Every finding on record at Regency at Livonia

This citation pertains to intake #3094316Based on observation, interview and record review, the facility failed to monitor blood glucose levels and follow hospital discharge medication (insulin) orders for one resident (R700) of three reviewed for medication orders. Findings include:A review of R700's medical record revealed a progress note dated 7/2/26, Observed resident with clammy skin and not able to talk but responding to verbal stimuli by looking at writer when talking. BS (Blood Sugar) taken and reading was HI (indicating elevated BS level). NP (Nurse Practitioner) notified and ordered 10 units of Novolog (rapid acting insulin) to be given. Writer waited 20 minutes and the reading was still indicating HI. NP notified and gave orders to give 8 units of Novolog, and the residents blood sugar still remained HI. Medical Doctor in building went to see resident and ordered their transfer to hospital. Unit Manager, Nurse Practitioner, Director of Nursing, (DON) and daughter notified of resident's status.A facility medical record review revealed, R700 was admitted to the facility on [DATE] with diagnoses including Type I Diabetes Mellitus with Hyperglycemia, Hyperthyroidism, and Atrial Fibrillation. A review of the hospital after summary visit (ASV-discharge orders) dated 6/30/2026 for R700 revealed the following: Continue insulin Lispro (rapid acting insulin) 100 unit/ML (millimeter) patient supplied (insulin) pump. (Lispro insulin) Commonly known as Humalog. One each by continuous sub -Q (cutaneous) infusion (via wearable injector) route continuously.Further review of R700's medical record revealed a nursing note dated 6/30/26 at 8:00 AM, documenting, Treatment: Continue medications as per AVS (after visit summary), rounding provider to f/u (follow up). Patient medications were reviewed/verified against discharge summary which nursing had supplied. On 7/31/26 at 11:57 PM, Licensed Practical Nurse (LPN) A was queried regarding R700's insulin and blood sugar monitoring orders from the hospital and explained R700 was admitted with an order to continue insulin Lispro (rapid acting insulin) 100 unit/ML (millimeter) patient supplied (insulin) pump. LPN A confirmed they did not add blood sugar monitoring when transcribing the orders and because the resident had an insulin pump at home, and the orders should have been changed to manage the resident's insulin per facility protocol. On 7/31/2026 at 1:26 PM, an interview was completed with the DON who stated, The facility usually 'catches' orders of pumps, and insulin orders are changed to being monitored daily. This was not caught upon admission.A review of the facility policy titled, Diabetic Management dated 3/1/2013 and revised on 9/22/2023 revealed the following: Diabetic management involves both preventative measures and treatment of complications. Upon admission, the interdisciplinary team works together to implement a plan of care to minimize complications. Upon admission the interdisciplinary team evaluates the diabetic resident and implements a plan of care to ensure: Orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow and when to notify the physician; Appropriate nutritional orders are in place; and Preventative skin care measures are in places.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:Both staff were interviewed, the Acting DON re-educated both staff on transcribing the medication orders from the After Visit Summary, obtaining an order from the physician regarding blood sugar monitoring and how often and doing a thorough skin assessment and validating the pump was actually at the facility along with the actual medication.How facility identified resident(s) affected and residents with the potential to be affected by the same deficient practice. Reviewed the newly admitted residents transcribed medication orders from the After Visit Summary. Measures or systemic changes made to ensure that deficient practice will not occur and affect others: The facility immediately reviewed recent admitted residents' transcribed orders from the After Visit Summary. Nursing staff were re-educated on transcribing the medication orders from the After Visit Summary.How facility monitors its corrective actions to ensure deficient practice was corrected and not recur.The DON / Designee will review new admitted residents transcribed medication orders from the After Visit Summary. Any concerns will be addressed immediately, and the finding will be reported to the QAPI (Quality Assurance Process Improvement) committee for further recommendations.Date of compliance 7/14/26The facility was able to demonstrate monitoring of the corrective action and maintained compliance as confrimed onsite.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include: On 03/01/2026 during an initial observation of the kitchen between 9:00 AM- 9:30 AM, the following items were observed: There were no paper towels in the paper towel dispenser at the handwashing sink. On 03/01/2026 at 9:45 AM, Dietary Manager (DM) K confirmed the empty paper towel dispenser. In the walk-in cooler, there was a pool of spilled milk on the floor, an opened, undated 1 gallon container of Italian Dressing, an undated container of prepared tuna salad labeled tuna, and an undated container of cut onions. On 03/01/2026 at 9:45 AM, DM K confirmed the items should be dated. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . On a clean dishware rack, there were 2 stacks of wet metal pans. On 03/01/2026 at 9:45 AM, DM K confirmed that clean pans should be dry before stacking. According to the 2022 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD. In the dining room, there were 2 uncovered stacks of clean plates. On 03/01/2026 at 9:45 AM, DM K stated the plate warmer should have been covered when not in use. On 03/01/2026 at 9:50 AM, in the dry storage room in the basement, there was standing water on the floor in several spots. when queried, DM K' stated it was ground water that had seeped in from the exterior walls and stated it was an ongoing problem. On 03/01/2026 at 10:00 AM, the Administrator was queried regarding the stormwater in the basement and stated that they have had a company out to address the issue and are waiting to have the issue fixed.

Based on interview and record review, the facility failed to adequately monitor an intravenous (IV) medication for one resident (R1) of one resident reviewed for medication monitoring. Findings include: Review of the physician's orders revealed an order dated 2/3/26 (Tuesday) for Vanco (Vancomycin-antibiotic) trough (lowest level of antibiotic) every Monday.fax results to Infectious Disease .The next Vanco trough was due on 2/9/26 (Monday), however a blood sample was collected on 2/10/25 (Tuesday) with the result of no sample received. The next Vanco trough was due on 2/16/26 (Monday), however a blood sample was collected on 2/18/26 (Wednesday) with the result of no sample received.Review of the clinical record revealed R1 was admitted to the facility on [DATE] with the following diagnoses: Sepsis due to Methicillin Resistant Staphylococcus Aureus, Diabetes Type 2, Congestive Heart Failure and Epilepsy. R1's Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive impairment and was dependent on staff for activities of daily living (ADL) and mobility.A progress note dated 2/19/26 authored by Registered Nurse (RN) E documented they had received a call from Infection Control Physician (ICP) I from an outside hospital requesting trough levels for the Vancomycin and reported there were no results for Vancomycin trough levels.On 3/3/26 at 2:00 PM, an interview with the Director of Nursing (DON)/Acting Infection Control Nurse (DON/ICN) confirmed the Vancomycin trough level was not completed on 2/10/26 or 2/18/26. No further vancomycin trough values were located.A review of the policy Medication Monitoring Policy 6.02, effective date 1/1/2021 documented; .trough concentration is lowest level in the blood and should be drawn from 30 minutes to immediately before the next dose .vancomycin monitoring is recommended weekly for trough levels weekly to determine the lowest plasma (blood) concentration levels .prescriber or pharmacist should verify whether a dose of the medication should be held until lab results are received.

Based on observation, interview, and record review, the facility failed to implement pressure ulcer interventions for one resident (R11) out of three reviewed for pressure ulcers. Findings include:On 3/1/2026 at 10:49 AM, R11 was observed lying in bed, unable to answer interview questions. A purple wedge pillow that is used to assist in repositioning, was observed sitting on R11's bedside table. R11 was noted to be lying on their back, with the head of the bed lying flat.A review of the medical record revealed R11 was admitted into the facility on [DATE] with the following medical diagnoses, Moderate Protein-Calorie Malnutrition and Muscle Wasting and Atrophy. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was unable to complete the assessment. R11 also required staff assistance with bed mobility and transfers. Further review of the medical record revealed the following wound care note, .Wound #1 sacrum is a chronic unstageable pressure injury.has received a status of not healed.Initial wound encounter measurements are 2.6 cm (centimeters) length x 2.9 cm width x 0.2 cm depth.Off-loading.Other-Pressure relief chair cushion.Further review of the care plan revealed the following pressure ulcer interventions: Date initiated:1/6/2026. Positioning wedge Date initiated:12/1/2025. Turn and reposition frequently and PRN (as needed)On 3/1/2026 at 11:28 PM, R11 was observed lying on their back, with the head of bed lying flat. The purple wedge pillow was noted to be on the bedside table.On 3/1/2026 1:45 PM, R11 was observed lying on their back, with the head of bed lying flat. The purple wedge pillow was noted to be on the bedside table. On 3/3/2026 12:42 PM, R11 was observed to be up in a geri-chair, no pressure reducing cushion was noted to be in chair. On 3/3/2026 at 12:54 PM, an interview was conducted with Wound Care Nurse (WCN) A. WCN A reported R11's wound was facility acquired when the resident began declining, refusing to eat, signed onto hospice services, and the wound began to deteriorate. WCN A reported the everyday interventions in place for the pressure ulcer include the wedge cushion to assist with repositioning and turning as tolerated. WCN A reported R11 has a pressure relieving cushion that should be used when they are in the chair, and they were unsure why it was not placed.A review of a facility policy titled, Skin Management noted the following, .Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes.

Based on observation, interview, and record review, the facility failed to apply heel protection boots for one resident (R53) out of three reviewed for care interventions. Findings include:On 3/1/2026 at 9:48 AM, R53 was observed lying in bed sleeping with their heels resting on the mattress. A pair of heel protection boots were noted to be on the dresser.A review of the medical records reviewed R53 admitted into the facility on [DATE] with the following medical diagnoses, Protein-Calorie Malnutrition and Type 2 Diabetes Mellitus. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental status (BIMS) score of 3/15 indicating an impaired cognition. R53 also required staff assistance with bed mobility and transfers.Further review of the physician's orders revealed the following, Order date: 1/23/2026.Status: Active.Description: Heel lift boots while in bed.On 3/1/2026 at 11:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) C. LPN C was asked if R53 had any wounds on their heels. LPN C reported they did not believe so, but they were not assigned to care for the resident that day. On 3/1/2026 at 11:51 AM and 2:00 PM, R53 was observed lying in bed. No heel protection boots were in place, and their heels were resting on the mattress.On 3/3/2026 at 12:56 PM, an interview was conducted with Wound Care Nurse (WCN) A. WCN A reported R53 had a diabetic ulcer on their right heel that has since healed and the boots are preventative, so it does not reopen. WCN A reported they expect for the heel protection boots to be put on R53 by floor staff when wound care is not in the facility.A review of a facility policy titled, Physician's Orders noted the following, Physician's orders are obtained to provide a clear direction in care of the resident.

Based on observation, interview, and record review, the facility failed to develop a current vision care plan for one resident (R22) out of five residents reviewed for comprehensive care plans. Findings include:On 03/01/26 at 10:30 AM, R22 was observed lying in the bed under the covers. When asked if they had any concerns, R22 said they had dropped the bed remote and could not see due to blindness.A review of R22's medical record revealed they were admitted into the facility on 8/08/25 with diagnoses of Glaucoma, Legal Blindness and Hypotension. A review of R22's Minimum Data Set (MDS) assessment dated [DATE] revealed, R22's Brief Interview for Mental Status assessment score was a 7/15 indicating impaired cognition.Further review of R22's medical record revealed there was no vision care plan as it had been resolved on 10/5/25. On 3/03/26 at 2:00 PM, an interview with Social Worker J occurred and they were queried regarding the date the care was resolved and confirmed the care plan had been resolved accidently. A copy of the facility's care plan policy was requested but not received by the end of survey.

Based on observation, interview, and record review, the facility failed to maintain a safe, homelike environment affecting two residents (R31 and R78) of two reviewed for environment. Findings include:R31 On 03/01/26 at 9:51 AM, R31 was observed lying in bed facing the wall in their room. Areas of large white peeling paint were observed on the wall next to their bed. When asked about the peeling paint on the wall, R31 stated they didn't like it and wished it was fixed. Medical record review revealed R31 was admitted on [DATE] with the following medical diagnoses of Interstitial Pulmonary Disease, Anxiety Disorder and Depressive Disorder. A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated R31's Brief Interview of Mental Status assessment score was 14/15 indicating intact cognition. R78 On 3/01/26 at 10:15 AM, the veneer covered windowsill was noted to be half covered due to paint peeling which exposed a raw wooden edge. The wooden edge was splintered and had sharp areas. R78's bed was noted to be pushed against the sill. Further observation revealed the plastic light cover on the ceiling was broken and the railing which held the privacy curtain was hanging down off the ceiling. Medical record review revealed R78 was admitted on [DATE] with the following medical diagnoses of Nontraumatic Intercranial Hemorrhage and Dementia. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R78's Brief Interview of Mental Status assessment score was 99 indicating severely impaired cognition. R78 is nonverbal and unable to communicate their needs. On 3/02/26 a tour of or R31 and R78 rooms was held with Nursing Home Administrator (NHA). The NHA was asked about areas of concern. The NHA upon observing the rooms stated, these rooms are in need of repair and confirmed all of the residents to be able to live in a safe, homelike environment. A review of the facility's policy titled, Resident Rights dated 9/01/13 and revised 5/14/17 revealed that residents have the right to a safe, clean, comfortable and home-like environment, including but not limited to receiving treatment and support for daily living safely. On 3/1/26 between 1:30 pm- 2:00 pm, the following items were observed: room [ROOM NUMBER]: There were numerous missing baseboards inside the room. room [ROOM NUMBER]: The front cover for the baseboard heater was detached and hanging down off the unit. room [ROOM NUMBER]: There was a large piece of acrylic sheet plastic propped up against the wall at the front entrance of the room. When queried on 3/1/26 at 2:25 pm, Maintenance Supervisor L stated the sheet plastic must have become detached from the wall. The handrail in the hallway outside room [ROOM NUMBER] was cracked and sharp to the touch. room [ROOM NUMBER] and 119: The wardrobe closets were not secured to the wall and were unsteady and could easily be rocked from side to side. When queried on 3/1/26 at 2:30 pm, Maintenance Supervisor L confirmed the unsteady wardrobe closets and stated that they should be secured to the wall.

This citation pertains to the Complaint Intake # 272114.Based on observation, interview and record review the facility failed to ensure proper diagnosis or clinical indication to support the insertion of an indwelling catheter for three (3) residents: Resident #501 (R501), Resident #502 (R502), and Resident #504 (R504) of 4 residents reviewed for indwelling catheter resulting in improper catheter management leading to a potential recurrent catheter-associated urinary tract infection (CAUTI), sepsis and hospitalization.Findings include:Resident #501: (R501) On 1/27/26 at 12:40 PM, R501 was observed in her room lying in bed, alert and oriented. R501 expressed concerns about her catheter care. She had an indwelling catheter in place with clear-to-light-yellow urine output. The catheter tubing was patent and connected to a privacy drain bag. No signs of cloudiness, bleeding, or foul odor were observed.During an interview with R501 on 1/27/26 at 12:40 PM, she did not know why she had complained about a recent incident related to her indwelling catheter. R501 stated: Something went wrong with it, and they couldn't fix it. I felt I needed to be transferred to the hospital, but the staff refused to call 911. R501 reported that the staff did not allow her to go to the hospital. They said they needed the physician's permission to approve the transfer. R501emphasized that she has not seen the physician at all during her entire stay at the facility. R501 called her daughter to call 911. R501 expressed being upset because she was her own person and felt her rights were violated, and was kept against her wishes. A review of R501's clinical record was conducted on 1/27/26 at 12:40 PM. R501 was [AGE] years old and was admitted to the facility on 9//25/2025. According to her Brief Interview of Mental Status (BIMS) Score with an assessment dated [DATE], R501 scored 15/15. A score of 15 means that R501 was cognitively intact. R501's list of diagnoses was reviewed. R501 did not indicate any Urinary retention or difficulty in urination to support the indwelling catheter placement. However, R501 had laboratory results on 12/10/25 and another on 1/13/26, diagnosed with Urinary Tract Infection, and received an order for antibiotic therapy. On 1/27/26 at approximately 1:32 PM, the Director of Nursing (DON) was interviewed regarding R501's indwelling catheter and the reason for its placement. The DON admitted that R501 has urinary retention but was not recorded in the list of diagnoses. R501 goes to her urologist, and the staff must have missed putting the diagnosis in R501's list of diagnoses. She asked to leave the room to review the resident's clinical record. A few minutes later, the DON returned and told the surveyor that a diagnosis had been added to the R501 record. On 1/27/26, an unidentified nursing staff member created a new entry in the electronic medical record for R501 (the nursing staff member was not listed on the facility-provided staff list). Date created: 1/27/26; new diagnosis code: R33.9; description: Retention of Urine, unspecified.The DON explained on 1/27/26 at 1:35 PM that the diagnosis was found in the urology consult notes dated 1/11/26. She confirmed that they just entered the diagnosis of urinary retention today. Further review of R501's clinical record was conducted on 1/27/26 at 2:00 PM. R501 was dependent on staff in toileting hygiene: the ability to maintain perineal hygiene and to adjust clothes before and after voiding or after a bowel movement. She is also dependent during showers/bath, including washing, rinsing, and drying herself. R501 required Substantial/Maximal assistance from staff with most activities of daily living ADL however remained totally dependent with movements from side to side in bed and transfers in the Minimum Data Set (MDS) assessment dated [DATE]. R501 was non-ambulatory according to the MDS assessment under the section GG conducted on 1/16/26. Section H of the MDS revealed that an indwelling catheter was in place during the 1/17/26 assessment. R501 was always incontinent with her bowel movement. A review of R501's clinical laboratory results dated [DATE], revealed a positive for Urinary tract infection. An order for an antibiotic (Amoxicillin-Pot Clavulanate) 825/125 mg, 1 tablet every 12 hours, was ordered for Urinary Tract Infection (UTI) for 7 days. According to the R501's Medication Administration Record (MAR )dated December 2025, R501 received only 3 dosages from 12/10 to 12/11 and was transferred to the hospital on [DATE] and returned on 12/18/2025.On January 13, 2025, Laboratory results confirmed a UTI. An order for Augmentin (an antibiotic) dated 1/12/2026 was noted: a leaking Foley and concerns for UTI, as noted in the clinical observation notes, with other symptoms of dark brown urine and increased sediment. R501 was Afebrile (no fever).According to R501's MAR dated January 2026, R501 received two separate antibiotic therapies: one ordered on 1/12/26 to 1/17/26 (5 days) and another ordered on 1/21/26, which was completed on 1/27/26. Resident #502(R502) R502 was observed with an indwelling catheter on 1/27/2026 at 12:22 PM. R502 was with her son at the bedside. During the interview, R502's son, who is the POA (Power of Attorney), expressed that R502 just recently had a UTI from her catheter and was on antibiotics. Although R502 did not have any concerns regarding the catheter, she did have concerns about the wait when she needed care. It takes a while. R502 stated she does have wounds and was worried about getting them infected if she gets soiled and unattended for prolonged periods. On 1/27/26, R502's indwelling catheter tubing was observed patent with yellow colored urine and no abnormal discoloration or blood in urine. R502 was ask by the surveyor why she has the catheter and when did she have them? She shrugged her shoulder and did not give a definite answer. A review of R502's list of diagnoses in the clinical record shows no diagnosis that indicates the reason for the placement of an indwelling catheter. An order dated 12/17/25 to change Foley as needed and to secure the Foley catheter tubing with a secure strap. Check placement q shift. Replace as needed. Date ordered on 12/17/25. R502 was [AGE] years old and admitted to the facility on [DATE] with the primary diagnosis of Paroxysmal Atrial Fibrillation, Hypothyroidism, Type 2 diabetes mellitus, and Essential hypertension in addition to other diagnoses. On 1/27/26 at 2:00 PM, during the review of R502's clinical record, there was no diagnosis related to retention of urine, bladder obstruction, or any neurologic bladder anomaly. R502's care plan was created upon admission on [DATE], indicating that R502 had an indwelling catheter requiring catheter care. No urinary retention or neurologic problems indicating urinary retention or obstruction were listed in the facility's record in R502's Diagnosis list. There were no wounds in R502's list of diagnoses in the clinical record. Urine laboratory testing dated 1/13/26 confirmed a Urinary tract infection with multiple organisms, including Candida albicans, Klebsiella, and E. coli, among others.A review of R502's Medication Administration Record indicated that an antibiotic therapy, Amoxicillin-pot clavulanate 875-125 mg 1 tab every 12 hours for 10 days, which started on 1/14/26 and ended on 1/23/26. A new order entry for Foley catheter care every shift, starting on 1/23/26, was noted in the MAR. R502 had an indwelling catheter since admission on [DATE]. On 1/27/26 at approximately 1:32 PM, the Director of Nursing (DON) was interviewed regarding R502's indwelling catheter and the indication for its placement. The DON agreed that R50's list of diagnoses did not mention R502's recent UTI, and the reason why she has a Foley catheter was that she had one upon admission. The DON further explained that they kept her catheter because of her multiple wounds. The DON stated that R502 had been seen by the wound consultant regularly for her skin and pressure ulcers. The Director of Nursing (DON) presented a wound consult dated 1/20/26; however, the consultation notes did not mention an indwelling catheter placement as part of the intervention essential for R502's wound prevention and/or healing. The DON was asked where the wound consult mentioned the catheter placement. The DON could not find it. The wound consult dated 1/20/26, provided by the DON, was reviewed. R502 wounds were the following: Pressure Ulcer Stage 3 (Right Buttock), Pressure Ulcer Stage 3 (Left Buttock, Type 2 DM (Diabetes Mellitus with foot Ulcer, Non-pressure chronic ulcer (right heel and mid foot), non-pressure chronic ulcer of other part of left foot with unspecified severity. In the 1/20/26 Wound Consult, an indwelling catheter was not noted by the wound provider as part of the wound Plan, a physician's order, or wound intervention. And there was no mention that an indwelling catheter was part of the treatment goals. In fact, R502 was assessed on 1/20/26 specifying: Gastrointestinal (GI): Patient has incontinence of bowel, Genitourinary (GU): Patient has incontinence of bladder. Integumentary (Hair, Skin): Open wound. Resident #504(R504) On 1/27/26 at 1:00 PM, R504 was observed to have her indwelling catheter clear, draining with no apparent discoloration, and with no indication of pain related to catheter placement. R504 stated she had not had any UTI problems recently.R504 clinical record review on 1/27/26 at 2:00 PM revealed that R504 was admitted on [DATE] with a diagnosis of Acute Respiratory Failure with hypoxia, Herpes Viral Vulvovaginitis, Pneumocystosis, Iron Deficiency Anemia, Hyperlipidemia, Insomnia, Essential Hypertension, Congestive Heart Failure, GERD (Gastro-Esophageal Reflux Disease), Muscle Wasting and Atrophy, and other symptoms involving the musculoskeletal System. No Genito-Urinary Systems-related diagnosis was found as a diagnosis in R504's Diagnoses. R504's Progress Notes dated 12/30/2025, revealed R504 complained of flank pain, and noted gross hematuria (blood in urine). A urinalysis (UA)with culture and sensitivity (C&S) was ordered on 12/30/25. laboratory results dated [DATE], confirmed a Urinary tract Infection (UTI) with multiple organisms, including Klebsiella Pneumoniae, Proteus Mirabilis, Pseudomonas aeroginosa, and E. coli, which were among the few detected in her urine. A review of R504's Medication Administration Record indicated that an antibiotic therapy of Cipro 500 was ordered to treat the UTI Symptoms as noted by the Physician Assistant's progress notes on 1/4/2026. R504 had an indwelling catheter since admission on [DATE]. There was no diagnosis to support the indwelling catheter placement in R504's Clinical Record, and R504 had a UTI on 12/30/25 and received antibiotic therapy for the signs and symptoms of Urinary Tract Infection. During the interview with the DON, on 1/27/25 at approximately 2:00 PM, the DON was asked for the indication of placing a urinary for residents R501, R502, and R504. She admitted that she was unable to justify the use of the indwelling catheter in the Face Sheet and the Resident's Diagnosis page. A few minutes later, the DON reported that she had added a diagnosis of urinary retention for R501. She explained that R502 had multiple wounds, and the urinary catheter was placed to help with healing. When resident R502's diagnosis list was reviewed with the DON, no diagnosis was indicated for the use of the urinary catheter, and no diagnoses of wounds were found in their face sheet or in the diagnosis lists for R501, R502, and R504. The DON reviewed the wound consultation dated 1/20/26 with the surveyor, but the consult notes did not reflect or mention a Foley catheter as part of the intervention for wound healing, nor was it mentioned in the consult notes. The DON admitted that R504 did not have a diagnosis for the use of the urinary catheter amongst the list of diagnoses. The DON confirmed that the antibiotic treatment was administered for UTI in 3 residents (R501, R502, and R504). During the exit conference on 1/27/26 at 4:15 PM, the DON and the Administrator were informed of concerns regarding R501, R502, and R504 that lacked a diagnosis for the catheter placement, CAUTI and repeated UTIs. The DON explained that the diagnosis was missed but stated that she added diagnoses of R501 and R502 based on the Dr.'s previous consultations and progress notes. The DON confirmed that it was not entered previously. A Facility's Policy was requested and reviewed. On 1/27/26 at 3:45 PM, the facility policy entitled Indwelling Urinary Catheter (Foley) Care and Management dated 12/17 2025, indicated that: Inappropriate or unnecessary use of an indwelling urinary catheter can result in catheter-associated urinary tract infection CAUTI). CAUTIs are the most common healthcare-associated infections in adult patients. Researchers estimate that as many as 70% of these infections are preventable by following evidence-based practices.Implementation:. Review the necessity of continued urinary catheter use; remove the catheter (according to the practitioner's order or facility protocol) as soon as it's no longer clinically indicated to reduce the risk of CAUTI.Documentation: Documentation associated with indwelling urinary catheter care and management includes:Indication for continued catheter useMaintenance care providedAssessment findings of any specimens collectedTeaching provided to the patient and family .

This citation pertains to Intake MI00152501. Based on observation, interview, and record review, the facility failed to ensure resident showers were provided as scheduled for one resident (R701) of three reviewed for acitivites of daily (ADL) care. Findings include: On 5/7/25 at 11:00 AM, R701 was observed in bed with a hospital gown on, and with a large amount of facial hair, R701 was asked about the care at the facility. R701 explained things could be better. R701 continued and explained staff are either too busy or there is not enough staff. R701 reported they did not get out of bed the entire weekend and this was not the first time this had happened. R701 was asked if they receive their showers at minimum two times per week, R701 stated, Maybe once per week. A review of R701's medical record noted R701 was admitted to the facility on [DATE] with diagnosis of Influenza. A review of R701's Minimum Data Set (MDS) assessment dated [DATE] noted, R701 with an intact cognition and required assistance by staff to complete activities of daily living. A review of R701's shower record for the last 30 days revealed six documented showers on 4/10, 4/14, 4/21, 4/28, 5/1, and 5/5/25. On 5/7/25 at 11:33 AM, Certified Nurse Assistant (CNA) A was asked the reason R701 had not been dressed and out of bed. CNA A reported they had been getting the dialysis residents up and dressed and had not had time to come back to get R701 up for the day. CNA A reported they typically work the afternoon shift and came in at 8:30 AM to pick up a shift. On 5/7/25 at 11:40 AM, the Director of Nursing (DON) reported R701's shower schedule is Mondays and Thursday. The DON confirmed after a review of the 30-day report R701 had some days when the residents shower was not documented as being provided. A review of the facility's policy titled Routine Resident Care dated 3/12/25 noted, Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Steps are taken to ensure that a resident's capacity for self-performance of these activities does not diminish unless circumstances of the resident's clinical condition demonstrate the decline is unavoidable. Care is taken to ensure resident safety at all times. Guidelines: 2. Showers, tub baths, and/or shampoos are scheduled according to person centered care or state specific guidelines; Bed linens are changed at this time. Additional showers are given as requested .

Based on observation, interview, and record review, the facility failed to ensure timely assessment and monitoring following an identified weight loss for one resident (R56) of two reviewed for nutrition resulting in, weight loss and unmet nutritional needs. Findings include: On 12/17/24 at 1:00 PM, R56 was observed sitting in their room in their wheelchair. Attempts to interview R56 were occured to no avail due to their cognition. A review of R56's medical record revealed they were admitted into the facility on [DATE] with diagnoses which included Anxiety Disorder, Hypertension, and Muscle Weakness. Further review revealed a moderately impaired cognition, and was dependent for bathing and dressing. Further review of R56's care plan revealed the following: Focus: [R56] has alteration in nutritional and/or hydration status r/t (related to) CVA (Cerebral Vascular Accident), hx (history) of PCM (protein calorie malnutrition), dysphagia, therapeutic diet. Date Initiated: 12/03/2024. Interventions . Observe and report to physician Significant weight changes: 3% in 1 week, > (greather than) 5% in 1 month, >7.5% in 3 months, >10% in 6 months. Date Initiated: 12/03/2024 . Provide 1:1 feeding assistance with meals . Further review of R56's medical record revealed the resident had sustained a 10lb (pound) weight loss in less than a month based on the following weights: 112.0 Lbs-11/28/2024 112.0 Lbs-12/1/2024 102.0 Lbs-12/10/2024 Further review of R56's medical record revealed the following progress note: 12/12/2024 12:15 (12:15pm) Dietary Note Note Text: WEIGHT WARNING: Value: 102.0 Vital Date: 2024-12-10 13:14:00.0 (1:14pm) -5.0% change [ 8.9% , 10.0 ] -7.5% change [ 8.9% , 10.0 ] RD (registered dietician) requesting re-weight to confirm accuracy of weight changes. Weight upon admission likely not accurate as this is consistent with hospital documented weight of 112 lbs. On 12/18/24, further review of R56's medical record did not reveal a re-weight. On 12/18/24 at 8:49 AM, R56 was observed in their room alone sitting in their wheelchair. The resident's breakfast meal tray was sitting in front of them with approximately 80% of the meal still on their plate and consisted of eggs, toast, oatmeal and a hashbrown. In addition, 1:1 feeding assistance was listed on the resident's meal ticket. On 12/18/24 at 12:43 PM, R56 was observed in their room alone sitting in their wheelchair. The resident's lunch meal tray was sitting in front of them untouched. 1:1 feeding assistance was noted on the resident's meal ticket. On 12/19/24 at 8:57 AM, R56's re-weight was requested from the facility. On 12/19/24 at 9:30 AM, the Director of Nursing (DON) explained the facility had identified an issue with weights and the resident was weighed yesterday, and would be added to the electronic medical record. A review of R56's medical record revealed the resident weight on 12/19/24 was 96.2 lbs noting a 5.69% weight loss in nine days. On 12/19/24 at 10:51 AM, the facility dietician, Registered Dietician (RD I) was asked about R56's weight loss, and the interventions put into place for R56. RD I explained she was new to the facility, and would speak to the regional dietician for guidance. On 12/19/24 at 11:18 AM, RD I explained the intervention for R56's weight loss on 12/12/24 was the re-weigh to confirm whether the weight loss was accurate. RD I explained that once a re-weight is obtained, they talk to the resident and reassess for possible supplements. RD I was asked how soon re-weights are supposed to be obtained, and she explained they should be completed within 72 hours. On 12/19/24 at 12:25 PM, the Director of Nursing (DON) was asked about the weight loss of R56, and explained she would look further into it, but did acknowledge that the facility had identified concerns related to weights not being completed per facility policy. A review of the facility's Weight Management policy revealed the following, .2. Residents will be weighed upon admission/readmission; weekly x 4, then monthly as indicated by the physician and/or medical status of the resident and document results in the medical record. Re-weights are initiated for a five pound variance if the resident is > than 100 lbs and for a three-pound variance of < than 100 lbs .Re-Weights will be done within 48-72 hours .9. Residents with the following clinical condition may also be at risk, this is determined by the IDT (interdisciplinary team) .Dependent eating skills, mechanically altered diets .7. Dietary Manager, Unit Manager and/or RD are able to communicate weight changes to the IDT, attending physician and resident's responsible party .10. The Dietary Manager and/or dietician will calculate the Monthly and Significant Weight Changes )5% in one month, 7.5% in three months, ad 10% in six months) .

Based on observation and interview, the facility failed to provide a homelike environment throughout residential common areas and rehabilitation area. Findings include: On 12/18/24 at 11:20 AM, an observation of the first and second floor dining and common areas were observed with the following: sticky matter on the floors, garbage lying on the ground, two ice machine's tray with white debris on it and with the face of the ice machine dirty. Two popcorn machines were observed with the interior of the glass greasy and with moderate amounts of popcorn kernels adhered to the walls and in the basin. While making the observation of the popcorn machine, a staff member commented that it needed to cleaned. The baseboards were observed with dust, and debris. The floors were observed with a moderate amount of dried spilled matter where residents were socializing. The first and second floor windowsills were observed to be dirty and with dead insects on the sills and in the tracking of the windows. The back door was observed with insect webs, dead insects, and leaves around the perimeter of the door. A dirty mop, dustpan and broom were observed stored against the wall amongst residents who were drinking sodas and socializing. An observation of the first-floor dining room revealed, damaged dry wall with a pile of dry wall debris within the proximity of food delivery carts. Throughout the first floor of the facility, the carpet looked as if not vacuumed and various debris was noted in the common areas, and in the resident hallways. Upon entering into the first-floor rehabilitation room, the access door to the outside was observed with three small white insect nests, webs, and dead insects. Debris were noted in between the carpet and floor mat. The rehabilitation room revealed the entire perimeter of the baseboards throughout had debris and dust. A visibly soiled dustpan and broom were observed stored against the wall amongst rehabilitation equipment. In the rehabilitation kitchen a Geri chair was observed to be stored in the area, the chair had a dried tan colored matter on the seat and backside. The rehabilitation kitchen was also observed with dried crumbs on the counter tops and stove. The inside and outside of the microwave was also observed to be unkempt. On 12/18/24 the following observations were made with the Housekeeping Manager (HM) G. During the tour, HM G acknowledged the findings were unkempt specifically around the baseboards. HM G confirmed dead insects, and webs amongst the residential common and rehabilitation areas. Review of the facilities policy titled; Housekeeping Services dated 2/2023 documented: .promote a sanitary environment . Housekeeping Services play a large role in maintaining a clean healthcare environment .

Based on observation, interview, and record review, the facility failed to initiate an activities care plan for one resident (R94) of one reviewed for care plans. Findings include: On 12/17/24 at 1:00 PM, R94 was observed sitting in their lounging chair awake, and alone in their room. Attempts to interview R94 were to no avail due to their cognition as they remained pleasantly confused. There were no activities observed in R94's room at this time. A review of R94's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Cerebral Infarction, Hypertension, and Muscle Weakness. Further review revealed that the resident was severely cognitively impaired, and required one person assistance for bed mobility and transfers. Additional review revealed the resident had sustained multiple falls in the facility since admission. On 12/18/24 at 8:48 AM, 9:22 AM, and 12:45 PM, R94 was observed in their room without activities or stimulation. On 12/19/24 at 8:57 AM, activity logs for R94 were requested from the facility. The facility's Nursing Home Administrator (NHA) indicated the activities department did not have any activity logs for R94. A review of R94's care plan revealed they did not have a care plan adressing Activites. On 12/19/24 at 12:25 PM, the Director of Nursing (DON) was asked about activities for R94 and acknowledged there had been issues with the Activities Director. A review of the facility's Activities Program policy revealed the following, The facility provides an ongoing activity/recreation program based on the individual resident comprehensive evaluation, care plan, and stated preferences .

Based on interview and record review, the facility failed to ensure medication was administered as orders for one resident (R93) of one reviewed for medication administration. Findings include: A clinical record review of R93 revealed, R93 was first admitted to the facility in March 2024 with diagnoses of Quadriplegia (paralysis) chronic pain syndrome, Kidney failure, Chronic foley and Urinary tract infections. A review of R93's most recent BIMS (Brief Interview for Mental Status) score was 15/15 indicating R93 was cognitively intact. On 12/17/24 at 9:51 AM, R93 voiced concern during initial interview that they were recently hospitalized for a urinary tract infection and required antibiotics. R93 expressed concerned regarding not being administered their antibiotic medication since their readmission to the facility on [DATE]. R93 explained they had asked the staff since readmission about the location the medication and was not provided an explanation. R93 further revealed they were scared the infection would come back and they would have to go back to the hospital. Further review of R93's record revealed, on 12/11/24, R93 was transferred to the hospital for with symptoms of severe nausea, was diaphoretic, and had gross hematuria (large amounts of blood in the urine). R93 was readmitted to the facility on [DATE], with the diagnosis of a urinary tract infection, and required surgical placement of a supra pubic catheter (tube placed into the bladder through abdomen to drain urine). On 12/19/24 at 9:40 AM, Unit Manager (UM F) was asked about R93's antibiotic medication, UM F was observed to review the After Visit Summary (AVS) revealed, dated 12/15/24. The AVF documented to start Cipro (Ciprofloxacin, an antibiotic to treat bacterial infections) 500 milligrams (mg) twice daily for 10 days, start on 12/15/24 and complete on 12/25/24. UM F acknowledged the admission nurse did not order the medication upon R93's readmission on 12/15/24, therefore, the pharmacy never received the order and R93 was not provided the antibiotic. On 12/19/24, at 3:45 PM, the Director of Nursing (DON) was informed of the above interview and acknowledged the medication was not transcribed upon readmission on 12/15/24 and R93 should have started the ordered Cipro on 12/15/24. Review of the facility's policy titled; Physician's Orders dated 10/2023 documented: .Physician orders are obtained to provide a clear direction in the care of the resident . Once the order is verified, the receiving nurse verifies the order . Notify the pharmacy of a new order .

Based on observation, interview, and record review, the facility failed to document and provide activities for one resident (R94) of one reviewed for activities. Findings include: On 12/17/24 at 1:00 PM, R94 was observed sitting in their lounging chair alone in their room. Attempts to interview R94 were to no avail due to their cognition as they remained pleasantly confused. There were no activities observed in R94's room at this time. A review of R94's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Cerebral Infarction, Hypertension, and Muscle Weakness. Further review revealed that the resident was severely cognitively impaired, and required one person assistance for bed mobility and transfers. Additional review revealed the resident had sustained multiple falls in the facility since admission. On 12/18/24 at 8:48 AM, 9:22 AM, and 12:45 PM, R94 was observed in their room without activities or stimulation. On 12/19/24 at 8:57 AM, activity logs for R94 were requested from the facility. The facility's Nursing Home Administrator (NHA) indicated the activities department did not have any activity logs for R94. On 12/19/24 at 12:25 PM, the Director of Nursing (DON) was asked about activities for R94 and acknowledged there had been issues with their Activities Director. A review of the facility's Activities Program revealed the following, The facility provides an ongoing activity/recreation program based on the individual resident comprehensive evaluation, care plan, and stated preferences .3. Supportive activities: Promotes a comfortable environment while providing stimulation or solace to residents who cannot benefit from either maintenance or empowerment activities . These activities are generally provided to a resident with severe impairments and/or unable to tolerate the stimulation of a group program .

Based on observation, interview, and record review, the facility failed to ensure hand splint and elbow brace were applied for one (R38) of one resident reviewed for range of motion. Findings include: On 12/17/24 at 9:58 AM, R38 was observed lying in bed with the television on and was asked about the stay at the facility. During the interview R38's right arm and hand was observed to be contracted (a condition that causes the fingers to bend and the palm to thicken) and without a brace on. R38 was asked if they had a brace for their right arm. R38 explained that they (staff) use to put it on but, has been without it for about a month. On 12/18/24 at 10:01 AM and 1:01 PM, R38 was observed lying in bed and reported they had not had the brace applied. On 12/19/24 at 11:00 AM, R38 was observed lying in bed, R38's right arm was observed without a brace. R38 was asked if they knew where the brace was kept and reported, they were not sure. An observation was made with a general glance of R38's closet the braces were not observed. A review of R38's order noted, Donning and doffing of R (right) hand splint and R Elbow Brace up to 4 hours as tolerated alternating days with R elbow Brace and R Hand Splint. Monitor for s&s (signs and symptoms) of skin breakdown. Order Clarification: started on 8/6/21. A review of R38's medical record revealed, R38 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Contracture right elbow. A review of R38's Minimum Data Set (MDS) assessment, dated 11/01/2024 noted R38 with a moderately impaired cognition and was dependent on staff for activities of daily living. A review of R38's care plan noted, Focus: [R38] has a functional ability deficit and requires assistance with self-care/mobility R/T (related to) decreased mobility and weakness dx (diagnosis) spinal stenosis, vascular dementia, HTN (hypertension), DM (diabetes mellitus), and depressive disorder. Date Initiated: 02/23/2018. Interventions: Donning and doffing of R hand splint and R (right) Elbow Brace up to 4 hours as tolerated alternating days with R elbow Brace and R Hand Splint. Monitor for s&s of skin breakdown. Date Initiated: 02/13/2024. Interventions: Provide [R38] assistance with donning and doffing of R orthosis. Patient able to tolerate orthosis up to 4 hours without any signs and symptoms of pain or pressure. Date Initiated: 02/13/2024. On 12/19/24 at 11:20 AM, the therapy director was asked about R38's brace and state he would look into it. On 12/19/24 at 1:42 PM, Therapy Director H explained, he found the braces in R38's closet and the restorative team is responsible for applying them on the resident. On 12/19/24 at 1:44 PM, the Director of Nursing (DON) was asked about R38's braces and explained, the braces are on the MAR (Medication Administration Record) and the Nurses or Restorative staff are responsible for the application of the devices. A review of the R38's MAR for the month of December revealed, the braces were not documented as applied on the following dates, [DATE]th and 17th. After a review of the MAR, R38 was asked if they had the brace on this month and explained they have not had the brace on for about a month. A review of the facility's policy titled, Brace and Splint Program, dated 4/5/24 noted, Purpose: Properly used splint and braces can enhance mobility, correct alignment and protect a specific extremity while maintaining skin integrity and circulation, and avoiding other possible adverse effects of the device. The purpose of the Brace and Splint Program is to: 2. Avoid or delay any loss of independence, 3. Achieve the highest level of independence possible. Procedure: 4. If the resident enters the facility with a brace or splint, or the specialized therapist determines that a brace or splint is appropriate the nurse will obtain a physician's order. The order will define the following information: a. Where the splint/brace is to be worn, b. When the splint/brace is to be worn, c. Why the splint/brace is to be worn, d. Who will apply the splint/brace (nursing or therapy). 5. Interdisciplinary care plan . c. Staff has a scheduled program of applying and removing the appliance that includes: d. Scheduled hours to be worn .

Based observation, interview, and record review the facility failed to ensure proper storage of medication in two of two medication carts and one resdent's room (R38) reviewed for medication storage. Findings include: On 12/17/24 at 9:58 AM, R38 was observed lying in bed with the television on. R38's overbed table was observed with a small oval shaped pill on the table. R38 was asked what medication it was and when did they received the medication. R38 stated, I'm not sure what it is, it might have fell out one of my cups. On 12/17/24 at 10:02 AM, the assigned Nurse was asked about the pill that was observed on R38's overbed table. The Nurse explained they had not administered R38's medication and that the pill observed may have been from the midnight shift. The Nurse was asked to identify the medication with R38's medications in the med cart. The medication was identified as atorvastatin 20mg (milligrams), which is scheduled to be administer at bed time. 49083 On 12/18/24 at 8:54 AM, an observation of medication cart South-2 was conducted with Licensed Practical Nurse (LPN) D. The following medications were observed loosely throughout the cart unpackaged and without patient identifiers. Drawer 2 2 round white pill #12/A 1 white elongated 7206/TV 1 white round 209 1 round peach 41/H 1 white elongated ATV/20 1 elongated peach C03/77 1 pink elongated 5/894 2 white round/damages 1 white round scored M/5 1 yellow elongated 151 1 capsule Q02/ blue white 1 orange round unidentifiable 1 small round white ATN/25 Drawer 3 2 white elongated 2 peach round 1 blue elongated 1 yellow tab Drawer4 1 white elongated 729612/18/24 On 12/18/24 at 9:46 AM, an observation of medication cart East Hall was conducted with LPN C. The following medications were observed loosely throughout the cart unpackaged and without patient identifiers. Drawer 2 1 pink elongated 5 1 yellow round 2.5 Multiple broken white colored medications On 12/18/24 at 10:00 AM, the Director of Nursing (DON) was informed of the above findings in both medication carts and acknowledged medications should not be stored in the carts without patient identifiers or packaged. A review of the facility's policy titled; Storage and Expiration Dating of Medications and Biological's dated 8/2024 documented: .Facility should ensure the medications for each resident are stored in the containers in which they were originally received .

This citation pertains to intake MI00147311. Based on observation, interview, and record review, the facility failed to initiate a facility wide elopement code (notification for a missing resident) in a timely manner for one sampled resident (R902) of three reviewed for accidents. Findings include: Incident summary on 9/21/2024 at approximately 5:38 am, resident [R902] exited the door and was returned to the facility with no injury. A review of R902's medical record noted, R902 was admitted to the facility on [DATE] with diagnoses of Vascular Dementia unspecified severity without behavioral disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. A review of R902's Minimum Data Set revealed, R902 with a moderately impaired cognition and required some assistance with activities of daily living. On 10/29/24 at 2:18 PM, R902 was asked about the incident. R902 explained, they left out the front door of the facility, because they needed to go handle some business. R902 also explained they did not give notice to the staff they were leaving. On 10/29/24 at 2:29 PM, Licensed Practical Nurse (LPN) A was interviewed via phone and was asked about the incident with R902. LPN A explained they heard the front door alarm and went to look around to see who went out and didn't see anyone. LPN A continued and explained that she came back to her medication cart to pass medication and is when she was unable to locate R902. LPN A stated, We started to look around in rooms and didn't see [R902]. LPN A explained that she had Certified Nurse Assistant (CNA) B to look around on the unit prior to calling the official facility wide code. LPN A was asked where was R902 found. LPN A explained, R902 was found by the police on Middlebelt and [NAME] at the grocery store. The store is located approximately 0.8 miles away from the facility and is about a 17 minute walk according to Google. The store is at a busy intersection that leads to the freeway. R902 told them they were waiting for the bus to go to the Detroit. LPN A was asked about R902's alertness and stated, [R902] has a little bit of confusion. A review of the facility's written revealed, LPN A, At approx (approximately) 5:38am. I returned from 2nd floor. Getting supplies, the door alarm was sounding. I opened the floor and looked out from and didn't see anyone. I returned and stated med pass and I didn't see him. I searched the hallways, bathrooms and Kitchen. I instructed the CNA B to search the other hallways and rooms. We were unable to locate him. At approximately 5:55 AM I called a code search overhead, still didn't locate him. I called 911/police at 5:58 AM, Director of Nursing (DON), family and physician. A review of facility's documentation noted, At approximately 6:30am, the resident was returned to the facility by (local police department). There were no injuries noted. The resident was not in any distress. Facility's statement, Laundry Aide, 5:35 AM I was picking up laundry from 1st floor. I observed the resident walking towards the Nurses station, I got on the elevator and approx. 10-15 min (minute) later [LPN A] Overhead paged code search I started looking for the resident in my work area (basement). I then went outside and drove around the building and surrounding streets. I did not locate the resident. I returned to the facility and gave my statement to the police. Facility statement with R902, Resident stated that [R902] left the facility to return to Detroit so that [R902] could be in control of [R902's] finances and affairs. When asked why [R902] didn't notify staff so that we could arrange transportation, [R902] stated it was bets if we didn't know because we would try to talk him into staying. [R902] said the freeway was right up the street and [R902] was going to have the grocery store call [R902] a cab. On 10/29/24 at 12:52 PM, the DON was asked about the incident with R902. The DON explained LPN A was supposed to call the elopement code right away to start the facility wide search for the resident. A review of the facility's policy titled, Elopement Policy dated 4/26/2022, revealed, Policy: It is the policy of this facility to prevent to the extent reasonably possible, the elopement of guests/residents from the facility . Missing Guest/Resident: 1. Check the sign-out form to see if the guest/resident signed out without notifying the staff or left with family if not, call a code Search or designated code for your facility . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which include interventions/actions to correct the past noncompliance. The facility was able to demonstrate monitoring of the corrective action and maintained compliance. FACILITY QAPI / PAST NON-COMPLIANCE FORM Elopement Date: 9/21/24 Description of deficient practice: Facility failed to prevent a resident, who requires supervision, from going outside the facility doors independently. The resident was able to exit the Front entrance of the facility lobby. Staff did respond to the alarm initially, look outside the door/perimeter, and searched the facility, however did not immediately call the code search. How facility identified resident affected and residents having potential to be affected by the same Deficient practice. Administrative Nurses and or the Social Worker reviewed the residents that reside at the facility to identify residents that are expressing a desire to leave the facility. The IDT (interdisciplinary team) reviewed and validated the last risk for elopement evaluation, any concerns were address, the care plans for elopement are up to date and the wander guard is in place and functioning. Corrective action taken for the resident affected: Resident was assessed and the elopement evaluation was completed The Resident Chart was reviewed The Elopement care plan developed Physician orders for wander guard device were put in place Measures of systemic changes made to ensure the deficient practice will not occur and affect others. A QAPI Meeting was held to review the elopement and the event. Rounds were made on all doors in the facility that exit to the outside to validate alarms are functioning. All doors were alarmed properly. The Elopement policy was reviewed and deemed appropriate. All staff was educated on elopement policy with emphasis on what steps to take when a door alarm sounds. How facility monitors its corrective actions to ensure same deficient practice is corrected and will not recur. The Maintenance Staff or designee will complete Elopement Drills on each shift weekly for 4 weeks, than monthly to ensure staff are responding properly, any concerns will be addressed. Findings will be reported to the QAPI committee monthly for 3 months for recommendations. The IDT will interview staff on rounds on the Elopement Policy and what steps to take when they hear and alarm sounding, weekly for 4 weeks, than monthly for 2 months to ensure staff are responding properly, any concerns will be addressed. Findings will be reported to the QAPI committee monthly for 3 months for recommendations. POC Date: 9/30/24

This citation pertains to Intake MI00144815. Based on interview and record review, the facility failed to provide Notice of Medicare Non-Coverage (NOMNC) to one resident (R700) out of one reviewed for discharge from the facility. Findings Include: A review of an Intake called into the State Agency noted the following, The family appealed the discharge and received a telephone call . the appeal went in patient's favor due to not informing the patient in ample time. A review of the medical record revealed R700 admitted into the facility on [DATE] with the following medical diagnoses, Muscle Weakness and End Stage Renal Disease. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R700 also required assistance with bed mobility and transfers. Further review of the NOMNC revealed that R700 services were to end on 05/3/2024 and was signed and dated by R700 on 5/2/2024. On 06/20/2024 at 12:13 PM, an interview was conducted with Business Office Manager (BOM) A regarding R700's NOMNC. BOM A stated usually the resident receives at least 48 hours of notice. BOM A stated they are unsure what happened with R700 and why they were given the NOMNC the day before services ended. BOM A stated the only thing they could think of is the insurance company sent the NOMNC in late to be signed, because they issue them on the same day they receive them from the insurance companies. On 06/20/2024 at 12:20 PM, an interview was held with MDS Registered Nurse (RN) B. MDS RN B stated R700 did appeal, however they did not appeal in a timely manner. MDS RN B stated they attached the NOMNC to the information regarding the appeal, along with the other required medical documents for the appeal process. A review of a facility policy titled, Medicare Notice of Non-Coverage Advance Beneficiary Notice did not address timely delivery of NOMNCS.

This citation is related to Intake M1001445014. Based on observation, interview and record review, the facility failed to properly care for pressure ulcers for one of one resident (R702). A review of an Intake called into the State Agency noted a resident had a bedsore for so long that she got a bad infection which she was hospitalzied for. On 6/20/2024, record review revealed R702 was admitted on [DATE] with following relevant diagnoses: Sepsis, Quadraplegia C5-7 Complete, Neuromuscular Dysfunction of Bladder, Muscle Weakness, Chronic Iron Deficiency, Depression, Anxiety Disorder, Essential Hypertension, Gastro-esophageal Reflux Disease, Acute Kidney Failure. R702 is alert and oriented to person, place, time and situation. R702 is physically dependent for all activities of daily living. On 6/20/2024 at 9:30 AM, R702 was observed laying on their back, bed flat, awake, alert and conversant. R702 was queried regarding his overall care. R702 revealed that approximately a week ago after a shower, the wounds were left uncovered, and R702 became incontinent of bowel. R702 revealed the Certified Nurse Assistant (CNA) providing his care was notified. R702 stated he waited five hours for a nurse to provide care to the wounds. On 6/20/2024 at 9:45 AM, an interview with Wound Care Nurse (WCN) C revealed they were preparing to provide wound care to the R702. WCN C revealed R702 had Stage III pressure ulcers (sores that have progressed to the third stage have broken completely through the top two layers of the skin and into the fatty tissue below) on each ischium (seating bones) and on the sacrum (low back). WCN C also revealed R702 had Deep Tissue Injuries on bilateral heels. The WCN C revealed they provide wound care on Monday, Tuesday, Thursday and Friday. WCN C confirmed that on Wednesday, Saturday, and Sunday, wound care is completed by the nurse responsible for the resident. WCN C revealed if a resident with dressings are showered, the dressing is removed and a (CNA) would notify the responsible nurse. WCN C revealed when a dressing becomes soiled, the CNA notifies the responsible nurse. If WCN C is not in house, the resident's responsible nurse is required to provide wound care. On 6/20/2024 at 10:00 AM, R702's wound care was observed. WCN C unfastened R702's brief on the left side (R702) was laying on right side. The left ischial dressing was bunched, leaving the wound exposed with a small amount of drainage noted on the brief. On 6/20/2024 at 10:30 AM, upon completion of wound care, WCN C confirmed R702's allegation they were left for approximately 5 hours with feces in their wounds. WCN C further revealed Nurse D was written up. WCN C provided documentation of the corrective action. On 6/20/2024 at 1:30 PM, met Director of Nursing (DON) regarding the incident described above. The DON confirmed her awareness of R702's wounds not receiving proper care and that an in-service had been provided on 5/30/2024.

This citation pertains to Intake M100144133. Based on observation, interview and record review, the facility failed to ensure orders for catheter care was provided for one (R906) of four residents reviewed for catheter care. Findings include: Review of the facility record for R906 revealed an original admitted [DATE] and a most recent admitted [DATE] with diagnoses including Multiple Sclerosis, Diabetes Mellitus, and Fibromayalgia. The record further revealed R906's readmission on 03/01/24 was following hospitalization due to Urinary Tract Infection (UTI) attributed to an indwelling catheter. The record indicated R906 continued to have the indwelling catheter when they were readmitted to the facility on [DATE]. During review of R906's catheter care it was noted the most recent catheter care orders were discharged no later than 02/27/24 and no catheter care-related orders were documented for the most recent admission period of 03/01/24 to 04/14/24. Review of R906's Kardex Task item which states Was indwelling catheter care performed per the resident's plan of care? revealed no documentation entries for the dates 04/01/24 thru discharge on 04/14/24. On 04/30/24 at 3:00 PM, the facility Director of Nursing (DON) was interviewed. The DON acknowledged the absence of catheter care orders for R906 during the most recent admission and reported that they were not obtained or entered into the electronic medical record (EMR). The DON reported that a catheter care Kardex item was produced when the catheter care plan was entered which would allow direct care staff to see the catheter care Kardex question, however, because the Kardex item was not renewed there were no related checklist questions produced to allow staff to enter documentation of care completion. The DON reported that the expectation is that the catheter care orders would be obtained and entered and the related Kardex Task questions would be available for staff completion when the resident was readmitted to the facility. Review of the facility policy Physician's Order dated 10/20/23 revealed the Purpose statement Physician orders are obtained to provide a clear direction in the care of the resident. The Information portion of the policy includes the following entries: - Orders given by a physician must be accepted by a licensed nurse and documented on the physician order sheet or in the EMR system if electronic, and must be cosigned and dated by the ordering physician per state guidelines. - On a regular basis or as required by state and/or federal law the attending physician will review the plan of care, including physician orders. The physician is to review the orders at the time of the physician's visit. Admission physician orders will be signed within 24-72 hours. - Treatment rendered to a resident must be in accordance with the specific standing, written, verbal, or telephone order of a physician . - Standing and written orders must be recorded in the resident record and signed by the licensed health professional who issued the order in accordance with the policy of the health facility or agency.

This citation pertains to intake numbers: MI 180 and MI 267. Based on interview and record review the facility failed to provide supervision to prevent resident to resident abuse involving four sampled residents (R504, R505, R507, and R508) of five residents reviewed for abuse, resulting in physical injury to two residents, self-isolation and psychosocial harm with feelings of being terrorized, and anxiety for a reasonable person for a year. Findings include: On 8/23/21 at 3:00 PM, an incident and accident (I/A) report dated 7/2/21 was reviewed involving R507 and R508 which revealed the following, [R508] was sitting in a chair at nurses station when they became agitated and stood up and made contact with [R507's] face. Residents immediately separated .rendered treatment to R507's upper lip. On 8/24/21 at 12:15 PM, a progress note in R508's Electronic Health Record (EHR) was reviewed and indicated that on 7/2/21 R508 was sitting in a chair by the nurses station, became agitated with R507, stood up, walked over to R507 and, Punched [R507] in the mouth. R508 was petitioned to the hospital for a psychiatric evaluation. On 8/24/21 at 12:22 PM, further review of R508's EHR revealed that R508 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R508's most recent Minimum data set assessment (MDS) dated [DATE], indicated that R508 had a severely impaired cognition. On 8/24/21 at 1:09 PM, a review of a progress note in R507's EHR dated 7/2/21 indicated the following, Other resident got upset and made contact with resident's face. Care rendered to resident's lip. On 8/24/21 at 2:10 PM, R507 was met in their room and interviewed regarding the incident which occurred between themselves and R508 on 7/2/21. R507 was unable to answer any questions and had no recollection of the incident. On 8/24/21 at 2:20 PM, Nurse A was interviewed about the incident which occurred on 7/2/21 involving R507 and R508. Nurse A indicated that R507 had placed their hand on the back of the chair that R508 was seated in and R508 got up from their chair and hit R507 in the face. Nurse A stated, I gave [R507] ice to put on their lip. On 8/25/21 at 2:03 PM, Certified Nursing Assistant (CNA) F was interviewed about the incident which occurred on 7/2/21 involving R507 and R508. CNA F stated, I separated the residents and took [R508] to their room. On 8/25/21 at 2:30 PM, the Director of Nursing (DON) was interviewed regarding the incident involving R507 and R508, and ask about what their expectations were for staff regarding the handling of resident to resident contact and physical aggression. The DON indicated that staff were trained to intervene immediately. If behavior is noticed, we act on it. We separate both residents as much as possible. On 8/25/21 at 2:47 PM a further review of R507's EHR revealed that R507 was originally admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R507's most recent MDS dated [DATE] revealed that R507 had a severely impaired cognition. On 8/25/21 at 3:00 PM a facility policy titled, Abuse Prohibition Policy, Revised: 07/2019 stated the following, Each resident shall be free from abuse .Abuse shall include freedom from .physical abuse .To assure residents are free from abuse .the facility shall monitor resident care .on an ongoing basis. It is the responsibility of all staff to provide a safe environment for the residents .Definitions Abuse means the Willful infliction of injury .Willful, as used in this definition of abuse, means the individual must have acted deliberately .Physical Abuse includes hitting .Examples: Hitting, slapping, punching . Resident #504 and Resident #505 A review of a facility reported incident revealed On 5/13/2021, At approximately 3:30 PM resident [R504] was leaving the 2nd floor dining room, [R505] was on [their] way. [R504] asked [R505] to move out of [their] way, but [R505] refused. Both residents started verbal altercation, [R505] proceeded with the kick to [R504] right leg causing abrasion. Both residents were separated immediately. The facility reported incident revealed the resident to resident was witnessed by a staff member. A progress note in R504's Electronic Health Record (EHR) was reviewed and indicated that on 5/13/2021, [R504] had a verbal altercation with another resident. [R504] was kicked by another resident, which was witnessed. Residents were separated by ward clerk. A 2 mm (millimeter) skin abrasion on right shin is reported. Requested abrasion be cleansed and [Triple Antibiotic Ointment] TAO be applied. Paperwork is being filed. Another progress note was reviewed in R504's EHR and indicated that, Patient is a [AGE] year-old .seen for reported altercation. Nursing reports pt. was trying to get to [their] room and another resident was in [their] way. Pt. states that the other resident was using racial slurs. Report that pt was kicked in [their] right shin. Pt states that [they] did get kicked and the skin had a small wound. On exam, 0.5 cm (centimeter) abrasion present on right anterior superior lower leg. No TTP, slight [CONDITION(S)], no ecchymosis, no [CONDITION(S)]. Facility policy and staff to stop interactions between residents in the future. Will continue to monitor. A further review of R504 medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R504's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition. On 08/25/2021 at 1:40 PM, an interview was conducted with R504 regarding the incident. R504 revealed they remembered the incident very well. R504 stated that R505 was blocking the hallway to their room and when they asked them to move R505 began using racial slurs and they began arguing. R504 stated that R505 then kicked them in the right leg causing a cut. R504 stated that R505 always had behaviors and they felt terrorized by them for a whole year. R504 also revealed, he would stay in his room more because of R505 and would leave activities when R505 came around, so he would not have to interact with him. R504 stated that after the incident they were told they were looking for R505 new placement, but that R505 was still around them with no supervision. R504 stated that they did not feel that was fair and [R505] behavior had not changed. R504 stated that they constantly complained about R505, and nobody ever did anything about it. A review of R505 progress note dated 05/13/2021 revealed, Resident had a verbal altercation with another resident and the resident proceeded to kick another resident on [their] rt. Leg. The incident was witnessed by a staff who separated them immediately. R505's progress notes dated 5/14/2021 revealed, Resident having increased behaviors. At times when intercepting resident from getting [on] elevator. Resident gets verbally aggressive with staff, voice cont to increase louder and will throw items at staff. Resident had verbal altercation with another resident and had contact with another resident. R505's progress notes dated 5/24/2021 revealed, Pt. had an episode of outburst. [They] thought it was [their] house. [They went down the hall telling everyone to leave. [They] said there were too many lights left on in the house. [They] was worried that [their] parents would be upset if they found all these people in the house this time of the night. Staff members were able to talk to pt. in a calm manner. Pt. became less agitated, but cont. to roam the hall in W/C (Wheelchair). A further review of R505's EHR revealed that R505 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R507's most recent MDS dated [DATE] revealed that R507 had a severely impaired cognition. On 08/25/2021 at 11:25 AM an interview was conducted with Social Work G about how people with behaviors are cared for. Social Work G stated that they make sure they are safe and that other residents are safe. Social Work G stated that if behaviors escalate then they will petition residents out. On 8/25/2021 at 2:25 PM, the Director of Nursing (DON) was interviewed regarding the incident. The DON stated that R505 was a wanderer and would go into different rooms and if you told them that it was the wrong room he would go off. When queried about what interventions were put into place to prevent R505 from having another resident-to-resident altercation the DON stated that there was a psych consult with medication adjustments and R504 stated that they would stay out of R505's way.

Based on observation, interview and record review, the facility failed to ensure the provision of care and treatment per professional standards of practice to prevent the development of a facility acquired pressure ulcer (wound caused by pressure), for one sampled resident (R67) of four Residents reviewed for pressure ulcers, resulting in Resident #67 developing a stage III (full thickness of the skin and may extend into the subcutaneous tissue layer), pain, and the potential for delayed wound healing, infection, and overall deterioration in health status. Findings include: On 4/19/21 at 11:51 AM, R67 was observed in bed on their back. R67 stated that sometimes they wait hours to be repositioned. The resident indicated that they (the facility) were not taking care of their needs and it made them angry. On 4/20/21 at 8:15 AM, R67 was observed in bed laying on their back. R67 reported that they had been in the same position for about four to five hours. R67 said, This is what I go through. I cannot get up on my own. I cannot move on my own. I'm always in pain. I can't do nothing, and they won't turn me, and they won't do therapy because they said I reached my limit. But they won't help me. A review of the electronic medical record noted R67 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R67's Brief Interview for Mental Status showed an intact cognitive response. R67 required extensive two or more assistance with activities of daily living. A review of the progress note dated 3/13/20 Skin/wound Progress noted the following: Seen for skin assessment. Hx (History) of cervical spine injury s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . (R67) is alert and oriented x 4. Skin warm and dry. No skin breakdowns noted. Heels intact. Very limited ROM to hips and unable to bend knees - very stiff. Positioned with pillows to offload pressure. Heels floated on pillows. A review of the progress note dated 3/16/20 noted the following: Pt (patient) was also evaluated by wound care and had right buttock healing skin tear with Allevyn dressing, bilateral heel decubitus closed abrasions with Allevyn dressing, postop cervical wound healed keeping clean and dry. A review of the Behavior progress note dated 8/23/20 noted the following res (resident) thought (they) had a wound on butt, (they) did not have any at that time. A review of the Total Body Skin assessment dated [DATE] noted zero wounds. A review of the PCC (Point Click Care) Skin & Wound-Total Body Skin assessment dated [DATE] noted zero wounds. A review of the PCC Skin & Wound-Total Body Skin assessment dated [DATE] noted zero wounds. A review of the Total Body Skin assessment dated [DATE] noted zero wounds. A review of the Skin/Wound Progress Note dated 11/9/20 noted the following: Seen today during treatment rounds. (R67) expressed that (their) bottom was tender. New pressure injury noted. A review of the progress note dated 11/10/21 noted the following: Resident has a stage 3 to sacrococcyx. A review of the Dietary progress note dated 11/9/20 noted the following: Addressing new wound. A review of the Wound Care Progress Note dated 11/11/20 & 11/18/20 noted the following: Wound assessment(s) Wound #2 Sacrococcyx / bilat (bilateral meaning both) buttocks is a Stage 3 Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 4.5 cm length x 4 cm width x 0.3 cm (sq cm ) depth, with an area of 18 sq cm (square centimeter) and a volume of 5.4 cubic cm (centimeter). There is a moderate amount of sero-sanguineous drainage noted which has no odor. Wound bed has Pink base epithelialization, minimal Yellow slough . Diagnosis 1. Pressure Ulcer Stage II sacrococcyx/ bilat (bilateral meaning both) buttocks. Plan: Wound Orders: Wound #2 coccyx/bilat buttocks. Treat Recommendations: Santyl daily and prn. Additional Orders: Roho mattress. frequently reposition, float heels, soft heel protector boots . On 4/21/21 at 10:15 AM, the Director of Nursing (DON) was interviewed and asked about the development of the stage three wound on R67. The DON stated, I spoke with the wound nurse about the pressure ulcer. (R67) can be hard to deal with at times because he only wants certain Aides (Certified Nurse Aides) to care for him. A review of the Resident Rights policy revised on 11/2016 noted the following: The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination .Resident have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care. Requested the wound care/skin assessment policy on 4/21/21 at 10:30 AM. However the facility did not provide the requested wound care/skin assessment policy at the time of exit on 4/21/21.

This citation pertains to intake # 6. Based on interview and record review, the facility failed to respond to an alarming door and adequately supervise one resident (Resident #703), of four reviewed for elopement (unsupervised exit from the building), with a known history of exit seeking behavior. Resulting in, on 9/27/2020 at approximately 6:45 PM, Resident #703 had self propelled their wheelchair through the common area, through a detex (an alarm box located on the door, that was not turned on normally until 7:00 PM) door, through the lobby to the front doors. Resident #703 then pushed through the alarmed front doors, which staff were not able to hear, and then through another set of doors and got outside the building unsupervised, and was located stuck in a pothole in the driveway of the facility, near a busy road. Findings include: The Immediate Jeopardy (IJ) started on 09/27/2020 and was identified on 10/09/2020. The Administrator was notified of the Immediate Jeopardy on 10/09/2020 at 1:49 PM and was asked for a plan to remove the immediacy. The IJ was removed on 9/27/2020, based on the facility's implementation of the removal plan as verified onsite on 10/09/2020. Although the immediacy was removed, the facility's deficient practice remained isolated with the likelihood of actual harm that is not immediate jeopardy. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #703 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #703 had a Brief Interview for Mental Status (BIMS) score of 03/15, indicating a severe cognition impairment. Resident #703 needed extensive assistance with transfers and was noted to have wandering behavior. A record review of the Risk for Elopement assessment dated [DATE] revealed that Resident #703 was a risk for elopement. A record review of the Care Plan for Resident #703 revealed the following: Focus (initiated 9/27/2020)- .is risk for elopement and/or wandering R/T (related to) Alzheimer's . Goal- .will not leave the facility unattended through next review date . Interventions- .apply wanderguard per order . Keep resident in visual site (sic) Distract resident when wandering . Observe wandering behavior and attempted diversion activities . Provide reassurance/Redirect as needed . Provide structured activities . Refer to psych services . Wanderguard to left ankle. A record review of the Progress Notes for Resident #703 revealed the following: 8/22/2020 15:28 (2:28 PM) Pt (Patient) witnessed approaching exit door even after being redirected several times by staff. Writer placed wonder (sic) guard (bracelet that alarms when resident near armed doors) on left ankle, wanderguard tested and effective. On coming staff aware of PT's exit seeking behavior will continue to monitor. 8/23/2020 19:04 (7:04 PM) Resident kept trying to exit the facility today, I called (their)daughter at 12 PM and she came and spoke with (Resident #703) .resident calmed down for an hour and then continued exit seeking a way out of the facility. 9/8/2020 10:32 (AM) Writer spoke with daughter about (Resident #703's) Behavior. Resident ask writer to keep (them) away from the phone because (Resident #703) wants to go home and there is nothing she (daughter) can do about it. Resident daughter said she will speak with (Social Worker) about other options of seeing (Resident #703) due to (their) behavior of being aggressive the last few weeks. 9/14/2020 18:55 (6:55 PM) Writer spoke to residents daughter regarding incident that happened today. Daughter brought up residents exit seeking behaviors and asked writer if 'staff could give (Resident #703) something to calm (them) down to make (Resident #703) stop exit seeking?' .Writer discussed a more secure facility for residents with dementia and exit seeking behaviors. 9/19/2020 14:11 (2:11 PM) Resident appear to wander throught (sic) out the facility. Resident attempt to open door and get on elevator constantly. Staff redirect .Resident continue to attempt to get on elevator . 9/23/2020 23:17 (11:17 PM) Resident pushed open the exit door to stairwell. The resident was redirected by staff. 9/24/2020 13:20 (1:20 PM) Resident is an elopement risk. (Resident #703) is on the second floor currently with a wanderguard in place, however, (Resident #703) continues to breech doors. The second floor doors all lead to stair cases putting the resident at risk for falling down the stairs .Resident would be potentially safer should (they) breech an exit/entry way door on the first floor to a level surface . 9/25/2020 2:39 PM Resident transferred rom (sic) 2nd floor to room [ROOM NUMBER] bed 2. Resident received up in w/c (wheelchair), self propelling. Resident becomes verbally and physically abusive with staff attempting to swing at them. Resident also noted to beat on glass door again in attempt to leave . 9/26/2020 6:28 PM Resident attempting to exit seek several times. Resident goes on all hallways and attempts to open the door, unable to be redirected at times and (Resident #703) tries to hit staff and gets mad and starts to yell at them . 9/27/2020 4:03 AM Resident continues to exit seek at all exit doors on the first floor, at times resident is difficult to redirect .Staff keeps resident in common areas for safety. 9/27/2020 8:15 PM Writer (authored by Nurse A) was informed that resident was observed outside of building by exit door by a staff member (Environmental Porter B). Resident immediately brought back into building .Resident remains in visual site (sic) while up in wheelchair. 9/28/2020 1:41 PM resident breeched front entry door, was quickly located and brought back into building. Resident with increased exit seeking behaviors and agitation .Resident continually exit seeking and opening exit/entrance doors and becomes aggressive when staff attempt to redirect. 9/28/2020 2:47 PM .Resident exit seeking throughout shift, multiple numerous attempts to open exit doors. Resident is yelling at staff, fighting as staff removes (them) from doors and elevators .exit seeking behavior verbal and physical striking out at staff continues . On 10/9/2020 at 11:46 AM, an interview with Nurse A (who was assigned to Resident #703 on 9/27/2020) was completed regarding Resident #703 exiting the building on 9/27/2020. Nurse A stated, I was taking a break and I came out (of the break room to the floor) and (Resident #703) was in their wheelchair with two staff members at the med (medication) cart. I knew it (the situation) wasn't good. Someone had come into work and seen (Resident #703) outside in front in their wheelchair. The nurse (Licensed Practical Nurse/LPN C) from the second floor came and got (them). They (the staff) didn't hear the alarms (from front door) until they got close to the doors (then they realized that someone had gotten out through the front doors). The detex door (the door in between the common area of the first floor and the lobby) doesn't go on until after 7:00 PM. Nurse A explained that Resident #703 would often wait until staff were busy to try to get outside. On 10/09/2020 at 12:15 PM, an attempt was made to call Environmental Porter Staff B (first observed Resident #703 outside on 9/27/20). There was no return phone call by the end of survey. On 10/9/2020 at 12:36 PM, an interview was completed with the Director of Nursing (DON) and Nursing Home Administrator (NHA). The DON explained that she had assisted the previous DON with the investigation. The DON explained that the resident (Resident #703) got out the door (detex) leading from the common area to lobby. The Detex was not on at the time of Resident #703 going through it, as staff were not directed to put on until 7:00 PM per facility policy (previous). Then, (Resident #703) went out the first alarmed locked lobby door, which sounded, then through second set of doors. The NHA explained that although the lobby doors lock, they are fire doors and are able to be gone through by pushing in the handle for 15 seconds, as a fire safety measure. During this time, the NHA and DON demonstrated how loud the front door alarm sounds from the common area. When the detex door is shut, the alarm was very faint and difficult to hear while in the common area. When the detex door was open, the alarm was still very hard to hear while in the common area. The DON was asked if staff could hear the front door alarms sounding from care areas and the DON shook her head no. On 10/9/2020 at 1:00 PM, the written statement of the Environmental Porter B was reviewed and revealed the following: Coming back from break, noticed Resident (#703) sitting in w/c outside doorway, immediately parked car and ran in to get staff. (LPN C) the 2nd floor nurse assisted (Resident #703) in bringing the resident in. On 10/9/2020 at 1:06 PM, LPN C was questioned (via phone) in regard to retrieving Resident #703 from outside on the evening of 9/27/2020. LPN C stated, A staff member (Environmental Porter B) came in and got me. I had taken care of (Resident #703) when they were on the second floor. We found (Resident #703 in their wheelchair) in the driveway stuck in a pothole, so they couldn't move. (Resident #703) was mad that we were bringing them in (but cooperative). I don't remember what (Resident #703) was wearing. It was warm out. A review of the facility policy titled, Elopement Policy revised 6/2019 revealed the following: f.wandering system doors will be checked for functionality 7 days per week . 4. Care plans are to reflect the potential of the resident and will be reviewed, revised and updated as needed by the interdisciplinary team . 8. Rounds of all residents are made at the beginning of the shift, at meal times, and at the end of shift at minimum . Removal of Immediate Jeopardy 1. The Environmental Services Director / designee checked all doors on 9/27/2020 for functioning of alarms and all were found operating appropriately; Environmental Services Director /designee will continue to check all alarmed doors including doors with wandergaurds, sequential key pad systems, and the doors with a mag lock system on a daily basis and will report any areas of concern to the Administrator beginning 9/27/2020. 2. The door leading to the lobby by the DON's office; has an alarm (detex) that will be set if there is no employee in the lobby. Also, the last employee to leave will make sure to alarm the this door 3. The elopement book was updated for any new admissions that are identified as an elopement risk and/or when existing residents are identified as an elopement risk on September 27, 2020 by the DON or designee. The newly admitted residents will be reviewed regarding their elopement risk status by the IDT team at the morning stand up meeting beginning September 28th 2020. 4. The list of at risk residents (3 identified) has been reviewed and placed in the elopement books at the nurse's station and receptionist desk on 9/27/2020. 5. Front office staff was Re-educated on change of time of alarming the door; including not limited to the last person to ensure alarm is set. 6. New admissions will be assessed for elopement risk and the elopement book, care plan and care guide will be updated as needed beginning 9/27/2020 by the licensed nurses. Resident's identified with escalating behaviors will be assessed and the physician will be contacted and appropriate interventions will be implemented as ordered. 7. New admission charts will be reviewed daily in the morning stand-up meeting to ensure that residents identified as at risk for elopement have had interventions implemented beginning 9/27/2020. 8. New admission charts will be reviewed daily in the morning stand-up meeting to ensure that residents identified as at risk for elopement have had interventions implemented beginning 9/27/2020.

This citation pertains to intake 4. Based on interview and record review, the facility failed to complete diagnostic testing per order for one sampled resident (R900), resulting in delayed [DIAGNOSES REDACTED]. Findings include: A review of intake 4 revealed the following: (R900's) first fall (in the facility) occurred on 7/12/2020 .received a phone call from a nurse stating (R900) was sitting on the edge of the bed all night and eventually fell .On 7/29/20, they decided to (send resident to the hospital) for x-ray to see if (there was a) possible pelvis fracture from 7/12/20 fall. (R900) did endure a pelvis fracture .(and) remained in the hospital until 8/7/2020. A review of R900's medical record revealed the resident was originally admitted into the facility on [DATE] and re-admitted on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was cognitively impaired. Review of R900's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident required supervision of one staff member for bed mobility, transfers, ambulation, and eating, and limited assistance of one staff member for dressing and hygiene/bathing. Review of R900's MDS assessment dated [DATE] revealed that the resident now required extensive assistance of one staff member for bed mobility, transfers, ambulation, dressing, and hygiene/bathing, indicating a decline in functional status. A review of R900's medical record and progress notes revealed the following: 7/12/2020 08:26 (8:26 AM) Type: Nurses Notes .: At 6:25am, haerd (sic) resident yelling Help. Observed resident sitting on side of bed with table to side .Resident c/o (complained of) hitting (their) head. Has goose egg size lump on left side of head . 7/21/20 Encounter .Date of Service: 7/21/2020 .I was called to see the resident after the nurse noticed a large bruise on the lateral thigh. The bruise was large and extending down the lateral aspect of the thigh towards the knee. There was also some swelling raising the suspicion of a hematoma since (the resident) is on anticoagulation. Nurse and patient denied and fall ot (sic) trauma. (The resident) had some difficulty moving the leg so a stat xray and (ultrasound) (to check for hematoma) was ordered .large ecchymosis/bruise with some swelling on the lateral thigh .is on anticoagulation. Not sure if (the resident) had a fall so a stat xray and US to look for hematma (sic) will be ordered. A skin assessment completed on 7/22/20 for R900 noted no skin issues and did not identify bruising on the resident. 7/24/2020 Encounter .Date of Service: 7/24/2020 .Nursing staff also reports that on Tuesday (Doctor) saw the resident due to left hip bruising and order was placed for x-ray and ultrasound. Nursing staff and secretary to follow-up as to the status of those orders and get them done stat today if not already done .ecchymosis to left hip. No recent injuries reported .denies any pain .does continue on Eliquis (blood thinner) so (the resident) bruises easily, get stat left hip x-ray and left hip ultrasound as previously ordered . A review of R900's record revealed the following orders: X-ray of left hip, STAT for left hip bruise, ordered 7/21/2020 and entered by Unit Manager (UM) A. No result for this x-ray was noted in the resident's medical record. Ultrasound of left hip, created 7/21/20, discontinued 8/3/20 and entered by UM A. No result for this ultrasound was noted in the resident's medical record. Obtain CBC (complete blood count) with Differential, created 7/21/20, discontinued 8/3/20 and entered by UM A. No completed labwork for this order was noted in the resident's medical record. Assess resident for pain every shift, Start Date 6/30/20, D/C (discontinue) Date: 8/3/20. No pain assessment was completed in the record on afternoon shift on 7/25/20, or on day shift on 7/26/20 or 7/27/20. Xray right hip, ordered 7/28/20. The result of the x-ray ordered on [DATE] revealed, Exam Date: 7/28/2020 12:00, Reported Date: 7/28/2020 12:23, Reason for study: Pain in right hip .The right hip joint is in alignment, but there is narrowing of the joint space due to modest [MEDICAL CONDITION] changes. There is modest [MEDICAL CONDITION] spurring involving the acetabular border and femoral head and neck junction. Recent fracture of right inferior pubic ramus with minimal displacement. No other fracture or dislocation is seen. Modest osteopenia. Conclusion: Modest [MEDICAL CONDITION] of the right hip. Recent fracture of right inferior pubic ramus with minimal displacement. Please correlate clinically, and F/U (follow up) is recommended. Electronically signed on 7/28/20 at 12:23 PM. Further review of R900's progress notes revealed: 7/29/2020 Encounter .Date of Service: 7/29/2020 .Abnormal right hip x-ray to review, pain .resident was seen today for review of abnormal right hip x-ray and pain. On exam today (the resident) does appear resting comfortably in bed .does complain of pain with movement to that right hip, verbal orders were given for left hip x-ray yesterday upon returning from [MEDICAL TREATMENT] although it appears that right hip x-ray was done. The x-ray was initially done due to noted hematoma to the left hip .is actually able to move the left leg without any pain or difficulty and hematoma is resolving but now .complains of the right hip and leg pain. The x-ray shows right pubic ramus fracture with minimal displacement .Right hip x-ray read modest [MEDICAL CONDITION] of the right hip. Recent fracture of right inferior pubic ramus with minimal displacement. Please correlate clinically and follow-up is recommended. There was a documented fall on 7/12/2020 per nursing notes .pain with movement to right LE (lower extremity), no pain with movement to LLE (left lower extremity) .bruising to left hip area, soft, diffuse ecchymosis, non-tender .Fracture of right inferior pubic ramus, Resident has decreased range of motion on the right. Initially we were concerned with left hip as (the resident) has some bruising in that area but .does have range of motion to that side. There was a fall reported on 7/12/2020 but without any initial pain .will be sending resident to (hospital) for orthopedic evaluation and full imaging of bilateral hips and pelvis . 7/29/2020 08:13 (8:13 AM) Nurse Practitioner Note Note Text: Resident was seen today .reviewed right hip XR (x-ray) indicating pubic ramus fx (fracture) with minimal displacement .has pain and LROM (limited range of motion) on the right, also noted left hip bruising but only XR on right available to review .will be sending resident to (hospital) for evaluation . A review of R900's hospital documentation revealed the following: History and Physical dated 7/30/20 at 5:32 PM .Presenting with pelvic pain, hx (history of) fall 2 weeks ago .unable to provide adequate hx .Painful ROM (range of motion) lower extremity and on palpation hip .Active Problems: .Pelvic fracture not requiring surgical intervention . On 9/30/20 at 9:43 AM, Licensed Practical Nurse (LPN) D was interviewed and queried on the facility's policy/procedure for completing ordered diagnostic tests. LPN D stated, Get the order from the doctor, then put it into (electronic medical record) as an order, and it will get put into the lab system. Then make sure it's marked STAT if that's how it's ordered. When queried how quickly STAT diagnostic testing should be completed, LPN D stated, Fast. Faster than usual. I expect the same day if not faster than that. When queried if she had run into any problems completing STAT orders, LPN D stated, I haven't had any problems. On 9/30/20 at 2:10 PM, an attempt to contact UM A via phone was made. The number was not in service. On 9/30/20 at 2:26 PM, an interview with Licensed Practical Nurse (LPN) B, who worked with R900 on multiple occasions, was conducted. LPN B was asked who ensures diagnostic orders are carried out after receiving the order from the physician. LPN B stated, The person putting the order in usually makes sure the test gets ordered, or the ward clerk will order the test. When queried regarding caring for R900, LPN B stated, There was a language barrier with the resident but (they) did understand limited English. On 9/30/20 at 3:12 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed. When queried regarding bruising noted on R900's leg on 7/21/20 and a stat X-ray, ultrasound, and bloodwork orders that were not carried out, the DON stated, Let me check in the chart and see what happened with that. The DON reviewed the chart and stated, If I remember correctly they showed up and (R900) was at [MEDICAL TREATMENT] then they came back and did it. When queried if there was documentation of that, the DON provided no response. The DON stated, I think the ultrasound was done on 7/25. Upon review of the resident's chart, the ultrasound result on 7/25 was for the resident's right upper extremity and was not the result of the ultrasound ordered for the hematoma on 7/21/20, the DON acknowledged this was a different test result than the one in question. The DON then acknowledged that R900's orders on 7/21/20 for STAT left hip X-ray and ultrasound of left hip were not carried out. The DON then stated, On 7/28 a hip unilateral (x-ray) and pelvis was done. The results were recent fracture of right inferior pubis. The expectation would be for the orders to have been carried out when they were ordered on 7/21. On 9/30/20 at 3:38 PM, the Assistant Director of Nursing (ADON) contacted UM A via telephone. When queried regarding R900 and the diagnostic tests that were ordered on [DATE], UM A stated, Whatever my note states is reflective of what happened. I no longer work there. I let the nurse know who was working with (R900). It's up to the nurse to make sure (the orders) are carried out. The facility's policy/procedures titled, Fall Management, dated 10/2019 and, physician's orders [REDACTED]. A review of the facility's provided procedure titled, Change in status, identifying and communicating, long-term care, dated 2020, revealed, In a long-term care setting, identifying and addressing any change in a resident's status from baseline is important .Early recognition, assessment, and intervention assist in providing necessary care, which can decrease the need for transfer to an acute care facility or emergency department .Record nursing interventions and the resident's response. Make sure to document all communication with other health care providers as well as the practitioner's orders and any diagnostic test results .

This citation pertains to intakes 8, 6 and 4 Based on observation, interview, and record review, the facility failed to provide services for the treatment of [REDACTED]. Findings include: R904 On 8/4/20 at 9:50 AM, during a tour of the facility, R904 was observed lying in bed on their back with their face slightly turned toward their right shoulder. No pillows or positioning devices were observed. The resident had protective boots on both feet. The resident appeared to be sleeping. On 8/4/20 at 10:50 AM, R904 was observed lying in the same position in bed. The resident was lying on their back with their face slightly turned toward their right shoulder. No pillows or positioning devices were observed. On 8/4/20 at 1:26 PM, R904 was observed lying in the same position in bed. The resident was lying on their back with their face slightly turned toward their right shoulder. No pillows or positioning devices were observed. On 8/4/20 at 1:38 PM, Nurse Aide J was asked when they changed R904's brief last. Aide J stated, I haven't yet. When asked to clarify, Aide J indicated they had not yet changed R904 on their shift. Aide J indicated midnight shift changed the resident before they left. Aide J stated, I have people getting up needing to use the bathroom. Then I need to get that resident up over there. (R904) usually has a BM (bowel movement) after lunch. So that's when I was planning to do it. Aide J indicated they had multiple residents to care for and stated, Just can't do it all in one shift. On 8/4/20 at 1:44 PM, R904 was visited by their Hospice Aide I, who was observed feeding the resident lunch. Hospice Aide I indicated they were going to perform ADL (activity of daily living) hygiene care on R904. On 8/4/20 at 2:00 PM, Upon performing ADL care, R904's blue brief was visibly soiled in the front of the brief. The stool was able to be observed through the brief material prior to the brief being opened. R904 had an indwelling urinary catheter. The resident's fitted sheet had a brown stain observed on the right side of the bed and had dried flakes of what appeared to be dead skin and dried red spots at the foot of the bed. Hospice Aide I stated they were going to change the resident's linen as well. On 8/4/20 at 2:17 PM, Licensed Practical Nurse (LPN) B entered the room and was queried if R904 had a wound on their sacrococcyx area. LPN B stated, Yes. When informed that the resident's brief appeared soiled, LPN B then helped Hospice Aide I with ADL care. The resident's brief was opened to reveal that it was full of stool in the front and the back. The resident had a wound dressing over their coccyx with no observation of a date written on it. The dressing was saturated with stool and was no longer completely adhering to the skin but was still intact. The lift pad underneath the resident was observed to have a moderately large pink/red stain on it. When queried regarding the stain, LPN B indicated it was drainage from the coccyx wound. LPN B stated that she would leave the dressing as it was because the WCN (wound care nurse) was going to be doing wound rounds. LPN B did not give a time at which she expected the WCN to do wound rounds. R904 was then placed back in the same position as they had been observed in earlier, on their back with their face slightly turned toward their right shoulder. LPN B placed a pillow under R904's left arm, however, the resident was not turned/re-positioned, and pillows were not put into place for repositioning off the coccyx wound. A review of R904's care plan revealed the following: (R904) has actual impairment to skin integrity r/t (related to) pressure injuries to right and left heel .is at risk for impaired skin integrity/pressure injury r/t: DTI (deep tissue injury) (no location specified) .date initiated: 5/29/20, revision on 6/6/20 .Interventions: turn and reposition .follow facility policies/protocols for the prevention/treatment of [REDACTED].Turn/reposition resident every (left blank) hours and PRN (as needed) . A review of R904's Kardex (a brief overview of each patient and care needs) revealed: Bed Mobility: Resident required assistant of (left blank) to reposition and turn in bed .Brief Usage: Resident uses disposable briefs. Change ((freq)uently) and prn. Check q 2 hr (every 2 hours) and prn (as needed) for incontinence. Wash, rinse, and dry perineum .Turn and Reposition . A review of R904's progress notes revealed the following: -An admission progress note dated 5/28/20 that did not address skin. -A skin/wound progress note by the Wound Care Nurse (WCN) dated 5/29/20 that read, .Scar noted to midsternum, three scars on abdomen, scar on left thigh, three scars on left knee, long scar on left outer thigh. DTI (deep tissue injury- pressure related skin damage with intact skin) to right and left heel and right lateral ankle. Scab noted to right 2nd toe . -A nurse practitioner note on 6/2/20 that addressed wounds to heels and ankle. No mention of any additional skin issues. -A total body skin assessment dated [DATE] that read, Number of new skin conditions: 0. -A physician/provider note dated 6/8/20 that read, .Continue repositioning monitoring of patient's sacrococcygeal and buttock area which is reported to be excoriated . -A nurse practitioner note dated 6/9/20 that read, Resident was seen today as the wound care nurse reports worsening skin condition since admission to the facility .there are treatments orders in place for bilateral heels, now area to sacrococcyx region .continue with frequent repositioning, turning every 2 hours, offloading of pressure areas . -A physician/provider note dated 6/11/20 that read, sacrococcygeal area unstageable . -A total skin body assessment dated [DATE] that read, Number of new skin conditions: (left blank). -A skin/wound progress note by the WCN dated 6/18/20 that read, .Unstageable pressure injury to sacrococcyx/bilateral buttocks. Stage 3 pressure injury to scrotum. Pressure injuries noted to left posterior heel, left medial malleolus, right foot 4th tow, right foot 2nd toe, right medial foot, right lateral foot, right lateral malleolus (ankle), left medial heel, right lateral heel .is positioned with pillows to reduce pressure over boney prominences. -A note on 6/21/20 indicating the resident was transferred to an acute care hospital, and a nursing summary note dated 6/26/20 that read, Resident has a foley catheter with blood-tinged urine in tubing. Has several skin issues including a large open deep area on sacrum . -A physician/provider note dated 7/14/20 that read, .Wound care nurse is completing .treatment to sacral coccyx impaired skin to the bone, status [REDACTED].Continue to offer pressure offloading and frequent repositioning due to significant impaired skin . -A physician/provider note dated 7/30/20 that read, .Also collaborated with patient's wound care nurse. Left heel appears to be slightly improved and right heel is stable but the patient's coccyx wound is extremely deep . A review of R904's wound care institute documentation was reviewed and revealed: -Visit on 6/5/20: Assessments of Wound #1 Right lateral ankle DTI, Wound #2 Left Medial Heel DTI, Wound #3 Right Lateral Heel DTI, Wound #4 Right Second Toe with Eschar (dead tissue), and Wound #5 Right Lateral Foot DTI. No assessment of a sacral/coccyx wound was present. -Visit on 6/9/20: Assessment of wounds on bilateral feet and assessment of Wound #9 - Sacrococcyx/bilat buttock is a Stage 3 (full-thickness tissue loss extending to fatty layer below skin) Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 8.9 cm (centimeters) length x 8.8 cm width with an area of 78.32 sq (square) cm. There is a moderate amount of sero-sanguineous (thin, blood tinged) drainage noted. Wound bed has Necrotic Base [MEDICATION NAME] (new tissue growth). The periwound skin exhibited: [DIAGNOSES REDACTED] (red and swollen). General Notes: Discoloration noted, irregular edges fragile periwound. -Visit on 6/30/20: Wound #9 Sacrococcyx/bilat(eral) buttock is a Stage 4 (full-thickness tissue loss extending to muscle, tendon, or bone) Pressure Injury, Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 13 cm (centimeters) length x 8.5 cm width x 2.5 cm depth, with an area of 110.5 sq (square) cm .Bone is exposed. There is a large amount of sero-sanguineous (thin, blood tinged) drainage noted which has no odor. Wound bed has pale pink base [MEDICATION NAME]. The periwound skin does not exhibit signs or symptoms of infection. General Notes: 10% yellow Necrosis to midcore irregular edges. -Visit on 7/14/20: Wound #9 Sacrococcyx/bilat buttock is a Stage 4 (full-thickness tissue loss extending to muscle, tendon, or bone) Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 11.6 cm (centimeters) length x 10.1 cm width x 1 cm depth, with an area of 116.16 sq (square) cm .Bone is exposed. There is a large amount of sero-sanguineous (thin, blood tinged) drainage noted which has no odor. Wound bed has pale pink base [MEDICATION NAME]. The periwound skin does not exhibit signs or symptoms of infection. -Visit on 7/21/20: Wound #9 Sacrococcyx/bilat buttock is a Stage 4 (full-thickness tissue loss extending to muscle, tendon, or bone) Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 12.7 cm (centimeters) length x 14 cm width x 1 cm depth, with an area of 177.8 sq (square) cm .Bone is exposed. There is a large amount of sero-sanguineous (thin, blood tinged) drainage noted which has no odor. Wound bed has pale pink base [MEDICATION NAME]. The periwound skin does not exhibit signs or symptoms of infection. General Notes: Scattered necrosis irregular edges. -Visit on 7/28/20: Wound #9 Sacrococcyx/bilat buttock is a Stage 4 (full-thickness tissue loss extending to muscle, tendon, or bone) Pressure Injury, Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 11.2 cm (centimeters) length x 11 cm width x 1.2 cm depth, with an area of 123.2 sq (square) cm .Bone is exposed. There is a large amount of sero-sanguineous (thin, blood tinged) drainage noted which has no odor. Wound bed has pale pink base [MEDICATION NAME]. The periwound skin does not exhibit signs or symptoms of infection. General Notes: Scattered necrosis irregular edges. A review of R904's Treatment Administration Records (TARs) from admission on 5/28/20 to present revealed the following: Order: Cleanse sacrococcyx/bilateral buttocks with NS (normal saline), pat dry, apply hydrogel impregnated gauze and cover with bulky gauze, top with ABD and bordered gauze to secure qd (every day) and prn (as needed) soiled/wet every day shift for Pressure injury -Start Date- 07/02/2020 0700. No documentation (blank area on TAR) of completion of order was present on 7/3/20, 7/26/20, 8/2/20, or by survey exit on 8/4/20. A review of R904's medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted into the facility on [DATE] and most recently re-admitted on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was severely cognitively impaired, was always incontinent of bowel, and required extensive to total assistance from staff for bed mobility, transfers, dressing, eating, toileting, and hygiene. On 8/4/20 at 3:24 PM, the Director of Nursing (DON) was interviewed and queried regarding R904's sacrococcyx wound and if they had developed the wound at the facility. The DON looked in the medical record and indicated the resident was initially admitted into the facility on [DATE]. The DON acknowledged that the 6/5 wound care note and WCN admission note did not address the resident's coccyx, only the wounds on the feet, and stated that, Unfortunately, the 6/9 wound care note is the first documentation of a Stage 3 pressure ulcer on the coccyx. When queried if that information meant the resident developed the wound at the facility, the DON stated she would have to review further and would provide any further information she had regarding the wound. When queried regarding facility policy and procedure for prevention and management of pressure ulcers, the DON stated, Every two hours is the standard of care for turning and repositioning; Also what I expect for checking and changing (briefs). When queried regarding the statement made by Aide J regarding not changing the resident during their shift, and the observed incontinence care (including leaving the soiled wound dressing in place) with LPN B and Hospice Aide I, the DON stated, In general, that observed care is not what I expect. The DON stated, The standard expectation would be for the nurse to have changed the dressing as it was soiled and not have waited for wound rounds. On 8/4/20 at 4:12 PM, the DON was asked if she had any further information to provide regarding R904's sacrococcyx wound. The DON stated, There's nothing I can do, it was contracted here. I do not have anything further to provide for the wound. R903 A review of intake MI 674 revealed the following: Patient presents to (hospital) . As per nursing, patient has multiple possible sources of infection .has multiple ulcer wounds to back and legs bilaterally. As per nursing, patient is very frail, underweight with many pressure injuries, hygiene is very poor . A review of R903's medical record and MDS assessment dated [DATE] revealed the resident was admitted into the facility on [DATE] and discharged on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was severely cognitively impaired, was always incontinent of bowel, and required total assistance from staff for bed mobility, dressing, eating, toileting, and hygiene. The MDS section for skin noted one Stage 3 pressure ulcer present on admission, two Stage 4 pressure ulcers present on admission, and one DTI (deep tissue injury) present on admission. A review of R903's wound care institute notes revealed the following: -Visit on 7/7/20 indicated the resident had four wounds: Wound #1 Right Hip is a Stage 3 Pressure Injury .Initial wound encounter measurements are 3.3 cm length x 3.6 cm width, with an area of 11.88 sq cm . Wound #2 Sacrococcyx is a Stage 4 Pressure Injury .initial wound encounter measurements are- 4.7 cm length x 4.4 cm width x 1 cm depth, with an area of 20.68 sq cm . Wound #3 Left hip is a Stage 4 Pressure Injury .initial wound encounter measurements are 6.6 cm length x 7.6 cm width x 1.7 cm depth, with an area of 50.16 sq cm .Bone is exposed . Wound #4 Left Posterior Thorax is a Deep Tissue Injury (DTI) .initial wound encounter measurements are 5.5 cm length x 2.1 cm width, with an area of 11.55 sq cm. Wound bed has Dark Maroon Base [MEDICATION NAME] . -Visit on 7/14/20 wound care note assessed the same four wounds as mentioned on the 7/7/20 visit. -Visit on 7/21/20 wound care note assessed the same four wounds as mentioned on the 7/7/20 and 7/14/20 visit but included two new wound assessments: Wound #5 Right scapula is a DTI .measurements are 9 cm length x 3.9 cm width, with an area of 35.1 sq cm . Wound #6 Left Scapula/Shoulder is a DTI .measurements are 2.6 cm length x 10.4 cm width, with an area of 27.04 sq cm . A review of R903's July 2020 TAR revealed the following: -Cleanse left posterior thorax with NS, pat dry, apply Allevyn Life (protective foam dressing) q2d (every 2 days) and prn every evening shift every 2 day(s) for Pressure injury -Start Date- 07/08/2020 1500 -D/C Date- 07/22/2020 1100 - Not charted as completed on 7/10/20. -Cleanse left scapula with NS, pat dry, apply Allevyn Life q2d and prn every evening shift every 2 day(s) for Pressure injury -Start Date- 07/22/2020 1500 -D/C Date- 07/29/2020 1051 - Not charted as completed on 7/22, 7/24, 7/26, 7/28. -Cleanse right scapula with NS, pat dry, apply Allevyn Life q2d and prn every evening shift every 2 day(s) for Pressure injury -Start Date- 07/22/2020 1500 -D/C Date- 07/29/2020 1051 - Not charted as completed on 7/22, 7/24, 7/26, 7/28. -Moisturize left leg and foot with lotion, pad boney prominences with ABD pads and wrap in kerlix q2d and prn every evening shift every 2 day(s) for Heel protection -Start Date- 07/02/2020 1500 -D/C Date- 07/29/2020 1051 - Not charted as completed on 7/10, 7/22, 7/24, 7/26, 7/28. -Moisturize right leg and foot with lotion, pad boney prominences with ABD pads and wrap in kerlix q2d and prn every evening shift every 2 day(s) for Heel protection -Start Date- 07/02/2020 1500 -D/C Date- 07/29/2020 1051 - Not charted as completed on 7/10, 7/22, 7/24, 7/26, 7/28. -Santyl Ointment 250 UNIT/GM ([MEDICATION NAME]) Apply to Left hip topically every evening shift for Pressure injury Cleanse Left hip with NS, pat dry, apply Santyl to [MEDICATION NAME] and lay in wound, cover with dry dressing -Start Date- 07/02/2020 1500 -D/C Date- 07/29/2020 1051 - Not charted as completed on 7/10, 7/15, and 7/21 to 7/28. -Santyl Ointment 250 UNIT/GM ([MEDICATION NAME]) Apply to Left posterior thorax topically every evening shift for Pressure injury Cleanse left posterior thorax with NS, pat dry, apply Santyl and cover with padded protective dressing qd and prn soiled/wet -Start Date- 07/22/2020 1500 -D/C Date- 07/29/2020 1051 - Not charted as completed on 7/22 to 7/28. -Santyl Ointment 250 UNIT/GM ([MEDICATION NAME]) Apply to Right hip topically every evening shift for Pressure injury Cleanse right hip with NS, pat dry, apply Santyl to calcium alginate and lay directly on wound, cover with dry dressing qd and prn -Start Date- 07/08/2020 1500 -D/C Date- 07/29/2020 1051 -Not charted as completed on 7/10, 7/15, and 7/21 to 7/28. -Santyl Ointment 250 UNIT/GM ([MEDICATION NAME]) Apply to sacrococcyx topically every evening shift for Pressure injury Cleanse sacrococcyx with NS, pat dry, apply Santyl to [MEDICATION NAME] and lay in wound, cover with dry dressing -Start Date- 07/02/2020 1500 -D/C Date- 07/29/2020 1051 - Not charted as completed on 7/10, 7/15, 7/16, and 7/21 to 7/28. On 8/4/20 at 12:20 PM, the WCN was interviewed regarding R903's wounds and treatments at the facility. The WCN pulled up the resident's records when queried regarding their wounds on admission and stated, Wound on the right hip, left hip, and sacrococcyx. When queried regarding the right and left shoulder DTIs noted on the 7/21/20 wound care institute visit, the WCN stated, We had like six pillows positioning (R903). We pulled out all the stops. I don't remember when exactly the Allevyn orders were put in when we noticed the discoloration on the back. The WCN stated that the resident was very thin and had contractures. When queried regarding who is responsible for wound care treatments, the WCN stated that both she and the floor nurses were responsible for carrying them out, depending on the workload. The WCN stated, In July the wound caseload was very heavy in the building. I had to rely on the nurses to also do the treatments. When queried regarding the missing documentation for the wound treatment orders on the resident's TAR, the WCN stated, It's possible I did the dressings in the afternoons and forgot to chart. But it should all be documented as done.Yes, for all the gaps in the TAR. On 8/4/20 at 12:59 PM, the DON was queried regarding charting off carrying out orders on the TAR. The DON was asked if something is ordered, should it be signed off in the TAR as completed, to which she replied, Yes. When asked if there should be any blanks present on the TAR, the DON stated, No. A review of the facility's policy titled, Skin Management, revised 10/2019, revealed: Guests/residents with wounds and/or pressure injury and those as risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided .Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan. Guests/residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing, A physician's orders [REDACTED]. The licensed nurse will initiate documentation in the electronic health record .the licensed nurse will document preventative measures on the care plan/kardex. The licensed nurse will monitor, evaluate and document changes regarding skin condition .in the medical record .

Based on observation, interview and record review, the facility failed to prevent and identify a change in Range of Motion (ROM) timely for one resident (Resident #122) of six residents reviewed for position and mobility, resulting in a left knee contracture, decreased level of functioning and pain. On 8/26/19 at 10:27 AM, Resident #122 was observed lying in bed in a hospital gown. Resident #122 was alert and oriented and had clear speech. When queried as to how the Resident ended up at the facility, the Resident stated, I got an infection in my bone in my leg. It ate away at the bone. I was in a coma for 39 days. I am hoping to walk again so that I can go back home and work again. I am holding my apartment still. At that time Resident #122 removed the blanket from their left leg to reveal a halo device (an external device with pins that screw into the bone). The halo was on the lower left leg. The Resident's left knee was flexed, almost in a fetal position and the right leg was also flexed, but not in a fetal position. The Resident was asked if they could bend and straighten out their right knee/leg and said they could. When asked if they could bend/straighten out their left knee and leg, they stated, No, my knee is constricted, it wasn't like that when I got here. My surgeon is very upset because he needs to do more surgeries on me so I can walk again. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #122 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS revealed that the Resident needed extensive assist with activities of daily living and had an intact cognition. The MDS also revealed an impairment in ROM. A record review of the care plans revised 3/15/19 for Resident #122 revealed the following: Focus- .has ADL (activities of daily living) Self Care Performance Deficit and requires assistance with ADL's and mobility . Intervention-Bed Mobility: Resident requires maximal assistance to reposition and turn in bed. PT/OT (physical therapy/occupational therapy) evaluation and treatment as needed/as ordered. Initiated 2/17/19. There were no care plans demonstrating noncompliance by Resident #122. A record review of the Physical Therapy Evaluation revealed the following: 2/21/19- .LLE (left lower extremity) ROM=impaired L(left) ankle not tested secondary to pain. L knee PROM (passive range of motion) WNL (within normal limits) Hip FL (flexion) knee=WFL (within functional limits) L Lknee PROM WNL L ankle not tested secondary to pain Strength-Lower Extremity-LLE strength=1/5 tension is palpated in muscle or feeble contraction is felt but no visible motion occurs in joint. 8/13/19- L knee in contracted state (flexed to 120 degrees) L knee in flexed stated There was no therapy notes of the resident refusing therapy. On 8/27/19 at 2:39 PM, Resident #122 was observed lying in bed and stated, They did physical therapy, it was rough, they are trying to straighten out my leg. I did get a pain pill before therapy. On 8/28/19 at 9:42 AM, PT B was queried in regards to why Resident #122 was picked up for physical therapy again and stated, I am trying to do what we can for (Resident #122) because they are already contracted. (Resident #122) said it (the left knee) wasn't like that before, that is why I am looking at them now. On 8/28/19 at 9:45 AM, PT C was queried in regards to physical therapy upon admission to the facility for Resident #122. PT C explained that he was Resident #122's PT when they first were admitted to the facility. PT C was asked if Resident #122's left knee was contracted upon admission and stated, They weren't like that before, they were in a lot of pain before so we did PROM with them and referred them to restorative. On 8/28/19 at 10:53 AM, the Restorative Nurse was interviewed in regards to Resident #122's restorative therapy and stated, We tried three times, they just wouldn't do it. That was in April. The Restorative Nurse provided a document of the resident refusing therapy on 4/15/19, 4/18/19 and 4/22/19. There were no other documented attempts. A record review of the ortho consult dated 7/24/19 revealed that Resident #122 was to start weight bearing on both lower extremities and gait training (walking). On 8/28/19 at 12:41 PM, the Director of Rehab (ST A) was queried as to what prompted the initiation of therapy again for Resident #122 and stated, We discuss it in the morning meetings and review the 24 hour report. ST A was asked if Resident #122 had ever been screened after therapy was completed in (MONTH) and stated, We do quarterly screens. We did one on 5/21/19, and there was no change (in ROM to left knee). ST A also explained that physical therapy had initially ended on 4/1/19 and then had resumed on 8/13/19. On 8/28/19 at 12:56 PM, the Director of Nursing (DON) was queried in regards to Resident #122's facility acquired left knee contracture and stated, (Resident #122) came in with it slightly bent at the knee, we tried pillows, we can't put a brace on it because of the halo. There is normally a process (for monitoring ROM) but with that halo we really couldn't do a brace. Normally the aides do ROM with their everyday care. On 8/28/19 at 1:45 PM a policy on ROM was requested from the DON but not received by the end of the survey process. On 8/28/19 at 2:00 PM, Resident #122 was lying in bed eating lunch and stated, They haven't done therapy yet with me today. It hurts when they do but I need them to straighten it out. Physical therapy is working with me again because the surgeon wrote an order for [REDACTED]. Resident #122 was queried about refusing restorative and stated, I didn't refuse restorative, what happened was they came in when I was being changed and I didn't want to do it while being changed and I told them that. They came in two minutes later and said that I refused a couple of times so they couldn't work with me anymore. The truth is they don't have enough staff, restorative gets pulled to the floor so they don't have the staff to work with me. On 8/28/19 at 1:39 PM, the Administrator was queried on the process of residents who have had a decline in ROM and stated, Every QA (quality assurance meeting) we are able to pull reports to look if there is a decrease, if there was they are referred to therapy or restorative. (Resident #122) is a social worker and knows how the system works. We had a game plan for them to get up and when it was time they would not get up because of the cradle on their leg. A review of the facility policy titled, Restorative Nursing revised 12/2018 revealed the following: 5. If resident refuses to participate then care needs will be managed by nursing and other clinical staff as indicated. 7. Re-evaluate at minimum, quarterly to determine if resident would benefit from restorative .

This citation pertains to intake MI 848. Based on observation, interview, and record review, the facility failed to prevent 1 (# 3) of 1 sampled residents from falling out of the bed, resulting in fractured fingers and a laceration to the bridge of the nose. Findings include: On 9/25/18 at 3:00 PM, R3 was observed in their room. During interview R3 reported no concerns regarding care at the facility. When asked about the fall out of bed, R3 was unable to recall details of the incident. On 9/27/18 at 9:45 AM, R3 was observed sitting in a wheelchair in dining room. On 09/27/18 at 11:47 AM, a phone called was made to Licensed Practical Nurse (LPN B) to be interviewed regarding the incident, but was unavailable. On 9/27/18 at 3:30 PM, during a phone interview, Certified Nurse Assistant (CNA) A was asked to explain the incident that occurred with R3. CNA A stated, 10 or 15 minutes prior (R3) call light was on, I went in and (they) stated that (they) needed to be cleaned. I was helping another resident and told (them) that I would come back, but give me about 5 minutes. When I went back in I got my stuff together and woke up (R3). I had never had any problems with (R3) before, (R3) has always helped me with (their) care. As soon as I laid my hand on (R3), (they) rolled off the bed. I had never had that problem before. CNA A was asked if R3 was rolled towards her or away. CNA A stated, Away. (R3) was always able to help me with care. That is how we always did it. CNA A was asked if R3 was a two person or one person assist. CNA A stated, (R3) was a one person. I remember (R3) transferring being a two person. For personal care I never had anyone else to help me. CNA A was asked to explained what happened after R3 fell to the floor. CNA A stated, (R3) screamed/yelled. It happened so fast. I went and got help. The next day I was scheduled to work and I was told I did not follow protocol and that I could have killed (them) and was terminated. CNA A was asked what was the protocol that they did not follow. CNA A stated, I should have pulled (R3) towards me and not away. On 09/27/18 review of facility documents revealed: Incident and Accident Report: Date/Date of occurrence 7/22/18. Type of A/I: Fall. Injury Location: (Patient) Pt - Forehead, Bridge of the nose and right arm fingers. Describe the nature of the Accident/Incident and if injuries sustained, location of injuries: Per CNA report states patient rolled out of bed while giving care Writer observed resident laying on the floor facing down next to (their) bed. Pt. states I don't know what happened. Physician statement: Stat X-ray of the skull complete view, and right arm view. Interventions Implemented - Ensure resident is fully awake and aware before performing ADL's patient is 2 person assist at all times. To whom was it reported: LPN B who reported to DON, 7/22/18, 2:05 AM. Facility Investigation Summary: Date: 7/22/18. Allegation: Fall with Injury. Investigation: On 7/22/18 at about 2:00 am resident (name) rolled out of (their) bed which resulted in laceration to the bridge of (their) nose, facial bruising and fractures to the right hand . The X-ray technician arrived at the facility at 04:20 am with the facility notified of results at 07:12 am. The results are as follows: Unremarkable skull, fracture involving fourth base proximal and middle phalanges with no displacement. There is associated soft tissue swelling. A temporary splint to immobilize affected fingers was applied . Interviews were completed as part of the investigation and included an interview with (R3). (R3) was asked about the incident and if (they) could remember what happened to which (they) replied that (they) fell out of bed . Resident did not recall events that lead up to (them) rolling out of bed or activity prior to incident . Nurse (LPN B) was interviewed who stated that she was notified by CNA (A) that the resident had rolled out of bed while she was providing care. (LPN B) went on to state the (CNA A) was alone in room providing care at the time of the incident. (LPN B) also stated that (CNA A) stated, when asked, the position the resident was in prior to the fall, and (CNA A) replied that the resident was on her side facing away from her. Interview was completed with (CNA A) who stated that the resident was on (their) side facing away from her, (CNA A) had her on hand on the resident's hip and was starting to clean the resident's backside when the resident rolled out of bed. (CNA A) went on to state she immediately notified the Nurse . Physicians Progress Note: Date of service 7/23/2018. History: Patient is . being evaluated after significant injury to (their) right hand. Apparently patient had a fall while providing (Activities of Daily Living) ADL care and sustained fractures of the 2 fingers of the right hand . Pt observed to have swelling (and) discoloration on her forehead, open small cut on bridge of nose with mild bleeding, staff cleansed the area with (Normal Saline Triple Antibiotic Ointment) NS TAO applied, right arm fingers swelling with c/o pain (complaint of), ice pack applied as needed. patient was assisted back to bed . Labs/Radiology/Test: Labs: fracture involving fourth base and middle phalanges with no displacement, associated with soft tissue swelling per X-ray of the right hand. On 9/27/18 at 12:31 PM, during an interview, the Director of Nursing (DON) was asked if R3 was a one or two person assist with ADL care. The DON reviewed R3's care plan and stated, The care plan shows one person. The DON was asked if that was reflected on the Minimum Data Set (MDS) that was active at the time of the incident. The DON reviewed the MDS dated [DATE], which noted Bed mobility as a two person assist. The DON was asked if the care plan reflected the MDS assessment that she was a 2 person. The care plan history had her at a one person. We did a past non compliance to correct this incident. Continued review of R3's clinical record revealed R3 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessments dated 6/13/18 and 9/13/2018 documented R3 as cognitively impaired and required extensive assistance for bed mobility and transfers. Review of the facility's policy titled Fall Management dated 8/2016, Policy: The facility will identify hazards and resident risk factors and implement interventions to minimize falls . Practice Guidelines: 1. The licensed nurse will assess residents for fall risk upon admission, re-admission, quarterly, annually and with a significant change. 2. Residents identified at risk for falls will have a care plan developed and implement appropriate fall prevention interventions . The facility submitted a Plan of Correction: Licensed staff will follow policy and procedure related to incontinence care and bed mobility when care is provided by 1 staff member. In depth analysis how the deficiency occurred: CNA rolled the resident away from her causing the resident to toll out of bed onto the floor. How facility identified resident affected and residents having potential to be affected by the same deficient practice. CNA alerted nurse immediately that resident had fallen out of bed. Corrective action taken for resident affected - A head to toe was completed and the resident had facial bruising, a small cut to nasal bridge and c/p pain to right hand. Physician notified and new orders for xray of face and right hand, new order for Tylenol extra strength Q6 hours PRN pain. Xray results revealed: fracture involving fourth base proximal and middle phalanges with no displacement. Temporary splint applied per physician orders [REDACTED]. Resident was assessed by a physician on 07-23-2018. Resident has been and showed no signs or symptoms of mental anguish related to incident. Social Worker will continue to follow up with resident as needed. Hand splint was ordered by therapy and is currently in place on resident hand. Measures of systemic changes made to ensure that deficient practice will not occur and affect others. -Re-education was completed with the staff bed mobility of a resident while providing ADL care with an emphasis on direction to turn resident when there is only one licensed staff member providing the care. How facility monitors its corrective actions to ensure same deficient practice is corrected and will not recur. The DON/designee will conduct audits weekly x4 and monthly x3 to ensure groups of residents are supervised at all times. Results of the audits will be taken to the QA Committee for review and recommendation. Any areas of non-compliance will be addressed immediately. The Administrator will be responsible for attaining and sustaining compliance. Date of completion of Plan of Correction: 07/26/2018.

This citation have 2 Deficient Practice Statements ( DPS) DPS #1 This citation pertains to intake and Based on interview and record review, the facility failed to implement a comprehensive care plan to address potential problems and risks associated with admitting a resident with a known history of intravenous (IV) drug use, as well as developing a care plan that addressed resident's pain management, for one resident (R421) of one reviewed for hospitalization s resulting in, the hospitalization for a drug overdose. Findings include: On 9/26/18 at 3:52 PM, The Director of Nursing (DON) was interviewed regarding the drug overdose of R421. They stated that they received a call from the nursing staff stating that the resident was suspected of having an overdose. The DON instructed staff to contact 911 as they Don't keep [MEDICATION NAME] (a prescription medicine that blocks the effects of opioids and reverses an overdose), in the building. The DON stated that once Emergency Medical Services (EMS) arrived, they administered [MEDICATION NAME] to the resident and transported them to the hospital. When the DON was asked who gave the resident the suspected drugs, she stated, We don't know exactly who it was, but we believe it to be the resident's brother. When asked if the facility was aware of the resident's substance abuse history, they replied Yes. When asked if any assessments had been completed regarding the resident's substance abuse history, the DON stated, No, just the usual assessments. When the DON was asked if the resident's substance abuse history was care planned they stated, No, I don't see that there was a care plan related to that. On 9/27/18, a record review was conducted and revealed that R421 was admitted into the facility on [DATE] with a [DIAGNOSES REDACTED]. R421 was also admitted with a Peripherally Inserted Central Catheter (PICC line), which is used for long-term intravenous (IV) antibiotics, nutrition or medications, and for blood draws). The record also revealed that the resident had a history of [REDACTED]. On 9/27/18, a record review was conducted and revealed the following physician's note, History of Substance Abuse. Avoid narcotics and use them judiciously considering patient's history of substance abuse. On 9/27/18, a record review was conducted and revealed that on 9/8/18 a nurse's note, time stamped at 19:30 (7:30 PM) stated the following, Resident signed out at 6:22p to go get clothing from home. Resident is her own RP (responsible party). Resident informed that her IV/ABT (Intravenous Antibiotics) had to be infused and she stated, 'I'm coming right back! I want to get some clothes and go to the bank and get some money out for him' (referring to the gentleman that came to pick her up). At this current moment resident has not returned to the facility. R421 did return to the facility however, the date or time of their return was not documented in the record. On 9/27/18, a record review was conducted and revealed that R421's physician entered an order on 9/9/18 stating that the resident, (MONTH) not go on LOA (Leave of Absence). On 9/27/18, a record review was conducted and revealed that R421 was ordered, [MEDICATION NAME] 50 MCG (microgram)/HR Patch. Apply 1 [MEDICATION NAME] (a medicated adhesive patch that is placed on the skin to deliver a specific dose of medication through the skin and into the bloodstream), topically every 72 hours; Nortrptyline HCL Capsule 25 mg (milligram), give 1 capsule by mouth every 8 hours for pain. [MEDICATION NAME] HCL tablet 2 mg. Give 2 mg by mouth every 8 hours as needed for pain. The care plan was dated for 9/8/18, and does not address pain management. On 9/27/18 at 10:24 AM, The DON was further asked about the R421's admission into the facility. They reported that the resident transferred from another facility and while there, had no concerns, or was at risk for substance abuse. The DON was asked about the resident's order for no LOA (Leave of Absence), and they stated that the order was due to, the riskiness of R421's PICC line, and their history of drug abuse. When asked about the facility's process for admitting resident's with a substance abuse history, they stated, Every resident is different and it's based on the resident and their needs. On 9/27/18 at 11:06 AM, Certified Nursing Assistant (CNA) E was interviewed about the incident. They stated that they were picking up dinner trays when they went into the resident's room and observed the resident as shaky and described them as looking stuck. CNA E stated that they asked the resident if they were ok and whether or not they had [MEDICAL CONDITION] in which the resident stated, No. CNA E stated that R421 had a visitor prior to this incident, and that it was a Very, very short visit, and that they were in and out. When asked about the resident's behavior and demeanor prior to the visit, CNA E stated, Normal, They were able to hold a conversation and look directly at you. On 9/27/18 at 11:36 AM, Nurse D was asked about the incident with R421. They reported that after being called into the resident's room, they observed the resident sitting on the edge of their bed and appeared rigid. When R421 was questioned about what was going on, they didn't initially respond. When the resident was asked, Did your visitor give you something, R421 responded, Yes. Nurse D reports that R421 had a visitor prior to the incident that was there for 3-4 minutes and had also seen the visitor earlier that day. Nurse D stated that they did not see the resident get administered [MEDICATION NAME], but reports overhearing the police mentioning that it was given to the resident. Nurse D also reported that when resident's family member was called regarding the incident, they knew exactly who the visitor was and stated, He brought the resident something because he are a drug addict. On 9/27/18 at 2:11 PM, the Administrator was asked about the alleged overdose incident and stated that they were aware of the resident's substance abuse history but, It was not an issue at the other facility. On 9/27/18, a record review of the police report revealed that R421 was administered two doses of [MEDICATION NAME], with positive results after the second dose. The police officers reviewed the visitor sign-in, and there were no visitors listed for R421, and the cameras within the facility were not working. Review of the facility's Care Planning policy revised on 11/17 stated, Residents will be assessed as they are admitted and readmitted to the nursing facility to determine their physical, psychological, emotional, medical and psychosocial needs. The results of the interdisciplinary assessments will be used to develop, review, and revise the resident's comprehensive care plan. A Baseline Care Plan will be developed within 48 hours identifying immediate needs, initial goals and interventions needed to provide effective person-centered care. The care plan must be specific, resident centered, individualized and unique to each resident . DPS #2 Based on observation, interview, and record review, the facility failed to change a bandage per physician's orders [REDACTED].#85) of 1 sampled resident reviewed for skin conditions non pressure ulcer, resulting in bandage not being changed timely and the likelihood for infection. Findings include: On 9/25/18 at 3:32 PM, R85 was observed sitting in a wheelchair in bedroom. R85's right wrist and left arm was observed with a bandage date of 9/23. R85 was asked how often is the bandage changed and the resident stated, Everyday I think. R85 was asked the reason for the bandage and stated, For an infection. R85 was unsure of the type of infection. Review of a physician order, noted, Cleanse left/right wrists abrasion with Normal Saline (NS) apply allevyn (every) other day. Active. Dated: 7/21/18. On 9/27/18 at 10:26 AM, during an interview, Wound Nurse J was interviewed about the observation and was asked who is responsible for R85's treatment. Nurse J stated, I am not sure who put that on him. I was putting Allevyn on there but I don't think I maintained that. On 9/27/18 at 10:15 AM, R85 was observed in the front lobby. Hand bandage was observed to be dated 9/23/18. Record review of the (MONTH) (YEAR), Treatment Administration Record noted, Cleanse left/right wrists abrasion with Normal Saline (NS) apply allevyn (every) other day. (MONTH) 11, (YEAR) was blank and (MONTH) 25, (YEAR) was marked as completed. On 9/27/18 at 10:51 AM, during an interview, Unit Manager C was informed of the observation and was asked the reason for the date observed on R85's arm of 9/23. Nurse C stated, I will have to asked that Nurse and see what happened. On 9/27/18 at 3:05 PM, during an observation, the Director of Nursing verified that resident # 85's bandage was dated 9/23. The DON stated, I will look into this. No explanation offered by the end of this survey. Further review of 85's clinical record revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly minimum data set (MDS) assessment with an assessment reference dated 8/21/18 documented R85 had intact cognition, required limited assistance with Activities of Daily Living, and Skin Problems: Skin tear(s). A review of facility document, titled, Skin Management (Revised 8/16), revealed the following: Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed, and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes . Treatments of Skin Tears: . All skin tears will be assessed, documented and treated based on physician's orders [REDACTED].

This citation pertains to intake#: Based on observation, interview and record review, the facility failed to prevent physical and mental abuse from a staff member for 3 (#702, #703, and #704) of 4 residents reviewed for abuse, from a total sample of 6, resulting in physical and emotional abuse, mental anguish and the inability to obtain help or complete care. Findings include: Resident #702 On 4/26/18 at 11:00 AM, a record review of Resident #702's Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was admitted into the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #702 had a Brief Interview of Mental Status (BIMS) score of 15, indicating an intact cognition, and required extensive assist with activities of daily living (ADL). On 4/26/18 at 11:20 AM, Resident #702 was observed lying in bed awake and was queried about an incident involving a staff member on 4/1/18. Resident #702 stated, Oh, that happened so long ago, I don't remember. On 4/26/18 at 11:25 AM, an interview was completed with Resident #704, who was the room mate of Resident #702. Resident #704 stated, I heard the aide (Certified Nurse Assistant/CNA A) telling her (Resident #702) to quit pushing her call light and then I think she tapped her hand because I heard (Resident #702) telling her she was going to report her for hitting her. I could tell something was going on, I just couldn't see it because I had my curtain drawn. On 4/26/18 at 11:30 AM, a review of the Incident and Accident Report dated 4/3/18 revealed that Resident #702 had alleged that a CNA had smacked her hand and told her that she uses the call light too much and then took the call light away from her. Resident #703 On 4/25/18 at 11:00 AM, a review of the MDS dated [DATE] revealed that the resident was admitted into the facility on [DATE], and readmitted on [DATE]. Resident #703 had a BIMS of 07, indicating moderately impaired cognition and required extensive assist with ADL's. On 4/25/18 at 11:35 AM, Resident #702 was observed sitting up in a wheelchair and was queried regarding an incident that happened between he and CNA A on 4/1/18. Resident #703 stated, Yes, I remember what happened. I was in bed and needed to be changed. Well, we almost had a fight. She took off my pants and told me to turn towards the wall. I guess I wasn't fast enough for her and she just pushed me towards the wall and grabbed me by my chest. I told her I was going to knock the[***]out of her if she does that again. She told me she was going to call the cops on me if I did that. On 4/25/18 at 11:40 AM, a review of the Incident and Accident Report dated 4/3/18 stated that Resident #703 had alleged that CNA A was rough with him during care. The report also stated, She wanted me to roll over but didn't give me time and just pushed me over on my side. Resident #704 On 4/25/18 at 10:45 AM, a review of Resident #704's MDS dated [DATE] revealed that the resident was admitted into the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS also revealed that Resident #704 required extensive assist with ADL's and had a BIMS score of 15, indicating an intact cognition. On 4/15/18 at 11:25 AM, Resident #704 was observed in a wheelchair and was queried regarding the care CNA A had given to her on the night of 4/1/18. Resident #704 stated, She worked on midnight shifts, 11(PM) - 7(AM), sometimes she worked over on to days shift. She was very abrasive and rough. That particular night she would not give me a basin to wash myself up. She told me that they were too short and didn't have enough staff so no one was getting up or getting AM care. I reported her because I did not like how she treated (Resident #702). I had to use my call light for her (Resident #702) because she took hers away from her because she said she used the call light too much. The police came and spoke to us about it. On 4/25/18 at 12:00 PM, a review of the Incident and Accident Report dated 4/3/18 stated that Resident #704 refused to get her ADL supplies so she could perform independent AM care. On 4/25/18 at 12:05 PM, a review of the nurses schedule revealed that CNA A had worked on the night of 3/31/18 through the morning of 4/1/18. On 4/25/18 at 1:00 PM, a review of the facility Incident and Accident Investigation Form revealed the following: 4/1/18-(Resident #702) alleges that a CNA (CNA A) slapped her hand telling her 'you are on your call light too much' and took my (Resident #702) call light from me. Registered Nurse (RNB) stated she asked a different CNA to change (Resident #703) because he did not want CNA A providing care for him. RN B also stated she answered Resident #704's call light and when she entered the room, Resident #702's call light was located under her pillow and out of her reach. (Resident #704) stated that when she asked CNA A to get her a basin, CNA A stated, We are not doing that today. Resident #704 also stated she heard CNA A tell Resident #702 You are on your call light too much. Resident #704 also reported that Resident #702 had reported that CNA A slapped her hand. On 4/25/18 at 2:25 PM, the Director of Nursing (DON) was queried about the incidents that happened between CNA A and Residents #702, #703 and #704 that occurred on 4/1/18. The DON stated, (Administrator) got a call and then I was notified that day. We suspended the CNA (CNAA) immediately. I called her at home and told her she was suspended, she didn't say much. I then talked to the residents and we called the police. The police came in and talked to the residents. The CNA (CNA A) was subsequently termed (terminated from employment). She was termed on 4/3/18 and I reported her (CNA certification) to the state. On 4/25/18 at 2:45 PM, a review of the employee disciplines for CNA A revealed a discipline in her file on 3/21/18. The discipline revealed the following: Attitude, disrespectful Several residents had complaints re:CNA (CNA A) for her attitude and disrespectful way she spoke to them. Several residents requesting CNA does not continue to care for them . On 4/25/18 at 2:50 PM, a record review revealed that CNA A had refused to sign her termination form but was terminated from employment on 4/3/18. On 4/26/18 at 3:55 PM a record review of the facility policy titled, Abuse Prohibition Policy revised 11/2017 revealed the following: Policy-Each resident shall be free from abuse, neglect, mistreatment .Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or convenience that are not required to treat the resident's medical symptoms. To assure residents are free from abuse, neglect .or mistreatment, the facility shall monitor resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the residents. On 4/25/18 at 4:30 PM, an interview was attempted via phone to CNA A, however there was no answer and no ability to leave a voicemail message.

Based on interview and record review the facility failed to consistently administer [MEDICATION NAME], effecting one Resident (#404) of two residents sampled during an abbreviated survey, resulting in Resident #404 being hospitalized for [REDACTED]. Findings include: On 10/17/17, record review of Resident #404's (R#404) medical records revealed admission to the facility on [DATE] and readmission on 6/17/17 with [DIAGNOSES REDACTED]. According to Quarterly MDS dated [DATE] R#404 had Dementia and was extensive assist with all Activities of Daily Living (ADLs) and transfers. On 10/17/17 at 8:30 a.m., phone interview with adult child G of R#404, when asked about concern with R#404, Child G replied, R#404 had been on [MEDICATION NAME] (Treats and prevents blood clots) for a while and when R#404 was sent to hospital for a stroke, We (family) found out when the hospital called the nursing home R#404 had been taken off the medication. The hospital called because the wanted to give her TPA (medication used to break up blood clots). On 10/17/17, review of physician's orders [REDACTED]. Physician order [REDACTED]. Order was created by Nurse (D) and authorized by Physician (B). Progress Note of R#404 revealed a late entry on 7/25/17, Late entry-INR on 7/24/17 was 2.3. Physician was notified. No new orders were given and was documented by Nurse (E). MAR (Medical Administration Record) documents that PT/INR monitoring levels were continued after 7/22/17 with the following results: 7/24/17- 2.3, 7/27/17-2.1,7/31/17- 1.6. On 10/18/17 at 9:00 a.m., phone conversation with Nurse Practioner C, when asked if she was aware of the discontinuing of R#404's [MEDICATION NAME] therapy on 7/22/17, Nurse Practioner C stated, I would have to review the medical records. When asked if [MEDICATION NAME] therapy should be discontinued abruptly, Nurse Practioner C stated. I would not stop [MEDICATION NAME] ([MEDICATION NAME]) therapy abruptly. When asked if she was ever called regarding patients, Nurse Practioner C stated, No they would call the physicians. On 10/18/17, record review of Nurse Practioner notes revealed visit on 7/26/17 no mention of [MEDICATION NAME] therapy mentioned, 8/2/2017, Not in room will see next visit. No mention of [MEDICATION NAME] therapy, 8/6/17 19:06 (7p.m.) per phone conversation was informed by nurse that patient has recently worsened. Change of mental status. Patient is not alert to self and is not responding to questions. Patient has decreased movement on left side. Vital signs are noted as WNL (within in normal limits) Ok to transfer to hospital for further evaluation. On 10/18/17 at 9:30 a.m., phone conversation with Physician B. When asked how [MEDICATION NAME] therapy is monitored, Physician B stated, A PT/ INR (test) is done to see if there is a therapeutic level as ordered. When asked the normal values for a therapeutic level he states, Between 2 and 3. When asked awareness of R#404's [MEDICATION NAME] order being discontinued on 7/22/17 he stated, It should have not been discontinued it should have been rechecked in a couple of days and restarted. When asked why the medication would be held Physician B stated. When the level is high it is held so blood will not get to thin. When asked if the physician who authorized the order should be called to confirm reasoning of discontinuation of order he stated, No, he is positive the order should have been held not discontinued. On 10/18/17 at 10:30 a.m., phone conversation with Physician A, when asked why R#404 was started on [MEDICATION NAME] therapy Physician A stated, R#404 had a [MEDICAL CONDITION] in her right leg. When asked about [MEDICATION NAME] order that was discontinued on 7/22/17, Physician A stated, I was out of the country. I did not authorize the order it must have been Physician B. When asked if medication should have been discontinued Physician A stated, R#404 level was at 4.1 and should have been held then rechecked, when it was at 2.3 the medication should have restarted. On 10//18/17 at 11:15 a.m., phone conversation with Nurse D when asked if order for [MEDICATION NAME] was discontinued by Physician A, Nurse D states. Yes. When asked if she was positive that it was Physician A, Nurse D stated, I know Physician A comes in there (facility) all the time. On 10/18/17 at 11:30 a.m., interview with ADON F (Assistant Director of Nursing) when asked the procedure for monitoring [MEDICATION NAME] therapy, ADON F stated. Once we receive and order for [MEDICATION NAME] therapy the staff will give the medication as ordered and perform PT/INR as ordered by physician. When asked when the nursing staff would call physician regarding results, ADON F stated, When nursing performs the test and it is not in therapeutic level. At that time they will call to get an order to hold or change medication. When asked if R#404's [MEDICATION NAME] therapy was discontinued on 7/22/17 and was the medication ever restarted, ADON F stated, Yes it was discontinued on 7/22/17 and it was not restarted. When asked how this is monitored by the nursing administration, ADON F stated, There is a 24 hour report we look at every day and we also look at any orders that would be done the day before. On 10/18/17, record review of admitting hospital records reveal R#404 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Lab Results - INR level 1.3. Review of Assessment- [AGE] year old patient with cebrovascular accident . Patient has multiple comorbidities as listed in HPI (medical record) including [MEDICAL CONDITION] (abnormal rhythm of heart), and history of [MEDICAL CONDITION] but was taken off [MEDICATION NAME] therapy on 7/22/17.

Based on observation, interview, and record review, the facility failed to consistently implement interventions for one (#501) of six sampled residents reviewed for skin integrity from a total of 21, resulting in the development and worsening of a facility acquired pressure sore. Findings include: On 7/18/17, record review revealed that Resident #501 (R#501) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #501's Admission Minimum Data Set, R#501 has intact cognition and required extensive assistance with all Activities of Daily Living (ADL's). On 7/18/17 at 9:30 a.m., when asked about the pressure ulcer acquired at the facility, R#501 stated, The Physical Therapist put this device between my thighs to keep them separated. When asked how long this device was put in place, R#501 stated, It was put there two days in a row. When asked if there was any pain when the device was in between his thighs, R#501 stated, I don't have good feelings in my legs anymore. On 7/19/17 at 9:15a.m., observation of wound care done by floor nurse, reveals a stage III (full thickness skin loss) pressure ulcer on R #501's right inner thigh. It measured 0.8 cm in length by 6.6 cm in width by 0.01 cm in depth. Wound bed had yellow, necrotic (dead) tissue with intact perimeter and moderate serosanguinous (blood/body fluid mixed) drainage. On 7/19/17 at 9:45 a.m., when asked why therapy staff was using this device, the Therapy Director replied, It was used to separate the patient's thighs. When asked why the device would cause a pressure ulcer, the Therapy Director replied, The therapist was trialing it and it (the device) was not in good condition. When asked to clarify what was meant by trialing it, the Therapy Director replied, Trying to see if it worked, but it was not care planned. When asked to see the device, the Therapy Director stated, It was thrown out. It was not in good condition (faulty). On 7/20/17 at 3 p.m., after reviewing an Incident and Accident Investigation Form for R#501 under section Conclusions- give a brief description of conclusion, it was documented: Resident acquired a Stage III pressure injury to right medial (inside) thigh. Secondary to abductor placed on by Therapy Department. The Form was dated 7/18/17 and was signed and completed by the Director of Nursing. Attached to the Investigation and Accident Investigation Form was a Clinical Review of Incident involving R#501, completed on 7/18/17 by the Regional Manager for the Physical Therapy Department. It documented the following: Chart was thoroughly reviewed and upon review, findings were that (Physical Therapist S) applied the abductor leg brace to patient without proper documentation, therapy notes or communication to nursing. On 7/20/17 at 3:30 p.m., per review of the facility's Brace and Splint Program policy dated 1/2012, under section Procedures. #5. A care plan will be developed that has measurable objectives and interventions that include: B. Staff has a scheduled program of applying and removing the appliance that includes: Scheduled hours to be worn and when skin will be inspected for signs and symptoms of pressure areas, irritations, rashes, etc. and will be reported to charge nurse and attending physicians. C. Communicate individualized interventions to the direct care providers. Provide specific directions and training as needed (e.g., correct splint application, range of motion tech, skin integrity). Update Care plan and Resident Care Guide. #6. Document resident daily participation, including actual number of minutes participating on the Restorative Delivery Record.

This citation pertains to intake # MI 682. Based on observation, interview, and record review, the facility failed to ensure one (#701) of four sampled Residents reviewed for abuse/neglect in a total sample of four, was free from verbal abuse and rough treatment from staff, resulting in the potential for injury of a physically compromised Resident, feelings of fear or humiliation and increased anxiety and depression. Findings include: On 12/7/16 at 10:05 a.m., an interview was conducted with the complainant who reported concern that Resident #701 had been abused by a CNA (certified nursing assistant), and the abuse consisted of Slapping, yelling, slamming the resident in the bed, and kicking. Additionally, it was reported these abusive situations were witnessed and that there was actual video showing the abuse had occurred. On 12/7/16 at 8:40 a.m., an interview was completed with the Administrator and the Director of Nursing (DON). At that time, the Administrator was asked about the abuse allegation for Resident #701 and reported that although the investigation had initially been unsubstantiated during a facility and investigation by the State Agency on 12/29/15, the facility had received video evidence in May 2016 that confirmed the verbal abuse and rough treatment from staff during Resident #701's care. At that time, the Administrator was asked to provide all documentation of the facility's investigation since the submission of the video, as well as request to view the video. Review of the clinical record revealed Resident #701 was admitted into the facility on [DATE] and discharged on [DATE] per family request to the hospital. According to the face sheet, [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessments included: Quarterly MDS dated [DATE] documented the Resident had unclear speech, was sometimes understood, had impaired long and short term memory with moderately impaired decision making skills, had no mood or behavior concerns, required extensive assistance of two people for bed mobility, total assistance of two people for transfers, and was incontinent of bowel and bladder. Quarterly MDS dated [DATE] documented the Resident had unclear speech, was sometimes understood, had impaired long and short term memory with moderately impaired decision making skills, had physical behavioral symptoms directed towards others for 1-3 days, had verbal behavioral symptoms directed towards others for 4-6 days during this assessment period of seven days, required extensive assistance of two people for bed mobility, total assistance of two people for transfers, and was incontinent of bowel and bladder. Discharge MDS dated [DATE] documented the Resident had impaired short term memory with moderately impaired decision making skills, had physical behavioral symptoms directed towards others for 1-3 days, had verbal behavioral symptoms directed towards others for 4-6 days during this assessment period of seven days, required extensive assistance with bed mobility, transfers, and was incontinent of bowel and bladder, and received antianxiety medication for 7 of 7 days during this assessment period. On 12/7/16 at 10:45 a.m., the Administrator and DON provided the requested documentation of the facility's investigation since the submission of the video. At that time, upon review of the documentation the Administrator also reported that upon receipt of and viewing of the first video on 5/27/16, the employees involved were immediately suspended on 5/27/16 pending the investigation and terminated on 6/1/16 for witnessed abuse and unreported witness of abuse to a Resident. The employees involved included Licensed Practical Nurse (LPN E); and CNA (C and D). The Administrator reported there was a second video clip provided by the Resident's family at a later date (10/7/16) which identified Housekeeper F was present during Resident #701's incontinence care and abuse incident with CNA C and was suspended on 10/7/16 and terminated on 10/11/16 for not reporting witnessed abuse. The Administrator reported that CNA C was the staff who was witnessed abusing Resident #701 and the other three staff (D, E, and F) were witnesses that had not reported the abuse. On 12/7/16 at 12:30 p.m., review of the actual video camera footage submitted by Resident #701's family was conducted in the Administrator's office in the presence of the Administrator and DON. At that time, the Administrator reported, The information on the videos as far as dates are not accurate so can't tell when it occurred, but that it did. The Administrator was asked to identify the staff as the videos clips were played. The DON reported that LPN E, CNA C, CNA D, and Housekeeper F all worked the day shift. Review of the video clips revealed the following events (the dates and times are not necessarily accurate and unable to verify actual dates/times): On 4/20/2045 at 05:24:10, Resident #701 was observed seated in a wheelchair facing the right side of the bed, with a lap buddy (cushion that fits into the wheelchair frame) secured across the lap area. The Resident was very restless, with non-sensical speech and after a couple of attempts, removed the lap buddy. Once the Resident removed the lap buddy, CNA C (who was already in the room at the foot of the bed and did not respond initially to the Resident's attempts to remove the lap buddy and slide down in the wheelchair) was observed to walk towards the Resident, grabbed the Resident's left arm and abruptly began walking towards the bed while pushing and lifting the Residents knee to walk and kicking behind the knee area to propel the leg forward. Once they reach the bed, CNA C was observed abruptly dropping the Resident onto the bed and then covered with a blanket. On 4/20/2045 at 07:26:12, Housekeeper F was observed standing facing the Resident's bed, while CNA C stood next to the right side of the bed, the Resident was lying down in the bed. At that time, CNA C roughly removed the Resident's pants and roughly turned the Resident onto the side (facing towards the door), removed the brief and without cleaning, put another brief on the Resident. (During this time, Housekeeper F proceeded to remain at the end of the bed and conversed with CNA C while the Resident's peri area was exposed.) CNA C then proceeded to abruptly grab the Resident's back of the head and pull the Resident up from the bed. CNA C then abruptly turned the Resident and roughly (slammed) the Resident into the wheelchair and placed the lap buddy in place. On 4/20/2045 at 07:59:16, CNA C was observed pulling the Resident from the wheelchair next to the right side of the bed, while holding the Resident under the arms and stated, Walk, Walk over there. At that time, once they reached the bed, CNA C roughly pushed the Resident onto the bed and repositioning the Resident in the bed while roughly pulling on the right shoulder. Resident #701 was observed during this time to be making non-sensical sounds repeatedly, Ah, Ah, Ah. On 4/22/2045 at 03:38:13, CNA C and CNA D were observed in the Resident's room. CNA C was observed putting on gloves, removed the blanket from the Resident, and proceeded to grab the Resident roughly and abruptly transferred from the bed to the wheelchair while holding the Resident at the armpits. At this time, LPN E was observed behind the Resident holding the wheelchair while conversing with CNA C who stated, Every mother f*****. CNA C proceeded to roughly and abruptly transfer the Resident from the wheelchair into the bed. At this time, the Resident was observed to be making non-sensical sounds repeatedly, Ah, Ah, Ah. CNA C was observed stating to the Resident, Shut up! Shut up! Don't make no noise! At that time, LPN E told the Resident, Lay down, lay down. At no time, did CNA D or LPN E intervene or acknowledge the rough handling during care or the use of profanity and verbal abuse. On 12/19/16 at 10:00 a.m., a phone interview was conducted with Resident #701's son who was identified by the facility's face sheet as the primary responsible party. The following questions and responses included: -Who had placed the camera in the Resident's room and when? It was placed about three to four days prior to taking my father out (transferred to hospital on [DATE]). -What prompted the family to place a video camera? He (Resident #701) was always complaining and we thought he didn't want to be there. When he said he was thrown in the bed and shoved, I wanted to find out what went on, so the video was placed. The son was unable to recall specific time/date of when the Resident reported this to him. -What was done with the video after you saw what was on it? We contacted the attorney and gave the camera over. From there the attorneys took over. We also filed a police report with the Livonia Police Department after he was gone from the facility. -Did any family member voice a complaint to the facility of Resident abuse? We made the facility call an ambulance and once (Resident was) there (at hospital) I explained to them (facility staff) what happened when they called to find out about returning. -How did the facility get a copy of the video? Where was it sent and by who? I'm not sure, probably the attorney they handled it after we contacted them. I'm not sure of the details. -Why were the dates wrong on the video? Was the tape altered or adjusted at all? When I got the camera from the manufacturer I didn't know dates were set and were not changed. After seeing this on video I wanted to get him out. -How was the Resident able to communicate with you and you to him? When we got there that night (12/18/15), he complained of not feeling well. My siblings and my brother insisted on sending him to the hospital. -How did the facility communicate with the Resident? Was he able to speak English? He would look to follow. He didn't speak English. We told them they could call us and also brought in picture boards and wrote out the English/Arabic words. -Did you notice any mood or behavior changes in the Resident prior to his transfer to the hospital? He kept telling us he didn't want to be there. There was increased anxiety and restlessness and started on new medications. On 12/19/16 at 2:00 p.m., an interview was conducted with the Administrator. The following questions and responses included: -How did you get the videos and what were you told by whomever gave them to you? They were submitted to corporate office when the first video came in May. I went to Corporate and picked up the flash drive. Asked me to review to identify the employees. Came back and watched the video and identified the employees and suspended that same day. -What Corporate directions did you get? They wanted me to investigate as abuse and followed our policy to remove the employees while the investigation was being conducted. -Was the video altered, edited or changed in any way? It (video camera footage) came to Corporate on a flash drive and Corporate encrypted the video onto another flash drive to protect the nature of the video. The second video was submitted as well to Corporate in October and upon viewing the second video it was identified that a Housekeeper was also a witness, but there were no further abuse incidents. That Housekeeper was immediately suspended and terminated due to lack of reporting witnessed abuse. -What specific evidence was there of abuse reporting to the police? The Livonia police was contacted by the Director of Nursing in regard to the allegation of abuse as reported from the family in December 2015. Review of the facility's documentation identified an Officer had arrived at the facility on 12/23/15. According to the Administrator, The Police Department reported they would not be filing a report because the Resident was no longer in the facility and that the family had not made a complaint. Additionally the facility reported the allegation to the State Agency (which the investigation had been completed on 12/29/15 with unsubstantiated findings). In May once videos were provided I called and talked to (State Agency) as well as the Livonia Police Department and when I went down to the PD, I was told the complaint filed in December was closed and unless the family pushed further the case would remain closed. I was told by (State Agency) that we had 'Done our due diligence'. -What staff were targeted for abuse prevention in servicing? All staff were included. -How were Residents assessed of evaluated for abuse concerns/possibilities? The Residents that were alert were interviewed by Social Work about whether they had any concerns of verbal or physical abuse. The Residents that were not able to, the family was contacted and interviewed about the same concerns. There were no concerns expressed by any Residents or Families. Also, Nursing completed head to toe skin audits to determine if there were any injuries of unknown origin and there were no concerns. -What evidence is available regarding reporting of the staff involved? I gave you the paperwork that was submitted to the State Agency which was submitted by the Director of Nursing on 6/2/16. -What system is in place to ensure there have been no other perceptions of, or allegations of abuse? We do 'Quality Rounds' which is done by management staff five times a week. They have assigned rooms. We also do 'Abacus' monthly which is a random audit of 15 Residents in which the Residents and families are interviewed and are asked about things such as dignity, and abuse. There have been no abuse concerns reported. Both of these programs are run through our QA (Quality Assurance) program. On 12/19/16 at 11:12 a.m., CNA D was contacted via telephone and a message was left to return the call. There was no return call by the end of the survey. On 12/19/16 at 11:13 a.m., Housekeeper F was unsuccessfully contacted via telephone, the available phone number was no longer in service. On 12/19/16 at 11:14 a.m., LPN E was interviewed by telephone. At that time, LPN E confirmed she had been suspended and subsequently terminated for lack of reporting witnessed abuse. When asked about the observation of the video and lack of intervention or reporting of the physical and verbal actions from CNA C, LPN E stated, They showed me briefly (video footage). I didn't hear her (CNA C) say what she said cause I don't remember her saying it at all. When asked about whether she felt the actions from CNA C were rough during the transfer, LPN E offered no further explanation. On 12/19/16 at 4:25 p.m., CNA C was interviewed by telephone. At that time, CNA C confirmed she had been suspended and subsequently terminated in June. When asked about the allegations of abuse and review of video camera footage, CNA C stated, I reviewed some of it. When asked about the observations during review of the video that showed CNA C pulling, tossing, and kicking the Resident's legs, CNA C denied and stated, I was moving his feet. When asked if she could recall saying Shut up to the Resident, CNA C stated, I don't recall saying that. When asked if she could recall the housekeeper in the room and whether that was normal procedure, CNA C stated, I don't recall a housekeeper in the room during care. But yeah they do. When asked if that had occurred would non direct care staff be redirected out of the room to ensure the Resident' s privacy, CNA C offered no response. CNA C was asked if the facility had provided any abuse prevention education and reported, Yes. I never signed a waiver to be videotaped. I don't feel any type of abuse occurred. On 12/20/16 at 10:00 a.m., review of the timeclock details for CNA C for the week of 12/10 -12/18/15 was reviewed and documented that CNA C had worked on 12/10/15 - day shift 8 hrs; 12/12/15 - day shift 8 hrs; 12/13/15 - day shift 8 hrs; 12/14/15 - day shift 8.25 hrs; 12/15/15 - day shift 8.5 hrs; 12/17/15 - day shift 8 hrs; and 12/18/15 - day shift 8 hrs. Additionally, review of the daily staff assignments during the week of 12/10 - 12/18/15 revealed: On 12/15/15 during the day shift, CNA C and Housekeeper F both worked. This is that same staff observed in the aforementioned video camera footage from 4/20/2045 at 07:26:12. According to CNA Cs room assignments on 12/15/15, Resident #701's room was assigned to CNA C. On 12/17/15 during the day shift, CNA C, CNA D, and LPN F were working. This is that same staff observed in the aforementioned video camera footage from 4/22/2045 at 03:38:13. (Housekeeper F did not work on 12/17/15.) According to CNA Cs room assignments on 12/17/15, Resident #701's room was assigned to CNA C. (Despite the discrepancy in the accuracy of the date/times on the video camera, there were two different dates which corresponded to the two different dates the employees actually worked on 12/15/15 and 12/17/15.) On 12/20/16 at 10:00 a.m., Social Worker (SW H) was interviewed about Resident #701's behaviors and overall well-being. At that time, when asked about the increase in behaviors noted throughout the interdisciplinary progress notes, SW H was unable to recall any specific details and deferred to the documented psychiatric evaluations. SW H reported, He could understand English. I'm aware of family being present majority of the days. Family assisted with translation. I'm not aware of any complaints of mistreatment while at facility. The son attended care conferences and the care plan was based on family input. According to the facility's Abuse Prohibition Policy dated 11/2016 documented: .Each resident shall be free from abuse, neglect, mistreatment .Substantiated complaints against nurse aides for acts of resident abuse .shall be reported to the state Nurse Aide Registry when the facility has knowledge . The facility was determined to be noncompliant with regulatory requirement F223 as a result of CNA Cs verbal abuse and rough treatment of [REDACTED]. However, the facility identified a past noncompliance in regard to the abuse incident with documentation, and a plan of correction date of 10/11/16. Therefore, although cited, no further action is necessary. On 12/7/16 - 12/20/16, during the unannounced onsite abbreviated survey, the Surveyor verified that the following plan of correction had been implemented. On 12/18/15 at 10:00 p.m., the son and daughter came to the facility and stated that they wanted him sent to the hospital because their family doctor wanted to see him to make sure he was ok to got to his sister's funeral on Saturday. They also said that the doctor wanted to see him because of the multiple falls he has had while in the facility. He was sent out per family request. On 12/21/15 the Admission Director called the son and asked if Resident #701 would be returning to the facility. Although he was the primary contact, he stated that we could not contact him anymore. He gave a name and number and instructed her to use that for any further information. The Admission Director left a message at the given number. On 12/22/15 the call was returned. She (Admissions Director) was on speaker phone with two men that said their names were ***** and *******. ***** said that Resident #701 would not be returning and claimed it was related to lack of care and abuse. On 12/23/15 the Director of Nursing reported it to the Livonia PD. Officer M arrived at the facility and said that he would not be filing a report because the resident was no longer in the facility and the family had not made a complaint. On 12/23/15 Director of Nursing reported to the state via 24 hour report. MI ACTS 7052. On 12/23/15 Director of Nursing submitted 5 day - unable to substantiate abuse. MI ACTS 7052. On 12/29/15 State complaint visit regarding Resident #701 with six allegations: Quality of care, resident abuse, resident safety, no water give, falls, call light not accessible. Unsubstantiated. Complaint # MI 839. On 5/26/16 Receipt of settlement summary and 11 video clips from the (name of attorney firm) on a flash drive arrives at (Company name). On 5/27/16 Facility is made aware of incident(s) to investigate three (3) employees. CNA C, CNA D, and LPN E were suspended pending investigation. On 5/27/16 Administrator contacts local police department, told would have to come down. Went down and was told there would be no report filed as the Resident remained out of the facility and no report from the family. On 5/27/16 Administrator notified the State Agency of new evidence of abuse via video clips. From 5/27/16 - 6/18/16 Abuse prevention and reporting in-services were completed with all staff. From 5/28/16 - 5/31/16 Interviews were conducted with Residents and families by Social Worker H which identified Have you ever been physically abused here at (name of facility)?; Have you ever been verbally abused here at (name of facility)?; Do you feel safe here at (name of facility)?. There were no reported concerns regarding physical or verbal abuse at that time, or since then. On 5/28/16 head to toe body audits were completed by Nursing staff with no identified concerns of any injuries of unknown origin. On 6/1/16 Facility meets with each employee to conclude investigation; each employee is fired. On 6/2/16 Director of Nursing submitted notification via fax to the State professional licensing agency for Report of Change in Staff Privileges for LPN E (not reporting witnessed abuse), CNA C (witnessed abuse of a resident) and CNA D (not reporting witnessed abuse). On 10/7/16 at the request of (Corporate name), additional video clips were provided which revealed Housekeeper F was present during one of the abuse incidents with CNA C and had not reported the incident to the Administrator or Director of Nursing. Housekeeper F was suspended pending investigation. On 10/11/16 Facility meets with Housekeeper F to conclude investigation; employee is fired. Additionally, during the onsite survey, review of the personnel records for LPN E, CNA C, CNA D and Housekeeper F confirmed Workforce Background Checks had been conducted upon hire with no concerns for employment within the facility. Interviews conducted with various Residents, families and Staff revealed no reported concerns with allegations of abuse or mistreatment during care. Staff were able to identify abuse, who to report to, and what would happen if allegation occurred. ( )

This citation pertains to intake # MI 682. Based on observation, interview, and record review, the facility failed to ensure three employees (D, E, and F) reported witnessed abuse to the Administrator or Director of Nursing (DON) for one (#701) of four sampled Residents reviewed for abuse/neglect in a total sample of four, resulting in the potential for ongoing, undetected physical and verbal abuse to vulnerable Residents within the facility. Findings include: On 12/7/16 at 10:05 a.m., an interview was conducted with the complainant who reported concern that Resident #701 was being abused by a CNA (certified nursing assistant), and the abuse consisted of Slapping, yelling, slamming the resident in the bed, and kicking. Additionally, it was reported these abusive situations were witnessed and that there was actual video showing the abuse had occurred. On 12/7/16 at 8:40 a.m., an interview was completed with the Administrator and the Director of Nursing (DON). At that time, the Administrator was asked about the abuse allegation for Resident #701 and reported that although the investigation had initially been unsubstantiated during an investigation on 12/29/15, the facility had received video evidence in May 2016 that confirmed the verbal abuse and rough treatment from staff during Resident #701's care. At that time, the Administrator was asked to provide all documentation of the facility's investigation since the submission of the video, as well as request to view the video. Review of the clinical record revealed Resident #701 was admitted into the facility on [DATE] and discharged on [DATE] per family request to the hospital. According to the face sheet, [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #701 had unclear speech, was sometimes understood, had impaired cognition, required extensive assistance of two people for bed mobility, total assistance of two people for transfers, and was incontinent of bowel and bladder. On 12/7/16 at 10:45 a.m, the Administrator and DON provided the requested documentation. At that time, upon review of the documentation the Administrator also reported that upon receipt of and viewing of the first video on 5/27/16, the employees involved were immediately suspended on 5/27/16 pending the investigation and terminated on 6/1/16 for witnessed abuse and unreported witness of abuse to a Resident. The employees involved included Licensed Practical Nurse (LPN E); and CNA (C and D). The Administrator reported there was a second video provided by the Resident's family at a later date (10/7/16) which identified Housekeeper F was present during Resident #701's incontinence care and abuse incident with CNA C and was suspended on 10/7/16 and terminated on 10/11/16 for not reporting witnessed abuse. The Administrator reported reported that CNA C was the staff who was witnessed abusing Resident #701 and the other three staff (D, E, and F) were witnesses that had not reported the abuse. On 12/7/16 at 11:15 a.m., an interview and record review conducted with both the Administrator and DON revealed the facility's abuse policy dated 11/2016 included, .The staff will report any allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property, and injuries of unknown origin to the Administrator or DON immediately . The Administrator was unable to explain why the employees had not reported the abuse per policy. On 12/7/16 at 12:30 p.m., review of the actual video clips submitted by Resident #701's family to the facility was conducted in the Administrator's office in the presence of the Administrator and DON. At that time, the Administrator reported, The information on the videos as far as dates are not accurate so can't tell when it occurred, but that it did. The Administrator was asked to identify the staff as the videos were played. The DON reported that LPN E, CNA C, CNA D, and Housekeeper F all worked the day shift. Review of the video clips revealed the following events (the dates and times are not necessarily accurate and unable to verify actual dates/times): On 4/20/2045 at 05:24:10, Resident #701 was observed seated in a wheelchair facing the right side of the bed, with a lap buddy (cushion that fits into the wheelchair frame) secured across the lap area. The Resident was very restless, with non-sensical speech and after a couple of attempts, removed the lap buddy. Once the Resident removed the lap buddy, CNA C (who was already in the room at the foot of the bed and did not respond initially to the Resident's attempts to remove the lap buddy and slide down in the wheelchair) was observed to walk towards the Resident, grabbed the Resident's left arm and abruptly began walking towards the bed while pushing and lifting the Residents knee to walk and kicking behind the knee area to propel the leg forward. Once they reach the bed, CNA C was observed abruptly dropping the Resident onto the bed and then covered with a blanket. On 4/20/2045 at 07:26:12, Housekeeper F was observed standing facing the Resident's bed, while CNA C stood next to the right side of the bed, the Resident was lying down in the bed. At that time, CNA C roughly removed the Resident's pants and roughly turned the Resident onto the side (facing towards the door), removed the brief and without cleaning, put another brief on the Resident. (During this time, Housekeeper F proceeded to remain at the end of the bed and conversed with CNA C while the Resident's peri area was exposed.) CNA C then proceeded to abruptly grab the Resident's back of the head and pull the Resident up from the bed. CNA C then abruptly turned the Resident and roughly (slammed) the Resident into the wheelchair and placed the lap buddy in place. On 4/20/2045 at 07:59:16, CNA C was observed pulling the Resident from the wheelchair next to the right side of the bed, while holding the Resident under the arms and stated, Walk, Walk over there. At that time, once they reached the bed, CNA C roughly pushed the Resident onto the bed and repositioning the Resident in the bed while roughly pulling on the right shoulder. Resident #701 was observed during this time to be making non-sensical sounds repeatedly, Ah, Ah, Ah. On 4/22/2045 at 03:38:13, CNA C and CNA D were observed in the Resident's room. CNA C was observed putting on gloves, removed the blanket from the Resident, and proceeded to grab the Resident roughly and abruptly transferred from the bed to the wheelchair while holding the Resident at the armpits. At this time, LPN E was observed behind the Resident holding the wheelchair while conversing with CNA C who stated, Every mother f*****. CNA C proceeded to roughly and abruptly transfer the Resident from the wheelchair into the bed. At this time, the Resident was observed to be making non-sensical sounds repeatedly, Ah, Ah, Ah. CNA C was observed stating to the Resident, Shut up! Shut up! Don't make no noise! At that time, LPN E told the Resident, Lay down, lay down. At no time, did CNA D or LPN E intervene or acknowledge the rough handling during care or the use of profanity and verbal abuse. The facility was determined to be noncompliant with regulatory requirement F226 as a result of staff failing to report witnessed abuse of a Resident during care by another staff member. However, the facility identified a past noncompliance in regard to the abuse incident with documentation, and a plan of correction date of 10/11/16. Therefore, although cited, no further action is necessary. On 12/7/16 - 12/20/16, during the unannounced onsite abbreviated survey, the Surveyor verified that the following plan of correction had been implemented. On 12/18/15 at 10:00 p.m., the son and daughter came to the facility and stated that they wanted him sent to the hospital because their family doctor wanted to see him to make sure he was ok to got to his sister ' s funeral on Saturday. They also said that the doctor wanted to see him because of the multiple falls he has had while in the facility. He was sent out per family request. On 12/21/15 the Admission Director called the son and asked if Resident #701 would be returning to the facility. Although he was the primary contact, he stated that we could not contact him anymore. He gave a name and number and instructed her to use that for any further information. The Admission Director left a message at the given number. On 12/22/15 the call was returned. She (Admissions Director) was on speaker phone with two men that said their names were ***** and *******. ***** said that Resident #701 would not be returning and claimed it was related to lack of care and abuse. On 12/23/15 the Director of Nursing reported it to the Livonia PD. Officer M arrived at the facility and said that he would not be filing a report because the resident was no longer in the facility and the family had not made a complaint. On 12/23/15 Director of Nursing reported to the state via 24 hour report. MI ACTS 7052. On 12/23/15 Director of Nursing submitted 5 day - unable to substantiate abuse. MI ACTS 7052. On 12/29/15 State complaint visit regarding Resident #701 with six allegations: Quality of care, resident abuse, resident safety, no water give, falls, call light not accessible. Unsubstantiated. Complaint # MI 839. On 5/26/16 Receipt of settlement summary and 11 video clips from the (name of attorney firm) on a flash drive arrives at (Company name). On 5/27/16 Facility is made aware of incident(s) to investigate three (3) employees. CNA C, CNA D, and LPN E were suspended pending investigation. On 5/27/16 Administrator contacts local police department, told would have to come down. Went down and was told there would be no report filed as the Resident remained out of the facility and no report from the family. On 5/27/16 Administrator notified the State Agency of new evidence of abuse via video clips. From 5/27/16 - 6/18/16 Abuse prevention and reporting in-services were completed with all staff. From 5/28/16 - 5/31/16 Interviews were conducted with Residents and families by Social Worker H which identified Have you ever been physically abused here at (name of facility)?; Have you ever been verbally abused here at (name of facility)?; Do you feel safe here at (name of facility)?. There were no reported concerns regarding physical or verbal abuse at that time, or since then. On 5/28/16 head to toe body audits were completed by Nursing staff with no identified concerns of any injuries of unknown origin. On 6/1/16 Facility meets with each employee to conclude investigation; each employee is fired. On 6/2/16 Director of Nursing submitted notification via fax to the State professional licensing agency for Report of Change in Staff Privileges for LPN E (not reporting witnessed abuse), CNA C (witnessed abuse of a resident) and CNA D (not reporting witnessed abuse). On 10/7/16 at the request of (Corporate name), additional video clips were provided which revealed Housekeeper F was present during one of the abuse incidents with CNA C and had not reported the incident to the Administrator or Director of Nursing. Housekeeper F was suspended pending investigation. On 10/11/16 Facility meets with Housekeeper F to conclude investigation; employee is fired. Additionally, during the onsite survey, review of the personnel records for LPN E, CNA C, CNA D and Housekeeper F confirmed Workforce Background Checks had been conducted upon hire with no concerns for employment within the facility. Interviews conducted with various Residents, families and Staff revealed no reported concerns with allegations of abuse or mistreatment during care. Staff were able to identify abuse, who to report to, and what would happen if allegation occurred. ( )

This citation pertains to intake #s MI 534 & MI 538. Based on observation, interview and record review, the facility failed to ensure adequate assistance during incontinence care for one (#701) of three sampled Residents reviewed for falls with injury in a total sample of three, resulting in a preventable fall when the Resident rolled off the bed and fell face down during incontinence care, subsequently sustaining an acute C2 vertebral fracture (cervical), an acute fracture of the left nasal bone, deep lacerations to the forehead which required eight sutures, bridge of nose which required three sutures and hospitalization for further evaluation and treatment. Findings include: On 11/22/16 at 12:15 p.m., during an interview with the Complainant, it was reported that the Resident fell out of bed during improper ADLs (activities of daily living) and sustained a C2 fracture and lacerations on 10/16/16. At that time, the concern was that the facility had not provided adequate assistance during care when the fall occurred which could have been prevented. On 11/29/16 at 9:00 a.m., Resident #701 was observed seated in the dining room eating breakfast. The Resident's nose was observed to have a large scar to the forehead. On 11/29/16 at 9:30 a.m., an interview was conducted with CNA C who confirmed she had been the nursing assistant assigned to Resident #701 on 10/16/16 at the time of the fall from the bed. When asked about the level of assistance the Resident had needed during incontinence care at that time, CNA C stated, One person, always been as far as I know. The kiosk (location of the documentation to notify staff what the specific Resident care needs are) didn't say she needed two person for care, only with transfers. When asked to recall the events of what occurred on 10/16/16, CNA C stated, Me and another CNA put her into bed from the wheelchair. The other CNA left the room. I started off on the right side (of the bed) and rolled her towards me. Now removing her pants and unstrapped one side of the brief. I then go to the left side and when I pulled the incontinence pad towards me (which was underneath the resident, on top of the mattress) she rolled out (fell ) from the right side. When asked if she felt the force of pulling of the incontinence pad was enough to end up propelling the Resident out of the bed, CNA C shook her head yes and stated, Well (Resident name) is kinda a big lady not no easy way. At that time, CNA C confirmed the Resident's mattress was a perimeter mattress (raised edges) and when asked how forceful of a pull it was to roll over the edge of the perimeter mattress, CNA C was unable to offer any further explanation. When asked about the positioning of the height of the bed when the Resident fell , CNA C stated, The bed was raised up to working level. The CNA continued to explain, She just rolled completely on her face. When she fell she said 'Ow' and there was blood. I put on the call light and once noticed it was taking too long, I yelled down the hallway. Both nurses responded. CNA C was unable to recall specifically how much time had lapsed since help arrived. When asked if there had been any follow up from management, CNA C reported, Nurse Manager 'F' reviewed that I should have got a second person with her being so heavy and hard to turn. On 11/29/16 at 11:00 a.m., Resident #701 was observed lying in bed with a perimeter mattress. At that time, the Resident was unable to participate in any meaningful conversation due to significant cognitive impairment. Certified Nursing Assistant (CNA H) who identified as the nursing assistant assigned to Resident #701 was asked about the Resident's level of assistance needed during incontinence care in bed and reported, She's a two person - to be on the safe side. Don't want what happened in the other room to happen again. Review of the Resident's Incident and Accident Report dated 10/16/16, documentation included: .CNA C was providing care to the resident rolled her over and she rolled to far. Resident fell face first resulting in a laceration to her forehead and the bridge of nose .Interventions Implemented .Have second staff present when rolling the pt in bed. This original document was completed by the nurse, however the sections for the Director of Nursing, Administrator and Physician were blank. Review of the clinical record revealed Resident #701 was initially admitted into the facility on [DATE] and readmitted on [DATE] following a hospitalization from ,[DATE] - 10/20/16 with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #701 had severe cognitive deficits, required extensive assistance of two persons for bed mobility and toilet use, had range of motion impairment to bilateral upper and lower extremities, and was always incontinent of bladder and bowel. According to the Resident's Self-care deficit care plan initiated 10/23/14, most recently revised 11/2/16, identified interventions which included, Assist of two with incontinent care every two hours and prn (as needed) which had a date initiated as 2/24/16, date revised as 10/21/16 and resolved date as 10/21/16. (This identified that since 2/24/16 and at the time of the fall on 10/16/16, the Resident required two person assist with incontinent care.) Review of the nursing documentation regarding the Resident's ADL needs included Nursing Comprehensive Evaluation which documented: On 8/24/16 Section G. ADL Status .Bed Mobility .2 person assist .Toileting .two person assist . On 10/20/16 Section G. ADL Status .Bed Mobility .Total assist .Toileting .total assist . Review of the interdisciplinary progress notes from 10/1 - 11/29/16 included: On 10/16/16 at 4:42 p.m., Resident sent out to (name of local hospital) after falling from her bed on to the floor. resident sustained [REDACTED]. CNA was providing care, when she turned the resident over and she rolled out of bed . On 10/20/16 at 8:56 p.m., .DX: Cervical Spine fracture of the neck .has 8 sutures across forehead and 3 sutures across bridge of nose, and swelling in face around eyes and nose . On 11/29/16 at 11:40 a.m., the Interim Director of Nursing was asked about Resident #701's incident on 10/16/16 and reported she had only been in the current position for approximately two weeks and deferred to Nurse Manager E for specific details. On 11/29/16 at 11:45 a.m., an interview and record review was conducted with Nurse Manager E. At that time, Nurse Manager E was asked about the revision of the self-care deficit care plan to remove the documented need for two person assistance confirmed she was the staff that revised the care plan and reported, We made her a two person assist upon return. Upon review of the revised care plan, Nurse Manager E reported, According to the therapy evaluation done a while ago that I reviewed, she (Resident #701 was a one person with bed mobility. When asked whether she had reviewed more recent information such as the quarterly MDS on 8/18/16, and/or the comprehensive nursing assessment on 8/24/16 which both reflected Resident #701 required two person assistance with bed mobility and toileting assistance, Nurse Manager E reported, No, I was not aware the MDS documented two person bed mobility in August and in the nursing comprehensive assessment. When asked about the earlier request upon arriving to the facility to provide documentation of the Resident's care needs (Kardex) prior to the fall, Nurse Manager E was only able to offer the current plan or care and reported the facility was unable to print care plans as well which reflected the resolved interventions, those were only available upon review in the electronic record. At that time, Nurse Manager E reviewed the electronic clinical record's care self-care deficit care plan and confirmed the documentation that showed Resident #701 had required two person assistance during incontinent care and was unable to offer any further explanation as to why that had not been provided on 10/16/16. Upon review of the facility's incident report, when asked about why there had not been any signatures from the Director of Nursing, Administrator, and Physician, Nurse Manager E reported, It's been in that file in (name of former DON) office. On 11/29/16 at 2:00 p.m., review of the documentation provided by the facility for their policy for Incontinence Management identified as an online form from the Lippincott Procedure documented, Always roll a resident toward you when providing care, unless there is another staff member present on the opposite side of the bed, to ensure safety . ( )

Based on observation, interview, and record review, the facility failed to consistently implement interventions for one (#703) of four sampled residents reviewed for pressure sores from a total of 24, resulting in the development and worsening of a facility acquired pressure sore. Findings include: On 8/15/16 at 9 AM, resident #703 was observed lying in bed with his eyes open and appeared to be in a vegetative state. He was unresponsive to verbal stimuli, immobile, had bilateral hand contractures, a gastric feeding tube and a suprapubic urinary catheter. The resident's right leg was contracted with his knee flexed and pointing outward, away from the body and the right foot was wrapped in gauze. His right leg was crossed over to the left leg with the right lateral ankle (bone area) lying on top of the left shin, which was thin, bony and prominent. The left foot was wrapped in gauze with the heel resting on the mattress. There were no pressure relieving devices on the feet or ankles. At 12:15 PM, the right lateral ankle was observed on top of the left shin with no pressure relieving devices for the ankles/feet in place. At 4:25 PM, there were blue foam boots observed covering the feet and ankles. The outer ankle area of the right boot was crossed over and on top of the left shin. On 8/16/16 at 8:10 AM, resident #703 was wearing the boots with the outer ankle area of the right boot crossed over and on top of the left shin. On 8/16/16 at approximately 9 AM, the resident's clinical record was reviewed and wound care records were reviewed, provided by facility wound care nurse 'D' as follows: Resident #703 was readmitted from the hospital on [DATE] following insertion of the suprapubic urinary catheter with [DIAGNOSES REDACTED]. A minimum data set ((MDS) dated [DATE] noted that the resident had severe cognitive impairment, was unable to communicate, non-ambulatory, required extensive 2-person assistance for bed mobility, had limited range of motion to all extremities and no pressure sores. The resident was prescribed bilateral heel lift boots at all times, remove for hygiene, check skin every shift. A Braden pressure sore risk assessment dated [DATE] noted that the resident was at high risk for development. Interventions in resident #703's Skin Integrity care plans created on 1/23/15 and on-going, included: bilateral heel lift boots at all times, pillow between legs at all times, avoid positioning resident on bony prominences in bed and heel protector over right lateral ankle for extra cushion. A Head-To-Toe Skin assessment dated [DATE], noted that the resident's skin was intact with no skin alterations. Two days later, per a nursing note dated 5/9/16: A nurse aide reported to the nurse that an open area was discovered to the resident's right lateral ankle. A consultation report by the facility's contracted wound specialist dated 5/10/16 noted: The resident had a right lateral ankle stage III (full thickness skin loss) pressure sore measuring 2.5 cm by 2.0 cm with a necrotic (black, dead tissue) base and moderate serous drainage. The resident also had a non-specific wound of the left anterior lower (shin area) leg measuring 1.4 cm by 1.2 cm. Wound treatments and dressings were prescribed for every other day to the right ankle and left leg. On 5/17/16, the specialist noted that the left leg wound was a deep tissue injury pressure area and wrote: Please note change in [DIAGNOSES REDACTED]. On 5/25/16, the frequency of the wound care for resident #703's right ankle was increased from every other day, to every day, until 6/7/16. On 6/7/16, the specialist noted that the left leg pressure area was resolved (healed); The right ankle pressure sore measured 2 cm by 2.7 cm with a necrotic base. The treatment was changed to a chemical agent to debride the necrotic tissue until 6/21/16. On 6/21/16, the specialist noted that the right ankle wound measured 1.7 cm by 1.6 cm by 0.2 cm and wrote: change in treatment (to an antibacterial gel) due to wound not responding to current treatment. On 6/28/16, the wound was noted to have a pink base measuring 2 cm by 1.5 cm. Resident #703 was hospitalized from approximately 7/5/16 thru 7/14/16. On 7/15/16, nurse 'D' noted that the resident returned to the facility with the pressure sore remaining on the right ankle and a sore on the right anterior distal leg. Nurse 'D' noted that the resident's contracted right leg was very stiff and hard to move and was underneath the left leg. She indicated in her notes that this immobile resident was holding the right leg in that position. On 7/19/16, the specialist measured the right lateral ankle sore at 1.1 cm by 1 cm by 0.2 cm and noted that the sore on the right anterior lower leg was an abrasion (stage II partial thickness skin loss pressure sore) measuring 0.4 cm by 0.4 cm. The antibacterial wound treatment was continued to the right ankle and a dry dressing on the right leg. On 8/9/16, the specialist noted that the right ankle sore had decreased in size to 1 cm by 1 cm and the right anterior leg sore was healed. On 8/16/16 at 10:15 AM, resident #703's right foot was observed with wound care nurse 'D' and the wound specialist. Nurse 'D' lifted the right foot, which was still on top of the left shin, and removed the boot. The gauze and dressing was removed to reveal the stage III, facility acquired pressure sore on the right ankle bone with moderate serous drainage that measured at 2 centimeters (cm) by 1.5 cm by 0.3 cm, an increase in size and depth since 8/9/16. The wound specialist said, It is slow to heal. The wound was re-dressed, the boot was placed back on and the outer ankle area of the boot was placed back on top of the left shin by nurse 'D' before leaving the room. Immediately following the wound observation, nurse 'H' was asked to facilitate an observation of the rest of resident #703's skin. She lifted the covers and saw the right boot on top of the left leg. She told the resident that she was going to move his right foot. She lifted it off of the left leg and re-positioned it next to the inside of the left leg. The resident was totally immobile and nurse 'H' had to get assistance to turn the resident completely on his side for the skin observation. At 1 PM, the resident's right foot remained next to the left leg and not on top. On 8/16/16 at 3 PM, nurse 'H' repositioned the resident in bed. At approximately 3:30 PM, the right foot was observed in the boot and off of the left shin. At 3:45 PM, the Director of Nursing (DON) was queried about resident #703's boots not being consistently applied, observing the right lateral ankle sore positioned on top of the left shin and the pressure sore increasing in size. The DON responded, Did she (nurse 'D') do an unavoidable (pressure sore) assessment? She did not address the foot position or the boots. On 8/17/16 at 9:15 AM, the DON and nurse 'D' presented an Unavoidable Pressure Ulcer Assessment form for resident #703, dated 3/7/16. The form noted that the resident had a poor prognosis [MEDICAL CONDITION] and that pressure sores will be clinically difficult to prevent and continued breakdown is expected. However, the left leg deep tissue injury healed on 6/7/16, the right leg sore was healed on 8/9/16 and the right ankle sore had decreased to 1 cm by 1 cm on 8/9/16, indicating that the resident's wounds were capable of healing. When it was mentioned again that the boots were not on initially during the survey, they were unable to explain why. When told that the right ankle was positioned on top of the left shin, but was capable of being repositioned and remaining repositioned, they said, He moves sometimes. We put pillows in place and he has contractures. They were unable to explain why boots, pillows and proper positioning were not consistently implemented. They did not respond when it was mentioned that nurse 'D' did not properly position the right foot after the wound observation with the wound specialist. At 1 PM, nurse 'D' was asked why and how the right lateral ankle wound had developed up to a stage III before it was reported to her. She did not respond. She was asked why and how the deep tissue pressure area developed on the left shin at the same time as the stage III on the right ankle. Nurse 'D' responded, His foot was not on top of the leg and did not explain how the pressure areas occurred. On 8/18/16 at 8 AM, per review of the facility's Skin Management policy dated 7/2014: It is the policy of the facility that a resident does not develop pressure ulcers unless clinically unavoidable. Residents with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes Appropriate preventive measures will be implemented on residents identified at risk When asked, there was no additional information provided by the facility regarding this citation by the end of the survey exit. ( )

Based on observation, interview and record review, the facility failed to properly assess and implement appropriate, consistent and timely interventions for one (#711) of five sampled residents reviewed for nutritional parameters from a total of 24, resulting in unplanned, severe weight loss and the potential for further weight loss. Findings include: On 8/16/16 at 12:45 PM, resident #711 was observed sitting in a wheelchair in the dining room being fed lunch by staff. The resident was confused, tremulous, very thin and appeared lethargic and cachectic with sunken cheeks. At 3 PM, the clinical record was reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Minimum data sets dated 2/24/16 and 5/25/16 noted that the resident had moderate to severe cognitive impairment, impaired ability to communicate and required extensive assistance from staff with eating. The resident was prescribed psychoactive medications: [REDACTED]. A Nutritional Re-evaluation for resident #711 written by the Registered Dietician (RD) dated 1/25/16 noted: the resident was 5 feet 5 inches in height, had a usual adult body weight of 135, was legally blind, was independent with eating with food set-up help, but remained at risk for unplanned weight loss related to dementia. The RD noted: Will continue to observe oral intake, weight Will follow-up routinely. The resident was receiving a regular mechanically altered diet with thin liquids. A Nutritional Re-evaluation dated 4/25/16 noted that the resident's weight was stable over the past 6 months with no chewing or swallowing difficulties. Per resident #711's weight record, the weights were as follows: 5/10/16=132.4 pounds 6/10/16=129.6 pounds 7/8/16=120 pounds, a 12.4 pound weight loss or severe 9% loss in 2 months. Per the RD's progress notes dated 7/8/16: On 7/7/16, the resident was started on health shakes for extra calories with meals, provided by dietary staff three times a day due to reported poor intake for the past week; A 4 ounce (oz) nutritional supplement was going to be added three times a day, provided by nursing staff during medication (med) pass to provide an additional 720 calories and 30 grams of protein. However, the resident's medication administration records for 7/2016 and 8/2016 indicated that the supplement was not provided. There was no documented weight for resident #711 until three weeks later on 7/29/16. The resident weighed 121.8 pounds. On 7/30/16, the RD noted: Weight improved this review. Will continue with supplements. Will continue to observe. On 8/9/16, the resident weighed 118.8 pounds, a severe 10.3% loss in 3 months. On 8/15/16 (during the survey), the RD noted: The resident's weight continued to slowly decline even though she was started on two supplements a month ago recommendation for an appetite stimulant if physician approves. Weekly weights x 4 to better monitor weight. On 8/16/16 at 4:30 PM, the RD was asked if the resident's weight loss had been discussed by her with the physician and she said, No. I discussed it with the nurses and I leave it up to the nurse manager. She said, I recommended an appetite stimulant, but I have to wait for the physician to approve it. When asked which one she preferred, the RD said [MEDICATION NAME], an anti-depressant commonly used to stimulate appetite. When asked if she had discussed the resident's weight loss with the Psychiatrist, who was in the facility the previous day, to involve him in the decision to use [MEDICATION NAME] and to coordinate use with her other psychoactive medications, the RD said no. On 8/17/16 at 8:20 AM, the resident was observed sitting in the dining room for breakfast. She had a lidded cup with handles and a straw that contained orange juice. The resident was tremulous, but was able to lift the cup a few inches from the table and sip from the straw without assistance. Once the orange juice was consumed, she continued to attempt to sip from the empty cup and waited until staff finished passing plates of food to all of the other residents in the dining room (approximately 40 residents), to be fed. There were two other clean, empty cups, turned upside down, on the table directly in front of the resident. At 8:30 AM, nurse unit manager 'F' gave the resident a lidded cup of coffee with a spout and handles and then left to assist with others in the dining room. The resident repeatedly tried to drink the coffee, but kept missing the spout with her mouth. She then tried to figure out how to pick the lid off, but without success. At 8:40 AM, nurse 'F' gave a plate of food to the resident, began to feed her and gave her more orange juice. The nurse had to lift the cup of coffee and guide the spout into the resident's mouth each time she wanted a sip. Per review of the resident's meal card, she was supposed to receive 8 oz of milk, coffee, water and 4 oz of orange juice and health shake with each breakfast. The resident did not receive the health shake, milk or water. The resident consumed about 25% of oatmeal, eggs and a cinnamon roll then indicated that she was full, when asked by nurse 'F'. Following breakfast at 9 AM, resident #711 was observed being weighed by nurse 'J' when her weight was requested. The resident weighed 110.6 pounds, a severe 7% loss in 9 days and a severe loss of 16.5% in 14 weeks. At that time, the RD was queried about the continued weight loss and informed that the resident had not been receiving the med pass supplement or the health shake, milk and water that she was to receive during breakfast. The RD said that the dietary staff was supposed to give her the fluids and that she was unaware that nursing staff had not given the supplement. When asked if she had observed the resident during meals and if she was aware that the resident seemed more independent drinking from a straw rather than a spout, the RD indicated that she had not observed the resident. When asked whether enhanced/[MEDICATION NAME] cereal, soup, potatoes or other foods had been recommended, to provide extra calories in each spoonful in lieu of the resident's poor appetite, the RD said, I did today and said, She (resident) used to get double portions. When asked why it was not resumed when the weight loss first became apparent, the RD said she did not know. The RD did not respond why weekly weights were not implemented when the weight loss first became apparent, when asked. Per resident #711's Risk for Impaired Nutritional Status care plan created on 7/29/15 and on-going, the goal noted: Avoid significant weight changes as medically feasible; Interventions included: health shakes and med pass supplements 3 times a day, provide diet as ordered with thin liquids, weekly weights PRN (as needed). On 8/17/16 at 1:45 PM, when asked, the Director of Nursing (DON) indicated that she was aware of resident #711's weight loss. When asked about weight loss interventions and the med pass supplement and breakfast fluids/supplement not being provided, the DON responded, I have to look into it. On 8/18/16 at 8 AM, per review of the facility's Weight Management policy dated 7/2014: Residents are expected to maintain acceptable parameters of nutritional status, such as usual body weight unless the resident's clinical condition demonstrates that this is not possible. Since ideal body weight charts have not yet been validated for the institutionalized elderly, weight loss (or gain) is a guide for determining nutritional status. Therefore, the evaluation of significant weight gain or loss over a specific time period is an important part of the assessment process Any resident with unintended weight loss/gain will be assessed by the interdisciplinary team and interventions will be implemented to prevent further weight loss/gain The Dietary Manager/RD and DON are responsible for coordination of an interdisciplinary approach to managing the processes for prediction, prevention, treatment, monitoring and calculation of unintended weight loss/gain Residents determined to be at risk or have significant weight changes will be weighed on a weekly basis. Residents at risk are: .Residents with insidious weight loss 5% in one month, 7.5% in three months, 10% in six months Dietary Manager and/or RD are to communicate weight changes to the attending physician and resident's responsible party. This is documented in the clinical record; Suggested weight loss interventions include: med pass supplement, house supplements (health shakes), enhanced foods, assistance with meals, evaluation for depression and other psychological issues, appetite stimulant. When asked, there was no additional information provided by the facility regarding this citation by the end of the survey exit. ( )

THIS REGULATION HAS MULTIPLE DEFICIENT PRACTICES. #1. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT HOT WATER TEMPERATURES AT THE HANDWASHING SINKS WERE WITHIN A SAFE TEMPERATURE RANGE BETWEEN 105 AND 120 DEGREES FAHRENHEIT. THE HOT WATER TEMPERATURES RANGED BETWEEN 122.1 AND 125.6 DEGREES FAHRENHEIT FOR ROOMS 101, 102, 104, 105, 108, 110, 112, 113, 114, 130, 133, 134, 206, 207, 215, 219, 21, 231, 234, 235 AND 237. THE HOT WATER TEMPERATURES HAD THE POTENTIAL TO AFFECT 16 (#'S 1, 4, 7, 9, 18, 19, 23, 24, 26, 58, 71, 73, 74, 89, 105 AND 124) OF 124 RESIDENTS, RESULTING IN THE POTENTIAL FOR SERIOUS HARM, INJURY OR DEATH FROM SCALDING. THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON 10/28/11 AT 10:15 A.M.. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 10/28/11 AT 2:45 P.M. THE IMMEDIATE JEOPARDY WAS REMOVED ON 10/28/11 BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 10/28/11, AS VERIFIED ONSITE ON 10/28/11, DURING THE COMPLETION OF THE EXTENDED SURVEY. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE REMAINED AS A PATTERN. NO ACTUAL HARM WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE: ON OCTOBER 28, 2011 AT 10:15 A.M., HOT WATER TEMPERATURES WERE INITIALLY CHECKED. THE FOLLOWING HOT WATER TEMPERATURES WERE FOUND TO EXCEED THE MAXIMUM ALLOWABLE TEMPERATURE OF 120 DEGREES FAHRENHEIT (DF) FOR THE FOLLOWING HANDWASHING SINKS: UNIT ROOM DEGREES FAHRENHEIT 1 NORTH 102 124.1 D.F. 108 122.3 D.F. 1 SOUTH 130 123.6 D.F. 133 123.6 D.F. 2 EAST 221 123.4 D.F. SHOWER ROOM 123.0 D.F. 2 SOUTH 231 123.0 D.F. 234 122.9 D.F. THE MAINTENANCE SUPERVISOR WAS INTERVIEWED AT THIS TIME, REGARDING THE SOURCE OF HOT WATER. THE MAINTENANCE SUPERVISOR INDICATED THAT THE TWO RIGHT HAND UPRIGHT HOT WATER TANKS IN THE BOILER ROOM WERE THOSE HE ADJUSTED FOR HOT DOMESTIC WATER. LATER THAT DAY, IT WAS LEARNED FROM THE CONTRACTOR SUMMONED BY THE FACILITY THAT THE TWO BLUE HOT WATER TANKS ON THE LEFT WERE THE DOMESTIC HOT WATER TANKS, AND IT WAS THOSE THAT SHOULD BE ADJUSTED. THREE MONTHS OF HOT WATER TEMPERATURE LOGS WERE REVIEWED AND THE TEMPERATURES RECORDED DID NOT INDICATE A TEMPERATURE PROBLEM. ADDITIONALLY, HOT WATER TEMPERATURES WERE RECHECKED ON OCTOBER 28, 2011 AT 11:15 A.M. THE FOLLOWING TEMPERATURES WERE FOUND TO EXCEED THE MAXIMUM ALLOWABLE TEMPERATURE OF 120 DEGREES FAHRENHEIT (DF) FOR THE FOLLOWING HANDWASHING SINKS: UNIT ROOM DEGREES FAHRENHEIT 1 EAST 113 124.3 D.F. 114 123.6 D.F. 1 SOUTH 134 123.9 D.F. 1 NORTH 101 123.4 D.F. 104 125.4 D.F. 105 124.8 D.F. 110 122.7 D.F. 112 124.8 D.F. 2 EAST 215 125.0 D.F. 219 123.8 D.F. 2 NORTH 206 123.0 D.F. 207 123.4 D.F. 2 SOUTH 235 122.5 D.F. ON 10/28/11 AT 10:15 AM, THE HOT WATER TEMPERATURES OF THE HAND WASHING SINKS ON UNIT 1 NORTH AFFECTING RESIDENT #1 IN ROOM 101 WAS MEASURED TO BE 123.4 DEGREES FARENHEIT AND 125.4 DEGREES FAHRENHEIT FOR RESIDENT #7 IN ROOM 104 AND RESIDENT #4 IN ROOM 102. RESIDENTS #9 & #23 IN ROOMS 112 AND 105 HAD HOT WATER TEMPERATURES THAT MEASURED 124.8 DEGREES FARENHEIT. RESIDENT #19 IN ROOM 110 HAD HOT WATER TEMPERATURES OF 122.7 DEGREES. ON UNIT 2 EAST RESIDENT #89 IN ROOM 215 HOT WATER TEMPERATURES MEASURED 125 DEGREES AND RESIDENT #105 IN ROOM 219 MEASURED 123.8 DEGREES FARENHEIT. ON UNIT 2 NORTH RESIDENT #74 & #73 IN ROOM 207 HAD HOT WATER TEMPERATURES THAT MEASURED 123.4 DEGREES FARENHEIT AND RESIDENT #71 IN ROOM 206 MEASURED 123 DEGREES. RESIDENT #18 & #124 IN ROOM 235 AND 237 HAD HOT WATER TEMPERATURES THAT MEASURED 122.5 DEGREES FARENHEIT ON THE 2 SOUTH UNIT. ON UNIT 1 EAST RESIDENT #24 IN ROOM 113 HAD HOT WATER TEMPERATURES OF 124.3 DEGREES AND RESIDENT #26 IN ROOM 114 MEASURED 123.6 DEGREES FARENHEIT. RESIDENT #58 IN ROOM 134 HAD HOT WATER TEMPERATURES OF 123.9 DEGREES FARENHEIT ON UNIT 1 SOUTH. MDS RECORD REVIEW REVEALED THAT ALL THE IDENTIFIED RESIDENTS WERE INDEPENDENT IN AMBULATION OR MOBILITY VIA CANE, WALKER OR WHEELCHAIR AND HAD ACCESS TO THE HAND WASHING SINKS. ON 10/28/11 AT 11:15 A.M., DURING AN INTERVIEW WITH RESIDENT #26 STATED, "IF THE WATER GETS TOO HOT, I CAN ADJUST IT." ON 10/28/11 AT 11:20 A.M., IN INTERVIEWS RESIDENT #3, STATED THAT, " THE WATER IN HIS SINK IS HOT". RESIDENT #23 STATED, "I HAVE TO ASK THEM TO TURN IT DOWN." RANDOM INTERVIEWS ON 10/28/11 AT 11:30 A.M., REVEALED RESIDENT #105 STATED "THE WATER WAS REGULARLY HOT". ADDITIONALLY, REVIEW OF HOT WATER TEMPERATURE LOGS REVEALED THAT THE FACILITY DID NOT MONITOR OR MAINTAIN HOT WATER TEMPERATURE LOGS FOR INDIVIDUAL RESIDENT ROOMS. THERE WERE ONLY HOT WATER TEMPERATURE LOGS FOR ONE ROOM AND THE UNITS. THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THE FACILITY IMPLEMENTED THE FOLLOWING: AUTUMNWOOD OF LIVONIA SUBMITS THE FOLLOWING CREDIBLE ALLEGATION OF COMPLIANCE OUTLINING THE MEASURES IT HAS COMPLETED TO ABATE THE FINDINGS OF IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY IDENTIFIED BY THE SURVEY TEAM REGARDING THE FACILITY'S ALLEGED FAILURE TO ENSURE THAT WATER TEMPERATURES AT THE HANDWASHING SINKS IN RESIDENT ROOMS 101,102, 104, 105, 110, 112, 113, 114, 134, 206, 207, 215, 219, 235, 237 AFFECTING 16 RESIDENTS # 1, 4, 7, 9,18,19,23,24,26,58,71, 73,74,89, 105, AND 124 OF 124 RESIDENTS WERE WITHIN A SAFE TEMPERATURE RANGE BETWEEN 105 AND 120 DEGREES FARENHEIT. 1. RESIDENT IDENTIFIED TO BE AFFECTED BY THE ALLEGED DEFICIENT PRACTICE. AUTUMNWOOD OF LIVONIA BELIEVES THAT AS OF 10/28/2011 AT 2:41 PM THE MEASURES IT HAS IMPLEMENTED ARE SUFFICIENT TO DEMONSTRATE THE WATER TEMPERATURES ARE WITHIN A SAFE RANGE ACCORDING TO THE REQUIREMENT AND THE SAFETY OF THE RESIDENTS. BEGINNING ON 10/28/11 AT 12:00 PM THE HOT WATER HEATERS WERE ASSESSED AND ADJUSTED BY A LICENSED PROFESSIONAL CONTRACTOR TO MEET A SAFE RANGE (105-120 DEGREES FAHRENHEIT) FOR THE FOLLOWING OFF-SAMPLED RESIDENT # 1,4,7,9, 18, 19,23,24,26,58,71,73,74,89, 105 AND 124. 2. RESIDENTS WITH THE POTENTIAL TO BE AFFECTED BY THE ALLEGED DEFICIENT PRACTICE. ALSO ON 10/28/11 THE LICENSED PROFESSIONAL CONTRACTOR REVIEWED AND ADJUSTED TEMPERATURES ON BOTH DOMESTIC HOT WATER HEATERS THAT SERVICE ALL RESIDENTS ROOMS. ON 10/28/11, THE LICENSED CONTRACTOR ADJUSTED THE HOT WATER HEATER TEMPERATURES TO MAINTAIN A SAFE TEMPERATURE RANGE. ALL HOT WATER HEATERS WERE INSPECTED BY THE LICENSED CONTRACTOR AND NO OTHER CONCERNS WITH HOT WATER TEMPERATURES WERE IDENTIFIED. AT APPROXIMATELY 2:41 PM ON 10/28/11, THE MAINTENANCE DIRECTOR RECHECKED ALL RESIDENT HANDWASHING SINKS AND VERIFIED THAT THE HOT WATER TEMPERATURES WERE BETWEEN 105 AND 120 DEGREES FAHRENHEIT. 3. SYSTEM MEASURES THE MAINTENANCE STAFF/DESIGNEE WILL MONITOR HOT WATER TEMPERATURES IN ALL HANDWASHING SINKS HOURLY FOR TWENTY FOUR HOURS, THEN EVERY SHIFT FOR 24 HOURS, THEN RANDOM DAILY. THEN THE FACILITY WILL COMPLETE RANDOM DAILY WATER TEMPERATURE CHECKS FIVE TIMES WEEKLY. ANY NOTED IRREGULARITIES WILL BE ADJUSTED IMMEDIATELY. THE LICENSED PROFESSIONAL CONTRACTOR HAS IN-SERVICED THE MAINTENANCE SUPERVISOR AND THE MAINTENANCE ASSISTANTS 10/28/11 AT 2 PM ON PROPER PROCEDURE FOR TAKING HOT WATER TEMPERATURES AND THE IMPORTANCE OF MAINTAINING SAFE HOT WATER TEMPERATURES AS WELL AS ADJUSTING THE TEMPERATURES ON THE HOT WATER HEATERS. AS OF 10/28/11 84 OUT OF 179 LICENSED AND NON LICENSED STAFF HAVE BEEN IN SERVICED ON HOW TO REPORT UNSAFE/IRREGULAR WATER TEMPERATURES. THE REMAINING LICENSED AND NON LICENSED PERSONNEL WILL BE IN-SERVICED ON THE IMPORTANCE OF REPORTING IRREGULAR WATER TEMPERATURE PRIOR TO RETURNING TO WORK ON THEIR NEXT SCHEDULED DAY. ALL NEW EMPLOYEES WILL BE IN-SERVICED ON THE IMPORTANCE OF REPORTING IRREGULAR WATER TEMPERATURE 4. QUALITY ASSESSMENT AND ASSURANCE THE MAINTENANCE SUPERVISOR OR DESIGNEE WILL PERFORM RANDOM DAILY WATER TEMPERATURES ON HANDWASHING SINKS FIVE TIMES WEEKLY TO ENSURE THE TEMPERATURES ARE WITHIN A SAFE RANGE. ANY AREAS OF CONCERN WILL BE ADDRESSED IMMEDIATELY. THE AUDITS WILL BE REVIEWED AND FORWARDED TO THE QUALITY ASSURANCE COMMITTEE. THE ADMINISTRATOR OR DESIGNEE WILL REPORT FINDINGS TO THE QUALITY ASSESSMENT AND ASSURANCE COMMITTEE ON A MONTHLY BASIS UNTIL THE COMMITTEE DETERMINES THAT COMPLIANCE WITH THIS PLAN HAS BEEN MAINTAINED. THE ADMINISTRATOR IS RESPONSIBLE FOR OVERALL SUSTAINED COMPLIANCE. THE COMPLIANCE DATE IS 10/28/11. ( ) ( ) ( ) ( ) ( ) ( ) ( ) #2. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONDUCT POST FALL ASSESSMENTS FOR THREE (#'S 905, 917 AND 919) OF 11 RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL OF 26 SAMPLED RESIDENTS, RESULTING IN A POTENTIAL FOR UNIDENTIFIED FALL INJURIES. FINDINGS INCLUDE: ON 10/25/11 AT 11:05 A.M., RECORD REVIEW REVEALED THAT RESIDENT #905 WAS admitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED THAT RESIDENT #905 WAS "NOTED" ON THE FLOOR IN FRONT OF THE WHEELCHAIR ON 10/22/11 AT 12:10 P.M. ACCORDING TO THE INCIDENT AND ACCIDENT REPORT, RESIDENT #905 SUSTAINED NO INJURY. THERE WAS NO FURTHER DOCUMENTATION ADDRESSING THE RESIDENT'S CONDITION AFTER THE RESIDENT WAS FOUND ON THE FLOOR. ON 10/27/11 AT 2:30 P.M., RECORD REVIEW REVEALED THAT RESIDENT #917 WAS admitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. FURTHER REVIEW OF RESIDENT #917'S CLINICAL RECORD REVEALED THAT THE RESIDENT WAS "OBSERVED LYING ON THE FLOOR ON LEFT SIDE OF HALLWAY ON 10/24/11 AT 7:50 P.M." ACCORDING TO THE INCIDENT AND ACCIDENT REPORT DATED 10/24/11, RESIDENT #917 SUSTAINED NO INJURY FROM THIS FALL. THERE WAS NO FURTHER DOCUMENTATION ADDRESSING RESIDENT #917'S CONDITION AFTER THE RESIDENT WAS FOUND ON THE FLOOR. REVIEW OF THE FACILITY'S POLICY ON FALL MANAGEMENT DATED 5/2010, REVEALED FOR THE LICENSED NURSE TO DOCUMENT IN THE NURSES NOTES THE RESIDENT'S CONDITION FOR 72 HOURS FOLLOWING THE FALL. ( ) ( ) RESIDENT #919 WAS ORIGINALLY admitted INto the facility on [DATE] AND REadmitted on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE NURSING NOTES DOCUMENTED THAT ON 10/18/11 AT 7:55 A.M., RESIDENT #919 WAS OBSERVED SITTING ON THE FLOOR. PER INCIDENT AND ACCIDENT REPORT DATED 10/18/11 AT 7:30 A.M., DOCUMENTED THAT RESIDENT #919 SUSTAINED NO INJURY. THERE WAS NO FURTHER DOCUMENTATION OF RESIDENT #919'S POST FALL STATUS AFTER THE OCCURRENCE. ON 10/27/11 AT 2:30 P.M., DURING AN INTERVIEW AND RECORD REVIEW, UNIT MANAGER "A", CONFIRMED AND STATED "RESIDENT #919 SHOULD HAVE BEEN ASSESSED FOR 72 HOURS POST FALL AND IT SHOULD HAVE BEEN DOCUMENTED AS WELL." ( ) #3. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT A POTENTIAL HAZARDOUS CONDITION FOR ONE (#906) RESIDENT OUT OF A TOTAL OF 26 SAMPLED RESIDENTS, RESULTING IN THE POTENTIAL FOR ACCIDENTAL INGESTION. FINDINGS INCLUDE: ON 10/25/11 AT 6:50 A.M., DURING THE FACILITY TOUR, A MEDICATION CUP WAS OBSERVED WITH A PINKISH MATERIAL AT THE BEDSIDE TABLE OF RESIDENT #906. THE MEDICATION CUP WAS NOT LABELLED. DURING AN INTERVIEW ON 10/25/11 AT 7:00 A.M., IN THE PRESENCE OF NURSE "B", RESIDENT #906 STATED, "THE STAFF PLACED THAT (POINTING TO THE MEDICATION CUP WITH THE PINKISH MATERIAL) FOR MY "BEHIND". DURING AN INTERVIEW WITH NURSE "B" ON 10/25/11 AT 7:05 A.M., IT WAS REPORTED THAT THE MIDNIGHT STAFF PLACED THE PINKISH MATERIAL ON THE BEDSIDE TABLE. HOWEVER, NURSE "B" DID NOT OFFER ANY FURTHER EXPLANATION. ( )