Every finding on record at The Lakeland Center

This citation pertains to intake: 3104898.Based on interviews and record reviews the facility failed to ensure timely services and care for three (R's 202, 203 & 204) of three residents reviewed. This deficient practice had the ability to affect all residents residing on Unit 4 on 7/19/26. Findings include:A review of a complaint submitted to the State Agency (SA) noted the facility's failure to properly handle a sewage problem that affected residents care on 7/19/26, the evening shift on Unit 4.On 8/11/26 at 10:42 AM, an observation was conducted of the entire Unit 4. There was no water marks or damage observed on the unit walls or floors. A thorough walk through of the unit revealed no visible damage. No abnormal smells were identified. Observed by the Nurses station and vending machine room were circular silver metal plates on the floor (as if the plates were covering the floor drains). There was no damage or abnormal findings observed to these areas. The Certified Nursing Assistant (CNA) B (the aide assigned to Unit 4 on the evening of 7/19/26) was contacted on 8/11/26 at 10:58 AM, a return phone call was not received before the end of the survey.On 8/11/26 at 11:02 AM, a telephone interview was conducted with Licensed Practical Nurse (LPN) A (the Nurse assigned to Unit 4 on the evening of 7/19/26). When asked LPN A reported water was coming up from the silver plates on the floor of Unit 4 on the evening of 7/19/26. LPN A reported the water . did not reach above the sole of my shoe. LPN A stated they remembered housekeeping staff, the maintenance staff and a third party company working on the water issue. When asked, LPN A reported the medication administration for the residents on Unit 4 took a little longer that night.On 8/11/26 at 11:35 AM, Unit Manager (UM) C was asked to recall the water/sewage incident on the evening of 7/19/26. UM C reported clear water of puddles on certain parts of the unit and reported . it's not like the whole unit was flooded. UM C stated they gave the directive to CNA B and LPN A to ensure the residents stayed safely in their rooms, with the hazardous cones placed in the hallway. UM C also confirmed that the water did not come above the sole of their shoe. UM C stated they remembered going onto Unit 4 and finding the unit to be unattended by the staff. UM C stated they found CNA B and LPN A in the front foyer of the building. UM C stated they asked both CNA B and LPN A why they were not on Unit 4 attending to the residents and informed both that the Unit should never be unattended. UM C stated CNA B responded that they were not going to hurt themselves to provide care to the residents on Unit 4. UM C stated they observed CNA B and LPN A walk back to Unit 4. LPN A sat at the Nurses station and CNA B pulled up a chair and sat by the Nurses station. UM C stated when they left the unit both CNA B and LPN A were still sitting at the Nurses station.On 8/11/26 at 12:11 PM, the Director of Nursing (DON) was interviewed and asked to recall the water/sewage incident on the evening of 7/19/26. The DON reported they were informed of water coming up from the floor of Unit 4. The DON stated the maintenance director was informed and a third party company was also notified. The DON reported being notified of CNA B and LPN A refusal to go on the Unit and care for the residents. The DON stated they called LPN A who reported a smell on the unit and reported the unit to not be safe due to the puddles on the floor. The DON informed LPN A that all necessary parties had been notified with help in route and to ensure patient care continued. When asked why care was delayed for the residents for puddles of water that did not reach above the sole of the worker shoes, the DON replied they were under the impression that CNA B and LPN A went back to the unit to complete their duties. When asked if they were informed of UM C's observation of LPN A and CNA B sitting at the Nurses station observing the Unit instead of providing care for the residents, the DON reported they were not.The July 2026 medication administration audits were requested for R's 202, 203 & 204. A review of the audits revealed all of the resident medications were administered late, one was noted a few hours late while the other two were administered after midnight.Review of the medical records for R's 202, 203 & 204 revealed no documentation on why the resident's medications were delayed.On 8/11/26 at 2:30 PM, a follow up interview was conducted with the DON. The medication audits for R's 202, 203, & 204 were reviewed. The DON confirmed they were unaware of the late administration and stated that the residents care should have not been delayed as both CNA B and LPN A were both instructed to keep providing patient care.No further explanation or documentation was provided by the end of the survey.

This citation relates to Intake 3047919. Based on observation, interview, and record review, the facility failed to protect the residents' rights to be right to be free from physical abuse for three Residents (R902, R903, R904) of four residents reviewed for abuse, which resulted in injuries for R902, R903, and R904. Findings include: R902 and R903: On 6/29/26 at 9:38 a.m., R902 reported during an interview in their room they and R903 had a physical incident between them in April (2026), after R903 backed their wheelchair into them earlier, which had occurred on multiple prior occasions. R902 stated they punched R903 in the head, as this upset them. R902 clarified it upset other residents as well, when R903 was aggressive towards them with their wheelchair. R902 said the facility management told them they had the incident on their video cameras and saw them strike R903. R902 explained they had been told R903 had a prior head injury and never to do this again. R903 said they regretted their action and this would not recur. R902 was alert and oriented to their situation, surroundings, place, and time. Review of R902's psychiatric provider progress note, dated 4/10/26 at 14:41 (2:41p.m.), revealed, .Resident (R902) discusses recent incident with another resident (R903) at the facility. (R902) states other resident kept running into his wheelchair and then this other resident grabbed his arm and wouldn't let go. (R902) admits to reacting by hitting other resident but reports he knows he should not have done this. (R902) states has been keeping his distance (from R903) since the incident. If he (R902) sees the resident (R903) he just goes the other way. He (R903) reports feeling safe at the facility. He (R902) reports understanding that he should not have reacted in this way and we discussed other healthy ways to deal with situations in the future. He is at his psycho-social baseline. The note also showed R902 denied need for medication adjustments and was on Cymbalta 30 mg twice daily (an antidepressant medication). Review of R902's physician team note, dated 4/09/26 at 16:00 (4:00 p.m.) revealed, .Mild wrist pain s/p (status post) altercation x1 day. HPI (History of Present Illness): Pt (R902) involved in altercation with another resident yesterday. Reports mild right wrist pain. R902 was noted as alert and oriented x 3 - 4 (spheres) during the visit. Review of R902's progress note, dated 4/13/26 at 13:34 revealed, Reviewed resident's x-ray post incident; no fractures or other injury noted. Review of R902's profile revealed they were their own responsible party. Review of R902's Minimum Data Set (MDS) assessment, dated 4/24/26, revealed R902 was admitted to the facility on [DATE], with diagnoses including heart failure, stroke, depression, and malnutrition. The assessment showed R902 was independent with eating and dependent for transfers. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed R902 was cognitively intact. The behavior assessment showed no signs of psychosis or behaviors. Review of R903's investigation incident file revealed R902's prior BIMS score on 1/22/26 was 14/15, which showed R902 was cognitively intact at that time, prior to the incident. Review of R903's MDS assessment, dated 5/15/26, showed R903 was admitted to the facility on [DATE], with diagnoses including head injury, seizure disorder, anxiety, and depression. R903 was able to feed themselves with set up and was dependent for transfers. The cognitive assessment showed R903 was severely cognitively impaired. The assessment showed no psychosis or behaviors. On 6/29/26 at 12:55 p.m., Licensed Practical Nurse (LPN) A acknowledged they were working on 4/08/26 when the incident occurred between R902 and R903. LPN A said they were at the nurse's station when they overheard R902 say, If you touch me, I will hit you. and then they saw R903 close and trying to reach out so they separated them and took them back to their rooms. LPN A said R902 denied touching R903 at that time and they could not ask R903 as they were nonverbal. LPN A said when they returned to work a few days later they heard there was a physical confrontation between R902 and R903. LPN A said neither resident appeared injured. LPN A clarified when asked there were no staff present when they intervened.On 6/29/26 at approximately 1:10 p.m., LPN B was asked about any incident between R902 and R903. LPN B said they were doing medication pass with LPN A on 4/08/26, when the incident occurred and said they did not see anything happen. LPN B said R903 was capable of understanding and could answer yes and no questions accurately but was nonverbal essentially. LPN B said when asked R903 bumped their wheelchair into everything, and R903 had the ability to be intentional in their actions. On 6/29/26 at 2:05 p.m., R903 was observed dressed in their power wheelchair in the dining room on the second floor, watching television while other residents were engaged in an activity. R903 had no bruising observed and was wearing a right elbow orthopedic brace (longstanding). When asked how they were doing, R903 was alert, made eye contact, and nodded yes. R903 was unable to answer any additional questions.On 6/29/26 at 2:13 p.m., R902 was observed seated in their power wheelchair on their unit; it was noted they had above knee amputations of both their legs. R902 reclarified the incident, and said R903 backed into their wheelchair three times earlier and said they clocked him in the head, and said staff told them the camera told the story. R902 reported they did this intentionally, as they had become tired of R903 wheeling their wheelchair into them and the other residents, and said they believed R903 backed into them on purpose. On 6/29/26 at approximately 3:00 p.m., Social Worker (SW) C was asked about the incident between R902 and R903 on 4/08/26. SW C reported R902 said R903 was antagonizing him and they made physical contact. SW C said they only saw part of the camera footage and saw swatting but did not elaborate when asked. SW C was asked about any additional interventions put in place as R902 and R903's care plans showed none. SW C said they reached out to psychiatry services and confirmed that there were no medication changes or other interventions added after this first incident. SW C confirmed there was no consistent increased supervision of R903 care planned. SW C acknowledged R903 had been observed taking the elevator up and down independently and with a BIMS of 0 (severe cognitive impairment) would benefit from increased supervision when on the elevator and in the lobby.Review of R903's investigation summary, provided by management, revealed on 4/08/26, .Watching TV while seated in his wheelchair Res (R902) approached (R903), stated words and then reached toward him, making contact with his open-handed finger (to) resident's (R903) head; no deficient practice was identified.No pain.Review of R902's investigation summary, dated 4/08/26 at 3:14 p.m., .Staff reported (R902) bragging about hitting (R903). This was reported to Admin (administration). Investigation began. Statements were obtained. A review of video surveillance separate.Review of a typed investigation summary, undated, showed, On 4/09/26, (R902) reported to staff that an incident occurred between (R903) and himself. Investigation initiated.A review of the facilities video surveillance system of April 8, 2026, revealed that (R903) was seated in his wheelchair in the dining room at approximately 9:30 a.m. watching television. At approximately 9:37 a.m. on April 8, 2026, (R902) enters the dining room near the location where (R903) was sitting. (R903) could see (R902) from his peripheral; (R902) began speaking to (R903); (R902) turned his head slightly to acknowledge (R903) then quickly turned his head away towards the television. (R902) continued to speak to (R903). (R902) began to navigate his wheelchair closer to (R903) until he was within his arms reach. (R902) then reached out towards (R903)'s head, making contact to (R903's) head with the tip of his four fingers of his right hand. (R903) then reached for (R902's) wheelchair, striking it a few times. (R902) grabbed (R903's) left hand in an effort to stop him from striking his chair. (LPN A) attests to hearing (R902) yell and quickly intervened. Review of findings showed physical contact was substantiated and abuse was denied, and the police were contacted. Surveyor requested to review video footage of the incident and was informed by management the video footage was no longer available.Review of R902 and R903's care plans showed no new interventions to address R902 and R903's behaviors were put in place after the resident-to-resident incident on 4/08/26, until a second resident-to-resident incident occurred with R903 and another resident, on 5/29/26. R903 and R904On 6/29/26 at approximately 9:50 a.m., R902 stated there was a second physical altercation between R903 and R904 in the facility elevator in May (2026), when they punched each other. R902 said R903 went up and down the elevator unsupervised frequently and had a third resident-to-resident physical incident last year in November (2025). R902 said they felt safe however believed R903 needed to be supervised more closely, as R903 often rode up and down the elevator alone, and kept backing their wheelchair into residents and striking them intentionally. Review of a typed investigation summary, undated, showed, On 5/29/26 at approximately 9:10 a.m., the Administrator was notified there was a physical altercation between (R903) to (R904). MN (midnight) nurse reported being on the elevator with (R904) and (R903) to assist them getting on the bus for Work Day, when (R903) grabbed (R904's) coat and (R904) took a swing at (R903) .causing him to lose his balance and stumble over. MN nurse continued to intervene with elevator reaching the 1st floor. Therapy (staff) and a Day Shift Nurse was awaiting and observed the incident, immediately assisted with intervention and separated residents successfully.The investigation report further revealed, .According to the MN nurse that was on the elevator, (R903) mumbled something to (R904) while grabbing his coat, when (R904) took a swing at (R903), . attempted to stop them but .couldn't. The elevator (door) came open and therapy and day shift nurse helped. The report showed the intervention after the incident was to change R903 and R904's rooms to ensure no contact between them on separate units and halls. R903 was found to test positive for a UTI (urinary tract infection) and placed on an antibiotic and found to have cognitive impairment. The report showed the conclusion was that abuse was unable to be substantiated.Review of R904's Accident and Incident report, dated 5/29/26 at 8:00 a.m. revealed, Altercation with another resident (R903) witnessed by other staff members. Staff alerted nurse of altercation. During altercation resident (R904) had a fall after residents were seen grabbing and hitting each other. Another resident (R903) had gotten on the elevator and used his wheelchair to hit (R904). Resident (R904) tried to move resident and that (sic) grabbed at his shirt aggressively. After getting off elevator, (R903) swung and (R904) threw a punch and then fell to the floor. Then staff came to break up the altercation. (R903) placed in his room and an assessment was done. (R904) reported no pain or discomfort, although (R904) had a skin tear on her index finger and a layer of skin removed under elbow. The assessment showed R904 was alert and oriented x 4 and sustained a left-hand abrasion and bruise (to) left elbow.Review of R903's Accident and Incident report, dated 5/29/26 at 8:00 a.m., revealed, .During altercation, (R903) had become aggressive with another resident (R904) and hit him with wheelchair, then both resident (sic) was seen hitting and grabbing at each other.Resident had a bruise under left eye.Other info: Resident was involved in an altercation with another resident. Per the report, R903 was only oriented to themselves. Review of LPN E's witness statement, dated 6/04/26, revealed, Noticed x 2 nurses coming in and out of elevator yelling, Stop (R903), Stop. Writer proceed to elevator to find (R904) on the floor against L (left) wall and (R903) in wheelchair. (R904) proceeded to pull self towards rail and struck (R903). Writer proceed to remove (R903) hand from rail and separated (R903) from situation. (R903) was placed safety distance aware from elevator and remained with him (R903) until all clear.Review of LPN F's witness statement, dated 5/29/26, revealed, I (LPN F) was in the elevator with (R903) when (R904) entered. As (R904) stepped in, he remarked that (R903) needed a jacket and then accused him of being aggressive and tripping (him) yesterday. (R903) then grabbed (R904's) shirt, and they began hitting each other in the head. They were arguing intensely. I quickly tried to separate them, urging them to stop and not to hit each other. When the elevator doors opened, staff were present to assist me in breaking up the altercation.Review of LPN G's witness statement, signed by LPN G, dated 6/05/26, revealed, I (LPN G) was standing in front of elevator door waiting to go upstairs to the second floor with a new orientee when I heard, Stop, stop y'all, (R903), stop, stop. When the elevator door opened, I saw (R904) and (R903) and a nurse from midnight (LPN F). (R904) and (R903) were swinging fist (sic) at each other. I saw (R903) punch (R904) in the face and (R904) fell to the floor. It looked like it happened in slow motion. After witnessing (R903) punch (R904) in the face, I grab (sic) (R903's) wheelchair and began pulling him out of the elevator using his wheelchair. (R903's) wheelchair wheel became stuck, so (therapy staff member) ran out and assisted me. (R904) was assisted off the floor and given back his cane. (R903) began to angrily wheel (R903) down the hall. From what I witnessed, (R903) was the aggressor. I did witness (R904) swing a punch towards (R903) however the punch did not make contact.On 6/29/26 at 3:45 p.m., LPN G was contacted by phone and left a voicemail, with no call returned by survey exit.On 6/29/26 at 3:52 p.m., LPN F was contacted by phone and left a voicemail, with no call returned by survey exit.Review of R904's mood and behavioral Care Plan confirmed after the incident their room was changed. Review of R904's medical record showed they were admitted to the facility on [DATE], with diagnoses including a brain injury, mood disorder, repeated falls, depression, and epilepsy, and ambulated with a cane. Review of R904's psychology consult, dated 6/05/26 (after the incident), revealed R904 had a diagnosis of psychotic disorder with hallucinations however presented with no delusions, paranoia, hallucinations, or perceptual disturbances, with normal affect and a history of traumatic brain injury.Review of R904's labs, dated 6/01/26, showed no abnormalities indicative of an infection or UTI.Review of R903's progress note, dated 5/29/26 at 11:35 a.m., showed R903 had bruising on left eye after the incident, which was treated and stated they had no pain.On 6/29/26 at approximately 3:15 p.m., SW C was asked about the second incident, between R903 and R904, on 5/29/26. SW C acknowledged physical contact occurred between R903 and R904. SW C was asked about any new intervention for R903 after the first resident to resident incident on 4/08/26. SW C acknowledged they did not see any updated interventions. SW C was asked if there had been any medication changes and reported there were none. SW confirmed R904's room had been changed.On 6/26/26 at 4:11 p.m., LPN D stated on 5/29/26, they were the nurse for both residents when R903 hit R904's foot with their wheelchair and R903 and R904 were then hitting each other, with a nurse in the elevator with them. LPN D said they did not witness the incident themselves, and said the altercation went from the elevator and when the doors opened the incident continued. LPN D explained there were mild injuries including R903 had swelling and bruising over their left eye which they addressed, and R904 had skin tears which they cleaned up. When asked about R903's behaviors, LPN D shared R903 was aggressive at times and rolled their wheelchair over people's feet and was hitting people although they did what they could to supervise them on the unit. LPN D said R903 liked to go up and down on the elevator himself and watched television downstairs. LPN D clarified they contacted R903's physician after the incident, who did not make any medication changes. which they confirmed as they were R903 and R904's nurse regularly. Per LPN D, both residents went to their work program after the incident. Surveyor attempted to interview R904 during the survey on 6/26/26, however they were unavailable as they were at their work program. Review of R903's Care plan showed a revision, dated 5/29/26 (after the second incident), with two new interventions related to addressing R903's agitation and behaviors. There were no updated interventions since 11/04/25, including after the 4/08/26 to address R903's ongoing behavioral concerns reported by staff and residents. Review of R903's progress note, dated 6/25/26, revealed, Xanax (short-term anxiety medication) Oral tablet 0.25 MG (milligrams). Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 days. Resident showing signs of anxiety, propelling himself aggressively through facility, and going up and down the elevator repeatedly, 1 tablet given. Review of R903's progress note, dated 6/21/26, revealed, Xanax Oral tablet 0.25.resident displaying restlessness or anxious behavior, propelling himself through the facility and repeatedly going up and down on the elevator. Review of R903's progress note, dated 6/12/26, revealed, PA (physician assistant) in to visit, nurse voice concerns with resident impulsive behavior. Resident noted to be up/down hallway, on and off elevator, staff assisting and monitoring resident to ensure resident safety, easily agitated when redirected. Staff attempts diversion and distraction techniques, successful momentarily. New order given for Xanax prn (as needed) . Review of R904's progress noted, dated 6/14/26 at 18:44 (6:44 p.m.), revealed, Writer was made aware of a physical altercation involving the resident and another resident with his cane. Writer was notified that the resident almost placed his cane to another resident's head but was stopped by a housekeeper. This was a second resident-to-resident aggression incident for R904. Review of R904's psychiatric provider note revealed R904 was seen on 6/19/26 for follow up and medication review after the incident. The note showed, Assessment and Plan: .Traumatic Brain Injury.Mood disorder.Patient has been irritable with low frustration tolerance and impulsive behaviors recently. On 6/14/26, nursing documented that resident voiced frustration regarding his roommate and was involved in a physical altercation with another resident (unnamed) involving his cane. R904 was started on Depakote (a mood stabilizer) per the provider note. It was noted R904 was not on any new psychotropic medication recently/ prior to this second resident-to-resident incident for R904. R904 was prescribed Melatonin for sleep at the time of the incident. On 6/26/26 at 4:37 p.m., the Nursing Home Administrator (NHA) was asked about the incident with between R903 and R904 on 5/29/26. The NHA confirmed they did not have any video footage of the incident anymore as they could not save it. The NHA reported R903 could not report what happened with the incident due to severe cognitive impairment and both R903 and R904 were on the elevator with a staff member and being supervised. The NHA acknowledged R904 had a BIMS score of 13 (cognitively intact). The NHA was asked if they reported this incident to the police and denied reporting the incident to them. Surveyor shared abuse findings with the NHA who indicated they questioned whether the incident rose to abuse and understood a physical altercation occurred. Surveyor reviewed findings related to abuse and the incident between R902 and R903 on 4/08/26. The NHA respectfully denied the incident between R902 and R903 rose to abuse per their review of camera footage and their internal investigation. Review of the policy, Abuse, updated 5/24/26, Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint that is not required to treat the patient / resident's medical symptoms. The facility will develop and implement written policies and procedures that include: Screening.Training.Prohibiting, Preventing, and Identifying abuse, neglect, mistreatment, exploitation, and misappropriation of resident property.Identification: The facility will educate the staff in identifying abuse (mental/verbal abuse, sexual abuse, physical abuse, and the deprivation of an individual of goods and services, neglect, exploitation, mistreatment, and misappropriation of resident property). Possible indicators of abuse include, but are not limited to: Resident, representative, or staff reports of abuse.physical abuse of a resident observed.

This citation pertains to intake #'s 2998574, 2991736 and 3001096.Based on observation, interview and record review, the facility failed to ensure sufficient staffing to meet resident needs for three residents (R801, R804 and R805) of four residents reviewed for staffing. Findings include:On 5/6/26 multiple concerns that were submitted to the State Agency were reviewed which alleged the facility had insufficient staffing levels. On 5/6/26 a review of the facility resident council minutes for February and March 2026 revealed the following Nursing concerns: February- [Anonymous Resident] sits in her chair to long . March-Long wait time for help . Some days it takes too long to get out of bed. On 5/6/26 at approximately 12:21 p.m., Nurse A was queried regarding the facility staffing levels and they indicated that the facility does not have enough CNA's (Certified Nursing Assistants) Nurse A reported they have had one CNA that worked on Unit one many days of the week when three CNA's should be assigned to work. Nurse A was quired how the low level of CNA's assigned to the units affected resident care and they reported that call lights do not get answered on time and residents will have to wait for toileting care to be provided. Nurse A reported that Wednesday 4/22/26 only had one CNA and residents were delayed in getting out of bed until late in the morning due to many of the residents being a two-person assist. On 5/6/26 at approximately 1:03 p.m., CNA C was queried regarding the staffing levels in the facility. CNA C indicated that the staffing is bad and that the facility cannot keep CNA's employed. CNA C indicated that Unit one is supposed to have three aides working on the unit due to the acuity and lately they have been the only CNA on dayshift working the unit. CNA reported they typically work four shifts a week and of the four shifts, three of them they will be the only aide. CNA C was queried how the staffing levels affected resident care in the facility and they reported that the Residents do not get the care they deserve and it takes longer for incontinence care to be provided so residents will have to be wet/soiled longer. CNA C reported that some residents cannot be gotten up out of bed for the day because they are two-person assist and the Nurse is busy passing medication and cannot assist. CNA C reported that residents are missing showers because they do not have time to give them and it is taking a longer time to reposition residents who are supposed to be repositioned every 2 hours for wounds, but they cannot get to them. CNA C indicated that often times they will have 17-18 residents and they cannot give the care they deserve. On 5/6/26 a review of the April and March staffing assignments revealed Unit one was assigned one or two CNA's 9-10 times during the months with multiple call off's and staff being late on other units. On 5/6/26 at approximately 1:34 p.m., during a conversation with Nurse Manger I (NM I), NM I was queried regarding the facility staffing challenges and they reported they had been doing the staffing assignments as the acting staffing coordinator and reported the facility does not have enough CNA's to fill out the schedule appropriately. NM I was queried regarding the CNA assignments for Unit 1 and they indicated they could only put on the schedule who they had available to work and lately they have had problems [NAME] staffing the unit. NM I reported the facility does not utilize staffing agencies to fill vacant holes in the schedule and will sometimes be able to use a Nurse as a CNA. NM I was queried how the lack of staffing has affected the residents and they reported they have heard that the residents experience longer wait times for their call button to be answered. NM I reported they had notified the Director of Nursing (DON) and Administrator regarding the staffing shortages, and they were working on hiring more staff. On 5/6/26 at approximately 1:57 p.m., the DON was queried regarding the staffing shortages in the facility, and they reported they were aware to it and were working to correct the issues. The DON indicated they were new to the facility in the last few weeks, and they had recently requested an increase in PPD's (total number of Nursing hours worked in a 24-hour period) to try to cover all of the no-shows and call-offs the facility had been experiencing. On 5/6/26 at approximately 2:55 p.m., the Administrator was queried regarding the staffing levels in the facility and if they had picked up the concern in their QAPI (Quality Assurance Performance Improvement) meetings. the Administrator indicated they were aware of the lack of staffing in the facility and had identified it through the staffing audits they had been doing. The Administrator indicated they were attempting to put a plan into action to try to hire more CNA's and implement retention programs to try to keep the CNA's working in the facility. R804 On 5/6/26 at approximately 2:32 pm., R804 was observed in their room up in their electric wheelchair. R804 was queried regarding the staffing levels in the facility. R804 reported that the staffing was horrible and that they have been left in bed for hours because nobody was available to get them up in the morning. R804 reported they usually get up in the early morning with the assistance of the midnight shift but sometimes the midnight shift could not get them up and they had to rely on the dayshift which stated at 7:00 AM. R804 indicated that in April there were many days in which they were left in bed the entire morning due to the dayshift being understaffed. R804 reported that the Nursing staff told him they had no help and could not get him up. R804 indicated that they require two staff members due to them needing a mechanical lift and nobody can help them. R804 also reported they have had to wait hours for staff to clean them up after having a bowel movement due to their being only one Certified Nursing Assistant (CNA) assigned to their hallway and they need two staff members to safely provide changing. R805 On 5/6/26 at approximately 2:39 p.m., R805 was observed in their room, laying in their bed. R805 was queried if they had any concerns regarding the staffing levels in the facility and they reported it was terrible. R805 reported there are not enough staff to help them meet their needs. R805 reported they were quadriplegic and that they have to wait for hours for their call button to be answered when they push it for help. R805 reported they do not get out of bed anymore because they get left in their wheelchair all day due to their not being enough staff to help put them back into their bed when they want to go back in it. R805 reported the Nursing staff tell them that there are no staff to get them out of bed and they cannot get fresh water in the morning because the only Nursing aide is trying to get everyone up. R805 reported they have had their catheter bag full of urine for hours and nobody was able to empty it due to the staffing levels. R805 reported they have had meetings with the managers regarding the staffing levels, but nothing has improved and resident care keeps suffering because of it. On 5/6/26 a facility document titled Staffing was reviewed and revealed the following: POLICY OVERVIEW: The facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for the residents in accordance with the residents plan of care. A complaint was filed with the State Agency [SA] that alleged in part, .there was not an aid [sic] present in the facility to get [R801] dressed for her dialysis appointment on 4/24 [2026], so she did not make it to that appointment . there was just one aid [sic] for the entire unit on 4/24, and this is frequently an issue . Review of the clinical record revealed R801 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: end stage renal disease, dependence on renal dialysis and diabetes. According to the Minimum Data Set [MDS] assessment dated [DATE], R801 was cognitively intact and was marked as receiving dialysis in Section O0110 J1. On 5/9/26 at 11:11 AM, Nurse 'H', a Nurse Manager at R801's dialysis center was interviewed by phone and asked if R801 had received dialysis at the center on 4/24/26. Nurse 'H' explained R801 did not have dialysis that day, she never showed up to the center that day. On 5/9/26 at 11:46 AM, RN 'B' was interviewed and asked about getting R801 ready for dialysis in the mornings. RN 'B' explained she did not remember which day it was, but she was working as a CNA and the other CNA for that floor was late that day and she was trying to get R801 up and dressed when the other CNA showed up and they got her ready, she was late getting to the transportation van, but she did go to dialysis. On 5/9/26 at 12:21 PM, LPN 'A' was interviewed and asked about R801 being late for dialysis. LPN 'A' explained sometimes she has to get R801 up herself because there is no CNA, or only one CNA on the Unit, and the Unit Manager will assist with the mechanical lift to try to get her up and dressed on time. On 5/9/26 at 12:41 PM, Staff 'G', who was a driver of the facility transportation van, was interviewed by phone and asked about R801 not going to dialysis on 4/24/26. Staff 'G' explained R801 had called him to say she would not be going to dialysis that day because the facility was shorthanded. Staff 'G' was asked if R801 was usually on time for transportation to the dialysis center. Staff 'G' explained sometimes they were late in bringing her down to the van. On 5/9/26 at 3:20 PM, R801 was observed lying in bed. R801 explained she had just arrived back to the facility from her dialysis. R801 was asked what happened on 4/24/26 when she missed her dialysis treatment. R801 explained there was no one to get her up that morning . she was supposed to be taken down to the transportation van at 8:30 AM, and no one came to get her up until almost 10:00 AM that morning. R801 was asked if she is usually taken down to the van at 8:30 AM. R801 explained several times she has been taken down late, so she is late for her dialysis treatment, then her time is cut short and she does not receive the whole treatment when she is late. R801 continued to explain that there should be three CNA's for her Unit, but sometimes there is only one CNA . have to wait to be changed . missed a bed bath because there was not enough staff . there are six people on that Unit that staff have to hand feed breakfast, lunch and dinner . some CNA's tell her they will call in because having the whole Unit by themself is too hard and they are wiped out at the end of their 12 hour shift . when they have a new CNA they are supposed to work with somebody to learn how to do things, but they will have the new CNA do things alone and they do not know how to do things and then do not stay long. On 5/6/26 at 11:40 AM, an interview was conducted with Registered Nurse (RN) 'B'. RN 'B' reported the facility is often short on certified nursing assistants (CNAs) on most days. RN 'B' reported they worked as a CNA for 16 of 20 shifts since April 2026. RN 'B' reported only one CNA was often scheduled for Unit 1 where approximately 30 residents resided. When a nurse worked as a CNA that split up the residents, so they had 15 each. According to RN 'B', the CNA assigned to the unit followed the nurse which meant however many residents the nurse was assigned to, the CNA had the same amount. RN 'B' reported it was difficult to get all the required tasks completed unless their forfeited a break. At times, the midnight shift was short and if they did not get the residents up on their shift, the day shift had to do it, and often that resulted in residents not getting up according to their preferred times. RN 'B' reported CNAs call off, but there are not enough available to pick up shifts so only one is scheduled on Unit 1 a lot of the time, when there should be three. RN 'B' reported they have discussed the difficulty with staffing with Administration, and the new Director of Nursing was trying to advocate to get another CNA scheduled in, just in case of call ins.

This citation pertains to intakes 2615522, 2645363, and 2671721. Based on interview and record review, the facility failed to ensure that nursing staff received the required skills/competencies/performance evaluations for five of five Certified Nursing Assistants (CNA Y, Z, AA, BB, and CC) reviewed for education/training. Findings include:On 2/11/26 at 8:06 AM, the facility was requested via email to provide the CNA (Certified Nursing Assistant) skills competencies for CNAs (Y, Z, AA, BB, and CC).Review of the documentation provided by the facility revealed:CNA 'Y's most recent skills competency evaluation was completed on 7/18/24.CNA 'Z's most recent skills competency evaluation was completed on 8/8/24.CNA 'AA's most recent skills competency evaluation was completed on 1/23/24.CNA 'BB's most recent skills competency evaluation was completed on 11/2/22.CNA 'CC's most recent skills competency evaluation was completed on 6/27/24.On 2/11/26 at 12:45 PM, an interview was conducted with the Infection Preventionist / Staff Development (Nurse 'C'). They reported they had been in their role as Staff Development since mid October (2025). When asked about the facility's process for ensuring nurse staffing skills competencies were completed, Nurse 'C' reported they did reconcile the skills competency were done upon hire. When asked if they completed annual skills competency evaluations to determine areas that might need improvement, Nurse 'C' reported they were not aware those needed to be completed annually. When asked if there was any oversight from corporate for support, Nurse 'C' reported they did and was unable to offer any further explanation.According to the policy titled, Skills Evaluations dated 2/9/2024: .The skills evaluation checklist(s) is completed during job-specific orientation, re-validated annually, and completed as needed .

Based on interview and record review, the facility failed to maintain an effective Quality Assurance and Process Improvement (QAPI) Program that identified multiple systemic issues that needed improvement and correction. This had the potential to affect all residents who resided in the facility. Findings include:On 2/11/26 at 2:55 PM, an interview was conducted with the Administrator regarding the facility's QAPI program. Systemic issues identified during the survey were discussed at that time. When queried about whether the facility's environment/housekeeping was identified as an issue through the facility's QAPI program, the Administrator said it was not identified. When queried about whether competency evaluations not being completed for Certified Nursing Assistants (CNAs) was identified, the Administrator said it was not identified through QAPI. When queried about whether it was identified that the facility did not have a Compliance and Ethics program that met the regulatory requirements and the facility policy, the Administrator reported it was not identified. When queried about whether staff members using electronic signatures and signing resident's names instead of their legal guardians was identified, the Administrator said it was not. When queried about whether it was identified that risk/benefit education was not provided prior to obtaining consent for immunizations, the Administrator reported it was not identified through QAPI. A review of a facility document titled, Quality Assurance Performance Improvement (QAPI) Plan), dated 10/15/18, revealed, in part, the following, .The scope of QAPI include the following .Maintenance .Housekeeping .Medical Record Integrity .Nursing Services .Call Light Response .All performance improvement opportunities will be prioritized based on safety and prevalence including high-risk, high-volume, or problem-prone areas . Cross-referenced tags: F551, F584, F725, F726, F883, F895

Based on interview and record review, the facility failed to ensure the required committee members attended the Quality Assessment and Assurance (QAA) meetings at least quarterly. This had the potential to affect all residents in the facility. Findings include:A review of a facility policy titled, Quality Assurance Performance Improvement (QAPI) Plan dated 10/15/18, revealed, the following, .The QA Committee shall be interdisciplinary and shall: .Consist at a minimum of . The director of nursing services .The Medical Director or his/her designee . At least three other members of the facility's staff, at least one of which must be the administrator, or other individual in a leadership role .The infection control and prevention (ICP) officer, or designee .On 2/11/26 at 2:55 PM, an interview was conducted with the Administrator regarding the facility's QAA program. The Administrator reported that the QAA committee met monthly. At that time, a review of QAPI Committee Attendance Sign in Sheets from May 2025 through January 2026 revealed the following:On 5/7/25, the ICP did not attend the meeting (as evidenced by no sign-in on the attendance sheet). On 6/26/25, the Administrator and ICP did not attend the meeting.There was no sign-in sheet for July 2025 or August 2025.On 9/18/25, the Administrator and ICP did not attend the meeting.On 10/16/25, the Administrator and ICP did not attend the meeting.On 11/13/25, the Administrator and ICP did not attend the meeting.The Administrator did not have an explanation for why her name was not on all of the sign-in sheets and reported she may have forgot to sign in. The Administrator reported the facility did not have an ICP in May 2025 but did not have an explanation for the absence of an ICP on the other dates.

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). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.Findings include:On 2/9/26 at 10:20 AM during an interview with Maintenance Director (MD) G he indicated that he started at this facility this past September. When asked to describe the Water Management Program (WMP) he indicated that they were putting it together and when asked who was on the Water Management Team (WMT) that it would be himself and one other maintenance staff person. When asked about any monitoring of the water system, he indicated daily water temperature checks throughout the facility. When asked about any flushing protocols to prevent stagnant water he indicated none. He explained that the hot water tanks are drained and refilled monthly. He also indicated no monitoring of chlorine levels or other control measures at this time.On 2/9/26 at 10:45 AM during a building tour with Housekeeping Director (HD) H observations included Unit 2 and Unit 3 shower rooms which contained therapy tubs connected to the water supply. When interviewed at this time HD H indicated he hasn't seen them used. On 2/9/26 at 11:00 AM during a building tour with HD H observation of Units 1-4 Soiled Linen rooms had hoppers with spray arm attachments. Three of the four hoppers worked when flushed. Unit 1 hopper had a sign on it indicating do not use. When handle was pushed it did not flush, the water had been turned off to this fixture. When interviewed at this time HD H indicated these hoppers and spray arms were not used.Record review of documents in the WMP binder included a stack of monthly reports (2023-2025) provided by a water treatment contractor indicating that a Corrosion Control/secondary treatment service was in place and being serviced by this company.On 2/9/26 at 1:30 PM during an interview with the Nursing Home Administrator (NHA) when asked about the water treatment contractor, she indicated that she thought they were providing a testing service and was not aware of a treatment system in place. She explained that the previous maintenance director is at another facility and can provide additional information and that she would reach out to him. When asked about the Water Management Team, she indicated that any water issues were discussed as part of monthly QAPI meetings.On 2/9/26 at 2:30 PM, during an interview with NHA, MD G and former MD K (via phone), MD K indicated that the corrosion control system has been in place since before he started at the building in 2021. He indicated he would be checking with the vendor about any permitting records and will provide additional information on site tomorrow. On 2/9/26 at 2:45 PM observation of the corrosion control system in operation, including MSDS product sheets (sodium silicate), product storage, tubing, and injection into the cold water distribution piping upstream of the mixing valve. This was with NHA and MD G and confirmed that the treatment system was operating at this time. Record review of WMP documentation noted several missing elements, including: no text description of the water system, no comprehensive assessment of where Legionella and other opportunistic waterborne pathogens (OOWP) can grow and spread; no measures indicated to prevent the growth of Legionella and OOWP in the building water systems that is based on nationally accepted standards, no documentation of any visible inspections, disinfectant levels, or flushing protocols to prevent stagnant water.Record review of Legionella Water Management Program, Revised July 2017 which was included in the WMP binder does not contain the name of the facility nor any site-specific information, or evidence that the policy has been reviewed and updated annually. This policy document indicates that the WMP will include the following elements: an interdisciplinary team, a detailed description and diagram of the water system, identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, identification of situations that can lead to Legionella growth, specific measures used to control the introduction and/or spread of legionella, control limits that are acceptable and monitored, a diagram of where control measures are applied, a system to monitor control limits, a plan for when control limits are not met, and documentation of the program.

Based on interview and record review, the facility failed to maintain and implement an effective and operational compliance and ethics program for three (R6, R88, and R3) of three residents reviewed for binding arbitration, resulting in staff signing resident's names on legally bindings documents without their consent. This could potentially affect all residents who resided in the facility. Findings include: A review of a facility policy titled, Compliance and Ethics Program Policy dated 11/1/19, revealed, in part, the following: .As part of the facility's culture of compliance, the facility provides development and distribution of written standards of conduct, polices, procedures and protocols that promote the facility's commitment to compliance with areas of potential fraud and abuse, quality of care issues .The facility has adopted appointment of a Compliance Officer .and a Compliance Committee .charged with the responsibility for developing, operating and monitoring the Compliance & Ethics Program. Each facility's Administrator is designated as the onsite Compliance Liaison .The facility also enforces development and implementation of regular, effective education and training programs for all employees .The facility regularly uses audits and quality assurance to monitor compliance, identify problem areas, and assist in the reduction of identified problems .The facility continually revises and promotes the development of policies that initiate prompt response to detected offenses with the development of corrective action, repayments and preventative measures .Compliance .Written compliance and ethics standards, policies, and procedures and staff education of such .Assigned individuals within the high-level personnel of the facility with the overall responsibility to oversee compliance with the facility's compliance and ethics program standards, policies and procedures .The Compliance & Ethics committee will be compromised of both members of various disciplines such as: CEO (Chief Executive Officer), Nursing, Social Services, IT (Information Technology), rehabilitation, licensed Administrator and billing .As part of an operating organization with multiple facilities, additional components of the facility's compliance and ethics program include .mandatory annual training program on the facility's compliance and ethics program .A designated compliance officer in which the program is their main responsibility .Designated compliance liaisons located at each of the organization's facilities (The Compliance Liaison is the Administrator in each building) .The Compliance Officer as well as the facility Administrator and the facility In-Service ADON (Assistant Director of Nursing) review the compliance and ethics program minimally on an annual basis, revising as needed .The Compliance Officer will conduct random Quality Assurance audits in each facility .An annual binder will be kept in the Administrator's office containing all documentation supporting facility efforts to ensure continued Compliance and Ethical implementation of patient care, state and federal regulations as well as facility policies .The facility designates: employee orientation, employee in-services, the employee bulletin board as well as an employee Compliance Policy Binder located in the breakroom as a centralized resources for distributing information . On 2/11/26 at 11:45 AM, an interview was conducted with Admissions Director (AD) 'A' to discuss the facility's process for explanation and receiving consent for binding arbitration agreements (binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds). At that time Arbitration Agreements for R3, R6, and R88 were reviewed with AD 'A'. The Arbitration Agreements were all electronically signed by the residents. However, R3, R6, and R88 all had legal guardians and were deemed incompetent to make informed decisions for themselves. It was also discovered that there was an electronic signature by R3 on a Consent to Medical Care and Treatment form and an electronic signature by R6 on all financial and medical consents and documents included in the admission Packet provided on admission into the facility. R3, R6, and R88 would not have been able to understand what they were signing. When queried, AD 'A' reported when the signature section on the forms was clicked in the Electronic Medical Record (EMR) it automatically electronically signed the forms with the resident's names. AD 'A' reported R3, R6, and R88 did not actually sign the forms themselves, and the signature was entered by AD 'A'. On 2/11/26 at 12:15 PM, an interview was conducted with the Administrator. The Administrator was unaware that residents with legal guardians who were unable to make their own decisions had their names electronically signed by staff and said staff should never sign a resident's name on any agreement or contract. At that time, the Administrator was asked to provide all documentation of the facility's Compliance and Ethics program, to include education, audits, committee members, etc. At that time, the binders referred to in the facility's policy were also requested. The Administrator reported she was going to look into it. On 2/11/26 at 2:01 PM, an interview was conducted with the Corporate Compliance and Security Officer (CCSO 'GG'). CCSO 'GG' explained she was the compliance officer for the corporation, and the Administrator was the Compliance Liaison for the facility. CCSO 'GG' reported she was in the process of revising and updating all of the policies related to the Compliance and Ethics program and was putting them online for each facility. CCSO 'GG reported she would email the policies. When queried about where the education, audits, and any information about the Compliance and Ethics program specific to that facility would be, CCSO 'GG' reported the Administrator would have additional information. When queried, CCSO 'GG' was unaware that staff were electronically signing residents' names on legally binding contracts and agreements. CCSO 'GG' emailed multiple links to a Corporate Compliance electronic manual. However, the documents were unable to be accessed. CCSO GG reported a staff member was going to print the documents and provide them. No additional documents were provided prior to the end of the survey. On 2/11/26 at 2:27 PM, the Administrator was further interviewed regarding the Compliance and Ethics Program. The Administrator reported CCSO 'GG' was helping her get things together. The Administrator reported she did not have a binder in her office or the breakroom according to what was documented in the policy, did not conduct any audits, or provide any education. Cross-reference tag: F551

This citation pertains to intakes 2603176, 2610188 and 2671721.Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, safe, and homelike environment, affecting all residents that reside on the second floor, including R20, R23, R24, R39, R51, R72, R96, and R103 and residents that utilize the shower rooms on all units. Findings include:Review of the complaints reported to the State Agency included multiple concerns regarding the facility's environment, including safety, cleanliness, and lingering odors. On 2/9/26, during a building tour with the Director of Housekeeping & Laundry (Staff 'H') the following observations were made: On 2/9/26 at 10:45 AM, in the Unit 4 first floor shower room observed a vinyl fabric liner attached under the shower bed full of cloudy liquid with odor of urine; HM H tipped the bed over the shower floor drain to drain away the waste liquid through the liner drain hole with attached tubing. The vinyl liner was then observed to be visibly soiled/stained with brown staining. During this observation, when asked if this liner was laundered, he indicated is not a laundered item and that housekeeping doesn't clean this item, it is the responsibility of the CNA (Certified Nursing Assistant) to clean this item. On 2/9/26 at 11:00 AM, in the Unit 3 shower room (room [ROOM NUMBER]) observed a therapy tub connected to the water supply. The floor was visibly soiled with buildup under and around the therapy tub. At the floor/wall juncture around the perimeter of the tiled shower observed torn and missing caulk seal and visibly soiled with black substance. The shower bed liner (catchment beneath the bed) also observed soiled/stained with a large brown area around the drain hole area connected to tubing. During this observation, when asked, HM H indicated he had not seen the tub be used. HM H also observed the soiled shower area and confirmed that it needed re-caulking and cleaning to remove the staining. When asked about the frequency of cleaning of shower rooms, he indicated that housekeeping staff cleaned all shower rooms daily with a deep/detail cleaning monthly. On 2/9/26 at 11:10 AM, in the Unit 2 shower room observed the floor visibly soiled with buildup under and around therapy tub. At the floor/wall juncture around the perimeter of the tiled shower observed torn and missing caulk seal and visibly soiled with black substance. During this observation, when asked, HM H indicated he had not seen this tub be used either. He also observed this soiled shower area and confirmed that it needed re-caulking and cleaning to remove the staining. On 2/9/26 at 11:20 AM, in the Unit 1 shower room observed the vinyl fabric liner attached under the shower bed full of cloudy liquid with odor of urine; HM H tipped the bed over the shower drain to drain away the waste liquid. This vinyl liner was also visibly soiled/stained with brown staining. Floor area at floor/wall juncture around perimeter of shower room also observed with soil build up. Additional observations included: On 2/9/26 at 9:27 AM, R96's room was observed. The floor in the room was littered with debris and numerous stains near the head of the bed and around the nightstand. On 2/9/26 at 9:35 AM and 2/10/26 at 1:25 PM, R24's room was observed. The closet door, the wall adjacent to the closet door, and the wall adjacent to the room door were observed with a dried purple substance in streaks down the surfaces. On 2/9/26 at 10:31 AM, R91's room was observed to be cluttered. The floor was sticky with debris scattered throughout the floor and appeared as if it had not been mopped. On 2/9/26 at approximately 10:40 PM, R23 and R39's room was observed with a dirty floor. Food crumbs, including scrambled eggs were observed around R39's bed. Food crumbs and trash were observed on the floor beside R23's bed. The floor appeared as if it had not been mopped and was sticky. On 2/9/26 at 12:15 PM, observations of the second floor revealed upon exiting the elevator there were very strong urine and bowel movement odors present throughout the hallways on Unit 1 and Unit 2. The flooring in the hallway just outside of the room occupied by R20 was observed soiled with a clear, sticky substance. On 2/9/26 at 12:21 PM, R20's room was observed to have a strong urine odor. The resident was not in the room at this time, and the bed linens were removed from the bed. The wall near the door was observed to be heavily damaged with deep grooves and the floor molding just on the inside of the room, near the door was observed peeling back with exposed debris. There was various food debris and trash scattered on the flooring throughout the room. On 2/9/26 at 12:40 PM, R51's room was observed to have debris and trash on the flooring scattered throughout the room. When asked about housekeeping, R51 reported housekeeping came into the rooms but lately there was a lot of housekeeping turnover with the housekeepers and supervisor. On 2/9/26 at 1:04 PM the handrail observed across from the housekeeping closet was observed separated, with sharp mental and plastic edges exposed. The handrail near the main lounge on Unit 1 was observed to have a missing end cap which exposed sharp metal and plastic edges. A resident was observed trying to propel their wheelchair throughout the hallway and used their hand to pull along the area of the handrail that was exposed. On 2/10/26 at 9:02 AM, observation of the entire hallway for rooms 215-225 revealed a very strong urine odor that was pervasive throughout the hallway, including in the central shower room. Upon further observation of the central shower room, there was no evidence of the source of the urine odor. The wallpaper throughout the hallways were observed heavily soiled with purple and brown colored debris splattered throughout and some sections were peeled away from the wall. The flooring outside and inside R20's room remained covered with a clear, sticky substance and a mechanical lift was stored directly over the substance. The floor molding in R20's room remained peeled away from the wall. On 2/10/26 at 10:09 AM, an observation of R72's room was conducted. Food and litter debris were observed on the floor and under R72's bed. A pedestal fan was observed at the foot of R72's bed and the cage around the fan and the fan blades were observed with a large accumulation of gray dust and debris. At that time, an interview was conducted with R72. During the interview, R72 expressed complaints with the facility's housekeeping. They said when they first admitted a couple of years ago the housekeeping staff would sweep and mop the floor daily and lately, they have only been coming in once a week. R72, said It's not sanitary. R72 then said the facility frequently has unpleasant odors. They said they usually refuse to go out to dialysis on Wednesdays but sometimes they go just to get away from the smell in the building. On 2/10/2026 at 1:09 PM, the housekeeping closet 212 door was observed opened and not secured. There were several containers of cleaning chemicals stored in the room. There was no housekeeping staff observed in the hallways nearby. On 2/10/26 at 1:11 PM, Housekeeper 'E' was observed walking to the unlocked closet and when asked about the closet being unsecured, they reported that should've been locked. On 2/10/26 at 1:16 PM, the handrail end caps and peeling, soiled wallpaper remained. The floor molding inside room [ROOM NUMBER] remained peeled away. On 2/10/26 at 1:17 PM, R96's room was observed. R96 was not in the room, nor were there staff present. The bed was stripped of the linens, and the linens were thrown on the floor under the window. At the foot of the bed, the floor was observed with copious amounts of skin flakes, and the floor near the nightstand was soiled with light brown, sticky stains. On 2/10/26 at 1:40 PM, R23 and R39's room remained in the same condition as mentioned above. The floor was dirty with food crumbs and scrambled eggs alongside R39's bed. A plastic spoon, medication cup, and food crumbs were on the floor beside R23's bed. At that time R23 was interviewed and asked how often the room was cleaned. R23 said they did not know but mentioned a nurse aide thought staff members were using the toilet in their room. At that time, an observation or R23 and R39's bathroom was conducted. Two wheelchairs were stored in the bathroom. A pink stain was observed on the toilet seat. The water in the toilet bowl appeared to have a film on the top and was discolored. The toilet bowl had black stains on it. On 2/11/26 at 8:10 AM, an interview was conducted with the Maintenance Director (Staff 'G') who reported they had started working at the facility in September 2025. When asked about how the facility staff notified maintenance of any items that might need to be addressed, Staff 'G' reported the facility staff utilized an electronic reporting system. At that time, Staff 'G' was asked to observe the environment on Unit 1 and Unit 2 and confirmed the same findings with the sharp handrails and missing end caps, floor molding, and peeling wallpaper. Upon observing the Unit 1 shower room, the shower bed was observed to have a lower white plastic shelf layer under the shower bed that was visibly soiled. Staff 'G' reported they had identified that yesterday and would be removed today. Upon further inspection of the shower bed, there was a metal object on the tile floor directly under the shower bed and a broken black zip tie to the left side of the shower bed. When asked about the metal object and broken zip tie, Staff 'G' reported that was a broken pin which secured the railing to one side of the shower bed rails. When asked if staff were aware it was broken, why was the shower bed still available for use, and further asked if Staff 'G' had been notified it needed repairs, Staff 'G' reported they were not aware of that, it should've been reported and not been available for use. When asked about the floor molding for room [ROOM NUMBER], Staff 'G' reported they had just seen that yesterday and had not been reported by any staff. On 2/11/26 at 8:26 AM, an interview was conducted with the Director of Housekeeping and Laundry (Staff 'H'). They reported they had been in their role for about a month. When asked about their staffing for the department, Staff 'H' reported there were several openings that needed to be filled. They further reported their housekeepers were assigned seven days a week from 7:00 AM to 3:30PM and they also had a night housekeeper who worked seven days a week from 3:00 PM to 11:00 PM. When asked about to explain their process of ensuring resident rooms and environment were adequately cleaned, Staff 'H' reported their staff used a checklist and cleaned all rooms daily. When asked about the earlier observations of housekeeping concerns as well as the multiple complaints from residents and families, Staff 'H' acknowledged there were concerns with housekeeping. When asked about the stains throughout the hallway on Unit 1 and 2, Staff 'H' confirmed the areas of concern and proceeded to use their nail on the brown stain on the wall and handrail across from the nursing station and stated that could be tube feeding residue. When asked why no one had addressed the areas since these were evident since the survey began on 2/9/26, Staff 'H' offered no further explanation. When asked about the storage of chemicals and informed of the observation with Housekeeper 'E', Staff 'H' reported that should not have occurred and the housekeeping closet should be locked at all times. On 2/11/26 at 2:25 PM, review of the electronic reporting documentation provided by the facility included four pages with dates from 9/23/25 - 2/9/26. None of the concerns mentioned above were included within this documentation. According to the policy titled, Homelike Environment dated 2/3/2026: .Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary, and orderly environment .pleasant, neutral scents .Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment .Staff may assist in providing a safe and homelike environment by .reporting lingering odors and bathrooms needing cleaning to the housekeeping department .Reporting any unresolved environmental concerns to the administrator. According to the policy titled, Chemical Storage dated 5/7/2013: .It is the Center's Policy to store chemicals in a safe manner . On 2/9/26 at 9:27 AM, R96's room was observed. The floor in the room was littered with debris and numerous stains near the head of the bed and around the nightstand. On 2/9/26 at 9:35 AM and 2/10/26 at 1:25 PM, R24's room was observed. The closet door, the wall adjacent to the closet door, and the wall adjacent to the room door were observed with a dried purple substance in streaks down the surfaces. On 2/10/26 at 10:09 AM, an observation of R72's room was conducted. Food and litter debris were observed on the floor and under R72's bed. A pedestal fan was observed at the foot of R72's bed and the cage around the fan and the fan blades were observed with a large accumulation of gray dust and debris. At that time, an interview was conducted with R72. During the interview, R72 expressed complaints with the facility's housekeeping. The said when they first admitted a couple of years ago the housekeeping staff would sweep and mop the floor daily and lately, they have only been coming in once a week. R72, said It's not sanitary. R72 then said the facility frequently has unpleasant odors. They said they usually refuse to go out to dialysis on Wednesdays but sometimes they go just to get away from the smell in the building. On 2/10/26 at 1:17 PM, R96's room was observed. R96 was not in the room, nor were there staff present. The bed was stripped of the linens, and the linens were thrown on the floor under the window. At the foot of the bed, the floor was observed with copious amounts of skin flakes, and the floor near the nightstand was soiled with light brown, sticky stains.

This citation pertains to intake # 2610188. Based on observation, interview, and record review, the facility failed to ensure activity of daily living care (personal hygiene, bathing, nail care) for four residents, (R's 72, 6, 20, and 51) of six residents reviewed for activities of daily living, resulting in poor hygiene, body odor, complaints of not receiving care, and the potential for embarrassment from poor hygiene. Findings include: R72 On 2/10/26 at 10:09 AM, an interview was conducted with R72. R72 verbalized complaints that sometimes there were not enough aides on the unit. When queried why they thought the facility was short staffed they said, It takes a long time to get waited on, and further indicated they missed some of their scheduled bed baths. They said recently they went about a week without receiving a bed bath. On 2/10/26 at 10:12 AM, a review of R72's Certified Nurse Aide (CNA) task for bathing for a 30-day look-back period was conducted and revealed they received a bed bath on 1/21/26 and did not receive their next one until 1/28/26. The task form further revealed their last documented bed bath was completed on 2/3/26. R6 On 2/9/26 at 9:27 AM, R6 was observed sleeping in their bed in a hospital gown. The fingers on R6's left and right hands were contracted in a fist into the palm of their hands. R6's fingernails that could be observed (not all could be observed due to contractures) were long in length approximately 1.25 inches beyond the tip of the finger with debris under the nails. It was noted R6 had an unpleasant, sour body odor. On 2/9/26 at 12:08 PM, R6 was observed in their bed awake, dressed in a hospital gown. R6 did not respond to attempts at an interview and made only non-sensical grunting noises. The foul, sour odor persisted about the room. On 2/10/26 at 10:45 AM, an observation of R6 was made with Unit Manager 'X'. R6 was observed in the same gown as observed on 2/9/26. At that time, Unit Manager 'X' was asked about the foul odor in the room and confirmed the room had an unpleasant odor. They further said R6 was scheduled to receive a shower later on in the day. They were then asked if an observation of R6's right palm could be made to check skin integrity and ensure no sores developed in the palm from the long nails on R6's contracted fingers. Unit Manager 'X' was only slightly able to uncurl R6's fingers from their palm given R6's contractures and resistance, but when they did a very strong, foul, bitter, sour odor emanated from R6's hand. Unit Manager 'X' confirmed the odor was coming from R6's hand. They were asked how staff ensured R6's cleanliness and hygiene and said about a month ago, the therapy department was able to work with R6 to clean the palm of their hand. On 2/10/26 at 11:05 AM, an interview was conducted with Rehab Director 'I' regarding R6's hand contractures and hygiene for the hand. They indicated R6 was resistive for opening their hands but thought if they took enough time with R6 he would eventually let them clean the palm of the hand. On 2/10/26 at approximately 3:00 PM, R6 was observed in their room, dressed in a long sleeve shirt and fleece pants seated in their geri-chair. R6's nails were observed to remain long in length. Though some of the strong odor had diminished in the room, the room and R6 remained with a sour, stale odor. A review of R6's CNA task for bathing for a 30-day look-back period was conducted and revealed their last scheduled shower was documented on 2/3/26. R6's clinical record further revealed they had severely impaired cognition and was dependent of staff for all activities of daily living. R20 Review of concern forms provided by the facility from R20's family included: 9/19/25.Notified by administrator that family called and was very upset that resident had not been dressed and still in bed. Writer went to staff to address problem and instructions were given to get resident dressed and in chair. Writer notified a hour later tasks had not been done. 9/9/25.Son reports delay in personal care on 9/8/25. Son reports resident in same clothing (facility gown) per resident. Son also reports a strong urine smell from bed which suggests she hasn't had any change in linen . Review of the clinical record revealed R20 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, vascular dementia unspecified without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and epileptic seizures related to external causes no intractable without status epilepticus. According to the MDS assessment dated [DATE], R20 had intact cognition, had no behaviors, had impaired functional limitation in range of motion on both upper and lower extremities, and was dependent for shower/baths and personal hygiene. Review of the care plans included: [R20] has an ADL Self-care deficit related to diagnosis of vascular dementia, Hx (History) of CVA (Cerebrovascular accident) with residuals, Left Hemiparesis, upper and lower extremity ROM (Range of Motion) impairment. Date Initiated: 06/28/2024. Interventions included: Assist [R20] to bathe/shower as scheduled and as needed via gurney x2 person assist. Date initiated: 10/16/2025. Review of the available shower/bath documentation for the past 30 days revealed R20 only had one shower documented on 1/14/26 at 12:52 PM. There were no documented refusals. R51 On 3/9/26 at 12:40 PM, an interview was conducted with R51 at bedside. When asked about whether they received their showers/baths as scheduled, the resident reported their preference was to get a shower but at times when there wasn't enough nursing staff, they received a bed bath or didn't get a shower. Review of the clinical record revealed R51 was initially admitted into the facility on 5/19/21, readmitted on [DATE] with diagnoses that included: generalized anxiety disorder, major depressive disorder recurrent moderate, adjustment disorder, other osteochondrodysplasia with defects of growth of tubular bones and spine, short stature due to endocrine disorder unspecified, and neuralgia and neuritis. According to the MDS assessment dated [DATE], R51 had intact cognition, was dependent on staff for assistance with toileting hygiene, required substantial/maximal assistance for shower/bathing, required partial/moderate assistance with upper body dressing, was dependent for lower body dressing, and was dependent for tub/shower transfers. Review of the resident's bathing/shower documentation in the electronic medical record revealed for the past 30 days, R51 received only three showers on 1/13/26, 1/20/26, and 1/30/26. There were no documented refusals. According to the ADL care plan initiated 5/19/21: SELF-CARE DEFICIT (ADLs): [R51] needs assistance with ADLs and bed mobility. [R51] is <sic> risk for ADL Decline related to [R51's] disease process. Performance deficit related to Activity Intolerance, Limited Mobility, and Limited ROM. Interventions/Tasks included: [R51] has a preference of shower chairs to be used as available. She prefers to use the gray shower chair. date initiated 5/7/25. On 2/10/26 at 2:02 PM and 4:40 PM and 2/11/26 at 8:16 AM, the facility was requested via email to provide the shower/bath schedules for all units. There was no further follow-up or documentation of this request provided by the end of the survey. On 2/11/26 at 8:43 AM, an interview was conducted with the Director of Nursing (DON). When asked about the facility's process for documenting when shower/baths were provided, the DON reported the CNAs (Certified Nursing Assistants) were told everything should be documented in (electronic medical record). When asked if they used any other documents such as an actual shower forms, the DON reported they did not use additional forms and should be documented in (electronic medical record). A review of a facility provided policy titled, Activities of Daily Living (ADL) reviewed 2/2026 was conducted and read, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal, and oral hygiene .

This citation pertains to intakes 2615522, 2645363, and 2671721.Based on observation, interview, and record review, the facility failed to ensure there was sufficient nursing staff to meet the needs of the residents, resulting in delayed and/or lack of activities of daily living (ADL) care including incontinence care, dressing and showers/baths for residents that reside on the second floor, including R17, 27, 51, 54, 72, 96 and nine residents who wished to remain anonymous that attended the resident council interview. Findings include:Review of complaints reported to the State Agency included multiple concerns from residents, families and staff that the facility was not adequately staffed to meet the residents' needs.According to the facility's documentation of their staffing guidelines within the facility assessment last updated 1/15/26, .The facility's staffing is based on resident population and acuity. The following generally represents the daily staffing at the facility utilizing the number of employees .Unit 1 .Licensed Nurse 7a-7p .2 .7p-7a .1 .Nursing Assistant 7a-7p .3 .Unit 2 .Licensed Nurse 7a-7p .1-2 .7p-7a .1 .Nursing Assistant 7a-7p .2.Unit 3 .Licensed Nurse 7a-7p .1 .7p-7a .1-2 .Nursing Assistant 7a-7p .2.Review of the documentation provided by the facility which included assignment sheets with rooms assigned, census for each unit, as well as the time punch reports for all nursing staff that worked on 2/7/26 and 2/8/26 revealed there were multiple staff call-offs and the staffing assignments were not reflective of the above staffing levels identified in accordance with the facility assessment.On 2/9/26 at 9:50 AM, R54 was observed in their bed. They were asked about their stay in the facility and said the facility does not have enough staff. R54 said they have been left an entire shift without incontinence care. They further reported it was more prevalent on the night shift. They were asked if staff reported they were working short and R54 said, They always cry that. They further reported because of staffing they don't get their scheduled bed baths.On 2/9/26 at 10:02 AM, R17 was observed lying on their back and an interview was conducted with the resident at that time. R17 stated the facility did not have enough staff to provide care. R17 stated they missed therapy a lot because the facility did not have enough staff to get them ready for therapy.A review of R17's Physical Therapy notes revealed the following:9/1/25 . could not be seen due to BM (bowel movement) and later dinner, team will follow up tomorrow.8/23/25 . Pt (patient) received supine in bed with gown on, stating. Last time they did the therapy in the room. I would like that today because I am not dressed yet.On 2/9/26 at 12:40 PM, R51 reported their roommate's family (R27) repeatedly asks staff to make sure she is up but everyday the staff leaves her in bed. R51 further reported the facility frequently had only one nurse and two aides for the whole hallway and frequently have to wait for assistance longer than a half hour. R51 was asked if they had missed any activities of daily living such as showers due to not having enough nursing staff and they reported they missed multiple showers and will get a bed bath at times, but their preference is a shower. R51 further reported that due to the low nursing staff this past weekend, None of us got out of bed and meals were brought to eat in our rooms.On 2/10/26 at 9:18 AM, review the staffing assignment sheets for second floor included some residents that were documented as early get up which included rooms 280 bed A and bed B.On 2/10/26 at 9:25 AM, both residents in room [ROOM NUMBER] were observed lying in bed, not dressed and wearing hospital gowns.According to the current assignment sheet, there were supposed to be three CNAs assigned to Unit 1 on the North and South side.However, on 2/10/26 at 9:25 AM, Nurse 'O' was asked about the assignment sheet and reported CNA 'W' was not in yet. When asked who was covering their assignments, Nurse 'O' offered no further explanation.On 2/10/26 at 9:32 AM, Nurse 'R' was asked about the residents still in bed that were scheduled to be on the early get up list according to the assignment sheet and Nurse 'R' reported they had marked that on the assignment sheet so that the staff do get them up, but reported the CNAs typically do meals, get residents ready for appointments, then showers before they get residents out of bed. When asked what they considered as early, Nurse 'R' offered no further explanation.On 2/10/26 at 10:05 AM, an interview was conducted with the Director of Nursing (DON). When asked about who the facility's staffing scheduler was, the DON reported that person started yesterday. When asked who was handling it prior to that, they reported that was their Unit Manager (UM 'X').On 2/10/26 at 10:09 AM an interview was conducted with R72 and expressed concerns regarding lack of staff. R72 was queried further and said sometimes there were not enough aides saying, It takes a long time to get waited on. They said sometimes there was only one CNA for all of unit one and part of unit two. R72 further reported last week they did not receive their scheduled shower or bed bath.On 2/10/26 at 11:00 AM, a Resident Council interview was conducted with nine residents who wished to remain anonymous. When queried about any concerns about care in the facility, the following concerns were expressed by five of the residents:One resident reported the staff did not answer the call lights in a timely manner. The same resident reported due to there not being enough staff, they are forced to receive a shower at whatever time the certified nursing assistants (CNA) give it to them rather than at their preferred time. A second resident reported there were only two CNAs and two nurses at times on the second floor, and they worked on multiple units. That resident reported the CNAs said, Be there in a minute. but they did not return for hours. That resident further reported last Saturday they had to take a shower at 6:00 AM due to short staff and that was not their preferred time. A third resident reported they were left in bed this past weekend from the time they were put in bed until 1:00 or 2:00 PM the following day. They required assistance from staff to get out of bed. They typically liked to spend their days out of bed and in their wheelchair. That same resident reported there was another weekend when they were left in bed for two whole days. A fourth resident stated, The midnight shift disappears and reported when they rang the buzzer it often took hours and hours to get help. A fifth resident reported they also experienced long call light response and felt there were not enough nursing staff. On 2/10/26 at 11:34 AM, an interview was conducted with the Human Resources / Payroll (Staff 'V'). When asked about the facility's open nursing positions, Staff 'V' reported they were constantly hiring and expressed challenges with three different staff in the scheduler position.On 2/10/26 at 12:01 PM, a phone interview was conducted with Certified Nursing Assistant (CNA 'S'). When asked about the staffing for this past weekend, they reported there were multiple call-offs on Sunday. When asked if anyone from management came in to assist, they reported sometimes that happened but that did not happen this past Sunday. When asked if they were able to complete all their tasks when they worked with less staff, CNA 'S' reported they were not.On 2/10/26 at 1:04 PM, an interview was conducted with R96. R96 said the facility was short nurses on the night shift. They further reported the facility has nurses on staff to pass the nighttime medications, but then most of them are sent home after the medications have been passed.On 2/11/2026 at 8:59 AM, an interview was conducted with the Administrator. When asked about the concerns reported by multiple residents, families and staff in regard to lack of adequate nurse staffing, the Administrator reported there were challenges and they've hired a lot of people.On 2/11/26 at 8:43 AM, an interview was conducted with the DON. When asked about the concerns with lack of adequate nursing staff, the DON reported they had the appropriate staff assigned, but the call offs were excessive. The DON reported their facility has been doing mass hirings and just had a new weekend supervisor start three days ago. When asked about the staffing ratios for Unit 1, the DON reported Should have three CNAs on day shift and acknowledged the staffing documentation they provided to review confirmed there were not.According to the facility's policy titled, Staffing dated 4/18/2025: .Licensed nurses and nursing assistants are available 24 hours a day, ,seven days a week to provide competent resident care services including.Responding to resident needs.Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments, and the facility assessment.Inquiries or concerns related to the facility's staffing should be directed to the Administrator or their designee.

This citation pertains to Intake #'s 2615522 and 2610188. Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than five percent when five errors were made from 25 opportunities for two residents (R#'s 57 and 92) of three residents reviewed during the medication administration task, resulting in a medication error rate of 19%. Findings include: R57On 2/11/26 at 8:30 AM, Nurse 'EE' was observed preparing medications for R57. Among the medications prepared, Nurse EE prepared a magnesium oxide (supplement) 400 mg (milligram) tablet, a folic acid (supplement) 400 mcg (microgram) tablet, and a gabapentin (neuropathy medication) 100 mg capsule. Nurse 'EE' then crushed all the medications including the gabapentin capsule, mixed them with applesauce, entered R57's room and administered them. Upon the completion of the administration, Nurse 'EE' confirmed all medications due at that time were administered to R57. Nurse 'EE' was asked about crushing the gabapentin capsule as opposed to emptying the capsules content and discarding the outside capsule halves and said they did not see a warning in the electronic medical record that advised them it could not be crushed. On 2/11/26 at 9:40 AM, the medications administered by Nurse 'EE' to R57 were reconciled (compared) with the physician's orders. During the reconciliation it was discovered R57's order for magnesium oxide dated 6/26/25 was to administer 440 mg. It was further discovered R57's order for folic acid dated 6/26/25 was to administer 1 mg as opposed to the 400 mcg dose observed to be administered to R57. Continued review of the physician's orders revealed R57 had an order dated 6/26/25 for famotidine (for gastroesophageal reflux) 20 mg that was not observed to be prepared and administered to R57 during the observation. On 2/11/26 at 8:43 AM, Nurse 'FF' was observed preparing medications for administration to R92. Among the medications prepared was a sennosides (laxative) 8.6 mg tablet. After preparing the medications, Nurse 'FF' entered R92's room and administered the medications due at that time. On 2/11/26 at 9:30 AM, the medications administered by Nurse 'FF' to R92 were reconciled with the physician's orders. It was discovered R92 did not have an order for 8.6 mg of sennosides laxative, rather; they had an order dated 1/15/26 for Senna-S, a combination medication containing sennosides 8.6 mg combined with 50 mg of docusate sodium (stool softener). On 2/11/26 at 10:23 AM, an interview was conducted with the facility's Director of Nursing. They were asked about Nurse 'EE' crushing the gabapentin capsule and said it should not be crushed, rather the contents of the capsule should have been emptied from it. They were then asked about how, in general; nurses should administer medications and they reported medications should be administered per the 5-rights of medication administration (Right resident, Right medication, Right dose, Right Route, Right time). A review of a facility provided policy titled, Medication Administration reviewed 2/2026 was conducted and read, Policy Overview: To safely and accurately prepare and administer medication according to physician order, professional standards of practice and resident needs .Medications are administered in accordance with the following rights of medication administration: Right resident, Right medication, Right dose, Right route, Right time and frequency, Right documentation .Do not crush medication when contraindicated or without a physician's order .

This citation pertains to intake #2615522. Based on observation, interview, and record review, the facility failed to promote resident self-determination through support of resident choice for two residents (R72 and R96) of two residents reviewed for self-determination and resident choice resulting in frustration, verbalized complaints, and the withholding of occupational therapy rehab services. Findings include:R72 On 2/10/26 at 10:09 AM, R72 was observed in their room. At that time, an interview was conducted regarding an allegation lodged with the State Agency regarding the facility's refusal to apply a seat belt to R72's wheelchair. They explained that when they used to go to their outpatient day program, they were allowed to have a seatbelt in their wheelchair, which gave them a sense of security and safety. They continued to explain that since they stopped attending the outpatient day program (in the summer of 2025) they had been given a different wheelchair and the facility repeatedly refused to equip it with a seatbelt upon their request. They continued to say they were physically able to unbuckle the seatbelt on their own free will and did not understand why they were no longer allowed to have one. They were asked who in the facility they requested the application of the seatbelt on their new wheelchair and said they inquired with both Rehab Director 'I' and Maintenance Staff 'N'. They were asked what the facility's reply was when they were told they could not have seatbelt and said, They told me the State doesn't allow it, but I know that's a lie.On 2/10/25 11:05 AM, an interview was conducted with Rehab Director 'I'. They were asked if they were aware of R72's request for the application of a seatbelt on their new wheelchair and they denied any knowledge of R72's request. Rehab Director 'I' said they would look into R72's request and perform an assessment. On 2/11/26 at 12:15 PM, an interview was conducted with the facility's Administrator, and they were made aware R72 had been told by staff they could not have a seatbelt in their wheelchair because, The State doesn't allow it. The Administrator indicated this was an inappropriate response to R72's request and said they had been made aware of R72's request from Rehab Director 'I' on 2/10/26 and they were going to have R72 assessed for the proper use of a seatbelt in their wheelchair. R96On 2/11/26 at 1:04 PM, an interview was conducted with R96. R96 verbalized complaints about rehabilitation services. They said they have frequent transfers out to the hospital and when they return to the facility from an admission at the hospital, Physical Therapy (PT) comes to assess them, but they refuse the Occupational Therapy (OT) assessment. They continued to say they don't want PT services, but they would like OT services. When queried why they were not getting OT services they said they did not like Certified Occupational Therapist Assistant (COTA) 'DD' and refused treatment from them but would be willing to work with another therapist. They said they were told by Rehab Director 'I' COTA 'DD' was the only COTA on staff. The further said, Rehab Director 'I' said they would come in and supervise COTA 'DD' when working with them, but it didn't matter because they (R96) still did not want COTA 'DD' performing the therapy. On 2/11/26 at approximately 1:30 PM, a facility provided Concern Form initiated by R96 on 9/3/25 was reviewed and read, .Describe the concern using factual terms: Reports that he would like a different OT for his therapy .Action taken regarding the concern: Spoke with Resident & COTA separately. Plan to have Therapist and DOT (Director of Therapy, Rehab Director 'I') attend next OT tx (treatment) & determine if common ground can be found to continue with OT tx . A review of R96's progress notes revealed the following:A note entered into the record on 10/7/25 from COTA 'DD' that read, .Ot {sic} attempted OT evaluation as pt (patient) has returned from the hospital. Pt refused ot {sic} evaluation .Pt stated when the department hires a new therapist then let him know . A note entered into the record by Rehab Director 'I' on 2/10/26 that read, Attempted OT eval on this date with resident declining, stating, I'm not feeling up to it and I want to wait till you get a new (OT). Suggested to resident to agree to OT assessment and trial treatment with the current OT team. Resident again declined.On 2/10/26 at 2:19 PM, an interview was conducted with Rehab Director 'I'. They were asked why R96 was refusing OT services and said R96 did not like COTA 'DD'. They were asked what they were doing to accommodate R96's preferences for an OT service provider and said they (Rehab Director 'I') offered to be present with COTA 'DD' during the therapy sessions, however; R96 continued to decline services provided by COTA 'DD'. Rehab Director 'I' was asked if they could provide the therapy services since they were a licensed OT and said they could not promise to do all sessions as the role of Rehab Director had too many other things going on. They were then asked if the Rehabilitation Contract Company could send another COTA that worked for the company and said they didn't think they would send someone out for one resident. On 2/11/26 at 12:15 PM an interview was conducted with the facility's Administrator. They were asked if they were aware of R96's ongoing concerns with OT services, particularly with COTA 'DD' and said they said they were not, but they should have been made aware, and something should have been done to accommodate his preferences. A review of a facility provided policy titled, Accommodation of Needs reviewed 2/2026 was conducted and read, The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preference of a resident .The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis .

Based on observation, interview and record review the facility failed to thoroughly investigate an allegation of mistreatment for one (R28) of five residents reviewed for abuse/neglect. Findings include:On 2/9/26 at 9:32 AM, R28 was observed in their motorized wheelchair entering their room. When interviewed, R28 said an aide entered their room in May of 2025 and stated they were going to get R28 up. R28 stated they were telling the aide how to properly transfer them and the aide said they were getting R28 up however they (the staff member) wanted to get them up. R28 stated the aide then proceeded to transfer them into the sit to stand machine and left them strapped to the machine hanging while the aide changed the resident's brief while they were in the standing position. R28 explained the position they were left in for that extended period of time have caused them pain they still endure from the incident. R28 stated they had called the police over the incident, however, they were denied the opportunity to file charges with the police. R28 stated the Administrator told them they would handle it internally.A review of the medical record revealed R28 was admitted to the facility on [DATE] with diagnoses that included quadriplegia and required staff assistance for all Activities of Daily Living (ADLs).On 2/20/26 at 12:39 PM, the Administrator was asked to provide all grievances and Incident and Accident reports for R28 from May 2025 to current. One concern form was provided by the Administrator which was not associated with the concern R28 verbalized.Review of the medical record revealed no documentation of the incident to have been identified or to have occurred.On 2/10/26 at 2:00 PM, the Therapy Director (TD) I was asked to provide therapy notes and/or evaluations for the resident during the time frame of May 2025.A review of an Occupational Therapy Discharge summary dated [DATE] to 6/11/25, that documented in part . Resident reporting concerns including discomfort and limited ability to optimize standing with use of some slings and various staff members. expressing concerns related to EZ stand lift transfers. Direct care staff in need of education related to utilization of EZ stand and specific needs of resident. TD I was interviewed and asked about the documented concerns with the various staff members and asked if they remember the names of the staff and TD I stated they did not.On 2/10/26 at 3:19 PM, an interview was conducted with the Administrator. The Administrator was asked about the incident regarding the reported concern of mistreatment and improper transfer for R28. The Administrator denied having any knowledge of an incident to have occurred. At this time, it was confirmed with the Administrator that R28 had no Incident and Accident reports on file and one concern form from May 2025 to current and the Administrator confirmed.On 2/11/26 at 10:26 AM, an interview was conducted with Certified Nursing Assistant (CNA) J (a CNA mentioned by R28 to have been involved in the incident) was interviewed via telephone and asked about the transfer of R28. CNA J stated it was not them. CNA J stated they remember this incident occurred over Memorial day weekend and came in the next day and was told not to go into R28's room because of an allegation. CNA J stated a month later they were contacted by the Administrator via telephone and was told they were suspended because R28 called the police to report an allegation on CNA J. CNA J stated during this same phone call the schedule was reviewed and it was confirmed that CNA J was not assigned to the resident on the weekend the incident occurred. CNA J stated they were told they can return back to work before the phone call ended with the Administrator. CNA J stated they remember a young CNA to have been identified as the aide that was assigned to R28, however the aide had worked at the facility for maybe a month and was no longer employed at the facility.A review of the assignment sheets for the Memorial day weekend of 2025 was conducted. There was seven identified CNAs scheduled that weekend that was no longer employed by the facility. The personnel files that included the documentation for discontinued employment with the facility was requested from the Administrator on 2/11/26 at 11:46 AM.On 2/11/26 at 12:14 PM, the Administrator provided six of the personnel files requested and there was no documentation contained in any of the personnel files on why either CNA was no longer employed at the facility. The Administrator was asked to provide the missing personnel file and the documentation for discontinued employment for all of the seven CNAs. The requested information was not provided by the end of the survey.On 2/11/26 at 12:30 PM, the former Director of Nursing (DON) (who was the DON at the time of the incident) was interviewed and asked about the reported transfer incident with R28. The DON stated they remembered a hoyer incident to have occurred with R28 but vaguely remembered the details.On 2/11/26 at 2:35 PM, the Administrator was interviewed and asked about the police to have been called by R28 regarding the incident of mistreatment and asked about the telephone interview with CNA J to have been suspended due to the start of the investigation for the concern reported by R28. The Administrator stated they could not remember the incident and had no documentation of the incident to provide.A review of a facility policy titled Abuse updated 5/24/23, documented in part . Residents have the right to be free from. mistreatment. It is the Center's policy to investigate all alleged violations involving Abuse, Neglect. Mistreatment. Prevent further. mistreatment while the investigation is in progress. The investigation process includes. Determining the purpose of the investigation and issue(s) to be investigated, whether or not the alleged violation has occurred, the extent, and cause. Identifying and interviewing all involved persons. providing complete and thorough documentation of the investigation.No further explanation or documentation was provided by the end of the survey.

This citation pertains to intakes 2615522, 2645363, and 2671721. Based on interview and record review, the facility failed to ensure that one of five Certified Nursing Assistants (CNA 'AA') whose in-service training files were reviewed, had the required 12 hours of in-service training within the required time period. Findings include:On 2/11/26 at 8:06 AM, the facility was requested via email to provide the CNA (Certified Nursing Assistant) inservice/education training hours for five CNAs (Y, Z, AA, BB, and CC).Review of the documentation provided by the facility revealed CNA 'AA' only had 7.75 hours of education from 2024.On 2/11/26 at 12:45 PM, an interview was conducted with the Infection Preventionist / Staff Development (Nurse 'C'). They reported they had been in their role as Staff Development since mid-October (2025). When asked about the facility's process for ensuring annual education in-services were completed, Nurse 'C' reported they did reconcile of the hours and was not sure if the electronic system was glitching or not, but the documentation provided was what they were able to find.When asked about whether they received any assistance since they also performed the role as the Infection Preventionist, Nurse 'C' reported there was corporate oversight but was unable to offer any further explanation as to why the facility had not identified CNA 'AA's lack of education/training. They were requested if there was any additional documentation, they could provide by the survey exit but there was no additional documentation provided.According to the facility policy titled, In-Service Tracking dated 2/4/2024: .Each Center Administrator will appoint a Staff Development Nurse or Human Resources Representative to be responsible for tracking in-service education.The department manager will assure timely student in-service education completion.

Based on interview, and record review, the facility failed to adequately assess one (R22) of one resident reviewed for social services to ensure they received appropriate medically related social services. Findings include: A review of R22's clinical record revealed R22 was admitted into the facility on 5/6/22 with diagnoses that included: hemiplegia right dominant side, motor vehicle accident injury, hypothyroidism, aphasia (difficulty speaking), dysphagia (difficulty swallowing), epilepsy, brain injury, depression, and anxiety. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R22 had severely impaired cognition. A review of R22's annual and quarterly Social Services Assessments revealed the last assessment was completed on 5/6/22. A review of R22's quarterly assessment progress notes revealed the last note was documented in 2023. On 2/11/26 at 9:04 AM, an interview was conducted with the Social Services Director (Social Worker - SW 'B'). When queried about when residents were assessed for medically related social services, SW 'B' reported a full social services assessment was completed on admission, readmission, if there was a change in condition, and quarterly. SW 'B' explained the assessment was documented on the Social Services Assessment Form. At that time, R22's clinical record was reviewed with SW 'B' and the lack of assessment was discussed. SW'B reported he would look into it. On 2/11/26 at 9:19 AM, SW 'B' followed up and reported R22 was not assessed since 2022. On 2/11/26 at approximately 9:30 AM, an interview was conducted with the Administrator who said there should have been an assessment done quarterly. A facility policy regarding social service assessments was requested. However, only a policy regarding admission assessments was provided by the end of the survey.

This citation pertains to Intake Numbers: 2671563, 2671721. Based on observation, interview and record review, the facility failed to report an injury of unknown origin and an allegation of neglect to the Abuse Coordinator and State Agency, and failed to report resident to resident physical abuse to the State Agency without misleading information that minimized the seriousness of the incident for three (R22, R76, and R96) of five residents reviewed for abuse and neglect. Findings include: R22 and R76 A review of a Facility Reported Incident (FRI) revealed on 11/3/25, the facility reported the following to the State Agency: physical contact made by resident (R22) to resident (R76) .Resident (R22) placed on one-on-one supervision .Investigation initiated . The report did not document the type of physical contact that was made. A review of R76's progress notes revealed a Nursing-Progress Note dated 11/3/25 that documented, Writer called to the unit for an incident involving res (resident) and another resident from unit, staff CNA (Certified Nursing Assistant) stated res was in dining area in wheelchair when another res rolled up and grabbed res by the collar and pulled her to the floor, incident was witnessed .had pain in R (right) arm and hip area . A review of an investigation file provided by the facility into the resident-to-resident incident between R22 and R76 revealed the following: .Witnesses: CNA 'P' . Witnesses: Avion [NAME] .Investigation Summary .Incident Details: On 11/3/2025 at approximately 3:45pm the facility was notified of an allegation involving physical contact initiated by (R22) toward (R76). (R76) had a fall from the wheelchair related to the incident. The incident occurred in the dining room with one staff member present. Staff Witness Statement Summary: (R76) had just returned from (an outside appointment). She was placed by the window in the dining room. As she was being assisted, (R22) approached her from behind making physical contact that resulted in (R75) falling from the wheelchair . The statement was handwritten by the Director of Nursing (DON) and signed by CNA 'P'. On 2/10/26 at 10:08 AM, an interview was conducted with CNA 'P' via the telephone regarding the incident between R22 and R76 on 11/3/25. When queried about what happened, CNA 'P' explained R76 returned from an outside appointment in the afternoon and although she was not R76's assigned CNA that day, she brought R76 back up to the unit when she returned, took her coat off, placed her near the window in the dining room because she was warm, and got her situated. CNA 'P' was opening the window when R22, who was previously on the other side of the dining room, appeared by R76. R22 Grabbed her out of the chair by her shirt and would not let go. CNA 'P' said R76 fell out of the wheelchair onto the floor and R22, who was only able to use one arm, continued swinging at R76. CNA 'P' reported a nurse (Registered Nurse - RN 'Q') came into the dining room while it was happening and assisted CNA 'P' to separate the residents. CNA 'P' said she gave all of the details to the DON, she wrote them down, and then CNA 'P' signed off on the statement. On 2/10/26 at 10:20 AM, an interview with RN 'Q' was attempted via the telephone. RN 'Q' was not available for interview prior to the end of the survey. On 2/9/26 at approximately 10:00 AM, R76 was not in her room. At 1:14 PM, R76 was not in her room. Staff said she was at an outside appointment. On 2/10/26 at 9:19 AM, R76 was observed in the dining room, sleeping in a wheelchair. Was unable to interview R76 at that time. A review of R76's clinical record revealed R76 was admitted on [DATE] with diagnoses that included Lupus, anxiety disorder, major depressive disorder, auditory hallucinations, cerebral palsy, and legal blindness. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R76 had moderately impaired cognition. On 2/9/25 at 1:09 PM, R22 was observed in his room eating lunch. When spoken to, R22 did not make eye contact or respond verbally. On 2/10/26 at 9:17 AM, R22 was observed in the dining room, making grunting noises and watching television. R22 was unable to be interviewed. A review of R22's clinical record revealed R22 was admitted into the facility on 5/6/22 with diagnoses that included: brain injury and epilepsy. A review of an MDS assessment dated [DATE] revealed R22 had severely impaired cognition. On 2/11/26 at 8:55 AM, an interview was conducted with the Administrator who was the Abuse Coordinator for the facility. When queried about why only physical contact was reported to the State Agency and not exactly what happened according to the witness (CNA 'P') and what was documented in the clinical record, the Administrator reported she understood it should have more detail to explain what actually happened. R96 On 2/10/26 at 1:30 PM, a review of facility provided, Concern Form dated 8/4/25 reported from R96 was conducted and read, Describe concern using factual terms: Resident alleges when call light is pressed staff turn of {sic} call light from desk without completing the task .[NAME] taken regarding concern: Verbal statement from nurse during Admin (Administrator) investigation: Nurse admitted to turning off call light without addressing issues. Staff educated on call light response .Nurse provided one-on-one . On 2/11/26 at 12:15 PM, an interview was conducted with the facility's Administrator regarding R96's concern form. They were asked if they recalled the incident and to identify the nurse that admitted to turning off R96's call light without tending to their needs/request. The Administrator indicated they remembered the incident and identified Nurse 'O'; who admitted to turning off the call light from the nursing station without going to check why R96 activated the call light. They were then asked if they reported R96's documented allegation of Nurse 'O' neglecting to answer their call light and turning it off from the nursing station and said they did not. On 2/11/26 at 12:36 PM, R96 was observed in their bed with a specialized, breath activated call light designed for patients with limited or no motor skills, such as quadriplegia. A that time, an interview was conducted with R96 regarding staff turning off the call light from the nursing station desk without tending to their needs/request and reported staff were still doing it. When they were asked how they knew the call light was deactivated from the nursing desk they explained that when the light is activated a bell sounds in the hallway, and when the bell stops sounding, and no one comes to their room the light was deactivated from the nursing station. A review of R96's clinical record revealed they admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnoses that included: quadriplegia, peripheral vascular disease, chronic pain, pressure ulcers, neuromuscular dysfunction of the bladder, presence of a suprapubic catheter, and urinary tract infections. A review of a facility provided policy titled, Abuse updated 5/2023 was conducted and read, .Initial Reporting: The facility will ensure that all allegations involving abuse, neglect, exploitation .are reported immediately to the Administrator and: Reported to the State Survey Agency immediately but not later than two hours after the allegation is made if the allegation involves abuse .

This citation pertains to intake #2671721. Based on observation, interview and record review, the facility failed to ensure freedom from neglect for one resident (R96), of four residents reviewed for neglect resulting in R96's frustration and complaints that staff do not tend to their needs/requests when they activate their call light. Findings include: On 2/10/26 at 1:30 PM, a review of facility provided, Concern Form dated 8/4/25 reported from R96 was interviewed and read, Describe concern using factual terms: Resident alleges when call light is pressed staff turn of {sic} call light from desk without completing the task .[NAME] taken regarding concern: Verbal statement from nurse during Admin (Administrator) investigation: Nurse admitted to turning off call light without addressing issues. Staff educated on call light response .Nurse provided one-on-one . On 2/11/26 at 12:15 PM, an interview was conducted with the facility's Administrator regarding R96's concern form. They were asked if they recalled the incident and to identify the nurse that admitted to turning off R96's call light without tending to their needs/request. The Administrator indicated they remembered the incident and identified Nurse 'O'; who admitted to turning off the call light from the nursing station without going to check why R96 activated the call light. On 2/11/26 at 12:36 PM, R96 was observed in their bed with a specialized, breath activated call light designed for patients with limited or no motor skills, such as quadriplegia. A that time, an interview was conducted with R96 regarding staff turning off the call light from the nursing station desk without tending to their needs/request and reported staff were still doing it. When they were asked how they knew the call light was deactivated from the nursing desk they explained that when the light is activated a bell sounds in the hallway, and when the bell stops sounding, and no one comes to their room the light was deactivated from the nursing station. R96 further reported, in the past the Administrator had been in their room, activated the call light and witnessed staff deactivating it without coming into the room to check why it was activated. A review of R96's clinical record revealed they admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnoses that included: quadriplegia, peripheral vascular disease, chronic pain, pressure ulcers, neuromuscular dysfunction of the bladder, presence of a suprapubic catheter, and urinary tract infections. A review of a facility provided policy titled, Abuse updated 5/2023 was conducted and read, .Residents have the right to be free from abuse, neglect, exploitation, mistreatment .Definitions: Neglect .Failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .

Based on observation, interview, and record review, the facility failed to ensure decision making was exercised by residents' court-appointed representatives for three (R3, R6, and R88) of three residents reviewed for arbitration. Findings include:R3 On 2/9/26 at 10:48 AM, R3 was observed lying in bed sleeping. R3 had a tracheostomy (a tube surgically inserted into the windpipe to assist with breathing) and a feeding tube delivering nutrition into a surgically inserted tube into the stomach. When addressed, R3 did not open her eyes. R3 was unable to participate in an interview. A review of R3's clinical record revealed R3 was admitted into the facility on 9/15/25 and most recently readmitted on [DATE] with diagnoses that included: epilepsy, respiratory failure, aphasia (difficulty speaking), and dysphagia (difficulty swallowing). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R3 had severely impaired cognition and was dependent on staff for all activities of daily living. Further review of R3's clinical record revealed R3 had a court-appointed legal guardian who made decisions for the resident due to the resident being incapable of making their own decisions. A review of a Consent to Medical Care and Treatment form for R3 revealed the form was E-signed (electronically signed) by R3 and not their legal guardian. The form documented, The Resident and/or Resident's Representative consent to and request medical care and treatment at the Facility . A review of an Arbitration Agreement (binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) for R3 revealed it was E-signed by R3 on 9/16/25. The form also included R3's electronically entered initials acknowledging each section of the arbitration agreement. The form documented, You have the opportunity to ask questions before signing this document .The Resident/Resident's Legally Authorized Representative, by signing this agreement, also acknowledges that he/she has been informed and understand that: .b. The agreement may not be submitted to a Resident for approval when the Resident has been deemed incompetent by two physicians. c. The decision whether or not to sign the agreement is solely a matter for the Resident's (or the Resident's legally authorized representative) determination without any influence. d. The agreement waives the Resident's right to trial in court for any future malpractice claim the Resident may have against the healthcare provider, absent revocation of the agreement consistent with state law . The form was then signed by Admissions Director 'A'. There was no evidence the legal guardian was provided these documents. R6 On 2/9/26 at 12:08 PM, R6 was observed lying in bed, awake and alert. When addressed R6 made noises but was unable to have a sensical conversation. R6 was unable to be interviewed. A review of R6's clinical record revealed R6 was admitted into the facility on 1/7/22 and most recently readmitted on [DATE] with diagnoses that included: secondary parkinsonism, paranoid schizophrenia, dysphagia, epilepsy, and bipolar disorder. A review of a MDS assessment dated [DATE] revealed R6 had severely impaired cognition. Further review of R6's clinical record revealed R6 had a court-appointed legal guardian who made decisions for the resident due to the resident being incapable of making their own decisions. A review of an Arbitration Agreement for R6 revealed it was E-signed and initialed by R6 and not their legal guardian on 10/31/25. The form was then signed by Admissions Director 'A'. R88 On 2/9/26 at 10:21 AM, R88 was observed lying in bed. An interview was attempted. R88 did not speak when questions were asked and did not make direct eye contact. R88 was unable to be interviewed. A review of R88's clinical record revealed R88 was admitted into the facility on [DATE] with diagnoses that included: dementia, diabetes, hypertension, aphasia, and hemiplegia. A review of R88's MDS assessment dated [DATE] revealed R88 had severely impaired cognition. Further review of R88's clinical record revealed R88 had a court-appointed legal guardian who made decisions for the resident due to the resident being incapable of making their own decisions. A review of a Resident admission Application (admission packet) for R88 revealed all consent and documents, including financial consent and medical consents, were signed by R88 on 10/22/25 and not their legal guardian. A review of an Arbitration Agreement for R88 revealed it was signed and initialed by R88 and not their legal guardian on 10/22/25. The form was then signed by Admissions Director 'A'. On 2/11/26 at 11:45 AM, an interview was conducted with Admissions Director (AD) 'A'. When queried about how the binding arbitration agreements and any admission consents and/or documents were presented to resident's or their legal representatives, AD 'A' reported on admission they met with the resident and/or their resident representative to go over the admission contract, consent to treat, and binding arbitration agreements. AD 'A' said she explained what the arbitration agreement was in detail and ensured they understood what they were signing. AD 'A' further reported residents and/or their representatives were not required to sign the arbitration agreement in order to receive care in the facility. When queried about how they determined if the resident's physical condition and cognitive status affected their ability to understand and make an informed and appropriate decision, AD 'A' reported if she questioned the resident's cognitive status, they had the resident assessed by social services and waited for a capacity evaluation. When queried about electronic signatures and how they were initiated, AD 'A' reported they were generated in the electronic medical record and if the resident did not have a legal representative when she clicked on the signature section it automatically entered the resident's name and E-signed it and there was no option to opt out. When queried about how R3, R6, and R22 were able to E-sign the arbitration, consent to treat, and admission documents if they were unable to understand or make decisions for themselves, AD 'A' reported they did not actually sign the documents themselves. On 2/11/26 at 12:15 PM, an interview was conducted with the Administrator. When queried about the facility's protocol for signing documents such as arbitration agreements, consent to treat, and/or admission contracts, the Administrator reported it was discussed and presented on admission and if a resident had a legal guardian, it would be discussed with them, and they would be responsible to sign the documents. The Administrator was not aware of the use of electronic signatures and reported if the resident was unable to sign or if a resident or representative did not want to sign the agreements and/or contracts, it was just left blank or documented that they refused. The Administrator reported staff should never sign a resident's name on any agreement or contract.

This citation pertains to intakes 2603176 and 2610478.Based on observation, interview and record review, the facility failed to implement interventions per plan of care following a resident to resident incident (between R51 and R16) for one (R51) of six residents reviewed for accidents. Findings include:Review of a complaint reported to the State Agency on 9/9/25 documented R51 reported an incident from 9/8/25 in which another resident (R16) came into their room with just a brief on and scared her.Review of the clinical record revealed R51 was initially admitted into the facility on 5/19/21, readmitted on [DATE] with diagnoses that included: generalized anxiety disorder, major depressive disorder recurrent moderate, adjustment disorder, other osteochondrodysplasia with defects of growth of tubular bones and spine, short stature due to endocrine disorder unspecified, and neuralgia and neuritis.According to the Minimum Data Set (MDS) assessment dated [DATE], R51 had intact cognition.Review of the care plans included, The resident expressed desire for enhanced safety and privacy measures in her room. This care and interventions had been initiated on 9/22/25 by Former MDS Coordinator (Nurse 'D') and had not been discontinued as of this survey.Interventions included:Place a red stop sign on the resident's door as a visual cue to discourage uninvited entry.Reinforce the residents' rights to privacy and safety.Observations during the survey on 2/9/26 at 12:39 PM, 2/10/26 at 8:50 AM, and 2/10/26 3:17 PM revealed there was no placement of any Velcro stop signs within R51's doorway. Throughout the survey, R16 was observed lying in bed in their room which was located directly across from R51's room.On 2/11/26 at 8:35 AM, an interview was conducted with Certified Nursing Assistant (CNA 'F') who was assigned to R51. When asked about whether they were aware there should be a Velcro stop sign for R51's room, according to the care plan, CNA 'F' reported they had worked at the facility for a year and had never seen anything like that for R51.On 2/11/26 at 8:43 AM, an interview was conducted with the Director of Nursing (DON). When asked to review R51's care plan following the concern from 9/8/25, the DON reported that was prior to their employment which began in October 2025 and was unable to offer any explanation, but reported if that was an intervention it should've been in place for R51. The DON further reported Nurse 'D' no longer worked at this facility. When asked if the facility had Velcro stop signs to utilize, the DON reported they definitely did and they just saw one at the nursing station today.According to the facility's policy titled, Care Plan - Comprehensive and Revision dated 2/2/2026: .Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to .Receive the services and/or items included in the plan .

This citation relates to Intake 1302878. Based on observation, interview, and record review, the facility failed to ensure proper positioning to prevent an avoidable fall with injury for one Resident (R703) of one resident reviewed for falls, which resulted in actual harm, with increased pain, emergent care, hospitalization, and fearfulness. Findings include: Review of a complaint intake received on 6/20/25 revealed R703 resided at the nursing facility with a diagnosis of stroke and limited range of motion in their extremities. The complaint showed R703 had a fall at night on 6/19/25 after warning the aide not to turn her, as she felt like there was not enough room on the bed. The aide reportedly proceeded to turn R703, and R703 hit their head on the floor. R703 was reportedly supposed to be a two-person assist at all times. R703 was subsequently taken to the hospital, and had no fractures or brain bleeds but did have increased pain and swelling of their right knee. The complaint stated, “(R703) is in a lot of pain is completely traumatized…” On 7/01/25 at 4:12 p.m., R703 was observed laying on their back in their hospital bed, wearing a gown. It was noted R703’s hands were closed in fists. R703 agreed to be interviewed. On 7/01/25 at 4:15 p.m. R703 was asked about their care, and responded, “The person (staff) was asked not to turn me in bed, and I said, ’I am a fall risk. I am supposed to have two people,’ and it was just one person. She (staff) turned me and I fell on the floor on my left side. I was to the ground. I hit my head really bad. They x-rayed me from head to toe, and they said that I didn’t have any broken bones. My head was hurting really bad. It is still going on and I am still having sharp shooting pain. I can’t move my arms well…” R703 reported they needed help feeding themselves and had pain in the back of their legs. R703 reported they fell a month ago directly onto the floor. R703 reported they went to the hospital, who kept them for a few days and said they had a head injury and pain in their legs and back which had worsened since their fall. R703 reported their pain was 8/10 (with 10 the highest pain) and said they needed more pain medication after the fall. R703 said they did not want to work with them ever again. R703 continued, “I am experiencing all the pain still and have a lot of fear (of moving and getting out of bed). Since then, I don’t want to be touched…” R703 confirmed they used a Hoyer lift to get out of bed. R703 was alert and oriented to their name, situation, and surroundings. Review of R703’s Minimum Data Set (MDS) assessment, dated 3/29/25, revealed R703 was admitted to the facility on [DATE] with diagnoses including heart failure, stroke, and epilepsy (a seizure disorder). The assessment revealed R703 required moderate assistance with eating and was dependent for bed mobility and transfers. The cognitive assessment revealed R703 was usually understood and could usually understand others. On 7/01/25 at 4:30 p.m., R703’s nurse, licensed practical nurse (LPN “K)”, was asked about their care and any pain. LPN “K” stated R703 had been requesting pain medication regularly, which was a change, as they had rarely asked for it prior to the recent fall. LPN “K” reported R703 was newly on scheduled Tramadol since the fall, however said they were not aware of her reporting fearfulness. LPN “K” stated R703’s routine was getting up out of bed with staff assistance before their fall in June (2025) every day and going to the dining room, attending activities, talking to the other residents, and watching television however since the fall they were in bed more often. LPN “K” reported R703 fed themselves with adaptive silverware. LPN “K” said R703’s affect was more solemn since their fall. On 7/02/25 at 12:37 p.m., LPN “N” was asked about R703’s fall on 6/19/25. LPN “N” said they were in another room taking care of another resident when the fall with injury occurred. LPN “N” reported there was only one aide in the room, and said they were a newer aide. The aide stated to them they were cleaning R703 (providing peri-care) and said the aide had the bed up and R703 fell out of bed. LPN “N” said the Kardex showed R703 was a two-person assist for bed mobility at the time of their fall. LPN “N” reported when they observed R703, they were laying on their back on the side of the bed, and said they hit their head, and their back was hurting. LPN “N” stated they called the doctor, EMS (emergency medical services) and the Director of Nursing (DON) and said, “(R703) was in pain in the neck, head, and on her back .” On 7/02/25 at approximately 1:20 p.m., R703’s guardian, Guardian “P”, stated in a phone interview LPN “N” called them on 6/20/25 and said they were sending R703 out (emergently) after a fall when staff were trying to change their (briefs) and rolled them out of bed and told them R703 landed on her back and hit their head on the floor. R703’s guardian stated R703 was a two-person assist at all times for care, and reported R703 was traumatized and kept saying at the hospital, “I’m falling; I’m falling…” Guardian “P” said they got R703’s pain under control at the hospital but the next day the facility staff sent R703 back to the hospital with increased leg pain and said R703 was diagnosed with a pelvic fracture. Guardian “P” stated, “Why would you try to roll them if they (resident) say not to roll them? R703 is a two-person assist at all times. There is signage in the room. That I don’t understand…” Guardian “P” reported prior to their fall R703 went to the dining room to eat and attended activities but since the fall had not gone much as R703 felt scared. Review of R703’s Accident and Incident report, dated 6/19/25 at 10:00 a.m., revealed, “Writer was in hallway and heard resident yelling for help. Upon entering room, resident was on the floor on her back accompanied with assigned CNA (Certified Nurse Assistant/CNA “Q”). CNA stated, “’The resident fell during patient care.’” RCA (Root Cause Analysis): Improper positioning in bed. Staff to ensure resident is positioned in the center of bed. Resident stated, “’I fell out of bed.’” …Resident complained of pain to hand, neck, and back…Resident sent to hospital via EMS accompanied by two CNAs…” The report showed R703 was alert and oriented x 3 (3 spheres of 4). Review of R703’s facility investigation report showed on 6/19/25 at 9:45 p.m., CNA “Q” rolled R703 out of bed the opposite way (of CNA “Q”) and rolled them completely out of bed and onto the floor. R703 reportedly hit her head and was found between two nightstands. R703 stated they were being changed (brief) and told the CNA they needed two staff to take care of her, but the CNA did it anyways and they fell out of bed. R703 explained they hit their head and said they were having headaches. CNA “Q” confirmed R703 fell between two nightstands and hit their head. The conclusion showed the staff member (CNA “Q”) did not use proper positioning techniques, resulting in the fall. The report revealed R703 was sent to the ER (emergency room) and said their CT scan and x-rays were negative (with no fracture). The resident returned with orders for Tylenol and Robaxin (a muscle relaxant which was newly ordered). Review of R703’s nursing progress note dated 6/21/25 at 4:20 a.m. (second note) showed R703 experienced pain during the night shift hours between 3:00 a.m. and 3:30 a.m. and they requested to go out to the hospital. Nurse assessed to see where the pain was coming from and patient stated their legs were in “so much pain”. The note when the EMT’s (emergency medical technician) arrived and were transferring R703 to the stretcher R703 screamed out in pain. Review of R703’s progress note, dated 6/26/25 at 12:08 p.m., revealed, “Wellness check completed. (R703) states she feels safe being at the facility however c/o (complains of) pain and that her pelvis is broken. Says she is anxious and agreed to see psych services…Spoke to case manager regarding resident asking for something (medication/intervention) to help her calm down…” Review of R703’s progress note dated 6/25/25 at 1:37 p.m. revealed, “Writer notified by SW (social worker) of residents’ increased anxiety/pain. NP (Nurse Practitioner) notified. New orders received for Tramadol (controlled pain medication) 50 mg every six hours as needed for pain, and a one-time dose of Zyprexa for increased anxiety, with psych service consult ordered…” Review of R703’s nursing progress note, dated 6/29/25 at 17:34 (p.m.), by LPN “K”, revealed, “(R703) reported to writer that current pain medication was not helping to alleviate pain…stating, “…I’m still in a lot of pain .” Writer notified on-call provider, awaiting new pain medication order…” Review of R703’s nursing progress note, dated 6/30/25 at 10:19 a.m., revealed, “Primary NP (Nurse Practitioner) in house, new orders given to change Tramadol 50 mg prn (as needed) to Tramadol 50 mg (scheduled) every 6 hours. On coming nurse notified.” Review of R703’s psychiatric progress note, dated 6/30/25 at 11:15 a.m., revealed the provider was seeing R703 for restlessness and agitation post hospitalization, with no new interventions or medications added. R703’s mood was stable, and pain was found managed by the visit. Review of R703’s hospital History and Physical report (H & P), dated 6/21/25, revealed R703 was a [AGE] year-old patient with prior stroke with right side hemiparesis (weakness) and seizure disorder who fell out of bed while being changed. Her acute diagnoses was intractable pain and UTI (urinary traction infection) symptoms. The report showed R703 reported hitting their head when they fell. The report diagnoses showed CT of their pelvis yielded, “Impression: focal defect (localized area of irregularity or damage) and cortical irregularity (causing pain or instability) involving the right inferior pelvic ramus (pelvic bone). No adjacent infiltration or hematoma. Findings may represent subacute injury however no callus formation is present (indicating bone growth)…” This report did not confirm or deny the presence of a pelvic fracture. Review of R703’s hospital occupational therapy evaluation, dated 6/22/25, revealed R703 had fair participation in the assessment due to severe back pain and muscle spasms. Review of R703’s hospital palliative report, dated 6/22/25, showed R703 had no acute fractures or dislocations, including right knee imaging, and showed they were not choosing palliative care at that time. On 7/03/25 at approximately 2:35 p.m., CNA “Q” was called about R703’s fall on 6/19/25. No call was returned by the end of survey. On 7/02/25 at approximately 3:00 p.m., Physical Therapist “R” reviewed R703’s pelvic scan report with Surveyor and said they had prior reviewed the scan. PT “R” reported the report did not clearly show a pelvic fracture and there was no bone growth which would have likely showed healing (if there was a fracture). PT “R” clarified there would be no different treatment for a pelvic fracture or injury, as the goal would be pain management. PT “R” confirmed R703 was currently receiving treatment for pain management in PT after their fall with injury. On 7/02/25 at approximately 3:30 p.m., the Director of Nursing (DON), along with Infection Preventionist (IP) Nurse “T”, reviewed the Electronic Medical Record (EMR) with Surveyor. Both confirmed R703’s Kardex at the time of their fall should not have shown 1–2-person assistance with ADL’s (activities of daily living), as then the aides had to choose the level, when this should have been specified by therapy. Both confirmed CNA “Q” had been newly hired on 5/28/25 and said they reeducated CNA “Q” on safe transfers. Both explained CNA “Q” was reportedly trying to change R703 and had been rushing, so no abuse or intent was found. Review of CNA “Q”’s personnel file showed they received bed mobility training during their orientation. Review of CNA “Q”’s reeducation regarding bed mobility respective to the incident read a follows: “…1st written warning: Patient Care:…During ADL care employee pushed (R703)…away from her, instead of towards her, for proper body alignment, resulting in resident injury…” Signed by the DON, and LPN “I”, delivered via phone to CNA “Q” on 6/20/25. Review of R703’s PT evaluation, dated 6/26/25 (after their fall), revealed R703 struggled with pain during the assessment in their legs with slightest movement at 10/10. The assessment revealed, “…Writer noticed patient screaming in pain while actively attempting to move her legs…” The assessment revealed a goal of 3/10 pain with modalities including heat and cold, with prior level of function showing n/a (no) pain, and a caregiver goal of safe patient handling to not aggravate pain. Review of the policy, “Fall Management Guidelines”, issued 12/13/23, revealed, “The purpose of this policy is to provide guidelines to assist with fall risk identification and fall management of residents in the facility…Intrinsic factors that may increase the risk of falls include…cognitive impairment, CVA/TIA…Evaluate for signs and symptoms and complaints of pain…Attempt to determine the root cause of the event…The interdisciplinary team (IDT) will review the resident’s fall including: the circumstances surrounding the resident’s fall and any changes in the resident’s risk factors, condition, and/or functional status to validate or determine the root cause of the fall, the interdisciplinary team will review the resident’s current plan of care and interventions to ensure that the interventions are appropriate and the resident’s post-fall interventions correlate to the root cause of the fall, in an attempt to prevent future fall, a progress note will be placed in (the EMR), documenting the IDT review and findings…”

This citation has two Deficient Practice Statements (DPS). DPS #1 This citation pertains to intakes MI00144702, MI00144797, and MI00144715. Based on observation, interview and record review, the facility failed to provide adequate supervision and implement elopement policies for one (R500) of four residents reviewed for elopement, resulting in a severely cognitively impaired resident being let out of a secured door to the patio by an unknown staff member, unsupervised and was found approximately 36 hours later, about five miles away from the facility. This deficient practice resulted in the likelihood for serious harm, injury, impairment, or death. Findings include: The Immediate Jeopardy (IJ) began on 5/26/24. The Administrator was notified of the IJ on 5/28/24 at 5:18 PM and a removal plan was requested. The State Agency completed onsite verification that the Immediate Jeopardy was removed on 5/29/24, however the facility remained out of compliance at a scope of isolated and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. On 5/28/24 at 11:17AM an interview was conducted with the Administrator. When asked what happened with R500 and where was R500 found, the Administrator replied R500 was found in Detroit near eight mile and Telegraph road, in a wheelchair. The Administrator further reported R500 didn't state where they were going and the resident was very selective too whom they speak too. The Administrator was then asked about the facility's patio area (where R500 exited) and then explained the patio area had locks but were using it as the front entrance because the main entrance was still under repair. On 5/28/24 at 11:20AM, an interview was conducted with the Director of Nursing (DON). When asked to provide details of where and when R500 was found and when they were first notified that R500 was missing, the DON replied the resident was found at 8:33 PM on Evergreen and Eight Mile Road, about 10 minutes away. The DON further reported the Nurse on Duty on 5/27/24 (Nurse 'B') notified them around 1:30 PM and they arrived at the facility to help with the search. The DON reported when R500 was located, they did not mention an agenda on why they left the facility and R500 was not much of a talker but they did tell their brother that they wanted to go for a walk and get some air. The DON explained the residents are allowed to sit outside on the patio and that staff does not have to physically be out there, but the receptionist is to monitor residents and let them in and out. The DON also reported they keep the gate open because there is no doorbell or buzzer. The DON was asked if there was a log of who goes in and out the building (according to the facility's investigation documentation the receptionist was suspended) and they replied there was no log that keeps track of who goes out to sit in the patio area but they did have a leave of absence (LOA) book. The DON reported at that time, a housekeeper (HK 'C') was covering for the receptionist. When asked about what covering for receptionist entailed, the DON reported a housekeeper can monitor but would have to follow-up to see if they were educated on the responsibilities. On 5/28/24 at 11:47 AM, an interview was conducted with Receptionist (Staff A). When asked about their ability to effectively monitor or supervise the gate, or people out on the patio from their location in the facility, Staff A reported the view was limited and was not able to see the gate or anything behind that area. On 5/28/24 at 12:31 PM, a phone interview was conducted with Nurse B. When asked to recall the events of R500 on 5/27/24, Nurse B reported when they come in every morning, they do walking rounds with the off-going nurse and they did not see R500 in their room, so they assumed that they were outside, or in the dining room where they'd usually be. Nurse B further reported they continued their rounds and started on the medication pass. Nurse B then went back to check on R500 around 1:00 PM, and noticed they still were nowhere to be found and they called a code w (missing resident alert), notified the Administrator and DON, called the family and continued to follow the protocol for a missing resident. Nurse B reported they never laid eyes on (R500) during their shift, the resident doesn't take any medications, and they felt bad because they assumed R500 was there and the off-going (midnight nurse) didn't mention anything about the resident being gone. On 5/28/24 at 12:56 PM, a phone interview was conducted with HK C. When asked to explain what their responsibilities were when they covered the front desk for a receptionist, HKC replied they did not know, and that Maintenance Worker (Staff Q) asked if they could sit in the room for a minute while they went to the basement. HK C reported they were watching the area for all of five minutes, if that. They further reported they were never told that they needed to watch the outside patio and the facility noticed (after the incident) the resident leaving the facility on Sunday 5/26/24 around 9:45 AM and they got it on the security cameras. HK C was then asked about the details and education provided on their suspension and HK C reported they were not aware of any suspensions. On 5/28/24 at 2:28 PM, a phone interview was conducted with Certified Nursing Assistant (CNA E). When asked if they were assigned to R500 on 5/26/24, they reported yes. When asked about R500's routine and when they last saw the resident on 5/26/24, CNA E replied they saw R500 Sunday (5/26/24) at the beginning of their shift when they did morning rounds, and again around 8:00 AM during breakfast. CNA E recalled the resident refused their tray and wanted to eat it with lunch, but that was the last time they saw the resident. CNA E was asked if they should've checked on R500 throughout their shift and replied Yes. On 5/28/24 at 3:00 PM, an observation of the facility's video surveillance from 5/26/24 - 5/27/24 confirmed R500 exited via wheelchair on 5/26/24 at around 9:45 AM, off the property, through the gate of the patio, and returned to the facility via family on 5/27/24 around 9:00 PM (approximately 36 hours later). On 5/29/24 at 9:25AM, an interview was conducted via phone with Family Member G. When asked what happened with the elopement of R500, Family Member G reported the facility never contacted them, but instead called their husband stating they were doing a wellness check. Family Member G then reported they told the facility that R500 does not live with them and they stay at the facility they were calling me from. They further reported Nurse B was the only person who contacted them to tell me what was going on around 2:20 PM on 5/27/24. They told us the Maintenance Director (Staff N) was looking over the cameras and noticed R500 had left the faciity on Sunday (5/26/24) around 9:15 AM. Family Member G then reported they pulled up to the facility the same time the .Police department arrived and told them that R500 used to live in the independent living next door, so the Police were able to go there and view the cameras and confirmed R500 was seen there around 10:00 AM going to their old apartment unit. Family Member G stated they and their family began to search for R500 and even posted they were missing on social media, and that the whole ordeal was very stressful and should never have happened. On 5/29/24 at 2:10 PM, a phone interview was conducted with Nurse I who confirmed they were assigned to R500 on 5/26/24. When asked about their routine during their shift, Nurse I reported upon their shift on 5/26/24 starting at 7:00 AM, they laid eyes on R500, then started their medication pass. They recalled R500 asked them for pull ups around 8:00 AM and after they finished the medication pass they went to try to get R500 pull ups and the staff person that stocks briefs, so they informed the CNA that R500 needed pull ups and to make sure they got some. Nurse I reported they continued rendering care to their other patients at about 9:00 AM, they laid eyes on R500 going to the elevator on Unit 2, by the dining room where the resident would usually be. When they were doing treatments way after lunch, but before dinner they asked the CNA if they had seen R500 and they didn't but we assumed that R500 was outside on the patio. Nurse I was asked if they checked on R500 after they last saw them at 9:00 AM on 5/26/24 and they stated they did not check on them like they should have. Nurse I further reported that was not like R500 to leave the campus, and they were dealing with a difficult resident who wanders all the time so it was just a crazy day. On 5/29/24 at 2:14 PM, an interview was conducted with Nurse J. When asked if they were assigned to R500 during the midnight shift (on 5/26/24, into 5/27/24), Nurse J reported no, they did not take care of R500. They reported when they came onto shift, they got a report from the dayshift nurse that R500 was out somewhere so I didn't follow-up immediately. Nurse J reported they have a resident that wanders, and it was busy and the that resident made their night very busy and chaotic. Nurse J reported the off-going Nurse told them that R500 was outside somewhere. This was their second week so they didn't know how the patients were and how they acted, so they thought R500 was out with a family member and they gave the oncoming nurse the following day the same report. Nurse J reported that nurse took the keys from them, so they did not think anything of it. Nurse J confirmed R500 was not present at the start of their shift on 5/26/24 at 7:00 PM. According to the facility's policy titled, Elopement - For Facilities With a Wander Alert Bracelet System dated 8/2022, revised 5/27/2024: .GUIDELINES FOR STAFF WITNESSING A RESIDENT ATTEMPTING TO LEAVE THE FACILITY: Staff members will report to the charge nurse any resident who tries to leave the facility. If a staff member observes a resident attempting to leave the facility or premises, they should .Get help from other staff members in the immediate vicinity or call for assistance .If the resident leaves the facility: Instruct another staff member to inform the charge nurse or director of nursing that a resident has left the facility or premises while staying with the resident . The Immediate Jeopardy that began on 5/26/24 was removed on 5/29/24 when the facility took the following actions to remove the immediacy: Immediate action(s) taken for the resident(s) found to have been affected include: 1) Resident [Name of R500] on 5/27/2024, it was noted at approximately 1330 that resident was missing in the facility, and after initiating the procedure for a missing resident and searching the facility, the resident could not be located. DON, Administrator, Physician, Medical Director, resident's sister, State of Michigan, and the Southfield police department were notified. It was identified the gate was unlocked and resident wheeled himself through the gate to the sidewalk and left facility premises. The receptionist who was responsible for supervising the resident while on the patio alone was immediately suspended, pending investigation. The resident has been returned to the facility, evaluated, and deemed stable with no negative outcomes. Identification of other residents having the potential to be affected was accomplished by: 1) Residents who reside in the facility who are at risk for elopement have the potential to be affected. A facility-wide audit was conducted and residents in the facility had a elopement assessment completed on 5/27/24 to establish elopement risk, and wander guards were applied to residents as appropriate, with physician orders and care plans updated. 2) Facility doors were checked by the Maintenance Department. 3) The facility process changed on 5/27/24 and residents must be attended to on the patio by staff or family. 4) On 5/28/24 the facility gate has been locked and will be observed by 1:1 staff member until a door camera is installed. The gate will remain locked at all times. (It should be noted that this was not verified as implemented adequately until 5/29/24.) Measures put in place and systemic changes you will make to ensure that the deficient practice dose not reoccur: 1) Education was initiated on 5/27/24 for the facility staff by the Director of Nursing, Assistant Director of Nursing, and designee. Staff are educated on elopement policy, procedures for a missing resident, that residents are not allowed on the patio without being attended by staff or family, and that nurses are to complete a head count of their assignment at the start of their shift. Additionally, Nurse Aides and Nurses received and in-service to visualize residents their residents throughout the shift to ensue residents are safe and accounted for. In the event that a resident cannot be located, A staff member will notify the nurse supervisor, administrator, or director of nursing of the possibility that a resident is missing. The supervisor will coordinate and document the search efforts. Any staff member and/or contracted staff who has not been educated will be educated before working their next shift. 2) Patio gate will remain locked and secured. 3) Director of Nursing, or designee, will audit 5x weekly x4 weeks to ensure that residents are not on the patio without being attended by staff or family, and that nurses are completing a head count of their assignment at the start of their shift, to ensure that all residents are in the facility and accounted for. Describe the Quality Assurance & Process Improvement Program that will be put into place (track and trend data over time to ensure action plan met the initially identified goal(s). 1) An Ad Hoc QAPI meeting was held on 5/27/2024 with the Medical Director and QAPI Team 2) QAPI committee will be held weekly for 4 weeks, then monthly for recommendations and further follow-up regarding the above-stated plan. Audits will continue to be submitted to the QAPI committee for review and to ensure compliance goals. QAPI committee reserves the right to modify or extend monitoring times according to outcomes. The Administrator is responsible for the oversight of this plan to ensure ongoing compliance. 32568 DPS #2 Based on observation, interview, and record review, the facility failed to adequately supervise and implement effective interventions to prevent wandering into unsafe spaces for one (R502) of four residents reviewed for accidents, resulting in the resident, who had a history of wandering behaviors, using the elevator multiple times to leave the unit and enter the first floor which was a construction zone and off limits to residents. Findings include: On 5/28/24 at approximately 5:15 PM, R502 was observed in the hallway. R502 walked over to the elevator and attempted to enter it. R502 was redirected away from the elevator by a staff member. On 5/29/24 at 9:36 AM, 10:40 AM, and 12:10 PM, R502 was observed sleeping in bed in the same position. A review of R502's clinical record revealed R502 was admitted into the facility on [DATE] with diagnoses that included: Huntington's Disease and schizoaffective disorder. A review of R502's Minimum Data Set (MDS) assessment revealed R502 had severely impaired cognition and wandering behaviors. A review of R502's progress notes revealed the following documentation: On 5/9/24, it was documented in a Behavior Note that R502 was exit seeking. On 5/10/24 at 10:10 AM, it was documented in a Social Work note that R502 was exit seeking in addition to other behaviors. It was noted that R502's care plan needed to be updated. On 5/10/24 at 12:49 PM, it was documented R502 was observed walking toward the entrance behind staff .(R502) expressed, 'I'm about to go. I'm going home.' Writer made attempt to redirect her back to her room to retrieve footwear. Upon walking to her room, she tried to get on the elevator. Writer redirected her with staff assist . On 5/10/24 at 4:22 PM, Registered Nurse (RN) 'K documented, Resident was observed on the first floor by maintenance worker ('Q') in the old PT (physical therapy) room. (Maintenance Worker 'Q') brought resident back up to unit and stated that was where he observed her .She has been wandering around the facility, on all of the units .throughout this shift .Writer is placing resident on 15 min (minutes - check on resident every 15 minutes) at this time to ensure the safety of resident. On 5/14/24 at 7:43 PM, RN 'K' documented, Resident made several attempts to enter the elevator this shift . On 5/18/24 at 5:10 PM, RN 'K' documented, .Writer observed resident attempting to get on the elevator, but I was able to re-direct her back to the unit . On 5/19/24 at 4:26 PM, RN 'K' documented, Resident was observed by a couple dietary staff members, walking around on the lower level of the facility. They brought resident back to unit and writer explained to resident that it is not safe for her to go down to the lower level and walk around. Resident did not verbalize understanding and cont (continued) to wander around the facility. After several minutes, I was able to re-direct resident back to the unit, but she cont. to wander off the unit when I was doing my med (medication) pass. On 5/19/24 at 6:33 PM (two hours after the previous progress note), RN 'K' documented, Resident was, once again, observed by staff walking on the lower level of the facility into the kitchen. Writer was called and assigned CNA (Certified Nursing Assistant) went down and brought resident back to the unit. Once again, writer reiterated with resident that it is not safe her her to go down to the lower level of the facility, at this time. Resident did not verbalize understanding. Just prior to resident doing downstairs, she was observed by staff attempting to exit the facility through the current (temporary) facility's maintenance door, per CNA . On 5/28/24 at 7:08 PM, RN 'K' documented, Writer was paged and told that resident was on the lower level, in the kitchen. Writer went down and brought resident back to unit. Wander-guard was on left ankle and did not alarm, due to the fact that she did not walk through the 'double' doors, because she walked through the first kitchen door .Staff had to constantly re-direct resident after this incident so that she would not get on the elevator. Administrator made aware. On 5/29/24 at approximately 9:40 AM, an observation was made of the first floor of the facility. The elevator was accessible from the second floor. Upon exiting the elevator onto the first floor, signage was posted to the left that read Danger. Do Not Enter - Emergency Exit Only. The hallway was partitioned off with plastic. The flooring was removed from that hallway and a fan was installed. Various tools and equipment were observed on the first floor and there were many rooms with open doors. The kitchen was located on the first floor which was accessible from two different doors, one that was accessible after entering through double doors down the hallway. An interview was conducted with Maintenance Director 'N' who explained the first floor was closed off due to a flood that occurred. They were in the process of repairing the damage. On 5/29/24 at 10:37 AM, an interview was conducted with RN 'K'. When queried about R502's wandering behaviors, RN 'K' reported R502 wandered everywhere. When queried about what interventions were in place to prevent R502 from wandering into unsafe spaces, RN 'K' reported R502 had a wander alert bracelet and staff had to supervise and redirect her. RN 'K' explained that she felt R502 required one on one supervision, but due to the way the unit was staffed it was hard to constantly supervise R502 while performing other required duties and caring for other residents. When queried about how R502 got to the first floor on 5/10/24, twice on 5/19/24, and again on 5/28/24 during her shift, RN 'K' reported she did not know R502 went to the first floor until maintenance and dietary staff notified the unit. RN 'K' explained that the wander alert bracelet did not alarm at the elevator and once on the first floor, unless R502 crossed over the sensor at the double doors, it would not alarm. On 5/29/24 at approximately 10:45 AM, an interview was conducted with Unit Manager, Licensed Practical Nurse (LPN) 'P'. When queried about R502's wandering behaviors, LPN 'P' reported R502 wandered all the time in addition to other behaviors. LPN 'P' further reported the elevator was shut down starting at 5:00 PM until 7:00 AM, but it was accessible during the day. LPN 'P' reported R502 required a lot of supervision and she did not feel there was enough staff to watch her. On 5/29/24 at 11:05 AM, an interview was conducted with Maintenance Director 'N'. Maintenance Director 'N' explained that the elevator did not have a sensor for the wander alert bracelets. Maintenance Director 'N' reported that his staff found R502 on the first floor multiple times and the elevator was turned off from 5:00 PM to 7:00 AM each day. When queried about other times of day, Maintenance Director 'N' reported he was just told (on 5/29/24) to shut the elevator down until we can get rid of the wanderer (R502). On 5/29/24 at 2:10 PM, an interview was conducted via the telephone with CNA 'M'. When queried about how R502 got downstairs to the first floor on 5/28/24, CNA 'M' reported she was unaware that the resident went to the first floor. CNA 'M' reported nobody notified her that R502 went down there. Further review of R502's clinical record revealed a physician's order for a wander alert bracelet started on 4/2/24 and discontinued on 4/22/24. A new order for a wander alert bracelet was ordered on 5/27/24 with a start date of 5/28/24. A review of a Behavior Note progress note dated 5/28/24 at 7:40 PM revealed R502 entered into the activity room and used a pair of scissors and cut off the wander alert bracelet. A review of R502's care plans revealed a care plan initiated on 4/1/24 that noted R502 was exit seeking and an elopement risk. Interventions were initiated on 4/8/24 that included: a wander alert bracelet; distraction with food, activities, conversation, television, and books; and eliciting family input into former routine that might explain attempts to leave unescorted. There were no additional care plans that addressed R502 leaving the second floor unit on the elevator and going to the off limits first floor of the facility that was under construction. There were no additional interventions included on the care plan for exit seeking and elopement after 4/8/24 despite R502 going to the first floor without staff knowledge four times between 5/10/24 and 5/28/24. Further review of R502's progress notes revealed the resident had exhibited exit seeking behaviors since her admitted on 3/29/24. On 5/29/24 at 2:30 PM, an interview was conducted with the Director of Nursing (DON), who started in that position on 5/28/24. When queried about expectations for supervision of residents who wander, the DON reported staff were supposed to redirect residents from wandering, provide diversional activities, attempt to follow the resident's routine, and continue to monitor the resident to ensure they are not in any immediate harm. When queried about what should be done if a resident wandered into an unsafe area, such as the first floor construction zone, the DON reported additional interventions should be implemented. The DON reported the elevator was shut down at 5:00 PM on Monday 5/27/24, but was unsure why as she just started in the DON role one day ago. The DON reported she was unaware R502 got to the first floor on 5/28/24.

This citation pertains to Intake Number(s): MI00137119. This citation contains two Deficient Practice Statements (DPS). DPS #1 Based on observation, interview, and record review, the facility failed to protect residents' rights to be free from deprivation of goods and services by staff for sixteen (R's 707, 708, 709, 710, 711, 712, 713, 714, 705, 715, 704, 716, 717, 718, 719, 722) of 24 residents reviewed for neglect. This resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident when these residents did not have an assigned licensed or registered nurse for 6 hours and 22 minutes (12:38 AM to 7:00 AM on 5/18/23) and did not receive multiple physician ordered medications needed to treat medical conditions, such as, insulin, blood pressure, seizure, pain, Parkinson, thyroid, diuretic, gastroesophageal reflux disease & potassium, and provided consistent supervision and monitoring; and respond to potential crisis/medical complications, resulting in the increased likelihood of serious harm, serious injury and/or death. Findings include: The IJ began 5/18/23. The Immediate Jeopardy was identified on 7/6/23. The Director of Nursing (DON) was notified of the Immediate Jeopardy on 7/6/23 at 1:37 PM, and a plan to remove the immediacy was requested. The immediacy was removed on 7/6/23 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the deficient practice was not corrected and remained patterned with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. Review of a complaint submitted to the State Agency (SA) documented the allegation regarding the residents that resided on Unit 3 to not have received their midnight shift medications. Review of the May 2023 Medication Administration Records (MAR) for R704 revealed the following for 5/18/23: 6 AM Levothyroxine Sodium 88 MCG (microgram) for thyroid condition, Enteral Feed Order, Isosource 1.5 ml to be stopped at 6 AM or until goal volume is reached for nutrition, Flush of H20 (water) 45 cc (cubic centimeter) every hour, while pump is running for, Diltiazem HCl 90 MG tablet for high blood pressure, Hydralazine HCl 25 MG (milligram) for high blood pressure, and Isosorbide Dinitrate 40 MG for high blood pressure was not administered and/or monitored. Review of the medical record revealed R704 resided on Unit 3 on 5/18/23, with diagnoses that included: chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, chronic kidney disease (stage 3B), diastolic congestive heart failure, hypertensive heart and chronic kidney disease, type 2 diabetes mellitus, seizures, history of transient ischemic attack, atherosclerotic heart disease and ileus unspecified. Review of the May 2023 MAR for R705 revealed the following for 5/18/23: 6 AM Benzocaine oral analgesic 20% gel for pain, blood sugar level & Novolog Solution per sliding scale was not obtained, administered, or monitored. Review of the medical record revealed R705 resided on Unit 3 on 5/18/23, with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction, speech and language deficits, protein-calorie malnutrition, type 2 diabetes mellitus, hypertensive heart disease with heart failure, chronic respiratory failure, obstructive sleep apnea, and acute kidney failure. Review of the May 2023 MAR for R707 revealed the following for 5/18/23: 6 AM Gabapentin 400 MG, Hydralazine HCl 10 MG for high blood pressure, Keppra 500 MG for seizures was not administered or monitored. Review of the medical record revealed R707 resided on Unit 3 on 5/18/23, with diagnoses that included: hemiplegia and hemiparesis, severe protein-calorie malnutrition, type 2 diabetes mellitus with diabetic neuropathy, critical illness myopathy, encephalopathy, aphasia, hypertension, and epilepsy. Review of the May 2023 MAR for R708 revealed the following for 5/18/23: 6 AM Hydralazine HCl 50 MG for high blood pressure was not administered or monitored. Review of the medical record revealed R708 resided on Unit 3 on 5/18/23, with diagnoses that included: dementia, hemiplegia and hemiparesis following cerebral infarction, hypertensive chronic kidney disease stage 5, end stage renal disease, dependence on renal dialysis, and hyperkalemia. Review of the May 2023 MAR for R709 revealed the following for 5/18/23: 6:30 AM Omeprazole 40 MG not administered or monitored. Review of the medical record revealed R709 resided on Unit 3 on 5/18/23, with diagnoses that included: systolic and diastolic congestive heart failure, longstanding persistent atrial fibrillation, acute respiratory failure with hypoxia, pulmonary hypertension, hypertension heart and chronic kidney disease (stage 3A), dependence on supplemental oxygen and gastroesophageal reflux disease (gerd). Review of the May 2023 MAR for R710 revealed the following for 5/18/23: 6:00 AM Levothyroxine 75 MCG for thyroid condition, Baclofen 5 MG for muscle spasms, Depakote 500 MG delayed release for anticonvulsant, and Tylenol 650 MG for pain (midnight dose as well) was not administered or monitored. Review of the medical record revealed R710 resided on Unit 3 on 5/18/23, with diagnoses that included: toxic encephalopathy, dementia, hypothyroidism, mild cognitive impairment, kidney failure, repeated falls, bradycardia, and epilepsy. Review of the May 2023 MAR for R711 revealed the following for 5/18/23: 6:00 AM Levothyroxine 100 MCG was not administered or monitored. Review of the medical record revealed R711 resided on Unit 3 on 5/18/23, with diagnoses that included: cerebral infarction, epilepsy, type 2 diabetes mellitus, hypertension, hypothyroidism, and chronic kidney disease (stage 3A). Review of the May 2023 MAR for R712 revealed the following for 5/18/23: 6 AM Baclofen 10 MG, Bromocriptine Mesylate 5 MG for antidiabetic & antiparkinson, hydralazine HCl 25 mg for high blood pressure, and Potassium Citrate extended release 20 Meq (milliequivalent) that was not administered or monitored. Review of the medical record revealed R712 resided on Unit 3 on 5/18/23, with diagnoses that included: paralytic syndrome following intracranial hemorrhage, quadriplegia, epilepsy, dementia, asthma, and hypertension. Review of the May 2023 MAR for R713 revealed the following for 5/18/23: Enteral Feed order Isosource, stop time at 3 AM that was not monitored. Review of the medical record revealed R713 resided on Unit 3 on 5/18/23, with diagnoses that included: epilepsy, moderate protein-calorie malnutrition, and heart failure. Review of the May 2023 MAR for R714 revealed the following for 5/18/23: 6:00 AM Novolog Solution per sliding scale and blood sugar level obtained, administered, and monitored. Review of the medical record revealed R714 resided on Unit 3 on 5/18/23, with diagnoses that included: end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, hypertensive heart, systolic congestive heart failure, paroxysmal atrial fibrillation, Parkinson's, and hemiplegia and hemiparesis following cerebral infarction. Review of the May 2023 MAR for R715 revealed the following for 5/18/23: 6:00 AM Carbidopa-Levodopa 25-250 MG for Parkinson's (also the midnight dose) was not administered or monitored. Review of the medical record revealed R715 resided on Unit 3 on 5/18/23, with diagnoses that included: Parkinson's disease, repeated falls, and dementia. Review of the May 2023 MAR for R716 revealed the following for 5/18/23: 6:00 AM Lasix 20 MG for edema, Omeprazole 20 MG for gerd, and gabapentin 800 Mg for neuropathy was not administered or monitored. Review of the medical record revealed R716 resided on Unit 3 on 5/18/23, with diagnoses that included: orthopedic aftercare following surgical amputation, absence of right leg above knee and left leg below knee, type 2 diabetes mellitus, chronic obstructive pulmonary disease, embolism and thrombosis of iliac artery acute kidney failure, hypertension, and gastro-esophageal reflux disease. Review of the May 2023 MAR for R717 revealed the following for 5/18/23: 6:00 AM Gabapentin 300 MG for neuropathy, and Propranolol HCl 20 MG for hypertension was not administered or monitored. Review of the medical record revealed R717 resided on Unit 3 on 5/18/23, with diagnoses that included: frontal lobe and executive function deficit following cerebral infarction, hemiplegia and hemiparesis, dysphagia, type 2 diabetes mellitus, acute kidney failure, hypertension, and epilepsy. Review of the May 2023 MAR for R718 revealed the following for 5/18/23: 6:00 AM cleanse s/p (suprapubic) site with ns (normal saline) apply split 4x4 gauze and give prn (as needed) BP (blood pressure) medication prior to dialysis if SBP (systolic blood pressure) is above 150 was not obtained, provided, or monitored. Review of the medical record revealed R718 resided on Unit 3 on 5/18/23, with diagnoses that included: paraplegia, dependence on renal dialysis, type 2 diabetes mellitus, end stage renal disease, hypertensive chronic kidney disease (stage 5), displacement of indwelling urethral catheter, retention of urine, legal blindness, and bradycardia. Review of the May 2023 MAR for R719 revealed the following for 5/18/23: 6:00 AM Oxybutynin Chloride 5 MG for urinary issues and 6:30 AM obtain blood sugar before meals for glucose monitoring was not obtained, administered, or monitored. Review of the medical record revealed R719 resided on Unit 3 on 5/18/23, with diagnoses that included: chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, insomnia, hypertension, overactive bladder, and repeated falls. Review of the May 2023 MAR for R722 revealed the following for 5/18/23: 6:30 AM Insulin Lispro solution pen-injector per sliding scale and obtained blood sugar level was not obtained, administered, or monitored. Review of the medical record revealed R722 resided on Unit 3 on 5/18/23, with diagnoses that included: acute respiratory failure with hypoxia, systolic congestive heart failure, type 2 diabetes mellitus, hypotension, and cardiomyopathy. The facility failed to ensure a nurse was assigned to all of the above residents from 12:38 AM to 7:00 AM on 5/18/23. Review of a census report dated 5/18/23 documented 24 residents in total resided on Unit three. Review of the facility staff sheet dated 5/17/23 documented the facility Census as 74. Further review of the staffing sheet, time sheets for facility employees, invoices for agency staff provided by the facility revealed the following for the 7 PM to 7:30 AM shift: Unit 1- Licensed Practical Nurse (LPN) A was assigned to 27 residents. LPN A worked from 7:30 PM on 5/17/23 to 7:45 AM on 5/18/23 on Unit 1. Unit 2- LPN B was assigned to 15 residents. LPN B time sheet was requested from the DON, but not provided. Unit 3- Registered Nurse (RN) C (agency nurse) was assigned to 24 residents. RN C worked from 6:54 PM on 5/17/23 to 12:38 AM on 5/18/23 on Unit 3. Unit 4- LPN D was assigned to nine residents. LPN D worked from 7:19 PM on 5/17/23 to 8:58 AM on 5/18/23. On 7/6/23 at 8:54 AM, LPN A was contacted via telephone for an interview. A message was left for LPN A to return the call. At 3:36 PM, LPN A returned the call and when asked about the nightshift on 5/17/23 to 5/18/23, LPN A stated LPN B informed them the Agency nurse (RN C) went home early. LPN A stated LPN B was upset because they had just returned back to work from being suspended and recently demoted. LPN A stated they asked LPN B who counted (the narcotics and cart) with RN C before they left the facility, LPN B replied another nurse (later identified as LPN E) instructed RN C to put the keys (for the medication and narcotic box) in the book (medication book). LPN A was asked who LPN E was and if they were on duty that night and LPN A stated they think LPN E was a unit manager and stated LPN E was not on duty that night. LPN A stated they told LPN B to let a manager know that RN C went home and that the nurses have a pretty heavy workload so that someone can come in to help. LPN A stated at that time they were under the impression that LPN B was contacting the DON to inform them of the situation so that a nurse will be assigned to come on duty to help. LPN A stated they saw LPN B a little later in the shift and asked if they had notified the DON and what directive the DON gave to LPN B. LPN A stated LPN B said they called the DON, and the DON did not answer their phone. LPN A stated at that time they asked LPN B to call the DON in front of them. LPN A explained that the facility has a box that is supposed to go on Unit 2 when there is no supervisor in the building. LPN A stated the nurse assigned to Unit 2 is supposed to call around to try and get someone to come in or call in a manager to help if something happens or the facility is short staffed with nurses. LPN A stated they were trying not to step on LPN B toes because LPN B was the assigned nurse on Unit 2, and it was their responsibility to ensure a manager was notified of RN C going home early and Unit 3 not having nurse coverage. LPN A stated LPN B went on the phone and acted as if they called the DON however stated the DON did not answer and LPN E is going to handle the situation. LPN A stated it was getting closer to 7 AM, so they asked LPN B again if they counted the narcotics with RN C before they left, and LPN B laughed and stated their (facility administration staff) are not going to use me when they need me. LPN A stated they asked LPN B to come with them to Unit 3 to count the narcotics on the cart and LPN B refused. LPN A stated they asked LPN B to split the workload (for Unit 3) with them, but LPN B stated they could not go over to Unit 3. LPN A explained a resident on Unit 3 made a complaint against LPN B and LPN B was not allowed to work with that resident. LPN A stated they told LPN B they would take the resident and LPN B would be assigned to another group of residents on Unit 3 and LPN B refused. LPN A stated there was another nurse LPN D assigned to Unit 4, however Unit 4 is downstairs, and that nurse has to stay on their floor for their whole shift to ensure a nurse is on the first floor with the residents. LPN A stated they called LPN E and the DON themselves and neither answered their phones. LPN A stated those residents (on Unit 3) missed their morning medications unnecessarily, we (LPN A and LPN B) could have split that unit to ensure the residents received their medications, however LPN A stated it was poor communication and LPN A was not forth coming with the information or what duties they did or did not do and who they informed of the situation and talked to. On 7/6/23 at 9:14 AM, LPN D (the nurse assigned to Unit 4) was interviewed and asked about the midnight shift on 5/17/23 7PM to 5/18/23 7AM and if they knew anything about a nurse leaving in the middle of their shift. LPN D stated they remember hearing about the nurse that left, but they worked downstairs and when you work on Unit 4 the nurse has to stay on that unit. LPN D stated they heard that no one counted her (RN C) out and took her keys (to the medication cart and narcotic box). LPN D stated no one asked them to help out on Unit 3 and they did not find out about the incident until the end of their shift. LPN D stated it was a big commotion when the dayshift came into the facility. On 7/6/23 at 9:28 AM, a phone interview was attempted with RN C, a message was left on their voicemail to return the call. A return phone call was not received by the end of the survey. On 7/6/23 at 10:02 AM, a phone interview was attempted with LPN B, a message was left on their voicemail to return the call. A return phone call was not received by the end of the survey. At the time of this survey the DON informed the surveyor that LPN B was terminated due to this incident. On 7/6/23 at 10:10 AM, the DON was interviewed and asked what the facility's protocol is when a nurse has to leave their assignment mid shift and the DON stated they (staff) are supposed to call around to replace that nurse. The DON stated the other two nurses on the second floor could also split the unit to cover the house. The DON stated the unit manager come in at 6AM and can take over and make sure that everything is good. When asked if they were aware of RN C leaving their shift early on 5/18/23, the DON stated they were aware that RN C had an issue with their child and had to leave. The DON stated they didn't find out until 6 AM the morning of 5/18/23. The DON stated LPN B had left a message on their phone. The DON confirmed LPN B was terminated due to the incident on 5/18/23. The DON stated they put all of this information in a binder. The DON was asked to provide the binder to the surveyor for review. On 7/6/23 at 10:33 AM, the Medical Director (MD) H was interviewed and asked if they were aware of Unit 3 to not have nursing coverage for six hours and twenty-two minutes on 5/18/23 and MD H stated they believe they were informed by their colleague. MD H explained at that time their colleague was the Medical Director of the facility and they were transitioning into the position. MD H stated there is no long-term consequence for the residents missing one dose of their medications, however the incident was awful . terrible and should have never happened. MD H went on to say how it was unacceptable, however believed with the new management in place the facility is now moving in the right direction. On 7/6/23 at 10:46 AM, the DON was asked for the second time to provide the binder with the investigation from the incident on 5/18/23. A third request for the binder was made at 11:08 AM. Review of the binder provided by the DON contained the following staff statements: RN C statement (dated 5/18/23) documented in part . I (RN C name) had an emergency. My one-year-old son had a very high Temp (temperature) of 103.7. I was notified by his caretaker. I called 2 different nurses' station but no answer. I walked over to another unit and explained to the nurse at the station my situation and asked her to call the DON. She did however, there was no answer She then called a unit manager named (LPN E name). She explained the situation. Due to the fact that the . nurse at the station saying she could not count the cart with me. The unit manager and other nurse said to count my cart and leave key in book. I counted the cart but then went back to the nurse and pleaded with her to count with me. She said no they demoted me cause of a resident named (resident name) and this is on them. They should have a supervisor on duty now look at them. You have to go, and I understand that. I asked her about the other nurse on duty. She said (LPN A name) is on break and I don't know what time she is coming back. Go ahead we will take care of everything. I then messaged my agency and messaged (the facility name) through my app before leaving. The other nurse signed me out on my app by using her signature (LPN B). She almost didn't want to do that. She said I'm not a supervisor. I then showed her that she could cause it only says, staff signature. I would never just leave any patients without trying to do all I could to find relief. She signed me out and confirmed she would handle things. I had no choice . This statement contained the signature of RN C. LPN F statement (dated 5/18/23) documented in part . arrived on unit at around 7 AM . No MN (midnight) nurse on unit . ask for supervisor . When supervisor get to unit 3 . count narcotics . LPN E statement (dated 5/19/23) documented in part . I received a call after midnight regarding a Nurse (RN C) leaving to tend to her sick child. Nurse (LPN B name) stated The nurse is leaving. She does not have the black box. She is no longer manager and will not go on the unit. I informed (LPN B name) that we cannot hold her (RN C), but someone will have to count down the narc (narcotic) box and pass meds (medications) at 6am. She (LPN B) stated I am not doing it. (DON name), told me my license was on the line and I am not allowed to go on the unit (Unit 3) for my safety. I am not taking those keys. (DON name) isn't answering and did not respond to the text. I asked where the others <sic> staff nurses were. She (LPN B) stated she (LPN A) was missing in action. I then explained they are staff; the meds have to be passed. Attempt to call (DON name) again . This statement contained the signature of LPN E. UM G statement (not dated) documented in part . I came in at 6:15 AM and went to my office to begin my day. At approx. (approximately) 6:35 Nurse (LPN B name) reported to me that the MN (midnight) Agency nurse left around midnight d/t (due to) family emergency. I questioned nurse (LPN B name) about the events and if the medications had been given. According to Nurse (LPN B name) the 0600 medications had not been given. When asked why she stated she was banned from Unit 3 because of (resident name) and nurse (LPN A) wouldn't go. She (LPN B) stated she called the DON but did not get an answer. I texted the DON for direction and to make her aware. The midnight nurse (RN C name) called me to explain what happened. She told me she tried to get nurse (LPN B name) to sigh out . LPN A statement (not dated) documented in part . Around 0100 AM, I returned from break. I returned to my unit, checked in with my aids <sic> then did a wellness check by walking the unit. I then came over to unit 2, (LPN B name) the assigned nurse asked if I received the medication from pharmacy. I confirmed I did. She said, Oh girl the nurse on Unit 3 left. I asked if she counted her out (counted the narcotics and took the cart keys), and did she notify management. She said (LPN E name) was notified. The nurse left the keys in the book, her child was sick. I asked who was going to go over to Unit 3, she said she wasn't the manager anymore. (LPN E name) went back to sleep. She (LPN B) then said she isn't allowed over on Unit 3. I asked if it was only one patient, she couldn't have? She said No, I'm not allowed over their <sic>. I then returned to give care to my unit. I then see (LPN B name) on unit 2 in hall, I asked if she would call (DON name). She said ok, she came over to unit one and walked in the clean utility. I then wanted to hear from (DON name) myself. I followed her. I walked after her. She literally held the door shut after I put the code in, she opened it and stated she (DON) didn't answer. After 0700 AM (LPN B name) came over to unit one and said (DON name) was now notified. I asked who needs to pass the meds she said she is no longer the manager, and they can't use her at there <sic> convenience and walked away . Further review of the binder revealed an education titled Medication order & timely administration of medication that was completed with the facility nursing staff as a result of the incident that occurred on 5/18/23 with RN C leaving mid-shift and Unit 3 to not have nursing coverage. On 7/6/23 at 11:37 AM, the DON was interviewed and asked what the nurses (LPN B and LPN A) was supposed to do when RN C left mid shift and they (the DON) was not answering their phone on 5/18/23. The DON stated LPN B was supposed to call around to get coverage and/or LPN B and LPN A could have split the unit to ensure Unit 3 had nursing coverage. The DON was asked why they didn't answer their phone when staff attempted to notify them of RN C leaving the facility and what the facility's protocol is when they (the DON) don't answer their phone or return the staff's phone calls and the DON stated they did not know why their phone didn't ring because they had it on their bedside by them all night. The DON stated they did not receive a call. The DON stated the staff could have reached out to the Administrator or whoever they could get a hold of. The DON was asked if the facility only educated the staff on medication orders & timely Administration and the DON confirmed the only education provided to the facility staff after the 5/18/23 incident was the medication order & timely administration of medication policy. The DON then stated they gave directive to Unit Manager (UM) G to give the residents on Unit 3 their morning medications on 5/18/23 when UM G came into work at 6 AM that morning and UM G notified them (the DON) that there was no nursing coverage on Unit 3 when RN C left the facility. When asked why UM G didn't administer the medications to the residents on Unit 3 the DON stated they did not know why UM G did not administer the medications to residents on Unit 3 which resulted in UM G to receive a written counseling. The DON was then asked besides the medication administration, who ensured Unit 3 had nursing coverage for the residents basic nursing needs, nursing assessment and nursing services if a crisis or medical complication had arisen and the DON did not have a response. On 7/6/23 at 1 PM, LPN F (the nurse who was assigned to Unit 3 on 5/18/23 for the dayshift) was interviewed via telephone. When asked who they received the Unit 3 medication and narcotic keys from, LPN F stated they received it from the unit manager (UM G). LPN F stated they obtained the keys from UM G and counted the Unit 3 narcotics and one of the narcotics was off by a pill. LPN F stated when they looked at the Unit 3 MARs on the computer all of the residents were red (which indicated they had medications that were overdue). LPN F stated the Administration staff was aware that the midnight shift medications were not administered. LPN F stated when they came on to Unit 3 there was only two CNA's (Certified Nursing Assistants) on the unit. The aides stated they didn't have a nurse on nightshift, but they didn't have any falls or anything. LPN F was asked if they ever came on duty to a Unit that didn't have a nurse assigned to them for the previous shift before at the facility and LPN F stated they had never had that happen to them at any facility until 5/18/23. On 7/6/23 at 12:05 PM, UM G was interviewed and when asked about the morning of 5/18/23 when they came on duty at 6 AM, UM G stated they came on duty and was made aware that Unit 3 did not have nursing coverage due to RN C leaving because of a family issue. UM G stated they notified the DON. When asked if the DON gave them directive to administer the residents on Unit 3 midnight shift medications, UM G stated the DON did not give them the instructions to administer the medications. UM G explained that they did not want to take the keys for Unit 3 medication and narcotic cart because there was no nurse to do the count of the cart/narcotic medications at that time. UM G stated when LPN F came on duty on the morning of 5/18/23 (to unit 3) they counted the narcotics with them, and the count was off. When asked, UM G could not remember the resident or the medication whose count was off. UM G explained they were following standard nursing practices and the facilities policy to complete the count with another nurse before resuming the duties of the medication cart/narcotic medications. UM G explained because they followed professional nursing standard practices and the policy, they were given a written counseling for not resuming the medication cart, without counting with a nurse to administer the medications to the residents on Unit 3. On 7/6/23 at 4:11 PM, a follow-up interview was conducted with the DON. The DON was asked to clarify LPN E position and why staff called LPN E at home regarding RN C leaving the facility mid shift and the DON stated LPN E was previously a manager, however they were not a manager at that time and the DON stated they were unsure on why staff called LPN E for further directive on 5/18/23. At the start of the survey the facility's Administrator was on vacation, however entered the building once the Immediate Jeopardy was served to the facility. Review of a facility policy titled Abuse revised 4/13/23, documented in part . Residents have the right to be free from . neglect . The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written . Neglect . Failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . DPS #2 Based on observation, interview, and record review the facility failed to prevent a resident-to-resident abuse incident for two (R's 701 and 702) of three residents reviewed for Abuse. Findings include: Review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) documented in part, . Incident Summary Resident (R702 name) allegedly assaulted resident (R701 name) on 05/16/2023 in their shared room . at approximately 3:30pm . On the afternoon of 05/16/23 the nurse, (Licensed Practical Nurse- LPN I name), was alerted to a disturbance coming from the room shared by (R701 name and R702 name). When she went to investigate, she observed (R702 name) lying on the floor between the two beds yelling and kicking (R701 name) in his back. The blows did make contact with (R701 name) . The nurse asked (R702 name) to stop kicking (R701 name) and at that point (R702 name) became aggressive with the staff nurse and other staff members who responded . On 7/5/23 at 1:22 PM, R701 was observed sitting in the community room in their wheelchair watching television. When asked, R701 stated that (R702) was a nut and stated the resident came into the room and started kicking him in the back. When asked, R701 stated they did not feel safe around R702. Review of the medical record revealed R701 was admitted to the facility on [DATE], with a readmitted [DATE] and diagnoses that included: dementia, wedge compression fracture of the third lumbar vertebra, cardiomyopathy, hypertension, spinal stenosis, and type 2 diabetes mellitus. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 5 (which indicated severely impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). On 7/5/23 at 1:22 PM, R702 was observed sitting in their wheelchair in their room, a cellphone was observed on their lap. An interview was attempted, however R702 repetitively stated I can't talk . I don't want to talk to you . while kicking their feet. The interview was concluded at that time. Review of the medical record revealed R702 was admitted to the facility on [DATE], with diagnoses that included: dementia, anxiety, depression, and intellectual disabilities. A MDS assessment dated [DATE], documented a BIMS score of 7 (which indicated severely impaired cognition) and required staff assistance for all ADLs. Review of a Behavior Note dated 5/16/23 at 4:12 PM, documented in part . Writer was called to room by roommate calling out for help. When writer got to the room, I witnessed him (R702) trying to kick the roommate with his legs from behind while he was on the floor. His legs were barely reaching the resident next to him, but his toes were able to reach resident as he kept trying to kick him. He was asked to stop and continued to be aggressive to staff and roommate . Resident was re directed, and it was not effective . New verbal order for Ativan 0.5 PRN (as needed) x1 a day. Seroquel 50 mg (milligram) 3x a day . Further review of the progress notes revealed the following: On 5/11/23 at 3:58 PM, a Behavior Note documen[TRUNCATED]

This citation pertains to Intake Number(s): MI00131469, MI00131551, MI00131999, and MI00131552. Based on observation, interview, and record review, the facility failed to protect residents' rights to be free from deprivation of goods and services by staff for nine (R28, R57, R14, R36, R45, R24, R68, R60, and R7) of 13 residents reviewed for neglect. This resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident when these residents were not assigned a licensed or registered nurse for 12 hours (7:00 PM on 9/22/22 until 7:00 AM on 9/23/22) and did not receive multiple physician ordered medications needed to treat medical conditions, such as, pain, cardiac disease, blood clots, psychiatric disorders, diabetes, and post kidney transplant therapy; did not provide wound treatments and catheter care; complete nursing assessments for pain and blood sugar monitoring; provide supervision; and respond to potential crisis/medical complications. This resulted in R28 and R60 calling 911 due to unrelieved pain and experiencing anxiety due to nobody being available to check their vital signs when they experienced blurry vision. Because there was no nurse willing to provide nursing care to these residents, it increased the likelihood of serious harm, serious injury and/or death. Findings include: The IJ began 9/22/22. The Immediate Jeopardy was identified on 3/30/23. The Administrator was notified of the Immediate Jeopardy on 3/30/23 at 1:30 PM, and a plan to remove the immediacy was requested. The immediacy was removed on 9/23/22 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the deficient practice was not corrected and remained patterned with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. Review of a complaint submitted to the State Agency on 9/23/22 revealed the following allegations: Last night, 9/22, there was no nurse and the midnight supervisor refused to pass medications on Unit 2. Resident called the police because medication was not being passed. Medication was still not passed even after the police was called . Review of a second complaint submitted to the State Agency on 9/23/22 revealed the following allegations: .Patient (R28 - who is quadriplegic) called police at 3am (3:00 AM) because he needed his pain medication and there is no nurse able to give it to him .The person in charge at that time is (Nurse 'FF'). She says she is responsible for Unit 1. (R28) is in Unit 2 and they have no nurse to hand out any medication until the day nurse comes in at 6AM (6:00 AM). (Nurse 'FF') said she was not going to be responsible for another unit's med (medication) cart. Unit 2 consisted of many beds, possible 30+ (more than 30) patients. (R28) said this situation occurs regularly . Review of a third complaint submitted to the State Agency on 9/23/22 revealed the following allegations: .(R28) is bedridden .(facility name) is short on staff. There are two aides at the facility who cannot administer medication. None of the patients are getting their medication. The supervisor, (Nurse 'FF'), is capable of administering medication to the patients but is refusing to do so. (R28) is supposed to get pain medication every six hours but have not received pain medication for 11 hours since day shift. This has occurred multiple times a week . Review of a Case Report from the local police department revealed the following: .Subject .Cruelty/Neglect .Report Date/Time 09/23/2022 02:41 (2:41 AM) .Occurrence Date/Time 09/23/2022 02:41 .Dispatched Offense .Welfare Check .Verified Offense .Cruelty/Neglect . .Suspect .(Nurse 'FF') .Victim .(R28) . .Officers were dispatched to (facility name) to check on (R28). We made contact with (R28) in (room number). (R28) said he has not received his medication since 5pm the previous day, which was almost 11 hours prior. (R28) said he is supposed to get his pain medication every 6 hours .(R28) said the medication neglect has been an on going issue with (R28), the only supervisor in the building when officers were on scene. (R28) said not getting his meds through the night has been happening several times a week. Officer spoke with staff on scene. There were two nurses on the floor near (R28's room). Offers inquired about medications. They said they did not have the ability of giving medication. I could hear numerous rooms complains that they did not get their medication. The nurses were just telling the patients to go to sleep. I asked the floor nurses why everyone was asking for meds. They said the <sic> do not have enough staff and the only person that could give medication is (Nurse 'FF'), the supervisor on scene. The nurses took us to (Nurse 'FF')'s office. When we opened the door (Nurse 'FF') was just sitting in the room listening to music on her phone. (Nurse 'FF') said she is the staffing manager. She said they have 4 wings and only 3 nurses that can give medication so the wing with (R28) on it will not get medication until day shift comes back to work. I noted that 15 plus patients will not be receiving any medication from approx. (approximately) 7pm to 7am on this date. (Nurse 'FF') is an LPN (Licensed Practical Nurse). When we were interviewing her she said she can give medications but she is not willing to take responsibility of signing out the medication cart and giving meds. (Nurse 'FF') said her boss is (former Director of Nursing, DON 'II')and gave us her phone number. I tried to call several times and (Officer name) tried to call her several times as well, with no response .(Officer) .filed a complaint about (facility) and the negligent medical care they are providing . On 3/28/23 at 10:12 AM, R28 was observed lying in bed. R28 appeared to have limited use of their arms and reported they were unable to move the lower half of their body. When queried about any time when they called the police, R28 reported they did call 911 before because there was no nurse to pass medications and they did not receive their pain medication for approximately 12 hours. R28 reported there was not enough staff to take care of the residents, but the facility continued to admit new residents. On 3/30/23 at 1:49 PM, R60 was interviewed. When queried about whether there was any time when a nurse was not available to provide nursing care or pass medications, R60 reported there was a night when they did not have a nurse. R60 explained it was several months ago. R60 reported they did not receive their pain medications and they were having trouble with blurry vision which they said they were instructed to have their blood pressure monitored if that happened. R60 further explained they tried to get a nurse, but there was nobody to come help them. R60 called the front desk from their cellular phone and nobody answered. They called their family to call the front desk and they did did not get anyone on the phone. R60 reported they called 911 and EMS (emergency medical services) came and took their blood pressure. R60 stated, After they left, I thought my nurse was going to get my medicine and we never got any meds that night. Review of a Grievance Documentation, Investigation & Follow-Up Form dated 9/23/22 revealed R28 filed a grievance on that date. The nature of the concern was documented as follows: Res (resident) stated it has been 2 nites <sic> of not receiving 9p (9:00 PM) and 6a (6:00 AM) meds due to no nurse on Unit 2. Res. stated that he used light multiple times and sent cena (CNA) to nurse who never came so he called 911. Police came out. Res. stated the police spoke with (Nurse 'FF') and said 'she is not doing it'. Police filled out a victim's report. Res. also stated that police came due to multiple calls. The signature of the person who received the grievance was illegible and the facility was unable to identify who signed it. The following was documented in the investigation section: Nurse suspended. Investigation indicates that she failed to supervise or pass medications on Unit 2. Termination paperwork pending. The investigation section was signed by the former Administrator, (Administrator 'JJJ). The following was documented in the Action Taken section: Nurse responsible, (Nurse 'FF'), suspended. Nurse was terminated .(the rest of the handwriting was illegible). That section was signed by former DON 'LL'. Review of a resident census for the date of 9/22/22 revealed all residents listed on the census did not receive nursing services, including medication administration, treatments, assessments/monitoring, and supervision on the 7:00 PM to 7:00 AM shift. Review of R28's Physician's orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) for September 2022 revealed they did not receive the following physician ordered treatments, medications, and assessments on 9/22/22 and 9/23/22: 1. Percocet (a narcotic pain medication), was given at 7:10 AM on 9/22/22 and was not given again until 12:10 PM on 9/23/22. According to R28, this medication was needed the night on 9/22/22 which is why they called 911. 2. Acetaminophen Tablet (medication used to treat pain) 9:00 PM dose. 3. Pain Assessment during second shift (7:00 PM-7:00 AM). 4. COVID-19 Screen for symptoms during second shift. 5. COVID-19 Screen to monitor vital signs during second shift. 6. Monitor catheter anchor during second shift. 7. Midodrine HCl (a medication to treat low blood pressure) 10:00 PM dose on 9/22/22 and 6:00 AM dose on 9/23/22. 8. Docusate Sodium (stool softener) 9:00 PM dose. 9. Assessment of heels and sacral areas which were ordered to be done during the evening shift. 10. Suprapubic catheter care ordered to be done every night shift. 11. Bowel movement monitoring during second shift. 12. Colostomy care during second shift. 13. Irrigation of suprapubic catheter during second shift. 14. Wound care to the sacro-coccyx area on second shift. Further review of R28's clinical record revealed R28 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: quadriplegia, stage 4 pressure ulcers, cervical spinal cord injury post gun shot wound, hypertension, morbid obesity, compression of the brain, and contractures of the right and left upper arms. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R28 had intact cognition, was totally dependent on staff for all activities of daily living (ADLs), had an indwelling catheter and a colostomy, had multiple pressure ulcers, and frequent pain. Review of R60's Physician's Orders, MAR, and TAR for September 2022 revealed they did not receive the following physician ordered treatments, medications, and assessments on 9/22/22 and 9/23/22: 1. Lidocaine to rectum 9:00PM dose. 2. Pain Assessment during second shift. 3. Calmoseptine Ointment to sacrococcyx, ordered to be done at 9:00 PM. 4. COVID-19 Screen for symptoms during second shift. 5. COVID-19 Screen to monitor vital signs during second shift. 6. Monitor catheter anchor during second shift. 7. Hydrocodone-Acetaminophen (a narcotic pain medication) 10:00 PM dose on 9/22/22 and 6:00 AM dose on 9/23/22. The medication was ordered to be administered every 8 hours. 8. Tizanidine HCl (a medication to treat muscle spasms) 10:00 PM dose on 9/22/22 and 6:00 AM dose on 9/23/22. 9. Assessment of heels and sacral areas which were ordered to be done during the evening shift. 10. Biscodyl Suppository (to treat constipation) due at 9:00 PM which was ordered every day at bedtime. 11. Bowel movement monitoring during second shift on 9/22/22 and first shift on 9/23/22. 12. Monitoring of urine output from indwelling catheter during second shift on 9/22/22 and first shift on 9/23/22. 13. Wound care to bilateral legs/feet/toes, 9:00 PM. 14. Catheter care during evening and night shift. Further review of R60's clinical record revealed R60 was admitted into the facility on [DATE] with diagnoses that included: quadriplegia, neuralgia (severe pain due to damaged nerves), type 2 diabetes mellitus, constipation, and neuromuscular dysfunction of bladder. Review of a MDS assessment dated [DATE] revealed R60 had intact cognition, required extensive physical assistance from staff for bed mobility, transfers, and all ADLs, had an indwelling urinary catheter, and experienced frequent pain. Review of a Staffing Assignment sheet for 9/22/22 revealed the facility census was 73 on that date. Further review of the staffing assignment sheet, time punches for facility employees, an invoice from a staffing agency used by the facility that indicated who worked in the facility, and MARs for residents who resided on the second floor on 9/22/22 revealed the following: The following nurses were scheduled and/or worked in the facility on 9/22/22 during the 7:00 PM to 7:00 AM shift: Nurse 'GG' worked from 7:00 PM until 7:15 AM and was assigned to Unit 3. Nurse 'HH' worked from 7:00 PM until 8:31 AM and was assigned to Unit 2. Nurse 'YY' was assigned to Unit 4 according to the assignment sheet, but there was no time punch for that day. Review of MARs for residents who resided on Unit 4 revealed Nurse 'GG' administered medications to those residents on the 7:00 PM-7:00 AM shift on 9/22/22. Nurse 'FF' was assigned to Unit 1 according to the assignment sheet, but there was no time punch for that day. Review of the MARs for residents who resided on Unit 1 on 9/22/22 revealed Nurse 'FF' administered medications on that day which indicated they did work. Five Certified Nursing Assistants (CNAs 'AA', 'BB', 'CC', 'ZZ' and 'AAA') worked the 7:00 PM to 7:00 AM shift according to the assignment sheet and corresponding time punches provided by the facility. Review of MARs for residents who resided on Unit 3 revealed Nurse 'HH' administered medications to residents on Unit 3 on the 7:00 PM-7:00 AM shift on 9/22/22. Review of MARs for residents who resided on Unit 1 revealed Nurse 'GG' administered medications to residents on Unit 1 on the 7:00 PM-7:00 AM shift on 9/22/22. Based on the time punches and documentation in the clinical record, there was no indication that Nurse 'YY' worked on 9/22/22. On 3/29/23 at 12:56 PM, a telephone interview was conducted with CNA 'AA'. CNA 'AA' reported she did not remember police coming to the building or the building being without a nurse. On 3/29/23 at 12:58 PM, CNA 'BB' who was assigned to work on Unit 1 on 9/22/22 was interviewed. CNA 'BB' was not available for interview prior to the end of the survey. On 3/29/23 at 12:34 PM, a telephone interview was conducted with CNA 'CC' who was assigned to Unit 2, the unit documented on the police report as not having an assigned nurse and residents who complained of not getting their medications. When queried about the night of 9/22/22, CNA 'CC' reported they did not remember that night. When queried about the police being called because residents were not getting their medications, CNA 'CC' reported they would not know if a resident did not get medications because they were not a nurse and further explained that they remembered police coming a couple of times. On 3/29/23 at 1:27 PM, a telephone interview was conducted with Nurse 'DD' who was the outgoing nurse on 9/22/22 at 7:00 PM and the incoming nurse on 9/23/22 at 7:00 AM. When queried about any knowledge of a set of residents not getting medications or nursing services and police response during the night shift, Nurse 'DD' reported they did not have any specific information, but that used to happen a lot because they cut one of the night shift nurses out. Nurse 'DD' reported when that occurred they would be coming in at 6:00 AM instead of 7:00 AM to pass medications. Nurse 'DD' further explained the nurse assigned to Unit 1 and the nurse assigned from Unit 3 would split Unit 2. When queried about who they counted the Unit 2 narcotics with when they left their shift on 9/22/22, Nurse 'DD' could not remember. When queried about what happened if a nurse did not show up to relieve them from their medication cart, Nurse 'DD' reported the narcotics were counted with the afternoon/night supervisor and keys to the cart were handed over to the supervisor. When queried about any time they arrived for their day shift and residents had not received medications from the previous 12 hour shift, Nurse 'DD' could not remember. When queried about what they would do if they discovered that happened, Nurse 'DD' reported they would report it to the unit manager or DON and stated, But, it is my word against the nurses. They will ask me who told me that and if I say it was the resident, then it's the resident's word against the nurse. They have to investigate. Review of Nurse 'FF's personnel file revealed the following: An Employee Personal Change Form that documented Nurse 'FF' was hired as a LPN - supv (supervisor) on 8/18/22. A Personal Change Form that documented Nurse 'FF' was discharged effective 9/27/20 (confirmed with Human Resources Director - HR 'C' that the date was 9/27/23). It was documented Nurse 'FF' was not recommended for re-employment in the same department or in other departments. In the remarks section the following was documented: Terminated first 90 days not taking cart. The form was not signed. An Employee Counseling & Corrective Action Record for Nurse 'FF' documented they were suspended (not terminated) on 9/29/22 and the form was signed by former Administrator 'JJJ' and former DON 'LL'. On 3/29/23 at 3:08 PM, an interview was conducted with the current DON of the facility. When queried about why Nurse 'FF' was terminated and/or suspended on 9/27/22 or 9/29/22, the DON reported she was not aware of the reason. On 3/29/23 at approximately 3:45 PM, the current Administrator was interviewed. The Administrator, who was also the Abuse Coordinator for the facility, reported they began working in the facility on 12/5/22. When queried about any investigation into the grievance provided for R28 from 9/23/22 regarding Nurse 'FF' and medications and care not being administered, the Administrator explained that was before they started working in the facility and they did not find an investigation. When queried about what was the protocol if a nurse refused to pass medications or there was nobody available or willing to pass medications or care for a set of residents, the Administrator reported it was fully investigated and the physician was called about missed medications. The Administrator reported they did not know anything about this incident. On 3/29/23 at 4:32 PM, a telephone interview was conducted with Nurse 'HH'. Nurse 'HH' reported they worked at the facility two times and was contracted through a staffing agency. When queried about whether they recalled if police came to the facility when they were working, Nurse 'HH' reported they recalled one night EMS came because there was a patient that wanted pain medicine and the young lady that was supervising would not pass medications. Nurse 'HH' explained that Nurse 'FF' sent a nurse home at the start of the night shift on 9/22/22 and that left the building short of nurses (three instead of four). Nurse 'HH' reported that they worked on Unit 3 on second shift. Nurse 'HH' further explained when they went upstairs, a resident was very upset because he had not yet received pain medication. Nurse 'HH' looked for Nurse 'FF', the nurse supervisor, to assist the resident. Nurse 'HH' stated, I found her (Nurse 'FF') in the cubby hole and told her that the resident needed pain medication. She was sitting there, with no socks or shoes on, eating candy, and on her phone. When Nurse 'HH' informed Nurse 'FF' that the resident needed medication, Nurse 'FF' told Nurse 'HH', Well do you want to give it to him? Nurse 'HH' explained that she did not acquire the keys to that cart and did not count the narcotics on the cart and was not comfortable. Nurse 'HH' further explained that they were assigned to 20-30 patients on the other side of the floor. Nurse 'FF' accused Nurse 'HH' of refusing an assignment and Nurse 'FF' remained in the cubby for the shift eating candy and sitting on her phone. Nurse 'HH' explained they did not pass medications to any residents on Unit 2 and either did Nurse 'FF' who was the supervising nurse. When queried about if they contacted anybody to report that there was nobody to take care of the residents on Unit 2, Nurse 'HH' reported that she told her manager at the agency, but did not contact anyone at the facility. On 3/30/23 at 8:32 AM, Nurse 'FF' was interviewed. When queried about why the police came to the facility on [DATE], Nurse 'FF' reported there was a situation where they did not have a nurse scheduled for a particular unit. When queried about what was done about that, Nurse 'FF' reported they contacted the DON, but the DON did not return the phone call and they were given no directives. When asked if they were a nurse supervisor, Nurse 'FF' stated, The position I had was not specific of my title. I was more of a working supervisor or charge nurse. I just made CNA assignments. When queried about who acquired the keys from the Unit 2 medication cart at the beginning of second shift on 9/22/22, Nurse 'FF' reported the keys were in the cart and they reported to the DON that another nurse was needed. When queried about their interaction with the police, Nurse 'FF' reported the police asked what was going on and they told them they were working on a whole other unit and the DON was notified. When queried about any interaction with other nurses who were working to ensure all residents were cared for, Nurse 'FF' reported there was interaction but one of the nurses concerns was that it was unsafe to assign them to Unit 2 when they were already working on Unit 3 because of how the floor was designed. When asked if they took the medication cart on Unit 2 in the absence of another nurse due to being the supervisor, Nurse 'FF' reported they did not because I had a whole other cart. Nurse 'FF' explained they did not pass medications or provide any nursing care to the residents on Unit 2 for the entirety of second shift and they told the police they would have to wait until the day shift (first shift) came in at 6:00 AM. When queried about whether there was any disciplinary action taken due to them not providing medications, treatments, and assessments on Unit 2, Nurse 'FF' reported they were taken off the schedule while the facility investigated and then they brought them back to work. Nurse 'FF' reported the DON 'II' stopped coming to work and never returned after that night. On 3/30/23 at 9:04 AM, a telephone interview was attempted with former DON 'II'. There was no response from DON 'II' prior to the end of the survey. On 3/30/23 at 9:34 AM, an interview was conducted with the Assistant Director of Nursing (ADON). When queried about whether they were aware of the reason for termination/suspension of Nurse 'FF' in September 2022, the ADON reported they were informed by the previous Administrator that Nurse 'FF' refused to pass medications when staffing was short. When queried about what the proper protocol would be, the ADON reported Nurse 'FF' was the second shift supervisor and had access to the medication cart. In the absence of another nurse, Nurse 'FF' would have been responsible to pass medications, provide treatments, and do assessments on the residents without an assigned nurse. In addition, the nurse supervisor was responsible to contact the contracted staffing agencies to find a nurse to come in and then contact the DON and/or on call managers if there was one assigned. and DON should be contacted. When queried about what should be done if a staff member became aware that a set of residents did not have an assigned nurse, the ADON reported the DON and Administrator would be contacted. On 3/30/23 at 9:42 AM, a telephone interview was attempted with the Medical Director, Physician 'JJ'. There was no response from Physician 'JJ' prior to the end of the survey. On 3/20/23 at 10:26 AM, a telephone interview was conducted with former Administrator 'KK'. Administrator 'KK' reported they were the former interim Administrator in the facility and their last day at the facility was 11/18/22. When queried about any knowledge of what occurred on 9/22/22 when the police came to the facility, Administrator 'KK' reported they remembered the police coming to the facility because there was a resident who said they did not get their medications and the nurse would not administer them. Administrator 'KK' did not have any further details and reported she thought there was an investigation, but it might have been done by Administrator 'JJJ'. Administrator 'KK' reported there were several different DONs and Administrators within a six month period. On 3/30/23 at 10:32 AM, a phone interview was conducted with former DON 'LL'. DON 'LL' reported they worked at the facility as a consultant for two months and left the first week of October 2022. DON 'LL' could not remember details of what occurred on 9/22/22 with R28 and Nurse 'FF' and stated, There were several times when nurses had to split a unit and staffing was such a problem. When queried about whether they recalled being contacted and they could not remember. Review of the residents who resided on Unit 2 on 9/22/22 revealed a total of 21 residents total did not receive medications, treatments, assessments, and/or supervision by a licensed nurse between the hours of 7:00 PM and 7:00 AM (on 9/23/22). Review of R45's clinical record revealed R45 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), osteoarthritis, anxiety disorder, hyperlipidemia, lymphedema, chronic kidney disease, and depression. Review of a MDS assessment dated [DATE] revealed R45 had intact cognition, was totally dependent on staff for transfers, bed mobility, and most ADLs, and experienced frequent pain. Review of R45's physicians orders, MAR and TAR from September 2022, and progress notes revealed the following: On 9/22/22, R45 was not administered their 9:00 PM dose of melatonin (a medication used to treat insomnia, trazadone (a medication used to treat depression), sertraline ( a medication used to treat anxiety and depression), erythromycin ointment (a medication used to treat eye inflammation), meloxicam (a medication used to treat pain), hydralazine HCl ( a medication used to treat high blood pressure), and tramadol (a medication used to treat pain). In addition, R45 was not administered their 6:00 AM dose of tramadol on 9/23/22. R45 was not assessed on second shift according to physicians orders for COVID-19 symptoms and vital signs and their blood sugar was not checked at 9:00 PM according to physicians orders. There were no progress notes written to indicate a physician was contacted regarding the missed medications for R45. R57's clinical record was reviewed and revealed R57 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: type 2 diabetes mellitus, end stage renal disease (on dialysis), kidney transplant status (on immunosuppression therapy), anemia, hypothyroidism, hyperlipidemia, heart failure, peripheral vascular disease, major depressive disorder, hypertension, pleural effusion, constipation, and insomnia. Review of a MDS assessment dated [DATE] revealed R57 had intact cognition and required set up and supervision with most ADLs. Review of R57's physicians orders, MAR and TAR from September 2022, and progress notes revealed the following: On 9/22/22, R57 was not administered their 9:00 PM dose of tacrolimus (an immunosuppresive medication used to prevent organ rejection after a transplant), mycophenolate mofetil (a medication used to prevent organ rejection after a transplant), insulin glargine-yfgn (a medication used to treat diabetes), clonidine (a medication used to treat high blood pressure), hydralazine HCl, isosorbide dinatrate (a medication used to treat chest pain), amlodipine (a medication to treat high blood pressure), atorvastatin (a medication used to treat high cholesterol), levothyroxine ( medication used to treat underactive thyroid), remeron (a medication used to treat depression), carvedilol (a medication used to treat heart failure and high blood pressure), and colace (a medication used to treat constipation). In addition, R57 was not assessed for COVID-19 symptoms and vital sign monitoring according to physicians orders, pain was not assessed, and orthotic splints and ace wraps were not applied. There were no progress notes written to indicate a physician was contacted regarding the missed medications for R57. Review of R68's clinical record revealed R68 was admitted into the facility on [DATE] with diagnoses that included: COPD, bipolar disorder, major depressive disorder, thrombophilia (a blood clotting disorder), chronic pain disorder, spinal stenosis, and constipation. Review of a MDS assessment dated [DATE] revealed R68 had intact cognition, required set up and supervision for ADLs, and had frequent pain. Review of R68's physicians orders, MAR and TAR from September 2022, and progress notes revealed the following: On 9/22/22, R68 was not administered their 9:00 PM dose of allergy medication, antifungal medication for itching, atorvastatin, trazodone, diclofenac sodium gel (a topical medication used to treat pain), eliquis ( a medication used to prevent blood clots), acetaminophen (a mediation used to treat pain), their 10:00 PM dose of baclofen (a medication used to treat muscle spasms) on 9/22/22 and their 6:00 AM dose on 9/23/22, their 10:00 PM dose (9/22/22) and 6:00 AM dose (9/23/22) of gabapentin (a medication used to treat nerve pain), and their 12:00 AM and 6:00 AM dose of tramadol on 9/23/22. In addition, R68 was not assessed for pain, COVID-19 symptoms, or vital sign monitoring according to physician's orders. There were no progress notes written to indicate a physician was contacted regarding the missed medications for R68. On 3/30/23 at 1:45 PM, R7 was observed seated in a wheelchair in their room. When queried about any time when he did not receive medications, R7 reported they remembered a few months ago not getting medications at night, but could not recall if the police came. R7 reported he had seen police in the building before though. Review of R7's clinical record revealed R7 was admitted into the facility on [DATE] with diagnoses that included: wedge compression fracture of lumbar vertebra, cardiomyopathy, atrioventricular block, hypertension, type 2 diabetes mellitus, dementia, anemia, and depression. Review of a MDS assessment dated [DATE] revealed R7 had severely impaired cognition, required extensive assistance with ADLs, transfers and bed mobility, and experienced frequent pain. Review of R7's physicians orders, MAR and TAR from September 2022, and progress notes revealed the following: On 9/22/22, R7 was not administered their 9:00 PM dose of atorvastatin, melatonin, seroquel (a medication used to treat psychosis), enulose (a medication used to treat constipation), lidocaine patch (a patch used to treat pain), and acetaminophen. R7 did not receive insulin lispro at 12:00 AM and 6:00 AM on 9/23/22. In addition, R7 was not assessed for pain, COVID-19 symptoms, or vital sign monitoring according to physician's orders. There were no progress notes written to indicate a physician was contacted regarding the missed medications for R7. Review of R14's clinical record revealed R14 was admitted into the facility on [DATE] with diagnoses that included: cerebrovascular disease, vascular dementia, hypertensive heart disease, artherosclerosis, dysphagia (difficulty swallowing), osteoarthritis, major depressive disorder, and major depressive disorder. Review of a MDS assessment dated [DATE] revealed R14 had moderately impaired cognition and [TRUNCATED]

This citation pertains to intake #MI 900. Based on observation, interview, and record review the facility failed to develop and implement interventions and ensure adequate supervision to prevent the elopement of one of two residents reviewed for elopement (R701), resulting in immediate jeopordy when on 8/27/22 at 8:27 PM R701 eloped from the facility and was returned to the facility by police at 2:40 AM. Review of the facility investigation file reveale a document that read, .RESIDENT INTERVIEW/SUMMARY OF FINDING OR ALLEGATION .Resident was observed leaving the facility on camera and a staff member behind him within 30 seconds .CONTRIBUTING FACTORS AND INTERVENTIONS: .2. Assigned Staff did not follow the Policy and Procedure that was inserviced <sic> to all shifts at the end of July, which requires all staff members to check the perimeter and never reset the alarm without verifying resident location .SUMMARY OF FACTUAL INVESTIGATIVE FINDINGS: DATE: 8/28/2022 ROOT CAUSE ANALYSIS: (8:27 p.m.): Resident was observed leaving the facility on camera and a staff member behind him within 60 seconds. The staff member searched the whole room and hall, but not <sic> failed to look outside the glass door onto the patio. Observing the timeframe (60 seconds), it appears she could have seen the resident. She responded to the alarm, but her search of the perimeter did not include the courtyard (patio area). The courtyard has an exit with an egress handle that opens if touched within 30 seconds. TIMELINE OF EVENTS: Police were called then resident was not present at 9:30 p.m. bed check on 8/28/2022. All resident rooms were checked and documented by staff and police officers. NHA (Nursing Home Administration, DON, Regional Nurse, and COO (Chief Operating Officer) contacted when resident was not found in the building (calls at 1:15 p.m.) NHA began search in perimeter next door to the building after speaking with officers and nurse supervisor, verifying resident was not in building at approximately 11:15 p. m .12:00 a.m. to 2:30 a.m.: The Chief Operating Officer and Regional Nurse arrived and the COO went to join the police search. Police had initiated search in the surrounding area within 3 miles of the building. DON called surrounding hotels and emergency room s .2:40 a.m.: Police returned the resident to the facility from the (Hotel Name) which is approximately 1 mile from the facility. When interviewed by NHA, (R701) stated he left because no one listened to me when I said I was ready to leave. I have been planning this for a long time, but no one else is privy to my plans. Staff: .Multiple staff were interviewed in the investigation into (R701) leaving the building .NHA talked with (CNA 'H'), who had earlier been identified as resetting the alarm. (CNA 'H') was informed of disciplinary action for failure to follow policy . A review of a facility provided policy titled, Elopement Policy dated 8/22/18 was conducted and read, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary .4 .B. The interdisciplinary team will evaluate the unique factors contributing to risk to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements .5. Procedure for Locating Missing Resident a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. Announce a code W). b. The designated facility staff will look for the resident .Term .Elopement .Definition .occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. On 9/12/22 at 12:15 PM, a review of R701's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease and dementia with behaviors. R701's Minimum Data Set (MDS) assessment dated [DATE] indicated moderate cognitive impairment, experience of delusions, and exhibited wandering behaviors 1-3 times through the look-back period. The MDS assessment further documented R701 was ambulatory and required supervision with activities of daily living. R701's admission elopement risk assessment dated [DATE] indicated they were At Risk to Wander. A second elopement risk assessment dated [DATE] was reviewed and indicated they had progressed to High Risk to Wander. A review of R701's progress notes was conducted and revealed the following: Review of a facility provided investigation file for R701 revealed a typed document from Former Interim DON 'K' that summarized R701's exit from the building on 7/17/22. The document read, .On Sunday July 17th, 2022, writer was notified at approximately 11:30am by (Unit Manager 'C') advising me that one of our residents (R701) had attempted to elope from the facility. The resident was observed on the side of the facility by (Certified Nurse Aide, CNA 'B') She approached the resident without incident and led him back into the facility .After reviewing the facility's camera this is the time line: 10:52am resident passed the wonder <sic> guard which did sound by the beauty shop. 10:54am resident went out a service door and down a small hill out of sight. 10:59am resident is back by the door towards front. 11:03am resident in front of patio. 11:05am CENA had resident . A nursing progress note dated 8/7/22 at 6:57 PM entered into the record by Nurse 'D' that read, .Resident Attempted to exit out the rear door down unit one. Alarm sounded and resident stopped opening the door. He states he was trying to get out. A review of R701's care plans with revision history was conducted and revealed a care plan focus that read, The resident is an elopement risk/wanderer (SPECIFY) r/t (related to) Impaired safety awareness, Resident wanders aimlessly. It was noted the care plan contained only two interventions, the first dated 7/13/22 that read, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books, Resident prefers: and the second dated 8/28/22 that read, New wanderguard applied to right ankle. It was noted the care plan did not contain any new interventions after the elopement on 7/17/22 or when they attempted to exit the building on 8/7/22. It was further noted the care plan did not include any increased supervision or monitoring, or a room closer to the nursing station away from stairwells and exit doors. A nursing progress note dated 8/27/22 at 10:00 PM entered into the record by Nurse 'E' that read, .Writer clocked in building around 9:30 (PM). Writer did rounds noted that patient was not in room. writer <sic> aware that patient is exit seeker. Writer asked nurse on floor did she observe patient this shift nurse stated unaware, writer then notified supervisor of patient absence immediately. writer <sic> continued to search and request supervisor to notify DON (Director of Nursing) and administrator. staff <sic> continued to look around facility. patient <sic> not in building. authority <sic> searched premises, patient family made aware per administrator . A nursing progress note dated 8/28/22 at 2:52 AM entered into the record by Nurse 'E' that read, .patient back in building at this time . On 9/12/22 at 1:30 PM, an interview was conducted with Nurse 'E' and they were asked to describe R701's elopement incident they documented on their 7PM-7AM shift on 8/27/22-8/28/22. Nurse 'E' said they phoned the facility early in the day on 8/27/22 and informed them they were going to be late for their 7PM-7AM shift. Nurse 'E' said they clocked into the building around 9 PM and did not receive a shift hand-off report from any other nurse, and got the medication cart keys from the nursing station. Nurse 'E' was asked if they knew who was covering Unit 1 prior to their late arrival and they said they did not know. Nurse 'E' continued to explain they did rounds on their patient assignment and noticed R701 was not in his room. Nurse 'E' said they were aware R701 was an elopement risk and they proceeded to Unit 2 to ask Nurse 'F' if they knew where R701 was. Nurse 'E' said Nurse 'F' told her they didn't know where R701 was. Nurse 'E' said they then went downstairs and reported it to Nurse Manager 'C'. Nurse 'E' was asked if an overhead page was made about R701 being missing and said they could not remember. Nurse 'E' continued to explain that after Nurse Manager 'C' was made aware they began searching the building for R701. Nurse 'E' said the Administrator reported to the building, the police were contacted and eventually R701 was returned to the facility, but they were not sure who found him or where he was found. A review of staff statements contained in the facility's investigation file revealed a statement from Nurse 'G' dated 8/28/22 that read, .I was sitting at the desk for Unit .I went back to my unit, on 3, @ approximately 8:30 pm I went on 1 to see why the alarm was going off, I had heard it when I went to get some ice awhile back the maintenance guy and the CNA for that unit (CNA 'H') was trying to get the alarm off, I asked why it was going and neither one of them said anything. I went back to my unit. A staff statement from Nurse 'F' dated 8/27/22 that read, .Supervisor asked me to keep eye on .(R701). I checked him .he was standing by the nursing station .From that time I was passing night time medications and watching area around the elevator .I did not hear alarm coming from the 1st unit . It was noted the file contained only four statements from staff working the night of R701's elopement from the facility, CNA 'R', CNA 'Q', Nurse 'G', and Nurse 'F' . A review of the facility provided working schedule for the 7PM-7AM shift on 8/27/22 was reviewed and revealed four nurses had been scheduled, Nurses 'E', 'F', 'G', and Nurse Manager 'C', and six CNAs had been scheduled, CNA's 'H', 'M', 'O', 'P', 'Q', and 'R'. It was noted the file did not contain a statement from Nurse 'E', who discovered R701 missing, Nurse Manager 'C', CNA 'H' who reset the alarm, or the maintenance person referenced in Nurse 'G's statement. On 9/13/22 at 8:27 AM, an interview was conducted with the facility's Administrator regarding R701's elopement from the facility on the evening of 8/27/22. They were asked what the facility's process was in response to an alarming door. The Administrator explained CNA 'H' should have entered the patio and looked for a reason the door was alarming. They were then asked what happens when it is discovered a resident was missing, the Administrator said a code Wander should be paged and they should check off a location for all residents. The Administrator said a resident check was performed twice on 8/27/22. Next the Administrator was asked why there was no written statement from CNA 'H' and they said they were sure CNA 'H' had done one but since it wasn't in the file the Administrator said, I will type it up and have her come in and sign it. They were then asked about the identity of the maintenance person referenced in Nurse 'G's statement and whether they had done a statement or received a disciplinary action for attempting to re-set the door alarm and replied, I will prepare a statement. On 9/13/22 at 8:39 AM and 9/14/22 at 9:40 AM, phone calls were placed to Nurse 'F' (who had been instructed by Nurse Supervisor 'C' to keep an eye on R701 on 8/27/22. Voicemails were left, but no calls were returned by the end of the survey. On 9/13/22 at 8:51 AM, an interview was conducted with Nurse 'S', who worked 7AM-7PM on 8/27/22. Nurse 'S' said R701 eloped from the facility after they left their shift. Nurse 'S' was asked who took over her assignment of Unit 1 on the second floor and said they reported off to Nurse Supervisor 'C'. Nurse 'S' was asked approximately how many patient's they had assigned on their shift and said about 24. A review of the schedule provided by the facility indicated Nurse Supervisor 'C' had their own resident assignment of Unit 4 on the first floor On 9/13/22 at 9:04 AM, a phone call was placed to CNA 'H', and a voicemail was left, however; no return call was received by the end of the survey. On 9/13/22 at 9:09 AM, an interview was conducted with Nurse 'G' regarding any knowledge of R701's elopement. Nurse 'G' said she heard a door alarm on Unit 1 and saw CNA 'H' and who they believed to be a maintenance staff member attempting to reset a door alarm. Nurse 'G' said they asked why the alarm was sounding but neither CNA 'G' or the maintenance staff person would provide an explanation. On 9/13/22 at 9:45 AM, an interview was conducted with the facility's Administrator regarding R701's elopement from the building on 7/17/22. The Administrator explained it was not considered an elopement because, He didn't leave the property. They were then asked what was done on 7/17/22 to ensure R701 did not exit the building unauthorized and they said they would have to look at the care plan. At that time, the care plan was reviewed with the Administrator that showed no additional interventions to prevent elopement were implemented until 8/28/22. The Administrator said they did not know why the care plan did not show any updates. On 9/13/22 at 11:40 AM, an interview was conducted with Nurse Supervisor 'C' regarding R701's elopement. Nurse 'C' said they were assigned to work on Unit 4 on the first floor. They went on to explain during their break around 9 pm they were in their car and Nurse 'E' reported to them there was an alarm going off and R701 was missing. Nurse 'C' said they instructed staff to perform a head count and they phoned the Administrator and DON. Nurse 'C' was asked if they were assigned a set of patients on the second floor on 8/27/22 and said they were not, despite Nurse 'S's interview, where it was reported she gave her assignment to Nurse 'C'. They were then asked who was responsible for Nurse 'S's assignment (when they left) until Nurse 'E' arrived late for their scheduled shift, and Nurse 'C' said Nurse 'F' would have been assigned to Unit 1 until Nurse 'E' arrived, and their own assigned unit, Unit 2. A review of a facility provided census for 8/27/22 was conducted and revealed Nurse 'F' would have been assigned 48 residents until Nurse 'E' arrived. On 9/13/22 at 12:00 PM, an observation of Unit 1 was conducted and revealed R701's assigned room at the time of the elopement was located on the second floor, around a corner to the left of the nursing station and was the last room on the right-hand side, adjacent to a stairwell. On 9/13/22 at 12:59 PM, an interview was conducted with Maintenance Director 'J' regarding any involvement with R701's elopement. Maintenance Director 'J' said they received a call to come to the facility on [DATE] at approximately 12:30 AM. They said when they arrived at the building, they discovered an alarm sounding and it was the push bar for the patio gate R701 had eloped through. The Maintenance Director said staff had been able to reset both the patio door alarm and the wander guard alarm, but staff did not know how to reset the gate alarm as it had recently been installed. At that time, they were asked if any of their staff had assisted CNA 'H' with trying to reset any of the alarms earlier in the evening and said it wasn't a maintenance staff person, it had been a housekeeping staff person, Housekeeper 'I'. On 9/13/22 at 1:05 PM, an observation of second floor dining room and the doors leading to the patio where R701 eloped were conducted with the Maintenance Director 'J'. It was noted the building was constructed on the side of a hill which allowed the second-floor patio access to the facility's grounds outside of the patio gate. Observations of the patio door revealed a wanderguard alarm with a key pad on the right side of the door, a door alarm with a keypad on the left side of the door that when the code was entered would not alarm, or when opened without the code would alarm, and the gate alarm that required a key for resetting that alerted staff the patio gate had been opened. At the time of the observation Maintenance Director 'J' demonstrated exit out the patio gate by engaging the push bar for approximately 15 seconds and reset the alarm inside the dining room with the key. On 9/13/22 at 1:20 PM, an observation of the camera footage in the second-floor dining room that had direct view of the patio door on 8/27/22 when R701 eloped was reviewed with Maintenance Director 'J'. The following was revealed: 8:27 PM, R701 enters the second-floor dining room, pushes the patio door open and exits the building onto the patio. 8:31 PM, CNA 'H' enters the room. It was noted CNA 'H' enters four minutes after R701 exited the dining room to the patio building. It was noted this is in conflict with facility's investigation that read, .staff member was behind him within 30 seconds . in one section of the investigation, and in another section of the investigation that documented, .staff member behind him within 60 seconds . Continued review of the footage time-stamped at 8:31 PM, shows CNA 'H' proceed to the patio door and look out. CNA 'H' does not open the door and exit the dining room. CNA 'H' then goes to the keypad on the right side of the door and enters the code to reset the wander guard alarm, then goes to the left side of the door to reset the door alarm, and then goes back to the keypad on the right side of the door. 8:35 PM, CNA 'H' is still in the dining room arranging water cups on a rolling tray. 8:36 PM, a staff member not identified in the facility's investigation enters the dining room, then exits the dining room. 8:38 PM, CNA 'H' exits the dining room. 8:41 PM, A staff member not identified in the facility's investigation enters the dining room and was observed to key in a code to the wander guard alarm on the right side of the door. 8:43 PM, CNA 'H' and Housekeeper 'I' enter the dining room. Housekeeper 'I' is observed with keys attempting to reset the gate alarm on the left side of the patio door. 8:44 PM, Nurse 'G' observed to enter the dining room, Housekeeper 'I' continues with the keys in the patio alarm 8:45 PM, Housekeeper 'I' is observed opening and closing the patio door, but is not observed to enter the patio. Review of the footage was completed at timestamp 8:45 PM. On 9/13/22 at 4:31 PM, an interview was conducted with the facility's Administrator and Nurse Scheduler 'S'. They were asked who was assigned to R701's care after Nurse 'S' left before Nurse 'E' arrived and Nurse Scheduler 'S' said it was Nurse 'F'. On 9/14/22 at 8:40 AM, the facility's Administrator provided an investigation folder that had been located in the former DON's office regarding R701's unauthorized exit from the facility on 7/17/22. At that time, the administrator acknowledged concerns with the facility's implementation of their elopement policy for R701's elopement on 8/28/22. The IJ began on 8/27/22, it was identified by the survey team on 9/12/22 and the facility was notified of the IJ on 9/12/22. On 9/13/22, the State Agency completed onsite verification that the Immediate Jeopardy was removed on 8/28/22 when the facility implemented the following removal plan: -Resident was returned to the facility and placed on a 1:1 until discharge on [DATE] -Education to staff on responding to door alarms -Elopement drills were initiated Although the IJ was removed, the facility remained out of compliance at a scope of pattern and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency.

This citation pertains to intake #'s MI 731, MI 521 and MI 199 Based on interview and record review the facility failed to consistently complete weekly skin assessments, implement treatment as directed by the wound physician consistently for two residents (R707 and R710), of four residents reviewed for pressure ulcers, resulting in R707 developing an unstageable pressure ulcer to the coccyx and adjoining buttocks, and wound treatments not being completed for R710. Findings include: Review of a complaint submitted to the State Agency (SA) documented a concern regarding the facility providing adequate and appropriate care to prevent and treat pressure ulcers. On 9/12/22 an onsite survey was conducted to investigate the complainant's allegation. Review of the medical record revealed R707 was admitted to the facility on [DATE] with a readmitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) dated [DATE] revealed R707 had severely impaired cognition, required staff assistance for all Activities of Daily Living, and did not have any unhealed pressure ulcers. Review of R707's Braden Scale for Predicting Pressure Sore Risk dated 3/24/22 revealed a score of 13 indicating a Moderate Risk for the development of pressure sores. Review of the August 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented the following order in part, . Skin Assessment upon admission and weekly . WEEKLY PLEASE OPEN SKIN ASSESSMENT UNDER ASSESSMENTS TAB . Check skin for open areas, bruises, abrasions, DTI (Deep Tissue Injury) . On August 8th (Monday) the nurse documented a Y indicating that an abnormal area was identified. Further review of the medical chart failed to reveal any description of the abnormal area that was identified on 8/8/22. Further Review of the medical chart revealed it was not until 8/12/22 that a treatment was initiated to the abnormal skin area that was discovered on 8/8/22. Review of the medical order revealed, Coccyx stage 2. Cleanse with wound cleanser. Apply [MEDICATION(S)] on a 4x4, cover with bordered gauze every day shift for wound care, Start Date - 08/12/2022 . Review of a Wound Rounds Note dated 8/9/22 at 2:41 PM, documented in part . Seen on wound rounds re (regarding) rash with denudation to the glans penis and scrotum . Rash with denudation to the glans penis and scrotum related to Candidal MASD (Moisture Associated Skin Damage). Improving. Rx all with [MEDICATION(S)] cream bid (twice a day) x 2 weeks from 8/4/22. Apply Triad paste to scrotal denuded area bid at time different than [MEDICATION(S)] . Review of the August 2022 MAR and TAR revealed the [MEDICATION(S)] cream and Triad paste was never implemented as ordered by the wound physician. Review of a Nursing progress note dated 8/10/22 at 7:28 PM, documented in part . Noted coccyx stage 2 measuring 68 cm (centimeters) x 50 cm. (it is likely that these measurements are inaccurate) wound bed is reddened. Periwound is intact. No maceration noted. No odor noted. Cleansed with wound cleanser and [MEDICATION(S)] ag applied - followed by dry dressing . This order was implemented but never transcribed on the August 2022 MAR and TAR, which resulted in the treatment having been applied this one time and two days after the abnormal skin assessment was identified on 8/8/22. Review of a Wound Rounds Note dated 8/16/22 at 10:44 AM, documented in part . Seen on wound rounds re rash with denudation to the glans penis and scrotum and open area to the coccyx . Rash with denudation to the glans penis and scrotum related to Candidial MASD. Continue Rx all with [MEDICATION(S)] cream BID x 2 more weeks from 8/16/22. Apply Triad paste to scrotal denuded area BID at times different than [MEDICATION(S)]. Developed an unstageable ulcer to the coccyx and adjoining buttocks. Covered partly with yellow slough. Moderate serosanguinous drainage. Margin irregular. Rx with [MEDICATION(S)] on a 4x4 gauze and cover with dry dressing daily and prn (as needed) . Dementia with inability to follow directions . An additional review of the August 2022 MAR and TAR revealed although the [MEDICATION(S)] and Triad cream was ordered again, the treatments were never implemented. Review of a facility policy titled Skin & Wound Policy revised 2/2022, documented in part . It is our policy to perform a full body skin assessment and oral cavity assessment as part of our systemic approach to pressure injury prevention and management . All wounds will have treatment orders from the physician team . Wound treatments will be provided in accordance with physician orders, including cleansing method, type of dressing, and frequency of dressing change . On 9/14/22 at 12:45 PM, Registered Nurse (RN) U was interviewed, RN U stated they sent R707 out to the hospital via 911 on 8/22/22 due to observing recent mental status changes with the resident and poor appetite. R707 was still discharged from the facility at the time of survey. On 9/14/22 at 12:08 PM, the Director of Nursing (DON) was interviewed and asked about the facility's process and protocol of implementing wound treatments as ordered by the wound physician and the DON replied, the unit manager will round with the wound physician when they come in weekly. The DON stated they are currently reading through all of the wound consultation reports after the wound rounds, completing the documentation of the wound rounds and implementing the orders from the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated they would look into it and follow back up. There was no further explanation or documentation provided by the end of survey. R710 A complaint was received by the State Agency that alleged the facility was not changing the resident's dressings for a pressure ulcer on their sacrum/coccyx. A review of a facility provided policy titled, Skin & Wound Policy dated 2/2022 was conducted and read, .6. wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change . On 9/14/22 at 3:10 PM, an interview was conducted with R710 regarding care they received in the facility. R710 verbalized multiple concerns including concerns with their dressings not being changed per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R710's clinical record was conducted and revealed they admitted to the facility on [DATE], discharged to the hospital on 8/24/22 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R710's most recently completed Minimum Data Set assessment indicated they had intact cognition, were non-ambulatory, required total assistance from staff members for activities of daily living, and admitted to the facility with pressure ulcers. A review of R710's Treatment Administration Records was conducted and revealed the following: August 2022: Physician ordered daily treatment to the Sacro-coccyx wound left blank on 8/12/22 thru 8/17/22, 8/21/22, and 8/23/22. September 2022: Physician ordered daily treatment to the Sacro-coccyx wound left blank 9/1/22 thru 9/3/22, 9/5/22, 9/7/22, 9/9/22, 9/10/22 and 9/13/22. On 9/14/22 at 4:30 PM, an interview was conducted with the facility's Director of Nursing (DON) and they indicated they did not have a wound care nurse and had not completed any audits on wound care because they had recently become the DON in the building.

This citation pertains to intake #MI 153 Based on observation, interview, and record review, the facility failed to administer medications per a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A review of an undated facility provided document titled, Safe Medication Administration was conducted and read, Medication Administration Practices Standards .2. Follow the 5 Rs <sic> of medication .R dose .When does a medication Error Occur .Observed or Identified preparation and administration of medication and biologicals in accordance to: A. Prescribers order .Significant Medication Errors= causes discomfort or jeoperdizes <sic> the health and safety of residents. Discomfort may be subjective on individual situation and duration . On 3/1/22 at 1:55 PM, a review of R501's clinical record was conducted and revealed they admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R501's most recent Minimum Data Set assessment dated [DATE] revealed R501 had intact cognition, was non-ambulatory, and required extensive assistance from one or two staff members for activities of daily living. A review of R501's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It was noted the order was to give ten 10 mg tablets to make the 100 mg dose. It was further noted the [MEDICATION(S)] order prior to 2/25/22 had been to administer five 10 mg tablets for a total dose of 50 mg. R501's care plan was reviewed and included a focus and intervention initiated 1/26/22 that read, RISK FOR IMPAIRED COMFORT r/t (related to) Resident has breakthrough pain .Administer pain medication as ordered . A review of R501's medication administration records (MAR's) and corresponding progress notes about medication administration revealed the following: On 2/28/22 [MEDICATION(S)] (opioid pain medication often used for withdrawal from other prescription and illicit drugs) 100 mg scheduled for 9 AM was coded as a 5, meaning the medication was held. A corresponding progress note by Nurse 'F' read, Awaiting arrival from pharmacy. On 2/28/22 [MEDICATION(S)] 100 mg scheduled for 9 PM was coded as a 9 meaning the medication was not given. A corresponding progress note by Nurse 'A' read, Order per pharmacy is 5 tabs (50 mg). writer <sic> gave as per pharmacy stated. Will note in physician book if for 10 tab's <sic> a new script (prescription) will be needed. On 3/1/22 at 3:40 PM, an interview was conducted with R501. R501 was lying in their bed on their stomach and presented as anxious and upset. In an elevated voice volume R501 complained the facility had not been administering their medications per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R501 said they were given five, 10 mg [MEDICATION(S)] tablets and they knew they were supposed to receive ten, 10 mg tablets. R501 continued to explain they had a long history of chronic back pain and both prescription and illicit drug abuse including a [MEDICATION(S)] addiction. They went on to say that two years ago they chose to begin seeking treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R501 became increasingly anxious and agitated during the interview describing their pain, panic, and fear of withdrawal. R501 said it made them physically ill and stated, I thought I was going to die last night. R501 went on to say, they could not take it anymore and they were leaving the facility against medical advice as soon as their transportation got there. On 3/2/22 at 8:30 AM, a review if R501's progress notes from 3/1/21 revealed a note entered into the record at 7:32 PM that read, patient left with guardian AMA (against medical advice), refused to sign AMA form. patient state <sic>, 'I want to go home and you can not stop me' . On 3/2/22 at 9:20 AM, a review of the attending physician's logbook for R501's doctor and physician extenders was conducted and did not review any logs for communication to the physician from Nurse 'A' regarding R501's [MEDICATION(S)]. It was noted the last recorded log in the book was dated 2/22/22. At that time, the Director of Nursing (DON) was asked if that was the most recent log in the book and they said it was. On 3/2/22 at 3:20 PM, an interview was conducted with Nurse 'A' regarding R501's allegations they received only half of their dosage of [MEDICATION(S)], and the progress note they documented in the record. Nurse 'A' explained they saw an order to administer ten 10 mg tablets of [MEDICATION(S)] at 9 PM on 2/28/22. They said the compared the order to the pharmacy label and noticed a discrepancy. They said the pharmacy label indicated R501 was only supposed to receive 50 mg of [MEDICATION(S)]. Nurse 'A' said they called the pharmacy to clarify the order and was told the order was to give 50 mg. Nurse 'A' was asked if they called the physician to clarify the order and said they did not. They were asked about putting correspondence in the physician's logbook and said they did. At that time, they were asked if they could provide a copy of the correspondence. At 3:30 PM, Nurse 'A' reported they had put it in the logbook, but the page was missing. On 3/2/22 at 4:35 PM, an interview was conducted with the facility's DON regarding the concern with R501's [MEDICATION(S)]. The DON said they were going to look into it. At approximately 5:00 PM, the DON reported there was an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said the medication should have been administered per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/2/22 at 4:35 PM, an interview was conducted with Dr. 'FF'. Dr. 'FF' was asked about R501's [MEDICATION(S)] and said that on 2/25/22 they wrote an order to increase the [MEDICATION(S)] dose from 50 mg twice daily to 100 mg twice daily as well as placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Dr. 'FF' said they also faxed the two controlled substance authorizations to the pharmacy that day. Dr. 'FF' was then asked if were aware of any discrepancies with R501's orders and said they had not been made aware of any concerns.

Based on observation, interview and record review the facility failed to ensure effective pain management for one resident (R16) of two residents reviewed for pain resulting in R16 not receiving their prescribed pain medications and experiencing pain at a level of 10 on a scale of 1-10, with 10 being the worst pain ever experienced. Findings include: On 1/24/22 at approximately 10:27 a.m., R16 was observed in room, lying in bed. R16 was queried regarding their care in the facility, and they indicated on a communication program via computer that they had a pain medication change, had been experiencing pain, and that they did not know what happened to their pain medications and the facility was not adequately addressing their pain. On 1/25/22 at approximately 8:29 a.m., R16 was observed in their room, lying in their bed. R16 was queried if they were in any pain, and they indicated they were. On 1/25/22 at approximately 9:00 a.m., while still in R16's room, R16 indicated they were not receiving their [MEDICATION(S)] pain patch correctly. R16 pointed at their patch on their upper left chest, and it was observed to be dated for 1/19/22. On 1/24/22 the medical record for R16 was reviewed and revealed the following: R16 was initially admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R16's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/23/21 revealed R16 needed extensive assistance with most of their activities of daily living. Section C indicated R16 had intact cognition. Section J indicated R16 had frequent pain and was on a scheduled pain regimen. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Controlled Drug* Apply 1 patch transdermally every 72 hours for pain Rotate Site and remove per schedule . A review of R16's January 2022 MAR (medication administration record) revealed R16 did not receive a new [MEDICATION(S)] patch on 1/22/22 as scheduled. A Nursing note dated 1/22/2022 at [5:21 p.m.,] revealed the following: Nursing -Orders -Administration Note: [MEDICATION(S)] Patch 72 Hour 12 MCG/HR Apply 1 patch transdermally every 72 hours for pain Rotate Site and remove per schedule. Nurse called pharmacy and got confirmation they would send medication out today, still waiting on arrival from pharmacy . A Nursing note dated 1/25/2022 at[ 10:53 a.m.,.] revealed the following: Nursing -Progress Note- writer assessed res (resident) skin, no other [MEDICATION(S)] patch found. writer notified MD (Medical Doctor) and pharmacy. [representative] from pharmacy stated, [MEDICATION(S)] patches will be sent out to the facility at the 2pm run today. writer faxed removal of controlled substance medication form to pharmacy. writer waiting for pharmacy to fax back authorization number to pull from (backup medication supply). res stable. unit nurse will continue to monitor. A review of R16's pain assessment at the time of their [MEDICATION(S)] patch administration on 1/25/22 revealed R16 had a pain level of 10 (out of a 1-10 scale). A second physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Controlled Drug* Give 1 tablet by mouth every 12 hours for Pain DO NOT CRUSH . A review of R16's December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R16's Nursing progress notes for pertaining to their December 2021 [MEDICATION(S)] administration revealed the following: 12/28/2021 at [11:22 a.m.,] [MEDICATION(S)] ER (extended release) Tablet Extended Release 15MG (milligrams) .Medication not given. 12/28/2021 at 7:32 p.m.,] [MEDICATION(S)] ER Tablet Extended Release 15MG .Give 1 tablet by mouth every 12 hours for Pain DO NOT CRUSH .medication not available 12/29/2021 at [10:14 a.m.,] [MEDICATION(S)] ER Tablet Extended Release 15MG Give 1 tablet by mouth every 12 hours for Pain DO NOT CRUSH .unable to locate 12/30/2021 at [10:02 a.m.,] [MEDICATION(S)] ER Tablet Extended Release 15MG .Give 1 tablet by mouth every 12 hours for Pain DO NOT CRUSH .Medication not available. Further review of R16's comprehensive plan of care was conducted and did not reveal any focused areas regarding the facility's management of R16's pain. On 1/25/22 at approximately 1:25 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding their investigation of R16's [MEDICATION(S)] patch and why they were not provided a new patch on 1/22/22 according to the Physicians order . The DON indicated that a new patch should have been applied on 1/22/21 and that if narcotics were not available then they could be pulled from the backup box with pharmacy authorization and administered on time. On 1/26/22 at approximately 11:05 a.m., R16's medical record was reviewed with MDS Coordinator Q (MDSC Q). MDSC Q was queried regarding R16's focused plan of care for their Chronic pain. MDSC Q was observed reviewing R16's comprehensive careplan and indicated that R16 did not have a care plan addressing their pain and that one would need to be put in place. MDSC Q was queried why R16 did not have a plan of care addressing their pain and they indicated they did now know but that they should have had one. A review of a facility provided document titled Pain Management Program revealed the following: POLICY: To establish guidelines for pain management which emphasize an interdisciplinary approach to pain control, to maximize resident comfort .PROCEDURE: 3. After completing the initial nursing assessment if it has been determined that the patient is experiencing pain or is on a pain medication, a pain assessment will be completed within 24 hours of admission. 4. The assessment will describe and characterize the pain, including location, cause of pain (if able to determine), type of pain, chronic vs. acute, and intensity level. A scale of 0-10 will be used (with 10 being the worst pain). 5. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . If it is determined that a cause can not be identified it shall be documented to explain why the cause or causes of pain could not be or should not have been determined or why it was decided that in doing so would not affect the treatment or outcome. (Please seek out physician input) 6. All analgesics will be reviewed and evaluated by the physician to be sure they are appropriate for the resident. The basic principles of using analgesic medication in the frail elderly and chronically ill shall be followed. If a different approach is required due to for example, patient preference this will be documented in the clinical record. 7. The interdisciplinary team and the physician shall work in conjugation in reviewing the causes and to what degree pain is affecting the resident's quality of life (ability to perform ADL's (activities of daily living), sleep pattern, participation in activities, mood, cognition and behavior). Options related to managing the resident's pain, including non-pharmacological measures, will be considered. 8. If current medications and complementary therapies (non-pharmacologic) i.e., PT, OT, positioning, psychological and/or spiritual counseling, are not effective in relieving pain the physician will be notified to review the situation and prescribe or modify regimen. All unrelieved pain will be addressed with the physician if it persists. 9. A treatment plan shall be developed for all residents who may have risk factors that make them very likely for pain to occur. This plan shall take into consideration the patients underlying diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 10. Plans of care shall be developed for each resident with established goals to relieve pain, reduce pain to a tolerable level, or reduce the need for breakthrough pain. Plans of care should include individual interventions to meet the patient's needs such as giving a pain medication before certain events or activities known to regularly exacerbate the patients pain such as turning, dressing changes or therapy. In addition, the care plan should also include a statement regarding what intensity level we expect the patient to achieve. (i.e. what is the realistic pain level we expect the patient to be at. If a resident has chronic pain and always rates his/her pain at a 10 with current medication regimen, it would not be acceptable for this patient to be pain free.).

This citation pertains to intake: MI 277. Based on observation, interview and record review the facility failed to consistently complete skin assessments accurately, identify and notify the physician of skin changes timely for two (R#'s 707 and 710) of three resident's reviewed for pressure ulcers, resulting in delayed wound care treatment, complaints of a sore bottom, a stage IV pressure ulcer (full thickness skin and tissue loss with exposed or directly palpable fascia muscle, tendon, ligament, cartilage or bone in the ulcer) (R#707), a stage III pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer) (R#710) and requiring hospitalization for R#707. Findings include: R#707 On 2/2/21 at 1:42 pm, an interview with the complainant revealed the following in part . He came into the facility with nothing and left with a stage four infected wound. He would complain about being left to lay wet and in feces for long periods of time, with no one coming to help and feeling very uncomfortable in the bed he was in . We moved him to another facility . He is doing much better . A review of the clinical record revealed the following: R#707 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9 (indicating moderately impaired cognition) and required a two person assist for bed mobility and toileting. An Admission Skin/Wound Assessment/Consult dated 12/24/20 at 10:59 am, with an observation date of 12/23/20 at 10:47 am, completed by the facility's Wound Nurse (WN) A (who also serves as the ADON - Assistant Director of Nursing), documented in part, . Prognosis for wound healing - Fair . Does patient have co morbidities that affect overall prognosis or wound healing? Yes - if Yes, Explain - limited mobility, [MEDICAL CONDITION] . Is the Patient a Risk for Skin Breakdown? Yes, Braden Score: 14 . Color: Hyper pigmented areas . Location/Description of problem areas: . DTI (Deep Tissue Injury- Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue.) to sacrococcyx/bilateral buttock 7.5 x 8.4 cm (centimeters) dark black wrinkly skin, non-blanchable and tender . A Braden Scale for Prediction of Pressure Sore Risk dated 12/24/20 (one day after admission) documented a Braden score of 14, Moderate Risk. WN A documented the observation for the day of admission on 12/23/20, however completed the Admission Skin Assessment form on 12/24/20 and an order for [REDACTED]. A Weekly Skin assessment dated [DATE] documented in part, . BUTTOCKS - Blisters noted to coccyx and superficial excoriation noted to left buttock . The clinical record was reviewed and revealed no notification to the physician regarding the resident's skin changes. A Nursing noted dated 1/3/21 at 6:25 pm, documented in part . He has skin breakdown in the coccyx area. Nursing will add him to the wound care round list . Despite the WN A identifying a DTI to sacrococcyx/bilateral buttock area upon admission, the resident's buttocks was not assessed by a physician from the admission date of [DATE] until the residents first initial wound consultation on 1/5/21 (13 days after admission). An order received by WN A on 1/4/21, documented in part . Apply triad paste to sacrococcyx and bilateral buttock Q (every) shift and prn (as needed) . WN A failed to document a note on why the triad paste was implemented. Further review of the clinical record revealed no explanation on why the triad paste was implemented. An order to apply a low air loss concave mattress to bed, monitor for functioning Q (every) shift and PRN. Was added on 1/4/21 (12 days after admission). A wound consult dated 1/5/21 documented in part, . This patient was seen today as a consultation for evaluation of the patient's wounds . Wound Assessment(s) - Wound #2 Sacrococcyx/bilat buttocks is a Stage 3 Pressure Injury Pressure Ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer) and has received a status of Not Healed. Initial wound encounter measurements are 12cm length x 13 cm width x 0.3xm depth, with an area of 156 sq (square) cm and a volume of 46.8 cubic cm. There is a moderate amount of sero sanguineous drainage noted which has no odor. Wound bed has Yellow Necrotic Base [MEDICATION NAME] . Diagnosis - 1: Pressure Ulcer Stage III Sacrococcyx/bilat buttocks, 2: Vascular Ulcer L (left) heel . Treatment Recommendations - . Santyl Daily and PRN . Pressure Relief/Offloading - LOW AIR LOSS MATTRESS OR LOW AIR LOSS BED, FREQUENTLY REPOSITION, FLOAT HEELS, SOFT HEEL LIFT BOOTS . A review of the clinical record revealed no documentation identifying the DTI progressing to a Stage 3 pressure wound. A wound consult dated 1/9/21 documented in part, . Wound #2 Sacrococcyx/bilat buttocks is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 10cm length x 18cm width x 0.2cm depth, with an area of 180 sq cm and a volume of 36 cubic cm. There is a large amount of sero-sanguineous drainage noted which has no odor. Wound bed has Yellow Necrotic Base [MEDICATION NAME] . Diagnosis - 1: Pressure Ulcer Stage III Sacrococcyx/bilat buttocks, 2: Vascular Ulcer L heel . Treatment Recommendations - . Santyl + Calcium Alginate QD (everyday) and PRN - Sacrococcyx . A Nurse Practitioner (NP) progress noted dated 1/11/21 at 2:49 documented in part, . He complained of being sore at his bottom due to sitting . He denied any other acute concerns . A Weekly Skin assessment dated [DATE] at 2:11 pm, documented in part . Stage 3 pressure ulcer noted to bilateral buttock and coccyx with yellow necrotic base noted. Large amount of sero-sanguineous drainage noted, Has no odor or any s/s (signs/symptoms) of infection (10cm x 18cm x 0.2cm) . The assessment documented the same findings noted on 1/9/21 wound consultation. A Dakin's Solution (sodium hypochlorite) OTC (Over The Counter) 0.125% . Clean wound with Dakins Solution . Once A Morning . Diagnosis: [REDACTED]. was implemented on 1/14/21, however review of the clinical record failed to indicate why the order was implemented. A wound consult dated 1/19/21 documented in part, . Wound #2 Sacrococcyx/bilat buttocks is a Stage 4 Pressure Injury Pressure Ulcer (Full thickness skin and tissue loss with exposed or directly palpable fascia muscle, tendon, ligament, cartilage or bone in the ulcer) and has received a status of Not Healed. Subsequent wound encounter measurements are 14cm length x 18 cm width x 2cm depth, with an area of 252 sq cm and a volume of 504 cubic cm. There is a large amount of sero-sanguineous drainage noted which has a strong odor . Diagnosis 1: Pressure Ulcer Stage IV Sacrococcyx/bilat buttocks, 2: Vascular Ulcer L heel . Wound #2 (Pressure Ulcer) is located on the sacrococcyx/bilat buttocks. A Surgical debridement was performed . to remove devitalized tissue: necrotic/eschar . Treatment Recommendations - . Crushed [MEDICATION NAME] 500mg 2 tabs with hydrogel impregnated gauze BID (twice a day) X 14days to Sacrococcyx. Cleanse wound with Dakins ¼ strength sol (solution) prior to treatment change . X-Ray to R/O [DIAGNOSES REDACTED] . Foley for 30 days for aggressive wound management . Review of the clinical record revealed staff failed to identify the worsening of the wound and notify the physician. A [MEDICATION NAME] 1000mg order was documented in the Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. When the WN A nurse and Director of Nursing was queried on the delay of the [MEDICATION NAME] administration, neither could provide an explanation. A review of the resident's January 2021 toileting documentation revealed the following: 1/2 at 6:41 am and 6:56 pm - Activity did not occur. 1/3 at 1:45 pm - Activity did not occur. 1/4 at 11:02 pm - Activity did not occur. 1/7 at 4:04 pm - Independent (the resident was not independent and required a two person assist) 1/9 at 2:12 am - Activity did not occur. 1/11 at 6:37 am - Activity did not occur. 1/18 at 3:34 am - Activity did not occur. A Radiology Report dated 1/21/20 (two days after being ordered) documented in part, . SACRUM/COCCYX . There is absence of the distal sacrum and coccyx with skin defect . Conclusion: [DIAGNOSES REDACTED] of the distal sacrum . A Nursing note dated 1/21/21 at 7:25 pm, documented in part . X - ray of sacrum/coccyx done; results indicates [DIAGNOSES REDACTED] of distal sacrum. Physician aware and request resident be sent out to the hospital . Hospital records documented an admitting [DIAGNOSES REDACTED]. An ED (Emergency Department) consult dated 1/21/21 documented in part . Patient with necrotic stage IV decubitus ulcer and admitted for the above. Necrosis of the stage IV decubitus ulcer . excisional debridement and local wound care will follow . Stage IV sacral ulcer extending to bone which does not appear actively infected . The resident was admitted into the hospital from 1/21/21 until 1/26/21. On 2/2/21 at 2:30 pm, an interview was conducted with WN A. WN A was queried on the facility's protocol for a resident admitting with skin concerns, WN A stated in part . the admission nurse will complete a skin assessment then 24 to 48 hours, I see the resident . If a person comes in with a wound, we automatically put them on to be seen by the wound team . WN A was then queried on why the admitting nurse did not complete an admission skin assessment on the resident and why their (WN A) skin assessment was documented the day after admission with no notation of a late entry. WN A stated they completed the resident's initial skin assessment (instead of the admitting nurse) and they documented the assessment the day after the resident was admitted . When asked how often the wound team visited the facility, WN A replied every Tuesday. WN A was then queried on why there was a 13-day delay in initiating a wound care consultation for the resident and stated in part, .He had a DTI that was manageable in house, so no consultation was completed on admission . When queried regarding the 12/30/20 nurses note regarding changes to the resident skin and notification to the physician, WN A stated the nurse should have notified someone. When asked why triad paste was implemented on 1/4/21 and the Daskin solution was implemented on 1/14/21, WN A could not provide any documentation or explanation. When queried regarding the failure of the staff to identify the worsening of the residents Sacrococcyx and buttock area between the dates of the wound care physician visits from 1/12/21 to 1/19/21, WN A could not provide any further information. On 2/2/21 at 4:13 pm, the DON was queried regarding the resident sacrococcyx wound and provided a few documents regarding their investigation. The DON's summary report was reviewed and failed to adequately explain the concerns regarding the resident's wound care. The DON was also queried on the failure of the staff to timely toilet the resident by evidence of the staff documentation and stated documentation is an ongoing problem that they are working on. R#710 On 2/3/20 at 12:50 pm, an interview was attempted with R#710. The resident was observed lying on their back, eyes closed and not responding to verbal stimuli. An uneaten lunch tray sat on the overhead table over their bed. A review of the clinical record revealed the following: R#710 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented a BIMS of 11 (indicating moderately impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). A Weekly Skin assessment dated [DATE] at 5:08 pm, documented no skin issues and/or concerns. An order Assess resident's coccyx area and heels Q (every) MN (midnight) shift, every shift, if any new areas of concerns, initiate non-fall incident located in Events with a start date of 5/26/20, was signed for daily for the month of November (with the exception of 11/7 - not signed) and no concerns were documented, prior to 11/10/20. An order dated 11/9/20 documented in part, . Allevyn (foam bandage) 4 x 4 . 1 patch; topical, every shift every 3 days, Apply Allevyn patch to coccyx area Q 72 hours and PRN [DIAGNOSES REDACTED]. The clinical record was reviewed and revealed no documentation for the implementation of the Allevyn patch and no documented assessment and/or description of the coccyx area. A wound care consult order with an Start Date: 12/21/2020 documented in part, . WOUND CARE CONSULT AS OF 11/10/20: COCCYX WOUND . This order was completed after the date of the wound consultation. A wound consult dated 11/10/20 documented in part, . This patient was seen today as a consultation for evaluation of the patient's wounds . Wound #1 Coccyx is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 5cm length x 2.5cm width x 0.3 cm depth, with an area of 12.5 sq cm and volume of 3.75 cubic cm. There is a moderate amount of sero-sanguineous drainage noted which has no odor. Wound bed has yellow necrotic base [MEDICATION NAME] . Diagnosis - 1: Pressure Ulcer Stage III Coccyx . Treatment Recommendations - Santyl daily and PRN . Additional Orders: . Low air loss mattress or low air loss bed, frequently reposition and soft heel protector boots . This facility staff failed to identify any changes with the resident's skin until the resident was [DIAGNOSES REDACTED]. On 2/3/21 at 3:41 pm, the DON was queried regarding the facility failure to timely identify and report to the physician the resident's skin changes. The DON stated the facility identified the wound on 11/10/20 and stated they completed an investigation into the incident. When asked about the nurse that identified the wound on 11/9/20 and obtained a treatment order (prior to the facility claims of identifying the wound on 11/10/20), the DON stated they would have to follow up on it. At 4:49 pm the DON returned and could not provide any further documentation and/or explanation. The DON was queried on the inaccurate weekly skin assessments, the nurses signing orders daily regarding assessing the resident buttock area and staff's failure to identify and report to the physician all changes in the resident's skin. The DON stated they have reeducated their staff, continue to do skin audits, and discuss it in QA (Quality Assurance). A facility policy titled Skin - Pressure Ulcer Guidelines with an issue date of 8/13/20 documented in part, . Upon admission all residents shall have a comprehensive skin and oral cavity assessment completed and documented . When assessing an ulcer, it is important to do the following: . Document the follow: Size, Location, Depth & Stage of ulcer, The presence of absence of necrosis and slough, Tunneling or sinus tract, Condition of the wound bed, evidence of healing such as granulation (where visible), the presence of eschar and the status of surround skin . Monitor the progress toward healing and for potential complications . Assess, treat, and monitor pain . Weekly skin and oral cavity assessments will be completed on each patient regardless of Braden Scale score or skin condition . If there is any change in the patient's skin condition, the nurse or nurse manager should review and revise the patient's care plan accordingly and consult with the director of nursing, physician and/or wound care specialist as needed . If an ulcer is observed or develops post admission there must be thorough documentation of the ulcer upon admission or upon its initial discovery. If there is any change in the patient's skin condition, the nurse or nurse manager should review and revise the patients care plan accordingly and consult with the Director of Nursing, physician and/or wound care specialist as needed .

Based on observation, interview and record review the facility failed to institute and operationalize appropriate infection control principles and practices per the Centers for Disease Control Prevention (CDC) including the failure to adequately screen staff and visitors for precautionary safety measures to prevent the exposure of residents to 2019 Novel Coronavirus (COVID-19), and follow CDC guidelines for six (R#700, R#701, R#705, R#708, R#709 and R#711) of six Residents reviewed for cohorting (sharing a room) with COVID-19 positive or presumed positive residents, resulting in the increased likelihood of symptomatic persons entering the facility undetected and the increase likelihood of transmission of COVID-19. The failure to follow current CDC recommendations for COVID-19 resulted in an Immediate Jeopardy (IJ) to the health and safety of all residents, many of whom were at high risk due to age and co-morbidities, to be exposed and/or develop COVID-19, resulting in serious health complications from COVID-19 including the risk of death. Findings include: The IJ began on 3/20/20. The IJ was identified on 4/15/20. The Administrator was notified of the IJ on 4/16/20 at 5:31 PM and a plan to remove the immediacy was requested. Although the IJ was removed on 4/17/20, the facility remained out of compliance at a scope of widespread and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. Review of CDC guidelines for Long-Term Care Facilities Guidance read in part, . every individual regardless of reason entering a long-term care facility (including residents, staff, visitors, outside healthcare workers, vendors, etc.) should be asked about COVID-19 symptoms and they must also have their temperature checked . Screen all HCP (Health Care Professionals) at the beginning of their shift for fever and symptoms of COVID-19 . Actively take their temperature and document absence of shortness of breath, new or change in cough, sore throat, and muscle aches. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace . On 4/15/20 at 8:00 am, upon entering the facility, an observation of a table with a thermometer, sign in sheet, disinfectant, sanitizer and information on COVID-19 was posted. Surveyors were directed to the table by staff to take their own vitals, document it on the sign in sheet and answer the following questions . Cough?, Travel?, Proximity to Sick? . Do you have a fever?, Do you have a cough?, Have you traveled within the last 14 days?, Have you been in close proximity to anyone who has been sick? The facility assessment questions for staff did not include the complete assessment questions recommended by the CDC. Surveyors completed their temperatures and answered written questions with no oversite from any facility staff reviewing and verifying the temperatures or answers to the questions. On 4/15/20 at 10:07 am, an observation was completed of the facility's side entrance door (which was considered the staff entrance) where two staff members had been observed entering the building on 4/15/20 at 7:53 am. There was a table with a thermometer, alcohol pads, sign in sheets for each department, disinfectant wipes and directive sheets for staff. A green sign documented in part .100.6 fever, notify supervisor . No staff was observed to be present to monitor that each staff member took their temperature or completed the assessment questions. A review of the employee sign in sheets revealed the following: Business office/Administration staff sheet: A staff member circled a Y (indicating yes) for cough on 4/8/20, 4/9 and on 4/13, 4/14 and 4/15 also had a Y circled for Proximity to Sick (it was confirmed that the staff member continued to work). Laundry staff sheet: On 4/12/20 a staff member documented their temperature but did not complete the assessment questions and continued to work that day. Front Desk Reception staff sheet: On 4/15/20 documented one staff circled a Y for cough and three staff members circled a Y for proximity to sick and continued to work with the residents. On 4/15/20 at 10:10 am, Housekeeper (HK) A was queried on how the facility screened them at the start of their shift and stated in part, . Usually a nurse is there at the door to screen us but most of the time there is not (a nurse at the door) . On 4/15/20 at 10:27 am, Staffing Coordinator (SC) B was queried on how the facility screened them at the start of their shift and stated in part, . I come through the employee entrance. Put my name down, answer the questions and take my temp. When asked what they do if their temperature is abnormal, SC B stated, I would call up to the unit and tell the nurse. On 4/15/20 at 10:30 am, Recreational Therapist (RT) C was queried on how the facility screened them at the start of their shift and stated in part, . I stop at the front desk and take my vitals and answer the questions. When RT C was asked if their assessment was abnormal what would they do, RT C stated, I would tell my boss. On 4/15/20 at 8:50 am, the Administrator was queried on who reviewed the staff assessment questions when staff were coming on duty and stated in part, Every day we go through the listing. If they fall within the risk category, we would remove them . On 4/15/20 at 1:44 pm, the Administrator and Director of Nursing (DON), who served as the Infection Control Nurse and the COVID-19 task Nurse, were queried regarding the concerns of not having a staff member verify each employees temperature and review assessment questions prior to the employee starting their shift (to ensure healthcare personnel did not pose a risk for the residents residing at the facility) no response was offered and no additional information was provided before the end of the survey. Review of CDC guidance for Long-Term Care Facilities read in part, Monitor ill residents (including documentation of temperature and oxygen saturation) at least 3 times daily to quickly identify residents who require transfer to a higher level of care . Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, prioritize for testing, transfer to COVID-19 unit if positive) . Isolate symptomatic patients as soon as possible . place patients with suspected or confirmed COVID-19 in private rooms with the door closed and with private bathrooms (as possible) . Residents #700 and #711 A review of R#711's clinical record revealed the following: R#711 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED].) A Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (Intact Cognition) and was dependent on staff for all activities of daily living (ADL's.) A Nursing note dated 3/9/20 at 11:29 AM, documented Patient contact isolation d/c'd (discontinued). Patient IV (intravenous) ABT (antibiotic) completed and patient asymptomatic at this time. R#711 was previously diagnosed with [REDACTED]. A Nurse Practitioner (NP) noted dated 3/18/20 at 15:46 (3:46 pm) documented in part, . Patient also spiked a fever to 102.8 f (Fahrenheit) with associated chills. On encounter patient was lying in bed, with shivering . Vitals: BP (blood pressure): 196/91,P (pulse):107 ,R (respiration): 18,T (temperature): 102.8 . A Nursing note dated 3/18/20 at 18:03 (6:03 pm) documented in part, RESIDENT SENT OUT 911 TO (Name Redacted local hospital) @ 1710 (5:10 pm) FOR [MEDICAL CONDITION] PER NP (Name Redacted), RESIDENT TEMP 102.8 BP 196/91 HR 107 RESP 18 . A NP note dated 3/24/20 at 14:02 (2:02 pm) documented in part, . readmitted to the facility. He was transferred from here to the hospital for c/o (complaints of) hematuria (blood in the urine), fever and pain at catheter site. He was treated for [REDACTED]. Patient was stabilized and transferred back here. He currently denies any complaints, states that he feels better . A nursing note for R#711's roommate (R#700) dated 3/25/20 at 19:37 (7:37 pm) documented in part, . NURSE WAS APPROACHED BY CNA (Certified Nursing Assistant) STATING THAT PT FELT WARM, NURSE TOOK TEMP ORALLY 102.6 . Residents #711 and #700 remained sharing the same room despite R#700's fever and R#711 considered being high risk per a review of Centers for Disease Control and Prevention (CDC) guidelines which documented in part, . those at high-risk for severe illness from COVID-19 are: People [AGE] years and older . who live in a nursing home or long-term care facility . underlying medical conditions . including: . people with diabetes . [MEDICAL CONDITION] undergoing [MEDICAL TREATMENT] . A Medical Doctor (MD) note dated 3/26/20 at 14:25 (2:25 pm) for R#711 documented in part, .Patient was confused to where he was right now whether he was in the hospital or back at the nursing facility, but after reorienting he remembered that he is back at the nursing facility . On 3/30/20 at 12:56pm, a Nursing note documented in part . RESIDENT WAS SENT FROM [MEDICAL TREATMENT] TO HOSP (Hospital). BECAUSE RESIDENT HAD INCREASE TEMP . A Nursing note dated 4/9/20 at 16:06 (4:06 pm) documented in part, . RESIDENT POSITIVE FOR COVID. RESIDENT REMAINS IN HOSPITAL AT THIS TIME . A review of R#700's clinical record revealed the following: A nursing note dated 3/25/20 at 19:37 (7:37 pm) documented a temperature of 102.6. A Nursing note for R#700 dated 3/25/20 at 20:31 (8:31 pm) documented in part, . temperature of 100.0 as ordered . non-productive cough noted . A Nursing note for R#700 dated 3/26/20 at 2:12 am documented in part, . has negative result for influenza A and a negative result for influenza B physician and on call physician notified . A MD note dated 3/26/20 at 17:47 (5:47 pm) documented in part, . temp of 99.9 F with dry cough from morning. Patient lying in the bed, tired and drowsy . Fever with cough- Patient high risk for COVID-19 as he is [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) on HD ([MEDICAL TREATMENT]). Swab for Influenza, other respiratory viruses including RSV (Respiratory [MEDICAL CONDITION]) and COVID-19. Contact and droplet isolation . Residents #700 and #711 continued to share the same room despite the high-risk criteria, the physician's written directive to be placed on contact and droplet isolation and per CDC guidelines. A Nursing note for R#700 dated 3/29/20 at 16:36 (4:36 pm) documented in part, . Nursing monitoring resident r/t (related to) a non-productive dry cough, and fever . Influenza A/B and CoViB-19 (sic) precautions implemented, monitor resident for s/s cov-19 and influenza . A Nursing note for R#700 dated 3/31/20 at 19:56 (7:56 pm), documented Influenza AB test- negative. A Nursing note for R#700 dated 4/5/20 at 12:08 pm documented in part, . Patient + (positive) Covid-19 . On 4/16/20 at 5:23 pm, the Director of Nursing (DON) was queried on why R#711 remained in a shared room with R#700, when R#700 showed signs of a fever on 3/25/20. The DON stated that the residents were screened (with the facility's COVID screening guide) and didn't screen positive. A request was made at that time for the resident's COVID screening and it was not provided by the end of survey. An email was sent by the DON to Surveyor on 4/16/20 at 9:01 pm, which documented in part, . Patient did not present with symptoms that would require the IDT (Interdisciplinary team) to consider to move (R#700's name redacted). At the time (early March) what constituted positive screen was a temp of 100.4 or greater, cough, travel, or if you had been in proximity of anyone whom had a + dx (positive diagnosis) or presumed + (positive). His screen was negative . The inquiry regarding R#700 and R#711 was noted to be at the end of March which the CDC recommended in part, . Unrecognized asymptomatic and pre-symptomatic infections likely contribute to transmission in these settings . Identify infections early and take actions to prevent spread . Quickly recognize and manage severe illness . Actively monitor all residents . for fever (T> or equal to 100.0 F) and symptoms of COVID-19 (shortness of breath, new or change in cough, sore throat, muscle aches). If positive for fever or symptoms, implement Transmission-Based Precautions . Identification of these symptoms should prompt isolation and further evaluation for COVID-19 . Residents #709 and #705 Review of the census record revealed R#709 and R#705 became residents in the same room on or about 8/21/18. Resident #709 Review of the clinical record revealed R#709 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent quarterly MDS assessment dated [DATE], R#709 scored 12/15 on the BIMS exam, indicating moderately impaired cognition. The MDS assessment also indicated R#709 required the extensive assistance of staff for bed mobility and transfers. Review of R#709's temperatures revealed on 3/20/20 from 2:10 PM to 6:00 PM, R#709 had temperatures of 99 to 99.2 F, and one temperature of 99 F on 4/3/20 at 10:19 PM. The temperature record revealed no other elevated temperatures for R#709 through the end of the survey. Review of the observation history for R#709 revealed no facility COVID-19 screen was done on R#709. Review of R#709s physician progress notes [REDACTED].>A note dated 4/14/20 at 11:31 read in part, .Assessment/plan . Exposure to COVID suspect . A note dated 4/17/20 read in part, .patient's COID (sic) test has come back positive . It is noted the positive test was 28 days after R#709 had elevated temperatures on 3/20/20. Resident #705 Review of the clinical record revealed R#705 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the most recent quarterly MDS assessment dated [DATE], R#705 scored 3/15 on the BIMS exam, indicating severely impaired cognition. The MDS assessment also indicated R#705 required the total dependence of staff for bed mobility and transfers. Review of R#705's temperatures and oxygen saturation levels (SaO2) revealed no elevated temperatures or low SaO2 from 3/20/20 until 3/30/20, ten days after R#705's roommate, R#709, had an elevated temperature. Review of R#705's progress notes revealed: A nursing note on 3/30/20 at 10:26 AM read, received in bed with O2 per n/c (nasal cannula) at 2 lpm (2 liters per minute). SaO2 is 89% (normal range 94-100%). Bumped O2 up to 4 lpm and rechecked. Resident is at 92% . A nursing note on 3/30/20 at 5:34 PM read, Resident has recently been placed on O2. Temperature this afternoon is 100.0 F. Tylenol given and contact;droplet (sic) precautions initiated . A Registered Respiratory Therapist (RRT) note on 4/5/20 at 11:25 PM read, o2 sat on 5 liters is 92 percent breath sound diminished bilaterally . A RRT note on 4/7/20 at 4:43 AM read, Resident received on 3L O2 via nasal cannula. Pt (patient) spo2 89% so raised to 4L and Spo2 up to 92%. BS (breath sounds) dim (diminished) with productive cough . A RRT note on 4/9/20 at 10:36 AM read, Found pt without O2 nasal cannula spo2 84% placed back on O2 at 5L spo2 92% . Review of the facility's COVID-19 screening for R#705 revealed on 3/30/20 the document indicated R#705 had None of the above marked for 'Travel', None of the above marked for 'Exposures Identified through Contact Investigation', and Yes marked for 'Screening Results' for COVID-19. Review of lab orders for R#705 revealed an order dated 4/10/20 for a COVID-19 test to be done. The results were reported on 4/14/20 as positive for COVID-19. On 4/15/20 at 3:09 PM, the facility's Administrator and DON were interviewed by phone concurrently. During the interview, the Administrator and DON were queried about why R#709 was not moved out of the room on 3/30/20 when R#705 was put on contact/droplet precautions (for suspected COVID- 19). The Administrator and DON explained that since R#709 had run a fever on 3/20/20, they were presumed positive. The Administrator and DON were asked why R#705 was not moved out of the room when R#709 had an elevated temperature on 3/20/20. The Administrator and DON explained since R#705 was already exposed, it would have been irresponsible for the facility to move either roommate as it would have exposed more residents in the facility. Residents #701 and #708 Review of the census record revealed R#701 and R#708 became residents in the same room on or about 8/27/18. Resident #701 Review of the clinical record revealed R#701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent quarterly MDS assessment dated [DATE], R#701 scored 9/15 on the BIMS exam indicating moderately impaired cognition. The MDS assessment also indicated R#701 was independent with bed mobility and transfers. Review of R#701's temperatures revealed on 3/25/20 at 11:46 AM a temperature of 99.9 F. On 3/26/20 at 9:01 AM, R#701's temperature was documented as 99.8 F. Review of R#701's progress notes revealed: A NP note dated 3/27/20 at 1:53 PM read in part, .Assessment/plan- Fever: will obtain labs . Covid testing is pending . A nursing note dated 3/28/20 at 1:32 PM read, NURSING SUPERVISOR: Resident presents during shift with cough, diarrhea, low grade temperature of 99.9 oral . implement influenza A/B and co VIB-19 (sic) precautions per facility protocol, implement droplet/contact precautions, obtain culture for influenza A/B and place on quarantine x 14 days . A nursing note dated 3/28/20 at 6:57 PM read, NURSING SUPERVISOR: Assigned nurse report fever of 102.7 oral . implement influenza A/B, and Co VIB -19 (sic) precautions . A physician note dated 4/6/20 at 12:59 PM read in part, .Assessment/plan . Monitor closely, COVID testing pending. In isolation . Review of lab orders for R#701 revealed an order dated 4/10/20 for COVID-19. Results were reported on 4/14/20 as positive for COVID-19. Resident #708 Review of the clinical record revealed R#708 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent quarterly MDS assessment dated [DATE], R#708 scored 3/15 on the BIMS exam indicating severe cognitive impairment. The MDS assessment also indicated R#708 was independent for bed mobility and transfers. Review of R#708's temperatures revealed: On 3/28/20 at 12:12 PM, a temperature of 100.3 F. At 7:18 PM, a temperature of 99.6 F. On 3/29/20 at 12:34 AM, a temperature of 101.2 F. At 1:34 PM, a temperature of 99 F. On 3/30/20 at 12:24 AM, a temperature of 99 F. At 5:17 PM, a temperature of 99 F. At 9:26 PM and 9:28 PM, a temperature of 99.2. A nursing progress note on 3/28/20 at 1:43 PM read in part, NURSING SUPERVISOR: Resident presents during shift with cough, diarrhea, low grade temperature of 100.3 oral. Resident denies SOB (shortness of breath), malaise, fatigue or sore throat. Respirations unlabored and even, spo2 level at 98% RA (room air) . implement influenza A/B and co VIB-19 (sic) precautions per facility protocol, implement droplet/contact precautions, obtain culture for Co Vib-19 . On 4/6/20 at 9:41 PM, a temperature of 101 F. On 4/7/20 at 1:09 AM, a temperature of 99.5 F. At 5:08 PM, a temperature of 100.7 F. On 4/15/20 at 1:18 PM, the facility's Administrator and DON were interviewed concurrently. During the interview, the Administrator and DON were queried about why R#708 was left in the same room with R#701, when R#701 was positive for COVID-19 and R#708 had not been tested . The Administrator and DON explained R#701 and R#708 had the same symptoms on 3/28/20, so they were left in the same room as both were presumed to have COVID-19. The Administrator and DON were asked why R#708 was not moved out of the room when R#701 started running a fever on 3/25/20, three days before R#708 developed symptoms. The Administrator and DON explained the curtain between the residents' beds was kept closed. On 4/20/20 at 2:43 PM, the Medical Director was called and a voicemail was left. There was no return call before the end of the survey. A facility policy titled Coronavirus-19, Prevention and Control dated 3/2020 documented in part, . Staff Screening . All staff will be screened at the beginning of their shift for fever and respiratory symptoms. Actively take staff temperatures and document absence of shortness of breath, new or change in cough, and sore throat. If they are ill, they will put on a facemask and leave the workplace . Coronavirus Modes of Transmission 1. [MEDICAL CONDITION] is thought to spread mainly from person-to-person. a. Between people who are in close contact with one another (within about 6 feet). b. Through respiratory droplets produced when an infected person coughs or sneezes. c. These droplets can land in the mouth or nose of people who are nearby or possibly be inhaled into the lungs. 2. It may be possible that a person can get COVID-19 by touching a surface or object that has [MEDICAL CONDITION] on it and then touching their own mouth, nose, or possible their eyes . Nursing will monitor for and evaluate all new fevers and respiratory illnesses among patients. Any patient with unexplained fever or respiratory symptoms will be placed on appropriate Transmission-Based Precautions and evaluate . A patient with known or suspected COVID-19 will be placed in a single-person room if available or cohort with another resident with the same diagnosis . (Name of Facility) PLAN OF REMOVAL VISITOR/STAFF SCREENING The visitor/staff policy was revised on 4/15/2020. The new policy includes the following provision: A Staff member will be assigned to take temperatures and will document in the surveillance log absence/presence of shortness of breath, new or changed in cough, and sore throat. Anyone with a temp of greater or equal to 100.0 degrees will not be allowed to enter workplace. This screening policy applies to employees and all visitors including, but not limited to outside vendors, surveyors etc. The front entrance is now the only point of entry for visitors/staff to enter the facility. Any staff person/visitor who presents with shortness of breath, new or change in cough and sore throat will not be allowed entry into the building, and advised to seek medical attention. The entire receptionist team was re-educated on the revised visitor/employee screening policy, and their responsibility for temperature checks and documentation. The receptionists will be responsible for screening visitors/employees from 5:00am to 8:00pm. The Unit 2 Nurse will be responsible for screening/documenting temperatures for hours outside of this time frame. The entire staff was provided a copy of the new policy by group email on 4/17/20. A copy of the policy will be maintained at the receptionist desk for visitors/vendors. COHORTING Resident 700 continues to reside in the facility in room (number redacted). The nursing staff continues to do a COVID-19 screen on him daily. He remains in a room by himself. Resident 701 continues to reside in the facility in room (number redacted). He is currently in a room by himself. Resident 705 continues to reside in the facility in (number redacted). He remains in a room with a roommate who also has a positive for COVID-19 test. Resident 706 continues to reside in the facility in room (number redacted). Resident 708 (roommate to 701) remains in the facility in room (number redacted). Resident 709 continues to reside in the facility in room (number redacted). Resident 710 no longer resides in the facility. Resident 711 no longer resides in the facility. If he returns to the facility, he will reside in a private room for 14 days. For all residents who develop symptoms of COVID-19 we will: COVID-19 screen and vital signs every shift and as needed will continue to be done for all residents Apply mask if tolerated Contact the physician to report new symptoms and possibility of infection Place in droplet/medical isolation For symptomatic resident who have no roommate, they will remain in the room on Unit 1 If the symptomatic resident has a roommate, he/she will be screened for COVID-19 If the room-mate's screen is negative, we will move him/her to another room without a roommate, and monitor for development of symptoms for the next 14 days. The COVID-19 policy was revised, and the Admissions and Nursing staff were provided a copy of the updated policy by group email on 4/17/2020. The facility has engaged the services of a new lab to test for COVID-19. The new company has demonstrated that they have an adequate amount of supplies to meet our needs. The turn-around time for the testing is 72 hours. This additional service provider augments our existing contract with (Name Redacted local hospital). Audits of visitor/staff screening documents and resident COVID-19 screens will be conducted 5x/week for resident who develop symptoms. The findings of these audits will be summarized and brought to QAPI on an ongoing basis.

Based on observation, interview and record review, the facility failed to consistently and accurately conduct skin assessments, implement timely wound consultations, consult with dietary and ensure interventions were implemented and/or effective to prevent the development and/or reopening of multiple pressure ulcers for residents identified as having a history of and/or at risk for pressure ulcers for two (R#65 and R#4) of six residents reviewed for pressure ulcers, resulting in an Immediate Jeopardy when R#65 developed three reopened Stage 3 Pressure Ulcers (full-thickness skin loss) and one facility acquired Stage 2 (partial-thickness skin loss with exposed dermis) Pressure Ulcer, and R#4 developed two facility acquired Stage 3 Pressure Ulcers. This put the residents at risk for serious injury, serious harm and/or death. Findings include: The IJ began on 1/26/20. The IJ was identified on 2/12/20. The Administrator was notified of the IJ on 2/12/20 at 5:11 PM and a plan to remove the immediacy was requested. The immediacy was removed on 2/13/20 based on the facility's implementation of an acceptable plan of removal verified on-site by the survey team. Although the IJ was removed on 2/13/20, the facility remained out of compliance at a scope of patterned and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. Resident #65 On 2/10/20 at 8:50 AM, R#65 was observed lying on their left side with their knees bent up. R#65's eyes were open however, R#65 did not respond to any questions asked. On 2/11/20 at 8:11 AM, R#65 was observed lying on their left side with their knees bent up, and their heels were resting on the mattress. Heel boots were observed on top of what appeared to be a laundry hamper, across from R#65's bed against the wall. On 2/11/20 at 1:31 PM, R#65 was observed seated in a wheelchair at the nurses' station. On 2/12/20 at 8:04 AM, 9:16 AM, 9:53 AM, 10:38 AM and 11:20 AM, R#65 was observed seated on their buttocks in a wheelchair at bedside and at the nurses' station. A record review was conducted and revealed R#65 was originally admitted into the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. According to the most recent annual Minimum Data Set (MDS) assessment dated [DATE], R#65 had severely impaired cognition. The MDS assessment also indicated R#65 required the total dependence of staff for all Activities of Daily Living (ADL) including bed mobility. In addition, the MDS assessment indicated R#65 had no pressure ulcers however, was at risk for the development of pressure ulcers. Review of R#65's Weekly Skin assessment dated [DATE] revealed documentation of, Hip/Bony Prominence new skin tears tx (treatment) in place. Review of a nursing progress note dated 1/26/20 read, Writer was made aware by assigned aide of resident skin breakdown on bilateral hips/bony prominence, resident was also witnessed scratching thighs and legs. Wound consult in place unit manager and DON made aware of situation . Review of a facility provided Incident Report-Non Fall dated 1/26/20 documented, Description of Incident: new pressure skin tears to bi-lat (bilateral) hips/bony prominence. resident (sic) also witnessed scratching skin and legs excessively . Follow-up needed: Other - Wound consult . On 2/12/20 at 12:20 PM, wound care was observed with LPN 'H' and Assistant Director of Nursing (ADON) 'J' of R#65's pressure ulcers. ADON 'J' explained that while R#65 received a shower, new wounds were found, one on the left buttock and one on the right shoulder. The left buttock was observed to have three linear areas where the skin appeared to be open. The right shoulder was observed to be reddened with a visible circle indented into the skin. ADON 'J' was asked about the new wound on R#65's left buttock. ADON 'J' reported it was a reopened area, there had been a pressure ulcer there, but had healed previously. It was observed R#65 had a wound to the left hip that had a pink base and an open area of skin, the right hip had a wound with a dark area of scab like matter covering it. Review of physician orders [REDACTED]. Additional orders dated 12/26/19 read, OFFLOAD HEEL PRESSURE Every Shift Day Shift, Night Shift and ENCOURAGE AND ASSIT (sic) PATIENT TO REPOSITION EVERY 2 HOURS WHILE IN BED AND HOURLY IN CHAIR Every Shift Day Shift, Night Shift. Review of R#65's care plan for wound care with a start date of 10/24/19 and edited 1/22/20 read in part, .Up in w/c (wheelchair) qod (every other day) for Max of 2 hours as tolerated . OFF LOAD HEELS BY UTILIZING HEEL OFF-LOADING BOOTS OR HEEL PROTECTORS AS TOLERATED . Turn and reposition q2h (every two hours) when in bed and q1h (every one hour) when in chair as tolerated . An additional care plan for wound care with a start date of 2/4/20 also included the interventions for, OFF LOAD HEELS BY UTILIZING HEEL OFF-LOADING BOOTS OR HEEL PROTECTORS AS TOLERATED . Turn and reposition q 2hr when in bed and q 1h when in chair as tolerated . There were no documented changes to R#65's care plan when the wounds to R#65's bilateral hips were discovered on 1/26/20. Review of R#65's admission Braden Scale (an assessment used to assess risk for skin breakdown) dated 1/12/19 revealed a score of 10 indicating R#65 was at HIGH RISK for pressure ulcer development. On 2/12/20 at 9:16 AM, Licensed Practical Nurse (LPN) 'H' was interviewed and asked about R#65's pressure ulcer wounds. LPN 'H' reported R#65 had pressure ulcers in the past, but were healed up in early (MONTH) 2019, then the wounds came back about two weeks ago and were being treated again. Review of R#65's Weekly Skin Assessment with an observant date of 1/22/20, and a completed date of 1/27/20 revealed several areas of healed and healing scratches on head, shoulder, arm, hand, chest, back, buttocks, gluteal, leg and foot. Review of R#65's Braden Scale dated 1/22/20 revealed a score of 11 indicating HIGH RISK for pressure ulcer development. Review of R#65's wound care note signed by Wound Care Specialist, Dr. 'T' dated 2/4/20 (nine days after the new pressure skin tears were identified by the facility) read in part, . L (left) hip is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1cm (centimeter) length x 0.6cm width, with an area of 0.6 sq (square) cm . R (right) hip is an Unstageable/Unclassified Pressure Ulcer (obscured full-thickness skin and tissue loss) and has received a status of Not Healed. Initial wound encounter measurements are 1.5cm length x 0.9cm width, with an area of 1.35 sq cm . Review of a wound care note signed by Dr. 'T' dated 2/11/20 read in part, .L hip is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 0.7cm length x 1 cm width x 0.2cm depth, with an area of 0.7 sq cm and a volume of 0.14 cubic cm . R hip is an Unstageable/Unclassified Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2.5cm length x 1.8cm depth, with an area of 4.5 sq cm and a volume of 0.9 cubic cm . On 2/12/20 at 2:45 PM, the Director of Nursing (DON) was queried about R#65's facility acquired pressure ulcers. The DON explained R#65 had pressure ulcers in the past in the same places as the current pressure ulcers. When asked if any new interventions were put into place to prevent more pressure ulcers after 1/26/20 when R#65 developed new pressure ulcers, the DON reported the interventions were reviewed, but no new interventions were put into place. When asked how the interventions already in place were being monitored, the DON explained it was the expectation that the staff turn the resident every two hours, and interventions were monitored by the nurses and managers. The DON was asked how she and other managers were notified of new pressure ulcers. The DON explained they have a stand up meeting and discussed the issues found by incident reports. The issues were put on a board and not erased until the issue was complete. The DON reported R#65 was included as part of the sand up meeting. The DON went on to explain R#65 was being followed by the Registered Dietician (RD). When asked how pressure ulcers were being evaluated, the DON answered the facility had recently hired ADON 'J' as a wound coordinator because there had been an issue with wounds. On 2/12/20 at 3:46 PM, an interview was conducted and RD 'Z' was asked about R#65's nutritional status. RD 'Z' explained she and another dietician job shared the responsibilities at the facility. She went on to explain that she did not know of any of R#65's pressure ulcers until 2/11/20. When asked if she went to the stand up meetings, RD 'Z' reported there was a stand up meeting every day however, the dieticians usually found out a resident had a wound when the wound nurse gave them a packet containing the wound care notes. When asked if the other dietician could have known about R#65's wounds, RD 'Z' explained they have a communication book where they write down what the other dietician needed to know. RD 'Z' was asked if the other dietician was at the facility. RD 'Z' explained both dieticians were not there on the same days, but also, the other dietician was not available for interview during the survey. RD 'Z' confirmed there had been no new dietary consult after the pressure ulcers were found on 1/26/20. On 2/12/20 at 4:05 PM, an interview was conducted with the facility's wound coordinator ADON 'J', and she was queried about R#65's pressure ulcers. ADON 'J' explained the new wound on R#65's left buttock was a reopened Stage 2 Pressure Ulcer, and the right shoulder was a DTI (Deep Tissue Injury - persistent non-blanchable deep red, maroon or purple discoloration). ADON 'J' was asked about the time delay of nine days between documented wounds on 1/26/20 and Dr. 'T' seeing R#65 on 2/4/20 and it being documented as a Stage 3 Pressure Ulcer and an Unstageable Pressure Ulcer. ADON 'J' reported Dr. 'T' comes every Tuesday, the consult wasn't put in until after Dr. 'T' was here on 1/28/20, so R#65 didn't get seen until 2/4/20. On 2/13/20 at 8:59 AM, R#65 was observed seated in a wheelchair at bedside, a dressing was noted on the inside of R#65's left leg. LPN 'BB' was asked about the dressing, and LPN 'BB' explained a new wound was found on R#65's leg and a dressing was applied. On 2/13/20 at 9:37 AM, an interview was conducted and Dr. 'T' was queried about R#65's pressure ulcers. Dr. 'T' explained he, or one of his physician extenders, does rounds every week. The facility had asked him to come in that day to evaluate R#65 pressure ulcers. Dr. 'T' went on to explain R#65's left hip was a Stage 3 pressure ulcer, the right hip was now a Stage 3 pressure ulcer, the left buttock was a Stage 3 pressure ulcer, the right shoulder was an abrasion, not a DTI, and there was a new Stage 2 pressure ulcer to the left leg. When queried about what interventions were in place for R#65 to prevent pressure ulcers, Dr. 'T' reported R#65 should only be up in a wheelchair for one hour every day, should be turned frequently and be evaluated by dietary. When further queried about additional interventions the facility could have implemented, Dr. 'T' explained there should be a (Name Brand air fluidized bed), it is the best, but it is not covered by insurance. Dr. 'T' was asked if R#65's pressure ulcers would heal. Dr. 'T' reported R#65 had wounds that healed in the past, and he would be able heal the pressure ulcers again. Review of a wound care note signed by Dr. 'T' dated 2/13/20 read in part, Left Buttock is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 5.2cm length x 2.2cm width x 0.01cm depth, with area of 11.44 sq cm and a volume of 0.114 cubic cm . L hip is a State 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 3.5cm length x 1.6cm width x 0.2cm depth, with an area of 5.6 sq cm and a volume of 1.12 cubic cm . R hip is a Stage 3 Pressure Injury Pressure Ulcer and had received a status of Not Healed. Subsequent wound encounter measurements are 2.6cm length x 1.5cm width x 0.2cm depth, with an area of 3.9 sq cm and a volume of 0.78 cubic cm . Right Shoulder is an Abrasion and had received a status of Not Healed. Initial wound encounter measurements are 5cm length x 3.2cm width, with an area of 16 sq cm . L Medial Leg is a Stage 2 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2.2cm length x 1.4cm width x 0.01cm depth, with an are of 3.08 sq cm and a volume of 0.031 cubic cm . On 2/13/20 at 10:58 AM, an interview was conducted with the Administrator who explained there had been an issue with wound care at the facility. The facility had recently hired ADON 'J', and had plans to hire a new wound consultant. The Administrator reported changes in the interventions should have been put in the care plan. If we're not seeing these interventions being done, that can impact the outcome. Resident #4 On 2/11/20 the medical record for R#4 was reviewed and revealed the following: R#4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. R#4 had [DIAGNOSES REDACTED]. A Review of R#4's MDS with an ARD (Assessment Reference Date) of 7/31/19 revealed R#4 needed extensive assistance with most of their activities of daily living. R#4's BIMS score (brief interview of mental status) was 3 indicating severely impaired cognition. A review of R#4's careplan history revealed the following careplan with a start date of 7/24/19 and was discontinued on 11/1/19. Problem-Alteration in skin integrity (actual or potential) .Goal-Resident skin will remain intact free of new or worsening skin issues .Interventions-Avoid skin from shearing & friction. Keep skin clean and dry avoid skin contact with moisture. Skin assessment weekly. Turn and reposition Q2h and Q1h when in chair as tolerated . A Braden assessment dated [DATE] revealed a score of 15 that indicated the following: 15-18 - AT RISK - If other major risk factors are present e.g. advanced age, fever, poor dietary intake of protein, Diastolic BP (blood pressure) <60, hemodynamic instability advance to next level of risk. A physician's orders [REDACTED].Special Instructions: Complete Skin Assessment in Observation . Review of R#4's weekly skin assessments revealed the following: 8/27/19-Color: Pink .Tugor: Fair .Location:Other-Intact . No other weekly skin assessments were completed in observations until 9/17/19 which revealed the following:Color:Pink .Tugor: Fair .Location: Other-Intact . A nursing progress note dated 9/16/19 revealed the following: 09/16/2019 16:03 (4:03 PM) (name of Physician) phoned . notified of resident with open area @ inner buttocks. New orders per treatment nurse. Cleanse inner buttocks with wound cleanser. pat dry, apply [MEDICATION NAME] topically and cover with dry dressing daily. A progress note dated 9/17/19 revealed the following: Wound team in to see resident. Wound #1 Sacral is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1.3cm length x 0.5cm width x 0.3cm depth, with an area of 0.65 sq cm and a volume of 0.195 cubic cm. There is a small amount of sero-sanguineous (a mixture of serum and blood) drainage noted which has no odor. Wound bed has Pink Base [MEDICATION NAME] (new skin formation), Minimal Yellow Slough slough (non-viable tissue) . General Notes: Irregular edges Wound #2 Coccyx is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 0.9cm length x 0.7cm width x 0.3cm depth, with an area of 0.63 sq cm and a volume of 0.189 cubic cm. There is a small amount of sero-sanguineous drainage noted which has no odor. Wound bed has Pink Base [MEDICATION NAME], Minimal Yellow Slough slough . General Notes:Irregular edges. Order [MEDICATION NAME] to sacral and coccyx. Further review of R#4's medical record revealed no documentation that R#4's pressure ulcer was unavoidable. On 2/12/20 at approximately 11:59 a.m., R#4's medical record was reviewed with Nurse I, previous wound care nurse. Nurse I was queried what interventions should have been put into place to prevent skin breakdown when R#4 was admitted back into the facility on [DATE]. Nurse I indicated that since R#4 had a Braden score of 15 they were considered at risk for skin breakdown. Skin breakdown interventions for R#4 were reviewed with Nurse I. Nurse I indicated that they were not the wound care nurse when R#4 was admitted but after reviewing R#4's interventions, Nurse I indicated they would have provided R#4 a low air loss mattress when they were admitted and an Allevyn dressing (dressing for use in wound management and pressure ulcer prevention) to R#4's coccyx to prevent it from breaking down due to R#4's decline. Nurse I was queried what interventions were put into place to prevent breakdown when R#4 was readmitted . Nurse I reviewed the record and indicated that turning and repositioning and offloading heels was indicated, but not the air mattress or protective dressing. Nurse I was queried regarding skin assessments for R#4 and they indicated that R#4 should have had skin assessments done on a weekly basis and it should be documented in observations. Nurse I reviewed the skin assessments under the observations tab in the record. Nurse I indicated that some skin assessments that were missing and that they should have been done on a weekly basis per the physician's orders [REDACTED]. Nurse I was queried if R#4's stage 3 pressure ulcer identified on 9/16/19 was avoidable and they indicated that it was. On 2/12/20 at approximately 3:14 p.m., during a conversation with the DON, the DON was queried if they had identified a problem with the nursing staff completing skin assessments. The DON indicated that they had and the last few months they had been doing auditing to try to ensure the weekly skin assessments were completed. It should be noted that no further skin assessments and/or additional notes pertaining to skin breakdown were provided by the end of the survey Review of a facility policy titled, Prevention of Pressure Ulcers/Injuries dated 10/2019 read in part, Risk Assessment: 1. Assess the resident on admission . Repeat the risk assessment weekly and upon any changed in condition . 3. Use a screening tool to determine if resident is at risk for under-nutrition or malnutrition. 4. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries .; b. Inspect pressure points .; d. Moisturize dry skin daily; e. Reposition resident as indicated on the care plan . Mobility/Repositioning: 1. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance, and the resident's stated preferences. 2. At least every hour, reposition residents who are chair-bound or bed-bound with the head of the bed elevated 30 degrees or more . The facility provided the following plan to remove the immediacy and it was verified onsite by the survey team: (Name of Facility) PLAN OF REMOVAL Element 1 Resident #65 is a [AGE] year old man admitted on [DATE]. He was admitted to the facility with a Braden score of 10. During the course of his stay at (Name Redacted), he developed pressure ulcers to his right hp, left hip and right buttock. The resident had multiple risk factors including [DIAGNOSES REDACTED]. He is incontinent of bowel and bladder and requires total assistance with his daily care. On 02/12/2020 he was noted to have a new pressure injury on his right shoulder and left buttock. Upon review of the dietary documentation, it was identified that there was a delay in ht e assessment process and identification of new interventions. The dietician was immediately notified on 02/12/2020 and a dietary assessment was requested and completed. The nursing staff reviewed his care plan, conducted a skin assessment and competed a new Braden assessment. Additionally, the facility contacted the Wound Physician (Name Redacted) and the attending Physician (Name Redacted) to request an immediate evaluation of the resident's skin. A (Name Brand specialty bed) was ordered on [DATE] and will be delivered on the same day. In-servicing on the use of the bed will be conducted with all nursing staff on 02/17/2020. All nursing staff to be educated on 02/13/2020 (and again on 02/17/2020) about resident 65's care plan and specific risks and interventions. Agency staff will be educated on resident 65's plan of care through the agency contact person and as they come on duty. Audits of daily care and compliance with care planned interventions will begin on 02/13/2020 and continue until compliance is determined. Meeting held with the facility leadership team to discuss plan and implementation. The team will be responsible for assisting with the ongoing efforts to ensure compliance. Element 2 Braden scores were reviewed on all in house residents. Those that were identified as at risk for pressure ulcer development were reassessed. All care plans were reviewed, revised and updated. All in house residents with pressure ulcers have been reviewed by the dietician. The dietary department re-assessed all residents identified as having pressure ulcers. Element 3 Resident #65's (sic) was reassessed head to toe on 02/12/2020. His Braden score was re-done on 02/12/2020 with a finding of 11. The resident's care plan on skin integrity was reviewed, revised, and updated to include the new interventions. Nutrition and Wound assessment was conducted by the dietician on 02/12/2020. No dietary changes were recommended at that time. A wound care consult was initiated to the wound care specialists. (Name Redacted) to evaluate wounds on 02/13/2020. Nursing interventions per physician orders [REDACTED]. The facility's policy on Prevention of Pressure Ulcers/Injuries was reviewed and updated on 02/12/2020. Nursing staff, CNA were educated on the revised policy 2/13/2020 and again on 2/15/2020. The director of nursing and/or designee will conduct daily rounds and conduct random interviews with residents to determine that skin breakdown interventions are being implemented. Results of the rounds and interview will be brought to the leadership meeting and to QA for corrective measures.

Based on interview and record review, the facility failed to administer Pneumococcal vaccinations to residents who consented for immunization, assess residents for the eligibility of receiving Pneumococcal vaccinations, ensure residents were educated on risk versus benefits of the vaccination and administered the appropriate Pneumococcal vaccinations according to the CDC (Centers for Disease Control) prevention guidelines for five (R#4, R#45, R#64, R#73 and R#228) of seven residents reviewed for Pneumococcal vaccinations resulting in facility acquired pneumonia,[MEDICAL CONDITION] and hospitalization . The failure to implement policies following current recommendations for Pneumococcal immunization resulted in an Immediate Jeopardy (IJ) to the health and safety to R#73 and R#228 who developed pneumonia in the facility and residents who were not fully immunized against pneumonia. Facility residents, many of whom were at high risk due to age and co-morbidities, had the likelihood of developing pneumonia resulting in serious health complications from the disease including the risk of death. Findings include: The IJ began on 1/14/19. The IJ was identified on 2/19/20. The Administrator was notified of the IJ on 2/19/20 at 9:17 AM and a plan to remove the immediacy was requested. Although the IJ was removed on 2/19/20, the facility remained out of compliance at a scope of patterned and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. Review of the CDC publication titled, Adults Protect Yourself with Pneumococcal Vaccines read in part: Many adults may be at increased risk for pneumococcal disease and not know it. Two vaccines provide protection against this serious and sometimes deadly disease . Each year in the United States, pneumococcal disease kills thousands of adults. Thousands more end up in the hospital because of pneumococcal disease. It can cause severe infections of the lungs (pneumonia), bloodstream (bacteremia), and lining of the brain and spinal cord (meningitis). Vaccines are the best way to prevent pneumococcal disease. Two vaccines help prevent pneumococcal disease: PCV13 (pneumococcal conjugate vaccine); PPSV23 (pneumococcal [MEDICATION NAME] vaccine) . CDC recommends PCV13 for: All adults [AGE] years or older; Adults [AGE] years or older with certain health conditions. CDC recommends PPSV23 for: All adults [AGE] years or older; Adults 19 through [AGE] years old with certain health conditions or who smoke cigarettes . Most pneumococcal infections are mild. However, some can be deadly, especially for adults [AGE] years or older: Pneumococcal pneumonia kills about 1 in 20 older adults who get it; Pneumococcal bacteremia kills about 1 in 6 older adults who get it; Pneumococcal meningitis kills about 1 in 6 older adults who get it . Pneumococcal Disease Is Contagious: Pneumococcal bacteria spread from person to person through coughing, sneezing, and close contact. People can carry the bacteria in their nose and throat without being sick and spread the bacteria to others . On 2/12/20 at 11:51 AM, as part of a review of the facility's infection control program, five residents were selected for immunization status. Three residents, R#4, R#45 and R#64 had no documented evidence of having been assessed for Pneumococcal vaccinations, educated on risk versus benefits of the Pneumococcal vaccination, or given the appropriate Pneumococcal vaccinations according to the CDC guidelines. The other two residents, R#73 and R#228 were found to have had pneumonia while residing in the Facility. On 2/13/20 at 1:58 PM, an interview was conducted, with the Director of Nursing (DON), who served as the Infection Control coordinator. The DON was queried about Pneumococcal vaccination policies at the facility. The DON explained it was the facility's procedure not to give Pneumococcal vaccine to short term/rehabilitation (rehab) residents. These residents were recommended to follow up with their Primary Care Providers (PCP) after discharge from the facility. The DON went on to explain when a short term/rehab resident was admitted , the facility did not assess if the resident had received a Pneumococcal vaccine previously, and that Pneumococcal vaccines are only given every five years. Further review of the infection control program revealed the following: Resident #73 Review of the clinical record revealed R#73 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review of R#73's clinical record revealed a progress note dated 1/14/19 that read in part, (R#73) is complaining of a cough and mild shortness of breath for the past few days . chest X-ray which showed a LLL (left lower lobe) pneumonia . Review of R#73's admission paperwork on or about 8/2/17, and revealed R#73 had refused consent for the Pneumococcal vaccine. There was no documentation that R#73 had received any Pneumococcal vaccination prior to admission. There was no documentation R#73 was offered the Pneumococcal vaccine annually. R#73 received a PPSV23 vaccination on 12/17/19 (after R#73 had pneumonia on or about 1/14/19). There was no documentation that the vaccine received 12/17/19 was provided per CDC guidelines or that a second pneumococcal vaccine was provided by the facility per CDC guidelines. A review of CDC guidelines for R#73 reveal the following schedule, Give 1 dose of PCV13. Then give 1 dose of PPSV23 at least 8 weeks later. However, the facility administered the PPSV23 vaccine before administering the PCV13. Review of the Advisory Committee on Immunization Practices (ACIP) publication titled, Use of 13-Vaccine Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal [MEDICATION NAME] Vaccine Among Adults Aged (greater than or equal to) [AGE] years: Updated Recommendations of the Advisory Committee on Immunization Practices dated 11/22/19 read in part: Two pneumococcal vaccines are currently licensed for use in adults in the United States . PCV13 . PPSV23 . In 2014, the Advisory Committee on Immunization Practices (ACIP) recommended routine use of PCV13 in series with PPSV23 for all adults ages (greater than or equal to) [AGE] years based on demonstrated PCV13 safety and efficacy against PCV13-type pneumonia among adults aged (greater than or equal to) [AGE] years . ACIP recognized that some adults aged (greater than or equal to) [AGE] years are potentially at increased risk for exposure to PCV13 serotypes, such as persons residing in nursing homes or other long-term care facilities . and might attain higher than average benefit from PCV13 vaccination . Resident #228 Review of the clinical record revealed R#228 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of R#228's original admission paperwork revealed a Pneumococcal vaccine consent form marked YES, signed, and dated 8/29/19. There was no documentation of R#228 having received either PCV13 or PPSV23 while a resident at the facility. Review of #228's clinical record revealed R#228 was discharged to the hospital on [DATE] diagnosed with [REDACTED].#228 was readmitted into the facility on [DATE]. Further review of R#228's clinical record revealed a progress note dated 10/4/19 that read in part, (R#228) is readmitted here. She was transferred from here to the hospital due to Pneumonia. She was diagnosed with [REDACTED]. It should be noted that R#228 spent almost two weeks in the hospital. A review of CDC guidelines for R#228 reveal the following schedule, Give 1 dose of PCV13. Then give 1 dose of PPSV23 at least 8 weeks later. However, the facility did not administer either the PPSV23 or the PCV13 vaccine to the resident. Resident #4 A record review was conducted and revealed R#4 was admitted into the facility on [DATE], and no documentation of Pneumococcal assessment, education or immunization was found. Resident #45 A record review was conducted and revealed R#45 was admitted into the facility on [DATE], and no documentation of Pneumococcal assessment, education or immunization was found. Resident #64 A record review was conducted and revealed R#64 was admitted into the facility on [DATE], and no documentation of Pneumococcal assessment, education or immunization was found. On 2/18/20 at 10:40 AM, an interview with Licensed Practical Nurse (LPN) 'O' was conducted and LPN 'O' was asked who obtained the consent for Pneumococcal vaccinations. LPN 'O' explained that when residents were admitted into the facility the consents for Pneumococcal vaccination are obtained from the DON. On 2/18/20 at 1:19 PM, an interview with the DON was conducted, and the DON was asked about obtaining consents for the Pneumococcal vaccine. The DON explained the consents were signed when residents were admitted into the facility by the admissions coordinator. On 2/18/20 at 1:34 PM, an interview was conducted with Admissions Coordinator 'N' who was asked how Pneumococcal consents were obtained. Admissions Coordinator 'N' explained most residents admitted into the facility were admitted as short term/rehab residents. When residents were admitted , they were asked if they wanted the Pneumococcal vaccine. We had them sign a consent, and it was given to the DON. When asked if any education on the risk versus benefits of vaccination was provided to the resident, Admission Coordinator 'N' reported only what was written on the consent. Review of a facility provided CONSENT TO ADMINISTER PNEUM[NAME][NAME]CAL VACCINE dated 8/2006 read: The Advisory to all nursing facility Committee on Immunization Practices (ACIP) recommends a single dose of the vaccine for persons 65 and older who have not been previously vaccinated or whose vaccination status is unknown. A one-time revaccination is recommended. Common adverse reactions may include: Fever; Muscle pain; Redness and soreness at injection site. Nursing Assessment: Is the resident allergic to [MEDICATION NAME] (a preservative)? Has the resident experienced an allergic reaction or any type of neurological symptoms to a previous pneumococcal vaccine? Is the resident currently experiencing an acute febrile illness? The vaccine may be contraindicated if the answer is yes to any of the above. Please contact the physician before obtaining consent and administering the vaccine. RESIDENT'S CONSENT: YES - I wish to receive the Pneumococcal vaccine according to the recommended schedule; NO - I do not wish to receive the Pneumococcal vaccine at this time. Signature of Resident/Responsible Party; Date; Signature of Witness; Date; Resident: Last Name, First Name; Physician. It is noted there were no risk versus benefits education and the document was not revised to follow current CDC guidelines. On 2/18/20 at 4:21 PM, an interview with the Administrator and DON was conducted. During the interview, the Administrator explained in (MONTH) 2019 during a monthly meeting with the facility's Medical Director, it was confirmed that the short term/rehab residents would be offered consents for the Pneumococcal vaccine, but the facility would not give the vaccine, they would recommend the residents follow up with their PCP (primary care physician). The DON was asked if any education was provided to the residents. The DON explained that educational material from the CDC was provided to the resident after they got the vaccination. When asked if the facility offered both Pneumococcal vaccines, the DON reported they had not given PCV13 to any residents. On 2/19/20 at 8:57 AM, a phone interview was conducted, and the Medical Director was asked about giving Pneumococcal vaccines to residents. The Medical Director acknowledged the short term/rehab residents were not administered the vaccine due to the fact that it (vaccine) is not a time sensitive medication. The Medical Director went on to explain the short term/rehab residents are only at the facility from two to four weeks, and it needs to be dealt with in the community, not at the facility. Review of a facility policy titled, Pneumococcal Vaccine dated 10/2019 read in part: .1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission. 3. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine . (Name of Facility) PLAN OF REMOVAL Element 1 Resident #73 is a [AGE] year-old long-term care resident. His [DIAGNOSES REDACTED]. He initially entered the facility after a qualifying hospital stay and received rehab services. He currently resides on our 2nd floor. His most recent admitted at this facility was 08/02/2017. Resident #228 is a [AGE] year-old former resident, who discharged in (MONTH) of 2019. Neither resident was administered the pneumococcal vaccine while residing at the facility. Resident #73 will be presented a new consent form with explanation of risk/benefits on 02/19/2020. After a conversation with R#72's physician, a dose will be ordered if the resident qualifies and consent is provided. 1. The immunization policy was reviewed and revised on 02/19/2020. The following excerpt from the pre-existing policy will be monitored for compliance: Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. The following excerpt was added on 02/19/2020. Residents who remain in the facility will be offered the pneumococcal vaccine on an annual basis. The facility nursing leadership staff was re-educated on the immunization protocols and regulations on 2/19/2020. The physician and medical director will be provided a copy of the regulation and revised policy on 02/19/2020. Additional information will be provided to the physicians and medical director involving immunizations as recommended by the CDC Advisory committee. This information will be provided to the extenders on 02/21/2020. The DON and ADON will receive Infection Preventionist certification by 03/01/2020. They have both began the course work through the CDC. The designated infection Preventionist in the interim will be designated to the corporate level. Audits of pneumococcal immunization consent and administration will be conducted weekly for all new residents. The findings of these audits will be summarized and brought to QA on an ongoing basis. These audits will be completed by the DON/designee. Meeting held with the facility leadership team to discuss plan and implementation. The team will be responsible for assisting with the ongoing efforts to ensure compliance. Element 2 A full listing of current rehab clients was ran on the morning of 02/19/2020. The newly revised pneumococcal consent form will be provided to these rehab clients, with an explanation of risks vs. benefits. The guardian or personal representative will be contacted for those residents who cannot consent. A list of long-term residents who declined the pneumococcal previously, will be offered (and administered if they provide consent) the vaccine by 02/21/2020. For those clients/personal representatives who consent to the pneumococcal vaccine, a physician order [REDACTED]. 1. Age [AGE] years of age or older: PCV13: No history of pneumococcal vaccine Received PPSV23 before the age of 65 Received PPSV23 at 65 or older PPSV23: 1 year (8 weeks for groups B and C as defined in below chart) 1 year (8 weeks for groups B and C as defined in below chart) and 5 years after prior dose pf (sic) PPSV23 2. Age 19-[AGE] years with underlying conditions: PCV13: (blank) PPSV23: Smoker LT facility resident, or chronic conditions (heart, lung or liver) Immunocompromised: 8 weeks then 5 years CSF (cerebrospinal fluid) leaks or cochlear implants: 8 weeks Element 3 Resident #73 received the PPSV23 vaccine on 12/23/2019. Resident #73 will be offered the pneumococcal (PCV13) in 1 year. The risks and benefits of the vaccine administration will be verbally reviewed with R73 and personal representative at the time the consent is issued in 1 year. A progress note will be written into his record to reflect his response. If he wishes to receive the vaccine, and (sic) order will be obtained, and the vaccine given. An immunization tracking protocol will be developed and implemented on 02/19/2020. The Infection Preventionist will provide a report regarding our pneumococcal program, including data from the tracking tool and the results of the audit mentioned aforehand.

This citation pertains to intake #MI 712 Based on observation, interview and record review the facility failed to identify a resident and prevent an unauthorized exit for one resident (R#901) with identified cognitive deficits requiring supervision, of five residents reviewed for elopement, resulting in an immediate jeopardy when R#901 left the facility grounds through the front door without the knowledge of the facility staff, increasing the likelihood of serious injury, serious harm and/or death. Findings include: The Immediate Jeopardy (IJ) began on 11/6/19 when R#901 left the facility grounds without knowledge of the facility staff. The Immediate Jeopardy was identified on 11/12/19. The Administrator was notified on 11/12/19 at approximately 3:14 p.m. and a plan to remove the immediacy was requested. The immediacy was removed on 11/13/19 based on the facilities implementation of an acceptable plan of removal verified on site by the surveyor. Although the IJ was removed on 11/13/19, the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm that is not immediate jeopardy as the facility continues to implement its plan of correction. On 11/12/19 at approximately 10:17 AM, R#901 was observed in their room lying in their bed. R#901 was queried regarding their exit/elopement from the facility on 11/6/19 and they stated, I wanted to buy a lottery ticket. R#901 was queried if anyone had asked them where they were going when they left and they indicated that nobody had. R#901 was queried how they got out of the building and they stated, I just walked out the front door. R#901 was queried if they knew the name of the facility they resided in and they indicated that they did not. R#901 was queried if they knew the name of the major road(s) the facility was located on/near and they indicated they did not. R#901 was queried if they were aware of the name of the city were their facility was located and they indicated they did not. R#901 was queried if they had any issues with their memory and they stated, Yeah, sometimes I don't remember good. On 11/12/19 the medical record for R#901 was reviewed and revealed the following: R#901 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#901's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/11/19 revealed R#901 needed extensive assistance from facility staff with bathing and toileting and needed limited assistance with bed mobility and transfers. R#901's BIMS score (brief interview for mental status) was five indicating severely impaired cognition. A nursing progress note dated 11/06/19 revealed the following: At approx (approximately) 1150 (military time) driver at (name of facility) approached writer and stated that resident was located at the gas station. Driver stated that he brought resident back to facility. Resident was asked where he was going and he stated, 'I wanted to get some snacks from the gas station and I wanted to play the lottery.' Resident educated that he has to inform his nurse if he wishes to leave the facility and that the driver here would go to the gas station for him. Resident agreed to have wander-guard (an alert device used to prevent a resident from leaving the facility) on left ankle . A review of R#901's active careplan revealed the following: Problem-Resident has a daily decision making impairment R/T (related to) developmentally delayed . A Psychological Evaluation dated 11/5/19 performed by the facility contracted Psychologist revealed the following: Complaint: Cognitive evaluation to assist with treatment planning .The purpose of the evaluation was to assess capacity to participate in medical decision-making . In reviewing mental status, his demeanor was significant for outbursts of laughter that were inappropriate to the interaction. He responded to inquiries when he could, and when he could not, he burst into laughter. He could not recall or guess the current location or the type of facility; he did state his age correctly and said the year was 2019; the month was identified as (MONTH) after much giggling. He could not name or describe any medical problems, current or past, nor was he familiar with medications given to him. Introduced to the Short-Blessed (a screening tool that aides in detecting early cognitive changes), he fared no better. Essentially, seemingly unable to process instructions, he laughed uncontrollably. The EMR (electronic medical record) does not reflect whether the patient experienced head injury or a psychiatric disorder to explain the reflexive laughter CONCLUSION .The patient is not capable of making medical decisions. A facility document dated 10/31/19 that was signed by R#901's Physician revealed the following: (R#901 demographic information). He was sent to the hospital from an AFC (adult foster care) home with [MEDICAL CONDITION] .(R#901) is unable to manage his own medical/financial needs but has a sister (name of sister) who was involved early upon his admission. (R#901) will remain in long term care for the need of continued 24 hour care and supervision . A facility investigation dated 11/7/19 pertaining to R#901's elopement from the facility on 11/6/19 revealed the following: Event-On 11/6/19 at 10:00 AM, (R#901) was sitting in the facility lobby, a common gathering spot for families and residents, watching TV. After sitting for a while, he got up and went to reception desk and told the receptionist he needed some fresh air. She smiled and said OK. He exited the facility. At 10:15(AM), the facility driver in the company van saw him on the sidewalk just past the facility parking lot. He pulled over and asked (R#901) to get in his van. He asked (R#901) what he was doing and (R#901) stated there was a (name of convenience store) on the corner and he thought he'd get a couple of lotto tickets. The driver brought (R#901) back into the facility and to his unit .His elopement assessment was updated to show he is now at risk and a wander-guard bracelet was applied .The Social Worker had already started the guardianship process . On 11/12/19 at approximately 11:08 a.m., Staff member A was queried how they found R#901 outside of the facility grounds on 11/6/19. Staff member A indicated they found R#901 at the corner of an intersection they were at while they were driving the facility van. Staff member A stated, I saw him and told him to get in the van. He said he wanted a ride to the gas station. I took him back and brought him to the nurse. On 11/12/19 at approximately 3:19 p.m., the facility Administrator was queried how R#901 eloped from the facility. The Administrator indicated that the receptionist didn't know that R#901 was a resident in the facility and that R#901 was well dressed. The Administrator was queried how facility staff can identify residents in the facility and they indicated that all residents have wristbands on them to identify their status. On 11/13/19 at approximately 9:05 a.m., Staff member B was queried regarding R#901's elopement on 11/6/19. Staff member B indicated that they were the receptionist that day and that day was Very busy. Staff member B stated, I was doing some admissions stuff and answering phone calls. I saw him in the lobby watching TV and didn't know he was gone until the van driver brought him back and told me that he was a patient. Staff member B was queried if they had actually seen R#901 leave the facility and they indicated they didn't. Staff member B was queried if they knew R#901 was a resident in the facility when they saw them watching TV and they indicated that they didn't. Staff member B stated, I'm glad they brought him back safe. On 11/13/19 at approximately 1:55 p.m., Nurse D was queried regarding R#901's elopement. Nurse D indicated that they didn't know that R#901 had left their unit but that sometimes residents will go down to the first floor to use the vending machine. Nurse D was queried if R#901 had permission to leave the facility unattended and she indicated that he did not. Nurse D was queried if R#901 could be outside without staff supervision and she stated, No. He's got some cognitive problems. It's for his safety. When the van driver brought him back, we put a wander-guard on him and put him on 15 minute checks. On 11/13/19 a facility document with a subject of Elopement/Missing Patient/Resident dated 05/18 revealed the following: [NAME] All patients/residents leaving on a LOA (leave of absence) are required to have a Physician order [REDACTED]. On 11/12/19 the facility submitted the following plan for removal of the Immediate Jeopardy: Plan of Removal .Element 1-Resident 901 exited the facility through the front door exit on 11/6/19 at 10:30 AM. He was observed by the company van driver walking on the sidewalk just past the facility parking lot at 10: 40 AM. The driver knew the resident as he had taken him out on an appointment in the past. He pulled over and asked the resident where he was going. Resident stated he was going to (name of convienence store) on the corner to buy lotto tickets. He was returned to the facility at 10:45 AM. He was reassessed for elopement on 11/6/19 at 11:00 AM and found to be at risk. A Wanderguard bracelet was applied. He was assessed and not injured or expressed any concern about what he had done. All Elopement Books were updated with his picture and information on 11/6/19 at 11:30 AM. The Social Worker reassessed his BIMS score on 11/6/19 at 11:15 AM and the score was 9 .Element 2 On 11/6/19, 81 residents were assessed for elopement risk. Except for resident 901 , there were no changes .Element 3. The facility entrance door has a handicapped pad that opens the door for exit on the wall next to the door. On 11/6/19, this was replaced with a door release system that can only be accessed behind the reception desk. On 11/6/19, our internal Maintenance Director was able to rewire the system. This was initiated at 11:30 AM and finished at 1:00 PM. The door was secured by a facility employee during the new installation. On 11/6/19, receptionists received education that all guests must sign in and out and prior to the door being opened. Receptionists received education on 11/6/19 to check the Elopement Binder at their station at the beginning of their shift for updates. No one will act as a receptionist until they received education from the Admissions Director on Receptionist Duties. Visitor name badges were implemented on 11/6/19 and are to be worn by all guests and vendors. The receptionists received education on 11/6/19 to discourage residents from hanging out around the front door and to redirect disoriented residents back to their unit or resident lounge areas. The Entrance Door is opened by the Receptionist only at 8:00 AM and locked closed by the Security Guard at 11:00 PM. On 11/6/19, residents were checked for wrist bands and they were in place. Residents exiting the facility will have their wrist bands checked so the Receptionist can verify the identity of the resident and inquire as to their reason for leaving the facility. Actions were implemented on 11/6/19.

This citation pertains to intake number: MI 7415 Based on interview and record review the facility failed to prevent the development and worsening of a stage III and II pressure ulcers (a stage III pressure ulcer is a full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and a stage II pressure ulcer is a partial-thickness loss of skin with exposed dermis), ensured that staff identified and reported skin changes to the physician in a timely manner, identified the need for additional interventions for a resident at high risk for pressure ulcer development, promptly implement treatment for [REDACTED].#902) of three residents reviewed for pressure ulcers and a formal compliant being submitted to the State Agency. Findings include: On 10/25/19 at 9:08 AM, a complaint was submitted to the State Agency which documented in part, .Within his two week stay, he developed a severe bed sore by not being moved or rotated every two hours as ordered. He came from (name of local hospital) without a bed sore and since has been moved to another facility and is currently being treated by a wound doctor. The sore went to the bone and needs to be treated aggressively to prevent more infection and dead tissue around it had to be cut out .I requested that he be moved every two hours and he wasn't. I had to do it myself or ask an aide for help. It hurt me as I have back problems. It was not my job . On 11/12/19 -11/13/19 an onsite investigation into the complainant's allegations was conducted. A review of R#902's clinical record was conducted and revealed the following: R#902 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. loss of consciousness, traumatic hemorrhage of cerebrum, unspecified displaced fracture of third cervical vertebra, unspecified displaced fracture of sixth cervical vertebra, fusion of spine, cervical region, retention of urine, dysphagia, gastrostomy status and pedestrian injured in traffic accident involving unspecified motor vehicles. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 6 which indicated severely impaired cognition. R#902 required a two-person assistance for transfers, dressing, bathing and toilet use. A (facility name redacted) Braden Scale for prediction of pressure sore risk admission assessment completed on 9/10/19 at 22:33 (10:33 PM), documented a score of 14 indicating Moderate Risk on the Braden scale. The assessment inaccurately documented friction and shear at a score of 2- Potential Problem- moves feebly or requires minimum assist . R#902 was documented as a maximum assistance and should have been documented as a 1- Problem- requires moderate to maximum assist in moving as per the MDS assessment, which would have helped to identify R#902 as a High Risk resident on the Braden scale. A Nursing Admission Assessment completed on 9/10/19 at 22:26 (10:26 PM) documented Skin as pink and fair. A zero for rash/[MEDICAL CONDITION]. Location of Problem Areas as Head- scab on forehead and in R (right) ear, Neck- incision w (with) steri strips, arm-hand-chest~ tattoos, stomach- PEG (Percutaneous Endoscopic Gastrostomy), Peri Area- 16F cath (catheter), Back-Leg~ tattoos. No concerns or issues were identified or documented for the coccyx or buttock area. On 9/11/19 at 13:34 (1:34 PM) An Admission Skin/Wound Assessment Consult documented in part, .New Admit- wound care .skin condition: pink, abrasions- right forehead, right ear, surgical wounds- left side of neck, fragile coccyx .WOUND CARE - NEW ADMIT .MVA (motor vehicle accident) ABLE TO MAKE NEEDS KNOWN, HE HAS A LARGE NECK BRACE ON HE HAS A SURGICAL WOUND TO THE LEFT OF HIS NECK, COVER WITH STIR <sic> STIRPS, WOUND IS CLEAN AND INTACT NO DRAINAGE NOTED AT THIS TIME. HE HAS A FOLEY CATH (catheter) IN PLACE 16F (french - size), ALSO NOTED IS A PEG TUBE. THERE IS A SMALL HEALING SCAR TO THE C[NAME]CYX, AND A SCAB TO THE RIGHT FOREHEAD, AND A SCAB IN THE RIGHT EAR, THERE ARE NO OTHER SKIN ISSUES AT THIS TIME WRITER WIL <sic> CONTINUE TO MONITOR AS NEEDED (documented on 9/12/19 at 7:04 AM by Treatment Nurse (TN) E) . This assessment identified a small healing scar to the coccyx, however no notification to the physician or additional interventions to prevent worsening to the area was documented. A physician order [REDACTED]. 07:00-19:00 (7:00 AM - 7:00 PM). A Weekly Skin assessment dated [DATE] at 17:54 (5:54 PM) documented in part, .Buttocks- Tx (treatment) in place . The physician orders [REDACTED].#902 and revealed no implemented treatment for [REDACTED]. This indicates that there was some skin changes identified on 9/14/19, however the documenting nurse documented there was treatment in place and failed to notify the physician, review the Medication Administration Record (MAR)/Treatment Administration Record (TAR) to confirm there was treatment in place, failed to obtain treatment and implement additional interventions to prevent worsening of the skin. A Weekly Skin Assessment on the TAR for 9/21/19 was documented as completed, however there was no documentation in the observation section of a Weekly Skin Assessment completed for that day. On 9/24/19 at 10:52 AM, a Nursing progress note documented in part, .PT (patient) A <sic> OPEN WOUND ON C[NAME]CYX AREA WITH REDNESS, WOUND CARE NURSE NOTIFIED AND PT WAS SEEN DURING WOUND CARE ROUNDS . A Wound Care consultation report dated 9/24/19 at 9:44 AM, documented in part .This patient was seen today as a consultation for evaluation of the patient's wounds .Location: Trunk, Context: Pressure Ulcer .Musculoskeletal .Patient with multiple bony prominences, Decreased Activity, Muscle Weakness, Integumentary (Hair/Skin/Nails): Ulcers .Wound #1 Right Buttock is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2.5cm (centimeters) length x 3.1cm width x 0.2cm depth, with an area of 7.75 sq cm and a volume of 1.55 cubic cm. There is a moderate amount of sero-sanguineous drainage noted which has no odor. Wound bed has Necrotic Base [MEDICATION NAME]. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. Periwound skin does not exhibit signs or symptoms of infection. General Notes: 5% pink tissue exposure to distal aspect, irregular edges .Wound #2 Left Buttock is a Stage 2 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 3.9cm length x 2cm width x 0.01cm depth, with an area of 7.8 sq (square) cm and a volume of 0.078 cubic cm. There is a moderate amount of serous drainage noted which has no odor. Wound bed has Pink Base [MEDICATION NAME]. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. Periwound skin does not exhibit signs or symptoms of infection. General Notes: Irregular edges .Diagnosis 1. Pressure Ulcer Stage III R (right) Buttock, 2. Pressure Ulcer Stage II L (left) Buttock, 3. Debility (physical weakness) .Patient Assessment and Chronic Contributing Conditions factor(s): Impaired Mobility . A Incident Report-Non Fall form completed on 9/24/19 at 16:42 (4:42 PM) documented in part, .Skin breakdown to coccyx area .Cause of Incident (or most likely cause)- moisture .Corrective/Remedial measures taken to avoid repetition of the incident- Q2HR (every 2 hour) turn schedule .Follow-up needed- none of the above . A review of R#902's MAR and TAR for (MONTH) of 2019 revealed the following: A Monitor Bowel Movement q (every) shift . order, documented bowel movements on the following dates: 9/13 nights, 9/14 nights, 9/15 nights, 9/17 nights, 9/18 nights, 9/18 nights, 9/19 nights, 9/21 nights and 9/22 day and night. The facility staff failed to identify the development, worsening of the buttocks pressure ulcer and notify the physician while performing Activity of Daily Living (ADL) care for R#902's buttock areas on the above dates. A Shower 2 times a week (Tuesday & Friday) . order, documented a shower/bed bath given on the following dates: 9/10, 9/13, 9/17 and 9/20. This indicates the facility staff failed to identify the development/worsening of the buttock pressure ulcers and notify the physician while performing showers/bed baths for R#902 on the above dates. On 11/12/19 at 1:28 PM, a telephone interview was conducted with (TN) E. TN [NAME] was queried on R#902's documented Admission Skin/Wound Assessment Consult on 9/11/19 and stated in part I see so many people, I don't remember that resident specifically . The 9/11/19 note was read, in part to TN [NAME] pertaining to the THERE IS A SMALL HEALING SCAR TO THE C[NAME]CYX . documentation and was asked if additional interventions or treatment would normally be implemented and TN [NAME] stated, No, not really, if it's healing. If it's anything that is open the doctor will see that. If it's a resident that continuously lay in the bed, I would continue to monitor the person and would have an order in place to do that . On 11/12/19 at 1:37 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) F. LPN F was R#902's nurse on 9/24/19 the day that the pressure ulcers were identified. LPN F was queried and stated in part, .I called and notified the emergency contact over the phone .I believe the Certified Nursing Assistant (CNA) made me aware of it after changing the resident's brief that day .I did a skin assessment and informed the Wound Care Coordinator (WCC) and they came in and assessed the resident . On 11/12/19 at 1:54 PM, the WCC was queried on R#902's pressure ulcers and stated in part, .I remember after this situation I immediately started re-training the staff .We have weekly skin assessment's that are completed by the nurse's and the CNA's are to notify the nurses with any skin changes. The nurse then follows up and notify the physician to get treatment in place. When queried on the 9/11 admission wound assessment, the 9/14 weekly skin assessment, lack of the 9/21 weekly skin assessment, the multiple documented bowel movement brief changes and showers given to R#902 where staff failed to identify and report the skin changes for R#902, the WCC acknowledged and agreed that there were concerns, That's why we started education immediately. On 11/12/19 at 3:38 PM, the Director of Nursing (DON) was queried on R#902's pressure ulcer development and worsening of and stated in part, .I leave it up to the wound care coordinator to get this stuff done and investigate this stuff. This is her area of expertise . When queried on the 9/11 admission wound assessment, the 9/14 weekly skin assessment, lack of the 9/21 weekly skin assessment, the multiple documented bowel movement brief changes and showers given to R#902 where staff failed to identify and report the skin changes for R#902 and the re-education and training to the staff, DON stated, Again, I expect the WCC to follow up on these things and provide the education to the staff . When asked how the facility ensured that R#902 was turned and positioned as indicated by the physicians order the DON stated, .The nurse is to ensure that it is being completed. They are the one's signing off on it . A care plan titled, Alteration in skin integrity (Actual or Potential) created 9/10/19 documented in part, .Resident skin will remain intact/free of new or worsening skin issues .Skin assessments weekly .Turn and reposition q2h (every two hours) when in bed and q1h (every one hour) when in chair as tolerated . The DON and WCC was asked to provide any additional information pertaining to the above noted concerns regarding R#902's identification, development and worsening of their pressure ulcers and no additional information was provided by the end of survey. A facility policy titled Skin Care Protocol: Pressure Ulcer Prevention (no date indicated) documented in part, .Purpose: to define a protocol for the prevention of pressure ulcers .For high-risk patients, a care plan will be initiated utilizing appropriate prevention measures . All patients at risk will have a systematic skin inspection at least weekly, i.e., bony prominences .and document findings on the Weekly Skin Assessment Form .All patients will have a routine bathing schedule .Skin cleansing immediately after soiling will also be provided .Any questionable skin areas will be reported to the nurse caring for the patient .Pressure reducing measures will be followed according to patient's activity level. Immobile: utilize pressure reducing sleep and sitting surface, Turn patient every two (2) hours using pillows for proper positioning and record on positioning schedule, Avoid pressure on bony prominences (i.e., elbows, heels, ankles, and trochanter) .Care plans will be written according to individual patient needs and incorporating interdisciplinary consideration .The physician must be advised of wound status on a regular basis . A facility policy titled Skin Care Protocol: Pressure Ulcer Treatment (no date indicated) documented in part, Preventative measures to be incorporated in potential/actual skin impairment treatment plan: [REDACTED]. Skin cleansing immediately after soiling will also be provided .Any questionable skin areas will be reported to the nurse caring for the patient .The nurse will complete an incident report of any actual skin breakdown .Positioning transferring and turning will be provided utilizing appropriate assistance (i.e., second person) .Pressure reducing measures will be followed according to patient's activity level. Immobile: utilize pressure reducing sleep and sitting surface, Turn patient every two (2) hours using pillows for proper positioning and record on positioning schedule, Avoid pressure on bony prominences (i.e., elbows, heels, ankles, and trochanter) .Care plans will be written according to individual patient needs and incorporating interdisciplinary consideration .The physician must be advised of wound status on a regular basis .

This citation pertains to intake #MI 774 Based on observation, interview and record review the facility failed to prevent an unauthorized exit for one resident (R#903) identified as an elopement risk of five residents reviewed for elopement, resulting in an immediate jeopardy when R#903 left the facility grounds through an unlocked staff door without the knowledge of the staff, increasing the likelihood of serious injury, serious harm and/or death. Findings include: The Immediate Jeopardy (IJ) began on 9/21/19 when R#903 left the facility grounds without knowledge of the facility staff. The Immediate Jeopardy was identified on 10/15/19. The Administrator was notified on 10/15/19 at approximately 4:55 p.m. and a plan to remove the immediacy was requested. The immediacy was removed on 10/16/19 based on the facilities implementation of an acceptable plan of removal verified on site by the surveyor. Although the IJ was removed on 10/16/19, the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the state agency. On 10/15/19 the medical record was reviewed and revealed the following: R#903 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#903's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/27/19 revealed R#903 needed extensive assistance from facility staff with transfers and bathing and needed supervision with personal hygiene as well as having had a lower extremity impairment. A progress note dated 9/20/2019 revealed the following: Patient arrived from (local hospital) via car with sister present at 1420 (military time). Patient was in a motor vehicle versus pedestrian accident patient has a cast to his right lower extremity right foot fracture, patient has purple bruising to bilateral flanks patient also has purple bruising to lower abdomen where he has a open wound where he will be receiving [MEDICATION NAME] ointment 3 times on abrasions a day with wet to dry dressing on the wound. Patient is alert to self able to answer simple yes or no questions no distress or complaints of pain upon arrival .Patient has a history of MS ([MEDICAL CONDITION]). Patient has periods of incontinence and wears pull up briefs .swelling noted to abdomen due to accident. A progress note dated 9/20/2019 at 20:24 (military time) revealed the following: Writer observed patient going into his room at 5:30 p.m. patient stated that he was going to watch TV. Nurse went to check in on patient at 5:40 pm. Patient was not present in room. Patient was observed by staff leaving facility going towards (major road) heading to (name of apartment complex) apartments where patient lives. Patient was safely placed back in wheelchair and redirected and escorted by nurse back to (name of facility). Patient stated that he was going home and left his wheelchair at the door and walked. Patient denies pain. MD (medical doctor) aware, new orders for a wander guard ( a safety device that a resident wears in which an alarm will sound if the resident is close to an exit) and patient sitter (facility staff member assigned to provide 1:1 supervision) for 12 hours, re-evaluate tomorrow. Elopement care plan updated, sister (name of sister/legal guardian) notify of attempted elopement. An elopement assessment for R#903 dated 9/20/19 revealed the following: Is this a new admission? (Yes) .Independent use of a wheelchair? (Yes) .Able to walk with Assistance of others? (Yes) .Does the patient have a medical [DIAGNOSES REDACTED].? (Yes) .Are there any indications of Dementia? (Yes) . A review of R#903's careplan revealed the following: Problem-Resident presents with elopement risk AEB (as evidenced by) Mild cognitive impairment and exit seeking .Goal-Resident's safety will be maintained. Resident will not leave facility unattended .Interventions-Monitor whereabouts whenever not in therapy or receiving nursing care .Occupy resident with meaningful activities to lessen boredom . A progress note dated 9/21/2019 at 12:40 (military time) revealed the following: Writer notified per PT (physical therapy) staff .resident observed walking down sidewalk of building toward (local apartment complex) apartments. Writer notified supervisor of resident's departure from facility. Staff, proceeded to retrieve resident from ( local apartment complex) apartments. Resident was returned to the facility per writer via wheelchair, .Writer notified physician of incident, DON (Director of Nursing)and attempted to contact (name of legal guardian) without success. (wrong number). Writer received order to place resident on 24 hours 1:1 sitter per DON. Sitter called to sit with resident at bedside . A Psychological Evaluation dated 9/24/19 completed by the facility contracted Psychologist revealed the following: HPI (history of present illness): (demographic description of R#903) recovering from`closed [MEDICAL CONDITION] foot and laceration of abdominal wall; he was a pedestrian when struck by a motor vehicle. In that accident, the patient was said to be one of several individuals attempting to cross (name of major road); one of them was killed. Prior to the accident, he resided at (name of local apartment complex), a longer care facility. The ostensible reason is [MEDICAL CONDITION] diagnosed ,[DATE] years ago, with rapid deterioration in cognition and ability to care for himself. Since his arrival at this facility a few days ago, he has been observed to wander around the facility- and over the weekend, he left the facility to go across the street to (name of local apartment complex) undetected. Staff were alerted of his absence when called by (local apartment complex). He has since been assigned a sitter and is under constant surveillance. The EMR (electronic medical record) documents MS, in addition to cognitive disease/impaired cognition with decrease in decision-making capacity, and incontinence. A review of other clinical notes portray the patient as having urinated publicly, in addition to fecal incontinence, in the past. There were references also to sexual obsessions not operationally defined- as well as Pseudobulbar Affect (involuntary laughing/crying). Visited today, the patient smiled warmly and acted appropriately on meeting the psychologist for the first time. Cognitive deficits were immediately evident in long pauses, expression of confusion, and responding I don't know to inquiries that pertained to his remote and recent history. He did state the correct month and year which were on a wall-board across from the bed. He was also familiar with his age Judgment: +Marginal; .Insight: +Impaired; .Assessment & Plan-[MEDICAL CONDITIONS], unspecified, Dementia in other diseases classified elsewhere without behavioral disturbance-Plan: Coordination of care with providers . A review of a facility reported investigation pertaining to R#903's elopement on 9/21/19 revealed the following: Incident: (R#903) was admitted on [DATE]. He came to the facility in his sister's care at 2:00 AM <sic> and spent time in the car eating a fast food meal and talking to his sister. He did not enter the facility until 4:24 PM. At 5:30 PM he was observed in his room and at 5:40 PM, (nurse B) saw him at the facility entrance leaving the facility. She went outside and escorted him back in the facility. Resident stated he wanted to go to his apartment. The physician was notified, a wanderguard bracelet and a sitter was assigned for 12 hours to be evaluated in the AM. The sitter was discontinued in the morning of 9/21/19. At approximately 11:30 AM, we received a call from the (name of local apartment complex) apartments that (R#903) was entering his apartment to pick up some of his belongings (and cigarettes). Two staff members went next door and escorted (R#903) back to the facility. He was assessed and there were no injuries. The wanderguard bracelet he had on was removed and tested . It worked when the bracelet was in close proximity to the sensor, but when it was tested on the other side of the hall, it did not alarm. A new wanderguard was applied and a sitter was reassigned. Due to {R#903)'s short-term memory, he did not remember instructions not to leave the facility. The physician was notified. He again received instruction that he needed to stay in the facility and a nicotine patch was ordered. The sitter will remain in place . On 10/15/19 at approximately 2:20 p.m., during a walkthrough and conversation with the Director of Nursing (DON), the DON was queried regarding R#903's elopement on 9/21/19. The DON was queried if R#903 was an elopement risk when they eloped on 9/21/19 and they indicated they were. The DON indicated that R#903 went through the hallway past the double doors into the service hallway and out the side entrance to the facility that the employees use. The DON indicated that R#903's wanderguard did not work as it was supposed to when R#903 passed the double door into the service hallway. They stated that they did end up testing it and that it did not alarm when it was on the other side of the hall only when it was close to the door sensor. The DON indicated that when the nurses brought R#903 back to the facility they made sure he had a sitter to provide supervision until R#903 was discharged . During the walkthrough of R#903's route out of the building with the DON it was observed that none of the doors that R#903 went though to gain entrance into the service hallway or exit the building were locked from the inside. It was also observed that R#903 would have had to walk up a concrete ramp to get off of the facility property. On 10/15/19 at approximately 3:21 p.m., Nurse B was queried via phone regarding R#903's first elopement on 9/20/19. Nurse B indicated that R#903 went out of the building and was walking to the road in the parking lot when they got them. Nurse B indicated that a careplan was put into place and R#903 was provided a sitter and a wanderguard. Nurse B was queried if they had tested the wandergaurd to ensure proper functioning and they indicated they had not because they received it from another nurse and thought it was brand new. On 10/15/19 at approximately 3:56 p.m., Nurse C was queried via phone regarding R#903's second elopement on 9/21/19. Nurse C indicated that around lunchtime a therapist notified them that they saw R#903 outside the facility. When Nurse C went outside to bring R#903 back into the facility they could not find them. Nurse C indicated that they knew R#903 lived in the apartment complex behind the facility and that they went over to the apartment to see if R#903 had went home. In the lobby of the complex, the apartment staff informed Nurse C that R#903 had gone into their apartment. Nurse C indicated the apartment staff went to R#903's apartment, brought him down to the lobby and Nurse C and another facility nurse placed him in a wheelchair and brought him back to the facility and assigned a sitter to him again to watch him. Nurse C was queried how R#903 got out of the facility and they stated, he went out the side employee entrance. Nurse C was queried if R#903's wanderguard went off and they indicated that it didn't. On 10/16/19 a facility document titled The Wander Management Program (revised 9/2019) was reviewed and revealed the following: Purpose: To provide a safe environment for patients who are assessed as at risk for wandering away from facility .Policy: [NAME] The wander management program is used in conjunction with other management strategies to keep 'at risk' patients safe. Other strategies could include; provide familiar surroundings, review medications, encourage exercise, or provide a room near the nurses station . On 10/15/19 the facility submitted the following plan for removal of the Immediate Jeopardy: PLAN OF REMOVAL-F689 .Element 1 .Resident 903 was admitted on [DATE] at 5:00 PM. At 6:30 PM he attempted to leave the facility through the front entrance. He was observed leaving and was brought back into the facility by staff and a wanderguard bracelet was initiated. He wanted to go next door to the apartments he lived at to retrieve his belongings. On 9/21/19 at 10:30 AM the facility received a phone call that from his apartment complex receptionist stating he was in his apartment. Resident 903 exited through the employee exit door in the service area of the facility without supervision. This door is not alarmed and leads to the parking lot. Facility staff escorted him back to the facility. He was assessed and had no injuries. He was placed on 1:1 supervision until his discharge on 10/14/19 .Element 2 .Resident 903 is no longer in the facility Element 3 .All other facility exits are alarmed. In addition, there are two wanderguard monitors in the lobby and entrance into the service area. A facility employee was immediately placed by the employee exit door and will remain in place until the following is installed. A sign in sheet is available as proof that the door is being monitored 24/7. A keypad system will be installed on the wall for employee exit. The Technicians are scheduled to arrive on 10/16/19 to evaluate the project and begin instillation. The door will have a panic bar installed that will alarm if the door is opened without using the keypad for exiting. The alarm will sound until a facility employee deactivates it. The door monitor will be in place until the system is installed and fully operational. Immediately after resident 903 returned, the facility reassessed all residents for elopement risk, inspected each wanderguard monitor and bracelet for function and reviewed the Maintenance Daily system checks. All were in place and accurate. Education was provided to Licensed Nursing Staff on the use of the wanderguard system and documentation. The Administrator reviewed the Maintenance logs and wanderguard checks and they are in place. The Director of Nursing reviewed resident's at risk for elopement to ensure their plan is in place. There are double doors in the service hall that connects the resident area and service area. The doors are fire doors and on a magnetic latch that closes during a fire drill. This service area is busy with food carts, housekeeping carts and deliveries. The doors are kept open to allow traffic between both sides of the hall. These doors do not impact the employee entrance area or the traffic in other areas of the service hall .Element 4 .Door monitor sign in sheets will be turned in daily M-F (Monday through Friday) and weekend sign in sheets will be turned in Monday to the Administrator. The Director of Nursing is responsible for ensuring the door is always monitored with facility staff. The Incident will be reviewed by the QA Committee at their 10/25/19 meeting. The Maintenance Director will update the Administrator daily on the installation process of the new door alarm system. The Administrator is responsible for compliance.

Based on observation, interview, and record review, the facility failed to ensure a safe environment for one resident, (Resident #501) out of one resident reviewed for safety of the environment, out of a total sample of 17 residents, resulting in a fall from a shower chair causing a broken leg, pain, decreased mobility, and decreased social activity. Findings include: On 9/12/17 at 8:25 am, an in initial tour of the building was conducted. During the tour, Resident #501 was observed in bed. Resident #501's right leg was observed to be in a plaster cast and was elevated on a pillow. Resident #501 was asked what happened to her leg and she stated, The aide was going to give me a shower and she dropped me. On 9/12/17 at 8:30 am, facility incident and accident report and investigations were requested from the facility for Resident #501. On 9/13/17 at 11:30 am, the facility incident and accident reports and investigations for Resident #501 were provided and reviewed. During the review an electronic form titled, Fall incident indicated the location of the fall was in the shower room and there were, Obstacles in path-floor transition strip. The pain assessment on the electronic form was marked as, 7-Severe Pain-Horrible Intense. A nursing note dated 8/29/17 at 7:42 pm, read, Resident had a fall in the shower room, writer was informed that the resident weight was shifted in the bath chair, as a result the resident tipped to one side of the chair and fell to the floor. A second note by the interdisciplinary team documented on 8/30/17 at 9:41 am, read, .Team met to review fall on 8/29/17. Patient being pushed into shower room and met resistance with the door strip and fell out of the chair. Recommendation: Transfer patient into bath chair once patient is inside shower room . A review of facility provided document regarding the incident read, Description of Deficient Practice: Transition strip from hallway into shower room on unit 2 has a significant raised area. When staff propel residents into shower room, the raised area will cause the wheel chair/shower chair/ tub chair to come to an abrupt stop .In-depth Analysis of How Deficient Practice Occurred: CNA (Certified Nursing Assistant) was taking resident into the shower room on Unit 2 in the chair for the hydro-tub. As CNA attempted to propel resident into shower room, the hydro-tub chair came to an abrupt stop as CNA attempted to cross the threshold of the shower room. The resident's body continued to move forward and CNA attempted to hold on to the resident from behind, however resident (who weighs approximately 250+ pounds) did fall out of wheelchair onto floor . A review of CNA 'D's signed statement read, On 8/29/17 We transferred (Resident #501) from the bed to the tub-chair in her bedroom, once she was in the chair I pushed her down the hall to the shower room. When we got to the shower room door I attempted to push the chair in shower room but got some resistance due to a hump in the doorway on the floor which made the pt (patient) weight shift and she went falling out of the chair . On 9/13/17 at 11:50 am, a second interview with Resident #501 was conducted regarding the fall in the shower room. Resident #501 explained that CNA 'D' transferred her into the shower chair in her room and was pushing her to the shower room. During the interview the Resident indicated she couldn't remember exactly what happened but she knew she hit a bump and fell out of the shower chair in the shower room. Resident #501 stated, I know I broke my leg. At that time, resident #501 was asked about whether she had been getting out of bed and moving about the facility, going to the dining room, or participating in activities. Resident #501 stated, I used to get up everyday, but now I haven't since I broke my leg, it hurts too much. A review of Resident #501's clinical record was conducted on 9/13/17 at 1:15 pm. It was discovered that Resident #501 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #501's Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition (Brief interview for mental status score of 14 out of 15), total assistance of two staff members for transferring, and total assistance of one staff member for bed mobility, wheelchair mobility, dressing, hygiene, and bathing. The MDS assessment indicated range of motion deficits affecting both lower extremities. On 9/14/17 at 12:00 pm, an interview with the facility's Maintenance Director was conducted. The Maintenance Director was asked about the shower room on unit two and he explained that the floor threshold of the door entering the shower was pretty tall, and stated, The staff were having problems getting wheel chairs in and out of there. The Maintenance Director explained that new tile floors were put in the shower room in 2013. He explained that the difference between the old floors and the new tile floors resulted in an elevation of the threshold and the floor was no longer a smooth transition from the hallway floor into the shower room. He continued to explain that since it was difficult to get wheelchairs into the shower room he had closed it until the floor could be repaired. When asked if he was made aware of the concern with the uneven floors and the difficulty getting wheelchairs and shower chairs into the shower room, he indicated that no one had brought it to his attention. On 9/14/17 at 1:45 pm, an interview with CNA 'D' was conducted. CNA 'D' was asked to recount the incident of Resident #501 falling out of the shower chair. CNA 'D' explained that she was pushing Resident #501 to the shower room. She explained that when she reached the doorway to the shower room she said Resident #501's weight shifted at the same time she was trying to push the shower chair over that hump and Resident #501 fell out of the shower chair. She explained that it was hard to get the chairs over the hump in the doorway and stated, It's been a problem, everyone has had problems getting into that shower. When asked if she reported the uneven threshold to anyone in the facility, she indicated she had not. On 9/14/17 at 2:10 pm, an interview with the facility's Director of Nursing (DON) was conducted regarding the incident with Resident #501. The DON explained that the floor transition strip was raised up. She indicated that CNA 'D' hit resistance when trying to wheel the shower chair into the shower room. She explained that the shower chair wheels turned making the chair unsteady and Resident #501 fell out of the shower chair and hit the door frame. The DON also indicated that the facility recreated the incident of attempting to roll shower chairs and wheelchairs over the uneven threshold. She explained that the shower chair wheels turned when they hit the uneven threshold and would not roll easily into the shower room. The DON stated, It's always had to have been a problem, but I just heard about it. A request for policy on environmental safety was requested on 9/14/17 at 2:20 pm. Policies were provided, but did not address ensuring a safe environment for residents. At 4:00 pm, the facility's Administrator confirmed the facility did not have a specific policy ensuring a safe environment. The facility was asked if they had any additional information to provide regarding the concern, none was provided by the end of the survey. Deficient Practice Statement Two Based on observation, interview and record review, the facility failed to implement fall interventions for one Resident (#510) of four Residents reviewed for fall from a total sample of 17. Resulting in the potential for a fall with injury. Findings include: Resident #510 According to the electronic health record that was reviewed on 9-12-2017, Resident #510 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] reflected a brief interview score of 3, indicating severe cognitive impairment. The MDS further reflected Resident #510 was dependent upon staff for transfers and ambulation. The fall care plan dated 8-22-2017 reflected Resident #510 was at risk for falls due to decreased mobility, one of the interventions listed was bilateral floor mats at bedside. Resident #510 was observed in bed without bilateral floor mats in place on 9-13-2017 at 8:25 am and again on 9-13-2017 at 9:51 am. On 9-14-2017 at 1:00 PM during an interview with Unit Manager M she reported resident #510 was at risk for falls and tries to self transfer. Unit Manager M reported safety interventions for Resident #510 included a low bed, bilateral floor mats to be in place when Resident #510 was in bed. When the observations made on 9-13-2017 were discussed, Unit Manager M reported the bilateral floor mats should have been in place.

Based on observation, interview and record review, the facility failed to remove a damaged shower gurney from staff use for one (#702) of two residents sampled for falls with injury, from a total of three sampled residents, and failed to educate contracted direct care staff on facility policies, resulting in Resident #702 falling because of a defected shower gurney, hitting his head and sustaining a painful laceration that required an emergency room visit and suture repair. Findings include: This citation pertains to intake # . On 6/28/17 at 10:00 a.m., a record review of the face sheet and Minimum Data Set (MDS) assessment was completed for Resident #702. According to the face sheet, Resident #702 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED].#702 was severely cognitively impaired and was dependent for care with transfers, bed mobility, bathing, hygiene and had range of motion limitations of his lower extremities. On 6/28/17 at 9:10 a.m., Resident #702 was observed resting in bed with his eyes closed. Resident #702 was easily arousable and made eye contact but was unable to consistently voice his needs. There was a new red scar approximately one inch long on the right side of his head near his forehead. On 6/28/17 at 10:10 a.m., a record review of the incident report dated 6/8/17 revealed that Resident #702 was observed lying on the shower room floor with a laceration on the right side of his head that was bleeding. According to the incident report, Resident #702 had been receiving a shower and was on a shower gurney that had side rails on it. The report also confirmed that Resident #702 had been sent to the hospital that same night for evaluation and treatment of [REDACTED]. On 6/28/17 at 10:15 a.m., a record review of the statement hand written by Certified Nursing Assistant (CNA) D revealed that she was present during the shower. According to the statement, CNA D was assisting another CNA during the shower and was holding Resident #702 towards her body and she suddenly heard a loud pop from the side rail of the shower gurney and the rail fell down and the resident fell on to the shower floor and was bleeding profusely from his head. According to the statement, the shower gurney was also not locked at the time of the incident . On 6/28/17 at 10:20 a.m., a record review of the police report (# 2122) dated 6/8/17 revealed that the officer on duty had met with Resident #702 and his responsible party at the hospital and then had went to the facility to investigate the incident. The report states that the officer noted that the shower rails on the damaged gurney utilized had been missing safety pins in which there was one plastic swab present instead of the pin, and another plastic swab was broken on the shower room floor and the side in question had a broken hinge on it. The officer also noted in his report that he informed the facility staff to take the defective shower gurney out of service. On 6/28/17 at 10:25 a.m., a record review of the facility policy titled, Maintenance Repair Request revised 6/2017 stated the following: #1b. situations that present an immediate safety concern must be brought to the immediate attention of the maintenance staff by using the PA system or by calling the maintenance cell phone. c.7. Examples of emergency repairs include: Defective equipment (defective equipment should be tagged 'out of order' and taken to maintenance immediately. 2b. Actions taken by maintenance department: If any piece of equipment needing repair presents a safety issue for patient care or for staff safety, the equipment should be 'out of service' and remove immediately from the area. On 6/28/17 at 10:35 a.m., a record review of the, observation charting dated 6/9/17 revealed that Resident #702 had arrived back from the hospital with bruising on the back and side of his neck and had 4 stitches on his right head area. On 6/28/17 at 11:00 a.m., an interview was completed with the Director of Nursing (DON) who had completed the investigation of the incident with Resident #702. According to the DON, because the shower gurney was not locked, as Resident #702 began to roll off the gurney, the gurney moved in the opposite direction causing Resident #702 to fall to the ground. The DON also stated that the pins were not present for the side rails, causing them to collapse. The DON also stated that the CNA's used were pool CNA's (CNA's that work for an outside agency) and had not been orientated to the facility and did not know the procedure of what to do with defective equipment. On 6/28/17 at 11:30 a.m., and interview and observation of the defective shower gurney was made with the Maintenance Director C. According to the Maintenance Director C, he was unaware of the defective shower gurney being damaged prior to the incident with Resident #702. Maintenance Director C stated, We fix faulty equipment once we know about it. The shower gurney was observed outside the facility in a storage pod. The Maintenance Director C stated that there were supposed to be four pins that were used to secure the side rails in place. One silver metal pin was observed on the right side of the gurney. The Maintenance Director C also stated, We ordered two new ones (shower gurneys) that should be in soon. On 6/28/17 at 1:45 p.m., an interview was completed with the Administrator. The Administrator was aware of the incident with Resident #702 and had admitted that he became aware that the CNA's were not properly oriented to the facility policies prior to them starting to work at the facility. The Administrator stated, We were in a staffing crisis and we hadn't utilized agency staff in ten years. Now we keep a record of the ones who have been oriented and put them through a four hour orientation before they can work here. On 6/28/17 at 1:50 p.m., an interview was completed with the Staff Development Nurse A. Nurse A had stated that the agency CNA's now have to go through a four hour orientation given by her that discusses safety policies and defective equipment. Nurse A had stated that she had not oriented the CNA's involved with Resident #702 but that they were no longer able to work in the facility since the incident. On 6/28/17 at 2:00 p.m. an interview was completed with the staff member (Staff Member B) responsible for scheduling agency CNA's. Staff Member B had stated that she now keeps a list of what CNA's from the agency were orientated to the facility and does not schedule them unless they have had an orientation. A policy on the utilization and orientation of agency staff was requested but not turned in by the end of the survey.

Based on observation, interview, and record review, the facility failed to consistently perform weekly skin assessments as ordered and implement interventions for the prevention and treatment of [REDACTED].#502) of two residents reviewed for facility acquired pressure ulcers, out of a total sample of 19, resulting in the development of a pressure ulcer and the risk for the worsening and development for further ones. Findings include: On 9/3/15 at 9:20 a.m., the treatment to Resident #502's left elbow pressure ulcer (PU) was observed. The facility's treatment nurse (Nurse A) performed the treatment. Nurse A reported that it was a facility acquired PU. Resident #502 stage III PU measured 5.1 X 4.0 centimeters (cm). The wound bed was beefy red with moderate serosanguinous drainage, and irregular edges. Nurse A cleansed the wound with wound wash, pat dry, applied the prescribed treatment and dressing. Immediately after the dressing change, Nurse A was queried regarding the frequency of skin assessments. Nurse A reported that they are done at least weekly by the nurses. Weekly skin assessments, physician orders, skin/pu care plans, treatment administration records, Braden scales, and weekly wound notes were requested. On 9/3/15 at 12:50 p.m., record review of the following was conducted: Resident #502's face sheet revealed an admission into the facility on [DATE] and a re-admission on 7/24/13 with [DIAGNOSES REDACTED]. Resident #502's annual Minimum Data Set (MDS) assessment, dated 3/4/15, indicated that his cognition was vegetative and that he was completely dependent upon the staff for all activities of daily living (ADLs), including all mobility. The MDS also indicated the absence of pressure ulcers (PU). A nurse's note for Resident #502, dated 4/12/15 at 9:07 a.m., revealed the following documentation: CNA (certified nursing assistant) report open area to resident's left elbow .Doctor notified. Santyl ointment (a debridement agent) to left elbow after cleanse with wound cleanser, apply dry dressing daily and prn (as necessary) .Will continue plan of care. Nurse A reported this was when the pressure ulcer was first discovered. The last skin assessment documented prior to the discovery of the left elbow pressure ulcer was on 2/10/15. The skin assessment indicated Resident #502 had right hip fragile skin. The following documented skin assessment was done on 4/14/15 (nine weeks later). This skin assessment solely indicated Resident #502 had a healing wound on left hip. There was no mention of the left elbow pressure ulcer that had been discovered on 4/12/15. Further review of Resident #502's skin assessments revealed a total of four documented skin assessments for the time period of 1/6/15 to 2/10/15. There was also no mention of skin assessments in the nurses' notes for that time period. Review of nursing orders revealed the following: -Weekly skin assessment, Friday evenings, repeat every one week (written on 2/11/15) Resident #502's wound consultation, dated 4/14/15, included the following documentation: Left elbow 2.0 X 1.5 centimeters (cm), pale pink base, minimal yellow slough, minimal serosanguinous drainage, irregular edges .Diagnosis: [REDACTED]. Recommendations: Santyl QD (every day) and prn to left elbow, elbow protector to left elbow. Resident #502's physician's orders [REDACTED]. -Turn and reposition every two hours while in bed (11/26/14-present) -Frequently reposition off left side every shift; day, evening, night (12/10/14-present) -Soft elbow protectors to bilateral elbows every shift; day, evening, night (6/18/15) -Elevate left elbow above knee by using pillow to prevent knee or surface contact with elbow (8/26/15-present) Resident #502's nursing care plans related to the prevention and treatment of [REDACTED]. -Skin audits on regular bath days (11/13/14) -Patient teaching for off-loading pressure (11/13/14) -Positioning program as needed (11/13/14) -Skin audits per order -Wedge/pillow support while in bed to keep pressure off bony prominences (11/13/14) -Monitor for fragile skin (11/13/14) -Monitor skin for changes during daily care (11/13/14) -Dietary consult as needed to assist in wound healing (11/13/14) -Encourage/assist to reposition every two hours when in bed (11/13/14) -Monitor lab values, notify doctor of abnormals (T-Protein, [MEDICATION NAME]) (11/13/14) Resident #502's Annual Nutrition Reassessment, dated 3/3/15, indicated the following: planned weight loss of 7.4 pounds, a normal [MEDICATION NAME] level, and a multivitamin was ordered. Other nutrition-related lab values were also within normal range (hemoglobin, serum transferrin, creatinine, and blood urea nitrogen) Resident #502 received nothing by mouth. All of his nutrition was from tube feedings. Further review of the clinical record revealed no documentation from dietary of the notation of Resident #502's pressure ulcer that was discovered on 4/12/15 until 9/1/15. Review of the RD's note, dated 9/1/15 at 4:38 p.m., revealed the following documentation: CMP (comprehensive metabolic panel) ordered secondary to elbow wound and no recent protein labs. Will make adjustments to exogenous protein based on results of labwork. Resident #502 had a total of three Braden Scales (assessment for risk of developing pu). The dates of the Braden Scales were; 11/11/14, 4/12/14, and 8/28/14. All three Braden Scales indicated that Resident #502 was at a high risk for developing pressure ulcers. On 9/3/15 at 1:30 p.m. the DON was queried regarding Resident #502's facility acquired pressure ulcer. The DON reported that Resident was at high risk for the development of pressure ulcers. There was no explanation for the development of the pressure ulcer. On 9/3/15 at 1:50 p.m., Resident #502's Certified Nursing Assistant (CNA B) was queried regarding the frequency of turning him and the application of his elbow protectors (soft paddings to protect skin from breakdown). CNA B stated, He is on his right side. The resident was observed lying on his left side with his left elbow resting on a pillow. When queried about the application of bilateral elbow protectors, CNA B stated, He only wears heel protectors. He does not wear elbow protectors. On 9/3/15 at 2 p.m., the facility's Assistant Director of Nursing (ADON) was asked to observe Resident #502's position. The ADON witnessed Resident #502 lying on his left side. The ADON stated, I thought they turned him. CNA B reported that Resident #502 turns back onto his left side frequently after they (staff) repositions him. Resident #502 was observed lying on his left side during the following times: 9/1/15 at 12:10 p.m., 1:50 p.m., and 3:30 p.m., On 9/2/15 at 8:55 a.m., 9:20 a.m., and at 3 p.m. On 9/3/15 at 9 a.m., 10 a.m., 11:55 a.m., and 1:50 p.m. During each observation of Resident #502 lying on his left side, his left elbow was noted resting on a pillow. All four of Resident #502's limbs are contracted as he laid in a fetal position. Resident #502 was never observed wearing elbow protectors (as ordered), nor was he ever observed lying on his right side. On 9/3/15 at 2:50 p.m., review of the facility's policy titled Skin Care Protocol: Pressure Ulcer Treatment, last reviewed 3/2015, revealed the following documentation: Preventative measures to be incorporated in potential/actual skin impairment plan .Turn patient every two hours using pillows for proper positioning and record on positioning schedule. Avoid pressure on bony prominences (i.e., elbows, heels, ankles, and trochanter). Assure initiation of preventative measures. Position resident off affected area if possible. Reassess nutritional and fluid status as necessary. Assess appropriate lab values as ordered. Request dietary consult as necessary. Review of the facility's policy titled Skin Care Protocol: Pressure Ulcer Prevention, revised 11/2014, revealed the following documentation: All patients at risk will have a systematic skin inspection at least weekly, i.e., bony prominences .and document findings on the Weekly Skin Assessment form or the Wound Assessment form, and/or the Interdisciplinary Notes. A nutritional assessment/review will be completed by the dietician upon admission and prn (as necessary). On 9/8/15 at 11:10 a.m., the facility's Registered Dietician (RD) was interviewed regarding what interventions were put into place after the discovery of Resident #502's facility acquired pressure ulcer. The RD stated, We did not feel it was necessary to add new interventions because his labs were normal. His calorie and protein needs were adequate. There is nothing we would have added nutritionally. Normally we do a nutrition re-assessment when a resident develops a pressure ulcer, but we did not do one. The next assessment was done on 9/1/15. I did not make a notation in my notes when the pressure ulcer was reported to me back in April. ( )

This Citation pertains to intakes MI 175, MI 508, MI 753, MI 751 This Citation contains multiple deficient practice statements: A & B. A.) Based on observation, interview and record review the facility failed to ensure the use of an appropriate transfer technique per facility policy in 3 of 6 sampled residents (#101 #104 and #105), from a total sample of 6 residents, resulting in a skin tear for Resident #101, opening of a recurring foot ulcer after improper transfer for Resident #104, and Resident #105 sustaining a head injury after being dropped from a Hoyer lift after improper transfer technique. Findings include: Resident #101 Resident #101 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] post fractured right hip repair and discharged on [DATE]. According to the facility [DIAGNOSES REDACTED]. Review of the facility MDS (minimum data set) dated 11/14/12 Resident #101 was moderately impaired for daily decision making skills, required extensive assistance to transfer from surface to surface, dressing and personal hygiene, totally dependent on staff for feeding, toileting, bathing and was incontinent of both bowel and bladder. Review of the Facility Nursing Care Plan dated 11/6/12, Problem #7 titled "Resident unable to transfer self in a safe manner without physical assist from staff", revealed an intervention: "EZ stand with 2 person for transfers". Review of the Facility Physical Therapy Evaluation and Plan of Care dated 11/7/12 revealed "Transfer status sit-stand and to bed at level 2 requiring staff assistance above 75% to transfer Resident #101". Review of Facility Physical Therapy Daily Notes dated 11/8 and 11/9/12 transfer "Max X 2 above 75% assistance" with a narrative note dated 11/9/12 "Transfer training to increase functional mobility. Patient transfers are Max assist X 2 secondary to cognition, patient is unable to functionally contribute to standing pivot transfer". Review of the Facility Nurses Notes dated 11/11/12 at 3 PM "CNA asked writer to come to patient room to look at skin tear on left lateral leg. When writer entered room aide was holding towel on patient's leg to reduce the bleeding. Writer looked at wound, called doctor. Doctor ordered to send patient to ER bleeding would not stop and patient on blood thinner. Writer and another nurse went to room wrapped leg with gauze and kerlex (dressings) to keep pressure on wound". Nurses notes revealed that Resident #101 returned to the facility with 3 sutures to left leg at 6 PM on 11/11/12. Review of the Facility Incident Report dated 11/11/12 revealed at 1:50 PM that the 1:1 CNA assigned to Resident #101 transferred Resident #101 physically without using the EZ sit to stand lift. Resident 101's leg got caught on the chair causing a skin tear to his left lateral leg. Review of the Facility Policy and Procedure titled "Safe Lift/Transfer of Patients" revised date 11/11 Section 3 G: "Employees will not lift patients who require 50% or more assistance without the use of an appropriate mechanical device". During an interview on 12/12/12 at 10:45 AM, the Facility Therapy Manager reported it was the policy of the facility that for residents who needed above 50% assistance, it was required a mechanical device be used. "The information never was put on the care guide to use the device (for Resident #101). We are a no lift facility; yes he should have been transferred with a lift from admission it was not communicated to staff per the care guide until after the incident". ( ) Resident #104 Resident #104 was admitted to the facility 10/09 and, according to the Facility Face sheet [DIAGNOSES REDACTED]. Review of the Facility MDS (minimum data set) dated 10/8/12 revealed Resident #104 was cognitively intact for daily decision making skills, displayed no mood or behavior symptoms, was totally dependent on two person assistance from staff for transfers, toileting, and ADL's (activities of daily living). The MDS indicated Resident #104 was not steady or stable on his feet, had impairment with range of motion on both sides of his body, and was incontinent of both bowel and bladder. Review of the Nursing Care Plans dated 10/10/12 revealed Resident #104 was at "Risk for falls". Interventions included, "EZ stand for transfers with 2 person assist for support and guidance". Review of the Facility Resident Care Guide (care guide used by CNA staff) for Resident #104 revealed transfer orders: 2 person assist EZ Stand. Review of the Facility Nursing Department Safety Re-assessment dated [DATE] Intervention/Modification of Safety Plan: low bed, bilateral floor mats, bed alarm, EZ stand for transfers. Review of the Facility Incident Report dated 12/11/12 written by Licensed Practical Nurse (LPN) #4 at 6:15 AM revealed 2 CNA's transferred Resident #104 and did not use the sit to stand up lift. During an interview on 12/12/12 at 1:15 PM, Resident #104 stated "they didn't use the sit to stand, they just didn't wait for me to move, she pushed me into the chair, it made my foot bleed, lots of times they don't use it". During the first interview on 12/12/12 at 1:05 PM, Certified Nurse Assistant (CNA) #3 stated that 2 people were needed to transfer Resident #104 and the sit to stand transfer device was used. "he had been complaining of his foot hurting on midnights. When I got him into the shower chair we got into the hallway it started bleeding like a cut I don't know what happened". The sit to stand device used in the transfer was observed on 12/12/12 at 2:30 PM to have a platform where the resident places their feet with an edge of approximately 1/4 inch high with smooth edge. Resident #104's bed frame rail had no sharp edges and no screws, attachments and was painted with a smooth surface. The shower chair had smooth plastic tubing with no rough surfaces. During a telephone interview on 12/13/12 at 11:15 AM, LPN #4 reported the sit to stand was not used during the transfer for Resident #104 "it was down the hallway way down the hallway, I saw 2 CNA's in the room at 6:15 AM getting him into the shower chair there was absolutely no sit to stand lift in that room. When (CNA #3) came and told me he was bleeding from his left foot I asked her how she transferred him and she told me she had used the lift and I told her no she didn't. They did use one after the shower to transfer him back". During a second interview on 12/13/12 at 1:45 PM when asked about the conflicting information, CNA #3 stated that the shower chair was used during the transfer of Resident #104. This surveyor was informed by DON (Director of Nurses) #2 on 12/12/12 that CNA B (not currently employed at the facility) was also present in the room was called by herself (DON #2) and CNA B admitted that the sit to stand was not used and that she held the shower chair while CNA #3 lifted the resident and placed him in the shower chair and that is when his foot began bleeding. CNA #3 was suspended on 12/13/12 and employment was terminated on 12/14/12. ( ) Resident #105 Resident #105 was admitted to the facility 1/28/2008 and according to the Facility Physician History and Physical dated 10/12 with a medical history of [REDACTED]. Review of the Facility MDS dated [DATE] revealed Resident #105 was cognitively intact for daily decision making skills, displayed no behaviors or mood disturbances, was totally dependent on two person assistance with all activities of daily living, feeding, bathing and transfers. The MDS indicated Resident #105 was mobile in an electric wheelchair using puff technology (blows air into tube) and a chin joystick. During an observation and interview on 12/17/12 at 1:15 PM, with Resident #105 in his room, he stated on 12/9/12 at 4:15 PM he was being transferred from his wheelchair back to bed with 2 CNA's who were using using the total lift (Hoyer lift). Resident #105 stated he was hooked up and the CNA's should have "made sure my head, shoulders and butt were completely inside the sling. One CNA (#9) did but CNA B didn't pay attention on my right side. I am dead weight. They lifted me up, I was not securely seated in the sling and started going to my right and out. I went falling backwards onto the floor and had to get 8 staples in my head". Resident #105 was observed to have 8 staples with dried dark crust on the right side of his head to the back of the head. During an interview on 12/17/12 at 5 PM, CNA #9 stated that she had asked staff CNA B to assist in getting Resident #105 back to bed. "He lays down at around 4 PM, I had checked my side to make sure it was under his shoulder, butt, and head. I hooked the straps onto the hooks, CNA B did not pull the sling and make sure it was secured underneath him on her side, so half of his body was not in the sling, when she pushed the button to raise him up I was guiding his legs. He leaned forward and to the right backwards from the sling and fell on to the floor. I called the nurse who gave him first aid and he had to go to the ER and got staples. I was very upset". Review of the Medical Record Resident #105 was sent to the emergency roiagnom on [DATE] for evaluation and treatment with no other injuries found, 8 staples were required to close the 4 cm laceration. ( ) B.) Based on observation, interview and record review the facility failed to ensure alarms were functioning in 1 of 6 sampled residents (#106), from a total sample of 6 residents, resulting in the potential for injury. Findings include: Resident #106 Resident #106 was admitted to the facility on [DATE] and, according to the [DIAGNOSES REDACTED]. Resident #106 was observed on 12/17/12 at 11:32 AM sitting in the hallway in a wheelchair with a alarmed seatbelt. When this surveyor approached Resident #106 it was observed the alarm control box to alert staff that the safety belt has been disconnected was turned in the "OFF" position. When the connection cable was removed from the control box the alarm did not ring nor did the alarm sound when the safety seat belt was disconnected. Staff LPN #6 was unable to determine the cause of the non functioning alarm box. A new battery was placed in the control box and the alarm still did not sound. Staff LPN #6 was asked at 11:45 AM the process for checking safety alarms. LPN #6 stated "it's everyone's responsibility to check the alarms". Review of the MAR (medication administration record) revealed documentation that the equipment was checked on 12/16/12 at 5:27 AM, 8:09 AM, 11:51 AM and 12/17 at 2:15 AM. LPN #6 stated she had not checked the alarms up to the present time. LPN #6 stated that Resident #106 had the alarmed seat belt because he was a fall risk, had poor safety awareness and fall history. Review of Physician orders dated 11/12 revealed Resident #106 had orders for "alarmed seatbelt on wheelchair" for "decreased safety awareness". Review of the Facility Nursing Care Plan dated 9/25/12 titled "risk for falls" has history of falls, decreased safety awareness, cognitive impairment, falls risk score 15. Intervention # 6 "staff to ensure proper use of assistive devices", # 17 Implement all safety interventions appropriate; alarmed seatbelt. Care Plan titled "alternation in cognition and communication: "patient is non-verbal and cannot make own needs known requires all needs to be anticipated by staff, only grunts when spoken too". Review of the Facility Safety assessment dated [DATE] the alarmed seatbelt was added on 1/20/12 Facility Occupational Therapy note dated 1/20/12 "resident brought to gym by nurse secondary to client sliding under lap tray out of wheelchair, lap tray discontinued and seat belt with alarm placed on wheelchair, nurse notified of direct supervision for resident in wheelchair". This surveyor was notified at 2:10 PM on 12/17/12 that the alarmed seat belt was defective and had been replaced. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE TIMELY INTERVENTIONS TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS FOR ONE (#431) OF NINE SAMPLED RESIDENTS REVIEWED FOR PRESSURE ULCERS OUT OF A TOTAL OF 20 SAMPLED RESIDENTS, AND WHO ENTERED THE FACILITY WITHOUT PRESSURE ULCERS, RESULTING IN THE DEVELOPMENT OF THREE FACILITY ACQUIRED PRESSURE ULCERS, PAIN AND WOUND COMPLICATIONS. FINDING INCLUDE: ON 11/9/11 AT 9:00 A.M., RESIDENT #431'S WOUNDS WERE OBSERVED WITH THE WOUND CARE NURSE. OBSERVATIONS REVEALED A RIGHT BUTTOCK WOUND WITH MEASUREMENTS OF 4.58 CENTIMETERS (CM) BY 5.8 CM WITH A PINK BASE, LIGHT YELLOW SLOUGH AND MODERATE SEROUS DRAINAGE. THE RESIDENT'S BILATERAL ANKLES WERE DRY AND INTACT. WHEN QUERIED IF THE WOUND WAS PAINFUL, RESIDENT #431 STATED, "IT'S ABOUT THE SAME" AND MADE NO FURTHER COMMENT. ON 11/10/11 AT 9:05 A.M., RESIDENT #431 WAS AGAIN QUERIED WITH NO FACILITY STAFF PRESENT. RESIDENT #431 STATED "THE NIGHT I GOT THE BEDSORE, THE STAFF LEFT ME ON THE BEDPAN AFTER GIVING ME AN ENEMA. THEY DIDN'T COME AND CHECK ON ME FOR OVER A HOUR AND A HALF. THIS WAS TWO IN THE MORNING. I SAT IN STOOL AND WETNESS ALL OF THAT TIME." RESIDENT #431 CONTINUED TO STATE "IF I SIT UP TOO LONG, IT HURTS...I'M HAVING PROBLEMS WITH MY REHAB (PHYSICAL THERAPY PROGRAM) BECAUSE I NEED TO SIT...I NEED MY THERAPY WITH MY [MEDICAL CONDITION] AND SPINE CONDITION. TURNING IN CERTAIN POSITIONS ALREADY HURTS MY BACK; NOW IT HURTS MY BUTT. I'M EVEN AFRAID TO GET UP AND GO TO THE ACTIVITIES BECAUSE I WOULD HAVE TO SIT IN A CHAIR. THEY REALLY DID ME IN." THE ADMISSION FACE SHEET RECORD FOR RESIDENT #431 DOCUMENTED AN admission date of [DATE],WITH [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #431'S NURSING ADMISSION ASSESSMENT AND NURSING NOTES, BOTH DATED 10/7/11, DOCUMENTED RESIDENT #431 WAS admitted on [DATE] TO THE FACILITY WITH NO SKIN BREAKDOWN. THE FACILITY "ADMISSION PRESSURE ULCER ASSESSMENT/PREVENTION AND MANAGEMENT TOOL" DATED 10/10/11 FOR RESIDENT #431 DOCUMENTED THE RESIDENT'S BUTTOCK AS "PINK" AND BILATERAL HEELS, AS "SOFT." A CLINICAL LABORATORY REPORT DATED 10/10/11, DOCUMENTED RESIDENT #431 HAD A LOW TOTAL PROTEIN OF 5.5 (THE DESIRED RANGE FOR OPTIMAL WOUND HEALING IS 6.4-8.3 PER THE FACILITY'S LABORATORY) AND A LOW [MEDICATION NAME] OF 3.3 (THE DESIRED RANGE IS GREATER THAN 3.3 BUT LOWER THAN 4.9). THE ADMISSION MINIMUM DATA SET ((MDS) dated [DATE], DOCUMENTED RESIDENT #431 AS TOTALLY ALERT AND ORIENTED AND REQUIRED TOTAL ASSISTANCE FROM STAFF WITH TRANSFERS, DRESSING AND PHYSICAL HYGIENE. THE FACILITY'S Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. BY THE 7 P.M.-7 A.M. NURSE. THE FACILITY'S "PATIENT INCIDENT REPORT " DATED 10/11/11 2:00 A.M. FOR RESIDENT #431, DOCUMENTED "STAFF OBSERVED BLISTER SIZE OF A GOLF BALL ON COCCYX/BUTTOCKS AREA." DOCUMENTED THE CORRECTIVE ACTION AS "PATIENT INCLUDED IN TURNING AND REPOSITIONING SCHEDULE CARE PLAN UPDATED." THE FOLLOWING physician's orders [REDACTED]. 1. 10/11/11 "COCCYX BLISTER-LOG IN FOR WOUND CARE NURSE" 2. 10/12/11 LOW AIR LOSS MATTRESS AND WOUND CARE CONSULT 3. 10/12/11 NUTRITION CONSULT THE WOUND CARE CONSULT, DATED 10/12/11, DOCUMENTED "ABLE TO MAKE NEEDS KNOWN...NEW PRESSURE ULCER...LABS REVIEWED, MILD [MEDICATION NAME] (LOW [MEDICATION NAME]) AND TOTAL PROTEIN-STAGE THREE PRESSURE ULCER RIGHT BUTTOCK, ESCHAR." THE DIETARY CONSULT DATED 10/18/11 DOCUMENTED "MICRONUTRIENTS ADJUSTED SECONDARY TO STAGE THREE RIGHT BUTTOCK ESCHAR RIGHT FOOT." RESIDENT #431'S WOUND CARE LOGS DOCUMENTED THE DATE OF 10/17/11 AS THE FIRST WOUND CONSULT VISIT. THE WOUNDS MEASUREMENTS ARE AS FOLLOWING: 10/17/11 BUTTOCK 5.0 CM BY 5.4 CM YELLOW BASE IRREGULAR EDGES, MODERATE SEROSANGUINOUS DRAINAGE, PAIN ON PALPATION OF PERIWOUND. RIGHT POSTERIOR ANKLE 6.0 CM BY 1.0 CM (THREE WOUNDS WITH DRY DISCOLORED BASE). LEFT POSTERIOR ANKLE 4.5 CM BY 3.0 CM MULTIPLE DRY BASES. 10/21/11 RIGHT BUTTOCK 5.5 CM BY 7.5 CM, NECROTIC BASE WITH HEAVY SEROUS DRAINAGE. 10/24/11 RIGHT BUTTOCK 5.4 CM BY 6.6 CM, PINK BASE, NECROTIC MIDCORE, HEAVY SEROSANGUINOUS DRAINAGE. LEFT POST ANKLE 0.6 CM BY 0.4 CM DRY BASE. RIGHT POSTERIOR ANKLE 3.0 CM BY 0.8 CM DRY BASE. 10/31/11 RIGHT BUTTOCK 5.4 CM BY 6.0 CM NECROTIC SEROSANGUINOUS DRAINAGE. RIGHT POSTERIOR ANKLE 3.0 CM BY 0.8 CM DRY. LEFT POSTERIOR ANKLE IS RESOLVED. 11/7/11 RIGHT BUTTOCK 4.8 CM BY 5.8 CM PINK BASES, LIGHT YELLOW NECROTIC MIDCORE, MODERATE SEROUS DRAINAGE. RIGHT POSTERIOR ANKLE RESOLVED. THE BRADEN SCALE (A TOOL USED TO PREDICT PRESSURE SORE RISK) DOCUMENTED RESIDENT # 431 AS A MILD RISK ON 10/7/11 (ADMISSION) AND MODERATE RISK 10/20/11 AFTER THE PRESENCE OF THE BUTTOCK AND HEEL ULCERS. THE ADMISSION SKIN INTEGRITY CARE PLAN FOR RESIDENT #431 DATED 10/10/11, DID NOT INCLUDE "PRESSURE REDUCTION MATTRESS." A "PRESSURE REDUCTION MATTRESS" WAS DOCUMENTED IN ANOTHER SKIN CARE PLAN FOR RESIDENT #431 ON 10/12/11 AFTER THE DEVELOPMENT OF THE BUTTOCK PRESSURE ULCER. "FLOAT HEELS AS TOLERATED WHILE IN BED" WAS ALSO DOCUMENTED ON THE 10/12/11 CARE PLAN. ON 11/10/11 AT 9:45 A.M., THE DIRECTOR OF NURSING (DON), THE ADMINISTRATOR AND STAFF "G" WERE QUERIED REGARDING THE DEVELOPMENT OF THE PRESSURE ULCERS FOR RESIDENT #431. THE DON STATED "THE BUTTOCK WOUND STARTED AS A BLISTER ON 10/11/11. THE RESIDENT HAS A CARE PLAN FOR NON COMPLIANCE." WHEN QUERIED WAS THE STAFF AWARE OF RESIDENT #431'S HISTORY OF BACK PAIN AND POSITIONAL CHANGE PAIN, NO VERBAL EXPLANATION WAS OFFERED. THE CARE PLAN FOR NON COMPLIANCE DID NOT IDENTIFY OR ADDRESS THE RESIDENT'S HISTORY OF BACK PAIN OR POSITIONAL CHANGE PAIN. ON 11/10/11 AT 9:50 A.M., THE WOUND CARE NURSE WAS QUERIED REGARDING THE DEVELOPMENT OF RESIDENT #431'S PRESSURE ULCERS. THE WOUND CARE NURSE STATED RESIDENT #431 "WAS admitted on [DATE] WITH NO SKIN BREAKDOWN AND THE BUTTOCK WOUND WAS FOUND ON 10/11/11." THE WOUND CARE NURSE STATED RESIDENT #431 WAS ALSO admitted WITH LOW PROTEIN STORES. WHEN QUERIED WHY AN ALTERNATING PRESSURE MATTRESS WAS NOT ORDERED ON ADMISSION FOR A RESIDENT WITH "LOW PROTEIN STORES", SPINAL COMPROMISE AND [MEDICAL CONDITION], EVEN THOUGH THEY MIGHT HAVE HAD A BRADEN SCORE OF MILD RISK, THE WOUND CARE NURSE COULD NOT EXPLAIN. THE WOUND CARE NURSE STATED "THE DAY THE BLISTER WAS FOUND , I WAS NOT IN THE FACILITY. HOWEVER, I GOT RIGHT ON IT (THE WOUND) THE NEXT DAY. IT IS LOOKING BETTER NOW." WHEN QUERIED WHY PREVENTATIVE MEASURES WERE NOT INITIATED WHEN THE FACILITY "ADMISSION PRESSURE ULCER ASSESSMENT/PREVENTION AND MANAGEMENT TOOL" DATED 10/10/11 FOR RESIDENT #431 DOCUMENTED THE RESIDENT'S BUTTOCK AS "PINK" AND BILATERAL HEELS, AS "SOFT," THE WOUND CARE NURSE OFFERED NO EXPLANATION. REVIEW OF THE FACILITY'S POLICY TITLED "SKIN CARE PROTOCOL: PRESSURE ULCER TREATMENT" UNDATED, DOCUMENTED "PREVENTATIVE MEASURES TO BE INCORPORATED IN POTENTIAL/ACTUAL SKIN IMPAIRMENT: USE PRESSURE RELIEVING MATTRESS/THERAPEUTIC MATTRESS. NUTRITIONAL SCREENING IS COMPLETED WITHIN 72 HOURS OF ADMISSION. MAINTAIN/IMPROVE PATIENT'S CURRENT ACTIVITY LEVEL, MOBILITY, AND RANGE OF MOTION. PRESSURE REDUCING MEASURES WILL BE FOLLOWED ACCORDING TO PATIENT'S ACTIVITY LEVEL. KEEP HEELS OFF BED SURFACE." ( )

THIS CITATION PERTAINS TO INTAKE NUMBER (S): MI 308, MI 751 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND CARE TO ENSURE THAT TWO (#501, #502) OF THREE RESIDENTS REVIEWED FOR FALLS, WAS FREE FROM FALLS, FROM A TOTAL OF THREE SAMPLED RESIDENTS, RESULTING IN FALLS WITH FRACTURE. FINDINGS INCLUDE: RESIDENT #501: ON 7/20/11 AT 12:02 P.M., RESIDENT #501 WAS OBSERVED SEATED IN THE HALL. A STAFF MEMBER WHEELED HER INTO THE 2ND FLOOR DINING ROOM. WHEN ASKED ABOUT HER RIGHT LEG, RESIDENT #501 SAID "...I CAN'T REMEMBER WHAT HAPPENED. I KNOW I fell . IT HURTS..." ON 7/20/11 AT 12:22 P.M., RESIDENT #501 WAS OBSERVED IN THE DINING ROOM EATING LUNCH. RESIDENT #501 WAS FEEDING HERSELF. ONE STAFF MEMBER WAS PRESENT, SEATED AT A DIFFERENT TABLE AND WAS OBSERVED ASSISTING ANOTHER RESIDENT WITH FEEDING. ACCORDING TO THE FACILITY'S ADMISSION RECORD, RESIDENT #501 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #501 WAS REadmitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THAT RESIDENT #501 HAD SEVERELY IMPAIRED COGNITION IN DECISION MAKING, LONG AND SHORT TERM MEMORY PROBLEMS AND REQUIRED LIMITED TO EXTENSIVE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, LOCOMOTION ON AND OFF THE UNIT, PERSONAL HYGIENE, BATHING AND TOILETING. THE MDS FURTHER INDICATED THAT RESIDENT #501 HAD AN UNSTEADY GAIT AND RELIED ON A WHEELCHAIR FOR MOBILITY. ACCORDING TO THE CARE AREA ASSESSMENT (CAA), "...RESIDENT (#501) HAS DISORGANIZED THOUGHTS AND SPEECH. RESIDENT IS INATTENTIVE DECISION MAKING SKILLS AND POOR SAFETY AWARENESS. RESIDENT IS A WONDER/ELOPEMENT RISK THEREFORE REQUIRES 24/7 CARE AND SUPERVISION AND IS ON THE WANDERGARD (CLOSE MONITORING) PROGRAM. RESIDENT IS AT RISK FOR FALLS DUE TO A HISTORY OF FALLS AND POOR SAFETY AWARENESS..." ACCORDING TO RESIDENT #501'S "FALL RISK ASSESSMENT" DATED 5/17/11, RESIDENT #501 HAD A FALL RISK SCORE OF 17. "TOTAL SCORE ABOVE 10 REPRESENTS HIGH RISK". A REVIEW OF THE FACILITY'S INCIDENT AND ACCIDENT INVESTIGATION FORM DATED 6/27/11 REVEALED THAT ON 6/27/11 AT 10:30 P.M., "...RESIDENT SITTING IN WHEELCHAIR, LEANED OVER TO PICK UP SOMETHING FROM FLOOR AND fell TO FLOOR. CNA (CERTIFIED NURSING ASSISTANT) UNABLE TO PREVENT FALL..." A REVIEW OF THE FACILITY'S SUMMARY OF EVENTS (UNDATED) REVEALED "...RESIDENT #501 WAS OBSERVED ON THE FLOOR IN ONE SOUTH DINING ROOM AND HER CNA (CNA #2) WAS ALSO IN DINING ROOM WHEN INCIDENT OCCURRED. CNA #2 STATED RESIDENT #501 WAS AGITATED THROUGHOUT HER SHIFT AND WHEN THIS OCCURS, SHE (#501) WILL NOT ALL OW THE STAFF TO PLACE HER IN BED. ACCORDING TO CNA #2, RESIDENT #501 WAS UP IN HER WHEELCHAIR IN THE DINING ROOM WAITING FOR A SHOWER. ALL OF A SUDDEN, RESIDENT #501 LEANED OVER TO PICK SOMETHING UP OFF THE FLOOR AND fell OUT OF HER WHEELCHAIR..." THE SUMMARY OF EVENTS FURTHER REVEALED "...LATER THAT DAY THE NURSE OBSERVED SLIGHT SWELLING TO THE RIGHT LEG. THE NURSE INFORMED THE PHYSICIAN, WHO ORDERED A STAT X-RAY OF THE RIGHT LOWER EXTREMITY ON 627/11. X-RAY RESULTS CAME BACK ON 6/28/11 AND THE REPORT INDICATED A FRACTURE. THE RESIDENT (#501) WAS SENT TO A NEARBY HOSPITAL..." A REVIEW OF RESIDENT #501'S X-RAY REPORT DATED 6/28/11 REVEALED "...FOUR VIEWS OF THE RIGHT HIP AND RIGHT FEMUR/PAIN, IMPRESSION: ACUTE IMPACTED ANGULATED RIGHT FEMORAL INTERTROCHANTERIC FRACTURE WITH NO DISLOCATION..." ON 7/20/11 AT 1:29 P.M., DURING AN INTERVIEW, CNA #2 REPORTED "...SOMETIMES SHE (#501) GETS REAL IRRITATED. I HAD HER UP AND I WAS GOING TO GIVE HER A SHOWER TO HELP HER CALM DOWN BUT SHE DIDN'T WANT HER SHOWER. THIS WAS BETWEEN 8:30 P.M. AND 9:00 P.M. AFTER THAT, I TOOK HER TO THE DINING ROOM BECAUSE SHE WAS STILL AGITATED AND DIDN'T WANT TO SLEEP. I GOT A PAGE AND I LEFT TO ANSWER MY PAGE. MY BACK WAS TO HER. TWO OTHER CNAS SAW HER TRYING TO STAND UP. CNA #5 YELLED OUT BUT SHE (#501) HAD FALLEN ALREADY..." WHEN QUERIED ABOUT THE PAGE SHE HAD RECEIVED, CNA #2 SAID"...I HAD ORDERED SOME FOOD SO I GOT A PAGE TELLING ME MY FOOD WAS HERE. I LEFT THE DINING ROOM TO GO ANSWER THE PAGE AND TO PAY FOR MY FOOD. WHEN I CAME BACK, I TURNED MY BACK TO HER (#501) FOR A FEW MINUTES TO SIT THE FOOD DOWN..." WHEN ASKED IF RESIDENT #501 WAS ABLE TO WALK, CNA #2 SAID "...I'VE NEVER SEEN HER WALK. SHE WILL TRY TO GET UP AND WALK THOUGH, OR SELF TRANSFER AND SHE'S NOT SUPPOSE TO DO THAT. WE ALWAYS HAVE TO REDIRECT HER..." CNA #2 FURTHER REPORTED "...AFTER SHE (#501) fell , I PICKED HER UP AND PUT HER BACK IN HER WHEELCHAIR WHEN I WASN'T SUPPOSE TO..." ON 7/20/11 AT 2:52 P.M., DURING AN INTERVIEW, LPN #1 REPORTED "...SHE (#501) IS ALERT TO PERSON ONLY. SHE CAN'T WALK DUE TO ARTHRITIS AND DEBILITY. I WAS THE NURSE ON DUTY THE EVENING SHE fell . CNA #2 CAME TO ME AND SAID SHE (#501) fell . CNA #2 PUT HER BACK IN THE WHEELCHAIR. THEY TOLD ME SHE (#501) WAS LEANING FORWARD AND fell TO HER RIGHT SIDE. SHE APPEARED TO BE FINE. I CALLED THE DOCTOR AND THE FAMILY THAT EVENING. SHE (#501) WENT TO THE HOSPITAL THE NEXT MORNING..." ON 7/20/11 AT 3:55 P.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED ABOUT RESIDENT #501'S FALL AND REPORTED, "...CNA #2 TOLD ME SHE WAS IN THE DINING ROOM WITH THE RESIDENT (#501) BECAUSE THE RESIDENT WAS AGITATED. SHE (CNA #2) GOT AN OVERHEAD PAGE AND LEFT THE DINING ROOM. . .CNA #2 HAD HER BACK TURNED AWAY FROM THE RESIDENT AND SHE (#501) fell . CNA #2 WENT TO GET THE NURSE..." THE DON WAS UNABLE TO EXPLAIN WHY CNA #2 TURNED HER BACK TO RESIDENT #501 IN LIGHT OF HER REPORTED AGITATION. ON 7/21/11 AT 10:15 A.M., AN INTERVIEW WAS CONDUCTED WITH CNA #5 WHO REPORTED, "...I WAS IN THE DAY ROOM (DINING ROOM). I'D JUST WALKED IN. I HAD ORDERED SOME FOOD AND CNA #2 WAS IN THE DOOR WAY OF THE DAY ROOM AND SHE CALLED ME TO COME AND GET MY FOOD, BUT I ALREADY HAD MY FOOD SO I BROUGHT IT BACK TO THE DAY ROOM. THE RESIDENT (#501) WAS IN THE DAY ROOM SCOOTING AROUND IN HER WHEELCHAIR. SHE WAS A LITTLE BUSY THAT NIGHT. SHE'S CONFUSED. ME (CNA#5), CNA #2 AND ANOTHER CNA WERE IN THE DAY ROOM. I WAS SITTING AT THE TABLE FACING THE WALL. RESIDENT #501 WAS SEATED AT THE LONG TABLE AWAY FROM US. I WAS GETTING READY TO GET UP AND I SAW HER (#501) AND SHE WAS GOING DOWN. SHE fell on HER RIGHT SIDE..." WHEN QUERIED ABOUT CNA #2'S WHEREABOUTS AT THE TIME OF RESIDENT #501'S FALL, CNA #5 SAID "...SHE WAS SITTING AT THE TABLE WITH ME FACING THE WALL. I WAS FACING THE WALL DOING MY PAPERWORK AND SHE (CNA #2) WAS AT THE SAME TABLE WITH HER FOOD. SHE (CNA#2) WAS ORGANIZING THE FOOD SO SHE COULD GIVE THE NURSE HER FOOD THAT SHE HAD ORDERED. SHE (CNA #2) WAS FACING AWAY FROM THE RESIDENT..." WHEN ASKED WHERE THE OTHER CNA, WHO WAS PRESENT IN THE DINING ROOM ON THE EVENING OF 6/27/11, WAS SEATED, CNA #5 SAID, SHE WAS SITTING AT ANOTHER TABLE WATCHING TV (TELEVISION). SHE WASN'T WATCHING THE RESIDENT..." ON 7/21/11 AT 5:15 P.M., DURING A SUBSEQUENT INTERVIEW AND DISCUSSION OF RESIDENT #501'S HISTORY OF MULTIPLE FALLS, THE DON SAID "...SHE HAS SO MANY FALLS BECAUSE OF HER AGITATION..." RESIDENT #502 ACCORDING TO THE FACILITY'S ADMISSION RECORD, RESIDENT #502 WAS ORIGINALLY admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #502 WAS REadmitted to the facility on [DATE] WITH A [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THAT RESIDENT #502 HAD SEVERELY IMPAIRED COGNITION FOR DECISION MAKING, LONG TERM AND SHORT TERM MEMORY PROBLEMS AND WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADLS). A REVIEW OF RESIDENT #502'S ADMISSION HISTORY AND PHYSICAL DATED 2/19/10 REVEALED THAT RESIDENT #502 WAS admitted UNDER HOSPICE CARE, HAD ADVANCED DEMENTIA, WAS UNABLE TO FOLLOW COMMANDS AND HAD BEEN PRESCRIBED ATIVAN (USED TO TREAT ANXIETY DISORDERS) 0.5 MG (MILLIGRAMS), ONE TABLET EVERY FOUR HOURS AS NEEDED FOR FOR AGITATION. A REVIEW OF RESIDENT #502'S RE-ADMISSION HISTORY AND PHYSICAL DATED 6/3/11 REVEALED "...ADVANCED DEMENTIA WITH BEHAVIORAL SYMPTOMS. CONTINUE SUPPORTIVE CARE. LORAZEPAM (ATIVAN) FOR AGITATION. CONSIDER PSYCH (PSYCHIATRIC) EVAL (EVALUATION)..." A REVIEW OF RESIDENT #501'S FALL RISK ASSESSMENT FOR AUGUST 2010 AND JUNE 2011 REVEALED "...INTERMITTENT CONFUSION OR NON COMPLIANT WITH SAFETY INSTRUCTIONS..." RESIDENT #501'S FALL RISK SCORE ON 2/23/11 WAS 13 WHICH REPRESENTED HIGH RISK FOR FALLS. A REVIEW OF THE FACILITY'S "PATIENT INCIDENT REPORT" DATED 5/28/11 REVEALED "...CNA WAS TURNING PT (PATIENT) ON SIDE TO CLEAN PATIENT UP. CNA STATED PATIENT PUT HER LEGS OVER THE EDGE OF THE BED AND SLID. CNA GUIDED PATIENT TO FLOOR. CNA INSTRUCTED TO TURN PATIENT USING 2-PERSON ASSIST..." A REVIEW OF RESIDENT #502'S X-RAY REPORT DATED 5/28/11 REVEALED "...RIGHT KNEE PAIN AND SWELLING. IMPRESSION: SOFT TISSUE SWELLING AND JOINT EFFUSION WITH DISPLACED FRACTURE OF THE DISTAL FEMORAL SHAFT..." A REVIEW OF THE FACILITY'S SUMMARY OF EVENTS (UNDATED), REVEALED "...RESIDENT #502, A [AGE] year OLD FEMALE, WITH A [DIAGNOSES REDACTED]. IT IS CONCLUDED THAT RESIDENT #502 BECAME AGITATED AND BEGAN KICKING AND FLAILING, SHE SUSTAINED A DISPLACED FRACTURE..." ON 7/20/11 AT 2:08 P.M., DURING AN INTERVIEW, CNA #3 REPORTED "...CNA #6 ASKED FOR ASSISTANCE GETTING RESIDENT IN BED FROM HER WHEELCHAIR. SHE'S A 2-PERSON ASSIST. I ASSISTED HER AND WE USED THE HOYER LIFT (BRAND NAME PATIENT LIFT DEVICE) TO PUT HER IN BED. WHEN WE GOT HER IN BED, WE ROLLED HER BACK AND FORTH TO REMOVE THE SLING FROM UNDER HER. WHEN SHE (#502) WAS TURNED TOWARD CNA #6, SHE YELLED OUT, MY LEG, MY LEG. I ASKED CNA #6, WHAT DID YOU DO AND WHY IS SHE YELLING? SHE (CNA #6) SAID, I THINK I DROPPED HER THIS MORNING." CNA #3 FURTHER REPORTED "...I LAID HER (#502) BACK DOWN ON HER BACK AND SHE WAS STILL YELLING, MY LEG MY LEG, SO I TOLD HER (CNA #6) TO TELL THE NURSE..." ON 7/20/11 AT 3:13 P.M., DURING AN INTERVIEW, CNA #4 REPORTED "...CNA #6 ASKED ME FOR HELP AND SAID THAT RESIDENT #502 WAS ON THE FLOOR. I INSTRUCTED HER TO GO AND TELL THE NURSE. SHE (CNA #6) GOT THE NURSE AND I MET THEM IN THE HALLWAY. WE ALL WALKED INTO THE ROOM TOGETHER. RESIDENT #502 WAS ON THE FLOOR AND HER HEAD WAS NEAR THE FOOT OF THE BED. I UNLOCKED THE BED SO WE COULD GET TO HER AND ME AND CNA #6 PICKED HER UP AND PUT HER IN THE BED. WE COULDN'T EVEN OPEN THE DOOR TO THE ROOM BECAUSE HER HEAD WAS IN THE WAY. I WENT THROUGH ANOTHER ROOM AND THROUGH THE ADJOINING BATHROOM TO GET INTO HER ROOM..." ON 7/20/11 AT 4:54 P.M., WHEN QUERIED ABOUT RESIDENT #502'S FALL AND FRACTURE, THE DON SAID "SHE (CNA #6) WAS PROVIDING PERI-CARE. THE RESIDENT HAS A BEHAVIORAL [DIAGNOSES REDACTED]. THE RESIDENT (#502) STARTED KICKING HER LEGS DURING CARE AND HOLDING ON TO THE ASSIST BARS. SHE (CNA #6) TOLD ME SHE REPORTED IT TO THE NURSE..." ON 7/21/11 AT 9:50 A.M., DURING A SUBSEQUENT INTERVIEW, THE DON REPORTED, "...BEFORE THE INCIDENT, I BELIEVE THE NURSES ASSESSED HER (#502) AS A ONE PERSON ASSIST BUT KNOWING SHE BECOMES AGITATED AND FLAILS HER ARMS, I WOULD HAVE MADE HER A 2-PERSON ASSIST FROM THE BEGINNING. THE CARE PLANS HAVE SINCE BEEN UPDATED TO REFLECT 2-PERSON ASSIST..." ON 7/21/11 AT 11:09 A.M., DURING AN INTERVIEW WITH CNA #6, SHE REPORTED "...I HAD AN HOUR TO TAKE CARE OF HER. SHE (#502) LIKED TO FIGHT AND EVERYTHING. SHE RESISTS CARE AND CAN'T RESPOND TO THINGS LIKE YOU AND I...SHE ALSO BITES THE RAG WHEN YOU TRY TO CLEAN HER FACE. SHE WILL FIGHT YOU..." CNA #6 FURTHER REPORTED "...SHE HAD A LARGE BOWEL MOVEMENT AND SHE WAS TOO FAR TOWARDS THE WINDOW SO I PULLED HER TOWARDS ME AND I TURNED HER TO HER LEFT TO CLEAN HER UP AND SHE STARTED KICKING HER FEET. SHE KICKED HER LEGS. I TURNED TO GET THE BRIEF FROM THE TABLE AND PUT IT UNDER HER AND SHE KICKED HER LEGS SOME MORE AND SLID HERSELF OFF THE BED. SHE WAS KICKING SOME MORE AND I GRABBED HER FROM BEHIND BECAUSE I HAD ROLLED HER AWAY FROM ME SO SHE WAS FACING AWAY FROM ME. SHE WAS HALFWAY ON THE BED AND HALFWAY OFF SO I WENT AROUND TO THE OTHER SIDE OF THE BED AND TRIED TO EASE HER DOWN TO THE FLOOR. I THOUGHT SHE HAD A CLEAN FALL BECAUSE SHE DIDN'T SCREAM..." WHEN ASKED IF SHE (CNA #6) ASKED FOR ASSISTANCE WHEN PROVIDING CARE FOR RESIDENT #502 IN LIGHT OF HER HISTORY OF AGGRESSIVE AND COMBATIVE BEHAVIOR, CNA #6 SAID "NO." CNA #6 WENT ON TO SAY, "...WHEN SHE (#502) WAS ON THE FLOOR, I COVERED HER AND LEFT TO GET SOMEONE TO HELP ME. WE USED A COVER AND BODY-LIFTED HER BACK INTO THE BED AND THE NURSE ASSESSED HER. HER (#502) FEET WERE UNDER THE BED AFTER SHE fell . HER HEAD WAS NEAR THE BOTTOM (FOOT) OF THE BED. SHE (#502) TURNED HER WHOLE BODY WHEN SHE fell . SHE WAS COMPLETELY TURNED AROUND." WHEN ASKED WHY THE RESIDENT WAS LEFT ALONE IN THE ROOM ON THE FLOOR AFTER HER FALL AND WHY SHE FAILED TO UTILIZE THE CALL LIGHT SYSTEM TO SUMMONS FOR HELP, CNA #6 OFFERED NO EXPLANATION. CNA #6 OFFERED NO EXPLANATION OF WHY SHE FAILED TO ASK FOR ASSISTANCE WHEN PROVIDING CARE FOR RESIDENT #502 IN LIGHT OF HER HISTORY OF COMBATIVE BEHAVIOR, WHY SHE (CNA #6) FAILED TO UTILIZE THE CALL LIGHT SYSTEM AND WHY SHE LEFT RESIDENT #502 ON THE FLOOR UNATTENDED WHILE SHE (CNA #6) SOUGHT HELP. ON 7/21/11 AT 2:19 P.M., DURING AN INTERVIEW, THE REHABILITATION (REHAB) DIRECTOR SAID "...SHE (#502) REQUIRED EXTENSIVE ASSISTANCE WITH ALL OF HER ADLS. SHE WAS CONFUSED AND UNCOOPERATIVE..." THE REHAB DIRECTOR FURTHER REPORTED "...IT WOULD BE A GOOD IDEA TO ALWAYS ROLL THE PATIENT TOWARDS THE CARE GIVER AND NOT AWAY FROM..." ON 7/21/11 AT 4:10 P.M., THE ASSISTANT DIRECTOR OF NURSING (ADON #1) STATED "...FOR TURNING, ROLLING AND REPOSITIONING, SHE IS A 2-PERSON ASSIST. SHE WAS ALWAYS A 2-PERSON ASSIST BECAUSE SHE WOULD KICK AND BECOME COMBATIVE..." THE ADON #1 FURTHER REPORTED "...WHENEVER SHE (#502) BECOMES AGITATED OR COMBATIVE, I TOLD THE CNAS TO REPORT IT TO THE NURSE AND LEAVE HER ALONE AND COME BACK LATER WHEN SHE'S CALM. I WAS INFORMED THAT THE CNA (CNA #6) ROLLED HER (#502) AWAY FROM HER AND SHE WAS KICKING HER LEGS AND THE WEIGHT OF HER LEGS TOOK HER DOWN. I (ADON #1) TOLD THE CNA THAT SHE SHOULD NEVER ROLL THE RESIDENT AWAY FROM HER..." A REVIEW OF THE FACILITY'S "COMMUNICATION FORM" (CNA CARE GUIDE USED TO INFORM CNAS OF RESIDENT'S NEEDS) REVEALED "...BEHAVIORS: COMBATIVE DURING CARE, 2-PERSON ASSIST FOR ADLS. TOTALLY DEPENDENT ON STAFF (2-PERSON ASSIST FOR PERSONAL HYGIENE AND TURNING. FAMILY REQUEST: IF PATIENT BECOMES COMBATIVE-RETURN AT A LATER TIME TO RENDER CARE AFTER SHE (#502) SETTLES DOWN. REPORT TO CHARGE NURSE..." ON 7/21/11 AT 5:00 P.M., AN INTERVIEW WAS CONDUCTED WITH THE DON REGARDING INTERVENTIONS THAT WERE IN PLACE DURING THE TIME OF RESIDENT #502'S FALL. WHEN ASKED IF RESIDENT #502 HAD MATS ON HER FLOOR TO LESSEN THE IMPACT IN THE EVENT OF A FALL, AND IN LIGHT OF RESIDENT #502'S HISTORY OF KICKING AND FLAILING HER ARMS, THE DON REPORTED "...NO, SHE DID NOT HAVE ANY MATS ON THE FLOOR..." ON 7/21/11 AT 5:17 P.M., DURING AN INTERVIEW, THE SOCIAL WORKER REPORTED "...SHE (#502) DOES HAVE A HISTORY OF YELLING OUT, RESTLESSNESS, KICKING, FLAILING AND AGITATION. I ALSO INTERVIEWED STAFF AND THEY INFORMED ME OF THE RESIDENT'S BEHAVIORS. SHE IS COMBATIVE AS WELL..." THE FACILITY'S ADMINISTRATIVE STAFF WAS UNABLE TO EXPLAIN WHY CNA #6 FAILED TO COMPLY WITH RESIDENT #502'S NEED FOR 2-PERSON ASSISTANCE DURING CARE IN ACCORDANCE WITH THE PLAN OF CARE IN ORDER TO PREVENT INJURY AND FALLS.

This citation pertains to intake MI 060. Based on observations, interviews and record reviews, the facility failed to provide supervision to prevent 1) falls for one resident ( Resident #101) of 24 residents who had bed alarms resulting in Immediate Jeopardy for Resident #101 who fell out of bed and sustained a spinal cord injury, quadriplegia (paralysis of all four limbs), intubation (insertion of a breathing tube), and hospitalization in the Intensive Care Unit (ICU), placing 24 other residents who had bed alarms at a high risk for harm, injury, and/or death, and 2) the elopement of two residents (Residents #102 and #103) of 33 residents identified to be at risk for elopement resulting in Immediate Jeopardy when Resident #102 eloped from the facility to a nearby parking lot in his manual wheelchair where he fell and sustained abrasions to both below-the-knee amputations, delaying his rehabilitation, and also the elopement of Resident #102 and #103 into the middle of an inner-city two-way street, placing 33 other residents identified to be at risk for elopement at high risk for serious harm, injury, or death. Findings include: Resident #101: The face sheet of the medical record revealed that Resident #101 was an [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] disclosed that Resident #101 had no short- or long-term memory deficits, was independent in decision making, understood others, was understood by others, and required extensive assistance with most activities of daily living (ADL's). The 8/19/10 falls care plan revealed that Resident #101 had a history of [REDACTED]. The total score on a "Falls Risk Assessment" dated 8/13/10 was 12. The assessment stated that a total score above 10 represented a high risk for falls. A facility "Communication Form" dated 8/13/10 disclosed the bed and chair alarms were to be checked for placement and function every shift and, if not working, notify maintenance immediately. A facility incident report dated 8/20/10 at 8:30 a.m. revealed that Resident #101 was discovered on the floor, face down, in her room. Nurses' notes dated 8/20/10 at 8:30 a.m. disclosed that a "code" (emergency) was called, the physician arrived and started an intravenous (IV) drip, 911 was called, a dressing was applied to Resident #101's head as she was bleeding, oxygen was administered, and Resident #101 was transferred, unresponsive, to a local hospital emergency department by 911 responders. The bleeding from Resident #101's head had stopped at the time of transfer. The "Hospital Emergency Department Report," dated 8/20/2010, disclosed that Resident #101 presented to the emergency room unresponsive to deep painful stimulus, hypotensive with blood pressure (BP) 77/44 (normal BP 120 /80), a 3 centimeter laceration to the center of her forehead, a Glasgow Coma Scale (scale used to assess level of consciousness) of 3 indicating deep unconsciousness, and she was not breathing. Resident #101 was intubated (tube place through the mouth and into the windpipe) and admitted to the Intensive Care Unit (ICU) in critical condition. Review of the Hospital Discharge Summary dated 9/3/10 revealed that Resident #101's discharge [DIAGNOSES REDACTED]. Resident #101 no longer resided in the facility at the time of the investigation. On 9/8/10 at 12:30 p.m. and on 9/20/10 at 12:15 p.m., Certified Nursing Assistant (CNA) # 3 said that Resident #101 was in bed when she first came on shift at 7:00 a.m. on 8/20/10, the day of Resident #101's incident. CNA #3 said that she did not have time to check the function of the bed alarm at that time and she did not know if Resident #101's call light was within reach. CNA #3 stated she was a couple rooms down from Resident #101's room and did not hear the alarm sounding before hearing the nurse page CNA's and nurses STAT (right away) to Resident #101's room on 8/20/10 at about 8:30 a.m. During the 9/8/10 interview, CNA #3 said the bed/chair alarm was not working. On 9/8/10 at 12:50 p.m. and on 9/21/10 at 11:00 a.m., Registered Nurse (RN) #4 said that on 8/20/10 about 8:30 a.m., she was across the hall from Resident #101's room. RN #4 said she heard a resident in the next room "yelling" for a nurse. RN #4 said that when she got to the resident that was yelling out, he pointed across the hall to Resident #101's room and said "look." RN #4 stated that the bed alarm was not sounding and she did not see the location of the call light. Resident #101 was observed prone (face down) on the floor with her head bleeding and her face towards her right shoulder. RN #4 could not recall the position of the bed but stated it wasn't close to the floor. On 9/20/10 at 10:05 a.m., CNA #11, who had cared for Resident #101 for three days in a row, reported that Resident #101 was a two-person pivot transfer with a gait belt since she was not steady on her feet. CNA #11 reported that Resident #101 always used the call light or would yell out "Help, I got to go to the bathroom," if she needed to get up, and that Resident #101 never got up by herself when CNA #11 cared for her. CNA #11 said the fall happened on a Friday and that it tended to get very busy on Fridays with residents leaving the facility for appointments and also with resident discharges. On 9/22/10 at 10:35 a.m., LPN #17 reported that Resident #101 was in bed with her eyes closed between 7:30 and 7:45 a.m. on 8/20/10 during initial rounds. LPN #17 stated that she was busy at the central nursing station and heard the overhead page for all nurses to report to Room 292. LPN #17 went to the room and said that Resident #101 did not respond to verbal, tactile or painful stimulation and the bed/chair alarm was not sounding. LPN #17 said she did not know much about Resident #101, as that was the first time she had cared for Resident #101. Observations by Surveyors # and # on 9/17/10 between 11:45 a.m. and 12:15 p.m. revealed 18 total residents with pressure sensitive alarms. 1. Unsampled Residents #129 and #147 pressure sensitive alarms were not working. 2. Resident #105"s pressure sensitive alarm did not sound because the battery case was not secure. Observations by Surveyor # on 9/20/10 at 10:00 a.m. revealed 9 residents in wheelchairs with pressure alarms in place. 1. Resident #110's alarm had the cord disconnected from the alarm box; therefore, the alarm did not sound. 2. Resident #111, unsampled Resident #135, and Resident #147's chair alarms were not turned on. Resident #102: According to the face sheet of the medical record, Resident #102 was a [AGE] year old man who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the "Patient Incident Report" dated 7/30/10 at 7:20 a.m., revealed that Resident #102 was observed outside in the parking lot of the closed hotel next to the facility. He was sitting on the ground with the wheelchair tipped forward. The "Fall Investigation Report" dated 7/30/10 disclosed Resident #102 said "he was stuck in a hole in the parking lot." The "Sign Out Sheet" for Resident #102 revealed that Resident #102 did not sign out on 7/30/10. On 9/17/10 at 9:01 a.m. Licensed Practical Nurse (LPN) #7 said she worked the day shift on 7/30/10 and she did not realize he was not in the facility at the time of his fall in the adjacent parking lot. The facility was not able to identify from which door Resident #102 had exited. In an interview on 9/17/10 at 8:45 a.m., Occupational Therapist (OT) #6 said that he entered the employee parking area, which was the parking lot of an closed hotel located next to the facility, at about 7:20 a.m. on 7/30/10. OT #6 emergently stopped his vehicle for Resident #102, who was self-propelling in his manual wheelchair through the parking lot and appeared to not notice OT #6's approaching vehicle. After OT #6 parked his vehicle in the lot, he looked back to where Resident #102 had been. OT #6 observed Resident #102 seated on the paved parking lot with his wheelchair tipped forward above him. OT #6 assisted Resident #102 back into his wheelchair and observed scrapes to both his below the knee amputation stumps. OT #6 reported that Resident #102 did not want to return to the facility but said he wanted to go to the store to get lottery tickets. OT #6 said Resident #102 continued to wheel himself, unattended, toward the gas station/store. OT #6 stated he clocked in and then informed Resident #102's nurse of the incident. Record review of the Social Worker's notes dated 7/28/10 (no time) disclosed that Resident #102 had expressed suicidal thoughts. According to the Social Worker's notes, Resident #102 said, "He has thoughts about wheeling himself into traffic on Telegraph Road." The notes also documented that Resident #102 had been asked not to leave the facility without a staff member in attendance and that the Social Worker informed the nurse assigned to Resident #102 and all department managers, the Director of Nursing (DON), and both Assistant Directors of Nursing (ADON) of the precaution put in place (to not leave the facility without a staff member) to protect Resident #102. In an interview on 9/20/10 at 11:50 a.m., the Social Worker said she did not hear that Resident #102 had eloped from the facility and fell in a nearby parking area. The Social Worker said that she was unable to follow up on the precaution that she had put in place on 7/28/10, which was that Resident #102 was not to leave the facility without a staff member. Record review of the facility "Leave of Absence" (LOA) Policy dated 3/9/10 reflected that a physician's order was required for a leisure LOA (not a physician appointment). Record review of the clinical records for Resident #102 revealed that there was no physician order in Resident #102's chart pertaining to LOA's. Record review of "Patient Progress Notes" (Nursing Notes) dated 7/30/10 at 7:30 a.m. documented that the nurse had been informed that Resident #102 had been found on the ground in the parking lot of the closed hotel next to the facility with his wheelchair tilted forward, that Resident #102 had been assisted back into his wheelchair, and had proceeded to the gas station/store. No notation of calling the supervisor was documented. On 9/17/10 at 9:07 a.m., LPN #7 could not find any documentation in the medical record that indicated that Resident #102 had a physician's order to go to the store/gas station on an LOA. LPN #7 checked the LOA sign out sheet for Resident #102, which verified he had not signed out. LPN #7 said she couldn't remember if she notified the supervisor about the incident. On 9/17/10 at 10:00 a.m., Resident #102's physician reported that it was not safe for Resident #102 to go to the store by himself. The physician reported that the LOA policy required an order from the physician for residents to leave the facility grounds. Review of the "Patient Incident Report" dated 7/30/10 at 7:20 a.m., documented that the corrective/remedial measure, LPN #7 who completed the report, did to avoid repetition of the incident was to inform Resident #102 that he was not to leave the building. LPN #7 did not place a Wander Guard bracelet (an alarm that sounds when the person wearing it approaches a door that is equipped with a Wander Guard alarm) on Resident #102. In an interview on 9/21/10 at 11:50 a.m., LPN #7 reported talking to Resident #102 on 7/30/10 about signing in/out before he left the facility. LPN #7 reported considering placing a Wander Guard on Resident #102 but did not because he was bi-polar (a disorder that manifests as periods of excitability (mania) alternating with periods of depression) and that he usually just sat in his room unless he was "hyper." Observation of the front door that lead outside to the front of the facility was conducted on 9/17/2010. The door alarm was shut of on a daily basis at 6:30 a.m. Resident #102 and Resident #103: Review of the face sheet of the medical record disclosed that Resident #103 was a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) dated ,[DATE]//10 revealed that Resident #103 had short- and long-term memory impairment with moderately impaired decision-making skills, persistent indicators of anger with self or others, and that he used a wheelchair for mobilization. A facility incident report dated 8/1/10 at 2:30 p.m. revealed that Resident #103 and Resident #102 were in the middle of the road wheeling away from the facility. The residents were brought back by CNA #8. Resident #103 did not say what his reason was for going down the middle of the road. The incident report did not include any information regarding Resident #102. "Patient Progress Notes" (Nursing Notes) dated 8/1/10 (no time) disclosed that Resident #103 was found on a four-lane, 40 MPH road, with a center turn lane, along with Resident #102 one block away from the facility. The nursing note revealed that Resident #103 was brought back to his room and that smoking privileges were suspended. The fall care plan dated 1/23/10 and reviewed on 7/30/10 reflected that Resident #103 had decreased safety awareness, cognitive impairment, decreased muscular strength, an unsteady gait, and that he had attempted to ambulate unassisted. The approaches outlined in that care plan revealed that Resident #103 was to have a bed and chair alarm. A "Fall Risk Assessment' dated 7/30/10 documented Resident #103 had a total score of 15. (A total score above 10 indicated a HIGH RISK for a fall.) In an interview on 9/17/10 at 1:30 p.m., Certified Nursing Assistant (CNA #8) reported that she "just happened" to go out in the employee designated smoking area and observed Resident #102 with Resident #103 on the yellow line in the middle of a two-lane inner-city road in their wheelchairs moving away from the facility. CNA #8 stated if she hadn't seen Residents #102 and #103 at that time, they would have been around the corner. CNA #8 stated Residents #102 and #103 were close to the corner coming upon a 45 MPH road. Residents #102 and #103 were approximately 160 feet from the facility gate that exited from Unit 1 Dining/Sitting room outdoor patio which had a 3 foot brick wall surrounding it and two unlocked, wide-open gates. In an interview on 9/30/10 at 10:50 a.m., Resident #103 was in his room and did not respond to questions from the surveyor. In an interview on 9/17/10 at 3:30 p.m., LPN #12 said that the door to the patio, which was the door from which Residents #102 and #103 exited, was open from 9:00 a.m. to 9:00 p.m. daily 7 days a week and was not monitored unless there were residents in the Dining/Sitting room on Unit 1. In an interview on 9/17/10 at 3:40 p.m., the DON reported that CNA's were supposed to be in the Dining /Sitting room on Unit 1 if there are residents present in the room. The DON stated that the door to the patio off the Dining/Sitting room on Unit 1 was open at 9:00 a.m. and was not monitored unless residents were in the room. The DON was unable to provide a policy for use of the patio and how the facility monitored the safety of the residents. Observations on 9/8/10 at 9:50 a.m. during the initial tour revealed seven residents in wheelchairs in the Unit 1 Dining/Sitting Room with no staff members present. One resident asked to be taken to the bathroom at that time. At 10:00 a.m., there was still no staff member present and the patio exit door alarm was sounding. ADON #10, who was touring with the surveyor, turned off the exit alarm to the patio door by the Unit 1 Dining/Sitting Room and then stated that a resident had gone outside to smoke accompanied by his family. Resident #103 and his family were smoking on the Unit 1 patio. ADON #10 said that a CNA was supposed to be in the Dining/Sitting room with the residents to monitor. An observation on 9/17/10 at 3:15 p.m., of the exit door to the outdoor patio from the Unit 1 Dining/Sitting Room revealed that the door was unlocked and opened without alarming by pressing the handicap button on the wall. The gates to a two-lane inner-city road and ramp down to the facility entrance parking area, with access to a four-lane 40 MPH road with a center turning lane were unlocked and wide open. Two residents with chair alarms were sleeping in the Dining/Sitting room on Unit 1 at that time. There was no facility staff present. The Administrator and the DON were notified on 9/23/10 at 10:35 a.m. of the Immediate Jeopardy that, 1) began on 8/20/2010 when Resident #101 fell and sustained a severe head injury which resulted in a cervical spine injury that caused paralysis of all four extremities, 2) on 7/30/10 at 7:20 a.m. when Resident #102 eloped to the nearby parking lot in his manual wheelchair and fell , and 3) on 8/1/2010 when Residents #102 and #103 eloped from the facility and went into the middle of a busy road, these deficient practices places 24 other residents identified to have bed alarms for fall precautions, and 33 other residents identified to be an elopement risk at a high risk for serious harm, injury and/or death. On 9/30/10 at 9:00 a.m., Surveyors # and # verified that the facility implemented the following to remove the immediate jeopardy. 1. Resident #101 had a post-fall assessment and was treated by the physician and transferred to the hospital on [DATE]. 2. When Resident #102 returned from the parking lot, a head-to-toe body assessment was conducted at 9:30 a.m. on 7/30/10. The anterior portion of his legs were cleansed and dressed per the physician order. He was also assessed for pain which he denied. Resident #102 was counseled regarding the Leave-of-Absence Policy by the charge nurse. 3. Resident #102 was brought back to the facility by the charge nurse on 8/1/10. The charge nurse counseled the resident regarding the policy and leaving without signing out. Resident #102 was assessed and medications given. There were no complaints of pain and no signs or symptoms of distress. 4. Resident #103 was returned to the facility on [DATE] and his family notified. On 8/2/10 Resident #103 was placed on the Wander Guard program. Resident #103 was counseled regarding the Leave-of-Absence Policy. His parents were also counseled regarding the policy. 5. The facility elopement policy was reviewed and revised on 9/17/10. The facility implemented monitors in Unit 1 dining room/patio and hall monitors on Unit 2 near the elevator to ensure resident safety. 6. The policy regarding resident personal alarms was reviewed and revised. The facility implemented a process where the staff member physically pulls the tab out to ensure it sounds. This will alert the staff member that the alarm is functioning properly. 7. Staff in-services regarding the elopement policy were held on 9/17/10, 9/18/10, 9/20/10, and 9/23/10. There were 86 employees out of 166 in-serviced. Further in-servicing will continue until all staff members have been in-serviced. 8. Staff in-services regarding the resident alarm policy were held on 9/7/10, 9/8/10, 9/20/10, and 9/23/10. There were 39 nursing staff out of 79 in-serviced. Further in-servicing will continue until all staff members have been inserviced. 9. The resident elopement policy and the resident alarm policy have been added to the new hire employee orientation process. Upon hire, new employees will be in-serviced on these policies. 10. The Administrator will report to QA monthly for three consecutive months regarding the elopement policy and personal alarms. Although the Immediate Jeopardy was removed on 9/17/2010, the facility remained out of compliance at a scope of "Pattern" and severity of no actual harm, but potential for more than minimal harm, but not Immediate Jeopardy, due to all staff had not been in-serviced and sustained compliance had not been verified by the State agency. ( ) ( )