Every finding on record at Sanilac Medical Care Facility

Past Non-Compliance (PNC) was identified during the investigation of the deficient practice and was accepted by the survey team upon exit from the facility for this citation. Following discussion with the State Manager, Past Non-Compliance was accepted with a Compliance Date of 01/28/2026.Based on observation, interview and record review, the facility failed to ensure resident safety when care-planned interventions were not followed during a transfer to a wheelchair for one resident (Resident #1) of four residents reviewed for an injury of unknown origin. Findings include:Resident #1 (R1):On 2/2/26 at 12:29 PM, an observation was made of Resident 1 (R1) sitting in their wheelchair in the dining area of the secured unit of the facility. The Resident had her right leg elevated with a cast on it. The Resident had drinks in front of her and the residents in the dining area were getting ready to eat. An observation was made of a sling with red trim positioned underneath the Resident. The sling was a mechanical lift sling for use with a mechanical lift when transferring the Resident. An observation was made of a mechanical lift positioned in the hallway of the unit.A review of R1's medical record revealed an admission into the facility on 6/17/16 with a readmission on [DATE] with diagnoses that included Alzheimer's disease, muscle wasting and atrophy, muscle weakness, need for assistance with personal care and fracture of right tibia. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 00/15 that indicated severely impaired cognition, and the Resident was dependent on a helper for transfers, bathing, dressing and personal hygiene.A review of the facility reported incident revealed that on 1/8/26 at approximately 8:30 AM, staff notified the Director of Nursing that the resident was complaining of pain to the right lower extremity with deformity noted. The origin of the injury is unknown at this time. No fall, accident, or injury was witnessed or reported. The resident was under routine care and supervision at the time the injury was identified. Diagnostic imaging completed at (hospital) at approximately 9:15 AM revealed: Acute comminuted mildly displaced fracture of the distal tibial metadiaphysis Acute mildly displaced fracture of the distal tibial diaphysis. Due to the results of the x-Ray, the residents transferring status was changed from Assist of One (1) using the Hoyer Lift with a Red Trim Sling to Assist of Two (2) using the Hoyer Lift with a Red Trim Sling.A review of staff interviews during the investigation revealed, (CNA H) was scheduled to work on the 700 Hall on 1/7/26-1/8/26 from 10:00 PM (to) 6?00 AM. During the conduction of the interview, CNA ( H) reported assisting resident (R1) into own personal wheelchair prior to 6:00 AM on 1/8/26 with CNA ( H) reporting that a two (2) person assist was utilized; the resident's transferring status was Assist of One (1) using the Hoyer Lift with a Red Trim Sling per plan of care at this time. CNA ( H) was unable to recall who assisted with said transfer. Per CNA ( H) resident (R1) did not complain of pain following the completion of this transfer, and no accident or injuries occurred during this time. There was clear deviation from the residents individualized plan of care as a manual transfer was utilized in lieu of utilizing the required mechanical lift; the residents individualized plan of care was clear, and CNA ( H) was trained appropriately.Review of staff interviews revealed the evening on 1/7/26, R1 was transferred by a CNA and Nurse back to bed, the sling used had been soiled and was placed in the laundry.On 2/2/26 at 12:07 PM, an interview was conducted with the Director of Nursing (DON). The incident with injury of unknown origin of a fracture of R1's leg and investigation completed was reviewed with the DON. The DON indicated that they identified that the CNA had not followed the plan of care when transferring the resident into her wheelchair prior to the discovery of the injury. The DON revealed that she had reached out to the CNA after it was identified that he had not followed the plan of care, but the CNA had not called her back, and the facility had terminated employment of CNA H. The DON reported that all Residents had their plan of care reviewed and ensured that residents were being transferred safely and per the plan of care. Education was provided to Nurses and CNAs, all assigned staff had completed the education, and they were monitoring to make sure care plans were followed during transfers. The DON indicated that they were in compliance. On 2/2/26 at 12:25 PM, an interview was conducted with Laundry Staff A regarding laundering and availability of mechanical lift slings. The staff reported that a dirty sling would be brought down to the laundry if dirty and if brought down at night, would be cleaned in the morning of the next day. The Staff reported that there were extras of each color of slings available in the laundry department where the slings are stored and that the trim color needed goes by the weight of the Resident. The Laundry Staff stated, There is plenty of each color available in the laundry. On 2/2/26 at 12:52 PM, interviews were conducted with CNA B, CNA C, and Unit Clerk/CNA D regarding the available mechanical lifts. An observation was made of a mechanical lift in the hallway of the 300 hall and 500 Hall. The CNAs were asked if there were enough mechanical lifts available to meet the needs of the residents. The three CNAs responded that there was not an issue with a lift not being available and what they had available was plenty to meet the residents' needs. The CNAs reported recent abuse education and following plan of care for residents. All three CNAs indicated they had completed the education. When asked about the availability of slings, the CNAs reported that if they were not available in the room for the resident, they could get one from laundry that was not far to go and was open all the time including off hours. The CNAs reported they did not have concerns of slings not being available and that there was enough of the needed trim color available to meet resident needs. On 2/2/26 at 2:20 PM, an interview was conducted with Assistant Director of Nursing (ADON) F. The ADON reported that he had oversight of staff education and that mandatory education on abuse training and following the plan of care education was made mandatory for Nurses and CNAs with a completion date by 1/22/26. A review of education revealed some staff had not completed the training by 1/22/26 with staff completion by 1/28/26. On 2/2/26 at 2:47 PM, an interview was conducted with CNA I regarding availability of mechanical lift in the 700 Hall. The CNA reported that the lift was always available and that the one on the unit was enough to meet the needs of the Resident. The CNA reported that the CNA was responsible for looking at the care plan in the resident's closet that lists the transfer rules for the resident. On 2/2/26 at 3:15 AM, an observation was made of mechanical lift slings in the laundry area. There were approximately 30 slings available with various trim colors. An observation was made of three slings with red trim hanging on the hooks positioned just inside the laundry room door. On 2/2/26 at 3:45 PM, an interview was conducted with the DON and Administrator regarding the investigation for R1 and the past non-compliance identified during the survey investigation. Education records with some staff completing the education on 1/28/26 were reviewed. Audits have been reviewed. The date of compliance was agreed as 1/28/26. The concern was identified and followed by the Quality Assurance committee. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:-A review of resident transfers to ensure that residents are being transferred safely and per individualized plan of care.-Law enforcement had been contacted.-Education: Following the Resident Plan of Care; Preventing Neglect, Injury, and Licensure Consequences for Certified Nursing Assistants (CNAs) and Licensed Nursing Staff. Education was mandatory by 1/22/26 and had been completed by 1/28/26.-Audit of resident transfers to ensure that residents are being transferred safely and per individualize plan of care of 20 residents weekly for 4 weeks and then monthly for three months.-Director of Nursing responsible for sustained compliance.The State Surveyor verified the documentation provided by the facility and conducted interviews with facility staff regarding following care planned interventions and staff were knowledgeable about the facility policies. Other Residents were reviewed for injuries and following care planned interventions for transfers and noncompliance was not identified.The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review, the facility failed to ensure cleanliness of the water system and the use of appropriate backflow prevention on cross connections. This deficient practice increases the likelihood of contamination of the water supply due to uncleanliness and a potential backflow event, potentially affecting all residents, staff, and visitors who consume water at the facility. Findings include:On 08/19/2025 at 1:30PM during the environmental tour with the Director of Operations K, Maintenance Assistant L, and Maintenance Assistant M, observed the water softener brine tank filled with a black foam substance in the main boiler room. Conducted interview with Maintenance Assistant L, he stated that the brine tank is cleaned out every three years and that the cleaning is due. On 08/19/2025 at 1:45 - 2:20PM observed black foam inside the brine tank of the water softener located in the boiler room in the 800 hallway. On 08/19/2025 at 1:45 - 2:20PM observed the drain line to the water softener sitting inside the drain, located in the boiler room in 800 hallway. On 08/19/2025 at 1:45 - 2:20PM observed chemical dispenser connected to a utility sink by a hose downstream of an atmospheric vacuum breaker (AVB) without an attached wasting tee, located in the custodial closet in 600 hallway. On 08/19/2025 at 1:45 - 2:20PM observed spray nozzle attached to a hose connected to a utility sink downstream of an atmospheric vacuum breaker (AVB), located in the 700 hallway custodial closet. According to the 2008 Cross Connection Manual on water softeners, Typical water softener installations may pose a public health threat mainly due to the waste discharge piping being terminated in a floor drain or sewage piping system thereby creating a submerged inlet cross connection. According to the 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure.According to the 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve).

Based on observation, interview, and record review, the facility failed to maintain best practices in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include:On 08/19/2025 at 8:45AM during the initial kitchen tour with the Certified Dietary Manager (CDM) N, the rag sanitizer bucket was tested with Hydrion quaternary ammonia test strips, and the result was zero. The CDM N changed out the bucket and retested it, and the second result was between 150-200ppm. On 08/20/2025 at 9:03 AM the rag sanitizer bucket was retested with the quaternary test strips, and the result was zero. Conducted interview with the Certified Dietary Manager N on the desired concentration range for the sanitizer and she answered 50-100 ppm. When questioned about how often the sanitizer bucket was changed out, she stated that it is changed every morning and evening shift. She then proceeded to tell dishwashing staff to change out the bucket. Record review of the sanitizer with the label EPA Reg No. 10324-81, according to the product information sheet provided by the United States Environmental Protection Agency for sanitization of food contact surfaces, the dilution requirements are 150ppm for one gallon. According to the 2022 Food Code, 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness, A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation .shall be used in accordance with the EPA-registered label use instructions.

Based on observation, interview and record review, the facility failed to ensure adequate staffing to meet the care needs of the residents for a confidential group of residents, and Residents #10, # 50, #52, and #89, resulting in long call light wait times, scheduled activities being cancelled and delayed resident care. Findings include:Facility On 08/20/2025 at 2:00PM, a resident council meeting was held with a confidential group of residents. One confidential resident stated they have numerous long call light wait times. A review of call light response times revealed that on 8/16/25 the resident waited 36 minutes and 26 minutes. On 8/17/25 the resident had wait times 32 minutes, 28 minutes and 26 minutes. On 8/18/25 the resident had a wait time of 49 minutes. Another confidential resident stated, we only have one certified nursing assistant (CNA) per hall and if they are busy then we can wait too long. We need more help around here; the CNA's are so busy they can't answer call lights on time. The confidential group stated they believe the facility needs more CNA staff, they think they are too busy. They are pulling people from activities. There have been a couple of times where we haven't been able to do activities because the activity aides got pulled to the floor. A confidential resident stated they waited too long in pain and that they were in tears and hurting. The resident stated this occurred very recently but could not give an exact date. A review of the call light response times for this resident revealed that on 8/7/25 they had a 36 minute wait, on 8/11/25 they had wait times of 28 minutes, 25 minutes, and 33 minutes. On 8/14/25 they had a wait time of 40 minutes, on 8/15/25 they had wait times of 1 hour and 13 minutes, 26 minutes, 51 minutes and 57 minutes. On 8/16/25 they had wait times of 53 minutes and 56 minutes. On 8/19/25 the resident had wait times of 44 minutes and 55 minutes. One confidential resident stated, they just need more people and that management could help more as well and take the burden off the CNA's. Review of resident council notes for the last 6 months revealed the group had complaints of long call light times in April 2025 and August 2025. On 08/21/2025 at 10:11AM, an interview was conducted with the activity director (AD) J. AD J was asked if they keep track of the days your staff gets pulled to the floor. AD J replied, Yes, I keep track of when they are pulled. In August they were pulled on 8/5, 8/8, 8/9, 8/11, 8/12, 8/15, 8/18, 8/19, 8/21. In July 7/2, 7/6, 7/10, 7/14, 7/19, 7/23 and on 7/24 pulled twice. AD J stated that on a normal weekday we have 5 activity staff present. Today (8/21/25) my assistant got pulled to the floor to help out. AD J was asked if they have noticed an increase of their staff getting pulled to the floor. AD 'J stated that around May of this year it started to be more than usual and it has increased since then. AD J stated that on the weekend of August 9th one of my activity aides was pulled to the floor twice and we were unable to have any activities that day. Resident #10 On 8/19/25 at 12:12 PM, an observation was made of Resident #10 lying in bed. The Resident was interviewed and was able to answer questions using her computer that detected eye movement. The Resident was asked about concerns she had and indicated that she had been waiting all morning to get ready for the day, she had a care conference at 1:00 PM and reported she was still waiting for them (CNA) to get her going for the day. The Resident indicated she wanted fresh gown/clothes applied. An observation was made of whitish debris on her teeth and tongue. An observation was made of dried flaking debris to the left side of her mouth on her face. On 8/19/25 at 1:06 PM, an observation was made of Resident #10 lying in bed. When asked if staff had a chance to assist with morning care, the Resident reported she was still waiting. The Resident was asked if she had mouthcare completed and the Resident opened her mouth to show her teeth that had a whitish debris over the teeth and nods that she needs it done. The left check area had the flaking dried debris that was observed earlier. On 8/21/25 at 1:02 PM, an interview was conducted with CNA S regarding Resident #10's morning routine. The CNA reported that the Resident liked to get up about 10 or 10:30 AM for AM care for dressing, mouth care, repositioning or getting up to her chair. The CNA reported that the hall that Resident #10 resided had many Residents that needed two people to assist with care and getting up in the mornings, that it was a very heavy assignment for only two CNAs and that a float CNA would help out tremendously. CNA T was asked about Resident #10's AM care 8/19/25 and reported that it was busy in the morning and hard to get to residents timely sometimes with only two CNAs. The CNAs reported that there were about eight Residents that needed two-person assist with a mechanical lift and many residents needing to toilet more often. Resident #50: On 8/19/25 at 10:27 AM, an observation was made of Resident #50 lying in bed with her feet and lower legs elevated with boots on. The Resident was interviewed, answered questions and engaged in conversation. The Resident reported that she was paralyzed from the waist down. When asked if she had any concerns regarding her care received at the facility, the Resident stated, I am concerned about my legs getting stiff, I can't move them myself, I am supposed to get restorative therapy, but I have not had it for 2 weeks now. The Resident reported that the program made sure her legs received range of motion and that the staff that does the exercises on her legs got pulled to the floor and no one was in to do it. The Resident stated, I have limited movement of my hands, and I can do my hands myself, but I need them to work my legs, I can't do them. I am afraid they are going to get stiff. On 8/20/25 at 2:47 PM, an interview was conducted with Restorative Nurse D regarding Resident #50's restorative therapy plan. The Nurse reported that the Resident was always seen by the Restorative Therapy aide. The Nurse reviewed the last documented Restorative Therapy and indicated that 8/9/25 was the last paper that I have for Resident #50. When asked why no Restorative Therapy was completed, the Nurse reported that the Aide was pulled to the floor and if she was working that section, she would get to the Residents that were on the Restorative Therapy in that section but could not get to everyone. On 8/21/25 at 12:02 PM, an interview was conducted with Restorative Nurse D regarding Resident #50's documentation for the Restorative Program. The document revealed Resident #50 was to receive 3 to 5 times (a week). From 8/3 to 8/9 there were two marked days, Tuesday and Friday. Nurse D reported that the marked days with a X represented that the Resident had received the Restorative Therapy on those days. From 7/27 to 8/3 the Resident had three days indicated and from 7/20 to 7/26 there was one day indicated. The Nurse reported that the Restorative CNA gets pulled to the floor and if she has a resident in the area where she is working, she will get in there and do their restorative therapy plan and stated, but she can't cover the whole building when she is working the floor. We had a drop in the CNAs for the last two weeks, and she was unable to get to the Restorative therapy. Resident #52: On 8/19/25 at 10:20 AM, an observation was made of Resident #52 lying in bed. The Resident was interviewed, answered questions and engaged in conversation. The resident was asked about any concerns they had with the care received by the facility staff. The Resident reported long call light wait times and stated, I had over an hour on this last weekend. They need more staff, someone could be dying, and they wouldn't know it. The Resident expressed frustration in waiting for their call light to be answered. Resident #89: On 8/19/25 at 10:36 AM, an interview was conducted with Resident #89, who answered questions and engaged in conversation. The Resident was asked of any concerns with the care at the facility. The Resident reported that call lights can take a while to answer, and indicated a lack of staff and that the staff were too busy and could not answer call lights timely. Confidential Staff During the survey, an interview was conducted with Confidential Staff (CF) U regarding staffing concerns. The CF was asked about call lights response times and the CS stated, We try to keep up on call lights, but reported that the Residents that are not capable of using the call light do not get care like they should, not timely on a consistent basis. Confidential Resident Advocate During the survey, an interview was conducted with a Resident Representative who wanted to remain confidential. The Confidential Resident Advocate (CRA) R reported that they had concerns of under staffing and the CNAs (Certified Nursing Assistants) were over worked and mentally and physically drained. The CRA reported that their Resident has used the call light and has had to wait 30 minutes to an hour with the Resident having incontinent episodes due to having to wait to use the bathroom while waiting for the call light to be answered. The CRA reported that the CNAs had an exceptional attitude and worked very hard and that the issue was not how the CNAs worked but that the workload was too much and not enough CNAs to meet the Resident's needs timely. During the annual survey facility staff who wanted to remain anonymous reported the following regarding current staffing concerns at the facility: - Within the last two months they have lost approximately 20 certified nursing assistants (CNA's). - Since new administration they staff the units with less staff, which has effected the quality of patient care they are able to provide. - The quality of patient care has decreased given the mass exodus of staff in the last two months and how management how they staff the units. - Many of the aides left due to low wages and the increase in mandations. - Aides are leaving the facility due to the workload and lack of pay. It has affected the quality of patient care they can provide. On 8/20/2025 at 3:25 PM, an interview was conducted with Scheduler P she shared she has been mandating more and recently she was mandating daily due staffing concerns. They lost an extensive amount of CNA's in the last few months and she was not expecting it, so they are struggling to cover many of the shifts. They schedule the facility based off PPD and she is uncertain of the resident acuity of the unit. They typically have a float but when an aide calls in, they pull the float to work the regular assignment. She was asked if the restorative aide is pulled as well and she reported last week she pulled the aide everyday due to their 1:1. Scheduler P reported her staff have shared they are becoming burned out from working so many hours.

Based on interview and record review the facility failure to ensure availability and accurate documentation for Lexapro (antidepressant medication) for one resident (34) of 5 reviewed for medication management, resulting in Resident #34 not receiving her medications for approximately three weeks and imprecise medication administration documentation.Findings Include:On 8/20/2025 at approximately 9:15 AM, a review was conducted of Resident #34's medical record and it indicated she admitted to the facility on [DATE] with diagnoses that included Dementia, Hyperlipidemia, Hypertension, Adjustment Disorder with mixed anxiety and depressed mood and Anxiety. Further review revealed the following:Physician Orders:Lexapro Oral Tablet 5 MG (milligram)- Give one tablet by mouth one time a day for agitation, irritability, depressed mood.August 2025 MAR (Medication Administration Record)Of the twenty days reviewed on the MAR, Lexapro was administered 10 times. It can be noted Resident #34 did not have lexapro available for the facility to administer. The documentation in the MAR is erroneous.Progress Notes:7/29/2025 15:18: Per Pharmacy (outside pharmacy that mails Resident #34's medications)., Lexapro prescription needs to be renewed in order to be filled. Message sent to.PA (physician assistant). 8/18/2025 13:30: Phone call to Pharmacy. to determine when next order for Lexapro is being sent; has had no Lexapro for at least 2 weeks. Per pharmacy, last order was filled Dec. 2024 and no order requested since that time. Daughter. handles ordering medications through Pharmacy. and notified of need for medication by staff; currently out of the country.but available by phone. 700 hall med nurse left message for daughter to call. Per pharmacy, will expediate shipment for 90-day supply to daughter. 8/19/2025 09:00: Called Pharmacy.for status on Lexapro. Order is in process to be sent out for mail delivery today; however, it does take 5-7 days.On 8/20/2025 at approximately 1:00 PM, Resident #34 was observed sitting in the common area. She was well dressed and pleasant. On 8/20/2025 at 1:30 PM, Clinical Care Coordinator O was asked why Resident #34 had not received her lexapro in three weeks. She explained the resident's daughter orders the medication from an outside pharmacy, the pharmacy ships the medication to the daughter, who in turn brings it to the facility. At the end of July or early August, a nurse informed her she administered the last pill (lexapro) and when she called the outside pharmacy she was informed there were no refills left on the prescription. Coordinator O contacted the physician and requested a refill. About a week later she followed up with the pharmacy and they again said she did not have any refills. Coordinator O stated she believes the doctor forgot to call in the refill. She called the physician again and when they followed up this week, they stated they were filling the script but it would still be a few days before Resident #34's daughter received the medication.Coordinator O was unsure why the family was not utilizing the facility pharmacy. The coordinator was informed some of her nurses were documenting they were administering Lexapro to Resident #34. She was asked what medication were the nurses giving, since lexapro has not been available in three weeks. Coordinator O reported she did not know what medication the nurses were giving. She was asked if another resident is prescribed Lexapro and she stated yes , but it is a different dosage.Coordinator O shared the medication was not available in backup and an observation was made of the backup medications machine and it indicated Lexapro was not a medication that was offered. Furthermore, review was conducted of 700 medication cart and Resident #34 had the following medications accounted for:2 blister packs of Lisinopril 30 mg1 blister pack of Methenamine Hippurate 1 mg1 bottle of Docusate Sodium 100 mg1 bottle of Lisinopril 30 mg1 bottle of Acetaminophen ER (extended release) 650 mg1 bottle of Amlodipine 5 mg Resident #34 did not have Lexapro available in the medication cart.There is one other resident on 700 hall that is prescribed Lexapro at 10 MG daily. On 8/20/2025 at 2:30 PM, the DON (Director of Nursing) reported she found out about the issues with the Lexapro during their morning meeting on Monday. Typically, they will address things of that nature in morning meetings so they are all on one accord and can follow up as needed. It is a unique situation as the resident receives her medication from an outside pharmacy, and she is not fully abreast of why that is.The DON was informed that some facility nurses were charting they administered Lexapro throughout the month when it was not available. The DON reported this should not have occurred as its inaccurate documentation.

Based on observation, interview and record review, the facility failed to ensure restorative therapy services were provided for two Residents (#36 and 50), of three reviewed for limited range of motion. Findings include: Resident #36 On 8/20/2025, at 2:15 PM, a record review of Resident #36's electronic medical record revealed an admission on [DATE] with diagnoses that included muscle weakness, difficulty in walking and need for assistance with personal care. Resident #36 required assistance with all Activities of Daily Living and had intact cognition. A review of the physician orders revealed NURSING REHAB/RESTORATIVE: ACTIVE ROM Program AROM: Dumb bells 2# 2x15 BI/TRI-2.5 # A.W 2x25 kicks, knee lifts, hip Abd/add and ankle pumps. Static standing x3 to tolerance performing task. Start: 7/31/2025 End: 8/28/25. NURSING REHAB/RESTORATIVE: Walking Program 3 x week CGA FWW 150x2 no WC to follow: Start: 7/31/25 End 8/28/25 A review of the The resident has limited physical mobility r/t (related to) weakness Date Initiated: 04/23/2025 The resident will demonstrate the appropriate use of Therapy ordered device(s) to increase mobility through the review date. Date Initiated: 04/23/2025 Revision on: 07/25/2025 . Approaches . AMBULATION: The resident is able to: 1 assist using 2WRW (wheeled roller walker) room dining room, per therapy w/c (wheelchair) not to follow. Date Initiated: 04/23/2025 . NURSING REHAB/RESTORATIVE: ACTIVE ROM (range of motion) program AROM: (active range of motion) Dumb bells 2# 2 x 15 BI/TRI-2.5# A.W 2 x 25 kicks, knee lifts, hip Abd/add and ankle pumps. Static standing x 3 to tolerance performing task. Start: 7/31/25 End: 8/28/25. Date Initiated: 07/31/2025 . NURSING REHAB/RESTORATIVE: Walking Program 3 x week CGA FWW 150 x 2 no WC to follow. Start: 7/31/25 End: 8/28/25. On 8/20/2025, at 2:24 PM, CNA F was interviewed regarding the documented completion on the task list for Resident #36's ambulation that day. CNA F was asked where Resident #36 ambulated. CNA F offered that they had walked with the resident back and forth from their chair into their bathroom inside their room two times. On 8/20/2025, at 2:26 PM, CNA G was asked if they walked with Resident #36 that day and CNA G offered that they walked back and forth from their chair to the bathroom just one time. On 8/20/2025, at 2:27 PM, Both CNA's F and G were asked if they had walked in the hallway with Resident #36 and both said, no. On 8/20/2025, at 2:39 PM, The Director of Nursing (DON) was asked regarding the task list being check marked completed of ADL AMB 4WW 200 ft SBA no WC to follow and the DON stated, they can ambulate up to 200 feet safely with SBA with the 4 ww. The DON was asked if there was a check mark on the task list if that meant the resident ambulated the 200 feet and the DON offered, yes. On 8/21/2025, at 10:05 AM, Restorative Nurse (RN) D was interviewed regarding Resident #36's restorative therapy progress and how many visits they had received and RN D provided that Resident #36 only had the one day. RN D was asked for all documented completion of their restorative nursing visits. A record review of the restorative notes RN D provided revealed Week of: 7/27/8-2-25 Restorative Program Resident #36 did not receive any restorative therapy for their first week. For Thurs there was an X and for Fri there was nothing noted. For the Week of: 8-3/8-9-25 . Tues there was an X documented. For Wed Thurs they were left blank. On the bottom of the document, There was a handwritten note: pulled to 8's 6-2 under the Wed column and pulled to 8's 6-10 & 7's 10-2. There was an R written in the Fri column. RN was asked why Resident #36 did not receive any restorative therapy for the second week and RN D offered, I only have one Restorative CNA and they got pulled to the floor for resident care and couldn't offer restorative therapy. RN D was asked if they review the restorative completion documents daily and RN D stated, no the restorative CNA fills it out and hands it in on Friday's. On 8/21/2025, at 10:38 AM, Resident #36 was resting in their recliner in their room and offered that they walk to and from the bathroom with the staff and did not mention if they were doing their exercises and how often. On 8/21/2025, at 10:42 AM, Clinical Nurse B was asked regarding Resident #36's restorative therapy and their progress. Clinical Nurse B offered that Resident #36 had not been getting restorative therapy as ordered and Resident #36's wife had brought that to their attention the day prior and was upset. On 8/21/2025, at 12:05 PM, RN D offered, they met with Resident #36 and placed a new order for the resident to walk to the dining room for breakfast. RN D was asked if they offer restorative exercises when the Restorative CNA gets pulled to work as a care CNA and RN D stated, that they do wounds also and do not have time to offer the exercises. Resident #50 A review of Resident #50's medical record revealed an admission into the facility on [DATE] with diagnoses that included incomplete paraplegia, disease of spinal cord, cervical disk disorder with myelopathy, reduced mobility, muscle weakness and need for assistance with personal care. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 15/15 that indicated intact cognition and was dependent on a helper for toileting and personal hygiene, bathing, dressing, chair/bed to chair transfer and roll left and right. On 8/19/25 at 10:27 AM, an observation was made of Resident #50 lying in bed with her feet and lower legs elevated with boots on. The Resident was interviewed, answered questions and engaged in conversation. The Resident reported that she was paralyzed from the waist down. When asked if she had any concerns regarding her care received at the facility, the Resident stated, I am concerned about my legs getting stiff, I can't move them myself, I am supposed to get restorative therapy, but I have not had it for 2 weeks now. The Resident reported that the program made sure her legs received range of motion and that the staff that does the exercises on her legs got pulled to the floor and no one was in to do it. The Resident stated, I have limited movement of my hands, and I can do my hands myself, but I need them to work my legs, I can't do them. I am afraid they are going to get stiff. On 8/20/25 at 2:47 PM, an interview was conducted with Restorative Nurse D regarding Resident #50's restorative therapy plan. The Resident's restorative therapy plan was reviewed with the Nurse who indicated the Resident was passive range of motion for upper and lower extremities but reported that the Resident was off of the plan as of 7/10/25. The Nurse reported that Restorative Therapy was for a set amount of time and that when Resident #50 goes off, they re-add her. The Nurse reported that the Resident was always seen by the Restorative Therapy aide. The Nurse reviewed the last documented Restorative Therapy and indicated that 8/9/25 was the last paper that I have for Resident #50. When asked why no Restorative Therapy was completed, the Nurse reported that the Aide was pulled to the floor and if she was working that section, she would get to the Residents that were on the Restorative Therapy. The Nurse reported that there was not staff that covered and stated, Therapy is supposed to help but they have a full boat, and they can't do it. We had like 20 CNAs that just quit at once. The Nurse reported that the Resident needed Restorative Therapy for both the upper and lower. A review of Resident #50's documentation titled, Rehab Discharge Notice, dated 8/19/25, revealed, ROM: PROM (passive range of motion) to BUE (bilateral upper extremities) all joints 15 x2 to tolerance. Other: PROM to BLE (bilateral lower extremities) ankle flexion/extension, knee flexion/extension, hip abduction/adduction, hip flexion/extension 15x2 to tolerance. On 8/21/25 at 12:02 PM, an interview was conducted with Restorative Nurse D regarding Resident #50's documentation for the Restorative Program. The document revealed Resident #50 was to receive 3 to 5 times (a week). From 8/3 to 8/9 there were two marked days, Tuesday and Friday. Nurse D reported that the marked days with a X represented that the Resident had received the Restorative Therapy on those days. From 7/27 to 8/3 the Resident had three days indicated and from 7/20 to 7/26 there was one day indicated. The Nurse reported that the Restorative CNA gets pulled to the floor and if she has a resident in the area where she is working, she will get in there and do their restorative therapy plan and stated, but she can't cover the whole building when she is working the floor. We had a drop in the CNAs for the last two weeks, and she was unable to get to the Restorative therapy.

Based on observation, interview and record review, the facility failed to ensure that an indwelling urinary catheter bag and tubing were not in contact with the floor during transport of the Resident through the dining area and hallway and when the Resident was seated in their wheelchair in their room, for one Resident (#2), of two reviewed for indwelling urinary catheters. Findings include:A review of Resident #2's medical record revealed an admission into the facility on 4/30/25 with diagnoses that included diabetes, pressure ulcer of sacral region Stage IV, need for assistance with personal care, and dementia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 8/15 that indicated moderately impaired cognition, and the Resident was dependent on helper for activities of daily living, transfers and mobility. Further review of the medical record revealed the Resident had an indwelling urinary catheter. On 8/19/25 at 12:56 PM, an observation was made of Resident #2 in the dining room for the lunchtime meal. The Resident was seated in a wheelchair and was positioned up to the table. An observation was made of a urinary catheter bag inside a privacy bag. The bags were positioned underneath the wheelchair and laying on the floor. The Resident was observed to be moved from the dining area by a staff member and pushed in the wheelchair out of the dining room. The bag was dragging on the ground and could be heard dragging on the floor as they passed by. The Staff did not stop to adjust the catheter bag and tubing but continued down the hall to the Resident's room. On 8/20/25 at 12:52 PM, an observation was made of Resident #2 in the dining room for the lunchtime meal. The urinary catheter bag is inside the privacy bag that was hanging from the seat area of the wheelchair and partially lying on the floor. The Resident was observed to be pushed by staff through the dining area, down the hall to her room with the bag dragging on the floor. On8/20/25 at 1:40 PM, an interview was conducted with the Infection Control Preventionist (ICP), Nurse E regarding placement of a catheter bag and privacy bag of an indwelling urinary catheter. The ICP Nurse reported that the tubing and the bag should not be touching the floor. An observation was made with the ICP Nurse of Resident #2 sitting in the wheelchair in her room. The urinary catheter was in a privacy bag that was partially laying on the floor and the tubing of the urinary catheter was lying on the floor. The ICP Nurse reported that the Resident did not have a urinary tract infection and recently has been getting out of bed. The ICP Nurse reported the bag and tubing should be positioned so neither the tubing nor the bag was on the floor. The ICP Nurse applied gloves and adjusted the bag and tubing. The ICP Nurse indicated that education would be provided to staff. A review of facility policy subject Catheter Care, with an effective date 1/13/09, revealed, .Purpose: To prevent infection within the urinary system. Procedure: . 14. Privacy bags will be changed out when soiled, with a catheter change or as needed. Privacy bags are not to be in direct contact with the floor.

Based on observation, interview and record review, the facility failed to prevent verbal abuse for one (Resident #40) of 19 residents reviewed for abuse, resulting in refused care, frustration with the likelihood of increased behavioral disturbances. Findings include:This citation pertains to intake 2594908 On 8/19/2025, at 12:10 PM, Resident #40 was asked if they were happy with their room and Resident #40 offered, that it was a new room. Resident #40 complained there was a girl that worked there and that they had laughed at their grandmother. Resident #40 offered, that they always say hi to them but this girl has got it in for me. Resident #40 was unable to detail the girl's appearance other than she wore pink outfits. On 8/19/2025, at 12:30 PM, the Director of Nursing (DON) offered, they called CNA H to interview them regarding Resident #40 as they left out of the facility prior to the DON arriving. The DON stated, that CNA H was alerted they would be reported for verbal abuse and that CNA H stated, no worries, I quit. On 8/19/2025, at 10:00 AM, a record review of Resident #40's electronic medical record revealed an admission on [DATE] with diagnoses that included Stroke, Dysphagia, adjustment disorder with anxiety and major depressive disorder. Resident #40 required assistance with all Activities of Daily Living and had recently been deemed incompetent to make medical decisions for themselves. A review of the care plan The resident uses psychotropic medication(s) to manage symptoms of their psychiatric disorder(s). Date Initiated: 02/28/2025 Goal My symptoms/behaviors will be reduced using a combination of psychotropic medication(s) and nonpharmacological interventions through the review date. Date Initiated: . Approaches/Tasks . Provide me with a non-confrontational environment for care. Date Initiated: 02/28/2025 . On 8/20/2025, at 9:20 AM, Resident #40 was resting in bed on back and denied any abuse complaints that day. On 8/20/2025, at 3:27 PM, a phone interview was conducted with CNA I who witnessed the verbal abuse towards Resident #40. CNA I stated, earlier that day they were in caring for Resident #40 and had asked CNA H to bring in the hoyer and assist with a transfer out of the bathroom. CNA I asked Resident #40 if CNA H could assist with the transfer and Resident #40 stated, Nope, get out. At that time, CNA I witnessed, CNA H open the bathroom door hastily and stated to Resident #40, I did nothing to you and you tried to kill me as CNA H attempted to slam the bathroom door shut but CNA H quickly stopped the door from slamming, opened back up and stated to Resident #40, You're crazy and slammed the bathroom door shut before leaving out of the room. CNA I stayed with Resident #40 who complained about CNA H stating, she hates me and that she's out to get me. CNA I completed cares for Resident #40 and propelled them down to the dining room. As CNA I pushed Resident #40 into the dining room, CNA H was overhead and observed pointing towards both Resident #40 and CNA I and loudly stated, and that dumb ass over there wants to call me crazy when she's the crazy one. She tried to kill me. She thinks my grandma's here, and she doesn't even know what she's talking about. CNA I continued to propel Resident #40 towards a dining table and CNA H further stated loudly, At least I'm an independent woman and do things for myself and get my own drinks. CNA I was asked if Resident #40 overheard the abuse and CNA I stated, yes and had to provide reassurance of everyone needs to get along to the resident. CNA I called the Director of Nursing (DON) and alerted of the verbal abuse towards Resident #40 by CNA H . On 8/20/2025, at 10:34 AM, a phone interview was conducted with CNA H regarding the verbal abuse allegation towards Resident #40. CNA H was asked if they called Resident #40 a dumb ass and CNA H stated, they were going to help with a Hoyer lift and the resident said I couldn't help her and that Resident #40 told CNA I they didn't want me to care for her because I was mean to her grandma. She's not right. A week ago, she tried to stab me with a pen. She isn't cognitive. CNA H was asked if they called the resident crazy and CNA H stated, I did not call her crazy. CNA H was asked to explain what happened next and CNA H stated, the resident was on the toilet and they left to the dining room where they were putting meal trays on the cart. CNA H admitted to venting loudly and did admit saying this is some dumb shit. CNA H was asked if there were residents in the dining room and CNA H stated, yes, but they had their back to the residents, was approximately 10 feet away and didn't use resident names. CNA H was asked why they would be accused of verbal abuse and CNA H stated, the nurse has it out for them and that they did not swear in Resident #40's room, that was crazy and further stated, they knew venting in the dining room was wrong and they did not do what they are being accused of.

Based on interview and record review, the facility failed to ensure Preadmission Screening/Annual Resident Review (PASARR) form DCH-3877 and DCH-3878 were completed for one resident (Resident #67) of two residents reviewed for PASARR evaluation.Findings Include: A review of Resident #67's medical record revealed an admission into the facility on 7/30/2003 and readmission on [DATE] with diagnoses that included history of traumatic brain injury, anxiety, mood disorder, mental disorder due to known physiological condition, dementia and need for assistance with personal care. A review of the Minimum Data Set assessment revealed the Resident had severely impaired cognitive skills for daily decision making and was dependent on helper for activities of daily living and mobility. A review of Resident #67's medical record revealed PASARR Level I Screening dated 10/12/2023. The form (Form-3877) indicated Section II-Screening Criteria items 1-6 revealed the following:-1. Yes, The person has a current diagnoses of Mental Illness-2. Yes, The person has received treatment for Mental Illness-4. Yes, There is presenting evidence of mental illness or dementia, including significant disturbances in thought, conduct, emotions, or judgment. Presenting evidence may include, but is not limited to, suicidal ideations, hallucinations, delusions, serious difficulty completing tasks, or serious difficulty interacting with others; with explain any yes, Dx (diagnoses) of anxiety mood disorder and TBE prescribed Buspar.The Form-3877 had directions that indicated, Distribution: If any answer to items 1-6 in Section II is Yes, send one copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record and provide a copy to the patient or legal representative.Resident #67's medical record lacked a DCH-3878 exemption request or information that a Level II screen had been completed. The medical record lacked communication from CMHSP.On 8/21/25 at 9:33 AM, an interview was conducted with Social Services Q regarding Resident #67's PASARR information. SS Q reported that have not been doing the PASARR for the facility and that the Director of Nursing would have the information on the PASARR forms. Resident #67's PASARR forms and Level II screening information were requested. On 8/21/25 at 9:50 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #67's PASARR information. The DON had the PASARR Form DCH-3877, dated 10/12/2023. The DON reported they did not have any other information and stated, The last one was done October 2023. We don't have anything for 2024. I seen it yesterday and sent one out to the health department. The DON reported she had looked for a letter from the health department and stated, I can not find one for 2023, and reported having problems accessing into the website to generate the letters. The DON stated, We did not do one for 2024.

This Citation pertains to Intake Numbers MI00144103 and MI00144517. Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place, interventions were followed and supervision was provided to prevent falls with injury for 2 residents (Resident #38, and Resident #44) of 5 residents reviewed for falls, resulting in Resident #38 falling during a transfer, having pain and a decline in transfer status to a Hoyer lift, and Resident #44 sustaining fractures in her right foot during a transfer. Findings Include: Resident #44: Accidents: On 6/25/24 at 10:56 AM, Resident #44 was observed sitting in a wheelchair in her room. She was alert and talkative. She said she broke some of her toes on her right foot during a transfer in the bathroom. She said she was supposed to have 2 people help her with the transfer and only one staff member assisted her; She stated, I have a twist it board to stand on with transfers and my foot wasn't on it quite right. They said I broke my toes. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #44 was admitted to the facility on [DATE] and recently readmitted on [DATE] with diagnoses: history of a stroke, right sided weakness, heart disease, diabetes, COPD, peripheral vascular disease, hypothyroidism, bipolar disorder, dementia, neuropathy, history of falls, unsteadiness on feet, displaced fracture of third metatarsal (toe) right foot 4/9/2024, displace fracture of fourth metatarsal (toe) right foot 4/9/2024. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15 and the resident was dependent with transfers. A record review of an incident investigation for Resident #44 revealed the following: Resident #44 complained of pain in right foot on 4/7/2024. An x-ray was ordered 4/8/2024 that identified a fracture of distal fourth metatarsal (toe) and a fracture of the third metatarsal right foot. Initially the resident said she did not know how it happened. The resident continued to experience pain and Norco (pain medication) was ordered every 6 hours. An ortho consult was ordered and the resident was ordered to transfer via an electronic lift/Hoyer. The facility interviewed all staff assigned to the resident's hall during a 3 day period 4/5/2024-4/7/2024. Nurse E said on 4/7/2024 she was called to the shower room by an aide because Resident #44 was complaining of pain on the top of her right foot and was unable to put weight on the foot and stand up. It took 3 staff to assist her to transfer. At that time the physician was notified and x-rays were ordered. Nurse E said the resident had also complained of pain to her right foot on 4/6/2024 and requested something for pain. The facility interviewed Certified Nursing Assistant/CNA R on 4/10/2024, she was assigned to care for Resident #44 on 4/5/2024, she said the resident complained of pain during a toilet transfer on 4/5/2024. She said when the resident sat down on the toilet, she said her right foot twisted. She said it hurt at the time, but didn't complain about it for the rest of the night. CNA R said the resident would voice concerns about her right foot at times, because that was the side she had weakness on. The CNA said the resident did twist her foot at times. On 4/12/2024 CNA S was interviewed and said she was assigned to Resident #44 on 4/6/2024 and 4/7/2024 and said the resident complained of pain and needed 3 staff to assist her with transferring. On 4/12/2024 the resident was seen by the orthopedic surgeon and was ordered a EZ Tracker [NAME] boot to be worn for 6 weeks. A review of the physician orders for Resident #44 identified the following: 3/21/2024: Transfers- . Toilet and Shower chair transfers- assist of two. A review of the Care Plans for Resident #44 provided, The resident has an ADL (activities of daily living) self-care performance deficit related to Hemiplegia and Hemiparesis (weakness) following a CVA (stroke), dementia, with Intervention: Transfers: . 2 assist for toileting using stand and pivot disc. On 6/25/24 at 2:43 PM PM Corporate Compliance Officer B was interviewed related to Resident #44.-She said the resident started complaining of pain in her right foot about 4/5/2024 asking the nurse for Tylenol; after a couple days the pain increased. The resident initially said she had not injured it: no fall and she did not bump it. An x-ray was ordered and identified fractures on the right foot 3rd and 4th toes 4/8/2024. The right foot was re-x-rayed 5/9/24 and identified healing, although not yet healed. She said the facility interviewed staff from several days and shifts and identified Certified nurse aide R on 4/5/2024 as transferring the resident by herself with 1 assist. She said the aide was using a twist transfer board that the resident stood on. The Corporate Compliance Officer B said the aide received a reprimand from the Director of Nursing/DON in writing for transferring the resident in the bathroom by herself with 1-assist when she was supposed to have 2-assist. On 7/1/2024 at 11:30 AM, the DON was interviewed about Resident #44 fracturing two toes on her right foot during a transfer in the bathroom. The DON said CNA R had confirmed she transferred Resident #44 with 1 assist in the bathroom and then the resident complained of pain in her right foot. The DON said the CNA was reprimanded for not following the resident's plan of care, as she needed 2 assist with the toileting transfer. 37771 Resident #38: A review of Resident #38's medical record revealed an admission into the facility on [DATE] with diagnoses that included fracture of right femur, obesity, osteoporosis, unsteadiness on feet, difficulty in walking, and muscle weakness. The Minimum Data Set assessment revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 12/15 that indicated intact cognition. Further review of Resident #38's medical record of progress note dated 5/2/24, (Physician's Assistant) notified of possible injury from lowering resident to the floor. Order obtained for Right Knee x-ray and Right hip x-ray for post-fall [lowered to floor from standing position] . Progress note dated 5/3/24, Phone call to (hospital). Spoke with (Nurse's name), floor nurse. Verified per (Doctor's name) resident does not have an Acute Femur Fracture . A review of the Facility Reported Incident revealed the following: Alleged Action: On 5/2/2024 resident (name and medical record number (Resident #38)) was being assisted by CNA (certified nursing assistant also CENA), (name of CNA) with transferring from the side of her bed to her wheelchair. As (name of Resident) was being assisted with sitting on the edge of the bed with gait belt being applied and 2 wheeled rolling walker present, resident slipped resulting in the resident being lowered to the floor with the assistance of CNA, (name). (Resident's name) complained of pain in the right knee/leg immediately post incident with resident receiving PRN (as needed) Oxycodone for pain management. An X-ray of the right knee was obtained with results showing Postsurgical change with a spiral lucency of the distal femur suspicious for fracture. At the time the incident had occurred, it was noted that CNA, (name) was not following the residents plan of care as resident required assist of 2 using a 2 wheeled rolling walker for all transfers. The Resident was sent to a second hospital, and it was determined she did not have a fracture though she was admitted with sepsis, urinary tract infection, right lower leg cellulitis and acute diverticulosis. The Resident was readmitted into the facility on [DATE]. A review of the facility incident report revealed date and time 5/2/24 at 10:15 AM. Incident Description Staff called this writer into resident's room, reported resident lowered to floor after attempting to transfer from bed to WC (wheelchair). Resident found sitting at 90-degree angle on floor, leaning against bed, with both legs bent at the knees, to the right. Resident stated CENA was getting her up for therapy, was sitting on the side of the bed and when CENA helped stand her up, she felt her legs give out. CENA and resident's husband assisted lowering her to the floor On 6/26/24 at 1:42 PM, an interview was conducted with Corporate Compliance Staff, regarding the investigation for Resident #38's fall on 5/2/24. The Staff reported the Resident was getting ready to get up for therapy, husband was in room, sitting on edge of the bed, was being assisted into wheelchair by CNA D, Resident had stood up from the bed and stated she was going down, and assisted to the floor by the CNA. When asked what the Resident's transfer status was at that time, the Staff reported the transfer status was two-person assist with rolling walker or Hoyer lift. The Staff was asked if the CNA had followed the plan of care and indicated the CNA had been by themselves and should have had two staff assisting. When asked why he was not following the plan of care the Staff stated, He could not give me a definitive answer. The Staff reported the husband had not had training in transferring the Resident. The Staff reported the Resident had gone for x-rays at the emergency room , findings indicated post-surgical change and suggestive of a fracture and the Resident was transferred to another hospital from order from the surgeon where it was determined there was not a fracture. The Staff reported that the CNA who had not followed the plan of care for Resident #38 had been suspended until further investigation and was given education. On 6/27/24 at 10:45 AM, an observation was made of Resident #38 in bed with a gown on. The Resident indicated she was to go out again today for a bone density test. The Resident answered questions and engaged in conversation. The Resident was asked about the fall when the Resident had been lowered to the floor. The Resident explained the CNA was helping her into the wheelchair from the bed, had a gait belt on, felt like she was slipping when going to the wheelchair and stated, I ended up on the floor. When asked if one CNA was helping her, the Resident indicated one CNA and stated, They were supposed to have two, and explained that she had been a Hoyer lift and therapy had worked with her on transferring with the walker and they said that was ok, to transfer with the two-person assist. The Resident stated, Now since the accident, they have me getting up with the Hoyer lift now. On 6/27/24 at 1:00 PM, an interview was conducted with Assistant Director of Nursing, Education Nurse C regarding education of staff post Resident #38's fall on 4/2/24. The Education Nurse indicated that a message was sent to all Nursing Staff CNA/RN/LPN: There is new education in Relias CNA Closet Guideline and Transfer Education. Please complete this ASAP. Thank you, dated 5/6/2024. A review of the list of staff that completed the training from the facility document titled, Learner Status, revealed, the course assigned to 107, course completed on time 43, Course completed late 29 and course not complete overdue 35, with a total completion of 67.29% and total compliance % of 40.19%. When asked when the educations due was, the Education Nurse the due date was for 2 weeks and that some staff had not completed the education and stated, it is way past the due date. On 6/27/24 at 2:15 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #38 being lowered to the floor by the CNA on 4/2/24. A review of the CNA not following the plan of care for two-person assist was reviewed. The education provided to staff was reviewed with the DON that not all education was completed by the staff assigned. The DON reported that the Restorative Nurse started doing spot checks for transfers and staff were following transfer status.

This Citation pertains to Intake Numbers MI00140471 and MI00142854. Based on observation, interview, and record review the facility failed to ensure comprehensive documentation and evaluation to prevent the development of an unstageable facility-acquired pressure ulcer for one resident (Resident #63) of seven residents reviewed for alterations in skin integrity, resulting in Resident #63 acquiring and developing an unstageable pressure ulcer. Findings include: Resident #63: During initial tour on 6/25/2024, Resident #63 was observed sitting in bed visiting with his wife. He stated his goal was to return home but know he has some work to do before that can occur. On 6/25/2024 at approximately 1:30 PM, a review was completed of Resident#63's medical records and it revealed he initially admitted to the facility on [DATE] with multiple readmissions with diagnoses that included, Chronic Osteomyelitis, Diabetes, Acute Kidney Failure, Metabolic Acidosis, Monoplegia, Pressure Ulcer of Sacral Region, Stage 4, Bipolar disorder, Anxiety and Agoraphobia. Resident #63 is alert and oriented and able to make his needs known. Further review was complete of the records the resident discharged from the facility on 3/14/2024 and readmitted on [DATE]. On 06/27/24 at 09:00 AM, an interview was conducted with Wound Nurse J regarding Resident #63's coccyx/sacrum wound. Nurse J explained he readmitted to the facility on [DATE] and the area was documented at MASD on admission, 3/19/2024 and 4/5/2024. The area was not documented on the initial nursing admission assessment and there was not consistent, ongoing assessment/monitoring of the area. The wound developed as an unstageable coccyx wound that was facility acquired. Further review was conducted of Resident #63's record and yielded the following results: Progress Notes: 4/6/2024 at 12:36: .Noted resident's coccyx excoriated area now open with slough and necrotic tissue covering wound bed . 4/23/2024 at 08:24: .Coccyx Sacrum large necrotic unstageable pressure ulcer, staged at stage 4 per wound clinic however wound base is not visible with wound bed being 100% necrotic grey attached slough and scattered eschar noted, wound edges are irregular and non-rolling, large amount of purulent grey dark bloody drainage noted soaked entire dressing, however no odor noted, with noting BM was also in wound base as wound is very close to anus . 5/7/2024 at 07:32: .Coccyx wound has decreased some still remains unstageable with necrotic grey slough and eschar scattered throughout . Care Plan Revisions: .FA (facility acquired) unstageable to coccyx sacrum . Admission Assessment 3/18/2024: .wound to foot . There was no documentation regarding coccyx/sacrum skin alterations. Skin Observation Assessments: 3/19/2024: .intra-gluteal cleft- masd .MASD skin noted to intra-gluteal clef and peri area. Will continue to monitor and apply barrier cream after toileting . It can be noted after reviewed March 2024 MAR (Medication Administration Record) it showed the order for barrier cream was not ordered until 3/30/2024. 3/25/2024: There were skin concerns documented. 3/29/2024: There were skin concerns documented. 4/5/2024: Sacrum 11 x 3.1 x 0- MASD .Area remains present with MASD. Area appears to be getting smaller .Odor continues, moderate amount of drainage noted. 4/6/2024: Coccyx- pressure- unstageable .Resident noted with open area to sacral/coccyx, area previously presented at irritation from fecal contact; resident has been sitting in recliner without relief of pressure. Wound care initiated and message to wound nurse for assessment . 4/12/2024: .Sacrum presents with both beefy red, necrotic, and slough . There were no measurements listed. 4/20/2024: Coccyx- Pressure . There were no measurements listed. 4/23/2024: .Coccyx/sacrum- Pressure- 8.2 cm x 7.5 cm UTD (unable to determine) - Unstageable .Coccyx Sacrum large necrotic unstageable pressure ulcer, staged at stage 4 per wound clinic however would base is not visible with wound bed being 100% necrotic grey attached slough and scattered eschar noted ,wound edges are irregular and non -rolling, large around of purulent grey dark bloody drainage notes soaked entire dressing . 5/2/2024: Coccyx/sacrum- Pressure- 8.2 cm x 7 UTD- Unstageable . Coccyx Sacrum large necrotic unstageable pressure ulcer, staged at stage 4 per wound clinic however would base is not visible with wound bed being 100% necrotic grey attached slough and scattered eschar noted ,wound edges are irregular and non -rolling, mod amount of sero/sang grey tinged bloody drainage noted . 5/7/2024: Coccyx/sacrum- Pressure- 7.5 cm x 6.9 cm x UTD- Unstageable . Coccyx Sacrum large necrotic unstageable pressure ulcer, staged at stage 4 per wound clinic however would base is not visible with wound bed being 100% necrotic grey attached slough and scattered eschar noted, wound edges are irregular and non -rolling, mod amount of sero/sang grey tinged bloody drainage noted . 5/17/2024: Coccyx/sacrum-Pressure-7.5 cm x 6.8 cm x UTD Unstageable . Coccyx Sacrum large necrotic unstageable pressure ulcer, staged at stage 4 per wound clinic however would base is not visible with wound bed being 100% necrotic grey attached slough and scattered eschar noted ,wound edges are irregular and non -rolling, mod amount of sero/sang grey tinged bloody drainage noted . When the wound was acquired there the wound measurements were not consistently documented. Wound Clinic Notes: 3/25/2024: There was no mention of coccyx wounds. 4/15/2024: wound care for L (left) foot and BIL buttocks wounds . Wound #5 status open. Original cause of wound was Pressure Injury. The date acquired was: 3/1/2024. The wound is currently classified as Category/Stage IV wound with etiology of Pressure Ulcer and is located on Right Medial Coccyx. The wound measures 5.2 cm length x 7.3 cm width 3.1 cm depth .There is a medium amount of purulent drainage noted . 4/22/2024: .Wound #5 status open. Original cause of wound was Pressure Injury. The date acquired was: 3/1/2024. The wound is currently classified as Category/Stage IV wound with etiology of Pressure Ulcer and is located on Right Medial Coccyx. The wound measures 6.3 cm length x 5.6 cm width x 3.3 cm depth . 4/29/2024: .Stage 4 coccyx wound which was surgically debrided while inpatient. Patient has a lot of necrotic non viable tissue present to wound bed of coccyx wound. Wound debridement was done today .Wound #5 status open. Original cause of wound was Pressure Injury. The date acquired was: 3/1/2024. The wound has been in treatment 2 weeks. The wound is currently classified as Category/Stage IV wound with etiology of Pressure Ulcer and is located on the Right Medial Coccyx. The wound measures 7.2 cm length x 6.7 cm width x 4 cm depth; 37.888 cm ^2 area and 151.55 cm ^3 volume .foul odor after cleansing was noted .There is a small (1-33%) amount of necrotic tissue within the wound bed including Eschar and Adherent slough . 5/6/2024: .Pressure ulcer of right buttock, stage 4 . 5/13/2024: .Pressure ulcer of right buttock, stage 4 . On 6/27/2024 at 11:00 AM Resident #63's wound was observed in the presence of Wound Nurse J. Resident observed lying in bed on back, air mattress on bed, resident turned to left side, he said he can't turn to the right side because he does not have a grab bar on that side and can't turn himself over that way. He has a small grab bar on the upper left side of his bed. Resident with dressing dated 6/26/2024- dressing with copious amount brown drainage and a very foul smell. The wound nurse was asked about it and she said it was wound drainage and she thought it might be infected. She said the resident was routinely seen by the wound clinic and they did not culture the wound on his last visit. The resident was observed to have a large wound between the gluteal folds- the wound nurse said she completed measurements, and they were in the chart Skin Observation dated 6/25/2024. The wound was approximately 4 cm x 2 cm with depth. Very near the resident's anus. The wound was bright red with some yellow and black necrosis. The nurse cleansed the wound with normal saline and applied the dressing: triad paste to outside of wound, calcium alginate silver to wound bed and abd pad over top. The resident was asked if he already had the wound on admission and he stated, No. I got it here. He said he came to the facility for wounds on his feet and then developed the wound on his sacrum. He said he has trouble turning in bed, fell out of bed and then had been sitting for prolonged periods of time in a bedside recliner. He said the wound developed after that. On 07/01/24 at 01:06 PM, an interview was conducted with Nurse Practitioner I regarding Resident #63's coccyx/sacrum wound. Nurse Practitioner I stated the wound began at the facility. Review was completed of the facility policy entitled, A.M and H.S. Care, revised 11/4/21. The policy stated, .Inspect residents' skin for redness and open areas during care. Report any changes in condition to charge nurse . Review was completed of the facility policy entitled, Wound Care, revised 6/24/29. The policy stated, All new wounds noted will be measured by the wound care nurse or designee within one business day .Wound care nurse to document wound progress note with all new admission that skin assessment was reviewed and skin treatments are in place ordered.

This Citation Pertains to Intake MI00142721 Based on observation, interview and record review, the facility failed to administer a nebulizer treatment according to professional standards for Resident #35, administer medications as prescribed by the physician for Resident #224 and Resident #322, and ensure standards of practice for appropriate diagnosis and use of multiple psychotropic and antipsychotic medications for Resident #377, of seven residents reviewed for medication administration and five residents reviewed for medication regimen review, resulting in Resident #35 not assessed prior to administration or monitored during the duration of a nebulizer treatment with the potential for complications to go unnoticed, untreated or not receive the prescribed amount of medication used to treat lung disease, the potential for exacerbation of medical conditions for Resident #35, Resident #224 and Resident #322, and inappropriate diagnosis and treatment for Resident #377. Findings include: Resident #35: On 6/27/24 at 8:40 AM, an observation was conducted during the medication administration task of the survey of Nurse L preparing to give Resident #35 an Albuterol 2.5mg (milligrams)/3 ml (milliliters) breathing treatment. Resident #35 was sitting up in their wheelchair. The Nurse put the medication into the medication chamber of the nebulizer that was attached to a mask. The Nurse put the mask on the Resident, turned on the nebulizer at 8:45 AM and left the room. The Nurse was not insight of Resident #35. Nurse L continued with her medication pass. On 6/27/24 at 8:50 AM, an observation was made of CNA B entering Resident #35's room. The CNA left the room and had shut the door. The Resident was not insight of Nurse L who had administered the nebulizer treatment nor did Nurse L monitor the inhalation therapy. On 6/27/24 at 8:55 AM, CNA B entered the Resident #35's room with another surveyor and closed the door. Surveyor observation of CNA and Resident #35 On 6/27/24 at 8:55 AM, an observation was made of Resident #35 sitting in their wheelchair and had a nebulizer mask on receiving a nebulizer treatment. The Nurse was not in the room. The CNA was observed to remove the nebulizer mask from the Resident, shut the nebulizer machine off and laid the mask on the bedside table. The CNA performed morning care for the Resident. At 9:18 AM, on the completion of AM care, CNA B was queried regarding the nebulizer treatment. The CNA stated, I have to have the nurse do it. On 6/27/24 at 9:18 AM, CNA B and the surveyor were observed to leave Resident #35's room. Nurse L was not informed of the discontinuation of the nebulizer treatment. The Nurse did not check on the Resident after the AM care was given. On 6/27/24 at 10:15 AM, an interview was conducted with Assistant Director of Nursing, Education Nurse C regarding the administration of nebulizer treatments and facility policy. The Education Nurse was asked about standards of practice of assessment of lungs and vital signs. The Education Nurse indicated that the lung sounds should be assessed and vital signs taken prior to receiving the nebulizer treatment and the Nurse should monitor the Resident while the breathing treatment was given. A review of the facility policy that the Education Nurse indicated they followed revealed the following with a title Performance Checklist Skill 21.8 Using Small-volume Nebulizers, Assessment: .5. Assessed pulse, respirations, breath sounds, pulse oximetry, and peak flow measurements if ordered . 12. Had patient take a deep breath; encouraged brief, end-inspiratory pause; had patient exhale passively: .b. Reminded patient to repeat breathing pattern until drug was completely nebulized . Evaluation: 1. Assessed patient's respirations, breath sounds, cough effort, sputum production, pulse oximetry . On 6/27/24 at 10:56 AM, an interview was conducted with Nurse L regarding Resident #35's nebulizer treatment and facility policy. When asked about assessment of lung sounds, pulse, respirations and O2 saturation, the Nurse stated, I didn't know we had to do that. The Nurse was asked about not staying with the Resident during the treatment and if the Resident had received the full treatment. The Nurse stated, Yes, I should be sure he gets it all. An observation was made with Nurse L of Resident #35's room. The Resident was not in the room at that time. The nebulizer mask was assembled and laying on its side on the bedside table. An observation was made of the medication chamber with a small amount of liquid in the chamber. The Nurse stated, I can see some of the liquid still in there. The Nurse was asked about storage of the nebulizer and the Nurse reported they store them inside a bag. When asked if they rinsed and dried the nebulizer equipment prior to storage, the Nurse stated, No not usually, we just put it in the bag. A review of the facility policy titled, Nebulizer Equipment, dated 10/27/21, revealed, Policy: Nebulizer equipment will be properly cleaned and stored to prevent contamination and the potential for spread of infection. Procedure: Equipment for the treatment of respiratory conditions will be disassembled, cleaned, and stored in the Resident's room after every use . e. Wash, in Resident bathroom, using warm water and using a wash basin/barrier. d. Rinse thoroughly, pat excess water with paper towels. e. Allow to air dry on a barrier with second barrier covering the equipment. f. May store in respiratory bag once completely dry . Resident #224: On 6/27/24 at 9:11 AM, during observation of medication administration task, Nurse L was observed to prepare medication for Resident #224. The Nurse prepared the Residents medication and put them in a cup. The Protonix 40mg delayed release was not available. When asked why the medication was not available, Nurse L indicated that it had to be ordered and they did not have it available in the facility. The Nurse retrieved the Resident's inhaler from the box with the Residents name on the inhaler and box. The Nurse had to retrieve medication from the medication storage room refrigerator. Prior to retrieving the refrigerated medication, the Nurse wrote the Resident's name on the cup of medications and placed the cup and the inhaler in a top drawer of the medication cart. The Nurse retrieved the medication from the med room refrigerator and took out the cup of medications from the top drawer and administered the medications to the Resident who was at the medication cart waiting for their medication. The Nurse did not retrieve the inhaler from the top drawer or administer the inhaler to the Resident. At 9:12 AM, the Resident was waiting at the medication cart and an observation was made of Nurse L administering the oral medication to Resident #224. The Resident was waiting for the medication and had Therapy staff that was taking him to therapy. The medication received included: Augmentin ES-600 5 ml (milliliters). Calcium Carbonate chewable 500 mg (milligram) tablet. Prednisone 10 mg tablet. Fenasteride 5 mg tablet. Flomax 0.4 mg capsule. Psyllium Husk powder, 6 gm (grams) mixed in water. A review of Resident #224's medication orders and scheduled administration times revealed the following: -An order for Augmentin ES-600 oral suspension, give 5 ml (milliliters) by mouth every 12 hours for post-surgery for 7 days and was scheduled to be given at 7:00 AM. The medication was given late. -An order for Protonix tablet delayed release 40 mg, give 1 tablet by mouth two times a day for GI (gastrointestinal) upset and scheduled at 7:30 AM. The medication was not given due to not being ordered or available in the facility. -An order for Calcium Carbonate tablet chewable 500 mg, give 1 tablet by mouth before meals for GI upset and scheduled at 7:30 AM. The medication was given late and the Resident was heading to therapy. -An order for Symbicort inhalation aerosol, 2 puff inhale orally two times a day for SOB (shortness of breath), COPD (chronic obstructive pulmonary disease). The medication was not given during the observation of medication administration. Resident #322: On 6/27/24 at 9:26 AM, an observation was made of Nurse L setting up medication and administering medication to Resident #332. The medication included: Aspirin EC (enteric coated) 81 mg. Acetaminophen 325 mg, two tablets. Omeprazole DR (delayed release) 20 mg. Prednisone 10 mg, two tablets. Folic Acid 1 mg tablet. Lexapro 10 mg tablet. Lispro insulin 16 Units SQ (subcutaneous). A review of Resident #322's medication orders and scheduled administration times revealed the following: - Aspirin EC tablet, Delayed Release 81mg, give 1 tablet by mouth one time a day for supplement, scheduled at 8:00 AM. The medication was given late. -Acetaminophen 325 mg, give two tablets by mouth three times a day for pain, scheduled at 8:00 AM. The medication was given late. -Omeprazole DR (delayed release) 20 mg capsule, give 1 tablet by mouth one time a day for GI upset, scheduled at 8:00 AM. The medication was given late. -Prednisone 10 mg, give two tablets by mouth one time a day related to bullous pemphigoid for 14 days scheduled at 8:00 AM. The medication was given late. -Folic Acid 1 mg tablet, give 1 tablet by mouth one time a day for supplement, scheduled at 8:00 AM. The medication was given late. -Lexapro oral tablet 10 mg, give 1 tablet by mouth one time a day related to depression, scheduled at 8:00 am. -Insulin Lispro 100 units/ml, inject 16 Units subcutaneously three times a day related to Type 1 diabetes mellitus with hyperglycemia. On 6/27/24 at 9:35 AM, at the conclusion of the observation of medication administration task with Nurse L, the Nurse was asked about the medication left in the top drawer of the medication cart. The Nurse had opened the drawer where she had placed the medication. Resident #224's inhaler was in the drawer with another resident's medication that was placed in a cup. The Nurse was asked about the inhaler for Resident #224 and indicated she had not given it and reported she would give it to the Resident when he came back from therapy. The electronic medical record (EMR) showed the medication on the computer with a red background for Resident #322 that indicated they had not been given timely. When asked about the red background on the EMR for Resident #322 and for Resident #224, Nurse L indicated they were given late and stated, I started late and didn't get to them. On 6/27/24 at 11:07 AM, an interview was conducted with the Clinical Supervisor (CS) E regarding late medications. The late medications during medication administration observation were reviewed with the CS. The CS indicated that many of the medications would be late due to Residents not wanting to wake up early or leave of absence. The CS indicated that the medication was to be given within two hours of when it was scheduled, one hour before scheduled and one hour after scheduled. The CS indicated that the 400 hall was a heavy floor, can't get it done in two hours, and that some of the early meds that need to be taken early, try to get to them first thing but that does not always happen. When asked about the facility policy for the administration of nebulizer treatments, the CS reported that the Nurse was to assess lungs sounds, check SPO2, before and after administration of the nebulizer treatment. 37668 Resident #377: Review of Intake documentation dated as received 2/12/24 revealed allegations that Resident #377 was over sedated. The intake specified, (Resident #377's) health has declined drastically in two weeks. (Resident #377) can no longer walk or talk. The intake detailed the facility is giving (Resident #377) Risperdal (antipsychotic medication commonly used to treat schizophrenia and bipolar disorder) which causes them to be hunched over, and a sleeping medication. Information within the intake revealed the complainant believed the facility was keeping (Resident #377) drugged up so they won't have to deal with them. The intake revealed the Resident was 57-years old male with and they did not believe the facility was used to taking care of a younger man with dementia. Record review revealed Resident #377 was originally admitted to the facility on [DATE] with diagnoses which included early onset Alzheimer's disease, Pick's disease (also called frontotemporal dementia (FTD)- rare neurodegenerative disease that is similar to Alzheimer's disease but effects specific areas of the brain and is the most common type of dementia in individuals younger than 60), generalized anxiety, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, ambulated independently without an assistive device, and required supervision and/or set up assistance with toileting/personal hygiene activities. The MDS further revealed the Resident displayed no hallucinations and/or delusions but did display wandering, physical and verbal symptoms directed towards others as well as other behavioral symptoms not directed toward others one to three days during the seven-day look back period which did not have a negative impact on the Resident or others. Review of Resident #377's Face sheet revealed the diagnoses, Psychotic Disorder with Delusions due to Known Physiological Condition and Anxiety Disorder were added to the Resident's medical record while at the facility on 1/17/24. Review of Resident #377's Electronic Medical Record (EMR) revealed an Attending Physician's Admission and Annual assessment dated [DATE] which detailed, Diagnosis: Pick's Disease - front temporal lobe dementia with behavioral disturbance, generalized anxiety . Pleasant [AGE] year-old . male . has been living at home until now. (Spouse) is still working and is finding it difficult to take care of him at home . (Resident #377) is currently on no medications . quite agitated and behavioral when family was trying to leave him (at facility) . was very upset . lashing out at staff and facility. 1 mg (milligram) Ativan (anti-anxiety medication) IM (intramuscular injection) was given and did calm down . Assessment/Plan . Very behavioral and argumentative and swearing and lashing out at family and staff . did give Ativan . still very alert and active. Going to start Lexapro (antidepressant) 10 mg daily as well as Ativan 0.5 mg every 8 hours as needed . does appear to look as a regular visitor . will be seeing (Mental Health Provider) as well . Review of Resident #377's Electronic Medical Record (EMR) revealed the following Admission Documentation: - 11/30/23 12:50 PM: Nurses Note Narrative . Resident arrived to facility @ 12:30pm via private vehicle. Resident and family were escorted to 700 hall and sat in TV room to wait for Admission's Coordinator. Resident was calm until family went to leave. Resident became verbally combative with family and staff. Pushing on doors, yelling, unable to redirect resident. Resident became physically aggressive with family. Notified (Physician Assistant [PA]). Obtained order for 1 mg (milligram) Ativan (controlled medication used to treat anxiety and agitation) to be given IM (intramuscular injection) STAT . - 12/6/23 at 10:20 AM: Social Service Assessment . 1. Psychosocial: (Resident #377) came to the facility from home . was previously living with (Family Member G) but (Family Member G) is unable to care for him due to his Alzheimer's Disease. (The Resident) is a poor historian and is unable to give information . is known in the community as having worked at (Car Dealership) in the collision department for many years. He enjoys sports, hunting, and fishing . 2. Behavior . has had difficulty adjusting to being placed at the facility for long term care . behaviors are dementia related . (Mental Health Provider) and PCP (Primary Care Provider) are monitoring . Mood . scored 0/27 on PHQ-9 assessment indicating . no depressive symptoms . The following care plans pertaining to psychoactive medications were present in Resident #377's EMR: - The resident uses psychotropic medications Risperdal (antipsychotic medication indicated for the treatment of schizophrenia and bipolar disorder) and Haldol (antipsychotic medication indicated for the treatment of schizophrenia) r/t Alzheimer's disease with psychotic disturbance (Initiated: 12/7/23; Revised: 1/17/24). Haldol was added to the care plan as the revision on 1/17/24. Note: Both Risperdal and Haldol have black box warnings from the Food and Drug Administration (FDA) detailing the medications are not approved for the treatment of patients with dementia-related psychosis and may increase risk of death. - The resident uses anti-anxiety medications Ativan (controlled benzodiazepine class medicine used to treat anxiety) r/t Anxiety Disorder (Initiated and Revised: 12/7/23) - The resident uses antidepressant medication Lexapro (medication used to treat depression and anxiety) r/t Poor adjustment to admission to the facility. Resident also has a DX (diagnosis of Alzheimer's Disease with Psychotic Disturbance (Initiated and Revised: 12/7/23) Note: The diagnosis Alzheimer's Disease with Psychotic Disturbance was not included on Resident #377's face sheet/diagnosis list. An interview was completed with Social Services Director H on 6/26/24 at 2:27 PM. When queried if they recalled Resident #377, Director H verbalized they did and stated they were admitted directly from home to the facility because, Their (spouse) couldn't handle them at home. When asked about their stay at the facility, Director H replied, (Resident #377) could be aggressive with other residents and staff. When asked what happened to the Resident, Director H replied, Went out to the hospital, was put on Hospice and never came back. When queried if Resident #377 was receiving psychotropic medications, Director H confirmed they were. With further inquiry, Director H disclosed Resident #377 was not taking any psychotropic medications upon admission and all psychoactive medications were initiated at the facility. Resident #377's psychoactive medication consents and related documentation were requested from Director H at this time. At 2:54 PM on 6/26/24, Social Services Director H provided a paper consent form for Resident #377 titled, Informed Consent Psychotropic Medications. The form was signed by Resident #377's Representative Family Member Witness G and Social [NAME] Director H on 2/8/24. The Health Care Provider signed the consent form on 2/26/24. The consent included five medication names with no doses and/or administration routes. When asked if all the medications listed were started on 2/8/24, Director H replied, No. Director H was asked why the consent was dated 2/8/24 if the medications were not started then and stated, We get rid of old consents and only keep the new ones. When asked why, Director H replied, I don't know, just what we do. Review of the provided Informed Consent Psychotropic Medications form dated 2/8/24 for Resident #377 detailed, The resident's physician has ordered, or is considering ordering the following psychotropic medication (s) . Olanzapine (brand name - Zyprexa-antipsychotic medicine for treatment of schizophrenia and bipolar disorder), Ativan, Lurasidone (brand name- Latuda- antipsychotic medication indicated for the treatment of schizophrenia and bipolar disorder), Lexapro, Trazodone (indicated to treat major depressive disorder). Related Diagnosis: Psychotic Disorder with Delusions, Anxiety, Major Depressive Disorder . Therapeutic Classification: Antianxiety . Antidepressant . Antipsychotic . Note: Both Olanzapine (Zyprexa) and Lurasidone (Latuda) have black box warnings from the FDA specifying the drugs are not approved for the treatment of patients with dementia-related psychosis and may increase risk of death. When queried if all the psychoactive medications which had been prescribed and/or administered to Resident #377 were listed on the consent form, Director H did not reply. When asked why Haldol and Risperdal were listed on the Resident's care plan but included on the provided consent, Director H repeated prior statement that the facility only maintains the most recent psychotropic medication consent. Director H was then asked how they were able to show that informed consent was obtained prior to initiation of all medications and revealed they were not. When queried why multiple antipsychotic medications were initiated, Director H revealed the medications were started due to Resident #377's behavior. With further inquiry, Director H revealed Resident #377 was very confused, wanted to leave the facility, and would become very agitated and aggressive with others. When queried what non-pharmacologic interventions were attempted prior to medication initiation, Director H indicated staff attempted to redirect the Resident. When asked about revision and implementation of personalized interventions, Director H restated staff would attempt to redirect the Resident but did not provide specific interventions. Director H then stated the Resident had been sent to the hospital ER more than once due to their behaviors. Director H was asked how many times Resident #377 was sent to the ER related to behaviors and indicated it was more than once but were unsure without reviewing the EMR. When asked what happened when the Resident was sent to the ER related to behaviors, Director H relayed the ER would simply send the Resident back to the facility. A timeline of all Resident #377's non-pharmacological and pharmacological interventions were requested as well as the facility policies/procedures related to Dementia/Alzheimer's care and Psychoactive Medications at this time. Review of Resident #377's Order Summary documentation in the EMR revealed the Resident was started on Ativan, Haldol, Klonopin, Lexapro, Lurasidone, Olanzapine (Zyprexa), Risperdal, and Trazadone at the facility. A detailed review revealed the following psychoactive medication orders: - Ativan Injection Solution 2 mg (milligram)/mL (milliliter) .Inject 1 mg intramuscularly one time only for anxiety/aggressive behavior . Completed . (Ordered: 11/30/23; Discontinued: 11/30/23) - Ativan Solution 2 mg/mL . Inject 1 mg intramuscularly one time only for Anxiety/Aggression for 1 day (Ordered: 11/30/23; Discontinued: 12/1/23) - Ativan Oral Tablet 0.5 mg . Give 1 tablet by mouth every 8 hours as needed for anxiety . for 14 Days (Ordered: 11/30/23; Discontinued: 12/5/23) - Ativan Oral Tablet 0.5 mg . Give 1 tablet by mouth every 6 hours as needed for anxiety . for 14 Days (Ordered: 12/5/23; Discontinued: 12/19/23) - Ativan Oral Tablet 0.5 mg . Give 1 tablet by mouth every 6 hours as needed for anxiety . for 14 Days (Ordered: 12/19/23; Discontinued: 1/2/24) - Ativan Oral Tablet 0.5 mg . Give 0.5 mg by mouth one time only . Completed . (Ordered: 12/25/23; Discontinued: 12/26/23) - Ativan Oral Tablet 0.5 mg . Give 1 tablet by mouth every 6 hours as needed for anxiety . for 14 Days (Ordered: 1/2/24; Discontinued: 1/15/24) -Ativan Oral Tablet 0.5 mg . Give 1 tablet by mouth two times a day for Anxiety/agitation (Ordered: 1/4/24; Discontinued: 1/22/24) - Ativan Oral Tablet 0.5 mg . Give 1 tablet by mouth every 6 hours as needed for anxiety . for 14 Days (Ordered: 1/15/24; Discontinued: 1/22/24) - Ativan Oral Tablet 1 mg . Give 1 tablet by mouth every 4 hours as needed for anxiety/agitation related to Dementia . for 14 Days (Ordered: 1/22/24; Discontinued: 1/31/24) - Ativan Oral Tablet 1 mg . Give 1 tablet by mouth two times a day related to dementia . (Ordered: 1/22/24) - Ativan Oral Tablet 1 mg . Give 1 tablet by mouth every 4 hours as needed for anxiety/agitation related to Dementia . for 14 Days (Ordered: 1/31/24) - Ativan Injection Solution 2 mg (milligram)/mL (milliliter) .Inject 1 mg intramuscularly Inject 1 mg intramuscularly every 8 hours as needed for Anxiety-severe agitation for 14 days . (Ordered: 1/31/24) - Ativan Solution 2 mg/mL . Inject 1 mg intramuscularly every 8 hours as needed for anxiety/agitation for 7 Days (Ordered: 12/1/23; Discontinued: 1/8/24) - Haloperidol (Haldol) Tablet 1 mg . Give 1 tablet by mouth three times a day related to Dementia . (Ordered: 1/17/24; Discontinued: 1/22/24) - Haloperidol Tablet 5 mg . Give 1 tablet by mouth three times a day related to Dementia . (Ordered: 1/22/24; Discontinued: 1/29/24) - Haloperidol Tablet 10 mg . Give 1 tablet by mouth two times a day for anxiety (Ordered and Discontinued: 2/7/24) - Haloperidol Tablet 10 mg . Give 1 tablet by mouth two times a day for Anxiety and severe agitation (Ordered: 1/29/24; Discontinued: 2/7/24) - Klonopin Oral Tablet 0.5 mg . Give 2 tablet by mouth one time only for anxiety for 1 Day (Ordered: 1/12/24; Completed: 1/13/24) - Klonopin Oral Tablet 1 mg . Give 1 tablet by mouth at bedtime for anxiety/agitation (Ordered: 1/11/24; Discontinued: 1/17/24) - Lexapro Oral Tablet 10 mg . 1 tablet by mouth one time a day for anxiety (Ordered 11/30/23; Discontinued: 1/4/24) - Lexapro Oral Tablet 20 mg . 1 tablet by mouth one time a day for anxiety (Ordered: 1/4/24) - Lurasidone . 20 mg . 1 tablet by mouth one time a day for agitation (Ordered: 1/31/24) - Olanzapine . 5mg . 1 tablet by mouth one time a day for anxiety (Ordered: 2/7/24) - Risperdal . 2 mg . Give 1 tablet by mouth one time a day related to dementia .for 3 Days (Ordered: 12/5/23; Discontinued: 12/9/23) - Risperdal . 2 mg . Give 1 tablet by mouth two times a day related to dementia . (Ordered: 12/5/23; Start Date: 12/9/23; Discontinued: 2/2/24). The discontinuation reason listed was, reduced per POA (Power of Attorney) request. - Risperdal . 2 mg . Give 0.5 tablet by mouth two times a day related to dementia . (Ordered: 2/2/24; Discontinued: 2/7/24) - Trazadone . 100 mg . 1 tablet by mouth at bedtime for insomnia (Ordered: 1/11/24) - Trazadone . 50 mg . 1 tablet by mouth at bedtime for insomnia (Ordered: 1/8/24; Discontinued: 1/11/24) Review of Resident #377's EMR revealed Family Member Witness G was Resident #377's elected and activated Durable Power of Attorney (DPOA). Review of documentation in Resident #377's EMR demonstrated behaviors were not documented daily in progress notes. Additionally, the Behavioral Monitoring and Interventions report from 1/1/24 to 6/2/24 revealed no documentation of any behaviors and/or interventions and no behavior monitoring documentation was present in the scanned section of the EMR. Review of Mental Health Provider documentation in Resident #377's EMR revealed the following: -- 12/21/23: Social Worker Note: Complaint: Picks disease . Disposition: (Resident #377) is trying to engage self- level of frustration gets high and that is when his anger and agitation increases Has a hard time with word finding and engaging in conversations. This has been a process up until he could no longer manager at home . outbursts seem to be a build of thoughts in his mind that he is not able to express. Encourage activity level . - 1/15/24 PA Note: Complaint: agitation pacing, aggressive, poor concentration . spoke with staff . has not improved . according to nursing staff, has declined. The holidays were overwhelming for him . attention is poor . does not retain information. Redirection is hit and miss . Demeanor: Impulsive . Judgement: Impaired . Insight: Impaired . Impulse Control: Impaired . Speech: Word finding . cannot express anger or frustration . Thought Process: Disorganized . Flight of Ideas: It is difficult to determine what he is thinking . Memory . Severe Impairment . Mood: Distressed, aggressive, angry, combative, aggressive, sad, irritable . Trouble staying asleep . Assessment and Plan: Major depression disorder, single episode . Plan: 1:1 supportive care . - 1/17/24: PA Note: Complaint: aggressive behavior, choking staff member . Current Medications: Trazadone . 100 mg (at bedtime), Lexapro . 20 mg, Risperdal . 2 mg (two times per day), Ativan 0.5 . (Two tablets . every six hours PRN .) Changes in psychiatric and/or other relevant medications include the following: Started on Lexapro (start date: 11/30/23). Ativan PRN ordered by PCP (Primary Care Provider) . (Resident #377) has since started being physically aggressive, grabbing CNA by the throat against the wall. Redirection and Ativan use not effective. Was sent to ER . came back with no new orders recommending . start Haldol 1 mg TID (three times a day) .met with resident in person today . Demeanor: Impulsive, Resistant, Oppositional . Judgement: Impaired . Insight: Impaired . Impulse Control: Impaired . Speech: Disorganized . Thought Process: Disorganized . Thought Content: Delusional Material Not Expressed . Memory . Severe Impairment . Mood: anxious, angry, irritable . Delirium: + Present (Believes he is able to go home, does not know he has severe dementia. Does know know his own reality [sic]) . Assessment and Plan: Major depression disorder, single episode . Plan: 1:1 supportive care . Anxiety disorder . Plan: Lexapro; Ativan PRN 14 days . Dementia . Picks Disease . Plan: Supportive Care . Psychotic disorder with delusions due to known physiological condition (new). Plan: Haldol . Recommending . non-pharmacologic interventions such as: creating a calm environment and removing stressors when possible . implementing soothing rituals. Limit caffeine use. Avoiding environmental triggers noise, glare, and background distraction can act a triggers . Check for pain, hunger, thirst, full bladder, fatigue, infections . Making sure the room is at a comfortable temperature. Being sensitive to fears, misperceived threats and frustration with expression what is wanted. Simplifying tasks and routines, Providing an opportunity for exercise. Document any symptoms of aggression . - 1/29/24: PA Note: Complaint: agitation . seen my request of staff and PCP for immediate action . patient continues to have psychosis, delusions with agitation, hitting, refusing care, throwing items, resisting care/medications, striking staff member . Picks disease dementia. Last visit Haldol was increased . seen wandering in memory care unit, staff continues to provide one on one care, they state he continues with stated agitation, Ativan PRN very little help . Demeanor: Impulsive, Resistant, Oppositional . Judgement: Impaired . Insight: Impaired . Impulse Control: Impaired . Speech: Disorganized . Thought Process: Disorganized . Thought Content: Delusional Material Not Expressed . Memory/Immediate: Severe Impairment . Memory/Recent: Moderate Impairment .Mood: anxious, angry, irritable . Delirium: + Present (Believes he is able to go home, does not know he has severe dementia. Does know know his own reality [sic]) . Assessment and Plan: Major depression disorder, single episode . Plan: 1:1 supportive care . Anxiety disorder . Plan: Lexapro; Ativan PRN 14 days . Dementia . Picks Disease . Plan: Supportive Care . Psychotic disorder with delusions due to known physiological condition . Plan: Haldol . Will increase Haldol to 10 mg BID (two times a day). Continue supportive care . Review of Resident #377's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2024 revealed the Resident refused two medications during the month, once on 1/7/24 and one on 1/30/24. An interview was completed with Family Member Witness G on 6/27/24 at 7:24 AM. When queried regarding Resident #377, Witness G stated,

Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program encompassing outcome and process surveillance and failed to ensure readily available hand hygiene supplies, hand hygiene performance and catheter care per professional standards of practice, resulting in a lack of tracking of potential infections, a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis and the likelihood for the spread of microorganisms and illness to all 71 facility residents. Findings include: On 6/26/24 at 1:50 PM, a tour of the 400-hall of the facility was completed. No hand sanitizer dispensers were observed in the hallway and/or in the resident rooms in the hallway. On 6/26/24 at 2:03 PM, Certified Nursing Assistant (CNA) X and another facility staff member were observed in Resident #41's room. Resident #41 was sitting in a recliner chair. The staff member was observed touching items in the room and then exited the room without performing hand hygiene. They proceeded to enter the clean linen room and returned to Resident #41's room with supplies. CNA X remained in the room and continued to assist the Resident and touch them without gloves. The staff member who went to the clean utility observed this Surveyor upon returning to Resident #41's room. Upon entering the room, they handed CNA X a pair of gloves. CNA X donned the gloves without performing hand hygiene. An interview was conducted with Resident #41 on 6/26/24 at 2:08 PM in their room. A strong, foul, yeasty odor was present in the room. The Resident was observed to have wounds on both of their legs. When asked, Resident #41 revealed they required staff assistance for ambulation and transfers. A hand sanitizer dispenser was not observed in their room. When queried if staff wash their hands when they enter the room, before providing care to them, Resident #41 verbalized staff do not wash their hands in their room but they do not know what they do in the hall. When queried if staff wash their hands and/or use hand sanitizer prior to leaving their room after they have provided care, Resident #41 stated, No, they just take their gloves off. An interview and review of the facility Infection Control (IC) program and data was completed on 6/27/24 at 11:07 AM with IC Licensed Practical Nurse (LPN) A. When queried regarding process surveillance for hand hygiene, LPN A revealed audits are completed once a week. Upon request to review the hand hygiene surveillance audit forms, LPN A provided a summary indicating the total number of audits completed. When queried where the actual audit forms were, LPN A replied, Do not keep the forms. When queried how they knew what dates/times, shifts, and staff were audited if they did not maintain the audit forms, LPN A indicated they did not know. LPN A was then asked how the audits are completed and verbalized they ask staff to wash their hands and ensure they are using correct procedure. When queried regarding random observations on various shifts, including night shift, LPN A verbalized understanding of the value of random observations. LPN A was then queried how staff are able to easily perform hand hygiene when there in no hand sanitizer in the hallway and/or in resident rooms on the 400 hall of the facility, LPN A revealed there used to be hand sanitizer dispensers in the hallway, but they had been removed for painting and had not been put back on the walls. When queried if they observed staff not performing hand hygiene due to the lack of hand sanitizer dispensers, LPN A indicated they had not. When queried regarding observations of staff not performing hand hygiene in Resident #41's room and not wearing gloves, LPN A indicated that was incorrect and verbalized staff should have worn gloves and performed hand hygiene. LPN A was then queried regarding the facility IC committee and stated, Not met since I've started. When asked if they discuss the facility IC data anywhere, LPN A replied, Provide summary in the QA meeting. With further inquiry regarding what is discussed related to IC after they provide their monthly summary, LPN A revealed there are no questions or discussion regarding the data and/or program. LPN A was asked who attends the QA meeting when they report the IC data and replied, The DON (Director of Nursing), Administrator, Corporate Compliance, MDS (Minimum Data Set) Nurse, Therapy, Social Work, Department head of housekeeping/laundry, Activities Director, and the ADON (Assistant Director of Nursing). When queried if the Medical; Director Physician attends, LPN A replied, Through Video. With further inquiry regarding process surveillance, LPN A revealed they do audits for the Med fridge, glucometers, and wheelchair cleaning. When queried if audits are completed in the kitchen and laundry area, LPN A stated, No. When queried regarding their role in monitoring for Legionella, LPN A stated, I don't have anything to do with it. When queried regarding surveillance of reusable medical equipment, LPN A revealed they do not monitor reusable medical equipment. The monthly summary for May 2024 was reviewed and detailed there were 10 infections during the month including two bronchitis, one pneumonia, Four Urinary Tract Infections (UTI) including one with an indwelling urinary catheter, three skin infections, and one eye infection. The summary further that nine out of 10 infections meet McGeers Criteria. A review of the line listing for May 2024 revealed a list of 11 Residents who had all received antibiotics therapy. When queried if any residents had been diagnosed and treated for a fungal infection during May 2024, LPN A revealed they did not know. When queried if they track individuals who are being treated with anti-fungal medication related to a fungal infection as part of their IC surveillance, LPN A stated, No. When asked why they did not, LPN A replied, I was told not to. When asked if fungal infections are able to be spread from person to person, LPN A verbalized they could. When queried if a vital aspect of the IC program includes mitigation of microorganism spread, LPN A confirmed it is and verbalized that they understood the rationale for monitoring and tracking fungal infections. When queried how they track and monitor Residents with potential infections, who are not receiving antibiotics, LPN A revealed they do not have a process in place for monitoring residents not receiving antibiotics. An interview was completed with the DON on 7/1/24 at 1:29 PM. When queried regarding the facility IC program including surveillance and monitoring, the DON validated and confirmed concerns but did not provide further explanation. 37666 Resident #2: On 6/25/2024 at 12:56 PM, Resident #2 was observed sitting in a wheelchair in his room. He was alert, but did not answer any questions. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #2 was admitted to the facility on [DATE] and had multiple discharges and readmissions with the most recent readmission on 3/20/2024 with diagnoses: history of traumatic brain injury, paraplegia, chronic kidney disease, kidney stones, urinary catheter, history of seizures, gastrostomy tube, hypothyroidism, and anxiety. The MDS assessment dated [DATE] revealed the resident had severe cognitive dysfunction and needed assistance with all care. A record review of Resident #2's medical record, indicated he had multiple hospitalization s and emergency room visits in 2024 related to a change of condition and urinary tract infections. On 6/27/24 at 8:50 AM, Infection Prevention and Control/IPC Nurse A was interviewed about Resident #2. She said the resident had frequent urinary tract infections (UTI's) and most recently A UTI (urinary tract infection) that went on and on. The IPC said it was recently identified that the resident had a Multi-Drug Resistant Organism: Pseudomonas aeruginosa in his urine: it was diagnosed on [DATE]. On 6/27/2024 at 9:41 AM, during a tour of the facility, multiple residents were observed to be in Transmission Based Precautions, including Enhanced Barrier Precautions on the 300 and 500 halls. Personal Protective Equipment was observed hanging organizers on the residents' doors, but there was no readily accessible hand sanitizer in the hallways. Several staff and nurses were interviewed and said hand sanitizer was available on the nurses' medication carts, but Hall 300 had no medication cart visible on 6/27/24 at 9:41 AM. The 500 Hall had a medication cart in the hallway, but the hand sanitizer was situated to the back of the cart behind some of the nurse's other supplies. It was not accessible to staff, residents and visitors. Resident #26: Pressure Ulcer/Injury On 6/25/24 at 11:25 AM, during a tour of the facility, Resident #26 was observed lying in bed. She said she had a wound on left foot. A record review Face sheet and Minimum Data Set (MDS) assessment for Resident #26 indicated the resident was admitted to the facility on [DATE] with several discharges to the hospital and readmissions. The latest readmission was 2/6/2024 with diagnoses: history of a stroke, right side weakness, kidney stones, respiratory failure, COPD, diabetes, chronic kidney disease, renal dialysis dependence, morbid obesity, and heart failure. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15 and the resident needed assistance with all care. On 6/27/24 at 10:57 AM, wound care for Resident #26 was observed with Nurse J. She said the resident had an ongoing diabetic ulcer on the bottom of her left foot. The Nurse J and a nurse's aide were observed donning (putting on) Personal Protective Equipment/PPE, but there was no hand sanitizer near the PPE. They were asked about performing hand hygiene prior to applying their PPE and both stopped donning the PPE and went into the bathroom to wash their hands. There was no hand sanitizer near the PPE storage to aid in performing hand hygiene per standards of practice to prevent the spread of infection. On 6/27/2024 at 11:45 AM, the Director of Nursing/DON was interviewed about hand hygiene observations, reviewed there was a lack of accessible hand sanitizer to aid in performing hand hygiene prior to donning PPE. She said she would go out and look in the hallways and see what she could do. A review of the facility policy titled, Hand Hygiene, dated June 13, 2001, revealed the following, . Hand hygiene is the single most important means of preventing the spread of infection in the facility . When to perform Hand Hygiene . Before beginning work. Before eating . Before and after caring for each resident . before changing dressing and after dressing change . after removing gloves . Alcohol-based hand rubs are the preferred method for hand hygiene in most situations . 39059 On 6/25/24, at 11:38 AM, CNA D was observed in room [ROOM NUMBER] with gloves on. CNA D assisted the resident in bed 2 to a seated position and then walked over to the resident in bed 1. CNA D assisted the resident in bed 1 into their wheelchair. CNA D stopped and walked back to the Resident in bed 2 and placed the foot pedals on their wheelchair. CNA D removed their gloves and did not perform hand hygiene. CNA D then walked back to the resident in bed 1, grabbed the urinary catheter drainage bag and attached it underneath the wheelchair. CNA D then tied up the trash and walked it to the dirty utility room. CNA D left out of the dirty utility room, entered the nutrition room and took a drink of water. CNA D was asked where they perform hand hygiene and CNA D stated, in the residents rooms. CNA D still had not performed hand hygiene. CNA D exited the nutrition room and walked down to room [ROOM NUMBER], entered the room and walked to the bedside to assist another CNA with incontinence care. CNA D was asked where they washed their hands and CNA D stated, in the bathroom. CNA D entered the bathroom. The sink was dry of water. CNA D turned on the water and performed hand hygiene. On 6/27/24, at 10:42 AM, Education Nurse C was alerted of the observation of CNA C caring for multiple residents without performing hand hygiene and Education Nurse C offered that the staff should wash hands before and after glove use and in-between residents. On 6/27/24, at 10:57 AM, Nurse E was asked for an observation of Resident #62's dressing to their back. Nurse E was placing full blood specimen tubes into the centrifuge. Nurse E turned on the centrifuge and then walked to Resident #62's room. Nurse E assisted Resident #35 to a standing position, pulled up their shirt and touched their back approximately 2 inches from their skin wound that was exposed. Nurse E left out of the room, walked back to the office and removed a blood tube from the centrifuge, placed it into a plastic lab bag and then into the refrigerator. Nurse E did not perform hand hygiene during any of the above tasks. 49944 Resident #45 (R45): On 06/25/24 at 10:45 AM, R45's catheter drainage bag was observed inside a dignity bag and the dignity bag is sitting on the floor of the room. On 06/26/24 at 12:35 PM, R45's catheter bag was observed located inside of a dignity bag and sitting directly on the floor of the room. On 06/26/24 at 01:19 PM, an interview was conducted with Certified Nursing Assistant (CNA) 'F'. CNA 'F' was asked if the dignity bag should be sitting directly on the floor of the room? CNA 'F' stated they didn't think it should be resting on the floor but that other staff always leave it that way. CNA 'F' then stated they don't agree with it being on the floor. CNA 'F' was asked what they could do to prevent the dignity bag from touching the floor. CNA F' stated that sometimes they will leave the bed up a bit so the catheter bag does not touch the floor. CNA 'F' stated they would immediately get the catheter bag off of the floor.

This Citation pertains to Intake Number MI00140471. Based on observation, interview and record review the facility failed to ensure nail care was routinely provided for one resident (Resident #68) of 4 residents reviewed for Activities of Daily Living (ADL), resulting in Resident #68 having long, soiled, fingernails and long, cracked toenails. Findings Include, Resident #68 Activities of Daily Living On 6/25/24 at 12:51 PM, during a tour of the facility, Resident #68 was observed to have her left foot with long, cracked toenails. Her fingernails were extremely long and soiled. The resident said she couldn't trim them herself, but her granddaughter helped trim a couple of her toenails, although she couldn't trim 2 of them because the toenails were too long and difficult to cut. When asked if the staff assisted her, she said they had not trimmed them in a while. A review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #68, indicated the resident was admitted to the facility on [DATE] with diagnoses: kidney failure, right above the knee amputation, Stage 4 sacral pressure ulcer, weakness, depression, intestinal fistula, colostomy, Pulmonary hypertension, and atrial fibrillation. A review of the MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15 and she needed substantial/maximal assistance with hygiene care. A review of the Care Plan for Resident #68 revealed the following: The resident has an ADL self-care performance deficit related to pain, date initiated and revised 5/15/2024, with Interventions: Bathing/showering: Avoid scrubbing and pat dry sensitive skin, date initiated 5/17/2024. There was no mention of nail care. The resident has actual impairment to skin integrity of the Sacrum . Resident is at moderate risk for impairment in skin integrity related to age, skin fragility and thinness, decreased mobility, dry skin, . date initiated 5/15/2024 and revised 5/16/2024 with Interventions: . keep fingernails trimmed, clean and filed . dated initiated 5/16/2024. On 7/01/24 at 11:19 AM, the Director of Nursing was interviewed about Resident #68's lack of nail care. She said nail care was supposed to be provided with the resident's shower. She said if the resident was diabetic only nurses could cut them, and if they couldn't then podiatry could help with the toenails. The Director of Nursing said she would provide staff education on nail care. A review of the facility policy titled, A.M. (morning) and H.S. (night time) Care, dated November 4, 2021 provided the following, Personal care will be provided in a consistent manner to all residents daily . There was no mention of nail care.

Based on observation, interview and record review the facility failed to accommodate resident choice in Guardianship for 1 resident (#16) of 27 residents reviewed for resident choice, resulting in Resident #16 becoming upset and worried that she would not have someone to look out for her when her wishes were not considered. Findings Include, Resident #16 Choices On [DATE] at 9:30 AM, during a tour of the facility, Resident #16 was observed getting ready for the day. She was sitting in her wheelchair, dressed and preparing to attend an activity in the dining room. She said she spent most of her day in the facilities activities and that is what she enjoyed doing. She said she had some issues to discuss. Resident #16 said she was upset because the facility was suing her to remove her Guardian, who is her sister and replace her with a public guardian. The resident said they had to go to court twice and there is another hearing with an attorney over the resident losing her Medicaid eligibility and not having her bill paid. She said her bills had been paid by Medicaid until a waiver for Medicaid eligibility, that was enacted during the Covid-19 Pandemic in 2020, expired in September of last year/2023. She said it was confusing and her sister had not had to apply for Medicaid re-eligibility before and then her Medicaid lapsed. She said her Medicaid was reinstated in [DATE], but she said she was so upset about this, that it was all she could think about. Resident #16 said she tried to talk to the billing department about the situation and court hearings and was told, That's just the way it is. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #16 was admitted to the facility on [DATE] with diagnoses: quadriplegia at vertebra C5-C7, rheumatoid arthritis, diabetes, fibromyalgia, hypertension, anxiety, depression, atrophy left eye, cataract right eye, chronic pain, weakness. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] and the resident needed assistance with all care. On [DATE] at 3:30 PM, during an interview with Social Services H about Resident #16's Guardian/Conservator I , she said the resident had the same guardian during her stay at the facility since 2019: it was her sister. She said there had never been any issues with the resident's guardian, until she lost her Medicaid eligibility in [DATE]. She said the resident's Guardian I did a lot for the resident, visiting her often and bringing her what she needed. She said the guardian tried to reapply for Medicaid, but there was too much money in the resident's account. She said the guardian and resident were trying to find a handicap accessible van, to accommodate the resident on outings with her family, but they were having trouble finding a van. She said months went on, the money wasn't spent, and the bill was not paid to the facility. The Social Services H said she was asked by the Interim Administrator T to file a petition with the court to remove the resident's Guardian H as Conservator (overseer of the resident's finances) and appoint a predetermined conservator chosen by the facility. On [DATE] at 3:48 PM, [NAME] Staff U was interviewed about Resident #16. She said in [DATE] the facility received a Medicaid billing denial. Resident #16's Medicaid eligibility was checked in [DATE], and she no longer qualified for Medicaid. She said the amount the Resident received from Medicaid was $10,050/month. She said she called the sister/Guardian about it. Biller U said MDHHS (Michigan Department of Health and Human Services) had halted redeterminations for Medicaid eligibility during Covid. She said last fall that stopped and each person or their representative had to check on their own. She said she believed a notice went out to residents/representatives, but she wasn't sure. She said the resident and Guardian had cashed out a retirement policy and the guardian was trying to buy a van-handicap accessible. She said it would cost about $20,000 to find a van, but they could not find one. The biller said in December there was a conversation with the resident or representative about the Medicaid ineligibility because of too much money in the resident's account. She said the Guardian made payments towards the bill beginning in [DATE]. Another payment was received in [DATE] and [DATE] and the resident's Medicaid eligibility was restored in [DATE]. The Biller U said there had been no prior issues with the resident's payment prior to the discontinuance of the Covid-19 eligibility waiver. She said Resident #16 had had the same Guardian since [DATE], since the resident came to the facility. Biller U said there was still an outstanding balance for the resident's bill. During the interview with Biller U on [DATE] at 3:48 PM, she said both herself and Biller V went to court twice about the matter. She said it was very difficult. She said a local attorney was now hired to attend the next hearing over the resident's Conservatorship in court on [DATE]. A review of the court documents identified the following: [DATE]: A Petition to Modify Conservatorship/Adult was filed in court by Social Services H in the matter of removing Resident #16's Guardian related to the unpaid expenses at the facility. The document requested a specific named facility nominated person to be the Conservator. [DATE]: A court document titled, Order Appointing Person To Review/Investigate Guardianship, for Resident #16. The court order was for review of the resident's Guardianship. On [DATE] at 11:45 AM, the Interim Administrator T and Administrator in training were interviewed about Resident #16's court hearings related to past due Medicaid payments. The Interim Administrator T said he had requested a court order to remove Resident #16's Guardian/Conservator because of the past due bills. The Administrator T was asked if he attended the court hearings and he said he had not, that the 2 billers had went to court. Reviewed with the Administrators that Resident #16 was very upset about this situation, as she did not want to lose her sister as her Guardian for Healthcare. They both said the billers and Social Services had talked to the resident. The Administrators were asked if they had met with the resident and her representative to discuss the court hearings with the resident, as the resident thought her Guardian for Healthcare was being changed. The Administrators said they had not spoken with the resident or her Guardian. The Administrators were asked if there had been any issues with Resident #16's Guardian in the past and they both said there had been no issues. The Administrator in Training said the resident's Guardian was also the facilities Nurse Practitioner/NP. She said they had no issues with the NP's care of Resident #16 or other residents. The Interim Administrator T said a new Conservator for finances was requested at the court hearings, not a Guardian for Healthcare. During the interview with The Interim Administrator T, he said the billing department said they were not comfortable discussing the matter in court after the first 2 hearings and the facility obtained an attorney in [DATE] for the next hearing in July. At the time of the interview the Administrators were asked for copies of any documentation of conversations between the facility, resident and Guardian related to the resident's bill, guardianship and court hearings. A review of the documents received from the facility provided the following: The billing department Collection notes created by Billers U and V indicated there was no documentation of billing issues for Resident #16 until [DATE]: 3 months after Medicaid eligibility was denied. A note dated [DATE] said the Guardian I spoke with the billing office and said she was attempting to find a van for the resident for $20,000. Beginning in [DATE], the billing department documented conversations with the resident or her Guardian. On [DATE] Biller V documented that she had went to court to represent the facility related to Resident #16's bill and Biller V stated, I requested that (the county public Guardian) be put in place due to resident's overdue balance . Per the Interim Administrator, during the interview on [DATE] at 11:45 AM, the facility had not requested to change the Resident's guardian. They only wanted a Conservator for finances. On [DATE] 12:52 PM, Resident #16's Guardian/conservator I was interviewed about the resident's bill and court hearings. She said she was court appointed as the resident's Guardian and had been her Guardian since 2019. She said the facility did not tell her for a few months that there was too much money in Resident #16's account and it affected her Medicaid eligibility. She stated, They tried to catch me in the hall when I was seeing patients. They never sat down with me. Then I asked for a payment plan. She had never had a patient pay until now. There were no bills. They said the I was neglecting my sister. I went to the court hearings. They did not come to me. They are trying to remove me from caring for her. My sister is devastated by this. We were blindsided. We thought 'Work with us, explain it.' They were getting the bills and never said anything about it. I had no idea. She said the facility was attempting to remove her as healthcare Guardian also. She said the court documents said they were trying to remove her from conservator and guardian both. A review of the document titled, CMS (Centers for Medicare and Medicaid Services), Nursing Home Toolkit: Nursing Homes-A Guide for Medicaid Beneficiaries', Families and Helpers, dated [DATE] provided, .People living in a Nursing home have the right to be treated with dignity and respect . Nursing home beneficiary rights and protections under the law include, but are not limited to, the right to: . Be treated with dignity and respect . Participate in making choices in care . Quality of Life: The Social Security Act requires nursing home to care for beneficiaries in a manner that emphasizes their quality of life and ensures dignity, respect, and choice .

Based on observation, interview and record review the facility failed to obtain informed consent prior to initiating antipsychotic medication for two residents (Resident #25 and Resident #32) of three residents sampled for antipsychotic medication use, resulting in the resident and/or responsible party not being informed of the risk versus benefit of antipsychotic medication use prior to initiation. Findings include: Resident #25 (R25): Resident #25 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, dementia with agitation, anxiety and major depressive disorder. R25 has a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. On 06/25/24 at 04:30 PM, R25 was observed wandering in and out of multiple resident rooms in their wheelchair. R25 was yelling hello as they entered each room and they were looking for someone named [NAME]. This surveyor approached R25 and asked them who [NAME] was and if I could help them find her. R25 responded with jumbled speech and the response did not make sense. R25 continued to go room to room until staff intervened and led her back to the common area. On 06/27/24 at 09:33 AM, record review revealed R25 is followed by Behavioral Care Solutions (psych group that cares for residents at the facility) and is on Seroquel for mood disorder, Paroxetine for depression and Clonazepam for anxiety for 14 days with a stop date of 06/28/24. On 06/27/24 at 09:40 AM record review revealed R25 started on Seroquel 50mg on 03/28/24, Paroxetine 40mg started on 05/03/24 and Clonazepam 0.25mg started on 6/14/24. No progress notes or assessments were able to be located for the initiation of Clonazepam for 14 days. There was no documentation present that the resident or responsible party was notified of the initiation of Clonazepam. On 06/27/24 at 9:45 AM record review revealed consents are present for Seroquel and Paroxetine, the consents were dated 04/04/24, one week after admitted [DATE]. Seroquel was initiated on admission on 03/28/24, no documentation was present that the resident or responsible party was informed of the medication upon admission. There was no consent present for Clonazepam 0.25mg which was initiated on 06/14/24 for 14 days. Resident #32 (R32): Resident #32 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include dementia, post traumatic stress disorder and adjustment disorder with mixed anxiety and depressed mood. Resident #32 has a BIMS score of 3, indicating severe cognitive impairment. On 06/27/24 at 11:13 AM, record review revealed R32 was started on Ativan 1mg every 6 hours as needed for anxiety on 06/14/24 for 14 days with a stop date of 06/28/24. There was no documentation present in the electronic health record (EHR) that the responsible party or resident was informed of the treatment prior to initiation. A consent form was signed on 06/19/24, five days after the medication was initiated. On 06/27/24 at 11:16 AM an interview was conducted with the Director of Nursing (DON). The DON was asked if the staff should call the responsible parties for cognitively impaired residents for changes in psychotropic medication to inform them. The DON stated, yes the responsible parties should be informed prior to initiation of psychotropic medication. The DON then stated that recently they have been educating nursing staff to be sure they are informing families of med changes and documenting their notification of families with changes. On 07/01/24 the policy titled Use of Psychotropic Medications was provided by the facility. Review of the policy revealed: 3. Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use and the appropriate party to sign the consent regarding the psychotropic medication(s) being given.

Based on observation, interview and record review, the facility failed to update/revise individualized, person-centered care plans to reflect changing care needs for three residents (Resident #2, Resident #6, and Resident #32), of 30 residents reviewed for care plans, resulting in the potential for unmet care needs. Findings Include: Resident #2: Accidents On 6/25/2024 at 12:56 PM, Resident #2 was observed sitting in a wheelchair in his room. He was alert but did not answer any questions. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #2 was admitted to the facility on [DATE] and had multiple discharges and readmissions with the most recent readmission on 3/20/2024 with diagnoses: history of traumatic brain injury, paraplegia, chronic kidney disease, kidney stones, urinary catheter, history of seizures, gastrostomy tube, hypothyroidism, and anxiety. The MDS assessment dated [DATE] revealed the resident had severe cognitive dysfunction and needed assistance with all care. A record review on 6/27/24 at 1:42 PM, revealed Resident #2 had fallen 3 times in the past 12 months: 8/24/23, 5/31/24, and 6/25/24. 8/24/2023 at 12:55 AM: . resident was found on the floor . he was yelling when entering room found resident on the floor face down left arm straight out and right arm under resident. The tab alarm was not going off and was still attached to alarm . no injury . both center tab and outer ring had teeth marks on it from resident chewing . Immediate Action Taken: Resident not to wear gowns to bed, to be in tee shirts only to prevent from chewing on tab clip . 5/31/2024 at 11:00 PM: . resident was found lying on the floor next to his bed . lying on the floor in between his bed and floor mat. It appeared that the floor mat got moved out farther from the bed by resident. Resident was lying on his back on the floor. It was noted body pillow was not in place per orders . 6/25/2024 at 3:41 PM, . Resident had unwitnessed fall from bed onto floor mat. No injuries . A review of the Care Plans for Resident #2 identified the following: The resident has had actual falls since admission into (facility), date initiated and revised 8/25/2022 with 3 interventions: Continue interventions on the at-risk plan, date initiated and revised 8/25/2022; For no apparent acute injury, determine and address causative factors of the fall, date initiated and revised 8/25/2022; Physical therapy and or Occupation therapy screening recommended following each fall in order to address the resident's strength and mobility if applicable, date initiated and revised 8/25/2022. There were no additional interventions on the Fall Care Plan. The Care Plans were not updated with interventions to aid in preventing future falls after the falls on 8/24/2023, 5/31/2024 and 6/25/2024. There was no mention of fall mats or resident alarms. On 6/27/2024 at 2:45 PM, the Resident #2's Fall Care Plan was reviewed with Restorative Nurse P. Reviewed with Nurse P the 3 dates the resident had fallen. She said Restorative would update this Care Plan and said she would look at it. hospitalization A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #2 was admitted to the facility on [DATE] and had multiple discharges and readmissions with the most recent readmission on 3/20/2024 with diagnoses: history of traumatic brain injury, paraplegia, chronic kidney disease, kidney stones, urinary catheter, history of seizures, gastrostomy tube, hypothyroidism, and anxiety. The MDS assessment dated [DATE] revealed the resident had severe cognitive dysfunction and needed assistance with all care. A record review of Resident #2's medical record, indicated he had multiple hospitalization s in 2024, related to a change of condition and urinary tract infections. In addition he had several transfers to the emergency room without overnight stays for a change in condition. On 6/27/24 at 8:50 AM, Infection Prevention and Control/IPC Nurse A was interviewed about Resident #2. She said the resident had frequent urinary tract infections (UTI's) and most recently A UTI that went on and on. The IPC said it was recently identified that the resident had Pseudomonas aeruginosa in his urine. She said the resident had received ciprofloxacin multiple times, Keflex, Bactrim then gentamicin (all antibiotics). The IPC said the antibiotics were not effective until the resident received gentamicin. She said it was on April 22nd, 2024 when the resident's most recent UTI started. She said he had episodes when his temperature would drop and a change of condition, they would send him to the hospital and he was found to be septic (CDC (Centers for Disease Control): Sepsis is the body's extreme response to an infection. It is a life-threatening medical emergency.) A review of the Care Plans for Resident #2 identified the following: Urinary Tract Infection with culture result MDRO (Multi-Drug Resistant Organism) Pseudomonas aeruginosa, date initiated and revised 5/28/2024, with 1 intervention: Monitor laboratory results, date initiated 5/28/2024. Resident #2 had received multiple antibiotics since December 2023 for Urinary Tract Infections (UTI). The first Care Plan mentioning a positive urine culture was 5/28/2024. The resident also had positive urine cultures in December 2023 and March 2024. In addition, he received antibiotics for potential signs and symptoms of a urinary tract infection with no monitoring if the antibiotics were appropriate to an infectious organism. A review of the facility policy titled, Resident Care Plans, dated November 2, 2021 revealed, Policy: All residents will have a comprehensive person-centered care plan, consistent with resident rights, that includes measurable objectives and timeframes . 49944 Resident #6 (R6): Resident #6 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, vascular dementia, weakness and a history of falls. Resident #6 has a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. On 06/27/24 at 02:29 PM, R6 was observed sleeping in bed, R6 had the left side of their bed against the wall, there was a body pillow on the right side of their body. A wheelchair was observed to be about 5 feet from the foot of the bed by the dresser, no leg rests were on the wheelchair and the seat had miscellaneous items on it. On 06/27/24 at 02:32 PM, record review revealed R6 had a care plan for being at risk for falls and actual falls. The actual falls care plan indicated that R6 had their most recent fall on 01/04/24 with no injury. The interventions included placing the wheelchair at the foot of the bed with the seat facing the head of the bed when the resident is in the bed at all times. This is to facilitate safe transfer as the resident self transfers. This was last revised on 03/20/24. On 06/27/24 at 02:43 PM, record review of incidents revealed that R6 has sustained falls since 01/04/24: -On 01/04/24, R6 was observed on the floor leaned against the bed. The incident report did not have an intervention to prevent future falls. -On 05/16/24, R6 was observed on the floor between the bed and wheelchair, no injuries noted and there was no care plan intervention listed on the incident and accident form. -On 05/31/24, R6 was observed sitting on the floor by the bed, no injuries noted, resident stated they had to go to the bathroom. The care plan intervention was to place a pressure alarm pad to bed. Care plan wasn't updated until 6/4/24. On 06/27/24 at 04:15 PM, it was verified with the Director of Nursing (DON) that fall interventions in the resident room were not in place. Wheelchair was located by the dresser and not near the end of the bed. On 07/01/24 at 08:11 AM, RR of care plans for falls revealed that the most recent fall was on 01/04/24. Surveyor was unable to locate care plan interventions for falls that correlated to the most recent falls. Care plan was last updated 06/04/24 for a fall on 05/31/24. This is in the at risk for falls care plan and not the actual falls care plan. Resident #32 (R32): Resident #32 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include dementia, post traumatic stress disorder and adjustment disorder with mixed anxiety and depressed mood. Resident #32 has a BIMS score of 3, indicating severe cognitive impairment. On 07/01/24 at 08:17 AM, record review revealed R32 has sustained multiple falls since admission to the facility on [DATE]: -On 04/16/24, R32 was observed on the floor in the living room/open area in a kneeling position, no injury was noted and the fall was unwitnessed. The intervention was to change the pressure pad alarm to tab alarm while the resident is in the wheelchair or in bed. A review of the 'risk for falls care plan revealed the resident uses a pressure alarm to the wheelchair and bed. Date initiated 03/30/24 and last revised on 05/21/24. -On 05/02/24, R32 was observed on the floor in the living room area, no injury was noted and the fall was unwitnessed. The intervention on the incident report was to educate staff on the importance of toileting every two hours and for someone to remain in common areas when residents are in that area. A review of the risk for falls care plan revealed no intervention was entered to correlate with the date of the fall. -On 05/20/24, R32 was observed on the floor of their room after a certified nursing assistant (CNA) responded to the sound of R32's wheelchair alarm going off. R32 had some slight pain in their buttocks but overall no injury was noted and the fall was unwitnessed. There was no intervention listed on the incident form. -On 05/21/24, R32 was observed sliding out of their wheelchair by nursing staff. No injury was noted and the fall was witnessed. The intervention was to place dycem(item that prevents sliding) on the recliner. On 07/01/24 at 09:51 AM, an interview was conducted with the DON. The DON was asked who updates care plans after a fall. The DON stated that the floor nurse is responsible to update it at the time of the incident, then it is reviewed in morning meeting and updates are made if necessary. The DON was asked why there were no interventions put in place after some of the residents falls. The DON stated they did not know why. The DON was asked about the appropriateness of an intervention that was put in place in place for sliding out of the wheelchair, the intervention was to add dycem to the reclining chair. The DON stated that the intervention was not appropriate for the fall. A review of the policy titled Resident incident- Reporting and Monitoring, revised 10/12/23, revealed: 6. The restorative nurse or designee will investigate all incidents in a timely manner, next scheduled working day if not present at time of incident. Additional, appropriate interventions will be implemented per Restorative Nurse or designee, when applicable in an attempt to prevent recurrence.

Based on observation, interview and record review the facility failed to ensure coordination of dialysis care for one resident (Resident #26) of 1 resident reviewed for dialysis services, resulting in a lack of assessment for the left arm Dialysis fistula, dressing and site, resulting in the potential for unidentified complications. Findings Include: Resident #26: Dialysis A record review Face sheet and Minimum Data Set (MDS) assessment for Resident #26 indicated the resident was admitted to the facility on [DATE] with several discharges to the hospital and readmissions. The latest readmission was 2/6/2024 with diagnoses: history of a stroke, right side weakness, kidney stones, respiratory failure, COPD, diabetes, chronic kidney disease, renal dialysis dependence, morbid obesity, and heart failure. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15 and the resident needed assistance with all care. On 6/25/24 at 11:20 AM, during a tour of the facility, Resident #26 was observed lying in bed. She said she attended dialysis offsite on Mondays, Wednesdays and Fridays. She said she would take a packet of papers to dialysis and brings back a packet of papers from dialysis. A review of the facilities Hemodialysis Communication Forms indicated the dialysis access site location and instructions for post dialysis dressing changes was missing on most of the forms. The forms did not indicate the type of dialysis access site the resident had or where it was located to aid in assessment. The dialysis center had an entry on the form title, Instructions for Care of Access Site and Removal of Fistula Dressing, that they were supposed to complete after the resident finished dialysis for the day and prepared to return to the facility. The section was usually blank. There was no option if the resident did not have a fistula. A review of the physician orders indicated there was no mention of Resident #26's dialysis access site. A review of the Medication Administration Record and Treatment Administration Record for Resident #26 for the month of June 2024 provided the following: Post-Dialysis Assessment: Document in nurses progress note regarding the fistula site for signs and symptoms of bleeding, removal of dressing, positive thrill/bruit, full vitals and general appearance within 1 hour of return from dialysis. Notify physician for any complications. One time a day every Monday, Wednesday, Friday for Post dialysis related to End stage renal disease, start date 11/10/2023. The nurses wrote yes in the box and documented the resident's vital signs, but there was no progress note with the assessment of the dialysis site. There was also no specification on where the fistula was located. A review of the Care Plans for Resident #26 identified the following: I attend Hemodialysis at . dialysis center . three times a week on Monday, Wednesday, Friday-chair time 6:25 AM - 9:55 AM, for End Stage Renal Disease . The resident has had a mechanical complication of surgically created A/V (arteriovenous) fistula to LUE (left upper extremity), date initiated and revised 3/25/2024 with Interventions: Complete post-dialysis assessment at time of return from dialysis: document fistula site, s/s of bleeding, removal of dressing, positive thrill/bruit, full (set) of vitals and general appearance to be completed one hour of return from dialysis. Notify PCP (primary care provider) with any concerns or changes, date initiated 3/25/2024. On 7/1/2024 at 11:25 AM, the Director of Nursing was interviewed about the lack of nursing assessment of Resident #26's dialysis access site. Reviewed the dialysis communication form, did not have an entry to identify the type and location of the dialysis access site and the dialysis center nurses were not consistently documenting there portion of the assessment on the form. Also reviewed with the Director of Nursing, that the Treatment Administration Record (TAR) indicated the nurses were supposed to document in a progress note within 1 hour after the resident returned to the facility from dialysis, but they were not documenting an assessment of the resident's dialysis access site and the TAR did not indicate where the resident's fistula was located. She said she would look into it. A review of the facility policy titled, Dialysis, Hemodialysis: Proper assessment and care of residents/patients receiving hemodialysis, dated November 3, 2021 provided, Complete Hemodialysis Communication Form and send to dialysis center with resident/patient . 1.) Upon return from Dialysis: Retrieve Hemodialysis Communication Form from resident/patient and note any changes/updates; 2.) Assess dialysis site; 3.) Complete assessment on resident . 5.) Every shift fistula sight checks and dressing monitoring . Assess daily and feel for the thrill or use the stethoscope to listen for the bruit and monitor for signs/symptoms of infection . assess for peripheral edema .

Based on observation, interview and record review, the facility failed to provide oxygen per physician's order and store nebulizer equipment sanitarily for one resident (Resident #35) of three residents reviewed for respiratory needs, resulting in oxygen administration provided of improper dosage with the likelihood of decreased oxygenation and infection. Findings include: Resident #35: On 6/25/24, at 10:54 AM, Resident #35 was resting in bed. Their oxygen concentrator was dialed to 5 liters of oxygen and was on via a nasal cannula. Their nebulizer mask was lying on top of their nightstand face down. On 6/25/24, at 2:44 PM, a record review of Resident #35 electronic medical record revealed an admission on 10/4/2023 with diagnoses that included Chronic Obstructive Pulmonary Disease, Stroke and Congestive Heart Failure. Resident #35 required assistance with all Activities of Daily Living and had intact cognition. A review of the physician orders revealed Apply Oxygen at 6 liters/min per nasal cannula with humidified H20 continuously every day and night shift Start Date 5/1/2024 . On 6/27/24, at 8:54 AM, Resident #35 is sitting in their wheelchair with their oxygen on via nasal cannula. The concentrator was dialed to 5 liters. On 6/27/24, at 10:46 AM, Education Nurse C was interviewed regarding Resident #35's oxygen administration. Education Nurse C was asked to explain if the concentrator delivered the ordered 6 liters and Education Nurse C stated, no it only goes to 5 liters and offered that the facility could provide the ordered 6 liters. A further review of the physician orders revealed the 6 liter oxygen order was discontinued. A new oxygen order was placed that revealed Apply Oxygen at 5 liters/min per nasal cannula with humidified H20 continuously every day and night shift . Status Active Start Date 6/27/2024 . failed to provide oxygen per physician order for Resident #35.

This Citation pertains to Intake Numbers MI00142202 and MI00144560. Based on interview and record review, the facility failed to assess and monitor hydration status timely and notify family for one resident (Resident #376) of one resident assessed for Intravenous (IV) fluids, resulting in an undocumented amount of IV fluids administered, no family notification and ultimately hospitalization . Findings include: Resident #376: On 6/26/24, at 10:15 AM a review of Resident #376's electronic medical record revealed an admission on 11/16/2021 with diagnoses that included Diabetes Type 2, Dysphagia and Chronic Kidney Disease. A review of a laboratory result verified on 1/10/2024 . Sodium Lvl (level) Value 158 (H) .Ref. Range/Units 135 - 145 . A review of the Medication Administration Record 1/1/2024 - 1/31/2024 revealed no entry for the 1 liter or normal saline intravenous documented. A review of the IV Assessment Effective Date: 01/11/2024 16:48 . Location of IV Right Forearm . Type of IV Solution 0.9 % sodium Chloride . Bolus . there was no documentation noted as to how much the resident received and or how fast the IV solution was to be infused. A review of the progress notes revealed . 1/9/2024 12:46 . Per (Physician assistant) CBC, BMP, TSH to be collected r/t significant weight loss within a month. 1/11/2024 08:18 . Resident labs resulted. Valued indicate dehydration. (Physician Assistant) called and voicemail left . 1/11/2024 11:47 . Clinical addressed lab results. Per (Physician Assistant), we will give 1L(liter) bolus to resident . 1/11/2024 16:47 . PIV insertion completed. Resident tolerated well. Assist of one needed. 22 g placed without difficulty. Patent and infusing without difficulty . 1/11/2024 20:38 . IV NS infusing as ordered. IV site clear . 1/12/2024 06:333 . resident removed i.v. at 0130, no bleeding noted, site cleansed and covered with band aid . 1/13/2024 15:20 . 700 hall cart nurse . asked this writer to assess resident. Resident is noted to have a fever at this time. Resident is resting in bed comfortable. (Physician Assistant) and at this time we will continue to monitor patient. BP 110/62 p 56 r 18 temp 99.8. [NAME] sounds clear active bowel sounds noted. Educated floor staff to push fluids. Resident was tested for Covid and is negative at this time . 1/13/2024 19:11 . Resident was admitted to (local hospital) this evening. Per Clinical Nurse Family was in visiting and did request resident be admitted to the hospital. This Nurse did call hospital and give them report. Clinical Nurse sent paper work and resident was taken over to the hospital. On 6/26/24, at 4:06 PM, the Director of Nursing (DON) was interviewed regarding Resident #376's condition prior to their discharge to the hospital. The DON was asked how much of the 1 liter of NS did the resident receive and the DON offered that the facility generally does an IV sheet. A review of Resident #376's electronic medical record along with the DON revealed no IV sheet and no other documentation as to how much of the IV fluids Resident #376 received prior to pulling it out. The DON was asked if they were aware the resident pulled out their IV and the DON offered, yes and that they don't think the resident got the whole amount. The DON planned to look for an IV sheet that may have not been scanned to the electronic medical record. On 6/26/24, at 4:30 PM, the DON offered that they didn't find any documentation as to how much IV fluid Resident #376 received prior to pulling out the IV. On 6/27/24, at 1:30 PM, a record review of Resident #376's hospital documents revealed a diagnosis of Hypernatremia (high blood sodium) with a level of 161 . Physical Exam: . Not responding . Dry mucus membranes . Date of Service 1/13/2024 Time: 1802 . 1853 lab called with critical sodium level of 161 . On 6/27/24, at 3:43 PM, the DON was asked if Resident #376's family was made aware of the IV; the need for it and that the resident pulled it out, and the DON stated, no.

This citation pertains to Intake #MI 077. Based on observation, interview and record review, the facility failed to initiate and thoroughly investigate an observation of alleged sexual abuse and failed to prevent further sexual abuse from occurring for one Resident (#1) of six reviewed for abuse from a total sample of six, resulting in an immediate jeopardy when on 2/5/18, Resident #2 was observed, by CNA (Certified Nursing Assistant) M, making nonconsensual sexual contact with Resident #1 and on 4/23/18, when Resident #2 was observed by CNA G, making nonconsensual sexual contact with Resident #1. The Immediate Jeopardy is due to the facility's failure failing to thourougly investigate allegations of sexual abuse which lead to sexual abuse reoccurring. This deficient practice places all Residents residing in the Dementia Unit at risk for further sexual abuse. The Immediate Jeopardy was identified on 5/8/18 at 5:45 PM. The Administrator was notified, of the Immediate Jeopardy, on 5/9/18 at 2:00 PM and a plan to remove the immediacy was requested. The immediacy was removed on 5/9/18, at approximately 4:00 PM, based on the facility's implementation of an acceptable plan of removal as verified on-site by the surveyor. Findings include: A review of the facility's policy entitled Abuse Prevention Policy and Procedure, with a date on 3/2/18, revealed, It is the policy of (the Facility) to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion . Suspected or substantiated cases of resident abuse, . shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representative . The facility will identify and investigate all suspicions or allegations of abuse such as suspicious bruising or (on) residents, unusual occurrences, patterns and trends that may constitute abuse and will determine the direction of the investigation . During and after the investigation, the residents will be protected from harm through frequent supervision by staff. The first action taken when abuse is alleged or suspected is to protect the residents. If the alleged perpetrator of the suspected abuse is a resident, the charge nurse will separate the parties and parties will remain separated from one another until the investigation has been completed . When an allegation is received, the administrator will ensure that all alleged violations involving abuse, . are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, this in an online submission of the 24 hour report as required by the State. The Administrator or designee shall thoroughly investigate all allegations. This investigation shall be complete within five days of receipt of the allegation or suspicions. The investigation will include an interview and/or witness statement from staff involved in the resident's care and resident and/or visitors who may have information regarding the suspected abuse. Further review, of the policy, revealed, If the incident or allegation involves criminal activity, including but not limited to assault, sexual abuse, . the Administrator immediately notifies law enforcement in accordance with the Elder Justice Act. Review of Resident #1's medical record revealed an admission on 3/9/17 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment revealed Resident #1 had severely impaired cognition and needed limited assistance with dressing and extensive assistance with hygiene. Review of Resident #2's medical record revealed an admission on 9/22/17 with [DIAGNOSES REDACTED]. A review of the MDS assessment revealed severe cognitive impairment and the Resident needed limited assistance with dressing and hygiene. Resident #2 was able to ambulate unassisted. Review of Resident #2's Nursing Behavior Charting dated 2/6/18 at 12:52 AM revealed, At approx (approximately) 2245 (10:45 PM) hrs (hours) res (Resident #2) noted by CNA, to be resting head on female res (Resident #1's) bare left thigh while in bed, with face towards females crotch, pulling females brief to one side in the groin area, res had taken down yellow Velcro barrier to enter room, CNA told res (Resident #2) to stop and res (Resident #2) responded by telling her to get out of there, CNA had to pull res (Resident #2) by arm to get res (Resident #2) out of females (Resident #1's) room, female res was asleep, partially opened eyes, showing no facial expressions of fear or concern and went back to sleep after res (Resident #2) was out of room, 1:1 care for res (Resident #2) was initiated for the res (rest) of this shift. On 5/8/18 at 5:30 PM, an interview with the Director of Nursing (DON) B and the Nursing Home Administrator (NHA) A was conducted. The Nursing Behavior charting of the incident that occurred on 2/6/18 at 12:52 AM, was reviewed with NHA A and DON B. When queried if the incident of Resident #2 laying his head on the bare thigh of Resident #1 and pulling at her brief in the crotch area was reported to the Abuse Coordinator, NHA A stated, I don't know. When queried if NHA A was the Abuse Coordinator, she answered, Yes. It should have been reported to me. When asked if the incident was reported to her, NHA A stated, I don't remember. It could have been reported at stand up. Let me check. On 5/8/18 at 5:40 PM, NHA A returned with a typed document and stated, It was reported to us. The typed document had a date 2/5/2018 and revealed, At 2300 (11:00 p.m.) it was reported to writer (Nurse J) by (CNA M) that while responding to an alarm she was passing by room (Resident #1's room) when something caught her attention. CNA observed (Resident #2) laying across the bed with his head on resident (#1's) thigh facing her crotch trying to remove her brief. When staff approached resident (#2) he became angry telling her to get out of the room. CNA told resident (#2) he must leave the room he told her to get out and began to approach her, staff was able to take resident (#2) by the arm and escort him out of the room without incident. CNA staff stated resident (#1) did not appear upset of fearful she was just lying looking at the wall. Writer interview resident (#1) she is an unreliable historian and did not respond to any questions asked or appear distraught she continued to lay on her side looking at the wall. Resident (#2) was placed one on one with staff. Writer immediately contacted Administrator and Director of Nursing. Report completed by (Nurse J). NHA A was queried further regarding an investigation of the allegations of sexual abuse and stated, I didn't do anything further. (Resident #1) did not appear to be fearful or distraught. (Resident #2) was immediately removed and placed on one on one. When queried regarding an incident report, NHA A stated, This is all I have. When queried if a thorough investigation was completed, NHA A stated, This is all I have. DON B was queried if she had been contacted and stated, No, honestly I don't remember. NHA A was queried if she had been contacted and stated, I don't recall if they (facility staff) contacted me. If (Nurse J) said she contacted us, she would have. When queried regarding if there was any type follow up of the incident, NHA A stated, I don't know, and if Social Services was contacted and provided services, NHA A stated, I don't know. When queried further if an investigation of the incident was completed or reported to the State Agency, NHA A stated, No. (Resident #1) wasn't fearful or appeared upset or agitated. There was no harm. Review of the investigation report, obtained from the facility regarding an incident that took place on 4/23/18 revealed that on 4/23/18 at 7:30 PM Resident #2, again, sexually assaulted Resident #1. Further review of the report revealed, (CNA D) was on her lunch break. (CNA E) and (Nurse F) were in helping a resident. (CNA G) finished helping a resident and as she came around the corner, noticed that resident (#2), had his pants down standing in front of (Resident #1), holding her hand on his penis. (CNA G) was able to redirect (Resident #2) and no harm was done to either resident. (Resident #2) stated 'yes, I did pull my pants down, I was showing off.' (Resident #1), was not hurt in any way and could not remember the situation. On 5/8/18 at 11:15 AM, an interview, with Clinical Supervisor of the Dementia Unit, Nurse C, was conducted regarding the incident that occurred on 4/23/18 with Resident #1 and #2, who reside in the Dementia Unit. When queried about past behaviors that Resident #2 exhibited, Nurse C stated, There was one other incident that involved (Resident #1). (Resident #2) was in her (Resident #1's) room and he had his face close to the peri area. Clothes were all on. I don't remember exactly when that happened. He had a tendency to try to use the toilet in her room. We put up a border on the door with a stop sign and try to toilet him every two hours. He tends to target her. She looks younger, late 50's or 60's, like courting (Resident #1). When queried about interventions in place to prevent behaviors, Nurse C stated, He is on one on one, then 15 minute checks. Usually he is always in our sight. If we don't see him then we go find him. We have a border on the door with a stop sign. We try to toilet him every 2 hours. Activities get him involved. When queried about interventions in place for the second incident that happened on 4/23/18, Nurse C stated, One on one was done then 15 minute checks. On 5/8/18 at 12:50 PM, an observation was made of Resident #1 laying in bed with the covers on. The Resident's eyes were open and she was reaching up into the air and pinching her fingers together. When the Resident's name was called, she did not answer. When asked simple questions, the Resident did not answer or acknowledge the surveyor's presence. A yellow band was attached to one side of the door that had Stop on it but laid limp to the door frame and was not in place to alert others to not enter Resident #1's room. On 5/8/18 at 12:55 PM, an observation was made of Resident #2 in the dining area eating lunch. The Resident was able to answer simple questions. The Resident was eating on his own. At 1:00 PM, the Resident was seen in the hallway near the dining area and walking unassisted in the hallway, staff were nearby. On 5/8/18 at 1:45 PM, an interview, with the Social Services (SS) Nurse H, was conducted with the Director of Nursing B present. A review was done of the incident that occurred on 4/23/18 when Resident #2 was holding Resident #1's hand on his penis and Nurse H was queried regarding interventions in place to prevent reoccurrence, the Nurse stated, I don't think they put him on one on one and I did education, to the staff on the unit, of Resident #2's care plan. (Psychiatric Group) seen him that week. There was a dose reduction done on 4/5/18 and [MEDICATION NAME] (antidepressant) was decreased. The [MEDICATION NAME] was increased back up to 30 mg (milligrams). When queried about past behaviors, the SS Nurse H stated, There was an issue last night in the CNA charting. He was leaning over a female Resident with his hand on her upper thigh. He was put on one on one supervision. When queried how long the one on one continues, the Nurse stated, The one on one is done until he is deemed safe. When queried who makes the decision he is safe to be off the one on one staffing, Nurse H stated, The nurse should specify and be the one who makes that determination. When queried about documentation of the determinations to be taken off the one on one, when behaviors occur, the DON reviewed Resident #2's medical record and stated, There is none. It should be a specific policy of who determines and we should have documentation of the assessment to determine the one on one is completed. When queried about the length of time Resident #2 had remained on the one on one staffing, the DON stated, I didn't see any documentation of that. The SS Nurse H stated, It is care planned to do one on one until redirected. When queried regarding documentation that Resident #2 is put on one on one, the SS Nurse H stated, There is no specific form for one on one. The next morning (4/24/18 AM) I heard at stand up (meeting to discuss issues with residents) of the incident. No staff were doing one on one with him. I didn't see any documentation that he was placed on one on one . After the incident, some (staff) were aware there was a plan in place and some were not aware. Mostly the CNA staff that were not aware of the care plan. When queried about a documented assessment of a determination to take the Resident off one on one, the SS Nurse H stated, There is none. When queried about changes in interventions made in Resident #2's care plan, the SS Nurse H indicated there had been no changes that had been made. The SS Nurse H stated, But the staff was educated on the care plan. Documentation of when, how often and for how long Resident #2 had been placed on the one on one staffing was requested. No documentation was provided prior to the exit of the survey. Review of Resident #2's care plan, that SS Nurse H had staff review, revealed the following: Dated 2/13/18, Potential for inappropriate sexual/social interaction: Problem: (Resident #2) has displayed inappropriate sexual advances to a female resident. (Resident) has had inappropriate interactions with male residents (messaging shoulders, kissing top of head/shoulders). Potential for continued behavior Related To: Cognitive impairment, Manifested by: Wandering into other residents rooms, inappropriate touching. Goal: (Resident) will display no continued signs of inappropriate sexual/social interactions with those around him. Interventions include: (Resident #2) is to be on 15 minute checks for safety until determined he is no longer a threat. (Resident) is not to be in close proximity of any female resident at any time. Redirect him away from the female residents if needed. If at any time it is felt that his behavior cannot be redirected and he is displaying behavior that is inappropriate, harmful or sexual, (Resident) should be placed on 1:1 supervision with staff until his behavior can be deterred. Once decided that 1:1 supervision is no longer appropriate, then 15 minute checks should be re-implemented. On 5/8/18 at 4:58 PM, an interview was conducted, with CNA D, regarding the incident on 4/23/18. CNA D stated, (CNA G) said she came out and (Resident #2) was standing with pants down and he was holding (Resident #1's) hand on his penis. I took (Resident #1) and moved her away. We stayed for one on one with (Resident #2). When queried about the length of time Resident #2 was on the one on one staffing, CNA D stated, I can't tell you what length of time. Until we felt things were safe. I don't know the length of time, I am going to say about 45 minutes. It just occurred when I was coming back (from break). It just seemed he was aware and that minute he was alone on the floor. When queried regarding who makes the decision that one on one is not needed, CNA D stated, Collectively as a group. We run things through the Nurse. When queried about documentation, the CNA stated, We don't chart it, we just do it. We just communicate so that someone is watching him. On 5/8/18 at 5:15 PM, an interview with CNA E was conducted. CNA E indicated that she was assigned Resident #2 that night (4/23/18) as her Resident and stated, I was taking care of another Resident and the nurse was assisting me. He had shown his penis to another Resident (#1). We watched him close so it doesn't happen again. When queried about the one on one staffing, the CNA stated, Everyone stays in the living area and he was in the living area. When queried if Resident #2 was on one on one, the CNA stated, Yes, but you're also kinda watching the other Residents at the same time. We would have another CNA back there if another Resident needed help. When queried about past behaviors with Resident #2, CNA E stated, There was a time before that he was focused on (Resident #1) and he became 15 minute checks and one on one for being sexual towards the female Residents. When queried regarding other issues with sexual behaviors, the CNA stated, Yes, lately it's been increasing. It's not just her anymore. He will rub females legs, try to kiss (Resident #1) on the top of her head, sneaking into (Resident #1's) room on nights. When queried about the length of time the one on one took place after the incident on 4/23/18, the CNA stated, One on one was close to an hour and we still watched him to make sure. He was up for a while after that. When we see him focusing on (Resident #1), we redirect. When queried if the interventions are adequate to prevent sexual contact from reoccurring, the CNA stated, I don't know. On 5/8/18 at 5:15 PM, a review, of Resident #2's, Nursing Behavior charting revealed the following: On 2/5/18 at 10:04 AM, Resident seen to be rubbing shoulders of a male resident and kissing each shoulder. Cnas have stated to writer that there have been at least 2 other episodes and at least once to a female resident. Social Services notified. On 2/6/18 at 12:52 AM, At approx (approximately) 2245 (10:45 PM) hrs (hours) res (Resident) noted by CNA, to be resting head on female res bare left thigh while in bed, with face towards females crotch, pulling females brief to one side in the groin area, res had taken down yellow Velcro barrier to enter room, CNA told res to stop and res responded by telling her to get out of there, CNA had to pull res by arm to get res out of females room, female res was asleep, partially opened eyes, showing no facial expressions of fear or concern and went back to sleep after res was out of room, 1:1 care for res was initiated for the res (rest) of this shift. On 3/12/18 at 11:34 PM, Res was noted by CNA while sitting in a recliner chair to have his penis out of his pants and shaking it while looking and smiling at female res sitting in recliner chair across from him, room was dark, female res is alert to person, this nurse asked female if she was aware of a man sitting there, she stated yes, she was asked if she saw him do anything wrong or strange and her response was no, this nurse immediately assisted male res out of chair and walked him away from tv room and asked him if he knew that was illegal to be doing in a public place he said yes but didn't care, this nurse told him that he could do that in is (his) bathroom or behind his curtain in his room, he stated the the person who reported him shouldn't have been looking there, he is also alert to person. On 3/30/18 at 5:21 AM, Resident room (room number of Resident #1) slept in the living room recliner this shift. (Resident #2) was up in the living room standing near resident staring at her multiple times this shift. On one occasion resident was redirected from touching himself in his pants. He never touched other resident or exposed himself. He was also redirected from staring at people while they were in their rooms. Continuous checks continue. On 5/8/18 at 6:15 PM, an interview was conducted, with Nurse J, regarding the document, dated 2/5/18, that involved Resident #2 and Resident #1. Nurse J reviewed the typed documentation. Nurse J stated, I was the complaint investigator on the night shift. The staff approached me. I interviewed both Residents. (Resident #1) never responded, not a lot of speech. If upset (Resident #1) becomes combative, She was just looking at the wall. Really no response. (Resident #2) was escorted into the living room area. He didn't have any recollection of what happened. When queried if NHA A/Abuse Coordinator was contacted, Nurse J stated, I contacted the Administrator about 11:00 to 11:15 PM and left a message . I gave a copy (of the incident report) to the DON and (NHA A), left it in their mailbox. I called the DON and spoke with her. She answered . The DON asked if (Resident #1's) brief was off. Brief was not. Asked if (Resident #1)was upset, had pain or agitated. (DON B) said to do the one on one. When queried if the incident is a reportable incident to the State Agency, Nurse J stated, I don't make that determination. That is why I called the Administrator and DON. When queried if the incident was a reportable incident to the DON and the Abuse Coordinator, Nurse J stated, Yes. When queried if Resident #2 had access to Resident #1's genital area, the Nurse stated, My understanding is yes. He was pulling the brief down. When queried if the incident was sexual abuse, Nurse J stated, Yes I would call it that. When queried if the DON or Administrator had contacted her regarding investigation questions or a statement, the Nurse stated, No. When queried if she had heard anything after the incident about an investigation, the Nurse stated, No. When queried if she had asked the Administrator or the DON about the incident afterwards, the Nurse stated, No. When queried regarding documented interviews with the Residents and staff involved, Nurse J stated, None that I wrote up. On 5/8/18 at 7:00 PM, an interview, with DON B and Nurse L, who was assigned to Resident #1 and 2 on 2/5/18, was conducted regarding the incident. Nurse L stated, The CNA came and told me. She walked by the room and saw his pajamas and went in there. She had to pull him away. She (Resident #1) was laying in bed. He had his head resting on inner thigh and when she (CNA) walked in there he had his fingers pulling the brief to the side so he could see her crotch. He told her (the CNA) to go away, he was busy. When queried regarding when Resident #2 was last visualized prior to the incident, the Nurse stated, I don't know, I didn't see him. He wanders on his own. I don't know when he was last seen. When queried regarding when the 15 minute checks started, the DON stated, The 15 minute checks started on 2/7/18. The one on one status was removed and then started the 15 minute checks. Nurse L stated, The Aide said (Resident #1) barely opened her eyes. I tried to talk to her and she barely opened her eyes. When queried if she had done a skin assessment, Nurse L stated, No not really. When queried regarding any assessment to the genital region, she replied, I was under the impression that her brief was tight. I would have gone further if her brief was undone but it wasn't. The Nurse was asked if she had checked for swelling, bruising or bleeding, when it was not known how long Resident #2 was in the room, prior to the CNA finding him, and with his fingers seen near her genitals and stated, No I didn't. Nurse L was queried regarding an investigation of the incident and if the DON or Administrator had discussed the incident with her, the Nurse replied, (Nurse J) did when she came down but I don't remember anyone else. When queried about a documented incident report, she responded, I don't remember filling one out. The DON stated, No I didn't talk to her at all about it (the allegations of the sexual abuse). I didn't have her do an incident report. On 5/9/18 at 3:00 PM, an interview, with CNA G, was conducted regarding the nonconsensual sexual contact that occurred on 4/23/18. CNA G stated, I came out from taking care of another Resident and walked into the living area by the TV. (Resident #2) had his right hand overtop of her left hand, holding her hand on his penis. His left hand was holding his pants down. The head of his penis was exposed at the top of their hands but he was moving it. He was aware of what he was doing with her hand. I came to the side of him and could see his penis. I touched his arm and he jumped. He wasn't expecting me to be there. He was watching the TV while he was doing that. As soon as I startled him, he pulled his hand away and his pants up at the same time. He knew what he was doing was wrong and he quickly walked away. On 5/9/18 at 3:35 PM, an interview, with CNA M, was conducted regarding the sexual abuse allegations on 2/5/18, that involved Resident #1 and Resident #2. The CNA stated, I was working midnights and we got in report from the other shift that (Resident #2) was acting in a sexual way, hugging, trying to kiss (Resident #1), targeting (Resident #1). I saw his legs from the door way, he had pajamas on. I went in. She was laying in bed. The covers were half off and moved over and her night gown was pulled up and only exposing her brief and her legs. When queried if Resident #1 had behaviors of lifting her gown or pulling her covers off, the CNA stated, No. She usually sleeps through the night. When queried if she had a tendency to undress herself, the CNA stated, Nope. The CNA further explained, His whole upper body was on the bed with his face on her thigh, bare thigh. He was right in the area. The yellow tape thing was all on (yellow barrier on the doorway) so he must have crawled under it. When queried if Resident #2 was close enough to her genital area that his mouth was in close proximity to her genital area, the CNA stated, Oh yes. He was pretty close. A half an inch, he would be right there. His fingers were inside the brief ripping at it. His fingers and face were right there peaking in. When queried if she had seen Resident #2's fingers inside Resident #1, the CNA stated, No not inside her. I yelled '(Resident's name) Stop. You can't be in here. You can't be doing that.' He just stood up. I yelled for help and redirected him and got him out of the room. When queried about Resident #1, the CNA stated, She was laying there, eyes half open, looking at the wall, not saying anything, not hitting him, no facial expressions. When queried regarding when Resident #2 was last seen, the CNA stated, He had bad behavior that day so we checked to see if he was in his room. We were doing room checks. It was about 15 minutes after that that it occurred. When queried about the bad behavior, the CNA stated, The report from afternoon CNA that day, he was going into (Resident #1's) room. Expressing sexual behaviors towards (Resident #1) and we were to keep a close eye on them. When queried about 15 minute checks, the CNA stated, He was not on 15 minute checks. That was after that incident. When queried if the police were notified, the CNA stated, No. Just (Nurse J) came back and talked to me about the situation. When queried if the DON or Administrator contacted her at a later time or day about the incident, the CNA stated, No, I never talked to (Administrator) or the DON about it. Review, Resident #2's medical record, of the documented CNA Behavior charting, revealed the following Behavioral Comments that included: 2/6/18, at 9:46 PM, Several time got up to go in (Resident #1's) room was stopped an redirected! He hot up during meal time stating he had to use restroom and headed to (Resident#1's) room was redirected told him that he couldn't use that room 'he asked aid to show him to the ladies restroom' told him would show him where the mens restroom was then he refused an went an sat in recliner! Approached (Resident #1) during meal time was stopped by aide. 2/8/18, at 9:35 PM, wondering through out shift in and out of rooms trying to kiss on (Resident #1). 2/13/18, at 9:44 PM, Other: tried pushing a woman resident into his room. Also, tried going into a woman's bedroom. 2/14/18 9:14 PM, Other: kissing female resident 3/13/18 at 6:29 AM, sexual remarks, took out penis in the chair by the tv in common room in front of other residents! 3/13/18, at 9:31 PM, Other: touching female resident's breast. 5/6/18, at 8:59 PM, tonight he was grabbing a female resident while she was in the recliner in the tv room, he was grabbing her in the groin area. 5/7/18, at 2:27 AM, sexual remarks, uncooperative 5/7/18 at 9:18 PM, Other: resident was bent over female resident in rec, went up to him to see what was going on and he had his hand on her upper thigh and her legs were crossed. Cna asked him to go sit down and he made a fist and threatened to punch cna. became a 1 on 1. On 5/9/18 at 4:30 PM, a request was made, to the DON, for incident and accident reports for Resident #2 for the last 6 months. The documentation received was for the one incident that occurred on 4/23/18. The DON was queried if any other incident reports were filled out that coincided with the continued sexual behaviors of Resident #2, and stated, That is all that I could find. On 5/14/18 at 5:35 PM, an interview was conducted, with Administrator A and the DON, regarding the sexual abuse incident that occurred on 2/5/18 at 10:45 PM, with Resident #2 making nonconsensual sexual contact with Resident #1. When asked about interventions being started, but sexual behaviors by Resident #2 continued without any additional updates to the care plan, and Resident #2 having another occurrence of sexual contact with resident Resident #1 (4/23/18) and no evaluation of the effectiveness of the interventions, NHA A and DON B did not have an answer. When asked why there was no documentation for an assessment to determine that Resident #2 was to be removed from one on one staffing, the Administrator stated, One on one, it is a group effort. I can't tell you if we discussed pulling (Resident #2) off (one on one) in (MONTH) or not. When queried if the incident on 2/5/18, of alleged sexual abuse, should have been thoroughly investigated and reported to the State Agency, NHA A stated, Yes. It should have been. When queried if the law enforcement (police) were notified of the sexual abuse allegation on 2/5/18, NHA A stated, No, they were not notified. When queried if, per the facility policy, the police should have been notified, NHA A stated, Yes. When queried if the police were notified of the sexual abuse allegation on 4/23/18, NHA A stated, No they were not notified. When queried if, per policy, the police should have been notified, NHA A stated, Yes. The Immediate Jeopardy was removed when the facility had the following in place: 1) The facility immediately implemented 1:1 supervision for Resident #2. 2) All staff were educated on Abuse Policy and the Elder Justice Act. 3) The Abuse Coordinator will report all suspected and confirmed allegations of abuse. Although the Immediate Jeopardy was removed on 5-9-18 the facility remained out of compliance at scope and severity of isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy as sustained compliance could not be verified by the state agency.

This citation pertains to Intake #MI 077. Based on observation, interview and record review, the facility failed to prevent sexual abuse from occurring and re-occurring to one Resident (#1) of six reviewed for abuse from a total sample of six, resulting in an immediate jeopardy when on 2/5/18, Resident #2 was observed, by CNA (Certified Nursing Assistant) M, making nonconsensual sexual contact with Resident #1 and on 4/23/18, Resident #2 was observed by CNA G, making nonconsensual sexual contact with Resident #1. The Immediate Jeopardy is due to the facility's failure to prevent sexual abuse from occurring and reoccurring. This deficient practice places Residents residing in the Dementia Unit at risk for further sexual abuse. The Immediate Jeopardy was identified on 5/8/18 at 5:45 PM. The Administrator was notified of the Immediate Jeopardy on 5/9/18 at 2:00 PM and a plan to remove the immediacy was requested. Findings include: A review of the facility's policy entitled Abuse Prevention Policy and Procedure, with a date on 3/2/18, revealed, It is the policy of (the Facility) to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion . The facility will identify and investigate all suspicions or allegations of abuse such as suspicious bruising or (on) residents, unusual occurrences, patterns and trends that may constitute abuse and will determine the direction of the investigation . During and after the investigation, the residents will be protected from harm through frequent supervision by staff. The first action taken when abuse is alleged or suspected is to protect the residents. If the alleged perpetrator of the suspected abuse is a resident, the charge nurse will separate the parties and parties will remain separated from one another until the investigation has been completed. Review of Resident #1's medical record revealed an admission on 3/9/17 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment revealed Resident #1 had severely impaired cognition and needed limited assistance with dressing and extensive assistance with hygiene. Review of Resident #2's medical record revealed an admission on 9/22/17 with [DIAGNOSES REDACTED]. A review of the MDS assessment revealed severe cognitive impairment and the Resident needed limited assistance with dressing and hygiene. Resident #2 was able to ambulate unassisted. Review of the investigation report, dated 4/23/18 at 7:30 PM, obtained from the facility regarding an incident that took place on 4/23/18, revealed, (CNA D) was on her lunch break. (CNA E) and (Nurse F) were in helping a resident. (CNA G) finished helping a resident and as she came around the corner, noticed that resident (#2), had his pants down standing in front of (Resident #1), holding her hand on his penis. (CNA G) was able to redirect (Resident #2) and no harm was done to either resident. (Resident #2) stated 'yes, I did pull my pants down, I was showing off.' (Resident #1), was not hurt in any way and could not remember the situation. On 5/8/18 at 11:15 AM, an interview, with Clinical Supervisor of the Dementia Unit, Nurse C, was conducted regarding the incident that occurred on 4/23/18 with Resident #1 and #2, who reside in the Dementia Unit. When queried about past behaviors that Resident #2 exhibited, Nurse C stated, There was one other incident that involved (Resident #1). (Resident #2) was in her room and he had his face close to her peri area. Clothes were all on. I don't remember exactly when that happened. He has a tendency to try to use the toilet in her room. We put up a border on the door with a stop sign and try to toilet him every two hours. He tends to target her. She looks younger, late 50's or 60's, like courting (Resident #1). When queried about interventions in place to prevent behaviors, Nurse C stated, He is on one on one, then 15 minute checks. Usually he is always in our sight. If we don't see him then we go find him. We have a border on the door with a stop sign. We try to toilet him every 2 hours. Activities get him involved. When queried about the second incident that happened on 4/23/18, Nurse C stated, One on one was done then 15 minute checks . On 5/8/18 at 12:50 PM, an observation was made of Resident #1 laying in bed with the covers on. The Resident's eyes were open and she was reaching up into the air and pinching her fingers together. When the Resident's name was called, she did not answer. When asked simple questions, the Resident did not answer or acknowledge the surveyor's presence. A yellow band was attached to one side of the door that had Stop on it but laid limp to the door frame and was not in place to alert others to not enter Resident #1's room. On 5/8/18 at 12:55 PM, an observation was made of Resident #2 in the dining area eating lunch. The Resident was able to answer simple questions. The Resident was eating on his own. At 1:00 PM, the Resident was seen in the hallway near the dining area and walking unassisted in the hallway, staff were nearby. On 5/8/18 at 1:45 PM, an interview, with the Social Services (SS) Nurse H, was conducted with the Director of Nursing B present. A review was done of the incident that occurred on 4/23/18 when Resident #2 was holding Resident #1's hand in his penis and Nurse H was queried regarding interventions in place to prevent reoccurrence, the Nurse stated, I don't think they put him on one on one and I did education, to the staff on the unit, of Resident #2's care plan. (Psychiatric Group) seen him that week. There was a dose reduction done on 4/5/18 and [MEDICATION NAME] (antidepressant) was decreased. The [MEDICATION NAME] was increased back up to 30 mg (milligrams). When queried about past behaviors, the SS Nurse H stated, There was an issue last night in the CNA charting. He was leaning over a female Resident with his hand on her upper thigh. He was put on one on one supervision. When queried how long the one on one continues, the Nurse stated, The one on one is done until he is deemed safe. When queried who makes the decision he is safe to be off the one on one staffing, Nurse H stated, The nurse should specify and be the one who makes that determination. When queried about documentation of the determinations to be taken off the one on one, when behaviors occur, the DON reviewed Resident #2's medical record and stated, There is none. It should be a specific policy of who determines and we should have documentation of the assessment to determine the one on one is completed. When queried about the length of time Resident #2 had remained on the one on one staffing, the DON stated, I didn't see any documentation of that. The SS Nurse H stated, It is care planned to do one on one until redirected. When queried regarding documentation that Resident #2 is put on one on one, the SS Nurse H stated, There is no specific form for one on one. The next morning (4/24/18 AM) I heard at stand up (meeting to discuss issues with residents) of the incident. No staff were doing one on one with him. I didn't see any documentation that he was placed on one on one . After the incident, some (staff) were aware there was a plan in place and some were not aware. Mostly the CNA staff that were not aware of the care plan. When queried about a documented assessment of a determination to take the Resident off one on one, the SS Nurse H stated, There is none. When queried about changes in interventions made in Resident #2's care plan, the SS Nurse H indicated there had been no changes that had been made. The SS Nurse H stated, But the staff was educated on the care plan. Documentation of when, how often and for how long Resident #2 had been placed on the one on one staffing was requested. No documentation was provided prior to the exit of the survey. Review of Resident #2's care plan, that SS Nurse H had staff review, revealed the following: Dated 2/13/18, Potential for inappropriate sexual/social interaction: Problem: (Resident #2) has displayed inappropriate sexual advances to a female resident. (Resident) has had inappropriate interactions with male residents (messaging shoulders, kissing top of head/shoulders). Potential for continued behavior Related To: Cognitive impairment, Manifested by: Wandering into other residents rooms, inappropriate touching. Goal: (Resident) will display no continued signs of inappropriate sexual/social interactions with those around him. Interventions include: (Resident #2) is to be on 15 minute checks for safety until determined he is no longer a threat. (Resident) is not to be in close proximity of any female resident at any time. Redirect him away from the female residents if needed. If at any time it is felt that his behavior cannot be redirected and he is displaying behavior that is inappropriate, harmful or sexual, (Resident) should be placed on 1:1 supervision with staff until his behavior can be deterred. Once decided that 1:1 supervision is no longer appropriate, then 15 minute checks should be re-implemented. On 5/8/18 at 4:58 PM, an interview was conducted, with CNA D, regarding the incident on 4/23/18. CNA D stated, (CNA G) said she came out and (Resident #2) was standing with pants down and he was holding (Resident #1's) hand on his penis. I took (Resident #1) and moved her away. We stayed for one on one with (Resident #2). When queried about the length of time Resident #2 was on the one on one staffing, CNA D stated, I can't tell you what length of time. Until we felt things were safe. I don't know the length of time, I am going to say about 45 minutes. It just occurred when I was coming back (from break). It just seemed he was aware and that minute he was alone on the floor. When queried regarding who makes the decision that one on one is not needed, CNA D stated, Collectively as a group. We run things through the Nurse. When queried about documentation, the CNA stated, We don't chart it, we just do it. We just communicate so that someone is watching him. On 5/8/18 at 5:15 PM, an interview with CNA E was conducted. CNA E indicated that she was assigned Resident #2 that night (4/23/18), and stated, I was taking care of another Resident and the nurse was assisting me. He had shown his penis to another Resident (#1). We watched him close so it doesn't happen again. When queried about the one on one staffing, the CNA stated, Everyone stays in the living area and he was in the living area. When queried if Resident #2 was on one on one after the incident occurred, the CNA stated, Yes, but you're also kinda watching the other Residents at the same time. We would have another CNA back there if another Resident needed help. When queried about past behaviors with Resident #2, CNA E stated, There was a time before that he was focused on (Resident #1) and he became 15 minute checks and one on one for being sexual towards the female Residents. When queried regarding other issues with sexual behaviors, the CNA stated, Yes, lately it's been increasing. It's not just her anymore. He will rub female's legs, try to kiss (Resident #1) on the top of her head, sneaking into (Resident #1's) room on nights. When queried about the length of time the one on one took place after the incident on 4/23/18 occurred, the CNA stated, One on one was close to an hour and we still watched him to make sure. He was up for a while after that. When we see him focusing on (Resident #1), we redirect. When queried if the interventions are adequate to prevent sexual contact from reoccurring, the CNA stated, I don't know. Review, of Resident #2's, Nursing Behavior charting revealed the following: On 2/5/18 at 10:04 AM, Resident seen to be rubbing shoulders of a male resident and kissing each shoulder. Cnas have stated to writer that there have been at least 2 other episodes and at least once to a female resident. Social Services notified. On 2/6/18 at 12:52 AM, At approx (approximately) 2245 (10:45 PM) hrs (hours) res (Resident #2) noted by CNA, to be resting head on female res bare left thigh while in bed, with face towards females crotch, pulling females brief to one side in the groin area, res had taken down yellow Velcro barrier to enter room, CNA told res to stop and res responded by telling her to get out of there, CNA had to pull res by arm to get res out of females room, female res was asleep, partially opened eyes, showing no facial expressions of fear or concern and went back to sleep after res was out of room, 1:1 care for res was initiated for the res (rest) of this shift. On 3/12/18 at 11:34 PM, Res was noted by CNA while sitting in a recliner chair to have his penis out of his pants and shaking it while looking and smiling at female res sitting in recliner chair across from him, room was dark, female res is alert to person, this nurse asked female if she was aware of a man sitting there, she stated yes, she was asked if she saw him do anything wrong or strange and her response was no, this nurse immediately assisted male res out of chair and walked him away from tv room and asked him if he knew that was illegal to be doing in a public place he said yes but didn't care, this nurse told him that he could do that in is (his) bathroom or behind his curtain in his room, he stated the the person who reported him shouldn't have been looking there, he is also alert to person. On 3/30/18 at 5:21 AM, Resident room (room number of Resident #1) slept in the living room recliner this shift. (Resident #2) was up in the living room standing near resident staring at her multiple times this shift. On one occasion resident was redirected from touching himself in his pants. He never touched other resident or exposed himself. He was also redirected from staring at people while they were in their rooms. Continuous checks continue. On 5/8/18 at 5:30 PM, an interview with the Director of Nursing (DON) B and Nursing Home Administrator (NHA) A was conducted. The Nursing Behavior charting, of the incident that was charted on 2/6/18 at 12:52 AM, was reviewed with the Administrator and the Director of Nursing and it was verified that the Resident mentioned in the documentation was Resident #1 that the sexual contact was made by Resident #2. When queried if the incident of Resident #2 laying his head on the bare thigh of Resident #1 and pulling at her brief in the crotch area was reported to the Abuse Coordinator, the Administrator stated, I don't know. When queried if the Administrator was the Abuse Coordinator, she answered, Yes. It should have been reported to me. When asked if the incident was reported to her, the Administrator stated, I don't remember. It could have been reported at stand up. Let me check. On 5/8/18 at 5:40 PM, NHA A returned with a typed document and stated, It was reported to us. The typed document had a date 2/5/2018 and revealed, At 2300 it was reported to writer by (CNA M) that while responding to an alarm she was passing by room (Resident #1's room) when something caught her attention. CNA observed (Resident #2) laying across the bed with his head on resident (#1's) thigh facing her crotch trying to remove her brief. When staff approached resident (#2) he became angry telling her to get out of the room. CNA told resident (#2) he must leave the room he told her to get out and began to approach her, staff was able to take resident (#2) by the arm and escort him out of the room without incident. CNA staff stated resident (#1) did not appear upset or fearful she was just lying looking at the wall. Writer interview resident (#1) she is an unreliable historian and did not respond to any questions asked or appear distraught she continued to lay on her side looking at the wall. Resident (#2) was placed one on one with staff. Writer immediately contacted Administrator and Director of Nursing. Report completed by (Nurse J) On 5/8/18 at 6:15 PM, an interview was conducted, with Nurse J, regarding the document, dated 2/5/18, that involved Resident #2 and Resident #1. Nurse J reviewed the typed documentation. Nurse J stated, I was the complaint investigator on the night shift. The staff approached me. I interviewed both Residents. (Resident #1) never responded, not a lot of speech. If upset she becomes combative. She was just looking at the wall. Really no response. He was escorted into the living room area. He didn't have any recollection of what happened. When queried if the Admininstrator/Abuse Coordinator was contacted, Nurse J stated, I contacted the Administrator about 11:00 to 11:15 PM and left a message . I gave a copy to the DON (DON B) and Admin (NHA A), I left it in their mailbox. I called the DON and spoke with her. She answered . The DON asked if her brief was off. Brief was not. Asked if Resident was upset, had pain or agitated. She said to do the one on one. When queried if Resident #2 had access to Resident #1's genital area, the Nurse stated, My understanding is yes. He was pulling the brief down. When queried if the incident was sexual abuse, Nurse J stated, Yes I would call it that. On 5/8/18 at 7:00 PM, an interview, with DON B and Nurse L, who was assigned to Residents #1 and #2 on 2/5/18, was conducted regarding the incident. Nurse L stated, The CNA came and told me. She walked by the room and saw his pajamas and went in there. She had to pull him away. She (Resident #1) was laying in bed. He had his head resting on inner thigh and when she (CNA) walked in there he had his fingers pulling the brief to the side so he could see her crotch. He told her (the CNA) to go away, he was busy. When queried regarding when Resident #2 was last visualized prior to the incident, the Nurse stated, I don't know, I didn't see him. He wanders on his own. I don't know when he was last seen. When queried regarding when the 15 minute checks started, DON B stated, The 15 minute checks started on 2/7/18. The one on one status was removed and then started the 15 minute checks. On 5/9/18 at 3:00 PM, an interview, with CNA G, was conducted regarding the nonconsensual sexual contact that occurred, on 4/23/18, of Resident #2 holding Resident #1's hand on his penis. CNA G stated, I came out from taking care of another Resident and walked into the living area by the TV. (Resident #2) had his right hand overtop of her left hand, holding her hand on his penis. His left hand was holding his pants down. The head of his penis was exposed at the top of their hands but he was moving it. He was aware of what he was doing with her hand. I came to the side of him and could see his penis. I touched his arm and he jumped. He wasn't expecting me to be there. He was watching the TV while he was doing that. As soon as I startled him, he pulled his hand away and his pants up at the same time. He knew what he was doing was wrong and he quickly walked away. On 5/9/18 at 3:35 PM, an interview, with CNA M, was conducted regarding the sexual abuse allegations on 2/5/18, that involved Resident #1 and Resident #2. The CNA stated, I was working midnights and we got in report from the other shift that (Resident #2) was acting in a sexual way, hugging, trying to kiss (Resident #1), targeting (Resident #1). I saw his legs from the door way, he had pajamas on. I went in. She was laying in bed. The covers were half off and moved over and her night gown was pulled up and only exposing her brief and her legs. When queried if Resident #1 had behaviors of lifting her gown or pulling her covers off, the CNA stated, No. She usually sleeps through the night. When queried if she had a tendency to undress herself, the CNA stated, Nope. The CNA further explained, His whole upper body was on the bed with his face on her thigh, bare thigh. He was right in the area. The yellow tape thing was all on (yellow barrier on the doorway) so he must have crawled under it. When queried if Resident #2 was close enough to her genital area that his mouth was in close proximity to her genital area, the CNA stated, Oh yes. He was pretty close. A half an inch, he would be right there. His fingers were inside the brief ripping at it. His fingers and face were right there peaking in. When queried if she had seen Resident #2's fingers inside Resident #1, the CNA stated, No not inside her. I yelled '(Resident's name) Stop. You can't be in here. You can't be doing that.' He just stood up. I yelled for help and redirected him and got him out of the room. When queried about Resident #1, the CNA stated, She was laying there, eyes half open, looking at the wall, not saying anything, not hitting him, no facial expressions. When queried regarding when Resident #2 was last seen, the CNA stated, He had bad behavior that day so we checked to see if he was in his room. We were doing room checks. It was about 15 minutes after that that it occurred. When queried about the bad behavior, the CNA stated, The report from afternoon CNA that day, he was going into (Resident #1's) room. Expressing sexual behaviors towards (Resident #1) and we were to keep a close eye on them. When queried about 15 minute checks, the CNA stated, He was not on 15 minute checks. That was after that incident. Further review, on 5/9/18 at 4:00 pm, of Resident #2's medical record, of the documented CNA Behavior charting, revealed the following Behavioral Comments that included: 2/6/18, at 9:46 PM, Several time got up to go in (Resident #1's) room, was stopped and redirected! He got up during meal time stating he had to use restroom and headed to (Resident#1's) room was redirected, told him that he couldn't use that room 'he asked aid to show him to the ladies restroom told him would show him where the men's restroom was then he refused an went and sat in recliner! Approached (Resident #1) during meal time was stopped by aide. On 2/8/18, at 9:35 PM, wandering throughout shift in and out of rooms trying to kiss on (Resident #1). On 2/13/18, at 9:44 PM, Other: tried pushing a woman resident into his room. Also, tried going into a woman's bedroom. On 2/14/18 at 9:14 PM, Other: kissing female resident On 3/13/18 at 6:29 AM, sexual remarks, took out penis in the chair by the tv in common room in front of other residents! On 3/13/18, at 9:31 PM, Other: touching female resident's breast. On 5/6/18, at 8:59 PM, tonight he was grabbing a female resident while she was in the recliner in the tv room, he was grabbing her in the groin area. On 5/7/18, at 2:27 AM, sexual remarks, uncooperative On 5/7/18 at 9:18 PM, Other: resident was bent over female resident in rec, went up to him to see what was going on and he had his hand on her upper thigh and her legs were crossed. Cna asked him to go sit down and he made a fist and threatened to punch cna. became a 1 on 1. On 5/14/18 at 5:35 PM, an interview was conducted, with Administrator A and the DON B, regarding the sexual abuse incident that occurred on 2/5/18 at 10:45 PM, with Resident #2 making nonconsensual sexual contact with Resident #1. When asked about interventions being started, but sexual behaviors by Resident #2 continued without any additional updates to the care plan, and Resident #2 having another occurrence of sexual contact with resident Resident #1 (4/23/18) and no evaluation of the effectiveness of the interventions, NHA A and DON B did not have an answer. When asked why there was no documentation for an assessment to determine that Resident #2 was to be removed from one on one staffing, the Administrator stated, One on one, it is a group effort. I can't tell you if we discussed pulling (Resident #2) off (one on one) in (MONTH) or not. The immediacy was removed on 5/9/18, at approximately 4:00 PM, based on the facility's implementation of an acceptable plan of removal as verified on-site by the surveyor. The Immediate Jeopardy was removed when the facility had the following in place: 1) The facility immediately implemented 1:1 supervision for Resident #2. 2) All staff were educated on the facility's Abuse Policy and the Elder Justice Act. 3) Resident #2 was referred to Senior Wellness. Although the Immediate Jeopardy was removed on 5-9-18 the facility remained out of compliance at scope and severity of isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy as sustained compliance could not be verified by the state agency.

This citation pertains to Intake #MI 231. Based on observation, interview and record review, the facility failed to follow care planned interventions with toileting activities for one Resident (#3) of two reviewed for falls with major injury in a total sample of six, resulting in the Resident having a fall, sustaining a fracture to the right humerus (arm) and experiencing pain to the right shoulder. Findings include: A review of the facility policy entitled, Leaving Residents Unattended for Toileting, with a revised date on 5/3/18, revealed, The resident CAN NOT be left alone on a bedside commode or toilet if any of the following are present: For cognitively intact residents 'can not be left alone' means the caregiver must be physically present in the room where the resident is using the bathroom/toilet/commode. For those that are cognitively impaired 'can not be left alone' means you must maintain visual contact as well as being no more that 4-5 feet away from the resident at all times while they are being toileted. On 5/8/17 at 10:45 AM, a review of Resident #3's medical record revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment revealed the Resident had severely impaired cognition and needed limited assistance of one person with transfers, ambulation, hygiene and toileting. On 5/8/18 at 2:05 PM, a review of the facility document entitled, Guidelines For Daily Care, for Resident #3, that was in the Resident's closet, revealed, Toileting: Staff must maintain visual contact and be no more than 4-5 feet away from resident. Review of Resident #3's document entitled, Fall Risk Assessment, dated 5/3/18 at 8:48 AM, documented by Restorative Nurse N, revealed, Definition of Problem: Recent Fall, Date of Fall: 4/28/18, Time of Fall: 2:03 AM, Location of Fall: Restroom located in this Resident's own room. A summary, of the Problem Analysis, revealed, . this resident was noted to have ambulated self independently to the threshold of the the Entrance/Exit Door of this resident's own room with this resident inquiring regarding the location of this resident's Daughter. A summary of the document revealed that Resident #3 had a tab alarm on while they were in bed and was sounding when the Resident had gotten out of bed. The Resident was assisted, to the bathroom in the Resident's room, by Nurse I, and was seated on the toilet. Nurse I had removed the tab alarm from the Resident's clothes and had turned away from the Resident while the Resident was seated on the toilet to give the tab alarm to the CNA (Certified Nursing Assistant) that was entering the room. Upon returning to the Resident, the Resident was observed to be positioned on the floor of the restroom. Further review of the document revealed, Upon further assessment of this resident per (Nurse I), this resident was noted to have sustained an abrasion with bruising to the left knee as well as bruising to the upper portion of the right side of this resident's forehead. This resident denied pain at that time when asked directly with this resident not demonstrating any nonverbal behaviors that would indicate pain. This resident was able to move all extremities in the absence of difficulty and/or restriction with range of motion therefore remaining as within normal limits as for this resident in bilateral upper and bilateral lower extremities . A neurological assessment was completed post incident revealing PERL (pupil equal round and reactive to light). Further review revealed the Resident complained of pain in the right shoulder area and continued complaints of increased dizziness on 4/30/18. The doctor was notified and a CT scan of the head and X-ray of the right shoulder were ordered and completed on 5/1/18. The CT scan revealed, no evidence for [MEDICAL CONDITION] or sulcal effacement and the X-ray revealed, previously noted right proximal humural neck fracture continues to be visible-may reflect nonunion versus acute superimposed fracture. The doctor was notified of the results and an orthopedic consult was completed on 5/2/18 with the resident noted to have re-fractured the surgical neck of the right humerus. On 5/8/17 at 8:40 AM, an interview was conducted, with the Nursing Home Administrator (NHA A), regarding Resident #3's fall in the bathroom on 4/28/18. NHA A stated, The Care Plan, located in the Resident's closet, determines the care the Resident is to receive. Eyes have to be on at all times for this Resident. The Nurse turned her back and the Resident fell so she did not follow the plan of care. On 5/8/18 at 1:10 PM, an interview, with Nurse K, was conducted regarding Resident #3's toileting interventions that staff are to follow. Nurse K stated, The CNAs do not leave her unattended in the bathroom. When queried regarding interventions in place prior to the Resident's fall on 4/28/18, the Nurse stated, No. They (staff) are always with her, even before the fall occurred. On 5/8/18 at 2:07 PM, an interview, with Restorative Nurse N, was conducted regarding Resident #3's fall in the bathroom on 4/28/17. Nurse N stated, Based on my investigation, the tab alarm was sounding and the Resident was out of bed. (Nurse I) assisted the Resident to the bathroom and sat Resident on the toilet. She removed the tab alarm on the clothing and a CNA came in and she gave the tab alarm to the CNA. She turned around and (Resident #3) was on the floor. When queried if the Nurse came out of the bathroom, Nurse N stated, Yes. When queried if the nurse had closed the door, she replied, No, she did not. When queried if the Nurse's back was turned to the Resident, she stated, Yes. If she had not turned around she would have maintained visual with the Resident. She was to maintain visual contact of the Resident. She was outside the threshold of the door when the CNA had met her. I reported to (NHA A) and (Director of Nursing (DON) B) since we failed to follow the plan of care .After I seen (Resident #3), she complained of pain. When I assessed her Monday (4/30/18) she complained of pain to me but none prior. I knew her history of a fracture in the right shoulder. On 5/14/18 at 11:24 AM, Nurse I was interviewed on the phone regarding Resident #3's fall in the bathroom on 4/28/18. When queried about the incident, Nurse I stated, I made a mistake. It was totally my fault. She was anxious and looking for her daughter. Her alarm was sounding. I sat her down then took the alarm off of her and went to give it to the CNA coming in the room. I turned my back on her. I did not maintain my live of vision with her. I was right by the door. When I turned back around, she was on the floor. When queried if the Nurse was familiar with her care plan for toileting the Resident, Nurse I stated, Yes. It had not changed since last room change. I am not usually down that hall but I had her before. It had not changed.

This citation pertains to Intake #MI 077. Based on observation, interview and record review, the facility failed to report, to the law enforcement and the State Agency, allegations of Resident to Resident non-consensual sexual abuse that occurred on 2/5/18, when Resident #2 was observed, by CNA (Certified Nursing Assistant) M, making nonconsensual sexual contact with Resident #1, of six reviewed for abuse in a total sample of six, resulting in abuse to go unreported, continue and place Residents residing in the Dementia Unit at risk for further sexual abuse. Findings include: A review of the facility's policy entitled Abuse Prevention Policy and Procedure, with a date on 3/2/18, revealed, It is the policy of (the Facility) to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion . Suspected or substantiated cases of resident abuse, . shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representative . When an allegation is received, the administrator will ensure that all alleged violations involving abuse, . are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, this in an online submission of the 24 hour report as required by the State Further review, of the policy, revealed, If the incident or allegation involves criminal activity, including but not limited to assault, sexual abuse, . the Administrator immediately notifies law enforcement in accordance with the Elder Justice Act. Review of Resident #1's medical record revealed an admission on 3/9/17 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment revealed the Resident had severely impaired cognition and needed limited assistance with dressing and extensive assistance with hygiene. Review of Resident #2's medical record, revealed an admission on 9/22/17 with [DIAGNOSES REDACTED]. A review of the MDS assessment revealed severe cognitive impairment and the Resident needed limited assistance with dressing and hygiene. The Resident was able to ambulate unassisted. Review of Resident #2's Nursing Behavior Charting dated 2/6/18 at 12:52 AM revealed, At approx (approximately) 2245 (10:45 PM) hrs (hours) res (Resident #2) noted by CNA, to be resting head on female res (Resident #1's) bare left thigh while in bed, with face towards females crotch, pulling females brief to one side in the groin area, res had taken down yellow Velcro barrier to enter room, CNA told res (Resident #2) to stop and res (Resident #2) responded by telling her to get out of there, CNA had to pull res (Resident #2) by arm to get res (Resident #2) out of females (Resident #1's) room, female res was asleep, partially opened eyes, showing no facial expressions of fear or concern and went back to sleep after res (Resident #2) was out of room, 1:1 care for res (Resident #2) was initiated for the res (rest) of this shift. On 5/8/18 at 5:30 PM, an interview with the Director of Nursing (DON) B and the Nursing Home Administrator (NHA) A was conducted. The Nursing Behavior charting of the incident that occurred on 2/6/18 at 12:52 AM, was reviewed with NHA A and DON B. When queried if the incident of Resident #2 laying his head on the bare thigh of Resident #1 and pulling at her brief in the crotch area was reported to the Abuse Coordinator, NHA A stated, I don't know. When queried if NHA A was the Abuse Coordinator, she answered, Yes. It should have been reported to me. When asked if the incident was reported to her, NHA A stated, I don't remember. It could have been reported at stand up. Let me check. On 5/8/18 at 5:40 PM, NHA A returned with a typed document and stated, It was reported to us. The typed document had a date 2/5/2018 and revealed, At 2300 (11:00 p.m.) it was reported to writer (Nurse J) by (CNA M) that while responding to an alarm she was passing by room (Resident #1's room) when something caught her attention. CNA observed (Resident #2) laying across the bed with his head on resident (#1's) thigh facing her crotch trying to remove her brief. When staff approached resident (#2) he became angry telling her to get out of the room. CNA told resident (#2) he must leave the room he told her to get out and began to approach her, staff was able to take resident (#2) by the arm and escort him out of the room without incident. CNA staff stated resident (#1) did not appear upset of fearful she was just lying looking at the wall. Writer interview resident (#1) she is an unreliable historian and did not respond to any questions asked or appear distraught she continued to lay on her side looking at the wall. Resident (#2) was placed one on one with staff. Writer immediately contacted Administrator and Director of Nursing. Report completed by (Nurse J). NHA A was queried further regarding an investigation of the allegations of sexual abuse and stated, I didn't do anything further. (Resident #1) did not appear to be fearful or distraught. (Resident #2) was immediately removed and placed on one on one. When queried regarding an incident report, NHA A stated, This is all I have. When queried if a thorough investigation was completed, NHA A stated, This is all I have. DON B was queried if she had been contacted and stated, No, honestly I don't remember. NHA A was queried if she had been contacted and stated, I don't recall if they (facility staff) contacted me. If (Nurse J) said she contacted us, she would have. When queried regarding if there was any type follow up of the incident, NHA A stated, I don't know, and if Social Services was contacted and provided services, NHA A stated, I don't know. When queried further if an investigation of the incident was completed or reported to the State Agency, NHA A stated, No. (Resident #1) wasn't fearful or appeared upset or agitated. There was no harm. On 5/14/18 at 5:35 PM, an interview was conducted, with the Administrator and the DON, regarding the sexual abuse incident that occurred on 2/5/18 at 10:45 PM, with Resident #2 making nonconsensual sexual contact with Resident #1. When queried if the incident on 2/5/18 should have been investigated and reported to the State Agency, the Administrator stated, Yes. It should have been. When queried if the police were notified of the sexual abuse allegation on 2/5/18, the Admin. stated, No, they were not notified. When queried if, per the facility policy, the police should have been notified, the Admin. stated, Yes. When queried if the police were notified of the sexual abuse allegation on 4/23/18, the Admin. stated, No they were not notified. When queried if, per policy, the police should have been notified, the Admin. stated, Yes. On 5/8/18 at 12:50 PM, an observation was made, of Resident #1, laying in bed with the covers on. The Resident's eyes were open and she was reaching up into the air and pinching her fingers together. When the Resident's name was called, she did not answer. When asked simple questions, the Resident did not answer or acknowledge the surveyor's presence. A yellow band was attached to one side of the door that had Stop on it but laid limp to the door frame and was not in place to alert others to not enter Resident #1's room. On 5/8/18 at 12:55 PM, an observation was made of Resident #2 in the dining area eating lunch. The Resident was able to answer simple questions. The Resident was eating on his own. At 1:00 PM, the Resident was seen in the hallway near the dining area and walking unassisted in the hallway, staff were nearby. Further review of the view of Resident #2's Nursing Behavior charting revealed the following: On 2/5/18 at 10:04 AM, Resident seen to be rubbing shoulders of a male resident and kissing each shoulder. Cnas have stated to writer that there have been at least 2 other episodes and at least once to a female resident. Social Services notified. On 2/6/18 at 12:52 AM, At approx (approximately) 2245 (10:45 PM) hrs (hours) res (Resident) noted by CNA, to be resting head on female res bare left thigh while in bed, with face towards females crotch, pulling females brief to one side in the groin area, res had taken down yellow Velcro barrier to enter room, CNA told res to stop and res responded by telling her to get out of there, CNA had to pull res by arm to get res out of females room, female res was asleep, partially opened eyes, showing no facial expressions of fear or concern and went back to sleep after res was out of room, 1:1 care for res was initiated for the res (rest) of this shift. On 3/12/18 at 11:34 PM, Res was noted by CNA while sitting in a recliner chair to have his penis out of his pants and shaking it while looking and smiling at female res sitting in recliner chair across from him, room was dark, female res is alert to person, this nurse asked female if she was aware of a man sitting there, she stated yes, she was asked if she saw him do anything wrong or strange and her response was no, this nurse immediately assisted male res out of chair and walked him away from tv room and asked him if he knew that was illegal to be doing in a public place he said yes but didn't care, this nurse told him that he could do that in is (his) bathroom or behind his curtain in his room, he stated the person who reported him shouldn't have been looking there, he is also alert to person. On 3/30/18 at 5:21 AM, Resident room (room number of Resident #1) slept in the living room recliner this shift. (Resident #2) was up in the living room standing near resident staring at her multiple times this shift. On one occasion resident was redirected from touching himself in his pants. He never touched other resident or exposed himself. He was also redirected from staring at people while they were in their rooms. Continuous checks continue. On 5/8/18 at 6:15 PM, an interview was conducted, with Nurse J, regarding the document, dated 2/5/18, that involved Resident #2 and Resident #1. Nurse J reviewed the typed documentation. Nurse J stated, I was the complaint investigator on the night shift. The staff approached me. I interviewed both Residents. (Resident #1) never responded, not a lot of speech. If upset (Resident #1) becomes combative, She was just looking at the wall. Really no response. (Resident #2) was escorted into the living room area. He didn't have any recollection of what happened. When queried if NHA A/Abuse Coordinator was contacted, Nurse J stated, I contacted the Administrator about 11:00 to 11:15 PM and left a message . I gave a copy (of the incident report) to the DON and (NHA A), left it in their mailbox. I called the DON and spoke with her. She answered . The DON asked if (Resident #1's) brief was off. Brief was not. Asked if (Resident #1)was upset, had pain or agitated. (DON B) said to do the one on one. When queried if the incident is a reportable incident to the State Agency, Nurse J stated, I don't make that determination. That is why I called the Administrator and DON. When queried if the incident was a reportable incident to the DON and the Abuse Coordinator, Nurse J stated, Yes. When queried if Resident #2 had access to Resident #1's genital area, the Nurse stated, My understanding is yes. He was pulling the brief down. When queried if the incident was sexual abuse, Nurse J stated, Yes I would call it that. When queried if the DON or Administrator had contacted her regarding investigation questions or a statement, the Nurse stated, No. When queried if she had heard anything after the incident about an investigation, the Nurse stated, No. When queried if she had asked the Administrator or the DON about the incident afterwards, the Nurse stated, No. When queried regarding documented interviews with the Residents and staff involved, Nurse J stated, None that I wrote up. On 5/8/18 at 7:00 PM, an interview, with DON B and Nurse L, who was assigned to Resident #1 and 2 on 2/5/18, was conducted regarding the incident. Nurse L stated, The CNA came and told me. She walked by the room and saw his pajamas and went in there. She had to pull him away. She (Resident #1) was laying in bed. He (Resident #2) had his head resting on inner thigh and when she (CNA) walked in there he had his fingers pulling the brief to the side so he could see her crotch. (Resident #2) told her (the CNA) to go away, he was busy. Nurse L was queried if an investigation of the incident had taken place and if the DON or Administrator had discussed the incident with her, the Nurse replied, (Nurse J) did when she came down but I don't remember anyone else. When queried about a documented incident report, she responded, I don't remember filling one out. The DON stated, No I didn't talk to her at all. I didn't have her do an incident report. On 5/9/18 at 3:35 PM, an interview, with CNA M, was conducted regarding the sexual abuse allegations on 2/5/18, that involved Resident #1 and Resident #2. The CNA stated, I was working midnights and we got in report from the other shift that (Resident #2) was acting in a sexual way, hugging, trying to kiss (Resident #1), targeting (Resident #1). I saw his legs from the door way, he had pajamas on. I went in. She was laying in bed. The covers were half off and moved over and her night gown was pulled up and only exposing her brief and her legs. When queried if Resident #1 had behaviors of lifting her gown or pulling her covers off, the CNA stated, No. She usually sleeps through the night. When queried if she has a tendency to undress herself, the CNA stated, Nope. The CNA further explained, His whole upper body was on the bed with his face on her thighs, bare thighs. He was right in the area. The yellow tape thing was all on (yellow barrier on the doorway) so he must have crawled under it. When queried if Resident #2 was close enough to her genital area that his mouth was in close proximity to her genital area, the CNA stated, Oh yes. He was pretty close. A half an inch, he would be right there. His fingers were inside the brief ripping at it. His fingers and face were right there peaking in. When queried if she had seen Resident #2's fingers inside Resident #1, the CNA stated, No not inside her. I yelled '(Resident #2's name) Stop. You can't be in here. You can't be doing that.' He just stood up. I yelled for help and redirected him and got him out of the room. When queried about Resident #1, the CNA stated, She was laying there, eyes half open, looking at the wall, not saying anything, not hitting him, no facial expressions. When queried regarding when Resident #2 was last seen prior to this incident, the CNA stated, He had bad behavior that day so we checked to see if he was in his room. We were doing room checks. It was about 15 minutes after that that it occurred. When queried about the bad behavior, the CNA stated, The report from afternoon CNA that day, he was going into (Resident #1's) room. Expressing sexual behaviors towards (Resident #1) and we were to keep a close eye on them. When queried if the police were notified, the CNA stated, No. Just (Nurse J) came back and talked to me about the situation. When queried if the DON or Administrator contacted her about the incident, the CNA stated, No, I never talked to (Administrator) or the DON. Further review of Resident #2's medical record, of the documented CNA Behavior charting, revealed the following Behavioral Comments that included: 2/6/18, at 9:46 PM, Several time got up to go in (Resident #1's) room was stopped an redirected! He hot up during meal time stating he had to use restroom and headed to (Resident#1's) room was redirected told him that he couldn't use that room 'he asked aid to show him to the ladies restroom' told him would show him where the men's restroom was then he refused an went an sat in recliner! Approached (Resident #1) during meal time was stopped by aide. 2/8/18, at 9:35 PM, wondering through out shift in and out of rooms trying to kiss on (Resident #1). 2/13/18, at 9:44 PM, Other: tried pushing a woman resident into his room. Also, tried going into a woman's bedroom. 2/14/18 9:14 PM, Other: kissing female resident 3/13/18 at 6:29 AM, sexual remarks, took out penis in the chair by the tv in common room in front of other residents! 3/13/18, at 9:31 PM, Other: touching female resident's breast. 5/6/18, at 8:59 PM, tonight he was grabbing a female resident while she was in the recliner in the tv room, he was grabbing her in the groin area. 5/7/18, at 2:27 AM, sexual remarks, uncooperative 5/7/18 at 9:18 PM, Other: resident was bent over female resident in rec, went up to him to see what was going on and he had his hand on her upper thigh and her legs were crossed. Cna asked him to go sit down and he made a fist and threatened to punch cna. became a 1 on 1. Review of the investigation report, dated 4/23/18 at 7:30 PM, obtained from the facility, regarding an incident that took place on 4/23/18, revealed, (CNA D) was on her lunch break. (CNA E) and (Nurse F) were in helping a resident. (CNA G) finished helping a resident and as she came around the corner, noticed that resident (#2), had his pants down standing in front of (Resident #1), holding her hand on his penis. (CNA G) was able to redirect (Resident #2) and no harm was done to either resident. (Resident #2) stated 'yes, I did pull my pants down, I was showing off.' (Resident #1), was not hurt in any way and could not remember the situation. On 5/8/18 at 11:15 AM, an interview, with Clinical Supervisor of the Dementia Unit, Nurse C, was conducted regarding the incident that occurred on 4/23/18 with Resident #1 and #2, who reside in the Dementia Unit. When queried about past behaviors that Resident #2 exhibited, Nurse C stated, There was one other incident that involved (Resident #1). (Resident #2) was in her room and he had his face close to the peri area. Clothes were all on. I don't remember exactly when that happened. He had a tendency to try to use the toilet in her room. We put up a border on the door with a stop sign and try to toilet him every two hours. He tends to target her. She looks younger, late 50's or 60's, like courting (Resident #1). On 5/8/18 at 5:15 PM, an interview with CNA E was conducted. CNA E indicated that she was assigned Resident #2 that night (4/23/18) as her Resident and stated, I was taking care of another Resident and the nurse was assisting me. He had shown his penis to another Resident (#1). We watched him close so it doesn't happen again. When queried about the one on one staffing, the CNA stated, Everyone stays in the living area and he was in the living area. When queried if Resident #2 was on one on one, the CNA stated, Yes, but you're also kinda watching the other Residents at the same time. We would have another CNA back there if another Resident needed help. When queried about past behaviors with Resident #2, CNA E stated, There was a time before that he was focused on (Resident #1) and he became 15 minute checks and one on one for being sexual towards the female Residents. When queried regarding other issues with sexual behaviors, the CNA stated, Yes, lately it's been increasing. It's not just her anymore. He will rub females legs, try to kiss (Resident #1) on the top of her head, sneaking into (Resident #1's) room on nights. When queried about the length of time the one on one took place after the incident on 4/23/18, the CNA stated, One on one was close to an hour and we still watched him to make sure. He was up for a while after that. When we see him focusing on (Resident #1), we redirect. When queried if the interventions are adequate to prevent sexual contact from reoccurring, the CNA stated, I don't know.

This citation pertains to intake # MI 120 Based on observation, interview and record review, the facility failed to implement effective interventions to prevent falls for 1 ( # 703) of 1 resident with a history of impulsiveness, prior falls, low blood sugars and orthostatic hypotension, from a total of four sampled residents, resulting in a fall with a hip fracture that required surgical intervention. Findings include: On 5/17/17 at 9:15 a.m., record review revealed that Resident #703 was admitted into the facility on [DATE] and readmitted on [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #703 required limited assist with transfers, ambulation, personal hygiene, toileting and bed mobility, had a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognitive functioning and was continent of bowel and bladder. The MDS also revealed that Resident #703 had [DIAGNOSES REDACTED]. On 5/17/17 at 12:50 p.m., a confidential family interview was completed (Family Member F). Family Member F stated, My mom has been more confused since she has fallen. She has fallen three times there and they never placed an alarm on her or provided any fall precautions. The last fall they put her on the toilet and left her there. She put the call light on and no one answered it so she got up by her self and fell . Now she has a broken hip and an intestinal bleed. They are talking about hospice now. On 5/17/17 at 12:55 p.m., a review of the Admission Fall Risk assessment dated [DATE] revealed that Resident #703 had a low blood sugar and was hospitalized for [REDACTED]. It also stated, Resident remains cognitively able to understand safety interventions, however this resident makes an informed decision at times not to abide by safety interventions. Resident demonstrates impulsiveness at times. Resident remains at risk for falls at this time related to medications and medical conditions. On 5/17/17 at 1:00 p.m., a review of the incident reports revealed the following: On 3/26/17 at 11:40 p.m. Heard call light click on. fell in bathroom on right side. Blood on face coming from mouth. Intervention: Educated Resident (#703) to bring walker up to toilet and then pulling pants down and sitting on toilet. Fall Risk assessment dated [DATE] that was completed for the fall, revealed that Resident #703 stated that she lost her balance and fell and that she is unsteady when she does not use her walker. Orthostatic blood pressure: Laying 142/64 Sitting 140/76 Standing 108/70 (indicating that Resident #703 has a significant shift in blood pressure when standing that can cause dizziness and falls). On 4/7/17 at 3:00 a.m. states, found on floor just outside bathroom leaning against the door. Call light utilized. New intervention: 30 minute checks, transferring status changed to one person assist. Fall Risk assessment dated [DATE] stated Resident #703 had stated she, lost her balance--I was just unsteady. On 4/27/17 at 2:15 p.m. states, Call light utilized and on; found on floor in bathroom. New intervention: Have staff stay in bathroom while being toileted. Tab alarm to bed and wheelchair. Fall assessment dated [DATE] states that Resident #703 had stated she lost her balance and fell . The assessment stated the resident has a history of impulsiveness and having a pattern of falls during times of requiring completion of toileting and hygiene needs, an order was implemented immediately following the occurrence of the incidence, nursing staff is to remain with resident while toileting. Resident's daughter requesting a tab alarm to be placed in bed and wheelchair. On 5/17/17 at 11:15 a.m. and 3:15 p.m., observed Resident #703 lying in bed resting with her eyes closed. Resident #703 was very pale and had a catheter. Resident #703 had family at the bedside. On 5/17/17 at 2:15 p.m., the Physical Therapist (PT) D was interviewed and PT D stated that Resident #703 was safe after completion of therapy (in March 2017) to transfer independently. PT D stated that currently, Resident #703 is receiving therapy but Resident #703 is very weak and not able to aggressively participate in therapy. On 5/17/17 at 2:20 p.m., the Occupational Therapist (OT) E was interviewed in regards to the toileting needs of Resident #703. OT E stated that Resident #703 had an original goal to go back home after rehabilitation and that once she completed therapy, she got a respiratory infection and stayed longer and started to decline. OT E stated, It was almost like a failure to thrive. According to OT E, Resident #703 was screened for her decline and falls. During the interview, OT E provided the screen. The record review of the screen dated 4/10/17 states, increased difficulty transferring to and from commode. On 5/17/17 at 2:25 p.m., a review of the Physical Therapy Discharge Summary for dates of service 3/13/17 to 3/29/17 revealed the following under the topic transfers-CGA (contact guard assist), verbal cues 50 percent (%) with comments, Decline in transfer skills due to the fall incident last Saturday. Since it happened, resident has been having difficulty doing things by herself. She has been calling for help. She also has persistent cough for almost a week now that is also affecting her ability to function well. On 5/17/17 at 2:30 p.m., an interview was attempted with the Director of Nursing (DON) in regards to Resident #703's falls, the DON had stated that the Restorative Nurse A investigates all the falls and that she would have better knowledge of the incidents. On 5/17/17 at 2:35 p.m., an interview was completed with Restorative Nurse A. According to Nurse A, she is responsible for investigating falls after they occur and implemented changes as needed per the results of the investigation. Nurse A stated, If she (Resident #703) had fallen each time in the bathroom, I would have definitely changed her to a status of remaining with her while in the bathroom. That day (4/27/17), she had different aides than usual and they put her on the toilet and left her there. If she would have had her regular aides, they would not have left her alone. Nurse A felt the fall could have been prevented if staff would have remained in the bathroom with her or close outside the bathroom door. On 5/17/17 at 2:55 p.m., a review of the nurses notes for 4/3/17 and 4/12/17 revealed that Resident #703 had two low blood sugar episodes causing confusion. On 5/17/17 at 3:05 p.m., an interview with Certified Nurse Aide (CNA) B was completed. CNA B is a regular CNA that works with Resident #703. CNA B stated, I found her when she fell (4/27/17). I felt bad because if I had toileted her she would not have fallen. When I toilet her I stay with her because she gets up too fast. On 5/17/17 at 3:30 p.m., a review of the facility policy titled, Resident incident-Reporting and Monitoring effective 3/30/16 revealed the following: The Restorative Nurse or designee will investigate all incidents in a timely manner .Appropriate interventions will be implemented per Restorative Nurse or designee, when applicable in attempt to prevent recurrence.

This citation pertains to MI 552. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent the elopement of one cognitively impaired resident who was assessed by the facility as being an elopement risk (#201), out of a sample of four residents reviewed for risk of elopement in a total sample of four residents, and failed to implement a search for the missing resident when a door alarm was activated, placing Resident #201 in immediate jeopardy to his health and safety when he successfully entered the facility's front parking lot unsupervised, in possession of keys to a van which he attempted to access, and fell . Furthermore, facility staff did not become aware of Resident #201's fall until the following day, and facility staff on duty at the time of the elopement did not accurately report the circumstances of the elopement, including how long the resident was actually outside of the facility, to the facility's administrator. Additionally, the facility failed to assure the proper functioning of alarms on two of three facility doors with wander guard alarms installed, placing 17 of the facility's 104 residents who were assessed as at being risk of elopement at increased risk of injury from eloping, due to the non-functioning alarms and the failure of the staff to implement procedures to provide adequate supervision. Immediate jeopardy began on or before 6/16/2015 at 6:00 pm when, according to witness statements, Resident #201 gained possession of the keys to his spouse's minivan and would not relinquish them to his spouse or staff. According to witness statements and documentation, Resident #201 had been placed on 15 minute checks but was unaccounted for at 7:15 pm., although no missing resident alert was sounded at that time per facility policy. According to witness statements, Resident #201 activated the wander guard alarm system at the front entrance of the building at 6:54 pm and the alarm was deactivated by facility staff, who failed to search for the reason for the door alarming and failed to issue a missing resident alert per facility policy. According to date and time stamped video surveillance tapes, Resident #201 was outside in the front parking lot at 7:07 pm where he approached the minivan, and then his wheel chair was seen upside down on the driver's side of the van. The video surveillance tapes showed two motorists who aided Resident #201 off of the ground at 7:14 pm, and loaded his wheel chair into the back of the minivan, after Resident #201 opened the rear door. At 7:16 pm, the video surveillance tapes revealed facility staff approaching the minivan and Resident #201 moving around to the driver's door of the minivan. According to the Minimum Data Set Resident Assessment, dated 5/20/2015, Resident #201 scored 3 of 15 on the Brief Interview for Mental Status indicating severe cognitive impairment. According to the Medical treatment decision maker identification form, dated 3/25/2015, Resident #201's spouse made treatment decisions for him. The Nursing Home Administrator was notified of the Immediate Jeopardy situation on 6/29/2015 at 4:55 pm. Findings include: According to the Resident Admission Record, printed on 6/17/2015, Resident #201 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Resident Risk for Elopement Assessment, dated 3/27/2015, revealed that Resident #201 had a wander guard transmitter applied due to an elopement risk and that Resident #201 was placed on every 15 minute checks as well. According to documentation in Behavioral Comments, dated 6/16/2015 at 9:48 pm, Resident #201 had few behaviors at six pm this afternoon while wife was in. Resident was threatening to hurt wife and had ahold of her purse and bag she had with her. The nurse and I went in and interveined (sic) and calmed resident down some. Wife left without her bags and resident was sitting up at the nursing station at seven pm. The documentation for Resident #201, dated 6/16/2015 at 8:41 pm in the facility's Describe Incident report, recorded The wandergard alarm on front door was alarming. A Certified Nursing Assistant (CNA) went down and shut it off and noticed 2 men loading residents w/c (wheel chair) and resident into a minivan. At that time four staff members went out to assist with resident. The two men stated they helped resident into the van and loaded his w/c. The Alarm ordered section of the same report documented that Wandergard door sounded and staff acted appropriately. This section of the documentation also stated that No first aid needed at this time. and Staff acted appropriately and resident was brought back into the facility without incident. The corresponding Incident Report listed the date and time of the incident at 6/16/2015 at 7:20 pm. The Incident Report stated that the incident was witnessed by the CNA. On 6/17/2015 at 8:40 am, the Social Services progress note documented that Resident #201's spouse had been contacted by phone that morning regarding the elopement and had relayed that Resident #201 had not been happy and could not understand why he could not return home and had become physically aggressive. The spouse, according to the note, had left her purse with the keys to the van in it, in the dining room with Resident #201, and had called her son to take her home leaving the van in the parking lot. The social services progress note documented that Resident #201 would not be safe at home, the physician would not discharge him and that Resident #201's wife would not be able to care for him. During an interview with the Nursing Home Administrator (NHA) on 6/29/2015 at 10:45 am, she stated that she had received a phone call from the facility on the evening of 6/16/2015 informing her of Resident #201's elopement from the facility and that she had been assured that Resident #201 had been supervised by staff during the time he was in the front parking lot. The NHA stated that she had received a statement in her mailbox that was signed by six staff members who had been on duty on 6/16/2015 when Resident #201 had eloped from the building. The undated statement with a time of 7:30 pm at the top repeated that the door alarm was alarming on the main entrance. The CNA went down to shut it off and noticed 2 men loading a wheel chair and Resident #201 into a van. The note stated After our staff got outside, approximately 45 seconds after the alarm sounded, (Resident #201) never left our sight again and did not fall during this elopement event. The NHA stated that during the course of the investigation she noted inconsistencies between the documentation in Resident #201's medical record, the statement signed by the on duty staff members, and the video surveillance footage of the front parking lot from 6/16/2015 that she had viewed on 6/17/2015. During the interview with the Nursing Home Administrator (NHA) on 6/29/2015 at 10:45 am, she stated that she had called the company that installed and serviced the facility's nurse call system that includes pocket pagers for the staff and had been informed that the wander guard alarm had triggered and an alert had been sent to the pagers on 6/16/2015 at 6:54 pm. The NHA's investigation notes and an observation of the video surveillance tapes revealed that on 6/16/2015 the following events occurred: ~ at 7:05 pm the inside door opened in the breezeway and the door remained open for 31 seconds. ~ at 7:07 pm Resident #201 was seen in a wheel chair approaching a van in the parking lot. ~ at 7:08 pm Resident #201 was out of view of the camera on the driver's side of the van. ~ at 7:12 pm Resident #201's wheel chair is seen on its side then turns upside down with the wheels slowly spinning in the air then goes back to its side while movement is noted on the ground. ~ at 7:15 pm, two men emerge from a pickup truck that has pulled into the parking lot and assist Resident #201 from the ground. Resident #201 then walks to the back of the van, opens the rear door, and the two men load the wheel chair into the back of the van and close the door. ~ at 7:16 pm, a staff member is seen in the parking lot approaching the van and the men as Resident #201 moves around the van toward the driver's door. During the interview with the Nursing Home Administrator (NHA) on 6/29/2015 at 10:45 am, she stated that, when she had viewed the video surveillance footage on 6/17/2015, it was the first time the she and the staff became aware that Resident #201 had fallen in the parking lot the previous evening during the elopement. According to the investigation notes, on 6/17/2015 at 1:19 pm, the Registered Nurse Unit Manager was notified of the fall and was asked to perform a thorough assessment of Resident #201. However, by that time, another (witnessed) fall had been documented in Resident #201's medical record progress notes at 6/17/2015 at 11:04 am, and he had at that time struck his head on a pipe during the fall. During the interview with the Nursing Home Administrator (NHA) on 6/29/2015 at 10:45 am, she described the nurse call system. All of the direct care staff, certified nursing assistants (CNAs) and the nurses, had pagers for the call system. The pagers alerted when a call light was activated by a resident, when an alarmed exit door was activated, and when a wander guard alarmed door was activated by a resident wearing a wander guard device on their person or attached to their wheel chair and they came within sensor range. The pager system alerted the CNA staff immediately and again at 3 minutes if the alarm was not reset. At 6 minutes, the alarm would go to nurse managers. During interview on 6/29/2015 at 10:55 am, The Housekeeping Supervisor, Staff C, stated that there were 19 exit doors in the facility with an 800 series alarm that sound when the door opens without the proper code being entered and three doors that had wander guard alarms in addition to the 800 series alarms. During interview on 6/29/2015 at 11:00 am, Staff B, the Maintenance Director, stated that the door alarms had both the audible alarm that sounded and the alert that was sent to the pager system. Staff B stated that on 6/16/2015 the front door had in place a wander guard alarm but not an 800 series alarm. On 6/29/2015 at 10:45 am, the NHA stated that the wander guard and door alarms were checked on a routine basis, but the pagers had not been routinely tested , and there was no policy regarding the use of the pagers. During an interview with the Licensed Practical Nurse (LPN) who was responsible for investigating incidents, staff A, on 6/29/2015 at 2:30 pm, she stated that she had begun her investigation into Resident #201's elopement on the morning of 6/17/2015 when she reported for duty. LPN Staff A's documentation on 6/17/2015 revealed that she had spoken with some of the staff that had been on duty the evening of 6/16/2015 by phone and that she had left messages with no return phone calls for others. LPN Staff A stated during the interview that she had been suspicious of some of the information provided to her by the staff and had had difficulty getting information from other staff members because they were uncooperative and LPN Staff A described one of the phone conversations as almost hostile. LPN Staff A stated that only two of the staff members she spoke with remembered getting a pager alert that the front door wanderguard alarm had been activated. These two staff members had reported they were providing care to another resident and were unable to respond to the pager alert at that time. The rest of the staff either denied getting a pager alert, or told LPN Staff A that they could not remember, with one of the LPNs on duty that night telling LPN Staff A that she did not have the pager on her person at the time. During the interview with the Nursing Home Administrator (NHA) on 6/29/2015 at 10:45 am, she stated that during the course of the investigation one of the CNAs had come forward and admitted that she had disarmed and reset the wander guard alarm on the front door on the evening of 6/16/2015 with no investigation as to why the alarm was sounding or how it had been set off. The CNA had told the NHA that she had looked through the window and didn't see anything so she had asked a nurse for the code to reset the alarm. The CNA had further stated that no Code 10 (the facility code to search for a missing resident) had been conducted that evening. The facility policy and procedure for the Wanderguard Alarm System, dated 3/15/2012, stated that There will be a staff Alert Panel alarm at the point of activation and a signal will be sent through the nurse call system to alarm all employees having a nurse call pager. Any/all staff members are to respond instantly to the point of alarm activation. The instructions for Responding to an alarm included Locate the resident that activated the alarm. According to the investigation notes of LPN Staff A, dated 6/17/2015, the LPN and the CNA who were caring for Resident #201 on the evening of 6/16/2015, had gone to check on him at about 6:45 pm in the dining room where he had been since his argument with his spouse and he was not there. The investigation notes revealed the LPN went to another nursing unit in the building to look for Resident #201, and upon her return from that unit she looked out a window and saw Resident #201 standing by the van with two men putting a wheel chair into the van. The investigation notes reported that the LPN had not heard the wander guard audible alarm and that she did not have her pager on her person at that time. There was no documentation that a Code 10 had been initiated when the LPN and CNA were unable to locate Resident #201 at about 6:45 pm. The facility policy Code 10 - Missing Resident, dated 8/19/2014, stated A systematic approach of all staff members will be instituted in the event a resident is questioned or determined to be missing. The procedure included: 1. When it is suspected a resident may be missing, a staff member will inform the charge nurse who will alert the staff using the phone and overhead paging system. 2. In the event a door alarm is activated and the causative factor is unknown, a CODE 10 shall be initiated, indicating which door alarmed. 4. A thorough search will be done by all departments available. The search will include all resident rooms, ancillary rooms and the outside perimeter of the facility, including the parking lot and vehicles in said parking lots. During an interview with LPN Staff A on 6/29/2015 at 2:30 pm, she agreed that the facility policies had not been followed on 6/16/2015, the evening of Resident #201's elopement. LPN Staff A agreed that there were two instances when the Code 10 procedure should have been initiated; the first time was when Resident #201 was not located and being searched for by the floor LPN and CNA, and the second time was when the front door wander guard alarm sounded and the staff did not know the reason the alarm had been triggered. During observation on 6/30/2015 at 1:20 pm, LPN Staff A located the wanderguard alarm on a spoke of Resident #204's wheel chair. Staff A was observed to take Resident #204's wheel chair to the wander guard alarmed door on the 800 hall. LPN Staff A wheeled the chair through the door, turned it around and wheeled it back through the door without setting off the alarm. LPN Staff A also held a wanderguard alarm in her hand and was able to walk through the door and turn around and come back through the door without the alarm sounding. In the presence of this surveyor, LPN Staff A then took Resident #204's wheel chair, with the alarm on the spoke of the wheel, to and through the 400 hall door with a wander guard alarm, where again the door failed to alarm. According to LPN Staff A, the door should have alarmed when the wander guard device on the wheel chair came within three feet of the doors. LPN A was only able to set off the alarms on the doors of the 400 and 800 halls when she held the devices next to the alarm sensors. LPN A agreed, that would not be sufficient to prevent a resident from eloping since the devices were normally on a resident's ankle or a plastic part of the wheel chair, usually the spoke, and that would be lower and farther away than where she had held the device next to the sensor units to cause the alarms. On 6/30/2015 at 2:20 pm, Maintenance director staff B stated he had contacted the company for the wander guard alarms and had been told that the frequency on the alarms needed to be re-set for them to work properly. The immediate jeopardy was removed on 6/18/15. On 7/1/2015 at 1200 pm, the surveyor verified the following: 1. All staff completed education on elopement policies, Code 10/missing residents, the wander guard policy, the elopement risk assessment policy and pager use by 7/1/2015. 2. Code 10 drills had been conducted on every shift and on a weekend between 6/17/2015 and 6/24/2015. 3. The front door was locked from the inside and the outside on 6/22/2015. 4. Pagers were reprogrammed on 6/17/2015 to alert all carriers of an open alarmed door immediately and the wording was changed to include the word door with the word egress. 5. Functioning of the pagers began being routinely checked at the change of every shift. 6. Monitoring of the staff use of pagers and availability of pagers began being routinely checked at the change of every shift with quarterly monitoring by management. 7. Maintenance developed a log to document weekly checks of the pager system. 8. The double doors to the lobby are now kept open so the alert system alarms can be better heard (done on 6/17/2015). Although the immediate jeopardy was removed on 6/18/15, the facility remained out of compliance at a scope of pattern, and a severity of no actual harm with the potential for more than minimal harm, that is not immediate jeopardy, for 17 residents assessed by the facility as being at risk for elopement, pending the facility's ability to demonstrate sustained compliance as verified by the state agency. ( )

THIS CITATION PERTAINS TO INTAKES MI 365 AND MI 282. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT ADEQUATE SUPERVISION AND ASSISTANCE CONSISTENT WITH THE RESIDENT'S NEEDS AND PLAN OF CARE TO PREVENT ACCIDENTS FOR 2 (#101 AND #102) OF 4 SAMPLED RESIDENTS REVIEWED FOR SAFETY, FROM A TOTAL SAMPLE OF 4, RESULTING IN AN ACUTE MILDLY ANGULATED FRACTURES OF THE LEFT FIFTH AND SIXTH RIBS WHEN RESIDENT #102 WAS TRANSFERRED IN A MANNER INCONSISTENT WITH THE PLAN OF CARE AND THE POTENTIAL FOR PHYSICAL ALTERCATIONS BETWEEN RESIDENT #101 AND HIS SPOUSE. FINDINGS INCLUDE: RESIDENT #102: ACCORDING TO THE FACE SHEET DATED 1/30/2013 RESIDENT #102 WAS admitted to the facility on [DATE]. THE MINIMUM DATA SET (MDS) assessment dated [DATE], INDICATED THAT RESIDENT #102 WAS A [AGE] year OLD ALERT FEMALE WHO REQUIRED EXTENSIVE ASSISTANCE WITH TOILETING, BED MOBILITY, TRANSFERS AND AMBULATION. RESIDENT #103 WAS UNSTEADY WITHOUT STAFF ASSISTANCE AND HAD SEVERAL DIAGNOSES, WHICH INCLUDED A HIP FRACTURE, OSTEOPOROSIS AND PAIN. ACCORDING TO THE CARE PLAN DATED 12/17/2012 RESIDENT #102 WAS AT RISK FOR FALLS. INTERVENTIONS IMPLEMENTED INCLUDED THE ASSISTANCE OF 2 STAFF MEMBERS FOR TRANSFERS. ACCORDING TO THE NURSE'S NOTE DATED 12/25/2012 RESIDENT #102 COMPLAINED THAT SHE (#102) HEARD A POP WHILE BEING TRANSFERRED. RESIDENT #102 SAID THAT HER BONES BREAK EASILY DUE TO OSTEOPOROSIS AND COMPLAINED OF PAIN WITH MOVEMENT. ACCORDING TO THE FACILITY INCIDENT REPORT DATED 12/28/2012, ON 12/25/2012 AT A TIME THAT WAS NOT KNOWN PRECISELY, A CERTIFIED NURSE ASSISTANT (CNA #3) TRANSFERRED RESIDENT #102 WITHOUT HELP WHEN RESIDENT #102 WAS KNOWN TO BE A TWO PERSON ASSIST FOR TRANSFERS. ACCORDING TO THE FACILITY INCIDENT REPORT RESIDENT #102 COMPLAINED OF RIB PAIN AND X/RAYS WERE OBTAINED. ACCORDING TO THE DIAGNOSTIC RADIOLOGY REPORT DATED 12/28/2012 RESIDENT #102 SUFFERED FROM SEVERAL RIB FRACTURES THAT APPEARED OLD, AS WELL AS AN ACUTE MILDLY ANGULATED FRACTURES OF THE LEFT FIFTH AND SIXTH RIBS. DURING AN INTERVIEW ON 1/30/2013 AT 1:29 P.M., RESIDENT #102 SAID THAT SHE DID NOT WANT TO GET ANYONE IN TROUBLE, BECAUSE SHE LIKED CNA #3. RESIDENT #102 SAID CNA #3 WAS HELPING HER WHEN OTHER NURSING STAFF MAY NOT HAVE. RESIDENT #102 SAID SHE ASKED TO BE TAKEN TO THE REST ROOM AND CNA #3 REACHED AROUND HER (#102) FROM BEHIND AND GAVE HER A "...BEAR HUG..." RESIDENT #102 SAID CNA #3 THEN PICKED HER UP AND MOVED HER ONTO THE TOILET. RESIDENT #102 SAID CNA #3 SQUEEZED HER (#102) TIGHTER THAN WAS COMFORTABLE, BUT IT WAS PROBABLY BECAUSE CNA #3 WAS AFRAID THAT RESIDENT #102 MIGHT GET DROPPED. RESIDENT #102 SAID SHE FELT THE "...POP..." AS HER RIBS BROKE, BUT DID NOT WANT TO COMPLAIN. RESIDENT #102 DECLINED TO DESCRIBE THE PAIN ASSOCIATED WITH THE RIB FRACTURES, SAYING INSTEAD, " ...I LIKED HER (CNA #3). SHE TRIED TO HELP WHEN OTHERS WOULDN'T; AND I DON'T WANT HER IN TROUBLE..." IN AN INTERVIEW ON 1/30/2013 AT 12:07 P.M., THE ADMINISTRATOR (ADM) #1 SAID THAT ACCORDING TO THE FACILITY'S INVESTIGATION, STAFF FAILED TO PROVIDE RESIDENT #102 WITH ADEQUATE SUPERVISION AND ASSISTANCE IN ACCORDANCE TO THE PLAN OF CARE TO PREVENT ACCIDENTS AND THAT THE INAPPROPRIATE TRANSFER CAUSED RESIDENT #102'S RIB FRACTURES. DURING AN INTERVIEW ON 1/30/2013 AT 2:10 P.M., THE DIRECTOR OF NURSING (DON) #1 SAID THAT ACCORDING TO HER INVESTIGATION, CNA #3 DIDN'T FOLLOW THE GUIDELINES. DON #1 CLARIFIED THAT AT THE TIME CNA #3 TRANSFERRED RESIDENT #102, THERE WAS A PHYSICIAN ORDER [REDACTED]. DON #1 SAID THAT RESIDENT #102'S CARE PLAN INCLUDED DIRECTING STAFF TO TRANSFER RESIDENT #102 WITH THE ASSISTANCE OF 2 STAFF MEMBERS. DON #1 SAID THAT CNA #3 CHOSE TO FOLLOW NEITHER (THE PHYSICIAN ORDER [REDACTED]. IN AN INTERVIEW ON 1/31/2013 AT 1:20 P.M., CNA #3 SAID THAT ON 12/25/2012 AT SOME TIME DURING THE MIDNIGHT SHIFT, RESIDENT #102 CALLED FOR ASSISTANCE. CNA #3 SAID THAT RESIDENT #102 NEEDED HELP "...NOW..." CNA #3 SAID THAT RESIDENT #102 TOLD HER (CNA #3) TO "...WRAP YOUR (CNA #3) ARMS AROUND ME LIKE THE OTHER GIRLS DO..." AND RESIDENT #102 TOLD CNA #3 TO PICK HER (#102) UP. CNA #3 SAID, "...I KNEW IT (THE TRANSFER TECHNIQUE) WAS WRONG, BUT I WAS JUST TRYING TO HELP..." CNA #3 SAID THAT SHE (CNA #3) WAS TRAINED AT THE FACILITY BY OTHER STAFF MEMBERS HOW TO PERFORM A TWO-PERSON TRANSFER WITHOUT HELP. CNA #3 SAID THAT PERFORMING A TWO-PERSON TRANSFER WITHOUT HELP WAS A COMMON PRACTICE ON THE NIGHT SHIFT. CNA #3 SAID, "...IT'S NOT THAT THERE WAS NOT ENOUGH STAFF, THERE'S NOT ENOUGH STAFF THAT CARES ENOUGH TO HELP. WHEN YOU NEED SOMETHING THAT TAKES TWO (STAFF MEMBERS), YOU HAVE TO RUN TO FIND SOMEONE THAT WILL HELP. IF YOU'RE LUCKY, YOU FIND ONE. MOST OF THE TIME YOU JUST DO IT ALONE. THE OTHER STAFF EVEN TEACH YOU HOW TO DO IT ALONE..." ( ) RESIDENT #101: ACCORDING TO THE FACE SHEET DATED 6/13/2012, RESIDENT #101 HAD LIVED IN THE FACILITY SINCE 8/18/2011. THE MINIMUM DATA SET (MDS) assessment dated [DATE], INDICATED THAT RESIDENT #101 WAS AN [AGE] year OLD ALERT MALE. HE HAD SEVERAL [DIAGNOSES REDACTED]. ACCORDING TO THE FACILITY INCIDENT REPORT ON 11/5/2012 AT 11:15 A.M., RESIDENT #101 ' S WIFE SLAPPED RESIDENT #101 ON THE LEFT SIDE OF HIS FACE. ACCORDING TO THE CARE PLAN DATED 11/6/2012, RESIDENT #101'S WIFE "...SEEMS TO GET FRUSTRATED WITH ME (RESIDENT #101) AND MAY LASH OUT..." ACCORDING TO THE FACILITY INVESTIGATION REPORT "INTERNAL COMMUNICATION" DATED 11/28/2012, RESIDENT #101 WAS "...UNDER SUPERVISED VISITS WITH HIS SPOUSE. IF YOU (STAFF) ARE UNCERTAIN HOW TO PROVIDE SUPERVISION DURING THEIR VISITS, PLEASE REFER TO THE CARE PLAN..." ACCORDING TO THE CARE PLAN DATED 11/6/2012, STAFF WERE TO MONITOR RESIDENT #101 AND HIS WIFE'S VISITS "...FROM A DISTANCE. KEEP US (RESIDENT #101 AND WIFE) WITHIN YOUR SIGHT... " DURING AN INTERVIEW ON 1/30/2013 AT 10:40 A.M., ADMINISTRATOR (ADM) #1 SAID SHE EXPECTED ALL STAFF TO OBSERVE RESIDENTS, VISITORS AND STAFF MEMBERS FOR OBVIOUS SIGNS OF ESCALATION OF BEHAVIORS THAT COULD LEAD TO A PHYSICAL ALTERCATION. ADM #1 SAID THAT BECAUSE RESIDENT #101'S WIFE SLAPPED HIM (#101) IN THE FACE, STAFF WERE TO MONITOR HER VISITS WITH HIM (#101). ON 10/30/2012 AT 10:44 A.M., RESIDENT #101'S WIFE WAS OBSERVED IN RESIDENT #101'S ROOM. SHE WAS SITTING ON THE SIDE OF THE BED WHILE RESIDENT #101 LAY IN BED. NO FACILITY STAFF WERE OBSERVED DIRECTLY SUPERVISING FROM A DISTANCE. NO STAFF WERE OBSERVED KEEPING RESIDENT #101 AND HIS WIFE "...IN SIGHT..." FROM 10:44 A.M. THROUGH 10:50 A.M., STAFF MEMBERS WERE OBSERVED TO WALK BY RESIDENT #101'S ROOM 7 TIMES. ONE STAFF MEMBER, CERTIFIED NURSE ASSISTANT (CNA) #2 WAS OBSERVED TO GLANCE IN THE ROOM AS SHE (CNA #2) WALKED BY. FROM 10:50 A.M., UNTIL 10:52 A.M., FACILITY STAFF WERE OBSERVED PROVIDING SUPERVISED VISITATION ACCORDING TO THE CARE PLAN. FROM 10:52 A.M., UNTIL 10:55 A.M., NO FACILITY STAFF WERE OBSERVED DIRECTLY SUPERVISING RESIDENT #101 WHILE HE VISITED WITH HIS WIFE. NO STAFF WERE OBSERVED KEEPING RESIDENT #101 AND HIS WIFE "...IN SIGHT..." AT 10:55 A.M., CNA #2 GLANCED IN AS SHE WALKED BY THE ROOM. FROM 10:55 A.M. UNTIL 11:05 A.M., NO FACILITY STAFF WERE OBSERVED DIRECTLY SUPERVISING RESIDENT #101 WHILE HE VISITED WITH HIS WIFE. NO STAFF WERE OBSERVED KEEPING RESIDENT #101 AND HIS WIFE "...IN SIGHT..." FROM 11:05 A.M., UNTIL 11:09 A.M., FACILITY STAFF WERE OBSERVED PROVIDING SUPERVISED VISITATION ACCORDING TO THE CARE PLAN. FROM 11:09 A.M., UNTIL 11:15 A.M., NO FACILITY STAFF WERE OBSERVED DIRECTLY SUPERVISING RESIDENT #101 WHILE HE VISITED WITH HIS WIFE. NO STAFF WERE OBSERVED KEEPING RESIDENT #101 AND HIS WIFE "...IN SIGHT..." AT 11:15 A.M., 11:16 A.M., 11:19 A.M., AND AT 11:20 A.M., CNA #2 WAS OBSERVED TO GLANCE INTO THE ROOM AS SHE WALKED BY; HOWEVER, NO STAFF WERE OBSERVED KEEPING RESIDENT #101 AND HIS WIFE "...IN SIGHT..." AT 11:20 A.M., OBSERVATION REVEALED THAT RESIDENT #101'S WIFE LEFT RESIDENT #101'S ROOM, BUT STOPPED TO TALK WITH ANOTHER RESIDENT. RESIDENT #101'S WIFE LEFT THE FACILITY AT 11:23 A.M. IN AN INTERVIEW ON 1/30/2013 AT 11:00 A.M., CNA #2 SAID THAT HER JOB DUTIES INCLUDED WALKING AROUND THE UNIT LOOKING FOR PEOPLE WHO NEED HELP. CNA #2 SAID THAT WHEN RESIDENT #101'S WIFE COMES, "...I (CNA #2) TRY TO LOOK IN THE ROOM FREQUENTLY..." BUT SAID "...I (CNA 32) DON'T KNOW HOW OFTEN TO CHECK ON THEM (RESIDENT #101 AND HIS WIFE)..." CNA #2 SAID RESIDENT #101'S VISITS WERE SUPERVISED BEFORE, BUT THAT "...(I, CNA #2) DON'T KNOW WHY OR WHEN IT CHANGED. I FLOAT. EVERY TIME I COME TO THIS UNIT, THE PLAN CHANGES..." CNA #2 WAS UNABLE TO EXPLAIN WHAT KEEPING RESIDENT #101 AND HIS WIFE "...IN SIGHT..." MEANT AND THAT SAID SHE DIDN'T "...KNOW IF ANYONE ELSE LOOKS IN, OR WHAT HAPPENS WHEN (SHE, CNA #2) HAS TO GIVE A SHOWER OR CHANGE (INCONTINENCE CARE) ANOTHER RESIDENT. SOMEONE ELSE SHOULD BE WATCHING, BUT (I, CNA #2) DON'T KNOW IF THEY DO..." CNA #2 DESCRIBED RESIDENT #101'S SUPERVISION AS WALKING BY OCCASIONALLY AND LOOKING IN THE ROOM, NOT IN KEEPING THEM IN SIGHT AT ALL TIMES. DURING AN INTERVIEW ON 1/30/2013 AT 11:45 A.M., REGISTERED NURSE (RN) #1 SAID THERE WAS "...NO REAL TIMING..." RELATED TO THE SUPERVISION PROVIDED TO RESIDENT #101. RN #1 SAID RESIDENT #101'S WIFE NORMALLY CAME INTO THE FACILITY TWO TO THREE TIMES WEEKLY AND MORE AROUND THE HOLIDAYS. RN #1 SAID, "...WE TRY TO HAVE SOMEONE PASS BY THE ROOM FREQUENTLY..." AND SOMETIMES A HOUSEKEEPER WAS ASSIGNED TO CLEAN THE ROOM WHEN SHE (WIFE) WAS THERE. RN #1 DESCRIBED THE SUPERVISION AS WALKING BY AND LOOKING IN THE ROOM. RN #1 SAID THAT THE RESIDENT AND HIS WIFE WERE NOT IN SIGHT OF A STAFF MEMBER AT ALL TIMES WHEN SHE VISITED. ON 1/30/2013 AT 12:07 P.M., ADM #1 REVIEWED RESIDENT #101'S CARE PLAN AND SAID STAFF WERE TO MONITOR THEM "...FROM A DISTANCE AND KEEP THEM (RESIDENT #101 AND HIS WIFE) WITHIN SIGHT..." THE SURVEYOR REQUESTED EVIDENCE OF SUPERVISION IN ACCORDANCE WITH THE PLAN OF CARE. A DOCUMENT WAS PROVIDED THAT INDICATED RESIDENT #101 WAS SUPERVISED ON 1/2/2013, 1/9/2013, AND 1/25/2013. NO FURTHER DOCUMENTATION WAS PROVIDED. ADM #1 SAID STAFF WERE NOT MONITORING RESIDENT #101 ACCORDING TO THE CARE PLAN. ( )

THIS CITATION PERTAINS TO INTAKES NUMBER MI 921 AND MI 208. BASED ON INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO PREVENT FALLS IN 2 OF 5 SAMPLED RESIDENTS (#101 AND #102), IN A TOTAL SAMPLE OF 14 RESIDENTS AT RISK FOR FALLS, RESULTING IN RESIDENT #101 FALLING AND SUSTAINING A CLOSED BIMALLEOLAR FRACTURE OF THE LEFT ANKLE AND A HIP FRACTURE, WHEN SHE WAS NOT AMBULATED WITH USE OF A GAIT BELT, A 2 WHEELED ROLLER WALKER, AND 2 PERSON ASSIST, AND RESIDENT #102 FALLING AND SUSTAINING A LACERATION OF HER FOREHEAD REQUIRING SUTURES, WHEN FACILITY STAFF FAILED TO FOLLOW ORDERS TO USE A RECLINER SHOWER CHAIR. FINDINGS INCLUDE: RESIDENT #101 THE FACE SHEET REVEALED RESIDENT #101 WAS AN [AGE] year OLD WOMAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE FALLS RISK assessment dated [DATE] IDENTIFIED RESIDENT #101 AT RISK FOR FALLS, AND SPECIFIED THE RESIDENT USE A WALKER AND PHYSICAL ASSISTANCE SECONDARY TO IMPULSIVENESS AND UNSTEADINESS. THE MINIMUM DATA SETS ((MDS) dated [DATE] ASSESSED RESIDENT #101 AS REQUIRING EXTENSIVE ASSISTANCE WITH AMBULATION, AND ASSISTANCE OF TWO PERSONS. THE PHYSICIAN ORDER [REDACTED].M. SPECIFIED RESIDENT #101 AMBULATE WITH USE OF A TWO-WHEELED ROLLER WALKER WITH ASSIST OF TWO PERSONS. THE FACILITY POLICY REGARDING USE OF GAIT BELTS, DATED DECEMBER 7, 2009 SPECIFIED "GAIT BELTS SHALL BE USED TO AID IN TRANSFERRING AND AMBULATING OF ALL ASSISTED RESIDENTS." THE FACILITY INCIDENT REPORT DATED 11/8/2011, AND THE FACILITY INVESTIGATION REPORT DATED 11/14/2011, REVEALED RESIDENT #101 WAS AMBULATED FROM HER BED TO THE BATHROOM ON 11/8/2011 AT 3:20 A.M. BY A CERTIFIED NURSING ASSISTANT (CNA) #6 WITHOUT ASSISTANCE OR USE OF A GAIT BELT, AND WITHOUT USE OF A ROLLER WALKER. THE RESIDENT WAS DOCUMENTED AS EXPERIENCING A FALL AND WAS SENT TO A LOCAL HOSPITAL FOR EVALUATION. THE OPERATIVE REPORT DATED 11/10/2011 (UNTIMED) REVEALED RESIDENT #101 HAD SUSTAINED A CLOSED BIMALLEOLAR FRACTURE OF THE LEFT ANKLE, AND A HIP FRACTURE, FOR WHICH SHE RECEIVED CLOSED REDUCTION AND INTERNAL FIXATION WITH A NAIL, AND SUBSEQUENT CASTING OF THE AFFECTED EXTREMITY. DURING A PHONE INTERVIEW ON 12/8/2011 AT 2:15 P.M., CNA #6 SAID, "I'D CARED FOR HER (RESIDENT #101) TONS OF TIMES. I MADE A MISTAKE. SHE WAS SUPPOSED TO BE A 2 PERSON ASSIST WITH AMBULATION; I DIDN'T ASK FOR ANY HELP. I WAS SUPPOSED TO USE A GAIT BELT. I DIDN'T USE A GAIT BELT. SHE WAS SUPPOSED TO USE A ROLLER WALKER. I KNEW SHE USED A ROLLER WALKER, BUT IT WASN'T USED. IT'S EXPECTED THAT AIDES READ THE RESIDENTS' CARE GUIDES; I DIDN'T." DURING A PHONE INTERVIEW ON 12/12/2011 AT 12:10 P.M., RESIDENT #101'S ATTENDING PHYSICIAN #14 SAID, "SHE (RESIDENT #101) WAS SO WEAK. TO BE MOVED FROM ONE PLACE TO ANOTHER, SHE NEEDED 2 PERSON ASSISTANCE. IT WOULD'VE BEEN SAFER FOR THIS RESIDENT TO USE THE GAIT BELT, A ROLLER WALKER, AND TWO PERSON ASSISTANCE, AS I'D ORDERED." RESIDENT #102: THE FACE SHEET REVEALED RESIDENT #102 WAS A [AGE] year OLD WOMAN WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE PHYSICIAN ORDER [REDACTED].M., SPECIFIED RESIDENT #102 WAS TO UTILIZE A RECLINING SHOWER CHAIR, ONLY, FOR SHOWERS. THE FACILITY INCIDENT REPORT DATED 11/19/2011, AND THE FACILITY INVESTIGATION REPORT DATED 11/25/2011, REVEALED RESIDENT #102 fell FORWARD ONTO THE FLOOR OF THE SHOWER ROOM ON 11/19/2011 AT 9:45 A.M., WHEN SHE WAS PLACED IN A STANDARD SHOWER CHAIR, NOT THE RECLINING SHOWER CHAIR HER PHYSICIAN HAD ORDERED. SHE WAS DOCUMENTED TO HAVE SUSTAINED A LACERATION TO HER FOREHEAD, REQUIRING CLOSURE WITH SUTURES. DURING AN INTERVIEW ON 12/8/2011 AT 12:40 P.M., CNA #3 SAID, "I WAS ASSIGNED TO THE RESIDENT (#102) THE DAY OF HER FALL ON 11/19/2011. THE CARE GUIDELINE SAID SHE NEEDED TO USE A RECLINING SHOWER CHAIR. I KNEW THIS 'CAUSE I WAS A PERMANENTLY ASSIGNED AIDE TO HER HALLWAY. I'D WORKED WITH HER MANY TIMES BEFORE. I KNEW SHE WAS SUPPOSED TO USE A RECLINER SHOWER CHAIR. WE WERE IN A HURRY TO SHOWER HER. I KNEW IT WOULD BE UNSAFE TO USE A SHOWER CHAIR THAT WASN'T A RECLINER. I DON'T HAVE AN EXCUSE FOR NOT FOLLOWING AN ORDER. IT WAS A LAPSE OF JUDGEMENT." DURING AN INTERVIEW ON 12/8/2011 AT 1:20 P.M., CNA #4 SAID, "I WAS HELPING ANOTHER AIDE WITH HER (RESIDENT #102) SHOWER. WE WERE HOYER LIFTING THE RESIDENT FROM A GERI CHAIR TO A SHOWER CHAIR. WE LOWERED HER ONTO A STANDARD SHOWER CHAIR; SHE WAS SUPPOSED TO HAVE A RECLINER SHOWER CHAIR. I'D CARED FOR HER A LOT BEFORE AND KNOW SHE WAS SUPPOSED TO USE THE RECLINER SHOWER CHAIR. I HAD A LAPSE IN JUDGEMENT. WE USED A STANDARD SHOWER CHAIR, NOT THE RECLINER SHOWER CHAIR THAT THE DOCTOR ORDERED. IT WAS UNSAFE TO USE THE STANDARD SHOWER CHAIR." DURING AN INTERVIEW ON 12/9/2011 AT 3:00 P.M., AN OCCUPATIONAL THERAPIST #10 SAID, "IT WASN'T SAFE FOR THIS RESIDENT (#102) TO USE A STANDARD SHOWER CHAIR; SHE DOESN'T HAVE ENOUGH TRUNK SUPPORT AND WOULD REQUIRE CLOSE SUPERVISION WHILE SHE WAS IN ONE. A RECLINER SHOWER CHAIR WAS APPROPRIATE FOR HER; IT OFFERS TRUNK SUPPORT." DURING A PHONE INTERVIEW ON 12/12/2011 AT 12:55 P.M., RESIDENT #102'S ATTENDING PHYSICIAN #15 SAID, "SHE (RESIDENT #102) HAS TRUNK INSTABILITY. THERAPY RECOMMENDED SHE USE A RECLINER SHOWER CHAIR; I SIGNED THAT ORDER. USE OF A STANDARD SHOWER CHAIR WAS UNSAFE, BUT USE OF THE RECLINER SHOWER CHAIR WAS APPROPRIATE FOR HER." DURING AN INTERVIEW ON 12/12/2011 AT 1:10 P.M., THE NURSING HOME ADMINISTRATOR SAID, "PRIMARY CARE PROVIDER'S ORDERS, AND FACILITY POLICIES AND PROCEDURES FOR RESIDENT SAFETY SHOULD BE FOLLOWED 100 PER CENT."