Every finding on record at Norlite Nursing Center

Based on interview and record review, the facility failed to provide food in a manner that was at palatable (preferable) temperatures for four Residents (#4, #5, #6, and #7) of five residents reviewed for palatability of meals.Findings include:Resident #4 (R4) reported during an interview on 7/13/26 at 11:08a.m., The food here is on the cool side, and I like my food hot.the staff serve the residents in the dining room first and the food is cool on many days even if you eat in the dining room.An interview was conducted on 7/13/26 at 11:25 a.m., with Dietary staff B. Dietary staff B reported, I am one of the cooks here and we take temperatures three times for every meal.the first time we take the temperatures is when we take the food out of the oven.the second temperature is taken when we start dishing up the food for the meal.and the third temperature is taken halfway through meal service .On 7/13/26 at approximately 11:30 a.m., the Dietary Manager (DM) A provided facility documents titled Temperature Log and Daily Cleaning Task that were requested from 7/3/26-7/13/26 which revealed the following:One incomplete temperature log for one meal out of three meals dated 7/3/26.One incomplete temperature log for one meal out of three meals dated 7/4/26.No temperature logs for any meals on 7/5/26.One incomplete temperature log for one meal out of three meals dated 7/6/26.One incomplete temperature log for one meal out of three meals dated 7/7/26.No temperature logs for any meals on 7/8/26.One incomplete temperature log for one meal out of three meals dated 7/9/26.No temperature logs for any meals on 7/10/26.One incomplete temperature log for one meal out of three meals dated 7/11/26.No temperature logs for any meals on 7/12/26.No temperature logs for the breakfast meal on 7/13/26.An interview was conducted on 7/13/26 at 11:35 a.m., and Dietary Manager (DM) A reported, There is supposed to be a temperature log for every meal with three temperatures.the temperature logs are incomplete.During interviews conducted on 7/13/26, multiple residents expressed systemic dissatisfaction regarding dietary temperatures, specifically noting a consistent failure to serve meals at palatable or regulatory-compliant temperatures.12:43 p.m. - R5: Reported a chronic deficit in food temperature, explicitly stating, The food is always cold . the spaghetti and carrots are cold.12:46 p.m. - R6: Corroborated this trend, asserting that meals fail to meet thermal expectations and noting, The food is never hot here . even the coffee is cold. You just have to get used to cold food here.12:48 p.m. - R7: Echoed these grievances room-side, confirming, The food is cold. I am looking forward to feeling better so I can go to the dining room where the food is a little warm . now I just have to put up with cold food.During an interview on 7/14/26 at 7:18 a.m., DM A reported, With the temperature logs not being filled out, there is no way to ensure the food coming out of the kitchen was at a safe or warm enough temperature to be served to the residents.An interview was conducted on 7/14/26 at 9:22 a.m., the Director of Nursing (DON) acknowledged that the facility could not ensure the food was palatable for resident consumption.Review of policy titled Food Handling, Preparing, and Storage last revised 3/16/16, read in part .Food temperatures are to be taken when food is taken out of the oven or off of the stove, at the beginning of the service line for residents, and half-way through the meal service to ensure food temperatures are being met.

Based on observation, interview, and record review, the facility failed to ensure the necessary equipment was readily available to provide care for two dependent Residents (#62 and #46) out of 18 residents reviewed for quality of life. This deficient practice resulted in emotional distress, feelings of frustration, social isolation, and physical discomfort.Findings include:Resident #62 (R62)Review of R62's Electronic Medical Record (EMR) revealed initial admission to the facility on 3/8/23 with diagnoses including hemiparesis (partial weakness, reduced strength, and/or impaired motor function on one side of the body) following cerebral infarction (stroke), multiple sclerosis (MS), muscle weakness, and need for assistance with personal care. Review of R62's most recent Minimum Data Set (MDS) assessment, dated 12/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition.On 1/26/2026 at 4:03 PM, R62 was observed in bed lying in bed with greasy, unkempt hair.On 1/26/2026 at 4:06 PM, an interview was conducted with R62 regarding overall satisfaction with care at the facility. R62 stated she relied on a total lift (a mobile floor lift system that utilizes a sling and hydraulic or electric mast/boom) to transfer out of bed and into her wheelchair. R62 indicated there had been many times over the previous months where she had not been able to get out of bed, several times over an entire weekend (at least 48 hours), because the facility had run out of slings. When asked on how many occasions R62 was forced to remain in bed due to lack of slings, she replied, Many, many times. R62 also indicated there were several occasions over the previous months when she had to miss a shower due to the lack of transfer equipment.Review of R62's plan of care revealed a Problem with a start date of 3/8/23 that read, I need assistance from staff with my Activities of Daily Living (ADL's) as I have hemiplegia and hemiparesis following a stroke and also have multiple sclerosis and diabetes with the following approaches: TRANSFERS: Total assistance with [name brand] lift, edited 05/29/2025. TOILETING: [name brand] lift to toilet or use of bed pan, edited 12/18/2025. BATHING: extensive assist x1, created 3/08/2023.On 1/28/26 at 11:27 AM, a sign was observed posted on the 300 hallway that read, in part: WE HAVE A SHORTAGE OF SLINGS BECAUSE THEY ARE NOT PUT INTO LAUNDRY EVERY NIGHT.On 1/28/2026 at 9:28 AM, an interview was conducted with Certified Nursing Assistant (CNA) GG regarding facility supplies. CNA GG stated, I am only part time, but slings have been a problem before. When asked in what way slings have been a problem, CNA GG replied, Just not having enough. On 1/28/2026 9:30 AM, an interview was conducted with CNA HH who confirmed the facility experienced problems keeping slings in stock. CNA HH explained the facility sends the laundry out to a different facility. In the event there is a problem with turnaround time, the facility does not get the clean slings returned timely. CNA HH verified there had been multiple times where slings have, totally run out. CNA HH confirmed she has worked on more than one shift when she could not get residents out of bed or showered due to the lack of slings or unavailability of the correct size sling.On 1/28/2026 at 10:32 AM, an interview was conducted with Staff KK who stated, We run out of slings all the time. All the time.On 1/28/2026 at 11:46 AM, a phone interview was conducted with CNA II who stated the sling shortage has been an issue for, a couple months. CNA II explained, There's points where we totally run out [of slings] and then residents refuse to shower at times because if their sling gets wet, it has to go in the laundry after they get back into bed. the sling goes to laundry and then the resident gets stuck in bed. On 1/28/2026 at 11:35 AM, a follow-up interview was conducted with R62 regarding how the consistent equipment shortages affect her daily life. R62 stated, It pisses me off. I miss out on socialization and activities. I like playing BINGO. It's [the sling shortage] been going on for months. Sometimes I will refuse a shower because after the sling gets wet, we can't reuse them and then I'll be stuck in bed. R62 indicated intermittent problems with her skin integrity that is compounded by extended time in bed.Review of R62's plan of care revealed a, Problem with a start date of 4/20/23 that read, I am at risk for skin breakdown related to hemiplegia/hemiparesis, Muscle weakness, MS, Todd's Paresis (temporary focal weakness or paralysis), Type II DM [diabetes mellitus], urinary incontinence, CHF [congestive heart failure], anemia, and my left arm splint.Review of, Risk of Pressure Ulcers/Injuries in Section M: Skin Conditions in R62's most recent MDS assessment, dated 12/24/25, read, Is this resident at risk of developing pressure ulcers/injuries? Yes was selected.Review of R62's Weekly Resident Skin assessment, completed 1/9/26, read, in part: Any open areas, abrasions, lacerations, or skin tears? The assessor selected, Yes: .small linear split to upper gluteal cleft.Review of R62's Weekly Resident Skin assessment, completed 1/26/26, read, in part: Any rashes, pinkness, redness, ulcerations? The assessor selected, Yes: . sl [slight] redness to inner glutes.Resident #46 (R46)Review of R46's EMR revealed initial admission to the facility on 6/27/18 with diagnoses including disorders of psychological development, low back pain, mixed incontinence, morbid obesity, and dependence on wheelchair. Review of R46's most recent MDS assessment, dated 12/19/25, revealed a BIMS score of 14, indicative of intact cognition.On 1/28/26 at approximately 4:30 PM, an interview was conducted with R46 regarding the availability of slings. R46 confirmed the facility ran out of slings at times. When asked how she feels when there are no slings available, R46 replied, My back hurts. Review of R46's EMR revealed the following progress note written on 11/01/2025 at 16:52 [4:52 PM]: Wt [weight] was associated from last week due to not being able to get resident up for a weight because no slings were available.Review of, Risk of Pressure Ulcers/Injuries in Section M: Skin Conditions in R46's most recent MDS assessment, dated 12/19/25, read, Is this resident at risk of developing pressure ulcers/injuries? Yes was selected.Review of R46's plan of care revealed a, Problem with a start date of 9/25/19 that read, I need assistance from staff with my Activities of Daily Living (ADL's) related to my diagnosis of weakness, incontinence and Attention/Concentration disorder with difficulty focusing at times. with the following approaches: TOILETING: Bed pan or [name brand lift] to shower chair x2, edited 12/18/2025. TRANSFERS: Total assist of 2 with [name brand] lift. Staff may leave sling in place related to my body habitus and poor mobility, edited 11/28/2023.On 1/28/26 at 4:19 PM, an interview was conducted with the Nursing Home Administrator (NHA) regarding the sling shortage. The NHA called the situation unfortunate and expressed regret sharing the same brand mobile lift system as the facility that launders the slings as he believed the slings were being left and utilized at that facility.Review of the Facility Assessment, reviewed 10/3/25, read, in part: .Physical equipment includes. lifts, lift slings.

Based on observation, interview, and record review, the facility failed to provide sufficient staffing to address the care, needs, and safety of the entire facility population. This deficient practice resulted in unmet care needs and the potential for serious safety issues for all 82 residents of the facility.Findings include:On 1/27/26 at 2:05 PM, a confidential group interview was conducted regarding overall perception of nurse staffing levels. Six out of 14 confidential residents (CR's) expressed concerns with receiving timely assistance for care needs as well as the timely passing of meal trays. One CR stated, The place is understaffed, indicating Certified Nursing Assistants (CNAs) were often assigned to cover more than one hallway. CR10 stated the staffing shortage usually gets worse on the weekends.Review of the Resident Council Meeting Minutes revealed the following:1/6/26: .Old Business: . [Facility name] is looking to hire more CNAs to help with the shortage in nursing help concern.12/2/25: .Old Business: . Complaints from residents concerning late trays being served cold in halls. New Business: .Resident stated how only two nurses are available to pass out dining trays in the hall.11/4/25: .New Business: . Staff is pretty slow at times. Often only 1 or 2 CNA members to a hall or 1 nurse covering 2 halls.8/4/25: .New Business: .[CR1] states she does not receive meal trays down wings in a timely manner.7/1/25: .Old Business: Meal trays taking long to be served.4/1/25: .New Business: Concern about all light times were brought up.Several confidential residents voiced their frustration regarding wandering residents entering their personal living quarters. One CR stated wandering residents came into their room so often, I can't keep my door open. When asked if it takes staff a long time for staff to redirect the resident out of their room, the same CR stated, I redirect her because I don't want her near me. She follows me around all day. Another CR added, Yes, there's a problem with wanderers. She [the same resident mentioned above] stares at me and watches what I'm doing. I usually have to redirect her [instead of staff]. Yet another CR confirmed wanderers often entered her room but they were reliant on staff for redirection due to their physical limitations. Two additional CR's stated they were forced to keep their door shut to avoid wanderers even though they preferred to keep them open. On 1/26/2026 at 4:29 PM, Resident #92 (R92) was observed propelling himself in a wheelchair up and down the 300 hallway. R92 stopped at the entrance of a room and shouted, Stay in there and don't come out until I tell you! No staff intervention was observed after the verbal outburst toward another resident.Review of R92's Plan of Care revealed the following two, Approaches with a start date of 1/26/26: [R92] is on the high-risk list for increased risk of resident-to-resident altercations/behaviors. Use consistent verbal redirection when [R92] is observed attempting to entering other residents' rooms.On 1/26/26 at 4:17 PM, Resident #11 (R11), who resided on the 200 hall, was observed wandering on the 300 hallway, entering and exiting other resident rooms with no staff intervention.On 1/27/26 at 11:55 AM, R11 was observed wandering aimlessly on the 500 hallway, hugging staff and waving at other residents. No staff attempted to redirect her from the 500 hallway.On 1/28/26 at 1:00 PM, R11 was observed wandering in the dining room which was temporarily closed due to a COVID-19 outbreak. R11 wandered near the emergency exit door, attempted to push it, then proceeded to exit the dining room through a different door. No staff observed her. Review of, Wandering - Presence & Frequency in Section E: Behaviors in R11's most recent Minimum Data Set (MDS) assessment, dated 1/5/26, revealed, behavior of this type occurred daily.Resident #10 (R10)Review of R10's Electronic Medical Record (EMR) revealed initial admission to the facility on [DATE]. Review of R10's most recent Minimum Data Set (MDS) assessment, dated 12/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition.Review of a, Concern/Suggestion Form, written by R10 on 1/26/26 read, in part: What is your concern or suggestion about? Woke to man in the room wearing gown! He said my bed was his! Put his gown over my legs. Handled my legs! Handled items. Moved an item! [R92] . How can we address your concern/suggestion? That guy needs alarms on his doorway! Can't be allowed to wander into other people's rooms!On 1/28/2026 at 11:42 AM, an interview was conducted with Licensed Practical Nurse (LPN) G regarding the number of wandering residents in the facility. LPN G stated, We need a dementia ward, we have so many wanderers. LPN G indicated it was not sustainable to provide the wandering residents the one-on-one supervision they required given the current staffing levels.Resident #62 (R62)Review of R62's EMR revealed initial admission to the facility on 3/8/23 with diagnoses including hemiparesis (partial weakness, reduced strength, and/or impaired motor function on one side of the body) following cerebral infarction (stroke), multiple sclerosis, muscle weakness, and need for assistance with personal care. Review of R62's most MDS assessment, dated 12/24/25, revealed a BIMS score of 15, indicative of intact cognition.On 1/26/2026 at 4:06 PM, an interview was conducted with R62 regarding overall satisfaction with care at the facility. R62 expressed she had ongoing low staffing concerns. R62 stated often there were only 1-2 CNAs per hallway and during mealtimes, 1 CNA must assist in the dining room. R62 stated this leads to extensive wait times for care assistance. R62 indicated staffing is typically worse on the weekend and she frequently goes without assistance with activities for daily living for extensive periods. R62 stated, Many times I don't get washed up for the day. Just the other day, I asked three people, and finally got a new shirt at 8:20 PM. Again, that happens all the time on the weekends.Review of R62's plan of care revealed a Problem with a start date of 3/8/23 that read, I need assistance from staff with my Activities of Daily Living (ADL's) as I have hemiplegia and hemiparesis following a stroke and also have multiple sclerosis and diabetes with the following approaches: TRANSFERS: Total assistance with [name brand] lift, edited 05/29/2025. BATHING: extensive assist x1, created 3/08/2023. DRESSING: extensive assist x 1, created: 3/08/2023. HYGIENE: extensive assist x 1, created: 3/08/2023.Review of a, Concern/Suggestion Form, written by R62's Family Member (FM) FF on 1/20/26 read, in part: What is your concern or suggestion about? Due to lack of staffing [R62] is not getting her PT [physical therapy] appointment when requested. How can we address your concern/suggestion? Hire more staff. Is this an ongoing problem? This is an ongoing problem. Facility Response: We apologize for the inconvenience related to short staffing. Action to be Taken: We are always working on hiring more staff into the facility. We are considering alternate avenues for recruitment. On 1/28/2026 at 10:32 AM, an interview was conducted with Staff KK who stated, I can't believe we're still open when asked if they felt the facility had enough staff to meet the resident needs. Staff KK stated often there is one CNA scheduled per hallway (equating to four CNAs) for a facility census in the 80's. Staff KK stated residents are going without their scheduled check and changes or wash-ups and are then forced to lie in excrement for extended periods of time. Staff KK also indicated if a resident is care planned for a two-person assistant, the resident must wait until a CNA on another unit became available to help. Staff KK stated they often skipped schedule lunch and breaks to instead tend to the residents.On 1/28/2026 at 11:46 AM, a phone interview was conducted with CNA II regarding staffing levels. When asked if the facility was adequately staffed, CNA II stated, Not necessarily. When asked to elaborate, CNA II explained only one CNA per hallway or one CNA per hallway and a float were scheduled per hallway on the night shift which made it nearly impossible to deliver the expected care.Review of a scheduling lookback period from 1/11/26 - 1/25/26 revealed only four CNAs were scheduled for at least a 4-hour block on 8 of 15-night shift opportunities. Only three CNAs were scheduled for four-hour blocks (2:00 AM - 6:00 AM) on 1/12/26 and 1/14/26. The facility census ranged from 82-86 in that same timeframe.Review of the Facility Assessment, reviewed 10/3/25, read, in part: .[Facility's] goal for sufficient and efficient care of our residents is always to assure adequate staffing coverage for their respective needs. Resident acuity and specific care needs bear a lot of impact on individual staff assignments for coordination and continuity of care.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 1/27/2026 at 3:30 PM, three boxes of single serve items, including cups and lids, were observed sitting on the storage room floor. The boxes were opened with some of the contents used. When asked about deliveries, Dietary Manager (DM) T stated that the last delivery came in the day before.According to the 2022 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.On 1/27/2026 at 3:45 PM, the Roundup plate warmer, model HPD-2 was observed with the lid open and the gasket seal from the lid was missing, with some degraded parts of the gasket and adhesive still left in the groove of the lid. This unit had been unplugged, but plates were still warm as it was used for lunch service, per interview with DM T at this time.According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. On 1/27/2026 at 4:10 PM, staff member V was observed cleaning a large steam jacket soup kettle with soapy water and a brush. When asked how this unit was cleaned, DM T stated it was washed with hot soapy water and then rinsed out with clean hot water. DM T stated that they had never been told any other way to clean it.According to the 2022 FDA Food Code section 4-702.11 Before Use After Cleaning. UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning.On 1/27/2026 at 4:15 PM, in a utensil drawer, the tray the utensils were lying in was observed with dried up syrup and food debris stuck to the bottom of the drawer.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 1/27/2026 at 4:25 PM, boxes of canned soup, canned beans and other boxes of canned food items were observed sitting on the floor in the dry storage room.According to the 2022 FDA Food Code section 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.On 1/27/2026 at 4:30 PM, kitchen staff W was observed as he ran a tray of dirty utensils through the dish machine and then reached in and pulled a lid out of the chemical dispensing trough on the side of the unit and placed the dirty lid back onto the dirty side of the dish machine table to be ran through again. Staff W then proceeded to unload clean utensils with unwashed hands. According to the 2022 FDA Food Code section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (E) After handling soiled EQUIPMENT or UTENSILS

Based on observation, interview, and record review, the facility failed to ensure appropriate food temperatures and palatability for nine Confidential Residents (CR) of fourteen residents reviewed for food satisfaction.Findings include:On 1/27/26 at 2:05 PM, food palatability, food choices, and mealtimes were discussed at a confidential group interview. 9 out of 14 residents stated their food is almost always cold. One CR stated, [Food] temperature is a problem. Another CR said, Last night's dinner was inedible it was so cold. 6 out of 14 residents stated meals were served at inconsistent times. Yet another CR stated, You have to guess [what time meals will be served]. During the lunch meal, which was specified to hallway trays only due to an infectious outbreak, the following was observed: Hallway trays began on the 500 hall at approximately 12:04 p.m. and ended at 12:14 p.m. It was observed that all meal trays were passed out to resident rooms, even when a resident was not in their room or hallway. Hallway trays began on the 300 hall at approximately 12:23 p.m. and ended at 12:30 p.m. It was observed that all meal trays were passed out to resident rooms, even when a resident was not in their room or hallway. Hallways trays began on the 400 hall at approximately 12:57 p.m. and ended at 1:09 p.m. It was observed that all meal trays were passed out to resident rooms, even when a resident was not in their room or hallway. Hallway trays began on the 200 hall at approximately 1:19 p.m. and ended at 1:30 p.m. It was observed that all meal trays were passed out to resident rooms, even when a resident was not in their room or hallway. An interview was conducted with the Nursing Home Administrator (NHA) on 1/28/26 at 1:39 p.m. during the Quality Assurance Performance Improvement (QAPI) task. The NHA stated that mealtimes have been a known issue since the summer of 2025, acknowledging that weekends and supper times have been a concern. In an interview on 1/27/2026 at 10:14 AM., Certified Nurse Aide (CNA) E stated, when meal carts with resident meal trays are delivered to the units there's a magnet timer on the side of the metal meal cart. CNA E reported when passing meals out the timer is pressed and set at 15 minutes. CNA E reported staff were supposed to get all the meal trays to residents before the 15-minute timer goes off. CNA E reported any meal trays that are left on the meal carts when the timer goes off (after 15 minutes) staff take the meal tickets to the kitchen and the dietary staff make a new meal for any of the residents whose meal tray was on the meal cart after the time allotted. Review of Resident Council Minutes read in part: Dietary: 7/1/2025 Old Business: Old Business: Meal trays are taking long to be served states this is still happening with ALL meals. Residents want nursing staff to be reminded to make sure that they are all done eating before taking plates away even if the plate looks empty . Review of Resident Council Minutes read in part: Dietary: 8/5/2025 Old Business: Meal trays are still taking long.New Business: Dietary Concerns:. (Residents) state. meal trays down all the (units) wings (are note delivered/served) in a timely manner: (Residents) state that most nights (Residents) doesn't get dinner until 7 pm.(Residents) states that dinner in the dining room doesn't get served until closer to 7 and causes those in the dining room to feel rushed so it can be cleaned before bingo. Review of Resident Council Minutes read in part: Dietary: 9/2/25 New Business: (Residents) states that food (Residents) is still being received very late and felt like it came at midnight.(Residents) stated that 6 out of the last 7 days meals have been late.Expressed concern with it affecting/delaying cares, showers, medications, treatments, and even some activities. (Residents) stated that it is hard when there is a new nurse on the wing almost every day.(Residents) states that it causes confusion especially with treatments.(Residents) have to explain to each new nurse the treatment . Review of Resident Council Minutes read in part: Dietary: 10/8/25 Old Business: Meals still late. New Business: Dietary food over the weekend was 1.5 hours late started at 8:30. Sometimes orders are completely wrong. Things that are ordered are not being put on trays and things not ordered are being put on trays.Food is often cold; at least one item cold with each meal . Review of Resident Council Minutes read in part: Dietary: 11/4/25 Complaints from residents concerning late trays being served cold in the halls was discussed. Activities.Late meals prevented residents from being able to attend activities directly following mealtimes.

Based on interview and record review, the facility failed to maintain a homelike environment by ensuring resident room temperatures were maintained within the acceptable parameters for two Confidential Residents (CR's) out of 14 residents from a resident group interview and 2 Residents (#39 & #62) of 18 residents reviewed for environmental concerns.Findings include:Resident #62 (R62)Review of R62's Electronic Medical Record (EMR) revealed initial admission to the facility on 3/8/23 with diagnoses including hemiparesis (partial weakness, reduced strength, and/or impaired motor function on one side of the body) following cerebral infarction (stroke), multiple sclerosis, muscle weakness, and need for assistance with personal care. Review of R62's most recent Minimum Data Set (MDS) assessment, dated 12/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition.On 1/26/2026 at 4:06 PM, an interview was conducted with R62 regarding overall satisfaction with care at the facility. R62 indicated the facility had experienced a furnace failure around the Christmas holiday and her hallway unit was without heat for approximately six days. R62 stated she was told some type of belt broke on the furnace and it had smelled so badly of burning rubber, she was forced to wear a mask while in her room in an effort mitigate the strong odor. R62 disclosed the facility brought in electric space heaters but they did a poor job keeping her warm due to the location of her bed [R62's bed was located on the exterior wall, with the foot of the bed adjacent to a window]. R62 said she had extra blankets and slept in several sweaters but still got cold despite the space heater due to the draftiness of the window. R62 recalled a staff member was intermittently taking room temperatures and reported the temperature of the exterior wall to be 62 degrees. When asked if the facility offered to relocate her to a different room during the furnace failure, R62 stated, No. R62 indicated she would have moved rooms given the opportunity.Review of R62's EMR revealed a progress note written on 1/1/26 at 16:26 [4:26 PM] which read: [R62] refused her weekly shower due to being too cold.Resident #39 (R39)Review of R39's EMR revealed initial admission to the facility on 4/4/23 with diagnoses including intracerebral hemorrhage (stroke), generalized anxiety disorder, morbid obesity, and low back pain. Review of R39's most recent MDS assessment, dated 1/15/26, revealed a BIMS score of 14, indicative of intact cognition.On 1/26/2026 at 4:28 PM, an interview was conducted with R39 who stated the facility was without heat for an extended period during the Christmas and New Year holiday. R39 recalled the facility had brought in an electric space heater but it, didn't do much to keep her warm. R39 indicated the facility did not offer to temporarily relocate her to a warmer room.On 1/27/26 at 2:05 PM, a confidential group interview was conducted where two confidential residents (CR's) voiced their concerns regarding the furnace failure. One of the CR's stated the facility had no heat for six days and, every day they said it would be fixed and it was not fixed. The CR continued and stated the facility put, little heaters in the room and gave the residents, a bunch of extra blankets that didn't help much. The same CR recalled he had to resort to going to the nurse's station to warm up. Another CR expressed frustration stating, It was a maintenance problem. Nobody looks at anything. This CR indicated the facility didn't offer to temporarily relocate him to a warmer room. The same CR stated, I had to use extra blankets. it was cold. It was like winter camp.Review of an After Action Report, written by the Nursing Home Administrator (NHA) and Director of Nursing (DON) read, in part: Incident: HVAC (Heating, ventilation, and air conditioning) Failure - 300 Wing.Date(s) of Incident: 12/29/25 - 1/3/26. Event Summary: On 12/29/2025 at approximately 1800 hours (6:00 PM), [facility name] experienced a partial heating system failure (HVAC motor and heat exchanger) affecting the 300-wing following a severe blizzard. As a result of the heating failure, resident room temperatures on the affected wing decreased gradually over the next 19 hours to a low reading of 62 F near exterior walls and windows at 1300 [1:00 PM] on 12/30/25. Thermostats in adjacent hallways were increased to 76 F and hallway fans were placed directing warmer air down the 300 Wing in an attempt to stabilize temperatures in resident rooms. When this intervention did not sufficiently improve room temperatures, alternative measures were initiated. Residents were provided with additional blankets and comfort measures as needed. Portable space heaters were purchased on 12/30/25. they were then in resident rooms away from clutter on the 300 Wing as a temporary heating solution. Safe operation required limiting heaters to medium or lower heat settings to avoid exceeding breaker capacity.Review of a written temperature log provided by the NHA which listed rooms still containing occupants, read in part: 1/1/26 at 1430 [2:30 PM]:[Room] 307 - 65 308 - 65 310 - 64 1/1/26 at 2015 [8:15PM]:307 - 66 311 - 67 314 - 67 1/1/26 at 2200 [10:00 PM]:307 - 66 310 - 69 311 - 68 314 - 67 1/2/26 at 0235 [2:35 AM]:307 - 66 308 - 68 310 - 68 311 - 66 314 - 68 1/2/26 at 0340 [3:40 AM]:307- 66 308 - 68 310 - 66 311 - 66 314 - 68 1/2/26 at 0545 [5:45 AM]:307 - 65 308 - 65 310 - 66 311 - 68 314 - 66 Review of the facility's Emergency Preparedness plan, read, in part: SEVERE WEATHER PROCEDURES: .Cold Weather: Temperature below 72 degrees for 12 continuous hours. Facility must evacuate the room(s).Review of a document titled, Rights of Residents in Michigan Nursing Facilities, dated 11/28/16, read, in part: .you have a right to a safe, clean, comfortable and homelike environment.

Based on interview and record review, the facility failed to provide advanced written notification of a room change for 3 Confidential Residents (CR's) of 14 residents during the resident group interview and one Resident (#6) of one resident reviewed for room changes.Findings include:Resident #6 (R6)Review of R6's Electronic Medical Record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including Alzheimer's disease, panic disorder, generalized anxiety disorder, and obsessive compulsive disorder.Review of Section C: Cognitive Patterns in the most recent Minimum Data Set (MDS) assessment for R6, dated 11/10/25, ranked Cognitive Skills for Daily Decision Making as, Moderately impaired-decisions poor; cues/supervision required.On 1/27/2026 at 9:56 AM, an interview was conducted with the Durable Power of Attorney (DPOA) FF for R6 regarding any care concerns at the facility. DPOA FF indicated the facility had changed R6's room, awhile back without any explanation or written notification. When asked if he had given the facility permission for the move, DPOA FF stated, No, they [facility] told me a team of people came to the decision.Review of a facility census report revealed confirmation of R6's room change on 12/30/25.Review of R6's EMR revealed no written notification of the room change.On 1/28/26 at 8:43 AM, an interview was conducted with Social Worker (SW) L regarding facility protocol when changing resident rooms. SW L indicated there was no consent form that is signed by the resident and/or representative prior to conducting a room change. When asked if the reason for the transfer was documented anywhere in the EMR, SW L stated, Not usually, no. If it's an emergency situation where we're worried about a resident-to-resident [incident], we usually do. but regardless, we should be documenting all the time.On 1/27/26 at 2:05 PM, a confidential group interview was conducted where three residents voiced their frustration regarding room changes without prior consent/notification. One confidential resident (CR) stated, They seem to move people around a lot. After the heat went out, they moved him [points at another resident] into my room without telling me, so when I rolled into my room one day, he scared the crap out of me. Another CR added, They don't consult us [about changing rooms] . it's like a little prison. The last CR stated they experienced at least one room change in the previous year without proper notification.Review of the census reports for those three CR's verified room changes in the previous year. Neither the reason for the room changes nor the written notification for the room change were located in their respective EMRs.On 1/28/26 at 4:19 PM, an interview was conducted with the Nursing Home Administrator (NHA) who stated he was unaware residents and/or resident representatives had to be provided with advanced written notification of a room change. The NHA stated given the number of resident behaviors in the facility, room changes were often indicated and providing written notifications of room changes would be difficult for the facility to manage.Review of the facility policy titled, Room Changes, revised 12/30/15, read, in part: .The reason for the room change will be documented by the Social Services Department.Review of a document titled, Rights of Residents in Michigan Nursing Facilities, dated 11/28/16, read, in part: .You have the right to be treated with respect and dignity, including: .the right to receive written notice, including the reason for change, before your room or roommate in the facility is changed.

Based on observation, interview and record review, the facility failed to treat five Residents (#10, #30, #35, #37, & #56) with a dignified dining experience out of 18 residents reviewed for dignity. This deficient practice resulted in a lack of personal dignity and feelings of embarrassment based on the reasonable person. Findings include: During dining observation on 1/27/26 the following was observed: Resident #37 (R37) At approximately 12:17 p.m., Licensed Practical Nurse (LPN) Z was observed assisting R37 with a lunch meal in their room. LPN Z was seated next to R37 and was noted to have blue gloves on during the meal service. Resident #10 (R10) At approximately 12:23 p.m., Dining Assistant/Staff BB was observed assisting R10 with a lunch meal in their room. Staff BB was seated next to R10 and was noted to have blue gloves on during the meal service. Resident #56 (R56) At approximately 1:09 p.m., Dietary Aide/Staff AA was observed assisting R56 with a lunch meal in the hallway. Staff AA was seated next to R56 and was noted to have blue gloves on during the meal service. Resident #35 (R35) Review of R35's Electronic Medical Record (EMR) revealed initial admission to the facility on 4/5/21 with diagnoses including dementia, age related physical debility, and dysphagia (difficulty swallowing). Review of, Section C: Cognitive Patterns in R35's most recent Minimum Data Set (MDS) assessment, dated 12/15/25, ranked R35's, Cognitive Skills for Daily Decision Making as, Severely impaired-never/rarely made decisions. On 1/27/2026 at 12:21 PM, Hospitality Aide (HA) X was observed feeding R35 in the hallway outside her room. HA X was observed feeding R35 with a small brightly colored spoon which had a small, shallow bowl, resembling a baby spoon. Two other similar spoons of different colors were observed on R35's tray. Review of R35's tray ticket for the lunch meal on 1/27/26 read, Pureed – Regular **PLASTIC SPOONS ONLY** On 1/28/26 at 8:27 AM, R35 was observed receiving feeding assistance from Certified Nursing Assistant (CNA) Y in the hallway outside her room. CNA Y was utilizing a brightly colored spoon, resembling a baby spoon, holding approximately one teaspoon of food to feed R35. When asked, CNA Y was unsure why R35 was served spoons with the ability to only hold small volumes of food. On 1/28/26 at approximately 9:40 AM, a telephone interview was conducted with Speech Language Pathologist (SLP) CC regarding her dietary recommendations for R35. SLP CC stated she recommended plastic spoons for R35 because she had been biting down on metallic utensils and therefore wanted to avoid any potential tooth damage. SLP CC stated since making the recommendation, she had seen the facility use both disposable plastic spoons and utensils that resembled, baby spoons. SLP CC stated she didn't not specifically recommend the utensils resembling, baby spoons and reiterated that the spoon material rather than the bite portion was of relevance. On 1/28/26 at 9:50 AM, a telephone interview was conducted with R35's Durable Power of Attorney (DPOA) DD who stated he was unaware the facility was going to be utilizing the itty bitty spoons during mealtimes. On 1/28/26 at 5:54 PM, CNA N was observed feeding R35 the evening meal with blue medical gloves donned. R35 was again observed receiving assistance with a small utensil resembling a baby spoon. Review of R35's EMR and plan of care revealed no orders nor interventions regarding adaptive dining utensils. Resident #30 (R30) Review of R30's EMR revealed initial admission to the facility on [DATE] with diagnoses including Alzheimer's disease and dysphagia (difficulty swallowing). Review of, Section C: Cognitive Patterns in R30's most recent MDS assessment, dated 12/5/25, ranked R30's, Cognitive Skills for Daily Decision Making as, Severely impaired-never/rarely made decisions. On 1/28/2026 at approximately 8:30 AM, R30 was observed receiving feeding assistance from Dining Assistant (DA) EE. R30 was observed receiving food via a small brightly colored spoon with a small, shallow bowl, resembling a baby spoon. When asked, DA EE was unsure why R30 was served these specific spoons. On 1/28/2026 at 12:44 PM, R30 was again observed receiving assistance with a small brightly colored spoon with a small, shallow bowl, resembling a baby spoon. Review of R30's EMR and plan of care revealed no orders nor interventions regarding adaptive dining utensils. Review of the product description on the spoon manufacturer's website read in part, .Baby & Toddler Utensils. Long Handle Weaning Spoons. [for ages] 4+ Months. Easy for parents to hold. Perfect for baby's first foods. Bright, fun colors stimulate baby's senses. Review of the facility policy titled, Resident Rights, revised 12/10/14, read, in part: Policy: To ensure humane care and treatment with consideration consistent with Recognition of Residents' dignity. Upon admission, the Patient/Resident [NAME] of Rights will be given to the Resident and/or Resident Representative. The contents will be reviewed and explained. Review of a document titled, Rights of Residents in Michigan Nursing Facilities, dated 11/28/16, read, in part: .You have the right to be treated with respect and dignity.

Based on observation, interview, and record review the facility failed to maintain appropriate standards of infection control practices to prevent the spread of pneumonia for one Resident (R36) of one Resident reviewed for infection control practices. This deficient practice resulted in the potential for continued spread of pneumonia to other residents residing within the facility. Findings include:Review of R36's Progress Notes, read, in part, 1/27/26 at 9:24 a.m., This RN (Registered Nurse) notified by wing change nurse that resident appears to have had a change in condition.droplet precautions initiated, RN supervisor notified and to speak with emergency contact. Wing staff updated on precautions.On 1/27/26 at approximately 1:30 p.m., Hospitality Aide/Staff Y was observed assisting hallway meal trays. To the right of R36's door, a sign was observed which stated R36 was on precautions. Staff Y proceeded to enter R36's room without Personal Protective Equipment (PPE) to drop off her lunch tray. When exiting, Staff Y stated that she should have worn PPE into R36's room.An interview was conducted with Infection Preventionist (IP) H on 1/27/26 at approximately 1:45 p.m. IP H confirmed Staff Y should have worn PPE.Review of the facility's Transmission Based Precautions policy revised on 10/5/22 read, in part, Upon suspicion by a nurse that a resident has an infections/communicable disease the facility will implement the appropriate Transmission Based Precautions and Isolation (if required) to effectively prevent transmission of the infections agent.Droplet Precautions are required when respiratory droplets carrying microorganisms are transferred directly from the respiratory tract to susceptible mucous surfaces of the recipient. Droplets are generated when the infection person talks, coughs, or sneezes or during procedures such as suctioning. PPE will include, but is not limited to, gloves, gowns and masks. Droplets can travel 6-10 feet.

Based on observation, interview, and record review, the facility failed to provide the necessary supervision to prevent wandering residents entering private resident rooms resulting in feelings of frustration for five Confidential Residents (CR's) out of 14 residents in a confidential group interview and one Resident (#10) out of 18 residents reviewed for quality of care.Findings include:On 1/27/26 at 2:05 PM, a confidential group interview was conducted where several residents voiced their frustration regarding wandering residents entering their personal living quarters. One CR stated, wandering residents came into their room so often, I can't keep my door open. When asked if it takes staff a long time for staff to redirect the resident out of their room, the CR stated, I redirect her because I don't want her near me. She follows me around all day. Another CR added, Yes, there's a problem with wanderers. She [the same resident mentioned above] stares at me and watches what I'm doing. I usually have to redirect her [instead of staff]. Another CR confirmed wanderers often entered her room but they were reliant on staff for redirection due to their physical limitations. The same CR voiced, They wander all night long. Two additional CR's stated they were forced to keep their door shut to avoid wanderers even though they preferred to keep them open. On 1/26/2026 at 4:29 PM, Resident #92 (R92) was observed propelling himself in a wheelchair up and down the 300 hallway. R92 stopped at the entrance of a room and shouted, Stay in there and don't come out until I tell you! No staff intervention was observed after the verbal outburst toward another resident.Review of R92's Plan of Care revealed the following two Approaches with a start date of 1/26/26: [R92] is on the high-risk list for increased risk of resident-to-resident altercations/behaviors. Use consistent verbal redirection when [R92] is observed attempting to entering other residents' roomsOn 1/26/26 at 4:17 PM, Resident #11 (R11), who resides on the 200 hall, was observed wandering on the 300 hallway, entering and exiting other resident rooms with no staff intervention.On 1/27/26 at 11:55 AM, R11 was observed aimlessly wandering on the 500 hallway, hugging staff and waving at other residents. No staff attempted to redirect her from the 500 hallway.On 1/28/26 at 1:00 PM, R11 was observed wandering in the dining room which was temporarily closed due to a COVID-19 outbreak. R11 wandered near the emergency exit door, attempted to push it, then proceeded to exit the dining room through a different door. No staff observed her. Review of, Wandering - Presence & Frequency in Section E: Behaviors in R11's most recent Minimum Data Set (MDS) assessment, dated 1/5/26, revealed, behavior of this type occurred daily.Resident #10 (R10)Review of R10's Electronic Medical Record (EMR) revealed initial admission to the facility on [DATE]. Review of R10's most recent Minimum Data Set (MDS) assessment, dated 12/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition.Review of a, Concern/Suggestion Form, written by R10 on 1/26/26 read, in part: What is your concern or suggestion about? Woke to man in the room wearing gown! He said my bed was his! Put his gown over my legs. Handled my legs! Handled items. Moved an item! [R92]. How can we address your concern/suggestion? That guy needs alarms on his doorway! Can't be allowed to wander into other people's rooms!On 1/28/2026 at 11:42 AM, an interview was conducted with Licensed Practical Nurse (LPN) G regarding the number of wandering residents in the facility. LPN G stated, We need a dementia ward, we have so many wanderers. LPN G indicated it was not sustainable to provide the wandering residents the one-on-one supervision they required given the current staffing levels.

This citation pertains to intake #2687526.Based on interviews and record review the facility failed to implement their policy and procedure for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act and as a result of the facility's failure to implement the facility Abuse Policy and ensure resident safety, resulted in R82's physical abuse to continue and placed all residents at risk for serious injury, physical and psychosocial harm, and impairment.Review of an Anonymous Complaint to the State Agency dated 12/08/2025 1:58 PM read in part: (R82) grabbed (R90's) head aggressively, (facility staff name omitted) and (facility staff name omitted) intervened between the two. Both nurses called (Director of Nursing-DON) immediately after reporting the incident. (Nursing Home Administrator-NHA) told (staff name omitted) that he watched the video and (R82) was petting (R90's) head when that was not the case. This was a resident to resident not being reported by the facility .Resident #82 (R82)Review of an admission Record revealed R82, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease.Review of a Minimum Data Set (MDS) assessment for R82, with a reference date of 1/14/2026 revealed a Brief Interview for Mental Status (BIMS) score of 99/15 which indicated R82 was severely cognitively impaired.In an interview on 1/26/26 at 5:00 PM., Nursing Home Administrator (NHA) reported he was aware of a situation between R82 and R90 about a month ago NHA indicated he did not report or investigate the occurrence between R82 and R90 because he felt it did not rise to the occasion as a reportable or needing investigating NHA indicated that he no longer had video footage of the occurrence between R82 and R90.Review of R82's Behavior Charting read in part: 12/06/2025 17:00 (5:00 p.m.) Behavior Charting Behaviors exhibited by Resident (R82): Aggression towards others see below Additional information: Resident getting ready to eat dinner and was standing next to (R90) and put his hands over her hair/eyes. further review of this Behavior Charting revealed LPN S documented this note.In an interview on 1/26/26 at 5:35 PM., LPN S reported she was working on 12/6/25 when (R82) grabbed onto (R90's) head. LPN S reported the 2 residents were immediately separated. LPN S reported a phone call was made to the Director of Nursing (DON) to report the incident because R82 was known to have extremely aggressive behaviors. LPN S reported R82 has very aggressive behaviors including hitting, punching, spitting, swinging, kicking and reaching out towards others. LPN S reported when R82 grabbed R90's head, it was not gentle. Review of R82's Behavior Charting read in part: 12/07/2025 17:33 Behavior Charting Behaviors exhibited by Resident: Aggression towards others raised fists in threatening manner.Review of a R82's EMR read in part: 12/09/2025 19:02 Behavior Charting Behaviors exhibited by Resident: (R82) following a female resident up by desk, gently placed his hand on her back upsetting her. this nurse placed self between residents while other resident sat in chair. then again when female resident was ambulating to dining room, this resident walking up beside her reaching out hand towards her back .Resident #90 (R90)Review of an admission Record revealed R90 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease.Review of a Minimum Data Set (MDS) assessment for R90, with a reference date of 12/02/2025 revealed a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated R90 was cognitively impaired.Review of R90's Electronic Medical Record (EMR) progress notes dated 10/1/25-12/12/25 revealed no documentation of any aggressive physical or verbal interaction with any other residents, nor documentation of (R82) touching/grabbing her head on 12/6/25 charted/documented. R90's EMR progress notes revealed that R90 was [AGE] years old, blind, hard of hearing and receiving Hospice Care (End of life contracted agency staff to assist facility staff and family).Further review of R90s EMR from Contracted Hospice Agency Social Worker (SW) progress note dated 12/3/25 read in part: SW made a visit to see (R90). Upon arrival, SW found (R90) in her broda (wheelchair) in the dining room awaiting lunch. She was asleep and appeared very comfortable. She did not arouse SW verbal or gentle touch introduction. SW sat with her and provided presence and touch. She was peaceful and did not open eyes for SW during visit .Review of a Facility Policy and Procedure read in part: SUBJECT: Abuse; Investigative and Reporting. REVISION DATES: 03-20-19. POLICY: To ensure prompt and thorough investigation of all reported allegations and/or suspicions of abuse. PROCEDURE: A. The facility must ensure that all alleged violations involving mistreatment (inappropriate treatment or exploitation of a resident), neglect, or abuse, including injuries of unknown source and misappropriation of resident property are immediately (within two hours of occurrence). Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. It includes verbal abuse, sexual abuse, physical abuse and mental abuse .B. An Unusual Occurrence report (Matrix Event) will be completed by the Charge Nurse for all allegations or suspicions of abuse, especially with harm associated, and immediate investigation is begun, if indicated. The Administrator will be notified by the Charge Nurse of Event.D. Upon receipt of complaint, within twenty-four (24) hours of occurrence, alleging actual or suspected abuse, the Administrator and/or Director of Nursing will investigate the incident with the assistance of appropriate and designated personnel.E. The investigation may be guided by the use of the attached Investigation Checklist .F. The investigation may consist of, but not limited to: 1. Review of completed facility Unusual Occurrence Report / Event with harm to residents associated. 2. Interview with person[s] reporting incidents or suspicions.3. Interview with any witnesses to alleged actual or suspected incident.4. If possible, interview with residents.5. Review of resident's medical records.6. Interviews with staff members having contact with the residents during the period/shift of the reported actual or suspected incident.7. Interviews with resident's roommate, family members, visitors, or any others.10.Review of all circumstances surrounding the alleged actual or suspected incident. **Interviews with all the above may not be completed based on circumstances surrounding the incident. **I. The Administrator will keep the resident or his/her representative of the findings of the investigation and corrective action taken.J. Allegations of abuse, of any nature, will be reported to (State Agency) .within 24 hours of the incident .M. If the incident reported results in injury or sexual assault, the immediate welfare of the resident is priority. The physician and resident representative will be updated and together will determine if a hospital emergency room visit is indicated. The Administrator will be contacted, unusual occurrence report will be initiated, and the internal investigation will begin immediately.INVESTIGATION CHECKLIST for IDT (To be used for allegation of abuse to facilitate investigations when obvious root cause is not evident).Resident(s) involved.Date and Time of Event: .Type of Event: .Who reported Event: .Date and time incident reported to the DON/ADON/Administrator: . Identify and Interview Like Residents - if applicable.What Residents need to be interviewed? .Like Diagnosis or situation (cognition, dependent, etc.)? .Develop questions to be asked of like residents.Ensure issue is not a pattern issue that needs to be addressed.Identify and Interview Involved Employees.What Employees need to be interviewed? .Develop questions to be asked of Employees? .CNAs for that shift:.NURSE for that shift:.Other staff on the unit that shift:.The goal is to develop a timeline going back several hours (beginning of shift or previous shift) or days (if necessary) reviewing resident behavior & activity leading up to the event to help identify a root cause.

This citation pertains to intake# 2687526Based on interviews and record review, the facility failed to fully implement its Abuse Program Policy and Procedure and immediately identify and thoroughly investigate incidents of resident to resident abuse for 2 Residents (Residents #82 & #90) from 18 residents reviewed for abuse and based on the reasonable person concept would cause feelings of pain, fear and intimidation for Residents #90, and the potential for continued resident abuse to go unreported and/or undetected.Findings include:Review of an Anonymous Complaint to the State Agency dated 12/8/2025 at 1:58 PM read in part: (R82) grabbed (R90's) head aggressively, (facility staff name omitted) and (facility staff name omitted) intervened between the two. Both nurses called (the Director of Nursing [DON]) immediately after reporting the incident. (The Nursing Home Administrator [NHA]) told (staff name omitted) that he watched the video and (R82) was 'petting' (R90's) head when that was not the case. This was a resident to resident not being reported by the facility . Resident #82 (R82)Review of an admission Record revealed R82, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease.Review of a Minimum Data Set (MDS) assessment for R82, with a reference date of 1/14/2026 revealed a Brief Interview for Mental Status (BIMS) score of 99/15 which indicated R82 was severely cognitively impaired.In an interview on 1/26/26 at 5:00 PM., the NHA reported he was aware of a situation between R82 and R90 about a month ago. When asked, NHA informed this surveyor that he did not complete an Unusual Occurrence Report (UOR)., or a Facility Reported Incident (FRI) (State Agency-SA). NHA stated I do not have video footage of the incident between R82 and R90. Review of R82's Behavior Charting read in part: 12/06/2025 17:00 Behavior Charting Behaviors exhibited by Resident (R82): Aggression towards others see below Additional information: Resident getting ready to eat dinner and was standing next to (R90) and put his hands over her hair/eyes. further review of this Behavior Charting revealed Licensed Practical Nurse (LPN) S documented this note.In an interview on 1/26/26 at 5:35 PM., LPN S reported she was working on 12/6/25 when (R82) grabbed onto (R90's) head. LPN S reported the 2 residents were immediately separated. LPN S reported a phone call was made to the DON to report the incident because R82 was known to have extremely aggressive behaviors. LPN S reported R82 has very aggressive behaviors including, hitting, punching, spitting, swinging, kicking and reaching out towards others. LPN S reported when R82 grabbed R90's head, it was not gentle. Review of a R82's EMR Progress Notes Behavior Charting read in part: 12/07/2025 17:33 (5:33 p.m.) Behavior Charting Behaviors exhibited by Resident: Aggression towards others raised fists in threatening manner at activity aide . 12/09/2025 19:02 (7:02 p.m.) Behavior Charting Behaviors exhibited by Resident: (R82) following a female resident up by desk, gently placed his hand on her back upsetting her. this nurse placed self between residents while other resident sat in chair. then again when female resident was ambulating to dining room, this resident walking up beside her reaching out hand towards her back . 12/10/2025 01:18 (1:18 a.m.) Behavior Charting Behaviors exhibited by Resident: Aggression towards others aggressive w/staff during cares, Combativeness aggressive with staff and hitting staff during cares. 12/10/2025 09:47 (9:47 a.m.) Behavior Charting Behaviors exhibited by Resident: Aggression towards others backhanded CNA across face, grabbed arm leaving red gauge marks . 12/11/2025 16:04 (4:04 p.m.) (R82) with increasing behaviors and agitation resulting in fear, discomfort, agitation, anger, and dangerous actions to care staff. There have been instances that (R82) has reached out toward other residents . 01/06/2026 08:41 (8:41 a.m.) Noted in (R82's) (EMR-facility name omitted) charting that on1/3/26 (R82) had combative behaviors causing injury to staff; spilled coffee on self, 3 CNAs assisted (R82) in changing clothes. 'He proceeded to hit, punched, and pulled back CNA finger back.' Also was noted that he spitting that CNAs face. 01/08/2026 17:06 (5:06 p.m.) (Hospice Registered Nurse RN documented) (R82) has experienced decline in the last 2 months. (R82) has experienced agitation involving violence toward other residents. 12/07/2025 17:33 (5:33 p.m.) Behavior Charting Behaviors exhibited by Resident: Aggression towards others raised fists in threatening manner at activity aide . 12/09/2025 19:02 (7:02 p.m.) Behavior Charting Behaviors exhibited by Resident: (R82) following a female resident up by desk, gently placed his hand on her back upsetting her. this nurse placed self between residents while other resident sat in chair. then again when female resident was ambulating to dining room, this resident walking up beside her reaching out hand towards her back . 12/10/2025 01:18 (1:18 a.m.) Behavior Charting Behaviors exhibited by Resident: Aggression towards others aggressive w/staff during cares, Combativeness aggressive with staff and hitting staff during cares. 12/10/2025 09:47 (9:47 a.m.) Behavior Charting Behaviors exhibited by Resident: Aggression towards others backhanded CNA across face, grabbed arm leaving red gauge marks . 12/11/2025 16:04 (4:04 p.m.) (R82) with increasing behaviors and agitation resulting in fear, discomfort, agitation, anger, and dangerous actions to care staff. There have been instances that (R82) has reached out toward other residents . 01/08/2026 17:06 (5:06 p.m.) (Hospice Registered Nurse RN documented) (R82) has experienced decline in the last 2 months. (R82) has experienced agitation involving violence toward other residents. 01/13/2026 12:25 (12:25 p.m.) with cares., Combativeness with staff during cares . At one time the resident pushed CNA at her chest into the wall to where her back and head hit the wall. At another time resident punched CNA in the head with both fists while he was trying to get his pants back up after cares for him. 01/14/26 (R82's) becoming increasingly difficult to redirect; he seems to be more skeptical of staff prompts to initiate cares, often stopping at his room doorway or shower doorway and refusing to follow staff inside. The IDT is having difficulty in identifying new techniques to keep staff safe, as several incidents have resulted in staff injuries.Resident #90 (R90)Review of an admission Record revealed R90 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease.Review of a Minimum Data Set (MDS) assessment for R90, with a reference date of 12/2/2025 revealed a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated R90 was cognitively impaired.Review of R90's Electronic Medical Record (EMR) progress notes dated 10/1/25-12/12/25 revealed no documentation of any aggressive physical or verbal interaction with any other residents, nor documentation of (R82) touching/grabbing her head on 12/6/25 charted/documented. R90's EMR progress notes revealed that R90 was [AGE] years old, blind, hard of hearing and receiving Hospice Care (End of life contracted agency staff to assist facility staff and family). Further review of R90s EMR from Contracted Hospice Agency Social Worker (SW) progress note dated 12/3/25 read in part: SW made a visit to see (R90). Upon arrival, SW found (R90) in her broda (wheelchair) in the dining room awaiting lunch. She was asleep and appeared very comfortable. She did not arouse SW verbal or gentle touch introduction. SW sat with her and provided presence and touch. She was peaceful and did not open eyes for SW during visit .Review of a Facility Policy and Procedure read in part: SUBJECT: Abuse; Investigative and Reporting. REVISION DATES: 03-20-19. POLICY: To ensure prompt and thorough investigation of all reported allegations and/or suspicions of abuse. PROCEDURE: A. The facility must ensure that all alleged violations involving mistreatment (inappropriate treatment or exploitation of a resident), neglect, or abuse, including injuries of unknown source and misappropriation of resident property are immediately (within two hours of occurrence). Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. It includes verbal abuse, sexual abuse, physical abuse and mental abuse .B. An Unusual Occurrence report (Matrix Event) will be completed by the Charge Nurse for all allegations or suspicions of abuse, especially with harm associated, and immediate investigation is begun, if indicated. The Administrator will be notified by the Charge Nurse of Event.D. Upon receipt of complaint, within twenty-four (24) hours of occurrence, alleging actual or suspected abuse, the Administrator and/or Director of Nursing will investigate the incident with the assistance of appropriate and designated personnel.E. The investigation may be guided by the use of the attached Investigation Checklist .F. The investigation may consist of, but not limited to: 1. Review of completed facility Unusual Occurrence Report / Event with harm to residents associated. 2. Interview with person[s] reporting incidents or suspicions.3. Interview with any witnesses to alleged actual or suspected incident.4. If possible, interview with residents.5. Review of resident's medical records.6. Interviews with staff members having contact with the residents during the period/shift of the reported actual or suspected incident.7. Interviews with resident's roommate, family members, visitors, or any others.10.Review of all circumstances surrounding the alleged actual or suspected incident. **Interviews with all the above may not be completed based on circumstances surrounding the incident. **I. The Administrator will keep the resident or his/her representative of the findings of the investigation and corrective action taken.J. Allegations of abuse, of any nature, will be reported to (State Agency) .within 24 hours of the incident .M. If the incident reported results in injury or sexual assault, the immediate welfare of the resident is priority. The physician and resident representative will be updated and together will determine if a hospital emergency room visit is indicated. The Administrator will be contacted, unusual occurrence report will be initiated, and the internal investigation will begin immediately.INVESTIGATION CHECKLIST for IDT (To be used for allegation of abuse to facilitate investigations when obvious root cause is not evident).Resident(s) involved.Date and Time of Event: .Type of Event: .Who reported Event: .Date and time incident reported to the DON/ADON/Administrator: . Identify and Interview Like Residents - if applicable.What Residents need to be interviewed? .Like Diagnosis or situation (cognition, dependent, etc.)? .Develop questions to be asked of like residents.Ensure issue is not a pattern issue that needs to be addressed.Identify and Interview Involved Employees.What Employees need to be interviewed? .Develop questions to be asked of Employees? .CNAs for that shift:.NURSE for that shift:.Other staff on the unit that shift:.The goal is to develop a timeline going back several hours (beginning of shift or previous shift) or days (if necessary) reviewing resident behavior & activity leading up to the event to help identify a root cause.

This citation pertains to intake #2687526.Based on interviews and record review the facility failed to protect the resident's right to be free from physical abuse by a resident for one Resident (#90) of two residents reviewed for abuse resulting in R82 grabbing R90's head, and based on the reasonable person concept would cause feelings of pain, fear and intimidation for Resident #90.Findings include:Review of an Anonymous Complaint to the State Agency dated 12/8/2025 at 1:58 PM read in part: (R82) grabbed (R90's) head aggressively, (facility staff name omitted) and (facility staff name omitted) intervened between the two. Both nurses called (the Director of Nursing [DON]) immediately after reporting the incident. (The Nursing Home Administrator [NHA]) told (staff name omitted) that he watched the video and (R82) was 'petting' (R90's) head when that was not the case. This was a resident to resident not being reported by the facility .Resident #82 (R82)Review of an admission Record revealed R82, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease.Review of a Minimum Data Set (MDS) assessment for R82, with a reference date of 1/14/2026 revealed a Brief Interview for Mental Status (BIMS) score of 99/15 which indicated R82 was severely cognitively impaired.In an interview on 1/26/26 at 5:00 PM., the NHA reported he was aware of the situation between R82 and R90 about a month ago. When asked, NHA informed this surveyor that he did not complete an Unusual Occurrence Report (UOR)., or a Facility Reported Incident (FRI) (State Agency-SA). NHA stated I do not have video footage of the incident between R82 and R90. Review of R82's Behavior Charting read in part: 12/06/2025 17:00 Behavior Charting Behaviors exhibited by Resident (R82): Aggression towards others see below Additional information: Resident getting ready to eat dinner and was standing next to (R90) and put his hands over her hair/eyes. further review of this Behavior Charting revealed Licensed Practical Nurse (LPN) S documented this note.In an interview on 1/26/26 at 5:35 PM., LPN S reported she was working on 12/6/25 when (R82) grabbed onto (R90's) head. LPN S reported the 2 residents were immediately separated. LPN S reported a phone call was made to the DON to report the incident because R82 was known to have extremely aggressive behaviors. LPN S reported R82 has very aggressive behaviors including hitting, punching, spitting, swinging, kicking and reaching out towards others. LPN S reported when R82 grabbed R90's head, it was not gentle. Resident #90 (R90)Review of an admission Record revealed R90 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease.Review of a Minimum Data Set (MDS) assessment for R90, with a reference date of 12/2/2025 revealed a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated R90 was cognitively impaired.Review of R90's Electronic Medical Record (EMR) progress notes dated 10/1/25-12/12/25 revealed no documentation of any aggressive physical or verbal interaction with any other residents, nor documentation of (R82) touching/grabbing her head on 12/6/25 being charted/documented. R90's EMR progress notes revealed that R90 was [AGE] years old, blind, hard of hearing and receiving Hospice Care (End of life contracted agency staff to assist facility staff and family).Further review of R90s EMR from Contracted Hospice Agency Social Worker (SW) progress note dated 12/3/25 read in part: SW made a visit to see (R90). Upon arrival, SW found (R90) in her broda (wheelchair) in the dining room awaiting lunch. She was asleep and appeared very comfortable. She did not arouse SW verbal or gentle touch introduction. SW sat with her and provided presence and touch. She was peaceful and did not open eyes for SW during visit .Review of a R82's EMR Progress Notes Behavior Charting read in part: 12/07/2025 17:33 (5:33 p.m.) Behavior Charting Behaviors exhibited by Resident: Aggression towards others raised fists in threatening manner at activity aide . 12/09/2025 19:02 (7:02 p.m.) Behavior Charting Behaviors exhibited by Resident: (R82) following a female resident up by desk, gently placed his hand on her back upsetting her. this nurse placed self between residents while other residents sat in chair. then again when female resident was ambulating to dining room, this resident walking up beside her reaching out hand towards her back . 12/10/2025 01:18 (1:18 a.m.) Behavior Charting Behaviors exhibited by Resident: Aggression towards others aggressive w/staff during cares, Combativeness aggressive with staff and hitting staff during cares. 12/10/2025 09:47 (9:47 a.m.) Behavior Charting Behaviors exhibited by Resident: Aggression towards others backhanded CNA across face, grabbed arm leaving red gauge marks . 12/11/2025 16:04 (4:04 p.m.) (R82) with increasing behaviors and agitation resulting in fear, discomfort, agitation, anger, and dangerous actions to care staff. There have been instances that (R82) has reached out toward other residents . 01/06/2026 08:41 (8:41 a.m.) Noted in (R82's) (EMR-facility name omitted) charting that on1/3/26 (R82) had combative behaviors causing injury to staff; spilled coffee on self, 3 CNAs assisted (R82) in changing clothes. 'He proceeded to hit, punched, and pulled back CNA finger back.' Also was noted that he is spitting that CNAs face. 01/08/2026 17:06 (5:06 p.m.) (Hospice Registered Nurse RN documented) (R82) has experienced decline in the last 2 months. (R82) has experienced agitation involving violence toward other residents. 12/07/2025 17:33 (5:33 p.m.) Behavior Charting Behaviors exhibited by Resident: Aggression towards others raised fists in threatening manner at activity aide . 12/09/2025 19:02 (7:02 p.m.) Behavior Charting Behaviors exhibited by Resident: (R82) following a female resident up by desk, gently placed his hand on her back upsetting her. this nurse placed self between residents while other resident sat in chair. then again when female resident was ambulating to dining room, this resident walking up beside her reaching out hand towards her back . 12/10/2025 01:18 (1:18 a.m.) Behavior Charting Behaviors exhibited by Resident: Aggression towards others aggressive w/staff during cares, Combativeness aggressive with staff and hitting staff during cares. 12/10/2025 09:47 (9:47 a.m.) Behavior Charting Behaviors exhibited by Resident: Aggression towards others backhanded CNA across face, grabbed arm leaving red gauge marks . 12/11/2025 16:04 (4:04 p.m.) (R82) with increasing behaviors and agitation resulting in fear, discomfort, agitation, anger, and dangerous actions to care staff. There have been instances that (R82) has reached out toward other residents . 01/08/2026 17:06 (5:06 p.m.) (Hospice Registered Nurse RN documented) (R82) has experienced decline in the last 2 months. (R82) has experienced agitation involving violence toward other residents. 01/13/2026 12:25 (12:25 p.m.) with cares., Combativeness with staff during cares . At one time the resident pushed CNA at her chest into the wall to where her back and head hit the wall. At another time resident punched CNA in the head with both fists while he was trying to get his pants back up after cares for him. 01/14/26 (R82's) becoming increasingly difficult to redirect; he seems to be more skeptical of staff prompts to initiate cares, often stopping at his room doorway or shower doorway and refusing to follow staff inside. The IDT is having difficulty in identifying new techniques to keep staff safe, as several incidents have resulted in staff injuries.Review of a Facility Policy and Procedure read in part: SUBJECT: Abuse; Investigative and Reporting. REVISION DATES: 03-20-19. POLICY: To ensure prompt and thorough investigation of all reported allegations and/or suspicions of abuse. PROCEDURE: A. The facility must ensure that all alleged violations involving mistreatment (inappropriate treatment or exploitation of a resident), neglect, or abuse, including injuries of unknown source and misappropriation of resident property are immediately (within two hours of occurrence). Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. It includes verbal abuse, sexual abuse, physical abuse and mental abuse .B. An Unusual Occurrence report (Matrix Event) will be completed by the Charge Nurse for all allegations or suspicions of abuse, especially with harm associated, and immediate investigation is begun, if indicated. The Administrator will be notified by the Charge Nurse of Event.D. Upon receipt of complaint, within twenty-four (24) hours of occurrence, alleging actual or suspected abuse, the Administrator and/or Director of Nursing will investigate the incident with the assistance of appropriate and designated personnel.E. The investigation may be guided by the use of the attached Investigation Checklist .F. The investigation may consist of, but not limited to: 1. Review of completed facility Unusual Occurrence Report / Event with harm to residents associated. 2. Interview with person[s] reporting incidents or suspicions.3. Interview with any witnesses to alleged actual or suspected incident.4. If possible, interview with residents.5. Review of resident's medical records.6. Interviews with staff members having contact with the residents during the period/shift of the reported actual or suspected incident.7. Interviews with resident's roommate, family members, visitors, or any others.10.Review of all circumstances surrounding the alleged actual or suspected incident. **Interviews with all the above may not be completed based on circumstances surrounding the incident. **I. The Administrator will keep the resident or his/her representative of the findings of the investigation and corrective action taken.J. Allegations of abuse, of any nature, will be reported to (State Agency) .within 24 hours of the incident .M. If the incident reported results in injury or sexual assault, the immediate welfare of the resident is priority. The physician and resident representative will be updated and together will determine if a hospital emergency room visit is indicated. The Administrator will be contacted, unusual occurrence report will be initiated, and the internal investigation will begin immediately.INVESTIGATION CHECKLIST for IDT (To be used for allegation of abuse to facilitate investigations when obvious root cause is not evident).Resident(s) involved.Date and Time of Event: .Type of Event: .Who reported Event: .Date and time incident reported to the DON/ADON/Administrator: . Identify and Interview Like Residents - if applicable.What Residents need to be interviewed? .Like Diagnosis or situation (cognition, dependent, etc.)? .Develop questions to be asked of like residents.Ensure issue is not a pattern issue that needs to be addressed.Identify and Interview Involved Employees.What Employees need to be interviewed? .Develop questions to be asked of Employees? .CNAs for that shift:.NURSE for that shift:.Other staff on the unit that shift:.The goal is to develop a timeline going back several hours (beginning of shift or previous shift) or days (if necessary) reviewing resident behavior & activity leading up to the event to help identify a root cause.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 76 residents of the facility. Findings include: On 11/19/24 at approximately 7:20 AM, during morning meal service, a stainless steel pan of the pureed meal was observed on the steam table. [NAME] B was asked to identify the pureed food, to which she stated was, eggs, sausage and hashbrown potatoes. The temperature was measured with a metal stem probe thermometer and found to be 115 F. An interview with [NAME] B was conducted at this time and learned the food was put through a blender process and placed in the steam table. When the measured temperature was shared with [NAME] B, she stated that's not good. [NAME] B then placed the pan into the steamer to reheat. At 7:50 AM an interview was conducted with [NAME] B who was asked what temperature she had re-heated the food to. [NAME] B stated it had been reheated to 135 F. When asked if she knew what the temperature of reheated food was to be to, [NAME] B stated 165? [NAME] B also stated the temperature of the food had not been measured following the puree process. The FDA Food Code 2017 states: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 C (130 F) or above; Also: 3-403.11 Reheating for Hot Holding. (A) Except as specified under (B) and (C) and in (E) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74 C (165 F) for 15 seconds. On 11/19/24 at approximately 11:15 AM, Food Service Worker (FSW) C was observed conducting dish washing activities in the three compartment sink. FSW C was observed to wash and rinse food preparation equipment (blender bowl, mixing bowls, utensils), then place into the sanitizing solution for approximately two seconds, after which they were removed and placed on a rack to drain and dry. An interview with FSW C was conducted at this time and asked what his understanding was of using the sanitizing solution. FSW C stated he was taught to dunk the equipment in the solution and had never been told that a minimum of 60 seconds of immersion was required for proper sanitizing of the equipment. A review of the container of sanitizer, identified as a quaternary ammonium (Quat) and required a contact, or immersion time, of a minimum of 60 seconds. the FDA Food Code states: 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness. A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under S7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, P and shall be used as follows: (C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24 C (75 F), P (2) Have a concentration as specified under S 7-204.11 and as indicated by the manufacturer's use directions included in the e labeling, On 11/20/24 at 11:11 AM [NAME] B was observed preparing the noon meal, which included the use of the steamer equipment, located under the exhaust hood. [NAME] B was observed to open the door of the steamer, which at that time, released an enormous volume of steam. It was further observed the exhaust hood was unable to capture the volume of steam created and released by the equipment, and was estimated to allow over 60% of the released steam to roll up the front of the canopy of the hood and then roll across the kitchen ceiling. The steam was then observed to condense on the ceiling creating droplets of water which then dripped down to the floor potentially contaminating food being carried in the area. This condition was observed an additional three times during the food preparation. An interview was conducted with [NAME] B on 11/20/24 at approximately 11:25 AM concerning the release of the steam into the working area. [NAME] B stated this had been ongoing for as long as she could remember and felt it was a problem. On 11/20/24 at approximately 12:45 PM, an interview with Kitchen Manager (KM) A was conducted, who confirmed the ongoing problem with the inability of the exhaust hood to capture the volume of steam and smoke produced by the cooking equipment. On 11/20/24 at approximately 1:10 PM additional observations of the exhaust hood were made. Using a simple test of holding a paper towel to the filters of the hood, there was a demonstrated weak pull, or negative pressure being created by the motors of the unit. Further, the hood, not being a compensating type hood, in which exterior air is pushed into the kitchen to aid in funneling smoke and steam into the canopy and out the exhaust, created a low volume of make up air in the kitchen. It appeared the exhaust volume was not properly engineered to capture the volume of smoke and steam produced, nor was it capable of providing an equal volume of incoming air to balance the exhaust volume. Additional interview with KM A at this time confirmed the ongoing problem with the exhaust system in the kitchen. The FDA Food Code 2017 states: 4-301.14 Ventilation Hood Systems, Adequacy. Ventilation hood systems and devices shall be sufficient in number and capacity to prevent grease or condensation from collecting on walls and ceilings. And 6-304.11 Mechanical. If necessary to keep rooms free of excessive heat, steam, condensation, vapors, obnoxious odors, smoke, and fumes, mechanical ventilation of sufficient capacity shall be provided.

Based on observation, interview, and record review, the facility failed to ensure one medication cart remained locked when unattended of four medication carts reviewed, and failed to discard two expired glucose meter control solutions of six control solutions reviewed. This deficient practice resulted in the potential for misappropriation of medications for the nine residents on the 500 unit, and the potential for inaccurate blood glucose readings for six residents receiving blood glucose testing. Findings include: On [DATE] at 3:42 p.m. and [DATE] at 1:53 p.m., the medication cart on the 500 unit was unlocked and unattended. The Director of Nursing (DON) was questioned on [DATE] at 8:05 a.m. regarding the expectation for securing the medication carts. The DON said the expectation is for medication carts to be kept locked when not in use and for nurses to lock the medication carts when walking away from them. On [DATE] at 2:44 p.m., the medication storage room was inspected with Licensed Practical Nurse D (LPN D). Two blood glucose meter control solution bottles were observed on the countertop in a clear plastic bag. The date written on both bottles was [DATE]. LPN D said the dates were written when the bottles were opened. Both control solution bottles contained instructions that read, in part: .discard 3 months after first opening . LPN D was asked if other bottles of control solutions were available or in use. LPN D replied, I don't know. One of the cupboards in the medication room revealed two unopened boxes of glucose meter control solutions. During an interview with the DON on [DATE] at 8:05 a.m., the DON said the glucose control solutions should have been discarded within 90 days of opening. The policy Medications dated as revised [DATE] read, in part: .The medication cart will be locked when unattended . The policy Glucometer: Control Testing and Cleaning dated as last revised on [DATE] read, in part: .Policy- to ensure that blood glucose results are accurate .Glucose Control Solutions .Use before expiration date and discard any unused portion 90 days after opening. Date opened to be written on solution box . The manufacturer instruction manual for the blood glucose meter used by the facility read, in part: .Discard the used control solution and repeat the test using a new bottle of control solution .when the control solutions is past its discard date (the date the bottle was opened plus three (3) months) .

Based on observation, interview, and record review, the facility failed to provide a dignified dining experience in their Dining Room (DR) by standing over seated residents while assisting with feeding and failing to serve all residents at the same table together. This deficient practice had the potential to affect all residents dining in the main dining room. Findings include: During the lunch meal service on 11/19/24 at 12:30 PM, approximately 30 residents were observed in the DR. Six of the seven tables with multiple residents seated at them each were partially served. Some residents at each of the six tables were eating while other residents sitting at the tables did not have their meals. One table had one resident eating while three residents and several visitors at the same table were waiting. Approximately 20 minutes later at 12:50 PM, two of the three residents waiting at this table were served while one resident continued to wait. At 1:05 PM, the last resident at this table was served. During an interview on 11/19/24 at approximately 1:10 PM, the visitors at this table who had visited with their family member during the meal service acknowledged the last resident to be served at this table had been sitting and waiting with them before 12:30 PM. During the lunch meal observation on 11/19/24 at 12:39 PM, staff member L assisting with the serving of the meals told one resident after serving the first tray at a round table, Yes you are all going to get lunch. Thanks for your patience. The resident replied, I am just waiting and watching. I hope they bring me something pretty soon. At 12:47 PM the resident was served, but the other two residents waiting at the table were not served and watched the other residents at the table eat. One resident at the table moved the tablecloth and laid her forehead on the edge of the table to rest. At 12:56 PM she was served, and the last resident at the table was served at 12:57 PM. During this lunch meal observation of 11/19/24 at 12:45 PM, Resident #41 said he had been waiting quite a while. He stated, I was five minutes late coming in and now I will have to wait longer. Both of his table mates were eating. He sat there and dozed off while his other two table mates continued eating until 12:53 PM when his tray arrived. During the breakfast meal observation on 11/20/24 at 7:06 AM, several residents were in the DR awaiting the meal. At 7:43 AM, four residents were at the round table near the service area and the first resident was served. At 7:57 AM, the next table mate at this table was served. At 7:58 AM the resident who was observed in the dining room at 7:06 was served, and at 8:01 AM the last member of the table was served. During this time multiple staff members were assisting in the dining room and serving others at different tables in no particular order. One table had two residents eating by 7:48 AM and others were waiting. At 7:55 AM, five residents were served at this table and one last resident continued to wait for his breakfast. By 8:09 AM, two of the residents at the table had finished and were leaving but the final resident continued to wait. At 8:11 AM, the last resident at this table was served. This breakfast observation of 11/20/24 at 8:00 AM included five tables with multiple residents and four of those tables had been partially served while the others watched them eat and wait. During the breakfast observation on 11/20/24 at 8:34 AM, two dependent residents were being fed by staff who were standing over the residents while the residents were seated. Registered Nurse (RN) F was consulted and stated, No they should not be standing. Sitting is more personable. On 11/20/24 at 8:52 AM, staff member I who had been observed assisting residents while standing over residents, stated, We should sit (when feeding). During an interview on 11/20/24 at 2:58 PM, Certified Dietary Manager (CDM) stated the standard of practice was, We should serve the same table at the same time. On 11/20/24 at 8:55 AM, the Director of Nursing (DON) stated the expectation was staff should be seated while feeding the residents. The DON provided the training program for assisting and feeding residents but positioning while feeding or tray distribution per table was not found in this document. No further policies concerning these issues were provided prior to the conclusion of the survey.

Based on observation, interview, and record review, the facility failed to ensure a correct therapeutic diet was prescribed for 2 Residents (#25 and #41) of 5 Residents reviewed for nutritional issues. This deficient practice resulted in the potential for unmet nutritional needs and the potential for health complications. Findings include: Resident #25 (R25) R25 was admitted to the facility 8/19/2020 with diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, dysphagia (difficulty swallowing) and diabetes mellitus. The Minimum Data Set (MDS) assessment dated [DATE] revealed R25 was totally dependent for eating meaning the helper does ALL of the effort. R25 was also coded as dependent for dressing, bathing, toileting and personal hygiene. The Brief Interview for Mental Status (BIMS) assessment was not attempted and was coded No (resident is rarely/never understood). The physician orders included a Diet order: CCD NAS, Pureed (carbohydrate controlled diet, no added salt, pureed). On 11/19/24 at 8:25 AM, the breakfast meal for R25 was observed served in a three-compartment divided dish with only one compartment containing a beige scoop of a pureed item. The tray card indicated R25 should receive: Pureed Breakfast Skillet - 3 oz (ounces) and Pureed Toast - #8 Scp (#8 scoop is 3.75 oz). R25 was also to receive apple sauce - 1/2 cup, but was served a pre-portioned ready to serve 1/4 cup. The tray card included instructions of No Pepper Packets. This tray included pepper. During an interview on 11/19/24 at approximately 8:30 AM, dietary cook C, who prepared the breakfast, stated I just mixed the bread with the breakfast skillet and gave 2 ladles (2 oz each). During an interview on 11/19/24 at 3:16 PM, Certified Dietary Manager (CDM) A reviewed the therapeutic menus and stated the cook should have pureed breakfast skillet and pureed toast separately and the residents should be served the serving sizes and preferences listed on the tray card. R25 received 4 oz of a mixed product and should have received approximately 4 oz of toast and 3 oz of the breakfast skillet recipe. On 11/20/24 at 8:27 AM, R25 was observed with breakfast served in a three-compartment divided dish with only one compartment containing a beige scoop of Krupsua (a Finish baked breakfast custard). All other residents received a square formed serving of the Krupsua. R25 was also to receive apple sauce - 1/2 cup, but again was served a pre-portioned ready to serve 1/4 cup. The tray card included instructions of No Pepper Packets. Two pepper packets were served on the tray. On 11/20/24 at approximately 11:55 AM, R25 was observed with two pepper packets on her tray and the tray card read No Pepper Packets. The staff member (Staff L) assisting R25 with her meal stated, They continue to put pepper on the tray. I guess some people don't read. During an interview on 11/20/24 at 2:45 PM, CDM A was unsure why R25 should not get pepper packets and stated it may be because she would eat the paper packets of pepper. CDM A stated he would expect the cooks to follow the recipes and the tray cards and the puree Krupsua should be a square formed serving for all residents including those receiving a pureed diet. Resident #41 (R41) R41 was admitted on [DATE] with diagnoses including chronic (CHF) congestive heart failure (primary diagnosis),high blood pressure, fluid overload and diabetes mellitus. The physician orders included Diet Order Instructions: 2,000 ml (milliliters) Fluid Restriction 480 ml with meals 240 ml BID (twice daily) with medication pass 40 ml excess fluid per day. On 11/19/24 at 8:12 AM, the breakfast tray for R41 was observed and contained 120 ml of orange juice, 180 ml of coffee, and 120 ml of cranberry juice. R41 requested he substitute his 120 ml of cranberry juice for milk so he could use it with his dry cereal. He was given 240 ml of milk resulting in a total of 540 ml for the meal. On 11/19/24 at 3:47 PM, R41 was observed to have a water jug with ice water filled past the top 280 ml mark on the vessel. R41 stated the staff had just passed the ice water and he usually got ice water once a day or so. On 11/19/24 at 4:04 PM, R41 was frustrated and stated, I keep peeing all the time. Something is wrong. On 11/20/24 at 7:45 AM, R41 was in the main dining room waiting for his breakfast to be served. He had a 180 ml cup of coffee and had an empty 180 ml of coffee in front of him. R41 stated, I haven't got to that one yet. Eleven minutes later at 7:56 AM, R41 had his breakfast tray served with two cups of 120 ml orange juice and 180 ml of coffee. R41 stated he only wanted one glass of orange juice. The Licensed Practical Nurse (LPN) K who was assisting in the main dining room said, I don't know why you got two, if you don't want them you don't have to drink them. LPN K seemed unaware of the fluid restriction. Later during the breakfast meal R41 was observed drinking his third cup of coffee. (The total observed fluid consumption for the meal was 660 ml.) On 11/20/24 at 10:01 AM, R41 was observed in activities watching a musical group. Many of the residents had beverages while they listened to the entertainment. R41 had a 180 ml mug in front of him even though the ordered fluid restriction plan only included fluids with meals and medication passes. During an interview on 11/21/24 at 9:16 AM, a fluid report was reviewed by the Director of Nursing (DON) and the Clinical Consultant Registered Nurse (RN) M. The report did not reflect all the fluids consumed by R41. For example: breakfast of 11/20/24 with 3 cups of coffee (180 ml each) and a glass of orange juice (120 ml) was recorded as 120 ml rather than the actual 660 ml. The water pass sheet indicated R41 should not receive bed side water due to the physician ordered fluid restriction but approximately 300 ml of ice water was served on 11/19/24. The care plan in the medical record for R41 included concerns for weight fluctuations with CHF and edema with a diuretic and indicated a plan, I will attempt to maintain my recommended 2,000 ml Fluid Restriction 480 ml with meals, 240 ml BID with medication pass 40 ml excess fluid per day with nursing assistance. The policy titled Intake and Output and dated as most recently revised 12/22/2015, read in part: Policy: To ensure adequate hydration and provide a monitoring system for potential over-hydration or dehydration . Procedure: A. Intake and Output (I&O) will be initiated for the following: . 8. For specific diagnoses that include, but are not limited to: . h. Fluid Restriction . B. I&O should be measured and recorded ACCURATELY every shift .

Based on interview and record review, the facility failed to ensure a change in condition was assessed and monitored by the attending physician for one Resident (#22) of 19 sampled residents. Findings include: Resident #22 (R22) Review of R22's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including acute kidney failure and retention of urine. Review of R22's most recent Minimum Data Set (MDS) assessment, dated 9/26/24, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicative of intact cognition. On 11/21/24 at 8:02 AM, R22 was observed sitting in a wheelchair at a dining room table, slowly propelling forward and backward with his legs. When asked why R22 preferred the continued rocking motion, he stated, My leg still aches . I had a blood clot not too long ago. Review of R22's EMR revealed the following progress notes: 1. 2/27/24 at 14:00 [2:00 PM] written by Licensed Practical Nurse (LPN) G: Resident has 3+ [moderate] pitting edema to BLE [bilateral lower extremities]; L [left] lower leg is pink and warm to touch; [physician] paged; no return call from Dr. [Doctor] prior to leaving for day; passed information to 400 [unit] charge nurse . 2. 2/27/24 at 16:55 [4:55 PM]: [Physician] updated on resident weight increase and BLE 3+ pitting edema. Residents left lower leg is red and warm to the touch. [Physician] to come to facility to assess resident . R22's EMR revealed no physician assessment following identification of bilateral pitting edema of the lower extremities, as well as warmth and redness to the left lower leg. On 11/21/24 at approximately 10:00 AM, an interview was conducted with LPN G who verified she assessed R22 on 2/27/24 and identified the acute change in condition, which included a swollen, red, and warm left leg. LPN G stated she communicated concerns for a deep vein thrombosis [blood clot] to the charge nurse who was responsible for contacting the provider. LPN G stated, I didn't know [R22] was never evaluated by the physician. If I would have known that I would have followed up with the doctor myself .that's unacceptable. Review of R22's progress notes revealed he was transferred to the emergency room (ED) via ambulance on 3/4/24 for an unrelated concern: During routine shower CNA [certified nursing assistant] notified staff of swelling to resident's [R22's] penis . new order to send resident to ER for further evaluation and treatment . Review of a progress note dated 3/4/24 at 21:51 [9:51 PM] read, in part: Resident [R22] returned to [facility] with a diagnosis of L DVT [left leg deep vein thrombosis], paraphimosis (trapped foreskin) , and cystitis (bladder infection) . Review of the Radiology Report from the acute care hospital dated 3/4/24 read, in part: .nonocclusive (no blockage) thrombus [clot] noted in the left popliteal (vessel behind knee) vein and left peroneal (lower leg) vein . concerning for acute nonocclusive DVT . On 11/21/24 at 8:49 AM an interview was conducted with the Director of Nursing (DON) and Clinical Consultant/Registered Nurse (RN) M who confirmed R22 was never evaluated by the physician following identification of clinical symptoms which correlated with a possible blood clot. The DON stated the clinical expectations following a change in condition included notification of the physician, monitoring the resident, and ensuring follow-up by the provider. Both the DON and RN M stated the diagnosis of a DVT 6 days after initial identification of signs and symptoms was untimely. Review of facility policy titled, Change in Condition, Acute revised 12/10/14 read, in part: .Observations, subjective information from the resident, and clinical signs will be documented in the Nursing Notes and on the Change of Condition form .after the physician is notified .the completed notification will be forwarded to the RN Supervisor file [at] the Nursing Station . No Change in Condition form for R22 was located following identification of signs/symptoms of a DVT on 2/27/24. Review of The Clinical Diagnosis of Deep Venous Thrombosis Integrating Incidence, Risk Factors, and Symptoms and Signs, published by the Archives of Internal Medicine (https://doi.org/10.1001/archinte.158.21.2315), read, in part: Typical symptoms of DVT are pain, warmth, redness, and swelling of the lower extremity . Accurate and timely diagnosis and treatment of DVT are essential. Early treatment of DVT with anticoagulants has been demonstrated to (1) reduce the incidence of pulmonary embolism and its associated mortality, (2) relieve acute symptoms in the leg, and (3) prevent extension of DVT from calf veins to more proximal veins .

Based on interview, and record review, the facility failed to ensure adequate nutritional assessment, and interventions for one Resident (#63) of one resident reviewed for significant weight loss. Findings include: Resident #63 (R63): On 11/19/24 at 8:03 AM, R63 said they had been losing weight. R63 denied issues with their teeth or swallowing difficulties that could affect their eating habits. R63 stated they had spoken with the Certified Dietary Manager (CDM) to discuss food preferences, but did not have much hope that the food wood change to R63's liking. Review of R63 Electronic Medical Record (EMR) indicated R63 was admitted to the facility on [DATE]. On 10/24/24, a Brief Interview for Mental Status (BIMS) assessment was completed for R63, resulting in a score of 13 out of 15, indicating R63 was cognitively intact. Review of a progress note dated 11/15/24 at 1:13 PM, CDM note read in part [R63] has experienced an 11# or 9% weight loss over the course of one month . [R63] told the writer she didn't know how to fill out a menu so dietary could honor her meal preferences. So, the writer sat with her and filled out a few days so she would get the idea of how it worked. [R63] had complaints of cold scrambled eggs; stating: I love scrambled eggs but they're always cold . [R63] will be referred to the RD [Registered Dietician] per significant weight policy . R63's diet order was changed to a regular diet on 11/15/24. The care plan was not updated to reflect nutritional interventions based on the order change. While conducting a phone interview with the RD on 11/20/24 at 8:47, the RD said she had not been made aware of R63's weight loss. The RD said the process for referral for evaluation was for the facility staff to write the resident on the RD referral list located in the facility. The RD stated someone from the facility should call her via phone if the resident was experiencing nutritional concerns of significant weight loss. The RD stated she would look at R63 now that she was aware of the resident's significant weight loss. On 11/20/24 at 10:15 AM, during an interview, the Director of Nursing (DON) stated if a significant weight loss was identified they would call the RD. The DON stated that it would be any resident that would have a 5% or greater weight loss in a month, or 10% or greater in 6 months. A progress note dated 11/20/24 by the RD: RD referral for wt. [weight] loss. I spoke with the State Surveyor over the phone. She gave me a brief report on [R63] and made me aware of wt. loss. Diet: Regular. Wt.: 113 lbs. on 11/14/24. Previous wts (weights).: 124 lbs. on 10/10/24 --- 1 month ago 130 lbs. on 7/18/24 -- 4 months ago Wt. is down 11 lbs. (8.8%) in 1 month. This is considered significant wt. loss in the look back period. I see that the Dietary Manager has intervened and spoke with her to update food preferences . Intake has been 25-50% of meals . The doctor was made aware, and her diet was liberalized from Consistent Carbohydrate, No Added Salt to Regular. I agree with that, but because of her minimal intake at meals, I would recommend (Name Brand Meal Supplement) once a day . [R63's] wt. did go down 5 lbs. in ~1 week, so I also asked for a re-weight to ensure we have an accurate wt . On 11/21/24 09:11 AM, while conducting a follow up interview with DON, the DON stated the process for calling the RD would start with a message on their facility messaging system to check with the team to see if this resident was thought to have a significant weight loss. The DON stated they would reweigh the resident to make certain there was no user error. The DON could not state why R63 had not been re-weighed or why the RD was not notified timely of R63's significant weight loss. The facility's Nutritional Assessment policy dated 12/9/14 read in part . K. Dietician will be notified of any dietary concerns . M. More frequent assessments of resident nutritional status will be at the discretion of the Dietician and Food Service Director based on resident condition and care planned interventions

Based on interview and record review, the facility failed to assess and/or prevent or a significant weight loss for one Resident (R2), of three residents reviewed for nutrition. This deficient practice resulted in a significant weight loss of 12.9% within three weeks of admission to the facility for R2. Findings include: Review of R2's Face Sheet revealed the Resident was admitted on [DATE] from an acute care hospital with the following diagnoses, in part: fracture of lower end of right femur, orthopedic aftercare, cellulitis of right lower limb, fall on same level from slipping, tripping, and stumbling without subsequent striking against object, and pressure ulcer of unspecified buttock, Stage 2 . Review of R2's Minimum Data Set (MDS) Admission assessment, dated 7/18/24, revealed R2 had one Stage II pressure injury present upon admission, as well as a surgical wound. R2 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. The Resident's height and weight were documented as 63 inches and 155 pounds, respectively. During a telephone interview on 8/15/24 at 4:25 p.m., Complainant M said R2 was transferred out of the facility because they were not satisfied with the care provided. Complainant M said [R2] lost weight while they were in the facility. Review of R2's weight vitals, revealed the following documentation of their weight while in the facility: 7/11/24 (Date of Admission): Weight 155 pounds, BMI 27.45 7/12/24: Weight 155 pounds, BMI 27.45 7/29/24: Weight 135 pounds, BMI 23.91 8/2/24: Weight 140 pounds, BMI 24.8 There was no evidence to show R2 was re-weighed to verify the significant 20 pound, 12.9% body weight reduction between 7/12/24 and 7/29/24. Review of R2's Electronic Medical Record (EMR) found no dietary progress notes, completed by Certified Dietary Manager (CDM) K, or Consultant Registered Dietitian (RD) L, available for review. During an interview on 8/20/24 at 2:35 p.m., when asked about the completion of any dietary progress notes related to [R2], Assistant Dietary Manager (Staff) J said she was not responsible for any dietary progress notes and referred this Surveyor to CDM K. When asked if there was a dietitian that provided assessments for facility residents, Staff J stated, The dietitian doesn't come when I am here. She shows up, because she drops off paperwork. I don't know her name. She never introduced herself to me. During an interview on 8/20/24 at 2:40 p.m., the Director of Nursing (DON) was asked about the lack of dietary progress notes for R2. The DON said she would look into the matter and find whatever dietary information was available related to R2's significant weight loss. During an interview on 8/20/24 at 2:50 p.m., when asked about R2's significant weight loss, CDM K stated, What I was told is that it was an error from the hospital. It looks like weight loss like I have never seen before. They (nursing) sent me a note and they would send the physician a note as well. A copy of the note from nursing to CDM K was requested at that time. When asked what happens if someone experiences a significant weight loss. CDM said nursing would put it in a progress notes. When asked why there was not a progress note related to R2's significant weight loss, CDM K stated, Good question. CDM K said that he did not write a note about R2's significant weight loss because of the Significant Weight Loss policy, which required a referral to the dietitian, per CDM K. CDM K continued, Every month there is a dietary referral sheet. Nursing is responsible to put all the new admits on there for the dietitian. She (RD) comes about 2 weekends a month. CDM K was unaware if R2's significant weight loss had been assessed and/or addressed by Consultant RD L. During a telephone interview on 8/20/24 at 3:24 p.m., Consultant RD L was asked about assessment of R2's significant weight loss during the first few weeks in the facility. RD L stated, I will check my referral sheet. Usually, they put her on a list in the DON's office. There is a chance that she (R2) is on there (the list), and I didn't get to her yet. RD L stated, I don't even know how she could have lost that much weight. During an interview on 8/20/24 at 3:45 p.m., the DON acknowledged there was no progress note documentation in the Electronic Medical Record (EMR) for R2's significant weight loss. RN A, also present during the interview, provided a list of dietitian referrals for July 2024, revealing R2's name at the bottom of the list, documented as a New Admission. R2's name was not crossed off, indicating RD L had not completed a new admission dietary assessment of the Resident. No reference or indication of the 20-pound documented significant weight loss was present on the referral information line. The DON confirmed RD L had last been in the building on 8/7/24, but no dietary assessment based on the referral had been completed. The DON also acknowledged R2 had not received an RD or CDM dietary consult during the course of their stay in the facility (7/11/24 - 8/8/24) to address the significant weight loss or any other new admission concerns. Review of the Weight Management policy, last revision 11/2/16, revealed the following, in part: I. POLICY: To ensure proper weight measurement, prompt dietary notification and assessment of changes. II. PROCEDURE . The Skin Assessment sheets will already have the resident's prior weight noted on it by the Bath Nurse, so if a discrepancy of five (5) pounds or more is noted, the resident is to be re-weighed immediately. Both weights are to be recorded on the Skin Assessment sheet . The Bath Nurse will document the resident's weight and vital signs in Matrix, and make notifications, if necessary, as follows: 1. If resident's documented weight is more than a five (5) pound loss or gain, the Dietary Department will be notified by completing a Dietary Slip and forwarding it to the Food Service Director.

Based on observation, interview, and record review, the facility failed to prevent a Resident-to-Resident physical abuse, resulting in minimal harm for one Resident (R38) of two residents reviewed for abuse. This deficient practice resulted in numerous bruising sites and persistent fear of further abuse. Findings include: Intake Number: MI00139309 Review of the Facility Reported Incident (FRI) dated 9/10/23, revealed the following, .On 9/10/23 at 1556 (3:56 p.m.), (R50) exited his room on foot wearing socks, a shirt, and his brief. He glanced up the hall for a moment, and then proceeded to walk across the hall into (R38's) room. This had occurred 3 times prior in the past two weeks per (R38's) report. Upon seeing (R50) in her room again, (R38) removed her TB headphones and said to (R50), This isn't your room. Go back to your room. (R50) became agitated with (R38's) request, and began grabbing, slapping, and flailing at (R38), causing bruising to her R (right) thigh and pain in her upper arms and face. Certified Nurse Aide (CNA) N overheard the commotion and escorted (R50) back to his own room. (R38) was very upset . A witness statement, written by CNA N, dated 9/10/23 read, in part, .as I was walking to the linen closet (R38) was yelling help. (R50) was in (R38's) room without pants only a brief and shirt leaning over the bedside table hitting and slapping (R38). (R50) was also cussing. I proceeded to pull him out of her room and redirect him to his room across the hallway. While trying to redirect (R50) he was trying to get closer to her head part of her bed . Review of the facility's investigation report revealed the following, .Interview with (R38) 10:15 a.m. 9/11/23 .(R38) reported that she tried to tell (R50) that it wasn't his room and to 'go back to his own room.' (R38) described (R50) as coming up to her right side (as she lied on her back in bed, head elevated, per her usual, watching TB with 'TV ears' on). He moved to the R side over bed table a bit so he could reach her more easily. (R38) reports she was slapped in the face one time; she described it as having mostly avoided hard contact by pulling away into her pillow but noted that he still hit her. (R38) reported (R50) then squeezed her R thigh 'with this evil look on his face.' (R38) continued describing that (R50) then squeezed both of her upper arms. When asked for more description of hitting vs squeezing, (R38) described his actions as 'flailing at me.' (R38) was calling her 'a b****' - and may have stated he 'was going to get me' per (R38s) report .(R38) noted this is the 4th time in the past 10-14 days that (R40) has wandered into her room .(R38) did report during the most recent visit before this event, she similarly told (R50) 'this isn't your room, go back to your room,' and (R50) responded, 'you don't have to tell me that,' and appeared agitated . On 12/12/23 at 2:10 p.m., R38 was observed lying in her bed going through her mail on her bedside table. An interview was conducted with R38 about her stay at the facility. When asked about the incident between her and R50, she stated, It was more than a scuffle, he beat the crap out of me! He came into my room and beat me up for no reason. When asked how she felt after the incident, R38 stated, It was very traumatic. At first, they put a doorbell on his door frame so when he would get up, I would always hear it and think he was coming into my room. They have since moved him down the hallway and now I can't hear the doorbell anymore. I have no idea if he is going to come in or not. R38 appeared to be nervous talking about the incident that occurred on 9/10/23. Review of R38's Observation Detail List dated 9/11/23 read, in part, Observation date 9/11/23 12:27 a.m.Any bruises? Yes - Right inner thigh and right elbow from resident-to-resident altercation 9/10/23 . There were no measurements of the bruises on the 9/11/23 observation. Review of R38's progress notes dated 9/15/23 read, in part, Resident body assessed for bruising related to altercation; R medial to posterior upper thigh has a dk (dark) purple bruising; Bilateral elbows have brownish/fading bruising; L (left) upper arm fading bruising; no txs (treatments) at this time. Review of R38's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including age-related physical debility, depression, and pain. R38's 6/14/23 Minimum Data Set (MDS) assessment revealed she scored a 15/15 on the Brief Interview for Mental Status (BIMS) score, indicating she was cognitively intact. Review of R50's EMR revealed admission to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, visual hallucinations, and insomnia. R50's 8/17/23 MDS assessment revealed he scored a 7/15 on the BIMS, indicating moderate cognitive impairment. An attempted phone call was conducted to CNA N on 12/13/23 at 1:37 p.m. No return call was made before the exit date of 12/14/23. On 12/12/23 at approximately 1:45 p.m. an observation was made of R50 in his bedroom. R50 stated that he was doing well today and had no concerns at this time. It was noted that when entering R50's room, his door egress alarm did not sound. An interview was conducted with CNA I on 12/13/23 at approximately 1:30 p.m. CNA I stated that she primarily works the hallway that (R38) and (R50) reside on. CNA I stated R50 has a history of wandering and will wander more frequently during the late afternoon. CNA I stated when R50 is up and out of his room staff were instructed to keep supervision on him, and that he does prefer male caregivers over females. When asked if R50 had been wandering prior to the incident on 9/10/23, CNA I stated Yes, he was wandering the halls and into other rooms prior to the incident with (R38) . An interview was conducted with the Director of Nursing (DON) on 12/13/23 at approximately 4:00 p.m. The DON stated that R50 had been showing signs of confusion about a month prior. R50 would go into the hallway and forget where his room was or would state he was trying to find the bathroom. The DON stated that she did not know that he was wandering more frequently as the floor staff were stating. The DON stated that after the incident, the facility needed to wait for a single bed to open prior to moving R50 and proceeded to use the doorbell as a way of notifying staff that R50 was exiting his room. The DON stated she liked the doorbell and that it was a way for her to also know that he was leaving. The DON stated that R38 and her sister were requesting pepper spray as a means of protection from R50 after the incident, but that the facility could not allow that. The DON was asked to provide any additional documentation that disproved R50's wandering had increased prior to the incident on 9/10/23. There was no further documentation provided prior to the exit date on 12/14/23. An interview was conducted with Social Worker (SW) E on 12/14/23 at 8:51 a.m. SW E stated she was not made aware of R50's increase in behavior and confusion prior to the incident on 9/10/23. SW E stated that if she would have been notified through the behavior charting, a care plan would have been developed for R50 for his increase in behaviors and wandering. SW E stated R50 was made an elopement risk on admission but was discontinued because he had not attempted to leave the facility. SW E stated she was surprised about the incident on 9/10/23 and questioned why R38 had not mentioned the previous incidents of R50 coming into her room. SW E stated R38 had been receiving therapy services since the incident and provided documentation for the first and only visit to have taken place on 11/3/23, approximately 54 days after the incident had occurred. Review of R50's Care Plans revealed the following, Behavioral Symptoms Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). Created 12/13/23 . Review of the facility's Abuse Prevention- Education/Training revised on 12/10/14 read, in part, . [Facility name] will provide abuse prevention education, training and ongoing supervision .for all employees and regular volunteers during General Orientation to the facility and at least annually .Education/in-services will be held at least annually and include, but are not limited to: Cognitive Impairment in Residents, Redirecting Wanderers/Managing Aggressive Behaviors .

This deficient practice has two separate DPS's part A and part B: DPS A: Based on interview and record review, the facility failed to maintain an effective bowel management program for 17 Residents (#19, #4, #8, #9, #17, #27, #31, #46, #48, #49, #50, #52, #55, #59, #63, #66, & #225) of 73 residents reviewed. This deficient practice was identified as an immediate jeopardy (IJ) when one Resident (#19) developed signs and symptoms consistent with a bowel obstruction on 6/13/22. The facility failed to send Resident #19 to the emergency room (ER) per Resident #19's request and developed a perforated bowel which required emergency surgery on 6/20/22 and placement of a [CONDITION(S)] on 6/21/22. The sample was expanded to include all residents in the facility and subsequently there were 18 additional residents identified as requiring bowel management intervention. This deficient practice had the potential to affect all residents in the facility. Resident #19 On 11/1/22 at 11:29 a.m., during an interview, Resident #19 stated she did have to go to the hospital recently but could not remember when. The Electronic Medical Record (EMR) had D/C (discharge) Ret (return) Anticipated 6/20/22 in the census section. Resident #19 stated this sounded accurate. A review of the progress notes for Resident #19 revealed the following: On 5/5/22 (5:43 p.m.) (Resident #19) assessed due to report from (LPN CC) . Resident (#19) was reporting uterus and vagina pain. (Resident #19) wanted to go to ER due to pain. Resident (#19) reports sharp pain to abd (abdomen), It is rigid and flat, no swelling noted. Bowel sounds hypoactive, unable to state is passing gas. (Local Hospital) reported a large loose BM (Bowel Movement) before transport to (The Facility). Currently on exam resident (#19) is incontinent of stool which is loose . Pain at that time had not changed and was continuous . Has already taken [MEDICATION(S)] (Narcotic Pain Medication) at (2:45 p.m.) and this was not helpful per resident (#19) . Will continue to monitor and residents (#19) states understanding that (Resident #19) has right to transport to ER. Encouraged to stay in bed and relax at this time and report if pain becomes unbearable or changes. Report any nausea, vomiting, blood in stools. (Author: Registered Nurse (RN) GG) On 5/5/22 (8:38 p.m.) Resident (#19) continues to have abdominal pain unrelieved by Maalox and [MEDICATION(S)]. Resident (#19) had 2 large black emesis . on call for MD FF updated and resident will be sent to ER for eval (evaluation). (Author: RN CC) On 5/9/22 10:01 DCRA (discharge return anticipated) ASSESSMENT: Resident (#19) was readmitted to facility on 5/5/2022 and later that day (Resident #19) was sent back to the hospital for emesis and abdominal pain . She spent more than 24 hrs (hours) at hospital and that initiated a dcra ASSESSMENT. MDS (Author: RN HH) On 5/11/22 (7:47 p.m.) The resident (#19) is day #4 without a bowel movement. (Resident #19) declined a suppository. (Resident #19) accepted & was given MOM (milk of magnesia) at this time. Will continue to monitor. (Author: LPN II) On 5/30/22 (9:07 p.m.) The resident (#19) had Prune juice with MOM at (7:30 p.m.). It is day # 5 without a charted bowel movement. (Resident #19) declined a suppository or rectal check when asked earlier this evening. Will continue to monitor. (Author: LPN II) On 6/13/22 (11:48 p.m.) Around (11:10 p.m.) resident (#19) told CNA that she needed to go to the hospital. Current writer went and talked to resident (#19) to see what was going on, c/o (complaint of) nausea and 7/10 (seven out of 10 on pain scale) abd (abdominal) pain. No vomiting at this time. Vital signs stable: Temp (temperature)- 97.0 Resp (respirations)- 18 HR (heart rate)- 81 O2 (oxygen saturation)- 91% RA (room air) BP (blood pressure)- 139/88 Pain- 7/10 Resident (#19) appears to be acting the same as normal, when stating (Resident #19) needs to go to the hospital (Resident #19) keeps mentioning, I need that stuff they give me in my IV. When asked to clarify what (Resident #19) thinks she needs, as waving her arms around in the air (Resident #19) states, ummm, [MEDICATION(S)] (narcotic pain medication). On Call provider, (Nurse Practitioner (NP) EE), for (Medical Director FF) called at (11:25 p.m.), telephone order given for [MEDICATION(S)] (anti-nausea) 4mg (milligram) PO (orally) one time. If resident (#19) still complains of nausea and pain after PO [MEDICATION(S)] is given, send resident (#19) to the ER per her own request for evaluation. [MEDICATION(S)] given to to (sic)resident (#19) at (11:40 p.m.). Will continue to monitor. (Author: LPN V) On 6/16/22 (1:42 p.m.) Resident (#19) had small emesis during breakfast this morning. Resident (#19) refused AM (morning) medications and said she was unsure if she could keep them down. New order for PRN (as needed) [MEDICATION(S)] 4mg 3 times a day obtained, PRN [MEDICATION(S)] given at (10:21 a.m.). Resident (#19) stated that PRN [MEDICATION(S)] was effective, offered resident (#19) AM medications again and she refused them. (Author: RN JJ) On 6/19/22 (8:45 p.m.) Resident (#19) had a small emesis. Bowel sounds present X4 (All four abdominal quadrants) but hypo (hypoactive). Resident (#19) given [MEDICATION(S)] which was effective. Resident (#19) able to take medications. Resident (#19) says she has not wanted to eat much today. Resident (#19) is requesting IV (intravenous) [MEDICATION(S)]. I told (Resident #19) that is not what is given for N & V (nausea and vomiting). Resident (#19) does not appear to be in any pain. (Author: LPN CC) On 6/20/22 12:37 (p.m.) CNA notified RN that resident c/o (complains of) SOB (shortness of breath) and refusing [MEDICATION(S)] nebulizer. Upon entrance to room, resident (#19) was found to have RR (respiratory rate) =28 with use of accessory muscles (more muscles used than usually necessary to breathe). HR was 124 and regular. Lung sounds were diminished. Unable to obtain pulse ox either on ear or hand, or BP with a cuff. Next of kin notified. Report called to (ER). (Emergency Medical Services) called and resident taken (to the ER) hooked to telemetry monitor. (Author: RN KK) On 6/20/22 (4:14 p.m.) Phone call to ER for update, resident (#19) is currently in the OR (operating room), having abdominal surgery on a hernia. (Resident #19) will be admitted to the ICU (intensive care unit) after surgery. The (ER) couldn't give writer any more info, she is having the nurse that cared for (Resident #19) give a call back with a complete update. (Author: Unit Manager RN J) On 6/20/22 (4:40 p.m.) (ER nurse) from the ER called back. (Resident #19) went to the OR for a perforated bowel. So far (Resident #19) is doing ok from what (ER nurse) could tell in the notes. (Author: RN J) On 6/21/22 (9:58 a.m.) Spoke with (Physician LL) who is following (Resident #19) at the hospital, resident (#19) will be going back in (to surgery) for a [CONDITION(S)] today. (Author: RN J) A review of the facility diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Constipation 11/1/19 Nausea 6/13/22 [CONDITION(S)] 6/27/22 A review of a hospital History and Physical provided by the facility for Resident #19, dated 4/30/22, read in part: . CT (Cat Scan) ABD (Abdomen) PELVIS ENHAN (Enhanced) DOS (Date of Service): Apr (April) 29 2022 10:26 PM IMPRESSION: 1. Small right inguinal hernia containing a loop of small bowel and surrounding free fluid. There are fluid-filled nondilated small bowel loops with air-fluid levels suggestive of early or partial small bowel obstruction. 2. Small hiatal hernia . A review of a hospital Discharge Summary dated 5/7/22, for Resident #19, read in part: Reason for Admission: Dark emesis .Initial hemoglobin showed a 2 point hemoglobin drop and (Resident #19) was admitted for further management. She had no further episodes of nausea or vomiting. Subsequent hemoglobin checks were consistent with her previous baseline of 12. She tolerated oral intake on the day following admission and is stable for discharge . A review of a hospital Progress Note-Hospitalist, dated 6/26/22, for Resident #19, read in part: Minimal oral intake yesterday . complaining of pain in her abdomen .Family members have discussed, feels that comfort care is most appropriate at this time . ASSESSMENT/PLAN: 1. Perforated intestinal viscous status post [MEDICAL RECORD OR PHYSICIAN ORDER] -incarcerated (trapped) hernia ruptured, went to OR (operating room) 6/20 (2022), closed 6/21 (2022) . 2. [CONDITION(S)] (bacterial organism) pneumonia and [CONDITION(S)] perfringens bacteremia (infectious organism) in the setting of bowel perforation 3. Septic shock, resolved 4. suspected pneumonia . A review of the hospital Discharge Summary, dated 6/27/22, for Resident #19, read in part: .ADMISSION Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] Pneumoperitoneum (abnormal presence of gases in the abdomen) DISCHARGE Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] Incarcerated femoral hernia with perforation, status post [MEDICAL RECORD OR PHYSICIAN ORDER] Comfort care status Septic shock, resolved [CONDITION(S)] pneumonia and [CONDITION(S)] perfringens bacteremia Acute on chronic Hypoxic respiratory failure . HISTORY OF PRESENTATION: . In brief, the patient presented with complaints of mental status changes and abdominal pain from nursing home. She was found to be in septic shock with distended abdomen and was taken by General surgery to the operation room for exploratory laparotomy. HOSPITAL COURSE: Following this surgery, she remained intubated on multiple vasopressors and broad spectrum antibiotics in the ICU. She improved enough to be transferred to the floor, however was not able to maintain good oral intake. In discussion with family, decision was made to transition to comfort focused care . On 11/2/22 at 11:37 a.m., during an interview, Licensed Practical Nurse (LPN) V was asked about the details of her progress note dated 6/13/22. LPN V stated Resident #19 had complained on and off of nausea and vomiting and did make comments about needing a hernia repair. LPN V indicated abdominal pain and lack of appetite were somewhat normal for Resident #19. LPN V recalled Resident #19 had asked to go to the hospital so she could get [MEDICATION(S)] and indicated her [MEDICATION(S)] (narcotic pain medication) was not working. LPN V stated (Resident #19) never really expressed signs or symptoms of pain (verbal only per LPN V observations). LPN V stated a bowel assessment was performed at the time of this complaint and Resident #19's abdomen was not distended at the time. When asked why a bowel assessment was not documented, LPN V did not have an answer, but acknowledged documentation was missing and should not have been. When asked what Resident #19's bowel sounds were, LPN V stated she believed Resident #19 was positive in all four quadrants and they were hyperactive. LPN V stated she called Nurse Practitioner EE who was the on-call provider for Medical Director (MD) FF. LPN V stated she called the on-call physician and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN V then verified she gave the one time dose of [MEDICATION(S)] and scheduled [MEDICATION(S)] for Resident #19. When asked about a 5-day stretch with no bowel movement (BM) just prior to Resident #19 going to the hospital for emergency surgery, LPN V stated she was not aware Resident #19 had a recent stretch of 5 days with no BM. LPN V indicated it was possible the provider would have been encouraged to do more for Resident #18 if LPN V was aware of the BM issue. LPN V stated the bowel lists were printed daily and after bowel concerns are addressed for the residents, the documents are shredded. On 11/2/22 at 1:22 p.m., during an interview, RN KK stated one of the CNA's communicated Resident #19 didn't look good. RN KK stated she went down and assessed Resident #19 and called the provider to get an order to send Resident #19 to the ER. She requested to go when I talked to her. RN KK stated the primary nurse, RN MM, .was unavailable in that moment so I went down and addressed the concern. RN KK stated Resident #19 was ashen in appearance and had been complaining of nausea for a couple of days. After I talked to (RN J) we agreed (Resident #19) needed to go out to the ER. I knew just looking at (Resident #19) and after assessing her, (Resident #19) needed to go to the ER. On 11/02/22 at 1:01 p.m., during an interview, LPN CC stated she had passed on in report (Resident #19) had nausea and [MEDICATION(S)] was effective and reported hearing hypoactive bowel sounds. LPN CC stated she was aware of other clinical staff speaking to Resident #19's physician providers a couple of days prior. LPN CC stated she did not think Resident #19 was having any pain, just nausea and vomiting. On 11/2/22 at 1:30 p.m., during an interview, RN GG stated Resident #19 had emesis on several days before the ER visit on 6/20/22 and (Resident #19) had requested to go to the ER. RN GGG stated when (Resident #19) came back, the staff didn't think she was going to make it because she had a dramatic decline in functional ability and had a significant change triggered by the Minimum Data Set (MDS) team. RN GG stated Resident #19 developed Anasarca [CONDITION(S)] (generalized swelling of the whole body) and could not even lift her hands and arms to feed herself. RN GG stated Resident#19 returned from the hospital on comfort care. RN GG stated she had recalled Resident #19 had returned from a hospitalization on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/2/22 at 11:50 a.m., during an interview, the Director of Nursing (DON) stated she did not have a [CONDITION(S)] prior to the hospitalization on [DATE] but returned from the hospital with a [CONDITION(S)]. On 11/2/22 at 3:55 p.m., during a phone interview, NP EE stated was unaware Resident #19 had gone 4 to 5 days without bowel movements. NP EE stated she was not made aware Resident #19 had been to the hospital previously for similar issues of nausea and vomiting and had a suspected small bowel obstruction with the presence of an intestinal hernia. NP EE stated she could only confirm she was called about Resident #19 having nausea and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . NP EE confirmed she would have likely sent Resident #19 to the hospital at the time she was notified of the concerns had she known all the details. On 11/3/22 at 11:39 a.m., during an interview, RN J stated Resident #19 she first had issues with abdominal pain at the beginning of May 2022. RN J stated Resident #19 was sent out due to vomiting stool. RN J was asked what the policy was for bowel care management and stated at day 3 with no results, a bowel assessment should be completed, and physician should be called. RN J was asked to review the progress note from LPN II on 5/11/22 and 5/30/22. RN J confirmed a bowel assessment should have been charted and the physician should have been notified for each of those entries and acknowledged neither were documented. RN J was asked if nurses not being on a consistent assignment could have played a role in staff not being aware of the full clinical picture of their residents. RN J agreed staffing plays a contributing factor to lack of awareness of residents' clinical picture when nurses are not consistently on the same assignment. LPN J confirmed this was an issue at the facility. RN J stated staff should have recognized (Resident #19's) right to go to the hospital and advocated for such. When asked why Resident #19's request to go to the hospital was delayed, RN J stated, That's a good question. RN J agreed LPN V should have documented a bowel assessment for continuity of care. RN J stated Resident #19's clinical picture was . text book bowel obstruction. and agreed the pain concern of 7 (scale 0-10) was pretty significant because Resident #19 had a high pain tolerance. When asked if there should have been a bowel management care plan in place for Resident #19 given her clinical picture, RN J stated Yes. and confirmed there was no care plan in place. RN J stated, It makes me sad because you're correct, we could have done better. RN J stated Resident #19 had six days with no BM and the doctor should have been notified on day 3 to address the situation. RN J confirmed no PRN bowel medications charted for that six-day period. RN J stated it was confirmed no PRN bowel medications were documented as administered per Nursing Supervisor RN K and LPN G. RN J stated there may be notes showing refusals, and then reviewed the progress notes which did not show PRN bowel medications were offered or refused. On 11/3/22 at 12:52 p.m., during an interview, RN JJ stated she recalled having a conversation with MD FF on 6/13/22. RN JJ stated she received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #19 to the hospital. RN J stated she had no idea if Resident #19 needed bowel medication interventions and agreed this should have been in her progress notes. When asked if she had completed a bowel assessment, RN J stated she could not be sure but thinks she did. RN JJ agreed she should have charted her bowel assessment and that not charting the bowel assessment is a problem. On 11/3/22 1:00 PM, during an interview, LPN II stated she did not call the physician for either note on 5/11/22 or 5/30/22. When asked if a bowel assessment had been completed, LPN II stated she believes she did bowel assessment. LPN II then confirmed bowel assessments were not charted. LPN II confirmed she was aware a bowel assessment should be documented, and the physician should be called per the protocol, after day 3 with no bowel movement, for further orders. LPN II stated she is on a different hall quite frequently and doesn't have the ability to recall what's going on with a particular resident at any given time. On 11/3/22 at 1:16 p.m., during an interview, MD FF stated if the providers had been made aware of the recurrent issues surrounding Resident #19's bowels, they would have likely done additional testing to determine the next course of action such as x-rays and other additional testing. When asked about the lack of bowel assessments being performed and/or not documented, MD FF stated, I think the documentation and assessment is key to knowing what's going on. MD FF agreed the lack of communication was likely a key issue in the response to resident #19's condition. MD FF confirmed she could not say for certain the outcome would have changed related to the placement of a [CONDITION(S)] for Resident #19. MD FF reviewed the on-call provider note generated by NP EE on 6/13/22 and stated the note did not include any detail regarding bowel assessment or recent clinical picture was relayed by the nurse who placed the call. This surveyor informed MD FF, LPN V stated she had relayed the information of hyperactive bowel sounds to the provider on call. MD FF stated the on-call providers document everything the nurse placing the call relays in their note. On 11/3/22 at 12:15 p.m., upon completion of the interview with RN J, Bowel movement records, and MAR (Medication Administration Record) history containing any delivery of as needed bowel medications were requested for time period March 2022 through June 20th, 2022, when Resident #19 was sent to the hospital. Pain ratings were requested for the same time period. A review of the Vitals Report for Bowel Movement, provided by the facility, for Resident #19, with a date range of 2/28/22 - 6/20/22 revealed the following: A 3-day period between 3/9/22 and 3/11/22 with no BM charted. A 4-day period between 4/10/22 and 4/13/22 with no BM charted. A 4-day period between 5/8/22 and 5/11/22 with no BM charted. (This is the time period charted in the progress notes which stated day 4 no BM.) A 5-day period between 5/26/22 and 5/30/22 with a BM charted by RN J on 5/29/22 however CNA NN documented No BM for Resident #19. (This is the time period charted in the progress notes which stated day 5 with no BM on 5/30/22.) A 6-day period between 6/15/22 and 6/20/22 with no BM charted, before Resident #19 was sent to the hospital and subsequently went for emergency surgery related to a perforated bowel. There were multiple days and shifts on the vitals report where no information was recorded, whether Resident #19 had a BM or not. A review of Resident #19's Medication Administration History reports for the time period of 4/1/22 through 4/30/22 revealed the following: No Delivery of Milk of Magnesia (MOM) 30 ml (milliliters) 400 mg (milligram)/ml was charted as administered during this time period. A review of Resident #19's Medication Administration History reports for the time period of 5/1/22 through 5/31/22 revealed the following: Delivery of MOM 30 ml, 400 mg/ml was charted as administered on 5/11/22 and 5/31/22 for this time period. This was a standing order If no BM after 48 hours (2 days), give 30 ml of MOM. No Medication Administration History reports, regarding Resident #19, for the time period of 3/1/22 through 3/31/22 were received. Medication Administration History reports for time period 6/19/22 through 6/28/22 were received, but nothing for 6/1/22 through 6/20/22. Resident #19 was in the facility from 6/1/22 until 6/20/22 when she was sent to the hospital for emergency surgery and [CONDITION(S)] placement. Resident #19 returned from the hospital on 6/27/22. A review of the Vitals Report for Pain, provided by the facility, for Resident #19, with a date range of 3/28/22 - 6/28/22 revealed the following: Resident #19 rated pain complaints at an average of 7 (scale of 0 - 10) between 3/28/22 and 5/12/22. Pain complaints tapered off between 5/13/22 and 6/4/22, with variable ratings between 2 and 6. Pain complaints dropped to 0 between 6/5/22 and 6/12/22. Pain complaints resumed on 6/13/22, when Resident began requesting to be sent to the hospital. Pain complaints ranged between 3 and 7 on several occasions before Resident #19 was ultimately sent out to the hospital and subsequently underwent surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9 No BM recorded for six days from 10/25/22 through 10/30/22. Progress notes revealed no documented interventions for Resident #9 until 10/31/22 as follows: Resident (#9) is day 7 with no BM. Resident (#9) requested [MEDICATION(S)] (oral powder [MEDICATION(S)] dissolved in fluid) in apple juice 10-30-22 in the early am and also last night at (11:30 p.m.). No results at this time. No other interventions, no bowel assessment, and no notifications to the physician were documented prior to the above note. No documentation was observed confirming the bowel concern was taken care of. Resident #27 No BM recorded from 10/25/22 through 10/27/22 with no documented actions taken in the progress notes, no bowel assessment recorded, and no notification to the physician was documented. Resident #31 No BM recorded for 7 days from 10/24/22 through 10/30/22 with no documented actions taken in the progress notes, no bowel assessment recorded, and no notifications to the physician were documented. Resident #48 No BM recorded for 3 days from 10/25/22 through 10/27/22 with no documented actions taken in the progress notes, no bowel assessment recorded, and no notifications to the physician were documented. Resident #49 No BM recorded for 4 days from 10/24/22 through 10/27/22 with no documented actions taken in the progress notes, no bowel assessment recorded, and no notifications to the physician were documented. Resident #50 No BM recorded for 3 days from 10/22/22 through 10/24/22 with no documented actions taken in the progress notes, no bowel assessment recorded, and no notifications to the physician were documented. Resident #59 No BM recorded for 3 days from 10/28/22 through 10/30/22 with no documented actions taken in the progress notes, no bowel assessment recorded, and no notifications to the physician were documented. Resident #63 No BM recorded for 4 days from 10/25/22 through 10/28/22 with no documented actions taken in the progress notes, no bowel assessment recorded, and no notifications to the physician were documented. Resident #66 No BM recorded for 3 days from 10/24/22 through 10/26/22 with no documented actions taken in the progress notes, no bowel assessment recorded, and no notifications to the physician were documented. No BM for 4 days from 10/31/22 through 11/3/22. There were no interventions, no bowel assessment, and no notifications to the physician were documented. On 11/3/22 at 1:30 p.m., during an interview, LPN BB stated 'Bowel Reports' for the facility were supposed to be pulled by the nursing staff daily. LPN BB was asked to provide Bowel Reports for the entire facility population. LPN BB reviewed and identified additional residents who would have been currently checked for bowel concerns based on the reports. Those identified as needing intervention included Residents #4, #8, #17, #46, #52, #55, & #225. Each of the residents identified had 3 or more days with no bowel movement recorded. LPN BB was asked to look up in each of their records to see if any as needed bowel medications or documentation of assessments/interventions had been recorded. LPN BB reviewed each resident's PRN medications and progress notes and confirmed no bowel medications outside of scheduled bowel medication were given for any of the residents identified. LPN BB also confirmed of all the residents looked at, there was no documentation showing the bowel protocol had been initiated, no bowel assessments were completed, nor had the physician been called as appropriate per the facility policy. On 11/3/22 at 2:00 p.m., during an interview, the DON stated the residents who have been identified with bowel concerns are reported from shift to shift. The DON stated each shift is responsible for printing out the bowel report to determine what actions need to be taken for each resident, if any, based on the report. The DON stated nurses were expected to place concerns and interventions on the 24-hour report and nurses are then supposed to be documenting what actions they take to address bowel concerns in the progress notes. The DON acknowledged there was a concern with nursing staff following the bowel management program. On 11/3/22 at 2:15 p.m., during an interview, RN X was asked how the bowel management program was supposed to be handled by nurses. RN X stated, normally the bowel report is printed out on the night shift and then passed from shift to shift. RN X stated she did not have the bowel report passed on from night shift at the time of this interview. RN X stated she did not have a chance to print out a bowel report yet for that day. When asked about Resident #4 showing 3 days with no BM, RN X stated she was not aware of that. When asked about Resident #8 showing 3 days with no BM, stated she had received 2 senna with fluids scheduled, but nothing as needed was administered. RN X stated being on a different medication cart all the time makes it difficult to follow resident issues. On 11/3/22 at 2:30 p.m., during a follow-up interview, LPN V was asked if any bowel medications had been initiated for Resident #55 who had gone 3 days with no bowel movement. LPN V stated Resident #55 had not been out of bed in a couple of days. LPN V was asked if a bowel assessment was completed per policy and stated she had not performed one. LPN V was then asked about Resident #52, who had gone 5 days with no documented bowel movement. LPN V stated Resident #52 has been combative and challenging and stated she was going to attempt to have family help keep him calm enough to give him something. LPN V was asked if the physician had been made aware of Resident #52's bowel concerns. LPN V stated she had not notified the physician for any additional orders or guidance. LPN V was asked about Resident #225 who had 4 days with no documented bowel movement. LPN V stated she received Senna and prune juice. LPN V was asked if a bowel assessment and notification to the physician had been completed. LPN V stated a bowel assessment had been completed but she did not notify the physician. LPN V stated a suppository was not offered to Resident #225 because it was not passed on in report whether or not Resident #225 had already received a suppository or not. LPN V stated she did not see one documented. LPN V stated there was a definite problem with communication of bowel management concerns between shifts and there were often where the previous shift will not pass on anything until day 3. LPN V confirmed not having consistent hall assignments made it hard to follow what was going on with the residents. A review of the facility policy, Bowel Management Protocol, with an effective date of 4/10/22, read as follows: Policy: To ensure that every resident has consistent bowel management. Procedure: A. All residents will be assessed upon admission, quarterly and with a change of condition for continence and bowel status. Any resident with a change in incontinent status will be reassessed for 14 days to establish a new pattern. B. Licensed staff will print off a bowel report every shift for their wing assignment. C. The bowel report will be assessed per the charge nurse for bowel movement patterns. D. If no documented bowel movement, the following steps will be taken - If no bowel movement between 24-48 hours from last documented bowel movement from 6a(a.m.)-2pm(p.m.), nursing to encourage fluids, exercise and give prune juice. - If no bowel movement after 48 hours from the last documented bowel movement from 2pm-10pm, nursing to complete a bowel assessment, document in the progress notes and administer Senna 1 tablet x (times) 1 dose per standing orders in resident's MAR. Nursing also to continue to encourage fluids, exercise, and may administer more prune juice if needed. - If no bowel movement by 72 hours (3 days) from last documented bowel movement from 6am(a.m.)-2pm, nursing to complete a bowel assessment, document in the progress notes and administer Milk of Magnesia 30 ml per standing orders. - If no bowel movement in 72 hours (3 days) from last documented bowel movement and receiving Milk of Magnesia 30 ml in the morning then from 10p(p.m.)-6am, nursing to complete a bowel assessment, document in the progress notes and administer a Dulcolax Suppository per standing order. - If no bowel movement 8 hours post Dulcolax Suppository, nursing to complete a bowel assessment and notify the physician for further orders. E. Nursing will notify the on-coming shift of resident's bowel status and what interventions have been completed. F. If resident is consistently receiving bowel preparations for no bowel movements, nursing will contact the physician for a change in resident's bowel management. An Immediate Jeopardy was identified on 11/3/22, and at approximately 5:00 p.m. an email of the IJ notice was sent the Nursing Home Administrator (NHA). A removal plan was requested from the NHA at that same time. The removal plan for the facility submitted on 11/3/22 at 6:36 p.m., read as follows: Facility performed an audit of all in-house Residents. Bowel Report was pulled, identifying 9 Residents at risk. Bowel Assessments were performed on Residents at risk; several received medications per bowel protocol. Physician was updated as appropriate. The policy was reviewed and deemed appropriate. The DON and RN Supervisors were educated on 11/3/22. DON/Designee to run bowel report daily to ensure bowel protocol is followed per facility policy. The facility alleges all items were completed on 11/3/22. On 11/4/22 at 10:00 a.m., during a follow-up interview, the NHA and DON stated there were additional residents identified beyond the surveyor's expanded sample which also needed to be addressed and that the facility had done so. Pe

This citation pertains to Intake MI 352. Based on interview and record review, the facility failed to ensure a resident's choice for advanced directives of Cardiopulmonary Resuscitation (CPR) was followed. This deficient practice was detected at an Immediate Jeopardy (IJ) level due to staff not providing CPR to a Resident (#1) who had elected to have full code resuscitation status and was found to be unresponsive, without pulse, and not breathing. This deficient practice led to Resident #1 not receiving CPR prior to death and had the potential to affect 19 other residents who continued to reside at the facility, and who had elected to have Full Code resuscitation status. The IJ began on [DATE] at 10:51 PM when Resident #1, who had elected to be Full Code status, was found by Certified Nurse Aide (CNA) A to be unresponsive and CPR was not started. The IJ notification was communicated verbally to the Nursing Home Administrator (NHA) on [DATE] at 2:00 PM and followed with an email copy. The IJ was removed on [DATE] at 4:26 PM when the nursing staff with inadequate CPR training were identified and each shift was covered with appropriately trained personnel. The deficient practice continued at a pattern level of potential for more than minimal harm until onsite review confirmation of the full plan of correction. Findings include: A review of hospital admission paperwork dated [DATE], revealed Resident #1 earlier today was unloading wood from his truck with his son and stepped on a small piece of wood, lost his balance, and fell backwards off of the truck hitting his left hip area. He was discovered to have a left hip fracture non-displaced. Hospital notes revealed, No other concerns outside of this left hip pain. He was walking without any significant aid. Hospital Summarized Data dated [DATE], revealed a status of Full Code for life saving measures. A review of the facility Electronic Medical Record (EMR) for Resident #1 revealed an admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] ., high blood pressure, [CONDITION(S)], and [CONDITION(S)]. Resident #1 was designated as their own responsible party, per the facility EMR Face Sheet dated [DATE]. The facility Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This document was signed by Resident #1 on [DATE] and the physician on [DATE]. The facility Nursing Admission assessment dated [DATE], listed Resident #1's name and Full Code across the heading of the document. Details of the document further listed Full Code in the body of the document and read in part, The resident clearly comprehends the speaker's message and demonstrates comprehension by words or actions/behaviors, with clear speech and is understood. A review of the facility physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders in the EMR indicating Resident #1 had been changed to Do Not Resuscitate (DNR), and no discussions regarding the possibility of changing the code status were present in the EMR. The facility conveyed a Facility Reported Incident (FRI) occurring [DATE] to the State Agency (SA), the day of Resident #1's admission to the facility which read in part: .report from D.O.N. (Director of Nursing) this morning as a follow-up to the passing (death) of a Resident (#1) late evening [DATE]. D.O.N. notes she suspended RN (Registered Nurse B) pending investigation for not performing CPR on a Full Code Resident that went into pulmonary arrest .EMS was called at the time and pronounced Resident (#1) DOA (Dead on Arrival) . Resident Care Plan and stated wishes on POLST were not followed . The FRI Investigation Summary to the SA read in part, (Resident #1) was a [AGE] year old Resident at (facility name) for just 9 hours. He arrived at 1300 (1:00 PM) and he passed sometime between 2130 and 2251 (9:30 PM and 10:51 PM) on [DATE] .He admitted to (facility name) for rehabilitation of his L (left) Hip after falling from the back of his truck just a few days prior. Around 1500 (3:00 PM), (Resident #1) signed consents with RN (L). At that time he indicated he wished to be considered a full code for CPR should his heart stop beating. RN L indicated his preferences in the EMR and on the room door name plate with a red dot per policy. CNA (A) was starting her 11pm Rounds . She entered the room and behind the curtain observed (Resident #1) lying crosswise on his bed, on his back, with dark emesis on his head and torso. (CNA A) did not see (Resident #1's) chest rise for respiration and feared he had passed. (CNA A) and (Nurse Aide C), alerted the assigned nurse (RN B). Upon hearing the report from (CNA A), (RN B) appeared very anxious and unsure how to respond. (CNA A) suggested (RN B) check for a pulse. (RN B) replied, I can't and rather than enter the room, she went to the Nursing Office near the Nurses Station. (CNA A) alerted the other nurse in the facility, (LPN M), who was assigned to another hallway. (LPN M) immediately proceeded to (Resident #1's) room, and noted .He was noticeably cold to the touch and his eyes were wide open. She noted no pulse nor respirations. She was unsure of his code status, as she was not his assigned nurse. (LPN M) exited the room and went to (RN B) in the Nursing Office. She asked (RN B) if she had called 911 or a nursing director. Neither nurse initiated CPR nor grabbed the crash cart. Rather than call 911, (RN B) telephoned RN Supervisor . [who] directed (RN B) to initiate CPR and call 911. EMS was called . CPR was never initiated .Upon interview the next evening [DATE], (RN B) was unable to explain why she did not initiate CPR. She appeared extremely anxious, overwhelmed . She left the facility abruptly and was unable to provide a consistent account of the details to assist in this investigation. She was deemed by facility leadership to be incapable of adequately protecting the Residents of the facility and was terminated from employment . (Resident #1's) plan of care was clear that he wished for CPR attempts to occur in the event his heart stopped. On [DATE] at 11:01 AM, a phone call was made to RN B and a voice mail left. A return call was received on [DATE] at 10:50 AM, and RN B confirmed she had not performed CPR on Resident #1. On [DATE] at 11:08 AM, a phone call was made to LPN M and a voice mail left, but no return call was received. During a telephone interview on [DATE] at 11:15 AM, Nurse Aide C confirmed the FRI investigative summary. During a telephone interview on [DATE] at 11:25 AM, CNA A confirmed the FRI investigative summary. During an interview on [DATE] at 10:18 AM, the NHA stated the nurse (RN B) neglected to follow the care plan for Resident #1. The NHA said it was clear CPR should have been started. He stated, A nurse in our employ failed to employ the appropriate action. A review of RN B's personnel file revealed 2021 hire paperwork including a permission form signed by RN B to check references. No references had been checked. The personnel file for RN B also included an orientation skills checklist without any indication of the date each skill was reviewed or by whom or if further follow up was needed to ensure proper performance of the clinical tasks. An Employee Warning Notice was present in the file indicating RN B was terminated due to violation on [DATE] including: Irrational - Gave no direction to CNA or other nursing staff. Failed to initiate code after being told to . failure to initiate Code. Patient abandonment. During an interview on [DATE] at 2:10 PM, the DON reviewed the orientation skills checklist of RN B. The DON said it was not completed per current expectations. The DON stated it did not look like it was hands on training. RN J (the Education Director / Assistant DON) explained the process had changed and check marks or lines drawn on the orientation skills checklist as exhibited on RN B's paperwork were not good enough and no longer the practice. During an interview on [DATE] at 2:20 PM, the NHA explained References were overlooked as the process was not fully defined due to staff turnover at that time. During an interview [DATE] at 4:13 PM, the DON and RN J stated until this Surveyor asked, they did not know the status of CPR certified nurses on each shift. During an interview [DATE] at 4:16 PM, RN O confirmed she was the RN certified to train CPR for the facility and kept track of staff in need of training. Each staff member certified in CPR had a certificate in their personnel file. She had been holding CPR classes in the facility. RN O stated, Not to my knowledge had (RN B) had CPR training. The facility policy Advanced Medical Directives dated [DATE], was reviewed and read in part: .this facility will have a procedure to inform mentally competent residents of their right to write an Advanced Medical Directive . The facility Code Blue Procedure dated [DATE], was reviewed and read in part: Policy: To ensure that appropriate action will be taken by all staff in the event of a code, including: Identifying resident code status, When to call a code, How to initiate a code . Initiation of CPR . Full Code: CPR 1. All residents who are full code will be resuscitated if found without a pulse and or/respirations (sic) . Licensed Staff will be responsible for initiating and maintaining CPR and AED (automated external defibrillator) until EMS has assumed responsibility for the resident . On [DATE] at approximately 4:26 PM this surveyor verified the facility initiated the following to remove the Immediate Jeopardy: - Facility nursing licenses checked on [DATE] - verified all current - List of CPR certifications created; those with expired certifications scheduled for CPR training - No shift to have coverage without a CPR-trained individual. - Reference checks to be completed on all future hires as part of pre-employment process - Staff competency program to continue on current course with Education Director responsible for ensuring all staff go through a robust competency program upon hire, at least annually, and PRN as deficiencies noted. - The policy for the Code Blue Procedure was developed and education on this procedure had begun for all staff including: Identifying resident code status, When to call a code, How to initiate a code, Notifying EMS, How to respond to a code, Initiation of CPR, Notification of physician, Notification of family, Location of crash cart. - The code status of each resident was confirmed and a new system indicating Full code was posted on each name plate on each resident room door.

Based on observation, interview, and record review, the facility failed toensure timely follow-up with a physician specialist according to physician order and professional standards of practice for one Resident (#4) of 16 residents reviewed for quality of care. This deficient practice resulted in actual harm when Resident #4 developed severe tissue damage with the potential for infection and [CONDITION(S)]. Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . coli) (a type of bacteria normally found in the lower intestinal tract of humans), urinary tract infection, [CONDITION(S)], acquired (surgical) absence of the left leg above and right leg above knee, cognitive communication deficit, and diabetes. A review of the most recent Minimum Data Set (MDS) assessment for Resident #4, dated 4/26/2021, revealed Resident #4 required extensive assistance (two-person physical assistance) with bed mobility, and was totally dependent upon staff for transfers (moving from one surface to another) and toileting (includes management of urinary catheter). A review of Resident #4's electronic health record (EHR) revealed hospital discharge instructions for Resident #4, dated 6/2/2021. Further review of the discharge instructions, dated 6/2/2021, revealed the following, in part: Reason for Admission: 5/26/2021 unresponsive. 6/2/2021 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Comments: Maintain urinary catheter . Follow-up Appointment: Keep follow-up appointment as previously scheduled . Follow-up Appointment 1: 2 weeks with urology for foley catheter and [CONDITION(S)]. An observation with LPN M and LPN N on 8/10/2021 at 1:05 p.m., revealed Resident #4 lying in bed wearing an incontinence brief. Catheter tubing was observed coming from the right side of Resident #4's brief, leading to an adhesive catheter securing device attached to Resident #4's right upper thigh. LPN M unfastened Resident #4's brief, revealing an open wound from the distal end (glans) of Resident #4's penis down the under right side of the Resident's penile shaft. Resident #4's penile wound was observed to be approximately one centimeter (1 cm) wide, four- and one-half centimeters (4.5 cm) long and one and one-quarter (1.25 cm) deep. Further observation of the wound revealed Resident #4's urethra (tube inside the penis connecting the bladder to the opening at the end of the penis for removal of urine from the body) was open down the length of the wound, exposing the catheter tubing and causing the catheter tubing to protrude from the right side of Resident #4's penile shaft. Urine was observed on the incontinence brief and leaking from around the insertion site of the catheter. A foul smell was noted by this Surveyor as coming from the location of Resident #4's penile wound. In an interview immediately following the observation of Resident #4's wound care on 8/10/2021 at 1:05 p.m., LPN M reported being the wound care nurse for the facility. LPN M confirmed there had been urine leaking from around Resident #4's catheter insertions site. LPN M reported Resident #4 had been scheduled for a consultation with a urologist for evaluation for placement of a suprapubic catheter (surgically placed catheter inserted into the bladder from a small incision in the abdomen) to allow for Resident #4's current, indwelling catheter to be removed and for the evaluation of Resident #4's penile wound. LPN M was unsure when Resident #4 was scheduled to see the urologist. LPN M reported she was unsure how the wound had occurred but was aware Resident #4 often pulled at the catheter tubing. When asked if Resident #4's wound was measured to track healing or to determine worsening of the wound, LPN M reported Resident #4's wound had not been measured. On 8/11/2021 at 7:24 a.m., LPN M reported Resident #4 had been sent to the emergency department for evaluation on 7/11/2021, the day the wound had been discovered. LPN M reported Resident #4 had been sent back to the facility from the emergency department with instructions to follow-up with urology. LPN M reported the wound had worsened since Resident #4's emergency room evaluation on 7/11/2021. LPN M reported the facility had tried multiple types of catheter securing devices on Resident #4 to alleviate pressure from catheter tubing on the urethra, to prevent worsening of the Resident's penile wound but the wound continued to worsen due to the Resident's condition. LPN M reported the wound would not heal while the catheter was in place. LPN M reported all wound care and wound assessments were documented in the electronic health record (EHR) and there was no paper or additional documentation of Resident #4's wound. A review of wound care documentation, presented by the Director of Nursing (DON) on 8/11/21 at 7:58 a.m., revealed no measurements recorded of Resident #4's penile wound. Further review of Resident #4's wound care documentation revealed no wound care or wound assessments documented by the facility wound care nurse or licensed staff after 7/27/2021 through 8/10/2021. A review of Resident #4's EHR revealed the following, in part: Progress Note: 7/11/2021, 12:03 (p.m.), Discipline: Wound Care Nurse (LPN M) . per floor staff during weekly resident skin assessment, this nurse advised resident has severe tear to penis; upon assessment, (indwelling catheter) has tore through full glans penis; penis has moderate whitish, thick [MEDICATION(S)] like drainage surround tear . stat loc cath securement device (adhesive catheter securing device) released due to cath (catheter) tubing too (taut) and concern re: tearing to shaft causing further damage to penis and urethra . send to ER (emergency room ) for eval (evaluation). A review of the emergency department Physician H&P (history and physical), dated and signed 7/11/2021 at 1:26 p.m., revealed the following, in part: (Resident #4) presenting to the emergency department with a penis injury. Per report from nursing home 2 (two) days ago he pulled his foley (indwelling, urinary catheter) out with the balloon inflated . MD Note: Spoke with (urologist) - recommends follow-up in the (urology) clinic to get a suprapubic catheter scheduled. Called and spoke with the nursing home they are agreeable. Patient discharged back to facility. A review of the emergency department Aftercare Instructions, dated 7/11/2021 and located in Resident #4's EHR, revealed the following, in part: Follow up: (urologist) urology. Follow up date: 2-3 days. Further review of Resident #4's EHR revealed the following: Progress Note: 7/11/2021 (time not discernable). Resident sent back from ER . to follow up with urologist in 3 (three) days . 7/12/2021 12:02 (p.m.). Spoke with (Physician P) regarding resident's penis (wound) and the (indwelling urinary catheter) and follow up from ER visit . Did receive order to submit referral to urology at this time . 7/15/2021 16:27 (4:27 p.m.). (Physician U) in to see (Resident #4) with (Physician P). Aware of penis (wound) and wound care at this time, recommended to continue with current treatment until seen by urology. Appointment is scheduled on 7/26/2021. Resident #4's EHR revealed no record of Resident #4's appointment with urology on 7/26/2021. Further review of the progress notes for Resident #4 revealed the following, in part: 7/27/2021 05:55 (5:55 a.m.). Glans penis skin tear - tear from foley (indwelling urinary catheter) has now ruptured/split through glans and through skin fold related to circumcision (indwelling urinary catheter) tubing is tearing through shaft of penis at this time; charge nurse notified. On 8/11/2021 at 7:58 a.m., the DON reported Resident #4 was scheduled to see the urologist on 8/30/2021 at 8:30 a.m. When asked why Resident #4's appointment with urology on 7/26/2021 had been rescheduled, the DON reported Staff Q was responsible for scheduling residents' appointments. The DON confirmed there was a concern for Resident #4's penile wound worsening further and an increased risk of infection due to Resident #4's open penile wound and continued irritation from the indwelling urinary catheter. On 8/11/2021 at 10:30 a.m., Staff Q reported Resident #4 was originally scheduled for an appointment with urology on 7/26/2021 but did not make it to the appointment. Staff Q did not know why Resident #4 did not attend the appointment scheduled with urology on 7/26/2021. Staff Q confirmed Resident #4 had been rescheduled with the urologist for an appointment on 8/30/2021. A review of Resident #4's EHR with Staff Q revealed no documentation as to why Resident #4 did not attend the appoint with the urologist that had been scheduled for 7/26/2021. When asked if the urologist had been made aware of the worsening of Resident #4's penile wound, Staff Q reported the Nursing Supervisor, Registered Nurse (RN) F was responsible to relay information to the urologist. On 8/11/2021 at 11:35 a.m., Nursing Supervisor, RN F reported they had faxed Resident #4's referral form to the urologist's office on 7/12/2021. When asked if information regarding Resident #4's penile wound had been included with the referral form, RN F reported records and additional information would have been sent only upon the urologist's request. When asked if the urologist had been informed of the worsening of Resident #4's penile wound on 7/27/2021, RN F reported they were unsure if additional information had been relayed to the urologist after the referral had been sent on 7/12/2021. A review of a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . urinary tract infection . gross hematuria (blood in urine) . break down to the head of the penis from catheterization. On 8/11/2021 at 4:59 p.m., Physician P reported having observed Resident #4's penile wound on 7/15/2021. Physician P reported she was unaware Resident #4 did not attend the scheduled urology appointment on 7/26/2021. Physician P reported her assessment of Resident #4's wound on 7/15/2021 revealed the scheduled appointment with urology on 7/26/2021 would happen within an acceptable timeframe. When asked if they had been informed of the urologist's recommendation for Resident #4 to be seen within three days from the Resident's emergency room visit on 7/11/2021, Physician P reported she had not been given the emergency room documentation for review. Physician P reported they had not observed Resident #4's penile wound since 7/15/2021 and was not alerted to worsening of the wound on 7/27/2021. Physician P confirmed there was a concern that Resident #4 had missed the 7/26/2021 appointment with urology and of possible worsening of the wound and infection prior to the Resident's next scheduled appointment with urology on 8/30/2021. A review of the facility policy titled, Wound Dressing Changes, Clean and Sterile, revised 6/15/2021, revealed the following, in part: I. Policy: To ensure appropriate wound dressing change technique, provide optimum environment for wound healing and adhere to infection control practices. II. Procedure: I. Chart . Assessment/observation of wound is to be documented in the progress notes after EVERY dressing change (i.e., odor, redness, [CONDITION(S)], drainage, color, etc.). A review of the facility policy titled, Skin Care, revised 12/30/2015, revealed the following, in part: I. Policy: To ensure skin integrity and maintain homeostasis of epidermis. II. Procedure: B . 3. All wounds to be monitored daily/PRN by wound care nurses . D. Reported, Orders and Communication of concerns and special needs: 2. The wound care department or designee (charge nurse or RN) will assess the area of concern, document and update the MD (physician).

Based on observation, interview, and record review, the facility failed to complete bedrail assessments to determine resident need for bedrails, resulting in immediate jeopardy due to entrapment and serious harm for one Resident (#1) of five residents reviewed for bedrails. This deficient practice resulted in the potential for entrapment in the bedrail, with risk of serious injury and/or death, for the most vulnerable facility residents with limited range of motion and/or mobility. The immediate jeopardy began on [DATE] at approximately 5:30 a.m. when Resident #1 was found with her head lodged on/against the bedrail, and her lower body on the floor. Immediate jeopardy was identified on [DATE] at 4:00 p.m. with notification of the immediate jeopardy to the Director of Nursing (DON) in person, and with the Nursing Home Administrator (NHA) via telephone on [DATE] at 4:50 p.m. Request was made for an abatement plan. The immediate jeopardy was removed on [DATE] at 7:48 p.m., when the facility received acceptance of, and began implementation of its Abatement Plan for Removal of Immediate Jeopardy, that included: 1. Immobile and dependent residents were evaluated by a licensed staff member for Bed Rail Use beginning on [DATE]. 13 residents were identified for initial evaluation. Residents that are deemed unable to utilize the bed rail to improve mobility or independence will have their bed rails removed immediately, with orders discontinued and consents updated as appropriate. 2. The bed in room [ROOM NUMBER]A (previously used by Resident #1) was removed on [DATE] and locked out for future use until it can be assessed by Maintenance Director. 3. All current residents with Bed Rails will have an evaluation by a licensed staff member for appropriate Bed Rail Use by [DATE]. 4. A licensed staff member will evaluate each resident with bed rails for appropriate use upon admission and on a quarterly basis or with a change of condition. Noncompliance remained at a level of no actual harm with potential for more than minimal harm, until confirmation of completion of the abatement plan, and verification of the facility process to ensure resident assessment of bedrail need and safety has been completed. Findings include: Review of the [DATE] Minimum Data Set (MDS) assessment revealed Resident #1 was originally admitted to the facility on [DATE], with readmission on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Resident #1 was sometimes able to understand others and be understood. Resident #1 required extensive two-person assistance with bed mobility and transfers and scored 2 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severe cognitive impairment. The MDS assessment documented functional range of motion (ROM) limitations of bilateral upper and bilateral lower extremities. Bed rails were coded with zero (0) Not used. Following Resident #1's admission, the MDS assessment dated [DATE] revealed Resident #1 had clear speech and was able to understand and be understood, required extensive two-person assistance with bed mobility and transfers, and had no functional ROM limitations in either upper or lower extremities. Bed rails were coded with zero (0) Not used. Review of Resident #1s Progress Notes revealed the following: [DATE] 6:46 (a.m.) authored by Licensed Practical Nurse (LPN) B: At approximately 0525 I was called to resident's room. (Resident #1) was observed half way on the floor with her head/neck resting on the side rail (bed rail). Resident lowered to the floor and immediately assessed. (Resident #1) was found with no pulse or respirations at that time .DON (Director of Nursing) was immediately notified. Resident was lifted into bed using the (mechanical) lift. Resident pronounced (deceased ) by DON and he has notified her family and her doctor . [DATE] 6:56 (a.m.) authored by DON: Was notified by (LPN B) that resident had expired. Assessed resident to find absence of vital signs on auscultation and observation, no breath signs or pulse noted. Pronounced death at 0605 (6:05 a.m.). Noted mark on right side of neck measuring approx. 7 cm x 1 cm where residents neck had been against the bedrail. Family .have been notified of death. Physician order [REDACTED]. Review of Resident #1's Admission Nursing Assessment, dated [DATE], revealed no reference to any bed rail assessment. On [DATE], at 8:35 a.m., the Survey Team observed every bed in the facility, and found every bed, even those not occupied at that time, to have half side rails on the upper portion of the beds. On [DATE] at 9:10 a.m., when asked about Resident #1's fall from bed on [DATE], Maintenance Director /Staff G stated, I know a resident fell out of bed and got her head stuck in a rail (bed rail). I was not even informed (by facility administration) of this incident. I was never asked to inspect the bed .To me they should not be able to place a person on that bed until it was checked (inspected) . On [DATE] at 9:42 a.m., Resident #1's previous bed, (now occupied), was observed with LPN I and Housekeeping (Staff) J and the Survey Team. Both staff members were unable to operate the foot section of the bed, and confirmed the bed was not functioning properly. The bilateral upper bed rails were observed with movement possible up and down (toward the footboard and headboard) and with flexion of the top (upper portion) of the bed rail outward from the bed, with hand pressure applied. On [DATE] at 10:20 a.m. Confidential Complainant (CC) H was interviewed by telephone. CC H stated, (Resident #1) was completely immobile .she could hardly verbalize .She had to be fed. I can't figure out how (Resident #1) got out of that bed .She had a big bruise on her neck .It was a very nasty bruise . CC H reported Resident #1 had one arm (left) atrophied (contracted in position) to her chest, and her right hand was clenched in a fist: She could not grab things . On [DATE] at 10:53 a.m. Registered Nurse (RN) Supervisor K was asked how resident bed rail need would be determined for a resident, and if an assessment was completed. RN K said half bed rails were a typical order for a resident upon admission. When asked if there was a specific individualized bed rail assessment, RN K stated, Not specifically, and said the bed rail consent would be obtained from the resident by the MDS RN M. On [DATE] at 11:15 a.m. the DON reported the facility did not have an assessment policy for siderails. The DON stated, Upon admission the resident is asked if they want siderails .when they come in (at admission), there are siderails on their bed. If they don't want them (bedrails) we take them off. When the DON was asked if there was an assessment completed to determine resident need for siderails, (the DON) stated, Not really. The DON continued, If it was a restraint then we would get the signed consent. Review of the Side (Bed) Rail Policy, revised [DATE], read, in part: POLICY: To provide appropriate assessment and monitoring of side rail implementation and usage while also ensuring benefits of increased bed mobility, positioning, and safety per resident/representative request .PR[NAME]EDURE: A. Upon admission, and at any time per request, side rails will be offered to residents/representatives. Least restrictive alternatives and risk factors will be explained to the resident/representative and, if applicable, informed consent will be obtained .C. The attending physician will be contacted and an order including medical symptoms, (physical need, psychological need, and/or safety issues) for side rail usage, will be obtained. D. A written assessment of the resident's need(s) for side rails, including risk factors and alternatives, will be completed by the Nursing and Rehab Departments. E. Measurements will be taken, by a licensed staff, of the resident's head circumference and bed/mattress/side rail dimensions. These measurements will be documented on every shift for five (5) days, after side rail implementation and will be reviewed quarterly by the Nursing Department. F. Maintenance Department will inspect and document, every 30 days, by completing one wing per week. The bed frame, bed rails, and mattress will be assessed for damage, wear, and gaps exceeding the acceptable maximums. The mattress will be inspected to assure that it continues to be firmly affixed to the bed frame, if applicable, to avoid shifting. The side rails will be inspected to assure that they remain mechanically sound, firmly attached, and with latches in good working order. A Maintenance Department Work Order will be completed promptly for any noted adjustments or repairs necessary . On [DATE] at 11:30 a.m. Registered Nurse (RN)/MDS Coordinator M was asked about bed rail assessment upon admission and change of condition. RN M reported she did not do bed rail assessments. We explain the risk/benefits and the dangers of having bed rails .I don't have any role in a functional assessment for the need for the bed rail. They sign a consent if they want them (bed rails). Review of the Resident Bed Rail Consent Form, signed by Resident #1's Durable Power of Attorney (DPOA) U, dated [DATE], read, in part: .I understand that, in addition to this signed consent form, authorizing the use of bed rails for this resident, a written order from the resident's attending physician, specifying the medical rationale and circumstances for use, must be obtained prior to installation of this medical treatment device. It is also my understanding that the Facility will periodically review and re-evaluate the resident's need for bed rails and that the resident, responsible party and attending physician will be consulted in this matter . The ANNUAL REVIEW (regarding bed rails) for Resident #1 was signed by the DPOA U on [DATE], [DATE], [DATE], and [DATE]. The ANNUAL REVIEW was a signature sheet, with only lines for repeat signatures. The initial Bed Rail Consent Form was signed by Resident #1's DPOA U on the date of admission, [DATE], and was stapled to the Annual Review signature sheet received from the facility. During an interview on [DATE] at 11:42 a.m. Certified Nurse Aide (CNA) A described finding Resident #1 in the following position on [DATE]: Half of her body was on the floor. Half of her body was on the siderail .I saw the bruise on her neck .I couldn't tell if her head was on top of the rail, under the rail, or in between the rails .I knew she (Resident #1) was already gone because of her position, and (her white skin coloration) .If the (bed) rail had not been there she would have fallen out of bed, but the (bed) rails are never down .The body pillow would have been placed under her back (left side) so that she didn't roll back(ward). She didn't move (reposition herself) until you (staff) moved the pillow .There was nothing (no pillows) in front of her (on the right side). I seen the body pillow laying there. It (pillow) was just below the shoulders and down lower to the butt/legs . CNA A reported she was unaware of any falls from bed for Resident #1 in the two years of CNA A's employment at the facility. On [DATE] at 11:27 p.m. CNA D confirmed she had completed a bed bath for Resident #1 at approximately 3:50 a.m. CNA D said Resident #1 did not speak, and only peeked at her (CNA D) during the bath. CNA D stated, I used the blue pads to turn her on her side - onto her right side. She was facing toward the door. I put the body pillow behind her, under the blue pad .nobody helped me wash her up. She is a one person turn . CNA D confirmed she helped (with mechanical lift) return deceased , Resident #1 back into bed, on [DATE]. They found her at 5:20ish .She had a bruise across her neck on the right side/crease of her neck . Review of Resident #1's Falls Care Plan revealed the following, in part: Approach Start Date: [DATE]. ½ side rails x (times) 2 to my bed for positioning and mobility. Edited: [DATE] .Evaluation Notes: [DATE] .No noted falls this past quarter. Continue with plan of care. ADL (activities of daily living) Functional/Rehabilitation Potential Care Plan included: Approach Start Date: [DATE], Assistive devices to promote highest level of functioning: Bilateral ½ Side Rails on bed to facilitate position changes and bed mobility .edited [DATE] .Evaluation Notes: [DATE] .Continue with plan of care. On [DATE] at 12:15 p.m. the DON was asked for documentation of bed rail assessment for Resident #1 performed upon admission. The DON said it was most likely not in the Electronic Medical Record (EMR) because Resident #1 was admitted in 2011. During an interview on [DATE] at 2:30 p.m. written documentation of bed rail assessment of need, including quarterly assessments, rehab assessments, admission measurements, for Resident #1 was requested from the DON. The DON stated, It is an informal discussion, upon admission, when we ask them if they want bed rails. At the quarterly review, if they decide they do not want bed rails they can choose at any time to take them off . The DON said the quarterly (blue sheet) assessments were kept and were completed every quarter. No bed rail assessments of need or quarterly blue sheet bed rail specific assessments for Resident #1, were ever provided to the survey team, although multiple requests were made throughout the survey. On [DATE] at 11:45 p.m. CNA S, regarding Resident #1 stated, She could not help with the (bed) roll and turn .her arms were very contracted. She could not sit up unsupported .I am not aware of her falling or getting out of bed since I have been here (approximately 2 years). She couldn't move herself around . On [DATE] at 11:50 p.m. LPN B confirmed being called to Resident #1's room by CNA A. LPN B found (Resident #1) .off the right side of the bed .her feet were touching the floor .Her head was inside the siderail .I had to release her head from the bed rail .She was more on top of the mattress, with her back to the bed, and her neck cocked up against the bed rail .She did have a mark across her neck and it looked like an indentation in her neck. It was exactly where the (bed) rail was against her neck .I know when I walked in, she (Resident #1) was gone (deceased ) .The bruise was very visible (on (Resident #1's) neck) and I don't know how deep that was . LPN B said there was never any issue with Resident #1 falling out of bed, and Resident #1 was unable to reposition herself in bed. Review of the Death, Pronouncement of - DNR (Do Not Resuscitate) revised [DATE], read, in part: M. Unusual/Suspect Death: 1. In situations when the death is unusual, i.e., resident is found dead outside the facility, resident has died due to failure of devices such as: restraints, side rails, lifts, etc: a. DO NOT remove the body from the area, pending investigation. B. The licensed Staff will notify the facility Administrator and the Director of Nursing (DON). C. The Licensed Staff will notify the attending physician. D. The Licensed Staff will notify the (City Name) City Police Department . On [DATE] at 3:11 p.m. LPN I confirmed she had performed bed measurements many times, and stated, I have never been told to take a residents head circumference . On [DATE] at 3:15 p.m. the DON, regarding measuring head circumference, as specified in the facility Side (Bed) Rail Policy, cited above, stated, I have not seen any head circumferences being measured here at the facility .I get that it was part of our policy . On [DATE] at 3:55 p.m., when asked for bed rail assessments for Resident #1, Occupational Therapist (OTRL) Z stated, We (Rehab Department) would not have any bed rail assessment in writing for any resident. I only get involved if there is a specific clinical referral. We don't do routine bed rail assessments. On [DATE] Director of Wound Care/RN V stated, They (resident beds) all have side rails on every bed when they (residents) come in (upon admission) .MDS (staff) does the assessments (bed rail) too .and gets the consent from the families . RN V said she had performed clinical assessment of resident bed rails. When asked about documentation of the bed rail assessment, RN V stated, I usually just bring it verbally to the group (Interdisciplinary Team) . During a repeat interview on [DATE] at 12:30 p.m. RN V stated, No, I am not responsible for siderails (bed rails) upon admission. RN V confirmed Resident #1 had lost a lot of mobility (since admission to the facility in 2011). On [DATE] at 12:18 p.m. Detective BB was asked about the mark on Resident #1's neck. Detective BB said he believed marks on Resident #1's neck and chin were caused by the bed rail. I believe her (Resident #1's) chin was resting on the top rail, and her neck was resting on the next rail .The mark on her neck was much more pronounced than the chin .LPN B described most of her weight being held up by her head and neck . Detective BB reported the first police officers arrived at the facility at 7:47 a.m., and Detective BB arrived at 8:15 a.m. on [DATE]. On [DATE] at 5:27 p.m. Medical Examiner (ME) DD was interviewed via telephone. ME DD stated, The mark on her neck was caused by pressure up against the side (bed) rail .It (trachea) may have temporarily compressed and there may have been a decrease in oxygen that could have been a contributing factor (in her demise) . Review of the (manufacturer) User-Service Manual (Name Brand) Assist Device and Side Rails .copyright 2008, read, in part: When assessing the risk for entrapment, you need to consider your bed, mattress, head/foot boards, assist devices and other accessories, as a system. It is also extremely important to review the resident's physical and mental condition and initiate an appropriate individual care plan to address entrapment risk .Entrapment zones involve the relationship of components often directly assembled by the healthcare facility rather than the manufacturer. Therefore, compliance is the responsibility of the facility .While the guidelines (regarding entrapment zones) apply to all healthcare settings .long-term care facilities have particular exposure since serious entrapment events typically involve frail, elderly or dementia patients .(manufacturer) recommends the use of a support surface (mattress) with minimum dimensions of 35 (inches) in width by 6 in depth . The dimension of the bed rail used on Resident #1's bed, per the User-Service Manual, was 28.38 inches long, by 11.00 inches deep. On [DATE] at 7:08 p.m. Resident #1's Durable Power of Attorney (DPOA) U was interviewed by telephone. DPOA U confirmed Resident #1 was immobile with no ability to reposition in bed for the last year or two. She was fully incapacitated. She needed assistance with everything .If she was to fall over, she could not help herself to get out of that situation .There (were) many times I adjusted her after they (staff) would leave the room. I was concerned that she was tipped too far. I would put another pillow on the side she was tipped toward because I was afraid she would tip over .It was always at night when I was worried that she was being tipped to far forward at bedtime. They used to have two long body pillows on each side of her, so even if they tipped her too much . but since she got sick in November, they stopped putting on two body pillows . DPOA U reported she was informed by the DON of Resident #1's death. DPOA U stated, The first thing he said, 'It was an unusual event'. She was found with her head caught in the bed rail. He had said it several times . DPOA U stated she was the one who initiated police investigation of the incident: I contacted the police from (out of town city). Regarding Resident #1's bed rails, DPOA U stated, Obviously I have signed something, but I have never talked to someone about the risks and benefits of siderails .(Resident #1) didn't have the mental capacity, or any capacity, to use the siderails for positioning or mobility .