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

Based on observation and interview the facility failed to properly dispose of refuge and maintain cleanliness of the garbage and dumpster area, resulting in the potential harborage of pests. This deficient practice has the potential to affect all 109 residents in the facility. Findings include:On 8/19/25 at 8:30 A.M., at 10:30 A.M. and at 4:27 P.M. two of the facility's dumpsters were observed with open lids and overflowing garbage, broken and/or furniture and boxes. The surrounding grounds were littered with food particles that had been dropped or fell from the garbage bags by squirrels and birds. Occasionally birds were noted pecking holes in the garbage bags exposing the contents of the garbage to gnats and flies. Near the dumpster area and adjacent hall and back door to the kitchen were observed with flies.On 8/19/25 at approximately 9:00 A.M. Dietary manager F was interviewed concerning the dumpster area. Manager F indicated the maintenance department was responsible for cleaning the area and confirmed garbage was collected on Mondays and Wednesdays weekly.On 8/20/25 at 4:16 P.M., the surrounding grounds were swept but the garbage lids remained open. Periodically rain showers soaked the boxes and the garbage contents contributing to an environment for other unwanted pests and odors.On 8/25/25 at 10:30 A.M. Maintenance Director J confirmed the days of garbage collection and reported the facility had been in the process of renovation and replacing furniture and the opened dumpsters and food debis created an environment for pests to hide and harbor.

Based on observation, interview and record review the facility failed to ensure kitchen equipment was maintained in a safe operating condition, resulting in a potential for a delay in food preparation and the safety to staff preparing food. On 8/20/25 at 12:00 P.M., during an observation in the kitchen the South Bend stove was heavily soiled with accumulated baked on food residue and ash. One of the front gas eyes was coated with layers of a (whitish) unknown substance and was covered with soot which impaired the function of the gas eye of the stove. Staff members using the stove were observed constantly readjusting the gas gauges and repositioned cooking equipment because of non-functioning eyes on the stove. The gauges/knobs were present on the stove but were not calibrated adequately causing the bottom of the pans and fryers to be burnt during preparation of the food. Observation of the bottoms of pots and pans stored on racks near the stove were noted to have a coating of burnt on ash and residue from the high temperature. Dietary Manager F acknowledged the facility was discarding skillets because the inner surfaces were damaged. Due to the condition of the stove only one full pan of food could be positioned on the stove for cooking.The South Bend Double Deck Convection oven was soiled with old, accumulated grease and ash. The sides had visible grease residue which could not be easily cleaned due to the position of the adjacent equipment. The racks for both the stove and convection oven appeared to have years of accumulated food residue.Dietary Manager F was interviewed during the observation of the equipment and indicated staff had cleaned and tried to remove the buildup of food residue, but the stoves were old and had years of usage.According to 2013 Food Code section 4-602.13 Nonfood- Contact Surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues

Based on observation, interview and record review the facility failed to provide privacy for one resident (R3) of two residents reviewed for privacy resulting in the resident being exposed during wound care On 8/21/2025 at 11:30 AM, Registered Nurse (RN) S and Certified Nurse Assistant (CNA) R was observed providing wound care to R3's sacrum/coccyx (buttocks) area. RN S did not draw the curtain around R3's bed or close R3's room door which allowed visualization of the R3's exposed body from the hallway.Record review revealed that R3 was initially admitted on [DATE]. R3 had the following diagnosis: type 2 diabetes, COPD, hypertension, generalized anxiety, bipolar disorder, and suicidal ideations.Record review of R3 quarterly Minimum Data Set (MDS) from 7/7/2025 for a Brief Interview for Mental Status (BIMS) revealed R3 was cognitively intact with a score of 15 out of 15.On 8/21/2025 at 11:45 AM, CNA R was interviewed and confirmed the door was left open while R3 was receiving wound care. CNA R said the door should have been closed.On 8/21/2025 at 11:50 AM, RN S was interviewed and acknowledged the door was left open during wound care. RN S said the door should have been closed during the procedure.On 8/21/2025 at 2:40 PM, the Director of Nursing (DON) was queried and interviewed about R3's wound care. The DON said the privacy curtain should have been completely drawn around R3's bed and the door should have been closed during wound care.

Based on observation, interview, and record review the facility failed to provide a bed that was appropriate and in good condition for one (R66) of three residents reviewed for reasonable accommodations, resulting in unmet comfort needs. Findings include:On 8/19/2025 at 12:16 p.m. R66 was observed sitting in an upright position in a standard hospital bed (6.6 feet), watching television. R66 is non-verbal with severe cognitive impairment and was unable to participate in the resident interview. R66 was also observed with feet hanging off the end of the bed. The foot board was off the bed and propped against the wall. R66 was observed to appear taller than the length of the bed. On 8/19/25 at 12:19 p.m., CENA L was queried about the bed size and the disrepair. CENA L said R66 kicked the foot board off and is getting a new bigger bed. CENA L also said the bed had been in disrepair for a couple of weeks. The nurse's aide was uncertain of the bed's order status. Review of the clinical record documented R66 was admitted into the facility on 6/10/25 with diagnoses that included schizophrenia, dementia, unspecified severity, with other behavioral disturbance, antisocial personality disorder, myopia, bilateral, candidiasis, and pressure ulcer of left upper back, stage 3. According to the admission Minimum Data Set assessment dated [DATE], R66 had severe cognitive impairment and was dependent on all activities of daily care. The assessment also documented R66's admission height as 72 inches (6 feet) tall. On 8/21/25 at 11:45 p.m. LPN Q was queried about R66's requiring a new bed. LPN Q said nurses round every two hours, however, was not aware of the resident needing a new bed. LPN Q was queried about what nurse rounds consist of. LPN Q stated, We focus on clinical concerns when we do rounds. LPN Q was asked would a resident requiring a new bed be considered a clinical concern. LPN Q did not respond. On 8/21 25 at 1:15 p.m. Assistant Director of Nursing (ADON) P was queried about R66 needing a new bed and its order status. ADON P said the bed was ordered and waiting for maintenance to take to the resident's room. ADON P presented the Work Order from the medical equipment company dated 8/7/25. The invoice documented the new bed (bariatric 42 inches) was delivered to the facility on 8/11/25. ADON P was queried about the length of the bed and broken foot board. ADON P said an extender was ordered today (8/21/25). ADON P was unable to give an explanation why the extender was not ordered at the same time of the mattress or the delay in providing R66 with an appropriately sized bed. On 8/21/25 at 12:00 p.m. the Director of Nursing (DON) was interviewed. The DON said they were new to the facility (one week) and were not aware of the residents' needs, however, was told the mattress had been ordered and waiting for maintenance to replace the mattress. The DON said they were unaware the bed was broken. On 8/25/25 at 1:22 p.m. Maintenance Director J was interviewed about R66's bed needing to be replaced. Maintenance Director J said they were not aware the mattress was delivered to the facility and was under the assumption R66 required a new frame not an extender or new mattress. Review of the facility's policy titled Accommodation of Needs dated 12/24 documented in part the following: The facility will make reasonable accommodations to individualize the resident's physical environment including their personal bathroom and bedroom and the common living areas within the facility. Facility staff shall make efforts to reasonably accommodate the needs and preferences of the resident as they make use of their physical environment.

Based on observation, interview, and record review the facility failed to ensure one resident room (R62) of nine residents was in good repair.R62.On 8/25/2025 at 11:23 a.m., R62's room was noted with a loud unpleasant odor. Observed chipped paint and holes in the wall over the bed and a fan hanging near the bed with thick dust particles blowing from the fan. The bathroom was observed with multiple areas of black residue on the wall and behind the toilet. The vent was covered with thick dust particles, holes in the wall near the tissue holder and brown stains and scuff marks on the bathroom door.On 8/25/2025 at approximately 11:30 a.m. during an interview R62 stated, The bathroom is filthy and uncomfortable. I have no control over it. I have to wait until they get to it, I guess. R62 confirmed the facility was aware of the repairs and cleaning needed for a long time.On 8/25/2025 at 11:55 a.m., Maintenance Director (MD) J was asked during an interview in R62's bathroom what was the black areas on the wall? MD J stated, Oh yes, it got worse, but I don't think its mold. I think the black spots are from when we used mud to seal the cracks and holes and it just got black. MD J was asked had any staff member written any repair orders? MD J stated, The staff suppose to report that and document in TELS (a system used for staff to report repair needs) for a work order to be repaired. MD J was asked who was responsible for dusting and cleaning the residents' vents and fans MD J stated, The housekeepers supposed to dust the vents, and fans. The fans and vents should not have been that dusty.On 8/25/2025 at 11:55 a.m. while observing R62's room and bathroom, Regional Director of Operation (RDO) A confirmed R62's bathroom and room needed to be cleaned and in need of repairs. RDO A stated, I have not been here long, but this is something I see needs to be done.According to the electronic health record (EHR), R62 was readmitted into the facility on [DATE] with diagnoses of chronic obstruction pulmonary disease, hypertension, multiple sclerosis, and Parkinsonism. R62's 7/2/32025 quarterly Minimum Data Set (MDS) assessment revealed R62 had intact cognition with a BIMS (brief interview for mental status) score of 15/15.According to the facility's 1/23/2024 Safe and Homelike Environment policy: In accordance with resident ‘s rights, the facility will provide a safe, clean, comfortable and homelike environment.Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the resident's room, bathroom.

Based on observation, interview, and record review the facility failed to follow standards of practice for medication administration for one (R91) of three residents when a single-dose medication (eye drop) was unopened and intact at the bedside but signed out on the Medication Administration Record (MAR) as being administered. Findings include: On 8/21/25 at 10:37 AM R91 reported they did not get all of their eye drops today. Upon further inquiry R91 said, They keep saying they ain't got it. I haven't got those eye drops in the white box (Cyclosporine 0.05%) for a couple days now. I don't know what the problem is. A review of R91's MAR revealed Licensed Practical Nurse (LPN) B had documented R91's eye drops (Cyclosporine 0.05%) were 'administered' for the 8/21/25 10:00 AM dose. At 10:40 AM LPN B was interviewed regarding R91's eye drops. LPN B said R91's eye drops (Cyclosporine 0.05%) were not available in the medication cart and therefore not administered. An inspection of the medication cart revealed there were no Cyclosporine 0.05% eye drops for R91. LPN B acknowledged that the Cyclosporine 0.05% eye drops come as individual single-doses in a white box. LPN B confirmed they had documented in the MAR that the eye drops were administered. LPN B then said, Oh, yeah, his (R91's) eye drops are at the bedside. I must have gave them. LPN B went to R91's room and returned to the medication cart with one single-dose eye drop that was unopened and intact. Upon further inquiry LPN B acknowledged that the eye drops could not have been administered if the single-dose package was unopened and therefore should not have been signed out as administered. According to R91's Electronic Health Record (EHR) the resident admitted to the facility with multiple diagnoses that include Chronic Obstructive Pulmonary Disease, Diabetes, and history of fractured ribs and sternum. According to the Minimum Data Set, dated [DATE], R91 had no cognition impairment with a brief interview for mental status score of (BIMS) 15/15. A physician's order on 12/12/2024 prescribed the following eye drops: Cyclosporine emulsion 0.05% eye drops, instill 1 drop in both eyes twice a day for dry eyes due to inflammation. There is no order to allow medications at the bedside. There is no assessment or evaluation for the resident to self-administer medication. A review of the R91's August 2025 MAR indicated that the Cyclosporine 0.05% eye drops were administered everyday as prescribed. A note on 8/15/25 indicated that the pharmacy was requested to refill R91's Cyclosporine 0.05% eye drops. On 8/18/25, a second note indicated that the pharmacy was requested to be refill R91's Cyclosporine 0.05% eye drops. On 8/21/25 at 11:10 AM during an interview with the Nursing Home Administrator (NHA) they said it is a standard of practice that the nurse does not sign out a medication until after it is given. According to the facility's Medication Administration- General Guidelines (undated); Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system. C. Documentation1) The nurse who administers the medication records the administration on the resident's MAR immediately after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the nurse who administered the medications report off-duty without first recording the administration of all medications.

Based on observation, interview, and record review, the facility failed to provide residents (R63 and R77) shaves and hair care out of two residents reviewed for Activities of Daily Living (ADLs), resulting in unmet ADL needs. R63On 8/19/2025 at approximately 12:37 p.m., R63 was observed sitting in bed with unkempt hair. During an interview R63 reported not receiving assistance with hair care. R63 was asked to recall when hair care was last offered and provided by the staff. R63 stated, Oh, my God, it's been a long time. No one offers to comb my hair. I watch my roommate's hair get combed and not [NAME]. My hair needs to be combed because I have had these braids for a long time. My hair has not been combed, brushed or braided since my Birthday (approximately three months ago). I went out for my birthday on that day. Sometimes I get embarrassed because my hair is not combed. I would like for my hair to be combed or braided. According to the Electronic Health Record (EHR) R63 was initially admitted into the facility on 7/2/24 with diagnoses of asthma, hemiplegia unspecified (Hemiplegia is the total paralysis of one side of the body, affecting the arm, leg, and sometimes the face on the same side) and anemia. According to the admission Minimum Data Set assessment dated [DATE], R63's cognition was moderately impaired with a BIMS (brief interview for mental status) score of 08/15 and required one-person assistance with grooming/hygiene. Review of the 7/9/2024 ADL Care Plan documented, I have an ADL self-care performance deficit related to history of cerebral infarction (stroke) with hemiplegia, Diabetes Mellitus, non-ambulatory, wheelchair for locomotion. Interventions as follows:-Dressing: I require 1 staff participation to dress.-Person hygiene: I require 1 staff participation with personal hygiene and oral care.-Bathing: I need 1 person assistance to bathe.There was no documentation for refusal. On 8/25/2025 at 11:23 a.m. Licensed Practical Nurse (LPN) K was asked what were the daily duties of the Certified Nursing Assistance (CNA) when assisting residents with care. LPN K said the CNAs are to do ADL care like shaves, nail care, wash and comb their hair, moisturize the skin. R77.On 8/19/2025 at approximately 12:04 p.m. R77 was observed lying in bed with long, untrimmed, dirty fingernails and both feet with long, thick, untrimmed, discolored toenails. During an interview R77 reported not receiving assistance with fingernails and toenail care. R77 stated, They won't clean and cut my fingernails and toenails. I want my fingernails and toenails cut and cleaned. On 8/19/2025 at approximately 12:15 p.m., Licensed Practical Nurse (LPN) I was interviewed regarding providing residents with ADL care. LPN I said the nurses are to observe residents on their shower days to make sure nail care, hair care, shaves and all ADL care is provided and sign off in the electronic record once completed. According to the Electronic Health Record (EHR) R77 was initially admitted into the facility on [DATE] and readmitted [DATE] with diagnoses of moyamoya disease (a rare, chronic, and progressive cerebrovascular disorder that affects the brain's blood vessels), major depressive disorder, diabetes mellitus type two, cerebral infarction (stroke), chronic obstructive pulmonary disease, and quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs and torso). R77 was able to communicate consistently during an interview and voice ADL needs. Review of the 7/22/2025 ADL care plan documented, I have an ADL self-care performance deficit related to limited mobility, and moyamoya disease.Interventions as follows:-Dressing: I am totally dependent on staff for dressing.-Person hygiene: I require total assistance with personal hygiene care.-Bathing: I am dependent on the staff to bathe me.There was no documentation for refusal. On 8/25/25 at 1:29 p.m. the Director of Nursing (DON) was asked which staff should provide shaves, nail care and hair grooming to the residents. The DON said the CNAs are to provide nail care i.e., clean, trim, cut and complete shaves and hair grooming on scheduled shower days and as needed. According to the facility's 2/25/2024 Activity Daily Living (ADL) policy: The facility will base the resident's comprehensive assessment consistent with the resident's needs and choices.Policy Explanation and Compliance Guidelines:-3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain .grooming, and personal and oral hygiene.

Based on observation, interview, and record review the facility failed to provide vision services in a timely manner for one (R104) of two residents review for vision, hearing, and communication, resulting in the inability to utilize glasses to improve vision and the potential for a decline in vision. Findings include: On 8/19/2025 at 2:02 p.m., R104 was observed in the room sitting at the bedside. R104 presented as alert and oriented to person, place, and situation. R104 was also observed with a wad of white wound care tape on right side of the glasses. R104 said the glasses broke about a year ago and would not be able to get new glasses for another year. R104 said the glasses are not worn often because the white tape gets in the way of seeing at times, I'm supposed to where them every day to see, but I don't. R104 said he was also told there would be a wait to see if they could be repaired. The nurse put tape on the glasses to keep them together and could be worn. R104 said the last vision appointment was about two years ago when the glasses were given. Review of the clinical record documented R104 was admitted into the facility on 2/19/19 with diagnoses that included intraocular lens (an artificial lens implanted in the eye to replace the natural lens, during cataract surgery). According to the annual Minimum Data Set assessment dated [DATE], R104 was cognitively intact (BIMS-15) and required limited one-person assistance with activities of daily living care. The assessment documented R104 had adequate vision and did not have corrective lenses. There was no vision care plan to address vision impairment. There were no nurses or social services progress notes documenting vision impairment or broken glasses. Review of the eye exam consultation dated 6/2/23 eye exam documented the diagnosis of pseudo mania, both eyes and glasses prescription dispensed. Follow-up- prn (as needed). On 8/21/2025 at 2:57 p.m. Social Service Manager (SSM) O was queried about R104's vision needs. SSM O said they were unaware R104's glasses needed repair or replaced. SSM O confirmed R104 was last seen by the doctor 6/2/23 (two years ago), Somehow the resident was not put on the list to be seen. SSM O had no explanation for the absent vision care plan. SSM O said the MDS (Minimum Data Set) assessment was completed by the social service assistant and could not explain the inaccurate information. On 8/21/25 at 3:27 p.m. the Nursing Home Administrator was interviewed and stated, I didn't know (R104) wore glasses, let alone there was a problem with them. On 8/25/25 at 1:56 p.m. the facility was asked to provide a vision or ancillary services policy. The Regional Director of Operations A said the facility did not have the policies.

Based on observation, interview, and record review the facility failed to provide adequate pharmacy services when one (R91) of three residents reviewed for medication administration did not have their eye drops available for administration. On 8/20/25 at 9:37 AM during medication administration for R91, Licensed Practical Nurse (LPN) F said the resident's Cyclosporine 0.05% eye drops were not available for administration. An inspection of the medication cart confirmed R91's Cyclosporine 0.05% eye drops were not in the cart. At this time R91 said, I haven't got those eye drops in a while now, maybe 5 - 6 days. They always say they ain't got them. LPN F reviewed R91's Electronic Health Record and said, I requested the pharmacy to refill these eye drops on 8/15/25 and then someone else requested a refill on 8/18/25. I'll call the pharmacy to see where the eye drops are. On 8/21/25 at 10:37 AM R91 reported they did not get all of their eye drops today. Upon further inquiry R91 said, They keep saying they ain't got it. I haven't got those eye drops in the white box (Cyclosporine 0.05%) for a couple days now. I don't know what the problem is. A review of R91's MAR revealed Licensed Practical Nurse (LPN) B had documented R91's eye drops (Cyclosporine 0.05%) were 'administered' for the 8/21/25 10:00 AM dose. On 8/21/25 at 10:40 AM LPN B was interviewed regarding R91's eye drops. LPN B said R91's eye drops (Cyclosporine 0.05%) were not available in the medication cart and therefore not administered. An inspection of the medication cart revealed there were no Cyclosporine 0.05% eye drops for R91. LPN B acknowledged that the Cyclosporine 0.05% eye drops come as individual single-doses in a white box. LPN B confirmed they had documented in the MAR that the eye drops were administered. LPN B then said, Oh, yeah, his (R91's) eye drops are at the bedside. I must have gave them. LPN B went to R91's room and returned to the medication cart with one single-dose eye drop that was unopened and intact. At this time R91 was re-interviewed about the eye drops openly disagreed with LPN Bs recollection of the where the eye drops came from and reported they were not in his room. After consent from R91, the resident's room was inspected. No eye drops or additional medications were observed at the resident's bedside or in their room. On 8/21/25 at 10:49 AM Pharmacist (PH) E was interviewed by phone and reported that on 8/15/25, 30 individual single-dose Cyclosporine 0.05% eye drops were delivered to the facility at 11:15 PM for R91 and signed by LPN D. PH E went on to say that the facility requested another refill on 8/18/25 and was denied because a 15-day supply had just been delivered on 8/15/25. The resident should not need a refill until 8/30/25. PH E could not explain why the eye drops were not available to the administer to the resident. According to R91's Electronic Health Record (EHR) the resident admitted to the facility with multiple diagnoses that include Chronic Obstructive Pulmonary Disease, Diabetes, and history of fractured ribs and sternum. According to the Minimum Data Set, dated [DATE], R91 had no cognition impairment with a brief interview for mental status score of (BIMS) 15/15. A physician's order on 12/12/2024 prescribed the following eye drops: Cyclosporine emulsion 0.05% eye drops, instill 1 drop in both eyes twice a day for dry eyes due to inflammation. A review of the R91's August 2025 MAR indicated that the Cyclosporine 0.05% eye drops were administered everyday as prescribed. A note on 8/15/25 indicated that the pharmacy was requested to refill R91's Cyclosporine 0.05% eye drops. On 8/18/25, a second note indicated that the pharmacy was requested to be refill R91's Cyclosporine 0.05% eye drops. There were no orders are assessments to indicate R91 could self-administer medications or keep them at the bedside. On 8/21/25 at 11:10 AM the Nursing Home Administrator (NHA) was asked about the facility's policy for receiving medications from the pharmacy. Nursing staff should place the resident's medications in the medication cart upon receipt from the pharmacy. The NHA confirmed that LPN D worked the midnight shift on 8/15/25 and that an investigation would be initiated to determine where R91's eye drops were placed after receipt on 8/15/25. A request for the facility's policy/procedure for acquiring medications from the pharmacy was requested. LPN D was unavailable for interview during the survey. According to the facility's Medication Administration- General Guidelines (undated); Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system. A. Preparation9) If a medication with an active order cannot be located in the medication cart, [OneCare] Pharmacy is contacted.C. Documentation1) The nurse who administers the medication records the administration on the resident's MAR immediately after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the nurse who administered the medications report off-duty without first recording the administration of all medications.

This citation pertains to intake #MI00150510. Based on observation, interview, and record review the facility failed to assess and monitor one resident (R602) from four residents reviewed for change in condition resulting in lack of monitoring, assessment, and the failure to administer emergency medical care/treatment in a timely manner. The resident subsequently died while in the facility. Findings include: Review of a Facility reported incident revealed the following: Incident Summary: It was reported by Midnight staff cena's (Certified Nurse Assistant/CNA) and resident (R605) who was (Resident 602's) roommate that at approximately 5 am (R605) went to (Registered Nurse A) who was on duty Midnight nurse scheduled 7 pm-7:30 am that patient (R602) was in distress and required assistance. When (Registered Nurse A) didn't come to check (R602), (R605) again went and told (Registered Nurse A) that (R602) still requires assistance. (CNA D and CNA B) who were assigned to 4th floor both notified (Registered Nurse A) that (R602) didn't look good, (Registered Nurse A) observed (R602) and stated (R602) was snoring. Dayshift nurse (Nurse E) came on duty at 7 am and observed (R602) in wheelchair slumped back, (Nurse E) immediately assessed patient who had a faint pulse who was unarousable (Nurse E) began emergency measures. A review of R602's electronic medical record revealed an admission to the facility on [DATE] with the diagnoses of Syncope, Osteoarthritis, Myocardial Infarction (Heart Attack) Hypertension, Chest Pain, Leg Pain, Leg Swelling, Shortness of Breath, and Diabetes Mellitus. A review of R602's Brief Interview for Mental Status (BIMS) dated [DATE] revealed a score of ,d+[DATE] (cognitively intact). A review of R602's care plan revealed the following: Focus-I have potential for altered cardiovascular status r/t (related to): Hypertension, dated [DATE] . Intervention-Assess for chest pain .Assess for shortness of breath .Monitor/document/report to MD changes in lung sounds . Monitor/document/report to MD (Medical Doctor) Chest pain or pressure especially with activity, shortness of breath, excessive sweating, dependent edema, Vital Signs .Intervention-I have altered respiratory status .Intervention-Administer medication .Monitor for effectiveness and side effects Monitor/document/report to MD dated [DATE] .monitor for decreased pulse oximetry, increase heart rate, restlessness, diaphoresis, headaches, lethargy, confusion dated [DATE] . Review of R602's progress notes revealed a history of R602 experiencing episodes requiring acute care as follows: 1.) A review of R602's progress note dated [DATE] at 07:36 am revealed the following: Resident slid from w/c (wheelchair) onto the floor observed per writer. Resident is nonresponsive to verbal stimuli able to move all limbs free of pain . A review of the electronic medical record revealed that R602 was transferred to the hospital on [DATE]. R602 returned to the facility on [DATE] with the diagnosis of heart attack. 2.) A record review of R602's progress note dated [DATE] revealed the following: [DATE] 18:22 (6:22pm) Nursing Progress Note Approx. (approximately)4:45pm Writer was doing rounds. Writer observed (R602) sitting in (their) wheelchair with (R602) head tilted back unresponsive. Writer performed a sternum rub. (R602) was not able to respond to verbal stimuli, but able to respond to tactile stimuli. (R602) was able to come to conscious. (R602) was not able to tell me (their) name, date, or reason for (their) stay. (R602) became very lethargic, diaphoretic, and drowsy. Writer phoned on call (physician) New orders put in place to send (R602) to (hospital). Approx.5 pm 6 person (Emergency Medical Technician/EMT) arrived to transport resident to (hospital). (R602) refused any further treatment from EMT. (R602) refused EMT to get any vitals or EKG (electrocardiogram a noninvasive test that records the heart's electrical activity). Writer informed (R602) of the dangers of (their) health if (they) refused to get further treatment. EMT did not take (R602). Approx. 5:26pm writer observed (R602) unresponsive again sitting up in (their) wheelchair with (their) head tilted back. Writer performed sternum rub, this time (R602) did not come to conscious. Writer applied rebreather mask @8L of oxygen. VSS (vital signs)BP ,d+[DATE], P(Pulse) -115, R(Respiration)-24, SPO2(oxygen saturation)-94% on 8L (Liters), B/S(Blood Sugar)-178. Writer phoned 911. Approx. 5:30pm 6 person EMT arrived again to transport (R602) to (the hospital) . A record review of R602's progress note dated [DATE] revealed the following: [DATE] 15:59 Nursing Progress Note Note Text: Resident went LOA (leave of absence) for cardiac referral. Diagnosis/reason was that resident had 2 episodes of chest pain in nursing home .Resident returned with recommendations for multiple cardiac referrals. Follow up appt/ (follow up appointment) referral is Thursday February 20th @ 11:30AM for all testing. Continue with POC (plan of care). Record review of the facility's Statement of Staff member dated [DATE] revealed the following: CNA B: I was doing my work and around 5am (R605) (R602's roommate) came to me and (CNA D) and said (their) roommate (R602) was having a seizure .(CNA D) ran to room [ROOM NUMBER] right away and I went to tell the nurse (Registered Nurse A). (Registered Nurse A) said that (R602) is just sleeping and (R602) always snores. I (CNA B) left the nursing desk and went checked myself, the resident did not look good. (R602) was in the wheelchair with (their) head tilted back, mouth wide open and white foam coming out of (R602's) mouth. I (CNA B) went back to nurse (Registered Nurse A) telling (the nurse) (R602) does not look right and please come and see (R602). (Registered Nurse A) stated again (R602) was asleep .I (CNA B) went back finishing up my work. I asked nurse (Registered Nurse A) to come and check on (R602), (Registered Nurse A) is the nurse I cannot make (them). A record review of staff witness CNA D interview dated [DATE] revealed the following: Starting to do my last changes, (R605) came and stated (R602) was having a seizure. Me and the nurse (Registered Nurse A) went to the room trying to get in the room around 5oclock am, (R602) had the door jam shut .(R605) came back and told me (R605) got into the room I (CNA D) went around there and saw(R602) getting no response I (CNA D) went to (Registered Nurse A) to come check on (R602). I did more changes (and) went back to (R602 and asked (Registered Nurse A) to come check (R602) again. (Registered Nurse A) said (R602) was sleep .(CNA D) and CNA B waited on dayshift and notified them what was going on . On [DATE], a record review of (R605) (R602's roommate) was interviewed by the Director of Nursing (DON): (R605) said around 5 in the morning, (R605) heard some noise, got out of bed and saw (R602) having a seizure with white stuff coming from (R602's) mouth. I (R605) then went to the nursing station to tell the nurse (Registered Nurse A). The nurse said okay, but didn't move so I said it again. The nurse went down there but couldn't get in the room so (Registered Nurse A) walked away. I (R605) pushed on the door moving stuff around and was able to open the door. I (R605) went back to tell the nurse (Registered Nurse A) the door was opened, (Registered Nurse A) went to the room and said (R602) was just sleeping. (R605) said I am so sad, I should have call 911 myself. A record review of staff witness Nurse F interview dated [DATE] revealed the following: Arrived this morning in (sic) clocked in at approximately 6:53 am. Next I went up to the floor that I was assigned to which was the 3rd floor. After doing my rounds and receiving report from the night nurse. That's when a CNA from midnights came to where I was and asked if me and the night nurse could come help with a situation happening on the fourth floor. Upon arriving on the 4th floor, I could visibly see (R602) in room (redacted) unresponsive in (their) wheelchair .did not respond. Then that's when I began doing CPR and about ,d+[DATE] minutes later that's when EMS arrived and took over from there. Review of the facility's Statement of Staff member Registered Nurse A dated [DATE], interviewed by the DON, revealed the following: The roommate (R605) approached (Registered Nurse A) at the nursing desk informing me (Registered Nurse A) that (R602) was having a seizure and had foam coming from his mouth around 5a.m. (Registered Nurse A) went to the room and the door was blocked, the door would not open. I (Registered Nurse A) was thinking how did (R605) get out of the room and what was blocking the room? .I ( Registered Nurse A) was in the middle of doing something so I (Registered Nurse A) went back to the nursing desk to complete what I was doing and several minutes later some (sic) told me they was able to get the door opened .I don't remember who told me. Then, I went back to the room and (R602) was snoring and what was not unusual for him. I did not see any clonic or tonic activity, no seizure activity at all. No acute distress noted, (R602) was sleeping and I did not see any foam coming from (R602's) mouth . Registered Nurse A was asked by the DON: How did you ascertain no acute distress was noted, did you perform an assessment, obtain vital signs or attempt to arouse (R602)? Registered Nurse A said: No, as I said it was not unusual to see him snoring in the same position and there was no foam around (R602) mouth. A review of the electronic medical record progress note written by Nurse E revealed the following: Upon entering shift @0700, writer was making rounds and found resident (R602) unresponsive and when writer was calling resident's name, resident was unarousable. Writer was doing sternal rubs and checking for pulse. Resident (R602) had a faint pulse. Residents skin was warm and dry to touch. During transfer for CPR, residents (R602) extremities were easy to extends and flex. VS (vital signs) were taken BP (blood pressure),d+[DATE], Resp (Respiration)14. 911 was immediately called and arrived within minutes. Nursing staff began CPR immediately and CPR assistance from EMS and firefighters took over at 0714. CPR and defibrillator use continued. By 0741 EMS staff called the hospital in order for the physician to pronounce resident deceased . Resident (R602) was pronounced deceased @ 0741. A record review of the electric medical record progress note written by Registered Nurse A revealed the following: [DATE] 08:07 Nursing Progress Note: Note Text: (R602) was snoring in (their) wheelchair in front of the TV in (R602) room when Day Shift staff came in and could not arouse him from his sleep. EMS was called and 2 EMS crews arrived within minutes. EMS staff lowered him from his wheelchair to the floor to work on him. At 7:14 AM CPR with a defibrillator was still underway. By 7:41 AM the EMS staff called the hospital to let a physician pronounce (R602) as deceased .(R602) was last seen awake and watching TV in (their) room by Midnight CNA at 2:30 AM. At close to 6:00AM (R602) roommate (R605) said thinks (R602) may have had a seizure though none was witnessed by staff . On [DATE] at 1:01 pm, CNA B was interviewed via phone and queried about the incident that occurred with R602. CNA B said (R605) (R602's roommate) came to them (CNA B and CNA D) and said something was wrong with R602. CNA B said that they went to R602's room at about 5 am and R602 did not look right. CNA B went to Registered Nurse A and said something was wrong with R602. Registered Nurse A said the resident (R602) was sleeping. CNA B said that they (CNA B) went back to R602's room and R602's head was tilted back and R602's mouth was opened with foam coming out of their mouth. CNA B went back to Registered Nurse A and said, Please look at (R602) because (R602) wasn't looking right. CNA B said that Registered Nurse A kept saying that R602 was sleep. CNA B denied observing Registered Nurse A return to the room to check on R602. On [DATE] at 1:17 pm, CNA D was interviewed via phone and queried about the incident that occurred with R602. CNA D said that (R605) (R602's roommate) approached them at a different time other than when reported to CNA B said something was going on with the R602 and someone needed to look at R602 .CNA D said that R602's wheelchair was blocking the door (from the inside) and they had trouble getting into the room. CNA D said that Registered Nurse A said that he saw R602 and R602 was sleeping. CNA D went back to R602's room and R602 did not look good. CNA D said that they went back to Registered Nurse A and said that R602 was not looking good but Registered Nurse A said they was not going back in there (the room) because R602's was sleep. CNA D reported not observing Registered Nurse A return to the room to check on R602. On [DATE] at 2:56 pm, an attempt was made to interview Registered Nurse A. A male voice answered the phone. After this writer made a self-introduction, the phone connection was loss. At 2:58 pm, another attempt was made to contact Registered Nurse A, a voice message was left with contact information. On [DATE] at 3:42pm, Nurse F was interviewed via phone and queried about the incident that occurred with R602. Nurse F said they came to work a little before 7 am on [DATE]. Nurse F said that a CNA from the midnight shift asked them to come to the fourth floor because something had been going on with R602 for a while. I went to the fourth floor and R602 was unresponsive, that's when I started CPR. Nurse F said that Registered Nurse A was not in the room. On [DATE] at 11:34 am, an interview was conducted with the NHA and DON related to the care R602 received on [DATE]. The DON stated, When I think about this, it was horrific. The DON explained that both CNA B and CNA D tried telling Registered Nurse A that something was going on but Registered Nurse A said that the resident (R602) was sleep. The DON added that R605 went to Registered Nurse A and said that the resident (R602) wasn't okay and had froth coming out of (R602) mouth. The DON said that they asked Registered Nurse A if the two CNAs told him that something was wrong and Registered Nurse A said Yes but had other things to do. The DON said Registered Nurse A was terminated because they failed to recognize a change in condition. The NHA said that if a resident was not safe or well, any staff could call 911. R605 was unavailabe for interview as they had been discharged from the facility. Day Shift Nurse E was unable to be contacted by phone. A review of the facility policy Change in Condition revised on ,d+[DATE] revealed the following: The organization utilizes an interactive platform in the electronic health record to recognize and manage a potential change in condition. The facility submitted the Resident Assessment Critical Element Pathway. However, the provided document did not provide guidance for how staff react or respond to resident change in conditon.

This citation pertains to intake MI00146598. Based on observation and interview, the facility failed to provide disposable paper towels, a waste receptacle near a handwashing sink, liners for trash cans, and ensure a shower gurney pad was cleaned and sanitized after use. Findings include: It was reported to the State Agency that supplies were not available, and the facility was dirty and unsanitary. During a tour of the third floor on 10/29/24 starting at 8:20 AM, the following was observed: - A trash can liner had not been placed in the garbage can located in room [ROOM NUMBER] near bed one. Trash was observed inside the garbage can. - The shower gurney pad was soiled and stained. - No paper towels or garbage can were available for the handwashing sink in the shower room. - A trash can liner had not been placed in the garbage can located in the day room. The inside of the trash can was stained with dried liquid along the sides and bottom. During a tour of the second floor on 10/29/24 starting at 9:25 AM, no paper towels were available for the handwashing sink in the shower room. During a return observation of the third floor on 10/29/24 beginning at 12:10 PM the following was observed: - A trash can liner was still not placed in the garbage can in room [ROOM NUMBER] near bed one. - The shower gurney pad remained soiled and stained. Housekeeper J stated the pad was stained and one circular stain looked as if someone laid a cup on it. A stain appeared to be dried liquid about a foot in length. Housekeeper J said another stain was about the size of a quarter and resembled dried liquid supplement. On 10/29/24 at 12:40 PM, Certified Nurse Aide (CNA) K said she has used the shower gurney for a resident on the third floor and added that the gurney pad should be washed and dried after use. On 10/29/24 at 3:10 PM, the Director of Nursing (DON) said every time a person uses the gurney, it should be disinfected after each use. The DON said that trash can should be cleaned, disinfected and have a liner. Paper towels should be available (for hand drying). On 10/29/24 at 5:20 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

This citation pertains to intake MI00146598. Based on observation, interview, and record review, the facility failed to ensure medications for three residents (R113, R115, and R116) located in a treatment cart were not expired. Findings include: It was reported to the State Agency that expired medications were not being discarded. On 10/29/24 at 9:00 AM, the contents of the second-floor treatment cart were observed with Licensed Practical Nurse (LPN) G and revealed the following: - A four-ounce tube of menthol-zinc oxide ointment for R113 expired 9/5/24. - A four-ounce tube of menthol-zinc oxide ointment for R115 expired on 10/27/24. - A four-ounce tube of menthol-zinc oxide ointment for R116 expired on 10/4/24. - A 3.53-ounce tube of diclofenac sodium expired on 3/28/24. LPN G said these medications should have been reordered and the expired medications discarded. On 10/29/24 at 2:45 PM, the Director of Nursing (DON) said the outdated medications should have been discarded. The diclofenac sodium should have been re-ordered. On 10/29/24 at 5:20 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

This citation pertains to intake MI00147590. Based on interview and record review, the facility failed to provide adequate assessment after an injury for one resident (R105), resulting in missed opportunities to identify the potential latent effects of the injury. Findings include: It was reported to the State Agency that the resident did not receive adequate and appropriate care while in the facility. A review of the clinical record for R105 documented an initial admitted [DATE] and re-admitted [DATE]. R105 was transferred to the hospital on 10/15/24 and did not return to the facility. R105's diagnoses included vascular dementia, atherosclerotic heart disease, hypertension, and diabetes mellitus-type 2. A Minimum Data Set, dated dated [DATE], documented severe cognitive impairment. On 10/29/24 at 3:50 PM, an interview and review of R105's clinical record was conducted with the Director of Nursing (DON). R105's clinical record documented in part the following: 1. SBAR (Situation-Background-Assessment-Recommendation) summary for providers completed on 10/15/24 at 12:01 AM by Licensed Practical Nurse (LPN) M. The change in condition reported were bleeding (other than GI) skin wound or ulcer. At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 126/76 - 10/13/2024 3:31 PM. Position: Sitting right arm - Pulse: P 56 - 10/13/2024 3:31 PM. Pulse Type: Regular - Respiratory Rate: R 18.0 - 10/13/2024 3:31 PM - Temp: T 96.9 - 10/13/2024 3:31 PM. Route: Forehead (non-contact) - Pulse Oximetry: Oxygen 97.0 % - 10/13/2024 3:31 PM. Method: Room Air - Blood Glucose: Blood sugar 145.0 - 10/14/2024 9:56 PM. Relevant medical history is: Dementia Advance directives are: hospice care Resident/Patient had the following medications changes in the past week: none Outcomes of Physical Assessment: - Mental Status Evaluation: No changes observed - Functional Status Evaluation: No changes observed - Skin Status Evaluation: Laceration Nursing observations, evaluation, and recommendations are: laceration to right side of face noted. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: called no answer voice mail recording/monitor Resident for poor ambulation B. New Testing Orders: - n/a (not applicable/available) C. New Intervention Orders: - first aid/steri strips 2. Behavior note documented by LPN M on 10/15/24 at 12:41 AM. Resident continues to have unsteady gait, laceration to Right side of face. Resident was laying her face on the table when incident occurred, called Dr. no answer, voice mail recording noted. Steri-strips applied, tolerated well. No c/o (complaint of) pain noted. VSS (vital signs stable). 3. Nurse progress note on 10/15/24 at 3:15 PM. Resident was transferred to: (Local hospital) on 10/15/2024 at 3:36 PM. Reason(s) for Transfer: Other -- bradycardia, hypoglycemic. 4. Nurse progress note on 10/15/24 at 3:17 PM. Resident not easily aroused blood sugar 52. Glucagon injection given as ordered. Resident did not consume any of her meals today or fluids. Blood sugar rechecked after 10 min (minutes) 58. Hospice notified. Nurse practitioner notified of resident condition. Blood pressure 111/85, pulse 48, respirations 14. New orders to transfer to emergency room . 5. A review of R105's clinical record revealed no documented assessment of blood pressure, respirations, pulse oximetry, or heart rate between 10/13/24 at approximately 3:30 PM and 10/15/24 at approximately 3:15 PM. 6. Documentation of R105's blood sugars were as follows: 10/13/24 at 5:08 PM 76 mg/dl 10/13/24 at 9:13 PM 136 mg/dl 10/14/24 at 9:56 PM 145 mg/dl 10/15/24 at 12:03 PM 55 mg/dl 10/15/24 at 3:17 PM 52 mg/dl 10/15/24 at 3:19 PM 52 mg/dl 7. Neurological checks to assess R105's mental status, level of consciousness, pupil response, and motor strength were not performed. The DON provided witness statements from LPN M and Certified Nurse Aide (CNA) N. LPN M's witness statement: Resident noted sitting in chair in dinning (sic) room resting her head on the table. Nurse came into the dinning (sic) area and noticed resident bleeding from right side of face. Small laceration with minimal blood noted. Called Dr. No answer, voicemail picked-up. Called family concerning matter, spoke with (R105's Resident Representative) stated Thank you for calling and letting me know. First aid applied (with) butterfly closure strips. Change in Condition (form) completed. Will continue to monitor resident status and inform day shift nurses of incident. Dated 10/15/24. CNA N's witness statement: On Oct. 15, 2024, I (CNA N) came in at 7:00 AM and did round on the 4th floor and seened (sic) that (R105) had blood on her face and went to the MN (midnight nurse, LPN M) nurse and ask (sic) what happen, he said she felt (sic) and he was going out of the door. So we did not have a nurse and she was bleeding so I put butterfly strips on her and when the nurse came I told the nurse that she had a fall. Dated 10/15/24. The DON said a disciplinary action was imposed on LPN M because he should have done more than he did. He did not call me. He did not complete an incident report. R105 should have been monitored every half hour. It is questionable if the injury to (R105's) head was witnessed. LPN M should have started neurochecks on R105 since she hit her face. The DON said the information about R105's injury needed clarification and the investigation continues. The DON could not provide documentation to support that R105 had been monitored and vital signs were assessed between 10/15/24 at 12:41 AM and 10/15/24 at 3:15 PM, with the exception of blood sugar. The DON had no answer regarding why vitals taken on 10/13/24 were included on LPN M's SBAR note of 10/15/24. On 10/29/24 at 5:20 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

This citation pertains to intake MI00143714. Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen, maintain equipment in good repair, and safely store food. This deficient practice has the potential to affect all residents that consume food from the kitchen. Findings include: An initial tour of kitchen was completed with Dietary Manager (DM) J on [DATE] (approximately) between 8:45 AM - 10:00 AM. The initial tour included the storage area in the basement of the facility. During the initial tour the kitchen floor dirty. The floor has brown stains food debris throughout the kitchen. The trash can next to hand wash was overflowing and there were trash that included food debris outside the trash can. The surveyor moved the trash can and noticed more dried food waste and other debris behind the trash can. The surveyor queried DM J about the kitchen cleanliness and floor situation and how often they were cleaning the floors. They reported that they had started three weeks ago at the facility and the floor had not been cleaned since they had started. They reported that it should have been cleaned daily; they had been trying to get someone to clean the floor and they would address it. The dry storage room had an open bag of charcoal and two bottles of fire starter liquid stored with other kitchen items on a shelf. When queried DM J reported they were not sure why they were stored in the dry food storage area and they would address it. Outside the DM J office, in the kitchen hallway, there were two small trash cans there were overflowing with no lids with food and other debris. There were dried food and other debris on the floor under the tables. The food prep table with sink had visible dust and debris. The prep sink backsplash was ripped off from the dry wall with an extended gap and a gouge on the drywall. The slicer had visible dust was not covered. A plastic bag filled screws, bolts and other hardware was on the prep table next to the slicer. The prep table had few knives wrapped in a plastic wrap. DM J asked a kitchen staff member and they reported that they were not sure why they were there. A nonfunctional strainer was hanging over the table. When queried DM J reported that they were not sure if staff were using the slicing machine and they had removed the bag as it needed to be replaced. They also reported that they would replace the strainer. According to the 2017 FDA Food Code Section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Approximately 9:15 AM: The walk-in cooler floor was not clean. The cooler had container of butter cream icing with an open date of [DATE]. Walk in freezer had ice buildup on the top. When queried DM J reported that it happened a week ago after an incident when the freezer door was not closed properly and they were following up on it. The freezer had an opened pack of flour tortillas with freezer burn and no date wrapped in a plastic wrap. A cart with spices were stored next to the open drain from the prep sink table. The spice cart frame was in contact with the drain with potential for contamination from prep sink drain water. When queried DM J, they reported that they had reported this to the facility's corporate team and they were aware of the situation. The spice had several containers of opened spices with no open date. The spice rack had a container of cracked black pepper with an expiration date: [DATE]; a container of celery seed expired on [DATE]; and a container of ground thyme expired on [DATE]. An opened bag of powdered sugar wrapped in a plastic bag with no open date. A carton of mashed potatoes with no open date. The rack with clean dishes next to the oven had several cracked tiles underneath. Part of the floor had large metal covering, approximately ,d+[DATE] feet with a large hole. The hole was covered (not secured) with a plastic cover, that appeared like a disposable bowl. When the surveyor queried DM J reported that they did not know why the hole was there and had asked a kitchen staff member. The staff member who reported that they had been working at the facility for many years reported that it had been the same way for many years. The kitchen staff member also reported that it was maintenance storage/office under the hole and they were asked to keep that covered and that was the reason they had the plastic cover over the hole. The three compartment sink drains had leaks from the drainpipes. There were 2 plastic bins placed under the drainpipes and the bins had water. DM J reported that there were leaks in the drainpipes and the corporate team was aware of the issue. Review of the dish machine temperature log had missing entries for [DATE], [DATE], [DATE] and [DATE]. When queried about the process DM J reported that staff should be checking and logging daily before they used the dish machine. The food storage room in the basement had dry food storge area. The dry food storage shelf had two dented cans of lemon pudding that were removed by DM J when it was brought to their attention. The basement storage had a freezer. The bottom shelf of the freezer had heavy ice buildup. A box of chicken thighs was on the bottom shelf next to the ice buildup. When the surveyor opened the freezer door the temperature dropped instantly. The door was opened for approximately 30 seconds and the freezer temperature (on the inbuilt thermometer) went up to 11.7 degrees Celsius (53.06 degrees). When the door was closed there were loud noises from the freezer and it took approximately 5 minutes for temperature to drop to -1 degree (30.2 degrees). When queried DM J they reported that they were not aware of the freezer issue and they would follow up with facility administration. A follow up observation was completed later that day at approximately 12:40 PM. The kitchen staff were serving lunch from the steam table. DM J was asked to check the temperature of the food that were being served. They had pulled a thermometer that was placed next to the steam table. The thermometer was not working. There were no spare thermometers available to check the temperature. DM J was queried on the process and how staff were checking the food temperature, they reported that they would replace the thermometer. Review of facility's cooking temperature log from [DATE] to [DATE] revealed logs for the [DATE], [DATE], [DATE], [DATE], [DATE], and ,d+[DATE], the included incomplete logs. There were several days of missing entries and there was no evidence that the staff were consistently monitoring the food temperatures. When queried DM J they reported that the staff were not following the facility process and they had initiated the process around [DATE] when they had started and they would follow up. According to 2017 FDA Food Code Cooking sections: ,d+[DATE].11 Raw Animal Foods. ,d+[DATE].12 Microwave Cooking. ,d+[DATE].13 Plant Food Cooking for Hot Holding. Cooking, to be effective in eliminating pathogens, must be adjusted to a number of factors. These include the anticipated level of pathogenic bacteria in the raw product, the initial temperature of the food, and the food's bulk which affects the time to achieve the needed internal product temperature. Other factors to be considered include post cooking heat rise and the time the food must be held at a specified internal temperature . Review of facility's pest control reports from their provider between [DATE] and [DATE] revealed ongoing kitchen cleanliness and sanitation concerns that were brought to the facility's attention that included structural concerns in the concerns. An interview with the facility administrator was completed on [DATE] at approximately 8 AM. Administrator was notified of the observations and they reported that they understood the concerns. They also added that the new dietary manager was in the process of implementing the systems to ensure that their staff were consistently following the facility processes. They also added that the facility was under new management and they were going to fix the structural issues in the kitchen. A facility provided document titled Food Storage with the most recent revision date of ,d+[DATE], read in part, Food storage areas shall be maintained a clean, safe and sanitary manner. This includes maintaining temperatures of coolers and freezers at appropriate temperatures to promote food safety .

This citation pertains to intake MI00143714. Based on observation, interview and record review facility failed to maintain a good general repair of the facility with a safe and functional environment for multiple resident rooms/resident equipments and common areas reviewed for physical environment. This deficient practice has the potential to affect the residents living in those room(s)/using the equipment(s) and all residents who use the common areas/elevators with feelings of frustration and dissatisfaction with their living conditions. Findings include: room [ROOM NUMBER] room [ROOM NUMBER] had three residents. During an observation completed on 8/6/24 at approximately 10:15 AM, the surveyor observed the privacy curtains were not functional between 316-1 and 316-2. 8 of the 17 hooks that suspend the curtain from track on ceiling were broke and the curtain was mostly hanging down. The privacy curtains between beds 316-1 and 316-2 as well as the one between 316-2 and 316-3 were not clean. The latter one (between bed 2 and 3) had a large reddish-brown stain that measured approximately one foot in diameter. room [ROOM NUMBER]-1 On 8/6/24 at approximately 11:20 AM an observation was completed on room [ROOM NUMBER]. The surveyor observed resident sitting on their bed in 307-1. The headboard on the bed was broke and partly hanging towards the right side. There was no foot board on the bed. The two metal pieces that secures the foot board was sticking out. During this observation an interview was completed and resident was queried and they reported that I can't speak on it. They added that it broke a while ago and were not sure about time frame and stated may be a month. They added that the foot board was sitting under the bed and someone took it. An interview was completed with Housekeeper R who was outside in the hallway near room [ROOM NUMBER]. They were queried about the broken bed in room [ROOM NUMBER]-1. They reported that the resident broke their bed some time ago. When queried further they reported that would notify the maintenance staff to get them a new bed. Multiple follow up observations were completed later that day at approximately 12:30 PM and 1:30 PM. room [ROOM NUMBER]-1 had the broken bed and resident was sitting on their bed. On 8/7/24 at approximately 8:30 AM the broken bed was in room [ROOM NUMBER]-1 with missing foot board and broken headboard. When the surveyor queried if anyone had come to check the bed the resident stated No. room [ROOM NUMBER]-2 During an observation completed on 8/6/24 at approximately 8:30 AM. A resident was sitting up on their bed. The bedside table was missing veneer/molding around the table with porous non-cleanable and sharp areas around. When surveyor queried they reported that they had the same table for a while and the facility could fix it. room [ROOM NUMBER]-1 During an observation completed on 8/6/24 at approximately 12 PM, resident in room [ROOM NUMBER]-1 was sitting on their bed and watching their phone. When the surveyor queried about their stay the facility they reported they had been at the facility for approximately one month and they had been asking for television in their room. They had to use their phone watch something so they did not get bored. When queried if staff were aware they reported to facility staff resident reported that maintenance staff were aware and they did not know what was happening. A follow up observation was completed on 8/7/24 at approximately 11:15 AM and the resident did not have a television in their room and they reported that they had not seen anyone from maintenance. room [ROOM NUMBER]-2 During an observation completed on 8/6/24 at approximately 12:15 PM in room [ROOM NUMBER]. Resident in 311-2 had summoned the surveyor when they are speaking with their roommate and asked the surveyor to check their TV and stated look, I need a new TV. The screen appeared defective and broke internally with distorted pictures three quarters of the screen. Right 1/4 part of screen had picture. When queried if facility staff were aware of their concern they reported that facility staff were aware and they did not know what was happening. The surveyor observed ceiling tiles with brown stains the hallway outside of room [ROOM NUMBER]-bath/shower room. The floor indicator lights on the elevators were not working. On 8/7/24 at approximately 8:15 AM, surveyor was waiting in the elevator and had activated the 3rd floor and was waiting for the doors to close. After approximately 30 seconds the surveyor activated/pushed the switch again and the doors did not close. After a few more attempts the surveyor came out of the elevator to get assistance from the staff. The surveyor observed the Director of Nursing (DON) walking down the hall. Surveyor explained that they were attempting to go 3rd floor and doors did not close and had activated the floor switch more than once. DON reported that the elevators were slow but they were working and had asked the surveyor to just activate the floor switch once and wait for the doors to close. They added that it would take a few minutes, but if it gets activated multiple times it might freeze. An interview was completed with Maintenance Director MS T on 8/8/24 at approximately 10:20 AM. MS T was queried about their maintenance notification process and their preventative maintenance rounds. They reported they had maintenance log on every floor. They had two maintenance assistants and they were checking them daily and staff at times notified them verbally when they were on the floor. When queried about the missing foot board, bedside tables with missing veneers, television issues they reported that had addressed as soon as it was brought to their attention. They also reported that resident in 307 broke the footboard and they had replaced it and they had different kinds of bed frames at the facility and did not have the right part and had provided a different bed frame after the surveyor brought up the concern. Record review also revealed that facility had a behavior care plan on resident's record after the broken bed was brought to the facility's attention. An interview with the administrator was completed on 8/8/24 at approximately 8 AM. Administrator was notified of the concerns physical environment and they reported that they understood the concerns and thy would follow up. They had also reported that facility was under new management and they were in the process of making improvements with the physical environment. A facility provide document titled Safe and Homelike Environment with an implementation date of 1/11/21 read in part, In accordance with Resident's Rights the facility will provide as safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes the resident's independence and does not pose a safety risk . 38271 R112 On 8/06/24 at approximately 9:47 a.m., R112 was observed in their room, laying in their bed. R112's wheelchair was observed to have multiple ripped spots on the top of their wheelchair and missing half of the foam on the right arm rest. R112 was queried regarding the wheelchair and indicated that they needed a new one but they have had the same one for a long time. On 8/08/24 at approximately 2:29 p.m., R112 was observed in their room. R112's wheelchair was still observed to have the same multiple ripped spots on their wheelchair and missing half of the right arm rest foam. On 8/08/24 at approximately 2:33 p.m., Nurse U was queried regarding the worn status of R112's wheelchair and they indicated that they would let the staff know to get R112 a new wheelchair. ON 8/6/24 the medical record for R112 was reviewed and revealed the following: R112 was initially admitted to the facility on [DATE] and had diagnoses including Cerebral Infarction and Heart failure. A review of R112's MDS (minimum data set) with an ARD (assessment reference date of 6/4/24 revealed R112 needed supervision with their personal hygiene. R112's BIMS score (brief interview for mental status) was 11 indicating moderately impaired cognition.

This citation pertains to intake MI00145765 and MI00146157 Based on observation interview and record review, the facility failed to ensure an environment free from physical abuse for two residents (R12 and R100) of five residents reviewed for abuse/neglect/mistreatment, resulting in R12 being transferred to the hospital and sustaining soft tissue swelling and hematoma involving the right posterior parietal-occipital scalp and R82 being transferred to the hospital and sustaining peri-orbital ecchymosis and a left eye sub conjuntival hemorrhage. Findings include: R12 and R267 On 8/6/24 a facility reported incident (FRI) that was submitted to the Stage Agency was reviewed and revealed R12 was pushed over onto the floor by R267 on 7/12/24. R12 On 8/06/24 at approximately 12:59 p.m., R12 was observed in their wheelchair and was queried regarding their altercation with R267. R12 reported they were sitting in the dinning room and that another male resident was trying to get to another female resident and they were trying to protect the other female resident. R12 indicated that R267 came over and pushed their wheelchair over because they were mad and they hit their head and had to go to the hospital. On 8/6/24 at approximately 1:39 p.m., R12's DPOA (durable power of attorney) was queried if they had any concerns regarding R12's care and they reported that R12 was attacked by another resident, sent to the hospital and had a hematoma from hitting their head on the floor. On 8/6/24 the medical record for R12 was reviewed and revealed the following: R12 was initially admitted to the facility on [DATE] and had diagnoses including Anxiety disorder and Hemiplegia and Hemiparisis affecting left non-dominant side. A review of R12's MDS (minimum data set) with an ARD (assessment reference date) of 5/29/24 revealed R12 needed assistance from facility staff with most of their activities of daily living. R12's BIMS score (brief interview for mental status) was 11 indicating moderately impaired cognition. A progress note dated 7/12/2024 revealed the following: Incident Note- Resident was sitting in her wheelchair in the Dining Room at around 5:00pm before dinner, resident was in her w/c (wheelchair) while flipped over on her back by another male resident. Resident stated that I was trying to block him from touching the other female resident. He got angry and push me from my wheelchair. Resident (room and bed number) got upset and denied Aggression was stop by nursing staff .neurochecks initiated, injury to head, hematoma to RT (right) parietal lobe, ice pack to injury, Physician [attending Physician] notified stated' not to give resident any Bp (blood pressure) meds (medications) for elevated bp, ordered writer to send out to hospital . A second progress note dated 7/12/2024 revealed the following: Nursing Progress Note -Event occurred on 07/12/2024 5:00 PM. Resident was noted lying on her back in wheelchair dayroom another male resident pushed her backward . A progress note dated 7/13/2024 revealed the following: Resident returned from [local hospital], via stretcher accompanied by 2 attendants. Resident A&O (alert and orientated) verbally responsive. Resident returned with dx (diagnosis). of Head Contusion, .Resident B/P 175/104, [attending Physician] notified of return and the resident B/P (blood pressure) and was ordered to continue neuro checks for 24 hours. Writer ordered to give resident her pm medications now A Social Service note dated 7/15/2024 revealed the following: Writer met with [R12] for an overall safety and wellbeing check Writer asked [R12] if she has/had any concerns or issues regarding her safety and wellbeing in the facility due to the incident on 712/2023 with another peer. [R12] indicated she is 'fine' and has no fears or concerns about her safety. Writer asked [R12] if she would share the events that occurred from that incident. [R12] indicated she was in the common room with peers watching T.V. and observed resident [R267] attempting to hug resident [another female resident] [R12] indicated she was trying to prevent [R267] from getting close to [other female resident], [R267] became angry and pushed her out of her wheelchair A hospital Emergency Department evaluation dated 7/12/24 revealed the following: Chief Complaint Patient presents with Head Injury presents following a fall at her nursing home. Patient was in the community room when she was pushed in her wheelchair by another patient. She fell and reportedly hit her head .Comments: Large contusion in R (right) occipital region with no blood . A CT (Computed tomography) scan dated 7/12/24 revealed the following: Findings .Significant soft tissue swelling and increased attenuation about the right posterior parietal and occipital scalp consistent with hematoma .Impressions .2. soft tissue swelling and hematoma involving the right posterior parietal-occipital scalp . Resident #267 On 8/7/24 the medical record for R267 was reviewed and revealed the following. R267 was initially admitted to the facility on [DATE] and had diagnoses including Restlessness and Agitation. A review of R267's MDS (minimum data set) with an ARD (assessment reference date) of 4/10/24 revealed R267 was independent with most of their activities of daily living. A review of R267's comprehensive careplan revealed the following: Focus-I have the potential to exhibit behaviors that sound or appear sexual in nature r/t (related to) Dementia. Date Initiated: 12/11/2023 .Interventions-If I am interested in another resident and either of us are not competent, please gently separate/redirect us and help me to become interested in another activity. Date Initiated: 12/11/2023 .When I become agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff need to walk away calmly and approach later. Date Initiated: 12/11/2023 . Further review of R267's careplan revealed the following: Focus-have potential to demonstrate physical behaviors (hitting, kicking, resistive to care, slapping, repetitive movements, pushing). I am followed by [facility psychiatric provider]. Date Initiated: 03/13/2024 .Interventions-Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 03/13/2024 .When I become agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Date Initiated: 03/13/2024 . A progress note dated 7/12/2024 revealed the following: Incident Note. Resident was sitting in her wheelchair in the Dining Room at around 5:00pm resident suddenly pushed [R12] and caused her to flip over. Resident [R12] stated that I was trying to block him from touching the other resident. Above resident [R267] got angry and push me from my wheelchair . A second progress note dated 7/12/2024 revealed the following: Nursing Progress Note-Resident was reported by other nursing staff to writer that he was physically aggressive to other resident . Resident pushed [R12] that caused her to flip over from her wheelchair. Physical aggression was stopped by writer. Resident was taken out of the dining room Resident was petitioned out to be transferred. Police officers notified. Arrived at 6:25pm verbal report given and Paperworks filled out and printed. Resident was escorted by police officers transferred to [local hospital] . A third progress note dated 7/12/2024 revealed the following: Nursing Progress Note-According to [R12] resident was attempting to reach another resident but she rolled in front of him which stopped him from reaching anyone else in the dining room. That caused him to be upset so he pushes her out of the wheelchair, Resident was taken to his room and assigned CENA (Certified Nursing Assistant)stayed with him until police arrived A review of the facility investigation summary pertaining to the altercation between R12 and R267 on 7/12/24 revealed the following: FINDINGS-On 07-12-2024, writer received call from [facility Nurse] that resident [R267]was entering 2nd floor dining room where residents [other female resident] and [R12] were in dining area, [R12] stated [R267] was going toward [other female resident] and she told him not to bother them, he then became angry and pushed her wheelchair which made her fall backwards out of her chair and hit her head. Nursing staff immediately intervened upon hearing commotion coming from the dining room, upon entering dining room [R12] was on the floor stating he had pushed her wheelchair which made her fall, [R267] was removed from dining room where he was put on 1:1 supervision. [R12] was placed back into wheelchair and assessed she has hematoma on the right side of head, and right jaw. Dr. was notified new order to transfer resident out to hospital for further evaluation . On 8/8/24 at 12:19 p.m., CNA K was queried regarding R12 being pushed over by R267 on 7/12/24 and they indicated that they heard some screaming coming the dining room and that they were the first there and witnessed R12 flipped over in their wheelchair on the floor and that R12 reported that R267 had pushed them over and she had hit her head after they were protecting another female resident from R267's advances. CNA K indicated that no staff were noted in the dining room monitoring R267. R82 and R100 On 8/8/24 a concern submitted to the State Agency was reviewed which alleged R82 had assaulted R100 on 7/23/24. R82 On 8/8/24 at approximately 11:05 a.m., R82 was observed in their room, laying in their bed. R82 was queired regarding the alteration with R100 on 7/23/24 and they indicated that R82 had gone into their room uninvited and stated messing with their bed sheets and personal items. R82 reported they told R100 to get out of their room and that R100 had hit them twice on their head. R82 reported that after R100 hit them, they hit R100 multiple times in the face and gave them a black eye and went and told the staff about it. On 8/8/24 the medical record was reviewed and revealed the following: R82 was initially admitted to the facility on [DATE] and had diagnoses including Anxiety and Schizoaffective disorder. A review of R82's MDS (minimum data set) and an ARD (assessment reference date) of 7/16/24 revealed R82 was independent with most of their activities of daily living. R82's BIMS score was 13 indicating intact cognition. A review of R82's comprehensive careplan revealed the following: Focus-I have potential to demonstrate physical behaviors AEB (as evidenced by) alleged grabbing another resident around the neck sustained injury during altercation with the other resident. r/t Dementia/Alzheimer's. 7/23/24- physical altercation with another resident. 8/5/24- reported that resident rolls down the hall calling peers and staff morons. Date Initiated: 03/18/2024 .Interventions-Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 03/18/2024 . A progress note dated 7/23/2024 revealed the following: Nursing Progress Note-Resident Alert, oriented x 4, came to the nursing station screaming, using abusive speech', claiming that the other resident attacked him. Resident directed the attention to his injury. Resident was taken down to meet with Administrator. Resident was removing from 3rd room and transferred to second floor room. Resident skin tear was given first aide . A progress note dated 7/25/2024 revealed the following: Nursing Progress Note-Resident risk meeting held resident for resident to resident altercation, Nursing staff noted new edema in hand from incident . R100 On 8/08/24 at approximately 12:54 p.m., R100 was observed in their room, laying in their bed. R100 was queried regarding the altercation with R82. R100 reported he remembers fighting but did not remember what had caused the incident. On 8/8/24 the medical record for R100 was reviewed and revealed the following: R100 was initially admitted to the facility on [DATE] and had diagnoses including Violent behavior, Alzheimer disease, and Wandering. A review of R100's MDS (minimum data set) with an ARD (assessment reference date) of 6/13/24 revealed R100 needed supervision from facility staff with their personal hygiene. R100's BIMS score (brief interview for mental status) was three indicating severely impaired cognition. A progress note dated 7/23/2024 revealed the following: Nursing Progress Note- Resident was injured by another resident. Resident received injuries to both eyes, and scratch on forehead, eyes are black, red and swollen. Nurse did not witness the incident. Nurse received resident from other staff. They walked resident to nursing station Nurse is waiting for doctor to reply with further instructions, relating injuries. Nurse will continue to monitor the resident for safety and his wellbeing. A second progress note dated 7/23/2024 revealed the following: Nursing Progress Note-Resident was injured by another resident. Resident received injuries to both eyes, and scratch on forehead, eyes are black, red and swollen . Immediate intervention implemented: Nurse applied first aide to resident face and scalp A Practitioner Progress Note dated 7/24/2024 revealed the following: [R100] was injured by another resident yesterday 23rd July around afternoon. He received injuries to both eyes, and scratches on his forehead On examination his eyes has fading and improving peri-orbital ecchymosis and a left eye sub conjuntival hemorrhage His daughter and grand daughter visited his today and wanted him sent out Discussed with nurse to sent him to hospital for evaluation. A review of the facility investigation of the altercation between R82 and R100 revealed the following: Findings: Resident [R100] was observed by [CNA L) while giving patient care on 3rd floor that resident [R82] was in his room had thrown [R100] shoe outside into hallway where it hit the wall when she went to put shoe back on (R100), she observed his left eye swollen she took resident to nurse. [R82] was going to nurses station and had stated [R100] hit him when he came into his room on back of his head, and he said he also scratched him on his right arm, when he told him to leave his room. When questioned by the nurse regarding [R100] he said he didn't do anything to him/ [R100] was assessed by nurse and it was noted that both his eyes were darkened, resident unable to explain what happened, he also had scratch on his forehead, First Aide provided to resident Dr. and Guardian notified. [R82] was immediately separated from resident and assessed he had scratches on his rt (right) hand he was taken to administrator office where he was questioned by writer regarding the incident, he stated that resident [R100] came into his room and he told him to get out, when asked did he hit the resident he stated yes he hit in the eyes after he scratched him and hit him in the back of head. First Aide provided to resident's hand, no injuries noted to back of head, .Conclusion: No one witnessed what occurred with [R82] and [R100], Police was notified they came to facility and spoke with resident regarding incident he was educated to ask staff for assistance and not to hit any residents, [R82] room was moved to another floor. Both residents receives well being checks by social services, [R82] states he feels safe in the facility. [R100] shows no signs of distress, his eyes are doing well, he was seen by physician on 07-24-2024 his family was at bedside and wanted resident to be sent out to hospital for further evaluation of his eyes, resident transferred out he returned with no new orders. It was substantiated this incident occurred . On 8/7/24 at approximately 2:55 p.m., during a conversation with Social Worker C (SW C), SW C was queried regarding R267's behaviors and their altercation with R12. SW C reported that the staff were aware of R267's behaviors towards females and that they should be monitoring them. On 8/8/24 at approximately 1:18 p.m., during a conversation with the Administrator who served as the facility abuse coordinator, the Administrator was queried regarding the altercation between R12 and R267 and they reported that R267 got made and had knocked over R12's wheelchair when R12 was protecting another resident from them. The Administrator indicate that CNA K went into the room and saw R12 flipped over and separated everyone and the Nurse was made aware and R267 was petitioned out to the hospital and R12 was sent to the hospital for their head injury. The Administrator was queried how the staff were monitoring R267's behaviors and they indicated that they staff knew to watch them and to intervene. The Administrator was queried regarding the altercation between R82 and R100 on 7/23/24 and they reported that R100 was in R82's room and that R82 hit R100 after R100 hit them. The Administrator reported that R82 came down to their office to calm down and informed them of the altercation and what had occurred. The Administrator reported both altercations were substantiated due to their injuries, staff reports and resident reports and that R267 has not returned from the hospital and R82's room had been changed. On 8/8/24 a facility document titled Abuse/Neglect and Exploitation was reviewed and revealed the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. 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

This citation pertains to intake MI00145584 Based on observation, interview and record review the facility failed to ensure a thorough investigation into an allegation of misappropriation was completed and contact law enforcement for one resident (R13) of one residents reviewed for misappropriation. Findings include: On 8/6/24 a facility reported investigation (FRI) was reviewed that alleged the following: Incident Summary Resident (R13) states that he had three $50.00 bills, totaling $150.00 in his coat pocket he states he hung jacket up in his closet when he went back to get his coat he states his money was gone. He didn't see anyone in his closet or in his room just the cena (Certified Nursing Assistant Q)who was taking care of his roommate . On 8/8/24 at approximately 2:17 p.m., R13 was observed in their room, up in their wheelchair. R13 was queried regarding the allegation of his money and indicated that he thought the female CNA stole it out of his coat pocket. R13 was queried how much money they had and they could not remember the exact amount they had reported. On 8/8/24 the medical record for R13 was reviewed and revealed the following: R13 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Hypertension. A review of R13's MDS (minimum data set) with an ARD (assessment reference date) of 7/15/24 revealed R13 needed supervision from staff with most of their activities of daily living. R13's BIMS score was 10 indicating moderately impaired cognition. A review of the facility investigation pertaining to the allegation revealed the following: [R13] stated that on 05-17-2024 during day shift he had three $50.00 bills in his coat pocket, he states his coat was hung up by a cena, [CNA M] he then left his room when he returned he states money was gone. He didn ' t ' see anyone in his room or near his coat. He did say it was a tall cena taking care of his roommate, but he didn ' t see her around his coat. [R13] couldn ' t explain where he got the funds from, facility doesn ' t give out $50.00 bills, she gives out $20.00 bills, resident was encouraged to leave his funds in his trust account for safe keeping until he is ready to use it, he verbalized understanding. Investigation findings are as follow: Interview were conducted with [CNA M], [CNA O], and [CNA P] all job classifications are Certified Nurses Assistance, all verbalized they didn't see any money that [R13] had or go near his coat after it was hung up by [CNA M]. Conclusion: Incident was not substantiated, resident was again encouraged to let facility safeguard his funds, any valuables, he will receive weekly support visits from social services for 4 weeks then prn (as needed). On 8/08/24 at approximately 1:18 p.m., during an interview with the facility Administrator (Abuse Coordinator), the Administrator was queried pertaining to R13's allegation of misappropriated money and they reported they had talked to them and they could not come up with a timeframe of when their money was taken. At that time, the investigation file was reviewed with the Administrator and they queried why they only interviewed three CNA's. and if they had interviewed other residents who resided in close proximity to R13 to ascertain if anyone else had missing funds and they indicated they did not. The Administrator was queried if they had interviewed any other staff who may have come in contact with R13 such as Nurses and CNA's on different shifts and housekeeping, dietary or maintenance staff and they reported they did not. The Administrator was queired if they had notified the police of R13's allegation and they indicated they did not due to the facility not witnessing R13 having that amount of money on their person. The Administrator was queried if they should have completed more pertinent interviews with other staff and residents as well as notify police of the allegation and they indicated that was part of their usual process to complete the investigation. On 8/8/24 a facility document titled Abuse/Neglect and Exploitation was reviewed and revealed the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property V. Investigation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; a. The facility Administrator is the Abuse Coordinator of the facility. b. The facility Administrator may designate an interim Abuse Coordinator in their absence (i.e., vacation, PTO). 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation .

Based on interview, and record review, the facility failed to ensure Preadmission Screening (PAS)/Annual Resident (ARR) Mental Illness/ Intellectual Disability/ Related Conditions Identification forms DCH-3877 and/or DCH-3878) documents were reviewed, revised, and sent to the local state agency for review and/or evaluation for intellectual/ developmental disability needs for two residents (R79 and R102) of two residents reviewed for PASSARs, resulting in the potential for unmet intellectual/ developmental disability care needs. Findings include: R102 Record review R102's electronic medical record (EMR) revealed admission into the facility on [DATE] with a pertinent diagnosis of major depressive disorder and psychotic disorder with delusions and adjustment disorder. According to the Minimum Data Set (MDS) dated [DATE], R102 had severe impaired cognition and required partial/moderate assistance with most Activities of Daily Living (ADLS). Further review of EMR revealed an annual 3877/78 was completed on 4/18/24 by Social Worker (SW) C. Resident was marked for mental illness and a Level II Screening should have been requested. During an interview on 8/7/24 at 10:59 AM with SW C, it was reported that a Level II screening was never completed. SW C reported that when she contacted the agency that completes the Level II screenings that they had never received a request. When SW C was asked, since the 3877/78 was completed in April of this year, should you have followed up in a timely manner to see if there was a problem, SW C replied, Yes. During an interview on 8/7/24 at 1:18 PM with Nursing Home Administrator (NHA), it was reported that it was the facility's expectation that the Social Worker should follow up when a Level II has not been completed in a timely manner to ensure that there is no delay in services. 38271 R79 On 8/6/24 the medical record for R79 was reviewed and revealed the following: R79 was initially admitted to the facility on [DATE] and had diagnoses including Schizoaffective disorder, depressive type, Delusional disorders, A review of R79's MDS with an ARD of 5/1/24 revealed R79 needed supervision from facility staff with most of their activities of daily living. R79's BIMS score (brief interview for mental status) was 13 indicating intact cognition. A review of R79's most recent PASARR (pre admission screening/annual resident review) in the medical record was observed to be dated for 4/8/22 and indicated R79 had diagnoses of mental illness and was receiving treatment for mental illness and had stated the following: [R79] has a diagnosis of schizoaffective disorder depressive type, delusional disorder, personality disorder, and anxiety disorder. Further review of R79's medical record did not reveal any updated ARR (form 3877) since the one noted in the record that was dated for 4/8/22. On 8/7/24 during a conversation with Social Worker C (SW C), SW C was queried regarding the lack of an updated ARR (form-3877) in R79's record. They reported that the previous Social Worker in the facility should have updated the form and sent it into the local Community Mental Health Services Program (CMHSP) to ascertain if R79 needed a level two OBRA (Omnibus Reconciliation Act) assessment. SW C indicated that they just received access to the system in April 2024 and they were working to try to update all the outstanding assessments. SW C indicated they had not yet reviewed R79 but would would work on getting it updated appropriately. On 8/8/24 a facility document titled Resident Assessment-Coordination with PASARR Program was reviewed and revealed the following: Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I- initial pre-screening that is completed prior to admission i. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen - necessitates a PASARR Level Il evaluation prior to admission. b. PASARR Level Il - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission. 3. A record of the pre-screening shall be maintained in the resident's medical record. 4. Exceptions to the preadmission screening program include those individuals who: a. Are readmitted directly from a hospital. b. Are admitted directly from a hospital, requires nursing facility services for the condition for which the individual received care in the hospital, and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. 5. If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, or a related condition to the appropriate state designated authority for Level Il PASARR evaluation and determination. b. The Level Il resident review must be completed within 40 calendar days of admission. 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and refenoing to the appropriate authority. 7. Recommendations, such as any specialized services, from a PASARR level Il determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. 8. Any level Il resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level Il resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment .

Based on observation, interview, and record review the facility failed to follow professional standards of practice for medication administration for two (R101 and R44 ) of four residents reviewed for medication administration resulting in 1) R101's medications left unattended on the breakfast tray and extended/delayed release medications being crushed without an order and 2) R44's medications being unavailable for administration. Findings include: R101: On 8/6/24 at 9:48 AM, R101 was observed seated upright in his bed eating breakfast independently. A medication cup with 9 whole pills was resting on the breakfast tray next to his plate. R101 was unable to be meaningfully interviewed about the medications due to impaired cognition status. Registered Nurse (RN) G came into the resident's room and was asked about the medications on the resident's breakfast tray. RN G said, Oh he takes them himself, but I need to crush them first. RN G took the medication cup off the table, went to the medication cart and proceeded to crush the pills. RN G was asked about crushing a resident's medications and replied, There is no order to crush the meds, but it is easier for him (R101) to take them that way. Review of R101's Electronic Health Record (EHR) revealed the resident had multiple diagnoses that included major depressive disorder and schizoaffective disorder. The Minimum Data Set (MDS) dated [DATE] indicated the resident had severely impaired cognition and required a one person assist with eating. There were no physician's orders to crush the medications. The Medication Administration Record (MAR) had no documentation to indicate the medications were able to be crushed. Further review of R101's MAR revealed that 2 of the 9 medications should not have been crushed due to the medications being extended or delayed release (Divalproex 500 mg delayed release, and Isosorbide 30 mg ER extended release once a day). According to the Mayo Clinic and the manufacturer's guidelines for Divalproex delayed release and Isosorbide extended release the pills should be swallowed whole. Do not split, crush, or chew them. Doing so can release all the drug at once, increasing the risk of side effects. During an interview with the Director of Nursing (DON) on 8/7/24 at approximately 12:00 PM the DON confirmed that medications should not have been left at the beside unattended for R101. The DON went on to say that medications can only be crushed if there is a physician's order for it. According to the facility's Resident's Self-Administration of Medication policy last revised on 6/2023 in part reads; 3. No medication shall be left unattended without the resident's knowledge that it has been left there for them. According to the facility's Medication Administration - General Guidelines (undated) in part reads; 5. Tablet Splitting: Splitting of tablets should be avoided, and every attempt should be made to obtain an alternative dosage form, medication, or dosing schedule to avoid splitting a. Assure the tablet is appropriate to be split. No sustained-release, enteric coated, or unscored tablets should be split. Determining if a tablet can be safely and appropriately split should be based on an official reference list or by contacting OneCare Pharmacy. 6. Tablet Crushing/Capsule Opening: Crushing tablets may require a physician's order per facility policy. a. The instructions for crushing medications should be included on the resident's orders and on the Medication Administration Record. 38271 R44 On 8/6/24 the medical record for R44 was reviewed and revealed the following: R44 was initially admitted to the facility on [DATE] and had diagnoses including Gastroesophageal reflux disease and Hypertension. A review of R44's MDS with an ARD of 6/3/24 revealed R44 was independent with most of their activities of daily living. R44's BIMS (brief interview for mental status) score was nine indicating moderately impaired cognition. A review of R44's Physician orders revealed the following: Fluticasone Propionate Suspension 50 MCG/ACT 1 spray in each nostril one time a day for allergic rhinitis (AR). Start date-4/4/24. Claritin Oral Tablet 10 MG (Loratadine) Give 1 tablet by mouth one time a day for AR (Allergic rhinitis).-Start Date-02/14/2024 A review of R44's medication administration record (MAR) for July and August 2024 revealed the following dates in which R44 was not administered their Fluticasone spray: 7/5, 7/9, 7/29, 8/5, and 8/6. A review of R44's MAR for July and August 2024 revealed the following dates in which R44 was not administered their Claritin: 7/5, 7/9, 7/19, 8/5 and 8/6. On 8/7/24 at approximately 2:13 p.m., Nurse S was queried regarding the availability of R44's fluticasone and they were observed looking though the medication cart and indicated R44 did not have any fluticasone in the cart. Nurse S reported that it would have to be reordered. Nurse S was queried if they administered it to R44 that morning and they indicated they did not because they did not have any in the cart. On 8/7/24 at approximately 2:20 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the process of reordering medication it if is not available. The DON reported if the Nurses went to administer the medication and there was none available, they would have have to call the pharmacy and can have it delivered on the next shipment and call the Physician. The DON was queried why their were so many missed administrations in R44's MAR and they indicated that it was a standard of practice to reorder it after the first missed dose and that they would have to check the supply closet to see if any had been delivered and that they had to educate the facility Nursing staff on the proper procedures. The DON was queried regarding R44's claritin not being administered on 8/5 and 8/6 and they reported that it was a stock medication and they had it on other floors and the Nurses were supposed to go get it to administer instead of not administering and documenting that it was unavailable. On 8/8/24 a facility document titled Medication Administration-General Guidelines was reviewed and revealed the following: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions .C. Documentation-1) The nurse who administers the medication records the administration on the resident's MAR immediately after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the nurse who administered the medications report off-duty without first recording the administration of all medications

Based on observation, interview, and record review, the facility failed to ensure proper weight monitoring occurred for two residents (R27 and R71) deemed to be at nutrition risk out of six residents reviewed for nutrition status, resulting in weight changes to go undetected and potentially compromise nutrition status. Findings include: R27: On 8/6/24 at approximaely1:30 PM R27 was observed in her bed with her eyes opened and music playing on her radio. The resident could not be meaningfully interviewed due to severe cognition impairment. The resident had an IV pole with a tube feeding pump attached. No tube feeding was present on the IV pole. Registered Nurse (RN) C was asked if R27 received tube feedings and replied, Yes, she gets them over night. The feeding goes up at 5:00 PM and is usually completed by 7:00 AM. According to R27's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with history of a stroke, dysphagia (inability to swallow effectively), and dementia. On 3/6/24 a significant change Minimum Data Set (MDS) was completed for weight loss. The MDS indicated the resident had severe cognition impairment, was not verbal, and totally dependent on staff for all activities of daily living. R27 had a feeding tube (flexible tube inserted through the abdominal wall to administer liquid nourishment, fluids, and medications). On 3/11/24, the physician ordered Jevity 1.5 tube feeding at 70 milliliters (ml) an hour to run for a total of 1120 ml to provide 1680 kcalories per day. On 7/23/24 a progress note written by Registered Dietitian (RD) F indicated the resident's weight had not been documented since 5/28/24. A review of R27's weights revealed the last documented weight was on 5/28/24 and recorded as: 133 lbs. (pounds). On 8/7/24 at 2:53 PM RD F was asked how often residents who receive tube feeding should be weighed. RD F said, At least monthly if they are stable. The resident triggered for significant weight loss in March, so probably weekly until the weights are stable. RD F could not say if the resident's weights had been stabilized. RD F said, There is difficulty obtaining accurate weights at times. I don't do them, the CNAs (Certified Nursing Assistants) do the weights. On 8/8/24 at 1:28 PM the nurse unit manager, Licensed Practical Nurse (LPN) I was asked about the R27's weights and replied. She (R27) was weighed on 8/5/24 and was at 133 lbs. I just forgot to record it. At this time LPN I provided a handwritten weight record that indicated R27's weight on 8/5/24 was 133.0 lbs. LPN I was asked to weigh the resident for accuracy. On 8/8/24 at 2:00 PM the Director of Nursing (DON) reported that R27's weight was observed to be at 147.4 lbs. The DON could not explain the 14.4 lbs. weight difference in 3 days time. R71: On 8/06/24 at 10:54 AM R71 was observed ambulating in the hallway with missing and decayed teeth. R71 was unable to be interviewed due to cognition impairment. According to the Electronic Health Record (EHR) R71 admitted to the facility with Medicaid benefits on 7/11/23 with diagnoses that included schizophrenia and alcohol abuse. The Minimum Data Set (MDS) dated [DATE] identified R71 to have severely impaired cognition with a Brief Interview Mental Status (BIMS) score of 5/15. On 7/15/24 a progress note written by RD F read as follows: RD requesting a re-weigh. The weight records indicate a 20 lb. weight loss in three weeks time. R71's recorded weights were as follows: 5/23/24: 144.0 lbs. 6/9/24: 144.0 lbs. 6/23/24: 144.0 lbs 7/12/24: 124.0 lbs - (20 lb change) 8/6/24: 124.8 lbs. According to R71's nutrition care plan interventions initiated on 7/17/2023 included the following; report any significant weight changes to my physicain. 08/06/24 at 3:55 PM RD F was asked about R71's significant weight change on 7/12/24. RD F said she really could not explain it but would get a re-weight. On 8/6/24 a progress note written by RD F indicates the weight of 124.8 is accurate and the resident does not appear to have lost such a significant amount of weight. RD recommended Ready Care 2.0 (a nutritional supplement) once a day and that RD will monitor the next weight. On 8/7/24 at 3:32 PM during an interview with the Director of Nursing (DON) she said that R27 had lost some weight but doubted that it was over a short period of time. The DON said that it is possible the CNA's may not be weighing residents accurately. According to the facility's Weight Monitoring policy last revised 1/2021 in part reads; Based on the resident ' s comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 5. Weight will be obtained upon admission, readmission and weekly for the first four weeks after admission and at least monthly unless ordered by the physician. 6. Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight to determine if a re-weight is necessary. 7. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days) b. 7.5% change in weight in 3 months (90 days) c. 10% change in weight in 6 months (180 days).

This citation pertains to intake MI00139324. Based on observation, interview, and record review the facility failed to prevent resident to resident abuse for two Residents (R102 and R101) out of five residents reviewed for abuse resulting in R102's fractured mandible (jaw bone). Findings include: Record review of a face sheet revealed R102 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, seizures, and dementia. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11/15 for T102, which indicated a moderate cognitive impairment and supervision mobility in wheelchair. Record review revealed R101 admitted to the facility on [DATE] with diagnoses of seizures, adjustment disorder, alcohol abuse. Review of the MDS dated [DATE], revealed a BIMS score of 15/15 for R101, which indicated intact cognition and independent mobility. Record Review of the facility Accident/Incident Report (A/I Report) dated 8/28/23 revealed, Writer observed resident with scratches on left inner ear and behind his right ear. Resident stated, 'new resident for bed 2 came into room messing with the cabinets and closets' and I asked resident 'what you are doing?' New resident walked over to me and stated, 'what you going to do about it?' R102 stated 'I aint going to do nothing' R102 stated Resident (R101) started to pull off the bed, then R101 hit R102 with cane on left side of face. So, I tried to defend myself by gripping his shirt and I might have scratched him. The resident walked away so I got up to the nurse's station and told the nurse. Doctor and guardian notified of incident, new order for stat Xray of lt(left). side of face, police contacted, police interviewed resident R102, R101 was taken into custody for assault. Will provide well-being checks for R102. R102 remains in facility, will cont. to monitor. Record Review of the Administrator note dated 8/31/2023,, revealed Writer spoke with County Prosecutor, in regard to the incident involving R102 and R101. R101 remains in custody and spoke with R102 who again stated wants to press charges, a no court order has been issued, meaning the resident R101 can't have any contact with R102 and is not allowed in facility. R102 states feels safe in facility. Will cont. to monitor. In observations and interviews on 9/20/23 at 10 AM and 2 PM, R102 stated I was living in a different room when the incident happened. R102 pointed to the left side of face and demonstrated unable to open mouth fully. The guy (R101) came into my room and started going thru my roommate's stuff. When I asked what was R101 doing R101 said was moving in and I couldn't stop them. R101 started throwing items on the floor when I bent over to pick them up R101 pulled me off my bed by my ankles. While I was on the floor R101 left the room. I pulled myself back onto my bed. R101 then came back in with a cane it had 3-4 legs on it. I stood up and R101 hit me on the left side of my face with the cane. We got into a fight then I went down to the nurse's station in my wheelchair to report it and get help. When asked if R101 had a cane the first time in the room R102 stated no R101 did not have the cane until R102 came back into the room. In an interview on 9/20/23 at 10:30 AM with Licensed Practical Nurse (LPN) A explained R102 came from room to tell me at the nurse's station that R101 assaulted R102 with a cane. LPN A said she saw R101 coming down the hall and threatened R102. LPN A stated, I heard (R101) say 'yah I hit (R102) with my cane.' I separated the residents and notified my unit manager, the doctor and R102's guardian. I couldn't hear anything about the altercation at the nurse's station. When asked if R101 had a history of incidents LPN A reported R101 had an incident with another resident the night before and was being transferred to a new room. Record Review of the A/I Report dated 8/28/23 revealed, Writer observed scratched on residents (R101) right side of chin, neck, and ear, open are on lip. (R101) charging toward (R102) getting ready to swing cane again writer step in between residents. (R101) stated (R102) grabbed my shirt and busted my lip. (R101) was still aggressive toward writer and (R102.) Writer only observed visual scratches. Police was called (R101) was sent away. Record review of the facility reported incident revealed that there were no CNA interviews conducted regarding the incident between R101 and R102. Record Review of the facility reported incident dated 7/4/23 revealed R101 was in a physical altercation with another resident. Record Review of the A/I Report dated 8/26/23,(incident occurred 2 days prior to 8/28/23 incident) revealed R101 was involved in a verbal altercation with another resident, During rounds loud arguing noted coming from resident's room. Writer approached the room R101 noted yelling at another resident stated, fuck you. Writer intervened and separated the two residents. R101 was transferred to another room. Record review of R101's Care Plan dated 7/5/23 revealed Focus: I have demonstrated physical behaviors such as I pushed another resident causing him to fall to floor after we had a verbal altercation. Interventions/tasks: Intervene as necessary to protect the rights and safety of others and When I become agitated intervene before agitation escalates, Guide away from the source of distress, Engage calmly in conversation if response, if aggressive, staff to walk calmly away and approach later. In an interview on 9/20/23 at 11:30 AM with the Nursing Home Administrator (NHA) explained that she was aware of the incident when R101 hit R102 with a cane. The NHA reported was also aware that R101 was in a verbal altercation with another resident on 8/26/23 2 days prior to R101 assaulting R102. The NHA also revealed that she reported a facility reported incident to the State Agency on 7/4/23 that involved R101. The NHA agreed 2 nurses and 3 CNAs worked on 8/28/23 at the time of the incident between R101 and R102 but only 1 staff member was present for part of the altercation between R101 and R102. There was no evidence that staff intervened in the verbal altercation between R101 and R102. There was no evidence that staff intervened in the physical altercations between R101 and R102. In an interview with Certified Nursing Assistant (CNA) B on 9/20/23 at 12:26 PM revealed CNA B was assigned to both residents R101 and R102 on 8/28/23. CNA B stated I was in the shower room at the time of the incident. I saw R102 wheeling down the hallway when I asked what was wrong R102 stated they were going to the nurses' station to report a fight. I went back to work. In an interview on 9/20/23 at 12:59 PM with CNA C revealed CNA C was assigned to work the floor but was not present during the fight between R101 and R102. In an interview with CNA C on 9/20/23 at 1:15 PM revealed CNA D was assigned to the floor on 8/28/23 but was in the day room at the time of the incident between R101 and R102. CNA D stated I heard the commotion at the nurses' station but by the time I got there the fight between R101 and R102 was over. In an interview on 9/20/23 at 1:20 PM with LPN E revealed that LPN E was assigned to work the floor on 8/28/23 the day of the incident between R101 and R102 but wasn't on the floor at the time of the altercation. Review of the Facility Policy Abuse, Neglect and Exploitation dated 1/28/2002, revised 6/23 revealed in part The facility will identify, correct, and intervene in situations in which abuse is more likely to occur with the deployment of trained and qualified staff, to meet the needs of the residents and to assure that the staff assigned have the knowledge of the individual residents' care needs.

This citation pertains to Intake MI001137443. Based on observation, interview, and record review, the facility failed to protect one vulnerable cognitively impaired female resident (R908) from being touched sexually by one cognitively impaired male resident (R909) who also had a criminal sexual history, for one resident (908) of 10 residents reviewed for abuse resulting in actual harm, mental anguish, and feelings of compromised safety and the likelihood for ongoing sexual and/or physical abuse. The immediate jeopardy began on 5/22/23 at 4:08 p.m. when R909 was observed attempting to force R#908 down on the bed. In addition, after the 5/22/23 incident, the facility failed to implement interventions to protect the health and safety of residents. On 5/27/23 staff witnessed R908's face being licked by R909 while his hand was down her pants and his other hand was down his pants while at the nurse's station. The immediate jeopardy was identified on 6/14/23 at 11:37 a.m. The Administrator was notified of the Immediate Jeopardy on 6/14/23 at 2:30 p.m. A plan for removal was requested. The immediacy was removed on 5/27/23 at 3:00 p.m. The State Agency verified the removal of the immediacy by record review and interview on 6/16/23. It can be determined that the reasonable person in the residents' position would have experienced severe psychosocial harm because of the abuse. Although the immediacy was removed, the facility's deficient practice was not corrected and remained at actual harm that is not immediate jeopardy. Findings include: Review of the facility reported incident revealed the following: On 5/27/23 at approximately 2:45 pm, on the third-floor dining room, it was observed by two CNAs while they were standing at nurses' station that resident R909 was licking the face of R908 who was asleep in the geriatric chair. R909 also had his left hand in her pants. His pants were up. He wasn't undressed and her pants were up. They were not pulled down. Staff immediately went into the dining room and separated the residents. R909 was removed from the facility by the police. The facility substantiated the allegation. On 6/14/23 at 11:26 a.m. review of medical record documented R909 was initially admitted into the facility on [DATE] with diagnoses that included major depressive disorder, dementia, mood disturbance, anxiety, and bipolar disorder. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R909 had moderate impaired cognition and required supervision with set up with activities of daily living. The resident profile documented R909 had a parole agent relate to a conviction of criminal sexual conduct. As of 5/27/23, the local authorities were notified and arrested R909 for assault. R909 no longer resides in the facility. According to the Parole Conditions put in place for R909 8/6/20 (the day prior to admission into the facility on [DATE]) documented the following: Parole supervision is intended to protect the public while providing assistance and guidance to facilitate the parolee's transition from confinement to free society. To meet these goals, minimum conditions are established which may be enhanced by special individual conditions. A parolee's failure to comply with any condition may result in revocation and return to confinement . CONDUCT: You (R909) must not engage in any behavior that constitutes a violation of any criminal law of any unit of government. You must not engage in assaultive, abusive, threatening or intimidating behavior . On 6/14/23 at 1:31 p.m. R908 was observed reclined in a geriatric chair at the nurse's station on the third floor of the facility. The resident appeared to be resting comfortably. R908 did not respond when her name was called. The resident's hand was touched but did not awaken. On 6/14/23 at 2:43 p.m. review of the medical record documented R908 was initially admitted into the facility on [DATE] with diagnoses that included dementia, major depressive disorder, malignant neoplasm of the stomach, and anxiety. According to the quarterly MDS assessment dated [DATE], R908 had unclear speech and severe impaired cognition. R908 required extensive one person assistance with activities of daily living. The resident had wandering behavior daily. The resident had a legal guardian. R908 was also receiving hospice services as of 1/5/23. Further review of the medical record, a nurse's progress note, documented the following: 5/22/2023 16:08 Behavior Note Text: CNA notified writer that resident on top of female resident with pants still up when enter the room to question resident he became violet and aggressive. don and administer was notified. On 6/14/23 at 11: 37 a.m. the Nursing Home Administrator (NHA) was queried regarding the 5/22/23 incident involving R908 and R909. The NHA looked at the nurse's note and said the documented incident did not occur. I don't know anything about this note or this happening. That was not what I was told. There was no evidence the facility implemented interventions to protect the resident during their investigation apart from separating the residents. There were no care plans or monitoring tools put in place after the incident on 5/22/23 to prevent any further sexual or physical abuse involving the facility residents. On 6/14/23 at 12:10 p.m. Certified Nurse Aid (A) was interviewed and asked what she witnessed on 5/22/23. CNA (A) stated, I was walking pass the room when I saw the two residents on the bed. Something didn't look right so I went in the room. She (R908) was on the bed, but he (R909) was not on top of her but was trying to hold down trying to get to her pants. He was standing and she was down (the nurse aid demonstrated what she saw using the chair she was sitting on). She did not say anything but was strong. She was moving trying to get off the bed, but he kept trying to hold her down. I told him to stop then went to get some help. I told the nurse what happened but by the time the nurse came to the room, they were just sitting on the bed. The nurse told me to take her out the room. The Administrator and Director of Nurse's (DON) knew what happened because they came and talked to the resident about it. I told them exactly what I just told you. On 6/14/23 at 12:32 p.m. the NHA and the DON were interviewed and asked to recall the incident on 5/22/23. The Administrator stated, We were told what happened and went up to the floor. We talked to the resident (R909), the nurse, and CNA (A). I was told they were not undressed, and he (R909) wasn't on top of her (R908). The DON then stated, We did a full investigation on this. The staff were interviewed and everything. We made sure the residents were separated. The NHA then stated, I did not report it because nothing happened. The nurse said they were just sitting on the bed. The DON was asked to provide evidence of the investigation. The DON stated, We didn't write it down, we just talked to everybody. On 6/15/23 at 10:02 a.m. CNA (B) was attempted to be contacted via telephone for an interview regarding the incident that occurred on 5/27/23. CNA (B)'s written witness statement was reviewed. CNA (B) witness statement documented: Seen (R909) lick (R908) face with his tongue while I was standing at the nurse station. I also seen (R909) left hand in (R908) pants. By the end of the survey, CNA (B) had not been available for an interview. On 6/15/23 at 10:11 a.m. CNA (C) was attempted to be contacted via telephone for an interview regarding the incident that occurred on 5/27/23. CNA (C )'s written witness statement was reviewed. CNA (C) witness statement documented: I saw (resident's name) lick resident's name face with his tongue. I also saw his left hand in her pants while standing at the nurse's station. By the end of the survey, CNA (C) had not been available for an interview. Review of the facility's policy titled Abuse, Neglect, and Exploitation dated 4/23 documented: 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 . Protection: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation; Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator . Prevention: The facility will identify, correct, and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs . The facility will identify by ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect (i.e., verbally, physically, or sexually aggressive behavior, wandering, communication barriers, or who require extensive nursing care). On 6/16/23 at 12:01 p.m., the Administrator and the Regional Director of Operations presented the facility's plan to remove immediacy. The plan includedthe following: A. Identification of Residents Affected or Likely to be Affected: Include actions that were performed to address the citation for recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the facility's noncompliance and the date the corrective actions were completed. (Completion Date: 5/27/2023) 1. On 5/22/23 and 5/27/23, the staff immediately separated R908 and R909 at the time of the events. 2. On 5/27/2023, a nursing assessment, including a skin and pain assessment was completed on R908 - no identified deviations from the baseline. 3. R908's physician was notified of the event and no new orders were issued at this time. 4. Social Work completed wellness checks on R908. 5. R908 care plan was updated as appropriate. 6. R908 to be seen by psych services. B. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 05/27/2023). On 5/27/23 the local law enforcement was notified and resident R909 was removed from the facility and taken into custody. o R909 has not been at the facility since the time of the reported incident. o On (5/27/2023), a record audit was conducted on all non-verbal residents and residents with language barriers to assess for any change in condition; no concerns were identified. o The NHA initiated abuse reeducation with all staff on (5/27/2023). No staff were permitted to work after that date until first receiving the reeducation. o All residents are interviewed periodically during facility Guardian Angel Rounds and questioned specifically about abuse and feeling safe in the facility; no concerns have arisen regarding either identified resident or events in question. (5/27/2023) o All new admissions will have [NAME] background checks prior to entering the facility, any admitting residents identified to have a history of sexual assault will have a psychosocial care plan initiated to assist employees with the management of any potential behaviors of a sexual nature. In addition, all Staff has been re-educated on the abuse policy and the reporting of abuse guidelines. (5/27/202). o On 5/22/2023 R908 was found being held down by the shoulder by R909 in his room. Staff intervened by separating both residents. The facility did not conduct a full and thorough investigation on 5/22/2023. To prevent a reoccurrence the facility will ensure the following steps are taken with instances of alleged abuse: o The facility will ensure that all residents involved are safe. o Staff will contact the abuse coordinator immediately. o Law enforcement will be contacted if deemed necessary. o The resident's physician will be notified. o The residents Guardian, if necessary, will be notified. o The State Agency will be notified in accordance with notification guidelines for reporting abuse allegations. o The facility will conduct an audit of all residents. o The facility will update resident care plans when necessary or when appropriate. o The facility will educate all staff on abuse and abuse reporting. o The facility will conduct complete and thorough investigation of any allegations of abuse. o Any deviation from the steps will be taken to QAPI immediately.

This citation pertains to intake MI 9532 Based on observation, interview, and record review the facility failed to provide appropriate assessment, monitoring and treatment after a fall in 1 of 4 residents (R1) reviewed for assessment post fall, resulting in a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: An observation was conducted on 5/10/21 at 12:50PM in the room of resident (R1). The resident was lying in bed with a piece of foam wrapped around the right upper leg (log roll pillow). The resident was noted to have discoloration and bruising on right and left forearms, and under the right ear. Review of a form entitled: SNF/NF ( Skilled Nursing Facility/Nursing Facility) to hospital transfer form dated 4/25/21 at 8:45PM, indicated a pain level of 9/10, with a location of right ear and coccyx (bone at end of spine). The resident required assistance with bathing, dressing, toileting, and eating at time of transfer. On 5/10/21 at 11:00AM a review of the admission record was begun. (R1) was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS (minimum date set) within the clinical record dated 4/16/21 indicated resident (R1) was severely cognitive impaired (thought processes), and required supervision when walking in her room, in the hallway, and during toilet use. The incomplete fall risk assessment provided with an effective date of 1/14/21 indicated the resident was easily distracted, had an altered awareness of surroundings, demonstrated an unsteady gait at times, wandered and paced, and had an inability to see in adequate light. According to the assessment Resident (R1) was over [AGE] years old, received medications ( Blood pressure, dementia) that increased the resident's risk for falls. The incomplete fall risk assessment had a final score of N/A ( non-applicable) and provided no overall fall- risk score identifying whether R1 was at risk for falls. Per record review of the Investigation Summary Report dated 4/23/21, the facility social worker (D) was identified as witnessing Resident (R1's) fall. Social Worker(D) was the first person to arrive at the resident's room while doing her rounds. The investigation indicated that (Social Worker D) reported the resident was in her room, calling for help and she was not able to get to the resident in time to prevent her from falling to the floor on her buttocks. An interview was conducted on 5/10/21 at 2:45 PM with Social Worker (D). I was doing my rounds and the resident was in her room in the back hall on the observation unit. The room is private. I was outside the door, but I could look in, she has a distinct voice, I heard her call out for help. I did see her fall on her bottom. I called for the nurse that was outside in the hallway. She came down and got the resident up. When I saw her, she was in the process of falling. An additional interview was conducted with (D) on 5/11/21 at 2PM. (D) stated, I did not see the resident hit her head, I did not see her hit anything, in response to the surveyor's query regarding the resident's bruised ear. According to the Investigation Summary Report dated 4/25/21 Nurse (P) assessed (R1) with no marks, bruises, or cuts. Vital signs were obtained, and the MD was informed. Unit Manager (E) in an investigational note dated 4/25/21 indicated the receipt of a report that (R1) had a slip in the room that landed her on the floor. Range of motion was completed to all extremities with no resistance or changes noted. Unit Manager ( E) asked LPN (M) if range of motion and a head- to- toe assessment was completed. LPN (M) stated, yes and no changes were observed. On 5/10/21 a review of the nursing notes dated 4/23/21- 4/25/21 was conducted . The nursing notes revealed no written evidence of range of motion or head-to-toe assessment. The DON and Registered Nurse/Unit Manager (RNUM) E was quired regarding the missing documentation and was asked if an x-ray was performed . Unit Manager E stated the doctor did not order an x-ray but LPN (M) should have documented the head-to-toe assessment on 4/23/21. Both were asked to review the clinical records and Unit Nurse M verified there was no documentation or assessment from 4/23/21-4/25/21. On 5/10/21 at 4 :00 PM review of nurse's notes dated 4/25/21 within the clinical record revealed (R1) was screaming out in pain as LPN (O) was changing the resident's brief. LPN (O) performed a full skin assessment. The resident's right ear had discoloration, purple and black. The resident clenched the right side of face, the resident cried out in pain as LPN (O) was cleaning her up. The coccyx of (R1) was red and the resident cried out. The clincial note indicated R1 had mental status changes, now needed to be fed, but usually can feed herself, and can ambulate and communicate, but that now R1 was doing nothing. The note indicated (R1) grimaced and cried out in pain. The MD was notified and ordered the resident be sent to the hospital. Review of the hospital record dated 4/25/21 (no time) revealed R1 sustained a right intertrochanteric right femur fracture requiring surgical intervention and had a hematoma of the right auricular (ear) region that required incision and drainage, 7 sutures, and compression. On 5/11/21 at 11AM, Certified Nurse Aide (CNA I) was interviewed via phone concerning whether (R1) was observed on 4/24/21 during her shift. CNA (I) stated, I am familiar with the resident. The resident was not doing anything. This was unusual for the resident. The resident is usually up and out of her room. The resident usually feeds herself and goes to the bathroom by herself. When dinner came (LPN O) asked (CNA I) to feed her. CNA (I) reported she was later asked to help LPN (O) log roll the resident. (R1) was crying out in pain and CNA (1) noted the resident's right ear was swollen, purple and black. On 5/11/21 at 12:05 PM CNA ( L) was interviewed via the phone. The CNA worked from 11pm-7AM on 4/23/21 and (R1) indicated R1 remained in her room and in her bed his entire shift. CNA ( L) reported the resident was usually out wandering the halls in and out of rooms on the unit. On 5/11/21 LPN (O) was interviewed via the phone at 12:10PM stated, (R1) was not her normal self. She usually takes medication whole, but this day had to crush her pills and put them in applesauce. (LPNP) did not tell me anything about the resident falling (at shift change. On 5/11/21 on 9AM. a request was made to review the facility's Fall Policy. At approximately 9:30 A.M. a document entitled, Fall Reduction Policy with revision date of 12/20 was presented. The policy in part stated, when a resident experience a fall the facility will assess the resident, complete a post fall assessment, document assessment and actions. In an interview on 5/11/21 at 1:25 PM, RNUM E stated, (LPN P) should have documented her findings on 4/24/, but it was not there. RNUM E stated THE post-fall assessment should be conducted three times daily for 72 hours. RNUM E reviewed the clinical record and stated, the post-fall assessment was not done. RNUM E provided a second Fall policy entitled: (facility name) Fall Management Guidelines, dated January 2021 when a fall occurs, the nurse should assess the resident for injury and provide the appropriate first aid based on standards of practice. If there is a suspected head injury, neuro checks should be completed per MD order or policy. The nursing staff will assess the resident over the next 72 hours and document in the nurses notes to identify any possible injuries including pain that may not have been evident immediately after the fall. RNUM E indicated she was unable to show any documentation to indicate the appropriate assessments were completed for R1. RNUM E stated, The nurses should have completed that, but maybe it was not documented. Upon exiting the facility on 5/11/21 at 3:30PM, no additional information was provided to the surveyor.

This citation pertains to M 9532 Based on observation, interview, and record review, the facility failed to provide adequate supervision and ensure care planned footwear (nonskid socks) were implemented in 1 of 4 sampled residents (R1) reviewed for falls, resulting in a fall with a right femur fracture (thigh bone) and a right ear hematoma (bruising). Findings included: An observation was conducted on 5/10/21 at 12:50 PM in the room of R(1). The resident was lying in bed with a piece of foam wrapped around the right upper leg (log roll pillow). The resident was noted to have discoloration and bruising on the right and left forearms, and under the right ear. Review of the allegation revealed, (R1) was transported to the hospital on 4/25/21 via ambulance (EMS) from the nursing home. The documentation sent with the resident indicated the resident was frail, demented, and unable to care for daily needs. The staff reported to the EMS staff, the resident fell on Friday (4/23/21). It was a witnessed fall but there was no written documentation related to the fall provided to EMS. It was suspected by EMS the resident had a broken hip because the length of her right leg was not straight, and it was shorter than the left leg. On 5/10/21 review of the Admission Record documented R(1) was admitted to the facility on [DATE] with diagnoses that included: [CONDITION(S)] without behavior disturbances, and difficulty walking. A review of the MDS (minimum date set) within the clinical record dated 4/16/21 indicated R(1) was severely cognitive impaired (thought processes), and required supervision when walking in her room, in the hallway, and during toilet use. The resident's wandering care plan initiated 7/10/20 and revised on 7/22/20 identified the resident as a wanderer with a goal of maintaining the resident's safety. Interventions included the need to assess the resident for a fall risk. Review of the Falls Care Plan dated 7/10/20 revealed R1 had poor safety awareness, ambulates a slow, slightly unsteady gait. Interventions Encouraged to wear appropriate footwear (nonskid socks). Review of all the care plans for R(1) revealed no indication that the resident resisted care or removed her footwear. The incomplete fall risk assessment dated [DATE], indicated the resident was easily distracted, had an altered awareness of surroundings, demonstrated an unsteady gait at times, wandered and paced, and had an inability to see in adequate light. The assessment also indicated Resident (1) was over [AGE] years old and received medications (Blood pressure, dementia) that increased the resident's risk for fall. The incomplete fall risk assessment had a final score of N/A (non-applicable) and provided no overall fall-risk score identifying whether R(1) was at risk for falls. Review of the Therapy Screen Form dated 1/25/21 recommending R(1)'s need for proper footwear always. Review of the Investigation Summary Report dated 4/23/21, the facility Social Worker (D) was identified as witnessing R(1)'s fall. Social Worker (D) was the first person to arrive at the resident's room while doing her rounds. According to Social Worker (D) the resident was in her room, calling for help. Social Worker (D) was not able to get to the resident in time to prevent her from falling to the floor on her buttocks. In an interview was conducted on 5/10/21 at 2:45 PM with Social Worker (D). The Social worker stated, I was doing my rounds and the resident was in her room in the back hall on the observation unit. I was outside the door, but I could look in, R1 has a distinct voice, I heard the resident call out for help. I did see R(1) fall on her bottom. I called for the nurse that was outside in the hallway. She came down and got the resident up. When I saw R(1), the resident was in the process of falling. A post-fall document was completed for R(1) on 4/23/21 at 1:10PM (after R1 fall) included causative factors related to the resident's fall to include confusion, ambulating without assistance, improper footwear, recent room change, and wanderer . According to the Investigation Summary Report, dated 4/25/21 (after the fall) Certified Nurse Assistant (CENA-H) whom was assigned to R(1). According to the investigation CNA(H) was in another resident's room at the time of resident's fall. CNA(H) became aware of the fall when notified by Unit Manager (E). Unit Manager (E) documented upon assessing the environment it was noted R(1) was not wearing proper footwear at the time of the fall and corrected the issue. On 5/10/21 at 4:45 PM, during an interview with Unit Manager E she was asked what the appropriate footwear should have been, to which she responded, nonskid socks, and indicated that she put some on the resident after the incident. On 5/10/21 at 5:30 P.M., the Director of Nursing (DON) in the presence of the Administrator was queried concerning the supervision of the resident and the recommendations from the therapy screen recommending R(1) always wear proper footwear. The DON indicated staff were aware R(1) wandered but, provided no additional information if staff were aware that the resident should have been wearing nonskid socks or that, according to the MDS, required supervision when walking.

Based on observation, interview, and record review the facility failed to honor a resident's right to refuse care by forcing unwanted incontinent care for one (R#100), causing a catastrophic reaction (the inability to cope with trauma or shock that results in highly- disorganized behavior. This is characterized by deep feelings of anxiety, inadequacy, and helplessness. It manifests as extremely emotional behavior such as sudden crying or outbursts of aggression and hostility.), subsequently resulting in the resident's finger being fractured that required hospitalization . Finding include: This pertains to intake #MI 570. The complainant reported to the State Agency that resident #100 sustained a fracture on March 4th, 2021 during unwanted care provided by a Cena, and was transferred to the hospital for treatment, resulting in the resident having a cast to right hand to elbow. On 3/22/2021 at 9:05 a.m., observed R#100 lying in bed alert, interview able wearing a right hand/arm cast. An interview was conducted, and R#100 was asked to recall the March 4th incident. R#100 stated, I came here about 9:00 that night and a lady (CNA A) came into my room to change my diaper about 4:30 that morning. She (CNA A) woke me up out of my sleep to change my diaper, I didn't want my diaper changed. I was lying on my right side and she snatched my diaper off, and I turn over and we started tussling. I only had one hand to use because I had the stroke on my right-side. We wrestled for a while and she would not let my hand go. I kept telling her to let go because I was going to tussle with her some more. She still tried to change me but, she hooked the left side of my diaper but not the right side. I never been waking up out of my sleep. My hand was hurting doing the tussle. We didn't know until after the police was gone, it started to swell. It was a half an hour before I called the police 911 when they sent out a police car. My roommate was over there when the Certified Nursing Assistant (CNA) kept telling her to watch while we were tussling. R#100 was asked, did she know why the CNA was telling the roommate to watch? R#100 stated, I don't know why she told her to watch, but my roommate (R#101) said, she was watching anyway. R#100 was asked, was her privacy curtain open? R#100 stated, My curtain was open. The police came after she (CNA) left out the room. I called all my daughters before I decided to make a report. The police came about 6:20 that morning. Later one of the nurses said, its (My finger) was turning purple. I told them I wanted to go to the hospital because they tried to get some x-rays here. I went to the hospital and the doctor said, my baby finger was broken. They gave me a cast for my finger and wrapped it up with these bandages (Ace Wraps Bandages). They gave me [MEDICATION(S)] for the pain. I have not seen (CNA A) since. I don't go to therapy now because of my hand. They were going to teach me how to sit on the bed, use a walker and how to get in and out of the chair. R#100 was asked, what were the reason she was admitted into the facility? R#100 stated, To get therapy. On 3/22/2021 at 9:20 a.m., an interview was conducted with R#100's roommate R#101. R#101 was asked to recall the March 4th incident with her roommate. R#101 stated, The CNA A came in the room trying to change her diaper. She (CNA A) grabbed her (R#100) arm, and she (R#100) was saying no, give me a chance. This happened about 4:00 in the morning. I was asleep until that happened and woke me up. The CNA was A. On 3/22/2021 at 12:29 p.m., CNA A was interviewed via telephone and asked to recall the March 4th incident. CNA A stated, I walked into the room and addressed her by name, and she right off the Rip (An alternate meaning similar to going off .) start cursing me out. Then I said I wanted to check and change her brief and she said okay. As I pulled back the covers, she started to yell and started saying, I'm not going to let yall keep hitting me. So, I remove the brief, then she starts hitting, grabbing and trying to bite. She grabbed my shirt, she said again, I'm not letting yal hit me. She started to bite me, then I removed the brief, she was still hitting, and grabbing me. Because I had already removed the brief, I had to put another brief on her because I couldn't leave her like that. The resident was still threatening to call the police. CNA was asked, did she continued to change the resident's brief after the resident said she didn't want to be change? CNA A said, I couldn't just leave her with no diaper on because she would have wet all of her sheets and be lying in a wet bed. I would have to change the entire bed if I didn't put a brief on her. CNA A was asked, did she have the facility's Abuse and providing care to resident's with behavior in-services? CNA A stated, Yes, I did when I got hired back and I had in-services after this happened, CNA A was asked, what should be done when a resident is being combative (Ready or Eager to Fight .)? CNA A stated, I tried talking to her, comforting her to let her know I wasn't trying to hurt her but just trying to change her. Part of In-services is to talk to her and remove myself from the situation and let my nurse know what had happened. On 3/22/2021 at 1:30 p.m. an interview was conducted with a Cooperate Consultant B and the Administrator. The administrator was asked, what should the Cena had done when a resident is combative and refusing care? The administrator stated, She should have back away and maybe tried another approach. If that does not work, then let her supervisor or her nurse know. On 3/22/2021 at 1:45 p.m., review of the Facility's Incident and Accident Report dated 3/10/2021 documented, Nurse Aide went into the room to change resident. Moments later writer heard shouting and began walking in the middle of the nurse's station where writer could see directly in the room since the door was open. Writer witnessed the aid appeared to be moving the wheelchair out of the way, as she was trying to move the chair still talking to the resident. The resident grabbed her by the shirt and shouted, Get your hands off me you're hitting me Writer walked into the room and address the situation and the aid left the room .X-ray ordered . Reviewed the Radiology Report dated 3/10/2021 documented, Finger .Right .Results Minimally displaced extra-articular fracture at the base of the little finger proximal phalanx. Soft tissue swelling overlies the fracture. Reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .On 3/15/2021 PT treatment 3x/week x 4 weeks for the therapeutic exercise, therapeutic activity, and neuromuscular re-education as indicated and OT orders dated 3/18/2021 documented, evaluation only. Reviewed CNA A's employees'' file date April 2020 with In-services training titled Abuse and residents with behaviors. Reviewed the facility's in-services dated 9/9/2020 with CNA A's signature titled Abuse of the elderly on the job documented, .Care Skills include everything about caregiving: how you talk with residents, how to react to an angry resident . On 3/22/2021 at 2:15 p.m., review of the clinical record revealed R#100 was initially admitted into the facility 3/9/2021 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the admission Minimum Data Set (MDS) assessment dated [DATE] documented, R#100 was cognitively intact, required extensive assistance of one -person with bed mobility and All Activity Daily Living (ADLs), extensive assistance of two person with transfers and incontinent of bowel and bladder. Review of the resident's ADL care plan dated 3/10/2021 documented, I (R#100) have an ADL self-care deficit related to abnormalities of gait and mobility .personal hygiene requires one person staff participation . On 3/22/2021 at 2:35 p.m., a policy for providing care to residents with behaviors was requested, but not presented to the surveyor prior to exiting the facility.

Based on the unprecedented coronavirus global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 3/13/20, the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-14-NH revised on 3/13/20, Nursing Home guidance from the Centers for Disease Control (CDC), observation, interview and record review, the facility failed to ensure ten of ten new and/or readmitted residents in the past 14 days were placed on quarantine/isolation to ensure there was no development of signs or symptoms of the [DIAGNOSES REDACTED] Coronavirus 2 (COVID-19). This failure potentiated COVID-19 exposure to all 75 residents residing in the facility at the time of the survey, as well as the facility staff that worked with the new admissions and/or readmitted residents. On 5/29/20 at 5:00pm, the Administrator, Director of Nursing, and Vice President of Operations were notified that the facility failed to ensure ten new and/or readmitted residents (R)4, R5, R6, R7, R8, R9, R10, R11, R12, and R13) with negative COVID-19 tests prior to admission/re-admission, were placed in quarantine isolation for 14 days after admission/re-admission to the facility in the past two weeks. This failure to quarantine and/or isolate the newly/readmitted residents had the potential to negatively affect all 75 residents, as well as, staff working in the facility at the time of the survey. This constituted an immediate jeopardy at F880. Findings include: During the entrance conference with the Administrator and Director of Nursing (DON) on 5/28/20 at 2:00 PM, the DON stated there were currently no residents on isolation in the facility. Observations of the facility conducted during the tour, on 5/28/20 at 2:45 PM, confirmed there were no designated isolation rooms on the second or third floor. The fourth floor did not have anyone residing there at the time of the survey. 1. A review of R4's Admission Record showed an initial admission date of [DATE] with a re-admission date of [DATE] with medical [DIAGNOSES REDACTED]. A review of the Progress Notes in R4's electronic health record (EHR) showed 5/27/2020 20:30 (8:30 PM) Admission Note Note Text: Received this 53 y.o. (year old) female readmitted to this facility from (hospital name). Wheeled per stretcher by 2 EMS health crews, with admitting [DIAGNOSES REDACTED]. Alert and verbally responsive, no behavior issues at this time, seemed pleasant and cooperative with nursing staffs .Vital signs BP (blood pressure) 122/80mmHg (millimeters of mercury), Temp 97.1F, Pulse rate 79 bpm (beats per minute), Resp. rate (respiratory rate) 19 breaths per min (minute). Will continue with present plan of care. In an interview on 5/29/20 at 10:52 AM, the DON stated R4 was readmitted as ambulatory (able to move about independently) and was put in a private room. I called the doctor the next morning (the 28th) and found out she had a negative test. The DON did confirm from the time of the admission note on the 27th to the time she contacted the physician for COVID-19 test status, R4 was ambulatory and able to move around the building as s/he was not on droplet isolation. The DON stated the facility was [MEDICATION NAME] social isolation (social distancing). Observation on 5/29/20 at 2:25 PM showed R4 was in a private room, but no isolation signage was placed at the doorway to alert staff of isolation status, and no personal protective equipment (PPE) was located for staff to don when entering the room. A review of R4's paper chart revealed staff were monitoring temperature and oxygen saturation each shift since admission, with no documented abnormal values. A review of the hospital discharge packet, sent with R4 upon re-admission showed a Result Details sheet that stated COVID-19 nasal swab was done on 5/24/20 at 11:28 AM with a reported result of Not Detected. On the same page was the following: Test Information .Not Detected results do not preclude [DIAGNOSES REDACTED]-CoV-2 infection and should not be used as the sole basis for patient management decisions. Results must be combined with clinical observations, patient history, and epidemiological information. In an interview on 5/29/20 at 3:03 PM, Licensed Practical Nurse (LPN) 3 stated she worked the day after R4 was readmitted . No (R4) was not on isolation. She was in a private room. I reviewed the chart and saw she was (COVID) not detected. LPN3 clarified that R4 was in a private room, but not in droplet isolation, and could move around the facility. In an interview on 5/29/20 at 3:05 PM, Certified Nurse Aide (CNA) 1 stated she was off the day R4 was readmitted , but she thought there was an isolation cart there, but it was removed a day or two later. 2. A review of R5's Admission Record showed an admission date of [DATE] with medical [DIAGNOSES REDACTED]. A review of the hospital discharge paperwork, page 5 (of 69 pages) showed a dictated note: #COVID rule out. Rapid test negative. Page 31 of 69 showed COVID Lab .COVID-19 Negative 05/03/20 21:44:00 (9:44 PM) .COVID-19 Source Nasal 5/03/20 21:44:00 Observation on 5/29/20 at 4:38 PM showed R5 sitting in a wheelchair at the end of the roommate's bed having a conversation with the roommate. In an interview on 5/29/20 at 4:40 PM, LPN4 stated she was working when R5 was admitted and that R5 had not been on isolation here (in facility) since she came back. Review of R5's paper chart showed temperatures and oxygen saturation levels were being monitored each shift since R5's readmission with no abnormal entries noted. In an interview on 5/29/20 at 2:50 PM, the Vice President of Operations (VPO) confirmed no resident was to be admitted to the facility without a negative COVID-19 test, but that practice was not in any facility policy. At 3:30 PM, the VP Ops stated all hospitals in the country had COVID cases. In an interview on 5/29/20 at 3:40 PM, the DON and VPO stated the facility was not fully on the EHR, and some charting was still on paper. A request was made for any documentation related to the droplet isolation of R4 and R5 upon admission/re-admission to the facility. No documentation was provided prior to exiting the survey; and the VPO said that COVID-19 quarantine was not in any facility policy. On 5/29/20 at 7:50 PM, the Administrator provided a list of all admits since 5/14/20 and confirmed ten residents on the list remained in the facility. Besides R4 and R5: R6 was admitted on [DATE] and was not placed on droplet isolation precautions for a 14-day quarantine until after the facility was made aware of the infection control IJ concerns of the survey. R7 was admitted on [DATE] and was not placed on droplet isolation precautions for a 14-day quarantine period. And another six residents had been admitted within the past 14-days without being quarantined: R8 - admitted on [DATE]; R9 - admitted on [DATE]; R10 - admitted on [DATE]; R11 - admitted on [DATE]; R12- admitted on [DATE]; and R13 was admitted on [DATE] without being placed on isolation. Each of these residents were placed on isolation when made aware of the Immediate Jeopardy infection control concern. Review of the facility policy Mission Point Management Services COVID-19, dated and signed by the Administrator on 04/17/20, did not address the isolation/quarantine of new admissions or re-admissions to the facility. The policy stated: .Residents will be monitored for signs and symptoms of Coronavirus illness: fever, cough, shortness of breath. The physician will be immediately notified, if evident. Staff will follow established procedures when COVID-19 is confirmed or suspected. Review of the Centers for Medicaid and Medicare Services (CMS) Quality/Safety Oversight memo 20-14, issued 03/13/20, .Note: Nursing homes should admit any individuals that they would normally admit to their facility, including individuals from hospitals where a case of COVID-19 was/is present. Also, if possible, dedicate a unit/wing exclusively for any residents coming or returning from the hospital. This can serve as a step-down unit where they remain for 14 days with no symptoms (instead of integrating as usual on short-term rehab floor or returning to long-stay original room). Review of CMS Quality/Safety Oversight memo 20-28, issued 04/24/20 contained a document titled,COVID-19 Long Term Care Facility Guidance issued April 2, 2020, which revealed: The Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) are issuing new recommendations to State and local governments and long-term care facilities (also known as nursing homes) to help mitigate the spread of the 2019 Novel Coronavirus (COVID-19) .1. Nursing Homes should immediately ensure that they are complying with all CMS and CDC guidance related to infection control .Long-term care facilities should separate patients and residents who have COVID-19 from patients and residents who do not, or have an unknown status .and, if possible, isolate all admitted residents (including readmissions) in their room in the COVID-19-positive facility for 14 days if their COVID-19 status is unknown . The Facility presented an acceptable removal plan for the immediate jeopardy at F880 on 05/29/20 at 8:09 PM. The removal plan indicated R4 and R5 would be sent to the emergency room for a COVID-19 test, then be placed in quarantine for 14 days upon return to the facility. The remaining eight new/readmitted residents were moved to the 4th floor, which is the facility's designated isolation floor, placed in private rooms with droplet isolation precaution signs on the door and cart with a personal protective equipment (PPE) at the room entrance. The facility educated staff regarding the change in the resident's status and the need to implement a 14-day isolation for all new/readmitted residents. The facility also updated their Novel Coronavirus Prevention and Response policy to reflect the quarantine/isolation requirement for all new admissions and re-admissions. The removal plan was validated through observations, staff interviews, and policy review. Observations verified that the new/readmitted residents (except for R4 and R5 who were out of the facility) were placed in private rooms, droplet isolation signage was in place, and PPE supplies were at each room entrance. Review of revisions to the admission policy showed new and readmitted residents would be placed in quarantine isolation. Interview with facility staff revealed they had received education regarding the need for quarantine isolation for new/readmitted residents and were aware of the required droplet isolation PPE required.

This citation pertains to intake MI 217 Based on interview and record review, the facility failed to complete a thorough nutritional assessment when readmitted with a stage 3 Pressure Ulcer (PU) and evidence of weight loss for one (#801) of 4 residents reviewed for nutritional assessments out of a total of 4 sampled residents, resulting in the weight loss of greater than 7 percent (%) in 4 months and the potential for delayed wound healing. Findings include: On 9/25/17 at 8:24 AM, during a telephone interview, an interested party stated, My father has lost a lot of weight. He use to wear a 3X (size clothing) and now he's wearing a size medium. On 9/25/17 at 11:35 AM, a review of the clinical record revealed that Resident #801 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #801 had moderately impaired cognition and required total physical assistance from staff to complete activities of daily living. The Nursing Admission history & Assessment form, dated 8/7/17, documented that Resident #801 had an open area on the coccyx. On 9/25/17 at 1:31 PM, a interview and review of the clinical record, with Wound Care Nurse (WCN) A revealed the following: ---wound consultant form, dated 8/8/17, documented that Resident #801 had a stage 3 pressure ulcer on his coccyx that measured 3.0 centimeters (cm) long X 2.5 cm wide X 0.03 cm deep. The wound was described as not infected, red, with a moderate amount of sero-sanguineous drainage, no odor and no slough. ---wound consultant form, dated 8/14/17, documented that Resident #801's stage 3 pressure ulcer measured 2.5 cm long X 1.5 cm wide X 0.03 cm deep. The wound had slough, no odor, moderate sero-sanguineous drainage and by 8/22/17 the pressure ulcer had deteriorated and become unstageable and measured 4.0 cm long X 4.5 cm wide X with slough. WCN A stated, We started full strength Dakins, there was an odor and he was on an antibiotic for a urinary tract infection. He was eating and drinking. WCN A was asked if his diet had been assessed to determine if he was getting all the nutrients needed to assist his body with wound healing. WCN A reviewed the clinical record and stated, I do not see a dietary note that mentions Resident #801 had a pressure ulcer. A review of the comprehensive Nutritional Assessment form in the clinical record was dated 3/29/16. It did not indicated if it was an Initial, Annual, or Reassessment. Resident #801's height, weight, ideal body weight range, usual body weight, weight in last 30, 90, and 180 days was blank, Resident's acceptance of diet stated, adequate, the nutrients needed was blank, the medications and lab sections were blank. There was a subsequent dietary notes by the CDM, dated 8/8/17, that documented Resident #801's diet was down graded from mechanical soft to pureed, but no documentation that acknowledged Resident #801 had a stage 3 pressure ulcer and if the current diet and intake met his nutritional needs. This documentation had been completed by Certified Dietary Manager (CDM) with no follow-up documentation by a Registered Dietitian. A review of the weight log from January 2017 to May 30, 2017 documented Resident #801's average weight was 190 pounds. However, the following weight log in the Electronic Medical Record (EMR) were record as follows: June 9, 2017 = 186 pounds July 10, 2017 = 178.8 pounds August 10, 2017 = 171.1 pounds September 20, 2017 = 176 pounds The weight log documented that on 8/10/17 Resident #801 had a 7.5% weight loss compared to the May 30, 2017 weight of 190 pounds. There was no dietary documentation that addressed these weight changes. On 9/25/17 at 2:44 PM, during a telephone interview, the consultant dietitian was asked if Resident #801's nutritional needs had been re-evaluated when he was readmitted with a stage 3 pressure ulcer on the coccyx. The consultant dietitian stated, I can not give you any incite into his nutritional status or why there were no labs or supplements. The consultant dietitian revealed she divided her time between 3 other buildings, but said she was available by phone and that the dietary tech could leave her notes in the office. The consultant dietitian revealed she had not received notice that Resident #801 had returned to the facility with a stage 3 pressure ulcer. The Administrator, who was present during the telephone interview, was shown the missing assessment data on nutritional assessment dated [DATE]. On 9/25/17 at 3:00 PM, a telephone interview was conducted with the Certified Dietary Manager (CDM). The CDM was asked dietary interventions that had been put in place when he was readmitted to the facility with a stage 3 PU and if any blood work had been requested to evaluate his nutritional status. The CDM stated, I don't do that; nursing does. If the labs are there, I look at them. The CDM was asked if there was a protocol she followed that told her when she needed to call the Registered Dietitian (RD). The CDM stated, No. The CDM revealed she had not informed the RD about Resident #801's weight loss and stage 3 PU. The CDM was unable to articulate what her clinical role entailed. Resident #801 average weight of 190 pounds had decreased to 176 pounds. The Administrator, who was present during the telephone interview, revealed she had the responsibility to ensure the nutritional assessments were done, but currently had no process to ensure they were completed. The Administrator was asked for a job description for the RD and CDM. On 9/25/17 at 4:55 PM, the Administrator stated, I don't have a job description for the RD. I have to get it from one of the other buildings. The Administrator revealed she did not have a contract for the consultant RD that outlined the services she would provide. A review of the Dietary Manager job description documented the dietary manager had to have a high school diploma or equivalent and successful completion or current enrollment in course approved by the Dietary Managers Association. The job description failed to document that the dietary manager would have the responsibility or expertise to clinically evaluate a resident's nutritional needs based on their disease processes.

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT ACCIDENTS FOR TWO OF SEVEN SAMPLED RESIDENT (#609 AND 612) FROM A TOTAL OF 18 SAMPLED RESIDENTS, RESULTING IN A FRACTURED TIP OF NASAL BONE AND AN INJURED UPPER LIP FOR RESIDENT (#609) AND MULTIPLE FALLS FOR RESIDENT #612 RESULTING IN FACIAL BRUISING. THE FACILITY ALSO FAILED TO LOCK THE LOCK THE TREATMENT CART AND SECURE DISPOSED NEEDLES RESULTING IN A POTENTIAL FOR INJURY. FINDINGS INCLUDE: THE ADMITTING RECORD, DATED 7/20/11, INDICATED RESIDENT #609 WAS ORIGINALLY admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE Minimum Data Set, dated dated [DATE], INDICATED RESIDENT #609 HAD SEVERELY IMPAIRED COGNITIVE SKILLS FOR DECISION MAKING, WAS NON-AMBULATORY, AND REQUIRED EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING. HOWEVER, RESIDENT #609 WAS ABLE TO FEED HIMSELF AFTER SETUP. DURING THE INITIAL TOUR OF THE FACILITY ON 8/09/11 AT 9:00 A.M., WITH UNIT MANAGER (B), RESIDENT #609 WAS OBSERVED IN A WHEELCHAIR, NEAR THE ELEVATOR, ON THE 2ND FLOOR NURSING UNIT . IT WAS OBSERVED THAT THE BRIDGE OF RESIDENT #609'S NOSE WAS SWOLLEN WITH A RAISED LUMP PRESENT. MANAGER UNIT (B) STATED SHE WAS NOT SURE WHAT HAD HAPPENED TO RESIDENT #609'S NOSE. REVIEW OF RESIDENT #609'S CURRENT CLINICAL RECORD REVEALED THE FOLLOWING: NURSING NOTES: 4/29/11, 11:30 P.M. "...RESIDENT NOTED WITH BRIDGE OF NOSE SWOLLEN, UPPER LIP SWOLLEN, BASE OF NOSE IS RED WITH MUCUS NOTED. WOULD NOT ALLOW STAFF TO TOUCH AREAS... 4/30/11, 4:00 P.M., ...OBSERVED (RESIDENT NAME) NOSE SWOLLEN AND RED WILL NOT ALLOW THE AREA TO BE TOUCHED, WILL NOT EAT AND REFUSED MEDS... 5/01/11, 9:00 A.M., ...RECEIVED RESIDENT UP IN W/C (WHEEL CHAIR) YELLING OUT, FACIAL AREA AND NASAL AREA SWOLLEN...DR. MADE AWARE... 11:00 A.M., X-RAY DEPT. (DEPARTMENT) HERE TO DO X-RAY... X-RAY REPORT- 5/01/11, 11:49 A.M. - "...FACIAL BONES COMPLETE 3 VIEWS- IMPRESSION- 1. SOFT TISSUE SWELLING- 2. SLIGHTLY DEPRESSED FRACTURE OF THE TIP OF THE NASAL BONE OF INDETERMINATE AGE. X-RAY REPORT-5/01/11, 11:54 A.M., NASAL BONES COMPLETE 3 VIEWS... IMPRESSION-SLIGHTLY DEPRESSED FRACTURE OF THE TIP OF THE NASAL BONE OF INDETERMINATE AGE..." PHYSICIAN ORDER: 5/01/11- "...TRANSFER (TO) HOSPITAL FOR EVAL. (EVALUATION) OF FRACTURE OF FACIAL AND NOSE BONE..." GET X-RAY OF FACIAL AND NASAL AREA..." NURSING NOTES- 5/01/11, 2:30 P.M., "...TRANSFERRED TO THE HOSPITAL VIA STRETCHER..." ON 8/11/11 AT 2:30 P.M., AN INTERVIEW WAS CONDUCTED WITH THE ADMINISTRATOR AND THE DIRECTOR OF NURSING (DON) REGARDING THE CAUSE OF THE INJURY TO RESIDENT #609'S NOSE AND UPPER LIP. NEITHER THE ADMINISTRATOR OR THE DON WERE ABLE TO EXPLAINED HOW RESIDENT #609'S NOSE AND UPPER LIP WERE INJURED. ( ) THE CLINICAL RECORD FOR RESIDENT #612 WAS REVIEWED. THE RESIDENT WAS ORIGINALLY admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS (MINIMUM DATA SETS) DATED 11/19/10 AND 5/15/11, NOTED THAT THE RESIDENT WAS NON-AMBULATORY AND REQUIRED EXTENSIVE ASSISTANCE FOR ALL ADLS (ACTIVITIES OF DAILY LIVING), INCLUDING BED MOBILITY. THE 11/19/10 MDS NOTED THAT THE RESIDENT DID NOT EXPERIENCE FALLS. THE MDS ON 5/16/11 NOTED THE RESIDENT HAD A FALL, HAD IMPAIRED RANGE OF MOTION TO BOTH UPPER AND LOWER EXTREMITIES, AND WAS UNABLE TO MAINTAIN HER BALANCE DURING ANY ACTIVITY. AN "AT RISK FOR FALLS" CARE PLAN DATED 4/11/11 FOR RESIDENT #612 NOTED THAT THE RESIDENT WAS AT RISK RELATED TO STROKE WITH WEAKNESS "AS EVIDENCED BY TOTALLY DEPENDENT ON NURSING FOR ALL TRANSFERS INTO AND OUT OF BED OR WHEELCHAIR." PER HOSPITAL RECORDS, RESIDENT #612 HAD SURGERY ON 4/3/11 FOR [DIAGNOSES REDACTED]. THE SURGICAL PROCEDURE: "EXPLORATORY LAPAROTOMY WITH REMOVAL OF THE RIGHT OVARY AND FALLOPIAN TUBE, APPENDECTOMY, AND LYSIS OF ADHESIONS". THE RESIDENT RETURNED to the facility on [DATE] WITH 30 STAPLES TO THE MID-ABDOMEN. ON 8/10/11 AT 1 PM, RESIDENT #612 WAS OBSERVED IN A WHEELCHAIR WITH A SAFETY SEATBELT. THE RESIDENT WAS ALERT AND ORIENTED. SHE STATED THAT SHE HAD TWO FALLS BY ROLLING OUT OF BED WHILE GETTING HER INCONTINENT BRIEF CHANGED BY STAFF. SHE STATED THAT DURING THE SECOND FALL, SHE HIT HER FACE ON THE METAL BASE OF HER OVER-BED TABLE AND SUSTAINED A BLACK EYE. I/A (INCIDENT/ACCIDENT) REPORTS AND SUPPORTING DOCUMENTATION FOR RESIDENT #612 WERE REVIEWED: 1. ON 4/13/11 AT 7 PM, A NURSE AIDE WAS "CARING FOR PATIENT ON ONE SIDE OF BED AND PATIENT SLIPPED ONTO FLOOR ON OTHER SIDE OF BED." NURSE NOTES INDICATED: "PATIENT HIT THE LEFT SIDE OF BODY AND HEAD. PATIENT COMPLAINED BODY WAS ACHING ON LEFT SIDE AND LEFT SIDE OF HEAD. THE RESIDENT'S 30 ABDOMINAL STAPLES WERE NOTED TO REMAIN INTACT. ACCORDING TO physician progress notes [REDACTED]. PATIENT SHOULD BE POSITIONED IN THE CENTER OF BED." HOWEVER, THE CORRECTIVE MEASURE ON THE I/A REPORT TO PREVENT REOCCURRENCE: A THERAPY EVALUATION. ON 8/10/11 AT 3:30 PM, THE DON (DIRECTOR OF NURSING) WAS QUERIED ABOUT THE CORRECTIVE MEASURE AFTER THE FALL. THE DON PRESENTED DOCUMENTATION OF A ONE TO ONE IN-SERVICE TRAINING SESSION FOR THE NURSE AIDE THAT WAS CARING FOR THE RESIDENT AT THE TIME OF THE FALL (ON 4/13/11) REGARDING FALL PREVENTION DURING BED CARE. THE TRAINING SESSION WAS NOT CONDUCTED UNTIL 6/24/11 PER THE DOCUMENTATION. THE DON WAS UNABLE TO EXPLAIN WHY. THE DON WAS UNABLE TO STATE WHY THE RESIDENT, WITH 30 STAPLES IN THE ABDOMEN, WAS LEFT TOO CLOSE TO THE EDGE OF THE BED DURING CARE. A NEW "RISK FOR FALLS" CARE PLAN FOR RESIDENT #612 DATED 5/6/11, DID NOT ADDRESS SAFETY DURING CARE WHILE IN BED. FALL RISK ASSESSMENTS DATED 4/29/11 AND 6/17/11 NOTED THAT THE RESIDENT WAS AT HIGH RISK. 2. ON 6/17/11 AT 10 AM, A NURSE AIDE REPORTED: "RESIDENT (#612) WAS LAYING IN THE BED ON HER LEFT SIDE. I TURNED AROUND TO GET (INCONTINENT) BRIEF OUT THE CHAIR AND WHEN I TURNED BACK, SHE fell on THE FLOOR." THE RESIDENT STATED THAT SHE HIT HER HEAD ON THE BED-SIDE TABLE AND COMPLAINED OF A HEADACHE. PER NURSES NOTES, THE RESIDENT HAD A HEMATOMA ON THE RIGHT SIDE OF THE HEAD. ON 6/19/11, THE RESIDENT HAD "RIGHT EYE BRUISING (PURPLE)." ON 6/20/11: "BRUISING UNDER RIGHT EYE." ON 6/21/11: "NOTED PURPLE BRUISING UNDER RIGHT EYE." THE CORRECTIVE MEASURES AFTER RESIDENT #612'S FALL ON 6/17/11: "INSTRUCT (NURSE AIDE) TO ASK FOR ASSISTANCE WHILE PERFORMING ADL CARE FOR RESIDENT" AND ONE TO ONE IN-SERVICE TRAINING. THE IN-SERVICE TRAINING RECORD DATED 6/24/11, NOTED: "NEVER TO TURN BACK DURING NURSING CARE." ON 8/10/11 AT 3:30 PM, THE DON WAS UNABLE TO EXPLAIN WHY A SECOND NURSE AIDE LEFT THE SAME RESIDENT TOO CLOSE TO THE EDGE OF THE BED, DID NOT HAVE ALL SUPPLIES WITHIN REACH PRIOR TO PROVIDING CARE, AND TURNED AWAY FROM THE RESIDENT. THE FACILITY'S "REDUCE RISK OF RESIDENT FALLS" POLICY DATED 2005, DID NOT ADDRESS SAFETY DURING PROVISION CARE TO RESIDENTS IN BED. ( ) ON 8/9/11 AT 9:30 AM, THE 4TH FLOOR CLEAN UTILITY ROOM WAS OBSERVED WITH NURSE 'K.' THE ROOM WAS UNLOCKED. THERE WAS AN UNLOCKED TREATMENT CART IN THE ROOM CONTAINING A TUBE OF HYDROCORTISONE CREAM. THERE WAS A TUBE OF ATHLETE'S FOOT CREAM ON TOP OF THE CART. THERE WAS A BIN CONTAINING NUMEROUS SYRINGES WITH NEEDLES ATTACHED. THE NURSE STATED THAT THE ROOM COULD REMAIN UNLOCKED IF THE CART WAS LOCKED. SHE WAS UNABLE TO STATE WHY THE CART WAS UNLOCKED AND WHY THE ROOM COULD BE UNLOCKED WITH NEEDLES PRESENT. ON 8/11/11 AT 8:45 AM, NURSE 'A' OBSERVED THAT THE 4TH FLOOR UTILITY ROOM DOOR WAS UNLOCKED WITH THE UNSECURED NEEDLES IN THE ROOM. SHE WAS UNABLE TO EXPLAIN WHY THE ROOM WAS UNLOCKED WITH NEEDLES INSIDE. ( )