Every finding on record at Newaygo Co Medical Care Facility

Based on interview and record review, the facility failed to notify the resident or the resident's responsible party in writing of the reason for hospital transfers and/or the facility's bed hold policy for 2 of 3 residents (R43 and R58) reviewed for hospitalizations. Findings include: Resident #43 (R43) Review of R43's Electronic Medical Record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and congestive heart failure (CHF). Review of R43's MDS assessment, dated 5/13/26, revealed a BIMS score of 11, indicative of moderate cognitive impairment. Further review of the EMR revealed R43 appointed a medical Durable Power of Attorney (DPOA), effective 9/5/25. During an interview on 6/01/2026 at 11:38 AM, R43 confirmed several recent hospitalizations. R43 was unable to answer questions related to bed hold or transfer notifications. Review of a facility census report revealed R43 was hospitalized from [DATE]-[DATE], 3/19/26-3/21/26, 1/20/26-1/25/26, and 1/14/26-1/18/26. A review of R43's EMR did not reveal any documentation which indicated R43 or their medical DPOA were notified in writing of the reason for the hospital transfer or bed hold policy for any of R43's previous four hospitalizations. On 6/02/2026 at 11:24 AM, an interview was conducted with the DON who confirmed the facility did not send a transfer notification to R43's medical DPOA for any hospitalization and indicated it was a facility process failure. The DON stated the bed hold notice was sent with R43 during each transfer to the hospital and not retained in the EMR. Review of the facility policy titled, [Facility Name] Bed Hold, revised 1/28/26, read, in part: .the facility will have a process in place to ensure residents and/or their representatives are made aware of the facility's bed-hold and reserve bed payment policy well in advance of being transferred to the hospital. the facility will provide written information about these policies to residents and/or resident representatives prior to and upon transfer. a signed and dated copy of the bed-hold notice information will be kept in the resident's admission file. On 6/03/2026 at 8:45 AM, an interview was conducted with the Nursing Home Administrator (NHA) who stated the facility was in the process of creating a Transfer Notification policy. R58 A review of R58's admission Record, dated 6/2/26, revealed R58 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included anemia and weakness. In addition, the admission Record revealed R58 was their own responsible party, and their spouse was their first emergency contact in the event they were unable to make decisions in an emergent situation. A review of R58's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/25/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 14 which revealed R58 was cognitively intact. A review of R58's Health Status Note, dated 3/25/25, revealed R58 was concerned because she had blood in her brief and was unable to have a bowel movement. The physician/health care provider was notified and requested R58 be transferred to the emergency room for an evaluation and treatment. R58's spouse was called and R58 was sent via ambulance to the emergency room at 1:10 AM. A review of R58's electronic medical record, dated 3/18/26 to 6/2/26, failed to reveal any documentation that R58 and/or their spouse was notified in writing of the reason for the hospital transfer on 3/25/26. In addition, a review of R58's electronic medical record failed to reveal any documentation that R58 and/or their spouse was notified of the facility's bed hold policy (in writing or verbally) at the time of R58's transfer to the hospital on 3/25/26 or soon thereafter. During an interview on 6/2/26 at 1:30 PM, the Director of Nursing (DON) stated they call the resident's family/responsible party to notify them when the resident is transferred to the hospital and verbally tell them the reason for the transfer. The DON stated that she thought that was good enough for the notification and she was not aware that the facility had to give them something in writing. During a second interview on 06/02/2026 at 2:00 PM, the DON stated she knew that the facility was supposed to give residents the bed hold policy every time they go to the hospital. She stated that she can see that they did not give R58 and/or her spouse the bed hold policy in writing when they sent her to the hospital. The DON also verified that the copy of the bed hold policy form that was sent with R58 to the hospital on 3/25/26 was blank (indicating that the bed hold policy was not addressed with R58 and/or their spouse).

Based on interview and record review, the facility failed to initiate and/or properly follow bowel protocol for one Resident (#8) out of one resident reviewed for bowel and bladder management.Findings include:Resident #8 (R8)Review of R8's Electronic Medical Record (EMR) revealed initial admission to the facility on 3/6/26 with diagnoses including vascular dementia, congestive heart failure (CHF) and anxiety disorder. Review of R8's Minimum Data Set (MDS) assessment, dated 3/12/26, revealed a Brief Interview for Mental Status (BIMS) score of 6, indicative of severe cognitive impairment.Review of R8's EMR revealed the following progress notes:4/16/26 at 2:53 PM: .Patient does seem to have a large amount of hard stool in her rectum, but she states she's unable to pass it.4/30/26 at 1:37 PM: .[R8] also stated she felt like I gotta [sic] go to the bathroom but it won't come. She passed a small amount of hard stool but more stool is visable [sic] in her rectal vault.5/1/26 at 12:56 PM: residen[t] without reported BM [bowel movement] x5 days.5/5/26 at 3:47 PM: .[R8] complained of feeling like she needs to go but it won't come out. Stool is present in anus, but she is unable to push it out.5/6/26 at 11:16 AM: .Pt [patient] also with no BM documented since 5/2/[26].5/8/26 at 12:21 PM: .[R8] tolerated shower okay, but did complain of needing to pass stool but unable to and also lower back pain.5/15/26 at 1:25 PM: Shower provided for [R8]. She complained of constipation and right side back pain.5/28/26 at 11:18 AM: .Noted, no BM charted since 5/23/[26]. Abdomen is distended and firm, but non-tender.On 6/03/2026 at 7:58 AM, R8 was observed lying in bed eating breakfast. R8 was unable to answer questions related to her bowel regimen. On 6/03/2026 at 9:37 AM, an interview was conducted with Certified Nursing Assistant (CNA) L regarding R8's bowel regimen. CNA L stated R8 tends to have firm, hard stools.Review of R8's bowel elimination record during a lookback period from 5/4/26 - 6/2/26 revealed the following:No bowel movement from 5/4/26 to 5/8/26 at 10:27 PM (over 4 elapsed days).No bowel movement from 5/9/26 at 10:36 AM to 5/17/26 at 6:12 AM (over 7 elapsed days).No bowel movement from 5/17/26 at 6:12 AM to 5/23/26 at 2:45 PM (over 6 elapsed days).No bowel movement from 5/23/26 at 2:45 PM to 5/30/26 at 6:08 PM (over 7 elapsed days).Review of R8's plan of care revealed a focus, initiated 3/6/26, which read, I am at risk for altered elimination of bowel and/or bladder related to limited mobility. R8's plan of care revealed a goal which stated, I will have a normal bowel movement at least every third day. with the following interventions: Follow facility bowel protocol. Provide bowel medication as ordered by physician.On 6/02/2026 at 2:04 PM, an interview was conducted with Licensed Practical Nurse/Unit Manager (LPN/UM) D regarding the facility's bowel protocol. LPN/UM D stated each evening nurse should run a bowel report at the end of their shift and hand it off to their oncoming dayshift replacement. LPN/UM D indicated if a resident does not have a bowel movement for three days, milk of magnesia is administered at noon on the third day. LPN/UM D stated if the resident does not have bowel movement by evening of the third day, a suppository would then been administered. Should the suppository not be effective, LPN/UM D indicated a phosphate enema would then be administered on the following 11:00 PM - 7:00 AM shift.Review of R8's physician orders revealed the following active orders:Milk of Magnesia Suspension 1200 MG [milligrams]/15ML [milliliters]. give 30 ml po [by mouth] at noon for no BM in 3 days, initiated 3/6/26. Dulcolax Suppository (Bisacodyl) Insert 1 suppository rectally as needed for No BM in 3 days, give at hs [at night], initiated 3/6/36.Phosphate Enema 7-19 GM/118ML, give 1 enema rectally on 11-7 shift for no BM in 3 days, initiated 3/6/26.Review of R8's Medication Administration Record (MAR) revealed from 5/4/26 - 6/2/26, the following bowel medications were administered:Milk of Magnesia Suspension: 5/4/26 at 4:24 PM (effectiveness was unknown), 5/23/26 at 8:54 AM (ineffective).Dulcolax Suppository: 5/29/26 at 11:49 AM (ineffective).Phosphate Enema: 5/30/26 at 12:17 PM (effective).On 6/03/2026 at 8:45 AM, an interview was conducted with the Director of Nursing (DON) who validated concerns regarding noncompliance with R8's bowel protocol including failure to initiate the protocol timely and failing to follow the protocol per facility policy.Review of the facility policy titled, Bowel Management Program, revised 5/4/26, read, in part: .Step 1: At noon the Resident will be given Milk of Magnesia (MOM) as ordered or have a physician's order to hold the medication. The nurse will document the medication in the Residents EMR.Prior to the end of the Day Shift nurse reporting off to the next shift, She will review if the Milk of Magnesia was effective and document the results in [EMR] for the follow up prn [as needed] charting. If the Resident has not had a BM the nurse will report to the next shift nurse. 5. Step 2: Completed at HS: Evening shift nurse will review all Residents who were given Milk of Magnesia without results and proceed to second step of Bowel Protocol. A Dulcolax suppository will be given and documented in the Resident's EMR, unless a physician's order has been obtained to hold the medication. 6. The evening shift nurse will review the results of the Dulcolax suppository. If the suppository is ineffective, the nurse will document the results in the EMR and initiate step 3 of the bowel protocol. 7. Step 3 of Bowel Protocol: Completed prior to resident rising in the am: If the resident does not have a BM recorded after receiving Step Il and Step 2 of the bowel protocol, a Fleets enema will be given per Resident's orders, unless a physician's order has been obtained to hold the medication. 8. The Night shift nurse will record the results of the Fleets enema in the Resident's EMR- If there is no BM after the Fleets enema, Physician notification is required.

Based on interview and record review, the facility failed to consistently implement standards of practice and follow policy and procedures for narcotic reconciliation for 1 of 6 medication carts. Findings:On 06/02/26 at 7:05 AM, a review of the narcotic book for the medication cart on Sunflower unit revealed a Fentanyl Patch Proof of Use Form for the resident in room [ROOM NUMBER]-1. The entries dated 05/22/26 at 10:04 AM and 05/31/26 at 1:00 PM only had one nurses signature. On 06/02/26 at at 8:15 AM, a review of the same narcotic book on the Sunflower unit and the Fentanyl Patch Proof of Use Form for the resident in room [ROOM NUMBER]-1 revealed that the entry dated 05/31/26 at 1:00 PM now had two nurses signatures on it. During an interview on 06/02/25 at 8:25 AM, Registered Nurse (RN) B stated that she had signed the Fentanyl Patch Proof of Use Form this morning for the resident residing in room [ROOM NUMBER]-1 and for the entry made on 05/31/26, without witnessing the destruction of the Fentanyl patch on 05/31/26. During an interview on 06/02/26 at 8:34 AM, Licensed Practical Nurse (LPN) C indicated that signing a proof of use form for the destruction of a Fentanyl patch without witnessing the destruction of the patch was not a standard of practice and was something that she would never do. Review of the facility policy and procedure Narcotic Pain Patch reflected .the used (fentanyl) patch will be disposed of by the nurse removing the patch and another nurse verifying the destruction of the patch.

Based on observation, interview, and record review, the facility failed to update and implement care plan interventions for 2 residents (R2 and R6) of 3 residents reviewed for accidents and falls. Findings: R2Review of an admission Record revealed R2 initially admitted to the facility on [DATE] with pertinent diagnoses which included Parkinson's disease, dementia, delusional disorders, and hallucinations. Review of a current risk for falls Care Plan intervention for R2, initiated 12/12/2024, directed staff that R2 required a DPM mattress (a specialized mattress with edges or bolsters) to help define edges of R2's bed. Upon further review of R2's risk for falls Care Plan intervention initiated on 3/15/2021, it directed staff that R2 had a sign on his walker to remind him to use the walker when he ambulated. In an observation and interview on 6/2/2026 at 12:24 PM, Licensed Practical Nurse/Unit Manager (LPN/UM) D reported that R2's interventions that included the DPM mattress and the sign to remind R2 to use his walker were no longer in his room and had been discontinued. LPN/UM D reported she could not recall when those interventions were removed and that R2 no longer used his walker although his walker remained in his room. LPN/UM D reported that she was not sure how updating the fall risk Care Plan was missed. LPN/UM D reported that when R2's fall risk Care Plan is updated, the updated version is placed into R2's closet. In an interview on 6/2/2026 at 12:46 PM, Certified Nursing Assistant (CNA) E was queried how he would receive communication regarding change of fall interventions and he reported he would look at the Care Plan in the closet. R6Review of an admission Record revealed R6 initially admitted to the facility on [DATE] with pertinent diagnoses which included cerebrovascular disease (condition affecting blood flow), dementia, and hypertension. Review of a current risk for fall's Care Plan' intervention for R6, initiated 5/30/2026, directed staff that R6 required a urinary leg bag when up in his wheelchair as R6 would allow. In an observation and interview on 6/2/2026 at 12:24 PM, LPN/UM D reported that R6 had attempted to ambulate from his wheelchair on 5/30/2026 and tripped over his urinary catheter tubing and the intervention for that occurrence had been to direct staff that R6 required a urinary leg bag when he was in his wheelchair as he would tolerate. In an observation and interview on 6/2/2026 at 12:46 PM, R6 was seated in his wheelchair at the table with a catheter bag underneath his wheelchair in a privacy bag. CNA E reported he was not aware that R6's recent fall and intervention for that fall was to attach a urinary leg bag so R6 would not trip over his urinary catheter tubing. CNA E was queried how he would receive communication regarding change of fall interventions for R6 he reported he would look at the Care Plan in the closet. CNA E reported he had not reviewed R6's plan of care prior to assisting him from his bed to the dining room. In an interview on 6/3/2026 at 10:05 AM, the Director of Nursing (DON) reported that the risk for falls Care Plan should have been updated with any new or discontinued interventions to prevent further falls from occurring. DON reported that facility staff are expected to review plans of care prior to assisting residents. Review of facility policy/procedure Fall Prevention Program, reviewed 1/9/2026, revealed .When any resident experiences a fall, the facility will review the resident's care plan and update as indicated.

Based on interview and record review, the facility failed to notify the provider of a change in condition and the withholding of medications for 1 (R15) of 15 residents reviewed. Findings: Resident #15 (R15) Review of an Admission Record revealed R15 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure and Alzheimer's Disease. Review of R15's Orders - Administration Note dated 4/27/25 at 12:13 PM revealed medications were not administered due to, .Unable to arouse. Review of R15's Health Status Note dated 4/27/25 at 10:12 AM revealed, Unable to arouse to give AM medications .Skin slightly moist, color with yellow cast. Sleeping with mouth open .Will continue to observe for any distress or pain. Review of R15's Electronic Health Record revealed no documentation that the provider was notified of R15's change of condition or that her medications were not administered. During an interview on 05/01/25 at 10:18 AM, Assistant Director of Nursing (ADON) M confirmed the provider was not notified of R15's change in condition on 4/27/25. During an interview on 05/01/25 at 12:19 PM, the Nursing Home Administrator (NHA) reported it was the expectation that if the nurse identified a resident has a change in condition or was difficult to rouse the physician and family would be notified immediately. Review of Medication Parameter Education provided by the NHA and ADON on 5/1/25 at 12:19 PM revealed, .In the instance a medication must be held a progress note indicating the vital signs, physician notification and response (including any new orders) as well as resident representative notification with response must be documented .

Based on interview and record review, the facility failed to accurately document the administration of controlled medications and ensure medications were administered following the providers order for 3 (Resident #15, #17, and #32) of 7 residents reviewed for professional standards of nursing practice for medication administration. Findings: Resident #15 (R15) Review of an Admission Record revealed R15 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R15's Order Summary dated 5/9/24 revealed, Cardizem CD Oral Capsule Extended Release 24 Hour 120 MG .Give 1 capsule by mouth in the morning for heart .Hold if SBP (systolic [top number] blood pressure) is less 100 and hr (heart rate) less than 60. Review of R15's Order Summary dated 5/9/24 revealed, Toprol XL Oral Tablet Extended Release 24 Hour 200 MG .Give 1 tablet by mouth in the morning . There were no parameters ordered for this medication. Review of R15's March Medication Administration Record revealed: *Toprol was held (not administered) on 3/5/25, 3/6/25, 3/16/25, and 3/24/25. *Cardizem was held on 3/2/25, 3/3/25, 3/5/25, 3/6/25, and 3/31/25 despite R15's blood pressure and heart rate results within the acceptable range for Cardizem administration. Review of R15's April Medication Administration Record revealed: *Toprol was held on 4/7/25 *Cardizem was held on 4/7/25 and 4/11/25 despite R15's blood pressure and heart rate results within the acceptable range for Cardizem administration. Review of Licensed Practical Nurse (LPN) written statement received on 5/1/25 revealed, On 5/1/25 I receive an education on (R15) .The understanding was wrong. I may have confused diastolic BP for HR (for Cardizem use). When she runs low I hold med. Her normal HR runs very high so I may have associated a lower HR (with) holding med. Review of Assistant Director of Nursing (ADON) M's investigation dated 5/1/25 revealed, Spoke with (LPN F) regarding (R15's) medication order for Cardizem CD not being given due to heart rate parameters. During investigation (LPN F) has documented medication held due to Diastolic blood pressure less than 60. Conversation with (LPN F) revealed that she believes she confused the Diastolic blood pressure with Heart rate . During an interview on 05/01/25 10:18 AM, ADON M reported that parameters would be initiated for R15's Toprol. Resident #17 (R17) Review of an Admission Record revealed R17 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R17's Order Summary dated 2/25/25 revealed, traMADol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 1 tablet by mouth every 12 hours as needed for pain. Review of R17's Controlled Drug Log revealed: *On 3/28/25 a dose of tramadol was dispensed at 5:30 PM and 6:45 AM (date/time out of order indicating the medication was not documented as dispensed at the time it was removed/administered.) Review of R17's March Medication Administration Record revealed no documentation that R17's tramadol was administered on 3/28/25. Review of LPN F's written statement dated 5/1/25 revealed, .March 28 signed out (6:45 AM and 5:30 PM) Not in (electronic medication administration program) . Review of R17's Controlled Drug Log revealed: *On 4/14/25 at 1:10 PM a dose of tramadol was dispensed. *On 4/25/25 at 1:45 PM a dose of tramadol was dispensed. Review of R17's April Medication Administration Record revealed no documentation that R17's tramadol was administered on 4/14/25 and 4/25/25. Resident #32 (R32) Review of an Admission Record revealed R32 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R32's Order Summary dated 1/13/25 revealed, Digoxin Oral Tablet 125 MCG (Digoxin) Give 1 tablet by mouth in the morning for Hold if HR (heart rate) less than 60 and BP (blood pressure) less than 90 systolic (top number). Review of R32's April Blood Pressure Summary and Pulse Summary revealed R32's blood pressure and heart rate were assessed ONLY on 4/2/25, 4/7/25, 4/21/25, and 4/22/25. Indicating vital signs were not assessed prior to the administration of the digoxin. Review of R32's Electronic Health Record revealed no other documentation that R32's blood pressure and heart rate were assessed. Review of R32's Order Summary dated 4/12/25 Diphenoxylate-Atropine Oral Tablet 2.5-0.025 MG Give 1 tablet by mouth two times a day for Bowel Management. To be administered at 8:00 AM and 4:00 PM. Review of R32's Controlled Substance Log revealed: *On 4/24/25 at 9:30 AM, 6:00 PM, and 9:10 AM R32's Diphenoxylate-Atropine was dispensed. *On 4/27/25 at 9:00 AM a dose of Diphenoxylate-Atropine was dispensed. The 4:00 PM dose of Diphenoxylate-Atropine was not documented as dispensed. Review of R32's April Medication Administration Record revealed that on 4/27/25 both the 8:00 AM and 4:00 PM doses of Diphenoxylate-Atropine was documented as administered. Review of LPN F's written statement received on 5/1/25 revealed, 4/25 I signed out med @ 0910 (9:10 AM). I documented it on the wrong date (4/24). I went back to the narc sheet and signed the med @ 0800 (8:00 AM) thinking I missed the sign out. I signed it out twice. 4/27/25 I signed out the same drug (Diphenoxylate-Atropine) in (computerize medication administration program) @ 1600 (4:00 PM) but forgot to sign the narc sheet. Further review of the Controlled Substance Log revealed on 4/25/25 2 doses of Diphenoxylate-Atropine were signed out (dispensed) at 8:00 AM and 6:30 PM. Indicating the additional dose of Diphenoxylate-Atropine documented on 4/24/25 was not incorrectly dated/timed for 4/25/25 or a 3rd dose of Diphenoxylate-Atropine was administered on 4/25/25. Additionally, the quantity remaining column indicated a dose was dispensed on each of the dates/times listed on 4/24/25 and 4/25/25. The quantity remaining column indicated only 1 dose was dispensed on 4/27/25 (The quantity remaining on 4/27/25 at 9:00 AM was 4 and on 4/28/25 at 9:00 AM the quantity remaining was 3). During an interview on 05/01/25 at 10:18 AM, ADON M reported that the digoxin order would be modified to require supplemental documentation (blood pressure and heart rate) prior to the administration of the medication. During an interview on 04/30/25 at 08:30 AM, LPN F reported that parameters are found within the medication order. LPN F reported that the computer (electronic medication administration program) would prompt for supplemental documentation such as blood pressure or heart rate. During an interview on 05/01/25 at 07:53 AM, LPN L reported that if parameters are ordered for medications, it would be included in the order summary and reviewed prior to medication administration. LPN L reported that the computer would prompt the nurse to input the vital sign results. During an interview on 05/01/25 at 10:18 AM, ADON M and Nursing Home Administrator (NHA) reported that 1:1 education was provided to LPN F on the rights of medication administration. ADON M reported all licensed nurses would receive education on medication administration to ensure compliance with professional standards of nursing practice with medication administration. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, (Nurses) are also responsible for documenting any preassessment data required with certain medications such as a blood pressure measurement for antihypertensive medications or laboratory values, as in the case of warfarin, before giving the medication. After administering a medication, immediately document which medication was given on a patient's MAR per agency policy to verify that it was given as ordered. Inaccurate documentation, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about patient care. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 643-644). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, The seven rights of medication administration include the right medication, right dose, right patient, right route, right time, right documentation, and right indication. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 705). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview and record review, the facility failed to follow policy and procedures, monitor and assist 1 (Resident #18) of 4 residents reviewed for accidents and hazards, related to toileting, and implement meaningful care plan interventions that are re-evaluated for the effectiveness. Findings include: Resident #18 (R18) Review of a Face Sheet revealed R18 admitted [DATE] with pertinent diagnoses of Alzheimer's disease, dementia, muscle weakness and reduced mobility. Review of the Minimum Data Set (MDS) dated [DATE] revealed R18 was severely cognitively impaired and required partial/moderate assistance with toilet transfers and needed substantial/maximal assistance with walking 10 feet. During an observation on 5/6/24 at 11:40 AM, R18 was observed in his bathroom sitting in his manual wheelchair and transferring himself to the toilet with the room door and the bathroom door open with no privacy barrier. When R18 finished toileting, he stood up at the sink and brushed his teeth, then sat back down in the wheelchair and self-propelled further into his room. During an observation on 5/6/24 at 2:10 PM, R18 was in his room and self-propelled to the bathroom in his wheelchair and transferred himself to the toilet. When he finished toileting, he stood up at the sink to wash his hands and sat back down in the wheelchair. During an observation on 5/7/24 at 1:00 PM, R18 was in his room and self-propelled himself to the end of the bed that was against the wall near the window. R18 stood up and walked over to the window to close it and then walked back to his wheelchair. He was visiting with his wife and when asked if he remembered this surveyor from the day before, he said no. During an observation and an interview on 5/8/24 at 9:00 AM, R18 was sitting reclined in his recliner with the padded call light that was observed hanging on the wall out of reach from the resident. The second call light was observed wrapped around the enabler bar (a bar attached to the bed that a resident uses to assist in turning in bed) on his bed across the room. R18 did not remember this surveyor from the day before and said he does not remember things. When asked, he did not know where his call light was or how to ask for help if needed. R18 reported when he must use the bathroom, he just goes by himself. There was a sign in his room on the wall to remind him to use the call light. In an interview on 5/8/24 at 10:44 AM, the Assistant Director of Nursing (ADON) B reported the care plan is in the residents' rooms inside the closet doors for the staff to reference when caring for the residents. She did not know the current ambulatory status for R18 and reported she would have to reference the care plan to know how the resident would transfer and other care needs. At 1:26 PM, the ADON B reported there was not a system to evaluate interventions put in place after a resident has a fall to see if they were effective. Review of the following incident reports for R18 revealed: -1/25/24 at 7:20 PM- Resident had called out for help while attempting to self-transfer in the bathroom from the toilet to his wheelchair and was lowered to the floor. He was alert to self only. The care plan was revised to reflect a touch pad call light and a therapy request for commode over the toilet. No documentation when the resident was last toileted or offered toileting. -1/27/24 at 7:40 AM, Resident had an witnessed fall when he was found on the floor in his room facing the bathroom and incontinent of urine. New intervention was to encourage toileting (check/change) every two hours. No post fall neuro-checks (neurological checks) done. No documentation when the resident was last toileted or offered toileting. -1/27/24 at 2:50 PM, Resident had an unwitnessed fall near his bathroom and was incontinent of bowel and bladder. His bathroom call light had been activated by the housekeeper. He was oriented to self only and was ambulating with a walker. New intervention was to not leave unattended to finish my business. I forget to wait for you after I call you for assistance back to my previous activities. -2/12/24 at 10:40 PM, Resident had and unwitnessed fall near the bathroom and found on the floor with the wheelchair brakes unlocked and was incontinent. He was oriented to self only. Interventions included anti-rollback device was added and reminders given to use the call light and wait for staff assistance. The last care provided was at 10:10 PM for medication pass. -2/19/24 at 9:35 AM- Resident had an unwitnessed fall in the bathroom and the restroom call light was on. New intervention was to refer to optometry for possible depth perception difficulties for corrective lenses and signs with reminders to pull call light/call string and wait for assistance in bathroom and near bed [related to] short term memory impairment. He was last toileted approximately 7:30 -7:45 AM before breakfast. -3/20/24 at 8:00 AM- Resident had an unwitnessed fall near his bathroom when he stated he was trying to toilet himself. He was oriented to self only. The bathroom was dark and an intervention for a night light in the bathroom was implemented. No documentation when the resident was last toileted or offered toileting. Review of a I am a high risk for falls [related to] confusion, deconditioning, gait/balance problems, impulsiveness, muscle weakness, urinary incontinence care plan last revised 1/27/24 revealed interventions that included: -High fall risk, initiated 1/24/24. -Alternate call light pendant-I may forget to use my call light. Please anticipate my needs. Initiated 1/24/24. -Anti-roll backs to wheelchair. Initiated 2/13/24. -Anticipate and meet the elder's needs. Initiated 1/24/24. -Encourage toileting (check/change) every two hours and as needed. Initiated 1/27/24. -Ensure that I am wearing appropriate footwear grip socks/nonskid shoes when ambulating or propelling wheelchair. Initiated 1/24/24. -Follow facility fall protocol. Initiated 1/24/24. -I require a safe environment with a room free from clutter, adequate lighting, call light within reach and personal items within reach. Initiated 1/24/24. -Night light in bathroom. Initiated 3/20/24. -Offer toileting prior to bed for the night. Initiated 2/13/24. -Once assisted into the restroom, please do not leave me unattended as I forget to wait for assistance. Initiated 1/27/24. -Refer to optometry for possible depth perception difficulties and/or need for corrective lenses. Initiated 2/19/24. -Signs with reminders to pull call light/call string and wait for assistance in bathroom and near bed [related to] short term memory impairment. Initiated 2/21/24. -Touch pad call light. Initiated 1/25/24. Review of the Activities of Daily Living (ADL) Care Plan for R18 revealed: -ORAL CARE ROUTINE [morning, after meals, night]: I have my own teeth. Supervision/touching assist with cuing to brush teeth, rinse mouth with wash. Initiated 1/24/24. -TOILET USE- The resident requires part/mod (partial/moderate) assist with toileting hygiene and transfer. Please encourage me to toilet approx. every 2-4 [hours]. I will attempt to self-transfer to toilet. Initiated 1/24/24. -TRANSFER: The resident requires sub/max (substantial/maximum) assist for transfer from bed to chair. Initiated 1/24/24. -Encourage the resident to use bell to call for assistance. Initiated 1/24/24. Review of a policy titled Fall Prevention Program last revised 2/5/24 revealed: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . -5. Low/Moderate Risk Protocols: .iii. Call light and frequently used items are within reach. Iv. Adequate lighting. b. Implement routine rounding schedule. -6. High Risk Protocols: a. The resident will be placed on the facilities Fall Prevention Program . b. Implement Interventions from Low/Moderate Risk Protocols. c. Provide additional interventions as directed by the resident's assessment, including but not limited to . ii. Increased frequency of rounds vii. Scheduled ambulation or toileting assistance. Review of a Nursing-Post Fall Evaluation policy last revised 3/9/21 revealed To provide for ongoing evaluations of causative factors or potential factors that may lead to our elders falling or having a significant injury related to a fall. Should a fall occur witnessed or unwitnessed the following will occur: Post Fall Review: Root cause analysis of all falls will be completed by the interdisciplinary team to determine the cause of the fall and interventions will be put in place that addresses the root cause of the fall. Interventions will be re-evaluated to determine effectiveness, at regular intervals (post fall, readmission, significant change, and quarterly with MDS). Review of a Plan of Care Progress Note dated 1/26/24 for R18 revealed: Resident has impaired balance, weakness presence, cognition fluctuations, impaired processing time, and is impulsive. Goals are or resident to be independent with cuing for all ADLS for him to return home. However, therapy unsure if resident will be able to meet current goals. Discussed fall history. Wife stated it is hard to judge how many times he has fallen as sometimes it was daily and sometimes we would go a period of time with no falls. Falls were associated with resident ambulating and R leg would freeze, then he would continue to attempt to ambulate, legs would give out. Also attributed to resident having cognition fluctuations and being impulsive. Forgetting to use walker as well. Review of a IDT (Interdisciplinary Team) Intervention Review progress note dated 1/30/24 for R18 revealed: IDT met to discuss resident's progress with therapy. Physically able to independently dress self, toilet, ambulate. However, impulsive and cognition fluctuates. CGA to min assist for transfers. Processing delayed and needs cuing for standing. Sequencing issues present. Lack of carryover. Cont to work on balance, strengthening, fall risk reduction, how to get up from falls. (sic) Review of a Health Status Progress Note dated 2/4/24 for R18 revealed: Unable to maintain sitting position while sitting on bed. Assist x 1 for transfer from bed to w/c. Requires staff assist for propel w/c. Transfers self randomly and unable to maintain balance and falls. Review of an IDT Intervention Review Progress Note for R18 dated 2/13/24 revealed: IDT met to discuss resident's progress with therapy. Currently at highest potential for skilled therapy. Will be transitioning to restorative program for strengthening and reciprocal training. High fall risk. Review of a Health Status Progress Note for R18 dated 2/19/24 revealed: Elder frequently noted self-transferring without seeking staff assistance while utilizing assistive devices. Receptive to staff assistance. Elder is unreceptive to education. However, due to his dementia his retention is limited. Staff continues education reinforcement prior to ending all interactions, if appropriate. Review of an IDT Intervention Review Progress Note for R18 dated 2/20/24 revealed: IDT met to discuss resident's skilled therapy ending. Wife had concerns about resident receiving services as he just had falls. Has met goals with therapy and will be transitioned to restorative therapy program. Wife informed of therapy program plan, verbalized understanding with [NAME] specialist.

Based on observation, interview, and record review, the facility failed to ensure that an insulin pen was labeled with the resident's name for 1 of 2 medication carts inspected (C Wing Medication Cart), resulting in the potential for residents to receive insulin from another resident's insulin pen and the potential for the spread of disease. Findings include: During an inspection of the C Wing Medication Cart with Licensed Practical Nurse (LPN) F on 05/06/24 at 5:40 PM, a previously used Humalog insulin pen without a resident's name on it was observed in an unlabeled slotted compartment in the top drawer of the medication cart with other insulin pens. The other insulin pens in the unlabeled slotted compartment were labeled with R6's name on them. LPN F stated insulin pens should be labeled with the resident's name and the date it was first used and date it is supposed to be discarded. She stated she keeps the insulin pens together in a slotted compartment in the top drawer for each individual resident. LPN F stated that was how she knew that the Humalog pen belonged to R6 and not another resident, even though it did not have R6's name on it. She stated otherwise she would not know whose insulin pen it was. LPN F further stated there was another resident that had a Humalog pen in the C Wing Medication Cart along with R6 and if R6's Humalog pen was not in the slotted compartment with his other insulin pens she would not know for sure if it was his pen or the other resident's. During an interview on 05/07/24 at 7:45 AM, Registered Nurse (RN) G stated if she found a previously used insulin pen without a resident's name on it, she would get another one from the medication refrigerator if she did not know who the pen belonged to. RN G was asked if the insulin pen was not labeled with a resident's name, how would she know whose it was? RN G just stared at the surveyor and could not provide an answer to the question. RN G also stated that she had not ever come across an insulin pen without a resident's name on it because it always comes with a label [on it] from the pharmacy with a resident's name on it. During an interview on 5/07/24 at 8:15 AM, LPN H stated insulin pens come from the pharmacy with a label on them that contains the resident's name. She stated the only time an insulin pen would not have a label with the resident's name on it would be if the insulin pen was pulled from the medication back-up box. LPN H stated if she pulls an insulin pen from the medication back-up box, then she would label the pen with the resident's name and the date it was opened and/or the discard date. LPN H stated if she finds an insulin pen without a label or a resident's name on it, then she would throw it away because she would not know who the pen belonged to. LPN H further stated she would not want to take a chance that she would give a resident another resident's insulin. A review of the facility's Labeling of Medications and Biologicals policy, dated 12/1/23, revealed, All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications . 4. Labels for individual drug containers must include: a. The resident's name . 9. Labels for medications designated for multiple administrations (such as inhalers, eye drops), the label will identify the specific resident for whom it was prescribed .

This citation refers to MI00139660. Based on interview and record review, the facility failed to maintain complete, timely, and accurate medical records for 3 of 5 residents (R2, R3, and R5), resulting in incomplete medical records, inaccurate medical records, multiple late entries in the medical records, and the potential for providers not having an accurate and complete picture of the resident's stay at the facility. Findings include: Inaccurate and Incomplete Medical Records R3 A review of R3's Admission Record, dated 11/21/23, revealed R3 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's Admission Record revealed multiple diagnoses that included late onset Alzheimer's Disease and dementia with psychotic disturbance. A review of R3's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 10/31/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 4 which indicated R3 was severely cognitively impaired. A review of R3's progress notes, dated 5/30/23 to 7/30/23, revealed the following: - Behavior Note, dated 6/18/23, revealed, Elder sits in hall waiting for another resident to come out of his room and if she sees him she follows him around saying things like we are sleeping in the same room tonight and I know he is not married, etc. She has started to talk dirty (sexual) to him. She goes into this resident's room and will not leave. She is making him feel threatened and he is trying to keep away from her. No matter where he goes she is following and butting into his conversation and actions. She appears to be almost stalking him. We have intervened several times and have helped the other resident to leave his room and the floor without her. We have put [name of R3] out by the nurses station and given her coffee and ice cream to distract her. [Name of R3] does not understand reason. - COMMUNICATION - with Resident, dated 6/19/23, revealed, Note Text: Writer attempted to meet with elder in elders room for follow up visit after note r/t elder approaching and speaking to another elder. Elder was in the life enrichment room completing a craft activity. Elder was sitting at a table with the other elder. Writer observed their interactions for approximately ten minutes. Elders were engaging appropriately in conversation, no distress noted for either elder. During an interview on 11/21/23 at 1:50 PM, Registered Nurse (RN) D stated R3 has flirted with R2. She stated R2 did not appreciate it and tried to get away from R3. RN D stated R2 was cognitively intact so he could tell when R3 was flirting with him and he could say he did not want her near him. RN D stated R3 kept flirting with him even though he did not like it. RN D stated they moved R2 to C or D Hall to get him away from R3 per his request. RN D stated she was told R2 did not like the new room, so they moved him back to the Sunflower unit, but put his room farther away from R3's. It must have worked. I haven't heard him complaining about her. She must have forgotten about him. RN D stated R3 had never been in R2's bed. She stated R3 only flirted with R2. RN D stated she was not aware of any instances where R3 was found in any other residents' beds or had sexual relations with them. During an interview on 11/22/23 at 8:05 AM, Social Worker (SW) F stated R2 was the resident that R3 was waiting in the hall for and the resident that she was making dirty (sexual) comments to on 6/18/23. During an interview on 11/22/23 at 9:30 AM, Certified Nursing Assistant (CNA) G stated she knows R3 will seek out people to sit and talk with her. She stated R3 wants people to sit with her and hold her hand. CNA G stated R3 is not really physically aggressive, just needy. She stated she is not aware of any incidents where R3 had jumped into male residents' beds or tried to be intimate with them. R2 A review of R2's Admission Record, dated 11/21/23, revealed R2 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 2's Admission Record revealed multiple diagnoses that included multiple sclerosis, dementia, and expressive language disorder (difficulty verbally expressing ideas and thoughts). A review of R2's MDS, dated [DATE], revealed a BIMS score of 11 which indicated R2 was cognitively intact. During an interview on 11/21/23 at 9:15 AM, R2's spouse stated the facility called her the Friday before the Fourth of July (6/30/23). She stated they told her that they wanted to move R2 to another room on a different unit (from Sunflower Unit to the C Hall) because he visited frequently with his friends on that unit and they felt if they moved him it would better for him, and easier for him to socialize. She stated she was ok with the move. R2's spouse stated when she came in that weekend to visit with R2, she learned from the staff that the reason why R2 was moved was because he and another resident (R3) were in a relationship and the staff wanted to separate them. She stated she was told that they (R2 and R3) had been caught in bed together, but nothing happened. R2's spouse stated talking to the nurses over the weekend she learned that R3 had been hitting on R2 and other men on her unit. She stated staff told her that they did not know why R2 was moved when R3 was the aggressor. R2's spouse stated she was furious when she heard this and that no one had informed her when this had occurred. I'm his guardian and wife and should have been told. R2's spouse stated on Wednesday, 7/5/23, she called the Nursing Home Administrator (NHA) and told her she wanted R2 moved back to his former unit and room because she had been lied to about the move. She stated the facility moved R2 back to his former unit (Sunflower), but to a different room because his previous room had already been taken. She stated she met with the NHA and Director of Nursing (DON) with the Ombudsman and they talked about what had happened. R2's spouse stated because she was lied to, she does not feel that she can trust the facility. She also stated that when she spoke with the NHA and DON, they denied having knowledge of any relationship between R2 and R3. However, facility staff told her they definitely knew. R2's spouse also stated that R2 was currently in the hospital because he had been on a leave of absence with her yesterday and had not felt well. She stated she called an ambulance and he was taken to the emergency room . R2's spouse stated he was going to have gallbladder surgery. Therefore, R2 was not available for an interview during the investigation. A review of R2's progress notes, dated 6/1/23 to 8/1/23, revealed the following: - COMMUNICATION - with Resident, dated 6/19/23, revealed, Writer met with elder in elders room for check in visit. Elder was in good spirits at the time of this interaction. Elder reported no concerns with his care or interactions with other elders. Writer inquired if elder felt bothered by or threatened by another elders to which he replied no. Elder denied fear and/or anxiety. Writer inquired if elder has had anyone speak to him inappropriately, elder denied this. Elder asked why writer was asking. Writer informed him writer just wanted to make sure he was happy and felt safe in this facility. Elder stated I am happy here. No other questions or concerns discussed at this time. - COMMUNICATION - with Family/NOK/POA (Next of Kin/Power of Attorney), dated 6/30/23, revealed, Spoke to [name of R2's spouse] today via phone regarding a room change to [room number on a different unit]-private room. [Name of R2's spouse] stated that she was fine with the room move and stated I know he will adjust . - COMMUNICATION - with Family/NOK/POA, Late Entry: 7/18/23 for 7/6/23 (written 12 days after the event), revealed, Writer received call from [name of R2's spouse] requesting elder be moved back up to the Sunflower unit. [Name of R2's spouse] expressed concerns with the new room and the view. Elder has not expressed any concerns. Writer and [name of R2's spouse] did discuss that elder was moved to D-wing for increased interaction with male elders as well as due to another female elder believing elder is her boyfriend. [Name of R2's spouse] stated she was not concerned about the other female elder and wanted elder back on the Sunflower unit. [Name of R2's spouse] was offered for elder return to [R2's previous room number] as well as [a different room number on the same unit] as elder has been enjoying the close proximity to other male elders on the D wing over the weekend and [the different room that the previous room] is close to another male elders room. [Name of R2's spouse] agreed to [the different room than R2's previous room on the same unit] instead of return to previous room .Elder to move to [different room on same unit as previous room] today. During an interview on 11/22/23 at 8:05 AM, Social Worker (SW) F stated she was not at the facility when R2 was moved. She stated her understanding was on 6/30/23 R3 went into R2's room, sat down next to him, and put her hand on his thigh in a comforting manner. She stated the team moved R2 to Daffodil unit because they felt it would be better to move R2 away from R3. SW F also stated the move to Daffodil unit made sense since R2 associates with the male residents on the Daffodil unit almost every day. SW F stated she received a call on 7/5/23 from R2's spouse and responsible party saying they did not like view from the room and wanted R2 moved back to the Sunflower unit. She stated she offered to move R2 back to his original room or another room. SW F stated she told R2's spouse that the other room would be closer to the male residents that he spends time with and farther away from R3. SW F stated R2's spouse opted for the room farther away from R3. SW F further stated there was one other interaction between R2 and R3 where R3 was following R2 throughout the unit and made advances toward him. She stated she did a follow-up visit with both of them because when she read the note about R3 following R2, she felt, based on the note in R3's progress notes, that R2 may have felt threatened by R3. However, when she followed up with him, he stated he did not feel threatened by anyone and did he did not recall R3 following him around. During the interview on 11/22/23 at 8:05 AM, SW F reviewed R2's progress notes and verified that there was not a note regarding the interaction between R2 and R3 in his progress notes or medical record. She stated there should have been one. SW F also stated she was not aware of any other interactions of a sexual/intimate nature between R3 and other residents. SW F stated whenever there is an incident between two residents, then the incident should be documented in both residents' medical records. SW F also stated that incidents, notifications, assessments, observations, physician visits, etc., should be documented as so as possible after they occur. She stated she would think within twenty-four hours would be acceptable, but no more than 2 or 3 days later. During an interview on 11/22/23 at 9:30 AM, CNA G stated she was not aware of any incidents where R3 had jumped into male residents' beds or tried to be intimate with them. A further review of R2's progress notes, dated 6/1/23 to 8/1/23, failed to reveal that R3 had been following R2 around saying things like we are sleeping in the same room tonight and I know he is not married, etc. R2's progress notes also failed to reveal that R3 was talking dirty(sexual) to R2, that R3 went into R2's room and would not leave, that R3 was making R2 feel threatened and R2 was trying to keep away from R3, that no matter where R2 went R3 would follow and butting into his conversation and actions, and that R3 appeared to be almost stalking R2. In addition, R2's progress notes failed to reveal that he had requested a room change to get away from R3. Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care . High quality documentation, however, is a necessary and integral aspect of the work of registered nurses in all roles and settings . (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org). Late Entries R2 A review of R2's progress notes, dated 8/21/23 to 11/21/23, revealed the following additional late entries: - Communication- with Family/NOK, POA, dated 10/13/23 for 10/5/23 (8 days after the event), which revealed that R2 had been tested for COVID-19 with a rapid antigen test due to an outbreak/possible exposure. - Physician Progress Note, dated 11/21/23 for 11/6/23 (15 days after the event), which revealed the physician had seen R2 for a routine follow up visit and he had been feeling well overall. R3 A review of R3's progress notes, dated 8/21/23 to 11/21/23, revealed the following late entries: - Physician Progress Note, dated 9/26/23 for 9/11/23 (15 days after the event), which revealed the physician had seen R3 for a routine follow up visit and R3 did not have any concerns or issues. - Communication- with Family/NOK/POA, dated 10/13/23 for 10/5/23 (8 days after the event), which revealed that R3 had been tested for COVID-19 with a rapid antigen test due to an outbreak/possible exposure. R5 A review of R5's Admission Record, dated 11/21/23, revealed R5 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R5's Admission Record revealed multiple diagnoses that included Alzheimer's Disease. A review of R5's MDS, dated [DATE], revealed a BIMS score of 3 which indicated R5 was severely cognitively impaired. A review of R5's progress notes, dated 8/21/23 to 11/21/23, revealed the following late entry: - Physician Progress Note, dated 8/31/23 for 8/21/23 (10 days after the event), which revealed the physician had seen R5 for a routine follow up visit and R5 did not have any issues or concerns. During an interview on 11/22/23 at 9:15 AM, the NHA stated the facility does not have a policy regarding timeliness of documentation. She stated if staff are going to document a late entry, she would expect that they document it by the next day, but no later than three days later depending on if it is a weekend or holiday. The NHA stated anything documented more than a week would not be acceptable and could be interpreted as suspicious or questionable. Timely documentation of the following types of information should be made and maintained in a patient's EHR to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care . Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org).

Based on interview and record review, the facility failed to operationalize policies and procedures to assess, monitor, document, and notify physician for 1 (Resident #17) who reported she had two wounds that were not reflected in her medical records. Findings include: Review of a policy titled Skin Assessment implemented on 3/14/22 revealed: it is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Review of a policy titled Wound Treatment Management implemented 3/14/22 revealed: To promote wound healing of various types of wounds, it is policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Review of a policy titled Pressure Injury Prevention and Management last revised 9/27/22 revealed: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Resident #17 (R17) Review of a Face Sheet for R17 revealed she originally admitted to the facility on [DATE] and has pertinent diagnosis of sepsis, myasthenia gravis and chronic disease. In an interview on 4/18/23 at 10:00 AM, R17 was in bed and reported she has sores on her side and her bottom and did not have any dressings on them. In an interview on 4/19/23 at 10:21 AM, R17 was in bed and reported the nurse applied a new salve on her sores this day. The resident reported this surveyor can look at her wounds the next time care is provided for her. In an interview on 4/19/23 at 10:25 AM, Licensed Practical Nurse (LPN) G reported R17 has a stage II pressure ulcer on her right cheek and some excoriation in her butt crack and these were not new. When she came back from the hospital in February, her skin was not good. When queried where her skin assessments were, LPN G reported the skin assessments are documented on paper and then get put into a box where the Assistant Director of Nursing collects them and reviews them. LPN G reported physicians get notified of concerns by the communication book and at this time there were no concerns in the book for R17. Review of the Electronic Medical Records (EMR) on 4/19/23 for R17 revealed the last skin assessment documented was on 3/16/23. Review of an Admission Skin assessment dated [DATE] for R17 revealed she had some redness on her buttocks and no open wounds. Review of a Weekly Elder Assessment Screen document for R17 dated 3/16/23 revealed no abnormal skin assessment. In an interview on 4/19/23 at 10:48 AM, the Director of Nursing (DON) reported R17 should have skin assessments in the computer under the miscellaneous tab and verified that the last documented assessment was on 3/16/23. The DON reported she was unaware of medical records being backlogged on scanning in documents and was going to check to make sure. In an interview on 4/19/23 at 11:17 AM, LPN I and Unit Manager told this surveyor R17 changed her mind and did not want this surveyor to look at her wounds after several staff had left her room. In an interview on 4/19/23 at 12:03 PM, the DON reported she did not have any skin assessments for R17 and thought that another staff member may have them or LPN I. When questioned about how staff can provide continuity of care if there is no accessible documentation readily available for them to review, the DON reported she did not understand the question. The DON reported they have both paper charting and electronic charting. When asked what is charted on paper, the DON reported skin assessments and consents are on paper that get scanned into the electronic medical record. Review of the Treatment Administration Record (TAR) and orders for R17 revealed no orders or treatments for wounds until 4/19/23 when an order for Z Guard to buttocks twice daily and as needed was ordered. An order for weekly skin checks ordered on 2/16/23 revealed in April the skin checks were documented as done on 4/6/23 and 4/13/23. Review of the Progress notes for R17 revealed no mention of the resident having wounds or pressure ulcers. A Medical Practitioner note on 4/10/23 reveals no mention of the resident having any wounds or pressure ulcers. Review of the Care Plan for R17 revealed there is no focus for pressure ulcers. Review of a computer-based Skin assessment dated [DATE] (the last day of this survey), revealed R17 has a Stage II pressure ulcer on her right ischial tuberosity that is a new, in house acquired with no exact date of onset. It measured 0.7 centimeters (cm) X 0.9 cm X 1.0 cm and a depth of 0.1 cm. Another Skin Assessment was initiated for R17 on 4/20/23 but not completed.

Based on observation, interview, and record review, the facility failed to (a) maintain security measures to ensure controlled substances were double locked, and (b) periodically check medication storage locations for outdated medication and nutritional supplement supplies, for 1 of 2 medication storage rooms, resulting in the potential for misappropriation of controlled substances and administering medications beyond the expiration date with a possible decreased efficacy of the medication. Findings include: During an observation on [DATE] at 2:50 PM, the following were noted in the medication storage room for units C and D. (A) the refrigerator that contained medications/controlled substances was not locked, (B) inside the refrigerator, the red tray that contained the medications/controlled substances was not locked or secured to the inside of the refrigerator and could be removed, (C) three bottles of over-the-counter medications, i.e.( Tylenol, laxative, anti-diarrhea) were expired, and (D) twelve bottles of Jevity 1.5 (used to provide nutrition for someone with a tube feed) were expired. During an interview on [DATE] at 3:00 PM, Unit Nurse Manager G indicated that (a) the medication refrigerator in the medication storage room for units C and D should be kept locked, (b) the red tray that contained the medications/controlled substances should be kept locked, and (c) that nursing staff were responsible to periodically check over-the-counter medications and nutritional supplements for expiration dates. Review of a facility policy Controlled Substance Administration & Accountability, last reviewed [DATE], reflected .The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure .controlled substances are stored under double lock until administered. Review of a facility policy Storage of Medications, last reviewed [DATE], revealed .The facility shall not use discontinued, outdated, or deteriorated drugs or biological's.

This citation pertains to intake: MI 682 Based on observation, interview and record review, the facility failed to 1.) provide care following professional standards of practice and facility policy to prevent the development of avoidable pressure ulcers, 2.) accurately stage resident pressure ulcers, and 3.) promptly identify and provide necessary treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in the development of an unstageable pressure ulcer and likely [CONDITION(S)] for R32. Additionally, this deficient practice placed all residents residing in the facility at risk for the development of avoidable pressure ulcers, the delay in wound treatment, the potential for delayed wound healing, infection, and the high likelihood for overall deterioration in health status. Findings include: Review of the facility policy Documentation of Wound Treatments implemented 3/8/22 revealed, The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Policy Explanation and Compliance Guidelines: 1. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. 2. The following elements are documented as part of a complete wound assessment: a. Type of wound (pressure injury, surgical, etc.) and anatomical location. B. Stage of the wound, if pressure injury (stage 1, 2, 3, 4, deep tissue injury, unstageable pressure injury) . c. Measurements; height, width, depth, undermining, tunneling. d. Description of wound characteristics: i. Color of the wound bed ii. Type of tissue in the wound bed (i.e., granulation, slough, eschar, epithelium) iii. Condition of the per-wound skin (dry, intact, cracked, warm, inflamed, macerated) iv. Presence, amount, and characteristics of wound drainage/exudate v. Presence of absence of odor vi. Presence or absence of pain 3. Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift (i.e., clean, dry, intact). 4. Additional documentation shall include, but is not limited to: a. Date and time of wound management treatments. b. Weekly progress towards healing and effectiveness of current intervention c. Any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Notifications to physician and/or responsible party regarding wound or treatment changes Review of the facility policy Pressure Injury Prevention and Management implemented on 3/14/22 revealed, .5. Monitoring a. The Licensed nurse, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record . Review of the facility SKIN & WOUND CARE GUIDELINE revealed, .Unstageable Pressure Ulcers Necrotic Wounds-Unstageable-Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Further Description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and therefore stage, cannot be determined . Review of the NCBI (National Center for Biotechnology Information) article, [CONDITION(S)] revealed, Bone infection is called [CONDITION(S)]. It is an acute or chronic [CONDITION(S)] process involving the bone and its structures secondary to infection with pyogenic organisms, including bacteria, fungi, and mycobacteria . The bone becomes susceptible to disease with the introduction of a large inoculum of bacteria, from trauma, ischemia, or the presence of foreign bodies because bone sites to which microorganisms can bind are exposed . Contiguous [CONDITION(S)] frequently develops in debilitated patients who are wheelchair or bedbound and are predisposed to pressure-related skin ulcerations, especially in the sacrum, buttock, hips, and heel. Momodu II, Savaliya V. [CONDITION(S)]. [Updated 2022 [DATE]]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK 0/ Review of the Fundamentals of Nurse (Potter and Perry) revealed, When you identify the presence of a skin wound or pressure injury, closer assessment is required. Assess the type of tissue in the wound base so that you can plan appropriate interventions. The assessment includes the amount (percentage) and appearance (color) of viable and nonviable tissue. Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and it must eventually be removed by a qualified clinician or by an appropriate wound dressing before the wound is able to heal. Black, brown, tan or necrotic tissue is eschar, which also needs to be removed before healing can occur . Assessment of wound exudate should describe the amount, color, consistency, and odor of wound drainage. Excessive exudate indicates the presence of infection. Wound pain, including the location, distribution, type, quality and intensity, and any aggravating or relieving factors, also should be assessed ([NAME], 2016). Examine the skin around the wound (periwound) for redness, warmth, and signs of maceration, and palpate the area for signs of pain or induration. The presence of any of these factors on the periwound skin indicates wound deterioration. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 1247). Elsevier Health Sciences. Kindle Edition. Resident #32 (R32) Review of an Admission Record revealed R32 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: heart failure, respiratory failure, and cancer. Review of an Admission Minimum Data Set (MDS) assessment for R32, with a reference date of 2/1/22 revealed: Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated R32 was cognitively intact. Functional Status revealed that R32 required extensive 2 persons physical assist for bed mobility, total dependence of 2 persons for transferring and toileting, and total dependence of 1 person for personal hygiene. Skin Conditions revealed that R32 was at risk for pressure ulcer/injuries but had no pressure ulcers/injuries on admission to the facility. Review of R32's BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK dated 1/26/22 revealed that R32 was a moderate risk for pressure ulcer/injury. Review of R32's Physician Order dated 1/30/22 revealed, Check skin weekly and weigh on Bath/Shower day at bedtime every Sun Document findings in a progress note. Review of R32's January Treatment Administration Record (TAR) revealed that a Weekly Skin Assessment was not completed on 1/30/22. Review of R32's February TAR revealed that a Weekly Skin Assessment was not completed on 2/13/22 and 2/20/22. Review of R32's Health Status Note dated 1/30/22 revealed, .Elder is incontinent of bowel at this time, buttocks reddened and breaking down as noted upon arrival to our facility, with small blister noted on Right gluteal fold, z paste applied and elder repositioned every 2 hours. Will continue to monitor. There was no documentation that the Wound Care Nurse and/or the physician was notified of the skin breakdown. Review of R32's Skilled Charting dated 1/30/22 revealed no documentation that R32 had skin breakdown and/or new pressure injury. Review of R32's Nutrition/Dietary Note dated 1/31/22 revealed, .Elder has blister on R buttock fold, per nursing progress note upon return from the hospital .Elder has had numerous loose stools over the last several days, which he reports is abnormal for him . There was no documentation that the Wound Care Nurse and/or the physician was notified of the skin breakdown. Review of R32's Skilled Charting dated 1/31/22 revealed no documentation that R32 had skin breakdown and/or new pressure injury. Review of R32's Nutrition/Dietary Note dated 2/14/22 revealed, .No reported skin breakdown at this time. Review of R32's Health Status Note dated 2/18/22 revealed, Called to resident's room observed black area to bilateral buttocks and coccyx with yellow slough underneath. Contacted (provider name omitted)-New orders for air mattress; wound C&S (culture and sensitivity); new tx (treatment) order to cleanse with wound cleanser, pat dry, apply Santyl (treatment/ointment for pressure ulcer healing) to necrotic tissue, cover with ABD (wound dressing) secure with foam tape, change daily and as needed for incontinence. (Assistant Director of Nursing-ADON U) notified of new orders . Review of R32's Wound Skin Note dated 2/18/22 written by ADON U revealed, Type of Wound & Location: Unstageable Sacral wound Stage-Only if pressure related: Length: 8.8cm Width: 8.7cm Depth: 0.3cm Undermining: (Blank) Tunneling: none Wound Bed-Tissue Type: Necrotic with slough Exudate-Amount & Color: (Blank) Odor: yes Periwound- Texture, Color: pink Pain- in Wound/during change: yes Orders for care: Santyl on wound bed, moistened 4x4 with NS, apply this to the wound then secure with ABD pad and Foam tape. Change daily. Wound Progress (Improvement, No Improvement, Worsened): Worsened . (Note wound depth was measured for the unstageable wound without the removal of slough/eschar). Review of R32's Health Status Note dated 2/19/22 (Saturday) revealed, Observed rash to groin/scrotum that is moving up right abdomen and down right thigh. Resident has coccyx wound with pending culture and sensitivity. Advised staff/wife to continue to monitor and if worsening to notify nurse on duty. Added to Dr communication for Monday. Review of R32's Electronic Health Record revealed no documentation that a provider assessed and/or documented on R32's unstageable pressure ulcer. (Verified by the Director of Nursing-DON on 03/15/22 at 10:38 A.M.) Review of R32's Progress Notes revealed no further Progress Notes of the pressure ulcer, wound care, measurements, or culture results by the time of his discharge. Review of R32's Wound Culture obtained 2/18/22 revealed R32's wound culture was positive (required antibiotic treatment). R32's Wound Culture was resulted on 2/21/22 at 8:18 A.M. Review of the Wound Audit (listing of all residents with wounds and treatment) revealed that R32 was not added to the list in January or February. Review of R32's Interdisciplinary Discharge Assessment revealed no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the section titled Summary of Elder's Stay-Nursing revealed no documentation that R32 had an appointment with a wound care provider or documentation for follow up the with wound culture and sensitivity results. Review of the Current Medication revealed R32 was not started on antibiotics prior to his discharge. Review of a Discharge MDS assessment for R32, with a reference date of 2/21/22 revealed: Skin Conditions R32 was at risk for pressure ulcer/injuries but had no pressure ulcers/injuries at the time of discharge. Resident has a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing/devise-No. Does this resident have one or more unhealed pressure ulcers/injuries? No. Review of R32's Health Status Note dated 2/21/22 revealed, discharged to EMTS (Emergency Medical Technicians) at 2140 (9:40 P.M.) for home. Review of R32's Hospital Record dated 2/22/22 at 5:48 P.M. (Less than 24 hours from discharge from the facility) revealed, During the subacute rehab stay he did develop a large sacral wound. Today the home healthcare nurse went to visit him for the 1st time. They felt like the ulcer was too big to be cared for at home .He states that he was at the rehab facility until yesterday when he was discharged home. The patient states that he was discharged home on 3 L of supplemental oxygen. Today he had his 1st home care visit with nursing. When they arrived at his house, they noted that he was hypoxic on his 3 (liters) at 74%. He was also hypotensive. On physical exam they noted a large sacral wound. Secondary to all these findings they called EMS to bring him to the emergency room for evaluation . He is noted to be hypotensive with a blood pressure in the 80s. (symptoms of [CONDITION(S)]) I did initiate a code [CONDITION(S)] on the patient and started a septic workup. On physical exam he has pitting [CONDITION(S)] noted to bilateral lower extremities, there is a large unstageable sacral wound as well . I did speak with the intensive care physician at (name omitted) Hospital in regard to this patient. He did agree to accept this patient under his service for further workup and management .EMS is here to transfer the patient. He is finished with his IV antibiotics however is still requiring the IV [MEDICATION(S)] upon transfer ([MEDICATION(S)] is used to treat life-threatening low blood pressure). While in the Emergency Department, R32 was diagnosed with Septic shock and Pressure injury of buttock, unstageable. Resident #32 was transferred to an Acute Care Hospital for further care. Review of R32's Hospital Record dated 2/22/22 at 10:53 P.M. (following his transfer from the previous hospital) revealed, Septic shock- Likely secondary to sacral wound with concern for [CONDITION(S)] . Pseudomonas noted from superficial wound culture . change antibiotics to [MEDICATION(S)] plus [MEDICATION(S)] to cover for [CONDITION(S)] ([CONDITION(S)]-resistant staphylococcus aureus/superbug infection) and (gram) negative anaerobes and bacilli . will need evaluation by General surgery versus plastic surgery to evaluate wound - and likely debridement (removal of damaged/dead tissue from the wound) .(R32) is an 84 y.o. (year old) male who presents today with concern regarding wound on his sacrum. He initially presented to (name omitted) Emergency Department .He states that while he was at the facility he cannot recall being turned appropriately. He was discharged home from acute rehab on February 21st .While at the acute rehab facility he stated he was not turned appropriately and went 3-4 days without being turned at all (APS notified 2/23). On 2/22 he presented to the ED with concerns regarding his sacral wound. On arrival to the ED, he was found to be hypotensive and hypoxemic. He was also found to have a mild lactic acidosis. (symptoms of [CONDITION(S)]) He was started on peripheral norepi ([MEDICATION(S)] is used to treat life-threatening low blood pressure) and transferred to (name omitted) hospital ICU . On arrival to (hospital name omitted), wound was consulted, and he underwent a bedside debridement 2/23 .Infectious disease was consulted, and they recommended plastics consult for flap and bone biopsy and CRS consult for diverting [CONDITION(S)] (diverts stool from the rectum to an ostomy in order to improve wound healing). CRS did not feel he was a candidate for ostomy currently and plastic consult was deferred. Would care repeated bedside I&D (incision and drainage) on 2/25 but was aborted due to pain . Sacral decubitus ulcer with overt purulence and concern for OM ([CONDITION(S)]) - CT imaging: large sacral decubitus ulcer present with significant subcutaneous [CONDITION(S)] and gas, ulcer along skin surface measures 3cm and mild irregular [CONDITION(S)] in coccyx with [CONDITION(S)] not being excluded .He was seen by PT/OT (Physical Therapy and Occupational Therapy) who recommended SAR (subacute rehab). However, after Hospice meeting, the patient opted to go home with (name omitted) Hospice . Review of R32's Wound Consult while he was inpatient on 2/23/22 revealed, Large sacral decubitus ulceration is present with significant subcutaneous [CONDITION(S)] and gas. The ulceration along the skin surface measures upwards of 3 cm. There is mild irregular [CONDITION(S)] in the underlying coccyx and [CONDITION(S)] cannot be excluded .Patient has a large sacral decubitus filled with necrotic tissue. Extensive excisional debridement performed at bedside today. Wound extends down to bone- presumed [CONDITION(S)]. Dakin's (solution used for wound treatment) packing BID (twice a day) for further mechanical debridement. I'm hoping to perform further debridement on Thursday . Measurements for debridement. Excisional through subcutaneous tissue to bone. Tolerated well Approximately 10cc blood loss. 13 cm (length) x 16 cm (Width) x 7 cm (Depth) Tunneling from 10-2oclock 4cm. During an interview on 3/14/22 at 1:30 P.M., DON reported that Weekly Skin Assessments should be completed weekly on all residents by the nurse providing care for the resident. Once the skin assessment is completed it is documented in the resident's Treatment Administration Record (TAR). If skin breakdown is identified during a skin assessment the Wound Care Nurse (WCN) would be notified and they would document the skin concern in the progress note and notify the practitioner. DON reported that the facility did not have a Wound Care Certified nurse employed at the facility. DON reported that the WCN relied on the facility nurses to notify her if any breakdown of resident skin identified. The WCN would keep track of the residents with skin breakdown on the Wound Audit log and collaborate with the provider for wound healing treatments and/or testing. During an interview on 03/16/22 at 9:13 A.M., Certified Nursing Assistant (CNA) reported that any time there is any skin breakdown the CNA's will notify the nurses immediately. CNA W reported that skin should be assessed during toileting, showering, and incontinence care. CNA W reported that she had provided care for R32. CNA W reported that he had skin breakdown around the time of his admission, and he would have multiple episodes of bowel incontinence daily which did not help with the wound healing process. CNA W reported that R32's wound worsened while he was at the facility. During an interview on 03/16/22 at 09:25 A.M., Clinical Care Coordinator (CCC) M reported that she was responsible for wound care prior to 3/15/22. CCC M reported that she had never been notified of skin breakdown for R32 by facility nurses or CNA's. CCC M reported that had she been notified she would have immediately contacted the provider, put interventions and treatments in place, and follow his wound healing/progression closely. CCC M reported that she relied on staff to complete the Weekly Skin Assessments as ordered and document abnormalities in the progress note. CCC M reported that R32 was discharged home without antibiotics for the wound. Resident #31 (R31) Review of an Admission Record revealed R31 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: muscle weakness. Review of an MDS assessment for R31, with a reference date of 2/1/22 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated R31 was cognitively intact. Review of the Functional Status revealed that R 31 required extensive 2 person assist for bed mobility. Review of R31's Physician Order dated 1/29/22 revealed, Check skin weekly on Bath/Shower day at bedtime every Sat for Health maintenance Document findings in a progress note. Review of R31's February TAR revealed that a Weekly Skin Assessment was not completed on 2/26/22. Review of R31's March TAR revealed that a Weekly Skin Assessment was not completed on 3/12/22. During an interview on 03/14/22 at 09:54 A.M., R31 was in bed, on her back, with no positioning devices to offload pressure. R31 reported that her buttocks were painful and she was not routinely repositioned in bed. R31 reported she had been on her back for an extended period, and she could not reposition herself. R31 reported that she felt as though she was getting a pressure sore. During an interview on 03/14/22 at 12:07 P.M., Licensed Practical Nurse (LPN) V reported that she was not aware of any skin breakdown for R31. LPN V reported that skin assessments should be completed weekly or more if needed. Review of R31's Health Status Note dated 3/14/22 at 6:59 P.M. revealed, Skin assessment completed by this nurse and (ADON). Discoloration noted to bilateral buttock with right inner buttock open as identified earlier today. No additional issues noted. Review of R31's Wound Skin Note dated 3/14/22 revealed, Type of Wound & Location: Right inner buttock Stage-Only if pressure related: Length: 2.2 cm Width: 1.5 cm. Review of R31's Health Status Note dated 3/15/22 revealed, Skin assessment completed by this nurse and (name omitted) RN. Discoloration noted to bilateral buttocks with right inner buttock showing continued healing. Will continue z-guard to bilateral buttocks every shift and as needed for incontinence. Will continue to monitor bilateral areas on buttocks each shift for continued healing. During an interview on 03/15/22 at 02:48 P.M., R31 reported that her bottom was sore, and she had been notified that she had open areas on her buttocks and a new treatment would be put in place to heal the pressure sores. Resident #43 (R43) Review of an Admission Record revealed R43 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: muscle weakness and [CONDITION(S)]. Review of R43's Physician Order dated 2/6/22 revealed, Check skin weekly on Bath/Shower day at bedtime every Sun for Health maintenance Document findings in a progress note. Review of R43's February TAR revealed that a Weekly Skin Assessment was not completed on 2/13/22 or 2/20/22. Review of R43's March TAR revealed that a Weekly Skin Assessment was not completed on 3/6/22 and 3/13/22. Resident #6 (R6) Review of an Admission Record revealed R6 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: [CONDITION(S)] brain injury. Review of R6's Physician Order dated 2/18/22 revealed, Check skin weekly on Bath/Shower day every day shift every Fri Document findings in a progress note. Review of R6's February TAR revealed that a Weekly Skin Assessment was not completed on 2/25/22. Resident #44 (R44) Review of an Admission Record revealed R44 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: muscle weakness. Review of R44's Physician Order dated 1/8/22 revealed, Check skin and weigh weekly on bath day Saturday 7p shift. Review of R44's February TAR revealed that a Weekly Skin Assessment was not completed on 2/5/22, 2/12/22, 2/19/22 or 2/27/22 Review of R44's Physician Order revealed, Check skin and weigh weekly on Bath/Shower day every day shift every Sat Document findings in a progress note-Start Date 01/08/2022 0700 -D/C (Discontinue) Date 03/05/2022. There was no order for Weekly Skin Assessments following the discontinued order. Resident #30 (R30) Review of an Admission Record revealed R30 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: weakness. Review of R30's Physician Order dated 1/24/22 revealed, Check skin weekly on Bath/Shower day every day shift every (Monday) Document findings in a progress note. Review of R30's February TAR revealed that a Weekly Skin Assessment was not completed on 2/7/22, 2/14/22, or 2/21/22. Review of R30's March TAR revealed that a Weekly Skin Assessment was not completed on 3/7/22. Resident #14 (R14) Review of an Admission Record revealed R14 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: stroke. Review of R14's Physician Order dated 3/11/21 revealed, Check skin weekly on Bath/Shower day every day shift every Thu Document findings in a progress note. Review of R14's February TAR revealed that a Weekly Skin Assessment was not completed on 2/17/22 or 2/24/22. Review of R14's March TAR revealed that a Weekly Skin Assessment was not completed on 3/10/22. On 3/14/22 at 4:14 P.M., the Nursing Home Administrator and Director of Nursing were verbally notified and received written notification of the Immediate Jeopardy that was identified on 3/14/22 due to the facility's failure to prevent, monitor, and treat pressure ulcers. A written plan for removal for the Immediate Jeopardy was received on 3/15/22 and the following was verified on 3/15/22: Immediate Jeopardy Removal F686 Failure to prevent the development of pressure injury Element 1 Elder #32 no longer resides at the facility; closed chart will be reviewed to identify root cause analysis beginning on 3/14/22. Element 2 All elders 52/52 residing at the facility have the potential to be affected by the deficient practice. Beginning on 3/14/2022, all elders residing at the facility will have skin assessments completed by a licensed nurse. New concerns identified will be communicated with the physician, elder, or responsible party. For all new identified areas of concerns noted, care plans will be reviewed and revised as appropriate. For all new identified areas of concerns noted, orders will be obtained and documented as appropriate. DON is responsible for the oversight of this intervention. Beginning on 3/14/22, Braden Skin Assessments will be completed on all 52/52 Elders in the facility, DON will be responsible for the oversight of this intervention. Element 3 Beginning on 3/15/2022, the DON/ADON and Staff education Nurse will be educated on Pressure Wounds, staging of wounds and documentation of wounds. The nurse conducting training has the following credentials: RN, BSN, WCC (Bachelors Level Registered Nurse/Wound Care Certified). Beginning on 3/15/2022, the Wound care nurse will receive updated education on the NPIAP (National Pressure Injury Advisory Panel) Pressure Injury Stages. Beginning on 3/15/2022, wounds will be followed weekly and as needed and documented appropriately. Weekly wound meetings with the IDT (Interdisciplinary Team) team will be held to discuss wounds as evident of being documented in a wound progress note in (Electronic Health Record). Beginning on 3/15/2022, the following policies were reviewed and revised as appropriate: Skin Assessment Policy, Wound Cultures Policy, Pressure Injury Prevention and Management Policy, Pressure Injury Risk Assessment Policy, Documentation of Wound Treatments Policy, Wound Treatment Management, and Discharge Summary and Plan of Care. Policies implemented with no revisions. Beginning on 3/15/2022, a comprehensive wound care program will be initiated to assess, monitor, identify, and treat the identified pressure wounds. The wound care program will be done by the ADON, with oversight by the DON. Weekly wound rounding assessment and summary will include, elder name, wound location, wound type, stage of pressure injury, measurement, wound bed, tunneling, exudate amount and type, peri wound, order, pain, progress, complications, treatment and follow up. Treatment plans will be collaborated with ADON, DON and Physician. Beginning on 3/15/2022, wound care nurse duties were delegated to the ADON Beginning on 3/15/2022, the licensed nurses will be reeducated on the following policies to include: Skin Assessment Policy, Wound Cultures Policy, Pressure Injury Prevention and Management Policy, Pressure Injury Risk Assessment Policy, Documentation of Wound Treatments Policy, Wound Treatment Management, and Discharge Summary and Plan of Care by the DON and/or ADON. Beginning on 3/15/2022, the Director of Nursing, ADON and Staff Educator will provide education to licensed nurses and certified nurse aides. Licensed nurses and certified nurse aides will complete Pressure Ulcer/Injury competencies. Licensed Nurse and CNA's will receive education prior to their next scheduled shift, which will include Skin Assessment Policy, Wound Cultures Policy, Pressure Injury Prevention and Management Policy, Pressure Injury Risk Assessment Policy, Documentation of Wound Treatments Policy, Wound Treatment Management, and Discharge Summary and Plan of Care. Licensed nurses and CENA's will be educated on if an area of concern is noted on the skin assessment the ADON and DON will be notified. Beginning on 3/14/22, weekly skin assessments will be reviewed weekly be ADON. Beginning on 3/14/22, the facility will explore other opportunities for a traveling wound care specialist to follow wounds at the facility level. On 3/15/2022 the facility made contact with a wound certified nurse, (Contracted Wound Company name omitted) and (Contracted Wound Company name omitted), to explore in-house wound care program for the facility. The medical director was notified of the IJ (Immediate Jeopardy) on 3/15/2022 Element 4 Beginning on 3/15/2022, audits will be completed weekly x 4, then monthly x 2 or until the facility has reached substantial compliance. Results will be taken to QA (Quality Assurance). Although the Immediate Jeopardy was removed on 3/15/22, the facility remained out of compliance at a scope of isolated and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency.

Based on observation, interview, and record review, the facility failed to implement appropriate infection control procedures during the medication pass observation for 1 of 5 residents observed (R151), potentially affecting 28 facility residents, resulting in the potential for cross-contamination and the spread of illness and/or disease. Findings include: During an observation on 03/15/22 at 7:35 AM, Licensed Practical Nurse (LPN) S handled and emptied R151's urinal with bare hands. LPN S then put on gloves (without washing and/or cleansing her hands) and checked R151's blood sugar. After checking R151's blood sugar, LPN S put the used lancet in the right pocket of her scrub jacket and stated, I'll throw it away later, removed her gloves, and did not cleanse/wash her hands until she arrived at the medication cart (after she handled the room door handle, shut off the room light at the light switch, disposed of the lancet in the sharps container on the medication cart, and handled her papers that were on the top of the medication cart). During an interview on 03/15/22 at 4:35 PM, LPN D stated that not all of her resident rooms have sharps containers in them. She stated when she does a blood glucose check, she will put the alcohol swab, test strips, and lancet in a clean water cup and take it into the resident's room. LPN D stated when she's done, if the resident does not have a sharps container in their room, she will put the lancet and test strip back into the water cup, bring it to her medication cart, and dispose of it in the sharps container on the medication cart. LPN D further stated, I will sometimes put the used lancet in my scrub pocket and bring it to my med cart to throw it in the sharps container there. But I know I'm not supposed to (put the used lancet in her scrub jacket pocket). During an interview on 03/16/22 at 08:00 AM, LPN T stated when she has to do a blood glucose check and there is not a sharps container in the resident's room, she will put her supplies in a paper cup and bring them in the room. She stated after she checks the resident's blood glucose level, she will put the used lancet in the paper cup and dispose of it in the sharps container on the medication cart. LPN T further stated she would not put the used lancet in her scrubs pocket because it was a blood-borne pathogen and infection control issue. She stated, also, that's just gross and visibly shuddered. During an interview on 3/16/22 at 1:00 PM, the Director of Nursing (DON) stated staff should not be placing used lancets in their scrub jacket pockets. She stated they should be putting them in the trash can in the resident's room. She stated the nurse could also put the used lancet in a medication cup or water cup, carry it out of the resident's room, and dispose of it in the sharps container or trash bin on the medication cart. The DON also stated, That's gross and disgusting when asked if a nurse and/or staff member should be handling a resident's urinal without gloves on. The DON stated staff should be wearing gloves when handling and/or emptying residents' urinals. A review of the facility's Handwashing/Hand Hygiene policy and procedure, dated 2/11/21, revealed, 6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situation: . Before performing any non-surgical invasive procedures (e.g. blood glucose level checks) . After contact with blood or bodily fluids; After handling used dressings, contaminated equipment, etc; . 9. Single-use disposable gloves should be used; Before aseptic procedures (a procedure that could cause harmful germs to be introduced to a vulnerable area- e.g. a dressing change over a wound, inserting urinary catheter, inserting an intravenous line); When anticipating contact with blood or body fluids .

Based on observation, interview, and record review, the facility failed to maintain the confidentiality of 1 of 28 residents' medical records (R23) on the Sunflower Unit, resulting in lack of resident privacy/confidentiality of health information, the potential for unauthorized personnel accessing personal resident health information, and the potential for violation of the Health Insurance Portability and Accountability Act (HIPPA). Findings include: During an observation on 03/15/22 at 8:10 AM, Licensed Practical Nurse (LPN) S walked away from the Sunflower Medication Cart #2 and left the computer screen on top of medication cart open unattended and visible to anyone walking by. The Sunflower Medication Cart #2 was located next to the dining area where staff were serving breakfast and residents were eating. The Sunflower Medication Cart #2 was within a short distance from this area where unauthorized staff and residents could view and/or access the computer screen/computer within a very short amount of time (less than a minute or two) while LPN S was away from the medication cart. R23's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition to R23's information, because LPN S was still logged into the computer, anyone could access other residents' MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 03/15/22 at 4:35 PM, LPN D stated that when she leaves her medication cart during a medication pass, she lowers her computer screen and/or locks the screen so that people cannot see a resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 03/16/22 at 8:00 AM, LPN T stated when she walks away from her medication cart, she always hides the computer screen. She stated she would not leave the computer screen open to a resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Safeguarding of Resident Identifiable Information policy, dated 3/15/22, revealed, Policy: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information and to safe guard against destruction or unauthorized release of information and records . 4. Medical records shall not be left in open areas where unauthorized persons could access identifiable resident information . 7. Computer screens showing clinical record information may not be left unattended and readily observable or accessible by other residents or visitors.

This citation pertains to intake M 6413 Based on interview and record review, the facility failed to provide written notices to residents and their Guardians/Power of Attorneys (POA) to inform them of a room changes affecting all 62 residents who reside at the facility. Findings include: Resident #1 Review of a Face Sheet revealed Resident #1 is a [AGE] year old male originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In in an interview on 4/13/21 at 4:36 p.m., the Complainant I reported Resident #1 was transferred to another room on another unit in December of 2020 and the family/POA was notified via phone and not given the right to refuse the transfer. In in an interview on 4/14/21 at 1:15 p.m., the FM J reported Resident #1 was transferred to a locked unit on December 3,2020 after the resident had a fall. FM J reported the Social Worker called her to inform her of the transfer. FM J was hesitant at first then agreed to the transfer. After FM J thought about the transfer and how hard it could be for Resident #1 to adjust to a new room and surrounding, she called the facility to let them know she changed her mind. At that time, Resident #1 had already changed rooms and FM J was told it was too late. In an interview on 4/14/21 at 2:16 p.m., Social Worker (SW) E reported she notifies the residents family and their POA's when a resident has a room change. SW E remembered when Resident #1 was transferred to the Reflections unit a few months back and reported the daughter agreed to the resident being transferred to the unit and the how the resident did much better once he was on the unit. SW E reported she documents the notifications in the computer but realized right before this interview that where she documents the notifications is not part of the residents Electronic Health Record (EHR) and said where she does document the notification, it gets erased after a period of time. SW E did not have any written form to provide to residents or families for a written notification for room changes but said she sometimes will chart a progress note in the EHR. SW E reported on 4/6/21, the Reflections unit was closed and all the residents, including Resident #1, who resided on that unit were transferred to another unit and did not receive written notifications of the move. Review of a Late Entry Progress note dated 4/15/21, and effective date of 4/6/21 revealed This worker call to speak to [POA] about regarding room change . Review of a list provided by the facility of 56 residents, including Resident #1 who had room changes since January 1, 2021 revealed 56 opportunities of residents who had room changes without written notifications. Review of a policy titled Notification of Room Change/Roommate Assignment last revised 4/26/18 revealed: . Room changes made at the request of the facility: When an Elder is being moved at the request of the facility staff, the resident, family and/or responsible party must receive an explanation in writing of why the move is required. An Elder has the right to refuse a room change that is requested solely for the convenience of staff.

This citation pertains to intakes MI 739 and MI 496 Based on interview and record review facility staff failed to prevent and recognize abuse and neglect for 2 out of 3 sampled residents (Residents #1 and #3) resulting in pain, emotional distress and the denial of needed goods and services, also resulting in the delay in investigating abuse and neglect allegations and the potential for additional abuse and neglect to occur. Findings include: Review of facility policy and procedure Abuse Program with a most recently revised date of 11/14/19 revealed: It is the policy of (facility) to maintain an environment free of abuse and neglect. Abuse is defined as The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .Abuse includes verbal, physical, sexual or mental abuse, corporal punishment and involuntary seclusion. Physical abuse is defined as: Includes hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment: any type of impermissible or unjustifiable physical contact with an Elder that has resulted in injury or harm to the Elder. Verbal abuse is defined as The use of oral, written or gestured language that willfully includes disparaging or derogatory terms to Elders or their families, within their hearing distance; regardless of their age or ability to comprehend . Neglect is defined as: The failure, either intentionally or accidentally, to provide goods and services that are necessary to avoid physical harm, mental anguish or mental illness; with resulting harm to the Elder. Per the Abuse Program policy Employee training is to include: orientation to and ongoing training on the following topics, at least annually: 1. Abuse and neglect definitions .3. What constitutes abuse, neglect, exploitation and misappropriation of Elder property 4. How to identify abuse, neglect, exploitation and misappropriation. 5. How to intervene when abuse is witnessed or suspected. 6. Proper steps in reporting allegation or suspicion of abuse, neglect exploitation or misappropriation . Prevention strategies include: Elder care and treatment shall be monitored by all staff, on an ongoing basis, to assure that Elders are free from abuse, neglect, exploitation or mistreatment. It is the responsibility of all staff to provide a safe environment for the Elders. Under the section Investigation, reveals: Investigation will begin immediately upon identifying the situation as either a potential abuse situation or an allegation of abuse. Under Reporting Allegations of Abuse: Any allegation of suspicion of abuse, neglect, exploitation, misappropriation or mistreatment will be immediately reported to the Director of Nursing or her designee. Resident #3 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was a [AGE] year old female initially admitted to the facility on [DATE] and most recently admitted on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #3 had moderate cognitive impairment and required extensive assistance for most activities of daily life (ADLs). Per review of Resident #3's care plan there is a focus area with initiated date 11/18/2019: The resident has an ADL self-care performance deficit r/t (related to) [MEDICAL CONDITION]. Interventions include: LOCOMOTION: 1 assist with w/c (wheel chair) for long distances. Based on facility submitted Incident Summary an allegation of abuse perpetrated against Resident #3 by Certified Nursing Assistant (CNA) D occurred on 1/16/2020 at 8:00 AM and was discovered on 1/16/2020 at 8:25 AM. The finding of abuse was noted as inconclusive. The investigation summary revealed it is likely (CNA D) was rude and or disrespectful during the time she was providing care to (Resident #3). (CNA D) admitted that she did not follow the plan of care that was available to her on the Kardex, by assisting (Resident #3) in her wheelchair to the dining room. As defined in section 483.5 abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. (Resident #3) has no resulting harm, pain or mental anguish related to this incident. (Facility) has decided to separate employment with (CNA D) due to the likeliness that she was rude/disrespectful and her failure to follow the care plan. (Facility) cannot confirm nor deny that abuse and or neglect occurred. Per facility provided 5 Day Summary the incident details included: (Resident #3) reported to her daughter this am that the CNA who had taken care of her this morning, would not help her get to breakfast and told her that she could push her own chair to breakfast. (Resident #3) also reported to her daughter, that she felt like the CNA was yelling at her when the CNA told her she could push herself .(Resident #3) is care planned and has a kardex in her room with the intervention of one staff assist for mobility for long distances . Also per the 5 Day Summary report, during an Interview with (CNA I) on 1/16/2020 at 10:54 AM. (CNA I) stated that she went to go find (CNA D) and found her in (Resident #3's) bathroom assisting (Resident #3) with morning care. (CNA I) stated that (CNA D) said 'I am irritated with this one' .(CNA D) rolled her eyes and (CNA I) could tell the (sic) (CNA D) was frustrated. (CNA I) stated she stayed in the room until (CNA D) had (Resident #3) back in the wheelchair because she felt the elder was safe at that time. During a follow up interview with CNA I on 1/20/2020 at 1:15 PM she again stated (CNA D) said 'I can't stand this one' .When she left the room (CNA D) was still in the room cleaning up the bathroom. (CNA I) stated when she left the room she went to complete some other tasks including getting .(roommate of (Resident #3)) some coffee. (CNA I) states that after bring (sic) the coffee .she exited the room and reported .what had occurred. Per interview documented with (CNA D) on 1/20/2020 at 3:51 PM she placed herself in the room assisting (Resident #3) just before (7:15 AM) and call light times confirmed that Resident #3 turned on her call light at (6:55 AM) and the call light was turned off 2 minutes and 44 seconds later. Per facility provided interview transcript with CNA I completed by Registered Nurse (RN) G, RN G posed the question to CNA I: So am I right in saying that you left (Resident #3) in the room with (CNA D)? Then you went to do a 'few' things, and got (another resident name) her coffee from the dining room, took it back t her room, then helped her to sit up and drink the coffee? Then when you were leaving the room you saw (nurse) and then reported what you witnessed? Then when (former DON) came to the cart you did not say anything to her about what had happened? and CNA I responded: yes, that's right. During an interview with Resident #3 on 08/05/2020 at 10:15 AM in the Resident's room, she reported she could not recall the incident in question. During an interview with the Family Member G on 08/05/2020 at 1:40 PM, the incident with Resident #3 was discussed. Family Member G stated the day of the incident Resident #3 had informed her a staff member had been rough with her, yelled at her and made her feel unhappy. Per Family Member G, Resident #3 told her she had asked for help and the staff basically said you can do it yourself and refused to take her to breakfast. Per Family Member G, Resident #3 thought the staff member was disrespectful and she was reluctant and embarrassed to talk about it. Family Member G stated she immediately reported the incident to the charge nurse and the facility started an investigation. Per review of facility provided 5 day summary document and supported by facility provided Individual Timecard for CNA D, CNA D was suspended at 10:48 AM on 1/16/2020, at least 2.5 hours after another employee viewed CNA D display abusive behavior towards a resident at approximately 8:00 AM. The witnessed allegation was potentially earlier than the estimated time of 8:00 AM due to call light logs and CNA D reporting she completed the resident's morning cares prior to a 7:15 AM meeting. Per Facility provided disciplinary paperwork, CNA D employment was terminated because she failed to treat an elder with kindness, respect, dignity and courtesy during morning care .(CNA D) failed to follow the approved plan of care for an elder that resulted in the elder expressing that she felt 'disrespected.' During the investigation of the complaint it was identified that another staff member heard (CNA D) speaking in an unkind manner to the elder. Resident #1 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was a [AGE] year old female initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Staff Assessment for Mental Status for Resident #1 indicated she had severe cognitive impairment and required extensive assistance for most activities of daily life (ADLs). Per review of Resident #1's care plan, there is a focus area with a date initiated of 8/16/2017: I have pain secondary to h/o (history of) left hip fx (fracture), decreased mobility and a hx of RLS and [MEDICAL CONDITION]. Interventions include Monitor/record/report to nurse any s/sx (signs or symptoms) of non-verbal pain . On 8/05/2020 at 10:05 AM Resident #1 was observed sleeping in her room on a mattress of the floor. Per interview with LPN K, Resident #1 spends most of her time on the floor, either sleeping or scooting around. LPN K stated that Resident #1 is not very communicative and can get very agitated at times. Based on facility submitted Incident Summary an allegation of abuse perpetrated by CNA B against Resident #1 occurred on 5/20/2020 at 7:12 PM and was not discovered until 5/21/2020 at 3:50 PM. The Investigation Summary document notes that abuse was not substantiated by the facility and the section Incident Summary of the document revealed: Although (Resident #1) verbalized discomfort when (CNA B) moved her, (CNA B) did not willfully inflict pain . and that CNA B admitted she could have verbally responded differently to Resident #1. The facility provided 5 Day Summary for this incident further revealed that on 5/21/2020 Dietary Aide (DA) L reported hearing (Resident #1) say 'ouch' when moved out of the dining room doorway by CNA B on the evening of 5/20/2020. During a follow up interview on 5/28/2020 DA L stated that on 5/20/2020, (Resident #1) was in the doorway of the dining room and the CNA (whose name she didn't know) stepped over (Resident #1) and pulled her out of the way .(DA L) stated 'she reached over the elder and under her arms, sliding her backwards, out of the doorway to shut the door. When the CNA moved her, (Resident #1) said 'ouch' .began stuttering and basically said you don't know what you're doing to my body.' The CNA responded by saying, 'you don't know what you're doing to my body when I have to pull you.' Per the document, during an interview completed by the facility with CNA B on 5/29/2020, CNA B admitted that she moved Resident #1 and the resident stated my body hurts and CNA B stated she responded that my back hurts. An interview was completed with RN H on 8/5/2020 at 1:30 PM regarding the incident with Resident #1. RN H confirmed she had completed the investigation regarding the incident and she was the Director of Nursing for the facility from February 2020 through July 2020. RN H confirmed that DA L had not immediately reported the incident. RN H stated that DA L was a newer employee at the time and stated she was not aware of the process due to being new. RN H stated she immediately provided verbal education to DA L related to reporting allegations immediately and who to report to. RN H was not aware of or could not recall if re-education was provided to all staff after this incident. On 8/5/2020, the personnel file for DA L was reviewed and no documentation of re-education or discipline related to abuse reporting for the 5/20/2020 incident was observed. RN A was asked on 8/5/2020 at 2:15 PM if any education or discipline was completed, RN A looked into the matter and later stated on 8/5/2020 at 2:45 PM that DA L's supervisor had indicated they completed verbal re-education with her but did not document anything in her personnel file. Per review of facility provided Individual Timecard for CNA B, on 5/20/2020 CNA B worked from 6:42 PM to 5:08 AM on 5/21/2020. The alleged incident of abuse with Resident #1 occurred at 7:12 PM on 5/20/2020 and CNA B completed an additional 10 hours of her shift after a witnessed allegation. Per facility provided disciplinary paperwork, CNA B's employment was terminated on 5/29/2020 due to an interaction with elder- overheard by another staff member telling the elder 'she doesn't know what she does to her back' when repositioning her. Attitude: failure to treat all persons with kindness, respect, and dignity using the appropriate tone of voice, and body language. The disciplinary paperwork further revealed CNA B received a verbal warning on 12/9/19 for her interaction and attitude while in an elder's room. On 3/13/20 (CNA B) received a final written warning related to her attitude and demeanor while in a patient care area.

This citation pertains to intakes MI 739 and MI 496 Based on interview and record review the facility failed to protect 2 out of 3 sampled residents (Residents #1 and #3) from further abuse due to the staff delay in reporting allegations of abuse and neglect resulting in the potential for additional abuse and neglect to occur. Findings include: Based on interview and record review facility staff failed to prevent and recognize abuse and neglect for 2 out of 3 sampled residents (Residents #1 and #3) resulting in pain, emotional distress and the denial of needed goods and services, also resulting in the delay in investigating abuse and neglect allegations and the potential for additional abuse and neglect to occur. Findings include: Review of facility policy and procedure Abuse Program with a most recently revised date of 11/14/19 revealed: It is the policy of (facility) to maintain an environment free of abuse and neglect. Abuse is defined as The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .Abuse includes verbal, physical, sexual or mental abuse, corporal punishment and involuntary seclusion. Physical abuse is defined as: Includes hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment: any type of impermissible or unjustifiable physical contact with an Elder that has resulted in injury or harm to the Elder. Verbal abuse is defined as The use of oral, written or gestured language that willfully includes disparaging or derogatory terms to Elders or their families, within their hearing distance; regardless of their age or ability to comprehend . Neglect is defined as: The failure, either intentionally or accidentally, to provide goods and services that are necessary to avoid physical harm, mental anguish or mental illness; with resulting harm to the Elder. Per the Abuse Program policy Employee training is to include: orientation to and ongoing training on the following topics, at least annually: 1. Abuse and neglect definitions .3. What constitutes abuse, neglect, exploitation and misappropriation of Elder property 4. How to identify abuse, neglect, exploitation and misappropriation. 5. How to intervene when abuse is witnessed or suspected. 6. Proper steps in reporting allegation or suspicion of abuse, neglect exploitation or misappropriation . Prevention strategies include: Elder care and treatment shall be monitored by all staff, on an ongoing basis, to assure that Elders are free from abuse, neglect, exploitation or mistreatment. It is the responsibility of all staff to provide a safe environment for the Elders. Under the section Investigation, reveals: Investigation will begin immediately upon identifying the situation as either a potential abuse situation or an allegation of abuse. Under Reporting Allegations of Abuse: Any allegation of suspicion of abuse, neglect, exploitation, misappropriation or mistreatment will be immediately reported to the Director of Nursing or her designee. Resident #3 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was a [AGE] year old female initially admitted to the facility on [DATE] and most recently admitted on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #3 had moderate cognitive impairment and required extensive assistance for most activities of daily life (ADLs). Per review of Resident #3's care plan there is a focus area with initiated date 11/18/2019: The resident has an ADL self-care performance deficit r/t (related to) [MEDICAL CONDITION]. Interventions include: LOCOMOTION: 1 assist with w/c (wheel chair) for long distances. Based on facility submitted Incident Summary an allegation of abuse perpetrated against Resident #3 by Certified Nursing Assistant (CNA) D occurred on 1/16/2020 at 8:00 AM and was discovered on 1/16/2020 at 8:25 AM. The finding of abuse was noted as inconclusive. The investigation summary revealed it is likely (CNA D) was rude and or disrespectful during the time she was providing care to (Resident #3). (CNA D) admitted that she did not follow the plan of care that was available to her on the Kardex, by assisting (Resident #3) in her wheelchair to the dining room. As defined in section 483.5 abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. (Resident #3) has no resulting harm, pain or mental anguish related to this incident. (Facility) has decided to separate employment with (CNA D) due to the likeliness that she was rude/disrespectful and her failure to follow the care plan. (Facility) cannot confirm nor deny that abuse and or neglect occurred. Per facility provided 5 Day Summary the incident details included: (Resident #3) reported to her daughter this am that the CNA who had taken care of her this morning, would not help her get to breakfast and told her that she could push her own chair to breakfast. (Resident #3) also reported to her daughter, that she felt like the CNA was yelling at her when the CNA told her she could push herself .(Resident #3) is care planned and has a kardex in her room with the intervention of one staff assist for mobility for long distances . Also per the 5 Day Summary report, during an Interview with (CNA I) on 1/16/2020 at 10:54 AM. (CNA I) stated that she went to go find (CNA D) and found her in (Resident #3's) bathroom assisting (Resident #3) with morning care. (CNA I) stated that (CNA D) said 'I am irritated with this one' .(CNA D) rolled her eyes and (CNA I) could tell the (sic) (CNA D) was frustrated. (CNA I) stated she stayed in the room until (CNA D) had (Resident #3) back in the wheelchair because she felt the elder was safe at that time. During a follow up interview with CNA I on 1/20/2020 at 1:15 PM she again stated (CNA D) said 'I can't stand this one' .When she left the room (CNA D) was still in the room cleaning up the bathroom. (CNA I) stated when she left the room she went to complete some other tasks including getting .(roommate of (Resident #3)) some coffee. (CNA I) states that after bring (sic) the coffee .she exited the room and reported .what had occurred. Per interview documented with (CNA D) on 1/20/2020 at 3:51 PM she placed herself in the room assisting (Resident #3) just before (7:15 AM) and call light times confirmed that Resident #3 turned on her call light at (6:55 AM) and the call light was turned off 2 minutes and 44 seconds later. Per facility provided interview transcript with CNA I completed by Registered Nurse (RN) G, RN G posed the question to CNA I: So am I right in saying that you left (Resident #3) in the room with (CNA D)? Then you went to do a 'few' things, and got (another resident name) her coffee from the dining room, took it back t her room, then helped her to sit up and drink the coffee? Then when you were leaving the room you saw (nurse) and then reported what you witnessed? Then when (former DON) came to the cart you did not say anything to her about what had happened? and CNA I responded: yes, that's right. During an interview with Resident #3 on 08/05/2020 at 10:15 AM in the Resident's room, she reported she could not recall the incident in question. During an interview with the Family Member G on 08/05/2020 at 1:40 PM the incident with Resident #3 was discussed. Family Member G stated the day of the incident Resident #3 had informed her a staff member had been rough with her, yelled at her and made her feel unhappy. Per Family Member G, Resident #3 told her she had asked for help and the staff basically said you can do it yourself and refused to take her to breakfast. Per Family Member G, Resident #3 thought the staff member was disrespectful and she was reluctant and embarrassed to talk about it. Family Member G stated she immediately reported the incident to the charge nurse and the facility started an investigation. Per review of facility provided 5 day summary document and supported by facility provided Individual Timecard for CNA D, CNA D was suspended at 10:48 AM on 1/16/2020, at least 2.5 hours after another employee viewed CNA D display abusive behavior towards a resident at approximately 8:00 AM. The witnessed allegation was potentially earlier than the estimated time of 8:00 AM due to call light logs and CNA D reporting she completed the resident's morning cares prior to a 7:15 AM meeting. Per Facility provided disciplinary paperwork, CNA D employment was terminated because she failed to treat an elder with kindness, respect, dignity and courtesy during morning care .(CNA D) failed to follow the approved plan of care for an elder that resulted in the elder expressing that she felt 'disrespected.' During the investigation of the complaint it was identified that another staff member heard (CNA D) speaking in an unkind manner to the elder. Resident #1 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was a [AGE] year old female initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Staff Assessment for Mental Status for Resident #1 indicated she had severe cognitive impairment and required extensive assistance for most activities of daily life (ADLs). Per review of Resident #1's care plan, there is a focus area with a date initiated of 8/16/2017: I have pain secondary to h/o (history of) left hip fx (fracture), decreased mobility and a hx of RLS and [MEDICAL CONDITION]. Interventions include Monitor/record/report to nurse any s/sx (signs or symptoms) of non-verbal pain . On 8/05/2020 at 10:05 AM Resident #1 was observed sleeping in her room on a mattress of the floor. Per interview with LPN K, Resident #1 spends most of her time on the floor, either sleeping or scooting around. LPN K stated that Resident #1 is not very communicative and can get very agitated at times. Based on facility submitted Incident Summary an allegation of abuse perpetrated by CNA B against Resident #1 occurred on 5/20/2020 at 7:12 PM and was not discovered until 5/21/2020 at 3:50 PM. The Investigation Summary document notes that abuse was not substantiated by the facility and the section Incident Summary of the document revealed: Although (Resident #1) verbalized discomfort when (CNA B) moved her, (CNA B) did not willfully inflict pain . and that CNA B admitted she could have verbally responded differently to Resident #1. The facility provided 5 Day Summary for this incident further revealed that on 5/21/2020 Dietary Aide (DA) L reported hearing (Resident #1) say 'ouch' when moved out of the dining room doorway by CNA B on the evening of 5/20/2020. During a follow up interview on 5/28/2020 DA L stated that on 5/20/2020, (Resident #1) was in the doorway of the dining room and the CNA (whose name she didn't know) stepped over (Resident #1) and pulled her out of the way .(DA L) stated 'she reached over the elder and under her arms, sliding her backwards, out of the doorway to shut the door. When the CNA moved her, (Resident #1) said 'ouch' .began stuttering and basically said you don't know what you're doing to my body.' The CNA responded by saying, 'you don't know what you're doing to my body when I have to pull you.' Per the document, during an interview completed by the facility with CNA B on 5/29/2020, CNA B admitted that she moved Resident #1 and the resident stated my body hurts and CNA B stated she responded that my back hurts. An interview was completed with RN H on 8/5/2020 at 1:30 PM regarding the incident with Resident #1. RN H confirmed she had completed the investigation regarding the incident and she was the Director of Nursing for the facility from February 2020 through July 2020. RN H confirmed that DA L had not immediately reported the incident. RN H stated that DA L was a newer employee at the time and stated she was not aware of the process due to being new. RN H stated she immediately provided verbal education to DA L related to reporting allegations immediately and who to report to. RN H was not aware of or could not recall if re-education was provided to all staff after this incident. On 8/5/2020, the personnel file for DA L was reviewed and no documentation of re-education or discipline related to abuse reporting for the 5/20/2020 incident was observed. RN A was asked on 8/5/2020 at 2:15 PM if any education or discipline was completed, RN A looked into the matter and later stated on 8/5/2020 at 2:45 PM that DA L's supervisor had indicated they completed verbal re-education with her but did not document anything in her personnel file. Per review of facility provided Individual Timecard for CNA B, on 5/20/2020 CNA B worked from 6:42 PM to 5:08 AM on 5/21/2020. The alleged incident of abuse with Resident #1 occurred at 7:12 PM on 5/20/2020 and CNA B completed an additional 10 hours of her shift after a witnessed allegation. Per facility provided disciplinary paperwork, CNA B's employment was terminated on 5/29/2020 due to an interaction with elder- overheard by another staff member telling the elder 'she doesn't know what she does to her back' when repositioning her. Attitude: failure to treat all persons with kindness, respect, and dignity using the appropriate tone of voice, and body language. The disciplinary paperwork further revealed CNA B received a verbal warning on 12/9/19 for her interaction and attitude while in an elder's room. On 3/13/20 (CNA B) received a final written warning related to her attitude and demeanor while in a patient care area.

This citation pertains to intakes MI 739 and MI 496 Based on interview and record review facility staff failed to immediately report allegations of abuse and neglect for 2 out of 3 sampled residents (Residents #1 and #3) resulting in the delay in investigating abuse and neglect allegations and the potential for additional abuse and neglect to occur. Findings include: Based on interview and record review facility staff failed to prevent and recognize abuse and neglect for 2 out of 3 sampled residents (Residents #1 and #3) resulting in pain, emotional distress and the denial of needed goods and services, also resulting in the delay in investigating abuse and neglect allegations and the potential for additional abuse and neglect to occur. Findings include: Review of facility policy and procedure Abuse Program with a most recently revised date of 11/14/19 revealed: It is the policy of (facility) to maintain an environment free of abuse and neglect. Abuse is defined as The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .Abuse includes verbal, physical, sexual or mental abuse, corporal punishment and involuntary seclusion. Physical abuse is defined as: Includes hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment: any type of impermissible or unjustifiable physical contact with an Elder that has resulted in injury or harm to the Elder. Verbal abuse is defined as The use of oral, written or gestured language that willfully includes disparaging or derogatory terms to Elders or their families, within their hearing distance; regardless of their age or ability to comprehend . Neglect is defined as: The failure, either intentionally or accidentally, to provide goods and services that are necessary to avoid physical harm, mental anguish or mental illness; with resulting harm to the Elder. Per the Abuse Program policy Employee training is to include: orientation to and ongoing training on the following topics, at least annually: 1. Abuse and neglect definitions .3. What constitutes abuse, neglect, exploitation and misappropriation of Elder property 4. How to identify abuse, neglect, exploitation and misappropriation. 5. How to intervene when abuse is witnessed or suspected. 6. Proper steps in reporting allegation or suspicion of abuse, neglect exploitation or misappropriation . Prevention strategies include: Elder care and treatment shall be monitored by all staff, on an ongoing basis, to assure that Elders are free from abuse, neglect, exploitation or mistreatment. It is the responsibility of all staff to provide a safe environment for the Elders. Under the section Investigation, reveals: Investigation will begin immediately upon identifying the situation as either a potential abuse situation or an allegation of abuse. Under Reporting Allegations of Abuse: Any allegation of suspicion of abuse, neglect, exploitation, misappropriation or mistreatment will be immediately reported to the Director of Nursing or her designee. Resident #3 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was a [AGE] year old female initially admitted to the facility on [DATE] and most recently admitted on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #3 had moderate cognitive impairment and required extensive assistance for most activities of daily life (ADLs). Per review of Resident #3's care plan there is a focus area with initiated date 11/18/2019: The resident has an ADL self-care performance deficit r/t (related to) [MEDICAL CONDITION]. Interventions include: LOCOMOTION: 1 assist with w/c (wheel chair) for long distances. Based on facility submitted Incident Summary an allegation of abuse perpetrated against Resident #3 by Certified Nursing Assistant (CNA) D occurred on 1/16/2020 at 8:00 AM and was discovered on 1/16/2020 at 8:25 AM. The finding of abuse was noted as inconclusive. The investigation summary revealed it is likely (CNA D) was rude and or disrespectful during the time she was providing care to (Resident #3). (CNA D) admitted that she did not follow the plan of care that was available to her on the Kardex, by assisting (Resident #3) in her wheelchair to the dining room. As defined in section 483.5 abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. (Resident #3) has no resulting harm, pain or mental anguish related to this incident. (Facility) has decided to separate employment with (CNA D) due to the likeliness that she was rude/disrespectful and her failure to follow the care plan. (Facility) cannot confirm nor deny that abuse and or neglect occurred. Per facility provided 5 Day Summary the incident details included: (Resident #3) reported to her daughter this am that the CNA who had taken care of her this morning, would not help her get to breakfast and told her that she could push her own chair to breakfast. (Resident #3) also reported to her daughter, that she felt like the CNA was yelling at her when the CNA told her she could push herself .(Resident #3) is care planned and has a kardex in her room with the intervention of one staff assist for mobility for long distances . Also per the 5 Day Summary report, during an Interview with (CNA I) on 1/16/2020 at 10:54 AM. (CNA I) stated that she went to go find (CNA D) and found her in (Resident #3's) bathroom assisting (Resident #3) with morning care. (CNA I) stated that (CNA D) said 'I am irritated with this one' .(CNA D) rolled her eyes and (CNA I) could tell the (sic) (CNA D) was frustrated. (CNA I) stated she stayed in the room until (CNA D) had (Resident #3) back in the wheelchair because she felt the elder was safe at that time. During a follow up interview with CNA I on 1/20/2020 at 1:15 PM she again stated (CNA D) said 'I can't stand this one' .When she left the room (CNA D) was still in the room cleaning up the bathroom. (CNA I) stated when she left the room she went to complete some other tasks including getting .(roommate of (Resident #3)) some coffee. (CNA I) states that after bring (sic) the coffee .she exited the room and reported .what had occurred. Per interview documented with (CNA D) on 1/20/2020 at 3:51 PM she placed herself in the room assisting (Resident #3) just before (7:15 AM) and call light times confirmed that Resident #3 turned on her call light at (6:55 AM) and the call light was turned off 2 minutes and 44 seconds later. Per facility provided interview transcript with CNA I completed by Registered Nurse (RN) G, RN G posed the question to CNA I: So am I right in saying that you left (Resident #3) in the room with (CNA D)? Then you went to do a 'few' things, and got (another resident name) her coffee from the dining room, took it back t her room, then helped her to sit up and drink the coffee? Then when you were leaving the room you saw (nurse) and then reported what you witnessed? Then when (former DON) came to the cart you did not say anything to her about what had happened? and CNA I responded: yes, that's right. During an interview with Resident #3 on 08/05/2020 at 10:15 AM in the Resident's room, she reported she could not recall the incident in question. During an interview with the Family Member G on 08/05/2020 at 1:40 PM the incident with Resident #3 was discussed. Family Member G stated the day of the incident Resident #3 had informed her a staff member had been rough with her, yelled at her and made her feel unhappy. Per Family Member G, Resident #3 told her she had asked for help and the staff basically said you can do it yourself and refused to take her to breakfast. Per Family Member G, Resident #3 thought the staff member was disrespectful and she was reluctant and embarrassed to talk about it. Family Member G stated she immediately reported the incident to the charge nurse and the facility started an investigation. Per review of facility provided 5 day summary document and supported by facility provided Individual Timecard for CNA D, CNA D was suspended at 10:48 AM on 1/16/2020, at least 2.5 hours after another employee viewed CNA D display abusive behavior towards a resident at approximately 8:00 AM. The witnessed allegation was potentially earlier than the estimated time of 8:00 AM due to call light logs and CNA D reporting she completed the resident's morning cares prior to a 7:15 AM meeting. Per Facility provided disciplinary paperwork, CNA D employment was terminated because she failed to treat an elder with kindness, respect, dignity and courtesy during morning care .(CNA D) failed to follow the approved plan of care for an elder that resulted in the elder expressing that she felt 'disrespected.' During the investigation of the complaint it was identified that another staff member heard (CNA D) speaking in an unkind manner to the elder. Resident #1 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was a [AGE] year old female initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Staff Assessment for Mental Status for Resident #1 indicated she had severe cognitive impairment and required extensive assistance for most activities of daily life (ADLs). Per review of Resident #1's care plan, there is a focus area with a date initiated of 8/16/2017: I have pain secondary to h/o (history of) left hip fx (fracture), decreased mobility and a hx of RLS and [MEDICAL CONDITION]. Interventions include Monitor/record/report to nurse any s/sx (signs or symptoms) of non-verbal pain . On 8/05/2020 at 10:05 AM Resident #1 was observed sleeping in her room on a mattress of the floor. Per interview with LPN K, Resident #1 spends most of her time on the floor, either sleeping or scooting around. LPN K stated that Resident #1 is not very communicative and can get very agitated at times. Based on facility submitted Incident Summary an allegation of abuse perpetrated by CNA B against Resident #1 occurred on 5/20/2020 at 7:12 PM and was not discovered until 5/21/2020 at 3:50 PM. The Investigation Summary document notes that abuse was not substantiated by the facility and the section Incident Summary of the document revealed: Although (Resident #1) verbalized discomfort when (CNA B) moved her, (CNA B) did not willfully inflict pain . and that CNA B admitted she could have verbally responded differently to Resident #1. The facility provided 5 Day Summary for this incident further revealed that on 5/21/2020 Dietary Aide (DA) L reported hearing (Resident #1) say 'ouch' when moved out of the dining room doorway by CNA B on the evening of 5/20/2020. During a follow up interview on 5/28/2020 DA L stated that on 5/20/2020, (Resident #1) was in the doorway of the dining room and the CNA (whose name she didn't know) stepped over (Resident #1) and pulled her out of the way .(DA L) stated 'she reached over the elder and under her arms, sliding her backwards, out of the doorway to shut the door. When the CNA moved her, (Resident #1) said 'ouch' .began stuttering and basically said you don't know what you're doing to my body.' The CNA responded by saying, 'you don't know what you're doing to my body when I have to pull you.' Per the document, during an interview completed by the facility with CNA B on 5/29/2020, CNA B admitted that she moved Resident #1 and the resident stated my body hurts and CNA B stated she responded that my back hurts. An interview was completed with RN H on 8/5/2020 at 1:30 PM regarding the incident with Resident #1. RN H confirmed she had completed the investigation regarding the incident and she was the Director of Nursing for the facility from February 2020 through July 2020. RN H confirmed that DA L had not immediately reported the incident. RN H stated that DA L was a newer employee at the time and stated she was not aware of the process due to being new. RN H stated she immediately provided verbal education to DA L related to reporting allegations immediately and who to report to. RN H was not aware of or could not recall if re-education was provided to all staff after this incident. On 8/5/2020, the personnel file for DA L was reviewed and no documentation of re-education or discipline related to abuse reporting for the 5/20/2020 incident was observed. RN A was asked on 8/5/2020 at 2:15 PM if any education or discipline was completed, RN A looked into the matter and later stated on 8/5/2020 at 2:45 PM that DA L's supervisor had indicated they completed verbal re-education with her but did not document anything in her personnel file. Per review of facility provided Individual Timecard for CNA B, on 5/20/2020 CNA B worked from 6:42 PM to 5:08 AM on 5/21/2020. The alleged incident of abuse with Resident #1 occurred at 7:12 PM on 5/20/2020 and CNA B completed an additional 10 hours of her shift after a witnessed allegation. Per facility provided disciplinary paperwork, CNA B's employment was terminated on 5/29/2020 due to an interaction with elder- overheard by another staff member telling the elder 'she doesn't know what she does to her back' when repositioning her. Attitude: failure to treat all persons with kindness, respect, and dignity using the appropriate tone of voice, and body language. The disciplinary paperwork further revealed CNA B received a verbal warning on 12/9/19 for her interaction and attitude while in an elder's room. On 3/13/20 (CNA B) received a final written warning related to her attitude and demeanor while in a patient care area.

This citation pertains to intakes MI 739 and MI 496 Based on interview and record review the facility failed to implement their abuse policy for 2 out of 3 sampled residents (Residents #1 and #3) by failing to appropriately recognize and immediately report allegations of abuse and neglect resulting in the delay in investigating abuse and neglect allegations and the potential for additional abuse and neglect to occur. Findings include: Based on interview and record review facility staff failed to prevent and recognize abuse and neglect for 2 out of 3 sampled residents (Residents #1 and #3) resulting in pain, emotional distress and the denial of needed goods and services, also resulting in the delay in investigating abuse and neglect allegations and the potential for additional abuse and neglect to occur. Findings include: Review of facility policy and procedure Abuse Program with a most recently revised date of 11/14/19 revealed: It is the policy of (facility) to maintain an environment free of abuse and neglect. Abuse is defined as The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .Abuse includes verbal, physical, sexual or mental abuse, corporal punishment and involuntary seclusion. Physical abuse is defined as: Includes hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment: any type of impermissible or unjustifiable physical contact with an Elder that has resulted in injury or harm to the Elder. Verbal abuse is defined as The use of oral, written or gestured language that willfully includes disparaging or derogatory terms to Elders or their families, within their hearing distance; regardless of their age or ability to comprehend . Neglect is defined as: The failure, either intentionally or accidentally, to provide goods and services that are necessary to avoid physical harm, mental anguish or mental illness; with resulting harm to the Elder. Per the Abuse Program policy Employee training is to include: orientation to and ongoing training on the following topics, at least annually: 1. Abuse and neglect definitions .3. What constitutes abuse, neglect, exploitation and misappropriation of Elder property 4. How to identify abuse, neglect, exploitation and misappropriation. 5. How to intervene when abuse is witnessed or suspected. 6. Proper steps in reporting allegation or suspicion of abuse, neglect exploitation or misappropriation . Prevention strategies include: Elder care and treatment shall be monitored by all staff, on an ongoing basis, to assure that Elders are free from abuse, neglect, exploitation or mistreatment. It is the responsibility of all staff to provide a safe environment for the Elders. Under the section Investigation, reveals: Investigation will begin immediately upon identifying the situation as either a potential abuse situation or an allegation of abuse. Under Reporting Allegations of Abuse: Any allegation of suspicion of abuse, neglect, exploitation, misappropriation or mistreatment will be immediately reported to the Director of Nursing or her designee. Resident #3 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was a [AGE] year old female initially admitted to the facility on [DATE] and most recently admitted on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #3 had moderate cognitive impairment and required extensive assistance for most activities of daily life (ADLs). Per review of Resident #3's care plan there is a focus area with initiated date 11/18/2019: The resident has an ADL self-care performance deficit r/t (related to) [MEDICAL CONDITION]. Interventions include: LOCOMOTION: 1 assist with w/c (wheel chair) for long distances. Based on facility submitted Incident Summary an allegation of abuse perpetrated against Resident #3 by Certified Nursing Assistant (CNA) D occurred on 1/16/2020 at 8:00 AM and was discovered on 1/16/2020 at 8:25 AM. The finding of abuse was noted as inconclusive. The investigation summary revealed it is likely (CNA D) was rude and or disrespectful during the time she was providing care to (Resident #3). (CNA D) admitted that she did not follow the plan of care that was available to her on the Kardex, by assisting (Resident #3) in her wheelchair to the dining room. As defined in section 483.5 abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. (Resident #3) has no resulting harm, pain or mental anguish related to this incident. (Facility) has decided to separate employment with (CNA D) due to the likeliness that she was rude/disrespectful and her failure to follow the care plan. (Facility) cannot confirm nor deny that abuse and or neglect occurred. Per facility provided 5 Day Summary the incident details included: (Resident #3) reported to her daughter this am that the CNA who had taken care of her this morning, would not help her get to breakfast and told her that she could push her own chair to breakfast. (Resident #3) also reported to her daughter, that she felt like the CNA was yelling at her when the CNA told her she could push herself .(Resident #3) is care planned and has a kardex in her room with the intervention of one staff assist for mobility for long distances . Also per the 5 Day Summary report, during an Interview with (CNA I) on 1/16/2020 at 10:54 AM. (CNA I) stated that she went to go find (CNA D) and found her in (Resident #3's) bathroom assisting (Resident #3) with morning care. (CNA I) stated that (CNA D) said 'I am irritated with this one' .(CNA D) rolled her eyes and (CNA I) could tell the (sic) (CNA D) was frustrated. (CNA I) stated she stayed in the room until (CNA D) had (Resident #3) back in the wheelchair because she felt the elder was safe at that time. During a follow up interview with CNA I on 1/20/2020 at 1:15 PM she again stated (CNA D) said 'I can't stand this one' .When she left the room (CNA D) was still in the room cleaning up the bathroom. (CNA I) stated when she left the room she went to complete some other tasks including getting .(roommate of (Resident #3)) some coffee. (CNA I) states that after bring (sic) the coffee .she exited the room and reported .what had occurred. Per interview documented with (CNA D) on 1/20/2020 at 3:51 PM she placed herself in the room assisting (Resident #3) just before (7:15 AM) and call light times confirmed that Resident #3 turned on her call light at (6:55 AM) and the call light was turned off 2 minutes and 44 seconds later. Per facility provided interview transcript with CNA I completed by Registered Nurse (RN) G, RN G posed the question to CNA I: So am I right in saying that you left (Resident #3) in the room with (CNA D)? Then you went to do a 'few' things, and got (another resident name) her coffee from the dining room, took it back t her room, then helped her to sit up and drink the coffee? Then when you were leaving the room you saw (nurse) and then reported what you witnessed? Then when (former DON) came to the cart you did not say anything to her about what had happened? and CNA I responded: yes, that's right. During an interview with Resident #3 on 08/05/2020 at 10:15 AM in the Resident's room, she reported she could not recall the incident in question. During an interview with the Family Member G on 08/05/2020 at 1:40 PM the incident with Resident #3 was discussed. Family Member G stated the day of the incident Resident #3 had informed her a staff member had been rough with her, yelled at her and made her feel unhappy. Per Family Member G, Resident #3 told her she had asked for help and the staff basically said you can do it yourself and refused to take her to breakfast. Per Family Member G, Resident #3 thought the staff member was disrespectful and she was reluctant and embarrassed to talk about it. Family Member G stated she immediately reported the incident to the charge nurse and the facility started an investigation. Per review of facility provided 5 day summary document and supported by facility provided Individual Timecard for CNA D, CNA D was suspended at 10:48 AM on 1/16/2020, at least 2.5 hours after another employee viewed CNA D display abusive behavior towards a resident at approximately 8:00 AM. The witnessed allegation was potentially earlier than the estimated time of 8:00 AM due to call light logs and CNA D reporting she completed the resident's morning cares prior to a 7:15 AM meeting. Per Facility provided disciplinary paperwork, CNA D employment was terminated because she failed to treat an elder with kindness, respect, dignity and courtesy during morning care .(CNA D) failed to follow the approved plan of care for an elder that resulted in the elder expressing that she felt 'disrespected.' During the investigation of the complaint it was identified that another staff member heard (CNA D) speaking in an unkind manner to the elder. Resident #1 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was a [AGE] year old female initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Staff Assessment for Mental Status for Resident #1 indicated she had severe cognitive impairment and required extensive assistance for most activities of daily life (ADLs). Per review of Resident #1's care plan, there is a focus area with a date initiated of 8/16/2017: I have pain secondary to h/o (history of) left hip fx (fracture), decreased mobility and a hx of RLS and [MEDICAL CONDITION]. Interventions include Monitor/record/report to nurse any s/sx (signs or symptoms) of non-verbal pain . On 8/05/2020 at 10:05 AM Resident #1 was observed sleeping in her room on a mattress of the floor. Per interview with LPN K, Resident #1 spends most of her time on the floor, either sleeping or scooting around. LPN K stated that Resident #1 is not very communicative and can get very agitated at times. Based on facility submitted Incident Summary an allegation of abuse perpetrated by CNA B against Resident #1 occurred on 5/20/2020 at 7:12 PM and was not discovered until 5/21/2020 at 3:50 PM. The Investigation Summary document notes that abuse was not substantiated by the facility and the section Incident Summary of the document revealed: Although (Resident #1) verbalized discomfort when (CNA B) moved her, (CNA B) did not willfully inflict pain . and that CNA B admitted she could have verbally responded differently to Resident #1. The facility provided 5 Day Summary for this incident further revealed that on 5/21/2020 Dietary Aide (DA) L reported hearing (Resident #1) say 'ouch' when moved out of the dining room doorway by CNA B on the evening of 5/20/2020. During a follow up interview on 5/28/2020 DA L stated that on 5/20/2020, (Resident #1) was in the doorway of the dining room and the CNA (whose name she didn't know) stepped over (Resident #1) and pulled her out of the way .(DA L) stated 'she reached over the elder and under her arms, sliding her backwards, out of the doorway to shut the door. When the CNA moved her, (Resident #1) said 'ouch' .began stuttering and basically said you don't know what you're doing to my body.' The CNA responded by saying, 'you don't know what you're doing to my body when I have to pull you.' Per the document, during an interview completed by the facility with CNA B on 5/29/2020, CNA B admitted that she moved Resident #1 and the resident stated my body hurts and CNA B stated she responded that my back hurts. An interview was completed with RN H on 8/5/2020 at 1:30 PM regarding the incident with Resident #1. RN H confirmed she had completed the investigation regarding the incident and she was the Director of Nursing for the facility from February 2020 through July 2020. RN H confirmed that DA L had not immediately reported the incident. RN H stated that DA L was a newer employee at the time and stated she was not aware of the process due to being new. RN H stated she immediately provided verbal education to DA L related to reporting allegations immediately and who to report to. RN H was not aware of or could not recall if re-education was provided to all staff after this incident. On 8/5/2020, the personnel file for DA L was reviewed and no documentation of re-education or discipline related to abuse reporting for the 5/20/2020 incident was observed. RN A was asked on 8/5/2020 at 2:15 PM if any education or discipline was completed, RN A looked into the matter and later stated on 8/5/2020 at 2:45 PM that DA L's supervisor had indicated they completed verbal re-education with her but did not document anything in her personnel file. Per review of facility provided Individual Timecard for CNA B, on 5/20/2020 CNA B worked from 6:42 PM to 5:08 AM on 5/21/2020. The alleged incident of abuse with Resident #1 occurred at 7:12 PM on 5/20/2020 and CNA B completed an additional 10 hours of her shift after a witnessed allegation. Per facility provided disciplinary paperwork, CNA B's employment was terminated on 5/29/2020 due to an interaction with elder- overheard by another staff member telling the elder 'she doesn't know what she does to her back' when repositioning her. Attitude: failure to treat all persons with kindness, respect, and dignity using the appropriate tone of voice, and body language. The disciplinary paperwork further revealed CNA B received a verbal warning on 12/9/19 for her interaction and attitude while in an elder's room. On 3/13/20 (CNA B) received a final written warning related to her attitude and demeanor while in a patient care area.

Based on observation, interview, and record review, the facility failed to maintain appropriate infection control procedures on 2 of 6 halls (Clover Lane and Sunflower), potentially affecting 45 of 75 facility residents, resulting in the potential for the spread of COVID-19 and other respiratory illnesses. Findings include: A review of Resident #4's Admission Record, dated 7/22/20, revealed Resident #4 was an [AGE] year-old resident admitted to the facility on [DATE]. Resident #4's Admission Record revealed Resident #4 had multiple [DIAGNOSES REDACTED]. In addition, Resident #4's Admission Record, revealed Resident #4 was diagnosed with [REDACTED]. During an interview on 7/21/20 at 8:30 AM, Director of Compliance and Quality (DCQ) A stated the facility had 2 employees who tested positive for COVID-19 and no residents who tested positive. She stated the 2 employees that tested positive were both asymptomatic (displaying no symptoms of COVID-19) and were found during weekly testing of their staff. The first staff member to test positive was on 7/7/20. During an interview on 7/21/20 at 9:30 AM, certified nursing assistant (CNA) B stated since the COVID-19 pandemic they (facility staff) have been wearing face masks. She stated staff have to wear face masks the whole time they are in the facility, except to eat and/or drink. CNA B stated the units are basically run as self-contained areas with staff assigned to those areas spending their whole shift there. She stated there are designated staff break/eating areas on each unit. That way staff do not have to leave their units to eat or take breaks. During an interview on 7/21/20 at 9:50 AM, environmental services employee (ES) C stated staff have to wear masks all the time while in the facility, except when they are eating or drinking. During an observation on 7/21/20 at 1:45 PM, hospice aide (HA) F was observed walking on the Clover Lane hall with a mask on below her nose and only over her mouth. HA F exchanged pleasantries with me and then used hand sanitizer and went into Resident #2's room to provide care (could hear bits of conversation from outside the room from 1:45 PM to 2:00 PM) without adjusting her mask. During an observation on 7/21/20 at 2:00 PM, HA F exited Resident #2's room with her mask properly on (covering her nose and mouth). During an interview on 7/21/20 at 2:00 PM, HA F stated she comes to the facility twice a week on Tuesdays and Thursdays. She stated she always sees staff wearing face masks. During a second interview on 7/22/20 at 8:20 AM, DCQ A stated the hospital lab notified them this morning that one of their residents, (name of Resident #4), tested positive for COVID-19. She stated it was found when they did a house-wide testing of their residents. DCQ A stated Resident #4 was moved to the COVID unit (Apple Blossom hall) immediately after she was notified of the positive test result. A review of Resident #4's electronic medical record revealed Resident #4 had been a resident on the Sunflower hall prior to being transferred to the COVID unit. During an observation on 7/22/20 at 2:00 PM, Licensed Practical Nurse (LPN) I was observed sitting at the Sunflower nurse's station talking with another employee. Her mask was under her chin and around her neck. Her mouth and nose were not covered. When I approached the nurse's station, she turned away from me and quickly put her mask back on. During an interview at the Sunflower nurse's station on 7/22/20 at 2:00 PM, LPN I stated, I wasn't wearing my mask when you came up because I was drinking. If we're eating or drinking, we don't have to wear a mask. Otherwise we have to wear our masks. When LPN I was asked if she had been drinking from a bottle of water that she threw away as I came around the nurse's station (I had not observed her drinking or the container she had been drinking from) to talk with her or from a Styrofoam cup, she stated she had been drinking from a Styrofoam cup and moved her chair to show me the cup that she had drinking from placed behind her at the nurse's station. During the interview, LPN I had been deliberately placing her chair to block the cup from my view (she would move her chair from side-to-side when I shifted positions during the interview). During an interview on 7/22/20 at 2:10 PM, LPN J stated staff have to wear face masks at all times. The only time they do not have to wear their masks are when they are in designated areas on each unit that are set aside for eating and breaks. She stated while they are in these designated areas, they have to stay 6 feet apart from other employees, if there are other employees in the area at the same time. She stated that they can not eat or drink at the nurse's stations, in the hallways, or at their medication carts. LPN J stated as far as she knew, they never could have done that even before the COVID-19 pandemic. During a third interview on 7/22/20 at 4:30 PM, DCQ A stated staff have to wear face masks at all times while they are in the facility. The only exception is when they are in designated areas where they can eat. DCQ A stated staff cannot eat or drink at the nurse's station. She stated they cannot take their face masks off at the nurse's stations to eat, drink, or hold conversations with other staff members. During a second interview on 7/23/20 at 8:15 AM, LPN I stated the authorized area where staff eat and drink is in the room that was designated for staff on the Sunflower unit. She indicated that was the only place on the Sunflower unit that staff could eat and drink. A review of the facility's mandatory education training, dated 6/16/20 and 6/17/20, revealed the following: - Staff members must continue to wear cloth masks covering their nose and mouth while in the facility. Masks can only be removed to eat and staff members must eat their lunch in the assigned locations and remain at least 6 feet away from other employees while their mask is removed. If you are unsure where your department is assigned to eat please see your department head. - LPN I signed that she received the education on 6/16/20 on the staff sign-in sheet. A review of the facility's Personal Protective Equipment (PPE): Donning and Doffing policy and procedure, dated 3/31/20, revealed when staff don (put on) a face mask or respirator, they are to a. Secure ties or elastic bands at middle of head and neck. If Mask has elastic type ear straps, secure them around the ears. b. Fit flexible band to bridge of nose. c. Fit snug to face and below chin. A review of the Centers for Disease Control and Prevention (CDC) Use of Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 policy and procedure, undated, revealed, Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients.

Based on observation, interview and record review, the facility failed to report allegations of abuse to the state agency involving 11 residents (Residents #27, 12, 22, 18, 37, 46, 50, 59, 289, 290, and 86) resulting in incomplete investigations of allegations of abuse against Resident #27, #12 and #86 and the potential for their further abuse, pain and psychosocial harm as well as the potential for abuse for other vulnerable residents. Findings include: Review of facility provided policy Elder to Elder Altercations with a last revised date of 6/17/19 revealed no procedure or policy detailing the reporting of events to the state agency: All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator. Review of facility provided policy Abuse Program with a last revised date of 6/17/19 revealed: It is the policy of (facility) to maintain an environment free of abuse and neglect. Each and every Elder has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Elders will not be subjected to abuse, neglect or misappropriation of personal property by anyone. Definitions in the policy included Allegation: A statement saying someone had done something wrong, or illegal, typically made without proof, Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish (42.CFR488.301). Abuse involves willful, purposive and assertive action as opposed to negligent action, accidental action or lack of action. Abuse includes verbal, physical, sexual, or mental abuse, corporal punishment an involuntary seclusion, Physical abuse: Includes hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment: any type of impermissible or unjustifiable physical contact with an Elder that has resulted in injury or harm to the Elder, Verbal abuse: The use of oral, written or gestured language that willfully includes disparaging or derogatory terms to Elders or their families, within their hearing distance; regardless of their age or ability to comprehend . and Neglect: The failure, either intentionally or accidentally, to provide goods and services that are necessary to avoid physical harm, mental anguish or mental illness; with resulting harm to the Elder. Prevention strategies include: Elder care and treatment shall be monitored by all staff, on an ongoing basis, to assure that Elders are free from abuse, neglect, exploitation or mistreatment. It is the responsibility of all staff to provide a safe environment for the Elders. Under the section reporting: Any allegation or suspicion of abuse, neglect, exploitation, or mistreatment will be reported to the appropriate State Agency via MI-FRI website, by the Administrator or her designee, once sufficient data has been collected to be able to provide appropriate and accurate information. At no time will the initial reporting time period exceed twenty-four (24) hours, and Allegations that include suspicion of a crime being committed against and Elder will be reported within the specified time parameters of the Elder Justice Act. Reports under EJA will be made to the appropriate State Agency via the MI-FRI website and local law enforcement . Review of facility provided policy Abuse Prevention Policy with a last revised date of 6/17/19 revealed: Our residents have the right to be free from abuse, neglect, exploitation, misappropriation of Elder property, corporal punishment and involuntary seclusion. Under Policy Interpretation and Implementation: Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents . and abuse prevention is to include: Identification of occurrences and patterns of potential mistreatment/abuse, the protection of residents during abuse investigations, The development of investigative protocols governing Elder abuse, exploitation, theft/misappropriation of Elder property, resident-to-resident Elder abuse and resident-to-staff abuse, and All allegations of neglect, abuse, exploitation and misappropriation will be reported according to state and federal guidelines. Timely and thorough investigations of all reports and allegations of abuse will be conducted. Review of facility provided policy Abuse Investigations with a last revised date of 6/17/19 revealed: All reports/allegations of Elder abuse, neglect, exploitation, unauthorized photographs/images and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Interview guidelines include: The individual conducting the investigation will, as a minimum: a. Review the Elder's medical record to determine events leading up to the incident; b. Interview the person(s) reporting the incident; c. Interview any witnesses to the incident; Interview the Elder (as medically appropriate); e. Interview staff members who have had contact with the Elder during the period of the alleged incident; broadening the scope of interviews as necessary; f. Interview the Elder's roommate, family members, and visitors if appropriate; g. Interview other Elders to whom the accused employee provides care or services; if appropriate; h. Review all events leaving up to the alleged incident; j. submit preliminary report of the incident to survey agency as required. During the investigation any employee that is accused of patient abuse, whether physical, verbal or mental will be suspended without pay pending further investigation and the administrator and or designee will keep the Elder and his/her representative (sponsor) informed of the progress of the investigation. When the investigation is complete The Administrator/designee will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. Resident #27 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #27 was a [AGE] year old female initially admitted to the facility on [DATE] and most recently admitted on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #27 had moderate cognitive impairment and required extensive assistance for most activities of daily life (ADLs). Review of Resident #27's Electronic Medical Record (EMR) progress notes revealed a Health Status Note entered by Licensed Practical Nurse (LPN) Z on 9/29/2019 at 19:55 (7:55 PM): Elder call light was on CNA's (sic) went to answers (sic) the light. Elder had a complaint. They informed this nurse, I went into elders room with a cna, elder stated they bent my legs when they put me to bed, I told them not too (sic), now my leg is broke or smashed. Both legs slightly bent, Assess the right leg due to elder stating that was the leg that hurts. No swelling, no redness nor bruising noted at this time. Pedal pulse present. When this nurse raised her right leg up slightly, she stated ouch. Offered elder pain meds. She said no. Notified on call nurse and DON (Director of Nursing). There was no progress note detailing a contact with Resident #27's physician or an examination by the physician or physician assistant There was no progress note of any social work follow up or notification of Resident's #27's DPO[NAME] There was no documentation of a contact with law enforcement. Review of the facility provided a folder regarding the allegations of abuse reported by Resident #27 revealed no completion of an incident or unusual occurrence report. There was no contact with Resident #27's guardian or physician or local law enforcement. Written statements were obtained by the 2 certified nursing assistants currently on shift at the time of the allegation, however there were no follow up interviews completed with any other care providers or staff on other shifts to identify other potential perpetrators of abuse. There is no documentation of the CNAs on shift at the time of the allegation being suspended while an allegation of abuse was investigated. No interviews with like residents are documented. A follow up physical assessment is not documented. The investigation revealed Elder is care planned for two assist in room for all cares related to history of manipulation and false statements against staff. The conclusion by Registered Nurse (RN) A revealed: there was no [MEDICATION NAME] emotional, pain or psychosocial anguish as evidenced by the interview of (Resident #27) on 9-30-19. No social work follow up was provided in the incident folder. During an interview on 10/17/2018 at 11:25 AM completed with Resident #27 as well as with family members QQ and WW. Resident #27 was asked if she felt safe in the facility and she replied no, when asked if someone had hurt her, she stated yes, I have been poked in the bottom. Resident #27 stated she still has some pain from it, but not very much at this time. Resident #27 stated I have complained about it before and nothing has been done about it. Resident #27 stated that there were 3 staff I don't feel safe with, but don't know their names. Resident #27 could not recall specific dates of being harmed but indicated it's been quite a few times and it is not a specific time of day that it happened. Resident #27 stated that it doesn't do any good to tell anyone about it. Family member WW stated they had not been informed of any abuse investigation that they could recall and has heard Resident #27 state multiple times Why are they doing that to me? but did not know what she was talking about. Family member QQ stated they are the Resident's guardian and had also not been informed of any abuse concerns recently. Family member QQ was specifically asked about the incident on 9/29/19, and she stated she had not been informed of this incident. Both QQ and WW were very concerned about the allegations being made by Resident #27 and stated they often do not observe her care and step out of the room as she is being assisted. During an interview with the DON on 10/17/19 at 11:50 AM, she confirmed that a facility reported incident had not been reported to the state agency regarding the allegations made by Resident #27 on 9/29/19. The further disclosure made by Resident #27 to the surveyor was reported to the DON and the Nursing Home Administrator at this time. During an interview on 10/18/19 at 01:30 PM with the DON, the disclosure by Resident #27 on 9/29/2019 was discussed. The DON agreed that they would expect a physical exam and range of motion (ROM) to be assessed with [REDACTED]. The DON stated that the nurse probably should have called the doctor. The DON was asked if they had any proof that Resident #27 did not have a fracture at this time and she stated they did not have reason to believe Resident #27 had a fracture. The DON stated that Resident #27 has chronic pain and delusions. The DON went on that when Resident #27 was assessed on 9/29/19, there was no redness or bruising so there was no indication of a fracture. The DON stated the legs were most likely in bent position due to the resident just being transferred by Hoyer lift. Resident #12 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #12 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The staff assessment of mental status indicated Resident #12 had severe cognitive impairment and required minimal to extensive assistance for activities of daily life (ADLs). Review of Resident #12's care plan revealed a focus area: I have paranoid thoughts. I believe that people are stealing from me. I grew up in Germany during WWII. I would run through the fields with my siblings when the airplanes were dropping bombs. We used to hide. I do no do well with loud noises. I have a dx (diagnosis) of [MEDICAL CONDITION] .I am easily agitated .Behaviors have impacted ability to function and receive the care that I need. The listed goal is: I will feel safe and content through the review date . Review of Resident #12's medical record and incident reports revealed 7 separate incidents on 1/15/19, 2/6/19, 2/14/19, 4/11/19, 4/13/19, 7/2/19 and 9/6/19 involving resident to resident altercations. 5 of these Resident #12 is the victim and 2 of these incidents included a physical injury to Resident #12. Per review of a facility provided incident form, on 1/15/19: While coming out of the med room, I heard a slapping sound. Observed (2 staff members) separating (Resident #12 and Resident #289). Was informed (Resident #12) walked up to (Resident #289) and slapped (Resident #289) 'She hit me.' Neither the incident report nor the attached report noted where Resident #289 was slapped due to the physical contact being unwitnessed by staff. The conclusion revealed: Although there was direct elder to elder contact; neither elder sustained any injury or negative effect from the exchange . There was no documentation of referral to the state agency. Per review of a facility provided incident form, on 2/6/19: (Resident #12) was slapped across L side of check/neck by (Resident #50) after they argued and called each other [***] es .elder stated she's mean and nasty I can't stand her, no c/o pain. The conclusion on the attached report revealed: It is our professional opinion that no physical harm, [MEDICATION NAME] pain, or mental anguish occurred related to the interaction between the two elders. Although the contact was willful at the time it occurred, (Resident #50) is unable to understand the consequences of her actions, she did not remember the incident within 10 minutes following. (Resident #12) had no [MEDICATION NAME] effect as evidenced by her participation in the activity and later being witnessed by staff to be talking with staff and hugging workers in the area. There was no documentation of referral to the state agency. There was no additional attached report or further investigation. There was no documentation of referral to the state agency. Per review of a facility provided incident form, on 2/14/19: (Resident #12) was sitting next to (Resident #290) on the couch. (Resident #290) reached over and tried to grab (Resident #12's) arm, (Resident #12) yelled at her. (Resident #290) reached over and scratched (Resident #12) across the chest, breaking the skin. There was no additional attached report or further investigation. There was no documentation of referral to the state agency or local law enforcement. Per review of a facility provided incident form, on 4/11/19: (Resident #12) walked by (Resident #59) who was slapping at the cna who was caring for (Resident #59). During this time, (Resident #59) reached out and held on to (Resident #12's) dress. In turn, (Resident #12) made contact with (Resident #59's) cheek with her opened hand. This nurse immediately assessed (Resident #59 and #12), neither who had any marks. Neither elder had any recollection of the incident immediately after incident occurred. Per review of a facility provided incident form, on 4/13/19: CENA went into elders room to find (Resident #12 and Resident #50) squeezing each other's wrists and yelling at each other. Upon assessing (Resident #12), it was noted that the right top of her right hand/first knuckle is swollen and slightly bruised. It was also noted that her left top of hand had bruising- (Resident #12) was rubbing hand saying it was painful. There was an additional incident report completed by a separate staff member that revealed Upon assessing (Resident #12), it was noted that the right top of her hand/first knuckle is swollen and slightly bruised. It was also noted that her left top of hand had bruising-elder was rubbing hand saying it was painful .The conclusion by RN A revealed: no [MEDICATION NAME] pain, mental anguish or emotional distress occurred related to the interaction between these two elders. Although the contact was willful at the time it occurred, (Resident #50) is unable to understand the consequences of her actions; She did not remember the occurrence within 10 minutes following. (Resident #12) had no [MEDICATION NAME] effect as evidenced by her continued ambulation with her walker and participation in the activities of the milieu. The discoloration to (Resident #12's) hand had resolved within 24 hours and a negative x-ray finding was obtained. There was no documentation of referral to the state agency or local law enforcement. Per review of a facility provided incident form, on 7/2/19: While ambulating down the hallway with walker, CNAs observed (Resident #12) come from dining room and down the hall. (Resident #37) was sitting in the hallway in the path of direction for (Resident #12). (Resident #12) then bumped walker into (Resident #37's) back and told elder to 'move.' At this time, (Resident #37) sitting on the floor got up and raised fist at (Resident #12) with no contact made. The conclusion revealed: Neither elder remembered the incident within a few minutes of occurrence. Both elder's (sic) continued their normal routines without further interactions or signs of pain, discomfort or distress. The interactions by each elder was intentional, but neither elder is able to comprehend the consequences of their actions . There was no additional attached report or further investigation. There was no documentation of referral to the state agency. Per review of a facility provided incident form, on 9/6/19: RN notified CNA witnessed (Resident #12's) wrist being grabbed by (Resident #46) as (Resident #12) was walking down the hallway. Staff redirected them but (Resident #46) had a very firm grip on (Resident #12's) wrist. An attached statement completed by CNA T revealed: I was in the room with another elder, but could hear (Resident #12) scream let me go and when I came out of the elders room (CNA BB) told me (Resident #46) had grabbed (Resident #12's) wrist forcefully. The conclusion revealed: It is the professional opinion of (facility) that no abuse or neglect occurred when these elders interacted in the hallway of (unit residents reside). Both elders did hold the hand of the other elder which did not harm the other elder with the interaction . There was no documentation of referral to the state agency. During an interview with the Director of Nursing (DON) on 10/17/2019 at 8:45 AM she confirmed that resident #12 had no Facility Reported Incidents (FRIs) reported to the state agency in the last year. During a follow up interview with the DON on 10/17/2019 at 2:30 PM she was questioned on the lack of FRI reporting to the state agency. The DON stated that the incidents with Resident #27 and Resident #12 didn't fit the definition of abuse and therefore were not reportable. They also were note reported to law enforcement. The DON stated that the incidences did not include and willful acts in her opinion and there was no pain, mental anguish or harm. The DON was directed to review a specific incident with Resident #12 and Resident #290, where Resident #12 was scratched and describe why this incident was not reported. The DON replied I have no answer for that. Resident #22 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #12 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The staff assessment of mental status indicated Resident #22 had severe cognitive impairment. Review of Resident #22's medical record and incident reports revealed 2 separate incidents involving resident to resident altercations. Per review of facility provided incident form, on 7/21/19: CNA informed RN that (Resident #37) was scooting on the floor near (Resident #22) and then grabbed her ankles. The conclusion revealed: There was no infliction of injuries as noted in the skin assessment following the interaction. There were no outward signs and symptoms of distress to the elder following contact. She is in the 7th stage of dementia and did not recollect the incident shortly after it occurred. It is the professional opinion of (the facility) that no [MEDICATION NAME] pain, emotional distress, or mental anguish occurred related to the interaction. There was no additional attached report or further investigation. There was no documentation of referral to the state agency. Per review of facility provided incident form, on 9/4/19: (Resident #22) was in the common area in her broda chair. She reached over and grabbed ahold of (Resident #18) by the ankle. CNA intervened and separated the elders. A witness statement by CNA PP revealed .she grabbed (Resident #18's) right ankle, (Resident #18) screamed. I pulled (Resident #22) away from (Resident #18). (Resident #22) used curse words and started grabbing/squeezing my hand. There was no additional attached report or further investigation. There was no documentation of referral to the state agency. During an interview with the DON on 10/17/19 at 11:50 AM she confirmed that neither of the incidents involving Resident #22 had been reported to the state agency. Resident #86 (R86) Review of a Face Sheet revealed R86 was a [AGE] year old male, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. R86 was cognitively intact with a BIMS of 15/15. Review of a Bedside Kardex Report revealed R86 required assistance from two staff for repositioning and turning in bed. During an interview on 10/15/19 at 11:03 [NAME]M., R86 stated that about a month ago he had an issue with a CNA that was helping him get cleaned up in the morning. R86 described that he was being rolled onto his side and CNA R pulled his shoulder and knee, causing pain. R86 stated that he told CNA R that he was in pain and told the CNA to stop. (CNA R) did not stop. R86 stated that after the incident, a nurse did not come in to assess or evaluate his pain. R86 stated that he told the nurse assigned to him that morning, what had happened. During the same interview, R86 stated that he will no longer allow CNA R to care for him. What (CNA R) did was wrong. Review of a facility investigation, completed on 09/06/19, revealed CNA R was questioned by RN A and LPN FF. During that interview, CNA R reported that on 09/05/19 at approximately 10:30 [NAME]M., while giving cares, R86 had stated, Let go of my arm, he accused me of abuse. During the same interview, CNA R indicated that she had reported the incident with R86 to RN N and UM FF immediately following the incident. During an interview on 10/17/19 at 08:56 [NAME]M., RN N indicated that she did not tell anyone what CNA R had reported because she thought that (Unit Manager) UM FF was standing there and heard what CNA R was reporting. RN N stated I think I was told about the incident in the afternoon, but I'm not sure. My memory is not very good. During an interview on 10/16/19 at 4:04 P.M., the DON (director of nursing)/ abuse coordinator stated that CNA R had been permanently removed from caring for R86. The DON also indicated that the incident between CNA R and R86 had not been reported to the State of Michigan because it did not meet the criteria on the MI FRI web page. During an interview on 10/17/19 at 08:35 [NAME]M., the DON/abuse coordinator indicated that she was not notified of the incident between R86 and CNA R until the evening of 09/06/19, approximately 10 and a half hours after the incident. The DON/abuse coordinator also indicated that the evening of 09/06/19 she spoke by phone with CNA P, one of the CNA's in R86's room at the time of the incident on 09/05/19, and based on CNA 'P's statement, it was determined that abuse had not occurred based on the definition willful. Review of the facility policy/procedure Abuse Program, last revised 06/17/19, revealed (A) the definition of Allegation: A statement saying that someone had done something wrong or illegal, typically without proof. (B) Any allegation or suspicion of abuse .will be reported to the appropriate State Agency via MI-FRI website. Review of the facility policy/procedure Abuse Investigations, last revised 06/17/19, revealed All reports/allegations of Elder abuse, neglect, exploitation, unauthorized photographs/images and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Review of the same policy procedure also revealed . (3) The individual conducting the investigation will, as a minimum: . j. Submit preliminary report of incident to survey agency as required.

Based on observation, interview, and record review, the facility failed to prevent abuse for two residents (#86 and #12) resulting in injury and pain and neglected two residents (#86 and #27) by failing to assess and respond to pain related to an abuse allegations and failing to complete a comprehensive abuse investigation to identify potential perpetrators of abuse of Resident #27 resulting in the potential for continued abuse, pain and psychosocial harm. Findings include: Review of facility provided policy Elder to Elder Altercations with a last revised date of 6/17/19 revealed no procedure or policy detailing the reporting of events to the state agency: All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator. Review of facility provided policy Abuse Program with a last revised date of 6/17/19 revealed: It is the policy of (facility) to maintain an environment free of abuse and neglect. Each and every Elder has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Elders will not be subjected to abuse, neglect or misappropriation of personal property by anyone. Definitions in the policy included Allegation: A statement saying someone had done something wrong, or illegal, typically made without proof, Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish (42.CFR488.301). Abuse involves willful, purposive and assertive action as opposed to negligent action, accidental action or lack of action. Abuse includes verbal, physical, sexual, or mental abuse, corporal punishment an involuntary seclusion, Physical abuse: Includes hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment: any type of impermissible or unjustifiable physical contact with an Elder that has resulted in injury or harm to the Elder, Verbal abuse: The use of oral, written or gestured language that willfully includes disparaging or derogatory terms to Elders or their families, within their hearing distance; regardless of their age or ability to comprehend . and Neglect: The failure, either intentionally or accidentally, to provide goods and services that are necessary to avoid physical harm, mental anguish or mental illness; with resulting harm to the Elder. Prevention strategies include: Elder care and treatment shall be monitored by all staff, on an ongoing basis, to assure that Elders are free from abuse, neglect, exploitation or mistreatment. It is the responsibility of all staff to provide a safe environment for the Elders. Under the section reporting: Any allegation or suspicion of abuse, neglect, exploitation, or mistreatment will be reported to the appropriate State Agency via MI-FRI website, by the Administrator or her designee, once sufficient data has been collected to be able to provide appropriate and accurate information. At no time will the initial reporting time period exceed twenty-four (24) hours, and Allegations that include suspicion of a crime being committed against and Elder will be reported within the specified time parameters of the Elder Justice Act. Reports under EJA will be made to the appropriate State Agency via the MI-FRI website and local law enforcement . Review of facility provided policy Abuse Prevention Policy with a last revised date of 6/17/19 revealed: Our residents have the right to be free from abuse, neglect, exploitation, misappropriation of Elder property, corporal punishment and involuntary seclusion. Under Policy Interpretation and Implementation: Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents . and abuse prevention is to include: Identification of occurrences and patterns of potential mistreatment/abuse, the protection of residents during abuse investigations, The development of investigative protocols governing Elder abuse, exploitation, theft/misappropriation of Elder property, resident-to-resident Elder abuse and resident-to-staff abuse, and All allegations of neglect, abuse, exploitation and misappropriation will be reported according to state and federal guidelines. Timely and thorough investigations of all reports and allegations of abuse will be conducted. Review of facility provided policy Abuse Investigations with a last revised date of 6/17/19 revealed: All reports/allegations of Elder abuse, neglect, exploitation, unauthorized photographs/images and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Interview guidelines include: The individual conducting the investigation will, as a minimum: a. Review the Elder's medical record to determine events leading up to the incident; b. Interview the person(s) reporting the incident; c. Interview any witnesses to the incident; Interview the Elder (as medically appropriate); e. Interview staff members who have had contact with the Elder during the period of the alleged incident; broadening the scope of interviews as necessary; f. Interview the Elder's roommate, family members, and visitors if appropriate; g. Interview other Elders to whom the accused employee provides care or services; if appropriate; h. Review all events leaving up to the alleged incident; j. submit preliminary report of the incident to survey agency as required. During the investigation any employee that is accused of patient abuse, whether physical, verbal or mental will be suspended without pay pending further investigation and the administrator and or designee will keep the Elder and his/her representative (sponsor) informed of the progress of the investigation. When the investigation is complete The Administrator/designee will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. Resident #27 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #27 was a [AGE] year old female initially admitted to the facility on [DATE] and most recently admitted on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #27 had moderate cognitive impairment and required extensive assistance for most activities of daily life (ADLs). Review of Resident #27's care plan revealed a goal in regards to pain: I have a hard time saying what an acceptable pain level is for me because of the years I have had back pain. Review of Resident #27's Electronic Medical Record (EMR) progress notes revealed a Health Status Note entered by Licensed Practical Nurse (LPN) Z on 9/29/2019 at 19:55 (7:55 PM): Elder call light was on CNA's (sic) went to answers (sic) the light. Elder had a complaint. They informed this nurse, I went into elders room with a cna, elder stated they bent my legs when they put me to bed, I told them not too (sic), now my leg is broke or smashed. Both legs slightly bent, Assess the right leg due to elder stating that was the leg that hurts. No swelling, no redness nor bruising noted at this time. Pedal pulse present. When this nurse raised her right leg up slightly, she stated ouch. Offered elder pain meds. She said no. Notified on call nurse and DON (Director of Nursing). There was no progress note detailing a contact with Resident #27's physician or an examination by the physician or physician assistant There was no progress note of any social work follow up or notification of Resident's #27's DPO[NAME] There was no documentation of a contact with law enforcement. Review of the facility provided a folder regarding the allegations of abuse reported by Resident #27 revealed no completion of an incident or unusual occurrence report. There was no contact with Resident #27's guardian or physician or local law enforcement. Written statements were obtained by the 2 certified nursing assistants currently on shift at the time of the allegation, however there were no follow up interviews completed with any other care providers or staff on other shifts to identify other potential perpetrators of abuse. There is no documentation of the CNAs on shift at the time of the allegation being suspended while an allegation of abuse was investigated. No interviews with like residents are documented. A follow up physical assessment is not documented. The investigation revealed Elder is care planned for two assist in room for all cares related to history of manipulation and false statements against staff. The conclusion by Registered Nurse (RN) A revealed: there was no [MEDICATION NAME] emotional, pain or psychosocial anguish as evidenced by the interview of (Resident #27) on 9-30-19. No social work follow up was provided in the incident folder. During an interview on 10/17/2018 at 11:25 AM, completed with Resident #27 as well as with family members QQ and WW. Resident #27 was asked if she felt safe in the facility and she replied no, when asked if someone had hurt her, she stated yes, I have been poked in the bottom. Resident #27 stated she still has some pain from it, but not very much at this time. Resident #27 stated I have complained about it before and nothing has been done about it. Resident #27 stated that there were 3 staff I don't feel safe with, but don't know their names. Resident #27 could not recall specific dates of being harmed but indicated it's been quite a few times and it is not a specific time of day that it happened. Resident #27 stated that it doesn't do any good to tell anyone about it. Family member WW stated they had not been informed of any abuse investigation that they could recall and has heard Resident #27 state multiple times Why are they doing that to me? but did not know what she was talking about. Family member QQ stated they are the Resident's guardian and had also not been informed of any abuse concerns recently. Family member QQ was specifically asked about the incident on 9/29/19, and she stated she had not been informed of this incident. Both QQ and WW were very concerned about the allegations being made by Resident #27 and stated they often do not observe her care and step out of the room as she is being assisted. During an interview with the DON on 10/17/19 at 11:50 AM, she confirmed that a facility reported incident had not been reported to the state agency regarding the allegations made by Resident #27 on 9/29/19. The further disclosure made by Resident #27 to the surveyor was reported to the DON and the Nursing Home Administrator at this time. During an interview on 10/18/19 at 01:30 PM with the DON, the disclosure by Resident #27 on 9/29/2019 was discussed. The DON agreed that they would expect a physical exam and range of motion (ROM) to be assessed with [REDACTED]. The DON stated that the nurse probably should have called the doctor. The DON was asked if they had any proof that Resident #27 did not have a fracture at this time and she stated they did not have reason to believe Resident #27 had a fracture. The DON stated that Resident #27 has chronic pain and delusions. The DON went on that when Resident #27 was assessed on 9/29/19, there was no redness or bruising so there was no indication of a fracture. The DON stated the legs were most likely in bent position due to the resident just being transferred by Hoyer lift. Resident #12 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #12 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The staff assessment of mental status indicated Resident #12 had severe cognitive impairment and required minimal to extensive assistance for activities of daily life (ADLs). Review of Resident #12's care plan revealed a focus area: I have paranoid thoughts. I believe that people are stealing from me. I grew up in Germany during WWII. I would run through the fields with my siblings when the airplanes were dropping bombs. We used to hide. I do no do well with loud noises. I have a dx (diagnosis) of [MEDICAL CONDITION] .I am easily agitated .Behaviors have impacted ability to function and receive the care that I need. The listed goal is: I will feel safe and content through the review date . Review of Resident #12's medical record and incident reports revealed 7 separate incidents on 1/15/19, 2/6/19, 2/14/19, 4/11/19, 4/13/19, 7/2/19 and 9/6/19 involving resident to resident altercations. 5 of these Resident #12 is the victim and 2 of these incidents included a physical injury to Resident #12. Per review of a facility provided incident form, on 2/14/19: (Resident #12) was sitting next to (Resident #290) on the couch. (Resident #290) reached over and tried to grab (Resident #12's) arm, (Resident #12) yelled at her. (Resident #290) reached over and scratched (Resident #12) across the chest, breaking the skin. There was no additional attached report or further investigation. There was no documentation of referral to the state agency or local law enforcement. Per review of a facility provided incident form, on 4/13/19: CENA went into elders room to find (Resident #12 and Resident #50) squeezing each other's wrists and yelling at each other. Upon assessing (Resident #12), it was noted that the right top of her right hand/first knuckle is swollen and slightly bruised. It was also noted that her left top of hand had bruising- (Resident #12) was rubbing hand saying it was painful. There was an additional incident report completed by a separate staff member that revealed Upon assessing (Resident #12), it was noted that the right top of her hand/first knuckle is swollen and slightly bruised. It was also noted that her left top of hand had bruising-elder was rubbing hand saying it was painful .The conclusion by RN A revealed: no [MEDICATION NAME] pain, mental anguish or emotional distress occurred related to the interaction between these two elders. Although the contact was willful at the time it occurred, (Resident #50) is unable to understand the consequences of her actions; She did not remember the occurrence within 10 minutes following. (Resident #12) had no [MEDICATION NAME] effect as evidenced by her continued ambulation with her walker and participation in the activities of the milieu. The discoloration to (Resident #12's) hand had resolved within 24 hours and a negative x-ray finding was obtained. There was no documentation of referral to the state agency or local law enforcement. During an interview with the Director of Nursing (DON) on 10/17/2019 at 8:45 AM, she confirmed that resident #12 had no Facility Reported Incidents (FRIs) reported to the state agency in the last year. During a follow up interview with the DON on 10/17/2019 at 2:30 PM she was questioned on the lack of FRI reporting to the state agency. The DON stated that the incidents with Resident #27 and Resident #12 didn't fit the definition of abuse and therefore were not reportable. The DON stated that the incidences did not include and willful acts in her opinion and there was no pain, mental anguish or harm. The DON was directed to review a specific incident with Resident #12 and Resident #290, where Resident #12 was scratched and describe why this incident was not reported. The DON replied I have no answer for that. Resident #86 (R86) Review of a Face Sheet revealed R86 was a [AGE] year old male, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. R86 was cognitively intact with a BIMS of 15/15. Review of a Bedside Kardex Report revealed R86 required assistance from two staff for repositioning and turning in bed. During an interview on 10/15/19 at 11:03 [NAME]M., R86 stated that about a month ago he had an issue with a CNA that was helping him get cleaned up in the morning. R86 described that he was being rolled onto his side and CNA R pulled his shoulder and knee, causing pain. R86 stated that he told CNA R that he was in pain and told the CNA to stop. (CNA R) did not stop. R86 stated that after the incident, a nurse did not come in to assess or evaluate his pain. R86 stated that he told the nurse assigned to him that morning what had happened. During the same interview, R86 stated that he will no longer allow CNA R to care for him. What (CNA R) did was wrong. During an interview on 10/16/19 at 4:04 P.M., the DON (director of nursing) stated that CNA R had been permanently removed from caring for R86. During an interview on 10/18/19 at 8:37 [NAME]M., CNA L indicated that she was in R86's room when the incident occurred between R86 and CNA R. CNA L stated, When CNA R was rolling (R86), (R86) has a bad side, (CNA R) put a hand on him, (CNA R) pulled (R86) close, (R86) said ouch that hurts, let go of my leg, then (CNA 'R) grabbed his wrist or something, I really couldn't tell what was going on. I was in there 5 minutes or less. Review of a facility investigation, completed on 09/06/19, revealed CNA R was questioned by RN A and LPN FF. During that interview, CNA R reported that on 09/05/19 at approximately 10:30 [NAME]M., while giving cares, R86 had stated, Let go of my arm, he accused me of abuse. Review of a facility investigation, completed 09/06/19, revealed R86 was questioned by social worker VV'. During that interview, R86 stated that (CNA R) was changing me and rolling me over. (CNA R) pulled my knee to turn me. My wrist hit (CNA R's) leg or some part of (CNA R's) body and it made my wrist push into (CNA R). Both my knee and my wrist hurt. I told (CNA R) to let go of me and (CNA R) didn't. After (CNA R) was done, I told (CNA R) not to come to my side of the room again. I told (CNA R) that I was going to report this. CNA R said, 'I have got witnesses. Everyone knows what you are like'.

Based on observation, interviews, and record review, the facility failed to prevent accidents and provide adequate assistance to prevent falls for 7 of 19 Residents reviewed for falls, (Resident #3, Resident #4, Resident #8, Resident #16, Resident #17, Resident #18, and Resident #21) and 1 of 3 supplemental residents (Resident #26), from a total sample of 23 residents, resulting in Resident #8 sustaining fractures (thoracic vertebral fractures of T1 and T3 and a right hip fracture) and other residents having injures and potential for serious injury Findings include: Resident #4 Review of Resident #4's face sheet dated 6/28/16, revealed she was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #4 was not her own responsible party. Brief Interview of Mental Status score (BIMS) 4/18/16 was 11/15 (moderate cognitive impairment). Review of Resident #4's falls revealed she had a witnessed fall on 3/26/16 and an un-witnessed fall on 5/30/16. The fall on 3/26/16 resulted in a pelvic fracture and the care plan was updated to provide Resident #4 with assistance while walking. The incident report did not give a root cause analysis for the fall on 3/26/16 Review of the incident report for Resident #4's fall on 5/30/16 at 2:10 AM documented the fall was un-witnessed, and Resident #4 was found scooting in the hallway on her buttock and stated she fell outside the bathroom. There were no witness statements located or any root cause analysis for this fall. The care plan was updated for hipsters on at all times, wheel chair in hall when not in use, two wheeled walker at bedside (resident required assistance of one person with walking according to care plan) and call light attached to clothing and not placed under pillow. During an interview with Unit Manager (UM) L on 6/28/16 at 9:20 AM, L said she was working on 5/30/16 at 2:10 AM when Resident #4 fell . L said Resident #4 had been assisted to the toilet just prior to the fall and it is not unusual for Resident #4 to request to go to the bathroom again shortly after using the toilet. This Surveyor asked where this information and any investigation /witness statement was located and UM said there was not investigation and the incident report did not have this information. This Surveyor asked if Resident #4 had been assessed for bowel or bladder problems because she frequently requested going to the bathroom within minutes of using the bathroom and UM L said no it is just her dementia. Upon review of Resident #4's bowel record, Resident #4 had several days in May where she refused her bowel medication and had multiple days of no bowel movement. Resident #4 had some improvement of taking her bowel medication near the end of May, but was charted as no bowel movement for more than 24 hours prior to the fall on 5/30/16 when Resident #4 had just used the bathroom and within 15 minutes of using the bathroom and attempting to take herself back to the bathroom. There was no indication on Resident #4's fall care plan to watch for an increased need to use the toilet when bowel medication was refused or has not moved bowel for 24 hours. ( ) Resident #16 Review of Resident #16's medical record revealed he was a [AGE] year old male admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Review of Resident #16's falls revealed he had 4 un-witnessed falls since admission (4/11/16, 4/16/16, 4/30/16 and 6/15/16). None of the incident reports for these falls had an investigation or witness statements. None of the incident reports or fall documentation had a root cause analysis for the falls. Resident #16 had a fall care plan that documented Resident #16 was unaware of safety needs, had confusion, poor communication/comprehension, gait/balance problems and incontinence. Resident #16 was to be in view of staff or family at all times except when in bed and the bed was to be in the low position. This care plan was dated 3/7/16. Review of the incident report for Resident #16 dated 4/11/16 at 11:04 AM, documented Resident #16 was found on the floor in his room in front of his wheel chair and Resident #16 stated he was going to use the bathroom. According to a note added to the incident report on 4/15/16 Resident #16 was placed in his room by therapy the day off the fall (not following care plan to be in view at all times when out of bed). Therapy turned on the call light because Resident #16 had requested to use the bathroom staff did assist to the toilet but left him in the room again out of view, (not following fall care plan). When resident was assessed after the fall he again requested to use the toilet and had a bowel movement. Review of the un-witnessed incident report for Resident #16 dated 6/15/16 at 22:02 (10:02 PM), documented he was found on the floor in his room with his head under his wheel chair and back between the foot pedals. Resident stated, I wanted to go to bed. I wanted to go to the bathroom. (Fall care plan documented resident to be in view at all times when up in wheel chair, event was un-witnessed indicating he was not in view when he fell out of his wheel chair). Resident #17 Review of Resident #17's medical record revealed she was an [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #17's Brief Interview of Mental Status score on 6/9/16 was 3/15 (severe cognitive impairment). Review of Resident #17's fall care plan dated 6/4/16 and revised on 6/20/16 revealed Resident #17 had a history of [REDACTED]. Resident #17 suffered a hematoma within 96 hours of admission due to a fall and the care plan indicated Resident #17 was to use her call light (residents with severe cognitive impairment rarely remember to use there call light). The only interventions listed on the fall care plan were anticipate and meet the elders needs and ensure that I am wearing appropriate nonskid footwear/grippy socks when walking with staff with a two wheeled walker or propelling her wheel chair. Review of Resident #17's witnessed fall report dated 6/7/16 at 20:35 (8:35 PM)documented a Certified Nurses Aide was walking by Resident #17's room when she observed her fall. The nurse was called to the room and found Resident #17 on the floor next to her bed. Resident #17's pants and brief were down around her ankles. Resident #17 had a goose egg (raised area) on her forehead and a 2 cm x 1.5 cm skin tear on her left elbow. Resident #17 said she was going to the bathroom. (Resident #17 was care planned for assistance with transfer and walking). The initial intervention was 15 minute checks according to the incident report, but this was not on the current care plan. No long term intervention was identified to ensure Resident #17 was provided adequate assistance and supervision to this date. ( ) Resident #3 Review of a facility Admission Record indicated Resident #3 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 had severe cognitive impairment and needed extensive assistance from one person for transfers. Review of a Care Plan dated 3/23/15 indicated Resident #3 did not understand her limitations and was not allowed to go into her room unattended because on several occasions, I have gotten out of my wheelchair and I have fallen. Interventions indicated Resident #3 was on 15 minute checks and needed to be looked after from a distance to preserve her safety. Review of another Care Plan dated 9/23/15 indicated Resident #3 could be anticipated to have Recurrent falls related to her [DIAGNOSES REDACTED]. Interventions indicated staff were Not to leave (Resident #3) alone in her room/dayroom for my safety as I attempt to self transfer; I need activities that minimize the potential for falls while providing diversion and distraction .; Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter and remove any potential root causes if possible. Educate resident/family/caregivers/IDT as to causes. Review of an Incident Report dated 4/11/16 indicated Resident #3 had an unwitnessed fall in the day room at the end of the hall where the resident lived. The report indicated Elder self transferred herself into the dayroom at the end of Begonia Lane while staff member was assisting another elder .elder impulsive and has a history of self-transferring .elder remains on 15 minute checks . A statement included in the report indicated Certified Nurse Aide (CNA) X reported Resident #3 had been at the front of the hall people watching when she went to assist another resident, I know she can't be in there and last I saw her, she was by the front of the hall people watching. No indication Resident #3 had been given an activity to divert her attention was noted and the continuation of 15 minute checks as an effective intervention is questionable given Resident #3's ability to independently propel herself around the facility in short periods of time. No root cause analysis was noted in the incident report. Resident #18 Review of an Admission Record indicated Resident #18 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was cognitively intact and needed limited assistance of one person for transfers. Review of a Care Plan dated 5/19/15 indicated Resident #18 had Deconditioning, Gait/balance problems, frequent urinary incontinence, and dementia. Interventions included Dycem (a non-slip material) needs to be placed under my wheelchair pressure-relief cushion and recliner pressure-relief cushion in order to reduce the chances of my cushion sliding off my seat and falling. Additional interventions indicated staff were to Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review of an Incident Report dated 11/5/2015 indicated Resident #18 slipped off her recliner chair while she was attempting to put her shoes on to self-transfer to her wheelchair and go to the bathroom. The report indicated Incontinence pad noted to be on floor under elder's buttocks and appeared to have slipped off of chair. Dycem (a non-slip material) in place under pressure-relief cushion in recliner but not under the incontinence pad (a slip hazard). Further review of the report did not include statements from staff who were working at the time of the fall. The report did not include an investigation into why the resident was attempting to self-transfer, when she had last been assisted to the toilet or why she did not use the call light (calling into question the resident's ability to reach the call light). During an interview on 6/29/16 at 11:45 a.m., Registered Nurse (RN) D said she was the Quality Assurance/Process Improvement (QAPI) nurse at the facility. RN D reported there was a fall committee that reviewed resident falls that met monthly. RN D reported the falls committee did not do root cause analysis. Resident #8 According to an Admission Record (Face Sheet) printed 6/28/16, Resident #8 was a [AGE] year old female admitted to the facility 11/2/12 with a readmission 2/22/16. [DIAGNOSES REDACTED]. blood pressure). Resident #8's minimum data set (MDS), assessments dated 5/19/16 (a significant change, comprehensive assessment) and a quarterly assessment dated [DATE], both reflected a brief interview for mental status (BIMS) at a 3 of a possible 15, with severe cognitive impairment. Resident #8's MDS reflected significant changes in several areas: examples included: bed mobility: from oversight, encouragement, or cueing with help only, to extensive assistance of one staff; transfers: from oversight, encouragement or cueing with help only to extensive assistance of two staff; ambulation: from oversight, encouragement or cueing with help only for ambulating in her room or on corridors on the unit, to not ambulating. Now total dependence, full staff performance of one staff for assistance not only in her room, but also through corridors on the unit. In her wheelchair, not self sufficient, dependent upon staff; eating: from independent with setup help only to limited assistance of one staff's physical assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance); hygiene: from limited assistance of one staff to extensive assistance of one staff (resident involved in activity; staff provide weight bearing support); bathing: from extensive assistance of one staff to total dependence of one staff (full staff performance every time during 7-day 'look back assessment' period); Review of Incident Reports since August 2015 reflected Resident #8 acquired bruises on 2 occasions: on 8/23/15 and 1/17/16 and a total thus far of 7 falls (all un-witnessed) with 2 falls with injuries. An interview with the Director of Nursing (DON B) on 6/28/16 at approximately 2:30 pm, when asked for the full investigations of all of the incident reports, including the two with injuries revealed that there were no interviews or witness statements obtained nor were there any root cause analysis in either the report or in the nurse's progress notes for any of the incidents. However, for the fall which resulted in hospitalization on [DATE], DON B had provided a typed report summarizing the incident, the facility's immediate response, the injury sustained, care review with investigation and a conclusion. That same incident report (IR) had copies of some of the paperwork obtained from Resident #8's admission to the hospital (and changes made to the care plan at that time). Also, a fall and fracture Resident #8 experienced on 5/5/16 contained changes to her care plan. Otherwise, no additional information was available except the IRs and the nurses progress notes. Resident #8 experienced two (2) falls prior to the first fall with injury (Resident #8 had a history of [REDACTED]. It might also be noted that to this point (since at least October 2015) Resident #8 was ambulatory with a forward wheeled walker (4 WW) and was mobile within her room and out of her room, (see ambulation from quarterly MDS mentioned earlier). Resident #8's first fall was un-witnessed and occurred on 2/1/16 at 2:30 pm. Resident was observed on the floor with her back against the bed, a bruise was observed on her right hand that measured 4 centimeters (cm) by (X) 3 cm. Resident #8 stated (per the IR), she did not know what happened. Under the Mobility: section of the IR, Resident #8 was Ambulatory with assistance. The IR recorded under Other Info (information) that Elder (Resident #8) had a small amount of BM (bowel movement) in her brief, it is assumed Elder was trying to get to the bathroom when she fell . New intervention for toileting before (her) afternoon nap. The second un-witnessed fall occurred on 2/4/16 at 3:15 pm. The IR reflected that Resident #8 was observed on the bathroom floor (gave details as to how she was found). In addition, a statement that hard BM noted in the toilet. Under the Mobility: section of the IR Resident #8 was Ambulatory with assistance. However, neither this IR or the intervention documented or the previous IR or care plan interventions clarified how staff were to assist Resident #8 with ambulation since she was ambulatory with a four wheeled walker. She (Resident #8) was not cognitively able to ask for assistance with the use of a call light. No alarms were utilized in the facility. Additionally, her wheeled walker was to be within reach at all times. There was no indication either in the IR or the nurse's progress notes what time Resident #8 took her afternoon nap or if Resident #8 had been toileted prior to her afternoon nap (related to the intervention from her first fall which related to moving her bowels). Resident #8 stated (as recorded on the IR) that she had, hit her head, her back hurt and her butt hurts. Under the Immediate Action Taken documentation reflected complaints of right shoulder and hip pain and back of her head. Bruises to left elbow (6.5 cm X 2.5 cm), right elbow (6 cm X 4 cm) and a hematoma (a blood filled bump that measured 4 cm X 3.5 cm) on top of the head. Pupils were slow to react. A new (physician's) order for Senna Plus 2 tablets daily (to assist with stimulating and softening bowel movements). Under 'Other Info,' After assessment of elder and environment , elder appears to have had a vaso-vagal response (a syncopal episode in which low heart rate and low blood pressure occur at a critical level resulting in unconsciousness that can be evoked by emotional stress associated with pain, as in straining to move hard stool from the rectum). Hard stool in toilet, elder not on stool softner . Resident #8 was found in the restroom unresponsive twice by a certified nursing assistant CNA who had knocked on closed bathroom door to empty old drinking water in the sink. The staff 's recorded statement under Witnesses (to what she, the 'CNA' observed in the bathroom) reflected there was no response to her knock. When the CNA opened the door and observed Resident #8 on the bathroom floor, Resident #8's name was called out again but there was no response. The IR stated the CNA then went and notified the nurses. Care plan updated to not leave Resident #8 alone on the toilet. On 2/20/16 at 8 am, an IR recorded another un-witnessed fall. Moaning was heard coming from Resident #8's bathroom. Resident #8 was noted laying on her left side to the right of the toilet in the bathroom. The walker was laying below the elders hips. Elder was alert and able to answer questions appropriately. Stating all over body pain, neuro's (neurological checks) WNL (within normal limits), however bilateral pupils had a sluggish response. Large amount of blood surrounding left side of Elder's head. Elder was unable to give a description as to how she ended up in the bathroom or had fallen. Under the Mobility: section of the IR now recorded ambulatory without assistance. Then under Immediate Action Taken, dressing applied to the laceration on left side of the head to stop the bleeding . sent to the local emergency room (ER) for evaluation and treatment. The section titled Other Info reflected Resident #8 had periods of confusion, and poor safety awareness. Resident #8 was independent with transfers and ambulation. Resident #8 had last received care at 7:30 am, she was dressed, toileted and ready for breakfast. Additional note under Witnesses (prior to incident) Elder refused hipsters r/t (related to) dislike. Stating they feel too tight. Elder was last seen by CNA at 7:30 am walking around her room with her walker (which was her norm). Interventions upon return from the ER included: 15 minute checks for her safety, and Elder not to be left alone in room and to be in common area when awake (effective 2/22/16). The next four IRs relate to Resident #8's falls out of bed. An IR dated 4/2/16 at 7 am., reflected that In walking past elder's room, CNA saw elder lying on the floor next to her bed. Elder states 'I just rolled out of bed.' The Mobility: section of the IR recorded Resident #8 was ambulatory with assistance. There was nothing in the IR about 15 minute checks (Resident #8 was observed at 7 am, on the hour per the IR). A review of the 15 minute checks requested from their inception to present reflected initials on 4/2/16 at 7 am but then no initials until 3:15 pm, later that afternoon (at shift change). It was also noted that the initials of the CNA who made the observation at 7 am (identified on the IR), were not the initials of the CNA who witnessed Resident #8 on the floor. Initially, the immediate intervention was to add a gray mat next to the bed to soften falls. However, that was discontinued by the Falls Committee, with the rationale that Resident #8 was independent in ambulation and self transfers, a mat would potentially lead to additional falls. Instead the bed was to be kept at transfer level to decrease risk of falls and walker to be in reach at all times. Care plan updated to reflect the changes. On 5/2/16 at 1:57 am, an IR reflected that the nurse was called to Resident #8's room where she was observed sitting on a pillow on floor at bedside. No injuries were noted and Resident #8's statement was that she slid out of bed. The Mobility: section of the IR reflected that Resident #8 was Ambulatory without assistance. The investigation Notes in the IR reflected the body pillow was removed related to climbing over it and that Resident #8 had refused to be toileted at 11:30 pm, when the third shift started. The Report also reflected that 15 minute checks had been conducted, which included 12 minutes prior to the fall at 1:45 am. The new intervention implemented was to toilet or (if refused) check and change at 11:30 pm, 1:30 am, 3:30 am and 5:30 am. The last entry (sentence) under the Notes section, states She (Resident #8) is care planned for expected falls due to the progression of her dementia and disease process. An IR dated 5/5/16 at 6 am reflected a fall with fractures. The IR recorded that Resident #8 had a fall, was observed lying on her left side on the floor at the foot of her room-mates bed. Resident #8 was dry. Resident #8 stated she did not know what she was doing. Under the Mobility: section of the IR reflected Resident #8 was Ambulatory with assistance. Then under Immediate Action Taken, Resident #8 was noted to have raised bruise to right outer forearm, with complaints of pain to right arm, shoulder and neck, and to left hip area. Physician was notified and order given to send Resident #8 to the ER for evaluation and treatment. Resident #8's 15 check list reflected a check at 6 am, 6:15 am, 6:30 am and leave of absence (LOA) at 6:45 am - 11:15 am. The Notes section of the IR reflected that staff had just previously been in Resident #8's room providing care to her room-mate, who was vocal and may have been loud enough to disturb Resident #8. The new intervention listed was to provide care if Resident #8 was restless when care was provided to her room-mate, including toileting. However, the interventions implemented from the previous fall out of bed on 5/2/16 were to toilet or (if refused), to check and change at every half odd hour (11:30 pm, 1:30 am, 3:30 am and 5:30 am). There was no indication that the previous intervention had been implemented based on the information documented in the IR and in the nurse's progress notes. On 6/9/16 at 6:20 am, an IR reflected that Resident #8 was heard by a nurse at the desk asking for assistance. Resident #8 was observed naked with only her slippers on seated on the floor in front of her recliner. Her brief was next to her the IR documented that she continued on 15 minute checks (these were reviewed and were complete). The section titled Mobility: now recorded Wheelchair bound. The IR recorded that, Resident #8 was last checked at approximately 4:30 am and was dry. There was no mention however, of the intervention from her fall 5/2/16 which directed staff to toilet or check and change (if refused to be toileted) every half odd hour (11:30 pm, 1:30 am, 3:30 am and 5:30 am). On 6/10/16 the Notes section recorded, Fall committee review completed .care plan and interventions all are current at this time. Elder to be gotten up at 5-5:30 am daily. Will do toileting schedule at the end of each shift to promote continence . The fifteen minute check lists were reviewed and several time slots were noted incomplete, besides the one noted above on 4/2/16 they include, but are not all inclusive: On 3/6/16 from 4 am-6:45 am; 3/10/16 from 2:45 am-7 am; 3/10-11/16 from 10 pm thru 3/11/16 at 6:45 am; 3/12-13/16 from 11:15 pm thru 2:45 am (on 3/13/16) , then again from 4:30 am thru 6:45 am and 3:15 pm thru 6:45 pm (also on 3/13/16); on 3/17/16 from 5:15 am thru 6:45 am; 3/18/16 from 5:45 am thru 6:45 am; on 3/20/16 from 1 am-1:15 am, 3 am-3:30 am and 4:45 am- 5 am; on 3/21/16 from 11:30 am-11:45 am and 2:30 pm - 3 pm; on 3/28/16 the whole second shift, from 3:15 pm thru 11 pm; 3/31/16 from 5:15 am-7 am and from 2 pm- 2:30 pm; on 4/2/16 the whole day shift, from 7:15 thru 3 pm and then again from 9:15 pm- 11 pm; 4/15-16/16 from 11:15 pm (on 4/15/16) thru 12:15 am (on 4/16/16), from 1 am-1:45 am, from 3 am - 4:45 am and from 5:30 am - 6:45 am; on 4/18/16 the whole second shift was blank from 3:15 pm - 11 pm; 4/19/16 from 5:45 pm thru 11 pm; 4/20 and 21/16 neither day recorded the second shift from 3:15 pm thru 11 pm; on 4/22/16 from 12:15 pm thru 11 pm; on 4/23/16 from 2:45 pm thru 11 pm; on 4/25/16, 4/27/16, 4/28/16 and 4/30/16 none recorded the second shift from 3:15 pm thru 11 pm; on 5/1/16 there were only 5 fifteen minute checks on the night shift, they included (12:45 am, 1 am, 2:45 am, 3 am, and 3:15 am) the remainder of the shift was blank as was the second shift fro 3:15 pm thru 11 pm; 5/2/16 from 5:15 am - 6:45 am and from 3:15 pm thru 11 pm (nearly the whole second shift); on 5/4/16 there was NO documentation for the first or second shift (from 7:15 am thru 11 pm); 5/6/16 from 1 pm thru 11 pm (10 hours); on 5/8/16 from 3:15 am thru 3:45 pm (12 plus hours); on 5/10/16 from 7:15 - 8:15 am and the entire second shift; 5/13/16 from 3:30 am - 6:15 am and the entire second shift; both on 5/17 and 18/16 the entire third shift (from 11:15 pm on 5/16/16 thru 6:45 am on 517/16 and 5/17/16 thru 5/18/16); 5/24/16 no documentation for the entire day shift (from 7:15 am thru 2:45 pm); on 5/26/16, 5/29/16 and also on 6/5/16 and 6/15/16, no documentation for the entire second shift; and on 6/20/16 no documentation from 6:30 am - 3 pm. ( ) Resident #26 According to Resident #26's face sheet reflected she was a [AGE] year old female admitted to the facility 2/15/16 for rehabilitation after a cerebral vascular accident (CVA, a stroke). Additional [DIAGNOSES REDACTED]. Review of Resident #26's quarterly MDS assessment dated [DATE] as well as her 60 day Medicare assessment dated [DATE] both reflected a BIMS score of 10 or 15, which reflected she was moderately cognitively impaired. She (Resident #26) had fluctuating disorganized thinking (which included: incoherent, rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). A review of four incident reports (IRs), one bruise, one witnessed fall and two un-witnessed falls Resident #26 experienced since admission reflected her first fall occurred on 2/25/16 at approximately 6 pm when she (Resident #26) was observed laying on the floor, on her right side in front of her wheelchair in the dining (day) room. Resident #26 was unable to answer as to what had occurred. The new intervention added to the care plan included: Resident #26 was not to be in the dining (day) room unattended and to be the first one out of the day room after meals for safety reasons. The care plan dated initiated 3/2/16 read, I am not to be left alone in the dayroom or my bedroom while in my wheelchair as I recently self transferred and fell to the floor. Please allow me to be in common areas with staff in view of me for safety and cues not to self transfer. On 3/20/16 at 4:40 pm, the second un-witnessed fall occurred. The IR reflected that as the Registered Nurse (RN) came out of another Resident's room on the A hall, another elder (resident) yelled for her to come. As the RN went down the hallway the IR recorded that she was able to see Resident #26 lying on the floor in front of her wheelchair. Resident #26 response as to what happened, revealed that she was trying to get her (stuffed) dog. Under Immediate Action Taken, Noted slight swollen area above right eye. Resident #26 is alert and oriented X 3 and was able to make needs know with simple responses. Resident #26 has poor short term recollection due to CVA residuals and becomes impulsive attempting to stand, reposition, move ad lib (at will, as desired). Elder (Resident #26 care planned to be in common areas for safety so elder is in view of staff often. Resident #26 was seated adjacent from the nurse's station by shower room. Resident #26 had a stuffed animal dog which had fallen to the floor and elder leaned over to pick dog up from floor and came out of wheelchair, another elder sought help from nurse. Small knit leash was made for the elder's dog and is attached to the arm of the wheelchair, in the event the dog falls again, she can pulled it back to her lap without having to bend over, and potentially falling again. Care plan updated to reflect leach. The IR recorded Resident #26 sustained a hematoma to her face (in the eye area). However, the care plan intervention after the first un-witnessed fall on 2/25/16, to allow to be in common areas with staff in view of me for safety and cues not to self transfer was neither carried out (as no staff were around to view Resident #26 for safety, nor was the intervention even mentioned in this IR. There was no root cause analysis in the report. ( ) This refers to Resident #21 According to the admission record, dated 6/29/16, Resident #21 was a [AGE] year old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) (a tool used to assess a resident and help determine the amount/level of care needed), and was dated 9/30/15. Resident #21 had a Brief Interview for Mental Status (BIMS) (a tool used to determine a resident's cognitive ability) result which indicated Resident #21 was severely cognitively impaired with inattention and disorganized thinking. In addition, Resident #21's MDS indicated Resident #21 was dependent on staff for transferring from one surface to another (e.g. from a chair to the bed) and for toileting assistance. According to Resident #21's incident report, dated 12/17/15 and revised 1/4/16, at 19:10 (7:10 p.m.) Nurse called to elders (Resident #21) room . elder observed sitting on floor in front of her stationary chair, with her legs extended out in front of her, with slipp

This citation pertains to MI# 906 Based on observation, interview and record review, the facility failed to protect and promote care in a dignified, respectful manner related to inappropriate pictures of 1 out of 5 sampled residents (#101) resulting in psychosocial harm and complete disregard of resident #101's self-esteem and individuality. Findings include: Interpretive guideline 483.15(a) "Dignity" means that in their interactions with residents, staff carries out activities that assist the resident to maintain and enhance his/her self-esteem and self-worth... Maintaining the resident privacy of body including keeping residents sufficiently covered. Record review of the facility's 'Mission Statement' (undated) revealed .......We will ensure that residents are treated with [MEDICATION NAME], their needs are met, and their comfort and safety are well attended". A record review of Resident #101's 'Unusual Occurrence Report' dated 9/25/13 revealed an incident happened on 9/21/13 and was reported on 9/25/13. The location was identified as the resident's bathroom. Description of the incident included: Picture of elder taken while she was sitting on toilet, peri (private parts) area exposed and caption written, "limp dick". (See F 164 and F223). Record review of facility report incident summary dated 9/25/13 revealed that the facility reported that on 9/21/13 staff member (CNA) #7 took a cell phone photo of Resident #101 while sitting on the toilet with peri-area exposed and a stylus-created penis drawn on the photograph in red with the title "limp dick" written on bottom of photograph. On 9/25/13 at 12:45 PM Certified Nurse Assistant (CNA) #11 opened a "snap-chat" photograph in front of witnesses Licensed Practical Nurse (LPN) #6 and Registered Nurse (RN) #8 who was the unit manager to reveal inappropriate photographs of Resident #101. A record review of Resident #101's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old female with brief interview of mental status score of 4, meaning severe cognitive impairment. Her medical [DIAGNOSES REDACTED]. Observations on 10/8/13 at 9:00 am during the initial tour and 10/9/13 at about 9:30 am noted Resident #101 to be an elderly female with cognitive impairment that required assistance or supervision from facility staff to perform basic daily living task. In an interview on 10/9/13 at 12:00 PM with Staff #13 revealed that she had caught CNA #7 in an elder's room sitting on the bed with the curtain pulled around the bed, with the door partially closed, while the elder was in the restroom. Staff #13 stated that she went into the room to ask if the resident was ready for lunch and when she did, CNA #7 hid the cell phone under her thigh while seated on the bed. Staff #13 asked CNA #7 if she was using her cell phone and she said, "No". Staff #13 asked CNA #7 to stand up and CNA #7 refused. Staff #13 stated that she would inform the Director of Nursing and that was when CNA #7 stood up and revealed her cell phone. Staff #13 stated that was at least a year ago. The Director of Nursing came and spoke to CNA #7. Staff #13 stated that CNA #7 was caught multiple times by different staff and was spoken to multiple times about using her cell phone on hallways while working. Staff #13 stated that the cell phone policy was well known but was not enforced by management. In a phone interview on 10/9/13 at 10:20 AM with the power of attorney (POA) of Resident #101, she revealed that her initial reaction was why would someone do this, was hurt why someone would do this to a vulnerable adult and stated that Resident #101 would never allow this to happen to her. Record review of police report investigation dated 9/25/13 revealed that CNA #7's phone was being reviewed by the crime lab. An interview on 10/8/13 at 12:20 PM with the detective who was investigating the incident revealed the resident was abused and under the Vulnerable Adult Abuse Law, this incident would be referred to the prosecutor's office. A reasonable person concept denotes a hypothetical person in society who exercises average care, skill, and judgment in conduct and who serves as a comparative standard for determining liability. Applying the reasonable person concept for Resident #101, who was diagnosed with [REDACTED]. This was demeaning and a violation of her privacy by the caregiver ( CNA #7) and was a total disregard for resident #101's dignity. ( See also F 164 and F 223) (# )

This citation pertains to MI# 906 Based on observation, interview and record review, the facility failed to prevent mental and emotional abuse related to having a photo taken while on the toilet and while dancing in the facility, being put on social media "snap-chat" and being sent to facility workers for 1 out of 5 total sampled residents (#101) resulting in humiliation, mental anguish and degradation of her personhood. Findings include: Record review of facility 'Abuse Prevention Policy' dated 9/25/12 revealed the following: Residents will not be subjected to abuse, neglect, or misappropriation of personal property by anyone. Abuse was defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish ( State Operations Manual , 42 CFR 488.301) ...includes the deprivation by an individual, including a caretaker, or goods and services necessary to attain or maintain physical, mental and psychosocial well-being. Mental Abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Resident care and treatments shall be monitored by all staff, on an ongoing basis, to assure residents are free from abuse, neglect, or mistreatment. It is the responsibility of all staff to provide a safe environment for the residents. The facility used the definitions as written in the SOM ( State Operations Manual) and the BHCS (Bureau of Healthcare Services) Manual. Abuse involves a willful, purposive and assertive action.......There is presumption that all instances of abuse of residents, even those in a coma, cause some degree of physical harm, or pain or mental anguish. Mental or emotional abuse includes, but is not limited to, humiliation.......or deprivation. Interactions subject the resident to scorn, ridicule or humiliation. Abuse, misuse, mistreat.....in the American Collegiate Dictionary indicates that all of these verbs mean to treat a person or thing wrongfully or harmfully. It states that mistreat may imply negligence or lack of knowledge on the offender's part, but more often refers to harm inflicted deliberately. Record review of Resident #101's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old female with brief interview of mental status score of 4, meaning severe cognitive impairment and a medical [DIAGNOSES REDACTED]. Observation on 10/8/13 and 10/9/13 of Resident #101 revealed an elderly female with cognitive impairment that required assistance or supervision from facility staff to perform basic daily living task. Record review of Resident #101's 'Unusual Occurrence Report' dated 9/25/13 revealed the incident happened on 9/21/13 and was reported on 9/25/13. The location was identified as the resident's bathroom. Description of the incident included: Picture of elder taken while she was sitting on toilet, peri (private parts) area exposed. Record review of facility report incident summary dated 9/25/13 revealed that the facility reported that on 9/21/13 staff member #7 took a cell phone photo of Resident #101 while sitting on the toilet with peri-area exposed and a stylus-created penis drawn on the photograph in red with the title "limp dick" written on bottom of photograph. On 9/25/13 at 12:45 PM Certified Nurse Assistant (CNA) #11 opened a "snap-chat" photograph in front of witnesses, Licensed Practical Nurse (LPN) #6 and Registered Nurse (RN) #8 who was the unit manager to reveal photographs of Resident #101. Record review of the facility staff schedule dated 9/21/13 revealed that CNA #7 worked the A/B wing were Resident #101 resided. In an interview on 10/8/13 at 10:30 AM with CNA #11 revealed that CNA #7 had used her phone to down load the "Snap-chat" program on her phone and for a while she received funny photos. CNA #11 stated, "I started to get photos of her (CNA #7) at work about a month ago (August 2013) and I mentioned it to RN #8 who was the unit manager". CNA #11 stated that a week prior to the 9/25/13 incident she had received a photo of an elder's buttock/bottom side of a female with fecal material. However, the 'Snap-chat' program deleted the photo after 10 seconds or so and that she had no proof but that she told LPN #6. CNA #11 described the photo as an elder's bottom lying on a bed and incontinent of stool. CNA #11 stated that she thought the photo was of Resident #105 who has dementia and is incontinent of her bowels. CNA #11 stated that she was disgusted by the photo and reported it. CNA #11 stated that on 9/21/13 she received another snap-chat from CNA #7, but did not open them until she was with LPN #6 and RN #8 to witness what the snap-chat photos revealed. CNA #11 stated that the snap-chats included photo of an elder sitting on the toilet with pants down and shirt up, skin area of her abdomen to thighs exposed with the peri-area (private parts) with a drawn picture of a penis with caption "limp dick". CNA #11 stated that a short video of Resident #101 dancing with the same clothes on as the toilet photo was also sent. CNA #11 stated that she knew of 4 other co-workers that had the "Snap-chat" program on their phones and that the photo could have been sent to more than just her. CNA #11 stated that CNA #7 would use her phone during work in the presencen of residents and that CNA #7 would go into resident rooms and text. CNA #11 stated that LPN #6 was well aware of the CNA #7's phone use and that CNA #7 was written up prior to the incident for cell phone use in the facility. CNA #11 stated that she would be busy answering resident call lights while CNA #7 was on the phone. CNA #11 added that management was aware of the problem but was not monitoring. An interview on 10/8/13 at 2:11 pm with Licensed Practical Nurse (LPN) #6 was conducted. It was revealed that she had CNA #11 come to her related to a report that (CNA) #6 had received a previously compromising photo from CNA #7 showing an elder's buttock with fecal (bowel material) on it. CNA #11 stated that it was not appropriate. LPN #6 stated that she went to DON #2 and was advised to tell CNA #11 not to open them. LPN #6 stated that the "Snap-chat" photo opens for 10 seconds and then deletes. LPN #6 stated that CNA #11 came to her again and stated that she had received 4 photos from CNA #7 and wanted to open them in front of witnesses so they went to the RN unit manager #8's office. The photos showed the following: 1st photo was of CNA #7 holding her nose in the employee bathroom; 2nd photo was of CNA #7's face with a pimple; 3rd photo was an elder on the toilet with pants down, peri-area exposed, with "limp dick" caption on picture drawn of a red penis and scrotum; and 4th photo was same elder (Resident #101) in the same clothes as the toilet photo, sent within minutes of each other and showed Resident #101 dancing. LPN #6 stated that the photos were time stamped and were taken during work hours. LPN #6 added that she received several complaints in June/July 2013 about CNA #7 being on the phone. LPN #6 stated that she and RN #8 spoke with CNA #7 at that time and that CNA #7 put her phone in her locker. LPN #6 stated that she was angry that she (CNA #7) thought that it was funny that a cognitively impaired did not know what was going on. LPN #6 stated that CNA #7 had been at the facility for over [AGE] years, knew the rules and was not following them. Record review of CNA #7's educational record revealed that on 2/5/13 the CNA completed the Elder Justice Act/Abuse/Burnout in-service via internet through the facility educational site. Record review of CNA #7's employee record for disciplinary action written by LPN #6, revealed the following: On 3/23/12 CNA #7 was noted by LPN #6 to be in the B wing day room assisting the residents with their breakfast. LPN #6 noted that when she walked in the day room to pass medication, she observed CNA #7 on the phone and remained on the phone as she continued to walk in and out of the room passing medications. LPN #6 noted that at one point CNA #7 had been on the phone for a continuos 20 to 30 minutes and neglected to assist the residents who had their breakfast trays in front of them. The Director of Nursing RN #2 wrote that LPN #6 and RN #8 met with CNA #7 to discuss facility rule: No personal cell phone use during on-duty hours. Record review of disciplinary note dated 8/2/13 revealed that CNA #7 was noted to be taking photos of staff without asking permission and "Snap-chatting". CNA was notified of direct violation of facility social media policy and cell phone use policy and educated on not using social media while on duty. Telephone attempts were made to contact CNA #7 on 10/9/13 for an interview and elicit her reason for taking inappropriate photos of resident #101. CNA #7's voice mailbox was full and not taking messages. A phone interview on 10/9/13 at 10:20 AM with the power of attorney (POA) of Resident #101 was conducted. The POA revealed that her initial reaction was why would someone do this, and was hurt why someone would do this to a vulnerable adult and stated that Resident #101 would never have let this happen. Record review of police report investigation dated 9/25/13 revealed that CNA #7's phone was being reviewed by the crime lab. An interview on 10/8/13 at 12:20 PM with the detective who was investigating the incident revealed the resident was abused and under the Vulnerable Adult Abuse Law, this incident would be referred to the prosecutor's office. Record review of CNA #7's facility termination letter dated 10/2/13 revealed her termination was based upon CNA taking photographs of one of the facility's elder resident with a camera phone while the elder was in a compromised position in a private location within the facility and transmitting that photo to others individuals. This misconduct was a gross violation of the elder's right to dignity and privacy, and was in direct violation of facility training, facility rules and policy, the public health code and federal HIPPA law. Resident #101 has cognitive impairment. Applying the reasonable person concept in connection to this incident, Resident #101 was subjected to mental and emotional abuse since it violated her right to a dignified physical and psychosocial existence. Resident #101 was humiliated, demeaned and ridiculed. (# ) (# )

This citation pertains to intake number MI 258. Based on observation, interview, and record review, the facility failed to provide adequate care of a suprapubic catheter (a surgically created connection between the urinary bladder and the skin which is used to drain urine from the bladder) in 1 of 10 sampled residents (Resident #105), from a total sample of 10 residents, resulting in the Resident #105's supra-pubic catheter being removed and unable to replace it resulting in pain, bleeding, insertion of an indwelling urinary catheter in the penis and a urinary tract infection. Findings include: Review of the Face Sheet and facility [DIAGNOSES REDACTED]. Review of the Physician's Progress note dated 8/15/12, Resident #105 had a suprapubic catheter "recently placed" due to severe [MEDICAL CONDITION] (Benign Prostate Hypertrophy-enlarged prostate) and [MEDICAL CONDITION]. Review of the Admission immediate Needs Care Plan dated 8/15/12, Resident #105 had a suprapubic catheter placed on 8/14/12. Per the physician's orders [REDACTED]. Review of the written witness statement dated 8/15/12 revealed Registered Nurse (RN) #70 had been approached by another staff member and was asked to "write an order for [REDACTED].#70 documented that she wrote the order, even though she had not yet visualized Resident #105. RN #70 wrote "that she was told that policy for changing caths (catheter) were monthly. I wrote the order and handed to (staff persons name) and then wrote the order in the treatment book. I did not put a time or date in the treatment book." Per Resident #105's August 2012 Treatment Administration Record the change of the suprapubic catheter was scheduled for 8/25/12. Do not change a newly inserted catheter for 4 weeks; this allows the catheter tract to become established." (Shlamovitz, Gil Z, M.D.; "Suprapubic Catheterization" http://emedicine.medscape.com/article/ 9-overview). In a written statement dated "8/25/12" (sic) RN #67 wrote at the start of her shift on "8/24/12" (sic) at 10:30 p.m. she "checked the treatment records" which indicated Resident #105 "was to have his supra/pubic catheter changed on 8/25/12. There was a bold square drawn around that date." (Per the Incident Report and the Investigation file the incident occurred at 3:00 a.m. on 8/26/12.) Per the Nurses' Notes dated 8/26/12 at 2:00 a.m. RN # 67 removed the catheter from Resident #105's surgical site on his abdomen and tried to insert a new catheter. Resident #105 "complained of burning at the time of the change. Min(inum) bloody drainage at site." RN #67 documented that she tried to irrigate the catheter with sterile water was at 7:15 a.m., but the fluid she inserted into Resident #105 did not "return" and there was no urinary output. Resident #105 was sent by ambulance to the hospital and returned at 11:00 a.m. with an indwelling urinary catheter inserted in his penis, orders for an antibiotic, and orders to contact the urologist to schedule surgery to reinsert the suprapubic catheter. In a telephone interview on 10/24/12 at 9:54 a.m., RN #67 said she did not get the catheter into the bladder and the fluid she inserted during attempts to flush the catheter did not go into the bladder but did enter Resident #105's abdomen. Per the Physician's Progress Note dated 8/26/12 the Physician wrote "by mistake" Resident #105's suprapubic catheter was "removed...because it had become plugged..." Review of the medical record revealed there was no documentation found in the Nurses' Notes to indicated Resident #105's catheter was "plugged." Per the Physician's Progress Note dated 8/28/12 Resident #105 "had his suprapubic catheter inadvertently removed." In an interview on 10/24/12 at 9:54 a.m. RN #67 said she deliberately changed the catheter because she was instructed to do so per the treatment record. Attempts to interview the Physician were unsuccessful as he was out of the country at the time of the investigation. In an observation and interview on 10/10/12 at 12:20 p.m., Resident #105 was observed seated in his room with a urinary catheter drainage leg bag visible below the hem of his shorts. Resident #105 said he told the nurse not to change his catheter because it was supposed to be done by the urologist and it wasn't time to do this. Attempts to reach the nurse who wrote a physician's orders [REDACTED]. Review of the medical record revealed Resident #105 was hosptalized on [DATE] due to change in condition including unusual incontinence of stool, temperature of 103.2, coarse lung sounds and cloudy urine. ( )

This citation pertains to intakes MI 505 & MI 189 This citation has multiple deficient practice statements (A, B) A. Based on observation, interview, and record review the facility failed to prevent the elopement of 1 (Resident #101) of 7 sampled residents from a total sample of 7 residents, resulting in Immediate Jeopardy for Resident #101, who was a known elopement risk and who exited the facility twice on 8/11/12, unbeknownst to facility staff. Resident #101 was found at approximately 2:15 p.m. on 8/11/12, in her wheelchair outside the facility in a sitting area adjacent to the facility's main entrance and parking lot, 210 ft. from a 45 mph road. An alert and oriented resident (Resident #102), felt Resident #101 place her hand on her shoulder and ask for help. Resident #102 redirected Resident #101 back to the facility and through one sliding door and a set of double doors to the main entrance of the facility, when a Wandergaurd alarm, which had not sounded upon Resident #101's exit from the building, sounded, alerting staff to Resident #101's presence by the exit. Resident #102 was between the two sets of double doors and upon re-entry to the facility notified staff that Resident #101 had been outside, unsupervised. Resident #101 eloped again on 8/11/12 at approximately 10:00 p.m., unbeknownst to facility staff. Resident #101 was found outside the facility sitting in her wheelchair at the entrance doors after a staff member heard Resident #101 calling for help. Findings include: According to the facility Admission/Discharge (not dated), Resident #101 was an [AGE] year old woman admitted to the facility on [DATE]. Resident #101 was identified as an elopement risk based on the Elopement Risk Assessment, dated 4/11/12, and had a Wanderguard on her left ankle. According to the Master [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], indicated Resident #101 had both short and long term memory problems and severely impaired cognitive daily decision-making skills. During an interview on 8/15/12 at 4:00 p.m., Resident #102 stated she went outside at approximately 2:00 p.m. on 8/11/12 and had been dozing off when she felt someone put their hand on her shoulder and ask for help. Resident #102 said in the time it took her to fully waken and unlock her wheelchair breaks, Resident #101 had already wheeled herself to within inches of the curb of the sidewalk near the sitting area outside the front entrance of the facility. Resident #102 said no staff members were outside with Resident #101 and no alarms were sounding. Resident #102 approached Resident #101 calmly so as not to upset her and began to redirect Resident #101 away from the edge of the sidewalk and toward the entrance of the facility. Resident #102 stated she was afraid Resident #101 might go off the edge of the curb and "kill herself or break something". Resident #102 got to a button located on a post outside the sliding door of the facility which would open the interior double doors just beyond the automatic slider at the entrance of the facility. Resident #102 noticed that Resident #101 was having a hard time moving forward because her breaks had become locked and Resident #102 leaned forward to release the wheelchair breaks on Resident #101's chair. During an interview on 8/15/12 at 2:40 p.m., RN #4 stated she responded to the front entrance alarm on 8/11/12 at approximately 2:30 p.m. and found Resident #101 inside the facility in her wheelchair facing the outside in front of the main entrance double doors. RN #4 observed Resident #102 in her wheelchair between an automatic sliding door and the double doors to the inside of the facility. RN #4 stated Resident #102 told her that Resident #101 had just been outside. Per an "Unusual Occurrence Report" dated 8/12/12, Resident #101 was found with her wheelchair breaks engaged, sitting inside the facility at the main entrance to the facility. Resident #102 said Resident #101 had been outside the facility and Resident #102 got her to come back inside. Per a facility "Investigation Report" dated 8/11/12 at 10:25 p.m., on 8/11/12 RN #6 was walking through the front office area of the facility when she heard someone calling "Debbie, Debbie". RN #6 looked around the office area and observed Resident #101 outside the front doors, trying to come back into the facility. A Wanderguard alarm sounded when RN #6 assisted Resident #101 back into the facility. Per the report, no alarm had been heard prior to this. During an interview on 8/15/12 at 3:00 p.m., RN #6 stated she discovered Resident #101 on 8/11/12 at approximately 10:25 p.m., after hearing Resident #101 calling for help. RN #6 said she had not heard any alarm sounding prior to discovering Resident #101 outside. RN #6 reported she assisted Resident #101 back inside at which time the alarm did sound. RN #6 visually assessed for injury and returned her to the unit where Resident #101 lived and asked RN #5 and an aide when Resident #101 was last seen on the unit. RN #5 and the aide both deduced it had been approximately 25 minutes since the last time either of them had noticed Resident #101 on the unit seated in her wheelchair at the nurse's station. During an interview on 8/15/12 at 3:15 p.m., RN #5 said she was the charge nurse on the unit where Resident #101 lived. RN #5 said she last noticed Resident #101 sitting in her wheelchair at the nurses' station around 10:00 p.m. on 8/11/12. RN #5 said she did not hear an alarm sounding until it briefly alarmed at 10:25 p.m. followed by RN #6 bringing Resident #101 back to the unit, stating she had just found Resident #101 outside the building. An observation made during a tour of the facility on 8/15/12 at 10:45 a.m., with Maintenance Director #9, revealed a door equipped with a Wanderguard alarm device on the "F wing exterior entrance" did not consistently alarm when tested with a Wanderguard device worn by residents who are identified as an elopement risk. The F wing exterior door opened up to sloped sidewalks, one 50 ft. away from dryer vents that were found to be 152 degrees, and adjacent to a parking lot 150 ft. away. On 8/20/2012 at 4:05 p.m., Director of Nursing (DON) #2 was informed of the Immediate Jeopardy identified on 8/15/12 and began on 8/11/12 for Resident #101, who was identified as an elopement risk, who was found outside on 8/11/12 at approximately 2:15 p.m. by an alert and oriented resident and was found again by staff at 10:25 p.m. outside the facility at the entrance doors calling for help. This deficient practice places 59 additional residents, identified as an elopement risk, at risk for serious harm, injury, and/or death. On 8/20/2012, the surveyor confirmed the facility implemented the following to remove the Immediate Jeopardy. 1. On 8/12/12 at 10:00 am the ADON #13 initiated the investigation. DON #2 joined her at 3:20 pm. Nursing Home Administrator (NHA)#1 was also in the building at 11:30 am. ADON #13, the DON and the NHA reenacted Resident #101's exit from the building with Resident #101 to assess the functioning of the Wanderguard system. The alarm sounded 4 out of 5 times that they passed Resident #101 through the first set of double doors (interior) where the Wanderguatd sensor is located. The fourth time it did not sound. The fifth time it did. Resident #101's bracelet was on her ankle at that time. The new bracelet was testing and functioning well. 2. On 8/12/12 at 11:30 am NHA #1 placed Resident #101 on 1:1 supervision when out of bed pending further investigation. A central supply CENA then initiated and completed a house sweep by 3:05 for retest of function on all watchlet bracelets worn. 3. On 8/12/12 NHA #1 and DON #2 identified with master Wanderguard list that there was a potential for 60 residents at risk for elopement, and directed the central supply CENA to move ankle bracelets on anyone residing outside of the secured unit (AB, CD, and F wings), to the resident's wrists. This was completed by 7:30 pm that day. During the sweep, 1 resident no longer had a watchlet bracelet which was discontinued on 7/30/12, bringing the total at risk list to 59 units. Our first assumption was that the cause of the alarm not sounding twice the day before was that the ankle bracelet was out of range part of the time. This is why we moved any ankle bracelets to the wrist. 4. On 8/13/12 DON #2 directed the central supply CENA to move any watchlet bracelets on wheelchairs to the resident's wrists. By noon on 8/13/12 every resident with a Watchlet bractlet had them on their wrists. 5. On 8/13/12 at 8:30 am the Director of Plant Operations tested all of the doors with Wanderguard sensors and determined all were operational. He tested the electric conductivity in the front door unit and determined it was correct. 6. On 8/13/12 at 8:30 am the technician from the alarm company arrived at the facility in response to a call from the Director of Plant Operations. He tested the sensor bar at the front door and found the sensor field did have a blind spot in the corner on one side. He adjusted the sensor bar. It now covers the entire door opening. 7. On 8/13/12 at 7:00 PM the technician from the alarm company and the Director of Plant Operations #9 inspected and tested each of the eight doors with Wanderguard sensors. All were fully operational. 8. On 8/13/12 DON #2 confirmed that the nursing staff is testing the functioning of the Watchlet bracelet in accordance with the facility policy. 9. On 8/15/12 at 12:00 noon, immediately upon testing the Sunflower Door with the surveyor and finding it to sound intermittently Director of Plant Operations #9 called the Wanderguard technician to return. At 2:00 PM the technician determined that there are radio and wireless transmissions interfering with the signals. 10. On 8/15/12, immediately upon learning that the Wanderguard sensor bars were operational only intermittently, NHA #1 ordered staff to place tab alarms on all eight doors with Wanderguard sensors. The dryer area outside was also fenced in . These were completed by 1:00 PM. These remain in place. At 8:30 PM the tab alarm was placed at the front doors leading into the back service hall, as there are no staff scheduled back in this area after that time. 11. On 8/15/12 at 2:30 PM NHA #1 initiated face-to-face mandatory house education to all staff present on on-coming shift. Designated RN's continued with the face-to-face education throughout the evening and night hours of those staff that were scheduled. The agenda included the importance of follow-through assessment and notification of NHA #1 and DON #2 following any elopement attempts and immediate intervention of any potential faulty equipment. 121 out of 168 on payroll employees (not including those on vacations) were inserviced by 4:00 PM on 8/16/12. 3 of 168 employees on payroll are on medical LOA. All staff not inserviced as of 4:00 PM on 8/16/12 will be required to have face-to-face inserviceing prior to working their next scheduled shift. 12. Immediate intervention was also discussed for any unusual occurrence including elopements, at the Licensed staff meeting held on 8/16/12. Any licensed nurses not attending due to pre-approved time off or vacation, will be required to be inserviced prior to starting their next scheduled work shift. 13. On 8/13/12 DON #2 confirmed that a master list of all Elders wearing Watchlet bracelets is printed by the Ward Clerk for review by nursing management. It is the Ward Clerk's responsibility to keep this up to date. 14. On 8/13/12 DON #3 confirmed the Master picture ID books continue to be placed at each nursing unit and in front receptionist office, in the event of a missing resident, etc. DON #2 confirmed the Master picture ID books are up to date. 15. On 8/12/12, DON #2 confirmed that routine bracelet testing continues on a daily basis and is documented on the treatment sheets. 16. On 8/12/12, the Director of Plant Operations #9 confirmed that daily testing on the sensor bars will be done and recorded on Quality Assurance Checklist. 17. On 8/17/12, NHA #1 requested the Maintenance and central supply CENA placed additional pull tab alarms to the inner doors surrounding each neighborhood (other than the secured unit). 3-11pm RN supervisor to secure the inner door alarms at 9:00 PM on 8/17/12. This will continue throughout the weekend to 8/20/12. 18. On 8/12/12, discipline of licensed nurses involved in the 2:30 PM occurrence, was initiated. 19. On 8/16/12, NHA#1 and Maintenance purchased a new alarm system, with installation to begin on 8/22/12. Although the Immediate Jeopardy was removed on 8/15/12, the facility remained out of compliance at a scope of "pattern" and a severity of "actual harm that is not Immediate Jeopardy" due to all nurses had not been in-serviced and sustained compliance had not been verified by the State Agency. B. Based on interview and record review the facility failed to ensure that each resident received adequate and appropriate supervision and assistive devices to prevent accidents in 1 (Resident #103) of 7 sampled residents, from a total sample of 7 residents, resulting in a pelvic fracture. Findings include: Review of a facility "Admission/Discharge" record, Resident #103 was a [AGE] year old woman originally admitted to the facility on [DATE]. Review of a "Master [DIAGNOSES REDACTED]. According to a "Minimum Data Set" (MDS) quarterly assessment dated [DATE], Resident #103 was severely cognitively impaired, demonstrated signs and symptoms of delirium (inattentive with disorganized thinking). Resident #102 needed extensive assistance with transfers and personal hygiene and limited assistance with bed mobility, walking, dressing and toilet use. Review of a "Fall Risk Assessment" dated 5/29/12, indicated Resident #103 was a high risk for falls, as evidenced by a fall risk score of 28. The "Fall Risk Assessment" considers any score higher than 14 a 'high risk' for falling. Per a "Care Plan" dated 3/06/2012, Resident #103 did not remember to call for assistance for transfers and was at risk for falling. Interventions to prevent Resident #103 from sustaining serious injury from falling included the use of a chair and bed alarm. Per an "Unusual Occurrence Report" dated 7/1/2012, Resident #103 was found on the floor partially in the doorway to her room lying on her right arm and right side. Resident #103 sustained a skin tear and complained of pain to her right hip, the bed alarm was in place but did not sound. Resident #103 was last observed sitting on the edge of her bed with her feet on the floor, prior to falling. During an interview on 8/16/12 at 10:30 a.m., Competency Evaluated Nursing Assistant (CENA) #15 stated she discovered Resident #103 on the floor in the doorway to her room, no alarm was sounding and the call light was not on. CENA #15 immediately called for the assistance of RN #9 and Medical Director #21 to assess Resident #103. CENA #15 said she could not believe what she saw and denied hearing anything out of the ordinary prior to discovering Resident #103 lying in the doorway to her room. During an interview on 8/16/12 at 4:00 p.m., CENA #16 said she was assigned to care for Resident #103 on 7/1/12 and was on break when CENA #15 discovered Resident #103 on the floor. CENA #16 said the last time she transferred Resident #103 to her bed the bed alarm was "green", which indicated the alarm was on. According to hospital "Emergency and PreHospital Documentation", Resident #103 was found on the floor in her room at the (nursing home), the fall was unwitnessed and (staff at nursing facility) were unsure how long she was down for. Review of hospital "Diagnostic Radiology" for Resident #103, dated 7/1/12, indicated there were fractures of the superior (above) and inferior (behind) pubic rami (pelvis) medially on the right. Review of an "Emergency Department Addendum" dated 7/2/12, indicated that due to the nature of the fracture, Resident #103 was not a surgical candidate and was discharged back to the facility for pain control, in stable condition on 7/1/12 with a [DIAGNOSES REDACTED].

This citation pertains to intake #MI 709 Based on observation, interview and record review, the Facility failed to provide adequate supervision and assistive devices (not following the plan of care to keep within eye sight, when in a wheelchair), to prevent an accident for 1 of 4 Residents (#103), with a known history of falls with injuries, resulting in Resident #103 falling out of her wheelchair onto her face and fracturing her nose on 3/11/12, when she was left alone in her room, in a wheelchair and for not properly assessing Resident #103 following the fall, resulting in the potential for serious permanent harm due to a potential neck/spinal fracture. Findings include: Review of the clinical record revealed Resident #103 was an [AGE] year old woman admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE], revealed Resident #103 had severe Cognitive Deficits and was totally dependant on staff for all Activities of Daily Living. Review of the Facility's incident reports dated 3/11/12 at 7:05 PM revealed Resident #103 stood up out of her wheelchair and fell to the floor. She was sent to a Hospital and treated for [REDACTED]. Review of the last completed Fall Risk assessment dated [DATE], revealed Resident #103 scored 27 (21 or higher reflects high risk). Review of the plan of care for Resident #103 revealed instructions for nursing to check the placement and function of her bed, chair sensor pad and pull string alarms every shift. Another approach written was,"I need assist to propel self in wheelchair." Review of the Facility's "Guidelines for Care" (undated) , revealed Resident #103's instructions were written, "do not leave out of sight when up in wheelchair." Review of the Facility's incident reports dated 3/20/12 at 7:30 PM revealed Resident #103 stood up out of her wheelchair and fell on to her left side. Resident #103 was transferred to the Hospital for evaluation and treatment of [REDACTED]. Corrective measures were to "keep elder in site when up in wheelchair". Review of the Facility's incident reports dated 3/30/12 at 7:30 PM revealed Resident #103 stood up out of her wheelchair, got tangled up in her catheter tubing and fell on to her left side. Resident #103 sustained bruises on her right leg measuring 10 CM by 10 CM with swelling. A STAT lower leg x-ray was ordered. The only corrective measure was to put Resident #103 to bed after meals due to tiredness. Review of the Facility's incident reports dated 4/7/12 at 2:45 PM revealed Resident #103 stood up out of her wheelchair and fell on to her buttocks. The only corrective action was to apply a gait belt so staff would be able to grab it if they were close enough to her. Resident complained of pain later that evening in her left Scapula area and an x-ray was done with negative results. Review of the Facility Incident Report dated 6/4/12 at 7:00 PM, revealed Certified Nurse Assistant (CNA#10) heard Resident #103's fall alarm sounding and entered her room and found Resident #103 face down on the floor, in front of her wheelchair. Her head was on the bottom of the over-bed table. According to the report Resident, #103 sustained the following injuries to her face; a laceration above her right eye and a laceration to the right side of her nose; a skin tear on her left thumb and a bruise to the bridge of her nose. Under the current interventions were written, "to be in vies of staff when up in wheelchair." The report also had written, "CNAs counseled regarding them not following the care plan",which instructed them not to leave her in her room alone when she is up in the wheelchair. Review of the witness statement dated 6/4/12 at (right after supper), revealed CNA#10 was in a bathroom with Resident #104 when she heard an alarm. CNA#10 assisted Resident #104 to a sitting position, opened Resident #103's door and saw Resident #103 lying on the floor face down. Resident #103's head was on the over-bed table so CNA#10 moved the table and left Resident #103 to get help. In an interview on 6/7/12 at 3:00 PM Registered Nurse (RN#9), said she was the 3-11 "House Supervisor" on 6/4/12 and fed Resident #103 her supper that evening. RN#9 said Resident #103 was restless and when she was done RN#9 took her out of the dining room and into the hall, near her room. RN#9 said she did not let the LPN#8 know Resident #103 was left in the hallway, in her wheelchair but thought she told a CNA. RN#9 was unable to recall which CNA she thought she told that she left Resident #103 alone, in the hallway. RN#9 said she went back to the main dining after she brought Resident #103 to the hallway and then went to her supper at 6:30 PM. RN#9 said at 7:00 PM she got an overhead page to go to the unit Resident #103 lived on. RN#9 said she went into Resident #103's room and saw her sitting on the bed with CNA#10 and CNA#11. LPN#8 was also in the room and told RN#9 she did not check her extremities before she moved her because she saw a cut, applied pressure and got her off the floor. RN#9 said LPN#8 told her all she could think of was to get her up off the floor and see where the blood was coming from. RN#9 said she knew Resident #103 need stiches and called the Ambulance, Physician and Family. RN#9 said she asked who brought Resident #103 into her room and left her alone and everyone she asked said "no" they did not bring her in her room except CNA#10 said she could not recall. When asked why Resident #103 didn't have a seat belt to help deter or slow her from rising from her wheelchair, as an intervention to prevent falls, RN#9 said, "I asked that same question the next day and RN#3 (the Assistant Director of Nursing), said she didn't know. RN#9 said she did not know how the process worked at the Facility to assess a Resident for a seat belt to assist in preventing falls. In an interview on 6/7/12 at 12:05 PM, Licensed Practical Nurse (LPN#8) said she was the Charge Nurse for Resident #103 on 6/4/12 for the 3-11 shift. LPN#8 said Resident #103 was restless that evening and had her close to her while she did the medication pass and then Resident #103 went to dinner. LPN#8 said after dinner she was at the nurse's desk and CNA#11 told her she needed to go to Resident #103's room right away. She was with a Resident (not on the sample) , at the time, who could not be left alone, so she had someone watch her and then went to Resident #103's room and saw Resident #103 "face down, on the floor, in a pool of blood". One of the first things LPN#8 asked CNA#10 and CNA#11 was "who was supposed to be watching (named Resident #103), because no one was with her." LPN#8 said CNA#10 told her she did not know Resident #103 could not be left alone in her wheelchair. LPN#8 said the last time she saw Resident #103 was in the hallway between the nurse's station and the shower room door. LPN#8 said she paged the Supervisor (RN#9) and Resident #103 was sent to the Hospital with an obvious deviated septum ( nose). LPN#8 said RN#9 pushed Resident #103 from the dining room to the hallway after dinner but did not let her know. LPN#8 said she assumed Resident #103 had been put to bed. LPN#8 said there was obviously a "lack of communication". When asked why Resident #103 didn't have a seat belt to help deter or slow her from rising from her wheelchair, LPN#8 said, "I thing a seat belt would be helpful to (named Resident #103) but said she doesn't decide who gets a seatbelt at the Facility and said RN#4 makes that decision. CNA#10, in an interview on 6/7/12 at 3:40 PM, said she could not remember if she wheeled Resident #103 into her room on 6/4/12 after supper. CNA#10 said she was suspended because she failed to read the guidelines for Resident #103's care instructing staff not to leave her alone while she was in her wheelchair. CNA#10 said "we're not in a habit of looking at care plans." CNA#10 said she didn't know she wasn't suppose to be in her room alone and said she was not always working down that hall. CNA#10 did not put Resident #103 in bed following her meal on 6/7//12 as instructed on her Review of the typed report dated 6/5/12 and signed by RN#3 revealed LPN#8 did not assess Resident #103 prior to moving her and got Resident #103 to her knees and onto the edge of the bed prior to assessing her rather than rolling her while she was on the floor to examine her for possible fractures and potential spinal cord injury. In an interview on 6/7/12 at 2:15 PM, RN#3 said Resident #103 could not propel her own wheelchair and on 6/4/12, RN#9 put Resident #103, in the hallway, outside her bedroom door. All of the staff who worked on the unit Resident #103 were on were interviewed and said they did not push Resident #103 into her room except for CNA#10 who said she could not remember if she pushed her into her room or not. RN#3 said CNA#10 was suspended for putting Resident #103 in her room and leaving her alone. Review of the Hospital CT of the Maxillofacial Bones dated 6/4/12 at 8:22 PM for Resident #103 under findings was written, "There is a minimally displaced fracture of the nasal bone. An observation on 6/7/12 at 9:15 AM, revealed Resident #103, in her room, lying on her back in her bed and was moaning. Her bed was in the low position and she had "turn assist" metal bars on both sides of the upper portion of her bed. There was a mat on the floor, bed was next to the wall, she had a clip alarm attached to her nightgown and a pressure sensor pad when tested sounded immediately. Six Sutures were noted above Resident #103's right eye. Bruises were observed on Resident #103's knees. Resident #103 was not able to be interviewed due to cognitive deficits. #

This citation pertains to intake #MI 361 Based on observation, interview, and record review, the facility failed to correctly assess the elopement risk, prevent the elopement and ensure the safety in 1 of 5 Residents (#101), of a total sample of 5 Residents, resulting in an Immediate Jeopardy when Resident #101, who had a known history of an elopement attempt on 6/30/11, was incorrectly assessed on 12/23/11 as not being an elopement risk, had her Watchmate (WanderGuard) bracelet removed on 12/27/11 and eloped from the facility, unbeknownst to facility staff, on 4/10/12. Resident #101 was discovered outside sitting in her wheelchair, stuck in the grass, approximately 35 feet from the facility. These deficient practices placed 62 residents, who did not have a Watchmate bracelet and/or were not in a secured unit, at risk for serious harm, injury, and/or death. Findings include: Review of the Clinical Record revealed Resident #101 was a [AGE] year old woman admitted to the facility on [DATE]. Review of her cumulative [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #101 was coded as requiring one person physical assist for locomotion off the unit and had cognitive deficits noted under the section "temporal orientation". Review of the Unusual Occurrence Form, dated 4/10/12 at 3:15 PM, revealed Resident #101 was brought in from the outside by the hallway door by 7-3 personnel, where she was out in the parking area sidewalk, near the boiler room. Resident #101 stated she got off the edge of sidewalk and she could go no further. The "Licensed Nursing Assessment" section revealed Resident #101 was cold and a warm blanket was wrapped around her. The report did not have any vital signs or notification of a Physician. The section titled "corrective action, Physician's comments, Physician's statement were blank also. Resident #101's son was notified by leaving a message, at 6:33 PM (3 hours and 18 minutes later). In an interview on 4/12/12 at 12:50 PM, Assisted Living Assistant (AA) #3, who was employed at the senior living facility (located across the parking lot from the skilled nursing facility), said on 4/10/12 just after 3:00 PM she was in her car, pulling out of the parking lot when she saw a senior (Resident #101), rocking her wheelchair so she stopped her car, got out and went over to Resident #101. AA #3 asked Resident #101 if she was stuck and she said, "yeah". AA #3 said, "she really didn't want to go back inside but she let me take her". AA #3 helped Resident #101 back into the Facility and brought her to Registered Nurse (RN) #5 and then left the building. In an interview on 4/12/12 at 5:10 PM, Certified Nurse Aide (CNA) #14, said she saw Resident #101 after she came back inside and that Resident #101 told her "she almost made it". CNA #14 said the last time she saw Resident #101 prior to the elopement on 4/10/12 was "at 2:45 PM, in the hall, at the doors looking outside." In an interview on 4/12/12 at 1:38 PM, CNA #7 said she was assigned to Resident #101 on 4/10/12 for the day shift (7-3 PM). CNA #7 said she last saw Resident #101 on 4/10/12 at about 2:40 PM, during her last rounds. CNA #7 said Resident #101 asked her how the weather was that day because it was snowing. CNA #7 said she usually did not take care of Resident #10, but had her on 4/10/12 because someone was in training that day and the assignments were changed. CNA #7 said she did not know Resident #101 was an elopement risk. In an interview on 4/12/12 at 2:38 PM, Administrative Assistant (RN #2) said, she would check the outside temperature and wind velocity. RN #2 returned at 3:15 PM on 4/12/12 and presented an Internet search for the Facility's area for 4/10/12 at 3:15 PM of the actual temperature 36 degrees Fahrenheit, with a minimum at 32 to maximum 40 degrees Fahrenheit, and wind speed of 14 miles per hour with gust speed of 30 miles per hour. An observation on 4/12/12 at 11:55 AM, revealed that the "F" hallway had a single set of double doors that led down a curved cement path to the parking lot. Across from the doors was a large metal button (handicap door opener) which, when pressed, activated the doors to open to the outside. Along the edge of the cement path was a temporary edging, approximately 10 inches high to deter wheels from veering off the cement path and onto the grass and getting stuck. In an interview at the time of the observation, RN #2, said this is where Resident #101 got her wheelchair wheel stuck in the grass (approximately 35 feet from the door and near the parking lot). RN #2 said, "we now have temporary edging". An observation and interview on 4/12/12 at 1:50 PM, revealed Resident #101 sitting in a wheelchair, in her room with a Watchmate bracelet on her left wrist. When asked what happened a couple days ago on 4/10/12 when she was found outside, Resident #101 said, "I pushed the button and it opened the doors. I was wondering if my children were coming to see me but it was the guys working." The button, after further clarification, Resident #101 referred to was the handicap button on the wall across from the doors. Resident #101 stated, "I just went off the side, didn't hurt me at all, just kind of scared me." Resident #101 said she was trying to get back on the sidewalk but said she couldn't get "unstuck", and then a lady came from the parking lot and asked if she needed help. Resident #101 said she told the lady yes and the lady told her she had gotten quite far. When asked what the weather was like Resident #101 said, "Oh my God, it was cold. I sat there with a sleeveless shirt on and my teeth were chattering." Resident #101 then said she just wanted to get some fresh air. In an interview on 4/12/12 at 12:30 PM, when the surveyor requested the Facility's elopement book with pictures of residents who were an elopement risk, RN #2 said, "don't have any here". In an interview on 4/12/12 at 12:40 PM, RN #2 reported that Resident #101 did not have a Watchmate bracelet on when she eloped on 4/10/12, "that was the problem-knowing where your residents are". In an interview on 4/12/12 at 3:45 PM, Director of Nursing, (DON) #12 stated that prior to March 2012, the Facility was not doing elopement risk assessments on the residents at the Facility. In an interview on 4/12/12 at 5:00 PM, RN #2 said the Unit Managers are doing the elopement risk assessments now because the Supervisors who had been doing them, were not doing them accurately. In an interview on 4/12/12 at 4:15 PM, when asked if she put a Watchmate bracelet on Resident #101 (after she attempted to elope on 6/30/11), RN #4 stated, "I did! She was trying to exit out the front doors. She was between the two sets of front doors. I remember putting a Watchmate on her in June 2011 on the 3-11 shift. I didn't document anywhere, except the TAR. I was the supervisor. I was walking around here and saw it. Family wasn't with her. Didn't document it. Don't think I did a care plan. Didn't do an Occurrence Report." Review of the Treatment Administration Record (TAR), dated June 2011, revealed Resident #101 had a Wanderguard bracelet in place as of 6/30/11. The TAR had documentation, "Wanderguard bracelet status and placement". The TAR for July 2011 had written for Resident #101, "Check Wanderguard placement every shift Left wrist. Check function and battery status weekly at door." Review of the TAR for 12/1/11 revealed Resident #101's Wanderguard, which had been changed from her left wrist to her right ankle, was discontinued on 12/27/11 and Resident #101 was placed on every 15 minute checks for 1 week that discontinued on 1/3/12. The TAR for April 2012 revealed Resident #101 had the Wanderguard bracelet re-applied on 4/10/12 (no time other than 3-11 shift). In an interview on 4/12/12 at 4:20 PM, RN #10 said the Facility had no Occurrence report form completed for the attempted elopement of Resident #101 on 6/30/11. In a prior interview, on 4/12/12 at 4:05 PM, RN #10 said an assessment had not been done in June 2011 because the Facility did not have the assessment tool at that time. Review of the entire care plans for Resident #101, on 4/12/12, revealed no problem was identified for her elopement or previous elopement attempt. Under an approach for problems that included CVA (stroke), impaired memory cognition, depression, anxiety, incontinence, frequent UTI's (urinary tract infections), Fall risk and Short Term Memory Deficits (all grouped together), dated 4/10/12 (no time) revealed documentation,"Wanderguard (Watchmate), every shift and battery function. On 3-11 check Wanderguard weekly and document. Please ask me if I would like to go outside, weather permitting. I am not to be left alone." There were no other interventions or approaches for protecting Resident #101 from an elopement prior to 4/10/12 after her Watchmate was discontinued on 12/27/11. Review of the Elopement Risk Assessment (ERA) form, dated 12/23/11, for Resident #101 revealed RN #10 had completed it inaccurately. Under the section titled, "Dementia Type Diagnosis" a 1 instead of a 2 was put in the box. Under the section titled , "History of Elopement", a 0 instead of a 4 (which indicated a history of elopement) was documented. The 12/23/11 ERA total score was 5 instead of 10, which caused Resident #101 to not be accurately assessed. According to the tool, "if total score is 10 or more, the resident is AT RISK for elopement. Proceed to care plan." This was the first ERA done for Resident #101, however the Facility did not have a policy, procedure or protocol for nurses regarding the ERA tool until March 2012. The next assessment was not done until 4/11/12 (after Resident #101 eloped), and the total score was 12. In an interview on 4/16/12 at 2:50 PM, RN #10 said, "it was my mistake that I put a 1 instead of a 2 under the section titled, " Dementia Type Diagnosis". When asked why she put a zero instead of 4 under the title, "History of Elopement", RN #10 said, "I didn't think she was an elopement risk because I didn't know she attempted to leave before." In an interview on 4/18/12 at 3:30 PM, when asked if the Facility had guidelines for nurses to follow in order to perform accurate elopement risk assessments, RN #16 (the QA nurse), said no they did not have any guidelines. The Administrator was notified on 4/18/12 at 3:30 PM via telephone and 4:17 PM, in person(Administrator #1, RN #2, and DON #12 were not in the Facility), of an Immediate Jeopardy that was identified on 4/12/11 and began on 4/10/12 as a result of the facility's failure to provide a safe environment for Resident #101, who had a known history of an elopement attempt on 6/30/11 and who eloped from the facility, unbeknownst to facility staff, on 4/10/12 when Resident #101 was discovered outside sitting in her wheelchair, stuck in the grass, approximately 35 feet from the facility. On 4/23/12 the surveyor confirmed that the facility staff completed the following to remove the Immediate Jeopardy: 1. Resident #101 was returned to her unit and given a blanket after being brought back inside by a senior housing employee on 4/10/12 at 3:15 PM and a Watchmate device was placed on Resident #101's left wrist. 2. On 4/11/12 at approximately 1:45 PM, investigation revealed the elopement risk assessment form had potential for inaccuracies. At approximately 2:00 PM, Unit Managers were instructed to QA 5 elopement risk assessments to check for accuracy. At 2:15 PM the facility discovered the assessments were inaccurate. 3. On 4/11/12 at 2:15 PM, the unit managers evaluated 116 of 116 residents for elopement risk and found 4 additional residents requiring Wanderguards but who had not been provided them due to inaccurate assessments. 4. On 4/11/12 at 2:15 PM, a maintenance employee was notified of the incident and was instructed to place alarms on all exit doors. 5. On 4/11/12 at 3:00 PM, a maintenance employee reported that all exit doors had been modified to alarm when opened, regardless if Watch Guards were in the vicinity. 6. On 4/11/12 at 3:00 PM, signage was posted on all doors to inform staff, residents and visitors of the temporary changes to the doors. 7. On 4/11/12 at 6:00 PM, Maintenance employees edged the sidewalk where the incident occurred to prevent resident's wheelchairs from going off the edge of the sidewalk. 8. On 4/12/12 at 7:00 AM, 1:00 PM and 2:00 PM, mandatory all staff in-services were held. The following education was presented by the Assistant Administrator and DON: A. Unusual Occurrence Incident Reporting Policy B. Code Yellow Policy and Procedure C. You must know where your residents are. D. Residents that Wander and have potential risk for elopement All staff not attending the in-services have been notified of the requirements to view video taped education when manager present, prior to next scheduled shift. As of 4/18/12 the facility had 169 employees, 5 of whom were on LOA. Of the 169 employees, 159 had completed the in-services. 9. On 4/13/12 the elopement risk assessment form was reviewed and revised to more accurately assess resident elopement risk. 10. On 4/18/12 after 4:45 PM, the facility created elopement risk assessment guidelines for the current elopement risk assessment form. The purpose of the guidelines was to assure that all nurses completing the form would provide consistent and accurate data. 11. On 4/18/12 at 6:00 PM, 54 of the 116 residents, who had been determined an elopement risks, had watchmate bracelets in place along with care planning. The remaining 62 residents were re-assessed following the new guidelines. These assessments were completed by staff who had been in-serviced on how to use the new guidelines. 7 additional residents had watchmate bracelets added and care plans were completed by 4/18/12 at 9:00 PM. DON #12 will have new admission elopement risk assessments done only by the staff who received training on the guidelines as of 4/18/12. 12. On 4/19/12 at 1:30 PM, 24 of 31 licensed staff were educated on the new guidelines on how to complete the elopement risk assessment form. Although the Immediate jeopardy was removed on 4/19/12, the facility remained out of compliance at the scope of pattern and a severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to all of the staff had not been in-serviced and sustained compliance had not been verified by the state agency.