster shell calcium? The resident is currently on 2L (liters) of O2 (oxygen); acute issue; was rec after last Bowel Movement (BM). BM's previously were both diarrhea and formed. Review of a facility document for Resident #12 titled Medication Administration Record [REDACTED]. This was documented as given on 1/18/19 at 2:59 AM and was marked I for ineffective. A [MEDICATION NAME] suppository was to be given on shift 11 if no results from the Milk of Magnesia. There was no documentation that this had been given. Review of these sheets also reflected that monitoring for side effects such as constipation from an antidepressant, a narcotic and a stomach acid medication was not started until Resident #12 returned from the hospitalization on [DATE]. 02/08/19 10:03 AM during an interview with the Director of Nursing (DON) she said Resident #12 lack of BM should have alerted to the dashboard when no BM or small BM doesn't occur in 9 shifts. On 9th shift, staff was to follow the bowel protocol, and on the 10 th shift, administer Milk of Magnesia (MOM). The DON confirmed the consistency of stool was diarrhea stool before Resident #12 was sent to the hospital and she stated this may be due to stool leaking around hard stool. The DON stated her expectation would be that nursing would assess for impaction if a resident experienced a few days of diarrhea.

THIS CITATION PERTAINS TO INTAKE MI 720 AND MI 912. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO KEEP 2 OF 4 SAMPLED RESIDENTS (#101 AND #102) FREE FROM ABUSE, RESULTING IN RESIDENT #101 EXPERIENCING FEAR, CRYING, UNTREATED PAIN, AND HAVING TO URINATE IN HER BED, AND RESIDENT #102 EXPERIENCING FEAR OF PHYSICAL HARM. FINDINGS INCLUDE: RESIDENT #101: REVIEW OF RESIDENT #101's MEDICAL RECORD REVEALED A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. HER MINIMUM DATA SET (MDS) DOCUMENTED THAT SHE WAS COGNITIVELY INTACT WITH NO MEMORY PROBLEMS, REQUIRED ASSISTANCE WITH TRANSFERS, AMBULATION AND HYGIENE. REVIEW OF THE NURSE'S NOTES DATED 1/5/11 INDICATED RESIDENT #101 WAS PLEASANT AND COOPERATIVE WITH STAFF AND OTHER RESIDENTS, CONTINENT OF BOWEL AND BLADDER, WAS ON SCHEDULED PAIN MEDICATIONS TO MANAGE PAIN, AND WAS GIVEN PAIN MEDICATION FOR BREAK THROUGH BACK PAIN THAT RESIDENT #101 RATED AS 10 OUT OF 10. REVIEW OF THE physician's orders [REDACTED]. REVIEW OF THE FACILITY BEHAVIOR MANAGEMENT PROGRAM REVIEW AND SYMPTOM ANALYSIS FORM DATED 12/10/10 REVEALED THERE WERE NO DOCUMENTED SOCIAL WORK ISSUES OR CONCERNS AT THAT TIME AND RESIDENT #101'S MOOD WAS STABLE. REVIEW OF THE FACILITY BEHAVIOR TRACKING LOG REVEALED RESIDENT #101 HAD NO HISTORY OF FALSE ALLEGATIONS OF ABUSE DOCUMENTED. REVIEW OF A FACILITY RESIDENT/EMPLOYEE ASSISTANCE FORM (NO LEGIBLE DATE) FILLED OUT BY RESIDENT #101, THE RESIDENT (#101) STATED SHE TOLD STAFF #4 THAT "HER CHEST HURT AND SHE COULDN'T BREATH, IT WAS BECOMING VERY PAINFUL." RESIDENT #101 STATED STAFF #4 LOOKED SO MAD THAT RESIDENT #101 STARTED TO CRY. RESIDENT #101 STATED STAFF #4 WAS YELLING AND TOLD HER (RESIDENT #101) "NOT TO PUT WORDS INTO HIS MOUTH." RESIDENT #101 STATED SHE TRIED TO TELL STAFF #4 TO STOP YELLING, BUT HE WAS REALLY MAD, SO SHE (RESIDENT #101) JUST LAY THERE AND CRIED AND WAS AFRAID TO DO ANYTHING ELSE. RESIDENT #101 STATED SHE WAS AFRAID OF STAFF #4. A STAFF MEMBER DOCUMENTED ON THE FORM THAT RESIDENT #101 STATED "AS STAFF #4 EXITED THE ROOM HE SAID, "FAT ASS" AND TOSSED THE OXYGEN TUBING AT HER(RESIDENT #101)", AND THAT RESIDENT #101 "WAS AFRAID TO ASK FOR ANY FURTHER ASSISTANCE". RESIDENT #101 DOCUMENTED ON THE FORM THAT THIS WAS AN ONGOING PROBLEM FOR A FEW MONTHS. IN A WRITTEN STATEMENT BY RESIDENT #101, ON FACILITY NURSE'S NOTES PAPER, RESIDENT #101 DOCUMENTED SHE TOLD STAFF #4 SHE COULDN'T BREATH, AND STAFF #4 GOT REAL CLOSE TO HER, POINTED HIS FINGER IN HER FACE AND TOLD HER NOT TO PUT WORDS INTO HIS MOUTH. RESIDENT #101 WROTE SHE STARTED CRYING, AND ASKED STAFF #4 TO STOP, AND ACCIDENTLY PEED THE BED. RESIDENT #101 WROTE THAT SHE WAITED UNTIL MORNING BECAUSE NOW SHE IS AFRAID OF STAFF #4 AND ALWAYS WILL BE. IN AN INTERVIEW ON 2/10/11 AT 2:00 PM, RESIDENT #101 REPORTED THERE WAS ONE NIGHT SHE FELT LIKE SHE COULDN'T GET ENOUGH AIR SO SHE ASKED STAFF #4 FOR HER OXYGEN AND STAFF #4 TOLD RESIDENT #101 SHE COULDN'T HAVE IT "BECAUSE HER NUMBERS WEREN'T RIGHT." RESIDENT #101 REPORTED STAFF #4 ASKED HER WHY SHE THOUGHT SHE NEEDED THE OXYGEN. RESIDENT #101 STATED THAT SHE TOLD STAFF #4 "IT MIGHT BE BECAUSE SHE IS HEAVY AND HAS WEIGHT ON HER CHEST AREA, BUT SHE WOULDN'T ASK FOR THE OXYGEN IF SHE DIDN'T THINK SHE NEEDED IT." RESIDENT #101 STATED THAT STAFF #4 SAID, "AGAIN, I DON'T KNOW WHY YOU NEED IT." RESIDENT #101 STATED SHE THEN SAID TO STAFF #4, "IT MUST BE BECAUSE I'M FAT". RESIDENT #101 REPORTED STAFF #4 THEN LEANED OVER HER BED, WHERE SHE WAS LAYING AND POINTED HIS FINGER IN HER FACE AND YELLED, "DON'T PUT WORDS INTO MY MOUTH". RESIDENT #101 STATED SHE STARTED CRYING AND TOLD STAFF #4 TO STOP YELLING AT HER. RESIDENT #101 STATED, "HE IS A BIG MAN AND HE WAS LEANING OVER THE TOP OF ME AND YELLING AND WOULDN'T STOP. I WAS SCARED". RESIDENT #101 STATED STAFF #4 FINALLY LEFT HER ROOM AND SAID "FAT ASS" ON THE WAY OUT OF HER ROOM. RESIDENT #101 REPORTED SHE WAS AFRAID TO ASK FOR ANY HELP FOR THE REST OF THE NIGHT AND HAD TO WET HER BED BECAUSE SHE WAS SO SCARED. RESIDENT #101 STATED SHE TALKED TO THE ADMINISTRATOR ABOUT THE INCIDENT AND THE ADMINISTRATOR OF THE FACILITY TOLD HER THAT STAFF #4 WOULD NOT BE BACK AND WOULD NOT TAKE CARE OF HER AGAIN. RESIDENT #101 REPORTED SHE SAW STAFF #4 WORKING THE NEXT DAY. RESIDENT #101 STATED SHE WAS VERY SCARED BECAUSE SHE WAS AFRAID THE ADMINISTRATOR HAD TOLD STAFF #4 WHAT SHE HAD SAID. RESIDENT #101 STATED THAT STAFF #4 STILL WORKS HER HALL AND TAKES CARE OF HER. RESIDENT #101 STATED SOMETIMES STAFF #4 SEEMS TO BE IN A GOOD MOOD AND SOMETIMES STAFF #4 IS IN A BAD MOOD. RESIDENT #101 STATED IF STAFF #4 SEEMS TO BE IN A BAD MOOD, SHE WON'T ASK STAFF #4 FOR A PAIN PILL OR ANYTHING. RESIDENT #101 STATED SHE WOULD RATHER SUFFER. IN A WRITTEN STATEMENT BY STAFF NURSE #11, SHE DOCUMENTED THAT AT 6:00 AM, SHE FOUND RESIDENT #101 SOAKED IN URINE AND RESIDENT #101 TOLD HER THAT STAFF #4 HAD YELLED AT HER WHEN SHE ASKED FOR OXYGEN AND SHE (RESIDENT #101) HAD BEEN LAYING IN IT ALL NIGHT BECAUSE SHE WAS AFRAID. STAFF NURSE #11 WROTE THAT RESIDENT #101 STATED SHE HAD BEEN AFRAID OF STAFF #4 SINCE THE INCIDENT AND THAT A COUPLE OF DAYS AFTER THE INCIDENT STAFF #4 CAME INTO HER ROOM AND SAID, "ARE WE GOOD NOW?" RESIDENT #101 STATED SHE SAID YES BECAUSE IF SHE SAID NO, STAFF #4 WOULD CONTINUE TO BE MEAN TO HER. IN AN INTERVIEW ON 2/10/11 AT 1:20 PM, STAFF NURSE # 11 STATED SHE WAS UNSURE OF THE DATE, BUT SHE CAME IN ON FIRST SHIFT AND WENT INTO RESIDENT #101's ROOM AND FOUND HER LAYING IN A PUDDLE OF URINE IN HER BED. STAFF NURSE #11 STATED RESIDENT #101 IS USUALLY CONTINENT OF URINE, SO SHE ASKED RESIDENT #101 WHAT HAD HAPPENED. STAFF NURSE #11 STATED RESIDENT #101 WAS EXTREMELY UPSET AND TOLD HER THAT STAFF #4 HAD GOTTEN IN HER (RESIDENT #101) FACE BECAUSE SHE HAD ASKED STAFF #4 FOR HER OXYGEN. STAFF NURSE #11 STATED THAT RESIDENT #101 TOLD HER THAT STAFF #4 ARGUED WITH HER (RESIDENT #101) ABOUT WHY SHE NEEDED THE OXYGEN AND TOLD HER (RESIDENT #101) IT WAS BECAUSE SHE WAS SO HEAVY. STAFF NURSE #11 STATED RESIDENT #101 TOLD HER STAFF #4 GOT IN HER (RESIDENT #101) FACE, POINTED HIS FINGER IN HER FACE AND YELLED "DON'T PUT WORDS INTO MY MOUTH". STAFF NURSE #11 STATED THAT RESIDENT #101 TOLD HER STAFF #4 WAS LAUGHING AND CALLING HER FAT ON THE WAY OUT OF HER ROOM. STAFF NURSE #11 STATED THAT RESIDENT #101 TOLD HER SHE HAD URINATED IN HER BED BECAUSE SHE WAS AFRAID TO ASK STAFF #4 FOR HELP AND THAT HE HAD BEEN MEAN THE REST OF THE NIGHT. STAFF NURSE #11 STATED SHE HAD HEARD STAFF #4 MAKE DEROGATORY COMMENTS ABOUT RESIDENT #101 ON MULTIPLE OCCASIONS. WHEN ASKED BY THE SURVEYOR WHAT COMMENTS STAFF #4 HAD MADE ABOUT RESIDENT #101, STAFF NURSE #11 STATED STAFF #4 HAD SAID RESIDENT #101 DIDN'T NEED OXYGEN, THAT RESIDENT #101 WAS "WHINY", AND THAT STAFF #4 HAD CALLED RESIDENT #101 "FAT" TO HER (STAFF NURSE #11) AND THAT SHE (STAFF NURSE #11) HAD HEARD STAFF #4 CALL RESIDENT #101 "FAT" TO MULTIPLE OTHER STAFF MEMBERS. STAFF NURSE #11 STATED THAT STAFF #4 IS ABRUPT AND LOUD WITH CARE, AND DOES NOT HESITATE TO TALK IN A DEROGATORY WAY ABOUT RESIDENT'S TO STAFF. WHEN ASKED FOR SPECIFIC EXAMPLES OF DEROGATORY STATEMENTS THAT STAFF NURSE #11 HAD HEARD STAFF #4 MAKE, STAFF NURSE #11 STATED THAT STAFF #4 HAD SAID THAT HE (STAFF #4) DIDN'T CARE IF THESE PEOPLE WERE DEAD. STAFF NURSE #11 STATED THAT STAFF #4 MEANT THE RESIDENTS OF THE FACILITY WHEN HE STATED "THESE PEOPLE". STAFF NURSE #11 STATED STAFF #4 MADE THIS STATEMENT ALMOST EVERY TIME STAFF NURSE #11 SAW STAFF #4. IN AN INTERVIEW ON 2/11/11 AT 6:10 AM, STAFF #4 STATED ONE NIGHT RESIDENT #101 WAS CALLING AND WANTING OXYGEN INCREASED TO 4 LITERS PER MINUTE AND THAT HE TOLD RESIDENT #101 HE COULDN'T DO THAT WITHOUT A DOCTOR'S ORDER. STAFF #4 STATED RESIDENT #101 SAID SHE WAS HAVING PROBLEMS BREATHING, SO HE ELEVATED THE HEAD OF HER BED. STAFF #4 STATED RESIDENT #101's PULSE WAS ELEVATED AND SHE LOOKED "PANICKY". STAFF #4 STATED, "WE DID EVERYTHING WE COULD TO CALM HER DOWN BUT HER OXYGEN LEVEL WAS NEVER LOW ENOUGH TO CALL THE DOCTOR." WHEN ASKED BY THE SURVEYOR IF HE SAID "WE" BECAUSE SOMEONE ELSE WAS WITH HIM, STAFF #4 STATED, "THERE MIGHT HAVE BEEN". WHEN ASKED WHO WAS WITH HIM, STAFF #4 STATED HE HAD NO IDEA. WHEN ASKED BY THE SURVEYOR IF HE HAD EVER HAD AN ARGUMENT WITH RESIDENT #101, STAFF #4 STATED THAT HE AND RESIDENT #101 HAD CONVERSATIONS WHERE RESIDENT #101 WOULD GET UPSET ABOUT SOMETHING. WHEN ASKED BY THE SURVEYOR IF HE HAD EVER POINTED HIS FINGER IN RESIDENT #101's FACE, STAFF #4 STATED, "NOT THAT I KNOW OF". WHEN ASKED BY THE SURVEYOR IF HE HAD EVER MADE DEROGATORY REMARKS ABOUT RESIDENT #101 TO ANYONE ELSE, STAFF #4 STATED, "I CAN'T SAY THAT I HAVEN'T". WHEN ASKED WHAT HE SAID, STAFF #4 STATED HE DIDN'T KNOW. WHEN ASKED BY THE SURVEYOR IF HE HAD SAID OR DONE ANYTHING TO RESIDENT #101 ON THE NIGHT SHE COULDN'T BREATH, TO SCARE HER, THAT WOULD MAKE HER FEEL SCARED OF HIM, CALL HER ANY NAMES, OR SAY ANYTHING DEROGATORY TO HER, STAFF #4 STATED, "I DON'T THINK SO". WHEN ASKED BY THE SURVEYOR WHAT HE MEANT BY THE COMMENT, "I DON'T THINK SO", STAFF #4 STATED, "I'M 99 PERCENT SURE I DIDN'T." WHEN ASKED BY THE SURVEYOR IF HE WAS AWARE OF THE ALLEGATIONS MADE BY RESIDENT #101 THAT HE HAD CALLED HER A "FAT ASS" AND YELLED AT HER, STAFF #4 STATED HE HAD BEEN ASKED ABOUT RESIDENT #101 MAKING ALLEGATIONS ABOUT HIM (STAFF #4) NOT GIVING HER ORANGE JUICE WHEN SHE ASKED FOR IT. STAFF #4 STATED THIS WAS THE FIRST TIME HE HAD HEARD ANYTHING ABOUT RESIDENT #101 MAKING ALLEGATIONS OF ABUSE AGAINST HIM. IN A WRITTEN STATEMENT DATED 1/18/11, STAFF #12 STATED THAT SHE SPOKE WITH RESIDENT #101 PER THE RESIDENT'S REQUEST. IN THE WRITTEN STATEMENT, STAFF #12 DOCUMENTED, "(RESIDENT #101) STATED A COUPLE OF WEEKS AGO STAFF #4 WAS IN HER ROOM AND SHE (RESIDENT #101) ASKED STAFF #4 FOR OXYGEN." STAFF #12 DOCUMENTED, "(RESIDENT #101) REPORTED STAFF #4 TOLD HER (RESIDENT #101) SHE WAS JUST PRETENDING AND SHOOK HIS FINGER IN HER FACE AND YELLED, 'DON'T PUT WORDS IN MY MOUTH'." STAFF #12 DOCUMENTED, "(RESIDENT #101) SAID SHE WAS SCARED AND FEELS UNSAFE IN REGARDS TO STAFF #4. RESIDENT #101 STATED THAT SHE HAD SPOKEN WITH THE ADMINISTRATOR ABOUT THIS ISSUE ON SATURDAY (1/15/11) AND WAS TOLD BY THE ADMINISTRATOR NOT TO WORRY AND THAT STAFF #4 WOULD NOT BE BACK." STAFF #12 DOCUMENTED, "(RESIDENT #101) WAS VERY CONCERNED BECAUSE SHE (RESIDENT #101) SAW STAFF #4 WORKING MONDAY NIGHT (1/17/11)." ON 2/11/11 AT 5:50 AM, STAFF #4 WAS OBSERVED BY THE SURVEYOR, GOING INTO RESIDENT #101's ROOM AND OBTAINING VITAL SIGNS (BLOOD OXYGEN LEVEL). THE DIRECTOR OF NURSING WAS OBSERVED BY THE SURVEYOR TO BE SITTING AT THE NURSE'S STATION. IN AN INTERVIEW ON 2/11/10 AT 8:20 AM, THE ADMINISTRATOR WAS ASKED BY THE SURVEYOR IF HE HAD INTERVIEWED STAFF #4 ABOUT THE ALLEGATIONS MADE BY RESIDENT #101. THE ADMINISTRATOR STATED HE HAD ASKED THE DIRECTOR OF NURSING TO GET A WRITTEN STATEMENT AND TALK TO STAFF #4. THE ADMINISTRATOR STATED HE DIDN'T KNOW IF STAFF #4 HAD EVER BEEN QUESTIONED REGARDING THE ALLEGATIONS MADE BY RESIDENT #101. THE ADMINISTRATOR WAS ASKED BY THE SURVEYOR IF HE HAD TOLD RESIDENT #101 THAT STAFF #4 WOULD NOT BE BACK. THE ADMINISTRATOR STATED HE DID TELL RESIDENT #101 THAT STAFF #4 WOULD NOT BE TAKING CARE OF HER. HOWEVER, A COUPLE OF DAYS AFTER STAFF #4 CAME BACK TO WORK, RESIDENT #101 REPORTED TO THE ADMINISTRATOR THAT SHE HAD SEEN STAFF #4. THE ADMINISTRATOR STATED HE TOLD RESIDENT #101 THAT HE HAD INFORMED THE DIRECTOR OF NURSING TO SCHEDULE STAFF #4 ON A DIFFERENT HALL THAT HERS (RESIDENT #101). THE ADMINISTRATOR admitted TO THE SURVEYOR THAT STAFF #4 WAS AND REMAINS WORKING ON RESIDENT #101'S HALL AND PROVIDING CARE TO HER. WHEN ASKED IF ANYTHING HAD BEEN DONE TO ASSURE STAFF #4 DID NOT CARE FOR RESIDENT #101, THE ADMINISTRATOR STATED NO. IN AN INTERVIEW ON 2/11/10 AT 8:45 AM, THE DIRECTOR OF NURSING (DON) STATED A STAFF NURSE REPORTED TO HIM THAT RESIDENT #101 HAD MADE ALLEGATIONS OF STAFF #4 BEING MEAN TO HER, AND CALLING HER A "FAT ASS". THE DON STATED THE ADMINISTRATOR AND SOCIAL WORKER TALKED WITH RESIDENT #101, BUT HE HAD NOT TALKED WITH RESIDENT #101. THE DON STATED, "IT WAS MY UNDERSTANDING THAT SHE (RESIDENT #101) MAY HAVE MISUNDERSTOOD". WHEN ASKED BY THE SURVEYOR WHEN HE HAD TALKED WITH STAFF #4 REGARDING THE ALLEGATIONS MADE BY RESIDENT #101, THE DON STATED HE DID NOT SPEAK WITH STAFF #4 ABOUT THE ALLEGATIONS UNTIL STAFF #4 RETURNED TO WORK FROM SUSPENSION DURING THE INVESTIGATION. THE DON admitted HE WAS TOLD BY THE ADMINISTRATOR NOT TO PUT STAFF #4 ON RESIDENT #101'S HALL. THE DON STATED STAFF #4 WORKED SECOND AND THIRD SHIFT. WHEN ASKED BY THE SURVEYOR HOW MANY NURSES WORK THIRD SHIFT, THE DON STATED ONE NURSE WORKED THIRD SHIFT. THE DON STATED THAT WHEN STAFF #4 WORKED THIRD SHIFT IT WOULD BE IMPOSSIBLE FOR STAFF #4 NOT TO BE ASSIGNED TO CARE FOR RESIDENT #101. WHEN ASKED BY THE SURVEYOR IF STAFF #4 HAD EVER BEEN STOPPED FROM WORKING THIRD SHIFT SINCE THE ALLEGATIONS MADE BY RESIDENT #101, THE DIRECTOR OF NURSING STATED NO. RESIDENT #102: REVIEW OF RESIDENT #102'S MEDICAL RECORD REVEALED AN [AGE] year OLD MALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. HIS MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT HE WAS MODERATELY IMPAIRED WITH COGNITIVE SKILLS FOR DAILY DECISION MAKING, INDEPENDENT WITH TRANSFERS, AMBULATION, DRESSING AND EATING, AND WAS CONTINENT OF BOWEL AND BLADDER. IN AN INTERVIEW ON 2/11/11 AT 10:10 AM, THE MAINTENANCE MANAGER STATED 1/6/11 WHILE WORKING ON EAST HALL HE WAS APPROACHED BY RESIDENT #102, WHO ASKED HIM TO COME AND TALK TO HIS CO-WORKER BECAUSE HE WAS TAKING HIS (RESIDENT #102) TV. THE MAINTENANCE SUPERVISOR STATED HE SHOWED RESIDENT #102 HIS TV AND THEN TOOK RESIDENT #102 TO TALK TO STAFF #13. THE MAINTENANCE MANAGER STATED RESIDENT #102 ACCUSED STAFF #13 OF TAKING HIS TV AND STAFF #13 BEGAN TO ARGUE WITH RESIDENT #102. THE MAINTENANCE MANAGER STATED STAFF #13 KEPT GETTING CLOSER AND CLOSER TO RESIDENT #102 AND GOT INTO RESIDENT #102's FACE. THE MAINTENANCE MANAGER STATED HE TOLD STAFF #13 TO WALK AWAY, BUT STAFF #13 KEPT ARGUING WITH RESIDENT #102 AND WAS VERY CLOSE TO HIS FACE, SO HE CALLED FOR THE SOCIAL WORKER, WHO WAS SITTING AT THE NURSE'S STATION, FOR ASSISTANCE. THE MAINTENANCE MANAGER STATED THAT THE SOCIAL WORKER FINALLY GOT STAFF #13 TO LEAVE THE SITUATION, AND RESIDENT #102 WENT WITH THE MAINTENANCE MANAGER TO HELP HIM IN THE WORK AREA. THE MAINTENANCE MANAGER STATED THAT RESIDENT #102 LIKES TO HELP WORK ON THINGS IN THE MAINTENANCE DEPARTMENT, SO HE THOUGHT THAT MIGHT HELP CALM RESIDENT #102 DOWN, BECAUSE HE WAS UPSET. THE MAINTENANCE MANAGER STATED A COUPLE OF HOURS LATER HE OBSERVED RESIDENT #102 ATTEMPT TO APOLOGIZE TO STAFF #13. THE MAINTENANCE SUPERVISOR STATED THAT STAFF #13 TOLD RESIDENT #102 THAT HE DID NOT ACCEPT HIS APOLOGY, HE DIDN'T WANT ANYTHING TO DO WITH HIM (RESIDENT #102) AND THAT HE (RESIDENT #102) BELONGED IN JAIL. THE MAINTENANCE MANAGER STATED HE WAS SHOCKED AND MET WITH THE ADMINISTRATOR, AND STAFF #13 WAS ESCORTED OUT OF THE BUILDING. IN AN INTERVIEW ON 2/10/11 AT 11:30 AM, THE FACILITY SOCIAL WORKER STATED SHE WAS AT THE NURSE'S DESK WHEN SHE HEARD THE MAINTENANCE MANAGER HOLLER AT HER FOR ASSISTANCE. THE SOCIAL WORKER STATED SHE WENT TO WHERE THE MAINTENANCE MANAGER WAS AND SAW STAFF #13 STANDING NOSE TO NOSE WITH RESIDENT #102 WITH HIS (STAFF #13) FISTS CLENCHED, IN THE MIDST OF A VERBAL ALTERCATION. THE SOCIAL WORKER STATED STAFF #13 WAS USING TONES OF ANGER, ABOVE NORMAL CONVERSATION. THE SOCIAL WORKER STATED THAT RESIDENT #102 HAD HIS HANDS UP IN A DEFENSIVE MANNER, AND STAFF #13 WAS INTIMIDATING RESIDENT #102 WITH HIS STANCE AND CLENCHED FISTS. THE SOCIAL WORKER STATED THAT RESIDENT #102 WAS BACKED UP AGAINST A WALL. THE SOCIAL WORKER STATED AS SHE APPROACHED SHE YELLED AT STAFF #13 SEVERAL TIMES TO LEAVE AND FINALLY TOLD STAFF #13 TO CLOSE HIS LIPS AND MOVE ON. THE SOCIAL WORKER STATED SHE BELIEVED IT WAS ABOUT TO BECOME A "FIST A CUFF", AND STAFF #13 WAS STATING, "BRING IT ON" TO RESIDENT #102. THE SOCIAL WORKER STATED RESIDENT #102 WAS UPSET AND STATING, "HE CAN'T DO ME THAT WAY". SHE STATED THE MAINTENANCE SUPERVISOR BROUGHT RESIDENT #102 TO THE MAINTENANCE AREA TO CALM HIM DOWN, AS RESIDENT #102 ENJOYS THIS. THE SOCIAL WORKER STATED STAFF #13 INAPPROPRIATELY ESCALATED THE SITUATION. SHE STATED A WHILE LATER THE MAINTENANCE MANAGER CAME TO HER AND THE ADMINISTRATOR AND REPORTED THAT RESIDENT #102 HAD ATTEMPTED TO APOLOGIZE TO STAFF #13, STAFF #13 HAD REFUSED HIS APOLOGY AND STARTED ARGUING WITH RESIDENT #102 AGAIN. SHE STATED STAFF #13 WAS ESCORTED OUT OF THE BUILDING. IN AN INTERVIEW ON 2/10/10 AT 10:50 AM, RESIDENT #102 STATED HE REMEMBERED HAVING AN ARGUMENT WITH THE MAINTENANCE GUY THAT WAS TRYING TO TAKE HIS SON'S TV. RESIDENT #102 STATED HE KEPT TELLING THE MAINTENANCE GUY THAT IT WAS HIS SON'S TV, BUT HE TOOK IT ANYWAY. RESIDENT #102 STATED THAT HIM AND THE MAINTENANCE MAN WEREN'T YELLING, BUT THE MAINTENANCE MAN JUST WOULDN'T LISTEN AND HE "SCARED THE CRAP OUT OF ME". RESIDENT #102 STATED HE DID FEEL THREATENED BY THE MAINTENANCE MAN. RESIDENT #102 WAS ABLE TO TELL THE SURVEYOR WHERE HE WAS FROM, HOW MANY CHILDREN HE HAD, AND THAT HE WANTED TO LEAVE THE FACILITY AS SOON AS THE SNOW WAS GONE. FACILITY NURSE'S NOTES FOR RESIDENT #102 DATED 1/8/11 STATED THAT RESIDENT #102 CAME TO THE NURSE'S STATION ASKING FOR SOMEONE TO CALL THE POLICE ABOUT A TAG ON HIS CLOTHES AND THAT SOMEONE HAD STOLEN HIS TV. THE NURSE'S NOTES DOCUMENT THAT RESIDENT #102 WAS VERY UPSET, UNABLE TO BE REDIRECTED, PLACED ON 15 MINUTE CHECKS AND ALL STAFF, INCLUDING THE ADMINISTRATOR AND DIRECTOR OF NURSING WERE MADE AWARE OF THE SITUATION. A WRITTEN STATEMENT BY STAFF NURSE #8 STATED THAT RESIDENT #102 WAS FOUND SITTING IN HIS ROOM IN A CHAIR, HOLDING HIS HEAD AND FROWNING AND STATED THAT "TODAY NOT SO GOOD" AND "THAT MAN DONE PISSED ME OFF. HE TOOK MY TV...I DON'T EVEN WANT TO TALK ABOUT IT. BETTER TO JUST LEAVE IT ALONE". A WRITTEN STATEMENT BY THE FACILITY SOCIAL WORKER STATED THAT ON 1/6/11 RESIDENT #102 AND STAFF #13 HAD AN ARGUMENT AND STAFF #13 WAS IN RESIDENT #102's FACE AND HAD TO BE ASKED FOUR TIMES TO LEAVE BEFORE HE DID. THE SOCIAL WORKER DOCUMENTED THAT IT REQUIRED SOME TALKING TO CALM RESIDENT #102 DOWN. A FACILITY LETTER TO THE UNEMPLOYMENT INSURANCE AGENCY DATED 1/21/11 DOCUMENTED THAT THE SPECIFIC REASON FOR STAFF #13's DISCHARGE FROM EMPLOYMENT WAS THAT STAFF #13 VIOLATED THE POLICY REGARDING ABUSE, WHICH STATED "THE RESIDENT HAS THE RIGHT TO BE FREE FROM ABUSE, NEGLECT, MISTREATMENT, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY". A FACILITY CORRECTIVE ACTION FORM DATED 1/12/11 DOCUMENTED THAT THE EMPLOYEE WAS FOUND TO HAVE BEEN ARGUING WITH RESIDENT #102 IN AN INAPPROPRIATE WAY AND WOULD NOT ACCEPT RE-DIRECTION. #

This citation pertains to intake number MI 276 Based on observation, interview, and record review the facility failed to provide adequate supervision for 1 of 5 sampled residents (Resident #101) resulting in immediate jeopardy for Resident #101, when he eloped from the facility through the main entrance door that was not alarmed per facility policy, placing Resident #101 at high risk for serious harm, injury, and death. Findings include: Record review of the "Facility Face Sheet" and a "Minimum Data Set", (MDS) dated , 11/14/10, indicate Resident #101 was a [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #101 could usually understand-sometimes misses some part/intent of message but comprehends most conversation with regard to his ability to understand others, required some oversight with personal hygiene and was occasionally incontinent of bowel and bladder. Record review of an "Elopement Risk Assessment", dated 12/04/09, 3/10/10, 6/03/10, and 8/24/10, revealed that Resident #101 was at risk for elopement. Record review of a facility "Care Plan Conference Summary", dated 3/11/10, revealed Resident #101 was "elopement risk, no placement at assisted living r/t elopement risk" An "Elopement Care Plan", dated 11/17/10, included these interventions: Record and report behaviors that raise the risk of elopement to management and staff, direct supervision while outside, encourage participation with activities, collaborate with physician/guardian and family regarding wishes to leave and any elopement attempts, have awareness of plans for elopement: i.e., pack bags, wearing coat, states leaving, and exit seeking. Record Review of a "Nurses Note", dated 12/06/10, timed 6:00 AM, indicated that Resident #101 "continues to be forceful about going out of the facility with his brother." Record Review of a "Nurses Note", dated 12/06/10, timed 11:50 AM, indicated that Resident #101 was "observed by the dietary manager wearing coat and gloves and sitting by the door...staff made aware of risk of elopement." An interview with EMT #11, on 1/05/11 at 11:30 AM, revealed that on 12/06/10 at approximately 12:00 PM, EMT #11 was sitting in the ambulance cab parked in front of the building in view of the main entrance. EMT #11 observed resident #101 exit the main entrance and proceed down the sidewalk. EMT #11 observed activity aide #9 enter the facility through the ambulance bay doors without intercepting Resident #101. A telephone interview, on 1/05/11 at 11:35 AM, with activity aide #9 revealed that she had been in her car on break and was walking back to the building when she observed Resident #101 on the sidewalk outside of the facility. Activity aide #9 stated that she called to Resident #101 but he did not respond to her. Activity aide #9 continued into the facility through the ambulance bay door to notify staff about Resident #101 being outside but did not go to Resident #101 to attempt to redirect him back into the facility. In an interview, on 1/05/11 at 9:30 AM, the maintenance supervisor reported that he observed Resident #101 outside of the facility through a window in the North Hall and went immediately outside to redirect Resident #101 back into the facility and continued to walk along side him because Resident #101 could not be redirected at that time. Record review of a "Nurses Note", dated 12/06/10, timed 12:00 PM, indicated that "resident was observed leaving the building, walking up hill..." An observation, on 1/04/11 at 9:30 AM, of the main entrance to the facility revealed the main entrance door (where Resident #101 exited the building) locks upon closure with a magnetic device and a code must be entered into a keypad at the level of the door handle to disengage the magnet allowing for exit from within the facility. There was no alarm device associated with the door. An observation, on 1/05/10 at 12:10 PM, in the presence of the Director of Nursing, revealed that there is a 14 second delay from the time the door stands open to re-engagement of the lock once a person enters or exits the building using the main public entrance or the ambulance bay entrance, which is adjacent to the main entrance door. The DON agreed there was no alarm present on the door. A telephone interview with nurse consultant #8, on 1/05/11 at 9:46 AM, revealed she was in the building at the time Resident #101 eloped from the facility and had been rounding with the Director of Nursing. She did not see Resident #101 elope from the facility, and learned of the elopement from the dietary manager after Resident #101 was already outside the building. Nurse consultant #8 stated she assumed the resident got out of the building when the door had been opened by an ambulance attendant. When the surveyor informed the nurse consultant of the 14 second delay in closure, the consultant stated, "...that (the time it takes for the door to close) has been a concern of mine for quite some time...it isn't just Resident #101, it could've been anybody. Most people who really want to make a successful attempt (to elope from the facility) don't tell you when they are leaving." When asked what precautions should have been in place to prevent Resident #101 from eloping from the facility on 12/06/10, the nurse consultant replied, "...he should have been on checks..." Record review of the facility "Missing Resident Procedure", dated 1/12/09, found in the facility "Safety and Disaster Handbook" indicated, "The purpose of the missing resident procedure is to determine when a resident who has not been located shall be deemed missing and to offer guidance to staff in locating residents and preventing missing residents." Additional precautions described in the "Missing Resident Procedure", indicate "(The Facility)exits are equipped with door opening alarms" and "Any precautions or preventive measures which are to be used to address a resident's wandering behavior shall be included in the resident's plan of care." During an interview, on 1/04/11 at 11:00 AM, Resident #101 stated that he walked right out the front door. When asked how he was able to get out Resident #101 stated, "...I'm supposed to have a set of keys". When asked by the surveyor to demonstrate how exactly he was able to get out of the facility, Resident #101 walked to the main front entrance and attempted unsuccessfully to enter a code and stated "I don't know the code." When asked why he attempted to leave the facility, Resident #101 stated, "...to get a pack of smokes!" On 1/07/11, the Administrator and Director of Nursing were informed of the Immediate Jeopardy that began on 12/06/10 for Resident #101 who eloped from the facility through a door that was not alarmed, placing Resident #101 and 4 additional residents, who were at risk for elopement, at high risk for serious injury, harm, and/or death. On 1/07/11 the surveyor confirmed the facility implemented the following to remove the immediate jeopardy: 1. Resident #101 has had no further attempts to leave the facility unattended. 2. On 12/06/10, the code to the main entrance was changed and staff enters the door code to let visitors out of the building. 3. On 12/06/10, Resident #101 was placed on "every 15 minute" checks upon his return into the facility to ensure he was not planning to leave. 4. On 12/06/10, Resident #101's care plan and care guide were updated to include new behaviors for staff to identify risk for elopement. 5. As of 1/6/11, all residents will continue to be assessed for their elopement risk on admission for 4 weeks, then quarterly thereafter. Residents identified as an elopement risk are placed in the Elopement Manual which includes their picture, family and demographic information, and personal information to assist staff identification of the resident. An elopement care plan and the care guide will be initiated with interventions, as well as the Behavior Log Book. 6. On 1/05/11, door alarms were placed on both front entry doors. A procedure for alarms and door locks was initiated. Door alarms will be checked daily by maintenance and by nursing in their absence. Any malfunction in an alarm is to be reported to the Administrator and Maintenance Supervisor immediately. The alarm check log will be maintained by the Maintenance Supervisor. 7. All staff education began on 1/6/11 on the alarm procedure and the Elopement Manual and Policy. Of the 52 staff, 26 were educated on 1/05/2011; 8 staff were educated on 1/06/2011; 11 staff were educated on their return to work between 1/07/2011 and 1/10/2011. Two staff were in-serviced 1/07/2011, and the 5 remaining staff will be educated on their first day returning to work. 8. As of 1/6/11, Social Services will continue to be responsible for updating the Behavior Tracking Log and report to Quality Assurance monthly. 9. As of 1/5/11, the Maintenance Supervisor will report the door alarm log audits to the Quality Assurance monthly. The Administrator will review the maintence logs weekly. Although the Immediate Jeopardy (IJ) was removed on 1/06/11, 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 Alarm Procedure and the Elopement Manual and Policy, and sustained compliance has not been verified by the State Agency. ( )

This citation pertains to MI# 421 Based on observation, interview and record review, the facility failed to provide supervision and accidents of 1 of 4 sampled residents (#101), resulting in resident #101 with a known history falls and facility staff knowing that the resident #101 was able to turned off and remove his pressure pad alarm device, was found by staff in bed with a laceration on bridge of nose and laceration above left eye with slight edema and was sent to the hospital. State surveyor observed resident #101 continually removing the pressure alarm pad and turning it off with staff going in and out of the room not monitoring the safety devices. Findings include: Record review of resident #101's admission assessment dated [DATE] at 11:15 AM revealed that the admission nurse noted on the admission form that the new resident was able to walk and transfer, but was extremely unstable and should be supervised. Further admission note revealed that the resident was very unsteady but lacked understanding of safety risk and needed to be supervised. Record review of the resident #101's Fall Risk Status form dated 8/30/10 triggered for clinical conditions of: Cognitive status, behavior indicators, Mobility, Balance, Health conditions, medications. Placing the resident at risk for falls. Record review of the residents nurse notes dated 8/30/10 at 4:00 PM, noted resident in bed states he turned off alarm. Nurse was doing alarm checks when resident told him. Alarm was turned off. Nurse tried to educate resident on not turning alarm off. Nurse note dated 8/30/10 at 9:43 PM revealed that the resident needed to be monitored frequently. Nurse note dated 8/31/10 at 12:15 AM revealed that the resident was very unsteady on his feet, walks in room and had removed the tank top from toilet and splashing water out. Record review of facility incident/accident report dated 8/31/10 at 7:30 PM revealed that the resident #101 fell hitting night stand and received scratches, scrapes on head and abrasion to left shoulder area. Nurse note dated 8/31/10 at 8:30 PM revealed: Reported by roommate that resident fell hitting night stand and got himself into bed. Resident has abrasion Left shoulder 3 inches long, and thin scratch top of head 1 inch long. No active bleeding at this time. Resident was asked if he fell and stated "I'm OK". A second entry on 8/31/10 at 8:30 PM noted that resident had fall incident. Roommate stated "fall happened about 1 hour ago". Resident was found with abrasion on left shoulder and 2 separate scrapes on head that are new. Further note revealed that resident continues to get up turning alarm off. Record review of facility incident/accident report dated 9/1/10 at 2:30 AM revealed that the resident #101 observe in bed with laceration on bridge of nose and above left eye with slightly edema. Nurse note dated 9/1/10 at 3:00 am revealed: Resident observed in bed with dry blood on sheets of bed. Resident turned in bed and observed a fresh laceration on bridge of nose and above left eye in forehead area. Area above left eye slightly swollen. Attempted to apply ice wrapped in a washcloth to swollen area but resident continued to slap at staff and stating "I'm OK, I'm OK". Cleaned areas around lacerations with soap and water. Water noted on bathroom floor. The resident was transferred to St. Mary's Healthcare via ambulance. Review of Hospital consultation record dated 9/1/10 revealed that resident #101 was admitted following a fall. Resident #101 has history of multiple falls and stated that he fell last night and hit his head. Resident #101 reported pain in face and neck. Record review of facility incident/accident report dated 9/13/10 at 6:47 PM revealed that the resident #101 stated "I was up and hit my head on the door to my closet". New laceration noted over left eye. Record review of facility incident/accident report dated 9/17/10 at 11:20 AM revealed that the resident #101 was observe by his father to have jumped up from chair, ran in to bathroom, tripped hit head on wall/windowsill area, then bounced into bathroom door. Redness was noted to forehead. Observations on 9/24/10 at 12:20 PM of resident #101 sitting in a large recliner with his feet up on another chair revealed that the pressure pad alarm used for fall precautions/safety was turned off and located under the bed. The certified nurse assistant (CNA) #6 was noted by the state surveyor to have been in and out of the resident #101's room twice and did not notice that the safety device was located under the bed where the resident had thrown/placed it. The state surveyor had to tell the CNA #6 to please put the pressure pad alarm device back into place beneath the resident. An interview on 9/24/10 at 1:10 PM with nurse #7 revealed, "Yes, I know about (resident #101). He turns off his alarm or throws it across the room". An interview on 9/24/10 at 1:56 PM with CNA #6 revealed: "He takes the pressure pad sensor alarm off. He removes the pad, hides it under the bed, in the closet, takes the batteries out. We have to hunt for it sometimes. Tab alarm was tried, he unhooked it. He broke it. He has muscle spasm and threw it, it shattered. He gets up on his own". On 9/24/10 at 1:56 PM observed the CNA #6 replace again the pressure pad alarm. The alarm did sound/function. The CNA left the room to retrieve grape juice for the resident. When CNA #6 returned the resident #101 had removed the pressure pad alarm and placed it under the bed. The CNA #6 replaced the pad and left the room. An interview on 9/24/10 at 2:15 PM with the director of nursing (DON) revealed that an alarm was in place to alert the staff when resident was up. The DON stated that the resident had been on 15 minute checks, but not currently. The DON acknowledged that when the resident #101 came in (admission) an alarm was placed on him, and the resident showed the CNA's how he reached down and turned off the alarm. On 9/24/10 at 3:00 PM The state surveyor walked with the DON to the resident #101's room where the DON picked-up the pressure pad alarm from under the bed and placed back under the resident. Observation on 9/27/10 at 9:20 AM of resident #101's room revealed the pressure alarm to be found in the bathroom under the garbage can, hidden. The alarm was turned off. CNA #9 found the alarm. An interview on 9/27/10 at 9:30 AM with CNA#9 found the pressure alarm to be in the bathroom under the garbage can, hidden. The alarm was turned off. The CNA #9 stated, "I placed the pressure pad back under him in the bed". The documentation for 15 minute checks by staff were requested with begin date of 9/2/10 and ended on 9/12/10. On 9/24/10 there were no documentation forms found and voiced by the DON for the dates between 9/12/10 and 9/24/10, even though the facility had knowledge of the resident #101's ability to turn off his alarms and history of frequent falls. #