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

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 05/12/2026 beginning at 8:43 AM a kitchen tour was conducted with [NAME] B.On 05/12/2026 at 8:55 AM observed blue metal storage racks in the walk in cooler with worn paint exposing the rusted metal surfaces of the rack. On 05/13/2026 at 8:50 AM observed blue metal storage racks in the walk in cooler with worn paint exposing the rusted metal surfaces of the rack. In an interview at this time with Dietary Manager (DM) A when asked about cleaning of racks, DM A indicated the storage racks are cleaned weekly and they are slightly rusted.According to the 2022 Food Code, section 4-101.19 Nonfood-Contact Surfaces, NonFOOD-CONTACT SURFACES of EQUIPMENT that are exposed to splash, spillage, or other FOOD soiling or that require frequent cleaning shall be constructed of a CORROSION-RESISTANT, nonabsorbent, and SMOOTH material.On 05/12/2026 at 9:04 AM an interview with [NAME] B found the meat slicer is used about once a month and is cleaned after use. Further observation at this time of the equipment found dried debris accumulated on the back side of the meat slicer.On 05/12/2026 at 9:15 AM DM A arrived, and tour of the kitchen was conducted.On 05/12/2026 at 9:29 AM an interview with DM A found aids clean the ice machine and maintenance completes deep cleans on the ice machine. On 05/12/2026 at 9:33 AM observation of the ice machine found brown buildup on the inside corner of the drip tray. DM A acknowledged the buildup.On 05/12/2026 at 9:36 AM observed a sticky red residue on the blade of the can opener. In an interview at this time, when asked if it is cleaned, DM A indicated it is cleaned after use and run through the dishwasher. DM A removed the can opener to be cleaned.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of FFEQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 05/12/2026 at 9:09 AM observed an area of paint peeling and flaking on the upper back corner of the microwave. [NAME] B indicated it is cleaned after use.According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment, (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.On 05/12/2026 at 11:32 AM observed the floor drain lid broken and able to be moved near the walk-in cooler.According to the 2022 FDA Food Code section 6-201.11 Floors, Walls, and Ceilings, Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE.On 05/12/2026 at 11:46 AM observed [NAME] B in the tray line during lunch service wipe the back of their forehead with a gloved right hand while continuing tray service and plating food without changing gloves.According to the 2022 Food Code, section 3-304.15 Gloves, Use Limitation, (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.P.

Based on observation, interview, and record review the facility failed to properly dispose of waste and maintain the dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility. Findings include:On 05/12/2026 at 9:40 AM observed two outdoor waste receptacles adjacent to each other with their lids in the open position. One receptacle had multiple trash bags overflowing from the bin and resting on top of the lid. Birds were observed landing on the mound of trash and flying away. The second receptacle was also observed with its lids in the open position and trash piled over the rim of the receptacle. Further observation of the area found various scattered debris around and behind the receptacles including water bottles, plastic bags, gloves, a mask, utensils, cardboard, a folding table and tires. An interview at this time with Dietary Manager (DM) A found they were unsure the frequency of pickup. When asked if the lids are usually open, DM A indicated they are not usually open.On 05/12/2026 at 3:01 PM an interview with Maintenance Director (MD) D found the outdoor waste is picked up every other day and housekeeping maintains the area. On 05/12/2026 at 3:06 PM an interview with Housekeeping Supervisor (HS) C found the outdoor waste receptacles were not serviced due to miscommunication regarding payment. HS C indicated it should be picked up tomorrow.On 05/12/2026 at 3:43 PM observed a mound of trash bags and cardboard piled along the outside fence in the parking lot on the ground and on rolling carts.On 05/13/2026 at 8:32 AM observed the outdoor waste receptacles in a similar condition to the previous day with both waste receptacle lids in the open position and trash bags piled inside overflowing at the rim.On 05/13/2026 at 10:53 AM a phone interview with HS C found they had ordered a roll off bin to store trash along the parking lot wall so that animals did not get into it overnight. When asked who maintains the outdoor waste area, HS C indicated it is a collaboration effort but mostly maintenance and housekeeping.Record review of the facility provided document titled Disposal of Garbage and Refuse with a date implemented of 4/1/2026 states, Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insects/rodent attractions are minimized.

Based on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 05/12/2026 at 10:29 AM observed a nonfunction hot water faucet on the hand sink in the second floor activities room. On 05/12/2026 at 1:29 PM observed a hopper with no water in the bowl indicating low use in the second floor long hall storage room. Further observation found the hopper inoperable, and the spray hose head removed from the hopper.On 05/12/2026 at 1:38 PM observed the hot water handle missing from the janitor sink in the second floor short hall janitor closet. On 05/12/2026 at 2:06 PM an interview with Maintenance Director (MD) D was conducted regarding water management. When asked about control measures to reduce the growth of Legionella in the water system, MD D indicated they do legionella testing every three months, free chlorine monitoring monthly and flushing. When asked about the frequency of flushing, MD D indicated it is done weekly. When asked what is being flushed, MD D indicated they flush what needs to be flushed. When asked if there are logs of areas flushed, MD D indicated they do not keep logs. On 05/12/2026 at 2:16 PM an interview with MD D was conducted. When asked if there has been an annual review of the plan, MD D indicated they are not sure if they do that, and indicated the team meets in Quality Assurance and Performance Improvement (QAPI) monthly. When asked if there were any positive results from legionella testing, MD D indicted yes about two months ago and the faucet head was cleaned. When asked if there was a range they like to see the free chlorine samples within, MD D stated it should be in the binder.On 05/12/2026 at 2:48 PM observed the water lines to the foot pedals connected at the sink fixture and turned off at the point indicating stagnant water in the line in the second floor short clean linen room.On 05/13/2026 at 8:25 AM observed discolored water coming from the shower head faucet for a few seconds before running clear in unoccupied resident room [ROOM NUMBER].On 05/13/2026 at 8:26 AM observed discolored water coming from the shower head faucet for a few seconds before running clear in unoccupied resident room [ROOM NUMBER].On 05/13/2026 at 8:29 AM observed discolored water coming from the shower head faucet for a few seconds before running clear in unoccupied resident room [ROOM NUMBER].On 05/13/2026 at 8:30 AM observed the shower head removed and the hose intact in unoccupied resident room [ROOM NUMBER]. Further observation found discolored water coming from the shower hose for a few seconds before running clear.On 05/13/2026 at 8:42 AM observed the water lines to the foot pedals connected at the sink fixture and turned off at the point indicating stagnant water in the line in the first floor soiled utility room.On 05/13/2026 at 9:03 AM an interview was conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON). When asked if there had been an annual review of the water management plan, NHA indicated yes. When asked if they knew when that was, NHA indicated one of the months last year, but they would need to check.On 05/13/2026 at 11:38 AM an interview with MD D regarding flushing found they flush sinks and shower heads of empty rooms on the fourth floor. When informed discolored water came from some unoccupied rooms shower heads, MD D indicated it was possible they missed the shower heads. MD D indicated they would find the range for free chlorine and add it into the water management plan.On 05/13/2026 at 12:17 PM an interview with NHA found the annual review took place in August of last year.Record review of the facility provided document titled Legionella Water Management Program was last reviewed 3/24. The program states, 2. A risk assessment will be conducted by annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. 4. Based on the risk assessment, control points will be identified. 5. Control measures will be applied to address potential hazards at each control point. 6. Testing protocols and control limits will be established for each control measure. 7. The effectiveness of the water management program shall be evaluated no less than annually. Unoccupied rooms and connected water lines were not included in the facility risk assessment. No control limits were identified for the hazard condition flow diagram, and an annual assessment date of the water management program was not available in the binder.According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. Eliminate dead legs, which are sections of no- or low-water flow.

This citation pertains to intake 3001301.Based on interview and record review, the facility failed to ensure staff reported the results of an investigation to the State Agency within five working days of an incident for two of four residents (R15 and R56) reviewed for abuse.Findings include: On 04/21/2026, a Facility Reported Incident of a resident-to-resident abuse allegation was reported to the State Agency. The investigation report was received on 04/30/2026. A review of the facility's abuse investigation summary dated 04/30/2026 documented in part the following: R56 hit R15 on the left side of the face/head area; unprovoked. No injury reported. R56 was sent to the hospital for a psychiatric evaluation. During an interview on 05/15/2026 at 10:55 AM, the Nursing Home Administrator (NHA) was identified as the facility's abuse coordinator. The NHA said he submitted the Facility Reported Incident report and the investigation summary to the State Agency. The NHA was queried regarding the delayed submission of the investigation report. Queried as to the timeline for submittance of an investigation report. The NHA stated, I know it says five days, but the system gives us extra time. Discussed the facilities Abuse Policy and referred the NHA to the federal guidelines regarding the timeline for reporting and submission of an investigation report. The NHA said, I know it should be five days, but I thought I had extra time. During an interview on 05/15/2026 at 12:20 PM, the Director of Nursing (DON) was queried about timelines for reporting abuse allegations. The DON stated, We must report within 24 hours and submit our investigation within five days. Queried as to who is responsible for submitting the investigation report. The DON stated, The NHA is responsible for this submission. Queried about expectations of timely reporting. The DON stated, It's expected that we be in compliance with facility and state guidelines. A review of R15's electronic health record documented an original admission date of 09/12/2018. R15's diagnoses include Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Vascular Dementia and Anxiety Disorder. A Minimum Data Set assessment dated [DATE] documented a Brief Interview of Mental Status score of 0 out of 15 reflecting severe impairment. A review of R56's electronic health record documented an admission date of 12/01/2023. R56's diagnoses include Bipolar, Manic Severe with psychotic features, Traumatic Brain Injury and Adjustment Disorder. A Minimum Data Set assessment dated [DATE] documented a Brief Interview of Mental Status score of 0 out of 15 denoting severe cognitive impairment. A review of the facilities' document titled, Abuse, Neglect and Exploitation, last revised- October, 2024, revealed in part the following: The Administrator will follow up with government agencies during business hours to confirm the initial report was received and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on observation, interview, and record review, the facility failed to provide appropriate positioning assistance and safety interventions during incontinence care for one resident (R103) out of three residents reviewed for accidents, resulting in a fall. Findings include: On 3/26/26 at 11:30 AM, R103 was observed awake and lying in a bariatric bed (a specialized, heavy-duty bed designed to safely support plus size or obese people). R103 said they cannot walk or stand but can move about the bed. R103 said they fell out of bed a few days ago during incontinence care. R103 said staff clean them up one side at a time. Staff will have them cross one leg over the other and turn. R103 stated, I didn't know how close I was to the edge of the bed and when I flung my leg over, I slid out of the bed onto the floor. R103 said there was one person changing them at the time. Staff used a mechanical lift plus three people to get them back into bed. A review of the clinical record for R103 documented an initial admission date of 9/14/22 and a readmission date of 2/6/25. R103's diagnoses included acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment, no upper or lower extremity impairments, and dependence upon staff for toileting hygiene. Further review of R103's clinical record and post-fall documents revealed in part the following: 1. Nurse progress note date/time of 3/8/26 at 7:05 AM: Writer was alerted to the resident's room at 5:00 AM by CNA (Certified Nurse Aide) who reported that the resident rolled out of bed during care. Upon arrival, resident was observed lying on the floor on (their) left side with the bed noted to be in a low position. Resident was awake and responsive. 2. Fall incident report dated 3/8/25:- Nursing description: Writer was alerted to the resident's room by CNA who reported that the resident rolled out of bed during care. Upon arrival resident was observed lying on the floor on (their) left side with the bed noted to be in a low position.- Resident description: Resident stated (they) rolled out of bed during care.- Staff F statement: CNA reported that during care the resident was asked to turn onto (their) side. While repositioning, the resident continued rolling and inadvertently rolled out of bed onto the floor. (A witness statement from CNA G was not obtained.)- Root cause analysis: Interdisciplinary team met today to investigate, discuss and collaborate on intervention related to fall that occurred on 3/8/26. Investigation found that resident was not positioned in the center of the bed when staff entered to complete resident care rounds. Both CNAs were attempting to position resident in the center of the bed prior to care and resident rolled out of the bed. 3. Nurse practitioner note date/time of 3/11/26 at 3:48 PM: This patient is an [AGE] year-old seen today for evaluation status-post fall. On 3/8/26 nursing staff reported that the patient rolled out of bed during ADL (activities of daily living) care. 4. A review of R103's care plans documented in part the following:Focus: I have an increased risk for alteration in skin integrity secondary to decreased mobility, incontinent of bowel and bladder, extensive assistance with bed mobility and transfers, and bed fast most of the time. I will often refuse to be turned and repositioned and to be changed. Revised 11/9/22. Focus: I have an adl self care performance deficit secondary to history of lymphedema, chronic obstructive pulmonary disease, and obesity. I will often refuse to get out of bed and to be turned and repositioned and to be changed. Resident often refuses adl care and brief change.Resident chooses to be bed bound and stay in their room. Revised 2/17/26.Interventions included: Toileting - dependent on staff for toileting. I received care in the bed. Revised 6/9/25. Focus: I have an increased risk for falls and injuries related to falls secondary to cognitive impairment total assistance needed with adl care, incontinent of bowel and bladder, and medication side effects. Revised 12/18/24. During a telephone interview on 3/26/26 at 1:18 PM CNA G said despite R103's size, they are very mobile. CNA G said R103 was not a total assist because they can turn and reposition themselves. CNA G added that R103 was a two-person assist for safety purposes. CNA G said they were in the process of changing R103 when R103 fell from the bed. Regarding the fall of R103, CNA G stated that the two CNAs were positioned on opposite sides of the bed, claiming there was no room for R103 to fall. CNA G reportedly was on the window side of the bed. However, CNA G later said they did not know where CNA F was positioned. When asked directly about their presence during the fall, CNA G asked to end the call and stated, I don't want to answer, subsequently changing their statement to I don't remember. During a telephone interview on 3/26/26 at 1:33 PM, CNA F said R103 was part of their assignment on 3/8/26. CNA F reportedly was positioned on the side of the bed closest to the window when incontinence care was initiated. During the process of turning R103 to provide care, R103 threw their top leg over their other leg and fell out of the bed on the side closest to the door. CNA F said during this time, R103 was not centered in the bed but was somewhat close to the edge. CNA F said CNA G was at the foot of the bed on the side closest to the door when care was initiated. CNA F added that CNA G should have been at the center of the bed on the side closest to the door when care was initiated. On 3/26/26 at 2:00 PM, the Director of Nursing (DON) was interviewed regarding R103's 3/8/26 fall. The DON was unable to provide written statements from CNA F or CNA G regarding R103's fall. The contents of the CNA telephone interviews conducted today were shared with the DON. The DON indicated that if the CNAs were positioned close to the bed on either side, that it would have been reported that R103 bumped into one of them when R103 rolled out of the bed. This was not reported. The DON reported that R103's fall could have been prevented if the CNAs were close to the bed and used a draw sheet to move the resident to the middle of the bed prior to providing care. The DON said it was obvious that education has to be done and follow up provided in this regard. A review of the facility policy titled, Fall Reduction Policy, dated April 2023, documented in part the following:- A fall is an event in which an individual unintentionally comes to res on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes another resident).- A intercepted fall, also considered a fall, is when a resident would have fallen if someone else had not caught the resident from doing so.- When any resident experiences a fall, the facility will: (g.) Obtain witness statements, as applicable. A review of the facility policy titled, Activities of Daily Living (ADLs), dated 2/25/24, documented in part the following:- Care and services will be provided for toileting.- A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. During the exit conference conducted with the DON of 3/27/26 at 11:33 AM, the DON stated that in the future they plan to get handwritten statements from staff regarding investigations.

Based on interview and record review, the facility failed to ensure resident's medical record accurately documented the administration of prescribed medications (magnesium oxide, metoprolol tartrate, and Seroquel) for one resident (R101). Findings include: A review of the clinical record for R101 documented an admission date of 9/27/25 and discharge date of 3/7/26. R101's diagnoses included acute respiratory failure with hypoxia, hypertension, and bipolar disorder. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. Discharge note of 3/7/26 at 3:33 PM (author Licensed Practical Nurse [LPN] C) documented in part the following: Resident was transferred to local hospital. Reason(s) for Transfer: Behavioral symptoms (e.g. agitation, psychosis). Resident/Responsible party were notified of the reason for transfer. Nursing progress note of 3/7/26 at 3:38 PM (author LPN C) documented in part the following: Writer notified by EMT's (emergency medical technicians) that they were here from a 911 call for resident that stated (R101) was in bed and couldn't get out of the bed. Resident's guardian was notified and gave the okay for EMT's to take resident to hospital for evaluation. Facility physician and DON (Director of Nursing) made aware. Resident transported to local hospital via stretcher. A review of R101's March 2026 Medication Administration Record (MAR) documented that the following medications were administered by LPN H to R101 at bedtime on 3/7/26:1. Magnesium oxide tablet 400 mg. Give 400 mg by mouth two times a day for hypomagnesemia.2. Metoprolol tartrate oral tablet 100 gm. Give 1 tablet by mouth two times a day for tachycardia.3. Seroquel oral tablet 25 mg. Give 1 tablet by mouth two times a day for bipolar On 3/26/26 at 12:54 PM, LPN H was interviewed over the telephone. LPN H said they worked second shift (3:00 PM to 11:00 PM) on 3/7/26. A review of the nursing schedule dated 3/7/26 confirmed that LPN H was assigned to work the second shift on the nursing unit where R101 resided. LPN H indicated that bedtime medications were to be administered at 9 PM, allowing for administration one hour before or after 9 PM. LPN H indicated they could not remember if R101 was in the building around 9 PM on 3/7/26. On 3/26/26 at 1:10 PM, LPN C was interviewed over the telephone. LPN C said R101 was transferred to the hospital on 3/7/26 around 2:55 PM. On 3/26/26 at 2:20 PM, the DON reviewed R101's clinical record and referenced a progress note with a date and time of 3/7/26 at 3:33 PM that indicated R101 was sent to the hospital. The DON indicated the range for bedtime medications to be administered was between 7:00 PM to 10:00 PM. The DON reviewed R101's March 2026 MAR and confirmed the documentation that the bedtime doses of Magnesium Oxide, Metoprolol tartrate, and Seroquel had been administered to R101 on 3/7/26. The DON stated, How can it be administered when the resident was out of the building? The DON added, Someone documented that the medication was administered and the resident had been discharged from the building. On 3/27/26 at 11:33 AM, during the exit conference, the DON indicated education and corrective actions have begun regarding the identified concern.

This citation pertains to Intake #2617411. Based on observation, interview, and record review, the facility failed to effectively clean and maintain two common resident bathrooms, resulting in unsanitary and unsafe conditions and the potential for dissatisfaction of the residents' living area. Findings include:It was reported to the State Agency that resident bathrooms were not properly maintained. On 12/22/25 at 8:30 AM, observations of the first-floor common bathrooms were conducted with Certified Nurse Aide (CNA) D. The following items were noted: Back hall bathroom: A small wash basin containing used soiled towels was observed on the floor. The towels appeared to be dry. Four irregular streaks of solid brown matter were observed on the wall above and to the right of the wash basin on the floor. CNA D indicated resident showers had not yet been given on the day shift. CNA D added that CNAs were to remove soiled towels after use. Front hall bathroom: The soap dispenser near the handwashing sink was empty. A disposable razor was observed on the shelf above the handwashing sink. CNA D said the razor appeared to be used because the safety cover had been removed. CNA D added that housekeeping staff were responsible for ensuring the bathrooms have handwashing soap available. During an interview on 12/22/25 at 10:57 AM, Housekeeping Supervisor (HS) F said the first floor back hall bathroom should have been cleaned and sanitized after use, and staff should have brought it to the attention of the housekeeper on that floor for proper cleaning and sanitizing before the next use. HS F said the brown streaks on the wall may have occurred when a towel soiled with feces was tossed towards the wash basin, hit the wall, and that is what caused the smear of feces. HS F said the razor should have been put in the receptacle used to dispose of sharp items. HS F added that when soap dispensers are low on soap, housekeepers know to fill them. Housekeeping staff work during the week and on weekends. On 12/22/25 at 3:10 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed. The NHA said the brown stains on the walls and the used towels should have been removed. NHA expected that when the soap dispenser was low on soap, it should have been refilled. The DON said all used linen should be removed out of the shower room after the shower was given. All razors should be discarded in the appropriate container after use. The DON added there should always be soap in the dispensers. A facility policy titled, Routine Cleaning and Disinfection, dated February 2025 was reviewed and documented the following:-It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.-Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents or enzymatic products.-Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge.-Horizontal surfaces with infrequent hand contact (windowsills and hard surface flooring) in routine resident-care areas should be cleaned: On a regular basis. When soiling and spills occur.-Cleaning of walls, blinds and window curtains will be conducted when visibly soiled. During the exit conference on 12/22/25 at 4:10 PM, the NHA and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and no new information was provided.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergent or routine care that could cause negative outcomes. This deficient practice had the potential to affect all 84 residents in the facility. Findings include: On 3/5/25 at 11:13 AM review of the nurses' schedule for the months of July, August and September 2024 with staffing coordinator K, revealed there was no Registered Nurse (RN) coverage on the following dates: -September 2nd, 2024 -September 8th, 2024 Staffing coordinator K acknowledged the facility had difficulty finding RN coverage for weekends. O3/5/25 at 12:14 PM the Director of Nursing (DON) was interviewed and said there have been times when a RN was not available, and the expectation is that there is 8-hour RN coverage 7 days per week. The DON agreed the resident population consisted of residents with tube feedings, intravenous medications and the facility had previous residents with tracheostomies that would require RN supervision. On 3/5/25 at 12:14 PM RN coverage policy was requested. On 3/05/25 at 1:33 PM the DON was interviewed and said the facility does not have a RN coverage policy and that the facility refers to the Center for Medicare and Medicaid Services guidelines.

Based on observation, interview, and record review, the facility failed to: 1. Properly clean surfaces in the kitchen that were visibly soiled; 2. Properly seal food in the freezer; 3. Ensure pans were cleaned and air dried before stacking; 4. Properly maintain resident refrigerator; and 5. Ensure reusable resident meal service ware was properly sanitized. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: During the initial tour of the kitchen on 3/3/25 at 8:28 AM with Dietary Manager, (DM) G, the following was observed: 1. The inside of the ice scoop container was soiled with food debris and contained in a plastic sandwich bag. 2. The sides and bottom vents on the vegetable reach-in freezer and supplement reach-in freezer were soiled and stained with food debris. 3. The meat freezer contained an opened box of turkey sausage that was not adequately sealed exposing the contents to the freezer air. 4. A wet 1/2 pan and full-size pan soiled with food debris were observed nestled and stored with other pans in the clean pot/pan storage area. 5. The top and middle cooking utensil drawers were soiled with grease and food debris. DM G stated, They could use a wipe. 6. A double bar above the three-compartment sink was soiled with a buildup of grease, dust, and grime. A dust bunny was observed falling towards the three-compartment sink. On 3/3/25 at approximately 10:00 AM, DM G said the dishwasher temperature was not consistently reaching the temperature to properly sanitize and therefore disposable table wear would be used for lunch service. During a return visit to the kitchen on 3/3/25 at 11:30 AM, a maintenance worker was observed on a ladder at the three-compartment sink cleaning the soiled double bar and a vent located above the double bar. The maintenance worker used a putty knife to clean inside of the vent. Several ribbons, resembling twisted locks of hair, likely composed of grease, dust, and grime were observed being removed from the vent during the cleaning process. On 3/3/25 at 12:20 PM, during lunch meal service, resident meals were served using single-use disposable tableware and eating utensils, however, reusable meal trays and dome plate covers were being used. On 3/4/25 at 9:15 AM, DM G said the kitchen vent cleaned yesterday was supposed to have been cleaned one to two months ago, but the amount of debris that was removed yesterday could not have built up that quickly. DM G said the vent system could not have been effectively operating with the amount of dust build up. On 3/4/25 at 10:48 AM, the contents of the 3rd floor resident refrigerator were observed with Registered Nurse (RN) C. The following was noted in the refrigerator: - a plastic grocery bag containing food in a disposable food container was labeled with something that looked like FeF4. The bag was undated. - an opened snack pack of meat, cheese, and crackers was undated and not labeled with a resident's name. - an eight-ounce carton of 2% milk was labeled with a sell by date of 2/9/25. The freezer compartment contained an opened 48-ounce container of ice cream which was not labeled with a resident's name. A thermometer was not placed in the refrigerator or freezer. There was no log used to document the temperature of the refrigerator and freezer. On 3/4/25 at 11:20 AM, DM G affirmed that the dish machine was out of service between breakfast and lunch on 3/3/25. On 3/4/25 at 11:25 AM, Dietary Aide (DA) F was interviewed and said that yesterday between breakfast and lunch the dish machine water temperature was not hot enough to sanitize the dishes. DA F said yesterday between breakfast and lunch she washed the reusable meal trays and dome plate covers in soapy water in a one-compartment sink and then ran the trays and plate covers through the dish machine. On 3/4/25 at 11:30 AM, DM G said the reusable meal trays were sanitized using germicidal alcohol wipes. The reusable dome plate covers were not sanitized prior to lunch meal service. DM G said the plate covers should have been dipped in the three-compartment sanitizing sink. On 3/4/25 at 3:04 PM, when queried about the insufficient cleanliness of the kitchen, DM G stated, I probably should have redone the cleaning assignments. On 3/5/25 at 11:31 AM, the Director of Nursing (DON) said that a thermometer should have been in the resident refrigerator and freezer, a temperature log maintained, and food should have been labeled and dated. On 3/5/25 at 3:30 PM, the Nursing Home Administrator said the vent above the kitchen three-compartment sink draws in air that is filtered and recirculated back into the building. The NHA said there was no excuse for a dirty kitchen. On 3/5/25 at 3:30 PM, the NHA and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not. A review of the 2013 FDA Food Code documented the following: -Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. - Section 4-602.13, Nonfood-Contact Surfaces: Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. - Section 4-703.11, Hot Water and Chemical. After being cleaned, equipment food-contact surfaces and utensils shall be sanitized. - Section 4-903.11. Storing Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. - Section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition. (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials.

Based on observation, interview, and record review, the facility failed to ensure equipment used in food service operation was maintained in a safe and sanitary operating condition, resulting in the coffee machine and walk-in cooler not being protected against contamination from sewage or other sources of contamination. Findings include: On 3/3/25 at 8:28 AM, during the initial tour of the kitchen with Dietary Manager (DM) G, the following was observed: - The drain line from the coffee machine was partially positioned on a metal plate which resulted in a direct connection between the coffee machine drain line and the floor drain. - The drain line from the walk-in cooler was observed to not have an unobstructed vertical space between the end of the walk-in cooler drain line and the floor drain. When queried about an air gap for the coffee machine and walk-in cooler, DM G stated, There should have been an air gap. On 3/5/25 at 11:47 AM, the Nursing Home Administrator (NHA) said the coffee machine drainpipe needed to be moved over a couple of inches and the walk-in cooler drain was not properly air gapped. On 3/5/25 at 3:30 PM, the NHA and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not. The 2013 FDA Food Code was reviewed and revealed the following in Section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.

Based on observation, interview, and record review, the facility failed to ensure food items listed as always available were on hand to ensure resident food preferences were honored for one resident (R6). Findings include: During an interview on 3/3/25 at 10:50 AM, R6 was observed awake and lying in his bed. When queried if he was getting enough food to eat, R6 indicated he was not. When queried if he was offered an alternative menu item, R6 indicated that the menu items were not always available. A sheet of paper titled, Always Available Menu was attached to the bulletin board in R6's room. When queried if these menu items were always available, R6 indicated no. During an observation and interview on 3/3/25 at 11:30 AM with Dietary Manager (DM) G, the following items listed on the always available menu posted in R6's room were not in stock in the kitchen: sliced turkey lunch meat and cottage cheese. DM G acknowledged that always available menu items should always be available. During an interview on 3/4/25 at 3:01 PM, DM G said they should have had sliced turkey available. DM G indicated that cottage cheese had been removed from the always available menu. DM G said the purpose of the always available menu was to offer residents alternate food choices. During an interview on 3/5/15 at 11:19 AM, Certified Nurse Aide (CNA) J said R6 was able to communicate food items he wants to eat. CNA J confirmed that R6 had ordered food off the always available menu because occasionally he wanted something other than the main menu entree. A review of the clinical record for R6 revealed an initial admitted [DATE] and readmitted [DATE]. A Minimum Data Set assessment dated [DATE] documented intact cognition. On 3/5/25 at 11:47 AM, the Nursing Home Administrator (NHA) stated the always available menu was in place to offer the residents a variety of foods to cover the broad spectrum of their preferences. The NHA added the items on the always available menu should always be available during the hours that the kitchen was opened. On 3/5/25 at 3:30 PM, the NHA and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

Based on interview and record review the facility failed to ensure a physician responded to pharmacy recommendations in a timely manner for one resident (R52), out of five residents reviewed for unnecessary medications. Findings include: A review of the clinical record for R52 documented an admitted [DATE] with diagnoses that included heart failure, Parkinson's Disease, psychotic disorder with hallucinations, post-traumatic stress disorder, and adjustment disorder with mixed anxiety and depressed mood. A Minimum Data Set, dated dated dated [DATE] documented severe cognitive impairment and administration of antipsychotic and antianxiety medications. Physician's current orders for R52 documented to administer Xanax tablet 0.25 mg by mouth every 12 hours as needed for anxiety with a start date of 2/25/2025. Review of R52's pharmacy consultations identified irregularities on 8/7/24, 9/13/24, and 10/11/24 which all indicated, Recommend discontinuing PRN (as needed) use of Xanax for this Resident, OR reorder for a specific number of days, per the following federal guidelines: In accordance with State and Federal Guidelines, revised regulation 483.45(e) Psychotropic Drugs PRN, orders for psychotropic drugs are limited to 14 days, except when the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. Then he or she should document the rationale in the Resident's medical record and indicate the duration for the PRN order. There was no response to these repeated pharmacist's recommendations, signature or date from the physician until 11/11/24. Review of R52's care plans documented the following: - I have a history of trauma that can negatively affect my care and treatment. A survivor of 9/11. Signs/symptoms (anxiety/fear/anger/mood swings/nightmares/sleep changes/pain/withdrawal), revised on 1/22/25. - I have the potential for mood difficulties and/or adjustment concerns related to anxiety and depression, dementia and decrease in appetite, initiated on 2/4/25. On 3/5/25 at 1:34 PM, the Director of Nursing (DON) said the pharmacist conducts monthly medication reviews on the residents in the facility and will recommend a medication change if indicated. The DON added that the physician was responsible to respond to the recommendations. A review of R52's clinical record and pharmacist's recommendations was conducted with the DON. The DON could not provide documentation to support that R52's physician had reviewed and responded to the pharmacist's recommendations of 8/7/24, 9/13/24, and 10/11/24 prior to 11/11/24. The DON acknowledged that the response from R52's physician was not timely. The facility policy titled, Medication Regimen Review, dated January 2024, was reviewed and documented in part the following: - The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. - The Medication Regimen Review (MRR) includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. - Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. On 3/5/25 at 3:30 PM, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

Based on observation, interview and record review the facility failed to ensure the provision of hygiene and daily care for two residents, (R4 and R8) of two residents reviewed for assistance with Activities of Daily Living (ADL's), resulting in R4 not receiving timely fingernail care and R8 not receiving adequate facial hair care. Findings include: R4 On 03/03/25 at 10:10 AM, R4 was observed in bed, laying slightly towards the left side with their eyes open. R4 was confused and was able to answer only basic questions. R4's right arm appeared contracted, with their arm toward their chest and fingers curled into a fist. R4's nail on their first finger of their right hand was long and jagged. R4's other nails on their right hand curled into a fist. When asked if they could open their right hand, R4 replied, No. Observation of the R4's left hand and fingernails revealed the fingernails were long and jagged. A review of R4's Electronic Medical Record (EMR) revealed an admission of 09/11/2020 with the diagnosis of Schizophrenia, Contracture of Right Elbow, Muscle Wasting, Multiple Fractures, and Muscle Weakness. A review of R4's Brief Interview for Mental Status (BIMS) revealed the resident was unable to complete the interview. A review of R4's Care Plan revealed the following: Bathing: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 10/19/2022 .Personal Hygiene: I am total assistance with personal hygiene care. 03/05/25 at 12:23 PM, the Director of Nursing (DON) was queried regarding R4's fingernails and said R4 refuses care at times, its care planned. 38208 R8 An observation on 3/3/25 at 11:30 AM, R8 was sitting in a wheelchair, resident had a full, long, unkempt beard. R8 reported a preference to be clean shaven. It was further reported that staff does not ask or help him shave. Review of electronic health record (EHR) revealed admission into the facility on [DATE] with a pertinent diagnosis of debility. According to the Minimum Data Set (MDS) dated [DATE], R8 required partial/moderate assistance with personal hygiene. Review of Brief Interview for Mental Status (BIMS) dated 1/21/25, documented R8 scored 5 out of 15 (severely impaired cognition). Review of ADL Self Care Performance care plan initiated on 12/2/23, documented, Personal Hygiene/Oral Care -requires 1 staff participation with personal hygiene and oral care. Further review of care plans revealed no specific interventions for shaving and no history of refusing care. An observation of R8 on 3/4/25 at 9:27 AM, resident's beard remained full, long, and unkempt. An interview was conducted on 3/4/25 at 9:33 AM with Unit Manager (UM) E, it was reported that staff should ask and assist R8 with shaving. If a resident does not want to be shaven, a progress note should be written to reflect the resident's choice. Review of R8's progress notes from February and March of 2025 revealed no refusals to be shaven. Review of the facility policy Activities of Daily Living (ADLS) dated 2/25/24, documented the following: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1Bathing, dressing, grooming and oral care; 2. Transfer and ambulation; 3. Toileting; 4. Eating to include meals and snacks; and 5. Using speech, language or other functional communication systems.

Based on observation, interview and record review, the facility failed to ensure a urinary catheter drainage bag was maintained in a dignified manner for one resident (R4) of two resident reviewed for catheters, resulting in the potential for feelings of diminished self-worth using the reasonable person concept. Findings include: On 03/03/25 at 10:10 AM, R4 was observed in bed, laying slightly towards the left side with their eyes open. R4's right arm appeared contracted, with the arm toward their chest and fingers curled towards their palm. The drainage bag was exposed and revealed cloudy, amber colored urine. The catheter bag was not contained in a dignity bag and/or with a dignity covering. R4 was confused and was able to answer basic questions. On 03/03/25 at 2:28 PM, R4 was observed in bed on their right side. The urinary catheter drainage bag remained in the same place without a dignity bag/cover in place. A review of R4's Electronic Medical Record (EMR) revealed an admission of 09/11/2020 with the diagnosis of Schizophrenia, Contracture of Right Elbow, Muscle Wasting, Multiple Fractures and Muscle Weakness. A review of R4's Brief Interview for Mental Status (BIMS) revealed the resident was unable to complete the interview. A review of R4's Care Plan revealed the following: Focus: I have indwelling catheter r/t (related to) wound management .Dated 1/7/2025 .Interventions/Tasks: Catheter: Position catheter and tubing below the level of the bladder covered for dignity. On 03/04/25 at 12:55 PM, Nurse Manager E was informed that on 3/3/25 R4 did not have a privacy bag for their urinary drainage bag. Nurse Manager E said that it (the dignity cover) probably fell off but should have a cover. On 03/05/25 at 11:49 AM, the Director of Nursing (DON) was asked regarding privacy bags and dignity in the facility. The DON stated that she expects that we have a privacy bag for all urinary drainage bags for dignity. A review of the facility's policy Promoting/Maintaining Resident Dignity dated 2/2025 revealed the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .Maintain resident's privacy.

Based on observation, interview and record review the facility failed to provide timely personal care for one of (R15) four residents reviewed for ADL's resulting in untimely assistance with bathing, dressing, and transferring to their wheelchair and the resident verbalizing feelings of frustration and anger. Findings include: On 10/2/24 at 08:56am, R15's call light was on, and the resident was observed lying on their back, sheet and blanket was not covering the right side of R15's body, wearing a soiled brief and a faded black t-shirt with food stains across the front of the shirt. There was an odor of stool. R15 lips were dry with skin peeling. In addition, the resident face had dried food within their beard. R15 indicated they needed to be cleaned up due to an accident in their brief. On 10/2/24 at 09:40am, an unknown certified nurse aide (CNA) was observed with R15 changing their brief. During this time of care, staff did not perform bathing nor dressing the resident. R15 stated that they were waiting for the CNA to come back with the Hoyer lift. On 10/2/24 at 10:45am, R15 was observed in bed, wearing a brief and the same stained black t-shirt. The resident denied being bathed at this time. On 10/2/24 at 11:33am, R15 was observed in bed, wearing a brief and the same stained black t-shirt. R15 said, I'm waiting for the aide to wash me and get me up. On 10/2/24 at 11:51am, Licensed Practical Nurse LPN A was interviewed and asked if R15 was going to be dressed and assisted out of bed. LPN A said, (R15) has diarrhea and need to stay in bed because it doesn't make sence to keep getting (R15) in and out of bed. On 10/2/24 at 2:54pm, R15 was observed in bed with their eyes opened. R15 was wearing a brief and the same stained black t-shirt. The resident said, I'm getting mad now. On 10/3/24 at 08:06am, R15 was observed in bed, wearing a brief and the same stained black t-shirt. R15 lips were dry with skin peeling. In addition, the resident face had small pieces of dried food within their beard. R15 stated that staff never assisted with bathing and dressing. R15 stated, I'm frustrated because they never got me out of bed and they didn't helped me wash-up .I'm tired of laying in this bed .and I'm mad because I forgot to call my brother yesterday to wish him happy birthday because I was so upset trying to get somebody to help me get up. On 10/3/24 at 09:55am, R15 was observed in bed with their eyes closed. R15 was wearing the same stained black t-shirt. A review of R15's medical record indicated that the resident was initially admitted to the facility on [DATE] with the diagnosis of Peripheral vascular Disease, Cerebral Infarction, Hypertension, Immunodeficiency, and Non-Pressure Chronic Ulcer. A review of R15's Quarterly Minimum Data Set (MDS) assessment, dated 7/5/24, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 (cognition is intact). MDS Section GG - Functional Abilities. A review of R15's care plan noted I have an ADL (Activities of daily living) self-CVA care deficit secondary to history of CVA (Stroke) with impaired mobility. Date Initiated: 02/19/2024. Interventions noted the following: BATHING- I need 1 person assist to bath. Bed Mobility- I need 2 person assist. Personal Hygiene/Oral Care: I require (1) staff participation with personal hygiene and oral care. Dressing: I require (assistance with choices, physical assistance) to dress. Transfer- Hoyer lift for transfers X 2 person. Mobility: I use a wheelchair for locomotion. Bed Mobility-Extensive assistance. On 10/03/24 at 11:36am, the Nursing Home Administrator (NHA) was interviewed and informed that R15 was asking to be dressed and get out of bed since yesterday, resident remained in bed with same soiled t-shirt and not wearing pants. The NHA stated The expectation is that staff dress and assist all residents out of bed. A review of the facility's policy Activities of Daily Living dated 2/25/24 noted the following: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care; 2. Transfer and ambulation; 3. Toileting.

This citation pertains to intake MI00145699. Based on interview and record review the facility failed to ensure adequate assistance during a mechanical lift (Hoyer) transfer for one resident (R601) out of four residents reviewed for falls, resulting in a fracture of the right rib and hospitalization . Findings include: Review of an Admission Record revealed, R601 originally admitted to the facility on [DATE] with pertinent diagnosis which included hemiplegia and hemiparesis following a cerebral infraction. R601 discharged on [DATE] due to a fall and returned to the facility on [DATE] with the diagnosis of Fracture of one rib, right side. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R601 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 8 out of 15 and had impairment on one side of the upper and lower extremities. Review of a nurse's progress note with a date of 7/1/24 at 4:13 p.m. revealed, Event occurred on 07/01/2024 11:30 AM. res was being lifted in hoyer lift and the hooks from the hoyer pad slipped off the hooks of the hoyer lift and res fell to the floor at bedside in his room .(sic) Review of a nurse's progress note with a date of 7/2/24 at 3:10 p.m. revealed, FALL: Writer alert by staff that resident had c/o (complaint) chest pains. Upon immediate assessment resident stated that he had chest pains, and he had a fall. Physical assessment revealed pain 10/10 to right side and chest pains 3/10 . Physician notified and gave order for hospital transfer for post fall evaluation . Review of a care plan revealed R601 had the focus, I have an ADL self-care deficit secondary to history CVA with impaired mobility initiated 7/15/222. Intervention included, I require total assistance with transfers with an initiated date of 7/29/22. Review of a hospital H&P (History & Physical) report dated 7/1/24 revealed, R601 presented to emergency department after a fall from Hoyer lift on the AM of 7/1. A chest x-ray suggested R601 had a fractured right seventh rib. In an interview on 8/1/24 at 12:50 p.m., Certified Nursing Assistant (CNA) F reported she transferred R601 with a Hoyer lift without assistance. CNA F reported R601 fall on the bed frame. CNA F reported being aware that mechanical lift transfers required two people and stated, I was irresponsible and got him up by myself, I did not ask for help because there was nobody. In an interview on 8/1/24 at 1:25p.m., the Director of Nursing (DON) reported R601 was sent to the hospital after a Hoyer lift transfer that resulted in fractured right rib. The DON reported CNA F acknowledged that she made a mistake by not waiting for assistance when transferring R601with the Hoyer lift. The DON reported staff are trained upon hire and receive a competency for Hoyer lift use annually. The DON reported the importance of using two people for mechanical lift transfers is to maintain safety. In an interview on 8/1/24 at 2:04 p.m., the NHA (Nursing Home Administrator) reported being made aware that R601 had a fall out of the lift on 7/1/24. The NHA then reported two people are required for mechanical lift transfers. Review of a Mechanical Lift policy revised 12/2018 documented, A mechanical lift will be used to transfer any resident that is totally dependent and immobile . General Guidelines . 2. Do not operate the Hoyer lift alone. Assistance will be needed to guide the resident to another location . 5. The Hoyer lift should always be in good operating condition . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: 1. R601 was immediately assessed by the charge nurse and neuro checks, pain assessment and skin assessments completed. 2. All mechanical lifts were inspected. The malfunctioning Hoyer lift was removed and stored in a non-accessible area away from staff and new Hoyer lifts were ordered. 3. The Administrator and Director of Nursing provided a 1:1 education for the assigned CNA on the Fall Prevention Program, Mechanical Lift, Abuse/Neglect/Exploitation, and Change of Condition polices. 4. A facility audit was conducted and like resident care plans were updated. 5. The Administrator and DON reviewed the Fall Prevention Program, Mechanical Lift, Abuse/Neglect/Exploitation, and Change of Condition polices and were deemed appropriate. 6. All Certified Nurse Aids were educated on Mechanical Lift Transfers with return demonstration to ensure competency with emphasis on needing 2 persons when using a Hoyer lift. 7. All staff was educated on the Abuse/Neglect/Exploitation policy. 8. The Unit Manager/Designee will conduct audits on observations of mechanical lift transfers on 3 residents M-F weekly for 4 weeks to ensure compliance. Results of these audits will be reported to the QAPI Committee for further review and recommendations 9. The Administrator/Designee will audit all Hoyer lifts for functionality M-F for 4 weeks to ensure safety of residents. Results of these audits will be reported to the QAPI Committee for further review and recommendations The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to Intakes MI00141917. Based on interview and record review, the facility failed to consistently utilize the services of a Registered Nurse (RN) for eight consecutive hours per day (24-hour period), seven days a week, resulting in the potential for inadequate coordination of emergent or routine care that could cause negative outcomes, affecting the 89 residents who resided in the facility. Findings include: A complainant reported to the State Agency concerns with nursing staffing levels. On 2/1/24 at approximately 1:00 PM, an interview was conducted with Staffing Coordinator (SC) E who was responsible for scheduling nursing staff for the facility. A review of nursing schedules during the periods of 11/15/23 to 11/30/23 and 1/2/24 to 1/15/24 revealed there was no RN coverage per day (24-hour period) for the following dates: 11/15/23, 11/17/23, 11/20/23, 11/23/23, 11/24/23, 11/25/23, 11/26/23, 11/28/23, 11/29/23, 11/30/23, 1/2/24, 1/4/24, 1/7/24, and 1/12/24. On 2/1/24 at 2:34 PM, the Director of Nursing (DON) said the building should be staffed with eight hours of RN coverage every single day. The DON was aware that they are not meeting that expectation. The DON reviewed the nursing schedules for the periods of 11/15/23 to 11/30/23 and 1/2/24 and 1/15/24 and concurred with the findings of no RN coverage as previously indicated. On 2/1/24 at 4:50 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on interview and record review the facility failed to ensure that the Medical Director (MD) attended the Quality Assurance and Performance Improvement (QAPI-program aimed on improving processes involved in health care delivery and resident quality of life) meetings quarterly, resulting in the potential for impaired resolution of identified issues or decreased quality of care with the potential to affect all 89 residents that reside in the facility. Findings include: During an interview and record review on 2/01/24 at 1:58 PM, the QAPI program was reviewed with the Nursing Home Administrator (NHA). The NHA revealed that QAPI team members met monthly and included managers and interdisciplinary team members. When queried if the medical director attends the required quarterly QAPI meeting the NHA stated, The medical director did not participate in any of the 2023 QAPI committees or any meetings for 2024 nor did his representative. Record review of the provided 12 QAPI attendance records dated January 2023 through September 2023, and 3 undated sign in sheets next to the Medical Director title were blank. Review of the facility's policy titled, Quality Assurance and Performance Improvement dated 10/20/1989, revised/reviewed 10/22 revealed in part The QAPI program includes the establishment of a Quality Assessment and Assurance Committee and a written QAPI plan. The QA committee shall be interdisciplinary and shall consist at a minimum the director of nursing, the medical director or his/her designee .meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program.

Based on observation and interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for the facilities census of 89 residents and its staff resulting in an increased chance of harm and the spread of harmful pathogens. Findings include: On 1/31/24 between 11:02 AM and 11:25 AM, during a tour of the laundry room and its support spaces the following observations were made: An accumulation of dust and debris was observed on top and on the sides of both washing machines, underneath and behind both dryers, on the blades and grill of the wall mounted fan, on the furnace vent grates and its filters, and within the floor grates next to the washing machines. Multiple soiled towels were observed on top of the washing machines. The overhead light fixture above the dryers was observed with its light bulbs missing. Floor tiles/ a flooring material was observed deteriorated and missing in multiple areas throughout the laundry room. One of two washing machines was observed in a non-functional state, and one was actively leaking on the floor while in use. Multiple blankets and clothing items were observed stored on the floor in the Laundry's lost and found room. On 1/31/24 at 11:10 AM, upon interview with Laundry Aide, staff A, on the current state of the washing machines they stated, we have only had the one for a while now, and it does leak, but it works well so we just keep using towels to soak up the water during the day. At this time the surveyor inquired with staff A on what the facility would do if the leaking washing machine stopped working or needed to be repaired to which they replied, I really don't know. Buy new ones or get a laundry company to take our stuff I guess. On 1/31/24 at 11:15 AM, upon interview with staff A, the surveyor asked who was responsible for the cleaning in the laundry room to which they replied, some of it is maintenance, housekeeping, and some of it is us. On 1/31/24 at 11:24 AM, upon interview with staff A, on the current state of the lost and found room they stated, it's bad. I can't even get to the things to figure out what we have to give to the residents, and people just keep dropping more stuff off. 34901 Based on observation, interview, and record review, the facility failed to ensure the first-floor shower room and dirty utility room were maintained in a clean and sanitary manner, resulting in the residents' environment not being homelike and the potential for spread harmful pathogens. Findings include: During the initial tour of the facility on 1/30/24 beginning at 7:15 AM, the following observations were made on the first-floor housing unit: - two used and soiled towels were on the floor in the unit shower room near room [ROOM NUMBER]. - the soiled utility room near room [ROOM NUMBER] contained a trash can, approximately 44 gallons in size. The trash can overflowed and was stacked and packed with bagged and loose garbage including several disposable drinking cups and a used green incontinence bed pad. Two bags of garbage and two pairs of used disposable gloves were observed on the floor next to the trash can. A commercial mop bucket was stored containing dirty mop water. During an observation and interview of the trash in the soiled utility room on 1/30/24 at 7:29 AM, Certified Nurse Aide H stated, They need to pull it. During an interview on 2/1/24 at 12:46 PM, the Nursing Home Administrator (NHA) said the towels on the floor in the shower room should have been picked up after a shower because of sanitation purposes. The NHA stated, It's everyone's responsibility to ensure infection control policies are adhered to. The NHA said the trash in the soiled utility room should have been picked up, and it is unacceptable for trash to be on the floor. On 2/1/24 at 4:50 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

Based on observation, interview, and record review the facility failed to ensure an oxygen cylinder was stored properly Findings include: On 1/31/24 at 1:06 p.m. an observation of the medication room located on the second floor of the facility revealed an oxygen cylinder without a stand propped against the wall in the corner next to two fire extinguishers and a metal rack. Near the top of the oxygen cylinder regulator, the red needle was on 0 in the REFILL area (within or just outside of the red area, the cylinder is close to empty). This indicated the cylinder was not empty of oxygen. On 2/1/24 at 2:02 p.m. Unit Manager J was interviewed regarding the oxygen cylinder inappropriately stored in the medication room. Unit Manager J directed a staff person to remove the cylinder while stating, I didn't know this was in here. This should not be in here. On 2/1/24 at 3:11 p.m. the Director of Nursing was interviewed. The DON said the Central Supply staff person was responsible for removing oxygen equipment out of the medication rooms and ensure they are stored and placed safely. Review of the facility's policy titled Oxygen Safety dated 1/11/21 documented the following: Oxygen storage locations shall be in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors or gates that can be secured against unauthorized entry . Cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty.

This citation pertains to Intake number MI00126045. Based on interview and record review, the facility failed to adhere to one resident's (R74) Do Not Resuscitate (DNR) code status and failed to verify one resident's (R221) documented evidence (such as a medical power of attorney, patient advocate, legal guardianship, or living will) that a family member was authorized to designate a DNR directive of six residents reviewed for advance directives, resulting in unwanted and unmet end of life wishes where CPR was performed on R74 and no CPR was performed on R221. The Immediate Jeopardy (IJ) was identified on [DATE] at 11:15 a.m., as a result of Cardiopulmonary Resuscitation (CPR is defined as-emergency procedure consisting of chest compressions in an effort to restore spontaneous blood circulation) being performed on R74 for approximately 25 minutes and no CPR being performed on R221, leading to the likelihood of other residents affected due to lack of adhering to code status that could lead to serious harm, injury, impairment or death. The Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 1:35 PM. The Immediate Jeopardy began on [DATE]. A plan to remove the immediacy was requested. The IJ was removed on [DATE], based on the facility's implementations of the plan of removal as verified by the survey team on site. Although the IJ was removed, the facility's deficient practice was corrected and remained isolated with no actual harm with potential for more than minimal harm. Findings include: Resident R74 A review of R74's clinical record revealed R74 was admitted into the facility on [DATE] and readmitted on [DATE]. Diagnoses included: heart failure, schizoaffective disorder (mental health disorder), and kidney disease. Review of the annual Minimum Data set (MDS) assessment dated [DATE] documented R74 had severe cognitive impairment. According to the face sheet, R74's family member H was listed as emergency contact. Included in the record was court paperwork which documented R74's family member H was the Legal Guardian (LG). Further review of the clinical record identified R74 as being a Do Not Resuscitate (DNR-No to CPR). The clinical record contained a facility document which had an X marked next to Do Not Resuscitate (DNR) which had been signed by R74's LG H on [DATE]. Review of a physician's order dated [DATE] documented, DNR with hospitalization . Review of the [DATE] care plan documented, (R74) and responsible party have elected a DNR- with hospitalization Code Status with an intervention of; Ensure (R74's) comfort. Review of R74's nursing progress note dated [DATE] at 6:00 AM, Resident observed unresponsive. No vitals noted. 911 was called. CPR in progress until Emergency Medical Services (EMS) arrived. EMS put on Cardio Pads while doing CPR. Resident had no vitals. Police was called for an investigation. They left police report number. Family was called, they chose (Name of) Funeral Home of (name of location). Doctor has been notified. At 7:54 AM, (Name of) Funeral Home picked up body. In a phone call with the Director of Nursing (DON), Licensed Practical Nurse (LPN) I was interviewed. LPN I confirmed she was the nurse assigned to R74 on [DATE]. LPN I reported responding to R74's room and observed the resident unresponsive. LPN I indicated the resident was not doing well earlier in the shift and at that time confirmed the residents code status. When asked, LPN I reported R74 was a Full Code. LPN I confirmed performing chest compressions for about ,d+[DATE] minutes until EMS arrived. The nurse reported that when EMS arrived they performed CPR for approximately 20 minutes, they go through 5 cycles with a defibrillator. LPN I said after 5 unsuccessful cycles EMS called the hospital physician and pronounced the resident deceased . LPN I reported that all the residents in the facility are Full Code, with the exception of one resident who receives hospice services. The DON told LPN I during the phone interview that when a resident is found unresponsive, one staff member should be confirming the resident's code status, while another staff member stayed with the resident getting vital signs. The DON reported that CPR should never have been initiated on R74. Resident R221 A review of R221's clinical record revealed R221 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses which included: congestive heart failure, dementia, and high blood pressure. Review of the annual MDS assessment dated [DATE] documented R221 had severe cognitive impairment. According to the face sheet, R221 had a guardianship company as the Legal Guardian. Included in the record was court paperwork which documented R221's LG was appointed on [DATE]. Further review of the clinical record identified R221 as being a Do Not Resuscitate (No CPR). The clinical record contained a facility document which had an X marked next to Do Not Resuscitate (DNR). The document was signed by R221's family member O on [DATE] who was not the Legal Guardian. Review of the electronic revealed there was no supporting documentation available which confirmed R221's family member O was an authorized legal representative to withhold treatment such as a medical power of attorney, or legal guardian. A care plan revised on [DATE] titled, Advanced Directive established: I wish to be a DNR was reviewed. The interventions included provide all life sustaining measures (i.e. CPR .). Review of R221's nursing progress note dated [DATE] (2 days after family member O's unauthorized signature on DNR papers) documented, Performing rounds at patient bedside. 0 movements observed. 0 response to verbal or tactile stimuli. 0 breath or heart sounds. 0 pulses palpable. Nurse Practitioner notified of patient status .DNR code status. During an interview with the DON on [DATE] at 1:49 PM, it was confirmed that no CPR was performed on R221. R221 expired in the facility. The DON indicated not being employed by the facility at the time of the event and was unsure why the family member was allowed to sign the DNR papers, and not the Legal Guardian. The DON was unsure why the care plan interventions were not reflective of the Resident/LG wishes and not updated. Review of the facility's policy titled, Resident's Rights Regarding treatment and Advanced Directives revised ,d+[DATE] documented, . 5. The facility will periodically assess the resident for decision-making abilities and approach the healthcare proxy or legal representative if the resident is determined not to have decision making capacities . 8. Decisions regarding advance directives and treatment will be periodically reviewed, the existing care instructions and whether the resident wishes to change or continue these instructions. Abatement: 1. 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. The affected resident no longer resides in the facility. All current residents have the potential to be affected by this practice. The Medical Director was notified by the DON/designee of this event. The DON/designee will complete an audit of all current resident Advance Directives to ensure an Advance Directive is uploaded in the resident record and that the physician orders match the designation. 1. Actions to Prevent Occurrence/Recurrence: Include actions the facility will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, by whom and when those actions were completed. All Advanced Directives were reviewed to ensure that the legal party responsible has signed and designated selection. The DON reviewed the Residents 'Rights Regarding Treatment and Advance Directives Policy and deemed it appropriate. The DON/designee will educate all Licensed Nurses on the Residents' Rights Regarding Treatment and Advance Directives Policy. All licensed Nurses will receive education prior to their next scheduled shift. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: [DATE].

This citation pertains to intake MI 3500. Based on observation, interview and record review the facility failed to supervise and ensure that assessed safety measures were implemented for one sampled resident (R#502) out of three residents reviewed for falls resulting in a fall with head injury requiring hospial emergency room treatment and sutures. Findings include: On 6/4/19 at 10:20 am record review revealed that R#502 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] documented the resident's cognition was severely impaired and was totally dependent on staff for all activities of daily living. The MDS documented in Section G Functional Status, that R#502 was not steady, only able to stabilize with staff assistance. Review of a 8/8/18 Care Plan titled, (Resident name) has the potential to fall related to cognitive impairment, poor safety awareness, requires assistance with transfers and unsteady gait. Interventions: Keep me in view of staff sight . Review of an undated Certified Nurse Assistant (CENA) Care Guide (a guide to help the nurse aide individualize the residents plan of care) for R#502 documented, Patient to be secured while in dining room and at nursing station. At 11:00 am the facility's Director of Nursing (DON) provided an Incident/Accident (I/A) report dated 5/22/19 for R#502. The I/A documented; Writer (Nurse D ) was approached by aide (CENA E) that resident had fallen on the floor, aide voiced resident was reaching for something on the floor before she fell , writer noted bleeding from resident's right side of the head, laceration noted, area cleaned up pressure dressing applied to site of laceration, Nurse Practitioner okayed request to transfer to emergency room for stitching .resident not fully seated with her legs under the table and upper body close to the table. Review of the nursing progress notes documented; -5/22/2019 14:50 Nursing Note: Patient is alert x 1-2, she is incontinent of b/b (bowel and bladder),she is total assist, x,1 person, she is a fall risk. She has a lack of coordination, muscle weakness, [MEDICAL CONDITION], age-related physical debility, dementia. Resident has no safety awareness, putting her at a greater risk for falls. Patient on this day was not properly secured in the dining room resulting in a fall with injury. The assigned CENA (CENA E) has been educated on safety awareness for residents who are at risk for falls. Care plan has been updated instructing that patient is to be properly secured while in the dining room while in w/c (Wheelchair). Guardian notified of implementation. Staff will continue to follow care plan/care guide. Author: Director of Nursing Services. -Returned from (name of local hospital) in an ambulance, escorted by two EMTS (Emergency Medical Technicians) on stretcher, with several family members @ bedside, resident transferred into bed, body assessment done, 3 sutures noted @ right side of upper scalp . On 6/4/19 at 11:39 am, CENA [NAME] was interviewed and asked about the incident with R#502. CENA [NAME] stated, It happened around 10:30 and 11:00 am (on 5/22/19), we (CENA [NAME] and R#502) were in dayroom at the time I was sitting there talking to her. Her wheelchair was facing me. I got up to go to the sink to wash my hands without first positioning her up to the table. I was going to go back to her to push her back up to the table, but I got distracted. While I had my back to her, she fell forward out of her chair. When I turned around she was already on the floor. CENA [NAME] said that she was familiar with R#502 and knew of the resident's safety interventions of, secured while in dining room and at nursing station .Keep me in view of staff sight. I was just wasn't thinking at the the time. At 12:20 PM, during an interview with the DON she indicated that she was not aware that CENA [NAME] had got up and went over to the sink to wash her hands and turned her back to the resident. The DON stated, The CENA should have put safety measures in place before walking away from her. Review of the facility's policy titled, Fall Management Guidelines dated 3/14/19 documented, 2. Residents identified at risk for falls will have a care plan developed and implement appropriate fall prevention interventions.

Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision and effective monitoring for one resident (#501) who was observed exhibiting exit-seeking behaviors, of four residents that were reviewed for elopement/ wandering risk, resulting in an immediate jeopardy on 2/4/19 at approximately 5:30 p.m., when Resident #501 (R501) eloped from the facility undetected by staff and was found three days later in a neighboring city. This deficient practice placed all residents at high risk for further undetected elopements, significant harm, injury and/or death. The immediate jeopardy was identified on 2/7/19 at 3:40 p.m. The immediate jeopardy began on 2/4/19 at 5:30 p.m. when the resident exited the facility undetected by staff through the main entrance door. The Administrator was notified of the Immediate Jeopardy on 2/7/19 at 3:40 p.m. and a plan for removal was requested. Findings include: Review of the facility investigation and other pertinent documentation regarding a facility reported incident (FRI) that occurred on 2/4/19, revealed that it was reported R501 exited the facility through the main entrance at approximately 5:30 p.m. The Resident was discovered not to be in the facility at approximately 11:10 p.m. while staff were making rounds. At 11:15 p.m., the facility began to search for the Resident. At 11:40 p.m., the local authorities arrived at the facility and searched for the Resident. The Resident had not been found. On 2/7/19 at 10:30 a.m. review of R501's clinical record documented that the Resident was transferred from another facility and was admitted into the facility on [DATE]. The admission [DIAGNOSES REDACTED]. The Resident was identified as having moderately impaired cognition and ambulated independently with the aid of a walker. The Resident also had a court appointed legal guardian. Further record review of the admission documents sent by the previous facility revealed a psychiatric progress note dated 9/18/18 which documented, .He continues to require constant supervision and redirection and needs constant supervision and redirection. He still believes that he does not need to be in a nursing home, should be on his own . On 2/7/19 at 1:45 p.m., the Administrator was interviewed and asked to recall the events that lead to the elopement. The Administrator stated, I was out of town when the incident occurred and did not return until Wednesday (2/6/19). The DON (Director of Nursing) and Regional Director of Clinical Services initiated the investigation. They both reviewed the facility's cameras and they saw Resident #501 in the hallway with a walker, circling the door area around the front desk between 5 p.m. and 5:30 p.m He was then seen going into the Day room around 5:08 p.m. At 5:14 p.m. Resident #501 was seen leaving the Dayroom and go into his room. At 5:18 p.m., Resident #501 was then seen leaving his room and go back to the Day Room with his coat on and having his walker. At 5:26 p.m., the Resident came out of the Day Room turned the corner and exited the front door. The Administrator was asked if there was someone at the front desk. The Administrator stated, No. She went home for the day at 5 p.m. The Administrator was asked if the front door had an alarm. The Administrator stated, The front door had not alarmed. Now an alarm will be installed on the front door. The Resident never verbalized wanting to leave the building. He was not assessed to be an elopement risk however he was observed looming around the front desk area several times that day but was easily redirected away from that area. The Administrator was then asked what took staff five and a half hours to discover that Resident #501 was no longer in the building. The Administrator stated, The nurse aide (Certified Nursing Assistant (CENA) A) that had him on that shift was given a final warning for not doing every 2-hour checks on residents. The nurse for that shift had an unexpected admission around 6-6:30 p.m. and there was a lot of confusion with that admission. On 2/7/19 at 2:55 p.m., the Administrator's Assistant/ Front Desk Personnel C was interviewed and asked had she seen Resident #501 come to the front desk area (the front door is approximately five feet from the front desk area). Administrator's Assistant C stated, I noticed the Resident walking a lot in the hall. He walked this way (toward the front area) but walked away. He seemed very pleasant, calm, and quiet. He came to the front area about three times that day. I asked if he needed help because I figured he might have been confused or lost, but he would just say no and walk the other way. The Administrator's Assistant C was then asked if the front door had an alarm. The Administrator's Assistant C stated, The door only alarms when a Resident has on a wander guard on and gets close to the door. Other than that, the door exiting the building is unlocked however it beeps when it is opened. Anyone coming into the building have to be buzzed in by myself or staff to come into the building. On 2/7/19 at 3:01 p.m., the front door was opened from the inside. The door was observed to be unlocked and a constant moderate volume beeping sound was activated. The beeping sound continued until the door is closed. The beeping could only be heard on the first floor. Currently, staff did not appear to notice the door beeping. Staff did not react to the door being open. On 2/8/19 at 12:20 p.m., CENA A was interviewed via telephone. CENA A confirmed being Resident #501's nurse aide on the second shift (3 p.m. to 11 p.m.) on the date of 2/4/19. CENA A was asked what time she last saw the Resident and to recall the incident. CENA A stated, I saw him twice that day, once at the beginning of my shift in his room and again in the dining room around 4:30 p.m. and 5:30 p.m. He sat in there for about ten minutes, left the dining room stating he had to go to the bathroom. He never came back. When he didn't come back, I thought he might be on another floor. I asked the nurse where he was, and the nurse thought he was out smoking. When I noticed he didn't touch his dinner tray, I assumed he went to another floor to visit another resident. I didn't think much about it. A new admit arrived at the building and me and the nurse started assessing the new resident. That happened around 7 p.m. After assisting with the new resident, I passed ice. I still didn't see the resident assuming he was visiting or somewhere else in the building. I got in trouble for assuming but it will never happen again. On 2/8/19 at 12:41 p.m., Nurse B was confirmed to be R501's nurse from 7 p.m. to 7 a.m. by the Administrator. Nurse B was contacted via telephone for interview regarding the 9 p.m. medication pass and other pertinent information. A message was left for call back, however there was no call back from this nurse. On 2/8/19 at 2:30 p.m., R501 was observed in the room, now located on the second floor, sitting on the bed. The Resident was asked if he was able to recall the incident. Resident #501 stated, I'm ok but I don't feel like answering no questions. The interview with the Resident came to an end. On 2/7/19 at 2:45 p.m., the facility's policy titled Elopement Policy reviewed/revised date 7/17/18 included: It is the goal of the facility to provide adequate supervision that will prevent residents from leaving the premises. Surveyors verified the removal of the immediacy on site by record review and interview on 2/8/19, when the facility had the following in place: 1. Resident was located and returned to the facility on [DATE] at 4:30 p.m 2. Assessments completed on resident to include skin assessment, pain assessment, and vital signs. Resident care plan updated, and interventions instituted, including room move and wander guard placement. 3. 24-hour monitoring of hall for visual observation main floor door. 4. A door security staff person will be seated within visual oversight of the front exit door until the secure door alarm system is installed. The person will not leave the area unless replaced by another staff person. The identified door security staff person will utilize their cell phone to call for assistance or replacement and will not leave the area unsupervised. 5. Education to all nursing staff on every 2-hour checks to include visual oversight of residents began on 2/5/19, 70% of all staff educated and continues until all nursing staff are educated. 6. Education to all staff on elopement risk began 2/5/19, to include procedure and policy, with 80% of all staff educated and continues until all staff educated. 7. All residents admitted with last 30 days are reassessed for elopement risk and care plans updated as applicable. 8. Elopement Assessment will be administered to all residents upon admission and at least quarterly, annually and with any change in cognition or new exit seeking behavior. 9. Validated Elopement risk book are still pertinent and will be updated as applicable. 10. Door company contacted to install coded key pad lock on front door. 11. Staff was advised during the education, that in the event it was determined they did not follow policy or the noted education, disciplinary action would occur up to and including termination. Although immediacy was removed, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the fact that sustained compliance could not be verified by the State Agency.

Based on interview and record review the facility failed to follow up on STAT radiology (x- report) for one (#1) of two residents reviewed for an injury of unknown origin, resulting in a delay in treatment and prolonged pain. Findings Include: On 8/21/18 at 10:00 A.M. and 2:30 P.M., review of the Facility's Incident Report identified Resident#1 as having an injury of unknown origin that was identified on 5/23/18. On 8/21/18 at 2:50 P.M., review of the Quarterly Minimum Data Set (MDS), dated [DATE], documented R#1 was cognitively impaired, required two person/Hoyer transfer and was dependent on staff for all Activities of Daily Living (ADL's). The Face Sheet for R#1 documented the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Facility's Investigation documented R#1 had pain at rest during Physical Therapy on 5/21/18. This was verified after a review of the Therapy Notes dated 5/20, 5/21 and 5/22/18. Physical Therapy was discontinued at this time. On 8/21/18 at 3:00 P.M., review of the Nurse's Notes dated 5/23/18 indicated R#1 was examined by the Nurse Practitioner for concern of pain and swelling of the left hip and knee. On 5/23/18 at approximately 2:47 P.M., a Stat X-Ray was ordered by the Nurse Practitioner. The following medications were ordered: Administer: Tylenol 500 milligrams now and Tylenol 500 milligrams every night in addition to PRN (as needed) to Tylenol Order. Current order for [MEDICATION NAME] (used as antidepressant, may induce sleep) (7.5 milligrams at bedtime increase to 15 milligrams due to reported difficulty with sleep. On 8/21/18 at 4:00 P.M., review of the Medication Administration Record [REDACTED]. On 5/30/18 at approximately 5:30 P.M., during a follow-up visit, for continued pain for R#1, the Nurse Practitioner inquired about the results of the Stat X-Ray ordered and completed on 5/23/18. The staff reported, No Results were reported to the facility. The Nurse Practitioner reported to the Director of Nursing and the staff results of the 5/23/18 X-Ray Reports: Displaced Spiral Fracture of Left Distal Femur. Order placed to transfer R#1 to a local hospital for evaluation by Orthopedics. On 8/21/18 at 5:10 P.M., during an interview with the Administrator and Director of Nursing concerning the lapse in time (7 Days) before the facility followed up and confirmed the results of the Stat X-ray performed on 5/23/18, both acknowledged staff had not checked on the X-Ray results, the time frame was too long and the Fax Machine (was used to communicate tests results) was not working properly. No explanation was provided when queried as to why the Physician, had not checked or other mechanisms utilized for follow-up on the X-Ray results.

This citation pertains to intake: MI 349. Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision or a functional monitoring system (wanderguard, or door alarms) for four residents (#2, #5, #6, and #7) identified as having 'exit seeking' behaviors, resulting in an immediate jeopardy on 7/3/18 at approximately 7:00 p.m., when Resident #5 eloped from the facility undetected by staff and was later found at his sister's house. This deficient practice placed these four residents at high risk for further undetected elopements, significant harm, injury and or death. Resident #5: According to the facility reported incident (FRI) dated 7/4/18, on 7/3/18 at approximately 7:30 p.m. Resident #5 was observed walking outside the facility alone, by a staff person who was driving by the facility. The staff person called the nurse assigned to R#5 (staff # G) to confirm his whereabouts. Staff 'G' was unable to locate R#5 and a search was conducted. At approximately 11:00 p.m., R#5 was returned to the facility by the Director of Nursing (DON) and Administrator after being notified by R#5's sister that he was at her house. During an interview with the Administrator at 7/17/18 at 8:40 a.m., she confirmed that R#5 had eloped out of the building on 7/3/17, undetected by the nursing staff until he was seen walking outside the facility by a staff member who was driving by and thought she recognized him. The facility staff then conducted a walk through and concluded that R#5 had eloped out of the facility. R#5's sister was notified of the elopement. Later that evening (unknown time), R#5's sister called the facility to notify them that the resident was at her house, and unharmed. The Administrator said that her and the Director of Nursing went to R#5's sister's house and returned the resident to the facility at approximately 11:00 p.m. The Administrator indicated that the facility does not have any secured units, and the facility's door alarms and the wanderguard system had not been not functioning at that time, and are still not functioning. Upon further inquiry, the Administrator said the door alarms and wanderguard system had not been functioning for over a month. The Administrator went on to say that there was no receptionist on 7/3/17 at 7:00 p.m., when R#5 eloped, because she leaves at 5:30 p.m., and no staff person was at the front door to monitor. The Administrator confirmed that there had been no staff designated to monitor the exit doors, even though the alarms were not functioning for over a month. During an observation on 7/17/18 at approximately 9:30 a.m., the facility has three exit doors. Door 1, faces the front entrance (East) and did not alarm when opened. There was no receptionist at the window to screen who entered or exited the facility. The Administrator said the receptionist had the day off, and there was no replacement receptionist to monitor the front door. Door 2, faces South, exits into a fenced in parking lot, and did not alarm when opened. Door 3, faces north, exits directly onto a street, and did not alarm when opened. There was no staff present to monitor the exit doors. During an interview with the Director of Nursing (DON) on 7/17/18 at approximately 9:50 a.m., she reported that the facility had four residents that were identified to be 'at-risk' for elopement, R#2, R#5, R#6, and R#7. The DON said she was making binders for each nursing unit, including the receptionist area at the main entrance, to easily identify these four residents with a photo. The DON was in the process of compiling this information. During an interview with Nurse 'G', on 7/17/18 at 10:06 a.m., she said that she was unaware that R#5 was an elopement risk. Nurse 'G' said that she was new to the afternoon shift, and usually works midnights, and did not know that R#5 wanders around the facility freely in the afternoon. It was only after a staff person called her (she did not recall the staff who called) and said she thought R#5 was walking down the street that she became aware that R#5 had eloped. It was approximately 11:00 p.m., when R#5 was returned to the facility by the Administrator and DON, after picking him up from his sister's house. An assessment was conducted and the resident was without injury. During an interview with Certified Nursing Assistant (CNA) 'E' on 7/17/18 at 3:50 p.m., she said she was assigned to R#5 on 7/3/17, afternoon shift, and was unaware that he had eloped out of the building until nurse 'G' asked her to locate R#5. CNA 'E' said that she knew R#5 liked to walk around, and needed to be 'watched', but thought he was still with a visitor that was with him earlier that afternoon. CNA 'E' went on to say that R#5 had attempted to leave before and often had his belongings packed, but was always easily re-directed. CNA 'E' said that she did not see him on 7/3/17, or she would have been able to re-direct him. During an interview on 7/17/18 at 10:50 a.m., with the maintenance supervisor (staff 'I') he confirmed that the exit door alarms and the wandergaurd system had not been working for months. Staff 'I' did not have any monitoring logs for the door alarms or the wanderguard alarm system, and therefore could not be certain as to the exact date when the alarms actually stopped working. Staff 'I' did not have any logs or monitoring system to check functionality of the wanderguard bracelets. Staff 'I' did provide a quote from a alarm company dated 7/16/18 regarding replacing the alarm system, but no payment or contract had been issued. On 7/17/18 at 11:00 a.m., R#5 was observed laying on his bed with a wanderguard on his right ankle. He had a coat, hat, and bag of items on his bed. Upon inquiry, R#5 said that he may leave the facility again, if he feels like it, and go visit his mother. A medical record review for R#5 was conducted on 7/17/18. According to the face sheet R#5 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An elopement risk assessment conducted on 4/19/18 indicated that R#5 was at 'high-risk' for elopement. The admission progress note dated 4/19/18, documented that the resident had a history of [REDACTED]. The physician's progress notes dated 6/28/18 indicated that R#5 had a significant cognitive decline since (MONTH) (YEAR), and required 24/7 supervision due to a history of elopement and wandering. Resident #5 did not have a wanderguard bracelet order, nor was there any documentation in the medical record to support monitoring of the resident's whereabouts. Resident #2: According to the resident's medical record, reviewed on 7/17/18, he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#2 to be at 'high-risk' for elopement. R#2 was ordered to have a wanderguard bracelet. There was no documentation in the resident's medical record to support that the resident was being monitored for his whereabouts. There was no documentation to ensure that placement and functionality checks of his wanderguard bracelet had been conducted, at any time. During an observation on 7/17/18 at 11:20 a.m., R#2 was observed in the dining room, with a wanderguard bracelet on his right ankle. Staff 'C', who was assigned to R#2 was asked to check functionality of the resident's wanderguard bracelet. Staff 'C' said he had to go to the basement to obtain the 'testing machine' for the wanderguard. After several minutes Staff 'C' returned with the tester. It was observed and determined that the R#2's wanderguard bracelet was not registering and not functioning properly. Staff 'C' said that there was no specific order to check the wanderguard bracelets, and that they were good for either 30, 60, or 90 days. Staff 'C' was not certain if the resident's wanderguard bracelet had ever been checked for proper function. Resident #6: According to the resident's medical record, reviewed on 7/17/18, he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to elopement risk assessment, conducted on 7/17/18, R#6 was at a 'low-risk' for elopement. However, the physician's progress note dated 7/6/18 indicated that R#6 needs 24/7 supervision and is an elopement risk. A 'safety' care plan, dated 7/10/18 identified R#6 as being at risk for elopement due to eloping from the previous facility he was residing at, and impaired safety awareness. During an observation on 7/17/18 at 3:25 p.m., R#6 could not immediately be located by nurse 'C' (who was assigned to him). After several minutes R#6 was located in the dining room area. He was not wearing a wanderguard bracelet. Resident #7: According to the resident's medical record, reviewed on 7/17/18, he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An elopement risk assessment was 'in-progress', and therefore not complete. However a care plan for wandering and elopement initiated on 8/11/16 and revised on 2/21/18 indicated that the staff was to monitor and document the resident's whereabouts. There was no documentation to support this was being done. During an observation on 7/17/18 at 3:30, R#7 was observed laying in bed and denied having any thoughts of leaving the facility. There was no wanderguard bracelet on the resident. According to the facility's Elopement Management Program, dated 6/2016, upon admission a resident will be assessed for elopement risk. If yes, a care plan will be initiated and signally device (wanderguard) may be placed if there is a physician's orders [REDACTED]. On 7/17/18, the Administrator was notified of an Immediate Jeopardy that began on 7/3/18 at approximately 7:00 p.m., when R#5, who was identified as an elopement risk, eloped from the facility undetected by staff. On 7/17/18, at 4:15 p.m., the surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1) Resident #5 was being monitored every 15 minutes by nursing staff. 2) A door security staff person was seated within visual oversight of the first floor exit doors. 3) An 'elopement-risk' binder was placed on all nursing units and at the receptionist's desk that included photos of the four residents identified to be 'at-risk' for elopement Although the immediate jeopardy was removed on 7/17/18, the facility remained out of compliance with a scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to sustained compliance that could not be verified by the state agency.

This citation pertains to MI 858. Based on interview and record review the facility failed to provide supervision while eating for one resident (#503) of three reviewed for increased ADL (activities of daily living) help from a total sample of 8 residents resulting in second degree burns to the upper chest and upper extremities. Findings include: On 4/25/17 at 2:00 p.m., clinical record review revealed Resident #503 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set, dated dated [DATE], revealed Resident #503 had intact cognition, required total physical assistance for all activities of daily living with the exception of eating. Eating was assessed for Resident #503 and determined that she required extensive one person physical assistance with the task. On 4/25/17 at 10:00 am, Resident #503 was interviewed and reported that in January of 2017 she was served a lunch meal while in bed. Resident #503 stated that she had some hot tomato soup in a Styrofoam cup on her dinner meal tray and the dinner meal tray was placed on her overbed table. Resident #503 explained that when she moved the tray toward her the cup of soup spilled onto her upper right chest and inner right arm. Resident #503 then said that she began to yell for help because the soup was really hot. The next day when a certified nurse assistant (unidentified) assisted her with the removal of her gown, the CNA yelled, What is that? and then left the room and returned with a nurse. That is when I realized that I had burn blisters. It still hurts to this day and has not completely healed. They want it to heal from the inside out. It has left a total of 14 inch scar on my breast and arm. Review of the nurses notes revealed: On 1/12/17, Supervisor came to nurse on first floor stating resident spilled her beverage. Per the Nutrition Progress Note dated 1/13/17, Resident was seen today regarding dinner meal of 1/12/17. Soup was provided and resident explained she spill soup while eating dinner in bed. She requested another bowl of soup and stated she felt fine. However, upon further services she obtained blisters the following day. Will refer to PT/OT (Therapy services) for further evaluation for any need of adaptive devices. Per the physician notes dated 1/14/17, Resident #503 was seen for increase in pain due to a second degree burn. Second degree burns extend beyond the top layer of the skin, causes the skin to blister, and becomes extremely reddened and painful. Review of the ADL care plan, dated 10/18/16, did not reveal any interventions for eating. However, interventions that addressed eating were added to the care plan after the burn incident on 1/12/17. Review of the most recent Hot Beverage Risk assessment dated [DATE] (three days prior to the burn incident) revealed that Resident #503 had one of three risk factors checked in Section I. The assessment noted, If any of the questions in Section I (list of risk factors) are answered with a Yes, the resident should be screened by skilled Occupational Therapy and provided with supervision for meals and bathing until such time as a full assessment has been performed and interventions identified. On 4/26/17 at 2:10 p.m., the Hot Beverage Risk assessment dated [DATE] was reviewed with the Director of Nursing (DON). The DON was asked if Occupational Therapy assessed Resident #503 to determine if she was safe to consume hot beverages unsupervised. The DON was queried as Former Rehabilitation Director F was transitioning from employment with the facility. The DON reviewed the clinical record and the current Speech Pathologist reviewed previous Physical Therapy notes and both determined that no assessment had been done to help determine Resident #503's safety in consuming hot beverages. When queried further the DON acknowledged that the Hot Beverage Risk Assessment had been completed but Resident #503 should have been supervised by the nursing staff while consuming a hot beverage and referenced the assessment. A policy regarding the Hot Beverage Risk Assessment was requested, however the policy was not provided by the end of survey.

This citation pertains to Intake Number MI 507. Based on interview and record review, the facility failed to appropriately assess and use appropriate assistive devices and supervision during a two person assist transfer to prevent a fall for one resident (#701), from a sample of three residents all reviewed for falls. This deficient practice resulted in injury outcome and an avoidable fracture to the left distal femur and a mild displacement of the distal fragment with pain and a subsequent surgical repair with pin placement in the left knee for Resident #701. Findings include: On 6/9/16 at 9:45 a.m., the resident of concern, #701, was observed sitting on his bed in his room. Resident #701 was queried regarding the allegation of a fall with a fracture on 2/18/16. Resident #701 responded, I told the girl that I had to be picked up by a Hoyer lift. The Certified Nursing Assistant (CNA) responded with, 'I am going to put a small brace on you and watch your ass fall, she put a small brace on me and watched me fall. My leg broke and they put three pins in it. This happened while I was on the third floor at that time. It took me two days to see the doctor and that was in the hospital and then X-rays were ordered later after the fall. The administrator and the DON did not come in to talk to me. No one assessed me, they came and got me off the floor, about four people had to help. No one took vital signs on me at all, and I have high blood pressure too. On 6/9/16 at 11:00 AM, during a review of resident # 701's clinical record and Incident and Accident Report (I&A), dated 2/19/16 (no time), for the fall incident dated 2/18/16 at 4:55 PM revealed the following: an admission date of [DATE] and re-admission date of [DATE] with the following diagnoses; Displaced Unspecified Condyle Fracture of Lower End of Left Femur, Initial Encounter for Closed Fracture, Morbid Obesity due to excess Calories, Muscle Wasting and Atrophy, Difficulty in Walking and Unspecified Sequelae of Cerebral Infarction. An initial Minimum Data Set (MDS) score for resident #701 cognition as being intact and needing extensive assist with two person transfers from a wheelchair to other surfaces. The MDS further revealed that resident #701 did not have any falls prior to admission. Further review of resident #701's clinical record documented a Nursing History and Assessment, dated 1/27/16 at 6:30 p.m., revealed the following: Functional Status: 2 person assist, Non-weight bearing . Nursing Notes dated 2/13/16, at 4:30 AM, .Referred to PT (physical therapy) to help maintain proper positioning while up in wheelchair with recommendation for right lateral support to optimize upper positioning and prevent right side leanings, optimize positioning . Care Plans, safety evaluations or recommendations for safe transfers by Physical and Occupational Therapy (PT and OT) could not be found by time of exit. Physician documentation confirming whether a physician seen resident and provided any recommendations after the aforementioned incidents, could not be found by time of exit. There were no physician assessments within resident #701's clinical record after the 2/18/16 incident. A Fall Risk assessment dated on 1/27/16 to 3/10/16 scored resident as a 'High Risk' for falls. A Care plan for Falls was initiated on 1/27/16, prior to incident on 2/18, that indicated resident to be 'assisted with transfers' rather than that which was coded in the MDS assessment as a 2 person transfer Interventions were not updated after the incident on 1/27/16. A CNA's Care Guide dated 12/2015, was the only document available to guide the CENA's on transferring resident # 701. That guide listed how to transfer resident #701 as a 2 person assist with transfers and the part that listed, 'Hoyer' had a strike through but stated resident is a lift transfer only (no orders or documentation could support the decision to use the sit to lift equipment) . A review of the I&A Report (Incident and Accident) revealed the following: No hospitalization required, care plans were updated, Current devices that the staff and resident use listed a wheelchair. Injury assessment listed that swelling noted to left knee area, that X-Rays were ordered and that the resident received pain medication per floor nurse. Summary of changes to the resident's care plan: Resident stated, I slid off the bed and fell on both my knees. Posey vest had been ordered for resident to help with balance. Physician was notified and responsible party was notified. (Documentation could not be found supporting an order for [REDACTED]. An Unusual Occurrence Report dated 2/18/16 at 4:55 PM documented the following: Pt (patient) was noted sitting on the floor, no injury, physician notified and personal representative notified (sig other). An Unusual Occurrence Investigatory Tool dated 2/18/16 at 5:30 PM, as written by CNA A was reviewed, Room 305-1 resident was assistant (sic) to bed with the stand and lift with help at my self (sic), We place (sic) Mr. (NAME REDACTED) on bed with lift. Mr. (NAME REDACTED) was having a hard time holding on to lift. Pt. feet weren't under him he slid off. There were no other investigative report written that included details from the second CNA involved and in the room at the time of the incident. A review of the ordered Radiology X-ray report dated 2/19/16 at 2:53 PM revealed results indicating There is a fracture of the distal femur. There is mild displacement of the distal fragment. There is no apparent callus formation. There are no gross lytic or blastic lesions in the bones. There is no dislocation. Bone demineralization is present. Conclusion: There is a fracture as described above On 6/9/16 at 1:52 and 3:45 PM, an interview was conducted with CNA 'B.' When queried as to the equipment and to what level of assistance was provided during the transfer of resident #701 on 2/18/16, CNA 'B' responded, I did not assist with transferring the resident, I was in the room during the transfer and the other CENA sat him down on his bed and he fell out of his bed. When queried as to what a two person assist meant, CNA 'B' responded, Means that someone is supposed to be holding the resident while the other operates equipment. He should have not been on a sit to stand. I found out later he wasn't supposed to be on a sit to stand lift. It was told to me later from the person who put him on it. I watched her put him on it. I never heard him say I am supposed to have a Hoyer lift. The nurse told the CENA that I helped he wasn't suppose to be on a sit lift. This was not my normal floor and it wasn't hers either. I was not holding him and we are supposed to hold him, ensuring his safety. Once we got him on the bed, he slipped off the bed. No one interviewed me during the investigation except I told the nurse and he wrote what I said down. The CENA Care Guide we are supposed to evaluate the sheet to see how it is done. It is both of our responsibilities to see that guide before transferring and he complained of pain right away. I left the room to go and get the nurse. Immediately the nurse came in and assessed the resident. On 6/9/16 at 4:30 PM, an interview with CNA A was conducted. When CNA A was queried regarding the fall incident involving resident #701, she responded, A stand lift, that was the machine being used on him, from my years of being a CNA here, that was not the appropriate equipment. I knew he was non-weight bearing. There were two people. She assisted me from the back side. I controlled the lift and I set him down on his bed, she stood from the other side of the bed. I understand safety should have been for the resident. A current Guide had not been produced by this time. The CNA's did not have a current one. On 6/9/16 at 4:11 PM, during an interview with the Director of Nursing (DON), when queried regarding if there was a PT or OT safety assessment, was there any Interdisciplinary Team Review for resident #701's transfers, why wasn't the care plan reflecting the needs of the resident's transfer, where was the physician's notes regarding type of care or any assessments, the following was offered, It is my understanding that there should be a completed safety assessment by PT and the care plans in the nursing charts should reflect the MDS as it relates to providing safe care and it wasn't, based on the resident's chart. I have only been here for a week now, I do not know where the physician's progress notes are. On 6/9/16 at 4:30 PM, review of the facility's policy titled, Safe Lifting and Movement of Residents dated December 2013, revealed the following: 3. Nursing staff, in conjunction with the rehabilitation staff shall assess individual resident's needs for transfer assistance on an ongoing basis. staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's preferences for assistance; b. Resident's mobility (degree of dependency); C. Resident's size; d Weight-bearing ability; e. Cognitive status; F. Whether the resident is usually cooperative with staff; and G. The resident's goals for rehabilitation, including restoring or maintaining functional abilities. ( ) .

Based on observation, interview and record review, the facility failed to assess and provide supervision and assistance with hot liquids for one (#618) of nine sampled residents reviewed for safety with hot liquids from a total sample of 23, resulting in an Immediate Jeopardy (IJ) when Resident #618 whom had a BIMS score of 4, severe deformities of the hands, Kyphosis, was lying in bed, spilled hot coffee onto her thigh on 6/3/14 at 10:00 am, enduring second degree burns to the right inner and outer thigh, which required transfer and emergency room treatment for [REDACTED]. The Immediate Jeopardy was identified on 6/5/14 at 11:30 am. The Administrator was notified of the Immediate Jeopardy at 4:30 PM on 6/5/14. A Plan of Correction was requested to remove the immediacy. The Immediate Jeopardy was removed on 6/6/14 based on the provider's implementation of corrective actions on 6/6/14. Although the IJ was removed, the facility's deficient practice remained as isolated actual harm that is not Immediate Jeopardy. Findings include: On 6/3/14 at 9:45 a.m., during the initial tour, resident #618 was observed with bilateral hand contractures with deformity, and sitting on the side of the bed in a reclined position with an overbed table in front while eating breakfast. At that same time, resident #618 stated, "They (staff) didn't give me my coffee, or even ask me if I wanted coffee." On 6/5/14 at 10:10 a.m. the Administrator and the Director of nursing (DON) reported that Resident # 618 was, " burned with hot coffee on 6/3/14 and was sent to the emergency room for treatment on 6/4/14." During an interview on 6/5/14, Resident #618 stated, "... I picked up the cup to see what was in it, I spilled the hot coffee on my thigh..." According to the clinical record face sheet, Resident #618 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set resident assessment instrument, dated 3/11/14, reflected Resident #618 had a BIMS (Brief Interview of Mental Status) score of four, severe impairment of skills for decision- making and dependent on staff for bed mobility and transfer with limited range of motion of both upper and lower extremities. The nurse's notes dated 6/3/14, 10:00 am, reflected that Resident #618 had asked for coffee and a certified nurse assistant (CNA) obtained a hot cup of coffee for Resident #618. It was further documented, "...Writer got a call to come in resident room because resident had spilled the hot coffee on her rt (right) thigh. Myself,the wound nurse and MDS Coordinator in room to eval (evaluate) the resident skin and there was no apparent injury at this time, no redness...Approximately 7:30 PM writer was called in Resident room where I noted blistering and slight redness to resident right inner and outer thigh..." A physician order, dated 6/4/14,for Resident #618 reflected "Transfer to (Hospital Name) ER (emergency room ). The hospital discharge instructions, dated 6/4/14 for Resident #618, included treatment recommendations for second degree burns. On 6/5/14 at 10:15 a.m., during an observation of the burn, accompanied by the wound care nurse the following was noted: - Right lateral thigh distal area, 10 centimeters X 4 centimeters - Right lateral thigh proximal area 2.8 centimeters X 6.3 centimeters superficial - Right medial thigh 4 centimeters X 3.5 centimeters superficial The epidermis (1st layer of skin) and the dermis (2nd layer of skin) were removed from the burn on resident #618's right medial thigh exposing a bright pink area which was weeping straw colored drainage. The skin on the surrounding edge of the burn where the blister had opened,which was black in color had curled upward. The area on the lower thigh was black in color and had pink spotted areas throughout where the first layer of skin (epidermis) had been removed by the burn as well as areas where the second layer of skin (dermis) had been removed. When queried by the wound care nurse regarding pain, resident # 618 stated, " It (the burn area) hurts when you touch it." On 6/5/14 at 10:15 am, a review of the care plans for Resident #618 revealed no evidence of interventions for safe handling of hot liquids to limit the potential for burns. Additionally, there was no evidence that a risk assessment for the use of hot beverages had been completed. During an interview on 6/5/14 at 11:30 am, CNA "EE" confirmed that on 6/3/14 at approximately, 9:45 am, she had obtained a cup of coffee for Resident #618 and delivered it to Resident #618. CNA "EE" explained that she left Resident #618's room after she placed the coffee on the meal tray on Resident #618's overbed table. When she returned later (unknown time) she notice the area of clothing which covered Resident #618's thighs was wet. She further stated that she had positioned Resident #618 to sit at the side of the bed with the table over her lap, "...Maybe I should have put her in a chair..." On 6/5/14 at 3:00 pm, during an interview, the DON confirmed there was no evidence that the care plans for Resident #618 included interventions for safe handling of hot liquids, or any evidence that a risk assessment for the use of hot beverages had been completed. During an interview on 6/5/14 at at 4:55 pm, the Dietary Manager/RD (Registered Dietitian) confirmed that risk assessments for the use of hot beverages should have been completed to limit the potential for burns. On 6/5/14 at 5:00 pm, the temperature of the coffee in the coffee brewer in the kitchen, as measured by the Dietary Manager/ RD, was 170 degrees Farenheit (F). On 6/5/14 at 5:20 p.m., an observation of the first floor dining room was conducted. At that time, dietary aide Staff "T" was observed pouring a cup of coffee from an insulated container, into a coffee mug. Staff "T" winced when she poured the coffee into a mug and splashed some of the coffee onto her hand and stated, "Oh that's hot." At that time, a test of the coffee revealed a temperature of 157.6 degrees Fahrenheit (F). On 6/5/14 at 5:33 p.m., Staff "T" obtained a second temperature of the coffee which read 142 degrees F, and stated, "That's still hot." On 6/5/14 at 5:45 pm, in the dining room on the first floor, the coffee poured into cups to be served to the residents, as measured by the dietary staff, was 150 degrees F. and the hot water, used for tea, was 130 degrees F. According to the facility's policy "Safety Guidelines," dated 2013, Section 6-2, #5. " ...Monitor hot beverages and food temperatures on a regular basis at the point they are served. Appropriate supervision must be provided to any individual demonstrating decreased safety awareness and/or anyone who is at risk for burns or scalds per clinical assessments." The chart, referenced in the facility policy (Source: Michigan Department of Health, 2006) reflects that the estimated time for persons to receive second and third degree burns at a temperature of 150 degrees is less than one second to receive a second degree burn, and one second to receive a third degree burn. The immediate jeopardy was removed when the facility implemented the following: PLAN OF CORRECTION FOR REMOVAL OF IMMEDIATE JEOPARDY IMPOSED JUNE 5, 2014AT 4:30PM Element# I The resident has been examined by the physician; orders for the resident's safety have been noted and implemented. At 10:30 am Tuesday June 3rd resident# 618 sustained 2nd degree coffee burn to her right lateral and medial thigh .Initial first aid of application of cold water, and assessment of the exposed skin was implemented. The skin was initially assessed as intact with no breech in the skin integrity. At 7pm the resident's skin began to blister, the skin presented two areas of exposed skin on the right medial and lateral thigh. These areas were treated with silvadine. The resident was transferred to Providence Hospital where she was diagnosed to have second degree burns affecting the Rt medial and lateral thigh. The current measurements are: Rt lateral thigh 1Ox4 em (distal) Rt lateral thigh (2.8x6.3 (proximal) Rt medial thigh 4x3.5.All areas present with a pink superficial base with mild erythemia, and good granulating tissue. The wound is treated with silvadine, and dressed with non adhesive sterile dressings. The resident has not expressed pain, and required no pain medication for the past 24hrs. The care plan and care guide were reviewed and revised. The physician assessed the resident on 6/6/2014 and assessed the resident is healing well and to continue wound care, to be in an upright position during meals and to continue pain medication as necessary. Element# 2 &3 The nurse managers have referenced the MDS, therapy notes and the care plans in order to identify residents potentially at risk. In addition the DON has provided an assessment form to assist in the identification of residents potentially at risk, based on the resident's risk factors. Residents (104) have been screened by the DON and/or nurse managers on 6/5/2014 and 42 residents of 104 of them have been identified as at risk and have been initially assessed by the Nurse Managers. These residents have been endorsed to the therapy department for additional screening are receiving appropriate recommendations. These residents were screened for their ability to consume hot beverages independently. 40 of 104 residents identified at risk will be encouraged to consume their meals in the dinning room to allow for supervision during the consumption of hot beverages. The therapist is currently screening to assess for the resident's individual needs and to provide recommendations for assistive devices or special directives (i.e "fill cup half full, provide sippy cup etc.).The nurse managers have provided revised care plans and care guides. In? servicing on "The consumption of hot beverages" in-service education on "The proper temperature for hot beverages and proper use of the thermometer" in-servicing has been provided to 8 out of 14 dietary staff by the facility R.D. and 92 out of 128 staff members by the company nurse trainer regarding "Serving hot beverages to the resident." The DON held a meeting with the Medical Director to review the policies and discuss corrective measures. The nurses currently trained from the above in-service included emergency interventions for the treatment of [REDACTED]. The residents who prefer to eat in their room will receive coffee/water or tea from the carafes which have been temperature check from the kitchen. The Registered Dietician has in serviced 8 out of 14 staff members on this procedure and are ongoing until dietary staff has been inserviced.The dietary in service identifies the appropriate temperature for hot beverages to be 150 degrees coming out of the kitchen with the expectation that cooling will drop the temp to 130-140. Any employee on FMLA or other approved leaves will be sent an inservice packet, and must attend an in-service prior to returning to duty. The facility will strive to assess the residents for hot liquids upon admission, quarterly and change of condition and will supervise residents with hot liquids as deemed necessary. The Nurses will be responsible for monitoring the administration of hot beverages, by making daily surveillance rounds. These nurses will observe to verify hot beverages served comes from no other source than the carafes delivered from the kitchen with coffee and water for tea. The RD/designee will be responsible for ensuring that hot beverages are delivered at the proper temperature to the dining rooms/units. The DON/designee will be responsible for ensuring that hot beverages will be served at the proper temperature. The RD and Nurse Managers will review their surveillance findings weekly with the DON and Administrator. The findings will be reported to the QA committee weekly for 30 days and then monthly thereafter. Any concerns will be corrected immediately. The Administrator will be responsible for sustained compliance. The facility is confident that these corrective measures will ensure substantial compliance by June 6, 2014. ( ) ( ) ( ) ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS, MONITOR, AND CONSISTENTLY PROVIDE SERVICES TO PREVENT A DECLINE IN RANGE OF MOTION, FOR ONE (#6) SUPPLEMENTAL SAMPLED RESIDENT, AND ONE (#516) OF EIGHT SAMPLED RESIDENTS REVIEWED FOR RANGE OF MOTION, OUT OF A TOTAL SAMPLE OF 21 RESIDENTS, RESULTING IN THE DEVELOPMENT OF A CONTRACTURE FOR RESIDENT #6, AND DECREASED RANGE OF MOTION AND FUNCTIONAL INDEPENDENCE FOR RESIDENT #516. FINDINGS INCLUDE: ON 5/2/13 AT 10:00 A.M., SUPPLEMENTAL SAMPLED RESIDENT #6 WAS OBSERVED SITTING IN A WHEELCHAIR IN THE DINING ROOM, WITH A PILLOW WEDGED BETWEEN HER KNEES. SUPPLEMENTAL SAMPLED RESIDENT #6 WAS ORIGINALLY admitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. ACCORDING TO THE ANNUAL MINIMUM DATA SET ((MDS) dated [DATE], SUPPLEMENTAL SAMPLED RESIDENT #6 HAD SEVERELY IMPAIRED COGNITION. FURTHER REVIEW OF THE MDS ASSESSMENTS FOR SUPPLEMENTAL SAMPLED RESIDENT #6 REVEALED THAT THE 5/13/12 ANNUAL MDS, AND THE 11/13/12 QUARTERLY MDS, CODED THE RESIDENT AS HAVING NO LIMITATION IN RANGE OF MOTION. THE 2/13/13 QUARTERLY MDS FOR SUPPLEMENTAL SAMPLED RESIDENT #6, NOTED THAT THE RESIDENT HAD LIMITATION ON ONE SIDE OF THE LOWER EXTREMITY. REVIEW OF THE 5/3/11 ADMISSION RANGE OF MOTION (ROM) MEASUREMENTS FOR SUPPLEMENTAL SAMPLED RESIDENT #6, NOTED THAT THE RIGHT KNEE EXTENSION WAS "WITHIN FUNCTIONAL LIMITS". REVIEW OF THE 6/1/12 ROM MEASUREMENTS FOR SUPPLEMENTAL SAMPLED RESIDENT #6, REVEALED THAT THE LOWER EXTREMITY MEASUREMENTS WERE BLANK. THERE WAS NO ANNUAL RANGE OF MOTION ASSESSMENT COMPLETED FOR THE LOWER EXTREMITIES FOR SUPPLEMENTAL SAMPLED RESIDENT #6. A NURSING MONTHLY SUMMARY FOR SUPPLEMENTAL SAMPLED RESIDENT #6 DATED 10/21/12, NOTED: "...KNEE (RIGHT) BECOMING CONTRACTED/STIFF". A 10/21/12 PAIN ASSESSMENT FOR SUPPLEMENTAL SAMPLED RESIDENT #6 NOTED: "RIGHT LOWER EXTREMITY...CONTRACTURE...". REVIEW OF A PHYSICAL THERAPY (PT) EVALUATION FOR SUPPLEMENTAL SAMPLED RESIDENT #6 DATED 11/19/12, NOTED: "...REFERRED FOR SKILLED PT SERVICES BY NURSING DUE TO DECLINE IN HER ROM OF RIGHT KNEE...RESIDENT HAS DECREASED ROM OF RIGHT KNEE (RIGHT KNEE IN FLEXION)...". THE 11/19/12 ROM MEASUREMENTS FOR SUPPLEMENTAL SAMPLED RESIDENT #6 NOTED THAT THE RIGHT KNEE EXTENSION WAS AT -95 TO 100. IN THE COMMENT SECTION, IT NOTED: "RESIDENT RIGHT KNEE LOCKED IN FLEXION". DURING AN INTERVIEW AND RECORD REVIEW WITH THE DIRECTOR OF NURSING (DON) ON 5/3/13 AT 12:20 P.M., THE DON CONFIRMED THAT SUPPLEMENTAL SAMPLED RESIDENT #6 HAD NOT RECEIVED ANY SKILLED PHYSICAL THERAPY SERVICES FROM 6/2012 UNTIL THE RIGHT KNEE CONTRACTURE HAD BEEN DISCOVERED ON 10/21/12. WHEN QUERIED ABOUT RESTORATIVE SERVICES, THE DON STATED THAT SHE WAS UNSURE IF SUPPLEMENTAL SAMPLED RESIDENT #6 HAD BEEN RECEIVING RESTORATIVE SERVICES BETWEEN 6/2012 AND 11/2012. REVIEW OF THE CURRENT CLINICAL RECORD AND THE CHART THINNINGS, REVEALED THAT THERE WAS NO REFERRAL NOR an order for [REDACTED]. WHEN QUERIED ABOUT HOW OFTEN ROM MEASUREMENTS SHOULD BE COMPLETED, THE DON STATED THAT ROM MEASUREMENTS ARE TO BE DONE UPON ADMISSION, ANNUALLY, AND AS NEEDED. HOWEVER, WHEN A POLICY WAS REQUESTED, IT WAS NOT PROVIDED. ON 5/3/13 AT 12:30 P.M., THE RESTORATIVE PROGRESS NOTES FOR SUPPLEMENTAL SAMPLED RESIDENT #6 WERE REQUESTED FROM RESTORATIVE NURSE MANAGER "A". ON 5/3/13 AT 2:00 PM, RESTORATIVE NURSE MANAGER "A" PROVIDED RESTORATIVE ROM DOCUMENTATION FOR SUPPLEMENTAL SAMPLED RESIDENT #6 FROM JUNE 2012 THROUGH 5/3/13. REVIEW OF THE RESTORATIVE DOCUMENTATION NOTED THE FOLLOWING: JUNE 2012: THE DURATION SECTION WAS BLANK. THE FREQUENCY SECTION WAS BLANK. ACTIVE ROM/PASSIVE ROM SECTION WAS BLANK. UPPER EXTREMITY/LOWER EXTREMITY SECTION WAS BLANK. THE WEEKLY PROGRESS NOTES WERE NOT SIGNED BY THE RESTORATIVE AIDE, AND THE MONTHLY EVALUATION/REVIEW SECTION WAS BLANK. AUGUST 2012: THE DURATION SECTION WAS BLANK. THE FREQUENCY SECTION WAS BLANK. ACTIVE ROM/PASSIVE ROM SECTION WAS BLANK. UPPER EXTREMITY/LOWER EXTREMITY SECTION WAS BLANK. THE WEEKLY PROGRESS NOTES WERE NOT SIGNED BY THE RESTORATIVE AIDE, AND THE MONTHLY EVALUATION/REVIEW SECTION WAS BLANK. OCTOBER 2012: THE DURATION SECTION WAS BLANK. THE FREQUENCY SECTION WAS BLANK. ALL SECTIONS TO RECORD THE NUMBER OF MINUTES THAT THE RESIDENT HAD RECEIVED RESTORATIVE SERVICES WERE BLANK. THE WEEKLY PROGRESS NOTES WERE NOT SIGNED BY THE RESTORATIVE AIDE, AND THE MONTHLY EVALUATION/REVIEW SECTION WAS BLANK. NOVEMBER 2012: THE RESTORATIVE ROM LOG DOCUMENTED THAT SUPPLEMENTAL SAMPLED RESIDENT #6 BEGAN RECEIVING SERVICES ON 11/1/12, EVEN THOUGH A RESTORATIVE REFERRAL HAD NOT BEEN MADE UNTIL 11/19/12. THE RESTORATIVE LOGS ALSO DOCUMENTED THAT CERTIFIED NURSE AIDE (CNA) "M" HAD PROVIDED ROM TO SUPPLEMENTAL SAMPLED RESIDENT #6 ON 11/4/12 AND 11/18/12, HOWEVER ACCORDING TO THE NOVEMBER 2012 CNA WORKING SCHEDULE, CNA "M" HAD NOT WORKED ON THOSE DAYS. IN ADDITION, IT WAS DOCUMENTED THAT CNA "C" HAD PROVIDED SERVICES TO THE RESIDENT ON 11/12/12, 11/13/12, 11/15/12, 11/26/12, AND 11/27/12, HOWEVER THE NOVEMBER 2012 CNA WORKING SCHEDULE SHOWED THAT CNA "C" WAS OFF ON THOSE DAYS. DECEMBER 2012: THE DURATION SECTION WAS BLANK. THE FREQUENCY SECTION WAS BLANK. ALL SECTIONS TO RECORD THE NUMBER OF MINUTES THAT THE RESIDENT HAD RECEIVED RESTORATIVE SERVICES WERE BLANK. THE WEEKLY PROGRESS NOTES WERE NOT SIGNED BY THE RESTORATIVE AIDES. IN ADDITION, THE RESTORATIVE LOGS ALSO DOCUMENTED THAT CERTIFIED NURSE AIDE (CNA) "C" HAD PROVIDED ROM TO SUPPLEMENTAL SAMPLED RESIDENT #6 ON 12/2/12, 12/26/12, AND 12/30/12, EVEN THOUGH THE DECEMBER 2012 CNA WORKING SCHEDULE DOCUMENTED THAT CNA "C" WAS NOT WORKING ON THOSE DAYS. WHEN QUERIED ABOUT THE RESTORATIVE REFERRAL PROCESS, NURSE "A" STATED THAT SHE RECEIVES A "RESTORATIVE THERAPY REFERRAL FORM", WHICH DETAILS THE RESTORATIVE SERVICES FOR THAT PARTICULAR RESIDENT. WHEN ASKED FOR THE RESTORATIVE REFERRAL FOR SUPPLEMENTAL SAMPLED RESIDENT #6 FOR THE TIME PERIOD OF JUNE 2012 THROUGH NOVEMBER 2012, NURSE "A" WAS UNABLE TO FIND ANY REFERRALS. WHEN ASKED HOW THE RESTORATIVE AIDES KNEW WHAT TYPE OF ROM TO PROVIDE, INCLUDING THE FREQUENCY, DURATION, REPETITIONS AND SETS, WITHOUT ANY TYPE OF REFERRAL OR ORDER, NURSE "A" WAS UNABLE TO PROVIDE AN EXPLANATION. WHEN QUERIED AS TO THE DOCUMENTATION SHOWING THAT RESTORATIVE SERVICES HAD BEEN PROVIDED BY CNAS ON DAYS THAT THEY WERE SCHEDULED AS OFF, NURSE "A" PROVIDED NO EXPLANATION. ( ) ON 5/2/13 AT 11:45 A.M., RESIDENT #516 WAS OBSERVED IN A WHEELCHAIR SEATED AT A DINING ROOM TABLE. RESIDENT #516'S WHEELCHAIR HAD A POMMEL CUSHION ON THE SEAT. RESIDENT #516 KEPT PUSHING THE CENTER EXTRUSION OF THE CUSHION BETWEEN THE RESIDENT'S LEGS WITH BOTH HANDS TO READJUST. ON 5/2/13 AT 11:35 A.M., REVIEW OF THE CLINICAL RECORD REVEALED RESIDENT #516 WAS admitted INto the facility on [DATE] AND REadmitted on [DATE] WITH A [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS) ASSESSMENTS, DATED 11/11/12 AND 2/10/13 REFLECT RESIDENT #516 HAD NO FUNCTIONAL LIMITATION IN ROM IN EITHER THE UPPER OR LOWER EXTREMITIES. RESIDENT #516 REQUIRED EXTENSIVE PHYSICAL ASSISTANCE FOR ALL ACTIVITIES OF DAILY LIVING. HOWEVER, A PHYSICIAN'S PROGRESS NOTE, DATED ON 11/27/12 AT 9:15 A.M., WAS AS FOLLOWS "LEFT UE (UPPER EXTREMITY) CONTRACTED..." REVIEW OF THE CARE PLANS REVEALED THERE WAS NO CARE PLAN FOR RANGE OF MOTION OR RESTORATIVE THERAPY SERVICES. ADDITIONALLY, A REVIEW OF THE "CENA CARE GUIDE" FOR RESIDENT #516 DID NOT DIRECT CNA'S TO DO ROM. REVIEW OF THE "RANGE OF MOTION MEASUREMENTS" CONDUCTED BY THERAPY ON 12/7/12, DOCUMENTED THE FOLLOWING: LOCATION: SHOULDER NORMAL RANGE IN DEGREES FOR FLEXION (POSITION MADE POSSIBLE BY THE JOINT ANGLE DECREASING) = 180 FLEXION FOR LEFT AND RIGHT = WFL (WITHIN FUNCTIONAL LIMITS) NORMAL RANGE FOR ABDUCTION (MOVEMENT WHICH DRAWS A LIMB AWAY FROM THE BODY) FOR LEFT AND RIGHT = 180 LEFT AND RIGHT ABDUCTION = WFL REVIEW OF THE "JOINT MEASUREMENT RECORD" CONDUCTED BY PHYSICAL THERAPIST "L" ON 5/3/13 AT 1:20 P.M., REVEALED A LOSS IN RANGE OF MOTION IN RESIDENT #516'S SHOULDERS. THESE MEASUREMENTS WERE: LOCATION: SHOULDER ACTUAL FLEXION FOR LEFT = 150 (LOSS OF 30 DEGREES FROM 12/7/12), AND RIGHT = WFL ACTUAL ABDUCTION FOR LEFT = 110 (LOSS OF 70 DEGREES FROM 12/7/12), AND RIGHT = 160 (LOSS OF 20 DEGREES FROM 12/7/12) ON 5/3/13 AT 1:30 P.M., PHYSICAL THERAPIST "L" WAS ASKED ABOUT RECOMMENDATIONS MADE FOLLOWING THE 12/7/12 ASSESSMENT AND STATED, " WE JUST STARTED AT THE FACILITY. I WILL LIKELY EVALUATE AND RECOMMEND ACTIVE ASSISTIVE MOVEMENTS. RESIDENT #516'S ROM IS LIMITED FROM TIGHTNESS." ON 5/3/13 AT 1:40 P.M., AN INTERVIEW WITH RESTORATIVE CNA (CERTIFIED NURSING ASSISTANT) "C" WAS CONDUCTED. WHEN ASKED HOW FREQUENT RESTORATIVE THERAPY WAS PROVIDED, RESTORATIVE CNA "C" WAS UNABLE TO RECALL, AND WAS OUT OF THE FACILITY AT TIMES FOR RESIDENTS' APPOINTMENTS. WHEN ASKED ABOUT RESIDENT #516'S ROM SERVICES, RESTORATIVE CNA "C" STATED THERE WERE TIMES THAT DOCUMENTATION WAS NOT ACCURATE. RESTORATIVE CNA "C" WAS ASKED TO PROVIDE INFORMATION REGARDING RESIDENT #516'S SPECIFIC RESTORATIVE TREATMENT ORDERS, INCLUDING FREQUENCY AND EXERCISES, AND STATED, "YOU NEED TO GET THAT INFORMATION FROM RESTORATIVE NURSE MANAGER "A". ON 5/3/13 AT 1:45 P.M., AN INTERVIEW WITH RESTORATIVE NURSE MANAGER "A" REVEALED RESIDENT #516 HAD BEEN ON RESTORATIVE SERVICES SINCE JULY 2012. HOWEVER, REVIEW OF THE CLINICAL RECORD REVEALED THERE WERE NO PHYSICIAN ORDERS FOR RESTORATIVE SERVICES FROM JULY 2012 - APRIL 2013. REVIEW OF THE DOCUMENTATION PROVIDED REVEALED (FROM JULY 2012 - APRIL 2013) INCOMPLETE WEEKLY PROGRESS NOTES, MISSING SIGNATURES, AND DATES FROM THE RESTORATIVE CNA'S AND RESTORATIVE NURSE MANAGER "A". MOST OF THESE FORMS WERE LEFT BLANK. ALSO, THERE WAS NO DOCUMENTATION TO IDENTIFY IF THESE SERVICES WERE REVIEWED AND/OR NEEDED REVISIONS IF/WHEN THERE WAS A CHANGE IN RESIDENT #516'S CONDITION OR PARTICIPATION. NURSE MANAGER "A" ALSO STATED THAT RESIDENT #516 WAS AT MAXIMUM POTENTIAL AND WAS discharged TO FLOOR FROM RESTORATIVE SERVICES EFFECTIVE 5/2/13. WHEN ASKED WHY RESIDENT #516 WAS discharged FROM RESTORATIVE SERVICES, RESTORATIVE NURSE MANAGER "A" WAS UNABLE TO PROVIDE AN EXPLANATION. WHEN ASKED WHAT WAS INVOLVED IN THE "FLOOR" PROGRAM, RESTORATIVE NURSE MANAGER "A" STATED "THERE IS NO SPECIFIC INFORMATION, THE FLOOR STAFF WOULD PROVIDE ROM WITH DAILY CARE." ADDITIONALLY, WHEN ASKED HOW THE RESTORATIVE PROGRAM WAS AWARE OF WHAT RECOMMENDATIONS FROM THERAPY SERVICES AS TO WHAT EXERCISES SHOULD BE PROVIDED TO PREVENT A DECLINE IN ROM, THE RESTORATIVE NURSE MANAGER "A" STATED, "I CAN'T FIND THEM." ( , )