Every finding on record at Pinnacle Care of Battle Creek

Based on observations, interviews, and record review the facility failed to protect the resident's (Resident #1) right to be free from physical abuse by Resident #2. Findings Included:This citation pertains to intake number 3032111. Resident #1 (R1): Review of R1's electronic medical record (EMR) revealed R1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnoses included repeated falls and muscle weakness, Resident #2 (R2): Review of R2's EMR revealed R2 was a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnoses included psychotic disturbance, vascular dementia, severe, with behavioral disturbance. Review of a Social Services Quarterly Evaluation dated 6/4/2026 revealed that on 5/4/2026 R2's Brief Assessment of Mental Status (BIMS) score was a 13 out of 15 which indicated R2 was of normal cognitive functioning. Record review of a facility reported incident (FRI) dated 5/23/2026 revealed that on 5/23/2026 R2 was in the hallway in his wheelchair, when R1 also was coming around the corner. R1 was walking with his walker when R2 backed into R1 with his wheelchair and continued to back into R1 until R1 fell to the floor. The FRI report revealed R1 had a laceration 3.8 X 0.1 cm in size to the back of his head that was bleeding. R1 was also noted to complain of right hip pain, an ambulance was called, and R1 was found to have a right hip fracture and a laceration to the back of his head. The report revealed R1 stayed five days in the hospital and required surgery to repair the fractured right hip. The facility investigation summary dated 6/2/2026 revealed R2 was in his wheelchair heading to the dining room and R1 was coming from the dining room, when R2 started talking to R1 who continued to walk in the opposite direction. Then R2 started to reverse in his wheelchair, and R1 put his hand out to R2's back telling R2 not to bump into him. The summary revealed that R2 continued to bump into R1 until R1 fell to the floor. A nurse heard the commotion and upon arriving R2 was moved away from R1, and R1 was observed to be lying on his back with a small amount of blood under his head. The facility investigation summary further revealed that an interview was conducted with R1, and R1 stated that he was walking from the dining room when R2 came around the corner wheeling in his wheelchair. R1's documented interview revealed that R2 started mouthing to me and I kept walking. R1 said in the interview that as he was walking around the corner he felt R2's wheelchair bump into him. R1 stated that he put his hand out trying to tell R2 to stop backing up, but R2 continued to back up, and he lost his balance and fell to the floor. The facility investigation summary revealed that there were no witnesses however the incident was captured on the facility's surveillance camera. The summary also revealed that the facility notified the police who went to the facility and interviewed R2, and R2 was placed on a one-on-one supervision. The summary conclusion revealed that R1 stated that R2 did intentionally back into him causing him to fall, and after staff reviewing the video coverage the conclusion was documented to be that R2 did appear to keep backing up into R1 after being told to stop. The facility concluded that resident to resident abuse was substantiated. Review of the facility incident report dated 5/23/2026 revealed that when R1 was being assessed and prepared for transfer to the hospital R2 was separated from R1 during that time, but R2 attempted to return to R1 several times to begin an altercation again. Review of the hospital records dated 5/26/2026 revealed R1 had a fracture of his right femur and a laceration to the right scalp. The notes revealed that R1 had surgery to repair his fractured right hip on 5/24/2026. In an interview on 6/18/2026 at 12:00 PM, R1 stated that on 5/23/2026 an incident occurred with R2. R1 reported that he was walking down the hall with his walker when R2 approached him from behind and ran into him with the back of his wheelchair. R1 said he pushed R2 off of him and told R2 to stop, but then R2 came back at him even harder and rammed into him with the back of his wheelchair which caused him to fall backwards onto the floor. R1 said he hit his head causing a laceration. R1 stated that he was transferred to the hospital and had to get two staples in his head. R1 also said he fractured his right hip and had to have surgery. R1 revealed his incision scar, which was observed to be on the right hip. R1 described his decline since the event. R1 states that as a result of this he can no longer stand at the bathroom sink and shave or brush his teeth, because he is too weak since the fall. R1 said he could do all that before the fall. R1's laceration to the back of his head was observed with staples in place. In an interview on 6/18/2026 at 12:36 PM, an attempt was made to interview R2 however, R2 became angry and stated that R1 did not have his walker, fell down, and he did not know why R1 fell down. Observation of a surveillance video provided by the facility dated 5/23/2026 at 1:19 PM revealed R1 walking around the corner using his walker, and R2 was observed coming around the same corner in his wheelchair. The video revealed R1 showed up around the corner first followed immediately by R2 who self-propelling was purposefully backwards in his wheelchair next to R1. Then R1 walked behind R2's wheelchair and was observed using his left arm to touch R2's back and attempt to separate himself from R2. The video revealed that at that time R1 was able to turn forward with his back to R2 however, R2 was observed to purposefully continue to move backwards in his wheelchair looking back behind his shoulder at R1. The video revealed R2 with no attempt to move out of the path of R1 and without stopping or slowing down. Then R2 hit R1 with his wheelchair and upon hitting R1, R2 continued to move his wheelchair again up against R1 until R1 fell down to the floor lying flat on the floor. Review of R2's progress notes revealed a previous resident to resident event on 4/14/2026, (R2 resident's name redacted) had to be removed from BINGO after calling another resident a F**king N**er B**ch. He continued being disrespectful and using foul language., and on 4/15/2026, Resident (R2) was removed from dining room this shift for being disrespectful to residents/staff. Further review of R2's progress notes revealed that on 4/21/2026 R2 was being verbally abusive to other residents while in the hallway. Also, on 5/8/2026 R2's progress notes revealed R2 was in the main dining room being verbally abusive towards other residents. Of note the current NHA was new to the facility during the week of survey and had no further information to provide. In an interview on 6/18/2026 at 12:09 PM with Licensed Practical Nurse (LPN) C stated that R2 had always been aggressive and could not have a roommate because of his aggression. LPN C said R2 was verbally aggressive towards male residents, would poke female residents, and cuss at them. LPN C said that was abuse and management was aware of it. LPN C stated that before the incident on 5/23/2026 there were no interventions in place to stop R2 from verbally or physically abusing other residents.In an interview on 6/18/2026 at 12:59 PM Certified Nurse Aid (CNA) D stated that R2 was verbally aggressive towards residents and sexually towards women. CNA D stated that R2 would instigate pretty much all the fights by verbally saying things to residents like calling them a bitch, or a racial name, but he does know better. CNA D said R2 had always been this way towards other residents. CNA D stated R2 does touch and poke other residents and that management knows about the abuse. Review of R2's care plans revealed that a care plan for behaviors was in place. The care plan was dated 5/21/2019 as the dated the care plan was initiated. The care plan addressed that R2 was physically and verbally aggressive at times, may yell profanities at other residents. The care plan had no interventions for increased supervision related to R2's abusive behaviors towards other residents. The care plan had no new interventions added after each verbal abuse incident that occurred on 4/14, 4/15, 4/21, or 5/8/2026 with R2. The care plan had not been updated since 1/14/2026. The Care Plan meeting IDT note signed by the social worker on 6-3-26 reflected the facility attempted to reach the guardian. Noting R2s guardian no longer wants to be in place.

Based on interview and record review the facility failed to ensure required Quality Assurance Performance Improvement (QAPI) committee members attended all QAPI meetings. Findings Included: This citation pertains to intake number 3014134. In an interview on 6/18/2026 at 7:35 AM, Medical Director (MD) E, who was the facility's Physician, stated that he had not been to a QAPI meeting at the facility in so long that he could not recall the last time he was at one. MD E stated that the facility always scheduled the meetings at times he could not attend, and he told them several times the times he was available to attend but they still did not schedule the QAPI meetings around his availability. MD E was very angry while speaking of the concern and stated that all facilities scheduled their QPAPI around the Medical Director's availability, but this facility would not do that, so he was never able to attend.Immediately following the interview with MD E, Administrator A was requested to provide the last year of QAPI sign in logs. Administrator A stated that it was mandatory that MD E be present at all the QAPI meetings. Administrator A said she had only been employed at the facility for one week and said she would have to put a correction plan in place for QAPI. Review of the last years of QAPI sign sheets revealed that on 6/17/2025 MD E did not sign in as attending the QAPI meeting, furthermore, the sing sheet revealed that no infection Control Preventionist (ICP) signed in to the meeting either as in attendance. The ICP is a required committee QAPI member to attend QAPI every time QAPI meets. On 6/27/2025 there was no ICP signature attesting to attendance at the QAPI meeting, on 7/1/2025 there was no ICP signature, on 7/31/2025 there was no ICP signature, on 8/14/2025 there was no ICP signature, on 8/28/2025 there was ICP signature, on 9/25/2025 there was no ICP signature, on 10/21/2025 MD E did not attend the QAPI meeting; his signature was not on the sign in log. The log dated 10/21/2025 only had staff signatures but did not identify the roll of each staff member therefore it was not able to be determined it the ICP attended this meeting, on 11/5/2025 Director of Nursing (DON) B, MD E, and ICP did not sign the sign in log for attendance at the meeting, on 11/17/2025 MD E nor the ICP signed the sign in log indicating they were in attendance. For the month of November 2025, the two meetings listed were Ad Hoc (when necessary) meetings, no monthly QAPI meeting sign in log was received. On 12/3/2025 the sign log revealed that DON B, MD E and ICP did not sign the sign in log that they were in attendance at this monthly QAPI meeting. No sign in log for the month of January 2026 was received in order to show that the required QAPI meeting was held in the month of January 2026. For the QAPI meeting dated 2/26/2026 the sign in log revealed MD E did not sign in that he was in attendance and there was no indication anywhere on the log that an ICP sign in. On 4/30/2026 MD E did not sign the sign in log, and no where did the log indicate that an ICP signed into the meeting, on 5/28/2026 MD E did not sign the sing in log that he was in attendance at the meeting.Per the State Operations Manual, S483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services;(ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (iv) The infection preventionist.Review of the facility's Quality Assurance and Performance Improvement (QAPI) policy on page two revealed, The QAA (Quality Assessment and Assurance) Committee shall be interdisciplinary and shall: consist at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (iv) The infection preventionist.

Based on interview and record review, the facility failed to develop and maintain a Quality Assistance and Process Improvement (QAPI) program which identified and prioritized quality deficiencies, systematically analyzed the underlying causes of systemic quality deficiencies, and implemented effective corrective action or performance improvement activities to remedy those deficiencies. This deficient practice has the potential to affect the safety and quality of life of all 63 residents at the facility.Findings Included:Review of facility policy entitled Quality Assurance and Performance Improvement (QAPI), provided during survey, had a blank Date Implemented:, a blank Date Reviewed/Revised: and a blank Reviewed/Revised by: . Review of the QAPI documents provided revealed a copyright of 2025 and heading from another company.During an interview on 04/10/2026 at 09:57 a.m. Nursing Home Administrator A was asked if document provided entitled Quality Assurance and Performance Improvement (QAPI) had been approved or implement by the QAPI team. NHA A explained that the policy had not been implemented by the facility. NHA A confirmed that the provided Quality Assurance and Performance Improvement (QAPI), provided during survey, had a blank Date Implemented:, a blank Date Reviewed/Revised: and a blank Reviewed/Revised by: . NHA A was unable to provide why the policy had not been approved by the facility. NHA A explained that the facility had several Performance Improvement Plans that had been approved by the QAPI team. NHA A explained that a few of those Performance Improvement Plans included but not limited to: Annual competencies, annual 12 hours of continuing education hours for certified nursing aides, and Dietitian requirements. NHA A confirmed that the facilities date of compliance, following the abbreviated survey of 03/06/2026, was 03/27/2026. NHA A explained that the Performance Improvement Plans of annual competencies, annual 12 hours of continuing education hours for certified nursing aides, and Dietitian requirements had been reported and approved to the QAPI committee on 03/26/2026. NHA A explained that neither she nor the QAPI committee knew that the facility would not be in substantial compliance for annual competencies, annual 12 hours of continuing education hours for certified nursing aides, and Dietitian requirements by the alleged compliance date provided by the facility.

Based on interview and record review, the facility failed to ensure they had qualified Dietary Staff in a current facility census of 62 residents. Findings include:On 3/4/2026 at 1:39 PM, during an interview with Dietary Manager (DM) E, it was reported that she had been in the position for approximately four weeks and her staff consisted of 4 cooks and 6-7 aides. When asked if she was certified DM E reported she had a Food Safety Manager Certification. When asked if the facility currently had a Registered Dietitian (RD), she reported that she did not know. She reported that if she had questions related to the facility menu she would seek answers from their food vendor. DM E reported that nursing staff was responsible for notifying the kitchen when/if residents need high calorie supplements related to weight loss or if they required a specific therapeutic diet. She was not aware of any role that she was responsible for related to weight loss. On 3/6/2026 at 9:25 AM, during an interview with (former) RD N, it was reported that she is no longer employed by the facility and hasn't been since approximately October/November 2025 but reported having been in the building one day in December 2025. RD N reported that during her employment she worked 20 hours per week and was responsible for monitoring resident weights, therapeutic diets, menu adjustments, education, making sure the menu was adequate to meet nutritional needs of the residents, and generating a weight change report for the facilities QAPI (Quality Assurance and Performance Improvement) meetings. On 3/6/2026 at 10:01 AM, during a follow-up interview with DM E, when asked who was responsible for assessing the nutritional needs of the residents, it was reported that she believed the Registered Dietitian was responsible for that. When asked who was responsible for developing and evaluating regular and therapeutic diets, including texture of foods and liquids, to meet the specialized needs of residents, she reported that she believed the nurses were responsible for that. When asked who would be responsible for developing and implementing person centered education programs involving food and nutrition services for all facility staff, she reported that she assumed it would be her and reported that it had been discussed at resident council in the past. She reported that she was in charge of overseeing the budget and purchasing of food and supplies, and food preparation, service and storage, along with the owner and their food vendor. DM E reported that the facility owner had recently enrolled her in class to obtain her Dietary Manager Certification. A review of the resume for DM E revealed no prior dietary experience in the long-term care setting and no certification or degree related to dietary management. Most recent experience was in the bakery at a grocery store chain and a hotel.A review of the facilities Dietary Manager Job Description revealed, Required Qualifications; Minimum requirements include one of the following: Certification as a dietary manager, Certification as a food service manager, Has similar national certification for food service management and safety from a national certifying body, Has an associate's degree or higher degree in food service management or in hospitality, if the course of study includes food service or restaurant management, from an accredited institution of higher learning, Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. Must also meet State requirements for food service managers or dietary managers. Two years' experience in foodservice management. Prior experience in healthcare foodservice preferred.On 3/6/2026 at 10:01 AM, during an interview with Nursing Home Administrator (NHA), when asked if the current DM was qualified, reported that to her knowledge she was taking classes to become certified and added that when she has hired for that role in the past has required long-term care experience. When asked about the status of a Registered Dietitian, NHA reported that she had been told the facility had one on staff but that they hadn't been seen recently and that they are actively trying to find a full-time RD.The facility failed to employ a registered dietitian to manage nutritional needs for the residents and monitor weight loss/gain, failed to have a certified dietary manager with any long-term care experience and did not employ any Certified Dietary Managers.

Based on observation and interview, the facility failed to maintain the required in-service training for nurse aides.Findings include:Five random employee files were reviewed for Certified Nursing Assistants (CNA) required annual training. A review of the files revealed CNA's R, S, T, U, and A, did not have any annual or new hire education, training or competencies in their employee files. On 3/5/2026 at 1:59 PM, during an interview with Human Resources Director (HRD) D, it was reported that any annual competencies or education would be kept in each employee file. HRD D verified that for the 5 CNA's that were reviewed none of them had any formal competencies or in-services completed during the new hire process or yearly. HRD D reported that the Director of Nursing and the nursing team were currently working on a process for that. She reported that there wasn't any required online or hands on training in place at the time.On 3/6/2026 at 11:38 AM, during an interview with CNA A, it was reported that she had not had any formal competency evaluation or skills check but reported having that at other buildings she had worked at. On 3/6/2026 at 12:06 PM, during an interview with DON, it was reported that she is currently working on implementing a new hire and annual skills checklist and competency for both nurses and certified nursing assistants (CNA). DON reported that to her knowledge there has been nothing in place for annual competencies. DON reported that the new hire orientation prior to 2 weeks ago only consisted of verbal information provided by HR and an informal orientation with staff on the floor.

Based on interview and record review the facility failed to ensure 3 nurses of 5 reviewed had the required Cardiopulmonary Resuscitation (CPR) certifications in a current facility census of 62 residents.Findings include:On [DATE] at 12:21 PM, during an interview with Human Resources Director D, it was reported that the facility keeps CPR documentation in a separate binder, outside of each employee's human resources folder. A review of the facilities binder (containing staff CPR certifications) revealed that RN M had completed his CPR certification through LearnTastic, LPN G had completed here CPR certification through National CPR foundation, and no CPR certification was found for RN K. Human Resources Director D reported that the facility had recently done an audit of CPR certifications, and she was aware of 2 staff members that needed theirs updated, she was unsure if RN K was one of them or not. No additional documentation for RN K was received prior to survey exit.On [DATE] at 8:44 AM, during a telephone interview with RN M, he confirmed that his current CPR certification was completed online without any in-person, hands on training. RN M reported that if a code occurred during his shift he would be expected to assist.On [DATE] at 11:25 AM, during a telephone Interview with LPN G, she confirmed that her current CPR certification was completed online without any in-person, hands on training. LPN G reported that if a code occurred during her shift she would be expected to assist.On [DATE] at 4:32 PM, during an interview with Director of Nursing (DON), it was reported that she that at her previous building, staff were required to complete CPR certification in-person and not online.According to their website (https://learntastic.com/), LearnTastic is completely online, self-paced, offers instant certification and unlimited exam retakes.According to their website (https://nationalcprfoundation.com/) National CPR Foundation offers online certification courses.A review of the facilities policy titled Emergency Procedure-Cardiopulmonary Resuscitation documented in part If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a staff member who is certified in CPR/BLS (Basic Life Support) shall initiate CPR.Preparation for Cardiopulmonary Resuscitation: Obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support/Cardiopulmonary Resuscitation for key clinical staff members who will direct resuscitative efforts.Regulation requires that staff must maintain current CPR certification for Healthcare Providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. A review of the facilities Job Description for Nurses, documented in part Required Qualifications.Current CPR certification

Based on interview and record review, the facility failed to ensure that 5 randomly selected licensed nurses had the knowledge, competencies and skill sets to provide care.Findings include:Five random employee files were reviewed for nurse competencies. A review of these files revealed RN K, RN L, LPN O, LPN P, and RN Q, did not have any education, training or competencies in their employee files. On 3/4/2026 at 4:05 PM, during an interview with Human Resources Director (HRD) D, it was reported that any annual competencies or education would be kept in each employee file. HRD D verified that for the 5 nurses that were reviewed none of them had any formal competencies completed during the new hire process or yearly. HRD D reported that the Director of Nursing and the nursing team were currently working on a process for that. She reported that there wasn't any required online or hands on training in place at the time. On 3/6/2026 at 8:44 AM, during an interview with RN I, it was reported that he has worked in the building for 22 years. RN I reported that in the past the facility had provided monthly educational in-services but that had not been available for about 2 years and he did not recall any formal yearly competency evaluations. On 3/6/2026 at 12:31 PM, during an interview with RN L, it was reported that his new hire orientation included meeting with HR, reviewing policies/handbook and his floor orientation consisted of approximately 1.5 days of job shadowing with the unit manager. No hands on training, formal education or skill competency/checklist was completed that he could recall. On 3/6/2026 at 12:06 PM, during an interview with DON, it was reported that she is currently working on implementing a new hire and annual skills checklist and competency for both nurses and certified nursing assistants (CNA). DON reported that to her knowledge there has been nothing in place for annual competencies. DON reported that the new hire orientation prior to 2 weeks ago only consisted of verbal information provided by HR and an informal orientation with staff on the floor. A review of the facilities policy titled Orientation documented in part, It is the policy of this facility to develop, implement, and maintain an effective orientation process for all new staff, individuals providing services under a contractual arrangement, and volunteers, consistent with expected roles.The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's orientation program. This person works closely with each department head for scheduling orientation sessions and developing orientation plans. Orientation plans are maintained by the Staff Development Coordinator.Departmental orientation plans reflect the skills and competencies that each new employee will require to fulfill his or her job responsibilities.Departmental orientation will continue until the employee has demonstrated competency in all the skills necessary for performing his/her job and to meet resident needs.A preceptor will be assigned to each new employee. This person is assigned oversight responsibility of the new employee, and will facilitate completion of each employee's competency evaluation form.Each new employee is responsible for keeping track of his/her competency evaluation form throughout the orientation process. The preceptor, or designee, shall verify competency in each skill or content area at the time competency is demonstrated.The completed form is forwarded to the Staff Development Coordinator, or designee to verify competency in all areas. Once reviewed by the Staff Development Coordinator, or designee, the form is forwarded to the Human Resources Director to place in the employee's personnel file.

Based on interview and record review, the facility failed to ensure the Activities Director had the appropriate qualifications.Findings include:On 3/5/2026 at 10:43 AM, during an interview with Activities Director (AD) J, it was reported that she had been in the AD role since December of 2025. AD J reported that she was not certified but was currently in class. On 3/5/2026 at 3:34 PM, during a follow-up interview with AD J, it was reported that the previous administrator had offered her the job as Activities Director and AD J felt she met the job description qualifications because she was eligible for certification. When asked who performed the following AD duties: scheduling of activities, implementing and/or delegating the implementation of the programs, monitoring the response and/or reviewing/evaluating the response to the programs to determine if the activities meet the assessed needs of the resident and making revisions as necessary, AD J reported that she was currently responsible for those tasks.A review of the facilities Job Description for Activities Director revealed, Required Qualifications: The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who: Is licensed or registered, if applicable by the state in which practicing and Is: Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or Is a qualified occupational therapist or occupational therapy assistant; or Has completed a training course approved by the State.On 3/5/2026 at 3:44PM, during an interview with NHA, the activities director job description was reviewed, NHA reported that based on the job description and her understanding of the regulation, AD J was not currently qualified for the position.

This citation pertains to intake #2630915Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from resident-to-resident physical and verbal abuse for 2 (Resident #103 and Resident #104) of 4 residents reviewed for abuse, resulting in Resident #103 experiencing physical contact with facial laceration and verbal threats by Resident #104. Resident #103(R103)Review of the Face Sheet and Minimum Data Set (MDS) dated , 8/18/25 reflected R103 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that traumatic brain injury, intermittent explosive disorder, psychologic disorder, anxiety and depression. The MDS reflected R103 had a BIM (assessment tool) score of 13 which indicated his ability to make daily decisions was cognitively intact.Resident #104(R104)Review of the Face Sheet and Minimum Data Set (MDS) dated , 8/18/25 reflected R104 was a [AGE] year-old male admitted to the facility on [DATE], with vascular dementia, irritability and anger, anxiety and depression. The MDS reflected R104 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact.Review of the Facility Reported Incident, dated 9/17/25, reflected R103 and R104 were involved in a witnessed resident to resident altercation.During an observation and interview on 1/22/26 at 11:40 a.m., R103 was in the hall self-propelling in wheelchair. R103 appeared slightly anxious but appeared to calm and pleasant with general routine to conversation. R103 reported feels safe at facility and reported was not afraid of anyone at facility. During an observation and interview on 1/22/26 at 11:50 a.m., R104 was lying in bed and appeared calm and pleasant. R104 reported felt safe at facility and reported everyone treated him with dignity and respect. During an interview and record review on 1/22/26 at 12:06 p.m., Social Worker (SW) C reported was aware of Resident-to-Resident altercation on 9/17/25 and reported prior Nursing Home Administrator (NHA) G was only witnessed staff at the time of the altercation and completed most of investigation. SW C reported no prior altercations between R103 and R104 and none since. SW C reported did follow up with R103 after incident with no changes in baseline and verified after reviewing Progress Notes. SW C reported R104 was arrested and was currently in the facility. SW C reported had been a lot of staff turnover since September, and she was the only staff who was still employed that was involved in the incident.Review of NHA G witness statement, dated 9/17/25, reflected, At approximately 1:30 p.m. on 9/17/25 I was in the main dining room for a resident activity. While speaking with residents about planning for Halloween, I observed [named R103 and R104] in an altercation. [named R103] was ambulating in his wheelchair and bumped into [named R104] wheelchair. [NAME] swung back with his right arm and a closed fist, making contact with the right side of [named R103] face near his mouth. [named R103] yelled out as I ran over to separate them. Both residents were agitated and I took [named R103] out into the hallway to calm down. I contacted his nurse to assess his face for injury. [named R103] was observed to have a small open area on his bottom lip, and blood in his mouth. [named R103] went with his nurse and I approached [named R104]. When I asked him what happened, he stated, He ran into my chair. When I asked why he would become physically violent with someone over an accident, he stated it was a good reason to hit him. I notified the resident that I would need to contact the local police and he stated, I don't give a fu--, [explicit language] Resident was laughing regarding the situation.Officers notified me that [named R104] has multiple outstanding warrants and they would need to take him to jail.Review of the facility 5-day investigation, dated 9/24/25, reflected the facility was able to substantiate abuse had occurred, along with injury to R103.

This citation pertains to intake 2668291Based on observation, interview and record review the facility failed to allow one Resident (Resident #105) to return to the facility after being hospitalized immediately upon the first available bed and failed to implement required discharge policies and procedures, resulting in increased likelihood of anxiety, stress and uncertainty about placement.Review of the Face Sheet and Minimum Data Set (MDS) submitted 10/16/25, reflected R105 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included progressive neurologic disorder, dementia with agitation, and adjustment disorder with anxiety. The MDS reflected that R105 had a BIM (assessment tool) score of 9 which indicated his ability to make daily decisions was moderately impaired. Continued review of the MDS reflected R105 had no history of hallucinations or delusions and 1 of 3 days with verbal behavioral symptoms directed towards other and other behavioral symptoms directed towards self-including hitting, verbal behaviors, and pacing. Review of the Complaint filed with the State of Michigan, dated 11/14/25, reflected an allegation that indicated the facility had refused to readmit R105 after hospital admission. Review of R105 Electronic Medical Record (EMR) on 1/22/26 reflected R105 was not currently a resident at the facility and had been transferred to hospital on [DATE]. Continued review of the EMR reflected R105 orders and Care Plans were discontinued on 1/19/26. During an observation on 1/22/26 at 10:40 a.m., this surveyor observed five open beds on South halls of facility. Review of R105 Progress Notes, dated 11/13/25 at 4:58 p.m., reflected, Resident is exit seeking and not easily redirectable, trying to walk out of doors. Spoke to the dpoa [durable power of attorney], we are sending resident out for his safety. (Last documented note was 11/6/25 related to placement of wander guard.) Review of R105 Nurse Progress Note, dated 11/14/25 at 1:24 p.m., reflected, Resident arrived via police officer admitted under the care [named physician]. Resident readmitted from [named local hospital]. With a diagnosis of dementia. Review of R105 Social Work Progress Noted, dated 11/14/25 at 4:24 p.m., reflected, Due to residents exit seeking behavior we have placed resident on 1:1 supervision for resident safety. Spoke to guardian and attempted to send resident to [named psychiatric hospital] for psych eval.[evaluation] At this time they could not do the eval, suggesting for us to send to [named hospital] if behavior continues or worsens. Review of R105 Progress Note, dated 11/14/25, reflected, resident placed on 1:1. resident able to be redirected by staff. Review of R105 Elopement Evaluation Progress Note, dated 11/14/25, reflected, Elopement Evaluation: Wandering behavior a pattern or goal-directed: Yes. Wanders aimlessly or non-goal-directed: Yes. Wandering behavior likely to affect the safety or well-being of self / others: Yes. Wandering behavior likely to affect the privacy of others: No. Recently admitted or re-admitted (within past 30 days) and has not accepted the situation: Yes. Elopement Score: 7.0 Review of the Nurse Progress Note, dated 11/15/25 at 4:45 p.m., reflected, resident continues on 1:1, pleasant this shift and able to be redirected when needed. continues on ATB[antibiotics] for tooth infection, no adverse reaction noted. no c/o [complaint of] tooth pain this shift. wand guard in place to wrist. Review of R105 Electronic Medical Record (EMR), dated 11/14/25 through 12/27/25, reflected no evidence of documented behaviors with several Progress Notes that R105 continued to have 1:1 supervision and was pleasant and cooperative. Review of R105 Nurse Progress Notes, dated 12/27/25 through 12/28/25, reflected three entries with increased agitation and exit seeking behaviors. Continued review of the note, dated 12/28/25 at 12:50 p.m., reflected provider had been contacted after failed attempts to redirect R105 related to agitation, exit seeking and physical aggression toward staff. Review of EMR reflected no evidence of required Transfer Notice or Bed Hold policy provided to R105 or responsible party after R105 transfer to the hospital on [DATE]. Review of R105 Behavior Care Plans, dated 10/14/25, reflected goal of fewer episodes of physical and verbal aggression and interventions that included, Monitor behaviors episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes (dated 10/16/25). During an interview on 1/22/26 at 12:06 p.m. Social Worker (SW) C, reported R105 was currently admitted to [named Psychiatric Hospital]. SW C reported prior Nursing Home Administrator (NHA) D whose last day of employment was 1/19/26, had reported facility would not take R105 back because of safety risk to self and other residents. SW C reported R105 Psychiatric Hospital staff had reached out to the facility Director of Nursing (DON) B and asked SW C to communicate other options for placement to Psychiatric Hosptial staff for R105. SW C reported she was told other facilities were better equipped to care for R105 related to behaviors. SW C reported R105 had prior history of transfer to the hospital related to aggressive behaviors and exit seeking and reported had actually left hospital without staff knowledge and was escorted back to facility on 11/14/25(same time complaint was filed related to allegation of facility refusal to re-admit resident to facility.) by local police. SW C reported had emailed Ombudsman on 12/31/25 list of residents that had transfers and discharges that included R105's hospital transfer with anticipated return to facility on 12/28/25. SW C reported was responsible for completing Discharge Summary but had not yet completed because just found out 1/20/26 that R105 was not returning to the facility. SW C reported R105s personal items were still in his room on 1/16/26 and currently had been packed up and were waiting pickup. SW C reported was unsure if R105 or responsible party had been provided Transfer Notice and was unsure if facility followed appropriate discharge process. During an interview on 1/22/26 at 1:05 p.m., Director of Nursing (DON) B reported had worked at facility for about one month and reported R105 was on 1:1 supervision because he was aggressive with staff and had frequent attempts to leave the facility and was not him own responsible party. DON B verified R105 was transferred to the hospital on [DATE] and had not returned. DON B reported had planned to return to the facility but had been gone greater than the 10 day Bed Hold and guardian had not arranged to hold R105 bed and facility was getting close to not having available beds. DON B reported facility had not planned for R105 to be gone for that length of time. DON B verified the current census was 62 and the facility had at least 72 beds available total. DON B reported was unsure if Transfer Notice and Bed Hold had been provided to R105 responsible party and reported both should have been and medical record should show evidence of both. DON B reported would expect both Transfer Notice and Bedu Hold to be provided to responsible party at time of transfer to hospital. During an interview on 1/22/26 at 2:31 p.m. Business development staff (BD) D reported R105 had been gone longer than 10 days and responsible party declined to pay to hold the bed, so facility does not need to hold the bed for the hospitalized resident. BD D reported the facility has bagged R105 personal items and are awaiting responsible party to pick up. BD D reported R105 was not allowed to return to the facility because the clinical team, that included DON B, had made that decision related to R105 aggressive behaviors at the time of the hospital transfer on 12/28/26. BD D reported R105's bed had already been spoken for and awaiting authorization and reported was only male room available. BD D was unable to say when arrangements were made for new admission and planned to follow up. During a telephone interview on 1/22/26 at 3:37 p.m. Psychiatric Hospital Case Worker (CW) E verified R105 was a current patient and awaiting discharge. CW E reported had contacted facility on 1/19/26 to inform facility R105 was ready to discharge back to the facility (less than 30 days since admission), and was informed there were no beds available and would provide list of other possible options for R105. CW E reported had attempted to reach out to other facilities with no return calls and have been unable to find placement for R105 at current point in time. During a telephone interview on 1/22/26 at 3:48 p.m., Ombudsman F reported had communicated with facility staff in past related to concerns with appropriated discharge for R105. Ombudsman F reported R105 had reported concerns that facility had been threatening to not allow R105 to return to the facility and Ombudsman F assured R105 the facility could not do that without completing a Involuntary Discharge and verified the facility had not started that process for R105. Ombudsman F reported did not feel that R105 was being treated as though the facility was his home and given choices about making his own schedule and felt that made R105 upset. During an interview and record review on 1/22/26 at 4:20 p.m. BD D reported facility had no available male beds and reported secure memory unit was not appropriate for R105 according to clinical team. BD D reported had last spoke with R105 Psychiatric hospital on 1/13/26 and was not ready for discharge at that time and reported was unaware R105 was ready for discharge on [DATE]. BD D reported resident awaiting authorization for only male bed on unsecure unit was promised the bed on 1/21/26(two days after R105 denied re-admission related to no beds available). BD D reported R105 prior bed had been empty from 12/28/25 to current. Review of the provided bed board reflected 1 room with 2 beds available and BD D reported those were reserved for Medicare not Medicaid residents and R105 was Medicaid. Continued review of the bed board reflected R105 prior room remained empty along with several listed as offline and one room with no water and seven open beds on secure memory unit. Review of the, Facility Bed Hold and Return to Facility Policy and Procedure, dated 2025, reflected, Purpose: To ensure that residents being transferred to a hospital or placed on therapeutic leave are informed as to the facility's bed-hold and return policy.Before a resident is transferred to a hospital or the resident [NAME] on therapeutic leave, the Facility must provide written information to the resident or the representative regarding the Facility's bed-hold and return policy.The facility will permit residents to return to the Facility after they are hospitalized or placed on therapeutic leave.A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the Facility to his/her previous room if available or immediately upon the first availability of a bed in a semi-private room.If the Facility determines that a resident who was transferred with the expectation of returning to the facility cannot return to the facility, the Facility must comply with the requirements of its Resident Transfer and Discharge Policy and Procedure. Review of the State Operations Manual, dated 7/23/25, reflected, Facilities are required to determine their capacity and capability to care for the residents they admit. Therefore, facilities should not admit residents whose needs they cannot meet based on the Facility Assessment requirements at S483.71. For residents the facility has admitted , S483.15(c)(1)(i) provides that The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless. This means that once admitted , residents have a right to remain in the facility unless the discharge or transfer meets one of the specified exceptions in SS483.15(c)(1)(i)(A)-(F). Discharging a resident is a violation of this right unless the facility can demonstrate that one of the limited circumstances listed in the regulation is met.Without an assessment of the resident's status and needs at the time of proposed return to the facility, there can be no determination of (A), the resident's needs cannot be met, or (C) and (D), that the safety or health of individuals would be endangered.Facilities must develop and implement policies for bed-hold and permitting residents to return following hospitalization or therapeutic leave. These policies apply to all residents, regardless of their payment source. The facility policies must provide that residents who seek to return to the facility within the bed-hold period defined in the State plan are allowed to return to their previous room, if available. Additionally, residents who seek to return to the facility after the expiration of the bed-hold period or when state law does not provide for bed- holds are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided that the resident.The policies must also provide that if the facility determines that a resident cannot return, the facility must comply with the requirements at 42 CFR 483.15(c).

This citation pertains to intake 2668291. Based on interview and record review, the facility failed to notify the resident and/or resident's representative of the facility policy for bed hold and a written reason for the transfer, for one (Resident #105) of three reviewed for hospitalization.Review of the Face Sheet and Minimum Data Set (MDS) submitted 10/16/25, reflected R105 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included progressive neurologic disorder, dementia with agitation, and adjustment disorder with anxiety. The MDS reflected that R105 had a BIM (assessment tool) score of 9 which indicated his ability to make daily decisions was moderately impaired. Continued review of the MDS reflected R105 had no history of hallucinations or delusions and 1 of 3 days with verbal behavioral symptoms directed towards other and other behavioral symptoms directed towards self-including hitting, verbal behaviors, and pacing. Review of the Complaint filed with the State of Michigan, dated 11/14/25, reflected an allegation that indicated the facility had refused to readmit R105 after hospital admission. Review of R105 Electronic Medical Record (EMR) on 1/22/26 reflected R105 was not currently a resident at the facility and had been transferred to hospital on [DATE]. Continued review of the EMR reflected R105 orders and Care Plans were discontinued on 1/19/26.Review of R105 Nurse Progress Notes, dated 12/27/25 through 12/28/25, reflected three entries with increased agitation and exit seeking behaviors. Continued review of the note, dated 12/28/25 at 12:50 p.m., reflected provider had been contacted after failed attempts to redirect R105 related to agitation, exit seeking and physical aggression toward staff. Review of EMR reflected no evidence of required Transfer Notice or Bed Hold policy provided to R105 or responsible party after R105 transfer to the hospital on [DATE].During an interview on 1/22/26 at 1:05 p.m., Director of Nursing (DON) B reported had worked at facility for about one month. DON B verified R105 was transferred to the hospital on [DATE] and had not returned. DON B reported was unsure if Transfer Notice and Bed Hold had been provided to R105 responsible party and reported both should have been and medical record should show evidence of both. DON B reported would expect both Transfer Notice and Bed Hold to be provided to responsible party at time of transfer to hospital. During an interview on 1/22/26 at about 2:15 p.m., DON B reported was unable to locate evidence R105 responsible party was notified and received written notice of transfer or bed hold policy after 12/28/25 transfer to the hospital.

This citation pertains to intakes 1194799 and 2564904.Based on observation, interview and record review, the facility failed to protect the resident's (R1's) right to be free from sexual abuse by R2.Findings include: R1:Review of the medical record reflected R1 admitted to the facility on [DATE], with diagnoses that included Parkinson's and dementia. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/9/25, reflected R1 scored zero out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and required supervision or touching assistance for walking. On 9/10/25, at 9:12 AM, R1 was observed lying in bed, awake. She acknowledged having friends at the facility but did not know their names. R2 denied concerns pertaining to interactions with other residents.R2:Review of the medical record reflected R2 admitted to the facility on [DATE], with diagnoses that included Alzheimer's. The Annual MDS, with an ARD of 6/20/25, reflected R2 scored nine out of 15 (moderate cognitive impairment) on the BIMS, did not walk and required substantial/maximal assistance for transfers.On 9/10/25, at 8:25 AM, R2 was observed seated in a wheelchair, in his room. R2 denied having any interactions with female residents, including touching. R2 denied having been talked to about his interactions with other residents.R1's medical record included a Progress Note for 6/24/25 at 6:33 PM, which reflected she set off the door alarm when entering the North unit. R1 stated her boyfriend lived over there, and she was going to see him. According to the note, R1 was redirected to her unit.R1's medical record included a Progress Note for 6/25/25 at 4:09 AM, which reflected that at approximately 7:55 PM (on 6/24/25), a Certified Nurse Aide (CNA) reported R1 was observed in R2's room, with her shirt lifted above her breasts. R2's medical record included a Progress Note for 6/24/25 at 9:20 PM, which reflected a CNA observed R1 in R2's room. R1's shirt was up, her breasts were exposed, and R2 was touching R1's breasts.In a phone interview on 9/9/25 at 2:26 PM, CNA C reported that when walking by R2's room, she observed R1 in the room, with her back towards the door and her shirt lifted up. CNA C observed R2 touching R1's chest. CNA C reported she was unsure of what to do and left the unit to notify Registered Nurse (RN) D of the observation. When CNA C and RN D returned together, R1 continued to be in R2's room and was redirected out at that time. CNA C stated she received education, from RN D, that she should have removed R1 from R2's room at the time of her observation. CNA C was unaware of any further incidents between R1 and R2 since 6/24/25. In a phone interview on 9/9/25 at 2:52 PM, RN D recalled a CNA running up to her, stating R1 was in R2's room. Upon responding to R2's room, R1 was seated on R2's bed, fully clothed at that time. RN D was unaware of any further incidents between R1 and R2 since 6/24/25.R1's medical record included a Social Services Progress Note for 6/26/25, which reflected R1 could not recall the incident.R2's medical record included a Progress Note for 6/26/25, which reflected the Social Worker met with R2 to discuss the incident on 6/24/25. According to the note, R2 stated no harm was done.R1's Care Plan reflected an intervention, dated 7/1/25, that she was unable to consent to any sexual relations due to dementia and would require the consent of her Guardian. R2's Care Plan reflected an intervention, dated 7/1/25, that he may be verbally and physically sexually inappropriate with women. R1's medical record included a Progress Note for 7/5/25 at 2:23 PM, which reflected that around 10:30 AM, Maintenance staff observed R1 and R2 in the main dining room. R2 was observed rubbing R1's leg and buttocks. According to the note, the residents were separated.In an interview on 9/10/25 at 9:38 AM, Licensed Practical Nurse (LPN) F reported being notified, by Maintenance, that R2 was touching R1 on the outside of her pants. LPN F stated she had been aware that R1 had previously been in R2's room (on 6/24/25) but knew nothing more than that. During an interview on 9/10/25 at 10:24 AM, Nursing Home Administrator (NHA) A reported R1 wanted to see her friend and was let into the secure unit by a CNA (on 6/24/25). When walking by R2's room, a CNA observed R1 with her shirt lifted and R2 fondling R1's breasts. NHA A reported they were trying to keep R1 and R2 separated after the incident, and R1 was started on antibiotics for a urinary tract infection. NHA A reported there was a second incident (7/5/25), when Activities staff took R2 to the dining room, to go outdoors for a smoke break. While staff were gathering other residents, R1 went in the dining room and approached R2. R2 was observed touching R1's leg and buttocks, on the outside of her clothing.

This citation has two separate DPS's: A and B. DPS A) Based on observation, interview, and record review, the facility failed to ensure hot water temperatures were in the comfortable range of 100-120 degrees Fahrenheit for two of 20 residents who resided in the dementia unit (Resident #31 and 39), resulting in Immediate Jeopardy when R31, who was independent with ambulation had a bathroom water temperature of 150 degrees Fahrenheit; and R39 who and was independent with ambulation, had a bathroom water temperature of 144.6 degrees Fahrenheit; and 2) facility wide resident bathroom water temperatures that tempted at greater than 120 degrees Fahrenheit with potential for second and/or third degree burns. Findings Included: Resident #31 (R31) A review of the medical record showed that Resident #31 (R31) was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included generalized anxiety disorder, wandering, type 2 diabetes mellitus, psychotic disorder with delusions, dementia, and Alzheimer ' s disease. According to the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/4/25, R31 scored 1 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Resident #39 (R39) Resident #39 (R39) was admitted on [DATE] with diagnoses including generalized anxiety disorder, psychotic disorder with delusions, dementia, and Alzheimer ' s disease. The MDS with an ARD of 4/5/25 reflected a BIMS score of 12 out of 15, indicating moderate cognitive impairment. Domestic hot water temperatures were measured on multiple occasions in where both R31 and R39 resided: On 05/05/25 at 1:03 PM: R 39s Room= 152.6 F On 05/06/25 at 1:15 PM: R 31s Room =137.9 F and R 39s room [ROOM NUMBER].9 F, On 5/06/25 at 3:45 PM for R 31s Room =150.7 F and R 39s Room =144.6 F Temperatures above 120 F are considered hazardous and pose a risk of scalding, especially for vulnerable populations such as those with cognitive impairment. On 05/06/2025 at 5:00 PM, the Administrator was notified of the Immediate Jeopardy that was identified on 5/6/2025, and began on 5/6/2025 when two identified residents (Resident #31 and 39) bathroom water temperatures were found to be greater than 120 degrees Fahrenheit. On 5/12/2025 the surveyor verified the facility implemented the following corrective action to remove the Immediate Jeopardy on 05/06/2025: 1. 100% of community residents were assessed by the Director of Nursing and designees on 05/06/25 to ensure no negative effects related to water temperatures. Resident showers were taken offline to ensure safety of water temperatures, to include bed baths. 2. The water temperature was adjusted to ensure temperatures within regulatory standard. The Maintenance Director and designee conducted a 100% community audit of resident area water sources to ensure appropriate temperatures per regulatory guidance. 3. The Administrator reviewed the policy and procedure related to Safe Water Temperatures on 05/06/2025 with changes completed as necessary. Community staff will be educated on the policy for Safe Water Temperatures, with all staff completed or removed from the schedule by 05/09/25. 4. The Maintenance Director or designee will conduct an audit of resident room water temperatures daily, on both shifts for seven days, then twice weekly thereafter to ensure water temps meet regulatory standards. Results of the audits will be brought to the Quality Assurance Performance Improvement Committee for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Although the Immediate Jeopardy was removed on 5/6/2025, the facility remained out of compliance at a scope of widespread and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance had not been verified by the state agency. 22050 On 05/05/25 at 01:03 P.M., Domestic hot water temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following domestic hot water temperatures were recorded: Resident room [ROOM NUMBER]: 128.9 degrees Fahrenheit* Resident room [ROOM NUMBER]: 136.7 degrees Fahrenheit* Resident room [ROOM NUMBER]: 152.6 degrees Fahrenheit* Resident room [ROOM NUMBER]: 145.6 degrees Fahrenheit* Resident room [ROOM NUMBER]: 106.9 degrees Fahrenheit Resident room [ROOM NUMBER]: 105.0 degrees Fahrenheit Resident room [ROOM NUMBER]: 111.7 degrees Fahrenheit On 05/05/25 at 01:45 P.M., An interview was conducted with Environmental Services Director (ESD) E regarding domestic hot water temperature monitoring and documentation log sheets. (ESD) E stated: We routinely monitor hot water temperatures. (ESD) E also stated: The temperatures are recorded on the log sheet. On 05/06/25 at 01:15 P.M., Domestic hot water temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following domestic hot water temperatures were recorded: South Unit Resident room [ROOM NUMBER]: 142.7 degrees Fahrenheit* North Unit (Memory Care) Resident room [ROOM NUMBER]: 105.5 degrees Fahrenheit Resident room [ROOM NUMBER]: 126.9 degrees Fahrenheit* Resident room [ROOM NUMBER]: 129.9 degrees Fahrenheit* Resident room [ROOM NUMBER]: 129.8 degrees Fahrenheit* Resident room [ROOM NUMBER]: 134.6 degrees Fahrenheit* Resident room [ROOM NUMBER]: 147.1 degrees Fahrenheit* Resident room [ROOM NUMBER]: 137.9 degrees Fahrenheit* Resident room [ROOM NUMBER]: 147.9 degrees Fahrenheit* On 05/06/25 at 03:15 P.M., Domestic hot water monitoring log sheets were requested from (ESD) E. (ESD) E stated: I know I have all of the temperature log sheets. On 05/06/25 at 03:24 P.M., An interview was conducted with (ESD) E regarding facility domestic hot water monitoring. (ESD) E stated: Maintenance Technician F usually takes water temperatures. (ESD) E also stated: I have taken hot water temperatures occasionally. On 05/06/25 at 03:38 P.M., An interview was conducted with Maintenance Technician F regarding the device currently used to monitor facility domestic hot water temperatures. Maintenance Technician F stated: I use a [NAME] digital thermometer. Maintenance Technician F also stated: I dropped the old thermometer and broke it. On 05/06/25 at 03:45 P.M., Domestic hot water temperatures were monitored by this surveyor utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following domestic hot water temperatures were recorded: Resident room [ROOM NUMBER]: 127.6 degrees Fahrenheit* Resident room [ROOM NUMBER]: 137.1 degrees Fahrenheit* Resident room [ROOM NUMBER]: 137.1 degrees Fahrenheit* Resident room [ROOM NUMBER]: 143.0 degrees Fahrenheit* Resident room [ROOM NUMBER]: 138.2 degrees Fahrenheit* Resident room [ROOM NUMBER]: 150.7 degrees Fahrenheit* Resident room [ROOM NUMBER]: 144.6 degrees Fahrenheit* Resident room [ROOM NUMBER]: 142.3 degrees Fahrenheit* Resident room [ROOM NUMBER]: 124.2 degrees Fahrenheit* Resident room [ROOM NUMBER]: 125.0 degrees Fahrenheit* On 05/06/25 at 03:45 P.M., Domestic hot water temperatures were monitored by Maintenance Technician F utilizing a [NAME] (no model number) digital thermometer. The following domestic hot water temperatures were recorded: Resident room [ROOM NUMBER]: 127.4 degrees Fahrenheit* Resident room [ROOM NUMBER]: 136.2 degrees Fahrenheit* Resident room [ROOM NUMBER]: 136.4 degrees Fahrenheit* Resident room [ROOM NUMBER]: 143.4 degrees Fahrenheit* Resident room [ROOM NUMBER]: 137.4 degrees Fahrenheit* Resident room [ROOM NUMBER]: 150.0 degrees Fahrenheit* Resident room [ROOM NUMBER]: 144.6 degrees Fahrenheit* Resident room [ROOM NUMBER]: 141.6 degrees Fahrenheit* Resident room [ROOM NUMBER]: 123.8 degrees Fahrenheit* Resident room [ROOM NUMBER]: 124.8 degrees Fahrenheit* On 05/06/2025 at 04:30 P.M., Record review of the (Corporation Name) Immediate Jeopardy (IJ) Removal Plan revealed the following narrative: During annual survey, it was identified that water temperatures in resident room bathrooms were exceeding the regulatory standard. Below are the immediate action items completed in proposal for removal of the (IJ). 1. 100% of community residents were assessed by the Director of Nursing and designees on 05/06/25 to ensure no negative effects related to water temperatures. Resident showers were taken offline to ensure safety of water temperatures, to include bed baths. 2. The water temperature was adjusted to ensure temperatures within regulatory standard. The Maintenance Director and designee conducted a 100% community audit of resident area water sources to ensure appropriate temperatures per regulatory guidance. 3. The Administrator reviewed the policy and procedure related to Safe Water Temperatures on 05/06/2025 with changes completed as necessary. Community staff will be educated on the policy for Safe Water Temperatures, with all staff completed or removed from the schedule by 05/09/25. 4. The Maintenance Director or designee will conduct an audit of resident room water temperatures daily, on both shifts for seven days, then twice weekly thereafter to ensure water temps meet regulatory standards. Results of the audits will be brought to the Quality Assurance Performance Improvement Committee for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. On 05/06/25 at 04:45 P.M., Domestic hot water temperatures were monitored utilizing a ThermoWorks SuperFast Thermapen model CR2032 digital thermometer. The following temperature was recorded: Staff/Visitor Restroom Hand Sink - 155.0 degrees Fahrenheit*. The State Operations Manual (SOM) Appendix PP section F689 Accidents states: Note: (*) Water Temperature - Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure. Some States have regulations regarding allowable maximum water temperature. Table 1 illustrates damage to skin in relation to the temperature of the water and the length of time of exposure. Table 1. Time and Temperature Relationship to Serious Burns Water Time Required for a 3rd Degree Temperature Burn to Occur _________________________________________________________________ 155 F 68 C 1 sec 148 F 64 C 2 sec 140 F 60 C 5 sec 133 F 56 C 15 sec 127 F 52 C 1 min 124 F 51 C 3 min 120 F 48 C 5 min 100 F 37 C Safe Temperatures for Bathing (see Note) _________________________________________________________________ NOTE: Burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. Based upon the time of exposure and the temperature of the water, the severity of the harm to the skin is identified by the degree of burn, as follows. o First-degree burns involve the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. o Second-degree burns involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. o Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-degree burns surrounding third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black. On 05/07/25 at 09:14 A.M., An interview was conducted with (ESD) E regarding the domestic hot water supply. (ESD) E stated: We consulted with Facilities Supervisor for the Battle Creek Fire Department (FS) G. (ESD) E also stated: He [(FS) G] suggested a regulator was going out on the South Unit water heater. (ESD) E additionally stated: We bled out the hot water from the hot water storage tanks. (ESD) E further stated: room [ROOM NUMBER] was at 118.2 degrees Fahrenheit. (ESD) E also stated: room [ROOM NUMBER] was at 120.5 degrees Fahrenheit. (ESD) E additionally stated: room [ROOM NUMBER] was at 124.0 degrees Fahrenheit. (ESD) E further stated: The staff/visitor restroom hand sink was at 125.0 degrees Fahrenheit. (ESD) E also stated: Temperatures were monitored at approximately 7:00 AM this morning. On 05/07/25 at 09:40 A.M., An environmental tour of sampled resident rooms was conducted with Housekeeper H. Domestic hot water temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following restroom hand sinks domestic hot water temperatures were noted: 117: 125.1 degrees Fahrenheit* 122: 128.1 degrees Fahrenheit* 123: 128.8 degrees Fahrenheit* 124: 130.3 degrees Fahrenheit* 128: 124.0 degrees Fahrenheit* 129: 124.5 degrees Fahrenheit* 131: 121.3 degrees Fahrenheit* On 05/07/25 at 12:06 P.M., An interview was conducted with (ESD) E regarding the facility maintenance work order system. (ESD) E stated: We have TELS. On 05/07/25 at 12:23 P.M., Domestic hot water temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following domestic hot water temperatures were recorded: South Unit Shower Room Hand Sink - 123.8 degrees Fahrenheit* On 05/07/25 at 12:30 P.M., An interview was conducted with Maintenance Technician F regarding the South Unit Shower Room floor drain concern. Maintenance Technician F stated: We have contacted (Contractual Vendor Name) for commercial repairs related to both plumbing and hot water heater issues. On 05/07/25 at 01:26 P.M., Domestic hot water temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following domestic hot water temperatures were recorded: Staff/Visitor Restroom: Hand Sink - 126.4 degrees Fahrenheit* On 05/07/25 at 01:33 P.M., An interview was conducted with Nursing Home Administrator (NHA) A regarding removal of the domestic hot water supply excessive hot water temperature immediacy. (NHA) A stated: We are not providing showers or bed baths until further notice. (NHA) A also stated: We have posted signage in all resident rooms and shower rooms. On 05/07/25 at 01:41 P.M., Record review of the resident room and shower room posted signage revealed the following narratives: Resident Room posted signage states: Please do not use water without first calling for staff assist. Shower Room posted signage states: Showers are out of order until further notice. On 05/07/25 at 03:50 P.M., An interview was conducted with Commercial Contractor (CC) I regarding the domestic hot water temperature concern. (CC) I stated: The recirculation pump switch was turned off. (CC) I also stated: If the recirculation pump is off, you can't get consistent hot water temperatures. (CC) I further stated: The cold-water supply was also closed to the tempering system. On 05/08/25 at 08:45 A.M., Record review of the Policy/Procedure entitled: Safe Water Temperatures dated (no date) revealed under Policy: It is the policy of this facility to maintain appropriate water temperatures in resident care areas. Record review of the Policy/Procedure entitled: Safe Water Temperatures dated (no date) further revealed under Policy Explanation and Compliance Guidelines: (4) Staff will report abnormal findings, such as complaints of water too cold of hot, burns or redness, or any problems with water temperature (ex. water is painful to touch or causes redness) to the supervisor and/or maintenance staff. (5) Water temperatures will be set to a temperature of no more than (120 degrees Fahrenheit) or (49 degrees Celsius), or the state's allowable maximum water temperature. (6) Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. (7) Documentation of testing will be maintained for 3 years and kept in the maintenance office. On 05/08/25 at 09:00 A.M., Record review of the Hot Water Temperature Monitoring Log Sheets for the last 126 days revealed no specific entries related to excessive domestic hot water temperatures. Note: Numerous Hot Water Temperature Monitoring Log Sheets were observed completely missing from the requested timeframe. 46954 DPS B) Based on observation, interview and record review, the facility failed to 1) investigate falls, develop and implement post fall interventions, and prevent further falls for one of one (Resident #58) reviewed for falls and 2) facility failed to ensure resident was free from potential accidents or hazards by allowing unsupervised access to chewing tobacco for one (R38) of three residents reviewed for accidents. Findings include: Resident #58 A review of the medical record revealed that Resident #58 (R58) was admitted to the facility on [DATE], with diagnoses including difficulty walking, muscle weakness, wandering, and dementia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/24/2025, indicated that R58 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), reflecting severe cognitive impairment. On 5/05/2025 at 12:19 PM, R58 was observed ambulating independently and attempting to exit the locked memory care unit. When redirected, she became agitated and expressed a desire to go outside. R58 was noted to be pleasantly confused and non-interviewable. During an interview conducted on 5/05/2025 at 12:13 PM, Family Member DD reported that R58 had experienced multiple falls, including one that resulted in hospitalization . A review of incident and accident reports, as well as progress notes, revealed the following fall incidents: On 10/26/2024 at 6:35 PM, R58 was found sitting on the floor next to her bed. The care plan was updated to ensure that R58's walker remained within reach while she was in bed. On 1/28/2025 at 1:39 AM, R58 was discovered lying on her back on the floor of her room. A moderate amount of blood was noted around her head, and a laceration was observed on the left parietal region. She was transferred to a local emergency department, where she received one staple to close the head wound. Per the incident report, staff stated she had been ambulating with her walker at the time of the fall. Despite the severity of this incident, no new fall interventions were added to her care plan, no incident report was completed, and no investigation was initiated. On 1/29/2025 at 7:45 AM, R58 stood up from her wheelchair, lost her balance, and fell backward, striking her head against the medication cart. Although no apparent injuries were noted, this was R58's second fall in two days. Again, the care plan was not updated to include new fall interventions-only a request for a therapy screen was noted. No incident report was created, and no investigation occurred. On 3/12/2025 at 6:00 AM, R58 was found lying on her left side on the floor, leaning against the closet in her room. No injuries were reported, yet no additional fall prevention strategies were added to her care plan. Further observation on 5/07/2025 at 9:45 AM revealed that R58 was in bed with her call light draped over the headboard, out of her reach, and her walker placed against the wall, also out of reach, raising ongoing safety concerns. In an interview on 5/08/2025 at 11:22 AM, the Director of Nursing (DON) B stated that the facility's expectations following a fall include completing an incident report and implementing an immediate intervention to prevent recurrence. 49272 Resident # 38 (R38) Review of the medical record revealed R38 was admitted to the facility on [DATE] with diagnoses that included: legal blindness, muscle weakness, need for assistance with personal care, anxiety disorder, and depression. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/25 revealed R38 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 5/5/25 at 10:15 AM, R38 was observed asleep on his back with a can of chewing tobacco on his bedside tray table, as well as a Styrofoam cup with tobacco spit in it. On 5/5/25 at 12:24 PM, a staff member was observed entering R38's room to see if he was done with his lunch tray. This staff member exited the room and reported that R38 was still eating his lunch. The chewing tobacco and cup with spit in it was easily visible on R38's bedside table, next to his lunch tray. On 5/5/25 at 12:28 PM R38 was queried about the chewing tobacco on his bedside table, R38 reported that he was told prior to his admission that it was ok for him to have it on him and to use it in his room, they let me have it here. On 5/6/25 at 2:07 PM, R38 was observed to still have chewing tobacco and a spit cup on his bedside table. On 5/6/25 at 2:12 PM, the director of nursing (DON) was asked what the facilities policy on chewing tobacco was. She reported that she would have to look it up. On 5/6/25 at 2:14 PM, DON and this surveyor entered R38's room. DON stated that she would clean up the dry tobacco on resident's clothing and bedside table. DON removed the can of tobacco and the cup of tobacco spit. DON reported that she believed chewing tobacco should be treated like a medication and would need to be assessed to determine if it would be safe for the resident to have at his bedside. On 05/08/25 at 12:54 PM, during an interview with CNA II reported that she was aware that R38 had chewing tobacco and had observed it at his bedside. She reported that it was something new. CNA II further stated that the resident was not supposed to have it unless he went outside to use it. On 5/12/25 at 8:19 PM during a telephone interview with R38's family member (FM KK), they reported that they had been bringing in chewing tobacco to R38 for a few months and that the staff was aware and that there wasn't a problem with it until this week. On 5/08/25 at 2:01 PM, during an interview with Director of Nursing (DON) and Assistant Director of Nursing (ADON), it was reported to her that a review of the smoking policy revealed that it does not specifically address chewing tobacco and how was the facility planning to address it, she stated that what she had done for R38 specifically was talked to social services staff to do an assessment to if R38 could self-administer. She further stated that he could use it during smoking breaks and that she plans to bring it to QAPI (Quality and Assurance Performance Improvement). DON reported that she took the tobacco to the nurse and had her lock it up in the narcotic drawer in the medication cart and label it. Assistant director of nursing (ADON) reported that social services staff had placed it in the lock box with the other resident's cigarettes. When asked if they would agree that it isn't safe for a visually impaired resident to have access to chewing tobacco and associated spit cup both the DON and ADON agreed, with the ADON adding especially unattended/unassisted. On 5/6/25 at 2:41 PM a request was made via email to the facility administrator (nursing home administrator-NHA) to clarify whether the facility had a policy that specifically addressed chewing tobacco and on 5/6/25 at 2:50 PM, NHA responded that they have searched and do not have anything specific to chewing tobacco. Review of the facilities policy titled Pinnacle Care of Battle Creek Smoking Contract, documented in part I am not allowed to have my own cigarettes, E-cigarettes, vape pens, matches of lighters while I reside at the facility. If I have any cigarettes, E-cigarettes, vape pens, matches or lighters on my person, I will turn all smoking materials in to the Activities Director before returning inside the facility . I am not allowed to give, get, or request cigarettes, E-cigarettes, or vape pens from any other resident at any time .

Based on observation, interview and record review the facility 1) failed to implement and update Physician orders, 2) accurately assess and document a pressure ulcer, 3) failed to ensure pressure ulcer prevention interventions were implemented, 4) failed to adequately assess and treat pain prior to wound care and 5) failed to prevent the development of pressure ulcers for 2 (Resident #11, Resident #20) out of 3 reviewed for pressure ulcers resulting in worsening of a pressure ulcer, unrelieved pain during wound care, and an increased risk of further skin breakdown. Findings include: Resident #20 (R20) Review of the medical record reflected that Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included muscle weakness, contractures of both right and left legs, pressure-induced deep tissue damage of the left heel, dementia, and acute and chronic respiratory failure with hypoxia. The Minimum Data Set (MDS), with an Assessment Reference Date of 02/10/25, reflected that Resident #20 scored 3 out of 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. Resident #20 was not interviewable. On 05/05/25 at 10:07 AM, Resident #20 was observed seated in the dining room wearing pressure-relieving ankle-foot orthosis (PRAFO) boots on both feet. However, the right boot was nearly detached from Resident #20's foot. During an interview conducted on 05/05/25 at 10:43 AM, Family Member O reported that Resident #20 had developed a sore on his heel. Family Member O stated that Resident #20 was unable to move his legs independently due to muscle atrophy and contractures. A review of the Activities of Daily Living Care Plan indicated that Resident #20 required maximum assistance of two persons for bed mobility. A skin assessment dated [DATE], completed upon readmission, described an unstageable pressure ulcer on the left heel with a length of 5 centimeters and a width of 7 centimeters. The Skin Integrity Care Plan for Resident #20 included an intervention dated 02/06/25 that stated, I need to wear off-loading boots for heel protection. A review of the Physician's Orders revealed an active order initiated on 03/13/25, which stated Cleanse left heel deep tissue injury with Dakin's solution, pat dry, apply hydrogel, cover with Kerlix gauze. Change dressing daily and as needed. Resident to have pressure-relieving ankle-foot orthosis boots on at all times. An outside wound care service note dated 04/21/25 described the left heel wound as an unstageable, pressure-induced tissue injury measuring 7.2 centimeters in length by 5.6 centimeters in width, with an undetermined depth. The wound bed was described as 10 percent granulation tissue, 20 percent slough, and 70 percent eschar. Treatment instructions included Clean with Dakin's solution, apply Santyl and alginate. A facility Weekly Wound Healing Record dated 04/21/25 assessed the same wound as a suspected deep tissue injury. The facility nurse described the wound bed as having granulation tissue and 20 percent slough, with measurements of 7.2 centimeters in length by 5.6 centimeters in width and an undetermined depth. The treatment plan included Cleanse with normal saline, apply Santyl and alginate topically, wrap with Kerlix daily. The corresponding physician's order was not updated to reflect these changes in treatment. An outside wound care service note dated 04/28/25 described the left heel wound as an unstageable, pressure-induced tissue injury measuring 7.0 centimeters by 4.7 centimeters, with an undetermined depth. The wound was noted to have 20 percent granulation tissue, 20 percent slough, and 60 percent eschar. Treatment instructions included Clean with normal saline and apply Santyl and alginate daily. Cover with an abdominal pad and wrap with Kerlix. A Weekly Wound Healing Record dated 04/28/25 documented the wound as a suspected deep tissue injury with measurements of 7.2 centimeters in length by 4.9 centimeters in width, and no depth recorded. The wound bed was noted to contain 20 percent slough. The treatment plan included Cleanse with normal saline, apply Santyl and alginate daily. Review of the Physician's Orders revealed that the orders still reflected the prior, outdated treatment: Cleanse left heel deep tissue injury with Dakin's solution, pat dry, apply hydrogel, cover with Kerlix gauze. Change daily and as needed. No update had been made to reflect the current wound care plan. On 05/07/25 at 09:24 AM, Resident #20 was observed lying flat in bed without wearing PRAFO boots. The boots were seen on the resident's wheelchair. At 09:47 AM on 05/07/25, Registered Nurses Q and J gathered supplies to perform wound care for Resident #20. The resident remained in bed, lying flat and without the boots. Registered Nurse Q verified the current physician order and gathered Dakin's solution and hydrogel as per the outdated order. Registered Nurse J confirmed that the left heel wound was a suspected deep tissue injury and stated she participates in wound rounds with the nurse practitioner weekly and updates orders based on the plan of care. During the procedure, Registered Nurse Q removed the dressing and described the wound as an open area with slough. She applied Dakin ' s solution, then hydrogel, covered the wound with an abdominal pad, and secured it with Kerlix and tape. Resident #20 verbalized ouch multiple times during the dressing change. Following the dressing change, Registered Nurse Q applied the PRAFO boots and stated she would notify the assigned nurse that Resident #20 required acetaminophen for pain. At 10:27 AM on 05/07/25, Certified Nursing Assistant R stated she was familiar with Resident #20's care and confirmed that the resident does not refuse care, including wearing the PRAFO boots. On 05/08/25 at 11:35 AM, Director of Nursing B explained that an outside wound care provider visits the facility, assesses wounds, and recommends treatment changes. She confirmed that facility staff are responsible for updating the physician's orders accordingly. After reviewing the Weekly Wound Healing Record, the Director of Nursing agreed that the facility's assessment of the left heel wound was inaccurate, as it continued to describe the injury as a suspected deep tissue injury rather than an unstageable pressure ulcer. At 12:12 PM on 05/08/25, Registered Nurse J reviewed the nurse practitioner's wound treatment recommendations alongside the current physician's orders in the electronic medical record. Registered Nurse F agreed that the physician orders did not match the nurse practitioner's plan of care. She updated the physician's order to Cleanse with normal saline, apply Santyl and alginate, and cover with Kerlix gauze. Additionally, review of the Medication Administration Record revealed that Resident #20 did not receive as-needed acetaminophen for pain until after the wound care procedure had been completed. 38383 Resident #11 (R11): Review of the medical record reflected R11 admitted to the facility 7/3/14 and readmitted [DATE], with diagnoses that included vascular dementia, dependence on wheelchair and diabetes. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/31/25, reflected R11's cognition and mood were not assessed. The same MDS reflected R11 did not walk, was dependent for transfers and required substantial/maximal assistance with personal hygiene and partial/moderate assistance with rolling left and right. Weekly Wound Healing Records, dated 4/21/25 and 4/28/25, reflected R11 had a facility-acquired pressure ulcer to the posterior (back) scrotum, which developed 4/18/25. The wound was documented as stage II (two) (partial thickness loss of dermis/middle layer of skin, presenting as a shallow open ulcer with a red/pink wound bed; may also present as an intact or open/ruptured blister), measuring 0.9 centimeters (cm) in length by 0.9 cm in width and 0.1 cm in depth. The appearance of the wound bed was not documented. Weekly Wound Healing Records, dated 4/21/25 and 4/28/25, reflected R11 had a facility-acquired pressure ulcer to left intergluteal (between the buttocks) region, which developed 4/18/25. The wound was documented as stage II, measuring 0.9 cm in length by 0.5 cm in width and 0.1 cm in depth. The appearance of the wound bed was not documented. On 05/06/25 at 9:21 AM, R11 was observed seated in a wheelchair, in the hallway. A seating cushion was not observed in the wheelchair. On 05/06/25 at 12:44 PM, R11 was observed seated in their wheelchair, in the hallway. A seating cushion was not observed in the wheelchair. On 05/06/25 at 2:10 PM, R11 was observed seated in their wheelchair, in the main dining room. A seating cushion was not observed in the wheelchair. On 05/06/25, R11 was observed seated in their wheelchair, without a seating cushion at 3:42 PM, 4:05 PM and 4:52 PM. On 05/07/25 at 8:12 AM, R11 was observed seated in their wheelchair, in the hallway. A seating cushion was not observed in the wheelchair. On 05/07/25 at 8:22 AM, a request was made, to staff, to observe R11's skin during care that day. On 05/07/25 at 9:22 AM, Certified Nurse Aide (CNA) W and CNA V began care, including preparing to transfer R11 to bed as Licensed Practical Nurse (LPN) X prepared wound care supplies. Once LPN X had gathered wound care supplies and returned to the room, R11 refused assessment and treatment of their wounds. On 05/07/25 at 11:00 AM, R11 was observed lying in bed, on a standard mattress, positioned towards their right side. An additional mattress was on the floor at the right bedside. R11's wheelchair was observed in the room, with a seating cushion in place. On 05/07/25 at 1:31 PM, R11 was observed lying in bed, on a standard mattress, positioned towards their right side. An additional mattress was on the floor at the right bedside. On 05/07/25 at 2:52 PM, R11 was observed lying in bed, on a standard mattress, positioned towards their right side. An additional mattress was on the floor at the right bedside. In an interview on 05/07/25 at 2:54 PM, CNA W reported R2 received a wheelchair cushion from the Therapy Department that morning, after being transferred from their wheelchair to bed. CNA W reported sometimes, R2 did not have a wheelchair seating cushion for weeks at a time. During a phone interview on 05/08/25 at 1:11 PM, Nurse Practitioner (NP) AA reported visiting the facility weekly for wounds. NP AA reported they had seen R11 two to three times, and R11's stage II pressure ulcers had remained stable. NP AA stated they had recommended a low air loss mattress (specialty mattress) and a cushion for R11's wheelchair. Regarding the type of wheelchair cushion recommended, NP AA reported they usually recommended Roho cushions (specialty cushion for pressure relief). According to NP AA, their recommendations had been conveyed to the facility. NP AA's visit notes for 4/21/25 and 4/28/25 reflected, .The patient is noncompliant with repositioning .Change positions often to keep pressure off the wound, and spread body weight evenly with cushions, mattresses, pillows, foam wedges, or other pressure-relieving devices . A risk for skin breakdown Care Plan reflected it was created on 7/9/2014 and was initiated 3/5/25. An additional Care Plan, initiated on 5/5/25, reflected R11 had impaired skin integrity on the scrotum and intragluteal region. R11's Care Plan did not reflect the presence of pressure ulcers, nor interventions for pressure relief.

Based on interview and record review the facility failed to maintain an effective Quality Assurance and Performance Improvement program that identified areas of focus and improvement in a current facility census of 61 residents. Findings Included: During the survey a concern was identified at an Immediate Jeopardy level regarding hot water temperatures in which the facility was unaware off. Also, it was identified during the survey a concern of accommodation of resident needs regarding call light accessibility. Review of resident council meeting minutes, dated 3/5/2025, revealed a concern was brought up regarding not having hot water in the resident rooms. The facility's response was to check the hot water temperatures, and to also check them weekly. Review of QAPI minutes revealed no further discussion of weekly hot water temperatures, nor were any documented logs noted. In an interview on 5/08/2025 at 2:35 PM, Administrator A was not able to verify that a QAPI meeting had been held for the month of April 2025. Administrator A stated that she had no idea if there had been QAPI discussion regarding water temperatures not being at a comfortable level. Administrator A also stated that she was not aware of any perfomance improvement plan (PIP) that was in place regarding the resident call light system or accessibility.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 61 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased air quality, and potential cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 05/06/25 at 09:20 A.M., A common area environmental tour was conducted with Environmental Services Director (ESD) E. The following items were noted: South Unit Occupational Therapy/Physical Therapy: The wall mounted grab bar, located directly in front of the wheelchair scale, was observed loose-to-mount. 2 of 2 oval shaped mobile swivel chair cushions were also observed (etched, scored, particulate). 1 of 2 chair cushions were additionally observed with green duct tape covering the damaged vinyl surface. (ESD) E indicated she would have staff repair the loose-to-mount grab bar and remove the damaged chairs as soon as possible. Shower Room: 2 of 2 shower wand assemblies were observed missing an atmospheric vacuum breaker. (ESD) E stated: I will have them installed this week. Janitor Closet: The flooring surface and mop sink basin were observed soiled with accumulated and encrusted dust/dirt and debris (paper products, dust balls, etc.). (ESD) E indicated she would have housekeeping staff thoroughly clean the room as soon as possible. Nurses Station: The restroom return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. (ESD) E indicated she would have housekeeping staff thoroughly clean the ventilation grill as soon as possible. Soiled Utility Room: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. (ESD) E indicated she would have housekeeping staff thoroughly clean the ventilation grill as soon as possible. Lift Storage Room: 2 of 2 overhead light assemblies were observed non-functional. (ESD) E indicated she would have staff make necessary repairs as soon as possible. North Unit Dining Room: 9 of 9 overhead light assembly clear plastic protective lens covers were observed soiled with accumulated and encrusted (dust, dirt, dead insect carcasses). (ESD) E indicated she would have staff thoroughly clean the soiled lens covers as soon as possible. Activities Storage Room: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. (ESD) E indicated she would have housekeeping staff thoroughly clean the ventilation grill as soon as possible. Beauty Shop: 2 of 2 hand sink basins were observed draining very slowly. (ESD) E stated: I will have (Maintenance Technician F) clear the drains. Storage Room: The flooring surface was observed missing vinyl tiles. The damaged flooring surface measured approximately 3 feet-wide by 5 feet-long. (ESD) E indicated she would have staff make necessary repairs as soon as possible. On 05/07/25 at 09:40 A.M., An environmental tour of sampled resident rooms was conducted with Housekeeper H. The following items were noted: 101: The Bed 2 overbed light assembly clear plastic protective lens cover was observed cracked/broken. Human fecal material was also observed on the drywall surface, located directly above the restroom waste receptacle. The restroom commode base caulking was additionally observed (etched, scored, stained, particulate). 102: The restroom commode base caulking was observed (etched, scored, stained, particulate). 111: The restroom commode base caulking was observed (etched, scored, stained, particulate). 117: The Bed 1 overbed light assembly lower 48-inch-long fluorescent bulb was observed non-functional. The restroom entrance door was also observed ill-mounted and not latching. 122: The Bed 1 overbed light assembly was observed missing the light switch and pull string extension. The wall mounted thermostat was also observed loose-to-mount and missing a protective cover plate. The restroom hand sink faucet assembly was additionally observed loose-to-mount. The restroom commode base caulking was further observed (etched, scored, stained, particulate). 123: The restroom commode seat was observed loose-to-mount. The Bed 1 overbed light assembly pull string extension was also observed missing. The vinyl base coving strip was further observed loose-to-mount. The damaged vinyl base coving strip measured approximately 6-inches-wide by 6-inches-long, along the corner edge of the drywall partition. 124: The restroom return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. The restroom commode base caulking was also observed (etched, scored, stained, particulate). 127: The Bed 2 metal frame was observed in the retracted position without a mattress, creating a potential safety hazard for R21. 128: The Bed 1 overbed light assembly pull string extension was observed missing. The restroom commode base caulking was also observed missing. The restroom commode seat was additionally observed loose-to-mount. 129: The Bed 2 overbed light assembly pull string extension was observed missing. 130: The restroom commode base caulking was observed missing. The restroom return-air-exhaust ventilation grill was also observed heavily soiled with accumulated and encrusted dust/dirt deposits. 131: The restroom commode base caulking was observed missing. The restroom return-air-exhaust ventilation grill was also observed heavily soiled with accumulated and encrusted dust/dirt deposits. 133: The restroom commode support was observed loose-to-mount. The restroom commode seat was also observed loose-to-mount. The restroom interior door surfaces were additionally observed (etched, scored, particulate). 135: The Bed 1 overbed light assembly upper 48-inch-long fluorescent bulb was observed non-functional. The Bed 1 overbed light assembly pull string extension was also observed missing. The Bed 2 enable bar was additionally observed loose-to-mount. The restroom shower stall overhead light assembly was further observed non-functional. Human fecal material was also observed, adjacent to the restroom shower stall unit. The restroom toilet tissue holder center pin was also observed missing. The restroom commode base caulking was additionally observed missing. 143: The restroom commode base caulking was observed missing. The resident room entrance overhead light assembly clear plastic protective lens cover was also observed soiled with (dust, dirt, dead insect carcasses). On 05/07/25 at 12:06 P.M., An interview was conducted with (ESD) E regarding the facility maintenance work order system. (ESD) E stated: We have TELS. On 05/07/25 at 12:30 P.M., An interview was conducted with Maintenance Technician F regarding the South Unit Shower Room floor drain concern. Maintenance Technician F stated: We have contacted (Contractual Vendor Name) for commercial repairs related to both plumbing and hot water heater issues. On 05/08/25 at 11:00 A.M., Record review of the Policy/Procedure entitled: Maintenance Inspection dated (no date) revealed under Policy: It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. On 05/08/25 at 11:15 A.M., Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated (no date) revealed under Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated (no date) further revealed under Policy Explanation and Compliance Guidelines: (1) The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. On 05/08/25 at 11:30 A.M., Record review of the Policy/Procedure entitled: Routine Cleaning and Disinfection dated (no date) revealed under Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment, and to prevent the development and transmission of infections to the extent possible. Record review of the Policy/Procedure entitled: Routine Cleaning and Disinfection dated (no date) further revealed under Policy Explanation and Compliance Guidelines: (1) Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge. On 05/08/25 at 11:45 P.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific items related to the aforementioned maintenance concerns.

Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, and (2) effectively date mark all potentially hazardous ready-to-eat food products effecting 61 residents who consume food, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 05/05/25 at 09:10 A.M., An initial tour of the food service was conducted with Dietary Head [NAME] (DHC) K. The following items were noted: One gallon (one-sixteenth full) of [NAME] Select 2% Milk was observed, within the Arctic Air 2-door reach-in cooler, without an effective open or discard date. The manufacturer's use-by-date read 5-15-25. One gallon (one-eighth full) of [NAME] Select Whole Milk was observed, within the walk-in cooler, without an effective open or discard date. The manufacturer's use-by-date was observed to read 5-15-25. The 2022 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Non-pasteurized shell eggs (7) were observed within the Arctic Air 2-door reach-in cooler. (DHC) K stated: We use the eggs for breakfast. (DHC) K also stated: We do eggs over easy for those who want them. The 2022 FDA Model Food Code section 3-202.14 states: (A) EGG PRODUCTS shall be obtained pasteurized. (B) Fluid and dry milk and milk products shall: (1) Be obtained pasteurized; and (2) Comply with GRADE A STANDARDS as specified in LAW. (C) Frozen milk products, such as ice cream, shall be obtained pasteurized as specified in 21 CFR 135 - Frozen desserts. (D) Cheese shall be obtained pasteurized unless alternative procedures to pasteurization are specified in the CFR, such as 21 CFR 133 - Cheeses and related cheese products, for curing certain cheese varieties. The can opener assembly was observed soiled with accumulated and encrusted food residue. (DHC) K stated: We clean the can opener every Monday and Wednesday. 1 of 2 [NAME] convection oven interior and exterior surfaces were observed soiled with accumulated and encrusted food residue. The Bunn Coffee Machine (backsplash, under splash, drip tray) was observed soiled with accumulated and encrusted food residue. The coffee machine drip tray was also observed completely full of liquid waste. (DHC) K stated: We clean the coffee machine daily. The Panasonic microwave oven interior was observed soiled with accumulated and encrusted food residue. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The Panasonic microwave oven interior door surface protective mesh screen was observed (etched, scored, torn), creating a microwave safety issue. The damaged door screen measured approximately .25-inches wide by 2-inches-long. The 2022 FDA Model Food Code section 4-501.13 states: Microwave ovens shall meet the safety standards specified in 21 CFR 1030.10 Microwave ovens. Failure of microwave ovens to meet the CFR standards could result in human exposure to radiation leakage, resulting in possible medical problems to consumers and employees using the machines. The Ecolab mechanical dish machine pounds-per-square inch (PSI) gauge was observed to read 33 (PSI) during the final rinse cycle. The (PSI) reading should be between 5-30 (PSI) during the final rinse cycle. (DHC) K indicated she would have Dietary Manager L contact the contractual vendor for necessary repairs as soon as possible. The 2022 FDA Model Food Code section 4-501.113 states: The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch). The Walk-In Cooler flooring surface was observed covered with laminate pattern rolled vinyl. 2 of 3 anti-skid strips near the entrance of the Walk-In Cooler were also observed loose-to-mount and partially missing. The 2022 FDA Model Food Code section 6-201.11 states: Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE. The Walk-In Cooler automatic door closer assembly was observed out-of-adjustment, allowing the door to not close and latch completely. The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. On 05/08/25 at 12:00 P.M., Record review of the Policy/Procedure entitled: Sanitation Inspection dated (no date) revealed under Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations. Record review of the Policy/Procedure entitled: Sanitation Inspection dated (no date) further revealed under Policy Explanation and Compliance Guidelines: (1) All food service areas shall be kept clean, sanitary, free from litter, rubbish, and protected from rodents, roaches, flies, and other insects. On 05/08/25 at 12:15 P.M., Record review of the Policy/Procedure entitled: Cleaning and Sanitizing Dietary Areas and Equipment dated (no date) revealed under Policy: All kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease, or other soil. The facility will provide sanitary foodservice that meets state and federal regulations. On 05/08/25 at 12:30 P.M., Record review of the Policy/Procedure entitled: Culinary Operating Procedures 501 Sanitation-General dated (no date) revealed under Policy: It is the policy of this facility to maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. On 05/08/25 at 12:45 P.M., Record review of the Policy/Procedure entitled: Culinary Operating Procedures 502 Cleaning Equipment and Utensils dated (no date) revealed under Policy: Equipment and utensils will be properly cleaned, sanitized, and stored to prevent contamination. On 05/08/25 at 12:55 P.M., Record review of the Policy/Procedure entitled: Date Marking for Food Safety dated (no date) revealed under Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Record review of the Policy/Procedure entitled: Date Marking for Food Safety dated (no date) further revealed under Policy Explanation and Compliance Guidelines for Staffing: (1) Refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41 degrees or less for a maximum of 7 days. (2) The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. (5) The discard day or date may not exceed the manufacturer's use-by-date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday.)

Based on observation, interview, and record review the facility failed to ensure six out of 15 residents (Resident # 4, 7, 23, 26, 46 & 134) had call lights that were accessible. Findings Included: Resident #4 (R4): During an interview on 5/05/2025 at 10:42 AM, Resident #4 (R4) was observed in bed. The call light was observed to be hanging out of reach of R4. R4 was alert and able to answer questions. R4 stated that he does not have a call light, but there was one hanging on the wall. It was then observed that a call light was wrapped around the call light outlet box that was on the wall. The call light was not within reach of R4, and R4 stated he was not able to reach the call light, and also stated he never used that call light. During the same interview it was observed that a bell was on R4's over the bed table, and upon asking R4 the reason for the bell, R4 stated it was so he could ding it to get someone to come in his room when he needed assistance. R4 said, but said they (staff) never hear it, so he gets himself up to his wheelchair and takes himself to the BR, but sometimes he falls on the floor so he yells out really loud for help. In another interview on 5/05/2025 at 4:33 PM, R4's room call light button was pushed and it was revealed that the call light did not turn on, did not light up in the room, nor outside the room. Also, no audible sounds was heard from the call light. R4 was asked how long he had the ding bell, in which he stated about one year. Immediately after the interview with R4 on 5/5/2025 at 4:33 PM, Certified Nurse Aid (CNA) N confirmed R4 had the ding bell for about one year ever since the call light system was new from one year ago. On 5/06/2025 at 12:13 PM, R4 call light situation had not changed. However, R4 resided in bed one, and for bed two there was no bed in that space, so the call light for bed two was pushed which revealed that call light was functional. The call light for bed two reached over far enough to be fully accessible to R4 in his bed; bed one however, that call light had not been given to R4. In an interview and observation on 5/06/2025 at 12:16 PM, CNA CC was asked to ring R4's bell for an audible test at the nurses station. Upon CNA CC ringing the bell the ding was only vaguely heard, and was washed out due to other noise. R4's room was room [ROOM NUMBER] which was four rooms down form the nurse's station. Resident #7 (R7): On 5/5/2025 at 11:45 AM, R7 was observed in his room in bed awake, and was also observed to not have a call light within reach. The only call light that was observed on the wall was at the head of R7's bed which was the emergency red string light, but the string was behind R7's headboard and out of reach for R7. R7 was asked where his call light was located, and he said right here, and pointed to the side of his bed. Upon telling R7 there was no call light there, R7 was asked what color was the call light in which R7 stated it was red, a red string. No other call light system was observed on the wall. The cord was observed to have no support mechanism to prevent it from falling back behind the headboard. Resident #23 (R23): On 5/08/2025 at 9:25 AM, R23 was observed in bed with legs hanging off the side of the bed, stated she was not trying to get out of bed, but wanted to get out of bed. R26's call light was observed to be out of reach, and located behind the head of the bed between the headboard and the wall. Resident #26 (R26): In an observation and interview on 5/5/2025 at 1:34 PM, R26 was yelling out for the nurse from his bed in his room. R26 asked if he had his call light, in which R26 very angrily stated no, and threw his arm roughly over his head which suggested his call light was behind him. Upon entering R26's room the call light was found to be on the floor underneath R26's bed. R26 stated that when his call light falls on the floor it makes him very angry. In an observation on 5/5/2025 at 4:00 PM, R26 began yelling out for nurse. R26's call light was observed to be wrapped around the call light outlet box on the wall and was out of R26's reach. Resident #46 (R46): In an observation and interview on 5/05/2025 at 11:58 AM, R46 was observed to be in bed eating his lunch. R46 asked how he would call for a Certified Nurse Aid or nurse in the even he needed assistance. R46 was observed to reach for his bed remote and said that was his call light. R46 was made aware that was not his call light. The R46 reached for his TV remote and said that was the call light. R46 was told that was the TV remote, then R46 stated Hell I don't know then. A red string emergency call light was observed behind R46's headboard on the wall, which was out of R46's reach. R46 stated that the red cord was the cord he pulled when he needed the nurse. The cord was observed to have no support mechanism to prevent it from falling back behind the headboard and out of reach. Review of the facility's policy and procedure, not dated, titled Call lights: Accessibility and Timely Response revealed, Policy Explanation and Compliance Guidelines: 5. Staff will ensure the call light is within reach of resident and secured as needed.

Based on observation, interview and record review the facility failed to 1) follow physician orders (Resident #20) 2) assess and monitor edema (Resident #11) 3) secure and monitor a urinary catheter (Resident #38) and 4) implement wound care orders upon admission from the hospital (Resident #67) for 4 out of 15 reviewed for quality of care. Findings include: Resident #20 (R20) A review of the medical record revealed that Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including heart failure and both acute and chronic respiratory failure with hypoxia. On 05/07/25 at 9:24 AM, Resident #20 was observed lying flat in bed while wearing a nasal cannula. At 9:47 AM that same day, the resident was again observed lying flat in bed with the nasal cannula in place. A nurse's note dated 05/07/25 at 5:21 AM indicated that Resident #20 had returned from an Emergency Department visit with a diagnosis of possible pneumonia. The After Visit Summary from the Emergency Department revealed that Resident #20 presented with shortness of breath. Emergency medical services reported that the resident had a low pulse ox of 91% on room air. The resident was placed on 2 liters of oxygen via nasal cannula, which improved the oxygen saturation to 93%. A review of a physician's order initiated on 02/06/25 stated: The resident cannot lie with head of bed flat due to shortness of breath while lying flat and diagnosis of chronic respiratory failure. Another physician's order, initiated on 03/12/25, stated: Oxygen at 2 liters via nasal cannula PRN (as needed) for SpO2 below 90%. In an interview conducted on 05/08/25 at 12:06 PM, Registered Nurse (RN) J stated that she also observed Resident #20 lying flat in bed. She acknowledged that, based on the physician's order, the expectation was that the resident should not have been lying flat. 38383 Resident #11 (R11): Review of the medical record reflected R11 admitted to the facility 7/3/14 and readmitted [DATE], with diagnoses that included vascular dementia, dependence on wheelchair and diabetes. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/31/25, reflected R11's cognition and mood were not assessed. The same MDS reflected R11 did not walk, was dependent for transfers and required substantial/maximal assistance with personal hygiene and partial/moderate assistance with rolling left and right. On 05/06/25 at 9:21 AM, R11 was observed seated in a wheelchair, in the hallway. Gripper socks were observed on both feet. Rear anti-tip bars and anti-rollback brakes were observed on the wheelchair. A seating cushion was not observed in the wheelchair. Upon entering R11's room, a standard mattress was noted on their bed, without linens in place. R11's medical record reflected weights that included 210.5 pounds on 4/24/25, 275.5 pounds on 5/1/25 and 237 pounds on 5/8/25. An eINTERACT SBAR (Situation Background Assessment Recommendation) Summary for Providers Progress Note for 4/30/25 reflected R11 had new or worsening edema (swelling), with edema around both eyes, to the right side of the abdomen, to the scrotum and both legs. The edema on R11's legs was documented as +2 pitting edema (measurement of swelling with indentations that remain after pressing on the skin). A hospital After Visit Summary, dated 4/30/25, reflected R11 was seen due to edema and was to receive 40 milligrams of Lasix (diuretic medication) daily for seven days. Review of R11's medical record, including Progress Notes, the Assessments section and Physician's Orders did not reflect assessment and monitoring of R11's edema. In an interview on 05/08/25 at 2:48 PM, Director of Nursing (DON) B agreed that there had not been assessment and monitoring of R11's edema since their return from the hospital. Regarding assessments for edema, DON B reported R11 would be placed on daily weights, as well as monitoring of lung sounds, vital signs and assessment of edema and circulation. 49272 Resident #R38 (R38) Review of the medical record revealed R38 was admitted to the facility on [DATE] with diagnoses that included: retention of urine, legal blindness, muscle weakness, need for assistance with personal care, anxiety disorder, and depression. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/25 revealed R38 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 5/5/25 at 12:45 PM, resident was observed laying on his back in bed, reported that his penis is splitting in half and that he is going to have a suprapubic catheter placed. On 5/7/25 at 3:04 PM, during an interview with RN Q, she reported completing R38's catheter care that morning. When asked about the condition of his penis, she reported that it didn't look pink or rashy but was split down the length of the head of his penis. On 5/7/25 at 3:39 PM, observed R38's penis with RN Q, there was a split where the urethral opening should be that extended the length of the penis head (approximately 1 inch long and 1/4 inch wide). R38 had been observed wearing a brief and sweat pants and no catheter securing device was in place at that time. The tubing for his catheter had been fed through the left leg of his sweat pants. R38 reported at that time he didn't have any feeling in his penis which was new and prior to that he had significant pain with any slight movement, R38 rated it 8/10 on the pain scale. When asked what he could tell me about the history of his penile injury, R38 reported that it was due to them placing the catheter, that it had slowly gotten worse and that he didn't have any slack with the tubing which caused it to pull and tear. R38 reports that there was a time where the staff were placing a catheter securing device and he believed that had made an improvement. He further reported that it (the catheter securing device) would come off at night due to sweat. When asked about documentation that resident had refused to see urology in the past, R38 reported that was a misunderstanding and that he had wanted to be seen by the provider in the facility and did not want to have to be sent out to see the provider if possible. On 5/8/25 at 2:28 PM, during an interview with ADON, when asked what she could tell me about R38's penis injury, stated that it started as deterioration from the tip of his penis. When asked what led to the injury ADON reported she believed it was from his refusal to use a cath secure (device used to secure catheter in place) which caused tugging and wear and tear from the catheter. She further stated that when R38 would experience hallucinations he would tug at it. It should be noted that progress notes or care plan do not reflect resident tugging on his catheter or any interventions to help prevent this from occurring. On 5/8/25 at 2:45 PM, during an interview with Doctor MM, when asked what he could tell me about R38's split penis, reported that he knows there was a delay in getting his suprapubic catheter placement scheduled. When asked what caused the split/injury to the head of R38's penis, Doctor MM reported that all long term, male catheters will cause a split in the penis. During a phone interview on 5/12/25 at 8:19 AM, with R38's family member (FM KK), when asked about the injury to her father's penis, stated that he doesn't know when he is peeing so he required a catheter. She further stated that the facility waited too long to change it and ripped his penis hole. FM KK reported that she was previously the caregiver for R38 and that he had normal penile anatomy prior to this injury. On 5/12/25 at 12:44 PM, during an interview with DON, when asked what she could tell me about the injury to R38's penis, reported that Doctor MM said it was chronic and that resident was supposed to have a suprapubic catheter placed. DON reported that with a leg strap and proper catheter care an injury to the penis is avoidable for male catheter patients. A review of R38's physicians orders revealed, 1/20/24 A and D ointment (skin protectant) to excoriated underside of penis, twice a day for damage to penis from Foley catheter. A review of R38's progress notes revealed: 1/8/2025 11:38 Nurses Note Late Entry: Received from night nurse that resident was c/o (complaint of) pain at the site of insertion of foley catheter. It was reported that resident's catheter was changed by night nurse and resident tolerated well. This nurse answered the resident's call light at approximately 11am to the resident stating that he needed his emesis emptied and the basin returned to him quickly due to nausea and vomiting. Resident stated that he was in a lot of pain in his abd (abdomen)/bladder. This nurse assessed his foley, emptied the balloon and tried to advance the foley further to see if this would relieve the resident's pain. The resident stated that his pain was relieved with the balloon being deflated, however upon advancing the catheter, this nurse noted frank red blood into the foley bag. The resident continued to have decreased pain as this nurse advanced the catheter into the bladder and refilled the balloon with 10cc of NS. This nurse flushed the resident's catheter and noted more blood in the foley bag. At this point, the resident asked that the catheter be removed stating that he no longer wanted it because it hurt him. The catheter was removed by this nurse's hall partner. The resident was presenting with confusion, vomiting, copious amounts of frank red blood with clots to his brief. At this point, this nurse spoke with the resident about going to the ED (emergency department) for evaluation r/t (related to) bleeding from his urethra. The resident agreed. (EMS company name redacted) EMS was called to transport. (Name redacted), resident's daughter was called to notify. Report called to (name redacted) at (Hospital name redacted) . On 1/8/25 at 3:38 PM Nurses note Resident c/o (complained of) discomfort at Foley catheter insertion site. Foley changed per sterile procedure; resident tolerated well. On 1/27/25 at 3:36 PM Nurses note .Foley cath (catheter) patent with clean tallow urine in bag . On 2/25/25 at 1:23 PM Nurses note (Doctor MM) in to see resident, (Doctor MM) suggested that he see a urologist for suprapubic cath placement as soon as possible. Per resident he stated that the did not want to go out to the urologist or to the hospital, refused urology consult. On 2/26/26 at 2 PM Admission Note: Late Entry: Resident arrived via stretcher accompanied by 2 EMTs (Emergency Medical Technician) at 12:28 pm today, Wed [DATE] .Resident returns to (name of facility redacted) after about one week in (hospital name redacted), where he was treated for a urinary tract infection and resulting encephalopathy .Wound on undersurface of tip of penis continues. Treatment with A&D ointment continues. Resident still has his Foley catheter. On 3/6/25 at 4:35 PM Nurses Note: (Doctor MM) notified of resident change in condition including increased confusion, hallunications, and picking at skin. Doc recommended transfer to (hospital name redacted) due to recurrent UTI's . On 3/13/25 at 2 PM Admission Note, Late Entry: Resident arrived at (facility name redacted) at 12:39 PM via stretcher in the company of two EMTs . On 3/17/25 at 3:39 PM Nurses Note Spoke to Dr regarding delusions and hallucinations vivid to resident causing distress, and recurrent UTI with sepsis. New orders for Seroquel and prophylactics added to orders . Review of urology consult revealed, 3/18/15 Ventral erosion of penis, UTI (urinary tract infection) symptoms, Recommend suprapubic catheter, surgery scheduled will contact, change foley today and collect sample to send out for culture, will call with results and prescribe antibiotic once culture is back. Review of office visit notes from R38's primary care provider revealed 4/4/25 (age redacted)-year old male has a indwelling Foley catheter that is literally splitting his penis in half. Patient was scheduled to get a suprapubic catheter placed but this apparently is still trying to be scheduled. Patient gets frequent urinary tract infections secondary to the eroding of the catheter, he had significant metabolic encephalopathy .Patient will benefit from avoiding metabolic encephalopathy which comes with his urosepsis which comes from his catheter eroding through his penis while waiting for urology to place a suprapubic catheter . Review of R38's care plan revealed no interventions related to foley catheter care or securement. Review of Kardex revealed the following: CATHETER: I have a catheter, please position my catheter bag and tubing below the level of my bladder and away from the entrance room door. Provide me with a leg strap and use a dignity bag to cover my catheter bag. It should be noted that staff reported that resident would refuse to use a leg strap however no progress notes were found indicating refusal, education or re-education on the importance of securing the catheter. Requested incident/accident reports related to injury, none provided prior to survey end. Review of facilities policy titled Catheter Care, documented in part It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .Leg bags will be attached to the residents thigh or calf making sure to have slack on the tubing to minimize pressure and tension. Ensure straps are snug but not tight. It should be noted that the facilities policy does not address securing a catheter except for when a leg bag is used. 32064 Resident #67 (R67) Review of the medical record revealed R67 was admitted to the facility on [DATE] with diagnoses that included diabetes, quadriplegia, anxiety, and atrial fibrillation. The Discharge Minimum Data Set (MDS) with an Assessment Reference Date of 4/6/25 revealed R67 was independent with cognitive skills for daily decision making and had an unplanned discharge to the hospital with a return not anticipated. Review of hospital records from prior to admission revealed a wound assessment dated [DATE] which revealed an abdominal wound to the left lower quadrant. The wound measured 3.5 centimeters (cm) long x 15 cm wide x 1 cm deep. The wound had moderate serous: thin, water, clear drainage. Wound management was listed as Negative Pressure Wound Therapy (NPWT/wound vacuum assisted closure [vac]). Another assessment dated [DATE] revealed a second wound on the midline abdomen measuring 12 cm long. The wound was approximated with sutures and moderate amount of serosanguineous: thin watery, pale red/pink drainage. The wound management was listed as alginate; transparent film. Review of the Hospital After Visit Summary dated 4/2/25 revealed wound care instructions were as follows: 1) Left lower quadrant abdominal wound: NPWT wound management with continuous pressure set at -125 mmHg (millimeters of Mercury) with black foam and drape; change Monday, Wednesday, Friday, and as needed if dressing is no longer intact. These instructions were circled with two stars drawn on the left side and wound vac? written above the circled area. 2) Abdominal midline surgical wound: cleanse with vashe wash, prep with skin prep and allow to dry, apply Xeraform/fluffs, cover with ABD (abdominal pad), and secure with tape. Change daily and as needed if the dressing is no longer intact. Review of the Physician Orders revealed these orders were not implemented. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed these treatments were not completed. Review of the Nurses Note dated 4/3/25 revealed Drsg D/I [dressing dry and intact] to LL [left lower] abdominal wound. Colostomy intact . The medical record did not reflect what dressing was in place or when it was applied. Review of the Nurses Note dated 4/4/25 revealed Resident surgical incision has grayish colored drainage with no odor noted with sutures in place. Review of the Nurses Note dated 4/5/25 revealed Resident surgical incision has grayish colored drainage with no odor noted with sutures in place. Review of the Alert Note dated 4/6/25 revealed Residents [sic] had an old wound that opened back up. Some milky drainage noted. Open area cleaned and calcium alginate, kerlix and abdominal pads applied to the open incision. [Doctor] made aware of the drainage and open incision. Per Physician he would like an [sic] culture collected from the drainage. Review of the Health Status Note dated 4/6/2025 revealed Nurse was alerted by aide that resident was requesting to be sent to hospital. When nurse spoke with resident, resident stated that she did not feel well and she was concerned that she had an infection from abdominal incision dehiscence. Aide got vitals on resident and BP [blood pressure] was 101/63, Temp [temperature] 103.7, RR [respiratory rate] 16, HR [heart rate] 106, O2 [oxygen saturation] 90% on room air. Resident complained of discomfort, but no complaint of pain. After nursing assessment of resident, nurse decided to call emergency transport to take resident to the hospital for further evaluation. Review of the culture obtained from the abdominal wound on 4/4/25 with results available on 4/7/25 revealed the wound was positive for many Escherichia coli (E-coli), few klebsiella pneumoniae, rare staphylococcus aureus, and few pseudomonas aeruginosa. The culture results revealed this organism [klebsiella pneumoniae] has been determined to produce an extended spectrum beta lactamase (ESBL) and is considered to show multiple drug resistance, requiring that the patient be placed in contact precautions In a telephone interview on 05/08/25 at 12:23 PM, Registered Nurse (RN) P reported they worked with R67 on the night of 4/4/25. RN P reported they received in report that R67 had just received a wound vac that day (two days after admission). When asked about any treatment for the midline abdominal surgical incision, RN P reported the wound was seeping continuously and a dry 4x4 sponge gauze was used after cleansing with saline. In a telephone interview on 05/08/25 at 12:31 PM, RN EE reported R67 did not have a wound vac placed upon admission. RN EE reported they believed R67 had wound orders in place while waiting for the wound vac but could not recall which dressing/treatment was used. In an interview on 05/08/25 at 12:45 PM, Director of Nursing (DON) B reported R67 showed signs and symptoms of infection upon admission to the facility. DON B reported they did not visualize R67's wounds upon admission. DON B reported R67's admission assessment did not reflect any abdominal wounds. When asked about treatments for R67's abdominal wounds, DON B reported the first treatment ordered was dated 4/6/25, the day R67 transferred to the hospital DON B reported they would have to consult with Assistant Director of Nursing (ADON) J for further information. ADON J joined the interview at 1:03 PM. ADON J reported the facility was informed that R67 needed a wound vac and that the facility had a wound vac available. ADON J reported when R67 arrived, it was determined that R67 needed two wound vacs and the physician was contacted for a treatment order until the second wound vac arrived. ADON J reported it took two to three days for the second wound vac to arrive. DON B and ADON J reported they could not locate any wound treatment orders or documentation that wound treatments were completed prior to 4/6/25.

Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff to respond to resident needs timely for three (R2, R25 and R37) and the Resident Council, from a census of 61 residents. Findings include: Resident #2 (R2): Review of the medical record reflected R2 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic obstructive pulmonary disease and diabetes. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/1/25, reflected R2 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 05/05/25 at 11:39 AM, R2 was observed in a wheelchair, in their room. R2 reported call light response times of 35 minutes to one hour and 45 minutes. R2 reported the extended call light response times could be on any shift, depending on who was working. R2 reported they were able to determine their call light response times using the clock in their room. Resident #25 (R25): Review of the medical record reflected R25 admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke). The Quarterly MDS, with an ARD of 2/20/25, reflected R25 scored nine out of 15 (moderate cognitive impairment) on the BIMS. On 05/05/25 at 1:06 PM, R25 was observed lying in bed. R25 reported at times, they had to sit in feces for hours at a time, mostly on the day shift. R25 reported it took more than one person to change them. Resident #37 (R37): Review of the medical record reflected R37 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included iron deficiency anemia due to blood loss, muscle weakness, difficulty walking and need for assistance with personal care. The Quarterly MDS, with an ARD of 2/13/25, reflected R37 scored 15 out of 15 (cognitively intact) on the BIMS. On 05/05/25 at 11:11 AM, R37 was observed seated in a wheelchair, in their room. R37 reported at times, it took one hour for their call light to be answered on day shift. R37 also reported staff would respond to the call light, say they would be back but would not return. The extended call light wait times occurred when R37 wanted to get out of bed for the day. R37 reported they liked to be out of bed between 9:30 AM and 10:00 AM. In an interview on 05/08/25 at 10:49 AM, Certified Nurse Aide (CNA) N reported when the facility was not able to cover shifts, they worked short-handed. CNA N reported that occurred more on the weekends and approximately three times in the prior three months. In an interview on 05/12/25 at 12:06 PM, Scheduler U reported the facility staffed based on census and acuity. Regarding extended call light response times, Scheduler U reported there was a resident that required a higher number of staff to assist with care, which could be time consuming. When the Restorative Aide was working, they assisted with getting that resident up. 49272 On 5/7/25 at 12:24 PM, during a confidential Resident Council meeting, when asked if the residents get the help and care they need without waiting a long time and if staff respond to their call lights timely, responses included: One resident laughed and replied not on nights Usually takes at least a half an hour. Staff turn off call lights and don't take care of the need. It depends on who is working, with certain people I have to wait 45 minutes When asked if there is enough staff, 10 of 10 residents responded no and provided the following responses: We are always short that is why we have to wait so long for call lights. Nights is worse. Good luck getting something done after 6pm (resident mentioned specific concerns with delay in getting brief changed)

This citation pertains to MI00149061 and MI00151480 Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from abuse for three of nine residents reviewed, resulting in resident-to-resident physical abuse, bruising for R11, bruising and bleeding for R12, and a head laceration requiring sutures and hospital admission for R17. Findings include: Review of the facility reported incident (involving R11 and R12) revealed on [DATE] While these residents were playing bingo, (R11) attacked (R12). R11 wheeled his wheelchair behind R12 and then started hitting him and biting him. R12 did not retaliate and was hit twice and bit twice. The second bite was enough to leave teeth marks . Review of the second facility reported incident (involving R11 and R12) revealed on [DATE], Resident (R12) was using the phone in the front lobby when resident (R11) wheeled behind him and tried to take the phone from him. (R12) started hitting (R11) and (R11) was hitting back ., another resident witnessed the altercation and called for help. A nurse responded and separated the residents. The witness acknowledged that both residents made contact with each other. It should be noted that the facility initially provided information related to the [DATE] incident. R11 Review of the medical record revealed Resident #11 (R11) was admitted to the facility on [DATE] with diagnoses that included hemiplegia, vascular dementia and generalized anxiety disorder. The Minimum Data Set (MDS) with an Assessment date (ARD) of [DATE] revealed R11 scored 12 out of 15 (mildly impaired cognition) on the Brief Interview for Mental Status (BIMS). Review of R11's progress notes revealed: [DATE] Resident hitting head on wall while cares being provided. Unable to redirect behavior. [DATE] I spoke with resident's guardian today regarding sending resident's referral somewhere that would be more suitable for behaviors. Guardian would like us to follow psych recommendations first and see if there is any improvement. [DATE] Resident hitting and kicking at staff AM, grabbing and pulling at TV cord trying to pull from wall. [DATE] Social work met with resident in their room to discuss code status directive. Resident refused to sign upon getting very agitated, after her verbally sated that he wanted to be a full code. Resident jammed the pen into the paper which was clipped to a clip board and smacked the wall. [DATE] Resident pushed lunch tray off of table onto floor. Resident agitated with staff as they try to provide ADL care. [DATE] This writer returned from lunch to the news that (R11 and R12) got into another fight, This nurse spoke with (R11), who reported that (R12) was blocking the hallway. When (R11) tried to pass (R12), (R12) struck (R11) in the face. Resident assessed for injuries. Resident has a small scratch, 0.7cm long by 0.1 cm wide, over his left eye. Resident denies pain. [DATE] Resident has gone to a psych facility. Resident agreed to leave willingly . [DATE] Spoke with patients guardian rt patients increase of behaviors. SW (social worker) told guardian that patient has been becoming increasingly aggressive with staff and with other residents and facility recommends referral to inpatient psych. Guardian is agreeable to this . [DATE] writer observed res hit a picture with a glass pane in the hallway of south unit. R (right) hand ring finger (4th digit) has a small ST approx. 1cmx0.1cm . [DATE] Late Entry (R11) was in his wheelchair heading into the lobby to use the resident phone, which was in use by another resident. (R11) attempted to grab the phone from the other resident and then other resident began hitting (R11) to the left side of the face. Residents were immediately separated and safe. (R11) denied pain and was offered an ice pack for his left side of face, noted discoloration and swelling seen instantly after incident. [DATE] res (resident) cont. (continue) on 15min checks . [DATE] res cont on 15min checks . [DATE] res cont on 15min checks . [DATE] At approximately 1420, the resident was noted in the dining room with activities running bingo. This nurse was alerted of an incident between this resident and another resident. Apparently, this resident was self-propelling around the table while the other residents were playing bingo when he went past another resident and per the activity's aide, this resident started to bite another resident. Per the activities staff, the other resident did not react to this resident, however it was noted that this resident did have scratches on his face and neck and a red mark on his nose. Per activity's aide this resident bit the other resident on the right shoulder and the right hand. A skin assessment was completed on this resident, and it was noted that this resident had red scratch marks in linear shape on both sides of his neck as well as linear shape scratch on the outer side of his right eye. Resident also noted to have a red spot on the end of his nose. Resident noted to remain with full function at this time and reports no pain. Resident states to this nurse that he did hit and bite the other resident, but the other resident hit him as well. The resident apologized to this nurse for fighting with the other resident. The resident is reminded that it is inappropriate to fight with other residents. Resident voiced understanding. Residents separated from each other by staff at the scene . [DATE] Resident noted to refuse to get out of bed this AM. Resident stated later. Resident then proceeded to yell out nurse several times. When entering the resident room, resident stated that he needed a hospital gown. When resident was given a gown, resident did not want this gown. Resident was then noted to call out nurse again down the hallway and kick over his bed side tray table. When this nurse entered the room, the resident stated that he needed a hospital wheelchair. This nurse asked him if he was ready to get out of bed. The resident stated that he was not ready to get out of bed yet. This nurse showed the resident that he had a w/c (wheelchair) in his room. The resident voiced understanding. All needs are noted to be met at this time. Will continue to monitor for behaviors throughout the shift and document as necessary. [DATE] Pt (patient) has been very behavioral tonight. Pt yelled for his meds shortly after the shift started. Administered medication and a pain pill. After 30 minutes was on the side of the bed yelling again for a staff member from first shift that had gone home. Pt was asked by staff could she help him pt ignored her. This writer moved cart so could make sure pt was not going to fall to the floor. Pt tried to move forward so the left side of the mattress was starting to life up. Staff repositioned pt on the mattress. Pt stopped trying to slide out of the bed. However pt started banging on the wall with hand inside the blanket and bothering the next door pt from his sleep. Pt slept well after that until he asked for something for pain again. Pt did state that he was sorry. On [DATE] at 1:24 PM, R11 was observed lying on his back in his bed. Strong smell of urine noted. Resident was covered with 2 blue pads. When asked if he could tell me anything about incidents were he had been physically touched or been touched by another resident he replied yes but did not offer any additional information. When asked a second time he began to stutter well, well, well and stated that she got fresh and so all I did was hang onto her finger. He reported that incident was with a staff member and could not recall any incidents with other residents then thanked me followed by good bye. R12 Review of the medical record revealed Resident 12 (R12) was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, major depressive disorder and generalized anxiety disorder. The Minimum Data Set (MDS) with an Assessment date (ARD) of [DATE] revealed R12 scored 7 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). A review of R12's progress notes revealed: [DATE] Resident in room (redacted) struck resident in the doorway of room (redacted), resident separated. Resident in room (redacted) then began striking the nurse and they fell to floor, resident did not hit his head. Resident continued yelling at nurse, vital signs 97.1, 107/68, 64, 92% r/a (room air), resp (respirations) 17. Resident had no signs of injuries noted. No signs and symptoms of pain or discomfort. [DATE] This writer and the north unit manager were in the south nurses station attempting to do report when we heard this resident yelling in the hallway on Boardwalk. After a few minutes of this, we began to hear two voices shouting. This writer turned to look and saw that this resident from room (redacted) and the resident from room (redacted) (R12 and R17) had their hands on each, and were shouting at each other. This writer walked down the hall to intervene. The resident in room (redacted) (R17) fell and hit his head, which began to bleed. This writer tried to get this resident to sit down in his wheelchair, but he pulled this writer back with him, and we both tipped over backward and ended up on the floor. This resident began to hit this writer about the head and face, causing quite a lot of bleeding. This writer was finally able to get away from this resident. [DATE] This writer returned from lunch to the news that (R11) and (R12) got into another fight. This nurse spoke with (R11), who reported that (R12) was blocking the hallway. When (R11) tried to pass (R12) struck (R11) in the face. Resident was assessed for injuries. None were found. Resident denied pain. [DATE] Resident up in W/C (wheelchair) at start of shift asking for ride home, he was tearful when staff was unable to given rides . [DATE] Resident up during night asking staff to give him a ride home. No other behaviors noted this shift . [DATE] Guest called 911 yesterday evening from phone in lobby, stating that there were no nurses or staff and the building was abandoned. At that time there were 3 nurses and 3 CNAs (certified nursing assistants) on unit. Guest was reassured that staff were available to help at all times and was assisted back to room. Guest later accused nurses of sneaking pills to him. Guest reassured that he could take or not take meds as he wished . [DATE] In evening guest was noted wandering in halls, asking staff if they could give him a ride home. Explained to guest that he would need to be discharged by doctor before he could leave d/t (due to) memory issues and needing help with med administration. Reassured guest that his family knows they are here and will be in touch soon. No episodes of aggression or attempts at egress. Cont (continue) on 15 min checks . [DATE] resident pulled fire alarm at front door. Writer asked resident why he would pull alarm. He stated he was going to continue pulling them until someone stops stealing all of his tools. Resident not easily redirected. [DATE] Resident hollering out this noc (night). When this nurse entered room to ask if he was in pain. He said No, I want my mom and dad. Will continue to monitor. [DATE] Before dinner, resident was out in hallway in his wheelchair and began repeatedly asking when he is going home. This nurse and other staff attempted to redirect the resident, but he became verbally aggressive and began moving toward the direction of room (redacted), whose occupant was shouting and cursing. This resident was redirected away from the direction of (redacted), and eventually settled down. [DATE] Resident returned to facility at approx. 2130, resident was tearful for short period, no aggression noted. Placed on 15 min checks . [DATE] (R12) has again had a physical interaction with a nurse and another resident causing physical harm. He is not able to be redirected, and this incident was not provoked. He sought out someone to harm. I have attempted to contact (redacted) inpatient psych. I spoke with nursing, (name redacted) she stated we are not taking him back, we are not a long-term care you are 911 called due to physical assault that he did to a nurse and another resident. [DATE] We reciaved (sp) a call from (name redacted) transportation company that R12 became physically aggressive on the way from inpatient psych returning to Pinnacle. To ensure (R12) and the driver's safety the driver pulled into the first business parking lot and called his base for assistance. Another driver came to the location, loaded R12 into his vehicle without incident and returned him to Pinnacle. DON (director of nursing) met with owner of (redacted name of transportation company) to discuss the situation. R12 was never left unattended or in an unsafe situation. (name of neuropsych group redacted) was called regarding the event, and they agreed to have R12 transported back to inpatient psych due to this recent escalation .R12 will be returning on the original petition and certification . [DATE] Social Service Director has been attempting to reach guardian via phone for the majority of the day to discuss the influx of more aggressive behaviors and R12 seeking out other residents and physically attacking them . [DATE] Follow up skin assessment following another resident-to-resident right middle finger at the first joint is bruised as it was Friday after the first resident-to-resident. The bruising in no larger, not swollen, and just slightly darker than Friday. R12 denies pain. [DATE] per witness statements: R12 was using the resident phone when another resident attempted to grab the phone from R12. R12 began hitting the other resident in the left side of the face, staff intervened instantly and ensure their safety, incident was witnessed by other residents that were in the lobby. [DATE] It was reported to writer by staff that this resident reached back hitting another resident and staff heard a smack. Staff separated both residents safely. Small bruises noted to back of right hand, denies pain . [DATE] res cont (resident continues) on 15 min checks . [DATE] res cont on 15 min checks . [DATE] res cont on 15 min checks . [DATE] res cont on 15 min checks . [DATE] Cont on 15 min checks [DATE] Resident is also noted to have two linear scratches to the right side of his mouth were he says that the other resident punch him (R12). [DATE] At approximately 1420, the resident was noted to be in the dining room playing bingo with activities. This nurse was alerted of an incident between this resident and another resident. Apparently, this resident was sitting at the table playing bingo when another resident was self-propelling around the dining room. Per the activities staff, the other resident was going past this resident when all of the sudden the other resident started to bite this resident. Once in the back of the right shoulder and once in the right hand. This resident was not noted to retaliate. A skin assessment was completed on this resident, and it was noted that this resident had red marks in a circular shape both on the back of his right shoulder between the top of his shoulder and his scapula as well as the third knuckle on his right hand . [DATE] Resident noted to be up this AM roam(ing) about the facility. Resident noted to yell at staff as well as pick up staff material from the front desk and carry them around the facility. This nurse had a chat with the resident about appropriate behavior and not getting into things that don't belong to him . [DATE] .Resident was noted to yell at staff this AM . [DATE] Resident noted to be yelling this AM. Yelling in hallway, yelling at kitchen staff for pushing carts down the hallway. Resident also noted to be inappropriate with staff, hitting staff rear end, etc . [DATE] Resident noted to be upset this AM. Resident noted to be questioning why he is here this AM .Resident noted to be swearing and yelling about why he is here and why we are holding him here, how he got here and where he is . [DATE] Up in wheelchair, alert x2 .Yelling and fussing about neighbor's radio. Staff intervened and turned down radio. Reminding patient not to enter anyone else's room. Patient eventually retreating to his own room and remained there quietly. On [DATE] at [DATE] at 1:24 PM, R11 was observed lying in his bed, covered with 2 blue pads with a strong urine odor present. R11's speech was stuttered, and he reported not recalling being the aggressor or victim in any incidents with other residents. It should be noted that the reasonable person would not expect that they would be harmed in his/her own home or a health care facility and would experience a negative psychosocial outcome. R12 had been discharged from the facility and unavailable for interview. R16 was listed as a witness for both incidents. On [DATE] at 2:12 PM, R16 was asked what he recalled about the incidents between R11 and R12. R16 reported that he saw 2 fights and that R11 is an a*sh*le. When asked what staff have done to keep residents safe he reported that they try to keep R11 out of his room. R16 went on to report R11 is a dumb*ass and he goes around in circles and turns tables around and everything, he should be gone too. On [DATE] at 12:39 PM, during an interview with Registered Nurse (RN) F, when asked what she recalled about an incident that occurred between R12 and another resident, she stated R12 did a lot of things and then reported that the resident that was struck by R12 was R15. When asked what she could tell me about R12's behaviors and any interventions put in place to keep R12 and other residents safe, she reported that you had to have a relationship with him and that he was sent out to psych a few times. Additional interventions that she noted were video games, TV, pop and fake chewing tobacco that he enjoyed. On [DATE] at 2:29 PM, during an interview with the Nursing Home Administrator (NHA) and director of nursing (DON), NHA reported that R12 had a history of acting out and due to a medical condition he was very easy to agitate. He further stated that the facility could have done a better job with care plans/interventions. Obviously he had a history and this was not a one off. I would see this as an acceleration of behavior and some behaviors just got worse and worse. He repeated that care plans and interventions were inadequate and he did not see a lot of new intervention put in place and I completely acknowledge that. When asked what interventions were put in place when both residents (R11 and R12) were involved in physical incidents on both [DATE] and again on [DATE], NHA reported the residents were immediately separated following both incidents. Discussed with NHA and DON that R11's chart revealed the facility had completed every 15 minute checks completed from 12/7-[DATE], a progress note from [DATE] indicated that they should continue and no documentation indicated they should end, and R11 and R12 were involved in a physical altercation on [DATE]. DON reported that an IDT (interdisciplinary team) should determine when it is appropriate to stop every 15 minute checks, which does not appear to have happened in this case. NHA added that in addition to an IDT discussion there should have been back up with a psychological re-evaluation for interventions to prevent further aggressive occurrences. R11 was care planned for being physically and verbally aggressive since [DATE] but no new interventions had been added except labs ordered on [DATE] and removal of his footboard on [DATE]. When asked if they could tell me why additional interventions were not put in place, DON confirmed the information I provided was correct and not additional information was provided. DON/NHA reported that they were not aware of any like residents being interviewed or screened, just that witness statements were taken. Review of the facility reported incident (involving R12 and R17) revealed on [DATE], at approximately 2:45 pm the unit nurse (name redacted) (RN G) reports a resident-to-resident altercation occurred. Resident #1 (R12) was heard yelling in the hallway. Within a few minutes multiple voices were heard shouting and both unit nurses (RN G and RN H) responded. Resident #2 (R17) fell out of his wheelchair and hit his head on the floor causing a head laceration that was bleeding. Resident#1 (R17) also verbalized that resident #2 (R12) had hit him. (name redacted) (RN G) held pressure to the head wound while (name redacted) (RN H) attempted to deescalate Resident #1 (R12). Resident #1 (R12) continued shouting and attempting to punch and kick staff. (name redacted) (RN G) immediately reported the incident to Director of Nursing and building administrator. The following interventions were put in place: the residents were separated immediately, and each resident was transported to the local emergency room (hospital name redacted) for prompt medical care . Staff member (name redacted) (RN H) went to the ER following his shift. Resident (last name redacted) (R17) had a laceration on his left temple which required stitches .Staff member (name redacted) (RN H) had a blackened eye and bloodied eye .The incident was witnessed and is substantiated. R17 Review of the medical record revealed Resident 17 (R17) was admitted to the facility on [DATE] with diagnoses that included history of falling, memory deficit following cerebrovascular disease, adjustment disorder with mixed anxiety and depressed mood. The Minimum Data Set (MDS) with an Assessment date (ARD) of [DATE] revealed R17 scored 8 out of 15 (moderately impaired cognition) on the Brief Interview for Mental Status (BIMS). A review of R17's progress notes revealed: [DATE] Removed 6 sutures from left forehead no s/s (signs or symptoms) of infection noted no bleeding steri strips applied. Denies pain or discomfort . [DATE] Resident was struck by another resident and fell in his room hitting his head. Laceration left temple, neuros wnl (neurological assessment within normal limits) .Applied pressure dressing to area and ice EMS (Emergency Medical Services) contact and resident transferred to (hospital name redacted) for eval (evaluation) and treat (treatment). [DATE] Guest yelling and swearing at staff repeatedly since early this morning. Difficult to soothe or calm. Does become more amenable after med admin. [DATE] Guest yelling and cursing at staff, also refusing care. Went back asleep after demanding to get up and then being upset that it was very early in the morning. [DATE] Resident yelling and cursing at staff re (about) I can't find my call light, which was right under his hand. Noted increase in emotional outbursts in early evening since Trazadone changed from BID (twice daily) to HS (at bedtime) only . [DATE] Resident increasily (sp) agitated and aggressive towards staff since Trazodone changed from BID (twice daily) to QD (once daily). Yells and swears at staff, up walking in room with unsteady gait. Able to calm but only temporarily and with great effort . In a telephone interview with RN H, he reported that on [DATE]nd R12 was pushing himself up and down the hallway, muttering to himself (which he reported was normal behavior for R12), R12 was near R17's room, toward the end of the hallway, R12 had a raised voice and R17 came out of his room to tell him to stop being loud, then they began to exchange words. R17 was standing and R12 was in his wheelchair facing eachother and within seconds they had their hands on each other. They each had ahold of the others shirt. RN H went to intervene. He reported that R12 was strong and shortly after he got to the 2 residents R12 let go of R17 and R17 fell to the ground, hitting his head on the floor. His verbal account aligned with the information in the FRI investigation. RN H stated that he was the only nurse for 40-45 residents that night and that him and several other staff members had raised concerns that it was an unsafe assignment to both the scheduler and the administrator. RN H reported that R12 had a known history of being violent. On [DATE] at 2:38 PM, during in interview with NHA, when asked what he could tell me about the incident involving R12 and R17, he reported that from what he [NAME] there was an altercation, R12 struck and pushed R17, R17 fell over his chair and received a head laceration, staff intervened immediately then R12 stuck a nurse resulting in a black eye. R12 was known to be physically aggressive, when asked what interventions had been put in place to keep R17 and other residents safe, NHA reported that after the incident R12 was placed on every 15 minute checks. When asked if they were aware that staff had expressed concern that the nursing assignments were not safe, both NHA and DON said they were not aware. When asked if any like residents were interviewed/screened or assessed following this incident both NHA and DON were not aware that had occurred. A review of the facilities policy titled Abuse, Neglect and Exploitation, documented in part The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: increased supervision of the alleged victim and residents .

Based on observation, interview and record review, the facility failed to provide appropriate monitoring and treatment for a resident experiencing symptoms of repeat Urinary Tract Infection (UTI), for 1 resident (R18) of 2 residents reviewed for UTI, resulting in a lack of monitoring, a delay in the treatment of a UTI, hospitalization , and sepsis (a life threatening complication of infection.) Findings include: Review of the facility, Antibiotic Stewardships Program Policy, dated 12/1/23, reflected, Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .The Medical Director, Director of Nursing, and Consultant Pharmacist serve as the leaders of the Antibiotic Stewardship Program and receives support from the Administrator and other governing officials of the facility .Medical Director - sets the standards for antibiotic prescribing practices for all healthcare providers prescribing antibiotics, oversees adherence to antibiotic prescribing practices, and reviews antibiotic use data and ensures best practices are followed .Director of Nursing - establish standards for nursing staff to assess, monitor and communicate changes in a resident's condition that could impact the need for antibiotics, use their influence as nurse leaders to help ensure antibiotics are prescribed only when appropriate, and educate front line nursing staff about the importance of antibiotic stewardship and explain policies in place to improve antibiotic use .Infection Preventionist - utilizes expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms .The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: i. Nursing staff shall assess residents who are suspected to have an infection and notify the physician. ii. Laboratory testing shall be in accordance with current standards of practice. iii. The facility uses the (CDC's (Centers for Disease Control) NHSN Surveillance Definitions, updated McGeer criteria, or other surveillance tool) to define infections. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics .Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g., antibiotic time-out). ii. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. iii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness .11. Documentation related to the program is maintained by the Infection Preventionist, including, but not limited to: a. Action plans and/or work plans associated with the program. b. Assessment forms. c. Antibiotic use protocols/algorithms. d. Data collection forms for antibiotic use, process, and outcome measures. e. Antibiotic stewardship meeting minutes. f. Feedback reports. g. Records related to education of physicians, staff, residents, and families. h. Annual reports Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R18 was .admitted to the facility on [DATE] and readmitted [DATE] post hospital admission related to sepsis due to urinary tract infection(UTI), with other diagnoses that included Alzheimer's disease, hypertension (high blood pressure), history of UTI, history of falls with bilateral hip and pelvis fractures, depression and anxiety . The MDS reflected R18 had a BIMS (assessment tool) score which indicated her ability to make daily decisions was severely impaired, and she was dependant on care and required maximal assist with toileting. The MDS reflected R18 was not on a urinary toileting program and was frequently incontinent of urine. During an observation on 3/12/24 at 9:50 AM, R18 was laying in bed. R18 was observed to have a peripherally inserted central catheter (PICC) in the right arm. An empty intravenous bag was hanging at R18's bedside labeled with R18's name and Ertapenem 1gm (gram)/100 every 24hr (hours) for 17 days. No isolation signage was posted outside R18's room. During an observation on 3/14/24 at 10:15 AM, R18 was laying in bed with feet off edge of bed with eyes closed. No isolation signage was posted outside R18's door. Review of the Hospital Discharge documents, dated 2/25/24 through 3/1/24, scanned into the facility Electronic Medical Record(EMR) on 3/1/24, reflected R18 was admitted into the hospital on 2/25/24 with diagnosis of sepsis .from urinary tract infection. Continued review of the documents reflected R18 had a Infectious Disease Consult on 2/28/24 that reflected, The patient is .with a history of advanced Alzheimer dementia and bilateral hip hemiarthroplasty who presented to ER (emergency room ) via EMS (Emergency Medical Services) from SNF[skilled nursing facility] with AMS[altered mental status] outside of baseline, fevers, and rigors. At baseline the patient is able to speak a few words to family and also follows commands .Per chart review: The patient did have a positive urine culture .on 1/31/24 .Assessment 1. Complicated .UTI with ESBL klebsiella bacteremia, with .findings of right hydroureteronephrosis and calculus, stent placement planned for 2/29 . Continued review of documents reflected R18 discharge plan to include, Discharge Plan PICC: yes Antibiotics: Ertapenem Duration: complete 3 weeks (3/18) Weekly Labs .Follow-up: 2 weeks from discharge via telemed with nurse at SNF . Review of the Hospital Discharge Summary, dated 3/1/24, scanned into the facility electronic medical record (EMR) on 3/1/24, reflected R18 required contact isolation. R18's room reflected no evidence of contact isolation precautions 3/12/24 through 3/14/24. Review of the facility EMR, dated 7/12/23 through current 3/14/24, reflected no evidence of physician notes. During an interview on 3/14/24 at 11:40 AM, Director of Nursing(DON) B reported R18 was followed by PACE (a community service for seniors) services including physicians. DON B reported R18 was not followed by facility physicians because of billing and verified R18 had been a resident on and off since 2021 and verified was unable to locate evidence of Physician notes in the facility EMR. Review of the facility Bowel and Bladder assessments, dated 7/12/23, 7/25/23, and 3/1/24, reflected R18 was a good candidate for bladder retraining. Review of R18's the Care Plans, dated 7/12/23, reflected R18 was incontinent of bladder with goal to be free of signs and symptoms of UTI with one intervention, Keep me as clean and dry as possible. Apply protective barrier cream prn. Additional interventions were added 3/1/24 that included, Assist me to the toilet after meals .Assist me to the toilet before meals .Observe and report any signs and symptoms of an infection such as frequency, urgency, burning upon urination, mental status changes, fever, etc .Provide me my mediations as ordered. (The Care Plans did not mention use of antibiotic treatment until 3/1/24.) Review of R18's Nursing Progress Notes, dated 10/18/23 at 11:48 p.m., reflected, Resident had orders to obtain a urine sample. Resident complained about urgency and frequency and burning up on voiding. Sample was obtained and sent to [named] lab. Urine was very dark in color and noted to have a strong odor. Will notify Dr .when lab results received. Review of R18's Nursing Progress Notes, dated 10/21/23, reflected, Verbal order given to start resident on Monurol 3mg x1 day d/t klebsiella pneumoniae (UTI). Med is to be mixed in 3-4oz of water and drank immediately. Per PA (Physicians Assistant) the sensitivity for urine isn't back yet but she would call facility if changes needed to be made . Review of R18's Nursing Progress Note, dated 10/23/23, reflected, This Lpn contacted PACE for new antibiotic order for UTI. [named provider] (on call)ordered Amoxicillin- Clavulanate 875 mg BID (twice per day) for 7 days . Review of the Medication Administration Record(MAR), dated 10/1/23 through 10/31/23, reflected R18 received single dose of Monurol 3 grams on 10/22/23 and on 10/24/23 started Amoxicillin- Clavulanate 875 mg BID for 7 days. Review of the Laboratory reported, faxed 10/21/23, reflected R18 had urinalysis collected on 10/18/23 with preliminary culture results of >100K col/mL Klebsiella pneumonia (A). Review of R18's Physician Order, dated 10/30/23, reflected, Collect UA with C&S post ATB (antibiotic) one time only for 1 day on 11/1/23. (No evidence of urine culture results in EMR was located). Review of the Nursing Progress Notes, date 1/30/24 through 2/4/24, reflected R18 had increased weakness documented on 1/30/24 at 10:08 a.m., unwitnessed incident with injury at 6:45 p.m., continued weakness with repeat attempts to self transfer, fever with UA obtained on 1/31/24, and unwitnessed fall on 2/4/24 and 2/8/24 with injury. Review R18's Physician orders, dated 2/1/24, reflected, Fosfomycin Tromethamine Oral Packet 3 GM (Fosfomycin Tromethamine) Give 1 packet by mouth one time a day for UTI for 1 Day. Review of R18's Physician order, dated 2/5/24, reflected, Macrobid Oral Capsule 100 M(Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED (N39.0) for 7 Days. (No evidence of urinalysis or culture located in EMR.) Review of R18's Einteract SBAR (situation, background, assessment, recommendation) Change of Condition note, dated 2/25/24 at 7:01 p.m., reflected, resident shaking profusely. unable to grasp/squeeze writer's hands. Resident alert during assessment. Writer asked resident if she is having any pain, resident shook head yes and rubbed right arm and then shoulder .[R18 Responsible Party] notified and request for her mother to be sent hospital. Pace contacted again and order given to send to ED (ER) . During an interview on 3/14/24 at 12:21 PM, Infection Control Preventionist (ICP) U reported had been in the infection control role since June 2023. ICP U reported the facility did not use McGeer's or Loeb criteria to determine if the resident likely had an infection, in which an antibiotic was indicated. ICP U reported McGeer's should be used according to professional nursing standards. ICP U reported they would expect staff to complete a Change of Condition Assessment, notify physician of symptoms, enter orders into EMR and document with signs and symptoms of UTI. ICP U verified R18 admitted to the hospital on 2/25/24 related to UTI. ICP U reported she tracks antibiotic use in the facility and reported R18 did not return to facility with urine culture and sensitivity results, therefore did not verify proper use of antibiotics. ICP U reported R18 was difficult to manage because PACE services were involved and verified did not have access to PACE documentation and PACE visits were not part of R18's EMR. ICP U reported verbal communication with PACE staff in facility and nurses expected to document on Progress Notes. ICP U verified they were unable to locate R18 Urinalysis with Culture and Sensitivity from 1/31/24 or 10/18/23 in the EMR and reported they did not have access to Hospital lab results. Review of the January and February Infection Control Line listing reflected incorrect or missing data including admitted , onset date, cultures, organism, antibiotic and dated cleared and outcome. ICP U reported they were not aware of R18's UTI organism at the time of hospital discharge on 3/1/24 because was not in the discharge documents and stated she must have overlooked it. ICP U verified R18 received physician ordered antibiotics 2/2/24, 2/6/24 and re-admission on 3/1/24 that were not documented on the Infection Control Line Listing. ICP U reported often completes Sepsis Screen Assessment for each Resident on antibiotics and verified R18 had an incomplete assessment on 3/8/24 and was unsure why. ICP U reported R18 did not meet mcgeers for 2/2/24 use of antibiotics with only one symptom of increased agitation. Review of R18's urinalysis with culture and sensitivity (UA with C&S), dated 1/31/24 to 2/3/24, reflected, Culture >100K col/mL Klebsiella pneumoniae! This organism has been determined to produce an extended spectrum beta lactamase (ESBL) and is considered to show multiple drug resistance, requiring the the patient be placed in contact precautions. Cefoxitin or piperacillin/tazobactam are appropriate treatment options for ESBL producing organisms in low inoculum infections (such as urinary tract infections). (R18 had same organism on 10/18/23, treated with single dose of Monurol 3 grams on 10/22/23 and on 10/24/23 started Amoxicillin- Clavulanate 875 mg BID for 7 days with no evidence of ordered UA with C&S on 11/1/23. R18 was treated with Fosfomycin Tromethamine Oral Packet 3 GM 1 packet by mouth on 2/1/24 followed by Macrobid Oral Capsule 100 M one capsule by mouth two times a day for 7 Days on 2/5/24. Not as recommended by 2/3/24 culture results and no evidence of justification not to follow recommendations.) During an interview on 03/14/24 at 2:48 PM, Registered Nurse (RN) C reported R18 had a current UTI and if residents had infection with treatment on antibiotics nursing staff should completed Infection Progress Notes every shift. Review of R18 EMR, dated 1/31/24 through 2/25/24, reflected no evidence of Infection Progress notes including when R18 was treated with antibiotics for UTI 2/2/24 through 2/12/24. Review of the Senior Care Partners P.A.C.E.(Program of All-Inclusive Care for the Elderly) Provider Agreement, dated 9/9/2020, reflected, Provider Obligations. Provider must meet Federal, State, and any applicable Medicare and Medicaid requirements and comply with service delivery, Participant rights, and Quality Improvement activities .Services. Provider shall provide all Provider Services normally provided by Provider and within the scope of Provider's license. Provider services provided under this Agreement shall be of the same type and quality, and provided in the same manner as services provided to all other patients of Provider .RECORD MAINTENANCE, AVAILABILITY, INSPECTION, AND AUDIT 6.1 Maintenance. Provider shall prepare and maintain appropriate medical and billing records concerning Provider Services provided to Participants, including such records as necessary for the evaluation of the quality, appropriateness, and timeliness of such services. All such records shall be maintained in accordance with prudent record keeping procedures and as required by law. Participants and their representatives shall be given access to the Participant's medical records, to the extent and in the manner provided by law and, subject to reasonable charges, be given copies thereof upon request .Senior Care Partners PACE relies on Provider to communicate any quality of care changes as they may occur. The Contract was signed by prior facility owner on 8/23/21 including prior facility name.

This citation pertains to intakes: #MI 743, MI 746. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falls with injury and ensure supervision for 2 of 3 residents (Resident #107 & #110) reviewed for falls/ injuries of unknown origin resulting in Resident #107 falling and sustaining an arm fracture, and Resident #110 falling and sustaining rib fractures, as well as the potential for further resident falls and injuries/injuries of unknown origin. Findings include: Resident #107 Review of a Face Sheet revealed Resident #107 had pertinent diagnoses which included but not limited to: [CONDITION(S)] with seizures or convulsions. Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 12/13/21, revealed a Brief Interview for Mental Status (BIMS) score of 03, out of a total possible score of 15, which indicated Resident #107 had cognitive impairment. Review of a Facility Reported Incident (FRI) dated 2/10/22 revealed: Incident Summary It was reported to the (Nursing Home Administrator-NHA A) Administrator/Abuse Coordinator on 2-4-2022 by the Director of Nursing (DON B) that (Resident #107) had bruises and swelling noted on her left elbow. There was also bruises in the crease of the left arm and wrist by the Nurse Supervisor, (Registered Nurse (RN) Y) who was on duty. Doctor was notified and an x-ray was obtained which confirmed a non displaced fracture of (Resident #107's) elbow. The x-ray technician reported the injury was consistent with having a fall. In an interview with the Administrator (NHA A) (Resident #107) reported I may have bumped it,, This resident was currently on 15 minute observations and there was no indication that (Resident #107) had a fall. An investigation was initiated. Investigation Summary Staff noted bruising and some [CONDITION(S)] to (Resident #107) left elbow while assisting resident. An unusual occurrence (incident) report was completed and appropriate staff were notified. (Resident #107) did complain of pain to the left elbow and left hip . There was no report of a fall . Interviews of staff that were on duty in that area from 2/1/22 began As of this time, no one remembers a fall from (Resident #107). Review of Resident #107's Care Plan (CP) revealed: FOCUS- I am at risk for falls, while ambulating I walk at a rapid pace. I will wear proper footwear at all times-Date Initiated: 12/16/2021 .GOAL-I (Resident #107). hope to be free from falls without a serious injury by next review-Date Initiated: 12/16/2021 .INTERVENTIONS-Be sure my call light is within reach and encourage me to use it for assistance as needed Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Encourage resident (Resident #107). to use grip socks. Provide reminders and cueing as needed. I (Resident #107). am to have non skid footwear on when up. Date Initiated: 12/16/2021 . Review of Resident #107's Incident/Accident reports revealed: Resident #107 had a unwitnessed fall on 12/15/21 in the dining room with a laceration on Resident #107's nose, an unwitnessed fall on 1/3/22 in a hallway, an unwitnessed fall on 1/20/22 in a hallway, on 2/4/22 bruising noted on left arm (unwitnessed event), and a witnessed fall on 2/9/22 in the dining room. Review of Resident #107's Progress Notes dated 12/15/2021 at 16:36 revealed: Nurses Note Text: resident (Resident #107). observed on the floor in the hallway resident (Resident #107) has small laceration to the bridge of her nose Review of Resident #107's Progress Notes dated 1/3/2022 at 21:15 revealed: Incident Note Text: Staffs reported to nurse that resident (Resident #107) observed on floor and same time get herself up, staffs assist resident to her room ambulate Review of Resident #107's Progress Notes dated 2/4/2022 at 10:14 revealed: Nurses Note Text: Resident (Resident #107) complained of left arm pain when nurse assisted resident to remove her jacket noted resident's left elbow discolored, swollen,warm to touch . Review of Resident #107's Progress Notes dated 2/4/2022 at 14:47 revealed: Nurses Note Text: X-ray tech(technician) reported (Resident #107) non displaced fracture left elbow . Review of Resident #107's Progress Notes dated 2/7/2022 at 10:13 revealed: Interdisciplinary (IDT) notes Note Text: IDT met to discuss resident's recent x-ray that showed a break in (Resident #107) left elbow. Resident has had multiple falls recently, but has never complained of any pain in her elbow following any fall. Last known fall 01/20/2022 . Review of Resident #107's Progress Notes dated 2/10/2022 at 00:10 revealed: Incident Note Text: Around 1145 on 2/9/22 a staff member yelled for assistance in the dining room. Resident (Resident #107) was laying on the dining room floor on the right side of her body with her wheelchair behind her. This nurse immediately got down on the floor with resident to help calm her down and to start assessing. When asked what happened the resident (Resident #107) stated, I fell . Resident (Resident #107) denied any pain except for discomfort in her left arm that is broken related to a recent prior fall . Review of Resident #107's Progress Notes dated 2/27/2022 at 10:30 revealed: Nurses Note-Late Entry: Note Text: Resident (Resident #107) having trouble ambulating today; more bent over than usual. Resident (Resident #107) c/o (complained of) left hip pain and favoring that side. Sore to the touch . During an interview on 3/10/22 at 11:40 PM., 'Registered Nurse (RN) G reported Resident #107 has fallen a lot in the last month or so. RN G reported Resident #107 leans forward when she walks, as if she is top heavy. RN G reported most of Resident #107's falls have been unwitnessed. RN G reported the unit (dementia unit) is very busy with behavioral residents, as well as residents who self ambulate (able to walk). RN G reported increased supervision/staffing would help a lot. During an interview on 3/10/22 at 3:00 PM., Licensed Practical Nurse (LPN) Y reported Resident #107 has had a lot of falls recently. LPN Y reported Resident #107 can be behavioral, and restless. LPN Y reported the North is a very busy unit. LPN Y reported usually there are 2 Certified Nurse Aides (CNA's) or TNA's, and 1-2 activity staff. LPN Y reported when 1 of the activity staff take residents from this unit (North) to the South unit for an activity, the other staff (nurse, CNA/TNA/Activity) are left on the unit. LPN Y reported a lot of the time, with the behaviors of other residents, it's difficulty to keep on and eye on the residents such as Resident #107, because a staff might also be on break. LPN Y reported no other staff/managers come to the unit to cover those staff who are off the unit for whatever reason. LPN Y reported there should be more staff to adequately supervise and monitor the residents on the North unit. In an observation/interview on 3/10/22 at 3:30 PM., noted Resident #107 with a splint brace on her left arm. Resident #107 was walking around the dining room unassisted. noted 2 staff in a charting room. Resident #107 continued to move around dining room tables, and sit down, and back up again. Resident #107 observed sitting down very closed to the edge of the dining room chairs, and unable to pull the chair fully behind her legs, or scoot her bottom back. This movement of around the dining chairs, and tables continued for approximately 10-15 minutes before a staff member noted to approached Resident #107. During an interview on 3/10/22 at 3:45 PM., Temporary Nurse Aide (TNA) S reported Resident #107 moves around a lot, and should be closely monitored. not only for falls, but behaviors, it would be nice if there was another staff on this unit. During an interview on 3/15/22 at 12:30 PM., TNA E reported on 2/4/22 Resident #107 needed help putting a jacket on, and TNA E assisted Resident #107 with the jacket. TNA E reported Resident #107 complained of pain on her upper arm, and there was a bruise. TNA E reported she told the nurse, and Resident #107 had x-rays completed, resulting in a fracture of Resident #107's left arm. TNA E reported Resident #107 moves around quickly, and very randomly. TNA E reported Resident #107 goes from a seated position, to standing and typically looks like she is going to fall forward. TNA E reported as Resident #107 walks, she is hunched over forward, and has a shuffle type walk. TNA E reported we think she fell and got up off the floor herself. we try to keep our eyes on her, but she moves quickly. TNA E reported the North unit could most definitely use another staff or two because it's so busy with residents and their behaviors. Resident #110 Review of a Face Sheet revealed Resident #110 had pertinent diagnoses which included but not limited to dementia. Review of a Minimum Data Set (MDS) assessment for Resident #110, with a reference date of 12/30/21, revealed a Brief Interview for Mental Status (BIMS) score of 00, out of a total possible score of 15, which indicated Resident #110 had cognitive impairment. Review of a Facility Reported Incident (FRI) dated 2/14/22, 12:29 PM., Revealed: Incident Summary It was reported on 2/6/2022 to . (NHA A') . that resident (Resident #110) had a fracture , x-ray results reported a fractures of the lateral 6th,7th and 8th Left Ribs .(Resident #110) had a fall on 2/2/2022 had complained of right hip pain and was x-rayed post fall with negative results but then .(Resident #110) . began complaining of hip pain again but was grabbing her left side. The nurse contacted the doctor who ordered more X-rays including the ribs showing the fractures. Review of Resident #110's Incident/Accident (IR) reports revealed: on 1/3/22 (Resident #110) was laying on the floor in her bedroom in front of her door laying on her left side. Resident stated, I was trying to runaway. further review of the IR revealed: this fall was unwitnessed. Review of Resident #110's Incident/Accident reports revealed: on 1/17/22 (Resident #110) was ambulating without her walker from her chair to her bathroom and lost her balance. She states she did not hit her head, but there was no witness .Resident Description: I was going to the bathroom and lost my balance, but I did not hit my head. further review of the IR revealed: this fall was unwitnessed. Review of Resident #110's Incident/Accident reports revealed: on 1/19/22 (Resident #110) was sitting on floor next to the doorway of her room Resident Description: I was putting my dinner tray on the cart in the hallway. further review of the IR revealed: this fall was unwitnessed. Review of Resident #110's Incident/Accident reports revealed: on 2/2/22 at 6:18 PM., (Resident #110) . Nursing Description the nurse, walked into the resident's (Resident #110) room to give her her medications, she (the nurse) observed the resident (Resident #110) on the floor. Resident Description: Resident stated that she was going to the bathroom. further review of the IR revealed: this fall was unwitnessed. Review of Resident #110's Incident/Accident reports revealed: on 2/2/22 at 6:46 PM., (Resident #110) .Nursing Description: This nurse went into resident's room to check on her and found her on the floor. Resident said she was trying to self transfer to use the toilet when she fell . Resident Description: Resident said she was trying to self transfer when she fell on the floor. further review of the IR revealed: this fall was unwitnessed. Review of a Facility Reported Incident (FRI) dated 2/10/22 revealed: Incident Summary: Incident Summary . (Resident #110) resident had a fracture, x-ray results reported a fractures of the lateral 6th,7th and 8th Left Ribs.Resident had (2) fall (s) on 2/2/2022 had complained of Right Hip Pain and was x-rayed post fall with negative results but then began complaining of hip pain again but was grabbing her (Resident #110) Left side. The nurse contacted the doctor who ordered more x-rays including the ribs showing the fractures. During an interview/observation on 3/10/22 at 10:45 AM., Resident #110 noted to be in pain, facial grimacing when sitting up in wheelchair and slowly moving while talking with this surveyor. Resident #110 reported she fell going to the bathroom and hurt something. Resident #110 reported staff does not help her to the bathroom, she goes herself. Resident #110's call light not noted in reach. Resident #110 reported she can walk without assistance. Resident #110 unable to give details of how many falls she has had, and did not recall falling and breaking ribs. Review of Resident #110's Progress Notes dated 1/3/2022 20:38 revealed: Incident Note Text: On 1/3/2022 at 2005 resident was laying on the floor in her bedroom in front of her door laying on her left side. (Resident #110) stated, I was trying to run away.Full assessment completed and (Resident #110) placed on neurological assessments due to fall. Resident only complaint of her buttocks sore from fall. No injuries noted. Resident assisted backup and into her (Resident #110) chair by her bed. INTERVENTION: Resident (Resident #110) to have a medication reconciliation completed due to the increased number of falls recently . Review of Resident #110's Progress Notes dated 2/2/2022 19:06 revealed: Unusual Occurrence Note Text: This nurse when into resident's (Resident #110) room to check on her because she (Resident #110) had a previous fall about 30 minutes earlier and found her on the floor. Resident said she (Resident #110) was trying to self transfer to use the toilet when she fell Resident (Resident #110) encourage to use call light and ask for assistance Review of Resident #110's Progress Notes revealed no progress note for 1st fall on 2/2/22. Review of Resident #110's Progress Notes dated 2/4/2022 11:11 revealed: Nurses Note Late Entry: Note Text:This nurse was called down to the shower room r/t increased pain. Resident was assessed and noted to have pain in her hips. Resident is currently on pain medication regimen and resident has had several falls recently. X rays were performed on bilateral hips yesterday and were negative for any fractures . Review of Resident #110's Progress Notes dated 2/5/2022 11:34 revealed: Nurses Note Late Entry: Note Text: resident (Resident #110) noted in report this am that she (Resident #110) was favoring her left flank side, this nurse ask (Resident #110) if her left side is hurting resident stated her hip hurt, but this nurse noticed (Resident #110) favoring her left flank side as well . Review of Resident #110's Progress Notes dated 2/8/2022 21:04 revealed: Incident Note Text: While this nurse was obtaining vital signs on this residents' roommate, this nurse noted the patient trying to sit down in her recliner chair and as she was sitting down the chair flipped forward towards her causing her to end upon the floor in a sitting position . Review of Resident #110's Care Plan (CP) revealed: FOCUS I (Resident #110) am at risk for falls r/t (related to) I have a history of Falls . Unaware of safety needs I am also incontinent. 10/28/21 . I receive opioid and [CONDITION(S)] medication and I have impaired vision and hearing. Date Initiated: 06/26/2018 Created on: 06/26/2018 GOAL: I hope to be free from falls without a serious injury by next review. Date Initiated: 06/26/2018 Target Date: 03/30/2022 .INTERVENTIONS: OT (occupational therapy) to work on bathroom hygiene and safety transfers Date Initiated: 02/08/2022 .Remove my rocking chair from my room Date Initiated: 02/10/2022 . During an interview on 3/15/22 at 8:15 AM., LPN M reported Resident #110 has had many falls recently. LPN M reported Resident #110 does not use her call light. LPN M reported Resident #110 would most definitely benefit from increased supervision and a toileting schedule. LPN M reported many residents on the South unit are 2 person assists, and Resident #110 was walking with a walker, but with all the falls she now has a wheelchair in place of her recliner. LPN M reported both the North/South units could use more hands on deck. During an interview on 3/16/22 at 11:15 AM., Occupational Therapy Technician (OT) Z reported Resident #110 would benefit from increased toileting, and supervision. OT Z reported, she has not heard or been notified of an increase in toileting, supervision or an increase in check in's for Resident #110. OT Z reported Resident #110 has pain when toileting, dressing, and during therapy. OT Z reported Resident #110 no longer has a recliner, and Resident #110 has reported being uncomfortable in her wheelchair while sitting in it as her chair. During an interview/observation on 3/16/22 at 11:30 AM., Resident #110 reported being uncomfortable, in pain and does not like the wheelchair to sit in for long periods. Resident #110 noted to be tearful, and wincing (facial signs of pain) when moving slightly in her wheelchair. Resident #110 reported she did not know how to use the call light. During an interview on 3/16/22 12:45 PM., Physical Therapy Director (PTD) AA reported at times Resident #110 is non-compliant with the use of her call light. PTD AA reported Resident #110 would benefit with an increased toileting schedule, and he is unaware of what her toileting routine is.

Based on observation, interview and record review the facility failed to provide treatment and care in accordance with professional standards of practice, the plan of care, and residents' choices, in 2 of 17 residents (Resident #35 and #66) reviewed for quality of care, resulting in increased risk of infection (Resident #35 and #66) lack of person-centered care (Resident #35 and #66), lack of coordination of care (Resident #35 and #66), lack of emergency hospital transfer (Resident #66), and death (Resident #66). Findings include: Resident #66 (R66) In review of R66's Admission Minimum Data Set (MDS) assessment dated [DATE], he was admitted to the facility on [DATE]. R66's same MDS assessment introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 00 (00-07 Severe Impairment). R66's electronic medical record (EMR) indicated his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In review of a Psychiatric Evaluation dated 5/13/21, R66 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R66's discharge instructions dated 7/06/21 revealed he was an emergency transfer to the hospital on 7/01/21 due to somnolence and was readmitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R66's [MEDICATION(S)] instructions were underlined and in bold print Last day of IV [MEDICATION(S)] is July 20. Pharmacy dosing of [MEDICATION(S)] per protocol/monitoring of her (sic) renal function. With any questions, please contact Dr. [name] infectious diseases-phone number provided. The same discharge instructions indicated to administer [MEDICATION(S)] over 12 days, the first dose was to be administered on 7/07/21 and the last dose was to be administered on 7/19/21, and then the peripherally inserted central catheter (PICC, a long thin tube inserted through a vein and passed through the larger veins near heart) was to be pulled; in which contradicted the same instructions to administer [MEDICATION(S)] until July 20, 2021. In the same discharge instructions, under Line, Drain, and Airway Care, revealed R66 was to have routine PICC care, and PICC the line to be removed after antibiotic therapy completed on July 20. [MEDICATION(S)] 1.25 g was transcribed to the July 2021 admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R66's electronic medical record (EMR) indicated prior to the 7/07/21 dose of [MEDICATION(S)], R66 had pulled out the PICC line, and the PICC line had not been replaced until 7/08/21. There was no documentation in R66's EMR of communication with the infectious disease physician of not receiving the 7/07/21 dose of [MEDICATION(S)], the need to extend the treatment regimen an extra day, or clarification of the stop date. There was no documentation that a follow up appointment had been attempted or scheduled with Infection Disease as ordered. R66's same discharge summary indicated he was classified as a medium hospitalization re-admission risk. In review of the 7/07/21 nurses' notes, R66 pulled out the PICC line that had been placed in his right arm. R66's nurses notes dated 7/08/21 at 3:04 PM, indicated a PICC line insertion was attempted in R66's left arm on 7/08/21; but the insertion was unsuccessful due to scar tissue in the left arm from a pacemaker insertion. Licensed Practical Nurse (LPN) I was interviewed on 9/27/21 at 8:45 AM and stated she was not aware R66 had a pacemaker prior to 7/08/21 when reinsertion of his PICC line was attempted by the Registered Nurse (RN) in his left arm. Due to the scar tissue, the RN was not successful in placing a PICC in R66's left arm, the PICC was placed in his right arm again. In review of R66's care plans, there was no mention he had a pacemaker, PICC line, or for IV [MEDICATION(S)] antibiotic treatment. According to Medscape.com, prior to the placement of a central line, pacemaker status should be considered when determining placement. In review of R66's Lab Results Report, the trough (lowest concentration of medication in bloodstream) blood sample was collected on 7/12/21 at 5:18 AM; the laboratory received the sample on 7/12/21 at 2:27 PM; the laboratory reported the trough results on 7/12/21 at 3:20 PM. According to a pharmacy document provided by facility titled New Prescription request, received 7/13/21 at 11:55 PM, under [MEDICATION(S)] Clinical Notes, on 7/08/21, RN EE was contacted by the pharmacy to confirm R66 would require labs to be drawn on Monday, 7/12/21 before the next dose of [MEDICATION(S)]. The same document dated 7/12/21 indicated there was no answer at the nurse's station 2 times to confirm labs were drawn, the pharmacist left a message with the receptionist to have the RN call back and fax results as soon as possible. R66's EMR did not reflect R66's lab results were called or faxed to the pharmacy on 7/12/21; results were received by the facility on 7/12/21 at 3:20 PM. The same note indicated the pharmacist did not receive R66's lab results until 7/13/21, and R66 required a new dose of 1.5 grams daily; RN EE confirmed the discontinue date for [MEDICATION(S)] was 7/18/21. There was no documentation RN EE confirmed the [MEDICATION(S)] discontinue date with R66's primary physician or the infectious disease physician. In an interview with Director of Quality Assurance and Pharmacist AA on 9/30/21 at 8:41 AM, it was confirmed that the pharmacist had talked with RN EE on 7/13/21 at the facility and obtained the date for R66's [MEDICATION(S)] stop date was to be 7/18/21. Pharmacist AA confirmed according to their records R66's physician was not contacted. Pharmacist AA stated the trough level should be obtained within 30 minutes prior to R66's 4th dose of [MEDICATION(S)]. Pharmacist AA stated in the same interview, 1 bag of [MEDICATION(S)] was sent to the facility on [DATE] for R66, pending lab results. In an interview with RN EE on 9/30/21 at 9:40 AM she stated she told the pharmacist R66's [MEDICATION(S)] stop date was on 7/18/21, and she obtained that information from the orders in his electronic medical record. R66's July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R66 did not receive [MEDICATION(S)] on 7/07/21, 7/12/21, 7/19/21 or 7/20/21; and the missed doses were not reported to R66's primary physician or the infectious disease physician. In review of R66's vital signs in the EMR, under Respiration Summary, on 7/20/21 at 6:37 PM, R66's respiratory rate was 26 (normal 12 to 16) breaths per minute. R66's EMR, under Blood Pressure Summary revealed his blood pressure was 108/66, a drop from his blood pressure obtained earlier, on the same day, on 7/20/21 at 4:25 AM was 134/75. According to medlineplus.gov, blood pressure varies form one person to another; a drop as little as 20 (millimeters of mercury) mmHg can cause problems for some people. Severe [CONDITION(S)] can be caused by sudden loss of blood, severe infection, heart attack or severe allergic reaction. No other vital signs were obtained for R66 after 6:37 PM. Vital signs obtained 7/20/21 at 6:37 PM were not reported to the physician. Registered Nurse (RN) H notified physician approximately an hour after R66's vital signs were obtained, on 7/20/21 at 7:46 PM. Nurses note revealed Resident observed to be breathing with abdominal muscles, and to be making gurgling sounds upon inhalation as well as exhalation. Physician notified; new order for CXR [chest x-ray] received . RN H was interviewed on 9/23/21 at 1:55 PM and stated he did not remember R66. In review of the chest x-ray order, under Order Details in EMR, R66's chest x-ray was ordered 7/20/21 at 7:07 PM, two views, stat. The same order revealed R66 was .using abdominal muscles to breath and had gurgly lung sounds (rhonchi, air traveling through narrowed passages). There was no documentation of the location of the rhonchi or the type (fine, course, sibilant). There was no care plan initiated regarding R66's change of condition or documentation of increased assessment/monitoring. There was no documentation R66's durable power of attorney (DPOA) was notified of his change of condition. In review R66's 7/20/21 at 10:59 PM nurses note entry written directly after the 7/20/21 at 7:46 PM note . this nurse went in pts [patients] room and pt [patient] was trying to get out of bed and put his feet back in bed. went to look on pt [patient] again due to him trying to get out of bed and pt [patient] had no resp. [respirations] no pulse no blood pressure it was at 2230 [10:30 PM] and pt [patient] is a no code status. Called Doctor [name] and then the guardian. She had arrangements for out of state. called [name] Funeral home and then [sic] are calling the guardian and the funeral home is on its way. Also called the don [Director of Nursing] of this. LPN I was interviewed on 9/27/21 at 8:45 AM and stated she honestly did not remember receiving in report (shift began at 6:30 PM) that R66 had a stat chest x-ray ordered or that his respirations were 26. LPN I stated she did not remember completing a respiratory assessment or a head-to-toe assessment, calling R66's physician or the DPOA regarding need for hospital transfer. LPN I stated she did not remember approximately what time R66 attempted to get out of bed before finding him without vital signs. LPN I stated during the same interview she didn't recall if there was adequate staffing on 7/20/21, 90 percent of the time she was the nurse and the CNA [nurse assistant]; LPN I stated she typically had to leave the unit every 5 minutes to go to the other unit, and she was all over the place. DPOA DD was interviewed on 9/27/21 at 12:40 PM and stated she was not contacted on 7/20/21 of R66 having trouble breathing or any changes prior to notification he passed later that night. POA DD stated she would have probably asked that R66 be transferred to the hospital if she had known he was having difficulty breathing and added he had just had a recent hospital stay. POA stated in the same interview it was shocking to find out that he had passed away. During an interview on 9/27/21 at11:31 AM, DON B stated she was not contacted on 7/20/21 regarding R66's unexpected death. DON B stated she had been DON since 8/01/21. DON B stated she had not been part of an investigation into R66's death. DON B stated in the same interview, DON CC was the acting DON on 7/20/21. DON B stated prior to her position she was the MDS Coordinator since June or July 2020 and had been working at the facility as a nurse prior to MDS Coordinator since 2019. DON B stated she was responsible for care planning in her MDS role and confirmed R66 did not have any care plans for his PICC line, pacemaker, respiratory distress, or for antibiotic treatment. DON B stated she was not sure if R66 had completed the [MEDICATION(S)] as ordered and confirmed there were holes in the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/28/21 at 2:05 PM, Physician E stated did not recall being notified of R66 receiving 10 days of his [MEDICATION(S)] treatment. Physician E confirmed he had been notified of breathing with abdominal muscles and gurgling sounds on 7/20/21, but not R66's vital signs. Physician E stated he would have transferred R66 to the hospital to rule out [CONDITION(S)] if he would have been notified of his vital signs on 7/20/21. DON B was interviewed on 9/28/21 at 2:19 PM and stated her official start date was 8/01/21 for DON; however, her start date for Interim DON was 7/09/21. DON B stated LPN I was incorrect in her note on 7/20/21, she did not notify the DON, she may had contacted the former nursing home administrator. DON B confirmed in the same interview there was no order to assess the PICC line or change the PICC line dressing in R66's record. There was no documentation found that R66's PICC line was assessed, or dressing changed. DON B was interviewed on 9/29/21 at 1:45PM and stated she did not have a good answer when asked why R66's handwritten July 2021 MARs were not scanned into his EMR, and stated the records were in a pile to be scanned. On 9/30/21 at 8:50 AM, DON B stated R66's trough should have been done 30 minutes prior to administration of the [MEDICATION(S)] dose on 7/12/21. DON B confirmed R66's was [MEDICATION(S)] was not given at a set time and scheduled as prior (between 7:00 PM and 11:00 PM). DON B was unable to confirm R66's infectious disease physician had been contacted regarding clarification of orders or missed [MEDICATION(S)] doses. There were no progress notes to reflect collaboration with infectious disease. DON B stated in the same interview, she did not know when she started in her role, she would oversee infection control; and stated knowing what she did now, she would have investigated R66's death and R66's [MEDICATION(S)] treatment. Medical Assistant Z was interviewed on 9/30/21 at 9:30 AM and stated R66 had not been seen for follow-up and the last note she had regarding R66 was from 7/6/21, written by the physician, in which was to continue [MEDICATION(S)] for a minimum of 14 days. Resident #35 (R35): Per the facility face sheet R35 was admitted to the facility on [DATE], and readmitted on [DATE]. In an observation and interview on 9/22/2021, at 1:42 PM, R35 was observed to have a right below the knee leg amputation. Resident #35 stated when she was discharged from the hospital she had a vascular surgeon follow up appointment that was already scheduled, but could not recall the date of the appointment, however stated the appointment time was scheduled for 1:00 PM. R35 said she was ready to go at 12:30 PM, which was the time she was to be picked up by the transportation service, but said Licensed Practical Nurse (LPN) M had entered her room and informed her that the transportation service did not show up. R35 stated that LPN M then rescheduled her another appointment for one week later which she was transported to. R35 then stated that she had another follow-up appointment scheduled for 9/21/2021 at 1:00 PM, however stated that LPN M had informed her at 12:30 PM that the transportation service did not show up to transport her to her appointment, and had been rescheduled once again for the date of 10/5/2021. R35 said that the appointment she had scheduled for 9/21/2021 was an appointment for her vascular surgeon to give approval for her to be fitted for her prosthesis, but stated that was now delayed by two weeks which would cause a delay in her prosthesis being made. Review of a Concern Form, dated 8/6/2021, that was filled out by R35 revealed she had missed an appointment at the wound clinic. The form had documented follow-up by Administrator A that the facility was unaware of an appointment that was scheduled for R35 at the wound clinic. The Concern Form revealed under, Facility Response, Facility was unaware of wound care appointment., and was signed by Administrator A. Record review of R35's discharge instructions from the hospital, dated 7/31/2021, for her admission to the facility revealed the R35 had a vascular surgeon appointment scheduled for 8/10/2021, at 3:30 PM and was to arrive at the office at 3:15 PM. The discharge instruction also revealed R35 had a wound clinic appointment that was scheduled for 8/6/2021, at 10:00 AM and was to arrive at 9:45 AM. In an interview on 9/27/2021, at 8:56 AM, LPN M stated that either she or the admitting nurse was to review a resident's hospital discharge instructions and schedule any appointment that were needed for per the discharge instructions. LPN M said she would send an email to the facility's transportation services for the required pick up time, and then the transportation service scheduler would then email her back with the confirmation for pick up time. LPN M said R35 had missed her vascular appointment because the transportation service did not pick her up. In a further interview with LPN M on 9/27/2021, at 10:46 AM, LPN M said she did not know why R35 did not go to her vascular surgeon appointment on 8/10/2021. LPN M said R35 did go to her vascular appointment on 9/21/2021, but then stated that R35 did not go to the appointment because the transportation service did not show up to pick her up. Review of the transportation services schedule for R35's pick-up time revealed that on 9/21/2021, for R35's appointment that was scheduled with her vascular surgeon at 1:00 PM, revealed the facility had scheduled her pick up time from the facility to be at 1:45 PM for, and also revealed that her appointment was scheduled for 2:41 PM. Review of LPN M's appointment calendar for the month of August 2021 provided by LPN M, revealed R35 was documented on the calendar to have an appointment on 8/10/2021 at her vascular surgeons office at 3:30 PM with a pick up time of 2:30 PM. The calendar did not have R35's wound clinic appointment that was scheduled for 8/6/2021 documented on it. Review of LPN M's appointment calendar for the month of September 2021 revealed LPN had written on the calendar that R35 had a vascular appointment on 9/21/2021 at 12:45 PM and was to be picked up at 12:00 PM. In an interview on 9/27/2021, at 12:22 PM, Director of Nursing (DON) B said resident appointments were to be scheduled on admission and upon review the hospital discharge paperwork. DON B said she was not sure about R35's scheduled appointment that were on her hospital discharge paperwork. DON B stated that as far a R35's appointment to her vascular surgeon that was scheduled for 9/21/2021, at 1:00 PM, the transportation services showed up at the facility two hours late to pick her up. DON B said she was not sure why the transportation service was scheduled to pick R35 up on 9/21/2021 at 1:45, 45 minutes after her appointment time, but also stated that the facility was responsible to assure and verify all scheduled pick up times were correct.

This citation pertains to intake number MI 2923. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services consistent with professional standards of practice to prevent new pressure ulcers from developing for two residents (Resident #3 and R#58) of 17 residents reviewed for pressure ulcers. This deficient practice resulted in the development of new pressure ulcers and delayed healing with lack of pressure injury prevent interventions. Resident #58 (R58) Resident #58 (R58) admitted [DATE] with Brief Interview for Mental Status (BIMS, a short performance-based cognitive screener for nursing home (NH) residents) score was 13 (13-15 Cognitively Intact) on 8/29/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/21/21 at 12:20 PM During interview, R58 complained I haven't had a shower in 3 weeks, and I can feel new skin breaking down. He reported he had his first bed bath on Friday. Resident voiced They are not repositioning; I am in same position now as I was last night. Care plan shows resident requires a 2-person total lift and he was to have his brief checked every 2 hours and as needed. Resident stated Call light was on for 3 to 6 hours to get brief changed, but with only 1-person certified nurse's assistant working at night, a little hard to get this done. On 09/22/21 a Record Review shows resident had a bed bath on 9/10/21. Record review of shower sheets to be completed with each shower/bath to include a skin assessment on 8/11/21, 8/24/21, 9/10/21 and 9/14/21 from 01/02/2021 to 09/27/2021. On 09/23/21at 09:00- Care was observed with licensed practical nurse FF. Staff FF Applied barrier cream to buttock as ordered. Nurse did not perform a full skin assessment. Certified nurse's assistant completed a brief change without completing peri care. Writer asked Certified nurse's assistant GG if she provided peri care, no response. Writer asked Certified nurse's assistant if she observed any skin breakdown, she replied no. Writer asked her to pull back the foreskin. Certified nurse's assistant observed the stage 2 pressure ulcer from the foley catheter tubing pressing against the skin due to no repositioning. Certified nurse's assistant brought it to the nurse's attention, who was still present in the room. At which time, R58 still did not receive peri-care. Facilities policy on pressure ulcer and skin care management read, A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless a residents clinical condition demonstrates that they are unavoidable. A licensed nurse documents that the body check was completed on the residents weekly head to toe skin record. In an observation and interview on 9/23/201, at 8:50 AM, Licensed Practical Nurse (LPN) FF was observed to perform pressure ulcer (PU) skin care and treatment to R58. LPN FF stated that R58 had no PUs, rather just a cream to be applied to his coccyx area. During the observation of R58's coccyx (tailbone) area it was revealed that he had an approximate 2 x 3 cm (centimeter) open area to his coccyx. LPN FF stated that he was not aware the area was open. Further observation of R58's peri area revealed he had a catheter inserted, and complained of a sore area on his penis, which when observed revealed an approximate 2 cm open ulcer to the right side of his penis from the tip area down. LPN FF stated he was not aware of the ulcer to R58's penis, and further stated that when the Certified Nurse Aids (CNAs) performed resident showers they were to document any skin changes and make nursing aware. In an interview on 9/23/2021, at 9:10 AM, LPN M, who was the wound nurse and Unit Manager, stated that she was not aware of the ulcer present on R58's right side of his penis. LPN M stated that she expected the CNAs to report to her any breakdown of any resident's skin, stated that upon a resident's admission to the facility the nurse performed an admission assessment and would document all skin breakdown, and staging of wounds if applicable. LPN M further stated that she would perform a wound skin assessment every week. In an interview on 9/23/2021, at 9:15 AM, R58 stated that he was given a bed bath the past Friday (9/17/2021) by CNA GG and HH, and stated that he had told them about the sore area on his penis and coccyx. R58 said CNA GG and HH just told him there was nothing there. Resident #3(R3): In an observation and interview on 9/23/2021, at 9:30 AM, R3 was observed during a dressing change of his right and left foot ulcers with LPN FF, who stated that LPN M performed R3's wound measurements every week, and the treatments were to be done three times per week. During the wound care observation R3 stated that a few weeks ago (could not recall the exact dates) he had gone to the wound care clinic, and the physician had taken off his dressing on his right foot and found the wound to be infected. R3 states that the physician from the wound clinic informed him it was due to not receiving proper wound care at the facility, and stated that the dressing the wound clinic physician removed was dated from the previous week that the wound clinic had put into place.

Based on interview and record review, the facility failed to ensure that allegations of abuse were investigated per facility policy for one Resident (#4) out of five Residents reviewed for abuse. This deficient practice resulted in the potential for further abuse to occur. Findings include: A review of Resident #4's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 6/2/21 Quarterly Minimum Data Set (MDS) assessment revealed she scored 1/15 on the Brief Interview of Mental Status (BIMS) assessment, indicating severely impaired cognition. A review of a progress note for Resident #4 dated 6/14/21 3:30 a.m. revealed she was found unresponsive in her room and was sent to the emergency department. A review of hospital documentation for Resident #4 dated 6/14/21 revealed, .Assessment/Plan: Polypharmacy overdose . Presenting to the ED (Emergency Department) from (Name of Facility) for evaluation after being found unresponsive about 30 minutes prior to arrival . no recent trauma or medication changes reported . There are some concerns for narcotic use; although there are no narcotics on her medication list, she does have [MEDICATION(S)], [MEDICATION(S)], and [[MEDICATION(S)]] listed. There is additionally the possibility of an erroneously administered medication at her nursing home. The patient responded well to [nalaxone] (medication used to treat narcotic overdose) . Per review of the hospital Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a 7/12/21 Behavioral provider note revealed, .She (Resident #4) is upset because her Guardian has said that her daughter has to have supervised visits now. Apparently while pt (patient) was in the hospital it was believed her daughter may have given her outside medications . On 8/25/21 at 10:23 an interview was conducted with Complainant A via telephone. Complainant A reported that she had come in to the facility and was escorted by Social Worker (SW) B to see Resident #4 in July 2021. Complainant A reported that in her conversation with Resident #4 she reported she had been abused by Certified Nurses Aide (CNA) F. Complainant A reported that before leaving the facility she spoke with SW B and reported the allegation of abuse. On 8/25/21 at 10:55 a.m., an interview was conducted with the current Administrator who reported that during the time after the allegation of abuse regarding resident #4 no staff had been suspended pending investigation. When asked about Resident #4's hospitalization , the Administrator reported that Resident #4 had received three doses of [MEDICATION(S)] and there had been concerns about Resident #4's daughters giving her something. The current Administrator reported that these allegations did not to have been investigated nor reported to the State Agency. A review of CAN Fs employee file revealed a Disciplinary Action Record form dated 3/22/21 which revealed, . On 3/22/21, (Name of CAN F) clocked in for her shift and then decided to return home after deciding she was not happy with the current schedule . This was documented as a Final Warning. This write up for Resident abandonment is considered neglect. There were no disciplinary actions related to any abuse allegations nor documentation that she was suspended pending investigation. On 8/25/21 at 1:15 p.m., a phone interview was conducted with CNA F. When asked if she had ever received any allegations of abuse, CNA F reported she had not. When asked if Resident #4 had ever made any allegations against her, CNA F reported that she had not, and that she had been working with Resident #4 all summer. CNA F reported she had never been suspended from work pending an abuse investigation, CNA F confirmed that she had not, nor had Former Administrator C ever interviewed her about any allegations of abuse. CNA F reported that she felt she had good rapport with Resident #4, as she had confided in her (CNA F) that her daughter (Family Member E) used to give her [NAME], but that sometimes they tasted funny and were more thick than normal. On 8/25/21 at 2:14 p.m., a phone interview was conducted with Ombudsman G. Ombudsman G reported that she had been on a phone call the week of June 21st 2021, with Resident #4 and Family Member D and that Resident #4 had reported that she was being verbally abused by an unnamed CNA. Ombudsman G reported that she spoke with the former Administrator (Administrator C) about the allegation and that Administrator C had told her that she would investigate and report it. Ombudsman G reported that she never heard any follow up from the investigation. Ombudsman G went on to report that the Administrator C had also called to tell her that Resident #4's daughter was no longer allowed to visit the facility because she had given heroin to Resident #4 which caused her to have a drug overdose per the hospital. Ombudsman G reported that she told Administrator C that that was a crime and needed to be reported to the appropriate authorities, and that Administrator C said that she would do that. A review of the facility policy titled, Abuse Prevention revealed, . If a staff member is accused or suspected. If a staff member is accused or suspected of Abuse, Neglect, Exploitation, Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . F. Investigate. Once the Administrator and DOH (Department of Health/State Agency) are notified, an investigation of the allegation violation will be conducted . Interview the resident, the accused, and all witnesses . obtain a statement from the resident, if possible, the accused, and each witness .

This citation pertains to intake MI 004. Based on interview and record review, the facility failed to provide appropriate care to treat pressure ulcers for one (Resident #4) of three reviewed for pressure ulcers, resulting in lack of wound healing and [CONDITION(S)] (infection of the bone). Findings include: Review of the medical record reflected that Resident #4 (R4) was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission/Medicare 5 day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R4 did not walk and required extensive to total assistance with bed mobility, transfers, toileting, hygiene and bathing. The same MDS reflected R4 had one stage 3 pressure ulcer [full-thickness loss of skin; subcutaneous fat, slough (non-viable yellow, tan, gray, green or brown tissue) and/or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) may be visible], one stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) and three unstageable pressure ulcers (full-thickness skin and tissue loss; the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). All pressure ulcers were coded as being present on admission. R4's MDS history reflected a Discharge return anticipated MDS with an ARD of [DATE]. R4 did not reside in the facility at the time of the survey. R4's Nursing Admission Assessment With Care Plan, dated [DATE], reflected R4 had a stage IV (four) coccyx pressure wound, suspected deep tissue injury (SDTI) to the left bunion and left fifth toe and a stage II (2) pressure wound (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the right heel. R4's medical record did not reflect any further assessments for the right heel stage II pressure ulcer, as documented on the Nursing Admission Assessment With Care Plan, dated [DATE]. A Weekly Head to Toe Assessment, dated [DATE], reflected R4 had a pressure ulcer to the left foot big toe measuring 1.5 (centimeters in length) by 1.5 (centimeters in width). A stage IV coccyx pressure ulcer measured 7 (centimeters in length) by 6 (centimeters in width) by 4 (centimeters in depth). A left heel pressure ulcer measured 2 (centimeters in length) by 2 (centimeters in width). A left fifth toe pressure ulcer measured 1 (centimeter in length) by 1.5 (centimeters in width). R4's medical record did not reflect any further assessments for the left heel pressure ulcer, as documented on the Weekly Head to Toe Assessment, dated [DATE]. R4's medical record reflected Sure Prep to both heels twice daily for protection was ordered on [DATE]. R4's Weekly Wound Healing Records for [DATE] reflected R4's left great (big) toe wound was unstageable, had necrotic tissue and measured 1.5 (centimeters in length) by 1.5 (centimeters in width). R4's Weekly Wound Healing Records for [DATE], [DATE], [DATE] and [DATE] reflected the wound was unchanged, and there were no changes in the treatment plan in the last week. R4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Dakin's soaked gauze and cover with bordered gauze daily and prn [as needed]. The order reflected a start date of [DATE], a revision date of [DATE] and an end date of [DATE]. R4's [DATE] Treatment Administration Record (TAR) reflected the treatment was not signed out as completed for [DATE] and [DATE]. R4's Progress Notes did not reflect a rationale for why the treatment was not performed. R4's Weekly Wound Healing Record for [DATE] reflected a stage IV pressure ulcer to the sacrum. The visible tissue overall impression was marked as unchanged. Slough tissue was present. The assessment reflected there was no drainage and no odor. The wound measurements were documented as 3.5 centimeters (cm) in length by (x) 3.5 cm in width x 2.0 cm in depth. Tunneling (passageway of tissue destruction under the skin surface with an opening at the skin level from the edge of the wound) was documented as 2.o tunneling from ,d+[DATE].Describe any changes to treatment plan in the last week . reflected none. R4's medical record did not reflect any further assessments of a stage IV pressure ulcer to the sacrum. R4's Weekly Wound Healing Record for [DATE] reflected a stage IV coccyx pressure ulcer. The visible tissue overall impression was marked as unchanged. Slough tissue was present with a small amount of serous (watery, clear, or slightly yellow/tan/pink fluid) drainage. Odor was marked as present. The wound measurements were documented as 7 cm in length (x) 6 cm in width x 4 cm in depth, with tunneling at ,d+[DATE] positions.Describe any changes to treatment plan in the last week . reflected none. Wound Progress: reflected, unchanged. Comments reflected, will continue to follow current tx [treatment]. R4's Weekly Wound Healing Record for [DATE] reflected a stage IV coccyx pressure ulcer. The visible tissue overall impression was marked as unchanged. Slough tissue was present with a small amount of serous drainage. Odor was marked as present. The wound measurements were documented as 7 cm (length) x 6 cm (width) x 4 cm (depth), with tunneling at ,d+[DATE] positions.Describe any changes to treatment plan in the last week . reflected none. Wound Progress: reflected, unchanged. Comments reflected, will continue current tx. R4's Weekly Wound Healing Record for [DATE] reflected a stage IV coccyx pressure ulcer. The visible tissue overall impression was marked as unchanged. Slough tissue was present with a small amount of serous drainage. The wound was marked as moist. Odor was marked as present. The wound measurements were documented as 7 cm (length) x 6 cm (width) x 4 cm (depth), with tunneling at ,d+[DATE] positions.Describe any changes to treatment plan in the last week . reflected none. Wound Progress: reflected, unchanged. Comments reflected, will continue to follow current Tx order. R4's Weekly Wound Healing Record for [DATE] reflected a stage IV coccyx pressure ulcer. The visible tissue overall impression was marked as unchanged. Slough tissue was present with a small amount of serous drainage. The wound was marked as moist. Odor was marked as present. The wound measurements were documented as 7 cm (length) x 6 cm (width) x 4 cm (depth), with tunneling at ,d+[DATE] positions.Describe any changes to treatment plan in the last week . reflected none. Wound Progress: reflected, unchanged. Comments reflected, will continue to follow current tx as ordered. R4's Weekly Wound Healing Record for [DATE] reflected a stage IV coccyx pressure ulcer. The visible tissue overall impression was marked as unchanged. Slough tissue was present with a small amount of serous drainage. The wound was marked as moist. Odor was marked as present. The wound measurements were documented as 7 cm (length) x 6 cm (width) x 4 cm (depth), with tunneling at ,d+[DATE] positions.Describe any changes to treatment plan in the last week . reflected none. Wound Progress: reflected, unchanged. Comments reflected, will continue to follow current tx ordered. A Progress Note for [DATE] at 3:16 PM reflected R4's wounds were discussed in the Quality of Life meeting, and treatment remained in place as ordered. A late entry Progress Note for [DATE] at 5:57 PM reflected R4's wounds were discussed at IDT [interdisciplinary team] and will continue to monitor. A Progress Note for [DATE] at 1:00 PM reflected R4's wounds to the left foot and sacral area were discussed during the Quality of Life meeting. The note reflected treatments were to remain in place. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Pressure ulcer to sacrum- is getting daily dressing changes [sic] Doing well . A Quality of Life Progress Note for [DATE] at 11:24 AM reflected, Discussed resident's wounds in QOL [quality of life]. Labs and x-ray ordered for coccyx/sacral area to rule out [CONDITION(S)]. Treatments to continue as ordered. A Progress Note for [DATE] at 5:53 PM reflected R4's wounds were discussed at IDT and will continue to monitor. A Progress Note for [DATE] at 2:38 PM reflected R4 had new orders for a urinalysis (UA), chest x-ray and wound culture of the sacral wound. The note reflected the wound culture and UA were sent to the lab, and the x-ray order was in place. A laboratory report for [DATE] reflected a wound culture was rejected. There was notation that the culture was collected in the wrong tube and an expired tube. The reported reflected, Please recollect and return to the laboratory with a new requisition within 7 days for testing . R4's medical record did not reflect evidence that the wound culture had been repeated and sent back to the lab. A Progress Note for [DATE] at 5:50 PM reflected R4's wounds were discussed at IDT, and an MRI was discussed to rule out [CONDITION(S)]. The note reflected will continue to monitor. A Progress Note for [DATE] at 2:17 AM reflected a nurse from the hospital called earlier in the shift to state that R4 was staying at the hospital after their MRI. R4 resided in the facility from [DATE] to [DATE]. R4's medical record did not reflect documentation that the treatment to their sacral/coccyx wound had been revised, despite lack of wound improvement/healing. R4's medical record did not reflect documentation that the Physician had personally evaluated the status of R4's wounds. The report for R4's sacrum/coccyx x-ray on [DATE] reflected three views of the sacrum and coccyx were obtained. The report reflected there was no definite focal osteolytic lesion, and there was no sizable decubitus ulcer formation. R4's MRI report for an exam date of [DATE] at 9:18 PM reflected, .IMPRESSION: 1. Deep soft tissue ulceration overlying the lower sacrum and coccyx which appears to extend to the bone. There is sacral and coccygeal [CONDITION(S)] . .Imaging tests ·X-rays. X-rays can reveal damage to your bone. However, damage may not be visible until [CONDITION(S)] has been present for several weeks. More-detailed imaging tests may be necessary if your [CONDITION(S)] has developed more recently. ·Magnetic resonance imaging (MRI). Using radio waves and a strong magnetic field, MRI scans can produce exceptionally detailed images of bones and the soft tissues that surround them . (https://www.mayoclinic.org/diseases-conditions/[CONDITION(S)]/diagnosis-treatment/drc- 917) During an interview on [DATE] at 10:51 AM, Licensed Practical Nurse/Unit Manager (LPN) D reported R4 was admitted to the facility with a big wound on the coccyx, a wound on the left heel, a wound on the bony prominence of the left foot, a wound on the medial (inner) aspect of the left foot, near the great toe (big toe) and a wound on the lateral (outer) aspect of the left foot, near the fifth digit (little toe). LPN D reported they did R4's weekly skin assessments. When asked if they ever discussed the progression of R4's wounds with the physician, LPN D reported the Director of Nursing (DON) spoke to the physician and was trying to get an MRI to rule out [CONDITION(S)]. LPN D reported R4 left for the MRI and never returned to the facility. According to LPN D, R4 was admitted to the facility for [CONDITION(S)] (life-threatening illness from the body's response to infection). LPN D reported R4 had [CONDITION(S)]. LPN D reported R4's [coccyx] wound was the same for the duration of their stay, and their treatment orders were from their admission to the facility. LPN D reported they wore two masks and did not smell a wound odor on admission. When asked if the facility re-evaluated treatments and prevention to promote wound healing, LPN D reported they discussed wounds every week in the Quality of Life meeting. LPN D stated that was why the DON suggested the wound clinic for debridement or an MRI. When queried about R4's Weekly Wound Healing Records for [DATE], which reflected a stage IV pressure ulcer to the sacrum and a stage IV pressure ulcer to the coccyx, LPN D reported there was just one wound, in the crack. When asked why the same wound had different measurements, LPN D did not know why. LPN D reported seeing R4's wounds on admission. During an interview on [DATE] at 11:30 AM, DON B was queried about what was discussed regarding wounds in Quality of Life meetings. DON B reported they discussed progress or lack of progress because there were more nurses in the meeting. When asked if R4's wounds changed during the duration of their admission, DON B reported towards the end there was a change. R4's coccyx wound had more slough towards the bottom on admission. Near the end of their admission, it began to look like it was lifting. DON B reported that to them, R4's labs indicated [CONDITION(S)]. According to DON B, Physician F stated an MRI was needed to confirm. When asked when they would consider changing a treatment [due to lack of wound healing], DON B reported usually between two to three weeks. DON B reported R4's wound was more of a situation where it instantly got worse. When asked why the treatment was not changed after R4's wound assessments showed the wound remained unchanged, DON B did not know why. During a phone interview on [DATE] at 12:06 PM, Physician F reported R4 admitted to the facility with a very large decubitus ulcer (pressure ulcer) to the sacrum and heel decubitus wounds that the wound team was trying to resolve. Physician F reported the sacral/coccyx wound was not doing well. The wound was not healing or getting better and was not shrinking in size. According to Physician F, the wound was a good depth, and they made the decision to get an MRI to look for possible [CONDITION(S)]. Physician F reported the wound did not resolve or respond to treatment. According to Physician F, while at the hospital [for the MRI], R4's Family Member advocated to have R4 seen in the emergency room due to a foul smelling decubitus ulcer. Physician F reported R4 was admitted to the hospital for a sacral wound and possible [CONDITION(S)]. According to Physician F, the scans [MRI] showed [CONDITION(S)]. Physician F acknowledged they did not personally evaluate R4's wounds. According to Physician F, the [facility] wound care team had R4's wound measurements and description. Physician F stated the wounds were being treated almost daily, and they did not want to uncover them. Physician F stated most times, unless there was an issue, the facility's wound care team was trained to provide initial therapy. If there were problems or the wound was not getting better, they consulted him. If the nurses were seeing no improvement or some problems, they should make a change [to the treatment], according to Physician F. Physician F reported they would have expected to be notified [of lack of wound healing/progress].

This citation pertains to intake MI 004. Based on interview and record review, the facility failed to identify weight loss and conduct timely follow-up for one (Resident #4) of three reviewed for nutrition, resulting in documented weight loss of greater than 17 percent in less than one month and the potential for continued weight loss and delayed or lack of wound healing. Findings include: Review of the medical record reflected that Resident #4 (R4) was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission/Medicare 5 day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/9/21, reflected R4 did not walk and required extensive to total assistance with bed mobility, transfers, toileting, hygiene and bathing. The same MDS reflected R4 had one stage 3 pressure ulcer [full-thickness loss of skin; subcutaneous fat, slough (non-viable yellow, tan, gray, green or brown tissue) and/or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) may be visible], one stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) and three unstageable pressure ulcers (full-thickness skin and tissue loss; the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). All pressure ulcers were coded as being present on admission. R4's MDS history reflected a Discharge return anticipated MDS with an ARD of 5/13/21. R4 did not reside in the facility at the time of the survey. R4's Nursing Admission Assessment With Care Plan, dated 4/7/21, reflected R4 had a stage IV (four) coccyx pressure wound, suspected deep tissue injury (SDTI) to the left bunion and left fifth toe and a stage II (2) pressure wound (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the right heel. A Weekly Head to Toe Assessment, dated 4/7/21, reflected R4 had a pressure ulcer to the left foot big toe measuring 1.5 (centimeters in length) by 1.5 (centimeters in width). A stage IV coccyx pressure ulcer measured 7 (centimeters in length) by 6 (centimeters in width) by 4 (centimeters in depth). A left heel pressure ulcer measured 2 (centimeters in length) by 2 (centimeters in width). A left fifth toe pressure ulcer measured 1 (centimeter in length) by 1.5 (centimeters in width). R4's Weekly Wound Healing Record for 4/14/21 reflected a stage IV pressure ulcer to the sacrum. The visible tissue overall impression was marked as unchanged. Slough tissue was present. The assessment reflected there was no drainage and no odor. The wound measurements were documented as 3.5 centimeters (cm) in length by (x) 3.5 cm in width x 2.0 cm in depth. Tunneling (passageway of tissue destruction under the skin surface with an opening at the skin level from the edge of the wound) was documented as 2.o tunneling from 9-12.Describe any changes to treatment plan in the last week . reflected none. R4's Weekly Wound Healing Record for 4/14/21, 4/21/21, 4/28/21, 5/5/21 an 5/12/21 reflected a stage IV coccyx pressure ulcer. The visible tissue overall impression was marked as unchanged. Slough tissue was present with a small amount of serous (watery, clear, or slightly yellow/tan/pink fluid) drainage. Odor was marked as present. The wound measurements were documented as 7 cm in length (x) 6 cm in width x 4 cm in depth, with tunneling at 9-12 positions.Describe any changes to treatment plan in the last week . reflected none. Wound Progress: reflected, unchanged. The assessments dated 4/28/21, 5/5/21 and 5/12/21 also reflected the wound was moist. R4's MRI report for an exam date of 5/12/21 at 9:18 PM reflected, .IMPRESSION: 1. Deep soft tissue ulceration overlying the lower sacrum and coccyx which appears to extend to the bone. There is sacral and coccygeal [CONDITION(S)] [infection of the bone] . R4's medical record reflected a hospital discharge summary, dated 1/18/21, which was almost 3 months prior to R4's admission to the nursing facility. On the document dated 1/18/21, R4 was recorded as weighing 62.7 kilograms (138 pounds), which was consistent with R4's weight upon admission to the nursing facility on 4/7/21. Review of R4's weight history in the medical record reflected the following: 4/7/21: 138.0 pounds 4/20/21: 138.0 pounds 4/22/21: 137.0 pounds 4/29/21: 113.4 pounds 5/4/21: 113.8 pounds 5/5/21: 112.6 pounds 5/11/21: 113.0 pounds A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note for 5/5/21 at 4:06 PM reflected R4 was reviewed by the interdisciplinary team [IDT]. According to the note, R4's current body weight was .112.6# [pounds] (confirmed) is a 24.4# loss compared with weight as documented 4/22. Meal acceptance varies from bites to 75% per FAR [food acceptance record]. [R4] receives ProStat [supplement] BID [twice daily], some refusals are noted. Will order Medpass supplement 120mL [milliliters] TID [three times daily] after meals. Diet was downgraded to puree/nectar on 4/30. Labs are pending. Physician and guardian are aware of status. Care plan updated. R4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no order for Medpass supplement referenced in the Progress Note dated 5/5/21. A late entry Progress Note for 5/12/2021 at 10:34 AM reflected, .Resident reviewed by IDT this date. CBW [current body weight] is noted to be 112.6# and this has been confirmed. Previously her weight was documented at 137#. The previous weight is thought to be erroneous given there is no observable weight change and resident appears as shedid [sic] at the time of admission and her clothing fits appropriately. She is noted to eat poorly however and she has c/o [complained of] dentures fitting poorly. She receives a puree diet and is on the list to be seen by the dentist at next facility visit. She receives ProStat for wound healing. She will be going for an MRI. 5/6 labs note elevated blood sugars, N.O. [new order] for novolog [insulin] for better management. Glucerna will be added BID for increased calories given poor meal acceptance. During a phone interview on 6/2/21 at 12:06 PM, Physician F was asked if weight loss or nutrition concerns were reported to them [for R4]. Physician F stated, no, they did not have weight loss on there as a concern. Physician F acknowledged they had access to the Electronic Medical Record during the phone interview, and they could see that R4's weight declined. Physician F stated that was not brought to their attention, and they would have expected it to be. Physician F stated that significant of a weight loss should have been reported to them. Physician F stated they would have checked a metabolic panel, looking for loss of proteins or anything else. Physician F reported a wound could not be healed without proper proteins in the system. Physician F again stated that should have been brought to their attention. During an interview on 6/2/21 at 12:39 PM, Registered Dietitian (RD) G reported R4 was followed weekly in the IDT meeting. RD G reported the team determined R4's admission weight was an error. According to RD G, there was no observable physical change with R4. RD G stated with a weight change that significant, one would think you would notice clothes not fitting the same. When asked if they thought R4's weights of 137 pounds to 138 pounds on 4/7/21, 4/20/21 and 4/22/21 were inaccurate, RD G stated that would not have come to their attention until there was an actual drop, so that was the time they looked into it deeper. When asked how they looked into it, RD G stated they pulled a weekly weight report, so they would have seen the change then. According to RD G, given that following that, [R4] had four weights that were also in the same ballpark over the period of time, those were the weights we determined were accurate. RD G reported that in their admission assessment, they used a weight of 138 pounds for R4. RD G reported Prostat was always in place for R4, and, Medpass was added in addition to Prostat. RD G stated that Medpass was generally put in as an order. When asked if they knew why Medpass was not ordered for R4 (as referenced in a Progress Note for 5/5/21), RD G stated they did not know what happened. RD G stated they entered their own orders that were then confirmed by a nurse. When asked if they spoke to the physician about R4's weights, RD G stated they were at the facility one week day, and the physician was not in the building during that time. RD G reported they provided a copy of their report from the high risk meeting, which showed the current weight, what the weight change has been, any interventions that are going to be put into place and other updates. When asked how they knew the physician received that information, RD G reported, Well, from one week to the next when I am here, it is no longer in the box, so that is one way . RD G stated re-weights should be done quickly and should be verified by a nurse. When asked how quickly, RD G stated they thought it was best to repeat a weight within 24 hours. Review of R4's weights reflected they were 137.0 pounds on 4/22/21 and 113.4 pounds on 4/29/21. R4's next recorded weight was 113.8 pounds on 5/4/21 (5 days later). Prior to the survey exit, the facility provided a copy of a document titled, Quality of Life-weight variance, dated 5/5/21. Documentation pertaining to R4 reflected, .CBW 112.6# down 24.4# from documented weight on 4/22. Meal acceptance varies from bites [to] 75%. Receives fortified foods. Receives ProStat BID. Will add Medpass TID after meals. Wt [weight] will be obtained weekly. Diet downgraded 4/30. The document reflected the physicians would receive a copy of the document. There was no physician signature on the document. R4's medical record did not documentation that R4's physician had been notified of their weight loss. During a phone interview on 6/3/21 at 7:29 AM, Licensed Practical Nurse (LPN) H reported R4 was not eating well and was losing weight. LPN H remembered R4 physically looking like they were losing weight. LPN H stated that after R4's diet was changed to puree with thickened liquids, R4's intake was worse. According to LPN H, they could see it in R4's face that they were losing weight. LPN H reported R4's coccyx wound seemed a lot sloughier because they were losing weight. LPN H reported R4's wound seemed a little deeper with the weight loss because there was not as much skin there. LPN H reported R4 was already skinny anyway, but it was easy to see their weight loss after a couple days.

This citation pertains to intake MI 318 Based on observation, interview, and record review, the facility failed to prevent resident to resident abuse for two (Resident #18 and #45) of six reviewed for abuse, resulting in Resident #18 punching Resident #45 in the face and Resident #45 sustaining facial bruising, pain, and fear. Findings include: Resident #18 (R18) Review of the Resident Profile revealed R18 admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed R18 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of R18's care plans revealed I have the potential to be physically aggressive. Anger. I may become physically and verbally aggressive to staff and my peers. The care plan was initiated on 2/28/19 and included an intervention of closer supervision initiated on 6/4/19. In an interview on 09/26/19 at 11:08 AM, Unit Manager G reported closer supervision meant R18 was on 15 minute checks. On 09/24/19 at 10:27 AM, R18 was observed self ambulating in her room. When asked if she ever had any altercations with other residents, R18 reported approximately 6 months ago, she punched a resident and then approximately a month ago, she punched another resident (Resident #45). R18 reported R45 punched her first in the gut and stated she almost got me right in my [MEDICAL CONDITION]. If she would have hit me there, I would have probably killed her. R18 stated If someone hits me, I'm hitting back. I ain't scared of nobody in here. R18 reported there were no staff in the dining room when the incident between her and R45 occurred. Review of R18's incident reports revealed on 5/26/19, she punched Resident #364 (no longer in the facility) twice in the face. Review of the incident and facility investigation dated 9/3/19, revealed at approximately 7:00 AM, R18 punched Resident #45 (R45) in the face. R45 sustained a bruise on the lower left side of her jaw. Resident #45 (R45) Review of the Resident Profile revealed R45 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], revealed R45 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). In an interview on 09/26/19 at 08:50 AM, Cook L reported he just happened to be going through the dining room when he witnessed a resident to resident altercation between R18 and R45. Cook L stated There were some words exchanged .R18 was the aggressor. She got up, went back to where R45 was. When she (R18) went back there, she just hauled off and hit her (R45) in the face. (R45) is not going to fight back. She just put a hand up to try to block (R18). Cook L reported R18 is kind of aggressive with everybody. When asked what he did, Cook L reported he went and got a nurse because he was not able to deal with a resident to resident altercation and needed someone who was professional with dealing with that. Cook L could not recall if any other staff were in the dining room, but reported he was the only staff member to respond to the incident when it occurred. Review of R45's Progress Notes revealed the following: 9/3/2019 07:28 Health Status Note: Resident approached nurse crying. Nurse asked resident what happened?. Resident was really upset and stated (R18) was upset over another resident and and I told her she would have to wait she told me to shut the (f**k) up and she came over to me and hit me in my face. She continued stating She didn't have to hit me in my face, my face hurts. RN (Registered Nurse) reassured resident that she is safe now. RN assessed residents face and tip of residents nose is reddened. Resident was given pain medication . 9/3/2019 07:54 Health Status Note: Resident is currently in sunshine room having breakfast. Resident remains teary eyed and upset over incident that happened. Nurse continues to provide emotional support. Nurse also observed a nickel sized bruise on right side of chin. ice pack was provided for comfort. Will continue to monitor patient 9/3/2019 17:16 Social Services Note Text: Social worker attempted to talk with resident three times today following the resident to resident incident. Resident has been sleeping most of the day. She acknowledged that the social worker was talking to her but stated that she was too tired to talk. Her chin has significant bruising. She was ensured that the other resident is 1:1 to hopefully make this resident feel more safe. 9/4/2019 10:37 Social Services Late Entry: Note Text: Social worker met with the resident to follow up regarding the resident to resident incident. Resident was awake this morning and she reported that her nose hurts. She continues to have significant bruising on her chin area. Resident reports that therapy wants her to work with them today, but she is too tired and her nose hurts . 9/5/2019 15:46 Social Services Note Text: Social worker met with resident for the third follow up day after the incident with another resident. This resident is in good spirits and is talkative. She is feeling better today, but still has some soreness. She asked about the incident report number and still wants to press charges. She continues to feel safe to go outside of her room. In an interview on 09/30/19 at 02:10 PM, when asked about the incident, R45 stated I was scared to death .I was scared to even see her .had a bruise under my chin. In an interview on 09/26/19 at 12:36 PM, Nursing Home Administrator (NHA) A reported when the incident occurred between R18 and R45, staff was in and out of the dining room since it was right after a smoke break. NHA A reported there should have been some Resident Care Aides (RCAs) in the dining room, but none of them were in there when the incident occurred.

This citation pertains to MI 055. Based on observation, interview and record review, the facility failed to provide adequate supervision for one (Resident #3) of three reviewed for supervision, resulting in R3 acquiring and using illegal drugs while residing at the facility; being hospitalized with a positive drug screen and going missing for six days, without medication, after eloping from a medical appointment. Findings include: Review of the Face Sheet, dated for 5/7/19 at 3:27 PM, reflected that Resident #3 (R3) was admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with a reference date of 2/26/19, reflected that R3 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status. On 5/7/19 at 10:54 AM, R3 was observed lying in bed. R3 reported that she had been in the hospital for renal (kidney) failure and a nodule on her lung. R3 became upset during discussion and declined to speak further. Review of the Order Regarding Appointment of Guardian of Incapacitated Individual dated 11/16/18, revealed R3 was appointed a limited guardian with powers that included: 1) decision making authority regarding medical and health care; and 2) decision making authority regarding placement. Review of the Order Regarding Termination/Modification of Guardian dated 2/13/19, revealed R3 continued to be an incapacitated individual and in need of a guardian as a means of providing continuing care and supervision of the person. On 2/13/19, R3's guardian was changed from a limited guardian to full guardian. Review of R3's medical record reflected a progress note for 11/21/18 at 11:34 AM that revealed that R3 had recently been found unable to make informed decisions and that a Guardian was in place. Further review of the note reflected that R3 abused drugs, such as crack cocaine and marijuana. R3 had requested to be able to leave the facility and walk outside. The note reflected that the Social Worker spoke to R3's Guardian, who did not give permission for R3 to sign herself out without supervision. A progress note for 11/30/18 at 5:52 PM, reflected that R3 had signed herself out of the facility at 2:30 PM and had not yet returned. Review of R3's sign-out sheets reflected that R3 signed herself out of the facility at 2:45 PM on 11/30/18, without a documented destination or expected time of return. The box for Nurse Signature revealed notation of an item that was marked out and illegible and a time of 5:45. A sign-out sheet for 12/1/18 reflected a Time Out of 7:22 with a destination listed as outside. The Resident/Responsible Party Signature box reflected, refused to sign. The time of return was documented at 7:45. A progress note for 12/2/18 at 10:05 AM reflected, .Resident was showing s/s (signs/symptoms) of altered mental status this morning. She was falling asleep while speaking and slurring her words. Her movements were uncoordinated and slow, and she was unable to follow simple commands. She also has a history of illicit drug abuse. I called (Physician's Name) and he gave the order to send her to the ER (emergency room ) for evaluation . An ER note for 12/2/18 at 11:44 AM reflected that R3 had a history of [REDACTED]. The note further reflected that R3 had a lot of visitors at the skilled nursing facility and that visitors had also been passing her things through her windows. Review of ER documentation for 12/3/18 at 9:07 PM, reflected that R3 tested positive for Cocaine Metabolites. A progress note for 12/4/18 at 4:55 PM reflected, .When resident handed her purse to the SW (Social Worker), this RN (Registered Nurse) noticed that there was a zippered pocket that had 2 small master lock (sic) affixed to them. When resident was asked for the key, she stated it's right here on my wrist and you can't have it (sic) When resident was given the choice to unlock the lock or have them cutoff, she got up and unlocked the padlock. Inside the locked compartment there was drug paraphernalia, small empty clear baggies, a mirrored compact with white powdery/rocky residue. When this RN asked resident what the residue was either heroine or cocaine, resident stated cocaine. When resident asked when the last time was that she used and resident stated Friday . Review of ER documentation for 12/4/18 at 7:42 PM, reflected that R3 tested positive for Cocaine Metabolites. An ER progress note for 12/4/18 at 9:00 PM reflected, .Guardian voiced concern that pt (patient) has been using drugs at (Name of Facility) and has eloped a couple of times for hours at a time . A hospital progress note for 12/5/18 at 11:24 AM reflected .Pt admitted this morning with what appears to be cocaine [MEDICAL CONDITION](hypertension) and tachy . A progress note on 2/3/19 at 12:47 AM, reflected, .Approximately 1130pm. I was called down to this residents room. Upon entering the residents room, second resident was sitting in the bathroom with his hands between his legs, it appeared he dropped something in the toilet and flushed. The room was malodorous, and smelled chemically. (Name of) resident was barely able to sit up on the side of her bed, and appeared to be swaying, unable to keep her eyes open, her speech was slurred and resident was unable to stand . A progress note for 2/3/19 at 3:10 PM reflected that a crack pipe was discovered in a tissue box in R3's room. Progress notes for 3/28/19, 3/31/19, 4/2/19, 4/5/19, 4/6/19, 4/14/19 and 4/25/19 reflected that R3 was on closer supervision. A progress note for 4/25/19 at 5:33 PM reflected that R3 left the facility with a transportation company at approximately 10:00 AM that morning for a medical appointment. At approximately 5:13 PM, the transportation company notified the facility that R3 was not at the designated pick up location. R3 had signed herself out of her appointment around 2:00 PM and had not returned to the facility. Review of R3's care plans reflected a care plan focus area of, I am an elopement risk. I will not leave the facility unattended by guardian or staff. The care plan was initiated, created and revised on 12/7/18. The care plan goals of, I will not leave the facility unattended and My safety will be maintained were initiated and created on 12/7/18. The goals were revised on 12/24/18. An intervention for Observe me for my whereabouts frequently was initiated on 12/7/18. Interventions of I need to be accompanied by a staff member or guardian approved person for any outside appointments and Notify my guardian of any outside appointments were initiated on 4/26/19. During an interview on 5/7/19 at 12:38 PM, Licensed Practical Nurse/Unit Manager (UM) D reported that closer supervision was every 15 minute checks that nurses and Certified Nurse Aides (CNA's) documented on. UM D reported that the (facility) bus driver was going to take R3 to her appointment on 4/25/19, but the driver was busy with another appointment. UM D reported that Director of Nursing (DON) B arranged for (Transportation Company Name) to transport R3 to her appointment on 4/25/19. The elopement risk care plan focus area was reviewed with UM D, who stated that she was not aware that care plan was in place. She reported that if she had been aware of the need to be accompanied by a staff member or guardian approved person for any outside appointments and Notify my guardian of any outside appointments then she would not have sent R3 to her medical appointment alone. In regards to when the transportation appointment was made for the 4-25-19 appointment, it was determined the transportation was arranged well in advance of the appointment date. During a phone interview on 5/7/19 at 1:59 PM, (Transport Company Name) General Manager GM L reported that transportation arrangements for R3's medical appointment on 4/25/19 were made on 4/3/19. Upon arriving to the appointment, the driver verified that R3 had three different things to do for the appointment. The driver was told that R3 would be ready for pick up close to 5:00 PM or after. A driver returned to the appointment between 4:40 PM to 4:45 PM and checked in at the desk. The driver was informed that R3 checked out at 2:00 PM. The driver notified dispatch and attempted to locate R3, without success. GM L reported that she contacted the facility to notify them that R3 was not where she was supposed to be at the appropriate time. During an interview on 5/8/19 at 8:18 AM, DON B was asked if R3 should have been at her medical appointment by herself. DON B replied, probably not. She could not recall if R3 had gone to an appointment alone prior to 4/25/19. When asked if R3's Guardian was made aware of the appointment for 4/25/19, DON B replied that she should have been, but nurses and unit managers were responsible for the appointments. During a phone interview on 5/8/19 at 8:49 AM, previous Unit Manager, RN I, reported that R3 was difficult with wanting to leave (the facility). According to RN I, R3's Guardian did not want her leaving without someone with her. RN I stated that while she was the Unit Manager, they sent someone that R3 liked for her appointments to make sure that she made it back safely. When asked if there was ever a concern that R3 would leave one of her appointments, RN I stated, with (R3's first name), anything is possible, so yeah. RN I stated that while she worked at the facility, it was a must for someone to go with R3. Review of hospital records reflected that R3 received in-patient care for the dates of 5/1/19 to 5/6/19 with a primary [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. The hospital Physician's History and Physical for 5/1/19 at 7:23 PM reflected chief complaints of chest pain and abdominal pain. R3's blood pressure was 213/103, and it was noted that she had hypertensive urgency. It was documented that she had [DIAGNOSES REDACTED] and [MEDICAL CONDITION], likely secondary to dehydration with nausea, vomiting and diarrhea. It was noted that she had been off all medications since 4/26/19 at 9:00 AM, due to leaving the skilled nursing facility against medical advice (note that R3 actually left the facility and a medical appointment on 4/25/19). According to hospital records, her drug screen was positive for cocaine. A progress note in R3's medical record for 5/6/19 at 5:28 PM reflected that R3 readmitted to the facility after being hospitalized for [REDACTED]. During a phone interview on 5/7/19 at 10:17 AM, Guardian K reported that she was not made aware of R3's medical appointment on 4/25/19. Guardian K stated that if she had known about the appointment, she would not have allowed R3 to go alone. According to Guardian K, she would have met R3 at the appointment or had staff go with R3. Guardian K reported that R3 missed six days of medications and that she usually took 17 different medications per day.

This citation is related to intake MI 606 Based on observation, interview and record review the facility failed to provide incontinent care assistance in a timely manner for 2 of 2 residents (Residents #1 and #2), resulting in neglect, soiled overflowing briefs, full Foley catheter drainage bag causing back-flow of urine, soiled linen, recurrent request for assistance, feelings of uncomfortableness, embarrassment and frustration to a reasonable person, and the potential for urinary tract infection and disruption in skin integrity. Findings Include: Resident (R) #1: A complaint was reported for R1 on 4/12/18 reflecting an allegation that R1 was left wet for extended periods of time after his catheter bag was not emptied and overflowed. On 4/17/19 at 1:23 PM R1 was observed in his bed, dressed in a hospital gown and laying on his back. He was observed to have Foley tubing connected to a drainage bag, that contained clear yellow urine measuring at 400 Cubic Centimeters (CC's). R1 was asked if staff would come and empty his Foley drainage bag. R1 replied, It depends on who is working. The hospice aide emptied it earlier, she will check it every-time she comes. R1 revealed, the Foley drainage bag had been full before, but that he did not know all the time, because he could not see it. R1 also stated, It is supposed to be emptied every shift, with the 12 hours shifts it doesn't get done most the time. R1 revealed that his pad (cloth bed pad) gets wet because his Foley backs up at times, because it was full, which happened within that last couple weeks. I have a condom cath, and some of the nurses don't know how to put it on. When I'm wet, I have had to wait an hour before, for someone to answer the light. R1 was then asked how did the back-flow of urine, causing the wet pad, and waiting for assistance made him feel. R1 replied, Wet and uncomfortable. The Electronic Medical Record (EMR) reviewed on 4/18/19 at 09:00 AM for R1 reflected he was a [AGE] years old male, re-admitted to the facility on [DATE], and had the following Diagnoses: [REDACTED]. The bowel bladder assessment dated [DATE] for R1 reflected he never voided appropriately without incontinence, was incontinent daily, was immobile and required 2 person assistance. The Quarterly Minimum Data Set (MDS: resident assessment tool) dated 4/3/19 reflected R1 required total -to-extensive assistance of 1-to-2 persons for dressing, toilet use, and bathing. On 4/18/19 at 09:17 AM the Hospice Certified Nursing Assistant (CNA E) who cared for R1 was verbally interviewed, and asked if any incontinent concerns had been witnessed. CNA [NAME] revealed on Wednesday (04/17/19), He was a hot mess. He was wet with brown rings in his bed, everything was wet, and he had a bowel movement too. His catheter bag was on the floor and ready to explode. It looked like one of those full inflatable bath pillows. I got 2 and a half beacons (urine collection container when full measures at 1000 cc's, 2.5 beacons would equal 2500 cc's and 3785 cc's equals a gallon) full of urine. I got him cleaned up, bed changed and left for the day. CNA [NAME] revealed she shared her concern with R1's Registered Nurse at the time (RN V) and Nurse Manager Licensed Practical Nurse (LPN W), and commented that R1 should not have been wet like that, and a reply of Maybe we should start doing walk around's was given. CNA [NAME] revealed, The week before on a Monday, his sheets were so wet, you could take them off and wring them out. His catheter was coming off and it was about 600 cc's in the bag. They have to make sure they check the placement. There were dark brown rings on his sheet, and that's not the first time. He said he had been like that for a while. He told me he did not refuse care. 'I know they said I do but I did not'. He got rolled off the bed years ago and was injured at his ribs and won't let one person turn him. The facility has been aware for at least 2 months that he won't do care that consists of turning, unless there are two people. On 4/18/19 at 09:44 AM R1's Guardian (F) was verbally interviewed, and asked if she was aware of any care concerns. The Guardian F revealed it had been reported quite bit by Hospice, that when hospice staff arrived, R1 would be sitting soaked in urine. When asked to provide the dates of contact related to concern, the Guardian F revealed: 4/11/19, 3/14/19, 2/21/19 and 1/11/19. Guardian F was asked when was last time she visited R1. The guardian replied 4/2/19, but that R1 would not talk to her, screamed at her during the first visit when informed of guardianship and that R1 had a good relationship with Hospice staff. Feedback to her from the facility, was that R1 was non-compliant, and that they were short staffed. Lastly, Guardian F shared that R1 had amputated body parts, had been incarcerated, his son had abandoned their relationship and he had no support system. The orders in the EMR reflected, to check placement of condom catheter every shift 4/8/19. Condom catheter change, one time a day every Monday for condom catheter, cleanse area with soap and water before applying new catheter 3/4/19. On 4/18/19 at 12:49 PM Nurse Manager LPN W was personally interviewed, and asked how it was to care for R1. LPN W revealed she had cared for R1 for years over time, he could be difficult with some people and new people, and that he allowed her to do care. LPN W was asked if R1 refused care and replied, There have been a couple of times but most of time he is cooperative. With others he yells, name calls, tell them to not come in his room and can be very mean. When asked what are staff to do when he is unapproachable like that LPN W revealed, To walk away and tell nurse and let nurse address it. LPN W revealed, When I'm here they will come get me and I don't have an issue with him. He will say they don't listen, or care. He is particular with his care. LPN W was then queried what were staff to do, when she was not at the facility. LPN W stated, Recently I have been telling them, they don't have to wake him up to empty his Foley, and pull his covers back to check on him . When asked how often R1's Foley drainage bag should be emptied. LPN W revealed, They should check it every couple hours throughout the day. LPN W was asked if R1 had complained to her about being wet in the bed and replied, He will tell me no one comes to check on him during the night, and he will put his call light on and no one comes to answer it. It's been reoccurring for a couple of weeks now. It's more of a problem, and I came in at 06:00 AM. I have talked to the night nurses about it, and they said he won't let people in there to take care of him, was LPN W's response. LPN W denied she had come in on the night shift to audit the concern when asked. LPN W was queried if she had observed R1 having a full Foley drainage bag or wet/soiled bed. LPN W revealed she had seen R1 wet most recently on Monday (4/22/19). R1 had a brown ring around his bed pad, his catheter was off and his Foley was not full. Hospice had complained of R1 being wet with urine 2-3 times. They told me his Foley was full yesterday morning, and on Monday's. When hospice comes in on Monday morning it seems that he is wet. First time the Foley bag was full and backed up and yesterday morning it was extremely full. LPN W also revealed that, Hospice had complained of R1 being soiled with stool once and it was a Monday morning. It was a significant amount of stool, R1 said nobody would come in, he had his call light on that Sunday night not Monday morning. On 4/18/19 at 1:15 PM the Director Of Nursing (DON B) was personally interviewed and asked if she was aware of R1 complaining of being soiled of urine/stool or overflowing drainage bag and call light not being answered. DON B replied, The hospice aide told us once. I told LPN W and she addressed it with staff. The cath had kinked on his leg somehow, about a week ago. So we fixed. DON B denied being aware of R1 complaining of being soiled of urine/stool, or of not receiving assistance with call light activation. DON B was asked if audits had been done related to R1's care, whereby she stated the facility did bowel and bladder audits for catheters. When asked when was the last time one was done DON B replied, Yesterday, after stand up meeting we do walks in the morning and afternoon. DON B was asked about bowel/bladder audits at night time and replied, I'm not here at night. DON B denied being aware of R1's complaints of staff not wanting to come in to help him. However she revealed, Yes he will refuse care at times and is very particular about what staff he will allow to take care of him. If it's new staff, not until you get to know him. It takes a while for him to warm up to people. DON B was then asked what were staff instructed to do if R1 refused care. DON B replied, They should go tell the unit manager, she will try and then ask the next shift to try to agree on an approach. Then if that does not work, they put in their documentation that he refused, and we would re-approach him. DON B was then asked how often should Foley drainage bags be emptied. DON B revealed, every shift and as needed. DON B was informed that R1 was found soiled, with a full Foley drainage bag that back-flowed, and his bed was wet with rings on his sheets. When asked what could result from that experience DON B revealed, Overflow his bladder, denude his skin and cause infection. DON B was asked to provide the bowel and bladder audits for catheters, that the facility had completed, however prior to survey exit were not provided. Review of a concern form completed by Hospice staff (X) on 2/14/19 reflected, CNA reported that pt told her he had BM (bowel movement) on 2/13 at 10 AM and no one cleaned him up. Catheter back (sic) was full with 200 milliliters (ml) of urine. CNA was told by previous Staff (Y) that they were short staffed and pt refused 1 x to be changed. Pt states he was not asked after 1 x cont. Unidentified SW (Social Worker Z) was to visit pt today and pt told her he requested water on 2/13 and he did not receive any until next day. He also expressed the concern to her of not being changed when he had BM. On the back of the form was an un-dated/un-timed written paragraph by previous Staff (A1) and reflected: On 2/13/19 during wound rounds R1 became agitated while we were providing care. He needed to be cleaned up from a bowel movement. I talked to a CNA to provide care. R1 refused care at that time. The hospice aid (sic) came in later that day and reported that he had not been cleaned up. A concern form was filled out. I spoke with hospice aid (sic) and let her know about previous refusal. However the above note, did not reflect that staff had attempted to re-approach R1, to change his soiled brief on 2/13/19. Nor were there signatures provided by administrative staff that the concern had been addressed. On 3/7/19 a concern form dated 3/7/19 by SW Z reflected, Call light taking to (sic) long to be answered after 6 PM .ongoing .How can we address your issue? Improve call light response time and getting help. The facility's undated External Male Catheter policy Purpose reflected: An external catheter is an external drainage device to be used to manage male incontinence. This can be performed by a CNA. The facility's undated Emptying the Urine Drainage Bag policy Purpose reflected: To collect, contain, and measure the resident's urinary output. This may be done by a CNA. Resident (R) #2 Record review reflected R2 completed a concern form dated 1/31/19. The concern reflected, I had to wait from 12:30 to 02:10 before my diaper got changed. It was full of Poop this is a recurring problem. To address the issue reflected: Change me as soon I hit my call button. The form also reflected, it was an ongoing problem that had happened 3x's in the last week. A second concern from was completed on 1/31/19 by R2's friend (B1). The concern reflected, R2 has had many of days where she has had to wait up to two hours before she gets her diaper full of Poop changed. Change R2 in reasonable time frame, was the answer to address the issues. An X of yes reflected an ongoing problem. A third concern form was completed on 2/1/19 by Certified Occupational Therapist Assistant (COTA D). The concern form reflected, Res had light on when therapy came in at 11 AM , said she needed to be changed. Res stated a couple different people came in and said they'd find someone for her, at least 1 person turned light off. Res would put light back on. Therapy returned about 1:45 & 2:15 with res stating she had not been changed. That was when I, COTA D went to Unit Manger (C1). On going problem since res arrived. Answer call lite (sic) & do what as ask with timely manner. Upon facility entrance on 4/17/19 R2 had been discharged , however COTA D who had completed a concern form on 2/1/19, was interviewed on 4/17/19 at 02:06 PM and asked to recall concern. COTA D revealed, It was an ongoing problem, that's why I was encouraged to write a concern form. I turned the call light on, went and found CNA's and told them they needed to get her changed. I went back to see her after lunch and her light was still on, and she had not been changed. I hand delivered the concern form to the Administrator or DON. It had happened before, her having to wait a long time to be changed. She had wounds and I knew it was a big deal. When asked if R2 had voided or had a BM, COTA D revealed, I know it was at least urine. I think her husband had wrote up a report or talked to them too, he was agitated and had told us about it. COTA D was asked if administration had talked to her related to the concern form issue. COTA D replied, When I turned the form in, I told them everything that I had witnessed. I always tell my residents to push the call light when they need help, and if any staff cut it off without helping them to push it again. On 4/17/19 at 04:17 PM R2's Annual MDS dated [DATE] reflected R2 was cognitively intact, required extensive assistance of 1 to 2 persons for transfers, dressing, toilet use and hygiene. Prior to exiting the facility on 4/22/19, R2 was unable to be reached by phone.

This citation is related to intake MI 606 Based on observation, interview and record review the facility failed to provide a restorative program for up to 27 residents (Residents #'s 3, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31) who were receiving restorative therapy, resulting in an abruptly discontinued restorative program, the potential for decreased and/or limited range of motion, decreased ambulation, negative impact on activities of daily living, decline in their current highest functioning level, losing their independence, depression, withdrawal, feelings of frustration and anger. Findings Include: Resident (R) #8 While walking on the south unit, R8's room was entered on 4/17/19 at 10:31 AM . R8 was cleanly dressed and sitting up in electrical wheelchair. When asked about the care he received, R8 revealed that he had not received Restorative Therapy (RT) in over 3 months related to (r/t) restorative aides getting pulled to the floor to work as Certified Nursing Aides (CNA's). R8 revealed, I had made great progress. We had to wear gait belts at the parallel bars, and we did stretching with joints before getting up. They are so short. You may have may only have 1 CNA on the floor, therefore I don't get my restorative therapy. When asked who was the restorative aide R8 replied, It was only one guy to my knowledge and he gets pulled to the floor to work as a CNA. R8 revealed he felt stronger and was improving with restorative, and expressed a sense of loss of the program. R8 was transferred to RT for the functional maintenance program and was recommended for Range Of Motion (ROM) to bilateral Lower Extremity (LE), Omni cycle level 8, standing at parallel bars, and seated exercise with 2 pound (#) weights (wts). The RT sheet had a discharge date d of 3/26. The goal reflected, to maintain current level of function. R7 On 4/18/19 at 4:04 PM R7 was observed in his room cleanly dressed sitting up in his electric wheelchair. R7 was asked about his participation in RT. R7 revealed he used to received RT. When asked why he no longer received RT R7 revealed, They don't have anyone doing it. When they had the RT Aide (RTA K) they put him on the floor all the time (on the floor to the floor to work as a CNA). R7 revealed he did therapy of the arms, legs, standing and walking and that he felt strong when getting therapy. R7 was asked how he felt about not having RT anymore and replied, It's a set back for me. I don't walk anymore, I get out of this chair (electric wheelchair) to a regular wheelchair. I don't walk no more. I'm going to get out of this chair and walk one day. On 4/18/19 at 4:23 PM R7's EMR reflected R7 was readmitted on [DATE], was a [AGE] year old male with [DIAGNOSES REDACTED]. R7's Annual Minimum Data Sheet (MDS: resident assessment tool) dated 4/2/19 reflected he had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact: 13-15), and required extensive assistance of 1 person with transfers, dressing, toileting and hygiene. The RT from for R7, reflected he was referred to RT on 1/17/19 with a discharge date of ,[DATE]. The recommended program for R7 consisted of: Nu-step level, ambulation with platform walker, standing at parallel bars, seated LE exercises, and seated Upper Extremity (UE). Program Goals reflected, increase ambulation using platform walker to 100 feet (ft), increased seated LE exercises, and increased standing tolerance at parallel bars. R6 The EMR for R6 on 4/18/19 at 3:08 PM reflected a re-admission date of [DATE]. [DIAGNOSES REDACTED]. On 4/18/19 at 3:59 PM R6 was asked if she used to receive RT and replied, Yes. When asked why she did not receive RT anymore R6 stated, They stopped RTA K from doing it and put him on the floor to work as an aide. When R6 was asked how it made her feel, having her RT abruptly stopped she replied, I didn't like it and it made me upset. R6 was observed laying in her bed covered with a sheet with her windows opened. R6 was not observed by writer to be out of her bed on 4/17/19 or 4/18/19. R6 was referred to RT for functional maintenance on 12/5/18, with a discharge date of ,[DATE]. Recommended programs for R6 consisted of: Core strengthening exercises, Omni-cycle bi-directionally, fine motor coordination and Omni-VR while seated. Goals reflected to maintain current level of function. RTA K was interviewed by phone on 4/18/19 at 8:12 AM and asked how long did he work in the restorative program. RTA K revealed, since the program had started he believed about 4 years ago. RTA K revealed he would come in to do RT Monday thru Friday (5 days a week), but most of the time he would get pulled to the floor to work as an CNA. RTA K stated, I would be behind on the restorative assignments. Due to staffing issues especially on nights, he worked as a CNA and would do restorative after he ended his shift. RTA K revealed he was the only RTA, but originally there was another RTA. However, there was an issue keeping a second person, because they would get pulled all the time to work on the floor as a CNA and it became frustrating for the person. RTA K revealed, residents and staff would get upset, and some yelled asking why he wasn't doing restorative. Also, that there was always an issue keeping a part-time worker in restorative restorative. When question as to why RT was discontinued RTA K revealed, restorative stopped abruptly because he kept getting pulled. The pulling to the floor never stopped. When asked what happened to the residents who were supposed to receive RT, RTA K revealed he was not sure, but that they were probably not getting any RT. RTA K revealed, I would get the restorative form from Physical Therapy (PT) with the days the residents were to get restorative. Then write their discharge date on it, unless therapy needed to extend the RT out longer. When asked when did the Restorative Therapy Program stop, RTA K replied 2/22/19. However, if there was a way that he could work as a RTA and actually be able to do it, he would go back to it tomorrow. RTA K revealed RT plans varied, and were based on what PT wrote that the residents needed. Sometimes walking with them, working on standing, the bike and nu-step (helps you get back to walking, taking steps while sitting down). Upper body consisted of: ROM, weights, thera-band, thera-putty (putty used for hand strengthening with different strengths). RTA K was asked to share RT used for the following residents (R7, R6 and R8) and revealed: R7: Riding the new step for 15-20 min on level 4 and got to a level 6 by the time I was done. Ambulating with his walker, standing at the parallel bars and shifting weight from one leg to another. R6: Core strengthening, sit ups in the the w/c (engaging your core), Omni arm bike (pedaling a bike with your arms and could change the speed and resistance. R8: A lot of ROM of the UE/LE. He did the Omni arm bike, and worked on standing at the parallel bars. All of those people were really bumbed about RT stopping, they would come and find me. They were the ones who were eager to do it, and some people asked about RT everyday. RTA K denied that the Administrator (ADM A) or Director Of Nursing (DON B) had discussions with him, about restarting the RT program. The Restorative Weekly List reflected Residents 3, 6, 7, 8 and Residents 9 to 31 names (who were at the time receiving RT). The previously identified residents reflected on the list, were to have RT until their individual indicated discharge date . discharge date s for the residents reflected, the earliest date of discharge as 3/8/19 and the furthest date of discharge as 6/4/19. The facility's Restorative Nurse Aide Job Description Overview reflected: The Restorative Nurse Aide provides support to the nursing and therapy departments in assisting residents to achieve their highest level of function, and to restore level of functions lost through illness, debility, or lack of motivation. The restorative nurse aide reports directly to the Restorative Nurse. Care and Services: 1. Provides nursing rehabilitation/restorative nursing services -Promote resident's ability to adopt to and adjust to living as independently as possible. -Trains the resident in self-care according to the resident's abilities. -Trains the resident in the use of assistive devices for transferring, walking and mobility, dressing and grooming, eating and swallowing. -Maintains range of motion; proper turning and positioning in bed and chair. -Assist with bowel and bladder retraining. -Instructs the resident on the care and use of prosthetic and orthotic devices. -Incorporates training and skill practice activities, which include repetition, physical or verbal cueing and task segment. 9. Makes routine rounds on each assigned resident every two hours. Dates of service for the above residents ranged from 3 times a week to 5 times a week, for 12 to 16 weeks. On 4/18/19 at 11:21 AM Certified Occupational Therapist Aide (COTA D) was asked about the restorative program and revealed, We no longer have restorative because they kept having to pull them to the floor about a month ago, and they kept having them work the floor as CNA's when they were having trouble keeping people in here. On 4/18/19 at 1:55 PM DON B was asked if the facility had a restorative program and revealed not at the moment. When asked how long the facility had not had a RT program DON B replied, We have not had it for a month and a half. We had restorative, but he was pulled to work on the floor. So we are currently seeking someone for that position. RTA K was the only full time RTA and we had a part time RTA aide last year, probably about 9-10 months ago. DON B revealed she did not know whom or how many people received RT, when asked. On 4/18/19 at 2:11 PM Therapy Manager (TM E1) was interviewed about the facility's RT program. TM E1 revealed she just started her position at the facility about 4 weeks ago, and that there had not been a RT program since she had been at the facility. When asked what was being done for the residents who needed RT, TM E1 revealed, they were going to put them on the communication log for nursing to walk. TM E1 revealed she was not aware of the plans related to restorative, and that once a resident was discharged from therapy they would fill out the restorative form sheet and restorative would do that with them. On 4/18/19 at 2:19 PM the contracted Physical Therapist (PT F1) consultant was interviewed about the facility's RT program. PT F1 revealed they did not oversee restorative, but discharged residents to RT, and wrote down the plan of care. Nursing would make the determination of when they started, the date signed reflected the referral date, and that restorative was usually written for 90 days, 12 weeks and 15-16 weeks sometimes. The facility's undated Rehabilitation-Transition Process policy reflected the following Purpose: To provide communication regarding resident care and services needed to maximize physical function. 1) When a resident requires a change in programming, either in rehabilitation services or restorative, a physician's orders [REDACTED]. -Therapy to Restorative -Restorative to Floor Nursing -Therapy to Floor Nursing 4) Complete the Restorative Transfer from in PCC (Point Click Care)

Based on observation, interview and record review the facility failed to implement elopement risk interventions, prevent elopement for 1 (Resident #101), who was assessed and identified on 9/12/18 as ambulatory and no mobile device required for locomotion and not alert and oriented x3 at high risk for elopement resulting in Immediate Jeopardy when Resident #101 eloped from the facility, and was later found by Certified Nurse Aid C and D at the Family Video, walking in the dark, unsupervised. This deficient practice places 18 residents, who have been identified by the facility as an elopement risk, at risk for serious harm, injury, and/or death. Findings include: Review of the facility Elopement, Potential Resident Policy and Procedure, dated (MONTH) 2013, reflected, Policy: It is the policy of the facility to provide residents with a save and secure environment and identify residents who may be at risk for unobserved exit from the facility. Fundamental Information: Residents who enter the facility may display behaviors that are unsafe particularly since they are entering an environment that is unfamiliar. Residents with cognitive lose or impaired judgement may attempt to leave the premises, known as Exit Seeking Behavior. Residents are most vulnerable in the early admission period . Review of the Face Sheet and Nursing Assessment, dated 9/12/18, reflected Resident #101 was a [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Nursing Assessment reflected Resident #101 was alert to person only, and he required no physical help from staff for locomotion on unit or transfers and needed no type of device for ambulation. In an observation on 9/20/18 at 2:50 p.m., R101 observed ambulating in the halls of the Dementia unit and standing by the exit door with staff. R101 appeared slightly anxious with passing motions. R101 was easily redirected by staff. During an interview on 9/20/18 at 3:15 CNA I reported she knows how to care for a residents according to the Kardex on the computer and checks at the start of shift. CNA I reported if a new admission, they get interventions in within shift. CNA I reported they did not work 9/15/18. CNA I reported R101 had 1:1 since elopement on 9/15/18. CNA I reported R101 admitted to the facility on [DATE] and had exit seeking behavior on 9/13/18 when she was working and reported she works 6:00a.m. to 6:00p.m. routinely on the dementia unit. CNA I reported she thinks R101 had a wanderguard. CNA I reported dementia unit staffed today and routinely with 2 CNA staff and 1 CNA staff for 1:1 for R101. Review of the Hospitalist Progress Note, dated 9/10/18, reflected, he constantly walks the halls, his gait is steady, his behaviors have been stable, no aggressive behavior. He continues to have a safety companion because he remains an elopement risk. Review of the Hospital History and Physical, dated 8/22/18, reflected, This is a [AGE] year-old gentleman, who unfortunately has been recently diagnosed with [REDACTED]. Review of the Care plans dated 9/12/18 for R101 included the following problems: I am an elopement risk/I am a wanderer r/t Dementia with goals that included, I will not leave the facility unattended through the review date. Interventions included, distract me from wandering by offering me pleasant diversions, structured activities, food, conversation, television, book, radio as I like to listen to music; rock n roll. Identify my pattern of wandering: Is my wandering purposeful, aimless, or escapist? Am I looking for something? Does this indicate I need more exercise? Intervene as appropriate. Review of facility, Elopement Assessment, dated 9/12/18, reflected R101 was at high risk and indicated in the notes area, Resident has attempted to open all exits for the one hour is been here. Review of the Nursing Progress notes, dated 9/12/18 through 9/15/18, reflected R101 had continued attempts to exit seek including a Progress note on 9/14/18 that reflected, Resident was wandering halls and trying to get out the emergency exits . Review of the Unusual Occurrence Progress note, dated 9/15/18, reflected, @ approximately 21:05 p.m. I opened the north hall door and heard the exterior door alarm sounding. I checked the office alarm panel and discovered that the east door was alarming. I went to the east exit door and observed it open with no one in sight. I secured the door and began checking rooms beginning with 105. I checked bathrooms, closets, nooks and crannys in each room. I got to room [ROOM NUMBER] and observed CNA attempting to sooth a resident. The resident was banging on the wall crying. I instructed the CNA to continue the search with me. My other CNA came out of the shower room and assisted in the search. The building was searched quickly and there was no sign of (R101). We discovered the resident was NOT on north hall and I called a code GREEN. Resident was not in the building. CNA (C) was instructed to drive the 4 surrounding blocks, Resident was not in the building. I called the DON at 2110 pm. I checked the code green book and called the local police department at 2111. At 2113 as soon as I hung up the pone it rang and a CNA told me our resident was found in the parking lot of the Family Video. I relayed this to the DON. The officer (named) appeared on the hall as the resident was brought in the building. Resident was back in the building before 2130 hours. Note was written by LPN E. Review of the facility, Unusual Occurrence Report, dated 9/15/18, reflected R101 eloped unsupervised out of the east door of the Dementia Unit at 9:00 p.m. and was later located by staff driving car in the surrounding area and returned to the facility at 9:35 p.m. The Report was completed by Licensed Practical Nurse (LPN) E. The Report reflected, Immediate Investigation finding .When I walked onto North hall the exterior door alarm was sounding, after searching entire building, CNA sent to drive around surrounding area, resident found . Review of the MI-ACTS 24 hour report, dated 9/16/18, reflected incident occurred at 8:30 p.m. on 9/15/18 and Incident Summary included, (R101) was discovered to be missing, by nurse (LPN E with phone number), from the (named facility) at approximately 8:35p.m. on 09-15-18. (Named facility) elopement policy and procedure was implemented immediately. CNA, (C and contact number), located resident was located off site and returned to facility at approximately 9:30.p.m. Resident, who is a new resident to this facility and has advanced dementia was evaluated upon return and was unharmed. Review of the QAPI Performance Improvement Plan, undated, reflected project title as Elopement Prevention and included areas to address that included, staff education, 1:1 discipline for nurse related to leaving unit while CNA staff occupied, wander guard door system, and door sensors. During a telephone interview on 9/20/18 at 4:21 p.m., Certified Nurse Aid (CNA) C reported working routinely on the Dementia Unit and reported worked 9/15/18 from 3:00 p.m. to 6:00 a.m. on 9/16/18. CNA C reported the Dementia Unit had 2 CNA staff and one nurse. CNA C reported she had taken another resident into the shower room at about 9:00 p.m. after redirecting R101 from wandering in another resident room R101 sat in a chair in the hall. CNA C reported she did not hear the alarm while in the shower but was told by Licensed Practical Nurse (LPN) E when she exited the shower room that the door alarm had been on and the door was slightly open and they were unable to locate R101. CNA C reported CNA G had been in another resident room related to behaviors. CNA C reported she went to the door and noted CNA G was already in the parking lot. CNA C reported she was instructed by LPN E to drive car around the area. CNA C reported CNA D, from another unit, went with her because it was difficult for her to see in the dark. CNA C reported she drove down Wagner road (road directly in front of the facility) to the ballpark about 4-5 blocks because the river was across the road and was concerned that R101 may have gone that direction. CNA C reported they were unable to locate R101 in that direction and returned down Columbia road and stopped at Walgreens and asked a lady in the parking lot if she had seen the R101, who had not. CNA C reported they located R101 in the Family Video parking lot walking and reported CNA D walked with R101 back to the facility at about 9:35 p.m. During an interview on 9/21/18 at 9:30 a.m., Administrator (ADM) A, Director of Nursing B and regional staff F provided with surveyor with document labeled, Elopement Prevention Plan. The document included interventions that included 1:1 Supervision, Quote for wander guard doors, Egress sensor alarms, education, cameras, increase Elopement drills, and new admission 15 minute checks. No mention of staffing changes noted in Elopement Prevention Plan or QAPI Performance Improvement Plan. ADM A reported at the time of R101 elopement 2 cna staff were on the Dementia unit and were each providing care to different residents and did not hear the alarm and the only nurse was off the unit. ADM A reported she would expect staff to respond to an alarm in a few seconds. ADM A reported the facility had no cameras currently in place on the unit. DON reported usually 2 CNA staff and 1 nurse were scheduled for the dementia unit(28 residents) and unlocked unit has 3 cna staff and 2 nurses for about 35 residents. Review of the facility list provided by the ADM A on 9/21/18 at 10:00 a.m., reflected 14 residents in the building that were at high risk for elopement and in the code green binder. During an interview on 9/21/18 at 10:40 a.m., Unit Manager H reported the Dementia unit currently had 30 residents that included 12 residents that are at high risk for elopement. Unit Manager H verified R101 was at risk for elopement at time of admission and interventions were added to the Care Plan. Review of the facility provided one week Nursing Staffing Report, dated 9/18/18 through 9/25/18, reflected three of the seven day shifts were less than the required direct resident care hours to meet resident needs. Nursing Home Administrator (NHA) A was presented with Immediate Jeopardy Notification on 09/21/2018 due to the facility's failure to implement elopement risk interventions, prevent elopement for 1 (Resident #101), who was assessed and identified on 9/15/18 as ambulatory and no mobile device required for locomotion and not alert and oriented x3 at high risk for elopement, when on 9/15/18 at approximately 9:00 p.m., Resident #101 eloped from the facility. A corrective action plan was requested from the facility to remove the immediate jeopardy. Immediate Jeopardy was removed on 9/21/18 when it was verified that the facility implemented interventions which included the following interventions were put into place: 1. Resident # 101 was admitted to facility's North Unit (Memory Care) on 9/12/18. He has a history of frontal lobe dementia. Upon admission, elopement assessment was completed, and it was determined that resident was at risk for wandering and wander guard bracelet was applied, care plan initiated. Resident # 101 is ambulatory without an assisted device, oriented to self although follows direction. 2. On (MONTH) 15, (YEAR) at 2100, (Staff nurse) noted that the North unit egress door alarm was sounding and ajar. Elopement code was initiated immediately. Resident #101 was noted not to be in the building. At 2113 C.N.A. staff located the resident at nearby video store and was safely return to facility. No signs or symptoms of injury noted. Per C.N.A. statement resident stated he was looking for his daughter. 3. Investigation initiated by NHA immediately on 9/15/18 and was completed 9/17/18. NHA determined that the maximum time out of building was 23 minutes. Fire door operated correctly opening within 15 seconds. Exited door did not have wander guard system alarmed and sounding. Interview of LPN & C.N.A.s obtained 9/15/18 revealed nurse was off the unit at time alarm sounded. She observing resident resting in chair near his room at 2050. Both C.N.A.s on unit stated they were providing a shower and, in a room, providing HS care to a difficult resident. Re-enactment confirmed C.N.A.s report. Root cause analysis completed by facility which determined that resident lacked appropriate supervision. Nursing staff failed to implement appropriate interventions upon admit when it was recognized resident was exit-seeking. 4. 1:1 supervision was initiated upon return to facility and remains in place to date. Residents who were determined by the facility to be at risk for elopement were reassessed. Care plans reviewed and updated as necessary to prevent a reoccurrence. Elopement education started 9/15/18 and was completed 9/17/18. Only one staff member will go on break off unit at a time. Staff will communicate with other caregivers on the unit before leaving unit for any reason. Plan to ensure staff is able to hear alarms sounding will be made at that time (for example: hold off on showering a resident, leave door open with curtain closed, or request additional staff from other unit). Resident that attempt to exit doors or verbalize leaving will be placed on 15-minute checks. IDT team will review care plan and documentation to determine root cause and any interventions or referrals that may be necessary. 5. Audit of elopement assessment will be completed to ensure appropriate care plan interventions are identified and implemented as needed. Audits will be completed 5 days a week x 4 weeks then weekly x 3 then monthly review with QAPI. NHA is responsible for substantial compliance. During an interview on 9/25/18 at 6:30 p.m., ADM A reported R101 continues to be on 1:1 and reported the facility usually does an onsite assessment of residents prior to admission but because of the fact that R101 came from a hospital several hours away that was not completed. ADM A reported they most likely would not have excepted R101 because the facility was not a good match for R101. ADM A reported the facility is in the process of implementing more safety measures and until they are in place R101 will remain a 1:1. Although the Immediate Jeopardy was removed on 9-21-18, the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the State Agency.

Based on observation, interview, and record review, the facility failed to provide complete care and services for 1 of 1 residents reviewed for the management of end stage [MEDICAL CONDITION] (Resident #4), and the facility failed to provide medication as ordered for 1 of 15 residents reviewed for medications (Resident #5), resulting in Resident #4 and #5 not receiving physician orders [REDACTED]. Findings include: According to the facility's Fluid Intake & Output Measurement Policy and Procedure, not dated, Fluid intake: Includes all liquids entering the resident's body, including beverages, and foods that are liquid at room temperature, such as flavored gelatin, custard, and ice cream .Measuring Fluid Intake: 1. During each shift, measure fluid taken in by the resident. 2. Record amounts in cubic centimeters (cc) or milliliters (ml) . 3. Record amount of intake in the medical record . According to the MDS/Minimum Data Set, dated dated [DATE], Resident #4 was a [AGE] year old man (who scored 15/15 (revealing he was cognitively intact); he was originally admitted to the facility on [DATE]. According to the MDS's dated 3/04/17 and 6/02/17, Resident #4 needed one person physical assist with transfers and toileting, and was not steady going from a seated position to standing, but was able to stabilize with human assistance. According to Resident #4's current Face Sheet (6/14/17), he had [DIAGNOSES REDACTED]. His Face Sheet also revealed he had 3 Emergency Contacts (2 sisters and his mother) and was a Full Code. During an observation/interview, on 8/14/17 at 12:20 PM, Resident #4, who was laying in bed, reported he preferred watching TV alone in his room over attending group activities, and he wished he could attend AA (Alcoholics Anonymous) Meetings, but that was currently unavailable to him. Resident #4 said, That fizzled out .I've been in and out of the hospital . Resident #4 reported he sustained bilateral shoulder fractures when he fell during a self-transfer from him wheelchair to a weight floor scale while at the [MEDICAL TREATMENT] center (3/28/17). Resident #4 said, (Nurse EE) told me to get my butt out of the wheelchair and stand. My feet got tangled in the foot rest .I just got healed up from wrist fractures I got when I fell at a restaurant .I need help to stand. Resident #4 said there had not been an investigation, that he knew of, regarding the fall. Resident #4 reported it sometimes took 2 hours for his call light to be answered, and it had last happened about 2 weeks ago. Resident #4 said, They need a manager on at night. The other night no one came so I went to the nurses' desk at 3:10 AM to ask for help, and I didn't see anyone until 4:00 AM. A lot of them go outside and smoke all at once. Resident #4 was queried as to whether staff were monitoring his fluid intake and he reported he was not really on a fluid restriction. No, they are not monitoring it. Review of Resident #4's Admit/Discharge Report dated 8/15/17 revealed the following Hospital admissions/Readmissions to the facility: 8/16/16 - 8/22/16 (6 days) 9/17/16 - 9/20/17 (3 days 9/24/17 - 10/03/16 (9 days) 10/17/16 - 11/15/16 (2 days) 12/06/16 - 12/11/16 (5 days) 12/13/16 - 12/19/16 (3 days) 12/24/17 - 12/31/17 (7 days) 1/03/17 - 1/08/17 (5 days) 1/16/17 - 1/24/17 (8 days) 3/25/17 - 3/26/17 (1 day) 3/28/17 - 4/17/17 (20 days) 5/11/17 - 5/19/17 (8 days) 6/02/17 - 6/10/17 (8 days) 6/15/17 - 6/27/17 (12 days) Review of Resident #4's Hospital Progress Note, dated 6/27/17, revealed he was admitted for Chest pain due to fluid overload and/or musculoskeletal, [MEDICAL CONDITION] .due to missed [MEDICAL TREATMENT], now stable Blood pressure (!) 148/69 .presents to the ED (emergency department) with chest pain .Reports episode of [MEDICAL CONDITION] - one yesterday night, one this morning .I & O (intake and output) Gross per 24 hours .Net -4183 ml . Review of Resident #4's Hospital Discharge Instructions, dated 6/27/17, revealed 2000 ml fluid restriction .weigh yourself daily before breakfast .F/U (follow up) ASAP (as soon as possible) in (Orthopedic Surgeon's GG's) to discuss further management of arm fractures. Review of Resident #4's Physician Orders, revealed a current order for daily weights and a 2,000 cc fluid restriction (ordered 6/27/17). No order was found to follow up with Orthopedic physician GG. In an interview with the UM/Unit Manger (M) where Resident #4 resided, on 8/14/17 at 1:35 PM, she was queried as to whether Resident #4 was on a fluid restriction she replied, I'm not sure. At 2:15 PM that same day, UM M was queried as to whether Resident #4 was on daily weights and she replied, He gets weighed 3 times a week at [MEDICAL TREATMENT]. In an interview with the LPN licensed nurse assigned to Resident #4 on 8/14/17 at 2:16 PM, (LPN T ) was queried as to whether Resident #4 was on a fluid restriction and she replied, He was on daily weights at one time .He was on a fluid restriction, by not now. It went on the wayside. Daily weights were discontinued. When asked to check to see if there was an Physician Order, LPN T checked the EMAR (electronic medical record) and found an active order for daily weights and a 2,000 cc/day fluid restriction, dated to be started 6/28/17. When asked whether those orders were reflected on the MAR/Medication Administration Record [REDACTED] Review of Resident #4's Care Plans revealed the following: - (last reviewed 9/14/17) I wish to return to my previous living arrangement which was home with family. I have family support at home . - (last reviewed 7/03/17) I need assistance with my ADL's (activities of daily living) r/t (related to) weakness d/t (due to) end stage [MEDICAL CONDITION] on [MEDICAL TREATMENT], [MEDICAL CONDITIONS], chronic pain, anxiety, [MEDICAL CONDITIONS], and depression . (This Care Plan and all others did not reveal he had unhealed fractures or fragile bones). - (last reviewed 5/02/16/over 1 year ago) I am resistive to care and will refuse medications, treatments and assistance at times r/t adjustment to nursing home .Educate myself/family/caregivers of the possible outcome(s) of not complying with treatment or care . - (initiated 7/03/17) I have altered cardiovascular status r/t hx (history) of chest pain,[MEDICAL CONDITION](hypertension), [MEDICAL CONDITIONS], cardiomegaly, [MEDICAL CONDITIONS], and [MEDICAL CONDITIONS] .Monitor VITAL SIGNS and notify my doctor of any significant abnormalities. Observe and report any abnormalities in my Vital Signs. Observe for signs and symptoms of elevated BP (blood pressure) and report . This Care Plan did not list interventions recording/monitoring/reporting fluid restrictions and daily weights. - (initiated 7/03/17) I have [MEDICAL CONDITION] .Monitor my Vital Signs and Notify my MD (Medical Director Y) of significant abnormalities. Observe/report PRN (as needed) any s/sx (signs/symptoms) of [MEDICAL CONDITION] . This Care Plan did not list interventions recording/monitoring/reporting fluid restrictions and daily weights. - (initiated 7/03/17) I have alteration in my cardiac status r/t [MEDICAL CONDITIONS].Observe me for excessive [MEDICAL CONDITION] . This Care Plan did not list interventions recording/monitoring/reporting fluid restrictions and daily weights. - (initiated 7/03/17) I have fluid overload or potential for fluid volume overload r/t Kidney failure .I will comply with .fluid restrictions . This Care Plan did not list interventions recording/monitoring/reporting fluid restrictions and daily weights. - (initiated 4/19/17) I have [MEDICAL CONDITION] and [MEDICAL CONDITION] .Monitor/document/report any s/sx of [MEDICAL CONDITION] . This Care Plan did not list interventions to monitor for [MEDICAL CONDITION] nor [MEDICAL CONDITION]. In an interview, on 8/14/17 at 2:45 PM, Administrator A was queried about the fractures Resident #4 sustained at the [MEDICAL TREATMENT] center and she said, It didn't sit well with me. The [MEDICAL TREATMENT] center didn't take it seriously. (Resident #4) was a one person assist at the time and was pretty weak from being sick. When queried as to whether she called the State Agency complaint line, Administrator A said she did not and said, I didn't know what to do. I told the Ombudsman. (The Ombudsman was unavailable for comment. Her voicemail stated she was on vacation during the Survey 8/14 - 8/16). Administrator A stated Resident #4 developed [MEDICAL CONDITION], From drinking alcohol. Subsequently, this Surveyor requested documents that contained the original source of the [DIAGNOSES REDACTED].#4's EMAR/electronic medical record, including physician progress notes [REDACTED]. In addition, Resident #4's last Orthopedic Consult was not in the clinical record. After pulling and reviewing closed paper records, Administrator A presented a Home Health Report, dated 5/09/16 that revealed Resident #4 had a [DIAGNOSES REDACTED]. According to Mayo Clinic, 2017, Abnormal genes cause [DIAGNOSES REDACTED] kidney disease, which means that in most cases, the disease runs in families and causes kidney failure. <http://www.mayoclinic.org/diseases-conditions/[DIAGNOSES REDACTED]-kidney-disease/symptoms-causes/dxc- 506> Review of Orthopedic Consult, retrieved by the facility from the hospital, dated 3/29/17, revealed, .Yesterday patient arrived for [MEDICAL TREATMENT] and while trying to transfer from the wheelchair to chair his foot got tangled with the foot rest of the wheelchair and he fell out onto the floor hitting both shoulders .While in the ED patient became increasingly somnolent (sleepy) so was transferred to ICU for possible intubation .possible head injury . The continued report revealed, Result Date: 4/1/2017 . CT (Imaging report) Upper Extremity .There is a chronic fracture deformity of the distal clavicle .There is a large left pleural effusion and near complete atelectasis of the left lower lobe .Chronic healed right 2nd rib fracture is noted .An impacted proximal left humeral fracture through the surgical neck .An impacted fracture through the surgical neck of the right humerus . In an interview, on 8/14/17 at 3:20 PM, DON/Director of Nursing B stated she believed Resident #4's orders for daily weights and fluid restriction should have been discontinued when he last went out to the hospital. DON B said she discovered 1-2 months ago some licensed nurses were not discontinuing orders and reissuing order for residents who went out to the hospital and were then readmitted with the identical orders. When queried if the facility had conducted an audit and corrected the errors, she reluctantly said they had not. (Resident #4's last hospital admission was 6/15/17 - 6/27/17, and the review of facility Physician order [REDACTED]. Review of Resident #4's Blood Pressure documentation under the Vitals Signs tab in the EMR revealed it had only been assessed/recorded documented 3 times during August 2018: 8/13/17 - 14:35 - 180/100 8/12/17 - 6:53 - 180/110 8/01/17 - 11:48 - 170/82 His last 3 documented blood pressures in July 2017 were: 7/30/17 - 2:49 - 142/64 7/29/17 - 13:24 - 145/98 7/28/17 - 12:05 - 180/70 In an interview, on 8/14/17 at 3:43 PM, Nurse Aide U reported she often was assigned to Resident #4 and was currently assigned to him, and he was a daily blood pressure. When queried as to how often she obtained Resident #4's weight she replied, He is monthly. Nurse Aide ---said she obtained Resident #4's daily blood pressure, usually when she first arrived for the day around 6:00 AM, and said the Nurse Aides are given a list on a piece of paper at the beginning of the shift they record the vitals signs on and they give them to the nurse. When asked about why there were missing vital signs in the EMAR for Resident #4, Nurse Aide U replied, The girls (Nurse Aides) probably didn't chart it .Sometimes, I have to let MDS/Minimum Data Set nurse/RN/Registered Nurse W know. I can't chart in the EMAR. She changes it and submits them. Our daily vital sign papers end up in a file in Medical Records, but the nurse is supposed to record them in the chart. Nurse Aide U said the time shown in the EMAR is the time the nurse enters the data, not the time the vitals were actually taken. Nurse Aide U presented her daily vital signs sheet with vitals recorded that day and it was revealed she did not document the time the vital signs were obtained. When queried about this she said she never recorded the time she took the vitals. In an interview, on 8/15/17 at 9:06 AM, DON B was queried about Resident #4's elevated blood pressures, and she reported there were no set parameters for when to call the physician (Medical Director Y), and she said Resident #4's blood pressures are not alarming to me .I wouldn't call on them. If the doc hasn't set parameters, I have to use my nursing judgment. When queried as to whether daily blood pressures and fluid restriction monitoring should be in Resident #4's Care Plan, Nurse Aide Care Guide/Kardex, or the MAR indicated [REDACTED]. It would go on the Kardex. When queried as to whether Resident #4 had received education about restricting his fluids, DON B replied, We do a lot of education, but I don't know if the education is recorded. DON B stated she had not discussed Resident #4's fluid restriction with the Dietitian O and did not know whether the Dietitian O had educated Resident #4. When queried about where the facility found the [DIAGNOSES REDACTED]. where that came from .the nurse (DD) that entered that [DIAGNOSES REDACTED]. I think she made an error. When queried as to whether the facility coordinated care and collaborated with the creation of plans of care for Resident #4, she said, We get Communication Forms from them. We put them all in a folder. Review of the last 3 [MEDICAL TREATMENT] Communication forms revealed Resident #4's blood pressure prior to [MEDICAL TREATMENT] on 8/10/17 was 214/89. Review of Resident #4's physician progress notes [REDACTED]. The most recent physician progress notes [REDACTED].O (Observation) .B/P 170/82 .A (Assessment): Shaking/[MEDICAL CONDITION]. P (Plan): will order [MEDICATION NAME] (used for respiratory disease) level, [MEDICATION NAME] ([MEDICAL CONDITION] medication) level. In an interview, on 8/16/17 at 9:00 AM, LPN/Licensed Practical Nurse, the nurse assigned to Resident #4 that day, reported she did not enter Vital Signs (taken by the Nurse Aides around 6:00 AM) until the end of her shift (6:00 PM); she said, That's how I do it. In an interview, on 8/16/17 at 12:37 PM, Medical Director Y stated he may have not documented any education he had done with Resident #4, but had done so many times. When queried about Resident #4's documented blood pressures, he asked, Why did he have [MEDICAL CONDITION], uncontrolled hypertension?. This Surveyor informed Medical Director Y Resident #4 had a [DIAGNOSES REDACTED]. Medical Director Y said he was unaware of where Resident #4's blood pressures had been running and stated he would set parameters for nurse to call if Resident #4's systolic blood pressure was above 140 and diastolic blood pressure above 85. When presented with the facility's blood pressure documentation, Medical Director Y indicated nursing should have altered him. Medical Director Y expressed concern and confusion when told that his order for daily weights and 2,000 cc fluid restriction had not been carried out. When presented with the information that Resident #4 had had 14 hospital admissions (the last being 6/15/17 -6/27/17 for chest pain, fluid overload, and hypertension) since 8/16/16, but only one Care Conference (3/14/17), and that only Nursing and Social Work had attended that one Care Conference, Medical Director Y said a comprehensive review of his case needed to be conducted soon. Medical Director Y was unaware Resident #4 had chronic rib fractures, and a chronic clavicle fracture. Medical Director Y said, His renal condition probably makes him more susceptible to [MEDICAL CONDITION]. In an interview, on 8/16/17 at 6:00 PM, SSD/Social Services Director D reported, I sit and talk with him about how he can do things differently. He blames everything on the nurses and nurse aides! I tell him, I know you can walk and take yourself to the bathroom. When queried as to whether his Care Plan instructed for him to have assistance with transfers, SSD D said, I'm guessing he's Care Planned for some independence. When queried about Resident #4's Care Plan regarding non-compliant behavior, SSD D reported she may not have documented it, but she had discussed issues with him; she said, (Resident #4's) depression is better .we've talked about it, him getting angry, swearing, and his approach to staff. When queried as to whether she had discussed why he had refusals to go to [MEDICAL TREATMENT] with him, SSD D said, Says he doesn't feel good. When he doesn't go, he feels worse. SSD D stated, He doesn't have any family. When asked about Care Plan revision, and what attempts had been made to address non-compliance SSD D said, Psychiatric Services is involved. SSD D was asked to present the last 2 Behavioral Health consults and she presented Behavioral Health Consult notes dated 3/07/17 (New Patient) and 5/10/17 which contained a recommendation to increase [MEDICATION NAME] (antidepressant) to 20 mg. According to the MDS/Minimum Data Set, dated dated [DATE], Resident #5 was a [AGE] year old woman who was admitted to the facility on [DATE]. She scored 15/15 on the Brief Interview for Mental Status (indicating she had no cognitive impairment). According to the current Face Sheet in the EMAR/electronic medical record, she had [DIAGNOSES REDACTED]. In an observation/interview, on 8/15/17 at 7:30 AM, Resident #5, who was seated in the dining room, reported in a distressed tone, Sometimes, it takes days to get my meds; she had a tracheotomy canula in her throat. I didn't have my [MEDICATION NAME] ([MEDICATION NAME]). I need it. Last week, I couldn't get my [MEDICATION NAME] (Lorazapam). They told me Pharmacy never sent it. The nurses said don't tell them (State Surveyors) it's our fault. According to Mayo Clinic, March, 2017, [MEDICATION NAME] is a corticosteroid or steroid (cortisone-like medicine). It works by preventing inflammation (swelling) in the lungs, which makes the asthma attack less severe. Inhaled [MEDICATION NAME] may be used with other asthma medicines such as [MEDICATION NAME][MEDICATION NAME], which are also used to open up narrowed breathing passages in the lungs. <http://www.mayoclinic.org/drugs-supplements/[MEDICATION NAME]-inhalation-route/description/drg- 233> According to Mayo Clinic, March, 2017, [MEDICATION NAME] is used to treat anxiety disorders. It is also used for short-term relief of the symptoms of anxiety or anxiety caused by depression. [MEDICATION NAME] is a benzodiazepine that works in the brain to relieve symptoms of anxiety. Benzodiazepines are central nervous system (CNS) depressants, which are medicines that slow down the nervous system. <http://www.mayoclinic.org/search/search-results?q=[MEDICATION NAME]%[MEDICAL CONDITION]> In an interview, on 8/15/17 at 8:06 AM, DON B reported there were no Medication Error reports for Resident #5 and, There was no problem getting meds for (Resident #5). At 2:54 PM, DON B presented a copy of Resident #5's August 2017 MAR/Medication Administration Record [REDACTED]. In an interview, on 8/16/17 between 8:22 AM - 8:59 AM, this Surveyor reviewed Resident #5's August 2017 EMAR/electronic Medication Administration Record [REDACTED]. Due to lack of documentation and inconsistencies in the way the licensed nurses documented, it was impossible to verify exactly how many doses were not administered. According to the MAR, Resident #5 was supposed to receive [MEDICATION NAME] 2 ml inhale orally every 12 hours related to SHORTNESS OF BREATH and [MEDICATION NAME] 1 mg by mouth as needed for Anxiety related to GENERALIZED ANXIETY DISORDER .must be space dosed out at least 6 hours. There were only 2 notes in the EMAR revealing [MEDICATION NAME] was not administered because it was unavailable (8/07/17 and 8/13/17) and further investigation by the facility revealed [MEDICATION NAME] was not delivered from the Pharmacy until 8/09/17/time unknown. There was no documentation Resident #5's Physician FF or Medical Director Y had been notified about [MEDICATION NAME] had not been available and administered as ordered.

Based on observation, interview and record review the facility failed to accurately assess and prevent the development of a pressure ulcer in 1 of 3 residents (Resident #1) reviewed for pressure ulcers, from a total sample of 15 residents, resulting in Resident #1 developing an un-stageable pressure ulcer on the right heel. Finding include: According to the Pressure Ulcer Treatment, Quick Reference Guide, 2009, under Common Definition of Pressure Ulcers, defined a pressure ulcer as a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure with combination of shear. According to the National Pressure Ulcer Advisory Panel (NPUAP) defines a Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) in the wound bed. According to the American Heritage Medical Dictionary, 2007, Houghton Mifflin Company, Slough is defined as: noun- a layer or mass of dead tissue separated from living tissue, as in a wound, a sore, or inflammation. Verb- to separate from surrounding living tissue. Used of dead tissue. According to the facility, Wound Classification Guide, provided by the Director of Nursing (DON) B on 8/16/17, dated 2014, reflected, Suspected Deep Tissue Injury-Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue .Evaluation may include a thin blister over dark wound bed .Evolution may be rapid exposing of additional layer of tissue even with optimal treatment . According to the facility, Skin Management Facility Guidelines policy and procedure, undated, reflected, The facility is committed to providing care and services to residents to prevent the development of skin breakdown. The following guidelines are in place to reach this goal .2. The Braden Scale will be completed upon admission, quarterly and with a significant change .LN's complete appropriate skin form, which includes a description of the ulcer as follows; Use the Wound/Skin Healing Record for all identified pressure ulcer areas .5. A Care Plan is developed upon admission and may address: *Identifying the contributing Risks for breakdown *Hydration *Nutrition *Preventative devices *Physical activity *Positioning requirements *Proper body alignment *Education - when appropriate .7. Place each resident on a weekly head-to-toe skin assessment .8. Establish a day of the week to measure all pressure ulcers and complete the log going forward .9. Complete the Weekly Pressure and or the Non-Pressure Ulcer QI Log. Use the current pressure ulcer measurement and wound characteristics. 10. A Quality of Life or during Daily clinical meeting the Interdisciplinary Team will review and update plan of care for residents with: *Newly developed vascular/pressure ulcers .Management Tools .Stop and Watch/Interact . Resident #1 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #1 was a [AGE] year of female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #1 had a BIM (assessment tool) score of 3 which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, transfers, locomotion on unit, dressing, eating, toileting, hygiene, and bathing. Review of the facility acquired pressure ulcer list, provided by the facility on survey entrance on 8/14/17, reflected Resident #1 had a facility acquired pressure ulcer. In an observation on 8/14/17 at 3:06 p.m. Resident #1 was sitting in a wheelchair, close to the doorway of her room self propelling self with dark blue gripper socks on feet. Resident #1 appeared pleasantly confused and unable to answer questions appropriately. Resident #1's feet were dependent and appeared to have increased swelling between two to three plus [MEDICAL CONDITION] noted. Review of the facility, Nursing Progress Note for Resident #1, dated 8/11/17 at 5:04 p.m., reflected, this nurse observed an 4 cm x 2.5 cm abnormality on the right heel and it also is filled with clear fluid this nurse put a allevyn heel and wrapped with kerlix until (named Medical Director Y) can evaluate and to cont to float heels as well. Review of the facility, Nursing Progress Note, dated 8/14/17 at 11:50 a.m., for Resident #1 reflected, Per (named Medical Director Y) ok to apply skin prep to the right heel and place a optiform heel and wrap with kerlix until resolved. The note was written by Licensed Practical Nurse (LPN) Unit Manager M. An additional Nursing Progress Note, dated 8/14/17 at 12:00 p.m., reflected This nurse made son (named) aware of fluid filled blister on the right heel and also made him aware of the treatment that is applied . electronically signed by LPN M. Review of the facility electronic document labeled, Braden Two - V1, dated 8/6/17, reflected Resident #1 was at risk for developing a pressure ulcer. Review of the facility, Skin Observation task, dated 7/17/17 through 8/14/17, reflected Resident #1 had red area noted on 7/28/17 and 8/8/17 and discoloration noted on 8/4/17. The record reflected Resident #1 had no abnormal skin areas from 8/8/17 afternoon shift through 8/14/17 at 9:09 p.m. Review of the facility, Weekly Head-To-Toe Assessment, dated 8/14/17 at 11:44 a.m., reflected Resident #1 had a blister on the right heel that measured 0.5 cm x 0.7 cm x 0 cm. Review of the, Weekly Head-To-Toe Assessment, provided by the facility on 8/15/17, reflected no weekly skin assessments for Resident #1 between 7/21/17 and 8/14/17. Review of all of the facility active, completed and discontinued, Order Listing Report, dated 8/3/16 through 8/31/17, reflected Resident #1 had an discontinued right heel treatment order, dated 8/14/17, that included, apply skin prep Bid and cover with a optimaform heel and wrap wit [MEDICATION NAME], until resolved. The Physician orders reflected an active order right heel treatment order, dated 8/14/17, that included, Treatment to the right heel: apply skin prep daily and cover with a optimaform heel and wrap wit [MEDICATION NAME], until resolved. No physician orders noted prior to 8/14/17 for right heel treatments noted. Review of the Treatment Administration Record, dated 8/1/17 through 8/31/17, reflected Resident #1 received right heel treatment starting on 8/14/17. Review of the Skin Care Plans, dated 1/28/17 and revised on 2/7/17, reflected, (Resident #1) had potential for impairment of the skin integrity related to fragile skin, needing assist with bed mobility and [DIAGNOSES REDACTED]. The Care Plan goal was to maintain or develop clean and intact skin by the review date and interventions that included; Encourage good nutrition and hydration in order to promote healthier skin. ~Follow your Skin Management Program. ~If my skin is impaired - observe and document the location - report it to my nurse as soon as possible . The Care Plan did not include interventions to assist resident with positions changes or to elevate heels prior to 8/14/17. Review of the Impaired Skin Integrity Care Plan, dated 8/14/17, reflected, (Resident #1) have impaired skin integrity on my right heel related to I am frail and have bony prominence's., I decline care at times, I have a history of impaired skin, I have a Pressure Ulcer to right heel. The Care Plan reflected interventions that included; Assist in repositioning me frequently in my bed or chair . In an interview on 8/14/17 at 3:40 p.m., Licensed Practical Nurse (LPN) II reported Resident #1 currently had a skin treatment in place for a right heel wound that had been completed prior to breakfast that same day by the unit manager. In an observation on 8/15/17 at 9:30 a.m., Resident #1 was noted to be sitting in a wheelchair in the Dining Room finishing up 100% of breakfast independently. Several observation through out the day revealed Resident #1 remained in the wheelchair from 9:30 a.m. until after the evening meal after 5:15 p.m. with no noted positron changes noted. In an interview on 8/15/17 at 9:45 a.m., LPN J reported Resident #1 was part of her assignment that day and routinely worked on that unit in the past. LPN J reported the wound on Resident #1's right heel was the only skin issue being treated. In an interview on 8/15/17 at 10:13 a.m. Certified Nurse Aide (CNA) G reported she routinely works with Resident #1. CNA G reported a recent change in morning routines on the memory unit and if residents want to sleep in the staff allow them to do so. Usually Resident #1 does better with less behaviors if she is allowed to sleep in and will yell out when she is ready to get up. CNA G reported when she works she leaves her alone until Resident #1 wants to get up. CNA G reported Resident #1's right heel wound could possible be from, laying in bed. In an observation and interview on 8/15/17 at 4:45 p.m., Registered Nurse (RN) HH entered Resident #1's room. Resident #1 was sitting in a wheelchair with bilateral foot pedals. RN HH removed a foam dressing from Resident #1's right heel. Resident #1 had a large raised fluid filled blister on the right posterior heel that appeared about 2.5 inches by 2.5 inches. The skin appeared intact with 2-3 plus [MEDICAL CONDITION] noted. Resident #1 had a wandergaurd around her right ankle with positive indentations around the entire ankle area. RN HH reported the wanderguard was too tight and cut it off. RN HH performed the dressing and Resident #1 complained of pain one time and tolerated dressing change well. RN HH reported that was the first time she had seen Resident #1's right heel wound. In an interview on 8/16/17 at 3:27 p.m. Director of Nursing (DON) B reported Resident #1 developed a facility acquired pressure ulcer to the right heel that appeared to now be a deep tissue injury. DON B reviewed the CNA skin sheets and the Weekly Skin Assessments and the Nurse Progress Notes and reported the wound was identified on 8/11/17 in a Nurse Progress Note. DON B reported Resident #1 had a risk for developing pressure ulcers and reported Resident #1's Skin Care Plans did not include interventions to reposition resident or elevate heels in bed prior to 8/14/17. DON B reported there had been some recent changes on the memory unit related to meal times that allowed residents to sleep in over the past two months. DON B reported 1 to 2 weeks prior heels up pillows were ordered for the memory unit. DON B reported it was her expectation that when a new wound is identified the nurse is informed and the nurse is expected to assess the wound, document in the Progress notes, notify the responsible party, notify Physician obtain treatment orders, enter and perform orders. DON B reported the unit managers perform the weekly head to toe skin assessments that include weekly measurements and add wounds to the weekly wound logs and report new skin issues at the Quality of Life or daily clinical meetings. DON B reported it appeared the physician or family was not contacted until 8/14/17 related to Resident #1's right heel pressure ulcer and orders were not obtained until 8/14/17. DON B reported there were no orders for Resident #1 wound treatment on 8/11/17 when the nurse provided right heel wound care treatment. DON B reported the nurse should have contacted the Physician and family and entered the orders. DON B was unable to explain the differences in wound measurements from the 8/11/17 Progress Note and the 8/14/17 Weekly Head to Toe Assessment documented by LPN Unit Manager M. DON B reported they have not reviewed or investigated the wound yet to determine cause. In an interview on 8/16/17 at 4:45 p.m. LPN Unit Manager M reported she measured Resident #1's right heel wound on 8/14/17 and documented the measurements on the Weekly Head to Toe Assessment. LPN Unit Manager M reported the wound measured 5 centimeters(cm) by 7 cm. After reviewing Resident #1's Weekly Head to Toes Assessment LPN Unit Manager M reported she had accidentally documented 0.5 cm by 0.7 cm. LPN Unit Manager M reported she did not record Resident #1 right heel wound on the Weekly Wound Log.

Based on observation, interview and record review the facility failed to A)maintain a low temperature chemical sanitizing dish washer and 3 compartment sink for 67 out of 70 residents who received meals from the facility kitchen, B) maintain a refrigerator and food products at 41 degrees or lower, C) failed to label/date mark food products, D) failed to cool down food products properly, E) failed to use hair coverings properly, and F) failed to clean the North/South hall nourishment refrigerators stored with residents and non-resident food products, and resulting in the potential for food borne illnesses, and the spread other infections. Findings include: Immediate Jeopardy was identified on 6/28/16 at 9:10 am when it was discovered that the facility was unaware how long the kitchen sanitizing solution had been disconnected/non-functioning. The facility failed to use accurate test strips to check both the 3 compartment sink and the dish machine used to sanitize dish and cookware. On 6/28/16 at 9:08 AM the 3 compartment sink sanitization level was requested to be tested by Dietary Worker (DW F). DW F retrieved a container with white colored paper-like strips and dipped it into the water for approximately 1 second. The paper remained the same color (no change) after being submerged in the solution. When asked what parts per million (ppm) number should the paper result in DW F stated, I don't know, I'll have to ask. DW F then summoned the Dietary Manager (DM C) for assistance. At 9:10 AM Dietary Manager (DM C), took a strip of the same white colored paper and submerged it into the solution for approximately 1 second. Again, no change in color occurred. When the strip was checked against the color coding on the back of the strip vial, the color reflected less than 10 (the lowest number indicated on the container). When asked what ppm should the strip reflect, DM C stated, 450. DM C was informed that the number reflected the water was not prepared at a sanitizable level. Clean cookware was noted in the sink that had been previously submerged in the solution. There was no log available/completed reflecting daily checks for the 3 compartment sink ppm data. At 9:15 AM the facility's low temperature chemical dish washer was checked for its chemical sanitizing level with a test strip (plastic strip with a raised paper strip) by Dietary Manager (DM C), for a total of (3) times. Each time the tip of the strip turned an off-white color equaling the number 0. DM C was informed that the color and number of the strip reflected the dish washer was not sanitizing the dish-ware. DM C stated he would call someone to check the dishwasher, and would use paper ware/plastic ware to serve meals. At approximately 1:01 PM the contracted company representative sent to check the dishwasher arrived. Contractor (G) revealed that with a low temperature dish machine the sanitization reading should reflect around 50 ppm. Contractor G stated he activated the detergent pump, rinse, sanitizer bleach solution supply to the dishwasher. Contractor G stated the sanitizing solution pump had been turned off and was not functioning, prior to him re-setting it. Contractor G had a completely different set of test strips for the dishwasher, and stated they were the accurate strips to use for checking the sanitizing level. A set of dishes were sent through the dish washer. Once the cycle was completed, the dishes were checked with the strip for approximately 2-3 seconds which turned a purple color. The purple color matched the 75-100 ppm (according to product label not less than 50, normal 100-200 ppm) indicator reflected on the back of the strip container. In addition, the 3 compartment sink solution was checked for approximately 8-10 seconds with a test strip for quaternary solution, and reflected a value of 300 ppm (according to the product label normal 200-400 ppm). It was revealed DM C used the dish machine test strip to test the quaternary solution in the 3 compartment sink, and used the wrong testing strips to check the dish washer. Neither DM C, nor Dietary worker F knew the accurate strips to use to check the sanitizing solutions. The dietary staff had been using the wrong strips for the current month and/or longer, and were unaware of it until the contracted representative informed them of such. A clipboard reflecting Low Temperature Dish Machine Audit , was noted taken June 1-28, 2016. The temperatures recorded were of no use, as the dish machine was a chemical sanitizer not a heat sanitizer. At approximately 4:00 PM DM C was provided the correct strips used to check the dishwasher and 3 compartment sink by Contractor G. DM C revealed a log for the 3 compartment sink had not been done, and that they started one today. Also, DM C revealed that the wrong testing strips had been used to check the dish machine for an undetermined amount of time. ( ) Kitchen On 6/27/16 at 6:40 PM the facility's kitchen was observed and the following concerns were noted: The freezer #1 had a ziplock bag of fries with a use by date of 6/26/16 listed on them, and unsealed bag of onion rings with a use by date of 7/20/16, was noted on the lower shelf with frozen meat. The main reach in reach in refrigerator (located to the right of the food prep area) had a temperature of 54 degrees, and contained: -(1) bag of what appeared to be yellow colored cheese that was not labeled or dated. -(1) bag of what appeared to be while colored cheese that was not labeled with a date of 6/21/16 written on it. -A metal container full of beef stew that had Alt for Tuesday 6/27/16 6/28/16 written on top of it. The beef stew had a temperature of 80 degrees. -A container labeled green beans had a temperature of 58 degrees. -All the grated white coated metal shelves/racks were missing large amounts of the white coating with exposed rusted metal. -(1) metal container labeled sauerkraut with pork (sausage) had a temperature of 60 degrees. A pool of water had settled atop of the container. Water was noted dripping from the cooler unit. Dietary worker (D) who was present upon entering the kitchen stated, We have had trouble with defrosting for months and water comes down on it. The product was covered with aluminum foil. -(1) metal container labeled ham salad. The contained was covered with aluminum foil, that had a tear diagonally from corner to corner. A pool of water was noted atop of the aluminum foil portion without a tear, that was leaking into the food product. -A metal container of fruit cocktail covered with aluminum foil, had a temperature of 60 degrees. -4 large brown colored circular stained spots were noted in the ceiling tile. The following was observed in the walk in refrigerator: -(1) 2-layered cake with white confetti frosting was noted uncovered. -A container labeled cream of wheat had a temperature of 50 degrees. -A container labeled chopped ham had a temperature of 60 degrees. -(1) unlabeled unknown food product had a temperature of 58 degrees. -A large metal pan covered with aluminum foil labeled pork. The pan contained two long and thick rolls of pork. The pork product reached a temperature of 100 degrees in 5 seconds. Dietary worker D was asked when the food product had been put in the refrigerator. Dietary worker D stated, About 2-3 hours ago. -A container labeled cottage cheese had a temperature of 58 degrees. -A container of what appeared to be cucumbers (not labeled and not dated), had a temperature of 54 degrees. Dietary worker D was observed to remove all foods listed above that were above 41 degrees to dispose, from the refrigerator located near the food prep area. Dietary worker D was asked to provide the facility's cool down instructions, and replied I don't have any instructions. Yet, cool down instructions were noted on the back wall of the refrigerator. When asked how do you cool down food Dietary worker D stated, I usually let it cool down a couple hours before I put it in there. When asked if she checked the temperature of the food prior to putting in the refrigerator, Dietary worker D replied: Not usually. A metal container that was approximately 10 inches deep with a metal lid partially covering it, was noted to have a creamy like soup inside. The container was hot to touch and was located in the food prep area on the counter. Later on 6/27/16 at 9:16 PM the kitchen was entered with the Dietary Supervisor (DS C), who had just arrived to the facility. DS C was the only facility staff person with a key to the locked kitchen. The kitchen lights were off and no staff were noted in the area. DS C was informed of the warm refrigerator whereby he replied, he informed the dietary worker to unplug and not use the unit. In addition, he was informed of the warm foods. DS C was informed that the writer had observed a creamy colored soup on the counter earlier at 6:40 PM on the counter cooling. The walk in refrigerator was entered with DS C, and (2) metal containers of soup products were noted. The first container (approximately 5 inches deep) labeled cream of mushroom and had a temperature of 60 degrees, and the second container (approximately 10 inches deep) labeled cream of potato had a temperature of 110 degrees. Also, the pork noted earlier at 6:40 PM was still in the refrigerator had a temperature still of 100 degrees. DS C immediately removed all the food products from the refrigerator. The facility's Food Safety policy with a release date of April 2016 reflected the following: Policy: It is the policy of this facility that to follow the food protection guidelines as defined in the Hazard Analysis Critical Control Point system to reduce the risk of food contamination and food born illness . Procedure: .Refrigerated foods will be cold to the touch and at or below 41 degrees .(b) Food Storage: .Food items will be dated to ensure the product is fresh and to facilitate food usage with the he First In, First Out method.**Addendum: any open foods or items to be used in food production that ae stored under refrigeration or dry storage will be in a closed container, labeled with the name of the item, dated with an open by and a used by date . e. Serving: .Potentially hazardous foods will be held outside of the temperature danger zone of 41 to 135 degrees, and will be returned to refrigerator of freezer storage units within 2 hours. f. Cooling: .2. Larger food quantities such as soups will need to be placed in smaller pans. a. 2 inches of food will cool more quickly. 3. Bulk items such as roast will be cut in half or quarters to allow heat to escape . 6. Once hot food reaches 135 degrees, the temperature will be documented in one-hour increments on the food usage/temperature monitoring sheet. 7. Foods will be rapidly cooled from: a. 135 degrees to 70 degrees in 2 hours. b. 70 degrees to 41 degrees in 4 hours . 10. Dietary staff will be in-serviced on rapid cooling methods . There were no food usage/temperature monitoring sheets completed or available with cool down temperatures for the soups or pork. North/South Hall Units On 6/27/16 at approximately 9:30 PM the South Hall resident pantry refrigerator was observed. The refrigerator was noted to have a thick ice damn about the cooling unit. The refrigerator was soiled full of food and liquid products. Some products were labeled and dated with resident's names, while other products were not. Attached to the refrigerator was a sheet that reflected, Vaccine storage temperature log. No other temperature log sheet was noted on or near the refrigerator. The log obtained for the month of June 2016, reflected temperature were to be taken daily on the the am and pm shifts. The log reflected temperatures were not documented for an am/pm shift for June 2, 4, 7, 13, 16, 23, 25 and 26. Temperatures were not taken at all on June 3, 6, 9, 21, and 24. At approximately 9:40 PM the North Hall resident pantry refrigerator was observed. The refrigerator was noted to have a thick ice damn about the cooling unit. The refrigerator was soiled and full of food and liquid products. Upon opening food products spilled out onto the floor. Some products were labeled and dated with resident's names, while other products were not. Attached to the refrigerator was a sheet that reflected, Refrigerator Log Month June 2016. The sheet reflected temperatures were to be taken daily. From June 1-26 only 6 entries (20 not completed) had been made, and the unit had not been marked clean on any date. Kitchen On 6/28/16 at 8:30 AM the kitchen observation reflected: At 8:51 AM two dietary workers (who were in the food preparatory area) were noted to have their hair net on incorrectly. The first dietary worker's hair net covered approximately half of her head, exposing full hair bangs with flipped styled curls. The second dietary worker had approximately 1/3 of her hair exposed with bangs in a curly style. It wasn't until this writer informed DS C of the exposed hair, that he had the staff apply the hair nets properly. DS C was present in the kitchen upon entrance. The walk in refrigerator was viewed and noted to have the long metal pan with the 2 rolls of pork in it. The fluid, had been drained from the pan. DS C was asked why the pork was still in the refrigerator. DS C stated, It was in the danger zone we could not us it. I saved it for you, so you could see it and dispose it. ( ) On 6/30/16 at 8:15 a.m., a common area environmental tour was conducted with Director of Maintenance M and Director of Housekeeping/Laundry Services N. The following item was noted: On 6/30/16 at 9:05 a.m., one green insulated bowl with plastic lid containing chocolate pudding was observed stored on the top of the South Hall Nursing Station refrigerator at room temperature. The initial food product date observed on the top of the green insulated bowl plastic lid read 6-28-16. The expiration food product date observed on the top of the green insulated bowl plastic lid read 7-1-16. Director of Maintenance M stated: That should be in the refrigerator. and We will take care of the pudding. The 2009 FDA Model Food Code section 3-501.16 states: Potentially Hazardous Food shall be maintained: (1) At 135 degrees Fahrenheit or above, or (2) At 41 degrees Fahrenheit or less. ( ) On June 29th, 2016 the following corrective action plan to remove the immediate jeopardy was received and accepted for the facilities failure to maintain a low temperature chemical sanitizing dish washer and 3 compartment sink for 67 out of 70 residents who received meals resulting in potential for food borne illnesses and the spread of other infections. Element # 1- At 9:15 am the dish machine was removed from service and the Janitorial Equipment Supplier was called immediately for evaluation of the low temperature dishwasher's functionality. Meal service was immediately switched to paper ware and plastic products. Element #2-At approximately 1:00 pm contractor G arrived at facility and re-set the sanitizing solution and activated the detergent, pump, rinse, and sanitizer bleach solution supply to the dishwasher. Contractor G confirmed with dietary manager the correct set of test strips. A set of dishes were sent through the dish washer. The dishes were checked with the strip for approximately 2-3 seconds which turned a purple color. This color matched the 75-lOOppm indicator reflected on the strip container. (Normal range 100-200ppm). The 3 compartment sink solution was checked for approximately 8-10 seconds with a test strip for quaternary solution and reflected a value of 300ppm, (Normal range 200-400ppm). The low temperature dishwashing machine has been evaluated and is functioning properly. Appropriate test strips for 3 compartment sink and dishwashing machine have been obtained and the dish machine is registering between 50-200 ppm. The 3 compartment sink is registering between 200-400 ppm. Log for recording daily checks for the 3 compartment sink ppm data was initiated. The ppm data will be tested prior to each meal at 7am,12pm and 6pm 7 days a week. The dishwasher machine will not be used unless normal range data is obtained. The dietary manager/designee will be notified immediately with any variances. Element 3-The dietary staff have been educated on proper use of test strips, appropriate levels of sanitizers, acceptable ppm data for both sink and dish machine. In addition they have been instructed to check levels prior to meal service at 7am-12pm and 6 pm and proper documentation on log. Failure to do so will result in disciplinary action. Return demonstration of the test strip competency has been validated Element 4-The dietary manager/designee will audit the logs daily to ensure that accurate test strips were used to check the 3 compartment sink and dish machine and acceptable ppm levels were determined and documented. Findings will be reported to the QAPI committee monthly x 3 or until further directed. Element 5 The Administrator is responsible to assure the plan of correction is implemented and compliance maintained. Although the Immediate Jeopardy was removed on June 29, 2016, the facility remained out of compliance with a scope and severity of widespread and no actual harm with potential for more than minimal harm that is not immediate jeopardy as sustained compliance could not be verified by the state agency. ( )

Based on observation, interview, and record review, the facility failed to 1) implement interventions to prevent the development and worsening of pressure ulcers for 3 (Resident #2, #5, #12) and 2) perform hand hygiene with wound care according to policy for 1 (Resident #2) of 7 reviewed for pressure ulcers from a total sample of 15, resulting in the development of an unstageable hip ulcer, a worsening coccyx ulcer, and the potential for infection for Resident #2, worsening of heel ulcers and the development of excoriation for Resident #5, and the development of a recurrent stage 2 pressure ulcer for Resident #12. Findings include: Review of the facility's Pressure Ulcer & Skin Care Management policy and procedure, dated 7/2011, revealed "A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing...Procedure 1. A licensed nurse checks the resident's body for the presence of pressure ulcers, wounds and other skin conditions:...weekly on residents...2. The licensed nurse documents that the body check was completed on the resident's weekly head to toe skin record...8...The licensed nurse implements the wound care treatment procedures in accordance with current standards of practice." Review of the facility's Pressure Ulcer Preventative Measures policy and procedure dated 10/3/11, revealed "Residents at risk for the development of pressure ulcers receive interventions to reduce the risk of pressure ulcers. Procedure...2. Residents identified at risk for pressure sore development will be inspected weekly for skin integrity. 3. The nurse aide inspects the resident's skin during bathing, dressing and undressing, assisting with toileting or incontinent care. 4. The nurse aide reports to the nurse any reddened areas and/or breaks in the resident's skin. 5. The nurse inspects any reddened areas and/or breaks in the resident's skin and documents the inspection." Resident #2 Review of Resident #2's Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #2 was a [AGE] year old male, admitted to the facility on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #2 scored 6/15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), required extensive assistance of 2 staff members for bed mobility, and was always incontinent of bladder and bowel. The MDS revealed Resident #2 had two stage 1 pressure ulcers and two unstageable ulcers. The MDS revealed one of the unstageable pressure ulcers was present upon admission/entry or reentry to the facility. According to the National Pressure Ulcer Advisory Panel (www.npuap.org), unstageable pressure ulcers are "full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV." Review of Resident #2's Braden Scale (for predicting pressure sore risk), revealed a score of 13 on 3/17/14 and a score of 12 on 4/16/14 (12 or less represents high risk). Review of Resident #2's Weekly Head to Toe Skin Checks, revealed missing assessments for 2/5/14, 3/26/14, 4/23/14, 4/30/14, and 5/7/14. Review of Resident #2's Pressure Ulcer care plan dated 3/19/14, revealed a goal of "my ulcers will not increase in size..." Interventions dated 2/27/14 included: guide extremities during transfers, pressure reducing mattress on bed, pressure reduction cushion in wheelchair, monitor and medicate for pain, observe skin daily during care and report changes, preventive skin care after each incontinent episode, report changes in dietary intake, staff monitor my labs, staff turn and reposition every hour in bed and wheelchair, supplements as ordered, treatment as ordered, weights per policy, and wound consult as needed. On 3/20/14, an intervention of prevalon pressure relieving heel protectors was added. On 4/22/14, an intervention of derma brief (padded to protect hips, buttocks, and coccyx) on at all times was added. Review of Resident #2's At Risk for Impaired Skin Integrity care plan dated 5/21/14, revealed interventions dated 11/8/06, 9/10/08, 10/28/09, 1/7/11, 4/11/11, 7/29/13, 2/23/14, 3/20/14 (prevalon heel protectors), and 4/22/14 (dermabriefs). Left Hip Review of the Wound/Skin Healing Record for Resident #2's left hip pressure ulcer with an onset date of 2/23/14, revealed the following information: 2/26/14: no stage noted, measuring (length x width x depth) 7 cm (centimeters) x 4 cm x 0.1 cm, with a pain level of 4/10 3/5/14: stage 2, measuring 0.1 cm x 1.6 cm x 0.1 cm, without pain 3/12/14: resident was in the hospital 3/19/14: area resolved 4/2/14: unstageable left hip pressure ulcer with an onset date of 4/1/14, measuring 2 cm x 3.5 cm, with a pain level of 4/10, response to treatment "deteriorated", plan of care updated 4/10/14: unstageable, measuring 4 cm x 2.5 cm, with a pain level of 4/10, response to treatment: no change, plan of care not updated 4/16/14: unstageable, measuring 2.5 cm x 2.2 cm, pain level of 6/10, response to treatment: no change, plan of care not updated 4/23/14: unstageable, measuring 2 cm x 1.5 cm, pain level of 4/10, response to treatment: improved, plan of care not updated 4/30/14: unstageable, measuring 2 cm x 1.5 cm, pain level of 4/10, response to treatment: no change, plan of care not updated 5/7/14: unstageable, measuring 1.9 x 1.5, pain level of 6/10, response to treatment: no change, plan of care not updated Coccyx Review of the Wound/Skin Healing Record for Resident #2's coccyx pressure ulcer with an onset dated of 3/17/14 (identified upon readmission from the hospital), revealed the following information: 3/19/14: unstageable, measuring 3 cm x 3.3 cm, pain level of 4/10, response to treatment: no change, plan of care updated 3/26/14: unstageable, measuring 4.5 cm x 2.4 cm, pain level of 4/10, response to treatment: no change, plan of care not updated 4/2/14: unstageable, measuring 5 cm x 3.5 cm, pain level of 4/10, response to treatment: no change, plan of care not updated 4/10/14: unstageable, measuring 4.3 cm x 3.7 cm, pain level of 4/10, response to treatment: no change, plan of care not updated 4/16/14: stage 3 (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle not exposed), measuring 4.2 cm x 2.5 cm x 1.1 cm, pain level of 6/10, response to treatment: no change, plan of care not updated 4/23/14: stage 3, measuring 4.2 cm x 2.5 cm x 1.1 cm, pain level of 4/10, response to treatment: no change, plan of care not updated 5/1/14: stage 3, measuring 4.8 cm x 3.5 cm x 2.5 cm, pain level of 4/10, response to treatment: deteriorated, plan of care not updated 5/7/14: stage 3, measuring 4.8 cm x 3.5 cm x 2.5 cm, pain level 6/10, response to treatment: no change, plan of care not updated Review of the Pressure Ulcer Assessment Chart completed by Physician "D" and dated 5/14/14, revealed Resident #2's coccyx wound measured 6 cm x 4.5 cm x 1.8 cm. Review of the physician's orders [REDACTED].#2's coccyx treatment order was to cleanse open area on coccyx with wound cleanser, apply Santyl ([MEDICATION NAME] ointment to aide in removal of necrotic tissue), pack with Algisite (helps maintain moist wound environment), cover with Allevyn adhesive dressing, change daily, utilize skin prep. The physician's orders [REDACTED]. An observation on 5/13/14 at 2:35 pm, revealed Resident #2 was lying on his back, in bed. A wound care observation on 5/13/14 at 3:10 pm with Licensed Practical Nurse (LPN) "H" and Certified Nursing Assistant (CNA) "I", revealed Resident #2 had dressings intact to both hips and his coccyx. LPN "H" washed her hands and donned gloves. LPN "H" then removed Resident #2's right hip Allevyn adhesive dressing, removed her gloves, and donned new gloves. Hand hygiene was not performed. Resident #2's right hip was pink. There was no open area to the skin and LPN "H" cleansed the area, patted it dry, and then applied a new Allevyn adhesive dressing. LPN "H" then removed her gloves, washed her hands, and donned a new pair of gloves. LPN "H" then removed Resident #2's coccyx wound dressing. When LPN "H" removed the dressing from Resident #2's coccyx, there was no wound packing material removed and none visible in the wound or on the soiled dressing. LPN "H" then removed her gloves and donned new gloves without performing hand hygiene. LPN "H" then cleansed the coccyx wound with wound cleanser, placed Santyl onto a cotton tipped applicator and then applied to the healthy tissue around the wound edges, and then LPN "H" applied an Allevyn adhesive dressing. LPN "H" did not apply Santyl to the wound bed and did not pack the wound with Algisite. LPN "H" then removed her gloves, washed her hands, and donned new gloves. LPN "H" removed Resident #2's left hip dressing which was observed to be approximately 2 cm in diameter, with 90% yellow slough. LPN "H" then removed her gloves and donned new gloves without performing hand hygiene. LPN "H" cleansed the left hip wound with wound cleanser, patted dry, applied Santyl to a cotton tipped applicator, then applied the Santyl to the healthy tissue surrounding the wound, and covered the wound with an Allevyn adhesive dressing. LPN "H" did not apply the Santyl to the wound bed LPN "H" removed her gloves and washed her hands. During wound care, an open area on Resident #2's right buttock was discovered by this surveyor. CNA "I" reported that she noticed the area that morning during Resident #2's shower, marked the area on the shower sheet, and notified the nurse. There was no treatment in place to the right buttock wound. The open area was approximately 3 cm x 1 cm with a yellow wound bed. LPN "H" did not assess or treat the area during this observation. In an interview on 5/15/14 at 3:15 pm, Assistant Director of Nursing (ADON) "C" reported she was the infection control coordinator. ADON "C"was queried if staff was expected to perform hand hygiene in between glove changes. ADON "C" stated "every time they take their gloves off, they should wash their hands". ADON "C" reported that all staff was audited for handwashing with their skills check off after orientation and annually. Review of the facility's Hand Hygiene policy dated 6/13, revealed "Procedure...4. Appropriate hand hygiene must be performed under the following conditions: j. before and after changing a dressing...q. after handling soiled or used linens, dressings...t. after removing gloves or aprons..." Review of Resident #2's CNA Shower Audit dated 5/13/14, revealed "record any new skin issues noted above and inform nurse". The coccyx area was circled and "open?" was written on the sheet. Toward the top section of the sheet, "tx (treatment) in place" was written. The audit sheet was signed by CNA "I" and LPN "F". In an interview on 5/14/14 at approximately 9:00 am, LPN "F" reported that CNAs filled out shower audit sheets twice a week and that the weekly skin assessments were performed by the nurses. LPN "F" reported that no new areas were identified on Resident #2's shower audit sheet on 5/13/14. On 5/14/14 at 9:25 am, LPN "F" reported to this surveyor that the new and old areas should be marked on the shower audit sheets. LPN "F" reported that CNA "I" marked the coccyx area and did not inform LPN "F" of the new open area on Resident #2's right buttock and therefore she was unaware. LPN "F" stated "apparently there is a new area". Review of the Pressure Ulcer Assessment Chart completed by Physician "D" and dated 5/14/14, revealed Resident #2's right buttock pressure ulcer was a stage 2 and measured 3 cm x 1 cm x 0.1 cm. A wound care observation on 5/14/14 at 9:25 am with LPN "F" and CNA "G" revealed Resident #2 did not have a treatment in place to the new open area on his right buttock. LPN "F" assessed, measured the wound as 2.1 cm x 1 cm, applied a treatment and reported that the wound physician would be in that day to assess Resident #2. LPN "F" removed a saturated dressing from Resident #2's coccyx wound. There was no algisite packing removed from the wound or noted on the soiled dressing. Resident #2 then expressed pain. LPN "F" and CNA "G" then placed a brief and dermabriefs on Resident #2, and positioned him on his left side. LPN "F" administered pain medication to Resident #2. On 5/14/14 at 10:30 am, Resident #2 was observed lying on his left side in bed with a brief and dermabriefs on. LPN "F" and CNA "G" then removed the dermabriefs and the brief. LPN "F" cleansed the wound with wound cleanser, applied skin prep around Resident #2's wound, applied Santyl to a cotton tipped applicator and then applied the Santyl onto the Algisite packing material. LPN "F" then packed the Algisite into Resident #2's wound and covered the wound with an Allevyn adhesive dressing. In an interview on 5/14/14 at 2:00 pm, Unit Manager (UM) "E" was shown the weekly head to toe skin checks for Resident #2. UM "E" agreed that those forms were the weekly skin checks for Resident #2. When queried if there were any audits done to assure that the weekly skin checks were performed, UM "E" stated "the unit managers have been trying to make sure they are done weekly". UM "E" reported that Physician "D" staged and measured wounds and that she rounded with him on Wednesdays. UM "E" reported that she filled out the Wound/Skin Healing record after wound rounds, usually on Thursday or Friday. When queried why there was not a change in the plan of care when Resident #2's wounds showed no change or deterioration, UM "E" stated "I just go by what the doctor orders". When queried how Santyl was to be applied, UM "E" reported that Santyl was to be applied to the wound bed. When queried what interventions were in place to prevent Resident #2's left hip pressure ulcer from redeveloping, UM "E" stated "we put Allevyn adhesive on both hips". When asked if there were any other interventions, UM "E" stated "I mean basically we didn't change (interventions)". When queried if Resident #2's interventions were effective, UM "E" stated "I mean, would I say they were effective to prevent a sore? I mean, that's a hard question because he developed a sore despite our preventative measures". When asked what new interventions were put in place after the redevelopment of Resident #2's left hip pressure ulcer on 4/1/14, UM "E" reported the dermabriefs were implemented on 4/22/14 and Occupational Therapy started diathermy (deep heating of tissue) on 4/8/14. UM "E" did not identify any other new interventions. In an interview on 5/15/14 at 9:35 am, Physician "D" reported that he performed wound rounds with UM "E". Physician "D" reported that Santyl was being used as enzymatic debridement to Resident #2's wounds. When queried about the use of Santyl on the healthy tissue surrounding the wounds and placing the Santyl onto the Algisite and then packing the wound, Physician "D" reported that it was not the correct use of Santyl and that Santyl should be applied to the areas with necrotic and slough tissue. ( ) According to the admit Minimum Data Set (MDS) assessment dated [DATE] Resident #5 was an [AGE] year old male with [DIAGNOSES REDACTED]., and depression. Resident #5 was assessed with [REDACTED]. The MDS also indicated Resident #5 had a Foley catheter. According to Resident #5's Weekly head to toe skin checks dated 5/13/14 "Skin intact: Yes. Previous area identified: Yes, Bruises: Yes 1) has bruises on left eye and sutures & tx in place." (There was no mention of right heel or buttock area.) According to Resident #5's transfer form dated 5/13/14, " Reason for transfer (Hospital) observed on floor cut above l (left) eye. Right Heel According to Resident's #5's "Admission Nursing Assessment," dated 2/10/14, both heels were documented as "pink and mushy." According to Resident #5's "Wound / Skin Healing Record Resident #5's left heal was "resolved" on 2/19/14. Resident #5 has a treatment for [REDACTED]. According to the wound records the first date of measurements was 9 days later on 2/19/14. 2/19/14 3.7 x 5.0 x 0 blister 2/26/14 3.7 x 5.0 x 0 blister 3/19/14 3.4 x 5.2 x 0 black / brown eschar 4/16/14 3.4 x 5.2 x 0 scant serosanguineous, 4/30/14 4.0 x 6.0 x 0 black / brown eschar 5/7/14 4.0 x 6.0 x 0 black / brown eschar 5/14/14 no measurements available According to physician progress notes [REDACTED]. P(plan) Allevyn heel." According to Resident #5's physician progress notes [REDACTED]. A) vs ulcer P) Allevyn heel." According to Resident #5's physician progress notes [REDACTED]." On 5/15/14 at 11:00, Wound specialist "D" reported he had measured Resident #5's wound on his heel, was asked about the increase in size, responded, "it was the same size and had not changed." Wound Specialist "D" was asked to review the right heel measurements and increase in size and responded, " the wound is stable." Wound Specialist "D" was asked if pressure to the heels was a concern or if there were any other interventions he would recommend, physician wound specialist "D" responded, I can recommend treatments but I will not get into nursing related interventions. Coccyx area According to Resident #5's Medication Administration Record, [REDACTED]. On 5/13/14 at 2:25 pm, Certified Nurse Aide (CNA) "R" reported, he had come on shift at 10:00 pm. CNA "R" reported he had been in Resident #5's room to check on the room mate but had not repositioned or checked on Resident #5 since he had arrived on shift at 10:00 pm (3 hours). On 5/15/14 at 9:05 am, Resident #5 was observed during am care, Resident #5's entire right and left buttock area skin was peeling and was observed to have been reddened/excoriated with deep groves from the brief. On 5/14/14 at 9:05 am, Certified Nurse Aide (CNA) "N" reported Resident #5's gluteal area looked like there was an "small open area" on the lower left buttock and entire buttock area looked "chapped." On 5/15/14 at 11:00 am, Wound specialist reported he had not seen Resident #5's buttock area as he had not been informed Resident #5 had any skin issue concerns on the area. Resident #12 According to the admit Minimum Data Set (MDS) assessment dated ,[DATE]//14 Resident #12 was an [AGE] year old female with [DIAGNOSES REDACTED]. Resident #12 was assessed in a persistent vegetative state and was assessed and totally dependent on staff for all her activities of daily living. According to the Braden scale (predicting pressure sore risk) Resident #12 was assessed at a 9 which indicated she was at a high risk for a pressure sore. A total score of 12 of less represents a high risk. According to Resident #12's CNA shower sheet dated 4/25/13 revealed, "blister left inner leg and blister rt heel. " Resident #12's shower sheet dated 4/27/24, revealed "nothing new found." According to Resident #12's Care plan dated 2/2/07, "I am at risk for skin break down R/T my incontinence of B & B (bowel and bladder), hx (history) skin breakdown coccyx, lt (left) hip, lt buttock and rt (right) gluteal fold and heel. I have a dx of [MEDICAL CONDITION] quadriparesis (SP), MS as well as dementia. 1/27/12 I have the potential for bruising secondary to lab draws. 10/16/13 I also have dx of coma, [MEDICAL CONDITION], and [MEDICAL CONDITION]. 12/27/13 shearing rt buttock , 4/27/14 open area coccyx." Resident #12 care plan included a new intervention dated 4/28/14, which included "staff to turn and reposition me every 1 hour bed and geri chair." According to Resident #12's care plan dated 4/27/14, "Category: Pressure Ulcer Impaired skin integrity r/t my bowel and bladder incontinence, being dependent on staff for bed mobility, HX of skin breakdown coccyx, LT hip, LT buttock, RT gluteal fold and heels AEB (As Evidenced By) scar tissue. I have a DX [MEDICAL CONDITION] Quadriparesis, MS, Coma, [MEDICAL CONDITIONS], and Dementia AEB (sic) stage II coccyx. Resident #12 care plan included a new intervention dated 4/28/14, which included "staff to turn and reposition me every 1 hour bed and geri chair." According to Resident #12's Treatment records dated 4/30/14, revealed " coccyx, stage II, 0.8 x 0.8 x 0.3." with an onset date of 4/27/14. small, serosanguineous, wound slough, surrounding tissue wound edge normal for skin. deteriorated" According to Resident #12's Treatment record dated 5/14/14, revealed "coccyx, stage II 1.0 x 0.4 x 0.3 small, serosanguineous, wound bed pink/beefy red, surrounding tissue wound edge maceration. treatment protective cream." According to Resident #12's physician progress (wound specialist) note dated 4/30/14 revealed, "coccyx 0.8 x 0 x 0.3. " On 5/15/14 at 1:40 pm, Resident # 12's coccyx area was observed with Licensed Practical Nurse (LPN) "F." Resident#12's coccyx area was observed with an open wound, Stage II pressure ulcer, approximately 1.0 cm (centimeters) x 1.0 cm x .5 cm with moderate serosanguineous drainage. The wound bed was pink beefy red with wound edge reddened, and the surrounding tissue with white scare tissue present. On 5/15/14 at 11:10 am, Physician Wound Specialist "D" reported the cause of Resident #12' s Stage II pressure ulcer on the coccyx was from shearing related to staff repositioning incorrectly during transfers. On 5/15/14 at 4:00 pm, Director of Nursing "B" and Registered Nurse/treatment nurse "E" was asked if the nursing staff and Certified Nurse Aides had received any in-services on the proper techniques to prevent shearing during transfers and both DON "B" and RN "E" reported there had been no in-services in the last 6 months since Resident #6 had developed the last Stage II pressure ulcer on her gluteal fold from shearing on 12/27/13. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT INTERVENTIONS TO PREVENT THE DEVELOPMENT OF A PRESSURE ULCER ON THE RIGHT BUTTOCK OF ONE RESIDENT (#5) OUT OF FIVE RESIDENTS REVIEWED FOR WOUNDS IN A SAMPLE OF 15 RESIDENTS RESULTING IN A PAINFUL UNSTAGEABLE PRESSURE ULCER WITH THE POTENTIAL FOR COMPLICATIONS. FINDINGS INCLUDE: ACCORDING TO THE RESIDENT ADMISSION RECORD, WITH A CURRENT admitted [DATE] AND A RETURN admitted [DATE], RESIDENT #5 WAS AN [AGE] year OLD MALE WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET RESIDENT ASSESSMENT ((MDS) dated [DATE], RESIDENT #5 SCORED 12 OF 15 ON THE BRIEF INTERVIEW FOR MENTAL STATUS INDICATING MINIMAL COGNITIVE IMPAIRMENT. THE MDS REFLECTED THAT RESIDENT #5 REQUIRED EXTENSIVE ASSISTANCE OF TWO PERSONS TO PHYSICALLY ASSIST WITH TURNING SIDE TO SIDE AND CHANGING POSITIONS WHILE IN BED. ADDITIONALLY, THE MDS INDICATED THAT RESIDENT #5 WAS AT RISK FOR DEVELOPING PRESSURE ULCERS, BUT HAD NONE AT THE TIME OF THE ASSESSMENT ON 5/26/2013. THE MDS ALSO REFLECTED THE PRESENCE OF MOISTURE RELATED SKIN DAMAGE BUT NOT WHERE ON THE BODY THIS DAMAGE WAS LOCATED. UNDER THE MDS SECTION FOR SKIN AND ULCER TREATMENTS, THE FOLLOWING WERE CHECKED: PRESSURE REDUCING DEVICE FOR CHAIR; PRESSURE REDUCING DEVICE FOR BED; TURNING/REPOSITIONING PROGRAM AND; APPLICATIONS OF OINTMENTS/MEDICATIONS. ON 7/16/2013 AT 9:40 AM, CERTIFIED NURSING ASSISTANT (CNA) "H" WAS OBSERVED AS SHE PROVIDED CARE TO RESIDENT #5 IN HIS ROOM. AT THAT TIME, RESIDENT #5 WAS LAYING ON HIS BACK IN THE BED, WITH HIS HEELS NOT ELEVATED OFF OF THE MATTRESS, AND THE HEAD OF THE BED WAS ELEVATED ABOUT 20 DEGREES. WHEN RESIDENT #5 WAS TURNED TO HIS RIGHT SIDE FOR CARE, OPEN AREAS WERE OBSERVED ON BOTH BUTTOCKS. THE AREA ON THE LEFT BUTTOCK WAS ABOUT THE CIRCUMFERENCE OF A GOLF BALL WITH YELLOW SLOUGH TISSUE AT THE BASE AND SURROUNDED BY PEELING RED SKIN THAT EXTENDED DOWN THE BUTTOCKS. THE AREA ON THE RIGHT BUTTOCK WAS ALSO ABOUT THE CIRCUMFERENCE OF A GOLF BALL WITH YELLOW SLOUGH TISSUE AT THE BASE. DIRECTLY OVER THE COCCYX WAS A SMALLER BRIGHT RED AREA. AT THAT TIME, RESIDENT #5 COMPLAINED OF PAIN IN THE AREA OF HIS RIGHT BUTTOCK. AS CNA "H" WASHED AND RINSED THE AREAS, THE CLOTHS WERE OBSERVED TO HAVE A SMALL AMOUNT OF RED TINGE. AFTER THE AREAS WERE CLEANSED, CNA "H" APPLIED A WHITE PROTECTIVE CREAM TO THE AREAS. CNA "H" WAS ASKED IF RESIDENT #5 WAS ON A TURNING SCHEDULE. CNA "H" STATED SHE WAS NOT SURE AND LOOKED FOR THE CARE CARD FOR RESIDENT #5. CNA "H" WAS UNABLE TO LOCATE THE CARE CARD WHICH SHE STATED SHOULD HAVE BEEN HANGING ON THE BACK OF THE DOOR TO THE ROOM. ON 7/17/2013 AT 9:30 AM, RESIDENT #5 WAS HEARD MOANING FROM THE HALLWAY. UPON ENTERING THE ROOM, RESIDENT #5 WAS OBSERVED LAYING ON HIS BACK WITH HIS HEAD ELEVATED AND FOOD ON THE TRAY IN FRONT OF HIM. RESIDENT #5 WAS LEANING TO THE RIGHT AND RUBBING ON HIS RIGHT HIP WHERE HE STATED THE PAIN WAS LOCATED AND RATED THE PAIN A 10 ON A SCALE OF 1 TO 10. ON 7/17/2013 AT 11:30 AM, RESIDENT #5 WAS OBSERVED RESTING QUIETLY IN HIS BED, LAYING ON HIS BACK. CNA "I" WAS OBSERVED AS SHE COMPLETED CARE. THE APPEARANCE OF RESIDENT #5'S BUTTOCKS WERE UNCHANGED FROM THE PREVIOUS DAY, AND THE BRIGHT RED AREA WAS STILL PRESENT ON HIS COCCYX. CNA "I" LEFT RESIDENT #5 POSITIONED ON HIS BACK WITH THE HEAD OF THE BED ELEVATED AT ABOUT 20 TO 30 DEGREES. ON 7/17/2013 AT ABOUT 4:00 PM, THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED IN THE FRONT OFFICE. THE DON STATED THAT THE WOUNDS ON RESIDENT #5'S BUTTOCKS HAD BEEN IDENTIFIED BY THE PHYSICIAN AS "DENUDED" SKIN AND THE AREAS WERE UNDER HIS TREATMENT. THE DON WAS INFORMED THAT THE CNA HAD NOT BEEN ABLE TO LOCATE THE RESIDENT CARE CARD FOR RESIDENT #5 AND PROCEEDED TO LOCATE THE CARD ON THE DRESSER IN RESIDENT #5'S ROOM. AT THE NURSES STATION AT ABOUT 4:10 PM, THE UNIT MANAGER, LICENSED PRACTICAL NURSE "F" WAS ASKED IF THERE WERE WOUND MEASUREMENTS OR DESCRIPTIONS FOR RESIDENT #5. THE UNIT MANAGER STATED THAT THE PHYSICIAN MEASURED THE WOUNDS AND DOCUMENTED. TWO COPIES OF A CNA CARE CARD (TITLED "CNA RESIDENT STATUS RECORD"), BOTH DATED 7/7/2013, WERE PROVIDED. UNDER THE "SPECIAL SKIN CARE NEEDS" SECTION OF BOTH, THE LINE FOR "AT RISK FOR PRESSURE SORE DEVELOPMENT" WAS NOT CHECKED AND NO TURNING SCHEDULE WAS INDICATED. THERE WAS A DIRECTIVE TO APPLY PROTECTIVE OINTMENT AFTER EACH INCONTINENT EPISODE. ACCORDING TO THE CARE PLAN, DATED 2/6/2013, RESIDENT #5 WAS AS RISK FOR PRESSURE ULCERS BECAUSE OF DECREASED MOBILITY, LOW [MEDICATION NAME] LEVEL, THE USE OF ANTICOAGULANTS, SURGICAL WOUND, AND INCONTINENCE. AN UNDATED HAND WRITTEN ENTRY NOTED THAT RESIDENT #5 HAD "BOWEL/BLADDER INCONTINENCE, NON-COMPLIANCE WITH TURNING/REPOSITIONING, HISTORY OF OPEN AREAS ON BUTTOCKS, LIKES HOB (HEAD OF BED) ELEVATED GREATER 45 DEGREE ANGLE" AND ANOTHER HAND WRITTEN ENTRY DATED 7/9/2013 THAT READ "DENUDED SKIN RIGHT AND LEFT BUTTOCK". UNDER THE COLUMN FOR INTERVENTIONS, OR APPROACHES FOR THE CONCERN, TURNING, REPOSITIONING TO RELIEVE OR REDISTRIBUTE PRESSURE WAS NOT LISTED. ACCORDING TO THE "EUROPEAN PRESSURE ULCER ADVISORY PANEL AND NATIONAL PRESSURE ULCER ADVISORY PANEL'S QUICK REFERENCE GUIDE FOR THE PREVENTION OF PRESSURE ULCERS (2009)", THE USE OF REPOSITIONING SHOULD BE CONSIDERED IN ALL AT RISK INDIVIDUALS TO REDUCE THE DURATION AND MAGNITUDE OF PRESSURE BECAUSE HIGH PRESSURE FOR A SHORT PERIOD OF TIME, AND LOW PRESSURE FOR A LONG PERIOD OF TIME ARE BOTH DAMAGING TO THE SKIN. ON 7/18/2013 AT 9:10 AM, RESIDENT #5 WAS OBSERVED IN HIS ROOM LAYING WITH A PILLOW UNDER HIS LEFT SIDE SO HE WAS PROPPED TO THE RIGHT AND WAS RESTING QUIETLY WITH HIS EYES CLOSED. ACCORDING TO THE CARE PLAN, DATED 2/6/2013 FOR RESIDENT #5 THAT ADDRESSED THE PROBLEM OF RISK FOR PRESSURE ULCERS, ONE OF THE LISTED APPROACHES WAS FOR THE LICENSED NURSE TO CONDUCT A SYSTEMATIC SKIN INSPECTION WEEKLY WITH PARTICULAR ATTENTION PAID TO THE BONY PROMINENCES. THE JULY TREATMENT SHEET REFLECTED THAT RESIDENT #5 HAD REFUSED WEEKLY SKIN ASSESSMENTS ON 7/8/2013 AND 7/16/2013 ON THE 2 PM TO 10 PM SHIFT. THE BACK OF THE SHEET HAD NO COMMENTS THAT ADDRESSED THE SPECIFICS OF THE REFUSALS OR ADDITIONAL ATTEMPTS TO PERFORM THE ASSESSMENTS. THERE WAS NO ENTRY ON THE NURSE'S NOTES FOR 7/8/2013. THERE WAS NO ENTRY ON THE NURSE'S NOTES ON 7/15/2013 FOR THE 2 PM TO 10 PM SHIFT, ALTHOUGH THERE WAS AN ENTRY FOR 7/15/2013 FOR 1:20 PM THAT CONCLUDED THAT RESIDENT #5 HAD BEEN COOPERATIVE WITH MEDICATIONS AND CARE. ACCORDING TO THE PHYSICIAN'S PROGRESS NOTES, DATED 7/10/2013, TITLED "WOUND CARE", RESIDENT #5 HAD MISSING SKIN ON HIS LEFT AND RIGHT BUTTOCKS WITH A YELLOW BASE. THE PHYSICIAN HAD ASSESSED THESE AREAS AS "DENUDED SKIN". DURING AN INTERVIEW WITH THE PHYSICIAN, DOCTOR "L" ON 7/18/2013 AT 11:30 AM IN THE FRONT OFFICE, HE STATED THAT "DENUDED SKIN" WAS THE ABSENCE OF EPIDERMIS OR SKIN. DOCTOR "L" STATED THAT IT WAS HIS ROUTINE TO ASSESS WOUNDS EVERY TWO WEEKS BUT THAT HE HAD EXAMINED RESIDENT #5 THIS MORNING. DOCTOR "L" STATED THAT THE AREA ON RESIDENT #5'S LEFT BUTTOCK HAD CHANGED SINCE HIS LAST OBSERVATION AND WAS A PRESSURE SORE WITH SLOUGH IN THE BASE AND THAT RESIDENT #5 HAD TOLD HIM THAT THE AREA WAS PAINFUL. ACCORDING TO THE "EUROPEAN PRESSURE ULCER ADVISORY PANEL AND NATIONAL PRESSURE ULCER ADVISORY PANEL'S QUICK REFERENCE GUIDE FOR THE treatment of [REDACTED]. ( )

This citation pertains to intake number MI 413. Based on observation, interview, and record review, the facility failed to ensure the safety and prevent the elopement of 1 of 4 sampled residents (Resident #501), from a total sample of 8 residents, resulting in an Immediate Jeopardy when Resident #501, who was identified as an elopement risk and wore a Wanderguard bracelet (system used to activate door alarms), exited the facility on 10/19/11 at approximately 4:00 AM, without a timely and appropriate response by facility staff and was found approximately 15 minutes later attempting to reenter the facility. This deficient practice places 12 additional residents, identified as at risk for elopement, at a high risk for serious harm, injury and/or death. Findings include: Per the facility face sheet Resident #501 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the "Minimum Data Set" (MDS), dated [DATE], revealed Resident #501 had unclear speech, was unable to make herself understood, rarely was understood by others, had moderately impaired vision, a memory problem, moderately impaired cognitive skills, was inattentive, had disorganized thinking, and wandered daily. Record review of the "Resident Elopement Assessment", dated 7/15/2011, revealed Resident #501 scored a 20 (10 or greater equals a high risk for elopement) indicating Resident #501 was at high risk for elopement. Record review of the "Elopement" Care Plan", dated 8/3/2009, revealed Resident #501 was at risk for elopement related to an elopement score greater than 10. An approach was to give Resident #501 closer supervision and to monitor her movement in the facility. Record review of the "Resident Safety Check" record revealed Resident #501 was placed on 15 minute safety checks beginning on 9/1/2011. Record review of the "Behavioral Care Plan and Log" revealed that on 7/25, 7/26, 7/27, & 7/28/2011, Resident #501 went out the doors (unit doors) 15 times on each date. The log revealed that on 8/15/2011, Resident #501 went through the unit doors setting of the alarm 16 times. On 8/17/2011 the log revealed Resident #501 was up until 4:00 AM and had gone through the unit door setting off the alarm 8 times. On 9/11/2011 the log revealed Resident #501 was "Combative when re-direct not to go thru doors." Record review of the "Treatment Administration Record" for the months of August, September, and October 2011 revealed Resident #501's WanderGuard was verified to be in place and functional on every shift, as indicated by staff initials. Record review of the "Unusual Occurrence Report", dated 10/19/2011, revealed a door alarm sounded and staff began to search for Resident #501. A statement, written and signed by Registered Nurse (RN) #2 and dated 10/19/2011, revealed that RN #2 had taken Resident #501 with her into another resident's room so that RN #2 could watch her. The statement reflected that while RN #2 was administering a treatment to the other resident, Resident #501 left the room. RN #2 documented that she heard a door alarm sound and went to the door that was alarming (an exterior exit door with a small window), opened the door, looked to the left and to the right but did not see Resident #501 so she began to search inside the facility. The statement revealed that RN #2 did not find Resident #501 after her search inside so she went outside to look for Resident #501 and then she saw Resident #501 in the front of the facility and was able to get Resident #501 back into the facility. Record review of the facility policy and procedure for "Resident Elopement", dated 4/2011, revealed under "Procedure" #7, "If a resident cannot be located, the staff member identifying the situation should notify all staff to initiate search by using the facility code." In an interview on 10/25/2011 at 8:30 AM, RN #2 (Resident #501's primary care nurse) stated that on 10/19/2011 at approximately 4:00 AM, she took Resident #501 with her into another resident's room while she administered a treatment. RN #2 said Resident #501 was on 15 minute safety checks due to her wandering behavior. RN #2 said Resident #501 wandered out of the room and shortly thereafter, she heard a door alarm sound. RN #2 reported when she heard the door alarm, she was still administering a treatment and that because the alarm had not stopped after about 3 minutes, she decided to go respond to the alarm. RN #2 reported that she opened the door that had alarmed, looked outside to the left and right, but did not see Resident #501. RN #2 reported that she did go outside to look for Resident #501. RN #2 said she looked in all resident rooms, but Resident #501 was not found, so she went back to the door that had alarmed and again looked outside to the left and to the right, but did not see Resident #501. RN #2 said that she began to search the facility, did not find Resident #501, so she went back to the door that alarmed, and she saw Resident #501 looking in the window of the door, trying to open the door. RN #2 said that because Resident #501 was in front of the door, she sent Certified Nurse Aide (CNA) #4 outside to get Resident #501. RN #2 stated she failed to announce a "Dr. Walker" because she thought Resident #501 "would just come back". RN #2 said Resident #501 had wandered a lot the night of 10/19/2011 and had pushed open the doors that led to the outside and sounded the door alarms once or twice. RN #2 said that she did not increase the supervision of Resident #501 on 10/19/2011 because Resident #501 was always with a staff member. RN #2 said that she did not tell the CNA's that were working the unit with her that she was going to administer a treatment to another resident. RN #2 stated that the original statement she gave to the facility in regards to the incident was a made up story and this interview was the correct account of the incident. RN #2 stated that approximately 3 to 5 minutes had lapsed from the time the door alarm sounded to the time Resident #501 was brought back into the facility. According to Weather Underground, the temperature was 51 degrees at 4:00 AM on 10/19/11 with precipitation of light rain (http://www.wunderground.com/history/airport /KBTL/2011/11/8/DailyHistory.html?req_city=Battle+Creek&req_state =MI&req_statename=Michigan). In an interview on 10/25/2011 at 8:35 AM, CNA #1 said on 10/19/2011, Resident #501 had wandered the halls all night and had exited through the "Bridges Unit" double doors at least 30 times. CNA #1 said she had told RN #2 that Resident #501 needed to be on 1:1 observation and that RN #2 agreed with her, but did not place her on 1:1. CNA #1 said she was doing 15 minute safety checks on Resident #501. CNA #1 stated she had returned from break at 4:00 AM, and Resident #501 exited the facility at approximately 4:15 AM. CNA #1 said RN #2 told her that she could not find Resident #501 and the door alarm was sounding. CNA #1 said she went to all of her residents' room looking for Resident #501, but that she did not complete a head count of her residents, because she was only looking for Resident #501. CNA#1 said she went to the door where the alarm had sounded and saw Resident #501 standing on the outside of the door. CNA #1 said RN #2 and CNA #3 could not get the door to open to let Resident #501 back in (resident was blocking door) so CNA #4 went out and brought Resident #501 back into the facility. CNA #1 said Resident #501 was outside approximately 5 to 10 minutes. CNA #1 said Resident #501 was warm but her socks were drenched/soaked because it had been raining outside and it was about 45 to 50 degrees outside on 10/19/2011. In an interview on 10/25/2011 at 8:50 AM, CNA #3 (worked the "Bridges Unit" on 10/19/2011) said she arrived at the door that was alarming to find RN #2 and CNA #1. CNA #3 said that she and RN #2 went out the door and looked to the left and to the right but did not walk outside the facility. They went back into the facility and began to search resident rooms. CNA #3 said that when Resident #501 was not found, she re-approached the door where the alarm had sounded, and saw Resident #501 alone outside the door. CNA #3 said the door could not be opened because Resident #501 stood in the way of it, so CNA #4 went out the front door and brought Resident #501 back in. CNA #3 said Resident #501 was wearing a gown, sweater, and socks without shoes. CNA #3 said it had been raining and it was a bit cold that night. CNA #3 said Resident #501 had been up all night since 11:30 PM and had to be retrieved from going out the unit doors twice. In an interview on 10/25/2011 at 10:04 AM, CNA #4 (worked at the other end of the facility on 10/19/2011) said that when she heard the door alarm she stepped out of a resident room and waited to see if the alarm shut off. CNA #4 said the alarm did not stop so she asked RN #7 what that alarm was. CNA #4 said RN #7 looked at the alarm panel at the nurses station and told her which door was alarming, but did not go to the "Bridges Unit" to respond to the door alarm. CNA #4 said the alarm continued to sound, so she went to the "Bridges Unit" to assess the situation. CNA #4 said it was approximately 5 minutes from the time she first heard the alarm to the time she went to the "Bridges Unit". CNA #4 said when she arrived in the "Bridges Unit", RN #2 was holding the alarming door open and looking both ways. CNA #4 said she asked RN #2 if she knew where Resident #501 was but RN #2 did not answer her. CNA #4 said she helped search resident rooms but Resident #501 was not found. CNA #4 said she then left the "Bridges Unit" and told RN #7 that Resident #501 was missing. CNA #4 said RN #7 just said, "Oh really" and did not go assist to search for Resident #501. CNA #4 said she then went back to the "Bridges Unit" and searched the resident rooms again but did not find Resident #501. CNA #4 said she went back to the door that had alarmed and saw Resident #501 outside of the door looking in. CNA #4 said CNA #1, CNA #3, nor RN #2 could get the door open to let Resident #501 back in. CNA #4 said she went out the front door, but when she got to Resident #501, CNA #1, #3, and RN #2 had the door open. CNA #4 said that from the time she first heard the door alarm to the time she went outside to bring Resident #501 back in was approximately 15 minutes. CNA #4 said no staff ever went outside to look for Resident #50, but RN #2 when she looked both ways out the door. CNA #4 said RN #2 did not give any direction to staff in regards to what to do. CNA #4 said it had been raining outside and Resident #501 only had socks on, a short sleeve nightgown, no sweater, and it was cold outside. CNA #4 said that about 2 weeks prior she had cared for Resident #501 and at that time Resident #501 was on 15 minute safety checks for her wandering. In an interview on 10/26/2011 at 9:06 AM, CNA #6, who worked at the other end of the facility on 10/19/2011, said at about 4:00 AM she heard the door alarm and figured the alarm would just shut off and the staff in the "Bridges Unit" would take care of it. CNA #6 said she thought nothing about the alarm because it had sounded earlier in the night also. CNA #6 said the alarm had sounded for approximately 1 minute and stated that she told CNA #4 the staff in the "Bridges Unit" needed to announce a "Dr. Walker". CNA #6 said RN #7 never told staff to go anywhere or do anything in regards to the alarm sounding. CNA #6 said, with this type of incident, staff were to announce a "Dr. Walker". In an interview on 10/25/2011 at 11:14 AM, CNA #8, who worked the other unit at the other end of the facility on 10/19/2011, said that when the door alarm sounded, she did not get involved. CNA #8 said she heard the alarm sound for about 2 minutes then it stopped and stated that she did not know which door had alarmed. CNA #8 said she did a head count of her residents walked to the front door but did not go outside and look. CNA #8 said all of her residents were accounted for so she went back to doing her work. CNA #8 said Resident #501 was on 15 minute safety checks because she wandered all night and would not sleep. In an interview on 10/25/2011 at 10:50 AM, RN #7, who worked in the other unit at the other end of the facility on 10/19/2011, said he heard the door alarm, went to the panel box at the nurses' station, and saw that the door alarm was not on his unit. RN #7 said CNA #4 asked him if he wanted to go to the "Bridges Unit" and see what the alarm was about. RN #7 said he told CNA #4 to go. RN #7 said about 30 to 45 seconds after CNA #4 left he the alarm stopped, but 5 to 10 seconds later the alarm sounded again. RN #7 said that when a door alarm sounded staff was to announce a "Dr. Walker" as soon as the door alarm sounded. RN #7 said even if staff did not know why the alarm sounded a "Dr. Walker" was to be announced. RN #7 said he did not leave his unit to assist with the search for Resident #501. In an interview on 10/24/2011 at 1:00 PM, Administrator #5 stated that the facility policy and procedure, when a door alarm sounded, was to announce the facility code (Dr. Walker) over the intercom to inform all staff to initiate a resident search. Administrator #5 said this was a deficient practice related to the fact that RN #2 did not announce a "Dr. Walker" and follow facility policy and procedure for elopement. An observation of all facility doors was conducted on 10/25/2011 at 10:33 AM. All 8 doors were observed to have functional alarms. The front door was observed to be the only door equipped with a WanderGuard system alarm, and the 7 other doors were equipped with an alarm that would sound if the door was opened. The door Resident #501 eloped from was observed to not have a WanderGuard alarm, but rather an alarm that sounded when the door handle was pushed down. After the door handle was pushed, the door automatically locked and an alarm would begin sounding. After 15 seconds, the door would unlock and could be opened. The alarm continued to sound until it was reset. An observation of the outside environment was conducted on 10/24/2011 at 1:30 PM. The surveyor ascertained that the door, through which Resident #501 exited, was approximately 200 feet from a roadway with a posted speed limit of 35 mph and approximately 500 feet from a river. On 10/26/2011 at 3:51 PM, the Administrator was notified of an Immediate Jeopardy that was identified on 10/25/11 and began on 10/19/2011, when Resident #501, who was identified as an elopement risk and wore a Wanderguard bracelet, exited the facility on 10/19/11 at approximately 4:00 AM, without a timely and appropriate response by facility staff, and was found approximately 15 minutes later attempting to reenter the facility. This deficient practice places 12 additional residents, identified as at risk for elopement, at a high risk for serious harm, injury and/or death. On 10/27/2011 the surveyor confirmed the facility implemented the following to remove the Immediate Jeopardy: 1. On 10/19/2011, Resident #501's physician was notified of the elopement with orders received to obtain a urinalysis. A head to toe assessment of Resident #501 was also conducted and revealed no injuries. 2. On 10/19/2011, the facility Medical Director was notified of the elopement. 3. Beginning 10/19/2011, 95 of 96 employees were in-serviced, in a class room setting, on the facility policy and procedure for managing an elopement. The one employee who had not yet been in-serviced will not be allowed to work until the in-service has been completed. 4. On 10/19/2011, 61 of 61 residents were assessed for their elopement risk. Prior to the assessments 13 residents had been identified to be at risk for elopement; after the assessment the same 13 residents remained identified at a risk for elopement and no additional residents were deemed to be at risk. 5. On 10/19/2011, all 8 facility doors were tested for functioning of the alarms. All 8 were found to function properly. 6. On 10/19/2011, an elopement precautions audit was completed by the MDS Coordinator. All WanderGuard's were checked for functioning and will continue to be checked every shift and documented on the "Treatment Administration Record". The elopement book (Dr. Walker book) was reviewed to ensure that all 13 at-risk-for-elopement residents were included in the book. 7. On 10/19/2011, RN #2 was suspended. CNA #1 & #2 received, in addition to the classroom education, one-on-one education in regard to the facility policy on elopement. 8. On 10/19/2011, a test for knowledge proficiency of the facility policy on elopement was added to the new employee orientation packet. 9. On 10/19/2011, a Quality Assurance meeting was held to review the facility policy for elopement, review of resident charts, review of the in-service, schedule elopement drills, review audits, and investigation protocol. Although the Immediate Jeopardy was removed on 10/19/2011, the facility remained out of compliance at a scope of pattern 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 received the in-service and sustained compliance had not been verified by the State Agency. ( )