Every finding on record at Plainwell Pines Nursing and Rehabilitation Communi

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) attended the QAPI (Quality Assurance and Performance Improvement) meetings, resulting in the potential for lack of resident care policies and overall medical care that could affect all residents residing in the facility.Findings include:Review of the facility policy Quality Assessment and Assurance Committee dated 1/2022 revealed, .The Committee will be composed of staff who understand the characteristics and complexities of the care and services delivered in each unit and/or department. The QAA committee will be composed of, at a minimum: a. The Director of Nursing. b. The Medical Director or his/her designee. c. At least three (3) other facility staff members, one of which will be the administrator, owner, a board member or other individual in a leadership role. d. The Infection Preventionist (IP). 2. The infection preventionist must be a member of the QAA committee and report to the committee on the infection prevention and control program (IPCP) and incidents (e.g., healthcare-associated infections (HAIs) identified under the program on a regular basis. a. Reporting may include, but is not limited to: i. Facility process and outcome surveillance; ii. Outbreaks (ongoing and any since the last meeting) and control measures; iii. Occupational health communicable disease illnesses (e.g., TB, influenza) iv. The Antibiotic Stewardship Program (ASP) related to antibiotic use and resistance data. b. The infection preventionist should attend each QAA meeting, but if the IP cannot attend, another staff member should report on the IP's behalf. This does not change or absolve the IP's responsibility to fulfill the role of QAA committee member or reporting on the IPCP.In an interview on 05/29/2026 at 10:09 AM, Nursing Home Administrator (NHA) A reported that QAPI meetings are held at least monthly. NHA A reported that the facility did not have an Infection Preventionist (IP) in attendance since January 2026. NHA A reported that Regional IP FF started in March 2026 but was working from afar and did not attend any of the QAPI meetings. NHA A reported that infection control data had not been submitted for review and was not included in the QAPI meeting minutes.Review of the QAPI meeting sign in sheets from February-May 2026 revealed the IP was not in attendance.

Based on interview and record review, the facility failed to ensure infection control data was regularly analyzed during QAPI (Quality Assurance and Performance Improvement) meetings and completed at least one PIP (Performance Improvement Plan) related to quality issues identified by the quality assessment and assurance committee, resulting in the potential for systematic failures related to infection control and other quality deficiencies. Findings include: Review of the facility policy Quality Assurance and Performance Improvement (QAPI) dated 1/2026 revealed, . Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. c. Develop and implement appropriate plans of action to correct identified quality deficiencies. d. Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. e. The QAA committee must sign to verify approval of all plans of correction written.c. The facility conducts at least one distinct performance improvement project (PIP) annually that focuses on high risk or problem prone areas. Additional projects may be conducted as needed, and may be clinical or non-clinical in nature.In an interview on 05/29/2026 at 10:09 AM, Nursing Home Administrator (NHA) A reported that QAPI meetings are held at least monthly. NHA A reported that the facility did not have an Infection Preventionist (IP) in attendance since January 2026. NHA A reported that Regional IP FF started in March 2026 but was working from afar and did not attend any of the QAPI meetings. NHA A reported that infection control data had not been submitted for review and was not included in the QAPI meeting minutes.Review of the QAPI meeting sign in sheets from February-May 2026 revealed the Infection Preventionist (IP) was not in attendance.Review of QAPI data submitted from February-May 2026 revealed there was no data related to infection control, except the pharmacy list of antibiotics.In an interview on 05/29/2026 at 12:33 PM, NHA A reported that she would look for documentation from any PIP's (Performance improvement project) from the past 12 months. No documentation was provided prior to survey exit.Review of the provider history report revealed the facility had been cited for in 2023, 2024, and 2025 during the annual surveys for infection control non-compliance.

Based on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the physical, mental, and psychosocial well-being in 2 of 12 residents (Resident #22 & #26) reviewed for staffing, resulting in unmet care needs and the potential for physical and psychosocial harm for all residents in the facility. Findings include: Resident #22 Review of an admission Record revealed Resident #22 was a male with pertinent diagnoses which included dementia. Review of Care Plan for Resident #22 on 5/16/26 revealed the focus, .(Resident #22) is at risk for elopement related to memory deficit confusion and inability to read or write due to Alzheimer's. with the intervention .Calmly redirect and divert resident's attention when showing signs of exit seeking. Do not approach (Resident #22) from behind or the side he will startle and may strike out. In an interview on 05/29/2026 at 11:01 AM, Licensed Practical Nurse (LPN) GG reported providing supervision for Resident #22 was very problematic as he was wandering in other residents' rooms and this was causing concerns, residents were yelling at him to get out of their rooms, and he was going through his roommate's dresser. LPN GG reported he was exit seeking and would go to the exit doors. He was always wandering during the day, and staff would have to ensure not to leave anything where he could obtain it to keep him safe. LPN GG reported Resident #22 was someone who would benefit from more one to one staffing as he was ambulatory and it was difficult to do the job you were there for and keep an eye on him to keep him safe as well as other residents. In an interview on 05/29/2026 at 11:01 AM, LPN GG reported she was sitting at the nurse's station as it was shift change and she was the only nurse on the floor for second shift. Incident occurred on 5/26/26 at approximately 3:30 PM involving Resident #22 and Resident #14. In an interview on 5/28/26 at 11:26am, CNA S reported Resident #22 needed more supervision that the facility could provide on 5/23/26 and as a result, he had a physical altercation with another resident. CNA S reported Resident #22 always needed a staff member with him in order to remain safe. In an interview on 5/28/26 at 12:04pm, CNA R reported at times the facility could not fill openings in the schedule when a staff member called off. This resulted in staff members rushing during cares, working through lunch breaks, and not being able to address the residents' psychosocial needs. CNA R reported she regularly cared for 13-14 residents on her own. CNA R reported the facility could not provide the type of supervision Resident #22 needed and that resulted in him wandering in and out of other residents' rooms, resident's yelling at him and physical altercations between him and other residents. In an interview with Licensed Practical Nurse (LPN) JJ on 5/28/26 at 1:36 pm reported Resident #22 wandered all day on 5/23/26 and was frequently in and out of other residents' room. LPN JJ reported the staff tried to supervise him as much as possible but could not provide the constant supervision the resident needed that day. LPN JJ reported due to lack of supervision, Resident #22 had a physical altercation with another resident. Review of incident reports for Resident #22 revealed he initiated resident to resident altercations on 5/23/26 at 3:20pm. Review of the working nursing/CNA schedules for 5/23/26 revealed at the time of the incident involving Resident #22, the facility 1 nurse and 2 CNAs in the building. The facility had 3 CNAs scheduled to be present but 1 called in a replacement was scheduled to come in at 4:30pm. Of note, 12 facility residents required assist of 2 staff members for transfers so if staff were assisting one of those residents, the remaining residents throughout the facility were being supervised/care for by one staff member. In an interview on 5/28/26 at 3:30pm, Family Member (FM) BB reported the facility initiated 1:1 supervision for Resident #22 on 5/23/26 after a resident to resident altercation, but she received a call on 5/26/26 at 3:28pm from Licensed Practical Nurse (LPN) GG who informed her the resident would not receive 1:1 supervision on this date due to staffing issues. FM BB reported she was concerned Resident #22 would have another altercation with a resident. Review of an Incident Report for Resident #22 with a reference date of 5/26/26 at 4:44pm, revealed Resident #22 grabbed a female resident in a choke hold (restraining technique in which an arm is wrapped tightly around another person's neck) and punched her in the face, chest and upper back multiple times. Review of the working nursing/CNA schedule for 5/26/26 revealed the facility was staffed with 1 nurse and 3 CNAs at the time of the incident involving Resident #22. In an interview on 5/29/26 at 10:06am, Scheduler/CNA E reported at times the facility could not fill a shift when a staff member called in. Scheduler/CNA E reported the facility currently has 16 CNAs on staff with 4 positions open. Scheduler/CNA E reported he had worked every day for the last 8 weeks, because he filled in as a CNA on the weekends due to staffing shortages. Scheduler/CNA E reported the current recommended staffing level for the afternoon/evening shift was 1-2 nurses and 2-3 CNAs, any 1:1 supervision of residents would be in addition to these numbers. Resident #26 Review of an admission Record revealed Resident #26 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dependence on wheelchair and other reduced mobility. Review of a Minimum Data Set(MDS) assessment for Resident #26 with a reference date of 4/1/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Review of a Care Plan for Resident # 26 with a reference date of 4/22/25 revealed the following problem/goal/approaches: Problem: Alteration in ADLs (activities of daily living) . Goal: .Care needs will be met. Approaches: (Resident #26) requires a sit to stand mechanical (mechanical lift device that requires 2 staff for safe use) for transfers.involve resident in care and decision making as much as possible.Resident uses a wheelchair for mobility. During an observation and interview on 4/27/26 at 7:29am, Resident #26 was lying on his back in his bed. Resident #26 reported he wanted to get up for the day. Resident #26 was encouraged to activate his call light and did so at this time. During an observation on 4/27/26 at 7:31am, a staff member entered Resident #26's room, deactivated his call light and told the resident she would go get help to transfer him out of bed. During an observation on 4/27/26 at 7:34am, Resident #26 reactivated his call light while he remained in bed. During an observation on 4/27/26 at 7:38am, a staff member entered Resident #26's room, deactivated his call light and told the resident to give me a couple of minutes regarding his desire to get out of bed. During an observation on 4/27/26 at 7:44am, Resident #26 reactivated his call light. A staff member entered the room and deactivated the call light at 7:59am. During an observation on 4/27/26 at 8:02am, Resident #26 remained in bed and reactivated his call light at this time. During an observation on 4/27/26, Resident #26's call light remained activated until 8:17am when another staff member entered the resident's room, deactivated the call light and stated she was going to grab (staff member's name omitted) to help her transfer the resident. During an observation on 4/27/26 at 8:23am, 54 minutes after Resident #26 initially activated his call light to get out of bed, 2 staff members arrived to assist him with transferring from his bed to his wheelchair. In an interview on 5/28/26 at 3:00pm, Resident #26 reported he regularly experienced long call light wait times of greater than 30 minutes and frequently had to reactivate his call light because staff would turn it off without completing the care he needed. Resident #26 reported the facility frequently did not have enough staff to ensure residents received care promptly, especially those who needed the assistance of 2 staff members, and he was frustrated by the situation. Review of a 2-person bed mobility and transfers list provided by the facility, revealed 4 residents required assistance of 2 staff for bed mobility and 12 residents required assistance of 2 staff for transfers, including Resident #26. The census for the facility was 35 residents. In a confidential meeting on 4/28/26 at 2:00pm, 4 of 7 residents in attendance reported long call light wait times of greater than 30 minutes, resulting in feelings of frustration. Residents reported the facility frequently could not find a replacement when someone called off and this resulted in having to wait for longer periods of time to get help. 7 of 7 residents reported they experienced an unsupervised resident with advanced dementia wandering into their room. Review of a Payroll Based Journal Report revealed the facility was triggered for excessively low weekend staffing during the first quarter, October-December 2025. Review of an electronic communication with a reference date of 5/28/26 at 11:16am revealed confirmation from Chief Operating Officer (COO) NN the facility reported low weekend staffing for the first quarter, October-December 2025. In an interview on 05/28/2026 at 11:40 AM, Certified Nursing Assistant (CNA) T reported not all the time are we staffed the way we should be. CNA T reported it was very difficult to keep an eye on Resident #22 especially when the facility was not fully staffed. CNA T reported weekends were the worst as at times it was her and another CNA covering the resident's care. CNA T reported quite a bit of the time she missed breaks, worked through her lunch to be able to provide care to the residents. CNA T reported she was not able to spend as much time with each resident as she would like as she was always running from one resident to another, she was not able to sit and have conversations with residents, have to tell them she would be back and a lot of times hardly able to have a chit chat with residents. CNA T reported sometimes we were the only people the resident had and not being able to spend a few minutes with them talking to them could cause them to feel loneliness. In an interview on 05/28/2026 at 12:04 PM, CNA R reported staffing not able to always cover call ins for a shift. CNA R reported when the missing slot was not filled, the staff feel they weren't able to provide the quality of care and have to prioritize, sometimes only able to give a bed bad instead of a full shower. CNA R reported when this happened staff were not able to do as much as they would like to and would just have to work through it and do what they could as it was crazy busy. In an interview on 05/28/2026 1:23 PM, Maintenance Director (MD) E reported he worked as a CNA (Certified Nursing Assistant) quite a bit lately more than he would like to. MD E reported he would come in early for those staff members who were mandated over or who were to come in early to work for an earlier shift. MD E reported most of the time he worked weekends to cover call ins. MD E reported the facility had small building problems such as when a nursing staff member called in that was 30% of the floor staff so it affects the building more than it would if it was a larger building.

Based on interview and record review, the facility failed to complete accurate assessments for 1 of 12 residents (Resident#14) reviewed for accurate assessments, resulting in an inaccurate reflection of the resident's status and the potential for impaired medical, functional, and psychosocial problems due to unidentified needs. Findings include: Resident #14: Review of the Face Sheet revealed Resident #14 was a female with pertinent diagnoses which included dementia (progressive brain disease which affects memory, language, problem solving, and thinking severe enough to interfere with daily life) with behavioral disturbance, stroke (blood flow was interrupted or reduced causing brain damage), paralysis, dysphagia (difficulty swallowing), malnutrition, need for assistance for personal care, and speech impairment. Review of Minimum Data Set (MDS) for Resident #14 dated 4/23/26 revealed, she had a BIMS (Brief Mental Status Score) of 14. Review of the MDS for 4/23/26 revealed the assessment had been modified and then corrected. Review of MDS Assessments for Resident #14 revealed, 2/4/26 BIMS score of 3 (severely cognitively impaired); 11/4/25 BIMS score of 11 (moderately cognitively impaired); 9/16/25 BIMS score of 11; and 6/16/25 BIMS score of 9 (moderately cognitively impaired).In an interview on 05/28/2026 at 1:50 PM, Regional MDS Coordinator Y reported she had started on 5/1/26. Regional MDS Coordinator Y reported she had come to the facility to fill in for the MDS Coordinator as the facility did not currently have one as the last MDS Coordinator had left in February 2026. Regional MDS Coordinator Y reported prior to her starting the facility MDS evaluations were being completed by various staff members at the facility. Regional MDS Coordinator Y reported staff were to assess the resident by reviewing information from the medical record and if able to interview the resident. Review of Resident #14's medical record revealed no illness which would affect the outcome of the BIMS assessment dated [DATE]. Review of the MDS 3.0 RAI Manual vl. 16, Chapter 1: Resident Assessment Instrument (RAI), revealed .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations . It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment .

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration for 1 resident (Resident #29) of 5 residents reviewed for medication administration, resulting in an inhaler (medication that is inhaled) being administered outside of manufacturer recommendations and oral pills being administered without following resident preference for being crushed, and the potential for adverse side effects and choking.Findings include:Review of an admission Record revealed Resident #29 was originally admitted to the facility on [DATE].Review of a Minimum Data Set (MDS) assessment for Resident #29, with a reference date of 4/24/26 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #29 was cognitively impaired.During an observation on 05/28/2026 at 7:39 AM in Resident #29's room, Agency-Licensed Practical Nurse (A-LPN) II handed the resident a cup with 11 pills in it. Resident #29 emptied the cup into her mouth and began chewing, then grimacing and ultimately spitting the pills out. A-LPN II gave Resident #29 another cup of water and tried giving the pills to her (Resident #29) again, but the resident just spit them out again and said I can't swallow them. A-LPN II reported that she could try to crush the pills and put them in pudding and Resident #29 agreed. A-LPN II walked out to the medication cart and stated, .it says right here on the sheet that she (Resident #29) takes her pills crushed. A-LPN II crushed the pills and Resident #29 was able to take them with no issue. A-LPN II then handed Resident #29 her inhaler Breyna (steroid inhaler to treat breathing problems) and the resident took 2 puffs. A-LPN II did not offer water and/or encourage Resident #29 to swish and spit.In an interview on 5/28/26 at 7:50 AM, A-LPN II reported that Breyna inhaler was not a steroid and did not require a swish and spit after administration. This surveyor requested that A-LPN II double checked that information. A-LPN II reviewed the label of Breyna and reported that yes, it says to swish and spit after administration to avoid getting thrush (yeast (fungal) infection) in the mouth.During an additional observation on 05/29/2026 at 8:49 AM A-LPN LL was at the medication cart preparing medication for Resident #29. The report sheet on the cart indicated that Resident #29 took her pills crushed. A-LPN LL proceeded to prepare the oral medications and placed 11 pills into a cup and grabbed Resident #29's Breyna inhaler from the medication cart. A-LPN LL did not crush the pills. A-LPN LL entered Resident #29's room, A-LPN LL handed the cup of pills to Resident #29 and the resident put them all in her mouth and tried to swallow them. Resident #29 said, I can't, I can't, then spit the medications out. A-LPN LL picked up the pills and tried to give Resident #29 one pill at a time, but the resident started coughing and spit the pills out again. A-LPN LL explained to Resident #29 that she would have to start all over and she would try crushing the pills this time. At 9:05 AM A-LPN LL handed Resident #29 her Breyna inhaler and the resident took 2 puffs and handed it back to the nurse and took a drink of water. A-LPN LL did not encourage Resident #29 to swish and spit after administration of the inhaler.In an interview on 5/29/26 at 9:08 AM, Resident #29 reported that she had been having trouble swallowing pills and would like them to be crushed.In an interview on 05/29/2026 at 9:12 AM, A-LPN LL reported that her report sheet indicated that Resident #29 took her pills whole and she had not heard anything different. A-LPN LL reported that with Breyna inhaler, it is recommended to swish and spit afterwards and stated, .I think we just do what the resident allows.this is my first time with her.Review of Nursing Report Sheet observed on the medication cart at 9:12 AM indicated crushed next to Resident #29's name.Review of Resident #29's Physician Orders revealed, Budesonide-formoterol (Breyna) HFA aerosol inhaler.2 puffs inhalation twice a day. Start Date: 4/24/26.Review of Resident #29's Progress Notes dated 5/28/26 revealed, .Takes meds crushed in pudding without difficulty .Review of Resident #29's Progress Note Dated 5/5/29 revealed, .Medications administered crushed in pudding, as clinically appropriate .Review of Breyna Package Insert revealed, .Administration Information: BREYNA should be administered as 2 inhalations twice daily (morning and evening, approximately 12 hours apart), every day by the orally inhaled route only. After inhalation, the patient should rinse the mouth with water without swallowing.Adverse Reactions/Side Effects: .inhaled corticosteroid used may result in the following: Candida albicans infection.In clinical studies, the development of localized infections of the mouth and pharynx with Candida albicans has occurred in patients treated with budesonide and formoterol fumarate dihydrate inhalation aerosol. When such an infection develops, it should be treated with appropriate local or systemic (i.e., oral antifungal) therapy while treatment with BREYNA continues, but at times therapy with BREYNA may need to be interrupted. Advise the patient to rinse his/her mouth with water without swallowing following inhalation to help reduce the risk of oropharyngeal candidiasis.In an interview on 05/29/2026 at 9:25 AM, Director of Nursing (DON) B reported that there was no specific order for crushing pills and that the nurses were expected to review the report sheet for special instructions before they administer medications. DON B reported that when an inhaled steroid is administered the nurse should encourage the resident to swish and spill to avoid getting a mouth infection.

Based on observations, interviews and record review the facility failed to identify pressure ulcers and ensure appropriate treatment interventions were in place for 1 resident (Resident #4) of 1 resident reviewed for pressure ulcers, resulting in Resident #4 developing a Stage 2 pressure ulcer on the left buttock and the potential for overall deterioration in health status. Findings include:Resident #4Review of an admission Record revealed Resident #4 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: seborrheic dermatitis (flaky, itchy, inflamed skin). Resident #4 admitted to the facility with hospice services already in place.Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 3/24/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #4 was cognitively intact. Review of Resident #4's Functional Abilities revealed that she required substantial/maximal assistance (helper does more than half of the effort) to move her body in bed. Section M Skin Conditions indicated that Resident #4 was at risk for developing pressure injuries and had 0 unhealed pressure injuries. Section E Behaviors indicated that Resident #4 did not refuse care.Review of Resident #4's Braden Scale for Predication of Pressure Sore Risk revealed the following assessments (19 or higher is Not at risk, 15-18 is At risk, 13-14 is Moderate risk, 10-12 is High risk, and 9 or less is Very high risk): 5/25/26 indicated 15 At risk. 4/6/26 indicated 12 High risk. 3/30/26 10 High risk. 3/23/26 11 High Risk. 3/14/26 13 Moderate risk. It was noted that Resident #4's risk for pressure ulcers had decreased since admission. Review of Resident #4's Skin Care Plan revealed, Problem Start Date: 03/13/2026 Category: *Skin Integrity Resident is at risk for impaired skin integrity related to decreased mobility, left above the knee amputation (removed), bed bound, receiving Hospice services.Interventions: .Assist resident with turning and repositioning as needed. Complete skin inspection weekly and as needed. Encourage resident to reposition self if able. Encourage/assist as needed to elevate heels off the mattress as tolerated. Hospice services per orders. Notify nurse of any new areas of skin impairment noted during bathing or daily care (e.g., redness, blisters, bruises, discoloration, impairment related to medical device/tubing). Pressure redistribution mattress to bed . Preventative treatment(s) per orders . Provide a non-irritating surface to reduce friction or shearing forces (when skin drags across a surface). These interventions were created on 3/13/26.Review of Resident #4's Skin Care Plan revealed, Problem Start Date: 04/20/2026 Category: *Skin Integrity Resident has impaired skin integrity related to obesity and incontinence as evidenced by: self-inflicted scratched area on L buttock. Interventions: . Administer treatment(s) per orders. Assist resident with turning and repositioning as needed. Complete skin inspection weekly and as needed. Complete wound evaluation to observe the progress of the resident's skin condition. Encourage resident to reposition self if able. Encourage/assist as needed to elevate heels off the mattress as tolerated. Hospice services per orders. Notify (SPECIFY: Wound Care Company) of any noted worsening skin impairment. Notify Nurse of any new areas of skin impairment noted during bathing or daily care (e.g., redness, blisters, bruises, discoloration, impairment related to medical device/tubing). Notify Physician/NP (nurse practitioner)/PA (physician assistant) of noted worsening skin condition or any new areas of skin impairment. Notify Physician/NP/PA of signs/symptoms of infection (new or change in type/amount/color of drainage, bleeding, foul odor). Palliative services as ordered. Pressure redistribution device in chair. Pressure redistribution mattress to bed . Provide a non-irritating surface to reduce friction or shearing forces. (all of the above interventions were started on 04/20/2026). Provide incontinence care and apply protective barrier cream after each incontinent episode as needed. Start Date: 05/22/2026 air mattress to bed. Start Date: 05/22/2026 specialty cushion to w/c. It was noted that the care plan was nearly identical to the one already in place.In an interview on 5/27/26 at 6:49 AM, Licensed Practical Nurse (LPN) I reported that Resident #4 did not have any wound treatments ordered.During an observation and interview on 05/27/2026 at 9:09 AM Resident #4 was lying in her bed. Hospice Aide (HA) OO was performing a bed bath. HA OO reported that Resident #4 had a painful wound on her left buttocks and a new blister on her right ischial tuberosity (lower buttock/upper leg). Observed open wound approximately the size of a quarter on Resident #4's left buttock with a red firm area surrounding the wound, and the entire upper buttock area was dark red and non-blanchable (redness caused by prolonged pressure, indicative of underlying tissue damage). Both areas were painful when touched. Resident #4 had 2 open wounds on her left chin that were partially crusted with blood and multiple wounds on her chest that were crusted and/or bleeding. Resident #4 reported that she picked at her skin because it itched. Resident #4 reported that when she needed to use the bedpan, she had to wait a long time to have her call light answered.Review of Resident #4's Current Physician Orders revealed, Apply Skin protectant after each incontinent episode/toileting assistance/brief change. Every shift. Start date 3/13/26.'' L (left) buttock apply Triad or barrier cream to R (right) buttock, observe for s/s (signs and symptoms) of infection. Every shift. Start date: 4/29/26. In an interview and observation on 05/28/2026 at 6:50 AM, Resident #4 reported that she had been waiting all night for assistance and now she had a bowel movement in her bed. Resident #4 was positioned leaning to her right side, facing the door, with the head of the bed (HOB) approximately 30 degrees and her call light was on.During an observation and interview on 05/28/2026 at 6:57 AM in Resident #4's room, Certified Nursing Assistant (CNA) O answered Resident #4's call light and the resident requested to be cleaned up. CNA O turned Resident #4's call light off, told her that it would be a few minutes because she needed to find another CNA to help and walked out of the room. Resident #4 reported that she needed to have her head elevated but liked to have a pillow behind her back so that she was off her bottom. At 7:04 AM CNA O entered the room to perform incontinence care. CNA O pulled on the pad underneath Resident #4 to drag the resident to the left side of the bed and then positioned the resident onto her right side. Resident #4 did not help with repositioning. There was a small amount of bowel movement in Resident #4's brief and on the pad underneath her. CNA O cleaned Resident #4 with cleanser and dry wipes. Resident #4 complained of pain when CNA O tried to clean the buttocks area. CNA O wiped directly over the wound on Resident #4's left buttock and then with soiled gloves still on, CNA O grabbed a tube of zinc oxide (barrier cream to protect the skin from moisture), squeezed it into her hand, and smeared it all over Resident #4's buttocks, including the open wound on the left buttocks. Resident #4 complained of pain. CNA O finished with care and positioned Resident #4 on her right side, as she was prior to the care. Resident #4 reported that she normally used the bedpan to have a bowel movement because the stool burned when it touched her skin.In an interview on 05/28/2026 at 7:14 AM, CNA PP reported that she had worked third shift and was staying over to cover call ins. CNA PP reported that she had taken care of Resident #4 twice during the night and had documented the resident's bowel movements (BM's). Review of Resident #4's documentation by CNA's during third shift on 5/27/25-5/28/26 revealed no documentation of care or BM's. In a subsequent interview on 05/29/2026 at 2:01 PM, Director of Nursing (DON) B reported that CNA's are expected to document urine and BM's but there was no documentation for third shift on 5/27/26-5/28/26.In an interview on 05/28/2026 at 10:17 AM, Registered Nurse (RN) M reported that she had been filling in as wound nurse for the past couple of months. RN M reported that she went along with the wound provider once a week but was not familiar with wound staging or how to describe the characteristics of a wound. RN M reported that she could not describe what kind of wounds Resident #4 had. RN M reported that the provider saw Resident #4 on 5/27/26 but she (RN M) was only assisting with positioning and did not observe the wounds.In an interview on 05/28/2026 at 10:28 AM to seek clarification of Resident #4's wound locations and staging, DON B reported that left buttock and coccyx (tailbone area) were being used interchangeably for the same wound location in Resident #4's record. DON B reported that she was not sure why the assessments indicate the wound was first identified on 3/13/26 (admission) but that the first formal assessment in the record was on 4/9/26 and prior to that the skin assessments indicated that there were no open areas. DON B was not aware of a new blister on Resident #4's right ischial tuberosity. DON B reported that Resident #4 currently did not have any open wounds and did not require enhanced barrier precautions (EBP). DON B reported that the wound on Resident #4's left buttock was an abrasion. This surveyor requested an observation of Resident #4's wounds to confirm status and locations.During an observation on 05/28/2026 at 10:52 AM in Resident #4's room, the resident was still positioned on her right side (4 hours). DON B and RN M entered the room and put gloves on. Observed Resident #4's buttocks with a thick coating of white cream covering the entire coccyx/buttock area. The left buttock wound was completely covered with cream, but the redness over the coccyx/buttocks was visible even through the thick cream. DON B touched the left buttock and Resident #4 complained of pain. DON B reported that there was an area of firmness on the left buttock but that she did not see an open wound, it was just an abrasion and the area on the right ischial tuberosity that the hospice aide reported was observed pink and the blister was not visible. Resident #4's left chin wound was covered with ointment but did not have a bandage over it. DON B reported that she still did not feel that Resident #4 was a candidate for EBP. During an observation on 05/28/2026 at 1:09 PM Resident #4 was still lying in bed facing towards the right and her heel was laying flat on the surface of the bed. It was noted that the resident did not have EBP in place. Review of Resident #4's Admissions Assessment dated 3/13/26 at 12:0 0PM revealed, .Some redness in skin folds.otherwise skin intact, no active wounds present.Review of Resident #4's Nurse's Note dated 03/31/2026 at 10:57 AM revealed, Patient is A&O x4. Is able to make needs known.Has scabbed over lesions on the right breast and bilateral upper abdomen that are caused by scratching. Has a stage 1 pressure injury on her coccyx area with two small open areas and healing tissue around the wound. This was the first mention of a wound on Resident #4's buttocks/coccyx area.Review of Resident #4's Wound Provider Visit Note dated 4/8/26 revealed, .Reason for visit: new skin and wound consult. Wound assessment: . left buttock. Primary etiology (cause): Shearing (when skin sticks to a surface while underlying bones or deep tissues move), Stage/severity: Full thickness (through all the layers of the skin and into the fat layer), Wound Status: NEW, Size: 2.5 CM x 0.5 cm x 0.1 cm. Wound base: 25-49% slough (white dead tissue) 75-99% granulation (new tissue that fills the base of an open wound as it heals) Exudate (drainage): scant amount of serous (clear or yellow fluid). Assessment: non-pressure chronic ulcer of buttock with fat layer exposed. Treatment Recommendations: 1. Cleanse with normal saline. 2. Apply Triad paste (absorbs moisture and adheres to wet or broken skin) or similar zinc (skin protectant) based barrier cream, to base of the wound. 3. Secure with (sic) leave open to air. 4. Change BID (twice daily) and PRN.Review of Resident #4's Skin Body Assessment dated 5/18/26 completed by licensed nursing staff revealed, .Areas of skin impairment: .Scab to left cheek due to itching and open area to right ischial tuberosity.Review of Resident #4's Wound Provider Visit Note dated 5/20/26 revealed, .pt (patient) with worsening irritation to chin from scratching/picking; continued pain to left buttocks. Physical examination: . Skin rash, ulcers, cluster of red, crusted lesions to left chin/lower lip area, consistent with localized STAPH INFECTION. Wound assessment: .left buttock.worsening.Size: 3.5 cm x 2.5 cm x0.1 cm. Assessment: non-pressure chronic ulcer of buttock with fat layer exposed, Excoriation (skin picking) disorder, Local infection of the skin and subcutaneous tissue. Treatment Recommendations: 1. Cleanse with soap and water, pat dry. 2. Apply barrier cream, (house supply) to base of the wound. 3. Secure with (sic) leave open to air. 4. Change Q (every) shift and PRN. F/u (follow up) in 1 week; consider transition to hydrocolloid patch to affected area.Review of Resident #4's Progress Note dated 5/21/26 created by DON B revealed, .Resident has excoriation/shearing area on her L (left) buttock that has increased slightly in measurement. Wound NP (nurse practitioner) changed treatment at most recent visit Review of Resident #4's Progress Note dated 5/27/26 revealed, New intact blister reported by hospice aide with bed bath to L (left) posterior buttock near thigh .Review of Resident #4's Wound Provider Visit Note dated 5/27/26 at 8:19 PM revealed, .Skin: history of chronic wound, history of chronic skin condition, rash, history of skin picking on face and other areas.Wound Assessment: .left buttock. Primary etiology: Shearing, Stage/severity: Full thickness, Size: 1 CM x 0.4 cm x 0.1 cm. Wound base: 50-74% epithelial (light pink shiny new layer of skin), 50-74% granulation Exudate: scant amount of serous: Assessment: non-pressure chronic ulcer of buttock with fat layer exposed, Excoriation disorder, Local infection of the skin and subcutaneous tissue. Treatment Recommendations: 1. Cleanse with soap and water, pat dry. 2. Apply barrier cream, (house supply) to base of the wound. 3. Secure with (sic) leave open to air. 4. Change Q (every) shift and PRN.In a subsequent interview on 05/28/2026 at 3:52 PM, DON B reported that she and Regional Infection Preventionist (R-IP) FF had re-assessed Resident #4's bottom and observed an open wound on the resident's left buttock and have staged the wound as a Stage 2 Pressure Ulcer. DON B reported that they have initiated EBP and changed the wound treatment orders to include a Hydrocolloid dressing (water proof bandage) to be applied over the wound. DON B reported that the facility would be looking for a new wound provider but in the meantime the facility doctor will be overseeing Resident #4's wound treatment. DON B was not aware that Resident #4 had been on an antibiotic for an infection of the wounds on her face.Review of Resident #4's Progress Note Dated 5/28/26 at 4:06 PM revealed, At approximately 11 AM DON, charge/wound nurse and surveyor entered (Resident #4's) room to observe skin on L (left) buttock. At this time the area was charted as abrasion was not visualized as open. The area noted in progress notes as a blister was not visualized as a blister but a small pink blanchable area 0.5 cm x 0.3 cm not open will monitor. Barrier cream was applied to buttock. Area was reassessed with DON and regional nurse at approximately 3:30 PM, resident was turned onto R (right) side, and the L buttock had an open area 1 cm x 0.5 cm x 0.1 cm that was assessed as a Stage 2. The area (sic) awaiting return call from (Physician Assistant) for treatment order. CP (care plan)/profile updated, enhanced barriers initiated, Hospice notified, air mattress in place, dietary interventions in place with monitoring, gel cushion to wheelchair. (Resident #4) is on hospice and at risk for skin breakdown. She chooses to stay in bed and will refuse to get up in wheelchair, she frequently requires her HOB to be elevated for ease of breathing r/t (related to) CHF (congestive heart failure)/COPD (Chronic obstructive pulmonary disease). Staff will continue to assist with turning and repositioning frequently and as resident allows. Unavoidable wound assessment completed for MD (medical doctor) to sign.Review of the facility policies for Staging Classification per National Pressure Injury Advisory Panel dated 6/2019 revealed, Staging Classification per National Pressure Injury Advisory Panel: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.Review of the facility policy Pressure Injury Prevention and Care last reviewed 1/20226 revealed, . 5. Interventions will be implemented, and care planned to prevent pressure injury development or to promote pressure injury resolution. Examples of interventions based on individualized resident needs may include the following. This list is not all-inclusive, nor does it apply to every resident or situation: Pressure reduction cushion to wheelchair. Keep skin clean and dry . Avoid friction or shearing when assisting resident with transfers. Manage incontinence and use moisture barrier. Repositioning of residents; provision of required assistance as allowed and tolerated. Use positioning devices (pillow, blanket, folded sheet, etc.) to prevent skin-on-skin contact when positioning a resident on their side in bed.

This citation pertains to intakes #3026243, #3026437Based on interview and record review, the facility failed to develop and implement person centered dementia care interventions to address needs for 1(Resident #22) of 5 residents reviewed for dementia care, resulting in Resident #22 demonstrating symptoms of unmet care needs which included ongoing wandering, exit seeking, physical aggression toward others and rehospitalization.Findings include: Review of The Unmet Needs Model, [NAME]-[NAME] and [NAME] (1995), revealed that those with dementia develop problem behaviors from an imbalance in the interaction between life-long habits and personality, current physical and mental states, and less than optimal environmental conditions. Resident #22 Review of an admission Record revealed Resident #22 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia (an umbrella term for a decline in mental abilities severe enough to interfere with daily life). Review of a Care Plan for Resident #22 with a reference date of 5/16/26 revealed the following problems/goals/approaches: 1. Problem: Severe impaired cognitive function related to diagnosis of Alzheimer's (progressive, irreversible brain disorder that results in loss of memory, thinking skills, and the ability to carry out the simplest tasks). Goal: Resident will have reduced complications.related to his cognitive function.Approaches: Administer medications as ordered, do not overwhelm resident with too many choices, keep resident's routine as consistent as possible. 2. Problem: (Resident #22) is at risk for elopement related to memory deficit, confusion and inability to read or write due to Alzheimer's. Goal: (Resident #22's) safety will be maintained.Approaches: Calmly redirect and divert resident's attention when showing signs of exit seeking. Do not approach (Resident #22) from behind.Distract (Resident #22) .by offering pleasant diversions, structured activities.books.he was the head of the treasury department.give him papers to sort or loose binders to hold, ask him to assist you. Of note, the care plan did not address Resident #22's episodes of physical aggression toward others. In an interview on 5/29/26 at 10:37am Social Services (SS) D confirmed she was responsible for dementia care interventions for the residents at the facility. SS D reported she did not really know Resident #22 very well, didn't know his likes and dislikes or specific activities that might catch his attention. SS D reported she did know one statement that was useful in redirecting Resident #22, but it had not been added to his care plan. SS D reported Resident #22 displayed nearly constant wandering from the time of his admission to the facility. SS D reported Resident #22 repeatedly set off the exit alarm on the door near his room. SS D reported it seemed like Resident #22 did not know where he was and she planned to ask his wife to bring in familiar items to place in his room but hadn't gotten to it yet. SS D reported upon admission, Resident #22 was not monitored to determine what triggered his wandering or his other behaviors. When queried about what triggered Resident #22's restlessness, wandering, and physical aggression, SS D reported it was Just his dementia, we don't know. SS D confirmed Resident #22 had two episodes of physical aggression directed toward other residents and several toward staff prior to being discharged back to the hospital due his unmanaged behaviors. SS D reported Resident #22 had not been evaluated by the facility's contractual behavioral health provider. Review of the medical record revealed Resident #22 had resident-to-resident altercations on 5/23/26 and 5/26/26. In an interview on 5/28/26 at 1:36pm, Licensed Practical Nurse (LPN) JJ when she cared for Resident #22 on 5/23/26, the resident wandered all day and was frequently in and out of other residents' room. LPN JJ reported the staff tried to meet his needs that day but were not successful. LPN JJ reported Resident #22 was wandering around the facility when he approached another resident in her doorway and became physically aggressive toward her. LPN JJ reported immediately after the incident, Resident #22, who had been continent, urinated in the hallway. LPN JJ confirmed Resident #22 could not verbalize his needs and may have been stressed because he needed to urinate and did not know where his bathroom was. In an interview on 5/28/26 at 11:26am, Certified Nursing Assistant (CNA) S reported Resident #22 could not verbalize his needs and constantly wandered around the facility, including going in and out of other residents' rooms. CNA S reported she witnessed several occasions in which other residents yelled Get out! at Resident #22 as he entered their rooms. CNA S reported she tried to engage Resident #22 in activities to reduce his wandering, but did not know what he liked, and was not successful. In an interview on 5/28/26 at 12:04pm, CNA R reported Resident #22 wandered constantly and frequently went into other residents' room and tried to remove his pants. CNA R reported she did not know how to meet his needs and felt he always needed a staff member with him, but that was not possible. In an interview on 5/28/26 at 3:30pm. Family Member (FM) BB reported Resident #22 was admitted to a behavioral health hospital on approximately 5/2/26 due to episodes of physical aggression; Resident #22 was injured there, then admitted to an acute care hospital prior to coming to the facility. FM BB reported she had been very open with the facility about Resident #22's need for dementia care interventions and close supervision. In an interview on 5/29/26 at 1:28pm, Nursing Home Administrator (NHA) A reported Resident #22 came to the facility following an admission to an acute care hospital after a fall at a behavioral health hospital. When queried, NHA A reported she did not inquire about why Resident #22 was initially hospitalized in a behavioral health hospital. NHA A confirmed the facility must be aware of each residents' history to provide resident centered care. NHA A reported upon admission to the facility, Resident #22 wandered frequently, needed increased supervision and became combative toward staff when he was redirected too often. NHA A reported she later learned, prior to his admission to the facility, Resident #22 had been admitted to the behavioral health hospital due to stress responses that included physical aggression toward others. NHA A reported ultimately, Resident #22 was sent back to the acute care hospital following his second altercation with another resident. Review of a Care of a Resident with Dementia policy with a reference date of 1/25 revealed Purpose: To ensure that the individual needs of the resident with Dementia are met and that the staff have the knowledge to provide the appropriate care and services.Potential Interventions for the resident with Dementia: It is important to have an accurate assessment of the residents past life and current diagnosis.IDT (Interdisciplinary Team) should meet to discuss.best interventions needed for the specific resident.Ensure you are providing a patient centered care environment by communicating with the resident and or family. Review of Progress Note dated 05/26/2026 at 03:22 PM, .Pt (Patient) combative at 1515 (3:15 PM). Pt was witnessed assaulting another pt. Putting her in a headlock and punching her several times in the face. Pt was removed from other pts room. Placed on 1:1. On 10 (sic) minute checks was last observed making up bed within last 10 minutes . Review of Activity Note dated 05/15/2026 at 03:44 PM, .(Resident #22) has a dx (diagnosis) of dementia. He is married and has been for 51 years. He was an accountant .he has sat and listened to music . This intervention was not added to the resident's profile or care plan. Review of Progress Note dated 05/19/2026 at 08:00 AM, Received pharmacy recommendation r/t (related to) Risperdal usage.discontinued Risperdal as was used for sleeping per wife . Review of Orders for Resident #22 revealed, .risperidone tablet; 0.5 mg; amt: 1; oral Twice A Day; 07:00 AM - 11:00 AM, 07:00 PM - 11:00 PM .discontinued on 5/19/26. Risperidone is an atypical antipsychotic medication used to rebalance dopamine and serotonin (brain chemicals that regulate mood, emotion, and behavior) to improve thinking, mood, and behavior .it may take 2-3 months before you would feel the full effects of the medication .symptoms continue to get better the longer you take risperidone .do not stop taking risperidone suddenly, a gradual withdrawal when discontinuing to avoid acute withdrawal syndrome. https://www.nami.org/treatments-and-approaches/mental-health-medications/types-of-medication/risperidone-risperdal/ In an interview on 05/29/2026 at 11:01 AM, Licensed Practical Nurse (LPN) GG reported providing supervision for Resident #22 was very problematic as he was wandering in other resident's rooms and this was causing concerns, residents were yelling at him to get out of their rooms, and he was going through his roommate's dresser. LPN GG reported he was exit seeking and would go to the exit doors. Resident #22 was always wandering during the day and staff would have to ensure not to leave anything where he could obtain it to keep him safe. LPN GG reported Resident #22 was someone who would benefit from more one to one staffing as he was ambulatory and it was difficult to do the job you were there for and keep an eye on him to keep him safe and others. In an interview on 05/29/2026 at 1:39 PM, LPN J reported she would have Resident #22 walk with her and be with her where she went in the building as it was easier for her to do her job and to be able to keep an eye on him. LPN J reported Resident #22 was placed on 15-minute checks a few times during his stay at the facility. LPN J reported Resident #22 had attempted to hit her, was able to redirect him, and he tried to slap her again. LPN J reported he had a sitter and attempted to beat up the sitter so the facility had to send in a male CNA to sit with him. LPN J reported quite a few residents were complaining about Resident #22 walking into their rooms, and it was causing a problem. LPN J reported Resident #22 was having a decline and she was unsure if something medical was happening. LPN J reported he was not on a scheduled anxiety medication to help with his anxiousness and wandering and she was surprised he was not prescribed one. After he had assaulted another resident, he was prescribed Ativan as an as needed anti-anxiety medication. In an electronic correspondence from Nursing Home Administrator A reported there was not a true education schedule and the learning program was self paced. Review of completion report requested completed educations since last recertification survey for Dementia Care revealed several staff members from all areas of concentration had not completed the required training; Dementia Hand in Hand training, Dementia Care: Maintaining Routines and Consistency, Nursing Management -Dementia Related Behaviors, and Dementia Person Centered Care Plans.

Based on interview and record review the facility failed to maintain a medication error rate less than 5% in 1 resident (Resident #29) of 5 residents reviewed for medication administration, resulting in the potential for medication adverse effects. The medication error rate was 6.25%.Findings include: Review of an admission Record revealed Resident #29 was originally admitted to the facility on [DATE].During an observation on 05/28/2026 at 7:39 AM in Resident #29's room, Agency-Licensed Practical Nurse (A-LPN) II handed Resident #29 her inhaler Breyna and the resident took 2 puffs. A-LPN II did not encourage Resident #29 to swish and spit with water following the inhaler.In an interview on 5/28/26 at 7:50 AM, A-LPN II reported that Breyna inhaler was not a steroid and did not require a swish and spit after administration. This surveyor requested that A-LPN II double checked that information. A-LPN II reviewed the label of Breyna and reported that yes, it says to swish and spit after administration to avoid getting thrush (yeast infection) in the mouth.During an additional observation on 05/29/2026 at 9:05 AM in Resident #29's room, A-LPN LL handed Resident #29 her Breyna inhaler and the resident took 2 puffs and handed it back to the nurse and took a drink of her water. A-LPN LL did not encourage Resident #29 to swish and spit after administration of the inhaler.In an interview on 05/29/2026 at 9:12 AM, A-LPN LL reported that with Breyna inhaler, it is recommended to swish and spit afterwards and stated, .I think we just do what the resident allows.this is my first time with her.Review of Resident #29's Physician Orders revealed, Budesonide-formoterol (Breyna) HFA aerosol inhaler.2 puffs inhalation twice a day. Start Date: 4/24/26.Review of Breyna Package Insert revealed, .Administration Information: BREYNA should be administered as 2 inhalations twice daily (morning and evening, approximately 12 hours apart), every day by the orally inhaled route only. After inhalation, the patient should rinse the mouth with water without swallowing.Adverse Reactions/Side Effects: .inhaled corticosteroid used may result in the following: Candida albicans infection.In clinical studies, the development of localized infections of the mouth and pharynx with Candida albicans has occurred in patients treated with budesonide and formoterol fumarate dihydrate inhalation aerosol. When such an infection develops, it should be treated with appropriate local or systemic (i.e., oral antifungal) therapy while treatment with BREYNA continues, but at times therapy with BREYNA may need to be interrupted. Advise the patient to rinse his/her mouth with water without swallowing following inhalation to help reduce the risk of oropharyngeal (mouth & throat) candidiasis (yeast infection).In an interview on 05/29/2026 at 9:25 AM, Director of Nursing (DON) B reported that when an inhaled steroid is administered the nurse should encourage the resident to swish and spill to avoid getting a mouth infection.Review of Fundamentals of Nursing ([NAME] and [NAME]) revealed, Professional standards such as Nursing: Scope and Standards of Practice (ANA, 2010) .apply to the activity of medication administration. To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 39307-39313). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review, the facility failed to effectively implement Enhanced Barrier Precautions (EBP) and maintain infection control standards during incontinence (involuntary leakage of urine and feces) care per Centers for Disease Control and Prevention (CDC) guidance, in 2 residents (Resident #39 & #4) from a total sample of 20 residents, resulting in the potential for cross-contamination and the development and spread of infection to a vulnerable population.Findings include:Resident #39Review of an admission Record revealed Resident #39 was originally admitted to the facility on [DATE].During an observation on 05/27/2026 at 6:40 AM in Resident #39's room, the resident was observed lying in bed and a bag with urine was observed hanging on the bed frame. There was no signage indicating that Resident #39 had EBP in place.During an observation on 05/27/2026 at 8:17 AM in Resident #39's room, Certified Nursing Assistant (CNA) R entered the room to assist the resident with care. CNA R entered the room and was not wearing a gown. CNA R put gloves on and used disposable wipes to clean Resident #39's bottom after he had a bowel movement (BM). There was no signage indicating that Resident #39 had EBP in place.Review of Resident #39's Progress Notes dated 5/26/26 at 3:05 PM revealed, Resident arrived to facility via EMS (emergency medical services) at approximately 1:00 PM.Resident has a patent foley cath (catheter) (tube inserted through urethra into the bladder to drain urine), urine yellow. incontinent of bowel.Review of Resident #39's Physician Orders revealed, Catheter Care every shift.Start Date: 5/26/26.During an observation on 05/27/2026 at 9:31 AM, Director of Nursing (DON) B placed a sign indicating EBP on Resident #39's door and placed a cart with gowns, gloves, and masks in the hall outside of the resident's room.In an interview on 5/29/26 at 3:52 PM, DON B reported that Resident #39 should have been placed on EBP upon admission due to having an indwelling device. Resident #4Review of an admission Record revealed Resident #4 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: seborrheic dermatitis (flaky, itchy, inflamed skin).Review of Resident #4's Skin Care Plan revealed, Problem Start Date: 04/20/2026 Category: *Skin Integrity Resident has impaired skin integrity related to obesity and incontinence as evidenced by: self-inflicted scratched area on L buttock.Review of Resident #4's Behavior Care Plan revealed, Problem Start Date: 05/08/2026 Category: *Behaviors Resident has behavior(s): aggressively scratching skin and picking at skin causing injury/open areas. Interventions: .Approach Start Date: 05/08/2026 Attempt to redirect resident when exhibiting behaviors by reminding her she is picking at her skin; re-approach when resident has de-escalated.During an observation and interview on 05/27/2026 at 9:09 AM Resident #4 was lying in her bed. There was no indication that Resident #4 had EBP in place. Hospice Aide (HA) OO was performing a bed bath, wearing gloves and no gown. HA OO reported that Resident #4 had a painful wound on her left buttocks and a new blister on her right lower buttock crease. Observed open wound approximately the size of a quarter on Resident #4's left buttock with a red firm area surrounding the wound, and the entire upper buttock area was dark red and non-blanchable (redness caused by prolonged pressure, indicative of underlying tissue damage). Both areas were painful when touched. Resident #4 had 2 open wounds on her left chin that were partially crusted with blood and multiple wounds on her chest that were crusted and/or bleeding. Resident #4 reported that she picked at her skin because it itched.Review of Resident #4's Current Physician Orders revealed, 1. Mupirocin Calcium Cream 2 % (topical antibiotic), apply to facial lesions BID (twice daily) for 7 days then BID PRN (as needed) for recurrence. Start Date: 5/20/26. 2. Chin/lower face areas: monitor for signs/symptoms of infection Q (every) shift until healed. Start Date: 5/8/26. 3. L (left) buttock apply Triad (skin protectant cream) or barrier cream to R (right) buttock, observe for s/s (signs and symptoms) of infection. Every shift. Start date: 4/29/26. 5. Skin prep to L chest area daily and PRN. Start date: 5/20/26.During an observation and interview on 05/28/2026 at 6:57 AM in Resident #4's room, Certified Nursing Assistant (CNA) O answered Resident #4's call light and the resident requested to be cleaned up. There was no signage indicating that Resident #4 had EBP in place. At 7:04 AM CNA O entered the room to perform incontinence care. CNA O put gloves on but did not put a gown on. There was a small amount of bowel movement in Resident #4's brief and on the pad underneath her. CNA O cleaned Resident #4 with cleanser and dry wipes. Resident #4 complained of pain when CNA O tried to clean the buttocks area. CNA O wiped directly over the wound on Resident #4's left buttock and then with soiled gloves still on, CNA O grabbed a tube of zinc oxide (barrier cream to protect the skin from moisture), squeezed it into her hand, and smeared it all over Resident #4's buttocks, including the open wound on the left buttocks. Resident #4 complained of pain. CNA O finished with care and positioned Resident #4 on her right side, as she was prior to the care. CNA O did not change her gloves after they were soiled and prior to applying barrier cream to an open wound.In an interview on 05/28/2026 at 10:28 AM, DON B reported that Resident #4 currently did not have any open wounds and did not require enhanced barrier precautions (EBP). DON B reported that the wound on Resident #4's left buttock was an abrasion and the wounds on Resident #4's chin and chest were caused by scratching and just recently started. This surveyor requested an observation of Resident #4's wounds to confirm status and locations.During an observation on 05/28/2026 at 10:52 AM in Resident #4's room, DON B and Registered Nurse (RN) M entered the room and donned gloves. Observed Resident #4's buttocks with a thick coating of white cream covering the entire coccyx/buttock area. The left buttock wound was completely covered with cream, but the redness over the coccyx/buttocks was visible even through the thick cream. DON B touched the left buttock and Resident #4 complained of pain. DON B reported that there was an area of firmness on the left buttock but that she did not see an open wound, it was just an abrasion. Resident #4's left chin wound was covered with ointment but did not have a bandage over it. DON B reported that she still did not feel that Resident #4 was a candidate for EBP. Review of Resident #4's Wound Provider Visit Note dated 4/8/26 revealed, .Reason for visit: new skin and wound consult. Wound assessment: . left buttock. Stage/severity: Full thickness (through all the layers of the skin and into the fat layer), Wound Status: NEW, Size: 2.5 CM x 0.5 cm x 0.1 cm. Wound base: 25-49% slough (white dead tissue) 75-99% granulation (new tissue that fills the base of an open wound as it heals) Exudate (drainage): scant amount of serous (clear or yellow fluid).Review of Resident #4's Wound Provider Visit Note dated 5/20/26 revealed, .pt (patient) with worsening irritation to chin from scratching/picking; continued pain to left buttocks. Physical examination: . Skin rash, ulcers, cluster of red, crusted lesions to left chin/lower lip area, consistent with localized STAPH INFECTION (bacterial infection). Wound assessment: .left buttock.worsening.Size: 3.5 cm x 2.5 cm x0.1 cm. Assessment: non-pressure chronic ulcer of buttock with fat layer exposed, Excoriation (skin picking) disorder, Local infection of the skin and subcutaneous tissue.Review of Resident #4's Progress Note dated 5/21/26 created by DON B revealed, .Resident has excoriation/shearing area on her L (left) buttock that has increased slightly in measurement. Wound NP (nurse practitioner) changed treatment at most recent visit Review of Resident #4's Wound Provider Visit Note dated 5/27/26 at 8:19 PM revealed, .Skin: history of chronic wound, history of chronic skin condition, rash, history of skin picking on face and other areas.Wound Assessment: .left buttock. Stage/severity: Full thickness, Size: 1 CM x 0.4 cm x 0.1 cm. Wound base: 50-74% epithelial (light pink shiny new layer of skin), 50-74% granulation Exudate: scant amount of serous: Assessment: non-pressure chronic ulcer of buttock with fat layer exposed, Excoriation disorder, Local infection of the skin and subcutaneous tissue.In a subsequent interview on 05/28/2026 at 3:52 PM, DON B reported that she and Regional Infection Preventionist (R-IP) FF had re-assessed Resident #4's bottom and observed an open wound on the resident's left buttock and have staged the wound as a Stage 2 Pressure Ulcer. DON B reported that they have initiated EBP and changed the wound treatment orders to include a Hydrocolloid dressing (water proof bandage) to be applied over the wound. DON B reported that the facility would be looking for a new wound provider but in the meantime the facility doctor will be overseeing Resident #4's wound treatment. DON B was not aware that Resident #4 had been on an antibiotic for an infection of the wounds on her face.Review of Resident #4's Progress Note Dated 5/28/26 at 4:06 PM revealed, .resident was turned onto R (right) side, and the L buttock had an open area 1 cm x 0.5 cm x 0.1 cm that was assessed as a Stage 2. enhanced barriers initiated.Review of CDC guidance at www.cdc.gov/long-term-care-facilities, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes revealed, .13. If a resident does not have a history of a MDRO (multidrug-resistant organism) but does have an indwelling medical device or wound, should they still be placed on Enhanced Barrier Precautions? Yes. Enhanced Barrier Precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for Contact Precautions, even if they have no history of MDRO colonization or infection and regardless of whether others in the facility are known to have MDRO colonization (when the bacteria lives in or on the body without making you sick or causing symptoms). This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized. 14. Why did CDC expand Enhanced Barrier Precautions to include all residents with wounds or indwelling medical devices, regardless of MDRO status? Indwelling medical devices and wounds are risk factors for colonization with a MDRO. Once colonized, these residents can serve as sources of transmission within the facility. The expansion of EBP for all residents with wounds or indwelling medical devices is intended to protect these high-risk individuals both from acquisition and from serving as a source of transmission if they have already become colonized .23. The guidance describes that all residents with wounds would meet the criteria for Enhanced Barrier Precautions. What is the definition of a wound in relation to this guidance? In the guidance, wound care is included as a high-contact resident care activity and is generally defined as the care of any skin opening requiring a dressing. However, the intent of Enhanced Barrier Precautions is to focus on residents with a higher risk of acquiring an MDRO over a prolonged period of time. This generally includes residents with chronic wounds, and not those with only shorter-lasting wounds, such as skin breaks or skin tears covered with a Band-aid or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, and chronic venous stasis ulcers . Reviewed of Implementing the Use of Enhanced Barrier Precautions in Skilled Long-Term Care Nursing Facilities by APIC dated 2024 revealed, .What is considered a chronic wound? The longer a wound is present, the more concern we have for those wounds becoming colonized with an MDRO. Chronic wounds are often poorly healing wounds or areas of the skin in residents with underlying medical conditions, resulting in pressure areas, diabetic ulcers, and venous or arterial stasis wounds .Review of the Centers for Disease Control website (https://www.cdc.gov/handhygiene/providers/index.html) last revised on June 25, 2018 revealed, When to Perform Hand Hygiene .before and after having direct contact with a patient ' s intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed) .After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings .After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient .If hands will be moving from a contaminated body site to a clean body site during patient care . Steps for Glove Use .Change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face) .Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. Failure to remove gloves after caring for a patient may lead to the spread of potentially deadly germs from one patient to another.

Based on observation, interview, and record review, the facility failed to provide care and services to promote dignity and respect in 2 residents (Resident #25 & #5) from a total sample of 20 residents, resulting in long call light wait times and the potential for feelings of diminished self-worth, sadness, and frustration. Findings include:Resident #25Review of an admission Record revealed Resident #25 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #25, with a reference date of 3/9/26 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #25 was cognitively intact. Review of Resident #25's Functional Abilities indicated that she was dependent (helper does all the effort) on staff for toileting.During an observation on 05/28/2026 at 1:22 PM Resident #25's call light was observed on. At 1:29 PM Certified Nursing Assistant (CNA) Q entered Resident #25's room, turned the call light off and told the resident that she would let her (Resident #25's) CNA know that she needed to use the toilet. At 1:38 PM CNA Q entered the room closed the curtain and was providing care to Resident #25's roommate.In an interview on 05/28/2026 at 1:35 PM, Resident #25 reported that she needed to be changed now because she was wet. Resident #25 was in a rush because she wanted to attend a meeting in the dining room at 2:00 PM. In an interview on 05/28/2026 at 3:53 PM, Resident #25 reported that she feels at the mercy of the facility, she did not have time to use the toilet earlier and had to settle with having her brief changed because she waited so long. Resident #25 reported that she waits up to 2 hours for her call light and/or needs to be met. Resident #25 reported that staff frequently turn her call light off and then don't come back.Resident #5Review of an admission Record revealed Resident #5 was originally admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 5/18/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #5 was cognitively intact. Review of Resident #5's Functional Abilities indicated that he required substantial/maximum (helper does more than 50% of effort to perform task) assistance with toileting.In an interview on 05/27/2026 at 11:57 AM, Resident #5 reported that when he puts his call light on, they either don't answer it or don't come back. During an observation and interview on 05/28/2026 at 1:10 PM Resident #5's call light was observed on. At 1:14 PM CNA O yelled from the hall that she would be right there. At 1:30 PM (20 minutes later) CNA Q entered Resident #5's room, and Resident #5 requested to use the bathroom. CNA Q turned the call light off, gave him a urinal and walked out of the room. At 1:31 Resident #5 put his call light on and reported to this surveyor that he needed the urinal removed from between his legs. At 1:45 PM Resident #5's call light was answered. In an interview on 05/29/2026 at 10:09 AM, Nursing Home Administrator (NHA) A reported that the expectation was that staff leave a call light on until the need was met. NHA A reported that it had been quite a while since the facility had performed call light audits and it had not been a topic brought to the monthly QA (quality assurance) meetings.

Based on observation, interview, and record review the facility failed to perform an assessment for self-administration of medication, obtain an order, and update the care plan for 2 residents (Resident #15, #33) of 12 Residents reviewed for self-administration of medications, resulting in the mismanagement of medications with a potential for adverse side effects. Findings include: Resident #15: Review of an Face Sheet revealed Resident #15 was a female with pertinent diagnoses which included cognitive communication deficit (person struggles to communicate due to underlying impairments in mental processes), encephalopathy (disease, damage that affects the function of the brain), Adjustment disorder with mixed disturbance of emotions and conduct (reaction to an event causes more intense distress than normally would be expected), and moderate intellectual disabilities. During an observation and interview on 05/27/2026 at 7:32 AM, observed what appeared to be two crushed medications (one orangish, one yellowish in appearance) in a medication cup on the nightstand next to Resident #15's bed. Resident #15 had a small cup of water on the nightstand. Resident #15 also had an empty medication cup on her rolling bedside table. Review of Care Plan for Resident #15 dated 10/23/2024, revealed the focus, .Psychosocial Well-Being .(Resident #15) has a decision-making impairment R/T (related to) developmentally delayed. (Resident #15) has a court appointed guardian . Review of Resident #15's medical record revealed no orders, self-administration assessment, or updated care plan which allowed Resident #15 to take her medications independently without supervision. In an interview on 05/29/2026 at 10:26 AM, Resident #15 reported the staff took the medication, which was on her nightstand and threw it away. Resident #15 reported the nurses do bring her medication and leave it for her to take when she wants, They do that quite a bit. In an interview on 05/27/2026 at 2:07 PM, Licensed Practical Nurse (LPN) II reported when she entered Resident #15's room she noticed the crushed medications in a medication cup on the nightstand and she removed the medications. LPN II reported Resident #15 doesn't take her medications crushed and reported she could not determine what each of the medications were in the cup as there were two different colored medications in the cup. Resident #33: Review of Face Sheet revealed Resident #33 was a female with pertinent diagnoses which included multiple sclerosis (chronic, autoimmune disorder of the central nervous system) pressure ulcer sacral region (large triangular bone at the base of the spine) stage 4 (severe life threatening injury with tissue loss with exposed bone, muscle, tendon, or ligaments), muscle weakness, paralysis, dependence on wheelchair, diabetes, and heart failure. In an interview on 05/27/2026 at 8:40 AM, Resident #33 reported the medication cup with the room and bed number on it on her rolling bedside table was for medications the nurses had given her. Resident #33 reported the nurses leave her medication with her to take when she was ready as they do not need to stand over her. Resident #33 reported all the nurses leave her medication with her to self-administer.Review of Resident #33's medical record revealed no orders, self-administration assessment, or updated care plan which allowed Resident #33 to take her medications independently without supervision. In an interview on 05/29/2026 2:50 PM, Director of Nursing (DON) B reported in order for the resident to self-administer medications there would be an order in the medical record and a care plan would be implemented for self-administration of medications otherwise the resident should not be allowed to self-administer medications and medications should not be left at the bedside. Review of policy, Self-Administration reviewed 01/2026, revealed, .It is the policy of this facility to honor residents' rights to self-administer medications if a resident verbalizes that he/she wishes to self-administer medications and the interdisciplinary team (IDT) has determined that this practice is clinically appropriate and safe based on individualized resident assessment. with the intervention .5. A care plan will be initiated for residents who can safely self-administer medications .6. A physician's order will be obtained for residents who can safely self-administer medications .

This citation pertains to intakes #3026243 and 3926437Based on observations, interviews, and record review, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 (Resident #2 and Resident #14) of 3 residents review for abuse, resulting in 1. Resident #2 being struck in the head several times, slapped, and kicked in the leg by Resident #22, and experiencing fear and psychosocial harm. 2. Resident #14 being placed in a chokehold (restraining technique in which an arm is tightly wrapped around the neck of another person) by Resident #22 and struck in the head several times.Findings include: Resident #2 Review of an admission Record revealed Resident #2 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: major depressive disorder (common but serious mental health disorder characterized by persistent feeling of sadness, emptiness or loss of interests), anxiety disorder (mental health condition characterized by excessive, persistent and uncontrollable fear or worry), and post-traumatic stress disorder (mental health condition triggered by experiencing or witnessing a terrifying, shocking or dangerous event with symptoms that persist and disrupt daily life). Review of a Minimum Data Set(MDS) assessment for Resident#2 with a reference date of 5/26/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 14/15, which indicated the resident was cognitively intact. Review of a Care Plan for Resident #2 with a reference date of 5/22/26 revealed the following problem/goal/approaches: (Resident #2) has been assessed for the presence of traumatic events in her history and found to have been a victim of trauma. Goal: (Resident #2) will state to social worker if she experiences any traumatic event.Approaches: encourage (Resident #2) to express emotions to.facility social worker in a safe environment, establish trust with resident.behave in a calm manner.provide a calming and reassuring environment. She requests staff check on her though out the HS (night) safety checks. Review of a Trauma Informed Care Observation for Resident #2 with a reference date of 5/27/26 revealed Description.Event 5/23/26.Observation Details.Events: experienced a life-threatening illness, experienced a physical assault, experienced sexual assault(past).Any other very stressful events or experiences? . recent.dementia resident hit me.Comments on event resident was bothered by: I did not have control.How long were you bothered by the event(s)? . bothered by it more than a week.How much did it bother you emotionally? .very much. What are the triggers that remind you of the event? .people coming into my room even if they knock. How do you react when you are reminded of the event? .mad I wished I had fought back.Additional comments: offer (contractual behavioral health services), wishes staff to check on her though out the night. In an interview on 5/28/26 at 3:00pm, Laundry Aide (LA) X reported he was working in the laundry room across the hall from Resident #2's room on 5/23/26 when he heard a petrifying scream through the laundry room door that caused him to quickly investigate what was happening. LA X reported upon entering the hallway, he saw Resident #22 standing over Resident #2 as she sat in her wheelchair in the doorway to her room. LA X reported he saw Resident #22 punch Resident #2 in her left eye and kick her right shin. Resident #2 was screaming and began yelling Help!. LA X reported he feared for Resident #2's safety and placed himself between her and Resident #22 to stop the altercation. LA X described Resident #2 as scared, borderline terrified, wide-eyed, and shaking after the incident. LA X reported he took Resident #2 to Licensed Practical Nurse (LPN) JJ to report the altercation. In an interview on 5/28/26 at 1:36pm, LPN X reported she was assisting another resident in their room at the time of the altercation between Resident #22 and Resident #2. LPN JJ reported upon walking toward the nurse's station, she was approached by LA X as he pushed Resident #2 in her wheelchair. LPN JJ reported Resident #2 was very upset and told her Resident #22 came into her room and punched her in the left side of her head and kicked her legs. LPN X described Resident #2 as very upset and angry. LPN JJ reported Resident #2 voiced fear that Resident #22 would come into her room again and hit her. In an interview on 5/28/26 at 1:31pm, Resident #2 reported on 5/23/26, Resident #22 tried to come into her room and when she told him to leave, he punched her in the face, then slapped her. Resident #2 reported she extended her right leg to try to keep the resident away and when she did, Resident #22 kicked her leg. Resident #2 reported she yelled Help, he's beating me up! during the altercation and LA X responded. Resident #2 stated I was scared to death, and I don't ever want to see (Resident #22) again. Resident #2 reported the following day, she was very tearful about the incident and stated, it hit me hard that day and I felt vulnerable. Resident #2 reported she remained worried about Resident #22 coming back to her room and assaulting her. In an interview on 5/29/26 at 10:37am, Social Services Coordinator (SS) D reported Resident #2 was emotionally upset and angry when she assessed her psychosocial well-being on 5/27/26, 4 days after the altercation with Resident #22. SS D confirmed Resident #2 already had a history of trauma which could intensify her emotional reaction to the situation. SS D reported she did not know that Resident #22 had a history of physical aggression toward others prior to his recent admission to the facility, and interventions were not in place to address Resident #22's physical aggression toward others. In an interview on 5/28/26 at 3:30pm, Family Member (FM) BB' reported Resident #22 had received a 30-day involuntary discharge notice from the assisted living where he resided prior to coming to the facility. FM BB reported the notice was given as the result of Resident #22 demonstrating ongoing physical aggression toward other residents of the assisted living. FM BB reported Resident #22 was transferred to a local behavioral health hospital due to his physical aggression toward others, where he then fell and was then sent to a local acute care hospital before being accepted for placement at the facility. In an interview on 5/29/26 at 12:05pm, Regional Director of Sales (RDS) EE reported she was acting as the interim liaison for admissions for the facility and reviewed Resident #22 for admission to the facility. RDS EE reported she learned from a case manager in the acute care hospital that Resident #22 was sent to a behavioral health hospital from an assisted living setting after displaying unmanaged agitation. RDS EE reported she was told the assisted living was no longer willing to allow him to reside there. RDS EE confirmed she did not discuss the circumstances surrounding Resident #22's admission to the behavioral health hospital with the resident's family member and the resident could not answer questions. RDS EE confirmed she did not determine the extent of Resident #22's agitation that led to his hospitalization. RDS EE reported she observed Resident #22 while he was in the acute care hospital, and based on a brief observation, felt his care needs could be managed at the facility. RDS EE reported it was the expectation the facility would review the referral materials to determine if the resident's care needs could be met at the facility. In an interview on 5/29/26 at 1:28pm, Nursing Home Administrator (NHA) A reported the facility was aware Resident #22 had been hospitalized in a behavioral health hospital prior to coming to the facility but did not inquire about his behavioral health needs prior to his admission. NHA A reported she assumed Resident #22 went to the behavioral health hospital for medication management but did not inquire about the resident's behaviors that resulted in hospitalization. NHA A reported after Resident #22 punched and kicked Resident #2 on 5/23/26, the facility learned he had been hospitalized in the behavioral health hospital for similar behavior toward fellow residents in the assisted living where he previously resided. Review of an Abuse Prevention Program policy with a reference date of 1/26 revealed (Corporation Name) has prevention programs in which policies and procedures safeguard our residents to be free from abuse.abuse is defined as the willful infliction of injury.willful, means the individual .acted deliberately.having a.cognitive impairment does not automatically preclude a resident from engaging in deliberate.actions.Physical abuse includes.hitting, slapping, punching.kicking.Screening of prospective residents will be conducted to determine whether the facility has the capability to provide the necessary care and services for each resident admitted . The procedure includes, but is not limited to. a. An assessment of the functional and mood/behavior status. Resident #14: Review of a Face Sheet revealed Resident #14 was a female with pertinent diagnoses which included dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities), stroke, paralysis, dysphagia (difficulty swallowing), malnutrition, need for assistance for personal care, and speech impairment. Review of Progress Notes dated 05/26/2026 at 05:13 PM, .400pm DON (Director of Nursing) notified of another resident hitting (Resident #14) in the face and head. Residents were immediately separated by staff. Skin assessment completed by charge nurse (Licensed Practical Nurse (LPN) GG). DON observed a raised, red/purple area on (Resident #14's) L (left) proximal (central) cheek bone 3cm (centimeter) x 2cm.received orders to monitor bruised area and recheck skin on 5/27/26 for any additional bruising or injury. Review of Incident Summary dated 5/26/26, revealed, .On 5/26/26 at approximately 3:30 pm, staff reported to administrator that there had been a resident-to-resident physical abuse altercation. Staff witnessed (Resident #22) making contact with (Resident #14)'s right (injury was on the left) side of (her) head with a closed hand.(Resident #22) was placed back on 1:1 supervision. Skin assessment completed of (Resident #14), no obvious bruising noted yet but will continue to monitor for changes.(Resident #22) had been on 1:1 supervision from 5/23/26, up until 6am this morning, 5/26/26, r/t (related to) another allegation of abuse still in the investigation process. New order was obtained for Ativan PRN (as needed) during this time frame.this medication has a history of being effective in (Resident #22)'s past behavioral situations.Order obtained to send (Resident #22) to ER for psych evaluation. Review of Skin assessment dated [DATE] at 6:20 PM, revealed, .pt (patient) has bruising under L (left) eye. Pt has soreness on back and neck but no visible scarring, likely to bruise given skin integrity and force . During an observation and an interview on 05/27/2026 at 1:41 PM, Resident #14 reported Resident #22 had come into her room while she was eating some dark chocolate, and she had not been paying attention. Resident #14 reported he had mental problems and he belonged somewhere other than at the facility. She reported the facility had sent Resident #22 to the hospital. Resident #14 reported as Resident #22 was at the hospital she was not concerned for her safety but would be if he came back to the facility. Observed a red/pinkish area on her left upper cheek area approximately the size of a quarter. Review of Progress Note dated 05/27/2026 at 06:24 PM, .(Resident #14) when assessed her for trauma from the 05-26-2026 event she said she was more PO'd (pissed off) that the resident (Resident #22) caught her off guard. She told this social worker I was enjoying my piece of dark chocolate and then he came into my room, that's when he hit me. She knows this resident will not be returning to (Facility). Review of Progress Note dated 05/27/2026 at 12:27 PM, .Skin assessment finds redden area above L cheek bone, painful to touch. In an interview on 05/28/2026 at 11:40 AM, Certified Nursing Assistant (CNA) T reported everything happened so fast, she had just gone by Resident #22's room and he was in his room. Then (Resident #14) was in the hallway, crying bawling her eyes out. CNA T reported (Resident #22) moved so fast, he was quick and it was hard to keep an eye on him. CNA T reported Resident #22 had walked around constantly, and he was constantly at the exits, had to hurry up and get him, it was hard to try to supervise him and also give care to the other residents. CNA T reported one second he was down in bed and then he was up and in another resident's room. CNA T reported once the residents were separated and CNA P was assisting Resident #14 to the nurse's station; Resident #22 had hopped into bed with another resident whose room was across from his and next to Resident #14's room. CNA T reported he was redirected to his room and went to figure out what the DON wanted to do with Resident #22. During an observation on 05/29/2026 at 10:39 AM, Resident #14 had a redness/pinkish area under her left eye on her cheek bone. The area was approximately the size of a nickel. Resident #22: Review of an admission Record revealed Resident #22 was a male with pertinent diagnoses which included dementia. Review of Progress Note dated 05/12/2026 at 7:30PM PM, .Resident noted to be confused and disoriented during the shift. He was observed ambulating into another resident's room unclothed and displaying inappropriate behavior toward the resident occupying the room. Review of Progress Note dated 05/13/2026 at 04:01 PM, .(Resident #22) is a new admit with primary dx (diagnosis) of Multiple L (left) Rib Fractures after a fall. He also has fx (fracture) of the R (right) clavicle (collarbone) with dislocation.Has recently been in (Local Behavioral Unit at hospital) for treatment r/t (related to) Severe dementia. He is A&O (alert & oriented) x1 (to self) and has been walking in the hall independently without purpose. These are new surroundings for the resident, and he did go into other rooms.confusion of surroundings and severe dementia and frequent checks initiated per policy. 15 minutes checks discontinued. (Resident #22) admitted on Seroquel without current diagnosis. Provider aware and will evaluate record to determine need at initial visit. Note: Resident #22 did not have Seroquel as a prescribed medication upon admission. Review of Progress Note dated 05/15/2026 at 9:12 PM, .Resident wandering the halls in and out of resident's rooms, pushing on exit door next to room. Review of Resident Profile start date of 5/16/26, revealed, .Do not approach (Resident #22) from behind or the side he will startle and may strike out. Review of Progress Note dated 05/19/2026 at 08:00 AM, .Received pharmacy recommendation r/t (related to) Risperdal usage.discontinued Risperdal (on 5/19/26). Review of Progress Notes dated 05/21/2026 at 01:55 PM, .Resident continues to wander throughout facility and into other resident's rooms.Resident is placed on 15min checks. active working wander guard placed on the R (right) ankle. Review of Progress Notes dated 05/22/2026 at 10:10 AM, .Resident alert and oriented to self, confusion.Resident continues to wander throughout facility and into other resident's rooms.Resident walks independently throughout facility. Review of Progress Notes dated 05/23/2026 at 05:40 AM, .Resident oriented to self, very confused. Wanders in and out of rooms throughout the evening into the late hours. After so many redirections, resident becomes angry and pushing at staff.Resident wants to follow staff into rooms. Review of Progress Note dated 05/23/2026 at 07:14 PM, .Writer in assisting with new admission when loud outburst heard in hallway. Resident had taken another resident's phone and would not return it.After multiple attempts phone was returned.another resident and staff member approached nursing station to report an incident involving (Resident #22).wandered into another resident's room and became aggressive hitting her on the left side of her head, lt (left) side of her face and kicking her in her rt (right) leg below the knee.resident pulled out penis and began to void in the corner of the nursing station. Review of Progress Notes dated 05/24/2026 at 06:45 PM, .Resident wandering into other residents' rooms and throwing objects on floor. This nurse redirected resident to hallway and offered snack/puzzle to resident until caregiver present. Review of Skilled Note dated 05/24/2026 at 11:16 PM, .Resident alert and oriented to self, he spent the shift wandering the halls and required frequent redirection from staff.Staff provided continuous 1:1 supervision throughout the shift due to increased behaviors and safety concerns. Resident attempted to hit staff on a couple of occasions. Review of Progress Note dated 05/26/2026 at 12:06 PM, Resident continues to wander throughout facility and into other resident's rooms.really confused.currently on 15 min checks. Review of Progress Note dated 05/26/2026 at 03:22 PM, Pt (Patient) combative at 1515 (3:15 PM). Pt was witnessed assaulting another pt. Putting her in a headlock and punching her several times in the face. Pt was removed from other pts room. Placed on 1:1. In an interview on 05/28/2026 at 12:09 PM, CNA R reported when she worked on Sunday (5/24/26), Resident #22 was on a one on one for supervision. In an interview on 05/28/2026 12:53 PM, CNA KK reported he was taken off his assignment to be on a one on one with (Resident #22). CNA KK reported Resident #22 walked the hallways, attempted to wander in different residents' rooms, and was queued back to his room. In an interview on 05/29/2026 at 11:01 AM, LPN GG reported the day (5/26/2026) of the incident involving Resident #14 and Resident #22, she was sitting at the nurse's station with the other nurse as it was shift change, reported she would be the only nurse on the floor. LPN GG reported she had heard someone yelling out, Hey, Hey, Hey what are you doing? CNA came up to the nurse's station with (Resident #14) and reported (Resident #22) had her in a head lock and was punching her in the face. LPN GG reported she had another staff member stay with Resident #22 in his room. LPN GG reported Resident #14 was really upset. (Resident #22) was given an as needed dose of Ativan. LPN GG reported she assessed (Resident #14)'s skin, neck and face areas and her left eye had a mark under it, she was sore likely to bruise as she was so frail, no immediate bruising noted on her face. LPN GG reported the wandering into other residents' rooms was not new for (Resident #22) and he would have to be reminded to not go in their rooms and/or the residents were yelling at him to get out. LPN GG reported the EMS staff who reported already knew (Resident #22) from another facility due being transported for evaluation due to his behaviors. LPN GG reported after the PRN Ativan, he was still a little combative and did not cooperate to get on the stretcher before being taken for evaluation. In an interview on 05/29/2026 at 12:13 PM, CNA P reported when the incident happened between Resident #14 and Resident #22 on 5/26/2026, she had just cleaned up pee on Resident #22's floor in his room, and she was walking down the hallway towards the nurse's station to grab a hoyer to assist another resident out of bed. CNA P reported she had heard yelling, Call 911, Call 911! Help me! and when she arrived in Resident #14's room she observed Resident #22 had Resident #14 in a head lock with his arm around her head and he was punching her in the face, not light hits either, he got her 3 times hard in the face that she saw. CNA P' reported she had placed her body over Resident #14 to protect her from getting punched in the face and he continued to punch striking her on her back. While CNA P was pushing Resident #14 out of the room to get her away from him, Resident #22 then grabbed the call light, swung it at her and hit her (CNA P) in the head with it. CNA P reported she transferred Resident #14 to the nurse's station and went back down the hallway and observed Resident #22 was lying in bed with another resident whose room was next to Resident #14's room. CNA P reported a few days after Resident #22 had admitted he had swung at a nurse and struck her in the face, and he had assaulted another resident a few days before he assaulted Resident #14. CNA P reported the behavior was not new for Resident #22. In an interview on 05/29/2026 at 2:56 PM, Director of Nursing (DON) B reported the decision to place a resident on 15 minute checks was determined by behaviors when the resident was removed from 15 minute checks. The interdisciplinary team (IDT) discussed the observations, staff discussions, and behaviors and made a decision to remove the resident from 15 minute checks based on that information. DON B reported she went to the nurse's station to assess Resident #14 and determine what had happened. DON B reported it was reported Resident #22 had struck Resident #14 several times in the face in her room.

This citation pertains to intake #2677662Based on interview, and record review, the facility failed to provide adequate monitoring and supervision to prevent elopement and respond appropriately to door alarms and Wanderguard (an alert bracelet that triggers an alarm near specific exits in the facility) alarms to ensure resident safety in 2 residents (Resident #101 and #104) of 2 residents reviewed for elopement/supervision, resulting in an Immediate Jeopardy when on 11/23/25 at approximately 6:00 PM, Resident #101 who was an elopement risk, exited the facility, unbeknown to facility staff, and was found by another resident, standing outside of the facility at an emergency exit door and the potential for Resident #104 to elope due to unknown Wanderguard functionality. This deficient practice placed all residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include:The facility failed to provide adequate supervision to prevent elopement for Resident #101, who was an elopement risk with a known history of following staff to exit doors, and respond appropriately to an alarming exit door to ensure resident safety. Resident #101 was found by another resident approximately 10 minutes later, located approximately 70 feet from where she had exited the building, standing outside of the facility, pulling on an exit door in an attempt to reenter the facility. The Immediate Jeopardy began on 11/23/25 when the facility failed to supervise Resident #101 and she eloped from the facility at approximately 6:00 PM. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy on 12/16/25 at 2:20 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 12/17/25, but noncompliance remains at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance has not been verified by the State Agency.Resident #101Review of a Face Sheet revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 8/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #101 had severe cognitive impairment. Review of Resident #101's Elopement Risk Assessment dated 8/23/25 indicated the resident was at risk for elopement due to the resident being physically capable of walking out of the facility, having had a history of wandering or elopement, had verbalized the desire to leave the facility or return home, and the resident searches for spouse or family. Review of Resident #101's Fall Risk Assessment dated 8/23/25 indicated the resident was at high risk for falls due to cognitive impairments, incontinence, foot problems and medications that can cause low blood pressure. Review of Resident #101's Behavioral Care Plan dated 4/8/25 revealed, At risk for elopement from the facility r/t (related to) exit seeking behavior and/or verbalizations of wanting to leave. Interventions: .wears a wander guard, function and placement checked every shift.Review of Resident #101's Elopement Risk Biographical Data located in the elopement binder at the nurse's station revealed, a photograph of the resident, a list of physical characteristics, responsible party contact information, and Behavior Patterns: confused, seeking exit to find her car and significant other.Review of the Facility Reported Incident (FRI) for Resident #101 revealed, On 11/23/25, Administrator was notified of (Resident #101) having been outside unattended and unsupervised, and brought back into the facility. Per staff, resident was last seen indoors approximately 10 minutes prior to this event. Resident was dressed in sweat pants, a plaid button up shirt and a cardigan sweater with furry boots on her feet. Temperature outside was 43 degrees Farenheit at the time. Wanderguard was in place and functioning properly, verified by maintenance director upon inspection. Physician, DON (Director of Nursing), and brother of the resident was notified. Vital signs obtained and within normal limits. Head to toe assessment and pain assessment was completed and no areas of concerns noted at this time. Resident has a BIMS score of 3. Resident was pleasant and no acute distress was noted. During investigation of elopement on 11/23/25, the facility identified staff did not respond to the door alarm in a timely manner to reduce risk of elopement for a resident identified as an elopement risk.In an interview on 12/16/25 at 8:25 AM, NHA A reported that on 11/23/25 Resident #101 was believed to have exited the facility unsupervised through the employee entrance door, in an attempt to follow Certified Nursing Assistant (CNA) C, who had left the facility for break at approximately 6:00 PM. An agency nurse, Registered Nurse-Agency (RN-A) J was approached by another resident (at an unknown time), who reported that Resident #101 was seen outside of the facility at the end of west hall trying to open the emergency exit door. At that time RN-A J brought the resident inside. NHA A reported that CNA C have driven to a nearby store and returned to the facility reportedly 10 minutes later to find multiple alarms sounding, but Resident #101 was already back inside of the building at that time. NHA A reported that RN-A J stated that he had heard the alarms but had expected the alarms due to shift change as staff were entering the building through alarmed doors and therefore did not respond to them. During an observation on 12/16/25 at 9:18 AM near the nurse's station, Resident #101 was walking back and forth, speaking to staff, and asking where certain people were. The resident was easily redirected by staff. At 9:36 AM the resident was observed standing near the hall of the west employee entrance and watching staff come in the door. At 11:06 AM Resident #101 was observed trying to go thought the door that leads to the lobby but was easily redirected by staff. In an interview on 12/16/25 at 11:17 PM, CNA C reported that Resident #101 had followed her out of the facility in the past, but that CNA C was with the resident the whole time. CNA C reported that on 11/23/25 Resident #101 had been following her around the facility just prior to her leaving for break at approximately 6:00 PM. CNA C reported that she exited the west employee entrance door, which only stays unlocked for 5 seconds after the code is entered and she did not see Resident #101 near the door when she left for break. CNA C reported that her car was parked near the door, and the resident was not outside of the facility when she drove out of the parking lot. CNA C reported that she drove to a nearby store (6 minutes one way from the facility) and when she returned found multiple alarms going off in the facility, including the door and Wanderguard alarm at the west employee entrance. CNA C reported that she entered the codes to shut each alarm off, but there were still alarms sounding at other doors. CNA C reported that RN-A J, Licensed Practical Nurse-Agency (LPN-A) L and Resident #101 were all at the nurse's station when she returned, and CNA P and CNA R were together in a resident room on south hall. There were no other staff present. CNA C was concerned because RN-A J was not in agreement that the incident should be treated as an elopement, therefore she called DON B for further instructions. CNA C reported that she had been working in the facility for years, knew the door alarm systems, but was not sure what to do in the moment, or that there was an elopement binder at the nurse's station for reference. When CNA C spoke to DON B, she was instructed to complete a head count to ensure all residents were safe. In an interview on 12/16/25 at 11:39 AM, RN-A J reported that on 11/23/25 around 6:00 PM (shift change) he was on east hall when he heard the door alarm for the first time. RN-A J reported that at that same time LPN-A L had entered the building through the front lobby door and set the alarm off. RN-A J reported that he did not go to the door because he was not familiar with the facility alarm system and thought someone else would turn it off. Then while trying to report off to LPN-A L, RN-A J said that he could not concentrate because there were so many alarms and stated, it was excessively over stimulating. RN-A J reported that he didn't know CNA C was on break or that the two other CNAs were in a room and there were multiple call lights sounding. RN-A J reported that he looked down all the halls, did not go to the doors and then returned to the nurse's station to finish report. RN-A J reported that when he returned to the nurse's station he looked for something to indicate where the alarms were coming from, but that he was unable to find anything. RN-A J reported that a couple minutes had passed with the alarms still going off, when a resident from west hall came up to the nurse's station and reported to RN-A J that there was a resident outside of the door at the end of west hall. RN-A J reported that he found Resident #101 at the west hall door, near the driveway trying to get inside. RN-A J reported that it was his understanding that when a Wanderguard alarm was triggered, all the doors would alarm as a result, but at the time he did not know that the other alarm going off was a Wanderguard alarm. RN-A J reported that the south and west doors had Wanderguard alarms, but that the employee entrance door did not. It was noted that the information RN-A J provided was not in line with facility procedures. In an interview on 12/16/25 at 12:19 PM, LPN-A L reported that on 11/23/25 she entered the facility just before 6:00 PM for her first shift at the facility. LPN-A L reported that she did not know if coming in the front door triggered an alarm because there were already several other alarms going off when she entered the facility. LPN-A L reported that she found RN-A J at the nurse's station trying to figure out the alarms, so she sat down to wait for him. LPN-A L reported that a couple minutes went by and then a resident approached the nurse's station to report that there was a resident outside. LPN-A L reported that after Resident #101 was brought inside, the alarms continued to sound very loudly until CNA C returned from break and turned them all off a few minutes later. LPN-A L reported that she had not received any specifics about the facility prior to her first shift on 11/23/25 and RN-A J did not go over any information with her prior to her working that night. In an interview on 12/16/25 at 3:27 PM, CNA P reported that she was one of three CNAs in the facility on 11/23/25 and that Resident #101 was talking about her husband and had set off alarms several times that day. CNA P reported that all of the doors are locked and did not open unless a code was entered, so Resident #101 would not be able to get out, unless she followed someone. CNA P reported that she was in another resident's room with CNA R around 6:00 PM with the door closed for about an hour and they did not hear any alarms. CNA P reported that CNA C was on her way out for break when they went into the resident's room and when they came out CNA C was back from break and had instructed them to perform a head count on the hall. CNA C reported that three CNAs was the typical staffing for second shift, but when someone goes on break and then they need to provide care for a resident that required the assistance of two, that leaves only the nurse to cover the rest of the facility. Attempts were made to contact CNA R on 12/17/25 with no response. In an interview on 12/16/25 at 2:38 PM, Maintenance Staff (MS) H reported that the south hall door and the west employee entrance are both locked emergency exits and have the Wanderguard alarm in place, therefore there are two separate key code pads located at those exits. MS H reported that the west and east halls have locked emergency exits doors without the Wanderguard alarm system, and the front door is a locked emergency exit from 5:00 PM-8:00 AM. MS H reported that if a Wanderguard alarm was triggered, only the door that was breeched will alarm. MS H reported that he regularly conducted the facility elopement drills and the expectation is that all staff promptly locate which door is alarming, go to the door to assess why it is alarming and if no one is at the door, then they should be walking outside to search the immediate area, then regardless of if a resident is found there should also be a code called and a head count performed. Observed the west employee entrance door was located down a narrow hallway off of south hall and was not visible from the nurse's station. MS H demonstrated that the west employee entrance door remained unlocked for 20 seconds after the key code is entered to open the door but if a Wanderguard breeched the unlocked door, the alarm for Wanderguard sounded very loudly. Review of staff Time Clock punches dated 11/23/25 did not show that CNA C punched out or in from break on second shift.Resident #104Review of a Face Sheet revealed Resident #104 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia. Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 9/28/25 revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated Resident #104 had severe cognitive impairment. Review of Resident #104's Behavioral Care Plan dated 4/24/25 revealed, .at risk for elopement from facility r/t exit seeking behavior and/or verbalizations of wanting to leave. Interventions: .wears a wander guard. Function and placement checked every shift.Review of Resident #104's Physician Orders indicated that staff were to check placement and function of the resident's Wanderguard every shift, but there was no documentation related to the implementation of those orders. In an interview on 12/17/25 at 2:09 PM, LPN O reported that she was not able to find the machine that is used to check the Wanderguard bracelets. DON B walked up to LPN O and handed her the machine. LPN O reported that she was not sure if there were orders to check the Wanderguard bracelets, but that she believed they are supposed to be checked every shift.In an interview on 12/17/25 at 2:18 PM, DON B reported that Resident #104's orders for Wanderguard were never transcribed to the nursing orders, therefore nursing staff would not know to check the Wanderguard. DON B reported that she was not able to locate any documentation to indicate that Resident #104's Wanderguard had ever been checked. Review of the facility policy Elopement Prevention and Management Program last reviewed on 1/2025 revealed, .1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The policy and or additional staff education that was included did not indicate anything further related to expectations of staff when a door alarm is heard, how to locate where the alarm is coming from, different types of alarms in the facility or any mention of Wanderguard usage.Review of the facility policy Elopement Drill last revised 09/2023, revealed information that solely focused on locating a missing person and did not include any verbiage related to door alarms and/or Wanderguard alarms.In an interview on 12/17/25 at 9:05 AM, NHA A reported that the facility currently utilized a staffing agency for licensed nurses. NHA A reported that this was the same staffing agency that RN-A J and LPN L work for and that prior to picking up their first shift they are required to sign a document saying that they have read our numerous documents related to facility policies and procedures. NHA A reported that prior to Resident #101's elopement on 11/23/25 the facility policy related to elopement was not included in those that were required for them to sign, but that it has since been included in the required documents. NHA A reported that DON B maintained a binder of facility orientation information for agency staff that they must complete on their first day, prior to working on the floor.In an interview on 12/17/25 at 9:40 AM, DON B reported a policy post-test packet is left out on at the nurse's station for any new agency nurse to complete prior to working on the floor. DON B reported that there was also a binder in the file cabinet for agency staff to reference any facility policies. DON B reported that it was expected that the nurse on duty would ensure that the new agency nurse completes that packet prior to working with residents. DON B reported that on 11/23/25 RN-A J would have been expected to ensure that LPN-A L completed the packet prior to LPN-A L taking over resident care. It was discussed that on 11/23/25 when LPN-A L reported for her first shift in the facility, RN-A J was the only person on the floor due to CNA C being on break and CNA P and CNA R being in a room for an hour with a resident. DON B reported that she was not able to find the policy post-test packets for RN-A J and LPN-A L and could not verify that they were completed. Review of the packet Agency Personnel/Contractors Checklist dated 8/15/23 revealed, The following information is reviewed with agency personnel/contractors on his or her first visit to the facility and prior to contact with residents. After reviewing all information on the checklist, it is signed by the agency person/contractor and the facility representative to verify that the orientation has been completed. The completed checklist is returned to the facility's staff development coordinator or facility designee. The orientation materials are retained by the agency person/contractor for future reference. Included on the check list of information to be reviewed was the elopement protocol and safety protocols; code for security doors, but the packet did not include post-tests or any information related to door alarms, Wanderguard, and/or door codes.In a subsequent interview on 12/17/25 at 10:52 AM, NHA A reported that the current elopement document that has been uploaded to the staffing agency website for nurses to sign prior to picking up a shift also does not include information related to door alarms, Wanderguard usage, and/or door codes. NHA A reported that the facility will develop a plan going forward to complete an in-person orientation with new agency staff and also revamp their current elopement policy and procedures to include how to determine where the alarm is coming from, how the doors function, Wanderguard usage, door codes, and expectations for responding to a door alarm.The Immediate Jeopardy that began on 11/23/25 was removed on 12/17/25 when the facility took the following actions to remove the immediacy.1) During investigation of elopement on 11/23/25, the facility identified staff did not respond to the door alarm in a timely manner to reduce risk of elopement for a resident identified as an elopement risk.2) Resident #101 was placed on 1:1 supervision immediately until further interventions could be implemented. Law Enforcement, physician and Director of Nursing also notified. The Administrator notified the brother of the incident. 3) The EVS (environmental services) Director assessed the facility doors for proper function of the alarm system on 11/23/25; deemed to be functioning appropriately. 4) The Administrator reviewed the elopement binder on 11/23/25 and deemed appropriate. 5) The Elopement and Wandering Policy was reviewed by the facility Administrator and deemed appropriate. 6) Assessments were completed on the resident to ensure the resident did not experience any adverse effects of the elopement, including skin assessment, pain assessment and vitals signs were obtained.7) Care Plan was updated with proper interventions to reduce future risk of elopement.8.) The facility identified that residents at risk for elopement in the facility were determined to be at risk. On 11/23/25, the facility audited residents who were determined to be at risk for elopement (2 Residents). The Facility completed an elopement risk observation, reviewed and/or updated the elopement care plan and ensured appropriate interventions. On 12/17/25, Resident #104's orders were put in place to ensure Wanderguard functionality would be checked. 9.) On 11/23/25, 2 agency LPN's, 5 staff Cena's were educated by the DON, Maintenance and Administrator on the facility's policy on elopement and wandering. An elopement drill was completed on 11/23/25 at approximately 9:00pm.10.) Education of elopement and wandering policy was initiated on 11/23/25; any staff member who did not receive education by 11/23/25 will receive education prior to the start of their next shift. As of 12/10/25, 42/42 Staff have been educated. As of 12/10/25, 18 Agency Staff have received the education prior to working their next shift. As of 12/17/25, agency staff education will include an in-person orientation with new agency staff that will include how to determine where the alarm is coming from, how the doors function, Wanderguard usage, door codes, and expectations for responding to a door alarm.

This citation pertains to intakes #2677662 and #2648515.Based on observation, interview, and record review, the facility failed to maintain an effective training program for all facility and agency staff, consistent with their role in the facility to ensure the safety of residents in 1 resident (Resident #101) of 2 residents reviewed for elopement, and 2 residents (Resident #102 and #107) of 4 residents reviewed for the administration of controlled substance, resulting in agency staff not responding properly to door alarms and licensed nursing staff not maintaining an accurate account of controlled substances. Findings include: Resident #101Review of a Face Sheet revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 8/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #101 had severe cognitive impairment. Review of the Facility Reported Incident (FRI) for Resident #101 revealed, On 11/23/25, Administrator was notified of (Resident #101) having been outside unattended and unsupervised, and brought back into the facility. Per staff, resident was last seen indoors approximately 10 minutes prior to this event. Resident was dressed in sweat pants, a plaid button up shirt and a cardigan sweater with furry boots on her feet. Temperature outside was 43 degrees Farenheit at the time. Wanderguard (a bracelet device that triggers an alarm when in the proximity of an exit) was in place and functioning properly, verified by maintenance director upon inspection. Physician, DON (Director of Nursing), and brother of the resident was notified. Vital signs obtained and within normal limits. Head to toe assessment and pain assessment was completed and no areas of concerns noted at this time. Resident has a BIMS score of 3. Resident was pleasant and no acute distress was noted. During investigation of elopement on 11/23/25, the facility identified staff did not respond to the door alarm in a timely manner to reduce risk of elopement for a resident identified as an elopement risk.In an interview on 12/16/25 at 8:25 AM, NHA A reported that on 11/23/25 Resident #101 was believed to have exited the facility unsupervised through the employee entrance door, in an attempt to follow Certified Nursing Assistant (CNA) C, who had left the facility for break at approximately 6:00 PM. An agency nurse, Registered Nurse-Agency (RN-A) J was approached by another resident (at an unknown time), who reported that Resident #101 was seen outside of the facility at the end of west hall trying to open the emergency exit door. At that time RN-A J brought the resident inside. NHA A reported that CNA C have driven to a nearby store and returned to the facility reportedly 10 minutes later to find multiple alarms sounding, but Resident #101 was already back inside of the building at that time. NHA A reported that RN-A J stated that he had heard the alarms but had expected the alarms due to shift change as staff were entering the building through alarmed doors and therefore did not respond to them. In an interview on 12/16/25 at 11:17 PM, CNA C reported that on 11/23/25 Resident #101 had been following her around the facility just prior to her leaving for break at approximately 6:00 PM. CNA C reported that she exited the west employee entrance door and drove to a nearby store (6 minutes one way from the facility) and when she returned found multiple alarms going off in the facility, including the door and Wanderguard alarm at the west employee entrance. CNA C reported that she entered the codes to shut each alarm off, but there were still alarms sounding at other doors. CNA C reported that RN-A J, Licensed Practical Nurse-Agency (LPN-A) L and Resident #101 were all at the nurse's station when she returned. CNA C was concerned because RN-A J was not in agreement that the incident should be treated as an elopement, therefore she called DON B for further instructions. CNA C reported that she had been working in the facility for years, knew the door alarm systems, but was not sure what to do in the moment, or that there was an elopement binder at the nurse's station for reference. When CNA C spoke to DON B, she was instructed to complete a head count to ensure all residents were safe. In an interview on 12/16/25 at 11:39 AM, RN-A J reported that on 11/23/25 around 6:00 PM (shift change) he was on east hall when he heard the door alarm for the first time. RN-A J reported that at that same time LPN-A L had entered the building through the front lobby door and set the alarm off. RN-A J reported that he did not go to the door because he was not familiar with the facility alarm system and thought someone else would turn it off. Then while trying to report off to LPN-A L, RN-A J said that he could not concentrate because there were so many alarms and stated, it was excessively over stimulating. RN-A J reported that he didn't know CNA C was on break or that the two other CNAs were in a room and there were multiple call lights sounding. RN-A J reported that he looked down all the halls, did not go to the doors and then returned to the nurse's station to finish report. RN-A J reported that when he returned to the nurse's station he looked for something to indicate where the alarms were coming from, but that he was unable to find anything. RN-A J reported that a couple minutes had passed with the alarms still going off, when a resident from west hall came up to the nurse's station and reported to RN-A J that there was a resident outside of the door at the end of west hall. RN-A J reported that he found Resident #101 at the west hall door, near the driveway trying to get inside. RN-A J reported that it was his understanding that when a Wanderguard alarm was triggered, all the doors would alarm as a result, but at the time he did not know that the other alarm going off was a Wanderguard alarm. RN-A J reported that the south and west doors had Wanderguard alarms, but that the employee entrance door did not. It was noted that the information RN-A J provided was not in line with facility procedures. In an interview on 12/16/25 at 12:19 PM, LPN-A L reported that on 11/23/25 she entered the facility just before 6:00 PM for her first shift at the facility. LPN-A L reported that she did not know if coming in the front door triggered an alarm because there were already several other alarms going off when she entered the facility. LPN-A L reported that she found RN-A J at the nurse's station trying to figure out the alarms, so she sat down to wait for him. LPN-A L reported that a couple minutes went by and then a resident approached the nurse's station to report that there was a resident outside. LPN-A L reported that after Resident #101 was brought inside, the alarms continued to sound very loudly until CNA C returned from break and turned them all off a few minutes later. LPN-A L reported that she had not received any specifics about the facility prior to her first shift on 11/23/25 and RN-A J did not go over any information with her prior to her working that night.In an interview on 12/16/25 at 3:27 PM, CNA P reported that she was one of three CNAs in the facility on 11/23/25 and that Resident #101 was talking about her husband and had set off alarms several times that day. CNA P reported that all of the doors are locked and did not open unless a code was entered, so Resident #101 would not be able to get out unless she followed someone. CNA P reported that she was in another resident's room with CNA R around 6:00 PM with the door closed for about an hour and they did not hear any alarms. CNA P reported that CNA C was on her way out for break when they went into the resident's room and when they came out CNA C was back from break and had instructed them to perform a head count on the hall. CNA C reported that three CNAs was the typical staffing for second shift, but when someone goes on break and then they need to provide care for a resident that requires two assist, that leaves only the nurse to cover the rest of the facility. CNA P reported that she was not aware that the doors could be opened if they were pushed on for 15 seconds.Resident #102Review of a Face Sheet revealed Resident #102 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain.Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 10/6/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #102 was cognitively intact. Review of a Facility Reported Incident (FRI) revealed, On 10/3/25, The Director of Nursing (DON) notified the administrator that there was a discrepancy with a resident's narcotic count. (Licensed Practical nurse (LPN) M) worked the 6p-6a shift on 10/2/25. She counted off on 10/3/25 at approximately 6:00am with oncoming nurse (Registered Nurse (RN) D). No discrepancies were noted in the shift-to-shift narcotic count at this time. During AM med pass, as (RN D) was preparing (Resident #102's) morning medications, she noticed that the Oxycodone IR (immediate release) 5 mg (milligrams) count was not correct. She then Notified the DON.(RN D) who has been employed with (facility) since 9/5/2025 as a floor staff nurse. The date of this incident was her first day on the floor working by herself, as she had just completed her job shadow training.Conclusion: Based on interviews and investigation, this facility concludes this allegation of misappropriation is inconclusive. Although the pill was not found, it is not clear what may have happened to it, or that misappropriation did occur. The resident did not suffer any ill effects of the event. Education has been provided to (RN D), and initiated for all staff surrounding the narcotic handling process.Review of the facility Narcotic (controlled substance) Action Plan (AP) dated 10/2/25 (sic) revealed, .Concern leading to AP development: Facility not adhering to Narcotic policy. Facility identified that nurses are not documenting on the MAR (medication administration record) and Proof of Use sheet when a Narcotic medication is administered; Facility identified narcotic counts between shifts were incorrect resulting in a missing narcotic medication. The DON or designee will review all residents that have an order for narcotic medication to ensure nurses are documenting on the MAR and the Proof of use sheet when administering a narcotic medication, proper narcotic counting between shifts. The DON/designee will audit.to ensure licensed nurses are documenting on the MAR and Proof of Use sheet when administering a narcotic medication and narcotic counting between shifts is being done accurately.Review of Resident #102's Proof of Use sheet for discrepancies indicated a label for Oxycodone IR 5 mg 1 tablet three times a day for pain, and revealed that on 9/30/25 two of three doses were administered, on 10/1/25 two of three doses were administered, and on 10/2/25 three of three doses were administered. The Proof of Use sheet was then reconciled with the actual MAR which revealed, on 9/30/25 three of three doses were administered, on 10/1/25 3 of 3 doses were administered, and on 10/2/25 three of three doses were administered. The documentation did not match, noting that the MAR indicated that resident had received 2 more doses than the proof of use sheet indicated.Multiple attempts were made to contact RN D on 12/16/25 and 12/17/25 with no return call or text.In an interview on 12/16/25 at 3:44 PM, former LPN M reported that on 10/3/25 she had worked the previous night shift and counted off narcotics with oncoming day shift nurse, RN D. LPN M reported that all narcotic counts reconciled correctly with no discrepancies when she handed the medication cart keys over to RN D. LPN M reported that approximately 3 hours later, DON B confronted her with the concern that Resident #102's Oxycodone count was found to be missing 1 pill, based on the proof of use sheet count indicating that there were 20 pills, but only 19 in the card. LPN M reported that she had worked a 16 hour shift alone that night, the bedtime medication pass was hard and she was burnt out.Resident #107Review of a Face Sheet revealed Resident #107 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain syndrome.Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 11/27/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #107 was cognitively intact. During an observation of medication administration on 12/17/25 at 9:57 AM on Medication Cart #1 with RN N revealed, RN N was preparing 9 morning medications for Resident #107, which included a dose of Oxycodone. RN N put several pills in a cup, then retrieved the narcotic binder and completed the proof of use sheet for Oxycodone, indicating that there were 25 pills left in the card after removing 1 pill at 10:00 AM. RN N then continued and prepared an injection and an inhaler for the resident. Lastly, RN N unlocked the narcotic medication box, obtained Resident #107's Oxycodone-Acetaminophen 2.5-325 mg medication card and popped a pill out. RN N did not go back and reconcile the medication card with the proof of use sheet. RN N crushed all the pills and administered the medication to Resident #107. RN N did not discuss pain level and/or inform the resident of what medications were being administered.Review of Resident #107's MAR for December 2025 revealed orders for Oxycodone-Acetaminophen 2.5-325 mg 1 tablet three times a day and indicated that the resident had been given three of three doses on 12/16/25 and one of three doses on 12/17/25. The MAR was then reconciled with the proof of use sheet for the medication, which revealed the resident only received two of three doses on 12/16/25 and one dose on 12/17/25. The documentation did not match, noting that the MAR indicated the resident had received 1 more dose than the proof of use sheet indicated. In an interview on 12/17/25 at 10:14 AM, RN N reported that she counted narcotics that morning with the night nurse and did not have any concerns. In review of the Shift to Shift Count sheet RN N signed that the count was 12 narcotic medication cards that morning, which was reconciled through observation and correct. It was noted that on 12/15/25 there was no narcotic count documented for medication cart 1, but that RN N signed off doing a narcotic count on 12/16/25. There were also several signatures that were signed agency, but no actual name was recorded. RN N reported that she had noticed the inaccurate documentation but did not inform DON B because she did not have a concern with the current count of narcotics.In an interview on 12/17/25 at 11:13 AM, DON B reported that after the missing narcotic medication was discovered on 10/3/25 she performed audits of the MAR's and the proof of use sheets and found that staff were completing them accurately. DON B reported that the nurses were expected to have the narcotic proof of use sheet out, and document on the proof of use sheet, only after obtaining the medication card from the lock box and removing a pill from the card. Then, they should document on the MAR after the medication was successfully administered to the resident. In addition, the nurses are required to perform a count of all narcotics with the new oncoming nurse during each shift change, prior to exchanging keys to the medication cart. DON B reported that she was not aware that agency nurses were not signing the shift to shift count sheets properly and/or that there were missing counts on the shift to shift narcotic count sheet. DON B reported that agency nurses were not provided the education related to narcotics following the issue on 10/3/25, and the orientation packet for new agency nurses did not include anything related to narcotics.In an interview on 12/17/25 at 12:58 PM, Resident #107 reported that she was supposed to receive pain medications 3 or 4 times, but sometimes they don't bring it and other times after they bring the medication she gets very tired. She reported that the nursing staff did not normally inform her of what medications they are giving her, so she wasn't sure if she was getting the right medications.In an interview on 12/17/25 at 9:05 AM, NHA A reported that the facility currently utilized a staffing agency for licensed nurses. NHA A reported that this was the same staffing agency that RN-A J and LPN L work for and that prior to picking up their first shift they were required to sign a document saying that they had read numerous documents related to facility policies and procedures. NHA A reported that prior to Resident #101's elopement on 11/23/25 the facility policy related to elopement was not included in those that were required for them to sign, but that it had since been included in the required documents. NHA A reported that the facility policy related to controlled substances and/or the education that was recently done was not included in the documents that agency staff received. NHA A reported that DON B maintained a binder of facility orientation information for agency staff that they must complete on their first day, prior to working on the floor.In an interview on 12/17/25 at 9:40 AM, DON B reported a policy post-test packet was left out on at the nurse's station for any new agency nurse to complete prior to working on the floor. DON B reported that there was also a binder in the file cabinet for agency staff to reference any facility policies. DON B reported that it was expected that the nurse on duty would ensure that the new agency nurse completes that packet prior to working with residents. DON B reported that on 11/23/25 RN-A J would have been expected to ensure that LPN-A L completed the packet prior to LPN-A L taking over resident care, even though RN-A J was also new. It was discussed that on 11/23/25 when LPN-A L reported for her first shift in the facility, RN-A J was the only person on the floor due to CNA C being on break and CNA P and CNA R being in a room for an hour with a resident. DON B reported that she was not able to find the policy post-test packets for RN-A J and LPN-A L and could not verify that they were completed. Review of the packet Agency Personnel/Contractors Checklist dated 8/15/23 revealed, The following information is reviewed with agency personnel/contractors on his or her first visit to the facility and prior to contact with residents. After reviewing all information on the checklist, it is signed by the agency person/contractor and the facility representative to verify that the orientation has been completed. The completed checklist is returned to the facility's staff development coordinator or facility designee. The orientation materials are retained by the agency person/contractor for future reference . Included on the check list of information to be reviewed was the elopement protocol and safety protocols; code for security doors, but the packet did not include post tests or any information related to door alarms, Wanderguard, door codes and/or administration of controlled substances.

This citation pertains to intake #2648515Based on observation, interview and record review, the facility failed to ensure that medication records were in order and that an account of all controlled drugs was maintained and accurately reconciled for 2 residents (Resident #102 and #107) of 4 residents reviewed for the administration of controlled medications, resulting in the potential for ineffective management of pain and the potential for diversion of controlled drugs. Findings include:Resident #102 Review of a Face Sheet revealed Resident #102 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain.Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 10/6/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #102 was cognitively intact. During an observation and interview on 12/16/25 at 3:13 PM in Resident #102's room, the resident reported that she takes Tylenol and Oxycodone (controlled substance pain reliever) because she had a lot of pain in her neck, shoulders, legs, and back. Resident #102 reported that the nurse brings her medicine regularly and she does not have to ask for it. Resident #102 reported that it seemed like the night nurse at times skipped her medications or told her that it was too close to her daytime dose. Review of a Facility Reported Incident (FRI) revealed, On 10/3/25, The Director of Nursing (DON) notified the administrator that there was a discrepancy with a resident's narcotic count. (Licensed Practical nurse (LPN) M) worked the 6p-6a shift on 10/2/25. She counted off on 10/3/25 at approximately 6:00am with oncoming nurse (Registered Nurse (RN) D). No discrepancies were noted in the shift-to-shift narcotic count at this time. During AM med pass, as (RN D) was preparing (Resident #102's) morning medications, she noticed that the Oxycodone IR (immediate release) 5 mg (milligrams) count was not correct. She then Notified the DON. The DON searched the medication cart and the missing Oxycodone was not discovered. The DON and (RN D) re-counted the medication cart and no other discrepancies were noted. The DON and (LPN M) counted the other medication cart and no discrepancies were noted. Both Nurses were suspended pending investigation. MD (medical director) made aware. (Resident #102) was assessed for pain and no concerns were noted. Her scheduled pain medication was administered per MD order. (RN D) who has been employed with (facility) since 9/5/2025 as a floor staff nurse. The date of this incident was her first day on the floor working by herself, as she had just completed her job shadow training. (RN D) was the day shift nurse working on Med Cart 1, assuming responsibility for the cart on this day shift. (LPN M) was the off-going nurse, who was still in the facility, awaiting her relief for Med Cart 2. The shift change narcotic count between nurses was completed and signed off as accurate on med cart 1. (RN D) went to administer a scheduled Oxycodone to (Resident #102), when she noted only 19 pills on the narc card, instead of the 20 noted on the proof of use sheet. (RN D) reported this concern to the DON. A search of the cart was performed, and no pill was discovered. All other pills were recounted, and no other discrepancies were noted. (LPN M) then counted Med Cart 2 with the DON and no discrepancies were noted on Med Cart 2. Per policy, both employees were suspended pending investigation and asked to provide a urine specimen for testing. (RN D) was compliant and provided a specimen without incident and her drug screen was negative. She then left the facility, awaiting further instruction. (LPN M) refused to provide the specimen, leaving the facility, and was terminated, per policy. (LPN M) did return to the facility later in the afternoon, provided a specimen and her drug screen was negative. Conclusion: Based on interviews and investigation, this facility concludes this allegation of misappropriation is inconclusive. Although the pill was not found, it is not clear what may have happened to it, or that misappropriation did occur. The resident did not suffer any ill effects of the event. Education has been provided to (RN D), and initiated for all staff surrounding the narcotic handling process. Review of a statement by DON B dated 10/3/25 revealed, .At 7:40 AM, (RN D) was removing Oxycodone IR (immediate release) 5 mg for (Resident #102), signed proof of use sheet and noticed that the proof of use sheet had the number 20 in the QTY REM (quantity remains) column. The blister pack had 19 pills remaining. At 7:50 AM, RN D notified (DON B) that the number of pills did not match the number written on the proof of use sheet.(Director of Nursing (DON) B) made copies of the proof of use sheet and ran a report, medication administration (MAR) to match the signatures on the sheet with the initials in the administration record. There were 2 times that an agency nurse initiated in the MAR that was given but it was not signed out on the proof of use sheet.Review of the facility Narcotic (controlled substance) Action Plan (AP) dated 10/2/25 (sic) revealed, .Concern leading to AP development: Facility not adhering to Narcotic policy. Facility identified that nurses are not documenting on the MAR (medication administration record) and Proof of Use sheet when a Narcotic medication is administered; Facility identified narcotic counts between shifts were incorrect resulting in a missing narcotic medication. The DON or designee will review all residents that have an order for narcotic medication to ensure nurses are documenting on the MAR and the Proof of use sheet when administering a narcotic medication, proper narcotic counting between shifts. The DON/designee will audit.to ensure licensed nurses are documenting on the MAR and Proof of Use sheet when administering a narcotic medication and narcotic counting between shifts is being done accurately.Review of Resident #102's Proof of Use sheet for discrepancies indicated a label for Oxycodone IR 5 mg 1 tablet three times a day for pain, and revealed that on 9/30/25 two of three doses were administered, on 10/1/25 two of three doses were administered, and on 10/2/25 three of three doses were administered. The Proof of Use sheet was then reconciled with the actual MAR which revealed, on 9/30/25 three of three doses were administered, on 10/1/25 3 of 3 doses were administered, and on 10/2/25 three of three doses were administered. The documentation did not match, noting that the MAR indicated that resident had received 2 more doses than the proof of use sheet indicated. Multiple attempts were made to contact RN D on 12/16/25 and 12/17/25 with no return call or text. In an interview on 12/16/25 at 3:44 PM, former LPN M reported that on 10/3/25 she had worked the previous night shift and counted off narcotics with oncoming day shift nurse, RN D. LPN M reported that all narcotic counts reconciled correctly with no discrepancies when she handed the medication cart keys over to RN D. LPN M reported that approximately 3 hours later, DON B confronted her with the concern that Resident #102's Oxycodone count was found to be missing 1 pill, based on the proof of use sheet count indicating that there were 20 pills, but only 19 in the card. LPN M reported that she had worked a 16 hour shift alone that night, the bedtime medication pass was hard and she was burnt out. Resident #107 Review of a Face Sheet revealed Resident #107 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain syndrome.Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 11/27/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #107 was cognitively intact. During an observation of medication administration on 12/17/25 at 9:57 AM on Medication Cart #1 with RN N revealed, RN N was preparing 9 morning medications for Resident #107, which included a dose of Oxycodone. RN N put several pills in a cup, then retrieved the narcotic binder and completed the proof of use sheet for Oxycodone, indicating that there were 25 pills left in the card after removing 1 pill at 10:00 AM. RN N then continued and prepared an injection and an inhaler for the resident. Lastly, RN N unlocked the narcotic medication box, obtained Resident #107's Oxycodone-Acetaminophen 2.5-325 mg medication card and popped a pill out. RN N did not go back and reconcile the medication card with the proof of use sheet. RN N crushed all the pills and administered the medication to Resident #107. RN N did not discuss pain level and/or inform the resident of what medications were being administered. Review of Resident #107's MAR for December 2025 revealed orders for Oxycodone-Acetaminophen 2.5-325 mg 1 tablet three times a day and indicated that the resident had been given three of three doses on 12/16/25 and one of three doses on 12/17/25. The MAR was then reconciled with the proof of use sheet for the medication, which revealed the resident only received two of three doses on 12/16/25 and one dose on 12/17/25. The documentation did not match, noting that the MAR indicated the resident had received 1 more dose than the proof of use sheet indicated. In an interview on 12/17/25 at 10:14 AM, RN N reported that she counted narcotics that morning with the night nurse and did not have any concerns. In review of the Shift to Shift Count sheet RN N signed that the count was 12 narcotic medication cards that morning, which was reconciled through observation and correct. It was noted that on 12/15/25 there was no narcotic count documented for medication cart 1, but that RN N signed off doing a narcotic count on 12/16/25. There were also several signatures that were signed agency, but no actual name was recorded. RN N reported that she had noticed the inaccurate documentation but did not inform DON B because she did not have a concern with the current count of narcotics. In an interview on 12/17/25 at 11:13 AM, DON B reported that after the missing narcotic medication was discovered on 10/3/25 she performed audits of the MAR's and the proof of use sheets and found that staff were completing them accurately. DON B reported that the nurses were expected to have the narcotic proof of use sheets out, and document on the sheet, only after obtaining the medication card from the lock box and removing a pill from the narcotic medication card. Then, they should document on the MAR after the medication was successfully administered to the resident. In addition, the nurses are required to perform a count of all narcotics with the new oncoming nurse during each shift change, prior to exchanging keys to the medication cart. DON B reported that she was not aware that agency nurses were not signing the shift to shift count sheets properly and/or that there were missing counts on the shift to shift narcotic count sheet. DON B reported that agency nurses were not provided the education related to narcotics following the issue on 10/3/25, and the orientation packet for new agency nurses did not include anything related to narcotics.In an interview on 12/17/25 at 12:58 PM, Resident #107 reported that she was supposed to receive pain medications 3 or 4 times, but sometimes they don't bring it and other times after they bring the medication she gets very tired. She reported that the nursing staff did not normally inform her of what medications they were giving her, so she wasn't sure if she was getting the right medications.

Based on observation, interview and record review the facility failed to ensure access to a call light in 4 of 10 sampled residents (Resident #104, R#102, R#105, and R#106) reviewed for call light placement, resulting in the inability to call for assistance and the potential for unmet care needs.Findings include: Resident #104Review of an admission Record revealed Resident #104 was a female with pertinent diagnoses which included Alzheimer's disease, diabetes, fracture of lower end of left femur, fractur of lower end of right femur, overactive bladder, and dementia. Review of current Care Plan for Resident #104, revised on 1/24/25, revealed the focus, .At risk for falls and subsequent injury related to fx (fracture) of fall w/ bilat femur fx prior to admission, incontinence, DM II (diabetes), vascular dementia, Alzheimer's, dependence in ADLs and transfers. with the intervention .Recline Broda chair when resident is unattended.Call light to be in reach.Instruct and remind to use call light to ask for assistance. During an observation on 09/15/25 at 1:44 PM, Resident #104 was observed in her room, broda not reclined, and was sliding down in her chair, and she was attempting to get up out of the chair. This writer observed Resident #104's call light hung over the back of the headboard to her bed and her water was on the nightstand. Both clearly out of Resident #104's reach. Resident #104 had been observed in her room since after lunch. This writer attempted to press the call light to call for assistance for Resident #104. This writer checked the door and Resident #104's call light was not illuminated in the hallway. Certified Nursing Assistant (CNA) U was observed down at the nurse's station, and she was hailed to come and assist as no other staff were in the hallway. Resident #104's room was located at the end of the hallway by the emergency exit door out the side of the building. CNA U came to Resident #104's room and was queried if Resident #104 should have her call light in reach. CNA U reported she doesn't use it. Queried if her water should be by her, CNA U reported Yes, her water should be in reach. CNA U reported Resident #104 was able to eat and drink independently. CNA U pressed the call light, and it did not illuminate in the hallway above the door. This writer went to the nurse's station to determine if it was beeping at the nurse's station as no one was coming to assist. Assistant Director of Nursing (ADON) C reported the call light was beeping but the light was not illuminated on the board. [NAME] indicated the beeping was the call light, went to the board and it was not illuminated. Maintenance Director (MD) E was informed the call light in Resident #104's room was not working. MD E went to the call light board and the room as not illuminating on the board. During an observation on 09/15/25 at 2:07 PM, Resident #104 had her call light draped over her right side and she had he rolling bedside table next to her bed with her water mug on it. In an interview on 09/15/25 at 3:19 PM, MD E reported he replaced the bulb and it blew multiple bulbs and now the panel won't light up. MD E reported he took out the call light, tested it and it had looked as if someone had yanked the call light out of the wall socks so he placed a splitter on the other call light so both residents in the room had operating call lights. MD E reported the all the call lights were working, just the lights on the board. MD E reported the system had to be 20-[AGE] years old and the plastic shattered when he pressed it. MD E reported he had someone coming to look at the system. Resident #102: Review of an admission Record revealed Resident #102 was a male with pertinent diagnoses which included displaced midcervical fracture of right femur (break in the middle part of the neck of the femur, bone fragments, and are no longer aligned), adult failure to thrive, intracapsular fracture of femur (break of femoral neck which is located within the hip joint's capsule), anxiety, dysphagia (difficulty swallowing foods and liquids), and stroke.Review of current Care Plan for Resident #102, revised on 12/2/24, revealed the focus, .At risk for falls and subsequent injury related to dementia with cognitive decline over the last year, hx (history) of CVA (stroke), insomnia, CKD 3 (Chronic kidney disease, stage 3), urinary frequency r/t (related to) BPH. Non-compliant with medical care. Resident has poor cognition and weakness. Fall with hip fx (fracture) and surgical repair July 2025. with the intervention .Parameter mattress.Enabler bars to Right side of bed.Call light to be in reach. (Note: Fall mattress was not developed as an intervention to Resident #102's care plan).During an observation on 09/15/25 at 2:04 PM, Resident #102 was lying in his bed still, mattress on the floor next to his bed, he had not drunk any of his orange juice from this morning, his water was out of reach it was placed at the other end of the rolling bedside table which was placed against the wall/window area. This writer did not observe resident's call light cord or call light button. During an observation on 09/15/25 at 2:12 PM, Resident #102 was observed in his room and he was leaning out of bed, he had his left hand on the mattress which was on the floor and he had a cup of red juice in his right hand. Resident #102 then took his left hand and opened the lid and was trying to hand it to me while he was leaning out of the bed, his upper body was more than half off the bed. This writer was looking for his call light and discovered it under the foot of his bed. During an observation on 09/15/24 at 2:13 PM, CNA U came to Resident #102's room to respond to his call light. When queried when she last saw the resident's call light she reported she had given it to him this morning and it was not her fault it was under his bed, can't stop them from placing the call light on the floor as she was checking his brief, she pulled the curtain, informed him to roll to the other side and he yelled out in pain. In an interview on 09/15/25 at 2:14 PM, Assistant Director of Nursing (ADON) C reported the staff were to check and change the resident every 2 hours and when they left the room to ensure the resident had their call light in reach. In an interview on 09/15/25 at 2:19 PM, CNA U reported she had last checked on Resident #102 approximately 12:45 after lunch and she took him to his room to check his brief and get him in bed. Resident #105: Review of an admission Record revealed Resident #105 was a male with pertinent diagnoses which included dementia, diabetes, difficulty in walking, anxiety, adjustment disorder with mixed anxiety and depressed mood, muscle weakness, and heart failure. Review of current Care Plan for Resident #105, revised on 3/20/25, revealed the focus, .Resident experiences a communication deficit r/t (related to) cognitive impairment, Resident's speech is slurred at time. with the intervention .Staff to anticipate resident's needs. Keep call light within reach. Review of Event Report dated 8/20/25 at 09:24 AM, revealed, .Summary of Events: (Resident #105) had an unwitnessed fall/roll out of bed onto his floor mattress. Per staff interviews he was last checked approximately 40-45 minutes prior to occurrence when his brief was changed and catheter emptied. He was sleeping at that time. (Resident #105) did have socks on his feet and mattress was in place and the bed was in lowest position. Staff noted (Resident #105) to be partially on his fall mattress and partially on the floor. His head/face area was on the floor and rest of his body was on the mattress.Post Fall Findings: (Resident #105) was unable to tell staff what happened post fall. Per his normal he was not easily understood and at times mumbles. The nurse and staff assisted him back to bed and no complaints of pain were noted. He had mild redness on his R forehead. Contributing Factors: Dementia, poor safety awareness .Discussion: UTI treatment in progress. [NAME] was assessed by management nurse appropriately 830 when staff reported he was not at his baseline and appeared lethargic, and not responding to them per his normal. Neuro checks were completed, MD, DON, and daughter [NAME] notified. MD gave order to send to ER for evaluation and treatment .Root Cause: Dementia, poor safety awareness, rolled out of bed. Immediate Intervention: repositioning back to bed, order to send to ER for eval. IDT met and discussed the mattress placement next to bed and decided the mattress should be repositioned next to bed. Follow up: (Resident #105) had no visible injury and notes from ER state CT scan was normal/no changes from past. He returned to the facility. Review of Progress Notes dated 8/20/25 at 6:11 PM, .Resident return to facility via stretcher from ER (Local Hospital). Resident alert and oriented 1-2. Has no c/o (complaints of) pain or discomfort at this time. Resident is currently laying with call light in reach, fall mattress in place. Resident has no new orders from hospital noted.During an observation on 09/15/25 at 3:25 PM, observation he had a paddle call light at the foot of his bed, bunched up behind his blankets out of resident's reach. Resident #106: Review of an admission Record revealed Resident #106 was a male with pertinent diagnoses which included dementia, lack of coordination, anxiety, muscle weakness, difficulty in walking, and history of wedge compression fracture of first thoracic vertebra (when the bone collapses and the front part of the vertebra forms a wedge shape, first thoracic vertebra is part of the upper back, just below the neck). Review of current Care Plan for Resident #106, revised on 4/22/25, revealed the focus, .At risk for falls and subsequent injury related to dementia, decreased mobility, incontinence, malnutrition, failure to thrive, hx (history) of falls. with the intervention .Provide verbal reminders to resident to call when needing assistance.Staff to assist with pillows for positioning while in bed for fall precautions.Verbal education to CNA on fall precautions. During an observation on 09/15/25 at 2:33 PM, Resident #106 was observed seated in an scoot/broda chair next to the side of his bed, his call light was placed on the center of his mattress on his bed out of Resident #106's reach. During an observation on 09/15/25 at 3:28 PM, Resident #106 was observed seated in his wheelchair and his call light was placed in the middle of the bed out of his reach. During an observation on 09/16/25 at 3:23 PM, Resident #106 was observed seated in his broda chair and his call light was observed hanging off the side of the head of the bed behind the back rest of his broda chair, well out of Resident #106's reach. In an interview on 09/17/25 at 11:00 M, CNA T reported staff were to ensure to place the call light in reach, place water in reach, and lower bed for safety. CNA T reported Resident #104 would be able to drink her water independently as long at the tray table was placed over her lap and the water was in her reach. In an interview on 09/17/25 at 2:49 PM, Director of Nursing (DON) B reported the staff should ensure when they exit a resident's room the call light was in reach and all needs were met.

This citation pertains to intake: 2618457 and 2618789Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from staff to resident sexual abuse for 1 resident (Resident #108) reviewed for abuse, resulting in Resident #108 feeling concerned for physical safety enough to leave shortly after admission. Findings include: Review of Incident Summary submitted on 9/11/25, revealed, .Incident Summary: On 9/11/25, administrator received a call from staff of a sexual abuse allegation reported to them from resident (Resident #108), a newly admitted resident. Admin immediately went to the facility and made contact with the resident via phone, as resident has already left the building with her son prior to administrator's arrival. (Resident #108) reported that (LPN J), LPN, had performed a physical assessment of her, and during this assessment, when he got to my boobs, he pinched my nipples and rubbed them between his fingers. I don't think that is proper. He made me feel really uncomfortable. Resident states she is ok now and is grateful that administrator called her and followed up with investigation. Resident had contacted her son, (Family Member (FM) AA, after the alleged incident. (FM AA) arrived at the facility prior to administrators arrival and took (Resident #108) home, not signing any paperwork. Nurse (LPN J) was immediately suspended pending investigation. Administrator spoke to the son, (FM AA), who stated he had received this phone call from his mother regarding the allegation and took her out of there as quick as I could. (Local) County Police were notified of the incident. MD (Medical Director) made aware. No other residents had any concerns of this nurse at this time. DON (Director of Nursing) notified, RDO (Regional Director of Operations) notified. Investigation to follow. Resident #108: Review of an admission Record revealed Resident #108 was a female with pertinent diagnoses which included diabetes, chronic pain, congestive heart failure, dependency on oxygen, anemia, anxiety and kidney disease. Review of Return to Hospital Risk Assessment dated 9/11/25 at 5:20 PM, revealed, .Medical conditions: CHF, COPD, Diabetes, Stroke.Review of Fall Risk Assessment dated 9/11/25 dated 5:18 PM, revealed, .Medical Conditions: Cognitive Impairments: No. Review of Braden Scale For Prediction of Pressure Sore Risk dated 9/11/25 at 5:10 PM, revealed, .Sensory Perception: No Impairment - Responds to verbal commands. No sensory deficit limiting ability to feel or voice discomfort/pain. Review of Skin Assessment dated 9/11/25 at 5:09 PM, revealed, .Skin conditions: No areas of skin impairment. In an interview on 09/17/25 at 08:25 AM, Resident #108 reported the nurse came to her room to check me over and he pulled up my top, took my nipples and rubbed them between his two fingers, just my nipples, and when he was finished her walked out and never said a word to me. Resident #108 stated That was not acceptable and she couldn't stay there anymore. Resident #108 reported she contacted her son to come and get her. When queried if she had any bruises on her abdomen area, Resident #108 reported she had received blood thinner shots in the hospital but they were not on my boobs. Resident #108 reported LPN J was not interested in my abdomen area. Resident #108 reported she hailed down another staff member; to please help her, she explained what had happened to her by the nurse and wanted to report her concern. Resident #108 reported she was legally blind but was able to see brighter colors and shapes. Resident #108 stated, she knew if this had happened to her, it happened to others. In an interview on 09/17/25 at 08:11 AM, Family Member (FM) AA reported his mother (Resident #108) called him, reported to him what had happened to her by the nurse, and she wanted me to come and get her. FM AA reported Resident #108 felt very uncomfortable staying there and said there was no reason the nurse would need to touch her breasts especially her nipples like that. FM AA reported he was very upset at what happened to his mother. In an interview on 09/17/25 at 09:27 AM, Licensed Practical Nurse (LPN) J reported the prior nurse did most of the assessments, but the Critical admission assessment was left to finish. LPN J reported at approximately 7:00 PM, he went to Resident #108's room to complete the Critical admission assessment. Observed Resident #108's torso, noticed bruising and left the room to obtain a measuring tape from the nurse's station. LPN J reported Resident #108 accused him of touching her breasts inappropriately and he denied the allegation. LPN J reported he did not touch her breasts and did not see Resident #108's nipples. LPN J reported he was confronted by Resident #108's son and he didn't know what he was accusing him of. LPN J reported Resident #108 had informed his co-worker of her concern with him , and LPN J said to the co-worker, don't try to add your take on it. LPN J stated He did not even blame the lady, he blamed his co-worker who did the report. In an interview on 09/17/25 at 09:42 AM, Assistant Director of Nursing (ADON) C reported he had completed the initial assessments on Resident #108 needed at admission. ADON C reported for the Critical admission Assessment he only needed the last set of vitals, which he informed LPN J of this when he came on for his shift. ADON C reported he received a call approximately around 09:30 PM there as an allegation against the nurse and an investigation was opened. ADON C reported the Critical admission Assessment was a sweetened condensed form and was a quick snapshot of the completed other assessments. ADON C reported there were multiple steps to the assessment and the nurse couldn't move to the next section unless the prior section was completed hence why he was waiting for the last set of vitals to complete the Critical admission Assessment. ADON C reported he looked over Resident #108 for the initial skin assessment, checked whole body and her buttocks, her abdomen, and she had some scattered light bruising from receiving (Blood thinner name) shots. The bruises were light, small and fading and he didn't put them on the skin assessment as they were old bruises. In an interview on 09/17/25 at 3:40 PM, Certified Nursing Assistant (CNA) P reported he was completing cares for his resident and walked by Resident #108's room and she called him into the room. CNA P reported Resident #108 asked where she could file a complaint about what happened to her. CNA P indicated Resident #108 could talk to him or the nurse. CNA P reported LPN J walked by and CNA P reported Resident #108 stated, No, no, no not him. CNA P closed the door to her room and obtained her written statement which Resident #108 had alleged LPN J had grabber her nipples and she felt really uncomfortable with him and continuing to stay at the facility. CNA P reported the incident to his administrator. CNA P reported he reassured Resident #108 of her safety until Resident #108's son came and picked her up from the facility.In an interview on 09/17/25 at 08:19 AM, Nursing Home Administrator (NHA) A reported she was nearby and came to the facility to begin the investigation. NHA A reported she had reviewed LPN Js submitted written statement, and he alleged Resident #108 had bruises on her abdomen he was assessing. NHA A reported she had begun the investigation but had not finished the facility's investigation into the allegation.

Based on observation, interview, and record review, the facility failed to update and revise the person-centered care plan in a timely manner with appropriate interventions for the prevention of undefined care concerns for 1 of 10 residents (Resident #102) reviewed for care plans, resulting in the potential for physical, mental, and psychosocial unmet care needs and harm. Findings include: Resident #102: Review of an admission Record revealed Resident #102 was a male with pertinent diagnoses which included displaced midcervical fracture of right femur (break in the middle part of the neck of the femur, bone fragments, and are no longer aligned), adult failure to thrive, intracapsular fracture of femur (break of femoral neck which is located within the hip joint's capsule), anxiety, dysphagia (difficulty swallowing foods and liquids), and stroke. Review of current Care Plan for Resident #102, revised on 12/2/24, revealed the focus, .At risk for falls and subsequent injury related to dementia with cognitive decline over the last year, hx (history) of CVA (stroke), insomnia, CKD 3 (Chronic kidney disease, stage 3), urinary frequency r/t (related to) BPH. Non-compliant with medical care. Resident has poor cognition and weakness. Fall with hip fx (fracture) and surgical repair July 2025. with the intervention .Parameter mattress.Enabler bars to Right side of bed.Call light to be in reach. (Note: Fall mattress was not developed as an intervention to Resident #102's care plan). Review of Skilled Note dated 8/12/25 at 10:43 AM, .Floor mattress in place . During an observation on 09/16/25 at 7:58 AM, Resident #102 was observed in bed on his left side, he had his call light clipped to the bedding at the head of the side of the bed in the same position as yesterday. The fall mattress was up on its side leaning against his wheelchair. Resident #102 reported he did not get up for breakfast this morning. His wheelchair was up against his dresser which was on the opposite wall by the closet/bathroom. In an interview on 09/16/2025 at 8:09 AM, Director of Nursing (DON) reported the fall mattress should have been by the side of the bed for Resident #102 as he had fallen out of bed before and he had a hip fracture from that fall. back on the right side as the extra pillows were for positioning. In an interview on 09/17/25 at 1:23 PM, DON B reported the care plans were updated by all the clinical staff during morning meeting. DON B reported therapy had a communication binder where they would place information there for changes in residents' transfer status or how the resident transferred. DON B reported when the care plan was updated this was communicated to the staff verbally when the changed happened. Review of Fundamentals of Nursing ([NAME] and [NAME]) 8th edition revealed, If the patient's status has changed and the nursing diagnosis and related nursing interventions are no longer appropriate, modify the nursing care plan. An out of date or incorrect care plan compromises the quality of nursing care. Review and modification enable you to provide timely nursing interventions to best meet the patient's needs .It is necessary to revise related factors and the patient's goals, outcomes, and priorities. Date any revisions. Revise specific interventions that correspond to the new nursing diagnoses and goals. Revisions need to reflect the patient's present status. [NAME], P.A., [NAME], A.G., Stockert, P.A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby, p. 257-258.

This citation pertains to 1287744Based on interview and record review, the facility failed to prevent the misappropriation of narcotic pain medication in 1 of 10 residents (Resident #103) reviewed for misappropriation of property, resulting in the theft of narcotic medications and the potential for delayed pain treatment.Findings include: Resident #103: Review of an admission Record revealed Resident #103 was a male with pertinent diagnoses which included MS (multiple sclerosis), polyneuropathy (multiple sites of nerve damage), heart failure, end stage renal disease, and osteoarthritis (flexible tissue at the end of bones wears down). Review of current Care Plan for Resident #103, revised on 1/28/25, revealed the focus, .Resident has potential/actual pain r/t (related to) MS, hx (history) of falls, ESRD on dialysis, CHF (congestive heart failure), HTN (high blood pressure), Anemia, OA (Osteoarthritis). with the intervention .Administer pain medications as ordered.Review of Order dated 4/26/25 for Resident #103, revealed, .Percocet (oxycodone-acetaminophen) - Schedule II tablet; 7.5-325 mg; amt: one table; oral.Every 6 hours - PRN (as needed). In an interview on 09/16/25 at 2:44 PM, Licensed Practical Nurse (LPN) F reported Resident #103 requested a pain pill. LPN F reported she reviewed his medical record and the narcotic sign out sheet to see if he was able to receive a dose of Percocet. Upon review of the narcotic sheet, it was documented he had received a dose a 8:00 PM so she went to tell Resident #103 he was not able to receive a pain medication just yet as it had not been 6 hours since his last dose. LPN F reported Resident #103 indicated he had not received Percocet at 8:00 PM. Resident #103 was alert and oriented, he knows his medications and he would remember if he had received pain medication at 8:00 PM. LPN F reported when she and LPN I had counted the cart all the medications dispensed matched what was in the cart. LPN F reported after further review of the narcotic sheet, LPN I had signed out two doses of PRN (as needed) medication for Resident #103 for that day, 1400 (2:00 PM) and 2000 (8:00 PM). LPN F reported Resident #103 had been at dialysis most of the day and he did not receive the 2:00 PM dosage as indicated on the narcotic sheet and Resident #103 reported he did not receive the 8:00 PM dosage. LPN F reported she informed administration of the concern with medication misappropriation. In an interview on 09/17/25 at 2:12 PM, LPN I reported she was an agency nurse and there was a lot going on that day, it was her first day there and she was by herself from 2:00 PM until the next nurse came on. LPN I reported she had patients coming back from dialysis, an admission, and approximately 40 patients to take care of. LPN I reported when narcotic medications were given to a resident the nurse would verify the order, make a notation on the narcotic count sheet, dispense to the correct resident and then document in the electronic medical record. LPN I reported the main thing was sign it out on the sheet when took it out. LPN I reported the transfer and count off for the narcotics was good, nothing was wrong otherwise the oncoming nurse wouldn't have taken the keys. LPN I' reported Resident #103 reported he did not get his pain medication and LPN I reported she had given him the pain medication when she did his dressing change. LPN I denied the misappropriation of medication. In an interview on 09/17/25 at 10:19 AM, Resident #103 reported he did remember the incident and reported he was upset that she documented she gave him the medication when she didn't give it to him. Resident #103 reported he had a headache and had been at dialysis all day, when he went to dialysis it really wiped him out. Resident #103 reported it had been a long day and he was in pain. Resident #103 when LPN F told me a pain medication had been dispensed to me at 8:00 PM, he reported he told her if he had one earlier his pain wouldn't have been like it was. Review of Statement of interview between DON (Director of Nursing B) and (Resident #103) revealed, .At 0645 am I, (Name of Director of Nursing (DON) B), RN DON at (Facility), spoke with (Resident #103) related to his pain medication record from 6/25/26.(Resident #103) did state yes when asked if he received his Oxycodone-Acet 7.5mg-325mg at 0800.(Resident #103) goes to dialysis from 940 to approximately 430-500pm on M, W, Fri. He was not in the building at 1400.(Resident #103) said no, I did not get any pain medication at 8o'clock I fell asleep around 7pm with a migraine and did not wake up until 9 or 10pm and then I asked (LPN F) (nurse on duty 6p-6a) for a pain pill. I only got 2 yesterday.This is a true statement of the conversation between (DON B) DON and myself. Review of Medication Administration Record (MAR) dated 6/25/25 -6/26/26 revealed, .Percocet (oxycodone-acetaminophen) - Schedule II tablet; 7.5-325 mg; Amount to administer: one tablet; oral.Wednesday, 6/25/25 at 10:36 PM.(LPN F), LPN).PRN reason: Pain.PRN Result: E (Effective).Review of MAR dated 6/21/25 - 6/25/25 revealed, 6/22/25: (LPN F) at 1:35 AM, Pain, E.6/23/35: (LPN BB) at 8:16 AM, Pain, E.(LPN F) at 10:36 PM, Pain, E. (LPN BB), LPN.(LPN F), LPN . Review of Narcotic Medication Controlled Substances Proof of Use form revealed on 6/25/25, (Resident #103), Order for Oxycodone-Acet 7.5-325 tab, Give 1 tablet by mouth every 6 hours as needed for pain.6/25/25 at 0800 one used, quantity remaining: 20, nurse signature, yes in comments.6/25/25 at 1500 but changed to 1400, one used, quantity remaining: 19, nurse signature, dialysis in comments.6/25/25 at 2000 one used, quantity remaining: 18, nurse signature, no in comments.6/25/25 at 2300 one used, quantity remaining: 17, nurse signature J [NAME], yes in comments. Review of Transportation Log from scheduled for pick up at 1445 (2:45 PM) from 2902 E. [NAME] Rd. Kalamazoo, MI 49001 to Drop off address (Facility).approximate pick up at 14:54 (2:54 PM).approximate drop off - 15:29 (3:29 PM). Review of electronic communication from (Transportation Company) received on 6/16/25 at 11:36 AM, revealed, .Please find the attached documentation for (Resident #103) transportation's from yesterday on 6/25/2025.Leg A- Our driver (Name of Driver) was in the pick up radius at Plainwell Pines at 9:09AM (scheduled for a 9:15AM pick up). She dropped (Resident #103) off at 2901 E [NAME] Rd, Kalamazoo at 9:44AM.Leg B- Our return pick up for (Resident #103) was done by our driver (Name of driver). She was in the pick up radius at 2901 E [NAME] Rd, Kalamazoo at 14:36PM (scheduled fora 14:45PM pick up). She dropped (Resident #103) off at (Facility) at 15:18PM. In an interview on 09/17/25 at 2:37 PM, Director of Nursing (DON) B reported the nurses would review the order, make sure the correct mediation card was pulled, ensure the order and the medication card match the order in the electronic medical record (EMR), if those match, removed the medication, document on the pink sheet for proof of use, dispense directly into the cup. When the nurse entered the room to give to the resident, ensure the correct resident, if the resident had refused the medication document it was refused in the EMR and document in the EMR was given. For Resident #103, LPN I had signed the medication narcotic it was taken out around 1400 (2:00PM) and the resident was not back from dialysis at that time. DON B reported the medication count was correct, so if the resident was not present to take the medication at 2:00 PM and she documented the pill was dispensed can infer she took the medication. DON B reported the facility received GPS tracking for drop off and pick up for Resident #103 when he went to dialysis and when he had returned to the facility which corroborated he was not able to take the medication at 2:00 PM. DON B reported Resident #103 was interviewed and indicated he did not get the medication. DON B reported the current nursing staff were provided education on the process of medication administration, controlled substance standards of practice, abuse education, the nurses were re-educated on all things relevant to medications. In an interview on 09/17/25 at 4:04 PM, Nursing Home Administrator (NHA) A reported as it had been reported to her the medication count was good when LPN I left and LPN F took over the cart. Then Resident #103's pain medication was signed out at 8:00 PM but he reported he did not receive the medication and then it was noticed a PRN as given at 2:00 PM when Resident #103 had been gone to dialysis. NHA A reported she had reached out to their transportation company and had received confirmation Resident #103 had not been back at the facility at the time the medication was signed out. When LPN I was questioned she became very defensive and denied she took the medication. At that point, Resident #103 was not here , medication was signed out as dispensed and the count was correct, so it was determined medication was misappropriated by her. NHA A reported the facility contacted the agency and informed them of the events, and requested she not return. NHA A reported the police were contacted. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included education with all staff on the abuse policy, all nurses were re-trained on medication administration and controlled substance standard practice and deemed appropriate, and the facility had maintained compliance as of 9/3/25.

Based on observation, interview, and record review, the facility failed to protect resident privacy during personal care for 1 (Resident #109) of 10 residents reviewed for privacy/dignity, resulting in the potential for feelings of embarrassment. Findings include: Review of an admission Record revealed Resident #109 was a male with pertinent diagnoses which included cellulitis of right lower limb, edema, changes in skin texture to BLE (bilateral lower extremities), cellulitis of left lower limb, and erythematous condition (red or abnormally reddened that appears red due to inflammation, infection, and other irritation). Review of current Care Plan for Resident #109, revised on 3/21/25, revealed the focus, .Resident has a bilateral lower extremity chronic venous ulcers with potential for infection and discomfort to the area . with the intervention .Administer analgesic as ordered prior to wound care, dressing changs or debridement, avoid friction and shearing during transfers or repositioning, conduct a systemic skin inspection weekly and PRN ( as needed). CNA to observe skin integrity during daily cares . Review of Order dated 8/12/25 for Resident #109, revealed, .Unna Boot Zinc Calamine bandage; 3% -3%-4x10 yard; amt: one bandage; topical; Special instructions: apply one bandage to bilateral ankles and feet every other day unit area is healed, Once a day Every Other Day 09:00 AM . (Unna boot - zinc oxide impregnated compression bandage used to treat leg conditions like swelling and venous ulcers). During an observation on 09/15/25 at 09:19 AM, Resident #109 was observed in the hallway in his wheelchair, his bilateral lower extremities was covered with dry, flaky skin which was peeling off and he was instructed by Registered Nurse (RN) L his legs needed to wrapped and he was taken to the doorway of the nurse's station where RN L began to perform wound dressing. She had pulled a chair to the doorway and had began to wrap his lower leg with the dressing. Director of Nursing (DON B observed her performing the wound dressing in the doorway and asked her to take Resident #109 to his room, RN L reported his room was too small for her to dress his lower legs but she instructed Resident #109 to self-propel to his room so she could perform the wound dressing. Resident #109 had just returned from the whirlpool where he went to provide moisture to his lower legs. This writer observed Resident #109 seated just inside of his doorway with RN L kneeling on the floor in the hallway while she performed the wound dressing. There were no chucks on the floor under Resident #109's feet. In an interview on 09/17/25 at 1:14 PM, Assistant Director of Nursing (ADON) C reported Resident #109 would go to the whirlpool, when finished complete wound dressing, and on his bed and on the floor next to his bed would be lined with chucks, so if there was skin and blood it would be on the chucks. Observed his feet had blood between his toes and the tops of his foot by the toes, the dressing had spots of pink, fresh blood weeping through dressing. In an interview on 09/17/25 at 2:57 PM, Director of Nursing (DON) B reported RN L should not have been performing wound dressing at the nurse's station to maintain Resident #109's dignity. She reported couldn't believe she had started to perform the wound dressing at the nurse's station within 15 minutes of this writer observing the hallways.

Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent falls for 2 (Resident #26 and Resident # 7) of 12 residents reviewed for falls, resulting in falls with fractures, decline in functional abilities, increased pain, and a potential for further injuries. Findings include: Resident #26 Review of an Admission Record revealed Resident #26, was originally admitted to the facility with pertinent diagnoses which included: history of falling, unspecified dementia, and type 1 diabetes mellitus (lifelong condition in which the pancreas does not make sufficient insulin to maintain stable blood sugar levels) with diabetic retinopathy (damage to the blood vessels in the eyes causing poor vision). Review of a Minimum Data Set (MDS) assessment for Resident #26, with a reference date of 4/18/24 revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #26 was severely cognitively impaired. Section GG of the MDS revealed Resident #26 required moderate assistance (helper does less than 50% of the effort) to transfer himself from his bed to his wheelchair and could ambulate 150' with moderate assistance (helper does less than 50% of the effort). Section J revealed Resident #26 experienced no pain during the 5-day assessment period and he required no pain medication. Review of a Minimum Data Set (MDS) assessment for Resident #26, with a reference date of 5/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 4/15 which indicated Resident #26 was severely cognitively impaired. Section GG of the MDS revealed Resident #26 required maximal assistance (helper does more than 50% of the effort) to transfer from his bed to his wheelchair and an attempt to assess the resident's ability to ambulate 10' was not made due to his medical condition and/or safety concerns. Section J revealed Resident #26 occasionally experienced pain that limited his day-to-day activities, and he required the use of pain medication. Resident #26 rated his pain at a 5 on the pain scale of 1-10. Review of a Care Plan for Resident # 26, with a reference date of 4/2/24, revealed a focus/goal/interventions of: At risk for falls and subsequent injury .does not remember to use call light .is legally blind . Goal: to prevent or reduce the occurrence of falls and subsequent injury .Approaches: . call light will be in reach, instruct and remind to use call light, keep paths to bathroom and hallway clutter free, wear nonskid shoes .keep door open unless providing care . Review of a Fall Risk Assessment for Resident #26, with a reference date of 4/1/24, revealed the resident was assessed as having no history of falls, no confusion, disorientation, or overestimating/forgetting his limits, and was deemed not at high risk for falls with a fall risk score of 0. Review of an Event Report for Resident #26, with a reference date of 5/7/24, revealed the resident told Therapy Manager (TM) S that he fell and had pain in his right hip. Bruising was evident on Resident #26's right hip along with rotation/deformity/shortening of his leg and an x-ray was ordered. In an interview on 6/26/24, at 9:28am, Therapy Manager (TM) S reported Resident #26 complained of pain in his right hip on 5/7/24 and told TM S he had fallen in his room. TM S reported Resident #26 never complained of pain prior to this date. TM S reported Resident #26's x-ray revealed a hip fracture that was subsequently repaired surgically at a nearby hospital. TM S reported Resident #26 had a longstanding history of falls prior to his admission to the facility, had poor safety awareness and could not retain safety strategies. When further queried about Resident #26's history of falls, TM S reported Resident #26's daughter told the care conference team, in a meeting on 4/17/24, that the resident had poor safety awareness and had multiple falls he had at her home prior to his admission. TM S reported Resident #26's daughter felt the resident needed close supervision to remain safe and could not be left unattended. TM S reported Resident #26 was improving slowly after his fracture of his hip, but his recover was further complicated by his left wrist fracture that left him unable to bear weight on his wrist. In an interview on 6/27/24 at 12:03pm, Social Services (SS) D reported Resident #26's daughter told the care conference team on 4/17/24 that the resident fell frequently, did many unsafe things and was restless at home. SS D reported this information should have been incorporated into the resident's plan of care. Efforts to contact Resident #26's daughter during the survey were unsuccessful. Review of an Event Report with a reference date of 6/15/24 revealed a Certified Nursing Assistant who was assisting Resident #26 with getting dressed, noticed the resident had a swollen left wrist on this date, and the resident reported he fell . Further review revealed Resident returned from (local hospital name omitted) emergency room today at 1:30pm. Resident diagnosed with a L (left) wrist closed fx (fracture). New orders received for opioid (brand name omitted) pain medication .to wear splint .until specialist clears him . In an interview on 6/27/24 at 8:17am, Licensed Practical Nurse (LPN) CC reported she Resident #26 was very restless throughout the day and nighttime, got up on his own, could not remember to use a call light, and frequently had urinary urgency(sudden, strong, and uncontrollable need to urinate). LPN CC reported she was not able to provide enough supervision to keep him safe. LPN CC reported she found Resident #26 lying on the floor outside his bathroom on 5/2/24. LPN CC reported when asked what he was doing before he fell , Resident #26 reported he was trying to go to the bathroom. LPN CC reported Resident #26's clothing was saturated with urine when he was found on the floor. LPN CC reported the facility needed more staff to be able to monitor Resident #26 more closely. LPN CC stated I make suggestions all the time (to the facility), but they don't follow up. He'd be safer if his room was near the nurse's station. LPN CC reported she felt the facility had not done enough to ensure Resident #26 remained safe. In an interview on 6/27/24 at 11:58am, Registered Nurse (RN) H reported Resident #26 had multiple falls at the facility because he could not be adequately supervised. RN H stated we can't watch him all the time and we've been told we can't have extra staff to provide 1:1 supervision, but that's what he needs. During an observation on 6/25/24 at 9:40am, the door to Resident #26's room was closed. Upon opening the door, Resident #26 was observed sitting in his wheelchair in the middle of the room. No one else was present. During an observation on 6/26/24 at 4:18pm, the door to Resident #26's room was closed. Upon opening the door, Resident #26 was observed sitting in his wheelchair, alone in the room. During an observation on 6/27/24 at 9:16am, Resident #26 was alone in his room, as he stood in front of a large window, and raised the window blinds over his head. His wheelchair was behind him, unlocked. Resident #26 stood alone for 45 seconds, using both of his arms to hold the blinds over his head, then transferred himself back to his unlocked wheelchair. No staff witnessed the resident's actions. During an observation on 6/27/24 at 11:03am, Resident #26 sat alone in his room, the room door was closed, and his call light was activated. A nurse stood at the med cart 2 door down and did not respond to the activated call light. Social Services (SS) D answered Resident #26's call light at 11:11am, resident denied any needs and SS D left his room, leaving the door ajar approximately 2, which left the resident out of view from the hallway. During an observation on 6/27/24 at 11:14am, Resident #26 closed his room door. Rustling sounds were audible from behind the door. During an observation on 6/27/24 at 11:18am, 2 Certified Nursing Assistants (CNA's) walked by Resident #26's closed door. During an observation on 6/27/24 at 11:21am, Registered Nurse (RN) H walked by Resident #26's closed door and did not intervene. 38384 Resident #7 (R7) According to the Minimum Data Set (MDS) dated [DATE], R7 scored 99 on her BIMS (Brief Interview Mental Status) indicating the resident was unable to complete the interview due to her cognitive state. R7 had impairment in both of her legs requiring substantial maximal assistance to transfer and partial moderate assistance to walk 10 feet. Diagnoses included fracture, anxiety, depression, and a psychotic disorder other than schizophrenia. Review of R7's Care Plan, dated 4/18/24, focused on Falls including risk and subsequent injury related to history of falls with injury, impaired balance and mobility, cognitive impairment, and incontinence. The goal was to prevent or reduce the occurrence of falls and subsequent injury related to falls with interventions that included 1:1 supervision provided 1800 (6PM) until resident went to bed (5/3/24) Review of R7's Incident Report dated 6/9/24 indicated the resident was in a wheelchair with sitter by her side. Sitter turned to assist someone, and resident stood up and walked in the hallway. A witnessed fall occurred, and resident had a 3 cm x 2.5 cm skin tear to right distal elbow area. Resident also had a red area to her right shoulder. During an observation and interview on 6/25/24 at 8:50 AM, CNA M stated, (R7) had a fall last week. She will try to walk with a walker if staff get her up. Her knees do not bend. Observed next to bed was a walker with a wheelchair at the end of the bed. Review of R7's Progress Note dated 6/9/2024 at 3:21 PM revealed, This nurse heard a scream. Resident laying on floor about 5 feet from her W/C. Facilities director was with her and had witnessed the event .Red area on skin where she had been lying on floor and 0.5cm skinned area on R (right) elbow . Review of R7's Progress Note dated 6/9/2024 at 11:03 PM revealed, Resident in wheelchair . with sitter by her side. Sitter turned to assist someone, and resident stood up and walked in the hallway. A witnessed fall occurred, and resident has a 3 cm x 2.5 cm skin tear to right distal elbow area. Resident also has red area to her right shoulder, with no open areas found . During an interview on 6/26/24 at 3:38 PM, LPN J stated, (R7) was in her chair a few days ago in the hall and I was in the nurse's station. I saw her starting to get up out of her chair and went to help her back in it. She stood up when I got there and fell on top of me. That might have been when she broke her pinky and hand. But she went for xrays yesterday and now has a cast on it she is trying to bite off. She is impulsive. Staff try to keep an eye on her but we have things to do with other residents. During an interview and record review on 6/27/24 at 1:09 PM Director of Nursing (DON) B stated, (R7) was with a 1:1 sitter on 6/9/24 when the sitter turned to help someone else and (R7) walked away fell and got an injury. She does not have a 1:1 sitter all the time because of staffing. During an interview on 6/27/24 at 2:00 PM, RN H stated, (R7) has had a lot of falls. Most of them happen on 2nd shift. She almost needs a 1:1 person.

This citation pertains to intakes: MI0014331, MI00143140, MI00142071, MI00139687, and MI00144696 Based on observation, interview, and record review, the facility failed to protect residents rights to be free from mental abuse, verbal abuse, and physical abuse by staff and other residents in 5 of 8 residents' (Resident #101, Resident #103, Resident #105, Resident #106, and Resident #107) reviewed for abuse, resulting in Findings include: Resident #101: Review of an Admission Record revealed Resident #101, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia without behavioral disturbance, aphasia (deficit with verbally expressing self) delusional disorder, psychotic disorder, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 3/16/24 revealed a Brief Interview for Mental Status (BIMS) score of 0/15 which indicated Resident #101was severely cognitively impaired. Review of a Care Plan for Resident #101 dated 11/28/23 revealed a problem/goal/approach: (Resident #101) displays .behavioral symptoms that impact her by putting her at risk for physical injury .interferes with social interactions .disrupts living environment .Goal: (Resident #101) will not cause harm to residents, staff, self .Approach: Resident placed 1:1 from after lunch until bedtime .maintain calm environment and approach to resident .when resident becomes physically abusive .report to DON (Director of Nursing) Administrator . chart in behavior log. Review of a Incident Investigation Report dated 3/5/24 revealed on 2/25/24 at 2:54pm Certified Nursing Assistant (CNA) L reported to Nursing Home Administrator (NHA) A that she witnessed Resident #101, who was seated on the floor of the hallway wearing only a gown and brief, being pulled backwards down the hall by Registered Nurse (RN) T at 1:30am. Further review of the report revealed RN T admitted he pulled Resident #101 down the hall as she sat on the floor and had done so previously as well. Resident #101 received a skin tear on her buttocks because of RN T's actions. Review of a facility floor plan included in the facility's investigation file for the event that took place involving Resident #101 on 2/25/24 revealed a handwritten identification of the location in which the dragging of Resident #101 by RN T started and stopped. In an observation, the area in which Resident #101 was dragged measured a total distance of 70', 45' on a floor covered with a low pile carpet, and 25' on a tiled floor. Review of a Skin Observation Report dated 2/25/24 revealed Resident #101 had a new circular open wound on her left buttock that measured 2 centimeters in width. In an interview on 5/8/24 at 1:01pm, CNA L reported on 2/25/24 at 1:30am she saw Resident #101 crawling toward the end of the hall on the carpeted floor, wearing a hospital gown and brief. CNA L reported Resident #101 had been resistant to direction that night. CNA L reported she observed Registered Nurse (RN) T retrieve and gait belt and walk toward Resident #101 as she crawled on the floor, facing away from RN T. CNA L followed because she assumed RN T was going to help Resident #101 stand up and 2 staff members would be needed. CNA L reported RN T walked up behind Resident #101, placed the gait belt across her chest with both ends of the belt behind the resident and then pulled forcefully causing Resident #101's body to drag on the floor as RN T walked backwards. CNA L reported RN T dragged Resident #101 70' until he released her body near the nurse's station. CNA L reported she told RN T to stop as he dragged Resident #101 because she was concerned Resident #101 was going to get hurt, but he refused. CNA L reported Resident #101 cried as result of the event and although she had difficulty verbally expressing herself, Resident #101 repeatedly said You don't love me anymore and Ouch as she sat on the floor, cried, and rubbed her buttocks while rocking side to side. CNA L reported she witnessed an abrasion and a bruise Resident #101's buttocks. CNA L reported she felt the actions of RN T were abusive but did not feel safe to report the situation while working alone with RN T. In an interview on 5/8/24 at 2:58pm, Certified Nursing Assistant (CNA) K reported she heard RN T say to Resident #101 Shut up no one is talking to you several times when Resident #101 spoke after hearing others talk. CNA K reported she told former Director of Nursing (FDON) C that RN T was verbally abusive to residents, gave her the example of the statements she heard him say to Resident #101, and FDON C replied Oh that's just (RN T's name omitted). In an interview on 5/16/24 at 11:57am, former Certified Nursing Assistant CNA BB reported in the months leading up to the event that took place with Resident #101 on 2/25/24, CNA BB heard RN T verbally threaten to stomp on Resident #101 as she laid on the floor. In an interview on 5/10/24 at 9:54am, Guardian U (legal guardian of Resident #101) reported the abusive actions of RN T on 2/25/24 were dehumanizing and demoralizing for Resident #101. Guardian U reported a reasonable person who experienced that type of treatment would experience fear, frustration, and extreme stress related to being unwillingly dragged 70' by a care provider. In an interview on 5/10/24 at 10:48am, CNA L reported she witnessed another event prior to 2/25/24 in which RN T forcefully pushed Resident #101 from a standing position into a nearby wheelchair, and then lowered her onto the floor. The forceful nature of RN T's actions caused Resident #101 to yell out in fear. CNA L reported RN T appeared frustrated during his actions and it appeared abusive, so she told former Director of Nursing (FDON) C, but FDON C responded with she's care planned for it (being on the floor) so it's fine. Review of RN T's employee file revealed no corrective action related to potentially abusive behavior was taken prior to the event that occurred on 2/25/24. Using the reasonable person concept, though Resident #101 had decreased ability to verbally express her own thoughts due to her cognitive deficits, she clearly experienced emotional distress and pain following the physical abuse that occurred on and prior to 2/25/24. This emotional distress has the potential to continue well past the date of the incident based on the reasonable person concept. Resident #101's court appointed guardian confirmed that the abuse she endured caused psychosocial harm. Resident #103 Review of an Admission Record revealed Resident #103, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: nontraumatic acute subdural hematoma (bleeding between the brain and it's outermost covering), depression, weakness, post-polio syndrome (disorder of the nerves and muscles), and obesity. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 9/10/23 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #103 was cognitively intact. Review of a care plan for Resident #103 with a reference date of 8/24/23 revealed: Problem: self-care deficit related to recent hospitalization .weakness .paresthesia (feeling of tingling, numbness or pins and needles) .polio syndrome. Goal: Resident will be clean .and participate in cares to their fullest ability. Approaches: Do not rush resident .have consistent approach amongst caregivers .see resident care guide . Review of an Investigation Report dated 9/5/23 provided by the facility revealed Resident #103 reported feeling mistreated when Certified Nursing Assistant (CNA) F cared for on 9/4/24 at 4:00am. In an interview on 5/9/24 at 2:26pm Resident #103 reported on 9/4/24, CNA F came to her room at 4:00am, woke her and insisted on changing her brief. Resident #103 reported during the care, CNA F yanked on her leg that has nerve pain and it hurt so much that she almost kicked the staff member with her other leg. Resident #103 reported she heard her leg pop and began to cry due to pain and frustration. Resident #103 reported she tried to tell CNA F not to complete the care so quickly, but CNA F responded loudly and said, I know how to do my job and left the room without acknowledging that Resident #103 was upset and in pain. Resident #103 reported the experience left her feeling fearful and humiliated, and she remained emotionally uncomfortable with being a resident there throughout her stay. In an interview on 5/10/24 at 11:53am. Certified Nursing Assistant (CNA) F reported she recalled caring for Resident #103 on 9/4/23 at approximately 4:00am. CNA F reported she was very busy and had been told she had to assist every resident on her assignment with a brief change before the end of her shift. CNA F reported Resident #103 had a significant amount of pain and was supposed to have 2 staff members present during care. CNA F reported she asked another CNA to assist her, but the CNA refused because she was busy. CNA F reported she felt she had not time to spare so she woke Resident #103 and completed her cares alone. CNA F reported she hurried during the care and accidentally caused pain for Resident #103. CNA F reported she was aware that Resident #103 was upset after she completed her cares, but she wasn't concerned because the resident voiced pain all the time. Resident #105 Review of an Admission Record revealed Resident #105, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: encephalopathy, cognitive communication deficit, lupus (chronic disease that causes inflammation and pain), generalized anxiety disorder and unspecified intellectual disabilities. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 4/21/24 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #105 was cognitively moderately impaired. Review of a Care Plan for Resident #105 with a reference date of 11/14/23 revealed: Problem: (Resident #105's name) has the potential for vulnerability related to reduced family support or visitors, intellectual disability, and isolated behavior .Goal: (Resident #105's name) will verbalize content .will feel safe and their needs will be met. Approaches: Allow (Resident #105's name) to have control over situations when possible and safe/appropriate .convey an attitude of acceptance .encourage resident to verbalize their feelings .concerns .fears . Review of an Investigation Report dated 3/2/24, provided by the facility revealed on that date at 6:20pm, Resident #105 alleged she had been struck in the face by Resident #101. The event was unwitnessed, but staff found the 2 residents close to each other in the hallway. The report indicated Director of Nursing (FDON) C assessed Resident #105 and found no swelling, bruising, or redness. In an interview on 5/10/24 at 9:27am, agency Licensed Practical Nurse (LPN) O reported she was heard Resident #105 yelling out on 3/2/24 at approximately 6:20pm and ran to see what was happening. LPN O reported she saw Resident #105 and Resident #101 close together in the hallway and she assumed Resident #101 had run over Resident #105's foot. LPN O asked Resident #105 if her foot was run over and she said No, she hit me in the face. LPN O reported Resident #105 demonstrated what happened and described Resident #105's actions as a backhanded slap. LPN O reported Resident #105's face was red on one side, as though she'd been struck, and she was crying. LPN O then called FDON C and told her there had been a resident-to-resident physical altercation. LPN O reported Resident #101 continued to display physical aggression toward others that evening and required a staff member to stay with her at all times. In an interview on 5/9/24 at 2:58pm Certified Nursing Assistant (CNA) K reported she was in a nearby room when she heard Resident #105 yelling in the hallway on 3/2/24 at 6:20pm. CNA K had seen Resident #105 sitting in the hallway and Resident #101 approaching her a few minutes earlier. CNA K reported as she came up to Resident #105, she noticed her forehead was red and Resident #105 reported Resident #101 hit her in the face. When further queried, CNA K reported it was not unusual for Resident #101 to strike out at others as she passed by them in the hallway. In an interview on 5/10/24 at 3:37pm, former Director of Nursing (FDON) C reported she investigated the altercation between Resident #101 and Resident #105. FDON C reported she arrived at the facility approximately 30 minutes after LPN O called her about the incident. FDON C reported she talked with Resident #105 for quite a while but thought Resident #105 might be thinking of another time in which Resident #101 struck Resident #105. FDON C reported when asked, Resident #105 reported she was talking about the incident that happened that night. FDON C reported Resident #101 had a history of lashing out at others. When further queried about the condition of Resident #105's face, FDON C first stated there was no redness. When informed the staff who were initially on the scene reported Resident #105's forehead was reddened as though she'd been struck, FDON C reported Resident #105 did have some redness, but the redness was from her medical diagnosis of lupus. FDON C then reported she felt Resident #105 may have egged on Resident #101 with her child-like disposition, and Resident #101 reacted as a strict Momma and struck Resident #101. In an interview on 5/16/24 at 10:47am, Registered Nurse (RN) F, who cared for Resident #105 almost daily, reported Resident #105 occasionally developed a rash on her face related to her lupus and described the rash as not very noticeable with no bright redness. RN F reported Resident #105's rash occurred across the bridge of her nose and on her cheeks. Review of a physician's progress note for Resident #105 dated 3/1/24 revealed a diagnosis of butterfly rash (a flat or raised rash that occurs across the bridge of the nose and cheeks). In an interview on 5/9/24 at 2:58pm, Certified Nursing Assistant (CNA) K reported she heard Registered Nurse (RN) T tell Resident #105 she was fine and to shut up and go to sleep on several different occasions. In an interview on 5/10/24 at 4:14pm, Certified Nursing Assistant (CNA) V reported she witnessed Registered Nurse (RN) T yelling at Resident #105, turning off Resident #105's lights, pulling her curtain and closing her door while she screamed from her bed. When CNA V asked RN T what he was doing(referring to his unprofessional actions toward Resident #105), he said it was too bright in here and refused to turn the lights back on despite Resident #105's fear of the dark. In an interview on 5/10/24 at 10:19am, CNA J reported RN T's interactions with residents became hostile and when she asked him why, he told her it was bedtime, and they (the residents) should be in bed. I'm not going to engage in conversation with them at this time of night. In an interview on 5/10/24 at 10:48am, CNA L reported she told Director of Nursing (FDON) C that RN T was verbally abusive to Resident #105, but no actions were taken. In an interview on 5/10/24 at 4:21pm, CNA I reported she heard RN T say to Resident #105 Shut up and go to bed. There's nothing wrong with you. CNA I reported she heard him tell the resident to shut up on multiple occasions. In an interview on 5/14/24 at 2:56pm, Resident #105 stated Registered Nurse (RN) T wasn't very nice to her. When further queried, Resident #105 reported when she asked RN T for over-the-counter pain medication at night he always told her to just go to sleep. Resident #105 reported she asked for over the counter pain medication because she had a headache, but he wouldn't give her anything. Resident #105 also reported RN T would walk by her room at night and flick off her light and refuse to turn it back on even though she was afraid of the dark. Resident #105 reported RN T would not only turn off her light but then he'd close her door as well so she couldn't have light from the hallway. Resident #105 reported she felt scared and angry because of RN T's actions. Resident #106 Review of an Admission Record revealed Resident #106, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cerebral infarction (stroke), cognitive communication deficit, aphasia (deficit in verbalizing thoughts) and weakness. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of -2/1/24 revealed a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated Resident #106 was severely cognitively impaired. Section E of the MDS revealed Resident #106 wandered daily. Section GG of the MDS revealed Resident #106 walked independently and could pick up objects off the floor independently as well. Review of a SBAR Communication Form dated 12/21/23 for Resident #106 revealed Registered Nurse (RN) F felt Resident #106 had an altered mental status because she had not slept in 24 hours, displayed continual exit seeking and was disoriented. Further review revealed the resident usually displayed exit seeking for an hour and then settled down prior to this date. Review of a nursing progress note dated 12/21/23 at 1:09am revealed: observed that resident had taken pajama top and rolled a sleeve onto her right leg so tight that the garment could not be removed and had to be cut off. Note was entered by Registered Nurse (RN) T. Review of a nursing progress note dated 12/21/23 at 5:28am revealed Resident observed sitting on the floor next to her bed folding a sheet .She has not slept all . Note was entered by RN T. Review of a social services progress note dated 12/21/23 at 11:35am revealed Nursing noted both arms are bruised . (Resident #106's name) increased exit seeking was not redirectable .staff report she is more irritable and striking out . (Resident #106) left for the emergency department . Review of a nursing progress note dated 12/22/23 at 5:58am revealed .resident hitting and scratching nurse with redirection, running down hallway attempting to open exit doors .DON and Adm (Administrator) notified of resident uncontrollable behavior . Review of an Incident Investigation Report with a reference date of 12/28/23 at 1:02pm revealed Resident #107 reported she saw a staff member dragging a resident down the hall during the night, sometime shortly before Christmas. Further review revealed the facility thought Resident #107 likely saw Resident #106 being moved down the hall by a staff member. In an interview on 5/16/24 at 11:57am, Certified Nursing Assistant (CNA) BB reported Resident #106 regularly lowered herself to the floor and was active throughout at least a portion of the night. CNA BB reported Resident #106 often entered other resident's room during the night an as a result, staff closed the doors to other residents' rooms. CNA BB reported she worried about Resident #106's safety because she got down on the floor frequently and RN T, who regularly cared for her at night, had threatened to stomp another resident who was crawling on the floor. CNA BB described Resident #106 as covered in bruises around the time of 12/23/23. In an interview on 5/14/24 at 3:46pm, Family Member (FM) W reported she was frequently called to the facility during the night when staff felt they could not care for Resident #106. FM W reported on 12/23/23 at approximately 1:30am, she was called because Resident #106 was exit-seeking and staff could not redirect her. FM W reported Resident #106 was sent to the hospital that night, and she met Resident #106 in the emergency department. FM W reported when she arrived at the hospital, Resident #106 was wearing a hospital gown that left both of her forearms easily viewable. FM W reported she was shocked at the condition of Resident #106's arms. FM W reported she immediately noticed Resident #106's forearms were completely covered in reddened bruises from her wrists to her elbows. FM W reported Resident #106 had multiple bruises on her lower legs as well. FM W reported the hospital staff inquired about the source of Resident #106's injuries. FM W reported she called the facility right away and asked how Resident #106 was injured and was told the resident was found at the facility with a pair of sweatpants wrapped tightly around both arms and that the wrapping was so tight the material had to be cut off. Review of a progress note written by RN T on 12/21/23 at 1:09am revealed: observed that resident had taken a pajama top and rolled a sleeve onto her R (right)leg so tight the garment .had to be cut off. No obvious injury noted . Review of a skin assessment dated [DATE] at 1:31am revealed Resident #106 had no areas of skin impairment. Review of all progress notes dated 12/23-1/24 revealed no documentation of an incident involving Resident #106 having a garment wrapped around her arms. Review of all incident/accident reports for Resident #106 with reference date of 12/23 of 12/23 1/24 revealed no documented incidences of Resident #106 sustaining an injury to her arms. In an interview on 5/16/24 at 10:45am, NHA A denied any incidents related to Resident #106 being found with her arms wrapped in a garment. Review of a skin assessment dated [DATE] at 2:19pm, completed by FDON C, revealed: bruising bilateral UEs (upper extremities), Improving, Consistent with IV's and blood draws. Review of an After Visit Summary from a local hospital for Resident #106 revealed Resident #106 had blood work done on 12/23/23 at 3:08am, 12/24/23 at 11:39am, and 12/25/23 at 6:13am. Resident #107 Review of an Admission Record revealed Resident #107, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: displaced fracture of lateral condyle of right tibia, muscle weakness, unspecified fracture of the shaft of the right fibula, and depression. Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 2/2/24 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #107 was cognitively intact. Review of a Care Plan for Resident #107 with a reference date of 12/21/23 revealed a Problem/Goal/Approach as follows: Problem: Resident has a dx (diagnosis) of depression .Goal: Resident will accept .assist from staff .Approach: Maintain calm environment and approach to resident .convey attitude of acceptance . Review of an Incident Investigation Report dated 1/5/24 revealed Resident #107 reported she saw another resident being moved down a hall against her will and because of the experience, Resident #107 expressed feeling uncomfortable being at the facility. In an interview on 5/8/24 at 3:39pm Resident #107 reported within days of her admission to the facility she awoke to a commotion in the hallway one night and saw a staff member hauling a resident (Resident #106) down the hall forcefully. Resident #107 reported hearing yelling coming from the hallway. Resident #107 reported staff tried to close her door and she refused to allow them to, so she saw an interaction between a staff member and a resident that appeared to too rough and felt abusive toward the resident. Resident #107 reported because of the experience, she felt anxious and fearful about the care provided at the facility. Resident #107 reported she discussed the experience with her daughter but was so scared, she opted not to discuss until she was outside of the building. In an interview on 5/14/24 at 4:20pm, Family Member (FM) AA reported Resident #107 was fearful and anxious on 12/24/24 when the resident told her about a recent event in which she saw a staff member drag a resident down the hall during the night. FM AA reported Resident #107 stated You've got to get me out of here and would not further discuss the incident until she was outside of the facility. FM AA reported she spoke with the Nursing Home Administrator regarding Resident #107's concerns and his explanation of the event Resident #107 reported did not correlate with what Resident #107 observed. When further queried about Resident #107's mentation at that time, FM AA stated her thinking was clear at that point. FM AA reported Resident #107 remained apprehensive about the care she would receive throughout the remainder of her admission. Review of a facility Abuse Prevention Program policy with a reference date of 1/24 revealed a statement: Abuse is defined as the willful infliction of injury, .intimidation, or punishment with resulting physical harm, pain or mental anguish . willful defined as used in the definition of abuse means the individual .acted deliberately, not that the individual .intended to inflict injury or harm .all staff are expected to be in control of their own behavior .behave professionally, and should .understand how to work with the nursing home population.

This citation pertains to intake number MI00144696. Based on interview and record review, the facility failed to throughly implement the abuse policy to protect, investigate, report and prevent staff to resident abuse and bruises of unknown origin for 3 of 5 residents (Resident #101, Resident #105, and Resident #106) reviewed for abuse, resulting in ongoing staff to resident verbal and mental abuse of Residents #101 and Resident #105, escalation of the abuse to staff to resident physical abuse of Resident #101. Findings include: Resident #101 Review of an Admission Record revealed Resident #101, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia without behavioral disturbance, aphasia (deficit with verbally expressing self) delusional disorder, psychotic disorder, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 3/16/24 revealed a Brief Interview for Mental Status (BIMS) score of 0/15 which indicated Resident #101was severely cognitively impaired. Review of a Care Plan for Resident #101 dated 11/28/23 revealed a problem/goal/approach: (Resident #101) displays .behavioral symptoms that impact her by putting her at risk for physical injury .interferes with social interactions .disrupts living environment .Goal: (Resident #101) will not cause harm to residents, staff, self .Approach: Resident placed 1:1 from after lunch until bedtime .maintain calm environment and approach to resident .when resident becomes physically abusive .report to DON (Director of Nursing) Administrator . chart in behavior log. Review of a Incident Investigation Report dated 3/5/24 revealed on 2/25/24 at 2:54pm Certified Nursing Assistant (CNA) L reported to Nursing Home Administrator (NHA) A that she witnessed Resident #101, who was seated on the floor of the hallway wearing only a gown and brief, being pulled backwards down the hall by Registered Nurse (RN) T at 1:30am. Further review of the report revealed RN T admitted he pulled Resident #101 down the hall as she sat on the floor and had done so previously as well. Resident #101 received a skin tear on her buttocks because of RN T's actions. Review of a Skin Observation Report dated 2/25/24 revealed Resident #101 had a new circular open wound on her left buttock that measured 2 centimeters in width. In an interview on 5/8/24 at 2:58pm, Certified Nursing Assistant (CNA) K reported she heard RN T say to Resident #101 Shut up no one is talking to you several times when Resident #101 spoke after hearing others talk. CNA K reported she told former Director of Nursing/current MDS Coordinator (FDON) C (now the MDs Coordinator) that Registered Nurse (RN)T was verbally abusive to residents, gave her the example of the statements she heard him say to Resident #101, and FDON C replied Oh that's just (RN T's name omitted). In an interview on 5/10/24 at 10:48am, CNA L reported she witnessed another event prior to 2/25/24 in which RN T forcefully pushed Resident #101 from a standing position into a nearby wheelchair, and then lowered her onto the floor. The forceful nature of RN T's actions caused Resident #101 to yell out in fear. CNA L reported RN T appeared frustrated during his actions and it appeared abusive, so she told FDON C, but FDON C responded with she's care planned for it (being on the floor) so it's fine. Review of RN T's employee file revealed he was suspended pending an allegation of abuse on 2/25/24. Further review revealed RN T admitted he forcefully dragged Resident #101 approximately 70' on the floor during the early hours of 2/25/24 and admitted he sometimes put a gait belt around the resident's upper body and slid her down the hallway (while resident was on the floor). In an interview on 5/16/24 at 11:57am, former Certified Nursing Assistant CNA BB reported in the months leading up to the event that took place with Resident #101 on 2/25/24, CNA BB heard RN T verbally threaten to stomp on Resident #101 as she laid on the floor. When further queried about reporting the threat as abuse, CNA BB reported she did not tell FDON C because when she previously reported concerns, she was told she was lying, things were not followed up on, and she worried about retaliation. In an interview on 5/10/24 at 3:32pm, Nursing Home Administrator (NHA) A reported staff were recently re-educated about abuse reporting and were now expected to report all concerns of abuse directly to him. However, there were times when NHA A would not be accessible to staff. NHA A reported during the few times when he was unavailable, staff were educated to report abuse concerns to the manager on-call and that FDON C was the manager on-call 5/4-5/6/24.When further queried about what would happen if another manager received a staff concern of a potential situation of resident abuse but did not share the information with him, NHA A stated that's why we have a new Director of Nursing. NHA A reported he was concerned that FDON C had not always been forthcoming with information. NHA A did not indicate what would happen if FDON C, now the MDS Coordinator was the manager on duty over a weekend and something happened that required reporting. Review of a Performance Improvement Plan for DON C dated 2/1/24-3/26/24 revealed the areas for improvement were: follow up of clinical processes and concerns .accountability, ensuring items that need addressed are corrected and not just I told them . In an interview on 5/10/24 at 3:37pm, FDON C reported RN T acted like a model staff member until 2/25/24. FDON C denied receiving any staff concerns regarding RN T prior to the event on 2/25/24. When queried about potential outcomes for ongoing abuse, FDON C reported there was a risk that the level of abuse would escalate, worsening psychological impact and ultimately an increased risk of resident mortality. FDON C reported staff were expected to report concerns of abuse to the FDON, Weekend Supervisor, or NHA immediately. When further queried about why she stepped down as the Director of Nursing, FDON C reported she struggled with the responsibilities of the role and wanted to be the leader without being the boss. FDON C reported she struggled with holding staff accountable. FDON C reported in her current role (MDS Coordinator) she worked as Weekend Supervisor every 4th Saturday and was the Manager on call 5/4-5/6/24. Review of RN T's employee file revealed no corrective action related to potentially abusive behavior was taken prior to the event that occurred on 2/25/24. In an interview on 5/10/24 at 3:32pm, NHA A reported the facility had not investigated any allegations of staff to resident verbal abuse involving Resident #101 or any other alleged abuses prior to 2/25/24. Resident #105 Review of an Admission Record revealed Resident #105, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: encephalopathy, cognitive communication deficit, lupus (chronic disease that causes inflammation and pain), generalized anxiety disorder and unspecified intellectual disabilities. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 4/21/24 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #105 was cognitively moderately impaired. Review of a Care Plan for Resident #105 with a reference date of 11/14/23 revealed: Problem: (Resident #105's name) has the potential for vulnerability related to reduced family support or visitors, intellectual disability, and isolated behavior .Goal: (Resident #105's name) will verbalize content .will feel safe and their needs will be met. Approaches: Allow (Resident #105's name) to have control over situations when possible and safe/appropriate .convey an attitude of acceptance .encourage resident to verbalize their feelings .concerns .fears . In an interview on 5/9/24 at 2:58pm, Certified Nursing Assistant (CNA) K reported she heard Registered Nurse (RN) T tell Resident #105 she was fine and to shut up and go to sleep on several different occasions. In an interview on 5/10/24 at 4:14pm, Certified Nursing Assistant (CNA) V reported she witnessed Registered Nurse (RN) T yelling at Resident #105, turning off Resident #105's lights, pulling her curtain and closing her door while she screamed from her bed. When CNA V asked RN T what he was doing (referring to his unprofessional actions toward Resident #105), he said it was too bright in here and refused to turn the lights back on despite Resident #105's fear of the dark. In an interview on 5/9/24 at 10:48am, Certified Nursing Assistant (CNA) J reported she witnessed Registered Nurse (RN) T speaking harshly to residents, including Resident #105, and deny them food at night when they voiced hunger. CNA J said she reported RN T's behavior to FDON C and FDON C told her she would follow up with RN T, but his behavior continued. CNA J reported when asked, RN T said FDON C never spoke to him his behavior. In an interview on 5/10/24 at 10:19am, CNA J reported RN T's interactions with residents became hostile and when she asked him why, he told her it was bedtime, and they (the residents) should be in bed. I'm not going to engage in conversation with them at this time of night. In an interview on 5/10/24 at 10:48am, CNA L reported she told FDON C that RN T was verbally abusive to Resident #105, but no actions were taken. In an interview on 5/10/24 at 4:21pm, CNA I reported she heard RN T say to Resident #105, Shut up and go to bed. There's nothing wrong with you. CNA I reported she heard him tell the resident to shut up on multiple occasions. In an interview on 5/14/24 at 2:56pm, Resident #105 stated RN T wasn't very nice to her. When further queried, Resident #105 reported when she asked RN T for over-the-counter pain medication at night he always told her to just go to sleep. Resident #105 reported she asked for over the counter pain medication because she had a headache, but he wouldn't give her anything. Resident #105 also reported RN T would walk by her room at night and flick off her light and refuse to turn it back on even though she was afraid of the dark. Resident #105 reported RN T would not only turn off her light but then he'd close her door as well so she couldn't have light from the hallway. Resident #105 reported she felt scared and angry because of RN T's actions. In an interview on 5/10/24 at 3:32pm, NHA A reported the facility had not investigated any allegations of staff to resident verbal abuse involving Resident #105. Resident #106 Review of an Admission Record revealed Resident #106, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cerebral infarction (stroke), cognitive communication deficit, aphasia (deficit in verbalizing thoughts) and weakness. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 2/1/24 revealed a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated Resident #106 was severely cognitively impaired. Section E of the MDS revealed Resident #106 wandered daily. Section GG of the MDS revealed Resident #106 walked independently and could pick up objects off the floor independently as well. Review of a social services progress note dated 12/21/23 at 11:35am revealed Nursing noted both arms are bruised . (Resident #106's name) increased exit seeking was not redirectable .staff report she is more irritable and striking out . (Resident #106) left for the emergency department . In an interview on 5/16/24 at 11:57am, Certified Nursing Assistant (CNA) BB reported Resident #106 regularly lowered herself to the floor and was active throughout at least a portion of the night. CNA BB reported Resident #106 often entered other resident's room during the night an as a result, staff closed the doors to other residents' rooms. CNA BB reported she worried about Resident #106's safety because she got down on the floor frequently and RN T, who regularly cared for her at night, had threatened to stomp another resident who was crawling on the floor. CNA BB described Resident #106 as covered in bruises around the time of 12/23/23. In an interview on 5/14/24 at 3:46pm, Family Member W reported Resident #106 was sent to the hospital on 12/23/23, and she met Resident #106 in the emergency department. FM W reported when she arrived at the hospital, Resident #106 was wearing a hospital gown that left both of her forearms easily viewable. FM W reported although she was very involved in Resident #106's care, she had not seen her forearms regularly because the resident preferred to wear long sleeves. FM W reported she was shocked at the condition of Resident #106's arms. FM W reported she immediately noticed Resident #106's forearms were completely covered in reddened bruises from her wrists to her elbows, practically covering her entire lower arms. FM W reported Resident #106 had multiple bruises on her lower legs as well. FM W reported the hospital staff inquired about the source of Resident #106's injuries. FM W reported she called the facility right away and asked how Resident #106 was injured and was told the resident was found at the facility with a pair of sweatpants wrapped tightly around both arms and that the wrapping was so tight the material had to be cut off. In an interview on 5/16/24 at 2:04pm, CNA K reported she recalled seeing large bruises on Resident #106's arms on 12/22/24. Review of a skin assessment dated [DATE] at 1:31am revealed Resident #106 had no areas of skin impairment. Review of all progress notes dated 12/23-1/24 revealed no documentation of an incident involving Resident #106 having a garment wrapped around her arms. Review of all incident/accident reports for Resident #106 with reference date of 12/23- 1/24 revealed no documented incidences of Resident #106 sustaining an injury to her arms or having a garment wrapped around her arms. In an interview on 5/16/24 at 10:45am, NHA A denied any incident reports related to or an awareness of an incident in which Resident #106 was found with her arms bound in a pair of sweatpants. Review of a skin assessment dated [DATE] at 2:19pm, completed by FDON C, revealed: bruising bilateral UEs (upper extremities), Improving, Consistent with IV's and blood draws. Review of an After Visit Summary from a local hospital for Resident #106 revealed Resident #106 had blood work done on 12/23/23 at 3:08am, 12/24/23 at 11:39am, and 12/25/23 at 6:13am. Review of the facility's Abuse Prevention Program policy revealed an alleged violation was defined as a situation or occurrence that is observed or reported by .staff .but has not yet been investigated and, if verified could be .mistreatment, abuse, including injuries of unknown source . Injuries of unknown source was defined as the source of the injury was not observed .could be explained by the resident .the injury is suspicious because of the extent .or the number of injuries observed at one particular point in time or the incidence of injuries over time. The policy defined indicators of abuse as .negative attitudes toward residents .verbally aggressive behavior .bossing around, intimidating . demonstrating burnout. Indicators of neglect were defined as .failure to oversee the implementation of resident care policies .failure to provide supervision and/or monitoring of the delivery of care .

This citation pertains to intake #MI00144223 Based on observation, interview, and record review the facility failed to prevent residents from insect bites and install window screen in 1 of 3 residents (Resident #108) reviewed for quality of care, resulting in Resident #108 suffering a spider bite and subsequent significant wound requiring debridement (removal of dead or infected tissue), increased pain, need for antibiotic treatment, and ongoing wound care. Findings include: Review of an Admission Record revealed Resident #108 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cerebral infarction (stroke) aphasia (difficulty with verbal expression), depression, hemiplegia (paralysis on one side of the body), generalized anxiety disorder, and pain. Review of a Minimum Data Set (MDS) assessment for Resident #108, with a reference date of 2/28/24 revealed a Resident #108 could not complete a Brief Inventory for Mental Status due to her aphasia. Section B of the MDS revealed Resident #108 understood others and usually was able to make herself understood. Section C of the MDS revealed Resident #108 had no short or long-term memory deficits. Review of a Care Plan for Resident #108 with a reference date of 4/12/24 revealed problem/goal/approaches as follows: Problem: Wound to right outer thigh with abscess, Goal: Heal skin and prevent infection, Approaches: .Measure and assess weekly for progression of healing, provide weekly sin checks per licenses nurse . During an observation on 5/8/24 at 12:25pm, Resident #108 sat in her bed, watching television, her room window was open 3, no screen was present. During an observation on 5/8/24 at 2:55pm a brown spider crawled on the hallway floor outside resident room [ROOM NUMBER]. During an observation on 5/8/24 at 3:19pm the window in resident room [ROOM NUMBER] was open approximately 1, no screen was present. During an observation on 5/8/24 at 3:08pm, the screen in the bathroom of room [ROOM NUMBER] was noted to have a 1 hole in the screen and the window as open. During an observation on 5/8/24 at 12:52pm, 30 ants crawled on the wall near the baseboard in the facility's conference room and a dead wasp laid on the floor. In an interview on 5/8/24 at 2:49pm Resident #108 reported she liked to have her window open because she often got hot in her room and she liked the fresh air. Resident #108 reported she was told her wound on her right thigh was from a spider or insect bite. Resident #108 reported the wound had been very painful, and as a result she had not been able to tolerate getting up for a few weeks. Resident #108 reported the pain had improved now but the wound treatments were still painful. Resident #108 reported she wanted to have a screen in her window to reduce the likelihood of future insect bites. Resident communicated through yes/no responses, simple statements, facial expressions, and hand gestures. In an interview on 5/8/24 at 1:29pm, Family Member (FM) S reported she visited Resident #108 every other week and when she recently visited in April, Resident #108 expressed significant pain in her right leg and could not tolerate having the leg touched. FM S reported Resident #108 had never complained of pain in her right leg before. FM S reported she was told the resident had a wound from an insect bite on her leg. FM S reported she saw Resident #108's room window opened frequently when she visited and had never seen a screen in the window. In an interview on 5/9/24 at 2:58pm, Certified Nursing Assistant (CNA) K reported Resident #108 generally wanted her window opened every day and her window did not have a screen. CNA K reported other resident windows also did not have screens and she had seen several windows open with no screens in place. CNA K reported she saw ants and spiders in the building. CNA K reported Resident #108 had expressed being in pain following the tissue injury to her right leg. During an observation on 5/8/24 at 3:00pm, Maintenance Staff (MS) Q placed a screen in the window of room [ROOM NUMBER]. Review of a Skin Monitoring Shower Review dated 4/5/24 revealed Resident #108 was found to have blisters on her upper right thigh. Review of a nursing progress note for Resident #108, dated 4/10/24 at 7:32pm, revealed paged on-call physician at 7:32pm regarding wound on .posterior thigh . Review of a progress note written by Nurse Practitioner (NP) FF dated 4/11/24, revealed: Patient .has .an abscess on the right buttock which is a new wound, cellulitis with streaks of red going up her leg and wraps around her thigh .pain with touching and movement .1x1circle at the 2-3 o'clock (position) has black that is not removeable .plan: start (antibiotic name), stop (another antibiotic) .mark cellulitis and make sure it is going down . Review of a Wound Evaluation for Resident #108 dated 4/12/24 revealed: wound type: cellulitis, length 2cm, width 1.6cm, depth .1, surrounding skin redness 8cm, hardness 13cm, edema (swelling) 13cm, pain: yes. Review of a physician progress note dated 4/12/24 for Resident #108 revealed: the patient was seen for erythematous edematous (reddened, swollen) area over the right thigh. It appears the patient may have been bitten by a spider or another insect .cellulitis (bacterial skin infection) has expanded .patient is complaining of extreme pain. Review of a progress note dated 4/16/24 revealed: Resident received ultrasound to right posterior thigh, antibiotic in progress for spider bite. Review of a NP progress note written by NP FF for Resident #108 on 4/18/24 revealed: patient .had ID (incision and drainage) by (physician name) .it is still very painful. She has not been able to get out of bed due to the pain .change to (antibiotic name, glycopeptide antibiotic) due to(sic) I and D review. Review of a physician progress note for Resident #108, written on 4/24/24 revealed She is requesting pain medication, will increase (nerve pain medication) .Plan: increase her (nerve pain medication) to 100mg bid (twice a day) for her pain . Review of a NP progress note written by NP FF for Resident #108 on 4/25/24 revealed: She has gotten worse again as she states the pain is . causing problems which is then keeping her from being able to get up .states anything touching it is increasing the pain .she continues to have a pocket that is red, warm to touch .copious amounts of thick red/brown drainage .concern that patient is tunneling (wound is spreading deeper) wound it's self is 1cm x 1.5cm black eschar (dead tissue) .removed well over 30ml of drainage from pushing on wound, concern for tunneling . Review of a Wound Management Report dated 4/26/24 revealed Resident #108's wound measured 8cm deep with a 1.7cm x 1.6cm opening. In an interview on 5/9/24 at 10:23am, Registered Nurse (RN) F reported she regularly completed the wound care for Resident #108's wound on her right thigh. RN F reported the wound care was painful for the resident and although the resident had difficulty with verbal expression, the resident regularly said owie, owie, owie during wound care. During an observation on 5/9/24 at 10:25am, Resource Nurse/ Registered Nurse (RN) RR and RN F completed wound care to Resident #108's right posterior thigh. The wound on Resident #108's right thigh measured 1cm x 1.5cm at the opening. RN RR reported the tunneling was improving but measured approximately 5cm in depth. The wound was packed with 18 of medicated gauze. Resident #108 reported pain during the wound packing. In an interview on 5/10/24 at 12:14pm Wound Care Specialist (WCS) P reported Resident #108's wound was consistent with that of an insect bite. WCS P reported the wound was improving but had some tunneling and required wound care twice a day. In an interview on 5/10/24 at 11:29am, Maintenance Staff ( MS) (Q) reported he removed all the facility's window screens in the fall of 2023 because most were broken. MS Q reported he began replacing the window screens this week and, but he did not have enough screens to cover every window yet. During an observation on 5/16/24 at 10:44am all windows were closed in the conference room, as a wasp flew around the room. Review of a pest control inspection dated 5/2/24 revealed: Resident getting bit, inspected room [ROOM NUMBER] for spiders or bedbugs, no bedbugs or spiders found. No screen in window . Review of the facility's Pest Control policy with no reference date revealed: Policy: the facility will maintain an effective pest control program to eradicate and contain common house pets .Procedure 4. Windows are screened at all times(sic) . Review of Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee, 2019, www.cdc.gov, revealed: From a public health and hygiene perspective, arthropod and vertebrate pests should be eradicated from all indoor environments, including health-care facilities. When windows need to be opened for ventilation, ensuring that screens are in good repair .can help with pest control. Insects should be kept out of all areas of the health-care facility, especially .any area where immunosuppressed patients are located.

Based on observation, interview, and record review, the facility failed to comprehensively assess pressure related injuries and develop/revise care plan interventions to prevent the development/worsening of pressure ulcers in 1 of 3 residents (R1) reviewed for pressure ulcer prevention, resulting in the development and worsening of pressure ulcers, and the potential for infection, and overall deterioration of health status. Findings include: According to the Minimum Data Set (MDS), R1 scored 12/15 (moderately cognitively impaired) on her BIMS (Brief Interview Mental Status), clear speech, made her needs known, understood others, functional status for bathing required total dependence of one-person physical assist, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to https://www.cdc.gov, Pressure ulcers, also known as bed sores, pressure sores, or decubitus ulcers, are wounds caused by unrelieved pressure on the skin . Stage 2: A partial thickness is lost and may appear as an abrasion, blister, or shallow crater. Stage 3: A full thickness of skin is lost, exposing the subcutaneous tissues-presents as a deep crater with or without undermining adjacent tissue . During an observation on 3/4/22 at 11:01 AM R1 was in her bed with pressure reduction mattress (air mattress), wedge under back positioning resident to her left side. Head of bed (HOB) approximately 45 degrees. During an observation on 3/4/2022 at 12:15 PM R1 was in her bed with pressure reduction mattress, wedge under back positioning resident to her left side. HOB approximately at 45 degrees. During an observation and interview on 3/4/2022 at 1:30 PM R1 was supine in bed with pressure reduction mattress. HOB approximately 45 degrees. During an observation on 3/8/2022 at 9:45 AM R1 was in room [ROOM NUMBER], not her assigned room. Resident supine in bed, HOB 45 degrees, pillow under feet, no wedge positioning resident off-loading from coccyx. No pressure reduction mattress on bed. In R1's assigned room on her bariatric bed was her pressure reduction mattress. During an interview on 3/8/3033 at 9:50 AM Registered Nurse (RN) E stated, (R1) was moved yesterday, 3/7/2022, because her bed would not move up and down. I am hoping the company comes today to fix it. No, her air mattress (pressure reduction mattress) was not moved with her. She did not have it on the bed she was moved to, and it should have been. During an observation and interview on 3/8/2022 at 12:10 PM RN EE stated, I am (R1's) hospice nurse. I was not told by the facility that her bed was not working. I will order her a new one (today). I did not know she was moved to a different bed. Observed with the RN of R1 in a different room without pressure reduction mattress. Observed with RN of R1's prior room and bed with the pressure reduction mattress on the unmade bed. RN stated, No, she (R1) does not have her air mattress (pressure reduction mattress) on the bed she was transferred to. RN stated, Why is this air mattress not on the bed she is in now? How hard can it be to move it? Her wound is getting worse. It has yellow drainage and is malodorous; it smells. I looked at it today. It is not deep enough to measure but it will not take long for it to get worse, and it will by the looks of it. It is 4 cm x 3 cm approximately and has a red area next to it that looks like it will open soon. I cannot believe facility staff did not move her air mattress with her. There is no excuse for that. Observed RN moving R1's air mattress to room [ROOM NUMBER] stating, How hard can this be? During an interview on 3/8/2022 at 12:15 PM Certified Nursing Assistant (CNA) Y stated, I was told (R1) was moved because her bed does not work. I don't know why her air mattress (pressure reduction mattress) was not moved. She is to have it all the time while in bed. During an interview on 3/8/2022 at 1:00 PM Director of Nursing (DON) B stated, (R1) was moved from her assigned room to another room because her bed broke. She is to always have an air mattress (pressure reduction mattress) in her bed. I do not know why it was not transferred with her. It should have been. During an interview and record review on 3/08/22 at 1:30 PM DON B stated, I did not know (R1) had a wound on her coccyx. It must have opened back up. She has had a wound previously to that area. Nurses are to do a weekly skin assessment on each resident. Residents are also to have a skin check when they get a bath/shower from the CNAs whether they are hospice, agency, or facility staff. Review of R1's medical records with DON B revealed not all of R1's shower sheets had a skin assessment. DON B stated, CNAs are not consistently doing the skin monitoring. They have not been marking them on (R1's) shower sheets. Review revealed not all staff marking shower sheets. DON B stated, Looks like we have some education to do. When a CNA does a shower sheet the nurse is to review it for abnormal skin. DON B reviewed R1's weekly Nurse Skin Assessments, stating, Nurses have not been doing their skin assessments on (R1) weekly either. Surveyor reviewed R1's Wound Management History with DON B that revealed on 2/10/2022 an area was open on R1's coccyx. DON B stated, I did not know that. Our ADON (Assistant Director of Nursing) has been doing wound checks also. During an interview on 3/8/2022 at 2:15 PM ADON C stated, I do skin assessments as well as ADON duties. (R1) coccyx was healed and closed with very thin skin then it reopened on 3/3/2022. Weekly skin assessments are done by me. Braden scales are done on admission and quarterly. That would include (R1). During an interview and record review on 3/8/2022 at 2:20 PM of R1's Orders and Braden Scale with DON B revealed, (R1's) Orders state, Monthly Braden's to start after completion of 4 weekly Braden upon admission. DON B stated, Yes, (R1) is to have Braden's done per the order in November. (R1) is to have monthly Braden scales. Surveyor reviewed R1's Braden Scales with DON B who stated, She (R1) does not have Braden Scales completed monthly per the order. During an interview on 3/8/2022 at 2:25 PM ADON C did not comment on R1's Braden Scale order. ADON C stated, (R1's) care plan was not updated for the new wound. That would be my responsibility to update the care plan. Review of R1's Order start date 9/27/2021 end date open-ended revealed, Skin Assessment Weekly. Once a day on Sat (Saturday) 2pm-10pm. Review of R1's Order start date 2/10/2022 end date open-ended revealed, Apply skin protectant, Z guard cream to coccyx with cares. Every shift . Review of R1's Order start date 3/3/2022 end date 3/8/2022 revealed, Cleanse with saline and gauze, apply med honey gel to the wound base and cover with a bordered gauze dressing, change daily. Twice A Day . It was noted the order received by a facility RN did not state what wound base was to be treated. Review of R1's Orders revealed, Bath/Shower on Tuesday/Friday hospice 1st shift Once A Day on Tue, Fri 06:00 AM - 02:00 PM Review of R1's Care Plan dated 9/20/2021 revealed, Problem: Pain potential/actual pain r/t (related to) wounds .Goals .will demonstrate fewer non-verbal signs of pain by next review period .Approach .pressure reduction mattress . Review of R1's Care Plan dated 9/20/2021 provided by MDS RN D via email dated 3/4/2022 revealed, .Approach .maintain the head of the bed at the lowest degree of elevation possible . Pressure reduction mattress. Specialty air mattress . Review of R1's Care Plan start date 10/29/2021 revealed, Problem: Pressure Ulcer- Resident has a pressure ulcer on her coccyx area r/t (related to) poor skin integrity .Goals .Resident's ulcer will heal without complications .Approach .Assess the pressure ulcer for stage, size (length, width, and depth), exudate, necrotic tissue, presence/absence of granulation tissue and epithelization, and condition of surrounding skin weekly .Conduct a systematic skin inspection every week. Pay particular attention to-all bony prominences . It was noted R1's care plan was not revised when her coccyx pressure injury deteriorated or reoccurred. Review of R1's CNA Skin Monitoring/Shower Sheets revealed, Perform visual assessment of the resident's skin when giving the resident a shower for any abnormal looking skin (as described below) to the charge nurse immediately. Forward problems to the DON for review. Use this form to show the exact location and description abnormality. Using the body chart below describe and graph all abnormalities by number . -1/28/2022 no abnormal skin was noted. Charge Nurse signed form. -2/10/2022 the coccyx was circled with #12 little soft. Charge Nurse signed form. -2/21/2022 no abnormal skin was noted by the CNA. Charge Nurse signed form and reported, wound on inside right ankle. -2/24/2022 CNA reported refused shower. No abnormal skin was noted during cares. Charge Nurse signed form. No abnormal skin was noted. -3/1/2022 CNA wrote Bath Bath given (sic) Charge Nurse signed form. No abnormal skin was noted. -3/7/2022 an X was placed a coccyx with #8 open areas. Charge Nurse signed the form. Review of R1's CNA Skin Monitoring/Shower Sheets beginning 1/28/2022 through survey exit date 3/8/2022 revealed resident missed six (6) skin monitoring opportunities on 2/1/2022, 2/4/2022, 2/8/2022, 2/15/2022, 2/18/2022, 3/1/2022, and 3/4/2022. Review of R1's Skin Body Assessment revealed: -1/1/2022 sacrum-coccyx wound, Left ankle and heel wounds -1/15/2022 sacrum-coccyx redness. Heel bilateral, pink, soft skin. Sacrum has open area -2/5/2022 right ankle pressure ulcer' -2/12/2022 sacrum-coccyx redness open area. Heel ankle -2/19/2022 sacrum-coccyx excoriation. Heel right ankle wound -2/26/2022 sacrum-coccyx pink, blanchable, pressure injury to sacrum It was noted there were four (4) missed opportunities for a weekly skin body assessment on 1/8, 1/22, 1/29, and 3/5 (2022) in a 90-day period. Review of R1's SNF (Skilled Nursing Facility)-Hospice Collaboration Log dated 3/7/2022 indicating a hospice CENA (CNA) provided a visit with no change in the resident's condition. The hospice CENA documented All ADLs done with showers given on 1/28, 2/1, 2/7, 2/11, 2/15, 2/19, 2/21, 2/24, 3/2, 3/7 (2022). No conference wiht facility staff had been documented. Review of R1's SNF (Skilled Nursing Facility)-Hospice Staff Collaboration Log dated 3/8/2022, indicated RN EE documented a routine visit with a change in the resident's condition. No conference with facility staff had been conducted. Review of an email received on 3/8/2022 from DON B indicated (R1) wound timeline 10/27/21: in-house acquired coccyx (resolved 2/28/22), 12/19/21: in-house acquired left buttock (resolved 2/21/22). Review of R1's Review of R1's Weekly Pressure Ulcer Progress Report observed date 11/13/2021 revealed, coccyx . Date Initial Discovery 11/3/2021 .n House Acquired . stage 2 1.9 cm x 0.7 cm x 0.1 cm .moderate serous exudate (drainage) .Wound 70% thin slough (dead tissue) 30% granulation (new connective tissue) edges intact . Review of R1's Review of R1's Weekly Pressure Ulcer Progress Report observed date 11/3/2021 revealed, .coccyx . Date Initial Discovery 10/26/2021 .In House Acquired . mild pain .stage 2 .1.9 cm x 0.7 cm x 0.1 cm .moderate serosanguineous (blood tinged) exudate .70% slough 30% granulation . Review of R1's Weekly Pressure Ulcer Progress Report observed date 11/24/2021 revealed, .coccyx Date Initial Discovery 10/26/2021 .In House Acquired . stage 2 .1.9 cm x 0.6 cm x 0.1 cm .moderate serosanguineous (blood tinges) exudate .20% epithelial (skin cells) 20% granulated tissue 60% slough edges intact and attached . Review of R1's Review of R1's Weekly Pressure Ulcer Progress Report observed date 12/2/2021 revealed, .coccyx . Date Initial Discovery 11/11/2021 .In House Acquired .mild pain . stage 2 .2 cm x 0.6 cm x 0.1 cm .moderate serous exudate .20% epithelial 20% granulated tissue 60% slough edges intact and attached . Review of R1's Review of R1's Weekly Pressure Ulcer Progress Report observed date 12/9/2021 revealed, .coccyx . Date Initial Discovery 11/3/2021 .In House Acquired .mild pain . stage 2 .2.8 cm x 1.0 cm x 0.1 cm .scant serous (yellow tinged) exudate . Review of R1's Review of R1's Weekly Pressure Ulcer Progress Report observed date 12/16/2021 revealed, .coccyx . Date Initial Discovery 11/3/2021 .In House Acquired .stage 2 .4.3 cm x 2.0 cm x 0.1 cm . moderate serous exudate .wound is 40% slough 60% epithelial edges intact . Review of R1's Review of R1's Weekly Pressure Ulcer Progress Report observed date 12/23/2021 revealed, .L (left) buttock . Date Initial Discovery 12/16/2021 .In House Acquired . stage 2 .1 cm x 0.5 cm x 0.1 cm . wound is 100% epithelial edges intact . Review of R1's Review of R1's Weekly Pressure Ulcer Progress Report observed date 12/23/2021 revealed, .coccyx . Date Initial Discovery 11/3/2021 .In House Acquired . mild pain .stage 3 .3.1 cm x 0.9 cm x 0.1 cm .moderate serous exudate . wound bed is 70% slough and 30% epithelial . Review of R1's Review of R1's Weekly Pressure Ulcer Progress Report observed date 1/2/2022 revealed, .coccyx . Date Initial Discovery 11/3/2021 .In House Acquired . stage 3 .1.9 cm x 0.8 cm x 0.1 cm .moderate serous exudate . 90% slough and 10% epithelial . Review of R1's Review of R1's Weekly Pressure Ulcer Progress Report observed date 1/6/2022 revealed, .coccyx . Date Initial Discovery 11/3/2021 .In House Acquired .mild pain .stage 3 .2.0 cm x 0.6 cm x 0.1 cm .scant serous exudate . Review of R1's Review of R1's Weekly Pressure Ulcer Progress Report observed date 1/13/2022 revealed, .coccyx . Date Initial Discovery 11/3/2021 .In House Acquired .stage 3 .1.9 cm x 0.8 cm x 0.1 cm .scant serous exudate . Review of R1's Review of R1's Weekly Pressure Ulcer Progress Report observed date 1/20/2022 revealed, .coccyx . Date Initial Discovery 11/3/2021 .In House Acquired .stage 2 .1.8 cm x 0.7 cm x 0.1 cm .scant serosanguineous (blood tinged) exudate . Review of R1's Review of R1's Weekly Pressure Ulcer Progress Report observed date 1/27/2022 revealed, .coccyx . Date Initial Discovery 11/3/2021 .In House Acquired .stage 3 .mild pain .stage 3 .1.1 cm x 0.5 cm x 0.5 cm .scant serous exudate . Review of R1's Review of R1's Weekly Pressure Ulcer Progress Report observed date 2/3/2022 revealed, .coccyx .Date Initial Discovery 11/3/2021 .In House Acquired .stage 3 .1.1 cm x 0.4 cm x 0.1 cm .scant serous exudate . pink intact . Review of R1's Review of R1's Weekly Pressure Ulcer Progress Report observed date 2/10/2022 revealed, .coccyx .Date of Initial Discovery 11/3/2021 .In House Acquired .stage 3 .1.1 cm x 0.5 cm x 0.1 cm .scan serous exudate .pink intact . Review of R1's Weekly Pressure Ulcer Progress Report observed date 2/24/2022 revealed, .coccyx .Date of Initial Discovery 11/3/2021 .In House Acquired .stage 3 .size: closed .Resolved date 2/24/2022 . Review of R1's Wound Management revealed, .Left Buttock Date/Time Identified 11/3/2021 11:54 AM . date/time observed: - 11/3/2021 11:54 AM . Healed/Discontinued Date/Time: 02/28/2022 01:55 PM . 1.1 cm x 0.4 cm x 0.1 cm .light serous drainage .granulation tissue 80% .20% slough . -2/3/2022 12:56 PM .0.6 cm x 0.9 cm .100% epithelial scant serous drainage edges intact and attached . -2/10/2022 12:13 PM 1.1 cm x 0.5 cm x 0.1 cm .light serous exudate epithelial tissue 40% . -2/10/2022 12:29 PM .0.5 cm x 0.3 cm . -2/17/2022 1:37 PM .0.5 cm x 0.5 cm x 0.1 cm .light serous exudate .epithelial tissue 40% . -2/21/2022 1:04 PM Healed/Discontinued Date/Time . Review of R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .coccyx .pressure injuries .coccyx . wound on her coccyx was noted 5 weeks ago .admits .bottom . little sore . Ulcer on the coccyx measures 2.0 x 0.6 cm, there is a depth of 0.1 cm though this is not a true depth due to the presence of slough, the wound base is 20% epithelial tissue, 20% granulation tissue and 60% slough, there is moderate serous drainage with no odor, wound edges are intact and attached . Review of R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .coccyx and left buttock .pressure injuries on her .coccyx .wound on her coccyx was noted 6 weeks ago .admits .bottom . little sore .Ulcer on the coccyx measures 2.8 x 1.0 x 0.1 cm, the wound base is 100% epithelial tissue, there is moderate serous drainage with no odor, wound edges are intact and attached .is bigger today .has an air mattress . Review of R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .coccyx and left buttock .pressure injuries on her .coccyx .wound on her coccyx was noted 8 weeks ago. Last week resident was also noted to have a new wound on her left buttock which was believed to have been caused by the bed pan .admits .bottom . little sore . Ulcer on the coccyx measures 3.1 x 0.9 cm, there is a depth of 0.l cm though this is not a true depth due to the presence of slough, the wound base is 70% slough and 30% epithelial tissue, there is moderate serous drainage with no odor, wound edges are intact and attached. Ulcer on the left buttock measures 1.0 x 0.5 x 0.1 cm, the wound base is 100% epithelial tissue, there is no drainage and no odor, wound edges are intact and attached .has an air mattress . Review of R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .coccyx and left buttock .seen today to f/u (follow up) on the pressure injuries on her .coccyx .the wound on her coccyx was noted 9 weeks ago. Two weeks ago resident was also noted to have a new wound on her left buttock which was believed to have been caused by the bed pan .admit .bottom .little sore . Ulcer on the coccyx measures 1.9 x 0.8 cm x 0.1 cm .presence of slough, wound base is 90% slough and 10% epithelial tissue .scant serous drainage .Ulcer on the left buttock is closed .resident has an air mattress . Review of R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .coccyx .pressure injuries .coccyx . wound on her coccyx was noted 10 weeks ago .admits .bottom . little sore . Ulcer on the coccyx measures 2.0 x 0.6 cm, there is a depth of 0.1 cm though this is not a true depth due to the presence of slough, the wound base is 60% slough, and 40% epithelial tissue, there is scant serous drainage with no odor, wound edges are intact and attached .has an air mattress . Review of R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .coccyx .pressure injuries .coccyx . wound on her coccyx was noted 10 weeks ago .admits .bottom .little sore . Ulcer on the coccyx measures 1.9 x 0.8 x 0.1 cm, there is a depth of 0.1 cm though this is not a true depth due to the presence of slough, the wound base is 30% slough and 70% granulation tissue, there is scant serous drainage with no odor, wound edges are intact and attached .has an air mattress . Review of R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .coccyx .pressure injuries .coccyx . wound on her coccyx was noted 11 weeks ago . Ulcer on the coccyx measures 1.8 x 0.7 cm x 0.1 cm, there is a depth of 0.1 cm though this is not a true depth due to the presence of slough, the wound base is 60% slough and 40% granulation tissue, there is scant serous drainage with no odor, wound edges are intact and attached .has an air mattress . Review of R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .coccyx .pressure injuries .coccyx . wound on her coccyx was noted 13 weeks ago . Ulcer on the coccyx measures 1.1 x 0.4 x 0.1 cm, the wound base is 20% slough and 80% granulation tissue, there is scant serous drainage with no odor, wound edges are intact and attached .has an air mattress . Review of R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .coccyx .pressure injuries .coccyx . wound on her coccyx was noted 14 weeks ago .Last week she was also noted to have an ulcer on her left medial buttock 2/2 MASD . Ulcer on the coccyx measures 1.1 x 0.5 x 0.1 cm, there is scant serous drainage with no odor, wound edges are intact and attached .Ulcer on the left medial buttock is closed .has an air mattress . Review of R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .coccyx .pressure injuries .coccyx . wound on her coccyx was noted 16 weeks ago .Ulcer on the coccyx is closed . has an air mattress . Review of R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Resident also had a wound on her coccyx that was first noted 16 weeks ago but was closed last week. Staff state the wound has opened up again .Ulcer on the coccyx measures 1.6 x 1.4 x 0.1 cm, the wound base is 100% epithelial tissue, there is scant serous drainage with no odor, wound edges are intact and attached .Pressure injury to the coccyx is open again .has an air mattress, staff to continue to assist resident with frequent turning . Review of R1's Progress Notes revealed, 01/29/2022 04:27 PM Resident has a stage 3 pressure injury to her sacrum. It measures 2 cm by 1.5 cm with a depth of 0.2mm. There is subcutaneous tissue visible in the wound bed. Wound edges are defined. The Peri wound has scar tissue surrounding the open area with dry and intact skin beyond that. There is a scant amount of serous drainage. Area cleansed, skin prep applied and a [MEDICATION(S)] (prescription wound treatment) used to cover the wound . Review of R1's Progress Note revealed, 03/08/2022 10:18 AM Remains in Rm (room) 4-2 (bed) waiting for her bed to get fixed . Review of facility policy Pressure Injury Prevention and Care Reviewed 01/2022, revealed, This policy is intended to supplement the clinical staffs knowledge and provide a resource to guide on wound prevention and management procedures. The procedures and information contained herein are not intended to replace a licensed nurse's clinical judgment and experience and may not pertain to each individualized pressure injury occurrence. Purpose: To promote and facilitate pressure injury prevention and implement appropriate interventions and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Procedure: 1. Nurses will complete the Skin Body Assessment Observation upon admission/readmission, then weekly and as needed. 2. Nurses will complete Braden Scale for residents on admission/readmission, weekly for 4 weeks, monthly, at time of new pressure injury identification, and as needed. 3. Certified Nursing Assistants will inspect resident skin during bathing activities and report any irregularities or concerns to licensed nurse for evaluation. 4. Interventions will be implemented, and care planned to prevent pressure injury development or to promote pressure injury resolution. Examples of interventions based on individualized resident needs may include the following .A. Pressure reduction mattress to bed .I. Maintain the head of bed at the lowest position based on resident medical condition .L. Avoid positioning the resident directly onto medical devices such as tubes, drains, and other foreign objects. 5. Pressure injuries will be assessed and documented upon admission, readmission, upon discovery, and weekly thereafter . Potential/suggested procedure with pressure injury identification. 8 B. Initiate treatment in accordance with facility protocols, standing orders, or physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Implement pressure-relieving or pressure-reducing interventions as appropriate .F. Update the resident care plan to address the area of pressure injury, and approaches initiated .10. Residents at-risk for developing pressure injury will have a care plan implemented to minimize skin breakdown risk. Resident risk factors will be reviewed and considered when developing the plan of care . Review of facility policy Skin Care Revised 3/2021 revealed, This policy is intended to supplement the clinical staff's knowledge and provide a resource to guide on wound prevention and management procedures. The procedures and information contained herein are not intended to replace a licensed nurse's clinical judgment and experience and may not pertain to each individualized pressure injury occurrence. Purpose: To promote and facilitate skin integrity with appropriate interventions and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Procedure: 1. Nurses will complete a skin body assessment upon admission/readmission, then weekly and as needed. 2. Certified Nursing Assistants will inspect resident skin during bathing activities and report any irregularities or concerns to the licensed nurse for evaluation. 3. Interventions will be implemented, and care planned to reduce risk of skin impairment . Avoid positioning the resident directly onto medical devices such as other foreign objects .

This citation pertains to Intake # MI 012. Based on observation, interview, and record review the facility failed to provided adequate supervision to prevent the elopement in 1 of 1 resident (Resident #100), reviewed for elopement risk, resulting in an Immediate Jeopardy when on 8/5/2021 unbeknownst to staff at approximately 5:25 AM Resident #100 eloped through an unsecured door and was found approximately 1.6 miles away. The facility was alerted by the Hospital as to the whereabouts of the resident. This deficient practice placed 1 resident, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of the facility policy Elopement Prevention and Management Program dated 7/2021, Goal It is the policy of the facility that personnel who have residents under their care are responsible for knowing the location of those residents (minimum hourly), and in the case of a missing resident, ensuring appropriate action is taken. Review of a Face Sheet revealed Resident #100 was a male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, irritable and anger, [CONDITION(S)], [CONDITION(S)], major depressive disorder, and paranoid [CONDITION(S)] (mental disorder). Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 7/10/2021, revealed a .Staff Assessment for Mental Status .Moderately impaired-decisions poor, cues/supervision required .Signs and Symptoms of [CONDITION(S)] .C. Disorganized thinking-Was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)? 2=Behavior present, fluctuates Review of the Facility 5 day report dated 8/5/2021, revealed at approximately 5:20 AM on Thursday, August 5th (Resident #100) was noted to be sitting in the family room watching TV per staff member. Resident was not observed again by a staff member in the facility until his return from the hospital later that day. In an interview on 8/25/2021 at 1:30 PM, Director of Nursing (DON) B stated we think that even after [AGE] years of being here and never attempting it (Resident #100) entered the kitchen which was not wander guard protected and the staff did prop the doors open in the morning because it gets hot in there.DON B stated he went in to get water and may have got turned around and went out the back door and there was no lock on that door at the time or a wander guard, he went out the door then down the drive way to B Ave continued down B Ave till it hit 24th street turned left and continued until (good citizen) assisted him and flagged an off duty police officer down who called an ambulance. In an interview on 8/26/2021 at 1:07 PM, Off Duty Officer (OOO) H reported that when he saw (Resident #100) he could not tell him his name or the date, but aside from the cognitive issues he physically looked ok, his clothing looked cleaned, it was fairly dark out so he could not see if he had any concerns on his hands like he had fallen. OOO H reported that the resident was just sitting off in the ditch on the North side of (name to the road), a crew going to work pulled off when they saw him and were concerned enough that they flagged me down, it was about 5:40 AM on 8/5/202. Review of Pre Hospital Care Reported dated 8/5/2021 at 5:51 AM, revealed dispatch to above location for an elderly male who was found walking along the road side and confused when passerby stopped to offer help.Patient assisted to back of ambulance to cot with all straps secured. Patient was only able to state his first name when questioned. Patient was not able to say where he was coming from/date of birth/age. Patient was also not able to tell us if he as hurting anywhere. Patient clothing was damp and patient was cool to the touch. Patient exposed and covered with blankets. Patient had dried blood on bottom lip with no obvious injury. Zero findings on assessment. Monitor applied showing RSR (regular [MEDICATION(S)] rhythm) with no ectopy Blood glucose (BGL) 162. Saline lock established with condition as he rested In an interview on 8/26/2021 at 6:40 AM, Registered Nurse (RN) C stated if I go into the kitchen at night I go through the south hall door to disinfect the freezer buckets that are on the med carts to run them through the dishwasher. RN C reported that he never unlocked the door between the kitchen and the dining room, but that was where the Certified Nursing Assistant's (CNA's) got ice from, so someone may have gone in from the South door and unlocked the the door into the kitchen. RN C stated I did not lock the South door to the kitchen when when I had completed my task. RN C reported that the statement in the 5 day report documented under his name was factual. RN C reported that (Resident #100) never pushed on any doors, that the resident would go into the dining room to watch TV, go into the dining area to eat or watch the larger television and look into the kitchen through the window in the door to watch what they were doing, since that was where he got his water and ice from. RN C reported that about 7:15 AM on 8/5/2021 a phone call came from the hospital who said they had a John doe and they were calling local nursing homes they told me what he looked like, they knew his last name, we checked his room and the building and did not find him, we did not call a code, no other residents were missing. RN C reported that then the Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified. RN C reported that Resident #100 was the only resident in the building with a wander guard. In an observation and interview with Maintenance Director (MD) O on 8/26/2021 at 10:40 AM, revealed that all door locks were in working order. MD reported that he had tested the locks when he came in on 8/5/2021 and found the locks in working order, but that the kitchen did not have key pad locks prior to 8/5/2021, just a key access and the back door out of the kitchen to the back of the building was just a key lock with no lock to go out the door and no alarm. On 8/25/2021 at 4:14 PM, Nursing Home Administrator (NHA)A was notified of an Immediate Jeopardy that began on 8/5/2021 when Resident #100, who was identified as an elopement risk, eloped from the facility, unbeknownst to facility staff. On 8/25/2021 and 8/26/2021 the surveyor verified that the facility completed the following to remove the Immediate Jeopardy. On 8/5/2021, When Resident #100 returned from hospital he was assessed by nurse, no injuries found. On 8/5/2021, Resident #100 was placed on 1 to 1 immediately upon returning to the building from the hospital. On 8/5/2021, all door including lobby, employee doors, east, west and south door alarm systems checked for function. On 8/5/2021 -8/6/2021 21 staff education on elopement program. On 8/5/2021 -8/6/202, All residents had an elopement risk assessment completed for a total of (28). Resident #100 was the only resident found to be an elopement risk. On 8/5/2021, Inside kitchen exit door, east door was changed to a keyed lock doorknob. On 8/6/2021, Installed 4 keypad locks to kitchen access area, including north and west kitchen doors and east and west break room. On 8/6/2021 - 8/7/2021 Elopement drills completed on all shifts. The facility was granted a Past Non-Compliance (PNC) at the time of exit with a compliance date of 8/6/2021 as the facility completed all items needed for compliance and no additional noncompliance was identified for this concern during the onsite survey.

This citation pertains to Intake # MI 685. Based on observation, interview, and record review, the facility failed to ensure wound treatments were completed per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: According to Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book ([NAME] Locations - ). Elsevier Health Sciences. [NAME] Edition.The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient . According to Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book ([NAME] Locations - ). Elsevier Health Sciences. [NAME] Edition.A health care provider's order for changing a dressing indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound . According to Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book ([NAME] Locations - ). Elsevier Health Sciences. [NAME] Edition.Nurses are responsible for performing all procedures correctly and exercising professional judgment as they carry out health care providers' orders . Review of the policy/procedure Licensed Nurse - Skin Condition Discovery and Documentation, dated 1/2021, revealed .All dressing changes and cultures, if indicated, will be completed and documented in a manner compliant with accepted standards of clinical practice .Once completed, dressing changes will be documented on the treatment administration record (TAR) and in nursing notes, as appropriate . Review of a Face Sheet revealed Resident #102 was a male with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Braden Scale for Prediction of Pressure Sore Risk for Resident #102, dated 5/22/21, revealed a score of 9 which indicated VERY HIGH RISK for pressure ulcers (sores). Review of a Minimum Data Set (MDS) assessment, with a reference date of 4/16/21, revealed Resident #102 had severe cognitive impairment and was totally dependent on staff for bed mobility. Review of a current Care Plan for Resident #102 revealed the problem .(Resident #102) is at risk for skin breakdown r/t (related to) dx (diagnosis) of MS .bedridden . with a start date of 1/22/21. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Gently cleanse bilateral calves with NS (Normal Saline). Cover any excoriated areas with xeroform. Cover xeroform with padded comfort foam and wrap legs in kerlix .The foam is for added protection from pressure injury .Once A Day . with a start date of 5/19/21. Review of a Treatments Flowsheet for Resident #102, dated 6/1/21 through 6/30/21, revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover any excoriated areas with xeroform. Cover xeroform with padded comfort foam and wrap legs in kerlix .The foam is for added protection from pressure injury .Once A Day . had missed entries/no documentation on 6/2/21, 6/3/21, and 6/4/21. Review of the nursing Progress Notes for Resident #102 revealed no documentation of wound care completed on 6/2/21, 6/3/21, or 6/4/21. In an observation on 6/7/21 at 3:03 p.m., Licensed Practical Nurse (LPN) G and Registered Nurse (RN) D completed wound care for Resident #102 in his room. Observed Resident #102 laying in his bed, with a wound dressing noted on his right calf. Observed RN D remove the soiled dressing from Resident #102's right calf wound. Noted an area of eschar, with several other small open areas on the back of Resident #102's right calf. In an interview on 6/7/21 at 3:03 p.m., RN D reported the wound on Resident #102's right leg was an unstageable pressure ulcer and had been there for .three days . RN D stated .I don't even know how it happened . In an interview on 6/8/21 at 10:43 a.m., LPN F reported there is typically a Mid-Shift nurse scheduled from 11 a.m. to 7:00 p.m. who is responsible for wound treatments. LPN F reported last Friday (6/4/21) there was no Mid-Shift nurse at the facility. In an interview on 6/8/21 at 2:22 p.m., RN E reported Resident #102 originally had some excoriation on his right calf in May. RN E reported a treatment order was put in place for xeroform and a foam pad, with dressing changes to be completed daily for close observation. RN E stated .it was doing really well . in regard to Resident #102's right calf wound. RN E reported Resident #102 .unfortunately . went several days with no wound care to his right calf wound. RN E reported she completed Resident #102's wound care on his right calf wound on Tuesday 6/1/21, and was off of work Wednesday through Friday (6/2/21, 6/3/21, and 6/4/21). RN E reported when she returned to work on Saturday the wound was .extreme . with a significant amount of skin breakdown in a short amount of time. RN E stated in regard to the missed wound care treatments on Resident #102's right calf wound .we are a 24-hour facility. If you don't get it (wound care) done on your shift the next shift will need to help out . In an interview on 6/9/21 at 10:00 a.m., Nurse Practitioner (NP) T reported he evaluated Resident #102's right calf wound yesterday, 6/8/21. NP T reported Resident #102's right calf wound would be classified as an unstageable pressure ulcer due to slough and eschar, with another superficial open area that would be classified as a Stage 2 pressure ulcer. NP T reported new wound care orders were put in place after the wound was evaluated. In an interview on 6/9/21 at 2:17 p.m., RN E reported she is unsure why the wound treatments on 6/2/21, 6/3/21, and 6/4/21 were missed, and reported she was unsure if anyone was monitoring to ensure wound care was being completed timely. RN E stated she is .appalled . that the wound treatments were missed, and stated .wound care is supposed to be done by all of us .really and truly there is no excuse .If you don't get something done, communicate it to the next shift . In an interview on 6/9/21 at 2:31 p.m., RN D reported in regard to Resident #102's missed right calf wound treatments .on the day shift it's really hard to do more than what's absolutely necessary . RN D reported the split-shift nurse typically does the wound care. Review of a provider Progress Note for Resident #102, dated 6/8/21, revealed .Resident is being seen today as staff has requested to assess resident right leg. They have notified me that resident has a new wound on her (sic) right calf area .Right posterior leg wound .Wound #1 - 2.375 x 2cm - with slough and eschar formation - rolled wound edges, pink .Wound #2 - 1.75 x 1.75cm - with slough, rolled wound edges, pink .Wound #3 - 1.25 x 1cm - with slough, rolled wound edges, pink .Wound #4 - 2.25 x 1.75cm - with mild amount of slough, with purulent drainage .

This citation pertains to intake number MI 162. Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent elopement in 1 of 3 sampled residents (Resident #101) reviewed for supervision, resulting in Resident #101, who was an elopement risk, who walked out of the facility through unlocked/un-unalarmed door unbeknown to staff, and was found outside the facility on 7/4/20 at approximately 9:00 P.M., 2 feet into a 55 mph road by a driver passing by. This deficient practice placed 2 additional residents identified as at risk for elopement at risk for serious harm, injury, and/or death. On 09/03/20 at 12:25 P.M. the Nursing Home Administrator (NHA) A was verbally notified and received written notification of the Immediate Jeopardy that began on 07/04/20 and was identified on 09/03/20 due to the facility's failure to prevent the elopement of Resident #101. A written plan for removal for the Immediate Jeopardy was received on 09/04/20 and the following was verified on 09/04/20. 1. Registered Nurse (RN) E, who was on duty at the time of the elopement, completed a facility head count to ensure no one else was missing; all residents were accounted for - 07/04/20. 2. RN E completed a physical assessment of Resident #101 for injury. There were no negative physical or psychosocial effects as a result of the event of the affected resident. Resident was fully clothed, with shoes and dressed appropriately for the weather - 07/04/20. 3. RN E engaged the locks on the front door and office door (where Resident #101 eloped) to immediately ensure resident safety - 07/04/20. 4. RN E notified responsible party, (Resident #101)'s son, and the physician on call following the incident - 07/04/20. 5. NHA A immediately conducted education with the staff on duty the evening of 07/04/20 (the evening of the elopement), 20 staff were educated on 07/05/20, and remaining staff were educated on 07/06/20. An investigation of the event was initiated on 07/05/20. 6. Upon return to the facility, Resident #101 was placed on increased supervision by Certified Nurse Assistant (CNA) G. Resident #101 was then assisted to bed for the evening and remained on 15 minute checks - 07/04/20. 7. NHA A posted a sign on the office door which indicated that no one was to enter the front office after 5:00 p.m. or on weekends and that the door was to be locked at all times. Fifteen (15) minute checks ensued throughout the evening - 07/04/20. 8. NHA A and Maintenance Supervisor (MS) J met at the facility and determined that the locks on the door leading into the office and the front door leading to the outside needed to be modified to eliminate the human error potential of failing to lock them. Modifications made included: the doorknob going in to the front office was changed to a doorknob with a numerical key pad requiring a code be entered to gain access from the resident hallway into the office; regarding the door going from the office to the outside - the on/off switch of the door was changed to permanently stay in the on position, meaning that the door alarm would sound whenever the door was opened - 07/05/20. 9. Resident #101's risk assessment and care plans were reviewed and updated as needed - 07/04/20. 10. Facility completed an elopement risk assessment on all residents; pertinent resident documents were updated as appropriate with elopement risk assessment information - 07/05/20. 11. NHA A reviewed the elopement risk book to ensure compliance with routine resident checks and to ensure the book contained current information for residents at risk for elopement - 07/04/20. The facility presented, and the State Agency accepted, documents to prove a past non-compliance. The Immediate Jeopardy was removed on 07/06/20, and all elements of compliance were verified by the State Agency. Findings include: Review of a facility policy, Elopement Prevention and Management Program last revised 08/2017 revealed, Introduction: Goal: It is the policy of this facility that personnel who have residents under their care are responsible for knowing the location of those residents . All residents will be assessed on admission by the licensed nurse for potential risk of wandering and/or elopement . Resident #101 Review of a Face Sheet revealed Resident #101 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 06/10/20 revealed a Brief Interview for Mental Status (BIMS) score of 02, out of a total possible score of 15, which indicated Resident #101 was severely cognitively impaired. Review of a current Care Plan for Resident #101 revealed focus of (Resident #101) experiences wandering that places her at risk of . exit seeking and agitation . with interventions which included . Distract (Resident #101) from wandering by offering pleasant diversions . Ensure all staff is aware of (Resident #101)'s elopement risk . When (Resident #101) begins to wander, provide comfort measures for basic needs . with a last review/revised date of 07/11/2019. Review of a current Care Plan for Resident #101 revealed focus of At risk for elopement from facility r/t (related to) exit seeking behavior and/or verbalizations of wanting to leave . with interventions which included . Resident to be in elopement book with photo and information . Resident to be on 15 minute checks . Resident to remain in facility with door alarms . with a last review/revised date of 07/11/2019. Review of Resident #101's Elopement Risk Biographical Data last updated 04/12/19 and last reviewed 07/04/20 revealed, . Behavior Patterns: Ambulatory - independent or walker, short & long term memory deficits, pleasant, active, likes to pick items up from floor . Comments: Cognitive deficits. Alert to person, does recognize son & some other family/friends. Has difficulty recalling names, cannot define whereabouts. At times believes children are home & younger. Review of a facility document Incident Summary revealed, On July 4th at 9:10 pm the Administrator received a call on her cell phone from a person who identified himself as (Concerned Citizen (CC) K) . reported . had a lady named (Resident #101) . and thought she may be a resident at the facility . reported (Resident #101) was standing on the east side of (name of street omitted) at the end of facility driveway . was driving by saw her and decided to pull over and see if she was lost . asked her what her name was and she told him it was (Resident #101) . asked her where she was going and she said, home . asked her where home was and she told (CC K) (street name omitted) . then came up to the front door and called the number. The Administrator told (CC K) yes she was a resident and to go to the side door and ring the buzzer. In an interview on 09/30/20 at 9:25 A.M., Nursing Home Administrator (NHA) A reported Resident #101 had exited the facility (eloped), unsupervised, through the front doors (door from hallway to offices and door from offices to outside) that were unlocked/unalarmed (alarm system was disengaged at the time). NHA A indicated this was due to human error. NHA A indicated learned of Resident #101's elopement when received a telephone call on 07/04/20 at approximately 9:10 P.M. from CC K, who had called her while sitting outside of the facility with Resident #101. In an interview on 9/3/20 at 10:59 A.M., CC K indicated was heading south on (street name omitted) and turned east on (street name omitted) when noticed (Resident #101) on the south side of (street name omitted) approximately two (2) feet into the street in the eastbound lane. CC K stated the lady flagged me down. CC K reported rolled window down and asked if (Resident #101) needed assistance. CC K indicated (Resident #101) seemed alarmed and confused and immediately tried to get into the car and stated she was lost and wanted to go to (address omitted). CC K reported eventually let (Resident #101) into car. CC K reported first instinct was to go immediately to the nursing home to see if she was a resident there but the address (Resident #101) gave was close enough that took resident there first (note address was 1.2 miles from facility). CC K reported when got to the address, (Resident #101) stated, well, do I just go up and tell them who I am? CC K reported realized (Resident #101) did not belong at the address and took her back to the facility. CC K indicated time from first saw (Resident #101) to returned to facility was approximately 10 minutes. CC K reported when back to facility, first walked into the building (the door was unlocked) to look for assistance, called out for help, but could not find anyone. CC K stated, the hall was absent of anybody. CC K indicated walked back out of the building, saw sign on the door with phone numbers, and dialed the first number on the sign (which was the number to the facility). CC K reported no one answered the facility phone. CC K reported called the second number on the sign (which was the number for the Nursing Home Administrator (NHA) A). CC K indicated NHA A answered the phone was told (by CC K) was with (Resident #101) outside of the building. CC K indicated NHA A reported had to get ahold of someone from inside the facility to let them in. CC K stated, It took a while and I had to sit out there and keep her company until somebody came out. CC K reported a nurse came out to get (Resident #101) approximately 10 minutes after spoke with NHA A. Note that total time Resident #101 was outside of building according to CC K account was 20 minutes. In an interview on 9/3/20 at 11:36 A.M., Registered Nurse (RN) E was asked by this surveyor to recall the elopement of Resident #101. RN E reported was the only nurse on the floor that evening, had 2 Certified Nurse Assistants (CNA)s on duty at the time, and it was very busy, extra busy. RN E indicated typically have 3 - 4 CNAs on staff in the evening. RN E reported received a call from NHA A that someone had (Resident #101) outside. RN E indicated did not understand as (Resident #101) has a wanderguard (an ankle bracelet-type device - placed on residents at risk for elopement - that sounds an alarm when in close proximity of the sensor placed at an exit). RN E reported did not hear any alarm or anything. RN E indicated there is a door that leads from the resident hallway to the management office and a second door that that exits from the management office to the outside. RN E reported discovered that both doors were left unlocked, neither doors had a wanderguard sensor, and the alarm for the door leading to the outside was turned off (meaning no alarm sounded when the door was opened). RN E indicated Resident #101 was known to exit seek, liked to wander, and would often go to every door and push on them. RN E indicated no staff were in the hallway at the time of the elopement because providing care to other residents. In an interview on 09/03/20 at 1:10 P.M., Registered Nurse (RN) E reported evening medication pass usually runs from 7:00 P.M. - 11:00 P.M., but when only nurse on duty (as was the case on the date of the elopement), start early at 6:00 P.M. to get everything done. RN E indicated saw Resident #101 at beginning of medication pass around 6:00 P.M. and glanced at her when moving in and out of other resident rooms when administering medications. RN E was unable to recall specific time Resident #101 was last seen prior to elopement. In an interview on 9/3/20 at 3:03 P.M., Certified Nurse Assistant (CNA) G indicated last saw Resident #101 between 8:40 P.M. - 8:50 P.M. on the day of the elopement. CNA G indicated Resident #101 known to wander and known to push on the doors. CNA G indicated there were 2 CNAs working the evening of 07/04/20 but there was normally 3 CNAs working in the evening. CNA G reported there was normally office staff in the office and one of the office staff is supposed to lock the doors before they leave but it was a holiday when Resident #101 got out and nobody was in the office. CNA G indicated there was no reason for staff to check the door leading from the hallway into the office because we never go in there. In an interview on 9/3/20 at 3:28 P.M., Certified Nurse Assistant (CNA) F reported did not know for sure last time saw Resident #101 but knew it was after snack around 7:00 P.M. CNA F reported there were only 2 CNAs on duty at the time of the elopement (CNA F and CNA G).

This citation pertains to MI 099. Based on observation, interview and record review the facility failed to implement the care plan for 1 of 3 residents (Resident #103) reviewed for care plans resulting in a fall, fractured (broken bone) hip and surgery for [REDACTED]. Findings include: Review of the Face Sheet revealed Resident #103 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #103 had a brief interview for mental status (BIMS) score of 14 out of 15 which indicated she was cognitively intact. The MDS further revealed Resident #103 was a limited assist of 1 staff for transfer. Review of the Fall Risk assessment dated [DATE] revealed Resident #103 was a High Risk for falls. Review of the Care Plan At risk for falls and subsequent injury dated 3/23/17 and updated 9/28/18 revealed an intervention of See ADL (activities of daily living) care plan for updated transfer status for Resident #103. Review of the Care Plan ADL (activities of daily living) Functional/Rehabilitation potential dated 9/28/18 revealed Resident #103 was to Walk to activity daily with walker, gait belt and CGA (contact guard assist). Review of the Fall Events dated 10/16/18 at 3:30 pm revealed Resident #103 was sitting in recliner, call light on, requested to go to bathroom and Certified Nurse Aide (CNA) M was .transferring her (Resident #103) to electric wheelchair and Resident #103 fell to the floor. In an observation and interview on 11/7/18 at 11:05 am, Resident #103 was noted to be seated in her wheelchair in her room. Resident #103 stated that during the transfer on 10/16/18, she (CNA M) dropped me, she (CNA M) didn't use the belt thing (gait belt). Resident #103 further stated, I fell , I went to the hospital, it was terrible, I had a broken hip, had surgery, it (broken hip) hurt, I don't think I ever hurt so much. In an interview on 11/7/18 at 11:29 am, Activity Aide (AA) I stated that on 10/16/18, I was with her (Resident #103) the day she fell and Resident #103 told her she (Resident #103) was dropped by the CNA (CNA M). AA I stated she could tell she (Resident #103) was in a great amount of pain, she kept wincing in pain. In an interview on 11/8/18 at 2:21 pm, CNA M stated, on 10/16/18, she (Resident #103) said she need to use the bathroom and in middle of transferring her (Resident #103) thing went wrong and she fell . CNA M stated, I didn't use a gait belt, I know I was supposed to use a gait belt when transferring a resident. Review of the Hospital Note dated 10/16/18 revealed Resident #103 .presents with right hip and right foot pain after a ground level fall .transferring to her wheelchair .of note she has a history [MEDICAL CONDITION](stroke) causing residual weakness on right side .The pain in her hip is severe, comes and goes in spasms, worsened by movement .The pain in her foot .is not as severe at rest. Review of the Radiology Report dated 10/16/18 revealed Resident #103 had a Displaced [MEDICAL CONDITION] trochanter ([MEDICAL CONDITION]) and .if the patient fell with lateral impaction, then an interochanteric femur fracture should be excluded and possible non-displaced fracture at the 5th proximal phalanx base (broken toe). In an interview on 11/8/18 at 2:55 pm, Physical Therapy Assistant (PTA) O stated before the fall with [MEDICAL CONDITION], Resident #103 was probably walking minimum assist, walk to bathroom with minimum assist and after the fall Resident #103 was not able to walk.

This citation pertains to MI 099. Based on observation, interview and record review the facility failed to provide safety interventions to prevent falls (a gait belt) for 1 of 3 residents (Resdient #103) reviewed for accidents and hazards, resulting in a fall with leg fracture (broken bone). Findings include: Review of the Textbook Mosby for Long Term Care Nursing Assistants; Sixth edition dated 10/2013 by Shiela A. Sorentino revealed on page 241 - 242 Transferring the person to a chair or wheelchair, apply the transfer belt (gait belt) and grasp the transfer belt at each side and transfer the resident. Review of the Fall Events dated 10/16/18 at 3:30 pm revealed Resident #103 was sitting in recliner, call light on, requested to go to bathroom and Certified Nurse Aide (CNA) M was .transferring her (Resident #103) to electric wheelchair and Resident #103 fell to the floor. Review of the Face Sheet revealed Resident #103 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #103 had a brief interview for mental status (BIMS) score of 14 out of 15 which indicated she was cognitively intact. The MDS further revealed Resident #103 was a limited assist of 1 staff for transfer. Review of the Fall Risk assessment dated [DATE] revealed Resident #103 was a High Risk for falls. Review of the Care Plan ADL (activities of daily living) Functional/Rehabilitation potential dated 9/28/18 revealed Resident #103 was to Walk to activity daily with walker, gait belt and CGA (contact guard assist). In an observation and interview on 11/7/18 at 11:05 am, Resident #103 was noted to be seated in her wheelchair in her room. Resident #103 stated during the transfer on 10/16/18, she (CNA M) dropped me, she (CNA M) didn't use the belt thing (gait belt). Resident #103 further stated, I fell , I went to the hospital, it was terrible, I had a broken hip, had surgery, it (broken hip) hurt, I don't think I every hurt so much. In an interview on 11/7/18 at 11:29 am, Activity Aide (AA) I stated,10/16/18, I was with her (Resident #103) the day she fell and Resident #103 told her she (Resident #103 was dropped by the CNA (CNA M). AA I stated she could tell she (Resident #103) was in a great amount of pain, she kept wincing in pain. In an interview on 11/8/18 at 2:21 pm, CNA M stated, on 10/16/18, she (Resident #103) said she need to use the bathroom and in middle of transferring her (Resident #103) thing went wrong and she fell . CNA M stated, I didn't use a gait belt, I know I was supposed to use a gait belt when transferring a resident. Review of the Hospital Note dated 10/16/18 revealed Resident #103 .presents with right hip and right foot pain after a ground level fall .transferring to her wheelchair .of note she has a history [MEDICAL CONDITION](stroke) causing residual weakness on right side .The pain in her hip is severe, comes and goes in spasms, worsened by movement .The pain in her foot .is not as severe at rest. Review of the Radiology Report dated 10/16/18 revealed Resident #103 had a Displaced [MEDICAL CONDITION] trochanter ([MEDICAL CONDITION]) and .if the patient fell with lateral impaction, then an interochanteric femur fracture should be excluded and possible non-displaced fracture at the 5th proximal phalanx base (broken toe). Review of the Surgical Progress Note dated 10/18/18 at 6:42 am, revealed Resident #103 had an ORIF (open reduction internal fixation, surgical repair) of the right femur . on 10/17/18. Review of the Resident transfer status un-dated revealed Resident #103 was a 2 person assist with a gait belt for transfers. In an interview on 11/18/18 at 2:33 pm, Licensed Practical Nurse (LPN) D stated, on 10/16/18, she (Resident #103) was on the floor on her back and Resident #103 was expressing to me she's in more pain and wanted to go to the hospital. LPN D stated since Resident #103's fall, [MEDICAL CONDITION] and surgical repair, she's on routine [MEDICATION NAME] (pain medication) and doing much better with her pain. LPN D stated Resident #103 had no pain before she broke her hip. In an interview on 11/8/18 at 2:55 pm, Physical Therapy Assistant (PTA) O stated before the fall with [MEDICAL CONDITION], Resident #103 was probably walking minimum assist, walk to bathroom with minimum assist and after the fall Resident #103 was not able to walk. In an interview on 11/8/18 at 3:00 pm, Occupational Therapist (OT) N stated Resident #103 went to the hospital after the fall on 10/1618. OT N stated before the fall Resident #103 was a 1 assist with gait belt for transfer and after the fall was a 2 person assist for transfer. OT N further stated staff transfers were to be always with a gait belt to be on the safe side if they (Resident) did lose balance staff can correct it (fall) with the gait belt. OT N stated, yes Resident #103 should have had a gait belt on during her transfer on 10/16/18. In an interview on 11/8/18 at 3:20 pm, Director of Nursing (DON) B stated staff were to use gait belts with transfers; all transfers .to prevent falls and for safety of the residents during transfers.

Based on observation, record review and interview, the facility failed to prevent an elopement and ensure the safety of 1 resident who was on 1:1 (staff to resident) supervision (Resident #2) of 6 residents reviewed for elopement from a total sample of 13, which resulted in an unwitnessed fall. The deficient practice placed Resident # 2 at risk for serious harm, injury and death. Findings include: Review of the Elopement Prevention and Management Program dated 6/2010 revealed, Missing Resident Procedure .A staff person must be assigned to the resident requiring 1:1 supervision. The staff person must always ensure that 1:1 is maintained. If the staff person must leave the resident for any reason, the staff person will secure a replacement staff member during the time away. Review of the Face Sheet revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #2 had a BIMs of 4 out of a total score of 15 which indicated Resident #2 was severely cognitively impaired. Review of the Elopement Care Plan dated 8/12/16 revealed Resident #2 was at risk for elopement from facility r/t (related to) exit seeking behavior and/or verbalizations of wanting to leave. Interventions included: wanderguard applied on 8/11/16 and 1:1 observation initiated 8/20/16 Review of the facility investigation summary revealed, On 8/7/16 (Resident #2) was placed on 30 minute checks due to wandering in the halls trying exit doors and stating she was looking for her room .She continued to require staff intervention. On 8/11/16 she continued to wander about the facility during evening and night shift, stating she wanted to go home. (Resident #2) continued on 30 min. checks. On 8/12/16 she had a wander guard bracelet placed .On 8/13/16 she continued to pace throughout the facility with staff interventions and was standing at the door. At this time she was placed on 15 min. checks .On 8/20/16 at approximately 7:00 p.m., (Resident #2) attempted to exit the facility via the south hall door and staff intervened. She was placed on 1:1 observation. Her physician and family were notified and a new order was obtained for Ativan for restlessness and anxiety. (Resident #2) continued 1:1 observation and on 8/22/16 .the CNA left her for a very short time to assist another resident at which time (Resident #2) exited the south hall door, the alarm sounded and the staff immediately responded. Approximately 3-5 minutes prior, (Resident #2) had been observed by (RN E) at the nursing station, conversing with another resident under the observation of the CNA providing 1:1. (RN E) and (LPN D) left the nursing station and went to medication room for approximately 5 minutes. As they exited the Medication room we both heard the alarm sound, noticed (Resident #2) was not at the nursing station and began searching for her. (RN E) immediately went outside while LPN (D) checked inside. (RN E) observed the resident lying on her right side on the pavement near the garage . Review of the witness statement by Nursing Home Administrator (NHA) A dated 8/23/16 revealed, On August 22nd 2016, I was pulling into the back parking lot and I observed (RN E) running towards a person laying on the parking spaces located next to the garage. I exited my vehicle and ran towards them and was told by (RN E) it was (Resident #2). Review of the witness statement by RN E dated 8/22/16 revealed, On 8/22/16 at approximately 6:30pm, I heard the alarm sound .I noticed that (Resident #2) was no longer sitting at the nurses station. I immediately went outside to search while the charge nurse searched inside the facility. I observed (Resident #2) on her right side on the pavement near the garage .The last time I had seen (Resident #2) she was sitting at the nursing station under the observation of a CNA approximately 3-5 minutes prior to the alarm sounding. In an interview on 3/7/17 at 2:15 p.m., Licensed Practical Nurse, (LPN) D stated, I personally told (CNA C) that she was to be 1:1 with (Resident #2) three to 4 times because multiple times I'd see her get up and wander away from the resident. (RN E) and I were in the med room. By the time we heard the alarm we came out to the hall. We couldn't see her. RN E found her. When I saw RN E with her, I went to get more help. I'm not even sure what door she went out, but I can show you where she was found. In a telephone interview on 3/7/17 at 1:55 p.m., CNA I stated, As soon as I came in I was assigned to the hall. Schedules are posted on a sheet at the nurses' station. I heard the nurse tell (CNA C) she was the 1:1 (with Resident #2). I did see (CNA C) with (Resident #2) during the shift, but I was in room 1 during the elopement. I can't remember if I heard the alarm, I was providing care. In an observation and interview on 3/7/17 at 2:20 p.m., LPN D took this surveyor to the place Resident #2 was found in the back parking lot near the third parking space to the right of the garage. This location is not visible unless standing at the south hall door exit. Review of the signage on the south hall exit door revealed, Push until alarm sounds door can be opened in 15 seconds. In an observation and interview on 3/8/17 at 8:00 a.m., Maintenance Supervisor O measured 147 ft., 2 in., from where Resident #2 sat at the nurses' station to the south hall door exit. Maintenance Supervisor O measured 75 ft. from the south hall door exit to the shortest direct path to the place Resident #2 was found on the ground. Maintenance Supervisor O stated, This door takes 15 seconds to open. We tested in yesterday with the fire inspector. Maintenance Supervisor O tested a wander guard bracelet at the south hall door exit. The alarm sounded when the wanderguard came within 20 ft. of the door. In an interview on 3/7/17 at 3:25 p.m., LPN D reported that she and RN E were in the med room together. They left together and heard the alarm. They both headed down the south hall at the same time. LPN D stated, I didn't see her. I'm pretty fast, if I had seen her, I probably could've caught her. And, I wouldn't have turned down the hall to the time clock to look at that door-I would've chased her. LPN D reported that she (Resident #2) was already outside. When LPN D saw that the time-clock door wasn't going off, she checked back with RN E and that is when LPN D saw RN E outside with Resident #2. Review of the Corrective Action Plan (dated 3/7/17) revealed, Immediate interventions implemented upon (Resident #2) return to the facility 8/22/16 at 6:30 p.m. 1. Resident was assessed by a licensed nurse who found her to have a 3 cm x 1 cm laceration to her right temple was cleansed with normal saline and 3 steri strips were applied, 2 cm x 1 cm skin tear to right knee cleansed patted dry and band aid applied, 1 cm x 1 cm skin tear to right pinkie finger, cleansed with normal saline, patted dry and band aid was applied. She was showing no signs or symptoms of distress .within minutes of her return to the facility (on 8/22/16). 2. Resident was assigned a 1:1 staff member (other than CNA C) for supervision on 8/22/16 immediately on her return to the facility. 3. Simultaneously a complete head count was completed and all residents were accounted for.-Completed on 8/22/16 by 6:40 p.m. 4. Investigation into course of events begins by the administration- Investigation began immediately, and all residents were safe and facility in compliance on 8/22/16 at 10:00 p.m. 5. The exterior doors were checked and all alarms were function. Completed on 8/22/16 by 7:45 p.m. 6. All residents were assessed for risk of elopement .Assessments were completed on 8/22/16 by 10:00 p.m. Any resident found to be at risk of elopement had their plan of care reviewed/revised, as needed on 8/22/16 by 10:00 p.m. 7. All residents with wander guard bracelets had their bracelets checked for functionality- completed on 8/22/16 by 10:00 p.m. 8. Signage remains on the exterior doors placed to alert visitors to not allow a resident they do not know to leave the facility with them. 9. Education was done with employees before their first shift at work after the incident in regards to: A. Elopement policy and procedure to include response to alarms B. Safety checks and documentation C. Resident monitoring and supervision of those residents at risk of elopement D 1:1 Education .Completed on 8/22/16 by 10:00 p.m. for all staff working and in the facility. Education was continued for all staff coming into the facility to work for 8/23/16 and 8/24/16. No staff member worked prior to being education. 10. The exterior door alarm system was checked by Echo Fire and Security and found to be working properly on 8/22/16 by 10:00 p.m. Although the door alarms were functioning properly the facility made the decision to increase the sensitivity of the alarms to increase the distance from the door that the alarm began to sound. This was done only to increase the alert time (distance from the door) for staff. Completed on 8/24/16 11. Elopement drills completed on 8/23/16 and will continue quarterly. Completed 10/27/16. This surveyor verified on 3/8/17 that the above corrective actions were completed.

This citation pertains to intake number MI 220. Based on observation, interview, and record review, the facility failed to follow through on consulting physicians recommendations in 1 of 2 sampled residents (#101), reviewed for quality of care, from a total sample of 4 residents, resulting in exasperation of Resident #101's disease process and a delay in therapy and treatment. Findings include: Review of the Pharmacy Communication of Physician order [REDACTED]. Nurse enters orders in matrix (resident's EMR (electronic medical record), b. Nurse prints off the ordered (SIC) entered into matrix, .c. Nurse will sign on the faxed order, their name, date and time you faxed and faxes this copy of the actual order that you have entered into matrix to Pharmacy, d. Place the original prescription order for controlled substances in the yellow tote provided by pharmacy. In interviews on 12/1/15 at 12:15 p.m. and 12/2/15 at 11:45 a.m., Registered Nurse (RN)/Interim Director of Nursing (DON) #2 reported that if a consulting physician sends a prescription or order they are referred to the primary physician and that physician has the final say if the consulting physicians orders would be followed. Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #101 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS reflected that Resident #101's ability to make daily decisions was cognitively intact and she currently required the assistance of two staff members for toileting, hygiene, and bathing. Review of the Physical Therapy Progress Notes dated 8/4/15, reflected Analysis of function Outcome/Clinical Impression: Patients condition continues to not allow for weight bearing in her right lower extremities and hands will not open to hold onto AD in tradition position. Limiting our present progress. Impact on Burden of Care/Daily Life: Pt continues to require extensive assist for all functional mobility. Spends a great deal of time in bed and contractures continue to worsen. Updates to Treatment Approach: Desires to try sliding board for transfers but patient has no clothes. Desires to try to use platform on a walker. But there are none in the building. Desires to try use of spiked rims with loop at her wrist for self-propel wheelchair but none available. Even considered use of knee walker, again not available. Requested ankle brace 2 weeks ago, still not ordered. Review of the Physical Therapist (PT) Progress and Discharge Summary dated 8/7/15, reflected the goals were not met in the expected timeline, Explanation: Unknown to this therapist until today, patient has been removed from all medication related to MS and her tremors. Analysis of Functional Outcome/Clinical Impression: Unknown to this therapist until today, patient has been removed from all medication related to MS and her tremors. This has affected her performance and progress in all areas. I have been assertively advocating for this young lady since I learned of it. It is my hope she has potential to improve though likely not return to community to live once her tremors and hopefully the neuromuscular effect allowing for the high tone causing contracted area. Patient/Caregiver Training since Last Report: staff received training for safe use of use of mechanical device for transfers. Multiple staff members educated on improbable improvements in her mobility and function if her Neuro-muscular chemistry remains poor due to lack of medication and NEED for this to be corrected. Discharge Plans and Instructions: Patients medication to be addressed. Clothing has been brought by a staff member for patient use. Hope for return to skill PT after these addressed and insurance approved. Review of the Physician Prescription dated 8/17/15, reflected Resident #101's Neurologist ordered [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) 40 mg/mL subcutaneous injection 3 times a week, with 3 refills. Review of the Nursing Progress Notes dated 8/17/15 -8/20/15, reflected no documentation of the Neurologists' prescription order dated 8/17/15. Review of the Nursing Progress Notes dated 8/25/15 at 4:48 p.m., reflected Resident called this nurse into her room to talk. Resident had doctor's visit today with .Neurology. Resident stated that Physician told her we are 'killing her by not giving her her MS medication'. Explained that we cannot give her medications that are not ordered by a doctor. Resident then states we are 'treating her MS wrong' and that her 'hands are getting worse because she is not having physical therapy.' . Review of the physician progress notes [REDACTED].#101 is seen today for evaluation of patient at the request of nursing for complaints of pain in the bilateral hands. These have been painful for the patient, and she does have contractures of the tendons of the bilateral hands. Occupational Therapy would like to evaluate patient. At this time, it seems that she is not getting any relief and [MEDICATION NAME] is making her increasingly drowsy. She also has history of MS .I would like to have a consult If she is a candidate, she may benefit form [MEDICATION NAME] injections to improve her function and make her as independent as possible . Review of the Physician Phone Orders dated 10/12/15, reflected Resident #101's Neurologist again ordered [MEDICATION NAME] 40 mg/mL subcutaneous injection 3 times a week. Review of the Nursing Progress Notes dated 10/12/15 at 7:29 p.m., Received call from Neurologist office wondering why patient (Resident #101) had not been taking [MEDICATION NAME] injections. Informed her that we had issues getting insurance to pay for her meds, but that I was not sure if that was the issue here. Left note for the DON (Director of Nursing) to call neurologist tomorrow. Review of the Physician Phone Orders dated 10/12/15, reflected that the Neurologists' order for [MEDICATION NAME] 40 mg/mL subcutaneous injection, 3 times a week, was discontinued. Review of the Nursing Progress Notes dated 10/13/15 and 10/14/15, did not reflect any documentation that the DON contacted neurologist, got an order for [REDACTED]. Review of the Case Consultation Notes dated 10/12/15, reflected that during a call spoke with the Director of Nursing, regarding (Resident #101's) concerns of not being on [MEDICATION NAME] which is prescribed by her outpatient neurologist .The DON informed me that according to epocrates and google, [MEDICATION NAME] is only indicated for short bursts 1 month at a time, and that they did clarify with the neurologists office. I stated that it is prescribed by her neurologist, and asked who they spoke with at the neurologists office since I had talked to them last week and they indicated that (Resident #101) should be receiving [MEDICATION NAME] currently The DON also stated that [MEDICATION NAME] is not covered by insurance and that the facility cannot absorb the cost. Review of the Prior Authorization Request dated 10/29/15, reflected that Resident #101 was ordered [MEDICATION NAME] 40 mg, 3 times a week and that she had been seen by a neurologist who recommended the medication. Review of the Pharmacy Consultation Report dated 11/10/15, reflected after reviewing (Resident #101's) chart, there appears to be no medication for (her) [DIAGNOSES REDACTED].Please re-evaluate: 1. does patient need MS treatment with [MEDICATION NAME]? Patient thinks she is supposed to be on [MEDICATION NAME] .Physician's Response: Patient started on [MEDICATION NAME] .dated 11/18/15. In an interview on 12/1/15 at 2:05 p.m., Pharmacist #6 reported that the pharmacy did not receive an order to restart the [MEDICATION NAME] until 11/13/15, that there was no documentation of the prescription dated 8/17/15 on file or an order written [REDACTED]. Pharmacist #6 reported that when he was reviewing Resident #101's chart on 11/10/15 he noted that the [MEDICATION NAME] had been started and stopped on 10/12/15, Pharmacist #6 reported that this appeared strange and spoke with Resident #101 who informed him she should be on [MEDICATION NAME]. Pharmacist #6 reported that the DON and the physician were informed at that time about this information. In an interview and observation on 12/1/15 at 4:00 p.m., Resident #101 reported that when she was off [MEDICATION NAME] from 7/1/15 to 11/18/15 the contractures in her hands and her mobility became worse, which has delayed her ability to progress in therapy. Resident #101 reported that during the time she was not on [MEDICATION NAME] she had no energy, the intensity of pain was different and she felt like she was slowly dying when off medication ([MEDICATION NAME]). In interviews on 12/1/15 at 2:55 p.m. and 12/2/15 at 9:30 a.m., Nurse Practitioner (NP) #8 reported that when Resident #101 returned from the neurology consulting physician on 7/22/15 he agreed with the recommendation to continue the [MEDICATION NAME] and ordered that it be restarted. NP #8 reported that there was a hold up due to prior authorization requesting a sub-type of Resident #101's MS and that it was the facility staff responsibility to pursue a solution to obtain the [MEDICATION NAME] for Resident #101. NP #8 reported that he was not aware the consulting physician had again sent a prescription for the [MEDICATION NAME] on 8/17/15 and that if he had been notified the medication may have been restarted sooner. In an interview on 12/2/15 at 10:15 a.m., Physical Therapist (PT) #10 reported that her team discussed what could be done to help Resident #101's bilateral hand and left foot, ankle, and knee contractures improve, as the braces ordered were not improving the outcomes. PT #10 reported that between 7/1/15 and 11/13/15, Resident #101's symptoms progressively got worse. PT #10 reported that since the [MEDICATION NAME] had been restarted Resident #101 is now beginning to improve. In an interview on 12/2/15 at 3:35 p.m., Therapist #11 reported that Resident #101 was fairly functional in the community prior to her hospitalization and that the delay in receiving the [MEDICATION NAME] had slowed her progress for discharge planning.

THIS CITATION PERTAINS TO MI 145. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY IN 1 OF 6 SAMPLED RESIDENTS (RESIDENT #501), FROM A TOTAL SAMPLE OF 7 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY (IJ) WHEN RESIDENT #501, WHO HAD BEEN IDENTIFIED AS AN ELOPEMENT RISK, ELOPED FROM THE FACILITY ON 5/4/12 AT APPROXIMATELY 7:30 PM, UNBEKNOWNST TO FACILITY STAFF. RESIDENT #501 WAS FOUND AT APPROXIMATELY 7:59 PM, 0.6 MILES FROM THE FACILITY. THIS DEFICIENT PRACTICE PLACED 17 ADDITIONAL RESIDENTS, IDENTIFIED AS AT RISK FOR ELOPEMENT, AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET IN THE MEDICAL RECORD, DATED 3/17/12, REVEALED RESIDENT #501 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE ELOPEMENT RISK ASSESSMENT, DATED 2/16/12, REVEALED RESIDENT #501 WAS AT RISK FOR ELOPEMENT AND HAD A WANDERGUARD BRACELET ATTACHED TO HER LEFT ANKLE. REVIEW OF AN INCIDENT/ACCIDENT REPORT, DATED 5/4/12, REVEALED RESIDENT #501 WAS FOUND IN NEIGHBOR #10'S YARD ON 5/4/12 AT APPROXIMATELY 8:00 PM. IN AN INTERVIEW ON 5/15/12 AT 2:15 PM, REGISTERED NURSE (RN) #3 REPORTED SHE GAVE RESIDENT #501 HER MEDICATIONS ON 5/4/12 AT APPROXIMATELY 7:30 PM. RN #3 REPORTED SHE DID NOT HEAR ANY DOOR ALARMS SOUND ON 5/4/12 BETWEEN 7:30 PM AND 8:00 PM. IN AN INTERVIEW ON 5/15/12 AT 12:26 PM, CERTIFIED NURSING ASSISTANT (CNA) #6 REPORTED SHE OBSERVED RESIDENT #501 IN HER ROOM IN BED ON 5/4/12 AT APPROXIMATELY 7:30 PM. CNA #6 REPORTED SHE DID NOT HEAR ANY DOOR ALARMS SOUND ON 5/4/12 BETWEEN 7:30 PM AND 8:00 PM. REVIEW OF A WITNESS STATEMENT, WRITTEN BY LICENSED PRACTICAL NURSE (LPN) #4 AND DATED 5/4/12, REVEALED FAMILY MEMBER #11 CALLED THE FACILITY ON 5/4/12 AT APPROXIMATELY 8:00 PM AND INDICATED HE HAD TRIED TO CALL RESIDENT #501 AND SHE WAS NOT ANSWERING THE TELEPHONE. LPN #4 IMMEDIATELY WENT TO RESIDENT #501'S ROOM AND SHE WAS NOT IN HER BED OR IN THE BATHROOM. LPN #4 THEN IMPLEMENTED ELOPEMENT PROCEDURES BY NOTIFYING ALL STAFF IN THE FACILITY TO BEGIN TO SEARCH FOR RESIDENT #501. LPN #4 PERFORMED A COMPLETE HEAD COUNT AND VERIFIED THAT RESIDENT #501 WAS MISSING. REVIEW OF A WITNESS STATEMENT, WRITTEN BY MEDICAL RECORDS STAFF #5 AND DATED 5/5/12, REVEALED THE SHERIFF'S OFFICE CALLED THE FACILITY AT APPROXIMATELY 8:00 PM TO INFORM HER THAT NEIGHBOR #10 FOUND RESIDENT #501 IN THE DITCH IN FRONT OF HER HOUSE. REVIEW OF THE SHERIFF'S OFFICE "CALLS FOR SERVICE" REPORT, DATED 5/4/12, REVEALED ON 5/4/12 AT 7:59 PM, AN ELDERLY FEMALE WITH GRAY HAIR WAS SITTING IN FRONT OF A HOUSE WEARING GLASSES, A BEIGE SWEATER, PANTS, AN ANKLE TETHER, AND WHITE TENNIS SHOES. IN AN INTERVIEW ON 5/15/12 AT 2:00 PM, RESIDENT #501 REPORTED SHE WENT FOR A WALK DOWN A TWO-LANE ROAD WITH NO POSTED SPEED LIMIT SIGN. THE SURVEYOR VERIFIED THE DISTANCE FROM THE FACILITY TO NEIGHBOR #10'S HOUSE WAS 0.6 MILES. IN AN INTERVIEW ON 5/15/12 AT 2:15 PM, RN #3 REPORTED SHE AND CNA #7 DROVE TO NEIGHBOR #10'S HOUSE AND DROVE RESIDENT #501 BACK to the facility on [DATE] AT APPROXIMATELY 8:20 PM. RN #3 REPORTED #501 SUSTAINED NO INJURIES UPON COMPLETION OF A SKIN ASSESSMENT. RN #3 REPORTED THE "TIME CLOCK" DOOR ALARM DID NOT SOUND WHEN RESIDENT #501 WAS BROUGHT BACK INTO THE FACILITY. RN #3 REPORTED THE DOOR ALARM DID NOT SOUND UNTIL THE THIRD ATTEMPT. ACCORDING TO WEATHER UNDERGROUND, THE WEATHER ON 5/4/12 AT 7:53 PM WAS: TEMPERATURE-70.0 DEGREES FARENHEIT, WIND-NORTHEAST AT 8.1 MILES PER HOUR (MPH), AND PARTLY CLOUDY (HTTP://WWW.WUNDERGROUND.COM/HISTORY/AIRPORT/KAZO/2012/5/4/DAILYHISTORY.HTML). REVIEW OF THE FACILITY "INVESTIGATION/SUMMARY/CORRECTIVE ACTION" DOCUMENT, UNDATED, REVEALED WHEN RESIDENT #501 WAS RETURNED TO THE FACILITY, THE CODE ALARM DID NOT SOUND UNTIL THE THIRD ATTEMPT. THE DOCUMENT INDICATED THE FACILITY HAD THE ALARM COMPANY CHECK THE DOOR ALARM AND FOUND THE SENSITIVITY ON THE SIDE DOOR CODE ALERT UNIT TO BE SET "LOW". THE DOCUMENT INDICATED, "THIS MAY SUGGEST THAT THE RESIDENT (RESIDENT #501) EXITED THROUGH THE SIDE DOOR AND THE RESIDENT'S CODE ALERT BRACELET DID NOT SET THE ALARM OFF." REVIEW OF THE MINIMUM DATA SET (MDS), dated [DATE], REVEALED RESIDENT #501 HAD SEVERE COGNITIVE IMPAIRMENTS AND WAS INDEPENDENT IN TRANSFERS, BED MOBILITY, AND AMBULATION. ON 5/15/12 AT 2:00 PM, THIS SURVEYOR OBSERVED RESIDENT #501 LAYING IN BED. RESIDENT #501 APPEARED WELL-GROOMED AND FREE FROM ANY UNEXPLAINED PHYSICAL INJURIES. RESIDENT #501 HAD A WANDERGUARD BRACELET, WHICH WAS FUNCTIONING PROPERLY, ATTACHED TO HER LEFT WRIST. REVIEW OF THE TREATMENTS FLOWSHEET FOR MAY 2012 REVEALED FROM 5/1/12 THROUGH 5/4/12, RESIDENT #501'S WANDERGUARD BRACELET WAS CHECKED FOR FUNCTION AND PLACEMENT EVERY SHIFT. REVIEW OF THE DOOR ALARM CHECKLISTS FOR THE MONTHS OF JANUARY 2012 THROUGH MAY 2012 REVEALED ALL EXIT DOOR ALARMS (2 OUT OF 5 EXIT DOORS WERE WANDERGUARD ALARMED) WERE CHECKED DAILY AND HAD FUNCTIONED PROPERLY. AN OBSERVATION ON 5/15/12 AT 10:00 AM, REVEALED 5 OF THE 5 EXIT DOOR ALARMS FUNCTIONED PROPERLY AND THE 2 OF 5 EXIT DOORS, THAT HAD WANDERGUARD ALARMS, ALSO FUNCTIONED PROPERLY. AN OBSERVATION 5/15/12 AT 10:17 AM, REVEALED 18 OUT OF 18 WANDERGUARD BRACELETS FUNCTIONED PROPERLY. ON 5/16/12 AT 2:00 PM, THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 5/4/12, AND WAS IDENTIFIED ON 5/15/12, WHEN THE FACILITY FAILED TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY OF RESIDENT #501, WHO HAD BEEN IDENTIFIED AS AN ELOPEMENT RISK, ELOPED FROM THE FACILITY ON 5/4/12 AT APPROXIMATELY 7:30 PM, UNBEKNOWNST TO FACILITY STAFF. RESIDENT #501 WAS FOUND AT APPROXIMATELY 7:59 PM, 0.6 MILES FROM THE FACILITY. ON 5/17/12, THIS SURVEYOR CONFIRMED THAT THE FACILITY STAFF IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON 5/4/12 AT 8:20 PM, RESIDENT #501 WAS ASSIGNED A 1:1 STAFF SUPERVISION AND RESIDENT #501 WAS ASSESSED BY TWO LICENSED NURSES WHO FOUND HER TO BE UNHARMED AND SHOWED NO SIGNS OF DISTRESS. 2. ON 5/4/12 AT 8:20, A COMPLETE HEAD COUNT WAS PERFORMED AND AN INVESTIGATION INTO THE COURSE OF EVENTS BEGAN BY THE ADMINISTRATION. 3. ON 5/5/12, THE FACILITY COMPLETED HOURLY HEAD COUNTS ON ALL RESIDENTS. 4. ON 5/5/12, THE ALARM COMPANY ADJUSTED ALARM SENSITIVITY AND VOLUME AND INSTALLED A DOOR ALARM ON RESIDENT #501'S DOOR. 5. ON 5/5/12, ELOPEMENT ASSESSMENTS WERE UPDATED ON ALL ELOPEMENT RISK RESIDENTS AND ALL RESIDENTS WERE REVIEWED TO ENSURE POPULATION ELOPEMENT RISK WAS ACCURATELY REFLECTIVE. 6. ON 5/5/12, CARE PLANS WERE UPDATED TO REFLECT ELOPEMENT PRECAUTIONS AND ALL RESIDENTS' CODE ALERT BRACELETS WERE RECHECKED AND REPLACED IF NECESSARY. 7. ON 5/5/12, EDUCATION BEGAN IN REGARDS TO: A) ELOPEMENT POLICY AND PROCEDURE TO INCLUDE RESPONSE TO ALARMS, IMMEDIATE ALERT OF RESIDENT MISSING WITHIN THE FACILITY, AND TAKING THE SEARCH OUTSIDE; B) PROVIDING ONE TO ONE CARE; C) CHECKING CODE ALERT BRACELETS AT THE BEGINNING AND END OF EACH SHIFT FOR PLACEMENT AND FUNCTION; D) SAFETY CHECKS AND DOCUMENTATION; AND E) MONITORING AND SUPERVISING RESIDENTS AT RISK FOR ELOPEMENT. IN-SERVICING WAS DONE WITH EMPLOYEES BEFORE THEIR FIRST SHIFT AT WORK AFTER THE INCIDENT. 48 OF 50 EMPLOYEES HAVE BEEN IN-SERVICED. TWO PRN EMPLOYEES HAD NOT BEEN SCHEDULED AS OF 5/5/12 AND THEY WOULD BE IN-SERVICED PRIOR TO RETURNING TO WORK. 8. ON 5/5/12, THE ELOPEMENT POLICY AND PROCEDURES WERE REVIEWED. AN ELOPEMENT ADDENDUM WAS ADDED TO INCREASE ELOPEMENT DRILLS IN THE FACILITY FROM ONE TIME PER YEAR TO AT LEAST QUARTERLY. ALSO ADDED WAS IF A RESIDENT WAS ACTIVELY EXIT SEEKING, THE RESIDENT WOULD BE IMMEDIATELY PLACED ONE TO ONE SUPERVISION. 9. AS OF 5/5/12, ELOPEMENT DRILL IN-SERVICES WERE CONDUCTED FOR CURRENT STAFF. 10. AS OF 5/5/12, AN ASSIGNED NURSE WERE TO CHECK AND VERIFY THE FRONT DOOR WAS BEING LOCKED AFTER BUSINESS HOURS, WEEKENDS, AND AS NEEDED. THIS WOULD BE COMPLETED AND DOCUMENTED BY THE CHARGE NURSES. 11. ON 5/5/12, CODE ALERT BRACELET WAS MOVED TO RESIDENT #501'S WRIST. 12. ON 5/14/12, A NEW "ROAM ALERT" (WANDER PREVENTION ALARM) SYSTEM WAS INSTALLED AND WAS FUNCTIONING PROPERLY, NEW "ROAM ALERT" BRACELETS WERE PLACED ON ALL IDENTIFIED ELOPEMENT RISK RESIDENTS. 13. ON 5/14/12, EDUCATION BEGAN FOR ALL STAFF IN REGARDS TO: A) "ROAM ALERT" SYSTEM FUNCTION; B) "ROAM ALERT" BRACELET TESTING; AND C) "ROAM ALERT" SYSTEM TESTING. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 5/5/12, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND A SEVERITY OF NO ACTUAL HARM BUT A POTENTIAL FOR HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO THE FACT THAT ALL IN-SERVICING HAD NOT BEEN COMPLETED AND SUSTAINED COMPLIANCE HAD NOT YET BEEN VERIFIED BY THE STATE AGENCY. ( )

THIS CITATION PERTAINS TO INTAKE MI 641 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT FALLS IN 2 OF 4 SAMPLED RESIDENTS (RESIDENT #501 & RESIDENT #503), RESULTING IN A LEFT UPPER ARM FRACTURE IN RESIDENT #503 AND hospitalization AFTER A FALL IN RESIDENT #501. FINDINGS INCLUDE: RESIDENT #503: THE MEDICAL RECORD REVEALED THAT RESIDENT #503 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED THAT RESIDENT #503 HAD COGNITIVE DEFICITS INCLUDING SHORT AND LONG TERM MEMORY PROBLEMS AND SEVERELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION MAKING. ACCORDING TO THE "FALL PREVENTION PROGRAM RISK ASSESSMENT" DATED 9/30/10, RESIDENT #503 SCORED AN 18 INDICATING A HIGH RISK FOR FALLS. THE "FALL PREVENTION PROGRAM CARE PLAN," DATED 7/20/10 REVEALED THAT ALARMS WERE PLACED ON RESIDENT #503'S BED AND CHAIR. AN "INCIDENT/ACCIDENT REPORT," DATED 11/30/10 REVEALED THAT RESIDENT #503 WAS FOUND ON THE FLOOR FACE DOWN IN THE HALLWAY. ACCORDING TO THAT REPORT, AS A RESULT OF THIS INCIDENT, THE RESIDENT WAS FOUND TO HAVE SWELLING TO THE CHIN AND A BRUISE LOCATED IN THE UPPER LEFT ARM. THE REPORT ALSO INDICATED THAT THE RESIDENT HAD A LOSS OF FUNCTIONAL RANGE OF MOTION ON THE LEFT ARM. ACCORDING TO THE REPORT, ICE WAS APPLIED TO LEFT ARM AND THE LEFT ARM WAS ELEVATED WITH A PILLOW. THAT REPORT ALSO INDICATED THAT PRIOR TO THE FALL, RESIDENT #503 HAD DIZZINESS AND GENERALIZED WEAKNESS. THE REPORT INDICATED THAT CORDS WERE CHECKED FOR PLACEMENT OF ALARMS; RESIDENT #503'S ALARM PAD WAS SECURED TO THE BED USING DOUBLE SIDED VELCRO; AND, BOLSTERS WERE PLACED ON THE RESIDENT 503'S BED. THAT REPORT ALSO REVEALED THAT THE PHYSICIAN, FAMILY MEMBER, AND DIRECTOR OF NURSING WERE NOTIFIED OF THE FALL. IN AN INTERVIEW ON 3/17/10 AT 3:30 PM, DIRECTOR OF NURSING (DON) #2 REPORTED THAT RESIDENT #503 "MOVED A LOT IN BED" AND WOULD CAUSE THE BED ALARM PAD TO GO TO THE FOOT OF THE BED. DON #2 ALSO REPORTED THAT AFTER RESIDENT #503 fell on [DATE], THE BED ALARM PAD WAS AT THE FOOT OF THE BED AND WAS UNPLUGGED FROM THE BED ALARM BOX. DON #2 ALSO REPORTED THAT THE ALARM DID NOT SOUND BECAUSE RESIDENT #503 WAS NOT ON THE BED ALARM PAD WHEN IT WAS UNPLUGGED FROM THE BED ALARM BOX. AN X-RAY REPORT DATED 11/30/10 REVEALED THAT RESIDENT #503 SUSTAINED A FRACTURE TO THE LEFT UPPER ARM. ACCORDING TO A NURSE'S NOTE DATED 11/30/10, RESIDENT #503 WAS GIVEN VICODIN (PAIN MEDICATION) FOR LEFT SHOULDER PAIN. A PROGRESS NOTE DATED 12/1/10 REVEALED THAT A SLING WAS PLACED ON RESIDENT #503'S LEFT ARM. THAT NOTE REVEALED THAT RESIDENT #503 WAS TO HAVE A SLING ON FOR FOUR WEEKS AND THEN HAVE PHYSICAL THERAPY AFTER THE SLING WAS TAKEN OFF. ( ) RESIDENT #501: THE MEDICAL RECORD REVEALED THAT RESIDENT #501 WAS admitted to the facility on [DATE] AND HAD [DIAGNOSES REDACTED]. A NURSE'S NOTE DATED 6/29/10 REVEALED THAT RESIDENT #501 WAS ALERT AND ORIENTED TO TIME, PLACE, AND PERSON. A CERTIFIED NURSING ASSISTANT (CNA) FLOW SHEET DATED 6/29/10 REVEALED THAT RESIDENT #501 WAS TO BE A 2 PERSON ASSIST WITH TRANSFERS USING A GAIT BELT. A CARE PLAN FOR BACK SURGERY DATED 6/29/10 REVEALED THAT RESIDENT #501 WAS A 2 PERSON ASSIST WITH TRANSFERS AND AMBULATION. ACCORDING TO THE "FALLS PREVENTION PROGRAM RISK ASSESSMENT" DATED 7/2/10, RESIDENT #501 SCORED A 16 INDICATING A HIGH RISK FOR FALLS. IN AN "INCIDENT/ACCIDENT REPORT" DATED 6/29/10 REVEALED THAT RESIDENT #501 WAS TRYING TO GET OUT OF BED TO USE THE BATHROOM UNASSISTED AND THE RESIDENT WAS FOUND "KNEELING AT THE BEDSIDE." THAT REPORT ALSO DOCUMENTED INTERNAL RISK FACTORS FOR FALLS INCLUDING INCONTINENCE, MEDICATION CHANGES, UNSTEADY GAIT, LOSS OF LEG MOVEMENT, DECLINE IN COGNITIVE SKILLS, AND PAIN. THAT REPORT REVEALED THAT RESIDENT #501 WAS PROVIDED A URINAL, HAD A MAT PLACED AT THE BEDSIDE, AND INITIATED BED AND CHAIR ALARMS. THAT REPORT INDICATED THAT FAMILY, PHYSICIAN, ADMINISTRATOR, AND DIRECTOR OF NURSING WERE NOTIFIED OF THE INCIDENT. IN AN "INCIDENT/ACCIDENT REPORT" DATED 7/2/10 REVEALED THAT RESIDENT #501 WAS OBSERVED ON HIS KNEES BETWEEN HIS WHEELCHAIR AND BED ON HIS BEDSIDE MAT. THAT REPORT REVEALED THAT RESIDENT #501 WAS ATTEMPTING TO SELF-TRANSFER FROM THE WHEELCHAIR INTO HIS BED. THE REPORT ALSO REVEALED THAT RESIDENT #501 DENIED PAIN, THERE WAS NO APPARENT INJURY, AND RANGE OF MOTION WAS WITHIN IN NORMAL LIMITS. THE REPORT REVEALED THAT RESIDENT #501 HAD INTERNAL AND EXTERNAL RISK FACTOR FOR FALLS INCLUDING BALANCE PROBLEM, NON COMPLIANCE, UNSTEADY GAIT, PAIN AND HAD TAKEN VALIUM (SEDATIVE) AND VICODIN (NARCOTIC). THE REPORT ALSO REVEALED THAT PRIOR TO THE FALL, RESIDENT #501 HAD GENERALIZED WEAKNESS AND ONE-SIDED WEAKNESS. THE REPORT INDICATED THAT THE ALARM WAS NOT FUNCTIONAL. THE REPORT INDICATED THAT RESIDENT #501 WAS NOT BE LEFT IN ROOM UNATTENDED WHILE UP IN HIS WHEELCHAIR. THE REPORT INDICATED THAT FAMILY, PHYSICIAN, ADMINISTRATOR, AND DIRECTOR OF NURSING WERE NOTIFIED OF THE INCIDENT. IN AN "INCIDENT/ACCIDENT REPORT" DATED 7/9/10 REVEALED THAT WHILE RESIDENT #501 WAS IN THE BATHROOM WITH CNA #4 PRESENT, THE RESIDENT STOOD UP TO "URINATE, LOST HIS BALANCE AND fell " HITTING HIS RIGHT SHOULDER, RIGHT HIP AND RIGHT SIDE OF HIS HEAD. THAT REPORT INDICATED THAT THE RIGHT FOREHEAD WAS RED AND BLANCHABLE BUT NO OPEN AREAS WERE NOTED. THE REPORT ALSO INDICATED THAT RESIDENT #501 WAS IMPULSIVE AND DID NOT FOLLOW DIRECTIONS AND "HAS BEEN FAIRLY DISORIENTED SINCE ADMISSION." THE REPORT ALSO REVEALED THAT THE RESIDENT HAS A BALANCE PROBLEM, WAS UNSTEADY ON HIS FEET, AND HAD TAKEN VALIUM (SEDATIVE) AND VICODIN (NARCOTIC). THE REPORT REVEALED THAT RESIDENT #501 WAS PLACED IN BED IN A LOW POSITION, WAS MEDICATED FOR PAIN, AND BED ALARMS WERE CHECKED FOR PLACEMENT. THE REPORT INDICATED THAT FAMILY, PHYSICIAN, ADMINISTRATOR, AND DIRECTOR OF NURSING WERE NOTIFIED OF THE INCIDENT. IN AN INTERVIEW ON 3/17/10 AT 1:00 PM, CNA #4 REPORTED THAT ON 7/9/10, SHE WAS TRANSFERRING RESIDENT #501 FROM RESIDENT #501'S BED TO THE BATHROOM. CNA #4 REPORTED THAT THERE WAS NOT ANOTHER CNA OR NURSE WITH HER WHILE CNA #4 WAS TRANSFERRING RESIDENT #501 TO THE BATHROOM. CNA #4 REPORTED THAT SHE WAS NOT USING A GAIT BELT DURING THE TRANSFER. CNA #4 REPORTED THAT RESIDENT #501 WAS STANDING IN FRONT OF THE TOILET AND CNA #4 WALKED AWAY, LEAVING RESIDENT #501 UNATTENDED. CNA #4 WAS CLOSING THE DOOR TO THE BATHROOM WHEN SHE HEARD RESIDENT #501 FALL TO THE FLOOR. THE RESIDENT TRANSFER FORM DATED 7/10/10 REVEALED THAT RESIDENT #501 WAS TRANSFERRED TO A HOSPITAL BECAUSE OF A MENTAL STATUS CHANGE, MULTIPLE FALLS, AND INCREASE BACK AND SHOULDER PAIN. ACCORDING TO A HOSPITAL'S OPERATION REPORT DATED 7/10/10, RESIDENT #501 HAD A REVISED SURGERY TO HIS LOWER BACK. ( )