Every finding on record at Mission Point Nursing & Physical Rehabilitation Ce

Based on interview and record review, the facility failed to adequately monitor laboratory values and ensure the resident representative was involved with treatment decisions for 3 residents (Residents #58, #90, and #16) out of 21 residents reviewed for unnecessary medication.Findings Include;Review of the FDA prescribing information for Clozaril revealed, Severe Neutropenia CLOZARIL treatment has caused severe neutropenia, defined as an absolute neutrophil count (ANC) less than 500/uL. Severe neutropenia can lead to serious infection and death.Recommended Frequency of ANC Testing During CLOZARIL Treatment-Day 1 to Month 6: WeeklyMonth 7 to Month 12: Every 2 weeksMonth 13 and thereafter: Every month (if ANC continues to remain in the normal range)Resident #58 (R58)Review of an admission Record revealed R58 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: schizoaffective disorder.Review of R58's Order Summary dated 3/16/24 revealed, Clozaril Oral Tablet 50 MG (Clozapine) Give 1 tablet by mouth two times a day for schizoaffective disorder Give with 200mg tab = 250mg AND cloZAPine Oral Tablet 200 MG (Clozapine) Give 1 tablet by mouth two times a day for schizoaffective disorder Give with 50mg tab = 250mg.Review of R58's Monthly Medication Review dated 11/20/24 revealed, Due to potential for severe adverse drug reaction, it is recommended to monitor ANC (absolute neutrophil count) every 4 weeks during maintenance therapy with clozapine. If not already being done, please obtain CBC (complete blood count) monthly.Review of R58's Monthly Medication Review dated 2/27/26 revealed, This resident has several standing order labs on record including.CBC.During review of his electronic health record, I was unable to locate recent results.Review of R58's Psychiatry Initial Evaluation dated 5/14/26 revealed, .Recommend monthly CBC with differential for clozapine monitoring.During an interview via email on 5/27/26 at 3:47 PM a request for the last 6 months of R58's laboratory testing results was requested. On 5/28/26 at 8:32 AM the Nursing Home Administrator (NHA) reported there were 2 lab reports dated 3/9/26 and 5/11/26.Resident #90 (R90)Review of an admission Record revealed R90 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: schizoaffective disorder.Review of R90's Order Summary dated 1/30/25 revealed, Clozaril Oral Tablet 200 MG (Clozapine) Give 1 tablet by mouth two times a day for Schizophrenia.Review of R90's Psychiatry Follow up dated 12/17/25 revealed, Recommend continue regular interval lab draws of CBC. Review of R90's Psychiatry Follow up dated 4/15/26 revealed, .Recommend updated CBC with differential for Clozaril. Patient would benefit from updated CMP.During an interview via email on 5/27/26 at 3:47 PM a request for the last 6 months of R90's laboratory testing results was requested. On 5/28/26 at 8:32 AM the NHA reported there were 3 lab reports. 2 were dated 12/2/25 and 1 was dated 5/11/26.During an interview on 6/1/26 at 12:43 PM, the Director of Nursing (DON) reported the behavioral management team follows the providers orders, the psychiatric providers recommendations, and the pharmacist recommendations regarding laboratory testing for residents on Clozaril and confirmed R58 and R90 did not have monthly laboratory testing ordered.During an interview on 6/1/26 at 1:12 PM, Social Services Advocate (SSA) I reported the unit manager would be responsible for obtaining labs for Clozaril if they were required.Resident #16 (R16)Review of an admission Record revealed R16 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: psychotic disorder with hallucinations. Further review of the record revealed R16 had a guardian and was not his own decision maker.Review of R16's Order Summary dated 4/1/26 revealed, Abilify Oral Tablet 2 MG (Aripiprazole) Give 2 mg by mouth one time a day for psychotic disturbance GDR per (psychiatric consultant) recommendation.Review of R16's Psychiatry Follow up dated 2/24/26 revealed, .Patient is currently undergoing GDR of Abilify, currently tolerating 5 mg dose, will recommend trial of 2 mg dose.Review of R16's Progress Note dated 5/1/26 revealed, Abilify dose was reduced from 5 mg to 2 mg daily on 02/26/2026, after which behavioral symptoms increased.Review of R16's Electronic Medical Record (EMR) revealed no documentation that R16's guardian participated in the decision to continue with the GDR (gradual dose reduction) of abilify or that she was notified of the dose decrease in February 2026.During an interview on 6/1/26 at 1:12 PM, SSA I reported that the behavioral management team met monthly to review residents receiving psychotropic medications. If the psychiatric consultant recommended a GDR it was discussed as a team and did not automatically result in an attempted GDR if the behavior management team felt it was not safe and/or appropriate for the resident. SSA I reported the resident's guardian would be notified of the gradual dose reduction by the behavior management team.During an interview on 6/1/26 at 1:44 PM, Unit Manager (UM) H reported the resident's guardian is not notified of a dose change in medication further reporting that the guardian would be notified of the initiation of a medication and the discontinuation of the medication stating the facility staff don't have to get consent to change the dose of medications. UM H was asked if the residents guardian/representative was involved with the process to GDR a medication and if the decision to forego a dose decrease by the guardian/representative would be honored. UM H stated the facility (didn't) have a choice, CMS says we have to (complete a GDR on psychotropic medications). SSA I clarified that the behavior management team did not force dose reductions but would ask that they try (the GDR).During an interview via email on 6/1/26 at 2:09 PM, the DON stated, I do not see documentation of notification in the chart for the second GDR for (R16) in February.Review of the facility policy, Behavior Management Program last reviewed/revised June 2023 revealed, .d. As part of the least restrictive environment for each resident, gradual dose reductions will be attempted per the most current guidelines .Review of the State Operations Manual revealed In accordance with the requirements at S483.10(c), residents have the right to be informed of and participate in their treatment. Prior to initiating or increasing a medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, in advance of such initatiation or increase. The resident has the right to accept or decline the initiation or increase of a medication. To demonstrate compliance, the resident's medical record must include documentation that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and was able to choose the option he or she preferred .Medication management is based in the care process and includes recognition or identification of the problem/need, assessment, diagnosis/cause identification, management/treatment, monitoring, and revising interventions, in accordance with S483.45(d)(3) and (d)(5), as well as documenting medication management steps. Monitoring and accurate documentation of the resident's response to any treatment (such as, lab results, vital signs, progress notes, behavior flow sheets, medication administration records and the consultant pharmacist's drug regimen review) is essential to evaluate the ongoing effectiveness, benefits as well as risks of non-pharmacological approaches and psychotropic medications .One of the existing mechanisms to warn prescribers about risks associated with medications is the Food and Drug Administration (FDA) requirement that manufacturers include warnings about adverse reactions and potential safety hazards identified both before and after approval of a medication, and what to do if they occur (Visit: https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program or search for FDA Safety Alerts for Human Medical Products. Manufacturers are required to place statements about serious problems or contraindications in a prominently displayed box ( black box) in the medication labelling. The boxed warning is reserved for prescription drugs that pose a significant risk of serious or life-threatening adverse effects, based on medical studies.Review of the FDA Drug Safety Communication dated 8/27/25 revealed, Based on FDA's re-evaluation of the Clozapine REMS and on the November 19, 2024 Joint Meeting of the Drug Safety and Risk Management Advisory Committee and the Psychopharmacologic Drugs Advisory Committee, the Agency determined that the REMS was no longer necessary to ensure the benefits of clozapine outweigh the risk of severe neutropenia. Although there remains a risk of severe neutropenia with clozapine use, clozapine labeling (including a new Medication Guide) is sufficient to mitigate this risk and maintain a positive benefit/risk profile. ANC monitoring can help identify neutropenia early to allow for timely intervention. Therefore, prescribers should continue to monitor patients' ANC according to the monitoring frequencies described in the prescribing information. (https://www.fda.gov/drugs/drug-safety-communications/fda-removes-risk-evaluation-and-mitigation-strategy-rems-program-antipsychotic-drug-clozapine).

Based on interview and record review, the facility failed to ensure medications were administered and assessments were completed in accordance with physician orders for 2 of 21 residents (Resident #15 and #16), reviewed for nursing professional standards of practice.Findings:Resident #15 (R15)Review of an admission Record revealed R15 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain.Review of R15's Order Summary dated 3/26/26 revealed, traMADol HCl Oral Tablet 50 MG Give 1 tablet by mouth three times a day for pain. To be administered at 7:00 AM, 2:00 PM, and 9:00 PM.Review of R15's Controlled Substance Proof of Use Record revealed that on 5/25/26 a dose of tramadol was dispensed at 7:59 AM and at 8:10 PM. The 2:00 PM dose was not documented as dispensed.Review of R15's Medication Administration Record revealed documentation that all 3 doses of tramadol was documented as administered on 5/25/26.During an interview via email on 5/29/2026 at 2:50 PM, the Director of Nursing (DON) stated, On 5/25/26, the nurse did document Tramadol as administered in (electronic medication administration record) for the afternoon administration, but did not sign it out on the controlled substance record and did not administer the medication. Education is being provided to this nurse. Resident #16 (R16)Review of an admission Record revealed R16 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure.Review of R16's Order Summary dated 4/1/26 revealed, Midodrine HCl Oral Tablet Give 2.5 mg by mouth three times a day for hold for SBP >100 (systolic blood pressure [top number] less than 100) give if diastolic (bottom number) below 50. Review of R16's Blood Pressure Summary and Medication Administration Record revealed:On 4/4/26 R16's blood pressure was 113/65 and the midodrine was administered.On 4/6/26 blood pressure was 111/76 and the midodrine was administered.On 4/22/26 blood pressure was 108/76 and 113/57 and the midodrine was administered.On 5/2/26 blood pressure was 135/69 and the midodrine was administered.On 5/16/26 blood pressure was 115/70 and the midodrine was administered.On 5/21/26 blood pressure was 113/53 and the midodrine was administered.On 5/22/26 blood pressure was 107/55 and the midodrine was administered.During an interview via email on 5/29/2026 at 2:50 PM, the DON stated, (R16's) Midodrine was administered outside of parameters. Discussed with some of the nurses that regularly care for (R16) and initiated education regarding following provider order including risks associated with administration of cardiac medications outside of ordered parameters.Review of the facility policy Medication Administration-General Guidelines dated 9/1/23 revealed, .4. Rights-Right resident, right drug, right dose, right route, right reason, right documentation and right time, are applied for each medication being administered.

Based on observation, interview, and record review, the facility failed to ensure 3 residents (R57, R7 and R13) out of 4 residents reviewed for accidents, had appropriate interventions implemented to avoid accidents.Findings Include:Resident #57 (R57)Review of a Face Sheet reflected R57 admitted to the facility with diagnoses that included Parkinson's disease, dementia and spinal stenosis. During an observation on 5/26/26 at 11:00 AM, Certified Nurse Aide (CNA) F provided incontinent care for R57 without another staff member present to assist with positioning the resident. CNA F was observed rolling R57 away from their body without support at the edge of the bed, placing R57 at risk for rolling off the side of the bed. During an interview on 5/27/26 at 4:15 PM, Licensed Practical Nurse (LPN)/Unit Manager (UM) G reported CNAs are expected to review Kardex (a resident care guide) to identify what level of assistance a resident need. LPN G reported R57's ability to assist with bed mobility varies. It would be her expectation that the resident be pulled toward the staff member for cares and bed mobility, not away. Review of a Care Plan initiated on 4/10/2022 reflected R57 required assistance with Activities of Daily Living (ADLs). Interventions reflected the resident required 2 people for bed mobility, 2 people for transfers, and 1-2 people to assist with toileting needs (interventions initiated on 11/03/2024). If incontinent care is being provided in the bed, two people would be required to move R57 in the bed in order to render care. Resident #7 (R7)During an observation on 5/26/26 at 9:18 AM, R7 laid in bed resting with her eyes open. The call light laid on the floor, on the right side of the bed, out of sight and out of reach of R7.Resident #13 (R13)During an observation on 5/26/26 at 9:30 AM, R13 laid in bed with her eyes open. The call light hung from a plastic hook on the wall, behind and to the right of the resident. The button used to activate the call light laid on a bedside table behind some personal belongings, out of sight and out of reach of the resident. Review of a policy Call Light System revised 12/2020, reflected The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. The policy specified, 5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed.

This citation pertains to intake 2626738Based on observation, interviews and record review, the facility failed to protect the resident's (R4's) right to be free from physical abuse by another resident (R3), resulting in physical and psychosocial harm to R4. Findings:Resident #3 (R3)Review of an admission Record reflected R3 admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbances, anoxic brain damage, chronic obstructive pulmonary disease, anxiety, insomnia, and a personal history of sudden cardiac arrest. Review of a comprehensive Minimum Data Set (MDS) assessment dated [DATE] reflected R3 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status score of 8/15. The assessment did NOT indicate whether R3 exhibited wandering behavior or was intruded on the privacy or activities of others. Section F - Preferences for Customary Routine and Activities reflected it was 1 - Very important to have books, newspapers, and magazines to read, listen to music you like, keep up with the news, do things with groups of people, do your favorite activities, go outside and get fresh air when the weather is good and participate in religious services or practices.Review of a Care Plan initiated on 9/5/2025 reflected (R3) am at risk for elopement. I am a wanderer, and exhibit Exit seeking behavior r/t (related to) History of successful attempts (to) leave previous facility unattended. I am independent with mobility without a physical device, I have a diagnosis of dementia/other cognitive problem, I have impaired safety awareness. I wander the unit the majority of the day, lack personal boundaries, and enter other resident's personal space. I wander in-and-out of other resident rooms and have a history of getting into their personal belongings. On 9/09/2025, the facility initiated an intervention Distract me from wandering by offering pleasant diversions; I prefer listening to music, 'slow jams' and playing cards.Further review of the Care Plan, initiated on 9/5/2025 reflected that R3 has impaired cognitive function or impaired thought process related to dementia diagnosis and anoxic brain injury. I have impaired cognitive function or impaired thought process r/t Dementia diagnosis. I have the potential to demonstrate physical behavioral/verbal frustration related to dementia (impaired personal boundaries, defending my personal space, believing others to be in my home, etc.) I may not be invited to attend my care conference (with family and/or guardian), as my cognition is impaired, and my mood/behavior may escalate r/t talking about placement, behaviors, need for assist, etc. Review of a Nursing Progress Note dated 9/7/2025 at 1:12 PM reflected R3 was Pacing and exit seeking entire shift. Was using his roommate's phone. Attempting to call taxi. Continues to go door to door and checking to open. Repeatedly stated that he is not staying here.Review of Behavior Notes dated 9/7/2025 at 9:13 PM reflects Resident pacing all shift trying to get out of the unit nonstop. Resident using roommates' phone to call for rides and ask for drugs. Resident not allowing staff to take urinated clothes out of room. Resident increased yelling and aggressive behavior we (sic) staff asked for clothes to be cleaned. The Intervention to address the behavior was to explain how laundry works at the facility and was not effective in relieving R3's aggressive behavior. The note included space to document physician notification as well as what interventions were put into place to keep others safe. Both areas in the Behavior Note were left blank. Review of a Nursing Progress Note dated 9/11/2025 at 8:25 PM reflected R3 had exit seeking behaviors from onset of shift until dinner time . (R3) was attempting to open several doors including other resident's rooms. He was easily redirected. The note does not specify how or what R3 was redirected to do. Review of a Nursing Progress Note dated 9/12/2025 at 11:18 PM reflected (R3) with wandering, exit seeking and attempting to take others' items. Redirected easily by staff but increased verbal confrontations with other residents upon entering rooms. The progress note did not specify the residents R3 is having increased verbal confrontations with or what items R3 is trying to take. Review of a Incident Note dated 9/13/2025 at 8:13 PM reflected This resident was involved in a physical altercation with another resident @ (at) 1525 (3:25 PM) on 09/13. This resident (R3) entered another resident's room, made physical contact with the other resident's left cheek with a closed fist. Immediately separated, placed on 15-minute checks. Appropriate parties notified. Immediate intervention implemented: 15-minute checks.Resident #4 (R4)Review of an admission Record reflected R4 admitted to the facility on [DATE] with diagnoses that included bipolar disorder, frontotemporal neurocognitive disorder, schizoaffective disorder, psychoactive substance-induced persisting dementia, muscle weakness, primary open angle glaucoma, bilateral and chronic pain. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R4 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12/15. Review of a Care Plan Focus identified on 5/8/2023 indicated (R4) have the potential to demonstrate behaviors verbally i.e., to talk to myself and have the potential to use inappropriate language and potential for verbal frustration/agitation r/t dementia and mental illness. Profanity is often a part of my everyday vocabulary. I have the potential to become behavioral when I am not having my wants met immediately, I have the potential to become behavioral r/t guardianship and desire to discharge. I appear to be talking to or seeing things/people that are not there. I have potential to make false accusations. An intervention initiated 2/6/2023 included Analyze key times, places, circumstances, trigger, and what de-escalates behavior and document. Behavior management review per policy. Further review of the Care Plan initiated on 2/6/2023 indicates (R4) Have the potential to demonstrate physical behaviors (my guardian reports I have a history of being physically aggressive with other men in my AFC (adult foster care) r/t cognition and mental illness. My guardian reports that if I begin pacing or I put my coat/leather jacket this is a sign I am increasing in agitation. An intervention initiated 2/6/2023 included Analyze key times, places, circumstances, trigger, and what de-escalates behavior and document. Behavior management review per policy. Review of a Facility Reported Incident (FRI) reported to the State Agency (SA) on 9/13/2025 reflected the Nursing Home Administrator (NHA) was notified at approximately 3:30 PM of an alleged resident to resident incident between R3 and R4. Licensed Practical Nurse (LPN) A was called to R4's room and found R3 in R4's room with coffee spilled on the floor. Both residents claimed to be hit by the other resident. Residents were immediately separated. Bruising and a small skin tear noted to R4's left side of face. Neurological assessments started and every 15-minute checks implemented. Provider called for medication review. Mental health provider to see both residents and social work to follow up. NHA, Director of Nursing (DON), On-Call Provider, and local law enforcement notified. During an interview on 9/24/25 at 10:51 AM, R3 was seated in the dining room of the South 2 (S2) unit at the facility. When asked, he denied knowing anything about an altercation with another resident at the home. R3 said he had never been hit or confronted by another resident on the unit and denied having to defend himself from another resident or striking another resident.During an observation and interview on 9/24/2025 at 11:23 AM, R4 was in his room, seated in a recliner chair, drinking coffee and watching TV. A green and dark purple bruise was observed on R4's cheek bone under his left eye, a small scab was noted in the same area. R4 reported that R3 would come into and out of his room [ROOM NUMBER]-4 times a day over several days and that he kept telling him he couldn't be in his room. R4 said Nobody did anything about it! Then one day he was in my bathroom, and I said, 'You can't be in there' and he punched me! It made me miserable! R4 was asked if R3 has tried to enter his room since then and he said he had, and it made him feel not safe. R4 said that he is content in his room, I am more content in here than I am out there I will tell you that. I have a stop sign outside my room and it helps sometimes. I told staff he was coming into my room; he kept coming in anyway. My face hurts, of course it hurts, it hurt when he hit me! R4 rated his pain at 8-9/10 and said, Staff need to keep that guy out of my room, keep that guy up on the other side. During an interview on 9/25/25 at 1:12 PM, Certified Nursing Assistant (CNA) J reported that she was working on the unit where R3 and R4 lived at the time of the event on 9/13/25. CNA J said R3 was in and out of rooms taking freshly poured water cups that had just been passed out to residents which wasn't good. CNA J said she was struggling to find something for R3 to do and so she got him a large basket of washcloths to fold, but that only kept him occupied for a few minutes and nothing was working. CNA J said she was talking to LPN A who was at her medication cart, CNA D was in the nurse station and had just logged onto the computer to chart, R3 was in the dining room of the S2 unit and R4 was in his room with the door closed. CNA J reported that moments later she heard R4 yell loudly and ran into his room to see R4 on the floor, one arm on the recliner, saw his face and cheek bleeding, blood running down his cheek, coffee everywhere in his room, R3 was trying to exit and shut the door. R4 said R3 hit him two times and asked them to call the cops. CNA J said the R4's face was instantly swollen and purple in color, blood running down his face, as it went on it got way worse. CNA J said there was no indication R3 was physically aggressive before this incident but perhaps he worked himself into a physical altercation because they simply could not keep him occupied and out of other resident's rooms. During an interview on 9/25/25 at 1:43 PM, CNA B reported she worked the day shift on 9/13/25 the day of the incident between R3 and R4. CNA B said that on that day there were no planned activities, and they tried to keep residents busy but believes R4 may sundown (a change in cognitive status that occurs in the afternoon and evening). According to CNA B, 15-minute checks are routine on the unit due to most residents are at risk for falls and do not really amount to a significant new intervention. CNA B said that a lot can happen in 15 minutes due to the fact that many of the residents on the S2 unit are independently ambulatory. During an interview on 9/25/25 at 2:35 PM, LPN A reported that on 9/13/25 R3 was exit seeking at the start of the shift and going into other resident's rooms, Everyone was pretty tense and there were other residents that were not taking too kindly to it (R3 going in and out of resident rooms). When asked, LPN A indicated three residents specifically were at risk of a negative outcome of some kind due to R3's behavior. LPN A named R4, a resident that lived in room [ROOM NUMBER] and a resident that lived in room [ROOM NUMBER] yelled at R3 very loudly to Hey! Get out of here! (R4) was pacing the unit, pushing all the exit doors, asking where the elevator was and trying to enter other people's rooms. We were doing our best, we tried to have him fold laundry, gave him magnetic blocks, (R3) would not sit still. He was taking water cups out of resident rooms. I had redirected R3 just 2 minutes prior to the incident. R4's door had been shut, then I heard yelling and when I entered the room I see R4 in the recliner chair with blood on his cheek and a bruise turning purple. R3 seemed frustrated because he had been being redirected since the beginning of the shift. I got an order for Ativan (an anti-anxiety medication) but R3 did not calm down for a good six and a half hours, he continued pacing and exit seeking. During an interview on 9/26/25 at 9:00 AM, CNA D reported that she was working on the S2 unit on 9/13/25 at the time of the incident between R3 and R4. CNA D said that R4 and 2 other residents really do not like other residents getting into their space. CNA D reported that she did not see R3 enter R4's room and thinks R3 entered R4's room through the adjoining bathroom. CNA D said the coffee was spilled on the floor in front of the bathroom and heard the cup hit the floor and heard R4 yell that R3 had hit him. CNA D said that R4 didn't leave his room after the incident and R3 continued to pace the halls and exit seek. CNA D said that she did not recall what interventions were put into place after the incident and reported staffing in the afternoons and evenings is tough because resident behaviors increase, and many residents need two people to assist with cares and are a high risk for falls, sometimes requiring what amounts to 1:1 supervision. CNA D said there used to be activities on the unit from 8:00 AM - 8:00 PM, but now it's like activities doesn't exist, and we (nursing staff) can't do it all. During an interview on 9/26/25 at 10:45 AM, RN F reported that she worked on the S2 unit the first shift on 9/13/2025 and reported R4 was calm that day. RN F said that R3 was going into and out of other resident rooms trying to get resident water cups. RN F reported there were no activities happening that day which makes things harder on nursing staff. Review of a facility policy Abuse, Neglect and Exploitation last reviewed/revised 10/2024 reflected It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy includes Employee Training with topics that include 5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: a. Aggressive and/or catastrophic reactions of residents; b. wandering or elopement-type behaviors; c. resistance to care; d. Outbursts or yelling out; and e. Difficulty in adjusting to new routines or staff. Further review of the facility policy pertaining to Abuse, Neglect and Exploitation includes a discussion about Prevention - The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation that achieves: . B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation or resident property is more likely to occur with the deployment of trained and qualified registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms. D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

This citation pertains to intake 2626738Based on observation, interview and record review, the facility failed to ensure it provided a meaningful activity program for cognitively impaired residents living on the locked unit and 2 residents (R3 and R4) out of 7 sampled residents reviewed.Findings:During an observation on 9/24/25 at 10:45 AM, 1 activity assistant was observed in the South 1 dining room on the locked unit at the facility painting the fingernails of a resident. There were 15 other residents in the dining room. None of the other residents were engaged in an activity. No other staff were present in the dining room to engage or assist with the residents. During an observation on 9/24/25 at 10:51 AM, 4 residents were sitting in the South 2 dining room. A television was on, no activities were happening at this time. During an observation on 9/24/25 beginning at 11:05 AM, no activity calendars were posted in the hallways, in common areas, in dining or activity rooms, near nurse stations or in resident rooms on the South 1 or South 2 units announcing what activities were planned for the week or month. During an observation on 9/24/25 at 1:31 PM, a large sign for Activities of the Week is hanging in the hall outside a day room on the North Unit. The weekly calendar is blank; no activities are posted in the sleeves on the sign. During an observation on 9/25/25 beginning at 11:10 AM, 10 residents were in the dining room on the South 1 dining room on the locked unit. A television was on, but residents were positioned around tables that were not facing the television, none of the residents were engaged in an activity. At 11:30 AM another resident wandered into the dining room. A staff member entered the dining room and wheeled dirty dishes on a cart out of the room but did not speak to the residents. Another staff member entered the dining room and retrieved an item from a cupboard but did not engage with any of the residents in the dining room. Staff began wheeling residents into the dining room in preparation for the noon meal, never stopping to engage with the residents who were sitting in the dining room. By 12:00 PM, 17 residents were in the dining room. Almost one hour had gone by without meaningful activity or engagement between residents or from any staff members. During an observation on 9/25/25 at 12:13 PM, LPN K reported that there was not an activity happening on the South 2 unit. LPN K said that sometimes there would be a few higher functioning residents that could go to the North Unit and participate in some of the activities with the residents that live there, but that it doesn't work for everyone that lives on the locked unit. During an observation on 9/25/25 at 3:10 PM, a whiteboard outside a dining room on the North Unit indicated that a game of Skip-Bo was to be played at 3:00 PM in the dining room. The dining room door was closed, and the room was dark, no activity was taking place. During an interview on 9/25/25 at 3:40 PM, the Activity Director (AD) C reported that she was not aware that the card game was not being played, then recalled that her part-time staff member had worked her hours that week and needed to leave before the activity was scheduled. AD C was needed to supervise a resident who was at risk for falling and needed a 1:1 for supervision, therefore the activity did not happen. AD C reported she did not have enough staff to manage two full activity calendars, one for the dementia unit (locked, South unit) and the North unit for the more cognitively intact residents. When asked, AD C said there would be no way of telling by looking at the activity calendars which activities were carried out and which ones had to be cancelled. AD C said I have tried to integrate cognitively impaired residents with the cognitively intact residents, but it really doesn't work, it's a constant back and forth. Staffing makes all the difference. When asked, AD C reported that nearly half of the 102 residents living at the facility lived on the locked South units. Resident #4 (R4)Review of an admission Record reflected R4 admitted to the facility on [DATE] with diagnoses that included bipolar disorder, frontotemporal neurocognitive disorder, schizoaffective disorder, psychoactive substance-induced persisting dementia, muscle weakness, primary open angle glaucoma, bilateral and chronic pain. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R4 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12/15. Review of a Care Plan Focus identified on 5/8/2023 indicated (R4) have the potential to demonstrate behaviors verbally i.e., to talk to myself and have the potential to use inappropriate language and potential for verbal frustration/agitation r/t dementia and mental illness. Profanity is often a part of my everyday vocabulary. I have the potential to become behavioral when I am not having my wants met immediately, I have the potential to become behavioral r/t (related to) guardianship and desire to discharge. I appear to be talking to or seeing things/people that are not there. I have potential to make false accusations. An intervention initiated 2/6/2023 included Analyze key times, places, circumstances, trigger, and what de-escalates behavior and document. Behavior management review per policy. Further review of the Care Plan initiated on 2/6/2023 indicates (R4) Have the potential to demonstrate physical behaviors (my guardian reports I have a history of being physically aggressive with other men in my AFC (adult foster care) r/t cognition and mental illness. My guardian reports that if I begin pacing or I put my coat/leather jacket this is a sign I am increasing in agitation. An intervention initiated 2/6/2023 included Analyze key times, places, circumstances, trigger, and what de-escalates behavior and document. Behavior management review per policy. Resident #3 (R3)Review of an admission Record reflected R3 admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbances, anoxic brain damage, chronic obstructive pulmonary disease, anxiety, insomnia, and a personal history of sudden cardiac arrest. Review of a Life Enrichment Note dated 9/2/2025 at 6:37 AM from the transferring facility reflected Reviewed LE (life enrichment) participation over the past 14 days. Resident took part in 26 1:1 visits, refused group programing most days but took part in 3 groups. Residents enjoy communal dining, socializing with staff and residents, special snacks, going outside, playing basketball and active games, talking sports and about family, little interest in groups probably due to inattention. Will continue to provide 1:1 visits and engagement in leisure as accepted. Residents also enjoy spending time in the therapy gym. Interviewed LE staff regarding latest engagement in 1:1s and updated preferences. The Life Enrichment Note objectively identified R3 as physically active, social and needing a lot of 1:1 attention. Review of a comprehensive Minimum Data Set (MDS) assessment dated [DATE] reflected R3 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status score of 8/15. The assessment did NOT indicate whether R3 exhibited wandering behavior or was intruded on the privacy or activities of others. Section F - Preferences for Customary Routine and Activities reflected it was 1 - Very important to have books, newspapers, and magazines to read, listen to music you like, keep up with the news, do things with groups of people, do your favorite activities, go outside and get fresh air when the weather is good and participate in religious services or practices.Review of a Care Plan initiated on 9/5/2025 reflected (R3) am at risk for elopement. I am a wanderer, and exhibit Exit seeking behavior r/t History of successful attempts leave previous facility unattended. I am independent with mobility without a physical device, I have a diagnosis of dementia/other cognitive problem, I have impaired safety awareness. I wander the unit the majority of the day, lack personal boundaries, and enter other resident's personal space. I wander in-and-out of other resident rooms and have a history of getting into their personal belongings. On 9/09/2025, the facility initiated an intervention Distract me from wandering by offering pleasant diversions; I prefer listening to music, 'slow jams' and playing cards. Further review of the Care Plan, initiated on 9/5/2025 reflected that R3 has impaired cognitive function or impaired thought process related to dementia diagnosis and anoxic brain injury. I have impaired cognitive function or impaired thought process r/t Dementia diagnosis. I have the potential to demonstrate physical behavioral/verbal frustration related to dementia (impaired personal boundaries, defending my personal space, believing others to be in my home, etc.) I may not be invited to attend my care conference (with family and/or guardian), as my cognition is impaired, and my mood/behavior may escalate r/t talking about placement, behaviors, need for assist, etc. Review of a Nursing Progress Note dated 9/7/2025 at 1:12 PM reflected R3 was Pacing and exit seeking entire shift. Was using his roommate's phone. Attempting to call taxi. Continues to go door to door and checking to open. Repeatedly stated that he is not staying here. Review of Behavior Notes dated 9/7/2025 at 9:13 PM reflects Resident pacing all shift trying to get out of the unit nonstop. Resident using roommates' phone to call for rides and ask for drugs. Resident not allowing staff to take urinated clothes out of room. Resident increased yelling and aggressive behavior we (sic) staff asked for clothes to be cleaned. The Intervention to address the behavior was to explain how laundry works at the facility and was not effective in relieving R3's aggressive behavior. The note included space to document physician notification as well as what interventions were put into place to keep others safe. Both areas in the Behavior Note were left blank. Review of a Nursing Progress Note dated 9/11/2025 at 8:25 PM reflected R3 had exit seeking behaviors from onset of shift until dinner time . (R3) was attempting to open several doors including other resident's rooms. He was easily redirected. The note did not specify how or what R3 was redirected to do. Review of a Nursing Progress Note dated 9/12/2025 at 11:18 PM reflected (R3) with wandering, exit seeking and attempting to take others' items. Redirected easily by staff but increased verbal confrontations with other residents upon entering rooms. The progress note did not specify the residents R3 is having increased verbal confrontations with or what items R3 is trying to take. Review of a Incident Note dated 9/13/2025 at 8:13 PM reflected This resident was involved in a physical altercation with another resident @ (at) 1525 (3:25 PM) on 09/13. This resident (R3) entered another resident's room, made physical contact with the other resident's left cheek with a closed fist. Immediately separated, placed on 15-minute checks. Appropriate parties notified. Immediate intervention implemented: 15-minute checks. Review of a Behavior Notes dated 9/22/2025 at 1:46 PM reflected Resident (R3) observed pacing unit all shift making statement regarding getting out of here, that this place is to slow for him. Observed and redirected resident over a dozen times attempting to enter another resident's room. Easy to redirect but seems more agitated than usual with redirection. Resident verbally expressed he 'has nothing to do here.'. The Behavior note did not reflect any pertinent contributing factors related to the behavior, interventions, evaluations and/or notifications as applicable. Review of a Psychoactive Medication Progress Note dated 9/22/2025 at 7:16 PM reflected R3 was given Ativan 0.5 mg (milligram) TID (three times a day). The note specified Any change in mood or behavior noted with this change in medication (monitoring?): Increased wandering and exit seeking behaviors during the shift. During an interview on 9/25/25 at 1:12 PM, Certified Nursing Assistant (CNA) J reported that she was working on the unit where R3 and R4 lived at the time of the event on 9/13/25. CNA J said R3 was in and out of rooms taking freshly poured water cups that had just been passed out to residents which wasn't good. CNA J said she was struggling to find something for R3 to do and so she got him a large basket of washcloths to fold, but that only kept him occupied for a few minutes and nothing was working. CNA J said she was talking to LPN A who was at her medication cart, CNA D was in the nurse station and had just logged onto the computer to chart, R3 was in the dining room of the S2 unit and R4 was in his room with the door closed. CNA J reported that moments later she heard R4 yell loudly and ran into his room to see R4 on the floor, one arm on the recliner, saw his face and cheek bleeding, blood running down his cheek, coffee everywhere in his room, R3 was trying to exit and shut the door. R3 said R4 hit him two times and asked to call the cops. CNA J said R4's face was instantly swollen and purple in color, blood running down his face, as it went on it got worse. CNA J said there was no indication R3 was physically aggressive before this incident but perhaps he worked himself into a physical altercation. During an interview on 9/25/25 at 1:43 PM, CNA B reported she worked the day shift on 9/13/25 the day of the incident between R3 and R4. CNA B said that on that day there were no planned activities, and they tried to keep residents busy but believes R3 may sundown (a change in cognitive status that occurs in the afternoon and evening). According to CNA B, 15-minute checks are routine on the unit due to most residents are at risk for falls and so much can happen in the span of 15 minutes. During an interview on 9/25/25 at 2:35 PM, LPN A reported that on 9/13/25 R4 was exit seeking at the start of the shift and going into other resident's rooms, Everyone was pretty tense and there were other residents that were not taking too kindly to it (R4 going in and out of resident rooms). When asked, LPN A indicated three residents specifically were at risk of a negative outcome of some kind due to R4's behavior. LPN A named R4, a resident that lived in room [ROOM NUMBER] and a resident that lived in room [ROOM NUMBER] yelled at R4 very loudly to Hey! Get out of here! (R4) was pacing the unit, pushing all the exit doors, asking where the elevator was and trying to enter other people's rooms. We were doing our best, we tried to have him fold laundry, gave him magnetic blocks, (R4) would not sit still. He was taking water cups out of resident rooms. I had redirected R4 just 2 minutes prior to the incident. R3's door had been shut, then I heard yelling and when I entered the room I saw R3 in the recliner chair with blood on his cheek and a bruise turning purple. R4 seemed frustrated because he had been being redirected since the beginning of the shift. I got an order for Ativan (an anti-anxiety medication) but R4 did not calm down for a good six and a half hours, he continued pacing and exit seeking. During an interview on 9/26/25 at 9:00 AM, CNA D reported that she was working on the S2 unit on 9/13/25 at the time of the incident between R3 and R4. CNA D said that R4 and 2 other residents really do not like other residents getting into their space. CNA D reported that she did not see R3 enter R4's room and thinks R3 entered R4's room through the adjoining bathroom. CNA D said the coffee was spilled on the floor in front of the bathroom and heard the cup hit the floor and heard R4 yell that R3 had hit him. CNA D said that R4 didn't leave his room after the incident and R3 continued to pace the halls and exit seek. CNA D said that she did not recall what interventions were put into place after the incident and reported staffing in the afternoons and evenings is tough because resident behaviors increase, and many residents need two people to assist with cares and are a high risk for falls. CNA D said there used to be activities on the unit from 8:00 AM - 8:00 PM, but now it's like activities doesn't exist, and we (nursing staff) can't do it all. During an interview on 9/26/25 at 9:45 AM, the surveyor's 50-minute observation from 9/25/25 was discussed. RN E, the Unit Manager for the South 1 and 2 locked units said that she was not sure how many residents living on the South 1 and South 2 units needed 2 people to assist with care. RN E reported that the activity programming is not where we want it to be and said The aides can't do it (activities, cares, supervision) all. A lot can happen in a few minutes. During an interview on 9/26/25 at 10:45 AM, RN F reported that she worked on the S2 unit the first shift on 9/13/2025 and reported R4 was calm that day. RN F said that R3 was going into and out of other resident rooms trying to get resident water cups. RN F reported there were no activities happening that day. Review of a facility policy Activities dated 1/1/2024 reflected It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction with the community.5. Scheduled activities are posted in the resident's room, where appropriate, and in a prominent place in the facility.9. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs. These include, but are not limited to, considerations for: a. Residents who exhibit unusual amounts of energy or walking without purpose, b. Residents who engage in behaviors not conducive with a therapeutic home like environment, c. Residents who exhibit behaviors that require a less stimulating environment to discontinue behaviors not welcomed by others sharing their social space, d. Residents who go through others' belongings.

This citation pertains to intake 2626738Based on observation, interview, and record review the facility failed to thoroughly investigate resident-to-resident abuse for two residents (R3 & R4).Findings include:Resident #3 (R3)Review of an admission Record reflected R3 admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbances, anoxic brain damage, chronic obstructive pulmonary disease, anxiety, insomnia, and a personal history of sudden cardiac arrest. Review of a comprehensive Minimum Data Set (MDS) assessment dated [DATE] reflected R3 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status score of 8/15. Review of a Incident Note dated 9/13/2025 at 8:13 PM reflected This resident was involved in a physical altercation with another resident @ (at) 1525 (3:25 PM) on 09/13. This resident (R3) entered another resident's room, made physical contact with the other resident's left cheek with a closed fist. Immediately separated, placed on 15-minute checks. Appropriate parties notified. Immediate intervention implemented: 15-minute checks.Resident #4 (R4)Review of an admission Record reflected R4 admitted to the facility on [DATE] with diagnoses that included bipolar disorder, frontotemporal neurocognitive disorder, schizoaffective disorder, psychoactive substance-induced persisting dementia, muscle weakness, primary open angle glaucoma, bilateral and chronic pain. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R4 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12/15. Review of a Facility Reported Incident (FRI) reported to the State Agency (SA) on 9/13/2025 reflected the Nursing Home Administrator (NHA) was notified at approximately 3:30 PM of an alleged resident to resident incident between R3 and R4. Licensed Practical Nurse (LPN) A was called to R4's room and found R3 in R4's room with coffee spilled on the floor. Both residents claimed to be hit by the other residents. Residents were immediately separated. Brusing and a small skin tear noted to R4's left side of face. Neurological assessments started and every 15-minute checks implemented. Provider called for medication review. Mental health provider to see both residents and social work to follow up. NHA, Director of Nursing (DON), On-Call Provider, and local law enforcement notified. Further review of the full investigation report did not include statements from staff who had been working with R3 in the hours leading up to the incident. The investigation did not include statements from the nurse aides who were on duty at the time of the incident. There is no evidence in the investigation there were any visitors on the unit or employees on duty on the unit at the time of the occurrence who may have been a witness to the circumstances leading up to the event. During an interview on 9/24/25 at 3:40 PM, the NHA was asked if there were any additional witness statements to be included in the FRI pertaining to R3 and R4. The NHA contacted Registered Nurse (RN) (a unit manager) M, the Director of Nursing (DON), the Administrator in Training (AIT) P, RN E (the manager for the unit where R3 and R4 live). The NHA reported there were no additional witness statements. During an interview on 9/25/25 at 1:12 PM, Certified Nursing Assistant (CNA) J reported that she was working on the unit where R3 and R4 lived at the time of the event on 9/13/25. CNA J reported no one had asked her to provide a statement about the resident-to-resident abuse. During an interview on 9/25/25 at 1:43 PM, CNA B reported she worked the day shift on 9/13/25 the day of the incident between R3 and R4. CNA B reported she had not been asked to provide a statement pertaining to the resident-to-resident abuse between R4 and R3 on 9/13/25. During an interview on 9/25/25 at 2:35 PM, LPN A reported that she was working on the S2 unit on 9/13/25 at the time of the incident between R3 and R4. LPN A was not asked to provide any additional information for the investigation into the resident-to-resident abuse between R4 and R3 other than what is documented in the clinical record. During an interview on 9/26/25 at 9:00 AM, CNA D reported that she was working on the S2 unit on 9/13/25 at the time of the incident between R3 and R4. CNA D reported she was not asked to provide a statement for the abuse investigation. During an interview on 9/26/25 at 10:45 AM, RN F reported that she worked on the S2 unit the first shift on 9/13/2025. A statement from RN F was not included in the investigation report. RN F reported there were no activities happening that day. Review of the facility policy Abuse, Neglect and Exploitation last reviewed/revised 10/2024 reflected A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The policy specified, .4.Idetifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.

This citation pertains to intakes MI00153884 and MI0015408 Based on observation, interview and record review the facility failed to prevent one Resident (R1) of 3 Residents reviewed from leaving the facility unsupervised. Finding included: Review of R1's admission record revealed she was [AGE] years old and admitted to the facility on [DATE] and had diagnoses that included: vascular dementia, aphasia (language disorder that affects the ability to communicate), and history of falling. She was not her own responsible party. Review of the facility reported incident, 5 day report revealed R1 was found outside the facility on 6/24/25 at 4:31 PM. R1 was placed on 1:1 supervision for safety at that time. The conclusion revealed, After investigation and interviews the facility was able to identify that R1 did leave the facility unauthorized. R1 was unsupervised for approximately 3 - 4 minutes and does not have any lasting harm and no injuries. Review of Registered Nurse (RN) G's statement in the facility 5 day report revealed, on 6/24/25 noted R1 was observed outside the facility in the parking lot unattended by a recreation department staff member at approximately 16:32 (4:32 PM) Staff member redirected resident back into the facility after spending approximately 6 -8 minutes convincing resident to return back inside the facility. Review of Activity Aide AA F's statement in the 5 day report revealed, I clocked out at 4:31 and I left the building. When I got outside onto the sidewalk I saw R1 walking by the cars. She was trying to see if they would open. I ran over to her. I asked her what are you doing out here. We should go back inside. R1 responded with I just want to go home. I want my family. I continued to talk to her suggesting that we could try to call family back inside the building. R1 was observed in the facility on 7/8/25 at 8:30 AM standing over her bedside table. She was looking at her menu choices. She appeared to be trying to read the menu choices, but the words did not match what was written. Certified Nurse Aide (CNA) H came over to assist R1 get her wheeled walker and attempted to determine what R1 wanted. CNA H read the menu choices to R1 several times. After several attempts CNA H questioned R1 if she wanted the chicken and R1 nodded her head yes. R1 lifted her shirt and indicated she needed help. CNA offered to get R1 dressed, and she agreed to having CNA H provide care. During an interview with the Nursing Home Administrator (NHA) on 7/8/25 at 9:15 AM, the NHA confirmed that R1 had eloped from the facility on 6/24/25. The facility was not 100 percent certain how R1 got out of the facility. He believed the most likely way was out the door near the parking lot. To increase the safety, they have disabled to the button outside that allowed anyone entry (visitor now need to call for assistance to get in). The NHA said he decreased the locking time on the door to 5 seconds. They have also placed an alarm on R1 which locks the doors when she is in proximity to any outside door. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included . Review of the Past Noncompliance - Elopement, June 24, 2025 revealed, R1, was observed by an activity aide in the parking lot of the facility at approximately 16:32 (4:32 PM) on 6/24/25. This serves as the facility Plan of Correction, in response to the following action plan had been implemented. Action taken for issue involved: -Resident was returned to facility - nursing assessment and elopement risk assessment completed. -Resident was placed on 1:1 until 12:35 PM on 06/25/25 as soon as WanderGuard was put in place. -All resident charts were reviewed and verified that Elopement Risk Assessments were in place. -All mag-lock doors in the facility were checked and verified for functions by EVS Director -Review elopement book to validate it was up-to-date and included all at-risk residents. Action taken for the employees involved: -Verbal re-education provided to all staff in the facility the following day of the incident. Area identified requiring quality improvement: -Staff re-education on Elopement and Wandering policy. How facility identified resident(s) affected and residents with potential to be affected: - All residents deemed to be at risk for elopement have the potential to be affected. Quality Improvement measures or systemic changes made: - All facility staff were provided re-education regarding the following policies/procedure: Elopement and Wandering Policy. - Initiation of QAA Investigation on 06/24/25 to identify details of the incident and to identify any potential deficient practice that may have occurred in relation to the incident. - Maintenance care check of all facility doorways and checked and reviewed for completion and accuracy. - The facility substantiated that the resident did elope form the facility. The facility substantiated that the resident was able to leave without direct supervision. A Past-Non-Compliance was developed by the QAA Committee for immediate response to the identified concern: Resident's ability to exit the building without staff supervision. - The facility's Elopement and Wandering Policy has been reviewed and deemed appropriate by the Administrator and Director of Nursing. - Immediate in-serving of all facility staff on Elopement and Wandering Policy. All staff who have not received education by the end of the day 06/25/25 will be educated prior to their next scheduled shift. - Audits were developed for checking for new elopement risk residents and for exit seeking behaviors - DON/CCC's completed an audit on Elopement Risk Assessments for the current residents in the facility. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for five of six resident's reviewed (Resident #294, Resident #32, Resident #70, Resident #14, and Resident #9) who had been care planned or assessed for the use of a call light. Findings: Resident #294 (R294) Review of an Admission Record revealed R294 was a [AGE] year old female, originally admitted to the facility 03/10/25, with pertinent diagnoses of Alzheimer's, moderate protein-calorie malnutrition, unsteadiness on feet, degenerative macular eye disease, irritable bowel syndrome with diarrhea, and generalized muscle weakness. R294 was dependent on one staff person for all activities of daily living. During an observation on 04/02/25 at 7:44 AM, R294 laid in bed resting with her eyes open, the door to the room was closed, and the room was situated as the last room down the hallway on the right. The call light hung from the cord to the over bed light and was located behind the head board, out of sight and out of reach of R294. During an observation on 04/02/25 at 10:57 AM, R294 was sitting up in a rocking chair in her room, an unfinished breakfast tray sat on the over bed table and the call light remained attached to the over bed light cord, out of reach of the resident. Review of a Care Plan for R294 reflected the following safety interventions .(a) be sure my call light is within reach, and (b) reduce my risk for falls by providing an accessible working call light. Review of R294's EHR (electronic health record) revealed that a call light assessment had not been completed. Resident #32 (R32) Review of an Admission Record revealed R32 was a [AGE] year old male, last admitted to the facility on [DATE], with pertinent diagnoses of Alzheimer's, seizure disorder, and glaucoma. During an observation on 04/01/25 at 9:38 AM, R32 laid in bed resting with his eyes closed and the call light and cord were wrapped in a tight coil and hung over the edge of the over bed light, out of reach of the resident. During an observation on 04/02/25 at 8:38 AM, R32 laid in bed resting with his eyes open and the call light and cord hung over the right edge of the over bed light, out of reach of the resident. During an observation on 04/02/25 at 2:17 PM, R32 laid in bed resting with his eyes closed and the call light hung over the right edge of the over bed light, out of reach of the resident. During an observation on 04/03/25 at 8:23 AM, R32 laid in bed resting with his eyes closed and the call light remained wrapped up on the right edge of the over bed light, out of reach of the resident. Review of a Care Plan for R32 reflected the following safety intervention .I need an environment with my call light and personal items within reach. Resident #70 (R70) Review of an Admission Record revealed R70 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnoses of history of falls, bilateral cataracts, and neurocognitive disorder. R72 was completely dependent on staff to meet all of her daily needs. During an observation on 04/01/25 at 2:18 PM R70 laid in bed and the call light hung from the over bed light cord behind the head board, out of sight and out of reach of the resident. During an observation on 04/03/25 at 7:39 AM, R70 laid in bed resting with her eyes closed and the call light was attached to the over bed light cord and hung behind the head board, out of sight and out of reach of R70. Review of a Care Plan for R70 reflected no safety interventions that involved the use of a call light. Review of a Call Light Assessment for R70 and dated 01/17/25, revealed the following .resident has a paddle call light due to severe cognitive impairment, staff anticipate residents needs. Resident #14 (R14) Review of an Admission Record revealed R14 was a [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses of dementia, morbid obesity, seizure disorder, and hearing loss. During an observation on 04/01/25 at 9:22 AM, R14 sat in a wheelchair next to her bed. R14 indicated that if she needed assistance she would use her call light that was wrapped around the bed rail behind her over her left shoulder. When asked if R14 could reach the call light at this time if needed, R14 attempted to reach the call light and could not. During an interview on 04/03/25 at 11:58 AM, Certified Nurse Aide (CNA) G indicated that the expectation for staff was to ensure that call lights were within reach of the resident's each time they entered a residents room. Review of the facility policy Call Lights System last reviewed 06/23, reflected .with each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of the resident and secured, as needed. 45410 Resident #9 (R9) Review of an Admission Record revealed R9 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and anxiety. Review of R9's Call Light Assessment, dated 3/7/2025, revealed R9 was able to use her call light appropriately. In an observation and interview on 4/1/2025 at 1:57 PM in R9's room, R9 was sitting in a bedside chair, and her call light was under her bed, out of sight and out of reach. R9 was not able to tell me where her call light was located. In an observation and interview on 4/2/2025 at 10:00 AM in R9's room, R9 was sitting in a bedside chair, and her call light was resting at the head of her bed. R9 was not able to tell me where her call light was located. In an observation and interview on 4/2/2025 at 1:32 PM in R9's room, R9 was sitting in a bedside chair, and her call light was resting at the head of her bed. In an interview on 4/2/2024 at 1:44 PM, CNA R reported R9 was able to use her call light.

Based on interview and record review, the facility failed to follow professional standards of nursing practice for treatment and medication administration for 4 residents (Residents #48, #35, #83, and #69) out of 9 residents reviewed for the provision of nursing services. Findings: Resident #48 (R48) Review of an Admission Record revealed R48 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R48's Order Summary dated 2/14/25 revealed, Skin prep to bilateral heels for protection in the evening. Review of R48's March Treatment Administration Record revealed absent entries (blank boxes) on 3/2/25, 3/20/25, 3/21/25, and 3/28/25 indicating the treatment was not completed. Review of R48's Order Summary dated 3/8/25-3/11/25 revealed, Coccyx/right buttocks: Cleanse discoloration, pat dry, apply skin prep and allow to dry. Cover with bordered foam dressing .every day shift. Review of R48's Order Summary dated 3/12/25-3/26/25 revealed, Coccyx/right buttocks: Cleanse discoloration, pat dry, apply skin prep and allow to dry. Cover with bordered foam dressing .in the afternoon. Review of R48's March Treatment Administration Record revealed absent entries (blank boxes) on 3/8/25, 3/13/25, and 3/22/25 indicating the treatment was not completed. Resident #35 (R35) Review of an Admission Record revealed R35 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of 35's Order Summary dated 2/28/25 revealed, Hydrocodone-Acetaminophen (Norco) Tablet 5-325 MG *Controlled Drug* Give 1 tablet by mouth three times a day for Pain. To be administered in the morning, noon, and evening. Review of R35's Norco Controlled Substance Proof-Of-Use Record revealed that on 3/22/25 R35's Norco was administered at 9:12 AM and at 6:20 PM. A noon dose was not documented as dispensed. Review of R35's March Medication Administration Record revealed on 3/22/25 the noon administration box was left blank indicating the Norco was not administered. Review of R35's Electronic Medical Record revealed no documentation for the withholding of R35's Norco or that the provider was notified that the medication was not administered. Resident #83 (R83) Review of an Admission Record revealed R83 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R83's Order Summary dated 3/3/25-3/31/25 revealed, LORazepam (Ativan) Oral Tablet 0.5 MG *Controlled Drug* Give 0.5 tablet by mouth one time a day for Anxiety and agitation. To be administered at 1:00 PM. Review of R83's Norco Controlled Substance Proof-Of-Use Record revealed that on 3/22/25 R83's Ativan was not documented as dispensed. Review of R83's March Medication Administration Record revealed on 3/22/25 the 1:00 PM administration box was left blank indicating the Ativan was not administered. Review of R83's Electronic Medical Record revealed no documentation for the withholding of R83's Ativan or that the provider was notified that the medication was not administered. Resident #69 (R69) Review of an Admission Record revealed R69 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R69's Order Summary dated 3/3/25-3/25/25 revealed, Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 20 unit subcutaneously in the morning for DM2 Hold for BS <100 (blood sugar less than 100). Review of R69's March Medication Administration Record revealed: *On 3/11/25 the insulin was administered with a blood sugar of 96 *On 3/12/25 the insulin was administered with a blood sugar of 94 Review of R69's Order Summary dated 3/26/25 revealed, Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously in the morning for DM2 (diabetes mellitus type 2) Hold for BS <120 (blood sugar less than 120). Review of R69's March Medication Administration Record revealed: *On 3/26/25 the insulin was administered with a blood sugar of 108 *On 3/27/25 the insulin was administered with a blood sugar of 111 During an interview on 4/3/25 at 8:43AM, Director of Nursing (DON) reported the Unit Managers were expected to run reports every morning to identify and medication or treatments that had been missed the previous day and follow up as needed. DON reported that education was provided to the licensed nurses that administered medications outside parameters and change in the insulin orders for all residents receiving long-acting insulin was implemented to prevent licensed nurses from administering medications outside of parameters. DON reported that R35 and R83 did not receive their scheduled medication on 3/22/25 due to an internet outage and inability to utilize the Electronic Medical Record and identify residents due for medications. DON provided Ad-Hoc QAPI meeting minutes dated 4/3/25 which revealed, Any time there is an internet outage and (electronic) MARs (Medication Administration Records) and TARs (Treatment Administration Records) are not available as soon as the EMR (Electronic Medical Record) system/Internet is restored the nurse manager on call needs to be notified so that they can complete an audit of documentation ensuring that all meds and treatments are completed. Review of the facility policy, MEDICATION ADMINISTRATION ????GENERAL GUIDELINES dated June 2019 revealed, .B. Administration . 2) Medications are administered in accordance with written orders of the prescriber . 9) A schedule of routine medication administration times is established by the facility, and unless otherwise specified by the prescriber, routine medications are administered according to this schedule. 10) Medications are administered within 60 minutes of the scheduled time .

Based on observation, interview, and record review, the facility failed to perform a resident assessment for self-administration of prescription medication for 1 resident (R73), of 1 resident reviewed for self-administration of medication. Findings include: Review of an Admission Record revealed R73 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and chronic obstructive pulmonary disease. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R73, with a reference date of 12/23/2024 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 5, out of a total possible score of 15, which indicated R73 was severely cognitively impaired. In an observation and interview on 4/1/2025 at 10:00 AM in R73's room, two medication cups containing a white cream were on R73's television stand. R73 reported staff leave the cream for him to apply to the rash on his chest. R73 reported he did not know the name of the cream. In an interview on 4/2/2025 at 8:02 AM, Registered Nurse (RN) J reported R73 had an order for staff to apply hydrocortisone cream to the rash on his chest. RN J reported R73 demanded to apply this himself, and she had been leaving it in his room for him to apply. RN J reported the interdisciplinary team had not discussed this or determined R73 was safe to self-administer topical hydrocortisone. Review of R73's Physician's Orders active 4/2/2025 at 4:00 PM revealed an order for staff to apply hydrocortisone external gel to R73's left side topically. Further review of the electronic medical record (EMR) revealed no documentation that staff evaluated R73 and determined him safe to self-administer topical hydrocortisone. In an interview on 4/2/2025 at 4:04 PM, the Director of Nursing (DON) reviewed R73's EMR and reported staff had not assessed R73 to determine whether he was safe to self-administer topical hydrocortisone. The DON reported residents should not self-administer medication until they assessed them and determined them safe to do this. Review of facility policy/procedure Resident Self-Administration of Medication, revised 6/2023, revealed .It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely .

Based on interview and record review, the facility failed to 1.) implement a physician's order for daily weights, 2.) administer as needed medication for weight increase, and 3.) ensure the provider was notified of weight gain for residents with Congestive Heart Failure (CHF) for 2 residents (Residents #17 and #89) out of 11 residents, reviewed for quality of care. Findings: Resident #17 (R17) Review of an Admission Record revealed R17 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: acute on chronic combined systolic and diastolic congestive heart failure. Review of R17's Care Plan initiated 1/15/25 revealed, Report any significant weight changes I have to my physician . Review of R17's Order Summary dated 2/5/25 revealed, Ensure daily weights are charted every day shift. Review of R17's Cardiology Consult dated 3/5/25 revealed, .Patient presents today post 3 hospitalization s since last office visit. admitted ,d+[DATE] acute CHF .and subsequent admission 3 days after discharge for flash pulmonary edema, CHF .I have asked that (facility) weihh (sic) daily and send patient with written log next office visit. Indicating R17 required increased monitoring for CHF due to multiple hospitalization s pertaining to her CHF diagnosis. Review of R17's Cardiology Consult dated 3/19/25 revealed, .Please weight daily and bring weight log to next appointment. Review of R17's Weight Summary revealed weights were not obtained on 3/3/25, 3/10/25, 3/17/25, and 3/24/25. Further review of R17's Weight Summary revealed: *On 3/1/25 a weight of 180 pounds and on 3/2/25 a weight of 183.6 pounds (increase of 3.6 pounds). *On 3/7/25 a weight of 185 pounds and on 3/8/25 a weight of 189.2 pounds (increase of 4.2 pounds) *On 3/15/25 a weight of 180.8 pounds and on 3/16/25 a weight of 184.6 pounds (increase of 3.8 pounds). *On 3/18/25 a weight of 185.6 pounds and on 3/19/25 a weight of 188.6 pounds (increase of 3 pounds). Review of R17's Electronic Health Record revealed no documentation that the provider was notified of the weight increase of greater than 2-3 pounds in 1 day. (According to the American Heart Association, weight gain of 2-3 pounds within 24 hours, or at least 5 pounds within a week, could be a sign of worsening heart failure.) Resident #89 (R89) Review of an Admission Record revealed R89 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: chronic combined systolic and diastolic congestive heart failure. Review of R89's Order Summary dated 3/17/25 revealed, Lasix Oral Tablet 20 MG (Furosemide) Give 1 tablet by mouth every 24 hours as needed for weight gain 2 pounds per day or 5 pounds per week per heart failure clinic. Indicating a weight was to be obtained daily. Review of R89's Weight Summary revealed to weights were obtained on 3/12/25-3/16/25, 3/22/25, or 3/24/25. Further review of R89's Weight Summary revealed: *On 3/18/25 a weight of 127 pounds and on 3/19/25 a weight of 131.4 pounds (increase of 4.4 pounds) *On 3/19/25 a weight of 131.4 pounds and on 3/20/25 a weight of 134.8 pounds (increase of 3.4 pounds). Review of R89's March Medication Administration Record revealed the as needed Lasix was not administered on the above dates. Review of R89's Electronic Health Record revealed no documentation that the provider was notified of the weight increase of greater than 2 pounds in 1 day or a rationale for not administering the as needed Lasix. During an interview on 4/3/25 at 8:43AM, Director of Nursing (DON) confirmed R89 and R17 did not have their weights obtained daily. DON reported licensed nurses were to ensure weights were obtained daily and were also expected to monitor the weight trends and follow the providers treatment orders. DON reported the Unit Managers were expected to run reports every morning to identify and medication or treatments that had been missed the previous day and follow up as needed. During an interview on 4/3/25 at 11:22 AM, DON reported that she had identified that the inconsistencies with obtaining weights was due to nursing staff assuming the weights had been obtained by certified nursing assistants and not verifying the completion. DON reported that she had initiated education on caring for residents with CHF. DON reported the facility did not have a policy or procedure specific to residents with CHF. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Daily weights are an important indicator of fluid status. Each kilogram (2.2 lb) of weight gained or lost overnight is equal to 1 L of fluid retained or lost .Weigh patients with heart failure daily . [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1059). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, A weight gain of 0.9 to 1.4 kg (2-3 lb) in 1 day indicates fluid-retention problems . daily weight is measured at the same time of day and on the same scale (Ball et al., 2019). This allows an objective comparison of subsequent weights. Accuracy of weight measurement is important because health care providers base medical and nursing decisions (e.g., drug dosage, medications) on changes . [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 558). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review, the facility failed to ensure residents were transferred following care planned interventions for 2 residents (Residents #66 and #78) out of 3 residents reviewed for falls. Findings: Resident #66 (R66) Review of an Admission Record revealed R66 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Huntington's Disease and history of falling. Review of R66's Care Plan revealed, I am at an increased risk for falls r/t (related to) Confusion, Huntington's Disease with Gait/balance problems, History of Falls .Unaware of safety needs secondary to HD (Huntington's Disease) with spontaneous chorea (involuntary) movements .TRANSFERRING: 2 person assist Please use gait belt, as he allows. Date Initiated: 08/15/2024 .Revision on: 10/17/2024. Review of R66's Nursing Progress Note dated 2/15/25 and written by Registered Nurse (RN) P revealed, This nurse heard a noise and heard a CNA (Certified Nursing Assistant) calling out for assistance. Upon entering the room, resident was observed laying partially on top of CNA and partially on the floor. Resident had laceration to forehead and another on bridge of nose, abrasions to bilateral knuckles and an abrasion to right knee. All areas cleansed, pressure applied to forehead and steri-strips applied to forehead and bridge of nose . Review of CNA Q's Incident Follow Up Statement dated 2/15/25 revealed, I transferred (R66) from chair to bed successfully but I had him move up in bed closer to his pillow and he jumped way to quickly and I couldn't get in front of him in time and he went toward the floor and hit his head. Review of education written by RN P revealed, (R66) is a 2 person assist (with) transfers. CNA was transferring resident alone. CNA educated on resident's transfer status + verbalized understanding. Signed by CNA Q and RN P. Review of R66's Nursing: Antigravity Team Note dated 2/18/25 revealed, .Root Cause(s) of Fall: Resident has diagnosis of Huntington's chorea, unable to control body movements. Resident attempting repositioning after transfer. One staff present for transfer .Staff educated regarding kardex (simplified care plan) and importance of having 2 staff present for all transfers and repositioning. During an interview on 04/03/25 at 11:22 AM, Director of Nursing reported that following R66's fall CNA Q was provided 1:1 education. Facility wide education was not completed. 45410 Resident #78 (R78) Review of an Admission Record revealed R78 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and repeated falls. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R78, with a reference date of 1/15/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 4, out of a total possible score of 15, which indicated R78 was severely cognitively impaired. Further review of same MDS assessment revealed R78 required assistance with ambulation. Review of a R78's Kardex, active 4/1/2025, revealed R78 required the assistance of one staff with a wheeled walker and gait belt to ambulate. In an observation on 4/2/2025 at 1:10 PM, R78 was walking independently in the hallway with his wheeled walker outside the television room. Certified Nursing Assistant (CNA) H observed R78 ambulating independently and led him to a chair in the television room by the front of his walker without attempting to place a gait belt around his waist. In an interview on 4/2/2025 at 1:19 PM, CNA H reported he should have applied a gait belt when he assisted R78 to the television room. CNA H reported R78 required staff assistance with a walker and gait belt to ambulate. In an interview on 4/2/2025 at 1:17 PM, Physical Therapy Assistant (PTA) M reported staff were expected to have a gait belt on their person and attempt to apply a gait belt to a resident that required the use of a gait belt when they assisted them with ambulation. In an interview on 4/3/2025 at 11:03 AM, the Director of Nursing (DON) reported staff were required to follow resident care plans and use gait belts when required. Review of facility policy/procedure Use of Gait Belt Policy, revised 10/2024, revealed .It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety . Each nursing department employee will have access to a gait belt . It is the responsibility of each employee to ensure they have a gait belt available for use when at work . Failure to use gait belt properly may result in corrective action and/or termination of employment .

Based on interview and record review, the facility failed to thoroughly explain the arbitration agreement and complete paper work accurately for two of three residents ( Resident #58 and Resident #88) reviewed for arbitration. Findings: Resident #58 (R58) Review of an Admission Record revealed R58 was [AGE] year old cogently intact female, originally admitted to the facility on [DATE] with pertinent diagnoses of glaucoma. During an interview on 04/03/25 at 8:50 AM, R58 stated that she did not recall signing an arbitration agreement at admission. After describing the agreement to R58, she stated that she did not recall anything of that nature. After requesting and receiving a copy of the signed arbitration agreement for R58, it was shown to the resident. R58 indicated that she cannot see, has had multiple eye surgeries, and was unable to see at the time of admission. R58 also indicated that staff sat in a chair in the room and went through the admission paperwork and R58 had given permission for Administrative Personnel (AP) F to electronically initial and sign the forms for her. R58 stated that she was not given the opportunity to choose to listen to an audio recording that explained the arbitration process for visually impaired residents. During an interview on 04/03/25 at 9:18 AM, AP F indicated (a) that the arbitration agreement had only been in use over the past few weeks, (b) that she did not read every paragraph of the arbitration agreement to R58 despite initially for R58 in multiple sections of the agreement, and (c) was advised by corporate to tell Residents, when explaining the agreement, that if the resident had any concerns with the care they received from the facility they would contact a lawyer of talk to another third party. It seemed like they just explained a little bit about the forms but they didn't really explain any of them thoroughly. Review of the Arbitration Agreement for R58 that was electronically signed by AP F on 02/26/25, revealed that the document was signed as accepted but also checked, indicating that R58 declined to sign the agreement. Resident #88 (R88) Review of an Admission Record revealed R88 was a [AGE] year old cognitively intact male, last admitted to the facility on [DATE], with pertinent diagnoses of quadriplegia. During an interview on 04/03/25 at 9:44 AM, R88 could not recall whether or not the arbitration agreement was explained to him thoroughly when he signed the documents on 09/13/24. R88 indicated that he does know what an arbitrator is however cannot recall any of the details. After explaining the arbitration agreement to R88 he stated if it had been explained to me like that I might have taken more time to consider signing it.

This citation pertains to intake #MI00147642 and #MI00148721. Based on interview and record review, the facility failed to report alleged resident abuse within the two-hour required timeframe for 4 residents (R101, R102, R103, and R104), of 5 residents reviewed for abuse. Findings include: Review of the facility investigation of MI-FRI 00057973 revealed an incident of alleged staff to resident abuse involving R101 and R102 on 10/6/2024 was reported to the Nursing Home Administrator (NHA) by facility staff at 1:30 PM on 10/10/2024. Further review revealed this alleged resident abuse was reported to the state survey agency on 10/10/2024 at 3:50 PM. In an interview on 2/6/2025 at 9:20 AM, the NHA reported former Certified Nursing Assistant (CNA) C informed him of the allegation of staff abuse of R101 and R102 on 10/10/24 and four days after the allegation took place on 10/6/2024. The NHA reported staff are expected to report allegations of abuse immediately. Review of the facility investigation of MI-FRI 00058491 revealed an incident of alleged resident to resident abuse that took place on 11/22/2024 at 5:30 PM involving R103 and R104 was reported to the NHA on 11/22/2024 at 6:00 PM. Further review revealed this alleged resident abuse was reported to the state survey agency on 11/22/2024 at 9:19 PM. In an interview on 2/6/2025 at 8:40 AM, the NHA reported he did not have internet service at 6:00 PM on 11/22/2024 when staff notified him of the alleged resident to resident abuse involving R103 and R104. The NHA reported state was not notified of this allegation within the two-hour required timeframe because it took him time to find internet access. Review of facility policy/procedure Abuse, Neglect and Exploitation, reviewed 6/2023, revealed .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation occur . Investigations may include but not limited to . Identifying staff responsible for the investigation . The facility Administrator is the Abuse Coordinator of the facility . The facility will implement the following . Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies . within specified timeframes . Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .

This Citation has two Deficient Practice Statements (DPS) DPS #1 This Citation Refers to Intake Number MI00142983 Based on observation, interview, and record review the facility failed to identify, assess, properly monitor, and treat mental and/or physical changes in condition and failed to accurately and timely document changes for two Residents (Resident #85 (R85) and R76) resulting in admission to an Intensive Care Unit in critical condition for R85 and delay in treatment for R76. Findings: R85 Review of the electronic medical record (EMR) reflected R85 originally admitted to the facility 8/26/22 and had diagnoses that included: Pseudobulbar Affect (characterized by uncontrolled outburst of laughter or crying), Manic Depression (Bipolar Disease), Dementia and Anxiety. Review of the Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) dated 11/28/23 reflected a score of 2 out of 15 which indicated the Resident was severely cognitively impaired. Section GG of this MDS revealed R85 was functionally able to ambulate independently, could eat on her own with set- up assistance, and could toilet independently. Review of the EMR Progress Note dated 2/23/24 at 5:30 PM that R85 was to be transported to the hospital for Altered mental status and Functional decline. The entry reflected, At the time of evaluation resident/patient vital signs . were blood pressure (BP) of 132/92, although this result was documented as obtained on 2/18/24. Other vital signs documented as obtained at the time of the evaluation include a pulse of 60 beats per minute (BPM) and a temperature of 98.9 degrees Fahrenheit (F). Review of the Emergency Medical Services (EMS) document titled Prehospital Care Report Summary (also known as a Run Report) reflected EMS arrived on scene at 6:04 PM, 34 minutes after the above vital signs were documented. The vital signs obtained by EMS included a pulse of 135 BPM, respiratory rate of 34 breaths per minute, a BP of 133/106 and a temperature of 103.0 F. Review of hospital emergency room records reflected initial vital signs included a core body temperature of 102.74 F, pulse of 141, and a respiratory rate. of 30. Initial laboratory blood test results included a sodium level of 168 (normal of 134 to 146) which was redrawn to confirm the critically high abnormal value. A white blood count (wbc) lab result of 17.12 (normal range of 4 to 10.8. A high result is indicative of a systemic infection). A urinalysis reflected results that included that the urine specimen of R85 was red and tested positive for blood, white blood cells (infection), and protein. Blood cultures were also obtained and later reflected positive for staphylococcus and gram-positive cocci. Hospital physician documentation included: The facility reported (to the hospital) that R85 had increases in her Zyprexa (an antipsychotic medication) and clonazepam (a benzodiazepine often prescribed for the treatment of panic disorders)) two weeks ago which was thought to be the cause of the (R85) having increased weakness and decrease in mental status over last two weeks. And On arrival, (R85) was febrile (fever), tachycardic (high heart rate), had leukocytosis (high white blood cell count), lactic acidosis (potentially life-threatening build up of lactic acid in the blood), an (Acute Kidney Injury) AKI, severe hypernatremia (high sodium blood level), and was minimally responsive. Her (urine) was positive for leukocytes (white blood cells), nitrites, and blood. On exam, she opens her eyes but does not otherwise respond to staff. And .she did have a drop in her blood pressure and required fluid resuscitation .recheck of sodium (lab level) did confirm hypernatremia (high sodium level) . And Critical Care time (treatment) was required due to the life-threatening nature of this patient's condition . Also On arrival patient appears septic., and She did have strong urine odor . The hospital documentation reflected R85 was admitted to the Intensive Care Unit (ICU) in critical condition with diagnoses that included Severe sepsis, Acute metabolic encephalopathy severe and life-threatening with Hypernatremia secondary to free water loss (dehydration) likely contributing to above, Acute cystitis with hematuria, Acute Kidney injury. Subsequent Hospital Course physician documentation included I am concerned for polypharmacy (taking many prescribed drugs), SS (Serotonin Syndrome (SS) symptoms include high heart rate, high blood pressure, confusion, and high fever as a reaction to medication) or Neuroleptic Malignant Syndrome (NMS) . (NMS is a life-threatening reaction to antipsychotic medications characterized by high fever, altered mental status, high heart rate, rapid breathing and high or low blood pressure). Hold all possible drugs that could contribute (listed are medications R85 had ordered at the facility) And Social work consult to determine if (R85) was left in an minimally responsive state for a week given how dehydrated she was Another physician documented, Social work consult to determine if (R85) was left in a minimally responsive state for a week. If so, concern for neglect . The facility EMR was reviewed for the chronology leading to the admission of R85 to the intensive care unit. Review of the Doctor's Orders for R85 reflected Lorazepam (a controlled substance (benzodiazepine)) was prescribed initially on 8/22/23 which was renewed or had the order changed multiple times until 2/7/24. However, the EMR did not reveal that a Risk versus Benefit had been completed for this Resident to take this medication. Other medications R85 was receiving on 2/7/24 included Zyprexa (prescribed for bipolar disorder), pristique and trazodone (antidepressants), L-methyl folate (for depression or adjunct therapy with antidepressants), and Nuedexa (a central nervous system agent used to treat pseudobulbar affect). Review of the EMR reflected on 2/7/24 Lorazepam was discontinued, and clonazepam was ordered. The EMR did not reflect a Risk versus Benefit was completed for use of the clonazepam for R85. Also, on this date the order for Zyprexa had changed along with the addition of the Clonazepam. During an interview conducted 4/8/24 at 11:01 Social Worker (SW) S she initiates the Risk and Benefit form in the EMR anytime a resident has a Doctor's Order for a hypnotic, antidepressant, antipsychotic, anxiolytic, or mood stabilizer. SW S reported that she missed the Ativan order and did not catch the Doctor's Order for the clonazepam for R85. Therefore, Risk versus Benefit forms were not completed when R85 started on these two medications. SW S reported that there are a lot of pieces when a medication requiring a risk versus benefit is ordered to include Care Plan changes and monitoring. SW S reported that a task is added for monitoring but not until a week after the medication was initiated to give the medication a fair chance to take effect. Review of the Practitioner Progress Note completed by Physician Assistant (PA) T dated 2/7/24 at 8:05 AM included documentation of the medication changes. However, this note of 2/7/24 also included documentation of vital signs that were taken after this date to include a BP taken on 2/18/24, a pulse and oxygen saturation taken on 2/23/24 and a pain scale result dated 2/16/24. Further review of this 2/7/24 note by PA T revealed that this entry and two entries dated 2/20/24 by PA T were created and entered as Late entries into the medical record on 2/26/24 which was three days after R85 was admitted to the hospital ICU. Review of the EMR Progress Note dated 2/15/24 at 8:46 PM revealed, (R85) noted to be very tired. Refused supper. Refused popcorn and pop for snack which is very unusual, she has a flat affect and poor eye contact. I could not even get her to look at me . Very hard to get her medications in her. She needed help to get them to her mouth and reminders to swallow them. No documentation of vitals signs or further assessment or monitoring were located regarding this entry. The Late Entry Practitioner Progress Note by PA T dated for 2/20/24 at 8:36 AM but created 2/26/24 reflected Staff are concerned as (R85) is no longer anxious, restless, or crying but has started to have a blank stare to her the past week or so and she is not verbally communicating very well anymore. The documentation reflected PA T did observe that R85 does have a blank stare to her and has been eating less with meals. And Flat affect with blank stare look to her, generalized weakness, confused and disoriented, and Unsteady gait. Medication orders were changed per this entry. The vital signs documented in this note were from 2/18/24 and 2/23/24. The second Practitioner Progress Note by PA T entered as a Late Entry for 2/20/24 at 4:28 PM but created on 2/26/24 at 8:51 AM was reviewed. The entry reflected (R85) was revaluated (sic) later on today to see if there has been any improvement with recent med change, (R85) seems a bit worse. Medication orders again changed in the PM note in addition to the changes documented in the late entry from the AM of this same day Review of the Medication Administration Record (MAR) for February 2024 for R85 reflected four separate sections for monitoring for adverse side effects of medications. One section each was established for an anti-depressant, anti-psychotic, anxiolytic, and one for General Anticholinergic effect. Each section was documented in three times a day. A positive finding required this to be noted in the MAR with a Nursing Progress Note entry. Side effects to be observed for and documented included, altered mental status, excessive sedation, dry mouth, confusion, drowsiness, lethargy, irregular heartbeat/pulse. Review of these four sections of monitoring reflected staff initials of no abnormal findings despite staff reports of concerns alleged by PA T. Review of the EMR vital signs history from 2/7/24 until 2/23/24, when R85 was transported to the hospital, vital signs were only obtained twice (2/11/24 and 2/18/24) despite Progress Note documentation of difficulty taking medication, decreased communication, lethargy, and altered mental status (blank stare for the past week or so). No further Progress Notes regarding the mental or physical status of R85 are documented until the Resident was transported by EMS to the hospital where she was admitted in critical condition. On 4/4/24 at 3:27 PM an interview was conducted in an office with the Director of Nursing (DON). The DON reported she expects timely entry of Progress Notes. The DON reported that increased monitoring of R85 should have been ordered after the 2/7/24 evaluation by PA T. After reviewing the late entries of 2/20/24 by PA T the DON reported that the PA thought it was alarming enough to put in a note that the abnormal observations of R85 should have been acted upon. The DON stated, I have no idea why (PA T) made two notes (on 2/20/24) It just makes no sense to me. The DON reported that PA T is no longer at the facility and that the timeliness of pertinent documentation was part of the reason. The DON reported that nurses should have acted upon the findings that were documented in the EMR on 2/15/24 (lethargy, refusing food, helping R85 get medication into her mouth with reminders to swallow). The DON reported an expectation that vital signs would have been taken and the medical provider contacted. The DON reported she was not in-house during the time period prior to the hospitalization of R85 but that she would have been aware of the Resident's status and would have responded appropriately. The DON reported she had no further documentation or information to provide. No further documentation was provided prior to survey exit. 31197 R76 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R76 admitted to the facility on [DATE] with diagnosis of (but not limited to) Stroke with weakness, morbid obesity, and history of blood clots to both lower extremities. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represented R76 was cognitively intact. During an interview on 4/1/24 at approximately 2:00 PM, R76 was resting on his bed working on his computer. R76 stated that he had a fever yesterday (3/31/24) and he has a history of cellulitis in his lower legs. According to the progress notes on 3/31/24 at 1:39 PM, the note reflected, patient flush and warm to the touch. Axillary temp 101.4. denies s/s (signs and symptoms) feeling ill. No other s/s noted at this time. Administered Tylenol at 1:15 PM. Passed to next shift to monitor. At 3:01 PM the physician was notified of the fever and recommended, Alternated [NAME] (Tylenol) with Ibuprofen. Dip urine. According to the Temperature Summary reviewed from 3/31/24 - 4/2/24 the following temperatures were recorded for R76: 3/31/24 at 2:30 PM 102.9 (degrees Fahrenheit) 3/31/24 at 3:11 PM 102.6 3/31/24 at 4:15 PM 101.6 3/31/24 at 5:20 PM 101.2 3/31/24 at 5:47 PM 101.2 3/31/24 at 6:14 PM 99.9 3/31/24 at 9:58 PM 98.9 There were no further temperatures recorded from 3/31/24 -4/2/24 to review. A skin assessment documented on 3/31/24 at 10:45 PM was reviewed and reflected red open areas to the back of both thighs, and both buttocks. There was a rash to the right abdominal fold and the right axilla. Both legs were red with indentions. The assessment noted treatments in place for all areas. During a follow-up interview and observation on 4/3/24 at approximately 8:36 AM, R76 was resting in bed. When asked if his fever had come back, R76 stated that he didn't know. R76 stated that his lower leg was reddened and showed this surveyor the right lower leg with redness noted from the just below the knee to the ankle. When asked if the doctor had started him on an antibiotic for it, R76 stated, No, I don't think so. Record review of the medication administration record (MAR) for March 2024 and April 2024 reflected no order to alternate Tylenol and Ibuprofen for a fever. The Ibuprofen 200 mg, give 400 mg by month every 4 hours as needed for fever was started on 4/2/24 (not on 3/31/24 as the doctor had recommended). There were no antibiotic orders listed on the MAR at the time of this record review on 4/3/24 at approximately 8:45 AM. During an interview and record review on 4/3/24 at approximately 9:00 AM, the Clinical Care Coordinator (CCC) I reviewed R76's progress notes, temperature logs, physician notification and MAR with this Surveyor. There were no temperatures logged from 4/1/24 - through the time of this interview. When asked if the staff monitored R76's temperature after 3/31/24, CCC I stated that there were none recorded. When asked if the order to alternate Tylenol and Ibuprofen was initiated on 3/31/24, the CCC I stated that it did not get onto the MAR until 4/2/24 (2 days after receiving the order from the physician). When asked if the urine was collected for testing, CCC I stated that R76 refused because it is too painful for him. When asked if the physician was made aware, CCC I stated she was unable to find any notification in the record. The facility failed to assess and monitor for fever and potential for infection. The Practitioner wrote a progress note on 4/3/24 at 9:51 AM that reflected, This 57 y/o (year old) WM (white male) complains of increasing warmth, tenderness, and erythema in his RLE (right lower extremity). On exam, he has developed a RLE cellulitis (infection of the skin). I ordered Augmentin 875 mg bid (twice daily) for 10 days . 37666 DPS #2 Based on observation, interview and record review, the facility failed to 1). Ensure coordination of Hospice Services for Resident (#24); 2). Ensure wound treatments were completed as ordered for Resident #48 and 3). Ensure an air mattress was functioning properly for Resident #93, resulting in the potential for unmet care needs for Resident #24 and a decline in condition for Resident's #48 and 93. Findings Include: Resident #24 A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #24 indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: stroke with left sided weakness, dementia, chronic ulcer left foot and left calf, chronic kidney disease, heart failure, diabetes, COPD, history of respiratory failure, epilepsy, arthritis, gout, and peripheral vascular disease. The MDS assessment dated [DATE] revealed Resident #24 had moderate cognitive loss with a Brief Interview for Mental Status (BIMS) score of 9/15 and needed assistance with all care. The resident began hospice services 7/25/2023. During a tour of the facility on 4/02/24 at 8:10 AM, Resident #24 was observed lying in his bed. He was awake and alert and readily engaged in conversation. The resident said he had some lower leg pain and a nurse entered and provided pain medication for him. The resident said he was waiting to get out of bed into his wheelchair. He liked to be up for most of the day. A review of the hospice progress notes in the electronic medical record identified the last hospice note dated 1/31/2024. A review of the document section in the medical record revealed several hospice documents with the last being 3/29/2024, but they were not the notes/assessments from the Hospice nurse. On 4/03/24 at 8:34 AM, during an interview with the Director of Nursing/DON it was reviewed the hospice notes could not be found in the medical record after 1/31/2024. The DON said hospice was supposed to document in the chart and she would check into it. On 4/03/24 at 12:16 PM, Nurse Managers I and J were interviewed related to the missing hospice documents for Resident #24. Nurse Manager J said the resident had previously had a regular hospice nurse, but she left and then the resident didn't have a regular hospice nurse. She said various different hospice nurses saw Resident #24 until recently. Nurse Manager J said the resident now had a new regular hospice nurse. The Nurse Manager said the hospice nurses should have been charting in the medical record. She said she would contact the Hospice company to obtain the Hospice notes. The Nurse Managers said the Hospice nurse usually came in weekly and the nurse aide on Tuesdays. On 4/3/2024 the facility provided hospice documents faxed over from the Hospice company. The documents were not in the resident's medical record to utilize in planning his care. A review of the Care plans for Resident #24 identified the following: I have a terminal prognosis, end of life and am receiving care and comfort only with (Hospice services), r/t (related to) impaired respiratory system, date initiated and revised 7/27/2023 with Interventions including: Work cooperatively with (Hospice services) team to meet my spiritual, emotional, intellectual, physical and social needs, date created 7/27/2023 and revised 8/10/2023. There was no mention of when the Hospice staff were to visit the resident. A review of the facility policy titled, Hospice Services Facility Agreement, date implemented 10/17 and revised 6/23 provided, Policy: It is the policy of this facility to provide and/or arrange hospice services to protect a resident's right to a dignified existence, self- determination and communication with and access to persons and services inside and outside the facility . The facility will collaborate with hospice to ensure that the needs of the resident are addressed . It is the preference of (the facility) that partnered hospice agencies document in the facility electronic health record . Resident #48 A record review of the Face sheet and MDS assessment indicated Resident #48 was admitted to the facility on [DATE] with diagnoses: heart failure, chronic kidney disease, diabetes, osteomyelitis, right leg wound and left great toe wound. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a BIMS score of 15/15 and the resident needed some assistance with care. On 4/02/24 at 9:38 AM, during a tour of the facility, Resident #48 was observed lying in bed. He was observed to have an IV pole/pump near his bedside. He said he was receiving antibiotics for a wound infection. He said he had an infection in his right leg and had previously had surgery there and more recently his foot had rubbed against the foot board of the bed and he got a new sore. He said he was tall and they brought him a longer bed. He said he was comfortable in the longer bed, but his feet were observed rubbing against the footboard. On 4/03/24 at 11:04 AM, upon arriving to Resident #48's room with Nurse G, to observe the nurse providing wound care, the resident said his dressing was not supposed to be changed because the wound care provider changed the order to every other day. On 4/3/2024 at 11:10 AM, during an interview with Nurse J she said the order was not yet updated, but the resident's dressing was to be changed to every other day. She said she was working on it. The Nurse Manager J said the wound team saw the resident the day prior and looked at the wound and the Nurse Manager said she had to review the orders with the physician prior to changing the times. A record review of the physician orders identified the following: Right leg: Cleanse open areas with 0.125% Dakin's solution Pat dry, apply A&D to leg from knee to toes to promote autolytic debridement, then cover with kerlix. Change daily and as needed, start date 3/27/2024. Left great toe: Cleanse toe with wound cleaner, pat dry, apply gentamicin ointment directly to wound base, cover with non adherent and secure with kerlix. Change twice a day and as needed (don't forget to skin prep tip of toe, start date 3/27/2024. A record review of Resident #48's Treatment Administration Record/TAR for March 2024 revealed the following: The resident's treatment orders to the Left great toe, were changed on several occasions, but there were many instances when the treatments were not completed as ordered: 3/3/2024, 3/6/2024, 3/9/2024, 3/12/2024, 3/13/2024, 3/20/2024 x2 (twice a day treatment), 3/22/2024, 3/26/2024, 3/28/2024. The resident's treatment order to the Right leg, was changed on several occasions, and there were many instances when the treatment was not completed as ordered: 3/1/2024, 3/3/2024, 3/6/2024 x2, 3/9/2024, 3/12/2024, 3/13/2024, 3/20/2024, 3/28/2024. In addition to the left great toe and right leg treatments, the resident had treatments to his heels, bilateral lower extremities and buttocks. There were a total of 27 missed treatments. The nurses were supposed to monitor the resident's IV antibiotic treatment for the wound/bone infection, but the monitoring was not completed 16 times from March 1, 2024-March 31, 2024. A record review of laboratory results for Resident #48 indicated a critically high Vancomycin antibiotic level on 2/27/24. On 3/7/2024 the antibiotic was changed to Ceftriaxone IV daily for osteomyelitis of the left great toe and heel. A review of the laboratory results also identified a wound culture on 7/23 for the left great toe with the organisms proteus mirabilis and pseudomonas aeruginosa. On 4/03/24 at 12:01 PM, during an interview with Nurse Managers I and J it was noted that the last Wound note from the provider was dated 3/17/2024. Both nurses said they rounded with the wound care provider weekly and the provider charted in a different system and printed out the documentation for the facility. It was then reviewed with the facility physician and scanned into the resident's chart. After that the orders and Care Plans were updated. Reviewed with the nurses that there were many missing instances of documentation for Resident #48's wound treatments for March 2024. The resident was not receiving necessary treatments to aid in infection and wound healing. They said the nurses should have documented and if the resident refused the treatment, they should have documented the refusal. A review of the facility policy titled, Wound Treatment Management and Documentation, date implemented 8/11/06 and revised 2/24 provided, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders . Treatments will be documented on the Treatment Administration Record . Resident #93 A record review of the Face sheet and MDS assessment indicated Resident #93 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Quadriplegia, chronic pain, chronic obstructive pyelonephritis, acute respiratory failure, pressure induced deep tissue damage of right ankle, chronic ulcer left foot, history of traumatic brain injury, polyneuropathy and anxiety. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed assistance with all care. On 4/01/24 at 2:19 PM, Resident #93 was observed lying in bed. His head was above the top of the mattress and his feet were almost touching the foot board. The resident said he was 6'3 tall. He said his bed was not long enough and someone brought a bolster to place across the end of the mattress between the footboard. He said sometimes the bolster fell under the bed. It was observed hanging partially below the mattress. He was observed to have an alternating air mattress, but there were no settings on. There were no lights on the mattress pump. It was not on. There was air in the mattress, but it was not alternating. The resident said it didn't always alternate and had been unplugged at times and he was unsure why it was not on. A review of the physician orders identified the following: Skin, Pressure Ulcer & Wound Treatment Protocol- May follow facility protocol, dated 1/5/2024. There was no mention of the alternating pressure mattress/APM on the physician orders. A review of the Care Plans for Resident #93 revealed the following: I am at risk for impaired skin integrity r/t (related to) risk for immobility, nutritionally at risk, risk for shear & friction, history of pressure injuries, require assistance with my ADL's (activities of daily living . increased risk for reopening healed pressure injury located on posterior head (stage 3) and coccyx (stage 2), date initiated and revised 2/1/2024 with Goal: Minimize my risk for further breakdown through the review date, revised 10/18/2023. Interventions included: APM support surface on bed, dated 10/18/2023. There were no instructions for the APM settings. I have actual impairment to skin integrity that were present on admission . Right medial ankle (DTI/deep tissue injury); Right anterior thigh: Shear (healed); Left Distal left foot: DTI; Left distal, Medial great toe: Trauma (healed) . Date initiated 12/11/2023 and revised 12/12/2023 with Interventions including: Continue to follow the Skin at risk interventions, dated 10/18/2023. A review of the Kardex and Treatment Administration Record/TAR dated March and April 2024 for Resident #93, did not identify what settings the alternating pressure mattress pump should be set at. On 4/03/24 at 10:00 AM, during an observation of the mattress in Resident #93's room with Nurse Manager I, the air mattress had air in it but there were no lights on the mattress pump; no settings were showing. The Nurse Manager said she didn't know why it wasn't on but there was air in the mattress. It was not alternating. The Nurse Manager said she didn't know what the settings should be. Resident #93 had quadriplegia, was unable to reposition self, had a history of pressure ulcers and continued to be high risk for pressure ulcers. A review of the facility policy titled, Skin and Pressure Injury Risk Assessment and Prevention, date implemented 8/11/2006 and revised 2/24, . Residents determined as at risk for developing pressure injuries will have interventions documented in plan of care based on specific factors identified in the risk assessment . Interventions for Prevention and to Promote Healing . Evidence-based interventions for prevention will be implemented for residents who are assessed at risk and/or who have a pressure injury present .Provide appropriate, pressure-redistributing, support surfaces .

Based on observation, interview, and record review, the facility failed to ensure a dignified dining experience for 8 of 11 residents, 7 of the residents including (R70 and R29) were being assisted by staff standing over them and one Resident (R82) watched residents eat for 20 minutes prior to being served his meal, resulting in an undignified dining experience for residents. Findings include: During lunch meal service on 4/1/24 at 12:04 PM, Certified Nurse's Aide (CNA) D was observed standing over three Residents while assisting them with their lunches. CNA D would assist one resident with a few bites, she would then stop/turn and assist another resident while the others watched. R70 A review of R70's Admission Record, dated 4/4/24, revealed R70 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 70's Admission Record revealed multiple diagnoses that included depression, anxiety, and alcohol dependence with alcohol-induced persisting dementia. A review of R70's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/12/24, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) assessment which revealed R70 had short-term and long-term memory problems with severely impaired cognitive decision-making skills. Further review of Functional Abilities Assessment (Section GG) 130 A. Eating: The ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency. Resident was coded as 1. Dependent on staff for assistance with eating. On 04/01/24 at approximately 12:07 PM, R70 was observed sitting close to the wall hands in his lap with multiple bowls and cups with straws in front of him. CNA D was standing over R70 few bites of his meal then moved over to assist another resident at his table. After CNA D moved R70 leaned over and proceeded chase the straw with his mouth around his cup. CNA D was heard telling him you can do it. (Get his straw/drink.) After approximately 3 minutes of unsuccessfully trying to get the straw in his mouth, R70's shoulders slumped, he sat back and stated he needed the bathroom. On 04/01/24 at 12:24 PM, CNA D was observed standing over and alternating between assisting R70 with his lunch and another resident. CNA D failed to practice proper hand hygiene techniques between residents. During an interview on 4/3/24 at 11:50 AM, Registered Dietitian (RD) L stated (Name of R70) was 1 to 1 dependent on staff for eating. During lunch observation on 4/1/24 at 12:04 PM, Certified Nurse's Aide (CNA) E stood at a round table assisting 4 dependent residents with their lunch. Observation of CNA E walking around the table counterclockwise, assisting the residents with a few bites (of their meal) and offering a drink, prior to assisting the next resident. CNA E continued to move from resident to resident assisting them with their lunch and wiping their mouths off. Hand hygiene practices were not observed in between residents. On 4/1/24 at approximately 12:18 PM, South CCC F entered the dining room and began assisting CNA E with Resident lunches. South CCC F was observed alternating assistance between the two residents. South CCC F failed to practice hand hygiene techniques while assisting residents. R29 A review of R29's Admission Record, dated 4/4/24, revealed R29 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 29's Admission Record revealed multiple diagnoses that included Cerebral Palsy, Dysphagia, COPD, and Epilepsy. During dining observation on 04/01/24 at 12:29 PM, Certified Nurse's Aide (CNA) E was observed standing over R29's broda chair while she assisted him with his lunch. Further observation of CNA E revealed she stood to assist R29 with a couple bites of his meal, offer a drink then moved on to assist another resident. During dining observation on 4/1/24 South CCC F was observed assisting R29 with his lunch. Further observation reflected South CCC F standing over R29 assisting him with his lunch. R29 was repeatedly instructed by South CCC F to put his chin down while she stood and assisted him. During a dining observation on 4/3/24 at 8:30 AM, Certified Nursing Aide (CNA) Q was observed sitting next to R29 and another resident on her phone. R29 was coughing and had a difficult time clearing his throat. After approximately 2-3 minutes CNA Q turns and provided the resident with another bite of breakfast. Further observation revealed the resident continued coughing; CNA Q was focused on her phone in between assisting R29 with his breakfast. R82 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R82 was admitted to the facility on [DATE] with diagnosis of (but not limited to) Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), dementia (memory and safety impairment), and history of falls. Brief Interview for Mental Status (BIMS) reflected a score of 3 out of 15 which represented R82 had severe cognitive impairment involving short- and long-term memory deficits. On 04/01/24 at approximately 10:00 AM, R82 was observed sitting next to the window at the dining room table. At 12:05PM, R82 was observed (still sitting at the table) licking his lips while he watched other residents eat (be assisted) with their lunches. Staff were overheard stating, he is in this dining room for lunch because he fell . Residents' meal was not brought out until Regional Nurse Consultant (RNC) P asked staff to go find it. R82 received his meal approximately 20 minutes after the last resident was served. During an interview on 4/1/24 at approximately 3:40 PM, DON revealed she was aware of the hand hygiene concerns during lunch. DON further revealed hand hygiene should take place in between assisting each resident and staff were being re-educated.

This Citation pertains to Intake MI00142041 Based on observation, interview, and record review the facility failed to ensure meaningful Activities were provided to 1 facility residents directly (Resident #53 (R53)) and all facility residents in the S-1 and S-2 memory care units resulting in unengaged cognitively impaired resident not engaged in activities that a reasonable person would partake in to avoid boredom and to seek a sense of self-worth. Findings: R53 was originally admitted to the facility 3/7/19 and has current diagnoses that include Dementia, Anxiety, and Major Depressive Order. Review of the Minimum Data Set (MDS) dated [DATE] reflected R53 is severely cognitively impaired, is rarely or never understands or is understood, and has highly impaired vision. Review of the MDS section F for Preferences for Customary Routine and Activities reflected R53 enjoys Doing things with groups of people, and Participating in favorite activities. Review of the Care Plan for R53 revealed a Focus of I am here for long term care and will be invited to participate in the activity program initiated 3/12/19. The Goal of this Care Plan area reflected I will attend groups that I have a preference in and I will participate in individual leisure activities as desired. The Interventions to be implemented to reach this goal for R53 included leafing through books and magazines and doing things with groups of people and doing my favorite activities Further interventions included games that require strategy/ concentration, trivia, socials, coloring outdoor visits, reading groups. These interventions appear to exceed the capabilities of R53 as indicated by the MDS of 1/30/24. On 4/8/24 at 3:40 PM a review was conducted of the EMR of R53 for documentation for group activities and one on one (1:1) activities that R53 had been engaged in or offered for the previous thirty days. The review for both the Group and 1:1 activities revealed no documentation that R 53 had been offered or had participated in either. The facility has two adjoining memory care units, S-1 and S-2, for cognitively impaired residents. At the time of this survey 52 residents were residing in these two units with a total facility census of 104 residents. The S-1 unit and the S-2 unit each has its own separate dining area but residents can freely move between units. R53 resides in the facility S-1 memory care unit. On 4/02/24 8:45 AM an observation was made at the S-1 Dining Room of R53 is sitting at a table by herself rubbing the top of the table and talking to herself. No staff in room. At 9:24 AM R53 remains at the table rubbing the tabletop and occasionally verbalizing nonsensical speech. At 9:38 AM eleven residents are in the S-1 Dining Room, but no staff were present. A television was on, but no residents were observed watching the television. At 9:52 AM eight residents remain sitting scattered about the large dining area unengaged in any activity. At 10:17 AM Activities staff was observed playing a card game with three residents and the other five resident were unengaged in any activity or diversion. R53 remains as previously noted. On 4/02/24 3:58 PM eleven residents were observed in the S-1 dining room. No activities in progress. The residents were observed scattered about the room sitting at tables just looking around or staring. Three residents appeared to be sleeping. The television was on, but no one was near or watching. On 4/08/24 at 1:36 PM seven residents were observed in the S-1 dining room. Four residents appear to be sleeping in chairs, three residents sitting at separate tables each had a doll sitting in front of them on the table. The television was on, but no residents were observed watching the this. Outside the dining room in a common area were five residents sitting in chairs with one resident laying on a love seat. No activities or any resident engagement was observed. On 4/02/24 at 10:36 AM an interview was conducted with Activities Director (AD) U reported just after the beginning of 2024 staffing adjustments left her with only one assistant for the entire facility Activities program. AD U reported conducting an Activities program is beyond challenging for her and the one assistant. AD U reported she was only able to keep the assistant because of the two memory care units. AD U reported that prior to the staff cuts she always had two staff in the memory care units and two staff for the rest of the facility residents. AD U indicated at that time the Activities staff were effective in keeping residents engaged in meaningful activities. On 4/2/24 at 7:19 AM Registered Nurse (RN) V, who often works in the memory care units acknowledged staffing was cut some time after the first of the year. RN V reported that Activities staff were instrumental in keeping residents on both the S-1 and S-2 units engaged and busy. RN V indicated that the residents just don't get the attention they used to get, and the Certified Nurse Aide (CNA) staff just don't have the time to engage residents in Activities as they are addressing care needs. Review of the facility Activities Calendars for January, February, and March 2024 reflected two activities a day are scheduled at 10:00 AM and 2:00 PM five days a week. The calendars did not reflect any recreational Activities on weekends or in the evening. Review of the Activities Calendars revealed several activities are performed only on the general area of the facility and not in the locked memory care units. On 4/08/24 at 1:53 PM a second interview was conducted with AD U. AD U acknowledged that some activities were performed only outside the memory care units. AD U reported for those activities she does try to integrate memory care residents into those activities. At times she can take 10 or 12 of the 52 memory care residents up to engage in those activities. AD U did indicate that memory care residents sometimes do not have the abilities to engage in some of those activities. At no time during this survey was R53 observed to be engaged in any activity as the documentation of the Resident's EMR indicated. 37872

Based on observation, interview, and record review the facility failed to prevent repeated falls for 1 of 4 residents, Resident #82 (R82) reviewed for falls. The deficient practice resulted in R82 sustaining repeated falls with minor injury over a 60 day period. Findings include: The facility provided a copy of the Fall Reduction Policy dated 2/14/02, last revised date 4/2023 for review. The policy reflected, 2. The nurse will initiate interventions on the resident's baseline care plan, in accordance with the resident's identified risks .a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed . R82 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R82 was admitted to the facility on [DATE] with diagnosis of (but not limited to) Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), dementia (memory and safety impairment), and history of falls. Brief Interview for Mental Status (BIMS) reflected a score of 3 out of 15 which represented R82 had severe cognitive impairment involving short and long term memory deficits. R82 had a resident representative for all medical decision making. During an observation and interview on 4/4/24 at 3:26 PM, R82 was observed seated in the dining room at the table with his back to the TV. R82 was unable to answer any specific questions related to his falls. According to the Activities of Daily Living (ADL) care plan dated 1/11/24 was reviewed on 4/4/24. The care plan reflected, MOBILITY: I ambulate with 1 assist using a 4 wheeled seated walker. Provide cues for redirection as needed. Date Initiated: 1/11/24, Revision on 3/28/24 .TOILETING: I require 1 assist with peri care. Revision on 1/26/24 .TRANSFERRING- 1 assist with walker as I will allow. Revision on 3/29/24 . According to the physician's noted dated 3/27/24 at 11:15 AM, Pt (patient) is ambulatory but has an unsteady gait. He has Parkinson's festinating gait (individuals with Parkinson's disease, marked by short, shuffling steps that begin slowly but increase in rapidity until the walk becomes a half run. The body leans stiffly forward to maintain balance, and there is an associated risk of falling) and falls every time he turns or turns to sit down . During an interview and record review on 4/8/24 at 10:39 AM, the Director of Nursing (DON) stated that R82 had a physical therapy (PT) evaluation on 1/12/24 that stated R82 was determined to be unsafe with turning with his walker and recommended 1 assist. The PT evaluation further stated that due to poor safety awareness R82 required the assistance of 1 at all times with mobility. The DON stated that the evaluation on 2/22/24 reflected that R82 requires 1 assist with transfers at all times as he allows because he can not sense chair placement and misses when he attempts to sit. The DON stated the care plan was updated on 3/29/24 (2 months after the evaluation and recommendations were initially made). The facility provided 12 fall investigation reports from 2/20/24 - 4/1/24 for review. On 4/8/24 at 10:39 AM a review was done with the DON. The findings are as follows: -2/20/24 at 2:15 AM, R82 had an unwitnessed fall in his room by his bed. The DON stated the root cause was that he was unsteady and unassisted with new intervention of non-slip strips placed on floor next to bed. According to the 1/12/24 PT evaluation, R82 required assistance with mobility. -2/22/24 at 6:45 AM, R82 was observed in the activity room on the floor with broken glass and an abrasion to his back. The DON stated the root cause was he was attempting to sit in the recliner, missed and fell into the window, breaking it. The new intervention of placing a table in front of the window and to have PT re-evaluate R82 was initiated. The DON stated that PT continued to work with him for 1 month (until 3/27/24) but still remained a 1 assist with mobility, transferring and bathroom use. -2/23/24 at 9:35 AM, R82 was observed on the floor in the dining room. The DON stated he was attempting to self-ambulate and had poor safety awareness. The DON stated the facility did a medication review. -2/28/24 at 4:31 PM, R82 was witnessed attempting to stand from a chair in the dining room when he grabbed his walker and fell backwards, sustaining an abrasion to his back. The DON stated the root cause was attempting to stand without assistance and with the new intervention of a sign placed on his walker to remind him to set the brakes and grab the handles when standing. When asked if staff were to assist resident with transfers and mobility, the DON stated according to the PT evaluations, Yes. -3/4/24 at 8:36 PM, R82 observed on the dining room floor with a skin tear. The DON stated the root cause was attempting to self-ambulate with new intervention to encourage resident to sit in a wide based chair in the dining room. When asked if R82 should have assistance with transfers and ambulation, the DON stated, Yes. -3/23/24 at 7:30 AM, R82 was observed running out of his room, hit the wall and fell to the floor on his stomach. The DON state the root cause was self-ambulating. -3/24/24 at 3:58 AM, R82 was observed on the floor in front of the bathroom door. The DON stated the root cause was he slipped after using the bathroom and the new intervention of placing non-slip grip strips to the floor by the bathroom door. The DON stated that he requires assistance to use the bathroom. -3/25/24 at 1:00 AM, R82 was observed on the bathroom floor between the toilet and the wall, sustaining a skin tear above his eyebrow with steri strips applied to close the wound. The DON stated the root cause was self-transferring to the bathroom with the new intervention of a urinal to be kept at bedside. R82 has severe cognitive impairment and unable to learn new tasks. When asked if there was any evidence that R82 could remember the new urinal and use it effectively, the DON stated, I don't know. -3/28/24 at 4:17 PM, R82 had a witnessed fall in the dining room of the adjoining unit. The DON stated the root cause was attempting to stand on his own and transfer himself and the new intervention not to dine in the adjoining units dining room due to safety issues. -3/29/24 at 9:24 AM, R82 was observed self-ambulating in the hall, staff went to assist him to the activity room and both tripped over a trash can that was moved into the pathway and fell to the floor. The DON stated that R82 was attempting to self-ambulate and there was clutter in the pathway with new intervention of ensuring staff kept pathways and areas clear of clutter. When asked if that was a standard precaution that should always be taken, the DON stated, Yes. -3/30/24 at 10:10 AM, R82 was observed by staff pacing quickly down the hall leaning forward and fell before staff could assist him, sustaining an abrasion. The DON stated the root cause was self-ambulating and a sensor mat was placed on the floor by beside his bed. The DON stated the sensor mat is hooked into the call light system so if he attempts to get up without assistance his call light will light up and there is no sounding alarm associated with it. -4/1/24 at 8:45 AM, R82 was observed by a staff member coming out of another resident's room, self-ambulating at a quick pace without his walker, lost his balance and fell and sustained an abrasion to the knee. The DON stated the root cause was self-ambulating without assistance. The new intervention of reminding him to slow down and have something sturdy to hold on to. The staff stated he nodded his head after being educated. According to his BIM's assessment, R82 has severe short term memory loss and is unable to learn or retain new tasks or skills. According to the progress notes dated 4/7/24 at 8:25 PM, R82 was assisted to the bathroom and returned to his seat in the dining room. Staff walked away and resident attempted to stand and fell in front of his wheelchair. The DON stated this fall has not been thoroughly investigated yet. The facility failed to implement the appropriate safety precaution of 1 assistance for ambulating, transferring and toileting to prevent repeated falls.

Based on observation, interview, and record review, the facility failed to: 1) safeguard the confidentiality of medical records for 1 of 27 facility residents [R25) and 2) maintain complete, accurate, and timely medical records for 3 of 27 residents (R70, R85, and R98), resulting in inaccurate medical records and delayed entry of vital medical record information by the physician provider, the potential for providers not having an accurate and complete picture of the resident's stay at the facility, the potential for unauthorized access to resident medical records, and the potential for the loss of resident privacy and confidentiality of their personal health information. Findings include: R25 During an observation on [DATE] at 11:00 AM, the computer screen on top of the North [NAME] Medication Cart was observed open to R25's electronic Medication Administration Record, (e-MAR), specifically to the medication diclofenac sodium. R25's personal and health identifying information (i.e., picture, name, medical record number, physician name, room number, and age) were visible beside the open medication screen (which was a pulled up window over R25's other medications and to the right of R25's visible personal medical information). Anyone walking by the medication cart could have stopped and accessed all of R25's medications and/or medical records if they closed out the medication window. There were not any staff in sight of the medication cart at the time of the initial observation. During an observation and interview on [DATE] at 11:05 AM, Registered Nurse (RN) M walked up to the North [NAME] Medication Cart as the surveyor was reviewing R25's open e-MAR. She stated she should not have left the computer screen on top of the medication cart open to R25's e-MAR. When RN M walked up to the medication cart she asked the surveyor, What's the problem. Is it because I left the screen open to a medication and the screen was not hidden? She stated she should not have left the computer screen open, but I feel I did nothing wrong. The drug information was visible, but I believe the resident's name was covered [by the open medication screen]. The surveyor mentioned that R25's name, picture, medical record number, physician name, age, and room number were visible beside the open medication screen and RN M stated she could see that also. However, RN M still insisted that she did not do anything wrong because her perception was R25's information was not visible to anyone walking by the medication cart due to it being in a gray/lighter color than the medication screen. During an interview on [DATE] at 11:15 AM, RN N stated she logs off her computer screen and folds the computer screen down (the computers are laptops) so no one can access it without authorization and to protect the resident information. She stated, Some people know how to open the screens and log on with a push of a button. Then they can access any resident records. That's why I also close the computer (fold the screen down). A review of the facility's HIPAA (Health Insurance Portability and Accountability Act) Sanctions policy, dated [DATE], revealed, 2. All employees are expected to comply with all policies and procedures regarding the protection of personal identifiable health information of our residents . 6. Examples of violations include, but are not limited to . e. Leaving a secured application unattended while logged on . R70 A review of R70's Admission Record, dated [DATE], revealed R70 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 70's Admission Record revealed multiple diagnoses that included depression, anxiety, and alcohol dependence with alcohol-induced persisting dementia. In addition, R70's Admission Record revealed he had a legal (court appointed) guardian. A review of R70's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) assessment which revealed R70 had short-term and long-term memory problems with severely impaired cognitive decision-making skills. A review of R70's Letters of Guardianship, dated [DATE], revealed Guardian (GRD) A was appointed R70's guardian. A review of R70's Risk vs. Benefit/GDR (Gradual Dose Reduction) Form, dated [DATE], revealed a name was listed that was not R70's guardian's name as the person that was informed on [DATE] of the indications (reasons) for use and risks vs. benefits of the use of Zyprexa (olanzapine). During an interview on [DATE] at 11:00 AM, the Nursing Home Administrator (NHA) was informed about the name listed on R70's Risk vs. Benefit/GDR Form as the one who was informed of the indications for use and the risks vs. benefits of the use of Zyprexa and was asked if he knew who the person was. He stated he did not know, but would find out. During an interview on [DATE] at 11:14 AM, the Director of Nursing (DON) stated she did not know who the person was that was listed on R70's Risk vs. Benefit/GDR Form as being informed about R70's Zyprexa indications for use and risk vs benefits of use. She stated she would find out and get back to the surveyor. During a second interview on [DATE] at 02:15 PM, the DON stated they do not know who the person was that was listed as being informed about R70's Zyprexa on R70's Risk vs. Benefit/GDR Form, dated [DATE]. She stated, It was a typo even though the two names (the one listed on R70's form dated [DATE] and R70's guardian's name) were not close in spelling. The DON stated when the form was filled out, they meant to put GRD A's name on it, but instead put the other name on it. R98 A review of R98's Admission Record, dated [DATE], revealed R98 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included frontal lobe malignant neoplasm (brain cancer), cerebral edema (brain swelling), convulsions, delusional disorder, pulmonary embolism (blood clot in the lungs), and aphasia (difficulty verbally communicating). A review of R98's Medical Treatment Decision Form, dated [DATE], revealed R98 was a CPR (cardiopulmonary resuscitation) Full resuscitation. The Signature of Resident/ or Legal Representative line had via phone c/ (with) guardian written on it. However, the name of the guardian was not noted and there was not any signature of a guardian on the form that could have been attained at a later date. During an interview on [DATE] at 11:30 AM, the Nursing Home Administrator (NHA) was notified that R98's Medical Treatment Decision Form had via phone c/ guardian written on the signature line, but no name was listed. The NHA stated that the facility staff member(s) who completed the form should not have just written on the signature line via phone c/ guardian but should have included the guardian's name since the Medical Treatment Decision Form is an official, legal document. The NHA further stated that the guardian should have come in, or had the form mailed or faxed to them and returned, after the staff received verbal confirmation over the phone and the guardian should have signed the form since it was a legal document. Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing (i.e., medical) practice . Documentation of nurses' (or other health professional) work is critical as well for effective communication with each other and with other disciplines. It is how nurses (or other health professionals) create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's (or other health professionals) contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care . Documentation is sometimes viewed as burdensome and even as a distraction from patient care. High quality documentation, however, is a necessary and integral aspect of the work of registered nurses (or other health professionals) in all roles and settings . (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org). Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care- Assessments; Clinical problems; Communications with other health care professionals regarding the patient; Communication with and education of the patient, family, and the patient's designated support person and other third parties; Medication records (MAR); Order acknowledgement, implementation, and management; Patient clinical parameters; Patient responses and outcomes, including changes in the patient's status; and Plans of care that reflect the social and cultural framework of the patient . Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org). 31771 R85 Review of the electronic medical record (EMR) reflected R85 originally admitted to the facility [DATE] and had diagnoses that included: Pseudobulbar Affect (characterized by uncontrolled outburst of laughter or crying), Manic Depression (Bipolar Disease), Dementia and Anxiety. Review of the Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) dated [DATE] reflected a score of 2 out of 15 which indicated the Resident was severely cognitively impaired. Section GG of this MDS revealed R85 was functionally able to ambulate independently, could eat on her own with set- up assistance, and could toilet independently. Review of the EMR Progress Note dated [DATE] at 5:30 PM revealed that R85 was to be transported to the hospital for Altered mental status and Functional decline. The EMR was reviewed for the chronology of care and treatment leading to the hospital evaluation of R85. The review revealed three Practitioner Progress Notes by Physician Assistant (PA) T labeled as Late Entry with one dated [DATE] and two entries dated [DATE]. Further review revealed these assessments were not entered into the medical record until [DATE] which was three days after R85 was admitted to the hospital. The EMR Practitioner Progress Note by PA T entered as [DATE] at 8:05 AM was created on [DATE] at 8:06 AM and contained an assessment and pertinent information on psychotropic medication changes. The two EMR Practitioner Progress Notes by PA T dated [DATE] and timed as 8:36 AM and 4:28 PM were not created until [DATE]. Both entries contained information regarding a significant change in condition to include medication changes and data that R85 had a blank stare, was confused and disoriented, and had an Unsteady gait among other notable changes from [DATE]. The latest entry of [DATE] also reflected that R85 was worse than the earlier evaluation that same day. The EMR documentation of the created date of [DATE] reflects that the three Practitioner Progress Notes by PA T contained critical health information not available for review by other medical providers, nursing staff, social workers, or the interdisciplinary team (IDT). Had this information been available to these disciplines the potential exists that the decline and subsequent hospitalization of R85 could have been avoided. On [DATE] at 3:27 PM an interview was conducted in the office with the Director of Nursing (DON). The DON reported she would like a note (documentation) to be in (the EMR) right away. The DON reiterated that I want to see a note within 24. The DON reported that PA T is no longer at the facility and that timeliness of documentation was a contributing factor.

Based on observation, interview, and record review the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) committee that identified care concerns, respond to deficiencies, and maintain compliance for all residents that resided at the facility. The deficient practices resulted in repeated identified deficiencies from the previous annual survey, and undesired outcomes for residents. Finding include: According to the CMS-2567 dated 2/17/23 with a date of correction of 3/17/23 the facility was found to be out of compliance with F-679 meeting the activity needs/interests of residents when the residents of the memory care unit were observed sitting around with lack of meaningful engagement. According to the plan of correction, the staff were educated to provide individual activities according to the resident assessment. The policy was reviewed. The activity calendars were updated and posted monthly. Results were to be presented by the Activities Director/designee to the Administrator who would present results at QAPI meeting monthly. Results and system components will be reviewed by the QAPI committee with subsequent plans of correction developed and implemented as deemed necessary to ensure compliance is maintained. The administrator was responsible for attaining and maintaining compliance. During the annual survey the Surveyors observed residents on the memory care unit with no purposeful/meaningful engagement. Some residents were observed sitting and staring off. The activities calendar reflected no programing or offerings on weekends. Records were reviewed for Resident #53 (R53) and R82 and did not reflect routine/daily documentation for group activities or 1:1 activity. During an interview and record review on 4/8/24 at approximately 2:50 PM, the Director of Nursing (DON) was made aware of the surveyors' observations and record review related to activities on the memory unit. When asked if the facility QAPI committee was aware of the repeated deficient practice, the DON stated the facility went through some staff cuts and the QAPI committee felt it was meeting the expectation of the regulation, therefore there were no performance improvement plans in place to address the concern identified by the Surveyors. According to the CMS-2567 dated 2/17/23 with a date of correction of 3/17/23 the facility was found to be out of compliance with F-684 quality of care concerns such as identifying a significant weight loss, ensuring nutritional needs were not met, assessing, monitoring, and reporting changes to the physician. According to the plan of correction the DON educated the staff on the Weight Monitoring Policy and the Nutritional Assessments Policy. Audits were done and reported to the QAPI committee. Results and system components will be reviewed by the QAPI committee with subsequent plans of correction developed and implemented as deemed necessary to ensure compliance is maintained. The administrator was responsible for attaining and maintaining compliance. During the annual survey the Surveyors' found evidence of quality of care concerns for R85 when a change in condition was not identified that resulted in a hospitalization , R76 had fever reported to the physician and the staff failed to continue to assess and monitor for infection, R48 had an air mattress for his impaired skin that staff failed to ensure was on and operating as ordered, R24 had no evidence of coordination of care with hospice since 1/24/24, and R101 sustained a significant weight loss when her 5.72 % weight loss was not assessed or monitored. During an interview and record review on 4/8/24 at approximately 2:50 PM, the DON was made aware of the observations, interviews and record reviews done during the annual survey with the findings. When asked if the facility QAPI committee was aware of the repeated deficient practice, the DON stated they were not. These deficient practices were identified on the previous annual survey, the facility was able to regain compliance on 3/17/23 but did not maintain sustained compliance.

This citation pertains to intake number MI00140515. Based on observation, interview, and record review, the facility failed to ensure safe transfers with a mechanical lift (per manufactures guidance) and thorough assessment after a fall for 1 of 3 residents (Resident #51) reviewed for falls. This deficient practice resulted in Resident #51 (R51) falling from a mechanical lift with a delay in assessment and treatment for 3 fractures. Findings include: According to the facility investigation report submitted to the state agency on 10/23/23 at 10:50 PM, the facility reported that on 10/14/23 at 12:55 PM, R51 was being transferred from a wheelchair to the bed by 2 staff members that were operating a full body mechanical lift when the left leg strap of the sling became unattached from the lift causing R51 to slide out of the sling and onto the floor from a height of approximately 3 feet, coming to rest on her bottom with her right lower leg bent at the knee and tucked under her left leg. An onsite x-ray was ordered and confirmed a right leg fracture. On 10/14/23 at 5:48 PM, R51 was sent to the emergency room where it was discovered that R51 had also sustained a left hip and pelvis fracture in addition to the right leg. The facility provided a copy of the Falls Reduction Policy dated 2/24/2002, last revised on 4/2023 for review. The policy reflected, 4. When a resident experiences a fall, the facility will: a. Assess the resident. b. Complete a Post-Fall Assessment. c. Complete a Risk Management Incident Report . According to the Total Mechanical Lift Competency Checklist signed by the DON and the NHA on 10/20/23 reflected, 2. Mechanical Lift Operation .e. Positions resident on the appropriate sling size and style as per resident's Care Plan .g. Attaches the sling straps without pulling or tugging to the desired setting. Considers elevating the head of the bed to facilitate ease in completion. h. Gently raises resident minimally from surface. Unweight resident from bed. Performs a safety check . R51 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R51 was admitted to the facility on [DATE] with diagnosis of (but not limited to) traumatic brain injury, seizure disorder and dementia. Brief Interview for Mental Status (BIMS) reflected a score of 5 out of 15 which represented R51 had severe cognitive impairment. R51 had a guardian for all medical decision making. R51 required extensive staff assistance of 1-2 with all activities of daily living. According to the Activities of Daily Living care plan dated 7/25/23, reflected the following intervention for transfers, Dependent using the full body mechanical lift and 2 staff. Date initiated: 7/25/23. There was no indication of which style of lift sling (full body or divided leg) nor size indicated on the care plan as the Total Mechanical Lift Competency Checklist for lifts and slings reflected. On 11/1/23 at 10:13 AM the DON provided a copy of the [name of Total Mechanical Lift company] Full Body Slings Size Chart for review. The DON hand wrote on the bottom of the sheet that R51 was using the size large from this sizing chart that the facility labeled B-10. The DON provided a blue lift sling that reflected, B-10 written on it for inspection. The sling shape did not look like the Full Body Sizing Chart that was provided for review. The sling further reflected a tag that indicated the style of sling was a Divided Leg Sling. When asked what is documented on R51's care plan, the DON stated that the facility does not document the sling style and size to use on the care plans. The DON stated she expected the staff to check the current weight and refer to the sling sizing chart posted at the nurses' desk to determine the appropriate sling to use on residents. This direction was different than the instructions that the Total Mechanical Lift Competency Checklist reflected. During an interview on 10/31/23 at 1:00 PM, CNA A stated that she assisted CNA B on 10/14/23 at 12:55 PM with the transfer of R51 from the wheelchair to the bed. CNA A stated R51 was already seated on a sling pad, they positioned her next to the bed, attached the sling to the lift and proceeded to lift. CNA A stated that before R51's weight was completely off the chair they heard a clip noise, the CNA's paused and visually (not physically) rechecked the straps on the lift, then proceed with the transfer. When R51's weight was fully on the lift and before she was positioned over the bed, the left leg strap became unattached and R51 slid out of the sling and onto the floor. CNA A stated that she was able to guide R51's head so it did not hit the floor. When asked if the CNA's lifted R51's weight just off the seat of the wheelchair and did a safety check before proceeding with the transfer, CNA A stated, No, not exactly. We put them (the straps) on and tug down on them. When asked if the lift and sling were immediately taken out of service, CNA A stated that they used the lift and sling to transfer R51 off the floor and back into bed before taking it out of service. According to the Employee Counseling Notice dated 10/14/23, CNA A was given a verbal safety counseling that reflected, Employee was transferring the resident using a mechanical lift when the sling became unattached during the transfer resulting in the resident sliding to the floor. Employee failed to double check sling straps by pulling on them to ensure they were securely attached to the mechanical lift prior to lifting the resident using the mechanical lift. The counseling was signed by the CNA A and the DON. During an interview on 11/1/23 at 8:45 AM, CNA B stated that she assisted with CNA A as they transferred R51 with a mechanical left from the wheelchair to the bed. After they attached the sling to the lift with the straps, they began to lift R51, heard a clip noise and stopped the lift, visually rechecked the straps and proceeded with the transfer when midway R51's left leg strap became unattached from the lift causing her to slide out of the sling and onto the floor. When asked if the CNA's lifted R51 off the wheelchair, stopped and did a safety check before proceeding, CNA B stated, We look at the straps, tug on them, lift and normally keep on [NAME]. I'm not completely sure how it (the strap) popped off. According to the Employee Counseling Notice dated 10/14/23, CNA B was given a verbal safety counseling that reflected, Employee was transferring the resident using a mechanical lift when the sling became unattached during the transfer resulting in the resident sliding to the floor. Employee failed to double check sling straps by pulling on them to ensure they were securely attached to the mechanical lift prior to lifting the resident using the mechanical lift. The counseling was signed by the CNA B and the DON. During a telephone interview on 11/1/23 at 2:37 PM, RN C stated that CNA B came to get her in the hallway (on 10/14/23 at 12:55 PM) and told her that R51 had fallen from the mechanical lift. RN C stated that she was not R51's assigned nurse that day but stepped into the room to help the CNA's with the situation. RN C stated that she did not physically evaluate or perform a range of motion (an assessment used to move each joint to evaluate for function, pain, and changes from their baseline). RN C stated she asked R51 verbal questions about where her pain was. RN C stated that together with CNA A, CNA B and CNA F they rolled R51 back onto the sling and lifted her from the floor to the bed. When asked if the same mechanical lift and sling R51 had fallen from was used, RN C stated, Yes. RN C stated that when she asked R51 about her pain, R51 denied pain but had a shocked look on her face. During an interview on 11/1/23 at approximately 2:00 PM, RN D stated that she was assigned to R51 that day and when she entered the room, she noted R51 already back in her bed. RN D stated CNA A and CNA B were changing her brief. RN D stated she noted a reddened area to R51's right knee, subsequently called the physician, obtained a STAT x-ray order, and attempted to notify the guardian. When asked if she did a full range of motion assessment (ROM) on R51, RN D stated, No, I did not. When asked if she gave R51 anything for pain, RN D stated, No, I did not. RN D stated that at 2:00 PM she gave shift report to RN E. During a telephone interview on 11/1/23 at 3:35 PM, RN E stated she took over care of R51 on 10/14/23 at 2:00 PM approximately an hour after she had fallen from the lift. During the shift-to-shift report with RN D, RN E stated together they entered R51's room and examined her right leg. RN E stated that R51's had light bruising from her knee that had extended to her foot. RN E stated that R51 was not verbal at this time and could not rate or describe her pain. RN E stated that RN D reported that she had not provided pain medication yet. RN E stated she went out to the medication cart and obtained 2 tablets of Tylenol extra strength but R51 had her lips clenched tight and would not take the medication. RN E noted that R51's color was pale. RN E stated that the x-ray tech came about 2:30 PM. At about 3:30 PM, RN E was notified of the nondisplaced fracture of the proximal tibia (right leg fracture) which she reported to the physician and guardian. RN E reported that later in the shift, R51's color was even more pale, her blood pressure was very low, her pulse was high, staff were unable to obtain an oxygen saturation and was not able to palpate a pedal pulse (feel pulse in foot), so she notified the physician and guardian and sent R51 to the ER at approximately 5:48 PM. RN E stated that later that evening was made aware that R51 had also fractured her left hip and pelvis. During an interview on 11/1/23 at 4:30 PM, when asked if ROM was part of the post fall assessment the DON stated, Yes. The DON added if she thought it would further injure a resident she would stop and notify the physician of that as well. The DON stated that she expected this to all be documented in the medical record. There was no ROM assessment documented in the electronic health record. During an observation and record review on 11/1/23 at approximately 1:50 PM, R51 was sleeping in her bed and did not awaken when her name was called. The progress notes reflected that R51 was readmitted to the facility on [DATE]. The record reflected that R51 would not have been a good surgical candidate, therefore upon readmission to the facility R51's guardian elected to admit her to hospice for comfort and pain management of the fractures. Resident #52 (R52) During an interview and observation on 11/1/23 at 1:30 PM, CNA I and CNA J stated they both received mechanical lift education within the last few weeks. The Surveyor observed as they used a full body mechanical lift to transfer R52 from a wheelchair to the bed. The CNA's attached the sling to the lift and pulled down on the strap, lifted the resident and without stopping, transferred R52 from the wheelchair to the bed and unattached the sling. The CNA's failed to follow the Total Lift Mechanical Lift Competency Checklist to stop the lift after the resident's weight was fully supported by the lift (unweight) and perform a safety check before completing the transfer. Resident #53 (R53) During an interview and observation on 11/1/23 at 1:40 PM, CNA G and CNA H stated they both received mechanical lift education within the last few weeks. The Surveyor observed as they used a full body mechanical lift to transfer R53 from a wheelchair to the bed. The CNA's attached the sling to the lift and pulled down on the strap, lifted the resident and without stopping, transferred R52 from the wheelchair to the bed and unattached the sling. The CNA's failed to follow the Total Lift Mechanical Lift Competency Checklist to stop the lift after the resident's weight was fully supported by the lift (unweight) and perform a safety check before completing the transfer.

This citation pertains to intake number MI 860 and MI 058. Past Non-compliance was determined appropriate by the state agency for this citation. Plan outlined below. Based on observation, interview, and record review the facility failed to prevent an elopement for 1 of 3 residents (Resident #1) reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy when Resident #1 (R1) who was assessed as an elopement risk, eloped from an outside patio, unbeknownst to staff, through an outside patio gate during a supervised smoke break, allowing R1 to elope from the facility on 12/31/20 at approximately 3:15 PM, staff did not realize R1 was missing until 5:00 PM and he returned to the facility at 7:41 PM when his whereabouts could be located. This deficient practice placed R1, and other residents who were assessed as being at risk for elopement, at risk for serious harm, injury and or death from hazards outside the facility. Resident #1 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 (R1) admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 9 out of 15 which represents R1 had moderate cognitive impairment. R1 had a guardian who made medical decisions. R1 was assessed as a high elopement risk and placed in the locked unit of the facility. According to the facility 5-day report dated 1/8/21, reflected that R1 independently unlatched the courtyard gate and exited the enclosed patio area, while the staff member that was supervising the group of 4 residents smoking was assisting one of the other residents. R1 walked approximately 44 steps to the sidewalk and then crossed the street, entered a store, made a purchase at 3:21 PM (per store video), then proceeded an estimated 508 steps to a gas station where at that time R1 requested an ambulance. The EMS took R1 to the ER where he was evaluated and released to a homeless shelter. The facility located R1 and picked him up from the shelter at 6:41 PM. R1 willingly returned to the facility at 7:41 pm without injury. It was light out with an outside temperature of 32 degrees and snow on the ground. R1 was wearing a coat and rubber soled slippers. During an observation and interview with on 1/13/21 at approximately 12:00 PM, the NHA showed this surveyor the outside patio and gate that R1 used to elope during the smoke break. The NHA stated the gate is considered a fire exit and therefore cannot be locked down to prevent exit. The NHA stated that staff bring residents to this enclosed outside patio for supervised smoke breaks. The gate had two latches that could be easily opened to escape in case of a fire. During an interview on 1/13/21 at approximately 12:20 PM, Registered Nurse (RN) C stated that she was looking for R1 on 12/31/20 at approximately 4:45 PM because she had a medication to administer to him. RN C stated she was unable to locate R1 after asking other unit staff members and subsequently called a code for elopement. RN C stated R1 was not located so the NHA, DON, guardian and police were all notified. RN C stated the last the staff remembered seeing R1 was at 3:00 PM while on a smoke break in the outside patio area. RN C stated that she was still on shift when R1 was picked up by facility staff at approximately 6:30 PM and returned to the locked unit just after 7:30 PM. During an interview on 1/13/21 at approximately 12:45 PM, Recreational Aid (RA) A stated she was assigned to supervise the 3:00 PM smoke break for the residents on the locked unit. RA A stated that on 12/31/20 she was not available to take the residents out at 3:00 PM and another staff member took them. RA A stated when she completed her task she reported to the outside patio to relieve the other staff member and take over on the supervised smoke break. RA A stated there were 3 residents including R1 in the outside patio area when she took over and another resident joined them a couple minutes later. RA A stated that when the other resident arrived, she assisted the resident with obtaining her smoking supplies and when the break was done she assisted the group back inside. RA A stated she asked the other residents where R1 was at the time and a couple of them responded that he (R1) had already went back inside. RA A stated that R1 could independently ambulate and open the door so that did not surprise her that he had gone back inside. RA A stated that her shift ended at 4:00 PM and at 5:00 PM she received a call from the facility asking when she had last seen R1. RA A stated that she had last seen R1 during the 3:00 PM smoke break. RA A returned to the facility and participated with the search to locate R1. RA A stated that R1's smoking apron (a device used for burn prevention while smoking) was located laying on the ground about 4 steps just outside the patio gate and noted footprints in the snow leading away from the building. RA A stated facility immediately put a new plan in place that evening to have 2 staff members now supervise the smoke break. One staff is assigned to assist the residents and the other is solely assigned to sit in front of the gate until all residents are returned inside and accounted for each time. The NHA and DON were informed on 1/14/21 at 1:30 PM that Immediate Jeopardy had been identified, starting on 12/31/20 at approximately 3:15 PM when the facility failed to adequately supervise R1 (who was identified as an elopement risk with moderate cognitive impairment including safety awareness) on 12/31/20 at approximately 3:15 PM, when he eloped from an outside patio area, while on a smoke break, unbeknownst to staff. Staff did not realize R1 was missing until approximately 5:00 PM. R1 had ambulated down the sidewalk and across the street to a gas station. At approximately 5:40 PM, a Recreational Aid (RA) A looking for R1 found that he reported shortness of breath to the attendant at the gas station who subsequently called 911 and the resident was taken to the Emergency Department for treatment and released to a homeless shelter. R1 was picked up by facility staff at 6:41 PM and returned to the facility at 7:41 PM. R1 was wearing a coat and rubber soled slippers and it was 32 degrees outside with snow on the ground. The facility did not adequately supervise residents while smoking in the enclosed outside patio, allowing a cognitively impaired resident who is a known elopement risk to leave the grounds without supervision. This deficient practice placed R1 and all residents assessed to be elopement risks at risk for serious injury and/or death. On 1/14/21 the surveyor verified the following interventions were put into place and were effective to remove the immediacy: ELEMENT 1 RESIDENT AT RISK: 12/31/2020 Event: R1 eloped on 12/31/2020 -5:05 PM NHA notified by facility staff that R1 not in facility. At this time facility had been searched with no sign of him. Staff felt that he did not return into facility following the last smoke break between 3:00PM - 3:30PM. Staff were instructed to search facility looking for R1 and verifying that all other residents were accounted for, search grounds, notify Police, Guardian, DON and Medical Director. NHA returning to facility. -3:35 PM EMS (emergent medical services) contacted to help R1 at (name of gas station). -3:38 PM EMS arrived on scene- immediate assessment identified no obvious distress noted. R1 responded he has [MEDICAL CONDITION]. R1 requested to be transported to ER (emergency room ). Transfer was uneventful- no complaints or concerns. -4:28 PM Arrived at ER. -4:35 PM ER assumed care of patient per Physician Assistant (PA). R1 reported he ran out of his rescue inhaler. PA assessment was negative for any clinical distress. R1 reported he lived at (name of shelter). Physical exam noted high pitched wheezes (normal finding for [MEDICAL CONDITION]) otherwise benign. -5:09 PM NHA conferred with DON who was also returning to facility. Staff searching grounds and community on foot and in autos. -5:20 PM Guardian notified. -5:25 PM NHA went to local (name of gas station) spoke to manager and asked to review security cameras. -5:26 PM Fire Department was requested to help search. -5:30 PM Guardian updated. -5:36 PM Guardian updated. -5:40 PM Facility Staff at (name of gas station). (Name of gas station) Staff stated that an individual fitting description was there prior to 3:30 PM. He purchased cigarettes, stated to (name of gas station) Staff that he was short of breath and requested them to call an ambulance. (Name of gas station) staff stated that he was picked up by ambulance at 3:30 PM. They believed he was being taken to (name of hospital). -5:45 PM DON and NHA heading to (name of hospital). DON spoke to staff at (name of hospital) ER who stated that R1 did not come to their ER. -5:47 PM Guardian updated. 5:56 PM Facility staff spoke to EMS company and was told upon arrival of ambulance at the (name of gas station) R1 told EMT (emergency medical technician) that he wanted to go to (name of hospital) ER. -5:56 PM Facility Staff were updated with R1's potential whereabouts and were heading to (name of hospital). -5:58 PM DON contacted (name of hospital's) ER Department. -6:00 PM All exterior facility doors were checked for proper (magnet lock) operation and found to be secure. -6:00 PM NHA notified (name of police department) explained situation and asked for assistance. Dispatch assured me that they would head to hospital and look for R1. -6:00 PM DON informed by (name of hospital) ER staff that R1 was discharged to the community at 5:50 PM and that he may be headed to (name of shelter). -6:05 PM Facility staff were updated on R1 potential plan to go (name of shelter). They re- routed to (name of shelter). NHA called (name of shelter) at 6:05 PM and 6:11 PM and 6:14 PM with no answer. -6:11 PM Guardian updated. -6:17 PM Guardian updated. -6:20 PM NHA called (name of police department) to update them on R1 and inform him that he may be heading to (name of shelter. -6:29 PM NHA called (name of shelter) and was able to speak to Intake Nurse (unknown name) who stated he (R1) had not checked in yet. NHA Provided description and contact numbers should he check in. -6:41 PM facility staff stated that they arrived at (name of shelter) found R1, who consented to return to (name of facility). -6:45 PM Guardian updated. (Name of police department) notified that R1 was located. (Name of local police department) notified of same. -7:02 PM Guardian updated. -7:41 PM R1 Returned to facility (closed unit), a skin assessment was completed on R1 with no concerns present. R1 was [MEDICATION NAME] tested (test for COVID) and found negative. -8:01 PM Social Services assessed resident with no concerns. ELEMENT 2 IDENTIFYING OTHER RESIDENTS AT RISK: 12/31/2020 -A head count was completed for all current residents. All residents were accounted for. -All exit doors were assessed for functionality. No safety concerns noted. -ALL residents were assessed for elopement. No issues identified. -New smoking process was implemented for two staff members on all supervised smoking breaks. South (closed) unit's process- two staff with one stationed at the courtyard gate. -Implemented a head count log before and after smoke breaks. ELEMENT 3 PROCESS IMPLEMENTED TO PREVENT FURTHER OCCURRENCE 12/31/2020 -Smoking and Elopement policies were reviewed by NHA and DON and deemed regulatory and clinically compliant. -All staff educated by the NHA/DON/designee with the emphasis on smoking breaks and supervision to ensure they were two staff members present and a log to be utilized for a head count upon beginning and ending of smoking breaks. -Staff not present 12/31/2020 were educated next day prior to their scheduled shift. -All staff have been educated except for those on personal/medical/sick leave. -New hires will be educated on new supervised smoking process and elopement policy. ELEMENT 4 MONITORING -All Smoking logs have been audited by NHA/designee since 1/1/2021 for continued compliance. No deficiencies have been identified. -Facility has audited head count logs and smoking process biweekly since 1/1/2021 to 1/14/21. -Facility will continue audits weekly x four weeks to ensure compliance. -Audit results will be reported to QA committee for monitoring and follow up. -Administrator is responsible for compliance of this past non-compliance plan. On 1/14/21 this Surveyor reviewed documentation, conducted interviews and made observations the preceding interventions were completed prior to the abbreviated survey. A determination of past non-compliance was approved by the state agency as of 12/31/20.

This citation refers to intake MI 011 Based on observation, interviews, and record review, the facility failed to provide staffing and supervision to prevent a fall for 1 (Resident #5), of 3 residents reviewed, in a total sample of 14 residents, resulting in an immediate jeopardy on 1/26/19 at 2:30 p.m., when Resident #5, who was a known fall risk, was left in the South 2 dining room unattended and had an unwitnessed fall, resulting in a hospitalization with an [MEDICAL CONDITION]. This deficient practice placed all residents requiring supervision at risk. On 2/7/19 at 5:00 p.m. at 4:30 p.m., the Administrator was notified of an Immediate Jeopardy that began on 1/26/19 when Resident #5, who was identified as a fall risk and needed supervision, had an unwitnessed fall that resulted in an [MEDICAL CONDITION] and was sent to the hospital. On 2/8/19 surveyors verified the facility completed the following to remove the Immediate Jeopardy: 1. Resident #5 was reassessed for falls and the Care Plan was reviewed and updated as appropriate. 2. On 2/7/19 nursing completed another fall assessment and reviewed and updated plan of care as appropriate. 3. A staff member was positioned in the South 2 dining room whenever a resident is present and will be educated prior to taking their post. 4. Education began on 2/8/19 at 12:15 a.m. for staff was positioned in the S2 dining room. 5. On 2/7/19, Nursing started to complete fall risk assessment on all residents in the facility and the resident care plans were reviewed/initiated. 6. On 2/7/19 a fall intervention list was developed and shared with nursing staff. 7. On 2/7/19 at 5:30 p.m., all education was started for all nursing staff (38 out of 86 staff members completed), which included: Fall Prevention PowerPoint education which included prevention, staff education about falls and their residents' Care Plan and Kardex, and not to deviate from the Care Plan and Kardex. 8. On 2/7/19, the Fall Reduction Prevention Program and the Care Plan Person-Centered Comprehensive Policy was reviewed by NHA and found to be accurate. Review of a Face Sheet for Resident #5 revealed an [AGE] year-old male originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status was done for Resident #5 that indicated he was severely cognitively impaired and required extensive assistance of two staff for transfers. Review of Nursing Progress for notes dated 1/11/19 for Resident #5 revealed: Resident with impulsive behaviors. Intermittent standing and attempting to ambulate aimlessly. Gait unsteady. Occasional reaching at nonexisting items in front of him. Attempted to kick at staff when care provided. Review of an incident report for Resident #5 revealed that on 1/18/19 at 2:00 p.m., Resident #5 had an unwitnessed fall incident in the South 2 dining room. Incident description: Report performed at shift change. Nurses heard a thud and went to respond. Resident sitting on floor in S2 dining room. Positioned in front of his wheelchair. Resident with skin tears to right forearm and left elbow. Resident fully dressed with grippe socks on. Sensor alarm was on wheelchair, but not sounding. Resident was alert and acting appropriate. Unable to state (sic) Immediate Action Taken: Resident assessed .Wounds cleansed .Too unsteady standing to obtain standing orthos .Immediate intervention to have sensor alarm functioning properly and to have resident within staff eye contact while in wheelchair . Review of the Care Plan intervention for Resident #5, implemented on 1/18/19 after the fall incident revealed: Do not leave me in dining hall alone. Be present or take me to S1 dining hall to be part of activities. Review of an incident report for Resident #5 revealed that on 1/26/19 at 2:30 p.m., Resident #5 had an unwitnessed fall incident in the South 2 dining room and was taken to the hospital. Incident description: At 2:30 p.m. resident observed on the floor in the dayroom on his left side w/c (wheelchair) in lock position next to him, was alert and had a 3 inch laceration above his right eye, moderate amount of bleeding and obs to need sutures I don't know, baseline is confused, dementia Immediate Action Taken .Sent out to hospital Investigation conclusion: .The fall was unavoidable due to Resident #5's co-morbidities .The facility has no reason to believe, due to the physical impairments of the residents in the room with him and the nurses across the hall that any physical contact was made between any residents in the TV room . Review of a Nursing Witness Statement for Resident #5's incident dated 1/26/19 revealed: I was in the med room counting narcs (narcotics) when the resident fell . I heard a noise in the dining room. When I got in the dining room, the resident was lying face down on the floor next to his wheelchair. As the resident rolled over I observed bleeding from his right brow. Review of CNA F Witness Statement for Resident #5's incident dated 1/26/19 revealed: I was going room to room just starting alarm checks. Things were running late as we had to figure out where each CNA was going to be due to call-ins. (Resident #5s) alarm had been on all day and was on when I checked his chair. The exact moment he fell I was checking on (a resident) alarm and assisting her out of her bed Review of CNA G Witness Statement for Resident #5's incident date 1/26/19 revealed: I was assisting (CNA) with (a resident) in resident care. We heard a yell saying there was a fall. I went to look and found Resident #5 on the floor of the S2 dining room. I heard no alarm and discovered a faulty alarm Review of the Hospital Emergency Department progress notes for Resident #5 dated 1/26/19 revealed: The patient sent in from his nursing facility for concern for [MEDICAL CONDITION] and unwitnessed fall . Final Diagnosis & Disposition- [MEDICAL CONDITION] frontal lobe laceration Review of Physician order [REDACTED]. During an observation on 2/6/19 at 11:10 a.m., the South 2 dining room had three residents sitting at the table unsupervised and there was no staff in the hall or nearby. The South 2 unit hallways cross in a lower case t shape, and where the halls intersected on the upper left side was where the dining room was. The dining room had no windows and a doorway that exited on two sides of the dining room into the hallways. The nurses' station was across the hall from one doorway and the other doorway exited to the hallway with resident rooms. This surveyor walked the halls and found two staff, Certified Nursing Assistant (CNA) J and a CNA in training H, in a room assisting a resident with care. CNA J reported that the nurse on the S2 unit went on a break and left the floor while the other CNA went on a lunch break as well. That left CNA J and CNA H in training on the floor to care for the residents. CNA H reported she could not care for residents alone until she took her test the following weekend to become certified. During an observation on 2/6/19 at 11:20 a.m., four residents were observed in the South 2 dining room unsupervised. One female resident was standing independently in the doorway that exited toward the hall with resident rooms. A male resident was walking with a walker and tried to enter the doorway that the female resident was blocking. The male resident said, Come on, let's go! several times in a stern voice. The female resident appeared to not comprehend what the male resident was saying or trying to do. The male resident gently bumped the female resident with his walker and she gradually moved away and walked toward the other doorway in the dining room that was facing the nurses' station. The female resident then bent over and was randomly reaching and grabbing at the air and at the floor. The male resident then continued to follow the female resident and as she was bent over, he bumped his walker against her gently and his behavior started to escalate. At that time, CNA J and CNA H in training entered the S2 dining room and redirected the male resident. During an observation and an interview on 2/6/19 at 11:23 a.m., Licensed Practical Nurse (LPN) K was observed entering the door to the South 2 unit. LPN K reported she took a 10-minute break to assist the smokers on the North unit because they needed the help. LPN K reported that she informed the unit manager, who was in his office on the S2 unit with the door closed, that she was going on a break. During an observation on 2/6/19 at 11:28 a.m., Resident #5 was observed lying in bed, and appeared restless by moving and looking around in bed. LPN K came down the hall and looked into Resident #5's room and asked the CNAs to get him up. During an observation and an interview on 2/6/19 at 11:45 a.m., Activities Aide (AA) Z was in the South 1 dining room, which is locked unit before the S2 unit, engaging residents on the S1 unit with activities and reported that the South 2 unit did not have activities during the day because they were short staffed. AA Z reported that a couple of the residents from the South 2 unit would join the residents on the South 1 unit sometimes. During an interview on 2/6/19 at 12:30 p.m., CNA J reported that there were no activities provided for residents on the South 2 unit but sometimes residents may go to the South 1 unit if they had behaviors and would sometimes eat their lunch on that unit too. CNA J reported that Resident #5 was to be observed every 15 minutes for safety checks and may not always be able to chart every 15 minutes but would physically put eyes on the resident. When queried about this day at 11:10 a.m. when CNA J was in room [ROOM NUMBER] caring for another resident on the opposite end of the hall of Resident #5, who resided in room [ROOM NUMBER], CNA J reported she checked on Resident #5 first before going to room [ROOM NUMBER]. CNA J reported she was doing morning care for the resident in room [ROOM NUMBER] and said it usually took about 15 to 30 minutes to do care and acknowledged that she could not have checked on Resident #5 between 11:00 a.m. and 11:28 a.m. Review of a Frequent Checks documentation form for Resident #5 revealed: Task: Frequent Checks every 15 minutes r/t (related to) hx (history) of falls .dated 2/3/19 to 2/5/19 revealed several entries of checks done at the same time on the same day, and many entries with longer than 15 minute gaps in between checks. In an interview on 2/6/19 at 4:00 p.m., Certified Nursing Assistant (CNA) G reported Resident #5 had a fall on 1/26/19 during the shift change, in the South 2 dining room, while she was in another residents' room with CNA F. CNA G reported that there were two nurses on the floor giving report to each other when one nurse yelled that someone had fallen. CNA G reported she finished care for the resident in the room, then went to the S2 dining room and saw Resident #5 sitting on the floor and the two nurses attended the resident. CNA G reported Resident #5 had an open area above his eyebrow and there was blood on the resident and on the floor. CNA G reported Resident #5 went to the hospital after the fall. CNA G reported the last time she saw Resident #5 that day before the incident, was when he was in his wheelchair in the South 2 dining room with 4-5 other residents. CNA G reported that the fall incident could have been avoided if there was supervision in the dining room because the residents on that unit had behaviors, wandered and needed to be redirected at times. CNA G reported there were typically two CNA's on the floor and one nurse to provide care, and there was no staff to provide activities on the South 2 unit to engage the residents and give them something to do. CNA G reported she was told there was no budget available for activities or more staff. CNA G confirmed that when a staff member would take a break, then there would be only 2 staff members on the floor to take care of the residents. CNA G reported that the staff would get mandated to work past their scheduled shift all the time and had to get a physician note to restrict her working hours because it was physically affecting her. CNA G reported that the agency nurses that worked at the facility did not assist with resident cares as much as the regular staff, and when the other CNAs' would take a break, she relied on their help and would not always get it. In an interview on 2/7/19 at 10:45 a.m., the Director of Nursing (DON) and Nursing Home Administrator (NHA) reported they utilized position alarms for residents to help staff know when to check on the residents. The DON reported it helped with the quality of life for the residents because it would help staff know when a resident was moving or needed to use the restroom. The NHA reported that they followed the manufacturer's instructions for the alarms on how to use them, when to use them, and how to maintain them. The NHA and DON reported they did not have a policy for the position alarms and did not provide the manufacturer's instructions when requested at this time or by the end of the survey. In an interview on 2/7/19 at 12:11 p.m., CNA F (no longer employed at the facility) reported she was in another residents' room with CNA G toileting a resident who required two staff for care, when a nurse came to the room to tell them that Resident #5 had fallen. When the CNA's finished care on that resident, both CNA's went to the dining room to assist with Resident #5, who was then sitting up on the floor, and observed a nurse who took his vital signs. CNA F then reported she noticed a moderate amount of blood on the floor next to Resident #5. CNA F reported that Resident #5 was impulsive and had behaviors that were unpredictable. CNA F reported that all the residents on that unit needed to be supervised in the dining room but there was not enough staff available to stay in the dining room all the time. CNA F then reported that there was a time when the CNA's had to rotate who sat in the dining room to supervise the residents, but then that left one CNA on the floor for resident care. CNA F reported she no longer worked at the facility because of the short staffing. In an interview on 2/7/19 at 3:30 p.m., the DON reported that when Resident #5 was admitted to the facility, he had a hard time transitioning and was aggressive. DON said, His dementia and new surrounding was a huge factor to his instability. Every resident on the S1 and S2 unit needed supervision, but that did not mean 1:1 supervision. DON reported that on 1/26/19 there were two nurses outside the S2 dining room in the hallway when Resident #5 was found on the floor. DON reported that Resident #5 was supervised because the residents inside the dining room were in the nurses' peripheral vision even though the nurses could not see the residents on the other side of the wall. DON reported that supervision was a team effort. When asked to clarify what the supervision meant in Resident #5's Care Plan, that read Do not leave me in dining hall alone. Be present or take me to S1 dining hall to be part of activities, DON said it meant Heightened awareness, yeah, that's what that means. Although the immediate jeopardy was removed on 2/8/19, the facility remained out of compliance at a scope of isolated and severity actual harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency, all education had not yet been completed, and Resident #5 had a fall with injury and the facility was found to have deficient practice.

This citation pertains to intake # MI 391 Based on observation, interview, and record review, the facility failed to provide adequate supervision for two Residents (Resident #124 and Resident #101) of three residents reviewed, in a total sample of 19, resulting in unsupervised falls with injury. Findings include: Resident #124 According to the Minimum Data Set (MDS) assessment, dated 10/17/18, Resident #124 had multiple [DIAGNOSES REDACTED]. This same assessment indicated Resident #124 was severely cognitively impaired and required extensive to total assistance of two staff members for transferring, bed mobility, hygiene, dressing, and bathing needs. According to a Fall report, dated 1/10/19, Resident #124 was observed on the floor in the room by the bed and .resident had large amount of blood around her on floor . Resident #124 had a laceration on the top of the head and complained of pain when the left arm was assessed. This fall report indicated that Resident #124's bed alarm was not turned on. According to progress notes, dated 1/10/19, Resident #124 was sent to the hospital and returned that same day with a .Laceration (to) forehead with 3 sutures intact. Bruising to face, forehead, right index finger, left forearm and wrist. Skin tear (on) left elbow . According to a Fall report, dated 1/13/19, Resident #124 was found on the floor in the room by the bed and .bed alarm was in place and active however did not activate the alarm . The sensor pad was replaced. This same Fall report indicated Resident #124 .would benefit from a concave mattress and low bed . There were no new injuries documented as a result of this fall. During an observation in the dining room on 1/24/19 at 8:15 AM, Resident #124 was noted to have bruising on her face and forehead. A scabbed area was noted above the right eyebrow. A transparent dressing was on Resident #124's left elbow. Resident #124 was not taking offered bites of breakfast and was accepting sips of offered liquids. At this same time, Certified Nursing Assistant (CNA) BB stated that Resident #124's alarm is checked hourly to ensure it is on and working. A demonstration of Resident #124's wheelchair alarm check revealed the alarm was working at that time. During an observation on 1/25/19 at 11:20 AM, Resident #124 did not have a concave mattress. Review of Resident #124's care plan for Falls, revealed on 3/28/18, an intervention was read, .RESOLVED: 3-28-18: I now have a concave mattress . Review of Resident #124's care plan for Falls, revised 1/13/19, read, .I need a sensor pad alarm in my wheelchair and bed to remind me to ask for assistance to walk or transfer . On 1/24/19 at 3:00 PM, Administrator VV (an Administrator from a sister facility) stated there was no policy for alarm maintenance. During an interview on 1/25/19 at 1:15 PM, Clinical Care Coordinator (CCC) E stated. .It (Resident #124's bed alarm) was turned off the first time (fall occurring on 1/10/19). The second time (fall occurring on 1/13/19) the alarm was on but didn't alarm .Staff should be doing alarm checks every shift and every hour .batteries are changed at end of the month on third shift . CCC E was asked for a policy regarding alarm maintenance, it was reported there was no policy and that it was the culture of the facility when to check alarms and change the batteries. CCC E provided an education sign-in sheet indicating on 1/17/19 education was implemented to 10 staff members regarding when to check alarms and when to change the batteries. CCC E stated the education was ongoing and that not all staff members had received the education yet. No additional documents were received by end of the survey on 1/25/19 at 3:45 PM. Resident #101 Review of a Face Sheet for Resident #101 revealed an [AGE] year-old male originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 had a Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment and required extensive assistance of two staff for transfers and supervision with one staff for eating. Review of an incident report dated 1/18/19 for Resident #101 revealed: Incident Description: Entered the resident's room while making rounds. Resident was sitting on his foot pedals of his wheelchair and sitting upright with his back against the front of the seat. Resident had been seen earlier sitting in his wheelchair. Resident assisted into wheelchair around 1715 (5:15 p.m.) for dinner. Ate in his room in his wheelchair. Resident unable to state what happened. Immediate Action Taken: Resident assessed .Immediate intervention is to assist resident into his chair. Offer resident to be assisted back in bed after eating No witness statements noted, and no investigation or root cause concluded on the report. Review of the Care Plan for Resident #101 revealed: .EATING- I am able to feed myself after set up with periodic supervision/cues as needed, revised on 11/30/18 .Feeding Techniques I require: my level of independence with eating varies with my mood and cognition. Please encourage me to go to the S2DR for all meals and provide assistance as needed, revision on 11/30/2018 .I prefer to Dine in south 2 dining room, Revision on 07/20/2018 . Cue, reorient and supervise as needed, revision on 07/19/2018. Cue, reorient and supervise as needed, Revision on 07/19/2018 Review of the POS [REDACTED]. Unwitnessed. No obvious injuries .Last time resident was toileted: 1900 (7:00 p.m.) .Intervention: Staff will assist me to bed after dinner if I feel drowsy . Review of a Nursing Antigravity Team Note dated 1/20/19 for Resident #101 revealed: Date of Fall: 1-18-19, Cause of Fall: (Root Cause likely to have caused the fall): Resident was in his wheelchair in his room after consuming his meal and arose unassisted. Prior Interventions: Only staff will assist me with transfers; I can be transferred via mechanical lift. New Interventions: Offer to assist resident into bed after eating if he presents as fatigued During an observation on 1/23/19 at 2:45 p.m., there were 4 residents observed sitting the South 2 (S2) dining room alone with no staff supervision. During an observation and an interview on 1/25/19 at 11:25 a.m., Hall Monitor (HM) TT was on the S2 unit redirecting residents wandering in the hall. HM TT reported that her job was to check the hall, resident rooms, redirect residents, help pass out waters, and monitor for safety and resident conflicts. HM TT reported that there were usually 2 CNA's on the floor and a hall monitor during the days. During an observation on 1/25/19 at 11:35 a.m., 7 residents were observed in the S2 dining room and no staff were in there or in the halls. A nurse was observed across the hall in the nursing room. In an interview on 1/25/19 at 12:40 p.m., CNA QQ was in the hall on the S2 unit and reported there were 3 CNA's working on the S2 unit, but one CNA was at lunch at this time and the other CNA was in a resident's room. During an observation on 1/25/19 at 12:42 p.m., 6 residents were observed in the S2 dining room unsupervised. In an interview on 1/25/18 at 2:30 p.m., Clinical Care Coordinator (CCC) E reported there were usually two Certified Nursing Assistants on the floor with a nurse on the South 2 (S2) unit and sometimes a hall monitor. CCC E reported that the two CNA's that were working the night of 1/18/19 at the time of the incident were more likely in the dining room assisting other residents' with their meals. CCC E reported that Resident #101 was in his room eating his dinner at the time of the incident with no staff in the room and reported Resident #101 was probably tired after eating and wanted to get up and go to bed and they updated the care plan to have resident go to bed after meals. CCC E reported that falls were reviewed in the IDT (Interdisciplinary Team) meetings and that this investigation was not as thorough as it could have been and did not have any statements from staff or visitors stating where they were at the time of the incident or why Resident #101was eating alone in his room unsupervised. CCC E reported that the residents on the S2 unit required more supervision and that was why the residents were on that unit. When asked about the several observations of residents in the dining room with no activities or supervision this day, CCC E said, That's a problem. When CCC E was queried if having only 2 CNA's on the floor caring for the residents and had to do care for a resident in their room who may require 2 staff to assist, who was monitoring the residents wandering up and down the hallway, in the dining room, providing activities, or in the shower room, he did not have an answer. Review of a policy titled Fall Reduction? Prevention Program last revised 4/30/14 revealed: I. Policy: Our residents have the right to be free from falls, or to sustain no or minimal injury from falls. II. Purpose: Safety of the residents will be maintained to the greatest extent possible .III. Procedure: 1. Fall Risk Status Assessment .2.Fall Reduction/Prevention Care Plan a) To be completed 3. Actual Fall Follow-up Documentation a.) Each time a resident falls .

Based on observation, interview and record review, the facility failed to deploy staff in sufficient numbers to meet resident needs according to the facility assessment and individualized care plans for 9 Residents (Resident #25, #27, #1-91, #1-401, #1-405, #-410, #1-411, #1-412 and #1-419) of 31 residents reviewed for staffing needs, resulting in Immediate Jeopardy when Resident #27's call light was not answered timely, Residents #410, #411, #412 were harmed from resident to resident abuse, physical and psychosocial harm from neglect, ongoing neglect and placing all residents who live at the facility at risk for negative physical, mental and psychosocial outcomes. Findings include: Review of the (Name of Facility) Facility Assessment last reviewed and updated in (MONTH) (YEAR) reflected, (Facility Name) is licensed to provide care for 128 (people). The assessment indicated it was able to care for residents with many common conditions including but not limited to residents with Psychiatric/Mood Disorders, Heart/Circulatory System diseases (including [MEDICAL CONDITION]), diseases of the Neurological System (including [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] among others), [MEDICAL CONDITION] System (including urinary incontinence), Digestive System (including conditions such as gastroenteritis, ulcerative [MEDICAL CONDITION], and bowl incontinence), Integumentary System (skin ulcers, Injuries) and Infectious Diseases (including skin and soft tissue infections among many others). The assessment detailed Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies and reflected the staffing plan was for the North Unit to have three licensed nurses for the first and second shift and two licensed nurses on third shift. The South Unit was to have two nurses on first and second shift with one licensed nurse on the night shift. The Staffing Plan called for there to be 13 FT (full time) licensed nurses to provide direct care 24 hours a day 7 days a week. The plan called for 33 FT nurse aides in addition to 12 FT other staff needed for behavioral healthcare and services. In an interview on 10/4/18 at 10:57 AM, CNA W reported that on Sunday (9/30/18) she was the only aide on the printed schedule for the south units (16 two person assists out of a total of S1 hall 25 residents, S2 hall 23 for a total of 48 residents). CNA W said she told Scheduler Z and nurses on duty that she would not jump from hall to hall, and that they needed to bring in more help for the night because she was going to stay on her S1 hall. Review of a schedule for 9/30/18 reflected that CNA W was the only aide assigned to work on the south units. Two CNA's were mandated to stay over from the afternoon shift, one left at 2 a.m. According to the schedule, at 2:00 a.m. on 10/1/18, there were 3 nurses and 2 CNA's to care for 105 residents in the facility. Multiple requests for Time Detail Reports were made to validate the claim made by CNA W. A Time Detail Report was provided on 10/10/18 that confirmed the second CNA S was present in the facility on 10/01/18 from 2:00 a.m.-7:00 a.m., but no other staff available. Resident #27 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #27 was an [AGE] year-old female, who was admitted to the facility on [DATE] (with a readmission date of [DATE]), with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), dated 8/10/18 reflected a score of 13 out of 15 which represents Resident #27 was cognitively intact. Resident #27 required staff assistance with all activities of daily living and transfers. Review of a Care Plan last revised on 8/27/18 reflected Resident #27 was Frequently incontinent of bladder and bowel. My use of diuretics and other medications can also impact my continence status and I require extensive assistance with toileting needs and my need for a hoyer lift for transfers impairs my ability to be toileted in my bathroom. My decreased physical ability and possible medication side effects put me at increased risk for constipation. I also have a history of [MEDICAL CONDITION] with a partial colectomy and divirticulosis. Goals of the care plan indicated that Resident #27's risk for risk for [MEDICAL CONDITION] will be minimized through/prevented through prompt recognition and treatment of [REDACTED]. Interventions included Assist to bed pan upon my request and especially prior to going to meals, activities and before going to bed at night, and Check me with rounds and as required for incontinence. Wash, rinse and dry perineum, apply barrier cream after each incontinence episode and as needed. Review of a Care Plan last revised on 8/7/18 reflected Resident #27 had an ADL (Activities for Daily Living) Self-care Performance deficit related to NSTEMI (a mild [MEDICAL CONDITION]), fatigue, recurrent UTI's, Cardiac issues, anxiety, shortness of breath with exertion, obesity, diabetes with diabetic [MEDICAL CONDITION], depression, [MEDICAL CONDITIONS], frequent bladder incontinence, pain, impaired mobility with need for hoyer transfer (mechanical lift), and possible medication effects. The goal of the care plan was for Resident #27 to Maintain my current level of function in bed mobility, eating, dressing and personal hygiene as my cognitive and physical status will allow. Interventions included Offer me the bed pan as I can make my needs known as needed. During an interview on 10/2/18 at 1:42 p.m., Resident #27 reported staff kept turning off her call light when she needed assistance to the bedpan earlier that day, between 10:00 a.m. and two minutes before lunch at noon. Resident #27 reported she had had an accident and everything got wet which made her feel embarrassed. During an interview on 10/01/18 at 10:00 a.m., Resident #32, (Resident #27's husband and roommate) expressed frustration regarding his wife's care. Resident #32 reported that staff call in when they aren't sick and the staff that are working don't get his wife out of bed on time because they are too short handed. Resident #1-405 Review of a facility Admission Record reflected Resident #1-405 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1-405 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15/15. During an interview on 10/3/18 at 5:08 p.m., Resident #1-405 reported that he had been getting sick for 2-3 days prior to being transferred to the hospital on [DATE]. Resident #1-405 did not report refusing to be sent to the hospital, but did report he didn't feel safe at the facility due to having to wait so long for staff to respond to his call light. Resident #1-405 said he had to sit in his feces for over an hour on 10/2/18 and 10/3/18 due to staff not responding to his call light. Resident #1-405 said I get mad and frustrated. I could be in trouble and it takes 15-20 minutes to get help. I don't really feel safe but what can I do?. Resident #1-410 Review of a facility Admission Record reflected Resident #1-410 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1-410 was severely cognitively impaired and exhibited wandering behavior daily. Review of a Care Plan last updated on 8/31/16 reflected Resident #1-410 was At risk for elopement related to attempts to elope from my home, one of which was successful. I have dementia and am no longer aware of my safety needs. I wander looking for a way out. The goal of the care plan was for Resident #1-410's risk for elopement from the secured unit and facility will be minimized with interventions that included Hall monitor in place to assist and redirect me out of other resident's rooms, distract me from wandering by offering pleasant diversions, ask me to help you with a simple task that will help distract me for a short period of time, provide structured activities: toileting, walking inside and outside, reorientation strategies including signs and pictures. Review of a Care Plan last revised on 4/9/18 reflected (Resident #1-410) is sometimes combative (hitting, pushing etc.) with staff. I may not always understand the environment, actions or statements of others related to severely impaired cognition. The goal of the care plan was that Resident #1-410 would not harm self or others. Interventions included Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. During an observation on 10/3/18 at 10:12 a.m., Resident #1-410 was observed wandering into and out of resident rooms on the south unit. A Hall Monitor was situated in the middle of the unit and was unable to respond or redirect from her station. No other staff were observed in the area while Resident #1-410 wandered into and out of other occupied resident rooms. Review of an incident report dated 10/7/18 at 3:00 p.m. reflected Resident #1-410 Wandered into (another resident's room), removed a hoodie from his room and was pushed on the shoulder by the other resident as a result. According to the incident report, staff were not available at the time of the incident to intervene. Review of an incident report dated 10/7/18 at 3:29 p.m. (29 minutes after the previous incident), Resident #1-410 was struck several times in the face by another resident. According to witness statements included in the incident report, Hall Monitor (HM) CCC reported she had gone looking for help after the previous incident and was not on the unit providing any supervision at the time of the occurrence. CNA VV's statement reflected the following: I was walking toward the large shower room on S2 unit with (another resident) when I heard screaming down the hall toward the door by room [ROOM NUMBER] and 2. I redirected (other resident) and walked toward the noise. When I reached the end of the hallway, I noticed the noise was coming from room [ROOM NUMBER]. I knocked and opened the door with my right hand. As I opened the door I observed (another resident) straddled on top of (Resident #1-410) laid horizontally across the bed. (Name of Resident) struck (Resident #1-410) using her closed fist (right hand) on the right side of (Resident #1-410's) face. The statement provided by Registered Nurse (RN) DDD was that she was in the nurses station on the telephone when the incident occurred. Resident #1-411 Review of an Admission Record and MDS dated [DATE] reflected Resident #1-411 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment indicated Resident #1-411 has severe cognitive impairment and wandered daily. Review of a Care Plan implemented on 6/08/12 reflected Resident #1-411 was At risk for elopement related to my [DIAGNOSES REDACTED]. The goal of the care plan was that Resident #1-411's risk for elopement will be minimized with interventions that included Hall monitor in place to assist and redirect me out of other residents rooms, distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television and books, provide structured activities: toileting, walking inside and outside, 1:1 conversation During an observation on 10/3/18 at 10:12 a.m., Resident #1-411 was observed wandering into and out of resident rooms on the south unit where she lived. A Hall Monitor was situated in the middle of the unit and was unable to respond or redirect from her station. No other staff were observed in the area while Resident #1-410 wandered into and out of other occupied resident rooms. Resident #1-412 Review of a facility Admission Record reflected Resident #1-412 was an [AGE] year old gentleman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Record reflected Resident #1-412 was his own responsible party. A Minimum Data Set (MDS) assessment dated [DATE] reflected resident #1-412 was moderately cognitively impaired and did not need assistance for bed mobility or transfers, required supervision and encouragement for eating and toilet use and needed limited assistance from one person for personal hygiene. During an observation and interview on 10/3/18 beginning at 9:45 a.m., Resident #1-412 was observed seated in a chair outside of the activity room on the South 2 unit, a locked unit for severely cognitively impaired residents who wander. Resident #1-412 was wearing a Korean War Veteran hat. When asked, Resident #1-412 introduced himself and reported he had been in the Army and served in the Korean War and in Germany. Resident #1-412 said he had been a truck driver after he returned from active duty. During an interview on 10/3/18 at 10:00 a.m., Hall Monitor (HM) Q reported she was currently split between two halls, the S1 and S2 units (both locked/secure units for residents who were independently ambulatory and severely cognitively impaired). She was trying to keep an eye on one resident who was escalating his behaviors and also keep an eye on a resident who was getting irritated with cognitively impaired residents. HM Q reported the resident who was getting irritated was Resident #1-412 who was not really supposed to be living on the S2 unit because he was not very cognitively impaired and the other residents frustrated him. During an observation on the S-2 (primarily dementia with behavior problems) unit on 10/4/18 at 11:55 AM, a loud verbal exchange coming from a resident room was overheard. Upon arriving at the residents room, Resident #1-411 was noted walking around Resident #1-412's room. Resident #1-412 yelled, Get out repeatedly until this surveyor reached his room. Resident #1-412 stated, I'm sick of her (Resident #1-411) coming in here. She picked up my hat and threw it on the floor. She steals[***] Resident #1-412 then gestured that he had put his television remote in his shirt pocket and was concerned that someone was going to take it. Resident #1-412 then stated, She comes in here and gets in my dresser drawer. She is messing with my papers and taking them. A dietary staff member happened to be in the hall passing by and attempted to redirect Resident #1-411 out of Resident #1-412's room. No other staff were noted in the hallway or near by to respond to Resident #1-412's pleas for help. On 10/2/18 at 8:25 AM, on the S-2 unit an interview was conducted with Registered Nurse (RN) AA'. RN AA reported she was working as an Aide because she declined to take a (med) cart (work as a nurse). RN AA reported the facility had scheduled only 1 aide and no Hall Monitor for the S-2 unit and she considered this staffing level to be not safe. RN AA reported unsafe because of the needs and behaviors of the severely cognitively impaired residents on the S-2 hall. RN AA reported she had worked the S-2 unit before at that staffing level and that, it did not go well. RN AA reported when she had declined to work as a nurse today at that staff level (1 Aide) that she had received push back from the Scheduler and Administration. RN AA reported the Scheduler had told her that the previous day the unit had been staffed with only 1 aide and that Administration had questioned her ability. RN AA stated, I'm a good nurse and I care about these people, but it just isn't safe. RN AA reported last Wednesday she was the nurse on the S-1 unit when other staff were at back to back meetings. RN AA reported so many staff were at the meetings that it resulted in the unit being inadequately staffed. RN AA reported she and an Activities staff member were the only staff available to provide care to the S1 residents at meal time. RN AA reported just before the meal she had a fall with injury and prior to that the fall resident was involved in a Resident to Resident altercation. RN AA reported ample staff were in the building because the facility thought the state might be in that day .they always staff up on those days. RN AA indicated the state did not come in and that the meetings started right after the fall of the S-1 resident and during lunch. RN AA stated, we were paging for assistance but no response .trying to feed, watch a one on one resident (a resident that required constant supervision), behaviors in halls .it's like you don't know where to begin. RN AA questioned if facility will know of this interview. RN AA expressed concern of retribution from the facility for speaking of this and that she was aware other staff were fearful to speak to state surveyors. On 3:35 PM, an interview was conducted with Unit Manager (UM) G. UM G reported he was the manager of the S-1 and S-2 units. UM G was asked if staffing was a concern at the facility. UM G reported, I'm going to cut my own throat and say that yes (It was a concern), It's a huge problem for me . UM G reported he has talked to Administration, endlessly about it. Reported he had been told it's getting better, and we're working on it. Reported staffing has not improved. UM G reported, Call in's (Staff calling that they were not going to report to work) are not always replaced and that we work with what we have. UM G reported complaints about staffing levels from the staff were, Endless Review of the Facility Assessment document reflected it was last updated (MONTH) (YEAR), the month following the annual Recertification Survey. The document reflected the facility accepted residents that had, or could develop, physical and cognitive disabilities . or combinations of conditions that require complex medical care and management. The document reflected the Director of Nursing (DON) and Medical Director ensured staff, are competent and have the skill set to manage the resident population Part 2 of the Facility Assessment listed the Services and Care We Offer Based on our Resident Needs. This outline documented specific numbers of licensed and certified staff required to provide competent support and care. Comparison of the Facility Assessment Staffing Plan and the staff schedules provided by the facility reflected consistently fewer staff numbers that were physically providing care to the residents. Resident #1-91 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #1-91 was admitted to the facility on [DATE] (with a readmission date of [DATE]), with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), dated 9/04/18 reflected a score of 99 which represents Resident #1-91 was unable to answer questions. Review of Bathing Self Performance Report dated 8/8/18 - 10/04/18 revealed Resident #1-91 received one shower on 9/6/18 and did not receive another documented shower until after 10/1/18. The bathing self performance report revealed Resident #1-91 had refused to take a shower six times, and was marked not applicable once, the report also revealed that the resident was never reproached for a shower on those days. On 10/03/18 at 10:58 AM, Resident #1-91 was observed sleeping in the dining room, one sock on one sock off. Resident's jeans were visibly soiled with build up of food residue and grime. Resident had an evident body odor and looked unkept. In an interview on 10/03/18 at 11:00 AM, Registered Nurse (RN) AA stated that she was a hall monitor yesterday on 10/02/18 and that Resident #1-91 would not let us touch him yesterday, and that the resident would run up and down the halls like he was in a manic state. RN AA also revealed that Resident #1-91 refused to be touched, assisted and would not go to his room yesterday. RN AA stated the resident had been up for over 48 hours with out sleeping, however, the resident had been sleeping in the dining room chair since prior to 6 AM and has not moved. RN AA revealed that Resident #1-91 would often have these behaviors (Not sleeping, wandering, not allowing care, refusing to be touched). RN AA stated that they often did not document Resident # 1-91 behaviors. Review of a Nursing Progress Note dated 9/27/18 at 11:12 AM, for Resident #1-91 revealed the following, Resident frequent checks this shift as staffing allowed. Resident observed wandering throughout hall all shift. Resident reported to have been up all night and all this day shift. Resident needs constant redirecting as he attempts to wander in and out of other resident rooms. At one time resident had behavior that consisted of wanting to wander into another resident's room, RN attempted to redirect him, he grabbed the door very hard to try and shut it in RN's face, RN helped to make sure that the resident's fingers did not get slammed in the door, however this made the resident upset. CNA assisted to redirect this resident out of the other resident's room. No harm was done to any resident or staff, resident is difficult to redirect and having a hall monitor on staff would be much appreciated and helpful, especially for frequent checks. Resident also observed making delusional statements, looking staff in the eye and stating things like be careful in that bunker I am not moving into that apartment it is safer underground. Resident does have a strong BUE strength as evidence by the fact that he shoved the door very hard during the behavior this am. No signs/symptoms of weakened BUE's. Review of Resident #1-91 kardex with a print date of 10/03/18 revealed under, Newly Added that on, 9/19/18: I am on frequent 1 hour checks. Please document as ordered. Review of Resident's progress notes did not reflect any behaviors being documented for the resident starting on 9/19/18. During an interview on 10/10/18 at 12:49 PM, Head of Housekeeping (HOH) RR, stated that as of today he was no longer fearful of retribution. HOH RR stated that he worked for a third-party company and often had problems with the administrator trying to talk his staff into coming to work for her. I've worked at three nursing homes and I had never felt that employees couldn't talk to administrator like they do here. HOH RR revealed that, last week they had a meeting and were informed by the administrator that if the staff were heard talking and or complaining to other staff or the survey team that those employees were supposed to be brought to the administrator and they would be then discharged /walked out of the building. Stated all department heads were brought in on that meeting. HOH RR stated that as of today, I'm not worried about retaliation, my loyalty is to the residents, not to the management and that I could get a job someplace else. During an interview on 10/11/18 at approximately 1:18 PM, Clinical Care Coordinator G stated, I haven't been able to do my job this week because there was a hole in the schedule, so I have been on the cart (nurse cart to pass meds) two times this week. I haven't been able to do root causes for the falls that happened last week, (10/1, 10/2, 10/4 on Resident #1-91) I just haven't been able to look at things. It's just difficult, just been a difficult few weeks. An interview and record review was conducted with the NHA A and the COO X on 10/4/18 at 4:04 PM, to review the staffing concerns at the facility. NHA A stated that she has been the NHA A since 4/3/18. The NHA A states that she is responsible for development and oversight of all plan of corrections. According to the CMS 2567 dated 6/18/18 and 8/27/18 the facility provided a compliance date off 9/25/18 related to staffing. When asked how the facility determined the appropriate staffing needed at the facility, the NHA A stated, Staffing was based on past staffing patterns and budget. When asked what the minimum amount of staff the facility could function with, the NHA A stated, It would depend on what the resident status is. I don't know how to determine if there is enough staff. When asked if the assignment schedule is routinely posted with holes in it, NHA A stated, Yes. When asked if she was aware that the night shift for 9/30/18-10/1/18 had holes in the schedule, the NHA A stated that she was aware, but she was not aware that the staffing holes had not been filled. When asked what the procedure for staffing coverage was, the NHA A stated that the staff should be calling her directly if they are calling off, then the scheduler is notified to send out an alert via the on-shift system, and she starts making calls immediately. The NHA A stated, I was not made aware of the staffing holes (remained open) over the weekend. The NHA A stated, If the nurses need help they can just ask me. When asked if she was aware that the staff were afraid to call her about staffing concerns, the NHA A stated, No. When asked how the facility monitors that the resident care and services are being provided according to the care plans, the NHA A stated that they do care conferences weekly, the interdisciplinary team reviews the care plans during morning meetings, the incident/accident reports are reviewed and updated, and the facility uses a program called Guardian Angel Rounds (questions related to care and services) to check in with residents 2-3 times weekly. The NHA A stated, No negative feedback has been reported. When the surveyor clarified that there were no negative feedback voiced by the residents, the NHA A then stated that a resident had a call light on for 20 minutes but, It's a behavior problem and she just needs attention. The NHA A stated that she was aware of the call light audit over the weekend reflecting 45-minute waits and aware the resident's needs were not being met timely. During an interview on 10/18/18 at 12:28 PM, the COO X stated that the NHA A would text and communicate with him regarding filling staffing spots and asked her if there was anything that she needed. When asked if she reported the critically low staffing level from the midnight shift of 9/30/18, the COO X stated, No. When asked if he checked in on the status of the plan of correction, the COO X stated, Yes, and was told it was okay .She said the pressure ulcers was not doing well and that the CCC X was overwhelmed. I didn't know that she didn't close the loop with staffing. An interview was conducted with the Acting NHA WW on 10/17/18 at 9:45 AM. The Acting NHA WW stated that she found many grievance forms all around the NHA A's office that were not completed nor logged. The Acting NHA WW stated that she had logged 4 ½ pages of grievances that needed to be processed, and some that were reported to the state agency. Acting NHA WW stated that NHA A did not follow up on the grievances that she had received. Acting NHA WW stated, There were multiple concerns brought to her (NHA A) that things were not fine, and she insisted that all was good. Acting NHA WW stated, We've identified a pattern of care concerns with the same root cause of short staffing. During an interview and observation on 10/1/18 at 10:45, CNA's scheduled on the northeast unit stated they had two more residents to provide morning care to and get up for the day. This surveyor observed the two residents still in their sleepwear in bed. Resident #1-401 Review of the EMR reflected that the resident was admitted with an unstageable pressure ulcer on 9/6/18 that reflected the following surface area wound measurement: 9/7/18, 5.9 centimeters (cm)2 (squared), 9/13/18, 9.0 cm2, 10/4/18, 44.9 cm2. This deterioration reflected an increase of 35.9 cm2 of wound area since 9/13/18. On 10/1/18 at 4:11 PM, it was observed that the door to room [ROOM NUMBER]-1, which was located at the end of an S2 hall, was closed. On entry into the room it was observed that the room was darkened. Resident #1-401 turned to left side in low bed crying, stating, I can't move, I can't move- my leg, ouch, ouch, it hurts it hurts. Noted no call light in reach. Ringer-type bell on over the bed table past the fall mat on the floor out of reach of the Resident. Staff were alerted to the needs of the Resident. During the observation of care, it was noted staff discovered Resident #1-401 had been incontinent of stool. When Resident #1-401 was turned to be cleaned a large wound on the sacral area was observed to be exposed; the wound was not covered with a dressing. The wound remained exposed until 5:27 PM when wound care had been provided. On 10/11/18 at 4:03 PM, an interview was conducted with Nurse Wound Consultant (NWC) TT. NWC TT indicated that on 10/1/18, the Physician's Assistant (PA) had evaluated the sacral wound of Resident #1-401 at approximately 10:30 -11:00 AM. NWC TT indicated a new order for treatment of [REDACTED]. On 10/15/18 at 11:15 AM, a telephone interview was conducted with RN P. RN P reported he was aware the PA had evaluated the wound on Resident #1-401 on 10/1/18. RN P reported he been way behind and had left the wound on the sacral area of Resident #1-401 uncovered. RN P reported he had wanted the Wound Nurse or a Unit manager to be present when he followed the new order for wound care but indicated he was unable to coordinate this care with the other staff. RN P reported he did not complete the dressing change by the time he had left for the day at about 4:00 PM on 10/1/18. Review of the EMR Progress Notes for Resident #1-401 on 10/6/18, reflected a concern for the status of the wound and that the Resident was febrile (elevated body temperature). The medical record reflected the Resident was sent to the emergency room and was subsequently admitted for [MEDICAL CONDITION] (systemic infection). Review of the hospital records dated 10/6/18, for Resident #1-401 reflected the Reason for Visit to be, yesterday fever 103 (degrees Fahrenheit), wound on coccyx that had, increased by ½ (inch) in last 48 hours, and that the facility wants it noted (patient) has had a significant change in condition . Further review of the hospital records indicated a Computer Tomography Scan (CT) of the coccyx wound reflected, osteo[DIAGNOSES REDACTED] (bone infection). Review of education notes written by NWC TT reflected 10 points about care to the wound of resident #1-401. The notes reflected (Resident #1-401) was admitted [DATE], with a Stage 3 sacral pressure injury. There are a few issues related to this wound that need to be addressed. 1. Treatment: Cleanse pressure sore with normal saline (NS) apply Santyl to slough, cover with gauze and apply border gauze, change daily every day shift. 6. Order: (order of 9/7/18 restated) Santyl Ointment .apply to slough .Okay to peel back and replace and reuse same dressing daily. Dressing to be changed every Tuesday and Friday NWC TT added it all capital letters, WE DO NOT PEEL BACK DRESSINGS, DO A TREATMENT AND REAPPLY THE OLD DRESSING. THESE ORDERS DO NOT INCLUDE CLEANING OR PERIWOUND PROTECTION INSTRUCTIONS. THE DRESSING MUST BE CHANGED EACH DAY WITH CLEANING A

Based on observations, interviews, and record review, the facility administration failed to administer the facility by utilizing resources to correct known deficiencies and prevent abuse, neglect, pressure sores and other care and dignity issues, as a result of widespread system failures beginning with ineffective administration and quality assurance oversight, a lack of properly oriented staff in sufficient numbers to provide care to dependent residents based on the facility assessment and resident acuity and according to professional standards. These system failures resulted in Immediate Jeopardy (IJ) for 10 residents (Resident #25, 27, 1-401, 1-405, 1-406, 1-410, 1-411, 1-414, and 1-418, and 1-422) who sustained adverse events, serious physical and/or psychosocial harm and placed all residents living at the facility at risk for serious harm, injury and/or death. Findings include: An interview and record review was conducted with the NHA A and the COO X on 10/4/18 at 4:04 PM, to review the staffing concerns at the facility. NHA A stated that she has been the NHA A since 4/3/18. The NHA A states that she is responsible for development and oversight of all plan of corrections. According to the CMS 2567 dated 6/18/18 and 8/27/18 the facility provided a compliance date off 9/25/18 related to staffing. When asked how the facility determined the appropriate staffing needed at the facility, the NHA A stated, Staffing was based on past staffing patterns and budget. When asked what the minimum amount of staff the facility could function with, the NHA A stated, It would depend on what the resident status is. I don't know how to determine if there is enough staff. When asked if the assignment schedule is routinely posted with holes in it, NHA A stated, Yes. When asked if she was aware that the night shift for 9/30/18-10/1/18 had holes in the schedule, the NHA A stated that she was aware, but she was not aware that the staffing holes had not been filled. When asked what the procedure for staffing coverage was, the NHA A stated that the staff should be calling her directly if they are calling off, then the scheduler is notified to send out an alert via the on-shift system, and she starts making calls immediately. The NHA A stated, I was not made aware of the staffing holes (remained open) over the weekend. The NHA A stated, If the nurses need help they can just ask me. When asked if she was aware that the staff were afraid to call her about staffing concerns, the NHA A stated, No. When asked how the facility monitors that the resident care and services are being provided according to the care plans, the NHA A stated that they do care conferences weekly, the interdisciplinary team reviews the care plans during morning meetings, the incident/accident reports are reviewed and updated, and the facility uses a program called Guardian Angel Rounds (questions related to care and services) to check in with residents 2-3 times weekly. The NHA A stated, No negative feedback has been reported. When the surveyor clarified that there were no negative feedback voiced by the residents, the NHA A then stated that a resident had a call light on for 20 minutes but, It's a behavior problem and she just needs attention. The NHA A stated that she was aware of the call light audit over the weekend reflecting 45-minute waits and aware the resident's needs were not being met timely. During an interview on 10/18/18 at 12:28 PM, the COO X stated that the NHA A would text and communicate with him regarding filling staffing spots and asked her if there was anything that she needed. When asked if she reported the critically low staffing level from the midnight shift of 9/30/18, the COO X stated, No. When asked if he checked in on the status of the plan of correction, the COO X stated, Yes, and was told it was okay .She said the pressure ulcers was not doing well and that the CCC X was overwhelmed. I didn't know that she didn't close the loop with staffing. The Administrator Orientation Checklist was reviewed with COO X. Approximately 25% of the checklist was completed and did not contain the COO X or the NHA A's signature. The NHA job description was reviewed and did not contain the executive management signature. The COO X stated that approximately 3-4 weeks ago it was identified that two NHA's and one Director of Nursing had not fully completed all orientation expectations and were scheduled to attend an additional orientation the first part of (MONTH) (YEAR). Review of the (Name of Facility) Facility Assessment last reviewed and updated in (MONTH) (YEAR) reflected, (Facility Name) is licensed to provide care for 128 (people). The assessment indicated it was able to care for residents with many common conditions including but not limited to residents with Psychiatric/Mood Disorders, Heart/Circulatory System diseases (including [MEDICAL CONDITION]), diseases of the Neurological System (including [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] among others), [MEDICAL CONDITION] System (including urinary incontinence), Digestive System (including conditions such as gastroenteritis, ulcerative [MEDICAL CONDITION], and bowl incontinence), Integumentary System (skin ulcers, Injuries) and Infectious Diseases (including skin and soft tissue infections among many others). The assessment detailed Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies and reflected the staffing plan was for the North Unit to have three licensed nurses for the first and second shift and two licensed nurses on third shift. The South Unit was to have two nurses on first and second shift with one licensed nurse on the night shift. The Staffing Plan called for there to be 13 FT (full time) licensed nurses to provide direct care 24 hours a day 7 days a week. The plan called for 33 FT nurse aides in addition to 12 FT other staff needed for behavioral healthcare and services. In an interview on 10/4/18 at 10:57 AM, CNA W reported that on Sunday (9/30/18) she was the only aide on the printed schedule for the south units (16 two person assists out of a total of S1 hall 25 residents, S2 hall 23 for a total of 48 residents). CNA W said she told Scheduler Z and nurses on duty that she would not jump from hall to hall, and that they needed to bring in more help for the night because she was going to stay on her S1 hall. Review of a schedule for 9/30/18 reflected that CNA W was the only aide assigned to work on the south units. Two CNA's were mandated to stay over from the afternoon shift, one left at 2 a.m. According to the schedule, at 2:00 a.m. on 10/1/18, there were 3 nurses and 2 CNA's to care for 105 residents in the facility. Multiple requests for Time Detail Reports were made to validate the claim made by CNA W. A Time Detail Report was provided on 10/10/18 that confirmed the second CNA S was present in the facility on 10/01/18 from 2:00 a.m.-7:00 a.m., but no other staff available. Resident #27 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #27 was an [AGE] year-old female, who was admitted to the facility on [DATE] (with a readmission date of [DATE]), with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), dated 8/10/18 reflected a score of 13 out of 15 which represents Resident #27 was cognitively intact. Resident #27 required staff assistance with all activities of daily living and transfers. Review of a Care Plan last revised on 8/27/18 reflected Resident #27 was Frequently incontinent of bladder and bowel. My use of diuretics and other medications can also impact my continence status and I require extensive assistance with toileting needs and my need for a Hoyer lift for transfers impairs my ability to be toileted in my bathroom. My decreased physical ability and possible medication side effects put me at increased risk for constipation. I also have a history of [MEDICAL CONDITION] with a partial colectomy and divirticulosis. Goals of the care plan indicated that Resident #27's risk for risk for [MEDICAL CONDITION] will be minimized through/prevented through prompt recognition and treatment of [REDACTED]. Interventions included Assist to bed pan upon my request and especially prior to going to meals, activities and before going to bed at night, and Check me with rounds and as required for incontinence. Wash, rinse and dry perineum, apply barrier cream after each incontinence episode and as needed. Review of a Care Plan last revised on 8/7/18 reflected Resident #27 had an ADL (Activities for Daily Living) Self-care Performance deficit related to NSTEMI (a mild [MEDICAL CONDITION]), fatigue, recurrent UTI's, Cardiac issues, anxiety, shortness of breath with exertion, obesity, diabetes with diabetic [MEDICAL CONDITION], depression, [MEDICAL CONDITIONS], frequent bladder incontinence, pain, impaired mobility with need for Hoyer transfer (mechanical lift), and possible medication effects. The goal of the care plan was for Resident #27 to Maintain my current level of function in bed mobility, eating, dressing and personal hygiene as my cognitive and physical status will allow. Interventions included Offer me the bed pan as I can make my needs known as needed. During an interview on 10/2/18 at 1:42 p.m., Resident #27 reported staff kept turning off her call light when she needed assistance to the bedpan earlier that day, between 10:00 a.m. and two minutes before lunch at noon. Resident #27 reported she had had an accident and everything got wet which made her feel embarrassed. During an interview on 10/01/18 at 10:00 a.m., Resident #32, (Resident #27's husband and roommate) expressed frustration regarding his wife's care. Resident #32 reported that staff call in when they aren't sick and the staff that are working don't get his wife out of bed on time because they are too short handed. An observation and interview of a dressing change was done with Nurse XX on 10/3/18 at approximately 2:40 PM. Resident #27 was seated in her room in a wheelchair. Resident #27 had a skin tear to the left lower extremity, a pressure ulcer to the left heel and a pressure ulcer to the right heel. Resident #27 could not recall exactly when each area was first noted. According to the right heel wound measurement dated 8/21/18 reflected that Resident #27 developed a facility acquired pressure ulcer to the right heel that was staged at a deep tissue injury and measured 2.2 cm x 2.3 cm that was dark purple/maroon in color. The PA was notified and ordered skin prep and to float the heel. According to the (MONTH) and (MONTH) TAR the skin prep was not started until 9/9/18 (2 ½ weeks later). The most recent wound assessment provided was dated 9/27/18 and measured 1.8 cm x 2.2 cm. An interview and record review was conducted with CCC H on 10/11/18 at 10:45 AM. CCC H confirmed that the right heel pressure ulcer was first noted on 8/21/18 and the first noted treatment according to the (MONTH) and (MONTH) TAR was initiated approximately 2 ½ weeks later on 9/9/18. The CCC H reviewed the PA noted dated 8/21/18, 8/23/18, 8/24/18, 8/27/18 and the doctor's noted dated 8/28/18 and neither had an assessment of the new right heel pressure ulcer nor a plan of care, nothing was noted related to the new pressure ulcer. According to the skin policy/procedure the facility will complete an analysis for all new wound developments. When asked if an analysis was done of the new pressure ulcer development, the CCC H stated, Not that I can see. When asked if the care plan was updated, the CCC H stated, No, I don't see any updates because there doesn't seem to be a root cause done for the new wound. Resident #1-405 Review of a facility Admission Record reflected Resident #1-405 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1-405 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15/15. During an interview on 10/3/18 at 5:08 p.m., Resident #1-405 reported that he had been getting sick for 2-3 days prior to being transferred to the hospital on [DATE]. Resident #1-405 did not report refusing to be sent to the hospital, but did report he didn't feel safe at the facility due to having to wait so long for staff to respond to his call light. Resident #1-405 said he had to sit in his feces for over an hour on 10/2/18 and 10/3/18 due to staff not responding to his call light. Resident #1-405 said I get mad and frustrated. I could be in trouble and it takes 15-20 minutes to get help. I don't really feel safe but what can I do?. Resident #1-410 Review of a facility Admission Record reflected Resident #1-410 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1-410 was severely cognitively impaired and exhibited wandering behavior daily. Review of a Care Plan last updated on 8/31/16 reflected Resident #1-410 was At risk for elopement related to attempts to elope from my home, one of which was successful. I have dementia and am no longer aware of my safety needs. I wander looking for a way out. The goal of the care plan was for Resident #1-410's risk for elopement from the secured unit and facility will be minimized with interventions that included Hall monitor in place to assist and redirect me out of other resident's rooms, distract me from wandering by offering pleasant diversions, ask me to help you with a simple task that will help distract me for a short period of time, provide structured activities: toileting, walking inside and outside, reorientation strategies including signs and pictures. Review of a Care Plan last revised on 4/9/18 reflected (Resident #1-410) is sometimes combative (hitting, pushing etc.) with staff. I may not always understand the environment, actions or statements of others related to severely impaired cognition. The goal of the care plan was that Resident #1-410 would not harm self or others. Interventions included Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. During an observation on 10/3/18 at 10:12 a.m., Resident #1-410 was observed wandering into and out of resident rooms on the south unit. A Hall Monitor was situated in the middle of the unit and was unable to respond or redirect from her station. No other staff were observed in the area while Resident #1-410 wandered into and out of other occupied resident rooms. Review of an incident report dated 10/7/18 at 3:00 p.m. reflected Resident #1-410 Wandered into (another resident's room), removed a hoodie from his room and was pushed on the shoulder by the other resident as a result. According to the incident report, staff were not available at the time of the incident to intervene. Review of an incident report dated 10/7/18 at 3:29 p.m. (29 minutes after the previous incident), Resident #1-410 was struck several times in the face by another resident. According to witness statements included in the incident report, Hall Monitor (HM) CCC reported she had gone looking for help after the previous incident and was not on the unit providing any supervision at the time of the occurrence. CNA VV's statement reflected the following: I was walking toward the large shower room on S2 unit with (another resident) when I heard screaming down the hall toward the door by room [ROOM NUMBER] and 2. I redirected (other resident) and walked toward the noise. When I reached the end of the hallway, I noticed the noise was coming from room [ROOM NUMBER]. I knocked and opened the door with my right hand. As I opened the door I observed (another resident) straddled on top of (Resident #1-410) laid horizontally across the bed. (Name of Resident) struck (Resident #1-410) using her closed fist (right hand) on the right side of (Resident #1-410's) face. The statement provided by Registered Nurse (RN) DDD was that she was in the nurses station on the telephone when the incident occurred. Resident #1-411 Review of an Admission Record and MDS dated [DATE] reflected Resident #1-411 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment indicated Resident #1-411 has severe cognitive impairment and wandered daily. Review of a Care Plan implemented on 6/08/12 reflected Resident #1-411 was At risk for elopement related to my [DIAGNOSES REDACTED]. The goal of the care plan was that Resident #1-411's risk for elopement will be minimized with interventions that included Hall monitor in place to assist and redirect me out of other residents rooms, distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television and books, provide structured activities: toileting, walking inside and outside, 1:1 conversation During an observation on 10/3/18 at 10:12 a.m., Resident #1-411 was observed wandering into and out of resident rooms on the south unit where she lived. A Hall Monitor was situated in the middle of the unit and was unable to respond or redirect from her station. No other staff were observed in the area while Resident #1-410 wandered into and out of other occupied resident rooms. Resident #1-412 Review of a facility Admission Record reflected Resident #1-412 was an [AGE] year old gentleman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Record reflected Resident #1-412 was his own responsible party. A Minimum Data Set (MDS) assessment dated [DATE] reflected resident #1-412 was moderately cognitively impaired and did not need assistance for bed mobility or transfers, required supervision and encouragement for eating and toilet use and needed limited assistance from one person for personal hygiene. During an observation and interview on 10/3/18 beginning at 9:45 a.m., Resident #1-412 was observed seated in a chair outside of the activity room on the South 2 unit, a locked unit for severely cognitively impaired residents who wander. Resident #1-412 was wearing a Korean War Veteran hat. When asked, Resident #1-412 introduced himself and reported he had been in the Army and served in the Korean War and in Germany. Resident #1-412 said he had been a truck driver after he returned from active duty. During an interview on 10/3/18 at 10:00 a.m., Hall Monitor (HM) Q reported she was currently split between two halls, the S1 and S2 units (both locked/secure units for residents who were independently ambulatory and severely cognitively impaired). She was trying to keep an eye on one resident who was escalating his behaviors and also keep an eye on a resident who was getting irritated with cognitively impaired residents. HM Q reported the resident who was getting irritated was Resident #1-412 who was not really supposed to be living on the S2 unit because he was not very cognitively impaired and the other residents frustrated him. During an observation on the S-2 (primarily dementia with behavior problems) unit on 10/4/18 at 11:55 AM, a loud verbal exchange coming from a resident room was overheard. Upon arriving at the residents room, Resident #1-411 was noted walking around Resident #1-412's room. Resident #1-412 yelled, Get out repeatedly until this surveyor reached his room. Resident #1-412 stated, I'm sick of her (Resident #1-411) coming in here. She picked up my hat and threw it on the floor. She steals[***] Resident #1-412 then gestured that he had put his television remote in his shirt pocket and was concerned that someone was going to take it. Resident #1-412 then stated, She comes in here and gets in my dresser drawer. She is messing with my papers and taking them. A dietary staff member happened to be in the hall passing by and attempted to redirect Resident #1-411 out of Resident #1-412's room. No other staff were noted in the hallway or near by to respond to Resident #1-412's pleas for help. On 10/2/18 at 8:25 AM, on the S-2 unit an interview was conducted with Registered Nurse (RN) AA'. RN AA reported she was working as an Aide because she declined to take a (med) cart (work as a nurse). RN AA reported the facility had scheduled only 1 aide and no Hall Monitor for the S-2 unit and she considered this staffing level to be not safe. RN AA reported unsafe because of the needs and behaviors of the severely cognitively impaired residents on the S-2 hall. RN AA reported she had worked the S-2 unit before at that staffing level and that, it did not go well. RN AA reported when she had declined to work as a nurse today at that staff level (1 Aide) that she had received push back from the Scheduler and Administration. RN AA reported the Scheduler had told her that the previous day the unit had been staffed with only 1 aide and that Administration had questioned her ability. RN AA stated, I'm a good nurse and I care about these people, but it just isn't safe. RN AA reported last Wednesday she was the nurse on the S-1 unit when other staff were at back to back meetings. RN AA reported so many staff were at the meetings that it resulted in the unit being inadequately staffed. RN AA reported she and an Activities staff member were the only staff available to provide care to the S1 residents at meal time. RN AA reported just before the meal she had a fall with injury and prior to that the fall resident was involved in a Resident to Resident altercation. RN AA reported ample staff were in the building because the facility thought the state might be in that day .they always staff up on those days. RN AA indicated the state did not come in and that the meetings started right after the fall of the S-1 resident and during lunch. RN AA stated, we were paging for assistance but no response .trying to feed, watch a one on one resident (a resident that required constant supervision), behaviors in halls .it's like you don't know where to begin. RN AA questioned if facility will know of this interview. RN AA expressed concern of retribution from the facility for speaking of this and that she was aware other staff were fearful to speak to state surveyors. On 10/2/18 at 3:35 PM, an interview was conducted with Unit Manager (UM) G. UM G reported he was the manager of the S-1 and S-2 units. UM G was asked if staffing was a concern at the facility. UM G reported, I'm going to cut my own throat and say that yes (It was a concern), It's a huge problem for me . UM G reported he has talked to Administration, endlessly about it. Reported he had been told it's getting better, and we're working on it. Reported staffing has not improved. UM G reported, Call in's (Staff calling that they were not going to report to work) are not always replaced and that we work with what we have. UM G reported complaints about staffing levels from the staff were, Endless. During an interview and observation on 10/1/18 at 10:45, CNA's scheduled on the northeast unit stated they had two more residents to provide morning care to and get up for the day. This surveyor observed the two residents still in their sleepwear in bed. Resident #1-401 Review of the EMR reflected that the resident was admitted with an unstageable pressure ulcer on 9/6/18 that reflected the following surface area wound measurement: 9/7/18, 5.9 centimeters (cm)2 (squared), 9/13/18, 9.0 cm2, 10/4/18, 44.9 cm2. This deterioration reflected an increase of 35.9 cm2 of wound area since 9/13/18. On 10/1/18 at 4:11 PM, it was observed that the door to room [ROOM NUMBER]-1, which was located at the end of an S2 hall, was closed. On entry into the room it was observed that the room was darkened. Resident #1-401 turned to left side in low bed crying, stating, I can't move, I can't move- my leg, ouch, ouch, it hurts it hurts. Noted no call light in reach. Ringer-type bell on over the bed table past the fall mat on the floor out of reach of the Resident. Staff were alerted to the needs of the Resident. During the observation of care, it was noted staff discovered Resident #1-401 had been incontinent of stool. When Resident #1-401 was turned to be cleaned a large wound on the sacral area was observed to be exposed; the wound was not covered with a dressing. The wound remained exposed until 5:27 PM when wound care had been provided. On 10/11/18 at 4:03 PM, an interview was conducted with Nurse Wound Consultant (NWC) TT. NWC TT indicated that on 10/1/18, the Physician's Assistant (PA) had evaluated the sacral wound of Resident #1-401 at approximately 10:30 -11:00 AM. NWC TT indicated a new order for treatment of [REDACTED]. On 10/15/18 at 11:15 AM, a telephone interview was conducted with RN P. RN P reported he was aware the PA had evaluated the wound on Resident #1-401 on 10/1/18. RN P reported he been way behind and had left the wound on the sacral area of Resident #1-401 uncovered. RN P reported he had wanted the Wound Nurse or a Unit manager to be present when he followed the new order for wound care but indicated he was unable to coordinate this care with the other staff. RN P reported he did not complete the dressing change by the time he had left for the day at about 4:00 PM on 10/1/18. Review of the EMR Progress Notes for Resident #1-401 on 10/6/18, reflected a concern for the status of the wound and that the Resident was febrile (elevated body temperature). The medical record reflected the Resident was sent to the emergency room and was subsequently admitted for [MEDICAL CONDITION] (systemic infection). Review of the hospital records dated 10/6/18, for Resident #1-401 reflected the Reason for Visit to be, yesterday fever 103 (degrees Fahrenheit), wound on coccyx that had, increased by ½ (inch) in last 48 hours, and that the facility wants it noted (patient) has had a significant change in condition . Further review of the hospital records indicated a Computer Tomography Scan (CT) of the coccyx wound reflected, osteo[DIAGNOSES REDACTED] (bone infection). Review of education notes written by NWC TT reflected 10 points about care to the wound of resident #1-401. The notes reflected (Resident #1-401) was admitted [DATE], with a Stage 3 sacral pressure injury. There are a few issues related to this wound that need to be addressed. 1. Treatment: Cleanse pressure sore with normal saline (NS) apply Santyl to slough, cover with gauze and apply border gauze, change daily every day shift. 6. Order: (order of 9/7/18 restated) Santyl Ointment .apply to slough .Okay to peel back and replace and reuse same dressing daily. Dressing to be changed every Tuesday and Friday NWC TT added it all capital letters, WE DO NOT PEEL BACK DRESSINGS, DO A TREATMENT AND REAPPLY THE OLD DRESSING. THESE ORDERS DO NOT INCLUDE CLEANING OR PERIWOUND PROTECTION INSTRUCTIONS. THE DRESSING MUST BE CHANGED EACH DAY WITH CLEANING AND APPLICATION OF NEW SANTYL. SANTYL ONLY WORKS FOR 24 HOURS SO, THIS REQUIRES A (EVERY) 24 HOUR DRESSING CHANGE. THE WOUND IS ON HER SACRUM, NOT C[NAME]CYX. 7 Treatment Administration Record (TAR): A 9 (code meaning see nurses notes) was recorded on the TAR on 9/7 and 9/11. There are X's on 9/8 ,9/9 (on the new dressing applied portion of the TAR -an X indicated this was not done), on 9/10 there is a 5 (code meaning see nurses note). There is not a single note about this. So, her wound has not been cleaned. No Santyl applied and dressing has not been changed since she was admitted on [DATE]. There is no documentation in the chart to show otherwise. In an interview conducted 10/11/18, at 4:03 PM NWC TT reported, I cannot say the facility did not cause the osteo[DIAGNOSES REDACTED]. Whether things like no dressing change or no dressing (uncovered wound for approximately 6 hours), given her co-morbidities (other physical problems) .better care would have helped. Resident #1-419 On 10/16/18 at approximately 9:00 AM, Resident #1-419 was observed in bed, crying. Resident #1-419 was unable to answer specific questions. The facility provided a copy of the education provided to all nursing staff (including Nurse J) on 10/10/18. The education included pressure ulcer policy/procedure and reflected Nurse J's signature. Nurse J was interviewed on 10/1/18 at approximately 9:45 AM, and again on 10/17/18 at 12:30 PM. On 10/1/18, Nurse J stated that she is wound certified and does not believe the facility is accurately assessing pressure ulcers. Nurse J stated, They are calling things pressure ulcers that are not pressure ulcers. On 10/17/18, Nurse J reviewed the notes on 10/6, 10/7, 10/8, 10/9, 10/11, 10/12, and 10/13 (that Nurse J authored) that all reflected the same statement of, Area on the heel of concern. On 10/14/18, Nurse J documented that the right heel had a deep tissue injury (a pressure ulcer that is dark purple) that was non-blanchable and measured 2.5 cm x 3.5 cm and an area to the side of the foot that measured 0.5 cm x 1.0 cm. When asked what area on the heel of concern meant, Nurse J stated that heel was noted to be boggy and non-blanchable. Nurse J stated that she did not thoroughly and accurately chart the assessment finding of the heel from 10/6/18 - 10/13/18. Nurse J stated that she should have done an assessment, notified the physician and obtained an order on 10/6/18 when the area to the heel was first noted. Nurse J stated she called the physician on 10/14/18 and obtained treatment orders for the new pressure ulcers. The (MONTH) Treatment Administration Record (TAR) was reviewed with Nurse J and the treatment order that was initiated on 10/15/18 (not 10/14/18 as Nurse J stated). Nurse J stated, I thought I entered the orders on 10/14/18. Record review of the Physician Assistant (PA) JJ note signed on 10/17/18 reflected that Resident #1-419 had developed a new pressure ulcer to the right heel and that the resident was noncompliant with keeping her leg elevated and hip abductor in place. No alternate intervention was noted. An interview and record review was completed with the Director of Nursing (DON) B and the Wound Nurse Consultant (WNC) TT on 10/17/18 at 4:00 PM. WNC TT stated that she reviewed the wound information on 10/15/18 and noted that there was not a treatment order obtained for the new pressure ulcers and she (not Nurse J) talked with PA JJ and obtained the orders and entered them into the computer on 10/15/18. WNC TT also reviewed the 10/17/18 note by PA JJ and stated that the Resident #1-419 could not and should not elevate her leg due to recent hip surgery. WNC TT stated that she had ordered a cushioned boot that could be placed on both feet to promote healing and prevent further skin breakdown. WNC TT stated that a special mattress was also ordered for Resident #1-419 as well. WNC TT stated that Nurse J did not follow the facility policy/procedure for pressure ulcers. WNC TT stated that Nurse J signed on

Based on observation, interview and record review, the facility failed to prevent abuse and neglect as a result of widespread system failures beginning with ineffective administration and quality assurance oversite, a lack of properly oriented staff in sufficient numbers to provide care to dependent residents based on the facility assessment and resident acuity and according to professional standards. These system failures resulted in Immediate Jeopardy (IJ) for 8 residents (Resident #25, 27, 1-401, 1-405, 1-409, 1-410, 1-414 and 1-418), who sustained adverse events, serious physical and/or psychosocial harm and which placed all residents living at the facility at risk for serious harm, injury and/or death. Findings include: Review of a facility Abuse policy, last revised 7/2018, reflected It is the policy of (Name of Facility) to maintain an environment that is free from neglect, verbal, sexual, physical and mental abuse, exploitation, misappropriation of funds and involuntary seclusion. We will not tolerate abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The policy included definitions that included: 1. Abuse-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or cause harm. 2. Adverse event-an adverse event is an untoward, undesirable, and unusually unanticipated event that causes death or serious injury, or the risk thereof .5. Mistreatment means inappropriate treatment or exploitation of a resident. 6. Neglect is the failure of the facility, it's 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 .8. Involuntary seclusion is the separation of a resident from other residents or from his/her room or confinement to his/her room (with or without other resident present) against the resident's will, or the will of the legal representative. The facility Abuse policy included General provisions that included: b.) Resident care and treatments shall be monitored by all staff, on an ongoing basis, to assure residents are free from abuse, neglect, exploitation, misappropriation of property and involuntary seclusion. It is the responsibility of all staff to provide a safe environment for the residents. c.) Any allegation of resident abuse, neglect, exploitation, misappropriation of property and involuntary seclusion shall be reported to the administrator immediately (abuse coordinator)and shall be thoroughly investigated and documented by the Administrator or designee. d.) The subject of abuse should be routinely and openly discussed. Residents or/or their legal representative will be provided the opportunity for education concerning the commitment of the facility to deal quickly and effectively with abuse or suspected abuse on admission. e.) Staff members, volunteers, family members, and others are required to report immediately to the Administrator any allegation of abuse, and should be assured that they will be protected against repercussions . The policy identified Quality Assurance (QA) review activities necessary to identify patterns and/or trends of allegations and/or substantiated abuse. The facility QA team would then conduct an analysis of 1. Areas of the facility where abuse is more likely to occur, 2. The distribution of staff on each shift in sufficient numbers to meet the needs of the residents and assure that staff have knowledge of individual care needs. 3. The supervisor will identify inappropriate behavior such as using derogatory language, rough handling, or ignoring residents during care. 4. Residents exhibiting needs and behaviors that predispose them to have conflict with others or that subject them to neglect staff (such as: residents with history of aggressive behaviors, residents who enter other residents' rooms, residents with self injury behaviors, residents with communication disorders, residents requiring extensive or total nursing care). Resident #27: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #27 was an [AGE] year-old female, who was admitted to the facility on [DATE] (with a readmission date of [DATE]), with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), dated 8/10/18, reflected a score of 13 out of 15 which represents that Resident #27 was cognitively intact. Resident #27 required staff assistance with all activities of daily living and transfers. Review of a Care Plan, last revised on 8/27/18, reflected Resident #27 was Frequently incontinent of bladder and bowel. My use of diuretics and other medications can also impact my continence status and I require extensive assistance with toileting needs and my need for a hoyer lift for transfers impairs my ability to be toileted in my bathroom. My decreased physical ability and possible medication side effects put me at increased risk for constipation. I also have a history of [MEDICAL CONDITION] with a partial colectomy and divirticulosis. Goals of the care plan indicated that Resident #27's risk for [MEDICAL CONDITION] will be minimized through/prevented through prompt recognition and treatment of [REDACTED]. Interventions included Assist to bed pan upon my request and especially prior to going to meals, activities and before going to bed at night, and Check me with rounds and as required for incontinence. Wash, rinse and dry perineum, apply barrier cream after each incontinence episode and as needed. Review of a Care Plan, last revised on 8/7/18, reflected Resident #27 had an ADL (Activities for Daily Living) Self-care Performance deficit related to NSTEMI (a mild [MEDICAL CONDITION]), fatigue, recurrent UTI's, Cardiac issues, anxiety, shortness of breath with exertion, obesity, diabetes with diabetic [MEDICAL CONDITION], depression, [MEDICAL CONDITIONS], frequent bladder incontinence, pain, impaired mobility with need for hoyer transfer (mechanical lift), and possible medication effects. The goal of the care plan was for Resident #27 to Maintain my current level of function in bed mobility, eating, dressing and personal hygiene as my cognitive and physical status will allow. Interventions included Offer me the bed pan as I can make my needs known as needed. During an interview on 10/2/18 at 1:42 p.m., Resident #27 reported staff kept turning off her call light when she needed assistance to the bedpan earlier that day, between 10:00 a.m. and two minutes before lunch at noon. Resident #27 reported she had had an accident and everything got wet which made her feel embarrassed. During an interview on 10/01/18, Resident #32, (Resident #27's husband) expressed frustration regarding his wife's care. Resident #32 reported that staff call in when they aren't sick and the staff that are working don't get his wife out of bed on time because they are too short handed. Resident #1-405: Review of a facility Admission Record reflected Resident #1-405 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 9/8/18, reflected Resident #1-405 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15. Review of a Care Plan, last revised on 7/29/18, reflected Resident #1-405 was At risk for constipation related to decreased mobility, medication side effects and at times I decline to use the bowel protocol. I am frequently incontinent of bladder during the assessment period which puts me at increased risk for skin breakdown and UTI's (urinary tract infections). I have required extensive staff assistance with toileting/incontinence care related to spastic [MEDICAL CONDITION], pain issues, and possible medication side effects. I am non-weight bearing on bilateral lower extremities necessitating the need for Hoyer lift for transfers. I have been taking more initiative to use my urinal towards the end of the assessment period. One of the goals of the care plan was to have normal bowel movements at least every 3 days with an intervention that included: Observe/document/report to MD (medical doctor) as needed signs and symptoms of complications related to constipation: change in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation, slow heart rate, abdominal distention, vomiting, small or loose stools, fecal smearing, bowel sounds, diaphoresis, abdominal tenderness, guarding, rigidity, fecal compaction. The care plan also called for recording and reporting to the MD for signs and symptoms of UTI: pain, burning, no output, increased pulse, increased temperature, urinary frequency, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of a Progress Note, dated 9/11/18 11:47 p.m., reflected Resident #1-405 vomited after eating. Review of a Progress Note, dated 9/12/18 at 3:50 a.m., documented by Licensed Practical Nurse (LPN) EE reflected Resident #1-405 vomited once and according to the progress note, Resident #1-405 thought it was something he ate. Review of a Progress Note, dated 9/13/18 at 2:57 a.m., Documented by LPN EE reflected Resident #1-405 had two episodes of nausea this shift, shortly after back to resting. No sign of pain noted at this time. Dressings intact to bilateral feet, no dypsnea noted. Review of a Food Acceptance Record for Resident #1-405 reflected that staff documented Resident #1-405 refused to eat any meals on 9/12/18 and 9/13/18. Review of a Weights and Vitals Summary report indicated Resident #1-405 had a fever on 9/12/18 and 9/13/18. Review of a Progress Note, dated 9/13/18 at 9:20 a.m., documented by LPN BB reflected (Resident #1-405) having emesis multiple times. Also with temperature. Resident refused medications. PA (Physician Assistant) called and gave orders for stat (right away) labs. Writer contacted lab with orders. Review of a Progress Note, dated 9/13/18 at 2:52 p.m., documented by LPN BB at 2:52 p.m. reflected New order for IM (injection of medicine into the muscle) [MEDICATION NAME] and ABD (abdominal) x-ray. IM shot given, resident tolerated well. Stat x-ray ordered .Resident having multiple times of emesis. Review of a Progress Note, dated 9/13/18 at 7:00 p.m., documented by Registered Nurse (RN) II reflected IV started in left arm with a 24 Gauge needle. Resident tolerated procedure well. According to an SBAR Communication Form, dated 9/13/18 at 7:00 p.m., Resident #1-405 was having worsening nausea and vomiting since 9/11/18 with worsening of symptoms after eating and drinking. Review of Progress Note, dated 9/13/18, reflected Resident #1-405 had an emergent discharge to the hospital on [DATE] at 21:30 (9:30 p.m.) due to nausea and vomiting. Review of a Progress Note, dated 9/14/18 at 2:47 a.m., documented by RN LL reflected RN contacted (emergency room Nurse) at (Hospital Name) at 2:45 a.m., and was informed (Resident #1-405) was admitted due to results of CT scan showed possible ileus or sigmoiditis and mild dilation of the duodenum. (Resident #1-405) is being admitted to med/surg. (Name of hospital nurse) inquired about dressings to bilateral feet and RN explained how to change dressing and that it was done today just prior to him leaving and did not require changing for three days. During an interview on 10/3/18 at 5:08 p.m., Resident #1-405 reported that he had been getting sick for 2-3 days prior to being transferred to the hospital. Resident #1-405 did not report refusing to be sent to the hospital, but did report he didn't feel safe at the facility, due to having to wait so long for staff to respond to his call light. Resident #1-405 said he had to sit in his feces for over an hour on 10/2/18 and 10/3/18 due to staff not responding to his call light. Resident #1-405 said I get mad and frustrated. I could be in trouble and it takes 15-20 minutes to get help. I don't really feel safe but what can I do? During an interview on 10/01/18 at 12:30 p.m., Physician Assistant (PA) JJ reported he had not been notified Resident #1-405 had been vomiting until the second day of symptoms and multiple episodes of emesis. PA JJ said he would have expected to have been notified after the second episode of emesis due to Resident #1-405's history of bowel complications. As soon as he was notified he started IM [MEDICATION NAME] (an anti-emetic) and an abdominal x-ray. PA JJ reported that despite the x-ray ordered in the facility being negative for an obstruction, and because Resident #1-405 was having bowel movements, he suspected an ileus and ordered Resident #1-405 be sent to the emergency room for evaluation and treatment. During an interview on 10/3/18 at 4:18 p.m., LPN BB reported she was a travel nurse who had worked at the facility since (MONTH) 19, (YEAR). LPN BB said she had been somewhat familiar with Resident #1-405 and when she started her shift on 9/13/18 she had not been told in report that Resident #1-405 had been vomiting. LPN BB said that she learned from nurse aides that Resident #1-405 had been getting sick (vomiting) for days. LPN BB then said that she heard from RN LL that Resident #1-405 had been getting sick for days. LPN BB said she reported Resident #1-405's condition to PA JJ after she witnessed the second episode of emesis and acted on his orders, ultimately sending Resident #1-405 to the hospital for treatment. LPN BB said she reported her concern about not being told Resident #1-405 had been vomiting to Unit Manager (UM) Registered Nurse (RN) H. During a telephone interview on 10/04/18 at 9:23 a.m., LPN EE reported he had notified the physician of the changes in Resident #1-405's condition using the online dashboard (a messaging feature in the electronic medical record). LPN EE also said he reported Resident #1-405's change in condition to the oncoming nurse (LPN BB). During an interview on 10/04/18 at 10:30 a.m., Chief Clinical Officer (CCO) WW reported she reviewed the dashboard and secure communications documented by staff on behalf of Resident #1-405 and no record of a report of any kind related to his change in condition was found. During an interview on 10/5/18 at 9:30 a.m., Unit Manager/RN H reported she couldn't recall which nurse talked to her about Resident #1-405's emesis, but said she had been made aware and did encourage staff to push room temperature fluids because it would be easier for him to digest given his history of nausea and vomiting. RN H admitted she never encouraged any nurse to notify the physician about Resident #1-405's condition. During an interview on 10/9/18 at 3:37 p.m., evening supervisor RN II reported she worked on 9/13/18, the evening Resident #1-405 was discharged to the emergency department. RN II said she thought it was odd the physician ordered an IV for fluids because she was not aware Resident #1-405 had been having emesis, until she heard from RN LL that Resident #1-405 had been getting sick for two days. When asked, RN II said she did call the DON after starting the IV but did not report an allegation of neglect because she did not recognize the situation as neglect, despite learning Resident #1-405 had suffered for two days with emesis without notification to the physician. Review of a hospital ED Prov Note (Emergency Department Provider Note), dated 9/13/18 at 9:51 p.m., reflected Patient presents today from his living facility at (Name of Facility) for 3 days of vomiting. Patient (Resident #1-405) states has has also had associated fevers. He does endorse mild diffuse abdominal pain well as throat pain that he believes is from his vomiting. He denied associated diarrhea or blood in stool. He did have a bowel movement which he states was smaller than normal today. Patient on epic review (hospital system medical record) does have a history of [MEDICAL CONDITION]. Patient was [MEDICAL CONDITION] on arrival and did appear ill but not toxic. I did discuss with patient will place IV and give him [MEDICATION NAME] (an anti-nausea medication) and [MEDICATION NAME] for pain and nausea control. Also obtain blood work as well as CT abdomen pelvis. Further review of the document revealed Resident #1-405 stated The patient (Resident #1-405) states that he has been experiencing constant vomiting for 3 days. He states that he is unable to keep water or food down without vomiting. The patient states that he is experiencing general abdominal pain throughout his abdomen. He also notes on-and-off fevers, chills and headaches for 3 days. The patient states that he a sore throat from vomiting so many times. He reports the staff at (Name of Facility) gave him [MEDICATION NAME], which he immediately vomited up. Review of a hospital History and Physical, dated 9/13/18, reflected (Resident #1-405) with [MEDICAL CONDITION] (CP) and vascular ulcers presents today with vomiting. He has been vomiting for a few days and taking his [MEDICATION NAME] and [MEDICATION NAME] with no relief. He has been living at (Name of Facility) for a few months while treating chronic vascular ulcers on his feet. He has not been ambulatory for 4 years. He denies chest pain, dysuria, shortness of breath, or diarrhea. He has headaches while vomiting. On arrival, he has urinalysis consistent with UTI (urinary tract infection) and possible SBO (small bowel obstruction). On exam he is anxious and nauseated. Plans are discussed for admission and he is agreeable. He wishes to be listed as full code. Review of a Physician Assessment, dated 9/18/18, Resident #1-405 was readmitted to the facility from the hospital after complaints of abdominal pain. According to the progress note, Resident #1-405 had a CT scan at the hospital that showed Resident #1-405 had an ileus (paralysis or obstruction of the bowel) and possible SBO (small bowel obstruction). Resident #1-409: Review of a facility Admission Record reflected Resident #1-409 was a [AGE] year-old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 10/01/2018, reflected Resident #1-409 had severely impaired cognitive skills for daily decision making and needed extensive assistance from one person for bed mobility, transfers, toilet use and personal hygiene. Resident #1-409 was not able to balance without human assistance from standing from a seated position or moving on and off the toilet. Review of a Care Plan, initiated on 5/25/17 and last revised on 9/20/2018, indicated Resident #1-409 was At risk for falls related to decreased mobility, disease process from the [MEDICAL CONDITION] (MS) and brain mass, unstable gait, poor safety awareness, impulsiveness, generalized muscle weakness, muscle spasms, polyneuopathy, a history of repeated falls, use of antipsychotics, narcotics, antidepressants, [MEDICATION NAME], antianxiety and antisiezure medications. The goal of the care plan was that Resident #1-409's potential for falls or injuries would be minimized. An intervention added to the Care Plan by Registered Nurse (RN) H on 10/3/18 was I have an alarm on my bathroom door for my safety and to alert staff when I am trying to take myself to the bathroom. After completing a private interview in an empty resident room across the hall from Resident #1-409's room, on 10/03/2018 at 4:31 p.m., this surveyor and LPN BB emerged to discover Resident #1-409 was on the floor in her room in front of her wheelchair. Licensed Practical Nurse (LPN) BB entered Resident #1-409's room and called to Certified Nurse Aide (CNA) DD to assist her. Instead of completing an assessment on Resident #1-409 where she was found, LPN BB and CNA DD (who was wearing a gait belt) stood Resident #1-409 to her feet without using a gait belt and sat her in her wheelchair. While Resident #1-409 was standing, LPN BB asked her if her hip hurt, then sat her in her wheelchair. During an interview on 10/03/18 at 4:40 p.m., CNA DD reported she did not apply the gait belt she was wearing while assisting LPN BB with the transfer because it seemed like the nurse was trying to lift her up and so that's what happened. CNA DD said she should have used her gait belt. Review of a Fall Incident report, dated 10/3/18 at 17:12 (5:12 p.m.), documented by LPN KK reflected the Incident Description:(Resident #1-409) in squatting position then fell back onto left hip. The report described the Immediate Action Taken: Picked (resident #1-409) up off the floor, vital signs taken checked for injuries and pain which none noted (sic). The report indicated there were no witnesses to the event. Review of a Nursing Progress Note, dated 10/3/18 at 17:25 (5:25 p.m.), documented by LPN KK reflected Resident stood up from wheelchair went into squatting position and then fell back onto left hip. No injuries or pain noted. Review of a (Facility) Post Fall Assessment, dated 10/3/18, reflected Resident #1-409 had a witnessed fall on 10/3/18 at 4:30 p.m. The Post Fall assessment indicated the resident was last taken to the bathroom at 4:00 p.m. on 10/3/18 and the intervention put into place to prevent a fall was to install a door sensor for restroom door. During an interview on 10/4/18 at 11:17 a.m., LPN BB reported she was the nurse who discovered Resident #1-409 on the floor in front of her wheelchair in her room on 10/3/18 at 4:31 in the afternoon. LPN BB admitted she did not witness the fall and did not know if Resident #1-409 had hit her head. LPN BB said she did not assess Resident #1-409 for injuries before asking CNA DD to assist her to stand her to her feet. LPN BB said she was told she could not complete an incident report for the unwitnessed fall because she was not the nurse assigned to care for Resident #1-409 that day. During an interview on 10/4/18 at 11:38 a.m., LPN KK reported that she was a travel nurse on temporary assignment to the facility since (MONTH) (YEAR). LPN KK said she was told verbally that Resident #1-409 was in the squatting position in front of her wheelchair and fell on to her left hip. LPN KK said that by the time she got to the resident she was already in the wheelchair and her vital signs had already been taken. LPN KK said she did not observe Resident #1-409's backside until about 1/2 hour after the fall, but was told by LPN BB and RN II (the north hall evening supervisor) that the fall had been witnessed. LPN KK went on to explain that she had been told by the evening supervisor and the unit manager that for any fall Resident #1-409 had, the nurse assigned to the resident is to document the incident and assessment even if it was not witnessed or assessed by the floor nurse assigned to the resident. LPN KK reported she was told what the new immediate care plan intervention would be. LPN KK reviewed Resident #1-409's electronic medical record and identified 4 other fall incidents that she documented despite the fact she had not observed the incident and that she did not assess the resident. LPN KK reported those incidents occurred on: (MONTH) 1, 4 and 5 and again on (MONTH) 1, (YEAR). LPN KK said she did not initiate or monitor neurological status because she was told the fall was witnessed. Review of Antigravity Team Notes (an IDT fall review note) documented in Resident #1-409's clinical record from 10/3/2018-10/15-2018 did not reflect a new intervention had been added to Resident #1-409's care plan after her fall on 10/3/18 at 4:31 p.m. to prevent another fall incident. Resident #1-410: Review of a facility Admission Record reflected Resident #1-410 was a [AGE] year-old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 7/17/18, reflected Resident #1-410 was severely cognitively impaired and exhibited wandering behavior daily. Review of a Care Plan, last updated on 8/31/16, reflected Resident #1-410 was At risk for elopement related to attempts to elope from my home, one of which was successful. I have dementia and am no longer aware of my safety needs. I wander looking for a way out. The goal of the care plan was for Resident #1-410's risk for elopement from the secured unit and facility will be minimized with interventions that included Hall monitor in place to assist and redirect me out of other resident's rooms, distract me from wandering by offering pleasant diversions, ask me to help you with a simple task that will help distract me for a short period of time, provide structured activities: toileting, walking inside and outside, reorientation strategies including signs and pictures. Review of a Care Plan, last revised on 4/9/18, reflected (Resident #1-410) is sometimes combative (hitting, pushing etc.) with staff. I may not always understand the environment, actions or statements of others related to severely impaired cognition. The goal of the care plan was that Resident #1-410 would not harm self or others. Interventions included Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. During an observation on 10/3/18 at 10:12 a.m., Resident #1-410 was observed wandering into and out of residents' rooms on the south unit where she lived. A Hall Monitor was situated in the middle of the unit and was unable to respond or redirect from her station. No other staff were observed in the area while Resident #1-410 wandered into and out of other occupied residents' rooms. Review of an incident report, dated 10/7/18 at 3:00 p.m., reflected Resident #1-410 Wandered into (another resident's room), removed a hoodie from his room and was pushed on the shoulder by the other resident as a result. According to the incident report, staff were not available at the time of the incident to intervene. Review of an incident report, dated 10/7/18 at 3:29 p.m. (29 minutes after the previous incident), Resident #1-410 was struck several times in the face by another resident. According to witness statements included in the incident report, Hall Monitor (HM) CCC reported she had gone looking for help after the previous incident and was not on the unit providing any supervision at the time of the occurrence. CNA VV's statement reflected the following: I was walking toward the large shower room on S2 unit with (another resident) when I heard screaming down the hall toward the door by room [ROOM NUMBER] and 2. I redirected (other resident) and walked toward the noise. When I reached the end of the hallway, I noticed the noise was coming from room [ROOM NUMBER]. I knocked and opened the door with my right hand. As I opened the door I observed (another resident) straddled on top of (Resident #1-410) laid horizontally across the bed. (Name of Resident) struck (Resident #1-410) using her closed fist (right hand) on the right side of (Resident #1-410's) face. The statement provided by Registered Nurse (RN) DDD was that she was in the nurses station on the telephone when the incident occurred. Resident #1-414: According to the MDS assessment, dated 8/7/18, Resident #1-414 was admitted to the facility with multiple [DIAGNOSES REDACTED]. This same assessment indicated Resident #1-414 was severely cognitively impaired. A questionnaire, with no title and no date, was in the facility Plan of Correction book with Resident #1-414's name on the top and No was circled under the question, Are you feeling safe? People come into your room and steal your stuff here was handwritten next to the answer. There was no documentation found within the Electronic Medical Record indicating the resident was or was not missing items or that any follow up was conducted including notifying Resident #1-414's responsible party. An interview with the Administrator, on 10/10/18 at 9:00 AM, revealed the questionnaires were completed by SW ZZ and then given to the Administrator. An interview with SW ZZ, on 10/10/18 at 11:33 AM, revealed there were no concern forms generated and stated, I had not thought about that. SW ZZ also stated that she had not reviewed Resident #1-414's inventory list or contacted the Responsible Party regarding the allegation. A follow up interview with the Administrator that same day, at 12:07 PM, revealed that there was no concern form generated as a result of Resident #1-414's allegation of misappropriation, the State Agency was not contacted, the responsible party was not contacted, and no investigation was conducted per facility policy titled Abuse, dated 7/2018. Resident #1-401's Resident #1-401 was admitted to the facility 9/6/18, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], reflected Resident #1-401 demonstrated total dependence on staff for transfers and required extensive assistance of 2 staff members for bed mobility and toileting, was always incontinent of stool and had an indwelling catheter. The MDS Brief Interview for Mental Status (BIMS) review reflected the Resident scored 3 out of a possible 15 which indicated the Resident was severely cognitively impaired. Review of the medical record for Resident #1-401 reflected the Resident was discharged from the hospital and admitted to the facility on [DATE]. Review of the hospital discharge Clinical Summary reflected the Resident was discharged with a Pressure injury to coccyx and that wound was unstageable. The entry reflected, wound treatment of [REDACTED]. Entire sacral Opti foam changed every Tuesday/Friday. Review of the Electronic Medical Record (EMR) for Resident #1-401 revealed a Doctor's Order (DO) dated 9/7/18, for Santyl Ointment (an medication that breaks down dead tissue and helps to grow healthy tissue) .Apply to slough on coccyx topically one time a day for [MEDICATION NAME] Apply to slough on wound, nickel thick. Okay to peel back and replace and reuse same dressing daily. Dressing to be changed every Tuesday and Friday. The facility document reflected this treatment was ordered by Doctor (Dr.) SS. Review of the facility document titled Medication Review Report for Resident #1-401 reflected this same order on 9/7/18 and indicated that the communication method for the order was verbal (a direct verbal instruction from a physician). A telephone interview was conducted with Dr. SS on 10/16/18, at 1:50 PM. When the Santyl dressing

Based on observation, interview and record review, the facility failed to implement its policies and procedures to prevent abuse and neglect as a result of widespread system failures beginning with ineffective administration and quality assurance oversite, a lack of properly oriented staff in sufficient numbers to provide care to dependent residents based on the facility assessment and resident acuity and according to professional standards. These system failures resulted in Immediate Jeopardy (IJ) for 9 residents (Resident #25, 27, 1-401, 1-405, 1-406, 1-410, 1-414, and 1-418, and 1-422) who sustained adverse events, serious physical and/or psychosocial harm and placed all residents living at the facility at risk for serious harm, injury and/or death. Findings include: Review of a facility Abuse policy last revised 7/2018 reflected It is the policy of (Name of Facility) to maintain an environment that is free from neglect, verbal, sexual, physical and mental abuse, exploitation, misappropriation of funds and involuntary seclusion. We will not tolerate abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The policy included definitions that included: 1. Abuse-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or cause harm. 2. Adverse event-an adverse event is an untoward, undesirable, and unusually unanticipated event that causes death or serious injury, or the risk thereof .5. Mistreatment means inappropriate treatment or exploitation of a resident. 6. Neglect is the failure of the facility, it's 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 .8. Involuntary seclusion is the separation of a resident from other residents or from his/her room or confinement to his/her room (with or without other resident present) against the resident's will, or the will of the legal representative. The facility Abuse policy included General provisions that included: b.) Resident care and treatments shall be monitored by all staff, on an ongoing basis, to assure residents are free from abuse, neglect, exploitation, misappropriation of property and involuntary seclusion. It is the responsibility of all staff to provide a safe environment for the residents. c.) Any allegation of resident abuse, neglect, exploitation, misappropriation of property and involuntary seclusion shall be reported to the administrator immediately (abuse coordinator) and shall be thoroughly investigated and documented by the Administrator or designee. d.) The subject of abuse should be routinely and openly discussed. Residents or/or their legal representative will be provided the opportunity for education concerning the commitment of the facility to deal quickly and effectively with abuse or suspected abuse on admission. e.) Staff members, volunteers, family members, and others are required to report immediately to the Administrator any allegation of abuse, and should be assured that they will be protected against repercussions . The policy identified Quality Assurance (QA) review activities necessary to identify patterns and/or trends of allegations and/or substantiated abuse. The facility QA team would then conduct an analysis of 1. Areas of the facility where abuse is more likely to occur, 2. The distribution of staff on each shift in sufficient numbers to meet the needs of the residents and assure that staff have knowledge of individual care needs. 3. The supervisor will identify inappropriate behavior such as using derogatory language, rough handling, or ignoring residents during care. 4. Residents exhibiting needs and behaviors that predispose them to have conflict with others or that subject them to neglect staff (such as: residents with history of aggressive behaviors, residents who enter other residents' rooms, residents with self injury behaviors, residents with communication disorders, residents requiring extensive or total nursing care). Findings include: Resident #27 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #27 was an [AGE] year-old female, who was admitted to the facility on [DATE] (with a readmission date of [DATE]), with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), dated 8/10/18 reflected a score of 13 out of 15 which represents Resident #27 was cognitively intact. Resident #27 required staff assistance with all activities of daily living and transfers. Review of a Care Plan last revised on 8/27/18 reflected Resident #27 was Frequently incontinent of bladder and bowel. My use of diuretics and other medications can also impact my continence status and I require extensive assistance with toileting needs and my need for a hoyer lift for transfers impairs my ability to be toileted in my bathroom. My decreased physical ability and possible medication side effects put me at increased risk for constipation. I also have a history of [MEDICAL CONDITION] with a partial colectomy and [DIAGNOSES REDACTED]. Goals of the care plan indicated that Resident #27's risk for risk for [MEDICAL CONDITION] will be minimized through/prevented through prompt recognition and treatment of [REDACTED]. Interventions included Assist to bed pan upon my request and especially prior to going to meals, activities and before going to bed at night, and Check me with rounds and as required for incontinence. Wash, rinse and dry perineum, apply barrier cream after each incontinence episode and as needed. Review of a Care Plan last revised on 8/7/18 reflected Resident #27 had an ADL (Activities for Daily Living) Self-care Performance deficit related to NSTEMI (a mild [MEDICAL CONDITION]), fatigue, recurrent UTI's, Cardiac issues, anxiety, shortness of breath with exertion, obesity, diabetes with diabetic [MEDICAL CONDITION], depression, [MEDICAL CONDITIONS], frequent bladder incontinence, pain, impaired mobility with need for hoyer transfer (mechanical lift), and possible medication effects. The goal of the care plan was for Resident #27 to Maintain my current level of function in bed mobility, eating, dressing and personal hygiene as my cognitive and physical status will allow. Interventions included Offer me the bed pan as I can make my needs known as needed. During an interview on 10/2/18 at 1:42 p.m., Resident #27 reported staff kept turning off her call light when she needed assistance to the bedpan earlier that day, between 10:00 a.m. and two minutes before lunch at noon. Resident #27 reported she had had an accident and everything got wet which made her feel embarrassed. During an interview on 10/01/18 Resident #32, (Resident #27's husband) expressed frustration regarding his wife's care. Resident #32 reported that staff call in when they aren't sick and the staff that are working don't get his wife out of bed on time because they are too short handed. Resident #1-405 Review of a facility Admission Record reflected Resident #1-405 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1-405 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15/15. Review of a Care Plan last revised on 7/29/18 reflected Resident #1-405 was At risk for constipation related to decreased mobility, medication side effects and at times I decline to use the bowel protocol. I am frequently incontinent of bladder during the assessment period which puts me at increased risk for skin breakdown and UTI's (urinary tract infections). I have required extensive staff assistance with toileting/incontinence care related to spastic [MEDICAL CONDITION], pain issues, and possible medication side effects. I am non-weight bearing on bilateral lower extremities necessitating the need for Hoyer lift for transfers. I have been taking more initiative to use my urinal towards the end of the assessment period. One of the goals of the care plan was to have normal bowel movements at least every 3 days with an intervention that included: Observe/document/report to MD (medical doctor) as needed signs and symptoms of complications related to constipation: change in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation, slow heart rate, abdominal distention, vomiting, small or loose stools, fecal smearing, bowel sounds, diaphoresis, abdominal tenderness, guarding, rigidity, fecal compaction. The care plan also called for recording and reporting to the MD for signs and symptoms of UTI: pain, burring, no output, increased pulse, increased temperature, urinary frequency, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of a Progress Note dated 9/11/18 11:47 p.m. reflected Resident #1-405 vomited after eating. Review of a Progress Note dated 9/12/18 at 3:50 a.m., documented by Licensed Practical Nurse (LPN) EE reflected Resident #1-405 vomited once and according to the progress note, Resident #1-405 thought it was something he ate. Review of a Progress Note dated 9/13/18 at 2:57 a.m., Documented by LPN EE reflected Resident #1-405 had two episodes of nausea this shift, shortly after back to resting. No sign of pain noted at this time. Dressings intact to bilateral feet, no dypsnea noted. Review of a Food Acceptance Record for Resident #1-405 reflected that staff documented Resident #1-405 refused to eat any meals on 9/12/18 and 9/13/18. Review of a Weights and Vitals Summary report indicated Resident #1-405 had a fever on 9/12/18 and 9/13/18. Review of a Progress Note dated 9/13/18 at 9:20 a.m., documented by LPN BB reflected (Resident #1-405) having emesis multiple times. Also with temperature. Resident refused medications. PA (Physician Assistant) called and gave orders for stat (right away) labs. Writer contacted lab with orders. Review of a Progress Notes dated 9/13/18 at 2:52 p.m. documented by LPN BB at 2:52 p.m. reflected New order for IM (injection of medicine into the muscle) [MEDICATION NAME] and ABD (abdominal) x-ray. IM shot given, resident tolerated well. Stat x-ray ordered .Resident having multiple times of emesis. Review of a Progress Note dated 9/13/18 at 7:00 p.m., documented by Registered Nurse (RN) II reflected IV started in left arm with a 24 Gauge needle. Resident tolerated procedure well. Review of a Progress Note dated 9/14/18 at 2:47 a.m., documented by RN LL reflected RN contacted (emergency room Nurse) at (Hospital Name) at 2:45 a.m., and was informed (Resident #1-405) was admitted due to results of CT scan showed possible ileus or sigmoiditis and mild dilation of the duodenum. (Resident #1-405) is being admitted to med/surg. (Name of hospital nurse) inquired about dressings to bilateral feet and RN explained how to change dressing and that it was done today just prior to him leaving and did not require changing for three days. Review of Progress Notes dated 9/13/18 reflected Resident #1-405 had an emergent discharge to the hospital on [DATE] at 21:30 (9:30 p.m.) due to nausea and vomiting. According to an SBAR Communication Form dated 9/13/18 at 7:00 p.m., Resident #1-405 was having worsening nausea and vomiting since 9/11/18 with worsening of symptoms after eating and drinking. During an interview on 10/3/18 at 5:08 p.m., Resident #1-405 reported that he had been getting sick for 2-3 days prior to being transferred to the hospital. Resident #1-405 did not report refusing to be sent to the hospital but did report he didn't feel safe at the facility due to having to wait so long for staff to respond to his call light. Resident #1-405 said he had to sit in his feces for over an hour on 10/2/18 and 10/3/18 due to staff not responding to his call light. Resident #1-405 said I get mad and frustrated. I could be in trouble and it takes 15-20 minutes to get help. I don't really feel safe but what can I do? During an interview on 10/01/18 at 12:30 p.m., Physician Assistant (PA) JJ reported he had not been notified Resident #1-405 had been vomiting until the second day of symptoms and multiple episodes of emesis. PA JJ said he would have expected to have been notified after the second episode of emesis due to Resident #1-405's history of bowel complications. As soon as he was notified he started IM [MEDICATION NAME] (an anti-emetic) and an abdominal x-ray. PA JJ reported that despite the x-ray ordered in the facility being negative for an obstruction, and because Resident #1-405 was having bowel movements, he suspected an ileus and ordered Resident #1-405 be sent to the emergency room for evaluation and treatment. During an interview on 10/3/18 at 4:18 p.m., LPN BB reported she was a travel nurse who had worked at the facility since (MONTH) 19, (YEAR). LPN BB said she had been somewhat familiar with Resident #1-405 and when she started her shift on 9/13/18 had not been told in report that Resident #1-405 had been vomiting. LPN BB said that she learned from nurse aides that Resident #1-405 had been getting sick (vomiting) for days. LPN BB then said that she heard from RN LL that Resident #1-405 had been getting sick for days. LPN BB said she reported Resident #1-405's condition to PA JJ after she witnessed the second episode of emesis and acted on his orders, ultimately sending Resident #1-405 to the hospital for treatment. LPN BB said she reported her concern about not being told Resident #1-405 had been vomiting to Unit Manager (UM) Registered Nurse (RN) H. During a telephone interview on 10/04/18 at 9:23 a.m., LPN EE reported he had notified the physician of the changes in Resident #1-405's condition using the online dashboard (a messaging feature in the electronic medical record). LPN EE also said he reported Resident #1-405's change in condition to the oncoming nurse (LPN BB). During an interview on 10/04/18 at 10:30 a.m., Chief Clinical Officer (CCO) WW reported she reviewed the dashboard and secure communications documented by staff on behalf of Resident #1-405 and no record of a report of any kind related to his change in condition was found. During an interview on 10/5/18 at 9:30 a.m., Unit Manager/RN H reported she couldn't recall which nurse talked to her about Resident #1-405's emesis but said she had been made aware and did encourage staff to push room temperature fluids because it would be easier for him to digest given his history of nausea and vomiting. RN H admitted she never encouraged any nurse to notify the physician about Resident #1-405's condition. During an interview on 10/9/18 at 3:37 p.m., evening supervisor RN II reported she worked on 9/13/18, the evening Resident #1-405 was discharged to the emergency department. RN II said she thought it was odd the physician ordered an IV for fluids because she was not aware Resident #1-405 had been having emesis, until she heard from RN LL that Resident #1-405 had been getting sick for two days. When asked, RN II said she did call the DON after starting the IV but did not report an allegation of neglect because she did not recognize the situation as neglect, despite learning Resident #1-405 had suffered for two days with emesis without notification to the physician. Review of a hospital ED Prov Note (Emergency Department Provider Note) dated 9/13/18 at 9:51 p.m. reflected Patient presents today from his living facility at (Name of Facility) for 3 days of vomiting. Patient (Resident #1-405) states has also had associated fevers. He does endorse mild diffuse abdominal pain well as throat pain that he believes is from his vomiting. He denied associated diarrhea or blood in stool. He did have a bowel movement which he states was smaller than normal today. Patient on epic review (hospital system medical record) does have a history of [MEDICAL CONDITION]. Patient was [MEDICAL CONDITION] on arrival and did appear ill but not toxic. I did discuss with patient will placed IV and give him [MEDICATION NAME] (an anti-nausea medication) and [MEDICATION NAME] for pain and nausea control. Also obtain blood work as well as CT abdomen pelvis. Further review of the document revealed Resident #1-405 stated The patient (Resident #1-405) states that he has been experiencing constant vomiting for 3 days. He states that he is unable to keep water or food down without vomiting. The patient states that he is experiencing general abdominal pain throughout his abdomen. He also notes on and off fevers, chills and headaches for 3 days. The patient states that he a sore throat from vomiting so many times. He reports the staff at (Name of Facility) gave him [MEDICATION NAME], which he immediately vomited up. Review of a hospital History and Physical dated 9/13/18 reflected (Resident #1-405) with [MEDICAL CONDITION] (CP) and vascular ulcers presents today with vomiting. He has been vomiting for a few days and taking his [MEDICATION NAME] and [MEDICATION NAME] with no relief. He has been living at (Name of Facility) for a few months while treating chronic vascular ulcers on his feet. He has not been ambulatory for 4 years. He denies chest pain, dysuria, shortness of breath, or diarrhea. He has headaches while vomiting. On arrival, he has urinalysis consistent with UTI (urinary tract infection) and possible SBO (small bowel obstruction). On exam he is anxious and nauseated. Plans are discussed for admission and he is agreeable. He wishes to be listed as full code. Review of a Physician assessment dated [DATE], Resident #1-405 was readmitted to the facility from the hospital after complaints of abdominal pain. According to the progress note, Resident #1-405 had a CT scan at the hospital that showed Resident #1-405 had an ileus (paralysis or obstruction of the bowel) and possible SBO (small bowel obstruction). Resident #1-410 Review of a facility Admission Record reflected Resident #1-410 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1-410 was severely cognitively impaired and exhibited wandering behavior daily. Review of a Care Plan last updated on 8/31/16 reflected Resident #1-410 was At risk for elopement related to attempts to elope from my home, one of which was successful. I have dementia and am no longer aware of my safety needs. I wander looking for a way out. The goal of the care plan was for Resident #1-410's risk for elopement from the secured unit and facility will be minimized with interventions that included Hall monitor in place to assist and redirect me out of other resident's rooms, distract me from wandering by offering pleasant diversions, ask me to help you with a simple task that will help distract me for a short period of time, provide structured activities: toileting, walking inside and outside, reorientation strategies including signs and pictures. Review of a Care Plan last revised on 4/9/18 reflected (Resident #1-410) is sometimes combative (hitting, pushing etc.) with staff. I may not always understand the environment, actions or statements of others related to severely impaired cognition. The goal of the care plan was that Resident #1-410 would not harm self or others. Interventions included Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. During an observation on 10/3/18 at 10:12 a.m., Resident #1-410 was observed wandering into and out of resident rooms on the south unit where she lived. A Hall Monitor was situated in the middle of the unit and was unable to respond or redirect from her station. No other staff were observed in the area while Resident #1-410 wandered into and out of other occupied resident rooms. Review of an incident report dated 10/7/18 at 3:00 p.m. reflected Resident #1-410 Wandered into (another resident's room), removed a hoodie from his room and was pushed on the shoulder by the other resident as a result. According to the incident report, staff were not available at the time of the incident to intervene. Review of an incident report dated 10/7/18 at 3:29 p.m. (29 minutes after the previous incident), Resident #1-410 was struck several times in the face by another resident. According to witness statements included in the incident report, Hall Monitor (HM) CCC reported she had gone looking for help after the previous incident and was not on the unit providing any supervision at the time of the occurrence. CNA VV's statement reflected the following: I was walking toward the large shower room on S2 unit with (another resident) when I heard screaming down the hall toward the door by room [ROOM NUMBER] and 2. I redirected (other resident) and walked toward the noise. When I reached the end of the hallway, I noticed the noise was coming from room [ROOM NUMBER]. I knocked and opened the door with my right hand. As I opened the door I observed (another resident) straddled on top of (Resident #1-410) laid horizontally across the bed. (Name of Resident) struck (Resident #1-410) using her closed fist (right hand) on the right side of (Resident #1-410's) face. The statement provided by Registered Nurse (RN) DDD was that she was in the nurses station on the telephone when the incident occurred. Resident #1-422 Record review of a grievance form dated 10/8/18 reflected a complaint of that staff were not assisting resident after bowel incontinence, the complainant noted that this had been a problem in the past and it is again. When the complainant asked the staff about the situation a CNA reported that there was only one staff member on the hall and was unable to assist and clean resident. The complainant suggested more staff. There was no facility response and no signatures resolving the complaint. Resident #25 Record review of a grievance form dated 10/8/18 reflected the resident complained that 1st shift put them on the bed pan and didn't come back to take them off. Reports that they were on the bed pan for a very long time. Stated that it happened on 10/8/18 at 3:30 PM. Second shift CNA was unaware that resident was left on the bed pan. The form reflected, Is this an ongoing concern? Yes, I am frequently left on the bed pan for a long amount of time. There was no facility response but contained the NHA A's signature and date of 10/8/18. There was no signature resolving the complaint by the grievant. Resident #1-418 Record review of a grievance form dated 8/28/18 reflected the resident complained that staff removed her leg dressings around noon, left them undressed and when staff were alerted redressed the legs after 4:00 PM. Resident reports concern with the dressings being removed while eating their lunch and leaving them off for hours which was painful. The conclusion area was blank and there were no signatures resolving the complaint. An interview and record review was conducted with the NHA A on 10/10/18 at 6:40 PM. The NHA stated that she is the grievance coordinator at the facility. NHA A stated that the facility uses a program called Guardian Angel Rounds (questions related to care and services) to check in with residents 2-3 times weekly. If problems or concerns are brought up to the staff by residents a grievance would be initiated, and those forms are later used for the Quality Assurance Committee to determine if there are patterns or trends. The NHA A stated that policy says to do a concern form, but she has deviated from that practice and told the staff if they can take care of the concern right then and there to do it. The NHA A stated, I told them not to report it unless it was egregious, I guess I didn't make myself clear. When asked if she reviewed the grievances, the NHA A stated, I read some of them. I don't know why I did not read them all. If my signature is there, I reviewed them. When asked what examples of neglect were, the NHA A stated, Not taken care of, not being fed, social needs not met, lots of reasons .medication not given, I am not clinical, treatments not being done, briefs not being changed. When asked about the concern forms reviewed for Resident #1-422, #25, and #1-418, the NHA A agreed that the complaints were an allegation of neglect. The NHA A stated that they should have been investigated. When asked if the state agency, police or cooperate were notified, the NHA A stated, No. The NHA A attempted to deflect blame and responsibility upon other staff then stated, I didn't say it was (name of staff member) fault, it is my fault. Resident #1-401's findings are reflected in two parts, A & B. A.) Related to pressure ulcer worsening and inadequate staffing Resident #1-401 was admitted to the facility 9/6/18, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] reflected Resident #1-401 demonstrated total dependence on staff for transfers and required extensive assistance of 2 staff members for bed mobility and toileting, was always incontinent of stool and had an indwelling catheter. The MDS Brief Interview for Mental Status (BIMS) review reflected the Resident scored 3 out of a possible 15 which indicated the Resident was severely cognitively impaired. Review of the medical record for Resident #1-401 reflected the Resident was discharged from the hospital and admitted to the facility on [DATE]. Review of the hospital discharge Clinical Summary reflected the Resident was discharged with a Pressure injury to coccyx and that wound was unstageable. The entry reflected, wound treatment of [REDACTED]. Entire sacral Opti foam changed every Tuesday/Friday. Review of the Electronic Medical Record (EMR) for Resident #1-401 revealed a Doctor's Order (DO) dated 9/7/18, for Santyl Ointment (an medication that breaks down dead tissue and helps to grow healthy tissue) .Apply to slough on coccyx topically one time a day for [MEDICATION NAME] Apply to slough on wound, nickel thick. Okay to peel back and replace and reuse same dressing daily. Dressing to be changed every Tuesday and Friday. The facility document reflected this treatment was ordered by Doctor (Dr.) SS. Review of the facility document titled Medication Review Report for Resident #1-401 reflected this same order on 9/7/18 and indicated that the communication method for the order was verbal (a direct verbal instruction from a physician). A telephone interview was conducted with Dr. SS on 10/16/18, at 1:50 PM. When the Santyl dressing order was read Dr. SS stated, who wrote that?. Dr. SS was informed the record reflected his name as the prescribing physician. Dr. SS reported he did not remember giving or approving this order. Dr SS indicated he would have expected a clarifying phone call from nursing for an order instructing the re-use of a wound dressing. Dr. SS indicated that before transcribing a hospital discharge order such as this nursing should have known to contact him. Dr. SS stated, if they are using my name I better know. Review of the EMR Treatment Administration Record for Resident #1-401 for (MONTH) (YEAR) reflected a new dressing was applied to the coccyx on 9/7/18 and not changed until 9/11/18. The record reflected on 9/8, 9/9, and 9/10/18, the dressing was peeled back, and Santyl Ointment was applied and the dressing from 9/7/18 was unchanged and reused. The Treatment Record did not reflect the wound had been cleansed. Review of the entries on 9/7, 9/10, and 9/11/18, reflected a code of 9, and 5. The key of the code revealed the codes indicated, See Nurses Note. Review of the Nurses Notes for 9/7 and 9/10 reflected only, dressing intact about wound care. The entry of 9/11/18, reflected, New orders received for wound. Dressing to be changed daily. The entries do not include any information regarding the condition of the wound or information about the specific task of wound care that had been completed. Review of the Manufacturer's instruction for the use of Santyl reflected, Prior to application (of Santyl) the wound should be cleansed of debris and digested material by gently rubbing with a gauze pad saturated with normal saline or with (a compatible cleansing agent) followed by a normal saline solution rinse. Review of the EMR Skin and Wound assessment dated [DATE], reflected wound measurements as follows: Area - 5.9 centimeters (cm)2 (squared), Length 4.9 cm, Width 3.5 cm, Depth - not recorded. The section titled, Notifications reflected no notifications were made regarding the wound assessment. Review of the EMR Skin and Wound assessment dated [DATE], reflected wound measurements as follows: Area - 9.0 cm2, Length 2.9 cm, Width 4.2 cm, Depth - not recorded. Page 5 of this Skin and Wound Assessment reflected the wound was, Deteriorating. On 10/1/18 at 4:11 PM, it was observed that the door to room [ROOM NUMBER]-1, which was located at the end of an S2 hall, was closed. On entry into the room it was observed that the room was darkened. Resident #1-401 turned to left side in low bed crying, stating, I can't move, I can't move- my leg, ouch, ouch, it hurts it hurts. Noted no call light in reach. Ringer-type bell on over the bed table past the fall mat on the floor out of reach of the Resident. Staff were alerted to the needs of the Resident. During the observation of care, it was noted staff discovered Resident #1-401 had been incontinent of stool. When Resident #1-401 was turned to be cleaned a large wound on the sacral area was observed to be exposed; the wound was not covered with a dressing. The wound remained exposed until 5:27 PM when wound care had been provided. On 10/11/18 at 4:03 PM, an interview was conducted with Wound Nurse Consultant (NWC) TT. WNC TT indicated that on 10/1/18, the Physician's Assistant (PA) had evaluated the sacral wound of Resident #1-401 at approximately 10:30 -11:00 AM. NWC TT indicated a new order for treatment of [REDACTED]. On 10/15/18 at 11:15 AM, a telephone interview was conducted with RN P. RN P reported he was aware the PA had evaluated the wound on Resident #1-401 on 10/1/18. RN P reported he been way behind and had left the wound on the sacral area of Resident #1-401 uncovered. RN P reported he had wanted the Wound Nurse or a Unit manager to be present when he followed the new order for wound care but indicated he was unable to coordinate this care with the other staff. RN P reported he did not complete

Based on observation, interview and record review the facility failed to thoroughly investigate, protect and implement corrective actions to prevent the reoccurrence of abuse and neglect as a result of widespread system failures, beginning with ineffective administration and quality assurance oversite, a lack of properly oriented staff in sufficient numbers to provide care to dependent residents based on the facility assessment and resident acuity and according to professional standards. These system failures resulted in Immediate Jeopardy (IJ) for 9 residents (Resident #25, 27, 1-401, 1-405, 1-410, 1-414, 1-415 and 1-418, 1-422) who sustained adverse events, serious physical and/or psychosocial harm and placed all residents living at the facility at risk for serious harm, injury and/or death. Findings include: Review of a facility Abuse policy, last revised 7/2018, reflected It is the policy of (Name of Facility) to maintain an environment that is free from neglect, verbal, sexual, physical and mental abuse, exploitation, misappropriation of funds and involuntary seclusion. We will not tolerate abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The policy included definitions that included: 1. Abuse-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial wellbeing. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or cause harm. 2. Adverse event-an adverse event is an untoward, undesirable, and unusually unanticipated event that causes death or serious injury, or the risk thereof .5. Mistreatment means inappropriate treatment or exploitation of a resident. 6. Neglect is the failure of the facility, it's 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 .8. Involuntary seclusion is the separation of a resident from other residents or from his/her room or confinement to his/her room (with or without other resident present) against the resident's will, or the will of the legal representative. The facility Abuse policy included General provisions that included: b.) Resident care and treatments shall be monitored by all staff, on an ongoing basis, to assure residents are free from abuse, neglect, exploitation, misappropriation of property and involuntary seclusion. It is the responsibility of all staff to provide a safe environment for the residents. c.) Any allegation of resident abuse, neglect, exploitation, misappropriation of property and involuntary seclusion shall be reported to the administrator immediately (abuse coordinator) and shall be thoroughly investigated and documented by the Administrator or designee. d.) The subject of abuse should be routinely and openly discussed. Residents or/or their legal representative will be provided the opportunity for education concerning the commitment of the facility to deal quickly and effectively with abuse or suspected abuse on admission. e.) Staff members, volunteers, family members, and others are required to report immediately to the Administrator any allegation of abuse, and should be assured that they will be protected against repercussions . The policy identified Quality Assurance (QA) review activities necessary to identify patterns and/or trends of allegations and/or substantiated abuse. The facility QA team would then conduct an analysis of 1. Areas of the facility where abuse is more likely to occur, 2. The distribution of staff on each shift in sufficient numbers to meet the needs of the residents and assure that staff have knowledge of individual care needs. 3. The supervisor will identify inappropriate behavior such as using derogatory language, rough handling, or ignoring residents during care. 4. Residents exhibiting needs and behaviors that predispose them to have conflict with others or that subject them to neglect staff (such as: residents with history of aggressive behaviors, residents who enter other residents' rooms, residents with self-injury behaviors, residents with communication disorders, residents requiring extensive or total nursing care). Resident #27: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #27 was an [AGE] year-old female, who was admitted to the facility on [DATE] (with a readmission date of [DATE]), with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), dated 8/10/18, reflected a score of 13 out of 15 which represents that Resident #27 was cognitively intact. Resident #27 required staff assistance with all activities of daily living and transfers. Review of a Care Plan, last revised on 8/27/18, reflected Resident #27 was Frequently incontinent of bladder and bowel. My use of diuretics and other medications can also impact my continence status and I require extensive assistance with toileting needs and my need for a Hoyer lift for transfers impairs my ability to be toileted in my bathroom. My decreased physical ability and possible medication side effects put me at increased risk for constipation. I also have a history of [MEDICAL CONDITION] with a partial colectomy and [DIAGNOSES REDACTED]. Goals of the care plan indicated that Resident #27's risk for [MEDICAL CONDITION] will be minimized through/prevented through prompt recognition and treatment of [REDACTED]. Interventions included Assist to bed pan upon my request and especially prior to going to meals, activities and before going to bed at night, and Check me with rounds and as required for incontinence. Wash, rinse and dry perineum, apply barrier cream after each incontinence episode and as needed. Review of a Care Plan, last revised on 8/7/18, reflected Resident #27 had an ADL (Activities for Daily Living) Self-care Performance deficit related to NSTEMI (a mild [MEDICAL CONDITION]), fatigue, recurrent UTI's, Cardiac issues, anxiety, shortness of breath with exertion, obesity, diabetes with diabetic [MEDICAL CONDITION], depression, [MEDICAL CONDITIONS], frequent bladder incontinence, pain, impaired mobility with need for Hoyer transfer (mechanical lift), and possible medication effects. The goal of the care plan was for Resident #27 to Maintain my current level of function in bed mobility, eating, dressing and personal hygiene as my cognitive and physical status will allow. Interventions included Offer me the bed pan as I can make my needs known as needed. During an interview on 10/2/18 at 1:42 p.m., Resident #27 reported staff kept turning off her call light when she needed assistance to the bedpan earlier that day, between 10:00 a.m. and two minutes before lunch at noon. Resident #27 reported she had had an accident and everything got wet which made her feel embarrassed. During an interview on 10/01/18, Resident #32, (Resident #27's husband) expressed frustration regarding his wife's care. Resident #32 reported that staff call in when they aren't sick and the staff that are working don't get his wife out of bed on time because they are too short handed. Resident #401: Resident #1-401's findings are reflected in two parts, A & B. A.) Related to pressure ulcer worsening and inadequate staffing Resident #1-401 was admitted to the facility 9/6/18, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], reflected Resident #1-401 demonstrated total dependence on staff for transfers and required extensive assistance of 2 staff members for bed mobility and toileting, was always incontinent of stool and had an indwelling catheter. The MDS Brief Interview for Mental Status (BIMS) review reflected the Resident scored 3 out of a possible 15 which indicated the Resident was severely cognitively impaired. Review of the medical record for Resident #1-401 reflected the Resident was discharged from the hospital and admitted to the facility on [DATE]. Review of the hospital discharge Clinical Summary reflected the Resident was discharged with a Pressure injury to coccyx and that wound was unstageable. The entry reflected, wound treatment of [REDACTED]. Entire sacral Opti foam changed every Tuesday/Friday. Review of the Electronic Medical Record (EMR) for Resident #1-401 revealed a Doctor's Order (DO) dated 9/7/18, for Santyl Ointment (an medication that breaks down dead tissue and helps to grow healthy tissue) .Apply to slough on coccyx topically one time a day for [MEDICATION NAME] Apply to slough on wound, nickel thick. Okay to peel back and replace and reuse same dressing daily. Dressing to be changed every Tuesday and Friday. The facility document reflected this treatment was ordered by Doctor (Dr.) SS. Review of the facility document titled Medication Review Report for Resident #1-401 reflected this same order on 9/7/18 and indicated that the communication method for the order was verbal (a direct verbal instruction from a physician). A telephone interview was conducted with Dr. SS on 10/16/18, at 1:50 PM. When the Santyl dressing order was read Dr. SS stated, who wrote that?. Dr. SS was informed the record reflected his name as the prescribing physician. Dr. SS reported he did not remember giving or approving this order. Dr SS indicated he would have expected a clarifying phone call from nursing for an order instructing the re-use of a wound dressing. Dr. SS indicated that before transcribing a hospital discharge order such as this, nursing should have known to contact him. Dr. SS stated, if they are using my name I better know. Review of the EMR Treatment Administration Record for Resident #1-401 for (MONTH) (YEAR) reflected a new dressing was applied to the coccyx on 9/7/18 and not changed until 9/11/18. The record reflected on 9/8, 9/9, and 9/10/18, the dressing was peeled back, and Santyl Ointment was applied and the dressing from 9/7/18 was unchanged and reused. The Treatment Record did not reflect the wound had been cleansed. Review of the entries on 9/7, 9/10, and 9/11/18, reflected a code of 9, and 5. The key of the code revealed the codes indicated, See Nurses Note. Review of the Nurses Notes for 9/7 and 9/10 reflected only, dressing intact about wound care. The entry of 9/11/18, reflected, New orders received for wound. Dressing to be changed daily. The entries do not include any information regarding the condition of the wound or information about the specific task of wound care that had been completed. Review of the Manufacturer's instruction for the use of Santyl reflected, Prior to application (of Santyl) the wound should be cleansed of debris and digested material by gently rubbing with a gauze pad saturated with normal saline or with (a compatible cleansing agent) followed by a normal saline solution rinse. Review of the EMR Skin and Wound Assessment, dated 9/7/18, reflected wound measurements as follows: Area - 5.9 centimeters (cm)2 (squared), Length 4.9 cm, Width 3.5 cm, Depth - not recorded. The section titled, Notifications reflected no notifications were made regarding the wound assessment. Review of the EMR Skin and Wound Assessment, dated 9/13/18, reflected wound measurements as follows: Area - 9.0 cm2, Length 2.9 cm, Width 4.2 cm, Depth - not recorded. Page 5 of this Skin and Wound Assessment reflected the wound was, Deteriorating. On 10/1/18 at 4:11 PM it was observed that the door to room [ROOM NUMBER]-1, which was located at the end of an S2 hall, was closed. On entry into the room it was observed that the room was darkened. Resident #1-401 turned to left side in low bed crying, stating, I can't move, I can't move- my leg, ouch, ouch, it hurts it hurts. Noted no call light in reach. Ringer-type bell on over-the-bed table past the fall mat on the floor out of reach of the Resident. Staff were alerted to the needs of the Resident. During the observation of care, it was noted staff discovered Resident #1-401 had been incontinent of stool. When Resident #1-401 was turned to be cleaned, a large wound on the sacral area was observed to be exposed; the wound was not covered with a dressing. The wound remained exposed until 5:27 PM after wound care had been provided. On 10/11/18, at 4:03 PM, an interview was conducted with Wound Nurse Consultant (NWC) TT. WNC TT indicated that on 10/1/18, the Physician's Assistant (PA) had evaluated the sacral wound of Resident #1-401 at approximately 10:30 -11:00 AM. NWC TT indicated a new order for treatment of [REDACTED]. On 10/15/18, a telephone interview was conducted with RN P. RN P reported he was aware the PA had evaluated the wound on Resident #1-401 on 10/1/18. RN P reported he been way behind and had left the wound on the sacral area of Resident #1-401 uncovered. RN P reported he had wanted the Wound Nurse or a Unit manager to be present when he followed the new order for wound care but indicated he was unable to coordinate this care with the other staff. RN P reported he did not complete the dressing change by the time he had left for the day at about 4:00 PM on 10/1/18. Review of the EMR Skin and Wound Assessment, dated 10/4/18, reflected the wound was, improving despite a documented increase in wound measurements. The Area of the wound on 9/13/18, was 9.0 cm2, compared to the Area documented on the 10/4/18, assessment of 44.9 cm2. This deterioration reflected an increase of 35.9 cm2 of wound area since 9/13/18. Review of the EMR Progress Notes for Resident #1-401 on 10/6/18, reflected a concern for the status of the wound and that the Resident was febrile (elevated body temperature). The medical record reflected the Resident was sent to the emergency room and was subsequently admitted for [MEDICAL CONDITION] (systemic infection). Review of the hospital records, dated 10/6/18, for Resident #1-401 reflected the Reason for Visit to be, yesterday fever 103 (degrees Fahrenheit), wound on coccyx that had, increased by ½ (inch) in last 48 hours, and that the facility wants it noted (patient) has had a significant change in condition . Further review of the hospital records indicated a Computer Tomography Scan (CT) of the coccyx wound reflected, osteo[DIAGNOSES REDACTED] (bone infection). Review of education notes written by WNC TT reflected 10 points about care to the wound of Resident #1-401. The notes reflected (Resident #1-401) was admitted [DATE], with a Stage 3 sacral pressure injury. There are a few issues related to this wound that need to be addressed. 1. Treatment: Cleanse pressure sore with normal saline (NS) apply Santyl to slough, cover with gauze and apply border gauze, change daily every day shift. 6. Order: (order of 9/7/18 restated) Santyl Ointment .apply to slough .Okay to peel back and replace and reuse same dressing daily. Dressing to be changed every Tuesday and Friday WNC TT added in all capital letters, WE DO NOT PEEL BACK DRESSINGS, DO A TREATMENT AND REAPPLY THE OLD DRESSING. THESE ORDERS DO NOT INCLUDE CLEANING OR PERIWOUND PROTECTION INSTRUCTIONS. THE DRESSING MUST BE CHANGED EACH DAY WITH CLEANING AND APPLICATION OF NEW SANTYL. SANTYL ONLY WORKS FOR 24 HOURS SO, THIS REQUIRES A (EVERY) 24 HOUR DRESSING CHANGE. THE WOUND IS ON HER SACRUM, NOT C[NAME]CYX. 7 Treatment Administration Record (TAR): A 9 (code meaning see nurses notes) was recorded on the TAR on 9/7 and 9/11. There are X's on 9/8 ,9/9 (on the new dressing applied portion of the TAR -an X indicated this was not done), on 9/10 there is a 5 (code meaning see nurses note). There is not a single note about this. So, her wound has not been cleaned. No Santyl applied and dressing has not been changed since she was admitted on [DATE]. There is no documentation in the chart to show otherwise. In an interview conducted 10/11/18, at 4:03 PM WNC TT reported, I cannot say the facility did not cause the osteo[DIAGNOSES REDACTED]. Whether things like no dressing change or no dressing (uncovered wound for approximately 6 hours), given her co-morbidities (other physical problems) . better care would have helped. B) Related to neglect and involuntary seclusion. Review of a facility Abuse policy, last revised 7/2018, reflected It is the policy of (Name of Facility) to maintain an environment that is free from neglect, verbal, sexual, physical and mental abuse, exploitation, misappropriation of funds and involuntary seclusion. 8. Involuntary seclusion is the separation of a resident from other residents or from his/her room or confinement to his/her room (with or without other resident present) against the resident's will, or the will of the legal representative. Resident #1-401 was admitted to the facility 9/6/18, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], reflected Resident #1-401 was unable to walk and required total dependence on staff for transfers. The MDS also reflected the Resident required extensive assistance of two staff members for personal hygiene. The Brief Interview For Mental Status (BIMS) of the MDS reflected a score of 3 out of a possible 15 which indicated Resident #1-401 was severely cognitively impaired. On 10/1/18, at 4:11 PM, the room of Resident #1-401's was observed to be located at the end of S-2 hall and that the door was closed. On entry into the room it was observed that the room was darkened, and the Resident was turned to her left side in a low bed. It was observed that Resident #1-401 was crying, and stated, I can't move, I can't move- my leg, ouch, ouch, it hurts it hurts. There was no call light in reach. A ringer-type bell was observed on an over-the-bed table, out of reach of the Resident. On 10/1/18, at 5:06 PM, an interview was conducted with Family Member (FM) QQ in the room of Resident #1-401. FM QQ reported the Resident was initially admitted to another unit of the facility. FM QQ reported in the original unit Resident #1-401 had displayed behaviors and her call light had been taken away. FM QQ reported when the Resident was moved to the locked S-2 unit, she had asked Registered Nurse (RN) P for a re-evaluation for a call light but was told that two-hour bed checks were sufficient. FM QQ reported that the door to the Resident's room at the end of the hall was always closed because of wanderers. FM QQ reported when she arrived to visit the Resident this day there was a man urinating in the shared bathroom. FM QQ also reported the electricity to the air bed used by Resident #1-401 was turned off and she thought a wanderer had inadvertently turned the bed off. FM QQ reported that several small items have turned up missing from the Resident's room but that the wanderers have left items, as well. In an observation and record review conducted following the interview of FM QQ it was observed that several rooms on the S-2 units hall had Stop Signs attached to resident room doorways. This was a piece of red material attached by Velcro to doorways at approximately waist level. One end of the Stop Sign could be removed to gain entry into the room then replaced to discourage wanderers from entering the room. It was observed that the room of Resident #1-401 did not have a Stop Sign attached to the doorway. Review of the facility Roster Matrix reflected that the room that shared a common bathroom with Resident #1-401 was occupied by a female resident. On 10/8/18, at 10:45 AM, an observation was conducted on the S-2 Unit outside of the room of Resident #1-401. A male resident was observed wandering at the end of the hall. No staff were in view. The male resident was observed opening the closed door of the room of Resident #1-401 and walking into the room. The male resident pulled back the curtain at the bed of Resident #1-401, looked at her sleeping in the bed, walked into the bathroom, turned and left the room. On 10/8/18, at 10:41 AM, an interview was conducted with RN P. RN P reported that when Resident #1-401 was on the facility North unit the call light had been taken away. RN P reported that the Resident now had a bell. RN P reported that Resident #1-401 was checked on about every two hours and that the routine of the unit put a staff member in each resident's room about that often. On 10/8/18, at 10:41 AM Resident #1-401 was observed in her room at the end of the hall with the door closed. The resident was in a wheelchair with no call light, call bell, or water in reach. Review of the facility Abuse policy, last revised 7/2018 reflected, The Resident has the right to be free from abuse, neglect, and involuntary seclusion. The policy reflected the regulatory definition of neglect as, 6. Neglect is the 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. Section IV titled General of the facility policy on Abuse reflected, b. Resident care and treatments shall be monitored by all staff, on an ongoing basis, to assure residents are free from abuse, neglect, exploitation, misappropriation of property and involuntary seclusion. It is the responsibility of all staff to provide a safe environment for the residents. Resident #1-405: Review of a facility Admission Record reflected Resident #1-405 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 9/8/18, reflected Resident #1-405 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15. Review of a Care Plan, last revised on 7/29/18, reflected Resident #1-405 was At risk for constipation related to decreased mobility, medication side effects and at times I decline to use the bowel protocol. I am frequently incontinent of bladder during the assessment period which puts me at increased risk for skin breakdown and UTI's (urinary tract infections). I have required extensive staff assistance with toileting/incontinence care related to spastic [MEDICAL CONDITION], pain issues, and possible medication side effects. I am non-weight bearing on bilateral lower extremities necessitating the need for Hoyer lift for transfers. I have been taking more initiative to use my urinal towards the end of the assessment period. One of the goals of the care plan was to have normal bowel movements at least every 3 days with an intervention that included: Observe/document/report to MD (medical doctor) as needed signs and symptoms of complications related to constipation: change in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation, slow heart rate, abdominal distention, vomiting, small or loose stools, fecal smearing, bowel sounds, diaphoresis, abdominal tenderness, guarding, rigidity, fecal compaction. The care plan also called for recording and reporting to the MD for signs and symptoms of UTI: pain, burning, no output, increased pulse, increased temperature, urinary frequency, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of a Progress Note, dated 9/11/18 11:47 p.m., reflected Resident #1-405 vomited after eating. Review of a Progress Note, dated 9/12/18 at 3:50 a.m., documented by Licensed Practical Nurse (LPN) EE reflected Resident #1-405 vomited once and according to the progress note, Resident #1-405 thought it was something he ate. Review of a Progress Note, dated 9/13/18 at 2:57 a.m., Documented by LPN EE reflected Resident #1-405 had two episodes of nausea this shift, shortly after back to resting. No sign of pain noted at this time. Dressings intact to bilateral feet, no dyspnea noted. Review of a Food Acceptance Record for Resident #1-405 reflected that staff documented Resident #1-405 refused to eat any meals on 9/12/18 and 9/13/18. Review of a Weights and Vitals Summary report indicated Resident #1-405 had a fever on 9/12/18 and 9/13/18. Review of a Progress Note, dated 9/13/18 at 9:20 a.m., documented by LPN BB reflected (Resident #1-405) having emesis multiple times. Also, with temperature. Resident refused medications. PA (Physician Assistant) called and gave orders for stat (right away) labs. Writer contacted lab with orders. Review of a Progress Note, dated 9/13/18 at 2:52 p.m., documented by LPN BB at 2:52 p.m. reflected New order for IM (injection of medicine into the muscle) [MEDICATION NAME] and ABD (abdominal) x-ray. IM shot given, resident tolerated well. Stat x-ray ordered .Resident having multiple times of emesis. Review of a Progress Note, dated 9/13/18 at 7:00 p.m., documented by Registered Nurse (RN) II reflected IV started in left arm with a 24 Gauge needle. Resident tolerated procedure well. According to an SBAR Communication Form, dated 9/13/18 at 7:00 p.m., Resident #1-405 was having worsening nausea and vomiting since 9/11/18 with worsening of symptoms after eating and drinking. Review of Progress Note, dated 9/13/18, reflected Resident #1-405 had an emergent discharge to the hospital on [DATE] at 21:30 (9:30 p.m.) due to nausea and vomiting. Review of a Progress Note, dated 9/14/18 at 2:47 a.m., documented by RN LL reflected RN contacted (emergency room Nurse) at (Hospital Name) at 2:45 a.m., and was informed (Resident #1-405) was admitted due to results of CT scan showed possible ileus or sigmoiditis and mild dilation of the duodenum. (Resident #1-405) is being admitted to med/surg. (Name of hospital nurse) inquired about dressings to bilateral feet and RN explained how to change dressing and that it was done today just prior to him leaving and did not require changing for three days. During an interview on 10/3/18 at 5:08 p.m., Resident #1-405 reported that he had been getting sick for 2-3 days prior to being transferred to the hospital. Resident #1-405 did not report refusing to be sent to the hospital but did report he didn't feel safe at the facility, due to having to wait so long for staff to respond to his call light. Resident #1-405 said he had to sit in his feces for over an hour on 10/2/18 and 10/3/18 due to staff not responding to his call light. Resident #1-405 said I get mad and frustrated. I could be in trouble and it takes 15-20 minutes to get help. I don't really feel safe but what can I do? During an interview on 10/01/18 at 12:30 p.m., Physician Assistant (PA) JJ reported he had not been notified Resident #1-405 had been vomiting until the second day of symptoms and multiple episodes of emesis. PA JJ said he would have expected to have been notified after the second episode of emesis due to Resident #1-405's history of bowel complications. As soon as he was notified he started IM [MEDICATION NAME] (an anti-emetic) and an abdominal x-ray. PA JJ reported that despite the x-ray ordered in the facility being negative for an obstruction, and because Resident #1-405 was having bowel movements, he suspected an ileus and ordered Resident #1-405 be sent to the emergency room for evaluation and treatment. During an interview on 10/3/18 at 4:18 p.m., LPN BB reported she was a travel nurse who had worked at the facility since (MONTH) 19, (YEAR). LPN BB said she had been somewhat familiar with Resident #1-405 and when she started her shift on 9/13/18 she had not been told in report that Resident #1-405 had been vomiting. LPN BB said that she learned from nurse aides that Resident #1-405 had been getting sick (vomiting) for days. LPN BB then said that she heard from RN LL that Resident #1-405 had been getting sick for days. LPN BB said she reported Resident #1-405's condition to PA JJ after she witnessed the second episode of emesis and acted on his orders, ultimately sending Resident #1-405 to the hospital for treatment. LPN BB said she reported her concern about not being told Resident #1-405 had been vomiting to Unit Manager (UM) Registered Nurse (RN) H. During a telephone interview on 10/04/18 at 9:23 a.m., LPN EE reported he had notified the physician of the changes in Resident #1-405's condition using the online dashboard (a messaging feature in the electronic medical record). LPN EE also said he reported Resident #1-405's change in condition to the oncoming nurse (LPN BB). During an interview on 10/04/18 at 10:30 a.m., Chief Clinical Officer (CCO) WW reported she reviewed the dashboard and secure communications documented by staff on behalf of Resident #1-405 and no record of a report of any kind related to his change in condition was found. During an interview on 10/5/18 at 9:30 a.m., Unit Manager/RN H reported she couldn't recall which nurse talked to her about Resident #1-405's emesis but said she had been made aware and did encourage staff to push room temperature fluids because it would be easier for him to digest given his history of nausea and vomiting. RN H admitted she never encouraged any nurse to notify the physician about Resident #1-405's condition. During an interview on 10/9/18 at 3:37 p.m., evening supervisor RN II reported she worked on 9/13/18, the evening Resident #1-405 was discharged to the emergency department. RN II said she thought it was odd the physician ordered an IV for fluids because she was not aware Resident #1-405 had been having emesis, until she heard from RN LL that Resident #1-405 had been getting sick for two days. When asked, RN II said she did call the DON after starting the IV but did not report an allegation of neglect because she did not recognize the situation as neglect, despite learning Resident #1-405 had suffered for two days with emesis without notification to the physician. Review of a hospital ED Prov Note (Emergency Department Provider Note), dated 9/13/18 at 9:51 p.m., reflected Patient presents today from his living facility at (Name of Facility) for 3 days of vomiting. Patient (Resident #1-405) states has also had associated fevers. He does endorse mild diffuse abdominal pain well as throat pain that he believes is from his vomiting. He denied associated diarrhea or blood in stool. He did have a bowel movement which he states was smaller than normal today. Patient on epic review (hospital system medical record) does have a history of [MEDICAL CONDITION]. Patient was [MEDICAL CONDITION] on arrival and did appear ill but not toxic. I did discuss with patient will place IV and give him [MEDICATION NAME] (an anti-nausea medication) and [MEDICATION NAME] for pain and nausea control. Also obtain blood work as well as CT abdomen pelvis. Further review of the document revealed Resident #1-405 stated The patient (Resident #1-405) states that he has been experiencing constant vomiting for 3 days. He states that he is unable to keep water or food down witho

Based on observation, interview and record review the facility failed to promote the healing of existing pressure ulcers and prevent the development and/or worsening of new pressure ulcers in 5 of 5 residents (Resident #1-401, Resident #1-419, Resident #27, Resident #25, and Resident #54) reviewed for pressure ulcers resulting in Immediate Jeopardy when Resident #1-401 developed a serious bone infection requiring hospitalization due to a lack of assessment and adequate treatment of [REDACTED].#1-419, Resident #27, Resident #25, and Resident #54 did not receive adequate and appropriate care related to the development and worsening of pressure ulcers. This deficient practice placed all residents who had a pressure ulcer or were at risk for developing a pressure ulcer at risk for serious harm, injury and/or death. Findings include: The facility provided the policy/procedure for Skin Care and Wound Management dated 8/11/2006 with a revised date of 7/2/18 for review. The policy reflected, The facility staff strives to prevent resident/patient skin impairment and to promote the healing of existing wounds .C. weekly monitoring of resident/patient skin status .E. Interdisciplinary review of identified skin impairments, F. Care plan for identified risk areas, G. Monitoring for consistent implementation of interventions and effectiveness of interventions .Analysis of facility pressure ulcer data for quality improvement opportunities . Resident #1-401 Resident #1-401 was admitted to the facility 9/6/18, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] reflected Resident #1-401 demonstrated total dependence on staff for transfers and required extensive assistance of 2 staff members for bed mobility and toileting, was always incontinent of stool and had an indwelling catheter. The MDS Brief Interview for Mental Status (BIMS) review reflected the Resident scored 3 out of a possible 15 which indicated the Resident was severely cognitively impaired. Review of the medical record for Resident #1-401 reflected the Resident was discharged from the hospital and admitted to the facility on [DATE]. Review of the hospital discharge Clinical Summary reflected the Resident was discharged with a Pressure injury to coccyx and that wound was unstageable. The entry reflected, wound treatment of [REDACTED]. Entire sacral Opti foam changed every Tuesday/Friday. Review of the Electronic Medical Record (EMR) for Resident #1-401 revealed a Doctor's Order (DO) dated 9/7/18, for Santyl Ointment .Apply to slough on coccyx topically one time a day for [MEDICATION NAME] Apply to slough on wound, nickel thick. Okay to peel back and replace and reuse same dressing daily. Dressing to be changed every Tuesday and Friday. The facility document reflected this treatment was ordered by Doctor (Dr.) SS. Review of the facility document titled Medication Review Report for Resident #1-401 reflected this same order on 9/7/18 and indicated that the communication method for the order was verbal (a direct verbal instruction from a physician). In a telephone interview on 10/16/18, at 1:50 PM. , Dr. SS, when the Santyl dressing order was read to him stated, who wrote that?. Dr. SS was informed the record reflected his name as the prescribing physician. Dr. SS reported he did not remember giving or approving this order. Dr SS indicated he would have expected a clarifying phone call from nursing for an order instructing the re-use of a wound dressing. Dr. SS indicated that before transcribing a hospital discharge order such as this nursing should have known to contact him. Dr. SS stated, if they are using my name I better know. Review of the EMR Treatment Administration Record for Resident #1-401 for (MONTH) (YEAR) reflected a new dressing was applied to the coccyx on 9/7/18 and not changed until 9/11/18. The record reflected on 9/8, 9/9, and 9/10/18, the dressing was peeled back, and Santyl Ointment was applied and the dressing from 9/7/18 was unchanged and reused. The Treatment Record did not reflect the wound had been cleansed. Review of the entries on 9/7, 9/10, and 9/11/18, reflected a code of 9, and 5. The key of the code revealed the codes indicated, See Nurses Note. Review of the Nurses Notes for 9/7 and 9/10 reflected only, dressing intact about wound care. The entry of 9/11/18, reflected, New orders received for wound. Dressing to be changed daily. The entries do not include any information regarding the condition of the wound or information about the specific task of wound care that had been completed. Review of the Manufacturer's instruction for the use of Santyl reflected, Prior to application (of Santyl) the wound should be cleansed of debris and digested material by gently rubbing with a gauze pad saturated with normal saline or with (a compatible cleansing agent) followed by a normal saline solution rinse. Review of the EMR Skin and Wound assessment dated [DATE], reflected wound measurements as follows: Area - 5.9 centimeters (cm)2 (squared), Length 4.9 cm, Width 3.5 cm, Depth - not recorded. The section titled, Notifications reflected no notifications were made regarding the wound assessment. Review of the EMR Skin and Wound assessment dated [DATE], reflected wound measurements as follows: Area - 9.0 cm2, Length 2.9 cm, Width 4.2 cm, Depth - not recorded. Page 5 of this Skin and Wound Assessment reflected the wound was, Deteriorating. On 10/1/18 at 4:11 PM it was observed that the door to Resident #1-401 room was closed. On entry into the room it was observed that the room was darkened. Resident #1-401 turned to left side in low bed crying, stating, I can't move, I can't move- my leg, ouch, ouch, it hurts, it hurts. Noted no call light in reach. There was a ringer-type bell on over the bed table past the fall mat on the floor out of reach of the Resident #1-401. Staff were alerted to the needs of the Resident. During the observation of care, it was noted staff discovered Resident #1-401 had been incontinent of stool. When Resident #1-401 was turned to be cleaned a large wound on the sacral area was observed to be exposed; the wound was not covered with a dressing. The wound remained exposed until 5:27 PM when wound care had been provided. In an interview on 10/11/18 at 4:03 PM Wound Nurse Consultant (NWC) TT indicated that on 10/1/18, the Physician's Assistant (PA) had evaluated the sacral wound of Resident #1-401 at approximately 10:30 -11:00 AM. NWC TT indicated a new order for treatment of [REDACTED]. In an interview on 10/15/18 at 11:15 am, Registered Nurse (RN) P reported he was aware the PA had evaluated the wound on Resident #1-401 on 10/1/18. RN P reported he been way behind and had left the wound on the sacral area of Resident #1-401 uncovered. RN P reported he had wanted the Wound Nurse or a Unit manager to be present when he followed the new order for wound care but indicated he was unable to coordinate this care with the other staff. RN P reported he did not complete the dressing change by the time he had left for the day at about 4:00 PM on 10/1/18. Review of the EMR Skin and Wound assessment dated [DATE], reflected the wound was, improving despite a documented increase in wound measurements. The Area of the wound on 9/13/18, was 9.0 cm2, compared to the Area documented on the 10/4/18, assessment of 44.9 cm2. This deterioration reflected an increase of 35.9 cm2 of wound area since 9/13/18. Review of the EMR Progress Notes for Resident #1-401 on 10/6/18, reflected a concern for the status of the wound and that the Resident was febrile (elevated body temperature). The medical record reflected the Resident was sent to the emergency room and was subsequently admitted for [MEDICAL CONDITION] (systemic infection). Review of the hospital records dated 10/6/18, for Resident #1-401 reflected the Reason for Visit to be, yesterday fever 103 (degrees Fahrenheit), wound on coccyx that had, increased by ½ (inch) in last 48 hours, and that the facility wants it noted (patient) has had a significant change in condition . Further review of the hospital records indicated a Computer Tomography Scan (CT) of the coccyx wound reflected, osteo[DIAGNOSES REDACTED] (bone infection). Review of education notes written by WNC TT reflected 10 points about care to the wound of Resident #1-401. The notes reflected (Resident #1-401) was admitted [DATE], with a Stage 3 sacral pressure injury. There are a few issues related to this wound that need to be addressed. 1. Treatment: Cleanse pressure sore with normal saline (NS) apply Santyl to slough, cover with gauze and apply border gauze, change daily every day shift. 6. Order: (order of 9/7/18 restated) Santyl Ointment .apply to slough .Okay to peel back and replace and reuse same dressing daily. Dressing to be changed every Tuesday and Friday WNC TT added in all capital letters, WE DO NOT PEEL BACK DRESSINGS, DO A TREATMENT AND REAPPLY THE OLD DRESSING. THESE ORDERS DO NOT INCLUDE CLEANING OR PERIWOUND PROTECTION INSTRUCTIONS. THE DRESSING MUST BE CHANGED EACH DAY WITH CLEANING AND APPLICATION OF NEW SANTYL. SANTYL ONLY WORKS FOR 24 HOURS SO, THIS REQUIRES A (EVERY) 24 HOUR DRESSING CHANGE. THE WOUND IS ON HER SACRUM, NOT C[NAME]CYX. 7 Treatment Administration Record (TAR): A 9 (code meaning see nurses notes) was recorded on the TAR on 9/7 and 9/11. There are X's on 9/8 ,9/9 (on the new dressing applied portion of the TAR -an X indicated this was not done), on 9/10 there is a 5 (code meaning see nurses note). There is not a single note about this. So, her wound has not been cleaned. No Santyl applied and dressing has not been changed since she was admitted on [DATE]. There is no documentation in the chart to show otherwise. In an interview conducted 10/11/18, at 4:03 PM, WNC TT reported, I cannot say the facility did not cause the osteo[DIAGNOSES REDACTED]. Whether things like no dressing change or no dressing (uncovered wound for approximately 6 hours), given her co-morbidities (other physical problems) .better care would have helped. Resident #1-419 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #1-419 was a [AGE] year-old female, who was admitted to the facility on [DATE] (with a readmission date of [DATE]), with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score indicated significant cognitive impairment. Resident #1-419 required extensive staff assistance with all activities of daily living and transfers. On 10/16/18 at approximately 9:00 AM, Resident #1-419 was observed in bed, crying. Resident #1-419 was unable to answer specific questions. The facility provided a copy of the education provided to all nursing staff (including Nurse J) on 10/10/18. The education included pressure ulcer policy/procedure and reflected Nurse J's signature. Nurse J was interviewed on 10/1/18 at approximately 9:45 AM and again on 10/17/18 at 12:30 PM. On 10/1/18, Nurse J stated that she is wound certified and does not believe the facility is accurately assessing pressure ulcers. Nurse J stated, They are calling things pressure ulcers that are not pressure ulcers. On 10/17/18, Nurse J reviewed the notes on 10/6, 10/7, 10/8, 10/9, 10/11, 10/12, and 10/13 (that Nurse J authored) that all reflected the same statement of, Area on the heel of concern. On 10/14/18, Nurse J documented that the right heel had a deep tissue injury (a pressure ulcer that is dark purple) that was non-blanchable and measured 2.5 cm x 3.5 cm and an area to the side of the foot that measured 0.5 cm x 1.0 cm. When asked what area on the heel of concern meant, Nurse J stated that heel was noted to be boggy and non-blanchable. Nurse J stated that she did not thoroughly and accurately chart the assessment finding of the heel from 10/6/18 - 10/13/18. Nurse J stated that she should have done an assessment, notified the physician and obtained an order on 10/6/18 when the area to the heel was first noted. Nurse J stated she called the physician on 10/14/18 and obtained treatment orders for the new pressure ulcers. The (MONTH) Treatment Administration Record (TAR) was reviewed with Nurse J and the treatment order that was initiated on 10/15/18 (not 10/14/18). Nurse J stated, I thought I entered the orders on 10/14/18. Record review of the Physician Assistant (PA) JJ note signed on 10/17/18 reflected that Resident #1-419 had developed a new pressure ulcer to the right heel and that the resident was noncompliant with keeping her leg elevated and hip abductor in place. No alternate intervention was noted. An interview and record review was completed with the Director of Nursing (DON) B and the Wound Nurse Consultant (WNC) TT on 10/17/18 at 4:00 PM. WNC TT stated that she reviewed the wound information on 10/15/18 and noted that there was not a treatment order obtained for the new pressure ulcers and she (not Nurse J) talked with PA JJ and obtained the orders and entered them into the computer on 10/15/18. WNC TT also reviewed the 10/17/18 note by PA JJ and stated that the Resident #1-419 could not and should not elevate her leg due to recent hip surgery. WNC TT stated that she had ordered a cushioned boot that could be placed on both feet to promote healing and prevent further skin breakdown. WNC TT stated that a special mattress was also ordered for Resident #1-419 as well. WNC TT stated that Nurse J did not follow the facility policy/procedure for pressure ulcers. WNC TT stated that Nurse J signed on 10/10/18 and received education as part of the IJ removal plan but identified that the staff will need to be reeducated due to this new facility acquired pressure ulcer. Resident #27 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #27 was an [AGE] year-old female, who was admitted to the facility on [DATE] (with a readmission date of [DATE]), with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), dated 8/10/18 reflected a score of 13 out of 15 which represented Resident #27 was cognitively intact. Resident #27 required staff assistance with all activities of daily living and transfers. An observation and interview of a dressing change was done with Nurse XX on 10/3/18 at approximately 2:40 PM. Resident #27 was seated in her room in a wheelchair. Resident #27 had a skin tear to the left lower extremity, a pressure ulcer to the left heel and a pressure ulcer to the right heel. Resident #27 could not recall exactly when each area was first noted. According to the right heel wound measurement dated 8/21/18 reflected that Resident #27 developed a facility acquired pressure ulcer to the right heel that was staged at a deep tissue injury and measured 2.2 cm x 2.3 cm that was dark purple/maroon in color. The PA was notified and ordered skin prep and to float the heel. According to the (MONTH) and (MONTH) TAR the skin prep was not started until 9/9/18 (2 ½ weeks later). The most recent wound assessment provided was dated 9/27/18 and measured 1.8 cm x 2.2 cm. An interview and record review was conducted with Clinical Care Coordinator (CCC) H on 10/11/18 at 10:45 AM. CCC H confirmed that the right heel pressure ulcer was first noted on 8/21/18 and the first noted treatment according to the (MONTH) and (MONTH) TAR was initiated approximately 2 ½ weeks later on 9/9/18. The CCC H reviewed the PA note dated 8/21/18, 8/23/18, 8/24/18, 8/27/18 and the doctor's noted dated 8/28/18 and neither had an assessment of the new right heel pressure ulcer nor a plan of care, nothing was noted related to the new pressure ulcer. According to the skin policy/procedure the facility will complete an analysis for all new wound developments. When asked if an analysis was done of the new pressure ulcer development, the CCC H stated, Not that I can see. When asked if the care plan was updated, the CCC H stated, No, I don't see any updates because there doesn't seem to be a root cause done for the new wound. Resident #25 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #25 was an [AGE] year-old female, who was admitted to the facility on [DATE] (a readmission date of [DATE]), with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), dated 7/18/18 reflected a score of 15 out of 15 which represents Resident #25 was cognitively intact. Resident #25 required staff assistance with all activities of daily living and transfers. According to the Face Sheet, Resident #25 had a guardian. During an observation of care on 10/10/18 at 2:30 PM, Resident #25 was noted to have a dressing to the sacrum and the right heel. A telephone interview was conducted on 10/11/18 at 5:07 PM with Resident #25's guardian. The guardian stated that she received a telephone call either 9/15/18 or 9/16/18. The guardian stated that Resident #25 had called crying because she was left to lay in her own excrement (urine and feces). She reported that Resident #25 had put her call light on and no one had come to help her. The guardian reported that on 9/17/18, a staff member called to report that Resident #25 had developed 2 new facility acquired pressure ulcers. The guardian stated that she told the staff member that she wasn't surprised because she received a call from Resident #25 over the weekend and she reported that she had been left wet and soiled. The skin assessments reflected the following abnormal areas: 9/11/18 right and left blanchable areas to bilateral buttock 9/14/18 blister to the left heel and excoriation/blister to left buttock (no measurements for the new wounds noted) 9/21/18 blister to the left heel, open area to sacrum 9/28/18 blister to the left heel, open area to sacrum 10/5/18 open area to the right and left buttock (no mention of the blister to the right heel) According to the wound measurement dated 9/17/18, Resident #25 developed a new fluid filled diabetic ulcer to the right (not left as noted on weekly skin assessments) heel that measured 2.6 cm x 3.1 cm. The new sacrum pressure ulcer assessment also dated 9/17/18 reflected a stage 3 (full thickness skin loss) that measured 4.3 cm x 3.3 cm, Resident and care givers educated to off load sacrococcygeal area as much as possible. An interview and record review was conducted with Clinical Care Coordinator (CCC) H on 10/11/18 at 10:45 AM. The CCC H stated that the staff made an error in the skin assessments dated 9/14, 9/21, and 9/28 when they charted the heel blister was left when it was on the right heel. The CCC H states she would have expected the staff who first noted the blister to the heel and open area to the sacrum on 9/14/18 to call the doctor or use the facility standing orders for treatment. To clarify the CCC H was asked if the staff were required to notify the physician of two new facility acquired pressure ulcers and the CCC H stated, It's not necessary to notify the doctor because we have standing orders for treatment protocol. The CCC H stated, I would have expected the staff to measure the wounds on 9/14/18 and tell me but they didn't tell me when they found them. When asked what the facility does when a resident develops a facility acquired pressure ulcer and the CCC H stated, The doctor or the PA would have to [DIAGNOSES REDACTED]. When asked if the facility can effectively care plan without the physician assessment and input, the CCC H stated, No. When asked if the facility acquired pressure ulcer was analyzed by the interdisciplinary team, the CCC H stated, I don't know. Resident #154 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #154 was a [AGE] year-old male, who was admitted to the facility on [DATE] (with a readmission date of [DATE]), with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), dated 8/24/18 reflected a score of 14 out of 15 which represents Resident #154 was cognitively intact. Resident #154 required staff assistance with all activities of daily living and transfers. A record review of the weekly skin assessments reflected on 9/3/18, 9/10/18, 9/17/18, 9/24/18, and 10/2/18 the nurses checked the boxes for area of discoloration and open areas but did not complete the description portion to indicate the findings. An interview and record review was conducted with Clinical Care Coordinator (CCC) H on 10/11/18 at 10:45 AM. CCC H stated that Resident #25 had 3 facility acquired pressure ulcers prior to the facility plan of correction date of 8/8/18 for the annual recertification survey that included an unstageable to the right lower calf, a deep tissue injury to the right heel, and a stage 2 to the left heel. CCC H reviewed the weekly skin assessments from 9/3/18 - 10/2/18. CCC H agreed that the skin sweeps were not complete and accurate and stated, I will complete one today and we will need to re-educate the nurses on completing a proper skin sweep. When asked if she was involved with the dressing change monitoring for the plan of correction QA process, CCC H stated that the DON did most all of them and she had watched a couple of nurses. This surveyor advised CCC H of the dressing change that was observed for Resident #154. The nurse laid on the floor to treat the heel wounds, Resident #154 moved the clean dressing trays around while the nurse was washing her hands, and other infection control issues that could potentially impair the healing of the pressure ulcers. CCC H stated that education would also include proper dressing changes. Immediate Jeopardy (IJ) was verbally explained to the Nursing Home Administrator A and Chief Operations Officer (COO) X on 10/4/18 and a written notice of IJ was provided on 10/9/18 as a result of the facility's failure to provide adequate and appropriate care related to the development and worsening of pressure ulcers. On 10/15/18, the State Agency was able to verify the facility implemented the following to remove the immediacy: 1. The Skin Prevention Policy and Wound care program was reviewed by the QA policy and deemed appropriate. 2. Certified Wound Nurse, Registered Nurse (RN) Wound Nurse Consultant (WNC) TT' will be assigned to (Facility) Monday thru Friday effective 10/10/18 to oversee the skin prevention program and wound program until the facility is confident that the staff are following the systems consistently. 3. Director of Nursing (DON) and designees will conduct training with charge nurses starting 10/10/18 on wounds and the correct process from identification to treatment. 4. DON has begun grand rounds with the IDT (interdisciplinary team) on 10/9/18 to address wounds, falls, change in condition, physician notification and appropriate documentation. 5. Education for certified nurse's aides has begun on Wednesday 10/10/18 by DON/Designee on Identification of skin issues, reporting them to the nurse, turn and reposition, Plan of care for prevention. 6. Each resident in house was assessed for change in condition using the Interact change of condition tool (SBAR) 10/11/18. Anyone identified with a change in condition will be assessed by the physician or the extender with a note made. Nursing will continue to document on these identified resident for 72 hours. 7. The Policy on change in condition and assessment was reviewed and deemed appropriate by the QA committee. 8. The charge nurses are being educated by the DON /Designee 10/10/18 and ongoing till 100% of staff are informed on the change of condition policy, assessment, use of SBAR interact change of condition UDA before contacting the physician, documentation of contacts, care planning, orders and such. Although the Immediate Jeopardy (IJ) was removed on 10/11/18, the facility remained out of compliance at a scope of pattern and a severity of actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all nurses had not been in-serviced and sustained compliance has not been verified by the state agency.

This citation pertains to intake MI 116 Based on observation, interview and record review the facility failed to notify the physician/designee and resident's responsible party in a timely manner of significant changes in condition for 2 residents (Resident #25 and #1-405) out of 31 residents reviewed, resulting in a delay in the treatment of [REDACTED].#25 and hospitalization for treatment of [REDACTED].#1-405 who suffered with unreported vomiting and fevers for 2 days. Findings: Review of a facility policy Change in Condition, last revised 6/2017, reflected It is the policy of this facility to inform residents/legal representative, attending physician or designee of a change in the resident's condition. An acute significant change means deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications. The policy directed staff to call 911 in an emergency. In a non-emergency situation, licensed staff were expected to: Notify the resident's physician and the resident/legal representative or emergency contact of: a significant change in the resident's physical, mental or psychosocial status, a need to alter treatment or of the decision to transfer or discharge the resident from the facility. In addition to these primary responsibilities, Licensed staff were expected to: Assess any noted changes, including any changes reported by caregivers and family members and a) Review during change of shift, b) Create a progress note so that the 24-Hour Report contains assessment data. Licensed staff were also expected to: 4. Obtain a complete set of vital signs at the onset of the change and/or more often as appropriate or as ordered by the physician. 5. Licensed nurse will utilize the eInteract Change in Condition UDA (user defined assessment) 6. When notifying the physician have present: a) EHR (Electronic Health Record) available b) Completed eInteract UDA .e) If unable to contact the physician after 1/2 to 2 hours, depending on significance of the change, contact the Medical Director, as appropriate. 7. Enter new orders as needed 8. Social Services to assist with resident and/or family if needed. 9. Follow up by licensed staff of change in condition should continue following the onset of change: a) An entry in the nurses' notes regarding the assessment data, observations b) Use eInteract Change in Condition UDA as a guideline for ongoing assessment . Review of a Change in Condition and Physician Notification document attached to the Change in Condition policy included several instances when notification would be expected, including but not limited to: a temperature 2.4 degrees above or below the Resident's baseline temperature, new onset pain greater than 4 on a 10 point scale, change of usual pulse rhythm or regularity, vomiting and diarrhea beyond 24 hours . Resident #1-405: Review of a facility Admission Record reflected Resident #1-405 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 9/8/18, reflected Resident #1-405 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15. Review of a Care Plan, last revised on 7/29/18, reflected Resident #1-405 was At risk for constipation related to decreased mobility, medication side effects and at times I decline to use the bowel protocol. I am frequently incontinent of bladder during the assessment period which puts me at increased risk for skin breakdown and UTI's (urinary tract infections). I have required extensive staff assistance with toileting/incontinence care related to spastic [MEDICAL CONDITION], pain issues, and possible medication side effects. I am non-weight bearing on bilateral lower extremities necessitating the need for Hoyer lift for transfers. I have been taking more initiative to use my urinal towards the end of the assessment period. One of the goals of the care plan was to have normal bowel movements at least every 3 days with an intervention that included: Observe/document/report to MD (medical doctor) as needed signs and symptoms of complications related to constipation: change in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation, slow heart rate, abdominal distention, vomiting, small or loose stools, fecal smearing, bowel sounds, diaphoresis, abdominal tenderness, guarding, rigidity, fecal compaction. The care plan also called for recording and reporting to the MD for signs and symptoms of UTI: pain, burning, no output, increased pulse, increased temperature, urinary frequency, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of a Progress Note, dated 9/11/18 11:47 p.m., reflected Resident #1-405 vomited after eating. Review of a Progress Note, dated 9/12/18 at 3:50 a.m., documented by Licensed Practical Nurse (LPN) EE reflected Resident #1-405 vomited once and according to the progress note, Resident #1-405 thought it was something he ate. Review of a Progress Note, dated 9/13/18 at 2:57 a.m., documented by LPN EE reflected Resident #1-405 had two episodes of nausea this shift, shortly after back to resting. No sign of pain noted at this time. Dressings intact to bilateral feet, no dypsnea noted. Review of a Food Acceptance Record for Resident #1-405 reflected that staff documented Resident #1-405 refused to eat any meals on 9/12/18 and 9/13/18. Review of a Weights and Vitals Summary report indicated Resident #1-405 had a fever on 9/12/18 and 9/13/18. Review of a Progress Note, dated 9/13/18 at 9:20 a.m., documented by LPN BB reflected (Resident #1-405) having emesis multiple times. Also with temperature. Resident refused medications. PA (Physician Assistant) called and gave orders for stat (right away) labs. Writer contacted lab with orders. Review of a Progress Note, dated 9/13/18 at 2:52 p.m. documented by LPN BB at 2:52 p.m. reflected New order for IM (injection of medicine into the muscle) [MEDICATION NAME] and ABD (abdominal) x-ray. IM shot given, resident tolerated well. Stat x-ray ordered .Resident having multiple times of emesis. Review of a Progress Note, dated 9/13/18 at 7:00 p.m., documented by Registered Nurse (RN) II reflected IV started in left arm with a 24 Gauge needle. Resident tolerated procedure well. According to an SBAR Communication Form, dated 9/13/18 at 7:00 p.m., Resident #1-405 was having worsening nausea and vomiting since 9/11/18 with worsening of symptoms after eating and drinking. Review of Progress Notes, dated 9/13/18, reflected Resident #1-405 had an emergent discharge to the hospital on [DATE] at 21:30 (9:30 p.m.) due to nausea and vomiting. Review of a Progress Note, dated 9/14/18 at 2:47 a.m., documented by RN LL reflected RN contacted (emergency room Nurse) at (Hospital Name) at 2:45 a.m., and was informed (Resident #1-405) was admitted due to results of CT scan showed possible ileus or sigmoiditis and mild dilation of the duodenum. (Resident #1-405) is being admitted to med/surg. (Name of hospital nurse) inquired about dressings to bilateral feet and RN explained how to change dressing and that it was done today just prior to him leaving and did not require changing for three days. During an interview on 10/3/18 at 5:08 p.m., Resident #1-405 reported that he had been getting sick for 2-3 days prior to being transferred to the hospital. Resident #1-405 did not report refusing to be sent to the hospital, but did report he didn't feel safe at the facility due to having to wait so long for staff to respond to his call light. Resident #1-405 said he had to sit in his feces for over an hour on 10/2/18 and 10/3/18 due to staff not responding to his call light. Resident #1-405 said I get mad and frustrated. I could be in trouble and it takes 15-20 minutes to get help. I don't really feel safe, but what can I do? During an interview on 10/01/18 at 12:30 p.m., Physician Assistant (PA) JJ reported he had not been notified that Resident #1-405 had been vomiting until the second day of symptoms and multiple episodes of emesis. PA JJ said he would have expected to have been notified after the second episode of emesis due to Resident #1-405's history of bowel complications. As soon as he was notified he started IM [MEDICATION NAME] (an anti-emetic) and an abdominal x-ray. PA JJ reported that despite the x-ray ordered in the facility being negative for an obstruction, and because Resident #1-405 was having bowel movements, he suspected an ileus and recommended he be sent to the emergency room for evaluation and treatment. During an interview on 10/3/18 at 4:18 p.m., LPN BB reported she was a travel nurse who had worked at the facility since (MONTH) 19, (YEAR). LPN BB said she had been somewhat familiar with Resident #1-405 and when she started her shift on 9/13/18 she had not been told in report that Resident #1-405 had been vomiting. LPN BB said that she learned from nurse aides that Resident #1-405 had been getting sick (vomiting) for days. LPN BB then said that she heard from RN LL that Resident #1-405 had been getting sick for days. LPN BB said she reported Resident #1-405's condition to PA JJ after she witnessed the second episode of emesis and acted on his orders, ultimately sending Resident #1-405 to the hospital for treatment. LPN BB said she reported her concern about not being told Resident #1-405 had been vomiting to Unit Manager (UM) Registered Nurse (RN) H. During a telephone interview on 10/04/18 at 9:23 a.m., LPN EE reported he had notified the physician of the changes in Resident #1-405's condition using the online dashboard (a messaging feature in the electronic medical record). LPN EE also said he reported Resident #1-405's change in condition to the oncoming nurse (LPN BB). During an interview on 10/04/18 at 10:30 a.m., Chief Clinical Officer (CCO) WW reported she reviewed the dashboard and secure communications documented by staff on behalf of Resident #1-405 and no record of a report of any kind related to his change in condition was found. During an interview on 10/5/18 at 9:30 a.m., Unit Manager/RN H reported she couldn't recall which nurse talked to her about Resident #1-405's emesis, but said she had been made aware and did encourage staff to push room temperature fluids because it would be easier for him to digest given his history of nausea and vomiting. RN H admitted she never encouraged any nurse to notify the physician about Resident #1-405's condition. During an interview on 10/9/18 at 3:37 p.m., evening supervisor RN II reported she worked on 9/13/18, the evening Resident #1-405 was discharged to the emergency department. RN II said she thought it was odd the physician ordered an IV for fluids because she was not aware Resident #1-405 had been having emesis, until she heard from RN LL that Resident #1-405 had been getting sick for two days. When asked, RN II said she did call the DON after starting the IV but did not report an allegation of neglect because she did not recognize the situation as neglect, despite learning Resident #1-405 had suffered for two days with emesis without notification to the physician. Review of a hospital ED Prov Note (Emergency Department Provider Note) dated 9/13/18 at 9:51 p.m. reflected Patient presents today from his living facility at (Name of Facility) for 3 days of vomiting. Patient (Resident #1-405) states has has also had associated fevers. He does endorse mild diffuse abdominal pain well as throat pain that he believes is from his vomiting. He denied associated diarrhea or blood in stool. He did have a bowel movement which he states was smaller than normal today. Patient on epic review (hospital system medical record) does have a history of [MEDICAL CONDITION]. Patient was [MEDICAL CONDITION] on arrival and did appear ill but not toxic. I did discuss with patient will place IV and give him [MEDICATION NAME] (an anti-nausea medication) and [MEDICATION NAME] for pain and nausea control. Also obtain blood work as well as CT abdomen pelvis. Further review of the document revealed Resident #1-405 stated The patient (Resident #1-405) states that he has been experiencing constant vomiting for 3 days. He states that he is unable to keep water or food down without vomiting. The patient states that he is experiencing general abdominal pain throughout his abdomen. He also notes on-and-off fevers, chills and headaches for 3 days. The patient states that he a sore throat from vomiting so many times. He reports the staff at (Name of Facility) gave him [MEDICATION NAME], which he immediately vomited up. Review of a hospital History and Physical, dated 9/13/18, reflected (Resident #1-405) with [MEDICAL CONDITION] (CP) and vascular ulcers presents today with vomiting. He has been vomiting for a few days and taking his [MEDICATION NAME] and [MEDICATION NAME] with no relief. He has been living at (Name of Facility) for a few moths while treating chronic vascular ulcers on his feet. He has not been ambulatory for 4 years. He denies chest pain, dysuria, shortness of breath, or diarrhea. He has headaches while vomiting. On arrival, he has urinalysis consistent with UTI (urinary tract infection) and possible SBO (small bowel obstruction). On exam he is anxious and nauseated. Plans are discussed for admission and he is agreeable. He wishes to be listed as full code. Review of a Physician Assessment, dated 9/18/18, Resident #1-405 was readmitted to the facility from the hospital after complaints of abdominal pain. According to the progress note, Resident #1-405 had a CT scan at the hospital that showed Resident #1-405 had an ileus (paralysis or obstruction of the bowel) and possible SBO (small bowel obstruction). Resident #25: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #25 was an [AGE] year-old female, who was admitted to the facility on [DATE] (with a readmission date of [DATE]), with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), dated 7/18/18 reflected a score of 15 out of 15 which represents Resident #25 was cognitively intact. Resident #25 required staff assistance with all activities of daily living and transfers. According to the Face Sheet, Resident #25 has a guardian. During an observation of care on 10/10/18 at 2:30 PM, Resident #25 was noted to have a dressing to the sacrum and the right heel. A telephone interview was conducted on 10/11/18 at 5:07 PM with Resident #25's guardian. The guardian stated that she received a telephone call either 9/15/18 or 9/16/18. The guardian stated that Resident #25 had called crying because she was left to lay in her own exudate (urine and feces). She reported that Resident #25 had put her call light on and no one had come to help her. The guardian reported that on 9/17/18, a staff member called to report that Resident #25 had developed 2 new facility-acquired pressure ulcers. The guardian stated that she told the staff member that she wasn't surprised, because she received a call from Resident #25 over the weekend and she reported that she had been left wet and soiled. The skin assessment, dated 9/14/18, reflected two new abnormal findings. The resident was noted to have a blister to the heel and excoriation/blister to left buttock (no measurements for the new wounds). The nursing notes did not contain a physician or guardian notification and the (MONTH) TAR did not reflect a treatment order for the new wounds until 9/17/18 (3 days after the wounds were first noted). According to the wound measurement, dated 9/17/18, Resident #25 developed a new fluid filled diabetic ulcer to the right heel that measured 2.6 cm x 3.1 cm. The new sacrum pressure ulcer assessment, also dated 9/17/18, reflected a stage 3 (full thickness skin loss) that measured 4.3 cm x 3.3 cm. The assessment reflected that the physician and guardian were both notified, and treatment orders were obtained from the physician and approved by guardian. An interview and record review was conducted with CCC H on 10/11/18 at 10:45 AM. The CCC H states she would have expected the staff who first noted the blister to the heel and open area to the sacrum on 9/14/18 to call the doctor or use the facility standing orders for treatment. To clarify the CCC H was asked if the staff were required to notify the physician of two new facility-acquired pressure ulcers, the CCC H stated, It's not necessary to notify the doctor because we have standing orders for treatment protocol. The CCC H stated, I would have expected the staff to measure the wounds on 9/14/18 and tell me but they didn't tell me when they found them. When asked what the facility does when a resident develops a facility-acquired pressure ulcer, the CCC H stated, The doctor or the PA would have to [DIAGNOSES REDACTED]. When asked if the facility can effectively care plan if the doctor hasn't assessed the wound and the CCC H stated, No. When asked when the guardian was told of the new pressure ulcers and consented to the treatment orders, CCC H stated, It looks like 9/17/18 (3 days after the pressure ulcer was first noted). When asked why the staff did not notify the guardian on 9/14/18, CCC H stated, I don't know.

This citation pertains to intake MI 116 Based on observation, interview and record review the facility failed to provide quality care in a timely and professional manner for 4 residents (Resident #27, #1-405, #1-418 and #1-419), of 31 residents reviewed for quality of care when 1 resident stopped eating, experienced fever, nausea and vomiting that went unreported to a physician for 2 days, resulting in hospitalization and when surgical and non-pressure wounds were unmonitored and not treated according to physician's orders [REDACTED]. Findings include: Resident #1-405: Review of a facility Admission Record reflected Resident #1-405 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 9/8/18, reflected Resident #1-405 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15. Review of a Care Plan, last revised on 7/29/18, reflected Resident #1-405 was At risk for constipation related to decreased mobility, medication side effects and at times I decline to use the bowel protocol. I am frequently incontinent of bladder during the assessment period which puts me at increased risk for skin breakdown and UTI's (urinary tract infections). I have required extensive staff assistance with toileting/incontinence care related to spastic [MEDICAL CONDITION], pain issues, and possible medication side effects. I am non-weight bearing on bilateral lower extremities necessitating the need for Hoyer lift for transfers. I have been taking more initiative to use my urinal towards the end of the assessment period. One of the goals of the care plan was to have normal bowel movements at least every 3 days with an intervention that included: Observe/document/report to MD (medical doctor) as needed signs and symptoms of complications related to constipation: change in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation, slow heart rate, abdominal distention, vomiting, small or loose stools, fecal smearing, bowel sounds, diaphoresis, abdominal tenderness, guarding, rigidity, fecal compaction. The care plan also called for recording and reporting to the MD for signs and symptoms of UTI: pain, burning, no output, increased pulse, increased temperature, urinary frequency, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of a Progress Note, dated 9/11/18 11:47 p.m., reflected Resident #1-405 vomited after eating. Review of a Progress Note, dated 9/12/18 at 3:50 a.m., documented by Licensed Practical Nurse (LPN) EE reflected Resident #1-405 vomited once and according to the progress note, Resident #1-405 thought it was something he ate. Review of a Progress Note, dated 9/13/18 at 2:57 a.m., Documented by LPN EE reflected Resident #1-405 had two episodes of nausea this shift, shortly after back to resting. No sign of pain noted at this time. Dressings intact to bilateral feet, no dyspnea noted. Review of a Food Acceptance Record for Resident #1-405 reflected that staff documented Resident #1-405 refused to eat any meals on 9/12/18 and 9/13/18. Review of a Weights and Vitals Summary report indicated Resident #1-405 had a fever on 9/12/18 and 9/13/18. Review of a Progress Note, dated 9/13/18 at 9:20 a.m., documented by LPN BB reflected (Resident #1-405) having emesis multiple times. Also, with temperature. Resident refused medications. PA (Physician Assistant) called and gave orders for stat (right away) labs. Writer contacted lab with orders. Review of a Progress Note, dated 9/13/18 at 2:52 p.m., documented by LPN BB at 2:52 p.m. reflected New order for IM (injection of medicine into the muscle) [MEDICATION NAME] and ABD (abdominal) x-ray. IM shot given, resident tolerated well. Stat x-ray ordered .Resident having multiple times of emesis. Review of a Progress Note, dated 9/13/18 at 7:00 p.m., documented by Registered Nurse (RN) II reflected IV started in left arm with a 24 Gauge needle. Resident tolerated procedure well. According to an SBAR Communication Form, dated 9/13/18 at 7:00 p.m., Resident #1-405 was having worsening nausea and vomiting since 9/11/18 with worsening of symptoms after eating and drinking. Review of Progress Note, dated 9/13/18, reflected Resident #1-405 had an emergent discharge to the hospital on [DATE] at 21:30 (9:30 p.m.) due to nausea and vomiting. Review of a Progress Note, dated 9/14/18 at 2:47 a.m., documented by RN LL reflected RN contacted (emergency room Nurse) at (Hospital Name) at 2:45 a.m., and was informed (Resident #1-405) was admitted due to results of CT scan showed possible ileus or sigmoiditis and mild dilation of the duodenum. (Resident #1-405) is being admitted to med/surg. (Name of hospital nurse) inquired about dressings to bilateral feet and RN explained how to change dressing and that it was done today just prior to him leaving and did not require changing for three days. During an interview on 10/3/18 at 5:08 p.m., Resident #1-405 reported that he had been getting sick for 2-3 days prior to being transferred to the hospital. Resident #1-405 did not report refusing to be sent to the hospital but did report he didn't feel safe at the facility, due to having to wait so long for staff to respond to his call light. Resident #1-405 said he had to sit in his feces for over an hour on 10/2/18 and 10/3/18 due to staff not responding to his call light. Resident #1-405 said I get mad and frustrated. I could be in trouble and it takes 15-20 minutes to get help. I don't really feel safe but what can I do? During an interview on 10/01/18 at 12:30 p.m., Physician Assistant (PA) JJ reported he had not been notified Resident #1-405 had been vomiting until the second day of symptoms and multiple episodes of emesis. PA JJ said he would have expected to have been notified after the second episode of emesis due to Resident #1-405's history of bowel complications. As soon as he was notified he started IM [MEDICATION NAME] (an anti-emetic) and an abdominal x-ray. PA JJ reported that despite the x-ray ordered in the facility being negative for an obstruction, and because Resident #1-405 was having bowel movements, he suspected an ileus and ordered Resident #1-405 be sent to the emergency room for evaluation and treatment. During an interview on 10/3/18 at 4:18 p.m., LPN BB reported she was a travel nurse who had worked at the facility since (MONTH) 19, (YEAR). LPN BB said she had been somewhat familiar with Resident #1-405 and when she started her shift on 9/13/18 she had not been told in report that Resident #1-405 had been vomiting. LPN BB said that she learned from nurse aides that Resident #1-405 had been getting sick (vomiting) for days. LPN BB then said that she heard from RN LL that Resident #1-405 had been getting sick for days. LPN BB said she reported Resident #1-405's condition to PA JJ after she witnessed the second episode of emesis and acted on his orders, ultimately sending Resident #1-405 to the hospital for treatment. LPN BB said she reported her concern about not being told Resident #1-405 had been vomiting to Unit Manager (UM) Registered Nurse (RN) H. During a telephone interview on 10/04/18 at 9:23 a.m., LPN EE reported he had notified the physician of the changes in Resident #1-405's condition using the online dashboard (a messaging feature in the electronic medical record). LPN EE also said he reported Resident #1-405's change in condition to the oncoming nurse (LPN BB). During an interview on 10/04/18 at 10:30 a.m., Chief Clinical Officer (CCO) WW reported she reviewed the dashboard and secure communications documented by staff on behalf of Resident #1-405 and no record of a report of any kind related to his change in condition was found. During an interview on 10/5/18 at 9:30 a.m., Unit Manager/RN H reported she couldn't recall which nurse talked to her about Resident #1-405's emesis but said she had been made aware and did encourage staff to push room temperature fluids because it would be easier for him to digest given his history of nausea and vomiting. RN H admitted she never encouraged any nurse to notify the physician about Resident #1-405's condition. During an interview on 10/9/18 at 3:37 p.m., evening supervisor RN II reported she worked on 9/13/18, the evening Resident #1-405 was discharged to the emergency department. RN II said she thought it was odd the physician ordered an IV for fluids because she was not aware Resident #1-405 had been having emesis, until she heard from RN LL that Resident #1-405 had been getting sick for two days. When asked, RN II said she did call the DON after starting the IV but did not report an allegation of neglect because she did not recognize the situation as neglect, despite learning Resident #1-405 had suffered for two days with emesis without notification to the physician. Review of a hospital ED Prov Note (Emergency Department Provider Note), dated 9/13/18 at 9:51 p.m., reflected Patient presents today from his living facility at (Name of Facility) for 3 days of vomiting. Patient (Resident #1-405) states has also had associated fevers. He does endorse mild diffuse abdominal pain well as throat pain that he believes is from his vomiting. He denied associated diarrhea or blood in stool. He did have a bowel movement which he states was smaller than normal today. Patient on epic review (hospital system medical record) does have a history of [MEDICAL CONDITION]. Patient was [MEDICAL CONDITION] on arrival and did appear ill but not toxic. I did discuss with patient will place IV and give him [MEDICATION NAME] (an anti-nausea medication) and [MEDICATION NAME] for pain and nausea control. Also obtain blood work as well as CT abdomen pelvis. Further review of the document revealed Resident #1-405 stated The patient (Resident #1-405) states that he has been experiencing constant vomiting for 3 days. He states that he is unable to keep water or food down without vomiting. The patient states that he is experiencing general abdominal pain throughout his abdomen. He also notes on-and-off fevers, chills and headaches for 3 days. The patient states that he a sore throat from vomiting so many times. He reports the staff at (Name of Facility) gave him [MEDICATION NAME], which he immediately vomited up. Review of a hospital History and Physical, dated 9/13/18, reflected (Resident #1-405) with [MEDICAL CONDITION] (CP) and vascular ulcers presents today with vomiting. He has been vomiting for a few days and taking his [MEDICATION NAME] and [MEDICATION NAME] with no relief. He has been living at (Name of Facility) for a few months while treating chronic vascular ulcers on his feet. He has not been ambulatory for 4 years. He denies chest pain, dysuria, shortness of breath, or diarrhea. He has headaches while vomiting. On arrival, he has urinalysis consistent with UTI (urinary tract infection) and possible SBO (small bowel obstruction). On exam he is anxious and nauseated. Plans are discussed for admission and he is agreeable. He wishes to be listed as full code. Review of a Physician Assessment, dated 9/18/18, Resident #1-405 was readmitted to the facility from the hospital after complaints of abdominal pain. According to the progress note, Resident #1-405 had a CT scan at the hospital that showed Resident #1-405 had an ileus (paralysis or obstruction of the bowel) and possible SBO (small bowel obstruction). Resident #27: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #27 was an [AGE] year-old female, who was admitted to the facility on [DATE] (with a readmission date of [DATE]), with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), dated 8/10/18, reflected a score of 13 out of 15 which represents that Resident #27 was cognitively intact. Resident #27 required staff assistance with all activities of daily living and transfers. Review of a Care Plan, last revised on 8/27/18, reflected Resident #27 was Frequently incontinent of bladder and bowel. My use of diuretics and other medications can also impact my continence status and I require extensive assistance with toileting needs and my need for a Hoyer lift for transfers impairs my ability to be toileted in my bathroom. My decreased physical ability and possible medication side effects put me at increased risk for constipation. I also have a history of [MEDICAL CONDITION] with a partial colectomy and [DIAGNOSES REDACTED]. Goals of the care plan indicated that Resident #27's risk for [MEDICAL CONDITION] will be minimized through/prevented through prompt recognition and treatment of [REDACTED]. Interventions included Assist to bed pan upon my request and especially prior to going to meals, activities and before going to bed at night, and Check me with rounds and as required for incontinence. Wash, rinse and dry perineum, apply barrier cream after each incontinence episode and as needed. Review of a Care Plan, last revised on 8/7/18, reflected Resident #27 had an ADL (Activities for Daily Living) Self-care Performance deficit related to NSTEMI (a mild [MEDICAL CONDITION]), fatigue, recurrent UTI's, Cardiac issues, anxiety, shortness of breath with exertion, obesity, diabetes with diabetic [MEDICAL CONDITION], depression, [MEDICAL CONDITIONS], frequent bladder incontinence, pain, impaired mobility with need for Hoyer transfer (mechanical lift), and possible medication effects. The goal of the care plan was for Resident #27 to Maintain my current level of function in bed mobility, eating, dressing and personal hygiene as my cognitive and physical status will allow. Interventions included Offer me the bed pan as I can make my needs known as needed. During an interview on 10/2/18 at 1:42 p.m., Resident #27 reported staff kept turning off her call light when she needed assistance to the bedpan earlier that day, between 10:00 a.m. and two minutes before lunch at noon. Resident #27 reported she had had an accident and everything got wet which made her feel embarrassed. During an interview on 10/01/18, Resident #32, (Resident #27's husband) expressed frustration regarding his wife's care. Resident #32 reported that staff call in when they aren't sick and the staff that are working don't get his wife out of bed on time because they are too short handed. Resident #1-419: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #1-419 was a [AGE] year-old female, who was admitted to the facility on [DATE] (a readmission date of [DATE]), with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score indicative of significant cognitive impairment. Resident #1-419 required extensive staff assistance with all activities of daily living and transfers. On 10/16/18 at approximately 9:00 AM, Resident #1-419 was observed in bed, crying. Resident #1-419 was unable to answer specific questions. An interview and record review was completed with the Director of Nursing (DON) B and the Wound Nurse Consultant (WNC) TT on 10/17/18 at 4:00 PM. According to the records, Resident #1-419 was hospitalized from [DATE] - 8/30/18 for hardware removal of the right hip and readmitted to the facility on [DATE]. A dressing ordered was not noted on the readmission orders [REDACTED]. When asked what the expectation of the management of the surgical wound was at the facility, the WNC TT stated, Upon readmission the nurse is expected to obtain the initial orders. The nursing notes and TAR for (MONTH) were reviewed and there was no evidence of a treatment order for the surgical site to the right hip from 8/30/18 - 9/6/18 (6 days following her admission). The WNC TT stated that it is the facility expectation that the wound be measured weekly. Record review of the weekly wound measurements reflected that after the initial assessment on 8/30/18, the wound was not measured until 9/17/18 (18 days later), and then it was not assessed/measured again until 10/2/18 (15 days later). WNC TT stated again that the wound should have been measured weekly and agreed that the staff did not do it. Resident #1-418: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #1-418 was a [AGE] year-old female, who was admitted to the facility on [DATE] (with a readmission date of [DATE]), with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score that Resident #1-418 was cognitively intact. Resident #1-418 required extensive staff assistance with all activities of daily living and transfers. Record review of a grievance form, dated 8/28/18, reflected the resident complained that staff removed her leg dressings around noon, left them undressed and when staff were alerted redressed the legs after 4:00 PM. Resident reports concern with the dressings being removed while eating their lunch and leaving them off for hours which was painful. The conclusion area was blank and there were no signatures resolving the complaint. During an observation and interview on 10/16/18 at 8:15 AM, Resident #1-418 was resting on her bed with dressings noted to bilateral lower legs. Resident #1-418 stated that CCC H and another nurse wanted to remove her leg dressings when she was eating her lunch (on 9/27/18). Resident #1-418 stated she allowed them to do it, they photographed them as they do every week but didn't clean and redress the wounds to her legs. Resident #1-418 stated it was hours before another nurse came to do it. An interview and record review were conducted with CCC H on 10/11/18 at 10:45 AM. CCC H was asked about the dressing removal on 9/27/18 with Resident #1-418. CCC H stated that she and another nurse went to Resident #1-418's room, she was just about done eating her lunch, asked to remove her dressings to her legs, photographed them and told the resident that the floor nurse would redress the wounds. When asked why she (CCC H) didn't clean and redress the wounds right away, CCC H stated that she was too busy, and she had asked the floor nurse to do it. CCC H stated, I didn't know that it wasn't done right away until the next day .I found out the next day they weren't redressed until about 4:00 PM. The surveyor clarified that the dressings were removed around noon, and the wounds were left open (potential for infection) until approximately 4:00 PM, CCC H stated, Yes. When asked if an approximately 4-hour delay in a necessary treatment a potential for neglect could be, CCC H stated, Yes, I guess I didn't realize it then. When asked if the facility investigated the incident, CCC H stated, No. When asked why not, CCC H stated, I'm not sure.

Based on observation, interview and record review, the facility failed to ensure adequate staffing to provide care to residents in 3 of 3 residents (Resident #2, #154, and #310) reviewed for appropriate staffing, resulting in short staffing and delay of care for residents. Findings include: A telephone interview was conducted on 8/22/18 at approximately 10:00 AM with Nurse N. Nurse N stated that there were not enough staff to provide care as the residents were care planned. Nurse N stated that they were told there would be a float nurse assigned daily to cover the two units (North West and North East) and has not seen that done. Staff Member N stated, I start passing medications at 6:30 AM and I am still passing them after 9:30-10:00 AM. By then some are overdue. Nurse N stated that staff are routinely mandated over their shift. Nurse N stated that co-workers get upset about it, They have families at home to care for. Some employees volunteer so they can't get mandated but that doesn't always work out and they get it (mandated) anyway. When asked about the potential for staff burn out, Nurse N stated, I'm very concerned about the staff getting burned out. They are obviously working tired. There seems to be a lack of appreciation for all the extra hours worked by the staff too. When asked if the facility was aware and what they were doing about the situation Nurse N stated, Yes, they are aware. They keep saying they have a plan. Staff are afraid to complain to the management anymore. On 8/22/18 at 10:20 AM, an interview was conducted with Nurse F. Nurse F stated that she is unable to complete the medication pass within the timeframe and some were overdue. Nurse F stated that she routinely needs to stop, to assist the nurse aides with resident care. Nurse F stated, I can't keep up and the aides can't either. They just aren't receiving the quality care that they deserve. They (facility) keeps piling on more responsibilities and there just isn't enough staff scheduled to do everything. When we get here in the morning it smells like urine because the shift before couldn't keep up with checking and changing residents. I believe the fall rates are up because there just isn't enough staff to meet the residents needs timely. When asked if the facility was aware that there wasn't enough staff scheduled to meet the resident needs, Nurse F stated, Yes, they post the schedule with holes in it. Just the other day I told my manager that I needed help with 2 new admissions and a resident fall. I was overwhelmed. I was told to figure it out. They just keep putting more on us and when we can't do it we get bad feedback that it isn't done. When asked if the facility had a plan for the short staffing issues, Nurse F stated, They say they do but for every 3 aides they hire 2 won't stay past 2 weeks because they can't work like this. A group staff interview was conducted on 8/22/18 at approximately 8:30 AM with Staff C, G, L, and U. All admit to working voluntary and mandated overtime. The group staff stated that the schedule is routinely posted with holes in it and if it's not filled by the next shift then the facility will mandate to keep staff over for the next shift. Staff report being provided a break/lunch but often are asked to return to the floor early to assist with resident cares because there is not enough staff left on the unit to cover a full break or lunch. Staff report that residents are not getting the call lights answered timely because it is not possible with the two aides and one nurse per unit, especially with the high acuity of residents needing two-person assistance. When asked if the facility was aware of the staff shortage and what they are doing to do about it, the staff stated that we are being told that they have a plan, but they are not sure what that is. The staff report that the facility has hired new staff, but the staff quit after a couple of weeks because they just can't work all the mandated overtime and heavy assignments. Staff reported that coworkers were volunteering to work double a shift and then getting mandated on top of that so that some worked 3 and 4 doubles (approximately 15 hours shifts) in a row. Staff report that they are receiving poor performance ratings because they are not able to get all their assigned tasks done/completed timely. Staff stated they are not able to answer all the call lights within 15 min. They are aware that residents wait 20-30 minutes to get assistance. They stated that they feel the management will retaliate if they continue to speak out about the staff issues. Staff report they aren't allowed to look at the staffing schedule in advance because the managers are afraid the staff will call in if there are too many holes because they know they will get mandated over and they just can physically do it over and over. A group staff interview was conducted on 8/22/18 at approximately 2:45 PM with Staff DD, EE and FF. Staff were told that they cannot look at the schedule in advance because the managers will not let them. Staff state there is no float staff assigned to help with the assignments for the acuity of the resident care needed. Staff report that they sign up to work voluntary overtime doubles because they are afraid the residents won't get the care they need if they don't. A staff member reported that when they signed up to work a couple of double shifts in a row that they were then mandated the third day and ended up working 4 double shifts in a row. Staff admit to working tired and admit that residents are not getting the supervision needed, answer call lights answered timely and reposition residents as their care plans required. The staff state that the facility is aware of the care and staffing concerns and report the facility has hired but are unable to retain the new employees. The staff report that the new hires quit due to short staffing, exhausted from working the repeated mandated overtime, and feel that the facility doesn't staff accordingly to give residents good care. Record review of the electronic time keeping record reflected that Staff E worked 111.9 hours from 8/4/18 - 8/17/18. Staff Member E had worked 5 double shifts (2 were back to back). The record reflected 80 hours of regular time and 31.9 over time hours. Record review of the electronic time keeping record reflected that Staff CC worked 118 hours from 8/3/18 - 8/17/18. Staff Member CC had worked either a partial or a full double shift on 5 different days. The record reflected 80 hours of regular time and 38 hours of over time hours. Record review of the electronic time keeping record reflected that Staff BB worked 126.9 hours (46.1 hours was overtime) from 7/21/18 - 8/3/18 and 134.7 hours (54.7 hours was overtime) from 8/4/18 - 8/17. The record reflected that Staff BB had worked 4 double shifts (over 15 hours each day) in a row from 8/17/18 - 8/20/18 which was 62.6 hours in 4 days. On 8/22/18 at 8:30 AM, an interview and record review was conducted with the Staff Scheduler W. When asked if the schedule that was posted for Monday 8/20/18 had holes in it (no staff listed for assignments), the Staff Scheduler W stated, Yes, it had 13 open areas between the nurses and CNA's. When asked what the facility does about the holes in the schedule, the Staff Scheduler W stated, The shift supervisor attempts to fill them with volunteer overtime and if they can't then they have to mandate people over. During an interview on 8/23/18 at approximately 1:30 PM, the Nursing Home Administrator (NHA) A stated that she was aware that the call light response time takes too long across the board. NHA stated that the facility can pull the response time report, check the length of wait times and investigate any over 20 minutes. When asked if there were any recent lengths that exceeded 20 minutes the NHA A stated, Yes. The NHA A stated that the facility does use mandatory overtime to fill shifts called off due to staff illness and any open shifts that they can not fill. When asked if she was aware that staff have worked 3-4 double shifts in a row, the NHA A stated, I was aware of 3 but not 4. When asked about monitoring for staff burn out due to the extra hours worked, the NHA A stated, Yes, we do but I personally haven't seen any. An interview was completed with staff Y on 8/22/2018 at 2:25 PM. Staff Y stated they are concerned about the amount of staff scheduled. Staff Y stated that there are two CNA's scheduled on each hall and at least three CNA's are needed. Staff Y stated that if there is someone that is a two person assist, then no one else can respond. Staff Y stated that they know some staff have been mandated to work 3 sixteen hour shifts in a row and this is tiring. Staff Y stated with these concerns patients just aren't getting the same quality of care. An interview was completed with staff Z on 8/23/2018 at 9:00 AM. Staff Z stated there is not enough staff working the floor. Staff Z stated there used to be 3 aides on the hall but now there is two with a float staff, but often due to call ins there are just two staff per hall. Staff Z stated that this can be extremely stressful, especially if a resident who is a two person assist needs to be cared for. Staff Z stated they have worked a lot of overtime and have called in after being forced to work two double shifts in a row because they could just not physically handle a third double shift in a row. Staff Z stated there are always holes in the schedule and you know someone will be mandated. Staff Z stated there are a few workers who have doctors notes so that they can not be mandated anymore and at least 15 people have quit since the increased mandated overtime. Staff Z stated they are concerned, because resident care suffers. If someone is on their third double in a row, you aren't working at par and you are no good to any resident at that point. Staff Z stated that unfortunately administration has been condescending and dismissive about staff concerns about being overworked. Any time concerns have been brought up in staff meetings the administrator has said they are not arguing about it and dismisses the staff concerns without listening. Staff Z stated they do their best to fill in as much as possible but still get mandated even when they volunteer, which is difficult when it happens so often. An interview was completed with staff AA on 8/22/2018 at 4:00 PM. Staff AA stated that the amount of people on the schedule can be really hard on staff. There are not enough workers on each hall and there has been a lot of mandated overtime lately and staff are struggling to keep up. Staff AA stated that they have been assisting another resident and had to yell for other workers to follow up on an urgent situation with a resident, but they were also busy. Staff AA stated that some residents have complained to them about waiting to go to the bathroom and waiting for other care due to lack of staff but many are not cognizant to know how long they are waiting. Staff AA stated that employees have talked to the administrator and she made them feel like it was the staff's problem and not the facility's. An interview was completed with family member J on 8/22/2018 at 11:30 AM. Family member J stated that she is concerned about overturning of staff and staff being too overworked. Family member J stated the staff that is there does the best they can, but they are being mandated to work overtime constantly and with not enough staff on each shift. Family member J has noticed a lot of staff have left and is concerned more will leave. Family member J stated that staff are not always able to respond in a timely manner, just because there are not enough people on the floor. Family member J stated they see CNAs running from room to room and drenched sweat. Family member J stated that their resident family member needs assistance with dining and they do not have as many staff available to assist with dining as they used to. Family member J stated they assist the resident with dining whenever they are there, but don't know if the needed assistance is happening in a timely manner by staff when they are not there because so many others need help and staff are struggling to help others while they are there. On 8/23/2018 at about 2:30 PM, observations were made on the NE hall and CNA T was observed rushing from call light to call light on the hall. No other CNA's were viewed to be present on the hall. An interview was completed with Resident #154 at 2:45 PM. Resident #154 stated he had been waiting a while to get into bed. Resident #154 stated that the aide had responded to his call light, but they were waiting on the other aide to be available since he needs two people to help him into bed. Resident #154 stated that he waits at least 15 minutes for assistance usually and most of the time it is longer because he needs two people to help him. An interview was completed with Resident #310 at 2:47 PM. Resident #310 was asked about how long it takes for call lights to get answered, she laughed and stated it can be quite a bit. Resident #310 stated she could use the bathroom on her own but when she needs help she can be waiting for a while. At 2:50 PM Resident #2 was observed in the hall and yelling that they needed help and they needed to go to bed. CNA T assured the resident they would be back soon to help her but that the other CNA was giving a shower to another resident. At 2:50 PM CNA S was observed coming out of the shower room with a resident and requested that CNA T assist in transferring them. After exiting the resident's room CNA T was interviewed. CNA T was observed to be perspiring and breathing heavy. CNA T stated they had several people on the hall waiting to be transferred because they required two person assistance. CNA T stated that both Resident #154 and Resident #2 were exhausted and have been waiting to be laid down since after lunch, but the other CNA on the hall was taking care of resident showers. CNA S also came into the hall at this time and was perspiring and breathing hard. CNA S agreed that it was difficult to care for all the residents on the hall in a timely manner, since so many residents required two person assistance. Both CNA's became emotional and agreed it was hard to feel like they were doing a good job. Review of CNA T's time card for the 2 week pay period of 08/04-08/17/18 revealed that CNA T worked 118.20 hours in that time frame and logged 46.70 hours of overtime. CNA T worked 9 days in the pay period and 6 of those shifts were over 15 hours.

This citation is in reference to intake MI 279 Based on interview and record review, the facility failed to prevent physical abuse against 1 resident (#302) of 10 residents reviewed for abuse, resulting in the resident being physically abused and the potential for continued abuse of residents. Findings include: Review of Resident #302's Face Sheet dated 8/22/18 revealed initial admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) had a Brief Interview for Mental Status (BIMS) score of 3 of 15 which indicated the resident was severely cognitively impaired. The MDS also revealed the resident required minimal assistance for ambulation. Review of Resident #91's Face Sheet dated 8/22/18 revealed initial admission into the facility on [DATE] and a most recent admission of 4/05/18 with [DIAGNOSES REDACTED]. The staff assessment of mental status indicated the resident was severely cognitively impaired. The MDS also revealed the resident required minimal assistance for ambulation. Per review of facility provided incident summary, on 08/14/2018 at around 1:45 PM, Resident #91 and Resident #302 were involved in an altercation. Nurse Aide O heard yelling and arguing and then heard a sound of a 'thump' down the hall. (Nurse Aide O) also witnessed the hand of (Resident #91) returning from a 'punching' position .At the time of the incident, (Nurse Aide O) was redirecting another resident. (Nurse Aide O) witnessed (Resident #302) bent over and holding his chest and knee. (Nurse Aide O) notified the unit manager at once and he call the Physician Assistant (PA), (I) to the hall .(Resident #302) said to (PA I), 'he hit me.' (PA I) started the examination of the resident and each time he touched his chest area, (Resident #302) said, 'Ouch. At that time (PA I) ordered a chest x-ray. During the investigation it was noted that (Resident #302) was in his doorway when the incident occurred, and (Resident #91) was walking the hall .(PA I) reviewed the medications for (Resident #91) and noted that (Resident #91) had recently had a dose reduction of his antipsychotic. (PA I) has determined that this was a failed GDR .Frequent checks to (Resident #91 and Resident #302) have been initiated. Review was also completed of an additional facility provided incident summary, on 8/3/2018 at around 3:10 PM, Resident #91 was in a physical altercation with Resident #71. out of nowhere (Resident #91) slapped (Resident #71)'s right hand .this was an unprovoked event .both residents were placed on frequent checks for safety .care plans were reviewed and updated . An interview was completed with Nurse Aide O on 8/22/2018 at 3:50 PM, regarding the incident with Resident #91 and #302. Nurse Aide O stated that on the day of the incident she was assisting in redirecting another resident when she heard arguing in the hall. Nurse Aide O stated that she then saw Resident #91 pulling back his arm like he had hit Resident #302 and Resident #302 was hunched over. During the 8/14/2018 incident Nurse Aide O stated that she had to yell for help. Nurse Aide O stated that both of the CNAs were busy with residents in rooms and the nurse was as well. Nurse Aide O stated that since she was also busy redirecting a resident that there was not anyone watching the hall at the time the incident occurred. Nurse Aide O stated that more staff of the hall would be really helpful because if a resident needs two people to assist them, both of the CNAs are then off the hall and she can not provide physical interventions to residents, just verbal redirection. Nurse Aide O stated that Resident #91 can have days where he is aggressive but has never hit anybody previously to her knowledge. Nurse Aide O stated that Resident #91 is on close watch because he is a wanderer. Nurse Aide O was asked if she was aware that Resident #91 was in a physical altercation with another resident 11 days prior to the incident she witnessed. Nurse Aide O stated that she was not aware. Nurse Aide O stated that she does not have access to the electronic medical record or the residents' care plans due to her position. Nurse Aide O stated that she is only made aware of altercations by word of mouth from the CNAs, Nurses and other Nurse Aides. An interview was completed on 8/23/2018 at 8:45 AM with Social Worker (SW) K regarding resident #91. SW K stated that Resident #91 has sporadic behaviors, but behaviors had increased since his decrease in [MEDICATION NAME]. SW K stated that she did not believe that Resident #91 was on frequent checks due to behavior. SW K was asked what frequent checks meant and she replied frequent depends on the person and there was not any specific guidelines. An interview was completed with Nursing Home Administrator (NHA) A at 8/23/2018 at 10:25 AM. NHA A was asked what the guidelines were for frequent checks. NHA A stated that there was not a time frame put on frequent checks, it is expected that checks happen just as much as possible. Review of Resident #91's care plan revealed a focus area of I have a HISTORY of mood difficulties . and has the recent resident to resident incidents dates listed. An intervention initiated on 8/14/2018 is listed as Monitor my mood/behavior for seven days and perform frequent checks, both until 8/23/2018. A focus area initiated on 6/20/2016 is listed as I have potential to raise my fist at others/attempting/threatening to hit. And intervention initiated on 8/3/2018 is listed as I'm on frequent checks to monitor behaviors and maintain others' safety. An additional intervention listed under an elopement/exit seeking focus is 5-1-18 Hall Monitor in place to assist and redirect me out of other residents rooms. Review of facility policy, Abuse with a last revised date of 07/2018 revealed The resident has the right to be free from abuse, neglect, exploitation, misappropriation of property and involuntary seclusion .We will not tolerate abuse by anyone including, but not limited to facility staff, other residents . Resident safety following an allegation/incident of abuse, neglect .examine the resident's injury and/or psychosocial changes .Take measures to prevent recurrence if alleged perpetrator is a resident . The facility will conduct an analysis of the following: .Residents exhibiting needs and behaviors that predispose them to have conflict with others or that subject them to have conflict with others or that subject them to neglect staff (such as: residents with history of aggressive behaviors, residents who enter other residents' rooms, resident with self-injury behaviors, residents with communication disorders, residents requiring extensive or total nursing care).

This citation is in reference to intake MI 279 Based on interview and record review, the facility failed to implement their abuse policy for two residents (#302 and #91) of 10 residents reviewed for abuse, resulting in one resident being physically abused (#302) and one resident not having care plan interventions implemented to prevent abusive behavior (#91) and the potential for continued abuse of residents. Findings include: Review of Resident #302's Face Sheet dated 8/22/18 revealed initial admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) had a Brief Interview for Mental Status (BIMS) score of 3 of 15 which indicated the resident was severely cognitively impaired. The MDS also revealed the resident required minimal assistance for ambulation. Review of Resident #91's Face Sheet dated 8/22/18 revealed initial admission into the facility on [DATE] and a most recent admission of 4/05/18 with [DIAGNOSES REDACTED]. The staff assessment of mental status indicated the resident was severely cognitively impaired. The MDS also revealed the resident required minimal assistance for ambulation. Per review of facility provided incident summary, on 08/14/2018 at around 1:45 PM Resident #91 and Resident #302 were involved in an altercation. Nurse Aide O heard yelling and arguing and then heard a sound of a 'thump' down the hall. (Nurse Aide O) also witnessed the hand of (Resident #91) returning from a 'punching' position .At the time of the incident, (Nurse Aide O) was redirecting another resident. (Nurse Aide O) witnessed (Resident #302) bent over and holding his chest and knee. (Nurse Aide O) notified the unit manager at once and he call the Physician Assistant (PA), (I) to the hall .(Resident #302) said to (PA I), 'he hit me.' (PA I) started the examination of the resident and each time he touched his chest area, (Resident #302) said, 'Ouch. At that time (PA I) ordered a chest x-ray. During the investigation it was noted that (Resident #302) was in his doorway when the incident occurred, and (Resident #91) was walking the hall .(PA I) reviewed the medications for (Resident #91) and noted that (Resident #91) had recently had a dose reduction of his antipsychotic. (PA I) has determined that this was a failed GDR .Frequent checks to (Resident #91 and Resident #302) have been initiated. Review was also completed of an additional facility provided incident summary, on 8/3/2018 at around 3:10 PM Resident #91 was in a physical altercation with Resident #71. out of nowhere (Resident #91) slapped (Resident #71)'s right hand .this was an unprovoked event .both residents were placed on frequent checks for safety .care plans were reviewed and updated . An interview was completed with Nurse Aide O on 8/22/2018 at 3:50 PM regarding the incident with Resident #91 and #302. Nurse Aide O stated that on the day of the incident she was assisting in redirecting another resident when she heard arguing in the hall. Nurse Aide O stated that she then saw Resident #91 pulling back his arm like he had hit Resident #302 and Resident #302 was hunched over. During the 8/14/2018 incident Nurse Aide O stated that she had to yell for help. Nurse Aide O stated that both of the CNAs were busy with residents in rooms and the nurse was as well. Nurse Aide O stated that since she was also busy redirecting a resident that there was not anyone watching the hall at the time the incident occurred. Nurse Aide O stated that more staff of the hall would be really helpful because if a resident needs two people to assist them, both of the CNAs are then off the hall and she can not provide physical interventions to residents, just verbal redirection. Nurse Aide O stated that Resident #91 can have days where he is aggressive but has never hit anybody previously to her knowledge. Nurse Aide O stated that Resident #91 is on close watch because he is a wanderer. Nurse Aide O was asked if she was aware that Resident #91 was in a physical altercation with another resident 11 days prior to the incident she witnessed. Nurse Aide O stated that she was not aware. Nurse Aide O stated that she does not have access to the electronic medical record or the residents' care plans due to her position. Nurse Aide O stated that she is only made aware of altercations by word of mouth from the CNAs, Nurses and other Nurse Aides. An interview was completed on 8/23/2018 at 8:45 AM with Social Worker (SW) K regarding resident #91. SW K stated that Resident #91 has sporadic behaviors, but behaviors had increased since his decrease in [MEDICATION NAME]. SW K stated that she did not believe that Resident #91 was on frequent checks due to behavior. SW K was asked what frequent checks meant and she replied frequent depends on the person and there was not any specific guidelines. An interview was completed with Nursing Home Administrator (NHA) A at 8/23/2018 at 10:25 AM. NHA A was asked what the guidelines were for frequent checks. NHA A stated that there was not a time frame put on frequent checks, it is expected that checks happen just as much as possible. Review of Resident #91's care plan revealed a focus area of I have a HISTORY of mood difficulties . and has the recent resident to resident incidents dates listed. An intervention initiated on 8/14/2018 is listed as Monitor my mood/behavior for seven days and perform frequent checks, both until 8/23/2018. A focus area initiated on 6/20/2016 is listed as I have potential to raise my fist at others/attempting/threatening to hit. And intervention initiated on 8/3/2018 is listed as I'm on frequent checks to monitor behaviors and maintain others' safety. An additional intervention listed under an elopement/exit seeking focus is 5-1-18 Hall Monitor in place to assist and redirect me out of other residents rooms. Review of facility policy, Abuse with a last revised date of 07/2018 revealed The resident has the right to be free from abuse, neglect, exploitation, misappropriation of property and involuntary seclusion .We will not tolerate abuse by anyone including, but not limited to facility staff, other residents . Resident safety following an allegation/incident of abuse, neglect .examine the resident's injury and/or psychosocial changes .Take measures to prevent recurrence if alleged perpetrator is a resident . The facility will conduct an analysis of the following: .Residents exhibiting needs and behaviors that predispose them to have conflict with others or that subject them to have conflict with others or that subject them to neglect staff (such as: residents with history of aggressive behaviors, residents who enter other residents' rooms, resident with self-injury behaviors, residents with communication disorders, residents requiring extensive or total nursing care).

Based on observations, interviews, and record review, the facility administration failed to administer the facility by utilizing resources to correct known deficiencies and prevent abuse, neglect, pressure sores and other care and dignity issues, as a result of widespread system failures beginning with ineffective administration and quality assurance oversight, a lack of properly oriented staff in sufficient numbers to provide care to dependent residents based on the facility assessment and resident acuity and according to professional standards. These system failures resulted in Immediate Jeopardy (IJ) for 10 residents (Resident #25, 27, 1-401, 1-405, 1-406, 1-410, 1-411, 1-414, and 1-418, and 1-422) who sustained adverse events, serious physical and/or psychosocial harm and placed all residents living at the facility at risk for serious harm, injury and/or death. Findings include: An interview and record review was conducted with the NHA A and the COO X on 10/4/18 at 4:04 PM, to review the staffing concerns at the facility. NHA A stated that she has been the NHA A since 4/3/18. The NHA A states that she is responsible for development and oversight of all plan of corrections. According to the CMS 2567 dated 6/18/18 and 8/27/18 the facility provided a compliance date off 9/25/18 related to staffing. When asked how the facility determined the appropriate staffing needed at the facility, the NHA A stated, Staffing was based on past staffing patterns and budget. When asked what the minimum amount of staff the facility could function with, the NHA A stated, It would depend on what the resident status is. I don't know how to determine if there is enough staff. When asked if the assignment schedule is routinely posted with holes in it, NHA A stated, Yes. When asked if she was aware that the night shift for 9/30/18-10/1/18 had holes in the schedule, the NHA A stated that she was aware, but she was not aware that the staffing holes had not been filled. When asked what the procedure for staffing coverage was, the NHA A stated that the staff should be calling her directly if they are calling off, then the scheduler is notified to send out an alert via the on-shift system, and she starts making calls immediately. The NHA A stated, I was not made aware of the staffing holes (remained open) over the weekend. The NHA A stated, If the nurses need help they can just ask me. When asked if she was aware that the staff were afraid to call her about staffing concerns, the NHA A stated, No. When asked how the facility monitors that the resident care and services are being provided according to the care plans, the NHA A stated that they do care conferences weekly, the interdisciplinary team reviews the care plans during morning meetings, the incident/accident reports are reviewed and updated, and the facility uses a program called Guardian Angel Rounds (questions related to care and services) to check in with residents 2-3 times weekly. The NHA A stated, No negative feedback has been reported. When the surveyor clarified that there were no negative feedback voiced by the residents, the NHA A then stated that a resident had a call light on for 20 minutes but, It's a behavior problem and she just needs attention. The NHA A stated that she was aware of the call light audit over the weekend reflecting 45-minute waits and aware the resident's needs were not being met timely. During an interview on 10/18/18 at 12:28 PM, the COO X stated that the NHA A would text and communicate with him regarding filling staffing spots and asked her if there was anything that she needed. When asked if she reported the critically low staffing level from the midnight shift of 9/30/18, the COO X stated, No. When asked if he checked in on the status of the plan of correction, the COO X stated, Yes, and was told it was okay .She said the pressure ulcers was not doing well and that the CCC X was overwhelmed. I didn't know that she didn't close the loop with staffing. The Administrator Orientation Checklist was reviewed with COO X. Approximately 25% of the checklist was completed and did not contain the COO X or the NHA A's signature. The NHA job description was reviewed and did not contain the executive management signature. The COO X stated that approximately 3-4 weeks ago it was identified that two NHA's and one Director of Nursing had not fully completed all orientation expectations and were scheduled to attend an additional orientation the first part of (MONTH) (YEAR). Review of the (Name of Facility) Facility Assessment last reviewed and updated in (MONTH) (YEAR) reflected, (Facility Name) is licensed to provide care for 128 (people). The assessment indicated it was able to care for residents with many common conditions including but not limited to residents with Psychiatric/Mood Disorders, Heart/Circulatory System diseases (including [MEDICAL CONDITION]), diseases of the Neurological System (including [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] among others), [MEDICAL CONDITION] System (including urinary incontinence), Digestive System (including conditions such as gastroenteritis, ulcerative [MEDICAL CONDITION], and bowl incontinence), Integumentary System (skin ulcers, Injuries) and Infectious Diseases (including skin and soft tissue infections among many others). The assessment detailed Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies and reflected the staffing plan was for the North Unit to have three licensed nurses for the first and second shift and two licensed nurses on third shift. The South Unit was to have two nurses on first and second shift with one licensed nurse on the night shift. The Staffing Plan called for there to be 13 FT (full time) licensed nurses to provide direct care 24 hours a day 7 days a week. The plan called for 33 FT nurse aides in addition to 12 FT other staff needed for behavioral healthcare and services. In an interview on 10/4/18 at 10:57 AM, CNA W reported that on Sunday (9/30/18) she was the only aide on the printed schedule for the south units (16 two person assists out of a total of S1 hall 25 residents, S2 hall 23 for a total of 48 residents). CNA W said she told Scheduler Z and nurses on duty that she would not jump from hall to hall, and that they needed to bring in more help for the night because she was going to stay on her S1 hall. Review of a schedule for 9/30/18 reflected that CNA W was the only aide assigned to work on the south units. Two CNA's were mandated to stay over from the afternoon shift, one left at 2 a.m. According to the schedule, at 2:00 a.m. on 10/1/18, there were 3 nurses and 2 CNA's to care for 105 residents in the facility. Multiple requests for Time Detail Reports were made to validate the claim made by CNA W. A Time Detail Report was provided on 10/10/18 that confirmed the second CNA S was present in the facility on 10/01/18 from 2:00 a.m.-7:00 a.m., but no other staff available. Resident #27 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #27 was an [AGE] year-old female, who was admitted to the facility on [DATE] (with a readmission date of [DATE]), with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), dated 8/10/18 reflected a score of 13 out of 15 which represents Resident #27 was cognitively intact. Resident #27 required staff assistance with all activities of daily living and transfers. Review of a Care Plan last revised on 8/27/18 reflected Resident #27 was Frequently incontinent of bladder and bowel. My use of diuretics and other medications can also impact my continence status and I require extensive assistance with toileting needs and my need for a Hoyer lift for transfers impairs my ability to be toileted in my bathroom. My decreased physical ability and possible medication side effects put me at increased risk for constipation. I also have a history of [MEDICAL CONDITION] with a partial colectomy and divirticulosis. Goals of the care plan indicated that Resident #27's risk for risk for [MEDICAL CONDITION] will be minimized through/prevented through prompt recognition and treatment of [REDACTED]. Interventions included Assist to bed pan upon my request and especially prior to going to meals, activities and before going to bed at night, and Check me with rounds and as required for incontinence. Wash, rinse and dry perineum, apply barrier cream after each incontinence episode and as needed. Review of a Care Plan last revised on 8/7/18 reflected Resident #27 had an ADL (Activities for Daily Living) Self-care Performance deficit related to NSTEMI (a mild [MEDICAL CONDITION]), fatigue, recurrent UTI's, Cardiac issues, anxiety, shortness of breath with exertion, obesity, diabetes with diabetic [MEDICAL CONDITION], depression, [MEDICAL CONDITIONS], frequent bladder incontinence, pain, impaired mobility with need for Hoyer transfer (mechanical lift), and possible medication effects. The goal of the care plan was for Resident #27 to Maintain my current level of function in bed mobility, eating, dressing and personal hygiene as my cognitive and physical status will allow. Interventions included Offer me the bed pan as I can make my needs known as needed. During an interview on 10/2/18 at 1:42 p.m., Resident #27 reported staff kept turning off her call light when she needed assistance to the bedpan earlier that day, between 10:00 a.m. and two minutes before lunch at noon. Resident #27 reported she had had an accident and everything got wet which made her feel embarrassed. During an interview on 10/01/18 at 10:00 a.m., Resident #32, (Resident #27's husband and roommate) expressed frustration regarding his wife's care. Resident #32 reported that staff call in when they aren't sick and the staff that are working don't get his wife out of bed on time because they are too short handed. An observation and interview of a dressing change was done with Nurse XX on 10/3/18 at approximately 2:40 PM. Resident #27 was seated in her room in a wheelchair. Resident #27 had a skin tear to the left lower extremity, a pressure ulcer to the left heel and a pressure ulcer to the right heel. Resident #27 could not recall exactly when each area was first noted. According to the right heel wound measurement dated 8/21/18 reflected that Resident #27 developed a facility acquired pressure ulcer to the right heel that was staged at a deep tissue injury and measured 2.2 cm x 2.3 cm that was dark purple/maroon in color. The PA was notified and ordered skin prep and to float the heel. According to the (MONTH) and (MONTH) TAR the skin prep was not started until 9/9/18 (2 ½ weeks later). The most recent wound assessment provided was dated 9/27/18 and measured 1.8 cm x 2.2 cm. An interview and record review was conducted with CCC H on 10/11/18 at 10:45 AM. CCC H confirmed that the right heel pressure ulcer was first noted on 8/21/18 and the first noted treatment according to the (MONTH) and (MONTH) TAR was initiated approximately 2 ½ weeks later on 9/9/18. The CCC H reviewed the PA noted dated 8/21/18, 8/23/18, 8/24/18, 8/27/18 and the doctor's noted dated 8/28/18 and neither had an assessment of the new right heel pressure ulcer nor a plan of care, nothing was noted related to the new pressure ulcer. According to the skin policy/procedure the facility will complete an analysis for all new wound developments. When asked if an analysis was done of the new pressure ulcer development, the CCC H stated, Not that I can see. When asked if the care plan was updated, the CCC H stated, No, I don't see any updates because there doesn't seem to be a root cause done for the new wound. Resident #1-405 Review of a facility Admission Record reflected Resident #1-405 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1-405 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15/15. During an interview on 10/3/18 at 5:08 p.m., Resident #1-405 reported that he had been getting sick for 2-3 days prior to being transferred to the hospital on [DATE]. Resident #1-405 did not report refusing to be sent to the hospital, but did report he didn't feel safe at the facility due to having to wait so long for staff to respond to his call light. Resident #1-405 said he had to sit in his feces for over an hour on 10/2/18 and 10/3/18 due to staff not responding to his call light. Resident #1-405 said I get mad and frustrated. I could be in trouble and it takes 15-20 minutes to get help. I don't really feel safe but what can I do?. Resident #1-410 Review of a facility Admission Record reflected Resident #1-410 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1-410 was severely cognitively impaired and exhibited wandering behavior daily. Review of a Care Plan last updated on 8/31/16 reflected Resident #1-410 was At risk for elopement related to attempts to elope from my home, one of which was successful. I have dementia and am no longer aware of my safety needs. I wander looking for a way out. The goal of the care plan was for Resident #1-410's risk for elopement from the secured unit and facility will be minimized with interventions that included Hall monitor in place to assist and redirect me out of other resident's rooms, distract me from wandering by offering pleasant diversions, ask me to help you with a simple task that will help distract me for a short period of time, provide structured activities: toileting, walking inside and outside, reorientation strategies including signs and pictures. Review of a Care Plan last revised on 4/9/18 reflected (Resident #1-410) is sometimes combative (hitting, pushing etc.) with staff. I may not always understand the environment, actions or statements of others related to severely impaired cognition. The goal of the care plan was that Resident #1-410 would not harm self or others. Interventions included Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. During an observation on 10/3/18 at 10:12 a.m., Resident #1-410 was observed wandering into and out of resident rooms on the south unit. A Hall Monitor was situated in the middle of the unit and was unable to respond or redirect from her station. No other staff were observed in the area while Resident #1-410 wandered into and out of other occupied resident rooms. Review of an incident report dated 10/7/18 at 3:00 p.m. reflected Resident #1-410 Wandered into (another resident's room), removed a hoodie from his room and was pushed on the shoulder by the other resident as a result. According to the incident report, staff were not available at the time of the incident to intervene. Review of an incident report dated 10/7/18 at 3:29 p.m. (29 minutes after the previous incident), Resident #1-410 was struck several times in the face by another resident. According to witness statements included in the incident report, Hall Monitor (HM) CCC reported she had gone looking for help after the previous incident and was not on the unit providing any supervision at the time of the occurrence. CNA VV's statement reflected the following: I was walking toward the large shower room on S2 unit with (another resident) when I heard screaming down the hall toward the door by room [ROOM NUMBER] and 2. I redirected (other resident) and walked toward the noise. When I reached the end of the hallway, I noticed the noise was coming from room [ROOM NUMBER]. I knocked and opened the door with my right hand. As I opened the door I observed (another resident) straddled on top of (Resident #1-410) laid horizontally across the bed. (Name of Resident) struck (Resident #1-410) using her closed fist (right hand) on the right side of (Resident #1-410's) face. The statement provided by Registered Nurse (RN) DDD was that she was in the nurses station on the telephone when the incident occurred. Resident #1-411 Review of an Admission Record and MDS dated [DATE] reflected Resident #1-411 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment indicated Resident #1-411 has severe cognitive impairment and wandered daily. Review of a Care Plan implemented on 6/08/12 reflected Resident #1-411 was At risk for elopement related to my [DIAGNOSES REDACTED]. The goal of the care plan was that Resident #1-411's risk for elopement will be minimized with interventions that included Hall monitor in place to assist and redirect me out of other residents rooms, distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television and books, provide structured activities: toileting, walking inside and outside, 1:1 conversation During an observation on 10/3/18 at 10:12 a.m., Resident #1-411 was observed wandering into and out of resident rooms on the south unit where she lived. A Hall Monitor was situated in the middle of the unit and was unable to respond or redirect from her station. No other staff were observed in the area while Resident #1-410 wandered into and out of other occupied resident rooms. Resident #1-412 Review of a facility Admission Record reflected Resident #1-412 was an [AGE] year old gentleman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Record reflected Resident #1-412 was his own responsible party. A Minimum Data Set (MDS) assessment dated [DATE] reflected resident #1-412 was moderately cognitively impaired and did not need assistance for bed mobility or transfers, required supervision and encouragement for eating and toilet use and needed limited assistance from one person for personal hygiene. During an observation and interview on 10/3/18 beginning at 9:45 a.m., Resident #1-412 was observed seated in a chair outside of the activity room on the South 2 unit, a locked unit for severely cognitively impaired residents who wander. Resident #1-412 was wearing a Korean War Veteran hat. When asked, Resident #1-412 introduced himself and reported he had been in the Army and served in the Korean War and in Germany. Resident #1-412 said he had been a truck driver after he returned from active duty. During an interview on 10/3/18 at 10:00 a.m., Hall Monitor (HM) Q reported she was currently split between two halls, the S1 and S2 units (both locked/secure units for residents who were independently ambulatory and severely cognitively impaired). She was trying to keep an eye on one resident who was escalating his behaviors and also keep an eye on a resident who was getting irritated with cognitively impaired residents. HM Q reported the resident who was getting irritated was Resident #1-412 who was not really supposed to be living on the S2 unit because he was not very cognitively impaired and the other residents frustrated him. During an observation on the S-2 (primarily dementia with behavior problems) unit on 10/4/18 at 11:55 AM, a loud verbal exchange coming from a resident room was overheard. Upon arriving at the residents room, Resident #1-411 was noted walking around Resident #1-412's room. Resident #1-412 yelled, Get out repeatedly until this surveyor reached his room. Resident #1-412 stated, I'm sick of her (Resident #1-411) coming in here. She picked up my hat and threw it on the floor. She steals[***] Resident #1-412 then gestured that he had put his television remote in his shirt pocket and was concerned that someone was going to take it. Resident #1-412 then stated, She comes in here and gets in my dresser drawer. She is messing with my papers and taking them. A dietary staff member happened to be in the hall passing by and attempted to redirect Resident #1-411 out of Resident #1-412's room. No other staff were noted in the hallway or near by to respond to Resident #1-412's pleas for help. On 10/2/18 at 8:25 AM, on the S-2 unit an interview was conducted with Registered Nurse (RN) AA'. RN AA reported she was working as an Aide because she declined to take a (med) cart (work as a nurse). RN AA reported the facility had scheduled only 1 aide and no Hall Monitor for the S-2 unit and she considered this staffing level to be not safe. RN AA reported unsafe because of the needs and behaviors of the severely cognitively impaired residents on the S-2 hall. RN AA reported she had worked the S-2 unit before at that staffing level and that, it did not go well. RN AA reported when she had declined to work as a nurse today at that staff level (1 Aide) that she had received push back from the Scheduler and Administration. RN AA reported the Scheduler had told her that the previous day the unit had been staffed with only 1 aide and that Administration had questioned her ability. RN AA stated, I'm a good nurse and I care about these people, but it just isn't safe. RN AA reported last Wednesday she was the nurse on the S-1 unit when other staff were at back to back meetings. RN AA reported so many staff were at the meetings that it resulted in the unit being inadequately staffed. RN AA reported she and an Activities staff member were the only staff available to provide care to the S1 residents at meal time. RN AA reported just before the meal she had a fall with injury and prior to that the fall resident was involved in a Resident to Resident altercation. RN AA reported ample staff were in the building because the facility thought the state might be in that day .they always staff up on those days. RN AA indicated the state did not come in and that the meetings started right after the fall of the S-1 resident and during lunch. RN AA stated, we were paging for assistance but no response .trying to feed, watch a one on one resident (a resident that required constant supervision), behaviors in halls .it's like you don't know where to begin. RN AA questioned if facility will know of this interview. RN AA expressed concern of retribution from the facility for speaking of this and that she was aware other staff were fearful to speak to state surveyors. On 10/2/18 at 3:35 PM, an interview was conducted with Unit Manager (UM) G. UM G reported he was the manager of the S-1 and S-2 units. UM G was asked if staffing was a concern at the facility. UM G reported, I'm going to cut my own throat and say that yes (It was a concern), It's a huge problem for me . UM G reported he has talked to Administration, endlessly about it. Reported he had been told it's getting better, and we're working on it. Reported staffing has not improved. UM G reported, Call in's (Staff calling that they were not going to report to work) are not always replaced and that we work with what we have. UM G reported complaints about staffing levels from the staff were, Endless. During an interview and observation on 10/1/18 at 10:45, CNA's scheduled on the northeast unit stated they had two more residents to provide morning care to and get up for the day. This surveyor observed the two residents still in their sleepwear in bed. Resident #1-401 Review of the EMR reflected that the resident was admitted with an unstageable pressure ulcer on 9/6/18 that reflected the following surface area wound measurement: 9/7/18, 5.9 centimeters (cm)2 (squared), 9/13/18, 9.0 cm2, 10/4/18, 44.9 cm2. This deterioration reflected an increase of 35.9 cm2 of wound area since 9/13/18. On 10/1/18 at 4:11 PM, it was observed that the door to room [ROOM NUMBER]-1, which was located at the end of an S2 hall, was closed. On entry into the room it was observed that the room was darkened. Resident #1-401 turned to left side in low bed crying, stating, I can't move, I can't move- my leg, ouch, ouch, it hurts it hurts. Noted no call light in reach. Ringer-type bell on over the bed table past the fall mat on the floor out of reach of the Resident. Staff were alerted to the needs of the Resident. During the observation of care, it was noted staff discovered Resident #1-401 had been incontinent of stool. When Resident #1-401 was turned to be cleaned a large wound on the sacral area was observed to be exposed; the wound was not covered with a dressing. The wound remained exposed until 5:27 PM when wound care had been provided. On 10/11/18 at 4:03 PM, an interview was conducted with Nurse Wound Consultant (NWC) TT. NWC TT indicated that on 10/1/18, the Physician's Assistant (PA) had evaluated the sacral wound of Resident #1-401 at approximately 10:30 -11:00 AM. NWC TT indicated a new order for treatment of [REDACTED]. On 10/15/18 at 11:15 AM, a telephone interview was conducted with RN P. RN P reported he was aware the PA had evaluated the wound on Resident #1-401 on 10/1/18. RN P reported he been way behind and had left the wound on the sacral area of Resident #1-401 uncovered. RN P reported he had wanted the Wound Nurse or a Unit manager to be present when he followed the new order for wound care but indicated he was unable to coordinate this care with the other staff. RN P reported he did not complete the dressing change by the time he had left for the day at about 4:00 PM on 10/1/18. Review of the EMR Progress Notes for Resident #1-401 on 10/6/18, reflected a concern for the status of the wound and that the Resident was febrile (elevated body temperature). The medical record reflected the Resident was sent to the emergency room and was subsequently admitted for [MEDICAL CONDITION] (systemic infection). Review of the hospital records dated 10/6/18, for Resident #1-401 reflected the Reason for Visit to be, yesterday fever 103 (degrees Fahrenheit), wound on coccyx that had, increased by ½ (inch) in last 48 hours, and that the facility wants it noted (patient) has had a significant change in condition . Further review of the hospital records indicated a Computer [NAME]ography Scan (CT) of the coccyx wound reflected, osteo[DIAGNOSES REDACTED] (bone infection). Review of education notes written by NWC TT reflected 10 points about care to the wound of resident #1-401. The notes reflected (Resident #1-401) was admitted [DATE], with a Stage 3 sacral pressure injury. There are a few issues related to this wound that need to be addressed. 1. Treatment: Cleanse pressure sore with normal saline (NS) apply Santyl to slough, cover with gauze and apply border gauze, change daily every day shift. 6. Order: (order of 9/7/18 restated) Santyl Ointment .apply to slough .Okay to peel back and replace and reuse same dressing daily. Dressing to be changed every Tuesday and Friday NWC TT added it all capital letters, WE DO NOT PEEL BACK DRESSINGS, DO A TREATMENT AND REAPPLY THE OLD DRESSING. THESE ORDERS DO NOT INCLUDE CLEANING OR PERIWOUND PROTECTION INSTRUCTIONS. THE DRESSING MUST BE CHANGED EACH DAY WITH CLEANING AND APPLICATION OF NEW SANTYL. SANTYL ONLY WORKS FOR 24 HOURS SO, THIS REQUIRES A (EVERY) 24 HOUR DRESSING CHANGE. THE WOUND IS ON HER SACRUM, NOT C[NAME]CYX. 7 Treatment Administration Record (TAR): A 9 (code meaning see nurses notes) was recorded on the TAR on 9/7 and 9/11. There are X's on 9/8 ,9/9 (on the new dressing applied portion of the TAR -an X indicated this was not done), on 9/10 there is a 5 (code meaning see nurses note). There is not a single note about this. So, her wound has not been cleaned. No Santyl applied and dressing has not been changed since she was admitted on [DATE]. There is no documentation in the chart to show otherwise. In an interview conducted 10/11/18, at 4:03 PM NWC TT reported, I cannot say the facility did not cause the osteo[DIAGNOSES REDACTED]. Whether things like no dressing change or no dressing (uncovered wound for approximately 6 hours), given her co-morbidities (other physical problems) .better care would have helped. Resident #1-419 On 10/16/18 at approximately 9:00 AM, Resident #1-419 was observed in bed, crying. Resident #1-419 was unable to answer specific questions. The facility provided a copy of the education provided to all nursing staff (including Nurse J) on 10/10/18. The education included pressure ulcer policy/procedure and reflected Nurse J's signature. Nurse J was interviewed on 10/1/18 at approximately 9:45 AM, and again on 10/17/18 at 12:30 PM. On 10/1/18, Nurse J stated that she is wound certified and does not believe the facility is accurately assessing pressure ulcers. Nurse J stated, They are calling things pressure ulcers that are not pressure ulcers. On 10/17/18, Nurse J reviewed the notes on 10/6, 10/7, 10/8, 10/9, 10/11, 10/12, and 10/13 (that Nurse J authored) that all reflected the same statement of, Area on the heel of concern. On 10/14/18, Nurse J documented that the right heel had a deep tissue injury (a pressure ulcer that is dark purple) that was non-blanchable and measured 2.5 cm x 3.5 cm and an area to the side of the foot that measured 0.5 cm x 1.0 cm. When asked what area on the heel of concern meant, Nurse J stated that heel was noted to be boggy and non-blanchable. Nurse J stated that she did not thoroughly and accurately chart the assessment finding of the heel from 10/6/18 - 10/13/18. Nurse J stated that she should have done an assessment, notified the physician and obtained an order on 10/6/18 when the area to the heel was first noted. Nurse J stated she called the physician on 10/14/18 and obtained treatment orders for the new pressure ulcers. The (MONTH) Treatment Administration Record (TAR) was reviewed with Nurse J and the treatment order that was initiated on 10/15/18 (not 10/14/18 as Nurse J stated). Nurse J stated, I thought I entered the orders on 10/14/18. Record review of the Physician Assistant (PA) JJ note signed on 10/17/18 reflected that Resident #1-419 had developed a new pressure ulcer to the right heel and that the resident was noncompliant with keeping her leg elevated and hip abductor in place. No alternate intervention was noted. An interview and record review was completed with the Director of Nursing (DON) B and the Wound Nurse Consultant (WNC) TT on 10/17/18 at 4:00 PM. WNC TT stated that she reviewed the wound information on 10/15/18 and noted that there was not a treatment order obtained for the new pressure ulcers and she (not Nurse J) talked with PA JJ and obtained the orders and entered them into the computer on 10/15/18. WNC TT also reviewed the 10/17/18 note by PA JJ and stated that the Resident #1-419 could not and should not elevate her leg due to recent hip surgery. WNC TT stated that she had ordered a cushioned boot that could be placed on both feet to promote healing and prevent further skin breakdown. WNC TT stated that a special mattress was also ordered for Resident #1-419 as well. WNC TT stated that Nurse J did not follow the facility policy/procedure for pressure ulcers. WNC TT stated that Nurse J signed on 10/1 (TRUNCATED)

Based on observation, interview and record review the facility failed to prevent, monitor and promote the healing of pressure ulcers for 4 of 6 residents (Resident #76, #27, #28 and #30) reviewed for pressure ulcers. Findings included: The facility provided a copy of a policy/procedure for Skin Care & Wound Management dated 8/11/2006, last revised on 1/2018 for review. The policy reflected, The facility staff strives to prevent resident/patient skin impairment and to promote the healing of existing wounds .The interdisciplinary team evaluates and documents identified skin impairments and preexisting signs to determine the type of impairment, underlying condition contributing to it, and description of impairment to determine appropriate treatment .Components of skin care and wound management .C. Weekly monitoring of resident/patient skin status .E. Interdisciplinary review of identified skin impairments. F. Care plan for identified risk areas. G. Monitoring for consistent implementation of interventions and effectiveness of interventions. H. Review and modification of treatment plans, as applicable. I. Analysis of facility pressure ulcer data for quality improvement opportunities .A care plan will be developed and individualized according to assessments . An email request was sent to Nursing Home Administrator (NHA) A on 6/12/18 at 3:50 PM, and the following information related to pressure ulcers for Residents #19, 27, 28, 30, & 76 was requested: timeline of the pressure ulcers including onset, root cause, progression/measurements, interventions, and any supporting documentation of avoidable/unavoidable. Resident #76 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #76 was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 13 out of 15 which represents Resident #76 was cognitively intact. Resident #76 was unable to hear and required staff assistance with all activities of daily living and transfers. An interview and observation were conducted with Resident #76 on 6/12/18 at approximately 9:30 AM. Resident #76 was seated on his bed. Resident #76 stated aloud that he could not hear and used a writing board to communicate. Resident #76 had his right arm in a sling and stated that he had broke it during a fall (prior to his admission to the facility). When asked about his right elbow wound, Resident #76 stated that it hurts but did not know how it developed. On 6/13/18 at 3:00 PM an observation of a dressing change was conducted. Licensed Practical Nurse (LPN) EE was observed as he removed, cleansed and redressed Resident #76's right elbow. Resident #76 complained of discomfort during the process. The wound bed was open and pink with a small amount of bleeding after it was cleansed. According to the risk for alteration of skin integrity care plan dated 4/26/18, the use of a sling was identified in the focus area and the goal was for the skin to remain intact. The interventions included the following: I scratch my skin and develop irritated areas, assess for skin breakdown on the right upper extremity due to the humeral fracture, and to inspect skin daily and report any concerns to the nurse. According to the wound assessment dated [DATE] (signed by the nurse on 5/22/18) reflected the following information. A new development of a pressure ulcer, stage 3 full-thickness skin loss, it was acquired in house on 5/16/18. The wound measurement was 2.8 cm x 2.1 cm with slough (gray cover) covering 90% of the wound bed. The area was warm, non-[MEDICAL CONDITION] that extended >4 cm around the wound, and the periwound area was hot (localized heat). Under Additional Care there were 18 different interventions listed and the box for none was checked. The document indicated that the physician assistant was notified, and an order of wound care and antibiotics was provided. The electronic health record (EHR) reflected an initial skin assessment on admission on 4/26/18 that reflected no concerns with the right elbow. There were no further weekly skin checks done until the stage 3 facility acquired pressure ulcer was noted on 5/16/18 (20 days later). Record review of the weekly skin check (following the onset of the pressure ulcer) dated 6/6/18 was noted as intact which was inaccurate according to the weekly wound measurements. The weekly wound assessments and measurements were reviewed and reflected the following: 5/22/18 (signed by the nurse on 6/2/18) 2.5 x 2.9 cm (worsening of the pressure ulcer) 6/1/18 2.1 x 2.5 x 0.2 cm 6/8/18 2.3 x 2.0 cm An interview and record review were conducted with Unit Manager, Registered Nurse (RN) JJJ on 6/13/18 at 10:30 AM. When asked if she was aware that there was no weekly skin check done from 4/26/18 - 5/16/18 (20 days) until the pressure ulcer was noted on Resident #76's right elbow, RN JJJ stated she was unaware that weekly skin checks were not being done. When asked if the facility investigated the facility acquired pressure ulcer to determine a root cause for it, RN JJJ stated, We are now working to do root causes. It's been included in the IDT process. When asked if it was done for this wound, RN JJJ stated, No. When asked why the wound assessments effective date and signed date were not the same (7-10 days apart), RN JJJ stated that she has only been in the position (as unit manager) for approximately 2 months and she wanted her notes reviewed by the DON before she signed them and locked the notes. An interview and record review was conducted with RN JJJ, Unit Manager LPN CCC, and Director of Nursing (DON) B on 6/14/18 at approximately 10:30 AM. The weekly skin checks, wound assessments and care plans were reviewed. RN JJJ stated that Resident #76 was quite independent and sometimes refused cares. When asked if this was reflected on the care plans, RN JJJ stated that she would check. At 1:08 PM DON B stated that a care plan for refusals was not available and was unable to locate the root cause of Resident #76's elbow wound as well. Resident #28 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #28 was an [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 5 out of 15 which represents Resident #28 had severe cognitive impairment. Resident #28 required staff assistance with all activities of daily living, positioning and transfers. According to the at risk for alteration of skin integrity care plan dated 6/1/16 last revised on 1/13/18 (6 months ago) reflected that risk factors included (but not limited to) immobility, cognitive impairment, occasional bladder incontinence, and history of pressure ulcers on buttock. The interventions included (but not limited to) check for appropriate air pressure of cushion in recliner every shift (dated 6/9/18), apply barrier cream to buttocks every shift and observe for any signs and symptoms of recurrent stage II pressure injuries reopening. According to the wound assessments effective dated 6/8/18 (signed by the nurse on 6/13/18), Resident #28 developed two new facility acquired stage 3 pressure ulcers to the left buttock. Wound #1 measured 0.5 x 0.4 x 0.2 cm and wound #2 measured 0.2 x 0.2 x 0.1 cm. An interview and record review was conducted with RN JJJ, LPN CCC, and DON B on 6/14/18 at approximately 10:30 AM. The weekly skin checks, wound assessments and care plans were reviewed. There was no root cause analysis available for review but RN JJJ stated that Resident #28's air cushion for the recliner chair was not inflated and the CNA's (Certified Nursing Assistants) needed further education to assist with repositioning. According to the care plan, staff were to apply a barrier cream to the buttock every shift. When asked if staff had reported skin concerns prior to the two areas opening, LPN CCC stated, I asked the staff that question because the barrier cream is translucent (able to see through). We have identified that the staff need more education. Resident #27 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #27 was an [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 10 out of 15 which represents Resident #27 had mild cognitive impairment. Resident #27 required staff assistance with all activities of daily living, positioning and transfers. According to the risk for alteration for skin care plan dated 4/26/18 and last revised on 5/2/18, Resident #27 was at risk for shear & friction, and [MEDICAL CONDITION] of the lower extremities. The interventions included (but not limited to) assistance needed to don bilateral knee high TED hose in the AM and off in the PM, encourage to elevate legs when sitting in recliner or lying down periodically during the day to elevate the lower extremities and promote circulation, inspect skin daily with AM and PM cares and report any concerns to nurse, pressure relief off heels when in bed as will allow, report to nurse any increased redness or open areas to lower extremities as resident has history of chronic stasis ulcers on lower legs, and weekly skin assessment by nurse (dated 5/2/18). The weekly skin assessments from 4/1/18 - 6/11/18 were reviewed. There were 11 weeks for review and the facility provided 6 skin assessments, that were dated as follows: 4/4/18 (signed on 4/17/18), 4/17/18, 5/18/18 (signed on 5/21/18), 5/23/18, 6/4/18, and 6/11/18. According to the wound assessment dated [DATE] at 5:18 PM (signed by the nurse on 4/17/18 at 11:42 AM) reflected a new blister to the left heel that measured 1.7 cm x 1.2 cm. The assessment dated [DATE] (signed on 4/27) reflected that the type of wound was pressure and it was staged as a deep tissue injury (DTI) a persistent non-blanchable deep red, maroon or purple discoloration, that measured 1.5 cm x 1.3 cm. The following weekly measurement and finding were as follows: 5/7/18 (signed on 5/14/18) 1.6 x 1.3 cm 5/18/18 (signed on 5/22/18) no measurement was documented, now an unstageable obscured full-thickness skin and tissue loss due to slough/eschar covering the wound bed. 5/25/18 (signed on 5/30/18) (18 days since it was last measured) 1.5 x 1.7 cm 6/1/18 1.4 x 1.3 cm 6/8/18 1.2 x 1.2 cm wound bed remains 100% covered with eschar The facility provided a copy of Resident #27's pressure ulcer care plan created on 5/9/18 (23 days after the onset of the pressure injury) for review. The interventions included (but not limited to) assess/record/monitor wound healing weekly, measure length, width and depth where possible, and off load pressure to bilateral heels using heel floatation device, pillows or blanket rolls when in bed. An interview and record review was conducted with RN JJJ, LPN CCC, and DON B on 6/14/18 at approximately 10:30 AM. The weekly skin checks, wound assessments and care plans were reviewed. When asked if the facility was aware that there was no weekly skin check between 4/4/18 and 4/17/18 (the facility acquired pressure ulcer was first noted on 4/16/18) and there was no weekly skin assessment between 5/23/18 and 6/4/18, LPN CCC stated, We did become aware of this and did a facility wide skin sweeps. When asked if it was before or after the development of this pressure ulcer, LPN CCC stated, I believe it was after. Staff were asked when they expected a care plan for a new pressure ulcer be created, and LPN CCC stated, I would expect them to do it right away. The pressure ulcer care plan reflected a creation date of 5/9/18 (23 days after the onset of the pressure ulcer) and according to the wound measurements sustained non-healing during that period of time. LPN CCC stated she was unaware that it was that long. There were no further measurements provided for the period of 5/7/18 - 5/25/18 and no root cause analysis available for review for this pressure ulcer. Resident #30 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #30 was a [AGE] year-old male, who was admitted to the facility on [DATE], with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 14 out of 15 which represents Resident #30 was cognitively intact. Resident #30 required staff assistance with all activities of daily living and transfers. On 6/13/18 at approximately 11:50 AM an interview and observation of a dressing change was conducted with LPN EE, CNA FF and Resident #30. LPN EE and CNA FF positioned and prepared Resident #30 for the dressing change. When asked if there was any discomfort with the dressing changes, Resident #30 stated, It hurts a little. During the dressing change procedure Resident #30 called out loudly, Hurry it hurts. The buttock had a large area of excoriation noted that extended to the scrotum. There was an open area noted to the lower portion of the left buttock. DON B provided a copy of the at risk and pressure ulcer care plans for review on 6/14/18 at 3:00 PM. According to the risk for alteration skin integrity care plan dated initiated on 11/5/14, Resident #30 was at risk for moisture, frequently incontinent of bowel and occasionally incontinent of bladder, frequent loose stools, shear & friction. The goal was to prevent further skin breakdown will be minimized was last revised on 1/21/18 with a target date (date of evaluation) of 4/19/18 (approximately 2 months ago). There was no evidence the care plan was evaluated and updated. The interventions included (but not limited to): dry skin folds thoroughly with bathing and pericare, incontinence management per incontinence/elimination program, position body with pillows/support devices, protect bony prominence's, and turn and reposition every 2 hours lying and every 1 hour sitting. The wound assessment dated [DATE] reflected a new facility acquired stage 2 pressure ulcer to the left buttock that measured 2.3 x 1.6 cm. The following measurements were provided for review: 3/13/18 5.6 x 3.9 cm assessment reflects now a stage 3 4/2/18 (signed on 5/28/18, 56 days later) wound not measured for 20 days and worsened to 6.1 x 6.0 x 0.2 cm 4/16/18 - 4/20/18 hospitalized for [REDACTED].>4/20/18 admission assessment reflected no documentation or measurement of the pressure ulcer, and it was not assessed/measured until 19 days after readmission. 5/9/18 (signed on 5/16/18) 6.0 x 4.5 cm 5/17/18 (signed on 5/22/18) this assessment did not contain documented measurements 5/25/18 (signed on 5/30/18) 2.8 x 4.4 x 0.1 cm (not measured for 16 days) 6/8/18 wound worsened, 6.1 x 3.6 cm stage 3 According to the pressure ulcer care plan dated 1/18/18 the focus area identified a new stage 2 pressure ulcer and a deep purple blanchable area of discoloration related to pooling of blood. The plan was not updated to identify the decline to a stage 3. The goal reflected, I will experience progressive healing of moisture associated skin damage thru the next review. Date initiated: 11/5/14 .Target date: 4/19/18 (2 months ago, represents the date plan would be reviewed and evaluated). An interview and record review was conducted with RN JJJ, LPN CCC, and DON B on 6/14/18 at approximately 10:30 AM. The weekly skin checks, wound assessments and care plans were reviewed. LPN CCC confirmed that Resident #30's facility acquired pressure ulcer was first noted on 2/2/18 as a stage 2 and sustained a decline and now was a stage 3. When asked if the facility was aware that there was several missing weekly wound assessments and measurements, LPN CCC stated that for a period of time she was attempting to manage two units and it was too much. LPN CC confirmed that there was no assessment/measurement to review upon Resident #30's return from the hospital on [DATE] and it was not assessed for 19 days after the readmission. RN JJJ, LPN CCC and DON B confirmed and agreed that the care plans did not reflect that they were implemented timely, evaluated or updated to promote the healing of the facility acquired stage 3 pressure ulcer. The deficient practice was identified and there was no further evidence provided to the survey team to review before the exit of this survey. The facility was unable to provide the root cause analysis data for the facility acquired pressure ulcers before the exit of this survey, therefore the facility was unable to show evidence that the facility acquired pressure ulcers were avoidable.

Based on observation, interview and record review the facility failed to provide mouth care and dental services for one resident (Resident #96) out of 2 residents reviewed for dental care resulting in gingivitis and pain. Findings include: Review of a facility face sheet dated 6/13/18 at 7:41 PM reflected Resident #96 was a [AGE] year old female admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. During an interview with Resident #96 on 06/11/18 at 10:55 AM she revealed, Nobody brushes my teeth! Resident #96 denied seeing a dentist. Nobody asks me, they're (teeth) in bad shape! When Resident #96 smiled, her front teeth were with receding gum lines and yellowish plaque on top of teeth and brown staining. Resident #96 stated that her teeth hurt. Review of Resident #96's progress notes reflected, 6/11/2018 08:26 physician's orders [REDACTED].#96's family member) According to an article published by the (MONTH) Clinic (https://www.mayoclinic.org/diseases-conditions/gingivitis/symptoms-causes/syc- 453), Gingivitis is a common and mild form of gum disease (periodontal disease) that causes irritation, redness and swelling (inflammation) of your gingiva, the part of your gum around the base of your teeth. It's important to take gingivitis seriously and treat it promptly. Gingivitis can lead to much more serious gum disease called periodontitis and tooth loss. Healthy gums are firm and pale pink and fitted tightly around the teeth. Signs and symptoms of gingivitis include: · Swollen or puffy gums · Dusky red or dark red gums · Gums that bleed easily when you brush or floss · Bad breath · Receding gums · Tender gums The most common cause of gingivitis is poor oral hygiene. Good oral health habits, such as brushing at least twice a day, flossing daily and getting regular dental checkups, can help prevent and reverse gingivitis. Review of Resident #96's ancillary physician visits, reflected no documentation of visits from dental services. Review of Certified Nurses Aides (CNAs) care for personal hygiene including brushing teeth from 5/30/18 reflected Resident #96 needed extensive assistance to total dependence most of the time to perform personal care. An annual Minimum Data Set (MDS) assessment dated [DATE] reflected, 3/3 for hygiene (extensive assist of two people). Review of a care plan for Resident #96 reflected a need for ADL (activities of daily living) care, ORAL CARE: I have my own teeth. Cue me to brush my teeth with AM and HS (bedtime) care. Report any broken teeth, carious teeth, sore gums, or other oral issues to LN (licensed nurse). (CNA) PERSONAL HYGIENE: I require extensive staff assist with short, simple instructions with personal hygiene care. Review of a progress note dated 5/31/2018 at 5:14 AM for Resident #96 reflected, Nursing Progress Note Note Text: Resident (#96) had dried blood in front of mouth near top right front tooth. Nurse was able to clean area and found teeth intact with no open areas. Resident reporting no pain and doesn't recall injuring mouth or why it may have been bleeding. Resident (#96) in no pain or distress when nurse was cleaning mouth at this time. On 06/13/18 at 9:19 AM, during an interview with Social Worker (SW) W, Resident #96 had all consents for podiatry, dental, etc signed. SW W stated residents are seen by a dentist only if they have consented or if there is a problem. SW W stated that Administrative Assistant (AA) Y scheduled dental appointments. On 06/13/18 at 11:42 AM, during an interview with AA Y, she was asked if Resident #96 had a consent for Dental treatment and she stated, Yes, dated 1/30/16. AA Y stated there doesn't look like there's any notes from dental. AA Y revealed that nursing usually comes to her when a resident needed to be put on the list to be seen by a Dentist. AA Y confirmed that Resident #96 was not on the list dated 4/30/18 to see the Dentist. During an interview on 06/13/18 at 11:55 AM with CNA HH, she revealed Resident #96 needed assistance for hygiene. An interview on 06/13/18 at 02:14 PM with CNA OOO revealed Resident #96 needed assistance with personal hygiene. She stated Resident #96 needed to have a CNA brush her teeth but right now Resident #96's mouth is bad and needs mouth wash. CNA OOO stated Resident #96 needed mouth care every shift.

This citation pertains to MI 530, MI 517, MI 524, MI 320, MI 153, MI 801, and MI 186 Based on observation, interview and record review, the facility failed to prevent abuse towards 8 residents (Resident #1, #2, #3, #4, #5, #6, #7, #11) of 18 residents reviewed for abuse, from a total sample of 18 residents, resulting in the residents being abused, the potential for continued abuse of residents, and actual psychological harm of 3 residents (Resident #2, #7, #11). Review of facility policy, Abuse with a last revised date of 11/2016 revealed The resident has the right to be free from abuse, neglect, exploitation, misappropriation of property and involuntary seclusion .We will not tolerate abuse by anyone including, but not limited to facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident . Any Allegation of resident abuse, neglect, exploitation, misappropriation of property and involuntary seclusion shall be reported to the administrator immediately .and shall be thoroughly investigated and documented .abuse can occur between; resident-to-resident, staff-to resident, family-to-resident, visitor-to-resident, etc . Resident safety following an allegation/incident of abuse, neglect .examine the resident's injury and/or psychosocial changes .Take measures to prevent recurrence if alleged perpetrator is a resident .Review the resident's medical record for relevant information (diagnosis, history, similar injuries, etc.) .Initiate corrective measures (if applicable) to prevent recurrence. The facility will conduct an analysis of the following: .Residents exhibiting needs and behaviors that predispose them to have conflict with others or that subject them to have conflict with others or that subject them to neglect staff (such as: residents with history of aggressive behaviors, residents who enter other residents' rooms, resident with self-injury behaviors, residents with communication disorders, residents requiring extensive or total nursing care). Resident #1 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was a [AGE] year old female most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated significant cognitive impairment. Resident #1 was assessed to require extensive assistance for activities of daily life (ADLs). A review of incident and accident reports regarding Resident #1 were reviewed. A verbal incident on 11/23/2017 revealed an incident description: At 1635 this nurse heard residents arguing in S1DR. This nurse observed resident (Resident #18) sitting across from (Resident #1) at a table. Observed (Resident #1) sitting in chair with water on her shirt and pants. (Resident #1) was upset that (Resident #18) threw water on her. (Resident #1) stated 'why did she throw water on me.' An additional witness statement is documented The 2 residents were sitting across from each other at the table. There was water sitting in front of (Resident #1). (Resident #18) asked the other resident who's water is this. Then (Resident #18) threw water at (Resident #1). The incident report also indicated that the physician, unit manager/supervisor, DON, administrator and family member were notified of the incident. On 3/27/2018 at 10:09 AM, an interview was completed with Project Manager (PM) C regarding the incident on 11/23/2017 with Resident #1 and #18. PM C indicated that the incident had not been reported to the State as a facility reported incident. PM C stated I believe this one should have been reported. Resident #11 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 was a [AGE] year old male most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated a score of 10/15 which suggests moderate cognitive impairment. Resident #11 was assessed to require assistance for activities of daily life (ADLs). Review of Resident #6's face sheet dated 3/25/18 revealed she was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #6 was not her own responsible party. Review of Resident #6's care plan dated 2/26/2018 revealed the focus area I have potential to demonstrate behaviors verbally- I have the potential to make statements to staff about other residents behaviors/actions r/t (related to) my Ineffective coping skills and my Intellectual Disability. I tend to make statements to get a rise out of staff or others, and therefore the statements may not be true. I can be [MEDICATION NAME], and generally say whatever is on my mind. Interventions include 1/30/2018 Staff continue to monitor resident activity in dining room, Chair to face opposite incoming residents, 1/30/2018 .Social Services to provide at least 3 special visits to assess for either continued or increased aggression. Review was completed of a facility reported incident that occurred on 1/26/2018. Per facility provided summary, this investigation involves (Resident #6) striking (Resident #11) on 01/26/2018. No known injury resulted. Per the incident report .and multiple interviews it is reported that the two residents were eating in the dining room. (Resident #11) enjoys saying the prayer for the resident before meals. The interaction was not witnessed but staff was present and heard this altercation. Per (Resident #11)- (Resident #6) came up behind him and 'boxed his ears .' Staff member (Q) was in the dining room and heard the interaction. She reported '(Resident #6) was standing near (Resident #11) and he started making angry/distressed sounds at first I thought nothing of it and then (Resident #11) started yelling and stood up and was screaming about getting him out of there because he didn't want to be near her (Resident #6) . The report goes on to indicate that former Nursing Home Administrator (NHA) P interviewed (Resident #11) several times who said the incident upset him and he wasn't sure what he needed to do? (Resident #11) said he doesn't like (Resident #6) and doesn't want to be around her. He remains confused as to what to do about the incident. (NHA P) reassured him of the reporting process that was being done . The conclusion of the incident summary documents the facility believes (Resident #6) did strike (Resident #11) and the incident meets the definition of abuse as described by the department. It remains unknown if any injury occurred as (Resident #11) says he had a headache nearly a week after the incident but that it wasn't long [MEDICATION NAME] . On 3/26/2018 at 10:30 AM, an interview was completed with Resident #11. Resident #11 was asked if he recalled the incident from 1/26/2018 with Resident #6 and he indicated he did and it is still going on but they said they can't do anything about it. Resident #11 stated that Resident #6 was going back and forth with him verbally at dinner and then whapped me in the head. Resident #11 made a gesture of both open hands making contact to his temple area. When I say prayers she (Resident #6) makes fun of me . He indicated that Resident #6 gives thumbs down, makes faces, sticks her tongue out and makes other verbal comments that make him feel like she is mocking him. Resident #11 stated that these behaviors happened prior to the incident and continue every day. Resident #11 indicated he has discussed with staff back and forth about what they are going to do about it and they said they can't do anything. Resident #11 stated that it feels degrading. Resident #11 stated Resident #6 hit him once on that day and he had some pain, headache and was dizzy after but that the mocking behavior was happening before and after. It is still continuous, she is not stopping and no one is stopping her. Resident #11 stated he does not feel that facility staff are doing enough to avoid conflict and have peace. Resident #11 stated it is verbal abuse, I feel low, like I am degraded. Resident #11 stated he understands they are trying to make her free, but it affects me. They should be doing something to help me, it happens every day. Resident #11 stated that dealing with this stress has made him afraid to play Bingo because she is there and indicated he is cautious of attending activities she may be at. Resident #11 stated he has considered moving to a different facility due to the stress because there is nothing else to do but indicated he did not want to leave because he has a lot of friends here. He stated he is fearful and feels like crying all the time and worried that he will be physically attacked again by Resident #6. It was noted to Resident #11 that he was visibly distressed due to his facial expression, fidgeting and his eyes were tearing up. Resident #11 acknowledged it was definitely stressful, I should be protected in some way. Resident #11 stated that he has had verbal abuse in my life before and I'm sick and tired of it. He stated that the situation with Resident #6 is bringing up a lot of bad memories and he had not been sleeping well. Resident #11 indicated he feels anxious and agitated all the time. Resident #11 stated he did not feel facility staff have listened to him or that anyone has really addressed his anxiety or worry. At 11:30 AM on 3/26/2018, an interview was complete with Project Manager (PM) C, DON B and Corporate Social Services (CSS) J. The concerns with Resident #11 were shared and it was indicated that none present were aware Resident #6 was continuing behaviors towards Resident #11. On 3/27/2018 at 12:35 PM , a follow up interview was completed regarding Resident #11. CSS J stated they had followed up with Resident #11 and he was okay to be around Resident #6 but would like inpatient psychiatric care. DON B indicated that Resident #6 had some tongue sticking out and sighing related to Resident #11 saying prayers before meals. DON B indicated this knowledge came from the investigation of the incident on 1/26/2018 but acknowledged that Resident #6 has a history of sticking out her tongue and they know that (Resident #6) had a trigger of the prayer time. Resident #5 Review of Resident #5's face sheet revealed he was a [AGE] year old male admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Review of Resident #5's Brief Interview of Mental Status (BIMS) score dated 1/3/18 was 7/15 (moderate cognitive impairment). Review of Resident #5's State of Michigan Probate Court, Petition for Appointment of Guardian of Incapacitated Individual document dated 11/9/17 that Resident #5 had a court appointed guardian. Review of Resident #5's Facility Reported Incidence (FRI's) from 1/13/18 to 2/6/18 revealed Resident #5 verbally and/or physically abused 5 Residents (#3, #4, #6, #7 and #8). Review of the facility 5-day report for Resident #5's altercation with Resident #8 on 1/13/18 revealed, Resident #5 went into Resident #8's room unobserved. On 1/13/18 at 6:50 PM staff heard Resident #5 and #8 arguing. When staff entered Resident #8's room Resident #8 had Resident #5 head hair in his hand. Two staff separated Resident #5 and #8. While attempting to separate and calm the Residents down Resident #5 called one staff person chicken shift and said he was going to kick his ass. The facility conclusion was both residents suffer from dementia which led to the escalation and frustration. In addition, Resident #5 is hard of hearing and has vision problems. The facility was unable to determine if physical abuse occurred. Review of the facility incident Report for Resident #5 dated 1/13/18 at 7:05 PM confirmed the information in the facility 5-day report. The report had 3 witness statements confirmed the event and Resident #5 was not witness going to Resident #8's room. Staff intervened when they heard the arguing. Physical contact (hair in hand) was confirmed by the statements. There was no indication in the incident report or 5-day report of a facility plan to prevent further abuse. Review of Resident #5's CAA Worksheet part of his Minimum Data Set (MDS) nursing assessment tool dated 3/25/18 documented on page 25, Name of Resident is exhibiting both verbal and physical behavioral expressions. name of Resident often does not recall these instances after the fact. Staff must intervene with care plan situations that may be distressing to the resident. Review of Resident #5's care plan date 12/12/17 for I have the potential for mood difficulties related to dementia and decline in health/hospice admission. My mood difficulties have been noted to be increased between 3:30 - 7:30 leading to increased behaviors in this time period (as time frame as above incident on 1/13/18). The care plan listed the following dates of resident to resident disagreements (no details as to what the resident to resident event) 12/8/17, 12/10/17, 12/18/17, two on 12/20/18, 1/3/18, 1/13/18 (7 resident to resident disagreements prior to the disagreement documented above on 1/13/18. The dates of events continued with 1/19/18, 1/23/18, 1/30/18 and 1/31/18. There was an intervention for 1/13/18, that Resident #5 was to be redirected away from Resident #8's room. (The incident report and statements indicated staff were not aware of the problem until Resident #5 was in Resident #8's room). No specific instructions were care plan to supervise Resident #5 when he was up and independently moving about the facility. Interventions in place at the time of the incident were 1) encourage to avoid people that I do not get along with. 2) Redirect me to the Dining room to play the piano to help with de-escalation of aggressive behaviors. 3) encourage me to exit situations that I find distressing (no directions for supervision were care planned to achieve these interventions). Resident #7 Review of Resident #7's face sheet dated 3/25/18 revealed she was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #7 had a guardian. Review of Resident #7's Brief Interview of Mental Status (BIMS) score dated 1/30/18 was 6/15 (moderate cognitive impairment). Review of the facility incident report for Resident #5 dated 1/19/18 at 10:05 AM, documented Resident #5 was heard saying I am going to kick your ass to Resident #7. Staff separated both residents. There was one staff statement that confirmed the incident happened. There was no indication what the facility was going to do to prevent verbal abuse. No other witness statements were located. Review of Resident #5's care plan date 12/12/17 for I have the potential for mood difficulties related to dementia and decline in health/hospice admission. My mood difficulties have been noted to be increased between 3:30 - 7:30 leading to increased behaviors in this time period. Documented a resident to resident disagreement on 1/19/18 but no intervention was documented to prevent further verbal abuse. Resident #7 was interviewed on 3/22/18 at 9:15 AM, and had no recall of the incident with Resident #5 but was very upset about Resident #17 at that time. Resident #4 Review of Resident #4's face sheet dated 3/25/18 revealed she was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #4 was her own responsible party. The facility incident report was requested but was not provided. Review of the facility report for an incident with Resident #4 and #5 submitted to the state stated the incident occurred on 1/23/18 at 10:45 AM . The report documented, Resident #4 was the victim. On 1/23/18 both residents were getting ready to go smoke. Resident #4 accidentally bumped Resident #5's wheel chair and Resident #4 said, I'm sorry excuse me to Resident #5. Resident #5 hit Resident #4 with his hand in the thigh. Resident #4 denied injury and refused to be assessed. No witness statement was provided. Review of Resident #5's care plan date 12/12/17 for I have the potential for mood difficulties related to dementia and decline in health/hospice admission. My mood difficulties have been noted to be increased between 3:30 - 7:30 leading to increased behaviors in this time period revealed no documentation or intervention for the incident on 1/23/18. Resident #6 Review of Resident #6's face sheet dated 3/25/18 revealed she was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #6 was not her own responsible party. Review of Resident #5's incident report dated 1/30/18 at 8:30 AM, documented Resident #5 was involved in an incident with Resident #7, no description of the incident was provided in the description section. In the statement section two staff statements were provided. Statement #1, I saw name of Resident #5 enter DR (dining room). I heard hollering and turning around to see name of Resident #5 at Resident #7's table with clothing protector in hand, attempting to throw it at her. Dietary Aide came from behind steam table to pull Resident #5 away. Resident #7 grabbed clothing protector from him and slammed it down onto table. I redirected Resident #5 to his table. Started to offer him some drinks. He left dining room shortly after. Statement #2, Resident #5 came to Resident #7's table and started grabbing things and took a clothing protector. Resident #7 grabbed it back set it on the table then Resident #5 grabbed it again and started swinging it. I tried to pull him away, but he kept grabbing the table. Once I did get him away he started to go back at her and calling her son of a [***] and yelling as he was being pushed back to his table. There was no indication what interventions were placed to prevent further physical and verbal abuse. Review of Resident #5's care plan date 12/12/17 for I have the potential for mood difficulties related to dementia and decline in health/hospice admission. My mood difficulties have been noted to be increased between 3:30 - 7:30 leading to increased behaviors in this time period. There was no indication of a resident to resident altercation on this date and no new intervention was located for that date. Resident #6 was not available for interview during this investigation. Resident #3 Review of Resident #3's face sheet dated 3/22/18 revealed she was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #3 had a guardian. Review of Resident #3' Brief Interview of Mental Status (BIMS) score dated 1/9/18 was 14/15 normal cognition. The facility full investigation, witness statements and all documents related to this event were requested on 3/22/18, 3/26/18 and 3/27/18. The Nursing Home Administrator that was employed and in charge of all investigation was no longer employed by the facility at the time of this investigation, Current employees could not locate all documents requested. Review of Resident #3's Social Services Progress Note dated 2/6/18 at 2:06 PM, documented Resident #3 was hit by a resident when she moved a chair to get into her spot. Resident #3 also admitted hitting that resident back. Resident #3 said she was not sorry because the other person hit her first. Resident #3 said her face was scratched but had no pain. There was no indication in the note who the resident was that hit Resident #3. Review of Resident #3's nursing progress note dated 2/6/18 at 10:31 AM, documented Resident #3 stated that initials of Resident #5 placed a chair in her spot when she was waiting for activity. Resident #5 yelled at her and started swinging his arms. An order was placed for treatment to Resident #3's cheek. No assessment or incident report were provided to the Surveyor as requested above. Review of the facility report to the State dated 2/6/18 at 10:15 AM, documented Resident #3 and #5 had a physical altercation with minor injury and the police were notified. The report documented that both residents hit each other. Witness reported seeing both resident hit each other, slapping and punching. The beginning of the incident was not witnessed by staff. Resident #5 was sent to a Neuro Psych hospital after this event. Review of Resident #5's care plan revealed a care plan for I have potential to demonstrate physical behaviors including hitting other related to dementia. I was involved in a resident to resident which he was the aggressor 12/31/17 and I was involved in a resident to resident on 2/6/18. The intervention was to send Resident #5 to a Neuro Psych hospital. Another intervention was placed on 2/20/18 I will remain in eye sight of a staff member when I am out of my room. (Report to the State documented Staff did not witness the start of this incident) Incident between Resident #2 and #3 Review of the facility reported incident for Resident #2 and #3 dated 2/19/18 at 7:15 PM, documented Resident #3 ran over Resident #2's toes with her wheelchair purposefully. The report identified Resident #2 as the victim. Resident #2 said Resident #3 said she was in a hurry leaving the dining room because she had to use the bathroom. Resident #2 said she told Resident #3 she was moving as fast as she could but Resident #3 ran over her foot and kept going. 2 staff witness this incident. When Resident #3 was questioned about the incident she said, She seen me coming and wouldn't move so I ran over her feet. The facility conclusion determined no abuse occurred as the need to use the restroom created urgency. The intervention was to have the victim get help in congested areas and use foot pedals on her wheelchair. Resident #3 Review of Resident #3's face sheet dated 3/22/18 revealed she was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #3 had a guardian. Review of Resident #3' Brief Interview of Mental Status (BIMS) score dated 1/9/18 was 14/15 normal cognition. Review of Resident #3's progress note dated 2/20/18 at 1:17 AM, documented, Resident initiated physical aggression toward Resident #2. Resident stated, She seen me coming and wouldn't move, so I ran over her toes (shows intent) Review of Resident #3's progress note dated 2/20/18 at 3:31 PM documented, resident is able to ambulate in hallway independently and chooses to use w/c (wheelchair). Resident has history of being impatient with other when she feels that they are not moving fast enough. Resident is able to make needs know and is cognitively aware of actions. When interviewed she sates she should have moved: Intervention placed to remove w/c pedal and place in a bag on w/c. Care plan updated. Review of Resident #3's progress note dated 2/16/18 at 8:00 AM, documented, Resident's current behavior documentation for the last thirty days consist of verbal other x 3 and other physical x 1 which are increases since the last review. (showed knowledge in increase in negative behaviors). Review of Resident #3's progress note dated 10/4/18 at 10:15 PM documented, Name of CNA entered resident's room with her permission, to refresh her water and offer snack. CNA observed days old sour chocolate milk, and tomato juice and was going to give her fresh fluids. Resident became very angry and immediately physically and aggressively attacked name of CNA by forcefully hitting her in the head 3 times with a closed fist: scratching her arms; and punched her several times in the back. Name of CNA had both her arms up to her face and head to protect herself as she backed out of resident's room into the hallway. Resident then stepped back several feet then charged her by running into her and caused name of CNA to propel backwards across the other side of the hall. Unit Nurse name observed this and ran to intervene the assault. Review of Resident #3's care plan revealed a care plan I have a potential psychosocial well-being problem r/t (related to) my [DIAGNOSES REDACTED]. dated created 1/20/14. There were no new interventions identified on 10/4/17 after she violently attach and CNA when she went to remove spoiled food from Resident #3's room. There was not new intervention noted after 2/20/18 when Resident #3 intentionally ran over Resident #2's toes when she did not move fast enough. During a telephone interview with CNA R, CNA R said she was the CNA that was assaulted by Resident #3 last (MONTH) by Resident #3. CNA R said Resident #3 had a history of [REDACTED]. CNA R said Resident #3 had let her and other staff take out spoiled food in the past, but staff were not to remove other items from her room if Resident #3 was in her room. CNA R said the facility told her she should not have taken the soiled food out of Resident #3's room and she received discipline for this and quit. During a telephone interview with LPN S on 3/27/18 at 4:12 PM, LPN S said she was working the night Resident #3 violently assaulted CNA R for taking spoiled food out of her room. LPN S said it was care planned that Resident #3's room was not to be cleaned when she was in her room, but it was understood this did not include spoiled food. LPN S said removing soiled food in the past was not an issue. LPN S recalled Resident #3 had a tendency to hoard items and cleaning her room would upset her. LPN S said 911 was called and Resident #3 went to the hospital but returned the same day. LPN S said CNA S had bloody scratches on her arms and was soar but refused medical care. LPN S said she gave CNA S alcohol pads to clean the blood scratch. LPN S recalled facility staff being concerned that Resident #3's care plan was not being followed and staff were instructed after that time to leave spoiled food in Resident #3's room if she was in the room. At the time of exit a care plan to provide supervision for Resident #3 when she was around other residents was not located., Resident #2 Review of Resident #2's face sheet dated 3/22/18 revealed she was a [AGE] year old female admitted on [DATE] and had the following Diagnoses: [REDACTED]. Resident #2 was her own responsible party. Resident #2 was interviewed in her room on 3/22/18 at 9:10 AM, and when asked if she had any problems or concerns with Resident's, Resident #2 only mentioned Resident #17. Resident #2 said Resident #17 yells at her. Resident #2 did not mention the altercation with Resident #3. Resident #2 said she was afraid of Resident #17. Resident #17 Review of Resident #17's face sheet dated 3/27/18 revealed he was a [AGE] year old male admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #17 was not his own responsible party. Review of Resident #17's progress note dated 3/13/18 at 12:07 AM documented, Resident A & O (alert and oriented). Observed ambulating with bursts of speed to and from room. Stands and stares, lingers around staff and resident. without behaviors. Just smiles and ask questions, curiously. Review of Resident #17's progress note dated 3/14/18 at 10:01 AM, documented, This resident went up to resident #6 and attempted to but (sp) his hand on her head. Resident #6 squealed when she saw him approaching with his hand out. She hollered, don't touch me. This writer call (Resident #17) which stopped him before her reached her. After telling Resident #17 not to touch her, that she doesn't want to be touch, he eventually lowered his hand. Review of Resident #17's progress note dated 3/6/18, documented Res (resident) was talking to self while walking in hallway. He is intrusive of other personal space. He touches other when they do not want to be touched. Staff reminds him to keep hands to himself and redirect him. Review of Resident #17's Behavior log review dated 2/28/18 was reviewed. The documentation did not have any reference to Resident #17 yell at resident or attempting or touching other residents that did not want to be touched. The only behavior identified documented was, Voiding (urinating) on the floor /getting stool on areas other than toilet. Resident #2 Review of Resident #2's face sheet dated 3/22/18 revealed she was a [AGE] year old female admitted on [DATE] and had the following Diagnoses: [REDACTED]. Resident #2 was her own responsible party. Resident #2 was interviewed in her room on 3/22/18 at 9:10 AM. Resident #2 said Resident #17 yells at her. Resident #2 did said she was afraid of Resident #17. Resident #2 said she had reported this and everyone knows he yells. Resident #7 Review of Resident #7 face sheet dated During an interview with Resident #7 on 3/22/18 at 9:15 AM. Resident #7 was asked if she had any concerns with Residents and Resident #7 said Resident #17 puts his hands on my head and I don't like it. Resident #7 said Resident #17 takes her pop and no one does anything about it. On 3/26/18 at approximately 8:00 AM, Program director PD C was informed that some Residents were expressing fear, being yelled at and touched by a Resident with the same first name as Resident #17. PD C was asked for the Residents full name and C. C identified Resident #17. C was unable to locate any facility reports of these behaviors involving residents. During an interview with Social Worker F on 3/27/18 at 11:55 AM, F was aware one Resident not in the sample did not like Resident #17 but was not aware what concerns that resident had. SW F said she was aware Resident #7 had concerns about Resident #17 but again was not sure what the concerns were. SW F left to review her notes to see if she could identify what concern the residents had with Resident #17. SW F returned and said she could not located any documentation.

Based on observation, interview, and record review, the facility failed to prevent abuse for one resident (Resident #1), with cognitive deficits, resulting in an immediate jeopardy when Resident #1 was physically forced and restrained in order to receive care, resulting in multiple bruises following care, and for three residents (Resident #2, Resident #3, and Resident #4) with cognitive deficits, who were found to have bruising of unknown origin. This deficient practice placed all 37 residents, residing on the locked dementia unit, at risk for serious harm, injury and/or death. Findings include: Resident #1 Resident #1 is a [AGE] year-old female, who was admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #1's Minimum Data Set (MDS) nursing assessment, dated 1/17/17, documented that she had severely impaired cognition. Resident was not her own responsible party. A review of a facility injury report, dated 4/22/17 at 23:48, documented that Resident #1 was found to have 2 small bruises on her left arm and 3 small bruises on her right arm (no size or description given). Under the Witnesses heading, it was documented in Resident #1's guardian statement on 4/23/17 that the guardian was notified of the bruising to both arms and said the bruises were there when she visited on 4/21/17 and she understood the bruises because she knows Resident #1 is resistive to care, and runs into walls and doorjambs. Resident #1's guardian said she needs to hold on to resident's arms firmly to keep her safe. Under people notified was listed Unit Manager, Licensed Practical Nurse M, Director of Nursing N and Nursing Home Administrator (NHA) A. During multiple observations on 4/25/17, Resident #1 would not allow staff to remove her long sleeve shirt to observe her bruises. Resident #1 was not able to respond to any questions about bruises on her arms due to her cognitive state. During an interview on 4/25/17 at 4:35 PM, Certified Nurse's Aides (CNA) B and C stated Resident #1 cannot be redirected for care, she always resists. CNA B demonstrated how she wraps her hand and arms around Resident #1 to hold her in place to change briefs and provide showers. CNA B did not recall any recent training for dementia care except for the computer training. CNA C denied any recent training and said her computer training was not due until May. CNA B said her grandmother taught her how to hold residents like that when they resist care. CNA B said the facility training she had in the past did not include holding onto residents that resists but said she uses this way of holding residents in place whenever they resist care. CNAC said she also holds residents in place that resist care and did not recall any recent education that would have instructed her not to hold residents in place that were resisting care. Resident #1's guardian was interviewed on 4/25/17. The guardian said she provided care for Resident #1 at home, prior to her admission to the facility and care was difficult. Resident #1's guardian said she had to hold Resident #1 down to provide care and has continued to hold Resident #1 down during care at the facility and was not told she could not hold her down. Resident #1's guardian reported observing staff hold Resident #1 down for showers and care and said it works best if you have 3 people, so someone can hold her hands. During an interview with CNA D on 4/26/17 at 11:25 AM, CNA D explained to Nursing Home Administrator (NHA) A that when Resident #1 is soiled or needs a shower she cannot do it unless she physically holds Resident #1. NHA A had to instruct CNA D twice that this was not allowed and informed CNA D if she was not able to redirected Resident #1 she needed to have other staff attempt care. CNA D was instructed that if other staff were unable to provide care they are to notify the nurse and it would not be CNA D's responsibility for care at that point it would be the nurses responsibility for care. NHA A said she was not aware staff were holding Resident #1 in place to provide care. The facility provided a copy of the recent education the majority of the facility staff had recently been provided. The document contained the statement, F-223 Free From Abuse . Why we were cited: Failing to prevent abuse related to a resident being showered against his will and a resident to resident altercation. What do you need to know? Resident's have the right to refuse! Force cannot be used. CNA D signed that she received this education on 4/20/17. Resident #2 Resident #2 is an [AGE] year-old male, who was admitted to the facility on [DATE] and currently lives on the locked Dementia unit. Resident #2 is not his own responsible party. Resident #2 had the following Diagnoses: [REDACTED]. Resident #2's Brief Interview of Mental Status (BIMS) score, dated 2/7/17, was 6 /15 (severely cognitively impaired). Review of Resident #2's Injury Report, dated 4/22/17, documented Resident #2 had a large discoloration on his left forearm (No size or color). Under Notes was documented the discoloration on the left anterior forearm appeared to be a bruise or bleed under the skin and was outlined to see if it spreads. There was no indication how Resident #2 obtained this large bruise. Resident #2's bruise was observed on 4/25/17 at 1:30 PM with Licensed Practical Nurse (LPN) E. Resident #2's bruise on the left arm went from his wrist to his elbow and covered the back and part of the front of the arm. The bruise was outlined with a black marker and had increased in size since it was outlined. LPN F said she had never seen the bruise before and had no idea how Resident #2 obtained the bruise. Resident #3 Resident #3 is an [AGE] year-old male, who was admitted to the facility on [DATE] and lives on the locked Dementia unit. Resident #3 is on hospice care. Resident #3's Brief Interview for Mental Status (BIMS) score, dated 3/21/17, was 5/15 (severely cognitively impaired). Resident #3's injury report, dated 4/12/17 at 11:28 AM, prepared by LPN O revealed Resident #3 was observed to have bruising to the back his right elbow and surrounding area. Resident stated, I think I was going down the ramp and bumped it on the railing. No size or color of the bruise was given. Hand written note of the facility investigation, dated 4/12/17, documented there were 3 separate bruises that appear to be finger prints for an under arm lift. (No signature or name of person that did this observation/investigation. NHA A was unable to tell who did this investigation. Another handwritten note from this investigation documented Hospice CNA F said the bruises were present on 4/11/17 (one day prior to the injury report). Another hand written note documented CNA H and G assisted Resident #3 to the toilet on 4/8/17 and he was combative and attempted to throw himself on the toilet and he may have hit his arms and back on the armrest of the toilet. During a telephone interview on 4/25/17 at 2:15 with CNA F CNA F said she recalled seeing the three bruises that looked like finger prints on Resident #3 when he was in the shower on 4/11/17 and said she reported the bruises to the charge nurse. CNA F said she did not chart the bruises because she had not been given a password to the electronic medical record. During a telephone interview with LPN O on 4/25/17 at 4:00 PM, LPN O: said CNA F did not report any bruises on Resident #3 during his shower to her on 4/11/17 and after the bruises were found on Resident #3 the facility posted signs for the hospice staff reminding them to report all bruises. LPN O' said CNA Q told LPN O that over the weekend Resident #3 had an incident that may have caused the bruises and reported the incident to Registered Nurse (RN) P but RN did not do an incident report. LPN O said CNA S reported the bruises at the end of the shift on 4/12/17 and she did the incident report but not the investigation of the bruise. LPN O she did not know who did the investigation of the bruises she documented on 4/12/17. During tour on 4/25/17 at approximately 11:30 AM, CNA S was asked if she knew anything about Resident #3's bruises and CNA S said, yes I found them and reported them to LPN O. The injury report dated 4/12/17 did not document having a witness statement from CNA S On 4/26/17 at 9:00 AM, CNA J and CNA K were observed providing care to Resident #3. Resident #3 started to fall when he turned to sit on the bed and both CNA's grabbed Resident #3's arms. CNA J and K did have a gait belt on Resident #3 but frequently grabbed Resident #3 by his arms instead of using the gait belt. Resident #3 looked like he was leaning backward when he was transferred and when he was walking. When Resident #3 was in bed, 4 dark purple bruises (appeared to being the spacing of 4 fingers) were observed on Resident #3's left elbow CNA K said she saw the bruises at 7:05 AM but did not have time to report the bruises. LPN E was asked about the bruises on Resident #3's right arm, LPN E said she filled out a risk management report and reported the bruises to her Unit Manager L at 10:00 AM on 4/25/17. Unit managers L and M showed this Surveyor Resident #3's old bruises on 4/25/17 during tour around 11:20 AM. Unit Managers L and M did not remove Resident #3's the sleeve to Resident #3's left arm during the observation of the old bruise on the right arm. LPN F had reported the new bruises approximately 1 hour and 20 minute prior to this observation. On 4/26/17 at 10:00 AM Unit managers L and M were asked why they did not show this surveyor Resident #3's new bruises on tour 4/25/17 and Unit manager M said she had not investigated them yet and Unit Manager L did not say anything. This Surveyor reminded Unit Manager M and L that this Surveyor asked them multiple times during tour if other residents on the locked unit had any bruises and Unit Manager M an L reported no other bruises during the tour. Unit Manager M reported Resident #1 and Resident #2's bruises after the tour. Unit Manager M said the bruises were not investigated yet. Review of Resident #3's injury report dated 4/25/17 at 10:00 AM, prepared by LPN E documented, bruises were found on Resident #3 during his weekly skin sweep. Under notes was documented three bruises noted to posterior forearm all three dark purple and round in shape measurements 2 cm x 3 cm, 1.5 cm x .5 cm and 1.5 cm x 1 cm. (on 4/26/17 this Surveyor saw 4 round dark purple bruise in that same area that appear to be finger width apart). Resident #4 Resident #4 is a [AGE] year-old male, who was admitted to the facility on [DATE] and lives on the locked Dementia unit. His Brief Interview of Mental Status (BIMS), dated 12/21/16, was 0 /15 (severely cognitively impaired). Resident #4 had the following Diagnoses: [REDACTED]. Resident #4 is not his own responsible party. Resident #4's injury report, dated 4/25/17 at 9:15 AM, documented that a 3 cm by 3.5 cm dark purple bruise on the left wrist was found prior to morning care. Resident #4 was observed to have a red/purple bruise on his left wrist on his thumb side than was about 3 cm x 3.5 cm. Review of Resident #4's behavior note dated 4/25/17 at 9:17 AM documented Resident #4 was easily directed to the restroom for morning care, resident was cooperative to undress and sit on the toilet in his restroom, as staff began to provide care resident began hitting at staff and a second staff member approached. Care was explained, resident was allowed time, attempted to assist resident, kept resident cover, ensured proper water temperature but each approach resident remanded hitting, kicking, pinching staff, resident call staff f_ _ _ _g [***] , b_ _ _ _ _ d. and head butted staff. Resident #4's progress notes for 4/23/17 and 4/24/17 did not document any aggressive behaviors or any indication of an event that would cause an injury/bruise to his left wrist. On 4/27/17 at 3:20 PM, the Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy that was identified on 4/25/17 and began on 4/23/17 when the facility investigation of Resident #1's bruises revealed that the facility became aware that Resident #1's family was firmly holding (restraining) resident #1 during care, and that same treatment was continued by facility staff, and when bruising of unknown injury was identified on Resident's #2, #3, & #4 without thorough and timely investigation and reporting. On 4/27/17 the Immediate Jeopardy was removed when the Surveyor verified the following: 1. On 4/27/17, facility staff performed skin sweeps of identified residents (#1, #2, #3) & #4 out to psychiatric hospital), updated care plans and Kardex's. 2. On 4/27/17, Physical Therapy Assistant and Corporate Nurse Consultant evaluated Resident #3 for safe transfers. 3. On 4/27/17, Nurse Managers conducted head-to-toe skin assessments on all residents and no further unidentified injuries of unknown injury were found. 4. On 4/27/17, Director of Well-Being Services re-inserviced Administrator and Director of Nursing on the Abuse/Neglect policy and procedure which included performing timely investigations and reporting. Also on 4/27/17, all staff education began on abuse/neglect policy and procedure, specialized care provision approaches for residents with dementia, and gait belt use with all transfers. No staff will work until they have had the education. 5. On 4/27/17, Audits began for QAPI. Although the Immediate Jeopardy was removed on 4/27/17, the facility remained out of compliance at the scope of pattern and a severity of actual harm that is not Immediate Jeopardy due to the fact that not all of the staff have been educated and the sustained compliance has not been verified by the State.

Based on observation, interview, and record review, the facility failed to investigate and report to the State Agency an allegation of abuse for one (Resident #1) with cognitive deficits, resulting in an immediate jeopardy when Resident #1 was physically forced and restrained in order to receive care, resulting in multiple bruises following care, and for three residents (Resident #2, Resident #3, and Resident #4) with cognitive deficits, who were found to have bruising of unknown origin, resulting the abuse to continue after the allegation was made and not investigated or reported. This deficient practice placed all 37 residents, residing on the locked dementia unit, at risk for serious harm, injury and/or death. Findings include: According to the federal regulations the facility must: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures Resident #1 Resident #1 is a [AGE] year-old female, who was admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #1's Minimum Data Set (MDS) nursing assessment, dated 1/17/17, documented that she had severely impaired cognition. Resident was not her own responsible party. A review of a facility injury report, dated 4/22/17 at 23:48, documented that Resident #1 was found to have 2 small bruises on her left arm and 3 small bruises on her right arm (no size or description given). Under the Witnesses heading, it was documented in Resident #1's guardian statement on 4/23/17 that the guardian was notified of the bruising to both arms and said the bruises were there when she visited on 4/21/17 and she understood the bruises because she knows Resident #1 is resistive to care, and runs into walls and doorjambs. Resident #1's guardian said she needs to hold on to resident's arms firmly to keep her safe. Under people notified was listed Unit Manager, Licensed Practical Nurse M, Director of Nursing N and Nursing Home Administrator (NHA) A. During multiple observations on 4/25/17, Resident #1 would not allow staff to remove her long sleeve shirt to observe her bruises. Resident #1 was not able to respond to any questions about bruises on her arms due to her cognitive state. During an interview on 4/25/17 at 4:35 PM, Certified Nurse's Aides (CNA) B and C stated Resident #1 cannot be redirected for care, she always resists. CNA B demonstrated how she wraps her hand and arms around Resident #1 to hold her in place to change briefs and provide showers. CNA B did not recall any recent training for dementia care except for the computer training. CNA C denied any recent training and said her computer training was not due until May. CNA B said her grandmother taught her how to hold residents like that when they resist care. CNA B said the facility training she had in the past did not include holding onto residents that resists but said she uses this way of holding residents in place when ever they resist care. CNAC said she also holds residents in place that resist care and did not recall any recent education that would have instructed her not to hold residents in place that were resisting care. Resident #1's guardian was interviewed on 4/25/17. The guardian said she provided care for Resident #1 at home, prior to her admission to the facility and care was difficult. Resident #1's guardian said she had to hold Resident #1 down to provide care and has continued to hold Resident #1 down during care at the facility and was not told she could not hold her down. Resident #1's guardian reported observing staff hold Resident #1 down for showers and care and said it works best if you have 3 people, so someone can hold her hands. During an interview with CNA D on 4/26/17 at 11:25 AM, CNA D explained to Nursing Home Administrator (NHA) A that when Resident #1 is soiled or needs a shower she cannot do it unless she physically holds Resident #1. NHA A had to instruct CNA D twice that this was not allowed and informed CNA D if she was not able to redirected Resident #1 she needed to have other staff attempt care. CNA D was instructed that if other staff were unable to provide care they are to notify the nurse and it would not be CNA D's responsibility for care at that point it would be the nurses responsibility for care. NHA A said she was not aware staff were holding Resident #1 in place to provide care. The facility provided a copy of the recent education the majority of the facility staff had recently bee provided. The document contained the statement, F-223 Free From Abuse . Why we were cited: Failing to prevent abuse related to a resident being showered against his will and a resident to resident altercation. What do you need to know? Resident's have the right to refuse! Force cannot be used. CNA D signed that she received this education on 4/20/17. On 4/27/17 at 3:20 PM, the Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy that was identified on 4/25/17 and began on 4/23/17 when the facility investigation of Resident #1's bruises revealed that the facility became aware that Resident #1's family was firmly holding (restraining) resident #1 during care, and that same treatment was continued by facility staff, and when bruising of unknown injury was identified on Resident's #2, #3, & #4 without thorough and timely investigation and reporting. On 4/27/17 the Immediate Jeopardy was removed when the Surveyor verified the following: 1. On 4/27/17, facility staff performed skin sweeps of identified residents (#1, #2, #3) & #4 out to psychiatric hospital), updated care plans and Kardex's. 2. On 4/27/17, Physical Therapy Assistant and Corporate Nurse Consultant evaluated Resident #3 for safe transfers. 3. On 4/27/17, Nurse Managers conducted head-to-toe skin assessments on all residents and no further unidentified injuries of unknown injury were found. 4. On 4/27/17, Director of Well-Being Services re-inserviced Administrator and Director of Nursing on the Abuse/Neglect policy and procedure which included performing timely investigations and reporting. Also on 4/27/17, all staff education began on abuse/neglect policy and procedure, specialized care provision approaches for residents with dementia, and gait belt use with all transfers. No staff will work until they have had the education. 5. On 4/27/17, Audits began for QAPI. Although the Immediate Jeopardy was removed on 4/27/17, the facility remained out of compliance at the scope of pattern and a severity of actual harm that is not Immediate Jeopardy due to the fact that not all of the staff have been educated and the sustained compliance has not been verified by the State.

Based on observation, interview, and record review, the facility failed to follow its abuse and neglect policy for residents with cognitive deficits, for one (Resident #1) who was physically forced and restrained in order to receive care, resulting in multiple bruises following care, and for three residents (Resident #2, Resident #3, and Resident #4) who were found to have bruising of unknown origin, resulting in an immediate jeopardy when the facility failed to thoroughly investigate the allegation of abuse for Resident #1 and the bruising to Residents #2, #3, and #4, and failed to report to the State Agency, resulting in Resident #1 sustaining ongoing abuse. This deficient practice placed all 37 residents, residing on the locked dementia unit, at risk for serious harm, injury and/or death. Finding include: Review of the facility abuse policy dated revised 11/20/16 documented, All allegations of abuse, neglect, exploitation and misappropriation of property or involuntary seclusion shall be reported to the Administrator immediately. The Administrator or designee shall report immediately to the BHS (State Agency) but no later than 2 hours after forming the suspicion, if the events that cause the allegation involve abuse, neglect, exploitation or mistreatment, include injuries of unknown source, misappropriation of property or results in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury by completing the online submission form found on the BHS website though Spots/Champs. The facility will report to the State nurse aide registry or licensing authorities, any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. Resident #1 Resident #1 is a [AGE] year-old female, who was admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #1's Minimum Data Set (MDS) nursing assessment, dated 1/17/17, documented that she had severely impaired cognition. Resident was not her own responsible party. A review of a facility injury report, dated 4/22/17 at 23:48, documented that Resident #1 was found to have 2 small bruises on her left arm and 3 small bruises on her right arm (no size or description given). Under the Witnesses heading, it was documented in Resident #1's guardian statement on 4/23/17 that the guardian was notified of the bruising to both arms and said the bruises were there when she visited on 4/21/17 and she understood the bruises because she knows Resident #1 is resistive to care, and runs into walls and doorjambs. Resident #1's guardian said she needs to hold on to resident's arms firmly to keep her safe. Under people notified was listed Unit Manager, Licensed Practical Nurse M, Director of Nursing N and Nursing Home Administrator (NHA) A. During multiple observations on 4/25/17, Resident #1 would not allow staff to remove her long sleeve shirt to observe her bruises. Resident #1 was not able to respond to any questions about bruises on her arms due to her cognitive state. During an interview on 4/25/17 at 4:35 PM, Certified Nurse's Aides (CNA) B and C stated Resident #1 cannot be redirected for care, she always resists. CNA B demonstrated how she wraps her hand and arms around Resident #1 to hold her in place to change briefs and provide showers. CNA B did not recall any recent training for dementia care except for the computer training. CNA C denied any recent training and said her computer training was not due until May. CNA B said her grandmother taught her how to hold residents like that when they resist care. CNA B said the facility training she had in the past did not include holding onto residents that resists but said she uses this way of holding residents in place when ever they resist care. CNAC said she also holds residents in place that resist care and did not recall any recent education that would have instructed her not to hold residents in place that were resisting care. Resident #1's guardian was interviewed on 4/25/17. The guardian said she provided care for Resident #1 at home, prior to her admission to the facility and care was difficult. Resident #1's guardian said she had to hold Resident #1 down to provide care and has continued to hold Resident #1 down during care at the facility and was not told she could not hold her down. Resident #1's guardian reported observing staff hold Resident #1 down for showers and care and said it works best if you have 3 people, so someone can hold her hands. During an interview with CNA D on 4/26/17 at 11:25 AM, CNA D explained to Nursing Home Administrator (NHA) A that when Resident #1 is soiled or needs a shower she cannot do it unless she physically holds Resident #1. NHA A had to instruct CNA D twice that this was not allowed and informed CNA D if she was not able to redirected Resident #1 she needed to have other staff attempt care. CNA D was instructed that if other staff were unable to provide care they are to notify the nurse and it would not be CNA D's responsibility for care at that point it would be the nurses responsibility for care. NHA A said she was not aware staff were holding Resident #1 in place to provide care. The facility provided a copy of the recent education the majority of the facility staff had recently bee provided. The document contained the statement, F-223 Free From Abuse . Why we were cited: Failing to prevent abuse related to a resident being showered against his will and a resident to resident altercation. What do you need to know? Resident's have the right to refuse! Force cannot be used. CNA D signed that she received this education on 4/20/17. On 4/27/17 at 3:20 PM, the Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy that was identified on 4/25/17 and began on 4/23/17 when the facility investigation of Resident #1's bruises revealed that the facility became aware that Resident #1's family was firmly holding (restraining) resident #1 during care, and that same treatment was continued by facility staff, and when bruising of unknown injury was identified on Resident's #2, #3, & #4 without thorough and timely investigation and reporting. On 4/27/17 the Immediate Jeopardy was removed when the Surveyor verified the following: 1. On 4/27/17, facility staff performed skin sweeps of identified residents (#1, #2, #3) & #4 out to psychiatric hospital), updated care plans and Kardex's. 2. On 4/27/17, Physical Therapy Assistant and Corporate Nurse Consultant evaluated Resident #3 for safe transfers. 3. On 4/27/17, Nurse Managers conducted head-to-toe skin assessments on all residents and no further unidentified injuries of unknown injury were found. 4. On 4/27/17, Director of Well-Being Services re-inserviced Administrator and Director of Nursing on the Abuse/Neglect policy and procedure which included performing timely investigations and reporting. Also on 4/27/17, all staff education began on abuse/neglect policy and procedure, specialized care provision approaches for residents with dementia, and gait belt use with all transfers. No staff will work until they have had the education. 5. On 4/27/17, Audits began for QAPI. Although the Immediate Jeopardy was removed on 4/27/17, the facility remained out of compliance at the scope of pattern and a severity of actual harm that is not Immediate Jeopardy due to the fact that not all of the staff have been educated and the sustained compliance has not been verified by the State.

Based on observation, interview and record review, the facility failed to prevent the abuse of 3 residents (#1, #3 and #11), resulting in Resident #11 being forced to shower against his will and causing injury (bruised hand/arm and psychological harm based on reasonable person) and Resident #1 abusing another resident (#3) when the facility failed to implement interventions to prevent the abuse. Findings include: Resident #11 Review of Resident #11's electronic medical record revealed he was a [AGE] year old male admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident # 11 was not his own responsible party. Resident #11's Brief Interview of Mental Status (BIMS) dated 12/21/16 was 0/15 (severe cognitive impairment) and Resident #11's Minimum Data Set (MDS) an assessment tool, dated 1/3/17 scored him as severely cognitively impaired. Review of Resident #11's Risk Management incident report dated 12/22/16 at 16:57 documented, Resident was noted on this date by the first shift nurse to have a bruise on his left arm (no size or description of size, shape or color). Resident was agitated and angry while staff was showering him on second shift on 12/21/16 and attempted to strike and bite staff. He was not noted to have struck his arm on any surface, however, he may have done so. This note did not indicate the author but did show that it was locked by the the person that was the was the Director of Nursing (DON) at the time of the incident DON GG. Review of Resident #11's incident report dated 12/22/16 at 16:57, documented by Licensed Practical Nurse (LPN) LL, revealed the same information as the Risk Management incident report but had additional information. Under notes documented, Resident has a large purple bruise on his left forearm. 12-23-16 observation of bruise shows that the bruising light purple in color has spread to the top of the residents left hand. signed by LPN LL. Review of the facility investigation file revealed a hand written note with no signature or indication of who made the note and revealed 5 employees were interviewed about Resident #11's shower event on 12/21/16. The note dated 12/23/16 document Certified Nurses Aide (CNA) JJ reported she assisted with Resident #11's shower on 12/21/16. It took the LPN and two other CNA's to provide this shower (4 staff in shower to get the shower done). CNA JJ reported Resident #11 was swing his arms and hit LPN LL. LPN LL faced Resident #11 and held his arms at the hand/wrist and redirected him to the shower chair. Resident #11 calmed down and quit hitting and swinging his arms. 4 staff remained in the room while the highly agitated dementia resident gave clear indications he did not want a shower at that time. Review of CNA KK written statement dated 12/27/16 documented CNA KK helped give the shower on 12/21/16 and LPN LL took Resident #11 by the hands while facing him and lead him to the shower chair and Resident #11 was calm after that. Review of CNA MM written statement dated 12/27/16 documented CNA MM helped with Resident #11's shower and it took 4 staff to do the shower because Resident #11 was combative. MM said LPN LL took him by the hands and held him in the shower chair. LPN LL statement on 12/27/16 documented, I helped give Resident #11 a shower. I held his hands while facing him and led him to the shower chair. He was combative but once he was in the shower chair he calmed down and quit resisting. None of the staff statements indicated that they stepped back, redirected, or gave a time out when Resident #11 clearly indicated he did not want a shower. All 4 statements clearly showed physical force was used to get Resident #11 to comply with taking a shower which he clearly indicated he did not want to do. The last note on the statement was from CNA II' dated 12/23/16 and documented CNA II discovered the bruise on Resident #11's arm and hand during care on 12/22/16 (first shift). (incident report date 12/22/16 only documented a bruise on the arm 12/22/16 and the bruise on the hand came later on 12/23/16 (documented the bruise extended). CNA II report document Resident #11 was not combative during care on 12/22/16 and did not hit his hand. CNA II reported the bruise to the nurse on 12/22/16. (There was no incident report for the shower on 12/21/16 until 12/22/16 and there was not incident report done on 12/2216 by the first shift nurse when the bruise was discovered. The incident reports did not provide the size or full description of the bruises. During an interview with CNA KK on 3/21/17, in the conference room CNA KK, verified her hand written statement dated 12/27/16 about Resident #11's shower on 12/21/16 was accurate and stated LPN LL and CNA MM were also working right now. CNA KK, LPN LL and CNA MM were asked to demonstrate on the unit what happened when Resident #11 was showered on 12/21/16. CNA KK said Registered Nurse (RN) NN was on the unit that night and all 3 CNA's asked RN NN to help get Resident #11 into the shower room. (The facility investigation did not include RN NN). CNA KK said RN NN took Resident #11 by one arm and I took Resident #11 by the other arm. CNA KK said Resident #11 did not want a shower and had a history of [REDACTED].#11 was in the shower LPN LL also assisted with the shower. CNA KK and MM remembered CNA JJ was also present that night and had difficulty recalling when RN NN left the shower room. CNA KK, MM and LPN LL all recalled RN NN helping with getting Resident #11 to the shower room. LPN LL at first indicated he was the one that took Resident #11 into the shower room. CNA KK, MM and LPN LL all admitted they would never do a shower like that again and said they are now aware that even running water agitated Resident #11 and he is not placed in the shower any more (he is washed up with the shower on him). All 3 staff were asked if Resident #11 was given time out or any time to calm down when he first showed signs of agitation, or if they had made multiple attempts to shower him that night, and they all admitted they felt he had to have a shower at that time and when Resident #11 started getting upset they physically controlled him so he could not get away. All 3 staff were asked if they received any discipline or education related to the shower given on 12/21/16 and all 3 said, no. The staff did not indicate what they would do differently except not put Resident #11 under running water. (none of the staff verbalized standards of dementia care like giving time out, reproach, have a different staff approach). During and interview with RN NN on 3/22/17 at 4:15 PM, RN NN recalled assisting 3 CNA's give Resident #11 a shower months ago but could not recall for sure which CNA's were present or for sure what date the shower took place. RN NN said he was aware Resident #11 can become combative at times and was working on Resident #11's unit when the CNA's asked for help getting Resident #11 into the shower room. RN NN said it was clear Resident #11 did not want to go with staff so he took Resident #11 by one arm and another CNA took Resident #11's other arm so they would not be hit. RN NN said once they were in the shower room he took Resident #11's shirt off and Resident #11 head butted him in the chest. RN NN said LPN LL came into the shower room at that point and said he would take over. RN NN said LPN LL is in charge of at unit so I left and had not had not been interviewed or talked to about that event prior to today. RN NN said he did not ask staff if they had tried to approach again at a later time or what else had been tried prior to his arrival on the unit. RN NN admitted he should have asked questions before physically taking Resident #11 into the shower room Review of Resident #11's care giver care guide dated printed 3/23/17 documented under safety, 11-11-16 If I am resistive or aggressive with care Try another care giver, attempt to explain what you are doing, instruct me to do some of the care by giving step by step instructions. If able stop care and reapproach. (There was no evidence this was attempted when Resident #11 first became resistive to his shower on 12/21/16. There was no indication that is should take more than one person to assist Resident #11 shower on 12/21/16 yet he had at lease 4 people with him at all times that night). Under newly added, 3-7-17 showers are very distressing to me. Please assure that I have a full bath at the sink every day. If I require a shower please assign 2 staff to assist me safely to the shower chair one in the chair I may have 1 staff as this is less stressing to me. (This was not identified as an approach for more than 2 months after 5 staff forced Resident #11 into the shower). The section for behavior and mood offered more than 10 interventions to use to help keep Resident #11 calm and included staff are to walk calmly away and approach later. The 5 staff involved with forcing Resident #11 to shower on 12/21/16 did not mention any of these interventions. During the investigation on 3/23/17, Nursing Home Administrator (NHA) A verified all 5 staff (CNA II, CNA JJ, CNA MM LPN LL and RN NN) had abuse training at the facility in the last year. NHA A was unable to identify who did the hand written investigation of Resident #11's injury of unknown origin dated 2/23/16 to 12/27/16. NHA A said the NHA and DON that worked for the facility at the time of the investigation are no longer employed by the facility. NHA A was not able to locate any education or discipline for the 5 staff related to the shower incident on 12/21/16. Review of the facility policy for abuse dated revised 11/2016 revealed, Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, or pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Item #4 of the policy covered reporting/notification and documented at that all allegations of abuse, neglect and exploitation and misappropriation of property or involuntary seclusion shall be reported to the Administrator immediately. (the facility initially investigated and reported this incident as and injury of unknown origin on 12/22/16 but failed to report this allegations of abuse to the State Agency when they determined the injury was most likely cause by 4 staff forcing Resident #11 into a shower). The facility provided verification that all 5 staff involved in the forcing Resident #11 to have a shower or 12/21/16 had training in dementia care and the dementia care. Areas covered in the dementia training included: 1) Please use a non-demanding approach, be gentle and matter of fact (staff demanded Resident #11 shower at that time, were not gentle, physically forced Resident #11 to comply with the shower when staff wanted him to shower). 2) Many approaches to assisted the resident to engage in care were provided and included, spend the first few minutes quietly visiting with me, offer a glass of juice or water, give a gentle massage, play music, treat me like a friend, supply reassuring information, show me what you are trying to say. The inservice covered Things not to do: Don't argue, Don't order men around, Don't tell me what I can't do, Don't talk about me in front of me, Do not treat me like a child. It was not clear from the facility investigation or interviews that staff attempted any calm gentle approach to get resident #11 into the shower. The facility education lacked information on how to proceed with caring for a person with dementia once they become agitated. Resident #11 was observed receiving his morning care on 3/22/17 at 7:18 AM. CNA II and CNA QQ assisted Resident #11 from his bed to the bathroom (walked with assist of both CNA's and a gait belt. The CNA's washed Resident #11's body using water from the sink, changed his soiled brief and dressed him in clean clothing. Resident #11 was cooperative throughout the care. CNA's provided verbal reassurance and hand holding for comfort through out the care. CNA II and QQ said they have both cared for Resident #11 since his admission and do not have problems with providing care and said he cooperates when you use the right approach. CNA II and QQ said they have many new staff on 2nd and 3rd shift and think the problems related to Resident #11's care could be related to approach. CNA II and QQ were asked about the pressure ulcer that was on Resident #11 buttock for the last week and they said is it was healed. They Surveyor verified Resident #11 pressure ulcer was healed and asked the CNA's if they knew what caused Resident #11's pressure ulcer and both CNA's thought it could be related to 2nd and 3rd shift having difficultly getting Resident #11 to bed at night. Both CNA's reported he has been sleeping in a geriatric style chair at night. Resident #11 did not speak at all or answer any questions during the observation but did respond well to verbal cues and reassurance of what the care was being provided and that it would be done soon. This citation pertains to intake MI 613 Review of a facility Abuse policy last updated 11/2016 reflected The Resident has the right to be free from abuse, neglect, exploitation, misappropriation of property and involuntary seclusion. The policy defines abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy specifies that Resident care and treatments shall be monitored by all staff, on an ongoing basis, to assure residents are free from abuse, neglect, exploitation, misappropriation of property and involuntary seclusion. It is the responsibility of all staff to provide a safe environment for the residents. c. Any allegation of resident abuse, neglect, exploitation, misappropriation of property and involuntary seclusion shall be reported to the administrator immediately (abuse coordinator) and shall be thoroughly investigated and documented by the Administrator or designee. The policy directs The Administrator or designee shall report to the physician, families and/or legal representative, state agency and the appropriate law enforcement entities in which the facility is located, any reasonable suspicion of a crime against any individual who is a resident of the facility. The Administrator or designee shall report immediately to the (State Agency) but no later than than 2 hours after forming the suspicion, if the events that cause the allegation involve abuse, neglect, exploitation or mistreatment, including injuries of unknown source, misappropriation of property or results in serious bodily injury by completing the online submission form found on the (State Agency) website . Resident #1 Review of a facility Admission Record reflected that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had severe cognitive impairment and was able to ambulate independently with supervision. Resident #3 Review of a facility Admission Record reflected Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] reflected Resident #3 was severely cognitively impaired and needed limited assistance and supervision for ambulation. Review of a facility Incident Report dated 12/12/16 reflected (Resident #1) and (Resident #3) were in the hall by room [ROOM NUMBER] upon returning from a med pass. Informed by Certified Nurse Aide (CNA) E that residents were fighting. Both Residents standing and appeared agitated. The section in the incident report for Immediate action taken reflected that Residents were separated, examined head to toe and vital signs performed. Residents placed on 15 minute checks, residents placed in separate rooms for sleeping . Review of an Incident Note dated 12/14/16 reflected that a late entry for the 12/12/16 incident was made and described Resident previously verbally argued about ownership of purse belonging to (Resident #3). Residents separated and Resident #1 turned and hit Resident #3 and grabbed her by her hair and shoved her into door frame x 2 (twice). Residents separated, vitals performed, placed on 15 minute checks and sleeping arrangements in separate rooms. Notification to proper staff and family. Review of Progress Notes for Resident #1 reflected that on 12/7/16 (5 days before hitting Resident #3's head into a door frame) (Resident #1) following and targeting (another resident) attempting to get resident to go into her room. Review of a Progress Note for Resident #1 dated 12/11/16 (one day before the incident on 12/12/16) reflected that Resident #1 was trying to get another resident to stay in her room and was trying to get the other resident dressed into a gown, Resident #1 would become very agitated with staff and attempt to kick and push at staff and raise her fist to staff when staff tried to redirect Resident #1 away from the other resident. Review of an online progress note dated 12/11/16 reflected Resident #3 was Again targeting this other resident-pounding on door-putting hands around neck of registered nurse . Review of an online progress noted dated 12/12/16 reflected Resident #3 was given PRN (as needed) [MEDICATION NAME] given at 15:51 (3:51 p.m.) (Resident #3) continues to follow other resident Review of an online progress note at 12/12/16 at 1900 (7:00 p.m.), Incident, Grabbed resident by hair and hit her. Review of care plan interventions did not reflect new interventions or increased supervision were put into place for Resident #3 after an escalation in her resident focused behaviors leading up to the resident to resident abuse on 12/12/16. The reasonable person would not want to be grabbed by the hair and have her head hit into a door frame twice.

Based on observation, interviews, and record review, the facility failed to prevent an avoidable decline in ambulation, locomotion, eating, communication and transfers for one resident (Resident #9) out of 19 residents reviewed for ADL (activities of daily living), from a total sample of 22 residents, resulting in the resident no longer being able to assist getting in her chair, no longer being able to feed herself, and she is no longer singing. Findings include: According to a facility face sheet dated 3/21/17 at 15:56:27, Resident #9 was a [AGE] year old woman admitted in to the facility on [DATE] with the cumulative Diagnoses: [REDACTED]. Review of Medication Administration Record [REDACTED] [MEDICATION NAME](Concentrate) Solution 20 MG/ML give 5 mg by mouth every 4 hours as needed for pain AND Give 5 mg by mouth three times a day for pain. Order Date 2/17/17 and Start Date 2/27/17. An observation and interview occurred on 3/21/17 at 3:50 PM, with the Certified Nurses Aid (CNA) E as she entered Resident #9's room to get her up and get her ready for dinner. Resident #9 was observed to be sleeping soundly in her bed, and after several minutes of watching the CNA attempt to awaken the Resident (through constant talking to and some gentle rubs) CNAE was asked to tell this surveyor about this Resident who was sleeping soundly in her bed, CNAE stated, She has not been the same in the last 3 weeks, I was gone for 2 weeks and came back to a totally different person. When asked how so? CNA E proceeded with:1) So she didn't use to require a hoyer (a lift that assists in moving residents), she would get up on her own, now a 2 person assist. 2) For eating, she would eat on her own as long as you would put food in front of her. Now, she requires assistance to eat. 3) Resident #9 used to sing and talk all the time and now, all she does is sleep. CNA E stated again the resident is not the same. When asked, why the change? CNAE replied, now, she is on [MEDICATION NAME]. Review of Resident #9's Last Care Plan Review Completed 3/09/17 on page 38 of 44 under the heading of Focus reads as:I use physical restraints self releasing Velcro alarm seat belt r/t Confusion, Prevention of Injury. I continue to attempt to stand by self from my bed and chair, If staff try to assist I just let myself drop, complete non-weight bearing, I bite, hit, kick at staff, I am restless. I have tried a dyn-ergo chair with full tilt positioning to prevent rising on my own. Revision on 2/14/17 by Licensed Practical Nurse (LPN) W. Review of Resident #9's Progress Notes printed [DATE] at 16:19:48 ET revealed the following on 3/1/2017 at 12:31 under Social Service Progress Note: .Resident appeared tired as evidence by keeping her eyes closed and occasionally startling when lightly touched on hand by SW (social worker) intern. Resident occasionally vocalized during the piano playing. Resident opened eyes a few times and stated that's beautiful. Resident has been ill with [MEDICAL CONDITION] which may hinder the resident's ability to participate. On 3/8/2017 at 10:26 Social Service Progress Note revealed: .Resident participated in activity by sitting in her chair near the piano while intern sang/played for resident. Resident's eyes opened occasionally. Resident stated that is beautiful 2-3x during the half hour session. Resident vocalized occasionally with singing. Resident's level of participation stayed stable and was similar to session on 3/1. On 3/16/17 at 10:47 the Social Service Progress Note revealed: .SW intern met with resident to offer well being services, playing piano/singing with resident. Resident did not make any verbal statements or sing/vocalize during the activity. Resident opened her eyes twice and looked directly at intern during music playing. At the end of the time resident stated I am tired. SW intern has noticed a decrease in resident's participation the last two music sessions and today's session. Resident is less alert and less vocal during sessions. Interview occurred on 3/22/17 at 11:45 AM in the S2 unit nurses station with Licensed Practical Nurse(LPN) GGG, was asked to tell this surveyor about how Resident #9 had changed, LPN GGG replied,Resident's brain would not stop to rest, She would sing/was active, she would pop up and down in her chair (wheel chair), and she no longer feeds herself. So, the resident no longer does these things, LPN GGG, No. How long has the resident been declining? LPN GGG, stated: A couple of weeks. When asked if the Resident had any medication changes LPN GGG looked it up and stated Resident had been on [MEDICATION NAME] 3x day for a couple of weeks. Medication Administration On 3/22/17 at 12:07 PM, an observation and interview were conducted at the facility S-2 unit. As part of the Medication Administration Review an observation was arranged with Licensed Practical Nurse (LPN) U to observe the administration of the oral solution [MEDICATION NAME] sulfate to Resident #9 at the scheduled time of 12:00 PM. In the Dining Room of the S-2 unit Resident #9 was observed sitting reclined in a Geri-chair in front of a table prior to the noon meal. Resident #9 appeared to be sleeping. LPN U reported Resident #9 was originally placed on the medication [MEDICATION NAME] sulfate for pain. LPN U reported the Resident had displayed signs of being in pain and reported these signs were yelling and striking staff. LPN U indicated she was not going to administer the medication [MEDICATION NAME] sulfate to Resident #9 at this time because the order was being changed. LPN U moved to the Nurse Station at the S-2 unit where Nurse Practitioner (NP)HHH appeared to be reviewing the Electronic Medical Record (EMR) for Resident #9. NP HHH reported she was discontinuing the order for [MEDICATION NAME] sulfate and was going to order the medication [MEDICATION NAME]. NP HHH stated, We don't need to be knocking her (Resident #9) out. It was a big jump from Tylenol to ([MEDICATION NAME] sulfate) MS. We should be ok (with the [MEDICATION NAME]). On 3/22/17, at 12:49 PM, an observation and interview was conducted in the S -2 Dining Room. Resident #9 was observed in front of a table seated in a Geri-chair. Resident #9 appeared to be sleeping. Certified Nurse Aide (CNA) III showed a food tray and reported it was the tray that belonged to and was served to Resident #9 for the noon meal. It was observed the tray had been removed as the meal service had ended and that the food consumed by Resident #9 was approximately 1/2 of a pudding cup. It was observed the macaroni and cheese remained on the plate, as well as the stewed tomatoes and a drinking glass of milk or supplement.

Based on interviews and record review, the facility failed to provide an indication for use of a narcotic medication, specific monitoring of a pain medication, and failed to recognize the adverse consequences it had for one Resident (Resident #9), resulting in the use of a narcotic medication and the potential for increased adverse affects such as increased constipation, respiratory depression (such as chronic [MEDICAL CONDITION] or [MEDICAL CONDITION]), immunosuppression. Findings include: Resident #9 According to a facility face sheet dated 3/21/17 at 15:56:27, Resident #9 was a [AGE] year old woman admitted in to the facility on [DATE] with the cumulative Diagnoses: [REDACTED]. Narcotic drugs, are a drug such as [MEDICATION NAME] or heroine, that is derived from [MEDICATION NAME] or an [MEDICATION NAME] compound, relieves pain, often induces sleep, can alter consciousness, and is potentially addictive. http://medical-dictionary.thefreedictionary.com/narcotic Review of Progress Notes date [DATE] at 10:40:52 ET revealed that Resident#9 under the physician's orders [REDACTED].*Narcotic* Give 5 milligrams (mg) by mouth three times a day for pain AND Give 5 mg by mouth every 4 hours as needed for pain. Review of the Medication Administration Record [REDACTED] 2/23/2017 19:50 eMar-Medication Administration Note, [MEDICATION NAME](Concentrate) Solution 20 MG/ML Give 5 mg by mouth three times a day for pain . Resident appears more fatigued than normal. 3/2/2017 20:17 eMar-Medication Administration Note, [MEDICATION NAME](Concentrate) Solution 20 MG/ML Give 5 mg by mouth three times a day for pain held d/t excessive lethargy 3/7/2017 21:01 eMar-Medication Administration Note, [MEDICATION NAME](Concentrate) Solution 20 MG/ML Give 5 mg by mouth three times a day for pain held d/t excessive lethargy 3/16/2017 20:30 eMar-Medication Administration Note, [MEDICATION NAME](Concentrate) Solution 20 MG/ML Give 5 mg by mouth three times a day for pain held d/t excessive lethargy, sleeping in bed all shift sleeping, aroused enough to take meds then went back to sleep 3/21/2017 19:47 eMar-Medication Administration Note, [MEDICATION NAME](Concentrate) Solution 20 MG/ML Give 5 mg by mouth three times a day for pain held d/t excessive lethargy, difficulty eating, sleepiness In an interview on 3/22/17 at 11:45 AM at the S2 unit nurses station, Licensed Practical Nurse (LPN) GGG, was asked to tell this surveyor about how Resident #9 had changed, LPN GGG replied,Resident's brain would not stop to rest, She would sing/was active, she would pop up and down in her chair(wheel chair), and she no longer feeds herself. So, the resident no longer does these things, LPN GGG, replied No. How long has the resident been declining? LPN GGG, stated: A couple of weeks. When asked if the Resident had any medication changes LPN GGG looked it up and stated Resident had been on [MEDICATION NAME] 3x day for a couple of weeks. When asked why she was put on it, they had heard the resident state oww like in the dining room. When LPN GGG was asked if Resident #9 was on Hospice she stated no, husband does not want it. LPN GGG further explained that the Resident, did not have any indicators of pain, and can't explain why they went from tylenol to [MEDICATION NAME]. LPN GGG also added that the Group(of doctors, PA's etc ) that prescribed the medication is no longer with them. At this point LPN GGG leaves the S2 unit nurses station and the woman who had been working quietly at the computer station in the corner turned around and introduced herself as the Nurse Practitioner HHH, an alluded that the group she was working with had just taken over the care in here since the first of March. Nurse Practitioner HHH seemed to be concerned, that they had made the jump from tylenol to [MEDICATION NAME] and asked for Resident #9's name and room number so that she could look into it. Record Review of Order Recap Report date [DATE] at 09:03:38 ET, revealed that Resident#9 was prescribed by the Pharamcy, [MEDICATION NAME](Concentrate) Solution 20 MG/ML give 5 mg by mouth every 4 hours as needed for pain AND Give 5 mg by mouth three times a day for pain. Order Date 2/28/17 and Start Date 2/28/17. By Administrative order it was discontinued on 3/22/2017 at 12:19 for Reason Oversedation by Nurse Practioner HHH. Medication Administration On 3/22/17, at 12:07 PM, an observation and interview were conducted at the facility S-2 unit. As part of the Medication Administration Review an observation was arranged with Licensed Practical Nurse (LPN) U to observe the administration of the oral solution [MEDICATION NAME] sulfate to Resident #9 at the scheduled time of 12:00 PM. In the Dining Room of the S-2 unit Resident #9 was observed sitting reclined in a Geri-chair in front of a table prior to the noon meal Resident #9 appeared to be sleeping. LPN U reported Resident #9 was originally placed on the medication [MEDICATION NAME] sulfate for pain. LPN U reported the Resident had displayed signs of being in pain and reported these signs were yelling and striking staff. LPN U indicated she was not going to administer the medication [MEDICATION NAME] sulfate to Resident #9 at this time because the order was being changed. LPN U moved to the Nurse Station at the S-2 unit where Nurse Practitioner (NP)HHH appeared to be reviewing the Electronic Medical Record (EMR) for Resident #9. NP HHH reported she was discontinuing the order for [MEDICATION NAME] sulfate and was going to order the medication [MEDICATION NAME]. NP HHH stated, We don't need to be knocking her (Resident #9) out. It was a big jump from Tylenol to ([MEDICATION NAME] sulfate)MS. We should be ok (with the [MEDICATION NAME]). On 3/22/17, at 12:49 PM, an observation and interview was conducted in the S -2 Dining Room. Resident #9 was observed in front of a table seated in a Geri-chair. Resident #9 appeared to be sleeping. Certified Nurse Aide (CNA) III showed a food tray and reported it was the tray that belonged to and was served to Resident #9 for the noon meal. It was observed the tray had been removed as the meal service had ended and that the food consumed by Resident #9 was approximately 1/2 of a pudding cup. It was observed the macaroni and cheese remained on the plate, as well as the stewed tomatoes and a drinking glass of milk or supplement.

Based on observation, interview and record review the facility failed to prevent the development of a pressure ulcer for 1 Resident (#4) of 4 Residents sampled for pressure ulcers of a total of 22 sampled Residents, resulting in Resident #4 developing an unstageable ulcer on his right heel. Findings include: Review of Resident #4's face sheet revealed he was a [AGE] year old male, admitted to the facility on [DATE] and had the following diagnoses; [MEDICAL CONDITION], Muscle Weakness, and [MEDICAL CONDITION]. Review of Resident #4's Minimum Data Set (MDS) a nursing assessment tool, dated 2/24/15 revealed Resident #4 could not walk, and required extensive assistance of 2 people for transfers, dressing and hygiene. Review of Resident #4's Measurable Wound Assessment, dated 3/12/15 at 4:46 PM, revealed, Resident #4 had a pressure ulcer on his right inner heel that measured 6.5 cm x 6.0 cm (centimeter- unit of measurement) and was a stage II. The pressure ulcer was being treated with skin prep and wrapped with Kerlix (dry dressing) for protection. This assessment was signed by Licensed Practical Nurse (LPN) E. Review of Resident #4's Weekly Skin Sweep dated 3/12/15 at 7:34 PM revealed Resident #4 had an unstageable blister on his right heal that measured 6.5 cm x 6.0 cm, and was signed by LPN O. Review of Resident #4's progress note, dated 3/12/15 at 4:50 PM, revealed Resident #4 had a 6.5 cm x 6.0 cm intact thick blister on his right inner heel that protruded 1 cm out from the base of his foot and a 2 cm border of [DIAGNOSES REDACTED] (red area) surrounding the blister. The writer documented that Resident #4's leg rests on his wheel chair were too short and requested maintenance lengthen the foot rests. This progress note was signed by LPN H. Resident #4 was observed on 3/30/15 around 5:30 PM, sitting in his wheel chair in the hall. Two facility staff were attempting to put Resident #4's feet onto the foot rest of his wheel chair. Resident #4's legs were extended and past the foot rest by more than 5 inches and thick blue boots were on both feet. The staff were unable to bend Resident #4's knees to place his legs on the foot rests. Another employee came over to assist and was unable to get Resident #4's feet on the foot pedals. Resident #4's lower back was not in contact with the back rest (he slid down and was not seated properly). After approximately 20 minutes of attempting to put Resident #4's feet on the foot rest without success, staff took Resident #4 back to his room. Approximately 10 minutes later staff returned Resident #4 to the hall and Resident #4 was all the way back in his wheel chair and his feet were on the foot rests. (staff continue to struggle with pressure on feet due to positioning problems) During an interview with LPN E (Resident #4's unit manager) on 4/1/15 at 10:15 AM, LPN E reviewed Resident #4's wound and care plan documentation. When asked what was the root cause of Resident #4's pressure ulcer on his right heel, LPN E said Resident #4's foot rest were up too high . When asked if Resident #4's pressure ulcer was avoidable or unavoidable LPN Esaid the pressure ulcer was avoidable. Review of Resident #4's care plan for alteration in skin revealed Resident #4 had the skin care plan in place since 4/16/12 and an intervention was placed on 3/12/15 to elevate heels off he bed with pillow, blanket rolls or heel floatation device. No prior intervention for heel pressure relief in bed could be located in the 4 page care plan. Review of Resident #4's care plan for a Stage 2 intact, thick blister on the right inner heel related to foot rests being too short on wheelchair was dated 3/3/15 and revised on 3/12/15 revealed an intervention on 3/12/15 for maintenance to extend foot rests and thick protective boots to be on at all times except during hygiene and bathing. There was a resolved intervention dated 3/3/15 to float heels in bed and assure cushion padding on foot pedals or shoes when up (this showed prior knowledge of foot pressure problems while up in his wheel chair) Resident #4 was observed in bed on 4/2/15 at 9:50 AM. Resident #4 had thick blue boots on both feet. Both feet were placed on top of a heel floating device. Proper position is to have the calf of legs on the floating device and heels over the edge to prevent any pressure on the heel. LPN F was in the room to remove the dressing from Resident #4's right foot for observation. LPN F was asked if Resident #4's feet were properly placed on the floatation device and LPN F said, no the heels are not to be in contact with the floatation device. LPN F moved the floatation pillow to the proper position. LPN F removed the dressing from Resident #4's right heel and the inner heel had a circular black area approximately 2 inches in diameter. The outer area was black and the inner area was normal skin color. ( )

This statement of deficient practice has to two parts. A) Based on observation, interview and record review the facility failed to adequately supervise 2 of 9 residents reviewed for falls (#1 and #2) from a total sample of 22 resulting in a fall with fracture of the right hip for Resident #1 and a fall with fracture of the left hip for Resident #2. Findings include: Resident #1 Based on the Minimum Data Set (MDS) assessment, dated 2/6/15, Resident #1 was an [AGE] year old severely cognitively impaired male whose [DIAGNOSES REDACTED]. Based on the above MDS Resident #1 was dependent on staff for transfers, ambulation and toileting. Based on the MDS information in the electronic medical record (EMR) Resident #1 had been admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Resident #1 was readmitted to the facility from home on 3/13/15. Based on facility incident and accident reports Resident #1 had falls on 3/15/15 and 3/17/15 without injury and 3/19/15 resulting in a fractured right hip. All three falls were related to Resident #1 getting up out of bed (3/15/15) or the wheelchair (3/17/15 and 3/19/15) without staff assistance. On 3/29/15 at 12:00 PM Resident#1 was observed in his bed. He had removed his clothing and covers and was talking to and looking at someone not present in the room. Resident #1 had a foam abductor pillow (triangle shaped pillow that keeps the legs apart to prevent dislocation of the surgically repaired hip) between his legs and foam heal protectors on. Based on the (corporation name) Incident Accident Fall Report 1.1, dated 3/19/15 at 4:40 PM, Licensed Practical Nurse (LPN) R observed Resident #1 stand up from his wheelchair at the North nursing station, step over the foot pedals that were in use (in the down position), then take 2 steps and lose his balance falling to the floor on his right hip and shoulder. During the assessment after the fall Resident #1 was grimacing in pain with movement of the right leg and was sent to the hospital for treatment. Resident #1 had surgery to repair the fracture and returned to the facility on [DATE]. LPN R was not available for interview. On 4/1/15 at 10:20 AM Unit Manager (UM) LPN H stated that wheelchair pedals (footrests) should be removed or be folded up when a resident was not being transported by staff. Based on the (corporation name) Fall Risk Assessment, dated 3/19/15 after the fall, Resident #1 had problems with ambulation and balance, the wheelchair brakes were not locked and he had been restless at the time of the fall. Based on the nursing notes, dated 3/13/15 at 9:57 PM-3/19/15 at 6:21 PM, Resident #1 had multiple episodes of standing from the wheelchair and ambulating unassisted on 3/13/15, 3/14/15, 3/17/15 and 3/18/15. There was no documentation of what, if any, interventions had been used by staff to address Resident #1's restlessness. The Admission/Readmission Assessment, dated 3/13/15 reflected Resident #1 had a history of [REDACTED]. TheFall Risk Assessments completed on 3/17/15 and 3/19/15 reflected ambulation, balance and cognitive status issues that put him at risk for falls. The care plan for Risk of Falls, dated 1/31/15 and currently in use, reflected Resident #1 was unaware of safety needs, confused, had impaired balance and gait and was deconditioned (muscle weakness). Interventions to prevent falls included; string alarms (alarms when the string is stretched and pulls the magnetic contact away from the alarm box to sound the alarm) on in the wheelchair and bed (1/31/15) and a sensor alarm (pad under a weight bearing area alarms when the resident moves off it) on the wheelchair seat (3/17/15), anticipate and meet my needs, follow fall protocol, if I am restless and attempting to stand up by myself, take me for a walk (2/12/15), and transfer with 1 staff assist. The Activities of Daily Living care plan, dated 1/31/15, reflected the intervention I use a Front wheeled walker for AMBULATION with limited assist of one in the hallways. The care plan related to activities, dated 2/4/15, reflected interventions such as bingo, yahtzee, men's group, going outdoors, listening to his favorite music of Johnny Cash, watching TV, being around family, pets and snacks. The Kardex (used by nursing aides when giving care) reflected interventions of a busy board, blocks and water bottles filled with rice, beads and plastic toys to attempt to hold my attention. On 4/1/15 at 10:20 AM Unit Manager (UM) LPN H stated that on readmission to the facility on [DATE] Resident #1 had either walked with staff or used the wheelchair independently for mobility. UM LPN H stated Resident #1 was impulsive and would ambulate unassisted. On 4/2/15 at 1:55 PM UM LPN H stated Resident #1 had a very short attention span and staff would distract him by talking or walking with him and using an activity board. UM LPN H stated she had seen Resident #1 with his activity board on 3/19/15 at about 3:30 PM. UM LPN H stated there was no facility policy related to the footrest position on the residents' wheelchair but the facility used Perry and Potter's Clinical Nursing Skills and Techniques 7 th Edition, 2010, for their policy. The above reference pages 330-331 reflected safe transport using a wheelchair included raising the foot plates (footrests) before transferring to prevent tripping over the foot plate. ( ) According to the fall care plan created 1/7/15 and revised 3/27/15 Resident #2 was a [AGE] year old. The Annual Minimum (MDS) data set [DATE] reflected Resident #2 had Brief Interview for Mental Status score of 02 out of a possible 15, which indicated severe cognitive impairment. The progress notes dated 3/31/15 reflected Resident #2 was readmitted [DATE] with [DIAGNOSES REDACTED]. The progress notes dated 3/6/15 under Nursing Care Review reflected Resident #2 reflected for bed mobility, walking in room and unit, locomotion she needed to be set up and supervised. For transfers Resident #2 needed supervision and one person assistance. These same progress notes dated 3/6/15 also reflected medical devices used were tab alarm bed and chair, hipsters, pressure relieving cushion for recliner chairs or other chairs. Use Dycem to prevent sliding with cushion. The psychiatric follow-up report dated 2/16/15, under History of Present Illness reflected Since the last visit the resident (#2) had episodes of refusing medication. Severity: Moderate. Associated sx (symptoms): swearing, combativeness and mood swings x 7, change in appetite x 2, sleep difficulty x 1, crying x 1, statements of depression x 3, physical behaviors x 6, verbal behaviors x 5. This same follow-up psychiatric report dated 2/16/15, reflected the previous week Nursing Manager reported resident (#2) did have a fall with injury and under the Medical, Psychiatric, Family and Social History also reflected that Resident #2 has had significant changes in Psych Interval History. Resident #2 had 8 falls beginning 10/24/14 through 3/26/15. The new interventions that were put in place were appropriate for the circumstances for the falls that took place 10/24/14 through 3/18/15. The exception was the fall that took place on 3/26/15. According to the fall report dated 3/26/15 the following took place, This nurse was obtaining report from the second shift nurse in med room when a can (sic) shouted 'I need some help here.' This nurse then looked into the dining room and saw the resident (#2) lying on the floor. The resident (#2) was laying on her back leaning to the left side. She was positioned with her head toward the windows and feet toward the door leading to the hallway. Skin sweeps revealed a laceration behind the left ear approximately 0.5 cm by 0.5 cm and a reddened area approximately 2 inches in diameter to the left scapula. According to the staff witness statement, dated 3/26/15, Res. (#2) stood up and started walking, then resident (#2) lost her balance. Before I could get to her she state 'Oh as she fell on her left side and she hit her left side and she hit her left ear on the computer cart. The immediate intervention was to place tab alarm on resident while seated. The new or revised intervention for the 3/26/15 fall was I need a tab alarm in my chair or bed to remind me to ask for assistance to walk or transfer. Based on Resident #2's fall care plan, an intervention to use the tab alarm was already in place as of 1/31/15. The fall intervention dated 1/31/15 reflected Staff educated on use of alarm when in chair in dining room. Resident does get up and down frequently, sometimes not allowing time to put alarm on. Staff to be alert to residents mobility and close supervision with her getting up and down. The fall report investigation for the 3/26/15 fall indicated the resident does not have an alarm. There was no answer to the question Is the resident complaint with restraint and/or alarm use? On 4/2/15 at 1:15 PM, Unit Manager of S-2 was asked why was tab alarm on chair added as a new intervention after Resident #2's fall on 3/26/15, when it was already care planned 1/31/15. Unit Manager L stated Resident #2 refuses care, so the intervention was changed to sensor pad in chair on 3/27/15. However, between 1/31/15 and 3/27/15 the care plan had not been changed and the facility was aware Resident #2 was combative with care. Unit Manager of S-2 was asked why Resident #2 was not sent to the hospital on [DATE] immediately after her fall, Unit Manager L replied because Resident #2 did not show any signs of injury until 3/27/15. According to the hospital discharge summary report dated 3/29/15, Resident #2 was admitted to the hospital on [DATE] and discharged [DATE]. The hospital discharge summary reflected Resident #2 was sent to the emergency department after x-rays done at the facility which showed a left hip fracture. The Pain Assessment Summary dated 3/29/15 reflected Resident #2 moans with movement and requires assistance with activities of daily living because of the pain. During initial tour on 3/30/15 at about 10:45 AM, Unit Manager M stated Resident #2 had a recent fall and fracture and the family refused surgery, so Resident was in a Geri chair with a lap tray, because Resident #2 had poor safety awareness and kept trying to stand on the fractured hip. On 4/2/15 at about 1:30 PM, Unit Manager L stated Resident #2's family decided to proceed with surgical repair ton Resident #2's left hip. Resident #2 was readmitted to the hospital on [DATE] for repair of the hip fracture. ( ) B) Based on observation and record review the facility failed to follow manufacture instructions for safety (prevent accidents) when transferring 4 Residents (#4, #17, #18, #23) of 5 Residents sampled for lift transfers of a total of 22 sampled residents, resulting in the potential for injury or falling out of the lift sling when being transferred. Findings include: A review of the undated, Invacare's manufacturer guidelines reflected, 'Warning' When the sling is a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are NOT properly in place, lower the patient back onto the stationary surface and correct this position - otherwise, injury or damage may occur. The legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shifter handle immediately. Pump the lift handle or press the up arrow button to raise the patient above the bed. The patient should be elevated high enough to clear the bed with their weight fully supported by the lift'. Resident #4 Review of Resident #4's face sheet revealed he was a [AGE] year old male, admitted to the facility on [DATE] and had the following diagnoses; Alzheimer's Disease, Muscle Weakness, and Glaucoma. On 3/30/15 at 3:00 PM Resident #4 was observed being transferred from his bed to his wheel chair by Certified Nurses Aides (CNA) C and D. CNA C and D attached all 4 of the black loops of the sling to the Invacare Reliant 600 lift hooks, lifted Resident #4 up and placed Resident #4 in his wheel chair. When moving Resident #4 from his bed to his wheel chair both of Resident #4's feet dragged across his bed. The CNA's did not check the sling loops were connected to the hooks once Resident #4 was a few inches off his bed. The CNA's positioned the wheel chair over one of the lift legs and kept the lift legs in the closed position through out the entire transfer. Resident #17 Review of Resident #17's electronic medical record revealed she was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. On 4/1/15 at 1:20 PM CNA A and B were observed transferring Resident #17 from her wheel chair to her bed. CNA A and B placed the green loops on the Invacare Reliant lift hooks, lifted Resident #17 up and placed her in bed. When starting the transfer, the legs of the Invacare lift were in the full open position but after removing the wheel chair CNA B place the lift legs in the closed position and proceeded to move Resident #17 more than 10' to her bed with the legs in the closed position (see instructions below, legs are to be in full open position when moving the resident). The CNA's did not check the sling loops for connection to the hooks once Resident #17 was a few inches off the wheel chair. ( ) Resident #23 On 4/1/15 at approximately 4:50 p.m. Resident #23 was observed transferred from her bed to her wheelchair by CNAs I and J. via the facility's Invacare Reliant 450 hydraulic lift. Staff were observed to position Resident #23 in the sling, slip the loops onto / over the hooks attached to the lift and raised Resident #23 in the sling off her bed and then into her wheelchair. An additional check of the loops postioning on the hooks did not occur once Resident #23 was lifted (via the machine) off, but still over the bed, per manufacturer's directions. Additionally, the legs on the machine were not open to their maximum opened capacity while Resident #23 was positioned in bed, as well as, while performing the transfer from off her bed and into her wheelchair. ( ) Resident #18 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #18 was a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #18 required extensive assistance of 2 people for transfers. An observation on 4/1/15 with Certified Nursing Assistant (CNA) G and Licensed Practical Nurse (LPN) F, revealed Resident #18 was transferred from his Broda chair to the bed using the Invacare reliant 600 hydraulic lift. During the observation, LPN F and CNA G did not open the legs of the lift to the maximum open position. ( )

Based on observation, interview and record review the facility failed to provided adequate supervision and properly functioning assistance devices for 6 Residents (#4, 5, 13, 14, 22 and 25) of 8 sampled residents reviewed for falls out of a total of 22 Residents resulting in Residents #5 falling a suffering a hip fracture and significant decline in function, Resident #22 falling/suffering a laceration to her head resulting in hospitalization and a significant decline in function, Resident #13 falling and Resident's #4, 14 and 25 having the potential to fall due to alarms not set to function properly. Findings include: Resident #5 Review of Resident #5's face sheet revealed she was an [AGE] year old female admitted to the facility on [DATE] following a right hip fracture and she had Alzheimer's Disease. Resident #5 Minimum Data Set ((MDS) dated [DATE] revealed she was severely cognitively impaired and required minimal assistance of person to transfer and walk. During an interview with the Director of Nursing (DON) and Unit Manager, Licensed Practical Nurse (LPN), "B" on 3-25-14 at 10:55 AM. This Surveyor reviewed Resident #5's falls since 7-14-13 through 1-18-14 (fall with hip fracture). Resident #5 had 9 falls in 5 months (from 7-14-13 up to the fall 1-18-14) . When Unit Manager "B" reviewed the documentation for the fall on 1-18-14 she said Resident #5 was wearing slippers with an open heal and was not being assisted to walk with her walker. Unit Manager "B" reviewed Resident #5's care plan and found she was to be using gripper socks and 1-16-14 Resident #5 had been provided a walker but amount of assistance required to use the walker was not care planed. Resident #5 was care planned to have an alarm on her bathroom door and no alarm was sounding at the time of the fall. Review of Resident #5's falls with the DON and Unit Manager "B" on 3-25-14 at 10:55 a.m. revealed, Resident #5 fell on [DATE] at 11:30 p.m. and her alarm was not sounding. Resident #5 fell on [DATE] at 3:15 a.m. and was not care planned to have any new intervention to provide supervision or assistive devices. Resident #5 fell on [DATE] at 12:20 p.m., Resident #5 was not observed and was in another residents room using that residents walker and there was no new intervention care planned to provide increased supervision or assistive devices. Resident #5 fell on [DATE] at 4:53 p.m., Resident #5 was in another residents room and had an unwitnessed fall resulting in a laceration to her head, Resident #5 was care planned to be directed out of other resident rooms. Resident #5 fell on [DATE] at 9:00 a.m. walking in the hall with a cup, Resident #5 spilled her drink and slipped in the liquid and fell , Resident #5 was care planned to remove liquids while walking. Resident #5 fell on [DATE] at 1:30 p.m. when attempting to leave the nursing unit and staff lowered her to the floor, after this fall staff were educated to secure the unit door. Resident #5 fell on [DATE] at 6:40 a.m., Resident #5 was lowered to the floor when staff ran to catch her in the hall, Resident #5 was in slippers that she did not usually use and slippers were removed and gripper socks used.. Resident #5 fell on [DATE] at 7:15 a.m. in the main dining room attempting to put on her sweater the new intervention to prevent falls for this incident was to have her sweater on prior to breakfast. Resident #5 fell on [DATE] at 10:45 a.m. in the main dining room, the new intervention to prevent falls was keep out of congested areas. Review of the Incident Accident Fall Report 1.1 for Resident #5 dated 1-18-14 at 11:00 a.m. revealed Resident #5 was in the bath room, had used the toilet at 9:00 a.m.. Resident #5 did not have her walker when she fell . Resident #5 had alarms and they were not sounding. Under other was documented, "increased weakness trialing w/w (wheeled walker)". Under immediate intervention was documented, "Removed open back slippers from room, obtained pelvis x-ray." Under of history of falls was documented, "Number of falls in 90 days 7." Review of Resident #5's progress note dated 1-18-14 at 2:06 p.m. documented, "Cena (Certified Nurses Aide) heard a yell and observed res (resident) on BR (bath room) floor...1:1 to assure safety, open heeled slippers removed from room." Review of "#961 Fall" for Resident #5 dated 1-18-14 at 11:00 a.m. revealed on page 3, under Predisposing Situation Factors, "ambulating (walking) without Assist and Improper Footwear" Under Other Info on page 3 was documented, "Resident was on bathroom floor with alarm not sounding, resident trialing w/w (wheeled walker) though required several reminders by staff to use." On page 3 under notes was documented, "Report and staff statements reviewed all current safety precautions were in place, resident had on her hipsters, alarm was intact on her bathroom door. She had been given her walker by staff but pushed it away. Resident does have a dx (diagnosis) of osteopenia per Xray. Resident is independent with ambulation and fall risk factors have been discussed with family. It has been discussed by the family that resident being able to independently ambulate is a quality of life issue for her and out was the fall risks and possible injury." Review of a hand written statement provided in Resident #5's fall investigation, dated 1-18-13, signed by Certified Nurses Aide CNA "F' " revealed Resident #5 did not want to use her walker that morning and was pushing the walker away. CNA "F" documented she was passing fresh water at 11:00 a.m. when someone told her that they heard a "ahh", no alarms were sounding, Resident #5 was found on the bath room floor. During an interview with CNA "F" on 3-25-14 at 2:10 p.m. CNA "F" said she was working on 1-18-14 when resident #5 was found on the bath room floor and Resident #5's bath room door alarm was not sounding, CNA "F" recalled assisting Resident #5 earlier due to not wanting to use her walker. CNA "F" was asked if Resident #5 was to be assisted with her walker and she said therapy did not give them any direction and she did not recall any new information on the "Needs to know clip board" Review of a hand written statement provided with Resident #5's fall investigation for 1-18-14 signed by CNA "G", revealed she was assigned to work with Resident #5 on 1-18-14. Resident #5 was awake earlier than normal (6:15 a.m.) and after care took her to the dining room to wait for breakfast. CNA "G" documented, "Resident was leaving her walker very frequently and all staff would assist with giving her walker back and redirecting her. When the incident occurred I was not on the hall. I was on my lunch break." During an interview with CNA "G" on 3-25-14 at 12:05 p.m. CNA "G" said she was not instructed to walk with Resident #5 with her walker. CNA "G" said Resident #5 was provided the walker because she was leaning more and not walking good, but she did not get any instruction in the resident care guide to provided assistance walking with Resident #5. CNA "G" said the alarm did not sound on Resident #5 bath room door but it could have been because she entered from the other residents room (bath room has two doors). Review of "Incident Investigation Report" for Resident #5 dated 1-18-14 signed by CNA "H" revealed she was charting when she heard a yell and went looking to see where it came from. During an interview with CNA "H" on 3-25-14 at 1:55 p.m., CNA "H" said she was working on 1-18-14 when Resident #5 fell and CNA "H" said she had redirected Resident #5 early that morning out of unsafe locations and Resident #5 was not using her walker all the time. CNA "H" said she was told that Resident #5 was independent walking and was not aware of any change in Resident #5 Kardex (care giver guide). CNA "H said Resident #5 is not able to walk at all now and needs help of one person for transfers. Review of the Physical Therapy Discharge Summary for Resident #5 dated 1-16-14 through 1-17-14, revealed under "Summary Since Eval/SOC, " Pt (patient) and Caregiver Training: PT/Nursing staff education was completed regarding the use of fww (front wheeled walker). I have given a patient fww (front wheeled walker) non swivel wheeled walker at first due to needed stability with AD (assistive device). Pt (patient) did do well with that without signs or symptoms of a fall or any kind of LOB (loss of balance). I also communicated with PTA (Physical Therapist Assistant) "name" and floor nurse on that shift. However on Friday 1-17-14, I received a call from PTA "name", stating that as per the floor nurse and Unit Manager "B" , pt (patient) was trying to sit on the walker assuming like it is a 4ww (4 wheeled walker), and UM (Unit Manager) was requesting 4ww (4 wheeled walker), because of that. I agreed with the condition that pt (patient) receive constant supervision because pt (patient) is not familiar with breaks and could be too mobile for her. However, UM (Unit Manager "B" told PTA "name" that she has care planned her with constant supervision with verbal cues while using AD (assistive device). Therapy Discharge note was signed by Physical Therapist (PT) "I". Review of physical therapy notes revealed a "Tonetic Assessment Tool: Balance" was completed by PT "I" on 1-16-14 for Resident #5 and she scored 8/28. (patients scoring below 19 are at a high risk for falls.) During an interview with PT "I" on 3-25-14 at 3:00 p.m., PT "I" reviewed his notes on Resident #5 for 1-16-14 and 1-17-14. PT "I" said that Resident #5 was not independent with ambulation prior to the Physical Therapy Evaluation because when he spoke with the nurse practitioner the nurse practitioner had witness a near fall backward on 1-15-14 and staff assisted Resident #5 so she did not fall. PT "I" said when he interviewed staff they said she required assistance. PT "I" said when he gave Resident #5 the walker he expected staff would walk with her with a gait belt on. PT "I" said he had completed a balance assessment on Resident #5 on 1-16-14 and she scored 8/28 and that score would indicated she was not safe to walk independently. PT "I" said he gave this information to Unit Manager "B" and that Unit Manager "B" does the care plan and communication with the nursing staff. During an interview with Unit Manager (UM) "B" on 3-26-14 at 10:55 a.m., UM "B" reviewed Resident #5's care plan and caregiver care guide and was unable to locate any direction for amount of assistance needed when Resident #5 was walking prior to 1-16-14. UM "B" found a resolved care plan dated 1-16-14 that read, "Therapy has given me a walker, when I use it I am showing improved ambulation skills, I often forget to us the walker or will walk away from my walker I need frq (frequent) reminders to use 1-17-14 I have tried to sit on my walker therapy will be giving me a walker with a seat on it please continue to encourage me to use it." This Surveyor asked UM "B" if therapy gave her more directions as to the amount of assistance Resident #5 needed and UM "B" recalled PT said she required constant supervision, but UM "B" said we can not do that so I did not put that on the care plan." Review of a "Radiology" report for Resident #5 dated 1-18-14 revealed under "Impression: Suspicion for angulated acute right intertrochanteric hip fracture requiring complete hip radiographic series confirmation. Review of the "Operative/Procedure Report" for Resident #5 dated 1-19-14 revealed she had a preoperative [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set ((MDS) dated [DATE] revealed she had a significant change in her function after her hip fracture 1-18-14. MDS date 1-29-14 revealed Resident #5 now required extensive assistance of two people to transfer and was no longer able to walk. During the initial tour on 3-24-14 at 10:20 a.m. Resident #5 was observed in bed with her tab alarm sitting on the mattress (box not attached to the bed) Review of the tab alarm instruction book on page 3 revealed under patient set up and use, "#1. Securely mount the pulsating monitor to the wheel chair using the clip on the back of the monitor. If using on a bed, clip the monitor to the optional bed mounting bracket." ( ) Resident #22 Review of Resident #22's closed record revealed was admitted on [DATE] and passed away on 3-18-14 on Hospice care. Review of Resident #22's Minimum Data Set ((MDS) dated [DATE] revealed she scored 7/15 on her Brief Interview for Mental Status (BIMS), moderate mental impairment. Resident #22 required limited assistance of 1 person for transfers and limited assistance of one person to walk in her room or the hall. During an interview with Unit Manager (UM) "A", on 3-27-14 at 3:10 p.m. this Surveyor reviewed Resident #22's falls with UM "A". Resident #22 had 18 falls from 9-26-13 to 12-7-13 when Resident #22 fell and sustained a laceration and required hospitalization . Resident #22 fell on [DATE] had an unobserved fall and there was no evidence of any new fall intervention being care planned. Resident # 22 had a fall on 10-11-13 when in the main dining room her alarms sounded and she was care planned to have a decrease in alarms due to agitation. Resident # 22 fell on [DATE] was unobserved and her alarm was not functioning. Resident # 22 fell on [DATE], Resident #22 was observed putting herself on the floor and saying "I need to[***], Resident # 22 was care planned to check her hemorrhoids. Resident # 22 fell on [DATE] unwitnessed in her room and alarms were not sounding, no new fall interventions were care planned. Resident #22 fell on [DATE] unobserved found in front of roommates refrigerator (refrigerator, TV and VCR were on the floor. The new intervention care planned was to move the room mates refrigerator. Resident #22 fell on [DATE] when she climbed out of her recliner and the new intervention to prevent falls was frequent checks. Resident #22 was found on floor 11-10-13 with shoes and socks off, no new fall interventions care planned. 11-17-13 Resident #22 fell out of her wheel chair when staff pushed her without her foot pedals in place. Staff were educated to have foot pedals on wheel chair when transporting resident. Resident #22 was found on her floor in there room on 11-20-13 at 4:15 p.m. and no new fall interventions were care planned. Resident #22 fell again on 11-20-13 at 9:10 p.m. when she stood up on her wheel chair pedals, no new fall interventions were care planned. Resident #22 fell again on 11-10-13 at 10:10 PM getting out of her recliner, the new fall intervention was to remove the recliner. On 11-26-13 at 1:59 p.m. Resident #22 was observed sliding out of her wheel chair to the floor with her socks in hand and the new intervention care planned was to have shoes on. Resident #22 fell again on 11-26-13 at 6:30 p.m. (unobserved), new intervention was to check blood sugars due to her blood sugar was high. Resident #22 fell on [DATE] at 11:15 a.m. observed sliding out of wheel chair, new intervention was Dycem ( material to prevent sliding) in seat of wheel chair. Resident #22 found sitting on floor again on 11-29-13 at 4:20 p.m., Resident #22 had removed her socks (Resident did not have shoes on as care planned). Resident #22 was observed standing and falling on 12-3-13 at 10:59 p.m. the plan was for therapy to provide Resident #22 with a merri walker (assistive device for walking), no evidence in the care plan that this occurred. Resident #22 was observed scooting out of her wheel chair and slid to the floor and sustained a 7" skin tear to her left elbow, new intervention was Dycem to the top of wheel chair pad. Resident #22 was observer standing from her wheel chair and falling in hallway residents alarm was sounding and Resident #22 was transferred to the hospital for sutures. Resident #22 returned from the hospital on 12-10-13 on hospice. Review of Resident #22's Minimum Data Set ((MDS) dated [DATE] revealed she had a significant decline in function. Resident #22 Brief Interview for Mental Status decline to 3/15 (severe cognitive impairment). Resident #22 required extensive assistance of 2 people for transfers and limited assistance of 2 people to walk in her room. ( ) Resident #14 During the initial tour on 3-24-14 around 10:10 a.m. Residents #14 was observed in bed with is tab alarm sitting on the mattress not attached to the bed. Certified Nurses Aide (CNA) "F" was in the room and this Surveyor asked if the tab alarm was hooked up correctly and CNA "F" said she should have hooked the alarm to the bed and than hook it to the bed. Resident #4 On 3-24-14 at 3:30 p.m. Resident #4 was observed sitting in a chair by the nurses station. Resident #4 attempted to stand and was assisted by staff. When Resident #4 started to stand both feet slid forward and she sat back down. The staff person stated "darn slippers" as he assisted her back down. The staff person went to the nurses station and started doing paper work (staff did not assess Residents #4 slippers to see why they slid on the floor. On 3-24-14 at 3:42 p.m. this Surveyor asked CNA "L" to check the caregiver Kardex for fall precautions for Resident #4. CNA "L" read the Kardex which included non skid socks. This surveyor asked CNA "L" to check Resident #4's slippers because she had observed Resident #4 attempt to stand and the slippers slid out from her. When CNA "L" lifted Resident #4's feet large wads of gray lint and dirt were observed in bedded in the bottom of both slippers. CNA "L" replaced the slippers with gripper socks. On 3-25-14 at 8:25 a.m. Resident #4 was observed walking independently with the same slippers on that had been removed by CNA "L" on 3-24-14. Resident #25 On 3-25-14 at 8:27 a.m. Resident #25 was observed standing at the nurses station and his pressure alarm did not sound for approximately 30 seconds. Staff observed Resident #25 stand and assisted him back in his wheel chair. Staff did not assess or replace the alarm. Resident #25 was observed on 3-25-14 at 8:35 a.m. and was assisted to stand by CNA "F" and CNA "G". Resident #25's pressure alarm did not sound for 10 second after he was standing. CNA "F" and "G" did not assess or replace Resident #25's alarm. On 3-27-14 at 11:15 a.m. this Surveyor asked CNA "F" to demonstrate how Resident #25's pressure alarm should function when he was in the wheel chair. Resident #25 was in his bed at the time. CNA "F" pressed her had on the pad to activate the alarm and when she removed her hand the alarm immediately sounded. This Surveyor explained she had observed Resident #25's alarm not sounding immediately on another day and asked what could cause the alarm to delay and CNA "F" they do not work well when the batteries are low. ( ) Resident #13 According to the information section on the electronic record keeping system, Resident #13 was an [AGE] year old male who resided at the facility since 6/22/06 and readmitted [DATE] with [DIAGNOSES REDACTED]. Based on the Significant Minimum Data Set (MDS) assessment dated [DATE] Resident #13 had a Brief Interview for Mental Status score of 3, reflecting severe cognitive impairment. According to the incident and accident reports dated from 7/2013 to 3/2014, Resident #13 had eleven falls. The incident and accident fall report dated 8/4/13 reflected "resident observed lying on DR (dining room) (floor) after another res (resident) called out to help, res (#13) attempting to get self up, assessed for any injuries, hip misalignment or LE (lower extremity) deformities, good ROM (range of motion) ... amb (ambulated) with continuous lean to right limping gait... plan of care is to assist to DR and back to bed for meals or one to one activities." On 3/26/14 at 10:45 am, during an interview with South 1 Unit Manager "B" she stated Resident #13 was not alone in the dining room but the staff that were in the dining room had their backs turned to the residents while they were removing dishes. This same incident and accident report reflected "no witnesses were found." Unit Manager South 1 "B" stated the root cause was the staff had their backs turned. The 11/8/13 Incident and accident report reflected "Pt observed on the floor on his bottom with his back leaning up against another patient's wheelchair at one end of the room to the middle of the room. Pt unable to make clear statement." Under immediate action it reflected "the tab alarm not sounding and not attached to the pt (patient) sensor pad put in place." On 3/26/14 at 10:45 am, during an interview with South 1 Unit Manager "B" stated resident detached the tab alarm. ( ) ( )

This citation pertains to intake number MI 643. Based on observation, interview, and record review, the facility failed to prevent the elopement and ensure the safety of 1 of 4 sampled residents (Resident #101), from a total sample of 6 residents, resulting in an Immediate Jeopardy (IJ) when, on 1/13/13 at 9:46 AM, Resident #101, who was identified as an elopement risk, removed the screw from the window, cut the screen and exited out the window of her room. Resident #101 was returned to the facility on [DATE] at 11:10 AM escorted by a Belding police officer. This deficient practice placed 63 additional residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of the Face Sheet and Metron Admit/Readmit Assessment 1.2, dated 1/8/13, revealed Resident #101 was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Face Sheet, Resident #101 had a legal guardian. According to the assessment dated [DATE], Resident #101 had poor safety awareness and was an elopement risk. Resident #101 was placed on the secured unit and frequent checks were initiated (every 15 minutes). In a telephone interview on 2/26/13 at 11:32 AM, Registered Nurse (RN) #4 stated that Resident #101 was on 15-minute checks because she was an elopement risk. RN #4 stated on 1/13/13 at approximately 11:00 AM, Certified Nurse Aide (CNA) #5 reported that Resident #101 was missing. RN #4 stated a code for a missing resident was called over the intercom. RN #4 stated that Resident #101's window screw was removed, the screen was cut and it appeared that she had eloped out of her window. RN #4 stated that she called 911 to report the elopement at 11:05 AM, and at 11:10 AM, Resident #101 was returned to the facility by a Belding police officer. RN #4 stated that the officer found Resident #101 in front of the Police Department (approximately one mile away), "I thought it was strange that she (Resident #101) was on every 15 minute checks but made it so far away." Review of the Metron of Belding Frequent check Log, dated 1/13/13, revealed that Resident #101 was in her bed, in her room, at the following times: 9:00, 9:15, 9:30, 9:45, 10:00, 10:15, 10:30, and 10:45 AM. In a telephone interview on 2/26/13 at 11:00 AM, CNA #5 stated that Resident #101 was an elopement risk and was on 15-minute checks. CNA #5 stated that she did Resident #101's checks from 7:15-10:45 AM on 1/13/13. CNA #5 stated that she got behind on doing the checks, so she initialed the frequent check log and when she actually went to check on Resident #101, she discovered that Resident #101 was missing. CNA #5 stated that on some of the occasions that she documented on the frequent check log, she did not physically see Resident #101 and, therefore, was unable to determine how long Resident #101 was missing. In an interview on 2/25/13 at 2:15 PM, Nursing Home Administrator (NHA) #1 stated that the video of the parking lot was reviewed and it was established that Resident #101 had walked across the back parking lot at 9:46 AM, dressed in a red coat, gloves and a hat, carrying bags. NHA #1 stated Resident #101 was returned to the facility at 11:10 AM by a Belding police officer. NHA #1 stated that it was 31 degrees and misting outside when Resident #101 eloped. In an interview on 2/25/13 at 10:50 AM, Belding Police Officer #3 stated that he received a call from a citizen on 1/13/13 at 10:41 AM. Belding Police Officer #3 stated that the unknown caller reported that an elderly female was walking near the Belding Police Station and was asking people for a ride to Grand Rapids. Belding Police Officer #3 stated that he approached Resident #101 and she identified herself. Police Officer #3 stated that, after some time, the dispatch center was able to make contact with Resident #101's guardian and she was returned to Metron of Belding at 11:10 AM. Police Officer #3 stated that Resident #101 had walked approximately one mile from the facility to the police station and that the outside temperature was approximately 30 degrees. In an interview and observation on 2/26/13 at 10:00 AM, Resident #101 was dressed and sitting on her bed. Resident #101 stated that she worked on the screw to her bedroom window for a couple of days and, when no one was watching, she cut the screen on the window and left. Resident #101 stated that she wanted to go back to her house in Grand Rapids but was stopped by a police officer who noticed her and returned her to the facility. On 2/28/13 at 11:10 AM, Administrator #1 was notified of the Immediate Jeopardy that began on 1/13/13 and was identified on 2/25/13, when the facility failed to prevent the elopement and ensure the safety of Resident #101, who had been identified as an elopement risk and who eloped from the facility on 1/13/13 at 9:46 AM, when Resident #101 removed the screw from the window, cut the screen and exited out the window of her room. Resident #101 was returned to the facility on [DATE] at 11:10 AM, escorted by a Belding police officer. On 2/29/13, this surveyor confirmed that the facility staff implemented the following to remove the Immediate Jeopardy: 1. On 1/13/13, the facility staff completed a 100 % head count of all residents and no other residents were affected. 2. On 1/13/13, upon return, Resident #101 was assessed by the charge nurse and no injury was noted. 3. On 1/13/13, Resident #101's belongings were checked for any items that could be used for prying or removing screws and she was placed on 1:1 supervision. 4. On 1/13/13, Resident #101 was ordered a code alert bracelet and it was placed on her left ankle. The placement will be checked daily and functioning will be checked once weekly. 5. On 1/13/13, Resident #101 was moved to room 33, which has a window facing into a secure courtyard with a 7 foot locked surrounding fence. 6. On 1/13/13, all of the windows in the entire building were checked to make sure the screws were present and secure. 7. On 1/13/13, Resident #101's window (room 33) and adjoining bathroom window will be checked every 4 hours for tampering or damage. All other windows will be checked once daily. 8. All residents were reviewed by the Unit Managers for current elopement risk assessments which started on 1/15/13 and were complete on 1/18/13. 9. On 1/13/13, the Nursing Home Administrator and Director of Nursing initiated 100% of all nursing staff being re-educated regarding the expectation of frequent checks and making visual observation of the residents before documenting the check. There were 3 staff members on a leave of absence that will not be allowed to return to duty until the Director of Nursing has provided the re-education. Although the Immediate Jeopardy was removed on 1/15/13, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency. (# )

This citation pertains to intake MI 261. Based observation, interview, and record review, the facility failed to provide supervision and assistive devices in 2 of 8 sampled residents (Resident #501 and #504), from a total sample of 8 residents, resulting in: 1.) an Immediate Jeopardy for Resident #501 when Resident #501 who had a history of [REDACTED]. These deficient practices place all residents who required assistance with eating, at risk for serious harm and/or injury, and 2.) Resident #504, who required supervision while eating, spilled soup that was 192 degrees Fahrenheit onto her stomach causing a first degree burn. Findings include: Resident #501 Review of the Clinical Record Face Sheet revealed Resident #501 was a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #501 required supervision of one person for eating. In an interview on 12/1/11 at 10:46 AM, Activity Aide (AA) #1, said she served Resident #501 a bowl of soup taken from a "crock pot kettle" on 11/22/11 for lunch. AA #1 said she always helped serve lunch Monday through Friday. AA #1 said she told Resident #501 to go up closer to the table because he had pushed himself away from the table then assisted Resident #501 by pushing his wheelchair to the table and locked his wheelchair brakes so he could reach his food. AA #1 said she walked away to serve other Residents in the dining room. AA #1 said, "Next, I heard him screaming it was hot!" AA #1 said she then turned around and the Dietary Aide (DA) #2, was helping Resident #501 and DA #2 told her, "it's gotta be hot!" AA #1 said someone came to take him out. AA #1 said this is the second incident with Resident #501. The first incident was with coffee on a different day; however AA #1 could not recall the date. In an interview on 12/1/11 at 10:15 AM, DA #2 said on 11/22/11 at approximately 12:15 PM, she heard AA #1, who was in the main dining room serving lunch, tell Resident #501 to move his wheelchair closer to the table because he had rolled back away from it and she had just served him soup in an insulated bowl. DA #2 said she was concerned because Resident #501 "spilt hot coffee on himself before (DA #2 could not recall when but thought it was 6 months ago). DA #2 said, on 11/22/11, Resident #501 had his bowl of soup in his hand and he was fumbling and the next thing you know he had the whole thing in his lap". DA #2 said Resident #501 yelled, "Oh my God it's hot! Oh my God it's hot!" DA #2 said brushed the food off and said she, "tried to rub as much of the juice off his leg", (DA #2 demonstrated by repeatedly pressing her hand down and forward on her own right thigh). DA #2 said she called out for a nurse and said, "I need a nurse now". DA #2 said Licensed Practical Nurse (LPN) #3 came over, asked what happened, and then took Resident #501 out of the dining room. DA #2 said when she took the temperature of the soup, just before it was served to him, it was 206 degrees Fahrenheit. DA #2 said, "I don't know why I served it. I thought it was too hot. Over 180 degrees is too hot to serve." Review of the Facility's witness statement dated 11/22/11 at 12:15 PM and signed by LPN #3 revealed she was in the main dining room with a Resident (not on the sample), when she heard from behind her someone yell to get a nurse. LPN #3 documented that she turned to witness Dietary staff (DA #2) assisting Resident #501 and saw that Resident #501 had spilled a liquid on his lap and the Dietary staff said it was hot soup. LPN #3 then transferred Resident #501 out of the dining room, to a restroom, and washed his leg with cold water. In an interview on 12/1/11 at 11:15 AM, all Facility incident reports involving a spill of hot liquids were requested from the Director of Nursing (DON) #1. Review of the Incident Report dated 10/13/11 at 12:00 PM, revealed Resident #501 had spilled a cup of hot coffee in his lap while in the dining room which resulted in a pink left thigh. The only intervention was to give Resident #501 a half a cup of coffee. Review of the facility's incident report dated 11/22/11 at 12:15 PM revealed Resident #501, had another accident and spilled a bowl of soup, in his lap, while in the dining room. This resulted in a second degree burn on his right thigh when staff failed to cool the involved area immediately by pouring cold water on his thigh. The interventions were to have Occupational Therapy screen for use of adaptive equipment and to ensure that Resident #501 was properly seated "up to the table". Review of the nurse's notes dated 11/22/11 at 12:15 PM revealed Resident #501 was observed to spill soup on his right leg. The area was pink with 3 small (blood blisters was crossed through) and "red area" written. Review of the physician progress notes [REDACTED]. Patient states it's sore. No fever or chills reported. Patient makes no other complaints. Nursing states area blistered right away. Treatment is in place already. [DIAGNOSES REDACTED] has decreased per nursing...4 cm in diameter round area of sloughed skin. No exposure of epidermis, no exudate, no surrounding eschar...monitor for increased [DIAGNOSES REDACTED] or purulent drainage." Review of the care plan for Resident #501 under the problem titled "Impaired Vision/Legally Blind in Right Eye" and dated as last revised on 12/17/10 revealed instructions for nursing to "assist with food tray set up, use clock method if needed." Review of the "Patient Care Needs Summary" dated 10/13/11 revealed Resident #501's only intervention to prevent an accident of a burn from spilling hot liquids was to allow: "only half a cup of coffee at a time to prevent dropping the cup". There were no other interventions written until 11/27/11 which were to ensure that he was placed up to the table at meals and then on 11/30/11 which were to place his soup in a mug with no lid, hot beverages required a lid and a lap pad during meals. An additional piece of blank paper dated 11/23/11 was written: "Until further notice.....(named Resident #501), is to wear a protective lap apron at meal times. This is kept in the main dining room. He is to be transferred in a stationary chair and pushed up to the table for all meals. Thanks!!!!!!". During an interview on 12/1/11 at 9:36 AM, Resident #501 said he was "down in the dining room the other day eating soup and I didn't have a hold of it and I dumped it. It burned pretty bad. It still hurts right now." Resident #501 said he spoke some words other than OUCH and said, "fumble fingers fumbled it". Resident #501 said staff came and took him out but no one poured any cool liquid on his lap while he was in the dining room. An observation on 12/1/11 at 9:40 AM revealed Resident #501 was sitting in his room in a wheelchair with heavy jeans on. DON #1 and Certified Nurse Aide (CNA) #4 assisted him to remove his jeans and a taped gauze type dressing covered the wound. The dressing was removed and the wound was measured. DON #1 said, in an interview at the time of the observation, Resident #501's entire front thigh was red but reduced in size after the intervention of ice water on 11/22/11. The area measured (in centimeters) 7 x 8 x 7 x 6 x 7 circular and red and surrounded and had an open area that measured (in centimeters) 4 x 5 x 3 x 4 circular with yellow/tan colored center area. In an interview on 12/1/11 at 12:10 PM, DON #1, as she reviewed Resident #501's clinical record, said Resident #501, "was assessed on 3/19/08 and found to be independent with eating". Review of the Occupational Therapy (OT), Screening dated 11/23/11 (no time) revealed an observation was made of Resident #501, while in the main dining room at lunch. OT documented that Resident #501 rolled back slightly, during the meal because his wheelchair brakes were not on and he shuffled his feet slightly. OT noted that Resident #501 had a travel style mug with a lid and had Resident #501 demonstrate it's appropriate use. OT documented that Resident #501 was noted to remove the lid and empty contents into a bowl and other cup. According to the report "picking bowls up while dining appeared to be habitual in nature". OT made the following recommendations:1). trial a standard chair versus Wheelchair, 2).Warm liquids placed in standard coffee mugs and no more than half full, 3). Warm soups in bowls no more than half full and 4). Supervision required for safety with lap apron in place. Review of the Physician order [REDACTED].#501's burn. A physician order [REDACTED].#501's right thigh burn twice a day until healed and cover the wound from the burn with a non-stick Telfa and Silvadene Cream.. Review of the Facility Temperature log dated 11/22/11 under lunch, revealed the soup temperature was measured at 206 degrees Fahrenheit. An observation on 12/1/11 from 12:21 PM until 12:40 PM revealed there were no certified or licensed staff in the main dining room. The only staff observed in the main dining room, were AA #1, MR #7 and DA #2. Resident #501 was sitting in a dining chair with a plastic lined tablecloth folded over his lap which slid off, and his family member who was visiting, replaced it onto his lap. At 12:34 PM, AA #1 left the dining room and MR #7 stood in one doorway looking for DA #2. DA #2 was located in the doorway at the opposite end of the dining room with her back turned away from the Residents, talking to people who were in the hall. At 12:40 PM, a Physical Therapy Aide entered the dining room and transferred Resident #501 from the dining room chair to a wheelchair. At 12:44 PM, Registered Dietitian (RD) #1 and Certified Dietary Manager (CDM) #1 came into the dining room. Most of the Residents in the dining room had a glass of water at their place. There was no ice in any of the glasses of water. On 12/1/11 at 4:30 PM, this Surveyor requested DON #1 retrace the steps from the dining room doorway to the shower room. DON #1 took 20 seconds as she walked at a pace that was near running. DON #1 did not push a wheelchair with a Resident in it at that time. At the time of the incident on 11/22/11, Resident #501 was seated at the opposite end from the doorway, of the main dining room that was filled with other Residents which would have required the nurse to maneuver around to exit the doorway. The shower room where Resident #501 had been taken to, was down one hall to a nurse's station, around a corner, and halfway down a different hall. The Administrator was notified on 12/5/11 at 4:05 PM of the Immediate Jeopardy that was identified on 12/1/11 and began on 11/22/11 when Resident #501 who had a history of [REDACTED]. On 12/7/11, this Surveyor confirmed that facility staff completed the following to remove the immediate jeopardy: 1. On 11/22/11 Resident #501 was taken to the North East shower room and cool water applied to his right thigh within 1 to 2 minutes after he spilled hot soup in the dining room. The Administrator and Resident #501's Family were notified. Resident #501's pain from the burn was controlled through his routine narcotic analgesic medications. 2. On 11/22/11, Resident #501's treatment plan was altered to provide evaluation of the wound on his thigh twice a shift. 3. On 11/23/11, Occupational Therapy evaluated Resident #501 for the appropriateness of the interventions in place and to further evaluate his ability to safely handle hot liquids. OT recommended a standard dining room chair instead of a wheelchair at the dining table. 4. On 11/23/11, Resident #501 was assessed by a Licensed Nurse to determine his ability to handle hot liquids. The care plan was updated to include a covered travel mug for all hot beverages, a waterproof lap protector for all meals, and hot liquids were to be filled half way. 5. On 11/23/11, all 118 Residents were assessed for their safety to handle hot liquids. 31 of 63 North unit Residents were identified with risk factors and had interventions put in place. All 55 South Residents were provided lids when hot beverages were served. 14 of 55 South were able to handle hot beverages independently with a lid. 18 of 55 Residents on the South unit required supervision if hot liquids were served. 6. On 11/23/11, the temperature of food and beverages exiting the kitchen were evaluated. All beverages exiting the kitchen will be less than 150 degrees. Hot food in the main dining room for immediate services will be less than 160 degrees. Soup in the main dining room is will be maintained between 135-145 degrees. Dietary staff will monitor the temperatures at every meal and maintain a log reflective of those readings. Re-education of 16 of 16 Dietary staff by the Registered Dietitian regarding hot liquid temperatures and monitoring protocols was completed on 11/23/11. 7. Effective 11/23/11, the Registered Dietitian or designee reviewed temperature logs weekly and if found, reports non-compliance immediately to the Administrator for immediate correction. 8. On 11/30/11, dining room audits by Nursing staff observing the care planned interventions for hot liquids began and will be done daily for 7 days, then 3 times per week for 4 weeks, then weekly for 4 weeks. 9. On 11/23/11, burn first aid kits were placed in all dining rooms. 53 of 173 Dietary, Activity, Maintenance, Housekeeping, Therapy, Administration and Nursing Staff were educated regarding their placement and use by Nursing Unit Managers and their designees. 10. On 12/1/11, water bottles were placed in all dining rooms and staff began education regarding their placement. As of 12/5/11, 128 of 173 staff were educated. No staff will be allowed to work prior to receiving the education. 11. Occupational Therapy added Resident #501 to their case load as of 12/5/11 to evaluate for additional safety strategies for meals. 12. On 12/1/11, the Handling of Hot liquids policy was revised to reflect the new protocols and staff education began. 102 of 173 staff have been educated to this policy as of 12/6/11. The remaining 71 of 173 staff will be educated prior to the start of their next scheduled shift. Although the Immediate Jeopardy was removed on 12/1/11, the facility remained out of compliance at the scope of pattern and severity of no actual harm but potential more than minimal harm that is not immediate jeopardy due to all of the staff had not been in-serviced on the new hot liquid handling policy and assessment tool and sustained compliance had not been verified by the state agency. ( ) Resident #504 Review of the Clinical Record Face Sheet for Resident #504 revealed that she was a [AGE] year old woman admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #504 required supervision of one person for eating. Review of the facility's incident report dated 8/1/11 at 12:30 PM revealed Resident #504, was in the main dining room at lunch when she was observed to knock a bowl of hot soup off the table and onto her stomach. According to the report Resident #504 said she knocked over a bowl of soup on her stomach resulting in a slightly red area. Review of the Facility Temperature log dated 8/1/11 under lunch revealed the minestrone soup temperature was measured at 192 degrees Fahrenheit. An interview on 12/6/11 at 10:50 AM, Activities Assistant (AA) #1 reported she had been in the main dining room, serving lunch on 8/1/11 at 12:30 PM. AA #1 read her witness statement and said she observed Resident #504 trying to give her salad to another Resident, when her soup spilled on her stomach. AA #1 said she pulled Resident #504's clothing protector (bib) off and told the therapy girls to get a nurse because there was no nurse in the dining room. AA #1 said a nurse came and took Resident #504 out of the dining room. AA #1 did not report she supervised Resident #504 directly while eating. An interview on 12/6/11 at 10:35 AM, Medical Records Clerk (MR) #7 reported that she had been in the dining room serving lunch on 8/1/11, but was not directly supervising Resident #504 during the meal. MR #7 said she did not see Resident #504 spill the hot soup on her stomach, but heard the commotion and went to her. MR #7 said Resident #504 complained and stated "it burns" as she pointed to her stomach. Review of the nurse's notes dated 8/1/11 at 3:00 PM revealed Resident #504 spilled hot soup on her abdomen and sustained first degree burn the size of a half dollar. Review of the treatment record revealed Resident #504's burn on her abdomen did not heal until 8/6/11. An observation on 12/6/11 at 4:00 PM revealed Resident #504's abdomen, on the right lower quadrant had a 1 cm by 1 cm size open area, with no drainage or sign of infection. It was in the folds of her abdomen. Resident #504 was unaware there was a wound. In an interview on 12/6/11 at 4:05 PM, Licensed Practical Nurse (LPN) #16 said she was not aware of the open area on Resident #504's abdomen but indicated that it was not from the burn she sustained on 8/1/11 and said the burn had healed. ( )