Every finding on record at South Haven Nursing and Rehabilitation Community

This citation pertains to intake number 3031211. Based on interview and record review, the facility failed to protect the resident's right to be free from staff to resident physical mistreatment for 1 (Resident #100) of 3 residents, resulting in Resident #100 experiencing physical injury, emotional distress, and fear. Findings include:Resident #100:Review of an Face Sheet revealed Resident #100 was a male with pertinent diagnoses which included paralysis on his right side due to a stroke, contracture (permanent tightening and shortening of muscles, tendons, ligaments, or skin) of right hand and right wrist, contracture of right and left knees, Alzheimer's disease (progressive disease which destroys memory, thinking skills, and the ability to carry out simple tasks caused by an abnormal buildup of toxic proteins in the brain), blindness one eye and low vision of other eye, weakness, and need for assistance with personal care.Review of Resident Profile for Resident #100 dated 07/07/2023 revealed bed mobility one person assist. One person assist was a single caregiver helps a resident change position in bed, such as rolling over, sitting up, or scooting up/down in the bed. Review of Incident dated 5/16/26 revealed, .Incident Summary: Resident reported to daughter that CENA beat him up. Nurse and daughter were able to narrow timeframe to when resident was speaking of. Identified CENA suspended immediately pending investigation. Resident reports that he feels safe in facility and nurse to perform skin and pain assessment. This investigation is on-going. Investigation Summary/Actions Taken: The resident alleged the incident had occurred around 4PM. The nurse (Licensed Practical Nurse (LPN) R) interviewed his CENA (Certified Nursing Assistant (CNA) F) who said she had cared for the resident during that time. CNA F was suspended pending investigation. Administrator reported allegation to the state of Michigan and the (Local) Police Department. The police officer who responded called the Administrator after interviewing the resident and his family. The police officer said the story that was given to him by the family and resident was all over the place and there were no injuries that were consistent with an assault. LPN R), LPN observed some small scratches and a small bruise on the bridge of the resident's nose. (LPN R) also performed a skin and pain assessment on resident with no other change from his baseline. The MD (Medical Director) was notified, and it was attempted to get urine so resident could be tested for UTI (urinary tract infection), but he refused.(CNA F), CENA states she arrived at 2PM for her shift. She changed (Resident #100) at 330PM, and he put his call light on again 4 PM and he said he needed to be changed. (CNA F) went in and explained that she had just changed him, and she was doing her rounds and that she would come back and change him. (CNA F) states that the resident became agitated and began cussing at her. (CNA F) states that she was not comfortable going back in the room by herself because he was calling her racial slurs and names.she went and got (CNA Q), CENA. They then went and changed the resident together and the resident did not voice any concerns to them at any point during his care.Investigation submitted on 5/26/26 at 5:44 PM. In an interview on 6/16/26 at 12:24 PM, LPN R reported she was down on the 100 hallway, when Registered Nurse (RN) CC came to her and informed her an incident happened with Resident #100. LPN R reported Resident #100 informed her he had wanted his brief changed and he felt the CNA didn't want to do it, and he told her fine, don't do your job and the CNA had started to hit him, she had slapped him. LPN R reported when she assessed Resident #100 he had a bruise on his nose, abrasion on his forehead, and scratch under his eye. LPN R reported the bruise was a fresh bruise as well as the abrasion and the scratches. LPN R reported she had been assigned to Resident #100 the evening shift prior (5/15/26) and there was no skin impairment. When queried if Resident #100 was combative with cares, LPN R reported he was not, she never had a problem when she cared for him and would announce herself when she came in the room, he would greet her warmly. LPN R reported Resident #100 liked to have his eye drops first, asked to have his hand and legs adjusted because of his contractures. LPN R reported Resident #100 liked to have his care done how he liked to have things done. LPN R reported Resident #100 can shift himself in bed but not really well, he used the side rails and assist bars to help shift his body. LPN R reported Resident #100 had contractures to his legs, his right hand, and was impaired on his right side due to a stroke. LPN R reported she took care of Resident #100 frequently and he was able to recognize her by her voice. LPN R reported she had contacted the Nursing Home Administrator (NHA) and informed her of what had happened, the police came to speak to the resident and his family were present, and he asked for CNA F's phone number to contact her as she had been suspended pending investigation.In an interview on 6/17/26 at 11:06 AM, RN CC reported she was walking past Resident #100's room and was stopped by his wife and daughter and asked to come in Resident #100's room and his wife proceeded to tell me she was very upset. RN CC reported it was reported one of the CNAs was in his room earlier, and Resident #100 was claiming the CNA had slapped and scratched him in his face. RN CC reported she did observe Resident #100's face and he did have marks on his face, scratch under his eye, redness on his forehead, as well as there was redness on his face. RN CC reported the injuries appeared to be recent as there was no closing of the scratches, not scabbed over, appeared to have red fluid the length of the scratches. RN CC informed the family she would go and get his nurse, LPN R to come and speak to them. RN CC reported she entered Resident #100's room with LPN R and she had started speaking with Resident #100 and he had reported he didn't recognize the voice, so he did not know who did it, but they had scratched him on his face and slapped him. RN CC reported Family Member (FM) Y reported Resident #100 had an [NAME] (smart speaker, artificial intelligence powered with a screen to make video calls and watch streaming services) in his room and he had used it to call them, she and FM M came to the facility. RN CC reported she was assisting with interpreting as family members were speaking to her in Spanish. RN CC reported Resident #100 was able to speak and understand English and he reported he had pressed the call button to get assistance as he needed to be changed, reported the CNA had an attitude when she came in, Resident #100 told her if she was going to have an attitude to leave the room, he didn't want to deal and it escalated pretty quickly, she was upset, they argued, and Resident #100 had snapped back at her telling to do it or just leave. Resident #100 reported the CNA proceeded to slap him and scratch him while she provided the care to him. Review of Skin Assessment dated 5/15/26 at 7:13 PM, revealed it was a weekly skin assessment and Resident #100 had no areas of skin impairment. Review of Skin Assessment dated 5/16/26 at 7:04 PM, revealed .R (Right) eye abrasion, bruising on nose, forehead red slight abrasion.Review of Progress Notes dated 05/18/2026 at 04:27 AM, revealed, .Able to make wants/needs known refused to have UA (urinalysis) done states I am not confused I know what happened. Review of Progress Notes dated 05/17/2026 at 12:37 AM, .A&O (alert & oriented), able to make want/needs known, medicated for c/o (complaint of) pain/discomfort w/ (with) effective results.During an observation on 6/16/26 at 2:40 PM, Resident #100 was observed lying in his bed, supine, upper body leaning slightly to the right side, covered in a blanket, lights dimmed. Had his rolling bedside table on the left side of the bed. Resident #100 appeared frail in appearance. His bed was noted at a slight angle and not against a wall. During an observation and interview on 6/16/26 at 3:10 PM , Resident #100 was awake in bed. Pleasant in conversation. Stated female staff came in to provide cares and told him to grab the rail to roll himself over. He said it was hard for him to roll over, and he reported he was hit by a female staff. I am blind and can only use my left arm. Staff are to help me. If they cannot do their job then they do not need to be here. I do not know who the aide was. They were female that is all I know. I told (LPN R) the nurse and called my wife right away. My wife took pictures of my face. How do I protect myself? I am blind and have the use of one arm.Review of Social Services Note dated 05/18/2026 at 03:51 PM, revealed, .Resident is alert and able to make his needs known.Writer spoke with resident regarding allegation.Resident stated he is uncomfortable at times when using his call light because he does not want to upset staff. Writer allowed resident to express his feeling then offered emotional support. Resident was encouraged to continue using call light for needs and he was informed that all concerns will be taken seriously. Nursing and Administrator were notified of resident's statement. Family was present during visit. Staff will continue to observe and report any changes in mood and/or behaviors. In an interview on 6/17/26 at 11:29 AM, Social Worker (SW) Z reported when she went in to speak with Resident #100 on 5/18/26 in regard to the incident that happened over the weekend on 5/16/26. SW Z reported Resident #100 was very clearly upset when she spoke to him and he reported the female staff member came in his room and hit him, SW Z reported she was informed he had been punched in the face so she expected to see larger bruising but he did have marks on his face, something by his eye and bruising on his nose, and then the female staff member returned with a second person to provide care for him. When queried about his concern with using the call light, SW Z reassured him the staff member would not be providing care to him anymore and he should continue to use his call light for his needs. SW Z reported she was unsure if he was comfortable staying at the facility, but the family preferred the location of the facility. In an interview on 6/17/26 at 12:57 PM, CNA F reported she worked on second shift on 5/16/26, reported at 2:00 PM. CNA F reported she had completed a brief change on Resident #100 and he had pressed his call light a little while later approximately 45 minutes to an hour later as she was completing her rounds for check and changes with other residents and he had indicated his brief needed to be changed. CNA F reported she had informed him she was completing check and changes with other residents who hadn't been changed yet and she needed to get to them first. CNA F reported this infuriated him and he began yelling and calling her names she did not want to repeat what he had said to her. CNA F reported she had told him Okay and she left in search of someone to come and assist her as she did not feel comfortable going in his room without another staff. CNA F reported she had found CNA Q to come and assist her provide care to Resident #100 and at that time he was pleasant there were no issues. CNA F reported approximately an hour later the nurse came up to her and was asking questions about Resident #100's face as he had scratches and had indicated she had slapped him. CNA F reported at that time she was send home due to being suspended. She reported she had left the building at approximately 7:00 PM. When queried on Resident #100's bed mobility, CNA F reported she had to help him roll over on to his side, she had to position him on and off the rail but once there he was able to hold the bar but not for an extended period of time as he had only the use of his left hand. CNA F reported when he lost his grip she would have to push him back over to where the bar was for him to hold on while she was trying to complete the brief change. CNA F reported Resident #100 cannot pull himself over, had little movement, and can only turn with assist. CNA F reported she had to assist Resident #100 as well because he was legally blind. CNA F reported she was unsure how he had received the marks and scratches to his face, and she did not notice them when she provided care to him both times that day. CNA F reported while she was providing care for him and while CNA Q was in the room with them, Resident #100 did not hit his face, she did not push him over hard enough to hit his face on the enabler bar, and he did not hit his head eitherIn an interview on 6/17/26 at 12:25 pm, Shower Aide AA reported she did observed marks on Resident #100's face when she provided him with a shower on 5/18/26. Resident #100 had scratches on his face and above his eyebrow, and a bruise on his nose. In an interview on 6/16/26 at 1:29 PM, CNA P reported Resident #100 was usually pretty quiet, didn't' ask for much and was able to make his needs known. CNA P reported the resident did have an Alexa device in his room to make phone calls. CNA P reported Resident #100 was able to help roll on his side a little bit, but he had contractures due to a stroke. CNA P reported Resident #100 could be verbally aggressive, but he was not physically aggressive with staff.In an interview on 6/16/26 at 12:54 PM, CNA G reported 5/16/26 was a Saturday. CNA G reported she had no problems with Resident #100 as he let her change him, helped him with his meals but at times he does try to start an argument as he liked things done a particular way he liked them done, and if he feels like you're resistive to providing care to him he would say if you're tired get out of her, or if you don't feel like doing it (brief change) then don't, just leave. CNA G reported she would ignore his statements and provide his care; he didn't give her much trouble and let her provide his care. CNA G reported Resident #100 was a one person assist with bed mobility and cares, and he was a Hoyer transfer out of bed. CNA G reported Resident #100 did not like CNA P and he would tell her to get out of his room so they usually switched, and she would take care of Resident #100. CNA G reported he knew who CNA P was by the sound of her voice. In an interview on 6/16/26 at 1:05 PM, CNA Q reported she had worked 12 hours that day, and she had come in early at 10:00 AM. CNA Q reported when she and CNA F went into Resident #100's room to do a brief change, he was very quiet, she reported she was not sure what happened if he was mad, maybe. CNA Q reported she did not pay attention to his face, she went in and assisted with care and left. CNA Q reported Resident #100 was able to assist with bed mobility by grabbing the enabler bar to hold himself on his side. CNA Q reported she doesn't have any problems with Resident #100 and he usually talked to her. During an observation and interview on 6/17/26 at 3:07 PM, FM M and FM Y reported Resident #100 had called FM Y via the Alexa device. This writer observed an Amazon Echo (smart device with a visual display, has [NAME] services, can be used to make video calls, watch streaming services, and browsing) on Resident #100's table facing towards his bed. FM M reported Resident #100 had called he reported to them a female staff member had come into his room and had hit him, asked them to call the NHA to inform her of what had happened. FM M reported she had attempted to call the facility and no one had answered the phone. FM Y had contacted the son to come and get them to take them to the facility. FM M reported FM Y had indicated Resident #100 sounded scared and confused as to why someone would do that to him. During an observation, Resident #100 was lying supine with both of his legs leaning to the left side, both were bent at the knee and FM M reported this was the most comfortable position for Resident #100 due to his contractures to his legs, he had a right hip replacement and it was painful, and he had paralysis to his right side due to a stroke. Resident #100 had his right hand/wrist in a splint. Resident #100's bed had rectangular enabler bars on both sides, open in the center, on the right side he had a plastic basket attached to the bars by zip ties to the outside of the enabler bar, he had a night stand on the left side of his bed, and he had a rolling bedside table next to the left side of the bed. Resident #100's nose did not have a dark spot on it which could be misconstrued as something else other than a bruise on 5/16/26. Resident #100 reported if the staff don't want to take care of him, then don't, but don't be mean and hit him. Resident #100 reported he just wanted to be safe at the facility. Review of photos of Resident #100's injuries revealed he had a red/pink scratch underneath his right eye running horizontally with his lower eye lid, he had a scratch on his forehead running up and down above his inner right eyebrow which appeared to be open as there was blood present, he had scattered areas of purpura (red/purple spots when small blood vessels leak blood underneath the surface) across the top of his forehead from the right side to the middle with some swelling of the area, and what appeared to be a bruise which was deep red and purple in color midway down on the right side of his nose running across the top of his nose partially which measured approximately an inch long. Review of Police Report from (Local) Police Department received on 6/17/26, revealed, .I made contact with (Resident #100) at the (Facility). (Family Member Y) and (Family Member M), were also present on scene. (Family Member M) advised that (Resident #100) primarily speaks Spanish and has limited English proficiency, and that she could assist with translation if needed. (Resident #100) is also blind.(Resident #100) stated that on today's date he activated the indicator light in his room requesting nursing assistance to help change his clothes and diaper. (Resident #100) stated that, for no apparent reason, the nurse began striking him in the face. (Resident #100) stated he was struck numerous times but was unable to provide an exact number or state whether the strikes were closed-fist punches or open-handed slaps. (Resident #100) stated that after a brief period, the nurse stopped striking him, left the room, and later returned with a second nurse. (Resident #100) stated the two nurses then assisted him in changing his clothes and diaper. (Family Member M) stated that she and (Family Member Y), were the first individuals (Resident #100) told about the incident and that they reported the allegation to nursing home staff. (Family Member M) stated that she and (Family Member Y) visit (Resident #100) frequently and had visited him the previous day. (Family Member M) stated that on the previous day (Resident #100) did not have the cut underneath his right eye, the red marks on his forehead, or the bruise/scrape on his nose. (Family Member M) stated those injuries were new as of today's date. INJURIES: (Resident #100) sustained a laceration below his right eye, a scrape on his nose, a scrape above his right eyebrow, and redness/irritated skin on his forehead. I photographed the injuries and uploaded the photographs. CONTACT WITH (CNA F) (SUSPECT): I made contact with (CNA F) via phone call. (CNA F) stated that (Resident #100) activated his indicator light requesting nursing assistance. (CNA F) stated she responded to (Resident #100)'s room and observed him to be irate, which she stated is normal behavior for him. (CNA F) stated that rather than attempting to assist (Resident #100) alone, she left the room to retrieve a second nurse before providing care. (CNA F) stated that while assisting (Resident #100) in changing his clothes and diaper, his face may have scraped against one of the bedside rails, which she believed could explain the scratches on his face. (CNA F) denied striking or otherwise harming (Resident #100).CONTACT WITH (CNA Q): On 21 May 2026, at approximately 1800 (6:00 PM) hours, I made contact with nurse (CNA Q), who assisted (CNA F) in helping (Resident #100) change his clothes. (CNA Q) stated that (CNA F) requested her assistance in changing (Resident #100). (CNA Q) said that when (CNA F) came to her for help, (CNA F) did not mention (Resident #100) acting out of the ordinary. (CNA Q) advised that (Resident #100) is often very rude and gives the nurses a difficult time while they assist him with changing and other tasks. (CNA Q) stated that she assisted (CNA F) in changing (Resident #100) without incident. (CNA Q) stated that (Resident #100) was quiet and compliant the entire time she and (CNA F) were assisting him. (CNA Q) stated that she did not recall (Resident #100)'s face hitting any of the bed rails. (CNA Q) also advised that there are no cameras inside the facility.Charges Requested: This report will be forwarded to the (County Name) Prosecutor's office for review of assault charges against (CNA F) . In an interview on 6/16/26 at 4:08 PM, NHA A reported she had contacted the local police and spoke to the officer who reported to the facility on 5/16/26, but she had lost the call as she had been out on her boat. She reported she did not have the officers name or the report number. NHA A reported she did not request a police report and after this writer requested it, submitted a request with the local police department for the report. In an interview on 6/17/26 at 2:09 PM, Director of Nursing (DON) B reported staff were instructed per policy to contact the abuse coordinator when an incident occurred. DON B reported for any clinical concerns, staff were to contact her or Unit Manager DD as they were to be available 24 hours and switched weekends for on call. When queried if the on call clinical administration should have responded to the incident, DON B reported the primary nurse was instructed to conduct a head-to-toe assessment, complete a skin assessment and a pain assessment. DON B no clinical administration reported to the facility. In an interview on 6/17/26 at 2:15 PM, Nursing Home Administrator (NHA) A reported SW Z' had reported to her the family was upset, she was able to provide reassurance to them, and SW Z had come and informed her of the details of the situation she had learned of the incident. NHA A reported the progress noted entered into the medical record was the statement from SW Z where she went to speak to Resident #100 in regard to the incident. There was no other statement from SW Z. When queried if SW Z had informed NHA A Resident #100 had reported one person came in and performed care and he was assaulted then and then the female person came back with another female person and did a brief change again on him, NHA A reported she was not aware of that. NHA A reported CNA F went in approximately 3:30 PM and performed care on Resident #100 and went back in at approximately 4:00 PM she wouldn't be able to change him right then. NHA A reported she was not aware of the approximate time CNA F and CNA Q went in to Resident #100's room to perform care. When queried when LPN R was informed and went to assess Resident #100, NHA A reported she did not know that. When queried after review of the police report if NHA A would have changed her thoughts on the root cause of the events, she reported she felt no abuse occurred, there was no proof of abuse occurring, and the officer felt no abuse occurred. NHA A reported when an analysis was completed of the incident she came to the conclusion Resident #100 had received the injury from the enabler bar on his bed, and indicated the injuries were consistent with hitting his face on the enabler bar. NHA A reported she had worked in therapy prior to becoming an NHA and she reported she believed he was able to partially assist with bed mobility but was unsure. In an interview on 6/17/26 at 2:32 PM, DON B reported following review of Resident #100's medical record he was a one person assist with bed mobility. DON B reported the analysis was Resident #100 was able to reach over and grab the enabler bar without assistance and he had bumped his nose on the enabler bar. DON B reported the mark on Resident #100's nose was not a bruise but a discoloration when she and the provider assessed him on 6/20/26. DON B reported the other nurses who took care of Resident #100 following the incident reported it wasn't bruising but purpura. Note: review of the medical record revealed no documentation for the nurse who assessed him or other nurses who provided care to him following the event supported the injury was purpura and not a bruise. In an interview on 6/17/26 at 4:01 PM, NHA A and DON B reported when queried why Resident #100's statement was not included in the investigation, it was reported Resident #100 was insistent with his recollection of events, which he stated he had been hit by someone who entered his room and performed care on him and they believed the root cause was Resident #100 had hit his face on the enabler bar on his bed. Review of Resident #100's care plan did not indicate the resident made false allegations against staff prior to this incident. Review of the focus revealed last revised on 05/22/2026 at 01:10 PM. No new interventions were created for Resident #100's care plan. Review of policy, Abuse Prevention Program Policy & Procedure reviewed on 1/2026, revealed, .Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by staff or anyone. The facility will provide a safe environment and protect residents from abuse.Staff to Resident Abuse: All staff are expected to be in control of their own behavior, are to behave professionally, and should appropriately understand how to work with the nursing home population.Staff will held accountable to their actions to meet the Medicare and Medicaid requirements for participation by providing care in a safe environment. (Corporate) will not consider striking a combative resident an appropriate response in any situation. It is also not acceptable for any staff member to claim his/her action was reflexive or a knee-jerk reaction and was not intended to cause harm. Retaliation by staff is abuse, regardless of whether harm was intended, is unacceptable and must be cited.Possible Indicators of Physical Abuse: Bruises, including those found in unusual locations such as the head, neck, lateral locations on the arms, or posterior torso and trunk, or bruises in shapes (e.g., finger imprints); and Facial injuries, including but not limited to, broken or missing teeth, facial fractures, black (eye(s), bruising, bleeding or swelling of the mouth or cheeks.Mental abuse is the use of verbal or nonverbal actions, which cause or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility.Findings include:On 12/16/2025 starting at 9:25 AM, a tour of the kitchen found possible stagnant domestic water lines. One hot water fixture was capped off, by the coffee area, with no evidence of routine flushing. Two other water lines were protruding from the wall back by the walk-in cooler door, with no evidence the lines were regularly flushed. When asked if the maintenance director was here today, [NAME] KK stated that he has been off a couple weeks. When asked if she ever saw anyone regularly in the kitchen flushing these water lines, [NAME] KK didn't think so. On 12/15/25 at 1:22 PM, an interview with NHA A found that the Legionella information should be in the maintenance office. On 12/15/25 at 2:55 PM, observation of the 200-hall soiled utility room found a hopper with brown and yellow debris in the bowl and water sitting low in the hopper bowl (indicating stagnant water that has not been flushed or used recently). As the surveyor turned on the cold and hot water fixtures from the over hopper sink, brown and discolored water came out of the faucet for a couple seconds before running clear. Further review of the hopper found that momentarily brown and discolored water came out of the spray wand when used and tested. A record review of the facility entitled document, Legionella Plan Overview Control Measures and Corrective Actions, not dated, found that Maintenance or designee will conduct free chlorine testing monthly. log results of monthly samples taken from 2 cold water fixtures and at least 3 hot water fixtures. Under the section Risk Analysis: the document states that, The facility doesn't have dead ends or plumbing concerns. The only plumbing areas that could contain stagnant water have been identified in vacant resident rooms that have been vacant more than 30 days. No logs or documentation on ongoing free chlorine test were observed.A further record review of the facility entitled document, Water Pathogen Risk Reduction, not dated, found the following resources, .areas of stagnant water encourage biofilm growth and reduce temperature and level of disinfectant. Further review of the document found Biofilm is Germs and the slime they secrete that stick to and grow on any continually moist surface, furthermore, Biofilm provides housing, food, and security for many different types of germs, including Legionella.No documentation showing an annual review was found.

Based on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment resulting in an increased potential for contamination and a possible decrease in the satisfaction of living for all residents. Findings include: On 12/15/25 at 9:30 AM, observation of sheet pans stacked and stored under the counter found deposits of black encrusted grease was prevalent on the inside seems and corners of the pans. An interview with [NAME] KK found that this is the cleanest they can get the pans after scrubbing. On 12/15/25 9:55 AM, observation of the overhead sprayer, next to the dish machine, found that when in the hanging position the sprayer laid below the overflow rim of the sink, creating a cross connection between the domestic potable water and wastewater. When asked if maintenance takes care of items in the kitchen, [NAME] KK stated that they do, however our Maintenance Director is not able to be in today. On 12/15/25 at 2:55 PM, observation of the cushioned chair in the family room found excess accumulation of trash, food crumbs, wrappers, and debris under the cushion. On 12/15/25 at 3:01 PM, observation of the furniture in the front lobby showed accumulations of trash, crumbs, crushed potato chips, and other food debris. Further review found numerous scratched off [NAME] tickets, nail clippers, a package of taco sauce, and a receipt to the grocery store. On 12/15/25 at 3:13 PM, observation of the 400-hall shower room found excess accumulation of black debris and staining on the floor and wall juncture between the commode and the wall. The area was roughly a one foot by two-foot surface. On 12/15/25 at 3:20 PM, observation of the 400-hall linen room found a heavy accumulation of dust and debris under the wire rack used for clean linen storage. Further observation found used gloves, paper trash, and packages of crackers. On 12/15/25 at 3:32 PM, an interview with NHA A found that the facility has been working on repairs and updates and has a plan to repaint all resident rooms over the next year. When asked to speak with Housekeeping Supervisor R, NHA A stated she was not able to make it in today. On 12/15/25 at 9:51 am, the blinds hanging in the window in room [ROOM NUMBER] were observed to be broken. On 12/15/25 at 9:58 am and 3:30 pm, 12/16/25 at 8:15 am and 2:45 pm, and 12/17/25 at 8:28 am and 10:03 am, the front of the three-drawer dresser in the corner of the room near the bathroom in room [ROOM NUMBER] was observed to have a cream colored, milk-like substance dried in a splatter pattern on two of the three drawer fronts. The wall on the right when entering room [ROOM NUMBER], behind the head of both beds, between the positioning of the two beds, was observed to have several areas of spillage, white in color, cream in color, brown in color, and pink in color. The spillage was noted to have the appearance of dripping towards the floor with noted streaks on the wall. The enabler bar of the first bed on the right side of the bed was noted to have a pink in color dried substance on the top of the bar. The garbage can on the far side of the room from the door was noted to be soiled on the outside with dark colored substances. On 12/15/25 at 11:32 am and 12/16/25 at 7:53 am the fall mat on the floor next to the bed in room [ROOM NUMBER] was noted to be soiled with dirt, debris, and spotted with dried cream-colored milk-like substance. In an interview on 12/16/25 at 1:06 pm, Housekeeper (HK) L was outside of room [ROOM NUMBER] and reported every room should be cleaned every day. HK L reported cleaning fall mats were part of the daily cleaning when doing the floor. When queried, HK L reported she cleaned it today, but did not recall if she cleaned it the day before. In an observation and interview on 12/17/25 at 10:03 am, HK AA was observed cleaning room [ROOM NUMBER]. HK AA reported it was housekeeping's responsibility to clean dressers, walls, floors, beds, tables, and any other areas in the rooms. HK AA reported it was all staff's responsibility to clean up spills, but housekeeping was responsible for cleaning the resident rooms. HK AA reported the rooms were deep cleaned about once a month. HK AA reported he was assigned to the same rooms, and he cleaned his assigned rooms every day. When the noted dirty areas, the dresser, wall, enabler bar, and garbage can in room [ROOM NUMBER] were pointed out the HK AA he reported those areas should have been cleaned, and he would clean them now. In an interview on 12/17/25 at 10:20 am, Housekeeping /Laundry Supervisor (HLS) R reported each room should be cleaned daily and deep cleaned once a month. HLS R reported her expectations were that her staff visually observe every room for areas that my need to be addressed, such as dressers, walls, enabler bars. HLS R reported when a room was deep cleaned, it should include, dressers, bed frame, walls, curtains, and all surfaces. During an observation on 12/15/2025 at 10:34 AM, observed cobwebs in the corners of the windowsill in room [ROOM NUMBER]. During an observation on 12/15/2025 at 11:15 AM room [ROOM NUMBER] had an ash type of substance and/or drywall/plaster dust on the windowsill. The transition strip between the tile in the room and the laminate flooring in the hallway was missing, and the tile was chipped and broken at the door when it transitioned to the hallway laminate flooring. The floors were stained with dirt and debris and possibly dirty as they were so stained. Outside of the room, along the wall on the left side of the entry there was dried dark brown liquid material splattered over the wall and the rubber baseboard. During an observation on12/15/2025 at 11:22 AM, room [ROOM NUMBER] the floor had scattered dirt and debris, between the bed and the recliner there was a pile of wrappers, dirt, hair accumulated there, the tile floor in the room was stained and had dried liquid stains indicating it had not been mopped. The entry door had built up black dirt and debris, appeared also to have dirt and debris strip stuck to adhesive on the floor. During an observation on 12/15/2025 at 11:50 AM room [ROOM NUMBER] the door to the room had a space of approximately 6 inches long where the wood door splintered and come off the door near where the doorknob was located. room [ROOM NUMBER] had scraps along the wall with paint missing, the tile at the entry way was stained and appeared soiled. The transition strip was missing between the transition from tile to laminate flooring in the hallway. During an observation on 12/15/2025 at 12:00 PM room [ROOM NUMBER] observed the wallpaper peeled away from the wall like something had torn it away. There were black marks on the walls where bed or wheelchairs bumped into the wall. The tile floors were stained and appeared dirty and dingy. The resident's tray table was soiled with dried food and dried liquid. See photo. During an observation on 12/15/25 at 12:18 PM, room [ROOM NUMBER] observed built-up black dirt and debris caked up along the entryway appeared adhered to a strip on adhesive on the floor where the missing transition piece was missing from the floor. The wood door had a piece of wood broken off from the door by the bottom hinge. The floors in the room appeared stained with dirt and debris. See photo. During an observation on 12/15/2025 at 4:12 PM, room [ROOM NUMBER] had a fall mat on the floor next to bed 2 along the window and it had dirt/debris footprints from one end to the other. There was a fall mat folded up by the first bed and the sides had been cracked and broken open exposing foam. The first bed was discolored, stained, and uninviting. During an observation on 12/16/2025 at 9:00 AM room [ROOM NUMBER] had the fall mat by the first bed in the corner which had the sides broken open and the foam was exposed. During an observation on 12/16/2025 at 11:44 AM room [ROOM NUMBER] had the built-up black dirt and debris caked up along the lining the transition piece on the floor from tile to laminate flooring. The wall inside the room to the left had scrapped paint off the wall and black streaks along it to the bathroom door. See photo. During an observation on12/16/2025 at 11:44 AM, outside of room [ROOM NUMBER] the base board still had dried splashed brown liquid on it. During an observation on 12/16/2025 at 11:46 AM room [ROOM NUMBER] had the same build up on the transition piece as well as rust spots on the door frame with missing paint on both sides of the door. The bathroom door has scraps on it and missing paint as well. The tile in the room appeared soiled but needed to be stripped and waxed. In an interview on 12/16/2025 at 11:48 AM Housekeeper AA reported when a room was completed for cleaning the housekeeping staff completed a checklist for each room. It would be noted on the sheet. Housekeeper AA reported that when there was a concern for a tray table, he would inform Housekeeping & Laundry Supervisor R, and she would inform maintenance the tray table needed to be replaced. During an observation on 12/16/2025 at 11:49 AM room [ROOM NUMBER] had dried liquid spots on the floor with dirt and debris as well as footprints on the floor. The transition piece had built up dirt and debris caked on it, and up to the corner where the walls met there was dirt and debris, and the floor appeared dirty due to staining on the floor. During an observation on 12/16/2025 at 11:51 AM room [ROOM NUMBER] observed approximately 6 inches of a piece of the door missing, exposing wood by the doorknob and the trim along the wall on the right side at entrance was not secured and coming off. During an observation on 12/16/2025 at 11:56 AM room [ROOM NUMBER] had paint scrapped off the door frame, the transition piece was missing from tile to laminate flooring with the tile broken and chipped at the ends. During an observation on 12/16/2025 at 11:57 AM, the heater across from room [ROOM NUMBER] had a missing piece of rubber base board from it with exposed dried glue splotches splattered across the bottom 6 inches the length of the vent which was approximately 5 feet long. See photo During an observation on 12/16/2025 at 11:58 AM room [ROOM NUMBER] was missing the transition piece from tile to laminate floor in the hallway. There was black dirt and debris cake along the side of the transition piece. The tile was broken jagged pieces at the ends of them where the tile met the laminate flooring from the hallway. The door frame had dried liquid dripped down it. There were scraps of paint off the frame. During an observation on 12/16/2025 at 1:55 PM, room [ROOM NUMBER] the tile in the room was dirty and dingy, the transition strip was missing with the tile broken and chipped. The area along the wall had dirt and debris and black markings along it, see photo. In an interview on 12/17/2025 at 9:31 AM, Housekeeping & Laundry Supervisor R reported when the housekeepers notice something that needs to be fixed, they would tell the maintenance director. When queried if there was a work order or electronic submission form, she reported there was a work order form but mostly the communication was verbal. This writer and Housekeeping & Laundry Supervisor R observed a wall in room [ROOM NUMBER] which had paint scrapped off and black marks along the wall to the bathroom door, she reported those concerns should be reported to the maintenance director. Housekeeping & Laundry Supervisor R touched the rubber bumper guard along the wall as it appeared splattered with dirt and debris and reported it was dried wax. Observed the transition strip at the doorway for the transition from tile to laminate flooring and there was built up black dirt and debris hardened which would need to be scrapped up off the floor. Housekeeping & Laundry Supervisor R reported the housekeepers should address the build up there and take care of it. This writer and Housekeeping & Laundry Supervisor R observed room [ROOM NUMBER]'s floor which was visibly soiled and had not been swept. Housekeeping & Laundry Supervisor R reported the floor should have been addressed. Housekeeping & Laundry Supervisor R reported if a resident refused to allow housekeeping staff to come in and clean the staff were instructed to return at a later time, few hours later, and request to clean the room again. This writer and Housekeeping & Laundry Supervisor R observed room [ROOM NUMBER] and there was the dried caked on buildup of black dirt and debris at the transition strip, inside the door to the right the corner had dirt and debris as well as room [ROOM NUMBER] which had scraps on the wall with missing paint and there was no transition strip with the ends of the time broken and chipped.

Based on observation, interview, and record review the facility failed to provide food at a palatable temperature to 1 (Resident #75) of 4 residents and all residents who consume food resulting in the potential for decreased food consumption and potential nutritional decline.Findings include: Resident #75: Review of Face sheet for Resident #75 revealed, Review of a Face Sheet revealed Resident #75 was a male with pertinent diagnoses which included diabetes, gout (a painful inflammatory arthritis from uric acid crystals in joints), and kidney disease. Review of Care Plan for Resident #75, revealed, the focus, .Resident is at Nutritional / Hydration risk r/t (related to) admitted with hx (history) of chronic lymphedema (swelling from lymph fluid buildup, caused by damaged lymph nodes, leading to heaviness, tightness, and limited movement) RLE (Right Lower Extremity), high blood pressure, deep vein thrombosis (a serious condition where a blood clot forms in a deep vein), diabetes, stage 4 kidney disease, rheumatoid arthritis (a chronic autoimmune disease where the immune system attacks joint linings, causing pain, swelling, and stiffness and can lead to systemic issues affecting the heart lungs and eyes) Diuretic therapy in place . with the intervention .Offer available substitutes if resident has problems with the food that is served .Honor food preferences within acceptable dietary limits for resident's quality of life concerns .Offer substitutes if consumes less than 50% of meal . In an interview on 12/15/2025 at 10:34 AM, Resident #75 reported he had concerns with the temperature of the food. Resident #75 reported every Thursday the residents receive biscuits and gravy and the ones the residents received this last Thursday were stone cold. Resident #75 reported 5 out of 7 days the meals were cold, especially breakfast. In an interview on 12/16/2025 at 8:40 AM, Resident #75 reported the scrambled eggs and bagel were both cold this morning. On 12/15/25 at 9:59 AM, an interview with [NAME] KK found that lunch starts at 11:45 AM. On 12/15/25 at 11:43 AM, an interview with [NAME] KK found that they are a little behind schedule and still need to finish up a few things before service. On 12/15/25 at 12:40 PM, lunch service started. At this time, an interview with [NAME] KK found that the do not currently do test trays or tray audits on meals. On 12/15/25 at 1:05 PM, a regular test tray was placed as one of the first trays on the second 300 hall cart. On 12/15/25 at 1:13 PM, the cart was on the 300 hall and trays were being delivered. On 12/15/25 at 1:28 PM, all trays on the cart had been delivered and the test tray was back in the conference room with the following temperatures of hot food: vegetable soup 128F. On 12/15/25 at 2:05 PM, Observation of the 400-hall found resident lunch trays being delivered by staff. At this time, observation of a meal tray residing in room [ROOM NUMBER], found a couple bites eaten from the sandwich, and the soup still with its top on. With the residents' permission, a temperature of the soup was found to be 122F when taken with a rapid read thermometer.

Based on observation, interview, and record review, the facility failed to ensure 1. a dignified dining experience for 2 (Resident #1 and Resident #19); 2. an environment that promoted resident dignity in 1 (Resident #25) of 16 residents reviewed for dignity, resulting in the potential for a reasonable person to experience feelings of embarrassment, loss of self-worth, and a negative psychosocial outcome for the residents impacting their quality of life.Findings include:Resident #1 Review of a Resident Face Sheet revealed Resident #1 was a male who admitted to the facility on [DATE] and had pertinent diagnoses which included: delayed milestone in childhood, need for assistance with personal care, feeding difficulties, and encephalopathy (a disease that affects the brain's function). Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 11/14/25 revealed a Self-Care Assessment- Eating- Resident #1 was dependent, relying on staff to feed Resident #1 his meals. On 12/15/25 at 1:15 pm, Certified Nurse Assistant (CNA) S was observed standing next to Resident #1's wheelchair, next to the table, while she fed Resident #1 his lunch meal. Review of Care Plan for Resident #1 revealed .Status of eating ability: x1 assist. In an interview on 12/17/25 at 2:20 pm, CNA S reported Resident #1 was dependent on staff to eat, he had to be fed. CNA S reported she should not have been standing when she was assisting residents to eat in the dining room. CNA S reported staff was to sit when they were feeding residents. CNA S confirmed that she had stood next to Resident #19 when she was feeding him his lunch meal. Resident #19 Review of a Resident Face Sheet revealed Resident #19 was a male who admitted to the facility on [DATE] and had pertinent diagnoses which included: Anoxic brain damage (brain damage caused by a lack of oxygen), dementia, and quadriplegia (paralysis of all 4 limbs). Review of a Minimum Data Set (MDS) assessment for Resident #19, with a reference date of 09/24/25 revealed a Self-Care Assessment- Eating- Resident #19 was dependent, relying on staff to feed Resident #19 his meals. On 12/15/25 at 1:09 pm, Resident #19 was observed sitting in his wheelchair in the dining room at a table with two other male residents, who were eating. Resident #19 did not have a tray in front of him. On 12/15/25 at 1:15 pm, CNA S was observed serving Resident #19 his lunch meal. The meal was placed on the table in front of Resident #19, and the plate was left covered. The other two male residents at the table were observed eating their meals. On 12/15/25 at 1:20 pm, CNA EE was observed preparing Resident #19's lunch meal tray. CNA EE was observed standing between Resident #19's wheelchair and the table while she fed Resident #19 his lunch meal. On 12/16/25 at 12:12pm, CNA HH was observed standing between Resident #19's wheelchair and the table while she fed Resident #19 his lunch meal. On 12/16/25 at 12:13 pm, CNA HH was observed standing between Resident #19's wheelchair and the table while she fed Resident #19 his lunch meal. CNA HH was then observed answering a telephone call on her smart watch, speaking out loud in the dining room, conversing with Human Resources Director (HRD) E. The discussion lasted several minutes, included a discussion about open shift coverage, all while CNA HH continued to feed Resident #19 and did not acknowledge him while she provided him assistance with his meal. In an interview on 12/17/25 at 2:20 pm, CNA HH reported prior to her starting to feed Resident #19, the day before, she had already made the decision she would feed two residents at two different tables, and she had no intention of sitting while she did that. In an interview on 12/17/25 at 10:50 am, Director of Nursing (DON) B reported staff should be sitting down when they are feeding a resident. DON B reported she expected staff to feed one resident at a time and should sit down when they do it. Review of facility policy Dignity with a reviewed date of 01/25 revealed .to care for residents in a manner and in an environment that promotes maintenance or enhancement of each residents' quality of life, dignity and respect.Dignity means that in their interactions with residents, staff carries out activities that assist the Resident to maintain and enhance his/her self-esteem and self-worth.Social services will monitor and observe for the following practices: .promoting resident's independence and dignity with dining. Using the reasonable person concept, though both Resident #1 and Resident #19 had decreased ability to verbally express their own thoughts due to their mental diagnoses, Resident #1 and Resident #19 had the potential to feel shame and/or embarrassment and/or experience a loss of self-worth. As both residents had a court appointed guardian, no family was available to interview as to the presumed feelings of Resident #1 and Resident #19. According to Your Rights and Protections as a Nursing Home Resident revealed, .At a minimum, Federal law specifies that nursing homes must protect and promote the following rights of each resident. You have the right to .Be Treated with Respect: You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose . https://downloads.cms.gov/medicare/your_resident_rights_and_protections_section.pdf Resident #25: Review of an admission Record revealed Resident #25 was a male with pertinent diagnoses which included altered mental status, cognitive communication deficit ((progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language), Parkinson's disease, dementia, depression, mood disorder, and the need for assistance with personal care. Review of current Care Plan for Resident #25, revised on 5/27/2021, revealed the focus, . (Resident #25) a [AGE] year-old male with a DX (diagnosis) of Parkinson's disease. He tires easily, prefers to self-direct his activities and stays in his room. [NAME] enjoys listening to music, at times attending musical entertainment, watching TV and movies, flavored coffee social, ice cream social, sitting at the nurse's station play with his fidget toys, being around animals, going outside when the weather permits, visiting with family and friends, and doing anything dealing with motorcycles. He needs reminders of activities and assistance to/from activities. Staff should continue to offer one-on-one visits PRN (as needed). Continue POC (plan of care) . with the intervention .Adjust activities to accommodate resident's energy level and tolerance Assist resident PRN with locating a favorite TV channel/show .Encourage/invite resident to activities that suit his prior interest or are compatible with his prior life interests/hobbies .Offer 1-1 visits PRN to provide companionship as resident is able to tolerate .Offer activities such as reading poetry or scripture, gentle hand massages, reminiscing/storytelling, singing, listening to music, etc .Offer resident variety of materials such as books, magazines, puzzles, word searches, coloring books, etc . During an observation on 12/15/25 at 09:05 AM, Resident #25 was seated at the nurse's station with no water, no activities, just a fuzzy blanket. During an observation on 12/15/2025 at 10:15 AM, Resident #25 was sitting at the nurse's station desk still in his wheelchair, with the fuzzy blanket. Director of Nursing (DON) B reported he recently had a gradual dose reduction of a medication, and he had more personality. She did not notice he did not have any activities and nor did she offer him any activities of his interest, offer to take him to activities, or offer to lie him down in his room. During an observation on 12/15/2025 at 2:11 PM, Resident #25 was being assisted to eat by a staff member, he had not drunk the fluids on his tray but did have an open drink supplement. This writer observed resident for several minutes and he did not attempt to drink the supplement; the staff member left the supplement on the table but did not offer him a drink nor did she assist him with a drink. Resident #25 was left to sit at the table in the dining room independently with no other staff or resident interaction. During an observation on 12/16/2025 at 1:59 PM, Resident #25 was seated at the nurse's station with no activities or one to one visit. No music was playing, no television in sight. During an observation on 12/17/2025 at 9:23 AM Resident #25 was seated at the desk and he had a fidget [NAME] on the table in front of him. Using the reasonable person concept, though Resident #25 had decreased ability to verbally express his own thoughts due to his medical diagnoses, any reasonable person would likely feel a decreased sense of self-worth, anxiety, frustration, and confusion in the situations observed.

Based on interview and record review, the facility failed to address and resolve grievances reported in Resident Council Meetings as stated during a confidential Resident Council meeting resulting in unresolved concerns, unmet resident needs and frustration. Findings include:During a confidential Resident Council meeting on 12/16/2025 at 11:07 AM, 9 of 9 residents stated that management didn't follow up on concerns that they brought up in Resident Council meetings and individual concerns that came from the meetings.Two residents stated that they weren't sure if the Grievance official was Nursing Home Administrator (NHA) A or Social Services Director (SSD) P.One resident stated that SSD P doesn't respond to grievances. She said talking to SSD P about grievances was like talking to the wall since she doesn't do anything with them.9 of 9 residents stated that they don't like the food here and they don't get what they order. They said they have brought it up in Resident Council and nothing had changed. One resident said The food is horrible. Nothing will change since follow-up on concerns isn't being completed. Review of Resident Council Minutes dated 8/27/2025 revealed . Old business: (List follow-up on last month's minutes and identify staff person responsible): all issues and concerns have been reviewed and continue to be reviewed. New business.Dietary: All residents replied 'could use improvement. There is no flavor. The gravy is too thin, the toast was hard, the presentation could be better.'. There were no concern forms associated with this Resident council meeting. Review of Resident Council Minutes dated 9/17/2025 revealed . Old business: (List follow-up on last month's minutes and identify staff person responsible): all issues and concerns have been reviewed and continue to be reviewed. New business.Dietary: All residents stated, 'The food is horrible, no flavor, needs to be plated better.' Everyone would like fried chicken and fresh fruit. There were no concern forms associated with this Resident Council meeting.Review of Resident Council Minutes dated 10/15/2025 revealed . Old business: (List follow-up on last month's minutes and identify staff person responsible): all issues and concerns have been reviewed and continue to be reviewed. New business.Dietary: All residents 'Needs much improvement. Food has no flavor. There is no sauce for the noodles. We are still getting items that are listed on our dislikes list. Plating is horrible. Would like salt and pepper on our trays. Why are we only getting small portions?'. There were no concern forms associated with this Resident Council meeting.Resident Council Minutes dated 11/17/2025 revealed .Officers in Attendance: (NHA A). Residents in Attendance: Administrator went to west dining room at scheduled time of resident council meeting and no residents were present. Administrator spoke with (Resident #54). Concerns to be addressed via ambassador rounds. Old business: To be discussed at December resident council. New business.concerns to be addressed via ambassador rounds.During an interview on 12/16/2025 at 2:10 PM, Dietary Director (DD) G stated that he knew about some food concerns that came up here and there and said I don't have any specifics items I can work with to fix. DD G said he only received 1 concern form related to food and that was in June when he first started at the facility. DD G also stated that he didn't hear anything from Resident Council about the food or receive concerns forms from the meeting. DD G reported that he had a Food Committee meeting monthly after Resident Council and at those meetings the residents typically don't give him any information to work with. When discussing that the residents at resident council stated, the food is horrible and they don't get what they order, DD G mentioned that he would need more details from the residents to fix their concerns. During an interview on 12/16/2025 at 2:36 PM, NHA A stated that she couldn't locate the concern forms from Resident Council since it wasn't in SSD P's' grievance book. NHA A reported that follow-up from Resident Council probably wasn't documented since concerns were delegated to the department head and they checked in with the residents on ambassador rounds. NHA A stated that SSD P was the Grievance Official at the facility and she was on vacation this week. Review of the Resident Council Meeting Policy with a review date of 1/2025 revealed .5. Council meetings are scheduled monthly or more frequently if requested by residents or theAdministrator. The date, time, and location of the meetings are noted on the Activities Calendar. 6. A Resident Council Concern Form will be utilized to track issues and their resolutions. The form will be forwarded to appropriate Department Manager. 7. The Administrator reviews the Resident Council Minutes and Concerns. The Administrator is responsible to sign the concern form stating they have been made aware of the concern and are satisfied with the plan of action. 8. Responses are presented at the next meeting, or sooner if indicated. 9. The Facility Continuous Quality/Performance Improvement Committee will review the data from Resident Council as part of their review. Issues documented from Resident Council maybe referred to the Committee for action or recommendation taken as needed.

Based on observation, interview and record review, the facility failed to notify residents of where to find grievance forms and how to file a grievance as stated during a confidential Resident Council meeting resulting in unresolved concerns, unmet resident needs and frustration. Findings include:During a confidential Resident Council meeting on 12/16/2025 at 11:07 AM, 7 of 9 residents stated that they don't know where grievance forms were located and how to file one. They also stated that they didn't know who to go to with concerns. 9 of 9 residents stated that management doesn't follow up on individual concerns that they bring up. Two residents stated that they weren't sure if the Grievance official was Nursing Home Administrator (NHA) A or Social Services Director (SSD) P.One resident stated that SSD P doesn't respond to grievances. She said talking to SSD P about grievances was like talking to the wall since she doesn't do anything with them.During an interview on 12/16/2025 at 12:21 PM, Certified Nursing Assistant (CNA) GG stated that he didn't know where grievance forms were located. CNA GG said he would let the nurse know if there was a resident concern and then the nurse would follow up with the resident. During an interview on 12/16/2025 12:22 PM, Registered Nurse (RN) U stated that she wasn't sure where grievance forms were located and thought they were outside of SSD P's office. RN U said staff can help resident's fill out the form. During an observation on 12/16/2025 at 12:30 PM, grievance forms could not be located outside SSD P's office. During another interview on 12/16/2025 12:40 PM, RN U stated that she thought grievance forms were located outside SSD's office. This surveyor walked throughout the facility with RN U and grievance forms were located on the wall at the corner of 200 and 300 Hall and SSD's office was located in the middle of 300 Hall. It was observed that the grievance forms were hanging on the wall in a wire basket and which was not labeled with what the forms were or any information identifying who the Grievance official was or who to turn the forms into. During an interview on 12/17/2025 at 8:45 AM, CNA X stated that she would let the nurse know if a resident had a complaint because she didn't know where grievance forms were located. CNA X said she thought the forms were located by the SSD's office and the nurses' station. During an interview on 12/17/2025 at 8:47 AM, Licensed Practical Nurse (LPN) Z stated that grievance forms were located at the nurses' station. LPN Z also said that she thought the Grievance Official was NHA A. During an interview on 12/16/2025 at 2:36 PM with NHA A, this surveyor discussed how the residents in the confidential Resident Council meeting and some staff weren't sure where grievance forms were located and who to go to with concerns. NHA A stated that SSD P was the Grievance Official at the facility and was on vacation this week. NHA A reported that she was going to take over as Grievance Official now. Review of the Grievances/Concerns Policy dated 1/2025 revealed . Purpose: To support each resident's right to voice grievances and to ensure that a policy is in place to process grievance. Providing prompt actions to resolve grievances/concerns and to keep the resident apprised of progress towards resolution. The Administrator is the Grievance Officer who is responsible and will oversee the implementation of the facility grievance process, receiving and tracking grievances through to their conclusion in conjunction with the Social Service Director. Procedure: Upon admission, Social Services or designee will inform residents and resident representative of their right to voice grievances with respect to treatment received as well as a lack of treatment received during their stay in the facility and how to file or submit a compliant/ grievance. 1. Residents will be informed of the oral and written methods for communicating concerns to staff. Postings will be placed in prominent locations throughout the facility notifying of their right to file a grievance / compliant. Information provided includes: Right to File a Grievance Anonymously Contact information of the Grievance Official Whom a grievance can be filed with, name(s) of person. Reasonable expected time frame for completion of review/investigation. 2. The Social Services Director will coordinate the facility system for collecting grievances and tracking those grievances for timely and appropriate response. 3. Administrator and Social Service Director will lead investigation; maintaining confidentiality of all information associated with grievances and ensure residents are protected from discrimination or reprisal. 4. Upon receipt of grievance, an immediate action will be implemented to prevent further potential violation of any resident right while the alleged violation is being investigated. 6. Social Services will instruct facility staff to submit to the Social Services Director that all grievances received will be investigated within seventy-two hours (72) hours following receipt of the complaint. Within seven (7) days following the receipt of the complaint, the facility will inform the complainant with the results of the investigation in writing. 7. Grievances submitted to the Social Services Director who will provide a copy to the appropriate department head for resolution. Social Service will present grievances in theInterdisciplinary Team morning meeting to discuss and determine resolution. 8. The Social Services Director will report to the facility administrator during morning meeting the status of all grievances. 9. On a monthly basis, social services will analyze the grievance tracking system for trends or patterns in facility practices which lead to grievances. Identifiable trends will be addressed through the facility Continuous Quality Performance Improvement Committee an QAPI program. 10. Social Services and / or the Staff Development Coordinator will train staff upon hire and throughout employment on how to receive grievances voiced by residents and/or family members. Training will include at a minimum the following content: Listening without becoming defensive, Diffusing an emotionally charged resident or family member, The need to take all voiced grievances seriously, What to do with grievances voiced, When to put a grievance in writing.

Based on interview and record review, the facility failed to employ an Activity Director who possessed the required qualifications resulting in the potential for unmet met psychosocial needs, feelings of boredom, isolation, and a lack of person-centered activities. This citation has the potential to impact any resident who relies on the activities program to support their leisure involvement.Findings include:Review of certification standards of the National Certification Council for Activity Professionals revealed ADC (Activity Director Certified) Certification ensures an individual has the knowledge and skills to lead and direct an activities and life enrichment department. ADC Certification validates the competencies necessary to be an Activity Director including leadership, management, advocacy, care planning and documentation.Review of Participating in Activities You Enjoy as You Age, published by the National Institute on Aging, 3/28/22, revealed: Research has shown that older adults with an active lifestyle: Are less likely to develop certain diseases. Participating in hobbies and other social activities may lower risk for developing some health problems, including dementia, heart disease, stroke, and some types of cancer . Studies looking at people's outlooks and how long they live show that happiness, life satisfaction, and a sense of purpose are all linked to living longer. Studies suggest that older adults who participate in activities they find meaningful, .say they feel happier and healthier . When people feel happier and healthier, they are more likely to be resilient .Positive emotions, optimism, physical and mental health, and a sense of purpose are all associated with resilience .research suggests that participating in certain activities, such as those that are mentally stimulating or involve physical activity, may have a positive effect on memory - and the more variety the better.Resident #59 (R59)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R59 was a [AGE] year-old man who was admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R59 was cognitively intact (13 to 15 cognitively intact).During an interview on 12/15/2025 at 9:43 AM, R59 stated that there wasn't an Activity Director at the facility for about a month and some staff helped here and there with activities. R59 said that the calendar hadn't been followed during that time and the facility was doing the best they could. R59 stated that he loves going to religious services/church on Sundays and only attended 1 service on a Sunday since he was admitted to the facility. R59 reported that his main interest was attending church and he only attended BINGO since the residents liked him calling the numbers. Review of the November 2025 and December 2025 calendar revealed that there were 6 total church services scheduled every Sunday since R59 was admitted to the facility. Review of R59's Activity assessment dated [DATE] revealed . Is resident active in religion: yes. (R59) is a [AGE] year-old male. He prefers to self-direct his activities and stays in his room. (R59) enjoys reading, writing, watching TV, keeping up with the news, listening to all types of music especially country, jazz, and rock, arranging music, playing in a band, performing music at facilities, working on the internet, participating in religious services.Review of R59's Care Plan revealed .He (R59) prefers to self-direct his activities and stays in his room. (R59) enjoys reading, writing, watching TV, keeping up with the news, listening to all types of music especially country, jazz, and rock, arranging music, playing in a band, performing music at facilities, working on the internet, participating in religious services. Date initiated 11/4/2025.Goal: Attempt to accommodate/adapt to offer meaningful, satisfying and pleasurable activities to meet resident's individual needs. Resident will appear comfortable and satisfied with his daily facility activities/routine. Resident preferences will be honored to the extent possible. Approach: Encourage/invite resident to activities that suit his prior interest or are compatible with his prior life interests/hobbies.Review of R59's MDS Section F for Activities revealed .How important is it to you to listen to music you like? Very important.How important is it to you to participate in religious services or practices? Very important. Review of R59's November 2025 Activity Log through POC (Point of Care that staff documents in) revealed that he attended activities for 3 days since admission on [DATE] and none of them were church services.Review of R59's December 2025 Activity Log which was typed on a word document indicated R59 did not attend any church services provided by the facility and R59 led church services with a few residents on 12/7/2025 and 12/14/2025. During another interview on 12/17/2025 at 11:12 AM, R59 said he loves music and played the guitar in 2 different bands. He stated that he played with the church when they came in the 1 time since he has been at the facility. R59 reported since the church service has only occurred on 1 Sunday, he gathered some residents a few times on other Sundays in the chapel and they would sing some hymns and read a few passages from the bible. R59 stated it wasn't an official devotion and staff didn't help get residents to the chapel. During an interview on 12/17/2025 at 11:10 AM, Licensed Practical Nurse (LPN) Z stated that the church hasn't come to the facility on Sundays in months.During an interview on 12/17/2025 at 11:07 AM, Registered Nurse (RN) U stated that they haven't had activities besides BINGO on the weekends. RN U said that church hasn't been coming in for months. RN U reported that the previous Activity Director (AD) was supposed to look into why the church hadn't been coming in on Sundays but then she quit and no one looked into it. RN U said that the new AD just started on 12/15/2025. During an interview on 12/17/2025 at 11:34 AM, Certified Nursing Assistant (CNA) S stated that they only have a few activities on weekends. CNA S said that churches come in on Sunday, but she hasn't seen them in a long time. During an interview on 12/17/2025 at 9:28 AM, Human Resource Director (HRD) E stated that the new AD (AD F) just started at the facility on 12/15/2025. HRD E said that AD F was not certified as an AD and the facility would be signing her up and pay for her to take the Activity Director certification course.During an interview on 12/17/2025 at 11:35 AM, AD F stated she started as AD on 12/15/2025 and does not have her certification as an AD yet but she worked as a CNA at the facility before becoming the AD. AD F stated she was made aware of R59 wanting to attend church and how they haven't been coming on Sundays and she said she set up a meeting with the church, R59 and her to discuss this concern. During another interview 12/17/2025 at 11:53 AM, HRD E stated that AD F was training with their sister facility's AD and AD F would officially be done with training and be full time in the building on 12/29/2025, then then they would sign her up for the certification class. During an interview on 12/17/2025 at 12:30 PM, Nursing Home Administrator (NHA) A stated the previous AD left the faciity on [DATE] and after she left, they had an assistant that filled in for activities. NHA A said that they were aware that AD F wasn't certified but their sister facility was overseeing activities and training AD F who just started on 12/15/2025. NHA A stated that AD F was going to the sister facility on 12/18/2025 to train with the AD there and would officially be done with training and be full time at the facility on 12/29/2025. NHA A reported that AD F was a CNA at the facility so she has experience. Review of the Activity Program Staffing Policy dated 6/2017 revealed Policy: Our activity programs are staffed with personnel who have completed a job-specific orientation training and experience to meet the needs and interests of each resident. Procedure: 1. Our activity programs are under the direct supervision of a qualified professional who: Is a qualified therapeutic recreation specialist or an Activities Professional who: Is licensed or registered, if applicable, by the state in which practicing; AND Is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; OR Has two (2) years of experience in a social or recreational program within the last five (5) years, one (1) of which was full-time in a therapeutic activity program; OR Is a qualified occupational therapist or occupational therapy assistant; OR Has completed a training course approved by the state.

Based on observation, interview, and record review the facility failed to implement care plan interventions for 1 (Resident 7) of 16 sampled residents reviewed for care plan intervention implementation resulting in the potential for the development of pressure ulcers.Findings include:Resident #7Review of a Resident Face Sheet revealed Resident #7 was a female who admitted to the facility on [DATE] and had pertinent diagnoses which included: Type 2 diabetes (a disease when the body cannot regulate insulin use and blood sugar), history of falling, and severe protein-calorie malnutrition. Review of a Review of a Minimum Data Set (MDS) assessment for Resident #7, with a reference date of 11/26/25 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #7 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment).On 12/15/25 at 9:45 am, Resident #7 was observed in bed, with her heel directly on the mattress under the blankets, with no pillow for elevating heels of the bed. Observed in the room were a bolster (a padded piece of equipment that a person can rest their legs on to remove pressure from the heel) and a pair of padded boots. Review of Care Plan for Resident #7 revealed .at risk for skin breakdown.with interventions of elevation of heels. with a start date of 4/30/25.In an interview on 12/15/25 at 11:00 am, Certified Nurse Assistant (CNA) EE reported Resident #7 could assist with repositioning a little but did not reposition herself. On 12/15/25 at 11:21 am and 3:30 pm, Resident #7 was observed in bed, with her heel directly on the mattress under the blankets, with no pillow for elevating heels of the bed. Observed in the room were a bolster and a pair of padded boots.On 12/16/25 at 08:30 am and 11:15 am Resident #7 was observed in bed, with her heel directly on the mattress under the blankets, with no pillow for elevating heels of the bed. Observed in the room were a bolster and a pair of padded boots.In an interview on 12/16/25 at 11:19 Licensed Practical Nurse (LPN) Y entered Resident #7's room, pulled back the blankets on the bed to expose Resident #7's feet lying directly on the mattress. LPN Y reported Resident #7's feet should not be on the mattress; they should be elevated. LPN Y reported Resident #7 should be wearing the padded boots. LPN Y was observed applying the padded boots to Resident #7's bilateral (both) feet. LPN Y stated with her heels, yeah, she really needs the boots to be on.In an interview on 12/16/25 at 11:26 am, CNA S reported Resident #7 should be wearing the padded boots on both feet when she was in bed. CNA S reported she had not applied the boots to Resident #7's feet in the last two days. CNA S reported she was unsure if Resident #7 was to wear the padded boots or not.Review of Evaluation of Braden Scale (standardized assessment tool used to estimate a patient's risk of developing pressure ulcers) for Resident #7 dated 8/4/25 at 4:40 pm revealed .Score:11 Level High Risk (6-9 very high risk, 10-12 high risk, 13-14 moderate risk, 15-18 mild risk, 19-23 no risk).In an interview on 12/16/25 at 11:29 am, Director of Nursing (DON) B stated I'm going to go look at what is in her (Resident #7) room.In an interview on 12/16/25 at 11:37 am, DON B reported Resident #7 was to have her feet elevated off the mattress as she allowed. DON B reported Resident #7 did not need more specific interventions as she did not have any wounds and she was not at risk for skin breakdown. DON B reported she removed the boots from Resident #7's feet because her feet should be elevated on a pillow. DON B reported she did not know where the boots came from. Review of Care Plan for Resident #7 revealed no noted documentation regarding padding boots for bilateral feet.

This citation pertains to intake #2563732Based on interview and record review the facility failed to ensure as needed (PRN) psychotropic medications (a medication that alters a person's mental state) included a stop date not exceeding 14 days for 1 (Resident #68) of 6 residents reviewed for unnecessary medications.Findings include:Resident #68Review of a Resident Face Sheet revealed Resident #68 was a male who admitted to the facility on [DATE] and had pertinent diagnoses which included: schizoaffective disorder (a mental health condition including hallucinations and delusions, bipolar disorder (a mental health condition that includes extreme mood swings), and anxiety disorder.Review of a Minimum Data Set (MDS) assessment for Resident #68, with a reference date of 09/08/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #68 was cognitively intact.Review of Physician Orders for Resident #68 revealed .Hydroxyzine HCl tablet, 50 mg, amt (amount) 1 tablet; oral, special instructions; give 50 mg po (by mouth) q6 hours (every 6 hours) prn; anxiety with a start date of 7/11/25 and a discontinued (DC) date of 8/5/25 and again with a start date of 08/06/25 and a DC date of 9/8/25.In an interview on 12/17/25 at 10:38 am, Director of Nursing (DON) B reported PRN psychotropic medications were limited to 14 days. DON B reported the hydroxyzine was an antihistamine that was also used to treat anxiety. DON B reported Resident #68 took hydroxyzine for anxiety and would require a 14 day stop date. DON B reported the provider could extend the time frame for as needed use for a psychotropic medication with rationale. DON B reviewed Resident #68's hydroxyzine orders and confirmed there should have been stop dates for 14 days for both orders.No documentation including a provider rationale to extend Resident #68's hydroxyzine PRN use longer than 14 days was provided by the time of exit.

Based on observation, interview, and record review, the facility failed to follow professional standards of nursing practice for physician notification of a change in condition and medication administration for 1 of 1 residents (Resident #2) reviewed for medication administration resulting in the withholding of a medication without a physician's order and the potential for affected resident not maintaining or achieving their highest practical physical well-being.Findings include: Review of Fundamentals of Nursing ([NAME] and [NAME]] revealed, Professional standards such as Nursing: Scope and Standards of Practice [ANA, 2010) .apply to the activity of medication administration. To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: 1.The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]: Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 39307-393131. Elsevier Health Sciences. Kindle Edition. Resident #2: Review of a Face Sheet revealed Resident #2 was a male with pertinent diagnoses which included diabetes with foot ulcer, Stage 4 pressure ulcer left buttock, Stage 3 pressure ulcer right buttock, osteomyelitis (serious bone infection where germs have reached the bone through the bloodstream), sepsis (life threatening medical emergency where the body's extreme response to an infection triggers a chain reaction causing widespread inflammation, tissue damage, organ failure, and potentially death) and paralysis from the chest down. Review of Care Plan for Resident #2 dated on 7/13/24, revealed the focus, .Potential for episode(s) of hypo/hyper glycemia (hypoglycemia - blood glucose drops too low depriving cells, especially the brain, of energy causing shakiness, sweating, dizziness, confusion. Hyperglycemia - too much glucose in the blood usually because the body lacks enough insulin, symptoms include thirst, frequent urination, blurred vision, stomach pain, headache, difficulty concentrating) r/t (related to) DX (diagnosis) diabetes. Patient does not follow his diabetic diet . with the intervention .Administer diabetic medication(s) as ordered. Observe for effectiveness and any adverse side effects .Observe for signs of hyperglycemia: increased thirst; increased urination; increased appetite followed by lack of appetite; nausea, vomiting. In an interview on 12/15/2025 at 2:12 PM, Resident #2 reported he did not receive his long-lasting insulin last night as the facility didn't have the insulin in the medication cart or in the back up refrigerator. Resident #2 reported he had been told the facility had ordered the insulin and was told it should be at the facility today (12/15/25) for administration tonight. Review of Medication Administration Record (MAR) for December 2025, revealed, Resident #2 had not received degludec insulin on 12/11/25, 12/12/25, 12/13/25, 12/14/25. Nurse's initials of those assigned to administer the insulin were enclosed in parentheses which indicated the medication was not administered. Review of MAR December 2025, revealed, .12/11/2025 Prior to bed Not Administered: Other Comment: on order from pharmacy (RN J) .12/12/2025 Prior to bed Not Administered: Drug/Item Unavailable Comment: delivery pending from pharmacy (LPN V .12/13/2025 Prior to bed Not Administered: Drug/Item Unavailable Comment: pharmacy delivery pending (LPN V) .12/14/2025 Prior to bed Not Administered: Drug/Item Unavailable Comment: delivery pending .(LPN V) . Review of the medical record revealed the provider was not contacted or informed when the degludec insulin became unavailable to provide direction and/or new orders to the nurse on duty when there was no degludec insulin to administer. In an interview on 12/16/2025 at 12:06 PM, LPN Z reported for any medication which was not available in the medication cart or the backup box, the nurse would contact the pharmacy right away as well as the nurse would contact the provider to let them know and seek direction and/or obtain a new order for the medication to be replaced or placed on hold. LPN Z reported there was a form the pharmacy had the nurse fill out when pulling from the backup box. LPN Z reported the nurse could check with the local pharmacy to see if they had the medication needed. LPN Z reported for insulin it would depend on if it was on back order and if the facility was going to receive it prior to administration time, and it depended on the resident and the blood sugar readings and other diagnoses. LPN Z reviewed the medical record and reported the insulin was not placed on hold by the provider and there was no note the provider was contacted. In an interview on 12/17/2025 at 9:08 AM, Registered Nurse (RN) J reported the nurse had a form we fill out and faxed to the pharmacy to get permission to pull the medication from the lock box in the medication room. If the medication was in stock the nurse would pull it from there, if it was not in stock, there was a tab in the medical record to record it was not given, and the nurse would indicate not in stock option. RN J reported the provider would be notified and a progress note would be entered into the medical record to communicate with other nursing staff. RN J reported if the insulin was not in stock, she would contact the pharmacy to check if there were any long lasting insulin the facility had in stock which would be comparable to the prescribed insulin. RN J reported for Resident #2 he was prescribed an insulin she had been unfamiliar with, she went to get the insulin, and it was not in the cart, she looked in the cart for it and then went to check the medication refrigerator for extra and was unable to locate the degludec insulin. RN J reported she had seen there was an order placed for the insulin to come from the pharmacy, but it didn't come when she worked, she was not able to administer the insulin. RN J reported she should have contacted the provider to see how the provider wanted to proceed. RN J reported that if the resident did not receive his insulin, he could have high blood sugars, had a seizure, or went into a coma. In an interview on 12/17/2025 at 3:09 PM, Licensed Practical Nurse (LPN) V reported the degludec insulin was out and she had tried to call the pharmacy and was told the insulin would be in the tote delivered by pharmacy that night, and the insulin did not come, and she had contacted them again. LPN V reported she was told it would be coming, and it would be a different insulin but comparable to the degludec insulin. LPN V reported she had worked the previous Friday, Saturday, and Sunday. LPN V reported the insulin was not in Sunday's tote either and pharmacy reported the medication was temporarily out of stock and would be delivered the next day, Monday (12/15/25). LPN V reported she should have contacted the provider to see if there could be a substitute medication the provider wanted to administer on that first night she worked and the insulin was not available, she reported she thought it would be okay until the insulin came in and then each time it didn't' come in and she still did not contact the provider. LPN V reported when she checked Resident #2's blood sugar levels were in the 200s and she repeated she thought it would be okay. LPN V reported she held herself to a certain standard and she should have called the provider right away. In an interview on 12/17/2025 at 10:03 AM, Director of Nursing (DON) B reported if a medication was not in the medication cart, the nurse was to look in the back up box to see if the medication was in there. DON B reported the nurse would contact the provider when they found there was no medication and it had not arrived in the pharmacy tote, as well as document in the medical record the medication was not available. DON B reported Resident #2 did not receive the long-lasting insulin from 12/11 until 12/15 as noted in the medication administration record. DON B reported if a resident did not receive the long-lasting insulin he could have hyperglycemia, altered mental status, DKA (diabetes ketoacidosis - severe life-threatening diabetes complication the body lack insulin, causing it to burn fat for fuel, producing acidic ketones that build up in the blood leading to dehydration, potential coma or death). DON B reported a progress note would be entered per the policy as well as to communicate with other staff, proof what was documented was done, and the nurses were trained to document the provider was contacted and what was communicated. DON B reported prior to the missed degludec insulin doses Resident #2, from 12/2/25 to 12/11/25, had multiple blood sugar ranges from mid to lower 100s, and in the 200 range. From 12/11/25 to 12/17/25, Resident #2 had a few readings in the 100 range, most in the 200 range, and one in the 300 range.

Based on interview and record review, the facility failed to provide individualized activities based on resident preferences, needs, and abilities for 1 resident (Resident #59) of 16 residents for activities, resulting in potential for social isolation, decreased connectedness to the resident's environment, and decreased overall well-being.Findings include: Review of Participating in Activities You Enjoy as You Age, published by the National Institute on Aging, 3/28/22, revealed: Research has shown that older adults with an active lifestyle: Are less likely to develop certain diseases. Participating in hobbies and other social activities may lower risk for developing some health problems, including dementia, heart disease, stroke, and some types of cancer. Studies looking at people's outlooks and how long they live show that happiness, life satisfaction, and a sense of purpose are all linked to living longer. Doing things that you enjoy may help cultivate those positive feelings. Studies suggest that older adults who participate in activities they find meaningful, .say they feel happier and healthier. When people feel happier and healthier, they are more likely to be resilient, which is our ability to bounce back and recover from difficult situations. Positive emotions, optimism, physical and mental health, and a sense of purpose are all associated with resilience.research suggests that participating in certain activities, such as those that are mentally stimulating or involve physical activity, may have a positive effect on memory - and the more variety the better. Resident #59 (R59)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R59 was a [AGE] year-old man who was admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R59 was cognitively intact (13 to 15 cognitively intact).During an interview on 12/15/2025 at 9:43 AM, R59 stated that there wasn't an Activity Director at the facility for about a month and some staff helped here and there with activities. R59 said that the calendar hadn't been followed during that time and the facility was doing the best they could. R59 stated that he loves going to religious services/church on Sundays and only attended 1 service on a Sunday since he was admitted to the facility. R59 reported that his main interest was attending church and he only attended BINGO since the residents liked him calling the numbers. Review of the November 2025 and December 2025 calendar revealed that there were 6 total church services scheduled every Sunday since R59 was admitted to the facility. Review of R59's Activity assessment dated [DATE] revealed . Is resident active in religion: yes. (R59) is a [AGE] year-old male. He prefers to self-direct his activities and stays in his room. (R59) enjoys reading, writing, watching TV, keeping up with the news, listening to all types of music especially country, jazz, and rock, arranging music, playing in a band, performing music at facilities, working on the internet, participating in religious services.Review of R59's Care Plan revealed .He (R59) prefers to self-direct his activities and stays in his room. (R59) enjoys reading, writing, watching TV, keeping up with the news, listening to all types of music especially country, jazz, and rock, arranging music, playing in a band, performing music at facilities, working on the internet, participating in religious services. Date initiated 11/4/2025.Goal: Attempt to accommodate/adapt to offer meaningful, satisfying and pleasurable activities to meet resident's individual needs. Resident will appear comfortable and satisfied with his daily facility activities/routine. Resident preferences will be honored to the extent possible. Approach: Encourage/invite resident to activities that suit his prior interest or are compatible with his prior life interests/hobbies.Review of R59's MDS Section F for Activities revealed .How important is it to you to listen to music you like? Very important.How important is it to you to participate in religious services or practices? Very important. Review of R59's November 2025 Activity Log through POC (Point of Care that staff documents in) revealed that he attended activities for 3 days since admission on [DATE] and none of them were church services.Review of R59's December 2025 Activity Log which was typed on a word document indicated R59 did not attend any church services provided by the facility and R59 led church services with a few residents on 12/7/2025 and 12/14/2025. During another interview on 12/17/2025 at 11:12 AM, R59 said he loves music and played the guitar in 2 different bands. He stated that he played with the church when they came in the 1 time since he has been at the facility. R59 reported since the church service has only occurred on 1 Sunday, he gathered some residents a few times on other Sundays in the chapel and they would sing some hymns and read a few passages from the bible. R59 stated it wasn't an official devotion and staff didn't help get residents to the chapel. During an interview on 12/17/2025 at 11:10 AM, Licensed Practical Nurse (LPN) Z stated that the church hasn't come to the facility on Sundays in months.During an interview on 12/17/2025 at 11:07 AM, Registered Nurse (RN) U stated that they haven't had activities besides BINGO on the weekends. RN U said that church hasn't been coming in for months. RN U reported that the previous Activity Director (AD) was supposed to look into why the church hadn't been coming in on Sundays but then she quit and no one looked into it. RN U said that the new AD just started on 12/15/2025. During an interview on 12/17/2025 at 11:34 AM, Certified Nursing Assistant (CNA) S stated that they only have a few activities on weekends. CNA S said that churches come in on Sunday but she hasn't seen them in a long time. During an interview on 12/17/2025 at 11:35 AM, AD F stated she started as AD on 12/15/2025 and does not have her certification as an AD yet but she worked as a CNA at the facility before becoming the AD. AD F stated she was made aware of R59 wanting to attend church and how they haven't been coming on Sundays and she said she set up a meeting with the church, R59 and her to discuss this concern. During an interview on 12/17/2025 at 12:30 PM, Nursing Home Administrator (NHA) A stated that the previous AD left the faciity on [DATE] and after she left, they had an assistant that filled in for activities. Review of the Activity Programming Policy with a review date of 6/2017 revealed Policy: Activity programs designed to meet the needs of each resident are available on a daily basis. Our activity programs are designed to encourage maximum individual participation and are person-appropriate to the individual resident. 2. Our activity program consists of individual and small and limited large group activities that are designed to meet the needs and interests of each resident and include, as a minimum .at least one evening activity is offered per week Group Activities are offered on Saturday, Sunday and holidays. 7. Individualized and group activities provided will: reflect the schedules, choices and rights of the residents, are offered at hours convenient to the residents, including evenings .weekends .

Based on observation, interview, and record review the facility failed to ensure services and assistive devices were provided to maintain adequate vision in 1 (Resident #24) of 1 resident reviewed for vision services resulting in inadequate glasses, outdated prescription, and the potential for vision strain. Findings include:Resident #24Review of a Resident Face Sheet revealed Resident #24 was a male who admitted to the facility on [DATE] and had pertinent diagnoses which included: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (stroke). Review of a Minimum Data Set (MDS) assessment for Resident #24, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #24 was moderately cognitively impaired.In an observation and interview on [DATE] at 9:51 AM, Resident #24's glasses were noted to be missing the left lens. Resident #24 demonstrated where the frame of his glasses, near the nose piece on the left side, was broken completely through. Resident #24 reported the lens was in the drawer, and it would not stay in the frame. Resident #24 reported his glasses broke a while ago and the facility had not gotten them fixed yet. Resident #24 reported he had asked for his glasses to be fixed several times.Review of Social Service note for Resident #24 dated [DATE] at 3:38 pm revealed .Resident broke his glasses. Writer tried ordering new glasses, but his RX (prescription) has expired. (Name Omitted/optometry service) explained that the RX expired d/t (due to) resident refusing to see the optometrist. Resident will be seen at next visit to renew his RX.In an interview on [DATE] at 2:12 pm, Director of Nursing (DON) B reported that Social Service Director (SSD) P was responsible for vision services for residents in the building. DON B reported she thought vision services were offered quarterly.In an interview on [DATE] at 10:33 am, DON B reported Resident #24 had a history of refusing to see optometry. DON B reported that Resident #24 refused to be seen on [DATE]. When queried, if there had been any other appointments scheduled, or attempts to have his glasses repaired, DON B stated That's a good question, SSD P would coordinate that.In an interview on [DATE] at 2:45 pm, NHA A reported vision services were available as needed for the residents of the building. SSD P had communicated with her via text message that Resident #24 had repeatedly refused attempts to repair his glasses and services from optometry to acquire a new prescription for glasses. NHA A reported Resident #24 was scheduled for a visit with optometry on [DATE].Review of a letter addressed to SSD P and dated [DATE], revealed .list of residents we suggest being seen by our optometrist.on [DATE]th. Resident #24 was noted to be on the list.No other documentation was provided by the time of survey exit demonstrating any scheduled optometry appointments, any refusal of services, or any attempts made to repair/replace Resident #24's glasses after [DATE] when Resident #24's glasses were noted to be broken.

Based on observation, interview, and record review the facility failed to ensure proper treatment to maintain good foot health for 1 (Resident #5) of 1 resident reviewed for foot health, resulting in the potential for injury, unmet care needs and/or complications from chronic conditions that affect foot health.Findings include:Resident #5Review of a Resident Face Sheet revealed Resident #5 was a male who admitted to the facility on [DATE] and had pertinent diagnoses which included: Cerebral infarction (stroke) with left side weakness, type 2 diabetes (chronic condition resulting in high blood sugar levels due to ineffective insulin production or use), and hypertension (high blood pressure). Review of a Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 10/02/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #5 was cognitively intact.In an interview on 12/15/25 at 12:26 pm, Resident #5 reported he was concerned with his fingernails and toenails being clipped. Resident #5 reported he offered to do it himself, but the staff would not provide him with clippers or scissors.In an interview on 12/16/25 at 1:54 Resident #5 reported his nails were too long and he couldn't stand it. Resident #5 reported he was told several months ago he had diabetes, and he now needed to see a podiatrist (specialized foot doctor) for his foot care. Resident #5 reported occasionally someone looks at his feet, but no one had ever cut his toenails.On 12/16/25 at 1:54 pm, Resident #5's fingernails were observed to be long and extending well past the ends of his fingers. Resident #5's toenails on his right foot were observed to be long, extending beyond the ends of his toes and curing along the curvature of the toes; the great toenail extended beyond the end of the toe, was noted to be broken, jagged, and long.In an interview on 12/16/25 at 3:31 pm, Licensed Practical Nurse (LPN) Z reported nail care was completed with showers but could be done anytime it was needed. LPN Z reported CNA (certified nurse assistants) were not allowed to cut the nails of residents who had diabetes. LPN Z reported nurses could cut the nails of residents who had diabetes and those residents could be seen by the podiatrist for foot and nail care.Review of shower sheets: for Resident #5 from 11/25/25, 11/27/15, 12/02/25, and 12/04/25 revealed no documentation regarding nail care.In an interview on 12/17/25 at 10:21 am, CNA W who was working as the shower aide, reported that nail care could be done during showers. CNA W reported activities aides were who provided nail care to the residents. CNA W reported she did not cut the nails of residents who had diabetes. CNA W reported she would tell the nurse when a resident who had diabetes needed their nails cut. When queried, CNA W reported she did not document on the shower sheet if a resident needed nail care, if she cut nails or not, nor when she notified the nurse when a resident needed nail care she could not complete. CNA W stated I should probably start putting that on the shower sheets.In an interview on 12/17/258 at 10:27 am, Director of Nursing (DON) B reported resident's nails should be evaluated with every shower and bed bath. DON B reported CNAs should provide nail care, except to a resident who has diabetes, then nail care was done by the nurse or podiatrist. When queried, regarding Resident #5 nail care DON B was unsure if he had seen the podiatrist.In an interview on 12/17/25 at 10:28 am, Nursing Home Administrator (NHA) A reported Resident #5 signed consent to be treated by (Name Omitted) podiatrist on 9/25/25.Review of (Name Omitted) Consent for services for Resident #5 revealed .podiatry.I wish to use the service. signed by Resident #5 and dated 9/25/25.In an interview on 12/17/25 at 3:45pm, NHA A reported Resident #5 refused services by Podiatry provider. NHA A reported Resident #5's nails had been cut the nurse today.Review of Resident #5's medical record revealed no noted documentation regarding services of podiatry occurring or refusal of podiatry services. No documentation was provided regarding Resident #5 being seen by podiatry services, refusal of podiatry services, completion of nail care, or refusal of nail care by the time of exit.

Based on observation, interview, and record review, the facility failed to ensure hydration was readily available for 1 resident (Resident #25) of 1 resident, resulting in the potential for decline in function, fluid and electrolyte imbalance, dehydration, the development of skin breakdown, urinary tract infections, and altered mental status. Findings include: According to Bunn (2019), .Older people are more at risk of developing low-intake dehydration because, with age, kidney function decreases and muscle mass drops, reducing water stores in muscle. Older people may also develop difficulties remembering to drink, accessing drinks, and swallowing. If an older person is concerned about continence or needs help to get to the toilet, they often choose to drink less, thereby increasing their risk of low-intake dehydration. The risk of dehydration is increased in care homes residents because they are more likely to experience these problems, relying on staff to help with drinking.Residents rarely helped themselves to, or asked for, drinks, which puts the onus on nursing and care staff.Tips for improving hydration in care homes: Offer more drinks more frequently.Do not rely on residents asking for, or helping themselves to, drinks, but proactively offer them.If drinks are not finished, offer more frequent drinks.Improve continence support and access to toilets.Involve all care home staff in promoting residents' hydration. https://cdn.ps.emap.com/wp-content/uploads/sites/3/2019/09/054-058_RevDehydration-CT1.pdf Resident #25: Review of an admission Record revealed Resident #25 was a male with pertinent diagnoses which included altered mental status, cognitive communication deficit ((progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language), Parkinson's disease, dementia, depression, mood disorder, and the need for assistance with personal care. Review of current Care Plan for Resident #25, revised on 6/2/2021, revealed the focus, .(Resident #25) is at Nutritional / Hydration risk r/t (related to) hx (history) of UTI (urinary tract infection), Parkinson's, COPD, FE anemia, GERD, CAD (cardiovascular disease), HLD (high cholesterol), dementia, Antipsychotic therapy in place. Hx of wt (weight) fluctuations . with the intervention .Encourage fluids at bedside and with activities within ordered parameters if applicable .Observe for s/s (signs and symptoms) of fluid imbalance: edema, shortness of breath, dry mucous membranes, dry skin, poor skin turgor (your skin loses elasticity and doesn't snap back quickly after being pinched .key sign of dehydration) .Offer refreshments between meals .Observe labs . Review of Lab Results dated 9/23/25 revealed, .BUN Level (Blood Urea Nitrogen used to assess kidney function, hydration, and liver health) Score of 30. Normal range was 8-23 .BUN/Creatinine Ratio (used to assess kidney health, hydration, and protein metabolism) Score of 41. Normal range was 6-20 . During an observation on 12/15/25 at 09:05 AM, Resident #25 was seated at the nurse's station with no water, no activities, just a fuzzy blanket. During an observation on 12/15/2025 at 10:15 AM, Resident #25 was sitting at the nurse's station desk still in his wheelchair, with the fuzzy blanket and no water. Staff did not notice he did not have any fluids in front of him nor did anyone offer to obtain something for him to drink. During an observation on 12/15/2025 at 2:11 PM, Resident #25 was being assisted to eat by a staff member, he had not drunk the fluids on his tray but did have an open drink supplement. This writer observed resident for several minutes and he did not attempt to drink the supplement; the staff member left the supplement on the table but did not offer him a drink nor did she assist him with a drink. Resident #25 had consumed less than 25% of his meal, ate approximately 25% of pasta dish, did not eat any vegetables, nor his dessert. During an observation on 12/15/2025 at 4:12 PM, Resident #25 was lying in his bed in his room and there was a smaller sized Styrofoam cup with a straw on his dresser which was across the room and clearly out of reach. During an observation on 12/16/2025 at 9:00 AM, Resident #25 was lying in his bed, and his tray table was parallel with the right wall, there was water on the table but was out of reach for Resident #25 while he was in bed. During an observation on 12/16/2025 at 1:59 PM, Resident #25 was seated at the nurse's station, and he had a small clear plastic cup which had about an inch of clear fluid in the bottom of the cup. During an observation on 12/17/2025 at 9:23 AM Resident #25 was seated at the desk and he didn't have any fluid to drink. Resident #25's mouth was dry appearing and he had white coating on his tongue, skin was very dry appearing without good skin turgor. In an interview on 12/17/2025 at 10:17 AM, Director of Nursing (DON) B reported signs of symptoms of dehydration was poor skin turgor, altered mental status, dark urine, and foul-smelling urine. If the resident was not able to say they were thirsty, the staff would check for dry mucous membrane, frothy or thick saliva. DON B reported the staff pass fluids each shift and provide fluids as needed. However, in the event the fluid was gone and the resident would like more, the staff should provide the resident with more fluids. DON B reported if a resident was not able to express the need for fluids it is the staff's responsibility to off fluids when they enter the room at least every 2 hours, and in addition some people cannot drink much they would be offered mouth swabs/mouth care.

Based on interview and record review, the facility failed to ensure medications were administered at the correct dose per the physician's order for 1 (Resident #2) of 2 residents reviewed for significant medication errors, resulting in the potential for adverse effects. Findings include: Review of the Fundamentals of Nursing revealed, The National Coordinating Council for Medication Error Reporting and Prevention [2018] defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/ or failing to administer a medication. Preventing medication errors is essential.'' [NAME]. [NAME] A.: Perrv. [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p.605). Elsevier Health Science. Kindle Edition. Resident #2: Review of a Face Sheet revealed Resident #2 was a male with pertinent diagnoses which included diabetes with foot ulcer, Stage 4 pressure ulcer left buttock, Stage 3 pressure ulcer right buttock, osteomyelitis (serious bone infection where germs have reached the bone through the bloodstream), sepsis (life threatening medical emergency where the body's extreme response to an infection triggers a chain reaction causing widespread inflammation, tissue damage, organ failure, and potentially death) and paralysis from the chest down. Review of Care Plan for Resident #2 dated on 7/13/24, revealed the focus, .Potential for episode(s) of hypo/hyper glycemia (hypoglycemia - blood glucose drops too low depriving cells, especially the brain, of energy causing shakiness, sweating, dizziness, confusion. Hyperglycemia - too much glucose in the blood usually because the body lacks enough insulin, symptoms include thirst, frequent urination, blurred vision, stomach pain, headache, difficulty concentrating) r/t (related to) DX (diagnosis) diabetes. Patient does not follow his diabetic diet . with the intervention .Administer diabetic medication(s) as ordered. Observe for effectiveness and any adverse side effects .Observe for signs of hyperglycemia: increased thirst; increased urination; increased appetite followed by lack of appetite; nausea, vomiting.In an interview on 12/15/2025 at 2:12 PM, Resident #2 reported he developed a wound on his right-side bottom area, where the leg and the buttock met due to having him off load his left side due to a pressure ulcer and the staff had him lying on his right side. Resident #2 reported he did not receive his long-lasting insulin last night as the facility didn't have the insulin in the medication cart or in the back up refrigerator. Resident #2 reported he had been told the facility had ordered the insulin and was told it should be at the facility today for administration tonight. Review of Progress Notes dated 12/15/2025 at 03:28 AM, .This writer contacted (Medication Pharmacy Provider). regarding DEGLUDEC insulin (long lasting insulin). not arriving in tonight's delivery. Pharmacy will send brand Stating because generic is out of stock Insurance should cover cost. (Medication Pharmacy Provider) also stated medication would be delivered stat (life threatening or urgent situation that requires the order to be prioritized and administered as quickly as possible). (tomorrow) if approved by insurance . Review of Medication Administration Record (MAR) for December 2025, revealed, Resident #2 had not received degludec insulin on 12/11/25, 12/12/25, 12/13/25, 12/14/25. Nurse's initials of those assigned to administer the insulin were enclosed in parentheses which indicated the medication was not administered. Review of MAR December 2025, revealed, .12/11/2025 Prior to bed Not Administered: Other Comment: on order from pharmacy (RN J) .12/12/2025 Prior to bed Not Administered: Drug/Item Unavailable Comment: delivery pending from pharmacy (LPN V .12/13/2025 Prior to bed Not Administered: Drug/Item Unavailable Comment: pharmacy delivery pending (LPN V) .12/14/2025 Prior to bed Not Administered: Drug/Item Unavailable Comment: delivery pending .(LPN V) . Review of the medical record revealed the provider was not contacted or informed when the degludec insulin became unavailable to provide direction and/or new orders to the nurse on duty when there was no degludec insulin to administer. In an interview on 12/16/2025 at 12:06 PM, LPN Z reported for any medication which was not available in the medication cart or the backup box, the nurse would contact the pharmacy right away as well as the nurse would contact the provider to let them know and seek direction and/or obtain a new order for the medication to be replaced or placed on hold. LPN Z reported there was a form the pharmacy had the nurse fill out when pulling from the backup box. LPN Z reported the nurse could check with the local pharmacy to see if they had the medication needed. LPN Z reported for insulin it would depend on if it was on back order and if the facility was going to receive it prior to administration time, and it depended on the resident and the blood sugar readings and other diagnoses. LPN Z reviewed the medical record and reported the insulin was not placed on hold by the provider and there was no note the provider was contacted. In an interview on 12/17/2025 at 9:08 AM, Registered Nurse (RN) J reported the nurse had a form we fill out and faxed to the pharmacy to get permission to pull the medication from the lock box in the medication room. If the medication was in stock the nurse would pull it from there, if it was not in stock, there was a tab in the medical record to record it was not given, and the nurse would indicate not in stock option. RN J reported the provider would be notified and a progress note would be entered into the medical record to communicate with other nursing staff. RN J reported if the insulin was not in stock, she would contact the pharmacy to check if there were any long lasting insulin the facility had in stock which would be comparable to the prescribed insulin. RN J reported for Resident #2 he was prescribed an insulin she had been unfamiliar with, she went to get the insulin, and it was not in the cart, she looked in the cart for it and then went to check the medication refrigerator for extra and was unable to locate the degludec insulin. RN J reported she had seen there was an order placed for the insulin to come from the pharmacy, but it didn't come when she worked, she was not able to administer the insulin. RN J reported she should have contacted the provider to see how the provider wanted to proceed. RN J reported that if the resident did not receive his insulin, he could have high blood sugars, had a seizure, or went into a coma. In an interview on 12/17/2025 at 3:09 PM, Licensed Practical Nurse (LPN) V reported the degludec insulin was out and she had tried to call the pharmacy and was told the insulin would be in the tote delivered by pharmacy that night, and the insulin did not come, and she had contacted them again. LPN V reported she was told it would be coming, and it would be a different insulin but comparable to the degludec insulin. LPN V reported she had worked the previous Friday, Saturday, and Sunday. LPN V reported the insulin was not in Sunday's tote either and pharmacy reported the medication was temporarily out of stock and would be delivered the next day, Monday (12/15/25). LPN V reported she should have contacted the provider to see if there could be a substitute medication the provider wanted to administer on that first night she worked and the insulin was not available, she reported she thought it would be okay until the insulin came in and then each time it didn't' come in and she still did not contact the provider. LPN V reported when she checked Resident #2's blood sugar levels were in the 200s and she repeated she thought it would be okay. LPN V reported she held herself to a certain standard and she should have called the provider right away. In an interview on 12/17/2025 at 10:03 AM, Director of Nursing (DON) B reported if a medication was not in the medication cart, the nurse was to look in the back up box to see if the medication was in there. DON B reported the nurse would contact the provider when they found there was no medication and it had not arrived in the pharmacy tote, as well as document in the medical record the medication was not available. DON B reported Resident #2 did not receive the long-lasting insulin from 12/11 until 12/15 as noted in the medication administration record. DON B reported if a resident did not receive the long-lasting insulin he could have hyperglycemia, altered mental status, DKA (diabetes ketoacidosis - severe life-threatening diabetes complication the body lack insulin, causing it to burn fat for fuel, producing acidic ketones that build up in the blood leading to dehydration, potential coma or death). DON B reported a progress note would be entered per the policy as well as to communicate with other staff, proof what was documented was done, and the nurses were trained to document the provider was contacted and what was communicated. DON B reported prior to the missed degludec insulin doses Resident #2, from 12/2/25 to 12/11/25, had multiple blood sugar ranges from mid to lower 100s, and in the 200 range. From 12/11/25 to 12/17/25, Resident #2 had a few readings in the 100 range, most in the 200 range, and one in the 300 range.

Based on observation and interview the facility failed to properly store controlled substance medications in a secure manner in 1 of 2 medication rooms.Findings include:On 12/17/25 at 8:29 am, the lock on the medication storage refrigerator in the medication room on the west unit of the facility was observed hanging in place on the latch and was not secured. The lock was not locked.On 12/17/25 at 8:29 am, Registered Nurse (RN) DD was observed handling the lock, flipping the lock to remove it from the latch on the refrigerator, and opening the refrigerator door. RN DD did not use a key to unlock the refrigerator.On 12/17/25 at 8:29 am, RN DD reported there was a controlled substance stored in the refrigerator.On 12/17/25 at 8:33 am, RN DD was observed replacing the lock on the latch of the refrigerator and not locking the lock. RN DD exited the medication room leaving the refrigerator unlocked.In an interview on 12/17/25 at 8:38 am, RN DD reported the refrigerator in the medication room should be always locked.In an interview on 12/17/25 at 9:09 am, Director of Nursing (DON) B reported her expectations were that the refrigerators in the medication rooms were to be always locked.In an interview on 12/17/25 at 9:10 am, RN DD confirmed the refrigerator was unlocked and she did not lock the refrigerator when she exited the medication room. RN DD reported she returned to the medication room and locked the refrigerator.

Based on observation, interview, and record review, the facility failed to ensure resident food choices were obtained and honored for 1 (Resident #75) of 4 residents reviewed for meal services, resulting in resident dissatisfaction with their meal experience and the potential for inadequate food/fluid intake. Findings include:Resident #75: Review of Face sheet for Resident #75 revealed, Review of a Face Sheet revealed Resident #75 was a male with pertinent diagnoses which included diabetes, gout (a painful inflammatory arthritis from uric acid crystals in joints), and kidney disease. Review of Care Plan for Resident #75, revealed, the focus, .Resident is at Nutritional / Hydration risk r/t (related to) admitted with hx (history) of chronic lymphedema (swelling from lymph fluid buildup, caused by damaged lymph nodes, leading to heaviness, tightness, and limited movement) RLE (Right Lower Extremity), high blood pressure, deep vein thrombosis (a serious condition where a blood clot forms in a deep vein), diabetes, stage 4 kidney disease, rheumatoid arthritis (a chronic autoimmune disease where the immune system attacks joint linings, causing pain, swelling, and stiffness and can lead to systemic issues affecting the heart lungs and eyes) Diuretic therapy in place . with the intervention .Offer available substitutes if resident has problems with the food that is served .Honor food preferences within acceptable dietary limits for resident's quality of life concerns .Offer substitutes if consumes less than 50% of meal . Review of Lunch Dining Slip indicated Resident #75's preferences were to not receive pineapples, Mexican food, and sweet potatoes. In an interview on 12/15/2025 at 10:34 AM, Resident #75 reported he had informed the dietary staff he did not like sweet potatoes, malt o meal, oatmeal, fish, pineapple, waffles and he was still receiving those items on his meal trays. Resident #75 reported every Friday the kitchen served fish, and he reported he does not eat the fish but does eat whatever else was on the plate. Resident #75 reported during the care conferences the staff asked different questions, and he had reported to the registered dietician and shared with them his preferences and it doesn't change, Resident #75 reported he still gets items he had told them he doesn't like on his meal trays. During an interview on 12/16/2025 at 2:10 PM, Dietary Director (DD) G stated that he knew about some food concerns that come up here and there but I don't have any specifics items I can work with to fix. DD G said he only received 1 concern form related to food and that was in June when he first started at the facility. DD G also stated that he didn't hear anything from Resident Council about the food or receive concerns forms from the meeting. DD G reported that he has a Food Committee meeting monthly after Resident Council and at those meetings the residents typically don't give him any information to work with. When discussing that the residents at resident council stated, the food is horrible and they don't get what they order, DD G mentioned that he would need more details from the residents to fix their concerns.

Based on interview and record review, the facility failed to complete accurate assessments for 1 of 16 residents (R#75) reviewed for assessments, resulting in an inaccurate reflection of the resident's status and the potential for impaired medical, functional, and psychosocial problems due to unidentified needs. Findings include: Resident #75: Review of a Face Sheet revealed Resident #75 was a male with pertinent diagnoses which included diabetes, gout (a painful inflammatory arthritis from uric acid crystals in joints), kidney disease stage 4 (severe loss of kidney function, the kidneys only filter 15-29% if waste), chronic lymphedema (swelling from lymph fluid buildup, caused by damaged lymph nodes, leading to heaviness, tightness, and limited movement) RLE (Right Lower Extremity), high blood pressure, deep vein thrombosis (a serious condition where a blood clot forms in a deep vein), diabetes, rheumatoid arthritis (a chronic autoimmune disease where the immune system attacks joint linings, causing pain, swelling, and stiffness and can lead to systemic issues affecting the heart lungs and eyes). Review of the medical record revealed, Resident #75 had been originally admitted to the facility 7/25/2024 which would not qualify the resident as a new admission to the facility despite not appearing on the MDS data submitted by the facility prior to the survey start date. Review of Minimum Data Set (MDS) Assessments for Resident #75 revealed, Resident #75 had discharged from the facility with the expectation to return on 10/31/25 and the assessment was rejected by Centers for Medicare and Medicaid (CMS). In an interview on 12/17/2025 at 9:43 AM, MDS Nurse H reported he received a validation report which indicated the outcome of the submitted assessments. MDS Nurse H reported that the corporate MDS Nurse was capable of submitting a transfer file for the assessment as they have that capability. MDS Nurse H reported the corporate MDS Nurse had informed him of the rejection of the submission of the assessment for Resident #75 and he had forgotten to follow up on determining why and correcting it. MDS Nurse H reported he was unsure why the assessment had been rejected and proceeded to review the assessment. MDS Nurse H reported most of the information was automatically filled in for completion. MDS Nurse H reviewed the validation report for the submission, and it did show as rejected, he proceeded to open the assessment and explained the items were automatically filled in. Upon review of the report, MDS Nurse H was able to determine the cause of the rejection was the re-entry admission date kept his original admission date, and he had to physically change the date to the correct date. MDS Nurse H reported Resident #75 had managed care for insurance and the 5 Day Entry assessment was considered a place holder which indicated his re-entry date but was not required by CMS due to his insurance and therefore was not submitted but only completed. The RAI Manual revealed on page 1-7, .The RAI process has multiple regulatory requirements .and require that the assessment accurately reflects the resident's status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts . and on page AZ-6, .The importance of accurately completing and submitting the MDS cannot be over-emphasized. The MDS is the basis for: the development of an individualized care plan the Medicare Prospective Payment System, Medicaid reimbursement programs, quality monitoring activities, such as the quality measure reports, the data-driven survey and certification process, the quality measures used for public reporting, research and policy development and on page Z-8, .Federal regulation requires the RN assessment coordinator to sign and thereby certify that the assessment is complete .

This citation pertains to intake: MI00151221 Based on observation, interview, and record review the facility failed to ensure the safety and prevent an elopement of 1 (Resident #1) of 2 residents who were assessed to be at risk for elopement, resulting in an Immediate Jeopardy when Resident #1 left the premises alone, unbeknownst to staff, and was later observed (by a staff member who happened to drive by) walking along the road on 2/28/25, and was returned to the facility at approximately 3:30 pm. The elopement placed Resident #1 at risk serious harm, serious injury, and/or death. Findings include: The facility failed to ensure the safety and prevent an elopement of Resident #1 who left the premises unbeknownst to staff and was observed walking alone along the road by a staff member on 2/28/25, placing Resident #1 at risk for and resulted in the likelihood for serious harm, injury, and/or death. Nursing Home Administrator A was notified of the Immediate Jeopardy on 6/17/25 at 1:05 pm. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 2/28/25, and the deficient practice corrected, on 3/4/25, prior to the start of the survey and was therefore past noncompliance. Review of an Facesheet revealed Resident #1 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: unspecified dementia, unspecified mood disorder, unsteadiness on feet, and a need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 1/14/2025 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #1 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment). At facility entrance on 6/17/25 at 7:35 am, signage was observed posted on the window next to the front entrance door indicating that residents should not be let out of the building, and to alert staff if a resident is trying to exit the building, and to ensure that the door is closed all of the way after you exit the building. On 6/17/25 at 8:00 am, signage was observed posted on the window next to an emergency exit door near the chapel indicating that residents should not be let out of the building, and to alert staff if a resident is trying to exit the building, and to ensure that the door is closed all of the way after you exit the building. On 6/17/25 at 8:03 am, signage was observed posted on the window next to the front entrance door indicating that visitors attempting to exit the building needed staff assistance to open the door and to not push on the door unless it was an emergency. Medical Records (MR) W was observed approaching the front entrance door to enter a code and allowed someone (a visitor) into the building after the visitor pulled on the door from the outside and activated the alarm. In an interview on 6/17/25 at 9:13 am Nursing Home Administrator (NHA) A provided surveyor with an investigation report, and reported Resident #1 did elope from the building on 2/28/25. NHA A reported Resident #1 was last seen on 2/28/25 by an employee of the activity department at approximately 1:45 pm when they returned to the facility following an outing, and that Resident #1 was last seen approximately 15 minutes before being found outside by his assigned CNA (certified nursing assistant) J. In an interview on 6/17/25 at 10:18 am, Business Office Manager (BOM) F reported she left the facility in her car on the afternoon of 2/28/25, and when she exited the facility driveway onto the road, she observed Resident #1 walking alone along the road. BOM F reported she stopped, asked Resident #1 what he was doing to which he replied, going to get cigarettes BOM F assisted him into her car and drove to the front entrance and escorted Resident #1 back into the building approximately 3:30 pm. Review of Care Plan for Resident #1 revealed .Problem start dated 6/20/2023 behavioral symptoms at risk for elopement from facility r/t Dx (related to diagnosis of) dementia . Resident #1 engaged alarm at exit door in corridor stating he wanted to leave facility for cigarettes, Resident #1 makes statements that he feels like his family forgot about him and wants to get back to North Carolina . goal Resident will not leave building unattended with a target date of 4/23/25 .approach (interventions) . alarms placed on resident's door for safety (start date 3/14/25), elopement assessment quarterly and PRN (as needed), provide conversation/distraction PRN offer snack/drink, offer music, movie, magazine/book, etc. resident to be in elopement book with photo/information .seek feeling/reason behind resident's actions .when necessary reinforce reason for not leaving the facility without supervision .when resident is pacing/wandering exit seeking, assess for and attempt to provide measure to meet basic needs (hunger, thirst, pain, toileting) . all with a start date of 6/20/23. Review of Elopement Risk Assessment for Resident #1 with a completion date of 8/06/2024 at 3:59 am revealed .1. is the resident physically capable of eloping out of the facility by walking or using an assistive device such as a wheelchair? Answer Yes . 2. Does the resident have a history of wandering or elopement? Answer Yes . 4. Does the resident search for spouse of family? Answer Yes . if the answer to any of the questions 2-7 is yes, the IDT (interdisciplinary team) must implement the Elopement Protocol . Review of Investigation authored and provided by NHA A on 6/17/25 revealed .at approximately 3:30 pm Resident #1 was observed by BOM F walking down the street. The BOM F was going to the bank. Resident #1 was wearing long pants, long sleeved shirt, and a winter jacket. Resident #1 is independent and ambulatory with a cane. Resident #1 was immediately assisted into BOM F's car and was brought back to the facility. Resident #1 hands were not cold .the weather at the time Resident #1 was brought back inside was 42 degrees Fahrenheit .Resident #1 was last seen by CENA (CNA) approximately 15 minutes before he was found outside .Resident recently started to have the ideation of smoking and does not remember that the facility stores his cigarettes in a lock box .Resident was identified as an elopement risk on 11/18/2024, the elopement protocol was implemented, and the resident was identified in the elopement book . Review of Investigation Statement dated 2/28/25 revealed Certified Nursing Assistant (CNA) J was the assigned CNA to Resident #1 when he eloped from the building. CNA J reports that he last seen the resident approximately 15 minutes before he was found outside, and CNA J was immediately assigned to 1:1 supervision of Resident #1 when he was returned to the unit. Repeated attempts to contact CNA J were unsuccessful. No contact was made with CNA J by the time of survey exit. In an interview on 6/17/25 at 10:44 am Licensed Practical Nurse (LPN) S reported Resident #1's room was directly across the hall from the nurse's station and that Resident #1 loved to walk to the door and look out at the parking lot. LPN S stated he frequently looked out the window at the cars in the parking lot. LPN S reported that Resident #1 did push on the doors from time to time setting off the alarms. LPN S reported Resident #1 got out of the building, and no one knew he was missing, he was found and brought back. On 6/17/25 from 10:45 am to 11:00 am this surveyor walked the facility property, along the roadway where Resident #1 was located by staff on 2/28/25. This surveyor observed that directly in front of the facility, along the roadway there was no sidewalk, the sidewalk was present across the street only. The road was a two-lane divided highway with a turn lane (total of 3 lanes) with a speed limit of 35 MPH (miles per hour). In an interview on 6/17/25 at 12:07 pm, Activities Assistant (AA) D reported he didn't know anything about Resident #1 getting out of the building. AA D reported Resident #1 had been on the activity department outing for lunch on 2/28/25. AA D reported he had accompanied Resident #1 back to his room when they returned from the outing because he (Resident #1) doesn't remember how to get there (to his room). AA D reported he left Resident #1 in his room at about 1:30 pm that day. AA D reported that Resident #1 was amazed by white cars and spent significant time looking out the window at white cars. AA D reported that Resident #1 would drift off to get a better look at a white car, and that Resident #1 was known to slip away and walk down the street when on an outing. AA D reported Resident #1 would be fascinated by things and would follow his interest. In an interview on 6/17/25 at 12:43 pm, CNA I reported that Resident #1 would come out of his room to check the doors. CNA I reported that staff referred to Resident #1 as our security and he would walk to the doors, look outside, push on the doors and when the alarm sounded, he would back away. When queried if Resident #1 did that often, CNA I stated Yes, he always did that, it was his routine to check the doors. When further queried about why Resident #1 would check the doors CNA I stated he was trying to get out. In an interview on 6/17/25 at 1:27 pm, Activities Director (AD) E reported she would take Resident #1 on walks in the parking lot when he wanted to look at the white cars. AD E reported it was important to monitor resident's whereabouts if they were elopement risks, and she would encourage activity participation to keep an eye on residents who were elopement risks. In an interview on 6/17/25 at 1:37 pm, CNA H reported that Resident #1 was on normal every 2 hour checks before he eloped from the building and was placed on 15-minute checks after he eloped. In an interview on 6/17/25 at 1:54 pm CNA K and CNA M reported that Resident #1 enjoyed checking the doors and looking out the window at white cars in the parking lot. CNA M reported Resident #1 looked at white cars in the parking lot almost every day. In an interview on 6/17/25 at 2:25 pm Housekeeping Supervisor (HS) R reported that Resident #1 looked out the window at the cars in the parking lot frequently. In an interview on 6/17/25 at 2:30 pm, CNA O reported that Resident #1 was obsessed with white cars and loved to look out the window. In an interview on 6/18/25 at 9:35 am, Maintenance Supervisor (MS) U reported he checks the door alarms to every door in the building daily. There was no inoperable door alarm when Resident #1 eloped from the building. MS U reported that Resident #1 would stand at the window at the end of the west hall facing the parking lot and talk about all of the white cars in the parking lot. MS U reported that Resident #1 would push on the door and set off the alarm and then when the alarm sounded, he would back away from the door. In an interview on 6/18/25 at 10:26 am, Social Service Director (SSD) X reported Resident #1 was fascinated with white vehicles and cigarettes. SSD X reported she recalled that Resident #1 was trying to get to town to get cigarettes when he eloped from the building. SSD X reported that Resident #1 would go through spurts when he would want to leave the building. SSD X reported Resident #1 had a pattern of wanting to look out the window at the white cars and was fixated on cigarettes. SSD X reported that Resident #1 would go outside supervised with AD E to smoke. SSD X reported that Resident #1's guardian had granted privileges for Resident #1 to go outside to smoke to curtail his behaviors of exit seeking. SSD X reported that Resident #1 was quiet, but his mood would change, and Resident #1 would ask where home was, to go outside to smoke, and to see the white cars in the parking lot; SSD X reported staff would know his behavior was ramping up and Resident #1 would need to be watched closely. SSD X reported when Resident #1 verbalized wanting to go out and look at cars or wanting cigarettes he was placed on 15- or 30-minute checks. When queried if Resident #1's change in behavior towards leaving the building, fixation on white cars and cigarettes, pattern of looking out the windows, specifically asking where home was and to go outside to smoke, and the ramping up of exit seeking behaviors was noted, documented, monitored, or communicated with all staff, SSD X stated I don't know if we captured it in his record. When further queried, SSD X reviewed Resident #1's medical record and reported she did not locate any documentation that Resident #1 had increased behaviors or had been placed on 15- or 30- minute checks in the six months prior to his elopement from the building. SSD X reported the IDT team discussed Resident #1's elevated mood in morning meeting and the nursing staff was notified of Resident #1's elevated mood in a text message. When queried what information the nursing staff text message contained, SSD X stated I don't know about that, because I am not included. SSD X reported the communication to staff for increased supervision for Resident #1 was verbal. SSD X reported when a resident has specific behaviors, those behaviors should be documented, and the monitoring of behavior occurrences should be documented in the resident records. SSD X reviewed Resident #1's record and reported there was no documentation of monitoring specific behaviors and no indication that Resident #1 needed increased supervision until 2/28/25 when he was found alone outside of the building and was placed on one-to-one supervision. Review of Resident #1's medical record revealed no noted specific behaviors that Resident #1 displayed, nor any behavior monitoring. Requested behavior logs from NHA via email on 6/18/25 at 11:58 am. On 6/18/25 at 1:16 pm NHA A replied in an e-mail to the request for Resident #1's behavior logs any changed in behavior from baseline would be noted in a progress note. No behavior logs for Resident #1 were provide by the facility by the time of exit. In an interview on 6/18/25 at 1:25 pm, Unit Manager/Licensed Practical Nurse (UM/LPN) Z reported she did not have anything to do with behavior monitoring. UM/LPN Z reported behavior monitoring was not specific for residents; it was a standing order that was triggered at admission. In an interview on 6/18/25 at 1:32 pm Director of Nursing (DON) B reported every resident in the building was on behavior monitoring and it was a blanket order that was standardized, nothing was specific or individualized to residents. DON B reported that Resident #1 did not have specific interventions in his care plan related to his specific behaviors. DON B stated we don't monitor behaviors, no one was told to monitor Resident #1 as his behaviors escalated. DON B reported Resident #1 liked white cars and was fixated on cigarettes. At 1:45 pm on 6/18/25, during the interview with DON B; NHA A entered the office, joined the interview and stated, Resident #1 used to sit at the window and watch cars, specifically, white cars. When DON B was queried, if Resident #1's fixation on white cars or cigarettes was noted anywhere for staff to reference, DON B stated No paused and then stated Oh, I see where this is going. The Immediate Jeopardy began on 2/28/25 was removed on 2/28/25 when the facility took the following actions to remove the immediacy: 1) Resident #1 was assessed immediately upon being brought into the facility. It was documented as follows: progress note for DON B on 2/28/25 at 5:34 pm, elopement risk assessment on 2/28/25 at 4:08 pm, skin assessment on 2/28/25 at 5:20 pm, pain assessment on 2/28/25 at 5:46 pm. Resident #1 demonstrated no injuries. Resident #1 did not appear to be in psychosocial distress. SSD X sent referral to nearby memory care units with guardian's permission on 3/3/25. 2) Resident #1 was immediately placed on a 1:1 on 2/25/25 at 4:08 pm. Resident #1 remained on 1:1 supervision until 3/14/25 when the 1:1 was removed for third shift only. Resident was placed on q15 (every 15) minute checks for third shift on 3/14/25. Administrator also placed alarms on Resident #1's door for safety. On 3/17/25 Resident #1 was placed on q15 minute checks for all shifts with IDT monitoring and no exit seeking behavior. 3) On 3/24/25, a nearby memory care unit accepted Resident #1 and he was discharged from the facility at approximately 10:05 am. 4) Facility completed elopement assessments on all other residents on 2/28/25 with no new residents identified at the time as a risk. 5) Administrator, DON, and Social Service Director audited elopement book for accuracy on 2/28/25 and implemented a weekly audit to ensure compliance with elopement policy and procedures. 6) Interdisciplinary team discussed elopement policy and procedures in ADHOC QAPI on 2/28/25 and monthly QAPI on 3/27/25 to ensure elopement policy and procedures were in place and effective. 7) Signage posted on all EXIT doors on 2/28/25 by administrator at approximately 5 pm to indicate to all visitors to ensure no resident exit the building and to ensure the door is closed completely before leaving the area. 8) All residents were reassessed on 2/28/25 and no additional residents were identified as elopement risks. 9) All door alarms were checked and functioning properly on 2/28/25 at approximately 5 pm by the Maintenance Director. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included 1) All staff were educated on the elopement policy and procedure, elopement identification and additional resources to prevent elopements on 2/28/25. The current staff at the facility were educated immediately in person by the administrator. Administrator posted to this education to all staff on the Group Me application (an application that allows for mass messages to be sent and received on phones and/or electronic devices to many different recipients at one time) on 2/28/25 at 7:30 pm. An education binder with all education material was also placed at the EAST nurses' station. As new staff is hired, they will continue to be educated on these policies and procedures. 2) The facility's plan for when a resident is exit seeking is to notify their immediate supervisor who will then notify the DON and/or Administrator. Staff were educated this is something to report immediately. Staff was educated on the possible reasons for elopement and the possible strategies for avoiding such behavior. Staff was also educated on the expectations of being assigned the person doing the 1:1 supervision. 3) Periodically conduct elopement drills for all staff to ensure competency and effectiveness of all staff education on elopements. Quarterly elopement drills will be conducted. The first drill occurred on 4/1/25. 4) Weekly audits of the elopement book starting on 2/28/25 to monitor any current or new identified elopement risk residents. 5) Continued daily door alarm checks to ensure the door alarms are functioning properly to prevent further elopements. 6) Initial social service assessment and quarterly psychosocial assessments completed to ensure any newly identified elopement risk residents have effective interventions in place. 7) Door codes will continue to be changed monthly. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake MI 216 Based on observation, interview, and record review, the facility failed to ensure a safe environment and implement safety interventions for 1 (R51) of 23 residents reviewed for accidents and hazards, resulting in a fall with a cervical spine fracture and facial laceration, and the increased potential for further falls with injuries. Findings include: According to www.ncbi.nlm.nih.gov, The first vertebra (C1), also called the atlas, is a ring-shaped bone that begins at the base of your skull. The atlas holds the head upright. A C1 through C2 vertebrae injury is considered to be the most severe of all spinal cord injuries as it can lead to full paralysis-but is most often fatal. According to the Minimum Data Set (MDS) dated [DATE], R51 scored 5/15 on her BIMS (Brief Interview Mental Status). R51 had clear speech usually making her needs known and understanding others, missing part or the intent of the message. Required extensive physical assistance of one person for bed mobility. Totally dependent on two-plus persons for transfers. Movement on unit required total dependence on one-persons physical assistance, as did toileting. R51 required limited assistance of one-person for eating. Resident's balance during transition of seated to standing was unsteady and only able to stabilize with human assistance. There was no impairment in her arms but did have an impairment in her right leg. Always incontinent of urine and bowel. Received scheduled pain medication management without receiving non-medication management. It was indicated the resident had not had any falls prior to 9/27/2022. Diagnoses included Alzheimer's disease, fracture to right hip, malnutrition, and chronic obstructive pulmonary disease. Review of R51's Care Plan At Risk for Falls problem start date 4/23/2021 reported the resident was at risk and subsequent injury related to and including right hip fracture, Alzheimer's disease, dementia, non-ambulatory, limited mobility and weakness. The goal was to prevent or reduce the occurrence of falls and subsequent injury related to falls. Interventions to meet the goal prior to survey entrance included bed in lowest position (10/31/2021), call light to be with(in) reach (4/23/ ), instruct and remind to use call light to ask for assistance (4/23/2021, keep paths to bathroom and hallway clutter free (4/23/2021), wear non skid shoes/non skid socks while transferring (4/23/2021). Review of R51's Care Plan Diagnosis of [CONDITION(S)] with potential for fracture problem start date 10/10/2021 reported the resident had a history or [CONDITION(S)] with potential for fracture. The goal was to remain free from injuries. Interventions to meet this goal was to keep bed in low position with brakes locked (10/10/2021), keep call light within reach (10/10/2021, provide environment free of clutter (10/10/2021), and approved proper/well maintained footwear (10/10/2021). Review of R51's Histories and Habits by behavioral services dated 10/6/2022 reported the resident had a medical history that included a displaced fracture of base of neck of right femur. R51's Mental Status Exam reported she had impaired judgment/insight/impulse control. Her musculoskeletal range-of-motion (ROM)and strength and tone was limited. Review of R51's Baseline Care Plan reported Recent fall resulting in right hip pain. In weakened state .Fall/Safety Risk: recent fall with fracture. Encourage to use call light . Review of R51's Progress Note 10/27/2022 5:36 PM reported resident was found on floor with an open head injury that was bleeding. R51 was sent to hospital via ambulance. The hospital called the facility to report the resident sustained a c-spine fracture and a large knot on her forehead with a long laceration. Review of R51's Event Report-Safety Events-Fall Event dated 10/27/2022 reported the resident had a fall to the floor from her bed on 10/27/2022 that was discovered at 6:05 AM. When R51 was asked what she was attempting to do, she replied, I fell out of bed. I hit my head on something, now it hurts. The resident was not sure what she was doing before she fell . There were no witnesses to the fall, but when found she was laying on the floor with blood around her head. The resident was observed to have pain in her head with a c-spine (cervical) fracture and laceration (large cut) on her forehead resulting from the fall. Her pupil size was 2 mm with sluggish response. Her mood was agitated and restless. Risk factors included the resident was without shoes/footwear (gripper socks). R51's emergency was not contacted because the nurse forgot to contact family. The nurse's summary reported she was getting report from the prior shift when the CNA came to her and said she needed help fast. Upon walking into the room the nurse witnessed the resident laying on the floor and had a lot of blood around her head. When the nurse assessed R51's external injuries, she discovered an open area on the head. The resident was transferred to the hospital for further evaluation. The hospital called the facility and reported R51 had sustained a c-spine fracture and a large knot on her forehead with a long laceration. Review of R51's Hospital Discharge Summary 10/27/2022 reported a CT Neck Angiogram final result indicated an acute comminuted fracture of C1. Review of R51's Hospital After Visit Summary 10/27/2022 reported the resident's primary diagnosis a closed stable burst fracture of first cervical vertebra secondary to an unwitnessed fall at nursing home hitting her head on a nightstand. Resident was on the ground for approximately 20 minutes before being found. Resident was placed in an Aspen collar and laceration repaired before being transferred a larger acute care hospital. On exam, R51 was alert, appeared frail, was forgetful, and confused. The resident had not bee ambulatory for a year and had been in a wheelchair. Left upper extremity with chronic contracture. Past medical history: High risk for falls. CT Brain without Contrast large scalp hematoma in the frontal region extending to the left of midline with a small amount of air density in the scalp consistent with a laceration. CT Spine Cervical without contrast resulting in an acute comminuted fracture involving C1. Review of R51's Progress Note 10/28/2022 7:18 PM the resident arrived back to facility via stretcher to room with a large hematoma on frontal part of face and down cheek. Resident had a bruise around right eye and right knee redness. Also pink in peri area. All safety measures in place. During an observation on 10/30/2022 at 1:33 PM R51 was supine in bed wearing a cervical collar that was pushing up on face and ears. Her bed was not in the lowest position. R51 not wearing gripper socks. There was no fall mattress next to her bed on either side. The bed was on an angle with the left side away from the wall leaving enough room for an adult to stand. During an interview on 10/31/2022 at 10:12 AM Registered Nurse (RN) X stated, (R51) cannot move around very much. She needs help to do just about everything. I have no idea how she could have fallen out of her bed. During an observation on 10/31/2022 at 10:14 AM R51 was in bed with the HOB (head-of-bed) higher than 30 degrees making her body form a C to her left. She was moaning in pain. There was no pillow or wedge to support or position the resident. Resident was wearing a cervical collar that was pushing up on her ears causing them to turn red. The bed was not in the lowest position positioned at an angle to the right leaving a space an adult could stand to the left of resident between the bed and wall. A mattress was on the floor next to right side of resident's bed. Her call light was on the floor under her bed. RN X entered the room to perform care. RN X moved the mattress away from side of the bed and moved the call light from under her feet with her foot. RN X did not place the call light within the resident's reach when she left the room to find assistance. During an interview on 10/31/2022 at 10:20 AM RN X. stated, I know (R51). I was the nurse that was summoned when she fell . I had just walked in for the day, it was around 6 AM, and had not even gotten report yet. The aide (Certified Nursing Assistant (CNA J) found the resident first. I followed the CNA into the room. (R51) was on the floor face first in a pool of blood. I could not believe how much blood there was. I did not move her. I had someone get me a towel and I placed it under her face, so she was not face down in the blood. I tried to feel under her face to see where the blood was coming from. I did not call her family. I'm new here. I know from previous jobs I should have called them, but so much was going on I could not remember to do everything. I was on my own to get paperwork around and then get right back on the floor to start passing medications to other residents. During an interview on 10/31/2022 at 10:20 AM CNA J stated, When (R51) fell , I had just come in the door to start my shift, it was around 6 AM. I did not even have my coat off. I saw the call light was on for (R51's) room and I went in to answer it. (R51) was lying face first in a pool of blood. She was awake and wanted to get up off the floor. I ran out in the hall to call for help. (RN X) came in to help. She was just starting her sift and had not gotten report yet. We got a towel and put it under the resident's face, so she wasn't lying in all that blood. It looked like she had got shot in the face with a gun. It was horrible. The bed was not in a low position, it was about up to my waist and I'm about 5'3. The wheelchair was on the other side of the room, not next to the bed. (R51) has to have just about everything done for her. I feed her, I move her, I dress her, I change her brief. She has no bed sores. I try to take good care of her. I do not know where the night shift staff was when she fell . There was no staff in the hall when I went to go look for help. The roommate (R54) told me she had initiated the call light when (R51) fell and it was about 30 minutes after she put on the call light because she had a program on and it ended by the time I got there. She said she heard her fall. That (R51) was not in her wheelchair. She could not remember the last time staff was in but knew it had been a while since staff had been in. She said she did not know how (R51) could have fallen because she needed help for everything. During an interview on 10/31/2022 at 10:30 AM (R54) stated, I remember when my roommate (R51) fell . I heard her fall. The curtain was not all the way open between us but I could see her wheelchair over by the wall and she was not in it. I turned on the call light and it took about 30 minutes for help to come. My television was on, and the program ended by the time (CNA J) came in. There was so much blood. It was horrible. Just horrible. I try to look out for her. She can hardly do anything for herself. They (referring to the facility) do not have enough staff and they keep admitting people and not enough staff to take care of us. During an interview on 10/31/22 at 3:09 PM R51 was lying on her back in bed wearing a cervical collar with eyes closed. Her call light was on the floor under the fall mattress to the right side of her bed. During an observation and interview on 11/1/2022 at 9:45 AM R 51 was supine in bed wearing a cervical collar. The collar was over her right ear causing it to turn red. A blue wedge was under her left shoulder. A mattress was on the floor to resident's left side. The right side of the bed was angled away from the wall leaving a gap large enough for an adult to stand with no mattress on floor. At the foot of the bed was a bedside table with a Styrofoam drinking cup partially filled with water out of reach of the resident. A scabbed over hematoma protruding from the resident's left forehead had yellowing bruise around it. R51's face from left to right and from top of forehead to below nose had yellow bruising. Around the resident's eyes was purple bruising. R51 stated, I do not know how I fell out of bed. Right now, I am hurting and do not feel very good. why do I have this collar on and it is hurting my right ear. I cannot move around on my own. I need help to do things. I hurt all over this morning. During an interview 11/01/22 at 12:08 PM Family Member SS stated, I was told she (referring to R51) was found face down on the floor. I was told she was being sent to the hospital. Then they called and they said they were sending her to another hospital. I figured she would be having surgery. The facility has not told be about follow-up appointments. (R51) gained the ability to feed herself about mid-summer. She was not able to get out of bed on her own. She was not able to walk by herself. This is the 3rd time she has fallen. She fell at another facility and broke her arm, the first time, the second time she fell and broke her hip. That facility would not take her back. That is why she is at the current facility. During an interview on 11/01/22 at 2:54 PM CNA FF stated, I was working on the night shift on October 26th and into the morning of October 27th (2022). I was assigned to the 100 Hall as my main assignment and part of the 200 Hall including (R51). There were four aides that night. There was another aide that had the 300 Hall and the other part of the 200 Hall. That aide stayed on her main hall which was the 300 hall. She mostly stayed on the 300 hall. I mostly stayed on the 100 Hall. If call lights went off on the 200 Hall I would answer mine. I had rooms 200-206. When call lights go off for the 200 hall you only see the light beeping at the control panel behind the nursing station at the front lobby. That morning I gave (R51) care about 4:30 AM 4:35 AM. I washed her up and changed her, did all my care on her then went to her roommate and assisted her with care. When I left their room both residents were in their beds. I then went to room 204 to do AM care on those two residents. I walked past (R51's) room around 5:00-5:05 AM to go back down to the 100 Hall. (R51) and her roommates were in their beds. It is very busy that time of morning. I never went back over there (on the 200 Hall) after I finished up over there about 5-5:15 AM. I have never seen (R51) do anything for herself. When I go to do care for her, I have to move her. She has one arm that is contracted, and she cannot do anything with it. Her right arm is her good arm. She can move her legs a little bit, but they are contracted. She cannot move around in bed. She cannot reposition herself. That morning she did not have a mattress on the floor next to her bed. I did not let her bed all the way down that night. It was about at my waist height. I am 5'3. I was at the front lobby desk from 5:30 AM to 6:00 AM waiting to give report to the oncoming CNA. I left that day at 6:00 AM. I never saw (R51's) call light come on. The last time I looked in at (R51) was around 5:00-5:05 AM that morning. During an interview on 11/2/2022 at 8:25 AM CNA J stated, On October 27th (2022) when I found (R51) on the floor, she was on the floor parallel to her bed with her right arm above her head. There was so much blood. I thought she was dead. Her wheelchair was on the other side of the room. It is not left next to her bed. Her bed was not in the lowest position. During an interview on 11/2/2022 at 10:00 AM Director of Nursing (DON) B stated, I am still working on (R51's) fall investigation. I talked with therapy, and they said (R51) can use her right leg and arm. I know from the interviews I did for the fall investigation, when her fall occurred, her bed was not in the lowest position. During an interview on 11/2/2022 at 10:06 AM, Nursing Home Administrator (NHA) A stated, The transfer policy was not completed for R51 on 10/27/2022. During an observation on 11/2/2022 at 11:10 AM R51 was in her bed with eyes open. She was leaning to right side with her left leg bent up at the knee making her lean to the right. During an interview on 11/2/2022 at 11:25 AM Rehab Director HH stated, (R51) has a left side neglect. She can move her left leg but cannot really use her left hand. She can move both of her legs and use her right arm. I had her up walking before her fall.

This citation pertains to Intake # MI 728 & # MI 892. Based on observation, interview, and record review, the facility failed to prevent a resident-to-resident incident involving sexual abuse in 2 of 13 residents (Resident #6 & #7) reviewed for abuse, resulting in an Immediate Jeopardy when on 5/21/21 at approximately 5:45 p.m., Resident #7 (a cognitively impaired female) was found in Resident #6's bed (a cognitively intact male). Both residents were noted to be naked from the waist down. This deficient practice placed female residents at risk for serious physical and psychosocial harm. Findings include: On 6/2/22 at 5:40 p.m., Administrator A was notified of an Immediate Jeopardy that began on 5/21/22 when Resident #7 (a cognitively impaired female) was found in Resident #6's bed (a cognitively intact male). Both residents were noted to be naked from the waist down. On 6/7/22, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1) Action for residents involved: -Motion detection alarm placed on Resident #6's bedroom door to alert staff to Resident #6 exiting/entering his room and other potential residents entering Resident #6's room on 6/2/22. -Staff will maintain Resident #6 while out of his room on visual supervision and will be alerted by the motion detection alarm on 6/2/22. -Resident #6 and Resident #7 will remain on 15 min checks 6/2/22. -Resident #6 continues to have stop sign across bedroom door frame 6/2/22. -Resident #6 and #7 Care Plans have been reviewed and revised on 6/2/22 & 6/3/22. 2) Identification of residents - Residents in the facility are identified as being at potential risk. -Facility leadership interviewed 32 alert and oriented residents with a BIMS score of 8 or higher on 5/31/22 regarding staff treatment and overall feeling of safety in facility in regards to residents and staff. Findings: 32 interviewed residents expressed that they felt safe in the facility. -Facility leadership reviewed 85 skin assessments and 29 incident reports on 6/2/22 to identify potential abuse situations that require investigation and possible reporting to the State Agency. Findings: Review of 85 skin assessments within the past 2 weeks and review of 29 incidents reports from the past 30 days did not reveal any concerns. -Facility leadership reviewed 2 residents that exhibit inappropriate sexual behaviors on 6/3/2022. Findings: 2 Care Plans reviewed and updated with interventions. 3) The policy Abuse Prevention Program was reviewed on 6/3/2022 with no revision required at that time. The policy Elder Justice Act was reviewed on 6/3/2022 with no revision required at that time. The educational document Resident Abuse Prevention and Reporting: Protecting a Vulnerable Population was reviewed on 6/3/2022 with no revision required at that time. 4) Measures to ensure deficient practice will not recur - The facility Administrator and Director of Nursing was educated on 6/2/22 by the Regional Director of Operations on identifying situations that could potentially meet the definitions of abuse. Education will include review of the facility policy, specifically: -Types of abuse, including neglect -Possible indicators of abuse/neglect -Identifying abuse/neglect 5) As of 6/3/22, 67 out of 82 facility staff have been educated on the facility abuse policy and the addition of the motion sensor alarm on Resident #6's bedroom door. No staff will be allowed to work before education is complete. 6) Monitoring of corrective actions to ensure deficient practice will not recur - Beginning 6/3/22: -The facility IDT (Interdisciplinary Team) will review 24-hour reports, skin assessments, and grievance forms daily during morning meeting Monday through Friday to identify potential situations requiring investigation and reporting. -The facility IDT will review potential situations requiring investigation to determine what interventions are necessary and/or effectiveness of interventions to prevent abuse from recurring during daily stand-down meeting Monday through Friday. -The facility Social Services representative will interview 5 residents per week on staff treatment and on potential inappropriate behaviors/conversation/statements by other residents to identify potential situations requiring investigation and reporting. -The facility Director of Nursing will audit skin assessments and progress notes daily to identify potential situations requiring investigation and reporting to the state agency. 7) Any identified concerns will be reported immediately to the Administrator of the facility. If a situation meets the definition of abuse or neglect the administrator will be responsible to ensure reporting to the State Agency. The administrator will also be responsible to ensure facility policy is followed and a thorough investigation is completed. Although the immediate jeopardy was removed on 6/3/22, the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency and all education had not yet been completed. Resident #6 Review of a Face Sheet revealed Resident #6 was a male, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 3/24/22, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated he was cognitively intact. Review of a Care Plan for Resident #6, accessed 6/1/22, revealed the problem .Resident displays behavioral symptoms by making inappropriate sexual statements/comments to residents and staff . with a start date of 3/1/22, and interventions which included .Assess whether the behavior endangers the resident and/or others. Intervene if necessary .Observe for changes in behavior, document, and report to doctor .Obtain a psych consult/psychosocial therapy as needed .When resident becomes verbally abusive, keep distance between resident and others (e.g., staff, other residents, visitors) .When resident becomes verbally abusive, move resident to a quiet, calm environment . all with a start date of 3/1/22. Noted all interventions in Resident #6's Care Plan for this Problem had a start date of 3/1/22, with the exception of the intervention .Stop sign is put in front of room to discourage other residents from wandering into his room . which had a start date of 5/27/22. Review of a Progress Note for Resident #6, dated 3/22/22 at 9:01 p.m., revealed .Resident is alert and oriented able to make needs known to staff members. Resident is (asking) questions of female residents. The other (resident states) no and resident goes back to his room. Resident is resting in his room at this time . Review of a Progress Note for Resident #6, dated 3/31/22 at 9:38 p.m., revealed .Resident is up and about making rude comments to female resident and staff members. When talking to the resident he states he needs to find a way to beat his meat. Resident is escorted out of her room. Resident returns to females room and sets there with her (permission) but he states he can't wait to get her in bed. Resident is in his room and tells aide he is good at pushing (slang for breast) buttons Aide upset came out and requested another person to be in room while she provided care. Resident did not say anything else with two staff members in room . Review of a Progress Note for Resident #14, dated 3/31/22 at 9:35 p.m., revealed .Resident sitting in room a male resident (Resident #6) comes up and asks a question and aides takes him out of her room when asked if it bothered her she says no. Male resident comes back into room sitting and talking to her asked female resident if she wanted us to take him out of her room she says no. Male resident states he can't wait to get her in bed. Female is confused thinks she is in a motel and has trouble telling where her room is. Resident is oriented times one maybe two . Review of a Progress Note for Resident #6, dated 4/2/22 at 8:39 p.m., revealed .Resident up in (dining) room communicating with female resident. Resident is talking about various topics his significant other and what he wants to do with her. Talking about sex not being vulgar but a little inappropriate. Resident he is speaking to keeps reminding him that its not appropriate to talk about the subject of sex. Resident is willing to change subject but goes back to it . Review of a Progress Note for Resident #14, dated 4/2/22 at 8:42 p.m., revealed .Resident in (dining) room listening to another resident (Resident #6) does not get upset with the topic he is talking about but does mention that it is not appropriate and he should stop talking about sex. When asked resident states she is ok with him and is not upset . Review of a Decision Making Capacity Determination form revealed Resident #14 was evaluated by two physicians and determined to lack the capacity to make reasonable medical decisions on 4/12/22 and 4/14/22. Review of a Social Services Progress Note for Resident #14, dated 4/18/22 at 12:22 p.m., revealed .Resident was evaluated by 2 Physicians, and it was determined that she lacked the capacity to make reasoned medical decisions. Family has been notified and will move forward with petitioning the court for guardianship . Review of a Care Plan for Resident #6, accessed 6/1/22, revealed no new interventions were added after Resident #6's documented sexual behaviors on 3/22/22, 3/31/22, and 4/2/22. Review of a Social Services Progress Note for Resident #6, dated 5/20/22 at 2:36 p.m., revealed .Resident is alert and oriented. Resident has been making inappropriate comments to a staff member. Writer educated resident on what is appropriate and inappropriate conversation. Resident verbalized an understanding and stated he would be more careful with his comments. Staff will continue to observe and report any changes in mood and/or behaviors. There are no further issues or concerns at this time . Review of a Social Services Progress Note for Resident #6, dated 5/27/22 at 3:54 p.m., revealed .Writer, Administrator and DON (Director of Nursing) spoke with resident regarding what is appropriate behavior. Resident was educated on facility's expectation. Resident verbalized an understanding. Writer asked resident if he would be more comfortable in an AFC (Adult Foster Care) setting. Resident stated he's happy in the facility and understands what is expected. There's no further issues or concerns at this time. Staff will continue to observe and report any changes in mood and/or behaviors . Review of a Progress Note for Resident #6, dated 5/29/22 at 3:31 p.m., revealed .This morning resident was having behaviors making sexual statements to a female resident. This writer and a CNA (Certified Nursing Assistant) removed this resident from the (presence) of the female resident. Social Worker was notified, DON was notified, and Administrator was notified. Administrator informed this writer to call 911 and report the behavior to them. 911 call was placed, paramedics came and picked him up and was taken to the nearest hospital. Nurse notified physician . Review of a Progress Note for Resident #6, dated 5/29/22 at 3:48 p.m., revealed .Administrator placed this resident on 15 min checks. This writer notified Nurse and CNAs of this . Resident #7 Review of a Face Sheet revealed Resident #7 was a female, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #7, with a reference date of 5/23/22, revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated severe cognitive impairment. Review of a Care Plan for Resident #7, accessed 6/2/22, revealed the problem .At risk for elopement from facility r/t (related to) her dx (diagnosis) of Dementia . with interventions which included .Resident to be on designated timed checks . both with a start date of 5/27/21. Review of a Social Services Progress Note for Resident #7, dated 5/23/22 at 11:29 a.m., revealed .Resident's elopement checks have been changed from hourly to 15 minutes d/t (due to) wandering in rooms. Resident wandered into a male's room. Guardian, DON, and (Administrator) has been notified of incident. Staff will continue to document, observe and report any changes in mood and/or behaviors . In an observation on 6/1/22 at 12:21 p.m., Resident #6 was noted in his wheelchair in his room, beside his bed. Observed Resident #6 as he ate his lunch meal independently. Noted a Velcro stop sign hanging on one side of Resident #6's door frame, not in place at this time. In an observation on 6/1/22 at 1:50 p.m., observed Resident #7 as she propelled herself independently in her wheelchair down the hallway, past Resident #6's room. No staff present in hallway at this time. Observed the Velcro stop sign on Resident #6's door frame was in place at this time. In an interview on 6/2/22 at 10:34 a.m. with Administrator A and Director of Nursing (DON) B, Administrator A reported he and DON B were first made aware of an issue with Resident #6 on 5/27/22 when the police arrived at the facility to investigate several allegations of abuse that were called in by an anonymous complainant. Administrator A stated in regard to the allegations involving Resident #6 and Resident #7 .we did get some statements from staff and we are still investigating . Administrator A reported he and DON B had a meeting with Resident #6 on 5/27/22 and .told him the police would be involved . if there were further inappropriate behaviors. Administrator A reported Resident #6 was observed on 5/29/22 .saying inappropriate things to women . and was sent to the hospital. Administrator A stated .he's a younger resident and he loves women . In an interview on 6/2/22 at 10:58 a.m., Certified Nursing Assistant (CNA) I reported .maybe two weeks ago . or .the 21st of last month . (5/21/22) she was caring for the roommate of Resident #7 and noticed Resident #7 wasn't in the room. CNA I reported she eventually found Resident #7 (female) in Resident #6's (male) room, in his bed, next to each other, and under the covers. CNA I reported when she asked Resident #6 what they were doing, he stated .Nothing yet . CNA I reported when she pulled the covers back both Resident #6's and #7's pants and briefs were down and Resident #6's penis was erect. CNA I reported she wasn't sure if there had been any intercourse. CNA I confirmed Resident #7 was confused and couldn't say what had happened and Resident #6 was not confused. CNA I reported she was interviewed by Interim Administrator X that day. Review of a Witness Statement completed by CNA I, no date, revealed .I, (CNA I) was assisting (Resident #7's) roommate when I noticed I did not see (Resident #7) in the room nor in the hallways. I came out of the room to ask a nurse of (Resident #7's) whereabouts. The nurse stated she saw (Resident #7) hanging out on the West hall with (Resident #6). I proceeded to the West hall to check on (Resident #7). (Resident #7) was not in the hallway. I then checked (Resident #6's) room, and (witnessed) (Resident #6 and Resident #7) laying in the bed together with their pants and briefs off. I asked (Resident #6) if they had done anything together. (Resident #6) (stated) Not yet. I then asked how long were they in the bed together. (Resident #6) stated About 25 minutes. Whenever I asked a question, (Resident #7) just (smiled). She appeared as if she did not understand any of my questions. I assisted with getting (Resident #7) dressed, then I wheeled her to her bedroom. I informed the nurses for (Resident #6 and Resident #7) and then called the Director of Nursing. 15 minutes after informing the designated personnel, the Administrator called me to get my statement . In an interview on 6/2/22 at 11:25 a.m., Registered Nurse (RN) R reported on 5/21/22 .one of the evening aides came down the hall and told my work partner (Agency Licensed Practical Nurse (LPN) Y) that (Resident #7) was in the bed with (Resident #6) and they had their (briefs) off . RN R reported Agency LPN Y separated the residents and contacted Interim Administrator X and DON B .to let them know what was going on and what he should do about it . RN R stated .I guess what we would normally do is keep an eye on them .We have stop signs that go across the door and sometimes we use those . RN R stated .these things happen sometimes .People sometimes in these nursing home situations don't get a hug for years on end so I don't make a big deal out of it . RN R reported that Resident #7 is cognitively impaired and often wanders into other people's rooms. In an interview on 6/2/22 at 12:23 p.m., CNA D reported he was at the nurses desk on 5/21/22 when another staff member notified Agency LPN Y that Resident #7 was in Resident #6's bed, both naked from the waist down. CNA D reported he and Agency LPN Y went down to Resident #6's room to separate the residents. CNA D reported he asked what was going on and Resident #6 replied .What does it look like? CNA D reported he and Agency LPN Y assisted Resident #7 out of Resident #6's bed, got her dressed, and redirected her out of Resident #6's room. CNA D reported staff checked on Resident #7 throughout the shift to make sure she didn't return to Resident #6's room. CNA D stated .I don't know what (Resident #6's) intentions were if we hadn't caught the situation . CNA D reported after Resident #6 and #7 were separated, Resident #6 was observed masturbating in his room. CNA D reported he was not aware of any prior incidents involving Resident #6. CNA D reported DON B was notified of the incident and Social Worker (SW) N spoke to him a few days after the incident about what happened. CNA D reported he wrote a statement after the incident and submitted a copy to management. CNA D stated .You can't just let something like this slide . Review of a Witness Statement completed by CNA D, dated 5/23/22, revealed .I had pulled (Resident #7) out of (Resident #6's) room twice. Low and behold I found out by an aide that was passing by that (Resident #6 and Resident #7) were in bed naked together. When (CNA D, CNA I, and Agency LPN Y) went down there I asked What's going on? and (Resident #6) replied What does it look like? (Agency LPN Y) inquired, we removed (Resident #7) from room . In an interview on 6/2/22 at 1:27 p.m., SW N reported she had a conversation on 5/20/22 with Resident #6 .because he was saying inappropriate things to staff . SW N reported she became aware of the incident between Resident #6 and Resident #7 around 5/25/22 or 5/26/22. SW N reported Resident #6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .It was only one lady in particular (Resident #14) . SW N reported Resident #6 and Resident #14 developed a friendship while both resided on the Rehab Hall. SW N stated .When (Resident #6) found out he was transitioning to long-term care, that's when we started having problems. (Resident #6) would say inappropriate things to (Resident #14) .Asking her if she wanted to have sex. She would say no . SW N reported Resident #6 was moved to a room on the other end of the facility, and stated (Resident #6) .doesn't spend much time with (Resident #14) now . SW N reported the Progress Notes for Resident #6 dated 3/22/22, 3/31/22, and 4/2/22 were all involving Resident #14. SW N reported Resident #7 is a wanderer and frequently requires redirection out of other resident's rooms. SW N reported Resident #6 is cognitively intact and is his own decision maker. SW N reported Resident #14 is not her own decision maker, and was recently deemed incompetent to make her own medical decisions. SW N reported in regard to the Progress Note for Resident #6, dated 5/29/22, those inappropriate statements were made to Resident #14. SW N reported Resident #6 was sent to the hospital on 5/29/22 due to these inappropriate statements/behaviors. SW N reported a referral was placed today (6/2/22) for Resident #6 to be seen by BCS (Behavioral Care Solutions). SW N reported resident behaviors are documented in the Progress Notes, which are then reviewed each day before morning meeting. SW N reported DON B was aware of the incident between Resident #6 and Resident #7 .when it happened . In an interview on 6/2/22 at 2:08 p.m., Activity Director G reported on Sunday 5/29/22, she was instructed to call 911 after she observed Resident #6 make inappropriate statements to Resident #14. Activity Director G reported Resident #6 .wasn't gone long . and when he returned was placed on 15-minute checks. Activity Director G reported Resident #14 was .more shocked than upset . by the comments, and replied .oh not today . Review of a Witness Statement completed by Activity Director G, dated 5/31/22, revealed .On Sunday May 29th, 2022 I, (Activity Director G) was walking by the East nurse's station where I seen two Residents (Resident #6 and Resident #14) sitting close to each other. As I walked by I heard (Resident #6) making sexual comments to (Resident #14). (Resident #6) said I want to (expletive meaning intercourse) are you ready? (Resident #14) said What? (Resident #6) said I want to (expletive meaning intercourse) but first you have to take your clothes off. (Resident #14) said No. Not today. Myself and a CNA removed (Resident #6) from (Resident #14) and sent him to the west unit . In an interview on 6/2/22 at 2:28 p.m., LPN L reported the comments documented in Resident #6's Progress Notes on 3/22/22, 3/31/22, and 4/2/22 were all directed toward Resident #14. LPN L reported Resident #14 would say .that's not proper . in response to the comments. LPN L reported Resident #14 has some cognitive impairment and stated .She can't remember from second to second . LPN L stated .The more frustrated (Resident #6) gets with his significant other, the more he starts running his mouth . LPN L described Resident #6's statements as .locker room talk . and stated .(Resident #6) shouldn't talk like that in front of a female . LPN L reported resident behaviors are documented in the Progress Notes. LPN L reported after each incident involving Resident #14, Resident #6 was educated on appropriate behavior. LPN L reported the Administrator at the time of the verbal comments on 3/22/22, 3/31/22, and 4/2/22 (Previous Administrator HH) told her (LPN L) .if he (Resident #6) didn't touch her (Resident #14), just to monitor . In an interview on 6/2/22 at 2:37 p.m., DON B stated in regard to the incident involving Resident #6 and Resident #7 on 5/21/22 .I knew that there was something that happened that day . DON B reported she learned of additional details, such as neither resident wearing pants or a brief, on 5/27/22 when the police came to the facility. DON B reported she was notified on 5/21/22 by Agency LPN Y that two residents were found in bed together. DON B reported she directed Agency LPN Y to contact Interim Administrator X for further instruction. DON B reported she was unaware that CNA D had observed anything until 5/27/22. DON B stated .I did reach out to (Interim Administrator X) afterward . and stated that .(Most Administrators) usually have me ask people questions or call people . DON B reported that Interim Administrator X did not direct her to complete additional interviews. DON B stated .(Interim Administrator X) said it sounded like nothing had happened and I didn't need to worry about it. (Interim Administrator X) said she did interviews and found nothing concerning . DON B reported after the incident involving Resident #6 and Resident #7 on 5/21/22, staff .might have done 15-minute checks . and stated .I don't think anything was changed (no new interventions) .on the 21st . DON B reported when she talked to CNA D, days after the incident .I felt like I got more of the story . DON B stated in regard to why the incident was not reported to the police or the State Agency on 5/21/22 .(Interim Administrator X) didn't give me any specifics .She just said nothing happened and that was it . DON B stated in regard to whether or not the incident between Resident #6 and Resident #7 was reportable on 5/21/22 .I don't know .I didn't have enough information . DON B reported no education was completed with staff after the incident on 5/21/22 in regard to the Abuse policy/procedure or reporting requirements. Review of the Active Orders for Resident #6 revealed .Resident is on 15 minute checks due to behaviors .Every Shift . with a start date of 5/29/22. Note this intervention was not implemented until eight days after the incident between Resident #6 and Resident #7. Review of the Elopement Risk Frequent Intervals Checks sheet for Resident #6 (reviewed on 6/2/22 at 3:00 p.m.), dated May 2022, revealed the checks were initiated on 5/29/22. Noted no notation or indication of how frequently the checks should be completed. Review of the Elopement Risk Frequent Intervals Checks sheet for Resident #6 (reviewed on 6/2/22 at 3:00 p.m.), dated June 2022, revealed a handwritten notation at the top of the sheet which stated .Every 15 mins (minutes) . Noted missed entries (no documentation) on 6/1/22 from 8:00 p.m. to 12:00 a.m. Review of the Active Orders for Resident #7 revealed .Q (every) 15 minute checks . with a start date of 5/21/22. Review of the Elopement Risk Frequent Intervals Checks sheet for Resident #7 (reviewed on 6/2/22 at 3:00 p.m.), dated May 2022, revealed Resident #7 was on hourly checks prior to the incident on 5/21/22. Noted missed entries (no documentation) on 5/21/22 for the 5:00 p.m./5:30 p.m. check, and missed entries (no documentation) on 5/26/22 for the 2:30 p.m. check, and 5/26/22 for the 5:00 a.m. and 5:30 a.m. check. Review of the Elopement Risk Frequent Intervals Checks sheet for Resident #7 (reviewed on 6/2/22 at 3:00 p.m.), dated June 2022, revealed Resident #7 was on .15 min . checks. Noted missed entries (no documentation) on 6/1/22 from 12:00 a.m. to 6:30 a.m., 6/1/22 from 1:30 p.m. to 11:30 p.m., and 6/2/22 from 12:00 a.m. to 2:30 p.m. In an interview on 6/3/22 at 11:17 a.m., Interim Administrator X reported she was notified of the incident involving Resident #6 and Resident #7 via phone on 5/21/22 in the late afternoon. Interim Administrator X stated .I got a call from (CNA I) that she walked in the room and noticed (Resident #7) in bed with (Resident #6) and a brief on the floor and (Resident #7's) pants over her wheelchair .(CNA I said) What are you doing? as she pulled the covers back and (Resident #6) said Nothing we didn't do anything we were just going to fool around .They were both naked from the waist down .(Resident #6) did have an erection . Interim Administrator X reported there were .no signs that anything had happened. She was fine . Interim Administrator X reported staff got Resident #7 out of Resident #6's bed, got her dressed, and redirected her back to her room. Interim Administrator X reported staff spoke with Resident #6 and told him his behavior was .inappropriate . Interim Administrator X reported Resident #7 kept wandering down the hall, so they placed her on every 15-minute checks. Interim Administrator X stated .That was it. I spoke with the nurse. He said nothing happened .That was pretty much it . Interim Administrator X reported Resident #7 was not competent to make her own decisions and had a Guardian, who was contacted after the incident. Interim Administrator X stated in regard to whether or not the incident between Resident #6 and Resident #7 on 5/21/22 was reportable .the fact that nothing had happened .They did not have intercourse. There was no harm. He was still erect. No signs of anything on the sheets. I really can't remember if the other nurse did a skin assessment. I told the aide to check the sheets .(Resident #6) said nothing happened . Interim Administrator X reported she only spoke with Agency LPN Y and CNA I on 5/21/22. Interim Administrator X stated .I assumed everything was fine because (CNA I) walked in on (Resident #6 and Resident #7). (CNA I) said they were just laying there and (Resident #6) said nothing happened . Interim Administrator X stated in regard to whether a cognitively impaired individual can consent to sexual activity .No, not if they are severely impaired . Review of a Statement Form completed by Interim Administrator X, dated 5/21/22, revealed .On May 21, 2022 at approximately 5:45 p.m. it was reported to me by (CNA I) that she found two residents in bed together. (Resident #7) found her way down to (Resident #6's) room. They were lying in bed together. One brief in trash, another brief on floor, and (Resident #7's) pants laying over the wheelchair. When (CNA I) asked what they were doing, (Resident #7) just smiled and (Resident #6) replied Nothing happened, we were just going to fool around. (CNA I) pulled the covers back and both residents were naked from the waist down. (Resident #6) had an erection. There were no signs in the bed or on sheets that shows anything had happen (sic). (Resident #7) was gotten out of bed, dressed and taken back down to her room. (CNA I) told (Resident #6) that this behavior was inappropriate and even though nothing happened they could not get into bed together. He told her he understood . Review of the Observations list for Resident #6 revealed a scheduled weekly Skin Body Assessment was completed on 5/16/22 and again on 5/23/22. No Skin Body Assessment was noted for Resident #6 on 5/21/22. Review of the Resident Progress Notes for Resident #6 revealed no notes/documentation on 5/21/22 related to the incident involving Resident #7. Review of a Care Plan for Resident #6, accessed 6/1/22, revealed no new interventions implemented on 5/21/22 to address the incident between Resident #6 and Resident #7. Review of the Observations list for Resident #7 revealed a scheduled weekly Skin Body Assessment was completed on 5/19/22 and again on 5/26/22. No Skin Body Assessment was noted for Resident #7 on 5/21/22. Review of the Resident Progress Notes for Resident #7 revealed no notes/documentation on 5/21/22 related to the incident involving Resident #6. In an interview on 6/3/22 at 1:09 p.m., Guardian W reported she is the Guardian for Resident #7. Guardian W reported she was notified of the incident involving Resident #6 and Resident #7 on 5/21/22, and stated .(Resident #7 is) very, very (cognitively) impaired . Guardian W reported she knew Resident #7 prior to her cognitive decline, and stated .If (Resident #7) knew she did that she would just be mortified . Guardian W stated .(Resident #7) also was abused as a child and had lots of issues as an adult because of it. She never would have done that had she had control of her faculties . In an interview on 6/7/22 at 1:26 p.m., Agency LPN Y reported on 5/21/22, CNA I was returning from break when she went past Resident #6's room and noticed Resident #7 in bed with him. Agency LPN Y reported CNA I notified him of what she observed, and stated .I went to the room and confirmed they were in the bed together . Agency LPN Y reported he pulled the blankets back an[TRUNCATED]

This citation pertains to Intake # MI 728 & # MI 892. Based on interview, and record review, the facility failed to report a reasonable suspicion of a crime to the police in a timely manner in 2 of 13 residents (Resident #6 & #7) reviewed for abuse, resulting in an Immediate Jeopardy when on 5/21/21 at approximately 5:45 p.m., Resident #7 (a cognitively impaired female) was found in Resident #6's bed (a cognitively intact male). Both residents were noted to be naked from the waist down. The police were not notified upon identification of the incident, evidence was not collected, and the scene was not preserved. This deficient practice placed all 65 residents at risk for serious physical and psychosocial harm. Findings include: On 6/2/22 at 5:40 p.m., Administrator A was notified of an Immediate Jeopardy that began on 5/21/22 when Resident #7 (a cognitively impaired female) was found in Resident #6's bed (a cognitively intact male). Both residents were noted to be naked from the waist down. The police were not notified upon identification of the incident, evidence was not collected, and the scene was not preserved. On 6/7/22, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1) Action for residents involved - Alleged sexual crime between Resident #6 and Resident #7 was reported to the South Haven Police on 5/27/22. 2) Measures to ensure deficient practice will not recur - The facility Administrator and Director of Nursing were educated on 6/2/22 by the Regional Director of Operations on identifying situations that could potentially meet the definitions of abuse or suspicion of a crime and require investigation and reporting to the State Agency and police. 3) As of 6/3/22, 67 out of 82 facility staff have been educated on the facility policy Abuse Prevention Program which includes the topics 7 COMPONENTS, and Elder Justice Act. No staff will be allowed to work before education is complete. 4) Education will include review of the facility policy, specifically: Criteria to determine reasonable suspicion of a crime: -Facility leadership will revisit with the police what is considered a crime in this locality to ensure reporting requirements are met on or before 6/6/22. -An injury that is suspicious because the source of the injury is not observed or the extent or location of the injury is unusual, or because of the number of injuries either at a single point in time or over time. -Sudden or unexplained changes in the following behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. -Guidance facility will use to ensure that crime scenes are protected and reported: -Identify alleged perpetrator, remove from resident care area immediately, suspend pending investigation conclusion, obtain statement. -Caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence). -Identify and begin investigating different types of alleged violations. -Identify and interview (witness statements) all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s) such as roommate. -Interviews with co-workers or other supervisors in regards to the alleged perpetrator's work performance. -Review of alleged perpetrator's employee file to confirm background checks, reference checks and to review any possible past performance issues. -Determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. -Body assessment and psychosocial status of the resident. Signs of catastrophic reaction. -Methods of treatment and interventions. (i.e. psychological services, hospital transfer, first aide, medication, staff staying with resident for comfort, etc.) -Providing complete/thorough documentation of the investigation findings (timeline of events), summary or conclusion. -Follow-up actions to correct and prevent potential reoccurrence. -State and local agencies notified Facility Reportable Incident (FRI). 5) Monitoring of corrective actions to ensure deficient practice will not recur - Beginning 6/3/22: -The facility IDT (Interdisciplinary Team) will review 24-hour reports, skin assessments, and grievance forms daily during morning meeting Monday through Friday to identify potential situations requiring investigation and reporting. -The facility Social Services representative will interview 5 residents per week on staff treatment and on potential inappropriate behaviors/conversation/statements by other residents to identify potential situations requiring investigation and reporting. -The facility Director of Nursing will audit skin assessments and progress notes daily to identify potential situations requiring investigation and reporting. -Administrator will immediately notify the Regional Director of Operations and Regional Clinical Director for direction and guidance. If a situation meets the definition of abuse or neglect the administrator will be responsible to ensure reporting to the State Agency and police. The administrator will also be responsible to ensure facility policy is followed and a thorough investigation is completed. Although the immediate jeopardy was removed on 6/3/22, the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency and all education had not yet been completed. Resident #6 Review of a Face Sheet revealed Resident #6 was a male, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 3/24/22, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated he was cognitively intact. Review of a Care Plan for Resident #6, accessed 6/1/22, revealed the problem .Resident displays behavioral symptoms by making inappropriate sexual statements/comments to residents and staff . with a start date of 3/1/22, and interventions which included .Assess whether the behavior endangers the resident and/or others. Intervene if necessary .Observe for changes in behavior, document, and report to doctor .Obtain a psych consult/psychosocial therapy as needed .When resident becomes verbally abusive, keep distance between resident and others (e.g., staff, other residents, visitors) .When resident becomes verbally abusive, move resident to a quiet, calm environment . all with a start date of 3/1/22. Resident #7 Review of a Face Sheet revealed Resident #7 was a female, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #7, with a reference date of 5/23/22, revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated severe cognitive impairment. Review of a Care Plan for Resident #7, accessed 6/2/22, revealed the problem .At risk for elopement from facility r/t (related to) her dx (diagnosis) of Dementia . with interventions which included .Resident to be on designated timed checks . both with a start date of 5/27/21. Review of a Social Services Progress Note for Resident #7, dated 5/23/22 at 11:29 a.m., revealed .Resident's elopement checks have been changed from hourly to 15 minutes d/t (due to) wandering in rooms. Resident wandered into a male's room. Guardian, DON, and (Administrator) has been notified of incident. Staff will continue to document, observe and report any changes in mood and/or behaviors . In an interview on 6/2/22 at 10:34 a.m. with Administrator A and Director of Nursing (DON) B, Administrator A reported he and DON B were first made aware of an issue with Resident #6 on 5/27/22 when the police arrived at the facility to investigate several allegations of abuse that were called in by an anonymous complainant. Administrator A stated in regard to the allegations involving Resident #6 and Resident #7 .we did get some statements from staff and we are still investigating . In an interview on 6/2/22 at 10:58 a.m., Certified Nursing Assistant (CNA) I reported .maybe two weeks ago . or .the 21st of last month . (5/21/22) she was caring for the roommate of Resident #7 and noticed Resident #7 wasn't in the room. CNA I reported she eventually found Resident #7 (female) in Resident #6's (male) room, in his bed, next to each other, and under the covers. CNA I reported when she asked Resident #6 what they were doing, he stated .Nothing yet . CNA I reported when she pulled the covers back both Resident #6's and #7's pants and briefs were down and Resident #6's penis was erect. CNA I reported she wasn't sure if there had been any intercourse. CNA I confirmed Resident #7 was confused and couldn't say what had happened and Resident #6 was not confused. CNA I reported she was interviewed by Interim Administrator X that day. Review of a Witness Statement completed by CNA I, no date, revealed .I, (CNA I) was assisting (Resident #7's) roommate when I noticed I did not see (Resident #7) in the room nor in the hallways. I came out of the room to ask a nurse of (Resident #7's) whereabouts. The nurse stated she saw (Resident #7) hanging out on the West hall with (Resident #6). I proceeded to the West hall to check on (Resident #7). (Resident #7) was not in the hallway. I then checked (Resident #6's) room, and (witnessed) (Resident #6 and Resident #7) laying in the bed together with their pants and briefs off. I asked (Resident #6) if they had done anything together. (Resident #6) (stated) Not yet. I then asked how long were they in the bed together. (Resident #6) stated About 25 minutes. Whenever I asked a question, (Resident #7) just (smiled). She appeared as if she did not understand any of my questions. I assisted with getting (Resident #7) dressed, then I wheeled her to her bedroom. I informed the nurses for (Resident #6 and Resident #7) and then called the Director of Nursing. 15 minutes after informing the designated personnel, the Administrator called me to get my statement . In an interview on 6/2/22 at 11:25 a.m., Registered Nurse (RN) R reported on 5/21/22 .one of the evening aides came down the hall and told my work partner (Agency Licensed Practical Nurse (LPN) Y) that (Resident #7) was in the bed with (Resident #6) and they had their (briefs) off . RN R reported Agency LPN Y separated the residents and contacted Interim Administrator X and DON B .to let them know what was going on and what he should do about it . RN R stated .I guess what we would normally do is keep an eye on them . RN R reported that Resident #7 is cognitively impaired and often wanders into other people's rooms. In an interview on 6/2/22 at 12:23 p.m., CNA D reported he was at the nurses desk on 5/21/22 when another staff member notified Agency LPN Y that Resident #7 was in Resident #6's bed, both naked from the waist down. CNA D reported he and Agency LPN Y went down to Resident #6's room to separate the residents. CNA D reported he asked what was going on and Resident #6 replied .What does it look like? CNA D reported he and Agency LPN Y assisted Resident #7 out of Resident #6's bed, got her dressed, and redirected her out of Resident #6's room. CNA D reported DON B was notified of the incident and Social Worker (SW) N spoke to him a few days after the incident about what happened. CNA D reported he wrote a statement after the incident and submitted a copy to management. CNA D stated .You can't just let something like this slide . Review of a Witness Statement completed by CNA D, dated 5/23/22, revealed .I had pulled (Resident #7) out of (Resident #6's) room twice. Low and behold I found out by an aide that was passing by that (Resident #6 and Resident #7) were in bed naked together. When (CNA D, CNA I, and Agency LPN Y) went down there I asked What's going on? and (Resident #6) replied What does it look like? (Agency LPN Y) inquired, we removed (Resident #7) from room . In an interview on 6/2/22 at 1:27 p.m., SW N reported she became aware of the incident between Resident #6 and Resident #7 around 5/25/22 or 5/26/22. SW N reported Resident #7 is a wanderer and frequently requires redirection out of other resident's rooms. SW N reported Resident #6 is cognitively intact and is his own decision maker. SW N reported DON B was aware of the incident between Resident #6 and Resident #7 .when it happened . In an interview on 6/2/22 at 2:37 p.m., DON B stated in regard to the incident involving Resident #6 and Resident #7 on 5/21/22 .I knew that there was something that happened that day . DON B reported she learned of additional details, such as neither resident wearing pants or a brief, on 5/27/22 when the police came to the facility. DON B reported she was notified on 5/21/22 by Agency LPN Y that two residents were found in bed together. DON B reported she directed Agency LPN Y to contact Interim Administrator X for further instruction. DON B reported she was unaware that CNA D had observed anything until 5/27/22. DON B stated .I did reach out to (Interim Administrator X) afterward . and stated that .(Most Administrators) usually have me ask people questions or call people . DON B reported that Interim Administrator X did not direct her to complete additional interviews. DON B stated .(Interim Administrator X) said it sounded like nothing had happened and I didn't need to worry about it. (Interim Administrator X) said she did interviews and found nothing concerning . DON B reported when she talked to CNA D, days after the incident .I felt like I got more of the story . DON B stated in regard to why the incident was not reported to the police or the State Agency on 5/21/22 .(Interim Administrator X) didn't give me any specifics .She just said nothing happened and that was it . DON B reported the facility Administrator is considered the Abuse Prevention Coordinator, and stated .Usually I direct people to the Administrator to decide on if something is reportable . DON B stated in regard to whether or not the incident between Resident #6 and Resident #7 was reportable on 5/21/22 .I don't know .I didn't have enough information . In an interview on 6/3/22 at 11:17 a.m., Interim Administrator X reported she was notified of the incident involving Resident #6 and Resident #7 via phone on 5/21/22 in the late afternoon. Interim Administrator X stated .I got a call from (CNA I) that she walked in the room and noticed (Resident #7) in bed with (Resident #6) and a brief on the floor and (Resident #7's) pants over her wheelchair .(CNA I said) What are you doing? as she pulled the covers back and (Resident #6) said Nothing we didn't do anything we were just going to fool around .They were both naked from the waist down .(Resident #6) did have an erection . Interim Administrator X reported there were .no signs that anything had happened. She was fine . Interim Administrator X reported staff got Resident #7 out of Resident #6's bed, got her dressed, and redirected her back to her room. Interim Administrator X reported staff spoke with Resident #6 and told him his behavior was .inappropriate . Interim Administrator X stated .That was it. I spoke with the nurse. He said nothing happened .That was pretty much it . Interim Administrator X reported Resident #7 was not competent to make her own decisions and had a Guardian, who was contacted after the incident. Interim Administrator X stated in regard to whether or not the incident between Resident #6 and Resident #7 on 5/21/22 was reportable .the fact that nothing had happened .They did not have intercourse. There was no harm. He was still erect. No signs of anything on the sheets. I really can't remember if the other nurse did a skin assessment. I told the aide to check the sheets .(Resident #6) said nothing happened . Interim Administrator X reported she only spoke with Agency LPN Y and CNA I on 5/21/22. Interim Administrator X stated .I assumed everything was fine because (CNA I) walked in on (Resident #6 and Resident #7). (CNA I) said they were just laying there and (Resident #6) said nothing happened . Interim Administrator X reported based on this information, she determined the incident was not reportable to the State Agency or the police. Interim Administrator X stated in regard to whether a cognitively impaired individual can consent to sexual activity .No, not if they are severely impaired . Interim Administrator X stated in regard to documentation of the incident .I actually told (CNA I) that I was writing down what she was telling me, and (Agency LPN Y) said he had nothing to report because he didn't see anything . Review of a Statement Form completed by Interim Administrator X, dated 5/21/22, revealed .On May 21, 2022 at approximately 5:45 p.m. it was reported to me by (CNA I) that she found two residents in bed together. (Resident #7) found her way down to (Resident #6's) room. They were lying in bed together. One brief in trash, another brief on floor, and (Resident #7's) pants laying over the wheelchair. When (CNA I) asked what they were doing, (Resident #7) just smiled and (Resident #6) replied Nothing happened, we were just going to fool around. (CNA I) pulled the covers back and both residents were naked from the waist down. (Resident #6) had an erection. There were no signs in the bed or on sheets that shows anything had happen (sic). (Resident #7) was gotten out of bed, dressed and taken back down to her room. (CNA I) told (Resident #6) that this behavior was inappropriate and even though nothing happened they could not get into bed together. He told her he understood . Review of the Observations list for Resident #6 revealed a scheduled weekly Skin Body Assessment was completed on 5/16/22 and again on 5/23/22. No Skin Body Assessment was noted for Resident #6 on 5/21/22. Review of the Observations list for Resident #7 revealed a scheduled weekly Skin Body Assessment was completed on 5/19/22 and again on 5/26/22. No Skin Body Assessment was noted for Resident #7 on 5/21/22. In an interview on 6/7/22 at 1:26 p.m., Agency LPN Y reported on 5/21/22, CNA I was returning from break when she went past Resident #6's room and noticed Resident #7 in bed with him. Agency LPN Y reported CNA I notified him of what she observed, and stated .I went to the room and confirmed they were in the bed together . Agency LPN Y reported he pulled the blankets back and both residents were naked from the waist down. Agency LPN Y reported Resident #7 was assisted out of Resident #6's bed, dressed, and redirected back to her room. Agency LPN Y stated in regard to Resident #7 .we had her under watch . Agency LPN Y reported Interim Administrator X and DON B were made aware of the incident, but he wasn't sure if it was reported to the police or the State Agency. Agency LPN Y stated .being that (Resident #6 and Resident #7) were under the blankets with both bottoms removed that was pretty serious to me . Review of the policy/procedure Abuse Prevention Program, dated 1/2022, revealed .Each resident has the right to be free from abuse, neglect and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse .Sexual Abuse .Is non-consensual sexual contact of any type with a resident .Sexual abuse includes, but not limited to .Unwanted intimate touching of any kind especially of breasts or perineal area .All types of sexual assault or battery, such as rape, sodomy, and coerced nudity . Review of the policy/procedure Abuse Prevention Program 7 Components, dated 1/2022, revealed .The facility has developed and implement (sic) Policies and Procedures that include the following seven components: Screening; Training; Prevention; Identification; Investigation; Protection; and Reporting/response .INVESTIGATION .The Administrator and or Director of Nursing are to initiate and coordinate completion of a thorough investigation .Caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence) .State and local agencies notified .PROTECTION .Residents are protected from physical and psychosocial harm during and after the investigation. This include (sic) .Responding immediately to protect the alleged victim and integrity of the investigation .Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed .REPORTING/RESPONSE .All alleged or suspected violations are to be reported immediately to the Administrator or Director of Nursing, which are responsible to notify required officials, including to the State Survey Agency, Adult Protective Services, Local Public Safety, Licensure Boards, Regional Director of Operations or Regional Clinical Directors (representative of governing board) and any other agencies in accordance with State law through established procedures .If an allegation of sexual abuse has been reported, the facility must immediately .Protect the alleged victim(s) involved .Report the alleged violations to the Administrator and appropriate State and local authorities .Notify regional support team for assistance .Begin investigation of the allegation .Facility must not tamper with evidence during investigation: washing linens or clothing, destroying documentation, bathing or cleaning the resident until the resident has been examined (including a rape kit, if appropriate), or otherwise impeding a law enforcement investigation . Review of the policy/procedure Abuse Prevention Program Elder Justice Act, dated 1/2022, revealed .POLICY & PROCEDURE FOR REPORTING SUSPECTED CRIMES UNDER THE FEDERAL ELDER JUSTICE ACT .It is (Company Name) and it's facilities' policy to comply with the Elder Justice Act (EJA) about reporting a reasonable suspicion of a crime under Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act (ACA), (section) 6703(b)(3). Specifically, it is the facility's policy to .Suspicion of a Crime is defined by law of the applicable political subdivision where a LTC (Long Term Care) facility is located. Applicable facilities must coordinate with their state and local law enforcement entities to determine what actions are considered crimes within their political subdivision .Staff must report the suspicion of an incident to the facility Administrator or Director of Nursing or staff's supervisor, who in turn will immediately report to Administrator or Director of Nursing as per Abuse Policy and Procedure .When staff .suspect a crime has occurred against a resident at the facility, they must report the incident to SSA and local law enforcement .Staff must report a suspicion of a crime to the state survey agency, SSA and at least one local law enforcement entity within a designated time frame by e-mail, fax or telephone. The individual does not need to determine which local law enforcement entity to report a suspicion of a crime; but, must report to at least one local law enforcement entity. This will meet the individual's obligation to report .If the reportable event results in serious bodily injury, the staff member shall report the suspicion immediately, but not later than 2 hours after forming the suspicion .If the reportable event does not result in serious bodily injury, the staff member shall report the suspicion not later than 24 hours after forming the suspicion .Facility Reporting .The facility will file a report to SSA and local law enforcement .when becoming aware of a suspicion of a crime .

This citation pertains to intake MI 182. Based on observation, interview, and record review, the facility failed to follow the policy and procedure for laboratory testing for 1 of 8 sampled residents (Resident #100), reviewed for labs, who received a critical potassium lab value of 7.7 mmol/l (normal 3XXX,[DATE].3mmol/l) and on [DATE] at 9:08 AM read back by Licensed Practical Nurse (LPN) who did not notify the physician immediately upon receipt of lab results via phone or fax. This deficient practice places all residents who may require lab work at risk for serious harm, injury, and/or death. Findings include: On [DATE] at 9:07 A.M., the Nursing Home Administrator and Director of Nursing were verbally notified and received written notification of the Immediate Jeopardy that began on [DATE] and was identified on [DATE] due to the facility's failure to notify the physician of a critical lab result. A written plan for removal for the immediate jeopardy was received on [DATE] and the following was verified on [DATE]: 1. On [DATE] lab will provide a list of lab draws completed prior to exiting building on day of lab draws to charge nurses and a copy to the Director of Nursing (DON) upon her completion of the draws. This will be prior to her exit of the facility. She will give them to the charge nurse who will in turn, make a copy and provide to DON. 2. Critical lab are called to facility and reported directly to the nurse via lab, the nurse reads back the results for clarification. (physician) notified of results immediately. The lab results are then also faxed to the main fax machine. The secretary retrieves that faxed copies scans them immediately into (computer system) and puts the labs in the appropriate halls mailbox. Nursing obtains labs from the mailbox and puts them in the (physician) book for him to sign on his next visit. Any new orders and critical lab values are noted and documented in a progress note in matrix. 3. On [DATE] All Abnormal/critical lab results and (physician) notifications are to be noted on 24-hour report and in individual resident progress notes. Any new orders are to be addressed immediately. 4. On [DATE] All critical labs are to be addressed with Physician immediately, DON notified, and progress note in resident medical record. 5. On [DATE] Educated licensed nurses on the lab process related to (r/t) critical lab values. All Licensed Nurses will be educated by in person meetings and documentation of policies and process provided to nurses, with review of notifications to physician, documentation in progress notes and 24 hour report. 6. On [DATE] (85%) of all Licensed Nurses have been educated and continues until all Licensed Nurses are educated. Licensed Nurses will not be able to work until educated. 7. On [DATE] Any resident with a lab draw in last 30 days are being reviewed for any abnormal values and physician notifications. 8. Resident #100 no longer resides in the facility. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of widespread and severity of actual harm due the fact that not all facility staff have received education, and sustained compliance has not been verified by the State Agency. Review of the Laboratory Test Policy and Procedure dated ,[DATE], revealed Receiving Lab results 1. The License nurse receiving the lab results will review for abnormal or critical high results. The License nurse will notify the Physician of any abnormal results within 12 hours of receipt of the results. The nurse will notify the physician of any critical high results immediately upon results of the lab results via phone or fax. 2. The License nurse will document on the lab result form and the time the Physician was notified. 4. The License nurse will complete the lab tracking form by entering the date the lab result was received and Physician notified. 6. Abnormal labs will be communicated to the appropriate disciplines during the next Clinical AM meeting. Review of a Face Sheet revealed Resident #100 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) , not completed by staff, documented as acute onset of mental status change. Review of the Lab Report dated [DATE] at 4:41 AM, revealed Lab called the facility at 9:08 AM and spoke to Licensed Practical Nurse (LPN) R with CRITICAL RESULTS READ BACK. Lab results Potassium - Critical lab (C) 7.7 (3XXX,[DATE].3 MMOL/L (If you have high potassium, you have too much potassium in your blood. The body needs a delicate balance of potassium to help the heart and other muscles work properly. But too much potassium in your blood can lead to dangerous, and possibly deadly, changes in heart rhythm). Abnormal lab results H (High) Urea Nitrogen 241 (,[DATE] MG/DL) normal (high counts indicate dysfunction of kidneys), H - Creatinine 7.12 (0.70 -1.30 MG/DL) normal. (High Creatinine levels are an indicator of possible kidney damage, which may be temporary (acute) or persistent (chronic). Sometimes the damage is caused by low blood flow to the kidneys). H - BUN: Creation Ratio 34 (,[DATE]) (may signal dehydration or that your kidneys are not functioning properly). Review of the Care Plan dated [DATE], revealed Potential for fluid imbalance, fluctuating weights and [MEDICAL CONDITION] related to diuretic medication, Labs as ordered. Review of the Care Plan dated [DATE], revealed Resident has surgical site to abdomen, [DATE] receiving antibiotic for pegsite infection, labs as ordered. During interviews on [DATE] at 9:25 AM and [DATE] 7:58 AM, LPN R, reported that she took the critical lab report over the phone and a Certified Nursing Assistant (CNA) came to get her to assist with patient care. LPN R reported that the paper copy of the critical lab was in the office and she did not go and get it. LPN R reported that she knew the critical lab was for increase potassium but did not know why she did not call the physician after completing the care of the patient. LPN R reported the physician came in later that morning but the critical lab value on Resident #100 did not come up in conversation. During interviews on [DATE] at 10:56 AM and 5:32 PM, Physician's Assistant (PA) Z reported that he was not informed of the critical 7.7 potassium lab received from the lab at 9:08 AM by LPN R. PA Z stated (Resident #100) cannot stay in a nursing home and he would have had to go to a hospital for a 7.7 potassium level. PA Z reported that he came to the facility after 11 AM on [DATE]. PA Z reported that he had ordered the labs for [DATE] because Resident #100 was on a tube feeding. During interviews on [DATE] at 3:55 PM and [DATE] at 2:09 PM, LPN Q reported that she did not recall the day shift nurse passing on in report on [DATE] that she had received a critical lab for Resident #100. We know abnormal lab values that the physicians want to be informed of they are posted in the communication book we have for the physician (abnormal electrolytes, peaks and troughs, PT INR's and any critical labs). LPN R reported that you do not hold labs for the physician they expect the results immediately. LPN R stated getting the critical lab results to the physician immediately is a standard practice for nursing everywhere. LPN R stated that (Resident #100) with a potassium of 7.7 would have been shipped to the hospital and would require cardiac monitoring for a high potassium level, he would not have stayed in our facility. Review of the Progress Notes dated [DATE] at 6:31AM revealed, At 12:05 am this writer was informed by CNA that resident was unresponsive. Chart was flagged, full code noted. Stat Code Blue announced over PA system, crash cart taken to resident's room. AED applied, while this writer initiated compression. Ambu bag place on resident's face, covering nose and mouth. No shock advised from AED, compressions continued. EMS arrived at 12:11 am, EMS technician took over from this writer and performed compressions. No shock advised from AED. EMS personal called medical examiner, she called time of death at 12: 17 am. This writer notified DON and house physician of resident's passing. Next of kin, (name omitted) was notified by this writer. She stated she wanted (name omitted) Funeral home to remove the body. Staff performed after post mortem care on resident. Mortician here at facility at 2:00 am, he left with the remains of resident at 2: 24 am. Review of the Certificate of Death dated [DATE] revealed Resident #100 died on [DATE] at 12:17AM and cause of death was listed as [DIAGNOSES REDACTED], Pneumonia, and COVID-19. No medical examiner was notified per the death certificate. During an interview on [DATE] at 1:40 PM, Director of Nursing (DON) B reported that the nurse was to write down the call from the lab, verify what they were told by the lab with the time, resident, and critical data, and call the physician. DON B reported that if the door was locked to get the lab paperwork (fax) LPN R could have crawled through the window. DON B reported that the lab paperwork was then to be placed in the physician book for them to review and sign off. DON B reported that the office manager will usually get the fax from the lab and put it in each sections nurse box for them to pick up the days faxes and then they take the faxes back and place them in the physician book or wherever they need to go every shift.

Based on observation, interview, and record review the facility failed to prevent a fall, for 1 of 4 residents (Resident #103), reviewed for accidents, resulting in major injuries and subsequent surgery. Findings include: Review of a facility Admissions Record revealed Resident #103 was an [AGE] year-old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, completed on 10/3/19, revealed Resident #103 was an extensive assistance of 1 staff for transfers, ambulation and toileting, and required setup assistance for eating. Brief Interview for Mental Status (BIMS), on 10/3/19, revealed Resident #103 was severely cognitively impaired. Review of Resident #103's Care Plan problem, start date 6/10/14, revealed At risk for falls and subsequent injury related to: h/o (history of) fall resulting in fracture,[MEDICAL CONDITION](stroke) .anxiety, dementia .limited mobility, weakness .impaired cognition, impaired communication . Review of Resident #103's Event Report ., completed 9/27/19, revealed .Fall .activity prior to fall .using the bathroom sitting on toilet .what happened .observed resident lying on floor supine (on back) in bathroom .Root Cause Analysis .Resident was sitting on the toilet, the aide went around corner to grab her hairbrush she came back in the bathroom and resident was sitting on floor .resident stated to Dr. saw cats in the bathroom . Review of Resident #103's hospital progress note, dated 9/30/19, revealed .Assessment/Plan: Postoperative day #2 status [REDACTED]. In an observation and interview on 12/11/19 at 1:30 PM, Certified Nursing Assistant J (CNA) transferred Resident #103 from wheelchair to bed and performed incontinence care. CNA J indicated had a big fall in (MONTH) and broke her leg and arm. CNA J indicated since Resident #103's fall, usually perform incontinence care in bed and do not take her to the toilet anymore. CNA J indicated Resident #103 could not be left alone on the toilet and a CNA who was toileting her stepped out of the bathroom and she fell . In an interview on 12/11/19 at 2:20 PM, Licensed Practical Nurse L (LPN) indicated before Resident #103's fall and currently, she was a 1-person gait belt pivot transfer to the toilet. LPN L indicated would not leave Resident #103 alone on the toilet. LPN L indicated has always advised the CNA's to stay in the bathroom with her because she was impulsive and not reliable using her call light for assistance. In an interview on 12/11/3:30 PM, Director of Nursing B (DON) indicated staff should not leave a cognitively impaired resident in the bathroom unattended.

This citation pertains to MI 046. Based on observation, interview and record review the facility failed to provide adequate Cardio [MEDICAL CONDITION] Resuscitation (CPR), use of an automated external defibrillator (AED) or ensure a functioning suction device in 1 of 1 residents (Resident #102) reviewed for highest practicable well being, from a total sample of 5 residents, resulting in an Immediate Jeopardy when, on [DATE] at 4:28 am, Licensed Practical Nurse (LPN) K found Resident #102 to be unresponsive with no vital signs. Police Officer (PO) L arrived on scene on [DATE] at 4:34 am and observed licensed nursing staff not performing CPR, utilizing an automated external defibrillator (AED) or using a functional suctioning device. Findings include: Review of the Face Sheet revealed Resident #102 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 had a brief interview for mental status (BIMS) score of 15 out 15 which indicated she was cognitively intact. Review of the Medical Treatment Decision of Resident dated [DATE] (un-timed) revealed Resident #102 was to have cardiopulmonary resuscitation (CPR). Review of the Policy Cardiopulmonary Resuscitation with a revised date of ,[DATE] revealed The purpose of this policy and procedure is to ensure a consistent and appropriate response to emergency situations in the nursing home if requested, to provide basic life support (BLS) that is consistent with acceptable practice standards held by the American Heart Association (AHA) according to CMS (Centers of Medicare & Medicaid Services). The Policy further revealed .Once CPR is initiated, it must continue until the patient recovers or a Physician/Nurse Practitioner provides the pronouncement of death. Review of the American Heart Association (AHA) Cardiopulmonary Resuscitation and Airway Management dated 2010 revealed CPR is a technique of basic life support for the purpose of oxygenating the brain and heart until appropriate, definitive medical treatment can restore normal heart and ventilatory action and .emphasis is now on performing good, high quality chest compressions, with a minimum of interruptions in an effort to not only preserve life but prevent [MEDICAL CONDITION] brain injuries (brain injuries from a lack of oxygenation) as well. Review of the American Heart Association (AHA) Guidelines Update for CPR and ECC (Emergency cardiovascular care) dated 2015 revealed the If [MEDICAL CONDITION] (a stoppage of the heart, no heart beat) occurs patients depend on a smooth interaction of the institution's various departments and services and the Chains of Survival were Surveillance and prevention, Recognition and activation of the emergency response system, Immediately high-quality CPR, Rapid defibrillation, Advanced life support and post-arrest care. Review of the Police Report dated [DATE] at 6:53 am, revealed, I (PO L) responded to the (facility) for a resident who wasn't breathing. When I (PO L) walked into the room I (PO L) observed three of the (facility) staff trying to figure out how to work their AED, nobody was doing CPR on (Resident #102) when I entered the room. (LPN K) was applying the AED pads, (Certified Nurse Aide, CNA I) was standing next to the bed doing nothing and (LPN J) was trying to figure out how to plug the leads into the AED. I (PO L) asked (CNA I) if they were doing compressions (chest compressions for CPR) and she said yes, we did compressions, and just stood there. I (PO L) began doing compressions once I accessed none of the three staff members had any idea what they were doing. As I (PO L) was doing compressions (Resident #102) lungs and mouth were full of dark colored liquid. I (PO L) had to instruct the nursing staff to get suction into (Resident #102's) mouth .After instructing staff to get their suction machine going the nurse didn't know how .to get it (suction machine) working. The whole time I (PO L) was on scene I never once observed any of the nursing staff administer compressions (CPR) or do anything to assist in CPR. In an interview on [DATE] at 11:25 am, Certified Nurse Aide (CNA) I stated that on [DATE] at, a little after 4 (am), (I) touched her (Resident #102), she felt cool, she didn't appear to be breathing. I went down to the nurses station and told the nurse (Licensed Practical Nurse (LPN) K) I thought she (Resident #102) might be gone (deceased ). CNA I reported that LPN K went to Resident #102's room. CNA I reported Resident #102 was still in the recliner and that LPN K, listened to her (Resident #102) with the stethoscope. CNA I reported LPN K called 911. CNA I reported she, LPN K and LPN J picked her (Resident #102) up from the recliner and put her on the bed. CNA I stated, Yes, the nurses were doing CPR when the police officer arrived. In an interview on [DATE] at 11:50 am, LPN J stated that on [DATE], I was called down there (to Resident #102's room) about 4:,[DATE]:20 am. LPN J stated Resident #102 was in the chair and didn't have any vitals. LPN J stated she, CNA I and LPN K, assist her (Resident #102) into bed. LPN J stated when she touched Resident #102 I would say she wasn't warm. LPN J reported that she started compressions. LPN J stated that when the PO L entered Resident #102's room she (LPN J) was performing chest compressions. LPN J stated, yes, the police officer visualized LPN J performing chest compressions. In an interview on [DATE] at 2:05 pm, LPN K stated that on [DATE] at about 4:15 am CNA I came down and said she (Resident #102) is not breathing. I ran down there to do an assessment. LPN K reported Resident #102 did not have any radial pulse and was not breathing. LPN K stated she, LPN J and CNA I move her (Resident #102) to the bed from the recliner. LPN K stated, She was a full code (indicated CPR was to be performed). LPN K reported that LPN J was doing chest compressions when PO L entered Resident #102's room. LPN K stated, the officer (PO L) came in, he started doing compressions. Review of the Emergency Service report dated [DATE] revealed at 04:28 am (,[DATE] minutes after facility staff noted Resident #102 was without vital signs), a 911 call was placed by the facility. Review of the PO L body camera video dated [DATE] at 04:34 am, revealed PO L entered Resident #102's room. The body camera footage revealed CNA I was standing on the left side of Resident #102's bed, LPN J was standing on the right side at the foot of Resident #102's bed and LPN K standing on the right side of Resident #102's bed. The footage showed that none of the staff members were performing CPR, chest compressions or supplemental breathing when PO L entered Resident #102's room. In an interview on [DATE] at 11:45 am, Paramedic E stated that on [DATE], She (Resident #102) was laying in bed, 2 or 3 nursing home staff there, everyone's just standing around. Paramedic E stated, We had the officer (PO L) jump on compressions (perform chest compressions). In an interview on [DATE] at 11:57 am, Paramedic F stated when he arrived on [DATE] nobody's touching her (Resident #102). Paramedic F stated, Checked a pulse (heart beat), no pulse, moved her (Resident #102) down to the floor .then (PO L) jumped in doing compressions (perform chest compressions). In an interview on [DATE] at 11:50 am, LPN J stated if the police body camera did not show staff members performing CPR on Resident #102 on entry then that would mean compressions weren't being done. In an interview on [DATE] at 2:05 am, LPN K stated, if it's on video (police body camera), video doesn't lie (indicated staff were not performing CPR on Resident #102 on entry of PO L). Review of the American Heart Association (AHA) Cardiopulmonary Resuscitation and Airway Management dated 2010 further revealed, Utilize the AED .as soon as possible. Review of the Lippincott Manual of Nursing Practice, 10th Edition revealed the procedure for the Automated External Defibrillator (AED) was to Assess unresponsiveness and pulselessness (no heartbeat), Position patient in the supine (on back) position, Start Cardiopulmonary resuscitation (CPR) while automated external defibrillator is being applied. The Lippincott Manual further revealed the Rationale for use of the AED was for early restoration of oxygenation and perfusion is imperative in enhancing the resuscitative effort. In an interview on [DATE] at 11:50 am, LPN J stated, No, I didn't get the AED (automated external defibrillator). LPN J stated, No, I didn't put the AED pads on Resident #102. In an interview on [DATE] at 2:05 pm, LPN K stated, I grabbed the AED, I removed the patches (AED pads), plugged it (AED pads placed and plugged into the AED machine) in and turned it on. LPN K stated the AED machine stated 'no shock advised' so we (LPN J, CNA I) continued CPR and then the officer came in. LPN K stated, Yes, it was important the AED be used early on in a resuscitation effort. Review of the PO L body camera video dated [DATE] at 04:35 am, revealed there were AED pads that had placed onto Resident #102 but were not plugged into the AED machine. The body camera video revealed PO L indicated to staff to plug that in (indicated AED pads were not attached to AED machine and the AED had not been used before PO L entered Resident #102's room). The body camera video revealed the AED was turned on at 04:36 am (indicated AED not used for 8 minutes since 911 called was received). In an interview on [DATE] at 2:05 pm, LPN K reported that the AED should have been placed earlier for Resident #102. LPN K stated without [MEDICATION NAME] blood or blood circulation, the brain dies. In an interview on [DATE] at 3:25 pm, Director of Nursing (DON) B stated, Oh yes absolutely, immediately the AED should have been used on Resident #102 on [DATE]. Review of the American Heart Association (AHA) Cardiopulmonary Resuscitation and Airway Management dated 2010 revealed Taking no more than 10 seconds, open the airway and deliver 2 breaths (ventilation) to access patency of the airway and provide supplemental breathing. In an interview on [DATE] at 2:05 pm, LPN K stated Resident #102 had something coming out of her mouth, black liquid. LPN K stated LPN J, wasn't feeling confident so she goes and gets the one (suction machine) from her unit. LPN K stated, they (suction machines) were different that night. LPN K stated, I don't remember if it (suction machine) had even a little suction. In an observation on [DATE] at 3:25 pm, the facility suction machines were observed by the surveyor and Director of Nursing (DON B). The 2 suction machines were observed on the facility crash carts. The observed suction machines were from the same manufacturer and appeared to be the same models. In an interview on [DATE] at 3:40 pm, DON B stated, I've been the DON for 10 months and I haven't changed the suction machines. DON B stated the facility suction machines were the same for all units. In an interview on [DATE] at 11:50 am, LPN J stated, Some black stuff was coming from her (Resident #102's) mouth. I went to get the suction machine from my cart (crash cart on the other side of the facility). LPN J was asked by the surveyor if this delayed removing the dark liquid from Resident #102's mouth and providing an open airway for staff to provide ventilation of Resident #102. LPN J stated, yeah, I would say it was (a delay in clearing her airway). In an interview on [DATE] at 11:25 am, CNA I stated, No the suction machine on the crash cart did not work. In an interview on [DATE] at 11:57 am, Paramedic F stated Resident #102 had her mouth full of coffee ground emesis. (I) tried to suction but their's (facility suction) wasn't working, I ended up running out to the ambulance for another suction machine. Review of the PO L body camera video dated [DATE] at 04:36 am, revealed Resident #102 had a dark liquid coming from her mouth. The body camera video further revealed PO L told facility staff to just put it in the mouth (for staff to use suction machine) and audible staff response on the video was it's (suction machine) not working. Review of the PO L body camera video dated [DATE] at 4:40 am revealed Paramedic F stated, it's (facility suction machine) not doing much, gonna have to get our suction. Review of the PO L body camera video dated [DATE] at 4:44 am, revealed Paramedic F returned to Resident #102's room with a functioning suction machine. In an interview on [DATE] at 11:57 am, Paramedic F stated, Resident #102 was in asystole (no heart rhythm) the whole time. Review of the Record of Death dated [DATE] at 5:15 am revealed Resident #102 was pronounced deceased . On [DATE] at 5:15 pm, Nursing Home Administrator (NHA) A was notified of an Immediate Jeopardy that began on [DATE] at approximately 4:28 am when the facility failed to provide adequate Cardio [MEDICAL CONDITION] Resuscitation (CPR), use of an automated external defibrillator or ensure a functioning suction device for Resident #102 who had been found unresponsive without vital signs. On [DATE], the surveyor confirmed that the facility staff implemented the following to remove the Immediate Jeopardy: 1. On [DATE], the facility audited 53 out of 53 resident charts and orders for correct code status. 2. On [DATE], the facility ensured 53 out of 53 residents for the identification of code status per policy- red/green. 3. On [DATE], the facility verified 13 out of 13 nurses CPR certification are current. Healthcare Provider American Heart Association with AED. 4. Beginning [DATE], DON B began in-service of all licensed nursing staff to the code procedure, AED and crash cart equipment operation including suction machine and daily checks of all equipment on the crash cart. In-services completed by DON B by 8:10 pm on [DATE]. 5. Beginning [DATE], the facility began to conduct mock code drill all shifts starting on [DATE], 1st shift mock drill was completed by DON B on [DATE] at 7:30 pm, and second shift mock drill was completed by DON B on [DATE] at 11:15 pm. The 3rd shift mock drill was completed on [DATE] at 7:20 am by DON B. 6. Beginning [DATE], all new admissions will have their code status reviewed and any current resident with any changes in code status will be verified by the DON or designee with proper identification placed in the chart. 7. Beginning [DATE], all code status changes will be discussed in the morning clinical meetings Monday - Friday. 8. Beginning [DATE], nurse CPR certifications will be monitored and newly hired nurses must have valid CPR certification verified by the Administrator or designee. 9. Beginning [DATE], mock code drills will be conducted by the DON or designee monthly. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the State Agency had not verified sustained compliance.

Based on observation, interview and record review, the facility failed to prevent the development and worsening of pressure ulcers in 1 (Resident #6) of 3 residents reviewed for pressure ulcers, from a total sample of 15 residents, resulting in Resident #6 developing an unstagable pressure ulcer and three additional stage 2 pressure ulcers. Findings include: Review of a facility "Face Sheet" indicated Resident #6 was a [AGE] year old man originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a "Minimum Data Set" (MDS) assessment dated [DATE] indicated Resident #6 had short and long term memory problems, could rarely make his needs known and was rarely able to understand others. Resident #6 required extensive assistance of two people for bed mobility and dressing, was totally dependent on staff for transfers and eating, and was totally dependent on two people for toilet use. According to a skin assessment, documented in the MDS, Resident #6 was at risk for developing pressure ulcers and was not coded for having any unhealed pressure ulcers. Review of an "Admission Braden Scale for Prediction of Pressure Sore Risk" dated 6/30/2014, indicated Resident #6 was a "high risk" for developing a pressure ulcer. Review of a "Care Plan" dated 4/03/14, indicated Resident #6 was at risk for skin breakdown related to [MEDICAL CONDITION], impaired cognition, [MEDICAL CONDITION] issues, abnormal labs, limited mobility, admitted with a pressure ulcer right heel. The goal of the plan of care was "(Resident #6) will not exhibit further skin breakdown" Interventions included: assess resident for presence of risk factors, treat, reduce and eliminate risk factors to the extent possible, turn and reposition every 2 hours and as needed as resident will allow including elevation of heels, conduct a systematic skin inspection weekly. Pay particular attention to bony prominences, CNA to observe skin integrity daily with cares, large TED hose as ordered. Review of a "Care Plan" dated 4/03/14, indicated Resident #6 was admitted with an unstagable pressure ulcer to his right heel, risk factors noted were impaired cognition, abnormal labs, [MEDICAL CONDITIONS] and "rubs heels". Interventions on the "Care Plan" included "Assess the condition of skin surrounding the ulcer, assess ulcer for changes in size and characteristics weekly, conduct a systematic skin inspection weekly and PRN (as needed), report any signs of further skin breakdown, CNA to observe skin integrity during daily cares, keep resident off affected areas as much as possible, notify physician if site exhibits decline in status, signs and symptoms of infection or pain is uncontrolled or increased, turn and reposition every 2 hours and PRN as resident will allow, large TED hose as ordered. Review of "Skin Check" sheets (used by CNA's to document any abnormalities on the skin of residents noted during showers/baths) reflected the following: - On 4/4/14 Resident #6 had a "sore on heel" and "private parts is very sore and red (penis) - On 4/8/14 Resident #6 was noted to have "bleeding from penis", the sore on heel was not noted - On 5/6/14 Resident #6's skin was "intact" - On 5/8/14 "no open areas", red buttocks - On 5/16/14 Resident #6's right buttock had a "little sore" - On 5/20/14 Resident #6's skin was "intact" - On 5/29/14 no findings were documented - On 6/20/14 Resident #6's skin was noted to be "intact...nothing new" - On 6/29/14 Resident #6's skin was documented as "intact". Review of "Treatment Flowsheets" for the month of July 2014 indicated Resident #6 was to have "TED hose applied in AM and Removed in PM", "Weekly Skin Assessment" and "Cleanse Right heel with NS (normal saline), apply skin prep, cover with xeroform and island dressing on M-W-F and as needed, and "Cleanse Left inner foot with NS apply xeroform and island dressing daily and PRN. During an observation on 7/23/14 at 2:15 p.m., in Resident #6's room in the presence of Licensed Practical Nurse (LPN) "Q" and LPN "R", Resident #6 was noted to have a stage 2 pressure ulcer on both right and left heels and an unstagable pressure ulcer on his right inner ankle (as evidenced by a thick scab like area - eschar) as well as two stage two pressure ulcers on his buttocks. In an observation on 7/24/14 at 3:00 p.m., Resident #6 was noted to be lying supine in his bed, in his room with his feet located on the bed, not elevated. During an observation in Resident #6's room on 7/24/14 at 3:30 p.m., LPN "U", a wound care nurse filling in at the facility during the survey, performed a dressing change on Resident #6's wounds, staging both heels at stage 2, as well as the buttocks and the ankle. During an interview on 7/23/14 at 3:10 p.m., Physician/Medical Director (MD) "J" was asked if he was aware Resident #6 had 4 pressure ulcers in addition to the right heel ulcer he was admitted with and he said "No, I was not aware of any additional open area on (Resident #6)". MD "J" stated, "I guess we really do have a broken system (for identifying changes in condition)". In an observation on 7/25/14 Resident #6 was observed to be sitting in a chair at his room at 8:55 a.m. At 10:30 a.m., Resident #6 was observed to remain sitting in his chair in the same location.

This citation pertains to intake number MI 124 Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one resident (Resident #101) in 1 of 5 sampled residents from a total of 5 sampled residents by not immediately performing Cardiopulmonary Resuscitation (CPR) and by not immediately activating Emergency Medical Services (EMS), after Resident #101 was found unresponsive and had an Advanced Directive in place designating him as being a Full Code. This deficient practice resulted in an Immediate Jeopardy when Resident #101, who was a Full Code, was found unresponsive on [DATE] at 10:30 a.m. and CPR and an EMS response was not initiated by facility staff for 27 minutes. This deficient practice placed 30 residents, who were identified as being Full Codes, at risk for serious harm, injury, and/or death. Findings include: Review of the Face Sheet revealed Resident #101 was an [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #101 had [DIAGNOSES REDACTED]. The Medical Treatment Decisions of Resident Form, dated [DATE], revealed that Resident #101 prepared an Advanced Directive that indicated his wishes were to have CPR. Review of the Physicians Orders, dated [DATE], revealed the code status for Resident #101 will be Full Code until "no code" paperwork was signed. Review of Physician Standing Orders (no date), revealed Resident #101 "Emergency measures *CPR/no CPR per code status - see Advanced Directive sheet in front of chart *If desire CPR - call 911 and notify Physician." Review of the Facility CPR Policy and Procedure, revealed the Lippincott Manual of Nursing Practice 8 th Edition, Procedure Guideline ,[DATE], nursing action was to determine unresponsiveness of patient, activate EMS (call 911), lay patient on a firm flat surface, open airway with a head tilt, check breathing and perform rescue breathing. The Guidelines revealed that if a pulse was not palpable, start external chest compressions. In interviews conducted on [DATE] at 1:30 p.m. and 6:45 p.m., Licensed Practical Nurse (LPN) #1 reported that on [DATE] at 10:15 a.m., Resident #101 was receiving a breathing treatment. LPN #1 reported that she left Resident #101's room and went to prepare his morning medications. LPN #1 reported that at 10:30 a.m., she went back to Resident #101's room with his medications and he was positioned differently. She checked his peripheral pulses in both wrists and listened to his heart with her stethoscope. LPN #1 stated Resident #101 had "passed away". LPN #1 reported that she went to get Registered Nurse (RN) #2, to verify that Resident #101 had passed away. LPN #1 reported that it took her until about 10:45 a.m. to locate and return to Resident #101's room with RN #2. LPN #1 reported that RN #2 checked Resident #101's vital signs, checked Resident #101's chart, found he was a Full Code and called a code. LPN #1 reported that the ambulance arrived before CPR was started. Review of LPN #1's Written Statement, dated [DATE], revealed LPN #1 called 911 then call Family Member #1 and told her Resident #101 had passed. LPN #1's Written Statement revealed, "it was my judgment, that without the apical and respirations that he (Resident #101) had passed." In an interview on [DATE] at 3:10 p.m., RN #2 reported that on [DATE], LPN #1 had her come to assess Resident #101. She found that he was not breathing, felt for a pulse on his neck, did a blood pressure check, checked his pulse oxygen and got nothing. RN #2 reported that she went to check Resident #101's chart and saw he was a Full Code, so she told LPN #1 to call 911 while she went to get the crash cart. RN #2 reported that Emergency Medical Services (EMS) was arriving on scene at the same time as she was bringing the crash cart in Resident #101's room. Per the American Red Cross First Aid and Safety Handbook (2011), "A person in [MEDICAL CONDITION] is unconscious, not breathing and has no heartbeat." The Handbook revealed that a person in [MEDICAL CONDITION] will have the greatest chance of survival if there is 1) early access to the EMS system, 2) early CPR, 3) early defibrillation, and 4) early advanced medical care. The Handbook also revealed that "without early CPR and defibrillation, the chance for survival is greatly reduced." The Handbook mentioned that "once you begin CPR, do not stop except in one of these situations...another trained responder or EMS personnel take over." In an interview on [DATE] at 4:10 p.m., Certified Nursing Assistant (CNA) #2 reported that on [DATE] at 10:55 a.m., she was just returning from break and went to Resident 101's room. The crash cart had just arrived and the first Emergency Medical Responder was coming in and asked if CPR had been started and she heard LPN #1 state "no". Review of the Ambulance Report, dated [DATE], revealed EMS personnel received a call from the facility at 10:51 a.m. and arrived at the scene at 10:57 a.m., after which CPR was initiated. The Ambulance Report revealed, Resident #101 was transported to the hospital by the EMS personnel at 11:34 a.m., where Resident #101 died at 12:41 p.m. Review of the Emergency Physicians Record, dated [DATE], revealed Resident #101's "down-time before Advanced Cardiovascular Life Support (ACLS) (is) unknown (possibly 30 minutes)". The Emergency Physician Records revealed, the initial findings by the paramedics were that Resident #101 was unresponsive, with no respirations, and a weak pulse. The Emergency Physician Records revealed, Resident #101 received pre-hospital treatment which included oxygen, CPR, intravenous (IV) access, IV fluids, [MEDICATION NAME], and sodium [MEDICATION NAME]. The Emergency Physician Records revealed that the initial Electrocardiogram (EKG) for Resident #101 was sinus rhythm with multiple premature ventricular contractions (PVC's). The Emergency Physician Records revealed, CPR was continued from 11:35 a.m., when EMS brought Resident #101 to the hospital, until the code was stopped at 12:41 p.m. and Resident #101 was pronounced dead. On [DATE] at 2:49 p.m., the Administrator was notified of the Immediate Jeopardy which began on [DATE], and was identified on [DATE], when the facility failed to provide care and services to attain or maintain the highest practicable physical well-being (perform CPR and initiate EMS on a Full Code resident) for Resident #101, who had Advanced Directives in place for CPR. Resident #101 was found unresponsive on [DATE] at 10:30 a.m. and CPR was not started by EMS personnel until 10:57 a.m. On [DATE], this Surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1. On [DATE], upon realization that Resident #101 was a Full Code, 911 was called and nurses gathered a crash cart to initiate CPR. As a nurse was coming down the hall with the crash cart EMS arrived and started CPR. 2. On [DATE] the Assistant Director of Nursing (ADON) , the Director of Nursing (DON) , and the Regional Director of Nursing in-serviced 7 out of 7 nurses, who were educated on Advanced Directives, where to locate in the Advanced Directives in the residents' charts (Tab would be in the front of the chart), paging overhead to get rapid response for emergency occurrences, location of crash carts in facility, when/how to call 911, utilization of the crash cart, and to perform a code on Full Code residents at all times until EMS arrives and takes over. 3. On [DATE] the DON and ADON educated 3 out of 3 nurses on the information contained in paragraph #2, before the nurses were allowed to work. 4. On [DATE] the DON and ADON educated 3 out of 3 nurses before they were allowed to work. The nurse were educated on the information in paragraph #2. The ADON educated 1 out of 1 nurse on [DATE] prior to the nurse being allowed to work. 5. On [DATE] -- 59 out of 59 Residents charts were audited for DNR status/accuracy. 6. On [DATE] a new process was implemented to recognize DNR/Full Code status in 59 of 59 residents' charts, as well as placing color coded sheets in 59 of 59 residents' charts to immediately recognize what the code status was. 7. On-going monitoring of Code Status was initiated on [DATE] by the Social Service Director and continues today. This monitoring will be weekly times 4, then monthly times 2 and followed by review in QAPI. The DON and Social Service Director will review daily changes in Code Status during morning clinical meeting 5 times per week. 8. The Administrator/DON/Designee will review in QAPI to ensure and sustain overall compliance. Although the Immediate Jeopardy was removed [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, due to the State Agency not being able to verify sustained compliance. #

This citation pertains to intake number MI 124. Based on interview and record review, the facility failed to provide the necessary care according to professional standards of quality for one resident (Resident #101) in 1 of 5 sampled residents from a total of 5 sampled residents by not immediately performing Cardiopulmonary Resuscitation (CPR) and by not immediately activating Emergency Medical Services (EMS), after resident #101 was found unresponsive and despite Resident #101 being a Full Code. This deficient practice resulted in facility staff not performing CPR for 27 minutes after Resident #101 was found unresponsive. Findings include: Per the American Red Cross First Aid and Safety Handbook (2011), "A person in [MEDICAL CONDITION] is unconscious, not breathing and has no heartbeat." The Handbook revealed that a person in [MEDICAL CONDITION] will have the greatest chance of survival if there is 1) early access to the EMS system, 2) early CPR, 3) early defibrillation, and 4) early advanced medical care. The Handbook also revealed that "without early CPR and defibrillation, the chance for survival is greatly reduced." The Handbook mentioned that "once you begin CPR, do not stop except in one of these situations...another trained responder or EMS personnel take over." According to The Fundamental of Nursing (Potter and Perry, 6 th Edition, 2005), "[MEDICAL CONDITION] is characterized by an absence of pulse and respiration. If the nurse determines that the client has [MEDICAL CONDITION], cardiopulmonary resuscitation (CPR) must be initiated. CPR is basic emergency procedure of artifical respiration and manual external cardiac massage." According to The Legal and Ethical Issues In Nursing, Fourth Edition, by Guido (2006), "Standards of care must have and use the knowledge and skill ordinarily possessed and used by nurses actively [MEDICATION NAME] in the nurse's specialty area." According to the Nurse's Problem Solver, (1995), "by providing emergency resuscitative support, these procedures restore spontaneous heart rate and respirations and prevent hypoxic damage to the brain and other vital organs. Responding to a code swiftly and effectively is essential to saving a patients life." Review of the Facility's CPR Policy and Procedure, revealed the Lippincott Manual of Nursing Practice 8 th Edition, Procedure Guideline ,[DATE], nursing action was to determine unresponsiveness of patient, activate EMS (call 911), lay patient on a firm flat surface, open airway with a head tilt, check breathing and perform rescue breathing. The Guidelines revealed that if a pulse was not palpable, start external chest compressions. Review of the Face Sheet revealed Resident #101 was an [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #101 had [DIAGNOSES REDACTED]. The Medical Treatment Decisions of Resident Form, dated [DATE], revealed that Resident #101 prepared an Advanced Directive and stated his wishes were to have CPR. Review of the Physicians Orders, dated [DATE], revealed the code status for Resident #101 will be Full Code until "no code" paperwork was signed. Review of Physician Standing Orders (no date), revealed Resident #101 "Emergency measures *CPR/no CPR per code status - see Advanced Directive sheet in front of chart *If desire CPR - call 911 and notify Physician." In interviews conducted on [DATE] at 1:30 p.m. and 6:45 p.m., Licensed Practical Nurse (LPN) #1 reported that on [DATE] at 10:15 a.m., Resident #101 was receiving a breathing treatment. LPN #1 reported that she left Resident #101's room and went to prepare his morning medications. LPN #1 reported that at 10:30 a.m., she went back to Resident #101's room with his medications and he was positioned differently. She checked his peripheral pulses in both wrists and listened to his heart with her stethoscope. LPN #1 stated Resident #101 had "passed away". LPN #1 reported that she went to get Registered Nurse (RN) #2, to verify that Resident #101 had passed away. LPN #1 reported that it took her until about 10:45 a.m. to locate and return to Resident #101's room with RN #2. LPN #1 reported that RN #2 checked Resident #101's vital signs, checked Resident #101's chart, found he was a Full Code and called a code. LPN #1 reported that the ambulance arrived before CPR was started. In an interview on [DATE] at 3:10 p.m., RN #2 reported that on [DATE], LPN #1 had her come to assess Resident #101. She found that he was not breathing, felt for a pulse on his neck, did a blood pressure check, checked his pulse oxygen and got nothing. RN #2 reported that she then went to check Resident #101's chart and saw he was a Full Code, so she told LPN #1 to call 911 while she went to get the crash cart. RN #2 reported that Emergency Medical Services (EMS) was arriving on scene at the same time as she was bringing the crash cart in Resident #101's room. In an interview on [DATE] at 4:10 p.m., Certified Nursing Assistant (CNA) #2 reported that on [DATE] at 10:55 a.m., she was just returning from break and went to Resident 101's room. The crash cart had just arrived and the first Emergency Medical Responder was coming in and asked if CPR had been started and she heard LPN #1 state "no". Review of the Ambulance Report, dated [DATE], revealed EMS personnel received a call from the facility at 10:51 a.m., arrived at the scene at 10:57 a.m., after which CPR was initiated. The Ambulance Report revealed Resident #101 was transported to the hospital by the EMS personnel at 11:34 a.m., where Resident #101 died at 12:41 p.m. Review of the Emergency Physicians Record, dated [DATE], revealed Resident #101's down-time before Advanced Cardiovascular Life Support (ACLS) (is) unknown (possibly 30 minutes). The Emergency Physician Records revealed that the initial findings by the paramedics were that Resident #101 was unresponsive, with no respirations, and a weak pulse. The Emergency Physician Records revealed that CPR continued from 11:35 a.m., when EMS brought Resident #101 to the hospital, until the code was stopped at 12:41 p.m. and Resident #101 was pronounced dead. #