Every finding on record at Oakview Medical Care Facility

Based on observation, interview, and record review, the facility failed to provide a process for visitors, staff, and residents to submit concerns and grievances anonymously potentially affecting 73 total residents. An observation on 4/7/26 at 2:00PM throughout the facility revealed there was not a concern or grievance form available outside of asking for one at the nurse's station and no box or location could be found to drop a grievance anonymously. In an interview on 4/7/26 at 2:50 PM Director of Social Services (DSS) C reported that grievances are not completed for residents unless a resident asks for one. DSS C reported that the facility did not have grievance forms outside of the nurse's station and if a person wanted one, they had to ask for it. In an interview on 4/7/26 at 3:17 PM the Director of Nursing Services (DONS) reported that grievances can be filled out by anyone, and the facility policy reflects that a grievance should be accessible to be submitted anonymously and at that time there was not a specific location for residents to file grievances anonymously. Review of facility policy Resident & Family Grievances revised 9/2/25 revealed grievances or complaints may be submitted verbally in person, by telephone, in writing, or anonymously.

Based on interview and record review, the facility failed to assess a skin concern identified upon admission for 1 resident (R4) of 6 residents reviewed for skin and pressure ulcer concerns.Findings include:Review of an admission Record revealed R4 admitted to the facility on [DATE] with pertinent diagnoses which included dementia, diabetes, and dependence on renal dialysis.Review of R4's Baseline Care Plan, dated 12/16/2025, revealed .spot on bottom, long time, (no change), hurts, barrier cream, wife places bandaid. Further review revealed no assessment of this chronic wound and no interventions specific to this wound.Review of a current Care Plan focus and interventions for R4, initiated 3/23/2026, revealed a stage 2 pressure ulcer on his right gluteus. Further review revealed R4 was noted to be at risk for pressure injuries but there were no mention or interventions pertaining to the chronic wound on his gluteus prior to identification of the stage 2 pressure ulcer.Review of R4's admission Assessment, dated 12/15/2025 at 4:43 PM, revealed no assessment of R4's chronic buttock wound mentioned on his Baseline Care Plan. Further review of the Electronic Medical Record (EMR) revealed no documentation of R4's buttock wound until it was identified by staff on 3/22/2026. In an interview on 4/8/2026 at 11:13 AM, Registered Nurse (RN) D reported she was not aware of R4's history of chronic buttock pressure ulcer until it was recently identified. RN D reported nurses check a box on the Treatment Administration Record (TAR) when they perform weekly skin checks but do not document further unless they note a new skin concern. In an interview on 4/8/2026 at 11:20 AM, Wound Nurse E reviewed R4's admission Assessment and Baseline Care Plan and reported his chronic buttock wound should have been assessed at the time of his admission to the facility and appropriate interventions ordered. Wound Nurse E reported she could not prove whether R4's buttock wound was open or healed at the time of his admission to the facility on [DATE].

This citation pertains to intake 2729237. Based on interview and record review, the facility failed to follow policies and procedures to report injuries of unknown origin for one (R2) of 4 residents reviewed for injuries.Findings include:Resident #2 (R2)Review of a Face Sheet revealed R2 admitted to the facility on [DATE] with pertinent diagnoses of Parkinsons disease, Parkinsonism, and dementia. Review of an Incident Report titled Bruise dated 10/16/25 at 2:00 AM for R2 revealed: Incident Description: Nursing Description: purple discoloration noted to upper right arm. Resident Description: Resident does not recall any incident which could have caused bruising. Agencies/People Notified: Physician. No documentation to show the Abuse Coordinator was notified. Review of a Nursing Progress note dated 10/16/25 at 2:17 AM for R2 revealed: Large purple discoloration noted to right upper arm measuring 15cm (centimeters) x 6cm. Resident unable to recall any incident which may have caused the bruising. Message left in [Provider] binder for [Practitioner] review. Family to be notified by day shift in the morning. Review of an Incident Report titled Bruise dated 11/26/25 at 6:25 PM for R2 revealed: Incident Description: Nursing Description: Resident noted to have 4cm x 4cm bruise purple/blue in color with yellow fading around the edges to the lower lumbar region when CNA (Certified Nursing Assistant) was assisting the resident to the bathroom. Unknown how resident obtained the bruise. Resident Description: Resident Unable to give Description. Agencies/People Notified: Physician, Family Member, and MDS Nurse. No indication the Abuse Coordinator was notified. Review of a Nursing Progress note dated 11/26/25 at 6:48 PM for R2 revealed: : Resident noted to have 4cm x 4cm bruise purple/blue in color with yellow fading around the edges to the lower lumbar region when CNA was assisting the resident to the bathroom. Unknown how resident obtained the bruise. Charge nurse notified of new findings, monitoring set up until resolved, a note was place to [Provider]. During an interview on 2/24/26 at 10:20 AM, the Director of Nursing (DON) reported that the incidents on 10/16/25 and 11/26/25 were not reported to the State Agency. The DON reported she did not think she needed to report it because of the way R2 was regarding his restlessness and flailing at times. R2 could not verbalize what had happened. Review of a policy titled Abuse, Neglect & Exploitation last revised 2/9/26 revealed: Policy. This facility is committed to protecting the health, welfare, safety, and rights of all residents. The facility will maintain and enforce policies and procedures that prohibit, prevent, identify, report, and investigate all forms of abuse, neglect, exploitation, and misappropriation of resident property. All staff must comply with these requirements.3) Identification. This policy and corresponding forms guide staff in recognizing potential abuse, neglect and/or exploitation, including staff-to-resident abuse and certain resident-to-resident altercations. Indicators may include but are not limited to the following:-Resident, staff, or family report of abuse -Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on the body -Physical injury of an unknown source . -Reporting Requirements. Reporting guidelines are outlined below and summarized in Abuse Reporting-Suspected Crimes v. Alleged Violations (OMCF Form 1-09). Allegations of resident abuse must only be reported to the designated personnel and agencies identified in this policy to ensure protection of residents and staff. Any inquiries from external parties, including the media, must be directed to the Administrator. (1) Staff Reporting. All allegations or suspected abuse must be reported immediately to the Charge Nurse, who promptly notify the NHA and DON. If Charge Nurse is unavailable, report directly to NHA or DON. (2) Facility Incident Reporting. An NHA or DON who becomes aware of a prohibited act must immediately comply with all applicable regulations and report the incident to the Michigan Department of Health & Human Services (MDHHS) / Department of Licensing & Regulatory Affairs ([NAME]), Bureau of Community & Health Systems (BCHS). Refer External Reporting Procedures at Section 2.E for detailed requirements.

This citation pertains to intake 2729237. Based on interview and record review, the facility failed to follow policies and procedures to thoroughly investigate injuries of unknown for one (R2) of 4 residents reviewed for injuries of unknown origin.Findings include:Resident #2 (R2)Review of a Face Sheet revealed R2 admitted to the facility on [DATE] with pertinent diagnoses of Parkinsons disease, Parkinsonism, and dementia. Review of an Incident Report titled Bruise dated 10/16/25 at 2:00 AM for R2 revealed: Incident Description: Nursing Description: purple discoloration noted to upper right arm. Resident Description: Resident does not recall any incident which could have caused bruising. No statements from staff documented and no thorough investigation of the root cause was completed. Review of a Nursing Progress note dated 10/16/25 at 2:17 AM for R2 revealed: Large purple discoloration noted to right upper arm measuring 15cm (centimeters) x 6cm. Resident unable to recall any incident which may have caused the bruising. Message left in [Provider] binder for [Practitioner] review. Family to be notified by day shift in the morning. Agencies/People Notified: Physician. Review of the Treatment Administration Record (TAR) for R2 revealed there was no documentation of the bruise to R2's right upper arm for monitoring until it resolved. Review of an Incident Report titled Bruise dated 11/26/25 at 6:25 PM for R2 revealed: Incident Description: Nursing Description: Resident noted to have 4cm x 4cm bruise purple/blue in color with yellow fading around the edges to the lower lumbar region when CNA (Certified Nursing Assistant) was assisting the resident to the bathroom. Unknown how resident obtained the bruise. Resident Description: Resident Unable to give Description. Agencies/People Notified: Physician, Family Member, and MDS Nurse. No statements from staff documented and no thorough investigation of the root cause was completed. No documentation to show a thorough nursing assessment/skin assessment was completed. Review of a Nursing Progress note dated 11/26/25 at 6:48 PM for R2 revealed: Resident noted to have 4cm x 4cm bruise purple/blue in color with yellow fading around the edges to the lower lumbar region when CNA was assisting the resident to the bathroom. Unknown how resident obtained the bruise. Charge nurse notified of new findings, monitoring set up until resolved, a note was placed to [Provider]. No documentation to show a thorough nursing assessment/skin assessment was completed. During an interview on 2/24/26 at 10:20 AM, the Director of Nursing (DON) reported that the incidents on 10/16/25 and 11/26/25 were not reported to the State Agency. The DON reported she did not think she needed to report it because of the way R2 was regarding his restlessness and flailing at times. R2 could not verbalize what had happened. The DON reported bruises are to be monitored on the TAR once a day for a week, then weekly until resolved.Review of a policy titled Abuse, Neglect & Exploitation last revised 2/9/26 revealed: Policy. This facility is committed to protecting the health, welfare, safety, and rights of all residents. The facility will maintain and enforce policies and procedures that prohibit, prevent, identify, report, and investigate all forms of abuse, neglect, exploitation, and misappropriation of resident property. All staff must comply with these requirements.3) Identification. This policy and corresponding forms guide staff in recognizing potential abuse, neglect and/or exploitation, including staff-to-resident abuse and certain resident-to-resident altercations. Indicators may include but are not limited to the following:-Resident, staff, or family report of abuse -Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on the body -Physical injury of an unknown source .Investigation. The Abuse Prevention Coordinator or designee is responsible for completing the investigation. (1) Investigation Guidance. The Abuse Response Guide (OMCF Form 1-08) may be used as a reference tool to help ensure a thorough investigation. The Injury of Unknown Source Algorithm/Worksheet (OMCF Forms 1-07) may provide additional guidance. (2) Investigation Worksheet. Use the Abuse Investigation Worksheet (OMCF Form 1-20) to collect all information required for reporting an incident to the State Agency. Once the investigation is complete, the investigator will submit the completed Form 1-20 including the Investigation Summary to the Abuse Prevention Team for review and final approval.(3) Witness Statements. Interview all relevant witnesses and staff and document each interview. If possible, include a second person during the interview to verify the statements.(4) Other Input. Obtain input from the attending physician and/or legal counsel as appropriate.(5) Evidence Preservation. Carefully handle any evidence that may be relevant to a criminal investigation. Staff must not tamper with or alter evidence, as doing so can compromise both the facility's investigation and that of external authorities. This requirement is especially critical in cases of alleged or suspected sexual abuse. Examples of evidence tampering include, but are not limited to, washing linens or clothing, altering or destroying documentation, or bathing or otherwise cleaning the resident before a medical examination (including a rape kit, when applicable).

This citation pertains to intake 2729237. Based on interview and record review, the facility failed to follow policies and procedures and implement meaningful care plan interventions to prevent falls for one (R2) of 4 residents reviewed for falls.Findings include:Resident #2 (R2)Review of a Face Sheet revealed R2 admitted to the facility on [DATE] with pertinent diagnoses of Parkinsons disease, Parkinsonism, and dementia. Review of a Witnessed Fall Incident Report dated 11/27/25 for R2 revealed: Housekeeping pulled cart up to the door of room [ROOM NUMBER] and found him standing up with his walker. Staff witnessed resident's foot get stuck in the wheel of his walker causing him to lose balance and fall. Resident unable to give description. Injuries Observed at Time of Incident: Skin Tear, Right hand (back). Staff statement from the Housekeeper: . I waited because his CNA (Certified Nursing Assistant) was in there doing care. (R2) was in his chair when (CNA) left the room after caring for him. When I turned to enter (R2's) room, he was up and pivoting to his walker when his foot got stuck on the wheel and the walker moved. (CNA) was right behind me and we then put a pillow under his head and shut the alarm off that was sounding. We noticed there was blood on the pillow we just placed under his head. Nurses showed up and took over. (R2) did not hit his head that I witnessed. Review of a Fall Investigation Review document for the 11/27/25 fall for R2 revealed: Root Cause Analysis- 1. Why did this occur? (R2) experienced periods of anxiety. 2. Why did this occur? Terminal restlessness. 3. Why did this occur? Parkinsons. 4. Why did this occur? Loss of balance. Conclusion/Root Cause: Impaired balance unaware of safety needs. Review of a Nurse-Risk Management Note dated 11/27/25 for R2 revealed: . Recommendations to Prevent Reoccurrence/Immediate Intervention: All safety interventions in place. There were no meaningful post fall interventions documented/implemented. Review of a Fall Packet/Investigation Checklist dated 11/27/25 for R2 revealed: . Q (every) 15-Minute Safety Checks in POC (plan of care). 9. Intervention(s) initiated and added to Care Plan. The Care Plan does not reflect the addition of the 15-minute safety checks. Review of a Fall Investigation Review document for the 11/27/25 fall for R2 revealed: Root Cause Analysis- 1. Why did this occur? (R2) experiences periods of anxiety. 2. Why did this occur? End of life restlessness/Anxiety. 3. Why did this occur? Parkinsons Disease with dyskinesia. Conclusion/Root Cause: (R2) is experiencing anxiety and restlessness and forgets to ask for help/use call light prior to transferring. 7-Day Follow-up: Resident not to be left in room recliner/chair alone. Collaborating with hospice. The Care Plan does not reflect the 7-day follow-up interventions until 12/4/25. Review of an Unwitnessed Fall Incident Report dated 12/4/25 for R2 revealed: Cena (CNA) heard alarm and entered room to resident laying on the floor in front of recliner chair. Resident unable to give description. Statements: Heard chair alarm going off and entered room to find resident lying on the floor in front of recliner chair. I shouted for help and placed a pillow under his head for support while waiting. I suspect he slipped on either his blanket or slippers while trying to self-transfer and fell. Review of a Fall Investigation Review document for the 12/4/25 fall for R2 revealed: Root Cause Analysis: 1. Why did this occur? Terminal restlessness. 2. Why did this occur? Unsafe to be in room in chair without supervision. Conclusion/Root Cause: Not to be in chair in room alone. (Intervention of not leaving resident alone in recliner added already as intervention after 11/27/25 fall). Review of a Nurse-Risk Management Note dated 12/4/25 for R2 revealed: Seen 20 mins prior sitting in recliner chair. CENA answered chair alarm and noted resident on the floor. Blanket on the floor by feet. One slipper half on and one slipper off. Recommendations to Prevent Reoccurrence/Immediate Intervention: Maxi lifted to bed. R2 was to be on 15-minute checks per the Fall Packet/Investigation Checklist. This intervention had been implemented after 11/27/25 fall. Review of a Fall Packet/Investigation Checklist dated 12/4/25 for R2 revealed: . 6. Q (every) 15-Minute Safety Checks in POC (plan of care). already on. 9. Intervention(s) initiated and added to Care Plan: no new interventions. Review of the Fall Care Plan for R2 revealed: Focus: I am at risk for falls r/t Confusion, Deconditioning, Gait/balance problems, Incontinence and Dx of Parkinson's. Date Initiated: 09/30/2025. Interventions included:-Fall team to review information on past falls and implement new safety interventions, initiated 9/30/25. No 15-minute checks post falls are documented.- High Risk Falls program, initiated: 09/30/2025.- Follow facility fall protocol, date initiated: 09/30/2025.- Please do not place him in room recliner, he has fallen out of it twice within 7 days.-Assist him in recliner in front of nurses' station instead please, date initiated: 12/05/2025- Please do not place him in room recliner due to fall risk. Assist him in recliner in front of nurses' station instead please, date initiated: 12/05/2025. In an interview on 2/24/26 at 10:20 AM, the Director of Nursing (DON) was questioned about the care plan interventions post fall for R2. The DON acknowledged the concerns of implementing timely care plan interventions and not following the care plan to prevent a fall. Review of a Fall Prevention Program policy last revised on 12/13/24 revealed: It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents. Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. (1) Identify Risks. Identification of residents at risk for falling is an ongoing process through observation of the resident and communication with staff. (3) Assessments. Assess current interventions for effectiveness as well as initiate new interventions based on the following information related to resident falls . E (5) Mitigation & Interventions. The Falls Committee/IDT will attempt to implement a new intervention as appropriate after each fall to reduce hazards and risks based on the RCA. Development of interim safety measures may be necessary within the first 24 hours if interventions cannot immediately be implemented fully.

Based on observation, interview, and record review, failed to ensure 1) equipment was being maintained, 2) required information/reminders are being provided at hand sinks 3) maintain physical facilities in sanitary conditions and in good repair potentially effecting 69 residents that receive food/water from the facility. Findings include: The following observations were observed on 02/11/25 between 10:29 AM to 1:50 PM, during tour of the kitchen/facility with Directory of Dietary (DOD) A. Observation of the dish washing area revealed a large area of the flooring had low grout, resulting in a build-up of food residues/debris, standing water and grime between the floor tiles. Observation of the (Name of Living Center's) Kitchenette found, 1) An employee handwashing reminder sign was not provided at the hand sink. 2) Ice machine's water filter was not labeled/dated. Observation of the shared hallway kitchenette revealed, ice machine did not have a water filter installed. During an interview on 2/12/25 at 10:02 AM, Maintenance Director (MD) D revealed he was unsure of when maintenance (filter change) had last taken place on the (Name of Living Center's) ice machine. MD D further revealed he was not sure why the other ice machine did not have a filter but would investigate it further. The 2017 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. Review of the FDA 2017 Food Code Section, 6-301.14 Handwashing Signage. Reflected the following, A sign or poster that notifies FOOD EMPLOYEES to wash their hands shall be provided at all HANDWASHING SINKS used by FOOD EMPLOYEES and shall be clearly visible to FOOD EMPLOYEES. Review of the FDA 2017 Food Code Section, 5-204.13 Conditioning Device, Location. Reflected the following, A water filter, screen, and other water conditioning device installed on water lines shall be located to facilitate disassembly for periodic servicing and cleaning. Review of the FDA 2017 Food Code Section, 5-205.13 Scheduling Inspection and Service for a Water System Device. A device such as a water treatment device or backflow preventer shall be scheduled for inspection and service, in accordance with manufacturer's instructions and as necessary to prevent device failure based on local water conditions, and records demonstrating inspection and service shall be maintained by the PERSON IN CHARGE.

Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 4 of 18 residents (Resident #29, #40, #42, and #49), reviewed for the provision of nursing services, resulting in lack of vital sign assessments prior to medication administration and medications administered outside of physician ordered parameters. Findings: Resident #29 (R29) Review of an Admission Record revealed R29 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension and atrial fibrillation (abnormal beating of the heart) Review of R29's Order Summary dated 12/16/24 revealed, Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth two times a day .Hold if SBP (systolic blood pressure/top number) is less than 100, or DBP (diastolic blood pressure/bottom number) is less than 50 or HR (heart rate) is less than 60. To be administered at 9:00 Am and 9:00 PM. Review of R29's Pulse Summary revealed that from 1/1/25-1/31/25 R29's pulse was only assessed on 1/7/25, 1/14/25, 1/21/25, and 1/28/25. There were no other pulse assessments documented. Review of the January Medication Administration Record revealed that R29's metoprolol was administered twice a day from 1/1/25-1/31/25 despite the lack of a pulse assessments. Further review of R29's Pulse Summary and Medication Administration Record revealed that on 1/7/25 R29's pulse was documented as 58 and both doses of metoprolol were administered. Resident #40 (R40) Review of an Admission Record revealed R40 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension. Review of R40's Order Summary dated 12/17/24-1/10/25 revealed, Lisinopril Oral Tablet 5 MG (Lisinopril)-Give 1 tablet by mouth one time a day .HOLD if SBP is less than 100, DBP is less than 50 or HR is less than 60. Review of R40's January Medication Administration Record revealed: *On 1/5/25 R40's pulse was 52 and the lisinopril was administered. *On 1/6/25 R40's pulse was 56 and the lisinopril was administered. *On 1/7/25 R40's pulse was 56 and the lisinopril was administered. *On 1/8/25 R40's pulse was 58 and the lisinopril was administered. *On 1/9/25 R40's pulse was 56 and the lisinopril was administered. Resident #22 (R22) Review of an Admission Record revealed R22 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension. Review of R22's Order Summary dated 11/12/24 revealed, Lisinopril Oral Tablet 10 MG (Lisinopril)-Give 2 tablets by mouth one time a day .HOLD if SBP is less than 100, DBP is less than 50 or HR is less than 60. To be administered at 9:00 PM. Review of R22's Pulse Summary and Blood Pressure Summary revealed that on 1/22/25 R22's blood pressure was assessed at 5:24 PM and was documented as 111/63 with a pulse of 71. R22's blood pressure and pulse were not reassessed until 1/25/25 at approximately 8:00 PM. Review of R22's January Medication Administration Record revealed: *Lisinopril was administered on 1/22/25 with the blood pressure and pulse assessment of 111/63 and 71. *Lisinopril was administered on 1/23/25 with the blood pressure and pulse assessment of 111/63 and 71. *Lisinopril was administered on 1/24/25 with the blood pressure and pulse assessment of 111/63 and 71. Resident #49 (R49) Review of an Admission Record revealed R49 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: orthostatic hypotension. Review of R49's Midodrine HCl Oral Tablet 5 MG (Midodrine HCl)-Give 1 tablet by mouth two times a day .Check STANDING Blood Pressure. HOLD if SBP is greater than 120. To be administered at 11:00 AM and 5:00 PM. Review of R49's January Medication Administration Record revealed: *On 1/8/25 R49's blood pressure was 132/66 and the 5:00 PM dose of midodrine was administered. *On 1/13/25 R49's blood pressure was 138/75 and the 5:00 PM dose of midodrine was administered. *On 1/14/25 R49's blood pressure was 126/72 and the 5:00 PM dose of midodrine was administered. During an interview on 02/13/25 at 11:11 AM, Director of Nursing (DON) confirmed the above medication errors. DON reported vital signs should be assessed prior to the administration of medications with ordered parameters followed.

Based on interview and record review, the facility failed to update a care plan to reflect current treatment for 1 resident (R13) of 18 residents reviewed for accuracy of care plans. Findings include: Review of an Admission Record revealed R13 admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction (stroke) and dementia. Review of R13's Physician's Orders active 2/11/2025 at 1:37 PM revealed R13 had a urinary catheter and was being treated for a pressure ulcer on her coccyx. Review of R13's nursing Progress Note, dated 1/10/2025 at 11:22 AM, revealed a urinary catheter was inserted per the physician because her coccyx wound was not healing. Review of R13's current Care Plan, active 2/12/2025, revealed her coccyx wound was documented as healed. Further review revealed no urinary catheter care plan. In an interview on 2/12/2025 at 2:03 PM, Wound Registered Nurse (RN) H reported R13's care plan should have been updated to reflect her coccyx wound as active when it reopened on 7/26/2024. Wound RN H reported required care plan updates were discussed at the daily team meetings and the Minimum Data Set (MDS) Coordinator was responsible to update these. In an interview on 2/12/2025 at 2:18 PM, MDS Coordinator I acknowledged R13's current active care plan stated her coccyx wound was healed. In an interview on 2/13/2025 at 9:30 AM, Wound RN H reported R13's urinary catheter was placed on 1/10/2025 to facilitate healing of her coccyx pressure ulcer. Wound RN H reported R13 did not have a urinary catheter care plan in place. In an interview on 2/13/2025 at 10:50 AM, the Director of Nursing (DON) reported care plans were expected to be updated to reflect current treatment. Review of facility policy/procedure Comprehensive Care Plans, revised 3/6/2024, revealed .It is the facility policy to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . The comprehensive care plan will describe, at a minimum, the following . The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to follow standards of practice for medication storage and labeling. Finding: During an observation on 02/11/25 at 10:02 AM, the treatment cart sat unlocked and unattended and contained prescription medications including insulin pens. A partially used humalog insulin pen that was prescribed to the resident in room [ROOM NUMBER]-2 was not dated to indicate when it had been opened. During an observation on 02/11/25 at 10:16 AM, the green hall medication cart's narcotic box was unlocked and a drinking straw had been intentionally placed through the back hinge of the narcotic box so that it would not latch and lock. During an interview at the same time, Registered Nurse (RN) J indicated that this was not an acceptable practice and that this should not have been done. During an observation on 02/11/25 at 10:39 AM a small plastic medication cup that contained chocolate pudding and a spoon, sat unattended and uncovered on the green hall medication cart. It was unclear if the pudding contained any prescribed medications. During an interview on 02/12/25 at 08:28 AM, RN K stated that medication carts are to be locked at all times and the controlled substance separate lock box was always locked. Review of the facility policy Medication Storage reflected the following: (A1) All drugs and biological's will be stored in locked compartments . and (C1a) Scheduled 2 controlled medications are stored under double-lock and key.

Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 1 of 18 residents (Resident #4), reviewed for the provision of nursing services, resulting in medications being administered outside of the physician ordered parameters. Findings: Resident #4 (R4) Review of an Admission Record revealed R4 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension, atrial fibrillation (abnormal beating of the heart), and heart disease. Review of R4's Physician Order dated 4/6/23 revealed, amLODIPine Besylate Oral Tablet 2.5 MG (Amlodipine Besylate) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION. Hold of SBP (systolic blood pressure/top number) is < (less than)100 or HR (heart rate) < (less than) 60. Review of R4's September Medication Administration Record revealed R4's amlodipine was administered outside parameters (heart rate less than 60) on the following dates: 9/2/23 (HR 50), 9/3/23 (HR 46), 9/5/23 (HR 56), 9/6/23 (HR 47), 9/7/23 (HR 51), 9/14/23 (HR 47), 9/15/23 (HR 51), 9/16/23 (HR 51), 9/18/23 (HR 56), 9/19/23 (HR 52), 9/20/23 (HR 55), 9/21/23 (HR 51), 9/23/23 (HR 58), 9/24/23 (HR 56), 9/25/23 (HR 56), 9/27/23 (HR 58), 9/28/23 (HR 52), and 9/29/23 (HR 50). Total of 18 out of 30 administrations. Review of R4's October Medication Administration Record revealed R4's amlodipine was administered outside parameters (heart rate less than 60) on the following dates: 10/2/23 (HR 56), 10/3/23 (HR 51), 10/4/23 (HR 58), 10/5/23 (HR 52), 10/6/23 (HR 54), 10/7/23 (HR 56), 10/8/23 (HR 56), 10/9/23 (HR 53), 10/10/23 (HR 53), 10/13/23 (HR 53), 10/17/23 (HR 58), and 10/23/23 (HR 47). Total of 12 out of 31 administrations. Review of R4's November Medication Administration Record revealed R4's amlodipine was administered outside parameters (heart rate less than 60) on 11/2/23 (HR 56). (Amlodipine was discontinued on 11/9/23). Review of R4's Physician Order dated 11/30/23 revealed, Lisinopril Oral Tablet 2.5 MG (Lisinopril) Give 1 tablet by mouth every 24 hours as needed for Hypertension Administer QD: if SBP (systolic blood pressure/top number) is greater than 160 AND DBP (diastolic blood pressure/bottom number) is greater than 80. (As needed lisinopril was discontinued on 12/22/23). Review of R4's December Medication Administration Record revealed R4's as needed lisinopril was administered outside of parameters on 12/5/23 (177/70). During an interview on 01/24/24 12:32 PM, Director of Nursing (DON) reported that she had been auditing Medication Administration Records 5 times a week for compliance with physician ordered parameters for blood pressures but noncompliance with physician ordered heart rate parameters had not been identified as a concern. Review of the facility policy, Medication Administration last reviewed/revised 11/15/22 revealed, .(4) Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Use vital sign measurements to determine indications for medication administration. For example, give certain cardiac drugs only within a range of pulse or BP (blood pressure) values .Know the acceptable vital sign ranges for your patients before administering medications . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 467-468). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the facility failed to provide complete and comprehensive assessments and notify the provider and guardian of a resident's reported seizure activity 1 of 18 residents (Resident #7) reviewed for quality of care. Findings: Resident #7 (R7) Review of an Admission Record revealed R7 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: seizure disorder. Review of a Minimum Data Set (MDS) assessment for R7, with a reference date of 1/5/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R7 was cognitively intact. Review of R7's Order Summary revealed R7 had current orders for Lacosamide 100 mg twice a day, Zonisamide 200 mg twice a day, and Oxcarbazepine 300 mg twice a day for her seizure disorder. Review of R7's Care Plans revealed, Dx. (diagnosis) of Seizure disorder with treatment at an acute Hospital for repeated seizures .Date Initiated: 09/10/2014. I report to staff when I have a seizure, but commonly I do not report them until my seizure has ended .Date Initiated: 09/10/2014. Started on Vimpat (lacosamide): December 2015 due to increased seizure activity. Revision on: 03/09/2017. (Confirming R7 had a history of seizures requiring hospitalization and had required an increased dose of antiepileptic medications to control seizure activity.) Review of R7's Nursing Note dated 10/22/2023 9:54 PM revealed, Resident at 19:15 (7:15 PM) reported to this writer and she stated, I had a small seizure while in my room. She denies knowing what triggered it. She was sitting in her recliner chair when seizure happened. No c/o (complaints of) mouth pain, she denies any pain or discomfort, or any dizziness or headaches. She was ambulating well with rolling walker and speech was normal, She was given her anti-seizure meds and other meds with no problem. Her V/s (vital signs) 97.8 (temperature)-68 (heart rate)-19 (respirations)-132/68 (blood pressure), 98% sats (oxygen level) on RA (room air) but Blood sugar was 507 and was given coverage. Will continue to monitor throughout the night. Review of R7's Progress Notes revealed no documentation that R7's guardian/DPOA (designated power of attorney) was notified of R7's reported seizure and no documentation of continued neurological or physical assessments following R7's reported seizure. The Nurses Note revealed the nurse would continue to monitor however, there was no additional assessments, interventions, and/or evaluations documented in the Electronic Health Record (EHR). Review of R7's EHR revealed no Seizure Tracking Order had been completed following the facility policy and procedure regarding seizures (see below). Review of R7's EHR revealed no documentation that the provider had been notified of R7's reported seizure on 10/22/23. R7's EHR did not contain a provider assessment regarding R7's reported seizure, orders for follow up testing and/or laboratory testing, or neurology consults. Review of R7's EHR revealed vital signs were assessed on 10/22/2023 at 9:32 PM with no other assessments documented until 10/23/2023 at 06:24 AM. During an interview via email on 01/24/24 at 11:54 AM, Director of Nursing (DON) stated, Nurse on duty did not follow facility protocol of starting seizure tracking, however resident reports her own seizures (refer to care plan) and would have reported further seizures. During an interview on 1/24/24 at 12:32 PM, DON reported that R7 had not had a neurology consult in the last few years and her seizure medications and seizure activity were monitored by the facility providers. DON reported that in the past, R7 had reported seizure activity for attention or extra TLC, however, the facility nurse should have followed the facility policy for seizures. (Review of R7's Care Plans revealed no documentation that R7 had a behavior of reporting seizure activity for attention). Review of the facility policy Seizure Precautions & Response last reviewed/revised 8/10/23 revealed, It is the policy of this facility to ensure a resident is protected from injury and managed in the event of a seizure or suspected seizure according to current standards of practice .(7) Documentation. Document the following in the medical record .Notification of practitioner and family and response. (8) Seizure or Suspected Seizure Monitoring. In the event of a known or suspected seizure, use the Seizure Tracking Order template in PCC for at least 1 month and/or as ordered by the practitioner .

Based on observation, interview, and record review the facility failed to ensure Care Planned safety measures were implemented for a high fall risk resident (Resident #44 [R44]), resulting in delayed staff response to two falls and the potential for all facility residents who are at-risk for falls to not have Care Plan interventions implemented. Findings: Review of the Electronic Medical Record (EMR) Face Sheet reflected R44 was admitted to the facility 5/26/21 with diagnoses that included Alzheimer's Disease and Dementia. The EMR Face Sheet reflected that History of Falling was added to the diagnosis Information with an onset date of 3/29/22. Review of the Care Plan for R44 reflected a Focus concern of I am at high risk for falls (related to) Confusion, Deconditioning, Incontinence, Unaware of safety needs initiated 5/22/21. Review of the Interventions implemented to prevent R44 from falling included: High risk falls program initiated 5/24/21, and Do not leave on toilet unattended initiated 5/27/21. A Motion sensor alarm to entrance of bathroom was initiated 4/22/22. A motion sensor acts as an alarm and is activated on entry into the bathroom. Also, on 9/8/22 a Chair alarm was initiated. Review of the Quarterly Fall Risk assessment dated [DATE] reflected R44 was at high risk for falls with multiple falls over the previous six months. Review of the facility Resident Fall Report reflected on 10/1/22 at 2:40 PM R44 was found by a staff member on the floor of the bathroom. The Resident Fall Report reflected that the only alarm initiated was a chair alarm that was in the Resident's wheelchair. The Resident Fall Report did not indicate that the motion sensor alarm at the entrance of the bathroom, documented in the Resident's Care plan as initiated 4/22/22, had sounded or was in place and functioning at the time of the Resident's fall. This motion sensor alarm would have alerted staff when R44 had first entered the bathroom and before a self-transfer from the chair was attempted. Review of the Interdisciplinary (IDT) Note dated 10/24/22 at 9:38 AM reflected that safety interventions had been reviewed and revealed to .add motion sensor alarm to bathroom entrance at (wheelchair) level despite this intervention had been documented as initiated on 4/22/22 on the Care Plan of R44. Review of the facility Resident Fall Report reflected that on 12/25/22 at 10:55 AM, R44 was found by a staff member on the floor of the bathroom. The Resident Fall Report reflected that the chair alarm had malfunctioned and did not sound when the Resident had attempted to self-transfer. The Resident Fall Report did not indicate that the motion sensor alarm was in place at the entrance of the bathroom and was functioning. On 1/20/23 at 9:51 AM the Director of Nursing (DON) reported that on 12/25/22 R44 had returned from an isolation room in another area of the facility. The DON reported that the motion sensor alarm had not been moved before R44 had transferred back to the Resident's original room and had fallen in the bathroom. During an observation and interview conducted 1/19/23 at 12:14 PM at the bathroom of R44, a motion sensor alarm was observed attached to the wall approximately two feet from the floor at the entrance to the bathroom. The device did not alarm when entering the bathroom. Licensed Practical Nurse (LPN) J switched the device to the on position and reported that she would have to check the Care Plan to see if it only needed to be operating at night. On 1/19/23 at 3:19 PM an interview was conducted with the DON and the Assistant Director of Nursing (ADON) in the office of the DON. The DON and ADON were informed that the alarm was found to be turned off earlier in the day. The ADON reported that on 1/18/23 a Certified Nurse Aide (CNA) had informed her that the current roommate had been turning off the motion sensor alarm. The ADON reported that she had been previously aware that R44 and the roommate had been turning off the alarm. The ADON was asked, since she knew this, what measures had been implemented to ensure R44 had a functioning safety device in place. The DON reported that staff were supposed to be checking the alarms regularly. On 1/20/23 at 8:38 AM it was observed that the motion sensor alarm at the entrance to the bathroom in the room of R44 did not activate when passing in front of it. Review of the EMR reflected alarm checks had been an ongoing task in place prior to this survey. Review of the alarm check documentation reflected that the alarm had been checked at 7:16 AM on 1/20/23. No documentation was found in the EMR that indicated additional measures had been implemented to ensure all fall precautions for R44 were being implemented.

Based on observation, interview, and record review, the facility failed to implement safety measures and ensure staff were educated about the high risk fall program for 1 resident (Resident #52), resulting in the potential for additional falls and injuries. Findings: Resident #52 (R52) Review of an Admission Record revealed R52 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses of Alzheimer's Disease, muscle weakness, and had a history of a recent fall with major injury. Review of the facility policy/procedure Fall Monitoring and Mitigation, last reviewed on 07/13/22, indicated that residents assessed as High Risk Falls were identified by an orange tag on the name plate outside the resident's room and by an orange framed name badge holder on the back of the wheelchair. During an observation on 01/19/23 at 7:28 AM, Certified Nurse Aide (CNA) P pushed R52 in a wheelchair, in the common area of the unit, without the use of footrests. R52 had an orange framed name badge holder attached to the back of the wheelchair. During an interview on 01/19/23 at 9:30 AM, CNA P could not correctly identify the orange framed name tag attached to R52's wheelchair as part of the fall prevention program. CNA P stated that the orange tags were probably red ones that had faded, and that the tags were used to identify the resident by name and to list allergies. During an observation on 01/19/23 at 9:39 AM, CNA V pushed a male resident in a broda chair, in the common area. An orange framed name badge holder was attached to the back of the broda chair. When questioned, CNA V stated the orange framed name holder was used to identify the weight of the broda chair. This simplified the process for staff getting correct weights of the residents.

Based on interview and record review, the facility failed to prevent a fall for 1 of 3 residents (R3), resulting in R3 falling and sustaining a minor injury. Findings include: A review of R3's Admission Record, dated 6/30/22, revealed R3 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's Admission Record revealed R3 had multiple diagnoses that included dementia, left non-dominant side [CONDITION(S)] and [CONDITION(S)] (weakness and loss of strength on one side of the body), generalized muscle weakness, transient cerebral ischemic attack (mini stroke), and unsteadiness on feet. A review of R3's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 5/24/22, revealed R3 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 10 which revealed Resident #3 was moderately cognitively intact (had some memory problems). A review of R3's Fall Care Plan, date initiated 5/10/19, revealed the following interventions to prevent falls and/or reduce the risk of serious harm or injury from a fall: - Cordless bed alarm, date initiated on 4/25/22. - Check alarm function and placement every shift, prior to each use, and as needed, date initiated 4/25/22. - Keep bed at seated height and make sure R3 can put her feet on the floor when sitting on the side of the bed, date initiated 5/10/19. A review of R3's IDT (interdisciplinary team) Note, dated 6/29/22, revealed, Post fall review day 3 with IDT: Resident has dementia with poor safety awareness. On 6/25/22 at 0408 (4:08 AM) staff heard resident calling out for [name of someone not present]. Upon entering room, staff observed resident on the floor next to her bed. Her bed alarm was not turned on. Staff education was provided to CNA (certified nursing assistant). Upon interview with resident, she stated she attempted to walk, but lost her balance. She did not want to use her w/c (wheelchair) because the seat was uncomfortable. She was provided with a new w/c cushion and stated it was better. Staff reminded to continue to keep locked w/c next to bed. A review of R3's Nurse - Order Note, dated 6/27/22, revealed, Assessment: Physician in to see and examine resident. Informed resident had a fall 6/25, was found on floor next to her bed. On 6/26 bruises were noted to RFA (right forearm) . A review of R3's Nursing Note, dated 6/25/22, revealed, At 0520 (5:20 AM) new bruise post fall noted on left hand third digit 1.2 x (by) 0.8 cm (centimeters) faint purple, skin intact, resident states only sore when touched, set treatment to monitor until resolved . A review of R3's Nursing Note, dated 6/25/22, revealed, 0408 resident noted to be laying on the floor next to the bed. Very confused and looking for [name of someone not present]. Able to stand with easy and staff assist. No c/o pain or discomfort. No injuries noted. A review of R3's Resident Fall Report, dated 6/25/22, revealed on 6/25/22 at 4:08 AM, R3 was found on the floor in her room. No injuries were noted at the time of the fall. However, later a bruise was noted on the left hand. R3 was noted to have gripper socks on both feet, and she had one shoe on one off (sic). The report revealed R3 had been trying to get out of bed and her bed alarm was not turned on at the time of the fall. Her bed was also noted to be in a high position (level of the bed was raised up versus being in a low position where the level of the bed is closer to the ground). The report also noted R3 had been very confused tonight. A review of certified nursing assistant (CNA) C's written and signed statement, dated 6/25/22, revealed CNA C heard someone calling out. She walked down the hallway and started checking resident rooms because she could not tell where the person who was calling out was. CNA C stated she found R3 on the floor and R3 told her she was heading to her car before she fell . A review of CNA D's Staff Training Request form, dated 6/25/22, revealed R3's bed alarm had not been switched on. Alarms must be checked at beginning of shift to ensure functioning & turned on & throughout shift. During an interview on 6/30/22 at 12:05 PM, the Director of Nursing (DON) stated Registered Nurse (RN) E helped to investigate R3's fall on 6/25/22. She stated during RN E's interviews with staff, RN E found that CNA D had been the staff member that had not turned on R3's bed alarm or who had not checked to ensure R3's bed alarm was on at the beginning of her shift and/or throughout her shift. The DON stated RN E educated CNA D about ensuring that alarms are on and functioning at the beginning of her shift and throughout the shift. The DON stated she did not have any statements from RN E or CNA D, except for RN E's progress note (IDT Note, dated 6/29/22) stating that R3's bed alarm had not been turned on and the CNA was educated.

Based on observation, interview, and record review, the facility failed to monitor and maintain safe hot water temperatures at residents sinks (400 (Red) hall including R58, R42 and R38), resulting in an immediate jeopardy when temperatures in the residents rooms were found to be above 120 degrees with the potential for scalding of residents' skin. Immediate Jeopardy was identified: [DATE] at 2:40 PM. It began on [DATE]. The Administrator was verbally notified of the Immediate Jeopardy: [DATE] at 4:00 PM The Facility provided a written plan of removal via email: [DATE] at 8:17 AM Findings include: On [DATE] at 2:40 PM, the common hand sink, located in room 18, was observed to be at 122.2 degrees F, determined by a thermapen digital probe thermometer. The hand sink in the bathroom of room 18 was observed to be 123.0 degrees F. On [DATE] at 2:42 PM, the common hand sink, located in room 23, was observed to be at 123.0 degrees F, and the bathroom hand sink of room 23 was observed to be 122.5 degrees F. On [DATE] at 3:00 PM, the bathroom hand sink of room 18 was re-checked in the presence of Maintenance Coordinator M and the temperature was determined to fluctuate, but settled at 121 degrees F. On [DATE] at 3:03 PM, during an inspection of the boiler room, Maintenance Coordinator M stated that the mixing valve was 115 degrees F this morning but is now 122 degrees F. Maintenance Coordinator M also stated that the mixing valve temperature is usually checked in the morning unless there is a concern brought up. According to the facility's, RANDOM WEEKLY TEST REPORT LOG, it noted the following high water temperatures: ,d+[DATE] Room 21 - 123.6 degrees F Room 19 - 120.5 degrees F Room 22 - 121.7 degrees F Assisted Bath North - 121 degrees F ,d+[DATE] Room 25 - 120.5 degrees F ,d+[DATE] Room 20 - 125.1 degrees F Room 19 - 128.4 degrees F Room 18 - 125.5 degrees F R58 According to the Minimum Data Set (MDS) assessment, dated ,d+[DATE]//21, R58 had multiple diagnoses including traumatic [CONDITION(S)] and dementia. R58 required staff supervision for transferring and was independent with walking in their room. Staff assessed R58 as severely cognitively impaired. During an observation and interview on [DATE] at 11:11 AM, R58 was seated in the activity room in a stationary chair with arm rests. Their walker was near. Activity Aide L stated that R58 was able to independently walk all over the facility with the walker. R42 According to the MDS assessment, dated [DATE], R42 had multiple diagnosis including non-traumatic [CONDITION(S)] and dementia. R42 was independent with transferring and walking in their room. Staff assessed R42 as severely cognitively impaired. Observations were made of R42 ambulating in their room without staff or other assistance on [DATE] at 2:26 PM and on [DATE] at 9:12 AM. R38 According to the MDS assessment, dated [DATE], R38 had multiple diagnosis including orthopedic conditions and heart [CONDITION(S)]. R38 was required staff supervision for transferring and was independent with walking in their room. R38 was cognitively intact. During an interview on [DATE] at 4:20 PM, R38 stated that the water can get too hot sometimes. During an interview on [DATE] at 3:07 PM, Maintenance Coordinator M stated that this is the first he has heard of the water temperatures being high. Maintenance Coordinator M was queried on what they do if the water temperatures are high, and he stated they adjust the water temperatures accordingly. During an interview on [DATE] at 11:00 AM, Director of Maintenance A stated that he was unaware of the high water temperatures but isn't surprised as the person who flagged the high temperatures would sometimes take care of the issue immediately. At this time, no corrective actions were documented. Director of Maintenance A continued to say, I was a little surprised the paper work was left open ended. Lastly, Director of Maintenance stated, With our boiler system, it's not unheard of to have something creep up. Facility Policy titled Safe Water Temperatures dated [DATE] read in part, A.Safe Temperatures. Water temperatures shall not exceed 120°F. and B. Document temperatures and any immediate corrective actions taken to remedy temps found to be over 120°. C. Report any issues or problems related to water temperatures to include: (1) Complaints of water too cold or hot. (2) [CONDITION(S)] or redness from water use. (3) Any temperature readings over 120°. Facility Policy titled Water System Monitoring Control Points, Measures, Limits, dated [DATE], read in part, Control Measures and limits have been established for each control point in [Facility Name]'s water system. Regular monitoring of each control point is important to ensure the control measures are performing as designed. These monitoring measures are conducted routinely and documented on maintenance checklists. Corrective action needs to be taken when the water system performs outside the control limits. All actions are to be documented and Water Management Team notified as appropriate and indicated that sinks and showers are to be regulated between 105 degrees F and 120 degrees F. Facility Removal Plan Issue Cited: Facility failed to identify and correct hot water temperatures on the Red Hall where at least two cognitively impaired residents reside. Hot water temperatures exceeding 120°F were identified. 1. Identification of Residents Affected or Likely to be Affected: While all residents have the potential to be affected, the affected area was identified to be isolated to the Red Hall. Beginning ,d+[DATE] - Completed additional rounding/water checks of reported affected areas to ensure within appropriate range. No deficits noted. Beginning ,d+[DATE] - NHA (Nursing Home Administrator) conducted a review of all incident reports confirming that there have been no incidents of resident [CONDITION(S)]. Beginning ,d+[DATE] - NHA conducted a review of Resident Council minutes confirming that there have been no complaints his meeting about water temperatures. Beginning ,d+[DATE] - NHA confirmed with DON that there have been no resident complaints/grievances filed regarding water temperatures. 2. Actions to Prevent Occurrence/Recurrence: Upon receiving notice of elevated tap water temperature, the facility took the following actions: Beginning ,d+[DATE] - Maintenance staff made adjustment to boilers to lower temperature. Beginning ,d+[DATE] - Reviewed Water Management Program Weekly Monitor and confirmed no temps recorded outside of acceptable range including but not limited to the following: Hot Water Heaters, Hot Water Storage Tanks, Sinks/Showers. Beginning ,d+[DATE] - A review of Maintenance documentation revealed recorded temperatures above 120°F. While Maintenance worker reports that upon discovery of elevated temps he flushes line and retakes the water temp, he acknowledged that he did not document any corrective action, record the compliant temp, or notify the Director. We identified ways to improve the tool used for documentation and updated this form with explanation of changes noted below. Beginning ,d+[DATE] - A root cause analysis (RCA) of completed logs confirmed that there was an isolated area related to rooms on the same hot water circuit as the kitchen where higher temps are required and may not consistently cool enough prior to reaching resident rooms. We determine this is likely related to a reduced use of water. Director of Maintenance ordered compression inlet type mixing valves to install on sinks in the identified area of the facility. Beginning ,d+[DATE] - Revised Maintenance Random Weekly Test Report Log which includes checking of water temps to include the following: o Clear instructions that read as follows: Complete random weekly checks listing the room number and documenting temperatures of tap water, placement of over-bed lights and strings, and call cords. Temperatures shall be no more than 120°F. Discrepant findings will be remedied immediately. Completed forms will be submitted to the Director of Maintenance & Environmental Services (DOMES) or designee for review before filing. Documentation will be maintained for 3 years and kept in the DOMES office. o A place for the checker to document corrective actions taken to remedy discrepant findings. o Added signature lines for the Director of Maintenance or designee and Administrator to review and approve log prior to filing. Beginning ,d+[DATE] - Maintenance staff completed a water temp audit of all resident rooms finding no temps above 120°F. Beginning ,d+[DATE] - Maintenance to increase monitoring of Red Hall to twice daily until such time that QAPI committee determines the issue to be resolved and safe to return to weekly checks. Beginning ,d+[DATE] - The Corporate Compliance Director will provide mandatory face-to-face education with competency testing to the Maintenance Staff regarding safe temperature requirements and updated log. 3. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: [DATE]. During an interview on [DATE] at 8:10 AM, the NHA stated that mixing valves have been ordered for all rooms on Red hall. The NHA revealed that maintenance staff were aware that high water temperatures occurred prior to this survey and adjustments were made but that there was no documentation of such adjustments. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that has the potential to affect a large portion of the facility's residents due to the inability to verify staff education, all policy updates, system changes, and sustained compliance.

Based on interview and record review, the facility failed to identify abnormal blood pressure findings and notify the physician of blood pressure findings outside of facility standard of care parameters for one resident (R16), resulting in the potential for detrimental effects of untreated, abnormal blood pressures for this Resident and all facility residents whose blood pressure is monitored. Findings: R16 was admitted to the facility 6/1/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Electronic Medical Record (EMR) reflected R16 was prescribed [MEDICATION(S)] and [MEDICATION(S)]. Both medications are prescribed to treat high blood pressure. Review of the Doctor's Order dated 8/10/21 reflected, Monitor (blood pressure) daily (related to) interaction between [MEDICATION(S)] and [MEDICATION(S)]. Review of the Medication Administration Records (MAR) for September and October 2021 reflected R16 received [MEDICATION(S)] 10 milligrams (mg) once daily, [MEDICATION(S)] 5mg once daily, and [MEDICATION(S)] 250 mg twice a day every day in September and October 2021. Review of the EMR Blood Pressure history since the 8/10/21 Doctor's Order reflected Daily documentation of the blood pressure for R16. The documentation reflected elevated systolic readings of: 182 millimeters of mercury (mmHg) on 10/27/21, 183 mmHg on 10/9/21, 174 mmHg on 9/25/21, 177 mmHg on 9/19/21, and 186 mmHg on 8/25/21. The EMR blood pressure documentation also revealed that, since the Doctor's Order of 8/10/21, eight systolic readings of greater than 160 mmHg and fifteen systolic readings of greater that 150 mmHg. The EMR blood pressure history record did not reflect recheck blood pressures were obtained following the elevated systolic findings. Review of the EMR Progress Notes for R16 did not reveal documented justification of why recheck blood pressures were not conducted, that the physician was notified of the findings, nor that clarification was sought regarding consistent elevated systolic findings. On 10/29/21 at 9:36 AM, an interview was conducted with the Director of Nursing (DON) following a request for documentation of facility Standing Orders and Notifying Parameters. The DON reported the facility uses the EMR Standard of Care and provided a document titled Weights and Vitals Threshold Configuration. Review of the document provided by the facility reflected a blood pressure systolic, High threshold value greater than 139 (mmHg). The DON was informed of R16's elevated systolic blood pressure findings above. The DON indicated the expectation was that the nurses would recheck the blood pressure following a result outside of the defined parameters. The DON did not indicate an expectation that the physician would be notified of abnormal findings. Further review of the Weights and Vitals Threshold Configuration document reflected Diastolic, Low threshold value less than 60 (mmHg). Review of the blood pressure history for R16 since the Doctor's Order of 8/10/21 reflected twenty-nine diastolic readings less than 60 mmHg with one finding of 47 mmHg on 10/19/21. As previously noted, the EMR did not reflect recheck blood pressures were obtained nor that the physician had been contacted regarding the Low threshold value less than 60 (mmHg). During a telephone interview conducted on 10/29/21 at 10:43 AM, Physician C indicated a potential interaction between [MEDICATION(S)] and [MEDICATION(S)] on renal function. Physician C reported if an elevated blood pressure was obtained that he would expect to see a recheck shortly after. Physician C indicated he should be notified of an abnormal blood pressure. Physician C reported he could not remember being notified of an abnormal blood pressure with R16. At the time of Survey Exit no further information was provided by the facility.

Based on interview and record review, the facility failed to provide a physician ordered respiratory nebulizer treatment, for one Resident (#1) of three residents reviewed for respiratory care. This deficient practice resulted in respiratory distress, with subsequent hospitalization . Findings include: According to the Nursing Admission Assessment, dated 3/26/21, Resident #1 was admitted to the facility on [DATE], with normal speech, cognition and was pleasant and cooperative. The document also revealed Resident #1 became short of breath (SOB) with exertion and had diminished lung sounds with a regular heart rhythm. The Discharge Summary from the transferring hospital, printed 3/26/21, revealed Resident #1 was hospitalized on [DATE] and discharged to the facility on [DATE], with .Non-Hospital Problems . including [CONDITION(S)] (Chronic obstructive pulmonary disease), high blood pressure, pacemaker, chronic pain and tobacco dependence. Resident #1 was hospitalized for a hypertensive emergency (extreme high blood pressure) due to occluded kidney arteries, and underwent a procedure to put bilateral kidney stents into her renal (kidney) arteries to relieve the pressure. Upon discharge, the Resident was to take her home inhalers as directed and her home nebulizer medication, every six hours, as needed, for wheezing (difficulty breathing). Medications administered at the hospital during the last 24 hours of the Resident's stay included nebulizer treatments the morning of discharge and twice the day prior, (3/25/21). The hospital course was unremarkable, with no noted complications of [CONDITION(S)] or cardiac issues. During a phone interview on 7/9/21 at 8:30 a.m., Family Member (FM) I said Resident #1 used her nebulizer breathing treatments at home twice daily. Resident #1's medication orders for the facility, upon discharge from the hospital, included two home medication inhalers and the home use nebulizer treatment every six hours as needed for wheezing. The medication orders were signed off by Registered Nurse (RN) E on 3/26/21. The nebulizer treatment was not entered into the electronic medical record (EMR) or MAR (medication administration record). The State Agency (SA) received a complaint alleging Resident #1's nebulizer treatments were not given as ordered and the Resident suffered respiratory distress, resulting in hospitalization and heart attack. Resident #1 was discharged from the facility on 3/28/21, after being transferred to the hospital with respiratory distress. During a phone interview on 7/7/21 at 8:21 a.m., Resident #1 confirmed she was transferred to the hospital on 3/28/21 with respiratory distress. The Resident said she began having SOB over the night/early morning of 3/28/21 and could not breathe. She asked her nurse for her a nebulizer treatment and was told the facility did not do breathing treatments. Resident #1 said her breathing worsened and the nurse gave her an inhaler, which did not help. The Resident continued to say she was banging on the wall to get help, but no one would provide it, despite her insistence that her nebulizer treatments would work and resolve the problem. Resident #1 was upset in telling her story and stated, I have never been so frightened in my whole life .I thought I was going to die. During an interview on 7/7/21 at 11:37 a.m., the Director of Nursing (DON) said the [Centers for Disease Control and Prevention/ CDC] guidance for COVID said nebulizer's couldn't be used, unless the patient was in a private room and all precautions were taken. The DON confirmed Resident #1 was in a private room in quarantine for COVID, and in droplet precautions. The DON said the order for Resident #1's nebulizers were on the hospital discharge orders, but were set aside for clarification as the guidance said not to use them, and they were never followed up on. The DON said human error prevented them from being transcribed into the medical record. The policy Infection Prevention & Control Novel Coronavirus Prevention & Response, dated 2/22/21, revealed, .Suspected or Confirmed Resident COVID-19 .Implement Isolation Precautions. Confine resident in a private room .Implement standard, contact, and droplet precautions .Avoid aerosol-generating procedures .as possible. If required, take the following precautions .private room .Wear appropriate PPE (personal protective equipment) .Limit the number of healthcare personnel .Clean and disinfect room surfaces promptly after procedure . The facility conducted an investigation of the incident following a report made to a nurse, by FM I about the incident. The facility investigation revealed, .CONCLUSION After thorough investigation and interviews with nursing staff on duty at the time of the incident I am unable to substantiate that staff responded inappropriately to [Resident #1's] acute respiratory episode as alleged During a phone interview on 7/7/21 at 12:34 p.m., RN E confirmed she was the admitting nurse on 3/26/21, and admitted Resident #1, which included signing off the orders. RN E said she did not fill the nebulizer orders due to the pandemic guidance, but that if needed, she could. RN E said she put the nebulizer treatment orders aside, and later talked with the doctor who held them. When asked why the contact with the doctor, including order clarification, was not documented, RN E stated, I don't know. The Incident Observation Report, dated 3/28/21, noted an interview with FM I who said the Resident told her staff did not listen to her when she told them she was in distress and couldn't breathe. According to the interview, FM I said the Resident was banging on the wall because she couldn't breathe and staff told her to stop. A nursing progress note for Resident #1, dated 3/27/21, revealed, Resident is alert and oriented, able to make wants and needs known . The Incident Observation Report, dated 3/28/21, authored by Certified Nurse Aide (CNA) H noted Resident #1 had breathing issues at 4:30 a.m. on 3/28/21, and the Resident's oxygen was not in place and she replaced it. At 5:30 a.m., the Resident called again with breathing issues and was given an as needed inhaler. At 5:40 a.m., the Resident was banging on the wall, due to breathing difficulties. The report noted, the Resident was .screaming 'I can't breathe' .phone was up to her ear saying she needed the ambulance now and that a neb[ulizer] treatment would fix it all . A statement signed by CNA H, dated 3/29/21, revealed, .[Resident #1] stated I just want my nebulizer she was banging on the walls .I need to call the ambulance .I'm having a hard time breathing .I asked her if she was having chest pains .She stated no . During a phone interview on 7/7/21 at 2:49 p.m., CNA H confirmed the information in the interview, dated 3/28/21, and the statement, dated 3/29/21. A typed statement, dated 3/29/21, authored by RN J revealed, .[FM I] stated she was upset .[Resident #1] had to bang on the walls for help and the staff told her stop banging on the walls, we cannot get you a breathing treatment .I informed [FM I] about the infection control practices and that it is recommended to use an alternative such as an inhaler, but if medically necessary, the facility would implement protocols to prevent infection . The facility investigation included a statement, dated 3/29/21, signed by Licensed Practical Nurse (LPN) G that noted .called to room for SOB wanted nebulizer treatment we did not have order, took .inhaler to use .started to panic because of no order for nebulizer anxiety set in. Gave inhaler .when ineffective she got more anxious . During a phone interview on 7/7/21 at 2:00 p.m., LPN G said she couldn't remember the incident with Resident #1. She then said Resident #1 did have some SOB on 3/28/21, but she couldn't remember details of the incident. LPN G denied ever telling the Resident the facility didn't have nebulizer treatments. When asked if Resident #1 had orders for nebulizer treatments, LPN G said she couldn't remember. Then, when asked, LPN G said she checked the orders and there were none for nebulizers. LPN G said she couldn't remember if Resident #1 was in respiratory distress, but then said the Resident was anxious. LPN G was asked if she called the RN supervisor for an assessment of Resident #1 and confirmed she did. LPN G confirmed she gave the Resident inhaler treatment, without improvement. A nursing progress note, dated 3/28/21 at 4:52 a.m., revealed LPN G administered an as needed inhaler to Resident #1. A nursing progress note, dated 3/28/21 at 6:17 a.m. revealed the .Administration was: Ineffective .Resident remains SOB, wanting her nebulizer treatment like she had at home. A nursing progress note, dated 3/27/21, authored by RN K, revealed FM I was concerned about Resident #1 not getting breathing treatments and being distressed with labored breathing. Medications were reviewed and FM I was not aware that nebulizers were not on Resident #1's regimen. During an interview on 7/7/21 at 1:01 p.m. the DON confirmed RN K was on vacation during the current survey. During a phone interview on 7/9/21 at 8:30 a.m., FM I confirmed the phone call on 3/27/21 and said she told RN K Resident #1 really needed her nebulizer treatments and RN K said the doctor would be called about them. FM I said she trusted the facility staff would take care of Resident #1 and follow through. A progress note, dated 3/27/21, revealed Resident #1 requested a breathing nebulizer treatment, but none was available. On 7/7/21 at 1:50 p.m., RN F reviewed the back up medications available in the medication room with this Surveyor, and confirmed the back up medications available included nebulizer treatments. The Facility Assessment, dated 4/2020, revealed, .Equipment .Common medical equipment onsite and available for staff and resident use .nebulizer machines .Personnel .RN's and LPN's-Responsibilities include but are not limited to: Medical management .Medications-routine and [as needed] medication administration . A progress note on 3/28/21 at 6:15 a.m., revealed Resident #1 had respiratory distress, .with diminished lung sounds and minimal air exchange auscultated . The Resident's oxygen saturation was 77%, the physician was notified with orders to send to the emergency room . Resident #1's care plan, dated 3/25/21, revealed, .Give aerosol or bronchodilators as ordered . The hospital emergency room notes, dated 3/28/21, as part of the facility investigation, revealed, .Chief complaint: shortness of breath .diagnosis .dyspnea (SOB) .acute respiratory failure with [CONDITION(S)] (lack of oxygen to brain) .acute heart failure .NONSTEMI (heart attack) .Spoke to cardiology in (regional hospital city) .they were agreeable for transfer .was given her home dose of [name brand pain reliever] for chronic pain, subsequent breathing treatments .Patient has a chance of declined rapid deterioration given the findings today .Given the high probability of imminent or life threatening deterioration of the patient's condition without intervention, the patient was immediately assessed .

Based on interview and record review, the facility did not provide care in accordance with professional standards of practice when medications for nebulizer treatments listed on the discharge summary were not addressed for one Resident #1 of three residents reviewed for respiratory care. This deficient practice resulted in respiratory distress, with subsequent hospitalization . Findings include: According to the Nursing Admission Assessment, dated 3/26/21, Resident #1 was admitted to the facility on [DATE], with normal speech, cognition and was pleasant and cooperative. The document also revealed Resident #1 became short of breath (SOB) with exertion and had diminished lung sounds with a regular heart rhythm. The Discharge Summary from the transferring hospital, printed 3/26/21, revealed Resident #1 was hospitalized on [DATE] and discharged to the facility on [DATE], with .Non-Hospital Problems . including [CONDITION(S)] ([CONDITION(S)]), high blood pressure, pacemaker, chronic pain and tobacco dependence. Resident #1 was hospitalized for a hypertensive emergency (extreme high blood pressure) due to occluded kidney arteries, and underwent a procedure to put bilateral kidney stents into her renal (kidney) arteries to relieve the pressure. Upon discharge, the Resident was to take her home inhalers as directed and her home nebulizer medication, every six hours, as needed, for wheezing (difficulty breathing). Medications administered at the hospital during the last 24 hours of the Resident's stay included nebulizer treatments the morning of discharge and twice the day prior, (3/25/21). The hospital course was unremarkable, with no noted complications of [CONDITION(S)] or cardiac issues. During a phone interview on 7/9/21 at 8:30 a.m., Family Member (FM) I said Resident #1 used her nebulizer breathing treatments at home twice daily. Resident #1's MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication orders were signed off by Registered Nurse (RN) E on 3/26/21. The nebulizer treatment was not entered into the electronic medical record (EMR) or MAR (medication administration record). The State Agency (SA) received a complaint alleging Resident #1's nebulizer treatments were not given as ordered and the Resident suffered respiratory distress, resulting in hospitalization and heart attack. Resident #1 was discharged from the facility on 3/28/21, after being transferred to the hospital with respiratory distress. During a phone interview on 7/7/21 at 8:21 a.m., Resident #1 confirmed she was transferred to the hospital on 3/28/21 with respiratory distress. The Resident said she began having SOB over the night/early morning of 3/28/21 and could not breathe. She asked her nurse for her a nebulizer treatment and was told the facility did not do breathing treatments. Resident #1 said her breathing worsened and the nurse gave her an inhaler, which did not help. The Resident continued to say she was banging on the wall to get help, but no one would provide it, despite her insistence that her nebulizer treatments would work and resolve the problem. Resident #1 was upset in telling her story and stated, I have never been so frightened in my whole life .I thought I was going to die. During an interview on 7/7/21 at 11:37 a.m., the Director of Nursing (DON) said the [Centers for Disease Control and Prevention/ CDC] guidance for COVID said nebulizer's couldn't be used, unless the patient was in a private room and all precautions were taken. The DON confirmed Resident #1 was in a private room in quarantine for COVID, and in droplet precautions. The DON said the order for Resident #1's nebulizers were on the hospital discharge orders, but were set aside for clarification as the guidance said not to use them, and they were never followed up on. The DON said human error prevented them from being transcribed into the medical record. The policy Infection Prevention & Control Novel Coronavirus Prevention & Response, dated 2/22/21, revealed, .Suspected or Confirmed Resident COVID-19 .Implement Isolation Precautions. Confine resident in a private room .Implement standard, contact, and droplet precautions .Avoid aerosol-generating procedures .as possible. If required, take the following precautions .private room .Wear appropriate PPE (personal protective equipment) .Limit the number of healthcare personnel .Clean and disinfect room surfaces promptly after procedure . The facility conducted an investigation of the incident following a report made to a nurse, by FM I about the incident. The facility investigation revealed, .CONCLUSION After thorough investigation and interviews with nursing staff on duty at the time of the incident I am unable to substantiate that staff responded inappropriately to [Resident #1's] acute respiratory episode as alleged During a phone interview on 7/7/21 at 12:34 p.m., RN E confirmed she was the admitting nurse on 3/26/21, and admitted Resident #1, which included signing off the orders. RN E said she did not fill the nebulizer orders due to the pandemic guidance, but that if needed, she could. RN E said she put the nebulizer treatment orders aside, and later talked with the doctor who held them. When asked why the contact with the doctor, including order clarification, was not documented, RN E stated, I don't know. The Incident Observation Report, dated 3/28/21, noted an interview with FM I who said the Resident told her staff did not listen to her when she told them she was in distress and couldn't breathe. According to the interview, FM I said the Resident was banging on the wall because she couldn't breathe and staff told her to stop. A nursing progress note for Resident #1, dated 3/27/21, revealed, Resident is alert and oriented, able to make wants and needs known . The Incident Observation Report, dated 3/28/21, authored by Certified Nurse Aide (CNA) H noted Resident #1 had breathing issues at 4:30 a.m. on 3/28/21, and the Resident's oxygen was not in place and she replaced it. At 5:30 a.m., the Resident called again with breathing issues and was given an as needed inhaler. At 5:40 a.m., the Resident was banging on the wall, due to breathing difficulties. The report noted, the Resident was .screaming 'I can't breathe' .phone was up to her ear saying she needed the ambulance now and that a neb[ulizer] treatment would fix it all . A statement signed by CNA H, dated 3/29/21, revealed, .[Resident #1] stated I just want my nebulizer she was banging on the walls .I need to call the ambulance .I'm having a hard time breathing .I asked her if she was having chest pains .She stated no . During a phone interview on 7/7/21 at 2:49 p.m., CNA H confirmed the information in the interview, dated 3/28/21, and the statement, dated 3/29/21. A typed statement, dated 3/29/21, authored by RN J revealed, .[FM I] stated she was upset .[Resident #1] had to bang on the walls for help and the staff told her stop banging on the walls, we cannot get you a breathing treatment .I informed [FM I] about the infection control practices and that it is recommended to use an alternative such as an inhaler, but if medically necessary, the facility would implement protocols to prevent infection . The facility investigation included a statement, dated 3/29/21, signed by Licensed Practical Nurse (LPN) G that noted .called to room for SOB wanted nebulizer treatment we did not have order, took .inhaler to use .started to panic because of no order for nebulizer anxiety set in. Gave inhaler .when ineffective she got more anxious . During a phone interview on 7/7/21 at 2:00 p.m., LPN G said she couldn't remember the incident with Resident #1. She then said Resident #1 did have some SOB on 3/28/21, but she couldn't remember details of the incident. LPN G denied ever telling the Resident the facility didn't have nebulizer treatments. When asked if Resident #1 had orders for nebulizer treatments, LPN G said she couldn't remember. Then, when asked, LPN G said she checked the orders and there were none for nebulizers. LPN G said she couldn't remember if Resident #1 was in respiratory distress, but then said the Resident was anxious. LPN G was asked if she called the RN supervisor for an assessment of Resident #1 and confirmed she did. LPN G confirmed she gave the Resident inhaler treatment, without improvement. A nursing progress note, dated 3/28/21 at 4:52 a.m., revealed LPN G administered an as needed inhaler to Resident #1. A nursing progress note, dated 3/28/21 at 6:17 a.m. revealed the .Administration was: Ineffective .Resident remains SOB, wanting her nebulizer treatment like she had at home. A nursing progress note, dated 3/27/21, authored by RN K, revealed FM I was concerned about Resident #1 not getting breathing treatments and being distressed with labored breathing. Medications were reviewed and FM I was not aware that nebulizers were not on Resident #1's regimen. During an interview on 7/7/21 at 1:01 p.m. the DON confirmed RN K was on vacation during the current survey. During a phone interview on 7/9/21 at 8:30 a.m., FM I confirmed the phone call on 3/27/21 and said she told RN K Resident #1 really needed her nebulizer treatments and RN K said the doctor would be called about them. FM I said she trusted the facility staff would take care of Resident #1 and follow through. A progress note, dated 3/27/21, revealed Resident #1 requested a breathing nebulizer treatment, but none was available. On 7/7/21 at 1:50 p.m., RN F reviewed the back up medications available in the medication room with this Surveyor, and confirmed the back up medications available included nebulizer treatments. The Facility Assessment, dated 4/2020, revealed, .Equipment .Common medical equipment onsite and available for staff and resident use .nebulizer machines .Personnel .RN's and LPN's-Responsibilities include but are not limited to: Medical management .Medications-routine and [as needed] medication administration . A progress note on 3/28/21 at 6:15 a.m., revealed Resident #1 had respiratory distress, .with diminished lung sounds and minimal air exchange auscultated . The Resident's oxygen saturation was 77%, the physician was notified with orders to send to the emergency room . Resident #1's care plan, dated 3/25/21, revealed, .Give aerosol or bronchodilators as ordered . The hospital emergency room notes, dated 3/28/21, as part of the facility investigation, revealed, .Chief complaint: shortness of breath .diagnosis .dyspnea (SOB) .acute respiratory failure with [CONDITION(S)] (lack of oxygen to brain) .acute heart failure .NONSTEMI (heart attack) .Spoke to cardiology in (regional hospital city) .they were agreeable for transfer .was given her home dose of [name brand pain reliever] for chronic pain, subsequent breathing treatments .Patient has a chance of declined rapid deterioration given the findings today .Given the high probability of imminent or life threatening deterioration of the patient's condition without intervention, the patient was immediately assessed .

This citation refers to MI 043. Based on interview and record review, the facility failed to prevent a fall for 1 of 4 residents (Resident #6) reviewed for falls, resulting Resident #6 sustaining a fall with major injury. Findings include: A review of Resident #6's Admission Record, dated 2/26/21, revealed Resident #6 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 6's Admission Record revealed Resident #6 had multiple [DIAGNOSES REDACTED]. A review of Resident #6's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 11/27/20, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 3 which revealed Resident #6 was severely cognitively impaired. In addition, Resident #6's MDS revealed Resident #6 needed extensive assistance (resident involved in activity, staff provides weight-bearing support) of two staff members for transfers and toileting. A review of Resident #6's progress notes, dated 12/15/20 to present, revealed the following: - IDT (Interdisciplinary Team) Note, dated 2/24/21, revealed, Post fall review day 3 investigation with IDT: (name of Resident #6) has dementia with poor safety awareness. She does not use the call light to alert staff of her needs. On 2/20/21 @ 1055 (10:55 AM), with no one at her side, she fell off the commode as she attempted to self transfer into w/c (wheelchair). She did not use the call light. She had facial grimacing with c/o (complained of) pain to left groin/left medial (inside of leg- area facing right leg) leg area. She was sent to the ER (emergency room ), per physician order, for x-rays which revealed pelvic fractures. Nurse educated CNA (certified nursing assistant) to do not leave residents with alarms alone on the toilet. Care plan updated with - do not leave alone on toilet. - Nursing Note, dated 2/20/21, revealed, At 1055 (Resident #6's roommate) went in west hall and stated to med (medication) nurse her roommate was lying on the floor, med nurse immediately responded to note resident lying on the BR (bathroom) floor on her left side, head near wall between BR and room in front of sink and feet at base of commode, call light off, gripper socks on, brief and pants down around knees, shower chair in corner in front of commode tipped on side leaning on w/c that was just inside BR door with brakes locked, resident assessed and stated she hit her head with posterior (back of) left head noted with 3.0 cm (centimeter) round, red flat area, skin intact, resident c/o pain with facial grimacing to left groin/medial leg area, area palpated (felt) with no deformities noted, no leg shortening noted, was 3 assisted up to BR bar with no increase in pain, transferred in w/c to bed and 3 assisted into bed where she was further assessed, no skin issues noted, leg lengths rechecked with no shortening again verified, resident continues through assessment to c/o of pain in left groin/leg . (name of physician) notified at 1115 (11:15 AM) with orders to send to ER for Eval (evaluation) and Treat (treatment) . - IDT Note Late Entry, dated 1/14/21 for 1/13/21, revealed, Post fall investigation day 3 with IDT via email: (name of Resident #6) has dementia with poor safety awareness. She does not consistently use her call light nor consistently alert staff of needs/wants. Staff to anticipate needs. On 1/10/21 at 2325 (11:25 PM) resident fell during self-transfer at nurses' station from her w/c to recliner chair. Gripper socks with poor traction immediate intervention new pair of gripper socks provided. Additional interventions when she is at the nurses ' station offer to assist her into the recliner chair. - Nursing Note, dated 1/11/21, revealed, 2325 alarm heard and CENA (certified nursing assistant) noted resident sitting on floor tightly between WC (wheelchair) and recliner chair. Resident stated she wanted to sit in recliner chair. Denied pain and no injuries noted. Two (staff members) assisted off floor into recliner. - IDT Note, dated 12/22/20 revealed, Post fall investigation day 3 with IDT via email: (name of Resident #6) has dementia with poor safety awareness. On 12/17/20 resident fell out of w/c during a self-transfer attempt to bed. She stated she was getting into bed from the w/c. Staff noted only one of her w/c brakes was in locked position. Her call light was within reach, but not on. Care plan was followed. Immediate corrective action: w/c alarm provided; gripper pad added. - Nursing Note, dated 12/17/20, revealed, At 1700 (5:00 PM) resident observed sitting on the floor on her bottom with legs extended facing foot of bed, between bed and w/c. One brake locked and one brake unlocked on w/c. Call light off. States she was getting into bed from w/c. Denies pain, no unusual markings at this time . W/c alarm and gripper pad added to care plan. A review of Resident #6's Fall Report, dated 2/20/21, revealed Resident #6 was found on her bathroom floor with a major injury (fracture). Staff were not present at the time of the fall and her call light was not on. The report revealed Resident #6 had tried to get up by herself after the CNA left her on the commode to check charting at the nurse's station. She complained on left pelvis/groin, hip, and head pain. A review of Resident #6's emergency department notes, dated 2/20/21, revealed Resident #6 was seen in the emergency department for a fall from standing position. Is reported that she (Resident #6) winces in complains of left groin pain with any movement of the leg. Hip x-ray does show a pelvis fracture, did obtain a CT (cat scan) for further clarification. In addition, the emergency department notes revealed Resident #6 was diagnosed with [REDACTED]. A review of Resident #6's CT (of the) Pelvis, dated 2/20/21, revealed Resident #6 had two fractures of the left pelvis (left superior and inferior pubic rami). A review of Resident #6's Fall Risk Assessments, dated 12/15/20 to present, revealed the following:. - Resident #6's Fall Risk Assessment, dated 2/22/21, revealed Resident #6 scored a 19 (high risk). - Resident #6's Fall Risk Assessment, dated 2/15/21, revealed Resident #6 scored a 22 (high risk). - Resident #6's Fall Risk Assessment, dated 1/11/21, revealed Resident #6 scored a 19 (high risk). - Resident #6's Fall Risk Assessment, dated 12/18/20, revealed Resident #6 scored a 16 (high risk). - Resident #6's Fall Risk Assessment, dated 12/15/20, revealed Resident #6 scored a 16 (high risk). A review of CNA (certified nursing assistant) K's written and signed statement, dated 2/20/21, revealed, I put resident (Resident #6) on the toilet walked away for not even a minute and she was found on the floor. I didn't find her first. Someone else did. I know I shouldn't have left her alone but I did thinking she would be ok for 1 minute. (sic) A review of Registered Nurse (RN) L's, written and signed statement, dated 2/20/21, revealed, (Resident #6's roommate) came out into hall alerting this writer that a lady was on the bathroom floor. When I entered bathroom ( Resident #6) was laying on the floor. positioned on her left side, head under sink facing wall. pants and brief were down to resident's knees. commode chair was tipped over on its side facing toilet. Wheelchair positioned to side of toilet locked. Resident stated call light was not working. Call light was not on. (sic) During an interview on 2/26/21 at 10:00 AM, CNA K stated she normally takes care of Resident #6. She stated Resident #6 fell while under her care. She stated Resident #6 pushed her call light. She wanted to go to the bathroom. She's a 2-person assist with extensive assistance with a stand-up lift. CNA K stated she transferred Resident #6 with a 1-person assist. She stated she did it because she had a lot going on. It's not an excuse. CNA K stated put Resident #6 on the toilet. She stated she left Resident #6 on the toilet to finish some charting. CNA K stated she never leaves Resident #6 on the toilet herself because she is impulsive and I can't trust her. CNA K stated she went to the nurse's station after leaving Resident #6 supervised on the toilet because she had worked a 12-hour shift the day before and thought she might have missed some charting. She stated she immediately turned around without checking her charting and walked back to Resident #6's room. But by that time she (Resident #6) had already fallen. CNA K stated she left Resident #6 alone for no more than a minute.I know better than to leave (Resident #6 alone on the toilet). But this time I just walked away. CNA K stated she felt guilty about what happened and knows she was in the wrong. CNA K stated she had been educated and disciplined for leaving Resident #6 unsupervised on the toilet. A review of CNA K's typed and signed counseling statement, dated 2/23/21, revealed, On 2/20/ , (Resident #6) was transferred to the toilet by (name of CNA K). Resident was having a BM (bowel movement) and needed time. ( Name of CNA K) left the room to do another task. Within minutes, resident's roommate came out into the hallway to report that resident (Resident #6) was on the floor of the bathroom . ( Resident #6) is care planned to have a chair alarm. Any resident with alarms should not be left alone on the toilet. This is standard of care. An impulsive resident should have supervision when in the bathroom on the toilet. CNA K indicated on the counseling statement that she agreed with the report. A review of CNA K's typed and signed written warning, dated 2/23/21 and signed by CNA K on 2/25/21, revealed she received a written warning for the incident (Resident #6's fall with fracture) on 2/20/12 and referenced her counseling statement, dated 2/23/21. CNA K received the written warning for Violating established safety rules or procedure. The written warning indicated CNA K's actions are not in keeping with the (name of facility) mission and our Rules of Conduct. A review of the facility's investigation summary for Resident #6's fall on 2/20/21, dated 2/24/21, concluded After thorough investigation and interviews with nursing staff on duty, the root cause of the fall appears that (name of Resident #6) was attempting to self-transfer herself off of the toilet and care giver left (name of Resident #6) unattended in the bathroom. She does have a [DIAGNOSES REDACTED].At the time of this fall (name of Resident #6) was left unattended in the bathroom, while care planned for a chair alarm. (Name of Resident #6) was sent to (name of hospital) where she was treated for [REDACTED]. (Name of Resident #6) does have a [DIAGNOSES REDACTED]. Her care plan was updated with the intervention to not leave her alone on the toilet. A review of the facility's Fall Monitoring & Mitigation policy and procedure, revised 9/4/20, revealed, The facility assesses each resident for their risk for falls, designs a plan of care, and implements procedures to minimize falls and/or injury . As indicated by assessment, each resident will have an individualized plan of care containing interventions aimed towards fall mitigation and reduction of injury related to falls. A. Definitions . (3) Risk: Any external factor, facility characteristic (e.g. staffing or physical environment) or characteristic of an individual that influences the likelihood of an accident. Therefore, the intervention of do not leave alone on toilet. should have been added to Resident #6's care plans prior to her fall with fracture on 2/20/21 based on her past history of not consistently using her call light nor consistently alert staff of needs/wants, poor safety awareness, and self-transferring that lead to two falls prior to 2/20/21. A review of the facility's Resident Alarms policy and procedure, dated 6/18/18, revealed, D. Monitoring and Modification . (3) Ongoing Assessment. Ongoing assessment of the resident shall occur to identify changes in patterns, routines, or medical symptoms of the resident. Interventions shall be modified as needed to address any changes. Prior assessments (e.g. IDT post fall notes on 12/22/20 and 1/14/21) revealed Resident #6 had poor safety awareness and did not consistently use her call light nor consistently alert staff of needs/wants. In addition, Resident #6's four prior Fall Risk Assessments in the two months prior to Resident #6's fall on 2/20/21 revealed Resident #6 was a high fall risk. Therefore, the intervention of do not leave alone on toilet should have been added to Resident #6's care plans prior to her fall on 2/20/21.

This citation pertains to intake #'s 7 and 6. Based on interview and record review, the facility failed to provide quality care for two residents (Resident #3 & Resident #4) reviewed for injuries of unknown origin, when the facility failed to timely assess and respond to Resident #3's choking and gagging on fluids, and failed to assess the neurological status in Resident #4 after an unwitnessed fall, resulting in the potential for aspiration pneumonia in Resident #3 and undetected neurological changes in Resident #4. Findings include: Resident #3 (R3) Review of a Face Sheet revealed R3 was an [AGE] year old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. R3 had severe cognitive impairment and required assistance from staff persons for activities of daily living and required extensive assistance from staff to eat or drink. Review of Nursing Progress Note dated 04/05/20 at 6:20 A.M. revealed, R3 Noted to be coughing this am while taking a drink of coffee. Resident able to talk and coughed and cleared throat. Lungs clear. Set up monitoring for difficulty with drinking/swallowing. Review of a Nursing Progress Note dated 04/07/20 at 15:59 revealed, R3 was coughing with fluids, almost gagging at times. Review of a Dietary Progress Note dated 04/08/20 at 08:29 A.M. revealed, Nursing is reporting that resident (R3) is not waking up enough to chew her meals appropriately. Will do a trial of pureed foods for now and continue to monitor. There was no mention of any swallowing concerns for R3 in the dietary progress note. Review of a Nursing Progress Note dated 04/10/20 at 13:59 revealed that R3 continued to cough while taking in thin liquids. Review of a Nursing Progress Note dated 04/12/20 at 13:49 indicated R3 did gag with fluids. Review of a Nursing Progress Note dated 04/13/20 at 08:17 revealed R3 was having some issues with her fluids. Review of a Nursing Progress Note dated 04/13/20 at 15:14 revealed daughter called to see about her mother, was told that we were asking for thickened liquids, r/t (related to) resident (R3) gagging with fluid intake. Review of a Nurse Order Note dated 04/14/20 at 12:16 indicated a verbal order was obtained to trial nectar thickened liquids for R3. Review of a Nursing Progress Note dated 4/15/2020 at 06:25 Has only taken a few sips of thickened water. Review of an Electronic Treatment Administration Record (ETAR) dated April 2020, revealed the following treatment order for R3, Monitor drinking and swallowing for difficulty chewing, coughing on liquids every shift for 3 days. Start 04/05/20 at 0700. Review of the same ETAR revealed that out of 9 shifts of monitoring, one shift ( day shift on 04/06/20) indicated that R3 had some difficulty with swallowing. The other 8 shifts had NN (none noted) indicated for the respective shifts. Review of a Nutritional Status Assessment, dated 04/29/20, revealed R3 was being assessed for a significant change in the way she was safely drinking and swallowing. Under the section labeled Swallow Concerns, next to the line coughs/gags while eating/drinking, the assessment indicated that R3 had no concerns with this area. In the same section, under comments was written some dif (difficulty) chewing/dif (difficulty) with fluids in April 2020. Under the section labeled Diet Order the comments listed were 4-24-20 Puree nectar, 4-8 not waking up enough to chew-puree trial, and 4-13 trial nect(nectar thick liquids) rt (related to) gagging on fluids. The document was signed by Registered Dietician (RD) Q. During an interview on 08/20/20 at 8:20 A.M., the Director of Nursing (DON) indicated that the procedure that was followed for any resident with swallowing or drinking concerns was (a) any nurse could downgrade a diet for safety concerns at any time and follow up would occur as soon as possible after the downgrade, (b) if nursing downgraded a diet, they would put in an order for [REDACTED]. During an interview on 08/19/20 at 1:50 P.M., Speech Language Pathology (SLP) P stated that an assessment was completed on R3 in June 2020 when the family requested that R3 be allowed thin liquids to help meet hydration/nutritional needs. SLP P also indicated that an assessment from SLP was not requested for R3 during the month of April 2020. Resident #4 Review of a Face Sheet revealed R4 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Brief Interview for Mental Status (BIMS), dated 07/24/20, revealed R4 was cognitively intact. R4 was able to ambulate independently with a walker and required assistance from staff if fatigued. Review of an Incident summary, dated 04/23/20, revealed R4 reported to staff on 04/23/20 that she had fallen the previous morning (04/22/20) and that R4 was experiencing right wrist pain and was noted to have bruising on the left hip/outer thigh. Further review of the document indicated that R4 was sent to the emergency roiagnom on [DATE] for evaluation and treatment if indicated. Review of Part A Resident/Incident Information & Assessment, dated 04/23/20, indicated .Describe the injury and treatment : left hip hematoma (bruise) 24 cm (centimeters) x 16.5 cm, dark purple in color and right inner thigh bruise 4.5cm x 3.5cm. No monitoring for the bruise located in the right inner thigh could be located in R4's electronic medical record. Review of the electronic health record for R4 did not produce a neurological assessment (neuro checks) for R4 following the fall on 04/22/20. During an interview on 08/19/20 at 9:20 A.M., the Director of Nursing (DON) stated that a review of R4's electronic medical record was done and neuro checks could not be located for the 04/22/20 fall. Review of a facility policy titled Neurological Signs Observation, dated August 10, 2015, revealed the following .The purpose of this observation is to detect clinical manifestations of increased cranial pressure .neurological signs and vital signs are monitored every 15 minutes x 4, then every 30 minutes x 2, followed by every four hours x 5 .(D) Assess changes in level of responsiveness .(E) Observe for restlessness, headache, vomiting, forced breathing, and purposeless movement of body and limbs .(G) Assess grasp of both hands .(H) Assess pupillary change .(J) Use the Neurological Observation Form (OMCF 3-263) for documentation and/or the Electronic Health Record (EHR). Review of a facility Fall Packet Checklist included 8. Neuro observation for falls with head involvement and all unwitnessed falls .4. Orthostatic BP (blood pressure). Review of R4's Blood Pressure Summary, dated April 2020, indicated that orthostatic blood pressures were not assessed on R4 until the morning of 04/27/20.

This citation pertains to intake # MI 003 Based on observation, interview, and record review, the facility failed to implement care plan interventions to prevent a fall for 1 of 5 sampled residents (Resident #16) reviewed for falls, resulting in a laceration (cut) to the head that required sutures(stitches) and emergency medical treatment. Findings include: Resident #16 Review of a Face Sheet revealed Resident #16 was an [AGE] year old male, admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Resident #16 required extensive assistance from staff for most activities of daily living and had severe cognitive impairment. Review of an incident summary revealed that on 08/30/2019, Resident #16 was sitting in wheelchair by nurse's station when he was attempting to stand from wheelchair and step over leg rests. A nurse responded to chair alarm sounding and resident lost balance and fell to left side before nursing could reach the resident. Resident #16 hit left side of temple on metal bar on bottom of bedside table that was next to his wheelchair and sustained a 1 inch long laceration to his left temple. First aid was given to stop the bleeding .Sent to ER for evaluation and treatment. Review of a Resident Fall Report for Resident #16, dated 08/30/19, revealed the root cause analysis for the fall as leg rests were left on wheelchair when resident was sitting unattended. Review of emergency room documents, dated 08/30/19, revealed Resident #16 was treated for [REDACTED]. Review of Resident #16's Care Plan .Focus-I have a history of falls. I am impulsive and do not understand my limitations or safety awareness. Interventions- (1)All nursing staff and nursing station staff to assure footrests are in bag on back of wheelchair when not in use. Date initiated: 11/27/18. (2) High Risk Falls program. Date initiated: 05/03/18. During and interview on 09/04/19 at 3:30 P.M. Certified Nurse Aid (CNA) M stated that Resident #16 needs to have the footrests removed from the wheelchair because Resident #16 will get up impulsively and fall over them. During an interview on 09/05/19 at 4:00 P.M., the Administrator stated that staff were aware that Resident #16's leg rests should not be left on the wheelchair but that Resident #16 was resting quietly and staff did not want to disturb him.

Based on interview and record review, the facility failed to prohibit abuse, neglect and the likelihood for ongoing abuse and neglect for 1 resident (Resident #1) of 5 residents reviewed for abuse, resulting in an Immediate Jeopardy (IJ) that began on 5/29/19, as a result of the facility's failure to implement a protocol to follow when allegations of sexual or physical abuse are made; and failed to follow established procedures to thoroughly identify, protect residents, investigate, and report to the state agency and law enforcement, an allegation of staff to resident physical and sexual abuse for one resident (Resident #1). This deficient practice has the high likelihood to affect all vulnerable residents in this facility. Findings include: Review of the facility policy Abuse, Neglect & Exploitation dated (MONTH) 17, 2019 reflected the essential elements required for effective protection and prevention of abuse, neglect, and exploitations were present including provisions for Screening; Training; Prevention; Identification; Investigation; Protection; and Reporting/Response, including reporting to local law enforcement per the Elder Justice Act. Resident #1 Review of a facility Admission Record indicated Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment indicated Resident #1 had short- and long-term memory impairment with moderately impaired cognitive skills for daily decision making. The assessment revealed Resident #1 required extensive assistance from two persons for bed mobility, dressing, toilet use and personal hygiene. Review of a Care Plan initiated 5/17/2018 reflected I have the following Advance Directive on record: Guardianship. It includes: No Code as of 11/29/18. I am NOT capable of making informed consent regarding my health care or financial decisions. Name of my Guardian and Conservator is (Name of Guardian/Conservator (G/C N)). Interventions included, My appointed health care representative will make all health care decisions if I am incapacitated. Review of an Order Regarding Appointment of Guardian of Incapacitated Individual reflected full guardianship was granted to G/C N on 5/30/2018. Review of a Care Plan initiated on 8/13/2019 reflected (Resident #1) can be resistive to care and potential for wandering r/t (related to) adjustment to nursing home and dementia and depression. She was on a schedule of awake at night and asleep during the day when she was home, and this is the schedule she is adjusted to. She can become physically and verbally aggressive if she would like to be left alone and care is attempted. The goal of the care plan is that Safety will be maintained through next review date. Interventions in the care plan include Allow me to make decisions about treatment regime, to provide sense of control; Educate myself/my family/caregivers of the possible outcome(s) of not participating with treatment or care; Provide me with opportunities for choice during care provision. Review of a Facility Reported Incident received by the State Agency on 5/29/19 at 0150 (1:50 AM) reflected On 5/29/19 at 0100 (Resident #1) told (Certified Nurse Aide (CNA) A) that she had been sexually assaulted. (CNA A) notified Charge Nurse (Registered Nurse, RN B) of allegation immediately. (RN B) and (RN C) went in to speak with (Resident #1). Resident again stated that she was sexually assaulted. She was unable to state when it happened but thought it was either tonight or this morning. (Resident #1) stated that she scratched at her clitoris and it hurt. (RN B) and (RN C) assessed resident and did not see any injuries, areas of redness or open areas. (RN B) informed the Director of Nursing via phone at 0120. The Director of Nursing (DON) informed Nursing Home Administrator (NHA) of incident. 2-hour report completed and submitted via (State Agency) website at 0150. Further review of the Facility Reported Incident (FRI) investigation regarding Resident #1's allegation of sexual assault on 5/29/19 reflected, Corrective Action - Interviews were conducted with all staff that had provided care to (Resident #1) in the timeframe identified. Review of Nurses Notes and Lab results show that a Cath UA was obtained on 5/17/19 that was negative for bacterial infection. Care Plans were reviewed and are well developed and appropriate for (Resident #1). Review of (Facility) Policy Memorandum (PM) 06.01.07 Resident Abuse, Neglect and Exploitation completed and remains appropriate. Assessment of (Resident #1) exhibited no evidence of injury or trauma. Resident's demeanor has remained calm with no episodes of tearfulness, fearfulness exhibited. Through investigation and staff interviews it was deemed that (Resident #1) prefers not to have (CNA R) as her caregiver and the assignment will be changed, (CNA R) was educated to trade (Resident #1) with her hall partner when she is on her assignment. Review of a DONS (Director of Nursing Service) Incident Observation Report dated 5/29/19 timed 0100 reflected RN C documented (CNA A) came to the nurse's station to report an accusation of sexual abuse. This nurse came into the room with the Charge Nurse to assess the resident. She stated that it was a large burly woman from 1st shift named (Name), that scratched at her clitoris. She also said that she gets mad at her if she doesn't eat her breakfast-even if she does not have a tray. The resident was asked if the charge nurse could look at her peri area and the resident was agreeable. The charge nurse told the resident that she did not see any areas of concern on her outer peri area, but it didn't mean that there wasn't something noted on the inside. She was asked if staff did a catheter for a U/A (urinalysis) and the resident stated Yes. The resident was adamant that it was a woman who had assaulted her. (Urinary catheterization is the insertion of a catheter through the urethra into the urinary bladder for withdrawal of urine. Straight catheters are used for intermittent withdrawals.) Review of a DONS Incident Observation Report dated 5/29/19 timed 0100 documented by RN B reflected (CNA A) reported (Resident #1) stated she was sexually assaulted. I and another RN (RN C) went to resident's room and asked her if she needed to talk to me. Resident repeated to me that she was sexually assaulted. She was unclear if it was tonight or this morning. She told me it was not (Name) but (Name) the 'Big bulky one'. She stated she scratched at her clitoris and it hurt. Also talked about a UTI (urinary tract infection) and taking medicine for it. Resident did allow me to look at her labia and no red or open areas noted. Call placed to ADON (Assistant Director of Nursing) with message left to call facility. Call placed to Director of Nursing and reported resident's statement. Review of a statement obtained from Resident #1, documented by the DON on 5/29/19 at 11:00 AM reflected (DON) interviewed (Resident #1) in the privacy of her room. Upon entering her room, I noted (Resident #1) was lying in bed awake, I introduced myself and told her the reason for my visit. (Resident #1) states 'I woke up and the girls were using____, not a razor blade, you know to slit you open, between my legs. I can't tell you what it was but (Name of Resident #1's husband) and I had a lot of fun with it. I have an affliction that stops my urinary tract from working and they have to put that thing in me.' I asked (Resident #1) if it was a catheter and she stated yes, now [MEDICAL CONDITION] there when I urinate. I asked (Resident #1) when this happened, and she stated it was towards the first part of the night. 'I was having trouble sleeping so it didn't take much to wake me up, they wanted to change me, but my pants were dry. When I sit wrong the clitoris, it is irritating, it hurt so bad, I couldn't get them to stop with the catheter.' I asked her if she knew who had assaulted her and she stated it was a woman in a black dress, not (Name similar to CNA R) but something like that.' I asked her if it was (CNA R) and she stated 'No. She's a nice girl. It's the woman who likes to argue a lot.' (Resident #1) went on to state that 'This woman scares me.' When I asked if this is someone who usually takes care of her, she stated 'Not always. I've had (name of unknown CNA) all day, I like him.' I asked (Resident #1) if she felt safe in the facility and she stated she did, 'I just don't like that one woman'. During the interview I frequently had to redirect (Resident #1) back to the topic of conversation. (Resident #1's) speech rambled from subject to subject throughout the conversation and would often lose track of what she was telling me and go onto another subject. Review of a document included in the Facility Investigation file pertaining to Resident #1s allegation of sexual abuse reported on 5/29/2019 reflected the DON documented an interview with CNA R on 5/31/2019 regarding Resident #1s allegation. According to the document, the DON confirmed CNA R cared for Resident #1 on 5/28/2019 and asked CNA R, Did anything unusual happen during care? The response documented was Didn't wash her up that day, had another CNA do her. She gets upset with me and gets combative with toileting. Yelled out with peri care and was trying to sit back down (sic). (#1) has no concept to day/time. Often combative with care. The DON asked, Do you argue with (Resident #1)?. The response from CNA R was (Resident #1) Always feels that she (CNA R) is arguing with her when she tries cueing her. The DON asked, Do you get mad at her when she doesn't eat her breakfast?. The response given by CNA R was Will try waking her up for breakfast and asks her if she wants her breakfast. (Resident #1) will usually say no. If (Resident #1) refuses (CNA R) will have another CNA approach. Generally, has someone come in with her. The final notation on the document was (CNA R) was not here when (Resident #1) was straight cathed for UA (urinalysis) on 5/17 or 5/18 (2019). The investigation file did not include a written statement from CNA R, despite the facility policy directing staff to obtain a written statement from staff. Review of Resident #1's interdisciplinary Progress Notes for the date range 2/1/2019-6/6/2019 revealed no progress note or physical assessment was documented related to Resident #1's allegation of sexual abuse on 5/29/2019, despite the policy directing the on-duty Charge Nurse to do so. According to the Corrective Action the DON submitted to the State Agency; nursing notes were used as a basis for the conclusion of the DON's investigation into Resident #1's allegation of sexual assault. Review of Resident #1's Electronic Health Record (EHR) reflected a progress note was not recorded on 5/17/2019 regarding the straight catheterization performed on Resident #1 and was the basis for the conclusion of the facility investigation regarding Resident #1's allegation of sexual abuse. Review of the Investigation File into Resident #1's allegation of sexual assault revealed no record of witness statements or investigation into the straight catheterization conducted on 5/17/2019 other than the laboratory report indicating a urine specimen was collected via catheter. Review of Resident #1's Laboratory Services report dated 5/17/2019 reflected Urine Specimen (tracking number) from Urine, Catheter. Ordered by Unspecified. Authorized by (MD EE). Collected: 5/17/2019 1300 (1:00 PM) Received: 1307. The urinalysis report indicated there was no blood in urine sample provided. The Urine Microscopic result was No RBC (red blood cells), WBC (white blood cells), or bacteria seen under microscopic examination. The report does not identify the facility nurse who obtained the specimen. Review of a Nursing Note dated 5/9/2019 at 4:32 PM, documented by RN W reflected, Straight cath'd for urinalysis. Urine turbid with mild odor. Tolerated poorly with yelling, hitting, kicking. Internal and external vaginal area slightly red. CNA's provided peri care and Nutrashield (a cream) after procedure. Review of Resident #1's Laboratory Services report dated 5/9/2019 reflected Urine Specimen (tracking number) from Urine, Catheter. Ordered by Unspecified. Authorized by (MD EE). Collected: 5/9/2019 1420 (2:20 PM) Received 1715 (5:15 PM). The Urinalysis report indicated the presence of a moderate amount of blood, a large amount of leukocyte esterase, white blood cells, red blood cells, many bacteria in the sample and flagged the findings as Abnormal. Review of Resident #1's physician progress notes [REDACTED]. Review of a physician progress notes [REDACTED].#1) was sleeping in her bed and was easily awakened. She seems in good spirits today which is quite a change from usual and she didn't seemed depressed, she didn't ask about going home but she did tell me that earlier in the morning a tall stout person in a black dress took her to the bathroom by wheelchair and dumped her on the floor. This has already been investigated by nursing and there is no one matching that description here, there is no evidence of injuries and it seems quite unlikely. Otherwise she really did not complain of pain today. When I asked about any bruises or marks from this injury, she couldn't point out anything in particular to me, she had no obvious injuries. The Plan documented in the progress note reflected, I reviewed her medicines and will continue the same. Nursing is investigating her allegations about the morning, but I see no evidence of any injury. I will see her again in one or two months or PRN (as needed). During an interview with the DON on 6/12/2019 at 12:07 PM, evidence of previous reports to the State Agency pertaining to allegations of abuse or neglect made by Resident #1, incident and accident reports, physician progress notes [REDACTED].#1 on 5/29/2019 were requested. During a follow-up interview on 6/12/2019 at 12:25 PM, the DON reported the only Facility Reported Incident (FRI) pertaining to Resident #1 was the allegation of sexual assault on 5/29/2019. The DON reported she had no knowledge of the allegation of staff to resident physical abuse reflected in the physician progress notes [REDACTED]. The DON said MD EE did not document a more recent physician progress notes [REDACTED]. Review of the facility Abuse Investigation Checklist for Resident #1 dated 5/29/2019 reflected notification to the DON occurred at 1:20 AM on 5/29/2019, followed by the NHA on 5/29/2019 at 1:40 AM, and the Physician (Medical Director, MD EE) was notified on 5/30/2019 at 9:00 AM, more than a day after Resident #1 reported sexual abuse. According to the checklist, Resident #1 (who is not her own person and is not able to make medical decisions) notified the Resident Representative at 1:05 AM. The checklist reflected notification to local law enforcement did not occur. During a telephone interview on 6/12/2019 at 11:15 AM, Resident #1's Legal Guardian/Conservator (G/C) N reported the facility did not inform her of Resident #1's allegation of sexual assault made on 5/29/2019. G/C N said she was in town that weekend and would not have refused a hospital evaluation for Resident #1. G/C N also reported facility staff did not tell her they used a catheter to obtain a urine specimen. Review of a Nurse-Order Note documented by RN FF on 5/9/2019 at 2:33 PM reflected Assessment: (MD EE updated of increase in fatigue, behaviors, and combativeness. Temp 99.8. Order Details: U/A C & S (urinalysis with culture and sensitivity) if indicated (may straight cath to obtain specimen). [DIAGNOSES REDACTED]. Physician's Name: (MD EE). Family Notified: Not at this time. During a telephone interview on 6/12/19 at 11:34 AM, CNA A reported she cared for Resident #1 overnight 5/28/19 - 5/29/19. CNA A reported she entered Resident #1's room at midnight because Resident #1 wanted to call her husband. CNA A reported that again at 1:00 AM, Resident #1 told CNA A she needed to call her husband because someone had sexually assaulted her. According to CNA A, Resident #1 believed it was a night person. CNA A immediately informed the nurses on duty. CNA A said she provided incontinence care to Resident #1 before the end of her shift after the allegation of sexual assault. CNA A reported she received education about the abuse prevention policies and procedures but was not familiar with the EJA or the requirement to report the reasonable suspicion of a crime. CNA A could not report what precautions to take if a resident alleged sexual assault or abuse. During an attempt to interview Resident #1 on 6/12/19 at 2:05 PM, Resident #1 said Don't keep asking me questions. During an interview on 6/12/2019 at 2:20 PM, CNA P reported he assisted Resident #1 on 5/28/2019 at the request of CNA R because Resident #1 did not want CNA R to care for her. CNA P said he received education on the facility abuse policy annually and would report allegations of abuse to his charge nurse. CNA P did not know what the Elder Justice Act entailed but had heard of it. CNA P denied writing a statement for the DON. At the time of the interview, CNA P wore black scrubs. During an interview on 6/12/2019 at 2:38 PM, CNA R reported her primary assignment is on Resident #1's unit. CNA R confirmed the DON interviewed her about caring for Resident #1 on 5/28/2019 but did not know why and denied writing a statement for the DON. CNA R said she had a difficult time toileting Resident #1 on 5/28/2019 because Resident #1 wanted to sit back down in her wheelchair before her brief was in place. CNA R denied scratching Resident #1's genitals. CNA R reported, Today is the first day I am hearing I should switch assignments (when Resident #1 is on her assignment). At the time of the interview, CNA R wore a black scrub uniform. During an interview on 6/12/2019 at 2:40 PM, RN C reported she was the medication nurse assigned to care for Resident #1 on 5/29/2019. RN C said (Resident #1) said a big girl was rough on her clitoris and was adamant a woman sexually abused her. RN C said the charge nurse (RN B) called the DON, who instructed them to fill out the paperwork (witness statements). RN C said she did not document her assessment of Resident #1 because that would be the responsibility of the charge nurse (RN B) in that situation. RN C said she did not think there was a reason to call the police because there was no visible cause for alarm. RN C reported she received education about the facility policy and procedure for abuse but was unable to explain the EJA. RN C could not explain what specific steps to take to address an allegation of sexual abuse and said, I would take the lead from the Charge Nurse. During an interview on 6/12/2019 at 2:54 PM, the DON reported RN B did not document anything related to Resident #1's allegation of sexual assault in the progress notes or elsewhere in the clinical record because she forgot. The DON said the physician was informed of the allegation of abuse the morning of 5/29/2019 but did not examine her (this contradicts the Abuse Investigation Checklist, which indicates the physician was notified on 5/30/2019). The DON said Resident #1 would not allow her to examine her peri area on 5/29/2019. The DON explained RN B reported Resident #1 denied pain and had no obvious evidence of injury. The DON said she instructed staff to write statements but did not direct staff to call local law enforcement because she told them she was going to come into the facility. The DON said Resident #1's husband was notified, and he said he would notify G/C N. The DON said she interviewed other residents and staff regarding Resident #1's allegation of sexual assault but did not have documentation. During an interview on 6/12/2019 at 4:00 PM, The Nursing Home Administrator and the DON said they were partners as the Abuse Coordinators per the facility policy. The NHA said she and the DON did discuss calling the police but decided not to due to Resident #1's demeanor, lack of assessment findings and talk about a straight catheter procedure. The NHA said they did not want to send Resident #1 to the hospital at 2:00 AM for a rape kit, and asked, Do you know what that would have done to her? During a follow-up interview on 6/13/2019 at 11:10 AM, the NHA said the facility did not call the police (after Resident #1's allegation of sexual assault) because her allegation did not rise to the level of the reasonable suspicion of a crime. The NHA said the surveyor did not request a copy of the facility policy specific to the Elder Justice Act and provided it for review. Review of the facility policy Reporting Suspected Crimes - Elder Justice Act dated (MONTH) 30, 2019 reflected A. Elder Justice Act. To further protect resident rights, Congress Enacted the Elder Justice Act (EJA), which requires specific individuals in long-term-care facilities to report any reasonable suspicion of crimes committed against a resident to both local law enforcement and the State Survey Agency (SA). Failure to properly report any reasonable suspicion of a crime against a resident is a punishable offense, subject to civil money penalty and exclusion sanctions. The policy specifies (1) Timeframes. (a.) Serious Bodily Injury - Within 2 hours. The individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion; (b.) All Others - Within 24 Hours. The individual shall report the suspicion not later than 24 hours after forming the suspicion. (2.) Report To. (a) Report directly to the State Survey Agency (SA) and law enforcement; and/or (b) Report to the Facility Administrator who will then coordinate timely reporting to the SA on behalf of all covered individuals who made the report to the administrator. (c) Important Note. While covered individuals may report independently to the SA and law enforcement, Federal regulations require that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the Administrator in accordance with State law through established procedures, including to the State survey and certification agency. The policy defines Crime. (Defined by law of the applicable political subdivision where a long-term care facility is located) A violation of local ordinance or state or federal statute or federal statue punishable as either a misdemeanor or as a felony, or an act constituting a crime at common law punishable by imprisonment, fine or other criminal action. Additionally, situations that would likely be considered crimes in all subdivisions include but are not limited to: Murder; Manslaughter; Rape; Assault and battery; Sexual Abuse; Theft/[NAME]bery; Drug diversion for personal use or gain; Identity theft; and Fraud and forgery. The policy specified F. Serious Bodily Injury. Injury involving extreme physical pain; substantial risk of death; protracted impairment of a function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation. In addition, serious bodily injury is deemed to have occurred if the offense involved constitutes criminal sexual abuse. During a telephone interview on 6/13/2019 at 11:43 AM, RN B said a CNA (CNA A) reported Resident #1 alleged sexual abuse on 5/29/2019. RN B said Resident #1 reported a person scratched her clitoris but had no outward signs of injury. RN B said she asked the DON what she should chart in the electronic health record and if she should call Resident #1's family and was told by the DON she would take care of it in the morning. RN B said she has heard of the EJA but was not familiar with it. RN B also reported she did not have any special training in assessing sexual assault victims and did not know of any specific steps to take in managing an allegation of sexual assault or sexual abuse. Review of a Nurse - Order Note dated 6/1/2019 at 2:49 PM, documented by RN GG reflected Order Details: UA and C&S if indicated CCMS. The order note did not indicate family had been notified. Review of Resident #1's Laboratory Services report dated 6/01/2019 at 10:38 PM, reflected Urine specimen (tracking number) from Urine, clean catch. Ordered by Unspecified. Authorized by (MD EE) Collected 6/1/2019 1900 (7:00 PM) Received 2151 (9:51 PM). Review of a Nursing Note documented by RN C on 6/01/2019 at 7:09 PM reflected Catheter U/A obtained and sent to (name of hospital laboratory). The Nursing Note indicates a straight catheterization was performed, despite the physician order and what is noted on the laboratory report, raising questions that requires investigation to answer. During a telephone interview on 6/18/2019 at 10:45 AM, MD EE reported he did not know Resident #1 did not tolerate the straight catheter procedure to obtain a urine sample for urinalysis on 5/9/2019 and would not expect staff to force a resident to undergo a straight catheterization if the resident was combative or refusing. MD EE could not recall exactly when staff informed him of Resident #1's allegation of sexual assault on 5/29/2019 and did not examine her when informed of the allegation of sexual assault because the DON reported Resident #1 did not have any signs of injury or trauma. MD EE said (a physical assessment) might not reveal signs of inappropriate touching or fondling. MD EE said he ordered nursing to collect a Clean Catch Midstream (CCMS) (a non-invasive method of collecting uncontaminated urine for analysis) urine sample on 6/1/2019 to rule out a urinary tract infection. MD EE said he specified that method of collection because of Resident #1's allegation of sexual assault. MD EE said he did not force a pelvic exam of Resident #1 on 6/13/2019 because to do so would be assault. The Nursing Home Administrator and the Director of Nursing were informed on 6/13/19 at 1:20 PM of an Immediate Jeopardy (IJ) that began on 5/29/19 at 1:00 AM, as the result of the facility's failure to thoroughly identify, investigate, and report to law enforcement, an allegation of sexual abuse for one Resident (Resident #1) who reported she was sexually assaulted by a woman on 5/29/19. This deficient practice has the high likelihood to affect all vulnerable residents in this facility. On 6/18/19, the surveyors verified the facility implemented the following to remove the high likelihood the identified deficient practice would occur again: 1. 6/12/19 - The facility Corporate Compliance Director (CCD Z) completed a review of, and provided education to, the Administrator and Director of Nursing on facility abuse & reporting polices & procedures, with emphasis on managing sexual assault allegations and related reporting requirements, specifically with regard to reporting to local law enforcement. 2. 6/12/19 - Mandatory education entitled My Resident Just Reported to Me that He/She's Been Sexually Assaulted. What Do I Do? was distributed and face-to-face education began for all staff. Education to be documented on sign-in sheets and continue until complete. 3. 6/12/19 - NHA spoke by phone with G/C N by phone regarding notification of the allegation of sexual abuse Resident #1 made on 5/29/19. 4. 6/13/19 -The DON and NHA provided additional follow up by phone with G/C N (Resident #1's Responsible Party) to inform her of the alleged staff to resident abuse allegation that was found in physician progress notes [REDACTED]. 5. 6/13/19 - 1:1 education/counseling to be provided to Medical Director (MD EE) and RN FF regarding requirements to report ALL ALLEGATIONS to the DON and NHA. 1:1 education/counseling also to be provided to CNA R regarding following DON instructions related to not caring for Resident #1. 6. 6/13/19 - Director of Social Services (SW CC) conducted wellness interview with Resident #1 to ensure resident okay psychosocially. Resident verbalized that she was not scared of anyone and felt safe in the facility. Plan is to continue weekly checks with this resident. 7. 6/13/19 - Request made by DON to Medical Director to examine Resident #1 ASAP. MD EE attempted to examine Resident #1 at 7:59 pm. Resident was lying in bed with eyes open but refused exam multiple times. 8. 6/13/19 - NHA emailed and spoke by phone with local law enforcement to notify of the sexual assault allegation. 9. 6/13/19 - DON initiated review & investigation of 3/11/19 physician progress notes [REDACTED]. Investigation to include review of staffing reports at that time, any accident/injury reports, and interviews of the resident's roommate, staff and other residents. 10. 6/14/19 - CNA R is off work pending final results of current investigation. 11. 6/17/19 - Facility wide mandatory in-service to reinforce prior education. Although the Immediate Jeopardy (IJ) was removed on 6/17/19, the facility remained out of compliance at a scope of isolated and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the revised policy and procedure, and sustained compliance has not been verified by the state agency.

Based on interview and record review, the facility failed to prohibit abuse, neglect and the likelihood for ongoing abuse and neglect for 1 resident (Resident #1) of 5 residents reviewed for abuse, resulting in an Immediate Jeopardy (IJ) that began on 5/29/19, as a result of the facility's failure to implement a protocol to follow when allegations of sexual or physical abuse are made; and failed to follow established procedures to thoroughly identify, protect residents, investigate, and report to the state agency and law enforcement, an allegation of staff to resident physical and sexual abuse for one resident (Resident #1). This deficient practice has the high likelihood to affect all vulnerable residents in this facility. Findings include: Review of the facility policy Abuse, Neglect & Exploitation dated (MONTH) 17, 2019 reflected the essential elements required for effective protection and prevention of abuse, neglect, and exploitations were present including provisions for Screening; Training; Prevention; Identification; Investigation; Protection; and Reporting/Response, including reporting to local law enforcement per the Elder Justice Act. Resident #1 Review of a facility Admission Record indicated Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment indicated Resident #1 had short- and long-term memory impairment with moderately impaired cognitive skills for daily decision making. The assessment revealed Resident #1 required extensive assistance from two persons for bed mobility, dressing, toilet use and personal hygiene. Review of a Care Plan initiated 5/17/2018 reflected I have the following Advance Directive on record: Guardianship. It includes: No Code as of 11/29/18. I am NOT capable of making informed consent regarding my health care or financial decisions. Name of my Guardian and Conservator is (Name of Guardian/Conservator (G/C N)). Interventions included, My appointed health care representative will make all health care decisions if I am incapacitated. Review of an Order Regarding Appointment of Guardian of Incapacitated Individual reflected full guardianship was granted to G/C N on 5/30/2018. Review of a Care Plan initiated on 8/13/2019 reflected (Resident #1) can be resistive to care and potential for wandering r/t (related to) adjustment to nursing home and dementia and depression. She was on a schedule of awake at night and asleep during the day when she was home, and this is the schedule she is adjusted to. She can become physically and verbally aggressive if she would like to be left alone and care is attempted. The goal of the care plan is that Safety will be maintained through next review date. Interventions in the care plan include Allow me to make decisions about treatment regime, to provide sense of control; Educate myself/my family/caregivers of the possible outcome(s) of not participating with treatment or care; Provide me with opportunities for choice during care provision. Review of a Facility Reported Incident received by the State Agency on 5/29/19 at 0150 (1:50 AM) reflected On 5/29/19 at 0100 (Resident #1) told (Certified Nurse Aide (CNA) A) that she had been sexually assaulted. (CNA A) notified Charge Nurse (Registered Nurse, RN B) of allegation immediately. (RN B) and (RN C) went in to speak with (Resident #1). Resident again stated that she was sexually assaulted. She was unable to state when it happened but thought it was either tonight or this morning. (Resident #1) stated that she scratched at her clitoris and it hurt. (RN B) and (RN C) assessed resident and did not see any injuries, areas of redness or open areas. (RN B) informed the Director of Nursing via phone at 0120. The Director of Nursing (DON) informed Nursing Home Administrator (NHA) of incident. 2-hour report completed and submitted via (State Agency) website at 0150. Further review of the Facility Reported Incident (FRI) investigation regarding Resident #1's allegation of sexual assault on 5/29/19 reflected, Corrective Action - Interviews were conducted with all staff that had provided care to (Resident #1) in the timeframe identified. Review of Nurses Notes and Lab results show that a Cath UA was obtained on 5/17/19 that was negative for bacterial infection. Care Plans were reviewed and are well developed and appropriate for (Resident #1). Review of (Facility) Policy Memorandum (PM) 06.01.07 Resident Abuse, Neglect and Exploitation completed and remains appropriate. Assessment of (Resident #1) exhibited no evidence of injury or trauma. Resident's demeanor has remained calm with no episodes of tearfulness, fearfulness exhibited. Through investigation and staff interviews it was deemed that (Resident #1) prefers not to have (CNA R) as her caregiver and the assignment will be changed, (CNA R) was educated to trade (Resident #1) with her hall partner when she is on her assignment. Review of a DONS (Director of Nursing Service) Incident Observation Report dated 5/29/19 timed 0100 reflected RN C documented (CNA A) came to the nurse's station to report an accusation of sexual abuse. This nurse came into the room with the Charge Nurse to assess the resident. She stated that it was a large burly woman from 1st shift named (Name), that scratched at her clitoris. She also said that she gets mad at her if she doesn't eat her breakfast-even if she does not have a tray. The resident was asked if the charge nurse could look at her peri area and the resident was agreeable. The charge nurse told the resident that she did not see any areas of concern on her outer peri area, but it didn't mean that there wasn't something noted on the inside. She was asked if staff did a catheter for a U/A (urinalysis) and the resident stated Yes. The resident was adamant that it was a woman who had assaulted her. (Urinary catheterization is the insertion of a catheter through the urethra into the urinary bladder for withdrawal of urine. Straight catheters are used for intermittent withdrawals.) Review of a DONS Incident Observation Report dated 5/29/19 timed 0100 documented by RN B reflected (CNA A) reported (Resident #1) stated she was sexually assaulted. I and another RN (RN C) went to resident's room and asked her if she needed to talk to me. Resident repeated to me that she was sexually assaulted. She was unclear if it was tonight or this morning. She told me it was not (Name) but (Name) the 'Big bulky one'. She stated she scratched at her clitoris and it hurt. Also talked about a UTI (urinary tract infection) and taking medicine for it. Resident did allow me to look at her labia and no red or open areas noted. Call placed to ADON (Assistant Director of Nursing) with message left to call facility. Call placed to Director of Nursing and reported resident's statement. Review of a statement obtained from Resident #1, documented by the DON on 5/29/19 at 11:00 AM reflected (DON) interviewed (Resident #1) in the privacy of her room. Upon entering her room, I noted (Resident #1) was lying in bed awake, I introduced myself and told her the reason for my visit. (Resident #1) states 'I woke up and the girls were using____, not a razor blade, you know to slit you open, between my legs. I can't tell you what it was but (Name of Resident #1's husband) and I had a lot of fun with it. I have an affliction that stops my urinary tract from working and they have to put that thing in me.' I asked (Resident #1) if it was a catheter and she stated yes, now [MEDICAL CONDITION] there when I urinate. I asked (Resident #1) when this happened, and she stated it was towards the first part of the night. 'I was having trouble sleeping so it didn't take much to wake me up, they wanted to change me, but my pants were dry. When I sit wrong the clitoris, it is irritating, it hurt so bad, I couldn't get them to stop with the catheter.' I asked her if she knew who had assaulted her and she stated it was a woman in a black dress, not (Name similar to CNA R) but something like that.' I asked her if it was (CNA R) and she stated 'No. She's a nice girl. It's the woman who likes to argue a lot.' (Resident #1) went on to state that 'This woman scares me.' When I asked if this is someone who usually takes care of her, she stated 'Not always. I've had (name of unknown CNA) all day, I like him.' I asked (Resident #1) if she felt safe in the facility and she stated she did, 'I just don't like that one woman'. During the interview I frequently had to redirect (Resident #1) back to the topic of conversation. (Resident #1's) speech rambled from subject to subject throughout the conversation and would often lose track of what she was telling me and go onto another subject. Review of a document included in the Facility Investigation file pertaining to Resident #1's allegation of sexual abuse reported on 5/29/2019 reflected the DON documented an interview with CNA R on 5/31/2019 regarding Resident #1s allegation. According to the document, the DON confirmed CNA R cared for Resident #1 on 5/28/2019 and asked CNA R, Did anything unusual happen during care? The response documented was Didn't wash her up that day, had another CNA do her. She gets upset with me and gets combative with toileting. Yelled out with peri care and was trying to sit back down (sic). (#1) has no concept to day/time. Often combative with care. The DON asked, Do you argue with (Resident #1)?. The response from CNA R was (Resident #1) Always feels that she (CNA R) is arguing with her when she tries cueing her. The DON asked, Do you get mad at her when she doesn't eat her breakfast?. The response given by CNA R was Will try waking her up for breakfast and asks her if she wants her breakfast. (Resident #1) will usually say no. If (Resident #1) refuses (CNA R) will have another CNA approach. Generally, has someone come in with her. The final notation on the document was (CNA R) was not here when (Resident #1) was straight cathed for UA (urinalysis) on 5/17 or 5/18 (2019). The investigation file did not include a written statement from CNA R, despite the facility policy directing staff to obtain a written statement from staff. Review of Resident #1's interdisciplinary Progress Notes for the date range 2/1/2019-6/6/2019 revealed no progress note or physical assessment was documented related to Resident #1's allegation of sexual abuse on 5/29/2019, despite the policy directing the on-duty Charge Nurse to do so. According to the Corrective Action the DON submitted to the State Agency; nursing notes were used as a basis for the conclusion of the DON's investigation into Resident #1's allegation of sexual assault. Review of Resident #1's Electronic Health Record (EHR) reflected a progress note was not recorded on 5/17/2019 regarding the straight catheterization performed on Resident #1 and was the basis for the conclusion of the facility investigation regarding Resident #1's allegation of sexual abuse. Review of the Investigation File into Resident #1's allegation of sexual assault revealed no record of witness statements or investigation into the straight catheterization procedure on 5/17/2019 other than the laboratory report indicating a urine specimen was collected via catheter. Review of Resident #1's Laboratory Services report dated 5/17/2019 reflected Urine Specimen (tracking number) from Urine, Catheter. Ordered by Unspecified. Authorized by (MD EE). Collected: 5/17/2019 1300 (1:00 PM) Received: 1307. The urinalysis report indicated there was no blood in urine sample provided. The Urine Microscopic result was No RBC (red blood cells), WBC (white blood cells), or bacteria seen under microscopic examination. The report does not identify the facility nurse who obtained the specimen. Review of a Nursing Note dated 5/9/2019 at 4:32 PM, documented by RN W reflected, Straight cath'd for urinalysis. Urine turbid with mild odor. Tolerated poorly with yelling, hitting, kicking. Internal and external vaginal area slightly red. CNA's provided peri care and Nutrashield (a cream) after procedure. Review of Resident #1's Laboratory Services report dated 5/9/2019 reflected Urine Specimen (tracking number) from Urine, Catheter. Ordered by Unspecified. Authorized by (MD EE). Collected: 5/9/2019 1420 (2:20 PM) Received 1715 (5:15 PM). The Urinalysis report indicated the presence of a moderate amount of blood, a large amount of leukocyte esterase, white blood cells, red blood cells, many bacteria in the sample and flagged the findings as Abnormal. Review of Resident #1's physician progress notes [REDACTED]. Review of a physician progress notes [REDACTED].#1) was sleeping in her bed and was easily awakened. She seems in good spirits today which is quite a change from usual and she didn't seemed depressed, she didn't ask about going home but she did tell me that earlier in the morning a tall stout person in a black dress took her to the bathroom by wheelchair and dumped her on the floor. This has already been investigated by nursing and there is no one matching that description here, there is no evidence of injuries and it seems quite unlikely. Otherwise she really did not complain of pain today. When I asked about any bruises or marks from this injury, she couldn't point out anything in particular to me, she had no obvious injuries. The Plan documented in the progress note reflected, I reviewed her medicines and will continue the same. Nursing is investigating her allegations about the morning, but I see no evidence of any injury. I will see her again in one or two months or PRN (as needed). During an interview with the DON on 6/12/2019 at 12:07 PM, evidence of previous reports to the State Agency pertaining to allegations of abuse or neglect made by Resident #1, incident and accident reports, physician progress notes [REDACTED].#1 on 5/29/2019 were requested. During a follow-up interview on 6/12/2019 at 12:25 PM, the DON reported the only Facility Reported Incident (FRI) pertaining to Resident #1 was the allegation of sexual assault on 5/29/2019. The DON reported she had no knowledge of the allegation of staff to resident physical abuse reflected in the physician progress notes [REDACTED]. The DON said MD EE did not document a more recent physician progress notes [REDACTED]. Review of the facility Abuse Investigation Checklist for Resident #1 dated 5/29/2019 reflected notification to the DON occurred at 1:20 AM on 5/29/2019, followed by the NHA on 5/29/2019 at 1:40 AM, and the Physician (Medical Director, MD EE) was notified on 5/30/2019 at 9:00 AM, more than a day after Resident #1 reported sexual abuse. According to the checklist, Resident #1 (who is not her own person and is not able to make medical decisions) notified the Resident Representative at 1:05 AM. The checklist reflected notification to local law enforcement did not occur. During a telephone interview on 6/12/2019 at 11:15 AM, Resident #1's Legal Guardian/Conservator (G/C) N reported the facility did not inform her of Resident #1's allegation of sexual assault made on 5/29/2019. G/C N said she was in town that weekend and would not have refused a hospital evaluation for Resident #1. G/C N also reported facility staff did not tell her they used a catheter to obtain a urine specimen. Review of a Nurse-Order Note documented by RN FF on 5/9/2019 at 2:33 PM reflected Assessment: (MD EE updated of increase in fatigue, behaviors, and combativeness. Temp 99.8. Order Details: U/A C & S (urinalysis with culture and sensitivity) if indicated (may straight cath to obtain specimen). [DIAGNOSES REDACTED]. Physician's Name: (MD EE). Family Notified: Not at this time. During a telephone interview on 6/12/19 at 11:34 AM, CNA A reported she cared for Resident #1 overnight 5/28/19 - 5/29/19. CNA A reported she entered Resident #1's room at midnight because Resident #1 wanted to call her husband. CNA A reported that again at 1:00 AM, Resident #1 told CNA A she needed to call her husband because someone had sexually assaulted her. According to CNA A, Resident #1 believed it was a night person. CNA A immediately informed the nurses on duty. CNA A said she provided incontinence care to Resident #1 before the end of her shift after the allegation of sexual assault. CNA A reported she received education about the abuse prevention policies and procedures but was not familiar with the EJA or the requirement to report the reasonable suspicion of a crime. CNA A could not report what precautions to take if a resident alleged sexual assault or abuse. During an attempt to interview Resident #1 on 6/12/19 at 2:05 PM, Resident #1 said Don't keep asking me questions. During an interview on 6/12/2019 at 2:20 PM, CNA P reported he assisted Resident #1 on 5/28/2019 at the request of CNA R because Resident #1 did not want CNA R to care for her. CNA P said he received education on the facility abuse policy annually and would report allegations of abuse to his charge nurse. CNA P did not know what the Elder Justice Act entailed but had heard of it. CNA P denied writing a statement for the DON. At the time of the interview, CNA P wore black scrubs. During an interview on 6/12/2019 at 2:38 PM, CNA R reported her primary assignment is on Resident #1's unit. CNA R confirmed the DON interviewed her about caring for Resident #1 on 5/28/2019 but did not know why and denied writing a statement for the DON. CNA R said she had a difficult time toileting Resident #1 on 5/28/2019 because Resident #1 wanted to sit back down in her wheelchair before her brief was in place. CNA R denied scratching Resident #1's genitals. CNA R reported, Today is the first day I am hearing I should switch assignments (when Resident #1 is on her assignment). At the time of the interview, CNA R wore a black scrub uniform. During an interview on 6/12/2019 at 2:40 PM, RN C reported she was the medication nurse assigned to care for Resident #1 on 5/29/2019. RN C said (Resident #1) said a big girl was rough on her clitoris and was adamant a woman sexually abused her. RN C said the charge nurse (RN B) called the DON, who instructed them to fill out the paperwork (witness statements). RN C said she did not document her assessment of Resident #1 because that would be the responsibility of the charge nurse (RN B) in that situation. RN C said she did not think there was a reason to call the police because there was no visible cause for alarm. RN C reported she received education about the facility policy and procedure for abuse but was unable to explain the EJA. RN C could not explain what specific steps to take to address an allegation of sexual abuse and said, I would take the lead from the Charge Nurse. During an interview on 6/12/2019 at 2:54 PM, the DON reported RN B did not document anything related to Resident #1's allegation of sexual assault in the progress notes or elsewhere in the clinical record because she forgot. The DON said the physician was informed of the allegation of abuse the morning of 5/29/2019 but did not examine her (this contradicts the Abuse Investigation Checklist, which indicates the physician was notified on 5/30/2019). The DON said Resident #1 would not allow her to examine her peri area on 5/29/2019. The DON explained RN B reported Resident #1 denied pain and had no obvious evidence of injury. The DON said she instructed staff to write statements but did not direct staff to call local law enforcement because she told them she was going to come into the facility. The DON said Resident #1's husband was notified, and he said he would notify G/C N. The DON said she interviewed other residents and staff regarding Resident #1's allegation of sexual assault but did not have documentation. During an interview on 6/12/2019 at 4:00 PM, The Nursing Home Administrator and the DON said they were partners as the Abuse Coordinators per the facility policy. The NHA said she and the DON did discuss calling the police but decided not to due to Resident #1's demeanor, lack of assessment findings and talk about a straight catheter procedure. The NHA said they did not want to send Resident #1 to the hospital at 2:00 AM for a rape kit, and asked, Do you know what that would have done to her? During a follow-up interview on 6/13/2019 at 11:10 AM, the NHA said the facility did not call the police (after Resident #1's allegation of sexual assault) because her allegation did not rise to the level of the reasonable suspicion of a crime. The NHA said the surveyor did not request a copy of the facility policy specific to the Elder Justice Act and provided it for review. Review of the facility policy Reporting Suspected Crimes - Elder Justice Act dated (MONTH) 30, 2019 reflected A. Elder Justice Act. To further protect resident rights, Congress Enacted the Elder Justice Act (EJA), which requires specific individuals in long-term-care facilities to report any reasonable suspicion of crimes committed against a resident to both local law enforcement and the State Survey Agency (SA). Failure to properly report any reasonable suspicion of a crime against a resident is a punishable offense, subject to civil money penalty and exclusion sanctions. The policy specifies (1) Timeframes. (a.) Serious Bodily Injury - Within 2 hours. The individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion; (b.) All Others - Within 24 Hours. The individual shall report the suspicion not later than 24 hours after forming the suspicion. (2.) Report To. (a) Report directly to the State Survey Agency (SA) and law enforcement; and/or (b) Report to the Facility Administrator who will then coordinate timely reporting to the SA on behalf of all covered individuals who made the report to the administrator. (c) Important Note. While covered individuals may report independently to the SA and law enforcement, Federal regulations require that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the Administrator in accordance with State law through established procedures, including to the State survey and certification agency. The policy defines Crime. (Defined by law of the applicable political subdivision where a long-term care facility is located) A violation of local ordinance or state or federal statute or federal statue punishable as either a misdemeanor or as a felony, or an act constituting a crime at common law punishable by imprisonment, fine or other criminal action. Additionally, situations that would likely be considered crimes in all subdivisions include but are not limited to: Murder; Manslaughter; Rape; Assault and battery; Sexual Abuse; Theft/[NAME]bery; Drug diversion for personal use or gain; Identity theft; and Fraud and forgery. The policy specified F. Serious Bodily Injury. Injury involving extreme physical pain; substantial risk of death; protracted impairment of a function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation. In addition, serious bodily injury is deemed to have occurred if the offense involved constitutes criminal sexual abuse. During a telephone interview on 6/13/2019 at 11:43 AM, RN B said a CNA (CNA A) reported Resident #1 alleged sexual abuse on 5/29/2019. RN B said Resident #1 reported a person scratched her clitoris but had no outward signs of injury. RN B said she asked the DON what she should chart in the electronic health record and if she should call Resident #1's family and was told by the DON she would take care of it in the morning. RN B said she has heard of the EJA but was not familiar with it. RN B also reported she did not have any special training in assessing sexual assault victims and did not know of any specific steps to take in managing an allegation of sexual assault or sexual abuse. Review of Resident #1's Laboratory Services report dated 6/01/2019 at 10:38 PM, reflected Urine specimen (tracking number) from Urine, clean catch. Ordered by Unspecified. Authorized by (MD EE) Collected 6/1/2019 1900 (7:00 PM) Received 2151 (9:51 PM). Review of a Nursing Note documented by RN C on 6/01/2019 at 7:09 PM reflected Catheter U/A obtained and sent to (name of hospital laboratory). The Nursing Note indicates a straight catheterization was performed, despite the physician order and what is noted on the laboratory report, raising questions that requires investigation to answer. During a telephone interview on 6/18/2019 at 10:45 AM, MD EE reported he did not know Resident #1 did not tolerate the straight catheter procedure to obtain a urine sample for urinalysis on 5/9/2019 and would not expect staff to force a resident to undergo a straight catheterization if the resident was combative or refusing. MD EE could not recall exactly when staff informed him of Resident #1's allegation of sexual assault on 5/29/2019 and did not examine her when informed of the allegation of sexual assault because the DON reported Resident #1 did not have any signs of injury or trauma. MD EE said (a physical assessment) might not reveal signs of inappropriate touching or fondling. MD EE said he ordered nursing to collect a Clean Catch Midstream (CCMS) (a non-invasive method of collecting uncontaminated urine for analysis) urine sample on 6/1/2019 to rule out a urinary tract infection. MD EE said he specified that method of collection because of Resident #1's allegation of sexual assault. MD EE said he did not force a pelvic exam of Resident #1 on 6/13/2019 because to do so would be assault. The Nursing Home Administrator and the Director of Nursing were informed on 6/13/19 at 1:20 PM of an Immediate Jeopardy (IJ) that began on 5/29/19 at 1:00 AM, as the result of the facility's failure to thoroughly identify, investigate, and report to law enforcement, an allegation of sexual abuse for one Resident (Resident #1) who reported she was sexually assaulted by a woman on 5/29/19. This deficient practice has the high likelihood to affect all vulnerable residents in this facility. On 6/18/19, the surveyors verified the facility implemented the following to remove the high likelihood the identified deficient practice would occur again: 1. 6/12/19 - The facility Corporate Compliance Director (CCD Z) completed a review of, and provided education to, the Administrator and Director of Nursing on facility abuse & reporting polices & procedures, with emphasis on managing sexual assault allegations and related reporting requirements, specifically with regard to reporting to local law enforcement. 2. 6/12/19 - Mandatory education entitled My Resident Just Reported to Me that He/She's Been Sexually Assaulted. What Do I Do? was distributed and face-to-face education began for all staff. Education to be documented on sign-in sheets and continue until complete. 3. 6/12/19 - NHA spoke by phone with G/C N by phone regarding notification of the allegation of sexual abuse Resident #1 made on 5/29/19. 4. 6/13/19 -The DON and NHA provided additional follow up by phone with G/C N (Resident #1's Responsible Party) to inform her of the alleged staff to resident abuse allegation that was found in physician progress notes [REDACTED]. 5. 6/13/19 - 1:1 education/counseling to be provided to Medical Director (MD EE) and RN FF regarding requirements to report ALL ALLEGATIONS to the DON and NHA. 1:1 education/counseling also to be provided to CNA R regarding following DON instructions related to not caring for Resident #1. 6. 6/13/19 - Director of Social Services (SW CC) conducted wellness interview with Resident #1 to ensure resident okay psychosocially. Resident verbalized that she was not scared of anyone and felt safe in the facility. Plan is to continue weekly checks with this resident. 7. 6/13/19 - Request made by DON to Medical Director to examine Resident #1 ASAP (as soon as possible). MD EE attempted to examine Resident #1 at 7:59 pm. Resident was lying in bed with eyes open but refused exam multiple times. 8. 6/13/19 - NHA emailed and spoke by phone with local law enforcement to notify of the sexual assault allegation. 9. 6/13/19 - DON initiated review & investigation of 3/11/19 physician progress notes [REDACTED]. Investigation to include review of staffing reports at that time, any accident/injury reports, and interviews of the resident's roommate, staff and other residents. 10. 6/14/19 - CNA R is off work pending final results of current investigation. 11. 6/17/19 - Facility wide mandatory in-service to reinforce prior education. Although the Immediate Jeopardy (IJ) was removed on 6/17/19, the facility remained out of compliance at a scope of isolated and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the revised policy and procedure, and sustained compliance has not been verified by the state agency.

Based on observation, interview and record review, the facility failed to prevent abuse and neglect for 1 resident (Resident #1), of 5 residents reviewed for abuse and neglect when Resident #1 was unable to refuse a procedure; and when the facility did not implement policy and procedure and protect, respond, report to law enforcement, conduct a thorough investigation and implement interventions to prevent further harm after allegations of staff to resident physical abuse and sexual assault, resulting in Resident #1being fearful and combative when forced to recieve cares. The reasonable person would not want to be treated in this manner. Findings include: Review of the facility policy Abuse, Neglect & Exploitation dated (MONTH) 17, 2019 reflected the essential elements required for effective protection and prevention of abuse, neglect, and exploitation were present including provisions for Screening; Training; Prevention; Identification; Investigation; Protection; and Reporting/Response. The policy defined abuse as The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental or psychosocial wellbeing. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal, physical, sexual and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that they must have intended to inflict injury or cause harm. The policy described Catastrophic Reactions as Reactions or mood changes of the resident in response to what may seem to be minimal stimuli (e.g. bathing, dressing, need to use rest room, a question asked of a person) that can be characterized by weeping, blushing, anger, agitation or stubbornness. Mistreatment is The inappropriate treatment or exploitation of a resident. According to the policy, Neglect is the Failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident #1 Review of a facility Admission Record indicated Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment indicated Resident #1 had short- and long-term memory impairment with moderately impaired cognitive skills for daily decision making. The assessment revealed Resident #1 required extensive assistance from two persons for bed mobility, dressing, toilet use and personal hygiene. Review of a Care Plan initiated 5/17/2018 reflected I have the following Advance Directive on record: Guardianship. It includes: No Code as of 11/29/2018. I am NOT capable of making informed consent regarding my health care or financial decisions. Name of my Guardian and Conservator is (Name of Guardian/Conservator (G/C N)). Interventions included, My appointed health care representative will make all health care decisions if I am incapacitated. Review of an Order Regarding Appointment of Guardian of Incapacitated Individual reflected a judge granted full guardianship to G/C N on 5/30/2018. Review of a Care Plan initiated on 8/13/2019 reflected (Resident #1) can be resistive to care and potential for wandering r/t (related to) adjustment to nursing home and dementia and depression. She was on a schedule of awake at night and asleep during the day when she was home, and this is the schedule she is adjusted to. She can become physically and verbally aggressive if she would like to be left alone and care is attempted. The goal of the care plan is that Safety will be maintained through next review date. Interventions in the care plan include Allow me to make decisions about treatment regime, to provide sense of control; Educate myself/my family/caregivers of the possible outcome(s) of not participating with treatment or care; Provide me with opportunities for choice during care provision. Review of a Facility Reported Incident received by the State Agency on 5/29/2019 at 0150 (1:50 AM) reflected On 5/29/2019 at 0100 (Resident #1) told (Certified Nurse Aide (CNA) A) that she had been sexually assaulted. (CNA A) notified Charge Nurse (Registered Nurse, RN B) of allegation immediately. (RN B) and (RN C) went in to speak with (Resident #1). Resident again stated that she was sexually assaulted. She was unable to state when it happened but thought it was either tonight or this morning. (Resident #1) stated that she scratched at her clitoris and it hurt. (RN B) and (RN C) assessed resident and did not see any injuries, areas of redness or open areas. (RN B) informed the Director of Nursing via phone at 0120. The Director of Nursing (DON) informed Nursing Home Administrator (NHA) of incident. 2-hour report completed and submitted via (State Agency) website at 0150. Further review of the Facility Reported Incident (FRI) investigation regarding Resident #1's allegation of sexual assault on 5/29/2019 reflected, Corrective Action - Interviews were conducted with all staff that had provided care to (Resident #1) in the timeframe identified. Review of Nurses Notes and Lab results show that a Cath UA was obtained on 5/17/2019 that was negative for bacterial infection. Care Plans were reviewed and are well developed and appropriate for (Resident #1). Review of (Facility) Policy Memorandum (PM) 06.01.07 Resident Abuse, Neglect and Exploitation completed and remains appropriate. Assessment of (Resident #1) exhibited no evidence of injury or trauma. Resident's demeanor has remained calm with no episodes of tearfulness, fearfulness exhibited. Through investigation and staff interviews it was deemed that (Resident #1) prefers not to have (CNA R) as her caregiver and the assignment will be changed, (CNA R) was educated to trade (Resident #1) with her hall partner when she is on her assignment. Review of a DONS (Director of Nursing Service) Incident Observation Report dated 5/29/2019 timed 0100 reflected RN C documented (CNA A) came to the nurse's station to report an accusation of sexual abuse. This nurse came into the room with the Charge Nurse to assess the resident. She stated that it was a large burly woman from 1st shift named (Name), that scratched at her clitoris. She also said that she gets mad at her if she doesn't eat her breakfast-even if she does not have a tray. The resident was asked if the charge nurse could look at her peri area and the resident was agreeable. The charge nurse told the resident that she did not see any areas of concern on her outer peri area, but it didn't mean that there wasn't something noted on the inside. She was asked if staff did a catheter for a U/A (urinalysis) and the resident stated Yes. The resident was adamant that it was a woman who had assaulted her. (Urinary catheterization is the insertion of a catheter through the urethra into the urinary bladder for withdrawal of urine. Straight catheters are used for intermittent withdrawals.) Review of a DONS Incident Observation Report dated 5/29/2019 timed 0100 documented by RN B reflected (CNA A) reported (Resident #1) stated she was sexually assaulted. I and another RN (RN C) went to resident's room and asked her if she needed to talk to me. Resident repeated to me that she was sexually assaulted. She was unclear if it was tonight or this morning. She told me it was not (Name) but (Name) the 'Big bulky one'. She stated she scratched at her clitoris and it hurt. Also talked about a UTI (urinary tract infection) and taking medicine for it. Resident did allow me to look at her labia and no red or open areas noted. Call placed to ADON (Assistant Director of Nursing) with message left to call facility. Call placed to Director of Nursing and reported resident's statement. Review of a statement obtained from Resident #1, documented by the DON on 5/29/2019 at 11:00 AM reflected (DON) interviewed (Resident #1) in the privacy of her room. Upon entering her room, I noted (Resident #1) was lying in bed awake, I introduced myself and told her the reason for my visit. (Resident #1) states 'I woke up and the girls were using____, not a razor blade, you know to slit you open, between my legs. I can't tell you what it was but (Name of Resident #1's husband) and I had a lot of fun with it. I have an affliction that stops my urinary tract from working and they have to put that thing in me.' I asked (Resident #1) if it was a catheter and she stated yes, now [MEDICAL CONDITION] there when I urinate. I asked (Resident #1) when this happened, and she stated it was towards the first part of the night. 'I was having trouble sleeping so it didn't take much to wake me up, they wanted to change me, but my pants were dry. When I sit wrong the clitoris, it is irritating, it hurt so bad, I couldn't get them to stop with the catheter.' I asked her if she knew who had assaulted her and she stated it was a woman in a black dress, not (Name similar to CNA R) but something like that.' I asked her if it was (CNA R) and she stated 'No. She's a nice girl. It's the woman who likes to argue a lot.' (Resident #1) went on to state that 'This woman scares me.' When I asked if this is someone who usually takes care of her, she stated 'Not always. I've had (name of unknown male CNA) all day, I like him.' I asked (Resident #1) if she felt safe in the facility and she stated she did, 'I just don't like that one woman'. During the interview I frequently had to redirect (Resident #1) back to the topic of conversation. (Resident #1s) speech rambled from subject to subject throughout the conversation and would often lose track of what she was telling me and go onto another subject. Review of a document included in the Facility Investigation file pertaining to Resident #1s allegation of sexual abuse reported on 5/29/2019 reflected the DON documented an interview with CNA R on 5/31/2019 regarding Resident #1s allegation. According to the document, the DON confirmed CNA R cared for Resident #1 on 5/28/2019 and asked CNA R, Did anything unusual happen during care? The response documented was Didn't wash her up that day, had another CNA do her. She gets upset with me and gets combative with toileting. Yelled out with peri care and was trying to sit back down (sic). (#1) has no concept to day/time. Often combative with care. The DON asked, Do you argue with (Resident #1)?. The response from CNA R was (Resident #1) Always feels that she (CNA R) is arguing with her when she tries cueing her. The DON asked, Do you get mad at her when she doesn't eat her breakfast?. The response given by CNA R was Will try waking her up for breakfast and asks her if she wants her breakfast. (Resident #1) will usually say no. If (Resident #1) refuses (CNA R) will have another CNA approach. Generally, has someone come in with her. The final notation on the document was (CNA R) was not here when (Resident #1) was straight cathed for UA (urinalysis) on 5/17 or 5/18 (2019). The investigation file did not include a written statement from CNA R, despite the facility policy directing staff to obtain a written statement from staff. Review of Resident #1's interdisciplinary Progress Notes for the date range 2/1/2019-6/6/2019 revealed no progress note or physical assessment was documented related to Resident #1's allegation of sexual abuse on 5/29/2019, despite the policy directing the on-duty Charge Nurse to do so. According to the Corrective Action the DON submitted to the State Agency; nursing notes were used as a basis for the conclusion of the DON's investigation into Resident #1's allegation of sexual assault. Review of Resident #1's Electronic Health Record (EHR) reflected a progress note was not recorded on 5/17/2019 regarding the straight catheterization performed on Resident #1 and was the basis for the conclusion of the facility investigation regarding Resident #1's allegation of sexual abuse. Review of the Investigation File into Resident #1's allegation of sexual assault revealed no record of witness statements or investigation into the straight catheterization conducted on 5/17/2019 other than the laboratory report indicating a urine specimen was collected via catheter. Review of Resident #1's Laboratory Services report dated 5/17/2019 reflected Urine Specimen (tracking number) from Urine, Catheter. Ordered by Unspecified. Authorized by (MD EE). Collected: 5/17/2019 1300 (1:00 PM) Received: 1307. The urinalysis report indicated there was no blood in urine sample provided. The Urine Microscopic result was No RBC (red blood cells), WBC (white blood cells), or bacteria seen under microscopic examination. The report does not identify the facility nurse who obtained the specimen. Review of a Nursing Note dated 5/9/2019 at 4:32 PM, documented by RN W reflected, Straight cath'd for urinalysis. Urine turbid with mild odor. Tolerated poorly with yelling, hitting, kicking. Internal and external vaginal area slightly red. CNA's provided peri care and Nutrashield (a cream) after procedure. Review of Resident #1's Laboratory Services report dated 5/9/2019 reflected Urine Specimen (tracking number) from Urine, Catheter. Ordered by Unspecified. Authorized by (MD EE). Collected: 5/9/2019 1420 (2:20 PM) Received 1715 (5:15 PM). The Urinalysis report indicated the presence of a moderate amount of blood, a large amount of leukocyte esterase, white blood cells, red blood cells, many bacteria in the sample and flagged the findings as Abnormal. Review of Resident #1's physician progress notes [REDACTED]. Review of a physician progress notes [REDACTED].#1) was sleeping in her bed and was easily awakened. She seems in good spirits today which is quite a change from usual and she didn't seem depressed, she didn't ask about going home but she did tell me that earlier in the morning a tall stout person in a black dress took her to the bathroom by wheelchair and dumped her on the floor. This has already been investigated by nursing and there is no one matching that description here, there is no evidence of injuries and it seems quite unlikely. Otherwise she really did not complain of pain today. When I asked about any bruises or marks from this injury, she couldn't point out anything in particular to me, she had no obvious injuries. The Plan documented in the progress note reflected, I reviewed her medicines and will continue the same. Nursing is investigating her allegations about the morning, but I see no evidence of any injury. I will see her again in one or two months or PRN (as needed). During an interview with the DON on 6/12/2019 at 12:07 PM, evidence of previous reports to the State Agency pertaining to allegations of abuse or neglect made by Resident #1, incident and accident reports, physician progress notes [REDACTED].#1 on 5/29/2019 were requested. During a follow-up interview on 6/12/2019 at 12:25 PM, the DON reported the only Facility Reported Incident (FRI) pertaining to Resident #1 was the allegation of sexual assault on 5/29/2019. The DON reported she had no knowledge of the allegation of staff to resident physical abuse reflected in the physician progress notes [REDACTED]. The DON said MD EE did not document a more recent physician progress notes [REDACTED]. Review of the facility Abuse Investigation Checklist for Resident #1 dated 5/29/2019 reflected notification to the DON occurred at 1:20 AM on 5/29/2019, followed by the NHA on 5/29/2019 at 1:40 AM, and the Physician (Medical Director, MD EE) was notified on 5/30/2019 at 9:00 AM, more than a day after Resident #1 reported sexual abuse. According to the checklist, Resident #1 (who is not her own person and is not able to make medical decisions) notified the Resident Representative at 1:05 AM. The checklist reflected notification to local law enforcement did not occur. During a telephone interview on 6/12/2019 at 11:15 AM, Resident #1's Legal Guardian/Conservator (G/C) N reported the facility did not inform her of Resident #1's allegation of sexual assault made on 5/29/2019. G/C N said she was in town that weekend and would not have refused a hospital evaluation for Resident #1. G/C N also reported facility staff did not tell her they used a catheter to obtain a urine specimen. Review of a Nurse-Order Note documented by RN FF on 5/9/2019 at 2:33 PM reflected Assessment: (MD EE updated of increase in fatigue, behaviors, and combativeness. Temp 99.8. Order Details: U/A C & S (urinalysis with culture and sensitivity) if indicated (may straight cath to obtain specimen). [DIAGNOSES REDACTED]. Physician's Name: (MD EE). Family Notified: Not at this time. During a telephone interview on 6/12/2019 at 11:34 AM, CNA A reported she cared for Resident #1 overnight 5/28/2019 - 5/29/2019. CNA A reported she entered Resident #1's room at midnight because Resident #1 wanted to call her husband. CNA A reported that again at 1:00 AM, Resident #1 told CNA A she needed to call her husband because someone had sexually assaulted her. According to CNA A, Resident #1 believed it was a night person. CNA A immediately informed the nurses on duty. CNA A said she provided incontinence care to Resident #1 before the end of her shift after the allegation of sexual assault. CNA A reported she received education about the abuse prevention policies and procedures but was not familiar with the EJA or the requirement to report the reasonable suspicion of a crime. CNA A could not report what precautions to take if a resident alleged sexual assault or abuse. During an attempt to interview Resident #1 on 6/12/2019 at 2:05 PM, Resident #1 said Don't keep asking me questions. During an interview on 6/12/2019 at 2:20 PM, CNA P reported he assisted Resident #1 on 5/28/2019 at the request of CNA R because Resident #1 did not want CNA R to care for her. CNA P said he received education on the facility abuse policy annually and would report allegations of abuse to his charge nurse. CNA P did not know what the Elder Justice Act entailed but had heard of it. CNA P denied writing a statement for the DON. At the time of the interview, CNA P wore black scrubs. During an interview on 6/12/2019 at 2:38 PM, CNA R reported her primary assignment is on Resident #1's unit. CNA R confirmed the DON interviewed her about caring for Resident #1 on 5/28/2019 but did not know why and denied writing a statement for the DON. CNA R said she had a difficult time toileting Resident #1 on 5/28/2019 because Resident #1 wanted to sit back down in her wheelchair before her brief was in place. CNA R denied scratching Resident #1's genitals. CNA R reported, Today is the first day I am hearing I should switch assignments (when Resident #1 is on her assignment). At the time of the interview, CNA R wore a black scrub uniform. During an interview on 6/12/2019 at 2:40 PM, RN C reported she was the medication nurse assigned to care for Resident #1 on 5/29/2019. RN C said (Resident #1) said a big girl was rough on her clitoris and was adamant a woman sexually abused her. RN C said the charge nurse (RN B) called the DON, who instructed them to fill out the paperwork (witness statements). RN C said she did not document her assessment of Resident #1 because that would be the responsibility of the charge nurse (RN B) in that situation. RN C said she did not think there was a reason to call the police because there was no visible cause for alarm. RN C reported she received education about the facility policy and procedure for abuse but was unable to explain the EJA. RN C could not explain what specific steps to take to address an allegation of sexual abuse and said, I would take the lead from the Charge Nurse. During an interview on 6/12/2019 at 2:54 PM, the DON reported RN B did not document anything related to Resident #1's allegation of sexual assault in the progress notes or elsewhere in the clinical record because she forgot. The DON said the physician was informed of the allegation of abuse the morning of 5/29/2019 but did not examine her (this contradicts the Abuse Investigation Checklist, which indicates the physician was notified on 5/30/2019). The DON said Resident #1 would not allow her to examine her peri area on 5/29/2019. The DON explained RN B reported Resident #1 denied pain and had no obvious evidence of injury. The DON said she instructed staff to write statements but did not direct staff to call local law enforcement because she told them she was going to come into the facility. The DON said Resident #1's husband was notified, and he said he would notify G/C N. The DON said she interviewed other residents and staff regarding Resident #1's allegation of sexual assault but did not have documentation. During an interview on 6/12/2019 at 4:00 PM, The Nursing Home Administrator and the DON said they were partners as the Abuse Coordinators per the facility policy. The NHA said she and the DON did discuss calling the police but decided not to due to Resident #1's demeanor, lack of assessment findings and talk about a straight catheter procedure. The NHA said they did not want to send Resident #1 to the hospital at 2:00 AM for a rape kit, and asked, Do you know what that would have done to her? During a follow-up interview on 6/13/2019 at 11:10 AM, the NHA said the facility did not call the police (after Resident #1's allegation of sexual assault) because her allegation did not rise to the level of the reasonable suspicion of a crime. The NHA said the surveyor did not request a copy of the facility policy specific to the Elder Justice Act and provided it for review. Review of the facility policy Reporting Suspected Crimes - Elder Justice Act dated (MONTH) 30, 2019 reflected A. Elder Justice Act. To further protect resident rights, Congress Enacted the Elder Justice Act (EJA), which requires specific individuals in long-term-care facilities to report any reasonable suspicion of crimes committed against a resident to both local law enforcement and the State Survey Agency (SA). Failure to properly report any reasonable suspicion of a crime against a resident is a punishable offense, subject to civil money penalty and exclusion sanctions. The policy specifies (1) Timeframes. (a.) Serious Bodily Injury - Within 2 hours. The individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion; (b.) All Others - Within 24 Hours. The individual shall report the suspicion not later than 24 hours after forming the suspicion. (2.) Report To. (a) Report directly to the State Survey Agency (SA) and law enforcement; and/or (b) Report to the Facility Administrator who will then coordinate timely reporting to the SA on behalf of all covered individuals who made the report to the administrator. (c) Important Note. While covered individuals may report independently to the SA and law enforcement, Federal regulations require that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the Administrator in accordance with State law through established procedures, including to the State survey and certification agency. The policy defines Crime. (Defined by law of the applicable political subdivision where a long-term care facility is located) A violation of local ordinance or state or federal statute or federal statue punishable as either a misdemeanor or as a felony, or an act constituting a crime at common law punishable by imprisonment, fine or other criminal action. Additionally, situations that would likely be considered crimes in all subdivisions include but are not limited to: Murder; Manslaughter; Rape; Assault and battery; Sexual Abuse; Theft/[NAME]bery; Drug diversion for personal use or gain; Identity theft; and Fraud and forgery. The policy specified F. Serious Bodily Injury. Injury involving extreme physical pain; substantial risk of death; protracted impairment of a function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation. In addition, serious bodily injury is deemed to have occurred if the offense involved constitutes criminal sexual abuse. During a telephone interview on 6/13/2019 at 11:43 AM, RN B said a CNA (CNA A) reported Resident #1 alleged sexual abuse on 5/29/2019. RN B said Resident #1 reported a person scratched her clitoris but had no outward signs of injury. RN B said she asked the DON what she should chart in the electronic health record and if she should call Resident #1's family and was told by the DON she would take care of it in the morning. RN B said she has heard of the EJA but was not familiar with it. RN B also reported she did not have any special training in assessing sexual assault victims and did not know of any specific steps to take in managing an allegation of sexual assault or sexual abuse. During a telephone interview on 6/18/2019 at 10:45 AM, MD EE reported he did not know Resident #1 did not tolerate the straight catheter procedure to obtain a urine sample for urinalysis on 5/9/2019 and would not expect staff to force a resident to undergo a straight catheterization if the resident was combative or refusing. MD EE could not recall exactly when staff informed him of Resident #1's allegation of sexual assault on 5/29/2019 and did not examine her when informed of the allegation of sexual assault because the DON reported Resident #1 did not have any signs of injury or trauma. MD EE said (a physical assessment) would not reveal signs of inappropriate touching or fondling. MD EE said he ordered nursing to collect a Clean Catch Midstream (CCMS) (a non-invasive method of collecting uncontaminated urine for analysis) urine sample on 6/1/2019 to rule out a urinary tract infection. MD EE said he specified that method of collection because of Resident #1's allegation of sexual assault. MD EE said he did not force a pelvic exam of Resident #1 on 6/13/2019 because to do so would be assault. Review of a Nurse - Order Note dated 6/1/2019 at 2:49 PM, documented by RN GG reflected Order Details: UA and C&S if indicated CCMS. The order note did not indicate family had been notified. Review of Resident #1's Laboratory Services report dated 6/01/2019 at 10:38 PM, reflected Urine specimen (tracking number) from Urine, clean catch. Ordered by Unspecified. Authorized by (MD EE) Collected 6/1/2019 1900 (7:00 PM) Received 2151 (9:51 PM). Review of a Nursing Note documented by RN C on 6/01/2019 at 7:09 PM reflected Catheter U/A obtained and sent to (name of hospital laboratory). The Nursing Note conflicts with the physician order and the laboratory report. During a telephone interview on 6/18/2019 at 10:22 AM, RN W reported she performed a straight catheter procedure on Resident #1 on 5/9/2019. RN W recalled Resident #1 said, No! I don't want to be cathed for a urine! You're not my Doctor! RN W said Resident #1 yelled and kicked while she and three other staff made her lie down. RN W recalled Resident #1's brief had already been changed and she was in the process of getting up, yelling at the time she wanted to get back up. RN W denied difficulty with the straight catheterization and said, She calmed down once we got her to lay down. RN W said she completed the procedure in one attempt and did not cause injury. RN W said she did not stop the process and re-approach Resident #1 on 5/9/2019 because staff were available to help at that time and because she believed Resident #1's response would have been the same (yelling, hitting, kicking) no matter when she tried to obtain a urine sample. RN W said as of 6/18/2019, the DON never questioned her about the procedure conducted on Resident #1 on 5/09/2019. On 6/18/2019 at 2:20 PM, the DON provided a handwritten document reflecting investigation notes regarding the straight catheter procedure performed on Resident #1 on 5/17/2019. The DON said she found the document buried on her desk. The DON said she did not find the additional documentation she alleged she collected (resident statements, additional staff statements) with the newly discovered notes. The note reflected the DON identified RN DD unsuccessfully attempted twice to insert a catheter into Resident #1 on 5/17/2019. According to the notes, RN DD reported Resident #1 was kind of kicking but did not refuse the procedure. The DON identified RN G assisted RN DD and successfully completed the procedure in one attempt. According to the notes, both nurses denied any refusals or difficulty from Resident #1 during the procedure. During a follow-up telephone interview on 6/19/2019 at 3:20 PM, RN DD reported Resident #1 was not combative during the attempts she made to perform a straight catheter procedure on 5/17/2019. RN DD said the first time the DON asked about the straight catheter procedure on 5/17/2019 was 6/18/2019.

This citation refers to MI 875. Based on interview and record review, the facility failed to prevent a fall for 1 resident (Resident #8) reviewed for falls, resulting in Resident #8 sustaining a fracture from a fall. Findings include: A review of Resident #8's Admission Record, dated 11/8/18, revealed Resident #8 was an [AGE] year old resident admitted to the facility on [DATE]. Resident #8 had multiple [DIAGNOSES REDACTED]. Review of Resident #8's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 10/10/18, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 9 which indicated Resident #1 was moderately cognitively impaired. In addition, Resident #8's MDS revealed Resident #8 needed extensive assistance (resident involved in activity, staff providing weight bearing support) of two (2) persons physical assistance for transfers (e.g. wheelchair to chair) and extensive assistance of one (1) person physical assistance for transfers on and off the toilet. In addition, Resident #8's MDS revealed Resident #8 had-had 2 or more falls without injury and two or more falls with minor injuries (e.g. skin tears, bruises, sprains, lacerations, or complaints of pain) within the last 3 months. A review of Resident #8's fall risk assessment, dated 10/3/18, revealed Resident #8 was a high fall risk (score of 18). In addition, Resident #8's fall risk assessment revealed Resident #8 was unable to independently come to a standing position, required hands-on assistance to move from place to place, and had a decrease in muscle coordination. A review of Resident #8's Activities of Daily Living (ADL) care plan, revised 10/30/17, revealed Transfer: (name of Resident #8) use the (name of full mechanical lift device- a device that uses a sling to bear all of the resident's weight) for all transfers (dated 5/1/18). A review of Resident #8's Falls care plan, initiated 1/13/14, revealed Resident #8 prefers to wear her own gripper socks that have good traction that help prevent her feet from slipping during transfers (dated 5/11/18). A review of Resident #8's nursing progress note, dated 10/16/18, revealed At 1945 resident (Resident #8) became weak during a transfer from w/c (wheelchair) to toilet with gait belt assist (a belt positioned around a resident's waist to assist with guiding the resident during transfers or as a point for the caregiver to grab onto should a resident start to lose balance). Lowered to the floor gently. No bumping of the head. No deformities upon exam. Initially denied pain. Raised from floor to toilet with (name of full mechanical lift device) to complete toileting needs. Reported her right ankle was tender as she was finishing her toileting. Ankle is tender to firm palpation (touching) on the outer aspect of right ankle. Able to move the ankle WNL (within normal limits) for resident. Resident reports movement increases discomfort. No bruising or swelling. A review of Resident #8's right tibia and fibula (lower leg bones) x-ray (initial encounter), dated 10/17/18, revealed a spiral fracture (a fracture caused during a turning motion) of the proximal (side nearest to the center of the body) fibula with a couple millimeters of lateral (side to side) displacement (bone not aligned). There is a nondisplaced (bone aligned) [MEDICAL CONDITION] medial (far middle) tibia involving the medial malleolus (ankle bone). A review of CNA A's witness statement, signed and dated 10/16/18, revealed Transferred with gait belt/ pivot transfers; lowered to the floor. Used (name of full mechanical lift device) from floor to toilet to complete toileting and then to the bed. RN and charge nurse in the room to examine. Had regular socks on pre-sliding down and sitting when resident became weak. During an interview on 11/7/18 at 3:40 PM, certified nursing assistant (CNA) A stated on 10/16/18 I transferred her (Resident #8) from the wheelchair into the recliner in her room using a pivot stand (a type of transfer where the resident stands up and the caregiver pivots the resident's body towards where they want the resident to sit. Resident bears most of their weight and caregiver just provides guidance and minimal assistance with weight-bearing). I pivoted her and she did ok. Then she wanted to go to the bathroom. I pivot stood her from the recliner into the wheelchair. As I was transferring her to the toilet, her knees buckled. I lowered her to the ground. I was using a gait belt. She leaned forward more than she should. I think she got her leg caught on her ankle. She was saying it, her right leg, was hurting her. I pulled her off of her leg and straightened her out on the ground. Her leg (right) didn't look funny at the time. I called the nurse, (name of Registered Nurse (RN) D). We used the (name of full mechanical lift device) to get her up. I put her on the toilet. I then used the (name of full mechanical lift device) again to put her in the bed. She was complaining her leg (right) hurt a little bit when I got her back into bed. It was later that she said it was really hurting. (Name of RN D) was there when she first complained her leg was hurting. CNA A further stated, I work with her on and off. I work every hall. She (Resident #8) was supposed to be a (name of full mechanical lift device) in the first place. She wanted to do it (pivot turn). I was rushing and not thinking. I was just being stupid. During an interview on 11/8/18 at 10:35 AM, Licensed Practical Nurse (LPN) E stated, She's (Resident #8) my primary (a resident a staff member takes care of often). I heard the next day that she was lowered to the ground. At the time, I believe she was a two (person) assist with transfers. I think she was a sit-to-stand (a transfer device that bears some of the resident's weight and the resident bears some of the weight used to assist a resident in standing) as tolerated. Otherwise, she was a lift if she was weak. Now she's a lift, non-weight bearing. She will use the call light or holler out. She was always an assist (sit-to-stand) or a lift. She's not refused to use the sit-to-stand or lift. She's not insisted on just standing up. During an interview on 11/8/18 at 10:50 AM, CNA F stated, The past month I've cared for her (Resident #8) a lot. The next day (10/17/18) I came in and I heard she (Resident #8) got hurt. Before she got hurt, she used the sit-to-stand. She was fine standing up with it. She could bear her weight fine. Now she's a the (name of full mechanical lift device) because of her leg. She's never refused to use the lifts. She's never asked to stand on her own. She's pretty good about the lifts. During an interview on 11/8/18 at 3:30 PM, RN D stated, I was working across the hall. The aide, (name of CNA A), came out of the room to tell me he needed help. I went into the bathroom. She (Resident #8) was sitting on the floor. Her arms were out holding onto the wheelchair. She was sitting up with her back to the wheelchair. Her legs were straight out. She wasn't complaining of pain or anything. (Name of CNA A) said she became weak and he lowered her to the floor. I went to get (name of CNA A) some assistance. She (Resident #8) kept saying, I need to go to the bathroom. Get me on the toilet. She didn't say she hit her head or anything. I didn't help to get her up. (Name of CNA A and name of CNA G) got her off the floor. They used a gait belt to get her up and onto the toilet. They physically lifted her up. They didn't use a lift. I don't remember if I saw her get into bed. I asked where's the lift? She needs a lift. I assessed her after she was in bed. She complained her foot was a little sore. The only thing she had was tenderness of her right ankle. She said it hurt on palpation. She could do range of motion of her legs and feet (moving up and down and side-to-side). She only complained of tenderness to the ankle on palpation. That was it. My understanding was she was a lift only because of sudden weakness. She was care planned to use a lift. It doesn't make sense that they didn't use a lift. Maybe she over sold herself to (name of CNA A). A review of Resident #8's fall report, dated 10/16/18, revealed Resident #8 became weak and unable to stand while getting up from the chair or wheelchair during a CNA assisted transfer and fell in the bathroom. Resident #8's fall report revealed Resident #8 had plain socks only on at the time of the fall. Resident #8's fall report further revealed lift not used and that was a concern with the staff transfer technique. Resident #8's fall report revealed the cause of the fall was the resident is weak and the lift was not utilized as CP (care planned). A review of the facility's safe resident handling during transfers policy and procedure, dated 1/13/17, revealed 3. Procedure. A. Lifting and transferring of residents will be performed according to their (the resident's) individual plan of care.

Based on interview and record review, the facility failed to provide adequate supervision and assistance devices according to the plan of care, to prevent a fall with severe injury for one resident (Resident #101) of three residents reviewed for falls from a total sample of three residents. This deficient practice, inadequate supervision during meals and failure to use alarms to alert staff of resident movements, resulted in harm to Resident #101 when she fell and sustained a severe head injury and injured hip. Findings include: According to the facility Minimum Data Set (MDS) assessment dated [DATE], Resident #101 was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The above dated MDS showed Resident #101 was a one person assist for locomotion on the unit, was not steady for walking, and only able to stabilize her balance with staff assist for moving from sitting to standing. Resident #101 scored ,[DATE] on the Brief Interview for Mental Status (BIMS) examination dated [DATE], indicative of severe cognitive impairment for memory, recall and orientation. The facility provided document Visual/Bedside Kardex (electronic) Report revealed Resident #101 had the following interventions ordered for Safety: Alarming floor mat - place in front of recliner when sitting up in recliner. Place next to bed when in bed with bed in lowest position .chair alarm .Check alarm function and placement Q (every) shift and prior to each use and PRN (as needed) .High risk falls program (orange dot placed on door to indicate high risk fall resident) . and the following interventions ordered for Eating/Nutrition: Eating breakfast - assist .Eating lunch - assist .Eating supper - assist .Resident may need increased assistance with eating . During the survey, Resident #101 was no longer in the facility and was unable to be observed. A review of the undated facility document, Investigation - 5 day Report re: (Resident #101) fall on [DATE], showed: On [DATE], Certified Nurse Aide (CNA) B entered Resident #101's room at 6:10 p.m. and found the resident (Resident #101) on the floor. There were no alarms sounding .(CNA B) stated that the (alarm) floor mat was under the bed, the alarm was in the wheelchair and not sounding. The facility conclusion read, in part: After a thorough review of this incident, the root cause that lead to the incident was non-compliance with placement of alarms. The resident was identified as a high risk for falls and care planned to have alarms in chair and recliner and alarming floor mat in front of recliner when in recliner .The nurse aide (CNA H) failed to meet the resident's needs and did not follow the care plan and apply alarms to the recliner and place the alarming floor mat in front of the recliner after transferring resident from the wheelchair to the recliner to eat her meal . The hospital Emergency Department Report for Resident #101 dated [DATE], was reviewed. Medical Decision Making read, in part: The patient was emergently seen and evaluated. Patient was identified to have acute blunt head injury .I did repair the 4cm (centimeter) laceration to the posterior (head). CT (CAT or computed axial tomography) scan of the brain identified .for tiny midline interhemispheric fissure subdural hemorrhage (blood pooling between layers of the protective covering of the brain). The radiology report regarding Resident #101, dated [DATE], was also reviewed and showed: small subdural hemorrhage. The hospital Discharge Summary for Resident #101, dated [DATE] was reviewed. Discharge [DIAGNOSES REDACTED]. Scalp laceration; 3. Recurrent falls; 4. Suspected nondisplaced right hip fracture. A review of Resident #101's electronic medical record/Resident incident reports showed that Resident #101 had five recorded falls in the facility since her admission on [DATE] to [DATE]: [DATE]: She (Resident #101) slid off her recliner and was lying on her right side (on floor). She stated that she has a little tenderness to the right upper leg. (Facility Name) Fall Committee Meeting Notes dated [DATE] show care plan changes as: Will request a reacher (assistance device) for resident from OT (occupational therapy). Continue plan of care. [DATE]: CNA entered room, found resident (#101) kneeling on knees beside bed on the floor mat .No injuries noted. (Facility Name) Fall Committee Meeting Notes dated [DATE] show care plan changes as: keep bible, bookmarks, and items of interest within reach. [DATE]: CNA walked down hallway and noted resident sitting on floor in front of recliner .2.0 x 7.0 cm light red area on L (left) deltoid (arm). (Facility Name) Fall Committee Meeting Notes dated [DATE] show alarm did not sound. (Facility Name) Fall Committee Meeting Notes dated [DATE] show no changes to care plan documented. [DATE]: Upon entering room resident observed lying on R (right) side on the floor, legs extended .R wrist pain .1.5 cm by 1.5 cm purple bruise to anterior R wrist .R arm pain, resident able to lift arms up while p.j.'s (pajama's) were slipped on. (Facility Name) Fall Committee Meeting Notes dated [DATE] show care plan changes as: alarming floor mat. [DATE]: CNA (B) went to pick up dinner tray at 1810 (6:10 p.m.) and found resident on the floor. There were no alarms going off. Resident (#101) was laying on the floor asking to call her daughter .Alarms checked and were functional .Resident had a large pool of blood around her head and she had blood on her hands from rubbing her head .Resident c/o (complained of) pain in R hip and back of head. An interview was conducted with CNA B on [DATE] at 2:37 p.m. regarding Resident #101's fall on [DATE]. CNA B stated, I went in to pick up her (Resident #101's) dinner tray and I found her on the floor with no alarms going off. She didn't say anything except she wanted to call her daughter .She had bleeding from the back of her head - like she hit pretty hard. CNA B reported she got help from Registered Nurse (RN) C. CNA B witness statement dated [DATE] was reviewed and consistent with her above statement. In an interview with RN C on [DATE] at 3:07 p.m., she stated: I heard (Resident #101) was on the floor. I went in .she was lying by the bed .I noticed bleeding (and) got gauze to stop the bleeding .there were no alarms sounding. Normally, she does have bed and chair alarms .the alarm mat was underneath the bed and there was a pillow on the chair where her alarm was supposed to be. RN C witness statement dated [DATE] was reviewed and consistent with her above statement. A telephone interview was conducted with CNA H on [DATE] at 12:07 p.m. When asked by this Surveyor about Resident #101 and the fall on [DATE], CNA H stated, We were passing dinner trays (on [DATE]) and she (Resident #101) was in between the bathroom and her bed with her brief and pants to her knee's. I got those pulled up, took her to the recliner and gave her the call light. I put her dinner tray on her bedside table (in front of her). There was no alarm on the wheelchair when I got her up .I wasn't, off the top of my head, thinking she had an alarm .it wasn't my regular hallway. I asked for a copy (of the care plan) and was told 'No' - it was a waste of paper. It wasn't an area (hall) I was used to working, I was just there passing dinner trays. CNA H indicated she did not know Resident #101 required assistance with meals, nor did she see the orange dot to indicate Resident #101 was a high fall risk. CNA H witness statement dated [DATE] was reviewed and consistent with her above statement. The document Investigation Statement authored by the Director of Nursing (DON) and dated [DATE], read, in part: .(CNA H) stated that there was not an alarm present in the wheelchair or the recliner and she did not see a floor mat. Because she did not see any alarms or mats, she did not place them or check them. She did not check to see if the resident (#101) has alarms as part of their care plan, she stated that it takes too much time to check the resident care plans. A review of CNA H personnel file was conducted on [DATE]. The personnel file revealed CNA H was hired on [DATE] and had the following Counseling Statements and Nursing Incident Observation Report(s) documented: [DATE]: On XXX[DATE] you transferred a resident resulting in a fall. On investigation of the fall it was noted that you did not follow the Care Plan, transferring this resident with 1 assist when she is Care Planned to use the (mechanical) lift for all transfers .Group 2 offense - failing to follow a prescribed resident care plan. Recommend verbal warning. The facility could provide no documentation of follow up/education for CNA H following this incident. [DATE]: CNA (H) went to transfer resident (#104) .I heard resident say 'Whoa' and observed her legs start to buckle. I was able to put my arm around resident and assist her into bed. I asked CNA (H) 'What's her transfer status?' and CNA (H) said 'I think a one assist .good thing you were in here to help.' CNA was not using a gait belt on the resident at the time of transfer. I then reported this to the charge/supervisor. The facility could provide no documentation of follow up/education for CNA H following this incident. [DATE]: Nurse (unidentified) observed 2 large Styrofoam cups on bedside table consisting of orange pop and water (resident with fluid restrictions). Professional Nurse asked (CNA H) why she provided these liquids and (CNA H) response was that she thought it was .(roommate) with the fluid restrictions .(CNA H) has failed to read or follow this resident care plan. Failing to execute this part of (CNA H) job description is unacceptable .Group 2 offense .failure to follow a prescribed resident care plan. Second offense. Written warning. The facility could provide no documentation of follow up/education for CNA following this incident. [DATE]: Last one (CNA H) to toilet resident before a fall . Training given and duration: 5 minutes .verbal education given on proper application of soft posey hugger (wheelchair restraint) placement and double checking to ensure proper fit. No evidence was found to show CNA H received a written Counseling Statement for failure to follow a care plan. [DATE]: (CNA H) reported that she assisted resident (#101) into her recliner .and delivered her supper tray. (CNA H) admits she did not place chair alarm pad in recliner. Also admits she did not place alarm mat in front of recliner .(CNA H) failed to follow resident's (#101) care plan resulting in harm to the resident. The facility document Employee Disciplinary Procedure dated [DATE], was reviewed. The procedure read, in part: This Policy Memorandum addresses the procedures to be followed by supervisory staff when imposing necessary employee discipline on members of their staff .The facility progressive disciplinary policy provides for the imposition of a: A. Verbal or Oral Warning. A verbal warning is the first level of progressive .discipline imposed .B. Written Warning. A written warning is the second level of progressive .discipline imposed .C. Suspensions Without Pay. A suspension from work without pay is a third level of progressive .discipline imposed .D. Shift suspension. A shift suspension may be used .is imposed for the remainder of the employee's scheduled shift, and is to be used as an on-the-spot method of enforcing work standards, in lieu of full suspension without pay. A shift suspension is optional and not a required step in the progressive .disciplinary process. An interview was conducted with RN I on [DATE] at 1:15 p.m. RN I indicated she was responsible for staff education in the facility and indicated that prior to Resident #101's fall on [DATE], the expectation was for the nurse aides to access the care plan electronically (computer stations on the wall). RN I confirmed she was asked by CNA H about printing a care plan for her use. RN I stated, They (care plans) would be this thick (indicating there would be too many pages to print or carry.) RN I stated, Since this (fall) has happened we created a book (located at nurse station) of residents with alarms and type (of alarms) .We held an in-service and offered and updated CNA (pocket) worksheets (documenting resident care plan interventions). The Director of Nursing was present for the interview and confirmed this statement. RN I and the DON provided no comment when asked by this Surveyor about the facility progressive disciplinary procedures for CNA H, and provided minimal documentation of additional supervision and/or continued training provided for CNA H. In an interview with Resident 101's Family Member (FM) D on [DATE] at 3:31 p.m., FM D stated, I'll be honest, I think it (fall with injury) did her (Resident #101) in earlier than she would have died . FM D reported she went to the emergency department/hospital and, .(I was told) there was a hairline crack in her (Resident #101) hip from the previous fall. He (emergency department doctor) wanted me to take her by ambulance to (a neurosurgery hospital) to open her skull to drain the bleed .I think it (fall)shortened my mother's life. An interview was conducted with FM G on [DATE] at 11:15 a.m. FM G stated, I spent a few nights with my mom. They (staff) don't respond to the buzzers. (Staff) shut off (alarm) mats. After that fall .it wasn't my mother no more. I used to be able to call and talk to her at night at 6:00 p.m. about .recipes .how our day went .did she get out . After the fall she could no longer answer the phone. FM G reported after the fall on [DATE], Resident #101 no longer knew her family members. The document Medical Certificate of Death for Resident #101 dated [DATE], was reviewed and read, in part: PART I. Enter the chain of events .that directly caused the death .: Chronic Obstructive Pulmonary Disease. PART II. OTHER SIGNIFICANT CONDITIONS contributing to death .Dementia, Fall . An interview was conducted with the Assistant Director of Nursing (ADON) and the DON on [DATE] at 2:40 p.m. The DON confirmed CNA H failed to follow Resident #101's care plan for assistance and supervision during her evening meal, and failed to activate the personal alarms called for in the plan of care. ( )

Based on observation, interview and record review, the facility failed to ensure that the drug regimens for 3 of 4 sampled residents (#5, 6 and 8) reviewed for antipsychotic use from a total of 19 sampled residents, had regimens free from medications used without adequate indications for use, without adequate monitoring, in an excessive dose, for an excessive duration or in the presence of adverse effects, resulting in involuntary movements for residents #5 and 6 and the potential for adverse effects for Resident #8. Findings include: A review of the EMR (Electronic Medical Record) for Resident #5 revealed a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the timeline for the antipsychotic medication [MEDICATION NAME], created by Social Work Director D, Resident #5 was admitted to the facility without the antipsychotic medication. On 1/29/15, according to the timeline, the physician prescribed the antipsychotic medication [MEDICATION NAME], 5mg (milligrams) at bedtime for 14 days to address the hallucinations and paranoia that Resident #5 was experiencing, believed to be a side effect of the [MEDICAL CONDITION] medication [MEDICATION NAME]. The [MEDICATION NAME] was discontinued and the [MEDICATION NAME] ordered for 14 days was discontinued as well. The timeline indicated that the [MEDICATION NAME] was discontinued by the physician on 2/12/15. The [MEDICATION NAME] was restarted at 5mg (the maximum recommended dose) on 3/24/15 for dx (diagnosis) paranoid state. A review of nurses' notes from 3/10 - 24/15 revealed most notes indicating confused, upset (son called and calmed her down), good spirits, etc. until 3/24/15 when she was noted to be suspicious . refused to go to breakfast (ate in Social work office) . conversation all over the place . Resident refused to have clothing readjusted by staff and threw her plant on the floor, threw the phone on the floor . Doctor ordered [MEDICATION NAME], 5mg every day. The timeline stated that on 3/29/15, Resident #5 was taken to the emergency room for violent hallucinations and delusions, anxiety. The [MEDICATION NAME] was ordered to be increased to 5mg IM (injection) twice a day until able to take oral meds then resume 5mg BID PO (twice a day by mouth). There was no consideration documented that the [MEDICATION NAME] could be causing the behaviors as the side effects of [MEDICATION NAME] included, anxiety . hallucination, mania, impaired concentration, abnormal thinking and dreaming according to the Consent for the Use of Antipsychotic Medication signed 1/29/15 by the Resident's son. According to the timeline, on 4/7/15 Resident #5 saw the Neurologist and the [MEDICATION NAME] was increased to 10mg twice a day for the first two days then 5mg in the morning and 10 mg at bedtime. The Nurses' notes for the 3 days prior to the dose increase indicated Resident #5 had been hallucinating, aggressive and agitated; there was no mention that the drug could be causing the paradoxical effect. There was no risk vs. benefit explanation to the administration of [MEDICATION NAME] On 4/13/15 the Primary Physician for Resident #5 refused the Consulting Pharmacist's recommendation for a dose reduction in the [MEDICATION NAME] stating improved on present dose. On 5/12/15 the Primary Physician reduced the dose of [MEDICATION NAME] to 10 mg at bedtime. According to Nurses' Notes dated 6/13/15, Resident is having abnormal jaw movement. On 6/16/15 the Nurses' Note read, (doctor's name ) was faxed . also informed of uninvol. (sic) movement of jaw. There was no reason documented for not informing the physician of the involuntary movements for the 3 days. A Nurses' Note dated 7/4/15 stated . she does have noticeable uncontrollable jaw tremors. (doctor's name) was notified of tremors via fax on 6/17 but this issue wasn't addressed. Will address when he comes into see her on next rounds. This does not seem to impact (Resident #5's name) negatively. This contradicted the resident's response when interviewed on 7/22/15 at 8:30 AM. Resident #5 stated that the tremors had been going on for a long time and they are really upsetting. The Neurologist saw Resident #5 on 7/10/15 per his note which stated in part, Pt (patient) has had some involuntary movements of the chin in the past month. Some tremors of hands. There was no mention of these issues as possible side effects of the [MEDICATION NAME] and no change in the dose of the drug or any medication to minimize these involuntary movement. The [MEDICATION NAME] dose was not reduced until 7/21/15. It was reduced to 5mg daily for abnormal jaw movement. No indication that the medication was under consideration to be totally discontinued due to the side effects. The Social Work Director, D was asked on 7/22/15 for the Risk versus Benefit Statements for the initial order of [MEDICATION NAME] for paranoid state and for each of the subsequent increases in the medication, particularly since all doses after 5mg exceeded the recommended maximum dose from the State Operations Manual, F329 related to the use of antipsychotic medications in Nursing homes. She reported on 7/23/15 at 8:25 a.m. that there were no individualized assessments of the relative risks versus benefits of the use of the antipsychotic medication which addressed either specific targeted behaviors or addressed the Federal Food and Drug Administration ' s (FDA) Black Box Warning which stated these medications (Antipsychotic medications) are not approved for the treatment of [REDACTED]. In addition, there were no notes from either the Physician, Neurologist or the Consulting Pharmacist which addressed the potential side effects (of [MEDICATION NAME]) mentioned in the Consent form signed by the son of Resident #5 on 1/29/15 which included tremor . involuntary movement side effects . headache ., anxiety, pain . increased saliva joint pain and back pain as well as the effects mentioned above, all of which the nurses' notes indicated, and/or an interview with Resident #5 (7/22/15 at 8:30 AM.) confirmed, had been happening to her. ( ) Review of Resident #6's face sheet (undated) from the electronic medical record revealed Resident #6 was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #6 was not her own responsible party. Resident #6's last Brief Interview for Mental Status was dated 4-27-15 and she was listed as having moderately impaired cognition. During an interview with Social Services Director (SWD) D and facility Social Worker (SW) J on 7-22-15 at 2:05 PM, SWD D said that SW J had first seen Resident #6 this month and had attended the behavior management meetings and documented behaviors for Resident #6. The documentation to verify if Resident #6 had yearly gradual dose reduction (GD) for her [MEDICAL CONDITION] medications was requested. During this interview, it was discussed resident #6 was prescribed [MEDICATION NAME] ( antipsychotic medication) since 2010 but the facility could not produce a documentation to note this. SWD D and SW J said Resident #6 did not have a GDR this year because she had two failed GDR's in the past. SWD D provided a document titled Resident Behavior Management Team Review for Resident #6 dated 5/12/15. It was noted Under Behavior Management Team Recommendations and Rationale, The Res (Resident) had 2 failed past dosage reductions in antipsychotic & 2 past failed dosage reductions in antidepressant medication. Another gradual dosage reduction attempt is believed to be clinically contraindicated at this time as it cause harm by exacerbating target mood and behavioral symptoms has been noted & this appears to coincide with the increase in [MEDICATION NAME] (antidepressant medication) dosage. She has had fluctuations in the past so will continue to monitor. It is believed she is a maintenance dosages of [MEDICATION NAME] (antipsychotic medication, [MEDICATION NAME] (antianxiety medication) and [MEDICATION NAME] (antidepressant medication) to meet her needs at this time. The benefits of these medications continue to outweigh the potential risks. No further dosage reductions are recommended at this time. It was unclear from this notation what specific behaviors were identified for exacerbated target mood and behavioral symptoms as a result of the drug reduction. It was unclear if these exacerbated target mood and behavioral symptoms were distressing and impeded the resident's quality of life. It was unclear what interventions or GDR care plans were put in place when the GDR's were implemented. A request for the documentation that showed Resident #6 failed the GDR's for the [MEDICAL CONDITION] medications was requested. SW J said Resident #6 failed a [MEDICATION NAME] 2.5 mg dose reduction on 4-22-14 when the doctor decreased the [MEDICATION NAME] 2.5 mg dose from 7 days a week to 6 days a week. However, SW J was unable to locate any documentation that showed specific behaviors with dates and time to verify this. SWD D and SW J said Resident #6 did not have a GDR this year, 2015 because of her past failed dose reductions. SW D said Resident #6 was originally put on [MEDICATION NAME] years ago ( upon admission, 2010) due to hallucinations but was not able to find any documentation in the last two years that Resident #6 had any hallucination nor exhibited hallucinations during her last dose reduction ( 2014) of [MEDICATION NAME]. SW J said Resident #6 cries and looks for her daughter when she is not here. SW J did not give any dangerous behaviors that justify the use of [MEDICATION NAME]. SWD J provided a typed document for Resident #6 around 8:30 AM on 7-23-15. This document for Resident #6 stated Per ICF-MR (Intermediate Care Facility for the Mentally Retarded, this does not apply to nursing homes) Regulations: Federal guidelines were brought forward and would still apply in Resident #6's name per, name of facility psychiatrist. Per guidelines after two gradual dosage reductions have 3-5 years after her last failed reduction in [MEDICATION NAME] before another reduction attempt has to occur as this is considered grace period. Last failed reduction occurred in April 2014. Resident #6 was observed in bed receiving care on 7-23-15 at 4:00 PM. by Certified Nurses Assistant (CNA) L . During care Resident #6 was on her back in bed and did not respond to any questions. Resident #6's eyes were open and her jaw was moving forward and backward the entire time. CNA L was asked how long Resident #6 had been having the jaw movement. CNA L said that Resident #6 started doing the jaw movement when she stopped using her dentures but CNA L could not recall how long ago Resident #6 had stopped using her dentures. Review of Resident #6's Dyskinesia Identification System Condensed User Scale (DISCUS) dated 2/3/15 documented a score of zero, no examination date and was signed by Registered Nurse (RN) P. However, observation on 7/23/2015 at 4:00PM indicated jaw movement which was not captured in the DISCUS tool. During an interview with RN P on 7-24-15 at 9:00 AM, RN P verified she was the nurse that signed Resident #6's DISCUS on 2/3/15. RN P said she had observed Resident #6 several times in many situations prior to 2/3/15 but did not recall the date or the amount of time she spent in a room with Resident #6. RN P said she received training to do the DISCUS in 2000 when she was in college but did not recall the amount of time or specifics involved to complete the DISCUS examination. RN P was unable to locate any instructions on coding the DISCUS. During an interview with the Director of Nursing (DON), B on 7-24-15 at 8:20 AM this Surveyor asked for the training and instructions for completing the DISCUS; DON B said the instructions were on the form. The form did not provide any detailed explanation of any of the 15 items that were to be scored and did not give any qualifying descriptions on how to score accurately. DON B was unable to locate any training of staff or specific instructions for completing the DISCUS. ( ) A review of the Electronic Medical Record (EMR) for Resident #8 revealed an [AGE] year old female admitted to Facility on 10-29-14 with [DIAGNOSES REDACTED]. On her last Brief Interview for Mental Status dated 11-4-14, Resident #8 scored 4 out of 15 indicating significant cognitive impairment. According to June physician orders, Resident #8 was taking [MEDICATION NAME] ( antipsychotic medication) 5 mg by mouth daily for [MEDICAL CONDITION]. On 6-23-15 Resident #8 was transferred to an inpatient psychiatric hospital out of state. She returned to facility on 7-13-15 at which time she was readmitted with orders for [MEDICATION NAME] 10 mg (twice the maximum recommended dose) by mouth daily for [MEDICAL CONDITION] and generalized anxiety disorder as stated on July Order Summary Report. Interview with Employee ' s N and F on 7-23-15 at 12:30 PM. reported resident #8 ' s behavior as restless, danger to others, and agitated , behavior reports were not available and no specific targeted behaviors were identified. Upon interview with employee J on 7-23-15 at 12:58 PM. when asked for Risk versus Benefit Statements, replied She came from the other facility on 10 mg [MEDICATION NAME], Risk versus Benefit was not done . However, the current facility staff did not develop one. ( )

This citation pertains to MI# 131 Based on observation, interview and record review the facility failed to maintain safety equipment of a fall sensor alarm in the "on" position to prevent a fall with fracture for 1 (#101) of 3 sampled residents resulting in Resident #101 being found on the floor with pain to the left hip area with fall sensor/alarm box in the "off" position, resulting in Resident #101 sustaining a left hip fracture and surgical repair. Findings include: Record review of Resident #101's 'Resident Incident Report' dated 7/15/14 at 9:00 PM revealed that the nurse heard Resident #101 calling "Help me, Help me" and upon entering the room the nurse noted observing Resident #101 lying on left side of body on the floor facing the wardrobe/closet. The incident report noted that Resident #101 had a laceration to the left hand below the thumb of 4 cm X 3 cm and left hip pain and would not move the left leg. Resident #101 was noted to state "I fell out of my chair". The incident report noted that the chair alarm was not turned on. Record review of facility procedural memorandum 'Fall Monitoring and Prevention' dated 2/10/14 revealed a fall as an unintentional change in position to rest on the ground, floor or on to the next lower surface. The fall may be witnessed, reported by the resident or an observation or identified when a resident is found on the floor or ground.....Fall assessments a tool to assess the residents fall related risks can be completed quarterly and PRN (as needed). The procedural memorandum identified external risk factors such as appliances or devices. Internal risk factors of disease process with potential to contribute to falls, perceptual/cognitive impairments. Bed and chair alarm protocol included that nursing staff would monitor bed and chair alarms for proper placement and function every shift and prior to every use and PRN. Record review of facility 'Certified Nursing Assistant' job description dated 2/23/12 for Certified Nurse Assistant (CNA) "D" revealed under the 'Equipment and Supply Functions' heading that staff will operate all equipment in a safe manner. Record review of Resident #101's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old female with Brief Interview of Mental status (BIMs) score of 3 out of 15, severely impaired cognitively. The MDS noted that the resident had experienced previous falls. [DIAGNOSES REDACTED]. Observation on 7/25/14 at 9:40 AM of Resident #101 revealed the resident to be lying in bed with a foam tape dressing noted to the left hip area with bruising to the left knee. Resident #101 stated that she banged the leg and that she went to the hospital for a day or so. There was a fall matt noted to the bedside on the floor and a gray box 'Sensor Care' alarm observed to the top of the head board. Observation of the alarm box noted a black switch on the right side of the box in the on position with a sensor pad attached and placed under the resident while in the bed. Observations on 7/25/14 of multiple residents with fall alarms noted that there were the gray box style with an on/off switch with no light to indicate if the box was no or off at a glance, and a blue box style that had 'tamper resistant' with no on/off switch noted to the box with an indicator light of function. Observation of alarm boxes revealed that the alarms were placed in the back middle of the wheelchairs between the wheelchairs handles facing outward. There were two sampled residents that had releasing lap safety belts with alarms that alarmed when the resident leaned too far forward. Record review of Resident #101's 'Fall Committee Meeting Notes' dated 4/23/14 revealed that the resident was observed on the floor on 4/20/14 in her room. Fall team discussion included looking into if Resident #101 needed to be put to bed at a certain time. Daughter asked about a trunk restraint. The team reviewed the concept of the trunk restraint but it is meant as a last resort and other options need to be tried first. Careplan updated on 4/22/14 to add "put to bed between 8:00-8:30 PM" and to put at the nursing station after supper. Daughter would also be asked to place Resident #101 at nursing station when she left after supper. There was no documentation presented to the surveyor that the daughter was educated on the plan. Review of the 'Fall' care plan, dated 4/22/14, did not note the daughter was to place Resident #101 at the nursing station when she leaves. Record review of Resident #101's 'Falls' care plan revision date 4/22/14 revealed that the resident was a risk of falls due to poor safety awareness, history of falls, psychoactive drug use, balance problems, incontinence, arthritis, pain, being hard of hearing, and having the potential of psychosis, delirium, infection and dehydration. Interventions included the high risk fall program, chair alarm and to check alarm function and placement every shift and prior to each use and PRN. Resident #101 was care planned to be put to bed at 8:00-8:30 PM. In an interview on 7/25/14 at 2:35 PM with Registered Nurse (RN) "E" revealed that she was at the medication cart in the hallway when she heard Resident #101 "Help me, help me". RN "E" stated that she entered Resident #101's room and found the resident on the floor in front of her wardrobe/closet on her left side with a gash (laceration) to the left arm and the resident would not move her left leg. RN "E" stated that the chair alarm was not sounding when she entered the room and that the alarm was turned off. RN "E" stated that Resident #101 had no history of shutting off her alarm. RN "E" stated that Resident #101 would sit toward the front of her wheelchair and would lean forward to look into the closet. RN "E" stated that the alarm box was turned off and placed to the middle of the back of the wheelchair. In an interview on 7/25/14 at 2:55 PM with Registered Nurse (RN) "C" who was the evening supervisor on 7/15/14 revealed that she was called into Resident #101's room to assist RN "E". RN "C" stated that she did not hear Resident #101's alarm sounding to her chair and wondered why. RN "C" stated that she checked the alarm box and the switch was off. RN "C" stated that she flipped the switch to the on position and the alarm sounded and was functional, but just not on. RN "C" stated that she had never seen/observed Resident #101 turn off her alarm. RN "C" stated that alarms are expected to be on if care planned. RN "C" stated that the alarm switch is level with the alarm box and can be felt by the finger and that the gray alarm boxes have no light to indicate that the alarm is on. RN "C" stated that Certified Nurse Assistant (CNA) "D" stated that the alarm was on after she toileted the resident at around 7:00 PM. RN "C" stated that prior to the fall Resident #101 would self-propel her wheelchair and would go through her closet for clothes for the next day and just fussing with her stuff. In an interview on 7/25/14 at 11:20 AM with Certified Nurse Assistant (CNA) "D" revealed that she had toileted Resident #101 around 7:00 PM and did HS (bed time care) while in the bathroom. CNA "D" stated that when Resident #101 stands up the alarm sounds, and that Resident #101 had a gray alarm box that has to be turned on/off by a switch or they continue to sound. CNA "D" stated that she stood Resident #101 up and she shut off the alarm box and transferred Resident #101 to the toilet, did HS care and put on night gown. CNA "D" stated that she transferred the resident back into her wheelchair and turned on the alarm and took Resident #101 back into her room where the daughter was visiting and left the resident with the daughter, but did not place the resident in bed. CNA "D" stated that the daughter left while she was on lunch and that she did not see the daughter leave. CNA "D" stated that she was helping another resident when a call came over the walkie/talkies about Resident #101's fall. CNA "D" did not state if she checked the function and placement of the alarm prior to each use as care planned. Record review of 'Care Sense' chair monitor direction for use (undated) revealed under warning section 6.) Control unit will not alarm with the on/off switch in the off position. 9.) This is not suitable for "High Risk for fall" residents. #

This citation pertains to MI# 915 Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistive devices to prevent a fall in 1 (Resident #101) of 4 total sampled residents, from a total sample of 4 residents, resulting in Resident #101, who has a history of dementia and falls, having her safety alarm discontinued by facility staff, and sustaining a fall that resulted in fracture. Findings include: Record review of Resident #101's incident report dated 12/22/11 at 6:40 PM revealed [DIAGNOSES REDACTED]. The incident report reflected that Resident #101 was calling out "Help me" from her room while a nurse was walking by. Resident #101 was found lying on the floor on her left side next to her bed. Right leg extended forward and left leg bent inward with left arm under her side bent toward mid line. It was noted that the resident stated she was trying to get ready for bed. Wheelchair was in front of other bed in room and Resident #101 stating "it got there after I fell ". The incident report noted that Resident #101's left hand grasp was weak. Corrective action was noted as suggested that the wheelchair alarm be turned on during the day. Record review of Resident #101's minimum data set ((MDS) dated [DATE] revealed a [AGE] year old female with brief interview for mental status (BIMs) score of 9 (moderately impaired). Balance during transitions and walking were noted as unsteady from surface to surface. Record review of Resident #101's fall risk assessment dated [DATE] history of 1-2 falls in past 3 months, ambulation as chair bound, gait/balance as requires use of assistive devices, systolic blood pressure drop less than 20 points between lying and standing, takes 3-4 medications, predisposing diseases of 3 or more present. A total score of 15 was noted, a total score of 10 or above represents high risk. Record review of Resident #101's nurse note dated 12/22/11 at 10:00 PM revealed that at 6:40 PM Resident #101 sustained a fall and complained of pain to left hip, left top of head, left hand that radiates up to neck rated at "100". Pain medication was given at 6:50 PM. It was noted that the left elbow had 4.5 X 2 centimeter (cm) red area surrounded with light green area. Range of motion same as prior to fall, except left arm/hand slow to respond and "hurts to move". The nurses note reflected that the wheelchair brakes were not applied and that the resident was wearing slippers. Record review of Resident #101's nurse note dated 12/23/11 at 6:45 AM revealed that Resident #101 complained of pain in left hand and that ice was applied. Record review of Resident #101's nurses note dated 12/23/11 at 8:10 AM written by the RN MDS #3, revealed that the fall investigation was initiated related to fall on 12/22/11 at 6:40 PM. The nurses note reflected that the care plans were reviewed and that alarms to bed and chair were changed on 12/21/11 to be applied at night time only. The RN MDS #3 noted that Resident #101 had demonstrated safe transfers to the writer and per routine caregivers. The alarms to bed and chair were changed back to at all times (after the fall on 12/22/11). RN MDS #3 noted that Resident #101 would be reviewed at the next fall committee meeting. There was no note by the RN MDS #3 of an assessment of Resident #101 or of her left hand post fall which occurred 12/22/11. Record review of Resident #101's nurses note dated 12/23/11 at 8:30 AM reflected that Resident #101 was noted to be holding her left hand in a claw like position because it hurts to extend the fingers with shooting pain to elbow if she tries to extend them. The left hand was noted to be very swollen to wrist area and deeply colored blue/purple bruising. The nurses note reflected that an order was then received to send Resident #101 for x-rays. Record review of Resident #101's fall care plan dated 8/11/10 revealed Resident #101 had the potential for falling related to cognitive impairment, need for assistance, [DIAGNOSES REDACTED]. Approaches included anticipate needs, to maintain safe behaviors such as the need for toileting, food and drink, rest and change in position, that may cause self transfers, leaning or reaching in unsafe manner. Observe for gait unsteadiness. Observe for decreased or loss of functional status. Record review of Resident #101's cognitive care plan dated 11/15/10 revealed the Resident #101 displays some signs of cognitive impairment and to provide verbal reminders and cueing of safety interventions and daily activities. Record review of Resident #101's activity of daily living (ADL) care plan dated 8/11/10 revealed Resident #101 required assist with ADL's and mobility due to history of fractured ribs, chronic back pain and dementia. There was a note on 11/1/10 written: May be independent in room, then D/C'd (discontinued) on 9/15/11. On 9/21/11 SBA (stand by assist) of one person for transfers was added to interventions. Record review of Resident #101's social services progress note dated 12/5/11 in the fifth paragraph noted that the resident believed that her own memory was a little worse. Record review of fall committee meeting notes dated 12/28/11 for Resident #101 revealed a fall on 12/22/11 at 6:40 PM. The fall team noted that the (wheelchair) brakes were not locked, wheelchair on side of bed (bed across room) and that Resident #101 stated it (wheelchair) had gotten there after she fell . Resident #101's alarms were not on as care planned for at bed time. The fall team noted that care plans were updated for bed and chair alarms at all times. In an interview on 2/6/12 at 2:00 PM, the registered nurse minimum data set (MDS) #3 revealed: "That day of the fall, staff had been watching Resident #101 for a while.....we took off her alarms about 10:00 AM that day. Explained safety needs to lock brakes, grab bars on the bed. I went home at the end of the day. When I came back the next day I heard Resident #101 had fallen". Continued interview with the RN MDS #3 revealed that she did not write an assessment or notes in Resident #101's medical record to reflect safe removal of fall/safety alarms. The RN MDS #3 was asked why a physical therapy evaluation was not ordered or done to assess Resident #101 for safe transfers and strength, RN MDS #3 replied "I just didn't, I only observed her". In a second interview on 2/6/12 at 3:00 PM, RN MDS #3 revealed that when alarms are discontinued the resident is "reviewed in the falls committee, watched for a week and certified nurse assistants (CNA) will tell us (nurses), let us know if alarms can be removed". The RN MDS #3 reviewed the fall committee notes for Resident #101 and on 9/28/11 Resident #101 was reviewed and no changes were made. The RN MDS #3 stated that Resident #101 had a fall from toilet (9/14/11) with increased weakness and unsteady gait .... "I just observed her and decided to discontinue alarms. Staff would call me to go watch her (Resident #101) self transfer, did fine when I watched. No, I didn't write any assessment down, nothing. I might have wrote a nurse note, I don't recall". Record review of resident #101's physician progress dated 12/20/11 revealed that Resident #101 had dementia and was being monitored by the behavior management team. Record review of Resident #101's physician progress dated 12/23/11 revealed a hand written note added to the bottom of the note dated 12/20/11, revealed pain and ecchymosis in left hand after a fall last night. The physician noted that there will be x-rays of left hand and wrist/forearm. The physician noted that the forearm has only minimal tenderness, with the elbow/arm/shoulder non-tender. Record review of the facility 'Fall Prevention and Safety Intervention' policy dated 6/16/11 revealed that the facility had a policy and procedure for implementing safety alarms. The policy stated that there was a Fall Risk Assessment tool to assess a residents fall-related risk. In an interview on 2/6/12 at 3:20 PM, registered nurse assistant director of nursing (ADON) #4 revealed that there was no formal policy or procedure for discontinuing alarms. In an interview on 2/6/12 at 3:30 PM, registered nurse director of nursing (DON) #2 stated that to discontinue fall/safety alarms the resident is reviewed by the fall committee. The DON and the state surveyor along with the RN MDS #3 reviewed resident #101's medical record and found that there were no notes in the medical record about alarm removal assessment. The DON was asked why physical therapy had not evaluated resident #101 for strength prior to removal of alarm, and the DON stated that usually the facility does have physical therapy evaluate. The DON stated that there was no policy or procedure for the alarm/safety device removal and that there was no removal assessment tool. Observation on 2/6/12 at 9:10 AM during the entrance tour revealed Resident #101 to be self propelling her wheelchair in her room and that there was a cast to her left hand and wrist area. In an interview on 2/6/12 at 9:10 AM, Resident #101 stated that she was getting into bed and had put her knee onto the bed and somehow slid under the bed. Resident #101 stated that there was no one else in the room and that she started yelling for help. Resident #101 stated that her left wrist hurt after the fall and that her fingers and wrist swelled up and that she had x-rays at the hospital the next day. Record review of hospital x-ray results dated 12/23/11 reflected a displaced left 3rd metacarpal fracture and a nondisplaced fracture of the distal radius. #

THIS CITATION PERTAINS TO MI 597. BASED ON OBSERVATION, INTERVIEW, AND RECORDS REVIEW THE FACILITY FAILED TO SUPERVISE, ENSURE THE SAFETY AND PREVENT THE ELOPEMENT FOR 1 (#101) OF 7 SAMPLED RESIDENTS OF A TOTAL SAMPLE OF 17 RESIDENTS WHO WERE COGNITIVELY IMPAIRED AND AT RISK FOR ELOPEMENT DUE TO ELOPEMENT RISK ASSESSMENTS NOT BEING COMPLETED, RESULTING IN AN IMMEDIATE JEOPARDY WHEN CNA #7 LEFT RESIDENT #101 UNSUPERVISED IN THE FRONT LOBBY NEAR THE FRONT DOOR OF THE FACILITY, RESULTING IN RESIDENT #101 ELOPING FROM THE FACILITY UNBEKNOWNST TO FACILITY STAFF, AND BEING AT RISK FOR FALLS, INJURY AND DEATH. FINDINGS INCLUDE: REVIEW OF RESIDENT #101'S MEDICAL RECORD REVEALED AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. HER MINIMUM (MDS) data set [DATE] DOCUMENTED THAT SHE REQUIRED EXTENSIVE ASSISTANCE OF ONE PERSON FOR TRANSFERS, DRESSING AND HYGIENE, AND WAS ABLE TO SELF PROPEL HER WHEELCHAIR ON AND OFF THE NURSING UNIT. RESIDENT #101'S PLAN OF CARE DATED 4/28/10 IDENTIFIED HER TO BE AT RISK FOR FALLS DUE TO HER COGNITIVE IMPAIRMENTS FROM ADVANCING DEMENTIA WITH POOR SAFETY AWARENESS, DECREASED MOBILITY, AND [DIAGNOSES REDACTED]. ON 8/16/11 AT 9:45 AM, THE SURVEYOR AND DIRECTOR OF NURSING REVIEWED RESIDENT #101'S COMPLETE MEDICAL RECORD AND WERE UNABLE TO LOCATE AN ELOPEMENT RISK ASSESSMENT. REVIEW OF FACILITY POLICY, DATED 1/26/11, REVEALED THAT RESIDENTS WHO ARE NOT THEIR OWN LEGALLY EMPOWERED PERSON/REPRESENTATIVE AND WHO ARE NOT ABLE TO MAKE SOUND DECISIONS ABOUT THEIR OWN SAFETY, MAY NOT BE LEFT UNATTENDED ON OAKVIEW GROUNDS, INCLUDING THE FRONT ENTRANCE. THE POLICY ALSO STATED THAT RESIDENTS WILL BE ASSESSED FOR WANDERING AND FOR ELOPEMENT RISK UPON ADMISSION, QUARTERLY AND WITH A SIGNIFICANT CHANGE IN CONDITION. ON 8/16/11 AT 8:10 AM, THE SURVEYOR OBSERVED THE FRONT DOOR AND LOBBY AREA OF THE FACILITY. THE FRONT DOOR CONSISTED OF TWO DOORS WITH A VESTIBULE BETWEEN THE TWO DOORS. THERE WAS NO LOCKING MECHANISM OBSERVED ON EITHER DOOR. A KEY PAD WAS OBSERVED ON THE WALL NEXT TO THE ENTRANCE DOOR CLOSEST TO THE LOBBY. DIRECTLY OUTSIDE OF THE FACILITY DOOR, THE SURVEYOR OBSERVED A SIDEWALK, WHICH DECLINED DOWNWARD AWAY FROM THE FACILITY WITH ROCKS ON EITHER SIDE OF THE SIDEWALK, WHICH LED TO THE FACILITY PARKING AREA. IN AN INTERVIEW ON 8/16/11 AT 10:08 AM, THE FACILITY DIRECTOR OF MAINTENANCE STATED THAT THE FRONT DOOR OF THE FACILITY AUTOMATICALLY LOCKED AT 8:00 PM UNTIL 5:00 AM. THE LOCKED FRONT DOOR ONLY PREVENTED ENTRANCE INTO THE FACILITY AND NOT EGRESS FROM IT. THE DIRECTOR OF MAINTENANCE STATED THAT ANYONE INSIDE THE FACILITY, EXCEPT RESIDENTS WITH A WANDERGUARD BRACELET ON, COULD EXIT THE FACILITY AT ANYTIME. IN AN INTERVIEW WITH THE DIRECTOR OF NURSING ON 8/16/11 AT 8:15 AM, THE DIRECTOR OF NURSING STATED THAT RESIDENT #101 WAS FOUND BY VISITOR #11 ON THE SIDEWALK IN FRONT OF THE FACILITY WITH THE FRONT TIRE OF HER WHEELCHAIR STUCK IN THE ROCKS NEXT TO THE EDGE OF THE SIDEWALK. THE DIRECTOR OF NURSING (DON) STATED THAT VISITOR #11 BROUGHT RESIDENT #101 BACK INTO THE FACILITY. THE DIRECTOR OF NURSING STATED THAT THE LOBBY NEAR THE FRONT DOOR OF THE FACILITY WAS A RESIDENT AREA, THAT THE FRONT DOOR OF THE FACILITY WAS NOT ALARMED AND THERE WAS NOTHING TO STOP A RESIDENT FROM EXITING UNDETECTED FROM THE FACILITY THROUGH THE FRONT DOOR, INCLUDING DURING THE EVENING OR NIGHT HOURS. THE DIRECTOR OF NURSING STATED THE FRONT DOOR IS ALARMED SOLELY WITH A WANDERGUARD SYSTEM. IN AN INTERVIEW ON 8/16/11 AT 11:50 AM, THE DON STATED THAT CERTIFIED NURSE AID (CNA) #7 WAS OBSERVED ON THE FACILITY CAMERA, WHICH RECORDS ACTIVITY IN THE LOBBY OF THE FACILITY, LEAVING RESIDENT #101 UNSUPERVISED IN THE FACILITY LOBBY NEAR THE FRONT DOOR ON 8/10/11 AT 6:21 PM. A REVIEW OF PHOTOS FROM THE FACILITY CAMERA REVEALED THAT RESIDENT #101 EXITED THE FRONT DOOR OF THE FACILITY AT 6:22 PM, AND WAS BROUGHT BACK INTO THE FACILITY BY VISITOR #11 AT 6:25 PM. IN AN INTERVIEW ON 8/16/11 AT 3:20 PM, CNA #3 STATED SHE WAS ASSISTING ANOTHER RESIDENT AROUND 6:30 PM ON 8/10/11 WHEN VISITOR #11 CAME TO HER (CNA #3), ASKED IF RESIDENT #101 WAS SUPPOSED TO BE OUTSIDE BY HERSELF AND REPORTED THAT HE HAD FOUND RESIDENT #101 OUTSIDE IN FRONT OF THE FACILITY, ALONE. CNA #3 STATED VISITOR #11 TOLD HER RESIDENT #101 HAD GOTTEN HER WHEELCHAIR STUCK IN THE ROCKS NEXT TO THE SIDEWALK, AND THAT HE (VISITOR #11) HAD BROUGHT RESIDENT #101 BACK INTO THE FACILITY AND PARKED HER IN HER WHEELCHAIR NEXT TO THE NURSE'S STATION. CNA #3 STATED SHE IMMEDIATELY CHECKED RESIDENT #101 AND MADE SURE SHE WAS OKAY AND THEN REPORTED WHAT SHE HAD BEEN TOLD BY VISITOR #11 TO REGISTERED NURSE (RN) #2. CNA #3 STATED THAT RN #2 PUT A WANDERGUARD (BRACELET AND ALARM SYSTEM USED TO ALERT STAFF IF A RESIDENT ATTEMPTS TO EXIT FACILITY DOORS) ON RESIDENT #101 AND STAFF INITIATED 15 MINUTES CHECKS ON RESIDENT #101. CNA #3 STATED SHE WAS JUST VERY GLAD THAT RESIDENT #101 DID NOT FALL AND GET HURT. IN AN INTERVIEW ON 8/16/11 AT 3:00 PM, VISITOR #11 STATED ON 8/10/11 WHEN HE CAME TO THE FACILITY TO VISIT A FAMILY MEMBER, HE OBSERVED RESIDENT #101 SITTING IN HER WHEELCHAIR ON THE SIDEWALK OUTSIDE OF THE FACILITY WITH THE FRONT WHEELS OF HER WHEELCHAIR STUCK IN THE ROCKS NEXT TO THE SIDEWALK. VISITOR #11 STATED THERE WAS NO WAY THAT RESIDENT #101 COULD GO ANYWHERE, SO HE ASKED HER IF SHE NEEDED SOME HELP. VISITOR #11 STATED THAT RESIDENT #101 TOLD HIM SHE NEEDED HELP, SO HE RELEASED HER WHEELCHAIR FROM THE ROCKS, PUSHED HER BACK INTO THE FACILITY AND PARKED HER NEAR THE NURSE'S STATION. VISITOR #11 STATED HE WAS JUST GLAD THAT RESIDENT #101 DID NOT GET HURT. THE SURVEYOR REVIEWED A LIST OF RESIDENT'S WHO WERE INDEPENDENT WITH LOCOMOTION PROVIDED BY THE FACILITY DIRECTOR OF NURSING, AND A LIST OF RESIDENTS WHO WERE COGNITIVELY IMPAIRED AND REQUIRED A PERSON TO MAKE DECISIONS FOR THEM, PROVIDED BY THE FACILITY SOCIAL WORKER. 26 RESIDENTS WERE IDENTIFIED TO BE COGNITIVELY IMPAIRED AND INDEPENDENT WITH LOCOMOTION. THE MEDICAL RECORDS OF ALL 26 RESIDENTS WERE REVIEWED BY THE SURVEYOR ON 8/16/11. THE MEDICAL RECORDS OF 17 RESIDENTS DID NOT CONTAIN A WANDERING/ELOPEMENT RISK ASSESSMENT. ON 8/18/11 AT 8:55 AM, THE ADMINISTRATOR AND THE DIRECTOR OF NURSING WERE NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 08/10/11 WHEN RESIDENT #101 WAS LEFT UNSUPERVISED NEAR THE FRONT DOOR OF THE FACILITY AND EXITED THE FACILITY, UNBEKNOWNST TO FACILITY STAFF. ON 8/18/11 AT 3:00 PM, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. ON 8/10/11 FACILITY STAFF PLACED A MONITORING DEVICE ON RESIDENT #101. 2. 8/17/11 - 8/18/11 NURSING STAFF PERFORMED ASSESSMENTS OF ALL FACILITY RESIDENTS UTILIZING OMCF FORM 3-72 (MDS WANDERING/ELOPEMENT RISK ASSESSMENT). AN AUDIT WAS THEN COMPLETED FOR CONFIRMATION THAT EACH RESIDENT ASSESSMENT WAS COMPLETE. 3. 8/12/11 - FACILITY POLICY (RESIDENT WANDERING/ELOPEMENT/SUPERVISION) WAS UPDATED TO REFLECT THE CHANGE: STAFF IS NOT TO PHYSICALLY DIRECTLY PLACE A RESIDENT IN THE LOBBY AREA WITHOUT SUPERVISION UNLESS THE RESIDENT IS THEIR OWN DECISION MAKER, AND IS CAPABLE OF MAKING SOUND DECISIONS. 4. 8/12/11: A MEMORANDUM ALONG WITH THE REVISED POLICY WAS PUBLISHED AND DISTRIBUTED TO ALL STAFF FACILITY WIDE AND ALL DIRECTORS CONDUCTED AN INSERVICE WITH THEIR RESPECTIVE EMPLOYEES. 5. 8/17/11: THE FACILITY WILL EMPLOY STAFF AS A RECEPTIONIST IN THE FRONT LOBBY IN VIEW OF THE ENTRANCE 24/7, MONDAY THROUGH SUNDAY, INDEFINITELY. 6. 8/18/11: THE INITIAL AUDIT TO ENSURE THAT NURSING STAFF PERFORMED ASSESSMENTS OF ALL FACILITY RESIDENTS UTILIZING MDS WANDERING/ELOPEMENT RISK ASSESSMENT FORM. 7. STARTING 8/18/11 THE SAFETY COMMITTEE WILL REGULARLY REVIEW THE NUMBER OF RESIDENTS WHO HAVE ATTEMPTED TO EXIT FROM THE FACILITY, FOR ANY GENERAL FACILITY SYSTEMIC CHANGES THAT MIGHT BE INDICATED. 8. STARTING 8/18/11 THE DIRECTOR OF NURSING WILL REVIEW, DOCUMENT AND TRACK THE RESIDENTS THAT HAVE BEEN DOCUMENTED TO HAVE ATTEMPTED EXIT FROM THE FACILITY. THIS REPORT WILL BE MONITORED THROUGH THE QUALITY ASSESSMENT AND ASSURANCE COMMITTEE FOR ANY FURTHER SYSTEM CHANGES. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 8/18/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN, AND SEVERITY OF NO ACTUAL HARM BUT POTENTIAL FOR MORE THAN MINIMUM HARM THAT IS NOT AN IMMEDIATE JEOPARDY, DUE TO NOT ALL FACILITY STAFF HAVE RECEIVED THE IN-SERVICE EDUCATION AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. #