Every finding on record at Riverview Health and Rehab Center North

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 05/05/2026 at 8:48 AM an interview with Dietary Manager (DM) I regarding date marking found food items should have a receive, discard, and open date on them.On 05/05/2026 at 8:49 AM observed an opened package of sliced turkey with a facility marked receive date of 4/30 and a facility marked discard date of 6/1 in the walk in cooler. DM I stated that is not right and indicated it should have an open date.On 05/05/2026 at 8:52 AM observed a plastic bag containing sliced cheese with a discard date of 05/03/2026 in the walk in cooler.On 05/05/2026 at 9:37 AM observed a tossed salad in a container with a facility marked date of 4/30- 5/2 in the first floor west hall nourishment room refrigerator. DM I removed the item to be discarded.On 05/05/2026 at 9:40 AM an interview with DM I found porters will look through refrigerators and remove out of date items.On 05/05/2026 at 9:42 AM observation of the first floor activities refrigerator found a small carton of two percent milk with a manufacturer expiration date of 5/2/26. Further observation found a takeout bag with no date or label. An interview with DM I at this time found they do not check these refrigerators and are not sure if residents use them.On 05/05/2026 at 9:45 AM observed a container of pasta and meat sauce on the counter with no date or label in the first floor transitional rehabilitation east nourishment room.On 05/06/2026 at 1:23 PM an interview with Activities Director (AD) M found the refrigerator in the activities room is used to store resident food. AD M indicated it is usually cleaned out at the end of the day.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.On 05/05/2026 at 8:58 AM an interview with DM I regarding maintenance requests found the facility has a maintenance system in which requests can be submitted to. DM I indicated they will add request to the program and sometimes leave a sticky note.On 05/05/2026 at 9:09 AM observed water leaking from the prep sink when the faucets were turned off. DM I indicated it may need to be tightened up with washers.On 05/05/2026 at 9:11 AM observed the sink across from the kettle with water dripping from the cold handle nozzle when the faucets were turned off.On 05/05/2026 at 9:27 AM observed the sanitizer compartment faucet of the three-compartment sink leaking water when turned off. DM I indicated they would have the Maintenance Supervisor look at it.According to the 2022 FDA Food Code section 5-205.15 System Maintained in Good Repair, A plumbing system shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.On 05/05/2026 at 9:06 AM observed metal shavings accumulated next to the blade of the can opener. An interview with DM I at this time found the can opener is cleaned after use in the three-compartment sink. DM I acknowledged the metal shavings and placed can opener into the three-compartment sink.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 05/05/2026 at 9:07 AM an interview with DM I regarding use of the prep sink found it is used for washing produce and meat. Further observation of the prep sink found the drain line extending from the sink and leading into the wall with no air gap.On 05/05/2026 at 9:16 AM observed the three compartment sink drain lines for the wash, rinse, and sanitize basins all connect to a common drain line and discharge to the floor with no air gap.According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed.On 05/05/2026 at 9:19 AM observed two stacked quarter pans on the dry storage rack with water droplets inside. An interview with DM I at this time found a staff member had just placed the pans there and they will educate.On 05/05/2026 at 9:20 AM observed water pooled at the bottom at each of the utensil holder slots in the utensil drawer used to store ice scoops. DM I indicated there should not be water in there.According to the 2022 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining.On 05/05/2026 at 9:27 AM an interview with DM I found the dishmachine is a high temperature dishmachine and they like to see the wash temp at 160 F and rinse temperature at 180 F. DM I indicated the wash gauge is currently not working and staff use the test strip to ensure it is sanitizing. The dishmachine was run, and after two cycles the wash cycle gauge did not move from the resting position of the gauge, and the sanitize cycle gauge remained at 126 F during the two cycles.According to the 2022 FDA Food Code section 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature, (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than: (1) For a stationary rack, single temperature machine, 74oC (165oF); Pf.According to the 2022 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures, (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90oC (194oF), or less than: Pf (1) For a stationary rack, single temperature machine, 74oC (165oF); Pf or (2) For all other machines, 82oC (180oF). Pf.On 05/05/2026 at 9:34 AM observed the outdoor grease receptacle filled with water and grease and the lid on the ground next to the bin. The cement near to the bin was observed with water puddles containing grease. An interview with DM I at this time found the rainstorm had blown off the cover. DM I indicated they had switched companies recently and had thought it was emptied but was not sure.On 05/06/2026 at 11:24 AM observed the lid to the outdoor grease receptacle off. In an interview with DM I at this time, when asked if it is usually on DM I stated yes.On 05/06/2026 at 11:58 AM an interview with Maintenance Supervisor (MS) D regarding maintenance of the grease bin was conducted. When asked who is responsible for maintaining the bin, MS D indicated a company comes to service it. When asked if anyone at the facility also maintains it, MS D indicated it is difficult to maintain with staff.According to the 2022 FDA Food Code 5-501.13 Receptacles, FDA Food Code 2022 Chapter 5. Water, Plumbing, and Waste Chapter 5 - 11 (A) Except as specified in (B) of this section, receptacles and waste handling units for REFUSE, recyclables, and returnables and for use with materials containing FOOD residue shall be durable, cleanable, insect- and rodent-resistant, leakproof, and nonabsorbent.On 05/05/2026 at 11:52 AM observed the wooden countertop beneath the coffee maker in the kitchen worn and no longer smooth and easily cleanable.According to the 2022 Food Code, section 4-101.19 Nonfood-Contact Surfaces, NonFOOD-CONTACT SURFACES of EQUIPMENT that are exposed to splash, spillage, or other FOOD soiling or that require frequent cleaning shall be constructed of a CORROSION-RESISTANT, nonabsorbent, and SMOOTH material.On 05/05/2026 at 12:13 PM observed a cracked and loose floor tile near the three-compartment sink. The grout along the edges of four tiles was cracked and missing.According to the 2022 Food Code, section 6-201.11 Floors, Walls, and Ceilings, Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE.On 05/05/2026 at 12:27 PM observed [NAME] L on the serving line repeatedly touch their glasses and forehead with the back of their gloved hand and continue work at the serving line without changing gloves or washing hands.According to the 2022 Food Code, section 3-304.15 Gloves, Use Limitation, (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. P.

Based on observation, interview, and record review, the facility failed to ensure the water management plan was implemented and that appropriate infection control practices were followed for two residents (R129 and R71) out of two residents reviewed for infection control and prevention, resulting in the potential for spread of infection among residents in the facility. Findings include: On 05/05/2026 at 1:38 PM observed an inoperable water fountain on the second floor outside of the dining room indicating possible stagnant water in the line. On 05/05/2026 at 2:03 PM observed an inoperable water fountain in the first floor physical therapy room indicating possible stagnant water in the line. On 05/05/2026 at 2:10 PM observed a low water level indicating low use in the toilet bowl with debris at the bottom and brown stained streaks on the inside edges of the toilet in the first floor west transitional rehabilitation tub room. On 05/05/2026 at 2:16 PM observed a film like substance on the surface of the water in the toilet of the first floor west transitional rehabilitation shower room [ROOM NUMBER]. Further observation found the hand sink nonfunctional. On 05/05/2026 at 2:41 PM observed no water in the hopper bowl indicating low use of the fixture in the second floor soiled utility room [ROOM NUMBER]. On 05/05/2026 at 2:58 PM observed a hopper with the flush apparatus nonfunctional in the third floor soiled utility room [ROOM NUMBER]. On 05/06/2026 at 11:31 AM an interview was conducted with Maintenance Supervisor (MS) D regarding the water management plan. When asked if they are on the team, MS D indicated yes, they cover water management. When asked if there had been an annual review, MS D stated no. MS D was asked about control measures taken to reduce the growth of legionella and indicated they test chlorine in the water supply once a quarter. When asked if there are control limits for chlorine, MS D stated they look for it to be above 0.1 parts per million (ppm), MS D indicated they use a pool test kit that measures free and combined chlorine. When asked if there are any other controls taken, MS D stated no. When asked what the boiler domestic water is set to, MS D stated 119 degrees F. MS D was queried about unoccupied rooms and found they flush the sinks and are not concerned with the toilets. When asked if there are any other areas in the facility that are low use, MS D stated there are not a lot of stagnant lines in the facility. MS D indicated they completed the water management risk assessment and paperwork themselves. On 05/06/2026 at 11:46 AM an interview with MS D was conducted regarding the nonfunctional sink in the first floor west transitional rehabilitation shower room [ROOM NUMBER]. When asked if they knew why the sink was nonfunctional, MS D indicated the plumbing is clogged and they could not fix it. When asked how long it has been in this state, MS D indicated since covid. On 05/06/2026 at 11:49 AM an interview with MS D found some of the drinking fountains were broken and they had turned them off. When asked how long they have been off, MS D stated awhile. When asked if the eyewash stations get flushed, MS D indicated they are every couple of months. On 05/06/2026 at 12:37 PM an interview was conducted with Nursing Home Administrator (NHA) regarding water management. When asked who is on the water management team, NHA indicated Maintenance, Dietary Manager, Dietitian and Director of Nursing. When asked about an annual review, NHA indicated maintenance runs the program and the regional maintenance would be the head of communication. When asked if they would attend a meeting when they occur, NHA stated no. On 05/06/2026 at 1:28 PM an interview with Director of Nursing (DON) was conducted regarding the water management plan. When asked if they are a part of the water management team, DON stated yes. When asked if they attend meetings, DON indicated corporate manages meetings and the NHA would be the head of the program, DON stated they do not recall attending meetings. On 05/06/2026 at 2:09 PM an interview with Dietary Manager (DM) I regarding the water management team was conducted. When asked if they are on the team DM I stated yes. When asked if they perform tasks related to legionella, DM I stated no. Record review of the facility provided document titled POLICY AND PROCEDURE MANUALS included in the water management program binder states The policies have been reviewed and approved by the above-mentioned parties. Signatures are included from the Medical Director, Administrator, and Director of Nursing with a date of 1/21/26. Record review of the facility provided document titled Healthcare Water Management Program Frequently Asked Questions found within the water management program binder states, Seven key activities are routinely performed in a Legionella water management program. 3. Identify areas where Legionella could grow and spread 4. Decide where control measures should be applied and how to monitor them 5. Establish ways to intervene when control limits are not met 6. Make sure the program is running as designed (verification) and is effective (validation). The document continues to list the principles of effective water management including, Preventing water stagnation. Maintaining premise plumbing. The documents states, Members of a building water management program team work together to. Identify ways to minimize growth and spread of Legionella and other waterborne pathogens. Conduct routine checks of control measures to monitor areas at risk. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. Eliminate dead legs, which are sections of no- or low-water flow. R71 On 5/5/2026 approx. 11:07 a.m. during a morning medication administration (Med Pass) on the Transient West unit observed Licensed Practical Nurse (LPN) F use an Accu-Chek meter to assess R71's blood sugar level. LPN F was observed inserting a test strip into the Accu-Chek meter, lanced R71's finger for blood, applied blood on the test strip until the blood sugar reading results (304) appeared on the Accu-Chek meter. LPN F returned to the medication cart and removed the test strip and stored the Accu-Chek meter back in the med cart. LPN F did not sanitize the Accu-Chek meter before placing it back on the med cart. On 5/7/2026 at approx. 2:10 p.m. LPN F was interviewed with the Director of Nursing (DON) present regarding the infection control concern of the un-sanitized Accu-Chek meter after use. LPN F was asked should the Accu-Chek meter be cleaned and sanitized after use? LPN F stated, yes, I should have wiped it off after I was done to sanitized it. LPN F was asked what was the importance of sanitizing a blood used equipment after use. LPN F said to sanitize the Accu-Chek meter before using it on other residents. LPN F was asked what should have been used to clean blood collection equipment after use? LPN F demonstrated having sanitizing and bleach wipes available in the med cart. On 5/7/2026 at approx. 2:20 p.m. during another interview, the DON agreed that the Accu-Chek meter should have been disinfected and should be disinfected after each use by all nurses. According to electronic health records (EHR), R71 was admitted into the facility on 4/13/2026 with diagnoses of Type two diabetes mellitus with foot ulcers, hypertension, and severe protein-calorie malnutrition. According to the admission Minimum Data Set (MDS) assessment dated [DATE] indicated R17 was cognitively intact with a BIMS (brief interview for mental status) score of 15. The undated facility policy, Infection control Manual noted, How do Infections Spread: Germs can be found on the hands or gloves of health care workers, on surface in the facility, and on medical equipment. If these are not properly cleaned and disinfected, the germs may spread to other people and the environment. R129 On 5/5/2026 at approximately 11:30 AM, R129's room door was observed open. Two residents were observed in the room. Signage on the door indicated enhanced barrier precautions (EBP) were needed when providing care. There was no indication on the signage which resident in the room needed the enhanced barrier precautions. Inside the room, two staff members were providing care to R129. Neither staff member was observed to be wearing the appropriate personal protective equipment (PPE) needed as indicated by the EBP signage on the door. A record review was completed on 5/5/2026 and revealed R129 admitted to the facility on [DATE] with diagnoses that include Parkinsons disease, hypertension, chronic kidney disease, gastrostomy, type II diabetes, and dementia. Section C of the Minimum Data Set with an Assessment Reference Date of 2/17/2026 revealed R129s cognitive status was severely impaired. A physician order dated 6/25/2025 revealed: Order for Enhanced Barrier Precaution r/t (regards to) peg tube. A physician order dated 5/5/2026 revealed: Enhanced Barrier Precautions related to wound. R129's care plan indicated enhanced barrier precautions were in place, and included the following intervention dated 4/22/2026: Educate Staff/Resident/Family on Enhanced Barrier Precautions as needed. R129's care plan also indicated the following interventions dated 2/17/2025: Maintain enhanced barrier precautions for the duration of their stay as ordered or until resolution related to diagnosis has been resolved or no evidence of signs and symptoms of infection and Staff is to wear gown and gloves during high-contact care activities for identified resident, thorough use hand hygiene before and after any resident contact, including before applying and after removing PPE. On 5/5/2026 at approximately 11:30 AM, Licensed Practical Nurse C (LPN C) was queried as to what care was being provided to R129 during the observation. LPN C said that R129 had vomited and that her and the CNA (Certified Nursing Assistant) were cleaning the resident up. When asked how staff were aware of which residents needed PPE for care, LPN C said it is usually indicated on the door signage. LPN C confirmed the signage on the door did not indicate which resident in the room needed PPE. LPN C also confirmed that R129 was on enhanced barrier precautions related to their peg tube and wound and that her and the CNA should have had on PPE while performing care for R129. On 5/6/2026 at approximately 1:20 PM, Infection Preventionist B (IP B) was interviewed regarding enhanced barrier precautions. The Director of Nursing was also present for the interview. IP B confirmed that PPE for enhanced barrier precautions should have been worn by the nurse and the CNA while providing care to R129. IP B added that PPE should be worn as indicated to help stop the spread of infection among residents in the facility. A policy titled, Enhanced Barrier Precautions dated March 2024 was provided and revealed the following: EBP is used with standard precautions and expands PPE to donning gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. In addition, EBP are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with dressing.

Based on observation, and interview, the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies, resulting in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 05/05/2026 at 12:48 PM observed a section of wall covering cut out with two protruding utility lines extending from the wall in the third floor common area outside of the dining room. The lines were left uncapped and a paper towel was found pressed inside one of them.On 05/05/2026 at 1:28 PM observed an approximate four by two foot area of floor tiles missing under the clean linen rack in the first floor east transitional rehabilitation room.On 05/05/2026 at 1:31 PM observed various nursing equipment and bags containing linen piled along the half wall on the third floor across from the shower rooms.On 05/05/2026 at 2:10 PM observed a low water level in the toilet bowl with debris at the bottom and brown stained streaks on the inside edges of the toilet in the first floor west transitional rehabilitation tub room.On 05/05/2026 at 2:16 PM observed a film like substance on the surface of the water in the toilet of the first floor west transitional rehabilitation in shower room [ROOM NUMBER].On 05/05/2026 at 2:24 PM observed the cover missing from a wall mounted soap container with various items in the container including a box of gloves, ointment, a container of moisturizer and an opened ointment packaging on the glove box. Further observation found the lower portion of the adjacent door frame rusted with chipping of the metal surface.On 05/05/2026 at 2:28 PM observed brown stained streaks on the inside of the toilet bowl in the second floor toilet room [ROOM NUMBER].On 05/05/2026 at 2:29 PM observed aprons, padding, disposable gloves, and washcloths in the therapy tub located in the second floor toilet room [ROOM NUMBER]. The room was unoccupied upon entry and the shower was running. Puddles of water with a yellow tint were present across the floor from the tub area to the shower. Further observation of the room found deterioration of the lower corner walls near the shower room, including rusted and exposed framing. The lower portion of the wall near the door was missing siding, leaving sharp and exposed edges next to the door.On 05/05/2026 at 2:36 PM an interview with Maintenance Supervisor (MS) D found the shower water does not turn off. MS D indicated repairing the issue would require shutting off almost the entire water supply. When asked how long it has been in this condition, MS D stated about a month.On 05/05/2026 at 2:54 PM observed approximately five inches of the baseboard missing from the wall adjacent to the door in the third floor shower room [ROOM NUMBER].On 05/06/2026 at 9:20 AM observed brown and black buildup on multiple ceiling tiles indicative of water damage in the first floor library. The affected tiles were aligned in a linear pattern across the length of the room.On 05/06/2026 beginning at 9:33 AM a tour was conducted with Environmental Services Director (ESD) J.On 05/06/2026 at 9:42 AM observed a mop sink with a chemical pre-dispensing system in place and the faucet left on in the first floor custodial closet closet. This set up puts undue back pressure on the faucet's internal atmospheric vacuum breaker (AVB), which can compromise the integrity of the mechanism.On 05/06/2026 at 9:48 AM an interview with ESD J found a few residents use shower room [ROOM NUMBER], and most residents have showers in their room. When asked about cleaning of the shower room, ESD J indicated the room is cleaned daily and housekeeping cleans walls, floors, high and low dust areas, as well as weekly grout cleaning. ESD J indicated Certified Nursing Assistants (CNAs) are responsible for cleaning equipment in the room. When asked about the nonfunctional hand sink, ESD J stated it is usually working. Observation of the room found an accumulation of products on the countertop including opened and unopened shampoo bottles, gloves, wipes, baby powder, combs, toothbrush, and deodorant. When asked if there is a place to store these items, ESD J indicated that only two people use the room.On 05/06/2026 at 10:02 AM observed the corner of the baseboard wall broken and missing in the second floor tub room [ROOM NUMBER]. An interview with ESD J at this time found it was reported when they got here in February. Further observation found the wooden floor tile missing at the doorway with underlying cement exposed and cracked.On 05/06/2026 at 10:10 AM observed a mop sink with a chemical pre-dispensing system in place and the faucet left on in the second floor custodial closet room [ROOM NUMBER], creating undue pressure on the faucets internal AVB.On 05/06/2026 at 10:21 AM an interview with Unit Manager K was conducted. When asked if there is a place to store shower items that are opened after use Unit Manager K indicated they should remain in resident rooms after opening.On 05/06/2026 at 10:22 AM observed a mop sink with a chemical pre-dispensing system in place and the faucet left on in the third floor custodial closet room [ROOM NUMBER], creating undue pressure on the faucets internal AVB. An interview with ESD J at this time found the water is left on and a button is pushed to release chemicals.On 05/06/2026 at 10:28 AM an interview with ESD J found they had reported the water damage on the ceiling tiles in the library, and they are in the process of repairing.On 05/06/2026 at 11:02 AM observed the ceramic wall tile cracked along the bottom corner adjacent to the shower room entry in the third floor shower room [ROOM NUMBER], creating a rough and uneven surface.On 05/06/2026 at 11:05 AM observed opened personal shower supplies lining the shower handrail in the second-floor shower room [ROOM NUMBER].On 05/06/2026 at 11:08 AM observed an accumulation of supplies piled on the counter in the second-floor tub room [ROOM NUMBER]. Supplies included an opened box of gloves, opened tissue boxes, folded towels, used gloves, shower supplies, mouthwash, apron, padding, and containers to hold supplies.On 05/06/2026 at 12:35 PM observed the brown and black buildup along the ceiling tiles in the first floor library. MS D acknowledged the tiles.On 05/06/2026 at 2:19 PM observed brown staining on the ceiling tile indicative of water damage and raised paint on the wall surface in the second floor shower room [ROOM NUMBER].

Based on observation, interview, and record review the facility failed to provide a clean and homelike environment for one resident (R20) out of one resident reviewed for safe, clean, homelike environment resulting in resident dissatisfaction with living conditions. Findings include:On 5/5/2026 at 10:29 AM, a fly trap ribbon full of dead flies and gnats was observed in R20's room hanging from the ceiling near the foot of R20's bed. There were no active pests noted in the room or in the hallway.On 5/06/2026 at 9:08 AM, R20 was interviewed regarding the fly trap and stated, The fly trap has been up there for a year. Someone from the facility put it there. I haven't had a problem with flies. I'd take it down, but I can't reach it. It doesn't look good. I'd like it down. R20 was observed sitting in a wheelchair next to his bed. A fly trap ribbon full of dead flies and gnats was observed hanging in front of R20's bed.On 5/06/2026 at 11:56 AM, Housekeeper G was interviewed regarding R20's room and said that she saw the fly trap with dead flies on it when cleaning R20's room but didn't have anything to do with that.On 5/07/2026 at 8:38 AM, R20's room was observed with Unit Manager (UM) H. UM H acknowledged the flytrap full of dead bugs and said maintenance put up the fly trap and monitored it. R20 was unavailable for an interview due to a dialysis appointment. On 5/07/2026 at 8:49 AM, Maintenance Supervisor (MS) D was interviewed and said the maintenance department put up the flytraps in the building but must have forgotten to take them down. MS D observed the fly trap ribbon full of dead bugs in R20's room. When asked about the installation and monitoring of the fly traps MS D was unable to recall when the fly traps were installed and could not provide information regarding the monitoring of the trap. Record review of R20's Electronic Health Record (EHR) revealed admission to the facility 5/23/2023 with diagnoses that included end stage renal disease, and age-related physical debility.Review of the Minimum Data Set (MDS) dated [DATE] for R20 revealed intact cognition and wheelchair bound for mobility.On 5/07/2026 at 2:22 PM, the Nursing Home Administrator was interviewed and said the expectation was for the facility not to use fly traps at all and if they were used to be monitored and disposed of properly.Review of the facility policy titled Maintaining a clean environment with a review date of March 2026 revealed in part.Items that collect dust or secretions may harbor microorganisms that can colonize and infect susceptible residents or be inhaled by employees performing cleaning tasks. Special Cleaning 1. Some items need to be cleaned on a regular schedule, but not daily.

Based on interview, observation, and record review, the facility failed to assist with discharge planning for one resident (R74) of two residents reviewed for discharge planning. Findings include:On 5/5/2026 at approximately 11:20 AM, R74 was observed in their room in bed. R74 expressed a desire to return to community living, saying that they had been in the facility for two years and would like to live with their family or on their own. R74 said they did not have a guardian. When asked if the facility was assisting them with discharge plans, R74 said no. When asked if the facility ever provided them with information regarding returning to the community, R74 said no. A record review was completed on 5/5/2026 and revealed R74 admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, atrial fibrillation, hypertension, type II diabetes, and major depressive disorder. Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/19/2026 revealed R74 scored a 15/15 on the Brief Interview for Mental Status assessment - indicative of no cognitive impairment. Section Q of the MDS with the same ARD revealed that R74 had active discharge planning in place, but that a referral to a local contact agency (a state designated community contact agency that provides individuals with information about community living options and available support and services) was not made. R74's care plan was reviewed and revealed the following focus dated 9/24/2024: The resident has been placed for LTC (long-term care) with needs with no plan for discharge. A psychiatry progress note dated 5/5/2026 revealed the following: Goal 4: encourage the client to maintain motivation in seeking alternate housing for greater independence, with ongoing support from her family. A social work progress note dated 2/24/2026 revealed in part, The resident has been placed for LTC needs, the resident continues to make inquiries regarding community living, however, the resident does not have sufficient support for community transition/living. Continue POC (plan of care). There was no further evidence in the electronic health record to demonstrate that R74 did not have sufficient support for community living, or who made that determination. A social work progress note dated 11/22/2025 revealed in part, The resident has been placed for LTC needs, the resident continues to make inquiries regarding community living, however, the resident does not have sufficient support for community transition/living. Continue POC. There was no further evidence in the electronic health record to demonstrate that R74 did not have sufficient support for community living, or who made that determination. On 5/6/2026 at approximately 10:00 AM, Social Worker A (SW A) was interviewed regarding R74's request to return to community living. SW A confirmed they were aware R74 wished to return to community living. When asked if a referral was made to a local contact agency so they could be assessed for care and services, SW A said, no - they are on Medicaid and do not have the financial support. SW A added, Usually, I would make a referral to (name of local contact agency). An undated policy titled, Transfer and Discharge from the Facility was provided but did not address discharge planning processes, or referrals to local contact agencies to determine a resident's abilities for community living. An undated policy titled, Resident Rights and Dignity was provided and revealed the following: 19. Each nursing home resident shall be afforded the opportunity to discharge himself/herself from the nursing home.

Based on observation, interview, and record review, the facility failed to ensure tube feeding nourishment was dated for two residents (R13 and R129) of three residents reviewed for tube feeding management.Findings include:R13On 5/5/2026 at approximately 10:30 AM, R13 was observed in their room, in bed. R13 did not respond to questions. A bag of enteral nutrition formula was observed hanging on a tube feeding pole next to R13's bed. The enteral feeding pump was observed to be on and running at 50cc per hour. There was no date on the enteral nutrition formula bag to indicate when it was hung and started. A record review was completed on 5/5/2026 and revealed that R13 most recently admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis, gastrostomy status, hypertension, cardiomyopathy, chronic obstructive pulmonary disorder, and heart failure. Section C of the Minimum Data Set with an Assessment Reference Date of 3/28/2026 revealed R13s cognitive status was severely impaired. A physician order dated 4/15/2026 revealed Nutren 2.0 @ 50cc/hour until 1000cc completed via peg. R129On 5/5/2026 at approximately 11:25 AM, R129 was observed in their room, in bed. R129 did not respond to questions. A bag of enteral nutrition formula was observed hanging on a tube feeding pole next to the bed. The enteral feeding pump was observed to be on and running at 55cc per hour. There was no date on the enteral nutrition formula bag to indicate when it was hung and started. A record review was completed on 5/5/2026 and revealed R129 admitted to the facility on [DATE] with diagnoses that include Parkinsons disease, hypertension, chronic kidney disease, gastrostomy, type II diabetes, and dementia. Section C of the Minimum Data Set with an Assessment Reference Date of 2/17/2026 revealed R129s cognitive status was severely impaired. A physician order dated 4/23/2026 revealed DiabeticSource AC @ 55cc/hour until 1000cc completed. On 5/5/2026 at approximately 11:35 AM, Licensed Practical Nurse C (LPN C) was queried as to the dating of the tube feed nourishment for R13 and R129. LPN C confirmed no date was on the formula bags and said, there should be a date on the formula bags.On 5/7/2026 at approximately 9:20 AM, the Director of Nursing (DON) was interviewed regarding the facility process for tube feeding. The DON said that the floor nurse is responsible for putting a date and time and their initials on the enteral nutrition formula bag to ensure that the nutrition is provided correctly according to the provider's order. A policy titled, Enteral Feeding Ready-to Hang dated March 2024 revealed in part, 4. Fill in information on label (resident's name, room, date, start time, and rate).

This citation pertains to intake 2632800.Based on interview and record review the facility failed to report an allegation of physical abuse from a staff member to the State Agency in the required timeframe for one (R101) of four sampled residents reviewed for abuse resulting in an unreported allegation of abuse and the potential for more allegations of abuse to go unreported.Findings include:On 10/2/25 at 8:27 a.m., a complaint was submitted to the state agency. The complaint alleged (R101) was physically abused and sustained an injury. A Facility Reported Incident (FRI) related to the complaint allegation was not found.On 10/6/25 at 12:17 p.m. a facility reported incident report involving R101 was requested. The Nursing Home Administrator (NHA) reported the facility did not have any FRIs involving R101.On 10/6/25 at 1:06 p.m. the Nursing Home Administrator (NHA), the Director of Nursing (DON), the Social Service Director (SSD) B, and the Regional Nurse Consultant F were present and queried having knowledge of any reported concerns for or from R101. The NHA said there were no known concerns for the resident. The DON said there was knowledge of a concern with R101's elbow having soft tissue and swollen. The SSD B said there was no knowledge of R101 having any concerns. They all denied being aware of any care concerns regarding being physically abused by a staff member.On 10/6/25 at 1:27 p.m. Nurse Practitioner (NP) D was interviewed. NP D said on 9/30/25 (time unknown) while discussing R101's cyst on elbow with the legal guardian/family member, an allegation of physical abuse was said. NP D said the legal guardian/family member reported R101 was assaulted by a male staff member which caused a fracture to the elbow. NP D said the allegation was reported to the Unit Manager and SSD (via email) immediately.On 10/6/25 at 2:07 p.m. SSD B was interviewed. SSD B said an email about R101 being assaulted was not receive sent by NP D and had no knowledge of the resident being assaulted or injured.On 10/6/25 at 2:25 p.m. R101's legal guardian/family member was contacted via phone call. The legal guardian said on 9/30/25 while speaking to NP D, reported R101 was assaulted by a male staff member. The legal guardian also said later, on 9/30/25, they were contacted by the DON and Unit Manager A via phone call when again it was reported, R101 said they were physically assaulted by a male staff member which caused an injury to the left elbow.On 10/6/25 at 3:55 p.m. Unit Manager (UM) A was interviewed and said on 9/30/25 was informed by NP D the legal guardian reported R101 was physically assaulted by a male staff member. UM A said the NHA was notified immediately, and the male staff member was removed from the unit.Review of the clinical record documented R101 was admitted into the facility on [DATE] with diagnosis that included: schizoaffective disorder, rhabdomyolysis, pain in left arm, cellulitis of left upper limb, vascular dementia, severe, with psychotic disturbance, chronic embolism and thrombosis of unspecified vein, and polyarthritis. According to the quarter Minimum Data Set, dated [DATE], R101 had severe impaired cognitive function (BIMS-6), and required limited one person assistance with activities of daily living. Review of the facility's policy titled Event Reporting and Response Policy (undated) will report allegations and substantiated occurrences of mistreatment, abuse, neglect, misappropriation of property, or injuries of unknown source to the Bureau of Health Systems using on-line form 362, immediately. Immediately means as soon as possible, but not more than 24 hours after the discovery of the incident. The investigation findings will be reported to the Bureau of Health Systems within five (5) working days of the incident using on-line form 363.

Based on observation, interview, and record review, the facility failed to: 1. Properly date-label food stored in the walk-in freezer and walk-in cooler, 2. Ensure food past the use-by-date was not stored with active food stock; 3. Ensure two commercial ice machines were cleaned in a timely manner; and 4. Effectively clean surfaces in the kitchen. These deficient practices had the potential to affect all the residents who consumed food from the kitchen and consumed ice from the ice machines, resulting in the potential for food-borne illness. Findings include: On 3/31/25 at 8:50 AM, during the initial tour of the kitchen with Dietary Manager (DM) A, the following was observed inside of the walk-in freezer: a previously opened bag of approximately 12 bread sticks was not labeled. DM A stated, It's not labeled. It shouldn't be in here. The following items were observed inside of the walk-in cooler, but were not adequately date-marked to specify the opened date and/or prepared date, and the use-by date: 1. An 1/8 size pan of prepared tuna dated 3/30. 2. Three soup bowls of chicken noodle soup and one soup bowl of tomato soup dated 3/30/25. DM A was unsure if the soup had been previously cooked and cooled. Six soup bowls of various types of soup dated 3/28/25. 3. An 1/8 size pan of ground turkey dated 3/28. 4. A bag of approximately 12 slices of American cheese dated 3/28/25. 5. An opened five-pound pack of Swiss cheese - undated. 6. Two opened 2-pound bags of pepperoni dated 2/24/25. The following items were observed inside of the walk-in cooler stored past the designated used-by date: 1. Two opened 1-pound bags of corned beef with a use-by-date of 3/21/24 2. A bag of approximately 16 slices of Swiss cheese with a use-by-date of 3/22/25. Other items observed during the initial tour of the kitchen included: 1. An accumulation of build-up grease and dust was observed on a light cover over the stove. 2. The inside of four drawer fronts in the cook's area were stained with dried food debris and an accumulation of food crumbs. 3. A wet, mushy, beige colored line was observed on the front faceplate inside of the ice machine. A portion of the wet, mushy substance was easily removed with a piece of paper towel. DM A stated the ice machine is cleaned every three months. A document posted on the side of the ice machine titled, Ice Machine/Steamer Cleaning, indicated the last completed cleaning occurred on 12/13/24, signifying the ice machine was overdue for a cleaning. 4. A visible layer of dust was observed on the outside of the ice machine. On 4/1/25 at 3:23 PM, a document posted on the 3rd floor ice machine documented that the ice machine was last cleaned on 12/13/24, signifying the ice machine was overdue for a cleaning. On 4/2/25 at 1:05 PM, the Nursing Home Administrator (NHA) said he expected food in the kitchen to be labeled according to the policy. The facility policy titled, Food Purchasing and Storage, dated October 2017, was reviewed and revealed in part the following: - Accepted items are removed from cases, date with Date Received by date and stored in the appropriate areas as quickly as possible. - Leftover foods will be put in the refrigerator in shallow pans (two to four inches deep) so that the interior temperature of the food chills quickly to < 41 F. They will be covered, dated, and labeled. - All food items in refrigerators will be properly dated with an open date and/or date to be use by, labeled, and placed in containers with lids, or will be wrapped. - All frozen food will be dated with an open date and/or date to be used by, labeled and wrapped. According to the 2013 FDA Food Code: -Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. On 4/2/25 at 3:10 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information regarding this citation when asked.

Based on observation, interview, and record review, the facility failed to document and ensure resident's activity preferences were honored for one resident (R61) out of two residents reviewed for activities, resulting in resident frustration and boredom. Findings include: On 3/31/25 at 11:03 AM, R61 was observed alert and lying in bed wearing a facility gown. R61 stated, I like to be with people and get bored in my room. R61 stated, I can't do anything on my right side. To get up, staff must dress them and put them in their wheelchair. On 4/1/25 at 2:35 PM, R61 was observed alert and lying in bed wearing a facility gown. R61 stated, I want to be able to get up and go somewhere. I'm just bored. R61 added that staff can just roll them down the hall and they can talk with some people. R61 stated, It beats just laying here. On 4/1/24 at 2:46 PM, Unit Manager, Licensed Practical Nurse (LPN) E said that R61 was not on the list to get up. A conversation was conducted with LPN E, R61, and the Surveyor. During this conversation, R61 mentioned that they would like to get up and out of their room and not just count the dots on the ceiling. On 4/1/25 at 3:11 PM, Certified Nurse Aide (CNA) J reported working with R61 for about 20 days and estimated that R61 had been out of their bed three times on the afternoon shift. On 4/2/25 at 8:47 AM, R61 was observed dressed and having breakfast in the dining room with other residents. When approached, R61 stated, It feels good to be up. On 4/2/25 at 10:17 AM, CNA J said she was responsible for getting R61 dressed and transported to the dining room. CNA J said that initially R61 did not want to get up because they thought no one else would be in the dining room. After CNA J assured R61 that others would be there, R61 got up and wanted to sit with the people in the dining room. On 4/2/25 at 12:15 PM, Activity Director (AD) K said the activity staff provided room visits for residents that do not leave their room. AD K could not provide documentation to support that R61 had received interaction with activity staff on a one-to-one basis in their room and stated, That's bad. R61's activities care plan was reviewed with AD K and revealed the following: Problem: I prefer activities like listening to music watching tv. Approach: Provide materials of interest: (magazine, needlework, etc.) Approach: Provide setting in which activities are preferred (own room, day room, etc.). Approach: Allow resident to express feelings and desires. Approach: Involve resident with those who have shared interests. Approach: Adjust activities to accommodate resident's energy level and tolerance. The activity care plan was last reviewed/revised on 1/14/25. However, there have been no revisions to the approaches since 4/27/22. AD K said that starting in January 2025, R61 would state that they wanted to get up and would ask AD K to get them up out of the bed. AD K said that nursing would be informed. AD K said that as recently as about a week ago, R61 again expressed a desire to get out of the bed. AD K admitted that R61's current activity care plan did not reflect that they wanted to get up. A review of the clinical record for R61 documented an initial admitted [DATE] and readmitted [DATE]. R61's diagnoses included cerebral infarction, hemiplegia, and unspecified dementia. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment. On 4/2/25 at 1:05 PM, the Nursing Home Administrator (NHA) said that resident activities should be individualized and based upon what the resident wants. The desired activities should be reflected in the care plan. The NHA added that there could probably be better documentation of one-to-one visits. The NHA said that R61's activity preferences should have been documented in the care plan and implemented. On 4/2/25 at 3:10 PM during the exit conference, the NHA said that all requested documents had been provided. A facility policy that governs one-to-one resident activities was requested on 4/2/25 at 1:39 PM but not provided by the conclusion of the survey.

Based on observation, interview, and record review, the facility failed to ensure meals were served at palatable temperatures for one resident (R287) out of two residents reviewed for food preferences, resulting in the resident's dissatisfaction with the dining experience. Findings include: On 3/31/25 at 12:39 PM, R287 was queried about meals received in the facility. R287 stated, My breakfast is always cold. On 4/2/25 at 8:15 AM, R287 was observed in their room, awake and sitting in a wheelchair. On 4/2/25 at 8:19 AM an insulated meal cart was delivered to R287's housing unit. On 4/2/25 at 8:30 AM, Certified Nurse Aide (CNA) C delivered a breakfast tray to R287. The main entree was served on a plate covered with an insulated dome. R287 granted permission for the tray to be used as a test tray, and a replacement meal tray was ordered for R287. CNA C was present during the testing of food temperatures on R287's tray. The following temperatures were obtained using a metal stem thermometer: Scrambled eggs 92.8 F (Fahrenheit) Pancakes 90.1 F CNA C agreed to touch the pancakes. CNA C said the pancakes were only slightly warm and acknowledged the pancakes were not warm enough to melt butter. Oatmeal 135 F Coffee 130 F Milk 48 F Apple juice 50 F A review of the clinical record documented R287's admission to the facility on [DATE] with diagnoses that included legal blindness, Parkinsonism, and Type 2 diabetes mellitus. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment. R287 was ordered a regular textured, restricted concentrated sweets, thin liquid diet. On 4/2/25 at 1:05 PM, the Nursing Home Administrator (NHA) said everything should be at the proper temperature ranges. On 4/2/25 at 1:23 PM, the food temperatures obtained at 8:30 AM were reviewed with Dietary Manager (DM) A. In reference to the point-of-service temperatures for the scrambled eggs and pancakes DM A stated, That's too low. DM A said they should probably perform an audit to determine the reason for the low temperatures at the point of service. A facility policy titled, Food Temperatures, dated May 2024, was reviewed and revealed in part the following: - Hot food served to the resident will be no less than 135 degrees Fahrenheit. - The temperature of potentially hazardous cold food will be no greater than 41 degrees Fahrenheit when served to the resident. On 4/2/25 at 3:10 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information regarding this deficient when asked.

This citation pertains to intake MI00149358. Based on interview, and record review the facility failed to update/revise/review a care plan in a timely manner for one resident (R401) out of four residents reviewed for care planning. Findings include: On 1/14/25 at 8:55 AM R401's guardian A was interviewed and said that on 11/16/24 a nurse from the facility reported to her that R401's leg was swollen and warm to the touch, an x-ray showed that R401's hip was fractured again. Guardian A said the incident was not reported and no one could tell her how R401 fractured her leg. Record review of R401's Electronic Health Record (EHR) revealed admitted to facility on 9/5/24 with most recent readmission on 10/22/24 with diagnoses which included fracture of unspecified part of neck of left femur, encounter for other orthopedic aftercare, and dementia. Review of the Minimum Data Set (MDS) dated [DATE] for R401 revealed severely impaired cognition and required substantial assistance for activities of daily living (ADLs). Review of R401's EHR revealed that R401 had documented falls in the facility on 9/19/24, 10/15/24, 10/27/24, and 10/28/24. On 1/14/25 at 1:05 PM Licensed Practical Nurse (LPN) D was interviewed and R401's care plan was reviewed. Review of R401's care plan revealed Problem start date 9/6/24 Category Falls Resident at risk for falls due to decreased mobility and poor safety awareness related to diagnosis of left hip fracture and dementia. Actual Fall 10/15/24. Edited 12/2/2024 by LPN D Goal Short Term Goal Date: 1/29/25 Resident will remain free from fall related injuries. Edited 10/31/24. Approach start date: 10/27/24 Obtain PT consult Created 12/2/24 by LPN D. Approach start Date 10/15/24 Occupy resident with music and crafts. Edited 12/2/24 by LPN D. LPN D agreed R401's actual falls on 9/19/24, 10/27/24, and 10/28/24 were not updated on the care plan and that the updates made were not timely. On 1/14/25 at 12:05 the Director of Nursing (DON) was interviewed and agreed R401's fall care plan was not updated timely and care planned/reviewed after each fall. Review of the facility policy titled Fall management Guidelines revised 8/30/2021 revealed in part .Residents identified at risk for falls will have a care plan developed and implement fall prevention interventions as needed based on their assessment. After each fall the licensed nurse will document the incident on: Events, 24 hour nurse report, nurses' notes, interdisciplinary post-fall assessment, charting in the nurses notes over the next 24 hours, update the care plan.

This citation pertains to intake MI00149358. Based on interview and record review, the facility failed to ensure staff reported an injury of unknown origin to the abuse coordinator for one resident (R401) out of four residents reviewed for injuries of unknown origin. Findings include: On 1/14/25 at 8:55 AM R401's guardian A was interviewed and said that on 11/16/24 a nurse from the facility reported to her that R401's leg was swollen and warm to the touch, an x-ray showed that R401's hip was fractured again. Guardian A said the incident was not reported and no one could tell her how R401 fractured her leg. Record review of the Electronic Health Record (EHR) revealed R401 admitted to facility on 9/5/24 with most recent readmission on 10/22/24 with diagnoses which included fracture of unspecified part of neck of left femur, encounter for other orthopedic aftercare, and dementia. Review of the Minimum Data Set (MDS) dated [DATE] for R401 revealed severely impaired cognition and required substantial assistance for activities of daily living (ADLs). Review of R401's progress note dated 10/15/24 revealed Resident ambulating in common area witnessed going on floor, staff assessed x-rays ordered. Review of R401's x-ray report dated 10/16/24 revealed displaced left femoral neck fracture (hip fracture). Review of R401's hospital report dated 10/22/24 revealed R401 had a left hip hemiarthroplasty (partial hip replacement of thigh bone) on 10/18/24 with full weight bearing. Review of R401's progress note dated 11/13/24 at 8:28 AM revealed Writer and oncoming nurse obtaining urine specimen observed resident left hip swollen warm and painful to touch applied ice oncoming nurse received order for x-ray. Review of R401's progress note dated 11/13/24 at 8:34 AM revealed Writer received resident with left hip swollen warm to touch and painful. Pain med given doctor and Director of Nursing (DON) observed left hip. Review of R401's progress note dated 11/13/24 at 8:55 AM revealed Doctor notified of stat x-ray results of left hip, fracture involving the left proximal femur with 11 cm displacement and 3.4 cm overlap (thigh bone fracture). Fracture occurs at the distal prothesis (below the partial hip replacement). On 1/14/25 at 12:40 PM Certified Nursing Assistant (CNA) B was interviewed and said she worked with R401 on the morning of 11/13/24, R401 stayed in bed and did not notice anything out of the ordinary. If something happened, I would have reported it to the nurse. On 1/14/25 at 3:46 PM CNA C was interviewed and said she worked the midnight shift on 11/12/24 to 11/13/24 and did not recall R401 having any falls, or injuries. Review of the EHR revealed the most recent fall was documented on 10/28/24 with no injuries noted. On 1/14/25 at 2:55 PM the DON was interviewed and said she was in the building when R401 was sent to the hospital due to femur fracture. The DON agreed the incident should have been reported as an injury of unknown origin to abuse coordinator. On 1/14/25 at 3:00 PM the Nursing Home Administrator (NHA) was interviewed and said no one reported R401's femur fracture on 11/13/24 as an injury of unknown origin. The NHA agreed the incident should have been reported to him and then reported to State Agency. Review of the facility policy titled Abuse and Neglect Prohibition Policy undated revealed in part .G. Reporting and Response 1. The staff will report all allegations of abuse, neglect, and misappropriation of property to the Administrator, immediately. 2. The facility will report all allegations and substantiated occurrences of mistreatment, abuse, neglect, misappropriation of property, or injuries of unknown source to the Bureau of Health Systems using the on-line form 362, immediately.

Based on observation, interview, and record review, the facility failed to notify and discuss a room change with a resident and their responsible party for one resident (R801) of one residents reviewed for room changes, resulting in R801 being moved to a new room without approval of the responsible party and the increased potential for transfer trauma (physical, behavioral, and emotional reaction to a sudden change in ones surroundings). Findings include: On 8/20/24 at 10:40 AM R801 was observed seated in a wheelchair in a private room on the 1st floor. During interview the resident said the private room was nice but missed being on the 3rd floor with friends. R801 said, They moved me because I was hanging around some girls. Nobody told me I couldn't have girlfriends. I didn't do anything, just hanging around them in their room. I won't hang around them anymore if I can go back upstairs. They didn't tell me nothing before, just moved me down here. According to R801's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with multiple diagnoses that included Parkinson's disease and major depressive disorder. The Minimum Data Set (MDS) quarterly assessment on 5/23/24 indicated the resident had moderately impaired cognition and no behaviors. R801 had no care plans for behaviors or wandering. On 7/10/24, Social Worker (SW) E documented that R801's family member was in the process of becoming the resident's Legal Guardian and paperwork was in progress. On 8/6/24 at 2:34 PM, a progress note written by the unit manager, Licensed Practical Nurse (LPN) A documented R801 was transferred to another room and the doctor was made aware. There is no documentation to support the resident (R801) or the resident's family member was made aware of R801's room change. On 8/20/24 at 12:15 PM, LPN A was asked about R801's room change. LPN A said that R801 was moved to the first floor because the resident was wandering into other resident's room without their permission. LPN A could not provide any documentation to support that R801 had wandered into other resident's rooms or had ever been redirected by staff from other resident's room. There was no care plan or interventions implemented to prevent wandering. LPN A acknowledged that she did not notify R801's family member of the resident's room change. On 8/20/24 at 2:20 PM, the Nursing Home Administrator was asked about room changes and said, It is our facility's policy to inform resident's family members when a resident's room is changes. On 8/20/24 at 6:10 PM, R801's family member said that he was unaware the facility had moved the resident to the first floor. The family member said he feels he should have been notified of this. They call me with other things that go on with him (R801). Nobody said anything about this to me. The resident's family member said he had paperwork that made him the resident's LG and was delivering them to the facility shortly. According to the facility's undated Room Change Policy in part; It is the policy of this facility to promote a resident's right to make choices and to promptly receive written notice of a room change or change in an assigned roommate. The facility supports the resident's right to refuse a room change made for the purpose of moving the resident into or out of a SNF or NF certified distinct part of the facility, solely for the staff's convenience Moving to a new room or changing roommates is challenging for residents. A resident's preferences should be taken into account when considering such changes. When a resident is being moved at the request of facility staff, the resident, family, and/or resident representative must receive an explanation in writing of why the move is required. The resident should be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. OBJECTIVE OF THE ROOM CHANGE POLICY The objective of the room change policy is to ensure that the resident is informed of an impending room change or assigned roommate. The intent of the room change policy supports each resident ' s right to refuse a room change in specific circumstances. The policy provides guidance to facility practices for room and roommate management and notification to residents and the resident representative. CENTERS FOR MEDICAID AND MEDICARE SERVICES (CMS) - DEFINITIONS The following are CMS definitions or clarifications from the Draft State Operations Manual Appendix PP effective November 28, 2016 Resident representative The term resident representative means any of the following: An individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications; A person authorized by State or Federal law (including but not limited to agents under power of attorney, representative payees, and other fiduciaries) to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications; Legal representative, as used in section 712 of the Older Americans Act; or. The court-appointed guardian or conservator of a resident. Nothing in this rule is intended to expand the scope of authority of any resident representative beyond that authority specifically authorized by the resident, State or Federal law, or a court of competent jurisdiction.

Based on observation, interview, and record review the facility failed to develop or implement a person-centered behavior care plan for one (R801) of three residents reviewed for care planning resulting in R801 not having a care plan for behaviors of wandering and the potential for psychosocial needs to go unmet. Findings include: On 8/20/24 at 10:40 AM R801 was observed seated in a wheelchair in a private room on the 1st floor. During interview the resident said the private room was nice but missed being on the 3rd floor with friends. R801 said, They moved me because I was hanging around some girls. Nobody told me I couldn't have girlfriends. I didn't do anything, just hanging around them in their room. I won't hang around them anymore if I can go back upstairs. They didn't tell me nothing before, just moved me down here. According to R801's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with multiple diagnoses that included Parkinson's disease, Paranoid Schizophrenia, and major depressive disorder. The Minimum Data Set (MDS) quarterly assessment on 5/23/24 indicated the resident had moderately impaired cognition and no behaviors. R801 had no care plans for behaviors or wandering. On 6/25/24 a Behavioral Care progress note written by Nurse Practitioner (NP) F in part reads: Social Work requesting evaluation for behaviors. Nursing reports resident is sexually inappropriate and steals from the nursing station and the snack room. On 8/6/24 at 2:34 PM, a progress note written by the unit manager, Licensed Practical Nurse (LPN) A documented R801 was transferred to another room on a different floor. A review of R801's progress notes, assessments, and care plans did not reveal any documentation of R801's behaviors or that interventions were implemented. On 8/20/24 at 12:15 PM, LPN A was asked about R801's room change. LPN A said that R801 was moved to the first floor because the resident was wandering into other resident's room without their permission. LPN A had no knowledge of the resident stealing snacks from the nurse's station or snack room. LPN A could not provide any documentation to support that R801 had wandered into other resident's rooms or had ever been redirected by staff from other resident's room. There was no care plan or interventions implemented to prevent wandering. LPN A acknowledged that a care plan should have been implemented for the resident's behaviors. On 8/20/24 at 2:00 PM Social Worker (SW) E was asked about R801's behaviors. SW E said the resident had started to wander into other resident's rooms and that it needed to be care planned. SW E was not aware that R801 did not have a care plan for behaviors and said, It should have been in there. I will look into that. SW E said she was new to the building and had no knowledge of the resident stealing from the nurses station or snack room. On 8/20/24 at 2:10 PM, the Director of Nursing (DON) was asked about developing and implementing care plans for residents. The DON reviewed R801's EHR and said, Yes, the resident should have had a care plan for the behavior of wandering. I don't know why it wasn't done. According to the facility's RAI and Care Planning policy dated 8/20/23, in part reads; As required at 42 CFR 483.25, the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and physical well- being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. 3. The overall care plan should be oriented towards: -Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities. -Involving resident resident's family and other resident representatives as appropriate. -Assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs. -Involving the direct care staff with the care planning process relating to the resident's expected outcomes. -Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting.

This citation pertains to intake MI00145652. Based on interview and record review the facility failed to review the Plan of Care (POC) and ensure adequate assistance when providing care for one resident (R4) out of four residents reviewed for falls, resulting in a fractured pelvis and hematoma to the head. Findings include: On 7/16/24 the State Agency received a complaint stating on 7/2/2024 at approximately 11:00 P.M. the on-duty nurse (LPN A) and the Director of Nursing (DON) called the complainant reporting someone was changing R4 and in the process R4 was dropped on the floor. The complainant indicated R4 was taken to a local hospital and was found to have a fracture in the pelvis. R4 passed away in the hospital on 7/12/24, 10 days later. On 7/24/24 at 1:40 P.M., review of R4's Electronic Medical Record (EMR) revealed a Progress Note that documented in part: . Called to room by Certified Nurse Assistant (CNA B) resident laying on left side on floor facing room window. Writer assessed resident, large size hematoma noted to left side of head, red in color. ROM performed on upper and lower extremities. Resident complained of pain to left hip. Neuro check initiated . Writer asked (CNA B) what happened (CNA B) stated I was giving care and resident rolled into me and I could not catch her in time and resident fell on to the floor . Review of the Care Plan: ADLs (Activities Daily Living) Functional/Rehabilitation Resident is receiving total assistance with ADL as evidenced by reduced mobility, incontinence related to my Diagnosis of dementia, congestive heart failure, glaucoma, Peripheral arterial disease and history of cardiovascular accident with right sided hemiparesis. Documented for Approach: Dated: 12/22/2021, provide me two-person assistance with bed mobility. Assist me with repositioning as needed and ensure call-light within reach. Review of R4's Minimum Data Set (MDS) dated [DATE], under section GG for mobility, indicated R4 was dependent meaning (Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of two or more helper is required for the resident to complete the activity.) On 7/24/24 at 3:30 P.M. the DON was requested to provide the facility's policy pertaining to bed mobility requiring two-person assistance. During this interview the DON was asked what did the CNA use to check the status of their resident for care? The DON responded, The plan of care (POC - Guide for staff when providing care for residents) is in the computer. The DON added, We did not know until several days later R4 had a fracture, we called and checked on her at the hospital. During an interview (via Telephone) on 7/25/24 at 10:11 A.M. with LPN A (nurse on the unit on 7/2/24), concerning the incident, LPN A reported R4 was a two person transfer but was not sure of bed mobility status of the resident. LPN A stated it was the responsibility of the assigned CNA caring for the resident to check and review the Plan of Care (POC) for their assigned residents. During an interview (via Telephone) with CNA B at 10:19 A.M. the nurse aide reported on the day of the incident R4's POC was not reviewed before caring for the resident. CNA B stated, she had previously provided care to R4 and always rendered care (repositioned in bed) alone or without another Aide. CNA B reported R4 was facing her in the middle of the bed, on the window side of the room. The resident made a jerking movement causing the resident and air mattress to slide. I could not hold R4 and the mattress. R4 fell on my feet and the resident's head struck the floor. CNA B stated afterwards the Director of nursing gave her an Inservice. On 7/25/24 at 11:52 A.M. the DON reported CNA B should have checked R4's POC located in the computer. During the investigation of the incident, the DON realized staff was not checking the status of the residents prior to providing care but the CNAs had access to the POC on the units. The DON stated staff was instructed during orientation to always check the POC before caring for the resident. The DON provided no explanation why the POC's were no longer being utilized to check the status of the resident before care. Review of a Resident Care Bed Mobility policy with a revision date of May 2023 was provided. The policy did not identify where, when, who or the frequency staff should check the POC status of residents. According to the Admission Face Sheet R4 was admitted to the facility on [DATE], with pertinent diagnoses of: Dementia, hypertension, congestive heart failure, Diabetes Mellitus, peripheral vascular disease, chronic anemia, and hygiene. The Minimum Data Set (MDS) dated [DATE], indicated R4 had Brief Interview for Mental Status BIMS (BIMS) score of 6, out of a total possible score of 15. R4 was dependent and required assistance of two staff members with bed mobility.

This citation pertains to intake MI00143701. Based on interview and record review the facility failed to readmit one resident (R609) to the facility upon discharge from a hospital. Findings include: Record review of the Electronic Medical Record revealed R609 initially admitted into the facility on [DATE]. R609 had a recent readmitted [DATE]. On 3/11/24, R609 was discharged to a hospital via a mental health petition for aggressive behavior. According to the complainant's intake statement, submitted to the State Agency on 4/2/24, I have contacted the Admissions Director to confirm the discharge date for (R609). I was told the patient could not return to the facility because (R609) was a danger to himself and others. The Guardian was not informed neither did the facility go through the proper procedure. (R609) is abandoned at the hospital and will not accept him back to his home, the facility. On 5/23/24 at 12:25 pm, Admissions Coordinator B was interviewed regarding the readmission policy and stated, When a resident goes to the hospital we have to take them back. At this time, documentation was requested regarding the refusal to accept (readmit) R609 back to the facility after hospitalization . On 5/23/24 at 1:15pm the Interim Director of Nursing (IDON) A was interviewed and stated, We didn't accept the resident (R609) back because he was a danger to himself and other residents. During this interview it was explained that the previous Administrator and DON had made the decision not to readmit R609 back into the facility. On 5/23/24 at 1:45 pm the currect Business Office Coordinator (BOC) C who served as the previous Admission Coordinator was interviewed. The previous Admission Coordinator/BOC C explained there was no documentation of a resident assessment regarding refusal of readmission. On 5/23/24 at 3:05 pm, the Nursing Home Administrator (NHA) A was interviewed and agreed there needs to be a documented assessment in the EMR of why the facility is unable to care for the resident and justification for the refusal of readmission. Review of R609's EMR revealed R609 was admitteed with diagnoses that included schizophrenia, epilepsy, and cerebral infarction. According to the annual Minimum Data Set (MDS) assessment, R609 had moderately impaired cognition and was independent with activities of daily living (ADLs). The MDS also documented the Resident and legal guardian participated in the discharge planning. There were no active discharge plans to return to the community and return to long-term care was anticipated.

This citation contains two deficient practice statements: DPS#1 This citation pertains to intakes MI00142304 and MI00142542. Based on interview and record review the facility failed to provide adequate supervision and follow elopement protocol for one resident (R12) who left the facility at an unknown time to staff. R12 was determined to be missing at 8:15 AM on 1/23/24. A moderately cognitively impaired resident with a BIMS of 8 left the facility with a recorded temperature of that day of 33 degrees Fahrenheit and raining. The facility was made aware R12 was at a city hospital at 11:23 AM. This resulted in the likelihood of serious injury, serious harm, serious impairment or death related to being struck by a motor vehicle and/or injury related to inclement weather. Further investigation of the incident revealed facility staff failed to supervise a cognitively impaired resident and respond appropriately to a door alarm (Emergency Door) on the Transitional [NAME] Unit. The alarm was tripped at approximately 1:45 AM, Security Guard W responded to the alarm and interacted with Certified Nurse Assistant X. However, the facility failed to activate procedures to search for a missing resident. Facility staff were unaware of R12 eloped from the facility for approximately 11 hours (from 1:45 AM to 8:15 AM on 1/23/24). The Immediate Jeopardy began on 1/23/24 when facility staff failed to supervise R12 leading to the R12 exiting the building without staff knowledge. The facility failed to respond appropriately to the alarm for the door triggered by R12. The NHA and the DON were notified of the IJ on 2/11/24 at 1:30 PM. The IJ was removed on 2/12/24, but noncompliance remains at a potential for harm due to sustained compliance that has not been verified by the State Agency. Findings include: A review of R12's Electronic Medical Record (EMR) revealed R12 was admitted to the facility on [DATE]. R12 had the following medical diagnoses: Paranoid Schizophrenia and symptoms and signs involving cognitive functions and awareness. A review of R12's Minimum Data Set (MDS) dated [DATE] revealed R12 had a Brief Interview of Mental Status (BIMS) score of 10/15 (moderate cognitive impairment). According to the MDS, R12 required supervision when walking more than 10 feet. According to the elopement risk assessment, dated 1/19/24, R12 was not considered an elopement risk. A review of the interview document for Security Guard (SG) W, obtained by the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 2/12/24, revealed, at approximately 1:45 AM a door alarm went off on Transitional [NAME] unit. I went to Transitional [NAME] unit and shut it off. I checked the doors to make sure they were shut. I looked outside to see if a resident was outside. I didn't see any resident. I immediately went to Certified Nurse Assistant (CNA) X and told her that an inventory of all residents needed to be done immediately. CNA X told me she had already done that an(sic) all residents were accounted for. On 2/11/24 at 9:46 AM R12 was queried regarding the incident that took place on 1/23/24. R12 was unable to give times during this interview. R12 said he woke and walked out the front door. R12 said he went on the public transportation bus on east 7-mile rd. that would transport him to [NAME] Avenue (Ave.). The public transportation bus dropped him off close to the [NAME] Theatre (on [NAME] Ave.). R12 said he then started to walk in the direction of what he believed to be as [NAME] Ave., but he ended up at the local market. R12 said he saw the local police and asked for help. The local police took him to the local hospital where he stayed for 3 to 4 hours before being transported back to the long-term care facility. On 2/11/24 at 12:14 PM the NHA and the DON were interviewed regarding the incident that took place on 1/23/24. The NHA and the DON explained between 7:30 AM and 8:00 AM, Licensed Practical Nurse (LPN) Z notified the DON that R12 was not in the building after a head count was conducted. The NHA and the DON said between 8:45 AM and 9:00 AM, a code 86 (elopement code) was called. The NHA and the DON said they were unaware how R12 left the facility but gave a hypothetical summary that R12 pushed on the emergency door near the Transitional [NAME] unit (the door unlocks after 15 seconds of pushing on the door) and walked to the public transportation bus stop holding area next to the facility. The NHA and the DON said from there they believed R12 got on the public transportation bus. The NHA and the DON said that R12 was identified as being found at 11:38 AM when called by the local hospital. R12 was transported back to the facility at approximately 1:00 PM. On 2/12/24 at 12:30 PM an attempt was made to contact SG W. SG W was not able to be reached for an interview. On 2/12/24 at 12:31 PM CNA X was queried regarding the elopement that took place on 1/23/24. CNA X said she heard an alarm go off because she was in the middle of caring for a resident. CNA X said when she was done, she went into the hallway and checked a couple of rooms on her unit. CNA X said she checked the door but did not see anyone outside. CNA X said that SG W shut off the door alarm when he came to see about the alarm. On 2/12/24 at 12:52 PM, during a follow up interview, CNA X explained that she was in a resident's room providing care when she heard the alarm sounding. CNA X said she was not sure what time the alarm went off. When she was done providing care for the resident see went to where the door was alarming (the exit door nearest to Transitional [NAME] unit). CNA X said she looked out the door and there were no footprints in the snow. CNA X said at that time SG W came up to her and asked what set off the alarm. CNA X said she told SG W she did not know and had never heard that alarm before. When CNA X was asked if she ever received any training on elopement drills, she said she had not received any formal training. On 2/12/24 at 9:52 AM during an interview with the NHA, the NHA said that it was her expectation that any time an alarm goes off the staff should report to the door and start a search, which should include a search outside the premises. The NHA said that she should be notified immediately of any suspected elopements. A review of the facility policy titled Resident Elopement, undated, revealed in part, All exit doors on each unit will be checked to ensure they are locked and secure every shift. Door security exit doors will be documented every shift per nursing assignment sheet. The facility policy did not mention what facility staff had to do when a door alarm was sounded. The Immediate Jeopardy that began on 2/11/24 was removed on 2/12/24 when the facility took the following actions to remove the immediacy: 1) Upon receiving notice of R12's elopement, beginning 2/11/24, the policy on elopement was reviewed by the Administrator and Director of Nursing and deemed appropriate. 2) Beginning 1/23/24, all facility staff education was initiated and is ongoing with a date of compliance of 2/12/24. All staff will be in-serviced via phone and in person. 49103 DPS #2 Based on observation, interview, and record review, the facility failed to prevent injury when allowing nursing staff to care for residents with long/artificial nails, resulting in injury to a resident who preferred to remain anonymous and the potential for further injury and discomfort. Findings include: On 2/11/24 at 3:43 PM, an annonymous resident was interviewed. Resident had a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition. The annonymous resident reported that some of the staff members who provide personal care wear long nails. The annonymous resident reported that during personal care there has been discomfort due to the sensation of nail scratching. The anonymous resident reported a scratch of the perineal (private area) area occurred which had been uncomfortable for days and had then healed. On 2/15/24 at 10:50 AM, a CNA (certified nurse assistant) K was queried about fingernails and the facility policy. K described the fingernails as acrylic. When asked about the policy, CNA K said the word short. CNA K was wearing painted acrylic nails extending approximately a quarter inch beyond the tip of the finger. On 2/15/24 at 11:00 AM, an LPN (Licensed Practical Nurse) J was queried about fingernails and the facility policy. LPM J described the nails as acrylic. When asked about the policy, LPN J said nails are to be short. Nurse J was wearing painted acrylic nails extending approximately a quarter inch beyond the tip of the finger. On 2/15/24 at 11:50AM, an LPN unit manager L was queried about fingernails and the facility policy. LPN L described the fingernails as acrylic. When asked about the policy L responded, I have been trying to get these off. LPN L was asked if it was the acrylic nails L was attempting to remove. LPN L answered yes. LPN L was wearing acrylic nails extending approximately one inch beyond the tip of the finger. A few had been removed revealing clean looking short nails. On 2/15/24 at 11:58AM, the contracted wound care nurse (WCN) M was queried about fingernails and the facility policy. WCN M said there was not a policy on nails with the company she worked for. WCN M was wearing darkly painted acrylic nails which extended over an inch beyond the tip of the finger. A review of the facility policy (undated and not titled), stated in part; Fingernail length is a clinical and safety issue for Employees and Residents. The standard for fingernail length is 1/4 inch from the end of each finger. Fingernails longer than the standard length are not permitted. Employees involved with direct patient care are prohibited from wearing artificial fingernails and extenders when providing care. On 02/21/24 at 11:34 AM, the Director of Nursing (DON) acknowledged the facility policy on fingernails and the concern of the policy not being followed.

Based on interview and record review the facility failed to ensure that the Medical Director (MD) attended the Quality Assurance and Performance Improvement (QAPI-program aimed on improving processes involved in health care delivery and resident quality of life) meetings quarterly, resulting in the potential for impaired resolution of identified issues or decreased quality of care with the potential to affect all 141 residents that reside in the facility. Findings include: During an interview and record review on 2/21/2024 at 12:32 PM, the QAPI program was reviewed with the Nursing Home Administrator (NHA). The NHA said that QAPI team members met monthly and included managers and interdisciplinary team members. When queried if the medical director attends the required quarterly QAPI meeting the NHA stated The medical director did not participate in April, May, or June of 2023. The NHA agreed the medical director is required to attend quarterly meetings. Record review of the provided QAPI attendance records dated April 2023 through June 2023 sign in sheets revealed the signature space next to the Medical Director title were blank. Review of the facility's QAPI plan with the NHA, Quality Assurance and Performance Improvement undated revealed in part , The QAPI program includes the establishment of a Quality Assessment and Assurance Committee and a written QAPI plan. The QA committee shall be interdisciplinary and shall consist at a minimum the director of nursing, the medical director or his/her designee .meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program.

Based on observation, interview, and record review, the facility failed to: 1. Maintain food service equipment in a clean and sanitary manner; 2. Ensure walls in areas where food was prepared were clean; 3. Store the ice scoop in a clean and sanitary manner; 4. Ensure food items past the use-by-date were not stored with active food stock; 5. Properly date-label food; and, 6. Maintain cleanable surfaces (knife storage area and floor underneath the can opener). These deficient practices have the potential to affect all residents who eat food served from the kitchen. Findings include: On [DATE] at 8:50 AM the kitchen was observed and the following was noted: Brown colored, scale-like material on the silver plating inside of the ice machine. Dried and crusted, grayish/brown sediment/debris on grease trap. Shiny, black debris observed in various areas around the kitchen walls near the sinks and stove area. The shiny, black debris was approximately -,d+[DATE] to 1 and ,d+[DATE] inch thick. The ice machine scoop was stored in a bin with brownish-gray colored film at the bottom of the bin. The scoop rested on top of a plastic disposable lid which rested on top of the film. Containers of cereal revealed the following use by dates for the cereal indicating expired cereals: -Cornflakes ,d+[DATE] -Rice Krispies ,d+[DATE] -Raisin Bran ,d+[DATE] The container with Froot Loops was undated. The knife storage had a white, flaky film. The surface was not easily cleanable. The deep fryer was stained with blackened residue. The oven/stove equipment under shield was stained with blackened residue. Seasoning were stored with the active food stock and the following was noted: -ground nutmeg expired date of [DATE] -whole basil leaves expired date of [DATE] -cinnamon and maple seasoning expired date of ,d+[DATE] The following seasonings were undated: -poultry seasoning -chicken seasoning -ground cinnamon, -onion powder, -garlic powder, -blackened seasoning -taco seasoning, -old bay, -ground cumin, -pickling spice, -rubbed sage, -poultry seasoning, -ground nutmeg, -steak seasoning, -ground pepper, -lemon pepper The industrial can opener was covered with a sticky reddish-brown material. The floor underneath the can opener was soiled with various layers and colors of debris. The surface was not easily cleanable. There were three loaves of bread opened and undated. On [DATE] at 11:00 am, Acting Dietary Manager (ADM) KK was interviewed regarding the identified concerns. The ADM KK observed areas of concern and acknowledged that the kitchen had not had a deep cleaning since they last had a porter. ADM KK explained that some of the stored cereals and seasonings were undated and outdated. ADM KK acknowledged the soiled areas in the kitchen, touched the material that was caked on the grease trap to reveal that it was soiled, and acknowledged some of the areas on the floor were not easily cleanable. ADM KK was asked to produce a cleaning schedule that involved the areas of concern and explained that it had been over a year since the last deep cleaning and that no documents could be produced at that time. Review of the facility's policy titled Sanitation-General dated [DATE], revealed, It is the policy of this facility to maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule.

This citation pertains to intake MI00134838. Based on observation, interview, and record review, the facility failed to ensure unrestricted, 24-hour visitation for all 141 residents residing in the facility. Findings include: A complaint was submitted to the State Agency that the facility limited the times when family could visit residents in their rooms. On 2/11/24 at 8:30 AM, during the initial entry to the facility, there was no signage observed posted at the visitor entrance regarding resident visiting hours. During an interview on 2/12/24 at 10:03 AM, Resident #244's Concerned Family Member LL said she was upset because she had been previously denied visitation with her mother when she arrived at the facility around 8:00 PM. The facility visitation policy was requested on 2/13/24 at 3:07 PM. On 2/13/24 at 4:13 PM, a facility document titled, Visitation Policy, dated 3/1/22, was provided by the Nursing Home Administrator (NHA). A review of the Visitation Policy documented in part the following: - It is the policy of the facility to provide residents with a safe and secure environment our visitation is from 11 AM to 8:00 PM. - When visiting outside of these hours we ask that the visitor inform the facility and notify the security desk. --- Hours are posted on the facility Doors. --- Inform the charge nurse, the Director of Nursing, and/or the Administrator if after-hours visiting is needed. --- Determine what special circumstances are needed to visit outside of normal visiting hours. During an interview on 2/14/24 at 11:18 AM, the NHA said visiting hours were from 11:00 AM to 8:00 PM. The NHA said that if someone wants to visit outside of those hours, that they would have to let the NHA or Director of Nursing (DON) know. The NHA or DON would then let the security officer know if a visit outside of the established visiting hours could be accommodated. On 2/14/24 at 4:30 PM, a sign observed posted at the entrance of the facility indicated visiting hours were from 11:00 AM to 8:00 PM. On 2/21/24 at 5:00 PM during the exit conference, the NHA and DON did not offer additional documentation or information when asked. 38230 R120 On 2/11/24 at 3:12 p.m. during the resident representative (family member) interview for R120, the family expressed being angry following the resident's most recent fall which resulted in being transferred to the hospital. Out of concern, the family member wanted to come to the facility to see the resident before going to the hospital. The family member said they were told no and had to wait until visiting hours (after 11 am). The family member said visiting hours are 11 am- 8 pm and added some nurses will allow visitors to stay longer. The family concluded the interviewing by saying, I was very angry I was denied seeing my mother when she had an emergency. What if that could have been the last time to see her? On 2/12/24 at 4:47 p.m. [NAME] Clerk GG on the second floor was interviewed and said visiting hours are 10am -8 pm. The facility is lenient on the times though. On 2/12/24 at 4:49 p.m. Security Personnel HH on the afternoon shift (3 pm- 11 pm) was interviewed and said visiting hours are from 11am -8am Monday through Sunday. If family's wanting to come earlier, they need to call management and plan ahead of time.

This citation pertains to MI 708. Based on observation, interview, and record review, the facility failed to provide adequate monitoring and supervision to prevent an elopement from the facility for one sampled resident (#11) out of three residents reviewed for elopement, resulting in the elopement of a resident from the facility without staff being aware, due to a disabled alarm on the second-floor staircase and on a door which exits the building. The resident was located wearing a jacket, sweatpants, skull cap, and house shoes. According to the website world-weather.info, the low temperature on this date was 25 ºF (Fahrenheit) with a RealFeel temperature of 14 ºF, resulting in the likelihood for serious injury, harm, and/or death. Findings include: The Immediate Jeopardy (IJ) started on 2/27/2022 and was identified on 3/16/2022. Nursing Home Administrator (NHA) A was notified of the IJ on 3/16/2022 at 2:36 PM and was asked for a plan to remove the immediacy. A review of Intake MI 708 revealed the following: Incident Summary: On 2/27/22 around 6:30 AM, (Resident #11) [R11]) was observed on the 2nd floor in the common area with his coat and hat stating that his son was picking him up for church. The resident's son was contacted to confirm the leave of absence and son stated that he was in the hospital and that the resident does not have a church home. (R11) was informed that the son was not picking him up and resident returned to his room. The nurse noticed that the resident wasn't in his room around 7:15 AM. The staff checked the 2nd floor unit and contacted the security guard to call an elopement code. Two staff members drove the car around the outside premises and identified the resident on [NAME] Street. The resident was returned to the facility by 8:30 AM. (R11) was assessed with no signs and symptoms of injury. Resident's care plan was updated and added to the elopement binder. The administration began in house investigation and elopement in-service. During an interview on 3/16/2022 at 8:10 AM, front desk Security Guard (SG) D stated, We have a 24-hour operation. Security has to let you out of the building (when exiting from the front door). SG D identified a back door that staff use and said employees have to swipe their identification (ID) badge to get in and out of the back door. Keypad codes and ID badge swipes are used to access the stairwells. SG D identified Maintenance Supervisor (MS) E as the person over security in the building. During an interview and observation on 3/16/2022 beginning at 8:25 AM, MS E stated, One door was unsecured (when R11 eloped). Since then, we check all the doors every day. MS E said that through video surveillance it appeared R11 exited the second-floor housing unit via the Stair 8 door. MS E explained a push/panic bar is used to open the door. A magnetized bar at the top of the door prevents the door from opening when the push/panic bar is pushed. The magnetized bar is demagnetized when the emergency exit button is pushed, or staff swipes their ID badge in the badge swipe device. The magnetized bar is also deactivated during a fire alarm. An observation was made when MS E pressed the push/panic bar on the Stair 8 door. The door opened with no resistance and no alarm went off. MS E stated, Someone pushed the emergency button and didn't pull it back out. The door should be magnetized and unable to be opened. During an interview and observation on 3/16/2022 at approximately 8:55 AM, the staircase from the Stair 8 door was observed with MS E. This staircase leads to a door which exits the building. MS E identified the code used on the door to exit the building. MS E said when the code is used on a door that exits to the outside of the building, it deactivates the siren for that door. The code must be reentered to reactivate the siren. MS E said the door alarm annunciator (the alarm which sounds when a door opens) broke a few days prior to R11's elopement. During an interview on 3/16/2022 at 12:38 PM, Licensed Practical Nurse (LPN) F, said she was the person that found R11 after he eloped from the facility. R11 was wearing a jacket, but not a big jacket, skull hat, jogging pants, gripper socks, and thick house shoes. He did not have on gloves or a scarf. R11 was sitting on a bench and when asked where he was going, R11 pulled out a flyer for a church. During an interview and observation on 3/16/2022 at 2:30 PM, R11 was observed leaving the first-floor activity room, going into a nearby men's bathroom, and using a wheelchair for mobility. R11 told Activity Assistant M, I need to use the bathroom. When R11 returned to the activity room, he stated, The nurses told me to use the wheelchair, so I don't fall. (The use of a wheelchair) is okay because when I get ready, I'll just get up and walk. Regarding the day R11 left the building, he stated, I told the nurse I wanted to go to church. She told me to wait but she never got back with me after a long time. So, I left. During an interview on 3/17/2022 at 8:13 AM, Therapy Director (TD) N stated, We provide all residents with wheelchairs for transport. Everyone is given a wheelchair upon admission, but we want to promote independence. On 12/10/2020 when (R11) was discharged from therapy, he was walking over 150 feet. He hasn't been identified as a resident with a decline in functioning. The wheelchair was for transport only. He should use a wheelchair to come to activities on the first floor. A review of the clinical record for R11 revealed an admission to the facility on [DATE] with diagnoses that included Alzheimer's Disease. A Minimum Data Set of 2/9/2022 documented moderate cognitive impairment and supervision with setup help only for mobility about the housing unit. Nursing progress notes documented the following: - 2/27/2022 at 5:00 AM (created 2/27/2022 at 9:55 AM): Resident ask writer can he go to church. writer explained to resident we need a doctors order. Resident states he was responsible for himself and son was picking him up for church. Resident return to room. - 2/27/2022 at 5:40 AM (created 2/27/2022 at 10:02 AM): Resident approach fell ow nurse at nursing station stated his son was picking him up to going to church. fell ow nurse explained to resident facility must be notified by family and doctors before leaving facility because were still responsible for me. Resident stated he signed himself in here and he can sign himself out. Resident stood at nursing station for a minute while Nurse was still at nurses station. Staff called security to let them know to be on the look out if he tries to leave. Resident return back to room. - 2/27/2022 at 6:01 AM (created 2/27/2022 at 10:02 AM): Writer return to resident room to make sure he was in his room. Writer observed resident in his bathroom. - 2/27/2022 at 7:15 AM (created 2/27/2022 at 10:14 AM): Writer went to resident's room to check on whereabouts. Resident not observed in bed, knock on bathroom's door and no response, open door, no resident present. Writer ask roommate if he has seen resident, roommate response NO. Writer start searching immediate area and went to front and ask all staff to start searching immediately for resident. Called fell ow nurse for assist and notify security to call code 86. Administrator notified of alleged elopement of resident, unable to be located in facility. - 2/27/22 at 7:55 AM (created 2/27/2022 at 10:36 AM): Resident found by fell ow Nurse on [NAME] & [NAME] sitting at the bus stop. Stated he was going to church and showed the card of where he was trying to go. Resident returned to facility with extra blanket in a w/c (wheelchair). Skin assessment performed skin intact. Resident stated he did not fall and denies pain and discomfort. Writer added another pair of sock hat and gloves and to blanket for warmth. Also gave him a cup of tea. Adequate capillary refill to finger and toes pink in color. Oncoming staff informed of elopement and continue to Monitor resident whereabouts Q15 (every 15) minutes for day shift. reduce to Q30 (every 30) minute if no elopement attempts for afternoon shift. Q (every) 1 hr (hour) monitor for MN (midnight) if no elopement attempts. A facility policy titled, Resident Elopement, dated 8/17/2020, was reviewed and documented in part the following: - It is the policy of the facility to provide residents with a safe and secure environment and identify resident who may be at risk for unplanned exit from the facility. A written plan for removal for the immediate jeopardy was received and verified on 3/17/2022. 1. Resident #11 has been assessed, is stable, and continues to reside in the facility. 2. Nursing staff will verify for all resident care areas that all facility door alarms are functioning and in armed status each shift, daily. 3. Facility completed installation of door alarm annunciators for all doors that lead outside of the facility on March 16, 2022. Annunciators ensure that increased pitch will sound if the door is opened send an alert the security desk to provide secondary level of assurance that doors remain secure. 4. Installation of additional alarms on all staircase doors on the 2nd and 3rd floor to prohibit anyone from disarming or stopping the sound of the alarm without resetting the alarm door. 1st floor exit doors must continue to be able to open with force. 5. Completion of review, revision (if necessary), and re-education of all staff on facility Elopement Policy on March 17, 2022. 6. Continue general monitoring of door alarm status to ensure armed and functioning by designated Maintenance Department personnel at least twice per day. 7. Removal from the workplace of any staff known to be non-compliant with facility Elopement Policy or facility security measures in place to prevent elopement. Although the Immediate Jeopardy was removed on 3/17/2022, the facility's deficient practice remained isolated with the potential for harm that is not immediate jeopardy.

Based on observation, Interview and record review the facility to prevent and accident for one (#904) of three residents reviewed for falls, resulting in the resident sustaining a left clavicle fracture and a hemotoma of the head. Findings include: This citation pertains to Facility Reported Intake: 933 Intake number M 9886 Per the facility's Investigation Summary dated: 2/3/2020, reviewed 2/19/2020 at 1:00 P.M. On 2/1/2020 Nurse Aide E was providing Activities of Daily Living (ADL) care to R#904 around 5:00 A.M.R#904 was lying in bed on top of an air mattress. Nurse Aide E turned the resident on his left side to remove the soiled linen, the mattress shifted, and the resident rolled off the bed on the floor between the two beds. The resident fell face down. The resident's Foley tube came out during the fall. Nurse Aide E immediately called for assistance while staying with the resident. Nurse F responded immediately and went to the room and observed the resident lying face down on the floor. The resident was assessed by Nurse F, provided first aide to the forehead, administered neuro check and range of motion to upper and lower extremities, identifying decrease Rage of Motion ( ROM) to the left extremity. Resident was assessed as being alert and oriented to self and denied pain. The physician, family and Director of Nursing was contacted. Orders were obtained from the physician to transfer R#904 to the hospital for CT scan to rule out internal bleeding. R#904 was readmitted to the facility on [DATE] around 1:40 P.M. with a new diagnosis of fracture of left clavicle with hematoma ( a localized collection of blood, usually clotted) to the left aspect of the head. On 2/19/2020 at 1:30 P.M. review of the Face Sheet for R#904 indicated the resident was admitted to the facility on [DATE], with diagnoses of: [CONDITION(S)], amputation of limb, partial traumatic amputation of the right lower leg, [CONDITION(S)], end stage renal disease, dysphagia, retention of urine, pressure ulcer of sacral region (Stage 4), dysphagia, retention of urine, diabetes mellitus with foot ulcer and weakness. According to the Minimum Data Set (MDS) dated [DATE] stated R#904 had a Brief Interview for Mental status (BIMS) of 13 (Cognitively intact for thinking), and the resident was totally dependent on staff for bed mobility with two-person physical assist. The Falls Care Plan initiated 9/7/18, with a revised date of 2/4/2020, did not identify R#904 as a 2 person assist with Bed Mobility and transfers until after the fall on 2/1/2020. On 2/19/2020 at 1:50 P.M. R#904 was observed in an extra-large bed. The resident appeared alert and oriented with limited details of the fall. The resident stated, he remembered the fall and he fell in between the beds in the room. The resident explained Nurse Aide E had assisted him in trying to reposition himself in a bed (different than the present one) and the Aide stood in back of him and he had nothing to hold on, so he rolled off the bed onto the floor. On 2/19/2020 at 3:00 P.M. during an interview with the Administrator and Nurse K (Inservice Director/ SDC) concerning the resident's fall the nurse stated, Nurse Aide E had not fully assessed the position of R#904 in the bed before trying to reposition the resident on an air mattress with an amputation. The Nurse explained the fall was a result of improper techniques used for repositioning . Nurse Aide E thought she could turn R#904 alone when there should have been two assisting with the repositioning. Nurse Aide E should have rolled the resident toward her or another staff member . The resident should not have been rolled away from her. The air in the air mattress shifted during the positioning and the resident rolled out of the bed. R#904 should have been positioned in the middle of the bed with another staff. When asked, why didn't the Nurse Aide obtain help from other staff on the floor? Nurse A commented, Nurse Aide E stated, everyone was busy with there on set of residents. The Inservice Director/SDC and Administrator stated, after the incident with R#904, reeducation of all staff was initiated with a returned demonstration and Nurse Aide E was being monitored for four weeks for turning and repositioning weekly for four weeks.

This citation pertains to intake MI : Based on observation, interview, and record review, the facility failed to adequately supervise one resident (#801) from a total of 5 sampled residents reviewed for elopement when Resident #801 eloped and exited past security personnel stationed at the front entrance at 3:20 PM on 7/2/17. The resident was observed walking down Warren Avenue by an off-duty employee who alerted staff who searched the area for the resident and found the resident at a local store. The resident was returned to the facility at 3:40 PM on 7/2/17. Staff failed to properly assess the resident following the elopement incident increasing the risk for continued elopement incidents. This deficient practice placed the resident risk for the potential of bodily harm and/or death. The Immediate Jeopardy (IJ) was identified on 7/6/17 at 9:45 PM and the Administrator was asked for a plan of removal of the immediacy on 7/6/17 at 11:25 AM. The IJ was removed on 7/10/17 at 9:20 AM, based on the facility's implementation of the plan of removal as verified by the surveyor. Although the IJ was removed, the facility's deficient practice was not corrected and remained isolated with no actual harm with the potential for more than minimal hare that is not immediate jeopardy. Findings include: On 7/5/17 at 8:00 AM, a review of the facility's MI-Acts Incident report stated, Resident #801 is an alert and oriented X 3. Resident [DIAGNOSES REDACTED]. Resident is ambulatory. Resident is his own responsible party. Resident was attending church service in the 1st floor dining around 2:30 PM. Resident left the church service and exited the building. Resident report that he left the building to go get popcorn from the store. Resident report that he didn't ask or tell staff because he knew he would be told no. Resident is identified by staff walking down Warren street around 3 PM. The staff member went to facility to get additional assistance and resident was picked up from the store and brought back to the facility . On 7/5/17 at 8:17 AM, a review of the clinical record revealed that Resident #801 was admitted into the facility on [DATE] and re-admitted on [DATE]. Resident #801 had diagnoses that included Congestive Heart Disease, End-stage Renal Disease, Syncope and Collapse, and Alzheimer's Disease. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #801 had moderately impaired cognition and needed limited assistance with ambulation. A further review of the clinical record revealed the following information: - State of Michigan Probate Court County of Wayne, Letter of guardianship, dated 5/7/15, Resident #801, Legally Incapacitated Individual. The document awarded 2 individuals Co-Full guardianship of Resident #801. - A nursing care plan, dated 2/3/17, stated, Return to Community Referral - Discharge plans are uncertain at this time. Its recommended LTC (long-term care) will be required. Resident was not able to remember to return home. Requires more supervision. - A psychological evaluation, dated 2/22/17, stated, .he is pleasant, cooperative, but confused when seen today .oriented to person, but not to place or time .had difficulty with both recent and remote memory .A cognitive screening task (MMSE- Mini-Mental State Examination) was administered, and patient scored 10 out of 30 items administered, indicating significant impairment in memory and cognition .Judgement and Insight both impaired .Pt requires significant support due to cognitive decline. - The Resident Elopement Assessment tool was reviewed; A total score of 10 or higher is at risk. The assessment, dated 1/18/17, documented that Resident #801 scored a 9, was alert and oriented X 3 (oriented to person, place, and time). The elopement assessment, dated 7/2/17, the day Resident #801 eloped from the building, the facility gave him a score of 6 and stated Resident #801 was alert and oriented X 3, did not have Dementia or Alzheimer's, and had no history of elopement. The review of the nursing notes, dated 7/2/17, in the clinical record, revealed the following: - 2:45 PM, Pt (Patient) observed in church sitting in chair. - 3:05 PM, Pt observed outside of facility. Writer and oncoming nurse ran outside of facility. - 3:15 PM, Two activity employees observed outside with pt. Pt. assisted back into facility. Pt. stated, I wanted to get popcorn and I didn't know if you would let me go. Pt denies pain . On 7/5/17 at 8:04 AM, Resident #801 was observed in the second floor dining room waiting to be served breakfast. Resident #801 was asked about leaving the building and stated, I went to the store to get some popcorn and then I came on back. They (facility) ran out. I didn't know I couldn't leave. If I'd known that I wouldn't have went. Resident #801 was asked who he informed that he was leaving. Resident #801 stated, I told the man at church. Resident #801 was asked if he had told a staff person. Resident #801 stated, No. I didn't see anyone. On 7/5/17 at 11:00 AM, the Administrator presented the facility's investigation. The Administrator stated, He stayed on the Transitional Unite (1 East) and was in the Courtyard dining room for church. He was headed down to the gift shop when an activity person (Activity Aide C) saw him and told him the gift shop was closed. He went back to the unit. He usually is all over the place, but he has never tried to get out. He will sit outside the gift shop. On the video, we saw him go down the hall, in front of the security desk, to the Rose Garden Exit. He came back down the hallway and walked out of the building. The security guard was at the desk when he walked out. He was not an elopement risk. On 7/5/17 at 11:35 AM, the video footage was reviewed with the Administrator and Maintenance Director. The video showed Resident #801 walked past the security desk toward the Rose Garden Exit. A few seconds later, Resident #801 was observed on video coming back down the hallway in the direction of the security desk, turned left and exit the building at 3:20 PM. The security officer who was seated in a chair behind a counter, with a wall in front of it, had visitors that were signing in. Other residents in wheelchairs were observed to rolled by the desk unquestioned. The Administrator revealed it was Officer E that was on duty that day and offered no explanation how Resident #801 exited without his notice. The Administrator revealed it was Activity Aide C and D that brought the resident back to the facility. At 11:56 AM, Activity Aide C was asked about Resident #801's elopement. Activity Aide C stated, Activity Aide D and his wife were riding past (the facility) and thought he (Resident #801) looked familiar. Further review of the video showed at 3:28 PM, Activity Aide D, identified by the Administrator, came into the building, stopped at the security desk and went down the hallway. At 3:30 PM, Activity Aide D and Activity Aide C are observed to leave the building. At 3:33 PM, two nurses left the building. At 15:40 PM, Resident observed entering the building with staff. On 7/5/17 at 12:37 PM, during an interview, Activity Aide D was asked about Resident #801's elopement from the facility. Activity Aide D stated, I was driving by with my wife down East Warren and he (Resident #801) was walking with his cane when I saw him. I didn't say anything to him because I didn't want to scare him. I pulled over and called the building. I didn't get anyone. We have an answering machine on the weekends and it went to voicemail all three times I called. By this time, he was at Davita (Dialysis Center). He had not made it to the store yet. I came over to the building and told the guard and I went to the nursing station. (Activity Aide C) went with me. We didn't see him (on the street). So I dropped (Activity Aide C) at the Dollar Tree and I went to the store behind Davita. They (store personnel) said 'he had just left, that he wanted popcorn, but we don't sale popcorn'. I knew he was at the Dollar Tree. He was actually in the popcorn aisle when we saw him. We drove him from the Dollar Tree to the nursing home. There were 3 nurses standing there waiting for us when we arrived . On 7/5/17 at 12:45 PM, Activity Aide C stated, (Activity Aide D) came in and asked me if Resident #801 was on a LOA (Leave of Absence). I told him to stop playing. He said I'm serious. He (Activity Aide D) went to the nursing station and asked if he (Resident #801) was on a LOA and the nurses told him 'No' he is in his room. At 1:30 (PM) me and him (Resident #801) had a conversation. He was going down the hall to the gift shop for popcorn and I told him the gift shop is closed on the weekends. He turned around and went to the dining room. We were getting ready to have church, which was scheduled for 2 (PM). They were setting up. He left at approximately 2:20 (pm). They hadn't started church yet. They were setting up. I remember him being there because he sat at a table by the door that goes to the nursing unit. I had to put up some calendars and he was sitting by that wall. As a matter of fact, he helped me hang them by holding it. On 7/5/17 at 1:30 PM, a review of the facility investigation revealed that Nurse H and Certified Nurse Aide (CNA) I were assigned to care for Resident #801 on 7/2/17 on the afternoon shift (3-11 PM). At 4:41 PM, CNA I was called on the telephone and asked about Resident #801's elopement. CNA I stated, I came on the floor and he (Resident #801) was not in his room. I thought he must have been in church, until they brought him back. I had figured he was with his family. He must have got out of church and left out the building. I didn't see him at all until they brought him back. I figured he was with his family. Normally, if he is not there, he is with his family. I never thought he would be wondering around and leave out the building. CNA I was asked if she checked with the nurse to be sure he was on a LOA. CNA I stated, I didn't check with the nurse to see. He is usually either with the daughter or his wife. On 7/5/17 at 3:47 PM, Security Officer E was asked about Resident #801's elopement. Security Officer E stated, It was the 2nd. He is up and down the hallway all the time. Did I notice anything? Not at all. A lot of resident are up ad down the hall and go out to enjoy the sun, usually the front doors. Security Officer E was asked if Resident #801 said anything to him before he left the building. No. I did not notice the resident go out the front door. I didn't give him permission to go the store .I can hardly see a wheelchair patient if someone is standing here like you are, in front of the officer, on the other side of the counter, with a wall in front of it. On 7/5/17 at 4:59 PM, during a telephone interview, Nurse H, day shift nurse (7-3:30 PM), was asked about Resident #801's elopement. Nurse H stated, He is alert and oriented X 3, he had no mental status change .He told me he would be attending church. Last time I saw him he was in church. Nurse H was asked if she and the on-coming nurse had made rounds at the change of shift and located all the residents. Nurse H stated, I walked and looked at the residents before she (the nurse for 3-11:30 PM shift) came, during my last rounds. I guess she did too (made her own rounds). We did not do it together. I had just handed her the keys (to the medication cart). We were just starting to do narcotic count when they came up and said he (Resident #801) was outside . On 7/6/17 at 12:56 PM, the Director of Nursing (DON) was interviewed and asked about Resident #801's elopement, the end-of-shift nursing practice, elopement assessment, nursing care plan, psychology notes, guardianship papers, and MDS. The DON stated, He told me he liked popcorn and that 'I went to get me some popcorn'. My practice is for them (nurses) to do walking rounds rather that sit at the desk. Walking rounds is what they know to do. I wanted to know the condition of the resident you are leaving me. The DON was informed the nurses did rounds separately. The DON stated, They shouldn't be doing it that way. She (Nurse H) knows better. I like them to do it together and see how the CNA's are leaving that patients. The CNA's are supposed to make rounds. They are supposed to know where the residents are and locate the resident. She should have asked the nurse (when Resident #801 was not seen in his room). The DON was asked about the Activity Aide leaving the resident on the street when he observed him. The DON stated, He should have approached the resident and find out where he is going. If the resident is approachable, and Resident #801 is, and try to assist him back to the facility. Resident #801 knew he shouldn't have left the facility. He stated, He wasn't sure they would let me go. At 1:18 PM, the elopement assessment, nursing care plan, psychology notes, guardianship papers, and MDS in the clinical record was reviewed with the DON. The DON was shown the cognition assessment on the guardianship papers, the above psychological note, and the MDS that documented Resident #801 had cognitive impairment and compared it to what was documented on the elopement assessment, that documented the resident was alert and oriented X 3. The DON stated, Oh. I see. The DON revealed there was no elopement care plan. The facility's Resident Elopement policy, revised 5/3/16, was reviewed with the DON, that documented 1. Upon admission, residents will be assessed for elopement risk using the Resident Elopement Assessment. 2. Residents will be assessed quarterly, with significant change, and as needed . The DON reviewed the elopement assessment for Resident #801 dated 1/18/17 and 7/2/17, and revealed the assessment that was supposed to have been done in April 2017 had not been done. The DON revealed she was not sure who was supposed to do the quarterly assessment, the MDS Nurse or the floor nurses. The 7/2/17 elopement assessment that documented Resident #801 had never eloped from the building, had no diagnoses of dementia or Alzheimer's, the DON revealed had been completed by her. The DON revealed she had looked at the question wrong. The DON revealed if Resident #801's impaired cognition had been recorded on the initial elopement assessment (1/18/17), the assessment tool would have revealed that Resident #801 was an elopement risk and a care plan would have been developed. On 7/6/17 at 11:00 PM, the facility provided the following removal plan for the immediate jeopardy regarding the failure to prevent the elopement of Resident #801 on 7/2/17. IJ Removal Plan: 1. On July 2, 2017, The Administrator is contacted by (off duty employee) at 4 PM and informed that he identified Resident #801 walking down East Warren Street. The Administrator contact the Director of Nursing. Resident# 801 was admitted on [DATE]. Resident #801 has a legal guardian. Resident #801 [DIAGNOSES REDACTED]. Resident is alert and oriented 1-2 with confusion. Resident is independent of ADL's with minimum oversight. Resident is ambulatory with an assistance of a cane. Resident is seen by Psych services and currently taking Celexa. Resident was last seen by facility staff at 2:30 in a church activity. Resident departed from church activity without assistance from staff walking toward the nurse station. Resident left the nurse unit without staff awareness. Resident preceding toward lobby area and eloped out of front entrance door without being questioned by security at 3:20 PM. An off duty staff observed resident walking down Warren. Staff alerted floor nurse and the activity worker assisted off duty employee with getting resident back to the facility. Resident #801 was picked up at the local store. Resident returned at 3:40 PM and reported no signs or symptoms of pain or reported any infliction of harm. The resident is assessed by the nurse on 7/2 and no injuries noted. Resident is transferred from the 1st floor to the 2' floor for additional safety. Resident is unable to leave the second floor unless supervised and staff release elevator with badge. Resident elopement assessment is completed and picture added to the elopement book. The elopement book was reviewed and updated (Resident #801 picture added) on July 2. There were a total of 12 residents at risk for elopement in the facility. The physician, family, administrator and DON are notified of the elopement and in house investigation began immediately. The Nurse Supervisor and DON interview and educate the resident, staff (PM and midnight shift) on the Elopement Policy, Resident# 801 is referred to psych services and seen on 7/5. Resident shows no signs of distress and continues to participate in the daily activities of living with supervision. On 7/2 the resident is educated on the elopement policy/leave of absence policy and he verbalized understanding. On July 6, the Interdisciplinary review resident #801 chart and the elopement assessment is updated and care plan created. 2. On July 2, Like residents are identified and care plans are updated on 7/2 and 7/6. On July 3, The Interdisciplinary team reviewed Elopement Policy and deem appropriate. On July 6, an Emergency Resident Council is held on 7/6 at 3 PM to educate residents on the Elopement Policy and the importance of signing in and out on the unit. Like residents were in attendance. On July 6, the interdisciplinary team re-assess the like resident's elopement assessment's and care plans and update as necessary. On July 6, The Director of Nursing and the clinical management team receive a 1:1 in-service from the Staff Development Nurse and the Administrator regarding properly completing the resident elopement assessment. The DON and clinical management team demonstrate and verbalize understanding. On July 6, the nursing staff receives in service on properly completing the elopement assessment. Resident will be assessed upon admission, quarterly and as needed. The elopement assessment will be checked by clinical manager team for accuracy. 3. On July 2, the administration began in-servicing all employees on procedures of signing residents out /in on the unit, during leave of absences, when attending activities or therapy sessions. Nursing staff are educated on physical head count and the importance of resident location. The Activity staff is in-serviced on notifying the nurse and documenting when taking and returning residents from an activity to the unit. The activity staff will notify nursing for assistance when a resident depart early from an activity. 4. The security staff/staff is educated on notifying nursing when residents are identified unaccompanied in the lobby area. The employee break room door will be secured to deter resident entrance (device ordered on 7/5). On July 6 at 5 PM, Administration added additional staff to sit at entrance door to ensure that no resident leave the facility unsupervised and without signing out of the facility. The staff member will monitor the front entrance door from 8 am to 8 PM daily. 5. The Administrator/designee will monitor for usage of all signage sheets and proper resident head count 2-3 times weekly x 4 weeks. Findings will be reported to QA for continued compliance.

This citation pertains to intakes #MI 924, MI 077, MI 091. Based on observation, interview and record the facility failed to implement mobility interventions consistent with plan of care and policy for one of three residents (701) sampled for falls, out a total sample of three residents, resulting in resident 701 falling from bed during care incurring distal left femur fracture and increased pain. Findings include: Review of the record on 09/12/14 at 11:30 am revealed the following documents: A face sheet dated 09/05/14 that indicated resident 701 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. An unusual occurrence report with multiple dates (last signed September 2014) that indicated, on 08/28/14 at 4:20 am, resident 701 fell in her room and physical assessment revealed complaints of left leg pain. This report indicated resident 701 was transferred to the hospital emergency roiagnom on [DATE]. This report indicated certified nurse aide (CNA) "A" was a witness to the event. An investigation of occurrence report signed 08/29/14 by the director of nursing (DON) that indicated, on 08/28/14 at 4:20 am, resident 701 was "being turned and incontinence care being provided" by CNA "A" while resident lay in bed. This report indicated CNA "A" instructed resident 701 to assist "by pulling herself over with the assist bar". This report indicated resident 701 "began pulling herself over" with the help of CNA "A" and resident 701's legs "began going over the edge of the bed" and resident 701 rolled off the edge of bed to the floor. This report indicated resident 701 had swelling above the left knee, pain with touch, and reported poor pain control. This report indicated resident 701 was transferred to a hospital emergency room for further medical evaluation and it was confirmed that resident 701 incurred a distal fracture of the left femur. Radiology report dated 08/28/14 that indicated resident 701 had fracture involving distal femur with mild displacement, with conclusion of, acute left femur fracture. A written statement by CNA "A" dated 08/28/14 that indicated CNA "A" was "changing" resident 701 and asked resident 701 to "roll on side" and resident 701 rolled completely out of bed. Recommendation for disciplinary action form dated 08/28/14 signed by the DON that indicated CNA "A" provided care to resident (701) not in accordance with care card which resulted in resident (701) rolling out of bed and sustaining a fracture. Reeducation record dated 08/28/14 that indicated CNA "A" was noted having violated work rules for care card not read, poor positioning during turning, and failure to get assistance. Minimum data set assessment ((MDS) dated [DATE] that indicated resident 701 had brief interview for mental status score (BIMS) of 11 (moderately impaired cognition) and was totally dependent on staff for bed mobility and transfer needs and required the physical assistance of one person for bed mobility and two persons for transfers. This assessment also indicated, under functional limitation in range of motion section, resident 701 had impairments to both upper and lower extremities. A care plan for skin breakdown with start date of 07/18/14 that indicated, under problem section, resident 701 was at risk for skin breakdown related to decreased mobility, as well as other reasons, and had a specialty bed. This care plan indicated, under approaches section, to turn and reposition frequently and to use two people. Resident care guide (undated) that indicated, under mobility section, that resident 701 required 2 person assist. Physician orders [REDACTED]. The facility policy/procedure entitled "Positioning The Resident" dated October 2010 was reviewed. This policy indicated, under procedure section, "ALWAYS OBTAIN HELP WHEN NEEDED". This policy also indicated, under section 6. entitled "TO TURN RESIDENT ON SIDE:", "c. Adjust legs; near leg over far leg.", and "e. Flex upper knee to keep resident from rolling on abdomen." Attempts to interview resident 701 on 09/12/14 at 9:05 am were unsuccessful as the resident could not provide any relevant information related to the incident. During this interview attempt resident 701 appeared to be grimacing in pain and was slow to respond to questions. During an interview with certified nurse aide (CNA) "A" on 09/12/14 at 11:10 am, CNA "A" said during the time of resident 701's fall from bed she was performing care alone. CNA "A" said resident 701 was laying on a specialty air mattress. CNA "A" said she planned on repositioning resident 701 on side with the buttocks facing her to facilitate checking the brief. CNA "A" said she asked resident 701 to assist with repositioning by pulling the assist bar on the opposite side of bed. CNA "A" said resident 701's legs were "kinda hanging off the side of bed" prior to this request but CNA "A" continued to turn resident 701 toward the opposite side of bed as resident 701 simultaneously pulled away on the assist bar. CNA "A" said resident 701 rolled off the opposite side of the bed and struck the floor. CNA "A" said she was unable to bend resident 701's legs or knees prior to the repositioning because they were "stiff" and "straight". CNA "A" said she was disciplined by facility leadership for not having a second person assisting with bed mobility needs and for using poor positioning. During an interview with the director of nursing (DON) on 09/12/14 at 1:30 pm, the DON said, prior to the fall, the facility had no policy or procedure specific to turning and positioning residents in a specialty bed. The DON said resident 701 was not able to bend knees and acknowledged resident 701 had range of motion impairments to both upper and lower extremities. ( )

THIS CITATION PERTAINS TO INTAKE MI 334. BASED ON RECORD REVIEW, INTERVIEWS, AND OBSERVATIONS, THE FACILITY FAILED TO PROVIDE ADEQUATE, APPROPRIATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT ACCIDENTS FOR 1 (RESIDENT #201) OF 3 SAMPLED RESIDENTS, ALL REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 3, WHEN THE resident sustained [REDACTED]. FINDINGS INCLUDE: THE FACILITY'S INVESTIGATION REPORT, INCIDENT AND ACCIDENT REPORT AND NURSE'S NOTES DATED FROM 8-31-2012 WERE REVIEWED. IT WAS IDENTIFIED THAT ON 8-31-2012, AT 1:30 A.M., EMPLOYEE #3 (A CERTIFIED NURSE AIDE OR CNA) WAS IN THE HALLWAY, CALLING FOR HELP BECAUSE RESIDENT #201 WAS ON THE FLOOR. CNA #3 IDENTIFIED THAT RESIDENT #201HAD ASKED TO GO TO THE BATHROOM. CNA #3 STATED THAT SHE (#3) LEFT THE ROOM FOR ASSISTANCE AND WHEN SHE (#3) RETURNED, SHE (#3) OBSERVED RESIDENT #201 ON THE FLOOR. EMPLOYEE #5 (A LICENSED PRACTICAL NURSE OR LPN) ENTERED THE ROOM AND OBSERVED RESIDENT #201 ON THE FLOOR IN FRONT OF THE OPENED BATHROOM DOOR, SITTING IN A PUDDLE OF URINE. ON THE NURSE'S ASSESSMENT, THE RESIDENT COMPLAINED OF RIGHT HIP PAIN. THE RESIDENT'S VITAL SIGNS WERE BLOOD PRESSURE: 150/75; TEMPERATURE: 98.4; PULSE AND RESPIRATION 20. THE PHYSICIAN AND RESPONSIBLE PARTY WERE NOTIFIED. THE PHYSICIAN ORDERED X-RAYS OF THE RIGHT HIP AND RIGHT FEMUR AND TYLENOL WAS ADMINISTERED FOR PAIN. RESIDENT #201'S CLINICAL RECORD WAS REVIEWED. THE RESIDENT WAS admitted [DATE] WITH [DIAGNOSES REDACTED]. THE NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING DATED 6-17-12 NOTED THAT RESIDENT #201 HAD COGNITIVE PATTERNS THAT WERE SEVERELY IMPAIRED. THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE WITH BED MOBILITY, TRANSFERS AND AMBULATION. THE FALL assessment dated ,[DATE] AND 7-18-2012 NOTED A HIGH RISK FOR FALLS. A PLAN OF CARE DATED 7-9-12 WAS IN PLACE TO ADDRESS FALL RISK AS EVIDENCE BY THE RESIDENT'S HISTORY OF FALLS (7-8-12) WITH INJURY. THE APPROACHES TO PREVENT FURTHER FALLS WITH INJURY INCLUDED AMBULATING WITH STAND BY ASSISTANCE AND THE USE OF A WHEELCHAIR AS A WALKER. IT WAS NOTED THAT THE RESIDENT HAD POOR SAFETY AWARENESS, WAS IMPULSIVE AND ATTEMPTED TO SOLO AMBULATE AND TRANSFER. OTHER SAFETY DEVICES INCLUDED A LOW BED, MATS, AND BED AND CHAIR SENSOR ALARMS. A REVIEW OF RADIOLOGY REPORTS EXAM DATED 8-31-2012, REVEALED THAT RESIDENT #201 HAD SUSTAINED AN ACUTE INTERTROCHANTERIC FEMORAL FRACTURE WITH MILD DISPLACEMENT. THE NURSE'S NOTES DATED 8-31-2012 AT 10:30 A.M. IDENTIFIED THAT THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL ON PHYSICIAN ORDERS [REDACTED]. A REVIEW OF HOSPITAL RECORDS DATED 8-31-12 INCLUDED X-RAYS SHOWING AN INTERTROCHANTERIC FEMUR FRACTURE. ACCORDING TO THE HOSPITAL ASSESSMENT AND PLAN: A [AGE] year OLD WOMAN WITH OSTEOPOROSIS AND PATHOLOGICAL INTERTROCHANTERIC FEMUR FRACTURE DUE TO OSTEOPOROSIS. SHE WAS admitted TO THE MEDICAL UNIT WITH ORTHOPEDIC CONSULTATION. SHE WAS OPTIMIZED AND CLEARED FOR SURGERY. RESIDENT #201 WAS discharged [DATE] WITH Diagnosis: [REDACTED]. ON 10-17-2012 AT 11:00 A.M., EMPLOYEE #2 (DIRECTOR OF NURSING) WAS INTERVIEWED. SHE IDENTIFIED THAT EMPLOYEE #3 (CERTIFIED NURSE AIDE) LEFT A DEPENDENT RESIDENT, WHO NEEDED TO USE THE BATHROOM ALONE, SITTING ON THE SIDE OF THE BED. EMPLOYEE #3 HAD NOT CHECKED THE CARE CARD (GUIDE) AS REQUIRED AND LEFT RESIDENT #201, WHO WAS AT RISK FOR FALLS WITHOUT SUPERVISION. AS A RESULT, RESIDENT #201 fell , SUSTAINING INJURY. EMPLOYEE #3 WAS SUSPENDED AND LATER TERMINATED. ON 10-17-12 AT 12:30 P.M. EMPLOYEE #3 (CERTIFIED NURSE AIDE) WAS CONTACTED BY PHONE. SHE WAS VERBAL OF PROVIDING THE FACILITY WITH A WRITTEN STATEMENT, DATED 8-31-2012. THE STATEMENT PROVIDED FOR THE FACILITY INVESTIGATION WAS REVIEWED. ACCORDING TO THIS STATEMENT EMPLOYEE #3 ENTERED THE ROOM TO TAKE VITAL SIGNS FOR ANOTHER AIDE. RESIDENT #201 WAS SEATED ON THE SIDE OF THE BED. THE RESIDENT STATED SHE HAD TO GO TO THE RESTROOM. EMPLOYEE #3 TOLD RESIDENT #201 TO WAIT "ONE MOMENT, LET ME (#3) GET HELP." ACCORDING TO THE STATEMENT, EMPLOYEE #3LEFT THE ROOM AND WALKED TO THE END OF THE HALLWAY TO GET ANOTHER AIDE TO ASSIST. WHEN EMPLOYEE #3 RETURNED TO THE ROOM, SHE (#3) OBSERVED THE RESIDENT SITTING ON THE FLOOR IN A PUDDLE OF URINE, WITH HER BACK AGAINST THE BATHROOM DOOR. THE ALARM WAS NOT SOUNDING BECAUSE IT HAD BEEN DISCONNECTED. THE PERSONAL FILE FOR EMPLOYEE #3 (CERTIFIED NURSE AIDE) WAS REVIEWED. THE EMPLOYEE WAS HIRED 3-18-2011. SHE HAD LICENSE THAT WAS CURRENT WITH NO HISTORY OF DISCIPLINARY ACTIONS AGAINST AND NO ABUSE FINDINGS. ON 8-31-12 THE EMPLOYEE WAS SUSPENDED PENDING THE FACILITIES INVESTIGATION. ON 9-5-12 THE EMPLOYEE WAS TERMINATED NOTING THAT ON 8-31-12 AT APPROXIMATELY 1:30 A.M. RESIDENT #201 ASKED FOR ASSISTANCE TO THE RESTROOM. ACCORDING TO THE TERMINATION NOTICE, "YOU (#3) LEFT THE RESIDENT ALONE TO GO GET ASSISTANCE INSTEAD OF USING THE CALL LIGHT WHICH WAS CARELESS BEHAVIOR AND CAUSED THE RESIDENT HARM. YOU HAD KNOWLEDGE OF THE RESIDENT'S BEHAVIORS." ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE INTERVENTIONS FOR ONE (#505) OF SIX SAMPLED RESIDENTS REVIEWED FOR SKIN INTEGRITY FROM A TOTAL OF 24, RESULTING IN THE DEVELOPMENT OF PRESSURE SORES. FINDINGS INCLUDE: ON 8/23/11 AT 11:15 AM, RESIDENT #505'S SKIN WAS OBSERVED WITH TREATMENT NURSE 'L' AND THE WOUND TEAM NURSE. THE RESIDENT'S FEET WERE VERY [MEDICAL CONDITION]. HIS LEFT HEEL HAD A 3.2 X 3 CM (CENTIMETER), UNSTAGEABLE PRESSURE SORE. THE RIGHT HEEL HAD A 2.5 X 2.8 CM, UNSTAGEABLE PRESSURE SORE. THE PRESSURE SORES WERE BLACK, ESCHAR (DEAD TISSUE) AREAS. THERE WERE NO PRESSURE RELIEVING DEVICES IN THE ROOM FOR THE HEELS. WHEN QUERIED ABOUT PRESSURE RELIEVING BOOTS, NURSE 'L' STATED THAT STAFF ATTEMPTED TO USE PILLOWS TO FLOAT THE RESIDENT'S HEELS BUT THE RESIDENT DID NOT LIKE IT AND KICKED THE PILLOWS AWAY. WHEN ASKED ABOUT PRESSURE RELIEF BOOTS, NURSE 'L' STATED THAT STAFF ATTEMPTED TO USE BOOTS BUT THE RESIDENT DID NOT LIKE THEM AND REFUSED TO ALLOW USE. WHEN QUERIED, THE RESIDENT STATED THAT STAFF DID NOT USE PILLOWS TO FLOAT HIS HEELS AND THAT HE WAS NEVER OFFERED BOOTS FOR HIS HEELS. WHEN ASKED, THE WOUND TEAM NURSE STATED THAT SHE RECOMMENDED FREQUENT REPOSITIONING TO RELIEVE PRESSURE ON THE HEELS. SHE THEN PROCEEDED TO ASK THE RESIDENT IF HE WOULD LIKE TO TRY PRESSURE RELIEF BOOTS. SHE AND NURSE 'L' WERE UNABLE TO EXPLAIN WHY THE BOOTS WERE NOT ALREADY IN PLACE. A REVIEW OF RESIDENT #505'S CLINICAL RECORD REVEALED: THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. A PRESSURE ULCER RISK (NORTON) SCALE DATED 5/27/11 NOTED THAT THE RESIDENT WAS AT HIGH RISK. PER NURSES NOTES DATED 8/10/11, THE RESIDENT WAS NOTED TO HAVE "DISCOLORED AREA ON BILATERAL HEELS." ON 8/11/11: "TWO PILLOWS UNDER BILATERAL HEELS, SLIPPED OFF FROM IT WHILE SLEEP, REPOSITIONED" AND THE RESIDENT WAS NOTED TO HAVE 3+ [MEDICAL CONDITION] TO FEET AND ANKLES. ON 8/11/11, NURSE 'L' DOCUMENTED ON "NON-PRESSURE" SKIN CONDITION REPORTS THAT THE AREA ON THE LEFT HEEL MEASURED 3.5 X 3.0 CM AND 3.0 X 2.0 CM ON THE RIGHT HEEL. SHE WAS UNABLE TO EXPLAIN WHY HER DOCUMENTATION WAS PLACED ON "NON-PRESSURE" RELATED SKIN RECORDS. THE RESIDENT WAS ON THE LIST TO BE SEEN BY THE WOUND CARE SPECIALTY TEAM ON 8/18/11 BUT, PER NURSE 'L:' "HE (THE RESIDENT) WAS NOT AVAILABLE SO HE WASN'T SEEN." SHE WAS ASKED IF THE RESIDENT WAS OUT OF THE BUILDING ON 8/18/11. NURSE 'L' SAID, "NO. I THINK HE WAS IN AN ACTIVITY." SHE WAS UNABLE TO EXPLAIN WHY THE RESIDENT WAS NOT BROUGHT FROM ACTIVITIES BACK TO HIS ROOM FOR THE WOUND CARE. THEREFORE, HE WAS NOT SEEN UNTIL 8/24/11 AND THERE WAS NO DOCUMENTATION ABOUT THE PRESSURE SORES FROM 8/12/11 UNTIL 8/24/11. IN ADDITION, THE RESIDENT'S CARE GUIDE, USED BY THE NURSE AIDES, DID NOT MENTION ELEVATING THE RESIDENT'S HEELS. AN "AT RISK" FOR PRESSURE SORE CARE PLAN DATED 5/16/11, THAT WAS LAST REVIEWED BY STAFF ON 8/18/11, DID NOT MENTION FLOATING THE HEELS OR PROVIDING BOOTS. THE CARE PLAN WAS NOT UPDATED REGARDING THE PRESSURE SORES THAT DEVELOPED ON THE HEELS. A CARE PLAN DATED 8/12/11 REGARDING THE "DISCOLORED AREAS" ON THE HEELS, MENTIONED ELEVATING THE LOWER EXTREMITIES DUE TO [MEDICAL CONDITION] BUT NO DEVICES FOR THE HEELS. A WOUND RECORD DATED 8/2011 NOTED "BILATERAL HEELS DISCOLORED. PILLOWS UNDER HEELS TILL FOAM BOOTS (COME) IN." WHEN QUERIED ABOUT THE FOAM BOOTS, NURSE 'L' STATED SHE WAS UNAWARE OF THE NOTATION FOR THE BOOTS ON THE WOUND RECORD. SHE THEN SAID: "WE HAVE TO GET an order for [REDACTED]. THAT'S A NURSING INTERVENTION" AND STATED THAT THERE WERE BOOTS ON HAND AT THE FACILITY. PER THE FACILITY'S "PRESSURE ULCER & SKIN CARE MANAGEMENT" AND "PRESSURE ULCER PREVENTION MEASURES" POLICIES DATED 12/2008: -PRESSURE SORES MUST BE DOCUMENTED WEEKLY. -INTERVENTIONS FOR PRESSURE SORE PREVENTION AND TREATMENT MUST BE PROVIDED AGGRESSIVELY BY ALL STAFF INVOLVED. -FOR RESIDENTS IN BED, USE DEVICES/INTERVENTIONS THAT RELIEVE PRESSURE ON THE HEELS BY RAISING HEELS OFF THE BED, USING PILLOWS, OR REPOSITIONING TO REDISTRIBUTE PRESSURE. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO MONITOR, IMPLEMENT INTERVENTIONS AND ENSURE A SAFE ENVIRONMENT TO PREVENT ACCIDENTS FOR ONE (#504) OF FOUR SAMPLED RESIDENTS IDENTIFIED WITH FALLS, OUT OF A TOTAL SAMPLE OF 24 RESIDENTS, RESULTING IN INJURIES AND hospitalization . FINDINGS INCLUDE: ON 8/23/11 AT 9:00 AM, DURING THE INITIAL TOUR OF THE ONE WEST NURSING UNIT, RESIDENT #504 WAS OBSERVED LYING AWAKE IN BED. THE LEFT SIDE OF RESIDENT #504'S FOREHEAD WAS BRUISED AND SWOLLEN. BOTH OF HIS EYES WERE ALSO BRUISED ABOVE AND BENEATH HIS EYE LIDS. WHEN QUESTIONED REGARDING HIS INJURIES, RESIDENT #504 STATED HE fell on THE FLOOR IN HIS ROOM ABOUT A WEEK AGO. HE FURTHER STATED HE DID NOT KNOW THEY HAD MOPPED HIS ROOM AND THE FLOOR WAS WET WHEN HE CAME OUT OF HIS BATHROOM, HE ALSO EXPLAINED THERE WAS NO SIGN SAYING WET FLOOR AND THAT WAS WHY HE fell . THE FACILITY FAILED TO ENSURE THAT THE ENVIRONMENT WAS SAFE WITH POSTED SIGNS INDICATING A WET FLOOR ON 8/23/11 AT 1:00 PM, REVIEW OF THE ADMISSION FACE SHEET FOR RESIDENT #504 REVEALED AN admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE 30 DAY MINIMUM DATA SET, WITH AN ASSESSMENT REFERENCE DATE OF 7/25/11, DOCUMENTED, RESIDENT #504 WAS INDEPENDENT WITH COGNITIVE SKILLS AND REQUIRED LIMITED ASSISTANCE WITH ONE PERSON PHYSICAL ASSISTANCE FOR TRANSFERS, AMBULATION, AND PERSONAL HYGIENE AND BATHING. ON 8/24/11 AT 2:00 PM, A REVIEW OF THE INCIDENT REPORT (UNUSUAL OCCURRENCE REPORT) FOR RESIDENT #504 DOCUMENTED THE FOLLOWING: DATE OF INCIDENT 8/16/11 TIME OF INCIDENT 5:55 PM WITNESS BY PHYSICAL THERAPIST (F) DESCRIPTION OF INJURY: BRUISE/HEMATOMA, HEAD TRAUMA. PLAN OF CORRECTION (INTERVENTION TO PREVENT THE REOCCURRENCE): ENCOURAGE PATIENT TO USE THE WALKER WHEN AMBULATING. REVIEW OF THE INTERDISCIPLINARY (IDT) POST-FALL ASSESSMENT DOCUMENTED ENVIRONMENTAL FACTORS: "WET FLOOR." A physician's orders [REDACTED]." ON 8/26/11 AT 9:15 AM THE UNIT MANAGER (D) AND THE RESTORATIVE NURSE MANAGER (G) WERE QUERIED REGARDING THE INCIDENT FOR RESIDENT #504 WHICH RESULTED IN THE FOREHEAD HEMATOMA AND hospitalization FOR THE RESIDENT. THE UNIT MANAGER (D) STATED THAT SHE DID NOT KNOW IF THE FLOOR WAS WET, HOWEVER SHE CONFIRMED RESIDENT #504 SHOULD HAVE BEEN ASSISTED TO THE BATHROOM. WHEN QUERIED REGARDING A SAFETY CARE PLAN THE RESTORATIVE NURSE MANAGER (G), CONFIRMED RESIDENT #504 WAS A HIGH RISK FOR FALLS, HOWEVER THERE WAS NO CARE PLAN FOR SAFETY TO PREVENT FALLS. ON 8/26/11 AT 10:20 AM, PHYSICAL THERAPIST (F) WAS QUERIED REGARDING THE INCIDENT FOR RESIDENT #504. WHEN QUERIED PHYSICAL THERAPIST (F) EXPLAINED, SHE SAW THE RESIDENT FALL ON THE FLOOR WHEN HE WAS GOING TO THE BATHROOM. SHE ALSO STATED THE RESIDENT WAS AMBULATING WITHOUT HIS WALKER. THE FACILITY'S "FALL MANAGEMENT GUIDELINES" POLICY, DATED 1/2011 STATES: -"RESIDENTS IDENTIFIED AT RISK FOR FALLS WILL HAVE A CARE PLAN DEVELOPED AND IMPLEMENT FALL PREVENTION INTERVENTIONS AS NEEDED BASED ON THEIR ASSESSMENT." -THE IDT WILL REVIEW ALL RESIDENT FALLS ....TO EVALUATE/INVESTIGATE THE CIRCUMSTANCES AND ROOT CAUSE FOR THE FALL. ( )

THIS CITATION PERTAINS TO INTAKE # MI 408BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ENSURE RESIDENTS REMAINED FREE FROM ACCIDENT HAZARDS AND PROVIDED ADEQUATE SUPERVISION AND ASSISTIVE DEVICES TO PREVENT ACCIDENTS IN 3 OF 6 SAMPLED RESIDENTS (#103, #104, #105), RESULTING IN A FALL FOR RESIDENT #103 FROM WHICH SHE SUSTAINED A FRACTURED RIGHT HIP NEEDING SURGICAL REPAIR, AND FALLS FOR BOTH RESIDENT #104 AND RESIDENT #105, WITHOUT INJURY, BUT WITH THE POTENTIAL FOR FUTURE ACCIDENTS.FINDINGS INCLUDE:RESIDENT #103ACCORDING TO THE UNDATED FACE SHEET, RESIDENT #103 WAS AN [AGE] year-OLD-FEMALE LIVING AT THE FACILITY SINCE 1/30/2011. HER [DIAGNOSES REDACTED].ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #103 SUFFERED FROM COGNITIVE IMPAIRMENTS WITH BOTH LONG AND SHORT-TERM MEMORY LOSS. SHE DID NOT AMBULATE AND WAS DEPENDENT ON MINIMALLY TWO STAFF MEMBERS FOR TRANSFERS. RESIDENT #103 COULD NOT BALANCE WHILE MOVING FROM A SEATED POSITION TO STANDING, WALKING, TURNING AROUND, MOVING ON AND OFF THE TOILET AND TRANSFERRING BETWEEN SURFACES.A CARE PLAN DATED 03/18/2011 IDENTIFIED RESIDENT #103 AT RISK FOR INJURY RELATED TO HER HISTORY OF FALLS, diagnosed OSTEOARTHRITIS, INABILITY TO RECOGNIZE DANGER AND IMPAIRED DECISION MAKING SKILLS.THE MOST RECENT RESTORATIVE NURSE RECORD AVAILABLE, DATED 09/2010, IDENTIFIED THAT RESIDENT #103 REQUIRED THERAPY TO INCREASE HER INDEPENDENCE WITH TRANSFERS BUT RECORDS OF CONTINUED THERAPY WERE NOT AVAILABLE AT THE TIME OF THIS SURVEY.THE MOST RECENT PHYSICIAN ACTIVITY ORDERS DATED 12/17/2010, REQUIRED STAFF TO PROVIDE MODERATE PHYSICAL ASSISTANCE FOR TRANSFERS.THERAPY NOTES DATED 04/19/2011 SPECIFIED THAT HISTORICALLY, RESIDENT #103 REQUIRED "ASSISTANCE WITH ALL ADL (ACTIVITIES OF DAILY LIVING) AND FUNCTIONAL TRANSFERS ... "A FALL RISK ASSESSMENT COMPLETED ON 4/11/2011 IDENTIFIED RESIDENT #103 AT "HIGH RISK" FOR FALLS.DAILY ADL FLOW RECORDS DATED 3/2011 THROUGH 4/12/2011, IDENTIFIED THAT RESIDENT #103 WAS USUALLY COMPLETELY DEPENDENT ON ONE STAFF MEMBER FOR TRANSFERS ALTHOUGH AT TIMES SHE REQUIRED EXTENSIVE ASSISTANCE WITH HER TRANSFERS.ON 04/27/2011 AT 11:15 A.M., THE RESTORATIVE NURSE SAID THAT SHE COMPLETED THE FALL ASSESSMENT FOR RESIDENT #103 ON 04/11/2011. SHE SAID THE ASSESSMENT FINDINGS HAD BEEN BASED SOLELY ON RECENT TRANSFERS COMPLETED WITH RESIDENT #103. THE RESTORATIVE NURSE SAID RESIDENT #103 REQUIRED SHOES FOR STABILITY AND AT LEAST ONE STAFF MEMBER WHO PROVIDED EXTENSIVE TRANSFER ASSISTANCE. AN UNUSUAL OCCURRENCE REPORT DATED 04/12/2011 AT 12:30 P.M., REPORTED A WITNESSED FALL IN THE SHOWER ROOM AS RESIDENT #103 DESCENDED TO THE GROUND FROM A STANDING POSITION. AT 11:45 A.M. ON 04/27/2011, THE CERTIFIED NURSING ASSISTANT IDENTIFIED AS EMPLOYEE "G" SAID SHE WITNESSED RESIDENT #103'S FALL ON 04/12/2011. EMPLOYEE "G" SAID SHE ASKED RESIDENT #101 TO STAND UP IN THE SHOWER ROOM, WITHOUT ANY FOOTWEAR IN PLACE. SHE SAID SHE HAD RESIDENT #103 HANG ON TO THE WALL RAIL FOR SUPPORT. EMPLOYEE "G" SAID SHE DID NOT PROVIDE ANY PHYSICAL ASSISTANCE FOR RESIDENT #103 WHILE SHE STOOD IN THE SHOWER ROOM. EMPLOYEE "G" SAID, SHE ASKED RESIDENT #103 TO SEPARATE HER FEET AT WHICH POINT SHE PLACED ONE HAND ON THE RESIDENTS BACK FOR "SUPPORT" AND MOVED AWAY FROM THE RESIDENT TO GET A BATH CHAIR. EMPLOYEE "G" SAID IT WAS WHILE SHE MOVED AWAY TO GET THE BATH CHAIR THAT RESIDENT #103 SAID SHE WAS "GOING DOWN." EMPLOYEE "G" SAID SHE RETURNED TO IMPLEMENT PHYSICAL SUPPORT DURING THE FALL TO ASSIST IN PREVENTING INJURY.NURSING NOTES DATED 04/12/2011 AT 3:10 P.M., REPORTED RESIDENT #103 WAS TRANSPORTED TO A LOCAL AREA HOSPITAL FOR EVALUATION AND treatment of [REDACTED]. UNDER WENT RT O.R.I.F. (OPEN REDUCTION INTERNAL FIXATION - HIP SURGERY).RESIDENT #104ACCORDING TO THE UNDATED FACE SHEET, RESIDENT #104 WAS A [AGE] year-old-FEMALE LIVING AT THE FACILITY SINCE 03/30/2011. HER [DIAGNOSES REDACTED].ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #104 COULD AMBULATE IN HER BEDROOM WHEN ONE STAFF MEMBER PROVIDED HER WITH LIMITED ASSISTANCE. TO TOILET SHE REQUIRED THE EXTENSIVE ASSISTANCE OF TWO STAFF MEMBERS. RESIDENT #104 WAS NOT STABLE DURING TRANSFERS ON AND OFF THE TOILET AND REQUIRED HUMAN ASSISTANCE TO STABILIZE.A CARE PLAN DATED 04/01/2011, IDENTIFIED RESIDENT #104 AT RISK FOR FALLS RELATED TO HER IMPAIRED MOBILITY. TO MINIMIZE HER RISK STAFF WERE TO PROVIDE ASSISTANCE FOR ALL AMBULATION.THE REHABILITATION SCREEN COMPLETED BY THE THERAPY DEPARTMENT ON 03/31/2011, REQUIRED STAFF TO PROVIDE ASSISTANCE WITH ALL TRANSFERS, UNSTEADY BALANCE AND AMBULATION.UNTIMED NURSING NOTES DATED 04/03/2011, IDENTIFIED RESIDENT #104 AS SELF-TRANSFERRING AND AMBULATING WITHOUT STAFF ASSISTANCE NOW "ON HER KNEES IN HER RESTROOM ... " ON 04/26/2011 AT 2:00 P.M., RESIDENT #104 SAID SHE BECAME UNSTEADY ON HER FEET AND STUMBLED CAUSING HER TO FALL ON 04/03/2011. SHE SAID AT THE TIME OF THE FALL AND SINCE THEN, SHE HAS NOT BEEN PROVIDED STAFF ASSISTANCE FOR TRANSFERS OR AMBULATION.ON 04/27/2010 AT 10:30 A.M., THE DIRECTOR OF NURSING WAS GIVEN THE OPPORTUNITY TO REVIEW THE RESIDENTS RECORDS. SHE DID NOT PRODUCE ANY EVIDENCE THAT STAFF IMPLEMENTED ANY ADDITIONAL MEASURES TO KEEP RESIDENT #104 SAFE AFTER THIS FALL.RESIDENT #105ACCORDING TO THE UNDATED FACE SHEET, RESIDENT #105 WAS A [AGE] year-old-FEMALE LIVING AT THE FACILITY SINCE 01/30/2011. HER [DIAGNOSES REDACTED].ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #105 SUFFERED SEVERE COGNITIVE IMPAIRMENTS WITH BOTH LONG AND SHORT-TERM MEMORY LOSS. HER SHE COULD NOT AMBULATE AND WAS DEPENDENT ON MINIMALLY TWO STAFF MEMBERS TO PROVIDE PHYSICAL ASSISTANCE WITH TRANSFERS. RESIDENT #105 REQUIRED STAFF ASSISTANCE TO BALANCE.A CARE PLAN DATED 08/03/2010, IDENTIFIED RESIDENT #105 AT RISK FOR INJURY RELATED TO HER INABILITY TO IDENTIFY DANGER AND DECREASED MOBILITY. TO ENSURE HER SAFETY STAFF IMPLEMENTED A BED AND CHAIR ALARM ON 09/22/2010.PHYSICIAN ORDERS [REDACTED].NURSING NOTES DATED 4/02/2011 AT 10:50 P.M., STATED RESIDENT #105 WAS FOUND SITTING ON THE FLOOR MAT NEXT TO HER BED. ON 04/27/2010 AT 10:30 A.M., THE DIRECTOR OF NURSING WAS GIVEN THE OPPORTUNITY TO REVIEW THE RESIDENTS RECORDS. SHE DID NOT PRODUCE ANY EVIDENCE THAT STAFF IMPLEMENTED ANY ADDITIONAL MEASURES TO KEEP RESIDENT #104 SAFE AFTER THIS FALL.NURSING NOTES DATED 04/16/2011 AT 12:30 A.M., STAFF RESPONDED TO RESIDENT #105 "SCREAMING" AND FOUND HER KNEELING ON THE FLOOR NEXT TO HER BED.