Every finding on record at Regency at Canton

This citation pertains to intake 3027558.Based on observation, interview, and record review the facility failed to provide adequate supervision and follow elopement protocol resulting in R101 leaving the facility unknown to staff and sustaining a fall out of a wheelchair resulting in a facial hematoma, an abrasion to the left hand and right toes for one resident (R101) at risk for immediate jeopardy out of six residents reviewed for supervision.Further investigation of the incident revealed facility staff failed to supervise a severely cognitively impaired resident (R101) with a high elopement risk and respond appropriately to a door alarm (Emergency Door) on the Ridge Unit. R101 was determined to have exited emergency door number 10 at approximately 3:01 PM on 5/20/2026 after setting off the emergency exit door alarm at approximately 3:00 PM. Emergency door number 10 was located on the northwest corner of the building not near a regularly used entrance or parking lot or frequently used driveway. Housekeeper F was observed in security footage turning off the emergency door number 10 alarm at approximately 3:02 PM without checking the area for residents. The facility failed to activate procedures to search for a missing resident. The facility was made aware R101 was outside the facility lying on the ground next to a wheelchair in a driveway approximately 25 yards from emergency exit number 10 by R102 at 3:22 PM. Staff responded to R101 at approximately 3:30 PM. The Immediate Jeopardy (IJ) began on 5/20/2026 when facility staff failed to supervise R101 and initiate a missing person protocol which resulted in R101 exiting the building without staff knowledge. The Nursing Home Administrator (NHA) was notified of the IJ on 6/24/2026 at 1:58 PM. The surveyor confirmed by interview and record review that the IJ was removed on 5/22/2026 but noncompliance remains at a potential for harm due to sustained compliance that has not been verified by the State Agency.Findings include: On 5/21/2026 the State Agency received a Facility Reported Incident.On 6/24/2026 at 9:40 AM, Receptionist B was interviewed and said that on 5/20/2026 at approximately 3:00 PM, she received a phone call from R102 regarding finding R101 outside of the building lying on the ground and appeared injured. Receptionist B said she initiated a missing resident alert. Receptionist B further said that earlier in the day R101 wheeled herself up to the reception area several times and that she notified License Practical Nurse (LPN) C that she was unable to watch R101.On 6/24/2026 at 9:50 AM, R101 was observed in bed. When R101 was asked about the incident that occurred on 5/20/2026 she was unable to recall the event and/or answer questions.On 6/24/2025 at 9:45 AM, R102 was interviewed about the elopement incident that occurred on 5/20/2026. R102 said she was in her room when she heard a door alarm go off around 3:00 PM. R102 said she signed out of the building around 3:15 PM, to cruise around the outside of the facility with her friend. When she approached the back corner of the building (near exit 10) she saw R101 lying on the ground near a wheelchair. R102 said she called the facility to report the incident at 3:22 PM and stayed with R101 until staff responded around 3:30 PM.On 6/24/2025 at 10:00 AM, LPN C was interviewed and said she was assigned to R101 on 5/20/2026. When LPN C was asked if she heard a door alarm, she said she could not recall. When asked if anyone notified her if R101 was agitated or wandering on 5/20/2026 LPN C said she did not remember. LPN further said that she was working on the [NAME] unit when R101 eloped on the Ridge unit.On 6/24/2026 at 10:55 AM, the Nursing Home Administrator (NHA) was interviewed regarding the elopement incident which occurred on 5/20/2026. The NHA provided video footage of the incident and identified R101 pushing on exit number 10 emergency door on 5/20/2026 at approximately 3:00 PM which set off the door alarm. Video reviewed with the NHA revealed R101 exiting emergency exit number 10 at approximately 3:01 PM. The NHA identified Housekeeper F turning off the emergency door number 10 alarm at approximately 3:02 PM without checking the area for residents. The NHA said the procedure was for the employee to look for any residents outside the door and then call a missing resident alert. The NHA said Housekeeper F did not follow the elopement procedure. The NHA said Housekeeper F was trained on the elopement procedure on 7/1/2025. The NHA further said Housekeeper F was terminated due to not following the elopement procedure and placing R101 at risk for injury.On 6/24/2026 at 11:15 AM, Scheduler D was interviewed and identified LPN C and Certified Nursing Assistant (CNA) E as assigned to work with R101 on 5/20/2026 during the elopement incident. On 6/24/2026 at 12:30 PM, CNA E was interviewed and said she was assigned to work with R101 on 5/20/2026 but was on break at 3:00 PM when the incident occurred and did not hear the door alarm.On 6/25/2026 at 10:15 AM, Unit Manager/LPN H was interviewed and said she was in her office at the time the alarm went off on 5/20/2026 and did not hear the alarm. LPN H said that LPN I was assigned to work the unit on 5/20/2026 where the elopement occurred but was on break. Unit Manager H said LPN J was expected to cover the ridge unit during LPN I's break.On 6/25/2026 at 10:25 AM, CNA K was interviewed and said she worked on the Ridge Unit on 5/20/2026 at 3:00 PM but did not hear the door alarm because she was working with another resident in the resident's room. On 6/25/2026 at 10:31 AM, LPN I was interviewed and said he was on break at 3:00 PM on 5/20/2026 and did not hear or respond to the door alarm on the ridge unit. LPN I said he told Unit Manager H he was going on break and that he expected Unit Manager H to cover the unit for him.On 6/25/2026 at 11:00 AM, CNA L was interviewed and said she started work at 3:00 PM on 5/20/2026 and did not hear the door alarm.On 6/25/2026 at 11:05 AM, LPN J was interviewed and said she was on lunch break at 3:00 PM on 5/20/2026 and did not hear the alarm sound. LPN J said she notified LPN C and LPN M she was going on lunch break to ensure coverage.On 6/25/2026 at 11:25 AM, LPN J was contacted via phone to attempt an interview with no return call.Record review of R101's Electronic Medical Record (EMR) revealed R101 was admitted to the facility on [DATE] with the most recent readmission on [DATE]. R101 had the following medical diagnoses: Wandering in diseases classified elsewhere, History of falling, Unspecified Dementia and Generalized Anxiety disorder.Review of R101's Minimum Data Set (MDS) dated [DATE] revealed R101 had a Brief Interview of Mental Status (BIMS) score of 3/15 (severe cognitive impairment) and required supervision for wheelchair mobility.Review of the elopement risk assessment dated [DATE], revealed R101 was considered high risk for elopement.Review of R101's care plan revealed, Focus (R101) is at risk for elopement and/or wandering r/t (related to) diagnosis of dementia, history of attempts to leave the facility unattended, impaired safety awareness states I want to go home frequently, requires redirection at time. Increase in confusion and aggression after 3 PM r/t wanting to go home, wander guard left ankle date initiated 7/1/2025, revision on 6/12/2026. Goal Will not leave facility unattended through the review date. Date initiated 7/1/2025 Target Date 9/30/2026. Interventions Observe wandering behavior and attempted diversional interventions when wandering into inappropriate locations such as other residents' rooms when not invited, behind nurses' stations, shower rooms, attempts at exiting facility etc. date initiated 7/2/2025, revised on 6/8/2026.On 6/25/2026 at 11:45 AM, the Director of Nursing (DON) was interviewed and said the expectation is for the nurses on [NAME] Unit to cover for Ridge Unit when the assigned nurse is on break. On 6/25/2026 at 11:55 AM, the NHA was interviewed and said staff did not respond to the emergency exit door alarm per the facilities elopement policy and procedure. The NHA further said the expectation was for residents with a high risk for elopement to be properly supervised. Review of the facility policy titled Elopement Policy last revised 4/26/2022 revealed in part, rounds of all guests/residents are made at the beginning of the shift, at mealtimes and at the end of the shift at a minimum by direct care staff and licensed nurses. Alarm Activation. If an employee hears a door alarm, he or she should: immediately go to the site of the alarm, if no guest/residents found to be exiting the facility, the employee should walk outside, conduct a visual observation of the immediate area to ensure that a guest/resident. In situations where the alarm sounds and a guest/resident is not found to have exited: Notify the licensed nurse immediately and ensure that a head count is completed to ensure that all guests/residents are accounted for.Review of the facility policy titled Nursing Staffing last revised 9/14/2023 revealed in part, the nursing services department provides 24-hour nursing services. The facility ensures sufficient nursing staff. Nursing service is provided by number and type of personnel to ensure that each resident is protected from accidents and injury.The Immediate Jeopardy that began on 5/20/2026 and removed on 5/22/2026 when the facility took the following actions to remove the immediacy:1) On 5/20/2026 the policy on elopement was reviewed by the Administrator and Director of Nursing and deemed appropriate.2) Beginning 5/20/2026, all facility staff education was initiated and is ongoing regarding the elopement policy and procedure.3) On 5/20/2026 All exit doors in the facility were tested to validate alarms were functioning.4) On 5/21/2026 staff identified residents at risk for elopement, care plan updated, wander guard orders were reviewed for placement and function.

This citation pertains to intake 2970985.Based on interview and record review, the facility failed to implement interventions during a Hoyer lift transfer for one resident (R104) of five residents reviewed for falls, resulting in a fall without injury.Findings include: Review of a progress note dated 03/30/2026 by Nurse G revealed, cna assisting resident to bed for a brief change via Hoyer lift resident was over the bed but top half was sliding to the left cna attempted to get resident legs in the bed, but resident left side of face was against the nightstand, to avoid injury to face cna lowered resident to the floor.On 04/14/2026 at 2:55p.m., Certified Nursing Assistant (CNA) F was interviewed and stated, I used the Hoyer lift by myself. I know I am supposed to have two people. I didn't have anyone to help me. I lowered R104 to the floor after realizing the sling wasn't on right. On 04/14/2026 at 3:15p.m., he Director of Nursing (DON) was interviewed and stated, CNA F was transferring R104 back into bed and R104's cheek was up against the nightstand. R104 began to fall and CNA F lowered R104 to the ground. The DON was queried on the expectation of Hoyer Lift procedures and interventions to prevent falls. The DON said, the expectation is for two people to provide Hoyer lift assistance.Review of the Electronic Health Record (EHR) revealed R104 has a diagnosis of Nondisplaced Comminuted Fracture of Shaft of Humerus Right Arm, Hyperlipidemia, Atrial Fibrillation and Presence of Right Artificial Shoulder Joint. R104 had an admit date of 03/21/2026 and a discharge date of 04/07/2026. The Minimum Data Set (MDS) dated [DATE], revealed: R104 was dependent for transferring and toileting. 2 Person assist needed for Hoyer Lift. Care plan dated 03/24/2026 revealed R104 has a functional ability deficit and requires assistance with care. is dependent for bed mobility and toilet transfer. Care plan intervention dated 4/2/26 revealed. provide reassurance to the resident that she is safe and the facility is doing what is needed to maintain safety for all. The facility policy on Hoyer lift transfers entitled, Transfer with a Mechanical Lift, Long Term Care Policy dated April 2025, reads in part: All Mechanical lifts require two staff members when moving a resident.Obtain the assistance of a coworker, as needed, to maintain the resident's safety.

This citation pertains to intake MI00153910. Based on observation, interview and record review, the facility failed to assess a cognitively impaired resident (R401) after expressing desire to leave the facility and an attempt to exit a back door of the facility on 6/19/25. On 6/23/25 at approximately 8:30 PM, R401 was found after exiting the facility unbeknownst to staff. R401 was located outside the facility in a hospital gown pushing their wheelchair. This resulted in an Immediate Jeopardy due to the facility's failure to identify, assess, and implement interventions to provide resident safety and prevent elopement for residents at risk. The Immediate Jeopardy (IJ) began on 6/19/25. The facility was notified of the IJ on 7/1/25 at 2:30 PM and a removal plan was requested. Findings include: Review of an intake revealed on 6/26/25 an anonymous complainant reported on the evening of 6/23/25 at around 8:30pm, R401 walked out of the front door of the facility, The resident walked out of the facility and continued walking up [NAME] Rd which is the main road. The resident was outside, maybe 10-15 minutes, wearing a hospital gown that opens in the back, pushing her wheelchair. The resident got all the way around to the end of the building. On 6/30/25 at 11:35 AM, the Surveyor observed R401 sitting at the nursing station. R401 was interviewed and said she remembered going outside but did not recall anything else about the incident. Review of nurse progress notes dated 6/19/25 at 6:59 PM, Licensed Practical Nurse (LPN) E documented R401, stated she wanted to go home, I informed (sic) that she is a resident of (Name of Facility). I showed her her room she asked to go back to the nurses station where she was sitting. (R401) She was sitting for 15 minutes and then tried to leave out the back door. Record review noted, R401 was admitted on [DATE] with diagnoses that included fracture of right femur, history of falls, abnormal posture, alcohol dependence with alcohol induced dementia, osteoporosis, chronic kidney disease stage three, glaucoma, and sarcopenia (muscle loss). According to the Minimum Data Set (MDS) dated [DATE], R401 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out 15. A review of R401's care plans revealed no documented evidence of an elopement care plan in place on 6/19/25 when LPN E noted R401 attempted to leave the building. R401's Elopement care plan was initiated on 6/24/25, five days after R401's attempt to exit the building. The Elopement care plan was reviewed and revealed the following: - A revision date of 7/2/25, which documented (R401) is at risk for elopement and/or wandering R/T (related to): decrease in cognition, history of attempts to leave facility unattended, impaired safety awareness. The Elopement was created on 6/24/25. - An intervention for 1:1 supervision on afternoon shift was created on 7/1/25. -An intervention for 30-minute visual checks were created on 7/1/25. -The intervention for wander guard to right ankle was created on 6/24/25. -The intervention for distract resident when wandering into inappropriate areas by offering pleasant diversions, structured activities, food conversation was created on 6/24/25. -The intervention to observe wandering behavior and attempt diversional interventional when wandering into inappropriate locations was created on 6/24/24. Review of R401 elopement assessment, dated 4/19/25, revealed R401 was evaluated as a 0 for elopement risk. Review of R401 elopement assessment dated [DATE], R401 was evaluated as a 7. Seven equates to no elopement risk. R401 was reevaluated on 5/19/25. The results were a 7 no risk. R401 was not evelauted for elopment risk after R401 attempted to exit the facility two times on 6/19/25. Further review of progress notes dated 6/23/25 at 8:28 PM, LPN B documented (R401) Resident attempted to leave. Resident redirected to unit. One on one put in place for resident safety. There was no documentation that R401 had actually left the facility. On 6/30/25 at 12:50 PM, during an interview, the Director of Nursing (DON) denied any residents had eloped from the facility. The DON said there was a resident that had attempted to elope but did not actually elope. Upon further interview the DON confirmed R401 had exited the building and was found in front of the facility. On 6/30/25 at 1:00 PM, the Nursing Home Administrator (NHA) was interviewed. The NHA said they did not consider the incident with R401 to be an elopement because R401 did not leave the premises. The NHA was unable to present any evidence where R401 was found or how R401 exited the building and how long the resident was outside unsupervised. On 6/30/25 at 1:30 PM, certified nurse assistant CNA A was interviewed and confirmed on 6/23/25 after 8PM R401 was observed outside the facility unsupervised in a hospital gown and pushing a wheelchair. CNA A observed R401 outside of the facility while walking to another unit. On 7/1/25 at 9:00 AM, License Practical Nurse (LPN) B was interviewed and said she initially documented in a progress note on 6/23/25 that R401 had attempted to leave the facility. LPN B said she received clarification that R401 was found outside of the facility but did not make an addendum to the original progress note. LPN B said they did inform the Director of Nursing on 6/23/25 that R401 had left the facility and was found outside. On 7/1/25 at 10:05 AM, the Surveyor observed there was no receptionist at the front desk for 15 minutes with multiple visitors entering and exiting the building. This indicated residents could exit the facility unbeknownst to staff On 7/2/25 at 9:28 AM, during a second interview, the DON said there was no investigation into R401's elopement. The DON was queried about staff coverage when the receptionist was on break. The DON said when the receptionist takes a break, they call the unit, and the receptionist desk is left unmanned. On 7/1/25 at 10:30 AM, in a second interview, the NHA was queried about security footage. The NHA said the camera recording system was not functional and was unable to provide evidence of where R401 was located outside of the facility. On 7/2/25 at 11:28 AM, LPN E was interviewed regarding documentation of a nurse's note dated 6/19/25. The nurse's note revealed R401attempted to elope. LPN E explained during the interview that R401 attempted to elope twice on 6/19/25, the first time R401 reached the back door, and the second time approximately 15 minutes later R401 was stopped before reaching the back door. On 7/2/25 at approximately 2:00 pm, the DON and the NHA were informed that R401 had made verbalized leaving the facility with two physical attempts to exit the facility on 6/19/25 without interventions being but in to place. Subsequently, R401 exited the building on 6/23/25 unbeknowst to staff. The DON and the NHA did not provide a response. According to the facility Elopement Policy dated 4/26/22, Elopement occurs when a guest/resident who needs supervision leaves a safe area without authorization .the facility will evaluate guest/resident's risk for elopement upon admission, weekly x 4, quarterly, and with a significant change. Periodic reviews will be completed as deemed necessary by the interdisciplinary team. Upon exiting the facility on 7/2/25 at approximately 3:00 PM no additional information was provided regarding R401's elopement from the facility. Removal Plan. Resident identified to be affected by the alleged deficient practice Resident #R401 was assisted back into the facility on 6/23/25, placed on 1:1 supervision and Q30 minute visual checks Resident #R401 was assessed for Elopement Risk on 6/24/25 Residents with the potential to be affected by the alleged deficient practice. On 7/1/25 the Administrative Nurses reviewed the residents' most recent elopement evaluation to identify the residents who are at risk for elopement o On 7/1/25 the Administrative Nurses reviewed the residents identified at risk for elopement to ensure care planned interventions are in place to prevent elopement Systemic Measures to Prevent Reoccurrence o On 7/1/25 A QAPI Meeting was held to review the root cause of the elopement, with the NHA, the DON, the Medical Director (by phone), the Social Worker the Social Worker, and Unit Managers. o On 7/1/25 The Elopement policy was reviewed and deemed appropriate. Re-education of the staff on the elopement policy began on 7/1/25, staff must be re-educated before they return to work for their scheduled shift. The facility asserts the immediacy was removed on 7/1/25. The Immediate Jeopardy was removed on 7/2/25, based on the facility's implementation of the removal plan as verified onsite on 7/2/25.

Based on interview and record review the facility failed to report an incident of resident elopement for one resident (R401) of three residents reviewed for elopement. This failure resulted in the facility not identifying or responding to a situation in which a resident exited the facility without supervision, posing a potential risk to residents' health and safety. Findings include: On 6/30/25 at 12:50 PM, during an interview, the Director of Nursing (DON) denied any residents had eloped from the facility. The DON said there was a resident that had attempted to elope but did not actually elope. Upon further interview the DON confirmed R401 had exited the building and was found in front of the facility. On 6/30/25 at 1:00 PM, the Nursing Home Administrator (NHA) was interviewed. The NHA said they did not consider the incident with R401 to be an elopement because R401 did not leave the premises. The NHA was unable to present any evidence where R401 was found or how R401 exited the building or how long the resident was outside the facility unsupervised. On 6/30/25 at 1:30 PM certified nurse assistant CNA A was interviewed and confirmed on 6/23/25 after 8PM R401 was observed outside the facility unsupervised in a hospital gown and pushing a wheelchair. CNA A observed R401 outside of the facility while walking to another unit. On 7/1/25 at 9:00 AM, License Practical Nurse (LPN) B was interviewed and said initially they documented in a progress note on 6/23/25 that R401 had attempted to leave the facility. LPN B said she received clarification that R401 was found outside of the facility but did not make an addendum to the original progress note. LPN B said they did inform the Director of Nursing on 6/23/25 that R401 had left the facility and was found outside. On 7/2/25 at 9:28 AM, during a second interview, the DON said there was no investigation into R401's elopement. The DON said she made the decision to put the incident on paper once the surveyor came out to investigate the concern of alleged elopement. The DON was queried about receptionist coverage when the receptionist was on break. The DON said when the receptionist takes a break, they call the unit, and the receptionist desk is left unmanned. On 7/1/25 at 10:30 AM, in a second interview the NHA was queried about security footage. The NHA said the camera system was not functional. Review of nursing progress created by the DON on 7/1/25 at 5:59 revealed the family notified of R401 6/23/25 elopement until 7/1/25. Record review noted, R401 was admitted on [DATE]. R401 had pertinent diagnosis of fracture of right femur, history of falls, abnormal posture, alcohol dependence with alcohol induced dementia, osteoporosis, chronic kidney disease stage three, glaucoma, and sarcopenia (muscle loss). According to the Minimum Data Set (MDS) dated [DATE], R401 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out 15. According to the 4/26/22 facility Elopement Policy documented . elopement occurs when a guest/resident who needs supervision leaves a safe area without authorization . Additionally in a section of elopement policy it states, if guest leaves the facility the facility must complete and file an incident report.

Based on interview and record review, the facility failed to ensure that an incident involving a resident elopement was reported, investigated, and documented in accordance with federal regulations. This failure affected one resident (R401) of three residents reviewed for elopement and had the potential to place the resident at risk due to inadequate supervision and failure to follow established protocols for investigating and reporting incidents. Findings include: On 6/30/25 at 12:50 PM, during an interview, the Director of Nursing (DON) denied any residents had eloped from the facility. The DON said there was a resident that had attempted to elope but did not actually elope. Upon further questioning the DON confirmed R401 had exited the building and was found in front of the facility. On 6/30/25 at 1:00 PM, the Nursing Home Administrator (NHA) was interviewed. The NHA said they did not consider the incident with R401 to be an elopement risk because R401 did not leave the premises. The NHA was unable to present any evidence where R401 was found or how R401 exited the building or how long the resident was outside unsupervised. On 6/30/25 at 1:30 PM certified nurse assistant CNA A was interviewed and confirmed on 6/23/25 after 8PM R401 was observed outside the facility unsupervised in a hospital gown and pushing a wheelchair. CNA A observed R401 outside of the facility while walking to another unit. On 7/1/25 at 9:00 AM, License Practical Nurse (LPN) B was interviewed and said initially she documented in a progress note on 6/23/25 that R401 had attempted to leave the facility. LPN B said she received clarification that R401 was found outside of the facility but did not make an addendum to the original progress note. LPN B said they did inform the Director of Nursing on 6/23/25 that R401 had left the facility and was found outside. On 7/2/25 at 9:28 AM, during a second interview, the DON said there was no investigation into R401's elopement. The DON said she made the decision to put the incident on paper once the surveyor came out to investigate an allegation of elopement. The DON was queried about receptionist coverage when the receptionist was on break. The DON said when the receptionist takes a break, they call the unit, and the receptionist desk is left unmanned. On 7/1/25 at 10:30 AM, in a second interview the NHA was queried about security footage. The NHA said the camera system was not functional. Record review noted, R401 was admitted on [DATE]. R401 had pertinent diagnosis of fracture of right femur, history of falls, abnormal posture, alcohol dependence with alcohol induced dementia, osteoporosis, chronic kidney disease stage three, glaucoma, and sarcopenia (muscle loss). According to the Minimum Data Set (MDS) dated [DATE], R401 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out 15. According to the 4/26/22 facility Elopement Policy documented . elopement occurs when a guest/resident who needs supervision leaves a safe area without authorization . Additionally in a section of elopement policy it states, if guest leaves the facility the facility must complete and file an incident report.

Based on observation, interview, and record review the facility failed to 1. Consistently maintain the kitchen in a clean and sanitary condition; 2. Properly date and label food in the refrigerator; 3. Ensure food is properly stored in the freezer. 4. Ensure the use of hair restraints of staff working in the kitchen. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in an increased risk for food borne illness. Findings include: On 6/23/25 beginning at 9:05 a.m., the initial tour of the kitchen was conducted with Certified Dietary Manager, (CDM) G. Upon entering the kitchen, Sous Chef H was observed near the tray serving line and steam table with a grown-out beard that was not covered with a beard guard. During the tour, the following items were observed in the walk-in refrigerators and freezer: Walk-in Refrigerators: -Upon entering the walk-in refrigerator, the entire floor was wet. -Wilted, wet lettuce and other food particles were on the floor. -Wilted lettuce was exposed in a partially opened box. - In the second walk-in refrigerator, there was a quart of milk that was opened and without an open date. - A clear plastic container with sliced cheese was soiled on the inside and outside with an unidentified white substance. - A clear plastic container with shredded cheese was soiled on the inside with an unidentified white substance. Walk-In Freezer: -The walk-in freezer was observed with frozen hamburger patties in a plastic bag that was opened to the air, with signs of freezer burn (dried discolored edges of the patties). -There was a bag of frozen pancakes in a plastic bag, inside a box that was opened. -There was a plastic bag of breaded chicken strip, unsealed and opened to the freezer air, with signs of freezer burn (dried discolored edges of the chicken pieces). Other kitchen observations included: -The floor in the food prepping and serving area (behind the steam table and food prep table) was observed with dried food and dirty. -Food crumbs and an unidentified liquid were on the food prepping table. -There was dried food on the stove top, near the burners. -There was dried food on the griddle. - At 9:37 a.m., Sous Chef H was again observed in the food serving area without a beard guard. On 6/23/25 at 9:39 a.m., CDM G was queried about the condition of the kitchen and was not able to explain the opened foods found in the refrigerators and freezer. CDM G explained the refrigerated cheese containers had frost on them and were not soiled. On 6/23/25 at beginning at 11:45 a.m., during the lunch meal dining observation, Sous Chef H still had not donned a beard guard and was observed entering and exiting the kitchen serving plated food to various residents in the dining room. CDM G was standing by and asked was facial hair nets were available for use. CDM G said the kitchen supplies facial and hair nets. Sous Chef H approached, and both were asked why Sous Chef H was not wearing a facial hair net. Sous Chef H retreated to the kitchen to retrieve a facial hair net. On 6/24/25 at 1:16 p.m. upon entering the kitchen, Sous Chef H was observed standing near the food serving area with the facial hair underneath the chin, exposing the beard. On 6/25/25 at 10:22 a.m. the Nursing Home Administration was interviewed about the condition of the kitchen and stated, If we overlooked some things, it will be corrected. Review of the facility's policy titled Food Purchasing and Storage, dated 12/10/24 documented in part the following: .Food Storage Areas: The stock will be rotated when stored. All food items will be dated with the In Date (or delivery date). Dating facilitates proper rotation of stack . Perishable Storage Facilities: The refrigerator/freezer facilities will be constructed to meet the sanitation code . Foods will be stored so there is no contamination . Perishable Food Storage: Fruits and vegetables will be refrigerated in their original or clean containers. These items will be sorted regularly, and damaged or spoiled pieces will be discarded . All food items in refrigerators will be properly dated, labeled, and placed in containers with lids, will be wrapped, or stored in sealed food storage bags . All opened frozen foods will be dated, labeled, and wrapped or sealed. Moisture-proof, tight-fitting materials will be used to prevent freezer burn . According to the 2013 FDA Food Code: - Section 2-402, Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Section 4-602.11. Equipment Food-Contact Surfaces and Utensils. Equipment food-contact surfaces and utensils shall be cleaned (5) at any time during the operation when contamination may have occurred. Section 3-101.11, entitled, Safe, Unadulterated, and Honestly Presented, was reviewed and revealed, Food shall be safe, unadulterated, and, as specified under § 3-601.12, honestly presented.

Based on observation, interview, and record review, the facility failed to provide timely nail care for one resident (R17) and scheduled showers for one resident (R51) out of three residents reviewed for activities of daily living, resulting in resident dissatisfaction. Findings include: R17 On 6/23/25 at 11:06 AM, R17 was observed awake and in bed. R17 was wearing a splint/brace on the right hand. R17's right hand appeared to be bent at the wrist and the fingers were noted to be flexed over and towards the palm. R17 stated, The nails on my right hand stabs my palm. They don't cut my nails. A review of the clinical record for R17 documented an initial admission date of 2/14/22 and readmission date of 3/24/25. R17's diagnoses included contracture of right hand and wrist. A Minimum Data Set assessment dated [DATE] documented intact cognition and functional limitation in range of motion on one side of his upper extremity. Review of the Certified Nurse Aide (CNA) plan of care for R17 documented to keep fingernails trimmed and clean. During an observation and interview on 6/25/25 at 10:58 AM of R17's hands with CNA A, R17 stated, My nails stab me a lot. They are all sharp. CNA A said the thumb nail on R17's right hand was thicker than the rest of his nails and was pointed on one side. The corners of some of R17's fingernails were pointed. The index and pinky nails on his left hand were jagged. CNA A stated, (R17) has never refused nail care. CNA A said R17's fingernails were long and needed to be cut. During an interview on 6/25/25 at 12:55 PM, the Director of Nursing (DON) said the reported shape of R17's fingernails could result in him poking himself, and R17's fingernails should have been trimmed when he received his shower. Record review revealed R17's last shower was on 6/21/25. A review of a facility document titled, Routine Resident Care, dated 3/12/25 revealed in part the following: Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Daily personal hygiene minimally includes assisting or encouraging residents with washing their face and hands, shaving, nail care, combing their hair each morning, and brushing their teeth and/or providing denture care. Any concerns will be reported to the nurse. On 6/25/25 at 3:45 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked. R51 On 6/23/25 at 9:21 a.m. R51 was observed resting in bed and watching television. The resident presented as alert, oriented to person, place, situation, and able to make all needs known. During the resident interview, R51 said they had not received scheduled showers in over a month. Shower days are Tuesdays and Fridays on the afternoon shift (3pm- 7pm). R51 continued to say they prefer showers at night before bed, It helps me to sleep better, and I don't feel dirty. Review of the electronic medical record documented R51 was initially admitted into the facility on 1/29/17 with diagnoses that included diabetes mellitus, type 2, bilateral osteoarthritis of the hip, and chronic pulmonary embolism. According to the quarterly MDS assessment dated [DATE] documented R51 was cognitively intact (BIMS-15) and required extensive one- person assistance with activities of daily living specifically bathing and showers. Review of the ADL care plan dated 3/18/24 documented the following: (R51) has a functional ability deficit and require assistance with self-care/mobility pertaining to weakness and impaired mobility . Intervention- Bath/shower: resident requires substantial/maximal assistance with one helper. Review of the Shower/Bathing Task with the look back period of 30 days documented R51 did not receive a shower or bed bath: 6/3/25 (Tuesday) - Not Applicable 6/6/25 (Friday)- Not Applicable 6/10/25 (Tuesday)- Not Applicable 6/17/25 (Tuesday)- Not Applicable 6/20/25 (Friday)- Not Applicable 6/24/25 (Tuesday)- No On 6/25/25 at 1:53 p.m. CENA E was queried about R51's receiving scheduled showers. CENA E said the resident's showers are done on the afternoon shift and documented they were done on the task. CENA E also said during the day shift, the resident is washed up, no showers or bed baths. On 6/25/25 at 1:55 p.m. Unit Manager (UM) F was interviewed and queried about R51 not receiving scheduled showers. UM F said the resident's shower days were changed to Mondays and Thursdays not Tuesdays and Fridays, however, was still not aware the resident did not get the scheduled shower. UM F said there was no notification the resident was not getting showers. Shower days are switched on the assignment sheet but not everywhere else. The unit currently does not have regular afternoon staff and possibly the showers were missing that way. The aides are to notify the nurse when residents don't receive scheduled showers for any reason. The aides are to offer the shower three times and document the reason for the missed shower. The nurse is to notify the Unit Manager if it continues. Review of the facility's policy titled Routine Resident Care, dated 3/12/25 documented in part the following: Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Steps are taken to ensure that a resident's capacity for self-performance of these activities does not diminish unless circumstances of the resident's clinical condition demonstrate the decline is unavoidable. Care is taken to ensure resident safety at all times . Showers, tub baths, and/or shampoos are scheduled according to person centered care or state specific guidelines . Any concerns will be reported to the nurse .

Based on observation, interview, and record review, the facility failed to provide podiatry services in a timely manner for one resident (R62) out of one resident reviewed for podiatry services, resulting in unmet care needs. Findings include: During an observation and interview on 6/25/25 at 10:24 AM of R62's feet, Licensed Practical Nurse/Unit Manager (LPN/UM) C described the condition of the toenails on R62's right foot as raised, long, thicken, discolored, darkened, fungal like, and in need of trimming. The skin around R62's toes was dry and scaly. LPN/UM C described the condition of the toenails on R62's left foot as follows, the 1st, 2nd, 3rd, and 4th digits were thick and long and in need of trimming. There was some toe discoloration and skin dryness around the toes but not as much as the right foot. LPN/UM C indicated R62's insurance did not cover in-house podiatry services, and they have been working on getting her podiatry services. LPN/UM C was unable to provide documentation of attempts to secure podiatry services for R62. A review of the clinical record for R62 documented an admission date of 12/14/22 with diagnoses that included dementia, polyneuropathy, and chronic pain syndrome. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment and functional limitation in range of motion on both sides of her upper and lower extremities. Record review of R62's at risk for impaired skin integrity/pressure injury care plan documented in part to Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician. Initiated on 12/14/22. During an interview on 6/25/25 at 12:00 PM, Social Worker (SW) D said a new mobile medical provider was offering podiatry services to the facility. SW D was unsure of the new company's start date. SW D provided a document dated 6/24/25 that indicated R62 opted out of podiatry services. SW D was unable to provide documentation that R62 had opted out of podiatry services prior to 6/24/25. During an interview on 6/25/25 at 1:04 PM, the Director of Nursing (DON) said they were having issues with R62's insurance company paying for podiatry services. The DON acknowledged there was a previous consent for R62 to receive podiatry services dated 8/24/23. The DON added that it could be assumed that her insurance paid for the podiatry service when previously rendered. Record review of a podiatry note dated 5/4/24 with the DON documented in part the following: Nails: elongated, dystrophic (deformed, thickened or discolored), black yellow/nails. Onychomycosis (nail fungus). Foot and toe pain. Examination, evaluation; debridement of the nails as much as possible. Flattened, thinned and trimmed the nails as much as the patient could tolerate. R/A (reassess) nine weeks or prn (as needed). The DON said she was unsure of what had occurred with podiatry services for R62 during the past year. The DON indicated there were no progress notes/documentation of facility staff contacting R62's guardian regarding issues with insurance coverage for podiatry services. The DON acknowledged that R62's care conferences would have been a good time to discuss podiatry coverage concerns with the guardian. Notes from care conferences held on 12/20/24, 3/17/25, and 6/16/25 were reviewed with the DON and concerns regarding insurance coverage for podiatry services were not addressed. The DON said based off LPN/UM C's observations, R62 should have been seen by podiatry regularly. A review of a facility document titled, Social Services Referral to Outside Providers, dated 10/27/23, revealed in part the following: Referrals to ancillary providers will be made in order to meet the psychosocial and/or concrete needs of a resident. Referrals will be made with consent from the resident or resident representative as needed. Follow up visits will be scheduled as needed. On 6/25/25 at 3:45 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to: 1. Ensure the dishmachine was in good working order; 2. Ensure pans and lids were properly cleaned and allowed to air dry before stacking; 3. Ensure the floor of the walk-in cooler was cleaned. 4. Store a plastic crate containing cartons of milk on a clean floor; 5. Ensure expired food was not stored with active food stock; 6. Properly date-label food stored in the walk-in cooler, walk-in freezer, and resident refrigerators; 7. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, goulash and sausage gravy; and 8. Ensure staff food was not commingled with residents' food. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in the potential for food-borne illness. Findings include: On [DATE] at 7:25 AM, during the initial tour of the kitchen with Dietary Manager (DM) B the following was observed: The temperature log for the dishmachine did not have an entry for [DATE]. DM B acknowledged that the temperatures of the dishmachine wash water and rinse water had not been obtained prior to washing kitchen items, a drinking glass, two knives, a green handled portion scoop, and an eight-quart clear plastic food container, that were drying on a rack on the dishmachine draining board. DM B said they use a high-temperature dishwasher, and they should have obtained water the temperatures before using it. DM B ran a dishwasher temperature label through the dishmachine two consecutive times. The indicator panel on the temperature label was to turn black when the wash and rinse temperatures reached the correct temperature to clean and sanitize kitchenware and tableware. Neither test strip turned black. DM B said he will request a technician service call from the company that services and repairs the dishmachine. The following was observed stored in the clean pot/pan area: - Three 16 x 24 sheet pans nestled together were wet and soiled with food debris. - Five clear storage container lids nestled together were soiled with coffee stains. The following was observed in the walk-in cooler: - A milk crate full of eight-ounce carton of milk was store on the floor. DM B said nothing should be on floor in walk in cooler. - An open bag of mozzarella cheese with a use-by-date of [DATE]. - A box of cheese manicotti shells with two of the shells uncovered in the box. - A sixth-size steam table pan containing a red sauce. The sauce was uncovered and undated. - Two 16.9 ounces of carbonated beverages. DM B said the pop belonged to staff. - The floor of the walk-in cooler was stained and soiled with debris. The following was observed in the walk-in freezer: - An opened package containing three pounds of uncooked sausage was not labeled with opened and use-by dates. - A full undated eight-quart container of goulash. - A half-full undated eight-quart container of sausage gravy. When asked for the cooling logs for the goulash and sausage gravy, DM B said they were not done. During a return visit to the kitchen on [DATE] at 3:05 PM, Cook E ran a dishwasher temperature label through the dishmachine. The temperature indicator panel did not turn black. On [DATE] at 3:15 PM, the dishmachine service technician, (Tech I) performed diagnostic tests on the dishmachine and determined that one of the heating elements for the dishmachine was not working and needed to be replaced. Additionally, the main power switch to the dishwasher booster heater had been turned off. On [DATE] at 9:40 AM, the following was observed in the Cherry Hill nourishment refrigerator: - two unopened snack meal kits containing meat and cheese. The meal kits were not labeled with a resident name. On [DATE] at 9:45 AM, the following was observed in the [NAME] nourishment refrigerator: - one unopened loaf of cinnamon bread. The loaf of bread was not labeled with a resident name. A review of the facility policy titled, Dish Machine Usage and Sanitation, dated [DATE], documented in part the following: - The Culinary staff will check the temperatures on a High Temperature Dish Machine for proper sanitation, using the machine Wash and Rise Gauges, before washing dishes. - In addition to recording the gauge temperatures, the Culinary staff will check the calibration of the gauges per Manufacturers' recommendations prior to washing dishes by using a commercial temperature test strip. - Corrective action will be taken immediately if . there is inadequate Wash or Rise Temperatures. - Minimum Wash Temperature ,d+[DATE] F (according to the type of dish machine, as defined by manufacturers' instructions; and Final Rinse Temperature must be at least 180 F. According to the 2013 FDA Food Code: - Section ,d+[DATE].11, entitled, Safe, Unadulterated, and Honestly Presented, was reviewed and revealed, Food shall be safe, unadulterated, and, as specified under S ,d+[DATE].12, honestly presented. - Section ,d+[DATE].11 Food Storage. Pressurized beverage containers, cased food in waterproof containers such as bottles or cans, and milk containers in plastic crates may be stored on a floor that is clean and not exposed to floor moisture. - Section ,d+[DATE].14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 F to 70 F; and (2) Within a total of 6 hours from 135 F to 41 F or less. - Section ,d+[DATE].11, Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts ,d+[DATE] and ,d+[DATE]. - Section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. - Section ,d+[DATE].12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. On [DATE] at 3:00 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to complete an assessment for the self-administration of medication for one resident (R51), out of 40 residents reviewed for medication administration, resulting in the potential for inappropriate medication administration. Findings include: On 6/11/24 at 9:30 AM, Resident #51 (R51) was sitting on the side of his bed. An overbed table was in front of the resident as he was eating breakfast. R51 said a podiatrist did minor surgery on his toe. A 30 cc (cubic centimeter) cup with white cream was observed on the overbed table. When queried about the contents, R51 stated, It's a pain lotion. I put it on myself. On 6/11/24 at 9:39 AM, Licensed Practical Nurse (LPN) K indicated she was the nurse for R51. R51's medications were reviewed with LPN K, and R51 had a prescription for diclofenac sodium topical gel 1%. This medication was to be applied to left foot topically three times a day for pain. LPN K said R51 puts the medicated lotion on his toe himself. LPN K acknowledged that R51 did not have a physician's order to self-administer the medicated lotion. LPN K stated, He wants to do it himself. When queried if it was right for R51 to administer the medication himself without a physician's order, LPN K stated, No. A review of R51's clinical record documented an initial admission to the facility on [DATE] and readmission on 8/28/23. R51's diagnoses included diabetes mellitus-type 2, peripheral vascular disease, and acquired absence of left toe(s). A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment. There was no care plan for self-administration of medication in R51's clinical record On 6/13/24 at 10:51 AM, the Director of Nursing (DON) said the nurse should have applied the (medicated) cream because of the physician's order. A review of the facility policy titled, Medication Administration, dated 10/17/23, documented in part the following: Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the guideline for self-administration of medication. A self-administration evaluation will be completed prior to the resident starting the self-administering process. Self-administration of medication will be reflected in the resident care plan along with any special considerations. On 6/13/24 at 3:00 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on interview and record review, the facility failed to notify the physician of an acute change in condition for one resident (R152). Findings include: A review of the clinical record revealed Resident #152 (R152) was initially admitted to the facility on [DATE] and readmitted on [DATE]. R152's diagnoses included chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, hypertension, congestive heart failure (CHF), and gastro-esophageal reflux disease. A Minimum Data Set assessment dated [DATE] documented intact cognition. On 6/13/24 at 10:55 AM, when a review of R152's clinical record was conducted with the Director of Nursing (DON), the following was noted: 1. Nurse progress note dated 4/7/24 at 12:57 PM: Resident refusing food and pills this AM. Requested to go to the hospital r/t (related to) stomach pain. 2. According to the April 2024 Medication Administration Record for R152, 9:00 AM medications refused by on 4/7/24 included: Bupropion (for depression), Duloxetine (for depression), Furosemide (for CHF), Lisinopril (for hypertension), Vesicare (for overactive bladder), Diclofenac (for pain), Metformin (for diabetes), Gabapentin (for neuropathy), and Mylanta (for indigestion). 3. Review of an eINTERACT Change in Condition Evaluation, dated 4/7/24 at 1:03 PM for R152 documented in part the following: - Signs & symptoms identified: Abdominal pain. Started on 4/6/24 at night. - Mental status evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) - Description of respiratory changes: labored or rapid breathing - Abdominal/GI status evaluation: Abdominal pain. Abrupt onset of severe pain or distention, OR with fever, vomiting. Acute on chronic abdominal pain. - Summary of observations, evaluation and recommendations: Resident refusing food and pills this AM. Requested to go to the hospital r/t stomach pain. - Were the change in condition and notifications reported to primary care clinician? No - If no, please explain: Resident requested to go to the hospital. 4. There were no nursing progress notes generated on 4/6/24. After R152's record review, the DON agreed that something acute was going on with R152. The DON said, I don't see that the physician was notified. The physician needs to be informed of any change in resident's condition and of the resident's request (to go to the hospital). The DON added that when R152 refused her 9:00 AM medications on 4/7/24, We should have notified the physician. A review of the facility policy titled, Notification of Change, dated 2/14/24, revealed in part the following: - The facility must inform the resident; consult with the resident's practitioner .when there is a change in status. - A change in status would include .a decision to transfer or discharge the resident from the facility. On 6/13/24 at 3:00 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on observation, interview, and record review the facility failed to administer a transdermal patch in accordance with the manufactures guidelines and physician's orders for two residents (R211 and R257) out of forty residents reviewed during medication administration, resulting in the potential for excessive medication dosage delivery and inadequate pain relief. Findings include: R211 On 6/12/2024 at 09:18 a.m. Medication Administration (Med Pass) for R#211 was performed with Licensed Practical Nurse (LPN) R. During the med pass, LPN R was informed by R211 that a right hip Lidoderm patch was not applied on 6/11/2024. LPN R observed a Lidoderm patch dated 6/11/2024 on R211's left hip. LPN R said the Lidoderm patch was put on the wrong hip. LPN R removed the left hip Lidoderm patch and placed another Lidoderm patch on R211's right hip. LPN R was asked was the physician's order written for the Lidoderm patch to be placed on the right hip. LPN R stated, Yes, the Lidoderm patch should have been on the side the resident was having pain. It was the nurse from yesterday (6/11/2024) that put it on the wrong hip. According to the electronic medical record, R211 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses of gout and end stage renal disease. R211's admission Minimum Data Set Assessment (MDS) with a reference date of 3/28/2024 indicated the resident's cognition was intact with a BIMS (brief interview for mental status) score of 13 out of a possible score of 15. Review of the physician order documented, Lidoderm External Patch 5%: Apply to right hip topically every twenty-four hours for pain on for twelve hours: off for twelve hours with a start date of 6/8/2024. On 6/13/2024 at 2:15 p.m., during an interview the director of Nursing (DON) was informed of R211's Lidoderm patch observed on the wrong hip. The DON confirmed the Lidoderm patches should have been applied as ordered. R257 On 6/12/2024 at 09:30 a.m. medication pass for R#257 was performed with Licensed Practical Nurse (LPN) Q. LPN Q reviewed the Medication Administration Record (MAR) for R257's Lidoderm Patches removal and application times. LPN Q said the patch was to be removed at 8:59 a.m. and applied to the right shoulder and right hip at 9:00 a.m. LPN Q was asked were the time of removing the patches one minutes apart. LPN Q confirmed the removal times documented on the MARs was correct. LPN Q was asked for the Lidoderm Patch Manufacture instructions. When LPN Q read the Lidoderm Patch manufacture instructions, the following was documented, Apply the Prescribed number of patches on once for up to twelve hours within a twenty-four-hour period. Remove patches if irritation occurs. LPN Q stated. It should stay on for twelve hours not almost twenty-four hours, I am glad you caught that. On 6/12/2024 at 9:50 a.m. during an interview, Unit Manager/Licensed Practical Nurse (UM/LPN) S confirmed R257's Lidoderm Patches should have been removed at 9:00 p.m. and applied at 9:00 a.m. UM/LPN S stated, The patches should be on for only twelve hours; I will follow up on it. On 6/13/2024 at 2:15 p.m., during an interview the Director of Nursing (DON) was informed of the inaccurate documented times of R257's Lidoderm patches removal and application. The DON confirmed that Lidoderm patches should only be left on for twelve hours and should have been removed at 9:00 p.m. and written on the MAR accordingly to those times. According to the electronic medical record, R257 was admitted into the facility on [DATE] with diagnoses of aged-related osteoporosis and chronic kidney disease. R257's admission MDS with a reference date of 6/4/2024 indicated the resident cognition was intact with a BIMS score of 13 out of a possible score of 15. Review of the physician order documented, Lidoderm Patch 5%: Apply to right shoulder and right hip topically in the morning for pain and remove per schedule with a revision date of 6/12/2024. According to the facility's revised date 10/17/2023 Medication Administration policy: Resident medications are administered in an accurate, safe, timely and sanitary manner. Physician's orders: Medications are administered in accordance with written orders of the attending physician.

Based on observation, interview, and record review the facility failed to provide audiology services for one of one resident (R65) reviewed for hearing concerns, resulting in inadequate accommodations of hearing needs. Findings include: On 6/12/24 at 8:46 am R65 was observed in bed eating breakfast. When R65 was asked about conditions in the facility she replied, I can't hear you can you speak up? R65 was asked do you have hearing aids R65 replied I still can't hear you. There were no hearing devices observed in R65's room. Record review of the Electronic Medical Record (EMR) revealed R65 was admitted into the facility on [DATE] with diagnoses that included unspecified hearing loss bilateral, cochlear implant status and history of falling. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R65 had severe cognitive impairment. The assessment also documented R65 had moderate difficulty hearing and had no hearing aids. Record review of the care plan dated 4/2/24 revealed in part . Focus: R65 has impaired communication as evidenced by hearing deficit, having to repeat words, Goal: will maintain communication by hearing devices, Interventions: Refer to Audiology for hearing consult as ordered. There were no audiology consults to review in the medical record. There were no physician's orders for an audiology consult in the medical record. On 6/12/24 at 3:25 p.m. Social Worker A was interviewed and said R65 was not referred to see the audiologist, so no consults were available for review. Social Worker A also said the process for hearing referrals are as follows: a consent is first obtained by the resident or legal guardian, then sent to the ancillary service provider. A physician's order is also obtained. Once the referral is sent to the ancillary service provider then residents are put on the list to be seen on the next visit. Social Worker A stated, The previous Social Worker left in April so R65 was not referred to the audiologist. On 6/13/24 at 9:30 a.m. the Director of Nursing (DON) was interviewed and said the Social Worker is responsible for facilitating audiology services and agreed R65 should have been referred to audiology services. Review of the facility's policy titled Social Services Referral to Outside Providers last revised 10/27/2023 revealed in part .Referrals to ancillary providers will be made to meet the psychosocial and/or concrete needs of a resident. Social services make a referral to the outside service and provides demographics and signed consent, as needed.

Based on interview and record review, the facility failed to ensure wound treatments were consistently documented per physician orders and nursing standards of practice for treatment administration for one resident (R3) of three residents reviewed for skin conditions, resulting in the potential for compromise and complications in health. Findings include: A review of the clinical record documented Resident #3 (R3) was initially admitted to the facility on [DATE] and readmitted on [DATE]. R3's diagnoses included schizophrenia, epilepsy, cerebral infarction, and hemiplegia. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. Wound note of 5/2/24 documented left 1st digit (hallux-great toe) wound size as 0.7 cm (centimeter) x 0.2 cm. Wound note of 6/8/24 documented left 1st digit wound size as 0.7 cm x 0.5 cm. Review of R3's care plans documented the following: - (R3) is at risk for skin integrity/pressure injury related to: decreased cognition, incontinence, decreased independent mobility, left side hemiplegia, limited turn sites, contractures bilateral upper extremities and lower extremities. Revised on 5/3/22. - Vascular wound tip of left great toe. Dated 4/13/24. Interventions included: - Follow facility policies/protocols for the prevention/treatment of impaired skin integrity. Dated 6/29/20. - Treatment per order. Dated 4/13/24. On 6/13/24 at 1:20 PM, a review of R3's physician's orders and Treatment Administration Records (TAR) with the Director of Nursing (DON) revealed that wound care was not documented on the TARs as follows: - Clean with normal saline. Dry and apply antifungal powder under left arm and inside the palm of left hand. Dated 1/2/24. Day administration not documented: 5/8/24, 5/13/24, 5/18/24, 5/19/24, 5/23/24, 5/24/24, 5/27/24, 5/29/24, 6/2/24, 6/6/24. Night administration not documented: 5/2/24, 5/6/24, 5/7/24, 5/8/24, 5/9/24, 5/11/24, 5/12/24, 5/15/24, 5/16/24, 5/27/24, 5/30/24, 6/3/24, 6/4/24, 6/5/24, 6/9/24. - Cleanse buttocks with soap and water. Apply Z Guard (used to treat and prevent minor skin irritations), cover with foam dressing every night shift for popped blister. Dated 7/12/23. Night administration not documented: 5/2/24, 5/6/24, 5/7/24, 5/8/24, 5/9/24, 5/11/24, 5/12/24, 5/15/24, 5/16/24, 5/19/24, 5/27/24, 5/29/24, 5/30/24, 6/3/24, 6/4/24, 6/5/24, 6/9/24. - Cleanse left great toe (big) with normal saline, apply medihoney (wound care gel) and border gauze every shift and prn (as needed) every shift. Dated 4/4/24. Day administration not documented: 5/8/24, 5/13/24, 5/18/24, 5/19/24, 5/23/24, 5/27/24, 5/29/24, 6/2/24, 6/6/24, 6/7/24. Night administration not documented: 5/1/24, 5/2/24, 5/6/24, 5/7/24, 5/8/24, 5/9/24, 5/11/24, 5/12/24, 5/15/24, 5/16/24, 5/19/24, 5/20/24, 5/24/24, 5/27/24, 5/29/24, 5/30/24, 6/3/24, 6/4/24, 6/5/24, 6/9/24. The DON stated, The nurses should have documented (on the TAR) even if they (the resident) refused. A review of the facility policy titled, Documentation Expectations, dated 6/21/23, revealed in part the following: - Chart events as they occur and maintain chronological order. - An electronic medication/treatment administration record is utilized, nurse initials, omissions, or other documentation relating to the administering of a medication/treatment will be documented in an electronic format per the electronic format per the electronic medication/treatment administration record software. On 6/13/24 at 3:00 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information when asked.

This citation pertains to MI000141717 Based on interview and record review, the facility failed to prevent the misappopriation of narcotic medication for two residents (R501 and R502) of three residents reviewed resulting in staff misappropriation of medication. Findings include: R501 A review of R501's Electronic Medical Record (EMR) revealed R501 was admitted to the facility 12/14/22. R501 had the following medical diagnoses: Dementia and Chronic Pain Syndrome. A review of R501's Minimum Data Set (MDS) dated [DATE] revealed R501 had a Brief Interview for Mental Status (BIMS) score of 0/15 (severe cognitive impairment). According to the MDS, R501 was on a scheduled pain medication regimen. A review of R501's pain care plan dated 12/22/22 revealed the following intervention: Administer medications as ordered. R502 A review of R502's EMR revealed R502 was admitted to the facility on [DATE]. R502 had the following medical diagnoses: Pain, Generalized Osteoarthritis, and Spinal Stenosis. A review of R502's Quarterly MDS dated [DATE] revealed R502 had a BIMS of 15/15 (cognitively intact). According to the MDS, R502 was on a scheduled pain medication regimen. A review of R502's pain care plan dated 8/10/23 revealed the following intervention: Administer medications as ordered. According to the incident report, on 12/16/23 at 10:30 AM, the Director of Nursing (DON) was called by Unit Manager (UM) A regarding sending Registered Nurse (RN) B home because RN B presented with slurred speech and dilated pupils. UM A took over RN B 's assignment. At 1:00 PM while passing medications, UM A noticed RN B had signed out Gabapentin 300 milligrams (mg) for R501 for the scheduled times of 12:00 PM and 6:00 PM. While passing medications for R502, UM A noticed RN B signed out R502's Hydrocodone 5-325 mg (scheduled for 12:00 PM) and Gabapentin 600 mg (scheduled for 2:00 PM). The DON was notified of the discrepancy and called the local police. RN B was suspended upon investigation. On 2/7/24 at 1:24 PM the Director of Nursing (DON) was interviewed and acknowledged R501's and R502's narcotic medication came up missing during medication pass by employee RN B on 12/16/23.

This citation pertains to MI00141717. Based on interview and record review, the facility failed to accurately perform a narcotic count for two of three residents reviewed for nursing staff misappropriation of medication resulting in missed pain medication. Findings include: R501 A review of R501's Electronic Medical Record (EMR) revealed R501 was admitted to the facility 12/14/22. R501 had the following medical diagnoses: Dementia and Chronic Pain Syndrome. A review of R501's Minimum Data Set (MDS) dated [DATE] revealed R501 had a Brief Interview for Mental Status (BIMS) score of 0/15 (severe cognitive impairment). According to the MDS, R501 was on a scheduled pain medication regimen. A review of R501's pain care plan dated 12/22/22 revealed the following intervention: Administer medications as ordered. R502 A review of R502's EMR revealed R502 was admitted to the facility on [DATE]. R502 had the following medical diagnoses: Pain, Generalized Osteoarthritis, and Spinal Stenosis. A review of R502's Quarterly MDS dated [DATE] revealed R502 had a BIMS of 15/15 (cognitively intact). According to the MDS, R502 was on a scheduled pain medication regimen. A review of R502's pain care plan dated 8/10/23 revealed the following intervention: Administer medications as ordered. According to the incident report, dated on 12/16/23 at 10:30 AM, the Director of Nursing (DON) was called by Unit Manager (UM) A regarding sending Registered Nurse (RN) B home because RN B presented with slurred speech and dilated pupils. UM A took over RN B 's assignment. At 1:00 PM while passing medications, UM A noticed RN B had signed out Gabapentin 300 milligrams (mg) for R501 for the scheduled times of 12:00 PM and 6:00 PM. While passing medications for R502, UM A noticed RN B signed out R502's Hydrocodone 5-325 mg (scheduled for 12:00 PM) and Gabapentin 600 mg (scheduled for 2:00 PM). The DON was notified of the discrepancy and called the local police. RN B was suspended upon investigation. On 2/7/24 at 11:12 AM, UM A was interviewed regarding the incident that took place on 12/16/23. UM A said they were notified by Social Worker (SW) C regarding RN B 's behavior. UM A said they came in to assess the situation. UM A said RN B was falling asleep at the medication cart. When queried, UM A said RN B explained she was tired. UM A described RN B as slurring her words, had dilated pupils, and could barely stand. UM A said she told RN B they were being relieved (dissmissed from duty). UM A said she was going to drug test RN B, but RN B refused and walked out. During the interview, UM A said that is when she called the DON to inform her about the incident involving RN B. UM A said afterwards she counted medication with Nurse D. When asked how the medications were counted, UM A said they were counted by matching the number of pills in the pill packet to the number last written on the count sheet. UM A said the numbers came out to be equivalent to each other. UM A reported she was not aware the pills were missing until she went to administer the narcotics. It was at this time UM A identified that the narcotics were signed out ahead of time and therefore the count was off. On 2/7/24 at 1:18 PM the DON was interviewed regarding the narcotic count. The DON said the nurses are supposed to verify the count by matching the page count with the pill packet and verifying that with the last line documented on the count sheet (including the time the last medication was administed.) Review of facility policy titled, Controlled Substances dated 10/26/23, was reviewed and did not reveal how a narcotic count should be conducted between nursing staff.

This citation pertains to MI00138511. Based on observation, interview, and record review, the facility failed to fully implement the elopement procedure when an alarm sounded but staff neglected to conduct an adequate search of the facility grounds, resulting in the likely occurrence of a serious adverse outcome to one resident (R101) who had a diagnosis of Dementia, was assessed at risk for elopement related to exit seeking and wandering, and had severely impaired cognition out of three residents reviewed for elopement. A citizen called the facility after Resident #101 (R101) was observed unattended outside of the facility at approximately 7:15 PM about 100 feet from a busy two-lane highway in one direction and a 6-to-7-foot drop into wetlands in the other direction. The Immediate Jeopardy (IJ) started on 7/13/2023 when a door alarm sounded but staff neglected to conduct an adequate search of the facility grounds. The Director of Nursing (DON) was notified of Immediate Jeopardy on 8/10/2023 at 4:51 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 7/14/2023, but noncompliance remained isolated with the potential for harm due to sustained compliance that has not been verified by the State Agency. The Immediate Jeopardy that began on 7/13/2023 was removed on 7/14/2023 when the facility took the following actions to remove the immediacy: - On 7/13/23 at approximately 7:00 pm resident #101 was observed by (Certified Nurse Aide M) sitting in the enclosed courtyard with other residents visiting. - On 7/13/23 at approximately 7:10 pm (License Practical Nurse [LPN] G) responded to Door #8 alarm that was sounding, looked outside and did not see resident #101, turned off the alarm and went to her unit to initiate a resident count. - On 7/13/23 at approximately 7:15 pm a passer-by saw resident #101 falling outside along the sidewalk. [NAME] -by called and notified the receptionist of resident outside. - On 7/13/23 Resident #101 was assessed by (LPN F) with no injury noted and assisted back into the facility at approximately 7:20 pm and was placed on 1:1 staff supervision to maintain safety. - On 7/13/23 at approximately 8:18 pm Physician and Responsible Party were notified of the incident. - On 7/14/23 (LPN G) and (LPN F) received individual education by the DON (Director of Nursing) on the Elopement Policy and to physically check outside surrounding area when responding to sounding door alarms and to announce a Code Search. - On 7/14/23 In-servicing was initiated by (the DON) on the Elopement Policy and response to door alarms and calling of Code Search if door alarming without identification of cause for alarm sounding. Education is continuing until all staff are completed. There are 139 employees out of 155 were re-in serviced by the DON/Designee since 7/14/23. The remaining employees will be educated prior to starting their shift. - On 7/14/23 132 (sic) 10 out of 112 Residents with Physician orders for (sensor alarms) were visually verified for proper placement and function, care plans and care cards have been reviewed and updated as indicated. - On 7/14/23 The (sensor alarm) system and all alarmed doors were checked with no variances noted for proper functioning and will continue daily per the Preventative Maintenance Program by Maintenance Department/Designee. - Continued compliance is being monitored daily through the morning clinical meeting, review of new orders, review of 24 hour report, resident at risk meetings, elopement drills per facility policy and through the facility's quality assurance program. Additional education and monitoring will be initiated for any identified concerns. Date of compliance: 7/14/2023 Findings include: During an observation on 8/10/2023 at 10:08 AM, R101 was observed sitting in a wheelchair near the nurse's station. A sensor bracelet, used to activate an alarm should the wearer exit a door, was observed on R101's right ankle. A review of the clinical record revealed R101 was initially admitted on [DATE] and readmitted on [DATE]. R101's diagnoses included psychotic disorder with delusions, vascular dementia with psychotic disturbance, and adjustment disorder with mixed anxiety and depress mood. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A Risk for Elopement assessment dated [DATE] resulted in a score of 12.0 which determined R101 was at risk for elopement. A physician order dated 7/6/2023 documented, Resident to wear (sensor bracelet) at all times. Review of R101's care plans documented in part the following: - Focus: (R101) is at risk for exit seeking/wandering related to multiple medication conditions including Dementia. Created on 7/3/2023. - Interventions: 1:1 sitter. Created 7/17/2023; (Sensor bracelet) to right ankle. Created on 7/3/2023; Observe wandering behavior and attempted diversional interventions when wandering into inappropriate locations such as other residents' rooms when not invited, behind nurses stations, shower rooms, attempts at exiting facility, etc. Created on 7/3/2023. A review of progress notes documented in part the following: 1. Nurse note of 6/30/2023 at 7:27 PM: Resident is noncompliant with asking for assistance when standing or ambulating. Resident continuously walks without walker or wheelchair throughout the day Resident was brought out to the nursing station to ensure safety and would grow frustrated with sitting in wheelchair and continued to get up out of wheelchair with no walker. 2. Nurse note 7/5/2023 at 6:40 PM: Patient is confused and needs re-direction multiple times during the shift. Patient noted to be using his side table to ambulate in the hallway. Patient instructed on using his wheelchair multiple times. 3. Social service note 7/11/2023: (R101) mentioned he was upset that his wife hasn't been up to visit. He also said that he was feeling abandoned by his family. Psych is following resident. 4. Nurse note of 7/13/2023 at 10:10 AM: Writer approached by social worker that multiple staff members have mention resident needing help to urinate (more frequently than usual). Resident confused and has delirium. Specimen to be collected for US C&S (urinalysis). 5. Nurse note of 7/13/2023 at 7:40 PM (This progress note was created on 7/13/2023 at 9:24 PM.): Resident observed outside, visitor brought back into building. Visitor stated resident fell . Assessment complete, no apparent injuries, no complaint of pain. 6. Nurse note of 7/15/2023 at 10:54 AM: Resident attempted to exit building, writer redirected patient from the door, and turned off the alarm at Door 12. A review of a facility document titled, Summary of Facility Investigation, undated but provided during the survey, documented in part the following: On 7/13/23 at approximately 7:15 PM the (sic) (R101) was observed outside of the building, on the side, by citizen. They stopped to assist the resident related to him falling on the sidewalk. They immediately called the building. The receptionist notified his nurse, (LPN) [Licensed Practical Nurse] F), who went outside to the resident. She assessed the resident than (sic) assisted him into the citizen's car and they drove to the front entrance During interviews and observations on 8/10/2023 beginning at 12:23 PM the Director of Nursing (DON) said at approximately 7:15 PM, R101 went to the restorative dining room in his wheelchair. The dining room was empty. R101 got up out of his wheelchair, opened the exit door, which had a delayed opening, and walked along the fence line. A nurse came, turned off the alarm, looked both ways outside of the door, and did not see the resident. The DON said the resident allegedly fell at the end of the walkway. A citizen driving along the main road, saw the resident on the ground, drove up the driveway, called the facility, and assisted getting the resident back into the facility. The DON said an elopement occurs when a resident leaves the facility without them being aware. The DON said LPN G should have activated the Code Search when the door alarm was activated but did not. When staff responded to the door alarm, someone should have gone out the door to find the resident. If the resident was not visible, then they should have called the Code Search and that did not happen. The facility learned about the missing resident when the citizen called the facility. During an interview on 8/10/2023 at 1:42 PM LPN C stated, I was going to clock off and heard the alarm in the restorative dining room. LPN C said LPN G was already in the dining room and couldn't shut the alarm off because she did not know the code. When LPN G went to get someone to turn off the alarm, I left. LPN C stated, I never looked outside and never even went to the door. During an interview on 8/10/2023 at 2:24 PM LPN G said she was in report with another nurse and heard the alarm for the restorative dining room door. The other nurse (LPN C) was on her way out and told me to turn off the alarm. When I opened the door, I looked one way and then the other and nobody was there. I turned off the door alarm. LPN G said she did not notice an empty wheelchair in the dining room. LPN G stated, I checked my unit, and it was fine. LPN G said she went to the [NAME] unit and was informed that one of their residents had left the building. LPN G said she did not go to the other two housing units, Cherry Hill and Lilly, to notify them to conduct a head count of their residents. LPN G stated, I did not activate 'Code Search' because I was unfamiliar with doing a page overhead for an elopement. I have been educated on the importance of a 'Code Search' even if there is nothing that you notice. During an observation and interview on 8/10/2023 at 3:10 PM of the outside property, Maintenance Director (MD) H estimated the following distances: - From the restorative dining room exit door to the end of the adjoining sidewalk was approximately 100 feet. MD H referred to the area at the end of the sidewalk as a service area in the back of the building. - From the service area in the back of the building to a 6-7 foot drop off into wetlands was approximately 15 feet. - From the service area in the back of the building to the main road in front of the building was approximately 200 feet. The main road in front of the building is a two-lane road with a speed limit of 50 MPH. On 8/10/2023 at 5:00 PM and 5:02 PM respectively, Staff Development Coordinator L and the DON confirmed that neither LPN F or LPN G were listed as receiving the 7/14/2023 training on the elopement policy. Verification of the education on the elopement policy for LPN F and LPN G was requested but not provided prior to the end of the survey day. During an interview on 8/14/2023 at 9:52 AM, the Nursing Home Administrator (NHA) said it was not an elopement if they see a resident leave and we go get him. The NHA acknowledged that those were not the circumstances regarding R101. During a record review on 8/14/2023 at 10:05 AM, the DON provided signed declarations from LPN F and LPN G that they received 1:1 education on 7/14/2023 regarding the elopement policy, responding to door alarms, and calling code search. During an interview on 8/14/2023 at 12:31 PM, LPN F said she was making rounds and checking on her residents when the facility's receptionist came and informed her that a resident was outside. When LPN F went outside, R101 was standing with a citizen. LPN F said the citizen had pulled up in the driveway and R101 and the citizen were positioned halfway between the back of the building and the main road in front of the building. The citizen offered to drive them to the front door. LPN F stated, He drove us to the front entrance, and we got out. (Staff) had a wheelchair and I put (R101) in the wheelchair and took him back into the facility. A review of the facility policy titled, Elopement Policy, dated 4/26/2022, documented in part the following: - Elopement occurs when a guest/resident who needs supervision leaves a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. - Alarm activation. 1. If an employee hears a door alarm, he or she should: a). Immediately go (sic) the site of the alarm; .c.) If no guest/resident is found to be exiting the facility, the employee should walk outside; conduct a visual observation of the immediate area to ensure that a guest/resident has not already exited the facility. If no guest/resident is observed, then the staff member will return into the building. 2. In situations where the alarm sounds and a guest/resident is not found to have exited: a.) Notify the licensed nurse immediately, and b.) Ensure that a head count is completed to ensure that all guests/residents are accounted for. - Missing Guest/Resident: Check the sign-out form to see if the guest/resident signed out without notifying the staff or left with family if not, call a code Search or designated code for the facility. On 8/14/2023 at 1:45 PM during the exit conference, the NHA and DON did not offer additional documentation or information when asked.

This citation pertains to MI00138511. Based on interview and record review, the facility failed to ensure than an incident of staff neglect resulting in a resident elopement was submitted to the State Agency for one resident (R101) out of three residents reviewed for elopement, resulting in the potential for future incidents of staff neglect to go unreported. Findings include: An anonymous complainant reported to the State Agency that Resident #101 (R101) was observed unattended outside of the facility at approximately 7:15 PM. A review of a facility document titled, Summary of Facility Investigation, undated but provided during the survey, documented in part the following: On 7/13/23 at approximately 7:15 PM the (sic) (R101) was observed outside of the building, on the side, by citizen. They stopped to assist the resident related to him falling on the sidewalk. They immediately called the building. The receptionist notified his nurse, (LPN) [Licensed Practical Nurse] F), who went outside to the resident. She assessed the resident than (sic) assisted him into the citizen's car and they drove to the front entrance A review of the clinical record revealed R101 was initially admitted on [DATE] and readmitted on [DATE]. R101's diagnoses included psychotic disorder with delusions, vascular dementia with psychotic disturbance, and adjustment disorder with mixed anxiety and depress mood. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A Risk for Elopement assessment dated [DATE] resulted in a score of 12.0 which determined R101 was at risk for elopement. A physician order dated 7/6/2023 documented, Resident to wear (sensor bracelet) at all times. Review of R101's care plans documented in part the following: - Focus: (R101) is at risk for exit seeking/wandering related to multiple medication conditions including Dementia. Created on 7/3/2023. - Interventions: 1:1 sitter. Created 7/17/2023; (Sensor bracelet) to right ankle. Created on 7/3/2023; Observe wandering behavior and attempted diversional interventions when wandering into inappropriate locations such as other residents' rooms when not invited, behind nurses stations, shower rooms, attempts at exiting facility, etc. Created on 7/3/2023. During interviews on 8/14/2023 beginning at 9:52 AM the Nursing Home Administrator (NHA) stated the incident of elopement was not reported to the State Agency because, We knew what happened. I didn't feel it was reportable. (R101) was still on grounds. An elopement is not a reportable event. When the NHA was informed that staff neglected to adequately monitor R101 which resulted in the elopement, the NHA and reported the situation was not willfull. A review of the following facility policies were reviewed and revealed in part the following: 1. Abuse Prohibition Policy, dated 9/9/2022: - Allegations of guest/resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies . - Neglect is the failure of the facility, its employees or service providers to provide goods and services to a guest/resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware, or should have been aware of, goods or services that a guest/resident(s) requires but the facility fails to provide them to the guest(s)/resident(s), resulting in physical harm, pain, mental anguish, or emotional distress. Allege violation of neglect include cases where the facility demonstrates indifference or disregard for guest/resident care, comfort or safety, resulting in physical harm, pain, mental anguish or emotional distress. - The Administrator or designee will notify . any State or Federal agencies of allegations per state guidelines (2 hours if abuse allegation or serious injury; all others not later than 24 hours). At the conclusions of the investigation and no later than 5 working days of the incident, the facility must report the results of the investigation and if the allege violation is verified, take corrective action. 2. Elopement Policy, dated 4/26/2022: - Missing Guest/Resident: .Notify the state agency, if required per state guidelines. On 8/14/2023 at 1:45 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

This citation pertains to Intakes MI00134521 and MI00134705. Based on observation, interview, and record review, the facility failed to ensure a proper pivot transfer for one resident (R23) of 6 residents reviewed for accidents resulting in an acute spiral lower leg fracture. Findings include: On 6/5/23 at approximately 8 AM R23 was observed lying in bed dressed, hair combed, and basic Arabic translation sheet at head of bed. On 6/05/23 at 11:57 AM the clinical record for R23 was reviewed and revealed that R23 was admitted into the facility on [DATE] with diagnoses of dementia, and weakness with primary language of Arabic. R23 readmitted to facility on 2/10/23 with of diagnosis of closed fracture of distal end of left tibia with routine healing unspecified fracture morphology and closed fracture of distal end of right radius with routine healing, unspecified fracture morphology. The Minimum Data Set (MDS) assessment dated [DATE] revealed R23 was a 2-person transfer and had a Brief Interview for Mental Status (BIMS) score of 00 (severely cognitively impaired). Record review of the Facility Incident and Accident Investigation form dated 1/31/23 revealed At 3:45 PM Certified Nursing Assistant (CNA) D was transferring resident with another CNA C from bed to Geri chair when she noticed resident grimacing in pain with movement of the left foot and notified Licensed Practical Nurse (LPN) E immediately. LPN E assessed R23 notified Physician Assistant (PA) F x rays were ordered. Received results of left distal tibia fracture. Medical Doctor G notified and ordered to send to ER. Record review of the Radiology Results Report dated 2/1/23 revealed in part images of the left ankle are submitted. There is an acute spiral fracture (a type of fracture that is a result of a twisting movement involving a great force) to the distal tibial shaft with minimal displacement. In interviews on 6/06/23 at 2:45 PM and on 6/08/23 at 8:21 AM with CNA D revealed she worked at the facility for 4 years and was familiar with R23. When asked how R23 was transferred on 1/31/23 CNA D replied R23 was a 2-person transfer, so she asked CNA C to help transfer R23 from the bed to Geri chair. CNA D indicated she put a gait belt around R23, placed her feet on the floor then along with CNA C, they each grabbed R23 under the arm on each side (an outdated transfer method that puts a vulnerable resident at risk for injury) and grabbed the gait belt from the back and in one twisting movement transferred the resident from the bed into the Geri chair. (R23) was not able to pivot her feet, leaving CNA D to physically picked the resident's feet up and reposition them after the transfer. CNA D went on to say she helped R23 recline and then grabbed her legs to straighten her out into the middle of the chair. I pulled her (R23) pant legs down and she started to cry when I touched her left ankle. I took her down to the nurses' station and notified LPN E. When asked how you communicated with R23 since she spoke Arabic. CNA D stated You know it is not very good, we used to have a staff member that would translate but they no longer work here. I usually use basic hand gestures to communicate with her. When asked could R23 pivot her feet herself during a transfer? CNA D replied Not really, we . When asked to demonstrate the transfer CNA D demonstrated the transfer by grabbing the simulated right upper arm with her right hand and reached around simulated back with her left hand to grab the gait belt and demonstrated a twisting motion. When asked did R23 exhibit any signs of discomfort or pain prior to to the transfer on 1/31/23 CNA D replied no she was ok. In interviews on 6/06/23 at 2:53 PM and on 6/07/23 at 9:37 with CNA C revealed she worked at facility for 8 years, and she assisted CNA D to transfer R23 from bed to Geri chair on 1/31/23. We each grabbed her (R23) under the arm on each side and transferred her into the Geri chair. I didn't notice anything was wrong until after CNA D pushed her in her Geri chair and parked her outside of the nurse's station. I noticed she (R23) started to rub her left leg. I notified LPN E. When asked how did you communicate with R23 since she speaks Arabic? CNA C stated we speak English to her and try to get yes and no answers. When asked was the resident able to stand or assist in standing at the time of the incident? CNA C stated the resident couldn't stand without assist. When asked was the R23 able to assist with pivoting into the chair? CNA C said No she was unable to pivot, we pivoted her. In an interview on 6/07/23 at 10:08 AM with the Director of Nursing (DON) was asked how should the CNAs transfer R23? She replied 2 CNAs would pivot her for a transfer. The DON demonstrated a twisting movement when she described a standing pivot transfer. When asked to define a 2-person transfer, she replied the transfer would require 2 people to perform sit to stand. The resident would need to be able to bear weight on her legs. The DON stated, If a resident can't stand at all without being held up, they should be a Hoyer transfer. She agreed the R23 displayed discomfort immediately after the transfer on 1/31/23. When asked how often does therapy perform reassessments? She replied initial, quarterly and after an incident. Record review revealed R23 was last seen by physical therapy in 2021. The facility did not provide therapy quarterly and/or incident assessments upon request. Record review of the facility document titled Helping to Transfer Someone Safely dated 2023 revealed in part If you need more help to stand: have your helper stand in front of you. Your helper should reach around your waist with both arms and grab your gait belt. Turning and sitting down: Turn your whole body. Move your feet instead of just twisting at your waist.

Based on observation, interview, and record review, the facility failed to ensure a care plan for a communication deficit was created upon admission for two (#78, #98) of two residents reviewed for baseline care plans, resulting in the potential for residents communication care need not being met. Findings include: R78 On 6/5/2023 at approximately 8:09 a.m., R78 was observed in her room, alert and sitting in the bed wearing a gown. R78 was queried if she had breakfast, R78 did not respond. Certified Nursing Assistant (CNA) I entered the room and asked R78 did she want to go to the bathroom. R78 did not verbally respond. R78 indicated to CNA I by nodding her head No. CNA I was asked was it difficult speaking to R78 to find out what she wanted, CNA I said, yes sometimes it is. According to the electronic medical record, R78 was admitted into the facility on [DATE] with diagnoses of spinal stenosis, lumbar region, type two diabetes mellitus, hypertension, a-fibrillation, chronic obstructive pulmonary disease, polyosteoarthritis, low back pain, and chronic kidney disease. R78's Minimum Data Set Assessment was not available. Review of the Admission Nursing Comprehensive evaluation dated 5/15/2023 documented, R78 was oriented to person, place and things. Review of the 5/15/2023 Nurses Notes Summary' documented, R78 had Limited English. Review of the care plans revealed, R78 had no communication care plan with no communication interventions. On 6/6/2023 at approximately 12:56 p.m., R78 was observed nodding her head and verbally saying 'yes and no' when CNA K entered R78's room to anticipate her needs. During an interview, CNA K stated, this is my first time working with the resident (R78) because I usually work on another station. The resident can only say water and point to the bathroom. On 6/8/2023 at approximately 1:14 p.m., the Director of Nursing (DON) was queried if there should be interventions for residents with language barrier. The DON stated, We can do a communication board and we have an interpreter service we use, but her (R78) language is rare, and the interpreter service does not have her (R78) language. The DON said residents with a communication barrier should have a communication care plan. 15194 R98 On 6/5/2023 at 8:49 A.M. during the initial tour R98 was observed in her room sleeping. On the walls near the door were two handwritten signs. Both signs were written in English with translations in Chinese. The signs provided instructions on taking a bath and ways to commuicate other care needs. Review of the face sheet revealed, R98 was Chinese,and was admitted to the facility on [DATE], with diagnoses of Alzheimer's disease, hypothyroidism, hypertension, dysphagia, and adult failure to thrive. According to the Minimum Data Set (MDS) dated [DATE], R98 was cognitively impaired (ability to think) and required limited assist with one-person physical assist to perform activities of daily living. On 6/6/2023 at 9:00 A.M., during a record review of the Care Plan section of the Electronic Health Record, no communication and/or language barrier care plan was observed. During a record review of the Electronic Health Record at 1:50 P.M. Unit Manager (UM) L was quired concerning the resident's care plan for communication. UM L stated, A communication care plan should have been generated upon the resident's admission. Glancing through the clinical record UM L acknowledged there was no communication/and or Language barrier care plan. Review of the facility's policy titled: Care Planning, effective date of 6/24/2021, every resident in the facility will have a person-centered plan of care developed and implemented that is consistent with the resident's rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a resident's medical, nursing and mental needs .and documented under (2). A Baseline Care Plan will be developed within 48 hours identifying any immediate needs, initial goals and interventions needed to provide effective and person-centered care.

This citation pertains to MI 424 Based on observation, interview and record review the facility failed to safely reposition a resident (R 601) in bed during the provision of care (changing a brief) resulting in the resident falling out of the bed and sustaining several fractures that required hospitalization and monitoring in the hospital's Surgical Intensive Care Unit for 3 days. Findings include: On 7/7/22 at 10:34 AM a phone interview was conducted with the primary representative and complainant of R 601. Complainant (C) stated she received a call from the facility at about 6:40 AM on 5/24/22, about a fall and was told the fall was witnessed and that my family member was alright. I was told she had some bruised knees. I received another call at about 8:59 AM, the person sounded like a nurse. I was told my family member did not look well and was having difficulty breathing and would be sent to the hospital. I received another call from the hospital at 3:53 PM and was informed my family member had several injuries (broken bones). They said she looked like she fell of a [NAME] bed. A review of medical records on 7/7/22 at 11:30 AM revealed R 601 was initially admitted to the facility on [DATE] with relevant diagnoses that included: Cerebral Infraction (Stroke), Polysteoarthritis, [CONDITION(S)] (sensation of everything moving) and Generalized Muscle Weakness. R 601 had impairment in Range of Motion in the upper extremities (shoulder, elbow, wrist, hand) on one side of the body, and impairment on both sides of the lower extremities (hip, knee, ankle, foot). According to the MDS (minimum data set) R 601 had a high level of cognitive (thought processes) functioning, scoring 15/15 on the Brief Interview of Mental Status (BIMS) Exam. During the initial admission R601 required extensive assistance and 1-person support with bed mobility, however this functional status was elevated to extensive assistance and 2-person support following hospitalization and readmission (5/27/22) due to the fall. A care plan created on 3/2/21 and revised on 3/10/21 identified R 601 at risk for fall related injury and falls in general related to a history of falls, impaired mobility, muscle weakness, and [CONDITION(S)]. The goal was to be free from injury due to falls. Interventions included anticipating and meeting the residents needs when necessary. R 601 was observed lying in bed on 7/7/22 at 12:30 PM. The surveyor asked the resident if she remembered falling since she has been at the facility. The resident stated, yes want to see and then partially pulled back the bedcovers revealing both legs covered with plaster, supported with metal bars. R 601 stated, I rolled out of bed and hit the floor. The aide, (CNA A) was trying to change my diaper. When asked if the aide, CNA A was able to stop the fall, R 601 stated, no, I was laying on the floor yelling for help. She was standing on the other side of the bed and ran around to my side. The aide, (CNA A) put her arms around my ribs and pulled me up off the floor and laid me on the edge of the bed, she was then able to get me the rest of the way into the bed. When asked if she was hurting once she was back in the bed, R 601, stated yes, my legs were hurting. R 601 added, this happened at about 6 AM in the morning. When they came at about 8 AM to give me my breakfast, and asked if I was alright, I told them I could not see them. That is when they said I needed to go to the hospital. The DON documentation of the incident and accident report involving R 601 on 5/24/22 was requested and reviewed on 7/7/22. According to the report on 5/24/22 at 6:30 AM R 601 was getting changed by CNA A and while being repositioned R 601 lost her grasp and started to roll and CNA A intercepted to prevent R 610 from falling. R 610 was observed with a scrape on her knee. The PA (physician assistant) E assessed R 601 on 5/24/22 at 9 AM and observed a change in mental status and blurry vision, and ordered the resident be sent to the hospital. The surveyor conducted an interview with CNA A on 7/7/22 at 3:39 PM, when asked to provide the surveyor with the details of the fall involving R 601 on 5/24/22, CNA A stated she went to change the brief of R 601 in the morning after working the midnight shift. CNA A told the resident to roll over and she said ok. R 601 gripped her hand on the nightstand for support. I went to the back of her and removed the brief, the resident's hand then slipped off the table. I had to get the remote control and let the bed all the way down, with my right hand on the remote and my left hand on her back I was able to stop her from falling. The surveyor questioned if the resident ever fell out the bed. CNA A stated, no the resident never fell out the bed on the floor. A review of the CNA skill training courses received by CNA A was conducted on 7/7/22 at 4:00 PM. The review revealed training courses focused on resident bed mobility and repositioning were received by CNA A during the following years: 2018- 2022. CNA A received a grade of passing each year. According to the training records, on 5-25-22, CNA A received a one-to-one training on bed repositioning. An interview was conducted with the Inservice Director D on 7/7/22 at 4:05 PM. When questioned about CNA training related to repositioning and turning residents in bed, Inservice Director D stated, the importance of not turning residents so far away from you that you are not able to control both sides of the resident (during 1-person repositioning) to prevent them from rolling out of bed was emphasized during training. A review of the hospital discharge summary report dated 5/27/22 indicated the reason for hospitalization was a mechanical fall, R 610 rolled out of bed while an aide at her nursing home was helping her change position. According to the summary R 601 was found to have a catalog of injuries to include R lower extremity soleus (leg muscle found on the back of the leg) hematoma (pool of mostly clotted blood), Closed left distal femur (thigh bone) fracture, Closed right upper tibia (leg bone) fracture, Closed right fibular (leg bone) fracture, Closed right distal (lower) tibia (leg bone) fracture, Right ribs 7-8 possible fractures. A review was conducted on 7/7/22 of a document entitled Fall Management with a last revision date of 7/14/21. Fall is defined as unintentionally come to rest on the ground, floor, or other lower level but not as a result of an overwhelming force (e.g., guest/ resident pushes another guest/resident).

This Citation pertains to intake MI 964 and MI 056. Based on observation, interview and record review, the facility failed to provide adequate supervision and proper positioning during ADL (Activities of Daily Living) care, transfers, and while sitting in a assistive device for three (R300, R301, R302) of three sampled Residents reviewed for falls and safety, resulting in a fractured toe, fall out of bed, pain and potential for continued serious harm or injury. Findings include: Resident #301 In an observation on 4/22/22 at 10:59 a.m., Resident #301 (R301) laid on the bed positioned on the right side (close to edge) and Certified Nursing Assistant (CNA) H provided incontinent care for R301. CNA H exited the room to dispose of bags of linen and trash. R301 remained positioned on right side and with the bed elevated without any staff present. R301 held the inside of a bedside stand. In an observation on 4/22/22 at 11:01 a.m., CNA H entered R301's room and completed incontinent care. R301 remained on the edge of the right side of the bed. In an interview on 4/22/22 at 11:07 a.m., CNA H reported she does not normally leave a resident in that position (edge of bed and bed elevated) when she leaves the room. CNA H reported the resident should be put in the center of the bed and the bed should be lowered. Review of an Admission Record revealed, R301 admitted to the facility with pertinent diagnosis which included Muscle Weakness and Polyosteoarrthritis (damage to cartilage). Review of a Minimum Data Set (MDS) assessment, with a reference date of 2/20/22 revealed R301 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15. R301 required extensive assistance of one staff member with ADL care. Resident #300 Review of an Admission Record revealed, R300 admitted to the facility with pertinent diagnosis which included Sprain of Ligament of Right Ankle, Muscle Weakness, and Anxiety. Review of a Minimum Data Set (MDS) assessment, with a reference date of 3/27/22 revealed R300 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15. R300 required extensive assistance of two staff members with bed mobility and transfers. Review of a Progress Note with a date of 3/27/22 at 4:19 p.m. revealed, called to room by CNA, observed face down at bedside on the floor . stated she was receiving incont (incontinent) care and when the CNA rolled her over, she fell OOB (Out of Bed) and landed on her hands and knees and lowered herself on her stomach . Resident assisted back to bed and stated he LLE (Lower Left Extremity) her (hurt). Writer observed a large red area, and it was raised and tender .Resident called writer back to room and state BLE (Bilateral Lower Extremities) hurt along with knees and lower back . Review of a Incident and Accident Report with a date of 3/27/22 revealed, R300 was rolled out of bed while receiving peri care for incontinence. Describe the nature of the Accident/Incident and if injuries sustained, location of injuries: Resident receiving incont care - Cna Rolled her OOB, Resident landed on all fours- hands and knees, face down. CENA Assigned: CNA F . In an interview on 4/22/22 at 2:28 p.m., CNA F reported she gave R300 a complete bed change. CNA F reported she crossed R300's legs to the right side of the bed and rolled resident over. CNA F reported R300 reached to the right side and R300's legs started to fall out of bed. CNA F stood on the opposite side of the bed. CNA F reported she then lowered the resident to the floor and got the nurse to assist R300 back to bed. In an interview on 4/22/22 at 2:47 p.m., Licensed Practical Nurse (LPN) E reported CNA F told her that R300 rolled out of bed when she rolled her over. LPN E reported R300 laid on the floor against a recliner the right side when she entered the room. R300 complained of pain in both lower legs and had a red area on the shin. LPN E reported R300 complained of pain for a few days after the fall. Resident #302 Review of a Progress Notes with a date of 4/19/22 at 12:03 a.m., revealed pt (patient) daughter brought to attention on writer that pt L (left) foot had a deep cut on ring toe, quite a bit of blood on a dressing that someone put on it and sock had blood on it. writer asked aid since day shift nurse had left for the day. afternoon aid stated day shift aid had put pt in gerry chair and foot got caught in chair when opening it . daughter took pt to the urgent care to see if toe needs stiches. In an observation and interview on 4/22/22 at 2:06 p.m., R302 laid in bed. R302 unable to answer, regarding how the left toe was injured. In an observation and interview on 4/22/22 at 2:08 p.m., CNA G reported R302 requires total assistance for ADL care. CNA G reported R302 required a gait belt for transfers. CNA G reported R302 could not stand without assistance and stated, She is light as a feather. R302's left foot was wrapped with a dressing. CNA G reported she was R302's assigned CNA the day of the incident. CNA G reported R302 was transferred to a Geri chair after receiving a shower. After lunch R302's leg was between the middle of the chair (where the chair opens and closes). CNA G put R302 in bed and noticed the left foot was bleeding. CNA G then reported the bleeding to Unit Manager C. Review of a Incident and Accident Report with a date of 4/18/22 revealed, R302 had a skin tear to the left 4th toe. Describe the nature of the Accident/Incident and if injuries sustained, location of injuries: Skin Tear L (left) 4th Toe. CNA providing resident care, upon transfer and propping foot on bed, Bleeding Noted on left 4th Toe. CENA Assigned: CNA G . Review of a After Visit Summary from an emergency room visit with a date of 4/18/22 revealed, R302 had a diagnosis Open fracture of phalanx of left fourth toe and Laceration of fourth toe of left foot. Review of an eInteract SBAR Summary for Providers with a date of 4/19/22 at 7:48 a.m. revealed, . left 3rd toes bleeding, daughter in facility to visit, requested to take mother to urgent care for evaluation, approx. 4 stiches required to close laceration and X-ray of foot completed=positive for fracture of left 3rd toe . In an interview on 4/22/22 at 2:59 p.m., Unit Manager (UM) C reported CNA G told her that while transferring R302 to bed blood was noticed on the left foot. UM C reported the incident occurred around 1pm. UM C reported R302 should be a two person assist with transfers. In an interview on 4/22/22 at 3:23 p.m., Director of Nursing (DON) B reported R302 required one person assistance with a gait belt for transfers. DON B reported CNA G said she sat R302 up in the Geri chair and R302 stated, Ouch. CNA G told DON B she saw blood when she put R302 back in bed. In an interview on 4/22/22 at 3:32 p.m., DON B reported R300 was rolled out of bed during care by CNA F. DON B reported CNA F received a verbal education to ensure residents are in the middle of the bed before repositioning. In an interview on 4/22/22 at 3:51 p.m., DON B reported a resident should not be left unattended with the bed elevated and laying close to the edge of the bed. DON B reported the resident should be positioned appropriately before staff exits the room. Review of a Routine Guest/Resident Care policy with a revised date of 6/16/21 revealed, . Guidelines . 10. Staff members should observe the following safety precautions with all guests/residents: a. Equipment with wheels (beds, wheelchairs, and other equipment) should be in the locked position when not moving. b. Beds may be raised when care is being provided. Following the provision of care the bed should be returned to the original position . Review of a Fall Management policy with a revised date of 7/14/23 revealed, The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls . Fall refers to unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force . If a guest/resident rolled off a bed or mattress that was close to the floor, this is considered a fall .

This citation pertains to intakes MI 590 and MI 591. Based on observation, interview and record review the facility failed to: 1) ensure residents were free from staff to resident physical abuse for one Resident (#75) and 2) ensure residents received appropriate care and services related to resident calls for assistance for one Resident (#280) of two Residents reviewed for abuse and neglect. This deficient practice resulted in actual pain and persistent feelings of fear and anxiety for Resident #75 and the potential for feelings of helplessness and humiliation for Resident #280. Findings include: Resident #75 Resident #75 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #75's most recent Minimum Data Set (MDS) Assessment, dated 2/19/2022, revealed Resident #75 required extensive, two-person assistance with toilet use and personal hygiene, and was totally dependent upon staff for bathing. Further review of Resident #75's MDS Assessment revealed the Resident scored 15 out of 15 (15/15) on the Brief Interview for Mental Status (BIMS), indicating Resident #75 had fully intact cognition. A review of the complaint details filed with the State Agency (SA) on 2/20/2022 at 5:22 p.m., revealed an allegation Resident #75 became emotional and distraught during a transport on 2/19/2022 and reported to emergency medical services (EMS) a facility staff member had inserted a finger into Resident #75's rectum repeatedly. During an interview on 4/6/2022 at 9:03 a.m., Resident #75 reported an incident occurred in which a Certified Nurse Aide (CNA) inserted a finger into Resident #75's rectum. Resident #75 stated she was unsure of the CNA's name because the CNA was sent from a staffing agency. Resident #75 reported during incontinence care she was placed on her side by the CNA and while cleaning the resident, the CNA had inserted a finger into the Resident's rectum repeatedly. Resident #75 stated she told the CNA, Please stop! You're hurting me! Resident #75 reported the CNA did not stop but continued. Resident #75 became tearful as she described feeling as though the CNA was attempting to clean inside her rectum. Resident #75 stated she had to hit the CNAs arm to get her to stop hurting her. When asked if she reported the incident to anyone, Resident #75 stated she reported to Social Worker (SW) G on the day of the incident and to staff at the [CONDITION(S)] center and EMS personnel during transport to [CONDITION(S)] the next day. Resident #75 reported staff at the [CONDITION(S)] center reported the allegation to law enforcement. Resident #75 was tearful and breathing rapidly while recalling the incident and stated she was now afraid to call for assistance while agency staff were working on her unit. When asked if she sustained an injury from the incident, Resident #75 reported she continued to have pain with bowel movements for one week after the incident, stating it felt like I was passing broken glass. Resident #75 reported she continued to be anxious and fearful the incident may happen again. Resident #75 stated the Director of Nursing asked her about the incident a couple of days later, but did not complete a physical assessment of the resident after the incident was reported to the facility. During an interview on 4/6/2022 at 9:16 a.m., Emergency Medical Technician (EMT) N confirmed the information included in the complaint intake received by the SA on 2/20/2022. EMT N reported during transport to the facility from the [CONDITION(S)] center Resident #75 became very upset about returning to the facility. EMT N stated Resident #75 reported she spoke to law enforcement after reporting to staff at the [CONDITION(S)] center of an incident occurring on 2/18/2022 when a CNA inserted a finger inside Resident #75's rectum multiple times, causing pain. On 4/6/2022 at 9:19 a.m., the DON presented the investigation file for the incident involving Resident #75. A review of an Incident and Accident Investigation Form, signed and dated by the DON on 2/25/2022. The DON stated the document included the entire investigation into the alleged event reported by Resident #75. A review of the form revealed the following, in part: Alleged Incident: Date 2/18/22, Time 12:30 p.m. (Resident #75) . Resident alleges that on Friday afternoon she was being changed and the aide stuck her finger in her rectum, and she told her to go away. The resident informed her [CONDITION(S)] nurse who called the police department. Reporting: Under what circumstances did the reporting person become aware of the incident? LPN (Licensed Practical Nurse S) was informed by the police. Date: 2/19/2022, Time: 1 p.m. Investigation: Was the site of the alleged incident examined? Yes. Site Examined: (Resident #75's room number). Further review of the investigation form revealed no documentation of a physical assessment of Resident #75. A review of the attached, Quality Assurance Interview Summary/Summary of Resident Interview, revealed the DON interviewed the resident on 2/21/2022, three days after the incident was reported. Further review revealed Resident #75 stated to the DON a CNA was cleaning her up from having a bowel movement, then she started messing with my rectum. I told her to stop and swung at her. A review of staff interviews revealed the following, in part: Name of Staff Member Interviewed: (CNA T), Date of Interview: 2/21/2022 - . did not take care of resident . Name of Staff Member Interviewed: (CNA R), Date of Interview: 2/21/2022: Position/Title: CENA (Agency) - The resident kept having loose stool. The resident bottom was sore and red. While cleaning her up and wiping her she yelled at me to stop then refused any further care. I never touched her rectum with my finger . Name of Staff Member Interviewed: Social Worker (SW G), Date of Interview 2/18/2022 - Resident stated that she was getting changed and that it felt like the aide was wiping hard. It felt like she was wiping with glass. It was noted the DON's interview with SW G occurred on 2/18/2022, the day the incident occurred. On 4/6/2022 at 2:04 p.m., the Nursing Home Administrator reported the facility did not keep files or contact information for agency staff. No contact information for CNA R was including with the incident investigation documents. During an interview on 4/12/2022 at 8:40 a.m., the DON reported CNA R admitted she wiped too rough while providing incontinence care to Resident #75 on 2/18/2022. The DON stated CNA R scratched the resident and denied inserting a finger into Resident #75's rectum. The DON stated she would expect all care staff to listen to residents and CNA R should have stopped what she was doing when Resident #75 asked her to. A review of Resident #75's electronic medical record (EMR) with the DON revealed no documentation of a physical assessment of Resident #75 regarding the alleged event on 2/18/2022. Further review of Resident #75's EMR revealed no documentation of a psychological evaluation of Resident #75 regarding the incident. In addition, Resident #75's EMR revealed no documentation of the Resident's physician being notified of the allegation. During an interview on 4/12/2022 at 10:05 a.m., Social Worker (SW) G stated Resident #75 reported to her on 2/18/2022 she was hurt by a CNA during care delivery. SW G stated during the conversation, Resident #75 reported a CNA was cleaning her buttocks and she felt the CNA digging in her rectum. SW G reported Resident #75 was very upset when speaking of the incident. SW G stated she did not assess the resident at that time because she immediately left to alert the DON of the allegation. SW G began shaking her head stating, as soon as she started talking about the incident, I knew it was not my concern. SW G reported she did not speak to Resident #75 about the incident since reported. During an interview on 4/12/2022 at 10:11 a.m., the NHA stated she was aware Resident #75 reported a CNA inserted a finger into her rectum during incontinence care on 2/18/2022. The NHA confirmed the agency CNA R worked for was asked not to send her back to work at the facility following the incident. The NHA reported CNA R had extremely long fingernails and that was believed to be the cause of Resident #75's pain when being cleaned up by CNA R on 2/18/2022. A review of the facility policy titled, Abuse Prohibition Policy, revised 11/2017, revealed the following, in part: Each resident shall be free from abuse, neglect, mistreatment . Definitions: Abuse means the willful infliction of injury . with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Resident #280 Review of Resident #280's face sheet revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #280 had a score of 15/15 on the BIMS assessment, which indicated Resident #280 was cognitively intact. Resident #280 was designated as his own responsible party. Review of Resident #280's facility summary of investigation, provided by the NHA via email, revealed, At 8:00 a.m. on 10/12/21, the facility administrator was called down to [facility hall]. Staff members [CNA UU] and [LPN VV] met with the Administrator and explained that [Resident #280] was found that morning to be in BM [bowel movement] from his chest down to his knees. Per staff it had taken almost an hour to clean him up and get him comfortable. I interviewed the resident [#280] and he stated he was cleaned up around 11:00 p.m on 10/11/21 and he needed assistance again in the early morning hours around 2:00 a.m. He stated the CNA [unnamed] came into his room, and he asked for staff to change him, but staff did not change him. He had another bowel movement around 6-6:30 a.m., and that's when the day shift came on to clean him, which was around 7:15 a.m. The Administrator further noted in their investigation summary LPN WW was interviewed (by the unit manager) and observed Resident #280 in his bed crying, with BM covering his body from his chest to knees. Resident #280 told LPN WW the night CNA [unnamed] refused to change him, LPN VV was also interviewed and reported Resident #280 was observed in bed crying, from BM from his chest to his knees. CNA UU reported during their interview Resident #280 was observed upset and crying during their morning rounds and had BM on most of his body, and reported the midnight CNA had refused to change him. CNA XX had told CNA UU when they arrived she would assist CNA UU to clean Resident #280 up but CNA UU was not made aware at that time Resident #280 had been in stool almost all of night, and was not assisted to clean up by CNA XX for an extended time period. CNA UU saw Resident #280 had wipes on his table, and was trying to clean himself up. The midnight nurse was questioned and reported they told CNA XX to clean up the resident in the night and early morning but was not aware if they done this. The NHA suspended CNA XX (who was asked to leave the facility at that time) pending investigation results. The investigation process by the NHA substantiated neglect, a form of abuse, and CNA XX was terminated. Surveyor was unable to interview Resident #280, as he had since passed away per facility staff. A Quality Assurance Interview Summary report, dated 10/12/21, provided by the NHA via email on 4/12/22, revealed Resident #280's interview, as follows: I had a BM and I was crying for staff to help change me. Staff came in (CNA XX] and she did not change me. I continued to [sic] crying and asked for help until day shift staff came to help change me and clean me up from BM. During an interview on 4/07/22 at approximately 2:13 p.m., LPN WW, who identified themself as the wound care nurse, was asked about the incident with Resident #280 and CNA XX. LPN WW reported when they went into Resident #280's room on 4/12/22 (in the morning), he was covered in BM from head to toe. LPN WW explained he was upset, and had cancer, with a cancer tumor around his spinal cord released surgically. They reported this was not good [the BM on his back], as it could have caused an infection. LPN WW reported CNA XX definitaly neglected Resident #280. LPN WW confirmed the employee, CNA XX, was terminated. LPN WW reported no negative outcome physically or psychologically after the occurrence. Review of the Electronic Medical Record (EMR) confirmed no outcome was found. During a phone interview on 4/08/22 at 5:06 p.m., CNA UU was asked about the incident. CNA UU reported, [Resident #280] was covered in poop. He had been that way for quite a while; he said all night. Then reported CNA XX said to them, 'It takes a team to clean him up.' CNA UU did not know what CNA XX meant by this, as they did not offer to assist cleaning Resident #280 after the BM, and remained sitting in the nursing area. CNA UU reported Resident #280 could only roll side to side for bed mobility, and was fully dependent for transfers, and only with therapy, and was otherwise dependent for activities of daily living (such as bathing, dressing, etc.). CNA XX added, [Resident #280] was in his right mind and told us how long he was sitting there like that, throughout the night. He said he kept putting on his call light and he kept telling them and they would say they would be right back. It [the stool] was dried from head to his back. He had a surgical wound, an open wound on his butt and he in his room trying to clean himself, and he was embarrassed and was crying. I was upset too. He did have a surgical wound on his back .He was able to be cared for and cleaned up by one person . CNA UU reported CNA XX's work performance was not good and said she had no compassion. CNA UU reported CNA XX was immediately removed from work and did not return. CNA UU reported Resident #280 was distressed the day of the occurrence, but after he was cleaned up he was smiling and had no [MEDICATION(S)] psychosocial effects per CNA UU. During an interview on 4/12/22 at 10:00 a.m., LPN VV reported, During shift change after report, I told CNA UU to go down and check [Resident #280] and [CNA UU] came back to me and said, You need to come down [to Resident #280's room]. He [Resident #280] was sitting in his BM, in tears, and he was covered in BM. It was on his hands and he was trying to clean himself up, and he had limited mobility. It was horrifying, and it brings me to tears now. He wasn't screaming, and he said he needed help since 3:00 a.m . He told LPN VV he had asked for help and no one would help him get cleaned up. She reported it took an hour to clean him up as he was a Hoyer lift for transfers and the stool was dry. LPN VV reported he had [CONDITION(S)] wounds on his back from cancer treatments, which made it [the clean-up] an unpleasant experience. which was a concern as well as they had to carefully clean these fragile skin areas which were raw but reported there was no change in the wounds after. Resident #280 thanked her profusely for the assistance. LPN VV explained he was tearful and apologetic at that time but soon after was happy and back to his old self. LPN VV confirmed the aide was CNA XX, and explained she was just sitting there at shift change and then left, and gave no information that Resident #280 was in distress or how severely he needed changing. LPN VV reported CNA XX had a negative attitude and sometimes questioned if they were completing the morning cares with residents, but it was nothing they could prove. During an interview on 4/12/22 at 11:00 a.m., the NHA reported they arrived at the facility on 10/12/21 at the time of the occurrence. They were doing morning rounds and staff reported, You have to see this. Staff summoned her down to Resident #280's room. The NHA reported how Resident #280 was left caused her much concern as he was covered in feces and on his hands he was trying to get into his wipes, and he said, The aide has not changed me. She left the room for staff to clean him up. The alleged aide was sitting at the nurses station earlier, and did not assist to clean Resident #280 up, or fully report the concern. The NHA confirmed during the investigation process they called CNA XX, who reported before any questions were asked, they told the oncoming CNA that Resident #280 would need a shower of sorts; because he was so messy. And then confirmed Resident #280 had a BM, and did need cleaning up when they left. The NHA confirmed they substantiated neglect and terminated the employment of CNA XX, who did not return to work after the incident. The NHA reported there was no psychosocial effect from the incident after the event itself, which was noted in their investigation summary as well. Review of the policy, Abuse Prohibition Policy, provided by the NHA via email on 4/05/22, revealed, Each resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation .To ensure residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor resident care and treatment on an on-going basis. It is the responsibility of staff to provide a safe environment for the residents .Neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .

Based on observation, interview and record review, the facility failed to prevent the development of pressure ulcers for one Resident (#23) of seven residents reviewed for pressure ulcers. This deficient practice resulted in harm when Resident #23 developed Stage 3 (full-thickness tissue loss) pressure ulcers and in the potential for delayed wound healing, infection and deterioration of condition. Findings include: A review of Resident #23's Minimum Data Set (MDS) Assessment, dated 1/06/2022, revealed the Resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #23's MDS Assessment revealed the Resident required extensive assistance with bed mobility and was totally dependent upon staff for toilet use and personal hygiene. Section M of the MDS Assessment revealed Resident #23 had one Stage 3 pressure ulcer, not present upon admission, and was at further risk for developing pressure ulcers. Resident #23 scored three out of 15 (3/15) on the Brief Interview for Mental Status, indicating severe cognitive impairment. An observation on 4/04/2022 at 2:11 p.m., revealed Resident #23 in bed, lying in a fetal position facing the right side of the bed. Resident #23's legs were contracted up toward the Resident's abdomen with his right and left knees pressed tightly against each other. No barrier was visible between Resident #23's knees. Further observation revealed Resident #23's right, lateral ankle was pressed against the bed and the Resident's left, medial ankle was resting directly on the bed. Resident #23 was observed wearing socks without pressure reducing devices on his feet at the time of the observation. A review of Resident #23's Skin & Wound Evaluation(s), for March and April 2022, provided by the Director of Nursing (DON), revealed the most recent Evaluation was dated 3/28/2022. Further review of Resident #23's Skin & Wound Evaluation, dated 3/28/2022, revealed the following, in part: Type: 15. Pressure, 15a. Stage 3: Full-thickness skin loss, 22. Location: Left lateral foot, 23. Acquired: 1. In-house Acquired, 24. How long has the wound been present? 2. Exact Date: 6/26/2021 . It was noted no other wounds were documented on Resident #23's Skin & Wound Evaluation(s) provided by the DON. A review of Resident #23's care plan revealed the following, in part: (Resident #23) is at risk for impaired skin integrity/pressure injury (related to): decreased cognition, incontinence, decreased independent mobility, left-side [CONDITION(S)], Date Initiated: 6/29/202. Goal: Minimize risk in an effort to reduce likelihood of pressure injury development through next review date. Interventions: Encourage to float heels while in bed and assist as needed, Date Initiated: 6/30/2020 . Position pillow between legs in bed, Date Initiated: 6/19/2021 . Turn/Reposition (Resident #23) per facility protocol and (as needed), Date Initiated: 6/30/2020. Further review of Resident #23's care plan revealed the following, in part: Alteration in skin integrity (as evidenced by) stage 3 to (left) lateral foot, dark area (left) fifth toe, (left) lateral foot resolved, Date Initiated: 6/26/2022, Date Revised: 4/06/2022. Goal: Area to heal without (signs and symptoms) of infections . Interventions: Position pillow between legs, Date Initiated: 7/06/2021 . Turn and reposition every two hours and (as needed) . ADL self-care performance deficit and requires assistance with ADLs and mobility (related to) weakness, cognitive impairment, contractures, Date Initiated: 6/29/2020 . Interventions: Bed Mobility - Resident requires total assistance of one person to reposition and turn in bed, Date initiated: 7/08/2020. An observation on 4/06/2022 at 8:35 a.m., revealed Resident #23 lying on his right side, in the fetal position with both knees contacted up toward the Resident's chest. A blue positioning wedge was positioned behind the Resident's mid-back. Further observation revealed Resident #23's knees to be in direct contact with each other with no barrier or pressure reducing device between Resident 23's knees. An observation on 4/06/2022 at 10:05 a.m., with Licensed Practical Nurse (LPN) A, revealed Resident #23 in bed lying on his right side, in a fetal position as previously observed by this Surveyor at 8:35 a.m. Resident #23's knees were pressed tightly together with no protective barrier in between the right and left knee. LPN A removed Resident #23's left sock, revealing a small adhesive bandage covering Resident 23's left fifth toe. LPN A removed the adhesive bandage revealing a Stage 3 pressure ulcer located at the lateral proximal phalanx (outside area of longest bone of the toe) of Resident #23's left fifth toe. The pressure ulcer on Resident #23's left, fifth toe was observed to be approximately one-half centimeter long and one-half centimeter wide (0.5 cm x 0.5 cm), with a pink wound bed. LPN A reported Resident #23 had no other wounds. When asked to observe the skin on Resident #23's buttocks, LPN A loosened the Resident's brief, revealing a four-inch by four-inch (4x4) nonadherent, gauze dressing located on Resident #23's coccyx (tailbone). The 4x4 gauze dressing was observed to be undated, loose and soiled with a dark brown substance. LPN A removed the 4x4 gauze dressing, revealing a Stage 3 (full-thickness tissue loss) pressure ulcer located on Resident #23's coccyx. The wound was observed to be an approximately one-half inch in length and one-quarter inch wide (0.5 in x 0.25 in) open crater with a pale wound bed. LPN A stated she was unaware of the wound on Resident #23's coccyx prior to the observation. A review of Resident #23's electronic medical record (EMR) with LPN A immediately following the observation, revealed no physician orders for care of Resident #23's coccyx wound. A review of Resident #23's skin assessments, wound care and progress notes with LPN A, revealed no documentation of the Resident's coccyx wound. During an interview on 4/6/2022 at 10:13 p.m., LPN WW reported to be the wound care nurse for the facility. When if Resident #23 had any pressure ulcers in addition to the Stage 3 pressure ulcer located on the Resident's left, fifth toe. When asked about preventative interventions to prevent pressure ulcers, LPN WW stated Resident #23's was care planned to have his heels floated while in bed. LPN WW reported Resident #23's feet and ankles should always be protected to prevent further skin breakdown. LPN WW reported Resident #23 had no wounds in addition to the Resident's left fifth toe wound. A review of Resident #23's weekly skin assessment and wound care notes with LPN WW at the time of the interview, revealed no documentation of the coccyx wound observed by this Surveyor and LPN A. LPN WW stated she was unaware of the Stage 3 pressure ulcer located on Resident #23's coccyx. LPN WW reported she did not place the 4x4 gauze dressing on Resident #23's coccyx wound. LPN WW stated when the wound was first discovered, nursing should have documented the wound in the Resident's EMR and informed the Resident's physician to obtain wound care orders. LPN WW confirmed there were no wound care order regarding the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/06/2022 at 10:30 a.m., the Director of Nursing reported the expectation for nursing care of wounds was for all skin abnormalities to be reported with weekly skin observations and shower skin observations. The DON stated any new wounds should be reported to the resident's physician for treatment initiation and reported to LPN WW. The DON confirmed a risk for worsening of wounds when appropriate treatment was not promptly initiated. A review of the facility policy titled, Skin Management, revised 7/14/2021, revealed the following, in part: It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Overview: Guest/residents with wound and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes. Practice Guidelines: 3. Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan . 5. The licensed nurse will initiate documentation in the electronic health record, which includes a description of the skin impairments . 9. The licensed nurse will monitor, evaluate and document changes regarding skin condition (to include dressing, surrounding skin, possible complications and pain) in the medical record . 11 . The CNAs will report any new skin impairment to the licensed nurse that is identified during daily care. 12. If a new area of skin impairment is identified, notify the guest/resident, responsible party, attending physician, DON/designee and treatment team, if applicable .

This citation pertains to intake MI 087. Based on interview and record review, the facility failed to provide safe, appropriate indwelling catheter care according to facility policy and professional standards of practice for four Residents (#228, #3, #78 and #100) of four Residents reviewed for catheter care. This deficient practice resulted in harm when Resident #228 was hospitalized for [CONDITION(S)] (a life-threatening, systemic infection) and in the potential for infection for Residents #3, #78 and #100. Findings include: Resident #228 Resident #228 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #228's most recent Minimum Data Set (MDS) Assessment, dated 12/23/2021, revealed Resident #228 had an indwelling, urinary catheter and required extensive assistance with toilet use (including management of the catheter). Further review of Resident #228's MDS Assessment, dated 12/23/2021, revealed Resident #228 scored 13 out of 15 (13/15) on the Brief Interview for Mental Status, indicating the Resident had intact cognition. A review of Resident #23's Emergency Department Note, dated 12/23/2022 at 12:39 p.m., revealed Resident #23 presented to the emergency department with a suprapubic catheter (indwelling-catheter inserted into the bladder through the abdominal wall) . worsening confusion and left sided abdominal pain. Further review of the note revealed the following, in part: Reports he had been having abdominal pain in his left side . On Tuesday (12/21/2021), he was seen y a (physician's assistant) at his care facility. Labs were ordered . demonstrated a WBC of 14.3 (normal level is 4.5 to 11) . NA (sodium) of 127 (normal level is 135 to 145) . A review of Resident #23's hospital History and Physical Note, dated 12/23/2021 at 4:16 p.m., revealed the following, in part: (Resident #228) . with (past medical history) of . [CONDITION(S)] . multiple (urinary tract infections caused by) urinary retention now the suprapubic catheter who is presenting with (left) flank pain, nausea, and (acute mental status) . was in his normal state of health until earlier this month . He has a SP (suprapubic) catheter, which usually gets changed on the 4th or 7th of every month . (Resident #228) noted he did not have his SP catheter changed and was overall not feeling well . eventually his SP catheter was changed on 12/21 (12/21/2021) . he developed significant (left) side flank pain and decreased (urinary output) in addition to nausea . Further review of Resident #23's hospital, History and Physical Note, dated 12/23/2021 at 4:16 p.m., revealed the following, in part: Assessment and Plan: (Resident #228) . multiple prior UTIs (caused by) urinary retention now with suprapubic catheter wo was admitted . with [CONDITION(S)] likely due to urinary source and [CONDITION(S)] (low sodium) . [CONDITION(S)]. Suspect Pyelonephritis. Patient presenting with slowly worsening (acute mental status), (left) flank pain, decreased (urinary output) in the setting of SP catheter exchange delay (of roughly two weeks). Meets [CONDITION(S)] criteria . highest suspicion is for pyelonephritis (kidney infection) . [CONDITION(S)] . High Priority Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Present on admission. 12/24/2021 Addendum: We're treating likely urosepsis (in setting of delayed exchange of (suprapubic catheter). A review of Resident #228's lab reports revealed the following: Blood Culture: Collected 12/23/2022 at 1:30 p.m., positive for infection, staphylococcus simulans. Urine culture: collected 12/23/2022 at 2:20 p.m., positive for infection, [CONDITION(S)] pneumoniae. Resident #228 remained hospitalized until expiring on 1/11/2022. A review of Resident #228's EMR revealed the following physician order: Change Suprapubic catheter size 16 (French), DX: Obstructive and Reflux [CONDITION(S)], every day shift starting on the 4th and ending on the 7th every month. Start Date: 12/04/2020 0700 (7:00 a.m.). During an interview on 4/12/2022 at 11:27 a.m., the DON reviewed the physician order to change Resident #228's suprapubic catheter on the 4th and ending on the 7th every month. The DON confirmed the order was for nursing staff to change Resident #228's suprapubic catheter one time between the 4th and 7th of each month. A review of Resident #228's Treatment Administration Records (TAR) for October 2021, November 2021 and December 2021, with the DON at the time of the interview, revealed nursing changed Resident #228's suprapubic catheter according to the order, as follows: October 2021: Catheter change documented on 10/4/2021, 10/5/2021. 10/6/2021 and 10/7/2021. November 2021: Catheter change documented on 11/6/2021 and 11/7/2021. December 2021: Catheter change documented on 12/5/2021 and 12/7/2021. The DON reported at the time of the record review, nursing misunderstood the order, dated 12/04/2020, to change Resident #228's catheter. The DON stated the catheter was changed too often according to the documentation and should have only been changed monthly, unless there was a documented reason to change the catheter more frequently. The DON stated nursing staff were expected to seek clarification from the physician if an order was unclear. The DON reported catheter changes should be documented in the Resident's progress notes to include an assessment of the Resident at the time of the catheter change. Further review of Resident #228's EMR with the DON, revealed the following physician order: Change SP (suprapubic) catheter one time only for 1 day. Start Date: 12/21/2021, 1045 (10:45 a.m.). A review of Resident #228's Encounter Note, dated 12/21/2021 at 5:04 p.m. and signed by Physician's Assistant (PA) FFF, revealed the following, in part: I was asked to see this resident for abdominal pain, as he points to left lower quadrant. He is also complaining of nausea and vomiting with emesis x2 last night . Discussion with (Family member [FM] GG) . Diagnosis, Assessment and Plan . suspecting constipation and possible bladder infection . change suprapubic catheter today . A review of Resident #228's December 2021 TAR, with the DON, revealed Resident #228's catheter was documented as changed on 12/21/2021 at 12:08 p.m. The DON reported she was unsure why Resident #228's catheter had been changed again on 12/21/2021 and confirmed there was no documentation regarding complications with the Resident's catheter on 12/21/2021 or to correspond with the catheter change, other than the Encounter Note, documented by PA FFF on 12/21/2021 at 5:04 p.m. The DON was asked to identify the staff members corresponding to each catheter change recorded on Resident #228's October 2022, November 2022 and December 2022 TARs. The DON was unsure at the time of the interview, which nurses had changed the Resident's catheter as recorded on Resident #228's TARs based upon each nurse's initialed completion of the catheter changes. The DON stated she would determine who had changed the Resident's catheter and provide the information to this Surveyor. No documentation was provided by the DON, prior to the end of the survey, to determine which facility nurses documented changing Resident #228's catheter on the Resident's October 2022 through December 2022 TARs. A review of Resident #228's EMR revealed no documented assessments of Resident #228 to correspond with each of the Resident's catheter changes recorded on the October 2022 through December 2021 TARs. A review of the facility policy titled, Suprapubic Catheter Care, reviewed 11/19/2021, revealed the following, in part: Introduction: A nurse should follow the practitioner's orders for care . Documentation: Document the characteristics and volume of the patient's urine output. Record the condition of the insertion site, the date and time of catheter dressing changes, the type of dressing you used, and the patient's tolerance of each procedure performed. A review of the Centers for Disease Control and Prevention's (CDCs) guideline titled, Catheter-Associated Urinary Tract Infections (CAUTI), revised 2/2017, revealed the following, in part: III. Proper Techniques for Urinary Catheter Maintenance: 111.E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Resident #3 Review of the Electronic Medical Record (EMR) face sheet and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 originally admitted to the facility on [DATE] and readmitted most recently 3/14/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 signifying intact cognition. During a room visit on 4/05/22 at 8:47 AM, Resident #3 stated she had an indwelling catheter which was leaking, and the staff had to change the dressings frequently. Resident #3 stated, I have had a lot of UTIs (Urinary Tract Infections). Resident #3 was sitting in her wheelchair and her catheter tubing was observed dragging on the floor. On 4/05/22 at 2:58 PM, Resident #3 was again sitting in her wheelchair and her catheter tubing, and the catheter privacy bag were both observed resting on the floor. On 4/06/22 at 1:30 PM, Resident #3 was in her room finishing up her meal. The catheter tubing was observed lying on the floor. The care plan for Resident #3 dated as initiated on 3/15/22 read in part: .is at risk for urinary tract infection and catheter-related trauma: has indwelling Catheter r/t (related to) [CONDITION(S)] bladder. The interventions for this care plan area of focus included: Ensure the catheter tubing is secured . Provide catheter care per policy. The nursing assessment for Resident #3 dated 4/9/22 indicated no catheter present. Another visit to Resident #3 on 4/11/22 at 1:14 PM revealed a catheter was still present. Physician orders for a super pubic catheter for Resident #3 also continued. Resident #78 Review of the EMR MDS assessment dated [DATE] revealed Resident #78 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The BMS reflected a score of 10 out of 15 signifying a moderate cognitive impairment. The physician orders dated 4/5/22 for Resident #78 included: - Foley Catheter for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - Ensure foley leg strap in place every shift and change on midnight shift and PRN (as needed). The nursing assessment for Resident #78 dated 4/7/22 included notation of an indwelling catheter. On 4/11/22 at 2:04 PM, the catheter tubing was observed dragging on the floor. Certified Nurse Aide (CNA EE) was present in Resident #78's room and observed the catheter tubing and said it should not be on the floor. Resident #100 Review of the EMR face sheet and MDS assessment dated [DATE] revealed Resident #100 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The BIMS reflected a score of 10 out of 15 signifying a moderate cognitive impairment. During a visit on 4/05/22 at 12:09 PM, Resident #100 stated he had a catheter at home for a year or so without any problems. The catheter tubing was observed with dark amber urine draining into a urinary drainage bag covered with a privacy bag lying on the floor. On 4/06/22 at 9:01 AM, the catheter tubing for Resident #100 again was observed resting on the floor. The urinary drainage bag was exposed and only partially covered with a privacy bag. Both the drainage bad and privacy bag had contact with the floor. CNA J observed the catheter tubing, drainage bag and privacy bag and said the bag and tubing should not be on the floor as it is an infection control problem. The EMR revealed a care plan for Resident #100 dated 3/6/22 which included: . is at risk for urinary tract infection and catheter-related trauma has indwelling Catheter r/t [CONDITION(S)] . Interventions for this focus included: Ensure catheter tubing is secured . Ensure the drainage bag is secured properly with a dignity cover in place . Provide catheter care per policy. The physician orders dated 3/30/22 for Resident #100 included: - Foley Catheter for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - Check foley catheter secure every shift and change on midnights as needed The facility suprapubic catheter care guidelines dated as reviewed 11/19/21, included: .secure the urine drainage bag to avoid contact with the floor .

This citation pertains to intake: MI 657 Based on interview and record review the facility failed to ensure that R#926 was free of chemical restraints, effecting one resident (R#926) of three residents reviewed for chemical restraints, resulting in R#926 being discharged to hospital for evaluation of lethargy(unresponsiveness) after receiving medication given without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Review of face sheet documented that R#926 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Nursing Progress Note dated 7/21/21 at 17:21 (5:21 PM), R#926 had intact cognition and was a one person assist with transfers and ambulation. During interview on 8/5/21 at 12:45 PM with Registered Nurse H, it was confirmed that R#926 was given [MEDICATION(S)] without an order and received [MEDICATION(S)] (antipsychotic) that was marked as not given on Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Registered Nurse H stated, It took three of us (staff) to get him back in the bed and he needed something to calm him down. Registered Nurse H confirmed R#926 had been sent to emergency room ER related to lethargy. Review of the Hospital Admission documentation dated 7/23/21 at 1:03 AM revealed, According to one nurse who works at (name of nursing home) (by telephone call today during night shift), patient was agitated and trying to pull his PEG tube out. A nurse gave the patient [MEDICATION(S)] without consent from a physician, unclear if IV/p.o. and what dose. When patients daughter went to see him today, his mental status was altered, and he was very sleepy with almost no response to stimuli. Review of the Hospital Discharge Summary dated 7/28/21 revealed, Patient arrived from (facility name), where he was given [MEDICATION(S)] for agitation, had also been recently started on a couple anti-psychotics for agitation. Reported he had not been receiving adequate tube feeds for several days with some malnutrition and dehydration likely contributing. On admission, patient noted to be A&OxO, with a baseline of A&Ox2-3. Suspect [CONDITION(S)] due to polypharmacy and malnutrition. Held any [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] over the course of admission. Tube feeds restarted with recommendations from nutrition consult. Patient's mental status improved on tube feeds, and discontinuing above meds. No episodes of agitation and mentation now at baseline . During interview on 8/4/21 at 10:30 AM with the Director of Nursing (DON) BB, it was confirmed that medications should not be administered without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON BB confirmed that residents should not be chemically restrained. DON BB confirmed that facility does not have a policy on chemical restraints. During interview on 8/4/21 at 12:30 PM with Physician G, it was confirmed that medications should not be given without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician G confirmed that R#926 had to be sent to ER for further evaluation due to lethargy. Physician G confirmed that [MEDICATION(S)] could make a resident become lethargic and it is not recommended in the geriatric population.

This citation pertains to intake: MI 657 Based on observations, interviews, and record reviews the facility failed to ensure that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: R#926 Review of Medication Error Report dated 7/22/21, documented that on 7/22/21 at 9:00 AM that R#926 was administered [MEDICATION(S)] (antihistamine) 25 milligrams. Description of error documented [MEDICATION(S)] given without order. Outcome to resident documented, Lethargic. Corrective Action documented, Sent to ER (emergency room ). Document was signed by Physician G, Director of Nursing BB and Administrator AA. Review of the Hospital Admission documentation dated 7/23/21 at 1:03 AM revealed, According to one nurse who works at (name of nursing home) (by telephone call today during night shift), patient was agitated and trying to pull his PEG tube out. A nurse gave the patient [MEDICATION(S)] without consent from a physician, unclear if IV/p.o. and what dose. When patients daughter went to see him today, his mental status was altered, and he was very sleepy with almost no response to stimuli. Review of the Hospital Discharge Summary dated 7/28/21 revealed, Patient arrived from (facility name), where he was given [MEDICATION(S)] for agitation, had also been recently started on a couple anti-psychotics for agitation. Reported he had not been receiving adequate tube feeds for several days with some malnutrition and dehydration likely contributing. On admission, patient noted to be A&OxO, with a baseline of A&Ox2-3. Suspect [CONDITION(S)] due to polypharmacy and malnutrition. Held any [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] over the course of admission. Tube feeds restarted with recommendations from nutrition consult. Patient's mental status improved on tube feeds, and discontinuing above meds. No episodes of agitation and mentation now at baseline . During interview on 8/4/21 at 10:30 AM with the Director of Nursing DON BB, it was confirmed that medications should not be administered without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 8/4/21 at 12:30 PM with Physician G, it was confirmed that medications should not be given without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician G confirmed that R#926 had to be sent to ER for further evaluation due to lethargy. During interview on 8/5/21 at 12:45 PM with Registered Nurse H, It was confirmed that R#926 was given [MEDICATION(S)] without an order and received [MEDICATION(S)] (antipsychotic) that was marked as not given on Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of face sheet documented that R#926 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Nursing Progress Note dated 7/21/21 at 17:21 (5:21 PM), R#926 had intact cognition and was a one person assist with transfers and ambulation. Review of Medication Administration policy dated 10/2019, it documented: .physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If a dose is inconsistent with the guest's/resident's age and condition or a medication order is inconsistent with the guest's/resident's current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Document the interaction with the physician in the progress notes and elsewhere in the medical record, as appropriate. Review of a Medication Management policy with a revised date of 10/2019 revealed, Medications are stored, dispensed and destroyed in a manner to ensure safety and conformance with state and federal laws . Guidelines . 3. Medications brought in by a guest/resident may not be used unless the medications are properly identified, packaged and correctly labeled . Resident #905 Review of a Resident Face Sheet revealed, Resident #905 admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Orthopnea (shortness of breath), and Chronic [CONDITION(S)]. Review of a Minimum Data Set (MDS) assessment, with a reference date of 6/9/21 revealed Resident #905 had minimal cognitive impairment with a Brief interview for Mental Status (BIMS) score of 11, out of a total possible score of 15. In an observation on 8/4/21 at 2:52 p.m., Resident #905 laid in bed. Resident #905 poured 5 ml (milliliters) of Robitussin Honey (cough syrup) in a medication cup and [MEDICATION(S)] inhaler sat on the bedside table. Resident #905 reported that was the last of the cough syrup and the inhaler is used every six hours. Review of Physicians orders revealed, Resident #905 did not have a current order for Robitussin or [MEDICATION(S)]. In an interview on 8/4/21 at 3:18 p.m., Licensed Practical Nurse (LPN) D reviewed Resident #905's MAR (Medication Administration Record) and confirmed Resident #905 had no order for Robitussin or [MEDICATION(S)]. In an observation and interview on 8/4/21 at 3:22 p.m., Resident #905 reported the inhaler came from the nurses the cart. Resident #905 then reporter family brought in the Robitussin. The label on the inhaler read [MEDICATION(S)] 2 puffs inhale every 6 hours as needed for wheezing with a ordered of 5/21/21. In an observation and interview on 8/4/21 at 3:23 p.m., Unit Manager (UM) E reported Resident #905 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER]

This citation pertains to intakes MI 521, MI 704, MI 526, MI 378. Based on interviews and record reviews the facility failed to ensure residents were safe during repositioning and transfers, in 3 of 3 residents (R#901, R#903, R#918) reviewed for safety and injuries, resulting in all three residents receiving injuries during care. Findings include: R#901 Review on 8/2/21 of R#901's face sheet revealed admission into the facility on [DATE] with diagnoses that included [CONDITION(S)], heart failure and muscle weakness. According to the Minimum Data Set (MDS) dated [DATE], R#901 had impaired cognition and was extensive assist with Activities of Daily Living (ADLS). Review of Incident and Accident Report documented R#901 had a fall on 7/11/21 at 10:45PM when a CNA (K) was providing care and the lower half of his body slid to the floor with the CNA holding his shoulders and head of his upper body. During interview on 8/3/21 at 3:10 PM with Certified Nursing Assistant (CNA) K, it was confirmed that R#901 was on the edge of bed facing away from CNA K during incontinence care. CNA K stated, When I went to get a towel, R#901 went to roll out of bed and I grabbed the gown, and it kept the resident from rolling completely onto floor. CNA K confirmed that the lower part of R#901's body did meet the floor. During interview on 8/5/21 at 2:45 PM with Staff Development Nurse (SDN) C, it was confirmed that residents should be repositioned in the middle of bed during care and the resident should be facing the staff member providing care. It was confirmed that if residents were in the middle of bed, they probably would not fall into floor. During interview on 8/5/21 at 3:15 PM with Director of Nursing (DON) BB it was confirmed that R#901 had been diagnosed with a fracture after the incident. It was confirmed that proper positioning in bed may have prevented a fall. Review of R#901's x-ray dated 7/12/21 at 9:15 AM revealed, CONCLUSION: Intact left hip arthroplasty, with an acute or recent appearing greater trochanteric fracture. R#118 Review of 8/5/21 revealed R#118 was admitted into the facility on [DATE] with diagnoses of [CONDITION(S)], right lower limb [CONDITION(S)] (inflammation of cells) and muscle weakness. According to the Minimum Data Set (MDS) dated [DATE], R#918 had intact cognition and was total dependence with ADLs and transfers. Review of Incident and Accident Report dated 12/18/20 documented that R#918 was lowered to the ground during transfer assisted by two staff using gait belts resulting in bleeding from a mole on leg. Review of Progress Notes dated 12/19/20 at 02:51 (2:51AM), documented the following: .at 2130 (9:30 PM) the resident (family memeber) came to pick her up and the CNA's went in to get her up and ready to go so as they were getting her up to put her in a wheelchair they had a gait belt around her, but as they were getting her up they said she was heavy and they decided to ease her to the floor and that is when they saw her right leg was bleeding from a mole she had on that leg . During interview on 8/5/21 at 3:20 PM with Director of Nursing (DON) BB it was confirmed that R#918 was a total assistance with transfers and staff transferring resident should have used a Hoyer lift to transfer patient to wheelchair. Review of a Transfer with a hydraulic lift policy with a reviewed date of 5/21/21 revealed, All mechanical lifts require two staff members be present. Always roll a resident toward you, or have another staff member on the other side of the bed, for safety . Using a hydraulic lift to raise an immobile patient from the supine (laying) to the sitting position allows safe, comfortable transfer from a bed to chair or other surface . it's better to have two staff members present during a transfer to stabilize and support the patient . Resident #903 Review of a Resident Face Sheet revealed, Resident #903 admitted to the facility with pertinent diagnosis which included [CONDITION(S)], Congestive Heart Failure and Muscle Weakness. Review of a Minimum Data Set (MDS) assessment, with a reference date of 6/9/21 revealed Resident #903 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 6, out of a total possible score of 15. Resident #903 required extensive assistance with transfers. Review of a Care Plan with an initiated date of 6/4/21 revealed focus, (Resident #903) has an ADL (Activities of Daily Living) Self Care Performance Deficit and requires assistance with ADL's . Interventions included . Transfer. Resident requires extensive assistance with transfers with two staff assistance . with an initiated of 6/16/21. Review of a Incident and Accident Report with a date of 6/23/21 at 7:30 p.m. for Resident #903 revealed, . Resident receiving care transferring to shower chair using lift to stand by CNA (Certified Nursing Assistant). Resident not participating getting up and help him slowly sit on the floor. Bruise to inner upper right arm and complain of pain 5/10 (pain scale) . Interventions implemented included Safety transfer resident to bed using gait belt and 2 person assist . Review of a Post Fall Evaluation with a date of 6/23/21 revealed, CNA re-educated for safety transfer. Review of a Progress Note with a date of 6/23/21 at 10:01 p.m. revealed, Resident receiving care transferring to shower chair. Resident not participating getting up and help him slowly sit on the floor. Complain pain to his upper arm. Resident seen by NP (Nurse Practitioner) and order an x-ray r/t (related to) moderate pain. Tylenol administered with the pain rate of 5/10 . Review of a Physician Progress Note with a date of 6/23/21 at 10:14 p.m. revealed, REASON FOR VISIT; Discharge Summary . Resident lowered to the ground by cna. Rubbed, pinched, his right inner arm on lift-to-stand equipment . In an interview on 8/5/21 at 9:26 a.m., Licensed Practical Nurse (LPN) A reported Resident #903 fell using the sit-to-stand (mechanical lift). LPN A then reported CNA B said she was going to transfer resident to the shower with the lift and had to lower Resident #903 to the floor. LPN A reported two staff are required to assist with the mechanical lift. In an interview on 8/5/21 at 9:35 a.m., Staff Development Nurse C reported mechanical lift transfers are two person assistance. Staff Development Nurse C then stated, No exceptions. In an interview on 8/5/21 at 9:32 a.m., CNA B reported she was transferring Resident#903 with the sit-to-stand and had to lower Resident #903 to the floor. In an interview on 8/5/21 at 9:53 a.m., Director of Nursing (DON) BB reported two people are required for sit-to-stand lift transfers. DON BB then reported CNA B received a verbal education on safety during transfers. DON BB reported Resident #903's care plan revealed two people were required with transfers. In an interview on 8/5/21 at 10:41 a.m., CNA B reported the nurse was not in the room during the transfer. CNA B reported she transferred Resident #903 without assistance and went to get the nurse after she lowered Resident #903 to the floor.

Based on observation, interview and record review, the facility failed to identify, assess and investigate multiple allegations of staff abuse and mistreatment verbalized by one (#107) of three sampled resident reviewed for abuse who was anxious, agitated, verbally and physically abusive with a [DIAGNOSES REDACTED].#107's multiple allegations of abuse and mistreatment were ignored, not investigated, and not reported to the state survey agency as required resulting in the potential for serious harm, injury or death. The immediate jeopardy was identified on 2/18/14. The administrator was notified on the IJ on 2/21/14 at 9:10 A.M. and a plan of correction to remove the IJ was requested at this time. The IJ was removed on 2/21/14 based on the provider's implementation of corrective actions on 2/21/14, as verified onsite on 2/21/14, during the completion of the extended survey. Although the IJ was removed, the deficient practice remained isolated at a potential for more than minimal harm that was not immediate jeopardy. Findings include: An interview during the entrance conference on 2/11/14 at 9:15 A.M. was conducted with the administrator. The administrator was asked if there were any facility investigations of allegations of abuse that were not reported to the state agency and stated, "No". A review of resident #107's clinical record on 2/13/14 at 11:00 A.M. revealed multiple allegations of abuse and mistreatment were documented in nursing and psychology progress notes that were voiced by Resident #107. Subsequent information obtained during the investigation process revealed the facility did not recognize or act on the resident's voiced concerns/allegations as abuse, neglect or mistreatment and attributed it the allegation as "behaviors" and symptoms of her mental illness. Resident #107 was not identified at "high risk" for being abused. A summary of the allegations voiced by the resident are as follows: Nursing progress notes from resident #107's admitted on 6/6/13 through 2/13/14 were reviewed and revealed no delusional ideations or aggressive behaviors displayed by the resident were documented from 6/6/13 through 8/9/13. Nursing progress notes (multiple entries) for 8/10/13 revealed that Resident #107 began rejecting care, refusing therapy, and refusing to eat. A nursing progress note entry from 8/17/13 documented that Resident #107 refused all care and medications and reported that a Certified Nursing Assistant (CNA) hit her with a television remote control unit. The note documented Resident #107 was "yelling at staff". On 8/25/13, Resident #107 began showing signs of distress and was crying out with episodes of "increased agitation". The CNA reported that Resident #107 was yelling and cursing. On 8/26/13, Resident #107 was verbally and physically abusive toward staff and resistant to care. On 8/27/13, Resident #107 verbalized that she "wanted a double edged razor blade to slit her wrist..." On 9/02/13, nursing progress notes from 9/2/13 documented five separate entries of behaviors displayed by Resident #107 (from approximately 4:15 pm to 8:30 pm) to include: yelling, hitting and kicking CNA; calling CNA derogatory names such as, "b*tch and n*gg*r"; throwing things; and calling 911. On this same date, at 19:23 (Military time--7:23 pm) it was documented that Resident #107 reported that a CNA hurt her fingers during care. A nursing progress note dated 11/13/13 documented that resident #107 had complained of her brief not being changed all morning. Resident was calling CNA's "dumb n*gg*rs", yelling, and using profanity. A nursing progress note dated 11/17/13 documented that Resident #107 was yelling at CNA's and stated, "They don't want to change me. They just leave." Multiple nursing progress note entries for 12/6/13 documented that Resident #107 was verbally abusive to staff and accused them of "lying" and "stealing". Resident #107 was described with episodes of increased anxiety with care, yelling out for help, and stated to a nurse that staff hate her and they don't want to take care of her. A psychology progress note dated 12/9/13, documented that Resident #107 reported "an aide came in her room yesterday and called her several derogatory names. Pt (patient) reports being shocked, surprised, and very upset over the incident...States that she will be okay as long as that 'aide' doesn't come in her room..." There was no nursing progress note regarding this allegation from Resident #107. A nursing progress note on 12/26/13 documented, "Resident had c/o (complained of) aide in her room today and made accusations against aide...Writer did not witness or hear any of the claims made against aide..." There was no documentation regarding the specific allegations that were made by Resident #107 recorded in the clinical record. There were multiple nursing progress note entries on 1/9/14 that documented Resident #107 was verbally abusive toward staff, specifically a pregnant CNA. It was documented Resident #107 stated to the pregnant CNA, "I hope your baby is born deformed and you're going to be a horrible mother". Resident #107 also requested a new CNA, was refusing care, screaming, calling the CNAs "ignorant black ladies", mouthing the words "I hate you" to the CNA; reported they were hurting her; and stated "I want to die". Further review of Resident #107's clinical record revealed that Resident #107 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly minimum data set ((MDS) dated [DATE] documented that resident #107 had moderately impaired cognition, was verbal aggression toward others, and rejected care. The resident required limited to total physical assistance from staff for completion of activities of daily living. The facility's policy and procedure titled "Abuse Prohibition Policy" with a revision date of 9/2013 was reviewed on 2/13/14 at 2:00 P.M. and documented that "...Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies, physician, families, and/or representative..." The policy further documented that "...Staff members, volunteers, family members, and others should be encouraged to report incidents of abuse and suspected abuse..." An interview was conducted with the abuse coordinator on 2/14/14 at 8:50 A.M. regarding the multiple allegations of abuse and mistreatment voiced by Resident #107 that were documented in the clinical record. The abuse coordinator stated the allegation, dated 9/02/13 was investigated by the facility; however, was not reported to the state agency. When queried about why other allegations of abuse and mistreatment voiced by Resident #107 were not reported or investigated, the abuse coordinator stated that Resident #107 had a [DIAGNOSES REDACTED]. The Abuse Coordinated also reported that Resident #107 often made false accusations against staff. When further questioned about how the facility determined which allegations were false, the abuse coordinator reported that two staff members were assigned to be in the resident's room at the same time during provision of care and when Resident #107's behaviors had escalated, they involved psychiatric services and Resident #107 was sometimes sent out to the hospital for evaluation. The Abuse Coordinator did not acknowledge or identify that Resident #107 was at "high risk" for abuse and mistreatment due to her verbally and physically aggressive behaviors toward staff or that all allegations of abuse or mistreatment should be investigated and reported. The facility did not have evidence that the alleged events reported by Resident #107 on 8/17/13, 11/13/13, 11/17/13, 12/6/13, 12/9/13, 12/26/13, and 1/9/14 were investigated by the facility and reported to the state agency. On 2/14/14 at 1:55 pm, the abuse coordinator was further interviewed regarding the "Abuse Prohibition Policy" and when the facility would report allegations of resident abuse to the state agency. The abuse coordinator stated that if abuse was suspected or substantiated it would be reported. The abuse coordinator was queried about the difference between the regulation that documents "The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse...are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including the State survey and certification agency)..." and the facility's policy which documented only suspected and substantiated abuse was investigated and reported to the state agency. The abuse coordinator stated, "We should follow the state guidelines. It should say alleged." The abuse coordinator also stated "we encourage staff to report everything", but did not state it was required. An interview was conducted with the administrator at 2:05 P.M. on 2/14/14 regarding the facility's abuse policy and the difference between suspected abuse and alleged abuse. The administrator stated, "It does mean something different (suspected vs. alleged) and should say alleged." A transcript from a staff "Abuse and Neglect" training was reviewed on 2/14/14 at 9:30 A.M. This training was a computer-based training module required to be completed by all facility staff. The transcript revealed the following: "All residents are at risk of abuse and neglect, but some are at greater risk than others. Residents with a history of abusive relationships are at a high risk of abuse..." The facility submitted a plan of correction (POC) dated 2/21/14 that indicated: "(Name of Facility) submits the following Credible Allegation of Compliance outlining the measures it has completed to remove the findings of immediate jeopardy regarding the facility's alleged failure to identify, assess and investigate multiple allegations of staff abuse and mistreatment and report to the state agency. 1. Resident identified to be affected by the alleged deficient practice. Resident #107 resides at the facility. The resident was assessed by psych services on 2/21/14. The findings are 'Resident #107 is a [AGE] year old, white, divorced female. She denies hallucinations, but tends to have suspicious and paranoid thoughts at times. She has a history of [MEDICAL CONDITION] disorder and has extended or unresolved grief related to the loss of husband and daughter. She denies any mistreatment or abuse at this time.' 2. Residents with the potential to be affected by the alleged deficient practice. The administrative staff interviewed all interviewable residents in the facility to identify other residents with allegations of staff abuse and mistreatment. On 2/21/14 there were 83 resident identified to have the potential to be affected. 82 of 83 were interviewed; (one resident was out at an appointment) by the facility social worker's and/or Minimum Data Set (MDS) nurse and there were no concerns of staff abuse, mistreatment, neglect and or misappropriation of property to report to the Nursing Home Administrator (NHA). 3. Systemic Measures 1. The Nursing Home Administrator was in-serviced by the Regional Clinical Coordinator on the Abuse Prohibition Policy and on the importance of reporting allegations to the state agency in accordance with federal guidelines. The NHA will report all allegations of abuse to the state agency by completing the Bureau Health Care Services - Long Term Care (BHS)-362 and BHS-363 in accordance with the state guidelines beginning 2/21/14 and in accordance with the facility Abuse Policy and Procedure. The NHA was educated by the Regional Clinical Coordinator on the Elder Justice Act on 2/21/14 and the NHA acknowledged understanding of reporting in accordance with the Elder Justice Act. 2. The facility policy on Abuse Prohibition was reviewed by the NHA and revised on 2/21/14. In-servicing began on 2/21/14 on the Abuse Prohibition Policy and on the importance of immediately reporting all allegations of abuse neglect and misappropriation of property to the Nursing Home Administrator immediately. There was 58 facility staff members our of 168 that was been in-serviced as of 2/21/14. The remaining facility staff will be re in-serviced on the Abuse Prohibition Policy prior to the start of their next shift beginning 2/21/14. Sixteen members of the contracted therapy staff were educated on the Abuse Policy and Procedure. All newly hired staff will be in-serviced on the Abuse Prohibition Policy and on the importance of reporting allegations of abuse neglect and misappropriation of property upon hire beginning on 2/21/14 by Staff Development director or designee. 4. Quality Assurance The administrative nurses will interview 10 percent (%) the residents weekly for 4 weeks, monthly times 2 months for allegations of staff abuse and mistreatment. All concerns will be investigated immediately and reported in accordance with federal guidelines. Findings will be reported to QA monthly for 3 months for recommendations. 5. The NHA is responsible for sustained compliance." ( , , , )