Every finding on record at Regency at Whitmore Lake

Based on observation, interview, and record review the facility failed to ensure for 96 out of 115 residents a homelike dining experience was maintained. Findings Included: On 5/12/2026 12:02 PM, a sign was observed to be at the main dining room door that stated that the dining room was closed for the week for all meals due to a week long activity from the activity department. Activity Director (AD) W was interviewed during the observation in which AD W stated, the residents all had to eat lunch in their rooms because the dining room was being used for a spirit week activity. On 05/13/2026 at 8:41 AM, 100 hall residents were observed being served their breakfast in their rooms. At the time of the observation Certified Nurse Aid (CNA) V was interviewed and stated that the residents eat breakfast and supper meals in their rooms but eat lunch in the dining room. CNA V stated she did not know why it was that way. In an interview on 05/13/2026 at 8:43 AM, CNA X stated that the dining room was not open for breakfast or dinner but stated that residents ate lunch in there. CNA X said she did not know why. In an interview on 5/13/2026 at 8:51 AM, CNA Y stated that it was only for the lunch meal that the residents were taken to the main dining room and said breakfast and dinner the residents had to eat in their rooms. CNA Y also stated that the dining room was closed down for spirit week this week and no resident could eat any meal in the dining room this week. CNA Y said residents want to eat their meals in the dining and stated the residents tell her that. On 5/13/2026 at 3:35 PM, Resident #124's (R124) family member, upon entering R124's room, asked if the facility had a dining room, and why the residents had to eat their meals in their rooms. Stated R124 was a very social person and would want to eat in the dining room but only gets to eat her meals in her room. In an interview on 5/14/2026 at 11:20 AM, AD W said that the dining room had been closed since last year because residents just stopped going to the dining room. Stated that the week of 5/11-5/15/2026 Monday through Friday the dining room was closed all day for all meals for planned spirit week activities, AD W stated that she did discuss and get approval from R48 the president of resident council to close the dining room from 5/11-5/15/26, and also stated that she discussed it in the resident council meeting for the month of May 2026 and documented it on the meeting notes. Record review of the resident council meeting minutes for the month of April and May 2026 revealed no documentation of having a discussion of the dining room being closed for the week of 5/11-5/15/2026 for the spirit week. In an interview on 5/14/2026 at 11:54 AM, R48 who is the president of resident council, stated that AD W did not speak to her about closing the main dining room for the week for spirit week, and it was not spoken about in resident council meeting this month nor last. R48 said no staff member had spoken with her about closing the dining room for the week of 5/11-5/15/26. R48 stated that the main dining room had been closed for breakfast and supper since last 2025, could not recall the exact date. R48 said she gets up into her wheelchair daily at 10:00 AM and stays up until about 2 pm. R48 stated that she eats her lunch in the dining room frequently while she is up in her wheelchair and said that she went to the dining room a day this week to go eat lunch and the dining room was closed, said she was told the dining room was closed all week for spirit week. R48 said she was upset and did not know that. R48 also stated that the only reason she gets up every day is to go to the dining room to eat lunch so this week she has had no reason to get up out of bed, and also stated that she would like to be able to go to the dining room for the dinner meal and it upsets her that she cannot do that. In an interview on 5/14/2026 at 2:06 PM, Dietary Manager (DM) C said the dining room had been closed for breakfast since she started working at the facility on 8/28/2025. DM C said the dining room was closed for breakfast and supper because the number of residents who went to the dining room went down but then stated she did not know why the dining room was closed. In an interview on 5/14/2026 at 2:17 PM, Registered Dietician (RD) AA stated that she had worked at the facility for 1.5 years and the dining room had only ever been open for lunch. RD AA said she was told by the previous RD that the reason the dining room was closed for the breakfast and dinner meals was because the number of residents who were going to the dining room for those meals was dwindling. RD AA stated the residents only other option was for them to eat in their rooms, said there was nothing else offered. In an interview on 5/15/2026 at 1:39 PM, R88 stated he eats lunch in the main dining room Monday-Friday, but stated that on the weekends for all meals the dining room was closed. R88 stated that his preference was that the dining room be open every day all the time for all meals, so that he has the option every day for all meals to go eat in the dining and stated he likes to interact with other residents at times. Observation on 5/15/2026 at 12:18 PM, revealed the dining room remained closed. AD W was in the DR setting up activity items and stated that the dining remained closed for the day, no lunch today due to the 2:30 activity. On 5/15/2026 at 3:11 PM, Nursing Home Administrator (NHA) A was asked why the dining room was closed off to residents for breakfast and dinner. NHA A said only a handful of residents would go to the dining room to eat so the dining room was closed down, and that is how it has been for at least the last 1.5 years. NHA A said there was an attempt to reopen the dining room, but no residents went to the dining room to eat, said residents would not get out of bed. NHA A had no answer for the lunch and dinner meals, and therefore the dining room continued to remain closed. NHA A was not able to state the date that this attempt was made, had no documentation of this attempt, no Quality Assurance and Performance Improvement (QAPI) documents that show any attempts by administration were ever made in the last 1.5 years to reopen the dining room to ensure residents rights to a homelike dining experience were ensured.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergency or routine care and unmet care needs, affecting all 115 residents who resided in the facility. Findings include:On 5/14/2026 at 10:05 AM, the actual working schedules for March, April and May 2026 were reviewed with Scheduler U. Scheduler U was unable to identify RN coverage for April 4th, 2026. On 5/14/2026 at 12:56 PM, the Timecard Report dated 4/4/2026 was reviewed with the Nursing Home Administrator (NHA). The NHA reported the facility did not have 8 consecutive hours of RN of coverage on 4/4/2026. The NHA said the expectation was to have 8-hour daily RN consecutive coverage in order to meet the needs of the residents. On 5/15/2026 8:57 AM, the Director of Nursing was interviewed and said the expectation was for the facility to have 8 hr daily consecutive RN coverage in order to meet the needs of the residents. Review of the facility assessment updated 8/15/2026 revealed C. nursing Must provide onsite RN coverage 24/7. Review of the facility policy titled Nursing Staffing last revised 9/14/2023 revealed in part . 2. The nursing services department is under the supervision of a registered nurse (RN) 8 consecutive hours a day, 7 days a week, or per state guidance.

Based on observation, interview, and record review, the facility failed to date food from the pantry and walk in cooler, store perishable items properly, ensure kitchen staff wore beard guards and maintain a clean ice machine. This deficient practice had the potential to affect all the residents who consumed food from the kitchen, resulting in the increased potential for food borne illness in a current facility census of 115 residents. Findings include:On 5/12/2026 beginning at 9:00 AM, the initial tour of the kitchen was conducted with Dietary Manager (DM) C. During the tour, the following item was observed in the walk-in cooler:-tub of individual butter undated approximately 50 butter packets.During the tour, the following item was observed in the pantry:-one box of individual butters, box stated Keep refrigerated. When DM C touched the butter, she said it was warm and needed to be thrown out. DM C stated, The butter should be stored in the cooler.-tub of mixed individual jellies undated. -tub of assorted individual salad dressings undated.DM C stated, All items needed to be labeled and dated.The ice machine was observed with DM C. A rusty brown colored debris was noted on the inside lid and inside top of the ice machine. When DM C was asked what the debris looked like DM C said it looked like mold. DM C further said that the maintenance department cleaned the ice machine.On 5/13/2026 at 11:45 AM, in an observation with DM C three male dietary aides L, M, N with facial hair were observed preparing food and were not wearing beard guards. DM C said the food code is for men with facial hair to wear beard nets. On 5/14/2026 at 2:05 PM, Maintenance Director (MD) D was interviewed and said the maintenance department cleaned the ice machine every month. When asked about the debris found on the inside of the ice machine, MD D acknowledged there was debris and it was cleaned. On 5/15/2026 at 10:11 AM, the Nursing Home Administrator (NHA) was interviewed and said the expectation was for the ice machine to be clean, for kitchen staff to wear hair/beard nets, food labelled and dated and perishable food items to be refrigerated.Review of the facility policy titled Food Handling and Production last revised 3/11/2026 revealed in part.1. The kitchen and equipment will be maintained in a clean, neat, and orderly manner to minimize bacteria formation and food contamination. 2. Practice good personal hygiene. Wear hair nets and beard guards. 4. Perishable food will be stored and refrigerated, except when being handled.

Based on interview and record review the facility failed through its quality assurance and performance improvement program (QAPI) to identify and put systems in place to correct deficiencies at F584, F730, F881 and F947 in a current facility census of 115 residents. On 5/15/2026 at 3:11 PM, Nursing Home Administrator (NHA) A was asked why the dining room was closed off to residents for breakfast and dinner. NHA A said only a handful of residents would go to the dining room to eat so the dining room was closed down, and that is how it has been for at least the last 1.5 years. NHA A said there was an attempt to reopen the dining room, but no residents went to the dining room to eat. NHA A had no answer for the lunch and dinner meals, and therefore the dining room continued to remain closed. NHA A stated she had not performed a root cause as to why residents would not go to the dining room to eat and had not addressed the dining room closure for reopening in any QA meeting in order to ensure residents rights to a homelike dining experience were ensured. In an interview on 5/15/2026 at 2:33 PM Director of Nursing (DON) B was asked what kind of oversight she provided to the staff education program to ensure compliance with the program. DON B stated that she would get with Staff Educator J a few times a month and go over the program. DON B stated that she had not asked for an audit of staff competencies to ensure they were being completed in a long while. DON B stated that the staff education program was brought to the QA meetings. ON 5/15/2026 at 1:58 PM, Staff Educator J stated that staff competencies, and Certified Nurse Aid required 12 hour yearly educational hours were behind and not completed. Staff Educator J stated that she did not take updates regarding the staff education program to the monthly QAPI meetings and stated the staff education program was never brought up in QA. Staff Educator said that DON B never checks on her staff education program nor ever asks her about it. Review of the QA agenda meeting minutes for the month of 3/27/2025-4/23/2026 there were no QA notes regarding the dining room closure nor the staff development program. Antibiotic Stewardship Review:Resident #30 (R30)Review of the medical record revealed R30 was admitted to the facility 06/07/2024 with diagnoses that included peripheral vascular disease (PVD), dementia with severe mood disturbance, abnormal posture, contracture of left hand, dysphagia (difficulty swallowing), malnutrition, traumatic brain injury, constipation, depression, anxiety, benign prostatic hyperplasia (enlarged prostate), and cognitive communication deficit. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/13/2026, revealed a Brief Interview of Mental Status (BIMS) that was not completed as R30 was identified as resident is rarely/never understood). Review of Section H- Bladder and Bowel, of the MDS with the same ARD, revealed R30 has an indwelling catheter.Review of facility document entitled Infection Surveillance Report April 01, 2026 -April 30, 2026, revealed R30 had a urinary tract infection on 04/21/2026. The same document revealed: Signs & Symptoms as urinary complaints. The same document revealed R30 had drainage was noted in cath. (sp). R30 was started on Macrobid oral capsule 100mg (milligrams).Resident #39 (R39)Review of the medical record revealed R39 was admitted to the facility 09/02/2025 with diagnoses that included multiple rib fractures, anxiety, depression, hypothyroidism (low thyroid hormone), obstructive sleep apnea, epilepsy (neuroglial disease causing seizure), type 2 diabetes, insomnia, hypertension, lymphedema (fluid buildup in arms and legs caused by lymphatic system damage or blockage), aortic valve insufficiency, suicidal ideations, personality disorder, and chronic migraine (severe headache). The most recent Minimum Data set (MDS), with an Assessment Reference Date (ARD) of 04/11/2026, revealed a Brief Interview of Mental Status (BIMS) of 10 (moderate cognitive impairment) out of 15. Review of Section H-Bladder and Bowel, of the MDS with the same ARD, revealed R39 did not have an indwelling urinary catheter.Review of facility document entitled Infection Surveillance Report April 01, 2026 -April 30, 2026, revealed R39 had a urinary tract infection on 04/21/2026. The same document revealed: Signs & Symptoms as new or marked increase in incontinence, Suprapubic pain. R39 was stated on Levofloxacin Oral Tablet 500mg (milligrams) on 04/21/2026.During an interview on 05/15/2026 at 02:57 p.m. Infection Preventionist (IP) J explained that the facility follows McGeer Criteria as part of their Antibiotic Stewardship Program. IP J explained that when a physician starts and antibiotic for a resident she would review the residents medical record to ensure that the appropriate McGeer Criteria is met. IP J also explained that she would review the laboratory results, such as cultures to make sure the resident are receiving the appropriate antibiotic. IP explained that if the resident did not meet the criteria the attending physician would have to write a benefit analysis for treating the infection. IP J was asked to review the facility document entitled Infection Surveillance Report April 01, 2026 -April 30, 2026. IP J confirmed that R30 had not met McGeer Criteria for urinary tract infection. IP J explained that she had asked the attending physician to complete documentation for a risk benefit analysis. IP J explained that the physician had not documented a risk benefit analysis. IP J confirmed that R39 had not met McGeer Criteria for urinary tract infection. IP J explained that she had asked the attending physician to complete documentation for a risk benefit analysis. IP J explained that the physician had not documented a risk benefit analysis. IP J explained that she had identified that the facility was not meeting McGeer Criteria since December 2025 for residents that had been started on antibiotics. IP J explained that she had reported this information to the Infection Control Committee but could not provide supporting documentation in the Infection Prevention Committee Meeting minutes. Review of http://medicalcriteria.com/web/mcgeer-uit/ revealed the revised McGeer criteria define UTI's (Urinary Tract Infections) in long-term care residents based on symptomatic infection, with specific requirements for residents with and without indwelling catheters, emphasizing microbiologic confirmation and excluding asymptomatic bacteriuria. The above citation also revealed, For Resident without indwelling catheter, a UIT is defined by the presence of at least three new signs or symptoms, with may include:-Change in urine character-Dysuria (painful urination)-Urinary frequency or urgency-Fever or Elevated temperature- Suprapubic pain or tenderness-Acute functional decline or new onset of incontinenceFor residents with an indwelling urinary catheter, a UTI is defined by at least two new signs or symptoms, including:-Change in urine character-Fever or rigors (sudden, severed shivering)-Flank or suprapubic pain- Acute mental status changesDuring an interview on 05/15/2026 at 04:00 p.m. Nursing Home Administrator (NHA) A explained that the Quality Assurance Committee was made aware of the non-compliance of following the McGreer Criteria in January 2026. NHA A denied that the facility had implemented any improvement plan and could not explain what actions had been taken or why an improvement plan was not started.

Based on interview and record review, the facility failed to ensure that four of five Certified Nurse Aides (CNA) E, F, G, and I completed the required 12 hours of annual training to ensure adequate resident care. Findings include:On 5/14/2026 at 1:25 PM, the following five randomly selected CNA annual 12-hour nurse aide training/ in-services were reviewed with Staff Educator (SE) J:-CNA E was hired on 9/17/2014. The training in services provided by the facility did not add up to 12 hours.-CNA F was hired on 7/18/2000. The training in services provided by the facility did not add up to 12 hours.-CNA G was hired on 1/11/2017. The training in services provided by the facility did not add up to 12 hours.-CNA H was hired on 4/15/2015. The training in services provided by the facility did add up to12 hours including dementia and abuse training.-CNA I was hired on 8/3/2022. The training in services provided by the facility did not add up to 12 hours.On 5/14/2026 at 3:52 PM, SE J was interviewed and said she started the position on August 2025, and that the facility recently changed to a different staff educator tracking system.On 5/15/2026 at 8:57 AM, the Director of Nursing (DON) was interviewed and said the expectation is for CNAs to have 12 hr. annual training which should include dementia and abuse training.Review of the facility policy titled Staff Development last revised 6/10/2024 revealed in part .The staff development coordinator provides training and orientation to assist staff in performing their assigned functions. Maintain records of classes and content of training conducted, and the presence and participation of facility employees. Nurse aides are provided no less than 12 hours of in-service education per year from the employee's date of hire.

Based on observation, interview and record review the facility failed to promote an environment that ensures dignity in 1 of 2 sampled residents (#117) reviewed for dignity, resulting in the potential for Resident #117 to feel embarrassment and worthless when facility staff fail to assist with toileting timely.Findings include:Resident #117 (R117)Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R117was a [AGE] year old female admitted to the facility on [DATE], with readmission post hospitalization on 2/11/26 and 4/22/26 for urinary tract infections, with diagnoses that included hypertension (high blood pressure), diabetic, anemia, renal disease, muscle weakness and depression. The MDS reflected R117 had a BIM (assessment tool) score of 13 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for toileting.During an observation and interview on 5/12/2026 at 2:31 PM, R117 was sitting in wheelchair in located in her room and appeared able to answer questions without difficulty. R117 requested to speak with this surveyor in private. R117 reported was at facility for therapy with plans to discharge home, however, had to be recently readmitted to the hospital two times related to bad urinary tract infections. R117 reported she required staff assistance with changing brief and has to wait greater than one to two hours, three to four times weekly on night shift for incontinence care. R117 reported often voids twice in brief before calling for assistance because there were not enough staff. R117 reported husband had completed two concern forms related to call light wait times and discussed at Care Conferences with no follow up or improvements. R117 reported made resident feel worthless sitting in own urine while waiting for assistance. Review of the Grievance Log, dated 12/1/25 through 5/12/26, reflected no grievances for R117.Review of the Electronic Medical Record (EMR), dated 12/1/25 through 5/12/26, reflected that R117 had been admitted to the hospital for Urinary Tract Infection (UTI) with septic shock on 4/22/26 altered mental status and UTI on 2/3/26.Review of R117 EMR task Report, dated 12/1/25 through 5/12/26, reflected several holes (no documentation) for completed tasks including incontinence hygiene. During an interview on 5/13/2026 at 4:55 p.m., Nursing Home Administrator (NHA) A denied any concerns reported for R117. NHA A reported managers round on hall 200, including R117, 3 x weekly. NHA A provided log that showed R117 present 3 times weekly even when R117 was not present at facility when admitted to hospital 4/13/26 to 4/22/26. NHA A verified staff speak with R117 in person and unable to explain why R117 had entries while at the hospital and verified was not present for 3 days of completed rounds.During an interview on 5/14/26 at 2:20 p.m., Certified Nurse Aid (CNA) BB reported often worked on 200 hall and reported was very heavy hall with most residents being dependent on staff for assistance. CNA BB reported often worked with R117 on first shift and on more than one occasion had arrived in morning and R117 was saturated in urine and R117 had informed CNA BB that night shift had never checked on her all night. CNA BB reported would inform nurse and document in alter charting on electronic medical record. During an interview on 5/15/26 at about 2:00 p.m., Director of Nursing (DON) B reported would expect if documented that task was completed. Reported would also expect staff to document if task was completed. During an interview on 5/15/2026 at 3:00 PM, R117 was located in room and again verified after speaking with husband grievance forms had been completed with no follow up. R117 reported yesterday she waited 45 minutes to have brief changed after waiting to have call light answered between 5:15 pm and 6:00 pm. R117 stated, makes me feel like last living cell in bottom of test tube.

Based on observation, interview, and record review, the facility failed to honor a resident's right to determine own schedule for showering for one resident (R18) of one reviewed for self-determination. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R18 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), diabetic, anemia, end stage renal disease with dialysis. The MDS reflected R18 had a BIM (assessment tool) score which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for bathing.During an observation and interview on 5/12/26 at about 2:30 p.m., R18 was observed in bed and able to answer questions without difficulty. R18 reported some staff are rude and stated, I do not want to be here but have to be and they give me attitude for asking for help. R18 reported have had several missed showers because they want her to shower on her dialysis days and reported was too exhausted. R18 reported had dialysis three days per week. R18 reported completed grievance form related to concern with no follow up.Review of R18 Electronic Medical Record, dated 4/26/26 through 5/12/16, reflected several missed showers.During an interview on 5/14/2026 at 2:00 PM, R18 reported had showers scheduled for Wednesday (day of dialysis and exhausted) and Saturday. R18 reported staff have never asked her when she wanted showers. During an interview on 5/14/2026 at 2:20 pm, Certified Nurse Aid (CNA) BB reported residents with dialysis schedule showers on other days because it is too much. CNA BB verified R18 was scheduled for Wednesday/Saturday showers and should not be Wednesday. CNA BB verified R18 had several refused showers and stated, that could be why. CNA BB reported was not sure why R18 was scheduled on dialysis days. During an interview on 5/15/2026 at 12:49 PM, Unit Manager (UM) CC reported worked with R18 about concern for showers and initially related to not offered and then just not feeling up to it and offered next day when R18 reported concern. UM CC reported new admitted residents informed of shower schedule that was according to room number, and she did not identify a preference. UM CC verified R18 scheduled for Wednesday and Saturday and verified dialysis Monday, Wednesday and Friday. When asked why R18 was scheduled on dialysis day on second shift, UM CC stated, why not?During an interview on 5/15/2026 at 3:23 PM, Director of Nursing (DON) B reported showers were assigned by room initially then tailored to resident needs. DON B reported would expect if grievance form completed for showers staff ask resident preference of showers.

Based on observation and interview the facility failed to protect resident's personal private information and confidentiality of records for two residents' (R92 and R97) of two residents reviewed for privacy of information.Findings Include;Resident #92 (R92)During an observation and interview on 05/14/2026 at 2:11 PM, the computer sitting on the medication cart was open with R92's personal private information and confidentiality of records visible to anyone walking by. There was not a nurse within sight of the medication cart. Writer stood by the medication cart and waited for the nurse to return to her cart. LPN P came out of the room stating she had spilt water and was trying to clean it up. LPN P looked up to notice she had left the computer open and she at that time closed it. Writer asked why the computer was left open and LPN P stated she was trying to clean up the water that she had spilt and forgot to close it. Resident #97 (R97)During an interview and observation on 05/15/2026 at 7:00 AM, Licensed Practical Nurse (LPN) O prepared medications to administer to R97, no hand hygiene was performed prior to setting up the medications, or after medications were prepared. LPN O picked up his medication cup from the medication cart and walked into R97's room. LPN O left his computer open with R97 personal private information and confidentiality of records left open for anyone to see that passes the medication cart.During an interview on 05/15/26 at 7:58 AM, Writer asked LPN O why he left the computer open with personal private information and confidentiality of records visible to anyone that walked by. LPN O stated he didn't know, he had worked all night and was tired.

Based on interview and record review, the facility failed to ensure that two of five Certified Nurse Aides (CNA) H, and I had annual competencies completed to ensure adequate resident care. Findings include:On 5/14/2026 at 1:25 PM, the randomly selected CNA annual performance reviews were reviewed with Staff Educator (SE) J:-CNA H was hired on 4/15/2015. The facility did not provide an annual performance review.-CNA I was hired on 8/3/2022. The facility did not provide an annual performance review.On 5/14/2026 at 3:52 PM, SE J was interviewed and said she started the position on August 2025, and that the facility recently changed to a different staff educator tracking system. SE J said she started the CNA performance reviews but was not able to get them all done.On 5/15/2026 at 8:57 AM, the Director of Nursing (DON) was interviewed and said the expectation is for CNAs to have an annual performance review in order to adjust trainings to cover areas of needed improvement.Review of the facility policy titled Staff Development last revised 6/10/2024 revealed in part .The staff development coordinator provides training and orientation to assist staff in performing their assigned functions. Maintain records of classes and content of training conducted, and the presence and participation of facility employees. Nurse aides are provided no less than 12 hours of in-service education per year from the employee's date of hire. A competency evaluation will be completed annually for all certified nurse aides. Training will be added to the calendar based on the weakness identified.

Based on observation and interviews the facility failed to ensure 4 outdated medications and supplies were removed from the central supply room with the potential to be used on residents.Findings Include:During an observation and interview on 05/14/2026 at 4:35 PM, Central Supply staff U stated she stocked the shelves with all the over-the-counter medication, wound care dressing supplies, supplemental feeding supplements, and basic items for personal care. Central Supply staff U stated she monitors the shelves for expiration dates and it there is a medication or supply that is in the month that it will expire, she will see if the nurses use this item frequently and if so, to use it before it expires. If this isn't something they use often, they will throw it away.The following items expired were observed to be still on the shelf to use:Derma Pak- its- packing strips- expired on 08-01-242 bottles of Skintegrity wound cleaner- expired on 04/30/25Aquasonic 100 ultrasound gel packs, expired on 09/11/25 During an interview on 05/14/2026 at 5:15 PM, DON B was asked about the 4 expired items found in the central supply. DON B stated there shouldn't be any expired medications or items in the central supply room. DON B was updated that the Central Supply staff U stated their process to throw out medications during the month it expired. Central Supply staff U would go to the medication carts to see if it is a medication that is used frequently. If not, they will throw them in a bag to throw them out. Writer asked DON B if they had a policy for use of medications during the month it expired. DON B stated she would have to look. Facility did not have a policy at the time of inquiry.

Based on observation and interview the facility failed to follow infection control measures during medication administration for three residents (R97, R66, R65) resulting in potential of spreading germs to other residents.Resident 97, Resident 66, Resident 65 (R97, R66, R65) During an interview and observation on 05/15/2026 at 7:00 AM, Licensed Practical Nurse (LPN) O stated he had already given some patients their medication but had not signed them out. LPN O stated he works nights and was still trying to catch up on his medication administration. LPN O prepared medications to administer to R97, no hand hygiene was performed prior to setting up the medications, or after medications were prepared. LPN O picked up his medication cup from the medication cart and walked into R97's room. LPN O donned gloves and checked R97's blood sugar on left hand 1st finger wearing gloves, read 119. LPN O did not use hand hygiene before putting on gloves or after removing them.During an observation of 05/15/2026 at 7:15 AM, LPN O prepared medications for R66, no hand hygiene before or after prepping R66's medication. LPN O took R66's medication to her in her room and exited her room, no hand hygiene after leaving her room.During this same observation period, LPN O prepared medication for R65, he pulled the medication from the over-the-counter supply in the top drawer and placed it in a medication cup. LPN O then walked into R65's room and administered the medication, exited the resident's room and went back to the medication cart. No hand hygiene before or after administered medication to R65.During an interview on 05/15/26 at 7:58- LPN O was asked what his process was for cleaning the glucometer, as this writer did not see him clean it. LPN O stated he cleaned it with an alcohol wipe. Facility policy review reflected cleaning equipment and bleach germicidal wipes are to be used, not alcohol wipes.

Based on interview and record reviewed the facility failed to follow an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for two Residents (#30, #39) out of four residents reviewed.Findings Included: Resident #30 (R30)Review of the medical record revealed R30 was admitted to the facility 06/07/2024 with diagnoses that included peripheral vascular disease (PVD), dementia with severe mood disturbance, abnormal posture, contracture of left hand, dysphagia (difficulty swallowing), malnutrition, traumatic brain injury, constipation, depression, anxiety, benign prostatic hyperplasia (enlarged prostate), and cognitive communication deficit. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/13/2026, revealed a Brief Interview of Mental Status (BIMS) that was not completed as R30 was identified as resident is rarely/never understood). Review of Section H- Bladder and Bowel, of the MDS with the same ARD, revealed R30 has an indwelling catheter.Review of facility document entitled Infection Surveillance Report April 01, 2026 -April 30, 2026, revealed R30 had a urinary tract infection on 04/21/2026. The same document revealed: Signs & Symptoms as urinary complaints. The same document revealed R30 had drainage was noted in cath. (sp). R30 was started on Macrobid oral capsule 100mg (milligrams).Resident #39 (R39)Review of the medical record revealed R39 was admitted to the facility 09/02/2025 with diagnoses that included multiple rib fractures, anxiety, depression, hypothyroidism (low thyroid hormone), obstructive sleep apnea, epilepsy (neuroglial disease causing seizure), type 2 diabetes, insomnia, hypertension, lymphedema (fluid buildup in arms and legs caused by lymphatic system damage or blockage), aortic valve insufficiency, suicidal ideations, personality disorder, and chronic migraine (severe headache). The most recent Minimum Data set (MDS), with an Assessment Reference Date (ARD) of 04/11/2026, revealed a Brief Interview of Mental Status (BIMS) of 10 (moderate cognitive impairment) out of 15. Review of Section H-Bladder and Bowel, of the MDS with the same ARD, revealed R39 did not have an indwelling urinary catheter.Review of facility document entitled Infection Surveillance Report April 01, 2026 -April 30, 2026, revealed R39 had a urinary tract infection on 04/21/2026. The same document revealed: Signs & Symptoms as new or marked increase in incontinence, Suprapubic pain. R39 was stated on Levofloxacin Oral Tablet 500mg (milligrams) on 04/21/2026.During an interview on 05/15/2026 at 02:57 p.m. Infection Preventionist (IP) J explained that the facility follows McGeer Criteria as part of their Antibiotic Stewardship Program. IP J explained that when a physician starts and antibiotic for a resident she would review the residents medical record to ensure that the appropriate McGeer Criteria is met. IP J also explained that she would review the laboratory results, such as cultures to make sure the resident are receiving the appropriate antibiotic. IP explained that if the resident did not meet the criteria the attending physician would have to write a benefit analysis for treating the infection. IP J was asked to review the facility document entitled Infection Surveillance Report April 01, 2026 -April 30, 2026. IP J confirmed that R30 had not met McGeer Criteria for urinary tract infection. IP J explained that she had asked the attending physician to complete documentation for a risk benefit analysis. IP J explained that the physician had not documented a risk benefit analysis. IP J confirmed that R39 had not met McGeer Criteria for urinary tract infection. IP J explained that she had asked the attending physician to complete documentation for a risk benefit analysis. IP J explained that the physician had not documented a risk benefit analysis. IP J explained that she had identified that the facility was not meeting McGeer Criteria since December 2025 for residents that had been started on antibiotics. IP J explained that she had reported this information to the Infection Control Committee but could not provide supporting documentation in the Infection Prevention Committee Meeting minutes.During an interview on 05/15/2026 at 04:00 p.m. Nursing Home Administrator (NHA) e A explained that the Quality Assurance Committee was made aware of the non-compliance of following the McGreer Criteria in January 2026. NHA A denied that the facility had implemented any improvement plan and could not explain what actions had been taken or why a improvement plan was not started.Review of http://medicalcriteria.com/web/mcgeer-uit/ revealed the revised McGeer criteria define UTI's (Urinary Tract Infections) in long-term care residents based on symptomatic infection, with specific requirements for residents with and without indwelling catheters, emphasizing microbiologic confirmation and excluding asymptomatic bacteriuria. The above citation also revealed, For Resident without indwelling catheter, a UIT is defined by the presence of at least three new signs or symptoms, with may include:-Change in urine character-Dysuria (painful urination)-Urinary frequency or urgency-Fever or Elevated temperature- Suprapubic pain or tenderness-Acute functional decline or new onset of incontinenceFor residents with an indwelling urinary catheter, a UTI is defined by at least two new signs or symptoms, including:-Change in urine character-Fever or rigors (sudden, severed shivering)-Flank or suprapubic pain- Acute mental status changes

Based on observation, interview, and record review the facility failed to ensure one out of three residents (Resident #12) received activities of daily living (ADL) care per the plan of care. Findings Included: Review of a Minimum Data Set (MDS) dated [DATE] on page #21 under section GG revealed, R12 was dependent on staff for Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed.The MDS defined dependent as, Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.On 12/23/2025 at 10:16 AM, Certified Nurse Aid (CNA) J was observed to perform catheter care for Resident #12 (R12) while R12 was in bed. R12 was observed to be laying on the left side of the bed, R12's left side and not in the middle of the bed, CNA J proceeded to tell R12 to roll over to his left side, in which R12 did. CNA J performed peri care and took out the old bedding from underneath R12; during that time R12 was rolled to his left side R12 stated to CNA J he was going to roll over the edge of the bed. CNA J said OKAY, however did not roll R12 immediately back onto his back, and continued to finish putting the new bedding and brief underneath R12.During the observation R12 was observed to be very close to the edge of the left side of the bed when he was rolled over to his left side. Furthermore, CNA J was observed to have rolled R12 away from her and not towards her when she turned R12 to his left and also to his right side while in the bed. There were not handrails for R12 to hold onto or to possibly stop him from rolling out of the bed onto the floor.Review of R12's care plans dated 11/12/2025, revealed a care plan was in place with a Focus of (R12) has a functional ability deficit and requires assistance with self care/mobility . The care plan included an intervention that instructed staff for BED MOBILITY: (R12) requires Dependent assist of two helpers with bed mobility. This is including rolling side to side, lying to sitting on side of bed and sitting to lying. The intervention was dated 11/12/2025. Review of R12's Kardex (a residents documented plan of care for CNA to review and know how to care for a resident) revealed under BED MOBILITY: (R12) requires Dependent assist of two helpers with bed mobility. This is including rolling side to side, lying to sitting on side of bed and sitting to lying. The intervention was dated 11/12/2025. In an interview with CNA J on 12/23/25 at 10:39 AM, CNA J stated R12 was a one person assist while in bed for bed mobility. CNA J was asked when the last time was that she had reviewed R12's Kardex (plan pf care), CNA J stated about three days ago. In an interview on 12/23/2025 at 10:41 AM Director of Nursing (DON) B stated that R12's care plans instruct staff to provide a two person assist for bed mobility and rolling side to side in bed, DON B said her expectation was that two staff members provided bed mobility care, including while rolling R12 side to side in bed. DON B also stated that her expectation for any staff member rolling a resident in bed side to side with just a one-person assist was to roll the resident towards them and not away from them.

Based on Observation, interview and record review, the facility failed to thoroughly investigate for two out of two residents (Resident #1, and Resident #3) allegations of abuse. Review of a facility reported incident (FRI) dated 07/07/25 at 5:45pm and reported to the state on 07/07/25 at 6:31 PM. 5 day follow up dated 07/10/25. R2 and CNA L were walking on hall 200 when R2 told R1 oh you look like you need a kiss, bent down and kissed R1 on the lips. R1 responded to R2 by telling R2 he was going to tell on her and called her a bitch. CNA L separated them and took R2 to another area. Social workers met with both residents. R2 did not recall the incident and remained ambulatory throughout the facility.R1 did recall the incident and was educated about the use of profanity and the need to call for staff for assistance.R1 was witnessed by LPN M yelling at R2, Get the fuck away from me. According to R1, R2 allegedly kissed him, and he shouted profane words towards her. LPN M immediately separated the residents. Resident # 2 (R2)Review of the medical record reflected R2 was a female who was admitted to the facility on [DATE]. Diagnoses of Alzheimer's Disease with early onset and Depression.R2 resided in the 100 hall. Per the census R2 was moved out of the dementia until and transferred to the 100 hall to room [ROOM NUMBER]-2 on 07/08/2025.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/26/2025, revealed R2 had a Brief Interview of Mental Status (BIMS) of 5 out of 15 (severe impairment) and is independent with transfers, walking. Resident # 1 (R1)Review of the medical record reflected R1 was admitted to the facility on [DATE]. Diagnoses of, generalized anxiety, major depression, Bi-polar disorder, schizoaffective disorder and dementia.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/01/2025, revealed R2 had a Brief Interview of Mental Status (BIMS) of 15 out of 15 (cognitively intact) and is dependent on mechanical lift to transfer from surface to surface, wheelchair bound. Resident #3 (R3)Review of the medical record reflected R3 was admitted to the facility on [DATE]. Diagnoses of vascular dementia, adjustment disorder with mixed emotions, cognitive social/emotional deficit and major depression.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) revealed R3 had a Brief Interview of Mental Status (BIMS) of 14 out of 15 (cognitively intact) and is dependent on mechanical lift to transfer from surface to surface, wheelchair bound.During the onsite investigation another incident occurred in which the facility provided the FRI. Upon review of the FRI on 08/14/2025 at 11:00AM, R2 was walking throughout the facility with a staff person providing intermittent supervision, and R2 told R3 that he looked like he needed a kiss and bent down and kissed him on the lips.During an interview on 08/27/2025 at 9:30 AM, Social Worker (SW) H stated that R2 attended activities, ate her lunch and dinner in the dining room and slept well all night. SW H added that R2 had the same routine now that she had back in the memory care unit. SW H stated that when they moved her off the memory care unit, her care plan was updated and had intermittent one to one supervision at times. SW H stated they were monitoring R2 as a team, SW H did not elaborate on what that m. SW H stated after the incident on 07/07/2025, SW H updated R2's nonpharmacological services, referred her to psychiatric services, medication changes to decrease her libido. After the incident on 08/14/2025, she referred R2 back to psychiatric services, stated she was not sure if there were any medication changes or not. SW H stated she continued having conversations with R2's sister who was her durable power of attorney as they looked for another female facility that was a female only locked unit. SW H stated R2 was supervised throughout the day doing her normal activities. SW H stated they had intermittent one on one more so in the evening hours of 8:00pm to 10:00pm. Writer asked SW H if they had done any root cause analysis regarding R2's inappropriate behaviors towards R1 and R3. SW H stated not really.Record review revealed R2 had started seeing psychiatric services before the first inappropriate sexual behavior had accrued, so referring R2 back to psychiatric services was not a new intervention. R2 was seen by psychiatric services on the following dates, 03/17/2025, 04/03/2025, 04/09/2025, 04/17/2025, 05/15/2025, 05/23/2025, 06/26/2025, 07/09/2025, 08/05/2025 and 08/20/2025. Review of R2's medication administration record (MAR) revealed R2 was never ordered a medication that would decrease her libido and therefore had never taken such medication.During an interview on 08/27/2025 at 10:38 AM, SW H stated they would continue non-pharmacological actions as they are detailed in her care plan. SW H added that the new interventions were for psychiatric services. SW H told writer to talk to LNA A about the one-on-one supervision for R2, as she was unclear.During an interview on 08/27/2025 at 1:55 PM, Director of Nursing (DON) B was asked why R2 was removed off from the memory unit? DON B stated R2 and a male resident had this delusion they were in a relationship, but they didn't have one. This writer asked about the second inappropriate sexual behavior between R2 and R1. DON B stated what she recalled was R2 was walking down the hallway with a CNA and R1 was sitting in his wheelchair in the hallway, R2 bent down and kissed him on the lips. DON B added that R2 was taken away from that resident and was distracted by giving her a snack. DON B added that R2 could not recall what took place, and R2 was referred to Social Work and psychiatric services again. DON B added that R2 had not had any more inappropriate sexual behaviors that she is aware of. This writer asked DON B if they had done a root cause analysis to see what factors may be contributing to this behavior and DON B stated no, because she didn't see anything common in these actions. DON B stated they discuss these issues at the morning Inter Disciplinary Team (IDT) meetings, discussed with the team in the morning, or at the end of the day during the stand down meetings. This writer asked DON B where that documentation would be and she stated under progress notes if there was any, no documentation to support this could be found in R2's electronic medical records. This writer asked about updating the care plan for R2, DON B stated it was updated in April and May adding R2 was no longer having inappropriate sexual behaviors. DON B added that the care plan section under social work, was updated in May and July of 2025. DON B was reading off previous interventions out loud and writer asked what new interventions were added after these three separate incidents. DON B stated there was a couple of interventions dated 07/31/2025, but no related to these behaviors. Writer asked when R2 was to have one on one supervision, DON B stated when they see R2 needing guidance such as staring off at nothing or needing help with the next thing she does. DON B stated that if R2 needs ongoing one on one, the CNA was to stay with her until they can get coverage for her assignment or have an activity person assist them. DON B could not say what shift or time frame that R2 would need that.During an interview on 08/27/25 at 3:00PM, Receptionist I stated she was walking out of the kitchen when saw R2 and R3 holding hands in front of the activity room, R2 bent down and kissed R3 on the lips. Receptionist I stated she separated them and told the nurses on their units, DON B and LNA A. Receptionist I stated she assisted the DON B with filling out the form and DON B told her that she would submit the form to the state. Receptionist I stated she didn't have anything more to do with that incident.During an observation and interview on 08/27/2025 at 3:35 PM, R1 was observed leaving his room and stopped in the hallway. R1 stated R2 continued to walk down his hall which was hall 200 and not the hall R2 resided on. R1 stated R2 continues to attempt to always sit be him during activities. R1 stated it pissed him off, he got mad about it, and it upset him. R1 state R2 goes into activities and other events to be near him, and he didn't like it. R1 stated again, it really pissed him off.During an interview on 08/28/2025 at 10:05 AM, Licensed Nursing Home Administrator (LNA) A stated that after the incident on 3/30/2025, R2 was transfer to the 100 hall and out of the memory care unit. LNA A stated R2 had kissed R1 and R3 outside of the memory unit. LNA A stated that R2 is now more involved in activities and eating in the dining room. LNA A added if nursing feels R2 needed one on one supervision, they would pull a CNA off the floor from providing care to be with R2 however, LNA A did not state what would cause nursing to feel R2 needed the one-on-one supervision. LNA A stated she didn't see R2 kissing R1 and R3 as inappropriate behavior, because R2 did not latch onto him but more of an affectionate thing.This writer asked LNA A if other residents and staff were interviewed that live or work on that hall. LNA A stated no. LNA A stated she did not interview the residents that live on that hall, she would have had to interview all residents because R2 walks throughout the whole facility. Writer asked LNA A if the staff working in that area on the dates that this took place were interviewed, LNA A stated no.This writer asked LNA A if IDT meetings were held and documented any follow up from these incidents. LNA A stated they discussed it during IDT meetings, but it is not documented anywhere.LNA A stated that I & A is a risk management report where the nurses document the event that accrued, notifies the LNA, family, DON, provider, describes the event, immediate action to take place, removed R2 from the memory care unit, SW H to follow up. Looked for any predisposition factors, SW H wrote what they did, referred to psychiatric services, SW H became the key person to oversee this. Could have had a telehealth visit made with the provider, LNA A and DON B discuss what should be done until they write up the 5-day report. LNA A stated they look at QA based on the audits, education to staff if there was a break in the process. LNA A stated they would put in new interventions if the current ones didn't work. LNA A stated they didn't have anything else to add. Stated they went back to the care plan and added one-on-one supervision based off her behavior. R2 is more involved with activities. Asked why she didn't change or add new interventions, because they were already doing everything, they said they were already in place and because it was working.

Based on observation, interview, and record review, the facility failed to update and revise resident care plan's, in three of three residents reviewed for care plans (Resident #2, Resident #1 and Resident #3), resulting in potential for not maintaining or obtaining their highest practicable physical and emotional wellbeing. Findings include:Review of a facility reported incident (FRI) dated 07/07/25 at 5:45pm and reported to the state on 07/07/25 at 6:31 PM. 5 day follow up dated 07/10/25. R2 and CNA L were walking on hall 200 when R2 told R1 oh you look like you need a kiss, bent down and kissed R1 on the lips. R1 responded to R2 by telling R2 he was going to tell on her and called her a bitch. CNA L separated them and took R2 to another area. Social workers met with both residents. R2 did not recall the incident and remained ambulatory throughout the facility.R1 did recall the incident and was educated about the use of profanity and the need to call for staff for assistance.R1 was witnessed by LPN M yelling at R2, Get the fuck away from me. According to R1, R2 allegedly kissed him, and he shouted profane words towards her. LPN M immediately separated the residents. Resident # 2 (R2)Review of the medical record reflected R2 was a female who was admitted to the facility on [DATE]. Diagnoses of Alzheimer's Disease with early onset and Depression.R2 resided in the 100 hall. Per the census R2 was moved out of the dementia until and transferred to the 100 hall to room [ROOM NUMBER]-2 on 07/08/2025.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/26/2025, revealed R2 had a Brief Interview of Mental Status (BIMS) of 5 out of 15 (severe impairment) and is independent with transfers, walking. Resident # 1 (R1)Review of the medical record reflected R1 was admitted to the facility on [DATE]. Diagnoses of, generalized anxiety, major depression, Bi-polar disorder, schizoaffective disorder and dementia.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/01/2025, revealed R2 had a Brief Interview of Mental Status (BIMS) of 15 out of 15 (cognitively intact) and is dependent on mechanical lift to transfer from surface to surface, wheelchair bound. Resident #3 (R3)Review of the medical record reflected R3 was admitted to the facility on [DATE]. Diagnoses of vascular dementia, adjustment disorder with mixed emotions, cognitive social/emotional deficit and major depression.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) revealed R3 had a Brief Interview of Mental Status (BIMS) of 14 out of 15 (cognitively intact) and is dependent on mechanical lift to transfer from surface to surface, wheelchair bound.During the onsite investigation another incident occurred in which the facility provided the FRI. Upon review of the FRI on 08/14/2025 at 11:00AM, R2 was walking throughout the facility with a staff person providing intermittent supervision, and R2 told R3 that he looked like he needed a kiss and bent down and kissed him on the lips. Review of a care plan with a focus of, (R2) has HX of going in and out of other resident rooms and holding hands with peers and/or sitting close to their body at times requiring redirection. [NAME] has HX of making sexual innuendos, sticking her tounge out, showing of fingers, doting behavior and drawing out attention toward particular male peer which was ceased since transition off of memory care unit. HX of peck kissing another male peer, dated 05/15/2025 revealed that all the interventions were dated 05/25/25 and there was no interventions added after 07/07/25 nor the 08/14/25 incidents of R2 kissing R1 and R3.Further review of R2's care plan revealed no other care plan or interventions were in place that addressed R2's inappropriate touching of other residents.During an interview on 08/27/2025 at 9:30 AM, Social Worker (SW) H stated that R2 attended activities, ate her lunch and dinner in the dining room and slept well all night. SW H added that R2 had the same routine now that she had back in the memory care unit. SW H stated that when they moved her off the memory care unit, her care plan was updated and had intermittent one to one supervision at times. SW H stated they were monitoring R2 as a team, SW H did not elaborate on what that m. SW H stated after the incident on 07/07/2025, SW H updated R2's nonpharmacological services, referred her to psychiatric services, medication changes to decrease her libido. After the incident on 08/14/2025, she referred R2 back to psychiatric services, stated she was not sure if there were any medication changes or not. SW H stated she continued having conversations with R2's sister who was her durable power of attorney as they looked for another female facility that was a female only locked unit. SW H stated R2 was supervised throughout the day doing her normal activities. SW H stated they had intermittent one on one more so in the evening hours of 8:00pm to 10:00pm. Writer asked SW H if they had done any root cause analysis regarding R2's inappropriate behaviors towards R1 and R3. SW H stated not really.Record review revealed R2 had started seeing psychiatric services before the first inappropriate sexual behavior had accrued, so referring R2 back to psychiatric services was not a new intervention. R2 was seen by psychiatric services on the following dates, 03/17/2025, 04/03/2025, 04/09/2025, 04/17/2025, 05/15/2025, 05/23/2025, 06/26/2025, 07/09/2025, 08/05/2025 and 08/20/2025. Review of R2's medication administration record (MAR) revealed R2 was never ordered a medication that would decrease her libido, and therefore had never taken such medication. During an interview on 08/27/2025 at 10:38 AM, SW H stated they would continue non-pharmacological actions as they are detailed in her care plan. SW H added that the new interventions were for psychiatric services. SW H told writer to talk to LNA A about the one-on-one supervision for R2, as she was unclear. During an interview on 08/27/2025 at 1:55 PM, Director of Nursing (DON) B was asked why R2 was removed off from the memory unit? DON B stated R2 and a male resident had this delusion they were in a relationship, but they didn't have one. This writer asked about the second inappropriate sexual behavior between R2 and R1. DON B stated what she recalled was R2 was walking down the hallway with a CNA and R1 was sitting in his wheelchair in the hallway, R2 bent down and kissed him on the lips. DON B added that R2 was taken away from that resident and was distracted by giving her a snack. DON B added that R2 could not recall what took place, and R2 was referred to Social Work and psychiatric services again. DON B added that R2 had not had any more inappropriate sexual behaviors that she is aware of. This writer asked DON B if they had done a root cause analysis to see what factors may be contributing to this behavior and DON B stated no, because she didn't see anything common in these actions. DON B stated they discuss these issues at the morning Inter Disciplinary Team (IDT) meetings, discussed with the team in the morning, or at the end of the day during the stand down meetings. This writer asked DON B where that documentation would be and she stated under progress notes if there was any, no documentation to support this could be found in R2's electronic medical records. This writer asked about updating the care plan for R2, DON B stated it was updated in April and May adding R2 was no longer having inappropriate sexual behaviors. DON B added that the care plan section under social work, was updated in May and July of 2025. DON B was reading off previous interventions out loud and writer asked what new interventions were added after these three separate incidents. DON B stated there was a couple of interventions dated 07/31/2025, but no related to these behaviors. Writer asked when R2 was to have one on one supervision, DON B stated when they see R2 needing guidance such as staring off at nothing or needing help with the next thing she does. DON B stated that if R2 needs ongoing one on one, the CNA was to stay with her until they can get coverage for her assignment or have an activity person assist them. DON B could not say what shift or time frame that R2 would need that.During an interview on 08/27/25 at 3:00PM, Receptionist I stated she was walking out of the kitchen when saw R2 and R3 holding hands in front of the activity room, R2 bent down and kissed R3 on the lips. Receptionist I stated she separated them and told the nurses on their units, DON B and LNA A. Receptionist I stated she assisted the DON B with filling out the form and DON B told her that she would submit the form to the state. Receptionist I stated she didn't have anything more to do with that incident.During an observation and interview on 08/27/2025 at 3:35 PM, R1 was observed leaving his room and stopped in the hallway. R1 stated R2 continued to walk down his hall which was hall 200 and not the hall R2 resided on. R1 stated R2 continues to attempt to always sit be him during activities. R1 stated it pissed him off, he got mad about it, and it upset him. R1 state R2 goes into activities and other events to be near him, and he didn't like it. R1 stated again, it really pissed him off. During an interview on 08/28/2025 at 10:05 AM, Licensed Nursing Home Administrator (LNA) A stated that after the incident on 3/30/2025, R2 was transfer to the 100 hall and out of the memory care unit. LNA A stated R2 had kissed R1 and R3 outside of the memory unit. LNA A stated that R2 is now more involved in activities and eating in the dining room. LNA A added if nursing feels R2 needed one on one supervision, they would pull a CNA off the floor from providing care to be with R2 however, LNA A did not state what would cause nursing to feel R2 needed the one-on-one supervision. LNA A stated she didn't see R2 kissing R1 and R3 as inappropriate behavior, because R2 did not latch onto him but more of an affectionate thing.This writer asked LNA A if other residents and staff were interviewed that live or work on that hall. LNA A stated no. LNA A stated she did not interview the residents that live on that hall, she would have had to interview all residents because R2 walks throughout the whole facility. Writer asked LNA A if the staff working in that area on the dates that this took place were interviewed, LNA A stated no.This writer asked LNA A if IDT meetings were held and documented any follow up from these incidents. LNA A stated they discussed it during IDT meetings, but it is not documented anywhere.LNA A stated that I & A is a risk management report where the nurses document the event that accrued, notifies the LNA, family, DON, provider, describes the event, immediate action to take place, removed R2 from the memory care unit, SW H to follow up. Looked for any predisposition factors, SW H wrote what they did, referred to psychiatric services, SW H became the key person to oversee this. Could have had a telehealth visit made with the provider, LNA A and DON B discuss what should be done until they write up the 5-day report. LNA A stated they look at QA based on the audits, education to staff if there was a break in the process. LNA A stated they would put in new interventions if the current ones didn't work. LNA A stated they didn't have anything else to add. Stated they went back to the care plan and added one-on-one supervision based off her behavior. R2 is more involved with activities. Asked why she didn't change or add new interventions, because they were already doing everything, they said they were already in place and because it was working.

This citation pertains to Intake(s) 1216042, 1216038, 1216041Based on observations, interviews, record reviews, and 1 (200) of 4 sampled residents, the facility failed to maintain ambient room temperatures within the acceptable regulatory parameters (71-81 degrees Fahrenheit) affecting 116 residents, resulting in the increased likelihood for resident dehydration and physical/emotional discomfort.Findings include:On 7/15/25 at 1:26 PM during an interview with LPN “D”, when asked if there had been any issues with the air conditioning, she reported “it is hell” (referring to the facility being excessively hot) and that they were trying to get portable air conditioning units for resident rooms [ROOM NUMBERS], as those rooms get direct sunlight and seem to be the warmest. LPN “D” reported that the unit she worked on was provided 6 fans for approximately 34 residents. LPN “D” further reported that when you enter the hallway of their unit from the main area you can feel a temperature increase. When asked if maintenance staff have been checking the room temperatures, she reported that the temperatures are checked around 7am, prior to full sun and temperatures outside rising. On 07/15/25 at 09:50 A.M., An interview was conducted with Resident #200 regarding ambient room temperatures. Resident #200 stated: “The portable air conditioning unit will trip the circuit breaker. Resident #200 also stated: “I have to unplug my firestick to have a place for the air conditioner plug.” On 07/15/25 at 10:23 A.M., An interview was conducted with Maintenance Director (MD) “E” regarding the facility air conditioning units. (MD) “E” stated: Our roof top units (RTU’s) are old., We have about 14 units total., We have documentation to replace 8 RTU's total including the residential Big Dogs on October 6th., Due to the excessive heat, we ended up getting portable air conditioners Swamp Coolers to cool the building., Unit 1 and Unit 4 resident rooms have portable air conditioners., We have 31 portable air conditioner units currently., Initially, the portable air conditioning units were tripping breakers., We relocated the portable air conditioning units to less crowded circuits. On 07/16/25 at 11:05 A.M., Ambient room temperatures were monitored utilizing an ETEKCITY LASERGRIP Model 1080 Infrared Thermometer”. The following temperatures were recorded: Unit 2 Hallway Corridor: 82.0 - 85.0 degrees Fahrenheit* Resident room [ROOM NUMBER]: 84.0 - 86.0 degrees Fahrenheit* Resident room [ROOM NUMBER]: 85.0 - 87.0 degrees Fahrenheit* Resident room [ROOM NUMBER]: 82.0 - 87.0 degrees Fahrenheit* Resident room [ROOM NUMBER]: 82.0 - 84.0 degrees Fahrenheit* Shower room [ROOM NUMBER]: 84.0 - 85.0 degrees Fahrenheit* Shower room [ROOM NUMBER]: 84.0 - 87.0 degrees Fahrenheit* Resident room [ROOM NUMBER]: 83.0 - 85.0 degrees Fahrenheit* Resident room [ROOM NUMBER]: 83.0 - 84.0 degrees Fahrenheit* Resident room [ROOM NUMBER]: 83.0 - 84.0 degrees Fahrenheit* (*) The State of Michigan Operations Manual Appendix PP states: “§483.10(i) Safe Environment. The facility must provide— §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F. “Comfortable and safe temperature levels” means that the ambient temperature should be in a relatively narrow range that minimizes residents’ susceptibility to loss of body heat and risk of hypothermia, or hyperthermia, or and is comfortable for the residents.” On 07/16/25 at 12:10 P.M., An interview was conducted with Maintenance Director (MD) “E” regarding monitoring ambient room temperatures. (MD) “E” stated: “I monitor air temperatures weekly.” On 07/16/25 at 12:26 P.M., Ambient room temperatures were monitored utilizing an ETEKCITY LASERGRIP Model 1080 Infrared Thermometer”. The following items were noted: Unit 3 Shower room [ROOM NUMBER]: 83.0 - 84.0 degrees Fahrenheit* Shower room [ROOM NUMBER]: 86.0 - 88.0 degrees Fahrenheit* Dining Room: 83.0 - 84.0 degrees Fahrenheit* Resident room [ROOM NUMBER]: 81.0 - 83.0 degrees Fahrenheit* Resident room [ROOM NUMBER]: 81.0 - 84.0 degrees Fahrenheit* Resident room [ROOM NUMBER]: 81.0 - 82.0 degrees Fahrenheit* (*) The State of Michigan Operations Manual Appendix PP states: “§483.10(i) Safe Environment. The facility must provide— §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F. “Comfortable and safe temperature levels” means that the ambient temperature should be in a relatively narrow range that minimizes residents’ susceptibility to loss of body heat and risk of hypothermia, or hyperthermia, or and is comfortable for the residents.” On 07/17/25 at 09:30 A.M., Record review of the “Air Temperature Monitoring Log Sheets” for the last 75 days revealed no specific entries exceeding the 71–81-degree Fahrenheit parameter.

This citation pertains to Intake 1216041Based on observations, interviews, record reviews, reviewed for food product palatability, the facility failed to provide palatable food products affecting 116 residents who consume food, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline.Findings include:On 07/15/25 at 09:43 A.M., An interview was conducted with Resident #200 regarding facility food products. Resident #200 stated: Food Sucks, “The waffles are hard.”, “The biscuits and gravy are stone cold.”, “The hushpuppies are hard as a rock.”, “The bread is dry and hard.”, The meat is dry., The menu is consistently the same., The vegetables are mushy., I go for days without eating facility food., The condensed soup is bad., The peanut butter is bad and doesn't spread., One day we had peanut butter and jelly and vegetable soup for dinner. On 07/15/25 at 09:45 A.M., An interview was conducted with Resident #200 regarding meal service times. Resident #200 stated: “Breakfast is served around 09:00 – 09:30 A.M.”, Lunch is served from 01:00 - 01:30 P.M. daily., and “Dinner is served from 06:00 -06:30 P.M.” On 07/15/25 at 11:44 A.M., An interview was conducted with Dietary Aide (DA) “H” regarding the resident meal tray delivery schedule. (DA) “H” stated: “We do the Main Dining Room, Unit 3, Unit 4, Unit 1, and Unit 2.” On 07/15/25 at 12:52 P.M., An interview was conducted with Dietary Aide (DA) “H” regarding the bread product delivery schedule. (DA) “H” stated: “Bread comes in on Monday once a week.” On 07/15/25 at 01:15 P.M., Lunch meal food trays (32) were observed leaving the food production kitchen, within an insulated transport cart. On 07/15/25 at 01:17 P.M., Lunch meal food trays (32) were observed arriving to Unit 4, within an insulated transport cart. On 07/15/25 at 01:34 P.M., Lunch meal food trays (21) were observed leaving the food production kitchen, within an insulated transport cart. On 07/15/25 at 01:36 P.M., Lunch meal food trays (21) were observed arriving to Unit 1, within an insulated transport cart. On 07/15/25 at 01:57 P.M., Resident #200’s lunch meal tray was observed stored within the insulated transport cart, located on the Unit 1 hallway corridor. On 07/15/25 at 02:04 P.M., Resident #200’s lunch meal food tray was observed delivered by Certified Nursing Assistant (CNA) “I”. (CNA) “I” was also observed providing feeding assistance to Resident #200. On 07/15/25 at 02:29 P.M., An interview was conducted with Resident #200 regarding his lunch meal food products. Resident #200 stated: “The food was OK today, but it was cold., The chicken was dry., The only way it was moist was from the BBQ sauce., I don't know what is going on in the kitchen., The tuna fish sandwiches contain no onion, pickle, or mayonnaise., and The bread is always hard and not fresh. On 07/16/25 at 08:45 A.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food temperatures were recorded for Resident #200’s Breakfast Meal food tray: Oatmeal (Two Bowls)- 116.3 / 121.4 degrees Fahrenheit * Frosted Flakes (Two Bowls) - Room Temperature Cranberry Juice - 66.7 degrees Fahrenheit* Note: No milk was observed provided on the meal tray for the dry cereal. Note: Salt and pepper packets were observed on the meal tray. Note: One packet of brown sugar was observed on the meal tray. Resident #200 stated: I don't use [NAME] Sugar. Resident #200 also stated: “I have told them over and over again.” (*) The “2022 FDA Model Food Code” section 3-501.16 states: “(A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under ¶ (B) and in ¶ (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in ¶ 3-401.11(B) or reheated as specified in ¶ 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5°C (41°F) or less.” On 07/16/25 at 09:40 A.M., An interview was conducted with Dietary Manager (DM) “F” regarding the bread product delivery schedule. (DM) “F” stated: “Bread shipments come in once a week on Monday.” (DM) “F” also stated: “The bread supplier is [NAME] Distributing.” On 07/16/25 at 01:45 P.M., A food palatability test was conducted by this surveyor. The meal tray presentation was observed less than [NAME]. The stuffed green pepper was also observed to be overcooked and supple. The marinara sauce was additionally observed bland and flavorless. The mashed potatoes were further observed to be somewhat dry and compact. The butterscotch pudding was also observed to lack in portion size. The beverage (apple juice) was additionally observed provided in a nectar thick consistency. No condiments (butter, pepper, salt, etc.) were provided with this lunch meal tray. On 07/16/25 at 02:00 P.M., An interview was conducted with Dietary Aide (DA) “G” regarding resident meal tray condiments. (DA) “G” stated: “The condiments should be listed on the meal ticket card.” On 07/17/25 at 08:30 A.M., Record review of the Policy/Procedure entitled: “Tray Accuracy and Test Trays” dated 11/11/24 revealed under Policy: “It is the policy of this facility to set up trays accurately to provide residents with meal trays correctly reflecting Therapeutic Diets, Proper Texture Diets, and Food Preferences listed on the tray ticket.” Record review of the Policy/Procedure entitled: “Tray Accuracy and Test Trays” dated 11/11/24 further revealed under Procedure: “(2) The items on each tray will be checked against the tray ticket to verify accuracy before the tray is loaded onto the delivery cart by the person working the last station on the tray line. (3) All foods will be covered.” On 07/17/25 at 08:45 A.M., Record review of the Policy/Procedure entitled: “Nutritional Services Department Staffing” dated 12/10/24 revealed under Policy: “It is the policy of the Nutritional Services Department to staff with sufficient, competent, supportive personnel to carry out the functions of the food services.” On 07/17/25 at 09:00 A.M., Record review of the Policy/Procedure entitled: “Food Preferences” dated 1/9/25 revealed under Policy: “It is the policy of the facility to obtain food preferences for all residents.” Record review of the Policy/Procedure entitled: “Food Preferences” dated 1/9/25 further revealed under Procedure: “(8) Food preferences will be identified on tray tickets to ensure residents are provided with appropriate food items.” On 07/17/25 at 09:15 A.M., Record review of the Policy/Procedure entitled: “Food Temperatures” dated 1/9/25 revealed under Policy: “Foods will be maintained at proper temperature to ensure food safety.” On 7/16/2025 at 9:55 AM, R202 was observed in the hallway awaiting discharge. During an interview with R202 it was reported that food arrives warm most of the time but not hot, that the lettuce served is brown and that his preferences are not always honored. It is noted that he didn’t want or like eggs but they are still sent on his breakfast trays. He further stated that the kitchen was supposed to send him a peanut butter sandwich with each meal and that was not done on a consistent basis. On 7/16/25 at 1:30 PM, R203 was observed sitting up in bed. When asked about the food at the facility, R203 reported it was her “worst enemy”. She reported that meals arrive cold most of the time and they are routinely not provided with condiments, like butter for pancakes, no salt or pepper and meals are not “balanced” (she explained that they receive a lot of vegetables in relation to other foods). On 07/16/25 at 01:49 PM, a food palatability test was conducted by this surveyor. The meal tray presentation was unappealing, bland and void of color. The tray consisted of chicken cordon blue, buttered noodles, butterscotch pudding and apple juice. The chicken cordon blue had very little actual meat, the center was observed to contain cheese/broccoli, it had burnt cheese on each end of the patty and was heavily breaded. It was further observed to have very little flavor. The noodles were observed to be overcooked, very soft with little flavor. The butterscotch pudding had a pleasant taste but the portion provided barely covered the bottom of the dessert dish and the color was an unpleasant shade of brown. The apple juice was observed to be nectar thick therefore was not tested. No condiments were provided (no butter, no salt or pepper, Mrs Dash etc). On 7/17/2025 at 9:34 AM, during an interview with Registered dietitian (RD) “J” and Dietary Manager (DM) “F”, it was reported that the facility has 2-3 positions responsible for ensuring tray accuracy. The first person on the “line” calls out the diet type and is responsible for placing silverware and condiments, the other staff are responsible for drinks and desserts. When asked if the RD or DM conduct any audits to ensure accuracy it was reported that they plan to do weekly audits soon. No explanation was offered as to why residents do not receive condiments on their meal trays.

This citation pertains to Intake 1216041Based on observations, interviews, record reviews, and 1 (200) of 4 sampled residents, the facility failed to provide timely meal service affecting up to 116 residents who consume food, resulting in the increased likelihood for delayed meal service, increased emotional/psychosocial distress, and decreased food acceptance/nutritional decline.Findings include:On 07/15/25 at 09:45 A.M., An interview was conducted with Resident #200 regarding facility meal service times. Resident #200 stated: Breakfast is served around 09:00 - 09:30 A.M., Lunch is served from 01:00 - 01:30 P.M. daily., and Dinner is served from 06:00 -06:30 P.M.On 07/15/25 at 01:57 P.M., Resident #200's lunch meal tray was observed stored within the insulated transport cart, located on the Unit 1 hallway corridor.On 07/15/25 at 02:04 P.M., Resident #200's lunch meal food tray was observed delivered by Certified Nursing Assistant (CNA) I. (CNA) I was also observed providing feeding assistance to Resident #200.(*) The State of Michigan Operations Manual Appendix PP states: F809 S483.60(f) Frequency of Meals S483.60(f)(1) Each resident must receive, and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. S483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care. On 07/17/25 at 10:00 A.M., Record review of the Policy/Procedure entitled: Always Available Menu dated (no date) revealed the following mealtimes: Breakfast 7:00 - 9:00 A.M., Lunch 12:00 - 2:00 P.M., Dinner 5:00 - 7:00 P.M.

This citation includes intake MI000152150. Based on interview and record review the facility failed to revise a comprehensive care plan for one out of three residents (Resident #1). Findings Included: Per the facility face sheet Resident #1 (R1) was admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease. Review of R1's Brief Interview for Mental Status (BIMS) score revealed that on 12/7/2026 R1 scored a six, and on 2/7/2025, R1 scored a three, both score were indicative of a severe mental impairment. Review of a Physician's Statement of Competency dated 12/27/2024, revealed R1 was deemed to be incompetent and not able to make his own medical decisions. Review of R1's progress notes revealed that on 3/30/2025, R1 was found to be lying in a bed with another female resident. The note revealed staff had been following R1 the majority of the day trying to keep R1 and the female resident separate, but were eventually observed in another resident's bed with R1 having his hand down the female's pants. Review of a progress note dated 3/31/2025, revealed R1 was put on one on one supervision. A plan when one staff stays with the resident all the time. The one on one supervision was not written as a Physician's order so all nursing staff would be aware of the one on one status of R1. In an interview on 4/29/2025 at 10:56 AM, Housekeeper D stated she had found R1 in a room, which was not his room standing over a female resident with his hand on her shoulder. Housekeeper D said she immediately got help and CNA E got up right away and removed R1 and the female resident from the room. Housekeeper D stated she did know that staff had been performing a one on one supervision with R1. In an interview on 4/29/2025 at 10:47 AM, CNA E said she was made aware of R1 in a room with a female resident who was lying in a bed. CNA E said when she got in the room R1 was lying in the bed with the female resident, and R1 had his hands in the female resident's pants. In an interview on 4/29/2025 at 11:12 AM Licensed Practical Nurse (LPN) F stated she reported the incident to the Director of Nursing (DON) B, and kept R1 and the female resident separated. In an interview on 4/29/2025 at 12:05 PM, LPN G stated that R1 was a one on one supervision, and stated he did place a CNA with R1 for one on one when he worked. LPN G stated he was not the nurse on 4/7/2025. Review of progress notes dated 4/7/2025 revealed R1 was found naked in bed laying next to a female resident. In an interview on 4/29/2025 at 11:26 AM, Certified Nurse Aid (CNA) C stated she worked on 4/7/2025 on the 3:00 PM- 11:30 PM shift. CNA C said at about 4:00-5:00 PM saw R1 in another resident's room in bed with another female resident, and both residents were naked with their clothes on the floor. CNA C stated that no one on one supervision was in place for R1. CNA C said she was not aware of any one on one supervision ever being in place for R1, and said she was only told to keep and eye on him (R1). CNA C said she was the CNA assigned to R1 on 4/7/2025, but was not told to perform one on one supervision for R1. CNA C said the daily assignment sheets was where the nurse would wright down who was one on one supervision, and which staff member was going to be doing that. Upon review of the daily assignment sheet for the date of 4/7/2025 with CNA C it was revealed that she was assigned to R1, but no staff member nor resident was written down for one on one supervision. CNA C also stated that there was no documentation for when staff perform a one on one for a resident. In an interview on 4/29/2025 at 1:56 PM, LPN H, who worked the second shift on 4/7/2025, stated she did not recall the incident on 4/7/2025. LPN H stated that if a CNA was assigned to be on a one on one with a resident it would have been with a fall risk resident and not with R1. Review of the Daily Assignment sheet dated 4/7/2025 for the 3:00-11:30 PM shift revealed CNA C was assigned to R1, however was not assigned to perform a one on one with R1. Review of a Task: Behavior Monitoring log revealed that on 4/7/2025, R1's sexual behaviors for the 3:00 PM-11:30 PM shift revealed no documentation of whether R1 had any behaviors including sexual behaviors on that day and shift. In an interview on 4/29/2025 at 12:45 PM, Administrator A stated there was no documentation of one on one supervision other than the CNA behaviors task, and the daily assignments sheets. Review of R1's care plans revealed that no care plan was put into place that addressed R1's sexual behaviors towards female resident(s) with an intervention of on one on until 4/7/2025. Therefore no care plan was initiated after the incident when R1 was found to be in bed with a female resident on 3/30/2025 with his hands down the females pants.

This citation includes intake MI000152150. Based on observation, interview, and record review the facility failed the provide one on one supervision for one out of two residents (Resident #1). Findings Included: Per the facility face sheet Resident #1 (R1) was admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease. Review of R1's Brief Interview for Mental Status (BIMS) score revealed that on 12/7/2026 R1 scored a six, and on 2/7/2025, R1 scored a three, both score were indicative of a severe mental impairment. Review of a Physician's Statement of Competency dated 12/27/2024, revealed R1 was deemed to be incompetent and not able to make his own medical decisions. Review of R1's progress notes revealed that on 3/30/2025, R1 was found to be lying in a bed with another female resident. The note revealed staff had been following R1 the majority of the day trying to keep R1 and the female resident separate, but were eventually observed in another resident's bed with R1 having his hand down the female's pants. Review of a progress note dated 3/31/2025, revealed R1 was put on one on one supervision. A plan when one staff stays with the resident all the time. The one on one supervision was not written as a Physician's order so all nursing staff would be aware of the one on one status of R1. In an interview on 4/29/2025 at 10:56 AM, Housekeeper D stated she had found R1 in a room, which was not his room standing over a female resident with his hand on her shoulder. Housekeeper D said she immediately got help and CNA E got up right away and removed R1 and the female resident from the room. Housekeeper D stated she did know that staff had been performing a one on one supervision with R1. In an interview on 4/29/2025 at 10:47 AM, CNA E said she was made aware of R1 in a room with a female resident who was lying in a bed. CNA E said when she got in the room R1 was lying in the bed with the female resident, and R1 had his hands in the female resident's pants. In an interview on 4/29/2025 at 11:12 AM Licensed Practical Nurse (LPN) F stated she reported the incident to the Director of Nursing (DON) B, and kept R1 and the female resident separated. In an interview on 4/29/2025 at 12:05 PM, LPN G stated that R1 was a one on one supervision, and stated he did place a CNA with R1 for one on one when he worked. LPN G stated he was not the nurse on 4/7/2025. Review of progress notes dated 4/7/2025 revealed R1 was found naked in bed laying next to a female resident. In an interview on 4/29/2025 at 11:26 AM, Certified Nurse Aid (CNA) C stated she worked on 4/7/2025 on the 3:00 PM- 11:30 PM shift. CNA C said at about 4:00-5:00 PM saw R1 in another resident's room in bed with another female resident, and both residents were naked with their clothes on the floor. CNA C stated that no one on one supervision was in place for R1. CNA C said she was not aware of any one on one supervision ever being in place for R1, and said she was only told to keep and eye on him (R1). CNA C said she was the CNA assigned to R1 on 4/7/2025, but was not told to perform one on one supervision for R1. CNA C said the daily assignment sheets was where the nurse would wright down who was one on one supervision, and which staff member was going to be doing that. Upon review of the daily assignment sheet for the date of 4/7/2025 with CNA C it was revealed that she was assigned to R1, but no staff member nor resident was written down for one on one supervision. CNA C also stated that there was no documentation for when staff perform a one on one for a resident. In an interview on 4/29/2025 at 1:56 PM, LPN H, who worked the second shift on 4/7/2025, stated she did not recall the incident on 4/7/2025. LPN H stated that if a CNA was assigned to be on a one on one with a resident it would have been with a fall risk resident and not with R1. Review of the Daily Assignment sheet dated 4/7/2025 for the 3:00-11:30 PM shift revealed CNA C was assigned to R1, however was not assigned to perform a one on one with R1. Review of a Task: Behavior Monitoring log revealed that on 4/7/2025, R1's sexual behaviors for the 3:00 PM-11:30 PM shift revealed no documentation of whether R1 had any behaviors including sexual behaviors on that day and shift. In an interview on 4/29/2025 at 12:45 PM, Administrator A stated there was no documentation of one on one supervision other than the CNA behaviors task, and the daily assignments sheets.

Based on observation, interview, and record review, the facility failed to prevent and correctly identify pressure ulcers for two out of seven residents (Residents 101, and 108) resulting in misidentifying of pressure ulcers, and worsening of pressure ulcers. Findings Included: Resident #101 (R101): Per the facility face sheet R101 had resided at the facility since 4/4/2023. Diagnoses included spinal cord injury, contractures of both hands and fingers, and muscle contractures. Review of a photo dated 12/17/24, of R101's buttocks area reveal moisture associated skin damage (MASD-damage of the skin caused by being constantly moist from things such as urine), and a stage III pressure ulcer (PU) (full thickness tissue loss, fat may be visible). The photo also had an assessment documented which revealed the PU was a stage III (3) in-house acquired PU. The PU was located on R101's right buttocks and the facility documented it as new on 12/17/2024. The facility also documented that the PU had granulation, per the assessment, in 100% of the wound. There was no granulation observed in the picture of the wound, but rather beefy bloody red tissue. In an observation on 3/26/2025 at 3:02 PM of R101's buttocks wounds, R101 had MASD, and an open approximately 3 centimeter (cm) wound located in the same place as the stage 3 wound identified on 12/17/2024. Observation of the wound revealed it to be stage III with a beefy red bed, and no dressing noted to be in place. Review of the photos dated 12/17, 12/18/2024, and 1/7/2024 revealed R101 had MASD in each photo, and also at the time of the observation on 3/26/2025. No other photos or assessments were found to have been completed, nor in R101's electronic medical record (EMR). Review of R101's skin assessments provided by Administrator A revealed that the only skin assessments R101 had conducted were on 2/2, 2/12, 2/19, 3/5, 3/12, 3/19, and 3/26/2025. The Administrator did not provide any further skin assessments. The facility did not provide any skin assessments showing they completed any for the months of November and December 2024, and January 2025, and the skin assessments provided did not identify or have documented any new wounds. Review of R101's care plan revealed a care plan was in place for R101 being at risk for impaired skin integrity, dated 4/4/2023, and last revised on 6/11/2024. The last intervention revision was on 1/4/2025, and that was to turn and reposition R101 from side to side as tolerated or will allow. No care plan was in place for R101's MASD or stage III PU. In an interview on 3/27/2025 at 2:50 PM, Licensed Practical Nurse (LPN) K stated R101 did not have a wound, but had MASD. LPN K said R101 did have a wound on his buttocks at one time. LPN K said R101's MASD had not resolved because he refused everything. LPN K said it was hit or miss with R101 because he had refused a low air loss mattress and ROHO (air mattress) mattress, it was hit or miss with turning him, he refused to eat, refused care, refused splints, refused heel boots at times because he is angry with his situation. LPN K did not state any possible staff concerns for the reason R101 had continuous MASD. Furthermore, LPN K was not aware that R101 had an open area to his buttocks as observed on 3/26/2025. Resident #108 (R108): Review of the facility face sheet revealed R108 had resided at the facility since 10/18/2024. During an interview on 3/24/2025 at 11:05 AM, R108 stated she had a PU on her right foot on the ball of her foot. R108 removed her shoe and sock and allowed observation of the wound. The wound observed to be approximately a 2 x 2 cm scab and was unstageable (U). R108 stated that it was very painful. R108 also stated that she had another PU on her buttock, but stated she did not know when that one occurred. R108 was in her wheelchair during the interview and observed to attend to her own needs at will. R108 stated that she was able to use the bathroom if someone would assist her. In an interview and observation on 3/24/2025 at 11:13 AM, R108 had a catheter. R108 stated she stated did not know why she had a catheter, and she wanted it taken out. R108 said she had asked to have it removed but staff did not provide an answer as to when the catheter could come out. R108 stated she used the bathroom before staff placed the catheter and wanted to use the bathroom now to urinate and have bowel movements. R108 stated it was humiliating because she also had to wear what R108 called a diaper. Review of a Physician's order dated 2/3/2025, revealed an order for R108 to have a catheter placed related to an unstageable sacral wound, and end of life care. In another interview on 3/27/2025 at 12:26 AM, R108 stated again that she wanted the catheter out, and again said she asked Hospice about having it removed but received no real answer. Record review of R108's skin assessments that staff provided upon request revealed that the only skin assessments that staff conducted were on 2/5, 2/12, 2/27, 3/6, 3/13, and 3/20/2025, and the skin assessments did not identify or have documented any new wounds. Review of a Clinically Unavoidable Pressure Injury-V2 document revealed the facility assessed R108 to have a PU that was a DTI (deep tissue injury-appears as a purple/dark area on the skin that is not open) on her right foot and sacrum (buttocks area). The document revealed the DTI developed on 1/15/2025 and was determined to be unavoidable on 2/6/2025, 22 days later. The document revealed that R108's PU's were clinically unavoidable due to malnutrition, terminal diagnosis, poor food intake, and revealed R108's Braden score (score that determines the likelihood of skin breakdown) was an 11 (indicating high risk), and that Hospice services were providing cares for R108. Further review of the Clinically Unavoidable Pressure Injury-V2 document revealed that the interventions in place were barrier cream (cream placed on the skin), a pressure-reducing mattress on the bed, off-loading bony prominences (not allowing bone areas of the body to rest on the bed mattress), and other positioning devices. However, interventions that were listed on the document but were not checked as interventions in place were, Turn q (every) 1 hour, turn q 2 hours, RD (Registered Dietician) consult, Draw-sheet (used to pull resident up in bed to prevent friction), Trapeze (a bar above the resident's bed so resident can move self around), Pressure Reducing Equipment in Chair, Resident/Guest/Family Education, and would also address R108's clinical reasons for skin breakdown. Review of a Skin & Wound Evaluation V7.0 dated 1/28/2025 revealed R108 to have a pressure ulcer to her sacrum on 1/15/2025. The document showed the pressure ulcer to be unstageable and acquired at the facility. The evaluation revealed that the wound was 50% filled with granulation tissue (new good tissue that forms on the wound during the healing process), and 50% filled with slough (dead dark tissue). The wound measured 7.2 x 3.3 x 2.9 x 1.2 cm (area, length, width, and depth) with 5.0 am of undermining (an unattached area under the edges of the wound). The evaluation revealed the PU was deteriorating. Upon review of the photograph of the pressure ulcer dated 1/28/2025, to R108's sacrum it was revealed that the wound was a stage IV (4) wound with undermining, red edges, and a visible wound bed at the deepest point. Record review of a Skin & Wound Evaluation V7.0 dated 2/5/2025, revealed R108 had a documented PU to be unstageable due to slough and/or eschar (hard, dry, black or brown dead tissue scab like covering) on her sacrum. The evaluation revealed the wound was a facility acquired. The exact date of the wound was 1/15/2025. The wound measured 8.9 x 3.5 x 3.0 x 1.5 cm with 2.4 cm of undermining. The evaluation also revealed that the wound was 80% filled with granulation, with 20% filled with slough. The evaluation revealed that the interventions were incontinence management, moisture control, nutrition supplementation, and repositioning devices. Review of the photograph of R108's wound to her sacrum dated 2/5/2025 revealed a stage IV wound that was not unstageable due to the deepest part of the wound bed was clearly visible and not obscured. The wound bed revealed beefy red exposed muscle, and some slough present. Review of a Skin & Wound Evaluation V7.0 dated 3/26/2025, revealed staff continued to document R108's sacral PU as an unstageable wound. The evaluation did not have any dressing treatment documented. Review of the photograph of R108's sacral wound dated 3/26/2025, revealed a stage IV beefy red wound bed that was visible at the deepest depth, and therefore was stageable. Record review of R108's care plans revealed a care plan was in place that had a Focus of (R108) is at risk for impaired skin integrity related to fragile skin. I (R108) am on Hospice. I frequently refuse to reposition and prefer to lay on my left side, dated 1/31/2025, and last revised on 2/25/2025. The care plan did not have an intervention that addressed R108's refusals to reposition, nor did the care plan have an intervention listed on how to approach or encourage R108 when R108 refused to reposition due to impaired skin integrity. The care plan also did not list an intervention on coordinating care with Hospice regarding R108's increased risk for impaired skin integrity. Review of a care plan dated 1/15/2025 and revised on 3/13/2025, revealed R108 have a Focus area of (R108) has an Actual impairment to skin integrity r/t (related to) 1) unstageable pressure injury to medical sacrum. 2) R (right) plantar (sole of the foot) foot DTI. The Focus also revealed, (R108) frequently refuse to reposition and prefer to lay on my left side. Further review of the care plan revealed that there were no interventions listed on R108's Actual impairment to skin integrity care plan that addressed R108's refusals to reposition and preferences to lay on her left side. There were no interventions to re-approach, attempt to understand R108's comfort levels, pain levels, no interventions to turn or reposition R108, no interventions to offer R108 to get out of bed to chair, no interventions to prop R108 off of bony prominences to relieve pressure areas, and there were no interventions to coordinate with Hospice any needs R108 may have with her pressure ulcers and interventions. In an observation and interview on 3/27/2025 at 12:26 PM, Licensed Practical Nurse (LPN) K, who was the wound care nurse, performed wound care on R108's sacral wound. The wound was a stage IV PU, with a beefy red wound bed not obscured by any slough/eschar or granulation tissue. Upon asking what stage the PU was, LPN K stated R108's sacral wound was unstageable. LPN K said the PU was unstageable because that was the highest stage the wound was ever staged at, so that was the stage the wound would always be staged as. Per the Resident Assessment Instrument (RAI) manual 3.0 Version 1.1.9.1 dated October 2024, on page M-24, pressure ulcers covered with slough and/or eschar with a wound bed that cannot be visualized, should be coded (or identified) as unstageable because the true anatomic depth of the soft tissue damage cannot be determined. The manual further revealed that when enough slough and/or eschar is removed to expose the anatomic depth of soft tissue damage involved, the stage of the can then be determined. In an interview on 3/27/2025 at 3:01 PM, LPN K stated that she did not perform a root cause analysis to determine why R101 and R108 had developed PU's at the facility. LPN K stated that she talks about the resident's wounds and only verbally discusses resident's wounds in the Quality Assurance Performance Improvement (QAPI) meetings, but stated she had no documentation of that. LPN K stated that no meetings occurred with Director of Nursing (DON) B to discuss PU's, the root causes, or to put a plan into place for further prevention of PU's. In a further interview with Registered Nurse (RN) M, who was also a wound care nurse, RN M stated that she learned that whatever stage a wound was staged at for the very first time was where the wound was to always be stage at up until the wound closed. In an interview on 3/31/2025 at 2:06 PM, DON B stated that with the wounds she just assists LPN K and RN M in getting the equipment needed for residents with wounds, such as mattresses, cushions, and to coordinate with the dietician or therapy. DON B stated that she met weekly with LPN K and RN M to go over the resident's wounds, and that was when she would find out what equipment or coordination, they needed from her. DON B stated she had not performed any audits, root cause analysis or put a plan into place to ensure healing of current wounds or prevent the occurrence of further wounds.

This citation pertains to intake: MI00145821 Based on observation, interview and record review the facility failed to: 1.) ensure the safety, 2.) implement care-planned interventions, 3.) ensure that those interventions were functional and in place; and 4.) provide timely assessment and treatment for 1 of 3 sampled residents (R104) reviewed for supervision from a total sample of 4 residents, resulting in actual harm for R104's fall with left femur fracture on 6/7/24, delay in assessment, pain and transfer to the hospital. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 was a [AGE] year old female admitted to the facility on [DATE], with re-admission post hospital transfer 6/11/24 following displaced transverse fracture left femur with other diagnoses that included cerebral vascular accident with left side paralysis, spastic hemiplegia left side, hypertension (high blood pressure), lupus, cervical disc disorder, anxiety, and depression. The MDS reflected R104 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. Review of the complaint intake reflected concerns that included resident supervision, staff assistance with activities of daily living, and monitoring and assessing residents. Review of the facility provided Resident Matrix, dated 7/30/24, reflected R104 had a fall with major injury. Review of R104 Nursing Progress Notes, dated 6/7/2024 at 6:00 p.m., reflected, Writer and charge nurse alerted by CNA that resident slid out of her shower chair with the assistance of CNA. Resident was assisted to the floor, next to the right side of her bed, shower chair was near the foot of the bed. Resident assisted back into her shower chair, shower provided. When resident was placed back into her bed she was c/o pain in left knee and left elbow. Left knee swollen and left antecubital swollen. Resident stated she began to slide out of her shower chair when she leaned forward to look at vaginal discharge and CNA assisted her to the floor. Resident states her left knee began hurting when she was placed back into her bed from the shower chair .NP notified .Resident's emergency contact present at bedside .DON .notified. Xray ordered of left knee and left elbow due to pain/ swelling. Neuro checks x 24 hours. Review of R104 Nursing Progress Note, dated 6/11/2024 3:07 p.m., reflected, patient returned 1410 via [named transport] on stretcher alert to baseline and in no apparent distress. patient seen and treated at [named hospital] s/p fall for left distal femur fracture. spouse, CN and physician notified. no med changes. full code. general diet. Review of R104 Nursing Summary Note, dated 6/11/2024 3:36 p.m., reflected, patient returned from hospital s/p fall with dx left distal femur fx. currently she denies pain and she has a full leg immobilizer in place. Review of R104 hospital discharge summary, dated 6/10/24, reflected principle diagnosis included closed bicondylar fracture of distal femur. During an observation and interview on 7/31/24 at 1:00 p.m., R104 was laying in bed and appeared calm pleasant and able to answer questions without difficulty. R104 reported had a fall 6/7/24 in room after staff assisted her to shower chair from her bed with one person assist pivot transfer. R104 reported aid was unable to position R104 far enough back in shower chair and stepped to doorway to get assistance from other staff. R104 reported she started to slip forward out of shower chair and fell on left side. R104 reported two staff members positioned R104 back in shower chair and completed the shower and the same aid transferred R104 from the shower chair to bed with pivot transfer. R104 reported developed left knee pain that was not controlled by medication and was transferred to the hospital. R104 reported she fractured left upper leg and chose not to have surgical intervention and was discharged back to facility after couple of days with immobilizer. R104 reported had fear of showers since fall but would prefer showers over bed baths. R104 reported has been getting bed baths and reported forgot she could use shower bed instead of chair and reported staff had not offered shower bed. R104 reported after fall remained in bed because of non-removeable immobillizer and pain for several weeks. R104 reported prior to fall had generalized pain controled with once daily medications at 5/10 pain level. R104 reported after the fall with fracture during staff assisted transfer had increased pain with need for two to three doses of narcotic pain medications daily with pain up to 8/10 on scale with 10 being worst pain. Reported also now has constipation. R104 reported is hesitant to get out of bed related to fear of another fall. Request for all of R104 incident/accident reports for past three months with complete investigation send by email request on 7/31/24 at 12:49 p.m. Received one Incident/Accident(IA) Report for R104 for the past three months, dated 6/7/24 at 6:00 p.m., on 7/31/24 at 2:20 p.m., with no evidence of investigation noted. The IA was titled, Slid out of Wheelchair and included description, Writer and charge nurse alerted by CNA that resident slid out of her shower chair with the assistance of CNA. Resident was assisted to the floor, next to the right side of her bed, shower chair was near the foot of the bed. Resident assisted back into her shower chair, shower provided. When resident was placed back into her bed she was c/o pain in left knee and left elbow. Left knee swollen and left antecubital swollen. The report reflected injuries observed at the time of the incident included hematoma to left knee and antecubital(elbow) area. Continued review of the report reflected R104 was alert and oriented with predisposing physiological factors that included mood/behavior, weakness/fainted, and gait imbalance. Continued review reflected incomplete form as evidenced by no documentation under predisposing situation factors or predisposing environmental factors. Review of the provided Post Fall Evaluation reflected R104 had an observed fall on 6/7/24 at 6:00 p.m. The Post Fall Evaluation reflected R104 was receiving assistance from staff per care plan. The evaluation included, Re-Creation of Last 3 Hours Before Fall, with instructions, Below, the primary nursing assistant who observed and/or assisted the guest/resident during the three hours prior to the fall was interviewed and described the life of the guest/resident before the fall . The information reflected, Pt[patient] taken to bathroom in shower chair and showered. Staff turned for moment to get supplies. Pt leaned forward and began to fall. Staff intervened and lowered patient to floor. The evaluation reflected fall huddle with no changes in fall details and root cause of fall included environmental factors/items out of reach. The Post Fall Evaluation was completed by LPN C and signed by the Interdisciplinary team. Review of R104 Care Plans, dated 10/20/23, reflected, I am at risk for fall related injury and falls R/T: Hx of CVA with L. sided weakness, chronic back pain, Lupus, Osteoarthritis, recent L. distal closed Femur Fracture with routine healing, Non ambulatory status Date Initiated: 06/11/2024 Created on: 10/20/2023 .Hoyer Lift with 2 assists for all transfers. Date Initiated: 10/27/2023 . Review of R104 Medication Administration Record(MAR), dated 6/1/24 through 6/30/24, reflected once daily use of Oxycodone 10mg 6/1/24 through 6/7/24 with pain levels less than 6/10 on scale. Continued review of MAR reflected R104 pain level 8/10 on pain scale of several occasions with use of Oxycodone 10mg two to three times daily after return from hospital on 6/11/24 post fall with fracture during staff assisted transfer without following Care Planned interventions for transfer status. Review of the Functional Abilities and Goals assessment, dated 4/23/24 and 6/12/24, reflected decline in overall activities of daily living including eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. The assessment reflected decline in overall mobility. The decline was a direct result of R104's fall with fracture during staff assisted transfer without following Care planned safetly interventions on 6/7/24. Received witness statements from R104 fall on 6/7/24, after second request for complete investigation, on 7/31/24 at 3:07 p.m. Review of the, Quality Assurance Interview Summary, with first interview on document, dated 6/13/24 (six days after fall), for R104. The interview reflected, CNA sat me on the shower chair and walked away to get help because wasn't fully sitting back. Toppled to the floor onto left side. CNA came back with help to put me back in shower chair. Took me into shower then was helped back to bed. Pain started to left knee after back in bed. Review of the next interview for CNA D, dated 6/10/24 (three days after fall), reflected, Went in room to get [named R104] ready for a shower. Transferred [named R104] to the shower chair. She wasn't fully sitting back in chair. Went behind chair and tried to pull resident back in chair under her arms. [named R104] didn't fully scoot back into chair. Told resident to stay here and went to doorway to get co-worker to help. When turned around to head back in room seen [named R104] leaning forward. Ran over to resident and grabbed resident under her arms from behind as she was falling forward lowering [named R104] to the floor. She was laying on her left side with legs bent up and under her. Co-worker [named CNA J] entered the room and assisted with getting resident back into the shower chair. Took resident into shower room and gave her a shower. After shower assisted [named R104] back to bed. Little while later [named R104] began complaining of pain to left knee. While placing a pillow under her knee noticed her knee was swollen. Nurse notified of pain and that resident had been lowered to the floor. Review of the next interview for CNA J, dated 6/10/24, reflected, Entered doorway after [named CNA D] called out for help with [named R104]. Upon entering room resident noted to be laying on her left side with legs bent, shower chair positioned at the head of the resident. Assisted [named CNA D] with picking [named R104] up off the floor and getting her back in shower chair then left the room. Review of the next witness statement on the page for LPN C, dated 6/11/24(five days after fall), reflected, [named R104] husband came out in hallway stating [named R104] was having pain. Went into speak with [named R104]. She told me she had ended up on the floor. Assessed resident noted swelling to left knee. Medication provided for pain, nurse manager [named Nurse Manager K] notified of fall. X-rays ordered. Review of the Neurological Assessment, dated 6/7/24 at 6:00 p.m., reflected the assessments 6:00 p.m. through 8:15 p.m. with no signature for day shift staff 6/7/24. The form appeared to have same writing for 6/7/24 for both day shift and night shift assessments. Review of R104 einteract Change of Condition Evaluation, dated 6/8/24 3:48 p.m., reflected R104 fall and uncontrolled pain with note that reflected, resident complained of pain 10/10 not relieved by Oxy or Tylenol. resident requested to go to the hospital. On call provider notified. DON notified. Husband was here and also requested resident go to the hospital. resident had a fall at 1800 on 06/07/2024. During an interview on 8/1/24 at 9:37 a.m., Licensed Practical Nurse(LPN) C reported was R104 nurse on 6/7/24. LPN D reported was first aware of R104 fall on 6/7/24 when R104's husband came to LPN C about two hours after the fall around 6:00 p.m. and reported R104 was having pain related to fall earlier that day. LPN C reported spoke with R104 and completed assessment and was informed by R104 had fall during a staff assisted transfer prior to shower that day out of shower chair and was currently having pain to left leg. LPN C reported then spoke Certified Nurse Aid(CNA) D who informed LPN C that prior to R104 shower that day around 4:00 p.m. R104 slid out of shower chair and CNA D lowered R104 to the floor. LPN C reported CNA D reported R104 was placed back in shower chair with another staff assist, shower completed and R104 was transferred back to bed and then complained of pain to left leg. LPN C reported thought R104 was required hoyer lift assistance with transfers at the time of the fall. LPN C reported staff are expected to follow transfer status according to care plan and kardex. LPN C reported R104 had swelling in left knee area and complained of pain in left knee and hip area. During the interview on 8/1/24 at 9:37am, LPN C reported did not complete any neurological assessments for R104 after reported fall and was not aware of R104 fall until about two hours after event. LPN C reported staff are expected to notify nurse of all falls and not to move residents until assessed by nurse. During an interview on 8/1/24 at 9:51 a.m., CNA E reported facility process for resident falls required staff to assure resident is safe, notify nurse immediately if fall is suspected or witnessed and nurse to complete assessment prior to moving resident. CNA E reported aware of resident transfer status by reviewing the kardex. CNA E reported was not present for R104 fall on 6/7/24, however all staff received education after fall related to importance of following kardex interventions including transfer status and definitions of falls and fall policy. CNA E reported staff educated to report all falls to nurse immediately and not to move resident. During an interview on 8/1/24 at 10:03 a.m., CNA F reported had worked at the facility for over seven years and reported aware of resident needs by review of Kardex including transfer status. CNA F reported if resident fall is suspected or observed staff expected to make sure resident is safe, notify nurse and not to move resident for any reason prior to notification of the nurse. During an interview and record review on 8/1/24 at 10:15 a.m., LPN G reported would expect staff to report all falls to her immediately prior to moving residents. LPN G reported all staff received fall re-education within past 2 months and resident alerts were updated in binder observed at nurse stations that included residents at risk for falls. LPN G reported staff expected to follow resident Kardex including transfer status needs During an interview on 8/1/24 at 10:20 a.m., CNA H reported had worked at the facility for over 9 years. CNA H reported staff expected to report to nurse immediately if fall suspected or observed and not to move resident and follow resident Kardex care interventions. During an interview on 8/1/24 at 10:46 a.m., NHA A was asked (for the third time) if this surveyor had been provided with R104 complete fall investigation from 7/6/24. NHA A stated, No, we have a past non-compliance. Surveyor again requested complete investigation first requested 7/31/24 at 12:39 p.m. NHA A reported completed staff education along with past survey that exited 6/5/24 with concerns with fall supervision. This surveyor requested residents with falls in from June and July 2024. During an interview and record review on 8/1/24 at 11:01 a.m., NHA A reported had not provided this surveyor with the supporting documentation of compliance yet because she was attempting to combine the recent Plan of Correction, with exit date 6/5/24 and requested Past Non-Compliance documents. NHA A reported was informed by corporate staff could provide named resident accident reports. Residents with facility falls, dated 6/1/24 through 7/19/24, reflected 38 resident falls at the facility. During a telephone interview on 8/1/24 at 11:07 a.m., CNA D reported was R104 CNA on 6/7/24 at the time of the fall between 4:00 p.m and 5:00 p.m. and had worked a double shift that day. CNA D verified witness statement and reported transferred R104 from the bed the the shower chair with one person assistance with pivot transfer. CNA D reported was unable to position R104 in shower chair correctly on own and went to bedroom door and asked CNA J to assist. CNA D reported turned around saw R104 lean foreword and ran toward R104 because she was coming out of chair and caught her under her arms and lowered R104 to floor. CNA D reported she assessed R104 by asking if she had pain and observing and CNA J assisted her transfer R104 off the floor back into the wheelchair with two person manual assist. CNA D reported proceeded to take R104 to shower room and completed shower. CNA D then reported transferred R104 from the shower chair into bed with one person pivot assist. CNA D reported was approach by LPN C who asked what had happened with R104. CNA D reported after R104 fall and shower was called to Nursing Home Administrator (NHA) A office for another resident investigation and was met by LPN C when returned to the unit to report R104 fall around 5:00 p.m. CNA D reported was suspended pending investigation. CNA D reported knows resident care needs including transfer status by asking residents and staff report and Kardex. CNA D reported had been transferring R104 with one person assist for several weeks. CNA D reported should have reviewed the Kardex and used hoyer lift per the Kardex. CNA D' reported did not think at first R104 fall on 6/7/24 was an actual fall because she was lowered to the floor so did not notify nurse prior to transferring R104 from the floor back to the shower chair with 2 person physical assist. CNA D reported was informed was terminated over a week later. During an interview and record review on 8/1/24 at 12:15 p.m., NHA A reported each fall was discussed at Quality Assurance and Performance Improvement (QAPI) meetings on 6/20/24 and 7/30/24. Review of the meeting notes, dated 6/20/24, reflected no evidence R104 fall concerns were discussed. NHA A reported completed Past Non-Compliance for R104 fall because fall was not immediately reported to the nurse and CNA staff moved resident post fall prior to nurse assessment. NHA A reported fall trends discussed at QA meetings and verified R104 fall on 6/7/24 was not issue of trending. During an interview on 8/1/24 at 12:30 p.m., Director of Nursing (DON) B reported was unable to verifiy that falls were reviewed at 6/20/24 QAPI meeting. DON B verified neurological checks completed and appeared all same writing covering more than one shift. DON B verified 6/7/24 day nurse did not sign it and reported was unsure who completed form. During an interview on 8/1/24 at 12:45 p.m., Registered Nurse (RN) K reported completed R104 incident accident report on 6/7/24 to assist floor nurse related to busy day. RN K reported was informed by CNA D that R104 was lowered to the floor and did not consider that a fall. RN K reported any change in elevation was fall and reported R104 fall should have been reported immediately to the nurse. During a telephone interview on 8/1/24 at 2:58 p.m., LPN L report worked 6/7/24 on R104 hall after fall on night shift that started at 6:45 P.m. Received in report that R104 had fallen during the day and the nurse had not been notified until around 6:00 p.m. LPN L reported when husband arrived to the facility requested resident be sent to the hospital related to unrelieved left leg pain post fall. LPN L reported assessed R104 who continued to have elevated pain in left leg and both husband and R104 requested to be transferred to the hospital. LPN L reported called 911 services, DON B and on call provider and resident sent out. LPN L reported day nurse completed one set of neurological assessments and she completed remaining until transferred out and reported she added day shift assessment to new form. During an interview and record review on 8/1/24 at 4:10 p.m., DON B reported R104 fall on 6/7/24 was not reported immediately and when reported and R104 complained of elevated pain sent to the hospital. DON B reported started asking everyone after notified R104 had left femur fracture. DON B reported would expect staff to follow Kardex including transfer status and call nurse prior to moving resident off the floor. DON B reported the facility completed investigation that included final summary and verified was part of R104 fall investigation. Informed DON B this surveyor had not yet received R104 fall summary for 6/7/24 after three requests from to the NHA A for the complete investigation. DON B left the area and returned with a typed fall summary for R104 dated 6/7/24.(over 24 hours after request for complete investigation). DON B reported were unable to determine when fall occurred even though documented on incident/accident report at 6:00 p.m. DON B reported knows fall occurred earlier in day and reported R104 shower was documented as given at 2:58 p.m.(not part of investigation). DON B reported wound expect staff to follow facility Fall Policy. DON B verified the Post Fall investigation was completed by the day nurse on 6/7/24 who was confused about where the fall took place and verified had indicated was in shower room but did occur in resident room. Continued review of R104 fall summary included, In Conclusion: Action Taken: Resident was assessed, The resident MD and RP were notified of the resident occurrence, X-ray ordered, Pain Medication offered, Care plan updated. No mention that R104 Care Plan and Kardex were not followed related transfer status of Hoyer lift of three staff assisted transfers and no mention of staff moving resident post fall without notifying nurse or delay in notification. As a direct result of R104 staff assisted transfer with fall and fracture on 6/7/24 R104 has increased pain and need for increase in pain medications with increased likelihood of constipation, decrease in activity related to fear of transfers and overall increased likelihood of worsening depressing. Review of the Fall Management Policy, dated 9/22/23, reflected, Fall Defined: Fall refers to unintentionally coming to rest on the ground .When a fall occurs, the licensed nurse will evaluate the resident for injury. Do not move the individual until he/she had been examined by a nurse. The first responder (first person to identify that the resident has fallen) will summon a nurse after ensuring the resident is safe, and then ask the resident what they were attempting to do. A hall huddle will be held to determine the root cause of the fall .

Based on observation, interview and record review facility failed to: 1) accurately assess, monitor, treat and prevent the development of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for one Resident (R38) of three reviewed for pressure ulcers, resulting in facility acquired stage 4(full thickness skin and tissue loss), and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status. Findings include: Resident #38(R38) Review of the Face Sheet and Minimum Data Set (MDS) with ARD date [DATE], reflected R38 was a [AGE] year old female admitted to the facility on [DATE] related to chronic obstructive pulmonary disease, stage 4 facility acquired pressure ulcer with chronic osteomyelitis, hypertension (high blood pressure), diabetes mellitus, cerebral vascular infarction with left non-dominant hemiparesis, anxiety, and depression. The MDS reflected R38 had a BIM (assessment tool) which reflected moderately impaired. The MDS assessment reflected R38 had no behaviors related to rejection of care. During an observation and interview on [DATE] at 11:03 AM, R38 was observed laying flat on back in bed with call light out of reach, draped over wall unit, about 3 feet from R38 reach. R38 appeared able to answer questions without difficulty. R38 reported wanted to get out of bed because she was not comfortable and could not get staff attention. R38 reported staff was last in room around at breakfast time but not since. When R38 quarried, how she got staff attention, R38 reported by yelling. R38 reported had wound on bottom and staff do not reposition her every two hours. During an interview on [DATE] at 1:45 PM, Licensed Practical Nurse (LPN) QQ reported was R38 nurse. LPN QQ reported wound rounds were every Tuesday with Nurse Practitioner and Assistant Director of Nursing(ADON) I. LPN QQ reported R38's daily wound treatments had been completed that day between 7:00am and 8:00am. LPN QQ reported floor nurses complete daily wound treatments on other days. Review of R38's Provider Note, dated [DATE], reflected, There is improvement in the depth of the tunnel this week. Continue treatment with Dakins soaked packing strip. Wound shows slight improvement. Continue current treatment .Stage 4 sacral ulcer -this wound measures 0.5 x 0.4 cm with a depth of 3.3 cm. There is a 4.8 cm tunnel at 10 o'clock. This is a full thickness wound. There is a moderate amount of serosangeous drainage from this area. Wound bed consists of 100% granulation tissue. Edges are attached and there is no slough, eschar, undermining, or odor. Surrounding tissue is fragile but without redness,warmth, swelling, pain, induration or sign of infection. This area can be cleaned daily and PRN if dressing becomes soiled or dislodged with wound cleanser and treated with Dakins soaked packing strip for 14 days packed to the depth of the tunnel. Wound should be covered with a border gauze .Continue supportive care. Patient should be repositioned frequently. Patient should be supported with pillows or wedges to prevent pressure on wound. Continue preventative measures and pressure relief. Elevate bilateral lower extremities, float heels, apply soft heel lift boots. Continue proper nutrition and hydration to support wound healing. Review of R38's Wound Clinic Consult Note, dated [DATE], reflected R38 was seen for debridement for chronic osteomyelitis of sacrum, stage 4 skin ulcer of sacral region. The consult note was date stamped as received by medical records [DATE]. The consult note reflected, Instructions Details .Wound 1 (Coccyx): In clinic and at facility wound management- wash wound with wound wash, triad cream or zinc oxide to all surrounding skin, ten pack wound with Aquacel Ag, cover with 4 fluffed 4x4 gauze and cover with 8x10 ABD pad .Follow up Appointment: 6 weeks with NP . Review of the facility Wound Care Provider Note, dated [DATE]. The Provider Note reflected, Stage 4 sacral ulcer -this wound measures 0.6 x 0.6 cm with a depth of 2.8 cm. There is a 5.0 cm tunnel at 10 o'clock. This is a full thickness wound. There is a moderate amount of serosangeous drainage from this area . Review of the facility Skin and Wound Evaluation, dated [DATE], reflected R38's had a facility acquired stage 4 pressure ulcer that was identified on [DATE] that measured 0.9cm length by 0.7cm width with 2.1cm depth with no tunneling. Review of the facility Wound Care Provider Note, dated [DATE], reflected, Wound is stable. Treatment was changed to Dakins soaked packing strip to reduce any possible bioburden in the wound tunnel to promote reduction in depth. Will continue this treatment an additional 7days and monitor progress .Stage 4 sacral ulcer -this wound measures 0.9 x 0.7 cm with a depth of 2.8 cm. There is a 6.3 cm tunnel at 11o'clock. This is a full thickness wound.There is a moderate amount of serosangeous drainage from this area. (wound decline compared to [DATE]). Review of the facility Skin and Wound Evaluation, dated [DATE], reflected R38 coccyx wound had tunnel that measured 5.2cm.(compared to one year later at 6.3cm on [DATE]). Review of R38's Physician Orders, dated [DATE] to current([DATE]), reflected, Irrigate sacrum with NS. Pat Dry. Dab with skin prep. Pack wound lightly with 1 continuous strip of Dakins moistened packing strip, Cover with border gauze every day shift for wound care. Continued review of the physician orders reflected no evidence of treatment order changes after R38's wound clinic visit on [DATE] with orders to change wound treatments. During an observation and interview on [DATE] at 12:27 PM, LPN G collected wound care supplies from the treatment cart including, opened, undated Dakins quarter solution with manufacture expiration date of ,d+[DATE], skin prep, ,d+[DATE] pack strip, border gauze, 4x4 gauze, and normal saline. LPN G entered R38 room at 12:30 PM with treatment supplies. R38 was in bed and was observed to have a urine soaked brief in place with small amount of stool as well. LPN G pulled down the soiled brief and exposed R38's coccyx area with no old dressing noted. LPN G cleaned the wound area with normal saline. The wound appeared to have an opening about the diameter of a nickel and unable to visualize base of wound. LPN G packed expired Dakins solution lodofrm strip into tunnel area. R38 stated, ouch, ouch with packing. LPN G requested assistance from Certified Nurse Assistant, who had been assisting another resident, to removed scissors form LPN G uniform pocket. LPN G used scissors to trim packing strip to leave short tail. LPN G applied border gauze over wound after applying skin prep to peri wound. LPN G then removed soiled brief and cleaned stool from R38 and applied clean brief without wiping urine from skin. LPN G reported was unsure why R38 did not have a wound dressing in place and reported R38 had just returned to bed from the wheelchair prior to the dressing change and had been up in wheelchair since start of shift at 6:00a.m. LPN G reported CNA staff are expected to notify nurse of dressing becomes soiled during incontinence care so as need wound care can by performed. LPN G reported was no informed dressing had been removed since start of shift at 6:00a.m. During an interview on [DATE] 03:40 PM, Unit Manager LPN J unlocked the 200 hall treatment cart and verified Dakins solution, used for R38 wound care had a manufacture expiration date of ,d+[DATE] and reported plan to discard and reported should have been disposed of prior to expiration date and not used for R38 wound treatment. Review of R38 Electronic Medical Record(EMR), dated [DATE] through current ([DATE]), reflected no evidence facility staff communicated with R38 provider related to wound clinic treatment orders changes dated [DATE]. Review of R38's wound Care Plan, dated [DATE], Administer treatments as ordered and observe effectiveness. Continued review of skin care plan reflected, Provide incontinence care as needed and apply moisture barrier cream/ointment per facility policy/orders . During an interview on observation on [DATE] at 12:26 PM, Central Supply staff Y reported Dakins solution disposed of in central supply [DATE] because were all expired and new order was placed and received shipment [DATE] for Dakins quarter strength solution. Observed several bottles on shelf. During an interview on [DATE] at 1:20 PM, Wound Nurse/Assistant Director of Nursing(WN) I reported would expect nursing staff to follow physician orders including for wound care. WN I reported would expect CNA staff to notify nurse of wound dressings become loose or soiled during incontinence care. WN I reported R38 wound healing had stalled and had show minimal changes over several weeks. WN I reported recent change in facility wound care provider with treatment changes and reported provider believes R38 needs surgical intervention. During a second interview on [DATE] 02:30 PM, WN I reported unsure when R38 was last seen by wound clinic. WN I reported would expect nurse on duty at the time of return from clinic to review visit notes and contact physician to review clinic orders and add to physician orders to EMR. WN I reported was not aware of R38 wound clinic recommendations to change treatment orders on [DATE] and verified had been scanned into medical record and verified orders were not updated per physician orders on [DATE]. WN I reported was not aware of R38's need for next follow up appointment until review of notes at that time. WN I reported facility Providers usually follows wound clinic recommendation and if not WN I would expect to see documentation reflected in the EMR. During an interview on [DATE] at 3:15 PM, Director of Nursing B reported would expect nurse on duty to review consult notes post wound clinic appointments, contact facility provider add orders to EMR. DON B reported would expect CNA staff to notify nurse immediately if wound dressing removed during incontinence care and nurse to replaced as needed. DON B reported would expect nurse to follow physician orders and verify treatment supplies were not expired prior to use.

This citation pertains to intake MI00142988. Based on interview and record review, the facility failed to thoroughly supervise, assess and investigate incident and accidents in three of five residents reviewed for accidents (Resident #77, #79 & #89), resulting in a change of condition, transfer to the hospital followed by death (R77), and avoidable accident (Resident #79) and safety risks with elopement (Resident #89). Findings include: Resident #77 (R77) R77's admission Minimum Data Set (MDS) assessment dated [DATE], revealed he admitted to the nursing home on [DATE], had severely impaired cognition, difficulty with focusing attention, and disorganized thinking. The same MDS assessment indicated R77 did not wander or have any physical, verbal or other behavioral symptoms during the 7-day look-back period. Fall risk assessment dated [DATE] revealed R77 was at risk for falls. Progress note dated [DATE] at 9:33 PM indicated R77 would not sleep or stay in his room, he was wandering into other residents' rooms all night and even getting in bed with two female residents. The same note indicated R77 received Ativan for anxiety symptoms. R77's Kardex care plan dated as of [DATE], indicated he required supervision or touching assistance of one helper with transfers. Incident report dated [DATE] at 5:44 PM indicated R77 had an unwitnessed fall at the bedside, observed lying down on the floor with his sheet, no injuries, vital signs stable. The same report did not indicate R77's responsible party was notified of the incident. Post Fall Evaluation dated [DATE] indicated the time of R77's fall was at 5:00 PM. The form instructed to check a blood sugar if the resident was diabetic, no blood sugar was checked and not applicable was checked; R77's diagnosis list in the electronic medical record (EMR) indicated he had type 2 diabetes mellitus. R77's EMR revealed his blood sugar was 280, on [DATE] at 4:51 AM and 4:53 AM, over 11 hours after the incident. The same form instructed to check orthostatic blood pressures if fall was within 5 feet of transfer surface; no orthostatic blood pressures were documented on the form or in his EMR. R77's February 2024 physician orders revealed orders for Seroquel (antipsychotic) medication for the diagnosis of depression and Lopressor for the diagnosis of high blood pressure. Drugs.com website indicated Seroquel and Lopressor could cause orthostatic hypotension (form of low blood pressure that occurred moving from sitting or standing positions and could cause dizziness). Licensed Practical Nurse (LPN) P was interviewed on [DATE] at 3:49 PM and stated she did not usually work on the dementia unit, where R77 lived, and was assigned to the unit on [DATE] on day shift for twelve hours. LPN P stated on [DATE] at 5:00 PM, a certified nurse assistant (CNA) reported R77 had been found lying on the floor in his room. LPN P stated when she went into R77's room, he was found in bed, and that his CNA had transferred him to his bed. LPN P stated R77 did not have injuries from his fall on [DATE] at 5:00 PM; R77 had an injury on his head that was observed prior to his fall, and he may have fallen prior to the start of her shift on [DATE]. LPN P stated she had written the name of R77's roommate on the neurological assessment form, and then drawn a line through the roommate's name and printed R77's name above. The neurological assessment form was presented to this writer with white-out covering the roommates name on [DATE]. LPN P stated she was confident that the neurological assessments were pertaining to R77 and not his roommate. CNA Q was interviewed on [DATE] at 8:43 AM and stated he did not usually work on day shift but had worked a split shift that day. CNA Q stated when R77 was observed on the floor, he looked like he had just laid down on the floor, on his back to sleep. CNA Q stated he took R77's vital signs and was assessed by the nurse after R77 was transferred into his bed. CNA Q stated R77's head wound looked old and there was no fresh bleeding. Director of Nursing (DON) B was interviewed on [DATE] at 9:31 AM and stated R77's fall was investigated by the interdisciplinary team (IDT) on [DATE]. DON B stated the IDT doesn't always review residents that transfer to the hospital following a change of condition. DON B stated she did not know how or when R77 obtained the injury on the right side of his head and was not investigated. DON B stated she would expect staff to not move a resident from the floor until after the resident was assessed by a nurse. DON B was not able to confirm R77's family/responsible party were notified of the fall on [DATE]. DON B stated she did not have an answer as to why vital signs/neurological assessment post fall were not included in the transfer notice or physician notification. DON B stated the IDT team did not discuss R77 getting into bed with female residents documented on [DATE]; and confirmed behavior was not on R77's care plan. CNA R was interviewed on [DATE] at 9:53 AM and stated she worked on [DATE] and did not work on the dementia unit often. CNA R stated she did not recall R77 having an injury on his head but did recall he didn't eat much for dinner that evening. CNA R stated R77 had been observed prior to [DATE] getting into two other female residents' beds. CNA R stated prior to [DATE], one female resident started screaming at R77 to get out, and R77 was combative with staff when they attempted to re-direct him from the other residents' room. Social Worker (SW) D was interviewed on [DATE] at 12:15 PM and stated there was a period of time the IDT team were not having at risk meetings to address behaviors due to lack of staff. SW D stated she was not aware R77 had been combative when staff attempted to re-direct from other residents' rooms. CNA T was interviewed on [DATE] at 1:21 PM and stated she had noticed R77 had been wandering more just prior to his transfer to the hospital. CNA T stated she had heard R77 was combative with other staff. Activities Assistant (AA) U was interviewed on [DATE] at 2:55 PM and stated she worked on [DATE] from 9:30 AM to 6:00 PM. AA U stated she found R77 lying on his back, on the floor in his room, parallel with the bed that was near the door on [DATE] right before dinner. R77 had a plaid flannel shirt bundled up under his head. AA U stated she did not think R77 had an injury, but noted his breathing looked labored, he wasn't wearing his shirt and was using his upper chest muscles to breathe. AA U stated she reported to the CNA that R77 was on the floor and stepped out of the room after that. AA U stated she noted he slept a lot during the day. R77's Change of Condition form dated [DATE] at 5:50 PM revealed a question if the vital signs were the most recent vital signs taken, the form indicated yes; the temperature, pulse, respirations, and blood pressure was documented as obtained on [DATE] at 9:06 AM, approximately 8 hours prior to R77's fall. R77's oxygen saturation level was obtained on [DATE] at 12:27 PM. Neurological Assessment form dated [DATE] indicated R77's blood pressure at 5:00 PM was ,d+[DATE] following the incident and dropped to ,d+[DATE] at 11:45 PM. Progress Note dated [DATE] at 4:37 AM revealed R77 was lethargic, opened his eyes and mumbled. R77's color was dusky, blood saturation was 87 percent (%, normal greater than 95 %), respirations were at 20 breaths per minute and shallow, his blood pressure dropped to ,d+[DATE] at 3:40 AM. Oxygen per mask was initiated at four liters. Emergency Medical Services were called and arrived at the facility at 4:10 AM and transferred to the hospital at 4:20 AM. Transfer Form dated [DATE] at 4:48 AM revealed the reason for R77's transfer to the hospital was lethargy and change in vital signs. The same form indicated R77 had an abrasion with swelling and bruising on the right side of his forehead. R77's Emergency Services Evaluation dated [DATE] at 4:48 AM revealed triage chief concern was fall and trauma. Emergency services reported R77 fell on [DATE] around 4:00 to 5:00 PM and around 3:00 AM he was found down and unresponsive. Blood pressure was ,d+[DATE], had minimal respirations with oxygen saturation was 70 % on a non-rebreather mask. R77 had a Glasgow scale (neurological scale to measure consciousness, scoring of 3 to 15), score of 7; a score of 3 to 8 indicated a severe traumatic brain injury. R77 had a 1-centimeter (cm) abrasion to his right forehead and had a significant amount of vomitus in his throat. The same Emergency Services Evaluation dated [DATE] at 4:48 AM note indicated at triage R77's physical examination indicated he was largely unresponsive and critically ill appearing. R77 had a right forehead abrasion that appeared several days old with granulation tissue (development of new tissue and blood vessels in a wound during the healing process) and no active bleeding. Vomitus and blood were noted in R77's throat and his mucus membranes were dry. R77's heart rate was 122 (normal at rest 60 to 80 beats per minute), respirations were 44 (normal at rest 12 to 16 breaths per minute), and oxygen saturation was 85 %. The same document revealed R77 had a history of atrial fibrillation (A-Fib, irregular heartbeat) not on anticoagulation medication, diabetes, lung disease, dementia, and heart failure. Medical Decision-Making and Emergency Department course after sign out document, dated [DATE] revealed R77 was found to have a spleen laceration, pulmonary embolism (blood clot in both lungs) and significant aspiration pneumonia (food or liquid breathed into the lungs instead of swallowed). This presented a difficult situation where heparinizing (anticoagulation) for pulmonary embolism would cause potentially fatal bleeding from splenic laceration. The trauma team felt that R77 would not tolerate surgery to address his splenic laceration in the setting of his severe pulmonary embolism. After several discussions, family decided to make R77 comfort care, he was taken off of pressor support (medications to raise blood pressure and increase cardiac output) and expired shortly thereafter on [DATE] at 11:40 AM. Progress Note dated [DATE] at 10:32 AM revealed the interdisciplinary team (IDT) reviewed R77's incident from [DATE] at 5:00 PM and concluded R77 was impulsive with poor safety awareness and may had lost his balance or slipped from bed. The same note didn't address the origin of R77's head injury or recent behaviors. The same note didn't indicate R77 was observed lying next to his roommate's bed or that the activity aide that first observed R77 on the floor was interviewed. DON B was interviewed on [DATE] at 3:25 PM and stated she had not been able to determine how R77 injured his head and did not have any additional information. 46954 Resident #79 Review of an Admission Record revealed Resident #79 (R79) admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included pneumonitis due to inhalation of food and vomit, major depressive disorder, nausea, syncope and collapse, and difficulty in walking. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R79 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The Care Plan reflected R79 did not ambulate and required one person for bed mobility. On [DATE] at 10:33 AM, R79 was observed in bed resting. R79 stated that he had a fall when he resided in a different room at the facility. R79 reported that he tumbled off the bed during a brief change. He was sent out to the hospital a few hours later but reported aside from some knee pain, he was uninjured. Review of a Nursing Note dated [DATE] at 09:55 revealed Pt (patient) had a fall from his bed this morning at approximately 0620 [AM] while turning in bed, performing peri-care. Pt fell out of bed onto his right side and is complaining of pain to his right side of forehead (with some bruising) right shoulder and arm area and right knee and leg. PRN (as needed) Tylenol administered at 0630 [AM] by nurse. NP (Nurse Practitioner) ordered transfer to ER for evaluation . Review of a Resident at Risk note dated [DATE] at 11:59 AM revealed Resident experienced a recent fall occurrence [sic] from bed during provision of care. It was noted that the mattress was ill fitted on the frame and as the resident turned he was unable to brace himself and slid off the side of the mattress. The resident will be provided with a wide bed with a secured mattress . In an interview on [DATE] at 10:22 AM, Licensed Practical Nurse (LPN) V confirmed she was working the night that R79 experienced the fall. LPN V reported that R79 was in bed being assisted with a brief change by Certified Nursing Assistant (CNA) W. When CNA W rolled R79 over in bed, R79 fell out of bed and onto the floor. LPN V stated that the mattress on the bed was not the correct size mattress for the bed frame. In an interview on [DATE] at 10:39 AM, CNA W confirmed that he was present at the time of the fall. CNA W stated that the mattress that R79 had on his bed was too big for his bed and the mattress hung over the bed frame about 4 inches on each side of the bed. CNA W was unaware that the mattress did not have a frame underneath of it to help support the weight of R79. CNA W also stated that the side of the bed frame had additional support on each side that maintenance can pull out and lock to give the mattress support, but this was not done, and CNA W was not aware. Review of the Incident Report dated [DATE] revealed Resident rolled out of bed onto the floor in between the bed and the bedside dresser While Aide was giving care. The resident landed on his right side. Resident Description: The resident stated that he rolled out of bed during a brief change onto the floor and that he hit his head on the table. Review of the Post Fall Evaluation dated [DATE] revealed that the intervention for R79's fall included providing R79 with a wide bed and a secured mattress. In an interview on [DATE] at 2:52 PM, Director of Nursing (DON) B reported that the fall was reviewed by the Interdisciplinary Team. Regarding R79's fall, the Certified Nursing Assistant was providing care and when the Certified Nursing Assistant turned R79, the mattress shifted and R79 fell on to the floor. When asked why the bed was not widened to support the mattress, DON B stated she was unsure what caused the bed frame malfunction. Resident #89 Review of an Admission Record revealed Resident #89 (R89) admitted to the facility on [DATE] with diagnoses which included repeated falls, major depressive disorder, schizophrenia, and sensorineural hearing loss. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R89 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The Care Plan reflected R89 was independent with ambulation with the use of his walker. Review of the Medical Record revealed that R89 had a court appointed guardian. In a screening interview on [DATE] at 12:41 PM, R53 who was easily conversant and understood, reported that the code to the door used to exit the building to smoke cigarettes had recently been changed because some people learned the code and have been getting out. When queried, R53 further explained that occasionally a non-smoking resident had joined the group of residents that sat outside to smoke. One on occasion recently, the resident that does not smoke was outside and got up and walked off. R53 stated that there was an employee present at the time, but no one seemed to observe the resident walk off the facility property because staff panicked and ran off attempting to locate the resident. In an observation and interview on [DATE] at 12:15 PM, R89 was observed dressed appropriately and lying in bed. R89 was easily conversant and understood questioning. A wander guard was observed on his right ankle. R89 reported no concerns and explained that he enjoys walking the hall and attending activities. In a screening interview on [DATE] at 10:12 AM, R317 who was easily conversant and understood, reported that his roommate (R89) had informed him that he walked away from the facility recently. R317 stated that R89 had been struggling with ideas that a motorcycle gang was going to harm his family and R89 had been increasingly anxious about wanting to go home to deal with these matters. In an observation and interview on [DATE] at 09:54 AM, R89 was observed in his room having a conversation with a case manager from outside of the facility. Case manager (CM) AA was explaining the process of transitioning to the community to R89. R89 was overheard stating to CM AA that he did not belong here (the facility) and that he was trying to get out. R89 reported to CM AA that he was thrown in here and someone took all of his stuff. Upon exit of R89's room, CM AA explained that she was escorting R89 down to the social worker office to assist her in explaining the process of transitioning to the community. In an interview on [DATE] at 12:33 PM, a confidential staff member (SM) reported that she was aware that R89 had walked away from the facility. SM CC stated that R89 told her that his intention was to leave the facility and go live in the woods. In an interview on [DATE] at 1:07 PM, Registered Nurse (RN) S stated that she heard from other residents and staff members that R89 had unknowingly walked away from the facility. RN S stated that R89 did not have an updated care plan after the elopement and was unsure if he had a wander guard after the elopement. In an observation and interview on [DATE] at 2:09 PM, R89 was observed in his room, laying in bed. There was no longer a wander guard present on the ankle of R89. R89 reported that he had recently arrived back to the facility from an outing with activity staff members. When queried about walking off the facility property, R89 explained that he really wanted to go home. Prior to living at the facility, R89 stated he was independent, managed his own finances, did his own shopping, and mowed his own lawn. R89 was unsure how he got to the facility and why he had a guardian. R89 recalled the day that he walked off. He stated that he had gone outside with the smoking group to get some fresh air. R89 said he made it to the edge of the property and after realizing that no one had noticed, he started walking down the sidewalk. R89 recalled seeing cars slowing down as they went past him, however, a blonde lady from activities stopped and had him get into her vehicle. R89 stated that he was educated on leaving the facility and had to wear a tether (wander guard). When asked what happened to the wander guard, R89 explained that it was removed yesterday. A telephone call was placed to the guardian of R89 but was not returned. In an interview [DATE] at 02:19 PM, Certified Nursing Assistant (CNA) EE reported that she had heard that R89 had eloped from the facility and that staffing had received education regarding the incident. Review of the most recent Elopement Risk assessment dated [DATE] reflected that R89 was categorized as no risk for elopement. Review of R89's Care Plan revealed no Care Plan for Elopement Risk. Review of the Physician Order's for R89 revealed no order for the wander guard. Review of the Elopement Book located behind the Nursing Desk of the unit that R89 resided on revealed that R89 was not listed as an elopement risk in the book. No Incident Reports were located for R89. Review of a Resident/Family Education Record dated [DATE] revealed that R89 received education from the Nursing Home Administrator regarding the Leave of Absence process. The Specific Education section of the form revealed talked with resident that if he wishes to leave the property, activity staff can assist him in arranging in outing in addition to going out with smoking group and additional time he requests to go outside. In an interview on [DATE] at 3:19 PM, Activities Aide (AA) Z reported she was working and present at the time when R89 walked away from the facility. AA Z stated that her and a coworker were taking the smoking group outside and R89 wanted to join. AA Z and the coworker were distributing smoking supplies and lighting cigarettes for the residents and when they looked up, R89 was gone. AA Z and the coworker stated, where is [R89] and they both went around the building to see if they could locate him, with no avail. AA Z stated that her co-worker got into her personal vehicle and exited the facility parking lot to find R89. R89 was located at a neighboring business a few doors down, got into the vehicle with the co-worker, and was returned to the facility. AA Z stated that the facility was re-educated after the incident and was stressed the importance of being careful when taking residents out of the building. A telephone call was placed to the co-worker and was not returned. In an interview on [DATE] at 2:59 PM, Director of Nursing (DON) B stated that residents are assessed quarterly to determine if they are an elopement risk. If the risk is present, interventions are implemented such as moving the resident to the secured unit, applying a wander guard bracelet, care planning to inform the staff, and adding the resident to the Elopement Book. Regarding the elopement for R89, DON B stated that she has heard that he was out in the smoking area with members of the activity department when he decided he wanted to go home, he felt the place was too restrictive. DON B stated that one of the activity staff members had gone out and retrieved him. Nuring Home Aminstrator A had a meeting with R89 and explained to him that he cannot walk off the property without going through the proper channels which including requesting permission from the guardian and following the leave of absence process. In an interview on [DATE] at 3:10 PM, Assistant Nursing Home Administrator stated that when R89 exited the property, it was not considered an elopement because staff had eyes on him the entire time.

Based on observation, interview, and record review, the facility failed to provide pain management service of Botox injections in one of three residents (Resident #317) reviewed for pain, resulting in unrelieved pain. Findings include: Review of an Admission Record revealed Resident #317 (R317) admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included fracture of neck, traumatic subarachnoid hemorrhage with loss of consciousness, need for assistance with personal care, disorder of the autonomic nervous system, and cellulitis of toe. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/9/23, reflected R317 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The Care Plan reflected R317 was dependent on staff for all activities of daily living. In an observation and interview on 02/25/24 at 12:15 PM, R317 was observed in bed dressed in a gown. R317's hands and wrists were exposed which revealed to be severely contracted. R317's left wrist was extended at an uncomfortable appearing angle. When queried if R317 has any pain from his bilateral hand and wrist contractures, R317 stated that he has spasms in his hands and wrist which causes him to have severe pain. R317 described it as his brain was telling him to move his hands but when he tries, they spasm out of control. R317 denied wearing braces or having any regular restorative nursing services to assist with his range of motion for his hands and wrist. R317 stated that his range of motion in his hands used to be better but since not having any services, the function in both limbs declined. R317 reported that he was followed by outside services for the management of his contractures and that he was prescribed pain medication and muscle relaxers to aid in pain relief. Review of the Physician Order set revealed that R317 was prescribed medication for pain control and was regularly receiving the prescribed medication. Review of a Progress Note dated 11/22/2023 at 00:00 revealed R317 was seen my Physical Medicine for rehabilitation for his spasms and pain. R317 was advised to have a Botox injection on both hands for spasm. Review of a Progress Note dated 12/5/2023 at 00:00 revealed R317 was seen by physiatrist for his muscle spasm in the wrist drop, was recommended to wear the hand braces and also schedule baclofen (used to treat muscle spasms) 3 times a day. We will continue monitor his spasm conditions . Review of a History and Physical Note dated 2/20/2024 at 00:00 revealed that his feet are having quite a bit of pain as well as his left wrist contracture area. Will change as needed Tylenol to schedule 650 mg [milligram] every six hours along with tramadol (pain reliever) one tablet every six hours . patient was quite irritable in his mood. Patient said he was having seven out of 10 pain in his left wrist at or above the same in his right . Review of an After Visit Summary dated 2/20/24 revealed R317 had an upcoming appoint on 2/21/24 at 10:00 AM at a local physical medicine rehabilitation center for the Botox injections to assist with his pain relief. The Appointment Book behind the nurses station on the unit R317 resided on was observed on 3/5/24 at 10:01 AM. Appointment dates ranged from current back to November 2023. There was no appointment for R317 in the appointment book for 2/21/24. In an interview on 3/05/24 at 10:09 AM, Licensed Practical Nurse E confirmed he was aware of R317 care needs. When queried if R317 had attended his appointment for Botox injections, LPN E was unsure but stated R317 would know if asked. In an observation and interview on 3/05/24 at 10:59 AM, R317 was seen resting in bed. R317 stated that he was currently experiencing pain in hands and wrist and stated that he had not gone out to any appointments recently and had not received the Botox injections. In an interview on 03/05/24 01:51 PM, Medical Records/Appointment Scheduler employee (MR) H stated that she was not aware of R317 going out to any appointments in the month of February and did not have him on the list for any future schedule appointments or appointment requests. In an interview on 03/05/24 at 2:59 PM, Director of Nursing (DON) B stated that she was unsure if R317 had received the Botox injections and would follow up regarding any upcoming appointments for R317. At the time of survey exit, no information was provided regarding R317's Botox injections.

This citation pertains to intakes MI 193 and MI 754. Based on observation, interview and record review, the facility failed to 1) protect the resident's right to be free from sexual abuse for one (Resident #54) by Resident #20 and; 2) protect the resident's right to be free from physical abuse for one (Resident #21) by Resident #466 of four reviewed for abuse, resulting in resident to resident sexual and physical abuse. Using the Reasonable Person Concept, findings could include fear, anxiety, trauma and withdrawal. Findings include: Resident #20 (R20): Review of the medical record reflected R20 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/23/22, reflected R20 had short-term and long-term memory problems. The same MDS reflected R20 performed activities of daily living with independence to extensive assistance of one person. Resident #54 (R54): Review of the medical record reflected R54 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS, with an ARD of 8/25/22, reflected R54 had short-term and long-term memory problems. The same MDS reflected R54 performed activities of daily living with independence to extensive assistance of one to two or more people. On 11/15/22 at 11:45 AM, R20 was observed lying in bed, facing the door. His room door was observed to be open, and his room was located directly next door to R54's room. During an interview on 11/10/22 at 10:45 AM, Housekeeper C reported that on 5/28/22, she was in the hallway, coming out of a room that she had just cleaned. R54 was asleep in a dining chair in the hallway. When she came out of the room that she had cleaned, R20 was in front of R54. R20 stood in front of R54, raised R54's head and tried to force. There was nobody else in hallway, according to Housekeeper C. She tried to have R20 step back, and he would not. Housekeeper C reported she could see R54's whole face, and she could see R20 trying to insert his penis into R54's mouth, while holding her head up. R20 could not get R54's mouth open, according to Housekeeper C. She reported R20's penis was on R54's mouth. R20 swung at Housekeeper C as she attempted to separate the residents. Housekeeper C reported that was the first incident she had knowledge of, and she was not aware of anything happening since. Housekeeper C reported that when she went in to clean the room, which took at least ten minutes, R20 was walking in the hallway, and R54 was sitting in a chair in the hallway. When she was unable to separate the two residents, she went to get the nurse. During that time, R20 was still attempting to put his penis in R54's mouth, according to Housekeeper C. She reported it took about ten to 15 seconds to get the nurse, who was in the dining room. R20 was then taken to his room, per her report. Review of the facility's investigation reflected an Incident and Accident Investigation Form, which indicated an incident occurred on 5/28/22 at 12:30 PM and was reported to the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 5/28/22 at 1:30 PM. The occurrence was observed by Housekeeper C and was reported to the nurse. The Investigation section reflected, .Was the site of the alleged incident examined? was marked Not necessary or feasible. The investigation included a Progress Note for R54, dated 5/28/22 at 1:55 PM and created by Licensed Practical Nurse (LPN) E on 5/29/22 at 1:58 PM, which reflected .Resident observed asleep siting [sic] in a chair in the hallway. Resident peer .was noted standing in front of resident attempting to engage with her in an inappropriate manner. Residents were separated and resident was assessed. No injuries noted. Resident seemed to be unaware of the actions of her peer as she was asleep at the time .15 minute checks initiated. The facility investigation included a statement from LPN E, which reflected she was notified by Housekeeper C that R54 was sitting in the hallway, sleeping with her head down. R20 walked up to R54, tilted her head up with his hand and touched his penis to her lips. R20 had clothing on with his genitals out of his pants. The statement reflected that the nurse reported to the unit and observed R20 sitting in a chair in the hallway and R54 walking in the hall. R54 stopped in front of R20 and took his hand. They chatted for a moment, very friendly, then she let go of his hand and continued to walk in the hallway. R20 was assisted to the day room and placed on 15 minute checks. Housekeeper C's statement reflected that around 11:00 AM, she was in the hallway at her cart. She noticed R54 sitting in a chair in the hallway, asleep, with her head down. She noted that R20 was standing in front of R54 with his back to her (Housekeeper C). Housekeeper C walked over to them and observed R20 with his penis out of his pants, putting it on R54's lips. R20 had R54's head tilted back with his hand, while R54 remained asleep. Housekeeper C addressed R20, told him his actions were inappropriate and stated, Let's go to him, as she took hold of his arm to redirect him. R20 hit the Housekeeper C on the arm with his hand. Housekeeper C obtained the assistance of the Certified Nurse Aide (CNA) on the unit to separate the residents. The CNA took R54 to her room, away from R20. The occurrence was reported to the nurse. A statement from LPN G reflected she came out of the bathroom and Housekeeper C reported that R20 walked up to R54, wanting to put his genitals in her mouth. LPN G went out into the hall and observed R20 walking away from R54, then up and down the hallway. According to the statement, the Housekeeper tried to redirect R20, and he hit her (Housekeeper). The Housekeeper reported to a CNA for assistance. A statement from CNA H included that he was assisting a peer to provide care to a resident. The Housekeeper entered the room and called for assistance, relaying that R20 was attempting to place his genitals on R54. When CNA H went into the hall to assist, R20 was observed walking in the hallway. R54 was sitting in a chair in the hall. The Description of the occurrence in the facility's investigation reflected that per the Social Worker, R20 denied having any inappropriate contact with his peer. He was advised that he could not touch his peers. Additionally, if he needed to pleasure himself, he should go to his room and do so in private. R20 verbalized understanding, according to the document. A Progress Note in R20's medical record, dated 8/17/22 at 11:05 AM, reflected R20 was observed holding R54 from behind. R20 had his penis out, masturbating and touched R54 with his penis. The Nursing Home Administrator (NHA) was notified, and the police were called, according to the note. An additional Progress Note in R20's medical record, dated 8/17/22 at 11:36 AM, reflected R20 approached R54 from behind. R20 took hold of R54's arm from behind, while he (R20) had his penis exposed and masturbating, as he pressed his penis against her (R54). The note reflected staff separated the individuals immediately. The NHA, Physician and police notified, according to the note. A Progress Note in R20's medical record, dated 8/17/22 at 11:37 AM, reflected R20 was approaching staff, wanting them to accompany him back to his room. When asked why, R20 stated, so you can suck my [d***]. According to the note, R20 was making the request to both male and female staff, while exposing his penis. A Progress Note in R20's medical record, dated 8/19/22 at 12:59 PM, reflected R20 was standing in the hallway, exposing himself while masturbating. R20 was stating he wanted someone to orally satisfy him and was redirected back to his room. A Progress Note in R20's medical record, dated 8/23/22 at 11:54 AM, reflected R20 was sexually inappropriate throughout the day 8/22, exposing himself and masturbating. He was redirected to his room multiple times. During an interview on 11/15/22 at 1:59 PM, CNA O reported they had worked on the dementia unit on and off for about one year. According to CNA O, R20 pretty much kept to himself and was more withdrawn, mostly staying in his room. CNA O denied knowledge of R20 having sexual behaviors or any inappropriate interactions between him and other residents. During an interview on 11/15/22 at 3:19 PM, NHA A denied that the facility had any surveillance footage. He reported the facility had cameras, but they pointed at the exits and captured live video stream only. Review of a facility investigation for R54 and R20 for an incident on 8/17/22 reflected the CNA reported to the nurse that she exited a room and noticed R20 standing behind R54 in the hall, near the shower room. Both residents were facing the CNA. R54 was smiling and giggling. The CNA approached the residents to redirect their proximity and noted R20 had his penis exposed, holding it in his hand and touching it to R54's clothing, near her lower back. The CNA redirected R20 to his room and brought R54 to the nurse to report the situation. A facility investigation statement from CNA F reflected she came out into the hall from a room and observed R20 in the hall, standing directly behind R54. Both residents were facing the CNA. When she approached to redirect their proximity, she observed that R20 had his penis out of his clothes, holding it in his hand and touching it to the back of R54's clothing, near the sacrum. R20's other hand was on R54's waist. The residents were immediately separated. R20 was taken to his room, and R54 was taken to the day room to report to the nurse. During an interview on 11/10/22 at 2:36 PM, LPN D reported R54 paced up and down the hall and sometimes went into other resident rooms. She sometimes sat on the bed if there was another resident in the room. LPN D reported the facility began having sexual incidents involving R20 about four months prior. He went out (to the hospital), and his medications were adjusted. LPN D reported hearing of an incident in the hall, between R54 and R20, when R20 had his penis out. They began paying more attention to R20 after that. That was the first time he had knowledge of an incident of that nature with another resident. During an interview on 11/15/22 at 2:20 PM, Registered Nurse (RN) L reported she did not know the specifics of any resident to resident incidents or encounters between R54 and other residents. She reported there was some sexual exposure between R54 and R20 that she heard of a couple months prior. There had not been anything recently or when she was on duty, per her report. A Progress Note in R20's medical record, dated 9/4/22 at 2:26 PM, reflected that at 10:45 AM, R20 was observed in another resident room, in close proximity to R54. R20 had his penis exposed. The note reflected no contact was made. According to the note, the NHA and Director of Nursing (DON) were notified. A Progress Notes in R20's medical record, dated 9/7/22 at 5:58 AM, reflected R20 was standing in the doorway of his room, attempting to coax R54 into his room. R20's medical record reflect he was sent to the hospital on 9/7/22 and returned to the facility on [DATE]. During a phone interview on 11/16/22 at 11:45 AM, Registered Nurse (RN) J reported (on 9/4/22) from the nurse's station in the day room, she observed R54 in bed two of a room (which was not R54's room), and there was a male resident in bed one. She happened to look up and observed R20 in the room, at the foot of the bed that R54 was lying in. When asked if R20 was exposed in any way, RN J stated it had been a while. She believed R20's zipper was down, and he was not that close to R54. RN J was unaware of any incidents between R20 and R54 prior to that. According to the facility's Abuse Prohibition Policy, with a revision date of 9/9/22, .Each guest/resident shall be free from abuse .To assure guests/residents are free from abuse .the facility shall monitor guest/resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the guests/residents .Sexual Abuse is a non-consensual sexual contact of any type with a guest/resident .Sexual abuse includes, but is not limited to: unwanted intimate touching of any kind especially of breasts or perineal area; all types of sexual assault or battery, such as rape, sodomy, fondling and/or intercourse or coerced nudity; forced observation of masturbation .Guests/residents have the right to engage in consensual sexual activity. If at anytime the facility has reason to suspect the guest/resident does not have the capacity to consent to sexual activity the facility should evaluate whether the guest/resident has the capacity to consent . Resident #21 (R21): R21 was an eighty-nine-year-old admitted to facility 2/18/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/22 revealed Brief Interview for Mental Status (BIMS) score of three (severely impaired cognition). Section G of MDS revealed that R21 required limited assist of one for bed mobility, transfers, and toileting. Section H of MDS reflected that R21 was frequently incontinent of bladder and always incontinent of bowel. Resident # 466 (R466): R466 was an eighty-two-year-old initially admitted to facility 3/23/22 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 9/24/22 revealed that resident was usually understood and understands with Brief Interview for Mental Status (BIMS) score of three (severely impaired cognition). Section D of MDS reflected Resident Mood Interview (PHQ-9) score of zero (no depression). Section E, physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others), of MDS indicated that Behavior of this type occurred 1 to 3 days during 7 day look back period. Activities of Daily Living Assistance revealed that R466 required supervision of one person assist for bed mobility and transfers, was independent with walking in room with supervision required in corridor and on unit. Limited assist of one person required for toilet use. Section H of MDS indicated that resident was occasionally incontinent of bladder and bowel. On 11/04/22 at 8:54 AM, R21 was observed laying in bed, on left side, dressed in facility gown. According to the facility reported incident dated 7/29/22 at 10:35 AM, Housekeeper C heard yelling in the hallway coming from room [ROOM NUMBER]. Housekeeper C entered the room, heard R21 yelling at R466, and observed R466 to have a hold of R21's left wrist and was hitting her on the left arm and left side of the face with his right hand. The report indicated that Housekeeper C intervened, separated the residents at which time R466 grabbed and dumped the water pitcher onto R21 and then proceeded to hit housekeeper C on left upper arm. Housekeeper C separated the residents, helped R466 out of room [ROOM NUMBER], and notified RN M. The facility investigation included a statement from Housekeeper C, which reflected that she heard yelling from the hallway, entered room [ROOM NUMBER], observed R466 to have a hold of R21's left wrist and was hitting her on the left arm and left side of face with his right hand. Housekeeper C separated the residents at which time R466 grabbed and dumped the water pitcher onto R21 and then proceeded to hit housekeeper C on left upper arm. Housekeeper C separated the residents, helped R466 out of room [ROOM NUMBER] and notified RN M. In an interview on 11/17/22 at 9:29 AM, housekeeper C stated that on 7/29/22 when she approached room [ROOM NUMBER] from hallway, she heard R21 scream. Housekeeper C stated that upon entering room [ROOM NUMBER], she saw R466 hit R21 twice with a closed fist, once on the arm and once on the face. Per Housekeeper C, she separated the residents and then ran to the nurses' station to notify the nurse as she did not see staff in the hallway. Housekeeper C stated she heard R21 scream but stated that was usual behavior for her if someone entered her room, thus did think it was urgent. In an interview on 11/17/22 at 11:15 AM, Social Worker (SW) R stated that R21 had dementia, was protective of her space and did not like other residents coming into her room or near her. Per SW R, R21 would yell get out of here or get away from me at other residents that entered her room. SW R stated that R466 was confused, did not engage a lot, and would wander into other residents' rooms and would be noted to rummage through their belongings requiring redirection. SW R stated that she was not surprised that R21 had yelled at R466 when he entered her room. SW R stated that R466 was known to be aggressive toward staff but, to her knowledge, had never been noted to be so with other residents prior to 7/29/22 incident. Review of facility policy titled Abuse Prohibition Policy with 9/9/2022 revision date indicated that Each guest/resident shall be free from abuse, neglect, mistreatment .To assure guests/resident are free from abuse .the facility shall monitor guest/resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the guests/residents .Physical abuse includes hitting, slapping, pinching, and kicking.

Based on observation, interview, and record review, the facility failed to implement pressure injury interventions for two (Resident #52 and Resident #97) of five residents reviewed for pressure injuries resulting in the development of facility acquired pressure injuries with the potential for delayed healing, wound deterioration, and formation of additional pressure injuries. Findings include: Resident #52 (R52): R52 was an eighty-nine-year-old initially admitted to facility 12/21/2018 with most recent readmission on 10/25/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/1/22 indicated that resident with Brief Interview for Mental Status (BIMS) score of 5 (severely impaired cognition). Section G of MDS revealed that R52 required extensive assist of one for bed mobility and two-person dependent assist for transfer. Section H of MDS reflected that R52 was frequently incontinent of bladder and always incontinent of bowel. Section M of MDS indicated that R52 had one Stage 4 pressure ulcer, an infection of the foot, a surgical wound and that resident was not on a turning/repositioning program. The MDS dated [DATE] revealed R52 had one venous/arterial ulcer, was at risk for developing pressure ulcers and was on a turning/repositioning program. The MDS dated [DATE] indicated R52 had one Stage 3 pressure ulcer, was at risk for developing pressure ulcers and was on a turning/repositioning program. The MDS dated [DATE] indicated that R52 had one Stage 2 pressure ulcer, was at risk for developing pressure ulcers and was on a turning/repositioning program. The MDS dated [DATE] indicated that R52 had one Stage 4 pressure ulcer and 2 unstageable pressure ulcers, was at risk for developing pressure ulcers and was not on a turning/repositioning program. The MDS dated [DATE] indicated that R52 had one Stage 4 pressure ulcer and 2 unstageable pressure ulcers, was at risk for developing pressure ulcers and was not on a turning/repositioning program. The MDS dated [DATE] indicated that R52 had one Stage 4 pressure ulcer, an infection of the foot, a surgical wound and was not on a turning/repositioning program. The MDS dated [DATE] indicated that R52 had one Stage 4 pressure ulcer, an infection of the foot, a surgical wound and was not on a turning/repositioning program. On 11/04/22 at 10:05 AM, R52 was observed laying in bed, in facility gown, positioned on back with head of bed elevated to approximately seventy-five degrees. Oxygen noted to be in place at 2 liters per minute via nasal cannula. R52 observed with yellow gripper socks to bilateral lower extremities with visible gauze wraps noted beneath socks at bilateral ankles/heels. Bilateral heels in direct contact with standard mattress. Clear plastic bag noted on floor labeled personal belongings with two black foam boots noted to be inside bag. On 11/04/22 at 11:29 AM, R52 was observed laying in bed, on back, with head of bed at approximately 30 degrees. Headphones noted to be in place with resident observed to be watching television. Lower extremities observed to be bent at knees with bilateral heels noted to be in direct contact with mattress. On 11/10/22 at 9:30 AM, R52 was observed laying in bed, on back, with head of bed at approximately 30 degrees. Headphones noted to be in place with television observed to be on. Left leg noted to be bent slightly at knee and right leg observed to be straight with both heels in direct contact with mattress. No footwear in place with gauze wrap noted to left foot/heel. No dressing noted to right foot/heel. Two black foam boots noted to be in wheelchair positioned at resident bedside. On 11/10/22 at 12:47 PM, R52 was observed laying in bed, on back, with head of bed at approximately 45 degrees. Left leg noted to be bent slightly at knee and right leg observed to be straight with bilateral heels in direct contact with mattress. No footwear in place with gauze wrap noted to left heel/foot. No dressing noted to right foot/heel. In an interview on 11/10/22 at 12:51 PM, Certified Nurse Aide (CNA) Z stated that she had not assisted R52 as CNA X was assigned to him. CNA Z confirmed that she was familiar with R52 and stated that he required total care which included assist with grooming, bathing, dressing and that he was incontinent of bowel and bladder. She stated that when assigned to R52, she would reposition him in bed approximately every two hours, would generally position a pillow between his legs, put his legs up on a pillow and would put boots on his heels. CNA Z stated, When I have him, I definitely put the boots on his heels as he has breakdown. CNA Z stated that she did not know the wearing schedule for the boots and upon checking the Kardex stated It doesn't say anything about the boots, but I know we put them on him when he gets up too. In an interview on 11/10/22 at 1:45 PM, CNA X stated that she had not assisted R52 as CNA Z was assigned to him. CNA X stated that she was familiar with R52 and that he required total assist with grooming, bathing, dressing and was incontinent of bowel and bladder. CNA X stated that she believed that R52 had wounds on his legs or feet and that she had seen him with the heel boots on. CNA X stated that she tried to look at each resident's Kardex daily but that sometimes relied on the nurse for resident updates as did not have time to check every Kardex daily. In an interview on 11/10/22 at 1:59 PM, CNA Y confirmed that she was assigned to R52. CNA Y stated that R52 was incontinent of bowel and bladder and that she tried to complete a check and change twice a shift (after breakfast between 9 to10 AM and after lunch between 1:30 to 2 PM). CNA Y stated that R52 required total assist for grooming, bathing, and dressing but that he repositioned himself and that she generally did not need to assist him with that as he rolls to the side a little and moves his legs up and down. CNA Y stated that R52 had sores on his feet and that she used a wedge cushion, at times, to position his legs but that he really didn't like things by his feet and would sometimes kick it off. On 11/10/22 at 2:30 PM, observed completion of R52 wound care by Licensed Practical Nurse (LPN) U. LPN U washed hands, applied gloves, and then was observed to remove gauze wrap from left ankle and foot and gauze dressing from dorsal left foot and left toes. Wound at left dorsal foot presented as oval shaped area with wound base covered by adherent dry, black tissue. In reference to left dorsal foot wound, LPN U stated There is no treatment order for that, but I clearly removed a dressing. Left third toe amputation site presented with open wound with visible depth and beefy red tissue in wound base. LPN U washed hands, applied gloves, and then cleansed left toe amputation site with normal saline, applied medicated gauze wound dressing, covered wound with 5inch (in) by 9in absorbent dressing (to cover left dorsal foot wound as well) and wrapped toe and foot with gauze wrap. In reference to the right foot/heel, LPN U stated As you can see there is no dressing on the right foot like there is supposed to be. Tissue observed to be intact to right dorsal foot and presented with deep purple and maroon discoloration. LPN U stated That was open, but it is healed now. LPN U stated that she believed the treatment ordered to the right dorsal foot wound was intended for the left dorsal foot wound and did not complete the ordered right dorsal foot wound treatment. LPN U stated that she would follow up with the wound nurse regarding wound presentation and treatments. Right heel presented with open wound with visible depth. Dark pink tissue noted in majority of wound base with minimal adherent white tissue observed at distal wound aspect. LPN U washed hands, applied gloves, cleansed wound with normal saline, patted dry, applied medicated gauze wound dressing, covered with 5in by 9in absorbent dressing, and wrapped heel with gauze wrap. Upon wound treatment completion, LPN U stated that she would put R52's bilateral heel boots back on sometime after treatment completion and prior to the end of her shift. LPN U confirmed R52 to spend most of the day in bed as stated that he was more restless when up in wheelchair and tried to transfer back to bed independently. LPN U stated that R52 was pretty still when in bed and didn't move around much. In an interview on 11/10/22 at 2:52 PM, Registered Nurse (RN) M confirmed that she was familiar with R52 and stated that she completed his weekly wound assessments with Nurse Practitioner (NP). RN M stated that R52 had an active Stage 4 pressure ulcer at right heel, a deep tissue injury at right dorsal foot, and an open wound at left toes from surgical removal of the left second and third toes. RN M denied knowledge of events that lead to right heel wound deterioration from original Stage 2 to current Stage 4 as stated, I started at facility when it was a Stage 4. RN M stated that the goal was to maintain right heel wound stability via prophylactic antibiotic use and routine wound care which included pressure relief. RN M stated that heel boots were ordered and were being used until new wound was noted to right dorsal foot. Per RN M, heel boots were discontinued at approximately end of August or beginning of September as the straps of the boots correlated to the formation of the right dorsal foot wound. RN M stated that a wedge was trialed next but as it did not work well have transitioned to float R52's heels with a pillow. RN M denied prior knowledge of wound at left dorsal foot and stated that there was no current treatment order in place as was not aware that wound was present until she was informed by assigned nurse earlier that day. During same interview, RN M acknowledged ongoing staff usage of heel boots to offload R52's heels stating, I did pull them out of his room this morning because the aides are not supposed to be using them as boot usage correlated to the formation of the right dorsal foot wound. RN M verbalized that as she had not yet assessed left dorsal foot wound, she could not discuss correlation of ongoing boot usage to new left dorsal foot wound. RN M stated that either she or the assigned floor nurse would have discontinued the order for the heel boots as she recalled that this change in R52's plan of care was discussed with the assigned floor nurse at the time of the boot discontinuation. RN M stated that as the assigned floor nurse was aware of the boot discontinuation, the expectation would have been that this information was passed on by staff through the daily 24-hour report and that the boot usage was stopped at the time the order was discontinued. RN M further stated that as R52 cannot independently move in bed enough for effective pressure reduction, the expectation would be that the CNAs assist R52 to be repositioned every two hours. Additionally, RN M stated that she believed R52 had a roho mattress but after further evaluation confirmed that he had a standard foam, raised edge mattress but acknowledged that he would benefit from enhanced pressure redistribution. On 11/15/22 at 11:23 AM, R52 was observed laying in bed, on back, dressed in facility gown. Two pillows noted to be positioned under bilateral lower extremities at knees with bilateral heels resting on standard mattress. In an interview on 11/15/22 at 12:10 PM, RN M confirmed that R52's heel boots were discontinued 9/22/22 and stated that it's possible that the care plan was not revised at the time of the boot discontinuation. RN M confirmed during same interview that the care plan was revised in early November to reflect heel boot discontinuation and the initiation of pillows for offloading of heels. RN M stated that the floor nurses, MDS nurses, unit managers all update care plans and that care plan updates was everyone's responsibility. RN M also clarified that R52 never did have a roho mattress and when questioned regarding weekly skin assessments as reflected mattress w/ pump stated Yes. Because I thought he did. That was my mistake. R52 record review complete on 11/10/22 with the following findings noted: 11/9/22 Skin & Wound Evaluation form reflected right heel pressure injury acquired in house on 2/8/22. Wound was documented as a Stage 4 pressure injury measuring 1.7centimeters (cm) by 1.4cm by 0.4cm. 11/1/22 Skin & Wound Evaluation form indicated Stage 4 pressure injury to right heel measuring 2.4cm by 1.2cm by 0.2cm. Wound bed indicated to present with 20% granulation tissue and 80% slough. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump neither of which noted to be used by R52 throughout survey. 10/25/22 Skin & Wound Evaluation form indicated Stage 4 pressure injury to right heel measuring 2.7cm by 2.6cm by 0.4cm. Wound base indicated to present with 70% granulation tissue and 30% slough. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 10/18/22 Skin & Wound Evaluation form indicated Stage 4 pressure injury to right heel measuring 2.2cm by 1.7cm by 0.1cm. Wound base indicated to present with 70% granulation tissue and 30% slough. Review of Section H (Treatment) of same assessment reflected mattress with pump. 10/11/22 Skin & Wound Evaluation form indicated Stage 4 pressure injury to right heel measuring 1.8cm x 1.9cm x 0.7cm. Wound base indicated as 80% granulation tissue and 20% slough. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 2/9/22 Skin & Wound Evaluation form reflected right heel pressure injury acquired in house on 2/8/22. Wound was documented as a Stage 2 pressure injury measuring 2.4cm by 2.0cm by 0.2cm with wound base indicated to present with 100% granulation tissue. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 2/8/22 12:34 AM PCC Skin & Wound - Total Body Skin Assessment indicated no new wounds. 2/8/22 6:52 AM Nurses Notes indicated Open area noted on pt's right heel. Area cleansed with NS, wet to dry gauze applied, and dry dressing intact. 2/16/22 5:03 PM Physician Note reviewed with no noted indication of right heel wound although note indicated no evidence of acute [CONDITION(S)] infection or gangrene on the foot noted. 11/9/22 Skin & Wound Evaluation form indicated pressure injury to the dorsum of right foot acquired in house on 8/30/22. Wound was documented as a Deep Tissue Injury (DTI) measuring 2.2cm by 0.5cm with depth not applicable. 11/1/22 Skin & Wound Evaluation form indicated Deep Tissue Pressure Injury to dorsum of right foot measuring 3.4cm by 1.7cm with depth not applicable. Wound bed indicated to present with 100% epithelial tissue. Review of section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump neither of which noted to be in use by R52 throughout survey. 8/30/22 Skin & Wound Evaluation form indicated Deep Tissue Pressure Injury to dorsum of right foot acquired in house on 8/3022. Wound indicated to measure 3.8cm by 2.8cm with depth not applicable and wound base indicated to present with 100% epithelial tissue. Review of section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 8/25/22 PCC Skin & Wound - Total Body Skin Assessment indicated no new wounds. 9/1/22 PCC Skin & Wound - Total Body Skin Assessment indicated no new wounds. 8/30/22 Wound Care Note completed by Nurse Practitioner (NP) indicated Right foot-cleanse area with normal saline, apply [MEDICATION(S)], cover with dry dressing for protection to prevent further skin breakdown and Continue supportive care. Patient should be turned every 2 hours. Patent should be supported with pillows or wedges to prevent pressure on wound Elevate bilateral lower extremities, float heels, apply soft heel lift [NAME]. 11/1/22 Progress Note completed by NP indicated Dorsum Right Foot-area previously noted as resolved, reoccurring DTI over a bony area and to Continue preventative measures and pressure relief. Frequent repositioning, elevate bilateral lower extremities, apply soft heel lift boots. Review of R52 Braden Scale for Predicting Pressure Sore Risk complete with findings as follows: 11/3/22 = 13 (moderate risk) 10/26/22 = 13 10/19/22 = 14 (moderate risk) 10/12 = 13 6/9/22 = 14 3/4/22 = 16 11/30/21 = 16 (low risk) Review of R52 Care Plan risk for impaired skin integrity/pressure injury complete with noted intervention created 1/2/19 and revised 11/9/22 to reflect Encourage and assist me to float my heels while in bed as tolerated and an intervention to Encourage and assist me to turn/reposition as resident allows while in bed as tolerated with 1/2/19 creation and 10/5/22 revision date. An intervention created 5/25/19 and revised 11/9/22 indicated to provide extensive assistance of one to reposition frequently and as needed. Review of R52 Care Plan actual impaired skin integrity complete with intervention created on 4/9/21 and revised on 11/9/22 to reflect elevate heels on pillow while in bed as resident tolerates. An intervention for Heel boots on when in bed with 3/9/21 creation date was noted to be canceled on 11/9/22. Resident # 97 (R97): R97 was an eighty-one-year-old admitted to facility 9/8/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/14/22 revealed that R97 was understood and understands with a Brief Interview for Mental Status (BIMS) score of 12 (moderately impaired cognition). Section G of MDS revealed that R97 required extensive assist of two for bed mobility, total dependent assist of two for transfers, and extensive assist of two for toileting. Section H of MDS reflected that R97 was frequently incontinent of both bowel and bladder. Section M of MDS indicated that resident did not have a pressure ulcer/injury, was at risk for developing pressure ulcers, and that resident was not on a turning/repositioning program. On 11/04/22 at 9:35 AM, R97 was observed laying in bed, on his back, with head of bed at approximately forty-five degrees and breakfast tray on over the bed table positioned in front of him. At time of observation, R97 stated that he had a sore spot at his tailbone that started to hurt after he sat up in wheelchair for too long. R97 did not recall a routine treatment to area but stated that the staff would put cream on it if he requested them to do so. Per R97, staff assisted him with repositioning off and on but stated that generally staff just instructed him to turn on your side and the pain will lesson. R97 stated that he could turn a little tiny bit onto side and the pain would lesson but that that when staff helped, he could turn onto his side more. R97 stated that he had sat in the wheelchair up to five hours as staff stated that We are in the middle of lunch. You will have to wait before being assisted back to bed. R97 stated that he normally remained up in the wheelchair from two to three hours before being assisted back to bed. During same interaction, R97 Stated I have a hole in my heel that I got here with gauze wrap noted to right ankle dated 11/2/22. R97 stated that he believed that the wound was gradually getting better and that the staff completed a treatment every other day. Resident noted with standard mattress on bed with bilateral heels in direct contact with mattress. Resident stated that staff sometimes put a boot on the right foot when he was in bed and stated The other day I woke up and the boot was on the wrong foot. It was on the left foot. One soft black boot was noted in chair at resident bedside. On 11/04/22 at 11:33 AM, R97 observed laying in bed, positioned on back with head of bed elevated at approximately thirty degrees. Bilateral lower extremities noted to be straight with both heels observed to be in direct contact with mattress. On 11/10/22 at 1:12 PM, observed completion of R97 wound care by Licensed Practical Nurse (LPN) U. LPN U washed hands, applied gloves, removed soft black boot from right lower extremity, and then removed undated gauze wrap at right heel. Right lateral heel wound noted to present with adherent dry tan to dark brown tissue covering wound base with intact pink tissue surrounding. LPN U washed hands, applied gloves, cleansed wound with normal saline, applied yellow ointment to wound base with tongue depressor, placed dry gauze and then wrapped heel with gauze wrap. R97 confirmed usage of black boot to right lower extremity when staff remember to put it on. In an interview on 11/10/22 at 1:33 PM, Certified Nurse Aide (CNA) X confirmed that she was assigned to R97. CNA X stated that she had delivered and set up both breakfast and lunch for R97 but that He doesn't ask for much. CNA X stated R97 had not asked for any assistance yet that shift and that he denied needing anything when he was asked. CNA X stated that R97 was continent of both bowel and bladder and had not checked him or assisted him with toileting needs that day. CNA stated he is fine just the way he is as he was comfortable positioned on back and denied knowledge of any skin concerns or use of any devices or splints. On 11/10/22 at 2:19 PM, CNA X observed exiting R97's room with clear plastic bag with brief noted to be inside. CNA stated that she had just checked R97 and as he was noted to be incontinent of both bowel and bladder had provided incontinence care. As resident reported sore spot on my bottom, coccyx/ buttocks visualized in presence of CNA X with intact skin and mild [CONDITION(S)] and dry/flakey skin noted to area. In an interview on 11/10/22 at 3:00 PM, RN M confirmed that she was familiar with R97, stated that she completed his weekly wound assessments with NP, and stated that R97 had a facility acquired unstageable pressure ulcer at right heel. RN M then verbalized the need to review R97 record prior to any further discussion. On 11/15/22 at 11:18 AM, R97 observed laying in bed, on back, with head of bed at approximately thirty degrees. Bilateral lower extremities noted to be extended straight out with heel boot noted on right lower extremity. Left heel in direct contact with mattress. In an interview on 11/15/22 at 12:14 PM, RN M stated that R97 had order for bilateral heel boots to offload both heels so that we don't create anything else. As weekly Skin & Wound Evaluation form reflected mattress with pump within Treatment section, RN M stated it might be something that we talked about and didn't have in the building .I'm not exactly sure. RN M stated that she would follow-up with rationale after reviewing notes. In a follow-up interview on 11/15/22 at 12:44 PM, RN M stated He does not have a roho mattress so that was my mistake in indicating that on his weekly assessments in reference to the indication of mattress with pump within Treatment section on weekly Skin & Wound Evaluation form. RN confirmed R97 to still have a standard mattress in place on bed. R97 record review complete on 11/15/22 with the following findings noted: 9/29/22 PCC Skin & Wound - Total Body Skin Assessment indicated 1 new wound 9/29 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is having no pain in his feet. I spoke with DON and ADON and they will get pressure off of his heel and apply appropriate dressing. 10/4/22 Skin & Wound Evaluation form reflected right heel pressure ulcer acquired in house on 10/4/22. Wound was documented as an Unstageable Pressure Ulcer measuring 1.8centimeters (cm) by 2.0cm with wound depth not applicable. Wound base indicated to present with 100% eschar. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device. 10/11/22 Skin & Wound Evaluation form reflected Unstageable right heel pressure ulcer measuring 1.7cm by 1.1cm with wound depth not applicable. Wound base indicated to present with 10% granulation tissue, 10% slough, 80% eschar. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 10/18/22 Skin & Wound Evaluation form reflected Unstageable pressure ulcer measuring 1.5cm by 1.2cm with wound depth not applicable. Wound base indicated to present with 100% eschar. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 10/25/22 Skin & Wound Evaluation form reflected Unstageable pressure ulcer measuring 1.8cm by 1.8cm by 0.6cm. Wound base indicated to present with 10% granulation tissue, 10% slough, 80% eschar. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 11/1/22 Skin & Wound Evaluation form reflected Unstageable pressure ulcer measuring 1.0cm by 1.4cm with depth not applicable. Wound base indicated to present with 70% slough and 30% eschar. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 11/8/22 Skin & Wound Evaluation form reflected Unstageable pressure ulcer measuring 1.2cm by 1.3cm with depth not applicable. Wound base indicated to present with 100% slough. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. Review of R97 Treatment Administration Record for September through November complete with orders noted as follows: 9/30 order noted for Protective foam until new order, one time a day for wound care 10/1 order noted to Cleanse heel with NS, pat dry, apply [MEDICATION(S)] and wrap it with kerlix. Change dressing daily for right heel 10/13/22 order noted to Cleanse heel with NS, pat dry, apply [MEDICATION(S)] and wrap it with kerlix. Change dressing every other day for right heel 11/10/22 order noted for Santyl Ointment-Apply to right heel topically every day shift for pressure wound. Cleanse with NS, Pat dry, apply thin layer santyl to wound bed, cover with dry dressing Order dated 10/2/2022 at 3:58 AM reflected heel boots bilaterally as tolerated Review of R97 Braden Scale for Predicting Pressure Sore Risk complete with findings as follows: 9/9 = 18 (low risk) 9/16 = 21 (low risk) 9/26 = 16 (low risk) 10/3 = 21 (low risk) Review of R97 Care Plan I am at risk for impaired skin integrity/pressure injury complete with interventions noted to Encourage to float heels while in bed and assist as needed created on 9/9/2022, Pressure reduction mattress to bed created on 10/28/22, and Observe for sliding down in the chair and assist to reposition in chair as needed created 9/9/22. Review of R97 Care Plan Actual impaired skin integrity related to pressure injury. Site: right heel created 10/2/22 with intervention noted for heel boots bilaterally as tolerated created 10/2/2022. Review of R97 Care Plan I am incontinent of bladder and bowel created 9/8/22 with intervention noted for BRIEF USAGE: I use disposable briefs. Check and Change every 2 hours and as needed created 9/8/22. Review of R97 Kardex complete and noted to reflect Heel boots bilaterally as tolerated and Encourage to float heels while in bed and assist as needed listed under Skin interventions. Within Kardex under Bladder/Bowel/Toileting interventions BRIEF USAGE: I use disposable briefs, Check and Change every 2 hours and as needed and Check q 2hr and prn for incontinence. Wash, rinse, and dry perineum. Apply moisture barrier. Review of facility policy titled Care Planning with 6/24/2021 revision date indicated that the purpose of the policy was to ensure Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment. The procedure indicated The care plan and resident Kardex will be updated on Admission, Quarterly, Annually and with significant changes. This includes adding new focuses, goals, and interventions and resolving ones that are no longer applicable. Review of facility policy titled Skin Management with 7/24/2021 revision date indicated that It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. and that Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan.

Based on observation, interview and record review, the facility failed to assure residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for two of five residents reviewed for pressure ulcers (Resident #39 and Resident #84), resulting in avoidable and worsening pressure ulcer for Resident #84 and avoidable pressure ulcers for Resident #39. Findings include: Resident #84 (R84) According to his Minimum Data Set, dated dated [DATE], R84 was severely cognitively impaired, had no behaviors, needed extensive assistance with bed mobility and personal hygiene, had an indwelling urinary catheter, was always incontinent of bowels, had one unhealed Stage IV pressure ulcer, moisture associated skin damage, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R84's Care Plan, dated 4/03/1 (last revised 6/27/21), revealed, I have actual impaired skin integrity related to Pressure and MASD injury AEB Stage 4 pressure ulcer to coccyx, MASD (moisture associated skin damage) to posterior right thigh r/t (related to) chronic re-occurring MASD, Hx (history) of chronic constipation, use stool softeners, frequent bowel incontinence, decreased mobility, obesity. The stage 4 pressure injury to my coccyx will show s/s (signs and symptoms) of healing without complication through the review date . Apply anal fecal bag as ordered (initiated 9/17/20) . There were no instructions for turning, repositioning, pressure relieving devices for wheelchair, or how long R84 should be up in his wheelchair. According to a Skin and Wound Evaluation for R84, dated 1/31/21, he had an, in-house acquired, Stage IV pressure ulcer that started on 4/03/21. A Skin and Wound Evaluation dated 4/03/21 revealed the Stage IV pressure ulcer measured 3.5 (cm) x 3.4 (cm) x 1.4 (cm). According to a Nurses Note, dated 12/05/20 at 12:25 PM, Skin sweep . Stage IV coccyx 1.5 (cm) x 2.5 (cm) x 8.0 (cm) . left posterior thigh 10.5 x 6.9 dark purple skin with 0.6 x 0.6 open area . left posterior thigh 18.0 x 20.0 dark purple area with scattered small open areas within . In an interview on 7/06/21 at 1:49 PM, R84's Guardian HH reported, I see (R84) every three months at the wound specialist. The wound fluctuates. There was a time when they were really bad. They have gotten better and worse. Just a handful of the staff are very consistent with his care. They need to clean him and turn him properly and do the orders that the Nurse Practitioner orders. The former Wound Nurse (II) used to call me every week or two with updates on wounds for my residents. Now, I've only gotten one phone call in the past three - four months. I would like to be called. I want to know how things are in that months' time. He has problems on his right thigh and coccyx. He has very loose stools, so they put a bag on his butt hole. I don't know why they (wounds) keep happening or why he has diarrhea. In an interview, on 7/08/21 at 2:17 PM, Assistant Director of Nursing (ADON) I reported, (R84's) wounds worsen. He is obese and difficult to reposition . he resists turns and repositions himself, favors one side over the other. We got a bigger bed. Roho mattress. In an interview, on 7/08/21 at 2:32 PM, Wound Nurse O reported she had no Pressure Ulcer/Wound Care certifications/training, just in-services. Wound Nurse O was interviewed as to why R84's pressure ulcer worsened, and she said, He is a very heavy man, and they are caused by the pressure of his body. It would get better, and it would get worse. If they get worse, I talk to the doctor. He goes to the wound clinic, and they direct the care. The charge nurse is responsible to keep an eye on whether he is turned and positioned properly . (R84) gets up in the chair; then he is (sitting directly) on it. I don't think there is a limit as to how long he can be up. He is up for a while. In an interview, on 7/08/21 at 3:15 PM, Nurse Aide L reported, We get (R84) up for at least one meal an hour before each meal. When he is in bed, we have wedges to keep him off his areas. Yes, they work, when we turn him every two hours. When he is facing the window, he would be lying on it (pressure ulcer). Nurse Aide L said if R84 was watching tv or on his back, he would be lying on the wound. Nurse Aide L said, The worst for the wound I think it is sitting up longer than for a meal. At this time, R84 was sitting straight up in bed with lunch tray still in front of him and it was observed, there was no pressure relieving device in the seat of his wheelchair. Nurse Aide L reported L said, I don't' know where it went. Review of R84's Nurse Aide Care Guide revealed no instructions about how long he was to be up in his wheelchair and no instructions to keep him off his pressure ulcer. On 7/08/2021 at 3:43 PM, Administrator A reported, Staff member told me (lunch was served to R84) a little before 1:00 pm. In an interview, on 7/08/21 at 3:48 PM, Director of Nursing (DON B) reported during Quality Assurance Meeting, there had been Nothing specific about (R84) recently. Review of R84's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #39 (R39): Review of R39's medical record reflected they were admitted to the facility on [DATE] and were readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS, with an Assessment Reference Date (ARD) of 4/25/21, reflected that R39 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected that R39 did not walk, did not transfer and required extensive assistance for bed mobility, dressing, toileting, hygiene and bathing. Review of R39's medical record reflected a discharge return anticipated MDS was in progress for an ARD of 7/8/21. Wound observations could not be made, as R39 had not returned to the facility prior to the survey exit on 7/14/21. Review of R39's MDS history included but was not limited to the following: -4/15/21 Discharge return anticipated -4/23/21 Entry -4/25/21 Discharge return anticipated -5/1/21 Entry -5/5/21 Discharge return anticipated -5/7/21 Entry -5/10/21 Discharge return anticipated -5/31/21 Entry -6/4/21 Discharge return anticipated -6/28/21 Entry -7/3/21 Discharge return anticipated -7/4/21 Entry -7/8/21 Discharge return anticipated According to the State Operations Manual, Appendix PP, an unstageable pressure ulcer is full-thickness skin and tissue loss. The extent of tissue damage cannot be confirmed because the wound bed is obscured by slough (non-viable yellow, tan, gray, green or brown tissue) or eschar (dead or devitalized tissue, which is usually black, brown, or tan in color, and may appear scab-like). A stage two pressure ulcer is partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist and may present as an intact or open/ruptured blister. A stage four pressure ulcer is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Review of wound timeline documentation, provided by the facility, reflected that R39 had an open area, documented as present on readmission from the hospital on 4/23/21, with measurements of 3.0 centimeters (cm in length) by (x) 0.5 cm (in width). The wound was classified as unstageable on 5/4/21. R39's wound assessments reflected that as of 7/7/21, R39's unstageable pressure ulcer to the sacrum was documented as deteriorating, with measurements of 8.4 cm x 3.2 cm x 1.0 cm. The wound bed had 20% granulation tissue, 40% slough and 40% eschar. There was moderate purulent (pus) drainage and faint odor after cleansing. R39's Progress Notes reflected that on 7/8/21, the Physician was in the facility and spoke to the wound care nurse. There was a new order to send R39 to the hospital to evaluate the sacral wound. According to the documentation, the Physician suspected the wound may have needed to be debrided (the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process). Review of R39's May 2021 Treatment Administration Record reflected a treatment was ordered on 4/24/21 and discontinued on 5/1/21 for an open area on the left buttock. Review of wound timeline documentation, provided by the facility, reflected R39 had a stage four pressure ulcer to the left buttock, documented as hospital acquired 6/29/21 and measuring 3.13 cm x 1.33 cm. On 7/6/21, the wound was documented as unstageable, measuring 5.57 cm x 1.58 cm x 0.4 cm. Wound assessments were dated for 6/29/21 and 7/6/21, and there were no additional wound assessments provided for the wound. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of wound timeline documentation, provided by the facility, reflected R39 had a stage two pressure ulcer to the left heel, documented as facility acquired on 6/3/21 and measuring 3.31 cm x 2.36 cm. On 7/6/21, the wound was documented as unstageable, measuring 2.69 cm x 1.99 cm. Review of wound timeline documentation, provided by the facility, reflected R39 had a wound to the left medial malleolus (inner side of the ankle), documented as present upon readmission from the hospital on 5/31/21, measuring 0.6 cm x 0.8 cm. On 7/6/21, the wound was documented as unstageable, measuring 1.21 cm x 1.21 cm. During an interview on 7/12/21 at 2:59 PM, Registered Nurse/Wound Care Nurse (RN) O reported being told by the Director of Nursing to documented wounds as present on admission if the wounds worsened while at the hospital. RN O reported R39's only facility-acquired pressure ulcer was on their heel, and it worsened while R39 was in the hospital. On 7/13/21 at 11:55 AM, Licensed Practical Nurse (LPN) D reported R39 went to the hospital because the Physician wanted them sent out for worsening wounds. LPN D had not personally observed the wounds on the day of discharge to the hospital [7/8/21] but reported being told by the wound nurse that there was more necrosis and more drainage. According to LPN D, when someone readmitted with wounds, they did a full assessment of them. If the wound nurse was not there, the admitting nurse did the skin assessment, which included location and size of wounds, wound/wound bed appearance and any treatments in place from the hospital. Review of R39's medical record did not reflect comprehensive wound assessments were conducted upon readmission: Nursing Comprehensive Evaluation for 4/23/21: left buttock has 3 [cm] x 0.5 cm open area Nursing Comprehensive Evaluation for 5/1/21: stage three pressure ulcer to coccyx; 7.0 [cm] x 5.0 [cm] x 0.2 [cm]; left foot 3rd toe small dark area, blister Nursing Comprehensive Evaluation for 5/7/21: coccyx pressure ulcer stage IV (four) 7 [cm] x 5 [cm] x 2 [cm] Nursing Comprehensive Evaluation for 5/31/21: coccyx 7 [cm] x 6 cm; left outer ankle 0.6 cm x 0.8 cm; left 2nd toe 1 [cm] x 1.7 cm Nursing Comprehensive Evaluation 6/28/21: coccyx wound, treatment in progress; left heel black Additionally, R39's transfer [to hospital] forms did not reflect comprehensive wound information was communicated to the receiving provider: -Transfer Form for 4/25/21 transfer to hospital did not reflect notation of skin impairments -Transfer Form for 5/5/21 transfer to hospital did not reflect notation of pressure ulcers -Transfer Form for 5/10/21 transfer to hospital did not reflect notation of pressure ulcers -Transfer Form for 6/4/21 transfer to hospital reflected there was a sacrum wound -Transfer Form for 7/3/21 transfer to hospital reflected there was a coccyx wound -Transfer Form for 7/8/21 transfer to hospital reflected a coccyx wound and heel wound Review of R39's Treatment Administration Record for June 2021 reflected their wound treatments for the buttocks, sacrum, left medial malleolus and left heel were not signed out as being completed until 6/30/21, even though R39 readmitted to the facility on [DATE]. During an interview on 7/13/21 at 3:15 PM, RN O was queried on what they would expect to see documented on readmission for wounds. RN O responded they would expect to see location and size documented. When queried on R39 not having wound treatments signed out for 6/29/21 or 6/29/21, RN O reported they got the order and did the treatments but did not start them until the next day. RN O stated 6/29/21 was the day the orders were put in, then the treatments would start the following day (6/30/21). RN O reported R39 was not on a turning schedule. Everyone was supposed to be turned, you would hope, every two hours, according to RN O.

This citation includes intake MI 6301. Based on observation, interview and record review, the facility failed to implement key components of infection control to prevent the spread of COVID-19 in the following areas: 1. Failed to comprehensively screen and prevent staff from entering the facility who displayed symptoms consistent with COVID-19. 2. Improper/lack of hand hygiene 3. Improper perineal hygiene for an incontinent female Resident (#130). 4. Improper use of Personal Protective Equipment (PPE) 5. Failed to Clean Reusable equipment per facility policy. 6. Inappropriately transferred a COVID-19 negative Resident (#129) into a COVID-19 positive unit 7. Failed to effectively communicate with the health department throughout the course of an identified outbreak. This deficient practice resulted in the likelihood of Spread of COVID-19 to the entire facility population, and resulted in 31 staff, 76 residents test positive for COVID-19, and resulting in 8 resident deaths. Findings include: An Immediate Jeopardy (IJ) concern was identified on [DATE] at 11:23 a.m. The IJ notice was delivered to the facility Administrator on [DATE] at 12:13 p.m. The IJ began on [DATE] when Staff O developed symptoms of COVID-19 while at work and continued to work the remainder of the scheduled shift. Staff O was tested on [DATE] which returned positive on [DATE] and had continued to work for two additional days with symptoms of COVID-19 before finally being removed on [DATE] when the positive test result was identified. On [DATE] at 1:15 p.m., Certified Nurse Aide (CNA) C was observed providing incontinence care to Resident #130. CNA C entered the room and failed to perform hand hygiene prior to providing care. CNA C took a stack of washcloths into the bathroom used bare hands to wet washcloths by placing them in the sink basin. CNA C then donned gloves and proceeded to Resident #130 to provide incontinence care. CNA C then performed perineal hygiene for Resident #130 and used a front to back motion to wash Resident #130's labia twice with the same washcloth surface using two consecutive [MEDICAL CONDITION]. CNA C was observed performing hand hygiene at the sink following care, following bagging of soiled items and following disposal of soiled items in the soiled utility room, CNA C washed hands [MEDICATION NAME] approximately 10 seconds, 5 seconds, and then 3 seconds for each respective observation noted previously. CNA C shut off the faucet each time with wet hands contaminating cleansed hands, and then proceeded to dry hands after shutting off the faucet. During the final hand hygiene observation in the soiled utility room, CNA C placed a wet hand on an exposed roll of paper towel to hold the roll in place to tear off enough paper towel to dry her hands leaving a wet hand print on the roll of paper towel. When asked if CNA C knew why the paper towel dispenser was open, stated she did not know. On [DATE] at 1:30 p.m., Housekeeper D was asked if the paper towel dispenser was reported malfunctioning and stated not to his knowledge. When shown the wet palm print on the roll left by CNA C, Housekeeper D stated he would get the dispenser fixed and replace the paper towel roll. When asked why a paper towel dispenser would be open like this, Housekeeper D stated, Best guess is the batteries need to be replaced. Housekeeper D returned and stated the paper towel roll had been replaced and the batteries were replaced, and the towel dispenser was working again. On [DATE] at 2:00 p.m., an interview with the interim Infection Preventionist Registered Nurse (RN) A revealed the following statements: There were two employees in [DATE] who were the first in the facility to test positive. Facility-wide testing was done for three weeks which ended on [DATE] following the first positive staff member. Weekly PCR (Polymerase Chain Reaction) testing began for all residents on [DATE] due to a second positive staff member identified on [DATE]. The facility identified their first positive Resident (#121) upon return to the facility from an outside appointment with fever and chills, and a POC (Point Of Care(rapid [MEDICATION NAME] test)) was completed on [DATE], which came back positive. Weekly PCR testing began for all residents on [DATE] due to the positive staff member identified on [DATE]. All residents returned negative at that time. Repeat testing of all residents on [DATE] returned on [DATE] with seven positive residents including Resident #121. The six other residents were tested who were either in close contact or roommates of Resident #121. A total of Six residents were identified on the 300 unit and one resident on 100 unit as COVID-19 positive. On [DATE], the facility received PCR results back confirming the 7 residents originally identified as COVID-19 positive via POC testing. The PCR results from tests completed on [DATE] came in on [DATE], and identified three COVID-19 positive employees. It was determined all three staff had worked on the 300 unit during the previous week and determined to have had contact with Resident #121. On the evening of [DATE] three symptomatic residents who developed symptoms were tested via POC and came back COVID-19 positive. One of those residents resided on the 300 unit and the other two residents resided on the 200 unit. The room mate of the two residents on the 200 unit were POC tested on [DATE] and also returned COVID-19 positive. Facility wide testing was started on [DATE] and was completed on [DATE] under the direction of the local health department. Sixteen (16) additional residents were identified COVID-19 positive on [DATE] and 6 additional residents were identified positive for COVID-19 when testing was completed on [DATE]. Some of the identified COVID-19 residents were on the 300 unit. The COVID-19 unit plan identified in the facility policy was initiated on [DATE] and 16 residents identified COVID-19 not residing on the 300 unit were moved to the 100 unit. On [DATE], Resident #131 was sent to the hospital for an increased temperature and respiratory rate, an oxygen saturation of 79%, and lung congestion. Resident #131 tested positive at the hospital and expired at the hospital on [DATE]. On [DATE], additional residents started to develop symptoms and 9 additional residents tested positive for COVID-19 and were also transferred to the 100 unit. Six additional residents were identified COVID-19 positive on [DATE], some of which were moved to the 100 unit. Resident #125 was sent to the hospital on [DATE] and expired while at the hospital the same day. Resident #127 who had tested positive for COVID-19 expired in the facility on [DATE]. Five residents tested positive for COVID-19 on [DATE] and three additional residents tested positive for COVID-19 on [DATE]. On [DATE] four residents tested positive for COVID-19 and 9 additional residents on [DATE]. The facility has been POC testing twice weekly for all resident since last week per the health department. A review of the COVID-19 resident line listing, undated, provided by the facility on [DATE], revealed a total of 76 residents had tested positive. The facility indicated a total of 8 residents had expired with COVID-19. A review of the COVID-19 employee line listing, undated, provided by the facility on [DATE], revealed a total of 31 staff who had tested positive. On [DATE] at 3:30 p.m., Licensed Practical Nurse (LPN) E was observed at the 300 unit nurses station housed inside a resident dining area with her face mask off her face and under her chin. Six unidentified residents were in the same room space during this observation. There were two unidentified staff members standing closer than six feet from LPN E during this observation. LPN E then pulled her mask from under the chin to over her face when this Surveyor approached LPN E to ask a question. On [DATE] at 4:23 p.m., LPN F was observed performing hand washing after handling the medication cart on the 300 unit. LPN F used wet hands to turn off the faucet and then proceeded to dry hands after contaminating them on the faucet handle. On [DATE] at 4:25 p.m. LPN E was observed performing a blood sugar check for Resident #132. LPN E performed hand washing and turned off the faucet using wet hands and re-contaminated her hands. LPN E then dried her hands with a paper towel. LPN E was informed of the hand contamination observed and stated she understood the problem. On [DATE] at 4:35 p.m., Social Worker (SW) G was observed in her office with her mask under her chin sitting at a computer. No food or drink was observed near SW G. The door to the office was observed open and an unidentified female resident was observed wandering and pacing the halls during this observation. SW G pulled her mask over her face when this Surveyor approached SW G to ask a question. On [DATE] at 4:40 p.m., an interview with RN B revealed the following: When asked how staff should be turning off the faucet after washing hands, RN B stated, staff should be dried before turning off the faucet, and a dry paper towel should be used to turn off the faucet handle to prevent re-contaminating hands. On [DATE] at 5:10 p.m., Activities Aide H was observed entering and exiting the room of Resident #122, who was residing on the COVID unit, wearing PPE. Activities Aide H removed gloves and then proceeded to pick up a phone located at the nurse's station without performing hand hygiene and brought it to her face. Activities Aide H then performed hand hygiene after using the phone but did not clean the phone receiver after contaminating it. On [DATE] at 5:20 p.m., Staff I and Staff J were observed performing a total lift transfer with Resident #124 following return from [MEDICAL TREATMENT] treatment. Staff I had pulled gloves off, exited the room touching the room side of the door handle and approached the desk. No hand hygiene was observed. Staff I placed her hands on the desk and waited for Staff J to help with the transfer. Following the transfer, Staff I removed the lift from the room and placed it into the hallway. When asked if there was anything else needing to be done to complete the task, Staff I stated she could not remember anything else she needed to do. Staff I was asked if the mechanical lift was supposed to be sanitized between residents. Staff I stated they do not sanitize the lift with anything because all the residents were positive on the unit. On [DATE] at 5:22 p.m., Staff K who was at the nurse's station was also asked about sanitizing the mechanical lift between residents. Staff K confirmed they were not cleaning the lift between residents because all residents on the unit were COVID-19 positive. Staff K acknowledged residents were in various stages of recovery from COVID-19 infection. On [DATE] at 8:05 a.m., an interview with Staff M revealed she had tested positive for COVID-19. Staff M stated she worked for about a week with symptoms of a headache, a fever on and off, which started on Saturday [DATE]. Staff M stated she was directed to worked with symptoms under the direction of infection control nurse RN A. According to Staff M, Staff O who also tested positive, stated she was reporting her symptoms to infection control. According to Staff M, Staff O stated she was told it was probably allergies and told to work anyway because she wasn't running a fever. Staff M stated Staff O had worked unit 300, unit 200 and unit 100 just before testing positive, and then Staff O ended up having a positive (COVID-19) test. When asked about the screening, Staff M stated, the receptionist would .take our temp and that was it. So I was reporting my symptoms directly to infection control. I was never told to go home. When asked why Staff M felt compelled to work with symptoms, stated she was afraid of retaliation so she would just show up. On [DATE] at 9:20 a.m., an interview with Staff O revealed the following statements: Staff O stated she came in on [DATE], and was feeling fine. Body aches developed during that day. Staff O came in the following day on [DATE] and the body aches were gone but was not feeling well at all. Staff O was asked to explain the symptoms being experienced. I had a really bad headache and felt really fatigued Staff O stated Staff K was able to see Staff O was not feeling well. (Staff K) told me I should not be there. On [DATE], Staff O came in to the facility thinking she had to work. Staff O stated she was feeling sweaty, had chills, and stated she was crying because she was having really bad body aches. Staff O stated when she realized she was not on the schedule she went home. On [DATE] Staff O came back to work, and did not have the body aches anymore, but still had congestion and a headache. I never spiked a fever. I got tested on ([DATE]) and I was told on Friday ([DATE]) I was positive. Staff O stated she worked the 100, 200 and 300 units prior to testing positive. I got ignored on the first day I reported my symptoms and I was reporting symptoms to (Staff BB) as well and she was also ignoring my symptoms. On [DATE] at 10:18 a.m., an interview with Staff Q revealed the following statements: Resident #129 was transferred by mistake to the COVID unit with a negative COVID-19 status. This happened sometime after the weekend of the [DATE] sometime during the week because when Staff Q came in the following weekend on [DATE], Resident #129 was already positive and symptomatic with a fever and fatigue. Staff Q was asked how she discovered Resident #129 was transferred by mistake into the COVID-19 unit. Staff Q was told Resident #130 was COVID-19 positive and would be coming down to the COVID-19 unit. Staff Q was told to look into the notes further on Resident #129 by another unidentified staff member. The unidentified staff member told her Resident #129 was transferred into the unit and his PCR prior to the transfer into the COVID-19 unit was negative. When this was discovered, Resident #129 was rapid (POC) tested before moving him back off the unit. Resident #129 was now discovered to be positive and remained on the COVID-19 unit. This transpired on her first official day in the COVID-19 unit. Staff Q stated she was exposed to her daughter who tested positive on [DATE]. Her daughter was showing symptoms on the weekend of the [DATE]. Staff Q started wearing surgical mask at home on Monday. The local heath department called for contact tracing and advised her to quarantine. The facility told her to come into work anyway since she had no symptoms except some stomach issues. The facility said she still needed to come into work even though the health department advised me to quarantine because of the exposure. Staff Q stated she subsequently worked the weekend of [DATE]. On [DATE] at 1:43 p.m., an interview with Receptionist S revealed she has been employed at the facility since August of 2019. When asked to describe the screening process, Receptionist S stated the facility uses a separate sheet for each employee with their name and date on it. Receptionist S Stated everybody is asked symptoms, if they have had exposure from anyone in the household, and a temperature is taken. Receptionist S stated if anybody has any of the symptoms, it gets reported to the DON or the Infection Control Nurse. When asked how staff were asked about symptoms, Receptionist S stated she has a list she points to and asks if they have any of those symptoms on the list. Receptionist S stated she did not read off the list to staff. On [DATE] at 12:15 p.m., an interview with Staff R revealed the following: Staff R stated she originally tested positive on [DATE], and received her COVID-19 positive result on [DATE]. Staff R stated she worked for approximately four hours on [DATE] before she went home. Staff R stated she went home because the health department directed her to go home. Of note, Staff R stated the DON was not going to let Staff R go home until Staff R revealed she had spoken with the local health department stating she was advised to go home. (Staff A) told me I was positive but said I could go back to work because it was already ten days. I was having pressure in the head and the face and a runny nose and a low-grade temp of 99.8F. I ended up with a headache, a higher temp and loss of taste and appetite and fatigued as it progressed. On [DATE] at 4:28 p.m. a follow-up interview with Receptionist S revealed the following: When asked why some of the staff reporting symptoms were not on the staff infection log, Receptionist S stated, Sometimes they will tell me 'No.', and go to infection control and tell them different. Receptionist S stated, usually nobody reports any symptoms. Receptionist S stated she recalled only one time where a staff member had a low grade temperature that was reported to the DON. Information on the completed logs was not verified by the facility staff. On [DATE] at 3:20 p.m., a follow-up interview was conducted with RN A and revealed the following statements: RN A was asked what the fourth column on the line listing for COVID-19 positive employees was for. The fourth column was what symptoms employees were experiencing at the time of testing. RN A was asked when staff are allowed to return to work following a COVID-19 positive test. We tell them they have to have a decrease in symptoms and no fever for the last 72 hours of their 10 days without use of anti-pyretics (fever reducing medication) before returning to work. RN A was asked if resolution of symptoms are documented anywhere. We don't document anywhere when symptoms are resolved. We call and check on them periodically throughout their illness. Staff FF was one of the staff who tested positive after developing symptoms at work, and was sent home that day. RN A was asked how the POC rapid test works. The rapid test has to wait 15 minutes before running through the machine, and the machine takes about 3 seconds to read. Staff FF remained on the unit he was assigned because he was already back working with COVID-19 positive residents until RN A got the results. If Staff FF would have been assigned to the general population she would have had Staff FF wait in the break room until she received the POC testing results, or send them home and call them later with the POC testing results. RN A was asked about her knowledge of Resident #129 being transferred to the COVID-19 unit by mistake. I know there was (Resident #130) who tested positive who was supposed to be moved down there, but then I am not sure what happened. If there was maybe a typo or something because (Resident #129) was moved down there instead of (Resident #130) and then before we could move (Resident #129) back off the unit we had to test him. (Resident #129) then tested positive so we left (Resident #129) in place. RN A stated Resident #129 was moved down to the COVID-19 unit for less than 24 hours and was mistakenly moved later that evening. A review of the staff line listing for COVID-19 infection, undated, revealed a total of 31 staff infections. The column RN A stated was designated to identify symptoms a positive staff member was experiencing in the days prior to testing revealed 26 of those employees had experienced symptoms consistent with COVID-19 prior to testing positive. On [DATE] at 5:28 p.m., an interview with Staff U revealed the following: When asked about her experience with testing positive, Staff U stated, It started out as a sore throat and cough I thought it was from wearing a mask. Staff U stated a day or two later she tested positive during the routine testing. Staff U stated she had told Housekeeping Manager W about the sore throat and cough. Staff U stated her boss agreed it was most likely from wearing a mask all the time and suggested a mint. When asked if Staff U was told to report her symptoms to the Infection Control Nurse, Staff U stated Housekeeping Manager W did not suggest reporting it to infection control. Staff U was asked if she knew if Housekeeping Manager W had reported Staff U's symptoms to anyone and stated she did not know. When asked about the screening process, Staff U stated, through one door at the front of the building. Staff U stated they just write down her temperature and let her in the door. When asked if she was asked any questions during the screening process, Staff U stated They didn't ask. Staff U added, but they are now. Staff U stated, she thought this was a little odd. On [DATE] at 9:13 am, Housekeeping Manager W stated Staff U tested negative on hire. Housekeeping Manager W denied being told by staff U about symptoms she was experiencing prior to testing positive for COVID-19. On [DATE] at 8:03 a.m., a follow-up interview with RN A revealed the following: When asked to review the case of Staff O, RN A stated Staff O had a PCR test done as part of the weekly testing. RN A stated she had asked Staff O if she had any symptoms in the past couple of days prior to her positive test result. RN A stated according to the form she completed with the employee, stated the form was filled out on [DATE]. RN A stated Staff O told her she had body aches and fatigue during the couple of days prior to testing positive, but chalked it up to chronic conditions. RN A stated she did look at the screening forms and noticed Staff O did not have any symptoms recorded in the days prior to her positive test result. A review of the Questions for an Employee who has tested + for COVID-19 dated [DATE] revealed Staff O was tested for COVID-19 on [DATE]. The form indicated symptoms of fatigue and body aches developed and started on [DATE]. The form indicated Staff O had also had contact with positive residents on the 300 unit on [DATE], [DATE], and [DATE]. According to the form, the last day worked for Staff O was [DATE]. A review of a hand written note received via email on [DATE] at 8:50 a.m., listed the assignments Staff O worked prior to testing positive on [DATE] on the following days: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] of 2020, which revealed the following: [DATE]- 100 unit [DATE]- 200 unit [DATE]- 300 unit per questionnaire above [DATE]- 200 unit [DATE]- 100 unit [DATE]- 300 unit [DATE]- 100 unit (Information conflicts with above questionnaire) On [DATE] at 12:45 p.m., a follow-up interview with Staff O revealed the following: When asked to confirm the onset of symptoms, Staff O stated her symptoms started on [DATE] and stated her test came back on [DATE]. Staff O stated she told staffing coordinator BB on [DATE] she didn't feel good and had body aches. Staff O stated she couldn't really explain it, but knew something was off. Staff O stated, I got no response, it was like I didn't say anything. I was so irritated because everybody knew I didn't feel well. Staff O stated she usually comes in about a half hour early and stated sometimes there was nobody at the screening area. Staff O stated there would only be a paper for us to write our name and temperature and the date. Staff O stated she would write it down and walk into work. Staff O stated, she had never seen the actual screening form. Staff O stated she remembered telling Staff AA who was at the front desk about her symptoms. Staff O stated she remembered telling Staff AA on [DATE], I felt really run down and something is not right. She just said, 'Oh, ok.' and let me in. Staff O was asked if she had any chronic issues which might mask symptoms of COVID-19. Staff O stated, No, not really, I have back pain all the time. I told them what I was experiencing is much different than usual, and I told them so. Staff O stated she specifically remembered Staff K telling Staff O when she came in, 'You should not be here.' and knew I wasn't myself. Staff member O stated she believed this was either on [DATE] or [DATE] when she worked with Staff K on the same unit. Staff O stated her results came back positive for COVID-19 on Friday [DATE]. Staff O stated, on [DATE] during her PCR test, RN A instructed Staff O she only needed to twirl the Q-tip applicator around for five seconds. Staff O stated she told RN A she wanted to be sure to get a good sample because of how she was feeling that day, so RN A knew Staff O was not feeling well. Staff O stated, I knew I was sick, it was different than the usual (symptoms). It's hard to explain, but I knew the difference and I reported it that day. On [DATE] at 12:00 p.m., Staff R stated she received a final write up on this day because she didn't report symptoms of COVID-19. Staff R stated she was given this write up by one of the union stewards for the facility. Staff R stated she was asked if she wanted to file a grievance, and Staff R stated she informed the union steward she wanted to go through with the grievance procedure. Staff R stated she reported her sinus pressure to RN A when she came into work on [DATE] and was told she was COVID-19 positive. A review of the facility line listing for COVID-19 positive employees revealed Staff R reported facial/head pressure, fatigue cough, and temperature prior to the positive COVID-19 test. Staff Rstated her fever came on when she was already off work. Staff R stated she didn't know head pressure was a symptom and did not report this. Staff R stated the fatigue and cough were also after she was off work. On [DATE] at 3:45 p.m., an interview with LPN L revealed the following: When asked about the screening area for the facility having nobody there to screen staff into the facility, LPN L stated, That's happened several times. I would just ring the bell and one of the nurses up front would come out and take my temperature and ask me if I had any symptoms. I have seen the pad of lined paper up front with names and temperatures on it, but that's not what I used. On [DATE] at 4:45 p.m. an interview with Staff X revealed the following: Staff X stated she had tested positive. Staff X stated, I got a test at an urgent care after my father got sick. My father started feeling ill Monday [DATE]th (2020) and he went and got a PCR test at (Local Urgent Care) in (Local City). On Thursday [DATE]th (2020), my father called and said he spiked a temp. I got nervous and was scared for my Dad. I told them I was going home early. So I punched out and went home. He was coughing like crazy and had a fever. So I called the urgent care to get his results, and they told me he was positive. So the next phone call was to work and I told (RN A) my father had tested positive for COVID-19. I asked (RN A) what the protocol was from there. (RN A) asked me if I was having any symptoms and I told her 'No.' So (RN A) said I had to come to work. I told (RN A) 'Are you flipping crazy?' (RN A) told me 'That's what we are doing right now.' After I got off the phone with (RN A), I called and talked to my doctor about the situation. (Primary Care Physician (PCP)) told me 'Absolutely not, you are exposed because you live in the same house as your father. You need to be quarantining for 14 days. You are not to go to work.' (PCP) told me to go and get tested tomorrow, which would have been Friday at 1 p.m. on [DATE]th (2020). That morning I woke up with a killer headache, a stuffed up nose, body aches, and fatigue, and I went and got tested . I spiked a temp of 101.8 around 6 p.m. after I got tested earlier that day. I was off a total of three weeks. I got my results on Monday ([DATE]) and it was positive. On [DATE] at 10:30 a.m., a follow-up interview with Staff R revealed the following: When asked if the facility had given Staff R any education specific to the screening process, Staff R stated facility leadership had told her to report symptoms consistent with COVID-19 to the receptionist. Staff R also stated the facility changed the door code so only the receptionist knew the code. When asked if she was questioned during the screening process, stated the receptionist was now asking questions they were not asking before. On [DATE] at 12:20 p.m. an interview with Staff K revealed the following: When asked about the screening process stated in the past, the 100 unit would be responsible for screening at the door when the receptionist was not there. Staff K then stated once COVID-19 hit, the 200 unit became responsible for this task when the receptionist was not there. When asked about what was done for entrance screening when the receptionist was not at the desk, Staff K stated, We would temp ourselves, write it on a sheet of paper, with our last name, and walk into work. When asked if Staff K knew this was not being done correctly, Staff Kstated, We were never told what to do when the receptionist wasn't there. When asked when Staff K knew the screening process was not being done correctly, Staff K stated Monday ([DATE]) when I got the education. Staff K stated, Communication here really lacks. On [DATE] at 3:00 p.m. an interview with Staff AA revealed the following: When asked how the screening was set up to be done, Staff AA stated the facility had changed all the door codes on all the other doors so staff had to come through the front door to get temped (temperature reading). Staff AA stated they would ask them questions like signs and symptoms and then let them in the door. Staff AA stated only once or twice did someone report symptoms that she could remember. When asked about staff writing temperatures down on a paper at the desk before she would come into work, Staff AA stated, The policy as far as I knew was the Nurses would Yes, but it was always the nurse temping the other staff who would come through the door and write them on the list. When asked about Staff O reporting any symptoms to staff AA on [DATE], Staff AA stated she remembered Staff O reporting 'allergy symptoms' on [DATE]. When asked why Staff AA had not written this down, Staff AA stated, it was 'common symptoms'. When asked if she had reported this to anyone in management, Staff AA stated she did not. A review of the [MEDICAL CONDITION] (COVID-19) Associate/Employee Daily Screening Log with a revised date of 10 ,[DATE] for Staff O revealed the following dates of entry to the building with no documented symptoms prior to positive COVID-19 test on [DATE]: Dates of entry to the facility for Staff O were [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 4:02 p.m., an interview with Staffing Coordinator BB revealed the following: When asked if she had reported any symptoms consistent with COVID-19, Staffing Coordinator BB stated, The only thing (Staff O reported to me in the past was back pain. When asked what was supposed to be done when staff are reporting symptoms consistent with COVID-19, Staff BB stated, They should not report to work, call the facility, and they will do a rapid POC (test) and if that is negative with symptoms, they will be PCR tested and sent home pending results. If (staff) develop symptoms while they are here, they will be swabbed and sent home. Staffing Coordinator BB did not have an explanation for why this did not occur with Staff O. A review of the Progress Notes Section of the Electronic Medical Record (EMR) for Resident #129 revealed the following: [DATE] 00:48 (12:48 a.m.) Nurses Notes .Resident (#129) transferred from unit (200). Stable at time of transfer .No c/o (complaint of) pain or discomfort at this time . (Staff N) XXX[DATE] 11:19 (a.m.) Nurses Notes .Resident (#129) tested positive [DATE] for Covid-19 POC testing. POA (Powe (TRUNCATED)

This citation pertains to intake #MI 771 and MI 872. Based on interview and record review, the facility failed to provide an alarm system with the auditory capacity that would alert staff in the event a resident were to unknowingly exit the facility, which allowed one resident (#701) of three residents reviewed as having exit seeking behavior to exit the facility through an alarmed door unbeknownst to staff. The resident was observed later up the road from the facility by an off-duty employee. This deficient practice had the potential to result in serious harm, injury or death, and required immediate corrective action. Findings Include: This Immediate Jeopardy (IJ) was identified on 11/05/18 at 12:00 p.m. The IJ began on 10/13/18 at approximately 9:05 p.m. The Administrator was notified of the Immediate Jeopardy (IJ) on 11/05/18 at 1:15 p.m., and a plan of removal was requested to remove the immediacy. On 11/05/18 at approximately 3:00 p.m., the provider implemented an acceptable plan of removal for the immediacy Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy. On 11/05/18 at 8:30 a.m., the Director of Nursing (DON) was interviewed about the facility reported incident (FRI) submitted to the State Agency regarding R#701's elopement from the facility on 10/13/18 at approximately 9:05 p.m. The DON stated she was not in the building when it (elopement happened). The DON further stated, I came in about 12:00 midnight. Staffing Coordinator 'A' brought him (R#701) back. On 11/05/18 at 8:40 a.m., a call was placed to Staffing Coordinator 'A' and a message was left on the voicemail. A review of the clinical record revealed R#701 was admitted into the facility on [DATE] from a group home for respite care with [DIAGNOSES REDACTED]. Further review of the admission minimum data set (MDS) assessment dated [DATE] revealed R#701 scored 4 out of 15 on a brief interview for mental status (BIMS) assessment that which indicated R#701 had severe cognitive impairment. The MDS assessment further revealed that R#701 was independent with ambulation/locomotion on and off the unit. Further review of the clinical record revealed R#701's elopement risk assessment score was 10. According to the facility, a score of 11 or higher is at risk. The facility's care plan dated 10/4/18 revealed (Resident's Name) R#701 is at risk for elopement and wandering behaviors r/t (related to) dx (diagnosis): dementia, observed wandering in hallway, history of pushing on exit doors to front lobby and exiting the facility . On 11/05/18 at 9:15 a.m., a review of the facility's investigation of the elopement incident that occurred on 10/13/18 in part, revealed the following handwritten Summary of Staff dated 10/13/18: Out driving approx. (approximately) 9pm saw an object on the side of the road. Upon further investigation . a gentleman lying on the side of the road. Stopped & (and) addressed him. The man reported he was 'resting and denied falling.' The individual looked familiar. I asked his name. The individual gave his name as ( .). Staffing Coordinator 'A' called facility @ (at) 9:15 p.m. and spoke with CNA (Certified Nurse Assistant) 'B'. Asked her if anyone was missing. Told her down the street with familiar looking man who gave the name ( .). Don't have anyone here by that name. Told husband to keep talking to him & waved at the police (Officer 'C') passing/pulling in. Assisted the man up from ground to truck. Officer 'C' begin talking to him (R#701) and was able to get correct name which was (Name of R#701). Staffing Coordinator 'A' called back facility at 9:20 (p.m.) & spoke with Licensed Practical Nurse (LPN) 'D'. Gave LPN 'D' the name. She said, 'he is not on 2, 3, 4' (units). Asked LPN 'D' to check computer system for his name. She confirmed he was occupant of RM (Room .) and gave description. Confirmed what he looked like & told her that Res (Resident) was with her and Officer 'C' down the street and informed her that she was calling (Administrator's Name). Called (Administrator's Name) 9:23 (p.m.). Officer 'C' accompanied R#701, Staffing Coordinator 'A' & husband back to facility . When entering facility with resident, could hear on . door alarm sounding as approach the building. After entering with resident, turned off wander guard alarm - Inner door not sounding at the time. A handwritten statement from Charge Nurse 'E' revealed at Approx. 9:20-9:25 p.m. was assisting a resident when Nurse 'D' came up to me and reported that resident in Room ( .) was found by police & is being brought back to facility . Asked CNA 'F' what time she last saw the resident. she said around 9:00 p.m. but was not sure of exact time . Res noted walking on unit 8:00-8:30 p.m. at bedside, easily redirected & returned to room to lie down. Nurse 'D' reports that @ no time did she hear door alarm sounding. Family Member 'G' of R#702 was in dropping off R#702 . @ approx 8-8:30 p.m . Res did have his clothes on & jacket when walking in hall. Had assisted him to his room to lie down. Coat removed. Once you remove his coat he will put it back on again . A handwritten statement from Family Member 'G' revealed . She was in to pick up mother (R#702) after dinner somewhere between 8-8:30 p.m . At some point there was a caucasian man wearing a dark blue jacket with a sports logo on it. He was either already in lobby or in doorway to lobby. remember having to maneuver w/c (wheelchair) around him . Was unable to tell if man was a visitor or resident, but stated he looked like a visitor. Could not recall if this encounter was while taking mom out or bringing her back. Did not notice/recall any alarms sounding as she left and did not hear the inner door alarm sounding either time that she came or left facility . Further review of the facility's investigation/timeline revealed in part the following: On 10/01/18 - the resident's sister, DPOA (Durable Power of Attorney), requested resident be moved off secured unit . Resident was moved to Room ( .). On 10/04/18 - the resident was noted pushing on the doors in attempt to enter the front lobby. The door alarm sounded, and staff redirected him away from the door. The resident also was noted with wandering behavior in hallway. An elopement assessment was completed, and the resident scored 13. The resident's plan of care was updated, and a wander guard was placed on the resident. Per the resident's record on 10/8/18 the resident was again noted pushing on the doors to the lobby and was easily redirected by the receptionist. On 10/13/18 - the facility Staffing Coordinator ('A') reported to the administrator that at approximately 9:05PM she and her husband were driving on (Name of Street) and saw a man on the side of the road. They stopped to see if he needed help and she thought she recognized him . The resident was assisted back to the facility by (Staff Coordinator 'A') and her husband accompanied by Officer 'C'. The resident ambulated without difficulty into the facility. The Employee (Staff Coordinator 'A') reports that as she accompanied the resident into the facility she could hear the exterior wander-guard door alarm sounding on approach. She reports that she reset it once through the doors and noted that the interior lobby door alarm was not sounding . Unit staff were interviewed following the occurrence. CNA 'F' who was assigned to the resident stated . She did not see him (R#701) leave nor did she hear any door alarms sounding indicating that anyone had exited and was unaware of his exit until the Nurse was notified. Charge Nurse 'E' also denied hearing any door alarms sounding as she was in the hallway passing medications . On 11/05/18 at 11:07 a.m., an interview was conducted with Maintenance Director 'I' who reported, I was called in that night (10/13/18) by the Administrator. I made sure that all of the equipment we had was functioning properly . I put a transmitter on the wander guard door in the front lobby that night. We didn't have one before. When asked about the purpose of the transmitter, Maintenance Director 'I' stated, It sends signals to the call light system to nurses' stations 1, 2, and 4). When asked why a transmitter was not on the door before, Maintenance Director 'I' stated, It wasn't put in before because we had magnetic lock doors, and if somebody tries to breach those, they (doors) sound into alarm. When asked if the magnetic doors sounded the night of 10/13/18, Maintenance Director 'I' stated, Not in this incident . On 11/05/18 at 12:05 p.m., during an interview, the Administrator was asked if the entrance and lobby doors of the facility were mandated in the evening and at night. The Administrator stated, No, The receptionist leaves at 7:00 p.m. When asked why the facility had not installed a transmitter to the call light system that would alert staff in resident care areas if residents are trying to leave the building unbeknownst to staff, the Administrator stated, We have never had this problem before. A review of the facility's Elopement Policy revised: 5/2017 documented the following: .Unsafe wandering may occur when the resident at risk enters an area that is physically hazardous or that contains potential safety hazards . Elopement occurs when a resident who needs supervision leaves a safe area without authorization .and/or any supervision to do so . 1. If an employee hears a door alarm, he or she should: a. Immediately go the site of the alarm . The facility submitted the following acceptable plan including supporting documentation to remove the immediacy on 11/5/17: 1. Resident identified to be affected by the alleged deficient practice. Resident #701 currently was discharged from the facility following a respite stay on 10/15/18. The following was completed for the resident #701 -was returned to the facility and assessed by the nurse -Total Body Skin Assessment was completed by the nurse with no injuries noted on 10/14/18 -Risk for Elopement was completed 10/14/18 -Resident's physician and POA were notified 10/13/18 -Resident was moved to the secure unit 10/13/18 -Administrator met with resident upon return 10/13/18 -Social Work met with resident on 10/14/18, he was resting in bed in no distress. He did not recall the incident. 2. Residents with the potential to be affected by the alleged deficient practice. On 10/13/18 there were 128 residents that have the potential to be affected. The administrative staff identified the residents in the facility that were at risk for Elopement, there are 14 residents that were identified to be at risk for elopement. 3. Measures or systemic changes made to ensure the deficient practice will not reoccur and affect others. -Staff were stationed at the doors following the event to ensure resident safety -Wanderguard system on the door was connected to the Call Light System at the nursing stations and staff were educated on this -All exit doors were checked for safety appropriateness -Signs were placed on lobby doors of egress stating Please do not open the door for anybody who is not in your party -Facility staff educated on the Elopement Policy -Residents identified as high risk for elopement were reviewed by Social Work to make sure there were physician orders [REDACTED]. The Care Plans were reviewed and revised as necessary. Wanderguards were checked to make sure they were in place. -Risk for Elopement Assessments were reviewed for all residents to make sure they were accurate The facility policy on Elopement was reviewed and deemed appropriate. In-servicing began on 10/13/18 on the Elopement Policy. 162 facility staff members out of 162 were in-serviced. The remaining facility staff were re in-serviced on the Elopement Policy at the start of their next shift. All newly hired staff will be in-serviced on the Elopement Policy by the Staff Development Director or designee. Quality Assurance How facility monitors its corrective actions to ensure same deficient practice is corrected and will not recur. -Maintenance will check functionality of door alarm(s) daily -Elopement drills will be done weekly for 4 weeks, then monthly. - Findings will be reported to the QA&A Committee monthly for 3 months for recommendations any areas of concern will be addressed. NHA is responsible for compliance.

This citation pertains to intake #s MI 482 and MI 590. Based on observation, interview and record review, the facility failed to protect the residents and ensure resident to resident physical abuse did not occur for 13 (R#s 10, 24, 26, 29, 31, 61, 91, 92, 98, 103, 116, 323, and 324) of 20 sampled residents reviewed for abuse from a total sample of 36, resulting in an Immediate Jeopardy (IJ) when R#26 who had known aggressive behaviors engaged in physical altercations which included hitting, pushing, punching, and yelling with six R#s 31, 61, 91, 92, 103, 116; R#323 repeatedly striking R#324 in the face and torso; R#116 slapped R#26 in the head; R#24 reporting she struck R#116; and R#98 struck R#29 in the head twice. This deficient practice places the residents at risk for serious harm, injury and/or death. Findings include: The Immediate Jeopardy (IJ) started on 5/31/17. The IJ was identified on 6/14/18 at 10:00 a.m. The Administrator was notified of the IJ on 6/14/18 at 10:15 a.m. A plan to remove the immediacy was requested. The immediacy was removed on 6/14/18 at approximately 5:10 p.m. based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the facility's deficient practice was not corrected and remained at a pattern that is not immediate jeopardy. On 6/11/18 at 9:50 a.m., upon entering the facility's secured unit, R#92 was observed seated in a wheelchair while being pushed by staff just outside of R#26's room. At that time, R#26 was observed holding onto the back part of R#92's wheelchair (near the handle) and R#92 was yelling out loudly, Help, help. Further observations revealed multiple Residents were observed ambulating independently throughout the hallways, in and out of other Resident rooms, the dining/activity room, and near the exit/entrance to the secured unit. Due to significant cognitive impairment, Residents were unable to participate in any interviews. On 6/11/18 at 9:57 a.m., Certified Nursing Assistant (CNA A) was asked about R#26's behaviors towards other residents on the secured unit and reported, Yeah, a couple of incidents, he's (R#26) very protective if anyone opens his door or comes close to him. When asked if he was aware of any issues with current roommate (R#103), CNA A stated, No, seems to do well with him, its others he (R#26) has an issue with. On 6/11/18 at 10:24 a.m., R#26 was observed lying in bed on the right side watching television and upon approach stated, I don't have anything to say to you. I'm watching the Pres (President) on TV here. On 6/12/18 at approximately 12:00 p.m., review of the facility's documentation provided from earlier request for any incidents/accidents since the previous recertification survey included the following Resident to Resident incidents which involved: R#26 and R#103 on 5/17/18; R#26 and R#92 on 5/8/18; R#26 and R#61 on 4/7/18; R#26 and R#92 on 4/7/18; R#26 and R#116 on 2/14/18; R#26 and R#92 on 11/18/17; and R#26 and R#31 on 6/24/17. Resident #26 and Resident #103 On 6/12/18 at approximately 1:00 p.m., an Incident and Accident Report dated 5/17/18 at 10:50 am documented, .CNA heard yelling in (R#26's) room with door shut. Upon entering room noted resident and roommate yelling at each other CNA immediately separated residents. R#26 stated roommate (R#103) was in his (R#26's) closet and he (R#26) asked him (R#103) why, then hit him (R#103) on rt (right) forearm . Review of the clinical record revealed R#26 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/15/18 indicated he had independent cognitive skills for daily decision making. R#26 had no mood, hallucinations or delusions, had verbal behavior symptoms directed towards others which occurred 1 to 3 days, and was independent with ambulation. Review of the clinical record revealed R#103 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment with an ARD of 5/14/18 documented R#103 was severely cognitively impaired, had no hallucinations or delusions, had no mood or behavior concerns, and was independent with ambulation. Resident #26 and Resident #91 On 6/12/18 at approximately 2:15 p.m., a facility reported incident to the State Agency (date of occurrence 5/8/18) regarding R#26 and R#91 was reviewed as well as incident reports which included, .Heard yelling observed R#91 sitting on floor between room (#s). R#26 was bending over him with arm out trying to help him up. R#26 stated he was in my room and he hit me first! Interviewed R#26 stated, 'I have nothing to say' .R#26 then stated, 'I think he hit me on my left jaw.' . Further review of the documented staff interviews included: On 5/8/18 at 10:40 p.m., Nurse H reported, .Approx (approximately) 10:20 pm Nurse reports she was in DR (dining room) at desk putting orders in computer when she heard yelling in hallway. She immediately responded to the area and observed R#91 sitting on the floor in the hall between room (#s). R#26 was bent over him trying to take him by the hand to help him up. Nurse noted a scratch near R#91's mouth. Nurse attempted to interview R#26 about the circumstances. R#26 only responded with 'I have nothing to say'. She continued to state to R#26 'There must have been a situation here because R#91 is sitting on the floor'. R#26 responded, 'R#91 came in here and hit me on the side of my jaw' he clarified when asked left side of jaw. No injury observed on assessment .The Nurse attempted to interview R#91 about the situation. But he could not explain. She asked him 'Did you get hit?' he responded by nodding his head 'yes' she asked 'did he (R#26) hit you (R#91) in the mouth area?' He (#91) again nodded his head yes .Assessed for injuries .1-inch scratch to his face near his mouth . Review of the clinical record revealed R#91 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment with an ARD of 5/11/18 R#91 had moderately impaired cognitive skills for daily decision making and exhibited wandering behavior and required supervision with ambulation. Resident #26 and Resident #92 On 6/13/18 at approximately 8:40 a.m., an Incident and Accident Report dated 4/7/18 at 12:30 pm documented, .Resident (R#92) had propelled w/c (wheelchair) into (R#26's room). R#26 pushed w/c into hall then slapped him (R#92) several times in head . Further review of the documented staff interviews included: .4/7/18 .Nurse K reports she was in DR at desk and heard loud voices in hall. Ran to hall and saw CNA DD bringing R#92 toward the day room and R#26 was walking behind them. CNA DD reported her observation of the exchange between them in the hallway . .4/7/18 .CNA DD: reports she was putting lunch trays in DR and heard R#92 call out. Rushed to hall toward end of hall and observed R#26 pushing R#92 in w/c out of his rm (room). As he did he (R#26) struck R#92 on back of his head with an open hand . Resident #26 and Resident #61 On 6/12/18 at 2:58 p.m. R#61 was observed walking in the dining room on the secured unit and was observed wearing (an exit alert bracelet) to the right wrist. On 6/13/18 at approximately 8:20 a.m., an Incident and Accident Report dated 4/7/18 at 10pm documented, .Another res (R#61) entered into res (R#26's) room and he (R#26) put the other Res (R#61's) hand behind his back and put his (R#26's) arm around his (R#61's) neck and push him (R#61) into day room . Further review of the documented staff interviews included: .4/7/18 (no time of interview) .Nurse F reports that as she returned to unit/dayroom from break she was met by CNA BB who reported exchange between R#26 and R#61 .Nurse assessed R#61 and observed small bruise to his left wrist . .4/7/18 (no time of interview) CNA BB at approx. 11p CNA was in DR sitting with (another Resident) when she heard loud voices in hall. Reports she responded to doorway and was met by R#26 and R#61. CNA reports that R#26 was standing behind R#61 and was holding R#61's hand behind his (R#61's) back and his (R#26's) other hand on the back of R#61's neck. R#26 then pushed R#61 through the doorway into the dayroom and exclaimed Keep this MF (Mother F*****) out of my room then balled up his (R#26's) fist and shook it at R#61 . Review of the clinical record revealed R#61 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment with an ARD of 4/12/18 documented R#61 had moderately impaired cognition and wandering behaviors. Resident #26 and Resident #116 On 6/13/18 at approximately 9:00 a.m., an Incident and Accident Report dated 2/14/18 at 2:45 pm documented, .Resident was walking in hallway when R#26 grabbed her right arm and told Resident not to go into his room again or he would throw water in her face, R#116 responded by smacking R#26 in face . Further review of the documented staff interviews included: .Approx 2:50 pm Activity Staff FF sitting in hall facing entrance door observed R#26 aggitated (sp) .he (R#26) saw R#116 go into his room. R#116 was walking in hall, he (R#26) looked up at her (R#116) took her (R#116) by arm and pulled her (R#116) toward him (R#26). He (R#26) said something about throwing water in her (R#116's) face if she went in his room .CNA went over to them then saw R#116 swat at R#26 striking him in forehead . .2/14/18 (no time noted) .walking in hall, saw R#26 walking with R#116 in the hall. R#26 had ahold of her right upper arm. Talking to her in a low voice. As CNA P approached she thought they were start walking and visiting with each other. CNA P overheard R#26 say to R#116 If you go in my room again, I'll throw water on you. CNA P removed R#26's hand from her arm. As she did R#116 struck R#26 in forehead . Review of the clinical record revealed R#116 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS with an ARD of 5/19/18 documented R#116 had moderately impaired cognition, no behaviors which included wandering (progress notes document R#116 ambulates up and down the halls). Resident #26 and Resident #92 On 6/13/18 at approximately 9:20 a.m., an Incident and Accident Report dated 11/18/17 at 5:15 pm documented, .Resident (R#92) wheeled himself into R#26's room, R#26 pushed his (R#92's) w/c into hallway struck him (R#92) in back with his (R#26's) fist yelling at him to stay out! . Further review of the documented staff interviews included: .Nurse K at desk in day room, heard R#92 calling out from hall. Nurse responded to hall. Observed R#92 in his w/c and CNA HH moving R#92 in his w/c away from R#26's room. CNA HH stated that R#26 pushed R#92 out of room in w/c and struck him on the back .R#92 had increased agitation which began around 4:30 pm r/t (related to) sundow[DIAGNOSES REDACTED] . Resident #26 and Resident #31 On 6/13/18 at approximately 9:40 a.m., an Incident and Accident Report dated 6/24/17 at 4:00 pm documented, .R#31 in (R#26's room), R#26 pushed him (R#31) thru door, then punched him in mid back with closed fist 2 x's (times) yelling at R#31 to stay out of his room . Further review of the documented staff interviews included: .Nurse K in DR, heard R#31 calling out. Went to hallway, CNA II was in the hall. CNA II reported that R#31 was in (R#26's room) and she saw R#26 push him (R#31) out of the room and struck him (R#31) on the back 2x .R#31 was rubbing back stated, 'He hit me.' . On 6/12/18 at 2:55 p.m., the Administrator was asked about how the facility determines identification of abuse such as verbal, mental, or physical altercations and reported, He (R#26) tends to mutter under his breath threats. When asked if threats to harm others would be considered verbal or mental abuse, the Administrator stated, Yeah. The Administrator further reported that some of the incidents involved with R#26, Did not have an outcome that resulted in physical injury and other residents were unable to recall specific incidents. Resident #323 and Resident #324 On 6/13/18 at 9:49 AM review of a facility reported incident summary with a date of occurrence of 12/10/18 revealed, in part, the following per the Description of the occurrence section of the report: On 12/10/17 at approximately 10:45PM CNA (NA 'M') reports that she was walking down the hallway when she heard noises coming from room (Room Number). She reports that she went into the room, turned on the light and looked around the curtain when she observed resident (R#323) standing over his roommate (R#324). She reports that (R# 323) was observed striking (R#324) on the chest and face area while stating I told you to shut up. The CNA instructed (R#323) to stop and called for assistance. (R#323) turned away from (R#324) and began to ambulate back to his bed when the charge nurse (Nurse 'N') and CNA (CNA 'Z') entered the room and assisted him back to bed. The charge nurse assessed (R#324) and noted abrasions to his left brow area, tip of his nose and right hand. (R#323) was also assessed and no injuries were noted. (R#324) was provided an alternate room for the night to maintain separation of the room mates. When interviewed by the charge nurse as to why (R#323) would strike his roommate (R#323) stated, Because he won't shut up. CNA (CNA 'M') reports that prior to the occurrence she did not hear any other noises coming from the resident's room and that (R#324) was quiet and was not calling out at all. (R#324) was also interviewed following the occurrence and related to the Charge Nurse that he was sleeping and woke up to his roommate striking him. The resident's charge nurse (Nurse 'N') reported that she believed that (R#324) was possibly snoring at the time . On 6/13/18 at 9:57 AM review of an Incident and Accident Report (I/A) report for R#323 dated 12/10/17 documented the following description of the incident: 0 (zero) injury to resident-resident got out of bed, walked to roommate that was in bed sleeping and began punching him in the face, chest and body . On 6/13/18 at 9:59 AM review of a witness statement by CNA 'M' dated 12/10/17 was reviewed and revealed the following: I walked down the hall and heard a commotion in RM (Room Number). I walked in and turned on the light and looked around the curtain and saw (R#323) over top of (R#324) punching him saying I told you to shut up. So, I yelled for help and then asked (R#323) to stop . On 6/13/18 at 10:04 AM an interview was conducted with CNA 'M'. When CNA 'M' was queried regarding the interaction between R#323 and R#324. CNA 'M' responded that she had not really witnessed the incident. Per CNA 'M' she had heard yelling and explained that once she had walked into the room (R#323) was over top of (R#324) and was punching him. CNA 'M' further explained that she had called (R#323's) name and the resident had stopped. CNA 'M' then explained that (R#324) had been brought out of the room. CNA 'M' was queried as to where R#323 had been hitting R#324, and responded that R#323 was blind, and said the resident had been throwing punches. When queried in regard to Resident #323's behaviors, CNA 'M' responded he was pretty unpredictable. On 6/13/18 at 10:10 AM review of an I/A report for R#324 dated 12/10/17 documented the following description of the incident: Resident was lying in bed-self reports that he was sleeping when he was awakened by his roommate punching him repeatedly. Also, per this I/A report it was documented the occurrence was a resident to resident altercation, with the type of incident documented as Assault by Roommate. It was documented that R#324 sustained abrasions to the left eyebrow, tip of nose, and right hand. On 6/13/18 at 10:14 AM review of a witness statement signed by Nurse 'N' dated 12/11/17 was revealed, in part, the following: I heard a call from CNA (CNA 'M') stating: (R#323) is beating up (R#324). Upon entering room, I observed (R#323) making his way towards his bed and (R#324) shaking and saying, What's wrong with that guy. (R#323) was helped back to bed and kept repeating 'He should have shut up. (R#324) had blood on his left eyebrow, nose and Rt (right) hand. He stated he was sleeping and woke up to being punched repeatedly in the face, chest, and body . On 6/13/18 at 11:42 AM an attempt was made to contact Nurse 'N' via telephone. A return call was not received prior to the exit of the survey. On 6/13/18 at 2:28 PM the facility Administrator and Director of Nursing (DON) were queried in regard to the interaction between R#323 and R#324. It was explained that R#323 had stayed in the same location at the facility and that R#324's room had been changed and interviews had been completed. Per the Administrator, Resident #323 was not given a roommate for the remainder of the resident's stay at the facility. Per the DON (R#324) did call out, and the DON explained that (R#324) may have been calling out or snoring. When queried if the event was considered to be abuse, the Administrator responded that a resident had hit another resident, and further stated the resident did not know what he was doing. When queried as to how other residents at the facility were protected the Administrator responded that R#323 primarily remained in his room. On 6/14/18 at 12:57 PM review of a care plan for R#323 created on 9/27/12, with date initiated of 10/18/16, and revised on 4/10/18 revealed the following: (R#323) has a dx of paranoid [MEDICAL CONDITION] and [MEDICAL CONDITION]. He is a (Country Name) veteran and at times will perseverate on his combat days in (Country Name). He can have manic speech and exhibits paranoia regarding his person and surroundings. Res (resident) also has a hx (history) of persecutory delusions/hallucinations. He at times believes his medications are placebos and that he needs to go to the (Hospital Name) to receive the correct meds (medications)/care. Res also has periods of sudden verbal/physical outbursts. Hx of physical aggression when angry ie: kicking, hitting, punching, physically charging at others. Sometimes these outbursts occur after periods of escalating behaviors. On 6/14/18 at 1:26 PM review of a psychiatric provider note dated 12/18/17 documented, in part, the following: Complaint: recent incident of aggression, [MEDICAL CONDITION] HPI (History of Present Illness): This an established patient at (Facility name) who was last seen for psychiatric evaluation on 11/16/17. On 12/12/2017 resident pummeled his roommate in the night because roommate was yelling out repeatedly. Nurse reports resident was apologetic and upset over his actions. He has a history of physically aggressive behaviors . On 6/12/18 at 1:45 PM the clinical record for Resident #323 was reviewed and revealed the resident was admitted into the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of a quarterly MDS assessment with an ARD of 3/31/18 the resident scored 15/15 on a brief interview for mental status (BIMS) exam, which indicated the resident was cognitively intact. On 6/14/18 at 10:15 AM review of R#324's clinical record revealed the resident was admitted into the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of R#324's MDS quarterly assessment dated [DATE] revealed the resident scored 4/15 on a BIMS exam, which indicated the resident was severely cognitively impaired. Resident #116 and Resident #24 On 6/12/18 at 9:42 A.M., R#116's clinical record was reviewed and revealed the following: R #116 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented R#116 had moderately impaired cognition and no behaviors. Progress notes documented R#116 had a history of [REDACTED]. Review of R#116's care plans documented: I am at risk for wandering r/t history of intruding/wandering into other residents' rooms, and impaired safety awareness, 'shopping behaviors', and going through belongings of others without their permission . A review of the IDT (interdisciplinary) progress notes revealed: On 3/25/2018 at 1:22 A.M., Nurse F documented, . (Resident - R#116) came out of room and showed nurse her Rt. upper forearm which had two scratches. She stated, that lady have a real kick about her. Unable to explain what lady. Nurse went into (resident) room to check with her roommate (later identified as R#24) that was awake and asked her did anything happen in this room. (R#116's roommate's bed number) stated 'That woman came over to her bedside and I hit her.' Nurse asked did you also scratch her, and she said No . On 6/12/18 at 4:25 P.M., Nurse F was interviewed via phone. At that time, the Nurse was unable to recall working with R#116. When reviewing the documented entry from 3/25/18, Nurse F stated, Oh yeah. When asked to recall any specific details of the incident between R#24 and R#116, Nurse F stated, She (R#116) came out and mentioned someone scratched her. That was it. I went in and spoke with the resident (R#116's roommate) and she's (R#116) a wanderer so therefore the other resident stated she didn't scratch her, she hit her. When asked if other staff such as the Administrator were notified, Nurse F stated, I can't remember other than the ADON (Assistant Director of Nursing) but I can't recall. When queried about the facility's protocol when resident to resident altercations occurred, Nurse F stated, Let the doctor know, let responsible party know, and I would also write up an incident report. I wasn't sure if it happened because resident (R#116) had a scratch and she (R#24) said she didn't scratch her, she hit her because she was messing with her. When asked if she would consider that incident a form of abuse, Nurse F stated, I'd consider that an altercation. When asked to explain what an altercation meant to her, Nurse F stated, An altercation is when a resident goes to another resident and they are defending themselves and we do something to stop it. When asked if the facility provided training about abuse prevention and reporting, Nurse F stated, Yeah. I didn't consider that abuse. It was an altercation. If it was abuse I'd report it to the Administrator if I felt it was abuse. I didn't feel it was abuse because she (R#116) will walk around the room, touch people, mess with people and take their things. I feel when resident (R#24) woke up it shocked her, and she tried to defend herself. She's not aware of what she's doing. She was supposed to be sleeping at that time. I hope I did the right thing. On 6/13/18 at 12:16 P.M., an interview with the Administrator was conducted. When queried about the above incident when R#24 hit R#116, the Administrator stated, There was no injury other than a scratch. (R#24) was scared and reacted. Her intention wasn't to harm (R#116) she just reacted. (R#24) was just confused and in the wrong place at the wrong time. The Administrator was asked what interventions were implemented after the incident and if there were any other resident to resident physical incidents that involved R#116 or R#24. The Administrator stated, I can't tell you off the top of my head (if anything was put in place). I don't think there were further incidents. Further review of R #116's clinical record on 6/13/18 at 12:30 P.M. revealed the following documentation in the progress notes: On 9/15/17 a progress note documented, Resident is constantly propelling herself through the day room and hallway. Resident runs into other residents .Her actions does upset the other residents . On 11/12/17 a progress note documented, This resident is constantly wandering in and out of dayroom and occasionally into other residents' rooms .runs into other residents and over their feet. Becomes agitated and combative with staff at times . On 6/14/18 at 11:56 A.M., R # 24's clinical record was reviewed and revealed the following: R#24 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] documented R#24 had severely impaired cognition, no behaviors, and required limited to extensive physical assistance for activities of daily living (ADLs). Resident #24 and Resident #10 On 6/14/18 at 12:00 P.M., R#24's clinical record was further reviewed and revealed the following: A care plan initiated on 3/19/12 and revised on 2/26/15 documented, .Has significant impairment d/t (due to) her dementia and [MEDICAL CONDITION]. (R#24) is also MR (mental [MEDICAL CONDITION]) also suffers from mood disorder and anxiety. (R#24) has the potential for catastrophic reactions r/t (related to) her dx (diagnoses) and is at risk for injury r/t her behaviors of rummaging in others' belongings, mumbling when she can speak clearly, going through others belongings .taking food and belongings away from others .She has delusional thoughts. (R#24) is at risk for unstable mood. (R#24) has had some fearful delusions re: someone strange in the room and may yell about the unknown person .Delusions can be distressing. Has periods of yelling out . Progress notes were reviewed and documented the following: A progress note written on 3/28/18 documented, Resident was sitting in day room with head on the dining room table. When resident raised her head, she (R#24) punched (R#10) in the face. When asked why she struck the other resident, R#24 replied she took my container . On 6/14/18 at 1:30 P.M. I&As were reviewed for R#24. An I&A dated 3/28/18 at 3:10 P.M. documented, Resident was resting head on table. She (R#24) raised her head and struck (R#10) in the face with her fist . An investigation into the physical altercation between R#24 and R#10 on 3/28/18 was requested from the DON. On 6/14/18 at 2:00 P.M. a file that contained the investigation conducted by the facility was reviewed and it revealed the following: A typed summary that documented, Date of Occurrence 3/28/18 .Charge Nurse (Nurse E) reports that on 3/28 at approximately 3:05 P.M. he was sitting at the nursing desk on Unit 3 when he heard housekeeper (name of Housekeeper U) call out. The nurse stood from the desk and observed residents (R#24) and (R #10) sitting at a table next to each other. He immediately responded to the area and was notified by housekeeper that (R #24) struck (R#10) on the right side of her face (R#24) was asked why she struck (R#10) to which she replied 'She took my case.' Referring to a tin box she keeps things in .(R#10) reported to the nurse 'She hit me' while holding her hand up to her face .(R#24) was at the table in a standard chair with her head resting on the table at which time she suddenly sat up, began staring at the table as if looking for something then scooted her chair back to look on the floor. She then according to the housekeeper scooted her chair over to (R#10) and unexpectedly struck (R#10) on the right side of her face . On 6/14/18 at 3:54 P.M., R#10's clinical record was reviewed and revealed the following: R#10 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented R#10 had severely impaired cognition, no behaviors, and required limited to extensive assistance with ADLs. A progress note dated 3/28/18 documented, Resident was hit in the face by (room number of R#24). Resident screamed out and began to cry . Resident #29 and Resident #98 On 6/13/18 at 4:18 p.m., a review of the facility's Incident and Accident Investigation Form revealed the following: On 5/31/17 at approximately 1:00 p.m., Housekeeper 'AA' walked into R#98's room when she was approached by R#29. R#98 reported to Housekeeper 'AA' he was hit on the head twice. Housekeeper 'AA' reported that R#29 appeared upset .Housekeeper 'AA' reported that R#98 was lying on his bed at that time .Housekeeper 'AA' reported a few moments later, Social Worker 'Y' came into the room and the occurrence was related to Social Worker 'Y' .CNA 'BB' reported that she was walking into the room when she heard R#29's report .CNA 'BB' states that she asked R#98 if he struck R#29, to which R #98 replied I sure did, twice. CNA 'BB' inquired as to why he did this and R#98 stated, I don't want him in my room. CNA 'BB' informed R#98 that R#29 was moving into the room and now would occupy it with him .The residents' charge nurse Licensed Practical Nurse (LPN 'CC') was notified of the occurrence and reported to the room .The residents' Responsible Parties (RPs) and Medical Doctors (MDs) were notified of the occurrence as well as the administrator . On 6/13/18 at 4:35 p.m., a review of the electronic clinical record revealed R#29 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of a quarterly MDS assessment dated [DATE] revealed R#29 had a BIMS score of 15/15 (which indicated intact cognition) and had no mood or behavior concerns. On 6/13/18 at 4:45 p.m., a review of R#98's clinical record revealed he was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review an admission MDS assessment dated [DATE] revealed R#98 had a BIMS score of 6/15 (which indicated severe cognitive impairment). On 6/14/18 at 1:05 p.m., R#29 was observed in his room watching television. During an interview, when asked about the incident, R#29 stated, I can't remember exactly when it happened or the details, but he (R#98) hit me a couple of times . On 6/13/18 at 2:30 p.m., review of the facility's Abuse Prohibition Policy dated Revised 11/2017 included: .Verbal Abuse is defined as the use of oral, written or gestured language that includes disparaging and derogatory terms to residents .or within their hearing distance, regardless of their age, ability to comprehend or disability .Examples .Threats of harm .Yelling or hovering over a resident, mocking, insulting, ridiculing, harassing a resident .Physical Abuse includes hitting, slapping, pinching, and kicking .Examples .A resident picks a fight with another resident and knocks him/her down .Mental abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation .Examples .A combative resident threatens to beat up another resident . The Facility submitted the following acceptable plan includi (TRUNCATED)

This citation has two deficient practice statements. Deficient Practice #1 This citation pertains to intake #s MI 482 and MI 590. Based on observation, interview and record review, the facility failed to report multiple instances and allegations of abuse to the administrator (who functions as the facility's abuse coordinator) and/or the State Agency within the required time frames for 14 (R#s 10, 24, 26, 29, 31, 61, 74, 85, 92, 98, 103, 108, 116, and 324) of 20 sampled residents reviewed for abuse from a total sample of 36, resulting in an Immediate Jeopardy (IJ) when actual incidents of verbal and physical abuse between residents (including hitting, pushing, punching, yelling, and derogatory statements towards residents) were not being identified, reported and investigated. This deficient practice places the residents at risk for serious harm, injury and/or death, and the likelihood for continued incidents of abuse to occur. Findings include: The Immediate Jeopardy (IJ) started on 5/31/17. The IJ was identified on 6/14/18 at 10:00 a.m. The Administrator was notified of the IJ on 6/14/18 at 10:15 a.m. A plan to remove the immediacy was requested. The immediacy was removed on 6/14/18 at approximately 5:10 p.m. based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the facility's deficient practice was not corrected and remained at a pattern that is not immediate jeopardy. On 6/11/18 at 9:50 a.m., upon entering the facility's secured unit, R#92 was observed seated in a wheelchair while being pushed by staff just outside of R#26's room. At that time, R#26 was observed holding onto the back part of R#92's wheelchair (near the handle) and R#92 was yelling out loudly, Help, help. Further observations revealed multiple Residents ambulating independently throughout the hallways, in and out of other Resident rooms, the dining/activity room, and near the exit/entrance to the secured unit. Due to significant cognitive impairment, Residents were unable to participate in any interviews. On 6/11/18 at 9:57 a.m., Certified Nursing Assistant (CNA A) was asked about R#26's behaviors towards other residents on the secured unit and reported, Yeah a couple of incidents, he's (R#26) very protective if anyone opens his door or comes close to him. When asked if he was aware of any issues with current roommate (R#103), CNA A stated, No, seems to do well with him, its others he (R#26) has an issue with. On 6/11/18 at 10:24 a.m., R#26 was observed lying in bed on the right side watching television and upon approach stated, I don't have anything to say to you. I'm watching the Pres (President) on TV here. On 6/12/18 at approximately 12:00 p.m., incident and accident reports for R#26 were reviewed and revealed the following Resident to Resident incidents which involved: R#26 and R#103 on 5/17/18; R#26 and R#92 on 5/8/18; R#26 and R#61 on 4/7/18; R#26 and R#92 on 4/7/18; R#26 and R#116 on 2/14/18; R#26 and R#92 on 11/18/17; and R#26 and R#31 on 6/24/17. Resident #26 and Resident #103 On 6/12/18 at approximately 1:00 p.m., an Incident and Accident Report dated 5/17/18 at 10:50 am documented, .CNA heard yelling in (R#26's) room with door shut. Upon entering room noted resident and roommate yelling at each other CNA immediately separated residents. R#26 stated roommate (R#103) was in his (R#26's) closet and he (R#26) asked him (R#103) why, then hit him (R#103) on rt (right) forearm . Review of the clinical record revealed R#26 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/15/18 indicated he had independent cognitive skills for daily decision making. R#26 had verbal behavior symptoms directed towards others and was independent with ambulation. A review of R#26's care plans included: R#26 has potential to demonstrate physical/verbal behaviors r/t (related to) Dementia and poor impulse control. He may aggressively approach others whom he perceives to be in an area he finds prohibitive or has an item he believes is his. R#26 is at risk for injury from others re his behaviors. Can try to take care of older, female residents. Can make inappropriate comments to female residents and negative comments to male peers. Is territorial and has potential to demonstrate physical/verbal behaviors to peers who wander into his room. He will often sit in hall to watch his door when he is not in room. R#26 has moved his stop sign on his door to a higher level out of others reach. However now it is out of their view if in w/c. This care plan documented it had been created on6/24/2015 and revised on 4/23/2018. Interventions had last been revised on 5/10/2018 which documented, Assist to redirect peers away from resident room/door as needed. Review of the clinical record revealed R#103 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment with an ARD of 5/14/18 documented R#103 was severely cognitively impaired, and was independent with ambulation. A review of R#103's care plans included: R#103 has potential to demonstrate physical or verbal aggression r/t Dementia . Interventions had last been implemented and/or revised on 2/28/2017. An Incident and Accident Investigation Form completed by the Assistant Director of Nursing (ADON) documented the incident took place on 5/17/18 at 10:50 a.m. The investigation form documented the resident's files were reviewed on 5/17/18 at 3:00 p.m. and Nurse I was interviewed on 5/18/18 (no time noted) and CNA JJ was interviewed on 5/18/18 (no time noted). An investigation summary was completed by the ADON which did not identify the date and/or time of completion and documented this summary had been submitted to the facility's QA (Quality Assurance) Committee. Resident #26 and Resident #92 On 6/13/18 at approximately 8:40 a.m., an Incident and Accident Report dated 4/7/18 at 12:30 pm documented, .Resident (R#92) had propelled w/c (wheelchair) into (R#26's room). R#26 pushed w/c into hall then slapped him (R#92) several times in head . An Incident and Accident Investigation Form completed by the ADON documented the incident took place on 4/7/18 at 12:30 p.m. The investigation form documented the resident's files were reviewed on 4/9/18 at 10:45 a.m. and Nurse K was interviewed on 4/7/18 (no time noted) and CNA DD was interviewed on 4/7/18 (no time noted). An investigation summary was completed by the ADON which did not identify the date and/or time of completion and documented this summary had been submitted to the facility's QA Committee. Further review of the documented staff interviews included: .4/7/18 .Nurse K reports she was in DR (dining room) at desk and heard loud voices in hall. Ran to hall and saw CNA DD bringing R#92 toward the day room and R#26 was walking behind them. CNA DD reported her observation of the exchange between them in the hallway .4/7/18 .CNA DD: reports she was putting lunch trays in DR and heard R#92 call out. Rushed to hall toward end of hall and observed R#26 pushing R#92 in w/c out of his rm (room). As he did, he (R#26) struck R#92 on back of his head with an open hand . Review of the clinical record revealed R#92 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment with an ARD of 5/11/18 documented R#92 had impaired cognitive skills for daily decision making, exhibited physical, verbal and other behavioral symptoms directed towards others, and had wandering behavior. A review of R#92's care plans included: R#92 has the propensity for catastrophic reactions related to ill approach. He startles easily when approached from the rear. He will swat, hit, yell, spit or cuss if startled. He can become agitated when touched .He wanders unit ad lib and may wandered (sp) into other's rooms . This care plan documented it was created on 1/29/2014 and interventions were last revised on 9/28/2016. A review of IDT progress notes revealed: Nurse K documented on 4/7/18 at 1:10 p.m., .R#92 propelled self into R#26's room, R#26 pushed his wheelchair into hall then slapped him several times in the head, stated he (R#26) was tired of him (R#92) in his room and getting into his stuff. Angry, difficult to redirect. Call placed to administrator to inform . Resident #26 and Resident #61 On 6/12/18 at 2:58 p.m., R#61 was observed to walking in the dining room and had an exit alarm bracelet to the right wrist. On 6/13/18 at approximately 8:20 a.m., an Incident and Accident Report dated 4/7/18 at 10pm documented, .Another res (R#61) entered into res (R#26's) room and he (R#26) put the other Res (R#61's) hand behind his back and put his (R#26's) arm around his (R#61's) neck and push him (R#61) into day room . An Incident and Accident Investigation Form completed by the ADON documented the incident took place on 4/7/18 at 10:00 p.m. The investigation form documented the resident's files were reviewed on 4/9/18 at 10:00 a.m. and Nurse F was interviewed on 4/7/18 (no time noted) and CNA BB was interviewed on 4/7/18 (no time noted). An investigation summary was completed by the ADON which did not identify the date and/or time of completion and documented this summary had been submitted to the facility's QA Committee. Further review of the documented staff interviews included: .4/7/18 (no time of interview) .Nurse F reports that as she returned to unit/dayroom from break she was met by CNA BB who reported exchange between R#26 and R#61 .Nurse assessed R#61 and observed small bruise to his left wrist . .4/7/18 (no time of interview) CNA BB at approx. 11p CNA was in DR sitting with (another Resident) when she heard loud voices in hall. Reports she responded to doorway and was met by R#26 and R#61. CNA reports that R#26 was standing behind R#61 and was holding R#61's hand behind his (R#61's) back and his (R#26's) other hand on the back of R#61's neck. R#26 then pushed R#61 through the doorway into the dayroom and exclaimed Keep this MF (Mother F*****) out of my room then balled up his (R#26's) fist and shook it at R#61 . Review of the clinical record revealed R#61 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment with an ARD of 4/12/18 documented R#61 had impaired cognitive skills for daily decision making, and had wandering behaviors. A review of the IDT progress notes revealed: Nurse K documented on 4/7/18 at 11:47 p.m., .Another res (R#92) entered res (R#26's) room and the res (R#26) that resided in the room put his (R#26) arm around the res (R#92's) neck and put the other res (R#92's) arm behind his back and push him down the hallway into the day room. The cena told him (R#26) to stop and assisted the other res (R#92) to a chair . Resident #26 and Resident #116 On 6/13/18 at approximately 9:00 a.m., an Incident and Accident Report dated 2/14/18 at 2:45 pm documented, .Resident was walking in hallway when R#26 grabbed her right arm and told Resident (R#116) not to go into his room again or he would throw water in her face, R#116 responded by smacking R#26 in face . An Incident and Accident Investigation Form completed by the ADON documented the incident took place on 2/14/18 at 2:50 p.m. The investigation form documented the resident's files were reviewed on 2/14/18 at 3:30 p.m. and Nurse E was interviewed on 2/14/18 (no time noted) and CNA P was interviewed on 2/14/18 (no time noted). An investigation summary was completed by the ADON which did not identify the date and/or time of completion and documented this summary had been submitted to the facility's QA Committee. Further review of the documented staff interviews included: .Approx 2:50 pm Activity Staff FF sitting in hall facing entrance door observed R#26 aggitated (sp) .he (R#26) saw R#116 go into his room. R#116 was walking in hall, he (R#26) looked up at her (R#116) took her by arm and pulled her toward him (R#26). He (R#26) said something about throwing water in her (R#116's) face if she went in his room .CNA went over to them then saw (R#116) swat at (R#26) striking him in forehead . .2/14/18 (no time noted) .walking in hall, saw (R#26) walking with (R#116) in the hall. (R#26) had ahold of her right upper arm. Talking to her in a low voice. As CNA approached she thought they were start walking and visiting with each other. CNA overheard (R#26) say to (R#116) If you go in my room again, I'll throw water on you. CNA removed (R#26's) hand from her arm. As she did (R#116) struck (R#26) in forehead . Review of the clinical record revealed R#116 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS with an ARD of 5/19/18 documented R#116 had moderately impaired cognition, no behaviors of wandering documented (progress notes document R#116 ambulates up and down the halls). Review of R#116's care plans included: I am at risk for wandering r/t history of intruding/wandering into other residents' rooms, and impaired safety awareness, 'shopping behaviors', and going through belongings of others without their permission . There were no documented interventions added since 5/17/2017 despite the care plan revision/review on 5/18/18. A review of the IDT progress notes documented: Nurse T documented on 2/14/18 at 4:15 p.m., .R#26 grabbed R#116 by the arm and threatened to throw water in her face if she went into his room again. R#116 smacked resident (R#26) in the face . Resident #26 and Resident #92 On 6/13/18 at approximately 9:20 a.m., an Incident and Accident Report dated 11/18/17 at 5:15 pm documented, .Resident (R#92) wheeled himself into R#26's room, R#26 pushed his (R#92's) w/c into hallway struck him (R#92) in back with his (R#26's) fist yelling at him to stay out! . An Incident and Accident Investigation Form completed by the ADON documented the incident took place on 11/18/17 at 5:15 p.m. The investigation form documented the resident's files were reviewed on 11/20/17 at 10:00 a.m. and Nurse K was interviewed on 11/18/17 (no time noted) and CNA HH was interviewed on 11/22/17 (no time noted). An investigation summary was completed by the ADON which did not identify the date and/or time of completion and documented this summary had been submitted to the facility's QA Committee. Further review of the documented staff interviews included: .Nurse K at desk in day room, heard R#92 calling out from hall. Nurse responded to hall. Observed R#92 in his w/c and CNA HH moving R#92 in his w/c away from R#26's room. CNA HH stated that R#26 pushed R#92 out of room in w/c and struck him on the back .R#92 had increased agitation which began around 4:30 pm r/t (related to) sundow[DIAGNOSES REDACTED] . A review of the IDT progress note dated 11/18/17 at 5:40 p.m. by Nurse K documented, .(R#92) had gone into (R#26's) room, (R#26) pushed his (R#92's) wheelchair out into hallway then (R#26) struck him (R#92) in his back with his fist/(R#92) was yelling help during altercation. R#26 was yelling 'stay out of my room' Administrator and supervisor notified. Resident #26 and Resident #31 On 6/13/18 at approximately 9:40 a.m., an Incident and Accident Report dated 6/24/17 at 4:00 pm documented, .(R#31) in (R#26's room), (R#26) pushed him (R#31) thru door, then punched him in mid back with closed fist 2 x's (times) yelling at (R#31) to stay out of his room . An Incident and Accident Investigation Form completed by the ADON documented the incident took place on 6/24/17 at 4:00 p.m. The investigation form documented the resident's files were reviewed on 6/26/17 at 10:30 a.m. and Nurse K was interviewed on 6/26/17 (no time noted) and CNA II was interviewed on 6/29/17 (no time noted). An investigation summary was completed by the ADON which did not identify the date and/or time of completion and documented this summary had been submitted to the facility's QA Committee. Further review of the documented staff interviews included: .Nurse K in DR, heard (R#31) calling out. Went to hallway, CNA II was in the hall. CNA II reported that (R#31) was in (R#26's room) and she saw (R#26) push him (R#31) out of the room and struck him (R#31) on the back 2x .(R#31) was rubbing back stated, 'He hit me .' Review of the clinical record revealed R#31 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment with an ARD of 3/17/18, R#31 had severe cognitive impairment, and was independent with ambulation. Review of R#31's care plans included: R#31 is at risk for elopement and/or wandering r/t (Disoriented to place, impaired safety awareness, Resident wanders aimlessly. Resident wanders into other rooms and difficult to redirect at times. Can become verbally and physically aggressive with re-direction or perceived interference . This care plan was created on 12/7/2016 and had no interventions changed since 3/29/2017. R#31 has a behavior problem r/t dx (diagnosis) of [MEDICAL CONDITION], dementia, resident lacks insight, safety awareness, boundaries .wander into others rooms and rummage .can strike others . This care plan was created on 12/9/2016 and had no documented interventions changed since 1/11/2017. A review of the IDT progress notes included: Nurse K documented on 6/24/17 at 4:38 p.m., .(R#31) went into (R#26's) room, (R#26) observed pushing him (R#31) through doorway then (R#26) striking him (R#31) 2 times on mid back with closed fist. Resident (R#26) aggitated (sp) and angry. Administrator informed of altercation, call placed to Physician J to inform .Resident (R#26) pacing hall and monitoring who is near his room. Nurse K documented on 6/24/17 at 5:07 p.m., .(R#26) making threatenting (sp) remarks to (R#31), stating 'I'm going to get you latter (sp)', resident (R#26) xtremly (sp) angry, talking about his brother and that he was the reason he was in here, difficult to redirect. On 6/12/18 at 2:55 p.m., the Administrator was asked about how the facility determined identification of abuse such as verbal, mental, or physical altercations and reported, He (R#26) tends to mutter under his breath threats. When asked if threats to harm others would be considered verbal or mental abuse, the Administrator stated, Yeah. The Administrator further reported that some of the incidents involved with R#26, Did not have an outcome that resulted in physical injury and other residents were unable to recall specific incidents. When asked despite not being able to recall a specific incident, if abuse incidents occurred, and it involved an abuse allegation whether witnessed or not, injury or not, and if the resident was unreliable given the significant cognitive impairment, would that be considered abuse, and should it be reported, the Administrator stated, Yes. On 6/12/18 at 3:03 p.m., an interview was conducted with the Administrator and the ADON. At that time, the Administrator reported, (Name of ADON) is our investigation nurse (responsible for completing Resident investigations). When asked about the preliminary review of the facility's investigation provided which revealed no time or dates of completion or determination of whether they ruled out abuse, the Administrator reported, No one has ever questioned that before. I acknowledge that portion wasn't written down. When asked how it could be determined if/when the Administrator was informed of the allegation of abuse, whether verbal, mental, or physical and/or with or without injury, the Administrator reported, I can assure you the process was followed, but it's not documented. At that time, the Administrator and ADON reviewed the facility's documentation of the resident to resident altercation on 5/17/18 between R#26 and R#103 and reported, the investigation had not been completed until 5/18/18 and had not been reported to the State Agency. On 6/13/18 at 9:57 a.m. an interview and record review was conducted with the Director of Nursing (DON), ADON, Nurse Manager I and Social Worker (SW Y) (assigned to Unit 2 and 3). At that time, upon review of the aforementioned resident to resident altercations which involved: R#26 and R#103 on 5/17/18; R#26 and R#91 on 5/8/18; R#26 and R#61 on 4/7/18; R#26 and R#92 on 4/7/18; R#26 and R#116 on 2/14/18; R#26 and R#92 on 11/18/17; and R#26 and R#31 on 6/24/17, the DON confirmed these incidents had not been reported to the State Agency. When asked to define abuse, the DON reported, We believe it is a willful intent to harm. When asked if abuse incidents were unwitnessed and involved Residents with cognitive impairment, how is abuse ruled out, the DON reported, I don't believe that resident (R#103) is capable of willful intent to harm due to his cognition. When asked what was being done to ensure the safety and protection of the Residents on the secured unit, the DON reported He (R#103) was taken to the dining room. When asked about when the facility made a determination that they felt these altercations were not abuse, the DON reported, Usually (Administrator) makes that determination and determines (if reportable) when he gets the details of the brief synopsis at the beginning (when staff notify Administrator). When asked where the documentation was to determine if abuse was ruled out and why, the DON reported, That is something (Administrator) will have to tell you. The DON further reported, SW 'Y' met with R#26 and said nothing was wrong. It was an isolated occurrence. They (R#26 and R#103) continue to room together. Staff is aware they need to monitor the residents whether they see anything or behaviors. On 6/13/18 at 10:16 a.m., the Administrator joined the interview and when asked about the resident to resident altercation between R#26 and R#103 on 5/17/18, the Administrator reported, I said (to R#26) show me how he (R#103) hit him (R#26). He (R#26) didn't say he (R#103) hurt him, he (R#26) knocked his (R#103's) arm away. I generally talk to (ADON) about that. There weren't signs of injury and said it looked like he (R#103) was going to get in his (R#26's) closet. I made the decision on this particular incident it was not abuse, there was no injury. The ADON reported, (R#26) was reminded to get staff assistance. A lot of times he'll know enough to say room numbers and say for example (room #) needs help.' He (R#26) tries to help others. He's (R#26) remorseful afterwards. He (R#26) was reminded to ask for help and offered another room off the unit but declined. (R#26) also placed a picture frame with a stop sign on his door. A while ago he had a velcro stop sign and other residents would remove and that irritated him. He's (R#26) very concerned about someone walking off with the stop sign. SW Y reported, R#26's Psych NP (Nurse Practitioner) came to see him on 5/11/18 and had no recommended changes. When asked what interventions had been put into place to protect R#26 and the other residents that resided within the secured unit, SW Y reported, Intervention was to redirect (R#26) with diversional activities when (behaviors) noted. We (facility) arranged to notify the brother and team to discuss (R#26's) difficulty with impulse control. Meeting was held 5/18/18. The outcome was maybe the brother could talk with him (R#26) about moving off the unit. The brother was going to go back and discuss and they (R#26 and brother) got into an argument and the brother left. When asked if there had been any further follow up by the facility since 5/18/18, SW Y reported, No, not at this point. On 6/13/18 at 11:00 a.m., when asked about whether the resident to resident altercation on 4/7/18 between R#26 and R#92 had been reported, the DON stated, That was (Administrator's) decision. When asked about whether the resident to resident altercation on 2/14/18 between R#26 and R#116 had been reported, the ADON stated, I don't think so. When asked about whether the resident to resident altercation on 11/18/17 between R#26 and R#92 had been reported, the ADON stated, No. On 6/13/18 at 11:30 a.m., continuation of the interview and review of the other resident to resident altercations, the ADON acknowledged the lack of documentation, and reporting to the Administrator and/or State Agency. When asked as her role as the DON, was she involved in the decision to rule out abuse and ensure protection of the residents, the DON reported, Yes. That's (reporting) up to (Administrator) as the Abuse Coordinator. Resident #29 and Resident #98 On 6/13/18 at 4:18 p.m., a review of the facility's Incident and Accident Investigation Form revealed the following: On 5/31/17 at approximately 1:00 p.m., Housekeeper 'AA' walked into R#98's room when she was approached by R#29. R#98 reported to Housekeeper 'AA' he was hit on the head twice. Housekeeper 'AA' reported that R#29 appeared upset .Housekeeper 'AA' reported that R#98 was lying on his bed at that time .Housekeeper 'AA' reported a few moments later, Social Worker 'Y' came into the room and the occurrence was related to Social Worker 'Y' .CNA 'BB' reported that she was walking into the room when she heard R#29's report .CNA 'BB' states that she asked R#98 if he struck R#29, to which R #98 replied I sure did, twice. CNA 'BB' inquired as to why he did this and R#98 stated, I don't want him in my room. CNA 'BB' informed R#98 that R#29 was moving into the room and now would occupy it with him .The residents' charge nurse Licensed Practical Nurse (LPN 'CC') was notified of the occurrence and reported to the room .The residents' Responsible Parties (RPs) and Medical Doctors (MDs) were notified of the occurrence as well as the administrator . On 6/13/18 at 4:35 p.m., a review of the electronic clinical record revealed R#29 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of a quarterly MDS assessment dated [DATE] revealed R#29 had a BIMS score of 15/15 (which indicated intact cognition) and had no mood or behavior concerns. On 6/13/18 at 4:45 p.m., a review of R#98's clinical record revealed he was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review an admission MDS assessment dated [DATE] revealed R#98 had a BIMS score of 6/15 (which indicated severe cognitive impairment). On 6/14/18 at 1:05 p.m., R#29 was observed in his room watching television. During an interview, when asked about the incident, R#29 stated, I can't remember exactly when it happened or the details, but he (R#98) hit me a couple of times . On 6/14/18 at 1:15 p.m., during an interview, LPN 'CC' was asked if she reported the incident that was told to her by Housekeeper 'AA'. LPN 'CC' stated, Yes, I told all of management. On 6/14/18 at 1:30 p.m., an interview was conducted with the Administrator. When asked if the incident had been reported to the State Agency, the Administrator stated, No, I don't think it was reported, because it wasn't an injury. When asked if he was aware of the incident, the Administrator stated, Anything in the folders (provided by the facility that contained their investigations), I know about. Resident #98 and Resident #108 On 6/11/18 at 1:03 p.m., R#98 was observed resting in bed. When asked about his stay at the facility, R#98 stated, I was going down the hall and she called me a 'N*****' (a derogatory racial slur). When asked who he was referring to, R#98 stated, (R#108) somebody down the hall. If she was in Flint where I come from, she would have been dead. I told the workers (nurse and aide), and they said don't say nothing to her. If I would've been at home and that would've been a man, I would have shot him. On 6/11/18 at 1:35 p.m., R#98 was observed talking to Unit Manager 'EE' in the hallway. R#98 was heard stating .She called me a N*****. On 6/13/18 at 11:20 a.m., during an interview, Unit Manager 'EE', when queried if R#98 had reported to her that R#108 had used a derogatory racial slur at him, Unit Manager 'EE' stated, I reported it Monday. I went immediately and told our Abuse Coordinator (Administrator's name). He asked me to have Social Worker 'Y' to go talk to him (R#98). On 6/13/18 at 11:45 a.m., when queried what was done about the allegation, Social Worker 'Y' stated, I talked to him right after that, and he didn't use that word. He just said that she (R#108) called him a bad name. I provided reassurance to him, asked if he was ok, and I told him that I was glad that he did not strike out at her, because he can be more aggressive. Social Worker 'Y' further stated, I talked to R#108, and of course, she denied it. I encouraged her to get staff if she is upset. R#108 has a personality disorder. I verbally reported it to (Administrator's name). On 6/13/18 at 11:55 a.m., an interview was conducted with the Administrator. When asked if an investigation had been conducted concerning R#98 and R#108, the Administrator, stated, I have not completed a thorough investigation. Social Worker 'Y' did an initial (investigation) to rule out any injury. The Administrator further stated, R#108 has a history of racial comments, but it's usually used toward the staff. Resident #85 and Resident #108 On 6/11/18 at 2:48 p.m., R#85 was observed in bed. R#85 voiced a concern about R#108 saying derogatory things to staff and other residents. When asked what was specifically said, R#85 replied, things like 'Go back where you came from.' When asked if comments were directed toward her, R#85 replied that even though it was not said to her directly, because I am a black woman, I took it to mean me as well. R#85 stated she had told the Administrator, but he told her R#108 doesn't know what she's saying. R#85 said, I don't believe that, because R#108 picks and chooses people to say racial things to, she doesn't say it to everyone. Resident #116 and Resident #24 On 6/12/18 at 9:42 A.M., R#116's clinical record was reviewed and revealed the following: An IDT (interdisciplinary) progress notes revealed: On 3/25/2018 at 1:22 A.M., Nurse F documented, .(Resident) came out of room and showed nurse her Rt. upper forearm which had two scratches. She stated, that lady have a real kick about her. Unable to explain what lady. Nurse went into (resident) room to check with her roommate (later identified as R#24) that was awake and asked her did anything happen in this room. (R#116's roommate's bed number) stated 'That woman came over to her bedside and I hit her.' Nurse asked did you also scratch her, and she said No. Nurse brought res into day room to monitor her since she would not go to bed or stay in room . On 6/12/18 at 4:25 P.M., Nurse F was interviewed via phone. At that time, the Nurse was unable to recall working with R#116. When r (TRUNCATED)

This Citation pertains to MI 857 Based on observation, interview and record review the facility failed to meet the highest physical well-being (not identifying, appropriately treating, and not following Facility Skin Management Guidelines) for 2 skin cracks in 1 of 3 sampled residents (#102) from a total sample of 3 residents, resulting in pain, potential infection and decline in functional status. Findings include: Resident #102 was a resident at the facility at the time of the investigation. Resident #102 was admitted to the facility 12/14/12 with chronic tension headaches, depression, gout, [MEDICAL CONDITION] reflux, end stage [MEDICAL CONDITION] with kidney transplant, chronic nocardia infection (bacterial infection common with transplant patients usually found in the lungs) high blood pressure, [MEDICAL CONDITION], diabetes and neuralgia according to the facility face sheet. Review of the Facility MDS (minimum data set) dated 12/23/12 revealed that Resident #102 was cognitively intact for daily decision making skills, expressed as very important the ability to do favorite activities, go outside in good weather and participate in religious services. Resident #102 required two person assistance with transfers, extensive assistance with dressing, was totally dependent on staff for toileting and all activities of daily living was frequently incontinent of bowel and continent of urine. Resident #102 believed he was capable of increased independence. Resident #102 was observed during initial tour on 6/17/13 at 9:25 AM lying in bed. Resident #102 began the conversation stating, "Oh boy do I have lots to tell you." Resident #102 reported that he had been a resident at the facility since 12/2012 and did not get his teeth brushed unless he specifically requested to do so. Resident #102 further stated, "I have issues with the HIPPA law that CNAs (certified nursing assistants) are not allowed to know my condition. That's a joke. They (CNAs) are the ones who do the care. A case in point is my right shoulder. They need to know it is bone on bone and hurts when you move it wrong. They get me up in the Hoyer (mechanical) lift; put me in the chair and I get left (in the chair) for 3 hours until they get 2 CNAs to get me back to bed. They tell me they are short of help. I have had colon surgery and have a brief on and when I have to go, I can't wait. I am on anti-rejection medications that causes frequent diarrhea, but the worse thing is that I now have 3 bed sores that I didn't come in here with because they are not moving me. None of it makes me feel good. I have such pain in my butt I just can't sit up long. I don't want to embarrass you (surveyor) but I need to be changed and have been sitting in my own crap since 7 AM. No one has checked me since. When I was at home, I was walking with a walker, and had no pressure sores. Overall, I have deteriorated, I think. I don't get up because the sores on my butt. If I could get up and back to bed when I want to, I would. They get me up and I'm stuck (in the chair). It irritates my psyche and my butt, it hurts, but it's just easier to stay in bed. I know that I need to get up, but I can't." During the conversation with Resident #102, CNA #4 knocked, opened the door, and said, "I will return when you are done." CNA #4 returned at 10:30 AM to do incontinence care for Resident #102. Resident #102 gave permission for this surveyor to observe care. Resident #102's skin was observed on 6/17/13 at 10:35 AM with 2 areas where his skin had cracked open. Area #1 was identified across the entire abdomen under the abdominal skin fold. The area was approximately 1/8 inch wide by approximately 18 inches long. During cleaning with soap and water, CNA #4 removed a pink-colored substance from Resident #102's skin. Resident #102 stated, "Ouch! That really hurts. It worries me; that's where my kidney is." After cleaning the abdominal fold area, CNA #4 applied "[MEDICATION NAME]" to area #1. Area #2 was identified as the penis, scrotum and left upper thigh. CNA #4 cleaned the area with soap and water. Area #2 was bright red, with multiple "bumpy areas" from the head of the penis down the entire shaft onto the scrotum and left and right upper thighs. During the cleansing of the areas, CNA #4 reported, "it (Resident #102's skin) has been like this for a while. I'm not sure exactly." During the cleaning and application of the "[MEDICATION NAME]" skin protector to his skin, Resident #102 grimaced with teeth clenched and moaned, "Oh, oh." Review of the Facility CNA "Resident Care Guide" dated 2/4/13, revealed that in the section entitled, "Other; Turn every 2 hours" a line have been written through it with the notation D/C (discontinue) beside it and "limit time up in wheelchair encourage to shift weight every 15 minutes while in wheelchair" was present. No documentation was present to apply "Calazmine" to areas #1 and #2. Review of the Physician order [REDACTED]." Physician orders [REDACTED]." Physician orders [REDACTED]. Review of the physician progress notes [REDACTED]. Review of Wound Care physician progress notes [REDACTED]. Review of Facility Nursing Notes dated 12/15/12 to 4/29/13 revealed no documentation related to areas 1 or 2. Review of Facility Nursing Care Plans dated 12/26/12 titled 1) assistance with ADLs, 2) incontinent of bowel related to decreased mobility, has skin breakdown and is at risk for skin breakdown/impaired skin integrity, and 3) Diabetes Mellitus revealed that they all listed interventions "monitor/document/report to MD prn changes in skin status, appearance, color, wound healing, signs and symptoms of infection. Follow facility policies/protocols for prevention/treatment of [REDACTED]." Review of Facility Clinical Guidelines dated 5/10 "Skin Management" Section titled; Overview" 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. Practice Guidelines: #1 Upon admission, all residents are assessed for skin integrity by completing a baseline head to toe skin assessment. The Braden Scale will be completed upon admission, weekly for 4 weeks, quarterly and with a significant change of status for their risk for development of pressure ulcers by a licensed nurse. #5 The licensed nurse will initiate the appropriate skin forms, which includes a description of the ulcer Use the Non-Pressure Skin Condition Report for all identified non-pressure skin alterations. Place the form in the treatment book, document weekly until area is healed. #9 The licensed nurse will monitor, evaluate document changes regarding skin condition in the medical record (to include dressing, surrounding skin, possible complications and pain). #11 Place each resident on a weekly head-to-toe skin assessment that is completed by the licensed nurse. Using the Weekly head to toe skin check form indicate day and shift on which the check will be conducted. The CNA's will report any new skin impairment to the licensed nurse that is identified during daily care. #12 If a new area of skin impairment is identified, notify the resident, responsible party, attending physician, DON and treatment team and place the resident on the 24-hour report". Review of Resident #102's medical record revealed no Braden Scales completed weekly for 4 weeks and also no Non-Pressure Skin Condition reports were present. Review of Facility Braden Scale (tool to predict skin breakdown) were dated 12/15/12 and 4/3/13. Review of the Facility Weekly Nursing Head-to-toe skin assessments dated from 12/17/12 to 6/13/13 revealed no documentation regarding areas 1 & 2. The dates of 2/14/13, 2/21, 4/4, 4/25 were completed for those months with the last documented skin check on 5/30/13. During an interview with Staff RN #2 at 11:55 AM on 6/17/13 when asked when the last time she had assessed Resident 102's skin, she reported that she works two days a week and "was probably last week. I can't say for sure." When asked as the supervising nurse did she know what areas the [MEDICATION NAME] was being applied, she responded "No." During an interview with CNA #4 on 6/17/13 at 2:30 PM reported that "I think I told the weekend nurse about his belly maybe 4 or 6 weeks ago. I don't really know." During an interview with the Unit 4 Manager on 6/17/13 at 3:10 PM when asked if she had seen Resident 102's skin she reported "No." The Unit Manager completed Resident 102's skin assessment on 6/17/13. During interview and record review with both the Unit 4 Manager and Wound Care Nurse on 6/21/13 at 12:50 PM, both reviewed the medical record and were unable to locate documentation that CNAs notified nurses regarding the skin breaks to Resident #102, when the treatment to apply Calazmine ointment was started and who ordered the treatment. Wound Care consulted on 6/21/13 regarding the skin breaks. They said, "This documentation is not good. We don't know when the skin breaks happened or how long he's had them." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND IMPLEMENT INTERVENTIONS FOR ONE (#709) SAMPLED RESIDENT OF NINE RESIDENTS REVIEWED FOR FALLS IN A TOTAL SAMPLE OF 24 RESIDENTS, RESULTING IN A FALL WITH INJURIES, WHICH REQUIRED TRANSFER TO A HOSPITAL emergency room AND treatment for [REDACTED]. FINDINGS INCLUDE: ON 4/2/13 AT 9:45 A.M., RESIDENT #709 WAS OBSERVED SELF-PROPELLING, UNASSISTED, IN A HIGH BACK WHEELCHAIR IN THE 200 UNIT HALLWAY. RESIDENT #709 HAD BLACK, BLUE, AND YELLOW BRUISING OVER THE RIGHT CHEEK AREA AND OVER THE BRIDGE OF THE NOSE, AND A CLOSED LACERATION OVER THE RIGHT EYEBROW. WHEN ASKED ABOUT HOW THE BRUISING OCCURRED, RESIDENT #709 STATED "I DON'T REMEMBER." ON 4/2/13 AT 9:50 A.M., NURSE "F" WAS INTERVIEWED ABOUT RESIDENT #709'S BRUISING AND STATED "HE HAD A FALL A COUPLE OF WEEKS AGO. WE SENT HIM TO THE ER (emergency room ) WHERE THEY FOUND HE HAD A BROKEN NOSE AND A CUT ABOVE HIS EYEBROW." ON 4/2/13 AT 2:30 P.M., RESIDENT #709 WAS OBSERVED SELF PROPELLING, UNASSISTED, IN A HIGH BACK WHEELCHAIR EN ROUTE TO VISIT HIS WIFE, A RESIDENT ON ANOTHER UNIT IN THE FACILITY. A REVIEW OF THE CLINICAL RECORD FOR RESIDENT #709 ON 4/3/13 AT 9:30 A.M., REVEALED ADMISSION INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE QUARTERLY MINIMUM DATA SET FOR RESIDENT #709 DATED 2/25/13, DOCUMENTED THE RESIDENT WAS SEVERELY COGNITIVELY IMPAIRED AND REQUIRED EXTENSIVE ASSISTANCE FROM STAFF FOR TRANSFERS, AND WAS UNABLE TO AMBULATE. THE NURSING COMPREHENSIVE EVALUATION DATED 3/2/13 REVEALED RESIDENT #709 WAS AT RISK FOR FALLS DUE TO A HISTORY OF FALLS, MUSCLE WEAKNESS, DECREASED LOWER EXTREMITY JOINT FUNCTION, USE OF ANTIHYPERTENSIVES, AND IMPAIRED COGNITION, JUDGEMENT, MEMORY, SAFETY AWARENESS AND/OR DECISION MAKING CAPACITY. REVIEW OF RESIDENT #709'S FACILITY RECORD REVEALED FALLS WHICH OCCURRED ON 10/2/12 (RIGHT FACE LACERATION), 10/30/12 (NO REPORTED INJURIES), 11/14/12 (NO REPORTED INJURIES), 11/28/12 (NO REPORTED INJURIES), 3/20/13 (REDDENED AREAS TO RIGHT UPPER AND MIDDLE BACK), 3/21/13 (FRACTURED NOSE AND LACERATED RIGHT EYEBROW), AND 3/25/13 (NO REPORTED INJURIES). THE INCIDENT AND ACCIDENT REPORT FOR THE FALL WHICH OCCURRED ON 3/20/13 AT 5:40 P.M., REVEALED "RESIDENT FOUND BY CNA (CERTIFIED NURSING ASSISTANT) LYING NEXT TO HIS BED, RESIDENT STATED HE ROLLED OUT OF BED. REDDENED AREAS NOTED TO RIGHT UPPER AND MIDDLE BACK." INTERVENTIONS DESCRIBED ON THIS REPORT INCLUDED: "REMOVED WHEELCHAIR FROM ROOM TO HELP PREVENT RESIDENT FROM ATTEMPTING TO TRANSFER HIMSELF." THE CARE PLAN FOR RESIDENT #709 INITIATED ON 2/29/12, AND DATED AS REVISED ON 3/3/13, DOCUMENTED A FOCUS AREA DESCRIBED AS "HIGH RISK FOR FALLS R/T (RELATED TO) H/O (HISTORY OF) FALLS, UNAWARE OF SAFETY NEEDS R/T MEDICAL DX (DIAGNOSES) OF ALZHEIMER'S/DEMENTIA, INCONTINENCE, AND DECREASED MOBILITY. FREQUENT ATTEMPTS TO SELF-TRANSFER." GOALS FOR THIS CARE PLAN FOCUS AREA, INITIATED ON 2/29/12, INCLUDED "THE LIKELIHOOD OF FALLS WILL BE DECREASED THROUGH THE NEXT REVIEW PERIOD," AND "WILL NOT SUSTAIN SERIOUS INJURY THROUGH THE REVIEW DATE," INITIATED ON 8/16/12 WITH A REVIEW DATE OF 3/3/13 FOR BOTH GOALS. ON 4/3/13 AT 3:00 P.M., THE FACILITY'S INCIDENT AND ACCIDENT REPORT DATED 3/21/13 AT 8:00 P.M. FOR RESIDENT #709 WAS REVIEWED AND REVEALED THE FOLLOWING: "PT WAS IN W/C (WHEELCHAIR) IN BEDROOM ENTRANCE. CNA "G" OBSERVED PT ON THE FLOOR ON PT'S BEDROOM FLOOR NEAR THE END OF BED. PT LAYING ON HIS (R) SIDE ON FLOOR. (R) EYEBROW/CHEEK AREA BLEEDING AND NOSE BLEEDING." REVIEW OF THE FACILITY'S INCIDENT AND ACCIDENT INVESTIGATION FORM, DATED 3/22/13, FOR THE ABOVE INCIDENT, WITH NAMES OF THE EXAMINER IDENTIFIED AS THE FACILITY'S ASSISTANT DIRECTOR OF NURSING AND THE ADMINISTRATOR, REVEALED THE FOLLOWING: "PER CN (CHARGE NURSE) AND CNA 'G,' RESIDENT WAS TOILETED AND ASSISTED TO BED. AT APPROX (APPROXIMATELY) 8 PM NOTED RES (RESIDENT) LYING ON FLOOR (R) SIDE AT FOOT OF BED FACING BR (BATHROOM) DOORWAY. RES NOTED WITH LAC (LACERATION) TO BROW AND BRIDGE OF NOSE." UNDER THE SECTION "PHYSICIAN FINDINGS" WAS DOCUMENTED "NASAL FX (FRACTURE) AND LAC TO (R) BROW." INTERVIEWS IDENTIFIED AS DONE DURING THE INVESTIGATION INCLUDED CNA "G" AND THE CHARGE NURSE WHO WORKED THE DAY SHIFT FOLLOWING THE DATE OF THE INCIDENT. THE CHARGE NURSE AT THE TIME OF THE INCIDENT, NURSE "H," WAS NOT INTERVIEWED. EXAMINATION OF THE CONCLUSION SECTION OF THE ABOVE INVESTIGATION FORM REVEALED THE FOLLOWING: "RESIDENT ATTEMPTED TO AMB (AMBULATE) FROM BED AND MAY HAVE BEEN HOLDING ONTO FOOT BOARD AS HE AMB HIT FOOT OF BED. LIKELY LOST BALANCE FALLING TO FLOOR AND MAY HAVE COME IN CONTACT WITH FOOT BOARD OR BED CRANK AS HE fell ." THE PERSON IDENTIFIED AS COMPLETING THE REPORT WAS THE FACILITY'S ASSISTANT DIRECTOR OF NURSING. ON 4/4/13 AT 11:45 A.M., CNA "G" WAS INTERVIEWED AT THE FACILITY REGARDING RESIDENT #709'S FALL ON 3/21/13. CNA "G" STATED THE FOLLOWING: "I REMEMBER THE FALL. EARLIER IN THE SHIFT, I REMEMBER RESIDENT #709 ATTEMPTING TO GET UP WITHOUT HELP A COUPLE OF TIMES. I SAW HIM ABOUT TWENTY MINUTES BEFORE HE fell . WHAT HAPPENED WAS, I WAS PUSHING ANOTHER RESIDENT IN HER WHEELCHAIR, WHEN THE OTHER RESIDENT TOLD ME RESIDENT #709 NEEDED HELP AS WE WERE PASSING BY HIS ROOM. RESIDENT #709 WAS LYING ON THE FLOOR AT THE FOOT OF HIS BED, AND THERE WAS BLOOD. I YELLED FOR NURSE "H," AND SHE CAME TO HELP." ON 4/5/13 AT 1:15 P.M., NURSE "H" WAS INTERVIEWED BY PHONE REGARDING RESIDENT #709'S FALL ON 3/21/13. NURSE "H" STATED THE FOLLOWING: "YES, I WAS THE NURSE ON DUTY FOR THE 200 UNIT THE EVENING RESIDENT #709 fell AND BROKE HIS NOSE. I REMEMBER CNA "G" YELLING TO ME FROM HIS DOORWAY, SAYING 'WE HAVE SOME TROUBLE DOWN HERE.' I WENT DOWN TO HIS ROOM, SAW RESIDENT #709 BLEEDING ON THE FLOOR BY THE FOOT OF HIS BED. I TRIED TO STOP THE BLEEDING FROM HIS NOSE BY APPLYING PRESSURE, I COULDN'T, SO WE CALLED HIS DOCTOR, CALLED THE AMBULANCE, AND SENT HIM OUT TO THE HOSPITAL." UPON INQUIRY, NURSE "H" STATED: "I KNEW HE had a history of [REDACTED]. HIS BED AND WHEELCHAIR ALARMS WERE DISCONTINUED SEVERAL WEEKS AGO. I SAW HIS WHEELCHAIR AT THE ENTRANCE OF HIS ROOM, I DON'T KNOW HOW IT GOT THERE." A REVIEW OF THE FACILITY'S POLICY TITLED "FALL MANAGEMENT" AND DATED 5/2010, REVEALED THE FOLLOWING UNDER THE SECTION "POLICY:" "THE FACILITY WILL IDENTIFY HAZARDS AND RESIDENT RISK FACTORS AND IMPLEMENT INTERVENTIONS TO MINIMIZE FALLS." WITHIN THE SECTION TITLED "OVERVIEW" WAS DOCUMENTED: "EACH RESIDENT IS ASSISTED IN ATTAINING/MAINTAIN HIS OR HER HIGHEST PRACTICAL LEVEL OF FUNCTION BY PROVIDING THE RESIDENT ADEQUATE SUPERVISION, ASSISTIVE DEVICES, AND/OR FUNCTIONAL PROGRAMS AS APPROPRIATE TO MINIMIZE THE RISK FOR FALLS." ( ).