Every finding on record at Regency at Jackson

Based on observations and interviews the facility failed to effectively 1) date all ready-to-eat food. 2) remove expired food. 3) effectively clean equipment potentially affecting all residents who resided in the facility and received food from the kitchen.Findings Include; During initial walk through on 06/02/2026 at 8:44 AM, it was noted that there were spices that were not dated when they were opened, no date when they expired. Chicken seasoning, black pepper, Dietary Manager V stated they came in on 05/24/26 so she wrote that date on the 2 containers, but no open date or expiration date. Observation of 6- 16oz bags of On-Top whipped topping with no receive dates or expirations dates. Angel food cake dated 05/01/26, unopened, expired 06/01/2026 and was not discarded. Observation of a large zip locked bag of Bacon- 5 pounds- dated 05/24/26, however the package was wide open, not sealed shut, and edges of the bacon were drying out.Dietary Manager V threw away the items of concern at the time of the observations. The Volcan double oven needed cleaning due to debris on the drip sheet/cookie sheet laying in the bottom of the top oven to catch grease and droppings. Dietary Manager V was asked how often they clean the kitchen equipment and kitchen overall, Dietary Manager V stated they try to do it weekly. Writer asked if they had a cleaning calendar written out on what equipment gets cleaned when? Dietary Manager V stated she saw an electronic calendar on her computer but couldn't pull it up, so she had to make a new one.Observation of the Dish machine low temp log was not checked on 06/01/26 for none of the 3 shifts. Was checked 1st shift on 06/02/2026.During an observation and interview on 06/03/2026 at 3:00 PM, writer noted the large six section steam table, with 6 shafting dishes/6 pans that sit down into the steaming table with covers. Observed edge of the steam table at the lip where the shafting rested on it, was dirty with buildup and stained. The bottom of the steam table had visible dark substance buildup, floating elements and stained. Dietary Manager V stated they change the water daily but didn't have a log or document to showing that changing the water or cleaning was being done. Santi-bucket sitting by the sink half full to use on the clean and dirty tables. Dietary Manager V stated they change it often, when it appears dirty. During an observation and interview at 4:30 PM, a repairman had been called to come and look at the stand-up steamer, as it was not functioning properly. The repair man stated the door gasket and screws needed replaced. He stated if the probe isn't sitting down in the water in the base of the steamer, it will not work. He stated he cleaned out the bottom of the steamer, as there was an oily mixture and the probes would not detect water to start heating. Stated he cleaned the unit and stated it is safe to use. Writer observed the repair man instructing Dietary Manager V on how to clean this equipment moving forward and how often it needed to be cleaned.

Based on interview and record review the facility failed to ensure effective administration was in place that monitored the Infection Prevention Control Program (IPCP) and Antibiotic Stewardship Program (ASP), ensure the facility assessment was reassessed at the needed time, assured the required staff were in attendance at the Quality Assurance Performance Improvement (QAPI) meetings, ensure IPCP data was presented to QAPI every meeting, and review of the facility policies and procedures were performed yearly. Findings Included: Review of the facility Infection Prevention Program policy and procedure revealed that the policy had not been reviewed for any revisions needed since 2/28/2025. The policy revealed that, the facility establishes a program under which it:, investigates, identifies, prevents, reports, and controls infection and communicable diseases for all residents, staff, contractors, volunteers, visitors, and other who provide care and services to the residents on behalf of the facility. The policy revealed that the major activities of the IPCP were surveillance of infections with implementation of control measures and prevention of infections. In an interview on 6/05/2026 at 12:24 PM Director of Nursing (DON) B stated that when she started working as the DON in February of 2026 there was no ICP and no IPCP in place. DON B said there was no IPCP documentation for the months of September, October, November, and December 2025, and also for the months of January, February, or March of 2026. Upon review of the IPCP binder with DON B for 2025 ICP revealed there was no documentation of infection control surveillance for the months of September, October, November, and December 2025. Additionally, the binder for 2026 was reviewed which revealed the months of January, February, and March also had no infection control surveillance documentation. Review of the Infection Prevention Program Overview policy and procedure that had not been revised since 2/28/2025 revealed under, DIVISION OF RESPONSIBILITIES FOR INFECTION PREVENTION ACITIVIES, The administrator is ultimacy responsible for the infection control program. The policy also revealed under Infection Prevention Committee, The Infection Prevention Committee meets on a regular basis as a component of the QAPI committee and provides input and direction for the infection prevention control program. The policy revealed that the QAPI committee recommended actions and control measures while monitoring data if needed, and reports from the IPCP were review and approved by the QAPI committee. Therefore, for the six months listed there was no functional IPCP or Antibiotic Stewardship Program (ASP), and no ongoing monitoring nor QAPI oversight of infections or antibiotic inappropriate usage in the facility for those six months of time. Review of the facility's facility assessment revealed the assessment was last performed on 8/1/2024 and went to 7/31/2025. In an interview on 6/05/2026 2:16 PM Administrator A stated yes that the facility assessment should have been performed at some point from September 2025 to present due to there being no IPCP nor ASP in place and functioning for the months of September, October, November, and December 2025. Additionally, the binder for 2026 was reviewed which revealed the months of January, February, and March also had no infection control surveillance documentation. Administrator A said she did not know why she did not perform or assure the facility assessment was reassessed/updated due to the lack of the ICP and ASP. Therefore, the facility did not identify current resident care needs and assure appropriate staff competencies and levels were in place to provide all the care needs for the current resident population based on an updated IPCP and ASP data. Review of the Water Management Program policy and procedure which had not been revised since 2/1/2024 revealed, The water management program team will meet quarterly in conjunction with the infection control committee to validate and verify the water management program. The policy listed the team to be Administrator A, DON B, Maintenance Director I, and Infection Preventionist C. In an interview on 6/05/2026 at 2:21 PM Administrator A. was asked if the IPCP data was presented at the QAPI monthly meetings. Administrator A stated that anabiotics that were in use were discussed at the morning meetings, which were not QAPI meetings. Administrator A was requested to show how the IPCP data was monitored, and Administrator A did not provide an answer to the monitoring of the data but rather stated that antibiotics were only spoken about in the morning meeting. Administrator A also said no IPCP data was ever spoken of or brought to the monthly QAPI meetings. Administrator A said, during the interview, she thought that oversight of the IPCP was being conducted by the precious by the ICP and stated at the monthly QAPI meetings the previous ICP would never have any data to present to the QAPI. Review of the Infection Prevention Program Overview policy and procedure which had not been revised since 2/28/2025 revealed under, DIVISION OF RESPONSIBILITIES FOR INFECTION PREVENTION ACITIVIES, The administrator is ultimacy responsible for the infection control program. The policy also revealed under Infection Prevention Committee, The Infection Prevention Committee meets on a regular basis as a component of the QAPI committee and provides input and direction for the infection prevention control program. The policy revealed that the QAPI committee recommended actions and control measures while monitoring data if needed, and reports from the IPCP were review and approved by the QAPI committee. Also noted the policy required.Minutes of the Infection Committee meetings are maintained and filed in the QAPI records after review and approval by the QAPI Committee, Review of the facility's Infection Control Antibiotic Stewardship & MDROs (multi resistant drug organisms) which had not been revised since 4/17/2025, revealed, Preventing the emergence and transmission of these pathogens requires a comprehensive approach that includes administration involvement . In an interview on 6/05/2026 at 10:36 AM Maintenance Director I (MD) stated that he did not attend QAPI monthly meetings, and said he did not know anything about them, nor did he know what QAPI even was, MD I said he did not know there were such meetings being held. MD I said he had started working at the facility about 3-4 months ago at the end of January 2026. MD I further stated that he had never been invited or been to a QA to any QAPI meeting. In an interview on 6/05/2026 at 2:21 PM with Administrator A of the QAPI sign in logs for the months of February, April, May, September, and October 2025 revealed MD I did not sign that he attended QAPI. Administrator A did not assure the IPCP or ASP was functioning, monitoring, data collecting for a consecutive six months, nor did Administrator A identify or put into corrective action a plan for the lack of the PCP and ASP. Administrator A did not perform a facility assessment due to no IPCP to ASP during the six months of time. Administrator A did not monitor and assure that all IPCP data was presented to the QAPI at every QAPI meeting and did not assure that Maintenance Director I attended the QAPI meetings and presented any data from the maintenance department as needed.

Based on interview and record review the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program that monitored the performance of the Infection Prevention Control Program (IPCP), and the Antibiotic Stewardship Program (ASP) in a current facility census of 60 residents. Findings Included: Review of the facility's Corporate QAPI (Quality Assurance Performance Improvement) Plan (QAPI) dated 10/24/2018 and last revised 1/25/2024 revealed under, Guiding Principle #4: QAPI focuses on systems and processes .The emphasis is on identifying system gaps . Further review of the facility's QAPI plan revealed the plan did not include the IPCP as part of the facility's QAPI plan as there was no documentation in the plan that included the IPCP. The plan did not address the IPCP requirements of presenting infection control data monthly to the QAPI committee, or monitoring for any systemic concerns, breaks in the system, needs to put plans in the place for corrective actions related to infection control in the facility. In an interview on 6/05/2026 at 12:24 PM Director of Nursing (DON) B stated that when she started working as the DON in February of 2026 there was no Infection Control Preventionist (ICP) and no infection prevention control program IPCP in place, nor was there an active ASP in place. DON B said there was no IPCP or ASP documentation for the months of September, October, November, and December 2025, and also for the months of January, February, or March of 2026. DON B stated that in April 2026 there was an Interdisciplinary Team (IDT) meeting where the IPCP was discussed including residents who were receiving antibiotics. DON B said those who were in attendance were the housekeeping manager, Administrator A, and the Assistant Director of Nursing (ADON) C. DON B said the purpose of the meeting was to summarize the IPCP had taken place in the last month (March 2026). DON B said that was the only meeting for the IPCP she had attended. DON B said she had only completed one month of surveillance and documentation for the IPCP which was the month of April 2026. Upon review of the IPCP binder with DON B for 2025 ICP revealed there was no documentation of infection prevention control nor surveillance for the months of September, October, November, and December 2025. Additionally, the binder for 2026 was reviewed which revealed the months of January, February, and March also had no infection control prevention nor surveillance documentation. In an interview on 6/05/2026 at 2:21 PM Administrator A was asked if the IPCP data was presented at the QAPI monthly meetings. Administrator A stated that anabiotics that were in use were discussed at the morning meetings, which were not QAPI meetings. Administrator A was requested to show how the IPCP data was monitored. Administrator A did not provide an answer to the monitoring of the data but rather stated that antibiotics were only spoken about in the morning meeting. Administrator A also said no IPCP data was ever spoken of or brought to the monthly QAPI meetings. Administrator A said, during the interview, she thought that oversight of the IPCP was being conducted by the previous ICP and stated at the monthly QAPI meetings the previous ICP would never have any data to present to the QAPI. Review of the Infection Prevention Program Overview policy and procedure dated 2/28/2025 revealed under, DIVISION OF RESPONSIBILITIES FOR INFECTION PREVENTION ACITIVIES, The administrator is ultimacy responsible for the infection control program. The policy also revealed under Infection Prevention Committee, The Infection Prevention Committee meets on a regular basis as a component of the QAPI committee and provides input and direction for the infection prevention control program. The policy revealed that the QAPI committee recommended actions and control measures while monitoring data if needed, and reports from the IPCP were review and approved by the QAPI committee. Also noted the policy required.Minutes of the Infection Committee meetings are maintained and filed in the QAPI records after review and approval by the QAPI Committee, In an interview on 6/05/2026 at 10:36 AM Maintenance Director (MD) I stated that he did not attend QAPI monthly meetings. MD I stated he did not know anything about them, nor did he know what QAPI even was. MD I said he did not know there were such meetings being held. MD I said he had started working at the facility about 3-4 months ago at the end of January 2026. MD I further stated that he had never been invited or been to a QA to any QAPI meeting. In an interview on 6/05/2026 at 2:21 PM along with Administrator A the QAPI sign in logs for the months of February, April, May, September, and October 2025 confirmed that MD I did not sign that he attended QAPI. The facility's QAPI program did not identify there was no IPCP in place for the listed six months to effectively and efficiently monitor, investigate, identify, prevent, report, and control infections and communicable diseases for all resident, staff, contractor, consultants, volunteers, visitors, and others who provided care and services to the residents on behalf of the facility. The QAPI committee did not identify there was no IPCP nor ASP data being presented to QAPI for six months, nor did the QAPI committee identify the lack of record of incidents and corrective actions related to infections. The facility's QAPI for the six months was not able to present to the surveyor any antibiotic usage, active infections, interventions conducted, education provided, therefor the facility for the six months' time had no knowledge themselves of what type of infections and where the infections in the facility were located in order for the QAPI committee to review for an action plan.

Based on interview and record review the facility failed to ensure an infection prevention control program (IPCP) and an Infection Preventionist (IP) were in place for six months out of the last eight months and failed to follow Enhanced Barrier Precautions for one (R72) of one resident reviewed. Findings Included: Resident 72 (R72) Review of the clinical record revealed R72 was admitted into the facility on 5/21/26 with diagnoses that included: depression and dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R72 scored 13/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). On 6/2/26 at 2:45 PM R72 was observed lying in bed with urinary catheter bag hanging from the side of his bed. No Enhanced Barrier Precaution (EBP) signage was observed on resident's door or near his room, and no personal protection equipment was observed to be in close proximity to R72's room. On 6/3/26 at 9:36 AM a second observation was made of no EBP signage or PPE outside of R72's room or in close proximity to his room. On 6/5/26 at 10:52 AM R72 was observed lying in bed on his right side, no EBP signage and no PPE cart in the hallway or close proximity to resident room. R72 reported that staff use gloves when they provide catheter care but do not wear a gown, only their regular clothes. A trash can was observed in close proximity to R72's bed with discarded blue gloves but no gowns noted to be discarded in trash can. On 6/5/26 at 10:56 AM during an interview with Unit Manager M, it was reported that a resident with a suprapubic catheter should have EBP signage and PPE on the door, along with a physician order for EBP. UM M verified that there was an active order for R72 to be in Enhanced Barrier Precautions which was placed on 6/2/26, despite the resident being admitted on [DATE] with a suprapubic catheter in place at that time. When asked who is responsible for placing the EBP signage and PPE on the door, UM M reported that it would normally be Infection Preventionist C. UM M then walked down to R72's room and verified there was no EBP signage or associated PPE. Review of the facilities policy titled Enhanced Barrier Precautions (EBP) updated 3/25, documented in part Enhanced Barrier Precautions are indicated for residents with any of the following.a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO (Multi-drug resistant organism) and should remain in place for the duration of a residents stay or until resolution of the wound or discontinuation of the indwelling medical device that place them at higher risk.Implementation-Post signage for precautions on the door or wall outside of the residents room indicating the type of precaution and required PPE.Make PPE, including gowns and gloves, readily available to staff.A health care personnel caring for residents on Enhanced Barrier Precautions should wear gloves and gowns during high-contact resident care. Examples of high-contact resident care activities requiring gown and gloves use: .device care or use; central line, urinary catheter. Review of the facility Infection Prevention Program policy and procedure revealed that the policy had not been reviewed for any revisions needed since 2/28/2025. The policy revealed that, the facility establishes a program under which it:, investigates, identifies, prevents, reports, and controls infection and communicable diseases for all residents, staff, contractors, volunteers, visitors, and other who provide care and services to the residents on behalf of the facility. The policy revealed that the major activities of the IPCP were surveillance of infections with implementation of control measures and prevention of infections. Per the State Operations Manual (SOM), Regulation Text 483.80 revealed, IPCP policies and procedures must include, at a minimum, the following: As necessary, and at least annually, review and revision of the IPCP . The policy further revealed under Water Management, The facility will implement measure to minimize the risk of Legionella and other opportunistic pathogens in the facility water system. Review of the Water Management Program policy and procedure which had not been reviewed since 2/1/2024 revealed, The water management program team will meet quarterly in conjunction with the infection control committee to validate and verify the water management program. The policy listed the team to be Administrator A, DON B, Maintenance Director I, and Infection Preventionist C. Review of the Water Management Team Meeting Minutes dated 5/5/2026 revealed, Administrator A, Maintenance Director I, and Infection Preventionist C were in attendance. DON B was not in attendance despite being a member of the water management team. In an interview on 6/05/2026 at 12:24 PM Director of Nursing (DON) B stated that Maintenance Director I (MD) was in attendance at the (IDT) meeting but said MD I did not discuss or validate and verify the water management program. DON B said she had not been to a water management meeting. DON B stated that she was not familiar with the Water Management Program. DON B further stated that when she started working as the DON in February of 2026 there was no ICP and no IPCP in place. DON B said there was no IPCP documentation for the months of September, October, November, and December 2025, and also for the months of January, February, or March of 2026. DON B stated that in April 2026 there was an Interdisciplinary Team (IDT) meeting where the IPCP was discussed including residents who were receiving antibiotics. DON B said those who were in attendance were the housekeeping manager, Administrator A, and the Assistant Director of Nursing (ADON) C. DON B said the purpose of the meeting was to summarize the IPCP had taken place in the last month (March 2026). DON B said that was the only meeting for the IPCP she had attended. DON B said she had only completed one month of surveillance and documentation for the IPCP which was the month of April 2026. Upon review of the IPCP binder with DON B for 2025 ICP revealed there was no documentation of infection control surveillance for the months of September, October, November, and December 2025. Additionally, the binder for 2026 was reviewed which revealed the months of January, February, and March also had no infection control surveillance documentation. Review of the Infection Prevention Program Overview policy and procedure dated 2/28/2025 revealed under, DIVISION OF RESPONSIBILITIES FOR INFECTION PREVENTION ACITIVIES, The administrator is ultimacy responsible for the infection control program. The policy also revealed under Infection Prevention Committee, The Infection Prevention Committee meets on a regular basis as a component of the QAPI committee and provides input and direction for the infection prevention control program. The policy revealed that the QAPI committee recommended actions and control measures while monitoring data if needed, and reports from the IPCP were review and approved by the QAPI committee. Therefore, for the six months listed there was no functional IPCP, and no ongoing monitoring, nor QAPI oversight of infections or antibiotic inappropriate usage in the facility for those six months of time.

Based on interview and record review the facility failed to ensure implementation of an ongoing antibiotic stewardship program for six months. Findings Include:Review of the facility Infection Control Antibiotic Stewardship and MDROs (multi drug resistant organicism) which had not been revised since 4/17/2025 revealed under, GUIDLINES AND RECOMMENDATIONS FOR SUCCESSFUL IMPEMENTATION OF ANTIBIOTIC STEWARDSHIP IN YOUR COMMUNITY., The program will encourage appropriate prescribing; and reduce adverse effects which often include gastrointestinal problems, C. Difficile diarrhea, yeast infections, and antibiotic resistance in aging adults. The policy further revealed, The medical director and director of nursing will use his/her influence as medical and nursing leaders to help ensure antibiotics are prescribed only when appropriate. The policy also revealed, The infection preventionist (ICP) will be responsible for promoting and overseeing antibiotic stewardship activities in the facility . In an interview on 6/05/2026 at 12:24 PM, Director of Nursing B (DON) stated that when she started as the DON in February of 2026 there was no infection prevention control program (IPCP) nor antibiotic stewardship program (ASP) in place. Upon review of the IPCP binder with DON B revealed that for the months of September, October, November, and December of 2025, and the months of January, February, and March of 2026 there was no documentation of any antibiotics that had been ordered, no documentation of any resident infections, viruses, fungus infections etc . there was no ASP in place at all for the above stated months.

Based on observations, interviews and record reviews, the facility failed to maintain a clean, homelike environment 1) drywall cut away from the wall 2) vents covered with dust on the inside and outside, 3) toilet riser covered in feces that could potentially affect all residents.This citation pertains to intake # 3025074Findings Include: During observations on 06/02/2026 at 12:25 PM, several residents' rooms and bathrooms were not clean, open holes in the wall and not a homelike environment: Bathroom between rooms [ROOM NUMBERS], the vent in the bathroom was covered with dust in the vent and up inside the vent. Bathroom between rooms [ROOM NUMBERS] wall/drywall was cut out above the sink and under the sink due to a leak a month ago or more and was not repaired. Bathroom between rooms [ROOM NUMBERS], the vent in the bathroom was covered with dust on the vent and up inside the vent. Bathroom between rooms [ROOM NUMBERS], the vent in the bathroom was covered with dust on the vent and up inside the vent. Bathroom between rooms [ROOM NUMBERS], the vent in the bathroom was covered with dust on the vent and up inside the vent. Bathroom between rooms [ROOM NUMBERS], the vent in the bathroom was covered with dust on the vent and up inside the vent. Bathroom between rooms [ROOM NUMBERS], the vent in the bathroom was covered with dust on the vent and up inside the vent. During observations on 06/03/2026 at 10:16 AM, the bathroom between rooms [ROOM NUMBERS] were not clean, open holes in the wall and not a homelike environment. Bathroom between rooms [ROOM NUMBERS] had drywall missing from the ceiling, above the sink and under the sink. The floor in room [ROOM NUMBER] was sticky from something being spilt on the floor and not cleaned up, writer's shoes stuck to the floor. During observation and interview on 06/04/2026 at 2:26 PM, Maintenance Director I walked through the resident's rooms and bathrooms on 200 hallway and observed the missing drywall, open holes in the wall, exposed pipes with no cover over it to protect residents. Maintenance Director I stated it had to be fixed after a leak and added he doesn't have the material to fix it. Maintenance Director I stated it's been that way a couple of weeks. Writer asked what the plans were for repair. Maintenance Director I stated he had a contractor lined up and he didn't show up. Writer asked if he had a cleaning schedule when he made rounds and did deep cleaning. Maintenance Director I stated no he did not, he just cleaned when he got time to do it. Maintenance Director I stated he did not have a schedule to inspect, clean or log certain areas of the building in use and not in use, and added if it broke, he fixed it. Writer asked Maintenance Director I about the schedules for routine testing the water temperature and legionnaires testing. Maintenance Director I stated he checked it weekly. Writer asked to see his maintenance log, and the Maintenance Director I stated he doesn't have any logs. Maintenance Director I had been there 3 months, stating nobody was training him. Writer asked how he was keeping track of the of the water testing, legionnaire's testing, work orders, mechanical devices, call lights and other devices that affect the care and safety of the residents that needed checked, Maintenance Director I stated he did it when he could find time. Maintenance Director I had no documentation proving what he had done or not completed. During an interview on 06/05/2026 at 1:19 PM, Housekeeping Manager P stated he gave NHA A past cleaning logs to upload into Egress. Housekeeping Manager P explained the terminal cleaning instructions when a resident is discharged , or if they were in isolation and the in-depth cleaning that takes place. Housekeeping Manager P stated his staff do daily cleaning as assigned, showing writer a copy of the assignments and who had completed which rooms. Housekeeping Manager P observed the vents of concern and stated they were cleaned a week again but would make sure it was cleaned right away today. Housekeeping Manager P stated housekeeping cleans the outside and surrounding the vent, but it was Maintenance Director I responsibility to get up inside of the vents to clean them out. Housekeeping Manager P stated he didn't have his staff go up into the vents to clean. Writer reviewed cleaning logs provided by Housekeeping Manager P. On 6/3/26 at 9:13 AM, the shared bathroom between rooms [ROOM NUMBERS] was observed to have a urinal laying on it's side on the back of the toilet with a small amount of urine spilled on the top of the toilet, stool was observed both on the rim of the inside of the toilet and heavily soiled on the back of the toilet riser, additionally there was a soiled towel observed on the bathroom floor (soiled with a brown substance, consistent with the color of the stool observed on the toilet).

Based on interview and record review, the facility failed to ensure the physician reviewed and acted upon identified medication regimen irregularities for four (Residents #1, 5, 39 and 59) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions. Findings include: Resident #1 Review of the clinical record revealed Resident 1 (R1) was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cerebral infarction, diabetes. Further review of r1's clinical record reflected a pharmacy review was completed on 4/23/26 and 5/07/26 both Pharmacy reviews indicted irregularities were noted to see report. There was no report for either 4/23/26 or 5/07/26 with the pharmacy recommendations/noted irregularities. Resident #5 Review of the clinical record revealed Resident 5 (R5) was admitted to the facility on [DATE] with diagnoses that included diabetes and dementia. The Monthly Medication Reviews (MMR) completed by the pharmacy reflected the pharmacy noted irregularities for R5 on 2/05/26 and 4/14/26 with see report. There was no report for R5's irregularities for either 2/05/26 and 4/14/26. R5's MMR dated 3/7 report did not reflect if there were any irregularities or completed with no irregularities. Resident #39 Review of the clinical record revealed Resident 39 (R39) was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of heart failure. Review of R39's MMRs dated 11/26/25, January 7, March 7, April 13 and May 5th were all noted to have irregularities/recommendations, with see report. None of the above reports were located in R39's clinical record. On 06/05/2026 12:20 PM interview with Director of Nursing (DON) B stated she did not have any information on pharmacy recommendations or the Providers response to those recommendations but would follow up. On 06/05/2026 at 2:08 PM, DON B reported she was unable to locate all of the missing pharmacy reports with the providers acknowledgments or response. Resident #59 (R59) Record review revealed R59 had a recommendation made by the pharmacy on 03/19/2026 during their monthly medication review. Record review did not reveal any documentation from any provider to agree or disagree with the recommendations. Record review revealed R59 had a recommendation made by pharmacy on 04/14/2026 during their monthly medication review. Record review did not reveal any documentation from any providers to agree or disagree with the recommendations. Record review revealed no recommendation from the pharmacy on 05/07/2026 during their monthly medication review. During an interview on 06/03/2026 at 12:30 PM, writer emailed DON B asked for the documentation from the providers regarding the recommendations from the pharmacy for the month of April 2026 and May 2026. During an interview on 06/03/26 at 5:00 PM, DON B stated the monthly medication review recommendations for 03/19/2026 and 04/14/2026 was not completed. DON B stated she could print off the recommendations from the pharmacist, but they were not addressed by the provider.

Based on observation, interview and record review, the facility failed to notify one (Resident #61) of one reviewed for room change. Findings include: Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident #61 (R61) was a [AGE] year-old male admitted to the facility with diagnoses that included congestive heart failure and anxiety. R61 scored 12 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 06/02/2026 at 2:09 PM R61 was observed sitting in a wheelchair in his room, upon approach R61 was upset and reported that last week [name redacted] Certified Nursing Assistant (CNA) E came to his room and was told it was time to go. R61 said he asked CNA E go where? and CNA E told R61 he was moving to the third floor. Resident #61 reported had no choice, his opinion or consent was irrelevant, and he was never given any explanation for the room change. Review of the physician progress notes dated 6/01/26 reflected in part . he requests to speak to nursing management as patient did have change in room over the past few days who would like to discuss this with them, did update this with nursing staff . Further review of R61's clinical record revealed no documentation that R61 was provided any notice, choice or explanation about a room change. Nor was there any documented follow up from Nursing Management as R61 requested. On 06/03/2026 at 3:07 PM, during an interview with Director of Nursing (DON) B stated she didn't have any information about R61's room change and was not aware R61 wanted to speak with Nursing Management. When queried about room change process, DON B reported the facility practice should be to do notifications and a consent. But maybe not actual signed consents. When queried why Nursing Management hadn't yet followed up with R61, DON B stated Well it was only two days ago. On 6/04/2026 10:26 AM, during an interview with DON B and Nursing Home Administrator (NHA) A, NHA stated Resident #61 brother was in the facility and requested a room change. When queried if it was routine practice to do room changes based on family requests without consulting the resident? NHA A offered no response.

Based on observation, interview and record review the facility failed to ensure Advanced Directives were thoroughly completed for one (R72) of three reviewed. Findings include:On 6/2/26 at 2:45 PM R72 was observed lying in bed with urinary catheter bag hanging from the side of his bed.Review of the clinical record revealed R72 was admitted into the facility on 5/21/26 with diagnoses that included: depression and dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R72 scored 13/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).A review of R72's Do-not-resuscitate order revealed no date was included with residents' signature and one witness signature was also noted to be missing a date.A review of R72's physician orders revealed no active DNR (Do not resuscitate order).On 6/5/26 at 9:24 AM, during an interview with DON B, it was reported that Advanced Directives are reviewed upon admission by the floor staff and more complex ones are referred to social services for follow up. DON B stated ultimately the DON and Administrator are responsible for ensuring they are completed thoroughly with the required signatures and dates. Stating the DNR form requires 2 witnesses to confirm the correct person is signing it and it's accurate.DON B confirmed that she did not see a date with the resident signature or with one of the two witness signatures. DON B further confirmed that the expectation is that there is also an active physician order reflecting code status (DNR or Full code) and that for R72 there was not an active order reflecting his wish to be a DNR.

This citation pertains to intake #3031215 Based on observation, interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for one (R39) of two residents reviewed. Findings include:On 6/2/26 AM R39 was observed lying in bed. R39 reported that his only concern was that his bathroom was not being cleaned properly and that he had been asked by housekeeping to clean his own bathroom. R39 reported that the housekeeper asked him if he had asked the CNA to clean his bathroom, indicating it was the CNA's job to clean up stool. R39 reported that the housekeeper left a washcloth at his bedside and staff were told to not clean his bathroom until the resident had cleaned up his own stool. R39 indicated that Unit Manager (UM M) was made aware. R39 further reported that he had chronic diarrhea and used the toilet a lot and verbalized being upset by the staff member telling him to clean his bathroom. Review of the clinical record revealed R39 was admitted into the facility on [DATE] with diagnoses that included: dementia and depression. According to the Minimum Data Set (MDS) assessment dated [DATE], R39 scored 12/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition).Review of the Facility Reported Incident Summary revealed that R39 reported that housekeeper O told him he needed to clean the toilet after experiencing diarrhea, stating that the resident should clean it rather than staff.an investigation was completed, including interviews with the resident, assigned CNA (certified nursing assistant) , second CNA witness (CNA L) and the housekeeper involved. The resident stated that the housekeeper appeared upset about having to clean the toilet and indicated that he should clean it himself. The assigned CNA reported that she then handed the wipes to the resident. The housekeeper denied handing the wipes to the resident and stated that the CNA gave the wipes to the resident; however, he acknowledged that the wipes were intended for the resident. A second CNA, who was assisting another resident in a nearby room, stated that she heard the resident yelling and went to see what was happening. She stated she did not witness the direct interaction between the resident, assigned CNA and housekeeper, but her statement supports the resident's report regarding the concern raised at the time of the incident. Based on interviews conducted, the resident and assigned CNA provided consistent statements that the housekeeper indicated the resident should clean the toilet. While accounts differed regarding who physically handed the wipes to the resident, statements were consistent that the wipes were intended for the resident to clean the bathroom. This interaction is not consistent with the facility's expectations regarding resident dignity, respect and appropriate staff conduct. Following completion of the investigation and review of all statements obtained, the housekeeper's employment was terminated. The resident was interviewed regarding safety and voiced no further concerns at the conclusion of the investigation. No further related concerns have been reported.A 5/22/26 Statement from Housekeeper O, At approximately 10:00 am on 5/21/26 I was asked for the bleach wipes from (CNA N) and (CNA L) I observed the CNA putting the wipes on the bedside table and (CNA N) said you need to clean it up. The resident threw the wipes at the CNA and called her a b*tch. The CNA left the room and reported to the unit manager, and she went in to talk to the resident. She told the resident that it was housekeeping's job to clean it. On 5/22/26 I noticed there was a mess in the bathroom and I asked him if he let the CNA know and he started yelling at me. I cleaned it up. He got up and started yelling in the hall; he was getting in my face and told me I am forbidden to go into his room. I told him I wasn't arguing with him. I left the area.A 5/27/26 Statement from CNA L, I was in taking care of the next room and I walked out and heard (R39) yell Hey CNA, I don't have to clean the bathroom that is housekeeping's job. I did not witness any interaction between him or the housekeeper. Did you hand him wipes and tell him to clean the bathroom- No'A 5/26/26 Statement from CNA N, Sometimes (R39) will have diarrhea and will get it on the floor and toilet seat. (Housekeeper O) will have a fit if he has to clean it up. (R39) cannot help it. I explained to (Housekeeper O) that if it is on the floor or the wall, I clean it up and if it is in the toilet then he needs to clean it up. He came to me in the hall and handed me Clorox wipes, and I thought it was for me to clean up, and stated just leave them there. He pulled a few out and left it on the table for the resident. As I turned around, (R39) yelled, I am not going to clean the toilet, it is housekeeping's job. He called me a b*tch and I left the room after I removed the Clorox wipes.A 5/22/26 Statement from Unit Manager (UM M), (name redacted-Housekeeper O) stated that (R39) is purposefully pooping every night. (R39) is offended by (Housekeeper O) because of the incident yesterday. Yesterday (Housekeeper O) was upset because the CNA would not clean the inside of the toilet bowl and felt the CNA should have cleaned it. Today (5/22/26) I was told by (name redacted) that the same incident occurred today. He stated that (Housekeeper O) went into the room and stated in a confrontational manner: Did you tell the CNA to clean it up? Referring to the issue of the toilet. During this conversation, he was on the phone with his girlfriend. As a follow up, I spoke with (R39) regarding loose stools. He stated that at home he took metformin and his PCP (primary care provider) took him off metformin due to uncontrollable diarrhea. I spoke with the NP (Nurse practitioner) about changing his medication since he had diarrhea. His medication order was obtained and ordered.Review of R39's progress notes revealed the following:5/18/26 Resident was seen by facilities Nurse Practitioner related to flatus (gas) at the request of nursing staff, Was asked to see this (age redacted) year old male by nursing staff's concern of increased flatulence and frequent bowel movements.Patient stated the is eating and drinking well, denies any nausea or vomiting. Patient states he is having 1-2 bowel movements a day. He does endorse passing gas, does not cause any discomfort.Patient having regular bowel movements.Is having regular bowel movements 1-2 a day, denies any diarrhea.5/21/26 Resident was seen by UM M, Referring to BCS (Behavioral Care Solutions-mental health services provider) for behaviors. Resident continues to purposefully defecate on a shared bathroom floor and all over the toilet. This occurs multiple times a week. Resident will not engage in conversation about this behavior.5/22/26 Resident was seen by facilities NP related to diarrhea, The patient was asked to be seen today due to continued diarrhea, patients feels that his diarrhea is related to medication. He would like to be off metformin, upon review of medication patient is not on metformin. Discussed with patient, we will monitor blood sugars and diarrhea.Intermittent diarrhea, will continue to monitor, patient is not on metformin, will hold Metamucil as fiber could be causing some increased indigestion.5/22/26 Resident was seen by UM M, UM discussed behavior with resident and reviewed his medications with him. Resident said that he used to take metformin at home for his DM (diabetes mellitus) but it gave him uncontrollable explosive diarrhea so Dr put him on Jardiance. Resident stated that he does not have any GI (gastrointestinal) issues when taking Jardiance. UM asked Dr to discontinue metformin and order Jardiance.Review of the facilities policy titled Abuse Prohibition Policy updated 9/9/22, documented in part Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property.To assure guests/residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor guest/resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the guests/residents.Definitions.Verbal abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the guest/resident to experience humiliation, intimidation, fear, shame, agitation, or degradation regardless of their age, ability to comprehend or disability. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to guests/residents within hearing distance, regardless of age, ability to comprehend, or disability.

This Citation Pertains to Intake 3027512 Based on observations, interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one of two residents reviewed (Resident 14) and failed to report allegations of abuse to the Nursing Home Administrator/Abuse coordinator for resident (Resident #19).Findings include: Resident #14 Review of the clinical record revealed R14 was admitted into the facility on 3/30/23 with diagnoses that included: bipolar disorder and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R14 scored 7/15 on the Brief Interview for Mental Status exam (which indicated severely impaired cognition). On 6/4/26 at 11:19 AM, during a telephone interview with LPN D regarding an alleged drug diversion (related to R14's Norco), that was reported on 5/19/26, she reported that another incident occurred on Saturday May 30th, also involving Norco (a narcotic pain medication) and the same nurse from the first allegation of drug diversion (LPN Y). LPN D stated that the second allegation was reported to Unit Manager (UM) M on May 30th by LPN Q. LPN D reported that LPN Q had called her because she was the on-call nurse and told her that while doing the narcotic counts at change of shift with LPN Y, there was a pill that was taped into the #9 spot of the Norco 7.5mg card and it was not the same size as the other 8 pills and the markings on the pill were not the same (indicating that a Norco 7.5mg tablet had been removed and replaced by a different medication which was later determined to be a Norco 5mg tablet based on the markings). LPN D reported that the second allegation had not been investigated and that the suspected perpetrator (LPN Y) had not been removed from the schedule. On 6/4/26 at 3:29 PM, during a telephone interview with LPN Y, she confirmed that on 5/30/26 during the end of the shift narcotic counts, it was discovered that the pill in the #9 spot of a Norco 7.5mg card (for a discharged resident) had been taped in place and the pill in the #9 spot was different than the other 8 pills. LPN Y reported that she did not know what had happened, that UM M was made aware, that she did not think it had been investigated yet and that nobody had reached out to her for a statement. She added that she had not heard anything more about the incident. On 6/4/26 at 4:10 PM, during an interview with UM M, she reported being aware of the Norco incident that occurred on Saturday 5/30/26. UM M reported that she was on call last weekend, a nurse identified that there was a card for a resident that was no longer here, and it had a pill that was taped back into it. UM M further reported that the marking/imprint on the pill that was taped in was M366 and the actual pill was M365. UM M reported that she had the nurse that discovered this take a photo, write a statement and locked the card in a different medication cart. When asked what she felt had happened UM M reported it was quite obvious that someone had swapped the pills. When asked if there was a concern for drug diversion UM M reported that her initial reaction based on the other recent allegation against LPN Y was yes there was a concern for drug diversion. When asked if she knew who could have taped the pill back into the narcotic card, UM M reported that she saw LPN Ys initials on the narcotic sheet and she is familiar with her signature. When asked if potential drug diversion should be reported to the State, UM M reported yes if it was diversion and that she was not aware of the timeline for reporting to the state or the process for reporting to the State. When asked if it should have been reported to the NHA (nursing home administrator) at the time of discovery she reported looking back I guess I probably could have. On 6/5/26 at 8:59 AM, during an interview with NHA A and Director of Nursing (DON) B, both NHA A and DON B initially reported not being aware of an incident related to narcotics over the weekend. DON B clarified that she wasn't sure what day it had occurred, but it happened over the weekend and that she was just going by one of the nurse's statements. When asked for additional details regarding that statement, DON B reported that LPN Q had reported that there was a different imprint on one of the pills in a Norco card. DON B reported that she spoke with LPN Y that day and that her and NHA A had talked about reporting that morning (it should be noted that the day of the interview was Friday-almost a full week after the incident occurred). When asked when she was made aware, DON B reported it had been a few days since a letter was dropped under her door. When asked if the police were called for either incident, NHA A reported they were notified of the first incident but not the most recent one. Facility staff failed to timely report an allegation of drug diversion to the Abuse Coordinator/NHA who failed to report it to the Police. Resident #19 Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident #19 (R19) was a [AGE] year-old male admitted to the facility 11/17/18 with diagnoses that include Alzheimer's disease, aphasia and schizophrenia. R73 was observed on 06/02/26 sitting in a wheelchair, with an unkempt appearance i.e.: long dirty fingernails, greasy hair, unshaven. On 6/4/26 at 3:28 pm- Licensed Practical Nurse (LPN) D was interviewed via phone and voiced concern about Management staff lack of response related R19 allegedly being abused by Certified Nursing Assistant (CNA) J. LPN D stated the allegation was recent, well known to floor staff, and the allegation was CNA J verbally abused and roughly shook Resident #19 in his wheelchair. LPN D stated again the incident was well known by facility staff and witnessed by other CNAs. CNA F was interviewed via phone on 6/4/26 at 3:35 pm and reported she did not witness the allegation, but she heard that CNA J was verbally abusive to R19 and shook R19s wheelchair really hard. When queried if she reported it to the NHA A CNA F stated no, because CNA H was the person who witnessed it firsthand and CNA H reported it to Assistant Director of Nursing (ADON) C. On 6/4/26 at 3:45 pm interview with CNA G she reported she didn't witness R19 be abused by CNA J but the allegation was well known by everyone, and it was reported to ADON C, and witnessed by CNA H. On 6/4/26 at 3:50pm, a Phone call made to CNA H immediately after introducing self and the purpose of the call the line was disconnected. Six additional attempts were made to contact CNA H on 6/4/26 and 6/526. On 6/05/26 at 9:30 am NHA A reported CNA H was on vacation and was not able to get a phone signal. admission Director K stated CNA H was her daughter and she was on vacation, and at CNA Hs vacation location it was 3:00 am and CNA H was not available to be interviewed. 0n 6/05/26 at 9:50 am during an interview with NHA A and DON B they both reported they were not aware of any allegation of abuse that involved Resident #19. NHA A Stated they would speak with ADON C. Of note, ADON C was on current suspension related to allegation of abuse and not available for interview.

This citation pertains to Intake #3027512Based on observation, interview and record review the facility failed to thoroughly investigate an allegation of drug diversion for one resident (R14) of two residents reviewed.Findings include:A review of the clinical record revealed R14 was admitted into the facility on 3/30/23 with diagnoses that included: bipolar disorder and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R14 scored 7/15 on the Brief Interview for Mental Status exam (which indicated severely impaired cognition).On 6/2/26 at 3:57 PM R14 was observed self-propelling a manual wheelchair in the hallway and resident was heard asking what he is supposed to be doing and stating he didn't know what was going on, without being prompted.A review of FRI (Facility Reported Incident) 5-day summary, completed on 5/24/26 revealed On 5/19/26 nurse (LPN Y) was suspended pending investigation following reasonable suspicion of possible medication diversion related to review of PRN (as needed) narcotic administration for a resident (R14) under her care. (LPN Y) was the only person identified as signing out the PRN narcotic in question during the timeframe reviewed.The facility initiated an immediate investigation. Medication Administration Records (MAR), electronic health record documentation were reviewed to verify timing, dosage, route and documentation of medications administered. Review identified documentation discrepancies between the MAR and narcotic sign-out sheets related to recording practices; however, no discrepancies were identified indicating medication was missing, diverted, withheld, or administered inappropriately.Relevant staff members involved in medication administration and medication counts were interviewed. Staff reported no concerns regarding the nurse's medication administration practices and denied observing missed, altered, delayed, or otherwise inappropriate medication administration. Interview findings were consistent with documentation reviewed. The 10-panel drug screen results returned negative for narcotic use. Conclusion: Based on review of medication records, narcotic documentation, resident interviews, staff interviews, and negative drug screen results, the facility found no substantiated evidence of medication diversion or medication administration misconduct involving nurse (LPN Y). While documentation variances between the MAR and narcotic sheets were noted, there was no evidence that medications were diverted, withheld, or administered outside physician order parameters. Investigation findings support that medications were administered as ordered and residents received prescribed medications without adverse outcome. Investigation is closed as unsubstantiated. LPN Y was re-instated on 5/22/26.Included in the FRI investigation folder were the following statements:5/19/26 LPN D, On 5/19/26 I asked the doctor if Norco for (R14) could be discontinued as I noticed only one person was signing it out and it started in January. I suspected abuse. (Physician's name redacted) said he would tell Admin and DON.5/28/26 UM M, I review the narcotic cards and have not seen a pattern of diversion. I have not seen any factual evidence to support drug diversion. Narcs in the carts are counted at shift change as they should be.A review of R14's Norco Controlled Drug Receipt/Record/Disposition Form (paper record used to account for narcotic medications being signed out) with date span of 9/30/25-5/9/26 revealed that 28 doses were given during that time, the last 15 were signed out by LPN Y (date span of 4/5/26-5/9/26) and that the last time R14 had been given a dose by anyone else was almost 3 months prior on 1/9/26. A second Controlled Drug Receipt/Record/Disposition Form with a date span of 5/12/26-5/19/26, was reviewed and revealed all 5 doses were signed out by LPN Y, therefore the last 20 doses that were documented as being given to R14 were signed out by LPN Y exclusively.A review of R14's pain scores for the timespan in question revealed that LPN Y did not consistently record pre and post administration pain scores as per standard of practice.On 6/4/26 at 10:01 AM during an interview with LPN D it was reported that R14 had been getting Norco for reported pain dating back to November 2025 but that all staff, except LPN Y had stopped giving it to him because he had an adverse reaction (nausea and vomiting). LPN D reported that R14 refuses his medications often, so it seemed unusual that LPN Y kept documenting that she was giving R14 the Norco each night she was working. LPN D reported that after the suspicion of drug diversion was reported a urine drug test was completed on R14 which was negative for opiates. LPN D reported that leadership (DON/NHA and ADON) were made aware and she was told that it would be taken care of. LPN D reported that NHA A had just taken her statement on Monday (6/1/26) when the incident had been reported on 5/19/26. It should be noted that LPN Ds statement provided in the FRI folder had a date of 5/19/26. LPN D further reported that the facility physician had ordered a blood drug screen to be ran with blood that was collected and sent to the laboratory however it was never resulted (no physician order for a blood drug screen was found in R14's record). On 6/4/26 at 10:40 AM during an interview with NHA A and DON B, DON B reported that it was brought to their attention by the facilities physician, during their morning meeting, that LPN D had expressed concern regarding drug diversion and that LPN Y was the only nurse signing out R14's Norco. DON B stated that she went through all the narcotic sign out sheets for all residents that had narcotics, looked for a pattern of abuse, and then looked into the electronic medical record to verify the medications were documented appropriately. DON B reported that she did not notice any patterns of diversion. When asked to explain what a pattern of diversion might look like she explained it would depend on the medication but if the medication was missing/not documented on the Medication Administration Record. I verified that DON A was aware of the last several doses being signed out solely by LPN Y, she was aware. When asked what was meant by documentation variances mentioned in the FRI investigation summary, DON B reported that there was a discrepancy between the times when the Norco was signed out on the narcotic sheet and when the medication was documented as being given on the MAR. DON B reported that this was not best practice but not diversion. DON B reported that LPN Y had a negative drug test and by the time the results had been returned she had reviewed a lot of charts and spent a lot of time ruling out drug diversion, so LPN Y was allowed to return to work.On 6/4/26 at 3:29 PM, during a telephone interview with LPN Y, it was reported that she was suspended pending an investigation of suspected drug diversion. She provided an observed urine sample for a drug test that was negative. LPN Y originally stated that she was not aware of the allegation being about a specific resident then recalled someone on the floor asking her about providing R14 with Norco, which she reported she gave him for his agitation and dementia. LPN Y denied any drug diversion and stated that she followed the physician's order. LPN Y reported that R14 appeared uncomfortable, had pain in his legs/back/hips and prior to her giving him the Norco would be wanting to punch staff. LPN Y reported that the Norco helped with some of R14's behaviors. LPN Y reported that a pain score should be recorded prior to giving a pain medication and again an hour or 2 after to determine if it was effective. When asked about pain scores not being recorded consistently she reported that she was surprised. When asked why it had been reported that R14 had a negative urine drug screen for opiates she reported not knowing why. LPN Y was asked about the more recent incident involving a Norco being taped back into the narcotic card, she reported that she did not know how it had happened but that it was reported to UM M. When asked if that incident had been investigated she replied, I don't think so, it happened recently, that she was not asked for a statement and had not heard anything more about it.Review of progress notes written by LPN Y (from 4/5/2026 to current) revealed the following:4/5/26 2:24 AM (R14-name redacted) continually refuses his evening medications. Despite the risks of refusing medications and he said I don't care. Doctor will be notified via doctors book. POA (power of attorney) will be notified in day time.4/5/26 11 PM (R14-name redacted) spent the evening propelling himself around the third floor. He is friends with other residents who sit with him during meals and when doing activities. He finally took his medications for me. His friends encourage him to take his medications and (R14-name redacted) does it. He did very well this evening and I was able to address his pain issues. He slept most of the night. He said he enjoyed talking to me so I am hoping as he will remember me enough to take his medications in the future and not refused his medications which had become his norm.4/29/26 6:55 AM (R14-name redacted) looks like he doesn't feel well. He looks weak and wants to be left alone. His color is pale. He doesn't want to get OOB (out of bed). His urine is foul smelling. He is more aggressive then he has been this is from day CENA reports. Will leave note with doctor. Will talk to day nurse.There was only one mention of R14 being aggressive and no documentation to support LPN Ys report of his pain or him wanting to hit staff.On 6/4/26 at 4:10 PM during an interview with UM M, when asked about the suspected drug diversion involving LPN Y, she reported that she had been asked to pull the narcotic logs which she provided to the DON and NHA. She further reported that she had no proof diversion occurred. When asked about the incident that occurred over the weekend, involving the wrong pill being taped into a narcotic card she reported that she was made aware because she was on-call, a nurse identified that there was a card for a resident that was no longer in the facility, and a different tablet had been taped into the card. The card was for Norco 7.5mg and the one taped in was Norco 5mg. When asked what had been done about this, she reported that she had the nurse write a statement, take photos of the pill card and lock it in a different medication cart. When asked what she thought had happened she reported that it was quite obvious that someone had swapped the pills. When asked if there was a concern for drug diversion UM M reported that her initial reaction based on the other recent allegation against LPN Y was yes there was a concern for drug diversion. When asked if she knew who could have taped the pill back into the narcotic card, UM M reported that she saw LPN Ys initials on the narcotic sheet and she is familiar with her signature. When asked if potential drug diversion should be reported to the State, UM M reported yes if it was diversion and that she was not aware of the timeline for reporting to the state or the process for reporting to the State. When asked if it should have been reported to the NHA (nursing home administrator) at the time of discovery she reported looking back I guess I probably could have.On 6/5/26 at 8:59 AM, during a follow up interview with NHA A and Director of Nursing (DON) B, I asked DON B to confirm that when she reviewed the Medication Administration Records and compared them to the Narcotic Count Sheets that the only discrepancy was related to the times being off, DON B confirmed that was correct. I reviewed the 2 narcotic sheets for R14's Norco with NHA A and DON B and 4 of the doses signed out by LPN Y were not documented as being given on R14's MAR. DON B replied I don't know how I missed this, it's a lot. When asked if a urine drug test had been done on R14, DON B reported an unofficial one had been done, it was collected in house but then she was told that the in house tests could only be used for new hires and that the test was never resulted, and that their contracted lab could not do urine drug screens or blood. When asked about the more recent incident both NHA A and DON B initially reported not being aware of an incident related to narcotics over the weekend. DON B clarified that she wasn't sure what day it had occurred, but it happened over the weekend and that she was just going by one of the nurse's statements. When asked for additional details regarding that statement, DON B reported that LPN Q had reported that there was a different imprint on one of the pills in a Norco card. DON B reported that she spoke with LPN Y that day and that her and NHA A had talked about reporting that morning (it should be noted that the day of the interview was Friday-almost a full week after the incident occurred). When asked when she was made aware, DON B reported it had been a few days since a letter was dropped under her door. When asked if the police were called for either incident, NHA A reported they were notified of the first incident but not the most recent one. NHA A provided a business card from a local police department, that she had in a separate/personal notebook. The facility FRI investigation provided by the facility for review for the 5/19/26 allegation of drug diversion did not include a police report and the facilities investigation summary did not mention notification of the police, it did not include MAR's that were reviewed for administration of the Norco in question, and it did not include copies of the narcotic logs that were reviewed for the Norco in question. The separate and second incident that occurred on 5/30/26 had not been formally investigated.

This citation pertains to Intake 3030189. Based on interview and record review, the facility failed to provide a written notice of transfer for one (R75) of two reviewed. Findings include: Review of the medical record revealed R75 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/8/26 revealed R75 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R75 transferred to the hospital on 5/17/26 and did not return to the facility. Review of the Nurses Notes dated 5/17/26 revealed R75 was transferred to the hospital. The notes revealed the ambulance was given paperwork that included R75's admission Profile, Order Summary, and Code Status. The bed hold policy was explained to the family. Review of the eInteract Transfer Form revealed R75 was transferred to the hospital on 5/17/26 at 6:15 PM for shortness of breath. In an interview on 06/05/2026 at 1:20 PM, Director of Nursing (DON) B reported the bed hold policy was given to the resident upon transfer to the hospital. When asked about a written notice of transfer, DON B reported the only transfer form she was aware of was the eInteract Transfer Form which was given to the ambulance staff and not the resident. The DON B agreed the eInteract Transfer Form did not include information regarding appeal rights and the contact information for the State Long Term Care Ombudsman. On 06/05/2026 at 3:27 PM, DON B reported the facility had a written transfer form they were supposed to use, but it was not given to R75.

Based on interviews and record reviews the facility failed to provide accurate Minimal Data Set (MDS) assessments for one resident (R20) of 15 residents reviewed for accuracy of assessments.Findings include;Resident #20 (R20)Review of the medical record reflected R20 was an initial admission to the facility on [DATE]. Diagnoses of rheumatoid arthritis, multiple sclerosis, polyneuropathy, osteoarthritis, spinal stenosis lumbar region, functional quadriplegia, anxiety and depression.The most recent Minimum Data Set (MDS) with an ARD/Target date of 03/26/2026 revealed R20 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. Under section GG0115, Functional Limitation in Range of Motion revealed R20was independent with eating and use of upper extremities. Under section GG0130, Self- Care, R20 was dependent on care for toileting, hygiene, Shower/baths and transfers.Record review of Minimum Data Set (MDS) revealed R20 was on an antibiotic, through further investigation, this resident was not on an antibiotic during time frame of 03/26/2026.On 06/03/2026 at 10:44 AM, writer emailed LNHA A requested R20's March and April's Medication Administration Record (MAR) and any orders for an antibiotic as documented on the MDS quarterly assessment. On 06/03/2026 at 11:25 AM, LNHA A forwarded email from DON A stated, I have reviewed R20's chart, and she was not on an antibiotic, no orders for an antibiotic for this resident.During an interview on 06/03/2026 at 2:05 PM, DON B stated she wondered why writer asked her to look at this, as R20 had not been on an antibiotic so it must have been an MDS discrepancy.

Based on interviews and record reviews the facility failed to complete a yearly PASARR assessment on one resident (R6) out of resident reviewed for PASARR assessments.Findings Include;Resident #6 (R6)Review of the medical record reflected R6 was an initial admission to the facility on [DATE]. Diagnoses of displaced mid-cervical fracture of right femur, malnutrition, vascular dementia, adjustment disorder, schizophrenia and anxiety.The most recent Minimum Data Set (MDS) revealed R6 had a Brief Interview of Mental Status (BIMS) of 8 (moderate cognitive impairment) out of 15. Under section GG0115, Functional Limitation in Range of Motion revealed R6 required partial assistance with eating and use of an adapted cup. R6 was dependent on bed mobility, toileting, hygiene, Shower/baths, dressing lower body and transfers.Record review revealed R6's PASSAR was completed and dated 03/26/25, did not find one dated for 2026.During an interview on 06/03/2026 at 1:15 PM, LNHA A stated they went through and made a list of every PASSAR in the building, and with the help of Community Mental health, they were working together to get every past due PASSAR up to date. During this same conversation DON B stated they divided the residents between herself and ADON C and tackled the past due ones and now on the current ones.Writer asked both NHA A and DON B about R6's annual PASSAR. NHA A stated review was past due and looked in her binder to see if she was completed or not. HNA A could not find it and asked DON B to go look and see if she or ADON C had it on their desk/file.During an interview on 06/03/2026 5:00pm, DON B, stated a PASSAR on R6 was not done.

Based on interviews and record reviews the facility failed to administer medications timely and document accurately for one resident (R32) of 15 residents reviewed.Findings Include;Resident #32 (R32)Review of the medical record reflected R32 was an initial admission to the facility on [DATE]. Diagnoses of osteoarthritis in the right knee, acute embolism and thrombosis of the right knee, obesity, diabetes mellitus 2, obstructive sleep apnea, pain in left hip, major depression and anxiety.The most recent Minimum Data Set (MDS) revealed R32 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section GG0115, Functional Limitation in Range of Motion revealed R32 was independent with oral care and eating. R32 was dependent on care for toileting, hygiene, Shower/baths and transfers.During an observation on 06/02/2026 at 4:39 PM, writer standing outside the room of R32 and over-heard R32 ask Licensed Practical Nurse (LPN) Q for her Nicotine Lozenges and LPN Q told R32 she already had it but R32 stated she has not.During an interview on 06/02/2026 at 4:40 PM, writer asked LPN Q if R32 could get her Nicotine Lozenges, writer had already run the Medication Administration Record (MAR) and R32 did not have any medications signed out today. LPN Q stated she had already given it to R32, writer told her there was not any Nicotine Lozenges signed out today. LPN Q stated she didn't always sign her medications out if she is busy. Writer asked LPN Q when R32 received Nicotine Lozenges, LPN Q stated that morning and about 15 minutes ago. Writer asked for times that Nicotine Lozenges were administered and LPN Q stated somewhere around 8:30am and about 15 mins ago. Writer informed LPN Q that Nicotine Lozenges had not been charted for today. During an interview on 06/02/2026 at 4:45 PM, writer asked DON B to print the medication administration record of actual time LPN Q signed out Nicotine Lozenges for R32, LHNA A was present in DON B s office during this interview. Writer added there was a concern with R32 was not getting her Nicotine Lozenges twice today, LPN Q stated she gave it, R32 stated she never received it, nor was it signed out as given. DON B pulled up the report and verified that LPN Q signed out both Nicotine Lozenges given at 16:46 PM, not at 08:30 AM nor at 16:15 PM when LPN Q stated she gave them. Writer reported there was a problem with R32 reported not receiving her Nicotine Lozenges as ordered. Writer requested a copy of the MAR report, uploaded to Egress.

Based on observation, interview and record review, the facility failed to provide assistance with routine showers for one dependent resident (R28) of three reviewed.Findings include:On 6/03/26 at 9:09 AM R28 was observed sitting up in a manual wheelchair, with his breakfast tray in front of him. R28 was further observed to have a stocking over his right below the knee stump, which he reported was surgically removed on April 14th. He further reported that he should be receiving at least 3 showers per week to keep his surgical incision clean and without infection but that is not happening. Review of the clinical record revealed R28 was admitted into the facility on 5/19/26 with diagnoses that included: generalized anxiety disorder, depression and acquired absence of right leg below knee. According to the Minimum Data Set (MDS) assessment dated [DATE], R28 scored 14/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).A review of R28's shower task log revealed resident is scheduled for weekly showers on Monday and Thursday evenings and for the past 16 days only 2 showers had been documented (5/21/26 and 6/1/26). Based on R28's admission date and a twice weekly shower schedule R28 should have received at least 5 showers at the time of review.On 6/05/26 at 1:46 PM, during an interview with Director of Nursing (DON) B she confirmed that she only saw 2 showers documented for R28 since his admission. DON B further reported that any refusals of showers should be documented and resident should reapproached and offered a shower later, upon any refusals. No refusals were documented.

Based on observation, interview and record review the facility failed to review anti-anxiety medication to meet resident needs for one (R28) of two residents reviewed.Findings include:Review of the clinical record revealed R28 was admitted into the facility on 5/19/26 with diagnoses that included: generalized anxiety disorder, depression and acquired absence of right leg below knee. According to the Minimum Data Set (MDS) assessment dated [DATE], R28 scored 14/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).On 6/03/26 at 9:09 AM, R28 was observed sitting up in a manual wheelchair, with his breakfast tray in front of him. R28 reported that he preferred to be spoken to very slowly due to his anxiety. R28 reported that his anxiety was high and that he would not be able to eat his breakfast.On 6/5/26 at 11:25AM, R28 was observed sitting in the main dining room, he reported that he had been out of his anxiety medication for a couple days and that his anxiety was through the roof.A review of R28's physician orders revealed no active orders for an anti-anxiety medication, Further review of orders for Xanax (anti-anxiety medication) revealed that his PRN (as needed) order for Xanax had ended on 6/3/26.A review of R28's Medication Administration Record (MAR) revealed in May R28 received at least one dose of Xanax for 10 out of the 12 days the order was active (no doses given on 2 days and 2 doses given one day) and in June R28 received doses all 3 days that the order was active (2 doses were given on one of the three days).A review of R28's progress notes revealed resident was seen by the facilities Nurse Practitioner on 6/3/26, her notes included in part: Patient does report feeling anxious today he has concerns about staff did discuss his concerns with him as well as encourage patient to discuss with management he did state he has followed with them as well.Did provide therapeutic communication regarding patient's anxiety.Patient does endorse some increased anxiety did discuss coping mechanisms.On 6/5/26 at 12:52 PM, during an interview with Certified Nursing Assistant E, he reported that he was familiar with R28 since he works both as a CNA and as the facilities transport technician. When asked about R28's mood, he reported that R28 gets mad easily and when he is transporting him he has to go really slow and he definitely has bad anxiety.On 6/5/26 at 1:51 PM, during an interview with Director of Nursing (DON) B, she reported that she was familiar with R28 to a certain extent. When asked about his mood DON B reported that he reports that he gets anxious and says that he is anxious but when she sees him, he seems relaxed and friendly but gets overwhelmed easily and wants to be talked to slowly. When asked what the expectation is for a PRN anti-anxiety medication after the 14 day duration has ended, she reported that it should be reviewed to see how the symptoms are doing, if the medication is being administered and whether or not it should be scheduled, continued on a PRN basis or discontinued.Despite staff indicating resident had continued reports of anxiety/anxiety symptoms and resident regularly receiving doses of a PRN anti-anxiety medication it was documented that resident was reassessed following the 14 day order.

Based on interviews and record reviews, the facility failed to provide medically related social services for one resident (R65) of one resident reviewed for services not received.Findings Include;Resident #65 (65)During an interview on 06/02/2026 at 1:06 PM, R65 stated she doesn't have her power wheelchair back yet. R65 stated again if I had my mother fucking chair fixed, I wouldn't have to be stuck in this damn bed all day! Writer asked R65 how long she had been without her powered wheelchair and R65 stated months, last fall sometime.On 06/03/26 at 3:00 PM, writer emailed Guardian Z related to the repair of her powered wheelchair, Guardian Z emailed back. Guardian Z stated no, she still had not heard anything back from repair company but was going to call them again.On 06/03/26 at 3:30pm- writer requested the repair company's name and phone number, Guardian Z stated yes, and shared the only number she knew of and it was their customer service, given phone number. Guardian Z stated she filled out the Contact Us form on their website and still hadn't received a response.During an interview on 06/04/26 at 4:40pm, writer placed a call to repair company at the given number. Writer spoke to a receptionist, stated she had to transfer writer to another department. Writer had to leave a voicemail, requesting a call back by tomorrow. During an interview on 06/05/2026 at 8:44 AM, writer called the repair company at the given number and received a message that they were not open at this time. Did not leave a message, will call back. During an interview on 06/05/2026 at 10:16 AM, Licensed Practical Nurse (LPN) D stated R65 had not had her power wheelchair since last fall. LPN D stated she was not sure what was wrong with it, but it isn't working. LPN D stated she talked with R65 that morning and R65 told her she wanted to get up out of her bed today, and LPN D stated she was going to make sure that happens. Writer asked LPN D how R65 would get around after she was transferred via mechanical lift into a manual wheelchair and was unable to get herself around with her paralysis. LPN D stated R65 would need someone to take her wherever she wanted to go. LPN D added activities were taking residents outside today and she would make sure R65 got outside today. Writer asked LPN D about changes in the care needs of R65 related being stuck in bed 24/7 and no way to get around. LPN D stated she was on the call light more for the little things she could not get herself, increased frustration because of being in her room [ROOM NUMBER]/7 and bored and was socially isolated. LPN D also stated R65 now had more issues with compromised skin integrity on her back side. LPN D stated the provider came in that week and looked at her altered skin integrity and told the resident she needed to get off her back side. LPN D stated she would get R65 up in the manual wheelchair and get her outside. During an interview on 06/05/2026 at 10:20 AM, R65 stated it was hard staying in this room [ROOM NUMBER] hours a day, 7 days a week. R65 stated she only had her TV and cell phone and stated she may have been on the call light more because she cannot get out of this room because nobody would see that her powered wheelchair got fixed. R65 stated this was not right, it was causing social isolation, decreased quality of life, and they didn't care. R65 stated they moved her powered wheelchair from the hallway out to the garage. R65 stated this was no way to live, in the same room [ROOM NUMBER]/7 with no means of getting around herself. R65 stated nobody had updated her on the progress of the repair of her power wheelchair. R65 stated it pissed her off, made her frustrated and mad, nobody cared that she couldn't get around, nobody cared that the powered wheelchair didn't work. R65 stated they would tell her they didn't have enough staff available to wheel her around. R65 stated she wasn't usually depressed, but this situation has really affected her mentally and emotionally. During an interview on 06/05/2026 at 10:54 AM, with repair company and spoke with receptionist who wanted to transfer this call to that department, writer explained that we have had several calls transferred to that department and no call back. Receptionist asked writer to hold on so he could see if there was a manager available. The Receptionist came back on the call and stated the supervisor would call writer back.During an interview on 06/05/2026 at 2:23 PM, DON B stated she was unsure what was wrong with the powered wheelchair and why it was not getting fixed. DON B stated that LHNA A said something about the family didn't want to pay to get it repaired.Received a call back from the repair company that went straight to voicemail stated they had been in contact with R65's sister who knew nothing about the powered wheelchair, and because she didn't know what was wrong, they couldn't schedule a repair visit.During an interview on 06/05/2026 at 2:53 PM, Guardian Z was updated that the repair company was contacting the sister who had nothing to do with making medical decisions. The repair company had not been updated with the Guardian Z contact information by the facility. Writer asked Guardian Z to provide the up dated information with her contact information so they can contact the correct person. Had the facility provided the updated Guardian information to the repair company, R65 may not have had to wait months to get her powered wheelchair repaired. R65 may not have had to spend months in her bed, in her room, 24 hours a day, 7 days a week.

Citation pertains to intake #3030189Based on observation and interview the facility failed to ensure medication administration was observed with a nurse for one resident (R3) of one resident reviewed.Findings include:Resident #3 (R3)Review of the medical record reflected R3 was an initial admission to the facility on [DATE]. Diagnoses of osteoarthritis in the right knee, acute embolism and thrombosis of the right knee, obesity, diabetes mellitus 2, obstructive sleep apnea, pain in left hip, major depression and anxiety.The most recent Minimum Data Set (MDS) revealed R3 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section GG0115, Functional Limitation in Range of Motion revealed R3 was independent with oral care and eating. R3 was dependent on care for toileting, hygiene, Shower/baths and transfers.During an observation and interview on 06/03/2026 at 9:34 AM, writer observed several of R3's medications in the med cup that were left on her over the bed table. No nurse was present in the room to observe R3 taking them. R3 stated the nurses usually leave her medications on the bedside table for her to take. R3 stated she had to take some of her pills on a full stomach, and others needed to be after that. During an interview on 06/03/2026 at 12:58 PM, Licensed Practical Nurse (LPN) D stated R3 was particular on how she took her medications, she would not take them at once. LPN D stated she went in there and R3 wouldn't take her morning medications at that time. Writer asked LPN D if R3 had been evaluated for self-administration of her medications. LPN D stated R3 had not been evaluated for self-administration of her medication and stated R3 would tell nursing how she wanted to take her medications. During an interview on 06/03/2026 at 1:26 PM, writer asked DON B what her expectations were for administering medications to residents. DON B stated hand hygiene, right resident, right medication, right route, right time, right dose and document administration of medications.

Based on observation, interview, and record review the facility failed to prepare and serve food in sanitary conditions resulting in an Immediate Jeopardy due to the likelihood of foodborne illnesses to affect 72 resident who ate meals out of the kitchen.Findings Included:During an observation on 2/19/26 at 8:42 a.m., garden hoses were observed coming from an open Dinng Room window to drain located near main entrance of the facility with what appeared to be water coming from the hose. Plumbing contractor van was parked in front of the Dining Room window. After entering the facility very loud sound of what sounded like jack hammering could be heard on the ground floor. During an interview on 2/19/26 at 8:45 a.m., Nursing Home Administrator (NHA) A reported had been employed at the facility for about five months. NHA A reported facility had recent water line break underground in the kitchen and started work this week Monday (2/16/26). NHA A reported the repair estimate was two days and reported need to extend time frame because contractors now need to dig up lines to the laundry as of today. HNA A reported temporary barrier walls were placed in the kitchen to contain area of repair. During an observation and interview on 2/19/26 at 10:35 a.m., upon entering main dining room table and carts were located around perimeter of dining room with no resident dining areas available. Table had kitchen items stacked on them and dry storage food was present on several carts. Garden hoses were observed coming from the kitchen, across the dining room floor and out an open window duct taped to the floor. Certified Dietary Manager (CDM) O reported had worked at the facility for about two weeks. Observed dietary staff holding kitchen door open with garden hoses duct taped to kitchen floor alongside tray line steam table. The garden hoses were observed coming from behind an area in the center of the kitchen that had temporary unsecured plastic walls hanging with loose dirt piles exposed on the floor located directly next to the tray service steam table and stovetop/overhead ventilation system. Dietary staff was observed prepping desserts on small table located in kitchen near dining room door. The kitchen floors appeared heavily soiled with boot prints through kitchen. CDM O reported contractors plan to expand hole in kitchen floor today so all refrigerator/freezer/dry storage items had to be removed because area of floor digging would block those areas. Continued tour of kitchen revealed several large open areas in temporary plastic walls with large holes in kitchen floor (about 4 feet deep and about 20 feet long), exposed plumbing, large piles of dirt, broken tile/concrete, and rocks. Observed a heavily soiled wheelbarrow and contractor equipment located near the three-compartment sink, reach in coolers, food warmer and several carts of dishes. CDM O reported had been serving resident meals on disposable dishes since Monday from kitchen and planned to wash all the uncovered dishes in kitchen prior to use after kitchen construction. Contractor was observed standing in about 4-foot-deep hole in ground actively digging dirt in office, located inside kitchen, with door open to kitchen with several large piles of dirt about 2-3 feet high. CDM O reported was currently working on moving items out of dry storage and door was open, located about 6-10 feet from contractor digging in floor with no barriers in place. Continued tour revealed several prepped and wrapped silverware located on steam table, directly next to plastic barrier on tray line (within 2 feet of large hole in kitchen floor and exposed piles of dirt on the floor). Several cardboard boxes of disposable meal service items directly on kitchen floor near tray line area. During an observation on 2/19/26 at 11:37 a.m., Observed dietary staff serving food from steam table located in kitchen, directly next to unsecured temporary plastic barrier with large hole in kitchen floor and exposed dirt piles, concrete debris, rocks and wastewater. Observed contractor staff walk past tray line steam table during tray line prep. Verified menu served on disposable dishware was glazed ham, potatoes, veggie collards, dinner roll, pudding with topping. Observed soiled blender in dining room, located on dining room table directly next to personal drinks and soiled towel. In an interview on 2/19/2026 at 2:09 PM, Certified Dietary Manager (CDM) O stated on 2/16/2026 at about 8:00 AM, after the breakfast meal was served, the first hole was dug in the floor around where the steamer (cooking appliance) sat. CDM O said all further meals after breakfast continued to be prepped and served in the kitchen next to where the hole in the floor was being dug. During the interview it was observed that the tray line (where the food was placed to keep it warm and be served onto plates) was next to a plastic barrier wall which was not sealed tight to the wall, having several openings. Mounds of dirt were observed to be piled up alongside the open hole, with some dirt seeping outside of the plastic barrier wall into the area where the food was being prepared. CDM O stated that with the digging and the dirt, the floor in the food prep area was hard to keep clean. The refrigerators were observed to be in the back of the kitchen which was beyond the barrier and passed by the large hole, and per CDM O food had been taken back and forth from the two refrigerators from the time the hole was dug at approximately 8:00 AM on Monday 2/16/2026, risking the chance and having the likelihood of pathogen contamination. In an interview on 2/19/2026 at 2:00 PM, Dietary Aid (DA) P stated that the kitchen floors were mopped between meals but were hard to keep clean because the plumbers walked through the food prep area all the time which tracked dirt in the food prep area. In an interview on 2/19/2026 at 2:43 PM Director of Nursing (DON) C stated that she agreed that if the wall barrier in the kitchen around the hole was broke open there was the risk of pathogens contaminating the food, and when the residents eat the food, they could become ill with most likely gastrointestinal (GI) illnesses. DON C stated that her expectations were that there be a sealed barrier and then food could have been prepared in the kitchen, but because the barrier was not sealed the food should not have been prepared in the kitchen but should have been taken out of the kitchen area. The Administrator was notified on 2/19/2026 at 12:06 PM of the Immediate Jeopardy that began on 2/16/2026 as a result of the facility's failure to prepare and serve food in sanitary conditions resulting in the likelihood of food borne illness for 74 residents who are food out of the facility's kitchen. In an interview on 2/20/2026 at 7:58 AM, Maintenance Director (MD) Q stated that the water had backed up in the laundry room and backed up under the three-compartment sink in the kitchen. MD Q said the drain had to be snaked out, and then when the laundry room drain was snaked out a broken pipe was found. MD Q said the pipes were rotted out, and the blockage was in the kitchen at the steamer and the tray line area. MD Q said the hole was dug starting on Monday 2/16/2026, and the plumbers put up the plastic prior to the digging which was next to the area of the food prep. MD Q stated that he did not verify that the plastic barrier wall was secured to prevent any containments over into the food prep area, nor did he check the barrier frequently to ensure the barrier was secure at all times. MD Q said the plumbers sealed the plastic. MD Q said the plumbers used a wet saw to break through the floor tiles but stated that does still cause dust. In an interview on 2/20/2026 at 11:32 AM the previous DON, DON B stated she was aware that the plumbers were digging a hole in the kitchen but did not know when it was going to start. DON B said she was fully aware that they were digging on 2/17/26 but did not go into the kitchen as she was under the impression that there was a barrier up. DON B said she had first entered the kitchen on 2/19/2026 and was monitoring the barrier wall by verbalizing in the morning meetings that the barrier needed to stay secure, but stated she never checked the barrier wall and said no one else did either. DON B said she did not know that food was still being prepped in the kitchen next to the hole that was being dug and stated that she thought the food preparation had been moved out of the kitchen but stated that she did not check. DON B said she would expect that no food was to be prepared in the kitchen during the time of the pipe repair. DON B said she should have asked more questions. DON B said the pathogens that would be of concern were things like e-coli and that would affect the residents with GI problems, vomiting, and diarrhea. In another interview on 2/20/2026 at 12:05 PM, CDM O stated she looked at the barrier wall all the time but did not document that it was secure. CDM O said she was never asked about the barrier wall in morning meeting and said no one monitored that the barrier was always secure. From 2/16/2026, beginning with the lunch meal until 2/19/2026 ending with the lunch meal, 10 meals were served out of the kitchen during the time the barrier was up, and the hole was being dug in the kitchen. In an interview on 2/20/2026 at 12:17 PM, Administrator A stated she went into the kitchen after the barrier was put up and said she did see that the barrier was secure and closed, however never ordered that the food preparation be removed from the kitchen to a clean area. Administrator A said the barrier wall was discussed at all morning meetings and said she did not assign a staff member to check the barrier to assure that it was secured. The Administrator submitted a Plan of Correction to remove the Immediate Jeopardy on 2/19/2026. On 2/24/2026 the surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: 2/13/26 Facility plans to use prepared food from US Food Vendor for upcoming meals; ordered and received from US food delivery today. This started on 2/13/2026 as a back-up plan. 2/13/26 Facility is using disposable paper products immediately. This was received in the facility on 2/12/2026 for back-up plan. 2/19/26 Facility discarded all lunch that was ordered for residents and lunch trays that were enroute to the units were stopped. Lunch was catered in for the residents. 2/19/26 Dietician and Medical Director were notified of the Immediate Jeopardy. 2/19/26 The kitchen immediately closed fir services. 2/19/26 The dining room next to the kitchen is being set up to be used as the temporary kitchen until the pipe work and construction are completed. The juice machine, coffee maker, steamer, steam table, tray line, prep area, and 3 compartment area, handwashing station are items being utilized in the temporary kitchen. 2/19/26 74/74 resident who eat meals were immediately assessed for food borne illness. 2/19/26 74/74 residents at risk for food borne illness. 2/19/26 Temporary refrigeration truck is at the building now and provides both freezer and refrigeration. 2/19/26 Electrician notified to inspect for correct plug for steamer to be used in temporary kitchen. They rewired to accommodate the steamer in the temporary kitchen and passed to use now in the temporary kitchen. 2/19/26 Steam table disinfected once it was removed from construction zone. 2/19/26 Hand washing station was delivered and is set up in the temporary kitchen While the Immediate Jeopardy was removed on 2/19/2026, the facility remained out of compliance at a scope of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy at scope and severity of widespread, due to the fact that sustained compliance has not been verified by the state agency.

Based on observation, interview, and record review, the facility failed to timely identify the formation of pressure ulcers and consistently implement ordered wound care treatments for 2 (Resident #3 and #5) of 2 residents reviewed for pressure ulcers, resulting in the development of a facility acquired Unstageable Pressure Ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) for R3 and a Deep Tissue Injury (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister) for R5, and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status. Findings include: Resident #3 (R3) Review of the medical record revealed that Resident #3 (R3) was initially admitted to facility 4/19/21 with diagnoses including diabetes mellitus type 2, lymphedema, morbid obesity, and localized edema. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/24/24 revealed that R3 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 6 (severe cognitive impairment). Section M of the same MDS reflected that R3 was at risk of developing pressure ulcers, had 2 venous ulcers, but was not on a turning/repositioning program. Review of R3's ADL (Activities of Daily Living) Care Plan reflected that R3 required assist of one for dressing and assist of 2 for toilet use, transfers, and bed mobility. In an observation and interview on 5/14/24 at 12:33 PM, R3 was observed sitting in wheelchair, in room, with gauze wraps visible to bilateral lower legs. R3 stated that she had sores on her legs and bottom, that she was uncomfortable and did not feel good but was unable to elaborate on either further. In an observation and interview on 5/14/24 at 3:02 PM, R3 was observed lying in bed, on back, with left leg bent at knee and right leg extended straight out. R3 again stated that she did not feel well and that her bottom was sore but was unable to elaborate further prior to closing eyes and providing no further response to questions. In an observation and interview on 5/15/24 at 8:11 AM, R3 was observed lying in bed, on back, with legs extended straight out. R3 opened eyes when name called and when questioned stated that her bottom was sore but better prior to closing eyes and providing no further response to additional questions. On 5/15/24 at 1:22 PM, Licensed Practical Nurse (LPN) I was observed to prepare wound supplies and complete R3's pressure ulcer treatments. During preparation of supplies at treatment cart, LPN I confirmed familiarity with R3, stated that she had fairly new pressure ulcers at buttock region and had provided pain medication to R3 just prior as the treatments were uncomfortable for her. Upon entering room in presence of LPN I and N, R3 was observed lying in bed, on back, with head of bed at an approximate 30 degree angle. Both LPN I and N repositioned R3 onto right side with LPN I observed to remove bordered foam dressings at right iliac crest and left buttock region. Left buttock noted to present with open ulcer measuring approximately 1.5centimeters (cm) x (by) 1.0cm with pale yellow slough (non-viable tissue adhered to the wound bed that must be removed from the wound for healing to take place) at central wound aspect and dark pink granulation (healthy pink to red tissue) toward wound edge. Right iliac crest region (bony surface toward upper buttock/hip region) observed to present with small open ulcer measuring approximately 0.5cm x 0.5cm with pale yellow slough at central wound aspect and light pink tissue toward wound edge. Surrounding tissue of both open wounds noted to be intact but fragile with mild dry/flaky skin. Review of R3's medical record completed with the following findings noted: Braden Scale For Predicting Pressure Sore Risk dated 4/24/24 reflected score of 11 indicating high risk for pressure ulcer development. Skin & Wound Evaluation dated 4/23/24 indicated a new in-house acquired unstageable (due to slough and/or eschar) right iliac crest pressure ulcer measuring 1.2cm x 2.2cm. Wound bed indicated as pink or red with remainder of wound assessment form including exudate, periwound, and wound pain noted to be blank. Skin & Wound Evaluation dated 4/26/24 indicated the same unstageable right iliac crest pressure ulcer now measuring 1.0cm x 1.1cm with 70% slough in wound base, light drainage, and moderate pain at dressing change. Skin & Wound Evaluation dated 5/3/24 indicated the same unstageable right iliac crest pressure ulcer now measuring 0.5cm x 0.5cm with 60% slough in wound base, light drainage, and moderate pain at dressing change. Skin & Wound Evaluation dated 5/10/24 indicated the same right iliac crest pressure ulcer to now be presenting as a Stage 3 pressure ulcer measuring 0.4cm x 0.3cm with 30% slough in wound base, light drainage, and moderate pain at dressing change. Skin & Wound Evaluation dated 5/3/24 indicated a new in house acquired deep tissue injury at left gluteus (buttock) measuring 2.3cm x 1.2cm with 100% epithelial tissue in wound base and moderate pain at dressing change. Skin & Wound Evaluation dated 5/10/24 indicated the same left gluteus pressure ulcer now presenting as a Stage 3 ulcer measuring 1.5cm x 0.9cm with 70% granulation tissue and 30% slough in wound base, light drainage, and moderate pain at dressing change. Physician order dated 10/18/22 stated, Ensure low-air loss pressure redistribution surface is on and operational. Physician order dated 3/13/24 stated Body audit one time a day every Mon for skin observation, 0-No skin breakdown, 1-Previously identified wound/breakdown, 3-Newly identified wound/breakdown-describe in progress note. Review of corresponding order on Treatment Administration Record (TAR) dated 4/1/24 - 4/30/24 reflected completion on 4/15/24, 4/22/24, and 4/29/24 with no newly identified wounds noted although facility acquired unstageable pressure ulcer identified at R3's right iliac crest on 4/23/24 (1 day after completion of body audit) and facility acquired deep tissue injury identified at R3's left gluteus on 5/3/24. Physician order dated 4/23/24 stated, Cleanse sacrum with wound cleanser, Apply medihoney to wound bed, Skin prep to peri wound, Cover with foam dressing, Complete treatment daily. Review of corresponding TAR dated 4/1/24 - 4/30/24 reflected that from the 4/24/24 date of treatment initiation through 4/30/24 that the treatment was completed only 5 out of the 7 days as the treatment administration boxes on 4/27/24 and 4/30/24 were noted to be blank. Physician order dated 5/1/24 stated, Cleanse sacrum with wound cleanser, pat dry, apply triad, apply comfort foam dressing. Physician order dated 5/3/24 stated, Wound: right iliac crest: Cleanse sacrum with wound cleanser, pat dry, apply medihoney to wound bed and cover with a bordered foam dressing. Physician order dated 5/10/24 stated, Wound: right iliac crest: Cleanse with wound cleanser, pat dry, apply Medi honey to wound bed and cover with a bordered foam dressing. Physician order dated 5/3/24 stated, Wound: Left Gluteus: Wash wound with wound cleanser and pat dry. Apply skin prep and cover with a bordered foam dressing daily . Physician order dated 5/10/24 stated, Wound: Left Gluteus: Wash wound with wound cleanser and pat dry. Apply Medi-honey and cover with a bordered foam dressing daily . Physician order dated 5/3/24 stated, please give resident morphine BEFORE wound care. Skin Impairment Care Plan Focus with an 8/4/21 date of initiation and 5/13/24 date of revision stated, I have skin impairments .right iliac crest pressure injury, left gluteus PI [pressure injury] with associated interventions including, low air loss mattress has been in use with a 4/28/24 date of initiation. Resolved interventions within the same care plan included Turn and reposition q2h (every 2 hours) and pressure redistribution cushion to wheel chair both with an 8/4/21 date of initiation and 4/11/24 resolution date and Low air loss mattress with an 8/4/21 date of initiation and 4/18/24 resolution date. Potential impairment to skin integrity care plan focus with a 4/11/24 date of initiation and 5/14/24 revision date was noted with associated interventions including, Assist and encourage to turn and reposition, Assist with incontinent care use moisture barrier cream after incontinent episodes, and Education to resident on wound prevention (R3's BIMS score = 6 limiting ability to understand/retain provided education) all with a 4/11/24 date of initiation. Comprehensive review of R3's progress notes from 4/1/24 through 4/23/24 was not noted to include a nursing progress note or Wound Nurse Practitioner (NP) Encounter Note to indicate monitoring of or concern/risk for skin alterations to coccyx/buttock region. No nursing progress note was noted for the 4/23/24 date to reflect right iliac crest pressure ulcer identification or treatment although R3's Skin & Wound Evaluation dated 4/23/24 indicated a new in-house acquired unstageable ulcer on that date and review of physician orders included a treatment order to same region on that date. Additionally, no preventative coccyx/buttock treatment order was noted prior to unstageable wound formation. Physician Encounter Note with an indicated Date of Service of 4/22/24 and Signed Date of 4/28/24 stated, .Chief Complaint .Seen regarding regulatory visit as well as coccyx wound .Skin: Somewhat unavoidable sacral wound to coccyx area. Patient with difficulty turning poor nutrition and hospice status all of which make the wound more likely to progress . Wound NP Encounter Note dated 4/26/24 reflected right iliac crest unstageable pressure ulcer assessment as contained within Skin & Wound Evaluation dated 4/26/24. Wound NP Encounter Note dated 5/3/24 reflected newly identified left gluteus deep tissue injury and ongoing right iliac crest unstageable pressure ulcer assessments contained within Skin & Wound Evaluations dated 5/3/24. IDT Note dated 5/8/24 stated, .IDT note r/t [related to] skin. Resident has an unstageable pressure ulcer to her right iliac crest .Resident has a DTI to her left gluteus .Resident has an air mattress and offloading boots in place. Care plan was reviewed and is appropriate. Wound NP Encounter Note dated 5/10/24 reflected right iliac crest and left gluteus stage 3 pressure ulcer assessments as contained within Skin & Wound Evaluation dated 5/10/24. In an interview on 5/15/24 at 4:06 PM, Director of Nursing (DON) B stated that the facility's skin management program included completion of a weekly skin assessment prompted by a Body Audit order with documentation within the TAR to reflect absence of skin breakdown, previously identified breakdown, or newly identified breakdown. DON B stated that with any newly identified breakdown the expectation was for a corresponding progress note to be completed and a treatment order to be obtained and written. DON B stated that the IDT reviewed all progress notes from the prior 24-hour period at a meeting each weekday morning and when any skin alteration was noted an audit would be completed to verify that an appropriate treatment order was in place. DON B further stated that if any noted concern exited for a newly identified would or ulcer (pressure, vascular, diabetic, surgical), that either she or one of the facility's unit managers would assess further, take a picture if warranted, and assure an appropriate treatment was in place until the Wound NP and RN (Registered Nurse) rounded each Friday. Per DON B, upon completion of weekly assessments, the Wound NP and RN would then provide her with a face-to-face report regarding each resident's wound status as well as any medical equipment recommendations, follow up testing, or wound clinic referrals. In a follow-up interview on 5/16/23 at 9:53 AM, DON B confirmed familiarity with R3, stated that she had both chronic vascular wounds and fairly recent facility acquired pressure ulcers to buttock region. Upon referencing R3's medical record, DON B confirmed that the right iliac crest pressure ulcer was identified, assessed, and documented on (per the Skin & Wound Evaluation dated 4/23/24) by the assigned nurse on 4/23/24. DON B further stated that although she did not assess R3's wound herself on that date she recalled discussing the wound presentation with the assigned nurse and following up with R3's physician for a treatment order (confirmed that the 4/23/24 sacral wound treatment order was for the newly identified right iliac crest ulcer). Upon review of the corresponding April TAR, DON B confirmed that as the 4/27/24 and 4/30/24 treatment administration boxes were not signed out as completed, there was no documentation to indicate that the ordered treatment was completed on either date. DON B further confirmed that upon identification, on 4/23/24, R3's right iliac crest wound presented as an unstageable pressure ulcer, stated that she could locate no notes or assessments that reflected any concern or compromise to region prior, or any prior physician order for protective skin care to buttock region. DON B stated that she would not have expected wound to be at an unstageable level with initial identification but acknowledged that R3's 4/15/24, 4/22/24, and 4/29/24 Body Audit reflected no newly identified wounds and could find no documentation that a CNA had identified or alerted nursing staff to any skin changes to region with routine cares or application of standard protective barrier cream. Per DON B, following the identification of R3's right iliac crest unstageable pressure ulcer, a new treatment was initiated but that as R3 was known to be at risk for breakdown due to incontinence, non-ambulatory status, and dependence for transfer and bed mobility, that pressure reduction measures were already in place including a low air loss mattress, boots to legs, standard wheelchair cushion, and assist with repositioning. DON B confirmed that despite identification of R3's unstageable pressure ulcer on 4/23/24 that no new pressure reduction measures were initiated as all warranted interventions were already in place. Upon further review of R3's medical record, DON B stated that the Wound NP and RN identified a new deep tissue pressure injury to R3's left buttock region with their routine weekly assessment on 5/3/24 and that further review included no documentation to reflect that the facility staff had identified the ulcer prior to that date/time. DON B confirmed that a treatment was initiated on that same date for the newly identified wound but that as all pressure reduction measures remained in place that no additional measures were implemented. Additionaly, DON B stated that she could follow-up with hospice services to see if they had a more specialized pressure reduction mattress or wheelchair cushion that could be trialed to decrease risk of additional pressure ulcer formation to R3's buttock region. Resident #5 (R5) Review of the medical record revealed that Resident #5 (R5) was readmitted to facility 1/3/24 with diagnoses including multiple sclerosis, unspecified dementia, polyneuropathy, peripheral vascular disease, and stiffness of right and left ankle not elsewhere classified. Review of the MDS with an ARD of 5/8/24 reflected a staff assessment for mental status indicating that R5 had both short and long-term memory impairment with severely impaired cognition for daily decision making. Section M of the same MDS reflected that R5 was at risk of developing pressure ulcers and had unhealed pressure ulcers including a facility acquired deep tissue injury. Review of R5's ADL Care Plan reflected that R5 was dependent with assist of two for transfers, bathing, dressing, toileting needs, and bed mobility. In an observation on 5/14/24 at 9:49 AM, R5 was observed lying in bed, on back, with head of bed positioned at an approximate 45-degree angle. R5's legs were observed to be extended straight out with soft, green, cushioned boots in place bilaterally. R5's eyes were open but R5 offered no response to questions. A blue positioning wedge was noted on floor to right of bed. On 5/14/24 at 12:30 PM, R5 was observed lying in bed, positioned toward left side with head of bed at an approximate 45-degree angle. A blue positioning wedge was noted on the windowsill to the right of R5's bed. On 5/15/24 at 1:22 PM, Licensed Practical Nurse (LPN) I was observed to prepare wound supplies and complete R5's pressure ulcer treatment. During preparation of supplies at treatment cart, LPN I confirmed familiarity with R5, stated that R5 had a chronic pressure ulcer to her sacrum and a new pressure ulcer to her right heel. LPN I stated that ongoing pressure reduction precautions for R5 included a low air loss mattress and green boots, both of which had physician orders and had been in place prior to formation of the right heel wound with no new interventions, to her knowledge, after formation with exception of skin prep (a protective film designed to protect intact skin) application for protection. Upon entering room in presence of LPN I and N, R5 was observed lying in bed, toward right side, with blue positioning wedge at left back region. Upon LPN I's removal of R5's soft green boot at right lower extremity and lifting of R5's right leg, an approximate 2.0cm x 1.5cm area of intact deep purple skin with brown discoloration at edges noted to back of right heel. Review of R5's medical record completed with the following findings noted: Braden Scale For Predicting Pressure Sore Risk dated 4/3/24 reflected score of 12 indicating high risk for pressure ulcer development. Skin & Wound Evaluation dated 5/3/24 indicated a new in-house acquired deep tissue injury at right heel measuring 2.3cm x 1.1cm with 100% epithelial tissue in wound base. Skin & Wound Evaluation dated 5/10/24 indicated the same right heel deep tissue injury now measuring 2.8cm x 1.3cm with 100% epithelial tissue in wound base. Physician order dated 3/13/24 stated, Ensure low-air loss pressure redistribution surface is on and operation. Physician order dated 3/26/24 stated, [NAME] offloading boots in place at all times, please remove q [every] shift and check skin integrity. Review of corresponding TAR dated 4/1/24 - 4/30/24 reflected availability for day shift documentation only with 4/1, 4/6, and 4/30 administration boxes noted to be blank/not signed out as completed. Review of corresponding TAR dated 5/1/24 - 5/31/24 reflected availability for day shift documentation only. No evening/night shift documentation noted in R5's medical record to reflect the routine application of R5's green offloading boots. Physician order dated 5/1/24 stated, Skin prep bilateral heels, leave open to air. Nursing/Clinical Note dated 5/1/24 stated, .During dressing change to coccyx writer observed a quarter sized area to right heel that was dark purple in color .Treatment orders adjust . Wound NP Encounter Note dated 5/3/24 reflected right heel deep tissue injury assessment as contained within Skin & Wound Evaluation dated 5/3/24. IDT Note dated 5/8/24 stated, .IDT note r/t wounds .DTI (deep tissue injury) to right heel which is stable .continues to have an air mattress and resident has off loading boots in place .Interventions and treatments remain in place and appropriate. Wound NP Encounter Note dated 5/10/24 reflected right heel deep tissue injury assessment as contained within Skin & Wound Evaluation dated 5/10/24. Care Plan Focus with a 10/2/20 date of initiation and 5/7/24 revision date stated, I have .PI [pressure injury] to my right heel . with associated interventions including, Assist to turn and reposition with a 10/2/20 date of initiation and 4/19/24 revision date, and Boots to Bilateral feet and Low air loss mattress to bed with a 5/4/24 date of initiation. Resolved care plan interventions within same care plan included, LAL [low air loss] mattress with a 3/4/24 date of initiation and 4/19/24 resolved date, low air loss mattress to bed with a 10/2/20 date of initiation and 3/4/24 resolved date, Float my heels using offloading boots with a 10/2/20 date of initiation and 3/12/24 resolved date. In an interview on 5/15/24 at 2:30 PM, Certified Nurse Aide (CNA) S confirmed familiarity with R5 and that she was her assigned aide that date. Per CNA S R5 was dependent for all care including bed mobility, bathing, dressing, incontinency care, and transfers. CNA S stated that R5 had wounds on her bottom for a long time and had just developed one at her right heel. Per CNA S, the assigned nurse did all the treatments but that she continued to make sure she had her green boots on and was repositioned in bed approximately every 2 hours. In an interview on 5/15/24 at 4:39 PM, DON B confirmed familiarity with R5, stated that she had a chronic sacral ulcer that would open and close and that she also had a DTI at right heel identified on 5/1/24 by assigned nurse. DON B stated that skin prep was implemented at the time of ulcer identification but that as had low air loss mattress, green offloading boots, routine assist with repositioning already in place prior to ulcer identification that no new interventions were initiated post ulcer identification including the implementation of new or alternative heel offloading devices. DON B further stated that IDT meeting held post wound identification with collaborative decision that all interventions and treatments remained in place and appropriate despite the fact that R5's right heel pressure ulcer developed with those same interventions in place.

Based on observation, interview, and record review, the facility failed to prevent a fall with major injury for one (Resident #38) of three reviewed, resulting in Resident #38 falling out of bed during care and sustaining a femur fracture. Findings include: Review of the medical record revealed Resident #38 (R38) admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included fracture of lower end of right femur and hemiplegia and hemiparesis following a stroke. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/10/24 revealed R38 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 5/14/24 at 10:25 AM, R38 was observed in bed with a brace on their right leg. On 5/14/24 at 10:55 AM, R38 was observed in a Broda chair. R38 reported they fell out of bed and broke their leg while Certified Nursing Assistant (CNA) F was providing care. Review of Witnessed Fall incident report dated 3/31/24 revealed Assigned Cena [CNA] to resident was giving care changing resident's brief while holding resident over on her side during care resident started to slide out of bed during change staff lowered resident to floor mat and called for help. Review of the Interdisciplinary Team (IDT) Note dated 4/1/24 revealed IDT reviewed fall from the day before, Resident rolled out of bed during care. Denied pain or discomfort at time of incident however reported pain a few hours later to the right knee. [Physician] ordered Xray of the right knee that indicated fracture of the femur. [Physician] made aware and gave order to send to hospital for eval [evaluation] and treatment. Review of the care plan revealed R38 required extensive assistance by two staff members to turn and reposition in bed. The intervention was dated 4/27/22. In an interview on 5/15/24 at 2:06 PM, Nursing Home Administrator (NHA) A reported R38 sustained a fall with fracture on 3/31/24 while CNA F provided care. NHA A reported CNA F did not use the appropriate number of staff required to provide bed mobility. In a telephone interview on 5/15/24 at 3:12 PM, LPN R reported R38 required two staff members for care. LPN R reported CNA F initially reported care was provided with two staff members, but it was later determined that CNA F provided care alone and R38 fell out of bed and fractured her leg. Attempts were made to contact CNA F via telephone on 5/15/24 at 3:04 PM and 5/16/24 at 12:23 PM but were unsuccessful. Review of the hospital discharge summary dated 4/3/24 revealed R38 sustained a right distal femur fracture with a locked hinged braced recommended for non-operative management. In an interview on 5/16/24 at 10:01 AM, Social Worker (SW) E reported R38 loves to sit in the dining room by the window. SW E reported since R38 sustained the fracture, R38 has had increased yelling, calling out, and signs of depression. SW E reported she believed some of that was attributed to pain and being stuck in bed due to the fracture. SW E reported R38 was very anxious while on bed rest. In a telephone interview on 5/16/24 at 10:57 AM, Licensed Practical Nurse (LPN) P reported R38 had increased pain after the fracture and has required a change in their pain medication regimen. LPN P also reported R38's anxiety had increased since the fracture and required an increase in anxiety and depression medications. In a telephone interview on 5/16/24 at 11:04 AM, LPN Q reported after R38 sustained the fracture, R38 was afraid to get out of bed and had a lot of anxiety. LPN Q reported R38 no required a Hoyer lift to transfer from bed, which was a change. Review of the care plans revealed prior to the fracture, R38 transferred with a sit to stand mechanical lift and after the fracture, R38 required a Hoyer lift to transfer. Review of the facility's Past Non-Compliance Worksheet revealed Resident was rolled out of bed while CNA was providing incontinent care. Root cause analysis was CNA did not use appropriate number of staff required to provide bed mobility. The deficient practice was corrected on 4/3/24 after the facility completed the following: 1. CNA F was suspended pending investigation. 2. R38 had x-ray completed that identified right distal femur fracture and was transferred to the hospital for further follow up. 3. Director of Nursing (DON)/designee completed audit of falls for the last 30 days to identify if any were related to not using appropriate number of staff required for bed mobility. 4. Nursing staff were reeducated on using appropriate number of staff per plan of care for bed mobility. 5. Nurse managers/designee completed random monthly audits of nursing staff to ensure they are using the appropriate number of staff required for bed mobility. 6. DON/designee completed 5 random weekly audits for four weeks of staff members assisting residents with bed mobility to ensure appropriate number of staff required per plan of care for bed mobility. 7. Results of audits were put through QAPI for further follow up and recommendation. On 5/16/24 at 2:46 PM, NHA A reported CNA F's employment was terminated on 4/3/24.

This citation pertains to intake MI00140183. Based on interview and record review, the facility failed to timely assess, accurately monitor and treat a resident with a history of known insulin-dependent diabetes mellitus (high blood sugar) for one resident (R101) out of three residents reviewed for quality of care, resulting in critically elevated blood sugars requiring emergency hospital treatment and admission. Findings include: Review of an intake submitted to the State Agency (SA) documented concerns the facility was not monitoring or treating resident with diabetes mellitus. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R101 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, hypertension (high blood pressure), osteoarthritis right shoulder, heart disease, renal failure with required dialysis, and depression. The MDS reflected R101 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required two person physical assist with bed mobility, transfers, toileting and one person physical assist with locomotion on unit, dressing, hygiene, and bathing. The MDS reflected R101 had no behaviors including rejection of care. Review of the Electronic Medical Record(EMR), dated 5/20/23 through 5/29/23, reflected R101 was admitted into the facility from the hospital on 5/20/23 and transferred back to the hospital on 5/29/23. Review of R101's Nursing Progress Note, dated 5/20/2023 at 4:42 p.m., reflected,Resident arrived via w/c. Oriented to room, bed controls, call light, tv remote, and RR. Instructed to use call light AAT when in need of assistance. Vitals are WNL, assessment complete, excoriated folds noted, misc bruising/scabbing, L chest port, and wounds to R foot and coccyx. Lungs are clear, bowel sounds are present x4, and pulses are equal. Resident is a FC, renal diabetic diet w/thin liquids and a fluid restriction . Review of R101's Physician Progress Note, dated 5/22/23, reflected, Patient is a [AGE] year-old with past medical history of end-stage renal disease on hemodialysis. Status post hospitalization . Takes Eliquis for atrial fibrillation, diabetes type 2, chronic systolic and diastolic heart failure. Recently admitted for shortness of breath and diarrhea . Review of R101's Nursing Progress Note, dated 5/24/2023 at 10:33 a.m., reflected, Writer spoke with NP regarding resident being a diabetic without any medications for diabetes NP advised writer to obtain a blood sugar 1 time a day for 7 days and then 1 time a week thereafter. Note completed by Unit Manager/Licensed Practical Nurse I. Review of R101's Hospital Discharge Summary, dated 5/20/23 at 2:10 p.m., reflected, .End-stage renal disease on hemodialysis .Patient has been on hemodialysis for several years and secondary to type 2 diabetes .Patient is on 6-8 U of Lantus daily depending on her dinner, per patient .Hospital Course [named R101] is a 71 y.o. female with PMHx of hypertension, atrial fibrillation on Eliquis 5mg twice per day, CAD s/p PCI to OM1 (5/2021), Chronic Obstructive Pulmonary Disease, insulin-dependent type 2 diabetes mellitus, ESRD on dialysis MWF who presented to the ED for increasing fatigue, loose stools/fecal incontinence . Continued review of the Hospital Discharge Summary reflected orders that included insulin pen needles including for use with Lantus(long acting insulin) and orders to monitor blood sugar three times daily. Review of the Hospital Records, dated 5/17/23 through 5/19/23, reflected R101 had orders for Lantus insulin 5 units daily with breakfast and Humalog per sliding scale before meals and bedtime (four times daily). Review of the Physician orders, dated 5/20/23 through 5/29/23, reflected no orders for blood glucose monitoring for R101 between 5/20/23 and 5/24/23. Continued review of the Physician orders reflected an order for daily blood glucose monitoring with start date of 5/24/23 for seven days. Review of the EMR, dated 5/20/23 through 5/29/23, reflected R101 blood sugar was monitored on 5/24/23 and 5/29/23 with no evidence of blood sugar monitoring on other eight days(5/20, 5/21, 5/22, 5/23, 5/25, 5/26, 5/27, and 5/28 as evidenced by holes on the Medication Administration Record). Continued review of the Medication Administration Record reflected no evidence R101 was administered insulin prior to 5/29/23. Review of the Nursing Progress Note, dated 5/25/2023 at 3:45 p.m., reflected, Writer spoke with resident regarding cortisone injection that was given 5-24-23, resident states she already feels less pain in right shoulder. Orders were put in chart for monitoring. (No evidence of blood sugar monitoring post cortisone injection). Review of R101's Nurse Practitioner Note, dated 5/26/23, reflected, Type 2 diabetes mellitus with foot ulcer Monitor sugars, currently not on any medications, will have nursing check her sugars daily for 7 days to trend. Review of R101's Progress Note, dated 5/29/2023 at 5:01 a.m., reflected, resident refuses to go to dialysis resident stated she does not feel well and doesn't feel good enough to go, requesting for physician to evaluate resident. Review of R101's Nursing Progress Note, dated 5/29/2023 at 7:15 a.m., reflected, residents BS[blood sugar] was obtained this morning BS read to high meaning over 600, on call physician was called on call gave orders of giving 14 units lispro[fast-acting insulin] one time rechecking BS in 2 hrs. call on call back after doing recheck to determine plan of care due to recheck results, will put in physicians book to evaluate residents medication and see if physician will add insulin. Review of the Nursing Progress Notes, dated 5/29/2023 at 9:53 a.m., for R101, reflected, Order to recheck blood sugar at 0845. Result read HI. Per on all doctor send to ER for treat and eval .EMS arrived at 0940. Patient left for ER via ambulance at 0945. Husband notified. Review of R101's Nursing Admission Assessment, dated 5/20/23, reflected diagnosis that included, TYPE 2 DIABETES MELLITUS WITH HYPOGLYCEMIA WITHOUT COMA, TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE, TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED, and TYPE 2 DIABETES MELLITUS WITH FOOT ULCER. Review of the facility, Skilled Daily: Medical Complex (MI) -V1 assessments, dated 5/21/23 through 5/29/23, reflected six daily assessments that indicated R101 was not diabetic(5/22, 5/23, 5/24, 5/26, 5/27, and 5/28). During an interview on 11/21/23 at 9:10 a.m. Unit Manager (UM) I reported had worked at the facility as Unit manager for about one year. UM I was familiar with R101 and was R101 UM during last admission from 5/20/23 to 5/29/23. UM I reported R101 had required dialysis, oxygen, had toe amputations, wound on bottom, was diabetic and shoulder pain. UM I reported the nursing admission assessment should have reflected R101 was diabetic as well as the Skilled Daily Assessments and the Admission Care Conference. UM I reported would expect documentation to reflect clarification on hospital discharge orders for insulin needles and no insulin orders as well as orders for blood sugar monitoring. UM I reported thought she recalled hospital had discontinued R101 insulin. UM I reported order was obtained on 5/24/23 to monitor R101 blood sugar daily for 7 days and should have been documented on the Medication Administration Record(MAR). Review of the Hospital Records, dated 5/29/23 to 6/2/23, reflected R101 was treated in the emergency room for hyperglycemia(high blood sugar). The records included a History and Physical, dated 5/29/23, reflected, [named R101] is a 71 y.o. female with PMHx of hypertension, atrial fibrillation on Eliquis 5mg twice per day, CAD s/p PCI to OM1 (5/2021), Chronic Obstructive Pulmonary Disease on 4 L of oxygen at baseline, insulin-dependent type 2 diabetes mellitus, ESRD on dialysis MWF. On my interaction, patient was somnolent but easily arousable and was able to provide most of the history. Patient was recently discharged from the hospital on 05/20/2023 following admission for constipation and overflow incontinence and physical deconditioning. During that admission, patient's symptoms improved after manual disimpaction of stool. Patient declined a colonoscopy during that admission. She was subsequently discharged to a SAR for physical rehab. Reports that since going to SAR , she was not receiving any insulin. She did tell the staff at the nursing home that she is diabetic but she was told that they did not have orders for administering insulin .Labs: Glucose 991 .In the ED, patient was given 1 dose of cefepime and vancomycin, was started on insulin drip. Patient was admitted to the Hospitalist service .PLAN .Hyperglycemia Type 2 DM Pseudohyponatremia Home regimen consist of 6-8 units of Lantus based on dinner. Patient was not getting any insulin when she was at SAR. Labs on admission: Glucose 991, corrected sodium 134, Bicarb 25, anion gap 15, VBG: PH 7.31, pCO2 56.6 .PLAN: - started patient on insulin drip 1-20 units/hour; RN to titrate as per normogram - administered Lantus 6 units - will proceed with caution replacing her potassium giver her h/o ESRD . During an interview on 11/21/23 at 10:10 a.m., UM I verified was able to locate evidence of R101 blood sugar on 5/24/23 and unable to locate R101 blood sugar on the other days. UM I verified several Skilled Daily Assessments were not accurately completed as evidenced by staff who marked R101 as not diabetic and should have reflected R101 was diabetic. UM I verified was unable to locate evidence that the hospital had discontinued R101 insulin. During an interview on 11/21/23 at 11:35 a.m., Director of Nursing(DON) B reported had been employed at the facility for three weeks. DON B reported when nurse receives new admission from the hospital would expect nurse staff to review medications discharged with from the hospital and compare with admission medications as well as home medications and communicate with physician. DON B reported would expect nurse staff to indicated if new admission was diabetic on the admission nursing assessment even if not the primary diagnosis and to monitor resident blood sugars even if the hospital had discontinued insulin. DON B reported would expect admission nurse to clarify with physician if in doubt about blood sugar monitoring and insulin orders if hospital discharge instructions included insulin needles only and expect staff to document. DON B reported would expect Skilled Daily Assessments to be accurately completed and Admission Care Conference and Nutritional Assessments to mention residents diagnosis including diabetes if applicable. DON B reported would have expected staff to monitor diabetic residents blood sugar closely after steroid treatments because increase risk for elevated blood sugar. DON B reported had identified area that needed improvements in past three weeks and plan on changes moving forward that included daily meetings. During an interview on 11/21/23 at 1:10 p.m., DON B reported was unable to locate evidence facility was monitoring R101 blood sugar between 5/20/23 and 5/29/23 and verified R101 did not receive insulin prior to 5/29/23 and reported R101 blood sugar should have been monitored at least daily and documented in the EMR. DON B verified several of R101 Skilled Daily Assessments were not accurate. DON B reported R101 Skilled Daily Assessments should have reflected R101 was diabetic. DON B reported after review of R101 hospital documents that R101 had orders for daily scheduled insulin and short acting sliding scale insulin while in the hospital and orders should have been clarified with physician.

This citation pertains to intake MI00138497. Based on observation, interview and record review, the facility failed to prevent a fall for one (Resident #3) of three reviewed for accidents, resulting in a fall with fracture when Resident #3 fell from her wheelchair in the facility's transport van. Findings include: Review of the medical record reflected Resident #3 (R3) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included dementia, muscle weakness, multiple rib fractures of the left side and psychotic disorder with hallucinations. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/13/23, reflected R3 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and performed activities of daily living with independence to limited assistance of one person. On 8/14/23 at 9:47 AM, R3 was observed lying in bed, watching TV. A splint was observed on her right arm, which extended from her hand to just below her elbow. R3 reported she broke her wrist while being transported to an appointment in the facility's transport van, when she flipped out of her wheelchair and landed on her head. An Incident Report for 7/14/23 at 4:21 PM reflected R3 reported her right wrist was painful. Her right wrist was noted to be slightly bruised with a moderate amount of swelling, and she had abrasions to both knees. When R3 was asked what happened, she stated she was not sure but thought she fell in the [facility's] transport van. R3 recalled waking up and catching herself with her hands. An x-ray report for 7/14/23 reflected, .Cortical irregularity involving the distal radial metaphysis is suspicious for acute nondisplaced fracture. Prominent deformity of the radial head could relate to acute or chronic fracture deformity . During an interview on 8/14/23 at 2:16 PM, Transportation Driver (TD) K described that while transporting R3 to an appointment, she was starting to fall asleep in her wheelchair. As he was maneuvering through traffic, he looked back and did not see her. When he stopped the van, R3 was completely out of the wheelchair, lying on her side. TD K reported R3 did not have a seatbelt on at the time of the incident. He reported R3's wheelchair had been secured to the van, and a seatbelt had been offered to R3 and she declined. TD K, indicated that at the time of R3's incident, seatbelts during van transport were optional. TD K reported seatbelts were no longer optional for residents during van transport. A Disciplinary Action Form reflected TD K failed to provide safe transportation and failed to report the occurrence of a resident fall with injury during transportation to an appointment. TD K was suspended starting 7/17/23 and ending 7/21/23. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance, which included assessment and treatment of R3, training on new policies and procedures and revision of the facility's transportation program, including driver safety responsibilities, staff vehicle safety policy and procedure, motor vehicle record questionnaire, job description, daily vehicle pre-trip checklist, daily and weekly vehicle inspection record, resident securement checklist and vehicle accident report. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to Intake number MI 263. Based on observation, interview, and record review the facility failed to prevent abuse for one out of two residents (Resident #22), resulting in actual abuse of cognitively intact resident, with 4 bruises as a result of the abuse, and the potential for further abuse to occur. Findings Included: Per the facility face sheet Resident #22 (R22) was admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment, dated 11/3/2021, revealed R22 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R22's cognition was intact. Record review of a Facility Incident Report (FRI), revealed that on 1/30/2022, upon R22's request, Certified Nurse Aid (CNA) K assisted R22 with changing his brief and washing his back. The report revealed CNA K was in a hurry to leave the facility, and R22 had told her that she was being rough. The report further revealed that on 1/31/2022 when CNA P went to provide morning care to R22 she observed a bruise on R22's back. The report also documented the bruise to be an approximately 3 centimeter contusion on his left mid back area over his ribs. The report also revealed that CNA K was terminated from her employment at the facility. An attempt was made to contact CNA K on 2/18/2022, at 8:51 AM however, the contact phone number was no longer a working number. A request was made to the facility for another phone number that may be on file for CNA K, but was informed no other phone number was on file. In an interview on 2/16/2022, at 7:07 AM. R22 stated CNA K caused bruises on his back. R22 said he needed his brief changed and had told CNA K, who told him that she would change his brief after supper. R22 said after supper was over he told CNA K again that he still needed to be changed. R22 stated that he perceived CNA K was not happy about having to assist him with the changing of his brief, and stated that CNA K used a wet towel to scrub his back. R22 said he repeatedly told CNA K that hurt and to please stop. R22 said CNA K did not stop rubbing his back with the wet towel. R22 said that when CNA K did stop she then began to hit him on his back with the palm of her hand over and over again, using both of her hands until two other staff members entered his room to complete his care, because CNA K was going off shift and had a ride waiting outside for her. R22 said he did not mention the incident to anyone, but stated that the next morning CNA P had gone into his room to wash his back, and upon rolling him over CNA P asked him who black and blued his back, and that was when he reported to CNA P what CNA K had done to him the day before. In an interview on 2/17/2022, at 12:49 PM, CNA P stated that the next morning on 1/31/2022 she had observed a palm size bruise on R22's back. CNA P said R22 told her that CNA K had been rough with him and tossed him around pulling on his arm. CNA P said she observed the bruise on R22's left side of his back by his rib cage. CNA P said she reported the incident and the bruise to Administrator A immediately. CNA P said R22 did not know the bruise was there, but stated his was painful. In another interview on 2/18/2022, at 9:41 AM, R22 again stated CNA K was in a hurry when she was cleaning him up on 1/3/2022, because she had a taxi waiting on her outside. R22 said CNA K got some water ready, and then started to wipe his back with a wet towel, scrubbing real hard real which was hurting him badly. R22 again stated that he asked CNA K to stop scrubbing his back so hard, but then when CNA K began to dry off his back she started hitting him on his back with her fist or palm and with both of her hands for about one minute which hurt him. R22 again stated that he asked CNA K several times to stop scrubbing his back so hard, and said please stop. R22 said CNA K threw the towel onto the floor and began hitting him on his back. R22 said he was afraid CNA K may do the same thing to other residents that she did to him. On 2/18/2022, at 10:43 AM, Administrator A stated she had a picture of the bruising on R22's back, and provided the picture for review. Review of the picture provided by Administrator A revealed a dark red/purple bruise to the lower back area that was not one bruise but four separate from each other bruises. Record review of abuse training documents revealed that CNA K signed a documented on 5/16/2020 titled, Acknowledgment of Receipt of Policy and Procedure Regarding Resident Freedom From Abuse, Neglect, and Exploitation and the Elder Justice Act. The documented revealed CNA K acknowledged that she received a copy of the facility's policy and procedure of the titled reference that included agreement to abide by the facility abuse policy and procedure. Further review of CNA K's abuse training revealed that on 1/7/2022 she had attended, via her signature, and inservice training on abuse. Record review of the facility investigation, dated 2/7/2022, revealed that the facility's conclusion of their investigation was documented as, The facility was unable to substantiate the allegation of abuse. Of note, the facility requested the following be evaluated at time of survey exit. Past Non Compliance Element 1. Resident still resides in facility. Resident was evaluated by physician. Skin and pain assessment completed. Social worker followed up with resident to ensure no adverse effect. Resident feels safe. Element 2. All residents can be affected. Element 3. Employee was terminated. Staff were educated on abuse by 2/8/22. Abuse policy reviewed and deemed appropriate. Element 4. Facility will audit residents and staff to ensure appropriate care and safety is being maintained when care is provided. Audits will continue weekly and be presented to QAPI committee. Date of compliance 2/8/2022.

This citation pertains to MI 482 Based on interview and record review the facility failed to prevent the development and worsening of a pressure ulcer and appropriately assess a pressure ulcer for one (Resident #1) of one reviewed, resulting in a facility acquired stage 4 pressure ulcer and hospitalization . Findings include: Review of the medical record revealed Resident #1 (R1) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/18/21 revealed R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS), required limited assistance of one person for bed mobility, transfers, and walking. R1 did not have a pressure ulcer present on admission to the facility but was coded as being at risk for the development of pressure ulcers. R1 was discharged from the facility on 5/28/21. Review of the care plans revealed R1 did not have a risk for pressure ulcer development care plan put into place until 4/23/21. The medical record revealed R1 wore a brace to her right leg and was non-weight bearing on her right leg. Review of the Occupational Therapy (OT) Encounter Note dated 4/1/21 revealed Continued education on positioning techniques while supine in bed to assist [with] [CONDITION(S)] management in distal BLE [bilateral lower extremities]. Pillows placed beneath BLE to provide elevation, pt [patient] reports an increase in comfort. Educated staff on positioning pt in bed [with] BLE elevated to decrease [CONDITION(S)] in BLE and maintain skin integrity. Review of the care plans, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Skin & Wound Evaluation dated 4/12/21 revealed R1 had a stage 2 (partial thickness skin loss with exposed dermis) pressure ulcer on her left heel, which measured 3.7 centimeters (cm) long by 2.2 cm wide. There was no wound bed description (epithelial, granulation, slough, or eschar). Review of the Physician/Practitioner Progress Note dated 4/12/21 revealed The patient has a pressure ulcer to the left heel towards the left outer aspect. It does appear that the patient most likely had a large blister to this area that has since popped .The patient typically does put most of her weight on this area due to the right leg being her affected leg .left heel ulcer outer aspect has large pressure ulcer with skin that is open today, middle aspect shows purplish coloring .keep heels bridged, apply dermafoam to this open area, needs to wear a shoe on the left foot when up and walking to avoid putting the pressure on this area. Review of the care plans revealed pressure ulcer interventions were not implemented until 4/21/21 (9 days after the development of R1's pressure ulcer). Floating heels was added on 4/21/21, but there was no care plan intervention regarding wearing a shoe on the left foot. Review of the Skin & Wound Evaluation dated 4/19/21 revealed R1's left heel pressure ulcer was now a stage 3 (full thickness skin loss) which measured 4.2 cm long by 2.6 cm wide. The depth of the pressure ulcer was documented as not applicable. The wound bed was documented as 80% slough. Review of the Physician/Practitioner Progress Note dated 4/19/21 revealed She is non weight bearing to the right leg and has to put all her weight on the left. When talking with therapy, she is grinding the left heel into the floor when she is walking which has caused the skin breakdown to the heel. Review of the Skin & Wound Evaluation dated 4/27/21 revealed R1's left heel pressure ulcer was documented as a stage 3 which measured 3.6 cm long by 1.3 cm wide. Again, the depth was documented as not applicable. The wound bed was documented as 60% eschar. Review of the Skin & Wound Evaluation dated 5/3/21 revealed R1's left heel pressure ulcer was documented as a stage 3 which measured 2.5 cm long by 2 cm wide. Again, the depth was documented as not applicable. The wound bed was documented as 70% eschar. R1 was sent to the wound clinic on 5/3/21. Review of the wound clinic notes and orders dated 5/3/21 revealed Wash with normal saline and pat dry. [MEDICATION(S)] paint to left heel, please allow to dry. Cover with ABD. Secure with conform or Kerlix. Keep dry when on. Change every other day. Review of the Wound Clinic notes dated 5/6/21 revealed [R1] arrives today for re-evaluation of her left heel wound as day before [name of Licensed Practical Nurse (LPN) I] from [the facility name] called to report new odor and deterioration of the wound from the Monday visit to wound clinic .Upon removing the dressing it was noted that xeroform was placed on the wound and not [MEDICATION(S)] as ordered. After the visit, I faxed new wound orders to [facility name] and spoke to [LPN I] again . Review of the Skin & Wound Evaluation dated 5/11/21 revealed R1's left heel pressure ulcer was documented as a stage 3. There were no measurements or description of the wound bed on the assessment. Review of the Wound Clinic notes dated 5/14/21 revealed Records indicate that the left heel ulcer started possibly as a blister from pivoting on her left heel during revision process of right TKA [total knee arthroplasty/replacement] in 3-2021 when antibiotic spacer was placed and 6 weeks of IV antibiotics were given. Recent notes indicate the wound was a dry eschar suggesting that the ulcer likely started as an unstageable pressure ulcer and the location is suggestive of a non ambulatory pressure ulcer .Her left heel eschar started to soften with odor when someone placed xeroform on the eschar rather than [MEDICATION(S)] recently. The heel wound remains with drainage and odor today . The wound clinic ordered for R1 to start taking [MEDICATION(S)] (antibiotic). Review of the Skin & Wound Evaluation dated 5/18/21 revealed R1's left heel pressure ulcer was documented as a stage 3 that measured 3.6 cm long by 3 cm wide. The depth was documented as not applicable. Review of the Wound Clinic After Visit Summary dated 5/21/21 revealed orders for R1 to continue taking [MEDICATION(S)] to completion and to start taking [MEDICATION(S)] (another antibiotic) 875-125 milligrams every 12 hours for 7 days to help improve drainage. Review of R1's medical record revealed the order for [MEDICATION(S)] was entered into the medical record on 5/24/21 (3 days later). According to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Skin & Wound Evaluation dated 5/24/21 revealed R1's left heel pressure ulcer was documented as a stage 3 that measured 2.5 cm long by 1.5 cm wide. The depth was documented as not applicable. The wound bed was documented with 60% slough. Review of the Wound Clinic Progress Notes dated 5/28/21 revealed She has new necrosis of tendon in center of wound likely due to infection as there is associated odor. The primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan revealed Patient sent to ER for evaluation and probable admission and starting IV treatment as she is failing OP [outpatient] treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing/Clinical Progress Note dated 5/28/21, revealed R1 returned to the facility after her wound appointment and then was transferred to the hospital. R1 did not return to the facility. According to the National Pressure Injury Advisory Panel (NPIAP), Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. (https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf) In a telephone interview on 10/26/21 at 2:01 PM, LPN I reported R1's wound began as a closed blister that was hard and dark red on her heel (to note, this is not documented in the medical record). LPN I reported R1 developed a pretty decent wound on her heel. LPN I reported she did not know how to stage pressure ulcers, but knew when the wound started, it was not opened, it was dark red. LPN I reported she has not received any education on how to stage pressure ulcers. LPN I could not recall the time the wound clinic called about the incorrect dressing being in place. In a telephone interview on 10/26/21 at 2:19 PM, LPN J reported she no longer worked at the facility and could not recall any details of R1's pressure ulcer. In an interview on 10/26/21 at 2:30 PM, Unit Manager (UM) K reported she was unsure as to why R1's order for [MEDICATION(S)] was not implemented for 4 days after the wound clinic order. UM K reported typically the receiving nurse reviewed the paperwork, contacted the physician, and wrote the orders. UM K reported if a resident returned without paperwork, the nurse should contact the wound clinic. In an interview on 10/26/21 at 3:01 PM, Owner F reported Director of Nursing (DON) B was not employed by the facility during R1's stay, therefore Director of Clinical (DOC) G would be the better person to speak with regarding R1. In an interview on 10/26/21 at 3:09 PM, DOC G reported the photograph of R1's wound on 4/12/21 appeared to be a ruptured blister. DOC G reported she was not sure when the blister started. DOC G reported if a pressure ulcer was covered with slough or eschar, the appropriate stage should be unstageable. On 10/27/21 at 8:41 AM, DOC G reported she reviewed R1's medical record and was not sure when the blister first developed. DOC G reported she could not explain why R1 went to the wound clinic with the incorrect treatment in place or why the [MEDICATION(S)] orders were not implemented timely. In a telephone interview on 10/27/21 at 8:17 AM, Registered Nurse (RN) L reported she was no longer employed by the facility. RN L was unable to recall when R1's wound developed or any details of the wound. RN L reported R1's wound was a result of transferring and putting weight on the left heel. RN L reported R1 wore gripper socks and not shoes. In an interview on 10/27/21 at 1:22 PM, Certified Nursing Assistant (CNA) N reported R1 would try to pivot and scoot .would put foot on ground and move it around .she would sit and grind her heel into the floor, move it and put pressure on it. CNA N reported when R1's wound began, it was like a blister or something on the bottom of her foot. CNA N could not recall any other details of the wound. CNA N reported R1 wore gripper socks and not shoes.

This citation pertains to MI 463. Based on interview and record review, the facility failed to implement care and treatment to a hematoma following a fall in one of two residents reviewed with wounds (Resident #51) resulting in pain, hospital admissions, and antibiotic medications. Findings include: Resident #51 (R51) R51's Discharge Minimum Data Set (MDS) dated [DATE], indicated she was admitted to the facility on [DATE] and discharged to another nursing home on 07/30/20. R51's same MDS introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 12 (08-12 Moderate Impairment). R51's quarterly MDS dated [DATE], revealed she did not walk, used a wheelchair for locomotion and required extensive assistance (staff provide weight bearing support) of two persons for transfers. Wound Clinic note dated 07/09/20 revealed R51 had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In review of R51's Interdisciplinary Recapitulation of Stay Summary dated 07/29/20, she had [CONDITION(S)] outside the facility three days a week. Incident Report dated 05/04/20 revealed R51 was observed on floor next to her bed and stated she had rolled out of bed and landed on her left hip. R51 sustained a skin tear to the right hand and a five-centimeter hematoma to her right calf. In review of the R51's nurses notes, care plans and incident report, there was no mention that care; such as an ice pack, dressing (to compress swelling and protect), or elevation was provided to her right calf hematoma. The Director of Nursing (DON) B was interviewed on 09/01/20 at 11:05 AM and stated no treatment orders were obtained after R51's fall on 05/04/20 because the wound did not show up right away. After review of R51's incident report, DON B stated the nurse was waiting for the Doctor to come in and give orders. DON B confirmed that a care plan was not initiated for R51's hematoma on her leg. DON B was not aware wound clinic orders were not on R51's treatment record. There was no record in the nurses notes on 09/01/20 that the nurse was waiting for Doctor's orders for the leg injury. Nurses Progress Note dated 05/05/20 at 9:25 AM, revealed it was a late entry and R51's right lower extremity presented an 8.0 centimeter (cm) dark purple hematoma with pink tinged fluid noted. There was no mention of any interventions implemented in the note, no care plan was initiated or updated and no orders for care were obtained. Nurses Progress Note dated 05/06/2020 at 4:25 PM, indicated R51 went to [CONDITION(S)], complained of leg pain, and was transferred from the [CONDITION(S)] center to the hospital for care. Hospital Progress Note dated 05/10/20 at 8:19 AM revealed R51 had developed a large hematoma when she fell on [DATE] at the nursing home and due to her history of losing her lower left leg from [CONDITION(S)] (blood vessels become blocked by a build-up of calcium in the walls of the vessels, preventing blood from flowing to the skin or internal organs; lack of blood flow damages healthy tissue) after a hematoma had formed; the family wanted her to be seen. The same note indicated R51 complained of significant pain in her right calf. Nurses note dated 05/11/20 at 3:11 PM revealed R51 was readmitted to the facility, was tired and sore during the dressing change to her calf and being turned. There was no mention of her history of [CONDITION(S)] in R51's care plans. In review of R51's nurses notes, a late entry note, effective date of 05/18/20 at 8:00 AM, the nurse noticed in the morning wound was seeping, the doctor advised to keep clean and dry and wrap with gauze dressings. The same note indicated the Doctor was to look at R51's leg wound on Tuesday 05/19/20; and R51 had no complaints of increased pain and no signs of infection. In review of R51's nurses notes dated 05/19/20 at 2:29 AM, reflected her bandage on her right lower leg was sliding down and bleeding. R51's wound was cleansed, a large hematoma with dead tissue was noted with open areas to surrounding tissue. The same nurses note indicated R51 took pictures that she sent to her daughter, and her daughter called the nursing home and requested her mother be sent to the hospital as soon as possible with R51 in agreement. R51's medical record indicated she was transferred to the hospital on 05/19/20. R51's hospital records indicated on 05/19/20 she had a debridement (removal of dead tissue) procedure to her leg wound and placement of a wound vac (vacuum-assisted wound dressing). R51's discharge summary 05/28/20 indicated she presented to the emergency room , on 05/19/20 with increasing pain to her right lower extremity, foul drainage with pus from her wound. R51 was prescribed intravenous antibiotics to continue at the nursing home following discharge. R51's nurses notes indicated she was readmitted to the nursing home on 05/30/20. [CONDITION(S)] Communication Form dated 06/24/20 indicated R51 had an open wound on leg and the wound should be covered for [CONDITION(S)]. The post [CONDITION(S)] assessment was not filled out by the facility nurse, no progress note reflected R51's wound was uncovered, or notes added to her care plan. R51's June 2020 treatment record indicated her wound treatment wasn't completed on 6/12/20, 06/15/20, 6/23/20, and 6/25/20. There were no explanations in the nurses notes. Wound clinic note dated 07/09/20 indicated order to clean R51's wound with normal saline, pat dry with a sterile gauze, apply a [MEDICATION(S)], a protective ointment around the wound, secure with a Unna boot (special dressing of inelastic gauze impregnated with [MEDICATION(S)] that becomes rigid when it dries and coban (compression wrap), change dressing every three to four days; this order was not implemented. The same note indicated R51 should elevate her legs when able and to avoid prolonged sitting and standing; these interventions were not added to her care plan. Wound clinic note dated 07/23/20 revealed orders to clean R51's ulcer on her right lower leg with normal saline, pat dry with a sterile gauze, apply [MEDICATION(S)] around the wound; [MEDICATION(S)], [MEDICATION(S)] AG and exudry dressings to the wound bed, secure with a [MEDICATION(S)] Unna boot; this order was not implemented. The same note indicated R51 should elevate her legs when able and to avoid prolonged sitting and standing; these interventions were not added to her care plan. R51's Discharge Plan Instructions signed 07/29/20, revealed wound dressing instructions that did not include the wound clinic's 07/23/20 recommendations. Discharge Plan Instructions indicated to cover wound bed with medical grade honey, cover with an abdominal pad dressing and follow with a gauze dressing twice daily.

Based on observation, interview and record review, the facility failed to provide effective pain management services in 2 of 2 residents reviewed for pain management (Resident #358 and #359), resulting in unrelieved pain (Resident #358 & #359) and decreased progress on therapy goals (Resident #359). Findings include: Resident #358 (R358) On 11/27/18 at 9:26 AM, R358 was observed lying in bed. Registered Nurse (RN) O entered R358's room to administer his morning medications. On the same date and time, pain was reported by R358, RN O replied I have a Tylenol for you and did not assess location or severity of pain. RN O left R358's room. On 11/27/18 at 9:42 AM, R358 stated he had a lot of pain, and had no relief with medication. R358 stated during the same interview that he had suffered through therapy due to pain. R358 stated during same date and time he had pain from his abdomen to his feet. On 11/27/18 at 9:46 AM, Certified Nurse Assistant (CNA) H answered R358's call light and R358 reported I'm in so much pain right now. On 11/27/18 at 09:49 AM, CNA H retrieved Licensed Practical Nurse (LPN) Z to assist R358. LPN Z instructed CNA H to look for RN O. LPN Z asked R358 where pain was located and rating; R358 rated pain as a 10 plus plus. LPN Z explained to R358 that she did not have keys to the medication cart, but would let RN O know of his pain. LPN Z did not attempted any non-pharmalogical interventions. On 11/27/18 at 9:59 AM, RN O came into R358's room and asked where the location of his pain was. R358 replied sharp pain in hips and legs. RN O told R358 that she had [MEDICATION NAME] (narcotic-like pain reliever used to treat moderate to severe pain) she could give him and told him she would be right back. R358's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The same MAR indicated [REDACTED]. R358's Minimum Data Set ((MDS) dated [DATE] revealed he was admitted to the facility on [DATE] and the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 06 (scale: 00-07 indicated severe impairment). The same MDS assessment, under J0600, revealed R358's numeric pain rating was a 04 (scale: 00-10 in rating pain over last 5 days, with zero being no pain and ten as the worst pain imagined). R358's MDS assessment and care plans with print date of 11/29/18, revealed active [DIAGNOSES REDACTED]. R358's Pain Care Plan, initiated 11/16/18 and print date of 11/29/18, did not include any non-pharmalogical pain interventions; only two intentions were listed on his pain care plan: Notify physician if reports or signs or symptoms of pain and Report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.16, (MONTH) (YEAR), revealed resident self-report was the most reliable means for assessing pain and pain intensity scales allow providers to evaluate whether pain was responding to pain medication regimen(s) and/or non-pharmacological interventions(s). Resident #359 (R359) On 11/27/18 at 10:45 AM, R359 was observed sitting on the side of her bed wearing a hospital type gown with a dressing covering her right knee. R359 stated she was in so much pain, I had surgery on my knee last week and stated she felt that she had to .beg for my pain medicine. R359 stated she had asked for an ice pack at 6:30 AM and was still waiting for it. During the same interview, R359 stated she was was not happy yesterday, the nurse stated I had taken my [MEDICATION NAME] ([MEDICATION NAME], opioid medication for moderate to severe pain) and I did not, I'm not taking it just cause, I need it, R359 started crying. R359's hospital Discharge Summary dated 11/23/18, revealed she had underwent a right total knee arthroplasty on 11/19/18 and had the [DIAGNOSES REDACTED]. R359's Progress Notes dated 11/23/18 at 10:20 PM and (MONTH) Medication Administration Record [REDACTED]. In review of R359's (MONTH) (YEAR) MAR, [MEDICATION NAME] 5mg, 2 tablets, was administered on 11/26/18 at 1:48 PM for severe pain and documentation indicated the medication was ineffective. The same document indicated R359 could receive 1-2 tablets of [MEDICATION NAME] every 4 hours as needed. Physical Therapist (PT) M was interviewed on 11/29/18 at 8:50 AM and stated on 11/26/18 R359 was very painful during her exercise session. PT M stated she went up to advise R359 to consider taking pain medication before her therapy session; R359 stated she hadn't had pain medication. PT M stated during the same interview, that she checked with R359's nurse and her nurse said she had just given her pain medication. PT M stated she was not sure if the patient forgot or if the nurse made a mistake. R359's PT Daily Treatment Note dated 11/26/18 at 4:03 PM, revealed she .states she is very sore and painful this afternoon. Insists that she had not had pain medicine recently. Spoke with nursing, who states Pt (patient) had pain meds (medications) approximately 1 hour before approached by PT. Pt moved very slowly and painfully throughout session, and was unable to tolerate much. On 11/28/18 at 4:55 PM, Licensed Practical Nurse (LPN) N was interviewed and stated she administered R359's [MEDICATION NAME] at around 2:00 PM, then she went to therapy and was in pain. LPN N stated it was to soon to give R359 another dose of [MEDICATION NAME] after therapy, but did not notify the physician of uncontrolled pain and added I'm a new nurse. On 11/29/18 at 12:28 PM, Director of Nursing (DON) B was interviewed and stated after reviewing the narcotic count sheet it was apparent that R359 did not receive the medication on 11/26/18 at 1:48 PM. Controlled Drug Administration Record Tablet dated 11/23/18 indicated R359 had received 2 tablets of [MEDICATION NAME] on 11/26/18 at 12:30 AM, 4:40 AM, and 7:20 PM. There was no [MEDICATION NAME] signed out on 11/26/18 at 1:48 PM. CMS's Long-Term Care Facility RAI 3.0, Version 1.16, (MONTH) (YEAR), revealed the effects of unrelieved pain impact the individual in terms of functional decline, complications of immobility, skin breakdown and infections. Pain Management Policy dated 7/17 revealed a guideline statement was to ensure that Medical Record documentation indicated that care and services were being provided to manage the Resident's pain through the appropriate use of non-drug interventions, as needed pain medication and routine pain medication administration.

This citation contains two deficient practice statements (A and B). A. Based on observation, interview, and record review, the facility failed to ensure that there was a protocol in place to ascertain that oxygen was administered and monitored according to physician's orders [REDACTED].#13, #15, #18) of 6 residents reviewed for oxygen therapy from a total sample of 15, resulting in the facility being placed in Immediate Jeopardy on 2/25/15 when Resident #13's oxygen concentrator had stopped functioning at some point in time prior to 12:05 pm, and was observed not to function for 17 minutes, during which time 2 nurses checked on Resident #13 and did not ascertain that his oxygen concentrator was not functioning. This deficient practice placed 16 residents, identified as using oxygen concentrators at risk for serious harm, injury, and/or death. On 2/26/15, Resident #15 was observed with oxygen being administered from a tank at 4 L (liters) per minute via nasal cannula, despite having a physician's orders [REDACTED]. The facility was placed in Immediate Jeopardy as a result of the facility's failure to ensure that there was a protocol in place to ascertain that oxygen was administered and monitored according to the physician's orders [REDACTED].#13) who was dependent on oxygen. On 2/26/15 at 12:30 pm, Nursing Home Administrator (NHA) "A" and Director of Nursing (DON) "B" were notified of the Immediate Jeopardy that began on 2/25/15, and was identified on 2/25/15, due to the facility's failure to ensure there was a protocol in place to ascertain that oxygen was administered and monitored according to physician's orders [REDACTED]. A request for a written plan of removal was requested at that time. On 3/2/15, the surveyor verified that the facility had done the following to remove the Immediate Jeopardy: - On 2/25/15, Resident #13 was assessed for signs and symptoms of respiratory distress. The oxygen concentrator was taken out of service and replaced. - On 2/25/15, Maintenance Director validated that the electrical outlet was functioning. - On 2/25/15, resident's identified as receiving oxygen per oxygen concentrators were observed by nurses for signs/symptoms of respiratory distress. Nurses and central supply were observed for the functionality of concentrators. [MEDICAL CONDITION] On 2/25/15, the facility began educating licensed nurses on functionality of concentrators, up to and including replacement of the concentrator when indicated. - On 2/26/15, care plans of residents who used oxygen concentrators were reviewed and updated. -On 2/27/15, the facility began educating licensed nurses on the signs and symptoms of respiratory distress in the geriatric population. The education provided to the nursing staff to remove the immediacy was reviewed by the survey team on 2/27/15. It was identified that the education provided was inappropriate to remove the immediacy identified. The education that was provided was from the National Heart, Lung, and Blood Institute and revealed "signs and symptoms of [DIAGNOSES REDACTED] (RDS) usually occur at birth or within the first few hours that follow..." The education was not relevant to the geriatric resident. The survey team informed NHA "A" and DON "B" that licensed nurses were educated on the signs and symptoms of [DIAGNOSES REDACTED] for Infants. NHA "A" and DON "B" were unaware of the incorrect education. On 2/27/15, the facility began educating licensed nurses on the signs and symptoms of respiratory distress in the geriatric population. Although the Immediate Jeopardy was removed on 2/27/15, the facility remained out of compliance with a scope of isolated and a severity of "No actual harm with a potential for more than minimal harm that is not immediate jeopardy" due to sustained compliance having not been verified by the State Agency. Findings include: Resident #13 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed that Resident #13 was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #13 had severe cognitive impairment, no speech, rarely/never understood, and rarely/never understands. Review of the respiratory care plan, dated 3/15/13, revealed "has/at risk for respiratory impairment related to [MEDICAL CONDITIONS], dysphagia, pt (patient) lips are always blue". Interventions included: evaluate lung sounds, vital signs, pulse ox as needed, oxygen as ordered, report signs of infection or [MEDICAL CONDITION]" The care plan identified that Resident #13's baseline is bluish tint to his lips, yet failed to mention signs and symptoms of respiratory distress for Resident #13. On 12/19/14, Resident #13's physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the Progress Notes revealed that Resident #13's sp02 was checked and noted on the following dates: 12/19/14- 93% (not specified if room air or with oxygen), 1/20/14- 93% on 2L of oxygen, 1/22/15- 93% with oxygen, 1/23/15- 93% (not specified if room air or with oxygen), 1/26/15- 94% (not specified if room air or oxygen), 1/31/15- 93% (not specified if room air or with oxygen). The Treatment Administration Record (TAR) revealed that on 2/2/15, Resident #13's sp02 was 94%. An observation on 2/25/15 at 12:05 p.m., revealed that Resident #13 was sitting in his wheelchair in his room with a nasal cannula in place and attached to his oxygen concentrator. The oxygen concentrator was not functioning. At 12:13 p.m., Unit Manager (UM) "C" walked by Resident #13's room and said hello to Resident #13. UM "C" did not notice nor check that Resident #13's oxygen concentrator was not functioning. At 12:14 pm, Licensed Practical Nurse (LPN) "D" stepped into Resident #13's room and said hello to Resident #13. LPN "D" did not notice nor check that the oxygen concentrator was not functioning. A continuous 17-minute observation revealed Resident #13's oxygen concentrator was not functioning. This surveyor queried LPN "D" regarding Resident #13's respiratory status. LPN "D" reported that Resident #13 was to be on 2 liters of oxygen at all times and "it (oxygen saturation) falls quickly" if Resident #13 is on room air. At this time, this surveyor requested that LPN "D" check Resident #13's oxygen saturation. At 12:22 p.m., Resident #13's oxygen saturation was 82% on room air, dropped to 79% on room air, and then increased to 87% on room air. LPN "D" got the oxygen concentrator functioning and Resident #13's oxygen saturation increased to 92% on 2 liters of oxygen via nasal cannula. LPN "D" reported that Resident #13's concentrator switch was in the on position, but the plug was partially out of the wall electrical socket. In an interview on 2/25/15 at 3:37 p.m., Registered Nurse (RN) "E" reported that Resident #13, never used his call light, was nonverbal and she had "never seen any response out of him". RN "E" stated "staff needs to anticipate his needs". In an interview on 2/25/15 at 3:45 p.m., Certified Nursing Assistant (CNA) "F" reported that she had never known Resident #13 to use his call light. CNA "F" was queried how Resident #13 would let staff know he was in distress. CNA "F" reported that staff checks on Resident #13 "often". In an interview on 2/25/15 at approximately 3:55 p.m., UM "C" was queried how Resident #13 notified staff if he was in need. UM "C" stated "he's not able to. It would be very rare for him to ring the call light. You might see him reach out or wave". When queried how often staff checked on Resident #13, UM "C" stated "I don't know if I could give you specifics, frequently, it's a busy unit". UM "C" was not able to locate records that Resident #13's oxygen saturation was monitored on a routine basis. When asked about the current system in place to check the functioning of oxygen concentrators, UM "C" reported she would have to check with maintenance, but that nursing should check with every interaction with the resident. UM "C" reported she was not aware that Resident #13's concentrator was not functioning when she walked by and said hello at 12:13 pm. UM "C" stated "his nasal cannula was on". In an interview on 2/25/15 at 4:17 p.m., Director of Nursing (DON) "B" was unable to describe the current system in place to ensure the functioning of oxygen concentrators. On 2/26/15 at 8:40 a.m., DON "B" and Nursing Home Administrator (NHA) "A" were in DON "B's" office. DON "B" reported that Resident #13's concentrator was replaced last night and his old concentrator was currently in her office. An observation at that time, revealed the concentrator had the power switch in the on position, was not plugged in, and was intermittently beeping. DON "B" reported that she timed the beeps and after 20 minutes, the concentrator gives a long beep and then goes silent. DON "B" reported that the beeping should have alerted staff. ( ) Resident #15 An observation on 2/26/15 at 2:56 pm, revealed Resident #15's oxygen tank was set at 4 L. The tank capacity indicator line was at the beginning of the red refill level, indicating the tank needed to be replaced. At 2:58 pm, a Certified Nursing Assistant (CNA) entered Resident #15's room at stated "Hey if you're going to be in here, can we put you on this (oxygen concentrator)". Resident #15 refused. The CNA left the room and did not return with a replacement oxygen tank. At 3:12 pm, Resident #15's oxygen tank capacity indicator line was halfway through the red refill section. At 3:18 pm, Certified Nursing Assistant (CNA) "M" and Resident Assessment Coordinator (RAC) "L" were observed standing outside Resident #15's room. CNA "L" was overheard asking RAC "L" "what's wrong?". RAC "L" was overheard stating "Nothing, I was just making sure his oxygen was on." RAC "L" then walked into the MDS office and CNA "L" walked down the hall. ( ) Resident #15 Review of the Face Sheet dated 2/27/15 and the Minimum Data Set ((MDS) dated [DATE], revealed that Resident #15 was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #15 had clear speech, was usually understood, usually understands and had moderate cognitive impairment. Review of the Monthly Physician order [REDACTED].#15 was to have Oxygen administered at 6 liters per minute via nasal cannula. During an observation on 2/26/15 at approximately 3:25 p.m., the Oxygen tank capacity indicator appeared to be at the empty line, indicating that the oxygen tank no longer was providing oxygen to the resident. During an interview on 2/27/15 at 10:10 a.m., when asked if Resident # 15 ' s oxygen tank ran out of oxygen, Unit Manager (UM) " C " stated, " it did yes " . Resident #18 Review of the Face Sheet dated, 2/27/15, and the MDS, dated [DATE], revealed Resident #18 was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician order [REDACTED].#18 at a rate of 2 liters per minute via nasal cannula. During an observation on 2/27/15 at 8:20 a.m., Resident #18 was in bed, appeared to be sleeping, the oxygen concentrator was running, the oxygen tubing was around resident's face/head but the nasal cannula was not positioned in the nostrils as the physician ordered. During an observation on 2/27/15 at 8:40 a.m., Resident #18 was in bed, appeared to be sleeping, the oxygen concentrator was running, the oxygen tubing was around resident's face/head but the nasal cannula was not positioned in the nostrils as the physician ordered. During an observation on 2/27/15 at 9:00 a.m., Resident #18 was in bed, appeared to be sleeping, the oxygen concentrator was running, the oxygen tubing was around resident's face/head but the nasal cannula was not positioned in the nostrils as the physician ordered. Resident #18 went at least 40 minutes without oxygen being administered to him as ordered by a physician, before this surveyor brought it to the attention of the floor nurse to address. ( ) B. Based on observation and interview, the facility failed to change oxygen tubing for 1 supplemental resident (#16) from a total of 15 sampled residents, resulting in the potential decreased equipment effectiveness. Findings include: According to the facility's Electronic Medical Record (EMR) Resident #16 had [DIAGNOSES REDACTED]. On 2/26/15 at 2:37 PM Resident #16 was observed in her room laying in the bed with her hospital gown on. An observation was made of a bedside commode in her room, a cushion seated wheelchair, and a oxygen tank connected to nasal cannula oxygen tubing. The tubing was dated, and reflected changed Tuesday 2/17/15. Resident #16 nasal tubing was connected to an oxygen concentrator while she was in bed, at a rate of 3 liters with humidified sterile water. Resident #16 stated she had went to physical therapy earlier in the day by wheelchair and used the oxygen tubing/tank connected to the wheelchair. At 2:46 PM the Nurse Manager ("U") was asked how often was oxygen tubing was supposed to be changed. Nurse "U" stated tubing was to be changed every 7 days for both the concentrators and oxygen tanks. The tubing was not changed within 7 days, as reflected by the change date and informed by Nurse "U". ( )

This citation pertains to intake MI 797. Based on observation, interview and record review, the facility failed to provide supervision to prevent a fall for 1 resident (Resident #100) with cognitive impairment, who required extensive assistance with bed mobility and was at high risk for falls out of 3 sampled residents from a total sample of 5 residents with decreased safety awareness, a history of falls and at high risk for falls, resulting in a fracture of the left knee, pain and hospitalization . Findings Include: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 12/18/13, Nurses notes dated 8/5/14 to 10/10/14, Physical Therapy notes dated 10/10/14, Physician orders [REDACTED].#100 was an [AGE] year old female, admitted to the facility on [DATE], with cognitive impairment and behaviors, poor attention span, impaired memory, judgment, impulse control and insight, blind in the right eye, non-ambulatory and required extensive assistance with Activities of Daily Living (ADL's, bed mobility and transfers. The resident's [DIAGNOSES REDACTED]. Review of Resident #100's Nursing Assistant (CNA) resident care plan (resident plan of care) dated 1/17/14, stated "Bed mobility: 2 person assist. Special Need: 2 person assist with bed mobility, turning, positioning, bedpan. Turn and/or reposition with two assist when care is provided." Review of facility incident report dated 10/8/14, revealed on 10/8/14 at 1:20 a.m., Resident #100 "fell without injury" and stated Resident was receiving care from CENA (CNA) being placed on the bedpan when resident turned herself without help to her right side and fell out of the bed onto the floor on her left side." Review of the nurse's notes dated 10/8/14 at 1:27 a.m., stated "Resident was being put on the bedpan when she rolled herself over and right out of the bed. CENA (Nursing Assistant/CNA) tried to hold on to her but couldn't, landing on her left side." Review of the nurse's notes dated 10/8/14 at 1:52 p.m., stated "Resident was observed having swelling in left knee and pain with ROM (range of motion), called (physician #1) to get x-ray of knee, approximately 11:50 a.m. resident had c/o (complained) of SOB (shortness of breath) and using accessory muscle (a sign of respiratory distress)." Review of nurses notes dated 10/8/14 at 2:19 p.m., stated "Notified (physician #1) of left knee x-ray, there is a fracture involving left distal femoral metaphysis with mild displacement that extends to the articular surface. Per (physician #1) sent to ER (emergency room ) for TX (treatment) & eval." Review of the physician order [REDACTED]." Review of the Hospital record dated 10/8/14, stated "pt. (patient) was being assisted on the bedpan, the staff rolled the patient and dropped her off the bed and the patient injured her left knee. Pt. states fell last night (on 10/8/14 at 1:20 a.m.), on both knees but pain is mostly in left knee. Pt. unable to move left knee." Review of the Hospital ex-ray dated 10/8/14, stated "fracture through the distal medial femoral condyle with extension to the distal articular surface." Review of nurse's notes dated 10/8/14 at 10:52 p.m., stated "Patient return from hospital with a full left leg immobilizer r/t (related to) closed fracture distal femur medial condyle." Review of nurse's notes dated 10/9/14 at 5:02 a.m., stated "Resident appears fearful of minimal movement and has refused fluids during noc (night) for fear of pain upon placement of bedpan." Review of nurse's notes dated 10/10/14 at 10:20 p.m., stated "Resident in bed c/o (complained) pain and discomfort 5/10 but 10/10 with movement of extremity (a 10 out of 10 on the pain scale with movement of her left leg)." Review of physician order [REDACTED]." Review of physician order [REDACTED]." Observation and interview of Resident #100 was done on 10/24/14 at 2:20 p.m., accompanied by staff member "C" (Nurse Unit Manager, RN). The resident had a full length soft immobilizer cast-like from the top of her left ankle area to her mid-thigh. Staff member "C" (Nurse Unit Manager) removed the resident's immobilizer, the top of her knee was slightly swollen and she would not move her left leg because it "hurt." Observation and interview with Resident #100 was done on 10/24/14 at 8:45 a.m., in her room in private. The resident was in bed and her left knee had an immobilizer cast-like from her left upper ankle area to her mid-thigh area. When this surveyor asked the resident if she was able to move her left leg she said "no" because "it hurt" to move it. Resident #100 stated "she (staff member "F", Nursing Assistant/CNA) was by herself; She (staff member "F", CNA) was up-set about her grandchildren. I told her to leave her troubles behind. I was not on the bed pan that good, she came back in complaining about her grand kids. I forgot to tell her to pull me over before she took me off the pan, she said my sheet was wet, she rolled me over and I went 'clump' on the floor. It hurt, then they (staff) all came running. They used the (mechanical lift) to get me on the bed. I could of split my head open, I was between the wall and my bed (on the floor). I flipped right over, I told her (staff member "F", CNA) to get someone." Review of the physician order [REDACTED]. (extremity) q (every) shift." Review of the TAR (treatment record) dated 10/14, revealed no documentation that 2nd shift (2:00 p.m. to 10:00 p.m.) staff had assessed the residents left leg circulation per physician orders [REDACTED]. During an interview done on 10/24/14 at 2:25 p.m. in the conference room, staff member "C" (Nurse Unit Manager, RN) stated "they (nursing staff) are supposed to be looking at her skin and circulation every shift and documenting it on the TAR (treatment record)." Review of the Physical Therapy Evaluation dated 10/10/14, revealed the resident had a "tendency to leaning towards R (right) side (the same way she fell out of bed)" and stated "L (left) leg pain during movement. Pt. (patient) don't want to do any movement, pt. don't want to do, fear of fall." Review of the facility Post Fall assessment dated [DATE], revealed the analysis of the fall was it could have related to the residents "behavior" and stated "Resident turned herself over in her bed quickly while CENA was going to change her sheets and landing on the floor." An interview was done on 10/24/14 at 12:50 p.m., in the conference room with staff member"F" (CNA) assigned on 10/8/14, to the hall the resident was on. Staff member "F" stated "I was orientated on 2nd shift for about 4 or 5 days only, not on 3rd shift, this was my first night on my own on 3rd shift. I was coming back from lunch and she was yelling "can someone put me on the bed pan." She said she was on the light for 30 minutes. I was told if I needed to go in there (to give care for Resident #100), I needed to take someone with me (the resident was an assist of 2). I walked up the hall and walked back, I couldn't find anyone. I put a bed pan under her, she rolled to the right, there was no rail for her to hang on to. I took her off the bed pan and cleaned her up. She fell out of the bed when I put the clean sheet on her bed. I was taught how to log (use the computer CNA charting program) the BM's (bowel movements), food acceptance and ADL care by the CNA's on 2nd shift. I wasn't taught where the CNA care plan was, I asked yesterday (10/23/14, the resident fell on [DATE]) for the first time another CNA how to find it. It could have been prevented if on 3rd' s there were more team players and if I would of known the residents CNA care plan. I had a lot to do; I did the best I could." When this surveyor asked staff member "F" (CNA) how long she had been a certified Nursing Assistant, she stated "since 1999 or 2000." Review of staff member "F's " (CNA) written statement dated 10/8/14, stated "changing resident and washing her during the fall, resident turned herself over in the bed during care and fell out of bed." An interview was done on 10/24/14 at 2:45 p.m. in the conference room, with staff member "E" (CNA). Staff member "E" (CNA) stated "I showed (staff member "F") how to find the CNA care plan. I told her you need 2 people in her (Resident #100) room, she been a 2 person with care." Review of the facility Training Topic Checklist (computer staff orientation sheet) dated "9/26/14 and signed by staff member "F", revealed documentation the "Task Documentation" (resident care plan) was demonstrated by staff member "F" and checked off as completed. An interview was done on 10/24/14 at 8:45 a.m. in the conference room, with staff member "A" (Charge Nurse, LPN). Staff member "A" (Charge Nurse) stated "She (Resident #100) rolled herself, I assume, I didn't ask the resident or the CNA (staff member "F"), I didn't ask what happened. She (the resident) needs 2 people to put her on the bed pan. (Staff membe "F", CNA) put her on the bed pan alone (the other CNA ' s) told her not to put her on the bed pan alone. She's been a 2 person assist for a long time; everybody knows she's a 2 person turn." An interview was done on 10/24/14 at 2:55 p.m. in the conference room, with staff member "D" (Charge Nurse, LPN). Staff member "D" (Charge nurse) stated "I talked with the CNA (staff member "F" ) and she said all the CNA's were busy so she did it (put Resident #100 on the bed pan) by herself." Review of the facility Falls Practice Guide and Guideline Flowchart dated 2001, revealed fall management focused on minimizing fall risk factors and fall related injuries. The facility would initiate and up-date as needed the residents "Kardex/Task List" (CNA resident care plan) and implement staff education as part of their fall prevention program. ( )

Based on observation, interview and record review the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being and provide appropriate respiratory care for 2 of 3 (#5 and #10) sampled residents with a [MEDICAL CONDITION] and 2 extended survey sample residents (#23 and #25) with a [MEDICAL CONDITION] from a total sample of 15, resulting in an immediate jeopardy for failure to provide proper tracheotomy care and treatment for [REDACTED].#10's room and the failure of facility staff to know the location of suction machines and to inspect and maintain the emergency crash carts which contain suctioning equipment; in addition to the failures that resulted in the immediate jeopardy for residents #5 and #10 the facility failed to identify appropriate emergency procedures for [MEDICAL CONDITION] residents with stomas (#23 and #25), the deficient practice results in the potential for all identified [MEDICAL CONDITION] residents to develop unrecognized symptoms of acute respiratory distress, potential for increased risk of respiratory compromise and the potential for obstructed airway and death. Findings include: The Immediate Jeopardy began on 3/18/2014 when resident #5 was observed in need of airway suctioning at approximately 9:20 am, with Director of Care Delivery (DCD) "F" (unit manager working under the direction of the Director of Nursing) and again on 3/20/14 at 9:15 am, with DCD "F." On both occasions Resident #5 was observed with large amounts of copious thick tan mucus covering the opening of Resident #5's airway, hanging down the [MEDICAL CONDITION], partially covering and obstructing the airway and covering the chest area of Resident #5's shirt down to the breast area. The suction machine was located hidden behind her curtain on the window sill. There were no suction catheters or [MEDICAL CONDITION] kits observed in the residents room. On 3/20/14 at 9:00 am, Resident #10 was observed with [MEDICAL CONDITION] attached to a compressed air oxygen concentrator. Inspection of the residents room revealed there was no suction machine or suction catheter at the bedside ready for resident use. The Director of Care Delivery (DCD) "F" looked for a suction machine and was unable to locate a suction machine in the room. On 3/20/14 at 9:25 am, the second floor crash cart was check with DCD "F" and the emergency "crash cart signature log" dated March 2014 revealed multiple days the nurses had not checked the emergency crash cart for supplies and suctioning equipment to ensure the cart was appropriately stocked. The immediate jeopardy was identified by the survey team on 3/21/14. The Nursing Home Administrator was notified of the immediate jeopardy on 3/21/14 at 4:30 pm due to the facility's failure to maintain the highest practicable physical well-being, monitor, evaluate and assess respiratory care for resident #5, and ensure respiratory supplies (suction machine, suction equipment) are available and readily accessible for Resident #5 and #10 with tracheostomies, and the facilities failure to know the location of suction machines and to inspect and maintain the emergency crash carts which contain suctioning equipment. A request for a written plan for removal of the immediate jeopardy was requested. The immediate jeopardy was removed, with a date of 3-21-14, when the surveyors verified implementation of the following plan to remove the Immediate Jeopardy: On 3/20/14, review of the facility's personnel records revealed nursing staff providing direct care to residents were 13 charge nurses, two (2) supervisors, and one (1) DCD (Director of Care Delivery) for a total of 16 out of a total of 24 licensed nurses had completed [MEDICAL CONDITION] training in the last year. In addition, personnel records refected the Director of Nursing had not received [MEDICAL CONDITION] training since her year of hire. On 3/21/14 after lunchtime the DON staff "B" reported the [MEDICAL CONDITION] training was only received at the time of an employee licensed nurse staff was hired and there was no ongoing or annual training that was offered. 1. As of 3/21/24, Resident #5 and 10 continued to reside at the facility. 2. On 3/21/14, 3 (#5, #10 and #13) of the facility'[MEDICAL CONDITION] were reassessed by nursing staff for any current change of condition, physician orders were received, care was reviewed and revised. On 3/22/14, 3 (#5, #10 and #13) of the facility'[MEDICAL CONDITION] were initiated for monitoring according to the facility's audit form. The facility form was reviewed on 3/24/14, (3) residents were documented for monitoring according to the facility's audit form from 3/22/14 through 3/24/14. 3. On 3/21/14, the crash cart check list was re-initiated. On 3/22/14 the "Crash Cart Signature Log," Emergency Management Crash Cart Policy dated 8/11/06, was reviewed, revised, with audits initiated. Reviewed on 3/24/14. On 3/24/14, 3 of the facility's crash carts were documented for monitoring according to the facility's audit form from 3/22/14 through 3/24/14. 4. On 3/21/14 there remained 14 of 24 current licensed nursing staff that required education on emergency crash cart maintenance, location of suction machines, proper tracheotomy care and treatment to include suctioning which was to be completed prior to the start of their next scheduled shift. On 3/24/14, 24 of 24 licensed nursing staff had completed the required education on emergency crash cart maintenance, location of suction machines, tracheotomy care and treatment to include suctioning. 5. The Director of Nursing or designee will complete random weekly audits on the crash cart signature log, licensed nurse assessment evaluation of tracheotomy residents respiratory status, tracheotomy care, and suctioning, suction machine location, and validate tracheotomy residents have suction machine [MEDICAL CONDITION] available for three months with findings corrected. Report of findings will be give to Administrator weekly and reviewed by the quality assurance committee monthly for further recommendations as needed. The Administrator will be responsible for assuring that compliance is attained and maintained. Although the Immediate Jeopardy was removed on 3/21/14, the facility remained out of compliance with a scope of pattern and severity of "No actual harm with a potential for more than minimal harm that is not immediate jeopardy" as sustained compliance could not be verified by the State Agency. Resident #5: According to Resident #5's annual Minimum Data Set assessment ((MDS) dated [DATE], Resident #5 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's physician monthly orders dated March 2014, revealed there was no physician order to suction Resident #5's [MEDICAL CONDITION] in the event of increased mucus secretions, obstruction of the airway, or respiratory distress/emergency. Review of Resident #5's RT note dated 2/6/14 at 10:19 am, revealed, Resident's oxygen saturation level was at 96 percent and her lung sounds were decreased at the bases." On 2/12/14 at 10:59 am, "patient had taken her non disposable inner cannula out. NDIC (Direct Care) cleaned, thick brown material removed." Review of Resident #5's care plan dated 12/30/13, "Has/At risk for respiratory impairment related to [MEDICAL CONDITION], status [REDACTED]. MD will give 1 x sxn (suction) order if necessary. Please call first." Review of Resident #5's care plan dated 12/30/13, revealed, "[MEDICAL CONDITION], opening sterile boxes for cleaning devices attempts to clean cannula herself to remove buildup r/t her sneaking fluids or food not consistent with her restriction," with an intervention to "monitor room as needed and return [MEDICAL CONDITION] to supply closet." Resident #5 was observed during the initial tour on 3/18/14 at approximately 9:20 am, with Director of Care Delivery (DCD) "F" and again on 3/20/14 at 9:15 am, with DCD "F." On both occasions Resident #5 was observed with large amounts of copious thick tan mucus covering the opening of Resident #5's airway, hanging down the [MEDICAL CONDITION], partially covering and obstructing the airway and covering the chest area of Resident #5's shirt down to the breast area. The resident was observed to have been coughing in an attempt to clear her airway. Resident was inquired as to if she had a suction machine and Resident #5 pointed to her window. The suction machine was located hidden behind her curtain on the window sill. There were no suction catheters or [MEDICAL CONDITION] kits observed in the room. Resident #5 nodded her head back and forth, indicating, "no" when she was asked if there were any suction catheters in the room. Resident #5 pointed towards the hall. On 3/20/14 at 9:20 am, DCD "F" was requested to Resident #5's room to locate suction catheters, after "several minutes" of looking through the closet with numerous boxes of various sizes. DCD "F" stated, we will discuss this in the hall." DCD "F" was requested to locate the suction machine and "found" it behind the curtain on the window sill. Resident was observed to continue to cough and have the large copious amount of thick tan mucus present surrounding the [MEDICAL CONDITION] opening. DCD "F" failed to identify and assess Resident #5's need for respiratory care. Upon leaving Resident #5's room DCD "F" stated that Resident #5 was not allowed to keep emergency supplies for her [MEDICAL CONDITION] in her room as she opened the kits and wiped the area around the [MEDICAL CONDITION] herself. DCD "F" reported the staff kept Resident #5's supplies in the supply room and in an emergency staff would use the emergency crash cart which was located in the dining room. On 3/20/14 at 2:30 pm, Resident #5 was observed for [MEDICAL CONDITION] care with Licensed Practical Nurse (LPN) "E." Prior to the procedure Resident #5 was asked if she had ever had any breathing difficulties, Resident #5 nodded her head up and down, whispered, "yes" and stated again in a whisper "a lot out-when it is coming out (mucus)." Resident #5 was observed to have a large amount of copious thick tan mucus present prior to the [MEDICAL CONDITION] care procedure being initiated by LPN "E." Resident #5 was requested to lay down on her bed for the procedure. The bed was noted to have been in a flat position. LPN "E" requested Resident #5 to lay down on the bed, Resident #5 shook her head back and forth, indicating no, Resident #5 was observed to be coughing, with mucus projecting out of the [MEDICAL CONDITION]. LPN "E" again repeated to Resident #5 to lay down more firmly, Resident #5 laid down flat and continued to cough. LPN "E" placed a towel over Resident #5's chest area, (covering some of the secretions). LPN "E" made no attempt to remove/suction any of the secretions prior to cleaning the [MEDICAL CONDITION]. LPN "E" used one cotton swab to swipe at the base of the stoma to remove minimal secretions from the site, using her right hand, clean sterile gloved hand touched and repositioned the outside of the supply container, then removed the inner cannula, and stated, "there is an odor." The inner metal cannula was observed to have dried, crusted yellow/green secretions present on the outside and inside surfaces. LPN "E" used the small brush with multiple scrubbing motions and pressure to remove the dried secretions and had to use the pipe cleaner several times to remove dried secretions from the inside of the inner cannula. LPN "E" while cleaning the inner metal cannula, described the secretions in the cleaning solution as, "a few yellow clots." Several (5) pinky sized yellow hardened clots were observed in the cleaning solution following the inner metal cannula being cleaned by LPN "E." LPN "E" then rinsed the inner cannula by pouring the solution over the inner cannula and placed back into the trachea. LPN "E" was not observed to have worn a mask, goggles or gown during the procedure. LPN "E" reported the inner metal cannula had been changed earlier that morning. LPN "E" was asked if Resident #5 had ever been suctioned to assist with the removal of the large amount of secretions or to keep the tube free from mucus build up and LPN "E" responded, "Never." Review of the facility policy "Respiratory [MEDICAL CONDITION] Care," dated 1/2011," Purpose: To describe a recommended method for: cleaning a [MEDICAL CONDITION] site and tube, keeping site and tube free from mucus buildup, maintaining tube patency, reducing risk of infection and maintain skin integrity at stoma site. Remember - suction trachea thoroughly before starting [MEDICAL CONDITION] care if necessary. Procedure: Establish sterile field on over bed table and maintain during procedure: ...Place sterile drape over chest area and surrounding site being treated...8. place in upright position. 9. put on sterile latex free gloves and personal protective equipment e.g., gown, goggles - if indicated. Remember when performing [MEDICAL CONDITION] care keep dominant hand sterile (usually right hand) and non dominant hand clean (usually left hand)." Non-disposable inner cannula tube cleaning 3. immerse cannula in sterile normal saline and agitate to remove remaining secretions." ( ) Resident #10 Review of record revealed Resident #10 was [AGE] year male admitted on [DATE], with [DIAGNOSES REDACTED]. The physician's order sheet dated March 2014 stated "trach site care every shift as needed." On 3/20/14 at 9:00 am, Resident #10 was observed with [MEDICAL CONDITION] attached to a compressed air oxygen concentrator. Inspection of room revealed there was no suction machine or suction catheter at the bedside ready for Resident use. The Director of Care Delivery (DCD) "F" looked for a suction machine and was unable to locate a suction machine in the room. DCD "F" stated the facility used a suction machine from the crash cart if there was none available. The suction machine located in the day room on the second floor was located on top of the emergency crash cart was observed to have been open/used and attached to the tubing. On 3/20/14 at 9:00 am, charge nurse Licensed Practical Nurse "D" who stated she had done [MEDICAL CONDITION] at 8:00 am this morning and yesterday had no knowledge of where the suction machine was and was not able to locate one. Staff "D" was asked how she performed trachea care. She said "I just cleaned around the trachea site." On 3/20/14 at 9:10 am, Central Supply Clerk (CSC) "G" stated he found the suction machine that had been located in Resident #10's room. CSC "G" reported the suction machine had been found in the soiled utility room with a note attached to the suction machine that stated the suction machine was not functioning. CSC "G" reported he did not know who had left the suction machine in the soiled utility room or how long the suction machine had remained in the soiled utility room. On 3/20/14 at 11:00 am, Respiratory Therapist "H" reported when he was in the resident #10's room on 3/19/14 he did not recall the presence of a suction machine in Resident #10's room. The "progress notes," utilized by all disciplines, dated 9/5/13 through 3/5/14 reflected resident #10 had been visited by staff "H" weekly and his respiratory care including [MEDICAL CONDITION] with non-disposable inner cannula cleaning. The notes described resident #10's lung assessment, his ability to cough up secretions as well as the characteristics of tracheal secretion and the condition of stoma site. However, there was no statement regarding suctioning no matter how tenacious secretions were. On 3/21/14 at 9:00 a.m., the "200" hall unit manager, (staff "F") was asked how many "full code," meaning all life saving procedures would be rendered in case of emergency, residents were in the facility. Staff "F" stated there were 54 "full code" residents out of the current census of 69. On 3/21/14 at 10:00 a.m., Director of Nursing, ("B") was asked for clarification. Staff "B" stated she could see how nurses could interpret differently. Staff "B" brought the facility policy: [MEDICAL CONDITION] care dated 01/2011. The policy called for providing [MEDICAL CONDITION] care once a day or as indicated per physician order. Not checking crash cart on a regular basis or keeping necessary equipment and supplies may significantly impact resident's survival. ( ) Emergency crash cart On 3/20/14 at 9:25 am, DCD "F was requested to obtain copies of documentation from the emergency crash cart log signature monitoring for all 3 of the facility's emergency crash carts. At 9:40 am, this surveyor assisted in sorting the forms that had been obtained from the central supply room staff. Administrator "A" and Director of Nursing (DON) "B" were questioned about the facility policy for monitoring the facility's emergency crash carts. ADM "A" responded, I do not know the facility policy, I am not sure, I will need to look it up." Administrator "A was also identified as a Registered Nurse on her name tag. DON "B" stated, "It is only checked if the lock is broken." DON "B" was asked what if the lock was broken or not replaced and nursing signatures are not present on the signature log to verify daily monitoring, how can you be sure there are going to be supplies in the emergency crash cart in the event of an emergency. DON "B" responded, "I hoped it is replaced." DON"B" reported the Central Supply staff was assigned to check the emergency cart monthly, and the nurses were assigned to check the chart daily. ADM "A" reported she had not been aware the signature pages were incomplete and they had not been reviewed in quality assurance. On 3/20/14 at 9:25 am, the second floor crash cart was check with DCD "F" and the emergency "crash cart signature log" dated March 2014 revealed multiple days the nurses had not checked the emergency crash cart for supplies to ensure the cart was appropriately stocked. DCD "F" was questioned as to who was responsible for the daily checking of emergency crash cart and DCD "F" stated the "midnight nurse was responsible. "DCD "F" was questioned as the manager of the nursing unit what were her responsibilities related to the emergency crash cart and she responded, "should check crash cart on my daily rounds" DCD "F" reported she had not checked the emergency crash cart daily. On 3/20/14 at 10:30 am, the third floor emergency crash cart was missing the lock. There was no form present to verify the contents of crash cart on the first floor, second floor or the third floor emergency crash cart. Review of the facility's monthly emergency crash cart documentation dated September 2013 through March 2014 for the first floor revealed: September 2013 was missing 5 of 30 days, October 2013 was missing 13 of 31 days, November 2013 was missing 7 of 30 days, December 2013 was missing 8 of 31 days, January 2014 was missing 12 of 31 days, February 2014 was missing 22 of 28 days, and March 2014 was missing 8 of 19 days. Review of the facility's monthly emergency crash cart documentation dated September 2013 through March 2014 for the second floor revealed: September 2013 was missing 14 of 30 days, October 2013 was missing 17 of 31 days, November 2013 was missing 17 of 30 days, December 2013 was missing, January 2014 was missing 8 of 31 days, February 2014 was missing 22 of 28 days, and March 2014 was missing 10 of 19 days. Review of the facility's monthly emergency crash cart documentation dated September 2013 through March 2014 for the third floor revealed: September 2013 was missing 16 of 30 days, October 2013 was missing 6 of 31 days, November 2013 was missing 6 of 30 days, December 2013 was missing 5 of 31 days, January 2014 was missing 8 of 31 days, February 2014 was missing 10 of 28 days, and March 2014 was missing 0 of 19 days. Review of the facility policy "Emergency Management," dated 8/11/16 and revised 11/2013, stated "*use a crash cart check sheet and signature log form daily to verify the contents of the crash cart. One sheet is used per cart per month. The on-coming licensed nurse completes the following steps: -verifies that all equipment and care items listed on the crash cart checklist are present on the top, back and sides of the cart -ensures breakaway lock securing drawers is intact and number on lock is unchanged from previous check -checks all internal cart contents against the crash cart checklist and replaces any missing items if the breakaway lock is open, missing or does not match the previous documented number *check emergency care items and equipment stored in the crash cart against the crash cart check list once a month and whenever the cart is opened to validate contents and expiration dates. The licensed nurse or designee: ...signs and dates crash cart checklist. *Check lists and signature logs are submitted to the ADNS and QAPI committee for review and follow up upon completion." On 3/24/14, 2 (# 23 and #25) additional residents were identified with tracheostomies and were not identified on the facility's census and condition, the facility audits for monitoring, or reassessed for change of condition. Resident #23 According to Resident #23's physician readmission evaluation dated 3/6/14, Resident #23 was a [AGE] year old male who had been sent to the hospital on [DATE] for evaluation of shortness of breath. Resident #23 had been discharged from the hospital on [DATE], and was admitted to the facility. Resident #23's previous hospital admission, revealed he was intubated on 2/14/14 and extubated on 2/16/14. Resident #23's [DIAGNOSES REDACTED]. On 3/24/14 at 12:35 pm, Resident #23 was observed in his room, lying in his bed. Resident #23 was observed to have a dressing covering his throat area ([MEDICAL CONDITION] stoma). Resident #23's dressing and shirt were covered with large amounts of thick white mucus. There was no observation of a suction machine in Resident #23's room in the event of emergency respiratory care was required for Resident #23. On 3/25/14 at 12:15 pm, staff "W" was asked if there was a suction machine in Resident #23's room and responded, " I don't remember there ever being one in his room." ( ) According to the face sheet in his medical record, resident #25 was a [AGE] year old man with admitting [DIAGNOSES REDACTED]. According to the Minimum Data Set assessment dated [DATE], the resident had short term and long term memory deficits with severely impaired ability to make decisions about tasks of daily living and he required moderate to maximum assistance with all areas of daily living. He was admitted from the hospital on [DATE], after brain surgery, with pneumonia and a [MEDICAL CONDITION] including cannula. According to the physician's progress note dated 3/10/14, "the resident pulled out his [MEDICAL CONDITION] on the 8 th of the month." The physician wrote an order dated 3/24/14 stating "D/C (discontinue) suctioning status [REDACTED]. The resident was observed on 3/25/14 at approximately 9:20 a.m. seated in his wheelchair in the dining room with 2 visitors. Resident #25 did not respond to greetings. He appeared to be attempting to place the nasal cannula under his chin.. A beard obscured the area. A visitor stated "He puts it (nasal cannula) under his chin or on his head." Closer inspection revealed a horizontal slit on the throat which was reddened. The area appeared dry with no secretions or moisture. On 3/25/14 at 12:15 pm, staff nurse "W" and staff nurse "V" were interviewed and inquired what they would do if a resident's [MEDICAL CONDITION] became plugged, Staff "W" responded,"proceed with the [MEDICATION NAME] maneuver, free out occlusion /plug." Staff "V" responded, "suction, [MEDICAL CONDITION] and provide oxygen." Both nurses were asked about [MEDICAL CONDITION] stoma care and managing airway emergencies. Both Staff "V" and Staff "W" reported [MEDICAL CONDITION] training that had just been provided by the facility had not covered the emergency care or treatment of [REDACTED]. "Staff "V" stated, "I don't have a clue what I should do." ( ) ( )

This citation pertains to intake numbers MI 685 & MI 890. Based on observation, interview, and record review, the facility failed to provide adequate supervision for 2 of 2 sampled residents (#500 & 501), out of a total sample of 3, resulting in Resident #500 having 5 falls within a 14 day period that resulted in injury, and Resident #501 having 11 falls within a 35 day time period that resulted in injury. Findings include: Resident #500 Per the facility face sheet Resident #500 was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #500 no longer resided at the facility at the time of the investigation. Record review of a "Minimum Data Set" ((MDS) dated [DATE] revealed that Resident #500 had inattention, and disorganized thinking. The MDS revealed that Resident #500 required extensive assistance for transferring, dressing, toilet use, personal hygiene, and bathing. The MDS revealed that Resident #500 did not ambulate and was totally dependent for locomotion. Record review of facility incident reports revealed that Resident #500 had a fall on 1/21/13, 1/23/13, 1/25/13, 1/30/13, and a second time on 1/30/2013. Review of the incident report dated 1/21/2013 revealed that Resident #500 was found sitting on the floor next to her bed, without evidence of injury. The incident report revealed that the intervention added was to add a mat to the floor. Record review of nurses' notes dated 1/22/2013 (this is the incident report date of 1/21/2013), and timed at 3:10 AM, revealed that Resident #500 was sitting on the floor with her pants down and would ambulate independently. Review of the incident report dated 1/23/2013 revealed that Resident #500 was found sitting on the floor in the hallway and Resident #500 received a skin tear to her right elbow. The intervention added was, "see if we can move patient (Resident #500) closer to nurses station." Record review of Nurses' notes dated 1/23/2013, and timed at 5:34 AM, revealed Resident #500 was found sitting in hallway at 3:00 AM. The note revealed Resident #500 had a skin tear and to continue to check on Resident #500 often to prevent her from ambulating by herself. Review of the incident report dated 1/25/2013 revealed Resident #500 was observed sitting on the floor at the bedside between her bed and a commode chair. The incident report revealed that Resident #500 admitted that she was attempting to get up to the commode chair when she slipped and fell . The incident report also revealed that Resident #500 hit her head on the bedside table resulting in a 1.5 cm laceration above her right eyebrow, with swelling, and a transfer to the emergency room . The interventions noted on the incident report was, "Pt (Resident #500) stabilized, wounds cleaned and dressed, assisted back into bed awaiting transfer to hosp (hospital) for eval (evaluation); assessed mentally & physically w/ STAT (with immediate) VS (vital signs) obtained...neurochecks (neurological assessment) initiated..." Record review of Nurses' notes dated 1/25/2013, and timed at 5:00 PM, revealed that at 4:15 PM Resident #500 was observed sitting on bedside floor mat between her bed and her commode. The note revealed that Resident #500 stated she was trying to transfer onto her commode when she slipped and fell , and hit her head on the bedside table. The note revealed that Resident #500 received a 1.5 cm laceration across and above her right eyebrow, with a large swelling mass developing. The notes revealed Resident #500 also received a 1.5 cm skin tear to her left wrist. The note revealed Resident #500 was transferred to the hospital. Record review of hospital records dated 1/25/2013 revealed that Resident #500 had a 1 cm laceration to her right forehead. The laceration was closed with dermabond (skin glue). Review of an incident report dated 1/30/2013, and timed at 5:50 AM revealed that Resident #500 was observed lying on her right side on a floor mat next to her bed. No injury was documented and no reason for Resident #500's attempt to ambulate on her own. Interventions documented on the incident report revealed, "frequent checks to be sure resident isn't trying to get up alone." Record review of Nurses' notes did not have documentation of Resident #500's fall on 1/30/2013 at 5:50 AM. Review of an incident report dated 1/30/2013 and timed at 1:04 PM revealed that Resident #500 was found lying on her back on the floor next to her wheelchair. The report revealed that Resident #500 stated she was looking for her daughter and slipped. Interventions revealed on the incident report was to add a Dycem to wheelchair, under and above seat cushion. Record review of Nurses' notes dated 1/30/2013, and timed at 12:55 PM, revealed Resident #500 was found lying on floor in hallway next to her chair, and as a result, an x-ray of Resident #500's left hip was ordered. Review of a care plan for "Falls" dated 8/3/2010 revealed that prior to Resident #500's fall on 1/21/2013 interventions dated 1/16/2013 included, assess for fall risk upon admission and re-assess as needed, encourage and assist as needed to wear proper and non-slip footwear, encourage to transfer and change positions slowly, have commonly used items within reach, provide assist to transfer and ambulate as needed, re-enforce the need to use call light. Further interventions added on 1/28/2013 (7 days after Resident #500's 1/21/2013 fall) revealed to put bed in low position, administer medications per physician's orders [REDACTED]. No other interventions were added to Resident #500's care plan until 1/30/2013 which included, offer frequent opportunity for bowel and bladder release. One other intervention was added on 1/31/2013 and consisted of Dycem (cloth that prevents sliding) on and under wheelchair cushion. Record review of an x-ray dated 1/30/2013, after Resident #500's second fall on 1/30/2013, revealed, "Left proximal (nearest) femur fracture at the site of the femoral implant of a hip replacement." Record review of physician progress notes [REDACTED]." Record review of a hospital physician examination report dated 1/31/2013 revealed, "Acute (recent) fracture involving the proximal shaft of the left femur adjacent to left hip arthroplasty (surgical repair of a fracture)..." The report revealed that Resident #500's previous surgical repair (arthroplasty) appeared to be intact. Record review of Resident #500's hospital "History and Physical" dated 1/11/2013 revealed that Resident #500's fracture, prior to her admission at the facility, was a hip fracture, at the base of the femoral head. In an interview on 2/22/2013 at 1:06 PM, Registered Nurse (RN) #8 stated that about two (2) days after Resident #500's admission to the facility Resident #500 became confused. RN #8 said Resident #500 was suppose to have assistance to ambulate but would attempt to ambulate on her own. RN #8 said staff would check on Resident #500 as much they could. RN #8 stated that Resident #500 had a fall on 1/22/2013 and not 1/21/2013 as indicated per the incident report. RN #8 said that after Resident #500's fall on 1/22/2013 she put a mat on the floor next to Resident #500's bed. RN #8 said after Resident #500's 1/23/2013 fall Resident #500's commode was moved to the corner of her room in an attempt to move it out of Resident #500's view, but stated the commode was still in Resident #500's view if the curtain was pulled back. RN #8 said that she did not move Resident #500 closer to the nurses' station after her fall on 1/23/2013 because she needed permission to do so first. RN #8 said Resident #500 never did learn to use her call light while at the facility. RN #8 said that staff checked on Resident #500 as an intervention after her second fall, but stated that no frequent checks had been documented to show that Resident #500 had been checked on frequently as RN #8 directed. RN #8 said that when Resident #500 had her fall on 1/25/2013 Resident #500's face hit the bedside table, breaking the table in half. In an interview on 2/22/2013 at 3:15 PM, RN #10 said Resident #500 would not use her call light, was forgetful, and non-compliant. RN #10 said on 1/25/2013 Resident #500 had a fall where Resident #500 obtained a laceration to her forehead and a left wrist skin tear. RN #10 said Resident #500's commode was placed out of reach, her bed was lowered, and she gave verbal instructions to the Certified Nurse Aids (CNA) to frequently check on Resident #500. RN #10 said she she did not update Resident #500's care plan to reflect her frequent check instructions and no documentation of the frequent checks were started. In an interview on 2/26/2013 at 2:30 PM, RN #16, who was the Unit Manager, stated that when a resident had a fall she expected the nurse caring for the resident to put into place an immediate intervention. RN #16 said there was not any documentation of any frequent checks that had been performed on Resident #500. RN #16, after review of Resident #500's care plan, stated that after Resident #500's fall on 1/25/2013 no new interventions were put into place. RN #16 said Resident #500 was transferred to the emergency room after her fall on 1/25/2013. RN #16 said Resident #500 fell again on 1/30/2013, and stated that at the time of this fall Resident #500 had been moved to the second floor. RN #16 said Resident #500 fell again on 1/30/2013 at 1:04 PM. RN #16 said that the intervention was added to place a Dycem to Resident #500's wheelchair (Dycem intervention had already been added previously). In an interview on 2/27/2013 at 10:56 AM, CNA #19 said Resident #500 would get up on her own and would not use her call light. In an interview on 2/27/2013 at 11:50 AM, CNA #5 said Resident #500 would attempt to get up out of bed on her own and had numerous falls when Resident #500 was on the third floor. Resident #501 Per the facility face sheet Resident #501 was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of an MDS dated [DATE] revealed that Resident #501 has delusional thinking, and per the "Care Area Assessment" (CAA) was at risk for falls. Record review of incident reports revealed that Resident #501 had 11 falls dated on the following dates, 1/6, 1/9, 1/10, 1/13, 1/14, 1/19, 1/22, 1/24, 2/1, 2/7, & 2/10/2013. The incident reports revealed that Resident #501 obtained the following injuries, on 1/6/2013 a small bruise on left forehead, 1/9/2013 bruise on left knee and a raised area and small laceration in the middle of forehead, 1/13/2013 complaints of hip pain and left side of forehead, 1/22/2013 a 2 cm abrasion on left forehead, 1/24/2013 a laceration to the left leg and drainage from a previous laceration on forehead, 2/1/2013 a 1 cm laceration to right forehead, and a laceration to the base of right foot little toe. Review of physician's "Progress Note" dated 1/31/2013 revealed Resident #501 was transferred to the hospital secondary to a fall and where Resident #501 received stitches to her left lower leg. Review of nurses' notes, dated as indication, revealed that on 1/6/2013 Resident #501 was observed on floor in front of her wheelchair and Resident #501 stated that she slipped out of her wheelchair. The notes revealed that Resident #501 had a quarter/fifty cent size bump on her left forehead. Dated 1/9/2013 nurses' notes revealed that Resident #501 was observed lying on the floor, and Resident #501 stated that she was leaning forward while in her wheelchair and fell forwards. A small laceration and raised area noted to Resident #501's forehead. Resident #501 was transferred to the emergency room . Dated 1/10/2013 Resident #501 was calling for help while in her room. The note revealed that the room door and bathroom door was wedged together and the room door was not able to be opened to get to Resident #501. The note revealed the room door was removed by the hinges to get to Resident #501. Dated 1/19/2013 the notes revealed that Resident #501 was observed sitting on the floor and Resident #501 reported that she was leaning over and her chair went back. Dated 1/21/2013 the notes revealed that Resident #501 was observed sitting on the floor and stated that she was reaching for coffee and slipped off her wheelchair. The note revealed that Resident #501 received a 2 cm abrasion to her left forehead. Notes dated 1/24/2013 revealed that Resident #501 had another fall and received a laceration to her left calf and a laceration to her forehead from a previous fall that was re-opened. Notes dated 2/1/2013 revealed that Resident #501 was observed sitting on the floor in her room and Resident #501 stated that she fell out of her wheelchair. The note revealed that Resident #501 received a 1 cm laceration on the right corner of her forehead and a large laceration to the base of her right little toe. Dated 2/10/2013 the notes revealed Resident #501 was found on the floor in her room at 9:35 AM, and Resident #501 bumped her previous wounds of the left side of her forehead and re-opened the wounds. Review of a frequent check monitoring log that began on 2/7/2013, revealed that Resident #501 was to be checked on every 30 minutes and on 2/10/2013, no documented check was conducted at 8:00 AM, 9:30 AM, or 10:00 AM, but instead 10:15 AM, and not again until 11:00 AM. The monitoring log dated 2/12/2013 revealed that Resident #501 had a documented check at 11:30 AM and then not again until 2:00 PM. The monitoring log dated 2/13/2013 revealed that Resident #501 had documented checks every hour from 7:15 AM until 12:15 PM, and then not again until 1:45 PM. The log dated 2/18/2013 revealed that Resident #501 had a check at 5:30 AM (2/19/2013 due to after midnight) and then not again until 7:00 AM. The log dated 2/20/2013 revealed that Resident #501 had a check at 8:30 PM and not again until 10:00 PM. Review of a care plan for falls dated 10/19/2007 revealed that after Resident #501's fall on 1/6 and 1/9/2013 a Dycem was added to the care plan, on 1/10 and 1/13/2013 no additional interventions were added to the care plan, on 1/19/2013 no additional interventions were added to Resident #501's care plan, on 1/24 and 2/1/2013 no additional interventions were added to Resident #501's care plan, and on 2/10/2013, after Resident #501 was placed on 30 minute checks on 2/7/2013, no additional interventions were added to the care plan. In an interview on 2/22/2013 at 1:40 PM, Licensed Practical Nurse (LPN) #3 said that all of Resident #501's injuries, bruising and lacerations were from falls that Resident #501 had, and stated that Resident #501's face looked "horrible". LPN #3 said Resident #501 would lean forward in her wheelchair touching her head to her knees and would refuse to get into bed. LPN #3 said Resident #501 had a habit of wedging her bathroom door against her room door so that staff would not be able to open the door unless staff reached their hand in and pushed the bathroom door shut. In an interview on 2/22/2013 at 2:35 PM, LPN #9 said that the interventions she was aware of to prevent Resident #501 from falling consisted of a Dycem to Resident #501's wheelchair, non-skid socks, a reacher (used to grab items out of reach). LPN #9 stated that it appeared that Resident #501 was falling asleep while in her wheelchair and falling forward. LPN #9 said that on 1/24/2013, after Resident #501 fell , Resident #501 received a laceration to her left calf that required a transfer to the hospital for sutures, and also stated that Resident #501 had a previous laceration to her forehead that opened back up after her fall. In an interview on 2/25/2013 at 10:10 AM, RN #11 stated that after Resident #501's fall on 1/10/2013 she could not recall any new interventions that she put into place to prevent Resident #501 from falling. In an interview on 2/25/2013 at 2:10 PM, RN #14, who no longer worked at the facility and was the Unit Manager, stated that after a fall the nurse assigned to the resident is expected to put an immediate safety intervention into place and then report to the Director of Nursing or Unit Manager in the morning. In an interview on 2/25/2013 at 2:45 PM, LPN #15 said Resident #501 would lean forward while in her wheelchair all the time. LPN #15 said Resident #501 would not use her reacher nor her call light. LPN #15 said that after Resident #501's fall on 2/10/2013, Resident #501 had the wounds on her forehead re-opened and also stated that she did not put into place any new interventions in regards to fall prevention. In an interview on 2/27/2013 at 10:10 AM, CNA #17 said that at the time of Resident #501's fall on 2/10/2013, she was Resident #501's CNA. CNA #17 said that at 8:00 AM she was passing trays out to residents in the hall. CNA #17 said she knew Resident #501 needed a 30 minute check done but stated that she was busy. CNA #17 said she did not tell any other staff member to perform the 30 minute check for her. CNA #17 said she was on her way down the hall towards Resident #501's room on 2/10/2013 when Resident #501 was found on the floor. CNA #17 said she had not gotten back to Resident #501's room at 9:30 AM to perform the 30 minute check. CNA #17 said Resident #501 was found on the floor at approximately 9:40 AM. CNA #17 said Resident #501 would lean forward while in her wheelchair with her head touching her knees, and her right arm hanging down with her fingers touching the floor. CNA #17 said Resident #501 would fall forward out of her wheelchair. In an interview on 2/27/2013 at 11:21 AM, Occupational Therapist (OT) #21 stated that Resident #501 received a therapy evaluation on 1/21/13. OT #21 said Resident #501 refused to wear supportive shoes and only wanted therapy to walk her. OT #21 said Resident #501 had anti-lock breaks on her wheelchair, and a tipped back seat was trailed but not successful. OT #21 said Resident #501 had been given many reachers but would not use the reachers. OT #21 said Resident #501 would lean forward and pick things up off the floor. OT #21 said that the therapy staff were aware Resident #501 would lean forward in her wheelchair and also fall asleep. Therapy documentation dated 1/21/2013 was reviewed during the interview, and OT #21 said there was no documentation in the notes that indicated therapy staff had addressed Resident #501's posture while sitting in her wheelchair and leaning/falling forward. OT #21 said that, per the therapy documentation, therapy staff worked on Resident #501's thoracic (upper body) region. Record review of the therapy notes dated 1/21/2013 revealed, under trunk and cervical, "impaired in thoracic/lumbar region." The notes did not revealed any documentation/treatment in regards to Resident #501's leaning forward posture while in her wheelchair. Record review of a hospital "Emergency Department Chart" dated 1/9/2013 revealed, under "progress notes, "She (Resident #501) does have multiple bruises of what appears to be varying ages on the forehead." Review of a hospital physician note dated 1/13/2013 revealed, under additional history, "Patient (Resident #501) had multiple falls with brusing (bruising) all over forehead and face." Review of hospital "Emergency Department Chart" dated 1/24/2013 revealed, under "skin", "there is a single laceration with a total length of 5 cm over the left shin...exam of the right shin revealed a 12 cm healing wound...there is a single laceration with a total length of 2 cm over the left side of the forehead." Review of a hospital "Emergency Department Chart" dated 2/1/2013 revealed, under "skin", "There is a single laceration with a total length of 1 cm noted over the right side of forehead." Observation of Resident #501's injuries was conducted on 2/26/2013 at 3:30 PM. Resident #501 was observed to have a superficial wound site to her right calf area, to the side of her leg. The wound measured 10.4 x 8.0 cm. Resident #501 was also observed to have a scabbed over wound to her left calf, to the side of her leg that measured 4.3 x 2.3 cm in size. Resident #501 was also observed on 2/21/2013 at 8:45 AM and on 2/26/2013 at 3:30 PM to have a healing laceration to the left side of her forehead, above her eyebrow. ( )

This citation pertains to intake number MI 445. Based on observation, interview, and record review the facility failed to ensure safety measures were in place for 1 (Resident #501) of 5 sampled residents reviewed for elopement risk, from a total sample of 7, resulting in Immediate Jeopardy for Resident #101, who was identified to be an elopement risk and wore a WanderGuard bracelet (bracelet that alarms upon approaching a WanderGuard protected door or elevator) on his person when (1) Resident #501's WanderGuard bracelet was removed by Registered Nurse (RN) #1 (without a physician's orders [REDACTED].#501 eloped from the facility at approximately 6:20 PM, when (2) nursing staff failed to visually check Resident #501's WanderGuard functioning and placement every shift as ordered, and when (3) Receptionist #2 unlocked the front door of the facility to allow Resident #501 to exit the because Receptionist #2 was unaware that Resident #501 was a resident. This deficient practice placed 8 other residents identified to be at risk for elopement and who wear WanderGuard bracelets at high risk for serious injury, harm, and/or death. Findings Include: Per the facility face sheet Resident #501 was a [AGE] year old male admitted to the facility on [DATE]. Resident #501 had [DIAGNOSES REDACTED]. Resident #501 no longer resided at the facility at the time of the investigation. Record review of a "Minimum Data Set" (MDS) assessment, dated 7/7/2012 revealed Resident #501 ambulated with limited assistance. Review of a "Care Area Assessment" (CAA) dated 7/5/2012 revealed that Resident #501 had been asking for the exit so he could "get out of here." The CAA revealed that Resident #501 was confused and not sure where he was or what state he was in. The CAA revealed that Resident #501 was able to ambulate. Record review of physician orders, dated 7/3/2012, revealed that a WanderGuard bracelet was ordered to be placed on Resident #501 and also that Resident #501 had permission to go on leave of absence (LOA) with his son. Review of the physician orders [REDACTED].#501's WanderGuard bracelet at any time. Record review of a care plan, dated 7/3/2012, revealed that Resident #501 wanted to go home and therefore was an elopement risk. The interventions included on the care plan to address elopement risk were to check for placement and functioning of the security (WanderGuard) bracelet every shift. Review of a "Treatment Administration Record" (TAR), dated 7/3/2012, revealed that Resident #501's WanderGuard was to be checked for placement and function every shift beginning 7/3/2012. The TAR revealed that nursing staff initialed to show that Resident #501's WanderGuard had been checked every shift except for the day shift on 7/10/2012. There were no nursing initials noted on the TAR verifying the placement and functioning of Resident #501's WanderGuard bracelet on 7/10/12. Registered Nurse (RN) #1 was interviewed on 7/23/2012 at 1:35 PM. RN #1 said that on 7/7/2012 around 10:00 AM Resident #501's son wanted to take Resident #501 out on LOA. RN #1 said Resident #501's son requested that Resident #501's WanderGuard bracelet be cut off. RN #1 said he cut the WanderGuard bracelet off of Resident #501. RN #1 said he reported to the next shift nurse (RN #3) that Resident #501's WanderGuard needed to be put back on when he returned to the facility. RN #1 said he put the WanderGuard in the top drawer of the medication cart and stated that was the location where the bands for the WanderGuard's were stored. RN #1 said apparently the WanderGuard was not put back on by RN #3. RN #1 said that the next day he (RN #1) worked was on 7/8/2012. RN #1 said he did not visually check the placement and functioning of Resident #501's WanderGuard. RN #1 said the placement and functioning of WanderGuard were to be checked every shift. RN #1 said that the next day he (RN #1) worked was on 7/10/2012. RN #1 said that during the day shift, he observed Resident #501 leave the third floor with physical therapy personnel and questioned as to why the elevator alarm did not sound when Resident #501 approached the elevator. RN #1 said he made a "mental note" to check Resident #501's WanderGuard alarm when Resident #501 returned to the floor. RN #1 stated that he forgot to do so. In an interview on 7/23/2012 at 11:44 AM, RN #3 stated that on 7/7/2012, RN #1 did in fact tell her that she needed to replace Resident #501's WanderGuard bracelet when he returned from LOA to the facility. RN #3 said she forgot. RN #3 said that she did not check Resident #501's WanderGuard for placement and functioning, and stated that she had documentation on the TAR that she had but that was false. RN #3 said that she would not ever cut a WanderGuard bracelet off of a resident even if family requested. In an interview on 7/23/2012 at 3:30 PM, RN #6 stated that nursing was responsible to check placement and functioning of resident WanderGuards. RN #6 said she did not know who removed Resident #501's WanderGuard, and that the WanderGuard was not on Resident #501 at the time he went out the facility's front door. RN #6 said Resident #501 had threatened to leave before and stated that she or a Certified Nurse Aid (CNA) would have to guard the elevator. In an interview on 7/23/2012 at 1:20 PM, Certified Nurse Aide (CNA) #7 stated that nursing checked the placement and functioning of the WanderGaurds and stated that CNAs did not. CNA #7 said he had not ever seen any staff perform the checks, but at random times, he (CNA #7) had been asked (did not state by whom) to check a WanderGuard, but not every shift. In an interview on 7/23/2012 at 3:05 PM, CNA #8 said that nursing was responsible to check placement and functioning of the WanderGuards. CNA #8 said she had not ever seen anyone check resident WanderGuards. CNA #8 stated that she knew what residents had WanderGuards on, but did not know Resident #501 had one on. In an interview on 7/26/2012 at 9:06 AM, Administrator #9 said that if a resident was to refuse a WanderGuard bracelet, then an assessment was to be completed in order to determine the continued need for the WanderGuard. Administrator #9 stated that even if a WanderGuard bracelet was discontinued, the resident's picture remained in the elopement book for staff awareness. Administrator #9 said that if a WanderGuard bracelet was to be removed, a physician's orders [REDACTED]. Administrator #9 stated that obtaining a physician's orders [REDACTED]. Record review of a "Facility Incident Report" dated 7/11/2012 revealed that Resident #501 walked out of the facility front door at approximately 6:20 PM, without signing out of the facility. The report revealed that at approximately 6:30 PM, Resident #501 was observed sitting at a picnic table on facility grounds talking on his cell phone. On 7/23/2012 at 12:20 PM, observation of the area Resident #501 was found sitting revealed that the picnic table was to be right next to the facility and within approximately 500 feet from the front door. The walking path leading to the picnic table consisted of waking in the main driveway, then up steps to the picnic table. Observation of the facility doors was conducted on 7/23/2012 at 1:55 PM with Maintenance Director (MD) #5. The facility was observed to have 3 floors with 2 elevators. The elevators were observed to be equipped with a WanderGuard alarm box (if a resident with a WanderGuard bracelet approached the elevator the alarm would sound). The facility exit doors were also observed to contain a WanderGuard alarm box. All were checked for functioning and were observed to work. The facility front door was observed to be locked, equipped with a WanderGuard alarm box, and could only be opened by staff upon entrance and exit of any person with or without a WanderGuard bracelet. On 7/23/2012 at 12:10 PM Receptionist #2 was interviewed. Receptionist #2 stated that she saw Resident #501 come down off the elevator on 7/10/2012. Receptionist #2 stated in another interview, conducted on 7/25/2012 at 3:00 PM, that the time she saw Resident #501 come off the elevator was approximately 6:20 PM. Receptionist #2 said Resident #501 was fully dressed and talking on a cell phone when she saw him. Receptionist #2 said Resident #501 approached the facility front door and that she (Receptionist #2) did not hear any WanderGuard alarm sound, so she opened the front door to let Resident #501 out. Receptionist #2 said Resident #501 looked "normal" (not like a resident). Receptionist #2 said she was talking with other residents at the time. Receptionist #2 said she learned that Resident #2 was a resident when Business Office Manager (BOM) #4 called her and asked her if Resident #2 was outside. Receptionist #2 said that she told BOM #4 no because she did not know who Resident #501 was. Receptionist #2 said that Resident #501's picture was in the elopement risk book and his name was on the list that sat on the receptionist desk, and stated that she was familiar with the residents in the book, but did not know Resident #501. In an interview on 7/25/2012 at 11:33 AM, BOM #4 said that she was leaving for the day at approximately 6:27 PM, and upon walking to the upper parking lot she noticed Resident #501 sitting at the picnic table taking on a cell phone. BOM #4 said she looked for Resident #501's son but did not see him so she approached Resident #501 and stayed with him until he was brought back into the facility. BOM #4 said Resident #501 told her that he just wanted to get a better signal on his phone, and that was why he went outside. Review of the facility "Policy and Procedure", dated 4/2009, for personal security bracelets (WanderGuard's) revealed, under "Personal Security Bracelets" on page 5, that a physician's orders [REDACTED]. The policy revealed that the bracelet was to be checked every shift and documented per the facility practice. On 7/24/12 at 3:20 PM, the Administrator was notified of the Immediate Jeopardy that was identified on 7/23/12 and began on 7/7/2012 for Resident #501, who was identified to be an elopement risk and wore a WanderGuard bracelet, when Resident #501's WanderGuard bracelet was cut off, when nursing staff failed to check Resident #501's WanderGuard for placement and functioning every shift, and when Resident #501 was let out the front door of the facility unbeknownst to Receptionist #2 that he was a resident at risk for elopement, placing Resident #501 as well as 8 other residents identified at risk for elopement and who wore WanderGuard bracelets at high risk for serious injury, harm and/or death. On 7/26/2012 the surveyor confirmed the facility implemented the following to remove the Immediate Jeopardy: 1). On 7/10/2012, Resident #501 was returned into the facility on [DATE] at 6:30 PM. A visual assessment was completed on 7/10/2012 at 6:30 PM with no abnormal findings. 2). On 7/10/2012 at 6:35 PM, a WanderGuard bracelet applied to Resident #501. 3). On 7/10/2012, Resident #501's son was notified. 4). On 7/11/2012, Resident #501's physician was notified. 5). On 7/10/2012, alert charting was initiated for Resident #501 at 6:30 PM. 6). On 7/10/2012, an investigation was initiated as directed by QA&A committee. 7). On 7/10/2012, Resident #501's behavior assessment was reviewed for risk elopement and care plan was also reviewed. No changes were made. 8). On 7/10/2012, the 5 other residents identified at risk for elopement had their assessments reviewed and no changes were required. 9). On 7/11/2012, 65 out of 65 residents were reviewed to identify whether they were at risk for elopement. Of those, 8 were identified as a possible risk for elopement and their behavioral assessments were reviewed and/or updated. No new residents were identified at risk for elopement through this assessment. 10). On 7/10/2012, the Center Watch Binders (elopement books) were reviewed for current elopement risk resident for accuracy and completeness at each nurses' station, receptionist desk, and employee break room. 11). Beginning 7/10/2012, staff were educated on the wandering/elopement guidelines/process, documentation of WanderGuard placement and functioning, including the seriousness of not visualizing the placement and functioning of the WanderGuard and false documentation, and disciplinary actions. As of 7/25/2012 110 out of 113 staff members had received the education and the 3 remaining will not be allow to work a shift until they had received the education. 12). On 7/11/2012, employee discipline was begun and included discipline for Receptionist #2, RNs #1 and #3. Although the Immediate Jeopardy that began on 7/7/2012 was removed on 7/11/2012, the facility remained out of compliance at a scope and severity of isolated with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to not all staff having received education on the wandering/elopement guidelines/process, including documentation, and that sustained compliance had not been verified by the State Agency. ( )

BASED ON OBSERVATION AND INTERVIEW THE FACILITY FAILED TO SECURE POTABLE OXYGEN TANKS RESULTING IN A POTENTIAL ACCIDENT HAZARD FOR ANY RESIDENTS AND VISITORS ACCESSING THE TANKS. FINDINGS INLCUDE ON 8/25/2011 AT 10:30 A.M. DURING THE ENVIRONMENTAL TOUR WITH THE MAINTENANCE DIRECTOR, STAFF "Q" A STORAGE CONTAINER FILLED WITH A COMBINATION OF FILLED AND UNFILLED PORTABLE OXYGEN TANKS WAS OBSERVED LOCATED OUTSIDE OF THE BUILDING, TO THE LEFT OF THE MAIN ENTRANCE NEAR A GARAGE AND THE STORAGE CONTAINER WAS FOUND UNSECURED. ON 8/25/2011 AT 10:30 A.M. AN INTERVIEW WITH MAINTENANCE DIRECTOR, STAFF "Q" WAS CONDUCTED AT THE TIME OF THE FINDING AND REVEALED THE OXYGEN STORAGE CONTAINER HAD BEEN LOCKED UNTIL THE OXYGEN DELIVERY VENDOR PERSONNEL EXPRESSED THE INCONVENIENCE THE LOCKED CONTAINER CAUSED HIM AND THE FACILITY DECIDED TO LEAVE THE OXYGEN STORAGE CONTAINER UNLOCKED. THE MAINTENANCE DIRECTOR STAFF"Q" WAS UNABLE TO GIVE AN APPROXIMATE TIME THE OXYGEN STORAGE CONTAINER HAD BEEN UNSECURED. ON 8/26/2011 AT 10:15 A.M. THE FACILITY ADMINISTRATOR PRESENTED A DOCUMENT TITLED "STORAGE REQUIREMENTS FOR NON-FLAMMABLE GASES LESS THAN 3000 CUBIC FT." DATED 5-31-2007 AND STATED "THIS WAS THE INFORMATION PROVIDED TO ME BY THE CORPORATION WHEN I ASKED ABOUT THE OXYGEN STORAGE POLICY" THE DOCUMENT READ UNDER THE SECTION TITLED "SUMMARY" "D) DOOR(S) OR GATE(S): INTERIOR/EXTERIOR...HOWEVER SHALL HAVE CLOSER AND BE SECURED AGAINST UNAUTHORIZED ENTRY." "H) CYLINDER PROTECTION: ALL OXYGEN CYLINDERS ARE TO BE SECURED IN SUCH A MANNER AS TO PREVENT THEM FROM BEING DAMAGED IN ANY WAY." THE UNSECURED OXYGEN TANK STORAGE CONTAINER COULD BE ACCESSED BY RESIDENTS, STAFF, VISITORS, OR ANYONE PASSING BY THE FACILITY DUE TO THE CONTAINER BEING VISIBLE FROM THE STREET THE FACILITY WAS LOCATED. ( )

This citation pertains to Intake #MI 406. Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices for 1 of 4 sampled residents (Resident #101) from a total of 58 residents who needed assist of one or two staff for toilet use resulting in Resident #101 sustaining a left wrist fracture. Resident #101 was no longer at the facility at the time of the investigation. According to Resident #101's "MDS" (Minimum Data Set), dated 5/12/11, Resident #101 was admitted to the facility on [DATE], had no cognitive defects, and did not walk in her room. Resident #101 documented weight was 174 pounds, she was on a blood thinner, was totally dependent for personal hygiene, and had impairment in both upper extremities (arms). Per Resident #101's Falls Care Plan dated 5/6/11 revealed Resident #101 was at risk for falls due to impaired balance/poor coordination, unstable health condition, unsteady gait, and poor safety awareness. Interventions included for facility staff to provide 2 person extensive assist with transfers, toileting, and bed mobility. Per Resident #101's "History and Physical" dated 5/6/11 revealed Resident #101 had a history of [REDACTED]. Per a facility "Incident Report" dated 5/24/11 regarding Resident #101, "During routine care, resident rolled off bed onto floor...Resident received 2 small ? inch skin tear L (left) elbow, area cleaned and op-site (dressing) applied ..." Per a "Statement of Witness" regarding Resident #101 dated 5/31/11, "...Name and Position of Witness: (Occupational Therapist #13)...I had therapy with (Resident #101) on Thursday and Friday (5/26/11 and 5/27/11). On Friday I noticed that (Resident #101's) left wrist was swollen and looked painful. (Resident #101) did not use her left hand at all on Friday during therapy". Per Resident #101's "Physical Therapy Summary dated 5/31/11, "...(Resident #101) had swelling on left upper extremity on 5/27/11 and has been hospitalized ..." Per an "In-House" imaging report regarding Resident #101, dated 5/27/11, "Wrist (left) ...Conclusion: 1. Acute (recent) moderately displaced (shifted from the usual position) fracture, distal radial metaphysis (broken wrist) ..." Per a hospital "Imaging" report regarding Resident #101, dated 5/27/11, "...Comminuted (crushed or splintered bone) displaced fracture is seen involving distal radial metaphysis (the growing part of the long arm bone near the wrist). There is also angulation (change)... As compared to April 12, 2010, this is a new fracture. There is also dislocation at the distal [DIAGNOSES REDACTED] joint (wrist joint)...There is soft tissue swelling around fracture ..." "Distal radial fractures: The usual injury mechanism is wrist hyperextension, usually during a fall. Dorsally displaced or angulated fractures ... Treatment is reduction and immobilization ... ORIF (surgery) may be necessary if the joint is disrupted or if there is excessive impaction or shortening". (http://www.merckmanuals.com/professional/sec21/ch309/ch309b.html) Per a hospital "Imaging" report regarding Resident #101, dated 5/28/11, "Reason given for exam: fall, fx (fractured) radius. Additional History: (Resident #101) states she fell out of bed a week ago and has not been able to use her left arm at all. (Resident #101) states she doesn't have any pain, has lots of bruising around her left wrist and up the forearm into some of the elbow, but no pain per (Resident #101)...There is soft tissue swelling in the elbow, forearm and wrist ..." In an interview on 6/27/11 at 9:24 AM, nurse aide #9 stated she had worked at the facility for 1? years and, for the past 9 months, on the unit where Resident #101 resided. Nurse aide #9 stated Resident #101 had weakness in her upper arm body and was always a 2 person assist in bed. Nurse aide #9 said she always made sure she found someone to help her when she performed cares with Resident #101, "whether another nurse aide, manager, or even a housekeeper". Nurse aide #9 stated, "(Resident #101) was hard to do. You need help. (I knew) it's not going to be easy". Per the "RIS" (Resident Information Sheet) regarding Resident #101, dated 5/23/11, "2 person Extensive Assist ...Extensive assist w (with)/bed mobility, toileting, and ADLs (Activities of Daily Living)". There was no information regarding Resident #101's upper extremity weakness in on "RIS". In an interview on 6/27/11 at 12:33 PM, nurse aide #10 reported she worked at the facility for 4 years and always on the unit where Resident #101 had resided. Nurse aide #10 said, "I didn't know she (Resident #101) had a stroke. They (licensed nurses) don't tell us anything much". Nurse aide #10 stated she had read the "RIS" and knew Resident #101 required the assist of 2 people for cares. Nurse aide #10 stated, "I could not find anyone to help; I didn't want to make her wait to be changed". Nurse aide #10 stated she had done cares alone on other residents who required the assist of two staff members when she was unable to find someone else to help her. Nurse aide #10 stated she turned Resident #101 to her side while changing Resident #101's brief independently. Nurse aide #10 stated when she took her hands off Resident #101, turned away to discard the soiled brief and turned back around, she saw Resident #101 fall onto the floor face down. Nurse aide #10 said Resident #101 kept saying 'I knew that was going to happen'. On 6/22/11 at 9:50 AM, this surveyor observed a call light on that was answered within one minute. On 6/22/11, between 10:17 AM and 11:31 AM, this surveyor observed 5 call lights answered, all answered within three minutes.( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 552 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT AN INCIDENT OF STAFF TO RESIDENT ABUSE AND FAILED TO MONITOR A FACILITY STAFF FOR SIGNS OF STRESS AND BURNOUT FOR 1 OF 4 SAMPLED RESIDENTS (#501) , RESULTING IN RESIDENT #501 BEING FORCEFULLY GRABBED AND PUSHED BY FACILITY STAFF WITH RESULTANT COMPLAINTS OF PAIN AND THE POTENTIAL FOR FURTHER ABUSE. FINDINGS INCLUDE: ON 2/7/11, AT 9:45, DURING AN INITIAL TOUR OF THE FACILITY WITH FACILITY STAFF, RESIDENT #501 WAS OBSERVED IN HIS ROOM LAYING IN BED WATCHING TELEVISION. RESIDENT #501 RESPONDED APPROPRIATELY TO GREETINGS FROM THE FACILITY STAFF MEMBER. THERE WERE NO VISIBLE SIGNS OF ABUSE OBSERVED. ACCORDING TO THE RESIDENT ADMISSION INFORMATION SHEET, RESIDENT #501 WAS INITIALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THAT RESIDENT #501 HAD SEVERELY IMPAIRED COGNITION, LONG AND SHORT TERM MEMORY PROBLEMS, MINIMAL DIFFICULTY IN HEARING, AND COULD SOMETIMES UNDERSTAND AND BE UNDERSTOOD. THE MDS FURTHER INDICATED THAT RESIDENT #501 REQUIRED EXTENSIVE ASSISTANCE TO TOTAL CARE WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, DRESSING, EATING, TOILETING, PERSONAL HYGIENE AND BATHING. THE MDS INDICATED THAT RESIDENT #501 WAS NON AMBULATORY. A REVIEW OF AN ADMINISTRATIVE CENSUS DOCUMENT DATED 2/8/11 INDICATED THAT RESIDENT #501 WAS CLASSIFIED AS A HOSPICE (END OF LIFE) PATIENT EFFECTIVE 1/6/11. A FACILITY REPORTED COMPLAINT ON FILE INDICATED THAT A STAFF PERSON WAS PHYSICALLY ABUSIVE TOWARD THE RESIDENT (#501). A REVIEW OF THE FACILITY'S INCIDENT REPORT DATED 12/22/10 DOCUMENTED THE FOLLOWING: "...ON 12/22/10 AT 4:00 P.M., A STAFF MEMBER REPORTED THAT A DIFFERENT STAFF MEMBER TOUCHED A RESIDENT'S FACE INAPPROPRIATELY...". REVIEW OF THE FACILITY'S 24 HOUR INCIDENT REPORT DATED 12/23/10 DOCUMENTED THAT ON 12/22/10 AT 4:00 P.M.:"...ALLEGATION BY A NURSING ASSISTANT THAT ANOTHER NURSING ASSISTANT HAD GRABBED THE RESIDENT BY THE CHIN AND PUSHED HIM INTO THE WHEELCHAIR AFTER THE RESIDENT STRUCK THE NURSING ASSISTANT..." A REVIEW OF THE FACILITY'S SUMMARY OF ALLEGATION REPORT DOCUMENTED THE FOLLOWING: "...CNA #2 (CERTIFIED NURSING ASSISTANT) ALLEGED THAT CNA #1 GRABBED RESIDENT #501 BY HIS CHIN AND PUSHED RESIDENT #501 IN HIS WHEELCHAIR IN RESPONSE TO RESIDENT #501 STRIKING HIM (CNA #1)...". "...DURING HER (CNA #2) INTERVIEW, CNA #2 STATED CNA #1 WAS HIT ON THE LEFT JAW AREA BY THE RESIDENT. CNA #1 GRABBED RESIDENT #501'S JAW AND SQUEEZED HIS FACE, PUSHED HIM (#501) IN HIS WHEELCHAIR BACK INTO THE WALL AND CURSED AT HIM (#501)...". A REVIEW OF RESIDENT #501'S MOOD CARE PLAN DATED 2/17/09; REVISED 1/31/11 DOCUMENTED: "...ASSESS FOR PHYSICAL/ENVIRONMENTAL CHANGES THAT MAY PRECIPITATE CHANGE IN MOOD...". "...ATTEMPT TO CALM HIM (#501) WITH REASSURING GENTLE VOICE, NEUTRAL BODY LANGUAGE AND GUIDE HIM TO HIS ROOM TO ALLOW HIM PERSONAL SPACE...". A REVIEW OF RESIDENT #501'S COGNITIVE LOSS CARE PLAN DATED 2/19/09; REVISED 1/31/11 DOCUMENTED: "...USE PATIENT'S NAME WITH ADDRESSING...". "...IDENTIFY SELF WHEN SPEAKING WITH PATIENT...". "...ATTEMPT TO PROVIDE CONSISTENT ROUTINE/CAREGIVERS...". OBSERVE FOR AND REPORT CHANGES IN COGNITIVE STATUS..." A REVIEW OF RESIDENT #501'S COGNITIVE IMPAIRMENT CARE PLAN DATED 3/9/09; REVISED 1/31/11 DOCUMENTED: "...TRY NOT TO INVADE PERSONAL SPACE...". "...IF STRATEGIES ARE NOT WORKING, LEAVE AND RE-APPROACH LATER IF SAFE TO DO SO...". "...OFFER CHOICES TO ENHANCE SENSE OF CONTROL...". "...TALK WITH IN A LOW PITCH, CALM VOICE TO DECREASE/ELIMINATE UNDESIRED BEHAVIOR AND PROVIDE DIVERSIONAL ACTIVITY...". "...DURING PERIODS OF ESCALATION SUCH AS YELLING AT STAFF OR OTHER RESIDENTS, ACCUSATORY, PARANOID OR AGGRESSIVE BEHAVIOR, STAFF TO PROVIDE 1 TO 1 OR EVERY 15 MINUTE CHECKS DEPENDENT ON SEVERITY OF ESCALATION..." ON 2/7/11 AT 10:50 A.M., DURING AN INTERVIEW, CNA #1 REPORTED THE FOLLOWING: "...HE (#501) WASN'T MY RESIDENT THAT DAY. CNA #2 ASKED ME TO HELP HIM (#501) BECAUSE HE HAS A HISTORY OF BEING VERY PHYSICAL. HE (#501) GAVE ME SOME FLACK WHEN I WENT IN HIS (#501) ROOM WITH SOMEONE ELSE..." "...I (CNA #1) WENT IN TO GET A GOWN ON HIM. HE HAD PUNCHED ANOTHER CNA BEFORE. HE (#501) PUNCHED ME BEFORE...". "...ON 12/22/10, HE (#501) HIT ME IN MY CHIN AND IT WAS PRETTY HARD. HE'S PRETTY DEFENSIVE. I (CNA #1) CROSSED MY EYES FOR A SECOND. I WILL ADMIT THAT I LEANED DOWN CLOSE TO HIS FACE WHILE I WAS TRYING TO TAKE HIS SHIRT OFF, AND I SHOULDN'T HAVE DONE THAT...". "...AFTER HE (#501) HIT ME, I (CNA #1) GRABBED HIS (#501) HANDS AND CROSSED HIS ARMS AND HELD HIS ARMS OVER HIS CHEST. I'LL ADMIT I WAS MAD. HIS (#501) WHEELCHAIR WASN'T LOCKED SO IT ROLLED BACK UNTIL IT HIT THE DOOR TO HIS (#501) ROOM...". "...I LET GO OF HIM AND WE CONTINUED TO FIGHT TO PUT HIS GOWN ON...". WHEN ASKED WHY HE (CNA #1) USED THE WORD FIGHT, CNA #1 SAID "...BECAUSE HE (#501) ALWAYS GAVE US A HARD TIME. THAT WAS HIS NORM...". CNA #1 FURTHER STATED "...I TOOK HIS (#501) SHIRT OFF, PUT HIS GOWN ON AND WE (CNA #1, CNA #2) USED THE HOYER LIFT TO PLACE HIM IN BED. WE TOOK HIS PANTS OFF, CHANGED HIS BRIEF AND TUCKED HIM IN...". WHEN ASKED WHY HE (CNA #1) MADE THE DECISION TO CONTINUE TO "FIGHT" WITH RESIDENT #501 TO GET HIS (#501) CLOTHES OFF AND PUT HIM TO BED IF HE (#501 RESISTED CARE, CNA #1 SAID "...BECAUSE IT WAS HIS NORM TO PUNCH AND FIGHT...". "...WE HAD TO GET A GOWN ON HIM...". WHEN ASKED IF THEY (CNA #1, CNA #2) ASKED RESIDENT #501 FOR HIS PERMISSION TO PROVIDE CARE, CNA #1 SAID "NO". CNA #1 STATED "...WHEN WE GOT HIM (#501) INTO BED, I HAD TO CONTINUE TO WRESTLE WITH HIM TO GET HIS PANTS OFF AND CHANGE HIS BRIEF. HE (#501) DID CALM DOWN SOME ONCE HE WAS IN BED...". WHEN ASKED IF HE (CNA #1) REPORTED TO THE NURSE, DURING THE INCIDENT, THAT RESIDENT #501 HAD RESISTED CARE, SO THAT THE NURSE WOULD BE ABLE TO ASSESS RESIDENT #501 FOR POSSIBLE CAUSES OF HIS BEHAVIOR, CNA #1 SAID "NO". WHEN ASKED WHY HE (CNA #1) FAILED TO REPORT TO THE NURSE THAT RESIDENT #501 HAD RESISTED CARE AS OPPOSED TO "FIGHTING" WITH HIM (#501) TO REMOVE HIS CLOTHING AND PUT HIM TO BED, CNA #1 HAD NO EXPLANATION. WHEN ASKED IF HE (CNA #1) WAS AWARE OF RESIDENT #501'S HISTORY OF AGGRESSIVE BEHAVIOR, CNA #1 SAID "...YES. THAT'S WHY THEY (NURSING STAFF) WOULD COME TO GET ME TO HELP WITH PROVIDING CARE. I GUESS THEY (NURSING STAFF) COULDN'T HANDLE HIM...". WHEN ASKED IF HE (CNA #1) DID IN FACT GRAB RESIDENT #501'S CHIN, CNA #1 SAID "...I MIGHT HAVE INADVERTENTLY GRABBED HIS CHIN...". ADDITIONALLY, CNA #1 STATED "...I'VE BEEN UNDER A LOT OF STRESS SINCE JULY OF 2010, AND I WORK VERY LONG HOURS AND LOTS OF EXTRA SHIFTS IN ORDER TO DEAL WITH THE STRESS...". WHEN ASKED IF HE (CNA #1) EXPERIENCED STRESS ON THE DAY IN QUESTION (12/22/10) WHEN HE PROVIDED CARE FOR RESIDENT #501, CNA #1 SAID "YES". WHEN ASKED IF HE (CNA #1) HAD BEEN TRAINED ON HOW TO HANDLE A CATASTROPHIC REACTION (EXTRAORDINARY REACTIONS OF PATIENTS TO ORDINARY STIMULI SUCH AS AN ATTEMPT TO PROVIDE CARE), CNA #1 SAID, THIS WASN'T A CATASTROPHIC REACTION, THIS WAS NORMAL BEHAVIOR FOR HIM (#501)..." SEVERAL UNSUCCESSFUL PHONE ATTEMPTS WERE MADE TO CONTACT CNA #2 FOR AN INTERVIEW. PER FACILITY STAFF, CNA #2 WAS NO LONGER EMPLOYED BY THE FACILITY. HOWEVER, A STATEMENT ON FILE FROM CNA #2 REVEALED THE FOLLOWING: "...CNA #1 AND I (CNA #2) WENT INTO RESIDENT #501'S ROOM. WE WERE TAKING HIS SHIRT OFF, I WAS ON THE LEFT SIDE OF HIS (#501) CHAIR, CNA #1 WAS ON THE RIGHT, ALL OF A SUDDEN, RESIDENT #501 SWUNG AT CNA #1 WITH A CLOSED FIST AND HIT HIM (CNA #1) IN HIS LEFT JAW AREA. CNA #1) THEN GRABBED #501'S JAW WITH HIS RIGHT HAND AND SQUEEZED HIS (#501) FACE VERY HARD AND PUSHED HIM (#501) BACK INTO THE WHEELCHAIR AND PUSHED HIM INTO THE WALL. HE (CNA #1) WAS HOLDING ONTO HIS FACE THE ENTIRE TIME...". "...CNA #1 SAID "LISTEN HERE YOU MOTHER [***] , DON'T YOU EVER HIT ME AGAIN". RESIDENT #501'S DENTURES WERE MOVING IN HIS MOUTH FROM CNA #1 SQUEEZING...". "...RESIDENT #501 STARTED CRYING AND SAID "PLEASE LET ME GO, YOU'RE HURTING ME". AFTER THIS, WE GOT HIM (#501) INTO BED. AFTER CNA #1 LEFT, I ASKED #501 IF HE WAS OK, HE (#501) COMPLAINED OF PAIN ON BOTH SIDES OF HIS MOUTH THEN HE (#501) ASKED ME IF I (CNA #2) HAD A GUN BECAUSE HE WAS GOING TO KILL THE BASTARD...". CNA #1'S WRITTEN STATEMENT FURTHER REVEALED: "...AFTER THIS, I (CNA #2) WENT AND TALKED TO LPN #1 AND REPORTED EVERYTHING TO HER. I THEN WENT ON BREAK AND CNA #1 CAME OUTSIDE AND STATED TO ME (CNA #2) "YOU KNOW I (CNA #1) DIDN'T MEAN TO GRAB HIM (#501) THAT HARD" "BUT HE (#501) NEEDS TO LEARN A LESSON THAT HE (#501) CAN'T DO THAT TO PEOPLE" "I (CNA #1) FELT KIND OF BAD WHEN HE (#501) STARTED CRYING, BUT HE (#501) SEEMED TO SETTLE DOWN"...". ON 2/7/11 AT 12:02 P.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED REGARDING THE ALLEGATION OF ABUSE TOWARDS RESIDENT #501. THE DON REPORTED THE FOLLOWING: "...I WAS INFORMED BY LPN #1 THAT CNA #2 HAD INFORMED HER THAT CNA #1 YELLED AT RESIDENT #501, GRABBED HIS FACE AND PUSHED HIS WHEELCHAIR AGAINST THE WALL...". "...I SPOKE WITH THE RESIDENT (#501) BUT HE DIDN'T REMEMBER THE SPECIFIC INCIDENT, BUT HE (#501) admitted THAT SOMEONE DID HURT HIM...". THE DON FURTHER SAID "...I SPOKE WITH CNA #2 DURING AN INTERVIEW AND SHE SAID THEY (CNA #1 AND CNA #2) WERE TAKING RESIDENT #501'S SHIRT OFF AND HE BECAME COMBATIVE. SHE (CNA #2) INFORMED ME THAT RESIDENT #501 HIT CNA #1 AND CNA #1 GRABBED RESIDENT #501'S FACE AND PUSHED RESIDENT #501 IN HIS WHEELCHAIR AGAINST THE WALL...". WHEN ASKED, WHAT FACILITY STAFF ARE TRAINED TO DO IF RESIDENTS RESIST CARE, THE DON SAID "REPORT IT TO THE NURSING SUPERVISOR". WHEN QUERIED ABOUT THE PROCESS TO BE UTILIZED FOR RESIDENTS WHO REFUSE CARE, THE DON SAID "...THE NURSING STAFF SHOULD TELL THE RESIDENT THAT THEY WILL BE BACK LATER TO PERFORM CARE...". "...IF THE RESIDENT IS ALERT AND ORIENTED, THE STAFF SHOULD ATTEMPT TO REASON WITH THEM...". "...IF THE RESIDENT IS SAFE, THE STAFF MEMBER SHOULD WALK AWAY AND TELL THE RESIDENT THEY WILL RETURN LATER TO PROVIDE CARE...". "...IF A RESIDENT IS RESISTING CARE, THE CNA IS TO INFORM THE NURSE SO THE NURSE COULD GO IN AND EVALUATE THAT RESIDENT FOR PAIN OR OTHER POSSIBLE REASONS FOR RESISTING CARE...". WHEN ASKED WHY RESIDENT #501 WAS NOT ASKED FOR PERMISSION TO REMOVE HIS CLOTHES, SHIRT AND PANTS, OR TO CHANGE HIS BRIEF AND PUT HIM TO BED, THE DON COULD OFFER NO EXPLANATION. A REVIEW OF CNA #1'S TIMECARD FOR 11/24/10 - 12/08/10 REVEALED THAT CNA #1 HAD WORKED A CUMULATIVE 90:42 HOURS THAT PAY PERIOD. A REVIEW OF CNA #1'S TIMECARD FOR 12/08/10 - 12/22/10 REVEALED THAT CNA #1 HAD WORKED A CUMULATIVE 93:48 HOURS THAT PAY PERIOD. CNA #1 HAD WORKED GREATER THAN 40 HOURS PER WEEK AND GREATER THAN 80 HOURS PER PAY PERIOD. ON 2/7/11 AT 12:02 P.M. WHEN ASKED WHY CNA #1 WORKED SO MANY HOURS, THE DON SAID "...BECAUSE HE (CNA #1) PICKED UP EXTRA HOURS...". THE DON FURTHER SAID "...I DIDN'T REALIZE JUST HOW MUCH HE (CNA #1) WAS WORKING UNTIL AFTER THE FACT...". THE DON ACKNOWLEDGED THAT CNA #1 WAS STRESSED UPON HIRE, BUT WAS INFORMED THAT HE (CNA #1) WAS RECEIVING HELP FOR THAT STRESS. "..WE DIDN'T PROVIDE HIM (CNA #1) WITH ANY ASSISTANCE AT THAT TIME...". WHEN ASKED WHY CNA #1 WAS ALLOWED TO WORK EXCESSIVE OVERTIME AND EXTRA SHIFTS IN LIGHT OF HIS (CNA #1) REPORTED STRESS, THE DON SAID "...BECAUSE HE (CNA #1) WANTED TO BE HERE.... ADDITIONALLY, THE DON STATED "...HE (CNA #1) WAS GOING THROUGH A LOT AND WANTED TO WORK MORE SHIFTS AND HOURS TO KEEP HIS (CNA #1) MIND OFF HIS PERSONAL PROBLEMS...". THE DON COULD NOT EXPLAIN WHY CNA #1 WAS ALLOWED TO WORK EXCESSIVE HOURS IN LIGHT OF HIS REPORTED HISTORY OF STRESS. ON 2/7/11 AT 3:08 P.M., AN INTERVIEW WAS CONDUCTED WITH LPN #1 WHO REPORTED THE FOLLOWING: "...AROUND 4:30 P.M., CNA #2 TOLD ME THAT RESIDENT #501 HIT CNA #1 AND CNA #1 GRABBED HIS (#501) FACE, STATED "YOU MOTHER [***] , YOU WON'T EVER HIT ME AGAIN, AND THEN SHOVED HIM (#501) INTO THE WALL...". "...I IMMEDIATELY WENT INTO THE ROOM TO CHECK ON HIM (#501). I DIDN'T SEE ANY MARKS AND HE (#501) WASN'T MAKING MUCH SENSE. CNA #2 WAS CRYING AND SAID SHE WAS AFRAID THAT CNA #1 WOULD LEARN THAT SHE'D (CNA #2) REPORTED THE INCIDENT...". WHEN ASKED WHY THE CNAS WERE TRYING TO TO PUT RESIDENT #501 TO BED, LPN #1 SAID "...I TOLD THEM TO LAY HIM DOWN BECAUSE HE (#501) CAN GET AGITATED AND WILL SELF PROPEL HIMSELF INTO OTHER RESIDENT'S ROOMS...". WHEN ASKED IF SHE (LPN #1) HAD BEEN INFORMED THAT RESIDENT #501 RESISTED CARE, LPN #1 SAID "...NO, NEITHER CNA INFORMED ME THAT THERE WAS A SITUATION GOING ON...". "...IF THEY HAD INFORMED ME, I WOULD'VE GONE IN TO ASSESS HIM (#501), CALM HIM DOWN AND I WOULD HAVE INSTRUCTED THE CNAS TO GO BACK AND TRY AGAIN AT A LATER TIME...". WHEN ASKED IF RESIDENT #501 WAS ASKED IF HE WANTED TO LAY DOWN OR HAVE HIS CLOTHING REMOVED, LPN #1 SAID "...NO. I DID NOT ASK HIM...". WHEN ASKED IF SHE (LPN #1) HAD AN OPPORTUNITY TO SPEAK WITH CNA #1 REGARDING THE INCIDENT, LPN #1 REPORTED THE FOLLOWING: "...I GAVE HIM A VERBAL WARNING FOR ANOTHER INCIDENT REGARDING HIS ATTITUDE AND FOR USING PROFANITY. THE RESIDENTS COULD HEAR HIM. I THREATENED TO SUSPEND HIM IF IT OCCURRED AGAIN...". "...I DID NOT SPEAK WITH HIM REGARDING THIS INCIDENT..." ON 2/8/11 AT 11:00 A.M., DURING AN INTERVIEW, CNA #3 REPORTED THE FOLLOWING: I (CNA #3) WENT IN HIS (#501) ROOM WITH CNA #4 TO SEE IF HE WAS OKAY. CNA #4 ASKED HIM WHAT HAPPENED AND HE SAID "HE GRABBED ME AND PUSHED ME HARD". HE (#501 PUT HIS HAND TO HIS CHIN TO DEMONSTRATE HOW CNA #1 GRABBED HIM...". "...HE APPEARED TO BE AFRAID, SO I REASSURED HIM AND TOLD HIM THAT I WOULDN'T LET ANYTHING HAPPEN TO HIM...". A REVIEW OF THE FACILITY'S ABUSE POLICY DATED 4/21/06 DOCUMENTED THE FOLLOWING: "...THE MOST CRITICAL STEP TOWARD DETECTING AND PREVENTING ABUSE, NEGLECT AND MISAPPROPRIATE OF PATIENT PROPERTY IS ACKNOWLEDGING THAT NO ONE SHOULD BE SUBJECTED TO VIOLENT, ABUSIVE, HUMILIATING OR NEGLECTFUL BEHAVIOR...". "...SIGNS OF BURNOUT, FRUSTRATION, STRESS: SITUATIONS THAT AN INDIVIDUAL FINDS DIFFICULT TO HANDLE CAUSE STRESS. SYMPTOMS OF STRESS CAN BE MANIFESTED PHYSICALLY, EMOTIONALLY OR RELATIONALLY..."

This citation pertains to intake number MI 016. Based on observations, interviews and records review, the facility failed to provide adequate supervision and assistive device (secureguard) for 1 of 28 sampled residents (#101) resulting in Immediate Jeopardy for resident #101 who eloped from the facility in her wheelchair and was retrieved over a block away in a bar parking lot which placed resident #101 and 27 other residents at risk for elopement at a high risk for elopement and serious harm. Findings include: According to the Admitting Record dated 10-08-09, resident #101 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (minimum data set assessment) dated 07-21-10 indicated resident #101 had memory problems, moderately impaired decision making skills and was independent with locomotion around the unit and a history of falls. The Incident Report dated 08-13-10 documented the Social Worker observed resident #101 down the street by a business in her wheelchair at 6:40pm and resident #101 was returned to the facility at 6:55pm. The Incident Report documented the cause of the incident was resident #101 had left the facility per wheelchair and the corrective action following the incident included the application of a secureguard (a personal security alert bracelet that alerts staff that an exit seeking event is in progress and locks the facility door leading to the outside) on resident #101's right ankle. During an interview on 08-25-10 at 11:40am, CNA #1 stated he was working in the main dining room the afternoon on 08-13-10 when resident #101 eloped. CNA #1 stated resident #101 was in her wheelchair in the the main dining room at approximately 5:50pm. CNA #1 stated resident #101 was "wandering all over the dining room", resident #101 then left the dining room into the front lobby and had to be returned by staff 3 different times while waiting for dinner to be served. CNA #1 stated that when dinner was served at approximately 6:20pm, resident #101 was not in the dining room or in the lobby and he "assumed" resident #101 had returned to the nursing unit by means of the elevator. CNA #1 stated that at approximately 6:35pm, the Social Worker returned to the facility and requested that he go get resident #101 from down the street at a bar parking lot. CNA #1 stated that he ran down the sidewalk (approximately 700') and found resident #101 over a block away from the facility on the sidewalk adjacent to a bar parking lot. CNA #1 stated resident #101 was next to a busy city street with increased traffic from the county fair. CNA #1 stated that resident #101 had left the building "between 6:05pm and 6:10pm". CNA #1 stated resident #101 used to wear a secureguard bracelet prior the elopement. During an interview on 08-25-10 at 8:45am, the Social Worker stated she did not pull over to assist resident #101 when she saw resident #101 in the bar parking lot "because there were like 5 cars behind me." The Wandering Patient Practice Guide dated 04/08 documented the resident's individual plan of care is reviewed and updated as needed to match the resident's current needs. During an interview on 08-24-10 at 5:15pm, RN #1 stated the facility had discontinued resident #101's secureguard bracelet when resident #101 was really sick and had a decreased elopement risk. RN #1 stated resident #101's recent behavior has included wandering into other resident's rooms and requiring redirection. RN #1 stated when resident #101 returned to the facility after the elopement, a secureguard was placed on resident #101's ankle. RN #1 stated she was surprised resident #101 still had her nasal cannula on and receiving oxygen as "she usually takes it off." RN #1 stated "it was hot that day." According to a Social Services Department Progress Note dated 08-03-10 (no time), resident #101 had a decline in medical status and "since then she seems to be back @ baseline." According to the Wandering Patient Practice Guide dated 04/08, a center bulletin board is kept in a specified area with current pictures of patients with known exit seeking or unsafe behaviors. During an observation on 08-25-10 at 12:45pm, resident #101's picture with her name below the picture was in an enclosed board on the wall in the employee break room. Inside the case was a sign that stated "Elopement Risk Residents Revised June 23rd 2010". During the observation, a confidential staff member in the break room stated resident #101's picture has been in the case for months. On 08-27-10 at 3:40pm, the Administrator and DON (Director of Nursing) #2 were notified of the Immediate Jeopardy that began on 08-13-10 at 6:20pm when resident #101 was not able to be located and had eloped through the unlocked double doors in the front lobby. On 09-03-10 at 3:00pm, the surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: 1. On 08-13-10, resident was returned to the facility and assessed with [REDACTED]. 2. Resident #101 had a securecare bracelet placed immediately upon return to the center and received 1:1 supervision until bedtime and was then placed on every 15 min checks. 3. Resident #101 had been assessed by the facility Social Worker immediately upon return to the facility. There were no negative outcomes as a result. 4. On 8-13-10, the QAA Committee met to initiate the investigation regarding resident #101. 5. On 08-13-10, the facility's main entrance doors were reprogrammed to automatically lock down at 5:30pm when the reception desk is unattended. The main entrance doors are also locked from 5:30pm Friday evening through 7:30am Monday morning. 6. On 08-17-10, a sign was posted on the main entrance doors requesting that visitors not escort or allow any residents out of the facility without first asking the front desk or a facility staff member to assure resident safety. 7. Effective 8-27-10, the facility has implemented having a door monitor 24 hours per day until reviewed by the QAA (Quality Assessment and Assurance) Committee. 8. Door alarm checks and missing resident locator drills have been conducted. The facility will continue to conduct door alarm checks daily and missing resident locator drills on all three shifts weekly for four weeks. 9. On 08-27-10, the facility management reviewed the Wandering Patient Practice Guide dated 04/08 and deemed it to be appropriate. 10. On 08-16-10, staff education regarding the Wandering Patient Practice Guide was initiated. Of 129 total staff members employed in the facility, 123 have received the education as of 8-30-10. The remaining six staff members were send a letter dated 08-19-10 indicating that they would be required to receive education before reporting to duty their next scheduled shift. 11. On 08-27-10, the new employee orientation program includes a review of potential missing residents and the actions that are taken. Review of the Wandering Patient Practice Guide was added to the facility's new employee orientation program. 12. Since 08-13-10, monitoring for residents with the potential for elopement has been in place and is discussed and updated 5 days a week at management meetings. The facility Watch Book (identifying potential exit seeking residents) located at the front desk and the exit seeking board located in the employee break room were also reviewed with updates completed 5 days weekly as needed. 13. On 08-14-10, 08-16-10, and 08-27-10, residents residing in the facility were re-assessed for potential elopement and placement in the exit seeking program. The facility Watch Book and exit seeking board were reviewed and deemed updated, complete and current on 08-27-10. Clinical records were updated to include updates to care plans and assessments. 14. Residents admitted to the facility will continue to be evaluated for exit seeking risk and placed into the exit seeking program to include assessments, application of a secureguard bracelet and care plan updates. 15. On 08-27-10, a QAA Committee meeting was again conducted to review and approve updates to the action plan previously established on 08-13-10. Additional actions were implemented on 08-27-10 as directed by the QAA Committee. While the Immediate Jeopardy was removed on 08-27-10 at 3:00pm, the facility remained out of compliance at a scope and severity of pattern with no actual harm but potential for harm that is not Immediate Jeopardy because all staff have not been in-serviced and sustained compliance has not been verified by the state agency. ( )